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Hou AN, Wang Y, Pan YQ. A Case Report of IPEX Syndrome with Neonatal Diabetes Mellitus and Congenital Hypothyroidism as the Initial Presentation, and a Systematic Review of neonatal IPEX. J Clin Immunol 2023; 43:979-988. [PMID: 36867340 DOI: 10.1007/s10875-023-01456-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
Immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX) is a serious disorder, which may comprise diabetes, thyroid disease, enteropathy, cytopenias, eczema, and other multi-system autoimmune dysfunction features. IPEX syndrome is caused by mutations in the forkhead box P3 (FOXP3) gene. Here, we report the clinical manifestations of a patient with IPEX syndrome onset in the neonatal period. A de novo mutation at exon 11 of the FOXP3 gene (c.1190G > A, p.R397Q) was found, and its main clinical manifestations included hyperglycemia and hypothyroidism. Subsequently, we comprehensively reviewed the clinical characteristics and FOXP3 mutations of 55 reported neonatal IPEX cases. The most frequent clinical presentation included symptoms of gastrointestinal involvement (n = 51, 92.7%), followed by skin-related symptoms (n = 37, 67.3%), diabetes mellitus (DM) (n = 33, 60.0%), elevated IgE (n = 28, 50.9%), hematological abnormality (n = 23, 41.8%), thyroid dysfunction (n = 18, 32.7%), and kidney-related symptoms (n = 13, 23.6%). In total, 38 variants were observed in the 55 neonatal patients. The most frequent mutation was c.1150G > A (n = 6; 10.9%), followed by c.1189C > T (n = 4; 7.3%), c.816 + 5G > A (n = 3; 5.5%), and C.1015C > G (n = 3; 5.5%), which were reported more than twice. The genotype-phenotype relationship showed that the repressor domain mutations were associated with DM (P = 0.020), and the leucine zipper mutations were associated with nephrotic syndrome (P = 0.020). The survival analysis suggested that treatment with glucocorticoids increased the survival of the neonatal patients. This literature review provides an informative reference for the diagnosis and treatment of IPEX syndrome in the neonatal period.
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Affiliation(s)
- A-Na Hou
- Department of Pediatrics, People's Republic of China, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, People's Republic of China
| | - Yuanyuan Wang
- Department of Anesthesiology, The Fourth Affiliated Hospital, China Medical University, Shenyang, Liaoning Province, People's Republic of China
| | - Yu-Qing Pan
- Department of Pediatrics, People's Republic of China, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, People's Republic of China.
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2
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Ke R, Zhu Y, Deng F, Xu D. Renal Involvement in IPEX Syndrome With a Novel Mutation of FOXP3: A Case Report. Front Genet 2022; 12:752775. [PMID: 35186001 PMCID: PMC8847221 DOI: 10.3389/fgene.2021.752775] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/22/2021] [Indexed: 11/13/2022] Open
Abstract
The immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a rare genetic disease characterized by multiple immune disorders. Different mutations of the FOXP3 gene may lead to distinct clinical manifestations. Here, we present a rare case of IPEX syndrome caused by a novel variant of FOXP3. Clinical manifestations include autoimmune hemolysis, bronchiectasis, diarrhea, and proteinuria but without diabetes or other endocrine disorders. The diagnosis of IPEX syndrome was confirmed by whole-exon sequencing. Supportive treatment did not ameliorate the patient’s symptoms, while immunosuppressive therapy showed a promising efficacy. The patient we reported will improve the understanding of renal manifestations in IPEX syndrome.
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Affiliation(s)
- Ruijuan Ke
- Anhui Provincial Children's Hospital, Hefei, China
| | - Ying Zhu
- Anhui Provincial Children's Hospital, Hefei, China
| | - Fang Deng
- Anhui Provincial Children's Hospital, Hefei, China
| | - Daliang Xu
- Anhui Provincial Children's Hospital, Hefei, China
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3
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Sato Y, Liu J, Lee E, Perriman R, Roncarolo MG, Bacchetta R. Co-Expression of FOXP3FL and FOXP3Δ2 Isoforms Is Required for Optimal Treg-Like Cell Phenotypes and Suppressive Function. Front Immunol 2021; 12:752394. [PMID: 34737751 PMCID: PMC8560788 DOI: 10.3389/fimmu.2021.752394] [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: 08/03/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Abstract
FOXP3 is the master transcription factor in both murine and human FOXP3+ regulatory T cells (Tregs), a T-cell subset with a central role in controlling immune responses. Loss of the functional Foxp3 protein in scurfy mice leads to acute early-onset lethal lymphoproliferation. Similarly, pathogenic FOXP3 mutations in humans lead to immunodysregulation, polyendocrinopathy, enteropathy, and X-linked (IPEX) syndrome, which are characterized by systemic autoimmunity that typically begins in the first year of life. However, although pathogenic FOXP3 mutations lead to overlapping phenotypic consequences in both systems, FOXP3 in human Tregs, but not mouse, is expressed as two predominant isoforms, the full length (FOXP3FL) and the alternatively spliced isoform, delta 2 (FOXP3Δ2). Here, using CRISPR/Cas9 to generate FOXP3 knockout CD4+ T cells (FOXP3KOGFP CD4+ T cells), we restore the expression of each isoform by lentiviral gene transfer to delineate their functional roles in human Tregs. When compared to FOXP3FL or FOXP3Δ2 alone, or double transduction of the same isoform, co-expression of FOXP3FL and FOXP3Δ2 induced the highest overall FOXP3 protein expression in FOXP3KOGFP CD4+ T cells. This condition, in turn, led to optimal acquisition of Treg-like cell phenotypes including downregulation of cytokines, such as IL-17, and increased suppressive function. Our data confirm that co-expression of FOXP3FL and FOXP3Δ2 leads to optimal Treg-like cell function and supports the need to maintain the expression of both when engineering therapeutics designed to restore FOXP3 function in otherwise deficient cells.
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Affiliation(s)
- Yohei Sato
- Department of Pediatrics, Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Jessica Liu
- Department of Pediatrics, Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Esmond Lee
- Department of Pediatrics, Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Rhonda Perriman
- Department of Pediatrics, Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Maria Grazia Roncarolo
- Department of Pediatrics, Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Center for Definitive and Curative Medicine (CDCM), Stanford University School of Medicine, Stanford, CA, United States
| | - Rosa Bacchetta
- Department of Pediatrics, Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States.,Center for Definitive and Curative Medicine (CDCM), Stanford University School of Medicine, Stanford, CA, United States
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4
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Shi D, Motamed M, Mejía-Benítez A, Li L, Lin E, Budhram D, Kaur Y, Meyre D. Genetic syndromes with diabetes: A systematic review. Obes Rev 2021; 22:e13303. [PMID: 34268868 DOI: 10.1111/obr.13303] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 01/19/2023]
Abstract
Previous reviews and clinical guidelines have identified 10-20 genetic syndromes associated with diabetes, but no systematic review has been conducted to date. We provide the first comprehensive catalog for syndromes with diabetes mellitus. We conducted a systematic review of MEDLINE, Embase, CENTRAL, PubMed, OMIM, and Orphanet databases for case reports, case series, and observational studies published between 1946 and January 15, 2020, that described diabetes mellitus in adults and children with monogenic or chromosomal syndromes. Our literature search identified 7,122 studies, of which 160 fulfilled inclusion criteria. Our analysis of these studies found 69 distinct diabetes syndromes. Thirty (43.5%) syndromes included diabetes mellitus as a cardinal clinical feature, and 56 (81.2%) were fully genetically elucidated. Sixty-three syndromes (91.3%) were described more than once in independent case reports, of which 59 (93.7%) demonstrated clinical heterogeneity. Syndromes associated with diabetes mellitus are more numerous and diverse than previously anticipated. While knowledge of the syndromes is limited by their low prevalence, future reviews will be needed as more cases are identified. The genetic etiologies of these syndromes are well elucidated and provide potential avenues for future gene identification efforts, aid in diagnosis and management, gene therapy research, and developing personalized medicine treatments.
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Affiliation(s)
- Daniel Shi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Mehras Motamed
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Aurora Mejía-Benítez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Leon Li
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ethan Lin
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dalton Budhram
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Yuvreet Kaur
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Meyre
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France.,Faculty of Medicine of Nancy INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure, University of Lorraine, Nancy, France
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Shangaris P, Ho A, Marnerides A, George S, AlAdnani M, Yau S, Jansson M, Hoyle J, Ahn JW, Ellard S, Irving M, Wellesley D, Pasupathy D, Holder-Espinasse M. A hemizygous mutation in the FOXP3 gene (IPEX syndrome) resulting in recurrent X-linked fetal hydrops: a case report. BMC Med Genomics 2021; 14:58. [PMID: 33637067 PMCID: PMC7908803 DOI: 10.1186/s12920-021-00901-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fetal hydrops is excessive extravasation of fluid into the third space in a fetus, which could be due to a wide differential of underlying pathology. IPEX (immune dysregulation, polyendocrinopathy, enteropathy, X-linked) syndrome primarily affects males. It is a monogenic primary immunodeficiency syndrome of X-linked recessive inheritance due to FOXP3 gene variants. It is characterised by the development of multiple autoimmune disorders in affected individuals. CASE PRESENTATION We present a rare cause of male fetal hydrops in the context of IPEX syndrome and discuss FOXP3 gene variants as a differential for 'unexplained' fetal hydrops that may present after the first trimester. DISCUSSION AND CONCLUSIONS In all similar cases, the pathological process begins during intrauterine life. Furthermore, there are no survivors described. Consequently, this variant should be considered as a severe one, associated with intrauterine life onset and fatal course, i.e., the most severe IPEX phenotype.
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Affiliation(s)
- Panicos Shangaris
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Alison Ho
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Andreas Marnerides
- Department of Histopathology, St Thomas Hospital, Westminster Bridge Road, London, SE17EH, UK
| | - Simi George
- Department of Histopathology, St Thomas Hospital, Westminster Bridge Road, London, SE17EH, UK
| | - Mudher AlAdnani
- Department of Histopathology, St Thomas Hospital, Westminster Bridge Road, London, SE17EH, UK
| | - Shu Yau
- Department of Clinical Genetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mattias Jansson
- Department of Clinical Genetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jacqueline Hoyle
- Department of Clinical Genetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Joo Wook Ahn
- Department of Clinical Genetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sian Ellard
- Department of Molecular Genetics, Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK
| | - Melita Irving
- Department of Clinical Genetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Diana Wellesley
- Wessex Clinical Genetics Service, Princess Anne Hospital, Southampton, SO16 5YA, UK
| | - Dharmintra Pasupathy
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, 10th Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Discipline of Obstetrics, Gynaecology and Neonatology, Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Weinstock A, Moura Silva H, Moore KJ, Schmidt AM, Fisher EA. Leukocyte Heterogeneity in Adipose Tissue, Including in Obesity. Circ Res 2020; 126:1590-1612. [PMID: 32437300 DOI: 10.1161/circresaha.120.316203] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Adipose tissue (AT) plays a central role in both metabolic health and pathophysiology. Its expansion in obesity results in increased mortality and morbidity, with contributions to cardiovascular disease, diabetes mellitus, fatty liver disease, and cancer. Obesity prevalence is at an all-time high and is projected to be 50% in the United States by 2030. AT is home to a large variety of immune cells, which are critical to maintain normal tissue functions. For example, γδ T cells are fundamental for AT innervation and thermogenesis, and macrophages are required for recycling of lipids released by adipocytes. The expansion of visceral white AT promotes dysregulation of its immune cell composition and likely promotes low-grade chronic inflammation, which has been proposed to be the underlying cause for the complications of obesity. Interestingly, weight loss after obesity alters the AT immune compartment, which may account for the decreased risk of developing these complications. Recent technological advancements that allow molecular investigation on a single-cell level have led to the discovery of previously unappreciated heterogeneity in many organs and tissues. In this review, we will explore the heterogeneity of immune cells within the visceral white AT and their contributions to homeostasis and pathology.
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Affiliation(s)
- Ada Weinstock
- From the Cardiovascular Research Center, Leon H. Charney Division of Cardiology, Department of Medicine (A.W., K.J.M., E.A.F.), New York University Grossman School of Medicine
| | - Hernandez Moura Silva
- Kimmel Center for Biology and Medicine at the Skirball Institute (H.M.S.), New York University Grossman School of Medicine
| | - Kathryn J Moore
- From the Cardiovascular Research Center, Leon H. Charney Division of Cardiology, Department of Medicine (A.W., K.J.M., E.A.F.), New York University Grossman School of Medicine.,Department of Cell Biology (K.J.M., E.A.F.), New York University Grossman School of Medicine
| | - Ann Marie Schmidt
- Diabetes Research Program, Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine (A.M.S.), New York University Grossman School of Medicine
| | - Edward A Fisher
- From the Cardiovascular Research Center, Leon H. Charney Division of Cardiology, Department of Medicine (A.W., K.J.M., E.A.F.), New York University Grossman School of Medicine.,Department of Cell Biology (K.J.M., E.A.F.), New York University Grossman School of Medicine
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7
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Jamee M, Zaki-Dizaji M, Lo B, Abolhassani H, Aghamahdi F, Mosavian M, Nademi Z, Mohammadi H, Jadidi-Niaragh F, Rojas M, Anaya JM, Azizi G. Clinical, Immunological, and Genetic Features in Patients with Immune Dysregulation, Polyendocrinopathy, Enteropathy, X-linked (IPEX) and IPEX-like Syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2747-2760.e7. [PMID: 32428713 DOI: 10.1016/j.jaip.2020.04.070] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/06/2020] [Accepted: 04/15/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a rare inborn error of immunity caused by mutations in the forkhead box P3 (FOXP3) gene. OBJECTIVE In this study, we conducted a systematic review of patients with IPEX and IPEX-like syndrome to delineate differences in these 2 major groups. METHODS The literature search was performed in PubMed, Web of Science, and Scopus databases, and demographic, clinical, immunologic, and molecular data were compared between the IPEX and IPEX-like groups. RESULTS A total of 459 patients were reported in 148 eligible articles. Major clinical differences between patients with IPEX and IPEX-like syndrome were observed in rates of pneumonia (11% vs 31%, P < .001), bronchiectasis (0.3% vs 14%, P < .001), diarrhea (56% vs 42%, P = .020), and organomegaly (10% vs 23%, P = .001), respectively. Eosinophilia (95% vs 100%), low regulatory T-cell count (68% vs 50%), and elevated IgE (87% vs 61%) were the most prominent laboratory findings in patients with IPEX and IPEX-like syndrome, respectively. In the IPEX group, a lower mortality rate was observed among patients receiving hematopoietic stem cell transplantation (HSCT) (24%) compared with other patients (43%), P = .008; however, in the IPEX-like group, it was not significant (P = .189). CONCLUSIONS Patients with IPEX syndrome generally suffer from enteropathy, autoimmunity, dermatitis, eosinophilia, and elevated serum IgE. Despite similarities in their clinical presentations, patients with IPEX-like syndrome are more likely to present common variable immunodeficiency-like phenotype such as respiratory tract infections, bronchiectasis, and organomegaly. HSCT is currently the only curative therapy for both IPEX and IPEX-like syndrome and may result in favorable outcome.
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Affiliation(s)
- Mahnaz Jamee
- Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran; Alborz Office of USERN, Universal Scientific Education and Research Network (USERN), Alborz University of Medical Sciences, Karaj, Iran
| | - Majid Zaki-Dizaji
- Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
| | - Bernice Lo
- Sidra Medicine, Division of Translational Medicine, Research Branch, Doha, Qatar
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Fatemeh Aghamahdi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Mehdi Mosavian
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Zohreh Nademi
- Children's Bone Marrow Transplant Unit, Great North Children's Hospital, Newcastle, United Kingdom
| | - Hamed Mohammadi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | | | - Manuel Rojas
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Gholamreza Azizi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran.
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8
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Park JH, Lee KH, Jeon B, Ochs HD, Lee JS, Gee HY, Seo S, Geum D, Piccirillo CA, Eisenhut M, van der Vliet HJ, Lee JM, Kronbichler A, Ko Y, Shin JI. Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome: A systematic review. Autoimmun Rev 2020; 19:102526. [PMID: 32234571 DOI: 10.1016/j.autrev.2020.102526] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/19/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a monogenic disorder characterized by early onset fatal multi-system autoimmunity due to loss-of-function mutations in the gene encoding the forkhead box P3 (FOXP3) transcription factor which is crucial for the development, maturation, and maintenance of CD4+ regulatory T (T-reg) cells. Various autoimmune phenomena such as enteropathy, endocrinopathies, cytopenias, renal disease, and skin manifestations are characteristic findings in patients affected by IPEX syndrome. OBJECTIVES In this systematic review, we focus on both clinical and demographic characteristics of IPEX patients, highlighting possible genotype-phenotype correlations and address prognostic factors for disease outcome. METHODS We performed a literature search to systematically investigate the case reports of IPEX which were published before August 7th, 2017. RESULTS A total of 75 articles (195 patients) were identified. All IPEX patients included had FOXP3 mutations which were most frequently located in the forkhead domain (n = 68, 34.9%) followed by the leucine-zipper domain (n = 30, 15.4%) and repressor domain (n = 36, 18.4%). Clinical manifestations were as follows: enteropathy (n = 191, 97.9%), skin manifestations (n = 121, 62.1%), endocrinopathy (n = 104, 53.3%), hematologic abnormalities (n = 75, 38.5%), infections (n = 78, 40.0%), other immune-related complications (n = 43, 22.1%), and renal involvement (n = 32, 16.4%). Enteropathic presentations (P = 0.017), eczema (P = 0.030), autoimmune hemolytic anemia (P = 0.022) and food allergy (P = 0.009) were associated with better survival, while thrombocytopenia (P = 0.034), septic shock (P = 0.045) and mutations affecting the repressor domain (P = 0.021), intron 7 (P = 0.033) or poly A sequence (P = 0.025) were associated with increased risk of death. Immunosuppressive therapy alone was significantly associated with increased cumulative survival compared to patients who received no treatment (P = 0.041). CONCLUSIONS We report the most comprehensive summary of demographic and clinical profiles derived from a total of 195 IPEX patients with deleterious mutations in FOXP3. Analysis of our findings provides new insights into genotype/phenotype correlations, and clinical and genetic factors associated with increased risk of death and response to treatment strategies.
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Affiliation(s)
- Jae Hyon Park
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Bokyoung Jeon
- Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Hans D Ochs
- Department of Pediatrics, University of Washington and Seattle Children's Research Institute, Seattle, WA, USA
| | - Joon Suk Lee
- Department of Pharmacology, Brain Korea 21 PLUS Project for Medical Sciences, Yonsei University College of Medicine, Seoul 03772, Republic of Korea
| | - Heon Yung Gee
- Department of Pharmacology, Brain Korea 21 PLUS Project for Medical Sciences, Yonsei University College of Medicine, Seoul 03772, Republic of Korea
| | - Seeun Seo
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dongil Geum
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ciriaco A Piccirillo
- Department of Microbiology and Immunology, McGill University, Montréal, QC, Canada; The Research Institute of the McGill University Health Center, Montréal, QC, Canada; FOCiS Centre of Excellence in Translational Immunology (CETI), Montréal, QC H4A 3J1, Canada
| | - Michael Eisenhut
- Luton & Dunstable University Hospital NHS Foundation Trust, Lewsey Road, Luton LU4ODZ, United Kingdom
| | - Hans J van der Vliet
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Jiwon M Lee
- Department of Pediatrics, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Medical University Innsbruck, Innsbruck, Austria
| | - Younhee Ko
- Division of Biomedical Engineering, Hankuk University of Foreign Studies, Gyeonggi-do, Republic of Korea
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea.
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9
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Carneiro-Sampaio M, Moreira-Filho CA, Bando SY, Demengeot J, Coutinho A. Intrauterine IPEX. Front Pediatr 2020; 8:599283. [PMID: 33330291 PMCID: PMC7714920 DOI: 10.3389/fped.2020.599283] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/26/2020] [Indexed: 01/18/2023] Open
Abstract
IPEX is one of the few Inborn Errors of Immunity that may manifest in the fetal period, and its intrauterine forms certainly represent the earliest human autoimmune diseases. Here, we review the clinical, histopathologic, and genetic findings from 21 individuals in 11 unrelated families, with nine different mutations, described as cases of intrauterine IPEX. Recurrent male fetal death (multigenerational in five families) due to hydrops in the midsemester of pregnancy was the commonest presentation (13/21). Noteworthy, in the affected families, there were only fetal- or perinatal-onset cases, with no affected individuals presenting milder forms with later-life manifestation. Most alive births were preterm (5/6). Skin desquamation and intrauterine growth restriction were observed in part of the cases. Fetal ultrasonography showed hyperechoic bowel or dilated bowel loops in the five cases with available imaging data. Histopathology showed multi-visceral infiltrates with T lymphocytes and other cells, including eosinophils, the pancreas being affected in most of the cases (11/21) and as early as at 18 weeks of gestational age. Regarding the nine FOXP3 mutations found in these cases, six determine protein truncation and three predictably impair protein function. Having found distinct presentations for the same FOXP3 mutation in different families, we resorted to the mouse system and showed that the scurfy mutation also shows divergent severity of phenotype and age of death in C57BL/6 and BALB/c backgrounds. We also reviewed age-of-onset data from other monogenic Tregopathies leading to IPEX-like phenotypes. In monogenic IPEX-like syndromes, the intrauterine onset was only observed in two kindreds with IL2RB mutations, with two stillbirths and two premature neonates who did not survive. In conclusion, intrauterine IPEX cases seem to constitute a particular IPEX subgroup, certainly with the most severe clinical presentation, although no strict mutation-phenotype correlations could be drawn for these cases.
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Affiliation(s)
- Magda Carneiro-Sampaio
- Laboratory of Medical Investigation (LIM-36, HCFMUSP), Department of Pediatrics, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Alberto Moreira-Filho
- Laboratory of Medical Investigation (LIM-36, HCFMUSP), Department of Pediatrics, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Silvia Yumi Bando
- Laboratory of Medical Investigation (LIM-36, HCFMUSP), Department of Pediatrics, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Martuszewski A, Paluszkiewicz P, Wawrzyniak-Dzierżek E, Drożyńska-Duklas M, Bąbol-Pokora K, Myśliwiec M, Szymczak D, Irga-Jaworska N, Młynarski W, Kałwak K, Ussowicz M. Successful Salvage Haploidentical Alpha-Beta T Cell-Depleted Stem Cell Transplantation After Busulfan-Based Myeloablation in a Patient With IPEX Syndrome: A Case Report. Transplant Proc 2019; 51:3150-3154. [PMID: 31611124 DOI: 10.1016/j.transproceed.2019.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/28/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND X-linked immunodysregulation syndrome with polyendocrinopathy and enteropathy (IPEX) is caused by FOXP3 gene mutations that block the generation of regulatory T lymphocytes. We report an 18-month-old boy with classic IPEX who underwent 2 hematopoietic stem cell transplantations (HSCTs). METHODS The first HSCT from an unrelated 8/10 HLA-matched umbilical cord blood donor (UCB) was performed after a conditioning regimen consisting of treosulfan, fludarabine, thiotepa, and thymoglobulin. Due to complete rejection of the UCB transplant, a second transplantation from a 6/10 HLA-matched mother was performed after alpha-beta T-cell depletion. The second conditioning regimen consisted of busulfan, fludarabine, a single dose of cyclophosphamide 1 g/m2, and Grafalon (Neovii Pharmaceuticals, Rapperswil, Switzerland). The T-cell depletion product contained 15.06 x 106 CD34+ cells per kilogram body weight (BW) and 4.19 x 105 alpha-beta T lymphocytes per kilogram BW. Due to acute graft rejection, the boy was treated with thymoglobulin, and full donor chimerism in both T lymphocytes and mononuclear cells was achieved. The immunosuppressive therapy was stopped 1 year after transplantation. To date, the patient remains free from graft-vs-host disease (GVHD) and immunosuppression. CONCLUSIONS HSCT after busulfan-based reduced-toxicity conditioning in patients with IPEX syndrome is feasible and well tolerated and can result in full donor engraftment. Monitoring of chimerism and aggressive therapy in cases of graft rejection are warranted due to the high reactivity of residual autologous T lymphocytes. T-cell depletion reduces the risk of GVHD and the need for steroid therapy, which is especially challenging in patients with diabetes.
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Affiliation(s)
- Adrian Martuszewski
- Department of Paediatric Bone Marrow Transplantation, Oncology and Hematology, Wrocław Medical University, Wrocław, Poland
| | - Patrycja Paluszkiewicz
- Department of Paediatric Bone Marrow Transplantation, Oncology and Hematology, Wrocław Medical University, Wrocław, Poland
| | - Elżbieta Wawrzyniak-Dzierżek
- Department of Paediatric Bone Marrow Transplantation, Oncology and Hematology, Wrocław Medical University, Wrocław, Poland
| | | | - Katarzyna Bąbol-Pokora
- Laboratory of Immunopathology and Genetics, Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Łódź, Łódź, Poland
| | - Małgorzata Myśliwiec
- Department of Paediatrics, Diabetology and Endocrinology, Medical University of Gdańsk, Gdańsk, Poland
| | - Donata Szymczak
- Department and Clinic of Haematology, Blood Neoplasms, and Bone Marrow Transplantation, Wrocław Medical University, Wrocław, Poland
| | - Ninela Irga-Jaworska
- Department of Paediatrics, Haematology and Oncology, Medical University of Gdańsk, Gdańsk, Poland
| | - Wojciech Młynarski
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Łódź, Łódź, Poland
| | - Krzysztof Kałwak
- Department of Paediatric Bone Marrow Transplantation, Oncology and Hematology, Wrocław Medical University, Wrocław, Poland
| | - Marek Ussowicz
- Department of Paediatric Bone Marrow Transplantation, Oncology and Hematology, Wrocław Medical University, Wrocław, Poland.
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11
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Zirilli G, Santucci S, Cuzzupè C, Corica D, Pitrolo E, Salzano G. Peculiarities of autoimmune polyglandular syndromes in children and adolescents. ACTA BIO-MEDICA : ATENEI PARMENSIS 2017; 88:271-275. [PMID: 29083330 DOI: 10.23750/abm.v88i3.5898] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 11/05/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND no reviews have specifically addressed , to now, whether autoimmune polyglandular syndromes (APSs) may have a peculiar epidemiology and phenotypical expression in pediatric ageObjectives: to review the most recent literature data about the specific epidemiological and clinical peculiarities of APSs in childhood and adolescenceDesign: the main features of the different APSs in pediatric age were compared among them. CONCLUSIONS 1) Among the different APSs, the one that is most typical of pediatric age is APS-1; 2) APS-1 is not characterized only by the classical triad (chronic moniliasis-hyposurrenalism-hypoparathyroidism) and its clinical spectrum is enlarging over time; 3)APS-2 may have a different epidemiological and clinical expression according to two different nosological classifications.
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Affiliation(s)
- Giuseppina Zirilli
- Department of Human Pathology of Adulthood and Childhood, University of Messina, Messina, Italy.
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12
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Pereira LMS, Gomes STM, Ishak R, Vallinoto ACR. Regulatory T Cell and Forkhead Box Protein 3 as Modulators of Immune Homeostasis. Front Immunol 2017; 8:605. [PMID: 28603524 PMCID: PMC5445144 DOI: 10.3389/fimmu.2017.00605] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 05/08/2017] [Indexed: 12/15/2022] Open
Abstract
The transcription factor forkhead box protein 3 (FOXP3) is an essential molecular marker of regulatory T cell (Treg) development in different microenvironments. Tregs are cells specialized in the suppression of inadequate immune responses and the maintenance of homeostatic tolerance. Studies have addressed and elucidated the role played by FOXP3 and Treg in countless autoimmune and infectious diseases as well as in more specific cases, such as cancer. Within this context, the present article reviews aspects of the immunoregulatory profile of FOXP3 and Treg in the management of immune homeostasis, including issues relating to pathology as well as immune tolerance.
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Affiliation(s)
- Leonn Mendes Soares Pereira
- Laboratório de Virologia, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém, Pará, Brazil.,Programa de Pós-Graduação em Biologia de Agentes Infecciosos e Parasitários, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém, Pará, Brazil
| | - Samara Tatielle Monteiro Gomes
- Laboratório de Virologia, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém, Pará, Brazil.,Programa de Pós-Graduação em Biologia de Agentes Infecciosos e Parasitários, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém, Pará, Brazil
| | - Ricardo Ishak
- Laboratório de Virologia, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém, Pará, Brazil
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13
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Allenspach EJ, Finn LS, Rendi MH, Eken A, Singh AK, Oukka M, Taylor SD, Altman MC, Fligner CL, Ochs HD, Rawlings DJ, Torgerson TR. Absence of functional fetal regulatory T cells in humans causes in utero organ-specific autoimmunity. J Allergy Clin Immunol 2017; 140:616-619.e7. [PMID: 28322850 DOI: 10.1016/j.jaci.2017.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 02/11/2017] [Accepted: 02/14/2017] [Indexed: 02/01/2023]
Affiliation(s)
- Eric J Allenspach
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Wash; Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Wash
| | - Laura S Finn
- Department of Laboratories, Seattle Children's Hospital, Seattle, Wash; Department of Pathology, University of Washington School of Medicine, Seattle, Wash
| | - Mara H Rendi
- Department of Pathology, University of Washington School of Medicine, Seattle, Wash
| | - Ahmet Eken
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Wash
| | - Akhilesh K Singh
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Wash
| | - Mohamed Oukka
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Wash
| | - Sean D Taylor
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Wash
| | - Matthew C Altman
- Benaroya Research Institute, Seattle, Wash; Department of Medicine, University of Washington School of Medicine, Seattle, Wash
| | - Corinne L Fligner
- Department of Pathology, University of Washington School of Medicine, Seattle, Wash; Department of Laboratory Medicine, University of Washington School of Medicine, Seattle, Wash
| | - Hans D Ochs
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Wash; Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Wash
| | - David J Rawlings
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Wash; Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Wash
| | - Troy R Torgerson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Wash; Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Wash.
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14
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Bacchetta R, Barzaghi F, Roncarolo MG. From IPEX syndrome to FOXP3
mutation: a lesson on immune dysregulation. Ann N Y Acad Sci 2016; 1417:5-22. [DOI: 10.1111/nyas.13011] [Citation(s) in RCA: 210] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/29/2015] [Accepted: 01/06/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Rosa Bacchetta
- Department of Pediatrics; Division of Pediatric Stem Cells, Transplantation and Regenerative Medicine; Stanford University Medical School; Stanford California
| | - Federica Barzaghi
- San Raffaele Telethon Institute for Gene Therapy; Division of Regenerative Medicine; Stem Cells and Gene Therapy; San Raffaele Scientific Institute; Milan Italy
| | - Maria-Grazia Roncarolo
- Department of Pediatrics; Division of Pediatric Stem Cells, Transplantation and Regenerative Medicine; Stanford University Medical School; Stanford California
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15
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Xavier-da-Silva MM, Moreira-Filho CA, Suzuki E, Patricio F, Coutinho A, Carneiro-Sampaio M. Fetal-onset IPEX: Report of two families and review of literature. Clin Immunol 2015; 156:131-40. [DOI: 10.1016/j.clim.2014.12.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 10/20/2014] [Accepted: 12/18/2014] [Indexed: 12/16/2022]
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16
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Agarwal S, Mayer L. Diagnosis and treatment of gastrointestinal disorders in patients with primary immunodeficiency. Clin Gastroenterol Hepatol 2013; 11:1050-63. [PMID: 23501398 PMCID: PMC3800204 DOI: 10.1016/j.cgh.2013.02.024] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 02/08/2013] [Accepted: 02/15/2013] [Indexed: 02/06/2023]
Abstract
Gastrointestinal disorders such as chronic or acute diarrhea, malabsorption, abdominal pain, and inflammatory bowel diseases can indicate immune deficiency. The gastrointestinal tract is the largest lymphoid organ in the body, so it is not surprising that intestinal diseases are common among immunodeficient patients. Gastroenterologists therefore must be able to diagnose and treat patients with primary immunodeficiency. Immune-related gastrointestinal diseases can be classified as those that develop primarily via autoimmunity, infection, an inflammatory response, or malignancy. Immunodeficient and immunocompetent patients with gastrointestinal diseases present with similar symptoms. However, intestinal biopsy specimens from immunodeficient patients often have distinct histologic features, and these patients often fail to respond to conventional therapies. Therefore, early recognition of symptoms and referral to an immunologist for a basic immune evaluation is required to select appropriate treatments. Therapies for primary immunodeficiency comprise immunoglobulin replacement, antibiotics, and, in severe cases, bone marrow transplantation. Treatment of immunodeficient patients with concomitant gastrointestinal disease can be challenging, and therapy with immunomodulators often is required for severe disease. This review aims to guide gastroenterologists in the diagnosis and treatment of patients with primary immunodeficiency.
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Affiliation(s)
- Shradha Agarwal
- Division of Clinical Immunology, Mount Sinai School of Medicine, New York, New York 10029, USA.
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17
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Mold JE, Anderson CC. A discussion of immune tolerance and the layered immune system hypothesis. CHIMERISM 2013; 4:62-70. [PMID: 23723085 DOI: 10.4161/chim.24914] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jeff E Mold
- Department of Cell and Molecular Biology; Karolinska Institutet; Stockholm, Sweden
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18
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Katoh H, Zheng P, Liu Y. FOXP3: genetic and epigenetic implications for autoimmunity. J Autoimmun 2013; 41:72-8. [PMID: 23313429 DOI: 10.1016/j.jaut.2012.12.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 12/16/2012] [Indexed: 12/12/2022]
Abstract
FOXP3 plays an essential role in the maintenance of self-tolerance and, thus, in preventing autoimmune diseases. Inactivating mutations of FOXP3 cause immunodysregulation, polyendocrinopathy, and enteropathy, X-linked syndrome. FOXP3-expressing regulatory T cells attenuate autoimmunity as well as immunity against cancer and infection. More recent studies demonstrated that FOXP3 is an epithelial cell-intrinsic tumor suppressor for breast, prostate, ovary and other cancers. Corresponding to its broad function, FOXP3 regulates a broad spectrum of target genes. While it is now well established that FOXP3 binds to and regulates thousands of target genes in mouse and human genomes, the fundamental mechanisms of its broad impact on gene expression remain to be established. FOXP3 is known to both activate and repress target genes by epigenetically regulating histone modifications of target promoters. In this review, we first focus on germline mutations found in the FOXP3 gene among IPEX patients, then outline possible molecular mechanisms by which FOXP3 epigenetically regulates its targets. Finally, we discuss clinical implications of the function of FOXP3 as an epigenetic modifier. Accumulating results reveal an intriguing functional convergence between FOXP3 and inhibitors of histone deacetylases. The essential epigenetic function of FOXP3 provides a foundation for experimental therapies against autoimmune diseases.
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Affiliation(s)
- Hiroto Katoh
- Division of Molecular Oncology, Institute for Genetic Medicine, Hokkaido University, Hokkaido, Japan
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19
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He F, Balling R. The role of regulatory T cells in neurodegenerative diseases. WILEY INTERDISCIPLINARY REVIEWS-SYSTEMS BIOLOGY AND MEDICINE 2012; 5:153-80. [PMID: 22899644 DOI: 10.1002/wsbm.1187] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A sustained neuroinflammatory response is the hallmark of many neurodegenerative diseases, including Parkinson's disease, Alzheimer's disease, amyotrophic lateral sclerosis, multiple sclerosis, and HIV-associated neurodegeneration. A specific subset of T cells, currently recognized as FOXP3(+) CD25(+) CD4(+) regulatory T cells (Tregs), are pivotal in suppressing autoimmunity and maintaining immune homeostasis by mediating self-tolerance at the periphery as shown in autoimmune diseases and cancers. A growing body of evidence shows that Tregs are not only important for maintaining immune balance at the periphery but also contribute to self-tolerance and immune privilege in the central nervous system. In this article, we first review the current status of knowledge concerning the development and the suppressive function of Tregs. We then discuss the evidence supporting a dysfunction of Tregs in several neurodegenerative diseases. Interestingly, a dysfunction of Tregs is mainly observed in the early stages of several neurodegenerative diseases, but not in their chronic stages, pointing to a causative role of inflammation in the pathogenesis of neurodegenerative diseases. Furthermore, we provide an overview of a number of molecules, such as hormones, neuropeptides, neurotransmitters, or ion channels, that affect the dysfunction of Tregs in neurodegenerative diseases. We also emphasize the effects of the intestinal microbiome on the induction and function of Tregs and the need to study the crosstalk between the enteric nervous system and Tregs in neurodegenerative diseases. Finally, we point out the need for a systems biology approach in the analysis of the enormous complexity regulating the function of Tregs and their potential role in neurodegenerative diseases.
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Affiliation(s)
- Feng He
- Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Campus Belval, Luxembourg
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20
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Barzaghi F, Passerini L, Bacchetta R. Immune dysregulation, polyendocrinopathy, enteropathy, x-linked syndrome: a paradigm of immunodeficiency with autoimmunity. Front Immunol 2012; 3:211. [PMID: 23060872 PMCID: PMC3459184 DOI: 10.3389/fimmu.2012.00211] [Citation(s) in RCA: 227] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 07/01/2012] [Indexed: 12/15/2022] Open
Abstract
Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a rare monogenic primary immunodeficiency (PID) due to mutations of FOXP3, a key transcription factor for naturally occurring (n) regulatory T (Treg) cells. The dysfunction of Treg cells is the main pathogenic event leading to the multi-organ autoimmunity that characterizes IPEX syndrome, a paradigm of genetically determined PID with autoimmunity. IPEX has a severe early onset and can become rapidly fatal within the first year of life regardless of the type and site of the mutation. The initial presenting symptoms are severe enteritis and/or type-1 diabetes mellitus, alone or in combination with eczema and elevated serum IgE. Other autoimmune symptoms, such as hypothyroidism, cytopenia, hepatitis, nephropathy, arthritis, and alopecia can develop in patients who survive the initial acute phase. The current therapeutic options for IPEX patients are limited. Supportive and replacement therapies combined with pharmacological immunosuppression are required to control symptoms at onset. However, these procedures can allow only a reduction of the clinical manifestations without a permanent control of the disease. The only known effective cure for IPEX syndrome is hematopoietic stem cell transplantation, but it is always limited by the availability of a suitable donor and the lack of specific guidelines for bone marrow transplant in the context of this disease. This review aims to summarize the clinical histories and genomic mutations of the IPEX patients described in the literature to date. We will focus on the clinical and immunological features that allow differential diagnosis of IPEX syndrome and distinguish it from other PID with autoimmunity. The efficacy of the current therapies will be reviewed, and possible innovative approaches, based on the latest highlights of the pathogenesis to treat this severe primary autoimmune disease of childhood, will be discussed.
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Affiliation(s)
- Federica Barzaghi
- Division of Regenerative Medicine, Stem Cells and Gene Therapy, San Raffaele Telethon Institute for Gene Therapy, San Raffaele Scientific Institute Milan, Italy ; Vita Salute San Raffaele University Milan, Italy
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21
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Mold JE, McCune JM. At the crossroads between tolerance and aggression: Revisiting the "layered immune system" hypothesis. CHIMERISM 2011; 2:35-41. [PMID: 21912717 PMCID: PMC3166482 DOI: 10.4161/chim.2.2.16329] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 05/05/2011] [Indexed: 01/20/2023]
Abstract
"We do not grow absolutely, chronologically. We grow sometimes in one dimension, and not in another; unevenly. We grow partially. We are relative. We are mature in one realm, childish in another. The past, present and future mingle and pull us backward, forward, or fix us in the present. We are made up of layers, cells, constellations."-Anaïs NinIt has long been recognized that the developing immune system exhibits certain peculiarities when compared to the adult immune system. Nonetheless, many still regard the fetal immune system as simply being an immature version of the adult immune system. Here we discuss historical evidence as well as recent findings, which suggest that the human immune system may develop in distinct layers with specific functions at different stages of development.
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Affiliation(s)
- Jeff E Mold
- Department of Cell and Molecular Biology; Karolinska Institute; Stockholm, Sweden
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22
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Recognizing gastrointestinal and hepatic manifestations of primary immunodeficiency diseases. J Pediatr Gastroenterol Nutr 2010; 51:548-55. [PMID: 20871412 DOI: 10.1097/mpg.0b013e3181efe56b] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Given the complex immune function of the gastrointestinal (GI) tract, it is not surprising that many children with primary immunodeficiencies present with GI tract manifestations. Although many immunodeficiency disorders present with overt evidence of immune dysregulation, a few can present in older children with more subtle signs and symptoms. Such children may present first to a gastroenterologist with common symptoms, including malabsorption, diarrhea, hepatomegaly, or inflammatory bowel disease, which may actually be a manifestation of their underlying immune disorder. A thorough clinical history in combination with a careful review of histology from biopsies may reveal clues that one is dealing with a disease entity outside the norm and may prompt additional laboratory studies beyond the usual set of screening laboratory tests. Once the true underlying diagnosis is revealed, more appropriate therapy can be initiated. Additionally, more appropriate anticipatory guidance regarding the expected disease course, response to medications, and any additional risks that therapy may entail can be provided to the family.
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23
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Abstract
The autoimmune polyglandular syndromes-a group of syndromes comprising a combination of endocrine and nonendocrine autoimmune diseases-differ in their component diseases and in the immunologic features of their pathogenesis. One of the three main syndromes, type 1 autoimmune polyglandular syndrome (APS-1), has a unique pathogenic mechanism owing to mutations in the autoimmune regulator (AIRE) gene, which results in the loss of central tolerance-a process by which developing T cells with potential reactivity for self-antigens are eliminated during early differentiation in the thymus. Patients with IPEX (immune dysfunction, polyendocrinopathy, enteropathy, X-linked) syndrome harbor mutations in the forkhead box P3 (FOXP3) gene in regulatory T cells, which leads to severe autoimmunity and immune deficiency. Although both of these disorders are rare, their well-defined mechanisms of disease provide a basis for the understanding of the more common condition, APS-2. In this syndrome, alleles of human leukocyte antigens (HLAs) determine the targeting of specific tissues by autoreactive T cells, which leads to organ-specific autoimmunity as a result of this loss of tolerance. Non-HLA genes also contribute to autoimmunity in APS-2 and, depending on the polymorphism, potentially predispose to a loss of tolerance or influence which organ is specifically targeted. This Review discusses the genetic basis of APS-1, APS-2 and IPEX syndrome, with an emphasis on the mechanisms of autoimmunity and presents currently available therapies to treat their underlying autoimmune disorders.
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Affiliation(s)
- Aaron W Michels
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, 1775 Aurora Court, MS B140, PO Box 6511, Aurora, CO 80045, USA
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24
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Congenital diarrheal disorders: improved understanding of gene defects is leading to advances in intestinal physiology and clinical management. J Pediatr Gastroenterol Nutr 2010; 50:360-6. [PMID: 20216094 DOI: 10.1097/mpg.0b013e3181d135ef] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Congenital diarrheal disorders (CDD, Online Mendelian Inheritance in Man [OMIM] 251850) represent one of the most challenging clinical conditions for pediatric gastroenterologists because of the severity of the clinical picture and the broad range of disorders in its differential diagnosis. The number of conditions included within CDD has gradually increased. Recent advances made in the pathophysiology of these conditions have led to a better understanding of the more common diarrheal diseases. Based on the body of data accumulated in recent years, we suggest that CDD be classified in 4 categories depending on the alteration in absorption and transport of nutrients and electrolytes, enterocyte differentiation and polarization, enteroendocrine cell differentiation, and modulation of the intestinal immune response. Our knowledge of the genes responsible for CDD is also rapidly increasing, thanks to linkage studies based on genome-wide analysis of polymorphisms. In this context, the identification of disease genes is a step forward in the diagnostic approach to a patient in whom CDD is strongly suspected. However, it is conceivable that faster, less expensive molecular procedures will, in the near future, become available. This approach could spare the patient invasive procedures and limit complications associated with a delay in diagnosis. Furthermore, carrier and prenatal molecular diagnosis may help pediatricians better manage the condition in the early stages of life.
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25
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Kuczma M, Podolsky R, Garge N, Daniely D, Pacholczyk R, Ignatowicz L, Kraj P. Foxp3-deficient regulatory T cells do not revert into conventional effector CD4+ T cells but constitute a unique cell subset. THE JOURNAL OF IMMUNOLOGY 2009; 183:3731-41. [PMID: 19710455 DOI: 10.4049/jimmunol.0800601] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Homeostasis in the immune system is maintained by specialized regulatory CD4(+) T cells (T(reg)) expressing transcription factor Foxp3. According to the current paradigm, high-affinity interactions between TCRs and class II MHC-peptide complexes in thymus "instruct" developing thymocytes to up-regulate Foxp3 and become T(reg) cells. However, the loss or down-regulation of Foxp3 does not disrupt the development of T(reg) cells but abrogates their suppressor function. In this study, we show that Foxp3-deficient T(reg) cells in scurfy mice harboring a null mutation of the Foxp3 gene retained cellular features of T(reg) cells including in vitro anergy, impaired production of inflammatory cytokines, and dependence on exogenous IL-2 for proliferation and homeostatic expansion. Foxp3-deficient T(reg) cells expressed a low level of activation markers, did not expand relative to other CD4(+) T cells, and produced IL-4 and immunomodulatory cytokines IL-10 and TGF-beta when stimulated. Global gene expression profiling revealed significant similarities between T(reg) cells expressing and lacking Foxp3. These results argue that Foxp3 deficiency alone does not convert T(reg) cells into conventional effector CD4(+) T cells but rather these cells constitute a distinct cell subset with unique features.
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Affiliation(s)
- Michal Kuczma
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta, GA 30912, USA
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26
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Abstract
Autoimmune diseases affect a significant segment of the population and are typically thought to be multifactorial in etiology. Autoimmune diseases due to single gene defects are rare, but offer an invaluable window into understanding how defects in the immune system can lead to autoimmunity. In this review, we will focus on autoimmune polyendocrinopathy syndrome type 1 and recent advances in our understanding of this disease. We will also discuss two other monogenic autoimmune diseases: immunodysregulation, polyendocrinopathy, and enteropathy, X-linked and Autoimmune lymphoproliferative syndrome. Importantly, the knowledge and principles gained from studying these diseases have been applicable to more common autoimmune diseases and have opened the door to better diagnostic and therapeutic modalities.
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Affiliation(s)
- Maureen A Su
- Diabetes Center and Department of Pediatrics, University of California, San Francisco, San Francisco, California 94143, USA
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27
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Queiroz MS. [Type 1 diabetes and autoimmune polyendocrine syndromes]. ACTA ACUST UNITED AC 2009; 52:198-204. [PMID: 18438530 DOI: 10.1590/s0004-27302008000200007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Accepted: 01/18/2008] [Indexed: 11/22/2022]
Abstract
Type 1 diabetes (T1D) is associated with autoimmune thyroid disease (AIT), celiac disease (CD), Addison's disease (AD), and other autoimmune diseases. These diseases can occur simultaneously in defined syndromes with distinct pathophysiology and characteristics: autoimmune polyendocrine syndromes (APSs) and the immunodysregulation polyendocrinopathy enteropathy X-linked syndrome (IPEX). APSs were initially defined as a multiple endocrine gland insufficiency associated to an autoimmune disease in a patient. APS-1 is characterized by the evidence of chronic candidiasis, chronic hypoparathyroidism, AD and T1D could be present as part of this syndrome. The combination of autoimmune adrenal insufficiency with AIT and/or type 1 autoimmune diabetes mellitus defines APS-2. AIT associated to other autoimmune diseases (excluding AD and/or hypoparathyroidism) are the main characteristics of APS-3. Different clinical combinations of autoimmune diseases which were not included in the previous groups are the characteristics of APS-4. IPEX is a recessive disorder characterized by the neonatal onset of T1D, infections, enteropathy, thrombocytopenia and anemia, as well as endocrinopathy, eczema and cachexia. These disorders are not common, but their consequences can be life threatening when the diagnosis is overlooked, and the treatment is the same prescribed for isolated disease presentation.
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Affiliation(s)
- Márcia S Queiroz
- Laboratório de Investigação Médica - 25 (LIM-25), Hospital das Clínicas, Faculdade de Medicina, Universidade São Paulo, São Paulo, SP, Brasil. marciasqz@gmail
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Clinical and molecular aspects of autoimmune enteropathy and immune dysregulation, polyendocrinopathy autoimmune enteropathy X-linked syndrome. Curr Opin Gastroenterol 2008; 24:742-8. [PMID: 19122524 DOI: 10.1097/mog.0b013e32830c9022] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Autoimmune enteropathy (AIE) is a distinct cause of severe and persistent inflammatory diarrhea in children. Recent research data allowed us to gain a first insight in the pathogenesis of AIE. On the basis of this data, we will discuss new aspects of AIE emphasizing new diagnostic and therapeutic possibilities. RECENT FINDINGS With the discovery of disease-causing mutations in the FOXP3 gene in patients with AIE, a dramatic advance in the understanding of AIE was made. Subsequent studies indicated that FOXP3 is a key transcription factor indispensable for regulatory functions of T cells pointing to a critical role of regulatory T-cell homeostasis in the development of AIE. Abnormal FOXP3 expression results in defective regulatory functions of T cells, which in turn cause a systemic T-cell-mediated autoaggressive disorder, now called immune dysregulation, polyendocrinopathy autoimmune enteropathy X-linked syndrome. Upon systematic review, we describe different phenotypes of immune dysregulation polyendocrinopathy autoimmune enteropathy X-linked syndrome, as well as immune dysregulation polyendocrinopathy autoimmune enteropathy X-linked-like forms of AIE, which are FOXP3 independent. No genotype-phenotype correlation could be established so far. SUMMARY On the basis of the profound immune dysregulation in AIE, new, most often T-cell-oriented treatment strategies were developed. The recent molecular advances in the understanding of AIE give a clear rational for the use of immunosuppression (combining steroids and tacrolimus or rapamycine) to stabilize AIE patients or to perform bone marrow transplantation in those who do not respond to immunomodulation.
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Abstract
The past several years have brought an increased awareness of the prevalence of autoimmunity and immune dysregulation among patients who have primary immunodeficiency disorders (PIDD). The recent clinical and molecular definition of PIDD, in which the primary defect is in the immunoregulatory compartment of the immune system, has offered insight into the basic mechanisms of immune tolerance, which has provided new targets and new techniques to study immune tolerance in PIDD. Many of these studies have focused on the presence and function of regulatory T (T(REG)) cells in PIDD, particularly since the discovery of murine and human syndromes associated with T(REG) deficiency. This article focuses on the current state of knowledge regarding the role of T(REG) in various PIDD that have clinical features indicative of dysregulated immunity.
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Abstract
Children with a history of recurrent or unusual infections present a diagnostic challenge. Differentiation between frequent infections caused by common risk factors, versus primary immune dysfunction should be based on a detailed history and physical examination and, if indicated, followed by appropriate laboratory studies. A high index of suspicion could lead to an early diagnosis and treatment of an underlying immune deficiency disease. This article presents to physicians an approach to the evaluation of children with recurrent infections. Important details from the history and physical examination, and an appropriate choice of screening laboratory test to be ordered in a given situation are discussed.
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Affiliation(s)
- Mark Ballow
- Division of Allergy/Clinical Immunology, Department of Pediatrics, Women & Children's Hospital of Buffalo, SUNY Buffalo School of Medicine and Biomedical Sciences, 219 Bryant Street, Buffalo, NY 14222, USA.
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31
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Yong PL, Russo P, Sullivan KE. Use of Sirolimus in IPEX and IPEX-Like Children. J Clin Immunol 2008; 28:581-7. [DOI: 10.1007/s10875-008-9196-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Accepted: 03/11/2008] [Indexed: 02/02/2023]
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32
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Abstract
PURPOSE OF REVIEW Several primary immune deficiency disorders are associated with autoimmunity and malignancy, suggesting a state of immune dysregulation. Here, we review the role of regulatory T-cell deficits in mediating the immune dysregulation associated with certain primary immune deficiency disorder syndromes. RECENT FINDINGS Systematic studies in primary immune deficiency disorders and their associated animal models have led to an increased understanding of both central and peripheral tolerance mechanisms, and in particular have yielded new insights into regulatory T-cell function, development and maintenance. SUMMARY Single-gene defects identified in patients with multiple autoimmune phenomena have defined new primary immune deficiency disorder syndromes in which the primary deficit is in the establishment or maintenance of immune tolerance. The disorder that has been most informative with regard to understanding the function and development of regulatory T cells is forkhead box P3 deficiency, known as immune dysregulation, polyendocrinopathy, enteropathy and X-linked syndrome in humans and Scurfy in the mouse. Recent studies in patients with other primary immune deficiency disorders, including autoimmune polyendocrinopathy, candidiasis and ectodermal dystrophy syndrome, CD25 deficiency, STAT5b deficiency, and Wiskott-Aldrich syndrome, have added to our understanding of regulatory T-cell biology. The study of patients with rare primary immune deficiency disorder syndromes provides an unparalleled opportunity to understand mechanisms of autoimmunity and immune tolerance in humans.
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33
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Appleby MW, Ramsdell F. Scurfy, the Foxp3 locus, and the molecular basis of peripheral tolerance. Curr Top Microbiol Immunol 2008; 321:151-68. [PMID: 18727491 DOI: 10.1007/978-3-540-75203-5_7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The ability to rapidly and efficiently recognize and eliminate pathogens while sparing normal self tissue is a hallmark of the mammalian immune system. When it fails, however, autoimmune disease results. The genetic and environmental factors that control the process of making such distinctions, not to mention the specific targeted tissues, are extraordinarily complex in the human population; only now are we characterizing the candidate genes responsible for these responses to pathogens. The examination of specific traits in murine models of disease has led to the identification of many of the candidate genes for human disease. The study of mouse mutations (both induced and spontaneous) has also greatly advanced our understanding of the immune responses and autoimmune disease. Here, we describe the use of classical mouse genetics to identify one gene centrally involved in the control of immune responses. Furthermore, although mutations in the orthologous human gene result in a virtually identical phenotype to that seen in the mouse, it is unlikely that studying the human disease populations alone would have successfully identified this gene. Thus, despite the complete sequencing of the human and mouse genomes, the examination of murine mutations remains a powerful and unbiased tool to connect genotype and phenotype.
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Torgerson TR, Ochs HD. Immune dysregulation, polyendocrinopathy, enteropathy, X-linked: forkhead box protein 3 mutations and lack of regulatory T cells. J Allergy Clin Immunol 2007; 120:744-50; quiz 751-2. [PMID: 17931557 DOI: 10.1016/j.jaci.2007.08.044] [Citation(s) in RCA: 228] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2007] [Revised: 08/28/2007] [Accepted: 08/29/2007] [Indexed: 12/31/2022]
Abstract
The rare X-linked disorder immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) and its murine counterpart scurfy have provided important new insights into the essential role of regulatory T cells (Treg) in maintaining tolerance to self-antigens. Mutations of the FOXP3 gene, identified in patients with IPEX, have helped pinpoint key structural domains of the protein that are essential for its function as a transcriptional regulator. Ongoing work using these and associated models has begun to elucidate factors important for the development, function, and competitive fitness of Treg. This improved understanding is beginning to lead to the identification of other defects that may be present in patients who have the clinical phenotype of IPEX but only wild-type FOXP3. It has also led to improved treatment options for IPEX including immunosuppressive drugs and bone marrow transplantation. We are hopeful that the knowledge gained about mechanisms that regulate FOXP3 expression and Treg function will have a major effect on how other autoimmune and allergic disorders are approached.
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Affiliation(s)
- Troy R Torgerson
- Department of Pediatrics, University of Washington School of Medicine and Children's Hospital and Regional Medical Center, Seattle, Wash., USA.
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35
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Wang J, Lu C, Min D, Wang Z, Ma X. A mutation in the 5' untranslated region of the BRCA1 gene in sporadic breast cancer causes downregulation of translation efficiency. J Int Med Res 2007; 35:564-73. [PMID: 17697535 DOI: 10.1177/147323000703500417] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We screened 117 breast tumour samples in Chinese females for mutations in the breast cancer 1 (BRCA1) gene and identified a novel mutation in the 5' untranslated region (5' UTR) in two patients with grade III infiltrating ductal breast carcinoma. We examined whether this 5' UTR mutation affected the translational efficiency of BRCA1 protein. A vector was constructed containing the mutated 5' UTR up-stream of luciferase and we compared its translational efficiency with a wild-type 5' UTR. The expression of BRCA1 protein in breast tumour samples was evaluated using immunohistochemistry. The mutated 5' UTR of BRCA1 resulted in less luciferase activity compared with the wild-type 5' UTR, while there were no significant differences in luciferase mRNA levels. BRCA1 protein was much less expressed in breast tumour tissue from patients with the 5' UTR mutation than in samples from patients without the mutation. Our results show that a mutation in the 5' UTR of the BRCA1 gene downregulates translational efficiency of the protein.
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Affiliation(s)
- J Wang
- Department of Genetics, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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36
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Ochs HD, Gambineri E, Torgerson TR. IPEX, FOXP3 and regulatory T-cells: a model for autoimmunity. Immunol Res 2007; 38:112-21. [DOI: 10.1007/s12026-007-0022-2] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 01/16/2023]
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37
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McGinness JL, Bivens MMC, Greer KE, Patterson JW, Saulsbury FT. Immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX) associated with pemphigoid nodularis: a case report and review of the literature. J Am Acad Dermatol 2006; 55:143-8. [PMID: 16781310 DOI: 10.1016/j.jaad.2005.08.047] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2005] [Revised: 08/23/2005] [Accepted: 08/23/2005] [Indexed: 10/24/2022]
Abstract
The immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX) is a rare disorder caused by mutations of the FOXP3 gene. The FOXP3 gene encodes a DNA-binding protein of the forkhead/winged-helix family and is the central controller of the development of CD4+CD25+ regulatory T cells. CD4+CD25+ regulatory T cells help prevent autoimmune disease; a deficiency of these cells causes increased immunologic reactivity and autoimmunity. We describe a 14-year-old boy with IPEX syndrome confirmed by mutation analysis of the FOXP3 gene. The patient had chronic dermatitis and later developed bullous pemphigoid. He subsequently formed diffuse prurigo nodularis-like lesions resistant to multiple topical and systemic immunosuppressive medications. These lesions were confirmed by biopsy, direct immunofluorescence, and enzyme-linked immunosorbent assay of the 180 kd bullous pemphigoid antigen to be pemphigoid nodularis. He recently responded to rituximab, allowing discontinuation of his oral prednisone.
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Affiliation(s)
- Jamie L McGinness
- Department of Dermatology, University of Virginia, Charlottesville, VA 22908, USA
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38
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Michaëlsson J, Mold JE, McCune JM, Nixon DF. Regulation of T cell responses in the developing human fetus. THE JOURNAL OF IMMUNOLOGY 2006; 176:5741-8. [PMID: 16670279 DOI: 10.4049/jimmunol.176.10.5741] [Citation(s) in RCA: 196] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Although human T cells enter the peripheral lymphoid tissues early during fetal development, the adaptive immune system in the fetus has largely been regarded as functionally immature and unresponsive to stimulation. In this study, we show that depletion of fetal CD4+CD25(high) T regulatory (T(Reg)) cells, which are present at high frequency in fetal lymphoid tissues, results in vigorous T cell proliferation and cytokine production in vitro, even in the absence of exogenous stimulation. Analysis of CD4+ and CD8(+) T cell populations revealed a large subset of cells that expressed the early activation Ag, CD69. We show that this population represents a subset of highly reactive fetal T cells actively suppressed by fetal CD4+CD25(high) T(Reg) cells during development. These findings indicate that fetal T cells are, in the absence of CD4+CD25(high) T(Reg) cells, highly responsive to stimulation and provide evidence for an important role for CD4+CD25(high) T(Reg) cells in controlling T cell responses in utero.
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Affiliation(s)
- Jakob Michaëlsson
- Gladstone Institute of Virology and Immunology, University of California-San Francisco, 1001 Potrero Avenue, San Francisco, CA 94158, USA
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39
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Mantel PY, Ouaked N, Rückert B, Karagiannidis C, Welz R, Blaser K, Schmidt-Weber CB. Molecular mechanisms underlying FOXP3 induction in human T cells. THE JOURNAL OF IMMUNOLOGY 2006; 176:3593-602. [PMID: 16517728 DOI: 10.4049/jimmunol.176.6.3593] [Citation(s) in RCA: 319] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
FOXP3 is playing an essential role for T regulatory cells and is involved in the molecular mechanisms controlling immune tolerance. Although the biological relevance of this transcription factor is well documented, the pathways responsible for its induction are still unclear. The current study reveals structure and function of the human FOXP3 promoter, revealing essential molecular mechanisms of its induction. The FOXP3 promoter was defined by RACE, cloned, and functionally analyzed using reporter-gene constructs in primary human T cells. The analysis revealed the basal, T cell-specific promoter with a TATA and CAAT box 6000 bp upstream the translation start site. The basal promoter contains six NF-AT and AP-1 binding sites, which are positively regulating the trans activation of the FOXP3 promoter after triggering of the TCR. The chromatin region containing the FOXP3 promoter was bound by NF-ATc2 under these conditions. Furthermore, FOXP3 expression was observed following TCR engagement. Promoter activity, mRNA, and protein expression of T cells were suppressed by addition of cyclosporin A. Taken together, this study reveals the structure of the human FOXP3 promoter and provides new insights in mechanisms of addressing T regulatory cell-inducing signals useful for promoting immune tolerance. Furthermore, the study identifies essential, positive regulators of the FOXP3 gene and highlights cyclosporin A as an inhibitor of FOXP3 expression contrasting other immunosuppressants such as steroids or rapamycin.
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Affiliation(s)
- Pierre-Yves Mantel
- Swiss Institute of Allergy and Asthma Research, Obere Str. 22, CH-7270 Davos, Switzerland
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40
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Stroud JC, Wu Y, Bates DL, Han A, Nowick K, Paabo S, Tong H, Chen L. Structure of the Forkhead Domain of FOXP2 Bound to DNA. Structure 2006; 14:159-66. [PMID: 16407075 DOI: 10.1016/j.str.2005.10.005] [Citation(s) in RCA: 153] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2005] [Revised: 09/27/2005] [Accepted: 10/04/2005] [Indexed: 11/24/2022]
Abstract
FOXP (FOXP1-4) is a newly defined subfamily of the forkhead box (FOX) transcription factors. A mutation in the FOXP2 forkhead domain cosegregates with a severe speech disorder, whereas several mutations in the FOXP3 forkhead domain are linked to the IPEX syndrome in human and a similar autoimmune phenotype in mice. Here we report a 1.9 A crystal structure of the forkhead domain of human FOXP2 bound to DNA. This structure allows us to revise the previously proposed DNA recognition mechanism and provide a unifying model of DNA binding for the FOX family of proteins. Our studies also reveal that the FOXP2 forkhead domain can form a domain-swapped dimer, made possible by a strategic substitution of a highly conserved proline in conventional FOX proteins with alanine in the P subfamily. Disease-causing mutations in FOXP2 and FOXP3 map either to the DNA binding surface or the domain-swapping dimer interface, functionally corroborating the crystal structure.
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Affiliation(s)
- James C Stroud
- Department of Chemistry and Biochemistry, University of Colorado at Boulder, Colorado 80309, USA
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41
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Abstract
Far from being mutually exclusive, immunodeficiency and autoimmunity may occur simultaneously. During the last years, analysis of Autoimmune Polyendocrinopathy--Candidiasis--Ectodermal Dystrophy (APECED) and Immunodysregulation--Polyendocrinopathy--Enteropathy--X-linked (IPEX), two rare monogenic forms of immunodeficiency associated with autoimmunity, has led to the identification of Auto Immune Regulator (AIRE) and Forkhead Box P3 (FOXP3), essential transcriptional regulators, involved in central tolerance and peripheral immune homeostasis, respectively. Characterization of the molecular and cellular mechanisms involved in APECED, and recognition that AIRE expression is sustained by effective thymopoiesis, has recently allowed to define that the autoimmunity of Omenn syndrome, a combined immunodeficiency due to defects of V(D)J recombination, also results from defective expression of AIRE. The implications of identification of the basis of autoimmunity in these rare forms of immunodeficiency have important implications for a better understanding of more common autoimmune disorders, and for development of novel therapeutic approaches.
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Affiliation(s)
- Luigi D Notarangelo
- Angelo Nocivelli Institute for Molecular Medicine, Department of Pediatrics, University of Brescia, Brescia, Italy
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42
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Abstract
This article covers some unusual or rare causes of diabetes mellitus chosen not necessarily on the basis of frequency or rarity, but rather on the basis of how well the disease and its implications in diabetes management is understood. A specific diagnosis is of help in these rare syndromes but not absolutely necessary for optimal management. The basic principles of diabetes management are well-defined, regardless of etiology. What is important is to understand the relative contribution of insulin resistance versus insulin deficiency, regardless of etiology, as the most important guide to management.
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Affiliation(s)
- Meranda Nakhla
- Department of Pediatrics, Division of Pediatric Endocrinology, McGill University Health Center, Montreal Children's Hospital, 2300 Tupper, Suite C-244, Montréal, Québec H3H 1P3, Canada
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43
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Abstract
The study of a rare human X-linked disease resulting in a characteristic clinical phenotype of multiple autoimmune disorders and the in-depth exploration of a spontaneous mouse model, scurfy (sf), have contributed to a better understanding of the regulation of immunologic responses, particularly to self. Forkhead box P3 (FOXP3), the gene responsible for IPEX (immune dysregulation, polyendocrinopathy, enteropathy, X-linked) and sf is located on the X chromosome and is of crucial importance for the generation of CD4+ CD25+ regulatory T cells. Loss of FOXP3 function and the resultant lack of regulatory T cells result in lethal auto-aggressive lymphoproliferation, whereas overexpression of this modulator results in severe immunodeficiency. The in-depth analysis of FOXP3 regulation and elucidation of the precise mechanisms by which FOXP3 exerts its regulatory effect will provide important insights into the understanding of autoimmunity and should predictably result in new therapeutic possibilities.
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Affiliation(s)
- Hans D Ochs
- University of Washington and Children's Hospital Regional Medical Center, Seattle, WA, USA.
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44
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Cupedo T, Nagasawa M, Weijer K, Blom B, Spits H. Development and activation of regulatory T cells in the human fetus. Eur J Immunol 2005; 35:383-90. [PMID: 15682453 DOI: 10.1002/eji.200425763] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
There is an increasing amount of knowledge on the functional properties of regulatory T cells (Treg) in the adult immune system, but data on the generation and function of these cells during human embryonic development are scarce. In this study, we show that in the fetal thymus, double-positive cells initiate expression of CD25, GITR, CTLA4 and CD122 during their transition from the CD27- to the CD27+ stage. Moreover, CD4+CD25+ fetal thymocytes already have the potential to suppress proliferation of CD25- cells. After leaving the thymus, FoxP3+CD4+CD25+ Treg enter the fetal lymph nodes and spleen, where they acquire a primed/memory phenotype. A model is proposed for the development of human fetal Treg that encompasses two sequential maturation steps: initiation of a regulatory phenotype and suppressive activity in the thymus; and subsequent activation within the peripheral lymphoid organs. Upon activation, FoxP3+CD4+CD25+ Treg suppress potentially deleterious responses by autoreactive lymphocytes and maintain homeostasis within the developing fetus.
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Affiliation(s)
- Tom Cupedo
- Department of Cell Biology and Histology, Academic Medical Center of the University of Amsterdam, Amsterdam, The Netherlands
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45
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Abstract
PURPOSE OF REVIEW Enteropathies causing temporary or permanent intestinal failure are a big diagnostic and therapeutic challenge for pediatric gastroenterologists. A now well-recognized and distinct entity is in the form of "autoimmune enteropathy (AIE)". Recent advances in the molecular workup of AIE gave first insight into the pathophysiology of AIE. In this review, we discuss new molecular concepts of AIE resulting in new diagnostic and therapeutic possibilities. RECENT FINDINGS The identification of disease-causing mutations in the FOXP3 gene as a basic defect resulting in AIE points to a defect in regulatory T-cell homeostasis. FOXP3, primarily expressed by CD4+CD25+regulatory T cells, is a potent transcriptional suppressor and key modulator of T-cell functions. Nonfunctional FOXP3 leads to a tremendous hyperactivation of T cells, resulting in autoimmune aggression, such as seen in patients with immune dysregulation, polyendocrinopathy autoimmune enteropathy X-linked (IPEX) syndrome, a subgroup of AIE. There is recent evidence suggesting that a defect of regulatory factors other than FOXP3 might cause AIE. Anti-enterocyte autoantibodies, another main characteristic of AIE, seem to be of a secondary nature and can no more be considered as directly disease causing. SUMMARY Based on the profound immune dysregulation, new treatment strategies emerged for AIE. The use of T-cell immunosuppressive drugs, such as tacrolimus combined to steroids, seems to be beneficial in some patients; however, long-term remission is not always possible. Bone marrow transplantation might be the treatment of choice in those patients who do not respond to immunosuppression; however, the first encouraging results remain to be confirmed since to date long-term outcome remains mixed.
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Affiliation(s)
- Frank M Ruemmele
- Pediatric Gastroenterology Unit, Department of Pediatrics, Necker-Enfants Malades Hospital, Paris, Université René Descartes, Paris V, France.
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46
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Gambineri E, Torgerson TR, Ochs HD. Immune dysregulation, polyendocrinopathy, enteropathy, and X-linked inheritance (IPEX), a syndrome of systemic autoimmunity caused by mutations of FOXP3, a critical regulator of T-cell homeostasis. Curr Opin Rheumatol 2003; 15:430-5. [PMID: 12819471 DOI: 10.1097/00002281-200307000-00010] [Citation(s) in RCA: 414] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Immune dysregulation, polyendocrinopathy, enteropathy, and X-linked inheritance (IPEX) is one of a group of clinical syndromes that present with multisystem autoimmune disease suggesting a phenotype of immune dysregulation. Clinically, IPEX manifests most commonly with diarrhea, insulin-dependent diabetes mellitus, thyroid disorders, and eczema. FOXP3, the gene responsible for IPEX, maps to chromosome Xp11.23-Xq13.3 and encodes a putative DNA-binding protein of the forkhead family. Recent data indicate that FOXP3 is expressed primarily in the CD4+CD25+ regulatory T-cell subset, where it may function as a transcriptional repressor and key modulator of regulatory T-cell fate and function. This review describes the clinical features of IPEX and the structure, function, and known mutations of FOXP3 that provide important insights into its role in maintenance of immune homeostasis.
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Affiliation(s)
- Eleonora Gambineri
- Department of Pediatrics, Division of Immunology, Rheumatology and Infectious Diseases, University of Washington, Seattle, Washington, USA, and Department of Pediatrics, A. Meyer Children's Hospital, University of Florence, Florence, Italy
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47
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Torgerson TR, Ochs HD. Immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome: a model of immune dysregulation. Curr Opin Allergy Clin Immunol 2002; 2:481-7. [PMID: 14752330 DOI: 10.1097/00130832-200212000-00002] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome is a fatal syndrome of overwhelming autoimmunity. Recent identification of FOXP3 as the causative gene and realization that this same gene defect occurs in the mutant mouse Scurfy has yielded new insights and hopes of unraveling the mechanism of autoimmunity in this and possibly other diseases. In this review, we describe the clinical features of immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome/Scurfy and compare this phenotype with similar syndromes caused by other single gene mutations. We examine therapeutic options to treat the syndrome, study its immunologic basis, and investigate the structure and function of the FOXP3 protein. RECENT FINDINGS The Scurfy mutant mouse has a characteristic phenotype that causes death by approximately 3 weeks of age. It is known that the effector cells in the Scurfy mouse are CD4+ T cells and that a population of normal T cells can control the overwhelming autoimmunity that they induce. Recent data have demonstrated that this process requires antigenic stimulation and that the degree to which the immune system responds is inversely proportional to the level of FOXP3 protein (Forkhead box P3) expression in peripheral T cells. Suppression of immune activation by FOXP3 may occur due to its ability to bind to DNA through a putative forkhead DNA-binding motif and to repress transcriptional activation from certain promoters in T cells. SUMMARY Because of the dramatic phenotype and rapidity of onset, immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome and Scurfy provide a powerful model in which to study mechanisms of T cell regulation. A more complete understanding of this syndrome will provide important insights into mechanisms of immune suppression, tolerance, and autoimmunity.
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Affiliation(s)
- Troy R Torgerson
- Department of Pediatrics, University of Washington School of Medicine and Children's Hospital Regional Medical Center, Seattle, 98195, USA
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48
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Wildin RS, Smyk-Pearson S, Filipovich AH. Clinical and molecular features of the immunodysregulation, polyendocrinopathy, enteropathy, X linked (IPEX) syndrome. J Med Genet 2002; 39:537-45. [PMID: 12161590 PMCID: PMC1735203 DOI: 10.1136/jmg.39.8.537] [Citation(s) in RCA: 509] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Immunodysregulation, polyendocrinopathy, enteropathy, X linked (IPEX, OMIM 304790) is a rare, recessive disorder resulting in aggressive autoimmunity and early death. Mutations in FOXP3 have been identified in 13 of 14 patients tested. Research in the mouse model, scurfy, suggests that autoimmunity may stem from a lack of working regulatory T cells. We review published reports regarding the genetics, clinical features, immunology, pathology, and treatment of IPEX. We also report three new patients who were treated with long term immunosuppression, followed by bone marrow transplantation in two. IPEX can be differentiated from other genetic immune disorders by its genetics, clinical presentation, characteristic pattern of pathology, and, except for high IgE, absence of substantial laboratory evidence of immunodeficiency. While chronic treatment with immunosuppressive drugs may provide temporary benefit for some patients, it does not cause complete remission. Remission has been observed with bone marrow transplantation despite incomplete engraftment, but the long term outcome is uncertain.
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MESH Headings
- Adolescent
- Animals
- Autoimmune Diseases/diagnosis
- Autoimmune Diseases/genetics
- Autoimmune Diseases/radiotherapy
- Autoimmune Diseases/therapy
- Child
- Child, Preschool
- Diabetes Mellitus, Type 1/diagnosis
- Diabetes Mellitus, Type 1/genetics
- Diabetes Mellitus, Type 1/radiotherapy
- Diabetes Mellitus, Type 1/therapy
- Diagnosis, Differential
- Disease Models, Animal
- Humans
- Lymphoproliferative Disorders/diagnosis
- Lymphoproliferative Disorders/genetics
- Lymphoproliferative Disorders/radiotherapy
- Lymphoproliferative Disorders/therapy
- Male
- Polyendocrinopathies, Autoimmune/diagnosis
- Polyendocrinopathies, Autoimmune/genetics
- Polyendocrinopathies, Autoimmune/radiotherapy
- Polyendocrinopathies, Autoimmune/therapy
- Protein-Losing Enteropathies/genetics
- Protein-Losing Enteropathies/immunology
- Protein-Losing Enteropathies/radiotherapy
- Protein-Losing Enteropathies/therapy
- Syndrome
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Affiliation(s)
- R S Wildin
- Department of Molecular and Medical Genetics, Oregon Health Sciences University, Mailcode MP350, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA.
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Bennett CL, Ochs HD. IPEX is a unique X-linked syndrome characterized by immune dysfunction, polyendocrinopathy, enteropathy, and a variety of autoimmune phenomena. Curr Opin Pediatr 2001; 13:533-8. [PMID: 11753102 DOI: 10.1097/00008480-200112000-00007] [Citation(s) in RCA: 158] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The rare syndrome known as IPEX (OMIM: 304930) is characterized by immune-dysfunction, polyendocrinopathy, enteropathy, and X-linked inheritance. The gene responsible for IPEX maps to Xp11.23-q13.3, a region of the X chromosome that also harbors the Wiskott-Aldrich syndrome gene ( WASP ). IPEX syndrome results from mutations of a unique DNA binding protein gene, FOXP3. Mutations invariably impair the seemingly essential forkhead domain of the protein, which is uniquely located in the carboxyl terminus, affecting protein function. In this review, we describe the identification of IPEX as a unique X-linked syndrome, the clinical features of IPEX, mutations of the immune-specific FOXP3 DNA binding protein, and bone marrow transplantation as a potential cure for the syndrome, which is usually lethal within the first year of life in affected males.
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Affiliation(s)
- C L Bennett
- Division of Genetics and Development, University of Washington, Seattle, Washington 98195, USA.
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