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Petley E, Yule A, Alexander S, Ojha S, Whitehouse WP. The natural history of ataxia-telangiectasia (A-T): A systematic review. PLoS One 2022; 17:e0264177. [PMID: 35290391 PMCID: PMC9049793 DOI: 10.1371/journal.pone.0264177] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 02/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ataxia-telangiectasia is an autosomal recessive, multi-system, and life-shortening disease caused by mutations in the ataxia-telangiectasia mutated gene. Although widely reported, there are no studies that give a comprehensive picture of this intriguing condition. OBJECTIVES Understand the natural history of ataxia-telangiectasia (A-T), as reported in scientific literature. SEARCH METHODS 107 search terms were identified and divided into 17 searches. Each search was performed in PubMed, Ovid SP (MEDLINE) 1946-present, OVID EMBASE 1980 -present, Web of Science core collection, Elsevier Scopus, and Cochrane Library. SELECTION CRITERIA All human studies that report any aspect of A-T. DATA COLLECTION AND ANALYSIS Search results were de-duplicated, data extracted (including author, publication year, country of origin, study design, population, participant characteristics, and clinical features). Quality of case-control and cohort studies was assessed by the Newcastle-Ottawa tool. Findings are reported descriptively and where possible data collated to report median (interquartile range, range) of outcomes of interest. MAIN RESULTS 1314 cases reported 2134 presenting symptoms. The most common presenting symptom was abnormal gait (1160 cases; 188 studies) followed by recurrent infections in classical ataxia-telangiectasia and movement disorders in variant ataxia-telangiectasia. 687 cases reported 752 causes of death among which malignancy was the most frequently reported cause. Median (IQR, range) age of death (n = 294) was 14 years 0 months (10 years 0 months to 23 years 3 months, 1 year 3 months to 76 years 0 months). CONCLUSIONS This review demonstrates the multi-system involvement in A-T, confirms that neurological symptoms are the most frequent presenting features in classical A-T but variants have diverse manifestations. We found that most individuals with A-T have life limited to teenage or early adulthood. Predominance of case reports, and case series demonstrate the lack of robust evidence to determine the natural history of A-T. We recommend population-based studies to fill this evidence gap.
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Affiliation(s)
- Emily Petley
- School of Medicine, University of Nottingham, Nottingham, United
Kingdom
| | - Alexander Yule
- United Lincolnshire Hospitals NHS Trust, Lincoln, United
Kingdom
| | - Shaun Alexander
- School of Medicine, University of Nottingham, Nottingham, United
Kingdom
| | - Shalini Ojha
- School of Medicine, University of Nottingham, Nottingham, United
Kingdom
- Children’s Hospital, University Hospitals of Derby and Burton, NHS
Foundation Trust, Derby, United Kingdom
| | - William P. Whitehouse
- School of Medicine, University of Nottingham, Nottingham, United
Kingdom
- Nottingham Children’s Hospital, Nottingham University Hospital NHS Trust,
Nottingham, United Kingdom
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Taylor AMR, Rothblum-Oviatt C, Ellis NA, Hickson ID, Meyer S, Crawford TO, Smogorzewska A, Pietrucha B, Weemaes C, Stewart GS. Chromosome instability syndromes. Nat Rev Dis Primers 2019; 5:64. [PMID: 31537806 PMCID: PMC10617425 DOI: 10.1038/s41572-019-0113-0] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2019] [Indexed: 01/28/2023]
Abstract
Fanconi anaemia (FA), ataxia telangiectasia (A-T), Nijmegen breakage syndrome (NBS) and Bloom syndrome (BS) are clinically distinct, chromosome instability (or breakage) disorders. Each disorder has its own pattern of chromosomal damage, with cells from these patients being hypersensitive to particular genotoxic drugs, indicating that the underlying defect in each case is likely to be different. In addition, each syndrome shows a predisposition to cancer. Study of the molecular and genetic basis of these disorders has revealed mechanisms of recognition and repair of DNA double-strand breaks, DNA interstrand crosslinks and DNA damage during DNA replication. Specialist clinics for each disorder have provided the concentration of expertise needed to tackle their characteristic clinical problems and improve outcomes. Although some treatments of the consequences of a disorder may be possible, for example, haematopoietic stem cell transplantation in FA and NBS, future early intervention to prevent complications of disease will depend on a greater understanding of the roles of the affected DNA repair pathways in development. An important realization has been the predisposition to cancer in carriers of some of these gene mutations.
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Affiliation(s)
- A Malcolm R Taylor
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK.
| | | | - Nathan A Ellis
- The University of Arizona Cancer Center, Tucson, AZ, USA
| | - Ian D Hickson
- Center for Chromosome Stability, Department of Cellular and Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Stefan Meyer
- Stem Cell and Leukaemia Proteomics Laboratory, and Paediatric and Adolescent Oncology, Institute of Cancer Sciences, University of Manchester, Manchester, UK
- Department of Paediatric and Adolescent Haematology and Oncology, Royal Manchester Children's Hospital and The Christie NHS Trust, Manchester, UK
| | - Thomas O Crawford
- Department of Neurology and Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Agata Smogorzewska
- Laboratory of Genome Maintenance, Rockefeller University, New York, NY, USA
| | - Barbara Pietrucha
- Department of Immunology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Corry Weemaes
- Department of Pediatrics (Pediatric Immunology), Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Grant S Stewart
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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Doshi A, Ryu J, Thornburg CD, Hershey D, Cherry R, Milligan K, Rosenzweig S, Leonard S. Ataxia telangiectasia presenting as hyper IgM syndrome without neurologic signs. Ann Allergy Asthma Immunol 2017; 117:221-6. [PMID: 27613453 DOI: 10.1016/j.anai.2016.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 07/15/2016] [Accepted: 07/19/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Ashmi Doshi
- Division of Allergy, Immunology, and Rheumatology, University of California, San Diego, Rady Children's Hospital, San Diego, California.
| | - Julie Ryu
- Division of Pulmonary Medicine, University of California, San Diego, Rady Children's Hospital, San Diego, California
| | - Courtney D Thornburg
- Division of Hematology and Oncology, University of California, San Diego, Rady Children's Hospital, San Diego, California
| | - Dan Hershey
- Division of Hospital Medicine, University of California, San Diego, Rady Children's Hospital, San Diego, California
| | - Rebecca Cherry
- Division of Gastroenterology Hepatology and Nutrition, University of California, San Diego, Rady Children's Hospital, San Diego, California
| | - Ki Milligan
- National Institutes of Health Primary Immunodeficiency Clinic, National Institute of Health, Bethesda, Maryland
| | - Sergio Rosenzweig
- National Institutes of Health Primary Immunodeficiency Clinic, National Institute of Health, Bethesda, Maryland
| | - Stephanie Leonard
- Division of Allergy, Immunology, and Rheumatology, University of California, San Diego, Rady Children's Hospital, San Diego, California
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Shiloh Y, Lederman HM. Ataxia-telangiectasia (A-T): An emerging dimension of premature ageing. Ageing Res Rev 2017; 33:76-88. [PMID: 27181190 DOI: 10.1016/j.arr.2016.05.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/02/2016] [Accepted: 05/10/2016] [Indexed: 12/28/2022]
Abstract
A-T is a prototype genome instability syndrome and a multifaceted disease. A-T leads to neurodegeneration - primarily cerebellar atrophy, immunodeficiency, oculocutaneous telangiectasia (dilated blood vessels), vestigial thymus and gonads, endocrine abnormalities, cancer predisposition and varying sensitivity to DNA damaging agents, particularly those that induce DNA double-strand breaks. With the recent increase in life expectancy of A-T patients, the premature ageing component of this disease is gaining greater awareness. The complex A-T phenotype reflects the ever growing number of functions assigned to the protein encoded by the responsible gene - the homeostatic protein kinase, ATM. The quest to thoroughly understand the complex A-T phenotype may reveal yet elusive ATM functions.
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Rothblum-Oviatt C, Wright J, Lefton-Greif MA, McGrath-Morrow SA, Crawford TO, Lederman HM. Ataxia telangiectasia: a review. Orphanet J Rare Dis 2016; 11:159. [PMID: 27884168 PMCID: PMC5123280 DOI: 10.1186/s13023-016-0543-7] [Citation(s) in RCA: 346] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 11/16/2016] [Indexed: 12/15/2022] Open
Abstract
DEFINITION OF THE DISEASE Ataxia telangiectasia (A-T) is an autosomal recessive disorder primarily characterized by cerebellar degeneration, telangiectasia, immunodeficiency, cancer susceptibility and radiation sensitivity. A-T is often referred to as a genome instability or DNA damage response syndrome. EPIDEMIOLOGY The world-wide prevalence of A-T is estimated to be between 1 in 40,000 and 1 in 100,000 live births. CLINICAL DESCRIPTION A-T is a complex disorder with substantial variability in the severity of features between affected individuals, and at different ages. Neurological symptoms most often first appear in early childhood when children begin to sit or walk. They have immunological abnormalities including immunoglobulin and antibody deficiencies and lymphopenia. People with A-T have an increased predisposition for cancers, particularly of lymphoid origin. Pulmonary disease and problems with feeding, swallowing and nutrition are common, and there also may be dermatological and endocrine manifestations. ETIOLOGY A-T is caused by mutations in the ATM (Ataxia Telangiectasia, Mutated) gene which encodes a protein of the same name. The primary role of the ATM protein is coordination of cellular signaling pathways in response to DNA double strand breaks, oxidative stress and other genotoxic stress. DIAGNOSIS The diagnosis of A-T is usually suspected by the combination of neurologic clinical features (ataxia, abnormal control of eye movement, and postural instability) with one or more of the following which may vary in their appearance: telangiectasia, frequent sinopulmonary infections and specific laboratory abnormalities (e.g. IgA deficiency, lymphopenia especially affecting T lymphocytes and increased alpha-fetoprotein levels). Because certain neurological features may arise later, a diagnosis of A-T should be carefully considered for any ataxic child with an otherwise elusive diagnosis. A diagnosis of A-T can be confirmed by the finding of an absence or deficiency of the ATM protein or its kinase activity in cultured cell lines, and/or identification of the pathological mutations in the ATM gene. DIFFERENTIAL DIAGNOSIS There are several other neurologic and rare disorders that physicians must consider when diagnosing A-T and that can be confused with A-T. Differentiation of these various disorders is often possible with clinical features and selected laboratory tests, including gene sequencing. ANTENATAL DIAGNOSIS Antenatal diagnosis can be performed if the pathological ATM mutations in that family have been identified in an affected child. In the absence of identifying mutations, antenatal diagnosis can be made by haplotype analysis if an unambiguous diagnosis of the affected child has been made through clinical and laboratory findings and/or ATM protein analysis. GENETIC COUNSELING Genetic counseling can help family members of a patient with A-T understand when genetic testing for A-T is feasible, and how the test results should be interpreted. MANAGEMENT AND PROGNOSIS Treatment of the neurologic problems associated with A-T is symptomatic and supportive, as there are no treatments known to slow or stop the neurodegeneration. However, other manifestations of A-T, e.g. immunodeficiency, pulmonary disease, failure to thrive and diabetes can be treated effectively.
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Affiliation(s)
| | - Jennifer Wright
- The Ataxia Telangiectasia Clinical Center, Johns Hopkins Medical Institutions, Baltimore, Maryland USA
| | - Maureen A. Lefton-Greif
- The Ataxia Telangiectasia Clinical Center, Departments of Pediatrics and Pediatric Respiratory Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland USA
| | - Sharon A. McGrath-Morrow
- The Ataxia Telangiectasia Clinical Center, Departments of Pediatrics and Pediatric Respiratory Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland USA
| | - Thomas O. Crawford
- The Ataxia Telangiectasia Clinical Center, Departments of Pediatrics and Neurology, Johns Hopkins Medical Institutions, Baltimore, Maryland USA
| | - Howard M. Lederman
- The Ataxia Telangiectasia Clinical Center, Departments of Pediatrics, Medicine and Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland USA
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Karafin MS, Humphrey RL, Detrick B. Evaluation of monoclonal and oligoclonal gammopathies in a pediatric population in a major urban center. Am J Clin Pathol 2014; 141:482-7. [PMID: 24619747 DOI: 10.1309/ajcp2jbdeelpa7ht] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES A growing body of literature has documented monoclonal proteins in children. Little is known about their associated diagnoses. METHODS We retrospectively evaluated all patients (aged 0-21 years) with abnormal findings on serum immunofixation electrophoresis (SIFE) from 2005 to 2011. We also documented the monoclonal immunoglobulin classes and light chain types involved and then correlated these data with the clinical diagnoses. RESULTS A total of 695 SIFE tests were performed on this patient population. Of these, 95 SIFE tests (14%) identified a gammopathy (from 83 different patients), and of these, 74 (11%) demonstrated only a monoclonal gammopathy (from 63 different patients). The most common associated diagnosis in the study interval was ataxia-telangiectasia (22%). No patient in the study population was diagnosed with multiple myeloma or Waldenström macroglobulinemia. CONCLUSIONS The significance and presence of a monoclonal or oligoclonal gammopathy in pediatric and young adult populations is distinct from that seen in adults.
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Affiliation(s)
- Matthew S. Karafin
- Medical Sciences Institute, Blood Center of Wisconsin, Milwaukee
- Division of Immunology, Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD
| | - Richard L. Humphrey
- Division of Immunology, Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD
| | - Barbara Detrick
- Division of Immunology, Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD
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Davies EG. Update on the management of the immunodeficiency in ataxia-telangiectasia. Expert Rev Clin Immunol 2014; 5:565-75. [DOI: 10.1586/eci.09.35] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Leiding JW, Holland SM. Warts and all: human papillomavirus in primary immunodeficiencies. J Allergy Clin Immunol 2012; 130:1030-48. [PMID: 23036745 DOI: 10.1016/j.jaci.2012.07.049] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Revised: 06/06/2012] [Accepted: 07/25/2012] [Indexed: 01/19/2023]
Abstract
Infection with human papillomavirus (HPV) is almost universal and eventually asymptomatic, but pathologic infection with HPV is severe, recurrent, and recalcitrant to therapy. It is also an underappreciated manifestation of primary immunodeficiency. Mutations in EVER1, EVER2, GATA2, CXCR4, and dedicator of cytokinesis 8 (DOCK8) are typically associated with extensive HPV infections, whereas several other primary immune defects result in severe HPV much less frequently. We review immunodeficiencies with severe HPV infections and the mechanisms underlying them.
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Affiliation(s)
- Jennifer W Leiding
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892-1684, USA.
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Borte S, Janzi M, Pan-Hammarström Q, von Döbeln U, Nordvall L, Winiarski J, Fasth A, Hammarström L. Placental transfer of maternally-derived IgA precludes the use of guthrie card eluates as a screening tool for primary immunodeficiency diseases. PLoS One 2012; 7:e43419. [PMID: 22916257 PMCID: PMC3420892 DOI: 10.1371/journal.pone.0043419] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 07/20/2012] [Indexed: 11/19/2022] Open
Abstract
There is a need for neonatal screening tools to improve the long-term clinical outcome of patients with primary immunodeficiency diseases (PID). Recently, a PCR-based screening method for both TRECs and KRECs using Guthrie card samples has been developed. However, the applicability of these excision circle assays is limited to patients with severe T or B cell lymphopenia (SCID, XLA and A-T), whereas the most common forms of PID are not detected. Absence of serum IgA is seen in a major fraction of patients with immunological defects. As serum IgA in newborns is considered to be of fetal origin, eluates from routinely collected dried blood spot samples might thus be suitable for identification of children with PID. To assess the applicability of such screening assays, stored Guthrie card samples were obtained from 47 patients with various forms of primary immunodeficiency diseases (SCID, XLA, A-T, HIGM and IgAD), 20 individuals with normal serum IgA levels born to IgA-deficient mothers and 51 matched healthy newborns. Surprisingly, normal serum IgA levels were found in all SCID, XLA, A-T and HIGM patients and, additionally, in all those IgAD patients born to IgA-sufficient mothers. Conversely, no serum IgA was found in any of the 16 IgAD patients born by IgA-deficient mothers. Moreover, half of the IgA-sufficient individuals born by IgA-deficient mothers also lacked IgA at birth whereas no IgA-deficient individuals were found among the controls. IgA in neonatal dried blood samples thus appears to be of both maternal and fetal origin and precludes its use as a reliable marker for neonatal screening of primary immunodeficiency diseases.
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Affiliation(s)
- Stephan Borte
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
- Translational Centre for Regenerative Medicine (TRM), University of Leipzig, Leipzig, Germany
- ImmunoDeficiencyCenter Leipzig (IDCL) at Hospital St. Georg gGmbH Leipzig, Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies Leipzig, Leipzig, Germany
- * E-mail: (SB); (LH)
| | - Magdalena Janzi
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Qiang Pan-Hammarström
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Ulrika von Döbeln
- Division of Metabolic Diseases, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Lennart Nordvall
- Department of Women’s and Children’s Health, Uppsala University, Academic Hospital, Uppsala, Sweden
| | - Jacek Winiarski
- Division of Pediatrics (CLINTEC), Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Anders Fasth
- Department of Pediatrics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lennart Hammarström
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
- * E-mail: (SB); (LH)
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Carney EF, Srinivasan V, Moss PA, Taylor AM. Classical ataxia telangiectasia patients have a congenitally aged immune system with high expression of CD95. THE JOURNAL OF IMMUNOLOGY 2012; 189:261-8. [PMID: 22649200 DOI: 10.4049/jimmunol.1101909] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ataxia-telangiectasia (A-T) is a rare neurodegenerative immunodeficiency disorder caused by mutations in the ataxia telangiectasia mutated gene. Patients commonly have lymphopenia and Ig-production abnormalities. We used multicolor flow cytometry and IL-7 ELISA to investigate the effect of A-T and age on the proportions of major lymphocyte subsets and their pattern of CD95 expression in relation to IL-7 levels in 15 classical A-T patients. We also analyzed the sensitivity of T cells from four classical A-T patients to CD95-mediated apoptosis using TUNEL and caspase-activation assays. Our results confirmed lymphopenia and a deficiency in naive T and B cells in A-T patients. In contrast to controls, the proportions of naive and memory T and B cell subsets in A-T patients did not vary in relation to age. There was no evidence of a deficiency in plasma IL-7 or IL-7R expression, and IL-7 concentration correlated positively with CD95 expression on CD4(+) T cells. CD95 expression on unstimulated A-T lymphocytes was high, and the apoptotic sensitivity of activated naive and central memory T cells was increased. These findings show that the immunodeficiency in A-T patients may be described as congenitally aged and is not progressive. The naive cell deficiency is not related to a deficiency in IL-7 or its receptor. However, IL-7 may upregulate CD95 on A-T lymphocytes. High CD95 expression and increased apoptotic sensitivity of activated naive and central memory T cells may result in an increased level of CD95-mediated apoptosis, which could contribute to the congenital lymphopenia in A-T.
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Affiliation(s)
- Ellen F Carney
- School of Cancer Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
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Abstract
Significant advances have been made in our understanding of the natural history, pathogenesis, mechanisms of progression and prognosis of monoclonal gammopathy of undetermined significance (MGUS). Although the overall incidence of MGUS progression is 1 per year, it is now possible to more accurately predict the risk of progression based on a new risk-stratification model. However, it is still hard to design chemopreventive trials given that the absolute risk of progression per year is low, even in the high-risk group. Therefore, further improvements in estimating the risk of progression are needed. Roughly 50% of MGUS may originate from primary translocation events at the heavy-chain immunoglobulin locus at chromosome 14q32. In most of the remaining MGUS patients, the initiating event is associated with genomic instability that results in hyperdiploidy of certain odd numbered chromosomes. Cytogenetically distinct subtypes of MGUS may carry significant differences in the risk of progression to malignancy. New markers, such as measures of bone marrow angiogenesis and circulating plasma cells may be additional prognostic factors. A better understanding of the mechanisms underlying the transition of normal plasma cells to the MGUS phenotype, and the transition of MGUS to myeloma or related malignancy, will help identify new risk factors for progression and new targets for chemopreventive interventions.
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Affiliation(s)
- Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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Bott L, Thumerelle C, Cuvellier JC, Deschildre A, Vallée L, Sardet A. [Ataxia-telangiectasia: a review]. Arch Pediatr 2006; 13:293-8. [PMID: 16423518 DOI: 10.1016/j.arcped.2005.11.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2005] [Accepted: 11/23/2005] [Indexed: 01/22/2023]
Abstract
Ataxia-telangiectasia (AT) is an autosomal recessive inherited disease caused by mutational inactivation of the ATM gene. It is a multisystemic disease, characterized by progressive neurological dysfunction, especially in the cerebellum, oculo-cutaneous telangiectasia, immunodeficiency, recurrent sino-pulmonary infections and high incidence of neoplasms. The responsible gene, ATM, encodes a large protein that belongs to a family of protein kinases with a phosphatidylinositol 3-kinase (Pi3K) domain. ATM is a key regulator of cell cycle checkpoints that causes DNA repair or apoptosis. Several studies report ATM function in target cells (such as neurons, fibroblast, endothelium, germ cells, lymphocytes). The pleiotropic phenotypes of AT reflect the multifaceted activities of ATM protein. In nucleus (lymphocytes, fibroblasts, germ cells) ATM is involved in regulation of cell-cycle checkpoints; in cytoplasm ATM regulates redox state (neurons).
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Affiliation(s)
- L Bott
- Service de Pédiatrie, Centre Hospitalier de Lens, France.
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Abstract
The monoclonal gammopathies include multiple myeloma (MM), monoclonal gammopathy of undetermined significance (MGUS), primary systemic amyloidosis (AL), and Waldenström's macroglobulinemia (WM). At Mayo Clinic, almost 60% of patients with a monoclonal gammopathy have MGUS. MGUS is characterized by the presence of a serum monoclonal protein value <3 g/dL, fewer than 10% plasma cells in the bone marrow, no or a small amount of monoclonal protein in the urine, and absence of lytic bone lesions, anemia, hypercalcemia, or renal insufficiency related to the plasma-cell proliferative process. During long-term follow-up of 241 patients with MGUS seen at Mayo Clinic from 1956 to 1970, MM, WM, AL, or a related disorder developed in 64. To confirm the findings, we conducted a population-based study on MGUS in the 11 counties of southeastern Minnesota from 1960 to 1994. The risk of progression to a malignant plasma-cell disorder was 1% per year.
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Affiliation(s)
- Robert A Kyle
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is characterized by the presence of a monoclonal protein (M-protein) without evidence of multiple myeloma (MM), Waldenstrom's macroglobulinemia (WM), amyloidosis (AL), or a related plasma cell proliferative disorder. Agarose gel electrophoresis followed by immunofixation is recommended for recognition of an M-protein. Monoclonal gammopathy of undetermined significance is found in approximately 3% of persons > 70 years of age and in about 1% of those > 50 years old. In a series of 1384 patients from Southeastern Minnesota in whom MGUS was diagnosed at Mayo Clinic from 1960 through 1994, the risk of progression was 1% per year. This risk of progression continued even after > or = 25 years of a stable M-protein. The risk for developing MM, WM, or AL was increased 25-fold, 46-fold, and 8.4-fold, respectively. The concentration of the serum M-protein, abnormal serum free light-chain ratio, and the presence an immunoglobulin (Ig)M or an IgA M-protein were risk factors for progression. The presence of a urine M-protein or the reduction of > or = 1 uninvolved immunoglobulins was not a risk factor for disease progression. Patients must be monitored for progressive disease throughout their lives. Variants of MGUS consist of IgM MGUS, biclonal gammopathies, triclonal gammopathies, idiopathic Bence Jones (light-chain) proteinuria, and IgD MGUS. Monoclonal gammopathy of undetermined significance may be associated with many disorders, including lymphoproliferative diseases, leukemia, von Willebrand's disease, connective tissue diseases, and neurologic disorders. Epidemiologic and statistical methods must be used to evaluate these associations.
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Affiliation(s)
- Robert A Kyle
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Bonilla FA, Bernstein IL, Khan DA, Ballas ZK, Chinen J, Frank MM, Kobrynski LJ, Levinson AI, Mazer B, Nelson RP, Orange JS, Routes JM, Shearer WT, Sorensen RU. Practice parameter for the diagnosis and management of primary immunodeficiency. Ann Allergy Asthma Immunol 2005; 94:S1-63. [PMID: 15945566 DOI: 10.1016/s1081-1206(10)61142-8] [Citation(s) in RCA: 311] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Francisco A Bonilla
- Department of Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA
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Stray-Pedersen A, Jónsson T, Heiberg A, Lindman CR, Widing E, Aaberge IS, Borresen-Dale AL, Abrahamsen TG. The impact of an early truncating founder ATM mutation on immunoglobulins, specific antibodies and lymphocyte populations in ataxia-telangiectasia patients and their parents. Clin Exp Immunol 2004; 137:179-86. [PMID: 15196260 PMCID: PMC1809075 DOI: 10.1111/j.1365-2249.2004.02492.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Eleven Norwegian patients (aged 2-33 years, seven males and four females) with Ataxia-telangiectasia (A-T) and their parents were investigated. Five of the patients were homozygous for the same ATM mutation, 3245delATCinsTGAT, a Norwegian founder mutation. They had the lowest IgG2 levels; mean (95% confidence interval) 0.23 (0.05-0.41) g/l versus 0.91 (0.58-1.26) g/l in the other patients (P = 0.002). Among the 11 A-T patients, six had IgG2 deficiency, six had IgA deficiency (three in combination with IgG2 deficiency) and seven had low/undetectable IgE values. All patients had very low levels of antibodies to Streptococcus pneumoniae 0.9 (0.4-1.4) U/ml, while normal levels were found in their parents 11.1 (8.7-13.4) U/ml (P < 0.001). A positive linear relationship between pneumococcal antibodies and IgG2 (r = 0.85, P = 0.001) was found in the patients. Six of 11 had diphtheria antibodies and 7 of 11 tetanus antibodies after childhood vaccinations, while 4 of 7 Hemophilus influenzae type b (Hib) vaccinated patients had protective antibodies. Ten patients had low B cell (CD19+) counts, while six had low T cell (CD3+) counts. Of the T cell subpopulations, 11 had low CD4+ cell counts, six had reduced CD8+ cell counts, and four had an increased portion of double negative (CD3+/CD4-/CD8-) gamma delta T cells. Of the 22 parents (aged 23-64 years) 12 were heterozygous for the ATM founder mutation. Abnormalities in immunoglobulin levels and/or lymphocyte subpopulations were also observed in these carriers, with no correlation to a special ATM genotype.
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Affiliation(s)
- A Stray-Pedersen
- Department of Paediatrics, Rikshospitalet University Hospital, Oslo, Norway.
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Nowak-Wegrzyn A, Crawford TO, Winkelstein JA, Carson KA, Lederman HM. Immunodeficiency and infections in ataxia-telangiectasia. J Pediatr 2004; 144:505-11. [PMID: 15069401 DOI: 10.1016/j.jpeds.2003.12.046] [Citation(s) in RCA: 188] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To characterize the immunodeficiency in ataxia-telangiectasia (A-T) and to determine whether the immunodeficiency is progressive and associated with increased susceptibility to infections. STUDY DESIGN Records of 100 consecutive patients with A-T from the Johns Hopkins Ataxia-Telangiectasia Clinical Center (ATCC) were reviewed. RESULTS Immunoglobulin (Ig) deficiencies are common, affecting IgG4 in 65% of patients, IgA in 63%, IgG2 in 48%, IgE in 23%, and IgG in 18%. Lymphopenia affected 71% of patients, with reduced B-lymphocyte number in 75%, CD4 T lymphocytes in 69%, and CD8 T lymphocytes in 51%. There was no trend for increased frequency or severity of immune abnormalities with age. Recurrent upper and lower respiratory tract infections were frequent: otitis media in 46% of patients, sinusitis in 27%, bronchitis in 19%, and pneumonia in 15%. Sepsis occurred in 5 patients, in 2 patients concurrent with cancer chemotherapy. Warts affected 17% of patients, herpes simplex 8%, molluscum contagiosum 5%, candidal esophagitis 3%, and herpes zoster 2%. Uncomplicated varicella infection occurred in 44% of patients; 2 patients had more than one clinical episode. No patient had Pneumocystis jerovici pneumonia or a complication of live viral vaccine. CONCLUSIONS In spite of the high prevalence of laboratory immunologic abnormalities, systemic bacterial, severe viral, and opportunistic infections are uncommon in A-T. Cross-sectional analysis suggests that the immune defect is rarely progressive.
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Affiliation(s)
- Anna Nowak-Wegrzyn
- Eudowood Division of Pediatric Allergy and Immunology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287-3923, USA
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Abstract
Monoclonal gammopathy of undetermined significance (MGUS) denotes the presence of a monoclonal protein (M-protein) in patients without evidence of multiple myeloma (MM), macroglobulinemia, amyloidosis (AL), or a related plasma cell proliferative disorder. MGUS is found in approximately 3% of persons older than 70 years and in about 1% of those older than 50 years. In a series of 1384 patients from south-eastern Minnesota in whom MGUS was diagnosed at Mayo Clinic from 1960 through 1994, the risk of progression was 1% per year. Patients were at risk of progression even after 25 years or more of a stable monoclonal gammopathy. The risk of development of MM was increased by 25-fold, the risk of macroglobulinemia was 46-fold, and the risk of primary AL was 8.4-fold when compared with a similar population (Surveillance, Epidemiology and End Results). The concentration of the serum M-protein was the major independent predictor of progression. Patients with an immunoglobulin M (IgM) or an IgA monoclonal gammopathy had a higher risk of progression than those with an IgG monoclonal gammopathy. The presence of a urine M-protein or the reduction of one or more uninvolved Igs was not a risk factor for progression. MGUS may be associated with many different disorders, including lymphoproliferative diseases, leukemia, connective tissue disorders, dermatologic diseases, and neurologic disorders.
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Affiliation(s)
- Robert A Kyle
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Giovannetti A, Mazzetta F, Caprini E, Aiuti A, Marziali M, Pierdominici M, Cossarizza A, Chessa L, Scala E, Quinti I, Russo G, Fiorilli M. Skewed T-cell receptor repertoire, decreased thymic output, and predominance of terminally differentiated T cells in ataxia telangiectasia. Blood 2002; 100:4082-9. [PMID: 12393664 DOI: 10.1182/blood-2002-03-0976] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Ataxia telangiectasia (A-T), a genetic disorder caused by the homozygous mutation of the ATM gene, frequently associates with variable degrees of cellular and humoral immunodeficiency. However, the immune defects occurring in patients with A-T are still poorly characterized. Here we show that the T-cell receptor (TCR) variable beta (BV)-chain repertoire of 9 A-T patients was restricted by diffuse expansions of some variable genes prevalently occurring within the CD4 subset and clustering to certain TCRBV genes (eg, 5.1, 11, 14, and 23). In addition, the study of the third complementarity-determining region (CDR3) showed, in all patients, significantly altered profiles in most BV genes examined suggesting diffuse oligoclonal expansions. The sequencing of TCR CDR3 regions revealed completely normal V(D)J coding joints and confirmed a reduced diversity of the antigen-receptor repertoire. The B-cell repertoire was similarly restricted and skewed by diffuse oligoclonal expansions with normal V(D)J joints. Thymic output, evaluated by measuring TCR rearrangement excision circles, was extremely low. The majority of peripheral T cells had the phenotype and the function of effector memory cells, indicating that in vivo they are able to respond normally by terminal differentiation to antigenic stimulation. These results indicate that ATM mutation limits the generation of a wide repertoire of normally functioning T and B cells.
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Gregorek H, Chrzanowska KH, Michałkiewicz J, Syczewska M, Madaliński K. Heterogeneity of humoral immune abnormalities in children with Nijmegen breakage syndrome: an 8-year follow-up study in a single centre. Clin Exp Immunol 2002; 130:319-24. [PMID: 12390322 PMCID: PMC1906518 DOI: 10.1046/j.1365-2249.2002.01971.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
During an 8-year period of observation, defects of immune responses were characterized and monitored in 40 of 50 Polish children with Nijmegen breakage syndrome referred to the Children's Memorial Health Institute in Warsaw. The following parameters were determined at diagnosis: (1) concentrations of serum IgM, IgG, IgA; (2) concentrations of IgG subclasses; and (3) lymphocyte subpopulations. In addition, naturally acquired specific antibodies against Streptococcus pneumoniae were determined in 20 patients with a history of recurrent respiratory infections. During follow-up, total serum immunoglobulins and IgG subclasses were monitored systematically in 17 patients who did not receive immunomodulatory therapy. Moreover, anti-HBs antibody response was measured after vaccination of 20 children against HBV. We found that the immune deficiency in NBS is profound, highly variable, with a tendency to progress over time. Systematic monitoring of the humoral response, despite good clinical condition, is essential for early medical intervention.
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Affiliation(s)
- H Gregorek
- Department of Clinical Immunology, Children's Memorial Health Institute, Warsaw, Poland.
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Kyle RA, Rajkumar SV. Monoclonal gammopathies of undetermined significance. REVIEWS IN CLINICAL AND EXPERIMENTAL HEMATOLOGY 2002; 6:225-52. [PMID: 12616697 DOI: 10.1046/j.1468-0734.2002.00076.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The term 'monoclonal gammopathy of undetermined significance' denotes the presence of a monoclonal protein in patients without evidence of multiple myeloma, macroglobulinemia, amyloidosis or related plasma cell proliferative disorders. The disorder has been found in approximately 3% of persons older than 70 years and in approximately 1% of persons older than 50 years. A population-based study included 1384 patients from south-eastern Minnesota who had the disorder diagnosed at the Mayo Clinic from 1960 through 1994. Risk of progression was about 1% per year, but patients were at risk of progression even after 25 years or more of stable monoclonal gammopathy of undetermined significance. The risk for development of multiple myeloma was increased 25-fold; the risk of macroglobulinemia, 46-fold; and the risk of primary amyloidosis, 8.4-fold. Concentration and type of monoclonal protein were the only independent predictors of progression. The presence of a urine monoclonal protein and the reduction of one or more uninvolved immunoglobulins were not risk factors for progression. Monoclonal gammopathy of undetermined significance may be associated with various disorders, including lymphoproliferative diseases, leukemia, von Willebrand disease, connective tissue diseases and neurologic disorders.
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Affiliation(s)
- Robert A Kyle
- Division of Hematology and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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