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Boz V, Zanchi C, Levantino L, Riccio G, Tommasini A. Druggable monogenic immune defects hidden in diverse medical specialties: Focus on overlap syndromes. World J Clin Pediatr 2022; 11:136-150. [PMID: 35433297 PMCID: PMC8985491 DOI: 10.5409/wjcp.v11.i2.136] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/03/2021] [Accepted: 01/08/2022] [Indexed: 02/06/2023] Open
Abstract
In the last two decades two new paradigms changed our way of perceiving primary immunodeficiencies: An increasing number of immune defects are more associated with inflammatory or autoimmune features rather than with infections. Some primary immune defects are due to hyperactive pathways that can be targeted by specific inhibitors, providing innovative precision treatments that can change the natural history of diseases. In this article we review some of these “druggable” inborn errors of immunity and describe how they can be suspected and diagnosed in diverse pediatric and adult medicine specialties. Since the availability of precision treatments can dramatically impact the course of these diseases, preventing the development of organ damage, it is crucial to widen the awareness of these conditions and to provide practical hints for a prompt detection and cure.
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Affiliation(s)
- Valentina Boz
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste 34137, Italy
| | - Chiara Zanchi
- Department of Pediatrics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste 34137, Italy
| | - Laura Levantino
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste 34137, Italy
| | - Guglielmo Riccio
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste 34137, Italy
| | - Alberto Tommasini
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste 34137, Italy
- Department of Pediatrics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste 34137, Italy
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Al-Owain M, Kaya N, Al-Zaidan H, Bin Hussain I, Al-Manea H, Al-Hindi H, Kennedy S, Iqbal MA, Al-Mojalli H, Al-Bakheet A, Puel A, Casanova JL, Al-Muhsen S. Renal failure associated with APECED and terminal 4q deletion: evidence of autoimmune nephropathy. Clin Dev Immunol 2010; 2010:586342. [PMID: 21197407 PMCID: PMC3010696 DOI: 10.1155/2010/586342] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Revised: 10/12/2010] [Accepted: 11/09/2010] [Indexed: 01/12/2023]
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autosomal recessive disorder caused by mutations in the autoimmune regulator gene (AIRE). Terminal 4q deletion is also a rare cytogenetic abnormality that causes a variable syndrome of dysmorphic features, mental retardation, growth retardation, and heart and limb defects. We report a 12-year-old Saudi boy with mucocutaneous candidiasis, hypoparathyroidism, and adrenocortical failure consistent with APECED. In addition, he has dysmorphic facial features, growth retardation, and severe global developmental delay. Patient had late development of chronic renal failure. The blastogenesis revealed depressed lymphocytes' response to Candida albicans at 38% when compared to control. Chromosome analysis of the patient revealed 46,XY,del(4)(q33). FISH using a 4p/4q subtelomere DNA probe assay confirmed the deletion of qter subtelomere on chromosome 4. Parental chromosomes were normal. The deleted array was further defined using array CGH. AIRE full gene sequencing revealed a homozygous mutation namely 845_846insC. Renal biopsy revealed chronic interstitial nephritis with advanced fibrosis. In addition, there was mesangial deposition of C3, C1q, and IgM. This is, to the best of our knowledge, the first paper showing evidence of autoimmune nephropathy by renal immunofluorescence in a patient with APECED and terminal 4q deletion.
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Affiliation(s)
- Mohammed Al-Owain
- Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Namik Kaya
- Department of Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Hamad Al-Zaidan
- Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Ibrahim Bin Hussain
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Hadeel Al-Manea
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Hindi Al-Hindi
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Shelley Kennedy
- Ontario Newborn Screening Program, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada K1H8L1
| | - M. Anwar Iqbal
- Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Hamad Al-Mojalli
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Albandary Al-Bakheet
- Department of Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Anne Puel
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Inserm U550, 75015 Paris, France
| | - Jean-Laurent Casanova
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Inserm U550, 75015 Paris, France
- Department of Pediatrics, College of Medicine and Prince Naif Center for Immunology Research, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia
| | - Saleh Al-Muhsen
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
- Department of Pediatrics, College of Medicine and Prince Naif Center for Immunology Research, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh 11461, Saudi Arabia
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Carneiro-Sampaio M, Coutinho A. Tolerance and autoimmunity: lessons at the bedside of primary immunodeficiencies. Adv Immunol 2007; 95:51-82. [PMID: 17869610 DOI: 10.1016/s0065-2776(07)95002-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The recent progress in the genetic characterization of many primary immunodeficiencies (PIDs) allows for a better understanding of immune molecular and cellular mechanisms. The present chapter discusses associations between PIDs and autoimmune diseases (AIDs) in this new light. PIDs are classified according to the frequency of association with AIDs, defining four groups of conditions: systematic (more than 80% of all patients), strong (10-80%), mild (less than 10%), and absent (no available descriptions). Several general conclusions could be drawn: (1) pathological autoimmune (AI) manifestations are very frequently associated with PIDs, indicating that, contrary to conventional notions, antimicrobial protection and natural tolerance to body tissues share many basic mechanisms; (2) in some gene defects, association is so strong that one could speak of "monogenic" AIDs; (3) basic types of PIDs are selectively associated with AID of a particular set of target tissues; (4) while for some gene defects, current theory satisfactorily explains pathogenesis of the corresponding AID, other situations suggest extensive gaps in the present understanding of natural tolerance; and (5) not exceptionally, observations on the AI phenotype for the same gene defect in mouse and man are not concordant, perhaps owing to the limited genetic diversity of mouse models, often limited to a single mouse strain. Overall, clinical observations on PID support the new paradigm of "dominant" tolerance to self-components, in which AID owes to deficits in immune responses (i.e., in regulatory mechanisms), rather than from excessive reactivity.
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Affiliation(s)
- Magda Carneiro-Sampaio
- Department of Pediatrics, Children's Hospital, Faculdade de Medicina da Universidade de São Paulo, Brazil
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Oven I, Brdicková N, Kohoutek J, Vaupotic T, Narat M, Peterlin BM. AIRE recruits P-TEFb for transcriptional elongation of target genes in medullary thymic epithelial cells. Mol Cell Biol 2007; 27:8815-23. [PMID: 17938200 PMCID: PMC2169392 DOI: 10.1128/mcb.01085-07] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Revised: 08/17/2007] [Accepted: 10/02/2007] [Indexed: 01/06/2023] Open
Abstract
AIRE is a transcriptional activator that directs the ectopic expression of many tissue-specific genes in medullary thymic epithelial cells, which plays an important role in the negative selection of autoreactive T cells. However, its mechanism of action remains poorly understood. In this study, we found that AIRE regulates the step of elongation rather than initiation of RNA polymerase II. For these effects, AIRE bound and recruited P-TEFb to target promoters in medullary thymic epithelial cells. In these cells, AIRE activated the ectopic transcription of insulin and salivary protein 1 genes. Indeed, by chromatin immunoprecipitation, we found that RNA polymerase II was already engaged on these promoters but was unable to elongate in the absence of AIRE. Moreover, the genetic inactivation of cyclin T1 from P-TEFb abolished the transcription of AIRE-responsive genes and led to lymphocytic infiltration of lacrimal and salivary glands in the CycT1-/- mouse. Our findings reveal critical steps by which AIRE regulates the transcription of genes that control central tolerance in the thymus.
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Affiliation(s)
- Irena Oven
- Department of Medicine, Rosalind Russell Medical Research Center, University of California-San Francisco, San Francisco, California 94143-0703, USA
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Meyer T, Ruppert V, Karatolios K, Maisch B. Hereditary long QT syndrome due to autoimmune hypoparathyroidism in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy syndrome. J Electrocardiol 2007; 40:504-9. [PMID: 17289071 DOI: 10.1016/j.jelectrocard.2006.12.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Accepted: 12/14/2006] [Indexed: 01/21/2023]
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), also known as autoimmune polyglandular syndrome type I, is a rare autosomal recessively inherited disorder characterized by variable combinations of endocrine and nonendocrine symptoms. In this report, we describe two 20- and 17-year-old Turkish siblings presenting with typical symptoms of APECED, including Addison disease, alopecia, vitiligo, and hypopituitarism, in whom electrocardiographic examinations demonstrated an abnormal prolongation of the QT interval. In both cases, excessive hypocalcemia due to primary hypoparathyroidism was identified as the underlying cause of the long QT syndrome. Sequencing the gene coding for the autoimmune regulator revealed a homozygous missense mutation in exon 14 with a C-to-T transition that resulted in the substitution of proline 539 for leucine in the carboxy-terminal protein molecule. Our data show that a single point mutation in the transcriptional active autoimmune regulator protein is associated with inherited alterations in calcium metabolism resulting from autoimmune reactions against the parathyroid glands. This finding defines a congenital autoimmune disease as a hereditary long QT syndrome.
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Affiliation(s)
- Thomas Meyer
- Abteilung Innere Medizin-Kardiologie, Philipps-Universität Marburg, Baldingerstrasse, 35033 Marburg, Germany.
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Yeh S, Matoba AY. Successful nonsurgical management of corneal perforation in a patient with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy. Cornea 2007; 26:880-2. [PMID: 17667629 DOI: 10.1097/ico.0b013e318073c213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe a patient with a history of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) who has experienced two episodes of noninfectious corneal ulceration with perforation that has been successfully managed with nonsurgical therapy. METHODS Case report. RESULTS An 18-year-old male with a history of APECED has been followed up with recurrent keratoconjunctivitis and episodes of microbial keratitis since 4 years of age. Ophthalmic complications have included two episodes of sterile corneal ulceration associated with corneal perforation. These episodes of stromal ulceration associated with a flat anterior chamber were managed with a bandage contact lens, topical antibiotics, and a topical cycloplegic agent. In one instance, addition of cyclosporine led to reformation of the anterior chamber and arrest of the ulcerative process. CONCLUSION Sterile corneal ulceration and perforation associated with APECED may be managed medically to avoid surgical intervention, which has been reported to lead to a poor outcome.
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Affiliation(s)
- Steven Yeh
- Cullen Eye Institute, Baylor College of Medicine, Houston, TX 77030, USA
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Gressner AM, Arndt T. A. LEXIKON DER MEDIZINISCHEN LABORATORIUMSDIAGNOSTIK 2007. [PMCID: PMC7120146 DOI: 10.1007/978-3-540-49520-8_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Klamp T, Sahin U, Kyewski B, Schwendemann J, Dhaene K, Türeci O. Expression profiling of autoimmune regulator AIRE mRNA in a comprehensive set of human normal and neoplastic tissues. Immunol Lett 2006; 106:172-9. [PMID: 16876259 DOI: 10.1016/j.imlet.2006.06.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Revised: 06/13/2006] [Accepted: 06/15/2006] [Indexed: 01/17/2023]
Abstract
Defects in the autoimmune regulator (AIRE) gene cause the monogenic autoimmune disease autoimmune polyendocrinopathy syndrome type 1 (APS-1), which is characterized by a loss of self-tolerance to multiple organs. In concordance with its role in immune tolerance, AIRE is strongly expressed in medullary thymic epithelial cells (mTECs). Data on mechanisms controlling AIRE activation and the expression of this gene in other tissues are fragmentary and controversial. We report here AIRE mRNA expression profiling of a large set of normal human tissues and cells, tumor specimen and methylation deficient cell lines. On this broad data basis we found that AIRE mRNA expression is confined to mTECs in thymus and to lymph node tissue and that DNA hypomethylation contributes to transcriptional control of this gene.
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MESH Headings
- Cell Line, Tumor
- DNA Methylation
- Gene Expression Profiling/methods
- Gene Expression Regulation, Neoplastic
- Humans
- Immune Tolerance/genetics
- Lymph Nodes/immunology
- Lymph Nodes/metabolism
- Lymph Nodes/pathology
- Neoplasms/genetics
- Neoplasms/immunology
- Neoplasms/metabolism
- Neoplasms/pathology
- Polyendocrinopathies, Autoimmune/genetics
- Polyendocrinopathies, Autoimmune/immunology
- Polyendocrinopathies, Autoimmune/metabolism
- Polyendocrinopathies, Autoimmune/pathology
- RNA, Messenger/biosynthesis
- RNA, Messenger/genetics
- RNA, Messenger/immunology
- Reverse Transcriptase Polymerase Chain Reaction
- Thymus Gland/immunology
- Thymus Gland/metabolism
- Thymus Gland/pathology
- Transcription Factors/biosynthesis
- Transcription Factors/immunology
- Transcription, Genetic/immunology
- AIRE Protein
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Affiliation(s)
- Thorsten Klamp
- Department of Internal Medicine III, Johannes-Gutenberg University Mainz, Obere Zahlbacherstr 63, 55131 Mainz, Germany
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Meager A, Visvalingam K, Peterson P, Möll K, Murumägi A, Krohn K, Eskelin P, Perheentupa J, Husebye E, Kadota Y, Willcox N. Anti-interferon autoantibodies in autoimmune polyendocrinopathy syndrome type 1. PLoS Med 2006; 3:e289. [PMID: 16784312 PMCID: PMC1475653 DOI: 10.1371/journal.pmed.0030289] [Citation(s) in RCA: 285] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Accepted: 02/24/2006] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The autoimmune regulator (AIRE) gene influences thymic self-tolerance induction. In autoimmune polyendocrinopathy syndrome type 1 (APS1; OMIM 240300), recessive AIRE mutations lead to autoimmunity targetting endocrine and other epithelial tissues, although chronic candidiasis usually appears first. Autoimmunity and chronic candidiasis can associate with thymomas as well. Patients with these tumours frequently also have high titre immunoglobulin G autoantibodies neutralising type I interferon (IFN)-alpha and IFN-omega, which are secreted signalling proteins of the cytokine superfamily involved in both innate and adaptive immunity. METHODS AND FINDINGS We tested for serum autoantibodies to type I IFNs and other immunoregulatory cytokines using specific binding and neutralisation assays. Unexpectedly, in 60/60 Finnish and 16/16 Norwegian APS1 patients with both AIRE alleles mutated, we found high titre neutralising immunoglobulin G autoantibodies to most IFN-alpha subtypes and especially IFN-omega (60% homologous to IFN-alpha)-mostly in the earliest samples. We found lower titres against IFN-beta (30% homologous to IFN-alpha) in 23% of patients; two-thirds of these (from Finland only) also had low titres against the distantly related "type III IFN" (IFN-lambda1; alias interleukin-29). However, autoantibodies to the unrelated type II IFN, IFN-gamma, and other immunoregulatory cytokines, such as interleukin-10 and interleukin-12, were much rarer and did not neutralise. Neutralising titres against type I IFNs averaged even higher in patients with APS1 than in patients with thymomas. Anti-type I IFN autoantibodies preceded overt candidiasis (and several of the autoimmune disorders) in the informative patients, and persisted for decades thereafter. They were undetectable in unaffected heterozygous relatives of APS1 probands (except for low titres against IFN-lambda1), in APS2 patients, and in isolated cases of the endocrine diseases most typical of APS1, so they appear to be APS1-specific. Looking for potentially autoimmunising cell types, we found numerous IFN-alpha(+) antigen-presenting cells-plus strong evidence of local IFN secretion-in the normal thymic medulla (where AIRE expression is strongest), and also in normal germinal centres, where it could perpetuate these autoantibody responses once initiated. IFN-alpha2 and IFN-alpha8 transcripts were also more abundant in antigen-presenting cells cultured from an APS1 patient's blood than from age-matched healthy controls. CONCLUSIONS These apparently spontaneous autoantibody responses to IFNs, particularly IFN-alpha and IFN-omega, segregate like a recessive trait; their high "penetrance" is especially remarkable for such a variable condition. Their apparent restriction to APS1 patients implies practical value in the clinic, e.g., in diagnosing unusual or prodromal AIRE-mutant patients with only single components of APS1, and possibly in prognosis if they prove to predict its onset. These autoantibody responses also raise numerous questions, e.g., about the rarity of other infections in APS1. Moreover, there must also be clues to autoimmunising mechanisms/cell types in the hierarchy of preferences for IFN-omega, IFN-alpha8, IFN-alpha2, and IFN-beta and IFN-lambda1.
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Affiliation(s)
- Anthony Meager
- Biotherapeutics, National Institute for Biological Standards and Control, South Mimms, United Kingdom.
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Abstract
Lymphopenia is defined as a peripheral lymphocyte count lower than 1500/mm3 in adults and 4500/mm3 in children younger than eight months of age. We propose a classification of lymphopenia according to the mechanism involved: lymphocyte production defects, including primary immune deficiencies and immune deficiencies secondary to malnutrition or zinc deprivation; excess catabolism, due to causes including radiotherapy, chemotherapy, immunosuppressive therapy, HIV infection, and systemic lupus erythematosus; abnormal lymphocyte trapping, including mainly splenomegaly, certain viral infections, septic shock, extended burns, systemic granulomatosis, and corticosteroids; other causes of lymphocytopenia, with mechanisms that remain poorly understood: ethnicity (Ethiopians), lymphoma, renal insufficiency, and idiopathic CD4 lymphocytopenia.
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Affiliation(s)
| | | | | | - Luc Mouthon
- Service de médecine interne, Hôpital Cochin, AP-HP, université Paris-Descartes, faculté de médecine, Paris (75)
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