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Altammar F, Alshamali M, Alqunaee M, Alali AJ, Elshafie RM, Al-Herz W. A case report of a patient with recurrent and severe infections highlighting the importance of considering inborn errors of immunity. Front Pediatr 2024; 12:1340367. [PMID: 38487470 PMCID: PMC10938594 DOI: 10.3389/fped.2024.1340367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/08/2024] [Indexed: 03/17/2024] Open
Abstract
Inborn errors of immunity (IEI) can often be misdiagnosed early in life due to their heterogenous clinical presentations. Interleukin-1 receptor-associated kinase 4 (IRAK-4) deficiency is one of the rare innate immunodeficiency disorders. We present the case of a patient who presented at the age of 15 days with meningitis and septic shock that responded to antibiotics. She was admitted again at the age of 45 days with pseudomonas aeruginosa bacteremia that was associated with increased inflammatory markers. Her third admission was at the age of 2.5 months due to left sided peri-orbital cellulitis that was again associated with elevated inflammatory markers. At 3.5 months, she experienced left orbital cellulitis, which was complicated by extensive sinus involvement, erosion, and abscess formation in the pterygopalatine fossa. Her condition progressed to septic shock and required multiple antibiotics and surgical interventions for drainage and control of the infection source. Both abscess and blood culture were positive for pseudomonas aeruginosa. An IEI was suspected but basic immunology testing was normal. Whole Exome Sequencing was performed and a novel mutation in IRAK4 was detected. In conclusion, we highlight the importance of raising awareness among pediatricians about the potentially lethal IEI and the need to consult specialists when these diseases are suspected. Among them is IRAK-4 deficiency which can be diagnosed by sophisticated functional assays and/or genetic testing.
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Affiliation(s)
- Fajer Altammar
- Pediatric Intensive Care Unit, Department of Pediatrics, New Jahra Hospital, Jahra Medical City, Kuwait
- Faculty of Pediatrics, Kuwait Institute for Medical Specialization, Kuwait City, Kuwait
| | - Mohammed Alshamali
- Pediatric Intensive Care Unit, Department of Pediatrics, New Jahra Hospital, Jahra Medical City, Kuwait
| | - Marwan Alqunaee
- Department of Otorhinolaryngology, Zain Hospital, Sabah Health Region, Ministry of Health, Kuwait City, Kuwait
- Department of Otorhinolaryngology, Sabah Hospital, Sabah Health Region, Ministry of Health, Kuwait City, Kuwait
| | - Ahmad J. Alali
- Department of Otorhinolaryngology, Zain Hospital, Sabah Health Region, Ministry of Health, Kuwait City, Kuwait
| | - Reem M. Elshafie
- Kuwait Medical Genetic Center, Sabah Health Region, Ministry of Health, Kuwait City, Kuwait
| | - Waleed Al-Herz
- Department of Pediatrics, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
- Allergy & Clinical Immunology Unit, Department of Pediatrics, Sabah Hospital, Sabah Health Region, Ministry of Health, Kuwait City, Kuwait
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Takada H. Creating Awareness for Primary Immunodeficiencies in Japan. Front Immunol 2021; 12:803459. [PMID: 34966393 PMCID: PMC8710485 DOI: 10.3389/fimmu.2021.803459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
Primary immunodeficiency (PID) is primarily characterized by susceptibility to infectious diseases. In addition, patients with some type of PID are prone to develop autoimmune, autoinflammatory, or malignant diseases. Therefore, the term, inborn errors of immunity (IEI), has been more used rather than PID. In recent years, the number of diseases which belong to PID has been increasing. There were approximately 110 diseases in the report of International Union of Immunological Societies in 1999. Since then, the number increased to 430 diseases in the latest IUIS report in 2019. We conducted PID nationwide survey in Japan for 3 times in the last 15 years. These studies were focused on incidence and complications of PID, the clinical course of viral infection, and methods to prevent infectious diseases in PID patients. For the awareness of PID, it is essential to know the general and fundamental information of PID patients. Needless to say, we need it to offer appropriate medical services for PID patients. Moreover, chances to provide answers to the questionnaires and seeing the results of the analysis should contribute to the awareness of PID among doctors. In this review, I am going to summarize the results of 3 nationwide survey in Japan, and pick up interleukin-1 receptor-associated kinase 4 (IRAK4) deficiency as an example for creating awareness for its appropriate management.
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Affiliation(s)
- Hidetoshi Takada
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Zheng K, He FB, Liu H, He Q. Genetic variations of toll-like receptors: Impact on susceptibility, severity and prognosis of bacterial meningitis. INFECTION GENETICS AND EVOLUTION 2021; 93:104984. [PMID: 34214672 DOI: 10.1016/j.meegid.2021.104984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/24/2021] [Accepted: 06/27/2021] [Indexed: 01/24/2023]
Abstract
Bacterial meningitis (BM) is a serious infectious disease of the central nervous system,which is mainly caused by Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, Group B Streptococcus and Listeria monocytogenes. Throughout the world, BM has become one of the most lethal diseases that commonly occurs in children. Toll like receptors (TLRs) are one of the most important immune defense lines in infectious diseases, and play an essential role in host defense. Accumulating evidence shows that genetic variations in TLRs are associated with host responses in BM. This review aims to summarize the role of different TLRs and their genetic variations in the susceptibility, severity and prognosis of BM and discuss the identified risk factors for better treatment and improvement of the course and outcome of BM.
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Affiliation(s)
- Kai Zheng
- Department of Medical Microbiology, Capital Medical University, Beijing 100069, China; Department of Neurorehabilitation, Wuxi Tongren Rehabilitation Hospital, Wuxi 214151, Jiangsu, China
| | - Felix B He
- Institute of Biomedicine, University of Turku, 20520 Turku, Finland
| | - Hongshan Liu
- Department of Medical Microbiology, Capital Medical University, Beijing 100069, China
| | - Qiushui He
- Department of Medical Microbiology, Capital Medical University, Beijing 100069, China; Institute of Biomedicine, University of Turku, 20520 Turku, Finland.
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Pneumococcal Serotype-specific Opsonophagocytic Activity in Interleukin-1 Receptor-associated Kinase 4-deficient Patients. Pediatr Infect Dis J 2021; 40:460-463. [PMID: 33470775 DOI: 10.1097/inf.0000000000003060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The antibody response after pneumococcal vaccines and their effectiveness against invasive pneumococcal disease (IPD) in patients with interleukin-1 receptor-associated kinase 4 (IRAK4) deficiency have not been fully evaluated. Here, we evaluated pneumococcal serotype-specific opsonophagocytic activity (OPA) in IRAK4-deficient patients along with their clinical course. METHODS We investigated 6 IRAK4-deficient patients in Japan, whose attending physicians could be contacted. We performed OPA measurements using stored and more recent serum samples obtained from these patients. RESULTS All patients had received pneumococcal vaccination. Among the 3 patients who had IPD, 2 had an episode of pneumococcal meningitis and the other developed pneumococcal bacteremia 3 years after the occurrence of pneumococcal meningitis. Only one episode of invasive bacterial infection was caused by a Streptococcus pneumoniae vaccine-type strain. An increased opsonization index was found in the sera after vaccination for all IRAK-deficient patients, including when the 23-valent pneumococcal polysaccharide vaccine was used. CONCLUSIONS A significant increase in levels of OPA against most of the pneumococcal vaccine antigens was observed for all IRAK4-deficient patients. However, IPD could not be prevented by pneumococcal vaccination alone. Therefore, adequate prophylaxis should be provided with antibiotics at least until 8 years of age, along with regular immunoglobulin therapy, particularly during the infantile period.
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IRAK4 Deficiency Presenting with Anti-NMDAR Encephalitis and HHV6 Reactivation. J Clin Immunol 2021; 41:125-135. [PMID: 33083971 PMCID: PMC7846526 DOI: 10.1007/s10875-020-00885-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/14/2020] [Indexed: 01/03/2023]
Abstract
IRAK4 deficiency is an inborn error of immunity predisposing patients to invasive pyogenic infections. Currently, there is no established simple assay that enables precise characterization of IRAK4 mutant alleles in isolation. Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune condition that is characterized by psychiatric symptoms, involuntary movement, seizures, autonomic dysfunction, and central hypoventilation. It typically occurs in adult females associated with tumors. Only a few infantile cases with anti-NMDAR encephalitis have been so far reported. We identified a 10-month-old boy with IRAK4 deficiency presenting with anti-NMDAR encephalitis and human herpes virus 6 (HHV6) reactivation. The diagnosis of IRAK4 deficiency was confirmed by the identification of compound heterozygous mutations c.29_30delAT (p.Y10Cfs*9) and c.35G>C (p.R12P) in the IRAK4 gene, low levels of IRAK4 protein expression in peripheral blood, and defective fibroblastic cell responses to TLR and IL-1 (TIR) agonist. We established a novel NF-κB reporter assay using IRAK4-null HEK293T, which enabled the precise evaluation of IRAK4 mutations. Using this system, we confirmed that both novel mutations identified in the patient are deleterious. Our study provides a new simple and reliable method to analyze IRAK4 mutant alleles. It also suggests the possible link between inborn errors of immunity and early onset anti-NMDAR encephalitis.
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Boisson B. The genetic basis of pneumococcal and staphylococcal infections: inborn errors of human TLR and IL-1R immunity. Hum Genet 2020; 139:981-991. [PMID: 31980906 DOI: 10.1007/s00439-020-02111-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/04/2020] [Indexed: 01/08/2023]
Abstract
Many bacteria can cause pyogenic lesions in humans. Most of these bacteria are harmless in most individuals, but they, nevertheless, cause significant morbidity and mortality worldwide. The inherited and acquired immunodeficiencies underlying these pyogenic infections differ between bacteria. This short review focuses on two emblematic pyogenic bacteria: pneumococcus (Streptococcus pneumoniae) and Staphylococcus, both of which are Gram-positive encapsulated bacteria. We will discuss the contribution of human genetic studies to the identification of germline mutations of the TLR and IL-1R pathways.
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Affiliation(s)
- Bertrand Boisson
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, USA. .,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, Paris, EU, France. .,Imagine Institute, Paris Descartes University, Paris, EU, France.
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Alsum Z, AlZahrani MS, Al-Mousa H, Alkhamis N, Alsalemi AA, Shamseldin HE, Alkuraya FS, Alangari AA. Multiple Family Members With Delayed Cord Separtion and Combined Immunodeficiency With Novel Mutation in IKBKB. Front Pediatr 2020; 8:9. [PMID: 32117824 PMCID: PMC7034298 DOI: 10.3389/fped.2020.00009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/09/2020] [Indexed: 02/03/2023] Open
Abstract
Background: Inhibitor of kappa kinase 2 (IKK2) deficiency is a recently described combined immunodeficiency. It undermines the nuclear factor-kappa B (NF-κB) activation pathway. Methods: The clinical and immunological data of four patients diagnosed with combined immunodeficiency (CID) from two related Saudi families were collected. Autozygosity mapping of all available members and whole exome sequencing of the index case were performed to define the genetic etiology. Results: The patients had early onset (2-4 months of age) severe infections caused by viruses, bacteria, mycobacteria, and fungi. They all had hypogammaglobulinemia and low absolute lymphocyte count. Their lymphocytes failed to respond to PHA mitogen stimulation. A novel homozygous non-sense mutation in the IKBKB gene, c.850C>T (p. Arg284*) was identified in the index patient and segregated with the disease in the rest of the family. He underwent hematopoietic stem cell transplantation (HSCT) from a fully matched sibling with no conditioning. The other three patients succumbed to their disease. Interestingly, all patients had delayed umbilical cord separation. Conclusion: IKK2 deficiency causes CID with high mortality. Immune reconstitution with HSCT should be considered as early as possible. Delayed umbilical cord separation in CID patients may be a clue to IKK2 deficiency.
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Affiliation(s)
- Zobaida Alsum
- Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
| | | | - Hamoud Al-Mousa
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Nouf Alkhamis
- Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
| | | | - Hanan E Shamseldin
- Department of Genetics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fowzan S Alkuraya
- Department of Genetics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Department of Anatomy and Cell Biology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,Saudi Human Genome Program, King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia
| | - Abdullah A Alangari
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Antinuclear Antibody-Positive Juvenile Idiopathic Arthritis Despite IRAK-4 Deficiency. J Clin Immunol 2018; 38:450-453. [PMID: 29707745 DOI: 10.1007/s10875-018-0501-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 04/10/2018] [Indexed: 01/13/2023]
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Immunodeficiency in Two Female Patients with Incontinentia Pigmenti with Heterozygous NEMO Mutation Diagnosed by LPS Unresponsiveness. J Clin Immunol 2017; 37:529-538. [DOI: 10.1007/s10875-017-0417-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 06/27/2017] [Indexed: 11/26/2022]
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Xu W, Yin M, Huo MC, Yan JL, Yang Y, Liu CF. [Changes in blood CD4 +CD25 + regulatory T cells in children with severe purulent meningitis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:821-825. [PMID: 27655537 PMCID: PMC7389974 DOI: 10.7499/j.issn.1008-8830.2016.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 07/05/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To preliminarily study the changes in CD4+CD25+ regulatory T cells (Tregs) in children with severe purulent meningitis at the early stage and its possible implications. METHODS A retrospective analysis was performed on the clinical data of 39 children with severe purulent meningitis who were admitted to the pediatric intensive care unit from August 2014 to December 2015. According to whether Tregs count was decreased within 12 hours of hospitalization (considering Tregs count <410/mm3 as decreased), they were divided into two groups: decrease group and non-decrease group. The associations between the changes in Tregs cells and the clinical manifestations, laboratory marker levels, and prognosis were analyzed. RESULTS Of the 39 cases, 13 (33%) showed a decrease in the proportion of Tregs cells (<31%) and 18 (46%) showed a decrease in the absolute Tregs cell count (<410/mm3). Four deaths were all in the Tregs decrease group. Compared with the non-decrease group, the decrease group showed a significantly higher proportion of children with a peripheral blood leukocyte count lower than the normal range and a significantly greater increase in the level of serum procalcitonin (P<0.05). CONCLUSIONS Tregs might be suppressed in children with severe purulent meningitis at the early stage. And its suppression could be related to the severer inflammation reaction and higher mortality in those patients.
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Affiliation(s)
- Wei Xu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang 110004, China.
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