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Lee WI, Chen CC, Chen SH, Lai WT, Jaing TH, Ou LS, Liang CJ, Kang CC, Huang JL. Clinical Features and Genetic Analysis of Taiwanese Primary Immunodeficiency Patients with Prolonged Diarrhea and Monogenetic Inflammatory Bowel Disease. J Clin Immunol 2023:10.1007/s10875-023-01503-w. [PMID: 37202577 DOI: 10.1007/s10875-023-01503-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/26/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE Diarrhea lasting longer than 14 days which fails to respond to conventional management is defined as severe and protracted diarrhea and might overlap with inflammatory bowel disease (IBD). METHODS The prevalence, associated pathogens, and prognosis of severe and protracted diarrhea without IBD (SD) and with monogenetic IBD (mono-IBD) in primary immunodeficiency patients (PID) were investigated in Taiwan. RESULTS A total of 301 patients were enrolled between 2003 and 2022, with predominantly pediatric-onset PID. Of these, 24 PID patients developed the SD phenotype before prophylactic treatment, including Btk (six), IL2RG (four), WASP, CD40L, gp91 (three each), gp47, RAG1 (one each), CVID (two), and SCID (one) without identified mutations. The most detectable pathogens were pseudomonas and salmonella (six each), and all patients improved after approximately 2 weeks of antibiotic and/or IVIG treatments. Six (25.0%) mortalities without HSCT implementation were due to respiratory failure from interstitial pneumonia (3 SCID and 1 CGD), intracranial hemorrhage (WAS), and lymphoma (HIGM). In the mono-IBD group, seventeen patients with mutant TTC7A (2), FOXP3 (2), NEMO (2), XIAP (2), LRBA (1), TTC37 (3), IL10RA (1), STAT1 (1), ZAP70 (1), PIK3CD (1), and PIK3R1 (1) genes failed to respond to aggressive treatments. Nine mono-IBD patients with TTC7A (2), FOXP3 (2), NEMO (2), XIAP (2), and LRBA (1) mutations were fatal in the absence of HSCT. The mono-IBD group had a significantly earlier age of diarrhea onset (1.7 vs 33.3 months, p = 0.0056), a longer TPN duration (34.2 vs 7.0 months, p < 0.0001), a shorter follow-up period (41.6 vs 132.6 months, p = 0.007), and a higher mortality rate (58.9 vs 25.0%, p = 0.012) compared with the SD group. CONCLUSION When compared to those with the SD phenotype, the mono-IBD patients had significant early-onset and poor responses to empiric antibiotics, IVIG, and steroids. Anti-inflammatory biologics and suitable HSCT still have the potential to control or even cure the mono-IBD phenotype.
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Affiliation(s)
- Wen-I Lee
- Primary Immunodeficiency Care and Research (PICAR) Institute, College of Medicine, Chang Gung Memorial University and Hospital, Kwei-Shan, #5 Fu-Shing St. (Pediatric Office 12 L), Taoyuan, Taiwan.
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Chien-Chang Chen
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shih-Hsiang Chen
- Division of Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wan-Tz Lai
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tang-Her Jaing
- Primary Immunodeficiency Care and Research (PICAR) Institute, College of Medicine, Chang Gung Memorial University and Hospital, Kwei-Shan, #5 Fu-Shing St. (Pediatric Office 12 L), Taoyuan, Taiwan
- Division of Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Liang-Shiou Ou
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chi-Jou Liang
- Primary Immunodeficiency Care and Research (PICAR) Institute, College of Medicine, Chang Gung Memorial University and Hospital, Kwei-Shan, #5 Fu-Shing St. (Pediatric Office 12 L), Taoyuan, Taiwan
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chen-Chen Kang
- Primary Immunodeficiency Care and Research (PICAR) Institute, College of Medicine, Chang Gung Memorial University and Hospital, Kwei-Shan, #5 Fu-Shing St. (Pediatric Office 12 L), Taoyuan, Taiwan
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jing-Long Huang
- Primary Immunodeficiency Care and Research (PICAR) Institute, College of Medicine, Chang Gung Memorial University and Hospital, Kwei-Shan, #5 Fu-Shing St. (Pediatric Office 12 L), Taoyuan, Taiwan.
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
- Department of Pediatrics, New Taipei Municipal TuChen Hospital, New Taipei, Taiwan.
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Infections in Inborn Errors of Immunity with Combined Immune Deficiency: A Review. Pathogens 2023; 12:pathogens12020272. [PMID: 36839544 PMCID: PMC9958715 DOI: 10.3390/pathogens12020272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/13/2023] [Accepted: 02/04/2023] [Indexed: 02/10/2023] Open
Abstract
Enhanced susceptibility to microbes, often resulting in severe, intractable and frequent infections due to usually innocuous organisms at uncommon sites, is the most striking feature in individuals with an inborn error of immunity. In this narrative review, based on the International Union of Immunological Societies' 2022 (IUIS 2022) Update on phenotypic classification of human inborn errors of immunity, the focus is on commonly encountered Combined Immunodeficiency Disorders (CIDs) with susceptibility to infections. Combined immune deficiency disorders are usually commensurate with survival beyond infancy unlike Severe Combined Immune Deficiency (SCID) and are often associated with clinical features of a syndromic nature. Defective humoral and cellular immune responses result in susceptibility to a broad range of microbial infections. Although disease onset is usually in early childhood, mild defects may present in late childhood or even in adulthood. A precise diagnosis is imperative not only for determining management strategies, but also for providing accurate genetic counseling, including prenatal diagnosis, and also in deciding empiric treatment of infections upfront before investigation reports are available.
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Lin YM, Hegde S, Cong Y, Shi XZ. Mechanisms of lymphoid depletion in bowel obstruction. Front Physiol 2022; 13:1005088. [PMID: 36213246 PMCID: PMC9533077 DOI: 10.3389/fphys.2022.1005088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/07/2022] [Indexed: 12/15/2022] Open
Abstract
Background and aims: Bowel obstruction (BO) causes not only gastrointestinal dysfunctions but also systemic responses such as sepsis, infections, and immune impairments. The mechanisms involved are not well understood. In this study, we tested the hypothesis that BO leads to lymphoid depletion in primary and peripheral lymphoid organs, which may contribute to systemic responses. We also sought to uncover mechanisms of lymphoid depletion in BO. Methods: Partial colon obstruction was induced with a band in the distal colon of Sprague-Dawley rats, and wild-type and osteopontin knockout (OPN-/-) mice. Obstruction was maintained for 7 days in rats and 4 days in mice. Thymus, bone marrow, spleen, and mesenteric lymph node (MLN) were taken for flow cytometry analysis. Results: The weight of thymus, spleen, and MLN was significantly decreased in BO rats, compared to sham. B and T lymphopoiesis in the bone marrow and thymus was suppressed, and numbers of lymphocytes, CD4+, and CD8+ T cells in the spleen and MLN were all decreased in BO. Depletion of gut microbiota blocked BO-associated lymphopenia in the MLN. Corticosterone antagonism partially attenuated BO-associated reduction of lymphocytes in the thymus and bone marrow. Plasma OPN levels and OPN expression in the distended colon were increased in BO. Deletion of the OPN gene did not affect splenic lymphopenia, but attenuated suppression of lymphopoiesis in the bone marrow and thymus in BO. Conclusions: BO suppresses lymphocyte generation and maintenance in lymphoid organs. Mechanical distention-induced OPN, corticosterone, and gut microbiota are involved in the immune phenotype in BO.
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Affiliation(s)
- You-Min Lin
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States,Department of Pathology, University of Texas Medical Branch, Galveston, TX, United States
| | - Shrilakshmi Hegde
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Yingzi Cong
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States
| | - Xuan-Zheng Shi
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States,*Correspondence: Xuan-Zheng Shi,
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Chen YE, Chen J, Guo W, Zhang Y, Li J, Xie H, Shen T, Ge Y, Huang Y, Zheng W, Lu M. Clinical Characteristics, In Silico Analysis, and Intervention of Neonatal-Onset Inflammatory Bowel Disease With Combined Immunodeficiency Caused by Novel TTC7A Variants. Front Genet 2022; 13:921808. [PMID: 35783276 PMCID: PMC9243236 DOI: 10.3389/fgene.2022.921808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 05/30/2022] [Indexed: 02/03/2023] Open
Abstract
We aimed to explore the genotypic and phenotypic characteristics of neonatal-onset inflammatory bowel disease (IBD) with combined immunodeficiency due to TTC7A mutation. We examined the clinical manifestations, imaging results, endoscopic and histological findings, interventions, and prognosis of a proband with neonatal-onset IBD and performed biochemical analyses, whole-exome sequencing (WES), and in silico analysis. Our proband developed severe early-onset diarrhea, malnutrition, electrolyte imbalance, dehydration, and recurrent infections after birth. Radiographic and ultrasonic images showed no specific manifestations. Endoscopic and histological examination revealed chronic inflammation. Immune function examination indicated immunodeficiency. WES identified compound heterozygous TTC7A mutations (c.2355+4A>G, c.643G>T) in the proband. In the expression analysis, no abnormal splicing in the TTC7A sequence was observed due to the c.2355+4A>G mutation; however, the mRNA expression was reduced. The proband’s condition did not improve after treatment with methylprednisolone or leflunomide. The proband died when treatment was stopped at the age of 5 months and 19 days. Compound heterozygous mutations (c.2355+4A>G, c.643G>T) in the TTC7A gene are described and verified for the first time. Our report expands the phenotypic spectrum of TTC7A mutations and the genotypic spectrum of very early-onset IBD with combined immunodeficiency.
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Affiliation(s)
- Yun-e Chen
- Department of Pediatrics, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Jingfang Chen
- Department of Gastroenterology, Xiamen Branch of the Children’s Hospital of Fudan University (Xiamen Children’s Hospital), Xiamen, China
| | - Wenxing Guo
- Department of Pediatrics, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Yanhong Zhang
- Department of Ultrasound Medicine, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Jialing Li
- Department of Gastroenterology, Xiamen Branch of the Children’s Hospital of Fudan University (Xiamen Children’s Hospital), Xiamen, China
| | - Hui Xie
- Department of Pediatrics, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Tong Shen
- Department of Pediatrics, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Yunsheng Ge
- Prenatal Diagnostic Center Laboratory, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Yanru Huang
- Prenatal Diagnostic Center Laboratory, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, China
- *Correspondence: Yanru Huang, ; Mei Lu,
| | - Wenying Zheng
- Genokon Institute of Medical Science and Laboratory, Xiamen, China
| | - Mei Lu
- Department of Pediatrics, Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, China
- *Correspondence: Yanru Huang, ; Mei Lu,
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Dannheim K, Ouahed J, Field M, Snapper S, Raphael BP, Glover SC, Bishop PR, Bhesania N, Kamin D, Thiagarajah JR, Goldsmith JD. Pediatric Gastrointestinal Histopathology in Patients With Tetratricopeptide Repeat Domain 7A (TTC7A) Germline Mutations: A Rare Condition Leading to Multiple Intestinal Atresias, Severe Combined Immunodeficiency, and Congenital Enteropathy. Am J Surg Pathol 2022; 46:846-853. [PMID: 34985046 PMCID: PMC9106838 DOI: 10.1097/pas.0000000000001856] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Mutations in the tetratricopeptide repeat domain 7A (TTC7A) gene are a rare cause of congenital enteropathy that can result in significant morbidity. TTC7A deficiency leads to disruption of the intestinal epithelium. The histopathology of this condition has been partly described in case reports and clinical studies. This manuscript describes an in-depth investigation of the pediatric gastrointestinal pathology of the largest histologically examined cohort with confirmed TTC7A mutations reported to date and, for the first time, compared the findings to age-matched and sex-matched control patients with intestinal atresia not thought to be associated with TTC7A mutations. Hematoxylin and eosin-stained slides of endoscopically obtained mucosal biopsies and surgical resection specimens from 7 patients with known TTC7A mutations were examined retrospectively. The microscopic findings were found to be on a spectrum from atresia-predominant to those with predominantly epithelial abnormalities. Several unique histopathologic characteristics were observed when compared with controls. These included neutrophilic colitis and prominent lamina propria eosinophilia throughout the gastrointestinal tract. Striking architectural abnormalities of the epithelium were observed in 4 of the 7 patients. The 5 patients with intestinal atresia demonstrated hypertrophy and disorganization of the colonic muscularis mucosae accompanied by bland spindle cell nodules within the intestinal wall. The components of the latter were further elucidated using immunohistochemistry, and we subsequently hypothesize that they represent obliterated mucosa with remnants of the muscularis mucosae. Finally, atrophic gastritis was noted in 4 patients. In conclusion, the unique histopathologic characteristics of TTC7A mutation-associated enteropathy described herein more fully describe this novel disease entity in infants who present with congenital enteropathy or enterocolitis.
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Affiliation(s)
- Katelyn Dannheim
- Department of Pathology, Rhode Island and Hasbro Children’s Hospitals, Providence, RI
| | - Jodie Ouahed
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, MA
- Congenital Enteropathy Program, Boston Children’s Hospital, Boston, MA
| | - Michael Field
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Scott Snapper
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, MA
| | | | - Sarah C. Glover
- Division of Digestive Diseases and Division of Pediatric Gastroenterology, University of Mississippi Medical Center, Jackson, MS
| | - Phyllis R. Bishop
- Division of Digestive Diseases and Division of Pediatric Gastroenterology, University of Mississippi Medical Center, Jackson, MS
| | - Natalie Bhesania
- Division of Digestive Diseases and Division of Pediatric Gastroenterology, University of Mississippi Medical Center, Jackson, MS
| | - Daniel Kamin
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, MA
- Congenital Enteropathy Program, Boston Children’s Hospital, Boston, MA
| | - Jay R. Thiagarajah
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, MA
- Congenital Enteropathy Program, Boston Children’s Hospital, Boston, MA
| | - Jeffrey D. Goldsmith
- Department of Pathology, Boston Children’s Hospital, Boston, MA
- Congenital Enteropathy Program, Boston Children’s Hospital, Boston, MA
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6
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Mou W, Yang S, Guo R, Fu L, Zhang L, Guo W, Du J, He J, Ren Q, Hao C, Gui J, Huang J. A Novel Homozygous TTC7A Missense Mutation Results in Familial Multiple Intestinal Atresia and Combined Immunodeficiency. Front Immunol 2022; 12:759308. [PMID: 34975848 PMCID: PMC8714664 DOI: 10.3389/fimmu.2021.759308] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/15/2021] [Indexed: 11/20/2022] Open
Abstract
Rare autosomal-recessive variants in tetratricopeptide repeat domain 7A (TTC7A) gene have been shown to cause intestinal and immune disorders of variable severity. Missense mutations in TTC7A gene, usually retaining most of the functional motifs, is associated with relative milder clinical presentations. In this study, we reported a patient who was suffering from severe multiple intestinal atresia (MIA) with combined immunodeficiency (CID) that led to the pyloric diaphragm, ileum atresia, colon stenosis, and multiple episodes of sepsis. In spite of several surgeries and supportive treatment, the patient died of severe sepsis and multiple organ failure at age of 3 months. The whole exome sequencing (WES) of peripheral blood samples identified a novel homozygous TTC7A missense mutation (c. 206T>C, p. L69P), inherited from his parents with consanguineous marriage. In silico analysis revealed that a hydrogen bond present between Gly65 and Leu69 in the wild-type TTC7A was disrupted by the Leu69Pro mutation. Moreover, this homozygous missense mutation led to a reduced TTC7A expression in lymphocytes and intestinal tissues, accompanied by impeded lymphocyte development. Further studies demonstrated that the PI4K-FAM126A-EFR3A pathway was impaired in colon tissues. Our data strongly support the linkage of severe MIA-CID with the missense mutation in TTC7A gene. More knowledge of the TTC7A protein functions will have important therapeutic implications for patients with MIA-CID.
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Affiliation(s)
- Wenjun Mou
- Laboratory of Tumor Immunology, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shen Yang
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Ruolan Guo
- Beijing Key Laboratory for Genetics of Birth Defects, Beijing Pediatric Research Institute; Ministry Of Education (MOE) Key Laboratory of Major Diseases in Children; Genetics and Birth Defects Control Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Libing Fu
- Department of Pathology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Li Zhang
- Key Laboratory of Advanced Theory and Application in Statistics and Data Science-Ministry Of Education (MOE), School of Statistics, East China Normal University, Shanghai, China
| | - Weihong Guo
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jingbin Du
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jianxin He
- Department of Respiratory Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Qinghua Ren
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Chanjuan Hao
- Beijing Key Laboratory for Genetics of Birth Defects, Beijing Pediatric Research Institute; Ministry Of Education (MOE) Key Laboratory of Major Diseases in Children; Genetics and Birth Defects Control Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jingang Gui
- Laboratory of Tumor Immunology, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jinshi Huang
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Immune function and infectious complications in children with jejunoileal atresia. J Pediatr Surg 2021; 56:454-458. [PMID: 32624206 DOI: 10.1016/j.jpedsurg.2020.05.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/19/2020] [Accepted: 05/24/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Little is known about differences in immune function among children with multiple intestinal atresia (MIA) and those with isolated intestinal atresia (IA), and how such differences may manifest as infectious complications and patient outcomes. This study aimed to investigate the immune function and its impact on patient outcomes in IA and MIA children. METHODS A single-center retrospective cohort study included children aged 0-19 years with intestinal atresia who were referred to a multidisciplinary intestinal rehabilitation program from 1/2000 to 12/2016. Data were collected for patient characteristics, surgical history, immunologic work-up, and infection-related hospitalizations. Groups of IA and MIA children were compared using chi-square test or Fisher's exact test for categorical variables and using Mann-Whitney test for continuous variables, as appropriate. RESULTS Twenty-seven children (18 IA, 9 MIA) were included. More than half of the patients had low CD counts for age in IA and MIA groups: CD3 58.3% vs. 66.7% (p = 1.0), CD4 50.0% vs. 66.7% (p = 0.7), CD8 67.7% vs. 88.9% (p = 0.3), respectively. Six out of 12 IA children and 3 out of 8 MIA children had hypogammaglobulinemia (p = 0.7). Three out of 10 IA patients and 3 out of 5 MIA children had frequent bacteremia (≥5/year). Eight children (6 IA and 2 MIA) underwent intestinal and/or liver transplant; MIA children had a worse posttransplant outcome. CONCLUSIONS IA children may have an immunodeficiency and associated infectious complications requiring hospitalization. We suggest performing immunologic evaluation not only in MIA but also in IA children presenting to an intestinal rehabilitation program to identify immunodeficiency. Early immunodeficiency screening may help initiate appropriate intervention and improve patient outcomes. LEVEL OF EVIDENCE Level III.
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Hale JE, Platt CD, Bonilla FA, Hay BN, Sullivan JL, Johnston AM, Pasternack MS, Hesterberg PE, Meissner HC, Cooper ER, Barmettler S, Farmer JR, Fisher D, Walter JE, Yang NJ, Sahai I, Eaton RB, DeMaria A, Notarangelo LD, Pai SY, Comeau AM. Ten Years of Newborn Screening for Severe Combined Immunodeficiency (SCID) in Massachusetts. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2060-2067.e2. [PMID: 33607339 DOI: 10.1016/j.jaip.2021.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Massachusetts began newborn screening (NBS) for severe combined immunodeficiency (SCID) using measurement of T-cell receptor excision circles (TRECs) from dried blood spots. OBJECTIVE We describe developments and outcomes from the first 10 years of this program (February 1, 2009, to January 31, 2019). METHODS TREC values, diagnostic, and outcome data from all patients screened for SCID were evaluated. RESULTS NBS of 720,038 infants prompted immunologic evaluation of 237 (0.03%). Of 237, 9 were diagnosed with SCID/leaky SCID (4% of referrals vs 0.001% general population). Another 7 were diagnosed with other combined immunodeficiencies, and 3 with athymia. SCID/leaky SCID incidence was approximately 1 in 80,000, whereas approximately 1 in 51,000 had severe T-cell lymphopenia for which definitive treatment was indicated. All patients with SCID/leaky SCID underwent hematopoietic cell transplant or gene therapy with 100% survival. One patient with athymia underwent successful thymus transplant. No known cases of SCID were missed. Compared with outcomes from the 10 years before SCID NBS, survival trended higher (9 of 9 vs 4 of 7), likely due to a lower rate of infection before treatment. CONCLUSIONS Our data support a single NBS testing-and-referral algorithm for all gestational ages. Despite lower median TREC values in premature infants, the majority for all ages are well above the TREC cutoff and the algorithm, which selects urgent (undetectable TREC) and repeatedly abnormal TREC values, minimizes referral. We also found that low naïve T-cell percentage is associated with a higher risk of SCID/CID, demonstrating the utility of memory/naïve T-cell phenotyping as part of follow-up flow cytometry.
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Affiliation(s)
- Jaime E Hale
- New England Newborn Screening Program, Commonwealth Medicine, University of Massachusetts Medical School, Worcester, Mass
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Francisco A Bonilla
- Division of Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Northeast Allergy, Asthma & Immunology, Leominster, Mass
| | - Beverly N Hay
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Mass
| | - John L Sullivan
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Mass
| | - Alicia M Johnston
- Harvard Medical School, Boston, Mass; Division of Infectious Disease, Boston Children's Hospital, Boston, Mass
| | - Mark S Pasternack
- Harvard Medical School, Boston, Mass; Pediatric Infectious Disease Unit, MassGeneral Hospital for Children, Boston, Mass
| | - Paul E Hesterberg
- Division of Allergy and Immunology, MassGeneral Hospital for Children, Boston, Mass
| | - H Cody Meissner
- Department of Pediatrics, Tufts Children's Hospital, Tufts University School of Medicine, Boston, Mass
| | - Ellen R Cooper
- Division of Pediatric Infectious Diseases, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Sara Barmettler
- Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Boston, Mass
| | - Donna Fisher
- Division of Pediatric Infectious Diseases, Baystate Children's Hospital, University of Massachusetts Medical School-Baystate, Springfield, Mass
| | - Jolan E Walter
- Division of Allergy and Immunology, MassGeneral Hospital for Children, Boston, Mass; Division of Allergy & Immunology, Department of Pediatrics, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, Fla
| | - Nancy J Yang
- Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Boston, Mass
| | - Inderneel Sahai
- New England Newborn Screening Program, Commonwealth Medicine, University of Massachusetts Medical School, Worcester, Mass; Department of Pediatrics, University of Massachusetts Medical School, Worcester, Mass
| | - Roger B Eaton
- New England Newborn Screening Program, Commonwealth Medicine, University of Massachusetts Medical School, Worcester, Mass; Department of Pediatrics, University of Massachusetts Medical School, Worcester, Mass
| | - Alfred DeMaria
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, Mass
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | - Sung-Yun Pai
- Harvard Medical School, Boston, Mass; Division of Hematology-Oncology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Mass.
| | - Anne Marie Comeau
- New England Newborn Screening Program, Commonwealth Medicine, University of Massachusetts Medical School, Worcester, Mass; Department of Pediatrics, University of Massachusetts Medical School, Worcester, Mass.
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Gut Microbiota-Host Interactions in Inborn Errors of Immunity. Int J Mol Sci 2021; 22:ijms22031416. [PMID: 33572538 PMCID: PMC7866830 DOI: 10.3390/ijms22031416] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/11/2022] Open
Abstract
Inborn errors of immunity (IEI) are a group of disorders that are mostly caused by genetic mutations affecting immune host defense and immune regulation. Although IEI present with a wide spectrum of clinical features, in about one third of them various degrees of gastrointestinal (GI) involvement have been described and for some IEI the GI manifestations represent the main and peculiar clinical feature. The microbiome plays critical roles in the education and function of the host's innate and adaptive immune system, and imbalances in microbiota-immunity interactions can contribute to intestinal pathogenesis. Microbial dysbiosis combined to the impairment of immunosurveillance and immune dysfunction in IEI, may favor mucosal permeability and lead to inflammation. Here we review how immune homeostasis between commensals and the host is established in the gut, and how these mechanisms can be disrupted in the context of primary immunodeficiencies. Additionally, we highlight key aspects of the first studies on gut microbiome in patients affected by IEI and discuss how gut microbiome could be harnessed as a therapeutic approach in these diseases.
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Combined Immunodeficiency With Inflammatory Bowel Disease in a Patient With TTC7A Deficiency. ACG Case Rep J 2019; 6:e00061. [PMID: 31616743 PMCID: PMC6658069 DOI: 10.14309/crj.0000000000000061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 01/31/2019] [Indexed: 11/17/2022] Open
Abstract
Tetratricopeptide repeat domain-7A (TTC7A) deficiency causing combined immunodeficiency with inflammatory bowel disease (IBD) is rare. This case report alerts physicians to the possibility of TTC7A deficiency causing combined immunodeficiency with IBD and also highlights some of the current treatment options. We describe a 19-year-old patient with a compound heterozygote TTC7A mutation causing combined immunodeficiency, IBD, and multiple intestinal atresia. Compound heterozygote TTC7A mutations are known to cause combined immunodeficiency and IBD. Although rare, clinicians should be alerted to this variant and should understand the general approach to treatment.
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11
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Gambineri E, Ciullini Mannurita S, Hagin D, Vignoli M, Anover-Sombke S, DeBoer S, Segundo GRS, Allenspach EJ, Favre C, Ochs HD, Torgerson TR. Clinical, Immunological, and Molecular Heterogeneity of 173 Patients With the Phenotype of Immune Dysregulation, Polyendocrinopathy, Enteropathy, X-Linked (IPEX) Syndrome. Front Immunol 2018; 9:2411. [PMID: 30443250 PMCID: PMC6223101 DOI: 10.3389/fimmu.2018.02411] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 09/28/2018] [Indexed: 12/22/2022] Open
Abstract
Background: Immune Dysregulation, Polyendocrinopathy, Enteropathy, X-linked (IPEX) Syndrome is a rare recessive disorder caused by mutations in the FOXP3 gene. In addition, there has been an increasing number of patients with wild-type FOXP3 gene and, in some cases, mutations in other immune regulatory genes. Objective: To molecularly asses a cohort of 173 patients with the IPEX phenotype and to delineate the relationship between the clinical/immunologic phenotypes and the genotypes. Methods: We reviewed the clinical presentation and laboratory characteristics of each patient and compared clinical and laboratory data of FOXP3 mutation-positive (IPEX patients) with those from FOXP3 mutation-negative patients (IPEX-like). A total of 173 affected patients underwent direct sequence analysis of the FOXP3 gene while 85 IPEX-like patients with normal FOXP3 were investigated by a multiplex panel of "Primary Immune Deficiency (PID-related) genes." Results: Forty-four distinct FOXP3 variants were identified in 88 IPEX patients, 9 of which were not previously reported. Among the 85 IPEX-like patients, 19 different disease-associated variants affecting 9 distinct genes were identified. Conclusions: We provide a comprehensive analysis of the clinical features and molecular bases of IPEX and IPEX-like patients. Although we were not able to identify major distinctive clinical features to differentiate IPEX from IPEX-like syndromes, we propose a simple flow-chart to effectively evaluate such patients and to focus on the most likely molecular diagnosis. Given the large number of potential candidate genes and overlapping phenotypes, selecting a panel of PID-related genes will facilitate a molecular diagnosis.
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Affiliation(s)
- Eleonora Gambineri
- Department of NEUROFARBA, University of Florence, Florence, Italy
- Oncology/Hematology Department, “Anna Meyer” Children's Hospital, Florence, Italy
| | - Sara Ciullini Mannurita
- Department of NEUROFARBA, University of Florence, Florence, Italy
- Oncology/Hematology Department, “Anna Meyer” Children's Hospital, Florence, Italy
| | - David Hagin
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
| | - Marina Vignoli
- Department of NEUROFARBA, University of Florence, Florence, Italy
- Oncology/Hematology Department, “Anna Meyer” Children's Hospital, Florence, Italy
| | | | - Stacey DeBoer
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
| | - Gesmar R. S. Segundo
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
| | - Eric J. Allenspach
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
| | - Claudio Favre
- Oncology/Hematology Department, “Anna Meyer” Children's Hospital, Florence, Italy
| | - Hans D. Ochs
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
| | - Troy R. Torgerson
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
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12
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Nunes-Santos CDJ, Rosenzweig SD. Bacille Calmette-Guerin Complications in Newly Described Primary Immunodeficiency Diseases: 2010-2017. Front Immunol 2018; 9:1423. [PMID: 29988375 PMCID: PMC6023996 DOI: 10.3389/fimmu.2018.01423] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/07/2018] [Indexed: 12/25/2022] Open
Abstract
Bacille Calmette–Guerin (BCG) vaccine is widely used as a prevention strategy against tuberculosis. BCG is a live vaccine, usually given early in life in most countries. While safe to most recipients, it poses a risk to immunocompromised patients. Several primary immunodeficiency diseases (PIDD) have been classically associated with complications related to BCG vaccine. However, a number of new inborn errors of immunity have been described lately in which little is known about adverse reactions following BCG vaccination. The aim of this review is to summarize the existing data on BCG-related complications in patients diagnosed with PIDD described since 2010. When BCG vaccination status or complications were not specifically addressed in those manuscripts, we directly contacted the corresponding authors for further clarification. We also analyzed data on other mycobacterial infections in these patients. Based on our analysis, around 8% of patients with gain-of-function mutations in STAT1 had mycobacterial infections, including localized complications in 3 and disseminated disease in 4 out of 19 BCG-vaccinated patients. Localized BCG reactions were also frequent in activated PI3Kδ syndrome type 1 (3/10) and type 2 (2/18) vaccinated children. Also, of note, no BCG-related complications have been described in either CTLA4 or LRBA protein-deficient patients; and not enough information on BCG-vaccinated NFKB1 or NFKB2-deficient patients was available to drive any conclusions about these diseases. Despite the high prevalence of environmental mycobacterial infections in GATA2-deficient patients, only one case of BCG reaction has been reported in a patient who developed disseminated disease. In conclusion, BCG complications could be expected in some particular, recently described PIDD and it remains a preventable risk factor for pediatric PIDD patients.
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Affiliation(s)
- Cristiane de Jesus Nunes-Santos
- Faculdade de Medicina, Instituto da Crianca, Universidade de São Paulo, São Paulo, Brazil.,Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Sergio D Rosenzweig
- Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, National Institutes of Health (NIH), Bethesda, MD, United States
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13
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Neves JF, Afonso I, Borrego L, Martins C, Cordeiro AI, Neves C, Lacoste C, Badens C, Fabre A. Missense mutation of TTC7A mimicking tricho-hepato-enteric (SD/THE) syndrome in a patient with very-early onset inflammatory bowel disease. Eur J Med Genet 2017; 61:185-188. [PMID: 29174094 DOI: 10.1016/j.ejmg.2017.11.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 10/04/2017] [Accepted: 11/21/2017] [Indexed: 12/13/2022]
Abstract
Tricho-hepato-enteric syndrome (SD/THE) and Multiple intestinal atresia with combined immune deficiency (MIA-CID) are autosomal recessive disorders that present immunological and gastrointestinal features. There are two different phenotypes of patients with TTC7A mutations: the severe form, caused by null mutations and leading to the classical MIA-CID; and the mild form, caused by missense mutations and leading to predominant features of VEO-IBD, less severe immunological involvement and hair abnormalities. We expand the knowledge about TTC7A deficiency, describing a patient with the mild phenotype of TTC7A deficiency but presenting overlapping features of SD/THE and MIA-CID: intestinal atresia and inflammatory bowel disease evocative of MIA-CID, but also dental abnormalities, huge forehead, liver abnormalities, autoimmune thyroiditis and hypogammaglobulinemia, evocative of SD/THE.
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Affiliation(s)
- João Farela Neves
- Primary Immunodeficiencies Unit, Hospital Dona Estefânia, CHLC, EPE, Lisbon, Portugal; CEDOC, Chronic Diseases Research Center, NOVA Medical School, Lisboa, Portugal.
| | - Isabel Afonso
- Gastroenterology Unit, Hospital Dona Estefânia, CHLC, EPE, Lisbon, Portugal
| | - Luis Borrego
- CEDOC, Chronic Diseases Research Center, NOVA Medical School, Lisboa, Portugal; Immunoallergy Department, Hospital CUF Descobertas, Lisbon, Portugal
| | - Catarina Martins
- CEDOC, Chronic Diseases Research Center, NOVA Medical School, Lisboa, Portugal
| | - Ana Isabel Cordeiro
- Primary Immunodeficiencies Unit, Hospital Dona Estefânia, CHLC, EPE, Lisbon, Portugal
| | - Conceição Neves
- Primary Immunodeficiencies Unit, Hospital Dona Estefânia, CHLC, EPE, Lisbon, Portugal
| | - Caroline Lacoste
- Laboratoire de Génétique Moléculaire, Hôpital d'enfants de la Timone, APHM, Marseille, France
| | - Catherine Badens
- Laboratoire de Génétique Moléculaire, Hôpital d'enfants de la Timone, APHM, Marseille, France; Faculté de Médecine, Inserm UMRS 910, Aix-Marseille Université, Marseille, France
| | - Alexandre Fabre
- Faculté de Médecine, Inserm UMRS 910, Aix-Marseille Université, Marseille, France; Service de Pédiatrie Multidisciplinaire, Hôpital d'enfants de la Timone, 264 rue Saint Pierre, APHM, 13005 Marseille, France
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14
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Ochs HD, Petroni D. From clinical observations and molecular dissection to novel therapeutic strategies for primary immunodeficiency disorders. Am J Med Genet A 2017; 176:784-803. [DOI: 10.1002/ajmg.a.38480] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 08/23/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Hans D. Ochs
- Department of Pediatrics and Seattle Children's Research Institute; University of Washington; Seattle Washington
| | - Daniel Petroni
- Department of Pediatrics and Seattle Children's Research Institute; University of Washington; Seattle Washington
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15
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Lien R, Lin YF, Lai MW, Weng HY, Wu RC, Jaing TH, Huang JL, Tsai SF, Lee WI. Novel Mutations of the Tetratricopeptide Repeat Domain 7A Gene and Phenotype/Genotype Comparison. Front Immunol 2017; 8:1066. [PMID: 28936210 PMCID: PMC5594067 DOI: 10.3389/fimmu.2017.01066] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 08/16/2017] [Indexed: 01/14/2023] Open
Abstract
The gastrointestinal tract contains the largest lymphoid organ to react with pathogenic microorganisms and suppress excess inflammation. Patients with primary immunodeficiency diseases (PIDs) can suffer from refractory diarrhea. In this study, we present two siblings who began to suffer from refractory diarrhea with a poor response to aggressive antibiotic and immunosuppressive treatment after surgical release of neonatal intestinal obstruction. Their lymphocyte proliferation was low, but superoxide production and IL-10 signaling were normal. Candidate genetic approach targeted to genes involved in PIDs with inflammatory bowel disease (IBD)-like manifestation was unrevealing. Whole-genome sequencing revealed novel heterozygous mutations Glu75Lys and nucleotide 520–521 CT deletion in the tetratricopeptide repeat domain 7A (TTC7A) gene. A Medline search identified 49 patients with TTC7A mutations, of whom 20 survived. Their phenotypes included both multiple intestinal atresia (MIA) and combined T and/or B immunodeficiency (CID) in 16, both IBD and CID in 14, isolated MIA in 8, MIA, IBD, and CID complex in 8, and isolated IBD in 3. Of these 98 mutant alleles over-through the coding region clustering on exon 2 (40 alleles), exon 7 (12 alleles), and exon 20 (10 alleles), 2 common hotspot mutations were c.211 G>A (p.E71K in exon 2) in 26 alleles and AAGT deletion in exon 7 (+3) in 10 alleles. Kaplan–Meier analysis showed that those with biallelic missense mutations (p = 0.0168), unaffected tetratricopeptide repeat domains (p = 0.0311), and developing autoimmune disorders (p = 0.001) had a relatively better prognosis. Hematopoietic stem cell transplantation (HSCT) restored immunity and seemed to decrease the frequency of infections; however, refractory diarrhea persisted. Clinical improvement was reported upon intestinal and liver transplantation in a child with CID and MIA of unknown genetic etiology. In conclusion, patients with TTC7A mutations presenting with the very early onset of refractory diarrhea had limit improvement by HSCT or/and tailored immunosuppressive therapy in the absence of suitable intestine donors. We suggest that MIA–CID–IBD disorder caused by TTC7A mutations should also be included in the PID classification of “immunodeficiencies affecting cellular and humoral immunity” to allow for prompt recognition and optimal treatment.
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Affiliation(s)
- Reyin Lien
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Feng Lin
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Zhunan, Taiwan
| | - Min-Wei Lai
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hui-Ying Weng
- VYM Genome Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Ren-Chin Wu
- Department of Pathology, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Tang-Her Jaing
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Hematology/Oncology, Department Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jing-Long Huang
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Primary Immunodeficiency Care and Research (PICAR) Institute, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shih-Feng Tsai
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Zhunan, Taiwan
| | - Wen-I Lee
- Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Primary Immunodeficiency Care and Research (PICAR) Institute, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
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16
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Lawless D, Mistry A, Wood PM, Stahlschmidt J, Arumugakani G, Hull M, Parry D, Anwar R, Carter C, Savic S. Bialellic Mutations in Tetratricopeptide Repeat Domain 7A (TTC7A) Cause Common Variable Immunodeficiency-Like Phenotype with Enteropathy. J Clin Immunol 2017; 37:617-622. [PMID: 28808844 DOI: 10.1007/s10875-017-0427-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 07/31/2017] [Indexed: 01/02/2023]
Affiliation(s)
- Dylan Lawless
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Wellcome Trust Brenner Building, St James's University Hospital, Beckett Street, Leeds, UK
| | - Anoop Mistry
- Department of Clinical Immunology and Allergy, St James's University Hospital, Beckett Street, Leeds, UK
| | - Philip M Wood
- Department of Clinical Immunology and Allergy, St James's University Hospital, Beckett Street, Leeds, UK
| | - Jens Stahlschmidt
- Department of Pathology, St James's University Hospital, Beckett Street, Leeds, UK
| | - Gururaj Arumugakani
- Department of Clinical Immunology and Allergy, St James's University Hospital, Beckett Street, Leeds, UK
| | - Mark Hull
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Wellcome Trust Brenner Building, St James's University Hospital, Beckett Street, Leeds, UK
| | - David Parry
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh, UK
| | - Rashida Anwar
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Wellcome Trust Brenner Building, St James's University Hospital, Beckett Street, Leeds, UK
| | - Clive Carter
- Department of Clinical Immunology and Allergy, St James's University Hospital, Beckett Street, Leeds, UK
| | - Sinisa Savic
- Department of Clinical Immunology and Allergy, St James's University Hospital, Beckett Street, Leeds, UK. .,National Institute for Health Research-Leeds Musculoskeletal Biomedical Research Unit (NIHR-LMBRU) and Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Wellcome Trust Brenner Building, St James's University Hospital, Beckett Street, Leeds, UK. .,Department of Clinical Immunology and Allergy, National Institute for Health Research-Leeds Musculoskeletal Biomedical Research Unit (NIHR-LMBRU) and Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Wellcome Trust Brenner Building, St James University, Beckett Street, Leeds, LS9 7TF, UK.
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