1
|
Cai Q, Feng F, Tian Y, Luo R, Mu D, Yang F, Yang Z, Zhou Z. A case report on deficiency of adenosine deaminase 2 with relapse-remission course and analysis of genotype-phenotype correlation. Am J Med Genet A 2024; 194:e63568. [PMID: 38353426 DOI: 10.1002/ajmg.a.63568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/25/2024] [Accepted: 02/02/2024] [Indexed: 05/02/2024]
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is a monogenic disease caused by biallelic mutations in adenosine deaminase 2 (ADA2). The varying phenotypes of the disease often lead to delayed diagnosis or misdiagnosis. We report an 11-year-old boy with DADA2 and provide a preliminary analysis of genotype-phenotype correlation. The age of onset of the disease was 8 years old. The disease successively involved the brainstem, muscles, joints, and cerebrum. After three relapse-remission episodes over 3 years, the patient was finally diagnosed with DADA2 by whole-exome sequencing. Compound heterozygous variants in the ADA2 gene (NM_001282225.2: c.1072G>A, p.Gly358Arg; c.419dupC, p.Arg141Lysfs*37) were found in the patient. He did not receive anti-TNF therapy and had no relapse after a 8-month follow-up. We identified a novel variant of the ADA2 gene, and the associated disease course may follow a relapse-remission pattern. Homozygous mutations of p.Gly358Arg can cause pure red cell aplasia, whereas compound heterozygous variations may lead to different phenotypes. Variants in the catalytic domain and frameshift mutations may also cause relatively benign phenotypes besides causing hematological disorders. Further studies are needed to clarify the genotypic-phenotypic relationship of this disease.
Collapse
Affiliation(s)
- Qianyun Cai
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Sichuan University, Chengdu, Sichuan, China
| | - Fan Feng
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Sichuan University, Chengdu, Sichuan, China
| | - Yanmei Tian
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Sichuan University, Chengdu, Sichuan, China
| | - Rong Luo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Sichuan University, Chengdu, Sichuan, China
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, Sichuan, China
- Department of Pediatrics, Key Laboratory of Development and Maternal and Child Diseases of Sichuan Province, Sichuan University, Chengdu, Sichuan, China
| | | | | | - Zhongjie Zhou
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
2
|
Wlodarski MW, Vlachos A, Farrar JE, Da Costa LM, Kattamis A, Dianzani I, Belendez C, Unal S, Tamary H, Pasauliene R, Pospisilova D, de la Fuente J, Iskander D, Wolfe L, Liu JM, Shimamura A, Albrecht K, Lausen B, Bechensteen AG, Tedgard U, Puzik A, Quarello P, Ramenghi U, Bartels M, Hengartner H, Farah RA, Al Saleh M, Hamidieh AA, Yang W, Ito E, Kook H, Ovsyannikova G, Kager L, Gleizes PE, Dalle JH, Strahm B, Niemeyer CM, Lipton JM, Leblanc TM. Diagnosis, treatment, and surveillance of Diamond-Blackfan anaemia syndrome: international consensus statement. Lancet Haematol 2024; 11:e368-e382. [PMID: 38697731 DOI: 10.1016/s2352-3026(24)00063-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/08/2024] [Accepted: 02/16/2024] [Indexed: 05/05/2024]
Abstract
Diamond-Blackfan anaemia (DBA), first described over 80 years ago, is a congenital disorder of erythropoiesis with a predilection for birth defects and cancer. Despite scientific advances, this chronic, debilitating, and life-limiting disorder continues to cause a substantial physical, psychological, and financial toll on patients and their families. The highly complex medical needs of affected patients require specialised expertise and multidisciplinary care. However, gaps remain in effectively bridging scientific discoveries to clinical practice and disseminating the latest knowledge and best practices to providers. Following the publication of the first international consensus in 2008, advances in our understanding of the genetics, natural history, and clinical management of DBA have strongly supported the need for new consensus recommendations. In 2014 in Freiburg, Germany, a panel of 53 experts including clinicians, diagnosticians, and researchers from 27 countries convened. With support from patient advocates, the panel met repeatedly over subsequent years, engaging in ongoing discussions. These meetings led to the development of new consensus recommendations in 2024, replacing the previous guidelines. To account for the diverse phenotypes including presentation without anaemia, the panel agreed to adopt the term DBA syndrome. We propose new simplified diagnostic criteria, describe the genetics of DBA syndrome and its phenocopies, and introduce major changes in therapeutic standards. These changes include lowering the prednisone maintenance dose to maximum 0·3 mg/kg per day, raising the pre-transfusion haemoglobin to 9-10 g/dL independent of age, recommending early aggressive chelation, broadening indications for haematopoietic stem-cell transplantation, and recommending systematic clinical surveillance including early colorectal cancer screening. In summary, the current practice guidelines standardise the diagnostics, treatment, and long-term surveillance of patients with DBA syndrome of all ages worldwide.
Collapse
Affiliation(s)
- Marcin W Wlodarski
- Department of Hematology, St Jude Children's Research Hospital, Memphis, TN, USA; Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Adrianna Vlachos
- Cohen Children's Medical Center, Hematology/Oncology and Stem Cell Transplantation, Hew Hyde Park, NY, USA; Feinstein Institutes for Medical Research, Manhasset, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jason E Farrar
- Arkansas Children's Research Institute and Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lydie M Da Costa
- Hôpital R. DEBRE, Groupe Hospitalier Universitaire, Assistance Publique-Hôpitaux de Paris Nord, Université de Paris Cité, Paris, France; HEMATIM, EA4666, UPJV, Amiens, France; Le LabEx Gr-Ex - Biogénèse et Pathologies du Globule Rouge, Paris, France
| | - Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Irma Dianzani
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Cristina Belendez
- Pediatric Hematology and Oncology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Instituto Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Sule Unal
- Hacettepe University, Department of Pediatric Hematology and Research Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey
| | - Hannah Tamary
- The Rina Zaizov Hematology-Oncology Division, Schneider Children's Medical Center of Israel, Peta Tikvah, Israel; Felsenstein Medical Research Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | | | - Dagmar Pospisilova
- Department of Pediatrics, Faculty Hospital of Palacky University, Olomouc, Czech Republic
| | - Josu de la Fuente
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK; Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Deena Iskander
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK; Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Lawrence Wolfe
- Cohen Children's Medical Center, Hematology/Oncology and Stem Cell Transplantation, Hew Hyde Park, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Johnson M Liu
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, The Tisch Cancer Institute, New York, NY, USA
| | - Akiko Shimamura
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Katarzyna Albrecht
- Department of Oncology, Paediatric Haematology, Clinical Transplantology and Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Birgitte Lausen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Ulf Tedgard
- Department of Pediatric Hematology and Oncology, Skåne University Hospital, Lund, Sweden
| | - Alexander Puzik
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paola Quarello
- Department of Pediatric and Public Health Sciences, University of Turin, Turin, Italy
| | - Ugo Ramenghi
- Department of Pediatric and Public Health Sciences, University of Turin, Turin, Italy
| | - Marije Bartels
- Pediatric Hematology Department, University Medical Center Utrecht, Utrecht, Netherlands
| | - Heinz Hengartner
- Pediatric Hospital of Eastern Switzerland St Gallen, St Gallen, Switzerland
| | - Roula A Farah
- Department of Pediatrics, LAU Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Mahasen Al Saleh
- King Faisal Hospital and Research Center Riyadh, Riyadh, Saudi Arabia
| | - Amir Ali Hamidieh
- Pediatric Cell and Gene Therapy Research Center, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Wan Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Etsuro Ito
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hoon Kook
- Chonnam National University Hwasun Hospital, Gwangju, South Korea
| | - Galina Ovsyannikova
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Leo Kager
- St. Anna Children's Hospital, Department of Pediatrics, Medical University Vienna, Vienna, Austria; Children's Cancer Research Institute, Vienna, Austria
| | | | - Jean-Hugues Dalle
- Pediatric Immunology and Hematology Department and CRMR aplasies médullaires, Robert Debré Hospital, Groupe Hospitalier Universitaire, Assistance Publique-Hôpitaux de Paris Nord, Université de Paris Cité, Paris, France
| | - Brigitte Strahm
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Charlotte M Niemeyer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium, Freiburg, Germany; German Cancer Research Center, Heidelberg, Germany
| | - Jeffrey M Lipton
- Cohen Children's Medical Center, Hematology/Oncology and Stem Cell Transplantation, Hew Hyde Park, NY, USA; Feinstein Institutes for Medical Research, Manhasset, NY, USA; Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Thierry M Leblanc
- Pediatric Immunology and Hematology Department and CRMR aplasies médullaires, Robert Debré Hospital, Groupe Hospitalier Universitaire, Assistance Publique-Hôpitaux de Paris Nord, Université de Paris Cité, Paris, France
| |
Collapse
|
3
|
Federici S, Cinicola BL, La Torre F, Castagnoli R, Lougaris V, Giardino G, Volpi S, Caorsi R, Leonardi L, Corrente S, Soresina A, Cancrini C, Insalaco A, Gattorno M, De Benedetti F, Marseglia GL, Del Giudice MM, Cardinale F. Vasculitis and vasculopathy associated with inborn errors of immunity: an overview. Front Pediatr 2024; 11:1258301. [PMID: 38357265 PMCID: PMC10866297 DOI: 10.3389/fped.2023.1258301] [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: 07/13/2023] [Accepted: 11/29/2023] [Indexed: 02/16/2024] Open
Abstract
Systemic autoinflammatory diseases (SAIDs) are disorders of innate immunity, which are characterized by unprovoked recurrent flares of systemic inflammation often characterized by fever associated with clinical manifestations mainly involving the musculoskeletal, mucocutaneous, gastrointestinal, and nervous systems. Several conditions also present with varied, sometimes prominent, involvement of the vascular system, with features of vasculitis characterized by variable target vessel involvement and organ damage. Here, we report a systematic review of vasculitis and vasculopathy associated with inborn errors of immunity.
Collapse
Affiliation(s)
- Silvia Federici
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Bianca Laura Cinicola
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco La Torre
- Department of Pediatrics, Giovanni XXIII Pediatric Hospital, University of Bari, Bari, Italy
| | - Riccardo Castagnoli
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Vassilios Lougaris
- Department of Clinical and Experimental Sciences, Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, University of Brescia and ASST-Spedali Civili di Brescia, Brescia, Italy
| | - Giuliana Giardino
- Pediatric Section, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Stefano Volpi
- Center for Autoinflammatory Diseases and Immunodeficiency, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Roberta Caorsi
- Center for Autoinflammatory Diseases and Immunodeficiency, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Lucia Leonardi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Annarosa Soresina
- Unit of Pediatric Immunology, Pediatrics Clinic, University of Brescia, ASST-Spedali Civili Brescia, Brescia, Italy
| | - Caterina Cancrini
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Academic Department of Pediatrics, Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Antonella Insalaco
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Marco Gattorno
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Gian Luigi Marseglia
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Michele Miraglia Del Giudice
- Department of Woman, Child and of General and Specialized Surgery, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Fabio Cardinale
- Department of Pediatrics, Giovanni XXIII Pediatric Hospital, University of Bari, Bari, Italy
| |
Collapse
|
4
|
Maccora I, Maniscalco V, Campani S, Carrera S, Abbati G, Marrani E, Mastrolia MV, Simonini G. A wide spectrum of phenotype of deficiency of deaminase 2 (DADA2): a systematic literature review. Orphanet J Rare Dis 2023; 18:117. [PMID: 37179309 PMCID: PMC10183141 DOI: 10.1186/s13023-023-02721-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/01/2023] [Indexed: 05/15/2023] Open
Abstract
INTRODUCTION Deficiency of adenosine deaminase 2 (DADA2) is a rare monogenic autoinflammatory disease, whose clinical phenotype was expanded since the first cases, originally described as mimicker of polyarteritis nodosa, with immunodeficiency and early-onset stroke. METHODS A systematic review according to PRISMA approach, including all articles published before the 31st of August 2021 in Pubmed and EMBASE database was performed. RESULTS The search identified 90 publications describing 378 unique patients (55.8% male). To date 95unique mutations have been reported. The mean age at disease onset was 92.15 months (range 0-720 months), 32 (8.5%) showed an onset of the first signs/symptoms after 18 years old and 96 (25.4%) after 10 years old. The most frequent clinical characteristics described were cutaneous (67.9%), haematological manifestations (56.3%), recurrent fever (51.3%), neurological as stroke and polyneuropathy (51%), immunological abnormalities (42.3%), arthralgia/arthritis (35.4%), splenomegaly (30.6%), abdominal involvement (29.8%), hepatomegaly (23.5%), recurrent infections (18.5%), myalgia (17.9%), kidney involvement (17.7%) etc. Patients with skin manifestations were older than the others (101.1 months SD ± 116.5, vs. 75.3 SD ± 88.2, p 0.041), while those with a haematological involvement (64.1 months SD ± 75.6 vs. 133.1 SD ± 133.1, p < 0.001) and immunological involvement (73.03 months SD ± 96.9 vs. 103.2 SD ± 112.9, p 0.05) are younger than the others. We observed different correlations among the different clinical manifestations. The use of anti-TNFα and hematopoietic cell stems transplantation (HCST) has improved the current history of the disease. CONCLUSION Due to this highly variable phenotype and age of presentation, patients with DADA2 may present to several type of specialists. Given the important morbidity and mortality, early diagnosis and treatment are mandatory.
Collapse
Affiliation(s)
- Ilaria Maccora
- Rheumatology Unit, ERN ReConnet Center, Meyer Children's Hospital IRCCS, Florence, Italy.
- NeuroFARBA Department, University of Florence, Florence, Italy.
| | | | - Silvia Campani
- School of Health Science, University of Florence, Florence, Italy
| | - Simona Carrera
- School of Health Science, University of Florence, Florence, Italy
| | - Giulia Abbati
- School of Health Science, University of Florence, Florence, Italy
| | - Edoardo Marrani
- Rheumatology Unit, ERN ReConnet Center, Meyer Children's Hospital IRCCS, Florence, Italy
| | | | - Gabriele Simonini
- Rheumatology Unit, ERN ReConnet Center, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA Department, University of Florence, Florence, Italy
| |
Collapse
|
5
|
Sharma V, Deo P, Sharma A. Deficiency of adenosine deaminase 2 (DADA2): Review. Best Pract Res Clin Rheumatol 2023; 37:101844. [PMID: 37328410 DOI: 10.1016/j.berh.2023.101844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/17/2023] [Accepted: 05/21/2023] [Indexed: 06/18/2023]
Abstract
The deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive disease caused by loss-of-function (LOF) mutations in the ADA2 gene and was first described in 2014. Initially, it was described as vasculopathy/vasculitis that mostly affected infants and young children and closely resembled polyarteritis nodosa (PAN). Skin rash and ischemic/hemorrhagic stroke are predominant symptoms. However, the clinical spectrum of DADA2 has continued to expand since then. It has now been reported in adults as well. Besides vasculitis-related manifestations, hematological, immunological, and autoinflammatory manifestations are now well recognized. More than 100 disease-causing mutations have been described. The decrease in ADA2 enzyme leads to an increased extracellular adenosine level that, in turn, triggers a proinflammatory cascade. The disease is highly variable, and patients carrying same mutation may have different ages of presentation and clinical features. Anti-tumor necrosis factor (TNF) agents are mainstay of treatment of the vasculitis/vasculopathy phenotype. Hematopoietic stem cell transplant (HSCT) has been performed in patients with severe hematological manifestations. Recombinant ADA2 protein and gene therapy hold a promise for future.
Collapse
Affiliation(s)
- Vikas Sharma
- Rheumatology Superspeciality Cell, Department of Medicine, IGMC Shimla and Clinical Immunology and Rheumatology Division, Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Prateek Deo
- Rheumatology Superspeciality Cell, Department of Medicine, IGMC Shimla and Clinical Immunology and Rheumatology Division, Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Aman Sharma
- Rheumatology Superspeciality Cell, Department of Medicine, IGMC Shimla and Clinical Immunology and Rheumatology Division, Department of Internal Medicine, PGIMER, Chandigarh, India.
| |
Collapse
|
6
|
Li GM, Han X, Wu Y, Wang W, Tang HX, Lu MP, Tang XM, Lin Y, Deng F, Yang J, Wang XN, Liu CC, Zheng WJ, Wu BB, Zhou F, Luo H, Zhang L, Liu HM, Guan WZ, Wang SH, Tao PF, Jin TJ, Fang R, Wu Y, Zhang J, Zhang Y, Zhang TN, Yin W, Guo L, Tang WJ, Chang H, Zhang QY, Li XZ, Li JG, Zhou ZX, Yang SR, Yang KK, Xu H, Song HM, Deuitch NT, Lee PY, Zhou Q, Sun L. A Cohort Study on Deficiency of ADA2 from China. J Clin Immunol 2023; 43:835-845. [PMID: 36807221 PMCID: PMC10110724 DOI: 10.1007/s10875-023-01432-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 01/08/2023] [Indexed: 02/21/2023]
Abstract
PURPOSE Deficiency of adenosine deaminase 2 (DADA2), an autosomal recessive autoinflammatory disorder caused by biallelic loss-of-function variants in adenosine deaminase 2 (ADA2), has not been systemically investigated in Chinese population yet. We aim to further characterize DADA2 cases in China. METHODS A retrospective analysis of patients with DADA2 identified through whole exome sequencing (WES) at seventeen rheumatology centers across China was conducted. Clinical characteristics, laboratory findings, genotype, and treatment response were analyzed. RESULTS Thirty patients with DADA2 were enrolled between January 2015 and December 2021. Adenosine deaminase 2 enzymatic activity was low in all tested cases to confirm pathogenicity. Median age of disease presentation was 4.3 years and the median age at diagnosis was 7.8 years. All but one patient presented during childhood and two subjects died from complications of their disease. The patients most commonly presented with systemic inflammation (92.9%), vasculitis (86.7%), and hypogammaglobinemia (73.3%) while one patient presented with bone marrow failure (BMF) with variable cytopenia. Twenty-three (76.7%) patients were treated with TNF inhibitors (TNFi), while two (6.7%) underwent hematopoietic stem cell transplantation (HSCT). They all achieved clinical remission. A total of thirty-nine ADA2 causative variants were identified, six of which were novel. CONCLUSION To establish early diagnosis and improve clinical outcomes, genetic screening and/or testing of ADA2 enzymatic activity should be performed in patients with suspected clinical features. TNFi is considered as first line treatment for those with vascular phenotypes. HSCT may be beneficial for those with hematological disease or in those who are refractory to TNFi.
Collapse
Affiliation(s)
- Guo-Min Li
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Xu Han
- Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Ye Wu
- Peking University First Hospital, Beijing, China
| | - Wei Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hong-Xia Tang
- Wuhan Children's Hospital Tongji Medical College Huazhong University of Science & Technology, Wuhan, China
| | - Mei-Ping Lu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xue-Mei Tang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Lin
- Affiliated Hospital of Qingdao University, Qingdao, China
| | - Fan Deng
- The Children's Hospital of Soochow, Suzhou, China
| | - Jun Yang
- Department of Rheumatology and Immunology, Shenzhen Children's Hospital, Shenzhen, China
| | - Xin-Ning Wang
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Cong-Cong Liu
- Division of Rheumatology, Immunology & Allergy in the Department of Pediatrics, The First Hospital of Jilin University, Changchun, China
| | - Wen-Jie Zheng
- Department of Rheumatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bing-Bing Wu
- National Children's Medical Center, Shanghai, China.,Medical Transformation Centre, Children's Hospital of Fudan University, Shanghai, China
| | - Fang Zhou
- No. 960 Hospital of the Joint Service Support Force of the Chinese People's Liberation Army, Jinan, China
| | - Hong Luo
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Liang Zhang
- Hunan Provincial People's Hospital, Hunan, China
| | - Hai-Mei Liu
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Wan-Zhen Guan
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Shi-Hao Wang
- Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Pan-Feng Tao
- Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Tai-Jie Jin
- Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Ran Fang
- Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Yuan Wu
- Peking University First Hospital, Beijing, China
| | - Jie Zhang
- Peking University First Hospital, Beijing, China
| | - Yao Zhang
- Peking University First Hospital, Beijing, China
| | - Tian-Nan Zhang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Yin
- Wuhan Children's Hospital Tongji Medical College Huazhong University of Science & Technology, Wuhan, China
| | - Li Guo
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wen-Jing Tang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Hong Chang
- Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qiu-Ye Zhang
- Affiliated Hospital of Qingdao University, Qingdao, China
| | | | - Jian-Guo Li
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Zhi-Xuan Zhou
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Si-Rui Yang
- Division of Rheumatology, Immunology & Allergy in the Department of Pediatrics, The First Hospital of Jilin University, Changchun, China
| | - Kang-Kang Yang
- Department of Rheumatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hong Xu
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Hong-Mei Song
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | | | - Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Qing Zhou
- Life Sciences Institute, Zhejiang University, Hangzhou, China.
| | - Li Sun
- National Children's Medical Center, Shanghai, China. .,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China.
| |
Collapse
|
7
|
Alabbas F, Alanzi T, Alrasheed A, Essa M, Elyamany G, Asiri A, Almutairi S, Al-Mayouf S, Alenazi A, Alsafadi D, Ballourah W, Albalawi N, Hanafy E, Al-Hebshi A, Alrashidi S, Albatniji F, Alfaraidi H, Ali TB, Al Qwaiee M, AlHilali M, Aldeeb H, Alhaidey A, Aljasem H, Althubaiti S, Alsultan A. Genotype and Phenotype of Adenosine Deaminase 2 Deficiency: a Report from Saudi Arabia. J Clin Immunol 2023; 43:338-349. [PMID: 36239861 DOI: 10.1007/s10875-022-01364-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 09/08/2022] [Indexed: 02/04/2023]
Abstract
Adenosine deaminase 2 deficiency (DADA2), a rare and potentially fatal systemic autoinflammatory disease, is characterized by low or lack of ADA2 activity due to ADA2 mutations. DADA2 symptoms are variable and include vasculitis, immunodeficiency, and cytopenia. Minimal data are available from Saudi Arabia. This retrospective study conducted at seven major tertiary medical centers examined the phenotypic and genotypic variabilities, clinical and diagnostic findings, and treatment outcomes among 20 Saudi patients with DADA2 from 14 families. The median age of the study cohort was 9.5 years (4-26 years). The clinical presentation was before the age of 5 months in 25% of patients. Homozygous c.1447-1451del mutation was the most frequent ADA2 alteration (40%), followed by c.882-2A:G (30%). All tested patients exhibited absent or near-absent ADA2 activity. Phenotypic manifestations included stroke (40%), hematological abnormalities (95%), lymphoproliferation (65%), and recurrent infection (45%). Five and three patients had extracranial vasculitis features and Hodgkin lymphoma, respectively. Atypical manifestations included growth retardation (30%) and transverse myelitis. Anti-tumor necrosis factor (anti-TNF) therapy was the main treatment. Some patients underwent blood transfusion, splenectomy, cyclosporine and colony-stimulating factor therapies, and hematopoietic stem cell transplantation due to anti-TNF therapy failure. Fulminant hepatitis and septic multiorgan failure caused mortality in three patients. Thus, this study revealed the variability in the molecular and clinical characteristics of DADA2 in the study cohort with predominant aberrant hematological and immunological characteristics. Consensus diagnostic criteria will facilitate early diagnosis and treatment. Additionally, disease registries or large prospective studies are needed for evaluating rare disease complications, such as cancer.
Collapse
Affiliation(s)
- Fahad Alabbas
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Prince Sultan Medical Military City (PSMMC), Sulimaniyah RD, Riyadh, 12233, Saudi Arabia.
- Scientific Research Center, Prince Sultan Medical Military City, Riyadh, Saudi Arabia.
| | - Talal Alanzi
- Department of Inborn Errors of Metabolism and Genetics, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Abdulrahman Alrasheed
- Department of Pediatric Rheumatology, King Abdullah Specialist Children's Hospital, Riyadh, Saudi Arabia
| | - Mohammed Essa
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, King Abdullah Specialist Children's Hospital, Riyadh, Saudi Arabia
| | - Ghaleb Elyamany
- Department of Central Military Laboratory and Blood Bank, Prince Sultan Medical Military Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman Asiri
- Department of Pediatric Rheumatology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Sajdi Almutairi
- Department of Pediatric Rheumatology, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Sulaiman Al-Mayouf
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullatif Alenazi
- Department of Pediatric Rheumatology, Children Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Danyah Alsafadi
- Department of Pediatric Rheumatology, Aziziah Children Hospital, Jeddah, Saudi Arabia
| | - Walid Ballourah
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Naif Albalawi
- Department of Pediatric Hematology and Oncology, Prince Sultan Oncology Center, King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
| | - Ehab Hanafy
- Department of Pediatric Hematology and Oncology, Prince Sultan Oncology Center, King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
| | - Abdulqader Al-Hebshi
- Department of Pediatrics, Prince Mohammed Bin Abdulaziz Hospital, Medina, Saudi Arabia
| | - Seham Alrashidi
- Department of Rheumatology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Fatma Albatniji
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Prince Sultan Medical Military City (PSMMC), Sulimaniyah RD, Riyadh, 12233, Saudi Arabia
| | - Huda Alfaraidi
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Prince Sultan Medical Military City (PSMMC), Sulimaniyah RD, Riyadh, 12233, Saudi Arabia
| | - Tahani Bin Ali
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Prince Sultan Medical Military City (PSMMC), Sulimaniyah RD, Riyadh, 12233, Saudi Arabia
| | - Mansour Al Qwaiee
- Department of Pediatric Pulmonology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Maryam AlHilali
- Department of Pediatric Immunology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Hayam Aldeeb
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Prince Sultan Medical Military City (PSMMC), Sulimaniyah RD, Riyadh, 12233, Saudi Arabia
| | - Ali Alhaidey
- Department of Radiology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Hassan Aljasem
- Department of Hematology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Sami Althubaiti
- Department of Pediatric Hematology and Oncology, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- Princess Nora Oncology Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Abdulrahman Alsultan
- Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
8
|
Pulvirenti F, Cinicola BL, Ferrari S, Guadagnolo D, Sculco E, Capponi M, Loffredo L, Sciannamea M, Insalaco A, Quinti I, De Benedetti F, Zicari AM. Case Report: Interindividual variability and possible role of heterozygous variants in a family with deficiency of adenosine deaminase 2: are all heterozygous born equals? Front Immunol 2023; 14:1156689. [PMID: 37207212 PMCID: PMC10188974 DOI: 10.3389/fimmu.2023.1156689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/19/2023] [Indexed: 05/21/2023] Open
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is a rare systemic autoinflammatory disease, typically with autosomal recessive inheritance, usually caused by biallelic loss of function mutations in the ADA2 gene. The phenotypic spectrum is broad, generally including fever, early-onset vasculitis, stroke, and hematologic dysfunction. Heterozygous carriers may show related signs and symptoms, usually milder and at an older age. Here we describe the case of two relatives, the proband and his mother, bearing an ADA2 homozygous pathogenic variant, and a heterozygous son. The proband was a 17-year-old boy with intermittent fever, lymphadenopathies, and mild hypogammaglobulinemia. He also had sporadic episodes of aphthosis, livedo reticularis and abdominal pain. Hypogammaglobulinemia was documented when he was 10 years old, and symptoms appeared in his late adolescence. The mother demonstrated mild hypogammaglobulinemia, chronic pericarditis since she was 30 years old and two transient episodes of diplopia without lacunar lesions on MRI. ADA2 (NM_001282225.2) sequencing identified both mother and son as homozygous for the c.1358A>G, p.(Tyr453Cys) variant. ADA2 activity in the proband and the mother was 80-fold lower than in the controls. Clinical features in both patients improved on anti-tumor necrosis factor therapy. An older son was found to be heterozygous for the same mutation post-mortem. He died at the age of 12 years due to a clinical picture of fever, lymphadenitis, skin rash and hypogammaglobulinemia evolving toward fatal multiorgan failure. Biopsies of skin, lymph nodes, and bone marrow excluded lymphomas and vasculitis. Despite being suspected of symptomatic carrier, the contribution of an additional variant in compound heterozygosity, or further genetic could not be ruled out, due to poor quality of DNA samples available. In conclusion, this familiar case demonstrated the wide range of phenotypic variability in DADA2. The search for ADA2 mutations and the assessment of ADA2 activity should be considered also in patients with the association of hypogammaglobulinemia and inflammatory conditions, also with late presentation and in absence of vasculitis. Furthermore, the clinical picture of the deceased carrier suggests a possible contribution of heterozygous pathogenic variants to inflammation.
Collapse
Affiliation(s)
- Federica Pulvirenti
- Reference Centre for Primary Immune Deficiencies, Azienda Ospedaliera Universitaria Policlinico Umberto I, Rome, Italy
| | - Bianca Laura Cinicola
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
- *Correspondence: Bianca Laura Cinicola,
| | - Simona Ferrari
- Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniele Guadagnolo
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Eleonora Sculco
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Martina Capponi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Loffredo
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Antonella Insalaco
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Isabella Quinti
- Reference Centre for Primary Immune Deficiencies, Azienda Ospedaliera Universitaria Policlinico Umberto I, Rome, Italy
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Anna Maria Zicari
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
9
|
Franco R, Lillo A, Navarro G, Reyes-Resina I. The adenosine A 2A receptor is a therapeutic target in neurological, heart and oncogenic diseases. Expert Opin Ther Targets 2022; 26:791-800. [DOI: 10.1080/14728222.2022.2136570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Rafael Franco
- CiberNed, Network Center for Neurodegenerative diseases, National Spanish Health Institute Carlos III, Madrid, Spain
- Molecular Neurobiology laboratory, Department of Biochemistry and Molecular Biomedicine, Faculty of Biology, Universitat de Barcelona, Barcelona, Spain
- School of Chemistry, Universitat de Barcelona, Barcelona, Spain
| | - Alejandro Lillo
- CiberNed, Network Center for Neurodegenerative diseases, National Spanish Health Institute Carlos III, Madrid, Spain
- Molecular Neuropharmacology laboratory, Department of Biochemistry and Physiology. School of Pharmacy and Food Science, Universitat de Barcelona, Barcelona, Spain
| | - Gemma Navarro
- CiberNed, Network Center for Neurodegenerative diseases, National Spanish Health Institute Carlos III, Madrid, Spain
- Molecular Neuropharmacology laboratory, Department of Biochemistry and Physiology. School of Pharmacy and Food Science, Universitat de Barcelona, Barcelona, Spain
| | - Irene Reyes-Resina
- CiberNed, Network Center for Neurodegenerative diseases, National Spanish Health Institute Carlos III, Madrid, Spain
- School of Chemistry, Universitat de Barcelona, Barcelona, Spain
- Molecular Neuropharmacology laboratory, Department of Biochemistry and Physiology. School of Pharmacy and Food Science, Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
10
|
Signa S, Bertoni A, Penco F, Caorsi R, Cafaro A, Cangemi G, Volpi S, Gattorno M, Schena F. Adenosine Deaminase 2 Deficiency (DADA2): A Crosstalk Between Innate and Adaptive Immunity. Front Immunol 2022; 13:935957. [PMID: 35898506 PMCID: PMC9309328 DOI: 10.3389/fimmu.2022.935957] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/10/2022] [Indexed: 11/30/2022] Open
Abstract
Deficiency of Adenosine deaminase 2 (DADA2) is a monogenic autoinflammatory disorder presenting with a broad spectrum of clinical manifestations, including immunodeficiency, vasculopathy and hematologic disease. Biallelic mutations in ADA2 gene have been associated with a decreased ADA2 activity, leading to reduction in deamination of adenosine and deoxyadenosine into inosine and deoxyinosine and subsequent accumulation of extracellular adenosine. In the early reports, the pivotal role of innate immunity in DADA2 pathogenic mechanism has been underlined, showing a skewed polarization from the M2 macrophage subtype to the proinflammatory M1 subtype, with an increased production of inflammatory cytokines such as TNF-α. Subsequently, a dysregulation of NETosis, triggered by the excess of extracellular Adenosine, has been implicated in the pathogenesis of DADA2. In the last few years, evidence is piling up that adaptive immunity is profoundly altered in DADA2 patients, encompassing both T and B branches, with a disrupted homeostasis in T-cell subsets and a B-cell skewing defect. Type I/type II IFN pathway upregulation has been proposed as a possible core signature in DADA2 T cells and monocytes but also an increased IFN-β secretion directly from endothelial cells has been described. So far, a unifying clear pathophysiological explanation for the coexistence of systemic inflammation, immunedysregulation and hematological defects is lacking. In this review, we will explore thoroughly the latest understanding regarding DADA2 pathophysiological process, with a particular focus on dysregulation of both innate and adaptive immunity and their interacting role in the development of the disease.
Collapse
Affiliation(s)
- Sara Signa
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Arinna Bertoni
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Federica Penco
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Roberta Caorsi
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Alessia Cafaro
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Giuliana Cangemi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Stefano Volpi
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Marco Gattorno
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
- *Correspondence: Marco Gattorno,
| | - Francesca Schena
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| |
Collapse
|
11
|
Hashem H, Dimitrova D, Meyts I. Allogeneic Hematopoietic Cell Transplantation for Patients With Deficiency of Adenosine Deaminase 2 (DADA2): Approaches, Obstacles and Special Considerations. Front Immunol 2022; 13:932385. [PMID: 35911698 PMCID: PMC9336546 DOI: 10.3389/fimmu.2022.932385] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/20/2022] [Indexed: 01/07/2023] Open
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is an inherited autosomal recessive disease characterized by autoinflammation (recurrent fever), vasculopathy (livedo racemosa, polyarteritis nodosa, lacunar ischemic strokes, and intracranial hemorrhages, end organ vasculitis), immunodeficiency, lymphoproliferation, immune cytopenias, and bone marrow failure. Allogeneic hematopoietic cell transplantation (HCT) is curative for DADA2 as it reverses the hematological, immune and vascular phenotype of DADA2. The primary goal of HCT in DADA2, like in other non-malignant diseases, is engraftment with the establishment of normal hematopoiesis and normal immune function. Strategies in selecting a preparative regimen should take into consideration the specific vulnerabilities to endothelial dysfunction and liver toxicity in DADA2 patients. Overcoming an increased risk of graft rejection while minimizing organ toxicity, graft-versus-host disease, and infections can be particularly challenging in DADA2 patients. This review will discuss approaches to HCT in DADA2 patients including disease-specific considerations, barriers to successful engraftment, post-HCT complications, and clinical outcomes of published patients with DADA2 who have undergone HCT to date.
Collapse
Affiliation(s)
- Hasan Hashem
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Bone Marrow Transplant Unit, King Hussein Cancer Center (KHCC), Amman, Jordan
- *Correspondence: Hasan Hashem, ; Isabelle Meyts,
| | - Dimana Dimitrova
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute of the National Institutes of Health, Bethesda, MD, United States
| | - Isabelle Meyts
- Department of Pediatrics, Microbiology, Immunology, and Transplantation, The European Reference Network Rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network (ERN RITA) Core Center, University Hospitals Leuven, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
- *Correspondence: Hasan Hashem, ; Isabelle Meyts,
| |
Collapse
|
12
|
Signa S, Dell’Orso G, Gattorno M, Faraci M. Hematopoietic stem cell transplantation in systemic autoinflammatory diseases - the first one hundred transplanted patients. Expert Rev Clin Immunol 2022; 18:667-689. [DOI: 10.1080/1744666x.2022.2078704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Sara Signa
- Center for Autoinflammatory diseases and Immunodeficiencies, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Gianluca Dell’Orso
- Hematopoietic stem cell Transplantation Unit, Department of Hematology-Oncology, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Marco Gattorno
- Center for Autoinflammatory diseases and Immunodeficiencies, IRCSS Istituto Giannina Gaslini, Genova, Italy
| | - Maura Faraci
- Hematopoietic stem cell Transplantation Unit, Department of Hematology-Oncology, IRCSS Istituto Giannina Gaslini, Genova, Italy
| |
Collapse
|
13
|
Tarrant TK, Kelly SJ, Hershfield MS. Elucidating the pathogenesis of adenosine deaminase 2 deficiency: current status and unmet needs. Expert Opin Orphan Drugs 2022. [DOI: 10.1080/21678707.2021.2050367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | | | - Michael S Hershfield
- Duke University School of Medicine, Durham, US
- Duke University School of Medicine, Medicine and Biochemistry, Durham, US
| |
Collapse
|
14
|
Barron KS, Aksentijevich I, Deuitch NT, Stone DL, Hoffmann P, Videgar-Laird R, Soldatos A, Bergerson J, Toro C, Cudrici C, Nehrebecky M, Romeo T, Jones A, Boehm M, Kanakry JA, Dimitrova D, Calvo KR, Alao H, Kapuria D, Ben-Yakov G, Pichard DC, Hathaway L, Brofferio A, McRae E, Moura NS, Schnappauf O, Rosenzweig S, Heller T, Cowen EW, Kastner DL, Ombrello AK. The Spectrum of the Deficiency of Adenosine Deaminase 2: An Observational Analysis of a 60 Patient Cohort. Front Immunol 2022; 12:811473. [PMID: 35095905 PMCID: PMC8790931 DOI: 10.3389/fimmu.2021.811473] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/08/2021] [Indexed: 11/21/2022] Open
Abstract
The deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessively inherited disease that has undergone extensive phenotypic expansion since being first described in patients with fevers, recurrent strokes, livedo racemosa, and polyarteritis nodosa in 2014. It is now recognized that patients may develop multisystem disease that spans multiple medical subspecialties. Here, we describe the findings from a large single center longitudinal cohort of 60 patients, the broad phenotypic presentation, as well as highlight the cohort’s experience with hematopoietic cell transplantation and COVID-19. Disease manifestations could be separated into three major phenotypes: inflammatory/vascular, immune dysregulatory, and hematologic, however, most patients presented with significant overlap between these three phenotype groups. The cardinal features of the inflammatory/vascular group included cutaneous manifestations and stroke. Evidence of immune dysregulation was commonly observed, including hypogammaglobulinemia, absent to low class-switched memory B cells, and inadequate response to vaccination. Despite these findings, infectious complications were exceedingly rare in this cohort. Hematologic findings including pure red cell aplasia (PRCA), immune-mediated neutropenia, and pancytopenia were observed in half of patients. We significantly extended our experience using anti-TNF agents, with no strokes observed in 2026 patient months on TNF inhibitors. Meanwhile, hematologic and immune features had a more varied response to anti-TNF therapy. Six patients received a total of 10 allogeneic hematopoietic cell transplant (HCT) procedures, with secondary graft failure necessitating repeat HCTs in three patients, as well as unplanned donor cell infusions to avoid graft rejection. All transplanted patients had been on anti-TNF agents prior to HCT and received varying degrees of reduced-intensity or non-myeloablative conditioning. All transplanted patients are still alive and have discontinued anti-TNF therapy. The long-term follow up afforded by this large single-center study underscores the clinical heterogeneity of DADA2 and the potential for phenotypes to evolve in any individual patient.
Collapse
Affiliation(s)
- Karyl S Barron
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Ivona Aksentijevich
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Natalie T Deuitch
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Deborah L Stone
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Patrycja Hoffmann
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Ryan Videgar-Laird
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Ariane Soldatos
- National Institute of Neurological Diseases and Strokes, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Jenna Bergerson
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Camilo Toro
- Undiagnosed Disease Program, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Cornelia Cudrici
- National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Michele Nehrebecky
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Tina Romeo
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Anne Jones
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Manfred Boehm
- National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Jennifer A Kanakry
- National Cancer Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Dimana Dimitrova
- National Cancer Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Katherine R Calvo
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Hawwa Alao
- National Institute of Digestive Diseases and Kidney Diseases, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Devika Kapuria
- National Institute of Digestive Diseases and Kidney Diseases, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Gil Ben-Yakov
- National Institute of Digestive Diseases and Kidney Diseases, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Dominique C Pichard
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Londa Hathaway
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Alessandra Brofferio
- National Heart, Lung, and Blood Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Elisa McRae
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Natalia Sampaio Moura
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Oskar Schnappauf
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Sofia Rosenzweig
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Theo Heller
- National Institute of Digestive Diseases and Kidney Diseases, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Edward W Cowen
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Daniel L Kastner
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Amanda K Ombrello
- National Human Genome Research Institute, National Institutes of Health (NIH), Bethesda, MD, United States
| |
Collapse
|
15
|
Albalawi R, Hanafy E, Alnafea H, Altowijiry M, Riyad S, Abufara F, Albolowi N. Novel Adenosine Deaminase 2 (ADA2) Mutations Associated With Hematological Manifestations. J Investig Med High Impact Case Rep 2021; 9:23247096211056770. [PMID: 34845942 PMCID: PMC8637373 DOI: 10.1177/23247096211056770] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Recent progress in laboratory techniques, particularly, identification of novel disease-causing genes, has led to the detection of different gene mutations that might be implicated in the pathogenesis of different hematological disorders like pure red cell aplasia (PRCA) and neutropenia. An autoinflammatory disorder known as deficiency of adenosine deaminase 2 (DADA2) has been recently noticed to present with variable hematologic abnormalities. We report 2 patients who presented with hematologic abnormalities in which 2 ADA2 gene mutations were detected. The first case is a 5-year-old girl who presented with severe PRCA and autoimmune hemolytic anemia without any other manifestation of DADA2 that resulted from a novel CECR1 c.714_738dup, p. (Ala247Glnfs*16) homozygous variant. The second case is a 10-year-old boy, known to have Hodgkin lymphoma and was under follow-up for 6 years; he presented with persistent neutropenia and was discovered to be homozygous for ADA2 c.1447_1451del, p. (Ser483Profs*5). In conclusion, we report two different novels ADA2 variants in two children; the first presented with PRCA and the second presented with persistent neutropenia. This report aims to raise the concerns regarding the use of genetic testing in different hematologic diseases with indefinite etiology, as it will lead to the best therapeutic strategies without the need for unnecessary interventions.
Collapse
Affiliation(s)
| | - Ehab Hanafy
- King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
| | | | | | - Shaima Riyad
- King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
| | - Fadwa Abufara
- King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
| | - Naif Albolowi
- King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
| |
Collapse
|
16
|
Yap JY, Moens L, Lin MW, Kane A, Kelleher A, Toong C, Wu KHC, Sewell WA, Phan TG, Hollway GE, Enthoven K, Gray PE, Casas-Martin J, Wouters C, De Somer L, Hershfield M, Bucciol G, Delafontaine S, Ma CS, Tangye SG, Meyts I. Intrinsic Defects in B Cell Development and Differentiation, T Cell Exhaustion and Altered Unconventional T Cell Generation Characterize Human Adenosine Deaminase Type 2 Deficiency. J Clin Immunol 2021; 41:1915-1935. [PMID: 34657246 PMCID: PMC8604888 DOI: 10.1007/s10875-021-01141-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/22/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Deficiency of adenosine deaminase type 2 (ADA2) (DADA2) is a rare inborn error of immunity caused by deleterious biallelic mutations in ADA2. Clinical manifestations are diverse, ranging from severe vasculopathy with lacunar strokes to immunodeficiency with viral infections, hypogammaglobulinemia and bone marrow failure. Limited data are available on the phenotype and function of leukocytes from DADA2 patients. The aim of this study was to perform in-depth immunophenotyping and functional analysis of the impact of DADA2 on human lymphocytes. METHODS In-depth immunophenotyping and functional analyses were performed on ten patients with confirmed DADA2 and compared to heterozygous carriers of pathogenic ADA2 mutations and normal healthy controls. RESULTS The median age of the patients was 10 years (mean 20.7 years, range 1-44 years). Four out of ten patients were on treatment with steroids and/or etanercept or other immunosuppressives. We confirmed a defect in terminal B cell differentiation in DADA2 and reveal a block in B cell development in the bone marrow at the pro-B to pre-B cell stage. We also show impaired differentiation of CD4+ and CD8+ memory T cells, accelerated exhaustion/senescence, and impaired survival and granzyme production by ADA2 deficient CD8+ T cells. Unconventional T cells (i.e. iNKT, MAIT, Vδ2+ γδT) were diminished whereas pro-inflammatory monocytes and CD56bright immature NK cells were increased. Expression of the IFN-induced lectin SIGLEC1 was increased on all monocyte subsets in DADA2 patients compared to healthy donors. Interestingly, the phenotype and function of lymphocytes from healthy heterozygous carriers were often intermediate to that of healthy donors and ADA2-deficient patients. CONCLUSION Extended immunophenotyping in DADA2 patients shows a complex immunophenotype. Our findings provide insight into the cellular mechanisms underlying some of the complex and heterogenous clinical features of DADA2. More research is needed to design targeted therapy to prevent viral infections in these patients with excessive inflammation as the overarching phenotype.
Collapse
Affiliation(s)
- Jin Yan Yap
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia
| | - Leen Moens
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium
| | - Ming-Wei Lin
- Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia.,Department of Clinical Immunology and Immunopathology, Westmead Hospital, Westmead, NSW, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Alisa Kane
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia.,Department of Immunology, Liverpool Hospital, Allergy and HIV, Liverpool, Sydney, Australia.,HIV and Immunology Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, Sydney, NSW, Australia
| | - Anthony Kelleher
- HIV and Immunology Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia.,The Kirby Institute for Infection and Immunity in Society, Sydney, Australia
| | - Catherine Toong
- Department of Immunology, Liverpool Hospital, Allergy and HIV, Liverpool, Sydney, Australia
| | - Kathy H C Wu
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,St Vincent's Clinical Genomics, St Vincent's Hospital Darlinghurst, Darlinghurst, NSW, Australia.,School of Medicine, UNSW Sydney, Sydney, Australia.,Discipline of Genetic Medicine, University of Sydney, Sydney, Australia.,School of Medicine, University of Notre Dame, Fremantle, Australia
| | - William A Sewell
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, Sydney, NSW, Australia
| | - Tri Giang Phan
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia.,HIV and Immunology Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Georgina E Hollway
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia
| | - Karen Enthoven
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia
| | - Paul E Gray
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, Australia.,School of Women's and Children's Health, UNSW Sydney, Sydney, NSW, Australia
| | - Jose Casas-Martin
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium
| | - Carine Wouters
- Department of Microbiology and Immunology, Herestraat 49, 3000, Leuven, EU, Belgium.,Department of Pediatrics, University Hospitals Leuven, Leuven, EU, Belgium
| | - Lien De Somer
- Department of Microbiology and Immunology, Herestraat 49, 3000, Leuven, EU, Belgium.,Department of Pediatrics, University Hospitals Leuven, Leuven, EU, Belgium
| | - Michael Hershfield
- Department of Medicine and Biochemistry, Duke University Medical Center, Durham, NC, USA
| | - Giorgia Bucciol
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium.,Department of Pediatrics, Division of Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, EU Leuven, Belgium
| | - Selket Delafontaine
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium.,Department of Pediatrics, Division of Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, EU Leuven, Belgium
| | - Cindy S Ma
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, Sydney, NSW, Australia
| | - Stuart G Tangye
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia. .,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia. .,Faculty of Medicine, St Vincent's Clinical School, Sydney, NSW, Australia.
| | - Isabelle Meyts
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium. .,Department of Medicine and Biochemistry, Duke University Medical Center, Durham, NC, USA.
| |
Collapse
|
17
|
Hashem H, Bucciol G, Ozen S, Unal S, Bozkaya IO, Akarsu N, Taskinen M, Koskenvuo M, Saarela J, Dimitrova D, Hickstein DD, Hsu AP, Holland SM, Krance R, Sasa G, Kumar AR, Müller I, de Sousa MA, Delafontaine S, Moens L, Babor F, Barzaghi F, Cicalese MP, Bredius R, van Montfrans J, Baretta V, Cesaro S, Stepensky P, Benedicte N, Moshous D, Le Guenno G, Boutboul D, Dalal J, Brooks JP, Dokmeci E, Dara J, Lucas CL, Hambleton S, Wilson K, Jolles S, Koc Y, Güngör T, Schnider C, Candotti F, Steinmann S, Schulz A, Chambers C, Hershfield M, Ombrello A, Kanakry JA, Meyts I. Hematopoietic Cell Transplantation Cures Adenosine Deaminase 2 Deficiency: Report on 30 Patients. J Clin Immunol 2021; 41:1633-1647. [PMID: 34324127 PMCID: PMC8452581 DOI: 10.1007/s10875-021-01098-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/06/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Deficiency of adenosine deaminase 2 (DADA2) is an inherited inborn error of immunity, characterized by autoinflammation (recurrent fever), vasculopathy (livedo racemosa, polyarteritis nodosa, lacunar ischemic strokes, and intracranial hemorrhages), immunodeficiency, lymphoproliferation, immune cytopenias, and bone marrow failure (BMF). Tumor necrosis factor (TNF-α) blockade is the treatment of choice for the vasculopathy, but often fails to reverse refractory cytopenia. We aimed to study the outcome of hematopoietic cell transplantation (HCT) in patients with DADA2. METHODS We conducted a retrospective study on the outcome of HCT in patients with DADA2. The primary outcome was overall survival (OS). RESULTS Thirty DADA2 patients from 12 countries received a total of 38 HCTs. The indications for HCT were BMF, immune cytopenia, malignancy, or immunodeficiency. Median age at HCT was 9 years (range: 2-28 years). The conditioning regimens for the final transplants were myeloablative (n = 20), reduced intensity (n = 8), or non-myeloablative (n = 2). Donors were HLA-matched related (n = 4), HLA-matched unrelated (n = 16), HLA-haploidentical (n = 2), or HLA-mismatched unrelated (n = 8). After a median follow-up of 2 years (range: 0.5-16 years), 2-year OS was 97%, and 2-year GvHD-free relapse-free survival was 73%. The hematological and immunological phenotypes resolved, and there were no new vascular events. Plasma ADA2 enzyme activity normalized in 16/17 patients tested. Six patients required more than one HCT. CONCLUSION HCT was an effective treatment for DADA2, successfully reversing the refractory cytopenia, as well as the vasculopathy and immunodeficiency. CLINICAL IMPLICATIONS HCT is a definitive cure for DADA2 with > 95% survival.
Collapse
Affiliation(s)
- Hasan Hashem
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Bone Marrow Transplant Unit, King Hussein Cancer Center (KHCC), P.O Box 1269, Amman, 11941, Jordan.
| | - Giorgia Bucciol
- Department of Pediatrics, ERN RITA Core Center, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Seza Ozen
- Department of Pediatric Rheumatology, Hacettepe University, Ankara, Turkey
- Hacettepe University Vasculitis Research Center, Ankara, Turkey
| | - Sule Unal
- Department of Pediatric Hematology, Research Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Hacettepe University, Ankara, Turkey
| | - Ikbal Ok Bozkaya
- Division of Pediatric Hematology and Oncology, Bone Marrow Transplant Unit, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Nurten Akarsu
- Department of Medical Genetics, Hacettepe University, Sihhiye, 06100, Ankara, Turkey
| | - Mervi Taskinen
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Helsinki University Hospital, Helsinki, Finland
| | - Minna Koskenvuo
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Children and Adolescents, Helsinki University Hospital, Helsinki, Finland
| | - Janna Saarela
- Institute for Molecular Medicine Finland, HiLIFE, University of Helsinki, Helsinki, Finland
- Centre for Molecular Medicine Norway, University of Oslo, Oslo, Norway
| | - Dimana Dimitrova
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute of the National Institutes of Health, Bethesda, MD, USA
| | | | - Amy P Hsu
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Steven M Holland
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Robert Krance
- Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Ghadir Sasa
- Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Ashish R Kumar
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ingo Müller
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monica Abreu de Sousa
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Selket Delafontaine
- Department of Pediatrics, ERN RITA Core Center, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Leen Moens
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Florian Babor
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Federica Barzaghi
- San Raffaele Telethon Institute for Gene Therapy (TIGET), Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute Milan, Milan, Italy
| | - Maria Pia Cicalese
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Robbert Bredius
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands
| | - Joris van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Valentina Baretta
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Polina Stepensky
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel
| | - Neven Benedicte
- Pediatric Immunology, Hematology and Rheumatology Unit, Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - Despina Moshous
- Pediatric Immunology, Hematology and Rheumatology Unit, Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - Guillaume Le Guenno
- Department of Internal Medicine, University Hospital Estaing, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - David Boutboul
- Clinical Immunology Department, Hospital Saint Louis, Université de Paris, Paris, France
| | - Jignesh Dalal
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Joel P Brooks
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Elif Dokmeci
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, USA
| | - Jasmeen Dara
- Department of Pediatrics, Division of Allergy, Immunology, Blood and Marrow Transplantation, University of California San Francisco, San Francisco, CA, USA
| | - Carrie L Lucas
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Sophie Hambleton
- Newcastle University Translational and Clinical Research Institute and Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, , Newcastle Upon Tyne, UK
| | - Keith Wilson
- Department of Hematology, University Hospital of Wales, Cardiff, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Yener Koc
- Stem Cell Transplant Unit, Medicana International, Istanbul, Turkey
| | - Tayfun Güngör
- Division of Hematology/Oncology/Immunology, Gene Therapy, and Stem Cell Transplantation, University Children's Hospital Zurich - Eleonore Foundation & Children's Research Center (CRC), Steinwiesstrasse 75, CH-8032, Zurich, Switzerland
| | - Caroline Schnider
- Pediatric Immuno-Rheumatology of Western Switzerland, Department Women-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Fabio Candotti
- Division of Immunology and Allergy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sandra Steinmann
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Ansgar Schulz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Chip Chambers
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Hershfield
- Department of Medicine and Biochemistry, Duke University Medical Center, Durham, NC, USA
| | - Amanda Ombrello
- Metabolic, Cardiovascular, and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Jennifer A Kanakry
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute of the National Institutes of Health, Bethesda, MD, USA
| | - Isabelle Meyts
- Department of Pediatrics, ERN RITA Core Center, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| |
Collapse
|
18
|
Fayand A, Chasset F, Boutboul D, Queyrel V, Tieulié N, Guichard I, Dupin N, Franck N, Cohen P, Bessis D, Guenno GL, Koné-Paut I, Belot A, Bonhomme A, Ducharme-Bénard S, Grateau G, Sarrabay G, Touitou I, Boursier G, Georgin-Lavialle S. DADA2 diagnosed in adulthood versus childhood: A comparative study on 306 patients including a systematic literature review and 12 French cases. Semin Arthritis Rheum 2021; 51:1170-1179. [PMID: 34571400 DOI: 10.1016/j.semarthrit.2021.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/31/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Deficiency of adenosine deaminase 2 (DADA2) is a rare autoinflammatory disease usually presenting before the age of 10 years. Non-specific clinical features or late-onset presentation may delay its diagnosis until adulthood. OBJECTIVE To determine whether DADA2 diagnosed in adulthood is associated with specific characteristics compared to DADA2 diagnosed in childhood. METHODS We pooled a cohort of 12 adult DADA2 patients followed in France with cases identified through a systematic literature review. For each patient, we determined the type of clinical presentation and assessed six key organ involvements. RESULTS A total of 306 cases were included. Among the 283 patients with available data regarding age at diagnosis, 140 were diagnosed during adulthood and 143 during childhood. The vascular presentation of DADA2 was more frequent in the adult diagnosis group (77.9% vs. 62.9%, p < 0.01), whereas the hematological presentation (bone marrow failure) prevailed in the pediatric diagnosis group (10.0% vs. 20.3% p = 0.02). In patients with vasculopathy, severe skin manifestations developed in 35% and 10% of the adult and pediatric diagnosis groups, respectively. Conversely, fewer strokes occurred in the adult group presenting with systemic vasculopathy (54% vs. 81%). Symptomatic humoral immune deficiency (HID) was rarely a clinical presentation in itself (5% and 2.8%) but accompanied other phenotypes of DADA2, especially the hematological phenotype in the adult group (33% vs. 4%). CONCLUSION DADA2 diagnosed in adulthood presents more often with a vascular phenotype and less often with bone marrow failure than DADA2 diagnosed in childhood. Adults diagnosed with DADA2 vasculopathy display more severe skin involvement but fewer strokes.
Collapse
Affiliation(s)
- Antoine Fayand
- Sorbonne Université, AP-HP, Tenon hospital, Department of Internal Medicine, Centre de référence des maladies auto-inflammatoires et des amyloses d'origine inflammatoire (CEREMAIA), Paris, France
| | - François Chasset
- Sorbonne Université, AP-HP, Tenon Hospital, Department of Dermatology, Paris, France
| | - David Boutboul
- AP-HP, Saint-Louis Hospital, Department of Clinical Immunology, Paris University, Paris, France
| | - Viviane Queyrel
- Pasteur 2 Hospital, Department of Rheumatology, Cote d'Azur University, Nice University Hospital, Nice, France
| | - Nathalie Tieulié
- Pasteur 2 Hospital, Department of Rheumatology, Cote d'Azur University, Nice University Hospital, Nice, France
| | - Isabelle Guichard
- Hôpital Nord, Department of Internal Medicine, Jean Monnet University, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Nicolas Dupin
- AP-HP, Cochin Hospital, Department of Dermatology, Paris Universisty, Paris, France
| | - Nathalie Franck
- AP-HP, Cochin Hospital, Department of Dermatology, Paris Universisty, Paris, France
| | - Pascal Cohen
- Service de Médecine Interne, Centre de Référence des Maladies Auto-Immunes Systémiques Rares d'Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France, Université de Paris, Paris F-75006, France
| | - Didier Bessis
- Saint-Eloi Hospital, Department of Dermatology, Montpellier University, Montpellier University Hospital, Montpellier, France
| | - Guillaume Le Guenno
- Estaing Hospital, Department of Internal Medicine, Clermont-Auvergne University, Clermont Ferrand University Hospital, Clermont Ferrand, France
| | - Isabelle Koné-Paut
- AP-HP, Bicêtre Hospital, Department of Pediatric Rheumatology, Paris-Saclay University, Le-Kremlin-Bicêtre, France
| | - Alexandre Belot
- Hospices Civils de Lyon, Femme Mère Enfant Hospital, Centre de référence des rhumatismes inflammatoires et maladies autoimmunes de l'enfant (RAISE), Lyon University, Lyon, France
| | - Axelle Bonhomme
- Metz-Thionville Regional Hospital, Department of Dermatology, Metz, France
| | | | - Gilles Grateau
- Sorbonne Université, AP-HP, Tenon hospital, Department of Internal Medicine, Centre de référence des maladies auto-inflammatoires et des amyloses d'origine inflammatoire (CEREMAIA), Paris, France
| | - Guillaume Sarrabay
- Arnaud de Villeneuve Hospital, Laboratory of rare and autoinflammatory genetic diseases, Centre de référence des maladies auto-Inflammatoires et des amyloses d'origine inflammatoire (CEREMAIA), Montpellier University, Montpellier University Hospital, Montpellier, France
| | - Isabelle Touitou
- Arnaud de Villeneuve Hospital, Laboratory of rare and autoinflammatory genetic diseases, Centre de référence des maladies auto-Inflammatoires et des amyloses d'origine inflammatoire (CEREMAIA), Montpellier University, Montpellier University Hospital, Montpellier, France
| | - Guilaine Boursier
- Arnaud de Villeneuve Hospital, Laboratory of rare and autoinflammatory genetic diseases, Centre de référence des maladies auto-Inflammatoires et des amyloses d'origine inflammatoire (CEREMAIA), Montpellier University, Montpellier University Hospital, Montpellier, France
| | - Sophie Georgin-Lavialle
- Sorbonne Université, AP-HP, Tenon hospital, Department of Internal Medicine, Centre de référence des maladies auto-inflammatoires et des amyloses d'origine inflammatoire (CEREMAIA), Paris, France.
| |
Collapse
|
19
|
|
20
|
Ito M, Nihira H, Izawa K, Yasumi T, Nishikomori R, Iwaki-Egawa S. Enzyme activity in dried blood spot as a diagnostic tool for adenosine deaminase 2 deficiency. Anal Biochem 2021; 628:114292. [PMID: 34171384 DOI: 10.1016/j.ab.2021.114292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/09/2021] [Accepted: 06/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Deficiency of adenosine deaminase 2 (DADA2) is an autoinflammatory disease caused by mutations in the adenosine deaminase 2 (ADA2) gene. Loss of functional ADA2 activity results in vasculitis syndrome, immunodeficiency, and hematopoietic disorders. Early diagnosis is required for effective treatment. METHODS We developed a dried blood spot (DBS)-based ADA2 activity colorimetric assay. Heparin-affinity purification was used during sample preparation to improve the assay more efficiently. The stability of ADA2 during DBS storage and ADA2 activity of DADA2 patients and healthy controls were examined. RESULTS Active ADA2 was extracted from the DBS of healthy controls. ADA2 activity in DBS, stored either frozen or refrigerated, remained stable for at least 90 days. A significant difference in ADA2 activity was observed between healthy controls and patients. No ADA2 activity was detected in DBS from patients. CONCLUSIONS Our new DBS ADA2 activity assay is experimentally simple, highly adaptable, and requires no special equipment except for a microplate reader. A low background was achieved with heparin-affinity purification. The method differentiates clearly between healthy controls and patients. ADA2 activity can be reliably measured in DBS, providing an opportunity to diagnose DADA2 at an early stage.
Collapse
Affiliation(s)
- Moeko Ito
- Division of Life Science, Faculty of Pharmaceutical Sciences, Hokkaido University of Science, 7-15-4-1 Maeda, Teine, Sapporo, Hokkaido, 006-8585, Japan.
| | - Hiroshi Nihira
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazushi Izawa
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Yasumi
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryuta Nishikomori
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Sachiko Iwaki-Egawa
- Division of Life Science, Faculty of Pharmaceutical Sciences, Hokkaido University of Science, 7-15-4-1 Maeda, Teine, Sapporo, Hokkaido, 006-8585, Japan
| |
Collapse
|
21
|
Kaya Akca U, Sag E, Unal S, Kasap Cuceoglu M, Bilginer Y, Ozen S. The role of vascular inflammation markers in deficiency of adenosine deaminase 2. Semin Arthritis Rheum 2021; 51:839-844. [PMID: 34157579 DOI: 10.1016/j.semarthrit.2021.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/23/2021] [Accepted: 04/22/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The first objective was to assess the role of vascular inflammatory factors in the pathogenesis of deficiency of adenosine deaminase 2 (DADA2) and to compare these markers among DADA2 patients with different phenotypes. We also aimed to investigate differences between DADA2 patients with vasculitic features and classic polyarteritis nodosa (PAN) for the aforementioned markers. METHODS The study included eighteen DADA2 patients, ten PAN patients, and eight healthy controls. Plasma levels of sST2, sRAGE, Tie-2, sCD40L, Tie-1, sFlt-1, LIGHT, TNF-α, PlGF, IL-6, IL-18, IL-10, MCP-1 were studied by cytometric bead-based multiplex assay panel. RESULTS Among the DADA2 patients, five had hematological manifestations, 13 had vasculitic findings, and accompanying immunological findings were present in seven patients. Nine patients had neurological findings, five of whom had neuropathy. Plasma levels of Tie-1 and sFlt-1 were higher in the overall DADA2 patients compared to healthy controls and PAN patients (p<0.001 and p = 0.004, respectively). DADA2 patients with PAN-like features had higher sRAGE, Tie-2, and TNF-α levels compared to PAN patients (p = 0.013, p = 0.003, and p = 0.001, respectively). In DADA2 patients with hematological findings, plasma IL-18 levels were higher than those with PAN-like phenotype (p = 0.001). Finally, DADA2 patients with neuropathy had higher sRAGE concentrations than patients without neuropathy and healthy controls (p = 0.03 and p = 0.008, respectively). CONCLUSIONS We suggest that the high plasma IL-18 levels observed in DADA2 patients with hematologic manifestations may be associated with an activated IFNγ pathway, and lack of response to anti-TNF treatment. We identified sRAGE as a potential biomarker of neuropathy in DADA2 patients. Higher concentrations of Tie-1, Tie-2, sFlt-1, sRAGE, and TNF-α distinguished DADA2 patients with PAN-like features from PAN patients.
Collapse
Affiliation(s)
- Ummusen Kaya Akca
- Department of Pediatrics, Division of Rheumatology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Erdal Sag
- Department of Pediatrics, Division of Rheumatology, Hacettepe University School of Medicine, Ankara, Turkey; Pediatric Rheumatology Unit, Translational Medicine Laboratories, Hacettepe University, Ankara, Turkey
| | - Sule Unal
- Department of Pediatrics, Division of Hematology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Muserref Kasap Cuceoglu
- Department of Pediatrics, Division of Rheumatology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Yelda Bilginer
- Department of Pediatrics, Division of Rheumatology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Seza Ozen
- Department of Pediatrics, Division of Rheumatology, Hacettepe University School of Medicine, Ankara, Turkey; Pediatric Rheumatology Unit, Translational Medicine Laboratories, Hacettepe University, Ankara, Turkey.
| |
Collapse
|
22
|
Pinto B, Deo P, Sharma S, Syal A, Sharma A. Expanding spectrum of DADA2: a review of phenotypes, genetics, pathogenesis and treatment. Clin Rheumatol 2021; 40:3883-3896. [PMID: 33791889 DOI: 10.1007/s10067-021-05711-w] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/16/2021] [Accepted: 03/21/2021] [Indexed: 01/02/2023]
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is a monogenic disease caused by biallelic mutations in ADA2 gene (previously CECR1). The aim of this review was to describe the clinical phenotypes, genetics, pathogenesis and treatment of DADA2. ADA2 is highly expressed on myeloid cells and deficiency leads to polarisation of macrophages to an M1 inflammatory type and activation of neutrophils. The pathogenesis of immunological and haematological manifestations is less clear. The spectrum of clinical presentations varies widely from asymptomatic individual to severe vasculitis, several autoinflammatory, immunological and haematological manifestations. Initially considered a childhood disease, the first presentation is now being reported well into adulthood. Vasculitis closely resembles polyarteritis nodosa. Livedoid reticularis/racemosa like skin rash and central nervous system involvement in the form of ischemic or haemorrhagic stroke are dominant manifestations. Immunological manifestations include hypogammaglobulinemia and recurrent infections. Lymphopenia is the most common haematological manifestation; pure red cell aplasia and bone marrow failure has been reported in severe cases. The disease is extremely heterogeneous with variable severity noted in patients with the same mutation and even within family members. Tumour necrosis factor inhibitors are currently the treatment of choice for vasculitic and inflammatory manifestations and also prevent strokes. Haematopoietic stem cell transplantation is a curative option for severe haematological manifestations like pure red cell aplasia, bone marrow failure and immunodeficiency. Further research is required to understand pathogenesis and all clinical aspects of this disease to enable early diagnosis and prompt treatment. Key Points • Deficiency of adenosine deaminase 2 (DADA2) is a monogenic disease caused by biallelic mutations in ADA2 gene. • The clinical features include vasculitis resembling polyarteritis nodosa, autoinflammation, haematological manifestations and immunodeficiency. • The severity varies widely from mild to fatal even in patients within a family and with the same mutation. • The treatment of choice for inflammatory and vasculitic disease is tumour necrosis factor α blockers. Bone marrow transplant may be considered for severe haematological disease.
Collapse
Affiliation(s)
- Benzeeta Pinto
- Department of Clinical Immunology and Rheumatology, St. John's National Academy of Health Sciences, Bangalore, India
| | - Prateek Deo
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Susmita Sharma
- Department of Obstetrics and Gynaecology, Adesh Medical College and Hospital, Mohri, Ambala, India
| | - Arshi Syal
- Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| |
Collapse
|
23
|
Wang W, Zhang T, Zheng W, Zhong L, Wang L, Li J, Liu Q, Dong Y, Song H. Diagnosis and management of adenosine deaminase 2 deficiency children: the experience from China. Pediatr Rheumatol Online J 2021; 19:44. [PMID: 33757531 PMCID: PMC7986504 DOI: 10.1186/s12969-021-00535-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 03/10/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Deficiency of adenosine deaminase 2 (DADA2) is a rare autoinflammatory disease caused by mutations in the ADA2 gene. Few Chinese cases have been reported. We describe and compare the clinical features, genotypes, and treatments of Chinese DADA2 patients and non-Chinese patients. METHODS Primary immunodeficiency disease panel or whole-exome sequencing was performed for suspected cases, and assays for adenosine deaminase 2 (ADA2) enzyme activity were also carried out for the patients and their parents. Case reports of Chinese and non-Chinese patients with DADA2 were searched in PubMed and Chinese national databases. RESULTS Seven unrelated children from China with DADA2 were included in our study. Five were identified at Peking Union Medical College Hospital, and two had been reported previously (1 on PubMed and 1 in Chinese literature). Fourteen mutations in ADA2 were identified, 7 of which have not previously been reported in non-Chinese patients. Four children who underwent enzymatic analysis had lower ADA2 activity compared with their parents. Phenotypic manifestations included fever, skin symptoms, vasculitis, and neurologic involvement. Treatments varying from steroids, immunosuppressants, and tocilizumab, anti-TNF therapy and hematopoietic stem cell transplantation (HSCT) were effective depending on phenotype and severity. CONCLUSION This study includes the largest number of Chinese DADA2 patients to date. We recommend the combination of enzymatic analysis with gene screening to confirm the diagnosis. Different genotypes were observed among Chinese DADA2 patients; most phenotypes were similar to those of non-Chinese DADA2 patients, except for growth retardation. Disease remission might not be achieved with anti-IL-6 therapy.
Collapse
Affiliation(s)
- Wei Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Tiannan Zhang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wenjie Zheng
- grid.417384.d0000 0004 1764 2632Department of Rheumatology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province China
| | - Linqing Zhong
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Lin Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ji Li
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qian Liu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yanqing Dong
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hongmei Song
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
| |
Collapse
|
24
|
Brooks JP, Rice AJ, Ji W, Lanahan SM, Konstantino M, Dara J, Hershfield MS, Cruickshank A, Dokmeci E, Lakhani S, Lucas CL. Uncontrolled Epstein-Barr Virus as an Atypical Presentation of Deficiency in ADA2 (DADA2). J Clin Immunol 2021; 41:680-683. [PMID: 33394316 DOI: 10.1007/s10875-020-00940-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/07/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Joel P Brooks
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew J Rice
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Weizhen Ji
- Pediatric Genomics Discovery Program, Yale University School of Medicine, New Haven, CT, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Stephen M Lanahan
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Monica Konstantino
- Pediatric Genomics Discovery Program, Yale University School of Medicine, New Haven, CT, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Jasmeen Dara
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, Benioff Children's Hospital, San Francisco, CA, USA
| | | | - Amy Cruickshank
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, USA
| | - Elif Dokmeci
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, USA
| | - Saquib Lakhani
- Pediatric Genomics Discovery Program, Yale University School of Medicine, New Haven, CT, USA. .,Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA.
| | - Carrie L Lucas
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, USA.
| |
Collapse
|
25
|
Padma Srivastava MV, Babtiwale S, Vishnu V, Garg A, Goyal V, Singh M. Young stroke and systemic manifestations: Deficiency of adenosine deaminase-2 (DADA-2). Ann Indian Acad Neurol 2021; 24:977-979. [PMID: 35359561 PMCID: PMC8965964 DOI: 10.4103/aian.aian_657_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/07/2020] [Accepted: 08/06/2020] [Indexed: 11/04/2022] Open
|
26
|
Süleyman M, Tan Ç, Uner A, İnkaya Ç, Aytaç S, Büyükaşık Y, Boztug K, Tezcan İ, Cagdas D. Adenosine Deaminase Type II Deficiency: Severe Chronic Neutropenia, Lymphoid Infiltration in Bone Marrow, and Inflammatory Features. Immunol Invest 2020; 51:558-566. [PMID: 33705245 DOI: 10.1080/08820139.2020.1853153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Deficiency of adenosine deaminase type 2 (DADA2) is an autoinflammatory disease characterized with immunologic, hematologic, and neurological features. Here, we presented two patients with severe persistent chronic neutropenia, which required differential diagnosis of congenital and autoimmune neutropenia, myelodysplastic syndrome (MDS), and primary immunodeficiency diseases, including autoimmune lymphoproliferative disease. The therapy of the disease except hematopoietic stem cell transplantation is a challenging experience.
Collapse
Affiliation(s)
- Merve Süleyman
- Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Çağman Tan
- Department of Pediatric Immunology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Aysegul Uner
- Department of Pathology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Çağkan İnkaya
- Department of Infectious Diseases and Clinical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Selin Aytaç
- Department of Pediatric Hematology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Yahya Büyükaşık
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Kaan Boztug
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria
| | - İlhan Tezcan
- Department of Pediatric Immunology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Deniz Cagdas
- Department of Pediatric Immunology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
27
|
Kendall JL, Springer JM. The Many Faces of a Monogenic Autoinflammatory Disease: Adenosine Deaminase 2 Deficiency. Curr Rheumatol Rep 2020; 22:64. [PMID: 32845415 PMCID: PMC7448703 DOI: 10.1007/s11926-020-00944-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW We aim to describe the pathophysiology, clinical findings, diagnosis, and treatment of deficiency of adenosine deaminase 2 (DADA2). RECENT FINDINGS DADA2 is a multi-organ disease of children and less often adults, which can present with wide-ranging manifestations including strokes, medium vessel vasculitis, hematologic disease, and immunodeficiency. Diagnosis is through detection of reduced activity level of the adenosine deaminase 2 (ADA2) enzyme and/or identification of bi-allelic mutations in the ADA2 gene. Outside of high-dose glucocorticoids, conventional immunosuppression has been largely ineffective in treating this relapsing and remitting disease. Vasculitic-predominant manifestations respond extremely well to tumor necrosis factor-α inhibition. Hematopoietic stem cell transplantation can lead to normalization of enzyme activity, as well as resolution of vasculitic, hematologic, and immunologic manifestations, although treatment-related adverse effects are not uncommon. Early detection of this disease across multiple disciplines could prevent devastating clinical outcomes, especially in genetically pre-disposed populations.
Collapse
Affiliation(s)
- Jennifer Lee Kendall
- Division of Allergy, Clinical Immunology and Rheumatology, Department of Medicine University of Kansas Medical Center, 3901 Rainbow Blvd MS 2026, Kansas City, KS, 66160, USA
| | - Jason Michael Springer
- Division of Allergy, Clinical Immunology and Rheumatology, Department of Medicine University of Kansas Medical Center, 3901 Rainbow Blvd MS 2026, Kansas City, KS, 66160, USA.
| |
Collapse
|
28
|
Schnappauf O, Zhou Q, Moura NS, Ombrello AK, Michael DG, Deuitch N, Barron K, Stone DL, Hoffmann P, Hershfield M, Applegate C, Bjornsson HT, Beck DB, Witmer PD, Sobreira N, Wohler E, Chiorini JA, Center TAG, Dalgard CL, Center NIS, Kastner DL, Aksentijevich I. Deficiency of Adenosine Deaminase 2 (DADA2): Hidden Variants, Reduced Penetrance, and Unusual Inheritance. J Clin Immunol 2020; 40:917-926. [PMID: 32638197 PMCID: PMC7416912 DOI: 10.1007/s10875-020-00817-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/29/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive disorder that manifests with fever, early-onset vasculitis, strokes, and hematologic dysfunction. This study aimed to identify disease-causing variants by conventional Sanger and whole exome sequencing in two families suspected to have DADA2 and non-confirmatory genotypes. ADA2 enzymatic assay confirmed the clinical diagnosis of DADA2. Molecular diagnosis was important to accurately identify other family members at risk. METHODS We used a variety of sequencing technologies, ADA2 enzymatic testing, and molecular methods including qRT-PCR and MLPA. RESULTS Exome sequencing identified heterozygosity for the known pathogenic variant ADA2: c.1358A>G, p.Tyr453Cys in a 14-year-old female with a history of ischemic strokes, livedo, and vasculitis. No second pathogenic variant could be identified. ADA2 enzymatic testing in combination with quantitative RT-PCR suggested a loss-of-function allele. Subsequent genome sequencing identified a canonical splice site variant, c.-47+2T>C, within the 5'UTR of ADA2. Two of her unaffected siblings were found to carry the same two pathogenic variants. A homozygous 800-bp duplication comprising exon 7 of ADA2 was identified in a 5-year-old female with features consistent with Diamond-Blackfan anemia (DBA). The duplication was missed by Sanger sequencing of ADA2, chromosomal microarray, and exome sequencing but was detected by MLPA in combination with long-read PCR sequencing. The exon 7 duplication was also identified in her non-symptomatic father and younger sister. CONCLUSIONS ADA2 pathogenic variants may not be detected by conventional sequencing and genetic testing and may require the incorporation of additional diagnostic methods. A definitive molecular diagnosis is crucial for all family members to make informed treatment decisions.
Collapse
Affiliation(s)
- Oskar Schnappauf
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA.
| | - Qing Zhou
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Natalia Sampaio Moura
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Amanda K Ombrello
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Drew G Michael
- Department of Laboratory Medicine, Center for Genetic Medicine Research, Children's National, Washington, DC, USA
| | - Natalie Deuitch
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Karyl Barron
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Deborah L Stone
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Patrycja Hoffmann
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Michael Hershfield
- Department of Medicine and Biochemistry, Duke University School of Medicine, Durham, NC, USA
| | - Carolyn Applegate
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hans T Bjornsson
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Landspitali University Hospital, Reykjavik, Iceland
| | - David B Beck
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - P Dane Witmer
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nara Sobreira
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Wohler
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John A Chiorini
- Molecular Physiology and Therapeutics Branch, National Institute of Dental and Craniofacial Research (NIDCR), Bethesda, MD, USA
| | | | - Clifton L Dalgard
- Department of Anatomy, Physiology & Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Nih Intramural Sequencing Center
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Daniel L Kastner
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Ivona Aksentijevich
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| |
Collapse
|
29
|
Lapides DA, McDonald MM. Inflammatory Manifestations of Systemic Diseases in the Central Nervous System. Curr Treat Options Neurol 2020; 22:26. [PMID: 32834714 PMCID: PMC7387810 DOI: 10.1007/s11940-020-00636-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review presents the current recommended therapeutic interventions for inflammatory disease in the central nervous system (CNS) secondary to systemic diseases of immune dysregulation. Treatment recommendations for CNS inflammation associated with rheumatologic conditions, immune-related adverse effects from immune checkpoint inhibitors (ICIs), and demyelinating disease from tumor necrosis factor-α (anti-TNFs) are explored. Additional therapeutic options for inflammation related to postviral syndromes and genetic immunodeficiencies are also discussed. RECENT FINDINGS In addition to treatment of mild, moderate, and severe CNS rheumatologic disease as guided by the European League Against Rheumatism (EULAR), early consideration of rituximab for severe IgG4-related disease and induction with anti-TNF therapy for severe neurosarcoidosis should be considered. Although often not first line, treatment options for CNS inflammatory diseases based on disease mechanism are emerging, including tocilizumab for Behcet's disease, natalizumab for ICI associated autoimmune encephalitis, and abatacept for treatment of infiltrative disease secondary to CTLA-4 deficiency. Hematopoietic stem cell treatments represent highly efficacious but risky options for autoimmunity related to genetic immunodeficiency. SUMMARY While early high dose steroids remains first line therapy for most CNS inflammatory conditions, a rapidly expanding arsenal of immune targeted therapies offers clinicians tailored disease specific options for treatment.
Collapse
Affiliation(s)
- David A. Lapides
- Division of Neuroimmunology, Department of Neurology, University of Virginia, 1222 Lee Street, Charlottesville, VA 22908 USA
| | - Mark M. McDonald
- Division of Neuroimmunology, Department of Neurology, University of Virginia, 1222 Lee Street, Charlottesville, VA 22908 USA
| |
Collapse
|
30
|
Keino D, Kondoh K, Kim Y, Sudo A, Ohyama R, Morimoto M, Nihira H, Izawa K, Iwaki-Egawa S, Mori T, Kinoshita A. Successful treatment with cyclosporine and anti-tumour necrosis factor agent for deficiency of adenosine deaminase-2. Scand J Rheumatol 2020; 50:243-245. [PMID: 32720851 DOI: 10.1080/03009742.2020.1772868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- D Keino
- Department of Pediatrics, St Marianna University School of Medicine Hospital, Kanagawa, Japan.,Division of Hematology and Oncology, Kanagawa Children`s Medical Center, Yokohama, Japan
| | - K Kondoh
- Department of Pediatrics, St Marianna University School of Medicine Hospital, Kanagawa, Japan
| | - Y Kim
- Department of Pediatrics, St Marianna University School of Medicine Hospital, Kanagawa, Japan
| | - A Sudo
- Department of Pediatrics, St Marianna University School of Medicine Hospital, Kanagawa, Japan
| | - R Ohyama
- Department of Pediatrics, St Marianna University School of Medicine Hospital, Kanagawa, Japan
| | - M Morimoto
- Department of Pediatrics, St Marianna University School of Medicine Hospital, Kanagawa, Japan
| | - H Nihira
- Department of Pediatrics, Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - K Izawa
- Department of Pediatrics, Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - S Iwaki-Egawa
- Department of Life Sciences, Hokkaido Pharmaceutical University School of Pharmacy, Hokkaido, Japan
| | - T Mori
- Department of Pediatrics, St Marianna University School of Medicine Hospital, Kanagawa, Japan
| | - A Kinoshita
- Department of Pediatrics, St Marianna University School of Medicine Hospital, Kanagawa, Japan
| |
Collapse
|
31
|
Le Voyer T, Boutboul D, Ledoux-Pilon A, de Fontbrune FS, Boursier G, Latour S, Le Guenno G. Late-Onset EBV Susceptibility and Refractory Pure Red Cell Aplasia Revealing DADA2. J Clin Immunol 2020; 40:948-953. [PMID: 32643137 DOI: 10.1007/s10875-020-00812-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/22/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Tom Le Voyer
- Department of Internal Medicine, Hôpital Estaing, 1 Place Lucie Aubrac, 63000, Clermont-Ferrand, France
| | - David Boutboul
- Department of Clinical Immunology, Hôpital Saint-Louis- AP-HP, 1 av Claude Vellefaux, 75010, Paris, France. .,Laboratory of Lymphocyte Activation and Susceptibility to EBV infection, Imagine Institute - Inserm UMR 1163, Paris, France.
| | | | | | - Guilaine Boursier
- Department of Medical Genetics, Rare Diseases and Personalized Medicine, University of Montpellier, CEREMAIA, CHU Montpellier, Montpellier, France
| | - Sylvain Latour
- Laboratory of Lymphocyte Activation and Susceptibility to EBV infection, Imagine Institute - Inserm UMR 1163, Paris, France
| | - Guillaume Le Guenno
- Department of Internal Medicine, Hôpital Estaing, 1 Place Lucie Aubrac, 63000, Clermont-Ferrand, France.
| |
Collapse
|
32
|
Abstract
The technological advances in diagnostics and therapy of primary immunodeficiency are progressing at a fast pace. This review examines recent developments in the field of inborn errors of immunity, from their definition to their treatment. We will summarize the challenges posed by the growth of next-generation sequencing in the clinical setting, touch briefly on the expansion of the concept of inborn errors of immunity beyond the classic immune system realm, and finally review current developments in targeted therapies, stem cell transplantation, and gene therapy.
Collapse
Affiliation(s)
- Giorgia Bucciol
- Inborn Errors of Immunity, Department of Immunology, Microbiology and Transplantation, KU Leuven, Herestraat 49, Leuven, 3000, Belgium.,Childhood Immunology, Department of Pediatrics, University Hospitals Leuven, ERN-RITA Core Member, Herestraat 49, Leuven, 3000, Belgium
| | - Isabelle Meyts
- Inborn Errors of Immunity, Department of Immunology, Microbiology and Transplantation, KU Leuven, Herestraat 49, Leuven, 3000, Belgium.,Childhood Immunology, Department of Pediatrics, University Hospitals Leuven, ERN-RITA Core Member, Herestraat 49, Leuven, 3000, Belgium
| |
Collapse
|
33
|
Affiliation(s)
- Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, 'Aghia Sophia' Children's Hospital, Papadiamantopoulou and Levadias, Athens, Greece
| |
Collapse
|
34
|
Lee PY, Kellner ES, Huang Y, Furutani E, Huang Z, Bainter W, Alosaimi MF, Stafstrom K, Platt CD, Stauber T, Raz S, Tirosh I, Weiss A, Jordan MB, Krupski C, Eleftheriou D, Brogan P, Sobh A, Baz Z, Lefranc G, Irani C, Kilic SS, El-Owaidy R, Lokeshwar MR, Pimpale P, Khubchandani R, Chambers EP, Chou J, Geha RS, Nigrovic PA, Zhou Q. Genotype and functional correlates of disease phenotype in deficiency of adenosine deaminase 2 (DADA2). J Allergy Clin Immunol 2020; 145:1664-1672.e10. [PMID: 31945408 DOI: 10.1016/j.jaci.2019.12.908] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/07/2019] [Accepted: 12/27/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Deficiency of adenosine deaminase 2 (DADA2) is a syndrome with pleiotropic manifestations including vasculitis and hematologic compromise. A systematic definition of the relationship between adenosine deaminase 2 (ADA2) mutations and clinical phenotype remains unavailable. OBJECTIVE We sought to test whether the impact of ADA2 mutations on enzyme function correlates with clinical presentation. METHODS Patients with DADA2 with severe hematologic manifestations were compared with vasculitis-predominant patients. Enzymatic activity was assessed using expression constructs reflecting all 53 missense, nonsense, insertion, and deletion genotypes from 152 patients across the DADA2 spectrum. RESULTS We identified patients with DADA2 presenting with pure red cell aplasia (n = 5) or bone marrow failure (BMF, n = 10) syndrome. Most patients did not exhibit features of vasculitis. Recurrent infection, hepatosplenomegaly, and gingivitis were common in patients with BMF, of whom half died from infection. Unlike patients with DADA2 with vasculitis, patients with pure red cell aplasia and BMF proved largely refractory to TNF inhibitors. ADA2 variants associated with vasculitis predominantly reflected missense mutations with at least 3% residual enzymatic activity. In contrast, pure red cell aplasia and BMF were associated with missense mutations with minimal residual enzyme activity, nonsense variants, and insertions/deletions resulting in complete loss of function. CONCLUSIONS Functional interrogation of ADA2 mutations reveals an association of subtotal function loss with vasculitis, typically responsive to TNF blockade, whereas more extensive loss is observed in hematologic disease, which may be refractory to treatment. These findings establish a genotype-phenotype spectrum in DADA2.
Collapse
Affiliation(s)
- Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Erinn S Kellner
- Division of Allergy/Immunology, Cincinnati Children's Hospital and University of Cincinnati, Cincinnati, Ohio
| | - Yuelong Huang
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Elissa Furutani
- Dana Farber and Boston Children's Cancer and Blood Disorders Center, Boston, Mass
| | - Zhengping Huang
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Wayne Bainter
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Mohammed F Alosaimi
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Department of Pediatrics, King Saud University, Riyadh, Saudi Arabia
| | - Kelsey Stafstrom
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Tali Stauber
- Primary Immunodeficiency Clinic, Sheba Medical Center, Jeffrey Modell Foundation, Tel Hashomer, Israel
| | - Somech Raz
- Primary Immunodeficiency Clinic, Sheba Medical Center, Jeffrey Modell Foundation, Tel Hashomer, Israel
| | - Irit Tirosh
- Pediatric Rheumatology Service, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Aaron Weiss
- Department of Pediatrics, Maine Medical Center, Portland, Me
| | - Michael B Jordan
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio; Division of Immunobiology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Christa Krupski
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Despina Eleftheriou
- University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Paul Brogan
- University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Ali Sobh
- Department of Pediatrics, Mansoura University Children's Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Zeina Baz
- Department of Pediatrics, St George Hospital University Medical Center, Beirut, Lebanon
| | - Gerard Lefranc
- Institut de Génétique Humaine, UMR 9002 CNRS-Université de Montpellier, Montpellier, France
| | - Carla Irani
- Internal Medicine & Clinical Immunology Department, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Sara S Kilic
- Department of Pediatric Immunology and Rheumatology, Uludag University Medical Faculty, Bursa, Turkey
| | - Rasha El-Owaidy
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - M R Lokeshwar
- Department of Pediatrics, Lilavati Hospital and Research Centre, Mumbai, India
| | | | | | - Eugene P Chambers
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn; DADA2 Foundation, Nashville, Tenn
| | - Janet Chou
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Raif S Geha
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Peter A Nigrovic
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Qing Zhou
- Life Sciences Institute, Zhejiang University, Zhejiang, China
| |
Collapse
|
35
|
A monogenic autoinflammatory disease with fatal vasculitis: deficiency of adenosine deaminase 2. Curr Opin Rheumatol 2020; 32:3-14. [PMID: 31599797 DOI: 10.1097/bor.0000000000000669] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
36
|
Moens L, Hershfield M, Arts K, Aksentijevich I, Meyts I. Human adenosine deaminase 2 deficiency: A multi-faceted inborn error of immunity. Immunol Rev 2019; 287:62-72. [PMID: 30565235 DOI: 10.1111/imr.12722] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 09/23/2018] [Indexed: 12/15/2022]
Abstract
Human adenosine deaminase 1 deficiency was described in the 1970s to cause severe combined immunodeficiency. The residual adenosine deaminase activity in these patients was attributed to adenosine deaminase 2. Human adenosine deaminase type 2 deficiency (DADA2), due to biallelic deleterious mutations in the ADA2 gene, is the first described monogenic type of small- and medium-size vessel vasculitis. The phenotype of DADA2 also includes lymphoproliferation, cytopenia, and variable degrees of immunodeficiency. The physiological role of ADA2 is still enigmatic hence the pathophysiology of the condition is unclear. Preliminary data showed that in the absence of ADA2, macrophage differentiation is skewed to a pro-inflammatory M1 subset, which is detrimental for endothelial integrity. The inflammatory phenotype responds well to anti-TNF therapy with etanercept and that is the first-line treatment for prevention of severe vascular events including strokes. The classic immunosuppressive drugs are not successful in controlling the disease activity. However, hematopoietic stem cell transplantation (HSCT) has been shown to be a definitive cure in DADA2 patients who present with a severe cytopenia. HSCT can also cure the vascular phenotype and is the treatment modality for patients' refractory to anti-cytokine therapies. In this review, we describe what is currently known about the molecular mechanisms of DADA2. Further research on the pathophysiology of this multifaceted condition is needed to fine-tune and steer future therapeutic strategies.
Collapse
Affiliation(s)
- Leen Moens
- Department of Microbiology and Immunology, Laboratory for Childhood Immunology, KU Leuven, Leuven, Belgium
| | - Michael Hershfield
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina
| | - Katrijn Arts
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Ivona Aksentijevich
- Inflammatory Disease Section, National Human Genome Research Institute, Bethesda, Maryland
| | - Isabelle Meyts
- Department of Microbiology and Immunology, Laboratory for Childhood Immunology, KU Leuven, Leuven, Belgium.,Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
37
|
Abstract
The pathogenesis of autoinflammatory diseases has shed light on the concept of inflammation in general and on our understanding of the role of the innate immune system. The autoinflammatory diseases have a large spectrum with varying features of inflammation. The most common autoinflammatory diseases are those associated with periodic fevers. The delay in diagnosis of these four common diseases (familial Mediterranean fever, cryopyrin-associated periodic fever syndrome, mevalonate kinase deficiency, and TNF receptor-associated periodic fever syndrome) results in secondary amyloidosis of the kidney. The new work towards classification criteria for these diseases is presented. Recently a group of autoinflammatory diseases that are associated with vasculitis have also been identified. These are stimulators of interferon genes (STING)-associated vasculopathy of infancy (SAVI), which is a monogenic defect associated with excessive activity in interferon alpha and deficiency of adenosine deaminase 2, which is characterized by a polyarteritis nodosa-like picture. These monogenic diseases are now in our differential diagnosis of vasculitides. Secondary amyloidosis is a complication of autoinflammatory diseases. Understanding the inflammatory mechanisms in these diseases has led to the use of targeted biologics for this complication. It is hoped that enlightening the mechanisms underlying these monogenic autoinflammatory diseases will also teach us about the pathways in common diseases.
Collapse
Affiliation(s)
- Seza Ozen
- Department of Pediatrics, Hacettepe University, Ankara, Turkey.
| |
Collapse
|
38
|
Özen S, Batu ED, Taşkıran EZ, Özkara HA, Ünal Ş, Güleray N, Erden A, Karadağ Ö, Gümrük F, Çetin M, Sönmez HE, Bilginer Y, Ayvaz DÇ, Tezcan I. A Monogenic Disease with a Variety of Phenotypes: Deficiency of Adenosine Deaminase 2. J Rheumatol 2019; 47:117-125. [PMID: 31043544 DOI: 10.3899/jrheum.181384] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive autoinflammatory disorder associated with ADA2 mutations. We aimed to investigate the characteristics and ADA2 enzyme activities of patients with DADA2 compared to non-DADA2 patients. METHODS This is a descriptive study of 24 patients with DADA2 who were admitted to the Adult and Pediatric Rheumatology, Pediatric Haematology, and Pediatric Immunology Departments of Hacettepe University. All ADA2 exons were screened by Sanger sequencing. Serum ADA2 enzyme activity was measured by modified spectrophotometric method. RESULTS Twenty-four patients with DADA2 were included: 14 with polyarteritis nodosa (PAN)-like phenotype (Group 1); 9 with Diamond-Blackfan anemia (DBA)-like features, and 1 with immunodeficiency (Group 2). Fourteen PAN-like DADA2 patients did not have the typical thrombocytosis seen in classic PAN. Inflammatory attacks were evident only in Group 1 patients. Serum ADA2 activity was low in all patients with DADA2 except one, who was tested after hematopoietic stem cell transplantation. There was no significant difference in ADA2 activities between PAN-like and DBA-like patients. In DADA2 patients with one ADA2 mutation, serum ADA2 activities were as low as those of patients with homozygote DADA2. ADA2 activities were normal in non-DADA2 patients. ADA2 mutations were affecting the dimerization domain in Group 1 patients and the catalytic domain in Group 2 patients. CONCLUSION We suggest assessing ADA2 activity along with genetic analysis because there are patients with one ADA2 mutation and absent enzyme activity. Our data suggest a possible genotype-phenotype correlation in which dimerization domain mutations are associated with PAN-like phenotype, and catalytic domain mutations are associated with hematological manifestations.
Collapse
Affiliation(s)
- Seza Özen
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey. .,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study.
| | - Ezgi Deniz Batu
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Ekim Z Taşkıran
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Hatice Asuman Özkara
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Şule Ünal
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Naz Güleray
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Abdulsamet Erden
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Ömer Karadağ
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Fatma Gümrük
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Mualla Çetin
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Hafize Emine Sönmez
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Yelda Bilginer
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Deniz Çağdaş Ayvaz
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Ilhan Tezcan
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| |
Collapse
|
39
|
Insalaco A, Moneta GM, Pardeo M, Caiello I, Messia V, Bracaglia C, Passarelli C, De Benedetti F. Variable Clinical Phenotypes and Relation of Interferon Signature with Disease Activity in ADA2 Deficiency. J Rheumatol 2019; 46:523-526. [DOI: 10.3899/jrheum.180045] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2018] [Indexed: 12/16/2022]
Abstract
Objective.An upregulation of type I interferon (IFN) stimulated genes [IFN score (IS)] was described in patients with adenosine deaminase 2 deficiency (DADA2). We describe the clinical course of 5 such patients and the role of IS as a marker of disease activity and severity.Methods.Expression levels of IS were determined by quantitative real-time PCR.Results.Five white patients were identified as carrying CECR1 mutations. The IS before treatment was elevated in 4 out of 5 patients and decreased after treatment.Conclusion.Our data confirm the high variability of DADA2 and suggest type I IS as a biomarker of disease activity.
Collapse
|
40
|
Claassen D, Boals M, Bowling KM, Cooper GM, Cox J, Hershfield M, Lewis S, Wlodarski M, Weiss MJ, Estepp JH. Complexities of genetic diagnosis illustrated by an atypical case of congenital hypoplastic anemia. Cold Spring Harb Mol Case Stud 2018; 4:mcs.a003384. [PMID: 30559313 PMCID: PMC6318771 DOI: 10.1101/mcs.a003384] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/29/2018] [Indexed: 11/24/2022] Open
Abstract
Diamond-Blackfan Anemia (DBA) is a rare polygenic disorder defined by congenital hypoplastic anemia with marked decrease or absence of bone marrow erythroid precursors. Identifying the specific genetic etiology is important for counseling and clinical management. A 6-yr-old boy with a clinical diagnosis of DBA has been followed by our pediatric hematology team since birth. His clinical course includes transfusion-dependent hypoplastic anemia and progressive autoimmune cytopenias. Genetic testing failed to identify a causative mutation in any of the classical DBA-associated genes. He and his parents underwent trio whole-exome sequencing (WES) with no genetic etiology identified initially. Clinical persistence and suspicion led to testing for adenosine deaminase 2 (ADA2) activity and whole-genome sequencing (WGS) that identified compound heterozygous pathogenic mutations in the ADA2-encoding CECR1 gene, a recently appreciated etiology for congenital hypoplastic anemia. This case illustrates current challenges in genetic testing and how they can be overcome by multidisciplinary expertise in clinical medicine and genomics.
Collapse
Affiliation(s)
- David Claassen
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
| | - Michelle Boals
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
| | - Kevin M Bowling
- HudsonAlpha Institute for Biotechnology, Huntsville, Alabama 35806, USA
| | - Gregory M Cooper
- HudsonAlpha Institute for Biotechnology, Huntsville, Alabama 35806, USA
| | - Jennifer Cox
- St. Jude Affiliate Clinic, Huntsville Hospital for Women and Children, Huntsville, Alabama 35801, USA
| | - Michael Hershfield
- Department of Medicine and Biochemistry, Duke University Medical Center, Durham, North Carolina 27710, USA
| | - Sara Lewis
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
| | - Marcin Wlodarski
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
| | - Mitchell J Weiss
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
| | - Jeremie H Estepp
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
| |
Collapse
|
41
|
Ulirsch JC, Verboon JM, Kazerounian S, Guo MH, Yuan D, Ludwig LS, Handsaker RE, Abdulhay NJ, Fiorini C, Genovese G, Lim ET, Cheng A, Cummings BB, Chao KR, Beggs AH, Genetti CA, Sieff CA, Newburger PE, Niewiadomska E, Matysiak M, Vlachos A, Lipton JM, Atsidaftos E, Glader B, Narla A, Gleizes PE, O'Donohue MF, Montel-Lehry N, Amor DJ, McCarroll SA, O'Donnell-Luria AH, Gupta N, Gabriel SB, MacArthur DG, Lander ES, Lek M, Da Costa L, Nathan DG, Korostelev AA, Do R, Sankaran VG, Gazda HT. The Genetic Landscape of Diamond-Blackfan Anemia. Am J Hum Genet 2018; 103:930-947. [PMID: 30503522 PMCID: PMC6288280 DOI: 10.1016/j.ajhg.2018.10.027] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/29/2018] [Indexed: 01/19/2023] Open
Abstract
Diamond-Blackfan anemia (DBA) is a rare bone marrow failure disorder that affects 7 out of 1,000,000 live births and has been associated with mutations in components of the ribosome. In order to characterize the genetic landscape of this heterogeneous disorder, we recruited a cohort of 472 individuals with a clinical diagnosis of DBA and performed whole-exome sequencing (WES). We identified relevant rare and predicted damaging mutations for 78% of individuals. The majority of mutations were singletons, absent from population databases, predicted to cause loss of function, and located in 1 of 19 previously reported ribosomal protein (RP)-encoding genes. Using exon coverage estimates, we identified and validated 31 deletions in RP genes. We also observed an enrichment for extended splice site mutations and validated their diverse effects using RNA sequencing in cell lines obtained from individuals with DBA. Leveraging the size of our cohort, we observed robust genotype-phenotype associations with congenital abnormalities and treatment outcomes. We further identified rare mutations in seven previously unreported RP genes that may cause DBA, as well as several distinct disorders that appear to phenocopy DBA, including nine individuals with biallelic CECR1 mutations that result in deficiency of ADA2. However, no new genes were identified at exome-wide significance, suggesting that there are no unidentified genes containing mutations readily identified by WES that explain >5% of DBA-affected case subjects. Overall, this report should inform not only clinical practice for DBA-affected individuals, but also the design and analysis of rare variant studies for heterogeneous Mendelian disorders.
Collapse
Affiliation(s)
- Jacob C Ulirsch
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA; Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Program in Biological and Biomedical Sciences, Harvard Medical School, Boston, MA 02115, USA
| | - Jeffrey M Verboon
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA; Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Shideh Kazerounian
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Michael H Guo
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Daniel Yuan
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Leif S Ludwig
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA; Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Robert E Handsaker
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
| | - Nour J Abdulhay
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA; Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Claudia Fiorini
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA; Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Giulio Genovese
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Elaine T Lim
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Aaron Cheng
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA; Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Beryl B Cummings
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Program in Biological and Biomedical Sciences, Harvard Medical School, Boston, MA 02115, USA
| | - Katherine R Chao
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Alan H Beggs
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Casie A Genetti
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Colin A Sieff
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA
| | - Peter E Newburger
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Edyta Niewiadomska
- Department of Pediatric Hematology/Oncology, Medical University of Warsaw, Warsaw, Poland
| | - Michal Matysiak
- Department of Pediatric Hematology/Oncology, Medical University of Warsaw, Warsaw, Poland
| | - Adrianna Vlachos
- Feinstein Institute for Medical Research, Manhasset, NY; Division of Hematology/Oncology and Stem Cell Transplantation, Cohen Children's Medical Center, New Hyde Park, NY; Hofstra Northwell School of Medicine, Hempstead, NY 11030, USA
| | - Jeffrey M Lipton
- Feinstein Institute for Medical Research, Manhasset, NY; Division of Hematology/Oncology and Stem Cell Transplantation, Cohen Children's Medical Center, New Hyde Park, NY; Hofstra Northwell School of Medicine, Hempstead, NY 11030, USA
| | - Eva Atsidaftos
- Feinstein Institute for Medical Research, Manhasset, NY; Division of Hematology/Oncology and Stem Cell Transplantation, Cohen Children's Medical Center, New Hyde Park, NY; Hofstra Northwell School of Medicine, Hempstead, NY 11030, USA
| | - Bertil Glader
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 02114, USA
| | - Anupama Narla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 02114, USA
| | - Pierre-Emmanuel Gleizes
- Laboratory of Eukaryotic Molecular Biology, Center for Integrative Biology (CBI), University of Toulouse, CNRS, Toulouse, France
| | - Marie-Françoise O'Donohue
- Laboratory of Eukaryotic Molecular Biology, Center for Integrative Biology (CBI), University of Toulouse, CNRS, Toulouse, France
| | - Nathalie Montel-Lehry
- Laboratory of Eukaryotic Molecular Biology, Center for Integrative Biology (CBI), University of Toulouse, CNRS, Toulouse, France
| | - David J Amor
- Murdoch Children's Research Institute and Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Steven A McCarroll
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
| | - Anne H O'Donnell-Luria
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Namrata Gupta
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Stacey B Gabriel
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Daniel G MacArthur
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Eric S Lander
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Monkol Lek
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Lydie Da Costa
- University Paris VII Denis DIDEROT, Faculté de Médecine Xavier Bichat, 75019 Paris, France; Laboratory of Excellence for Red Cell, LABEX GR-Ex, 75015 Paris, France
| | - David G Nathan
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA
| | - Andrei A Korostelev
- RNA Therapeutics Institute, Department of Biochemistry and Molecular Pharmacology, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA 01605, USA
| | - Ron Do
- Department of Genetics and Genomic Sciences and The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Vijay G Sankaran
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA; Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Harvard Stem Cell Institute, Cambridge, MA 02138, USA.
| | - Hanna T Gazda
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| |
Collapse
|
42
|
Rama M, Touitou I, Sarrabay G. Reply to Sönmez et al. Eur J Hum Genet 2018; 26:1564-1565. [DOI: 10.1038/s41431-018-0242-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 07/19/2018] [Indexed: 11/09/2022] Open
|
43
|
Warts and DADA2: a Mere Coincidence? J Clin Immunol 2018; 38:836-843. [DOI: 10.1007/s10875-018-0565-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 10/22/2018] [Indexed: 12/12/2022]
|
44
|
Genetic testing for DADA2: How can we avoid missing patients? Eur J Hum Genet 2018; 26:1563-1565. [PMID: 30206352 DOI: 10.1038/s41431-018-0240-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 07/18/2018] [Indexed: 11/08/2022] Open
|
45
|
Ozen S, Batu ED. Vasculitis Pathogenesis: Can We Talk About Precision Medicine? Front Immunol 2018; 9:1892. [PMID: 30154798 PMCID: PMC6102378 DOI: 10.3389/fimmu.2018.01892] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/31/2018] [Indexed: 12/27/2022] Open
Abstract
Precision medicine is designing the medical care by taking into account the individual variability for each person. We have tried to address whether the existing data may guide precision medicine in primary systemic vasculitides (PSV). We have reviewed genome-wide association studies (GWAS) data, lessons from monogenic mimics of these diseases, and biomarker studies in immunoglobulin A vasculitis/Henoch–Schönlein purpura, Kawasaki disease, anti-neutrophil cytoplasmic antibody-associated vasculitis, polyarteritis nodosa (PAN), Takayasu arteritis, and Behçet’s disease (BD). GWAS provide insights about the pathogenesis of PSV while whole exome sequencing studies lead to discovery of monogenic vasculitides, phenotype of which could mimic other types of vasculitis such as PAN and BD. Monogenic vasculitides form a subgroup of vasculitis which are caused by single gene alterations and discovery of these diseases has enabled more specific therapies in these patients. With increasing number of studies on biomarkers, new targets for treatment appear and better and structured follow-up of PSV patients will become possible. Proteomics and metabolomics studies are required to better categorize our patients with PSV so that we can manage them appropriately and offer more targeted therapy.
Collapse
Affiliation(s)
- Seza Ozen
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ezgi Deniz Batu
- Division of Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
46
|
Meyts I, Aksentijevich I. Deficiency of Adenosine Deaminase 2 (DADA2): Updates on the Phenotype, Genetics, Pathogenesis, and Treatment. J Clin Immunol 2018; 38:569-578. [PMID: 29951947 PMCID: PMC6061100 DOI: 10.1007/s10875-018-0525-8] [Citation(s) in RCA: 237] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/19/2018] [Indexed: 12/13/2022]
Abstract
Deficiency of ADA2 (DADA2) is the first molecularly described monogenic vasculitis syndrome. DADA2 is caused by biallelic hypomorphic mutations in the ADA2 gene that encodes the adenosine deaminase 2 (ADA2) protein. Over 60 disease-associated mutations have been identified in all domains of ADA2 affecting the catalytic activity, protein dimerization, and secretion. Vasculopathy ranging from livedo reticularis to polyarteritis nodosa (PAN) and life-threatening ischemic and/or hemorrhagic stroke dominate the clinical features of DADA2. Vasculitis and inflammation can affect many organs, explaining the intestinal, hepatological, and renal manifestations. DADA2 should be primarily considered in patients with early-onset fevers, rashes, and strokes even in the absence of positive family history. Hematological manifestations include most commonly hypogammaglobulinemia, although pure red cell aplasia (PRCA), immune thrombocytopenia, and neutropenia have been increasingly reported. Thus, DADA2 may unify a variety of syndromes previously not thought to be related. The first-line treatment consists of TNF-inhibitors and is effective in controlling inflammation and in preserving vascular integrity. Hematopoietic stem cell transplantation (HSCT) has been successful in a group of patients presenting with hematological manifestations. ADA2 is highly expressed in myeloid cells and plays a role in the differentiation of macrophages; however, its function is still largely undetermined. Deficiency of ADA2 has been linked to an imbalance in differentiation of monocytes towards proinflammatory M1 macrophages. Future research on the function of ADA2 and on the pathophysiology of DADA2 will improve our understanding of the condition and promote early diagnosis and targeted treatment.
Collapse
Affiliation(s)
- Isabelle Meyts
- Department of Pediatrics, Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.
| | - Ivona Aksentijevich
- Inflammatory Disease Section, National Human Genome Research Institute, Bethesda, USA.
| |
Collapse
|
47
|
Human A, Pagnoux C. Diagnosis and management of ADA2 deficient polyarteritis nodosa. Int J Rheum Dis 2018; 22 Suppl 1:69-77. [PMID: 29624883 DOI: 10.1111/1756-185x.13283] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Deficiency of ADA2 (DADA2) is a recently described systemic inflammatory vasculopathy caused by mutations in the CERC1 gene that often, but not always, clinically resembles polyarteritis nodosa (PAN). The condition was originally characterized by livedoid rash, systemic inflammation, variable hypogammaglobulinemia, and early-onset stroke. The phenotypic spectrum has expanded to include patients with immunodeficiency syndromes and bone marrow dysfunction, which are not typical features of PAN. Exploration into the pathogenesis and treatment options of DADA2 has added to our understanding of this condition, but more studies are needed. The purpose of this article is to review the various clinical phenotypes of DADA2, and raise awareness among rheumatologists to consider DADA2 when evaluating patients presenting with PAN-like disease.
Collapse
Affiliation(s)
- Andrea Human
- Division of Rheumatology, Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia, Canada
| | | |
Collapse
|
48
|
Alsultan A, Basher E, Alqanatish J, Mohammed R, Alfadhel M. Deficiency of ADA2 mimicking autoimmune lymphoproliferative syndrome in the absence of livedo reticularis and vasculitis. Pediatr Blood Cancer 2018; 65. [PMID: 29271561 DOI: 10.1002/pbc.26912] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 11/06/2017] [Accepted: 11/08/2017] [Indexed: 12/15/2022]
Abstract
Adenosine deaminase-2 (ADA2) deficiency (DADA2) is associated with early onset polyarteritis nodosa and vasculopathy. Classic presentation includes livedo reticularis, vasculitis, and stroke. However, the phenotype and disease severity are variable. We present a 5-year-old female who presented with features that mimicked autoimmune lymphoproliferative syndrome (ALPS) in the absence of classic features of DADA2. Exome sequencing identified a novel homozygous splicing variant in ADA2 c.882-2A > G. Patient responded to anti- tumor necrosis factor medication and is in complete remission. Hematologists should be aware of various hematological presentations of DADA2, including ALPS-like disorder, that might lack vasculitis and livedo reticularis to prevent delay in initiating optimal therapy.
Collapse
Affiliation(s)
- Abdulrahman Alsultan
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Enas Basher
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Jubran Alqanatish
- Department of Pediatrics, King Abdullah Specialist Children's Hospital and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Reem Mohammed
- Department of Pediatrics, King Abdullah Specialist Children's Hospital and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Majid Alfadhel
- Department of Pediatrics, King Abdullah Specialist Children's Hospital and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| |
Collapse
|
49
|
Novel Mutation in CECR1 Leads to Deficiency of ADA2 with Associated Neutropenia. J Clin Immunol 2018; 38:273-277. [PMID: 29564582 DOI: 10.1007/s10875-018-0487-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Adenosine deaminase 2 (ADA2) have been reported to cause vasculitic diseases and immunodeficiency recently. Patients present with stroke episodes and rashes mimicking polyarteritis nodosa (PAN). We report a patient who has been followed up with severe neutropenia and found an unexpectedly revealed novel mutation in CECR1 affecting ADA2. METHODS We reviewed medical records and clinical history of the patient. No mutations in other known neutropenia genes such as ELA, G6PC3, HAX1, AP3B1, LAMTOR2, VPS13B, VPS45, GFI1, JAGN1, or WAS could be detected. Sanger sequencing was used to confirm the genetic variants in the patient and relatives. RESULTS Genetic analysis by exome sequencing revealed a novel mutation in the gene CECR1 (c.G962A; p.G321E) which segregated perfectly in the relatives. CONCLUSION This is the first DADA2 patient presenting with severe neutropenia. We suggest that in patients with unexplained cytopenias combined with immunodeficiency, fevers of unknown origin and high inflammation markers, DADA2 should be considered.
Collapse
|
50
|
Michniacki TF, Hannibal M, Ross CW, Frame DG, DuVall AS, Khoriaty R, Vander Lugt MT, Walkovich KJ. Hematologic Manifestations of Deficiency of Adenosine Deaminase 2 (DADA2) and Response to Tumor Necrosis Factor Inhibition in DADA2-Associated Bone Marrow Failure. J Clin Immunol 2018; 38:166-173. [PMID: 29411230 DOI: 10.1007/s10875-018-0480-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/25/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Thomas F Michniacki
- Pediatrics and Communicable Diseases, Pediatric Hematology/Oncology, University of Michigan, 1500 E. Medical Center Drive, D4202 Medical Professional Building, Ann Arbor, MI, 48109, USA.
| | - Mark Hannibal
- Pediatrics - Genetics, University of Michigan, Ann Arbor, MI, USA
| | - Charles W Ross
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - David G Frame
- Department of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Adam S DuVall
- Pediatric Hematology/Oncology, Oregon Health Sciences University, Portland, OR, USA
| | - Rami Khoriaty
- Department of Internal Medicine, Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Mark T Vander Lugt
- Pediatrics and Communicable Diseases, Pediatric Hematology/Oncology, University of Michigan, 1500 E. Medical Center Drive, D4202 Medical Professional Building, Ann Arbor, MI, 48109, USA
| | - Kelly J Walkovich
- Pediatrics and Communicable Diseases, Pediatric Hematology/Oncology, University of Michigan, 1500 E. Medical Center Drive, D4202 Medical Professional Building, Ann Arbor, MI, 48109, USA
| |
Collapse
|