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High Inborn Errors of Immunity Risk in Patients with Granuloma. J Clin Immunol 2022; 42:1795-1809. [PMID: 35980494 DOI: 10.1007/s10875-022-01342-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 07/28/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE Granuloma etiology includes infections, vasculitis, chemicals, malignancies, lymphoproliferative disorders, and immunological diseases. We hypothesized that patients with granuloma have an underlying primary immunodeficiency disease (PIDD). PATIENTS AND METHODS We retrospectively enrolled 82 patients with immunological evaluation among 294 biopsy-proven granuloma patients (0- to 20-year-old). At the same time frame, we followed up with 1910 patients in the same age group. RESULTS Out of 82 patients, male/female ratio was 45/37. Median age at symptom onset was 5 years (28 days-17.4 years), age of granuloma at diagnosis was 8.6 years (36 days-19.4 years). Common symptoms at disease onset were fever (23.2%), lymphadenopathy (19.6%), abdominal pain (12.2%), and cough (12.2%). Granuloma was frequent in lymph nodes (26.8%), skin (19.5%), lung (13.4%), and bone (11%). Common infectious agents isolated were Mycobacterium spp. (23.2%) and EBV (4.9%). We document PIDD in 76.8% (63/82) of patients. 49.4% (40/81) of immunologically evaluated granuloma patients had hypogammaglobulinemia. Granuloma rate in pediatric PIDD was 3.3%(63/1910). Patients with multiple granulomas (n = 16) had a PIDD diagnosis. Lung involvement was three times more in PIDD. Brain involvement was only seen in PIDD. Fibroadipose tissue and liver involvement were more frequent in patients without documented PIDD and patients whose evaluation was not completed. The mortality rate in PIDD with granuloma was 15.9%, whereas there was no mortality in patients without PIDD. CONCLUSION As documented here, even in a university hospital, the immunologic evaluation ratio is about one-third. We showed high PIDD frequency in children with granuloma, and higher mortality in PIDD with granuloma. Thus, an immunologic evaluation performed meticulously by immunologists is a must for accurate diagnosis and decision of individualized therapeutic options.
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Aderibigbe OM, Priel DL, Lee CCR, Ombrello MJ, Prajapati VH, Liang MG, Lyons JJ, Kuhns DB, Cowen EW, Milner JD. Distinct Cutaneous Manifestations and Cold-Induced Leukocyte Activation Associated With PLCG2 Mutations. JAMA Dermatol 2015; 151:627-34. [PMID: 25760457 DOI: 10.1001/jamadermatol.2014.5641] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE PLCG2-associated antibody deficiency and immune dysregulation (PLAID) is a newly characterized immunodeficiency syndrome associated with distinct cutaneous features. Awareness of the cutaneous skin findings associated with PLAID may facilitate diagnosis and improve patient care. OBJECTIVES To characterize the cutaneous manifestations of PLAID and identify potential cellular mechanisms of the disease. DESIGN, SETTING, AND PARTICIPANTS In this retrospective analysis of patients with PLAID and PLAID-like disease evaluated at the National Institutes of Health from January 1, 2005, through December 31, 2014, patients with deletions in PLCG2 leading to PLAID and patients with PLAID-like disease for whom a PLAID mutation was not identified were studied. MAIN OUTCOMES AND MEASURES Characterization of cutaneous manifestations of PLAID and PLAID-like disease and analysis of PLAID immune cell activation. RESULTS Among 36 patients with PLAID and PLAID-like phenotypes, all of whom had evaporative cold urticaria, 8 patients had a history of unique neonatal-onset ulcerative and cutaneous lesions in cold-sensitive regions of the body. Granulomatous skin lesions sparing warm regions (eg, flexural surfaces and skinfolds) were identified in 4 patients. Neutrophils and monocytes from patients with PLAID exhibited enhanced baseline activation in vitro, which was potentiated by ambient temperature exposure. CONCLUSIONS AND RELEVANCE Collectively, these findings suggest that early identification of neonatal lesions may help in the diagnosis of PLAID and that leukocyte hyperactivation may underlie cutaneous lesions in patients with PLAID. Further characterization of mechanisms underlying leukocyte hyperactivation may contribute to the fundamental understanding of granuloma formation.
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Affiliation(s)
- Oyinade M Aderibigbe
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Debra Long Priel
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Chyi-Chia Richard Lee
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Michael J Ombrello
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Vimal H Prajapati
- Pediatric Dermatology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marilyn G Liang
- Pediatric Dermatology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan J Lyons
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Douglas B Kuhns
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Edward W Cowen
- Dermatology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Joshua D Milner
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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Harp J, Coggshall K, Ruben BS, Ramírez-Valle F, He SY, Berger TG. Cutaneous granulomas in the setting of primary immunodeficiency: a report of four cases and review of the literature. Int J Dermatol 2015; 54:617-25. [PMID: 25773292 DOI: 10.1111/ijd.12765] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 04/10/2014] [Accepted: 05/20/2014] [Indexed: 11/30/2022]
Abstract
IMPORTANCE Cutaneous granulomas without an identifiable infectious etiology are a rare manifestation of primary immunodeficiency (ID). These cutaneous lesions can be misdiagnosed, often as sarcoidosis, when the skin findings precede the diagnosis of immunodeficiency. OBJECTIVE We present four cases from our institution and review the literature in order to emphasize the clinical relevance of this association, discuss the histologic and immunohistochemical features, and explore possible pathogenic mechanisms of granuloma formation. EVIDENCE REVIEW We retrospectively reviewed case reports of all patients presenting with cutaneous granulomas in the setting of primary immunodeficiency. Cases with insufficient information to confirm an immunodeficiency state were excluded. Four patients from our clinic were included, for 54 total cases. FINDINGS The majority of cutaneous granulomas are seen in three types of immunodeficiencies: ataxia-telangiectasia, severe combined immunodeficiency, and combined variable immunodeficiency. Twenty-six percent of patients developed cutaneous granulomas prior to their immunodeficiency diagnosis. Histologically, various granulomatous patterns have been described. Immunohistochemistry revealed a CD4+/CD8+ lymphocyte ratio of less than or equal to 1 in our four patients, which may help differentiate cutaneous granulomas in primary ID from sarcoidal granulomas that typically show a CD4+ predominance. CONCLUSIONS AND RELEVANCE Cutaneous granulomas are a rare manifestation of primary ID and occur predominantly in immunodeficiencies that affect T and B cell compartments.
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Affiliation(s)
- Joanna Harp
- Department of Dermatology, Weill Cornell Medical College, New York, NY, USA
| | - Kathleen Coggshall
- Department of Dermatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Beth S Ruben
- Department of Dermatology, School of Medicine, University of California, San Francisco, CA, USA.,Department of Pathology, School of Medicine, University of California, San Francisco, CA, USA
| | - Francisco Ramírez-Valle
- Department of Dermatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Steven Y He
- Department of Dermatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Timothy G Berger
- Department of Dermatology, School of Medicine, University of California, San Francisco, CA, USA
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Gregoriou S, Trimis G, Charissi C, Kalogeromitros D, Stefanaki K, Rigopoulos D. Cutaneous Granulomas with Predominantly CD8+ Lymphocytic Infiltrate in a Child with Severe Combined Immunodeficiency. J Cutan Med Surg 2008; 12:246-8. [DOI: 10.2310/7750.2008.07061] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Combined immunodeficiency disorders comprise a heterogeneous group of diseases characterized by both humoral and cell-mediated immunodeficiency. Cutaneous granulomas manifestations in children with combined immunodeficiency are rare. Objective: We report the case of a 6-year-old boy who presented with disseminated cutaneous granulomas and a history of multiple infections. Methods and Results: Laboratory evaluation revealed severe combined immunodeficiency, and deoxyribonucleic acid (DNA) analysis confirmed mutations on a gene of chromosome 19 that encodes an enzyme called Janus kinase 3 (Jak-3). Immunohistochemistry revealed expression of CD8+ in the perivascular lymphocytic infiltrate Conclusion: Disseminated granulomatous lesions in children with a history of frequent infections should prompt the clinician to initiate detailed immunocompetence evaluation as they might prove to be the first manifestation of immunologic impairment.
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Affiliation(s)
- Stamatis Gregoriou
- From the 1st Department of Dermatology, 1st Department of Pediatrics, and Allergy Unit, University of Athens, and the Pathology Department of “Agia Sofia” Hospital, Athens, Greece
| | - Georgios Trimis
- From the 1st Department of Dermatology, 1st Department of Pediatrics, and Allergy Unit, University of Athens, and the Pathology Department of “Agia Sofia” Hospital, Athens, Greece
| | - Christina Charissi
- From the 1st Department of Dermatology, 1st Department of Pediatrics, and Allergy Unit, University of Athens, and the Pathology Department of “Agia Sofia” Hospital, Athens, Greece
| | - Dimitris Kalogeromitros
- From the 1st Department of Dermatology, 1st Department of Pediatrics, and Allergy Unit, University of Athens, and the Pathology Department of “Agia Sofia” Hospital, Athens, Greece
| | - Kalliopi Stefanaki
- From the 1st Department of Dermatology, 1st Department of Pediatrics, and Allergy Unit, University of Athens, and the Pathology Department of “Agia Sofia” Hospital, Athens, Greece
| | - Dimitris Rigopoulos
- From the 1st Department of Dermatology, 1st Department of Pediatrics, and Allergy Unit, University of Athens, and the Pathology Department of “Agia Sofia” Hospital, Athens, Greece
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de Jager M, Blokx W, Warris A, Bergers M, Link M, Weemaes C, Seyger M. Immunohistochemical features of cutaneous granulomas in primary immunodeficiency disorders: a comparison with cutaneous sarcoidosis. J Cutan Pathol 2008; 35:467-72. [PMID: 18201241 DOI: 10.1111/j.1600-0560.2007.00854.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cutaneous granulomas can occur in patients with a primary immunodeficiency disorder. In some cases, an infectious cause cannot be revealed. The pathogenesis of these granulomas still remains to be elucidated. The aim of this study was to study differences or overlap between these rare granulomas and sarcoidosis-related granulomas. METHODS Markers for T-cell subsets (CD3, CD4, CD8 and CD45RO), Langerhans' cells (CD1a), macrophages (CD68), B cells (CD20) and NK cells (CD56) were stained immunohistochemically. The amount of CD4+ and CD8+ cells in the granulomas was counted. Results were compared with the CD4+/CD8+ ratio in peripheral blood. RESULTS In the granulomas of two of three patients with a primary immunodeficiency disorder, the cytotoxic T cells (CD8+) outnumbered the T-helper cells (CD4+) with a counted CD4+/CD8+ ratio <<1. In contrast, the granulomas in the cutaneous sarcoidosis patients showed a predominance of CD4+ cells, with CD4+/CD8+ ratios >2. CONCLUSIONS A lower CD4+/CD8+ ratio was found in the cutaneous granulomas of patients with a primary immunodeficiency disorder (unclassified combined immunodeficiency, autoimmune lymphoproliferative syndrome and ataxia teleangiectasia) as compared with the patients with cutaneous sarcoidosis. The possible implications of these findings are discussed in this paper.
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Affiliation(s)
- Michelle de Jager
- Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Malphettes M, Oksenhendler E, Galicier L, Fieschi C. [Granulomatous disease in common variable immunodeficiency]. Rev Med Interne 2007; 29:28-32. [PMID: 18054123 DOI: 10.1016/j.revmed.2007.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Accepted: 10/02/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE Common variable immunodeficiency (CVID), defined by defective production of immunoglobulins, is the most common primary immunodeficiency in adulthood requiring a medical follow-up. Repeated bacterial infections and/or autoimmune manifestations and/or benign lymphoproliferation (including follicular hyperplasia and/or granulomatous disease) are the hallmark of the disease. This review aims at describing recent advances in the understanding and treatment of granulomatous disease in CVID. CURRENT KNOWLEDGE AND KEY POINTS Clinical features of granulomatous disease in CVID can mimic sarcoidosis, remarkable by the low levels of circulating immunoglobulins. Granulomas may be found in several organs in a single patient, and the main features are pulmonary, lymphoid, cutaneous, hepatic or splenic. The features of CVID is remarkable by the high frequency of autoimmune diseases complicating the immunodeficiency. Some immunological abnormalities have been described in such patients, including lymphopenia, decreased T-cells proliferations to mitogens and antigens. Rare polymorphisms in the gene encoding TNFalpha (Tumor Necrosis Factor) have been identified in CVID patients with granulomatous disease. FUTURE PROSPECTS AND PROJECTS The evolution of the disease is severe, particularly when the lung is involved. Treatment consists in immunoglobulins substitution, immunosuppressive agents (corticosteroids, cyclophosphamide) and anti-TNFalpha antibodies. These treatments are difficult to manage in such immunocompromised patients.
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Affiliation(s)
- M Malphettes
- Département d'immunologie clinique, hôpital Saint-Louis, 1 avenue Claude-Vellefaux, Paris, France
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Thatayatikom A, Thatayatikom S, White AJ. Infliximab treatment for severe granulomatous disease in common variable immunodeficiency: a case report and review of the literature. Ann Allergy Asthma Immunol 2005; 95:293-300. [PMID: 16200822 DOI: 10.1016/s1081-1206(10)61228-8] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Granulomatous disease resembling sarcoidosis is a well-described condition associated with common variable immunodeficiency (CVID). Its treatment remains problematic, and new therapeutic options are needed. OBJECTIVES To report the efficacy of treatment with infliximab, a chimeric anti-tumor necrosis factor alpha monoclonal antibody, in a patient with granulomatous CVID and to review the literature on the treatment of patients with granulomatous CVID. METHODS A 22-year-old white man with CVID developed acute multiorgan failure, with granulomatous inflammation on lung and liver biopsy specimens. He was initially treated with antibiotics, intravenous immunoglobulin, and corticosteroids for 5 weeks without improvement. High-dose infliximab was then infused weekly for 6 weeks and then monthly for 9 months. The response to infliximab was determined by changes on clinical examination, imaging studies, and histologic studies. RESULTS The patient's condition dramatically improved after 1 dose of infliximab infusion, with decreasing hepatosplenomegaly, ventilatory support requirements, and pulmonary infiltrates. Ventilatory support was successfully discontinued within 3 weeks. The corticosteroid dose was tapered without reactivation of the disease. After 9 months of therapy, follow-up imaging studies showed resolution of pulmonary infiltrates, no hepatosplenomegaly, and no portal hypertension, and a percutaneous liver biopsy revealed no granulomas; then, infliximab use was discontinued. The patient remains free of granulomatous disease after 18 months of follow-up. CONCLUSIONS To our knowledge, this is the first report of severe visceral granulomatous CVID successfully treated with infliximab. Infliximab may be an effective therapy for granulomas in CVID. Further studies of infliximab and other tumor necrosis factor a antagonist therapies in granulomatous CVID are warranted.
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Affiliation(s)
- Akaluck Thatayatikom
- Division of Immunology/Rheumatology, Department of Pediatrics, St Louis Children's Hospital and Washington University School of Medicine, St Louis, Missouri 63110, USA
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Mitra A, Pollock B, Gooi J, Darling JC, Boon A, Newton-Bishop JA. Cutaneous granulomas associated with primary immunodeficiency disorders. Br J Dermatol 2005; 153:194-9. [PMID: 16029350 DOI: 10.1111/j.1365-2133.2005.06619.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cutaneous granulomas are uncommon in primary immunodeficiency disorders. We report cutaneous granulomas in a child with ataxia telangiectasia (AT) and compare the clinical course with similar lesions in an adult with common variable immunodeficiency (CVI). A 4-year-old female with AT developed cutaneous granulomas as erythematous plaques. The largest lesion appeared on her left cheek and continued to progress despite treatment with topical and intralesional steroids. Disease control was obtained initially with oral antibiotics and low-dose oral steroids. On cessation of oral steroids, significant relapse of the facial granuloma occurred. Pulsed and then oral steroids were required to stop the disease process leaving significant scarring. The second case is of cutaneous granulomas in a 66-year-old man, with CVI, who presented with an erythematous reticulate rash on the legs. We consider it useful to report this patient here as disease control was obtained in a similar way with systemic immunosuppression. In this patient a combination of oral steroids and azathioprine was used. These cutaneous granulomas are thought to be a manifestation of immune dysregulation. No infectious cause has been found so far. We recommend the use of broad-spectrum antibiotics in conjunction with systemic steroids for progressive granulomas, as these patients are immunosuppressed and infection with an unidentified organism cannot be excluded.
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Affiliation(s)
- A Mitra
- Department of Dermatology, St James's University Hospital, Leeds, UK.
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Watters SK, Zacharisen MC, Drolet B, Fink J. Subcutaneous nodules in a patient with recurrent sinopulmonary infections and fatigue. Ann Allergy Asthma Immunol 2004; 91:438-43. [PMID: 14692425 DOI: 10.1016/s1081-1206(10)61510-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shelley K Watters
- Medical College of Wisconsin, Allergy Immunology Division, Milwaukee, Wisconsin 53226, USA
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Ziegler EM, Seung LM, Soltani K, Medenica MM. Cutaneous granulomas with two clinical presentations in a patient with common variable immunodeficiency. J Am Acad Dermatol 1997. [DOI: 10.1016/s0190-9622(18)30762-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Abstract
The authors report a case of pernicious anaemia in a 41-year old white man; this case has particular features: rise in mean corpuscular volume, neurological manifestation 8 and 2 years respectively before diagnosis, association with selective IgA deficiency. Relations between pernicious anaemia and immunoglobulin deficiency are discussed.
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Ament ME. Immunodeficiency syndromes and the gut. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1985; 114:127-35. [PMID: 3911369 DOI: 10.3109/00365528509093773] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The gastrointestinal tract in immunodeficiency disorders is involved with diseases similar to those seen in the immune competent. However, in some immune deficient states the incidence of gastrointestinal disease is high whereas in others it is no different than in the general population. This review clarifies the unique and specific abnormalities seen in immune deficient states and stresses the newest recognised abnormalities. It highlights the fact that the most frequent and severe abnormalities occur in patients with combined immune deficient states.
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