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Chear CT, Ismail IH, Chan KC, Noh LM, Kassim A, Latiff AHA, Gill SS, Ramly NH, Tan KK, Sundaraj C, Choo CM, Mohamed SAS, Baharin MF, Zamri AS, Yahya SNHS, Mohamad SB, Ripen AM. Clinical features and mutational analysis of X-linked agammaglobulinemia patients in Malaysia. Front Immunol 2023; 14:1252765. [PMID: 37809070 PMCID: PMC10560089 DOI: 10.3389/fimmu.2023.1252765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Background Bruton's tyrosine kinase (BTK) is a cytoplasmic protein involved in the B cell development. X-linked agammaglobulinemia (XLA) is caused by mutation in the BTK gene, which results in very low or absent B cells. Affected males have markedly reduced immunoglobulin levels, which render them susceptible to recurrent and severe bacterial infections. Methods: Patients suspected with X-linked agammaglobulinemia were enrolled during the period of 2010-2018. Clinical summary, and immunological profiles of these patients were recorded. Peripheral blood samples were collected for monocyte BTK protein expression detection and BTK genetic analysis. The medical records between January 2020 and June 2023 were reviewed to investigate COVID-19 in XLA. Results Twenty-two patients (from 16 unrelated families) were molecularly diagnosed as XLA. Genetic testing revealed fifteen distinct mutations, including four splicing mutations, four missense mutations, three nonsense mutations, three short deletions, and one large indel mutation. These mutations scattered throughout the BTK gene and mostly affected the kinase domain. All mutations including five novel mutations were predicted to be pathogenic or deleterious by in silico prediction tools. Genetic testing confirmed that eleven mothers and seven sisters were carriers for the disease, while three mutations were de novo. Flow cytometric analysis showed that thirteen patients had minimal BTK expression (0-15%) while eight patients had reduced BTK expression (16-64%). One patient was not tested for monocyte BTK expression due to insufficient sample. Pneumonia (n=13) was the most common manifestation, while Pseudomonas aeruginosa was the most frequently isolated pathogen from the patients (n=4). Mild or asymptomatic COVID-19 was reported in four patients. Conclusion This report provides the first overview of demographic, clinical, immunological and genetic data of XLA in Malaysia. The combination of flow cytometric assessment and BTK genetic analysis provides a definitive diagnosis for XLA patients, especially with atypical clinical presentation. In addition, it may also allow carrier detection and assist in genetic counselling and prenatal diagnosis.
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Affiliation(s)
- Chai Teng Chear
- Primary Immunodeficiency Unit, Allergy and Immunology Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health, Shah Alam, Selangor, Malaysia
| | - Intan Hakimah Ismail
- Clinical Immunology Unit, Department of Paediatrics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Kwai Cheng Chan
- Pediatric Department, Penang General Hospital, Ministry of Health, George Town, Penang, Malaysia
| | - Lokman Mohd Noh
- Pediatric Department, Tunku Azizah Hospital (Women and Children Hospital Kuala Lumpur), Ministry of Health, Kuala Lumpur, Malaysia
| | - Asiah Kassim
- Pediatric Department, Tunku Azizah Hospital (Women and Children Hospital Kuala Lumpur), Ministry of Health, Kuala Lumpur, Malaysia
| | | | - Sandeep Singh Gill
- Pediatric Department, Hospital Wanita Dan Kanak-Kanak Sabah, Ministry of Health, Kota Kinabalu, Sabah, Malaysia
| | - Nazatul Haslina Ramly
- Pediatric Department, Tunku Azizah Hospital (Women and Children Hospital Kuala Lumpur), Ministry of Health, Kuala Lumpur, Malaysia
| | - Kah Kee Tan
- Pediatric Department, Perdana University and Royal College of Surgeons in Ireland (PURCSI), School of Medicine, Perdana University, Kuala Lumpur, Malaysia
| | - Charlotte Sundaraj
- Pediatric Department, Hospital Putrajaya, Ministry of Health, Putrajaya, Malaysia
| | - Chong Ming Choo
- Pediatric Department, Hospital Sultan Abdul Halim, Ministry of Health, Sungai Petani, Kedah, Malaysia
| | | | - Mohd Farid Baharin
- Primary Immunodeficiency Unit, Allergy and Immunology Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health, Shah Alam, Selangor, Malaysia
| | - Amelia Suhana Zamri
- Primary Immunodeficiency Unit, Allergy and Immunology Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health, Shah Alam, Selangor, Malaysia
| | - Sharifah Nurul Husna Syed Yahya
- Primary Immunodeficiency Unit, Allergy and Immunology Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health, Shah Alam, Selangor, Malaysia
| | - Saharuddin Bin Mohamad
- Institute of Biological Sciences, Faculty of Science, Universiti Malaya, Kuala Lumpur, Malaysia
- Centre of Research in Systems Biology, Structural Bioinformatics and Human Digital Imaging (CRYSTAL), Universiti Malaya, Kuala Lumpur, Malaysia
| | - Adiratna Mat Ripen
- Primary Immunodeficiency Unit, Allergy and Immunology Research Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health, Shah Alam, Selangor, Malaysia
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The Role of m 6A Modifications in B-Cell Development and B-Cell-Related Diseases. Int J Mol Sci 2023; 24:ijms24054721. [PMID: 36902149 PMCID: PMC10003095 DOI: 10.3390/ijms24054721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/17/2023] [Accepted: 02/02/2023] [Indexed: 03/06/2023] Open
Abstract
B cells are a class of professional antigen-presenting cells that produce antibodies to mediate humoral immune response and participate in immune regulation. m6A modification is the most common RNA modification in mRNA; it involves almost all aspects of RNA metabolism and can affect RNA splicing, translation, stability, etc. This review focuses on the B-cell maturation process as well as the role of three m6A modification-related regulators-writer, eraser, and reader-in B-cell development and B-cell-related diseases. The identification of genes and modifiers that contribute to immune deficiency may shed light on regulatory requirements for normal B-cell development and the underlying mechanism of some common diseases.
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Sun D, Heimall JR, Greenhawt MJ, Bunin NJ, Shaker MS, Romberg N. Cost Utility of Lifelong Immunoglobulin Replacement Therapy vs Hematopoietic Stem Cell Transplant to Treat Agammaglobulinemia. JAMA Pediatr 2022; 176:176-184. [PMID: 34779842 PMCID: PMC8593831 DOI: 10.1001/jamapediatrics.2021.4583] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Lifelong immunoglobulin replacement therapy (IRT) is standard-of-care treatment for congenital agammaglobulinemia but accrues high annual costs ($30 000-$90 000 per year) and decrements to quality of life over patients' life spans. Hematopoietic stem cell transplant (HSCT) offers an alternative 1-time therapy, but has high morbidity and mortality. OBJECTIVE To evaluate the cost utility of IRT vs matched sibling donor (MSD) and matched unrelated donor (MUD) HSCT to treat patients with agammaglobulinemia in the US. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation used Markov analysis to model the base-case scenario of a patient aged 12 months with congenital agammaglobulinemia receiving lifelong IRT vs MSD or MUD HSCT. Costs, probabilities, and quality-of-life measures were derived from the literature. Microsimulations estimated premature deaths for each strategy in a virtual cohort. One-way sensitivity and probabilistic sensitivity analyses evaluated uncertainty around parameter estimates performed from a societal perspective over a 100-year time horizon. The threshold for cost-effective care was set at $100 000 per quality-adjusted life-year (QALY). This study was conducted from 2020 across a 100-year time horizon. EXPOSURES Immunoglobulin replacement therapy vs MSD or MUD HSCT for treatment of congenital agammaglobulinemia. MAIN OUTCOMES AND MEASURES The primary outcomes were incremental cost-effectiveness ratio (ICER) expressed in 2020 US dollars per QALY gained and premature deaths associated with each strategy. RESULTS In this economic evaluation of patients with congenital agammaglobulinemia, lifelong IRT cost more than HSCT ($1 512 946 compared with $563 776 [MSD] and $637 036 [MUD]) and generated similar QALYs (20.61 vs 17.25 [MSD] and 17.18 [MUD]). Choosing IRT over MSD or MUD HSCT yielded ICERs of $282 166 per QALY gained over MSD and $255 633 per QALY gained over MUD HSCT, exceeding the US willingness-to-pay threshold of $100 000/QALY. However, IRT prevented at least 2488 premature deaths per 10 000 microsimulations compared with HSCT. When annual IRT price was reduced from $60 145 to below $29 469, IRT became the cost-effective strategy. Findings remained robust in sensitivity and probabilistic sensitivity analyses. CONCLUSIONS AND RELEVANCE In the US, IRT is more expensive than HSCT for agammaglobulinemia treatment. The findings of this study suggest that IRT prevents more premature deaths but does not substantially increase quality of life relative to HSCT. Reducing US IRT cost by 51% to a value similar to IRT prices in countries implementing value-based pricing may render it the more cost-effective strategy.
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Affiliation(s)
- Di Sun
- Department of Pediatrics, Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer R. Heimall
- Department of Pediatrics, Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Matthew J. Greenhawt
- Children's Hospital Colorado, Section of Allergy and Immunology, Food Challenge and Research Unit, Aurora,Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Nancy J. Bunin
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Department of Pediatrics, Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Marcus S. Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, New Hampshire
| | - Neil Romberg
- Department of Pediatrics, Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Rodriguez JA, Bang TJ, Restrepo CS, Green DB, Browne LP, Vargas D. Imaging Features of Primary Immunodeficiency Disorders. Radiol Cardiothorac Imaging 2021; 3:e200418. [PMID: 33969305 PMCID: PMC8098094 DOI: 10.1148/ryct.2021200418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 11/10/2020] [Accepted: 12/01/2020] [Indexed: 06/12/2023]
Abstract
Primary immunodeficiency disorders (PIDs), which are humoral, combined, and innate defects of the immune system, are relatively uncommon and may go undiagnosed in patients experiencing recurrent infections, resulting in increased morbidity and mortality. PIDs are clinically characterized by a broad spectrum of disorders, including repeated infections, autoimmune disorders, lymphoproliferative diseases, congenital anomalies, and increased risk of malignancy. Cardiothoracic imaging plays a crucial role in the diagnosis of PIDs owing to the high rates of repeated respiratory infections leading to bronchiectasis and other forms of chronic lung disease. Although PIDs as a group may seem similar in terms of radiologic features and clinical manifestations, there are specific entities that are pertinent to each PID on an individual level. For example, patients with common variable immunodeficiency may develop a unique granulomatous lymphocytic interstitial lung disease, and Good syndrome is associated with thymoma. Familiarity with the imaging characteristics of these disorders may expedite diagnosis and prognostication, and better direct therapy. Reviewing the thoracic manifestations of all PIDs is beyond the scope of this article; thus, the focus herein is on discussing the thoracic manifestations of the most common PIDs and their imaging features. © RSNA, 2021An earlier incorrect version appeared online. This article was corrected on March 25, 2021.
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