1
|
Gray PE, Bartlett AW, Tangye SG. Severe COVID-19 represents an undiagnosed primary immunodeficiency in a high proportion of infected individuals. Clin Transl Immunology 2022; 11:e1365. [PMID: 35444807 PMCID: PMC9013505 DOI: 10.1002/cti2.1365] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 01/08/2023] Open
Abstract
Since the emergence of the COVID-19 pandemic in early 2020, a key challenge has been to define risk factors, other than age and pre-existing comorbidities, that predispose some people to severe disease, while many other SARS-CoV-2-infected individuals experience mild, if any, consequences. One explanation for intra-individual differences in susceptibility to severe COVID-19 may be that a growing percentage of otherwise healthy people have a pre-existing asymptomatic primary immunodeficiency (PID) that is unmasked by SARS-CoV-2 infection. Germline genetic defects have been identified in individuals with life-threatening COVID-19 that compromise local type I interferon (IFN)-mediated innate immune responses to SARS-CoV-2. Remarkably, these variants - which impact responses initiated through TLR3 and TLR7, as well as the response to type I IFN cytokines - may account for between 3% and 5% of severe COVID-19 in people under 70 years of age. Similarly, autoantibodies against type I IFN cytokines (IFN-α, IFN-ω) have been detected in patients' serum prior to infection with SARS-CoV-2 and were found to cause c. 20% of severe COVID-19 in the above 70s and 20% of total COVID-19 deaths. These autoantibodies, which are more common in the elderly, neutralise type I IFNs, thereby impeding innate antiviral immunity and phenocopying an inborn error of immunity. The discovery of PIDs underlying a significant percentage of severe COVID-19 may go some way to explain disease susceptibility, may allow for the application of targeted therapies such as plasma exchange, IFN-α or IFN-β, and may facilitate better management of social distancing, vaccination and early post-exposure prophylaxis.
Collapse
Affiliation(s)
- Paul E Gray
- Department of Immunology and Infectious Diseases Sydney Children's Hospital Randwick NSW Australia.,School of Women's and Children's Health University of New South Wales Randwick NSW Australia
| | - Adam W Bartlett
- Department of Immunology and Infectious Diseases Sydney Children's Hospital Randwick NSW Australia.,School of Women's and Children's Health University of New South Wales Randwick NSW Australia
| | - Stuart G Tangye
- Garvan Institute of Medical Research Darlinghurst NSW Australia.,St Vincent's Clinical School UNSW Sydney Randwick NSW Australia
| |
Collapse
|
2
|
Anderson WF, Blaese RM, Culver K. The ADA human gene therapy clinical protocol: Points to Consider response with clinical protocol, July 6, 1990. Hum Gene Ther 2001; 1:331-62. [PMID: 11642817 DOI: 10.1089/hum.1990.1.3-331] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
3
|
Blaese RM, Culver KW, Miller AD, Carter CS, Fleisher T, Clerici M, Shearer G, Chang L, Chiang Y, Tolstoshev P, Greenblatt JJ, Rosenberg SA, Klein H, Berger M, Mullen CA, Ramsey WJ, Muul L, Morgan RA, Anderson WF. T lymphocyte-directed gene therapy for ADA- SCID: initial trial results after 4 years. Science 1995; 270:475-80. [PMID: 7570001 DOI: 10.1126/science.270.5235.475] [Citation(s) in RCA: 893] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
In 1990, a clinical trial was started using retroviral-mediated transfer of the adenosine deaminase (ADA) gene into the T cells of two children with severe combined immunodeficiency (ADA- SCID). The number of blood T cells normalized as did many cellular and humoral immune responses. Gene treatment ended after 2 years, but integrated vector and ADA gene expression in T cells persisted. Although many components remain to be perfected, it is concluded here that gene therapy can be a safe and effective addition to treatment for some patients with this severe immunodeficiency disease.
Collapse
Affiliation(s)
- R M Blaese
- National Center for Human Genome Research, National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Abstract
The replacement of genetically deficient enzymes in patients with inherited metabolic disorders by infusion of purified enzymes or by organ transplantation has had very limited success, although good results with bone marrow transplantation have been obtained in some patients with mucopolysaccharidosis, Gaucher disease and inherited immunodeficiency diseases. Genetic engineering of the patient's lymphocytes may ultimately render these approaches redundant, at least for some of these diseases. Treatment of chronic pancreatic insufficiency and of disaccharidase deficiency with oral enzymes can be very effective; therapy can be monitored in the latter by measuring the breath hydrogen excretion and in the former by a range of tests of which stool chymotrypsin assay is the most convenient. Treatment of acute myocardial infarction by intracoronary perfusion of thrombolytic enzymes can improve both cardiac function and long-term survival if given early enough. Successful reperfusion can be identified by changes in the kinetics of serum enzyme release and clearance, especially for the isoenzymes and isoforms of creatine kinase. In cancer chemotherapy, L-asparaginase has long been a useful adjunct in the treatment of acute lymphoblastic leukemia, but recent experience suggests a role in acute nonlymphoblastic leukemia as well.
Collapse
Affiliation(s)
- D M Goldberg
- Department of Clinical Biochemistry, University of Toronto, Ontario, Canada
| |
Collapse
|
5
|
Pachman LM, Lynch PA, Silver RK, Ozog DL, Poznanski AK. Primary immunodeficiency disease in children: an update. CURRENT PROBLEMS IN PEDIATRICS 1989; 19:1-64. [PMID: 2647419 DOI: 10.1016/0045-9380(89)90034-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- L M Pachman
- Northwestern University Medical School, Chicago, Illinois
| | | | | | | | | |
Collapse
|
6
|
Morgan G, Levinsky RJ, Hugh-Jones K, Fairbanks LD, Morris GS, Simmonds HA. Heterogeneity of biochemical, clinical and immunological parameters in severe combined immunodeficiency due to adenosine deaminase deficiency. Clin Exp Immunol 1987; 70:491-9. [PMID: 3436096 PMCID: PMC1542189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
There was considerable heterogeneity of the biochemical, clinical and immunological findings in 12 patients and two fetuses from 16 kindreds affected by severe combined immunodeficiency (SCID) due to a complete deficiency of the enzyme adenosine deaminase (ADA). Despite this heterogeneity a consistent pattern was observed, in which levels of abnormal purine metabolites paralleled the severity of the immunodeficiency. A high level of urinary deoxyadenosine was a universal finding for homozygous ADA deficiency. ATP depletion, in association with raised deoxy-ATP (dATP) levels, was found in the erythrocytes of nine infants with profound cellular and humoral immunodeficiency. There was no erythrocyte ATP depletion in two patients with some residual immunity, who presented later, but adenosine accumulated in their plasma and urine. This finding, together with the presence of some T and normal B-lymphocytes in less severely affected patients, suggests that adenosine is relatively non-toxic. The other results are consistent with the hypothesis that the sequence of deoxyadenosine accumulation, dATP formation and ATP depletion represents the major mechanism of toxicity to the immune system. Low numbers of T lymphocytes and dATP accumulation were also found in the blood of affected fetuses at 18 weeks gestation. Since extreme instability of erythrocyte ADA was demonstrated in some heterozygotes, and heterozygote ADA levels were detected in one infant with SCID, simultaneous immunological and biochemical analysis of fetal blood are important for precise antenatal diagnosis.
Collapse
Affiliation(s)
- G Morgan
- Department of Immunology, Institute of Child Health, London, UK
| | | | | | | | | | | |
Collapse
|
7
|
Pérignon JL, Durandy A, Peter MO, Freycon F, Dumez Y, Griscelli C. Early prenatal diagnosis of inherited severe immunodeficiencies linked to enzyme deficiencies. J Pediatr 1987; 111:595-8. [PMID: 3116192 DOI: 10.1016/s0022-3476(87)80129-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- J L Pérignon
- Département de Biochimie, INSERM U75, Faculté de Médecine Necker-Enfants Malades, Paris, France
| | | | | | | | | | | |
Collapse
|
8
|
Hershfield MS, Buckley RH, Greenberg ML, Melton AL, Schiff R, Hatem C, Kurtzberg J, Markert ML, Kobayashi RH, Kobayashi AL. Treatment of adenosine deaminase deficiency with polyethylene glycol-modified adenosine deaminase. N Engl J Med 1987; 316:589-96. [PMID: 3807953 DOI: 10.1056/nejm198703053161005] [Citation(s) in RCA: 365] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
We treated two children who had adenosine deaminase deficiency and severe combined immunodeficiency disease by injecting bovine adenosine deaminase modified by conjugation with polyethylene glycol. The modified enzyme was rapidly absorbed after intramuscular injection and had a half-life in plasma of 48 to 72 hours. Weekly doses of approximately 15 U per kilogram of body weight maintained plasma adenosine deaminase activity at two to three times the level of erythrocyte adenosine deaminase activity in normal subjects. The principal biochemical consequences of adenosine deaminase deficiency were almost completely reversed. In erythrocytes, adenosine nucleotides increased and deoxyadenosine nucleotides decreased to less than 0.5 percent of total adenine nucleotides. The activity of S-adenosylhomocysteine hydrolase, which is inactivated by deoxyadenosine, increased to normal in red cells and nucleated marrow cells. Neither toxic effects nor hypersensitivity reactions were observed. In vitro tests of the cellular immune function of each patient showed marked improvement, along with an increase in circulating T lymphocytes. Clinical improvement was indicated by absence of infection and resumption of weight gain. We conclude that from the standpoints of efficacy, convenience, and safety, polyethylene glycol-modified adenosine deaminase is preferable to red-cell transfusion as a treatment for adenosine deaminase deficiency. Patients with other inherited metabolic diseases in which accumulated metabolites equilibrate with plasma could benefit from treatment with the appropriate polyethylene glycol-modified enzyme.
Collapse
|
9
|
|
10
|
Simmonds HA, Fairbanks LD, Morris GS, Hugh-Jones K, Morgan G, Levinsky RJ. Correlations between purine levels, clinical and immunological status in ADA deficiency. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1986; 195 Pt A:93-9. [PMID: 3728190 DOI: 10.1007/978-1-4684-5104-7_15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
11
|
Van der Weyden MB, Jack I, Ziegler JB. Characterization of adenosine deaminating activity in normal and adenosine deaminase deficient human tissue. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1984; 165 Pt B:67-70. [PMID: 6609541 DOI: 10.1007/978-1-4757-0390-0_14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
12
|
Hong R, Horowitz SD, Fortman C, Martin DW. Effect of ADA deficiency on cultured murine thymus transplantation. CLINICAL IMMUNOLOGY AND IMMUNOPATHOLOGY 1982; 23:448-58. [PMID: 6980759 DOI: 10.1016/0090-1229(82)90129-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
13
|
Peters GJ, Oosterhof A, Veerkamp JH. Effects of adenosine and deoxyadenosine on PHA-stimulation of lymphocytes of man, horse and pig. THE INTERNATIONAL JOURNAL OF BIOCHEMISTRY 1982; 14:377-85. [PMID: 6177567 DOI: 10.1016/0020-711x(82)90023-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
1. Adenosine inhibits thymidine and uridine incorporation of PHA-stimulated lymphocytes of man and horse at concentrations higher than 50 and 10 microM, respectively. Deoxyadenosine is inhibitory at concentrations higher than 100 microM. Thymidine and uridine incorporation of porcine lymphocytes are elevated 5-7-fold by 25-100 microM adenosine, deoxyadenosine, inosine and hypoxanthine. Leucine incorporation of PHA-stimulated lymphocytes was affected by adenosine and deoxyadenosine in the same way, but to a lower extent. 2. Effects of adenosine and deoxyadenosine were more pronounced at shorter cultivation times. 3. EHNA potentiated the effects of adenosine and deoxyadenosine on human and equine lymphocytes. With human lymphocytes inhibition by deoxyadenosine and EHNA was higher than by adenosine and EHNA. With porcine lymphocytes only the combination of deoxyadenosine and EHNA was inhibitory. 4. Homocysteine potentiated the inhibition of thymidine incorporation by the combination of adenosine and deoxyadenosine with equine lymphocytes, but not the inhibition of adenosine or deoxyadenosine alone. 5. Adenosine suppressed the PHA-stimulated elevation of PRPP concentrations. With porcine lymphocytes PRPP remained at the level of 0 hr, while with equine lymphocytes PRPP concentration decreased to below that level. 6. The various effects of adenosine and deoxyadenosine on lymphocytes of man, horse and pig can partially be related to differences in adenosine and deoxyadenosine metabolism.
Collapse
|
14
|
Perrett D, Sahota A, Simmonds HA, Hugh-Jones K. Deoxyadenosine metabolism in the erythrocytes of children with severe, combined immunodeficiency. Biosci Rep 1981; 1:933-44. [PMID: 6976189 DOI: 10.1007/bf01114963] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
|
15
|
Thuillier L, Garreau F, Cartier P. Inability of immunocompetent thymocytes to produce T-cell growth factor under adenosine deaminase deficiency conditions. Cell Immunol 1981; 63:81-90. [PMID: 6974051 DOI: 10.1016/0008-8749(81)90030-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
16
|
Hutton JJ, Wiginton DA, Coleman MS, Fuller SA, Limouze S, Lampkin BC. Biochemical and functional abnormalities in lymphocytes from an adenosine deaminase-deficient patient during enzyme replacement therapy. J Clin Invest 1981; 68:413-21. [PMID: 7263861 PMCID: PMC370813 DOI: 10.1172/jci110270] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Biochemical and immunological properties of lymphocytes were measured repetitively over a period of 40 mo during enzyme replacement by transfusion in a child with adenosine deaminase (ADA) deficiency and severe combined immunodeficiency disease. Catalytically defective ADA protein is present in the child's cells. ADA activity in his lymphocytes is 7 nmol/min per 10(8) cells with 51 ng of ADA protein/10(8) cells by radioimmunoassay. ADA activities in normal cord and adult lymphocytes average 193 and 92 nmol/min per 10(8) cells, respectively, with 429 and 223 ng of ADA protein/10(8) cells. Deoxy(d)ATP accumulates in the patient's erythrocytes and lymphocytes. Transfusion of irradiated packed erythrocytes partially corrects the metabolic defects. Frank metabolic relapse occurs if transfusions are discontinued for several months. The amounts of dATP in erythrocytes and lymphocytes averaged 13 and 2 times normal, respectively, during periods when transfusions were administered every 2-4 wk. Deoxyguanosine triphosphate and deoxycytidine triphosphate in lymphocytes were normal on 11 occasions, but deoxyribosylthymine triphosphate was ninefold increased. On 11 occasions dATP was measured in lymphocytes and erythrocytes isolated simultaneously. There was a positive, but statistically insignificant, correlation between amounts of dATP in the two types of cells (r = 0.25,P > 0.1). The absolute peripheral lymphocyte count was correlated with the activity of ADA in circulating erythrocytes and with the response of lymphocytes to phytohemagglutinin (r = 0.64, P < 0.01; r = 0.49, P < 0.05). Response of lymphocytes to stimulation by phytohemagglutinin in vitro and absolute peripheral lymphocyte counts were not significantly correlated with levels of dATP in the erythrocyte or lymphocyte during periods of intensive therapy. Although there was objective improvement during enzyme replacement, the child remained immunodeficient and biochemically abnormal.
Collapse
|
17
|
Ziegler JB, Van der Weyden MB, Lee CH, Daniel A. Prenatal diagnosis for adenosine deaminase deficiency. J Med Genet 1981; 18:154-6. [PMID: 7241535 PMCID: PMC1048693 DOI: 10.1136/jmg.18.2.154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Amniocentesis was performed in two successive pregnancies of the mother of a child with adenosine deaminase (ADA) deficient severe combined immunodeficiency. Assay of ADA in amniotic fluid fibroblasts showed the pregnancies to be normal and homozygous deficient, respectively. These findings were confirmed by the demonstration of a normal level of erythrocyte ADA in the cord blood of the healthy male born of the first pregnancy and by the demonstration of undetectable ADA activity in cord erythrocytes, spleen, liver, and kidney of the abortus of the second pregnancy. Prenatal diagnosis of ADA deficiency appears to be a reliable procedure.
Collapse
|