1
|
Elliman DAC, Gennery AR. Newborn screening for severe combined immunodeficiency-Coming to a region near you soon. Clin Exp Immunol 2021; 205:343-345. [PMID: 34235744 DOI: 10.1111/cei.13642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 01/01/2023] Open
Abstract
The most profound of primary immunodeficiencies, severe combined immunodeficiency (SCID), presents in infancy. Infants appear healthy at birth, but they are unable to clear pathogens, particularly viruses, and present with recurrent infection, progressive pnueumonitis and failure to thrive due to enteric viral infection, often associated with persistent vaccine-strain rotavirus. The administration of live vaccines is contraindicated in these infants, but most who are eligible receive bacillus Calmette-Guérin vaccination and the live rotavirus vaccine before the diagnosis of SCID is made, making treatment more complicated. Newborn infants with SCID can be screened using the newborn bloodspot to measure T lymphocyte receptor excision circles (TRECs), episomal DNA formed during T lymphocyte receptor development and very low or absent in SCID. Introduction of this programme in the United Kingdom will require the neonatal BCG vaccination programme to be altered, with vaccination at 28 days, once the SCID screening result is known. Although SCID newborn screening has been successfully introduced in other countries, the change in neonatal BCG vaccination requires the introduction of newborn screening to be carefully introduced. An evaluation of impact of screening on SCID diagnosis, treatment and outcomes, together with an evaluation of the technology used to detect TRECs, and the impact of screening and changes to the BCG programme on families will commence in six screening regions in England in September 2021 for 2 years - should the evaluation prove positive, it is likely that screening for this fatal disease will be introduced across the United Kingdom.
Collapse
Affiliation(s)
| | - Andrew R Gennery
- Newcastle University Translational and Clinical Research Institute and Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Queen Victoria Road, Newcastle Upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| |
Collapse
|
2
|
Rispoli F, Valencic E, Girardelli M, Pin A, Tesser A, Piscianz E, Boz V, Faletra F, Severini GM, Taddio A, Tommasini A. Immunity and Genetics at the Revolving Doors of Diagnostics in Primary Immunodeficiencies. Diagnostics (Basel) 2021; 11:532. [PMID: 33809703 PMCID: PMC8002250 DOI: 10.3390/diagnostics11030532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 12/14/2022] Open
Abstract
Primary immunodeficiencies (PIDs) are a large and growing group of disorders commonly associated with recurrent infections. However, nowadays, we know that PIDs often carry with them consequences related to organ or hematologic autoimmunity, autoinflammation, and lymphoproliferation in addition to simple susceptibility to pathogens. Alongside this conceptual development, there has been technical advancement, given by the new but already established diagnostic possibilities offered by new genetic testing (e.g., next-generation sequencing). Nevertheless, there is also the need to understand the large number of gene variants detected with these powerful methods. That means advancing beyond genetic results and resorting to the clinical phenotype and to immunological or alternative molecular tests that allow us to prove the causative role of a genetic variant of uncertain significance and/or better define the underlying pathophysiological mechanism. Furthermore, because of the rapid availability of results, laboratory immunoassays are still critical to diagnosing many PIDs, even in screening settings. Fundamental is the integration between different specialties and the development of multidisciplinary and flexible diagnostic workflows. This paper aims to tell these evolving aspects of immunodeficiencies, which are summarized in five key messages, through introducing and exemplifying five clinical cases, focusing on diseases that could benefit targeted therapy.
Collapse
Affiliation(s)
- Francesco Rispoli
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.R.); (V.B.); (A.T.); (A.T.)
| | - Erica Valencic
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Martina Girardelli
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Alessia Pin
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Alessandra Tesser
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Elisa Piscianz
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Valentina Boz
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.R.); (V.B.); (A.T.); (A.T.)
| | - Flavio Faletra
- Department of Diagnostics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy;
| | - Giovanni Maria Severini
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Andrea Taddio
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.R.); (V.B.); (A.T.); (A.T.)
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Alberto Tommasini
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.R.); (V.B.); (A.T.); (A.T.)
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| |
Collapse
|
3
|
Bush A, Floto RA. Pathophysiology, causes and genetics of paediatric and adult bronchiectasis. Respirology 2019; 24:1053-1062. [PMID: 30801930 DOI: 10.1111/resp.13509] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/16/2019] [Indexed: 02/06/2023]
Abstract
Bronchiectasis has historically been considered to be irreversible dilatation of the airways, but with modern imaging techniques it has been proposed that 'irreversible' be dropped from the definition. The upper limit of normal for the ratio of airway to arterial development increases with age, and a developmental perspective is essential. Bronchiectasis (and persistent bacterial bronchitis, PBB) is a descriptive term and not a diagnosis, and should be the start not the end of the patient's diagnostic journey. PBB, characterized by airway infection and neutrophilic inflammation but without significant airway dilatation may be a precursor of bronchiectasis, and there are many commonalities in the microbiology and the pathology, which are reviewed in this article. A high index of suspicion is essential, and a history of chronic wet or productive cough for more than 4-8 weeks should prompt investigation. There are numerous underlying causes of bronchiectasis, although in many cases no cause is found. Causes include post-infectious, especially after tuberculosis, adenoviral or pertussis infection; aspiration syndromes; defects in host defence, which may solely affect the airways (cystic fibrosis, not considered in this review, and primary ciliary dyskinesia); and primary ciliary dyskinesia or be systemic, such as common variable immunodeficiency; genetic syndromes; and anatomical defects such as intraluminal airway obstruction (e.g. foreign body), intramural obstruction (e.g. complete cartilage rings) and external airway compression (e.g. by tuberculous lymph nodes). Identification of the underlying cause is important, because some of these conditions have specific treatments and others genetic implications for the family.
Collapse
Affiliation(s)
- Andrew Bush
- Department of Paediatrics, Imperial College, London, UK.,Department of Paediatric Respirology, National Heart and Lung Institute, London, UK.,Royal Brompton Harefield NHS Foundation Trust, London, UK
| | - R Andres Floto
- Department of Respiratory Biology, University of Cambridge, Cambridge, UK.,Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge, UK
| |
Collapse
|
4
|
Lee AY, Frith K, Schneider L, Ziegler JB. Haematopoietic stem cell transplantation for severe combined immunodeficiency: Long-term health outcomes and patient perspectives. J Paediatr Child Health 2017; 53:766-770. [PMID: 28513891 DOI: 10.1111/jpc.13560] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 01/11/2017] [Accepted: 02/17/2017] [Indexed: 01/11/2023]
Abstract
AIM To examine the long-term follow-up and health outcomes of patients who have undergone haematopoietic stem cell transplant (HSCT) for severe combined immunodeficiency (SCID). METHODS Through a structured questionnaire, we examined follow-up arrangements and long-term health outcomes in 22 children who have had a successful HSCT for SCID during the period of 1984-2012 at the Sydney Children's Hospital, Sydney, Australia. RESULTS Most children considered themselves healthy and 'cured' from SCID. Whilst many children enjoy relatively good bio-social health outcomes, specific negative health outcomes and absenteeism from school were perceived negatively. Two-thirds of children see their general practitioner or specialist regularly; however, there did not appear to be consistency with the nature of this follow-up. CONCLUSION The findings from our study highlight the complex bio-psychosocial health needs of post-HSCT SCID children and encourage SCID centres to consider a multidisciplinary approach to their follow-up. Further studies into the determinants of patients' perceptions of their health are needed.
Collapse
Affiliation(s)
- Adrian Ys Lee
- Department of Medicine, Western Health, Melbourne, Victoria, Australia.,School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Katie Frith
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Lilian Schneider
- School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - John B Ziegler
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| |
Collapse
|
5
|
Luk ADW, Lee PP, Mao H, Chan KW, Chen XY, Chen TX, He JX, Kechout N, Suri D, Tao YB, Xu YB, Jiang LP, Liew WK, Jirapongsananuruk O, Daengsuwan T, Gupta A, Singh S, Rawat A, Abdul Latiff AH, Lee ACW, Shek LP, Nguyen TVA, Chin TJ, Chien YH, Latiff ZA, Le TMH, Le NNQ, Lee BW, Li Q, Raj D, Barbouche MR, Thong MK, Ang MCD, Wang XC, Xu CG, Yu HG, Yu HH, Lee TL, Yau FYS, Wong WHS, Tu W, Yang W, Chong PCY, Ho MHK, Lau YL. Family History of Early Infant Death Correlates with Earlier Age at Diagnosis But Not Shorter Time to Diagnosis for Severe Combined Immunodeficiency. Front Immunol 2017; 8:808. [PMID: 28747913 PMCID: PMC5506088 DOI: 10.3389/fimmu.2017.00808] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/26/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Severe combined immunodeficiency (SCID) is fatal unless treated with hematopoietic stem cell transplant. Delay in diagnosis is common without newborn screening. Family history of infant death due to infection or known SCID (FH) has been associated with earlier diagnosis. OBJECTIVE The aim of this study was to identify the clinical features that affect age at diagnosis (AD) and time to the diagnosis of SCID. METHODS From 2005 to 2016, 147 SCID patients were referred to the Asian Primary Immunodeficiency Network. Patients with genetic diagnosis, age at presentation (AP), and AD were selected for study. RESULTS A total of 88 different SCID gene mutations were identified in 94 patients, including 49 IL2RG mutations, 12 RAG1 mutations, 8 RAG2 mutations, 7 JAK3 mutations, 4 DCLRE1C mutations, 4 IL7R mutations, 2 RFXANK mutations, and 2 ADA mutations. A total of 29 mutations were previously unreported. Eighty-three of the 94 patients fulfilled the selection criteria. Their median AD was 4 months, and the time to diagnosis was 2 months. The commonest SCID was X-linked (n = 57). A total of 29 patients had a positive FH. Candidiasis (n = 27) and bacillus Calmette-Guérin (BCG) vaccine infection (n = 19) were the commonest infections. The median age for candidiasis and BCG infection documented were 3 months and 4 months, respectively. The median absolute lymphocyte count (ALC) was 1.05 × 109/L with over 88% patients below 3 × 109/L. Positive FH was associated with earlier AP by 1 month (p = 0.002) and diagnosis by 2 months (p = 0.008), but not shorter time to diagnosis (p = 0.494). Candidiasis was associated with later AD by 2 months (p = 0.008) and longer time to diagnosis by 0.55 months (p = 0.003). BCG infections were not associated with age or time to diagnosis. CONCLUSION FH was useful to aid earlier diagnosis but was overlooked by clinicians and not by parents. Similarly, typical clinical features of SCID were not recognized by clinicians to shorten the time to diagnosis. We suggest that lymphocyte subset should be performed for any infant with one or more of the following four clinical features: FH, candidiasis, BCG infections, and ALC below 3 × 109/L.
Collapse
Affiliation(s)
- Anderson Dik Wai Luk
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Pamela P. Lee
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Huawei Mao
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- Shenzhen Primary Immunodeficiency Diagnostic and Therapeutic Laboratory, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Koon-Wing Chan
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | | | - Tong-Xin Chen
- Department of Allergy and Immunology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Xin He
- Beijing Children’s Hospital, Capital Medical University, Beijing, China
| | | | - Deepti Suri
- Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Yin Bo Tao
- Guangzhou Children’s Hospital, Guangzhou, China
| | - Yong Bin Xu
- Guang Zhou Women and Children’s Medical Center, Guangzhou, China
| | - Li Ping Jiang
- Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Woei Kang Liew
- KK Women’s and Children’s Hospital, Singapore, Singapore
| | | | | | - Anju Gupta
- Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | | | | | - Tek Jee Chin
- Sarawak General Hospital Malaysia, Kuching, Malaysia
| | - Yin Hsiu Chien
- National Taiwan University Children’s Hospital, Taipei, Taiwan
| | | | | | | | - Bee Wah Lee
- National University of Singapore, Singapore, Singapore
| | - Qiang Li
- Sichuan Second West China Hospital, Sichuan, China
| | - Dinesh Raj
- Department of Paediatrics, Holy Family Hospital, New Delhi, India
| | - Mohamed-Ridha Barbouche
- Department of Immunology, Institut Pasteur de Tunis and University Tunis-El Manar, Tunis, Tunisia
| | - Meow-Keong Thong
- Faculty of Medicine, Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia
| | | | | | - Chen Guang Xu
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hai Guo Yu
- Nanjing Children’s Hospital, Nanjing, China
| | - Hsin-Hui Yu
- National Taiwan University Children’s Hospital, Taipei, Taiwan
| | - Tsz Leung Lee
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | | | - Wilfred Hing-Sang Wong
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Wenwei Tu
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- Shenzhen Primary Immunodeficiency Diagnostic and Therapeutic Laboratory, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Wangling Yang
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- Shenzhen Primary Immunodeficiency Diagnostic and Therapeutic Laboratory, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Patrick Chun Yin Chong
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Marco Hok Kung Ho
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Yu Lung Lau
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- Shenzhen Primary Immunodeficiency Diagnostic and Therapeutic Laboratory, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- *Correspondence: Yu Lung Lau,
| |
Collapse
|
6
|
Ding Y, Thompson JD, Kobrynski L, Ojodu J, Zarbalian G, Grosse SD. Cost-Effectiveness/Cost-Benefit Analysis of Newborn Screening for Severe Combined Immune Deficiency in Washington State. J Pediatr 2016; 172:127-35. [PMID: 26876279 PMCID: PMC4846488 DOI: 10.1016/j.jpeds.2016.01.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 12/16/2015] [Accepted: 01/07/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To evaluate the expected cost-effectiveness and net benefit of the recent implementation of newborn screening (NBS) for severe combined immunodeficiency (SCID) in Washington State. STUDY DESIGN We constructed a decision analysis model to estimate the costs and benefits of NBS in an annual birth cohort of 86 600 infants based on projections of avoided infant deaths. Point estimates and ranges for input variables, including the birth prevalence of SCID, proportion detected asymptomatically without screening through family history, screening test characteristics, survival rates, and costs of screening, diagnosis, and treatment were derived from published estimates, expert opinion, and the Washington NBS program. We estimated treatment costs stratified by age of identification and SCID type (with or without adenosine deaminase deficiency). Economic benefit was estimated using values of $4.2 and $9.0 million per death averted. We performed sensitivity analyses to evaluate the influence of key variables on the incremental cost-effectiveness ratio (ICER) of net direct cost per life-year saved. RESULTS Our model predicts an additional 1.19 newborn infants with SCID detected preclinically through screening, in addition to those who would have been detected early through family history, and 0.40 deaths averted annually. Our base-case model suggests an ICER of $35 311 per life-year saved, and a benefit-cost ratio of either 5.31 or 2.71. Sensitivity analyses found ICER values <$100 000 and positive net benefit for plausible assumptions on all variables. CONCLUSIONS Our model suggests that NBS for SCID in Washington is likely to be cost-effective and to show positive net economic benefit.
Collapse
Affiliation(s)
- Yao Ding
- Association of Public Health Laboratories, Newborn Screening and Genetics, Silver Spring, MD
| | - John D. Thompson
- Washington State Department of Health, Office of Newborn Screening, Shoreline, WA
| | - Lisa Kobrynski
- Allergy Division, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Jelili Ojodu
- Association of Public Health Laboratories, Newborn Screening and Genetics, Silver Spring, MD
| | - Guisou Zarbalian
- Association of Public Health Laboratories, Newborn Screening and Genetics, Silver Spring, MD
| | - Scott D. Grosse
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA
| |
Collapse
|
7
|
Abstract
T cell immunodeficiency can occur as one of a group of primary disorders or develop secondary to chronic infection, illness or drug therapy. Primary T cell disorders are rare, accounting for approximately 11% of reported primary immunodeficiencies, and generally present in infancy or early childhood. Early recognition is very important as many of these patients will require bone marrow transplantation prior to the onset of severe infection or other complications. Because of their rarity, these infants usually present to clinicians who have little or no prior experience of these conditions, and therefore laboratory-based clinicians with knowledge of the key laboratory/pathological abnormalities and clinical features have a valuable role in identifying the possibility of immunodeficiency. Secondary T cell deficiency is a cardinal feature of HIV infection and the specific susceptibility to infectious micro-organisms is highlighted. The possibility of T cell immunodeficiency should be considered in any patient presenting with unusual or severe viral, fungal or protozoal infection.
Collapse
Affiliation(s)
- J D M Edgar
- David M Edgar, Royal Hospitals, The Belfast Trust, Grosvenor Road, Belfast BT12 6BN, UK.
| |
Collapse
|
8
|
Kubiak C, Jyonouchi S, Kuo C, Garcia-Lloret M, Dorsey MJ, Sleasman J, Zbrozek AS, Perez EE. Fiscal implications of newborn screening in the diagnosis of severe combined immunodeficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2014; 2:697-702. [PMID: 25439359 PMCID: PMC5911282 DOI: 10.1016/j.jaip.2014.05.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 03/25/2014] [Accepted: 05/06/2014] [Indexed: 12/31/2022]
Abstract
In the United States, newborn screening (NBS) is currently recommended for identification of 31 debilitating and potentially fatal conditions. However, individual states determine which of the recommended conditions are screened. The addition of severe combined immunodeficiency (SCID) screening to the recommended NBS panel has been fully instituted by 18 states, with another 11 states piloting programs or planning to begin screening in 2014. Untreated, SCID is uniformly fatal by 2 years of age. Hematopoietic stem cell transplantation usually is curative, but the success rate depends on the age at which the procedure is performed. Short-term implementation costs may be a barrier to adding SCID to states' NBS panels. A retrospective economic analysis was performed to determine the cost-effectiveness of NBS for early (<3.5 months) versus late (≥3.5 months) treatment of children with SCID at 3 centers over 5 years. The mean total charges at these centers for late treatment were 4 times greater than early treatment ($1.43 million vs $365,785, respectively). Mean charges for intensive care treatments were >5 times higher ($350,252 vs $66,379), and operating room-anesthesia charges were approximately 4 times higher ($57,105 vs $15,885). The cost-effectiveness of early treatment for SCID provides a strong economic rationale for the addition of SCID screening to NBS programs of other states.
Collapse
Affiliation(s)
- Catherine Kubiak
- Department of Pediatrics, Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Soma Jyonouchi
- Department of Pediatrics, Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Caroline Kuo
- Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, Calif
| | - Maria Garcia-Lloret
- Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, Calif
| | - Morna J Dorsey
- Department of Pediatrics, Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - John Sleasman
- Department of Pediatrics, Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | | | - Elena E Perez
- Department of Pediatrics, Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla.
| |
Collapse
|
9
|
Engraftment of human iPS cells and allogeneic porcine cells into pigs with inactivated RAG2 and accompanying severe combined immunodeficiency. Proc Natl Acad Sci U S A 2014; 111:7260-5. [PMID: 24799706 DOI: 10.1073/pnas.1406376111] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Pigs with severe combined immunodeficiency (SCID) may provide useful models for regenerative medicine, xenotransplantation, and tumor development and will aid in developing therapies for human SCID patients. Using a reporter-guided transcription activator-like effector nuclease (TALEN) system, we generated targeted modifications of recombination activating gene (RAG) 2 in somatic cells at high efficiency, including some that affected both alleles. Somatic-cell nuclear transfer performed with the mutated cells produced pigs with RAG2 mutations without integrated exogenous DNA. Biallelically modified pigs either lacked a thymus or had one that was underdeveloped. Their splenic white pulp lacked B and T cells. Under a conventional housing environment, the biallelic RAG2 mutants manifested a "failure to thrive" phenotype, with signs of inflammation and apoptosis in the spleen compared with age-matched wild-type animals by the time they were 4 wk of age. Pigs raised in a clean environment were healthier and, following injection of human induced pluripotent stem cells (iPSCs), quickly developed mature teratomas representing all three germ layers. The pigs also tolerated grafts of allogeneic porcine trophoblast stem cells. These SCID pigs should have a variety of uses in transplantation biology.
Collapse
|
10
|
Severe combined immunodeficiency in Serbia and Montenegro between years 1986 and 2010: a single-center experience. J Clin Immunol 2014; 34:304-8. [PMID: 24481607 DOI: 10.1007/s10875-014-9991-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 01/20/2014] [Indexed: 10/25/2022]
Abstract
Severe combined immunodeficiency (SCID), including the 'variant' Omenn syndrome (OS), represent a heterogeneous group of monogenic disorders characterized by defect in differentiation of T- and/or B lymphocytes and susceptibility to infections since birth. In the period of 25 years, between January 1986 and December 2010, a total of 21 patients (15 SCID, 6 OS) were diagnosed in Mother & Child Health Institute of Serbia, a tertiary-care teaching University hospital and a national referral center for patients affected with primary immunodeficiency (PID). The diagnoses were based on anamnestic data, clinical findings, and immunological and genetic analysis. The median age at the onset of the first infection was the 2nd month of life. Seven (33 %) patients had positive family history for SCID. Out of five male infants with T-B+NK- SCID phenotype, mutation analysis revealed interleukin-2 (common) gamma-chain receptor (IL2RG) mutations in 3 with positive X-linked family history, and Janus-kinase (JAK)-3 gene defects in the other two. Six patients had T-B-NK+ SCID phenotype and further 6 features of OS, 11 of which had recombinase-activating gene (RAG1or RAG2) and 1 Artemis gene mutations. One child with T+B+NK+ SCID phenotype as well had proven RAG mutation. One child each with T-B+NK+ SCID phenotype, CD8 lymphopenia and unknown phenotype remained without known underlying genetic defect. Of the eight patients who underwent hematopoetic stem cell transplant (HSCT) 5 survived, the other 13 died between 2 days and 12 months after diagnosis was made. Early diagnosis of SCID, before onset of severe infections, offers possibility for HSCT and cure. Education of primary-care pediatricians, in particular including awareness of the risk of using live vaccines and non-irradiated blood products, should improve prognosis of SCID in our setting.
Collapse
|
11
|
The respiratory presentation of severe combined immunodeficiency in two Mennonite children at a tertiary centre highlighting the importance of recognizing this pediatric emergency. Can Respir J 2013; 21:17-9. [PMID: 24288697 DOI: 10.1155/2014/404506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Severe combined immunodeficiency (SCID) is considered to be a pediatric emergency, with respiratory distress being the most common presenting symptom. The authors present two cases of SCID in children <4 months of age with respiratory distress at a tertiary care centre due to a recently described homozygous CD3 delta mutation found only in the Mexican Mennonite population. Failure to respond to broad-spectrum antibiotics prompted investigation for possible SCID. Bronchial alveolar lavage fluid from both patients grew Pneumocystis jiroveci, and flow cytometry revealed absent T cells. The CD3 delta gene is believed to be important in T cell differentiation and maturation. The present article reminds pediatricians and pediatric respirologists that the key to diagnosing SCID is to have a high index of suspicion if there is poor response to conventional therapies.
Collapse
|
12
|
Zhang C, Zhang ZY, Wu JF, Tang XM, Yang XQ, Jiang LP, Zhao XD. Clinical characteristics and mutation analysis of X-linked severe combined immunodeficiency in China. World J Pediatr 2013; 9:42-7. [PMID: 22105576 DOI: 10.1007/s12519-011-0330-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 06/14/2011] [Indexed: 11/29/2022]
Abstract
UNLABELLED X-linked severe combined immunodeficiency (X-SCID) is a rare, life-threatening immune disorder, caused by mutations of the gene for the γ-chain (γc) of the interleukin-2 receptor, IL2RG. We analyzed the clinical, immunologic, and molecular characteristics of children with X-SCID, attempting to improve the diagnosis and treatment of X-SCID in China. METHODS X-SCID was suspected in male infants with recurrent or persistent infections. Eleven male infants from ten unrelated Chinese families were included. The IL2RG gene was amplified and sequenced, followed by mutation analysis in these children and their female relatives. X-linked short tandem repeat (X-STR) typing was done to define the maternal lymphocyte engraftment. RESULTS The 11 children exhibited recurrent infections and 10 of them had lymphopenia. B cells were present in all patients, T cells were markedly reduced in 10, and NK cells were markedly reduced in 9. Nine IL2RG gene mutations were identified in the 11 children, with 5 novel mutations. One patient was found to have the maternal lymphocyte engraftment. CONCLUSION The clinical presentations and immunologic characteristics of the X-SCID patients were accordingly quite uniform despite the heterogeneity of mutations locating almost in the entire γc gene.
Collapse
Affiliation(s)
- Cui Zhang
- Division of Immunology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | | | | | | | | | | | | |
Collapse
|
13
|
When to Think of Immunodeficiency? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 764:167-77. [DOI: 10.1007/978-1-4614-4726-9_14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
14
|
Yao CM, Han XH, Zhang YD, Zhang H, Jin YY, Cao RM, Wang X, Liu QH, Zhao W, Chen TX. Clinical characteristics and genetic profiles of 44 patients with severe combined immunodeficiency (SCID): report from Shanghai, China (2004-2011). J Clin Immunol 2012; 33:526-39. [PMID: 23250629 DOI: 10.1007/s10875-012-9854-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 12/09/2012] [Indexed: 01/18/2023]
Abstract
Severe combined immunodeficiency (SCID), a rare type of genetic associated immune disorder, is poorly characterized in mainland China. We retrospectively reviewed 44 patients with SCID who received treatment from 2004 to 2011 in Shanghai, China, and herein summarize their clinical manifestations and immunological and preliminary genetic features. The male-to-female ratio was 10:1. Twenty five patients presented with X-SCID symptoms. Only one patient was diagnosed before the onset of symptoms due to positive family history. The mean time of delay in the diagnosis of X-SCID was 2.69 months (range, 0.5-8.67). Thirty-seven of the 44 patients died by the end of 2011 with the mean age of death being 7.87 months (range, 1.33-31). Six patients received hematopoietic stem cell transplantation (HSCT); only one of them survived, who was transplanted twice. The time between onset and death was shorter in the HSCT-treated group compared with the untreated group (2.87 ± 1.28 and 3.34 ± 0.59 months, respectively), probably due to active infections during transplantation. Bacillus Calmette-Guérin (BCG) complications occurred in 14 of the 34 patients who received BCG vaccination. Transfusion-induced graft-versus-host disease occurred in 5 patients. Total 20 mutations in interleukin-2 receptor subunit gamma (IL2RG) were identified in 22 patients, including 11 novel mutations. Most patients were misdiagnosed before referred to our SCID Center. Therefore, establishing more diagnostic centers dedicated to the care of PID and accessible by primary immunodeficiency patients will facilitate early, correct diagnosis and better care of SCID in China.
Collapse
Affiliation(s)
- Chun-Mei Yao
- Department of Pediatrics, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 20092, China
| | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Barron MA, Makhija M, Hagen LEM, Pencharz P, Grunebaum E, Roifman CM. Increased resting energy expenditure is associated with failure to thrive in infants with severe combined immunodeficiency. J Pediatr 2011; 159:628-32.e1. [PMID: 21592502 DOI: 10.1016/j.jpeds.2011.03.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 02/16/2011] [Accepted: 03/21/2011] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To measure resting energy expenditure (REE) and determine whether increased REE (hypermetabolism) is associated with failure to thrive (FTT) in patients with severe combined immunodeficiency (SCID) at diagnosis. STUDY DESIGN REE was measured in 26 patients with SCID in a single transplant center. Predicted REE was determined with World Health Organization standards. Measured REE >110% of predicted REE was classified as hypermetabolism. Other data collected included FTT status, infections, genotype, phenotype, and the feeding methods used. RESULTS Fifteen of 26 patients (57.7%) had FTT, and 18 of 26 patients (69.2%) were hypermetabolic. Hypermetabolism occured in 14 of 15 patients (93%) with FTT, and only 4 of 11 patients (36%) without FTT had hypermetabolism (P = .003). There was a significant difference between the measured REE (71.75 ± 16.6 kcal/kg) and the predicted REE (52.85 ± 2.8 kcal/kg; P < .0001). Eleven of 17 patients (65%) required nasogastric feeding, parenteral nutrition, or both to meet their energy needs. CONCLUSIONS Hypermetabolism is common in patients with SCID and may contribute to the development of FTT. The hypermetabolism in these patients may necessitate intensive nutrition support.
Collapse
Affiliation(s)
- Mary A Barron
- Division of Immunology and Allergy, The Canadian Centre for Primary Immunodeficiency, The Jeffrey Modell Research Laboratory for the Diagnosis of Primary Immunodeficiency, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | | | | |
Collapse
|
16
|
van der Burg M, Gennery AR. Educational paper. The expanding clinical and immunological spectrum of severe combined immunodeficiency. Eur J Pediatr 2011; 170:561-71. [PMID: 21479529 PMCID: PMC3078321 DOI: 10.1007/s00431-011-1452-3] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 03/10/2011] [Indexed: 12/20/2022]
Abstract
Severe combined immunodeficiency (SCID) is one of the most severe forms of primary immunodeficiency characterized by absence of functional T lymphocytes. It is a paediatric emergency, which is life-threatening when recognized too late. The clinical presentation varies from the classical form of SCID through atypical SCID to Omenn syndrome. In addition, there is a considerable immunological variation, which can hamper the diagnosis. In this educational review, we describe the immunopathological background, clinical presentations and diagnostic process of SCID, as well as the therapeutic possibilities.
Collapse
Affiliation(s)
- Mirjam van der Burg
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 50, Rotterdam 3015 GE, The Netherlands.
| | - Andy R. Gennery
- Department of Pediatric Immunology, Great North Children’s Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK ,Institute of Cellular Medicine, Child Health, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| |
Collapse
|
17
|
Lipstein EA, Vorono S, Browning MF, Green NS, Kemper AR, Knapp AA, Prosser LA, Perrin JM. Systematic evidence review of newborn screening and treatment of severe combined immunodeficiency. Pediatrics 2010; 125:e1226-35. [PMID: 20403930 DOI: 10.1542/peds.2009-1567] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Severe combined immunodeficiency (SCID) is a group of disorders that leads to early childhood death as a result of severe infections. Recent research has addressed potential newborn screening for SCID. OBJECTIVE To conduct a systematic review of the evidence for newborn screening for SCID, including test characteristics, treatment efficacy, and cost-effectiveness. METHODS We searched Medline and the OVID In-Process & Other Non-Indexed Citations databases. We excluded articles if they were reviews, editorials or other opinion pieces, or case series of fewer than 4 patients or if they contained only adult subjects or nonhuman data. The remaining articles were systematically evaluated, and data were abstracted by 2 independent reviewers using standardized tools. For topics that lacked published evidence, we interviewed experts in the field. RESULTS The initial search resulted in 719 articles. Twenty-six met inclusion criteria. The results of several small studies suggested that screening for SCID is possible. Interviews revealed that 2 states have begun pilot screening programs. Evidence from large case series indicates that children receiving early stem-cell transplant for SCID have improved outcomes compared with children who were treated later. There is some inconclusive evidence regarding the need for donor-recipient matching and use of pretransplant chemotherapy. Few data on the cost-effectiveness of a SCID-screening program. CONCLUSIONS Evidence indicates the benefits of early treatment of SCID and the possibility of population-based newborn screening. Better information on optimal treatment and the costs of treatment and screening would benefit policy makers deciding among competing health care priorities.
Collapse
Affiliation(s)
- Ellen A Lipstein
- Center for Child and Adolescent Health Policy, Mass General Hospital for Children, Boston, Massachusetts, USA.
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Zwick DL. Time to drop routine reporting of differential percentage values from CBC reports. LABORATORY HEMATOLOGY : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR LABORATORY HEMATOLOGY 2010; 16:1-2. [PMID: 20223742 DOI: 10.1532/lh96.09017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
|
19
|
Abstract
The child who has recurrent infections poses one of the most difficult diagnostic challenges in pediatrics. The clinician faces a two-fold challenge in determining first whether the child is normal or has a serious disease, and then, in the latter case, how to confirm or exclude the diagnosis with the minimum number of the least invasive tests. It is hoped that, in the absence of good-quality evidence for most clinical scenarios, the experience-based approach described in this article may prove a useful guide to the clinician.
Collapse
Affiliation(s)
- Andrew Bush
- Imperial School of Medicine at National Heart and Lung Institute, London, UK.
| |
Collapse
|
20
|
Rezai MS, Khotaei G, Mamishi S, Kheirkhah M, Parvaneh N. Disseminated Bacillus Calmette-Guerin infection after BCG vaccination. J Trop Pediatr 2008; 54:413-6. [PMID: 18593737 DOI: 10.1093/tropej/fmn053] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The BCG is administered to all the newborns at birth in Iran. Systemic adverse reactions to BCG vaccine such as osteomyelitis and disseminated BCG infection are rare. This is a retrospective study of 15 cases <72 months who were admitted with systemic syndrome compatible with disseminated mycobacterial disease during 2004-07. Disseminated BCG disease occurred in eight children younger than 6-months old and 12 patient younger than 12-months old. Twelve patients were male. Nine of 15 patients had well known primary immune deficiency disorders including severe combined immunodeficiency, chronic granulomatous disease; cell mediated immune defect and HIV infection. Nine (60%) cases had good response to four anti-mycobacterial drug therapy and interferon gamma. Disseminated BCG disease is a rare but devastating complication of BCG vaccination that should be considered in the appropriate clinical setting. Severe immune-compromised infants are at greatest risk and they respond poorly to standard therapies.
Collapse
Affiliation(s)
- Mohammad Sadegh Rezai
- Department of Pediatrics, School of Medicine, Medical Sciences/University of Tehran, Tehran, Iran
| | | | | | | | | |
Collapse
|
21
|
Slatter MA, Gennery AR. Clinical immunology review series: an approach to the patient with recurrent infections in childhood. Clin Exp Immunol 2008; 152:389-96. [PMID: 18373701 DOI: 10.1111/j.1365-2249.2008.03641.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Recurrent or persistent infection is the major manifestation of primary immunodeficiency, which also results in atypical infection with opportunistic organisms. Young children are also vulnerable to infection and recurrent infection is common. While most children with recurrent infection have a normal immunity, it is important to recognize the child with an underlying primary immunodeficiency and investigate and treat appropriately and yet not over investigate normal children. Prompt, accurate diagnosis directs the most appropriate treatment, and early and judicious use of prophylactic antibiotics and replacement immunoglobulin can prevent significant end organ damage and improve long-term outlook and quality of life. This paper describes important presenting features of primary immunodeficiency and indicates when further investigation is warranted.
Collapse
Affiliation(s)
- M A Slatter
- Department of Paediatric Immunology, Newcastle upon Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | | |
Collapse
|
22
|
Malamut G, Verkarre V, Brousse N, Cellier C. [Gastrointestinal diseases in primary immunodeficiency disorders]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2008; 31:844-53. [PMID: 18166864 DOI: 10.1016/s0399-8320(07)73976-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Gastrointestinal symptoms are common and often reveal primary immunodeficiency. Although they mimic gastrointestinal diseases observed in immunocompetent patients, there have diagnostic and therapeutic specificities that should be known for optimal management of these patients. This review describes the gastrointestinal diseases found in primary immunodeficiency and proposes some diagnostic and therapeutic strategies.
Collapse
Affiliation(s)
- Georgia Malamut
- Service d'Hépato-gastroentérologie, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris Cedex 15
| | | | | | | |
Collapse
|
23
|
Clark M, Cameron DW. The benefits and risks of bacille Calmette-Guérin vaccination among infants at high risk for both tuberculosis and severe combined immunodeficiency: assessment by Markov model. BMC Pediatr 2006; 6:5. [PMID: 16515694 PMCID: PMC1458340 DOI: 10.1186/1471-2431-6-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2005] [Accepted: 03/03/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bacille Calmette-Guérin (BCG) vaccine is given to Canadian Aboriginal neonates in selected communities. Severe reactions and deaths associated with BCG have been reported among infants born with immunodeficiency syndromes. The main objective of this study was to estimate threshold values for severe combined immunodeficiency (SCID) incidence, above which BCG is associated with greater risk than benefit. METHODS A Markov model was developed to simulate the natural histories of tuberculosis (TB) and SCID in children from birth to 14 years. The annual risk of tuberculous infection (ARI) and SCID incidence were varied in analyses. The model compared a scenario of no vaccination to intervention with BCG. Appropriate variability and uncertainty analyses were conducted. Outcomes included TB incidence and quality-adjusted life years (QALYs). RESULTS In sensitivity analyses, QALYs were lower among vaccinated infants if the ARI was 0.1% and the rate of SCID was higher than 4.2 per 100,000. Assuming an ARI of 1%, this threshold increased to 41 per 100,000. In uncertainty analyses (Monte Carlo simulations) which assumed an ARI of 0.1%, QALYs were not significantly increased by BCG unless SCID incidence is 0. With this ARI, QALYs were significantly decreased among vaccinated children if SCID incidence exceeds 23 per 100,000. BCG is associated with a significant increase in QALYs if the ARI is 1%, and SCID incidence is below 5 per 100,000. CONCLUSION The possibility that Canadian Aboriginal children are at increased risk for SCID has serious implications for continued BCG use in this population. In this context, enhanced TB Control--including early detection and treatment of infection--may be a safer, more effective alternative.
Collapse
Affiliation(s)
- Michael Clark
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, General Campus, Room 1805A, 501 Smyth Road, Ottawa, Ontario, Canada, K1H 8L6, USA
| | - D William Cameron
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, General Campus, Room 1805A, 501 Smyth Road, Ottawa, Ontario, Canada, K1H 8L6, USA
| |
Collapse
|
24
|
Deeks SL, Clark M, Scheifele DW, Law BJ, Dawar M, Ahmadipour N, Walop W, Ellis CE, King A. Serious adverse events associated with bacille Calmette-Guérin vaccine in Canada. Pediatr Infect Dis J 2005; 24:538-41. [PMID: 15933565 DOI: 10.1097/01.inf.0000164769.22033.2c] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Targeted Bacille Calmette-Guérin (BCG) vaccination is offered to neonates in some First Nations and Inuit (FNI) communities in Canada. Serious adverse events associated with BCG vaccine prompted a review to assess causality. METHODS The Immunization Monitoring Program Active (IMPACT), a pediatric hospital-based active surveillance network, reported admissions for BCG-related adverse events between 1993 and April 2002. The Canadian Advisory Committee on Causality Assessment (ACCA) reviewed the reports to assess causality. Data between 1987 and September 2002 from the Vaccine-Associated Adverse Event Surveillance (VAAES) Program, a passive national reporting system, were also reviewed. RESULTS IMPACT identified 21 pediatric cases; 19 were Canadian-born, and 18 were FNI. Six disseminated BCG cases were identified; 5 were FNI infants who subsequently died. All had immunodeficiencies and concurrent infections. Other adverse events included 2 cases of osteomyelitis, BCG abscesses and lymphadenitis. ACCA reviewed the 21 cases and determined that 14 were very likely associated with the vaccine, including the 6 disseminated BCGs; 5 were probably associated and 1 was possibly associated with the vaccine; 1 was unclassifiable. The VAAES program identified 157 adverse events. No additional serious systemic adverse events (disseminated BCG or osteomyelitis) were identified. CONCLUSIONS Serious BCG vaccine-associated complications continue to occur in Canada. The numbers of FNI children with disseminated disease was greater than expected from reported rates in the literature.
Collapse
Affiliation(s)
- Shelley L Deeks
- Immunization and Respiratory Infections Division, Community Acquired Infections Division, Public Health Agency of Canada, Health Canada, Ottawa, Ontario
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Culic S, Kuzmic I, Culic V, Martinic R, Kuljis D, Pranic-Kragic A, Karaman K, Jankovic S. Disseminated BCG infection resembling langerhans cell histiocytosis in an infant with severe combined immunodeficiency: a case report. Pediatr Hematol Oncol 2004; 21:563-72. [PMID: 15552821 DOI: 10.1080/08880010490477257] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We present a very rare congenital immunologic disease, severe combined immunodeficiency syndrome (SCID) in 6-months-old-boy with prolonged mucocutaneous candidiasis, severe anaemia, skin rash similar to the infiltrative eczema of Langerhans cell histiocytosis (LCH) and subcutaneous nodules with histiocytic infiltration. Laboratory findings show profound absence of humoral and cell-mediated immunity. Pathology specimens analysis of subcutaneous nodule revealed numerous S-100 protein and Cd1a negative histiocytes, occupied by BCG intracellular growth. Histopathology and immunohistochemistry confirmed the diagnosis of BCG dissemination. BCG vaccination in infants with SCID can lead to life threatening dissemination, resembling to the infiltrative eczema of LCH and may mislead the clinician.
Collapse
Affiliation(s)
- Srdjana Culic
- Clinical Hospital Split, Pediatrics Clinic, Split, Spinciceva, Croatia.
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Gennery AR, Cant AJ. The immunocompromised host: the patient with recurrent infection. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2004; 549:109-17. [PMID: 15250523 DOI: 10.1007/978-1-4419-8993-2_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Andrew R Gennery
- School of Clinical Medical Sciences, University of Newcastle upon Tyne, Newcastle General Hospital, United Kingdom
| | | |
Collapse
|
27
|
Abstract
Early diagnosis of severe combined immunodeficiency (SCID) is important to enable prompt referral to a supraregional centre for bone marrow transplantation before the occurrence of end organ damage secondary to infective complications. This review outlines clinical, microbiological, and immunopathological clues that aid the diagnosis of SCID and emphasises the multidisciplinary approach needed to diagnose and treat these infants.
Collapse
Affiliation(s)
- A R Gennery
- Department of Paediatric Immunology, Newcastle General Hospital, Newcastle upon Tyne, UK.
| | | |
Collapse
|
28
|
Gaspar HB, Gilmour KC, Jones AM. Severe combined immunodeficiency--molecular pathogenesis and diagnosis. Arch Dis Child 2001; 84:169-73. [PMID: 11159300 PMCID: PMC1718644 DOI: 10.1136/adc.84.2.169] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- H B Gaspar
- Molecular Immunology Unit, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
| | | | | |
Collapse
|
29
|
Bellamy GJ, Hinchliffe RF, Crawshaw KC, Finn A, Bell F. Total and differential leucocyte counts in infants at 2, 5 and 13 months of age. CLINICAL AND LABORATORY HAEMATOLOGY 2000; 22:81-7. [PMID: 10792397 DOI: 10.1046/j.1365-2257.2000.00288.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Reference ranges for the total and differential leucocyte counts were determined from venous blood collected at 2, 5 and 13 months of age from a cohort of 112 healthy children of north European ancestry. At 2, 5 and 13 months, the ranges for neutrophils were found to be 0.7-4.7, 1.1-5.6 and 1.0-7.6 x 109/l, and for lymphocytes 3.3-10.5, 3.4-11.3 and 3.5-10.4 x 109/l, respectively. The upper limits for monocytes at each age were 1.2, 1.2 and 0.91 x 109/l, and for eosinophils 0.84, 1.0 and 0.88 x 109/l, respectively. Mean counts for all cell types, except monocytes, increased between 2 and 5 months of age. There was little change in mean counts between 5 and 13 months. Statistically significant correlations existed between the numbers of each cell type at 2 months of age, and were still present at 13 months between monocytes and each of the granulocyte series and between basophils and all other cell types. By comparison with older data these findings indicate a lower reference limit for neutrophils at 2 months of age, and a narrower range for this cell type at both 2 and 5 months of age. Reference ranges for lymphocytes and eosinophils are wider than indicated by some previous studies.
Collapse
Affiliation(s)
- G J Bellamy
- Sub-department of Paediatric Haematology and Division of Child Health, The University of Sheffield, The Sheffield Children's Hospital NHS Trust, Western Bank, Sheffield, UK
| | | | | | | | | |
Collapse
|
30
|
Deerojanawong J, Chang AB, Eng PA, Robertson CF, Kemp AS. Pulmonary diseases in children with severe combined immune deficiency and DiGeorge syndrome. Pediatr Pulmonol 1997; 24:324-30. [PMID: 9407565 DOI: 10.1002/(sici)1099-0496(199711)24:5<324::aid-ppul4>3.0.co;2-i] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Pulmonary disease is a common presenting feature and complication of T-cell immunodeficiency. We retrospectively reviewed 15 children with severe combined immune deficiency (SCID) and 19 children with DiGeorge syndrome at the time of their first presentation to the Royal Children's Hospital in the 15-year period from 1981 to 1995. In children with SCID, pulmonary disease was a common (67%) presenting feature and the organisms identified were Pneumocystis carinii (PCP) (n = 7), bacteria (n = 4), viruses (n = 3), and a fungus (n = 1). Late pulmonary complications included lower respiratory tract infections, bronchiolitis obliterans, and lymphointerstitial pneumonitis. Pulmonary infections were common (17 occasions) and the organisms identified were bacteria (n = 7), viruses (n = 6), fungi (n = 3), and Mycobacterium tuberculosis (n = 1). Pulmonary complications were responsible for 5 of 9 deaths. PCP was not identified as a late complication in any child, presumably as a result of effective prophylactic therapy. Although pulmonary disease was not a major presenting feature in children with DiGeorge syndrome, pulmonary complications were common. These included recurrent bacterial and viral infections and bronchomalacia, which complicated management and predisposed to morbidity and mortality, even in those without a T-cell defect. We conclude that pulmonary disease is a common manifestation in children with SCID and DiGeorge syndrome.
Collapse
Affiliation(s)
- J Deerojanawong
- Department of Thoracic Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | | | | | | | | |
Collapse
|