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Mehta SS, Bosticardo M, Notarangelo LD, Kitcharoensakkul M. Novel EXTL3 Variants Causing Neuro-Immuno-Skeletal Dysplasia. J Clin Immunol 2024; 44:188. [PMID: 39215781 DOI: 10.1007/s10875-024-01784-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 08/01/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Sarah S Mehta
- Department of Pediatrics, Washington University in Saint Louis, 660 S. Euclid, Campus Box 8116, Saint Louis, MO, 63110, USA
| | - Marita Bosticardo
- Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, MD, USA
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, MD, USA
| | - Maleewan Kitcharoensakkul
- Department of Pediatrics, Washington University in Saint Louis, 660 S. Euclid, Campus Box 8116, Saint Louis, MO, 63110, USA.
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2
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Soomann M, Prader S, Lorenzini T, Soulard C, Sayasith K, Haddad E, Pachlopnik Schmid J. Severe T-cell lymphopenia in a patient with microduplication 22q11.2 identified by newborn screening. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2199-2200.e1. [PMID: 38729303 DOI: 10.1016/j.jaip.2024.04.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Maarja Soomann
- Division of Immunology and the Children's Research Center, University Children's, Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Seraina Prader
- Division of Immunology and the Children's Research Center, University Children's, Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Tiziana Lorenzini
- Division of Immunology and the Children's Research Center, University Children's, Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Clara Soulard
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada; Department of Microbiology, Immunology and Infectious Diseases, University of Montreal, Montreal, Quebec, Canada
| | - Khampoun Sayasith
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Elie Haddad
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada; Department of Microbiology, Immunology and Infectious Diseases, University of Montreal, Montreal, Quebec, Canada; Research Center, Centre hospitalier universitaire (CHU) Sainte-Justine (CHU), Montreal, Quebec, Canada
| | - Jana Pachlopnik Schmid
- Division of Immunology and the Children's Research Center, University Children's, Hospital Zurich, University of Zurich, Zurich, Switzerland
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3
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Sonoda M, Ishimura M, Inoue H, Eguchi K, Ochiai M, Sakai Y, Doi T, Suzuki K, Inoue T, Mizukami T, Nakamura K, Takada H, Ohga S. Non-conditioned cord blood transplantation for infection control in athymic CHARGE syndrome. Pediatr Blood Cancer 2024; 71:e30809. [PMID: 38078568 DOI: 10.1002/pbc.30809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/04/2023] [Accepted: 11/27/2023] [Indexed: 01/24/2024]
Abstract
OBJECTIVE CHARGE syndrome is a congenital malformation syndrome caused by heterozygous mutations in the CHD7 gene. Severe combined immunodeficiency (SCID) arises from congenital athymia called CHARGE/complete DiGeorge syndrome. While cultured thymus tissue implantation (CTTI) provides an immunological cure, hematopoietic cell transplantation (HCT) is an alternative option for immuno-reconstitution of affected infants. We aimed to clarify the clinical outcomes of patients with athymic CHARGE syndrome after HCT. METHODS We studied the immunological reconstitution and outcomes of four patients who received non-conditioned unrelated donor cord blood transplantation (CBT) at Kyushu University Hospital from 2007 to 2022. The posttransplant outcomes were compared with the outcomes of eight reported patients. RESULTS Four index cases received CBT 70-144 days after birth and had no higher than grade II acute graft-versus-host disease. One infant was the first newborn-screened athymic case in Japan. They achieved more than 500/μL naïve T cells with balanced repertoire 1 month post transplant, and survived more than 12 months with home care. Twelve patients including the index cases received HCT at a median 106 days after birth (range: 70-195 days). One-year overall survival rate was significantly higher in patients who underwent non-conditioned HCT than in those who received conditioned HCT (100% vs. 37.5%, p = .02). Nine patients died, and the major cause of death was cardiopulmonary failure. CONCLUSIONS Athymic infants achieved a prompt reconstitution of non-skewing naïve T cells after non-conditioned CBT that led to home care in infancy without significant infections. Non-conditioned CBT is a useful bridging therapy for newborn-screened cases toward an immunological cure by CTTI.
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Affiliation(s)
- Motoshi Sonoda
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masataka Ishimura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hirosuke Inoue
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Katsuhide Eguchi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masayuki Ochiai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Research Center for Environment and Developmental Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takehiko Doi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Kyoko Suzuki
- Department of Pediatrics, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Takeshi Inoue
- Division of Neonatology, Perinatal Center, Kumamoto City Hospital, Kumamoto, Japan
| | - Tomoyuki Mizukami
- Department of Pediatrics, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto City, Kumamoto, Japan
| | - Hidetoshi Takada
- Department of Child Health, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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4
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Yakici N, Kreins AY, Catak MC, Babayeva R, Erman B, Kenney H, Gungor HE, Cea PA, Kawai T, Bosticardo M, Delmonte OM, Adams S, Fan YT, Pala F, Turkyilmaz A, Howley E, Worth A, Kot H, Sefer AP, Kara A, Bulutoglu A, Bilgic-Eltan S, Altunbas MY, Bayram Catak F, Karakus IS, Karatay E, Tekeoglu SD, Eser M, Albayrak D, Citli S, Kiykim A, Karakoc-Aydiner E, Ozen A, Ghosh S, Gohlke H, Orhan F, Notarangelo LD, Davies EG, Baris S. Expanding the clinical and immunological phenotypes of PAX1-deficient SCID and CID patients. Clin Immunol 2023; 255:109757. [PMID: 37689091 PMCID: PMC10958138 DOI: 10.1016/j.clim.2023.109757] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/13/2023] [Accepted: 09/02/2023] [Indexed: 09/11/2023]
Abstract
Paired box 1 (PAX1) deficiency has been reported in a small number of patients diagnosed with otofaciocervical syndrome type 2 (OFCS2). We described six new patients who demonstrated variable clinical penetrance. Reduced transcriptional activity of pathogenic variants confirmed partial or complete PAX1 deficiency. Thymic aplasia and hypoplasia were associated with impaired T cell immunity. Corrective treatment was required in 4/6 patients. Hematopoietic stem cell transplantation resulted in poor immune reconstitution with absent naïve T cells, contrasting with the superior recovery of T cell immunity after thymus transplantation. Normal ex vivo differentiation of PAX1-deficient CD34+ cells into mature T cells demonstrated the absence of a hematopoietic cell-intrinsic defect. New overlapping features with DiGeorge syndrome included primary hypoparathyroidism (n = 5) and congenital heart defects (n = 2), in line with PAX1 expression during early embryogenesis. Our results highlight new features of PAX1 deficiency, which are relevant to improving early diagnosis and identifying patients requiring corrective treatment.
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Affiliation(s)
- Nalan Yakici
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Faculty of Medicine, Karadeniz Technical University Trabzon, Turkey
| | - Alexandra Y Kreins
- Great Ormond Street Institute of Child Health, Infection, Immunity and Inflammation Research & Teaching Department, University College London, London, United Kingdom; Department of Immunology and Gene therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.
| | - Mehmet Cihangir Catak
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Royala Babayeva
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Baran Erman
- Institute of Child Health, Hacettepe University, Ankara, Turkey; Can Sucak, Research Laboratory for Translational Immunology, Center for Genomics and Rare Diseases, Hacettepe University, Ankara, Turkey
| | - Heather Kenney
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Hatice Eke Gungor
- Division of Pediatric Allergy and Immunology, Erciyes City Hospital, Turkey
| | - Pablo A Cea
- Institute for Pharmaceutical and Medicinal Chemistry, Heinrich Heine University, Düsseldorf, Germany
| | - Tomoki Kawai
- Shizuoka Children's Hospital, Shizuoka, Department of Allergy and Clinical Immunology, Japan
| | - Marita Bosticardo
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Ottavia Maria Delmonte
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Stuart Adams
- SIHMDS-Haematology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Yu-Tong Fan
- Great Ormond Street Institute of Child Health, Infection, Immunity and Inflammation Research & Teaching Department, University College London, London, United Kingdom
| | - Francesca Pala
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Ayberk Turkyilmaz
- Department of Medical Genetics, Faculty of Medicine, Karadeniz Technical University Trabzon, Turkey
| | - Evey Howley
- Department of Immunology and Gene therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Austen Worth
- Department of Immunology and Gene therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Hakan Kot
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Faculty of Medicine, Karadeniz Technical University Trabzon, Turkey
| | - Asena Pinar Sefer
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Altan Kara
- TUBITAK Marmara Research Center, Gene Engineering and Biotechnology Institute, Gebze, Turkey
| | - Alper Bulutoglu
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Sevgi Bilgic-Eltan
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Melek Yorgun Altunbas
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Feyza Bayram Catak
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | | | - Emrah Karatay
- Department of Radiology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Sidem Didar Tekeoglu
- Can Sucak, Research Laboratory for Translational Immunology, Center for Genomics and Rare Diseases, Hacettepe University, Ankara, Turkey; Department of Pediatric Immunology, Hacettepe University, Ankara, Turkey
| | - Metin Eser
- Department of Medical Genetics, Umraniye Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Davut Albayrak
- Department of Pediatrics, Division of Pediatric Hematology, Medicalpark Hospital, Samsun, Turkey
| | - Senol Citli
- Department of Medical Genetics, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Ayca Kiykim
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Elif Karakoc-Aydiner
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Ahmet Ozen
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Sujal Ghosh
- Department for Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich Heine University, Düsseldorf, Germany
| | - Holger Gohlke
- Institute for Pharmaceutical and Medicinal Chemistry, Heinrich Heine University, Düsseldorf, Germany; Institute of Bio- and Geosciences (IBG-4: Bioinformatics), Forschungszentrum Jülich GmbH, Jülich, Germany
| | - Fazil Orhan
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Faculty of Medicine, Karadeniz Technical University Trabzon, Turkey
| | - Luigi D Notarangelo
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - E Graham Davies
- Great Ormond Street Institute of Child Health, Infection, Immunity and Inflammation Research & Teaching Department, University College London, London, United Kingdom; Department of Immunology and Gene therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Safa Baris
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey.
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5
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Ramos SA, Armitage LH, Morton JJ, Alzofon N, Handler D, Kelly G, Homann D, Jimeno A, Russ HA. Generation of functional thymic organoids from human pluripotent stem cells. Stem Cell Reports 2023; 18:829-840. [PMID: 36963390 PMCID: PMC10147832 DOI: 10.1016/j.stemcr.2023.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 02/25/2023] [Accepted: 02/26/2023] [Indexed: 03/26/2023] Open
Abstract
The thymus is critical for the establishment of a functional and self-tolerant adaptive immune system but involutes with age, resulting in reduced naive T cell output. Generation of a functional human thymus from human pluripotent stem cells (hPSCs) is an attractive regenerative strategy. Direct differentiation of thymic epithelial progenitors (TEPs) from hPSCs has been demonstrated in vitro, but functional thymic epithelial cells (TECs) only form months after transplantation of TEPs in vivo. We show the generation of TECs in vitro in isogenic stem cell-derived thymic organoids (sTOs) consisting of TEPs, hematopoietic progenitor cells, and mesenchymal cells, differentiated from the same hPSC line. sTOs support T cell development, express key markers of negative selection, including the autoimmune regulator (AIRE) protein, and facilitate regulatory T cell development. sTOs provide the basis for functional patient-specific thymic organoid models, allowing for the study of human thymus function, T cell development, and transplant immunity.
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Affiliation(s)
- Stephan A Ramos
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Lucas H Armitage
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - John J Morton
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Nathaniel Alzofon
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Diana Handler
- Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Geoffrey Kelly
- Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Dirk Homann
- Diabetes, Metabolism and Obesity Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Antonio Jimeno
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA; Charles C. Gates Center for Regenerative Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Holger A Russ
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; Charles C. Gates Center for Regenerative Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA; Diabetes Institute, University of Florida, Gainesville, FL 32610, USA; Department of Pathology and Therapeutics, University of Florida, Gainesville, FL 32610, USA.
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6
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Mustillo PJ, Sullivan KE, Chinn IK, Notarangelo LD, Haddad E, Davies EG, de la Morena MT, Hartog N, Yu JE, Hernandez-Trujillo VP, Ip W, Franco J, Gambineri E, Hickey SE, Varga E, Markert ML. Clinical Practice Guidelines for the Immunological Management of Chromosome 22q11.2 Deletion Syndrome and Other Defects in Thymic Development. J Clin Immunol 2023; 43:247-270. [PMID: 36648576 PMCID: PMC9892161 DOI: 10.1007/s10875-022-01418-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/04/2022] [Indexed: 01/18/2023]
Abstract
Current practices vary widely regarding the immunological work-up and management of patients affected with defects in thymic development (DTD), which include chromosome 22q11.2 microdeletion syndrome (22q11.2del) and other causes of DiGeorge syndrome (DGS) and coloboma, heart defect, atresia choanae, retardation of growth and development, genital hypoplasia, ear anomalies/deafness (CHARGE) syndrome. Practice variations affect the initial and subsequent assessment of immune function, the terminology used to describe the condition and immune status, the accepted criteria for recommending live vaccines, and how often follow-up is needed based on the degree of immune compromise. The lack of consensus and widely varying practices highlight the need to establish updated immunological clinical practice guidelines. These guideline recommendations provide a comprehensive review for immunologists and other clinicians who manage immune aspects of this group of disorders.
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Affiliation(s)
- Peter J Mustillo
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, 43205, USA.
| | - Kathleen E Sullivan
- Division of Allergy Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Ivan K Chinn
- Division of Immunology, Allergy, and Retrovirology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, 77030, USA
| | - Luigi D Notarangelo
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Elie Haddad
- Department of Pediatrics, Department of Microbiology, Infectious Diseases and Immunology, CHU Sainte-Justine, University of Montreal, Montreal, QC, H3T 1C5, Canada
| | - E Graham Davies
- Department of Immunology, Great Ormond Street Hospital and UCL Great Ormond Street Institute of Child Health, London, WC1N 3HJ, UK
| | - Maria Teresa de la Morena
- Division of Immunology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, 98105, USA
| | - Nicholas Hartog
- Spectrum Health Helen DeVos Children's Hospital Department of Allergy and Immunology, Michigan State University College of Human Medicine, East Lansing, USA
| | - Joyce E Yu
- Division of Allergy, Immunology & Rheumatology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Winnie Ip
- Department of Immunology, Great Ormond Street Hospital and UCL Great Ormond Street Institute of Child Health, London, WC1N 3JH, UK
| | - Jose Franco
- Grupo de Inmunodeficiencias Primarias, Facultad de Medicina, Universidad de Antioquia UdeA, Medellin, Colombia
| | - Eleonora Gambineri
- Department of "NEUROFARBA", Section of Child's Health, University of Florence, Florence, Italy
- Centre of Excellence, Division of Pediatric Oncology/Hematology, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Scott E Hickey
- Division of Genetic & Genomic Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Elizabeth Varga
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - M Louise Markert
- Department of Immunology, Duke University Medical Center, Durham, NC, 27710, USA
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7
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Dvorak CC, Haddad E, Heimall J, Dunn E, Buckley RH, Kohn DB, Cowan MJ, Pai SY, Griffith LM, Cuvelier GDE, Eissa H, Shah AJ, O'Reilly RJ, Pulsipher MA, Wright NAM, Abraham RS, Satter LF, Notarangelo LD, Puck JM. The diagnosis of severe combined immunodeficiency (SCID): The Primary Immune Deficiency Treatment Consortium (PIDTC) 2022 Definitions. J Allergy Clin Immunol 2023; 151:539-546. [PMID: 36456361 PMCID: PMC9905311 DOI: 10.1016/j.jaci.2022.10.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/18/2022] [Accepted: 10/21/2022] [Indexed: 11/29/2022]
Abstract
Severe combined immunodeficiency (SCID) results from defects in the differentiation of hematopoietic stem cells into mature T lymphocytes, with additional lymphoid lineages affected in particular genotypes. In 2014, the Primary Immune Deficiency Treatment Consortium published criteria for diagnosing SCID, which are now revised to incorporate contemporary approaches. Patients with typical SCID must have less than 0.05 × 109 autologous T cells/L on repetitive testing, with either pathogenic variant(s) in a SCID-associated gene, very low/undetectable T-cell receptor excision circles or less than 20% of CD4 T cells expressing naive markers, and/or transplacental maternally engrafted T cells. Patients with less profoundly impaired autologous T-cell differentiation are designated as having leaky/atypical SCID, with 2 or more of these: low T-cell numbers, oligoclonal T cells, low T-cell receptor excision circles, and less than 20% of CD4 T cells expressing naive markers. These patients must also have either pathogenic variant(s) in a SCID-associated gene or reduced T-cell proliferation to certain mitogens. Omenn syndrome requires a generalized erythematous rash, absent transplacentally acquired maternal engraftment, and 2 or more of these: eosinophilia, elevated IgE, lymphadenopathy, hepatosplenomegaly. Thymic stromal defects and other causes of secondary T-cell deficiency are excluded from the definition of SCID. Application of these revised Primary Immune Deficiency Treatment Consortium 2022 Definitions permits precise categorization of patients with T-cell defects but does not imply a preferred treatment strategy.
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Affiliation(s)
- Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, San Francisco, Calif.
| | - Elie Haddad
- Department of Pediatrics, University of Montreal, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Jennifer Heimall
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, and Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Elizabeth Dunn
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, San Francisco, Calif
| | - Rebecca H Buckley
- Division of Pediatric Allergy and Immunology, Duke University Medical Center, Durham, NC
| | - Donald B Kohn
- Department of Microbiology, Immunology & Molecular Genetics, University of California, Los Angeles, Los Angeles, Calif; Department of Pediatrics, University of California, Los Angeles, Los Angeles, Calif
| | - Morton J Cowan
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, San Francisco, Calif
| | - Sung-Yun Pai
- Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, Bethesda, Md
| | - Linda M Griffith
- Division of Allergy Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Geoffrey D E Cuvelier
- Manitoba Blood and Marrow Transplant Program, CancerCare Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hesham Eissa
- Division of Pediatric Hematology-Oncology-BMT, University of Colorado, Aurora, Colo
| | - Ami J Shah
- Division of Pediatric Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Stanford School of Medicine, Palo Alto, Calif
| | - Richard J O'Reilly
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies Service, Memorial Sloan Kettering, New York, NY
| | - Michael A Pulsipher
- Division of Pediatric Hematology and Oncology, Intermountain Primary Childrens Hospital, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah
| | - Nicola A M Wright
- Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Roshini S Abraham
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Lisa Forbes Satter
- Pediatric Immunology Allergy and Retrovirology, Baylor College of Medicine, Houston, Tex
| | - Luigi D Notarangelo
- Division of Allergy Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Jennifer M Puck
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco, San Francisco, Calif
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8
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Howley E, Davies EG, Kreins AY. Congenital Athymia: Unmet Needs and Practical Guidance. Ther Clin Risk Manag 2023; 19:239-254. [PMID: 36935770 PMCID: PMC10022451 DOI: 10.2147/tcrm.s379673] [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: 12/14/2022] [Accepted: 03/04/2023] [Indexed: 03/14/2023] Open
Abstract
Inborn errors of thymic stromal cell development and function which are associated with congenital athymia result in life-threatening immunodeficiency with susceptibility to infections and autoimmunity. Athymic patients can be treated by thymus transplantation using cultured donor thymus tissue. Outcomes in patients treated at Duke University Medical Center and Great Ormond Street Hospital (GOSH) over the past three decades have shown that sufficient T-cell immunity can be recovered to clear and prevent infections, but post-treatment autoimmune manifestations are relatively common. Whilst thymus transplantation offers the chance of long-term survival, significant challenges remain to optimise the outcomes for the patients. In this review, we will discuss unmet needs and offer practical guidance based on the experience of the European Thymus Transplantation programme at GOSH. Newborn screening (NBS) for severe combined immunodeficiency (SCID) and routine use of next-generation sequencing (NGS) platforms have improved early recognition of congenital athymia and increasing numbers of patients are being referred for thymus transplantation. Nevertheless, there remain delays in diagnosis, in particular when the cause is genetically undefined, and treatment accessibility needs to be improved. The majority of athymic patients have syndromic features with acute and chronic complex health issues, requiring life-long multidisciplinary and multicentre collaboration to optimise their medical and social care. Comprehensive follow up after thymus transplantation including monitoring of immunological results, management of co-morbidities and patient and family quality-of-life experience, is vital to understanding long-term outcomes for this rare cohort of patients. Alongside translational research into improving strategies for thymus replacement therapy, patient-focused clinical research will facilitate the design of strategies to improve the overall care for athymic patients.
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Affiliation(s)
- Evey Howley
- Department of Immunology and Gene Therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - E Graham Davies
- Department of Immunology and Gene Therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Alexandra Y Kreins
- Department of Immunology and Gene Therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation Research & Teaching Department, University College London, London, UK
- Correspondence: Alexandra Y Kreins, Email
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9
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Bhalla P, Du Q, Kumar A, Xing C, Moses A, Dozmorov I, Wysocki CA, Cleaver OB, Pirolli TJ, Markert ML, de la Morena MT, Baldini A, van Oers NS. Mesenchymal cell replacement corrects thymic hypoplasia in murine models of 22q11.2 deletion syndrome. J Clin Invest 2022; 132:e160101. [PMID: 36136514 PMCID: PMC9663160 DOI: 10.1172/jci160101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 09/21/2022] [Indexed: 11/17/2022] Open
Abstract
22q11.2 deletion syndrome (22q11.2DS) is the most common human chromosomal microdeletion, causing developmentally linked congenital malformations, thymic hypoplasia, hypoparathyroidism, and/or cardiac defects. Thymic hypoplasia leads to T cell lymphopenia, which most often results in mild SCID. Despite decades of research, the molecular underpinnings leading to thymic hypoplasia in 22q11.2DS remain unknown. Comparison of embryonic thymuses from mouse models of 22q11.2DS (Tbx1neo2/neo2) revealed proportions of mesenchymal, epithelial, and hematopoietic cell types similar to those of control thymuses. Yet, the small thymuses were growth restricted in fetal organ cultures. Replacement of Tbx1neo2/neo2 thymic mesenchymal cells with normal ones restored tissue growth. Comparative single-cell RNA-Seq of embryonic thymuses uncovered 17 distinct cell subsets, with transcriptome differences predominant in the 5 mesenchymal subsets from the Tbx1neo2/neo2 cell line. The transcripts affected included those for extracellular matrix proteins, consistent with the increased collagen deposition we observed in the small thymuses. Attenuating collagen cross-links with minoxidil restored thymic tissue expansion for hypoplastic lobes. In colony-forming assays, the Tbx1neo2/neo2-derived mesenchymal cells had reduced expansion potential, in contrast to the normal growth of thymic epithelial cells. These findings suggest that mesenchymal cells were causal to the small embryonic thymuses in the 22q11.2DS mouse models, which was correctable by substitution with normal mesenchyme.
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Affiliation(s)
| | | | - Ashwani Kumar
- Eugene McDermott Center for Human Growth and Development
| | - Chao Xing
- Eugene McDermott Center for Human Growth and Development
- Departments of Bioinformatics and
- Population and Data Sciences, Departments of
| | | | | | | | | | - Timothy J. Pirolli
- Division of Pediatric Cardiothoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mary Louise Markert
- Departments of Pediatrics and Immunology, Duke University Medical Center, Durham, North Carolina, USA
| | - Maria Teresa de la Morena
- Division of Immunology, Department of Pediatrics, University of Washington, and Seattle Children’s Hospital, Seattle, Washington, USA
| | - Antonio Baldini
- Department Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Nicolai S.C. van Oers
- Department of Immunology
- Pediatrics
- Department of Microbiology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
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10
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Lev A, Sharir I, Simon AJ, Levy S, Lee YN, Frizinsky S, Daas S, Saraf-Levy T, Broides A, Nahum A, Hanna S, Stepensky P, Toker O, Dalal I, Etzioni A, Stein J, Adam E, Hendel A, Marcus N, Almashanu S, Somech R. Lessons Learned From Five Years of Newborn Screening for Severe Combined Immunodeficiency in Israel. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2722-2731.e9. [PMID: 35487367 DOI: 10.1016/j.jaip.2022.04.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/03/2022] [Accepted: 04/05/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Implementation of newborn screening (NBS) programs for severe combined immunodeficiency (SCID) have advanced the diagnosis and management of affected infants and undoubtedly improved their outcomes. Reporting long-term follow-up of such programs is of great importance. OBJECTIVE We report a 5-year summary of the NBS program for SCID in Israel. METHODS Immunologic and genetic assessments, clinical analyses, and outcome data from all infants who screened positive were evaluated and summarized. RESULTS A total of 937,953 Guthrie cards were screened for SCID. A second Guthrie card was requested on 1,169 occasions (0.12%), which resulted in 142 referrals (0.015%) for further validation tests. Flow cytometry immune-phenotyping, T cell receptor excision circle measurement in peripheral blood, and expression of TCRVβ repertoire for the validation of positive cases revealed a specificity and sensitivity of 93.7% and 75.9%, respectively, in detecting true cases of SCID. Altogether, 32 SCID and 110 non-SCID newborns were diagnosed, making the incidence of SCID in Israel as high as 1:29,000 births. The most common genetic defects in this group were associated with mutations in DNA cross-link repair protein 1C and IL-7 receptor α (IL-7Rα) genes. No infant with SCID was missed during the study time. Twenty-two SCID patients underwent hematopoietic stem cell transplantation, which resulted in a 91% survival rate. CONCLUSIONS Newborn screening for SCID should ultimately be applied globally, specifically to areas with high rates of consanguineous marriages. Accumulating data from follow-up studies on NBS for SCID will improve diagnosis and treatment and enrich our understanding of immune development in health and disease.
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Affiliation(s)
- Atar Lev
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Mina and Everard Goodman Faculty of Life Sciences, Advanced Materials and Nanotechnology Institute, Bar-Ilan University, Ramat-Gan, Israel
| | - Idan Sharir
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amos J Simon
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Hemato-Immunology Unit, Hematology Lab, Sheba Medical Center, Tel HaShomer, Israel
| | - Shiran Levy
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yu Nee Lee
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shirly Frizinsky
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Suha Daas
- National Newborn Screening Program, Ministry of Health, Tel-HaShomer, Israel
| | - Talia Saraf-Levy
- National Newborn Screening Program, Ministry of Health, Tel-HaShomer, Israel
| | - Arnon Broides
- Pediatric Immunology, Soroka University Medical Center, Beer-Sheva, Israel; Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY
| | - Amit Nahum
- Pediatric Immunology, Soroka University Medical Center, Beer-Sheva, Israel; Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY; Primary Immunodeficiency Research Laboratory, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Suhair Hanna
- Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY; Ruth Children Hospital, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Polina Stepensky
- Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY; Department of Bone Marrow Transplantation, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ori Toker
- Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY; Faculty of Medicine, Hebrew University of Jerusalem, Israel; Allergy and Immunology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ilan Dalal
- Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY; Department of Pediatrics, Pediatric Allergy Unit, E. Wolfson Medical Center, Holon, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amos Etzioni
- Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY; Ruth Children Hospital, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Jerry Stein
- Department for Hemato-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Etai Adam
- Division of Pediatric Hematology and Oncology, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
| | - Ayal Hendel
- Mina and Everard Goodman Faculty of Life Sciences, Advanced Materials and Nanotechnology Institute, Bar-Ilan University, Ramat-Gan, Israel
| | - Nufar Marcus
- Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY; Allergy and Immunology Unit, Schneider Children's Medical Center of Israel, Felsenstein Medical Research Center, Kipper Institute of Immunology, Petach Tikva, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Shlomo Almashanu
- National Newborn Screening Program, Ministry of Health, Tel-HaShomer, Israel.
| | - Raz Somech
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY; National Lab for Confirming Primary Immunodeficiency in Newborn Screening Center for Newborn Screening, Ministry of Health, Tel HaShomer, Israel.
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11
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Yu HH, Chien YH, Lu MY, Hu YC, Lee JH, Wang LC, Lin YT, Yang YH, Chiang BL. Clinical and Immunological Defects and Outcomes in Patients with Chromosome 22q11.2 Deletion Syndrome. J Clin Immunol 2022; 42:1721-1729. [PMID: 35925483 DOI: 10.1007/s10875-022-01340-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chromosome 22q11.2 deletion syndrome (22q11.2DS) is the most common microdeletion syndrome in humans and can present with highly variable clinical manifestations. Immune deficiencies occur because of thymic hypoplasia or aplasia. METHODS This retrospective study included patients diagnosed with 22q11.2DS at a medical center between 2000 and 2021. We analyzed the association between clinical phenotypes, immunological abnormalities, age, and outcomes. RESULTS Eighty-seven patients with 22q11.2DS had a median diagnostic age of 1.78 months. Patients presented with congenital heart disease (CHD; 86.2%), major infections (75.9%), and failure to thrive (FTT; 58.6%). Autoimmunity, neuropsychiatric disorders, and hypoparathyroidism were significantly associated. Neonatal seizures were associated with early diagnosis before 2 months (OR 8.56, 95% CI 1.21-60.58, P = 0.032). Immunological abnormalities included lymphopenia (93.1%), T lymphopenia (71.9%), CD4+ T lymphopenia (64.1%), a lack of hepatitis B vaccine antibodies (46.2%), and complete DiGeorge syndrome (cDGS) (2.3%). Severe lymphopenia and T lymphopenia improved at 3 years of age. Two patients with cDGS were treated with hematopoietic stem cell transplantation, and one survived. The mortality rate was 12.8% and the estimated 35-year survival probability was 77.5%. Major infections experienced > four times were significantly associated with a decreased survival rate of 60%. Patients with CHD without FTT or recurrent infections had a better 20-year survival rate (96.2%). CONCLUSIONS CHD, major infection, and FTT were common manifestations and poor prognostic factors. Autoimmunity, neuropsychiatric disorders, and hypoparathyroidism were significantly associated. Although T lymphopenia may improve with age, patients with 22q11.2DS require lifelong monitoring for immune dysregulation.
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Affiliation(s)
- Hsin-Hui Yu
- Department of Paediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Yin-Hsiu Chien
- Department of Paediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Yao Lu
- Department of Paediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Ya-Chiao Hu
- Department of Paediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Jyh-Hong Lee
- Department of Paediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Li-Chieh Wang
- Department of Paediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Yu-Tsan Lin
- Department of Paediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Yao-Hsu Yang
- Department of Paediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Bor-Luen Chiang
- Department of Paediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan.
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12
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Kobrynski LJ. Newborn Screening in the Diagnosis of Primary Immunodeficiency. Clin Rev Allergy Immunol 2022; 63:9-21. [PMID: 34292457 DOI: 10.1007/s12016-021-08876-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2021] [Indexed: 01/12/2023]
Abstract
Newborn screening for severe combined immune deficiency (SCID) is the first inborn error of immunity (IEI) to be detected through population screening. It also represents the first newborn screening test to utilize molecular testing on DNA from newborn dried blood spots. Newborn screening for SCID has provided opportunities to measure the population prevalence of this disorder and evaluate the effect of early interventions on the overall outcomes in affected infants. The success of SCID newborn screening has increased interest in developing and implementing molecular testing for other clinically significant inborn errors of immunity. This methodology has been adapted to screen for another monogenic inborn defect, spinal muscle atrophy. Advances in the clinical care and new therapeutics for many inborn errors of immunity support the need for early diagnosis and prompt institution of therapies to reduce morbidity and mortality. Early diagnosis may also improve the quality of life for affected patients. This article provides an overview of newborn screening for SCID, recommended steps for follow-up testing and early intervention as well as long-term follow-up. Numerous challenges remain, including the development of clinical consensus regarding confirmatory and diagnostic testing, early interventions, and best practices for immune reconstitution in affected infants.
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Affiliation(s)
- Lisa J Kobrynski
- Pediatrics Institute, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA.
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13
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Vaseghi-Shanjani M, Snow AL, Margolis DJ, Latrous M, Milner JD, Turvey SE, Biggs CM. Atopy as Immune Dysregulation: Offender Genes and Targets. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1737-1756. [PMID: 35680527 DOI: 10.1016/j.jaip.2022.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/06/2022] [Accepted: 04/06/2022] [Indexed: 06/15/2023]
Abstract
Allergic diseases are a heterogeneous group of disorders resulting from exaggerated type 2 inflammation. Although typically viewed as polygenic multifactorial disorders caused by the interaction of several genes with the environment, we have come to appreciate that allergic diseases can also be caused by monogenic variants affecting the immune system and the skin epithelial barrier. Through a myriad of genetic association studies and high-throughput sequencing tools, many monogenic and polygenic culprits of allergic diseases have been described. Identifying the genetic causes of atopy has shaped our understanding of how these conditions occur and how they may be treated and even prevented. Precision diagnostic tools and therapies that address the specific molecular pathways implicated in allergic inflammation provide exciting opportunities to improve our care for patients across the field of allergy and immunology. Here, we highlight offender genes implicated in polygenic and monogenic allergic diseases and list targeted therapeutic approaches that address these disrupted pathways.
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Affiliation(s)
- Maryam Vaseghi-Shanjani
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; Experimental Medicine Program, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew L Snow
- Department of Pharmacology and Molecular Therapeutics, Uniformed Services University of the Health Sciences, Bethesda, Md
| | - David J Margolis
- Department of Dermatology and Dermatologic Surgery, University of Pennsylvania Medical Center, Philadelphia, Pa; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Medical Center, Philadelphia, Pa
| | - Meriem Latrous
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joshua D Milner
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Stuart E Turvey
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; Experimental Medicine Program, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Catherine M Biggs
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; St Paul's Hospital, Vancouver, British Columbia, Canada.
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14
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Markert ML, Gupton SE, McCarthy EA. Experience with cultured thymus tissue in 105 children. J Allergy Clin Immunol 2022; 149:747-757. [PMID: 34362576 PMCID: PMC8810898 DOI: 10.1016/j.jaci.2021.06.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/23/2021] [Accepted: 06/29/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Currently, there are no approved therapies to treat congenital athymia, a condition of immune deficiency resulting in high early mortality due to infection and immune dysregulation. Multiple syndromic conditions, such as complete DiGeorge syndrome, 22q11.2 deletion syndrome, CHARGE (coloboma, heart defects, choanal atresia, growth or mental retardation, genital hypoplasia, and ear anomalies and/or deafness) syndrome, diabetic embryopathy, other genetic variants, and FOXN1 deficiency, are associated with congenital athymia. OBJECTIVE Our aims were to study 105 patients treated with cultured thymus tissue (CTT), and in this report, to focus on the outcomes of 95 patients with treatment-naive congenital athymia. METHODS A total of 10 prospective, single-arm open-label studies with patient enrollment from 1993 to 2020 form the basis of this data set. Patients were tested after administration of CTT for T-cell development; all adverse events and infections were recorded. RESULTS A total of 105 patients were enrolled and received CTT (the full analysis set). Of those patients, 10 had diagnoses other than congenital athymia and/or received prior treatments. Of those 105 patients, 95 patients with treatment-naive congenital athymia were included in the efficacy analysis set (EAS). The Kaplan-Meier estimated survival rates at year 1 and year 2 after administration of CTT in the EAS were 77% (95% CI = 0.670-0.844) and 76% (95% CI = 0.657-0.834), respectively. In all, 21 patients died in the first year before developing naive T cells and 1 died in the second year after receipt of CTT; 3 subsequent deaths were not related to immunodeficiency. A few patients developed alopecia, autoimmune hepatitis, psoriasis, and psoriatic arthritis after year 1. The rates of infections, autologous graft-versus-host-disease manifestations, and autoimmune cytopenias all decreased approximately 1 year after administration of CTT. CONCLUSION Treatment with CTT led to development of naive T cells with a 1-year survival rate of 77% and a median follow-up time of 7.6 years. Immune reconstitution sufficient to prevent infections and support survival typically develops 6 to12 months after administration of CTT.
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Affiliation(s)
- M. Louise Markert
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Durham, NC, 27710, United States,Department of Immunology, Duke School of Medicine, Durham, NC, 27710, United States
| | - Stephanie E. Gupton
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Durham, NC, 27710, United States
| | - Elizabeth A. McCarthy
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Durham, NC, 27710, United States
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15
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Framme JL, Lundqvist C, Lundell AC, van Schouwenburg PA, Lemarquis AL, Thörn K, Lindgren S, Gudmundsdottir J, Lundberg V, Degerman S, Zetterström RH, Borte S, Hammarström L, Telemo E, Hultdin M, van der Burg M, Fasth A, Oskarsdóttir S, Ekwall O. Long-Term Follow-Up of Newborns with 22q11 Deletion Syndrome and Low TRECs. J Clin Immunol 2022; 42:618-633. [PMID: 35080750 PMCID: PMC9016018 DOI: 10.1007/s10875-021-01201-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 12/12/2021] [Indexed: 01/03/2023]
Abstract
Background Population-based neonatal screening using T-cell receptor excision circles (TRECs) identifies infants with profound T lymphopenia, as seen in cases of severe combined immunodeficiency, and in a subgroup of infants with 22q11 deletion syndrome (22q11DS). Purpose To investigate the long-term prognostic value of low levels of TRECs in newborns with 22q11DS. Methods Subjects with 22q11DS and low TRECs at birth (22q11Low, N=10), matched subjects with 22q11DS and normal TRECs (22q11Normal, N=10), and matched healthy controls (HC, N=10) were identified. At follow-up (median age 16 years), clinical and immunological characterizations, covering lymphocyte subsets, immunoglobulins, TRECs, T-cell receptor repertoires, and relative telomere length (RTL) measurements were performed. Results At follow-up, the 22q11Low group had lower numbers of naïve T-helper cells, naïve T-regulatory cells, naïve cytotoxic T cells, and persistently lower TRECs compared to healthy controls. Receptor repertoires showed skewed V-gene usage for naïve T-helper cells, whereas for naïve cytotoxic T cells, shorter RTL and a trend towards higher clonality were found. Multivariate discriminant analysis revealed a clear distinction between the three groups and a skewing towards Th17 differentiation of T-helper cells, particularly in the 22q11Low individuals. Perturbations of B-cell subsets were found in both the 22q11Low and 22q11Normal group compared to the HC group, with larger proportions of naïve B cells and lower levels of memory B cells, including switched memory B cells. Conclusions This long-term follow-up study shows that 22q11Low individuals have persistent immunologic aberrations and increased risk for immune dysregulation, indicating the necessity of lifelong monitoring. Clinical Implications This study elucidates the natural history of childhood immune function in newborns with 22q11DS and low TRECs, which may facilitate the development of programs for long-term monitoring and therapeutic choices. Supplementary Information The online version contains supplementary material available at 10.1007/s10875-021-01201-5.
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Affiliation(s)
- Jenny Lingman Framme
- Department of Pediatrics, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
- Department of Pediatrics, Halland Hospital Halmstad, Halmstad, Region Halland, Sweden.
| | - Christina Lundqvist
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Anna-Carin Lundell
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Pauline A van Schouwenburg
- Department of Pediatrics, Laboratory for Pediatric Immunology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Andri L Lemarquis
- Department of Pediatrics, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Karolina Thörn
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Susanne Lindgren
- Department of Pediatrics, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Judith Gudmundsdottir
- Department of Pediatrics, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Children's Medical Center, National University Hospital of Iceland, Reykjavík, Iceland
| | - Vanja Lundberg
- Department of Pediatrics, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Sofie Degerman
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Rolf H Zetterström
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Stephan Borte
- ImmunoDeficiencyCenter Leipzig (IDCL), Municipal Hospital St. Georg Leipzig, Leipzig, Germany
| | - Lennart Hammarström
- Department of Biosciences and Nutrition, Neo, Karolinska Institute, Stockholm, Sweden
| | - Esbjörn Telemo
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Magnus Hultdin
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden
| | - Mirjam van der Burg
- Department of Pediatrics, Laboratory for Pediatric Immunology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Anders Fasth
- Department of Pediatrics, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Sólveig Oskarsdóttir
- Department of Pediatrics, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Olov Ekwall
- Department of Pediatrics, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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16
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Chitty-Lopez M, Duff C, Vaughn G, Trotter J, Monforte H, Lindsay D, Haddad E, Keller MD, Oshrine BR, Leiding JW. Case Report: Unmanipulated Matched Sibling Donor Hematopoietic Cell Transplantation In TBX1 Congenital Athymia: A Lifesaving Therapeutic Approach When Facing a Systemic Viral Infection. Front Immunol 2022; 12:721917. [PMID: 35095830 PMCID: PMC8794793 DOI: 10.3389/fimmu.2021.721917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 11/19/2021] [Indexed: 11/13/2022] Open
Abstract
Congenital athymia can present with severe T cell lymphopenia (TCL) in the newborn period, which can be detected by decreased T cell receptor excision circles (TRECs) on newborn screening (NBS). The most common thymic stromal defect causing selective TCL is 22q11.2 deletion syndrome (22q11.2DS). T-box transcription factor 1 (TBX1), present on chromosome 22, is responsible for thymic epithelial development. Single variants in TBX1 causing haploinsufficiency cause a clinical syndrome that mimics 22q11.2DS. Definitive therapy for congenital athymia is allogeneic thymic transplantation. However, universal availability of such therapy is limited. We present a patient with early diagnosis of congenital athymia due to TBX1 haploinsufficiency. While evaluating for thymic transplantation, she developed Omenn Syndrome (OS) and life-threatening adenoviremia. Despite treatment with anti-virals and cytotoxic T lymphocytes (CTLs), life threatening adenoviremia persisted. Given the imminent need for rapid establishment of T cell immunity and viral clearance, the patient underwent an unmanipulated matched sibling donor (MSD) hematopoietic cell transplant (HCT), ultimately achieving post-thymic donor-derived engraftment, viral clearance, and immune reconstitution. This case illustrates that because of the slower immune recovery that occurs following thymus transplantation and the restricted availability of thymus transplantation globally, clinicians may consider CTL therapy and HCT to treat congenital athymia patients with severe infections.
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Affiliation(s)
- Maria Chitty-Lopez
- Division of Pediatric Allergy and Immunology, University of South Florida, Tampa, FL, United States
| | - Carla Duff
- Division of Pediatric Allergy and Immunology, University of South Florida, Tampa, FL, United States
| | - Gretchen Vaughn
- Center for Cell and Gene Therapy for Non-Malignant Conditions, Cancer and Blood Disorders Institute at Johns Hopkins All Children’s Hospital, St. Petersburg, FL, United States
| | - Jessica Trotter
- Division of Pediatric Allergy and Immunology, University of South Florida, Tampa, FL, United States
| | - Hector Monforte
- Department of Pathology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, United States
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, United States
| | - David Lindsay
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, United States
- Division of Immuno-Allergy and Rheumatology, The Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Elie Haddad
- Division of Immuno-Allergy and Rheumatology, The Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
- Division of Allergy and Immunology, Children’s National Hospital, Washington, DC, United States
| | - Michael D. Keller
- Division of Allergy and Immunology, Children’s National Hospital, Washington, DC, United States
| | - Benjamin R. Oshrine
- Center for Cell and Gene Therapy for Non-Malignant Conditions, Cancer and Blood Disorders Institute at Johns Hopkins All Children’s Hospital, St. Petersburg, FL, United States
| | - Jennifer W. Leiding
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, United States
- Infectious Diseases and Immunology Division. Arnold Palmer Hospital for Children, Orlando, FL, United States
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17
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Silva CS, Reis RL, Martins A, Neves NM. Recapitulation of Thymic Function by Tissue Engineering Strategies. Adv Healthc Mater 2021; 10:e2100773. [PMID: 34197034 DOI: 10.1002/adhm.202100773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Indexed: 11/06/2022]
Abstract
The thymus is responsible for the development and selection of T lymphocytes, which in turn also participate in the maturation of thymic epithelial cells. These events occur through the close interactions between hematopoietic stem cells and developing thymocytes with the thymic stromal cells within an intricate 3D network. The complex thymic microenvironment and function, and the current therapies to induce thymic regeneration or to overcome the lack of a functional thymus are herein reviewed. The recapitulation of the thymic function using tissue engineering strategies has been explored as a way to control the body's tolerance to external grafts and to generate ex vivo T cells for transplantation. In this review, the main advances in the thymus tissue engineering field are disclosed, including both scaffold- and cell-based strategies. In light of the current gaps and limitations of the developed systems, the design of novel biomaterials for this purpose with unique features is also discussed.
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Affiliation(s)
- Catarina S. Silva
- 3B's Research Group I3Bs – Research Institute on Biomaterials Biodegradables and Biomimetics University of Minho Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine ICVS/3B's – PT Government Associate Laboratory AvePark, Parque da Ciência e Tecnologia, Zona Industrial da Gandra 4805‐017 Barco Guimarães Portugal
| | - Rui L. Reis
- 3B's Research Group I3Bs – Research Institute on Biomaterials Biodegradables and Biomimetics University of Minho Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine ICVS/3B's – PT Government Associate Laboratory AvePark, Parque da Ciência e Tecnologia, Zona Industrial da Gandra 4805‐017 Barco Guimarães Portugal
| | - Albino Martins
- 3B's Research Group I3Bs – Research Institute on Biomaterials Biodegradables and Biomimetics University of Minho Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine ICVS/3B's – PT Government Associate Laboratory AvePark, Parque da Ciência e Tecnologia, Zona Industrial da Gandra 4805‐017 Barco Guimarães Portugal
| | - Nuno M. Neves
- 3B's Research Group I3Bs – Research Institute on Biomaterials Biodegradables and Biomimetics University of Minho Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine ICVS/3B's – PT Government Associate Laboratory AvePark, Parque da Ciência e Tecnologia, Zona Industrial da Gandra 4805‐017 Barco Guimarães Portugal
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18
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Hsieh EWY, Kim-Chang JJ, Kulke S, Silber A, O'Hara M, Collins C. Defining the Clinical, Emotional, Social, and Financial Burden of Congenital Athymia. Adv Ther 2021; 38:4271-4288. [PMID: 34213759 PMCID: PMC8342356 DOI: 10.1007/s12325-021-01820-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/05/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Characterize the burden of illness in pediatric patients with congen̄ital athymia who were receiving supportive care. METHODS This cross-sectional study of adult caregivers of patients with congenital athymia used both a quantitative survey and qualitative interviews. Caregivers of patients currently receiving supportive care responded to questions about the past 12 months and completed the parent proxy version of the Pediatric Quality of Life Inventory Generic instrument (PedsQL) for patients aged 2-4 years. For caregivers of patients who had received supportive care in the past, questions were asked about the period when they were receiving supportive care only. RESULTS The sample included caregivers of 18 patients, 5 who were currently receiving supportive care and 13 who received investigational cultured human thymus tissue implantation before study enrollment and had received supportive care in the past. The impact of congenital athymia was substantial. Reports included the need to live in isolation (100% of respondents); caregiver emotional burden such as fear of death, infection, and worries about the future (100%); financial hardship (78%); and the inability to meet family/friends (72%). Patients had frequent and prolonged hospitalizations (78%) and had high utilization of procedures, medications, and home medical supplies. Caregiver-reported PedsQL scores for patients currently receiving supportive care (n = 4) indicated low health-related quality of life. CONCLUSIONS Caregivers of patients with congenital athymia reported high clinical, emotional, social, and financial burden on patients and their families.
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Affiliation(s)
- Elena W Y Hsieh
- Department of Pediatrics, Section of Allergy and Immunology, Children's Hospital Colorado University of Colorado School of Medicine, Aurora, CO, USA
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Julie J Kim-Chang
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Sarah Kulke
- Enzyvant Therapeutics, Inc., Cambridge, MA, USA
| | | | | | - Cathleen Collins
- Rady Children's Hospital, San Diego, CA, USA.
- Department of Pediatrics, Division of Allergy Immunology, University of California San Diego, San Diego, CA, USA.
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19
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Collins C, Sharpe E, Silber A, Kulke S, Hsieh EWY. Congenital Athymia: Genetic Etiologies, Clinical Manifestations, Diagnosis, and Treatment. J Clin Immunol 2021; 41:881-895. [PMID: 33987750 PMCID: PMC8249278 DOI: 10.1007/s10875-021-01059-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 05/03/2021] [Indexed: 12/17/2022]
Abstract
Congenital athymia is an ultra-rare disease characterized by the absence of a functioning thymus. It is associated with several genetic and syndromic disorders including FOXN1 deficiency, 22q11.2 deletion, CHARGE Syndrome (Coloboma, Heart defects, Atresia of the nasal choanae, Retardation of growth and development, Genitourinary anomalies, and Ear anomalies), and Complete DiGeorge Syndrome. Congenital athymia can result from defects in genes that impact thymic organ development such as FOXN1 and PAX1 or from genes that are involved in development of the entire midline region, such as TBX1 within the 22q11.2 region, CHD7, and FOXI3. Patients with congenital athymia have profound immunodeficiency, increased susceptibility to infections, and frequently, autologous graft-versus-host disease (GVHD). Athymic patients often present with absent T cells but normal numbers of B cells and Natural Killer cells (T-B+NK+), similar to a phenotype of severe combined immunodeficiency (SCID); these patients may require additional steps to confirm the diagnosis if no known genetic cause of athymia is identified. However, distinguishing athymia from SCID is crucial, as treatments differ for these conditions. Cultured thymus tissue is being investigated as a treatment for congenital athymia. Here, we review what is known about the epidemiology, underlying etiologies, clinical manifestations, and treatments for congenital athymia.
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Affiliation(s)
- Cathleen Collins
- Department of Pediatrics, Division of Allergy Immunology, Rady Children's Hospital, University of California San Diego, San Diego, CA, USA
| | | | | | - Sarah Kulke
- Enzyvant Therapeutics, Inc, Cambridge, MA, USA
| | - Elena W Y Hsieh
- Department of Pediatrics, Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO, USA.
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20
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Cooper MA, Zimmerman O, Nataraj R, Wynn RF. Lifelong Immune Modulation Versus Hematopoietic Cell Therapy for Inborn Errors of Immunity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:628-639. [PMID: 33551038 DOI: 10.1016/j.jaip.2020.11.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023]
Abstract
Advances in diagnosis of inborn errors of immunity (IEI) and an understanding of the molecular and immunologic mechanisms of these disorders have led to both the development of new therapies and improved approaches to hematopoietic cell transplantation (HCT). For example, monoclonal antibodies (mAbs) and small molecules, such as Janus tyrosine kinase inhibitors, that can modulate immunologic pathways have been designed for or repurposed for management of IEI. A better understanding of molecular mechanisms of IEI has led to use of drugs typically considered "immunosuppressive" to modulate the immune response, such as mammalian target of rapamycin inhibitors in disorders of phosphoinositide 3-kinase gain of function. Since the first HCT in a patient with severe combined immunodeficiency (SCID) in 1968, transplantation strategies have improved, with more than 90% probability of survival after allogeneic HCT in SCID and hence HCT is now the therapeutic standard for SCID and many other IEI. When tailoring treatment for IEI, multiple disease-specific and individual factors should be considered. In diseases such as SCID or agammaglobulinemia, the choice between HCT or medical management is straightforward. However, in many IEI, the choice between the options is challenging. This review focuses on the factors that should be taken into account in the quest for the optimal treatment for patients with IEI.
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Affiliation(s)
- Megan A Cooper
- Department of Pediatrics, Division of Rheumatology/Immunology, Washington University in St Louis, St Louis, Mo.
| | - Ofer Zimmerman
- Department of Medicine, Division of Allergy/Immunology, Washington University in St Louis, St Louis, Mo
| | - Ramya Nataraj
- Department of Blood and Marrow Transplant, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Robert F Wynn
- Department of Blood and Marrow Transplant, Royal Manchester Children's Hospital, Manchester, United Kingdom.
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21
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Kreins AY, Bonfanti P, Davies EG. Current and Future Therapeutic Approaches for Thymic Stromal Cell Defects. Front Immunol 2021; 12:655354. [PMID: 33815417 PMCID: PMC8012524 DOI: 10.3389/fimmu.2021.655354] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/03/2021] [Indexed: 12/14/2022] Open
Abstract
Inborn errors of thymic stromal cell development and function lead to impaired T-cell development resulting in a susceptibility to opportunistic infections and autoimmunity. In their most severe form, congenital athymia, these disorders are life-threatening if left untreated. Athymia is rare and is typically associated with complete DiGeorge syndrome, which has multiple genetic and environmental etiologies. It is also found in rare cases of T-cell lymphopenia due to Nude SCID and Otofaciocervical Syndrome type 2, or in the context of genetically undefined defects. This group of disorders cannot be corrected by hematopoietic stem cell transplantation, but upon timely recognition as thymic defects, can successfully be treated by thymus transplantation using cultured postnatal thymic tissue with the generation of naïve T-cells showing a diverse repertoire. Mortality after this treatment usually occurs before immune reconstitution and is mainly associated with infections most often acquired pre-transplantation. In this review, we will discuss the current approaches to the diagnosis and management of thymic stromal cell defects, in particular those resulting in athymia. We will discuss the impact of the expanding implementation of newborn screening for T-cell lymphopenia, in combination with next generation sequencing, as well as the role of novel diagnostic tools distinguishing between hematopoietic and thymic stromal cell defects in facilitating the early consideration for thymus transplantation of an increasing number of patients and disorders. Immune reconstitution after the current treatment is usually incomplete with relatively common inflammatory and autoimmune complications, emphasizing the importance for improving strategies for thymus replacement therapy by optimizing the current use of postnatal thymus tissue and developing new approaches using engineered thymus tissue.
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Affiliation(s)
- Alexandra Y. Kreins
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Paola Bonfanti
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Epithelial Stem Cell Biology & Regenerative Medicine Laboratory, The Francis Crick Institute, London, United Kingdom
- Institute of Immunity & Transplantation, University College London, London, United Kingdom
| | - E. Graham Davies
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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22
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King JR, Notarangelo LD, Hammarström L. An appraisal of the Wilson & Jungner criteria in the context of genomic-based newborn screening for inborn errors of immunity. J Allergy Clin Immunol 2021; 147:428-438. [PMID: 33551024 PMCID: PMC8344044 DOI: 10.1016/j.jaci.2020.12.633] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/18/2020] [Accepted: 12/18/2020] [Indexed: 11/25/2022]
Abstract
Wilson and Jungner's recommendations for population-based screening have been used to guide decisions regarding candidate disease inclusion in newborn screening programs for the past 50 years. The advent of genomic-based technologies, including next-generation sequencing and its potential application to newborn screening, along with a changing landscape in terms of modern clinical practice and ethical, social, and legal considerations has led to a call for review of these criteria. Inborn errors of immunity (IEI) are a heterogeneous group of more than 450 genetically determined disorders of immunity, which are associated with significant morbidity and mortality, particularly where diagnosis and treatment are delayed. We argue that in addition to screening for severe combined immunodeficiency disease, which has already been initiated in several countries, other clinically significant IEI should be screened for at birth. Because of disease heterogeneity and identifiable genetic targets, a next-generation sequencing-based screening approach would be most suitable. A combination of worldwide experience and technological advances has improved our ability to diagnose and effectively treat patients with IEI. Considering IEI in the context of updated recommendations for population-based screening supports their potential inclusion as disease targets in newborn screening programs.
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Affiliation(s)
- Jovanka R King
- Department of Clinical Immunology, Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Immunopathology, SA Pathology, Women's and Children's Hospital Campus, Adelaide, Australia; Robinson Research Institute and Discipline of Paediatrics, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Lennart Hammarström
- Department of Clinical Immunology, Karolinska University Hospital Huddinge, Stockholm, Sweden.
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23
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Expanding the Nude SCID/CID Phenotype Associated with FOXN1 Homozygous, Compound Heterozygous, or Heterozygous Mutations. J Clin Immunol 2021; 41:756-768. [PMID: 33464451 PMCID: PMC8068652 DOI: 10.1007/s10875-021-00967-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/06/2021] [Indexed: 12/11/2022]
Abstract
Human nude SCID is a rare autosomal recessive inborn error of immunity (IEI) characterized by congenital athymia, alopecia, and nail dystrophy. Few cases have been reported to date. However, the recent introduction of newborn screening for IEIs and high-throughput sequencing has led to the identification of novel and atypical cases. Moreover, immunological alterations have been recently described in patients carrying heterozygous mutations. The aim of this paper is to describe the extended phenotype associated with FOXN1 homozygous, compound heterozygous, or heterozygous mutations. We collected clinical and laboratory information of a cohort of 11 homozygous, 2 compound heterozygous, and 5 heterozygous patients with recurrent severe infections. All, except one heterozygous patient, had signs of CID or SCID. Nail dystrophy and alopecia, that represent the hallmarks of the syndrome, were not always present, while almost 50% of the patients developed Omenn syndrome. One patient with hypomorphic compound heterozygous mutations had a late-onset atypical phenotype. A SCID-like phenotype was observed in 4 heterozygous patients coming from the same family. A spectrum of clinical manifestations may be associated with different mutations. The severity of the clinical phenotype likely depends on the amount of residual activity of the gene product, as previously observed for other SCID-related genes. The severity of the manifestations in this heterozygous family may suggest a mechanism of negative dominance of the specific mutation or the presence of additional mutations in noncoding regions.
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24
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Collins C, Kim-Chang JJ, Hsieh E, Silber A, O'Hara M, Kulke S, Cooper MA. Economic burden of congenital athymia in the United States for patients receiving supportive care during the first 3 years of life. J Med Econ 2021; 24:962-971. [PMID: 34324414 DOI: 10.1080/13696998.2021.1962129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIMS Congenital athymia is an ultra-rare pediatric condition characterized by the lack of thymus in utero and the naïve T cells critical for infection defense and immune regulation. Patients with congenital athymia receive supportive care to minimize and treat infections, autoimmune phenomena, and autologous graft-versus-host disease (aGVHD) manifestations, but historically, die within the first 3 years of life with supportive care only. We estimated the healthcare resource utilization and economic burden of supportive care over patients' first 3 years of life in the United States. METHODS A medical chart audit by the treating physician was used to collect patient data from birth to age 3 on clinical manifestations associated with congenital athymia (clinical manifestations due to underlying syndromic conditions excluded). Using costs and charges from publicly available sources, the total economic burden of direct medical costs and charges for the first 3 years of life (considered "lifetime" for patients receiving supportive care) and differences in economic burden between patients with higher and lower inpatient hospitalization durations were estimated. RESULTS All patients (n = 10) experienced frequent infections and aGVHD manifestations; 40% experienced ≥1 episode of sepsis, and 20% had recurrent sepsis episodes annually. The estimated mean 3-year economic burden per patient was US$5,534,121 (2020 US dollars). The annual mean inpatient hospitalization duration was 150.6 days. Inpatient room charges accounted for 79% of the economic burden, reflecting the high costs of specialized care settings required to prevent infection, including isolation. Patients with high inpatient utilization (n = 5; annual mean inpatient hospitalization duration, 289.6 days) had an estimated 3-year economic burden of US$9,926,229. LIMITATIONS The total economic burden may not be adequately represented due to underestimation of some direct costs or overestimation of others. CONCLUSIONS Current treatment of patients with congenital athymia (supportive care) presents a high economic burden to the healthcare system.
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Affiliation(s)
- Cathleen Collins
- Department of Allergy and Immunology, Rady Children's Hospital, San Diego, CA, USA
- Department of Pediatrics, Division of Allergy Immunology, University of California San Diego, San Diego, CA, USA
| | - Julie J Kim-Chang
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Elena Hsieh
- Department of Pediatrics, Section of Allergy and Immunology, University of Colorado, Anschutz School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
- Department of Immunology and Microbiology, University of Colorado, Anschutz School of Medicine, Aurora, CO, USA
| | | | | | - Sarah Kulke
- Enzyvant Therapeutics, Inc., Cambridge, MA, USA
| | - Megan A Cooper
- Department of Pediatrics, Division of Rheumatology/Immunology, Washington University in St. Louis, St. Louis, MO, USA
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25
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Yamazaki Y, Urrutia R, Franco LM, Giliani S, Zhang K, Alazami AM, Dobbs AK, Masneri S, Joshi A, Otaizo-Carrasquero F, Myers TG, Ganesan S, Bondioni MP, Ho ML, Marks C, Alajlan H, Mohammed RW, Zou F, Valencia CA, Filipovich AH, Facchetti F, Boisson B, Azzari C, Al-Saud BK, Al-Mousa H, Casanova JL, Abraham RS, Notarangelo LD. PAX1 is essential for development and function of the human thymus. Sci Immunol 2020; 5:5/44/eaax1036. [PMID: 32111619 DOI: 10.1126/sciimmunol.aax1036] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 01/28/2020] [Indexed: 02/05/2023]
Abstract
We investigated the molecular and cellular basis of severe combined immunodeficiency (SCID) in six patients with otofaciocervical syndrome type 2 who failed to attain T cell reconstitution after allogeneic hematopoietic stem cell transplantation, despite successful engraftment in three of them. We identified rare biallelic PAX1 rare variants in all patients. We demonstrated that these mutant PAX1 proteins have an altered conformation and flexibility of the paired box domain and reduced transcriptional activity. We generated patient-derived induced pluripotent stem cells and differentiated them into thymic epithelial progenitor cells and found that they have an altered transcriptional profile, including for genes involved in the development of the thymus and other tissues derived from pharyngeal pouches. These results identify biallelic, loss-of-function PAX1 mutations as the cause of a syndromic form of SCID due to altered thymus development.
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Affiliation(s)
- Yasuhiro Yamazaki
- Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, MD 20892, USA
| | - Raul Urrutia
- Human and Molecular Genetics Center, Medical College Wisconsin, Milwaukee, MI, USA
| | - Luis M Franco
- Systemic Autoimmunity Branch, NIAMS, NIH, Bethesda, MD 20892, USA
| | - Silvia Giliani
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.,Cytogenetic and Medical Genetics Unit, "A. Nocivelli" Institute for Molecular Medicine, Spedali Civili Hospital, Brescia, Italy
| | - Kejian Zhang
- Coyote Bioscience USA Inc., San Jose, CA 95138, USA.,Division of Human Genetics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Anas M Alazami
- Department of Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia.,Saudi Human Genome Program, King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia
| | - A Kerry Dobbs
- Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, MD 20892, USA
| | - Stefania Masneri
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.,Cytogenetic and Medical Genetics Unit, "A. Nocivelli" Institute for Molecular Medicine, Spedali Civili Hospital, Brescia, Italy
| | - Avni Joshi
- Division of Pediatric Allergy and Immunology, Mayo Clinic Children's Center, Rochester, MN, USA
| | | | - Timothy G Myers
- Genomic Technologies Section, NIAID, NIH, Bethesda, MD 20892, USA
| | - Sundar Ganesan
- Research Technologies Branch, DIR, NIAID, NIH, Bethesda, MD 20892, USA
| | - Maria Pia Bondioni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Mai Lan Ho
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Huda Alajlan
- Department of Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | | | - Fanggeng Zou
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA.,GeneDx Inc., Gaithersburg, MD 20877, USA
| | - C Alexander Valencia
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA.,PerkinElmer Genomics, Pittsburgh, PA 15275, USA.,Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,Aperiomics Inc., Sterling, VA 20166, USA
| | - Alexandra H Filipovich
- Cancer and Blood Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Fabio Facchetti
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Bertrand Boisson
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY 10065, USA.,Laboratory of Human Genetics of Infectious Diseases, Necker Branch INSERM, Necker Hospital for Sick Children, Paris, France.,Paris Descartes University, Imagine Institute, Paris, France
| | - Chiara Azzari
- Pediatric Immunology, Department of Health Sciences, University of Florence, Florence, Italy.,Meyer Children's Hospital, Florence, Italy
| | - Bander K Al-Saud
- Alfaisal University, Riyadh, Saudi Arabia.,Department of Pediatrics, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Hamoud Al-Mousa
- Alfaisal University, Riyadh, Saudi Arabia.,Department of Pediatrics, Allergy and Immunology Section, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Jean Laurent Casanova
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY 10065, USA.,Laboratory of Human Genetics of Infectious Diseases, Necker Branch INSERM, Necker Hospital for Sick Children, Paris, France.,Paris Descartes University, Imagine Institute, Paris, France.,Pediatrics Hematology-Immunology Unit, Necker Hospital for Sick Children, Paris, France.,Howard Hughes Medical Institute, New York, NY 10065, USA
| | - Roshini S Abraham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA.,Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH 43205, USA
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, MD 20892, USA.
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26
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Kreins AY, Maio S, Dhalla F. Inborn errors of thymic stromal cell development and function. Semin Immunopathol 2020; 43:85-100. [PMID: 33257998 PMCID: PMC7925491 DOI: 10.1007/s00281-020-00826-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/09/2020] [Indexed: 12/31/2022]
Abstract
As the primary site for T cell development, the thymus is responsible for the production and selection of a functional, yet self-tolerant T cell repertoire. This critically depends on thymic stromal cells, derived from the pharyngeal apparatus during embryogenesis. Thymic epithelial cells, mesenchymal and vascular elements together form the unique and highly specialised microenvironment required to support all aspects of thymopoiesis and T cell central tolerance induction. Although rare, inborn errors of thymic stromal cells constitute a clinically important group of conditions because their immunological consequences, which include autoimmune disease and T cell immunodeficiency, can be life-threatening if unrecognised and untreated. In this review, we describe the molecular and environmental aetiologies of the thymic stromal cell defects known to cause disease in humans, placing particular emphasis on those with a propensity to cause thymic hypoplasia or aplasia and consequently severe congenital immunodeficiency. We discuss the principles underpinning their diagnosis and management, including the use of novel tools to aid in their identification and strategies for curative treatment, principally transplantation of allogeneic thymus tissue.
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Affiliation(s)
- Alexandra Y Kreins
- UCL Great Ormond Street Institute of Child Health, London, UK.,Department of Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Stefano Maio
- Developmental Immunology, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Fatima Dhalla
- Developmental Immunology, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK. .,Department of Clinical Immunology, Oxford University Hospitals, Oxford, UK.
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27
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Abstract
PURPOSE OF REVIEW Transplantation of cultured postnatal allogeneic thymus has been successful for treating athymia, mostly associated with complete DiGeorge syndrome, for more than 20 years. Advances in molecular genetics provide opportunities for widening the range of athymic conditions that can be treated while advances in cell culture and organ/tissue regeneration may offer the prospect of alternative preparations of thymic tissue. There are potential broader applications of this treatment outside congenital athymia. RECENT FINDINGS At the same time as further characterization of the cultured thymus product in terms of thymic epithelial cells and lymphoid composition, preclinical studies have looked at de-novo generation of thymic epithelial cells from stem cells and explored scaffolds for delivering these as three-dimensional structures. In the era of newborn screening for T-cell lymphopaenia, a broadening range of defects leading to athymia is being recognized and new assays should allow differentiation of these from haematopoietic cell defects, pending their genetic/molecular characterization. Evidence suggests that the tolerogenic effect of transplanted thymus could be exploited to improve outcomes after solid organ transplantation. SUMMARY Thymus transplantation, the accepted standard treatment for complete DiGeorge syndrome is also appropriate for other genetic defects leading to athymia. Improved strategies for generating thymus may lead to better outcomes and broader application of this treatment.
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28
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Hoenig M, Roesler J, Seidel MG, Albert MH, Hauck F, Maecker-Kolhoff B, Eiz-Vesper B, Kleinschmidt K, Debatin KM, Jacobsen EM, Furlan I, Suttorp M, Schuetz C, Schulz AS. Matched Family Donor Lymphocyte Infusions as First Cellular Therapy for Patients with Severe Primary T Cell Deficiencies. Transplant Cell Ther 2020; 27:93.e1-93.e8. [PMID: 33022377 DOI: 10.1016/j.bbmt.2020.09.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/03/2020] [Accepted: 09/30/2020] [Indexed: 10/23/2022]
Abstract
Patients with primary immunodeficiencies caused by severe defects in T cell immunity are at risk of acquiring life-threatening infections. Cellular therapies are necessary to establish normal T cell function and to allow for long-term survival. This is most commonly achieved by hematopoietic stem cell transplantation (HSCT), but the outcome of this procedure is impaired if active infections are present at the time of HSCT. Donor lymphocyte infusions (DLIs) are a well-established therapeutic strategy following HSCT to treat viral infections, improve donor cell engraftment, or achieve graft-versus-leukemia activity in malignant disease. Here we present a cohort of 6 patients with primary T cell deficiencies who received transfusions of unselected mature donor lymphocytes prior and not directly related to allogeneic HSCT. DLIs obtained from the peripheral blood of HLA-identical (10/10) family donors were transfused without prior conditioning to treat or prevent life-threatening infections. All patients are alive with a follow-up of 0.5 to 16.5 years after the initial T cell administration. Additional cellular therapies were administered in 5 of 6 patients at 0.8 to 15 months after the first DLI. Mild cutaneous graft-versus-host disease (GVHD, stage ≤2) was observed in 3 of 6 patients and resolved spontaneously. We provide evidence that unselected HLA-identical DLIs can effectively prevent or contribute to overcome infections with a limited risk for GVHD in T cell deficient patients. The T cell system established by this readily available source can provide T cell function for years and can serve as a bridge to additional cellular therapies or, in specific conditions, as definite treatment.
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Affiliation(s)
- Manfred Hoenig
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany.
| | - Joachim Roesler
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Markus G Seidel
- Division of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Michael H Albert
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Fabian Hauck
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany; German Centre for Infection Research (DZIF), Munich, Germany
| | - Britta Maecker-Kolhoff
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Britta Eiz-Vesper
- Institute for Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Katharina Kleinschmidt
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Hospital of Regensburg, Regensburg, Germany
| | | | | | - Ingrid Furlan
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Meinolf Suttorp
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Medical Faculty, Pediatric Hematology-Oncology, TU Dresden, Germany
| | - Catharina Schuetz
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ansgar S Schulz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
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29
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Giardino G, Borzacchiello C, De Luca M, Romano R, Prencipe R, Cirillo E, Pignata C. T-Cell Immunodeficiencies With Congenital Alterations of Thymic Development: Genes Implicated and Differential Immunological and Clinical Features. Front Immunol 2020; 11:1837. [PMID: 32922396 PMCID: PMC7457079 DOI: 10.3389/fimmu.2020.01837] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/08/2020] [Indexed: 02/06/2023] Open
Abstract
Combined Immunodeficiencies (CID) are rare congenital disorders characterized by defective T-cell development that may be associated with B- and NK-cell deficiency. They are usually due to alterations in genes expressed in hematopoietic precursors but in few cases, they are caused by impaired thymic development. Athymia was classically associated with DiGeorge Syndrome due to TBX1 gene haploinsufficiency. Other genes, implicated in thymic organogenesis include FOXN1, associated with Nude SCID syndrome, PAX1, associated with Otofaciocervical Syndrome type 2, and CHD7, one of the genes implicated in CHARGE syndrome. More recently, chromosome 2p11.2 microdeletion, causing FOXI3 haploinsufficiency, has been identified in 5 families with impaired thymus development. In this review, we will summarize the main genetic, clinical, and immunological features related to the abovementioned gene mutations. We will also focus on different therapeutic approaches to treat SCID in these patients.
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Affiliation(s)
- Giuliana Giardino
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
| | - Carla Borzacchiello
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
| | - Martina De Luca
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
| | - Roberta Romano
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
| | - Rosaria Prencipe
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
| | - Emilia Cirillo
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
| | - Claudio Pignata
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
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30
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Michniacki TF, Seth D, Secord E. Severe Combined Immunodeficiency: A Review for Neonatal Clinicians. Neoreviews 2020; 20:e326-e335. [PMID: 31261096 DOI: 10.1542/neo.20-6-e326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The proper development and function of T cells is imperative in the creation of adequate cell-mediated and humoral immunity. Healthy term newborns have baseline immune immaturity, increasing their risk of infections, but significant immunologic consequences can occur, because of abnormal T-cell maturation. Combined immunodeficiencies can result, because B cells and natural killer cells rely on successful interactions with T cells to ensure their proper performance and survival. Severe combined immunodeficiency (SCID) is the most noteworthy of these conditions, leading to considerable early morbidity and often death by the age of 1 year if left untreated. Newborn screening for SCID is effective and allows for early implementation of lifesaving supportive measures, including protective isolation, initiation of prophylactic antimicrobials, caution with blood product transfusions, and avoidance of live vaccinations. Once a definitive diagnosis of SCID has been established, treatment frequently involves bone marrow or stem cell transplantation; however, enzyme replacement and gene therapy are also becoming options in those with SCID due to adenosine deaminase deficiency and other forms of SCID. Neonatal clinicians should understand the screening and diagnostic approach to SCID along with the initial management approaches for these extremely high-risk patients.
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Affiliation(s)
- Thomas F Michniacki
- Pediatrics and Communicable Diseases, Division of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, MI
| | - Divya Seth
- Department of Pediatrics, Division of Allergy, Asthma, & Immunology, Wayne State University, Detroit, MI
| | - Elizabeth Secord
- Department of Pediatrics, Division of Allergy, Asthma, & Immunology, Wayne State University, Detroit, MI
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31
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Bhalla P, Wysocki CA, van Oers NSC. Molecular Insights Into the Causes of Human Thymic Hypoplasia With Animal Models. Front Immunol 2020; 11:830. [PMID: 32431714 PMCID: PMC7214791 DOI: 10.3389/fimmu.2020.00830] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/14/2020] [Indexed: 12/30/2022] Open
Abstract
22q11.2 deletion syndrome (DiGeorge), CHARGE syndrome, Nude/SCID and otofaciocervical syndrome type 2 (OTFCS2) are distinct clinical conditions in humans that can result in hypoplasia and occasionally, aplasia of the thymus. Thymic hypoplasia/aplasia is first suggested by absence or significantly reduced numbers of recent thymic emigrants, revealed in standard-of-care newborn screens for T cell receptor excision circles (TRECs). Subsequent clinical assessments will often indicate whether genetic mutations are causal to the low T cell output from the thymus. However, the molecular mechanisms leading to the thymic hypoplasia/aplasia in diverse human syndromes are not fully understood, partly because the problems of the thymus originate during embryogenesis. Rodent and Zebrafish models of these clinical syndromes have been used to better define the underlying basis of the clinical presentations. Results from these animal models are uncovering contributions of different cell types in the specification, differentiation, and expansion of the thymus. Cell populations such as epithelial cells, mesenchymal cells, endothelial cells, and thymocytes are variably affected depending on the human syndrome responsible for the thymic hypoplasia. In the current review, findings from the diverse animal models will be described in relation to the clinical phenotypes. Importantly, these results are suggesting new strategies for regenerating thymic tissue in patients with distinct congenital disorders.
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Affiliation(s)
- Pratibha Bhalla
- Department of Immunology, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Christian A. Wysocki
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Nicolai S. C. van Oers
- Department of Immunology, The University of Texas Southwestern Medical Center, Dallas, TX, United States
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, United States
- Department of Microbiology, The University of Texas Southwestern Medical Center, Dallas, TX, United States
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32
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Hosaka S, Kobayashi C, Saito H, Imai-Saito A, Suzuki R, Iwabuchi A, Kato Y, Jimbo T, Watanabe N, Onodera M, Imadome KI, Masumoto K, Nanmoku T, Fukushima T, Kosaki K, Sumazaki R, Takada H. Establishment of immunity against Epstein-Barr virus infection in a patient with CHARGE/complete DiGeorge syndrome after peripheral blood lymphocyte transfusion. Pediatr Transplant 2019; 23:e13424. [PMID: 31033123 DOI: 10.1111/petr.13424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 01/23/2019] [Accepted: 03/27/2019] [Indexed: 11/28/2022]
Abstract
CHARGE syndrome is a rare congenital malformation syndrome which may share symptoms with DiGeorge syndrome. Complete DiGeorge syndrome (cDGS) is a severe form of DiGeorge syndrome, characterized by a CD3+ T-cell count of <50/mm3 due to athymia, and is fatal without immunologic intervention. We performed peripheral blood lymphocyte transfusion (PBLT) from an HLA-identical sibling without pretransplant conditioning in a CHARGE/cDGS patient with a novel CHD7 splice site mutation. Cyclosporine and short-term methotrexate were used for graft versus host disease (GVHD) prophylaxis, and neither acute nor chronic GVHD was observed. After PBLT, T-cell proliferative response to phytohemagglutinin and concanavalin A recovered, and intractable diarrhea improved. EBV infection, evidenced by a gradual increase in the viral genome copy number to a maximum of 2861 copies/μgDNA on day 42 after PBLT, resolved spontaneously. HLA A2402 restricted, EBV-specific CTLs were detected from peripheral blood on day 148, and EBV seroconversion was observed on day 181. Thus, EBV-specific immunity was successfully established by PBLT. Our results indicate that PBLT is a simple and effective therapy to reconstitute immune systems in CHARGE/DiGeorge syndrome.
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Affiliation(s)
- Sho Hosaka
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan
| | - Chie Kobayashi
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan.,Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hirota Saito
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan
| | - Ayako Imai-Saito
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan
| | - Ryoko Suzuki
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan.,Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Atsushi Iwabuchi
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan.,Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yoshiaki Kato
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan.,Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Takahiro Jimbo
- Department of Pediatric Surgery, University of Tsukuba Hospital, Tsukuba, Japan
| | - Nobuyuki Watanabe
- Department of Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Masafumi Onodera
- Department of Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Ken-Ichi Imadome
- Department of Advanced Medicine for Infections, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Kouji Masumoto
- Department of Pediatric Surgery, University of Tsukuba Hospital, Tsukuba, Japan
| | - Toru Nanmoku
- Department of Laboratory Medicine, University of Tsukuba Hospital, Tsukuba, Japan
| | - Takashi Fukushima
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan.,Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kenjiro Kosaki
- Center for Medical Genetics, Keio University School of Medicine, Shinjuku, Japan
| | - Ryo Sumazaki
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan.,Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hidetoshi Takada
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan.,Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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33
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Deola S, Guerrouahen BS, Sidahmed H, Al-Mohannadi A, Elnaggar M, Elsadig R, Abdelalim EM, Petrovski G, Gadina M, Thrasher A, Wels WS, Hunger SP, Wang E, Marincola FM, Maccalli C, Cugno C. Tailoring cells for clinical needs: Meeting report from the Advanced Therapy in Healthcare symposium (October 28-29 2017, Doha, Qatar). J Transl Med 2018; 16:276. [PMID: 30305089 PMCID: PMC6180452 DOI: 10.1186/s12967-018-1652-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 10/01/2018] [Indexed: 02/07/2023] Open
Abstract
New technologies and therapies designed to facilitate development of personalized treatments are rapidly emerging in the field of biomedicine. Strikingly, the goal of personalized medicine refined the concept of therapy by developing cell-based therapies, the so-called “living drugs”. Breakthrough advancements were achieved in this regard in the fields of gene therapy, cell therapy, tissue-engineered products and advanced therapeutic techniques. The Advanced Therapies in Healthcare symposium, organized by the Clinical Research Center Department of Sidra Medicine, in Doha, Qatar (October 2017), brought together world-renowned experts from the fields of oncology, hematology, immunology, inflammation, autoimmune disorders, and stem cells to offer a comprehensive picture of the status of worldwide advanced therapies in both pre-clinical and clinical development, providing insights to the research phase, clinical data and regulatory aspects of these therapies. Highlights of the meeting are provided in this meeting report.
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Affiliation(s)
- Sara Deola
- Research Department, Clinical Research Center, Sidra Medicine, Doha, Qatar
| | | | - Heba Sidahmed
- Research Department, Clinical Research Center, Sidra Medicine, Doha, Qatar
| | - Anjud Al-Mohannadi
- Research Department, Clinical Research Center, Sidra Medicine, Doha, Qatar
| | - Muhammad Elnaggar
- Research Department, Clinical Research Center, Sidra Medicine, Doha, Qatar
| | - Ramaz Elsadig
- Research Department, Clinical Research Center, Sidra Medicine, Doha, Qatar
| | - Essam M Abdelalim
- Diabetes Research Center, Qatar Biomedical Research Institute, Hamad Bin Khalifa University, Qatar Foundation, Education City, Doha, Qatar
| | | | | | - Adrian Thrasher
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Winfried S Wels
- Georg Speyer Haus, Institute for Tumor Biology and Experimental Therapy, Frankfurt, Germany
| | | | - Ena Wang
- Immune Oncology Discovery and System Biology, AbbVie, Redwood City, CA, USA
| | | | | | - Cristina Maccalli
- Research Department, Clinical Research Center, Sidra Medicine, Doha, Qatar
| | - Chiara Cugno
- Research Department, Clinical Research Center, Sidra Medicine, Doha, Qatar.
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34
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Severe Congenital Neutropenia associated with SRP54 mutation in 22q11.2 Deletion Syndrome: Hematopoietic Stem Cell Transplantation Results in Correction of Neutropenia with Adequate Immune Reconstitution. J Clin Immunol 2018; 38:546-549. [PMID: 29956078 DOI: 10.1007/s10875-018-0518-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/28/2018] [Indexed: 01/05/2023]
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35
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Gallo V, Cirillo E, Giardino G, Pignata C. FOXN1 Deficiency: from the Discovery to Novel Therapeutic Approaches. J Clin Immunol 2017; 37:751-758. [DOI: 10.1007/s10875-017-0445-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/11/2017] [Indexed: 01/10/2023]
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36
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Davies EG, Cheung M, Gilmour K, Maimaris J, Curry J, Furmanski A, Sebire N, Halliday N, Mengrelis K, Adams S, Bernatoniene J, Bremner R, Browning M, Devlin B, Erichsen HC, Gaspar HB, Hutchison L, Ip W, Ifversen M, Leahy TR, McCarthy E, Moshous D, Neuling K, Pac M, Papadopol A, Parsley KL, Poliani L, Ricciardelli I, Sansom DM, Voor T, Worth A, Crompton T, Markert ML, Thrasher AJ. Thymus transplantation for complete DiGeorge syndrome: European experience. J Allergy Clin Immunol 2017; 140:1660-1670.e16. [PMID: 28400115 PMCID: PMC5716670 DOI: 10.1016/j.jaci.2017.03.020] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 03/03/2017] [Accepted: 03/15/2017] [Indexed: 12/17/2022]
Abstract
Background Thymus transplantation is a promising strategy for the treatment of athymic complete DiGeorge syndrome (cDGS). Methods Twelve patients with cDGS underwent transplantation with allogeneic cultured thymus. Objective We sought to confirm and extend the results previously obtained in a single center. Results Two patients died of pre-existing viral infections without having thymopoiesis, and 1 late death occurred from autoimmune thrombocytopenia. One infant had septic shock shortly after transplantation, resulting in graft loss and the need for a second transplant. Evidence of thymopoiesis developed from 5 to 6 months after transplantation in 10 patients. Median circulating naive CD4 counts were 44 × 106/L (range, 11-440 × 106/L) and 200 × 106/L (range, 5-310 × 106/L) at 12 and 24 months after transplantation and T-cell receptor excision circles were 2,238/106 T cells (range, 320-8,807/106 T cells) and 4,184/106 T cells (range, 1,582-24,596/106 T cells). Counts did not usually reach normal levels for age, but patients were able to clear pre-existing infections and those acquired later. At a median of 49 months (range, 22-80 months), 8 have ceased prophylactic antimicrobials, and 5 have ceased immunoglobulin replacement. Histologic confirmation of thymopoiesis was seen in 7 of 11 patients undergoing biopsy of transplanted tissue, including 5 showing full maturation through to the terminal stage of Hassall body formation. Autoimmune regulator expression was also demonstrated. Autoimmune complications were seen in 7 of 12 patients. In 2 patients early transient autoimmune hemolysis settled after treatment and did not recur. The other 5 experienced ongoing autoimmune problems, including thyroiditis (3), hemolysis (1), thrombocytopenia (4), and neutropenia (1). Conclusions This study confirms the previous reports that thymus transplantation can reconstitute T cells in patients with cDGS but with frequent autoimmune complications in survivors.
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Affiliation(s)
- E Graham Davies
- Infection, Immunity and Inflammation Theme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Immunology, Great Ormond Street Hospital, London, United Kingdom.
| | - Melissa Cheung
- Infection, Immunity and Inflammation Theme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Kimberly Gilmour
- Department of Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Jesmeen Maimaris
- Infection, Immunity and Inflammation Theme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Joe Curry
- Department of Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Anna Furmanski
- Infection, Immunity and Inflammation Theme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; School of Life Sciences, University of Bedfordshire, Luton, United Kingdom
| | - Neil Sebire
- Department of Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Neil Halliday
- Institute of Immunity and Transplantation, Division of Infection & Immunity, School of Life and Medical Sciences, Royal Free Hospital, University College London, London, United Kingdom
| | - Konstantinos Mengrelis
- Infection, Immunity and Inflammation Theme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Stuart Adams
- Department of Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Jolanta Bernatoniene
- Department of Paediatric Immunology and Infectious Diseases, Bristol Children's Hospital, Bristol, United Kingdom
| | - Ronald Bremner
- Department of Gastroenterology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Michael Browning
- Department of Immunology, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Blythe Devlin
- Division of Allergy and Immunology, Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Hans Christian Erichsen
- Division of Paediatric and Adolescent Medicine, Section of Paediatric Medicine and Transplantation, Oslo University Hospital, Oslo, Norway
| | - H Bobby Gaspar
- Infection, Immunity and Inflammation Theme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Lizzie Hutchison
- Department of Paediatric Immunology and Infectious Diseases, Bristol Children's Hospital, Bristol, United Kingdom
| | - Winnie Ip
- Infection, Immunity and Inflammation Theme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Marianne Ifversen
- Paediatric Clinic II, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - T Ronan Leahy
- Department of Paediatric Immunology and Infectious Diseases, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Elizabeth McCarthy
- Division of Allergy and Immunology, Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Despina Moshous
- Paediatric Immunology, Haematology and Rheumatology Unit, Hopital Necker, Paris, France
| | - Kim Neuling
- Department of Paediatrics, University Hospital, Coventry, United Kingdom
| | - Malgorzata Pac
- Department of Immunology, Children's Memorial Health Institute, Warsaw, Poland
| | - Alina Papadopol
- Paediatric Clinic, Polyclinic Regina Maria Baneasa, Bucharest, Romania
| | - Kathryn L Parsley
- Infection, Immunity and Inflammation Theme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Luigi Poliani
- Institute of Immunity and Translational Medicine, University of Brescia, Brescia, Italy
| | - Ida Ricciardelli
- Infection, Immunity and Inflammation Theme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - David M Sansom
- Institute of Immunity and Transplantation, Division of Infection & Immunity, School of Life and Medical Sciences, Royal Free Hospital, University College London, London, United Kingdom
| | - Tiia Voor
- The Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Austen Worth
- Infection, Immunity and Inflammation Theme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Tessa Crompton
- Infection, Immunity and Inflammation Theme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - M Louise Markert
- Department of Immunology, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Adrian J Thrasher
- Infection, Immunity and Inflammation Theme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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Rota IA, Dhalla F. FOXN1 deficient nude severe combined immunodeficiency. Orphanet J Rare Dis 2017; 12:6. [PMID: 28077132 PMCID: PMC5225657 DOI: 10.1186/s13023-016-0557-1] [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: 10/06/2016] [Accepted: 12/15/2016] [Indexed: 12/13/2022] Open
Abstract
Nude severe combined immunodeficiency is a rare inherited disease caused by autosomal recessive loss-of-function mutations in FOXN1. This gene encodes a transcription factor essential for the development of the thymus, the primary lymphoid organ that supports T-cell development and selection. To date nine cases have been reported presenting with the clinical triad of absent thymus resulting in severe T-cell immunodeficiency, congenital alopecia universalis and nail dystrophy. Diagnosis relies on testing for FOXN1 mutations, which allows genetic counselling and guides therapeutic management. Options for treating the underlying immune deficiency include HLA-matched genoidentical haematopoietic cell transplantation containing mature donor T-cells or thymus tissue transplantation. Experience from other severe combined immune deficiency syndromes suggests that early diagnosis, supportive care and definitive management result in better patient outcomes. Without these the prognosis is poor due to early-onset life threatening infections.
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Affiliation(s)
- Ioanna A Rota
- Developmental Immunology Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Fatima Dhalla
- Developmental Immunology Group, Department of Paediatrics, University of Oxford, Oxford, UK. .,Department of Clinical Immunology, Oxford University Hospitals, Oxford, UK.
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Wu EY, Ehrlich L, Handly B, Frush DP, Buckley RH. Clinical and imaging considerations in primary immunodeficiency disorders: an update. Pediatr Radiol 2016; 46:1630-1644. [PMID: 27655432 PMCID: PMC5083248 DOI: 10.1007/s00247-016-3684-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/20/2016] [Accepted: 08/02/2016] [Indexed: 01/16/2023]
Abstract
Primary immunodeficiencies are a group of genetically determined disorders with diverse presentations. The purpose of this review is to provide a practical and brief description of a select number of these diseases and to discuss the important role the radiologist can have in making an early diagnosis and in detecting and following disease complications. The role of diagnostic imaging and informed performance and interpretation are vital in the diagnosis, surveillance and management of all primary immunodeficiency disorders.
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Affiliation(s)
- Eveline Y Wu
- Department of Pediatrics, University of North Carolina at Chapel Hill, 030 MacNider Hall, CB#7231, Chapel Hill, NC, 27599, USA.
| | - Lauren Ehrlich
- Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Brian Handly
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald P Frush
- Division of Pediatric Radiology, Duke University Medical Center, Durham, NC, USA
| | - Rebecca H Buckley
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA.,Department of Immunology, Duke University School of Medicine, Durham, NC, USA
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Abstract
Severe combined immunodeficiency disorders represent pediatric emergencies due to absence of adaptive immune responses to infections. The conditions result from either intrinsic defects in T-cell development (ie, severe combined immunodeficiency disease [SCID]) or congenital athymia (eg, complete DiGeorge anomaly). Hematopoietic stem cell transplant provides the only clinically approved cure for SCID, although gene therapy research trials are showing significant promise. For greatest survival, patients should undergo transplant before 3.5 months of age and before the onset of infections. Newborn screening programs have yielded successful early identification and treatment of infants with SCID and congenital athymia in the United States.
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Booth C, Silva J, Veys P. Stem cell transplantation for the treatment of immunodeficiency in children: current status and hopes for the future. Expert Rev Clin Immunol 2016; 12:713-23. [PMID: 26882211 DOI: 10.1586/1744666x.2016.1150177] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Primary immunodeficiencies (PID) are rare inherited disorders affecting immune function and can be life-threatening if not treated. Haematopoietic stem cell transplantation (HSCT) offers a curative approach for many of these disorders and gene therapy is increasingly used as an alternative therapeutic strategy for patients lacking a suitable donor. Early diagnosis, improved supportive care and advances in gene and cell therapies have resulted in increased survival rates and improved quality of life. This review describes current strategies employed to improve outcomes in PID, focusing on new developments in HSCT, gene and cell therapy. We also address the challenges associated with newborn screening (NBS) programmes and novel mutations identified through improved diagnostic technology.
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Affiliation(s)
- Claire Booth
- a Department of Paediatric Immunology , Great Ormond Street Hospital , London , UK
| | - Juliana Silva
- b Department of Bone Marrow Transplantation , Great Ormond Street Hospital , London , UK
| | - Paul Veys
- b Department of Bone Marrow Transplantation , Great Ormond Street Hospital , London , UK
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The crossroads of autoimmunity and immunodeficiency: Lessons from polygenic traits and monogenic defects. J Allergy Clin Immunol 2016; 137:3-17. [DOI: 10.1016/j.jaci.2015.11.004] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 01/16/2023]
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Abstract
Primary immunodeficiencies are rare, inborn errors that result in impaired, disordered or uncontrolled immune responses. Whilst symptomatic and prophylactic treatment is available, hematopoietic stem cell transplantation is an option for many diseases, leading to cure of the immunodeficiency and establishing normal physical and psychological health. Newborn screening for some diseases, whilst improving outcomes, is focusing research on safer and less toxic treatment strategies, which result in durable and sustainable immune function without adverse effects. New conditioning regimens have reduced the risk of hematopoietic stem cell transplantation, and new methods of manipulating stem cell sources should guarantee a donor for almost all patients. Whilst incremental enhancements in transplantation technique have gradually improved survival outcomes over time, some of these new applications are likely to radically alter our approach to treating primary immunodeficiencies.
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Affiliation(s)
- Andrew Gennery
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Childrens' Hospital, Newcastle upon Tyne, UK
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Hagin D, Burroughs L, Torgerson TR. Hematopoietic Stem Cell Transplant for Immune Deficiency and Immune Dysregulation Disorders. Immunol Allergy Clin North Am 2015; 35:695-711. [DOI: 10.1016/j.iac.2015.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Dvorak CC, Hassan A, Slatter MA, Hönig M, Lankester AC, Buckley RH, Pulsipher MA, Davis JH, Güngör T, Gabriel M, Bleesing JH, Bunin N, Sedlacek P, Connelly JA, Crawford DF, Notarangelo LD, Pai SY, Hassid J, Veys P, Gennery AR, Cowan MJ. Comparison of outcomes of hematopoietic stem cell transplantation without chemotherapy conditioning by using matched sibling and unrelated donors for treatment of severe combined immunodeficiency. J Allergy Clin Immunol 2014; 134:935-943.e15. [PMID: 25109802 PMCID: PMC4186906 DOI: 10.1016/j.jaci.2014.06.021] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 06/18/2014] [Accepted: 06/20/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with severe combined immunodeficiency disease who have matched sibling donors (MSDs) can proceed to hematopoietic cell transplantation (HCT) without conditioning chemotherapy. OBJECTIVE We sought to determine whether the results of HCT without chemotherapy-based conditioning from matched unrelated donors (URDs), either from volunteer adults or umbilical cord blood, are comparable with those from MSDs. METHODS We performed a multicenter survey of severe combined immunodeficiency transplantation centers in North America, Europe, and Australia to compile retrospective data on patients who have undergone unconditioned HCT from either URDs (n = 37) or MSDs (n = 66). RESULTS Most patients undergoing URD HCT (92%) achieved donor T-cell engraftment compared with 97% for those with MSDs; however, estimated 5-year overall and event-free survival were worse for URD recipients (71% and 60%, respectively) compared with MSD recipients (92% and 89%, respectively; P < .01 for both). URD recipients who received pre-HCT serotherapy had similar 5-year overall survival (100%) to MSD recipients. The incidences of grade II to IV acute and chronic graft-versus-host disease were higher in URD (50% and 39%, respectively) compared with MSD (22% and 5%, respectively) recipients (P < .01 for both). In the surviving patients there was no difference in T-cell reconstitution at the last follow-up between the URD and MSD recipients; however, MSD recipients were more likely to achieve B-cell reconstitution (72% vs 17%, P < .001). CONCLUSION Unconditioned URD HCT achieves excellent rates of donor T-cell engraftment similar to that seen in MSD recipients, and reconstitution rates are adequate. However, only a minority will have myeloid and B-cell reconstitution, and attention must be paid to graft-versus-host disease prophylaxis. This approach might be safer in children ineligible for intense regimens to spare the potential complications of chemotherapy.
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Affiliation(s)
- Christopher C. Dvorak
- Division of Pediatric Allergy, Immunology, and Blood and Marrow Transplant, Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA
| | - Amel Hassan
- Centre for Immunodeficiency, Molecular Immunology Unit, UCL Institute of Child Health, London, UK
| | - Mary A. Slatter
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Manfred Hönig
- Department of Pediatrics, University Medical Center, Ulm, Germany
| | - Arjan C. Lankester
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Rebecca H. Buckley
- Departments of Pediatrics & Immunology, Duke University Medical Center, Chapel Hill, NC
| | - Michael A. Pulsipher
- Division of Hematology and Hematologic Malignancies, Primary Children’s Hospital, University of Utah School of Medicine/Huntsman Cancer Institute, Salt Lake City, UT
| | - Jeffrey H. Davis
- Hematology/Oncology/BMT Program, British Columbia Children’s Hospital, Vancouver, Canada
| | - Tayfun Güngör
- University Children’s Hospital, Stem Cell Transplantation Department, Zürich, Switzerland
| | - Melissa Gabriel
- Oncology Department, The Children’s Hospital at Westmead, Westmead, Australia
| | - Jacob H. Bleesing
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Nancy Bunin
- Division of Oncology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Petr Sedlacek
- Department of Pediatric Hematology and Oncology, Teaching Hospital Motol, Prague, Czech Republic
| | - James A. Connelly
- Division of Pediatric Hematology-Oncology, University of Michigan, Ann Arbor, MI
| | | | - Luigi D. Notarangelo
- Division of Immunology and The Manton Center for Orphan Disease Research, Children’s Hospital Boston, Harvard Medical School
| | - Sung-Yun Pai
- Division of Hematology and Oncology, Boston Children’s Hospital, and Department of Pediatric Oncology, Dana-Farber Cancer Institute
| | - Jake Hassid
- Division of Pediatric Allergy, Immunology, and Blood and Marrow Transplant, Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA
| | - Paul Veys
- Centre for Immunodeficiency, Molecular Immunology Unit, UCL Institute of Child Health, London, UK
| | - Andrew R. Gennery
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Morton J. Cowan
- Division of Pediatric Allergy, Immunology, and Blood and Marrow Transplant, Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA
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Clinical course and outcome predictors of critically ill infants with complete DiGeorge anomaly following thymus transplantation. Pediatr Crit Care Med 2014; 15:e321-6. [PMID: 25068252 PMCID: PMC4156516 DOI: 10.1097/pcc.0000000000000219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To identify risk factors for PICU admission and mortality of infants with complete DiGeorge anomaly treated with thymus transplantation. We hypothesized that age at transplantation and the presence of congenital heart disease would be risk factors for emergent PICU admission, and these factors plus development of septicemia would increase morbidity and mortality. DESIGN Retrospective review. SETTING Academic medical-surgical PICU. PATIENTS All infants with complete DiGeorge anomaly treated with thymus transplantation between January 1, 1993, and July 1, 2010. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Consent was obtained from 71 infants with complete DiGeorge anomaly for thymus transplantation, and 59 infants were transplanted. Median age at transplantation was 5.0 months (range, 1.1-22.1 mo). After transplantation, 12 of 59 infants (20%) required 25 emergent PICU admissions. Seven of 12 infants (58%) survived to PICU discharge with six surviving 6 months posttransplantation. Forty-two of 59 infants (71%) transplanted had congenital heart disease, and 9 of 12 (75%) who were admitted to the PICU had congenital heart disease. In 15 of 25 admissions (60%), intubation and mechanical ventilation were necessary. There was no difference between median ventilation-free days between infants with and without congenital heart disease (33 d vs 23 d, p = 0.544). There was also no correlation between ventilation-free days and age of transplantation (R, 0.17; p = 0.423). Age at transplantation and the presence of congenital heart disease were not associated with risk for PICU admission (odds ratio, 0.95; 95% CI, 0.78-1.15 and odds ratio, 1.27; 95% CI, 0.30-5.49, respectively) or PICU mortality (odds ratio, 0.98; 95% CI, 0.73-1.31 and odds ratio, 0.40; 95% CI, 0.15-1.07, respectively). CONCLUSIONS Most transplanted infants did not require emergent PICU admission. Age at transplantation and the presence of congenital heart disease were not associated with PICU admission or mortality.
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Abstract
PURPOSE OF REVIEW 22q11 deletion syndrome is the most common genetic abnormality. More patients are surviving cardiac surgery, and many do not have cardiac anomalies. Adult patients are now being described. It is important for paediatricians, and increasingly adult physicians, to be aware of the optimum management of these patients. RECENT FINDINGS Three main immunological patterns are recognized, namely, athymic and incomplete 22q11 deletion syndrome and autoimmunity. Newborn screening for severe combined immunodeficiency detects athymic patients, although diagnosis may be complicated, and instructive cases are described. Incomplete 22q11 deletion syndrome is the most common presentation; new findings predict which patients are likely to experience significant infection. B lymphocyte deficiencies are often overlooked. Data regarding autoimmunity in adult patients is reported, as well as newly reported immunological findings. Finally, management guidelines are now published, and these are highlighted. SUMMARY Newborn screening detects patients with athymic 22q11 deletion syndrome, but significant illness may complicate the picture, and dual diagnoses can confound treatment. Treatment options for these patients are becoming clearer. Hypoparathyroidism is associated with more severe infection, and immunoglobulin abnormalities are more common than previously recognized. Adult patients are symptomatic and management guidelines will help general physicians in managing these patients.
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Kuruvilla M, de la Morena MT. Antibiotic Prophylaxis in Primary Immune Deficiency Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:573-82. [DOI: 10.1016/j.jaip.2013.09.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 09/10/2013] [Accepted: 09/23/2013] [Indexed: 12/31/2022]
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Davies EG. Immunodeficiency in DiGeorge Syndrome and Options for Treating Cases with Complete Athymia. Front Immunol 2013; 4:322. [PMID: 24198816 PMCID: PMC3814041 DOI: 10.3389/fimmu.2013.00322] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 09/23/2013] [Indexed: 11/13/2022] Open
Abstract
The commonest association of thymic stromal deficiency resulting in T-cell immunodeficiency is the DiGeorge syndrome (DGS). This results from abnormal development of the third and fourth pharyngeal arches and is most commonly associated with a microdeletion at chromosome 22q11 though other genetic and non-genetic causes have been described. The immunological competence of affected individuals is highly variable, ranging from normal to a severe combined immunodeficiency when there is complete athymia. In the most severe group, correction of the immunodeficiency can be achieved using thymus allografts which can support thymopoiesis even in the absence of donor-recipient matching at the major histocompatibility loci. This review focuses on the causes of DGS, the immunological features of the disorder, and the approaches to correction of the immunodeficiency including the use of thymus transplantation.
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Affiliation(s)
- E Graham Davies
- Centre for Immunodeficiency, Institute of Child Health, University College London and Great Ormond Street Hospital , London , UK
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Maggadottir SM, Sullivan KE. The diverse clinical features of chromosome 22q11.2 deletion syndrome (DiGeorge syndrome). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:589-94. [PMID: 24565705 DOI: 10.1016/j.jaip.2013.08.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/24/2013] [Accepted: 08/06/2013] [Indexed: 01/15/2023]
Abstract
A 2-year-old boy with chromosome 22q11.2 deletion syndrome was referred for recurrent sinopulmonary infections. He was diagnosed shortly after birth by a fluorescence in situ hybridization test that was performed due to interrupted aortic arch type B. He had no hypocalcemia, and his recovery from cardiac repair was uneventful. He had difficulty feeding and gained weight slowly, but, otherwise, there were no concerns during his first year of life. At 15 months of age, he began to develop significant otitis media and bronchitis. He was hospitalized once for pneumonia at 18 months of age and has never been off antibiotics for more than 1 week since then. He has not had any previous immunologic evaluation. Recurrent sinopulmonary infections in a child with chromosome 22q11.2 deletion syndrome can have the same etiologies as in any other child. Atopy, anatomic issues, cystic fibrosis, and new environmental exposures could be considered in this setting. Early childhood can be problematic for patients with chromosome 22q11.2 deletion syndrome due to unfavorable drainage of the middle ear and sinuses. Atopy occurs at a higher frequency in 22q11.2 deletion syndrome, and these children also have a higher rate of gastroesophageal reflux and aspiration than the general population. As would be appropriate for any child who presents with recurrent infections at 2 years of age, an immunologic evaluation should be performed. In this review, we will highlight recent findings and new data on the management of children and adults with chromosome 22q11.2 deletion syndrome.
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Affiliation(s)
| | - Kathleen E Sullivan
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pa.
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Ip W, Zhan H, Gilmour KC, Davies EG, Qasim W. 22q11.2 deletion syndrome with life-threatening adenovirus infection. J Pediatr 2013; 163:908-10. [PMID: 23660376 DOI: 10.1016/j.jpeds.2013.03.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 02/14/2013] [Accepted: 03/25/2013] [Indexed: 12/17/2022]
Abstract
Adenovirus causes significant morbidity and mortality in immunocompromised children. We report how an infusion of HLA-matched sibling donor T lymphocytes rapidly eradicated life-threatening, high-level adenoviremia in a child with complete DiGeorge syndrome (22q11.2 deletion) who went on to reconstitute a diverse, donor-derived, postthymic T-cell repertoire.
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Affiliation(s)
- Winnie Ip
- Molecular Immunology Unit, Institute of Child Health, University College London, London, United Kingdom.
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