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Ameratunga R, Woon ST, Leung E, Lea E, Chan L, Mehrtens J, Longhurst HJ, Steele R, Lehnert K, Lindsay K. The autoimmune rheumatological presentation of Common Variable Immunodeficiency Disorders with an overview of genetic testing. Semin Arthritis Rheum 2024; 65:152387. [PMID: 38330740 DOI: 10.1016/j.semarthrit.2024.152387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/06/2024] [Accepted: 01/16/2024] [Indexed: 02/10/2024]
Abstract
Primary immunodeficiency Disorders (PIDS) are rare, mostly monogenetic conditions which can present to a number of specialties. Although infections predominate in most PIDs, some individuals can manifest autoimmune or inflammatory sequelae as their initial clinical presentation. Identifying patients with PIDs can be challenging, as some can present later in life. This is often seen in patients with Common Variable Immunodeficiency Disorders (CVID), where symptoms can begin in the sixth or even seventh decades of life. Some patients with PIDs including CVID can initially present to rheumatologists with autoimmune musculoskeletal manifestations. It is imperative for these patients to be identified promptly as immunosuppression could lead to life-threatening opportunistic infections in these immunocompromised individuals. These risks could be mitigated by prior treatment with subcutaneous or intravenous (SCIG/IVIG) immunoglobulin replacement or prophylactic antibiotics. Importantly, many of these disorders have an underlying genetic defect. Individualized treatments may be available for the specific mutation, which may obviate or mitigate the need for hazardous broad-spectrum immunosuppression. Identification of the genetic defect has profound implications not only for the patient but also for affected family members, who may be at risk of symptomatic disease following an environmental trigger such as a viral infection. Finally, there may be clinical clues to the underlying PID, such as recurrent infections, the early presentation of severe or multiple autoimmune disorders, as well as a relevant family history. Early referral to a clinical immunologist will facilitate appropriate diagnostic evaluation and institution of treatment such as SCIG/IVIG immunoglobulin replacement. This review comprises three sections; an overview of PIDs, focusing on CVID, secondly genetic testing of PIDs and finally the clinical presentation of these disorders to rheumatologists.
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Affiliation(s)
- Rohan Ameratunga
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand.
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Euphemia Leung
- Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand; Auckland Cancer Society Research Centre, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Edward Lea
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
| | - Lydia Chan
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
| | - James Mehrtens
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
| | - Hilary J Longhurst
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Richard Steele
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Respiratory Medicine, Wellington Hospital, Wellington, New Zealand
| | - Klaus Lehnert
- Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand; Applied Translational Genetics, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Karen Lindsay
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
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Ameratunga R, Leung E, Woon ST, Lea E, Allan C, Chan L, Longhurst H, Steele R, Snell R, Lehnert K. Challenges for gene editing in common variable immunodeficiency disorders: Current and future prospects. Clin Immunol 2024; 258:109854. [PMID: 38013164 DOI: 10.1016/j.clim.2023.109854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/09/2023] [Accepted: 09/21/2023] [Indexed: 11/29/2023]
Abstract
The original CRISPR Cas9 gene editing system and subsequent innovations offers unprecedented opportunities to correct severe genetic defects including those causing Primary Immunodeficiencies (PIDs). Common Variable Immunodeficiency Disorders (CVID) are the most frequent symptomatic PID in adults and children. Unlike many other PIDs, patients meeting CVID criteria do not have a definable genetic defect and cannot be considered to have an inborn error of immunity (IEI). Patients with a CVID phenotype carrying a causative mutation are deemed to have a CVID-like disorder consequent to an IEI. Patients from consanguineous families often have highly penetrant early-onset autosomal recessive forms of CVID-like disorders. Individuals from non-consanguineous families may have autosomal dominant CVID-like disorders with variable penetrance and expressivity. This essay explores the potential clinical utility as well as the current limitations and risks of gene editing including collateral genotoxicity. In the immediate future the main application of this technology is likely to be the in vitro investigation of epigenetic and polygenic mechanisms, which are likely to underlie many cases of CVID and CVID-like disorders. In the longer-term, the CRISPR Cas9 system and other gene-based therapies could be utilized to treat CVID-like disorders, where the underlying IEI is known.
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Affiliation(s)
- Rohan Ameratunga
- Department of Clinical Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand.
| | - Euphemia Leung
- Maurice Wilkins Centre, Applied Translational Genetics, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand; Auckland Cancer Society Research Centre, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Edward Lea
- Department of Clinical Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
| | - Caroline Allan
- Department of Clinical Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
| | - Lydia Chan
- Department of Clinical Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
| | - Hilary Longhurst
- Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Richard Steele
- Department of Clinical Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Respiratory Medicine, Wellington Hospital, Wellington, New Zealand
| | - Russell Snell
- Maurice Wilkins Centre, Applied Translational Genetics, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand; Applied Translational Genetics, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Klaus Lehnert
- Maurice Wilkins Centre, Applied Translational Genetics, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand; Applied Translational Genetics, School of Biological Sciences, University of Auckland, Auckland, New Zealand
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Ameratunga R, Edwards ESJ, Lehnert K, Leung E, Woon ST, Lea E, Allan C, Chan L, Steele R, Longhurst H, Bryant VL. The Rapidly Expanding Genetic Spectrum of Common Variable Immunodeficiency-Like Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1646-1664. [PMID: 36796510 DOI: 10.1016/j.jaip.2023.01.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/21/2023] [Accepted: 01/27/2023] [Indexed: 02/16/2023]
Abstract
The understanding of common variable immunodeficiency disorders (CVID) is in evolution. CVID was previously a diagnosis of exclusion. New diagnostic criteria have allowed the disorder to be identified with greater precision. With the advent of next-generation sequencing (NGS), it has become apparent that an increasing number of patients with a CVID phenotype have a causative genetic variant. If a pathogenic variant is identified, these patients are removed from the overarching diagnosis of CVID and are deemed to have a CVID-like disorder. In populations where consanguinity is more prevalent, the majority of patients with severe primary hypogammaglobulinemia will have an underlying inborn error of immunity, usually an early-onset autosomal recessive disorder. In nonconsanguineous societies, pathogenic variants are identified in approximately 20% to 30% of patients. These are often autosomal dominant mutations with variable penetrance and expressivity. To add to the complexity of CVID and CVID-like disorders, some genetic variants such as those in TNFSF13B (transmembrane activator calcium modulator cyclophilin ligand interactor) predispose to, or enhance, disease severity. These variants are not causative but can have epistatic (synergistic) interactions with more deleterious mutations to worsen disease severity. This review is a description of the current understanding of genes associated with CVID and CVID-like disorders. This information will assist clinicians in interpreting NGS reports when investigating the genetic basis of disease in patients with a CVID phenotype.
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Affiliation(s)
- Rohan Ameratunga
- Department of Clinical immunology, Auckland Hospital, Auckland, New Zealand; Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Emily S J Edwards
- The Jeffrey Modell Diagnostic and Research Centre for Primary Immunodeficiencies, and Allergy and Clinical Immunology Laboratory, Department of Immunology, Monash University, Melbourne, VIC, Australia
| | - Klaus Lehnert
- Applied Translational Genetics Group, School of Biological Sciences, University of Auckland, Auckland, New Zealand; Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Euphemia Leung
- Auckland Cancer Society Research Centre, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
| | - Edward Lea
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
| | - Caroline Allan
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
| | - Lydia Chan
- Department of Clinical immunology, Auckland Hospital, Auckland, New Zealand
| | - Richard Steele
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand; Department of Respiratory Medicine, Wellington Hospital, Wellington, New Zealand
| | - Hilary Longhurst
- Department of Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Vanessa L Bryant
- Department of Immunology, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia; Department of Clinical Immunology and Allergy, Royal Melbourne Hospital, Parkville, VIC, Australia
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Zampella J, Cohen B. Consideration of underlying immunodeficiency in refractory or recalcitrant warts: A review of the literature. SKIN HEALTH AND DISEASE 2022; 2:e98. [PMID: 35665206 PMCID: PMC9060099 DOI: 10.1002/ski2.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/12/2022] [Accepted: 01/16/2022] [Indexed: 11/16/2022]
Abstract
Although the exact mechanisms have yet to be elucidated, it is clear that cellular immunity plays a role in clearance of human papillomavirus (HPV) infections as it relates to the development of warts. Patients with extensive, recalcitrant, or treatment‐refractory warts may have an underlying immune system impairment at the root of HPV susceptibility. Early recognition of genetic disorders associated with immunologic defects that allow for recalcitrant HPV infection may expedite appropriate treatment for patients. Early recognition is often pivotal in preventing subsequent morbidity and/or mortality that may arise from inborn errors of immunity, such as WHIM (Warts, Hypogammaglobulinemia, Infections, Myelokathexis) syndrome. Among these, cervical cancer is one of the most common malignancies associated with HPV, can be fatal if not treated early, and is seen more frequently in patients with underlying immune deficiencies. A review of diseases with susceptibility to HPV provides clues to understanding the pathophysiology of warts. We also present diagnostic guidance to facilitate the recognition of inborn errors of immunity in patients with extensive and/or recalcitrant HPV infections.
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Affiliation(s)
- J. Zampella
- Ronald O. Perelman Department of Dermatology NYU Grossman School of Medicine New York New York USA
| | - B. Cohen
- Division of Pediatric Dermatology Johns Hopkins University School of Medicine Baltimore Maryland USA
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Ameratunga R, Longhurst H, Lehnert K, Steele R, Edwards ESJ, Woon ST. Are All Primary Immunodeficiency Disorders Inborn Errors of Immunity? Front Immunol 2021; 12:706796. [PMID: 34367167 PMCID: PMC8335567 DOI: 10.3389/fimmu.2021.706796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 06/01/2021] [Indexed: 12/31/2022] Open
Affiliation(s)
- Rohan Ameratunga
- Department of Clinical Immunology, Auckland Hospital, Auckland, New Zealand.,Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand.,Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Hilary Longhurst
- Department of Clinical Immunology, Auckland Hospital, Auckland, New Zealand.,Department of Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Klaus Lehnert
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Richard Steele
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
| | - Emily S J Edwards
- B Cell Differentiation Laboratory, Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
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Ameratunga R, Allan C, Lehnert K, Woon ST. Perspective: Application of the American College of Medical Genetics Variant Interpretation Criteria to Common Variable Immunodeficiency Disorders. Clin Rev Allergy Immunol 2021; 61:226-235. [PMID: 33818703 DOI: 10.1007/s12016-020-08828-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 02/05/2023]
Abstract
Common variable immunodeficiency disorders (CVIDs) are rare primary immunodeficiency diseases (PIDs) mostly associated with late onset antibody failure leading to immune system failure. Patients with CVID are predisposed to disabling complications such as bronchiectasis and systemic autoimmunity. In recent years a large number of genetic defects have become associated with these disorders. Patients with a causative mutation are deemed to have CVID-like disorders, while those with mutations predisposing to or modifying disease severity remain within the spectrum of CVID as defined by current diagnostic criteria. Next-generation sequencing (NGS) allows simultaneous analysis of multiple genes. Potential mutations identified from NGS are commonly evaluated with the American College of Medical Genetics (ACMG) variant interpretation criteria to determine their pathogenicity (causality). Patients with CVID and CVID-like disorders have marked genetic, allelic, and phenotypic heterogeneity. Although all patients with a CVID phenotype should undergo genetic testing, the complexity of the genetics associated with these disorders is challenging. Variants of unknown significance (VUS) remain a significant barrier to realising the full potential of NGS in CVID and CVID-like disorders. Here we explore the nuances of applying the ACMG criteria to patients with CVID and CVID-like disorders. Close collaboration between the clinician, bioinformatics, and genetics professionals will improve the diagnostic yield from genetic testing and reduce the frequency of VUS.
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Affiliation(s)
- Rohan Ameratunga
- Department of Virology and Immunology, Auckland City Hospital, Auckland, 1010, New Zealand. .,Department of Clinical Immunology, Auckland City Hospital, Auckland, 1010, New Zealand. .,Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1010, New Zealand.
| | - Caroline Allan
- Department of Virology and Immunology, Auckland City Hospital, Auckland, 1010, New Zealand
| | - Klaus Lehnert
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland City Hospital, Auckland, 1010, New Zealand.,Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1010, New Zealand
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Rispoli F, Valencic E, Girardelli M, Pin A, Tesser A, Piscianz E, Boz V, Faletra F, Severini GM, Taddio A, Tommasini A. Immunity and Genetics at the Revolving Doors of Diagnostics in Primary Immunodeficiencies. Diagnostics (Basel) 2021; 11:532. [PMID: 33809703 PMCID: PMC8002250 DOI: 10.3390/diagnostics11030532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 12/14/2022] Open
Abstract
Primary immunodeficiencies (PIDs) are a large and growing group of disorders commonly associated with recurrent infections. However, nowadays, we know that PIDs often carry with them consequences related to organ or hematologic autoimmunity, autoinflammation, and lymphoproliferation in addition to simple susceptibility to pathogens. Alongside this conceptual development, there has been technical advancement, given by the new but already established diagnostic possibilities offered by new genetic testing (e.g., next-generation sequencing). Nevertheless, there is also the need to understand the large number of gene variants detected with these powerful methods. That means advancing beyond genetic results and resorting to the clinical phenotype and to immunological or alternative molecular tests that allow us to prove the causative role of a genetic variant of uncertain significance and/or better define the underlying pathophysiological mechanism. Furthermore, because of the rapid availability of results, laboratory immunoassays are still critical to diagnosing many PIDs, even in screening settings. Fundamental is the integration between different specialties and the development of multidisciplinary and flexible diagnostic workflows. This paper aims to tell these evolving aspects of immunodeficiencies, which are summarized in five key messages, through introducing and exemplifying five clinical cases, focusing on diseases that could benefit targeted therapy.
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Affiliation(s)
- Francesco Rispoli
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.R.); (V.B.); (A.T.); (A.T.)
| | - Erica Valencic
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Martina Girardelli
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Alessia Pin
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Alessandra Tesser
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Elisa Piscianz
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Valentina Boz
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.R.); (V.B.); (A.T.); (A.T.)
| | - Flavio Faletra
- Department of Diagnostics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy;
| | - Giovanni Maria Severini
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Andrea Taddio
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.R.); (V.B.); (A.T.); (A.T.)
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
| | - Alberto Tommasini
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.R.); (V.B.); (A.T.); (A.T.)
- Department of Pediatrics, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, 34137 Trieste, Italy; (M.G.); (A.P.); (A.T.); (E.P.); (G.M.S.)
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Perspective: Evolving Concepts in the Diagnosis and Understanding of Common Variable Immunodeficiency Disorders (CVID). Clin Rev Allergy Immunol 2021; 59:109-121. [PMID: 31720921 DOI: 10.1007/s12016-019-08765-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Common variable immunodeficiency disorders (CVID) are the most frequent symptomatic primary immune deficiency in adults. At this time, the causes of these conditions are unknown. Patients with CVID experience immune system failure consequent to late onset antibody failure. They have increased susceptibility to infections and are also at risk of severe autoimmune and inflammatory disorders as a result of immune dysregulation. An increasing number of monogenic causes as well as a digenic disorder have been described in patients with a CVID phenotype. If a causative mutation is identified, patients are removed from the umbrella diagnosis of CVID and are reclassified as having a CVID-like disorder, resulting from a specific mutation. In non-consanguineous populations, next-generation sequencing (NGS) identifies a genetic cause in approximately 25% of patients with a CVID phenotype. It is six years since we published our diagnostic criteria for CVID. There is ongoing debate about diagnostic criteria, the role of vaccine responses and genetic analysis in the diagnosis of CVID. There have been several recent studies, which have addressed some of these uncertainties. Here we review this new evidence from the perspective of our CVID diagnostic criteria and speculate on future approaches, which may assist in identifying and assessing this group of enigmatic disorders.
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Qureshi S, Mir F, Junejo S, Saleem K, Zaidi S, Naveed AB, Ahmad K, Qamar FN. The spectrum of primary immunodeficiencies at a tertiary care hospital in Pakistan. World Allergy Organ J 2020; 13:100133. [PMID: 32793328 PMCID: PMC7414008 DOI: 10.1016/j.waojou.2020.100133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/29/2020] [Accepted: 05/18/2020] [Indexed: 01/08/2023] Open
Abstract
Background Primary Immunodeficiency Disorders (PIDs) are well-known disorders in the West. but the recognition and diagnosis of these disorders is challenging in developing countries. We present the spectrum of PIDs seen at a tertiary care center in Pakistan, identified using clinical case definitions and molecular methods. Methods A retrospective chart review of children suspected to have PID was conducted at the Aga Khan University Hospital (AKUH) Karachi, Pakistan from 2010 to 2016. Data on demographics, clinical features, family history of consanguinity, sibling death, details of laboratory workup done for PID and molecular tests targeted panel next generation sequencing (NGS) or whole exome sequencing (WES) performed at the Geha laboratory at Boston Children’s Hospital, USA was collected. The study was exempted from the Ethical Review Committee of AKUH. Results A total of 43 children visited the hospital with suspected PID during the study period. Genetic testing was performed in 31/43 (72.1%) children. A confirmed diagnosis of PID was established in 20/43 (46.5%) children. A pathogenic gene variant was identified in 17(85%) of the 20 confirmed cases (Table 1). Twelve (60%) of the confirmed cases of PID were male. The most common presenting symptom was recurrent diarrhea 11/20 (55%). The mean (±S.D) age of the cases at the time of diagnosis was 4.2 (±4.1) years. Chronic granulomatous disease (CGD) was the most common 6/20 (30%) disorder, followed by severe combined immunodeficiency (SCID) 3/20 (15%), leukocyte adhesion deficiency (LAD) 3/20 (15%), agammaglobulinemia/hypogammaglobulinemia 3/20 (15%), and Hermansky-Pudlak Syndrome (HPS) 2/20 (10%). Wiskott-Aldrich Syndrome, Immunodeficiency Centromeric Instability and Facial Anomalies Syndrome (ICF 2), Trichohepatoenteric syndrome (TRES), and C3 deficiency were each diagnosed once {1/20 (4.3%) each} (Table 1). Of these 20 confirmed cases, almost all 19/20 (95%) had a family history of consanguinity. Sibling death was reported in 5/20 (25%) of these cases. Five out of the 20 (25%) children died over the 7-year period for various reasons. Conclusion PIDs are not uncommon in Pakistan; their diagnosis may be missed or delayed due to the overlapping of clinical features of PID with other diseases and a lack of diagnostic facilities. There is a need to build capacity for early recognition and diagnosis of PIDs to decrease morbidity and mortality.
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Key Words
- AFIP, Armed Forces Institute of Pathology
- ARDS, Acute Respiratory Distress Syndrome
- BCG, Bacille Calmette-Guerin
- BMT, Bone Marrow Transplant
- CGD, Chronic Granulomatous Disease
- Children
- Chronic granulomatous disease
- Consanguineous marriages
- DHR, Dihydrorhodamine
- HPS, Hermansky-Pudlak Syndrome
- I/V, Intravenous
- ICF-2, Immunodeficiency Centromeric Instability and Facial Anomalies Syndrome
- LAD, Leukocyte Adhesion Deficiency
- LMIC, Low Middle Income Countries
- NBT, Nitrotetrazolium blue test
- NGS, Next-Generation Sequencing
- OPV, Oral Polio Vaccine
- PIDs, Primary Immunodeficiency Disorders
- Primary immunodeficiency disorders
- S/C, Subcutaneous
- SCID, Severe Combined Immunodeficiency Disorder
- TRES, Trichohepatoenteric syndrome
- USA, United States of America
- VDP, Vaccine Derived Poliovirus
- WES, Whole Exome Sequencing
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Affiliation(s)
- Sonia Qureshi
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Fatima Mir
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Samina Junejo
- Department of Pediatrics, The Indus Hospital, Korangi Road, Karachi, Pakistan
| | - Khalid Saleem
- Children's Hospital and The Institute of Child Health, Multan, Pakistan
| | - Samreen Zaidi
- National Institute of Blood Disease & Bone Marrow Transplantation, P.E.C.H.S, Karachi, Pakistan
| | - Abdullah B Naveed
- Medical College, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Khalil Ahmad
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Farah Naz Qamar
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
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Chen R. Primary Immunodeficiency. Rare Dis 2020. [DOI: 10.5772/intechopen.89624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Ameratunga R, Ahn Y, Tse D, Woon ST, Pereira J, McCarthy S, Blacklock H. The critical role of histology in distinguishing sarcoidosis from common variable immunodeficiency disorder (CVID) in a patient with hypogammaglobulinemia. Allergy Asthma Clin Immunol 2019; 15:78. [PMID: 31827542 PMCID: PMC6886192 DOI: 10.1186/s13223-019-0383-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 11/05/2019] [Indexed: 12/23/2022] Open
Abstract
Background Common variable immunodeficiency disorders (CVID) are a rare group of primary immune defects, where the underlying cause is unknown. Approximately 10–20% of patients with typical CVID have a granulomatous variant, which has closely overlapping features with sarcoidosis. Case presentation Here we describe a young man who sequentially developed refractory Evans syndrome, cauda equina syndrome and most recently renal impairment. Following immunosuppression, he has made a recovery from all three life-threatening autoimmune disorders. As the patient was hypogammaglobulinemic for most of the time while on immunosuppression, vaccine challenges and other tests were not possible. Histological features were in keeping with sarcoidosis rather than the granulomatous variant of CVID. In the brief period when immunosuppression was lifted between the cauda equina syndrome and renal impairment, he normalised his immunoglobulins, confirming sarcoidosis rather than CVID was the underlying cause. Conclusion We discuss diagnostic difficulties distinguishing the two conditions, and the value of histological features in our diagnostic criteria for CVID in identifying sarcoidosis, while the patient was hypogammaglobulinemic. The key message from this case report is that the characteristic histological features of CVID can be very helpful in making (or excluding) the diagnosis, particularly when other tests are not possible.
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Affiliation(s)
- Rohan Ameratunga
- 1Department of Virology and Immunology, Auckland City Hospital, Park Rd, Grafton, Auckland, 1010 New Zealand.,4Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Yeri Ahn
- 1Department of Virology and Immunology, Auckland City Hospital, Park Rd, Grafton, Auckland, 1010 New Zealand
| | - Dominic Tse
- 2Department of Neurology, Auckland City Hospital, Park Rd, Grafton, Auckland, 1010 New Zealand
| | - See-Tarn Woon
- 1Department of Virology and Immunology, Auckland City Hospital, Park Rd, Grafton, Auckland, 1010 New Zealand.,4Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jennifer Pereira
- 2Department of Neurology, Auckland City Hospital, Park Rd, Grafton, Auckland, 1010 New Zealand
| | - Sinead McCarthy
- 3Department of Histopathology, Auckland City Hospital, Park Rd, Grafton, Auckland, 1010 New Zealand
| | - Hilary Blacklock
- 4Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,5Department of Haematology, Middlemore Hospital, Auckland, New Zealand
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12
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Ameratunga R, Lehnert K, Woon ST. All Patients With Common Variable Immunodeficiency Disorders (CVID) Should Be Routinely Offered Diagnostic Genetic Testing. Front Immunol 2019; 10:2678. [PMID: 31824486 PMCID: PMC6883368 DOI: 10.3389/fimmu.2019.02678] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/30/2019] [Indexed: 12/23/2022] Open
Affiliation(s)
- Rohan Ameratunga
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand.,Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand.,Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Klaus Lehnert
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
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13
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Ameratunga R, Ahn Y, Steele R, Woon ST. Transient hypogammaglobulinaemia of infancy: many patients recover in adolescence and adulthood. Clin Exp Immunol 2019; 198:224-232. [PMID: 31260083 DOI: 10.1111/cei.13345] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2019] [Indexed: 01/11/2023] Open
Abstract
Transient hypogammaglobulinaemia of infancy (THI) is a relatively rare disorder where there is an exaggeration of the physiological nadir of immunoglobulin (Ig)G between loss of transplacentally acquired maternal IgG and production by the infant. Patients may be vulnerable to infections during the period of hypogammaglobulinaemia. The precise time to recovery in all infants is currently unknown. We sought to determine the clinical features and time-course of recovery for patients with THI. We reviewed our experience with THI over the last three decades in order to describe clinical and laboratory features, as well as the time-course of recovery. Forty-seven patients were identified with THI. Only thirty-seven per cent remitted by 4 years of age, while some patients did not recover until the third or fourth decade. In keeping with previous studies, the majority (25 of 47) presented with recurrent infections, nine had a family history of immunodeficiency and 13 had adverse reactions to food as their dominant clinical manifestation. Chronic tonsillitis developed in 10 patients and symptoms improved following surgery. The group with food allergies recovered sooner than those presenting with infections or with a family history immunodeficiency. Eight patients failed to respond to at least one routine childhood vaccine. Two have IgA deficiency and four individuals recovering in adolescence and adulthood continue to have borderline/low IgG levels. None have progressed to common variable immunodeficiency disorders (CVID). THI is a misnomer, as the majority do not recover in infancy. Recovery from THI can extend into adulthood. THI must be considered in the differential diagnosis of adolescents or young adults presenting with primary hypogammaglobulinemia.
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Affiliation(s)
- R Ameratunga
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand.,Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand
| | - Y Ahn
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - R Steele
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - S-T Woon
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
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14
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Review: Diagnosing Common Variable Immunodeficiency Disorder in the Era of Genome Sequencing. Clin Rev Allergy Immunol 2018; 54:261-268. [PMID: 29030829 DOI: 10.1007/s12016-017-8645-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Common variable immunodeficiency disorders (CVID) are an enigmatic group of often heritable conditions, which may manifest for the first time in early childhood or as late as the eighth decade of life. In the last 5 years, next generation sequencing (NGS) has revolutionised identification of genetic disorders. However, despite the best efforts of researchers around the globe, CVID conditions have been slow to yield their molecular secrets. We have previously described the many clinical advantages of identifying the genetic basis of primary immunodeficiency disorders (PIDs). In a minority of CVID patients, monogenic defects have now been identified. If a causative mutation is identified, these conditions are reclassified as CVID-like disorders. Here we discuss recent advances in the genetics of CVID and discuss how NGS can be optimally deployed to identify the causal mutations responsible for the protean clinical manifestations of these conditions. Diagnostic criteria such as the Ameratunga et al. criteria will continue to play an important role in patient management as well as case selection and sequencing strategy design until the genetic conundrum of CVID is solved.
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15
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Batistela DM, Stevani CV, Freire RS. Immunoassay for Human IgG Using Antibody-functionalized Silver Nanoparticles. ANAL SCI 2018; 33:1111-1114. [PMID: 28993583 DOI: 10.2116/analsci.33.1111] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A simple colorimetric immunoassay for quantification of human immunoglobulin G (hIgG) is herein described. The assay is based on the aggregation inhibition of silver nanoparticles (AgNP) functionalized with hIgG antibody (anti-hIgG) on the surface. The aggregation is measured in terms of attenuance values ratio at 400 and 530 nm (A400/A530). A linear response between A400/A530 and hIgG concentration is observed in the range 25 - 200 ng mL-1, and the detection limit is estimated as 11 ng mL-1 hIgG.
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Affiliation(s)
- Daniela M Batistela
- Department of Fundamental Chemistry, Institute of Chemistry, University of São Paulo (USP)
| | - Cassius V Stevani
- Department of Fundamental Chemistry, Institute of Chemistry, University of São Paulo (USP)
| | - Renato S Freire
- Department of Fundamental Chemistry, Institute of Chemistry, University of São Paulo (USP)
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16
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Abolhassani H, Aghamohammadi A, Fang M, Rezaei N, Jiang C, Liu X, Pan-Hammarström Q, Hammarström L. Clinical implications of systematic phenotyping and exome sequencing in patients with primary antibody deficiency. Genet Med 2018; 21:243-251. [PMID: 29921932 DOI: 10.1038/s41436-018-0012-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 11/20/2017] [Accepted: 03/20/2018] [Indexed: 02/08/2023] Open
Abstract
PURPOSE The etiology of 80% of patients with primary antibody deficiency (PAD), the second most common type of human immune system disorder after human immunodeficiency virus infection, is yet unknown. METHODS Clinical/immunological phenotyping and exome sequencing of a cohort of 126 PAD patients (55.5% male, 95.2% childhood onset) born to predominantly consanguineous parents (82.5%) with unknown genetic defects were performed. The American College of Medical Genetics and Genomics criteria were used for validation of pathogenicity of the variants. RESULTS This genetic approach and subsequent immunological investigations identified potential disease-causing variants in 86 patients (68.2%); however, 27 of these patients (31.4%) carried autosomal dominant (24.4%) and X-linked (7%) gene defects. This genetic approach led to the identification of new phenotypes in 19 known genes (38 patients) and the discovery of a new genetic defect (CD70 pathogenic variants in 2 patients). Medical implications of a definite genetic diagnosis were reported in ~50% of the patients. CONCLUSION Due to misclassification of the conventional approach for targeted sequencing, employing next-generation sequencing as a preliminary step of molecular diagnostic approach to patients with PAD is crucial for management and treatment of the patients and their family members.
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Affiliation(s)
- Hassan Abolhassani
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden.,Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mingyan Fang
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden.,BGI-Shenzhen, Shenzhen, 518083, China.,China National GeneBank, BGI-Shenzhen, Shenzhen, 518120, China
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Chongyi Jiang
- BGI-Shenzhen, Shenzhen, 518083, China.,China National GeneBank, BGI-Shenzhen, Shenzhen, 518120, China
| | - Xiao Liu
- BGI-Shenzhen, Shenzhen, 518083, China.,China National GeneBank, BGI-Shenzhen, Shenzhen, 518120, China
| | - Qiang Pan-Hammarström
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Lennart Hammarström
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden. .,BGI-Shenzhen, Shenzhen, 518083, China. .,China National GeneBank, BGI-Shenzhen, Shenzhen, 518120, China.
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17
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Ameratunga R, Woon ST, Bryant VL, Steele R, Slade C, Leung EY, Lehnert K. Clinical Implications of Digenic Inheritance and Epistasis in Primary Immunodeficiency Disorders. Front Immunol 2018; 8:1965. [PMID: 29434582 PMCID: PMC5790765 DOI: 10.3389/fimmu.2017.01965] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/19/2017] [Indexed: 12/16/2022] Open
Abstract
The existence of epistasis in humans was first predicted by Bateson in 1909. Epistasis describes the non-linear, synergistic interaction of two or more genetic loci, which can substantially modify disease severity or result in entirely new phenotypes. The concept has remained controversial in human genetics because of the lack of well-characterized examples. In humans, it is only possible to demonstrate epistasis if two or more genes are mutated. In most cases of epistasis, the mutated gene products are likely to be constituents of the same physiological pathway leading to severe disruption of a cellular function such as antibody production. We have recently described a digenic family, who carry mutations of TNFRSF13B/TACI as well as TCF3 genes. Both genes lie in tandem along the immunoglobulin isotype switching and secretion pathway. We have shown they interact in an epistatic way causing severe immunodeficiency and autoimmunity in the digenic proband. With the advent of next generation sequencing, it is likely other families with digenic inheritance will be identified. Since digenic inheritance does not always cause epistasis, we propose an epistasis index which may help quantify the effects of the two mutations. We also discuss the clinical implications of digenic inheritance and epistasis in humans with primary immunodeficiency disorders.
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Affiliation(s)
- Rohan Ameratunga
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand.,Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - Vanessa L Bryant
- Department of Immunology, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Richard Steele
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - Charlotte Slade
- Department of Immunology, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.,Department of Allergy and Clinical Immunology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Euphemia Yee Leung
- Auckland Cancer Society Research Centre, University of Auckland, Auckland, New Zealand
| | - Klaus Lehnert
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
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18
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Ameratunga R, Koopmans W, Woon ST, Leung E, Lehnert K, Slade CA, Tempany JC, Enders A, Steele R, Browett P, Hodgkin PD, Bryant VL. Epistatic interactions between mutations of TACI ( TNFRSF13B) and TCF3 result in a severe primary immunodeficiency disorder and systemic lupus erythematosus. Clin Transl Immunology 2017; 6:e159. [PMID: 29114388 PMCID: PMC5671988 DOI: 10.1038/cti.2017.41] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 07/21/2017] [Accepted: 07/21/2017] [Indexed: 12/22/2022] Open
Abstract
Common variable immunodeficiency disorders (CVID) are a group of primary immunodeficiencies where monogenetic causes account for only a fraction of cases. On this evidence, CVID is potentially polygenic and epistatic although there are, as yet, no examples to support this hypothesis. We have identified a non-consanguineous family, who carry the C104R (c.310T>C) mutation of the Transmembrane Activator Calcium-modulator and cyclophilin ligand Interactor (TACI, TNFRSF13B) gene. Variants in TNFRSF13B/TACI are identified in up to 10% of CVID patients, and are associated with, but not solely causative of CVID. The proband is heterozygous for the TNFRSF13B/TACI C104R mutation and meets the Ameratunga et al. diagnostic criteria for CVID and the American College of Rheumatology criteria for systemic lupus erythematosus (SLE). Her son has type 1 diabetes, arthritis, reduced IgG levels and IgA deficiency, but has not inherited the TNFRSF13B/TACI mutation. Her brother, homozygous for the TNFRSF13B/TACI mutation, is in good health despite profound hypogammaglobulinemia and mild cytopenias. We hypothesised that a second unidentified mutation contributed to the symptomatic phenotype of the proband and her son. Whole-exome sequencing of the family revealed a de novo nonsense mutation (T168fsX191) in the Transcription Factor 3 (TCF3) gene encoding the E2A transcription factors, present only in the proband and her son. We demonstrate mutations of TNFRSF13B/TACI impair immunoglobulin isotype switching and antibody production predominantly via T-cell-independent signalling, while mutations of TCF3 impair both T-cell-dependent and -independent pathways of B-cell activation and differentiation. We conclude that epistatic interactions between mutations of the TNFRSF13B/TACI and TCF3 signalling networks lead to the severe CVID-like disorder and SLE in the proband.
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Affiliation(s)
- Rohan Ameratunga
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand.,Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand
| | - Wikke Koopmans
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - Euphemia Leung
- Cancer Society Research Centre, University of Auckland, Auckland, New Zealand
| | - Klaus Lehnert
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Charlotte A Slade
- Department of Immunology, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.,Department of Allergy and Clinical Immunology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Jessica C Tempany
- Department of Immunology, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Anselm Enders
- Department of Immunology and Infectious Disease, John Curtin School of Medical Research and Centre for Personalised Immunology, Australian National University, Canberra, ACT, Australia
| | - Richard Steele
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - Peter Browett
- Department of Hematology, LabPlus, Auckland City Hospital, Auckland, New Zealand.,Department of Molecular Medicine, and Pathology University of Auckland, Auckland, New Zealand
| | - Philip D Hodgkin
- Department of Immunology, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia
| | - Vanessa L Bryant
- Department of Immunology, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.,Department of Allergy and Clinical Immunology, Royal Melbourne Hospital, Parkville, VIC, Australia
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19
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Ameratunga R, Bartlett A, McCall J, Steele R, Woon ST, Katelaris CH. Hereditary Angioedema as a Metabolic Liver Disorder: Novel Therapeutic Options and Prospects for Cure. Front Immunol 2016; 7:547. [PMID: 27965672 PMCID: PMC5127832 DOI: 10.3389/fimmu.2016.00547] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 11/16/2016] [Indexed: 12/19/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant disorder caused by mutations of the SERPING1 or the Factor 12 genes. It is potentially fatal, particularly if not identified at an early stage. Apart from androgens, which are contraindicated in children and in pregnant women, a range of effective, albeit very expensive treatments have recently become available for HAE patients. The cost of these new treatments is beyond the reach of most developing countries. At this time, there is no cure for the disorder. In spite of mutations of the SERPING1 gene, autoimmunity and infections are not prominent features of the condition. Here, we present the argument that HAE should be viewed primarily as a metabolic liver disorder. This conceptual paradigm shift will stimulate basic research and may facilitate new therapeutic approaches to HAE outlined in this paper. We suggest several novel potential treatment options for HAE from the perspectives of clinical immunology, molecular biology, and liver transplantation. Many of these offer the prospect of curing the disorder. The effectiveness of these options is rapidly improving in many cases, and their risks are decreasing. Given the very high costs of treating HAE, some of these curative options may become feasible in the next decade.
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Affiliation(s)
- Rohan Ameratunga
- Department of Clinical Immunology, Auckland Hospital, Auckland, New Zealand
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
| | - Adam Bartlett
- Liver Transplantation Service, Auckland Hospital, Auckland, New Zealand
| | - John McCall
- Liver Transplantation Service, Auckland Hospital, Auckland, New Zealand
| | - Richard Steele
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
| | - Constance H. Katelaris
- Immunology and Allergy Unit, Campbelltown Hospital and Western Sydney University, Sydney, NSW, Australia
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20
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Ameratunga R, Storey P, Barker R, Jordan A, Koopmans W, Woon ST. Application of diagnostic and treatment criteria for common variable immunodeficiency disorder. Expert Rev Clin Immunol 2016; 12:257-66. [PMID: 26623716 DOI: 10.1586/1744666x.2016.1126509] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Common variable immunodeficiency disorder (CVID) is the most frequent symptomatic primary immune deficiency disorder in adults. It probably comprises a spectrum of polygenic disorders, with hypogammaglobulinemia being the overarching feature. While the majority of patients with CVID can be identified with relative ease, a significant proportion can present with minimal symptoms in spite of profound laboratory abnormalities. Here we discuss three patients who were presented to the Auckland Hospital immunoglobulin treatment committee to determine if they qualified for immunoglobulin replacement. Two were asymptomatic with profound laboratory abnormalities while the third patient was severely ill with extensive bronchiectasis. The third patient had less severe laboratory abnormalities compared with the two asymptomatic patients. We have applied four sets of published diagnostic and treatment criteria to these patients to compare their clinical utility. We have chosen these patients from the broad phenotypic spectrum of CVID, as this often illustrates differences in diagnostic and treatment criteria.
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Affiliation(s)
- Rohan Ameratunga
- a Department of Virology and Immunology , Auckland Hospital , Auckland , New Zealand.,b Clinical Immunology , Auckland Hospital , Auckland , New Zealand
| | - Peter Storey
- b Clinical Immunology , Auckland Hospital , Auckland , New Zealand
| | - Russell Barker
- a Department of Virology and Immunology , Auckland Hospital , Auckland , New Zealand
| | - Anthony Jordan
- b Clinical Immunology , Auckland Hospital , Auckland , New Zealand
| | - Wikke Koopmans
- a Department of Virology and Immunology , Auckland Hospital , Auckland , New Zealand
| | - See-Tarn Woon
- a Department of Virology and Immunology , Auckland Hospital , Auckland , New Zealand
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21
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Ameratunga R, Brewerton M, Slade C, Jordan A, Gillis D, Steele R, Koopmans W, Woon ST. Comparison of diagnostic criteria for common variable immunodeficiency disorder. Front Immunol 2014; 5:415. [PMID: 25309532 PMCID: PMC4164032 DOI: 10.3389/fimmu.2014.00415] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/17/2014] [Indexed: 12/21/2022] Open
Abstract
Common variable immunodeficiency disorders (CVIDs) are the most frequent symptomatic primary immune deficiency condition in adults. The genetic basis for the condition is not known and no single clinical feature or laboratory test can establish the diagnosis; it has been a diagnosis of exclusion. In areas of uncertainty, diagnostic criteria can provide valuable clinical information. Here, we compare the revised European society of immune deficiencies (ESID) registry (2014) criteria with the diagnostic criteria of Ameratunga et al. (2013) and the original ESID/pan American group for immune deficiency (ESID/PAGID 1999) criteria. The ESID/PAGID (1999) criteria either require absent isohemagglutinins or impaired vaccine responses to establish the diagnosis in patients with primary hypogammaglobulinemia. Although commonly encountered, infective and autoimmune sequelae of CVID were not part of the original ESID/PAGID (1999) criteria. Also excluded were a series of characteristic laboratory and histological abnormalities, which are useful when making the diagnosis. The diagnostic criteria of Ameratunga et al. (2013) for CVID are based on these markers. The revised ESID registry (2014) criteria for CVID require the presence of symptoms as well as laboratory abnormalities to establish the diagnosis. Once validated, criteria for CVID will improve diagnostic precision and will result in more equitable and judicious use of intravenous or subcutaneous immunoglobulin therapy.
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Affiliation(s)
- Rohan Ameratunga
- Department of Virology and Immunology, Auckland Hospital , Auckland , New Zealand ; Department of Clinical Immunology, Auckland Hospital , Auckland , New Zealand
| | - Maia Brewerton
- Department of Clinical Immunology, Royal Melbourne Hospital , Melbourne, VIC , Australia
| | - Charlotte Slade
- Department of Clinical Immunology, Royal Melbourne Hospital , Melbourne, VIC , Australia
| | - Anthony Jordan
- Department of Clinical Immunology, Auckland Hospital , Auckland , New Zealand
| | - David Gillis
- Department of Clinical Immunology, Royal Brisbane Hospital , Brisbane, QLD , Australia
| | - Richard Steele
- Department of Virology and Immunology, Auckland Hospital , Auckland , New Zealand
| | - Wikke Koopmans
- Department of Virology and Immunology, Auckland Hospital , Auckland , New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital , Auckland , New Zealand
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22
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Clinical variability of family members with the C104R mutation in transmembrane activator and calcium modulator and cyclophilin ligand interactor (TACI). J Clin Immunol 2012; 33:68-73. [PMID: 22983507 DOI: 10.1007/s10875-012-9793-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 09/04/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Common Variable Immunodeficiency Disorder (CVID) is a complex disorder that predisposes patients to recurrent and severe infections. The C104R mutation in the transmembrane activator and calcium modulator and cyclophilin ligand interactor (TACI) is the most frequent mutation identified in patients with CVID. We carried out a detailed immunological and molecular study in a family with a C104R mutation. METHODS We have undertaken segregation analysis of a kindred with C104R mutations of the TACI gene. Detailed immunological and molecular investigations were carried out for this kindred and the clinical phenotype was compared to the genotype. RESULTS Segregation analysis of our kindred showed that inheriting single or double copy of the C104R mutation does not consign an individual to CVID. All heterozygotes in the family were phenotypically different, ranging from asymptomatic to ill-health. A family member with a wild type TACI variant had CVID-related phenotype including IgA deficiency and type 1 diabetes. Interestingly, a family member with the homozygous C104R/C104R variant did not meet the criteria for CVID because he had excellent, albeit unsustained, vaccine responses to T cell dependent and T cell independent vaccine antigens despite profound hypogammaglobulinemia. CONCLUSION The C104R mutation does not correlate with the clinical phenotypes in this family.
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23
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Ameratunga R, Woon ST, Brewerton M, Koopmans W, Jordan A, Brothers S, Singh R. Primary immune deficiency disorders in the South Pacific: the clinical utility of a customized genetic testing program in New Zealand. Ann N Y Acad Sci 2012; 1238:53-64. [PMID: 22129053 DOI: 10.1111/j.1749-6632.2011.06238.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Primary immune deficiency disorders (PIDs) are a group of diseases associated with a genetic susceptibility to recurrent infections, malignancy, autoimmunity, and allergy. The molecular basis of many of these disorders has been identified in the last two decades. Most are inherited as single gene defects. As discussed in this paper, identifying the underlying genetic defect plays a critical role in many areas-including patient management, diagnosis, identifying atypical presentations, family studies, providing prognostic information, prenatal diagnosis, and defining new diseases. New Zealand is a geographically isolated, developed country in the South Pacific. We have introduced a dedicated customized genetic testing service for PID patients in New Zealand. This accredited diagnostic program offers rapid turnaround times for genetic tests and minimizes the risk of laboratory errors. Here we review the clinical indications for genetic testing for PIDs based on cases referred to the molecular immunology diagnostic service at Auckland City Hospital.
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Affiliation(s)
- Rohan Ameratunga
- Department of Clinical Immunology, Auckland City Hospital, New Zealand.
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Wang HY, Jain A. Novel sequencing-based strategies for high-throughput discovery of genetic mutations underlying inherited antibody deficiency disorders. Curr Allergy Asthma Rep 2011; 11:352-60. [PMID: 21792638 PMCID: PMC3179846 DOI: 10.1007/s11882-011-0211-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Human inherited antibody deficiency disorders are generally caused by mutations in genes involved in the pathways regulating B-cell class switch recombination; DNA damage repair; and B-cell development, differentiation, and survival. Sequencing a large set of candidate genes involved in these pathways appears to be a highly efficient way to identify novel mutations. Herein we review several high-throughput sequencing approaches as well as recent improvements in target gene enrichment technologies. Systematic improvement of enrichment and sequencing methods, along with refinement of the experimental process is necessary to develop a cost-effective high-throughput resequencing assay for a large cohort of patient samples. The Hyper-IgM/CVID chip is one example of a resequencing platform that may be used to identify known or novel mutations in patents with various types of inherited antibody deficiency.
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Affiliation(s)
- Hong-Ying Wang
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, CRC, 5W-3840, 10 Center Drive, Bethesda, MD 20892, USA
| | - Ashish Jain
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, CRC, 5W-3840, 10 Center Drive, Bethesda, MD 20892, USA
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