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Ochfeld E, Khojah A, Marin W, Morgan G, Pachman LM. Proof-of-concept study evaluating humoral primary immunodeficiencies via CJ:KREC ratio and serum BAFF level. Sci Rep 2024; 14:14356. [PMID: 38906917 PMCID: PMC11192915 DOI: 10.1038/s41598-024-64942-4] [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: 12/26/2023] [Accepted: 06/14/2024] [Indexed: 06/23/2024] Open
Abstract
Humoral primary immunodeficiencies are the most prevalent form of primary immunodeficiency (PID). Currently, there is no convenient method to quantify newly formed B cells. The aim of this proof-of-concept study was to quantitate the ratio of coding joints (CJs) to Kappa-deleting recombination excision circles (KRECs) and serum B cell activating factor (BAFF) in patients with humoral primary immunodeficiency and assess if they correlate with disease severity. This IRB-approved study was conducted at one academic children's hospital. Patients with humoral PIDs and healthy controls were included. CJ and KREC levels were measured via qPCR. Serum BAFF levels were measured using Mesoscale. 16 patients with humoral PID and 5 healthy controls were included. The mean CJ:KREC ratio in the CVID, antibody deficiency syndromes, and controls groups, respectively were 13.04 ± 9.5, 5.25 ± 4.1, and 4.38 ± 2.5 (p = 0.059). The mean serum BAFF levels in CVID, antibody deficiency syndromes and controls were 216.3 ± 290 pg/mL, 107.9 ± 94 pg/mL and 50.9 ± 12 pg/mL, respectively (p = 0.271). When the CVID patients were subdivided into CVID with or without lymphoproliferative features, the BAFF level was substantially higher in the CVID with lymphoproliferation cohort (mean 372.4 ± 361 pg/mL, p = 0.031). Elevated CJ:KREC ratio was observed in CVID, although statistical significance was not achieved, likely due to the small sample size. Serum BAFF levels were significantly higher in CVID patients with lymphoproliferative features. We speculate that the CJ:KREC ratio and serum BAFF levels can be utilized in patients with humoral PID, once more extensive studies confirm this exploratory investigation.
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Affiliation(s)
- Elisa Ochfeld
- Pediatric Allergy-Immunology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Pediatric Allergy-Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amer Khojah
- Department of Pediatrics, College of Medicine, Umm Al-Qura University, Al-Abdiyyah campus, Taif road, 21955, Makkah, Saudi Arabia.
| | - Wilfredo Marin
- Division of Pediatric Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Gabrielle Morgan
- Division of Pediatric Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Lauren M Pachman
- Division of Pediatric Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Tessarin G, Baronio M, Gazzurelli L, Rossi S, Chiarini M, Moratto D, Giliani SC, Bondioni MP, Badolato R, Lougaris V. Rituximab Monotherapy Is Effective as First-Line Treatment for Granulomatous Lymphocytic Interstitial Lung Disease (GLILD) in CVID Patients. J Clin Immunol 2023; 43:2091-2103. [PMID: 37755605 PMCID: PMC10661825 DOI: 10.1007/s10875-023-01587-4] [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: 06/01/2023] [Accepted: 09/18/2023] [Indexed: 09/28/2023]
Abstract
Granulomatous lymphocytic interstitial lung disease (GLILD) represents a fatal immune dysregulatory complication in common variable immunodeficiency (CVID). Evidence-based diagnostic guidelines are lacking, and GLILD treatment consists in immunosuppressive drugs; nonetheless, therapeutical strategies are heterogeneous and essentially based on experts' opinions and data from small case series or case reports.We aimed to evaluate the efficacy and safety of first-line Rituximab monotherapy for CVID-related GLILD, by assessing symptoms and quality of life alterations, immunological parameters, pulmonary function tests, and lung computed tomography.All six GLILD patients received Rituximab infusions as a first-line treatment. Rituximab was administered at 375 mg/m2 monthly for six infusions followed by maintenance every 3 months; none of the patients experienced severe adverse events. Symptom burden and quality of life significantly improved in treated patients compared to a control group of CVID patients without GLILD. Rituximab treatment indirectly caused a trend toward reduced T-cell activation and exhaustion markers sCD25 and sTIM-3. Lung function improved in treated patients, with statistically significant increases in TLC and DLCO. Lung CT scan findings expressed by means of Baumann scoring system displayed a reduction in the entire cohort.In conclusion, first-line monotherapy with Rituximab displayed high efficacy in disease remission in all treated patients, with improvement of symptoms and amelioration of quality of life, as well as restoration of PFTs and lung CT scan findings.
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Affiliation(s)
- Giulio Tessarin
- Department of Clinical and Experimental Sciences, Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, University of Brescia and ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
- Department of Molecular and Translational Medicine, Institute for Molecular Medicine A. Nocivelli, University of Brescia, Brescia, Italy
| | - Manuela Baronio
- Department of Clinical and Experimental Sciences, Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, University of Brescia and ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Luisa Gazzurelli
- Department of Clinical and Experimental Sciences, Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, University of Brescia and ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Stefano Rossi
- Department of Clinical and Experimental Sciences, Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, University of Brescia and ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Marco Chiarini
- Diagnostic Department, Flow Cytometry Laboratory, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Daniele Moratto
- Diagnostic Department, Flow Cytometry Laboratory, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Silvia Clara Giliani
- Department of Molecular and Translational Medicine, Institute for Molecular Medicine A. Nocivelli, University of Brescia, Brescia, Italy
| | - Maria Pia Bondioni
- Department of Medical and Surgical Specialties, Pediatric Radiology, University of Brescia and ASST Spedali Civili of Brescia, Brescia, Italy
| | - Raffaele Badolato
- Department of Clinical and Experimental Sciences, Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, University of Brescia and ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Vassilios Lougaris
- Department of Clinical and Experimental Sciences, Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, University of Brescia and ASST Spedali Civili of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy.
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Park K, Wang Q, Lee RU. Navigating the management complexity in long-term asymptomatic immunodeficiency. Allergy Asthma Proc 2023; 44:436-439. [PMID: 37919850 DOI: 10.2500/aap.2023.44.230054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Background: Common variable immunodeficiency disorder (CVID) is a condition associated with recurrent infections and non-infectious outcomes, including lung disease like bronchiectasis and granulomatous and lymphocytic interstitial lung diseases (GLILD), autoimmune disease, enteropathy, and lymphoma. Treatment involves initiation of replacement immunoglobulin (Ig), which is a lifelong commitment. Prior to Ig replacement, life expectancy for patients with CVID was less than 15 years. With replacement Ig, it has improved to over 50 years. In most cases, patients present to a clinician with a history of recurrent infections, and treatment is indicated. However, in patients with asymptomatic disease, the best timing to start treatment can be difficult to determine. Case: We present a case of an otherwise healthy male who had an incidental diagnosis of CVID. Results: Workup revealed hypogammaglobulinemia for over 30 year. Discussion: Though successful in reducing infections, Ig replacement can come with many side effects, as well as a heavy medical burden to the patient and the healthcare system. It is also a big life adjustment, and can greatly affect a patient's quality of life. In the military, a diagnosis of an immunodeficiency, and the need for monthly intravenous immunoglobulin (IVIG) can be detrimental to deployment readiness, and a patient's military career. Risks and benefits need to be weighed prior to initiating Ig therapy.
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Milito C, Pulvirenti F, Garzi G, Sculco E, Cinetto F, Firinu D, Lagnese G, Punziano A, Discardi C, Costanzo G, Felice C, Spadaro G, Ferrari S, Quinti I. Decline of gastric cancer mortality in common variable immunodeficiency in the years 2018-2022. Front Immunol 2023; 14:1231242. [PMID: 37868983 PMCID: PMC10587402 DOI: 10.3389/fimmu.2023.1231242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction In patients with Common Variable Immunodeficiency, malignancy has been reported as the leading cause of death in adults, with a high risk of B-cell lymphomas and gastric cancer. Methods We conducted a five-year prospective study aiming to update the incidence and mortality of gastric cancer and the incidence of gastric precancerous lesions in 512 CVID patients who underwent a total of 400 upper gastrointestinal endoscopies. Results In the pre-pandemic period, 0.58 endoscopies were performed per patient/year and in the COVID-19 period, 0.39 endoscopies were performed per patient/year. Histology revealed areas with precancerous lesions in about a third of patients. Patients who had more than one gastroscopy during the study period were more likely to have precancerous lesions. Two patients received a diagnosis of gastric cancer in the absence of Helicobacter pylori infection. The overall prevalence of Helicobacter pylori infection in biopsy specimens was 19.8% and related only to active gastritis. Among patients who had repeated gastroscopies, about 20% progressed to precancerous lesions, mostly independent of Helicobacter pylori. Discussion While gastric cancer accounted for one in five deaths from CVID in our previous survey, no gastric cancer deaths were recorded in the past five years, likely consistent with the decline in stomach cancer mortality observed in the general population. However, during the COVID-19 pandemic, cancer screening has been delayed. Whether such a delay or true decline could be the reason for the lack of gastric cancer detection seen in CVID may become clear in the coming years. Due to the high incidence of precancerous lesions, we cannot rely on observed and predicted trends in gastric cancer mortality and strongly recommend tailored surveillance programs.
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Affiliation(s)
- Cinzia Milito
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Federica Pulvirenti
- Reference Center for Primary Immune Deficiencies, AOU Policlinico Umberto I, Rome, Italy
| | - Giulia Garzi
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Eleonora Sculco
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco Cinetto
- Rare Diseases Referral Center, Internal Medicine 1, Ca’ Foncello Hospital, AULSS2 Marca Trevigiana, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Davide Firinu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Gianluca Lagnese
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Alessandra Punziano
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Claudia Discardi
- Rare Diseases Referral Center, Internal Medicine 1, Ca’ Foncello Hospital, AULSS2 Marca Trevigiana, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Giulia Costanzo
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Carla Felice
- Rare Diseases Referral Center, Internal Medicine 1, Ca’ Foncello Hospital, AULSS2 Marca Trevigiana, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Simona Ferrari
- Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Isabella Quinti
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
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An Expert Opinion/Approach: Clinical Presentations, Diagnostic Considerations, and Therapeutic Options for Gastrointestinal Manifestations of Common Variable Immune Deficiency. Am J Gastroenterol 2022; 117:1743-1752. [PMID: 36148549 DOI: 10.14309/ajg.0000000000002027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 09/16/2022] [Indexed: 01/11/2023]
Abstract
Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency. It is characterized by impaired B-cell differentiation. Although patients can be diagnosed with CVID anytime during their lifetime, most patients have symptoms for 5-9 years before their diagnosis. The diagnosis of CVID starts with a detailed history focusing on the infectious and noninfectious manifestations of the disease. In patients who are suspected to experience CVID, quantitative immunoglobulins (Ig) should be checked to confirm the diagnosis. IgG should be at least 2 times less than the age-specific SD along with either a low IgA or IgM and with evidence of impaired vaccine response. CVID is usually associated with infectious and/or noninfectious conditions, the latter of which can be inflammatory, autoimmune, lymphoproliferative, or malignant, among other manifestations. Ig therapy has positively affected the disease course of patients with infectious complications but has limited effect on the noninfectious manifestations because the noninfectious complications are related to immune dysregulation involving B cells and T cells rather than primarily due to antibody deficiency. When the gastrointestinal (GI) system is involved, patients with CVID may display signs and symptoms that mimic several GI conditions such as celiac disease, pernicious anemia, or inflammatory bowel diseases. The inflammatory bowel disease-like condition is usually treated with steroids, 5-aminosalicylates, thiopurines, or biologic agents to control the inflammation. In this review, the clinical presentations, diagnostic considerations, and therapeutic options for GI manifestations of CVID will be discussed to facilitate the individualized management of these often-complex patients.
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Mistegaard CE, Jensen L, Christiansen M, Bjerre M, Jensen JMB, Thiel S. Low levels of the innate immune system proteins MASP-2 and MAp44 in patients with common variable immunodeficiency. Scand J Immunol 2022; 96:e13196. [PMID: 35673952 PMCID: PMC9542173 DOI: 10.1111/sji.13196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 11/28/2022]
Abstract
Patients with common variable immunodeficiency (CVID) display low antibody levels and associated symptoms, including an increased risk of infections. The causes of CVID are uncertain and likely heterogeneous. The complement system protects against pathogens and plays essential roles in homeostasis and development. The influence of the complement system in CVID is not established. We investigated CVID patients and healthy individuals for plasma levels of the complement proteins: MASP-1, MASP-2, MASP-3, MAp19 and MAp44. We also tested other patients with symptoms similar to the CVID patients. CVID patients had lower average MASP-2 and MAp44 levels than healthy individuals (P < 0.01); the MASP-2 level was 0.73-fold lower, and the MAp44 level was 0.87-fold lower. This was not observed in the other patient cohorts studied. Our findings in this exploratory study provide new insights into CVID and introduce a complement perspective for future investigations into the underlying mechanisms of the disease.
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Affiliation(s)
- Clara Elbaek Mistegaard
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lisbeth Jensen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Mette Christiansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Bjerre
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Medical Research Laboratory, Aarhus University, Aarhus, Denmark
| | - Jens Magnus Bernth Jensen
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Steffen Thiel
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
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