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Levy-Mendelovich S, Lev A, Avishai E, Budnik I, Dardik R, Barg AA, Somech R, Kenet G. Can T-cell and B-cell excision circles predict development of inhibitors in pediatric hemophilia A? Pediatr Res 2023; 93:1546-1550. [PMID: 36045224 DOI: 10.1038/s41390-022-02268-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/06/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hemophilia A (HA) therapy requires intravenous replacement infusions of factor (F) VIII concentrate. Inhibitors are high-affinity immunoglobulin G that are directed against FVIII and thereby render replacement therapy ineffective. This complication has significant prognostic implications. We aimed to examine the immune system involvement in inhibitor formation specifically T-cell excision circles (TRECs) and B-cell excision circles (KRECs), markers of new T and B cells, respectively, and examine them as surrogate markers for inhibitor formation. METHODS Blood samples were collected from 35 children with severe HA. Children were divided into two groups: with FVIII inhibitors and without FVIII inhibitors. TRECs and KRECs were measured in peripheral blood. RESULTS A total of 11 patients with inhibitors and 24 without were evaluated. Children with inhibitors had higher levels of TRECs however not statistically significant (p = 0.085). CjKREC levels were higher in the inhibitor patients (p = 0.003). Moreover, the sj/cjKREC ratio was lower in the inhibitor patients (p = 0.015). CONCLUSIONS Our findings may add to the notion that inhibitor formation is attributed to humoral immunity due to peripheral B-cell expansion and loss of peripheral tolerance. Improved knowledge regarding the involvement of the immune system in the formation of FVIII inhibitors will enable better therapy tailoring in the era of non-replacement therapies. IMPACT The etiology of FVIII inhibitor formation is multifactorial, in which the immune system plays a pivotal role. Our findings may add to the notion that inhibitor formation is attributed to humoral immunity due to peripheral B-cell expansion and production of antibodies against FVIII. Improved knowledge regarding the involvement of the immune system in the development of FVIII inhibitors will enable the identification of patients prone to inhibitor development and better therapy tailoring in the new era of non-replacement therapies.
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Affiliation(s)
- Sarina Levy-Mendelovich
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel.
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
- The Sheba Talpiot Medical Leadership Program, Tel Hashomer, Israel.
| | - Atar Lev
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation canter, Edmond and Lily Safra Children's Hospital, Sheba Medical Center affiliated with Sackler school of medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Einat Avishai
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ivan Budnik
- Department of Pathophysiology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Rima Dardik
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaaf Arie Barg
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raz Somech
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation canter, Edmond and Lily Safra Children's Hospital, Sheba Medical Center affiliated with Sackler school of medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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2
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Lev A, Asleh M, Levy S, Lee YN, Simon AJ, Stepensky P, Nalbandyan K, Nahum A, Ben-Harosh M, Yablonski D, Broides A, Somech R. SLP76 Mutation Associated with Combined Immunodeficiency and EBV-Related Lymphoma. J Clin Immunol 2023; 43:625-635. [PMID: 36474126 DOI: 10.1007/s10875-022-01412-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
Increased susceptibility to develop severe forms of Epstein-Barr virus (EBV) infection in early age is a significant hallmark of an underlying primary immunodeficiency (PID). Here, we present immunologic and genetic evaluations of a 3-year-old child who was born to first-cousins parents and presented with recurrent infections, failure to thrive, and severe EBV-related infection and proliferation. A diagnosis of diffuse large B cell lymphoma was made and the immunological workup was suggestive of T cell immunodeficiency. Unfortunately, the patient succumbed to EBV-related lymphoma. Whole-exome sequencing revealed a novel homozygous mutation, c.991del.C; p. Q331Sfs*6 in the SLP76 gene. The SLP76 protein, a TCR signaling molecule, was recently linked to a human disease of the immune system. In order to examine the effect of this new SLP76 mutation on T cell signaling, a SLP76-deficient Jurkat-derived T cell line was transduced either with wild-type (WT), or with the specific SLP76 mutant, or with a mock vector. Downstream TCR signaling events, including ERK1/2 phosphorylation, CD69 expression, and Ca2 + mobilization, were reduced in cells harboring the reported mutation, linking this novel mutation to the expected immunological outcome. SLP76 deficiency should be added to the growing list of monogenetic diseases that predispose affected individuals to acquire severe and uncontrolled EBV infections and to develop substantial complications. This case further links mutations in the SLP76 gene to a significant human immunodeficiency and extends its clinical phenotype.
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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
| | - Mahdi Asleh
- Pediatric Hemato-Oncology Department, Soroka University Medical Center, Beer Sheva, Israel.,Joyce & Irving Goldman Medical School, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, 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
| | - 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.,Division of Haematology and Bone Marrow Transplantation, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Polina Stepensky
- Department of Bone Marrow Transplantation, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Karen Nalbandyan
- Department of Pathology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Amit Nahum
- Pediatrics Department A and the Primary Immunodeficiency Research Laboratory, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Miriam Ben-Harosh
- Pediatric Hemato-Oncology Department, Soroka University Medical Center, Beer Sheva, Israel
| | - Deborah Yablonski
- Department of Immunology, Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Arnon Broides
- Pediatric Immunology, Soroka University Medical Center, Beer-Sheva, 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.
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3
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Iancu O, Allen D, Knop O, Zehavi Y, Breier D, Arbiv A, Lev A, Lee YN, Beider K, Nagler A, Somech R, Hendel A. Multiplex HDR for disease and correction modeling of SCID by CRISPR genome editing in human HSPCs. MOLECULAR THERAPY. NUCLEIC ACIDS 2022; 31:105-121. [PMID: 36618262 PMCID: PMC9813580 DOI: 10.1016/j.omtn.2022.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
Severe combined immunodeficiency (SCID) is a group of disorders caused by mutations in genes involved in the process of lymphocyte maturation and function. CRISPR-Cas9 gene editing of the patient's own hematopoietic stem and progenitor cells (HSPCs) ex vivo could provide a therapeutic alternative to allogeneic hematopoietic stem cell transplantation, the current gold standard for treatment of SCID. To eliminate the need for scarce patient samples, we engineered genotypes in healthy donor (HD)-derived CD34+ HSPCs using CRISPR-Cas9/rAAV6 gene-editing, to model both SCID and the therapeutic outcomes of gene-editing therapies for SCID via multiplexed homology-directed repair (HDR). First, we developed a SCID disease model via biallelic knockout of genes critical to the development of lymphocytes; and second, we established a knockin/knockout strategy to develop a proof-of-concept single-allelic gene correction. Based on these results, we performed gene correction of RAG2-SCID patient-derived CD34+ HSPCs that successfully developed into CD3+ T cells with diverse TCR repertoires in an in vitro T cell differentiation platform. In summary, we present a strategy to determine the optimal configuration for CRISPR-Cas9 gene correction of SCID using HD-derived CD34+ HSPCs, and the feasibility of translating this gene correction approach in patient-derived CD34+ HSPCs.
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Affiliation(s)
- Ortal Iancu
- The Institute for Advanced Materials and Nanotechnology, The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan 5290002, Israel
| | - Daniel Allen
- The Institute for Advanced Materials and Nanotechnology, The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan 5290002, Israel
| | - Orli Knop
- The Institute for Advanced Materials and Nanotechnology, The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan 5290002, Israel
| | - Yonathan Zehavi
- The Institute for Advanced Materials and Nanotechnology, The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan 5290002, Israel
| | - Dor Breier
- The Institute for Advanced Materials and Nanotechnology, The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan 5290002, Israel
| | - Adaya Arbiv
- The Institute for Advanced Materials and Nanotechnology, The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan 5290002, Israel
| | - Atar Lev
- The Institute for Advanced Materials and Nanotechnology, The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan 5290002, Israel,Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel-HaShomer, Ramat Gan 5266202, 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, Tel-HaShomer, Ramat Gan 5266202, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Katia Beider
- The Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-HaShomer, Ramat Gan 5266202, Israel
| | - Arnon Nagler
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel,The Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-HaShomer, Ramat Gan 5266202, Israel
| | - Raz Somech
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel-HaShomer, Ramat Gan 5266202, Israel,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ayal Hendel
- The Institute for Advanced Materials and Nanotechnology, The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan 5290002, Israel,Corresponding author Ayal Hendel, The Institute for Advanced Materials and Nanotechnology, The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan 5290002, Israel.
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4
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Delmonte OM, Castagnoli R, Yu J, Dvorak CC, Cowan MJ, Dávila Saldaña BJ, De Ravin SS, Mamcarz E, Chang CK, Daley SR, Griffith LM, Notarangelo LD, Puck JM. Poor T-cell receptor β repertoire diversity early posttransplant for severe combined immunodeficiency predicts failure of immune reconstitution. J Allergy Clin Immunol 2022; 149:1113-1119. [PMID: 34384841 PMCID: PMC9132846 DOI: 10.1016/j.jaci.2021.07.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/25/2021] [Accepted: 07/29/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Development of a diverse T-cell receptor β (TRB) repertoire is associated with immune recovery following hematopoietic cell transplantation (HCT) for severe combined immunodeficiency (SCID). High-throughput sequencing of the TRB repertoire allows evaluation of clonotype dynamics during immune reconstitution. OBJECTIVES We investigated whether longitudinal analysis of the TRB repertoire would accurately describe T-cell receptor diversity and illustrate the quality of T-cell reconstitution following HCT or gene therapy for SCID. METHODS We used high-throughput sequencing to study composition and diversity of the TRB repertoire in 27 infants with SCID at 3, 6, and 12 months and yearly posttreatment(s). Total RNA from peripheral blood was used as template to amplify TRB rearrangements. RESULTS TRB sequence analysis showed poor diversity at 3 months, followed by significant improvement by 6 months after cellular therapies. Kinetics of development of TRB diversity were similar in patients with a range of underlying gene defects. However, in patients with RAG and DCLRE1C defects, HCT with no conditioning or immune suppression only resulted in lower diversity than did HCT with conditioning. HCT from a matched donor correlated with higher diversity than did HCT from a mismatched donor. Naive CD4+ T-cell count at 6 months post-HCT correlated with higher TRB diversity. A Shannon index of diversity of 5.2 or lower 3 months after HCT predicted a need for a second intervention. CONCLUSIONS TRB repertoire after hematopoietic cell therapies for SCID provides a quantitative and qualitative measure of diversity of T-cell reconstitution and permits early identification of patients who may require a second intervention.
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Affiliation(s)
- Ottavia M Delmonte
- Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, Md
| | - Riccardo Castagnoli
- Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, Md
| | - Jason Yu
- Division of Allergy, Immunology and Blood and Marrow Transplantation, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, Calif; Smith Cardiovascular Research Institute, San Francisco, Calif; UCSF Benioff Children's Hospital, San Francisco, Calif
| | - Christopher C Dvorak
- Division of Allergy, Immunology and Blood and Marrow Transplantation, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, Calif; UCSF Benioff Children's Hospital, San Francisco, Calif
| | - Morton J Cowan
- Division of Allergy, Immunology and Blood and Marrow Transplantation, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, Calif; Smith Cardiovascular Research Institute, San Francisco, Calif; UCSF Benioff Children's Hospital, San Francisco, Calif
| | - Blachy J Dávila Saldaña
- Division of Blood and Marrow Transplantation, Children's National Medical Center, Washington, DC
| | - Suk See De Ravin
- Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, Md
| | - Ewelina Mamcarz
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, Tenn
| | - Catherine K Chang
- Division of Allergy, Immunology and Blood and Marrow Transplantation, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, Calif; UCSF Benioff Children's Hospital, San Francisco, Calif
| | - Stephen R Daley
- Centre for Immunology and Infection Control, School of Biomedical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Linda M Griffith
- Division of Allergy Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, Md.
| | - Jennifer M Puck
- Division of Allergy, Immunology and Blood and Marrow Transplantation, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, Calif; Smith Cardiovascular Research Institute, San Francisco, Calif; UCSF Benioff Children's Hospital, San Francisco, Calif.
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5
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Weiss B, Ben-Horin S, Lev A, Broide E, Yavzori M, Lahat A, Kopylov U, Picard O, Eliakim R, Ron Y, Avni-Biron I, Yerushalmy-Feler A, Assa A, Somech R, Bar-Gil Shitrit A. Immune function in newborns with in-utero exposure to anti-TNFα therapy. Front Pediatr 2022; 10:935034. [PMID: 36120653 PMCID: PMC9470929 DOI: 10.3389/fped.2022.935034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND AIM Anti-TNFα is measurable in infants exposed in utero up to 12 months of age. Data about the exposure effect on the infant's adaptive immunity are limited. We aimed to prospectively evaluate the distribution and function of T and B cells, in infants of females with inflammatory bowel disease, in utero exposed to anti-TNFα or azathioprine. METHODS A prospective multi-center study conducted 2014-2017. Anti-TNFα levels were measured in cord blood, and at 3 and 12 months. T-cell repertoire and function were analyzed at 3 and 12 months by flow-cytometry, expression of diverse T cell receptors (TCR) and T-cell receptor excision circles (TREC) quantification assay. Serum immunoglobulins and antibodies for inactivated vaccines were measured at 12 months. Baseline clinical data were retrieved, and 2-monthly telephonic interviews were performed regarding child infections and growth. RESULTS 24 pregnant females, age 30.6 (IQR 26.5-34.5) years were recruited, 20 with anti-TNFα (infliximab 8, adalimumab 12), and 4 with azathioprine treatment. Cord blood anti-TNFα was higher than maternal blood levels [4.3 (IQR 2.3-9.2) vs. 2.5 (IQR 1.3-9.7) mcg/ml], declining at 3 and 12 months. All infants had normal number of B-cells (n = 17), adequate levels of immunoglobulins (n = 14), and protecting antibody levels to Tetanus, Diphtheria, Hemophilus influenza-B and hepatitis B (n = 17). All had normal CD4+, CD8+ T-cells, and TREC numbers. TCR repertoire was polyclonal in 18/20 and slightly skewed in 2/20 infants. No serious infections requiring hospitalization were recorded. CONCLUSION We found that T-cell and B-cell immunity is fully mature and immune function is normal in infants exposed in utero to anti-TNFα, as in those exposed to azathioprine. Untreated controls and large-scale studies are needed to confirm these results.
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Affiliation(s)
- Batia Weiss
- Division of Pediatric Gastroenterology and Nutrition, Edmond and Lily Safra Children's Hospital, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Chaim Sheba Medical Center, Institute of Gastroenterology, Ramat Gan, Israel
| | - Atar Lev
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Immunology Laboratory, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Efrat Broide
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Pediatric Gastroenterology, Assaf-Harofe Medical Center, Ramat Gan, Israel
| | - Miri Yavzori
- Chaim Sheba Medical Center, Institute of Gastroenterology, Ramat Gan, Israel
| | - Adi Lahat
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Chaim Sheba Medical Center, Institute of Gastroenterology, Ramat Gan, Israel
| | - Uri Kopylov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Chaim Sheba Medical Center, Institute of Gastroenterology, Ramat Gan, Israel
| | - Orit Picard
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Chaim Sheba Medical Center, Institute of Gastroenterology, Ramat Gan, Israel
| | - Rami Eliakim
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Chaim Sheba Medical Center, Institute of Gastroenterology, Ramat Gan, Israel
| | - Yulia Ron
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Souraski Medical Center, Institute of Gastroenterology, Tel Aviv, Israel
| | - Irit Avni-Biron
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
| | - Anat Yerushalmy-Feler
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Pediatric Gastroenterology, Souraski Medical Center, Dana Duek Children's Hospital, Tel Aviv, Israel
| | - Amit Assa
- Schneider Children's Hospital, Institute of Pediatric Gastroenterology, Hepatology and Nutrition, Petah Tikva, Israel.,The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Raz Somech
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Immunology Laboratory, Chaim Sheba Medical Center, Ramat Gan, Israel.,Department of Pediatrics A, Edmond and Lily Safra Children's Hospital, Ramat Gan, Israel
| | - Ariella Bar-Gil Shitrit
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.,Medical School, The Hebrew University, Jerusalem, Israel
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Immune and TRG repertoire signature of the thymus in Down syndrome patients. Pediatr Res 2021; 89:102-109. [PMID: 32231346 DOI: 10.1038/s41390-020-0857-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/10/2020] [Accepted: 03/11/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patients with Down syndrome (DS) are at increased risk for infections and autoimmune disorders. Although several immunological abnormalities were previously found, differences in T cell receptor repertoire have never been shown. Thus we compared the T cell receptor gamma (TRG) repertoire in DS and non-syndromic pediatric patients by next-generation sequencing, in addition to other immunological markers. METHODS Genomic DNA was extracted from thymuses of pediatric patients who underwent heart surgery, where six were with DS and six were non-syndromic patients. Peripheral blood counts, T cell subpopulations, thymus TCR excision circles (TRECs), spectratyping, and next-generation sequencing for TRG were analyzed. RESULTS The mean age of the patients was 7 months and the mean lymphocyte count was slightly lower in patients with DS, whereas thymus TREC results were similar to non-syndromic patients (p = 0.197). The TRG repertoire analysis showed that patients with DS had a significantly larger number of unique TRG sequences, together with decreased clonal expansion. Lastly, the V and J gene usages in the thymus were similar in DS and non-syndromic patients. CONCLUSIONS Patients with DS showed increased TRG repertoire diversity with decreased clonal expansion compared to non-syndromic patients. IMPACT Alterations in T cell receptor gamma repertoire were found in patients with Down syndrome using next-generation sequencing (NGS) technique. Patients showed increased repertoire diversity and decreased clonal expansion compared to controls. These findings add to previous reports on abnormalities of other immune system components in patients with Down syndrome. NGS technique may point out differences not seen by previous methods. Repertoire abnormalities may contribute to those patients' predisposition to infections and autoimmune diseases.
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7
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Goldberg L, Simon AJ, Lev A, Barel O, Stauber T, Kunik V, Rechavi G, Somech R. Atypical immune phenotype in severe combined immunodeficiency patients with novel mutations in IL2RG and JAK3. Genes Immun 2020; 21:326-334. [PMID: 32921793 DOI: 10.1038/s41435-020-00111-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/14/2020] [Accepted: 09/02/2020] [Indexed: 11/09/2022]
Abstract
Mutations in the common gamma chain of the interleukin 2 receptor (IL2RG) or the associated downstream signaling enzyme Janus kinase 3 (JAK3) genes are typically characterized by a T cell-negative, B cell-positive, natural killer (NK) cell-negative (T-B+NK-) severe combined immunodeficiency (SCID) immune phenotype. We report clinical course, immunological, genetic and proteomic work-up of two patients with different novel mutations in the IL-2-JAK3 pathway with a rare atypical presentation of T-B+NK- SCID. Lymphocyte subpopulation revealed significant T cells lymphopenia, normal B cells, and NK cells counts (T-B+NK+SCID). Despite the presence of B cells, IgG levels were low and IgA and IgM levels were undetectable. T-cell proliferation in response to mitogens in patient 1 was very low and T-cell receptor V-beta chain repertoire in patient 2 was polyclonal. Whole-exome sequencing revealed novel mutations in both patients (patient 1-c.923delC frame-shift mutation in the IL2RG gene, patient 2-c.G172A a homozygous missense mutation in the JAK3 gene). Bioinformatic analysis of the JAK3 mutation indicated deleterious effect and 3D protein modeling located the mutation to a surface exposed alpha-helix structure. Our findings help to link between genotype and phenotype, which is a key factor for the diagnosis and treatment of SCID patients.
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Affiliation(s)
- Lior Goldberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Department A, Pediatric Immunology Service, Jeffrey Modell Foundation (JMF) Center, Sheba Medical Center, Tel HaShomer, Israel
| | - Amos J Simon
- Pediatric Department A, Pediatric Immunology Service, Jeffrey Modell Foundation (JMF) Center, Sheba Medical Center, Tel HaShomer, Israel.,Sheba Cancer Research Center, Sheba Medical Center, Tel HaShomer, Israel
| | - Atar Lev
- Pediatric Department A, Pediatric Immunology Service, Jeffrey Modell Foundation (JMF) Center, Sheba Medical Center, Tel HaShomer, Israel
| | - Ortal Barel
- Sheba Cancer Research Center, Sheba Medical Center, Tel HaShomer, Israel.,The Wohl Institute for Translational Medicine, Sheba Medical Center, Tel HaShomer, Israel
| | - Tali Stauber
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Department A, Pediatric Immunology Service, Jeffrey Modell Foundation (JMF) Center, Sheba Medical Center, Tel HaShomer, Israel
| | - Vered Kunik
- Bioinformatics Consulting, Gat Rimon, Israel
| | - Gideon Rechavi
- Sheba Cancer Research Center, Sheba Medical Center, Tel HaShomer, Israel.,The Wohl Institute for Translational Medicine, Sheba Medical Center, Tel HaShomer, Israel
| | - Raz Somech
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. .,Pediatric Department A, Pediatric Immunology Service, Jeffrey Modell Foundation (JMF) Center, Sheba Medical Center, Tel HaShomer, Israel.
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8
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Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is the effective mean of immune restoration in severe combined immunodefiency (SCID). Usually, HSCT without cytoreductive conditioning is attempted. Nevertheless, conditioning procedures are still preferred in a subset of patients. Herein, we describe the immunological outcome in a cohort of conditioned and unconditioned patients, from diagnosis, through transplantation, to follow-up. This retrospective study was conducted on 17 patients with SCID (10 conditioned, 7 unconditioned) who later underwent HSCT. Immune reconstitution was assessed in the post-transplant year by quantification of T cell receptor excision circles (TRECs) and kappa-deleting recombination excision circles (KRECs), among additional laboratory and clinical evaluations. Unconditioned patients were diagnosed and transplanted earlier. TREC and KREC quantification showed a gradual increase in both groups, with higher levels in the conditioned group. Engraftment percentages differed drastically between groups, favoring the conditioned group. Unconditioned patients were significantly more dependent on intravenous immunoglobulins (IVIGs). One patient from each group succumbed to disease complications. Conditioning demonstrated superior laboratorial outcomes. Patients with unique characteristics (i.e., consanguinity, Bacillus Calmette-Guérin vaccination, impaired access to IVIG) may require personalized considerations. The effort to implement secondary prevention of SCID with newborn screening should continue.
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Qin F, Shi L, Li Q, Zhang Z, Liu L, Li J, Yang G, Lai YR. Immune recovery after in vivo T-cell depletion myeloablative conditioning hematopoietic stem cell transplantation in severe beta-thalassemia children. Eur J Haematol 2019; 103:342-350. [PMID: 31276236 DOI: 10.1111/ejh.13289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND The clinical outcome of hematopoietic stem cell transplantation (HSCT) in those with severe beta-thalassemia (β-TM) is closely related to post-transplantation immune reconstitution (IR). However, the data on the IR in these settings are scarce. METHODS A prospective analysis of the clinical outcome and IR in 47 children with severe β-TM who underwent in vivo T-cell depletion myeloablative conditioning and matched sibling donor HSCT was performed. Immune reconstitution, including immune cell subset counts, as well as the generation of new T and B cells assays after HSCT, was measured. RESULTS In the first year after HSCT, bacterial infections and cytomegalovirus (CMV) reactivation were observed in 70.2% and 36.2% of the patients, respectively. In the same period, poor CD4+ T-cell recovery was observed. The B cells recovered within 6 months. Natural killer (NK) cells recovered as early as 1 month, but their function was defective. Cord blood and bone marrow (CB + BM) group had slower T-cell recovery, and higher B cells and NK cells in comparison with peripheral blood and bone marrow (PB + BM) group. CONCLUSIONS The high incidence of infection within 1 year after in vivo T-cell depletion myeloablative conditioning HSCT in severe β-TM was consistent with poor IR.
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Affiliation(s)
- Fang Qin
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.,Department of Rheumatology and Immunology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lingling Shi
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Qiaochuan Li
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhongming Zhang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lianjin Liu
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jing Li
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Gaohui Yang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yong-Rong Lai
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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10
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Marcus N, Stauber T, Lev A, Simon AJ, Stein J, Broides A, Somekh I, Almashanu S, Somech R. MHC II deficient infant identified by newborn screening program for SCID. Immunol Res 2019; 66:537-542. [PMID: 30084052 DOI: 10.1007/s12026-018-9019-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Newborn screening (NBS) programs for severe combined immunodeficiency (SCID), using the TREC-based assay, have enabled early diagnosis, prompt treatment, and eventually changed the natural history of affected infants. Nevertheless, it was believed that some affected infants with residual T cell, such as patients with MHC II deficiency, will be misdiagnosed by this assay. A full immune workup and genetic analysis using direct Sanger sequencing and whole exome sequencing have been performed to a patient that was identified by the Israeli NBS program for SCID. The patient was found to have severe CD4 lymphopenia with an inverted CD4/CD8 ratio, low TREC levels in peripheral blood, abnormal response to mitogen stimulation, and a skewed T cell receptor repertoire. HLA-DR expression on peripheral blood lymphocytes was undetectable suggesting a diagnosis of MHC II deficiency. Direct sequencing of the RFX5 gene revealed a stop codon change (p. R239X, c. C715T), which could cause the patient's immune phenotype. His parents were found to be heterozygote carriers for the mutation. Whole exome sequencing could not identify other potential mutations to explain his immunodeficiency. The patient underwent successful conditioned hematopoietic stem cell transplantation from healthy matched unrelated donor and is currently well and alive with full chimerism. Infants with MHC class II deficiency can potentially be identified by the TREC-based assay NBS for SCID. Therefore, MHC II molecules (e.g., HLA-DR) measurement should be part of the confirmatory immune-phenotyping for patients with positive screening results. This will make the diagnosis of such patients straightforward.
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Affiliation(s)
- Nufar Marcus
- Allergy and Immunology Unit, Felsenstein Medical Research Center, Kipper Institute of Immunology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Stauber
- Pediatric Department A, Pediatric Immunology Service, Jeffrey Modell Foundation Center, 52621, Tel Hashomer, Israel
- Edmond and Lily Safra Children's Hospital, Sheba Medical Center, 52621, Tel Hashomer, Israel
| | - Atar Lev
- Pediatric Department A, Pediatric Immunology Service, Jeffrey Modell Foundation Center, 52621, Tel Hashomer, Israel
- Edmond and Lily Safra Children's Hospital, Sheba Medical Center, 52621, Tel Hashomer, Israel
| | - Amos J Simon
- Pediatric Department A, Pediatric Immunology Service, Jeffrey Modell Foundation Center, 52621, Tel Hashomer, Israel
- Edmond and Lily Safra Children's Hospital, Sheba Medical Center, 52621, Tel Hashomer, Israel
| | - Jerry Stein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department for Hemato-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Arnon Broides
- Pediatric Immunology Clinic, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Ido Somekh
- Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Shlomo Almashanu
- The National Center for Newborn Screening, Ministry of Health, 52621, Tel HaShomer, Israel
| | - Raz Somech
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Pediatric Department A, Pediatric Immunology Service, Jeffrey Modell Foundation Center, 52621, Tel Hashomer, Israel.
- Edmond and Lily Safra Children's Hospital, Sheba Medical Center, 52621, Tel Hashomer, Israel.
- The 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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Mahtab S, Kar P, Saha S, Sreenivas V, Sottini A, Imberti L, Goswami R. Central Immune Tolerance of T and B Cells in Patients With Idiopathic Hypoparathyroidism, T1D, and Autoimmune Thyroiditis. J Endocr Soc 2019; 3:1175-1184. [PMID: 31139764 PMCID: PMC6532674 DOI: 10.1210/js.2018-00344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/15/2019] [Indexed: 02/07/2023] Open
Abstract
CONTEXT Pathogenesis of idiopathic hypoparathyroidism (IH) is under investigation. Abnormalities in central immune tolerance have yet not been investigated in this condition. T-cell receptor excision circles (TRECs) and kappa-deleting recombination excision circles (KRECs), formed during receptor gene rearrangements, are tools to assess central T- and B-cell output. OBJECTIVE We assessed the number of circulating TRECs and KRECs in patients with IH, autoimmune type 1 diabetes (T1D), and autoimmune thyroiditis (ATs) and healthy controls (HCs). DESIGN Comparative case-control at tertiary care center. SUBJECTS AND METHODS Absolute and relative TRECs and KRECs were measured in DNA extracted from whole blood of patients with IH (n = 181, 22 of whom were reassessed after a decade of follow-up) and T1D (n = 133), AT (n = 53), and HC (n = 135) using a quantitative real-time PCR/TaqMan® probe technique. RESULTS Absolute and relative means of TRECs and KRECs in IH were comparable to HCs, and no differences were found between IH with and without calcium-sensing receptor antibodies or class I HLA-A*26:01 association. TRECs and KRECs did not change after a decade of follow-up. T1D had significantly higher absolute TRECs than IH, AT, and HCs, whereas AT patients showed lower TRECs and the highest KRECs; these levels showed no noteworthy correlation with thyroid dysfunctions. CONCLUSION Patients with IH showed TRECs and KRECs comparable to HCs, indicating an intact mechanism of T- and B-cell central immune tolerance. Interestingly, absolute TRECs were significantly higher in T1D than HCs, suggesting impaired central immune tolerance in T1D.
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Affiliation(s)
- Samrina Mahtab
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Parmita Kar
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Soma Saha
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | | | - Alessandra Sottini
- Diagnostic Department, Centro di Ricerca Emato-oncologica AIL, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Luisa Imberti
- Diagnostic Department, Centro di Ricerca Emato-oncologica AIL, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Ravinder Goswami
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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12
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Benavides-Nieto M, Méndez-Echevarría A, Del Rosal T, García-García ML, Casas I, Pozo F, de la Serna O, Lopez-Granados E, Rodriguez-Pena R, Calvo C. The role of respiratory viruses in children with humoral immunodeficiency on immunoglobulin replacement therapy. Pediatr Pulmonol 2019; 54:194-199. [PMID: 30575324 PMCID: PMC7167964 DOI: 10.1002/ppul.24214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 11/14/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND The role of viruses in children with respiratory tract infections and humoral immunodeficiencies has hardly been studied. We have evaluated these infections in children with humoral immunodeficiencies who required immunoglobulin replacement therapy, considering their relationship with symptoms, lung function, bacterial co-infection, and outcomes. METHODS We conducted a prospective case-control study during a 1-year period, including children with humoral immunodeficiencies receiving immunoglobulin replacement therapy. For each patient, at least one healthy family member was included. Respiratory samples for viral detection were taken every 1-3 months, and in case of respiratory tract infections. Symptoms questionnaires were filled biweekly. Spirometry and sputum culture were performed in every episode. RESULTS Sixty-six episodes were analyzed in 14 patients (median age 12 years; IQR 7-17), identifying 18 respiratory viruses (27.3%), being rhinovirus the most frequently isolated one (12/18; 66%). Positive viral episodes were associated with clinical symptoms (89% vs 43%), more frequent antibiotic treatment (44% vs 15%) or hospital admission (22% vs 0%) than negative ones. Patients with positive viral detection showed impaired lung function, with lower FEV1 and FVC values. CONCLUSIONS In our experience, viral respiratory tract infections can cause significant respiratory symptoms and impaired lung function, in children with HID, despite immunoglobulin replacement therapy. These patients could benefit from the monitoring of viral infections, as these may be a gateway for ongoing lung damage.
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Affiliation(s)
- Marta Benavides-Nieto
- Pediatric Infectious Diseases Department, Hospital Universitario La Paz, Madrid, Fundación IdiPaz, Madrid, Spain
| | - Ana Méndez-Echevarría
- Pediatric Infectious Diseases Department, Hospital Universitario La Paz, Madrid, Fundación IdiPaz, Madrid, Spain.,Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - Teresa Del Rosal
- Pediatric Infectious Diseases Department, Hospital Universitario La Paz, Madrid, Fundación IdiPaz, Madrid, Spain.,Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - María Luz García-García
- Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain.,Pediatrics and Pneumology Department, Severo Ochoa Hospital, Leganés, Madrid, Spain
| | - Inmaculada Casas
- Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain.,Respiratory Virus and Influenza Unit, CNM, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Francisco Pozo
- Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain.,Respiratory Virus and Influenza Unit, CNM, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Olga de la Serna
- Paediatric Pneumology Department, Hospital La Paz, Madrid, Spain
| | | | - Rebeca Rodriguez-Pena
- Immunology Department, Hospital Universitario La Paz, Fundación IdiPaz, Madrid, Spain
| | - Cristina Calvo
- Pediatric Infectious Diseases Department, Hospital Universitario La Paz, Madrid, Fundación IdiPaz, Madrid, Spain.,Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain.,TEDDY Network (European Network of Excellence for Pediatric Clinical Research), Pavia, Italy
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13
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Somekh I, Marquardt B, Liu Y, Rohlfs M, Hollizeck S, Karakukcu M, Unal E, Yilmaz E, Patiroglu T, Cansever M, Frizinsky S, Vishnvenska-Dai V, Rechavi E, Stauber T, Simon AJ, Lev A, Klein C, Kotlarz D, Somech R. Novel Mutations in RASGRP1 are Associated with Immunodeficiency, Immune Dysregulation, and EBV-Induced Lymphoma. J Clin Immunol 2018; 38:699-710. [DOI: 10.1007/s10875-018-0533-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 07/09/2018] [Indexed: 12/25/2022]
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14
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Stepensky P, Keller B, Shamriz O, von Spee-Mayer C, Friedmann D, Shadur B, Unger S, Fuchs S, NaserEddin A, Rumman N, Amro S, Molho Pessach V, Abuzaitoun O, Somech R, Elpeleg O, Ehl S, Warnatz K. T + NK + IL-2 Receptor γ Chain Mutation: a Challenging Diagnosis of Atypical Severe Combined Immunodeficiency. J Clin Immunol 2018; 38:527-536. [PMID: 29948574 DOI: 10.1007/s10875-018-0514-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 05/17/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE All reported patients with hypomorphic X-linked severe combined immunodeficiency (X-SCID) due to c.664C>T (p.R222C) mutations in the gene (IL2RG) encoding the common γ chain (γc) have presented with opportunistic infections within the first year of life, despite the presence of nearly normal NK and T cell numbers. Reporting five children of one extended family with hemizygous mutations in IL2RG, we explore potential diagnostic clues and extend our comprehension of the functional impact of this mutation. METHODS Whole exome sequencing (WES); detailed immune phenotyping; cytokine-induced STAT phosphorylation; B, T, and NK cell activation; and quantification of sjTRECs in five Arab children with c.664C>T (p.R222C) IL2RG mutation. RESULTS The mean age at clinical presentation with respiratory tract infection or diarrhea was 6.8 (range: 2-12) months. None of the children presented with opportunistic infections. Diagnostic clues were early onset in the first year of life, and a suggestive family history associated with reduced naïve CD4 T cells and absent switched memory B cells. Number and phenotype of NK cells and innate-like lymphocytes were normal. The diagnosis was made by WES and corroborated by absent STAT phosphorylation and reduced functional response after IL-2 and IL-21 stimulation. Four patients underwent successful hematopoietic stem cell transplantation. CONCLUSIONS As early diagnosis and treatment are important, a high index of suspicion in the diagnosis of c.664C>T (p.R222C) X-SCID is needed. This requires prompt genetic testing by next generation sequencing in order to avoid unnecessary delays in the definite diagnosis since immunological work up may not be discriminating. Assays directly testing cytokine signaling or cytokine-dependent functions are helpful in confirming the functional impact of the identified hypomorphic variants.
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Affiliation(s)
- Polina Stepensky
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Hospital, POB 12000, 91200, Jerusalem, Israel.
| | - Baerbel Keller
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Oded Shamriz
- Pediatric Division, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Caroline von Spee-Mayer
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - David Friedmann
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bella Shadur
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Hospital, POB 12000, 91200, Jerusalem, Israel.,Immunology Division, Garvan Institute of Medical Research, Sydney, Australia.,Graduate Research School, The University of New South Wales, Sydney, Australia
| | - Susanne Unger
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Fuchs
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Adeeb NaserEddin
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah-Hebrew University Hospital, POB 12000, 91200, Jerusalem, Israel
| | - Nisreen Rumman
- Pediatric Department, Makassed Hospital, Jerusalem, Israel
| | - Sara Amro
- Pediatric Department, Makassed Hospital, Jerusalem, Israel
| | - Vered Molho Pessach
- Department of Dermatology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Omar Abuzaitoun
- Nablus Specialty Hospital, Palestinian Authority, Nablus, Palestine
| | - Raz Somech
- Pediatric Department A and the Immunology Services, "Edmond and Lily Safra" Children's Hospital, Jeffrey Modell Foundation Center, Sheba Medical Center, Tel Hashomer affiliated with Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Elpeleg
- Monique and Jacques Roboh Department of Genetic Research, Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | - Stephan Ehl
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Warnatz
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg and Faculty of Medicine, University of Freiburg, Freiburg, Germany
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15
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Krauthammer A, Lahad A, Goldberg L, Sarouk I, Weiss B, Somech R, Soudack M, Pessach IM. Elevated IgM levels as a marker for a unique phenotype in patients with Ataxia telangiectasia. BMC Pediatr 2018; 18:185. [PMID: 29866155 PMCID: PMC5987459 DOI: 10.1186/s12887-018-1156-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 05/22/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Ataxia telangiectasia (AT) is a rare, multi-systemic, genetic disorder. Mutations in the ATM gene cause dysfunction in cell-cycle, apoptosis and V (D) J recombination leading to neurodegeneration, cellular, humoral immunodeficiencies and predisposition to malignancies. Previous studies have suggested that a sub-group of AT patients with elevated IgM levels have a distinct and more severe phenotype. In the current study we aimed to better characterize this group of patients. METHODS We performed a retrospective review of 46 patient records, followed from January 1986 to January 2015 at the Israeli National AT Center. Demographic, clinical, radiological, laboratory data was reviewed and compared between AT patients with elevated IgM levels (EIgM) and patients with normal IgM levels (NIgM). RESULTS 15/46(32.6%) patients had significantly elevated IgM levels. This group had a unique phenotype characterized mainly by increased risk of infection and early mortality. Colonization of lower respiratory tract with Mycobacterium gordonae and Pseudomonas aeruginosa as well as viral skin infections were more frequent in EIgM patients. Patients with NIgM had a significantly longer survival as compared to patients with EIgM but had an increased incidence of fatty liver or cirrhosis. T-cell recombination excision circles and kappa-deleting element recombination circle levels were significantly lower in the EIgM group, suggesting an abnormal class switching in this group. CONCLUSIONS EIgM in AT patients are indicative of a more severe phenotype that probably results from a specific immune dysfunction. EIgM in AT should be considered a unique AT phenotype that may require different management.
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Affiliation(s)
- Alexander Krauthammer
- Department of Pediatrics, The Edmond and Lily Safra Children’s Hospital, 52625 Tel- Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Avishay Lahad
- Department of Pediatrics, The Edmond and Lily Safra Children’s Hospital, 52625 Tel- Hashomer, Israel
- Pediatric Gastroenterology Unit, The Edmond and Lily Safra Children’s Hospital, Tel- Hashomer, Israel
| | - Lior Goldberg
- Department of Pediatrics, The Edmond and Lily Safra Children’s Hospital, 52625 Tel- Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ifat Sarouk
- Department of Pediatrics, The Edmond and Lily Safra Children’s Hospital, 52625 Tel- Hashomer, Israel
- Pediatric Pulmonary Unit, The Edmond and Lily Safra Children’s Hospital, Tel- Hashomer, Israel
| | - Batia Weiss
- Pediatric Gastroenterology Unit, The Edmond and Lily Safra Children’s Hospital, Tel- Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raz Somech
- Department of Pediatrics, The Edmond and Lily Safra Children’s Hospital, 52625 Tel- Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michalle Soudack
- Department of Pediatrics, The Edmond and Lily Safra Children’s Hospital, 52625 Tel- Hashomer, Israel
- Pediatric Radiology Unit, The Edmond and Lily Safra Children’s Hospital, Tel- Hashomer, Israel
| | - Itai M. Pessach
- The Claudio Cohen Department of Pediatric Intensive Care, The Edmond and Lily Safra Children’s Hospital, Tel- Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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16
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Richardson AM, Moyer AM, Hasadsri L, Abraham RS. Diagnostic Tools for Inborn Errors of Human Immunity (Primary Immunodeficiencies and Immune Dysregulatory Diseases). Curr Allergy Asthma Rep 2018; 18:19. [PMID: 29470720 DOI: 10.1007/s11882-018-0770-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of diagnostic testing in primary immunodeficiency and immune dysregulatory disorders (PIDDs), particularly focusing on flow cytometry and genetic techniques, utilizing specific examples of PIDDs. RECENT FINDINGS Flow cytometry remains a vital tool in the diagnosis and monitoring of immunological diseases. Its utility ranges from cellular analysis and specific protein quantitation to functional assays and signaling pathway analysis. Mass cytometry combines flow cytometry and mass spectrometry to dramatically increase the throughput of multivariate single-cell analysis. Next-generation sequencing in combination with other molecular techniques and processing algorithms has become more widely available and identified the diverse and heterogeneous genetic underpinnings of these disorders. As the spectrum of disease is further clarified by increasing immunological, genetic, and epigenetic knowledge, the careful application of these diagnostic tools and bioinformatics will assist not only in our understanding of these complex disorders, but also enable the implementation of personalized therapeutic approaches for disease management.
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Affiliation(s)
- Annely M Richardson
- Division of Allergic Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ann M Moyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Linda Hasadsri
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Roshini S Abraham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
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17
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Varda-Bloom N, Danylesko I, Shouval R, Eldror S, Lev A, Davidson J, Rosenthal E, Volchek Y, Shem-Tov N, Yerushalmi R, Shimoni A, Somech R, Nagler A. Immunological effects of nilotinib prophylaxis after allogeneic stem cell transplantation in patients with advanced chronic myeloid leukemia or philadelphia chromosome-positive acute lymphoblastic leukemia. Oncotarget 2018; 8:418-429. [PMID: 27880933 PMCID: PMC5352130 DOI: 10.18632/oncotarget.13439] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 11/08/2016] [Indexed: 01/18/2023] Open
Abstract
Allogeneic stem cell transplantation remains the standard treatment for resistant advanced chronic myeloid leukemia and Philadelphia chromosome–positive acute lymphoblastic leukemia. Relapse is the major cause of treatment failure in both diseases. Post-allo-SCT administration of TKIs could potentially reduce relapse rates, but concerns regarding their effect on immune reconstitution have been raised. We aimed to assess immune functions of 12 advanced CML and Ph+ ALL patients who received post-allo-SCT nilotinib. Lymphocyte subpopulations and their functional activities including T-cell response to mitogens, NK cytotoxic activity and thymic function, determined by quantification of the T cell receptor (TCR) excision circles (TREC) and TCR repertoire, were evaluated at several time points, including pre-nilotib-post-allo-SCT, and up to 365 days on nilotinib treatment. NK cells were the first to recover post allo-SCT. Concomitant to nilotinib administration, total lymphocyte counts and subpopulations gradually increased. CD8 T cells were rapidly reconstituted and continued to increase until day 180 post SCT, while CD4 T cells counts were low until 180−270 days post nilotinib treatment. T-cell response to mitogenic stimulation was not inhibited by nilotinib administration. Thymic activity, measured by TREC copies and surface membrane expression of 24 different TCR Vβ families, was evident in all patients at the end of follow-up after allo-SCT and nilotinib treatment. Finally, nilotinib did not inhibit NK cytotoxic activity. In conclusion, administration of nilotinib post allo-SCT, in attempt to reduce relapse rates or progression of Ph+ ALL and CML, did not jeopardize immune reconstitution or function following transplantation.
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Affiliation(s)
- Nira Varda-Bloom
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Ivetta Danylesko
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Roni Shouval
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel.,Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Israel.,Bar-Ilan University, Ramat Gan, Israel
| | - Shiran Eldror
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Atar Lev
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel.,Pediatric Immunology Service, Jeffrey Modell Foundation, USA.,Edmond and Lily Safra Children's Hospital, Israel
| | - Jacqueline Davidson
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Esther Rosenthal
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Yulia Volchek
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Noga Shem-Tov
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Ronit Yerushalmi
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Avichai Shimoni
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Raz Somech
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel.,Pediatric Immunology Service, Jeffrey Modell Foundation, USA.,Edmond and Lily Safra Children's Hospital, Israel
| | - Arnon Nagler
- Sheba Medical Center, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Israel
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18
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Levy-Mendelovich S, Lev A, Aviner S, Rosenberg N, Kaplinsky C, Sharon N, Miskin H, Dvir A, Kenet G, Schushan IE, Somech R. Quantification of specific T and B cells immunological markers in children with chronic and transient ITP. Pediatr Blood Cancer 2017; 64. [PMID: 28544224 DOI: 10.1002/pbc.26646] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/25/2017] [Accepted: 04/18/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Immune thrombocytopenic purpura (ITP) is characterized by a transient (nonchronic) or permanent (chronic) decline in the number of platelets. Predicting the course of ITP, at the time of diagnosis, is of importance. Here we studied at diagnosis, clinical and immunological parameters in order to distinguish between different courses. The latter included the measure of new B and T cells using quantification of kappa-deleting recombination excision circles (KRECs) and T-cell receptor excision circles (TRECs), respectively. METHODS Blood samples were collected from 44 children with a clinical diagnosis of ITP. Real-time PCR was performed in order to quantify the number of copies of TREC and KREC followed by collection of clinical data from medical files. The children were retrospectively divided into two groups: chronic and nonchronic. RESULTS Twenty-four patients (54%) were classified as nonchronic ITP and 20 patients (46%) were classified as chronic ITP. We confirmed some clinical parameters (e.g., gender, age) but not others (e.g., preceding infection, level of thrombocytopenia) that distinguish patients with chronic and nonchronic course. While KREC quantification was similar in patients regardless the outcome of their disease, it was significantly higher than the level of controls (P < 0.05). TREC quantification was not different between patients and controls. CONCLUSIONS KREC but not TREC levels are different in patients comparing to controls, pointing to an overreaction of B-cell development as a role in the pathogenesis of ITP. These results may shed more lights on the immune mechanism of ITP.
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Affiliation(s)
- Sarina Levy-Mendelovich
- Pediatric Department A and the Immunology Services, "Edmond and Lily Safra" Children's Hospital, Jeffrey Modell Foundation Center, Sheba Medical Center, Tel Hashomer affiliated with Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Hemato-Oncology Department, "Edmond and Lily Safra" Children's Hospital, Sheba Medical Center, Tel Hashomer affiliated to Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,National Hemphilia and Thrombosis Institute, Sheba Medical Center, Tel Hashomer affiliated to Sackler School of Medicine, Tel Aviv University, Israel
| | - Atar Lev
- Pediatric Department A and the Immunology Services, "Edmond and Lily Safra" Children's Hospital, Jeffrey Modell Foundation Center, Sheba Medical Center, Tel Hashomer affiliated with Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shraga Aviner
- Department of Pediatrics, Barzilai University Medical Center, Ashkelon affiliated to Ben Gurion University, Beer-Sheva, Israel
| | - Nurit Rosenberg
- Institute of Thrombosis and Hemostasis, Chaim Sheba Medical Center, Tel Hashomer affiliated to Sackler School of Medicine, Tel Aviv University, Israel
| | - Caim Kaplinsky
- Pediatric Hemato-Oncology Department, "Edmond and Lily Safra" Children's Hospital, Sheba Medical Center, Tel Hashomer affiliated to Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nechama Sharon
- Pediatric Department, Laniado Hospital, Netanya affiliated to Sackler School of Medicine, Tel Aviv University, Israel
| | - Hagit Miskin
- Pediatric Hematoloy Unit, Shaare Zedek Medical Center, Jerusalem affiliated to Hebrew University School of Medicine, Jerusalem, Israel
| | - Aviya Dvir
- Institute of Thrombosis and Hemostasis, Chaim Sheba Medical Center, Tel Hashomer affiliated to Sackler School of Medicine, Tel Aviv University, Israel
| | - Gili Kenet
- National Hemphilia and Thrombosis Institute, Sheba Medical Center, Tel Hashomer affiliated to Sackler School of Medicine, Tel Aviv University, Israel
| | - Irit Eisen Schushan
- Neonatology Department, "Edmond and Lily Safra" Children's Hospital, Sheba Medical Center, Tel Hashomer affiliated to Sackler School of Medicine, Tel Aviv University, Israel
| | - Raz Somech
- Pediatric Department A and the Immunology Services, "Edmond and Lily Safra" Children's Hospital, Jeffrey Modell Foundation Center, Sheba Medical Center, Tel Hashomer affiliated with Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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19
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Rechavi E, Lev A, Simon AJ, Stauber T, Daas S, Saraf-Levy T, Broides A, Nahum A, Marcus N, Hanna S, Stepensky P, Toker O, Dalal I, Etzioni A, Almashanu S, Somech R. First Year of Israeli Newborn Screening for Severe Combined Immunodeficiency-Clinical Achievements and Insights. Front Immunol 2017; 8:1448. [PMID: 29167666 PMCID: PMC5682633 DOI: 10.3389/fimmu.2017.01448] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/17/2017] [Indexed: 11/29/2022] Open
Abstract
Severe combined immunodeficiency (SCID), the most severe form of T cell immunodeficiency, is detectable through quantification of T cell receptor excision circles (TRECs) in dried blood spots obtained at birth. Herein, we describe the results of the first year of the Israeli SCID newborn screening (NBS) program. This important, life-saving screening test is available at no cost for every newborn in Israel. Eight SCID patients were diagnosed through the NBS program in its first year, revealing an incidence of 1:22,500 births in the Israeli population. Consanguine marriages and Muslim ethnic origin were found to be a risk factor in affected newborns, and a founder effect was detected for both IL7Rα and DCLRE1C deficiency SCID. Lymphocyte subset analysis and TREC quantification in the peripheral blood appear to be sufficient for confirmation of typical and leaky SCID and ruling out false positive (FP) results. Detection of secondary targets (infants with non-SCID lymphopenia) did not significantly affect the management or outcomes of these infants in our cohort. In the general, non-immunodeficient population, TREC rises along with gestational age and birth weight, and is significantly higher in females and the firstborn of twin pairs. Low TREC correlates with both gestational age and birth weight in extremely premature newborns. Additionally, the rate of TREC increase per week consistently accelerates with gestational age. Together, these findings mandate a lower cutoff or a more lenient screening algorithm for extremely premature infants, in order to reduce the high rate of FPs within this group. A significant surge in TREC values was observed between 28 and 30 weeks of gestation, where median TREC copy numbers rise by 50% over 2 weeks. These findings suggest a maturational step in T cell development around week 29 gestation, and imply moderate to late preterms should be screened with the same cutoff as term infants. The SCID NBS program is still in its infancy, but is already bearing fruit in the early detection and improved outcomes of children with SCID in Israel and other countries.
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Affiliation(s)
- Erez Rechavi
- 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
| | - 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
| | - 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
| | - Tali Stauber
- 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
- The National Center for Newborn Screening, Israel Ministry of Health, Tel-HaShomer, Israel
| | - Talia Saraf-Levy
- The National Center for Newborn Screening, Israel Ministry of Health, Tel-HaShomer, Israel
| | - Arnon Broides
- Pediatric Immunology Clinic, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States
| | - Amit Nahum
- Pediatric Immunology Clinic, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States
| | - Nufar Marcus
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Allergy and Immunology Unit, Schneider Children's Medical Center of Israel, Felsenstein Medical Research Center, Petach Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Suhair Hanna
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Ruth Children Hospital, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Polina Stepensky
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Bone Marrow Transplantation Department, Hadassah Hebrew University Medical Center, Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - Ori Toker
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Allergy and Clinical Immunology Clinic, Department of Pediatrics, Shaare Zedek Medical Center, Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - Ilan Dalal
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Pediatric Allergy Unit, Wolfson Medical Center, Holon, Israel.,Pediatric Department, Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amos Etzioni
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Ruth Children Hospital, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Shlomo Almashanu
- The National Center for Newborn Screening, Israel 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.,The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,The National Lab for Diagnosing SCID - The Israeli Newborn Screening Program, Israel Ministry of Health, Tel-Hashomer, Israel
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20
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Levy-Mendelovich S, Lev A, Rechavi E, Barel O, Golan H, Bielorai B, Neumann Y, Simon AJ, Somech R. T and B cell clonal expansion in Ras-associated lymphoproliferative disease (RALD) as revealed by next-generation sequencing. Clin Exp Immunol 2017; 189:310-317. [PMID: 28500641 DOI: 10.1111/cei.12986] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2017] [Indexed: 12/29/2022] Open
Abstract
Ras-associated lymphoproliferative disease (RALD) is an autoimmune lymphoproliferative syndrome (ALPS)-like disease caused by mutations in Kirsten rat sarcoma viral oncogene homologue (KRAS) or neuroblastoma RAS viral (V-Ras) oncogene homologue (NRAS). The immunological phenotype and pathogenesis of RALD have yet to be studied extensively. Here we report a thorough immunological investigation of a RALD patient with a somatic KRAS mutation. Patient lymphocytes were analysed for phenotype, immunoglobulin levels and T cell proliferation capacity. T and B cell receptor excision circles (TREC and KREC, respectively), markers of naive T and B cell production, were measured serially for 3 years. T and B cell receptor repertoires were studied using both traditional assays as well as next-generation sequencing (NGS). TREC and KREC declined dramatically with time, as did T cell receptor diversity. NGS analysis demonstrated T and B clonal expansions and marked restriction of T and B cell receptor repertoires compared to healthy controls. Our results demonstrate, at least for our reported RALD patient, how peripheral T and B clonal expansions reciprocally limit lymphocyte production and restrict the lymphocyte receptor repertoire in this disease. Decreased naive lymphocyte production correlated with a clinical deterioration in our patient's immune status, suggesting that TREC and KREC may be used as an aid in monitoring disease progression. Both the methodologies used here and the conclusions regarding immune homeostasis may be applicable to the research of ALPS and other immune dysregulation syndromes.
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Affiliation(s)
- S Levy-Mendelovich
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, "Edmond and Lily Safra" Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Department of Pediatric Hematology-Oncology and BMT, "Edmond and Lily Safra" Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Israel, Ramat Gan, Israel.,National Hemophilia and Thrombosis institute, Sheba Medical center, Tel Hashomer, Ramat Gan, Israel
| | - A Lev
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, "Edmond and Lily Safra" Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Israel, Ramat Gan, Israel
| | - E Rechavi
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, "Edmond and Lily Safra" Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Israel, Ramat Gan, Israel
| | - O Barel
- Sackler School of Medicine, Tel Aviv University, Israel, Ramat Gan, Israel.,Cancer Research Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - H Golan
- Department of Pediatric Hematology-Oncology and BMT, "Edmond and Lily Safra" Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Israel, Ramat Gan, Israel
| | - B Bielorai
- Department of Pediatric Hematology-Oncology and BMT, "Edmond and Lily Safra" Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Israel, Ramat Gan, Israel
| | - Y Neumann
- Department of Pediatric Hematology-Oncology and BMT, "Edmond and Lily Safra" Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Israel, Ramat Gan, Israel
| | - A J Simon
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, "Edmond and Lily Safra" Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Israel, Ramat Gan, Israel.,Cancer Research Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Hematology Laboratories, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - R Somech
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, "Edmond and Lily Safra" Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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21
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Tessitore MV, Sottini A, Roccaro AM, Ghidini C, Bernardi S, Martellosio G, Serana F, Imberti L. Detection of newly produced T and B lymphocytes by digital PCR in blood stored dry on nylon flocked swabs. J Transl Med 2017; 15:70. [PMID: 28381232 PMCID: PMC5381048 DOI: 10.1186/s12967-017-1169-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/23/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A normal number of T-cell receptor excision circles (TRECs) and K-deleting recombination excision circles (KRECs) is considered a biomarker for adequate new T- and B-cell production. In newborns, detection of TRECs and KRECs by real time PCR from dried blood spotted on filter paper is used for the screening of severe immunodeficiency. In adults, elderly and during diseases, where the number of TRECs is lower than in newborns and children, a large amount of DNA and a sensitive method of amplification are necessary to identify newly produced lymphocytes. METHODS DNA was prepared from blood of 203 healthy adults (range: 18-91 years old) absorbed for 10 s on flocked swabs and let to dry, or from peripheral blood mononuclear cells. DNA was subjected to digital PCR and to well established conventional real time PCR-based method using TREC- and KREC-specific primers and probes. The number of TRECs and KRECs was expressed per mL of blood. Statistical analysis was performed by nested ANOVA, Pearson coefficient of determination, and by linear regression tests. RESULTS The novel method for the storage of dried blood on nylon flocked swabs and the use of digital PCR allow quantification of TRECs and KRECs with high degree of sensitivity, specificity, accuracy, and precision. TRECs and KRECs were amplified by digital PCR in all tested blood samples, including those obtained from elderly individuals (>70 years old) and that were negative by real time PCR. Furthermore, values of TRECs and KRECs obtained by digital PCR were in the range of those acquired by real time PCR. CONCLUSIONS Our findings demonstrate that DNA isolation from dried blood on flocked swabs followed by digital PCR-based analysis represents a useful tool for studying new lymphocyte production in adults and elderly individuals. This suggests the potential use of the methodology when monitoring of clinical variables is limited by the number of molecules that can be amplified and detected, such as in patients with immunodeficiency or under immunosuppressive therapies.
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Affiliation(s)
- Marion Vaglio Tessitore
- Centro di Ricerca Emato-oncologica AIL (CREA), ASST Spedali Civili, P.le Spedali Civili, 1, 25123, Brescia, Italy
| | - Alessandra Sottini
- Centro di Ricerca Emato-oncologica AIL (CREA), ASST Spedali Civili, P.le Spedali Civili, 1, 25123, Brescia, Italy
| | - Aldo M Roccaro
- Centro di Ricerca Emato-oncologica AIL (CREA), ASST Spedali Civili, P.le Spedali Civili, 1, 25123, Brescia, Italy
| | - Claudia Ghidini
- Centro di Ricerca Emato-oncologica AIL (CREA), ASST Spedali Civili, P.le Spedali Civili, 1, 25123, Brescia, Italy
| | - Simona Bernardi
- Centro di Ricerca Emato-oncologica AIL (CREA), ASST Spedali Civili, P.le Spedali Civili, 1, 25123, Brescia, Italy
| | - Giovanni Martellosio
- Centro di Ricerca Emato-oncologica AIL (CREA), ASST Spedali Civili, P.le Spedali Civili, 1, 25123, Brescia, Italy
| | - Federico Serana
- Centro di Ricerca Emato-oncologica AIL (CREA), ASST Spedali Civili, P.le Spedali Civili, 1, 25123, Brescia, Italy
| | - Luisa Imberti
- Centro di Ricerca Emato-oncologica AIL (CREA), ASST Spedali Civili, P.le Spedali Civili, 1, 25123, Brescia, Italy.
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22
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Rechavi E, Lev A, Eyal E, Barel O, Kol N, Barhom SF, Pode-Shakked B, Anikster Y, Somech R, Simon AJ. A Novel Mutation in a Critical Region for the Methyl Donor Binding in DNMT3B Causes Immunodeficiency, Centromeric Instability, and Facial Anomalies Syndrome (ICF). J Clin Immunol 2016; 36:801-809. [PMID: 27734333 DOI: 10.1007/s10875-016-0340-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 09/21/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Immunodeficiency, centromeric instability, and facial anomalies (ICF) syndrome is an extremely rare autosomal recessive disease. The immune phenotype is characterized by hypogammaglobulinemia in the presence of B cells. T cell lymphopenia also develops in some patients. We sought to further investigate the immune defect in an ICF patient with a novel missense mutation in DNMT3B and a severe phenotype. METHODS Patient lymphocytes were examined for subset counts, immunoglobulin levels, T and B cell de novo production (via excision circles) and receptor repertoire diversity. Mutated DNMT3B protein structure was modeled to assess the effect of a mutation located outside of the catalytic region on protein function. RESULTS A novel homozygous missense mutation, Ala585Thr, was found in DNMT3B. The patient had decreased B cell counts with hypogammaglobulinemia, and normal T cell counts. CD4+ T cells decreased over time, leading to an inversion of the CD4+ to CD8+ ratio. Excision circle copy numbers were normal, signifying normal de novo lymphocyte production, but the ratio between naïve and total B cells was low, indicating decreased in vivo B cell replication. T and B cell receptor repertoires displayed normal diversity. Computerized modeling of the mutated Ala585 residue suggested reduced thermostability, possibly affecting the enzyme kinetics. CONCLUSIONS Our results highlight the existence of a T cell defect that develops over time in ICF patient, in addition to the known B cell dysfunction. With intravenous immunoglobulin (IVIG) treatment ameliorating the B cell defect, the extent of CD4+ lymphopenia may determine the severity of ICF immunodeficiency.
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Affiliation(s)
- Erez Rechavi
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
- Edmond and Lily Safra Children's Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
- Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
| | - Atar Lev
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
- Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
| | - Eran Eyal
- Cancer Research Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
- Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
| | - Ortal Barel
- Cancer Research Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
- Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
| | - Nitzan Kol
- Cancer Research Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
- Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
| | - Sarit Farage Barhom
- Cancer Research Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
- Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
| | - Ben Pode-Shakked
- Edmond and Lily Safra Children's Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
- Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
| | - Yair Anikster
- Edmond and Lily Safra Children's Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
- Metabolic Disease Unit, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
- Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
| | - Raz Somech
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel.
- Edmond and Lily Safra Children's Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel.
- Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel.
| | - Amos J Simon
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel.
- Cancer Research Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel.
- Institute of Hematology, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel.
- Sheba Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel.
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23
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John T, Walter JE, Schuetz C, Chen K, Abraham RS, Bonfim C, Boyce TG, Joshi AY, Kang E, Carvalho BTC, Mahajerin A, Nugent D, Puthenveetil G, Soni A, Su H, Cowan MJ, Notarangelo L, Buchbinder D. Unrelated Hematopoietic Cell Transplantation in a Patient with Combined Immunodeficiency with Granulomatous Disease and Autoimmunity Secondary to RAG Deficiency. J Clin Immunol 2016; 36:725-32. [PMID: 27539235 DOI: 10.1007/s10875-016-0326-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 08/03/2016] [Indexed: 10/21/2022]
Abstract
The use of HLA-identical hematopoietic stem cell transplantation (HSCT) demonstrates overall survival rates greater than 75 % for T-B-NK+ severe combined immunodeficiency secondary to pathogenic mutation of recombinase activating genes 1 and 2 (RAG1/2). Limited data exist regarding the use of HSCT in patients with hypomorphic RAG variants marked by greater preservation of RAG activity and associated phenotypes such as granulomatous disease in combination with autoimmunity. We describe a 17-year-old with combined immunodeficiency and immune dysregulation characterized by granulomatous lung disease and autoimmunity secondary to compound heterozygous RAG mutations. A myeloablative reduced toxicity HSCT was completed using an unrelated bone marrow donor. With the increasing cases of immune dysregulation being discovered with hypomorphic RAG variants, the use of HSCT may advance to the forefront of treatment. This case serves to discuss indications of HSCT, approaches to preparative therapy, and the potential complications in this growing cohort of patients with immune dysregulation and RAG deficiency.
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Affiliation(s)
- Tami John
- Division of Hematology/Oncology, CHOC Children's Hospital, 1201 W. La Veta Avenue, Orange, CA, 92868, USA.
| | - Jolan E Walter
- Division of Immunology, MassGeneral Hospital for Children, 55 Fruit Street, Boston, MA, 02114, USA
| | - Catherina Schuetz
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Karin Chen
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of Utah School of Medicine, 81 Mario Capecchi Drive, Salt Lake City, UT, USA
| | - Roshini S Abraham
- Allergy and Immunology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Carmem Bonfim
- Bone Marrow Transplantation Unit, Federal University of Paraná, Rua XV de Novembro, 1299 - Centro, Curitiba, PR, 80060-000, Brazil
| | - Thomas G Boyce
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, 37232, USA
| | - Avni Y Joshi
- Allergy and Immunology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elizabeth Kang
- NIAID, National Institutes of Health, Building 10CRC, Room 5-3940, 10 Center Drive, MSC 1456, Bethesda, MD, 20892-9806, USA
| | | | - Arash Mahajerin
- Division of Hematology, CHOC Children's Hospital, 1201 W. La Veta Avenue, Orange, CA, 92868, USA
| | - Diane Nugent
- Division of Hematology, CHOC Children's Hospital, 1201 W. La Veta Avenue, Orange, CA, 92868, USA
| | - Geetha Puthenveetil
- Division of Hematology, CHOC Children's Hospital, 1201 W. La Veta Avenue, Orange, CA, 92868, USA
| | - Amit Soni
- Division of Hematology, CHOC Children's Hospital, 1201 W. La Veta Avenue, Orange, CA, 92868, USA
| | - Helen Su
- NIAID, National Institutes of Health, Building 10CRC, Room 5-3940, 10 Center Drive, MSC 1456, Bethesda, MD, 20892-9806, USA
| | - Morton J Cowan
- Department of Pediatrics, University of California, San Francisco, Box 1278, UCSF, San Francisco, CA, 94143, USA
| | - Luigi Notarangelo
- Division of Immunology, Children's Hospital Boston, Karp Building, Room 10217, 1 Blackfan Circle, Boston, MA, 02115, USA
| | - David Buchbinder
- Division of Hematology, CHOC Children's Hospital, 1201 W. La Veta Avenue, Orange, CA, 92868, USA
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24
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Abstract
Monosomy 21 is an extremely rare genetic disorder presenting with a wide array of symptoms. Recurrent infections, some life threatening, have been reported in several monosomy 21 patients and attributed to an, as of yet, undefined immunodeficiency. Here we report on a 3-year-old boy with mosaic monosomy 21 who presented with clinical and laboratory evidence of immunodeficiency. Despite suffering from infections highly suggestive of a cell-mediated immune defect, the patient's T cells displayed normal counts, subsets and proliferation capability. T cell receptor repertoire was diverse, and de novo T cell production was intact. Consistent with earlier case reports, our patient displayed mildly low B cell counts with hypogammaglobulinemia. B cell subsets demonstrated mainly naïve and marginal zone B cells that have not undergone class switch. Subsequently, IgG, IgA and IgE levels were near absent, whereas IgM level was normal. De novo B cell production and B cell receptor diversity were normal. Together, these results are indicative of a defect in immunoglobulin class switching as the principal cause of immunodeficiency in monosomy 21. A better understanding of the immunodeficiency in this syndrome will enable targeted treatment and prevention of infections in order to prevent morbidity and mortality in these patients.
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Lucchini G, Perales MA, Veys P. Immune reconstitution after cord blood transplantation: peculiarities, clinical implications and management strategies. Cytotherapy 2016; 17:711-722. [PMID: 25946726 DOI: 10.1016/j.jcyt.2015.03.614] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/12/2015] [Indexed: 12/26/2022]
Abstract
Umbilical cord blood (UCB) is now widely used as an alternative hematopoietic stem cell source for patients lacking closely matched related or unrelated adult donors. UCB transplantation has traditionally been associated with delayed engraftment, poor immune reconstitution and consequent increased risk of infection. More recent clinical studies, however, suggest that conditioning regimens and in particular the omission of in vivo T-cell depletion may play a crucial role in post-transplant T-cell expansion, facilitating a uniquely rapid immune recovery after UCB transplantation. The peculiar characteristics of UCB cells, the importance of thymic function and the role of conditioning regimens and graft-versus-host disease influencing immune reconstitution are described. The last part of the review reports available data on UCB, as well as third-party peripheral blood derived anti-viral cell therapy, which provides a novel approach to rescue UCB recipients with viral complications in the post-transplant period.
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Affiliation(s)
- Giovanna Lucchini
- Bone Marrow Transplantation Department, Great Ormond Street Hospital, London, United Kingdom.
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, and Weill Cornell Medical College, New York, USA
| | - Paul Veys
- Bone Marrow Transplantation Department, Great Ormond Street Hospital, London, United Kingdom
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Machnes-Maayan D, Lev A, Katz U, Mishali D, Vardi A, Simon AJ, Somech R. Insight into normal thymic activity by assessment of peripheral blood samples. Immunol Res 2015; 61:198-205. [PMID: 25294167 DOI: 10.1007/s12026-014-8558-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The thymus is a highly specialized organ for T cell receptor (TCR) rearrangement and selection mechanisms that ensure the formation of functional and self-tolerant cells. Little is known about how peripheral blood assessment of thymic function reflects thymus activity during infancy. We compared thymic function-related markers in the thymus with those in peripheral blood in order to check their correlations. We concomitantly blood samples from immunocompetent infants who underwent cardiac surgery that involved thymectomy. The studied thymic markers included TCR excision circles (TRECs), four different TCRD (TCR delta chain) gene rearrangements, the TCR repertoire, regulatory T cells (Tregs, defined as the CD4+CD25+FOXP3+ cell population) and real-time quantitative polymerase chain reaction (RQ-PCR) mRNA expression of forkhead box P3 (FOXP3). Twenty patients were enrolled in this study. Their mean age at the time of the surgery was 3 months/5 days ± 3 months/18 days. There was a significant correlation between thymic and peripheral blood levels of TREC, all four TCRD gene rearrangements and the amount of Tregs. The levels of these parameters were significantly higher in the thymus than those detected in the peripheral blood. The TCR repertoire distribution in both samples was similar. FOXP3 mRNA levels in the thymus and peripheral blood correlated well. Our findings demonstrated a strong and significant correlation between peripheral blood and intra-thymic activity parameters during infancy. Assessment of these parameters in peripheral blood can be used to accurately estimate different intra-thymic capacities for assessing T cell function in health and disease.
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Affiliation(s)
- Diti Machnes-Maayan
- Pediatric Department B, Pediatric Immunology Service, Jeffrey Modell Foundation (JMF) Center, Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel
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Rechavi E, Lev A, Lee YN, Simon AJ, Yinon Y, Lipitz S, Amariglio N, Weisz B, Notarangelo LD, Somech R. Timely and spatially regulated maturation of B and T cell repertoire during human fetal development. Sci Transl Med 2015; 7:276ra25. [DOI: 10.1126/scitranslmed.aaa0072] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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28
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van den Brink MRM, Velardi E, Perales MA. Immune reconstitution following stem cell transplantation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:215-219. [PMID: 26637724 DOI: 10.1182/asheducation-2015.1.215] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Marcel R M van den Brink
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medical College, New York, NY; Immunology Program, Memorial Sloan Kettering Cancer Center, New York, NY; and
| | - Enrico Velardi
- Immunology Program, Memorial Sloan Kettering Cancer Center, New York, NY; and Division of Pharmacology, Department of Medicine, University of Perugia, Perugia, Italy
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medical College, New York, NY
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Long-lasting production of new T and B cells and T-cell repertoire diversity in patients with primary immunodeficiency who had undergone stem cell transplantation: a single-centre experience. J Immunol Res 2014; 2014:240453. [PMID: 25756054 PMCID: PMC4270024 DOI: 10.1155/2014/240453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 08/13/2014] [Accepted: 09/08/2014] [Indexed: 11/29/2022] Open
Abstract
Levels of Kappa-deleting recombination excision circles (KRECs), T-cell receptor excision circles (TRECs), and T-cell repertoire diversity were evaluated in 1038 samples of 124 children with primary immunodeficiency, of whom 102 (54 with severe combined immunodeficiency and 48 with other types of immunodeficiency) underwent hematopoietic stem cell transplantation. Twenty-two not transplanted patients with primary immunodeficiency were used as controls. Only data of patients from whom at least five samples were sent to the clinical laboratory for routine monitoring of lymphocyte reconstitutions were included in the analysis. The mean time of the follow-up was 8 years. The long-lasting posttransplantation kinetics of KREC and TREC production occurred similarly in patients with severe combined immunodeficiency and with other types of immunodeficiency and, in both groups, the T-cell reconstitution was more efficient than in nontransplanted children. Although thymic output decreased in older transplanted patients, the degree of T-cell repertoire diversity, after an initial increase, remained stable during the observation period. However, the presence of graft-versus-host disease and ablative conditioning seemed to play a role in the time-related shaping of T-cell repertoire. Overall, our data suggest that long-term B- and T-cell reconstitution was equally achieved in children with severe combined immunodeficiency and with other types of primary immunodeficiency.
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Impact of acute and chronic graft-versus-host disease on human B-cell generation and replication. Blood 2014; 124:2459-62. [PMID: 25185266 DOI: 10.1182/blood-2014-05-573303] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Using B-cell rearrangement excision circle measurements, we analyzed B-cell reconstitution in a cohort of 243 patients who underwent allogeneic stem cell transplantation. Acute and chronic graft-versus-host disease (aGVHD and cGVHD, respectively) transiently increased B-cell replication but decreased overall B-cell neogenesis with a clear difference in terms of kinetics. Moreover, the impact of aGVHD in the absence of cGVHD was transient, recovering at month 6 similar values as in patients who did not suffer from GVHD. Conversely, impact of cGVHD at month 12 in multivariate analysis was independent of the previous aGVHD effect on B-cell output. Finally, we showed in patients affected with cGVHD a higher B-cell division rate that correlates with an elevated BAFF/CD19(+) B-cell ratio, supporting a B-cell hyperactivation state in vivo.
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Bashford-Rogers RJM, Palser AL, Idris SF, Carter L, Epstein M, Callard RE, Douek DC, Vassiliou GS, Follows GA, Hubank M, Kellam P. Capturing needles in haystacks: a comparison of B-cell receptor sequencing methods. BMC Immunol 2014; 15:29. [PMID: 25189176 PMCID: PMC4243823 DOI: 10.1186/s12865-014-0029-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 07/15/2014] [Indexed: 01/20/2023] Open
Abstract
Background Deep-sequencing methods are rapidly developing in the field of B-cell receptor (BCR) and T-cell receptor (TCR) diversity. These promise to revolutionise our understanding of adaptive immune dynamics, identify novel antibodies, and allow monitoring of minimal residual disease. However, different methods for BCR and TCR enrichment and amplification have been proposed. Here we perform the first systematic comparison between different methods of enrichment, amplification and sequencing for generating BCR and TCR repertoires using large sample numbers. Results Resampling from the same RNA or cDNA pool results in highly correlated and reproducible repertoires, but resampling low frequency clones leads to stochastic variance. Repertoires generated by different sequencing methods (454 Roche and Illumina MiSeq) and amplification methods (multiplex PCR, 5’ Rapid amplification of cDNA ends (5’RACE), and RNA-capture) are highly correlated, and resulting IgHV gene frequencies between the different methods were not significantly different. Read length has an impact on captured repertoire structure, and ultimately full-length BCR sequences are most informative for repertoire analysis as diversity outside of the CDR is very useful for phylogenetic analysis. Additionally, we show RNA-based BCR repertoires are more informative than using DNA. Conclusions Repertoires generated by different sequencing and amplification methods are consistent, but we show that read lengths, depths and error profiles should be considered in experimental design, and multiple sampling approaches could be employed to minimise stochastic sampling variation. This detailed investigation of immune repertoire sequencing methods is essential for informing basic and clinical research. Electronic supplementary material The online version of this article (doi:10.1186/s12865-014-0029-0) contains supplementary material, which is available to authorized users.
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Disturbed B and T cell homeostasis and neogenesis in patients with ataxia telangiectasia. J Clin Immunol 2014; 34:561-72. [DOI: 10.1007/s10875-014-0044-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 04/09/2014] [Indexed: 12/11/2022]
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Hu Y, Xu Y, Lu W, Quan H, Shen Y, Yuan Z, Zhang J, Zang W, He Y, Cao J. Effects of Microtus fortis lymphocytes on Schistosoma japonicum in a bone marrow transplantation model. Exp Parasitol 2014; 142:27-37. [PMID: 24746640 DOI: 10.1016/j.exppara.2014.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 02/16/2014] [Accepted: 04/06/2014] [Indexed: 10/25/2022]
Abstract
Microtus fortis is a non-permissive host for Schistosoma japonicum. While M. fortis lymphocytes are known to provide natural resistance against S. japonicum, the specific mechanism remains unclear. A bone marrow transplantation (BMT) model was established using immunodeficient mice, either nude (experiment 1) or V(D)J recombination activation gene deficient mice (RAG-1(-/-)) (experiment 2) as recipients and M. fortis or C57BL/6 mice as donors. The growth and development of S. japonicum were evaluated in each group to assess the role of M. fortis lymphocytes in the response to infection. Lymphocyte ratios and S. japonicum-specific antibody production in transplanted groups increased significantly compared to those in non-transplanted group. Spleen indices and density of splenic lymphocytes in transplanted RAG-1(-/-) mice were higher than those in non-transplanted RAG-1(-/-) mice. No difference in the worm burden was observed among group A (transplants derived from M. fortis), B (transplants derived from C57BL/6 mouse) and C (non-transplanted mice), although worms in group A were shorter than those in other groups, except non-transplanted RAG-1(-/-) mice. Reproductive systems of worms in mice (nude or RAG-1(-/-)) transplanted from M. fortis were not as mature as those in mice (nude or RAG-1(-/-)) transplanted from C57BL/6 mouse and non-transplanted nude mice, but they were more mature than worms in non-transplanted RAG-1(-/-) mice. Therefore, the transplantation model using nude and RAG-1(-/-) mice was successfully established. The M. fortis lymphocytes did not appear to affect the S. japonicum worm burden, but they led to schistosome shortening and a significant reduction in parasite spawning. Thus, M. fortis cellular and humoral immunity provides a defense against schistosomes by negatively impacting the parasite growth and reproductive development.
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Affiliation(s)
- Yuan Hu
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Key Laboratory of Parasite and Vector Biology, Ministry of Health, WHO Collaborating Center for Malaria, Schistosomiasis and Filariasis, Shanghai, People's Republic of China
| | - Yuxin Xu
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Key Laboratory of Parasite and Vector Biology, Ministry of Health, WHO Collaborating Center for Malaria, Schistosomiasis and Filariasis, Shanghai, People's Republic of China
| | - Weiyuan Lu
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Key Laboratory of Parasite and Vector Biology, Ministry of Health, WHO Collaborating Center for Malaria, Schistosomiasis and Filariasis, Shanghai, People's Republic of China
| | - Hong Quan
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Key Laboratory of Parasite and Vector Biology, Ministry of Health, WHO Collaborating Center for Malaria, Schistosomiasis and Filariasis, Shanghai, People's Republic of China
| | - Yujuan Shen
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Key Laboratory of Parasite and Vector Biology, Ministry of Health, WHO Collaborating Center for Malaria, Schistosomiasis and Filariasis, Shanghai, People's Republic of China
| | - Zhongying Yuan
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Key Laboratory of Parasite and Vector Biology, Ministry of Health, WHO Collaborating Center for Malaria, Schistosomiasis and Filariasis, Shanghai, People's Republic of China
| | - Jing Zhang
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Key Laboratory of Parasite and Vector Biology, Ministry of Health, WHO Collaborating Center for Malaria, Schistosomiasis and Filariasis, Shanghai, People's Republic of China
| | - Wei Zang
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Key Laboratory of Parasite and Vector Biology, Ministry of Health, WHO Collaborating Center for Malaria, Schistosomiasis and Filariasis, Shanghai, People's Republic of China
| | - Yongkang He
- Hunan Institute of Schistosomiasis Control, Yueyang, People's Republic of China
| | - Jianping Cao
- National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Key Laboratory of Parasite and Vector Biology, Ministry of Health, WHO Collaborating Center for Malaria, Schistosomiasis and Filariasis, Shanghai, People's Republic of China.
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Abstract
UNLABELLED Quantification of the T cell receptor excision circles (TRECs) has recently emerged as a useful non-invasive clinical and research tool to investigate thymic activity. It allows the identification of T cell production by the thymus. Quantification of TREC copies has recently been implemented as the preferred test to screen neonates with severe combined immunodeficiency (SCID) or significant lymphopenia. Neonatal genetic screening for SCID is highly important in countries with high rates of consanguinous marriages, such as Israel, and can be used for early diagnosis, enabling prompt therapeutic intervention that will save lives and improve the outcome of these patients. TREC measurement is also applicable in clinical settings where T cell immunity is involved, including any T cell immunodeficiencies, HIV infection, the aging process, autoimmune diseases, and immune reconstitution after bone marrow transplantation. TAKE-HOME MESSAGES Severe combined immunodeficiency, a life-threatening condition, can be detected by neonatal screening.The earlier the detection and the quicker the implementation of appropriate treatment, the greater the likelihood for improved outcome, even cure, for the affected children.TRECs and KRECs quantification are useful screening tests for severe T and B cell immunodeficiency and can be used also to evaluate every medical condition involving T and B cell immunity.
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Affiliation(s)
- Raz Somech
- Pediatric Department B North, Pediatric Immunology Service, Jeffrey Modell Foundation (JMF) Center, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- To whom correspondence should be addressed. E-mail:
| | - Amos Etzioni
- Meyer Children’s Hospital, Rappaport Faculty of Medicine, The Technion – Israel Institute of Technology, Haifa, Israel
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35
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Stepensky P, Keller B, Buchta M, Kienzler AK, Elpeleg O, Somech R, Cohen S, Shachar I, Miosge LA, Schlesier M, Fuchs I, Enders A, Eibel H, Grimbacher B, Warnatz K. Deficiency of caspase recruitment domain family, member 11 (CARD11), causes profound combined immunodeficiency in human subjects. J Allergy Clin Immunol 2013; 131:477-85.e1. [PMID: 23374270 DOI: 10.1016/j.jaci.2012.11.050] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Revised: 11/26/2012] [Accepted: 11/29/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Profound combined immunodeficiency can present with normal numbers of T and B cells, and therefore the functional defect of the cellular and humoral immune response is often not recognized until the first severe clinical manifestation. Here we report a patient of consanguineous descent presenting at 13 months of age with hypogammaglobulinemia, Pneumocystis jirovecii pneumonia, and a suggestive family history. OBJECTIVE We sought to identify the genetic alteration in a patient with combined immunodeficiency and characterize human caspase recruitment domain family, member 11 (CARD11), deficiency. METHODS Molecular, immunologic, and functional assays were performed. RESULTS The immunologic characterization revealed only subtle changes in the T-cell and natural killer cell compartment, whereas B-cell differentiation, although normal in number, was distinctively blocked at the transitional stage. Genetic evaluation revealed a homozygous deletion of exon 21 in CARD11 as the underlying defect. This deletion abrogated protein expression and activation of the canonical nuclear factor κB (NF-κB) pathway in lymphocytes after antigen receptor or phorbol 12-myristate 13-acetate stimulation, whereas CD40 signaling in B cells was preserved. The abrogated activation of the canonical NF-κB pathway was associated with severely impaired upregulation of inducible T-cell costimulator, OX40, cytokine production, proliferation of T cells, and B cell-activating factor receptor expression on B cells. CONCLUSION Thus in patients with CARD11 deficiency, the combination of impaired activation and especially upregulation of inducible T-cell costimulator on T cells, together with severely disturbed peripheral B-cell differentiation, apparently leads to a defective T-cell/B-cell cooperation and probably germinal center formation and clinically results in severe immunodeficiency. This report discloses the crucial and nonredundant role of canonical NF-κB activation and specifically CARD11 in the antigen-specific immune response in human subjects.
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Affiliation(s)
- Polina Stepensky
- Pediatric Hematology-Oncology and Bone Marrow Transplantation, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Network properties derived from deep sequencing of human B-cell receptor repertoires delineate B-cell populations. Genome Res 2013; 23:1874-84. [PMID: 23742949 PMCID: PMC3814887 DOI: 10.1101/gr.154815.113] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The adaptive immune response selectively expands B- and T-cell clones following antigen recognition by B- and T-cell receptors (BCR and TCR), respectively. Next-generation sequencing is a powerful tool for dissecting the BCR and TCR populations at high resolution, but robust computational analyses are required to interpret such sequencing. Here, we develop a novel computational approach for BCR repertoire analysis using established next-generation sequencing methods coupled with network construction and population analysis. BCR sequences organize into networks based on sequence diversity, with differences in network connectivity clearly distinguishing between diverse repertoires of healthy individuals and clonally expanded repertoires from individuals with chronic lymphocytic leukemia (CLL) and other clonal blood disorders. Network population measures defined by the Gini Index and cluster sizes quantify the BCR clonality status and are robust to sampling and sequencing depths. BCR network analysis therefore allows the direct and quantifiable comparison of BCR repertoires between samples and intra-individual population changes between temporal or spatially separated samples and over the course of therapy.
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Serana F, Chiarini M, Zanotti C, Sottini A, Bertoli D, Bosio A, Caimi L, Imberti L. Use of V(D)J recombination excision circles to identify T- and B-cell defects and to monitor the treatment in primary and acquired immunodeficiencies. J Transl Med 2013; 11:119. [PMID: 23656963 PMCID: PMC3666889 DOI: 10.1186/1479-5876-11-119] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 05/06/2013] [Indexed: 01/05/2023] Open
Abstract
T-cell receptor excision circles (TRECs) and kappa-deleting recombination excision circles (KRECs) are circular DNA segments generated in T and B cells during their maturation in the thymus and bone marrow. These circularized DNA elements persist in the cells, are unable to replicate, and are diluted as a result of cell division, thus are considered markers of new lymphocyte output. The quantification of TRECs and KRECs, which can be reliably performed using singleplex or duplex real-time quantitative PCR, provides novel information in the management of T- and B-cell immunity-related diseases. In primary immunodeficiencies, when combined with flow cytometric analysis of T- and B-cell subpopulations, the measure of TRECs and KRECs has contributed to an improved characterization of the diseases, to the identification of patients’ subgroups, and to the monitoring of stem cell transplantation and enzyme replacement therapy. For the same diseases, the TREC and KREC assays, introduced in the newborn screening program, allow early disease identification and may lead to discovery of new genetic defects. TREC and KREC levels can also been used as a surrogate marker of lymphocyte output in acquired immunodeficiencies. The low number of TRECs, which has in fact been extensively documented in untreated HIV-infected subjects, has been shown to increase following antiretroviral therapy. Differently, KREC number, which is in the normal range in these patients, has been shown to decrease following long-lasting therapy. Whether changes of KREC levels have relevance in the biology and in the clinical aspects of primary and acquired immunodeficiencies remains to be firmly established.
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Affiliation(s)
- Federico Serana
- Inter-Departmental AIL Laboratory, Diagnostics Department, Spedali Civili of Brescia, Brescia, Italy
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Geller-Bernstein C, Etzioni A. Pediatric allergy and immunology in Israel. Pediatr Allergy Immunol 2013; 24:187-94. [PMID: 23373733 DOI: 10.1111/pai.12044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2013] [Indexed: 11/29/2022]
Abstract
After the geographic and sociodemographic settings as well as the health care in Israel are briefly described, the scope of pediatric allergy and immunology in Israel is presented. This includes specific disorders commonly encountered, the environment that induces symptoms, the specialists who treat them, and the common challenges of patients, parents, doctors, and allied health personnel who collaborate to manage the maladies and patient care. Allergies usually affect some overall 15-20% of the pediatric population. The main allergens are inhaled, ingested, or injected (insects stings). Generally, the incidence of the various allergens affecting children in Israel, is similar to other parts of the Western world. Owing to the high consanguinity rate in the Israeli population, the prevalence of the various immunodeficiency conditions (in the adaptive as well as the innate system) is higher than that reported worldwide. Pediatric allergists/immunologists also treat autoimmune disorders affecting the pediatric group. Pediatric allergy and clinical immunology are not separate specialties. The 25 specialists who treat children with allergic/immunologic diseases have undergone a basic training in Pediatrics. They also received an additional 2-yr training in allergy and clinical immunology and then have to pass the board examinations. They work mainly in pediatric allergy units, in several hospitals that are affiliated to the five medical schools in the country. Aside from clinical work, most of the centers are also heavily involved in clinical and basic research in allergy and immunology.
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Affiliation(s)
- Carmi Geller-Bernstein
- Pediatric Allergy Clinic, Kaplan Medical Center Rehovot, Hebrew University, Jerusalem, Israel.
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39
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Purine nucleoside phosphorylase deficiency presenting as severe combined immune deficiency. Immunol Res 2013; 56:150-4. [DOI: 10.1007/s12026-012-8380-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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40
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Somech R, Lev A, Simon AJ, Hanna S, Etzioni A. T- and B-cell defects in a novel purine nucleoside phosphorylase mutation. J Allergy Clin Immunol 2012; 130:539-42. [DOI: 10.1016/j.jaci.2012.03.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 02/19/2012] [Accepted: 03/22/2012] [Indexed: 10/28/2022]
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