1
|
Fakih HM, Dbouk A. An Immunodeficiency Disorder Presenting in the Neonatal Period. Cureus 2024; 16:e59374. [PMID: 38817488 PMCID: PMC11139010 DOI: 10.7759/cureus.59374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/01/2024] Open
Abstract
Primary immunodeficiency (PID) Disorders include a variable group of diseases that are classified according to the functional defects encountered. Chronic granulomatous disease (CGD) is inherited as an X-linked recessive disorder in many cases, and it is the clinical model of disorders of phagocytosis. Skin and solid organs abscesses are the most common presenting symptoms; we will report the case of a four-day-old boy admitted to our hospital for a neck mass with purulent discharges associated with umbilical stump and circumcision site infection; the diagnosis of CGD was later confirmed by the Dihydrorhodamine (DHR) test that turned out to be positive.
Collapse
Affiliation(s)
- Hadi M Fakih
- Pediatrics, Faculty of Medical Sciences, Lebanese University, Beirut, LBN
- Pediatrics, Sheikh Ragheb Harb University Hospital, Toul, LBN
| | - Abdallah Dbouk
- Pediatrics, Faculty of Medicine, Lebanese University, Beirut, LBN
- Pediatrics, Sheikh Ragheb Harb University Hospital, Toul, LBN
| |
Collapse
|
2
|
Lev A, Somech R, Somekh I. Newborn screening for severe combined immunodeficiency and inborn errors of immunity. Curr Opin Pediatr 2023; 35:692-702. [PMID: 37707504 DOI: 10.1097/mop.0000000000001291] [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] [Indexed: 09/15/2023]
Abstract
PURPOSE OF REVIEW Severe combined immune deficiency (SCID) is the most devastating genetic disease of the immune system with an unfavorable outcome unless diagnosed early in life. Newborn screening (NBS) programs play a crucial role in facilitating early diagnoses and timely interventions for affected infants. RECENT FINDINGS SCID marked the pioneering inborn error of immunity (IEI) to undergo NBS, a milestone achieved 15 years ago through the enumeration of T-cell receptor excision circles (TRECs) extracted from Guthrie cards. This breakthrough has revolutionized our approach to SCID, enabling not only presymptomatic identification and prompt treatments (including hematopoietic stem cell transplantation), but also enhancing our comprehension of the global epidemiology of SCID. SUMMARY NBS is continuing to evolve with the advent of novel diagnostic technologies and treatments. Following the successful implementation of SCID-NBS programs, a call for the early identification of additional IEIs is the next step, encompassing a broader spectrum of IEIs, facilitating early diagnoses, and preventing morbidity and mortality.
Collapse
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 Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | | | | |
Collapse
|
3
|
Little BB, Shakib S, Pena Reyes ME, Karimi S, Vu GT, Dupré N, McKinney WP, Mitra R. COVID-19 infection and mortality among non-pregnant indigenous adults in Mexico 2020-2022: Impact of marginalisation. J Glob Health 2023; 13:06030. [PMID: 37506193 PMCID: PMC10386760 DOI: 10.7189/jogh.13.06030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023] Open
Abstract
Background Indigenous individuals have higher rates of mortality and poverty in Mexico and more than half are marginalised, and COVID-19 pandemic aggravated the existing burden of health disparities. We aimed to analyse the effects of being indigenous and marginalised on coronavirus (COVID-19) infection fatality in Mexico. Methods We identified 3 424 690 non-pregnant, COVID-19 positive adults ≥19 years in the Mexico national COVID-19 database with known date of symptom. We used demographic information, indigenous status, marginalisation status, and co-morbidities in binary logistic regression to predict mortality, adjusting for covariates, including hospitalisation, admission to the intensive care unit (ICU), and mechanical ventilation use. We also assessed the interaction between indigenous status and marginalisation. Results Marginalisation was much higher among indigenous (53.7%) compared to non-indigenous individuals (4.8%). COVID-19 fatalities were approximately 20 years older (64.4 and 63.0 years) than survivors (44.7 and 41.2 years) among indigenous vs non-indigenous individuals, respectively. The unadjusted risk of COVID-19 fatality among indigenous individuals was nearly two-fold (odds ratio (OR) = 1.92)) compared to non-indigenous individuals (OR = 1.05). COVID-19 fatality was higher among highly marginalised individuals (upper quartile) (OR = 1.51; 95% confidence interval (CI) = 1.49-1.54). Marginalised indigenous individuals had a significantly lower likelihood of ICU admission compared to non-indigenous non-marginalised individuals. The likelihood of mechanical ventilation for indigenous individuals was 4% higher compared to non-indigenous individuals. Indigenous marginalised individuals had a significantly lower probability of mechanical ventilation compared to non-indigenous non-marginalised individuals. COVID-19 comorbidity risks of fatality significantly differed between the two groups in the Cox survival analysis. In the fully adjusted model, indigenous individuals were 4% more likely to die from COVID-19 compared to non-indigenous. Conclusions Indigenous, marginalised individuals with COVID-19 had higher risk of hospitalisation and ICU admission than non-indigenous patients. Marginalised, indigenous individuals were less likely to receive mechanical ventilation compared to non-indigenous, but had a higher risk of COVID-19. Indigenous individuals had a 4% higher COVID-19 mortality risk COVID-19 compared to non-indigenous individuals. Improved community medical care and augmented health services in rural hospitals could mitigate barriers to health care access in indigenous, marginalised populations.
Collapse
Affiliation(s)
- Bert B Little
- School of Public Health and Information Sciences, University of Louisville, Kentucky, USA
| | - Shaminul Shakib
- School of Public Health and Information Sciences, University of Louisville, Kentucky, USA
| | - Maria E Pena Reyes
- Escuela de Nacional Antroplogia e Historia and Instituto de Nacional Antroplogia e Historia Mexico City, Mexico
| | - Seyed Karimi
- School of Public Health and Information Sciences, University of Louisville, Kentucky, USA
| | - Giang T Vu
- School of Global Health Management and Informatics, University of Central Florida, Orlando, Florida, USA
| | - Natalie Dupré
- School of Public Health and Information Sciences, University of Louisville, Kentucky, USA
| | - W Paul McKinney
- School of Public Health and Information Sciences, University of Louisville, Kentucky, USA
| | - Riten Mitra
- School of Public Health and Information Sciences, University of Louisville, Kentucky, USA
| |
Collapse
|
4
|
IgG antibody response to pneumococcal-conjugated vaccine (Prevenar®13) in children with immunodeficiency disorders. Med Microbiol Immunol 2023; 212:93-102. [PMID: 36595027 DOI: 10.1007/s00430-022-00759-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/01/2022] [Indexed: 01/04/2023]
Abstract
Measurement of anti-pneumococcal capsular polysaccharides (anti-PnPs) IgG titers is an important tool in the immunologic assessment of patients with suspected immunodeficiency disorders (ID) to reduce the morbi-mortality and minimize severe infections. Retrospectively, we studied the relationship among anti-PnPs IgG response to 3 doses of Prevenar®13, levels of immune system components, leukocyte populations, and clinical data in children with ID. Serum samples were collected at least 4 weeks post vaccination. Subsequently, multi-serotype enzyme-linked immunosorbent assay (ELISA) was performed. Eighty-seven children (under 12 years) were enrolled. Primary immunodeficiency disorder (PID) was the most common disorder (45) followed by possible immunodeficiency disorder (POID) (19), secondary immunodeficiency disorder (SID) (15), and mixed immunodeficiency disorder (MID) (8). The median age was 3 (1.50-5.33) years, 65% of patients were male. Deficient production of anti-PnPs IgG (titer ≤ 50 mg/L) was detected in 47 patients (54%), especially in the MID group, all of them under immunosuppressive therapy. In PCV13 responders, the mean of leukocyte population levels was higher with statistically significance differences in CD4 + /CD8 + T lymphocytes (p = 0.372, p = 0.014) and CD56 + /CD16 + NK (p = 0.016). Patients with previous bone marrow transplantation were the worst PCV13 responders. Pneumococcal IgG antibody titers (post-vaccination) along with clinical and analytical markers represented.
Collapse
|
5
|
Michniacki TF, Walkovich K, DeMeyer L, Saad N, Hannibal M, Basiaga ML, Horst KK, Mohan S, Chen L, Brodeur K, Du Y, Frame D, Ngo S, Simoneau J, Brown N, Lee PY. SOCS1 Haploinsufficiency Presenting as Severe Enthesitis, Bone Marrow Hypocellularity, and Refractory Thrombocytopenia in a Pediatric Patient with Subsequent Response to JAK Inhibition. J Clin Immunol 2022; 42:1766-1777. [PMID: 35976468 PMCID: PMC9381392 DOI: 10.1007/s10875-022-01346-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/09/2022] [Indexed: 11/24/2022]
Abstract
Haploinsufficiency of suppressor of cytokine signaling 1 (SOCS1) is a recently discovered autoinflammatory disorder with significant rheumatologic, immunologic, and hematologic manifestations. Here we report a case of SOCS1 haploinsufficiency in a 5-year-old child with profound arthralgias and immune-mediated thrombocytopenia unmasked by SARS-CoV-2 infection. Her clinical manifestations were accompanied by excessive B cell activity, eosinophilia, and elevated IgE levels. Uniquely, this is the first report of SOCS1 haploinsufficiency in the setting of a chromosomal deletion resulting in complete loss of a single SOCS1 gene with additional clinical findings of bone marrow hypocellularity and radiologic evidence of severe enthesitis. Immunologic profiling showed a prominent interferon signature in the patient's peripheral blood mononuclear cells, which were also hypersensitive to stimulation by type I and type II interferons. The patient showed excellent clinical and functional laboratory response to tofacitinib, a Janus kinase inhibitor that disrupts interferon signaling. Our case highlights the need to utilize a multidisciplinary diagnostic approach and consider a comprehensive genetic evaluation for inborn errors of immunity in patients with an atypical immune-mediated thrombocytopenia phenotype.
Collapse
Affiliation(s)
- Thomas F Michniacki
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
| | - Kelly Walkovich
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Lauren DeMeyer
- Division of Genetics, Metabolism & Genomic Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Nadine Saad
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Mark Hannibal
- Division of Genetics, Metabolism & Genomic Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Matthew L Basiaga
- Division of Pediatric Rheumatology, Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Kelly K Horst
- Division of Pediatric Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Smriti Mohan
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Liang Chen
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kailey Brodeur
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yan Du
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Frame
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Sandra Ngo
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Jillian Simoneau
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Noah Brown
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
6
|
ATS Core Curriculum 2021. Pediatric Pulmonary Medicine: Pulmonary Infections. ATS Sch 2021; 2:452-467. [PMID: 34667993 PMCID: PMC8518607 DOI: 10.34197/ats-scholar.2021-0034re] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/25/2021] [Indexed: 11/24/2022] Open
Abstract
The following is a concise review of the Pediatric Pulmonary Medicine Core reviewing pediatric pulmonary infections, diagnostic assays, and imaging techniques presented at the 2021 American Thoracic Society Core Curriculum. Molecular methods have revolutionized microbiology. We highlight the need to collect appropriate samples for detection of specific pathogens or for panels and understand the limitations of the assays. Considerable progress has been made in imaging modalities for detecting pediatric pulmonary infections. Specifically, lung ultrasound and lung magnetic resonance imaging are promising radiation-free diagnostic tools, with results comparable with their radiation-exposing counterparts, for the evaluation and management of pulmonary infections. Clinicians caring for children with pulmonary disease should ensure that patients at risk for nontuberculous mycobacteria disease are identified and receive appropriate nontuberculous mycobacteria screening, monitoring, and treatment. Children with coronavirus disease (COVID-19) typically present with mild symptoms, but some may develop severe disease. Treatment is mainly supportive care, and most patients make a full recovery. Anticipatory guidance and appropriate counseling from pediatricians on social distancing and diagnostic testing remain vital to curbing the pandemic. The pediatric immunocompromised patient is at risk for invasive and opportunistic pulmonary infections. Prompt recognition of predisposing risk factors, combined with knowledge of clinical characteristics of microbial pathogens, can assist in the diagnosis and treatment of specific bacterial, viral, or fungal diseases.
Collapse
|
7
|
Belsky JA, Tullius BP, Lamb MG, Sayegh R, Stanek JR, Auletta JJ. COVID-19 in immunocompromised patients: A systematic review of cancer, hematopoietic cell and solid organ transplant patients. J Infect 2021; 82:329-338. [PMID: 33549624 PMCID: PMC7859698 DOI: 10.1016/j.jinf.2021.01.022] [Citation(s) in RCA: 143] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/03/2020] [Accepted: 01/30/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The clinical impact of severe coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in immunocompromised patients has not been systematically evaluated. METHODS We reviewed current literature reporting on COVID-19 in cancer (CA), hematopoietic cell (HCT), and solid organ transplant (SOT) patients and compared their clinical data and outcomes to the general population. For adult CA, HCT and SOT patients, an extensive search strategy retrieved all articles published until July 20, 2020 by combining the terms coronavirus, coronavirus infection, COVID-19, and SARS-CoV-2 in PubMed, Cochrane, and Web of Science, and following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. For the pediatric CA cohort, a global COVID-19 registry was used. For the general population cohort, a large meta-analysis was used to compare pooled prevalence estimates, and two large meta-analyses were utilized to serve as pooled comparators for hospitalized COVID-19 patients. FINDINGS Compared to the general population, adult CA and SOT patients with COVID-19 had higher comorbidities, greater levels of inflammatory markers at diagnosis, and higher rates of intensive care and hospital mortality. Pediatric CA patients and HCT patients with COVID-19 tended to have clinical presentations and outcomes similar to the general population. INTERPRETATION To our knowledge, this is the first systematic review evaluating COVID-19 phenotype and outcomes in immunocompromised patients and comparing them to the general population, which shows that hospital outcomes appear to be worse in adult CA and SOT patients, potentially due to their higher co-morbidity burden. FUNDING None.
Collapse
Affiliation(s)
- Jennifer A Belsky
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205 United States; Department of Pediatrics, The Ohio State University School of Medicine, Columbus, OH, United States
| | - Brian P Tullius
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205 United States; Department of Pediatrics, The Ohio State University School of Medicine, Columbus, OH, United States.
| | - Margaret G Lamb
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205 United States; Department of Pediatrics, The Ohio State University School of Medicine, Columbus, OH, United States
| | - Rouba Sayegh
- Division of Infectious Diseases, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205 United States; The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Joseph R Stanek
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205 United States
| | - Jeffery J Auletta
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205 United States; Department of Pediatrics, The Ohio State University School of Medicine, Columbus, OH, United States; Division of Infectious Diseases, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205 United States; The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| |
Collapse
|
8
|
Ye C, Liu J, Song X, Zheng S, Liu J. A clinician survey for management of the secondary immunodeficiency caused by hematological malignancies in China. Medicine (Baltimore) 2021; 100:e23935. [PMID: 33545966 PMCID: PMC7837821 DOI: 10.1097/md.0000000000023935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 11/25/2020] [Indexed: 11/26/2022] Open
Abstract
Unlike Western countries, there are still few clinical immunology specialists in China, and the optimal care for secondary immunodeficiency caused by hematological malignancies is unknown. Therefore, we initiated this clinician survey study to describe the current situation of the care for malignancy patients with hypogammaglobulinemia in China.We adapted a previously published online questionnaire of current clinical practices regarding the management of secondary immunodeficiency caused by hematological malignancies and then distributed the questionnaire to 52 hematologists in China via WeChat mobile software; the survey collected demographic details, starting dosage, target immunoglobulin (Ig) level, monitoring, criteria for stopping Ig replacement, vaccination use, and oral antibiotic prophylaxis for hypogammaglobulinemia patients.Forty-eight hematologists responded. 28(58.33%) respondents had more than 10 years of experience. Nevertheless, 40(83.33%) respondents reported that they did not use any specific criteria for prophylactic Ig replacement in hypogammaglobulinemia patients. However, 27(56.25%) respondents reported that they had used intravenous immunoglobulin (IVIG); however, the starting dose, frequency, and target Ig level were significantly varied. Additionally, the criteria for stopping Ig replacement were significantly varied. Only one respondent (2.08%) used subcutaneous immunoglobulin (SCIG). Moreover, 35(72.92%) respondents reported no vaccination prior to Ig replacement, and 47(97.92%) respondents reported that they had not used antibiotic prophylaxis in secondary hypogammaglobulinemia patients.Official guideline for the care for secondary immunodeficiency (SID) of the hematological malignancies patients should be issued in China, and significant attention of the hematologists should be paid to the use of prophylactic antibiotics and Ig replacement for the care of patients with hypogammaglobulinemia caused by hematological malignancies, as these agents could significantly reduce the infection rate in China.
Collapse
Affiliation(s)
- Chunmei Ye
- College of Medical Technology, Zhejiang Chinese Medical University, 548 Bingwen Road, Hangzhou
- Department of Clinical Laboratory, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Hangzhou
| | - Juan Liu
- Department of Hematology, The 2nd Affiliated Hospital of Harbin Medical University, 246 Xuefu Road, Harbin
| | - Xiaolu Song
- Department of Hematology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Hangzhou, China
| | - Sujie Zheng
- Department of Clinical Laboratory, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Hangzhou
| | - Jinlin Liu
- College of Medical Technology, Zhejiang Chinese Medical University, 548 Bingwen Road, Hangzhou
- Department of Clinical Laboratory, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Hangzhou
| |
Collapse
|
9
|
Marcus N, Frizinsky S, Hagin D, Ovadia A, Hanna S, Farkash M, Maoz-Segal R, Agmon-Levin N, Broides A, Nahum A, Rosenberg E, Kuperman AA, Dinur-Schejter Y, Berkun Y, Toker O, Goldberg S, Confino-Cohen R, Scheuerman O, Badarneh B, Epstein-Rigbi N, Etzioni A, Dalal I, Somech R. Minor Clinical Impact of COVID-19 Pandemic on Patients With Primary Immunodeficiency in Israel. Front Immunol 2021; 11:614086. [PMID: 33519822 PMCID: PMC7840610 DOI: 10.3389/fimmu.2020.614086] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/01/2020] [Indexed: 12/13/2022] Open
Abstract
In the last few months the world has witnessed a global pandemic due to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection causing coronavirus disease 2019 (COVID-19). Obviously, this pandemic affected individuals differently, with a significant impact on populations considered to be at high-risk. One such population, was assumed to be patients with primary genetic defect involving components or pathways of the immune system. While human immunity against COVID-19 is not fully understood, it is, so far, well documented, that both adaptive and innate cells have a critical role in protection against SARS-CoV-2. Here, we aimed to summarize the clinical and laboratory data on primary immunodeficiency (PID) patients in Israel, who were tested positive for SARS-CoV-2, in order to estimate the impact of COVID-19 on such patients. Data was collected from mid-February to end-September. During this time Israel experienced two “waves” of COVID-19 diseases; the first, from mid-February to mid-May and the second from mid-June and still ongoing at the end of data collection. A total of 20 PID patients, aged 4 months to 60 years, were tested positive for SARS-CoV-2, all but one, were detected during the second wave. Fourteen of the patients were on routine monthly IVIG replacement therapy at the time of virus detection. None of the patients displayed severe illness and none required hospitalization; moreover, 7/20 patients were completely asymptomatic. Possible explanations for the minimal clinical impact of COVID-19 pandemic observed in our PID patients include high level of awareness, extra-precautions, and even self-isolation. It is also possible that only specific immune pathways (e.g. type I interferon signaling), may increase the risk for a more severe course of disease and these are not affected in many of the PID patients. In some cases, lack of an immune response actually may be a protective measure against the development of COVID-19 sequelae.
Collapse
Affiliation(s)
- Nufar Marcus
- Allergy and Immunology Unit, Schneider Children's Medical Center of Israel, Felsenstein Medical Research Center, Kipper Institute of Immunology, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States
| | - Shirly Frizinsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,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.,Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - David Hagin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Department of Medicine, Allergy and Clinical Immunology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Adi Ovadia
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Pediatric Allergy Unit, E. Wolfson Medical Center, Holon, Israel.,Pediatric Department, E. Wolfson Medical Center, Holon, 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, Haifa, Israel
| | - Michael Farkash
- Allergy and Immunology Unit, Schneider Children's Medical Center of Israel, Felsenstein Medical Research Center, Kipper Institute of Immunology, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States
| | - Ramit Maoz-Segal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Nancy Agmon-Levin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Arnon Broides
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Immunology Clinic, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Amit Nahum
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Immunology Clinic, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Elli Rosenberg
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Immunology Clinic, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Amir Asher Kuperman
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.,Blood Coagulation Service and Pediatric Hematology Clinic, Galilee Medical Center, Nahariya, Israel
| | - Yael Dinur-Schejter
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yackov Berkun
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Department of Pediatrics, Mount Scopus Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ori Toker
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,The Allergy and Immunology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Shmuel Goldberg
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Pediatric Pulmonary Unit, Pediatric Division, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ronit Confino-Cohen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar-Saba, Israel
| | - Oded Scheuerman
- Pediatrics B, Schneider Children Medical Center Israel, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Basel Badarneh
- Allergy and Immunology Unit, Schneider Children's Medical Center of Israel, Felsenstein Medical Research Center, Kipper Institute of Immunology, Petach Tikva, Israel.,Pediatric Department, Allergy and Immunology Clinic, Carmel Medical Center, Technion Faculty of Medicine, Haifa, Israel
| | - Na'ama Epstein-Rigbi
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (Former Assaf Harofeh) Medical Center, Zerifin, 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, Haifa, Israel
| | - Ilan Dalal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,Pediatric Allergy Unit, E. Wolfson Medical Center, Holon, Israel.,Pediatric Department, E. Wolfson Medical Center, Holon, Israel
| | - Raz Somech
- The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.,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
| |
Collapse
|
10
|
Dilley M, Wangberg H, Noone J, Geng B. Primary immunodeficiency diseases treated with immunoglobulin and associated comorbidities. Allergy Asthma Proc 2021; 42:78-86. [PMID: 33404391 DOI: 10.2500/aap.2021.42.200113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Primary immunodeficiency diseases (PIDD) consist of a heterogeneous group of disorders characterized by various aspects of immune dysregulation. Although the most universally recognized manifestation of PIDD is an increased susceptibility to infections, there is a growing body of evidence that patients with PIDD often have a higher incidence of lung disease, autoimmunity, autoinflammatory disorders, and malignancy. Objective: The purpose of this study was to better understand the noninfectious complications of PIDD by determining the comorbid disease prevalence across various age groups, genders, and immunoglobulin replacement types compared with the general population. Methods: A large U.S. insurance claims database was retrospectively analyzed for patients who had a diagnosis of PIDD and who had received intravenous immunoglobulin (IVIG) or subcutaneous immunoglobulin (SCIG). The prevalences of 31 different comorbid conditions in the Elixhauser comorbidity index were compared among the 3125 patients in the PIDD population to > 37 million controls separated by gender and by 10-year age cohorts. Results: In the PIDD population, statistically significantly higher comorbid diagnoses included chronic obstructive pulmonary disease-asthma in 51.5%, rheumatoid disease in 14%, deficiency anemia in 11.8%, hypothyroidism in 21.2%, lymphoma in 16.7%, neurologic disorders in 9.7%, arrhythmias in 19.9%, electrolyte disorders in 23.6%, coagulopathies in 16.9%, and weight loss in 8.4%. Conclusion: PIDD that require immunoglobulin replacement are associated with an increased risk of numerous comorbid conditions that affect morbidity and mortality. Recognition and increased awareness of these noninfectious complications can allow for better monitoring, care coordination, targeted treatments, and improved prognosis.
Collapse
Affiliation(s)
- Michelle Dilley
- From the Division of Allergy, Immunology and Rheumatology, University of California San Diego and Rady Children's Hospital, San Diego, California
| | - Hannah Wangberg
- From the Division of Allergy, Immunology and Rheumatology, University of California San Diego and Rady Children's Hospital, San Diego, California
| | - Joshua Noone
- Department of Public Health Sciences, University of North Carolina, Charlotte, North Carolina
| | - Bob Geng
- From the Division of Allergy, Immunology and Rheumatology, University of California San Diego and Rady Children's Hospital, San Diego, California
| |
Collapse
|
11
|
Chinn IK, Orange JS. A 2020 update on the use of genetic testing for patients with primary immunodeficiency. Expert Rev Clin Immunol 2020; 16:897-909. [DOI: 10.1080/1744666x.2020.1814145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Ivan K. Chinn
- Department of Pediatrics, Section of Immunology, Allergy, and Retrovirology, Baylor College of Medicine, Houston, TX, USA
- Center for Human Immunobiology, Texas Children’s Hospital, Houston, TX, USA
| | - Jordan S. Orange
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA
- NewYork-Presbyterian Morgan Stanley Children's Hospita, New York, USA
| |
Collapse
|
12
|
Jones GL, Williams K, Edmondson-Jones M, Prevot J, Drabwell J, Solis L, Shrimpton A, Mahlaoui N. The Development of a New Questionnaire to Measure the Burden of Immunoglobulin Treatment in Patients with Primary Immunodeficiencies: The IgBoT-35. Patient Prefer Adherence 2020; 14:1567-1584. [PMID: 32982185 PMCID: PMC7490431 DOI: 10.2147/ppa.s234669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 06/12/2020] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To describe the development and psychometric testing of a new questionnaire to measure the burden of immunoglobulin treatment (Ig) from the perspective of patients with primary immunodeficiencies (PID). PATIENTS AND METHODS An online, cross-sectional survey was administered to PID patients across 10 countries (nine European and Canada) who were receiving either intravenous (IVIg) or subcutaneous (SCIg) immunoglobulin therapy. The range and distribution of the responses (ie, levels of missing data, floor and ceiling effects), exploratory factor analysis (using factor loadings of 0.4 or greater) and measures of internal consistency reliability (ie, Cronbach's alpha coefficient, inter-item and item-total correlations) were used to identify the domain and item pool. RESULTS In total, 472 patients completed the questionnaire, of which 395 were included in the analysis (32% underwent IVIg and 67% underwent SCIg). The final instrument contained 34 items across eight domains of treatment burden (time, organisation and planning, leisure and social, interpersonal relationships, employment and education, travel, consequences of treatment and emotional) and an additional Ig treatment burden global question at the end of the measure. All the scales achieved good internal reliability (Cronbach's alpha coefficient ranged from 0.70 to 0.85) and, with the exception of one item exceeded the minimum threshold of 0.35 for item-total correlations. Treatment burden was lower than anticipated across the different treatment routes and countries, although overall was more burdensome for patients undergoing IVIg compared to SCIg treatment. CONCLUSION The IgBoT-35 appears to be a reliable, patient-generated questionnaire and may help to identify more individualised and preferred therapies for the PID patient when used in clinical practice. A new survey with a sample of US patients is currently being undertaken to further establish its validity and conceptual model. The overall Ig burden of treatment scores appeared to be low. PID patient preferences are important to guide treatment decisions and ensuring patients receive the right treatment at the right time.
Collapse
Affiliation(s)
- Georgina L Jones
- Department of Psychology, School of Social Sciences, Leeds Beckett University, Leeds, UK
- Correspondence: Georgina L Jones Department of Psychology, School of Social Sciences, Leeds Beckett University, Calverley Building, City Campus, Leeds, UKTel +44 113 8125106 Email
| | | | | | - Johan Prevot
- International Patient Organisation for Primary Immunodeficiencies, Downderry, CornwallPL11 3LY, UK
| | - Jose Drabwell
- International Patient Organisation for Primary Immunodeficiencies, Downderry, CornwallPL11 3LY, UK
| | - Leire Solis
- International Patient Organisation for Primary Immunodeficiencies, Downderry, CornwallPL11 3LY, UK
| | - Anna Shrimpton
- Clinical Immunology and Allergy Unit, Northern General Hospital, Sheffield Teaching Hospitals and NHS Foundation Trust, Sheffield, UK
| | - Nizar Mahlaoui
- French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Enfants Malades University Hospital, Assistance Publique-Hôpitaux De Paris, Paris, France
- Pediatric Immuno-Haematology and Rheumatology Unit, Necker Enfants Malades University Hospital, Assistance Publique-Hôpitaux De Paris, Paris, France
- IPOPI Medical Advisory Board, Chair
| |
Collapse
|
13
|
Villavicencio MF, Pedroza LA. Diagnosis of primary immunodeficiency diseases in the developing world: the need for education and networking with the developed world. Curr Opin Pediatr 2019; 31:835-842. [PMID: 31693595 DOI: 10.1097/mop.0000000000000834] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Even with the evident improvement in knowledge about clinical and molecular aspects and the technology used to diagnose primary immunodeficiency diseases (PIDs), there is still a significant delay in recognition of these diseases in the developing world, specifically in Latin America. In this review, the goal is to outline the challenges that need to overcome for the diagnosis of PIDs and the optimization of resources available based on our experience. RECENT FINDINGS We describe the advances achieved in the past decade in Latin America in terms of recognition of PIDs, as well as the need for improvement. We outline the need for continued medical education, the lack of resources for laboratory testing, and how genetic testing through next-generation sequencing (that is becoming a day-to-day tool) can be achieved in the developing world. SUMMARY We aim to gather information about the limitations and challenges for the diagnosis of PIDs in a low-resource environment and the opportunities to benefit from the available advanced tools for diagnosis.
Collapse
Affiliation(s)
| | - Luis Alberto Pedroza
- Universidad San Francisco de Quito, Colegio de Ciencias de la Salud-Hospital de los Valles, Quito, Ecuador
- Department of Pediatrics, Section of Immunology, Allergy, and Rheumatology, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW Primary immunodeficiency disorders (PIDs) are no longer defined by infections alone. First clinical sign or sequelae of PID may include autoimmunity, such as cytopenias, arthritis or enteropathy. This review addresses the latest in multidisciplinary approaches for expanding clinical phenotypes of PIDs with autoimmunity, including new presentations of known entities and novel gene defects. We also discuss diagnostic tools for identifying the distinct changes in immune cells subsets and autoantibodies, mechanistic understanding of the process, and targeted treatment and indications for hematopoietic stem-cell transplantation (HSCT). RECENT FINDINGS In the past years, increased awareness and use of genetic screening, confirmatory functional studies and immunological biomarkers opened the door for early recognition of PIDs among patients with autoimmunity. Large cohort studies detail the clinical spectrum and treatment outcome of PIDs with autoimmunity with specific immune genes (e.g., CTLA4, LRBA, PI3Kδ, NFKB1, RAG). The benefit of early recognition is initiation of targeted therapies with precise re-balancing of the dysregulated immune pathways (e.g., biologicals) or definitive therapy (e.g., HSCT). SUMMARY Clinical presentation of patients with PID and autoimmunity is highly variable and requires in-depth diagnostics and precision medicine approaches.
Collapse
|
15
|
Chinn IK, Chan AY, Chen K, Chou J, Dorsey MJ, Hajjar J, Jongco AM, Keller MD, Kobrynski LJ, Kumanovics A, Lawrence MG, Leiding JW, Lugar PL, Orange JS, Patel K, Platt CD, Puck JM, Raje N, Romberg N, Slack MA, Sullivan KE, Tarrant TK, Torgerson TR, Walter JE. Diagnostic interpretation of genetic studies in patients with primary immunodeficiency diseases: A working group report of the Primary Immunodeficiency Diseases Committee of the American Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol 2019; 145:46-69. [PMID: 31568798 DOI: 10.1016/j.jaci.2019.09.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 09/02/2019] [Accepted: 09/20/2019] [Indexed: 12/19/2022]
Abstract
Genetic testing has become an integral component of the diagnostic evaluation of patients with suspected primary immunodeficiency diseases. Results of genetic testing can have a profound effect on clinical management decisions. Therefore clinical providers must demonstrate proficiency in interpreting genetic data. Because of the need for increased knowledge regarding this practice, the American Academy of Allergy, Asthma & Immunology Primary Immunodeficiency Diseases Committee established a work group that reviewed and summarized information concerning appropriate methods, tools, and resources for evaluating variants identified by genetic testing. Strengths and limitations of tests frequently ordered by clinicians were examined. Summary statements and tables were then developed to guide the interpretation process. Finally, the need for research and collaboration was emphasized. Greater understanding of these important concepts will improve the diagnosis and management of patients with suspected primary immunodeficiency diseases.
Collapse
Affiliation(s)
- Ivan K Chinn
- Department of Pediatrics, Baylor College of Medicine, Houston, Tex; Section of Immunology, Allergy, and Rheumatology, Texas Children's Hospital, Houston, Tex.
| | - Alice Y Chan
- Department of Pediatrics, Division of Allergy, Immunology, and Bone Marrow Transplantation, University of California at San Francisco, San Francisco, Calif
| | - Karin Chen
- Division of Allergy and Immunology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Janet Chou
- Department of Pediatrics, Harvard Medical School, Boston, Mass; Division of Allergy and Immunology, Boston Children's Hospital, Boston, Mass
| | - Morna J Dorsey
- Department of Pediatrics, Division of Allergy, Immunology, and Bone Marrow Transplantation, University of California at San Francisco, San Francisco, Calif
| | - Joud Hajjar
- Department of Pediatrics, Baylor College of Medicine, Houston, Tex; Section of Immunology, Allergy, and Rheumatology, Texas Children's Hospital, Houston, Tex
| | - Artemio M Jongco
- Departments of Medicine and Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY; Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Great Neck, NY; Division of Allergy & Immunology, Cohen Children's Medical Center of New York, Great Neck, NY
| | - Michael D Keller
- Department of Allergy and Immunology, Children's National Hospital, Washington, DC
| | - Lisa J Kobrynski
- Department of Pediatrics, Division of Allergy and Immunology, Emory University School of Medicine, Atlanta, Ga
| | - Attila Kumanovics
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Monica G Lawrence
- Department of Medicine, Division of Asthma, Allergy and Immunology, University of Virginia Health System, Charlottesville, Va
| | - Jennifer W Leiding
- Departments of Pediatrics and Medicine, University of South Florida, St Petersburg, Fla; Division of Pediatric Allergy/Immunology, Johns Hopkins-All Children's Hospital, St Petersburg, Fla; Cancer and Blood Disorders Institute, Johns Hopkins-All Children's Hospital, St Petersburg, Fla
| | - Patricia L Lugar
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Jordan S Orange
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY; New York Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Kiran Patel
- Department of Pediatrics, Division of Allergy and Immunology, Emory University School of Medicine, Atlanta, Ga
| | - Craig D Platt
- Department of Pediatrics, Harvard Medical School, Boston, Mass; Division of Allergy and Immunology, Boston Children's Hospital, Boston, Mass
| | - Jennifer M Puck
- Department of Pediatrics, Division of Allergy, Immunology, and Bone Marrow Transplantation, University of California at San Francisco, San Francisco, Calif
| | - Nikita Raje
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, Mo; Division of Allergy/Asthma/Immunology, Children's Mercy Hospital, Kansas City, Mo
| | - Neil Romberg
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Allergy/Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Maria A Slack
- Department of Medicine, Division of Allergy, Immunology, and Rheumatology, University of Rochester Medical Center, Rochester, NY; Department of Pediatrics, Division of Pediatric Allergy and Immunology, University of Rochester Medical Center, Rochester, NY
| | - Kathleen E Sullivan
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Allergy/Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Teresa K Tarrant
- Department of Medicine, Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC
| | - Troy R Torgerson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Wash; Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, Wash
| | - Jolan E Walter
- Departments of Pediatrics and Medicine, University of South Florida, St Petersburg, Fla; Division of Pediatric Allergy/Immunology, Johns Hopkins-All Children's Hospital, St Petersburg, Fla; Division of Pediatric Allergy Immunology, Massachusetts General Hospital, Boston, Mass
| |
Collapse
|