1
|
Hamel BL, Patel J, Still J, Joshi A. A diagnostic quandary: Rotavirus vaccine associated diarrhea. Vaccine 2023:S0264-410X(23)00715-6. [PMID: 37336660 DOI: 10.1016/j.vaccine.2023.06.040] [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: 01/31/2023] [Revised: 06/10/2023] [Accepted: 06/11/2023] [Indexed: 06/21/2023]
Abstract
The patient is an otherwise healthy two-month-old boy who received the recommended vaccinations for his age group, which included the rotavirus pentavalent vaccine (RV5; RotaTeq) at his two-month well child visit. Three days later, he developed prolonged non-bloody diarrhea and was found to have persistently positive rotavirus antigen in his stool. Subsequent workup revealed mild defects in his functional T-cell immunocompetence. Genetic testing was obtained through the Invitae panel and was negative for hereditary forms of primary immunodeficiencies. The rotavirus antigen was found to have cleared from his stool around four months after receiving the RV5. Unfortunately, the source of the rotavirus infection was unable to be determined. The caregivers had misconceptions about the vaccine and the child's immune system function which led to refusal of any further vaccinations. Healthcare providers should strive to develop honest and respectful relationships with parents to have thoughtful dialogues regarding vaccine safety and efficacy.
Collapse
Affiliation(s)
- Benjamin L Hamel
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55902, United States.
| | - Jenny Patel
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55902, United States
| | - Jenna Still
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55902, United States
| | - Avni Joshi
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55902, United States; Division of Pediatric Allergy and Immunology, Mayo Clinic, Rochester, MN 55902, United States
| |
Collapse
|
2
|
Mongkonsritragoon W, Huang J, Fredrickson M, Seth D, Poowuttikul P. Positive Newborn Screening for Severe Combined Immunodeficiency: What Should the Pediatrician Do? CLINICAL MEDICINE INSIGHTS: PEDIATRICS 2023; 17:11795565231162839. [PMID: 37025258 PMCID: PMC10071162 DOI: 10.1177/11795565231162839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/23/2023] [Indexed: 04/03/2023]
Abstract
Severe combined immunodeficiency (SCID) is a group of diseases characterized by low T-cell count and impaired T-cell function, resulting in severe cellular and humoral immune defects. If not diagnosed and treated promptly, infants affected by this condition can develop severe infections which will result in death. Delayed treatment can markedly reduce the survival outcome of infants with SCID. T-cell receptor excision circle (TREC) levels are measured on newborn screening to promptly identify infants with SCID. It is important for primary care providers and pediatricians to understand the approach to managing infants with positive TREC-based newborn screening as they may be the first contact for infants with SCID. Primary care providers should be familiar with providing anticipatory guidance to the family in regard to protective isolation, measures to minimize the risk of infection, and the coordination of care with the SCID coordinating center team of specialists. In this article, we use case-based scenarios to review the principles of TREC-based newborn screening, the genetics and subtypes of SCID, and management for an infant with a positive TREC-based newborn screen.
Collapse
Affiliation(s)
- Wimwipa Mongkonsritragoon
- Division of Allergy, Immunology and
Rheumatology, Department of Pediatrics, Children’s Hospital of Michigan, Detroit,
MI, USA
- Division of Allergy, Immunology and
Rheumatology, Department of Pediatrics, Central Michigan University College of
Medicine, Mt. Pleasant, MI, USA
| | - Jenny Huang
- Division of Allergy, Immunology and
Rheumatology, Department of Pediatrics, Children’s Hospital of Michigan, Detroit,
MI, USA
- Division of Allergy, Immunology and
Rheumatology, Department of Pediatrics, Central Michigan University College of
Medicine, Mt. Pleasant, MI, USA
| | - Mary Fredrickson
- Division of Allergy, Immunology and
Rheumatology, Department of Pediatrics, Children’s Hospital of Michigan, Detroit,
MI, USA
| | - Divya Seth
- Division of Allergy, Immunology and
Rheumatology, Department of Pediatrics, Children’s Hospital of Michigan, Detroit,
MI, USA
- Division of Allergy, Immunology and
Rheumatology, Department of Pediatrics, Central Michigan University College of
Medicine, Mt. Pleasant, MI, USA
| | - Pavadee Poowuttikul
- Division of Allergy, Immunology and
Rheumatology, Department of Pediatrics, Children’s Hospital of Michigan, Detroit,
MI, USA
- Division of Allergy, Immunology and
Rheumatology, Department of Pediatrics, Central Michigan University College of
Medicine, Mt. Pleasant, MI, USA
- Pavadee Poowuttikul, Division Chief of
Allergy/Immunology and Rheumatology, Training Program Director of
Allergy/Immunology, Medical Director of Primary Immunodeficiency Newborn
Screening Follow-up Coordinating Center, Central Michigan University, Children’s
Hospital of Michigan, 3950 Beaubien, 4th Floor, Pediatric Specialty Building,
Detroit, MI 48201, USA.
| |
Collapse
|
3
|
|
4
|
Bækvad-Hansen M, Adamsen D, Bybjerg-Grauholm J, Hougaard DM. Implementation of SCID Screening in Denmark. Int J Neonatal Screen 2021; 7:ijns7030054. [PMID: 34449527 PMCID: PMC8395828 DOI: 10.3390/ijns7030054] [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: 06/17/2021] [Revised: 07/30/2021] [Accepted: 08/04/2021] [Indexed: 11/16/2022] Open
Abstract
Screening for SCID was added to the Danish Neonatal Screening Program in February 2020. The screening uses a RealtimePCR kit and we here present the results and experiences with the validation of the kit and the first 10 months of screening.
Collapse
|
5
|
Michniacki TF, Seth D, Secord E. Severe Combined Immunodeficiency: A Review for Neonatal Clinicians. Neoreviews 2020; 20:e326-e335. [PMID: 31261096 DOI: 10.1542/neo.20-6-e326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The proper development and function of T cells is imperative in the creation of adequate cell-mediated and humoral immunity. Healthy term newborns have baseline immune immaturity, increasing their risk of infections, but significant immunologic consequences can occur, because of abnormal T-cell maturation. Combined immunodeficiencies can result, because B cells and natural killer cells rely on successful interactions with T cells to ensure their proper performance and survival. Severe combined immunodeficiency (SCID) is the most noteworthy of these conditions, leading to considerable early morbidity and often death by the age of 1 year if left untreated. Newborn screening for SCID is effective and allows for early implementation of lifesaving supportive measures, including protective isolation, initiation of prophylactic antimicrobials, caution with blood product transfusions, and avoidance of live vaccinations. Once a definitive diagnosis of SCID has been established, treatment frequently involves bone marrow or stem cell transplantation; however, enzyme replacement and gene therapy are also becoming options in those with SCID due to adenosine deaminase deficiency and other forms of SCID. Neonatal clinicians should understand the screening and diagnostic approach to SCID along with the initial management approaches for these extremely high-risk patients.
Collapse
Affiliation(s)
- Thomas F Michniacki
- Pediatrics and Communicable Diseases, Division of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, MI
| | - Divya Seth
- Department of Pediatrics, Division of Allergy, Asthma, & Immunology, Wayne State University, Detroit, MI
| | - Elizabeth Secord
- Department of Pediatrics, Division of Allergy, Asthma, & Immunology, Wayne State University, Detroit, MI
| |
Collapse
|
6
|
Barbaro M, Ohlsson A, Borte S, Jonsson S, Zetterström RH, King J, Winiarski J, von Döbeln U, Hammarström L. Newborn Screening for Severe Primary Immunodeficiency Diseases in Sweden-a 2-Year Pilot TREC and KREC Screening Study. J Clin Immunol 2017; 37:51-60. [PMID: 27873105 PMCID: PMC5226987 DOI: 10.1007/s10875-016-0347-5] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/18/2016] [Indexed: 12/16/2022]
Abstract
Newborn screening for severe primary immunodeficiencies (PID), characterized by T and/or B cell lymphopenia, was carried out in a pilot program in the Stockholm County, Sweden, over a 2-year period, encompassing 58,834 children. T cell receptor excision circles (TREC) and kappa-deleting recombination excision circles (KREC) were measured simultaneously using a quantitative PCR-based method on DNA extracted from dried blood spots (DBS), with beta-actin serving as a quality control for DNA quantity. Diagnostic cutoff levels enabling identification of newborns with milder and reversible T and/or B cell lymphopenia were also evaluated. Sixty-four children were recalled for follow-up due to low TREC and/or KREC levels, and three patients with immunodeficiency (Artemis-SCID, ATM, and an as yet unclassified T cell lymphopenia/hypogammaglobulinemia) were identified. Of the positive samples, 24 were associated with prematurity. Thirteen children born to mothers treated with immunosuppressive agents during pregnancy (azathioprine (n = 9), mercaptopurine (n = 1), azathioprine and tacrolimus (n = 3)) showed low KREC levels at birth, which spontaneously normalized. Twenty-nine newborns had no apparent cause identified for their abnormal results, but normalized with time. Children with trisomy 21 (n = 43) showed a lower median number of both TREC (104 vs. 174 copies/μL blood) and KREC (45 vs. 100 copies/3.2 mm blood spot), but only one, born prematurely, fell below the cutoff level. Two children diagnosed with DiGeorge syndrome were found to have low TREC levels, but these were still above the cutoff level. This is the first large-scale screening study with a simultaneous detection of both TREC and KREC, allowing identification of newborns with both T and B cell defects.
Collapse
Affiliation(s)
- Michela Barbaro
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden
| | - Annika Ohlsson
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden
- Department of Medical Biochemistry and Biophysics, Division of Molecular Metabolism, Karolinska Institutet, SE-17177, Stockholm, Sweden
| | - Stephan Borte
- Department of Clinical Immunology, Karolinska University Hospital Huddinge, SE-14186, Stockholm, Sweden
- ImmunoDeficiencyCenter Leipzig (IDCL) at Hospital St. Georg Leipzig, Delitzscher Strasse 141, 04129, Leipzig, Germany
| | - Susanne Jonsson
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden
| | - Rolf H Zetterström
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden
| | - Jovanka King
- Department of Clinical Immunology, Karolinska University Hospital Huddinge, SE-14186, Stockholm, Sweden
- Department of Immunopathology, SA Pathology, Women's and Children's Hospital Campus, North Adelaide, South Australia, 5006, Australia
- Robinson Research Institute and Discipline of Paediatrics, School of Medicine, University of Adelaide, North Adelaide, South Australia, 5006, Australia
| | - Jacek Winiarski
- Department of Clinical Technology and Intervention, Karolinska Institutet, SE-14186, Stockholm, Sweden
- Department of Pediatrics, Karolinska University Hospital Huddinge, SE-14186, Stockholm, Sweden
| | - Ulrika von Döbeln
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden.
- Department of Medical Biochemistry and Biophysics, Division of Molecular Metabolism, Karolinska Institutet, SE-17177, Stockholm, Sweden.
| | - Lennart Hammarström
- Department of Clinical Immunology, Karolinska University Hospital Huddinge, SE-14186, Stockholm, Sweden.
| |
Collapse
|
7
|
Indications to Epigenetic Dysfunction in the Pathogenesis of Common Variable Immunodeficiency. Arch Immunol Ther Exp (Warsz) 2016; 65:101-110. [DOI: 10.1007/s00005-016-0414-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 06/10/2016] [Indexed: 12/12/2022]
|