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Alamoudi WA, Azar A, Barta SK, Alawi F, Tanaka TI, Stoopler ET, Sollecito TP. EBV-positive B-cell ulcerative proliferation in the oral cavity associated with EBV-negative follicular lymphoma in a patient with common variable immunodeficiency: A case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 133:e10-e19. [PMID: 34645592 DOI: 10.1016/j.oooo.2021.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
Lymphoproliferative disorders (LPDs) are a group of conditions characterized by excessive production of lymphocytes manifested in various patterns including lymphadenopathy, tumor-like lesions, and lymphomas. LPD may be stimulated by Epstein-Barr virus (EBV) infection that most commonly appears in the setting of immunocompromised status such as long-term use of immunosuppressive medications and in individuals with primary immunodeficiency disorders. EBV mucocutaneous ulcer is a benign LPD reaction that mostly regresses spontaneously but sometimes requires medical or surgical intervention. This article presents a case of oral EBV mucocutaneous ulceration that affected an individual with a history of complex primary immunodeficiency disorders consisted of common variable immunodeficiency disease associated with T-cell dysfunction. This case is unique because the oral lesions led to the diagnosis of concurrent widespread EBV-negative follicular lymphomas, seemingly unrelated to her EBV-positive LPD oral disease. Yet, both occurred in the setting of severe immunosuppression from the primary immunodeficiency disorders.
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Affiliation(s)
- Waleed A Alamoudi
- Resident, Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, Philadelphia.
| | - Antoine Azar
- Assistant Professor, Division of Allergy and Clinical Immunology, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Stefan K Barta
- Associate Professor, Department of Hematology/Oncology, School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Faizan Alawi
- Professor of Pathology, Department of Basic & Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Takako I Tanaka
- Professor of Oral Medicine, Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Eric T Stoopler
- Professor of Oral Medicine, Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
| | - Thomas P Sollecito
- Professor of Oral Medicine, Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA
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Sizyakina LP, Andreeva II, Danilova DI. Dysregulatory processes of the cellular link of the immune system in the dynamics of common variable immunodeficiency. Klin Lab Diagn 2021; 66:160-165. [PMID: 33793115 DOI: 10.51620/0869-2084-2021-66-3-160-165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Common variable immunodeficiency (CVID) is a variant of primary immunodeficiency in which inhibition of antibody production is formed due to disorders of intercellular interaction affecting cellular elements of both innate and adaptive immune responses. A feature of CVID is the late start and variability of clinical minifestation. These arguments determine the purpose of the study: to identify the dynamics of changes in the cellular parameters of the adaptive and innate immune response depending on the duration and severity of the infectious manifestation of CVID. In this regard, a retrospective analysis of medical histories and dynamic observation of fifteen patients with CVID were carried out. Selection of specific parameters of cellular indices of factors of innate resistance and adaptive immunity was carried out on the basis of systemic-functional approach of immunodiagnostics. It is shown that in patients with CVID -mediated hypogammaglobulinemia and infectious phenotype of clinical manifestation, enhancement of quantitative and functional potentials of T-link effector cells of adaptive immunity is recorded against the background of reduction of number of regulatory T-helpers. With a more severe clinical course of the disease, the number of CD3+HLA DR + limphocytes is lower than with a more favorable version, there is a tendency to decrease the number of these cells, as well as the number of peripheral Treg with an increase in the length of the disease. Cellular components of innate immunity are characterized by a decrease in neutrophil activity, inhibition of antigen-presenting monocyte activity, the number and cytotoxicity of natural killers. At the same time, the tendency to decrease the cytolytic potential of NK with an increase in the length of illness and statistically significant differences depending on the severity of the manifestation of the infectious phenotype of CVID was recorded. The obtained results determine the importance of evaluating the cellular link of the immune system in patients with CVID, including as a prognostic criterion for the severity of the course.
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Barilla-LaBarca ML, Rodriguez M, Connors K, Wanamaker T, Petrizzo MC. Common Variable Immunodeficiency: A Standardized Patient Case for Second-Year Medical Students. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2019; 15:10837. [PMID: 31976361 PMCID: PMC6974347 DOI: 10.15766/mep_2374-8265.10837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 06/05/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Common variable immunodeficiency (CVID) is the most common symptomatic antibody deficiency, with a prevalence of 0.6-6.9 depending on the population studied. In contrast to other primary immunodeficiency diseases (PIDDs), symptoms may not appear until the third decade of life. Lack of recognition of CVID is a persistent problem. Myriad confounding clinical phenotypes and frequent infections, including autoimmunity, malignancy, chronic lung disease, granulomatous disease, and gastrointestinal disease, complicate the diagnosis. Often it is years before a diagnosis is made, leading to irreversible morbidities and mortality. METHODS Second-year medical students are introduced to CVID during their session on PIDDs that occurs during the immunology/rheumatology course. To assess students' recognition of CVID, a 15-minute OSCE encounter was created that included a simulation of lung sounds (rhonchi), physical exam cards (clubbing, otitis media with effusion), and moulage of skin (petechiae). A standardized patient (SP) portrayed a patient requesting antibiotics for a sinus infection. Students were tasked to both interview the patient and perform a hypothesis-driven physical exam. A postencounter exercise queried the students on their differential diagnosis and their rationale. RESULTS Item analysis of the case showed high levels of difficulty and strong discrimination between high- and low-performing students in both communication skills and clinical reasoning in CVID. DISCUSSION This SP encounter can be used in both formative and summative assessments to measure the recognition of CVID.
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Affiliation(s)
- Maria-Louise Barilla-LaBarca
- Associate Professor, Department of Medicine/Division of Rheumatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
- Co-Course Director, Interacting With the Environment, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
| | - Monica Rodriguez
- Standardized Patient Educator, Clinical Skills Center, Northwell Health
| | - Kelly Connors
- Standardized Patient Educator, Clinical Skills Center, Northwell Health
| | | | - Marie Cavuoto Petrizzo
- Assistant Professor, Department of Science Education, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
- Assistant Professor, Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
- Assistant Course Director, Patient, Physician and Society, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
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Gutierrez MJ, Sullivan KE, Fuleihan R, Bingham CO. Phenotypic characterization of patients with rheumatologic manifestations of common variable immunodeficiency. Semin Arthritis Rheum 2018; 48:318-326. [PMID: 29599028 DOI: 10.1016/j.semarthrit.2018.02.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 01/31/2018] [Accepted: 02/20/2018] [Indexed: 12/12/2022]
Abstract
Patients with common variable immunodeficiency (CVID) have a higher incidence of rheumatologic disorders. To delineate this clinical association, we investigated the phenotypic features of patients with CVID affected by these conditions. METHODS We conducted a retrospective analysis of 870 pediatric and adult patients with CVID included in the United States Immunodeficiency Network (USIDNET) registry. Outcomes included clinical characteristics (age, gender, ethnicity, rheumatologic diagnosis, and comorbidities), infectious history and basic immunophenotype (serum immunoglobulin levels, CD19+ B cells, and CD4/CD8 ratio) in patients with CVID and rheumatologic disorders compared to those with non-inflammatory CVID. Demographic and clinical data were compared using chi-square, Fisher's exact or Wilcoxon-Mann-Whitney tests. Non-parametric tests, single and multiple logistic regression models were used to evaluate the relationship between CVID-associated rheumatologic disorders and basic immunophenotypic parameters (IgA, IgM, CD19+ B-cell counts, and CD4/CD8 ratios). RESULTS Physician-reported rheumatic diseases were present in 5.9% of patients with CVID (n = 51) included in the registry. Although CVID affects both sexes equally, and patients are of predominantly White-Caucasian ethnicity, there were more females (3.3:1 female to male ratio) and increased proportion of non-white patients in the rheumatologic disease group (p < 0.05). Specific disorders included: inflammatory arthritis (n = 18), Sjogren's syndrome (n = 11), SLE (n = 8), Raynaud's syndrome (n = 8), vasculitis (n = 9), MCTD (n = 3), and other (n = 5). In about one-third of patients, a rheumatologic condition was associated with an additional inflammatory complication or malignancy. In regards to the immunophenotype parameters compared (CD19+ B-cell counts, CD4/CD8 ratio, IgA, and IgM), no significant differences were demonstrated between the two groups. CONCLUSION Our findings highlight the coexistence of primary antibody immunodeficiencies and systemic rheumatologic disorders, describe the spectrum of rheumatologic manifestations, and contrast differences in relevant demographic, clinical and immunophenotype parameters in the largest registry of CVID patients in the U.S. In spite of its limitations, our study details the intersection of systemic autoimmunity and CVID and provides valuable insights into these two groups of disorders. Further delineating the link between systemic autoimmunity and humoral immunodeficiencies can provide novel insights into the immune abnormalities underlying these related conditions.
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Affiliation(s)
- Maria J Gutierrez
- Division of Pediatric Allergy and Immunology, Johns Hopkins University, Baltimore, PA.
| | - Kathleen E Sullivan
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ramsay Fuleihan
- Division of Allergy and Immunology, Ann & Robert H. Lurie Children's Hospital, Chicago, IL
| | | | - Clifton O Bingham
- Divisions of Rheumatology and Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD
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Roberts TK, Chen X, Liao JJ. Diagnostic and therapeutic challenges of EBV-positive mucocutaneous ulcer: a case report and systematic review of the literature. Exp Hematol Oncol 2016; 5:13. [PMID: 27127726 PMCID: PMC4848873 DOI: 10.1186/s40164-016-0042-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 04/21/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) is a recently recognized B cell lymphoproliferative disorder that is driven by latent EBV infection and causes discrete ulcerations in the oropharynx, gastrointestinal tract, and skin. Local attenuation of immunosurveillance associated with iatrogenic immunosuppressant use, primary immunodeficiency, or age-associated immunosenescence has been implicated as a predisposing factor. This disorder is likely under reported, as it was only first defined in 2010 and shares histological features with other B-cell proliferative neoplasms. The first case series that described EBVMCU suggested that EBVMCU is generally self-limited and is likely to resolve without treatment. Since that publication, additional cases have been reported that describe a more heterogeneous clinical course, often requiring aggressive therapy. We now systematically review all published cases of EBVMCU and detail a case of aggressive and progressive EBVMCU, including diagnostic and management challenges, as well as successful treatment with radiation therapy. CASE PRESENTATION A forty-nine year old woman presented with painful and debilitating multifocal oral EBVMCU that initially responded to four weekly doses of rituximab. Her disease relapsed within 3 months and continued to progress and cause significant morbidity. She was successfully treated with local external beam radiation therapy of 30 Gy in 15 fractions, with duration of response of at least 6 months. CONCLUSIONS We suggest that although many patients with EBVMCU experience a self-limited course, for others EBVMCU can be a debilitating, persistent disorder that requires aggressive therapy to prevent disease progression. CD20- and CD30-directed antibody therapy, local radiation therapy, local surgical excision, systemic chemotherapy, and a combination of these therapies have all been successfully used to treat EBVMCU with high rates of durable clinical remission. As EBVMCU is not currently included in the 2008 WHO classification of lymphoproliferative disorders and no evidence-based guidelines or expert opinions have been proposed to guide therapy, this case report and systematic review provides a foundation on which to guide therapeutic decisions.
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Affiliation(s)
- Toni K. Roberts
- Department of Hematology Oncology, Fred Hutchinson Cancer Research Center, University of Washington Allied Hospitals, 1100 Fairview Ave N-D5-100, Seattle, WA 98109-1024 USA
| | - Xueyan Chen
- Department of Laboratory Medicine, UW Hematopathology Laboratory, University of Washington, Box 358081, 825 Eastlake Ave E, Seattle, WA 98109 USA
| | - Jay Justin Liao
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific St, 1st floor, NN106, Seattle, WA 98195 USA
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Milota T, Šumník Z, Obermannová B, Králíčková P, Vondrák K, Klocperk A, Kayserová J, Šedivá A. Negativity for Specific Autoantibodies in Patients with Type 1 Diabetes That Developed on a Background of Common Variable Immunodeficiency. Int Arch Allergy Immunol 2016; 168:197-204. [DOI: 10.1159/000441723] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 10/14/2015] [Indexed: 11/19/2022] Open
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Villa A, Treister NS. Intraoral herpes simplex virus infection in a patient with common variable immunodeficiency. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 116:e277-9. [PMID: 23933299 DOI: 10.1016/j.oooo.2013.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 05/13/2013] [Accepted: 05/18/2013] [Indexed: 10/26/2022]
Abstract
We report a challenging case of an atypical presentation of recrudescent herpes simplex virus infection in a patient with common variable immunodeficiency. Oral infections in immunosuppressed patients may present with unusual clinical features that can mimic non-infectious diseases. This report discusses the diagnostic steps necessary for definitive diagnosis and to guide appropriate and effective management.
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Affiliation(s)
- Alessandro Villa
- Oral medicine resident; Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, MA, USA; Assistant Professor, Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, USA.
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Karaulov AV, Sidorenko IV, Kapustina AS. Major approaches in early diagnostics of common variable immunodeficiency in adults in Moscow. F1000Res 2012; 1:46. [PMID: 24358827 PMCID: PMC3782364 DOI: 10.12688/f1000research.1-46.v1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2012] [Indexed: 01/16/2023] Open
Abstract
Common variable immunodeficiency (CVID) is a primary immunological disease characterized predominantly by hypogammaglobulinemia. The main clinical manifestations are severe recurrent infections that often lead to structural damage of affected organs. The early start of adequate intravenous immunoglobulin therapy has significantly improved the prognosis of this serious disorder. Patients with CVID are also predisposed to autoimmune and lymphoproliferative complications. This article deals with the features of this primary immunodeficiency in adults. Clinical manifestations, immunological features and treatment concepts were gathered during 21 years of observation of such patients in Moscow. The authors suggest early predictive clinical signs of CVID in adults.
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Affiliation(s)
- Alexander V Karaulov
- I.M. Sechenov First Moscow State Medical University, Moscow, 119991, Russian Federation
| | - Irina V Sidorenko
- I.M. Sechenov First Moscow State Medical University, Moscow, 119991, Russian Federation
| | - Anna S Kapustina
- I.M. Sechenov First Moscow State Medical University, Moscow, 119991, Russian Federation
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Seijas AB, Graziani S, Cancrini C, Finocchi A, Ferrari S, Miniero R, Conti F, Zuntini R, Chini L, Chiarello P, Bengala M, Rossi P, Moschese V, Di Matteo G. The Impact of TACI Mutations: From Hypogammaglobulinemia in Infancy to Autoimmunity in Adulthood. Int J Immunopathol Pharmacol 2012; 25:407-14. [DOI: 10.1177/039463201202500210] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- A.B. Barroeta Seijas
- Department of Public Health and Cellular Biology, University of Rome Tor Vergata, Rome, Italy
| | - S. Graziani
- Department of Pediatrics, Policlinico of Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - C. Cancrini
- Department of Public Health and Cellular Biology, University of Rome Tor Vergata, Rome, Italy
- Department of Pediatrics, Children's Hospital Bambino Gesù/University of Rome Tor Vergata, Rome, Italy
| | - A. Finocchi
- Department of Public Health and Cellular Biology, University of Rome Tor Vergata, Rome, Italy
- Department of Pediatrics, Children's Hospital Bambino Gesù/University of Rome Tor Vergata, Rome, Italy
| | - S. Ferrari
- Medical Genetics Unit, S. Orsola Malpighi Hospital, Bologna, Italy
| | - R. Miniero
- Department of Pediatrics, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - F. Conti
- Department of Public Health and Cellular Biology, University of Rome Tor Vergata, Rome, Italy
| | - R. Zuntini
- Medical Genetics Unit, S. Orsola Malpighi Hospital, Bologna, Italy
| | - L. Chini
- Department of Public Health and Cellular Biology, University of Rome Tor Vergata, Rome, Italy
- Department of Pediatrics, Policlinico of Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - P. Chiarello
- Department of Pediatrics, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - M. Bengala
- Medical Genetics Unit, Department of Laboratory Medicine, Policlinico Tor Vergata, Rome, Italy
| | - P. Rossi
- Department of Public Health and Cellular Biology, University of Rome Tor Vergata, Rome, Italy
- Department of Pediatrics, Children's Hospital Bambino Gesù/University of Rome Tor Vergata, Rome, Italy
| | - V. Moschese
- Department of Public Health and Cellular Biology, University of Rome Tor Vergata, Rome, Italy
- Department of Pediatrics, Policlinico of Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - G. Di Matteo
- Department of Public Health and Cellular Biology, University of Rome Tor Vergata, Rome, Italy
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Dagaonkar RS, Sen T, Udwadia ZF, Desai MB. Primary immune deficiency in the intensive care unit: It is never too late to diagnose and treat. Indian J Crit Care Med 2011; 15:179-81. [PMID: 22013312 PMCID: PMC3190471 DOI: 10.4103/0972-5229.84903] [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] [Indexed: 11/28/2022] Open
Abstract
Common variable immunodeficiency disorders (CVIDs), a heterogeneous group of primary immune deficiencies, can present at all age. Our patient with a hitherto undiagnosed CVID, symptomatic since middle ages, presented with severe pneumonia. Specific management of his CVID in addition to standard therapy was life-saving.
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