Therapeutic strategies in common variable immunodeficiency

Good Long-Term Outcome Following Liver Transplant in a Patient With Common Variable Immunodeficiency Syndrome Despite Multiple Infections and Recurrent Nodular Regenerative Hyperplasia

Common variable immunodeficiency can be associated with various hepatic conditions, the most common being nodular regenerative hyperplasia. Multiple cases of liver transplant in adults with common variable immunodeficiency have been reported. Here, we report a 51-year-old man with common variable immunodeficiency and noncirrhotic portal hypertension due to nodular regenerative hyperplasia who underwent liver transplant. The patient received tacrolimus/steroid immunosuppression and remained rejection free; however, he developed cytomegalovirus infection, disseminated nocardiosis, Pseudomonas pneumonia, and Clostridioides difficile- associated colitis. All infections were successfully managed. The graft was well functioning after 18 months; however, alkaline phosphatase remained elevated and a liver biopsy showed evidence of recurrent nodular regenerative hyperplasia. The patient was started on a steroid taper, which led to normalization of the alkaline phosphatase. Two years later, a repeat biopsy confirmed recurrent nodular regenerative hyperplasia. Immunosuppression was kept low, and intravenous immunoglobulin infusions were continued. More than 10 years later, the patient is alive with a functioning graft. This case emphasizes that intensified prophylaxis for infections and less intense immunosuppression may be strategies to enable long-term survival in liver transplant recipients with common variable immunodeficiency and nodular regenerative hyperplasia relapse despite recently reported poor outcomes in this patient population.

A significant therapeutic effect of immunoglobulins administered alone, or in combination with conventional chemotherapy, in experimental pulmonary tuberculosis caused by drug-sensitive or drug-resistant strains

The recommended chemotherapy for drug-sensitive tuberculosis (TB) consists of four different antibiotics administrated for 6 months. This long treatment leads to significant compliance problems and consequently to recrudescence of the disease and to the development of multidrug-resistant (MDR) strains. Thus, new alternatives are needed to shorten or simplify the treatment of TB. Antibodies have therapeutic effects in animal models of TB, so their use as adjuvants in drug-sensitive and MDR TB is an interesting alternative. To assess the effect of antibodies, BALB/c mice with active late disease 60 days after infection with drug-sensitive TB strain H37Rv were treated with intravenous immunoglobulin (IVIg), alone or in combination with conventional chemotherapy. When compared with control non-treated animals, IVIg alone produced a significantly decreased burden of pulmonary bacilli. This decrease was even greater when IVIg was used in combination with conventional chemotherapy. The combined therapy also significantly reduced tissue damage (pneumonia) when compared to infected animals treated only with antibiotics. IVIg treatment also caused decreased bacillary burdens in mice infected with an MDR strain. In vitro experiments suggested that improving phagocytosis by efficient opsonization is perhaps the principal mechanism of this beneficial therapeutic effect.

A review on guidelines for management and treatment of common variable immunodeficiency

Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency in adults. As symptoms of CVID are usually heterogeneous and unspecific, diagnosis and follow-up of CVID can be challenging. In light of this, a broad review of advances in management and treatment of CVID is performed here in order to reach a distinct protocol. However, it should be noted that owing to the nature of the disease, it can only be treated symptomatically but not cured. There is little evidence to guide appropriate or universal guidelines to improve the current status of management of the disease. The most satisfactory treatments of CVID could be achieved by the use of immunoglobulin replacement, antibiotics, immunosuppressants and hematopoietic stem cell transplantation. This review is written based on the importance of clinical surveillance of asymptomatic CVID cases and early recognition of different clinical complications. Moreover, for each complication, appropriate interventions for improving outcomes are mentioned.

Major approaches in early diagnostics of common variable immunodeficiency in adults in Moscow

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.

Modern management of primary B-cell immunodeficiencies

B-cell defects constitute the majority of primary immunodeficiencies. Although a heterogeneous group of diseases, all are characterized by the reduction in or absence of immunoglobulins and/or specific antimicrobial antibodies. Substitution of immunoglobulin G (IgG) is therefore the mainstay of treatment. While from the late 1970s, the intravenous route of administration was the most common, in the past decades, subcutaneous immunoglobulin replacement therapy has become more popular among patients and physicians. Independently of the optimal route of administration, dosage and IgG trough level remain subjects of debate. Higher IgG trough levels seem to improve the protection against recurrent infections and thus better prevent complications such as bronchiectasis. Some patients, however, achieve protection with IgG trough levels on the lower IgG limit of healthy persons. Therefore, an individual protective IgG trough level needs to be defined for each patient. Use of additional prophylactic antibiotics and immunosuppressive drugs differs amongst specialized immunodeficiency centres and clearly requires future investigation in multi-centre trials. Haematopoietic stem cell transplantation (HSCT) is to date indicated as curative treatment in certain patients with B-cell defects associated with cell deficiencies, for example in two class-switch recombination defects and in selected severe forms of common variable immunodeficiency.

Interleukin-21 restores immunoglobulin production ex vivo in patients with common variable immunodeficiency and selective IgA deficiency

Interleukin-21 (IL-21) is an important promoter for differentiation of human B cells into immunoglobulin (Ig)–secreting cells. The objective of this study was to evaluate an IL-21–based approach to induce immunoglobulin production in B cells from patients with common variable immunodeficiency (CVID) or selective IgA deficiency (IgAD). We show that a combination of IL-21, IL-4, and anti-CD40 stimulation induces class-switch recombination to IgG and IgA and differentiation of Ig-secreting cells, consisting of both surface IgG+ (sIgG+) and sIgA+ B cells and CD138+ plasma cells, in patients with CVID or IgAD. Stimulation with IL-21 was far more effective than stimulation with IL-4 or IL-10. Moreover, spontaneous apoptosis of CD19+ B cells from patients with CVID or IgAD was prevented by a combination of IL-21, IL-4, and anti-CD40 stimulation. Analysis of IL-21 and IL-21 receptor (IL-21R) mRNA expression upon anti-CD3 stimulation of T cells, however, showed no evidence for defective IL-21 expression in CVID patients and sequencing of the coding regions of the IL21 gene did not reveal any mutations, suggesting a regulatory defect. Thus, our work provides an initial basis for a potential therapeutic role of IL-21 to reconstitute immunoglobulin production in CVID and IgAD.

Common variable immunodeficiency: etiological and treatment issues

One of the great advances in clinical medicine was the recognition of the pleomorphism of the immune response and the multiple afferent and efferent limbs of antigen processing and responsiveness. A significant contribution to this understanding was derived from studies of human immunodeficiency states, including both inherited and acquired syndromes. Amongst these syndromes, one of the most common, and least understood, is common variable immune deficiency (CVID). CVID is a syndrome that leads to a reduction in serum immunoglobulins and complications including recurrent infections. Management includes immunoglobulin replacement therapy; however, patients with CVID are at risk for complications of exogenous immunoglobulin administration as well as CVID-associated diseases such as autoimmune processes and malignancies. To assess the current state of knowledge in the field, we performed a literature review of a total of 753 publications covering the period of 1968 until 2008. From this list, 189 publications were selected for discussion. In this review, we demonstrate that while the molecular basis of CVID in many cases remains incompletely understood, significant strides have been made and it is now clear that there is involvement of several pathways of immune activation, with contributions from both T and B cells. Furthermore, despite the current gaps in our knowledge of the molecular pathogenesis of the syndrome, there have been dramatic advances in management that have led to improved survival and significantly reduced morbidity in affected patients.

Granulomatous-lymphocytic interstitial lung disease associated with common variable immunodeficiency: CT findings

PURPOSE

To evaluate computed tomography (CT) scans of individuals with granulomatous-lymphocytic interstitial lung disease and common variable immunodeficiency (CVID) to determine if there are imaging features that distinguish this manifestation of CVID from the more usual imaging findings.

MATERIALS AND METHODS

A review of the CVID population at our institution identified a series of 5 patients with CVID who had documented granulomatous disease on biopsy specimens. The initial and follow-up CT examinations were reviewed by 2 radiologists, and imaging findings in the chest and abdomen were tabulated by consensus. In addition, a pathologist reviewed histopathologic specimens and clinical presentations and therapeutic interventions were obtained from patient charts.

RESULTS

In all, 5/5 patients (100%) had widespread pulmonary micronodules with a lower lung zone predominance, 4/5 (80%) had smooth interlobular septal thickening with mid to lower lung zone predominance, 1/5 (20%) had mild bronchiectasis, 4/5 (80%) had multifocal pulmonary consolidation, 5/5 (100%) had thoracic or abdominal lymphadenopathy, 2/5 (40%) had hepatomegaly, 5/5 (100%) had splenomegaly, 1/5 (20%) had nonspecific hypoattenuating splenic lesions, and 2/5 (40%) had nonspecific hypoattenuating renal lesions. The pulmonary nodules and lymphadenopathy commonly tended to wax and wane in severity over time, and more marked disease was often associated with areas of focal consolidation.

CONCLUSION

Granulomatous-lymphocytic interstitial lung disease, which can occur in patients with CVID, presents with CT findings distinct from the usual airway abnormalities most commonly associated with CVID.

Common variable immunodeficiency: a new look at an old disease

Primary immunodeficiencies comprise many diseases caused by genetic defects primarily affecting the immune system. About 150 such diseases have been identified with more than 120 associated genetic defects. Although primary immunodeficiencies are quite rare in incidence, the prevalence can range from one in 500 to one in 500 000 in the general population, depending on the diagnostic skills and medical resources available in different countries. Common variable immunodeficiency (CVID) is the primary immunodeficiency most commonly encountered in clinical practice, and appropriate diagnosis and management of patients will have a significant effect on morbidity and mortality as well as financial aspects of health care. Advances in diagnostic laboratory methods, including B-cell subset analysis and genetic testing, coupled with new insights into the molecular basis of immune dysfunction in some patients with CVID, have enabled advances in the clinical classification of this heterogeneous disease.

Common variable immune deficiency and lung transplantation

We report on a male patient with bronchiectasis secondary to common variable immune deficiency (CVID) receiving lung transplantation. The patient had been diagnosed with CVID many y prior to right-sided single lung transplantation and was receiving appropriate immunoglobulin substitution therapy. He received antithymocyte globulin induction and maintenance triple therapy with cyclosporine, azathioprine and prednisolone. The early post-operative course was complicated by the development of severe acute cellular rejection and organizing pneumonia. Despite immunoglobulin replacement and antifungal prophylaxis and treatment, Aspergillus fumigatus was repeatedly cultured from bronchoalveolar lavage fluid, 18 months after transplantation. The patient died following a protracted period of repeated hospital admissions, 46 months after transplantation. A review of the literature suggests that many CVID patients appear to have had a complicated post-operative course after lung- and other solid-organ transplantation, and highlights the need for the establishment of international registries for transplanted patients with uncommon conditions.

Asymptomatic choroidal granulomas in common variable immunodeficiency

Common variable immunodeficiency disease represents the most common cause of significant antibody deficiency in adults. It is a heterogeneous group of disorders that can be sporadic or familial with various modes of inheritance with defects in B-cell function, regulatory T-cells and macrophage function all being reported. Herein a case of asymptomatic bilateral choroidal granulomatous disease in a 27-year-old man with common variable immunodeficiency disease is described.

Therapeutic efficacy of high-dose intravenous immunoglobulin in Mycobacterium tuberculosis infection in mice

Intravenous immunoglobulin (IVIg) is used to treat patients with primary antibody deficiencies and, at high doses, to treat a range of autoimmune and inflammatory disorders. With high-dose IVIg (hdIVIg), immunomodulatory mechanisms act on a range of cells, including T cells, B cells, and dendritic cells. Here, we demonstrate that the treatment of M. tuberculosis-infected mice with a single cycle of hdIVIg resulted in substantially reduced bacterial loads in the spleen and lungs when administered at either an early or late stage of infection. Titration of the IVIg showed a clear dose-response effect. There was no reduction in bacterial load when mice were given equimolar doses of another human protein, human serum albumin, or maltose, the stabilizing agent in the IVIg preparation. HdIVIg in vitro had no inhibitory effect on the growth of M. tuberculosis in murine bone marrow-derived macrophages. In addition, the effect of hdIVIg on bacterial loads was not observed in nude mice, suggesting the involvement of conventional T cells. Analysis of T cells infiltrating the lungs revealed only small increases in CD8(+) but not CD4(+) T-cell numbers in hdIVIg-treated mice. The mechanism of action of hdIVIg against tuberculosis in mice remains to be determined. Nevertheless, since hdIVIg is already widely used clinically, the magnitude and long duration of the therapeutic effect seen here suggest that IVIg, or components of it, may find ready application as an adjunct to therapy of human tuberculosis.

The Outcomes of Lung Transplantation in Patients With Bronchiectasis and Antibody Deficiency

BACKGROUND

Lung transplantation is an established treatment for end-stage bronchiectasis. A proportion of patients with bronchiectasis have an associated antibody deficiency. This group benefits from immunoglobulin replacement therapy, but the outcome of lung transplantation is not known.

METHODS

We conducted a retrospective observational study of all who received a transplant for bronchiectasis at our unit. We compared the survival after transplant, number of infective and rejection episodes, and the change in forced expiratory volume in 1 second (FEV1).

RESULTS

Five of the 37 patients identified with bronchiectasis had an antibody deficiency that required immunoglobulin replacement therapy. Actuarial survival was similar in the 2 groups, being 81% at 12 months in the Bronchiectasis Group and 80% in the Antibody Deficiency Group. The FEV1 at 12 months after transplantation was similar in each group, with a predicted mean +/- SD FEV1 of 83.7% +/- 24.2% in those with bronchiectasis and 83.0% +/- 30.4% in those with antibody deficiency as well. The infection and rejection rates in the first year after transplantation were lower in the Antibody Deficiency Group. Infection episodes per 100 patient-days for bronchiectasis alone were 0.90 vs 0.53 and rejection episodes per 100 patient-days were 0.59 vs 0.24.

CONCLUSIONS

There was no evidence that transplant recipients with bronchiectasis and antibody deficiency have a worse prognosis than those with bronchiectasis alone.

Common variable immunodeficiency: test indications and interpretations

Common variable immunodeficiency (CVID) is a primary immunodeficiency disorder that can present with multiple phenotypes, all of which are characterized by hypogammaglobulinemia, in a person at any age. A specific genetic defect that accounts for all CVID phenotypes has not been identified, and it is likely that several distinct genetic disorders with similar clinical presentations are responsible for the observed variation. In this review, we summarize the known genetic mutations that give rise to hypogammaglobulinemia and how these gene products affect normal or abnormal B-cell development and function, with particular emphasis on CVID. Additionally, we describe specific phenotypic and genetic laboratory tests that can be used to diagnose CVID and provide guidelines for test interpretation and subsequent therapeutic intervention.

Common variable immunodeficiency in three horses with presumptive bacterial meningitis

Three adult horses were evaluated for signs of musculoskeletal pain, dullness, ataxia, and seizures. A diagnosis of bacterial meningitis was made on the basis of results of CSF analysis. Because primary bacterial meningitis is so rare in adult horses without any history of generalized sepsis or trauma, immune function testing was pursued. Flow cytometric phenotyping of peripheral blood lymphocytes was performed, and proliferation of peripheral blood lymphocytes in response to concanavalin A, phytohemagglutinin, pokeweed mitogen, and lipopolysaccharide was determined. Serum IgA, IgM, and IgG concentrations were measured by means of radial immunodiffusion, and serum concentrations of IgG isotypes were assessed with a capture antibody ELISA. Serum tetanus antibody concentrations were measured before and 1 month after tetanus toxoid administration. Phagocytosis and oxidative burst activity of isolated peripheral blood phagocytes were evaluated by means of simultaneous flow cytometric analysis. Persistent B-cell lymphopenia, hypogammaglobulinemia, and abnormal in vitro responses to mitogens were detected in all 3 horses, and a diagnosis of common variable immunodeficiency was made.

[29-year-old female patient with pneumonia and enlarged abdominal lymph nodes]

Common variable immunodeficiency (CVID) is the most common clinically manifested primary immunodeficiency disease. A 29-year-old female patient presented with pneumonia and enlarged thoracal and abdominal lymph nodes. Frequently recurring infections, especially in the respiratory tract were observed in the patient's history. A hypogammaglobulinaemia could be detected. By exclusion of other disorders and a complete analysis of the immune status a CVID Ib/B was diagnosed. Regular ambulatory treatment with immune globulin substitution reduced the incidence and severity of infections.