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Sgrulletti M, Baselli LA, Castagnoli R, Del Duca E, Graziani S, Moscato GMF, Di Cesare S, Di Matteo G, Cifaldi C, Rossano M, Ballerini C, Piciocchi A, Licari A, Marseglia GL, Consolini R, Moschese V. IPINeT Ped-unPAD Study: Goals, Design, and Preliminary Results. J Clin Med 2024; 13:4321. [PMID: 39124588 PMCID: PMC11312696 DOI: 10.3390/jcm13154321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/19/2024] [Accepted: 07/20/2024] [Indexed: 08/12/2024] Open
Abstract
Background: An unclassified primary antibody deficiency (unPAD) is a widely heterogeneous clinical entity, recently identified within the spectrum of Inborn Errors of Immunity (IEIs). Since unPAD has been traditionally considered as a mild condition, it has incorrectly received little attention, resulting in the paucity of extensive and comparable studies describing its natural history. To address the gaps in characterizing, understanding, and managing pediatric unPAD patients, the Italian Primary Immunodeficiency Network (IPINet) Ped-unPAD study has recently been launched. Methods: Seventeen IPINeT Centers have expressed interest to participate, and data collection is still on-going. Hereby, we anticipate preliminary key issues emerging from the first 110 enrolled patients, attending three IPINet Centers. Results: A proportion of unPAD patients have experienced a severe infectious phenotype, which required hospitalization in a quarter of patients and antibiotic prophylaxis or Immunoglobulin Replacement Therapy in approximately 10% of patients. In this partial cohort, a mean follow-up (FU) of 5 years confirmed unPAD diagnosis in fifty percent of cases, with the remaining being reclassified as the Transient Hypogammaglobulinemia of Infancy (25%) and other IEIs (25%), such as a Common Variable Immunodeficiency, Selective IgA deficiency, Selective IgM deficiency, and IgG3 subclass deficiency. Conclusions: Despite a phenotype overlap at diagnosis, clinicians should be aware that unPAD is a mutable condition that deserves comprehensive evaluation and long-term monitoring to dissect the final diagnosis for optimal treatment.
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Affiliation(s)
- Mayla Sgrulletti
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Rome Tor Vergata, 00133 Rome, Italy; (M.S.); (E.D.D.); (S.G.); (G.M.F.M.)
- PhD Program in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Lucia Augusta Baselli
- Pediatric Immunorheumatology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (L.A.B.); (M.R.)
| | - Riccardo Castagnoli
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (R.C.); (A.L.); (G.L.M.)
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Elisabetta Del Duca
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Rome Tor Vergata, 00133 Rome, Italy; (M.S.); (E.D.D.); (S.G.); (G.M.F.M.)
| | - Simona Graziani
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Rome Tor Vergata, 00133 Rome, Italy; (M.S.); (E.D.D.); (S.G.); (G.M.F.M.)
| | - Giusella Maria Francesca Moscato
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Rome Tor Vergata, 00133 Rome, Italy; (M.S.); (E.D.D.); (S.G.); (G.M.F.M.)
- Department of System Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (G.D.M.); (C.C.)
| | - Silvia Di Cesare
- Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Gigliola Di Matteo
- Department of System Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (G.D.M.); (C.C.)
- Primary Immunodeficiency Research Unit, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy
| | - Cristina Cifaldi
- Department of System Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (G.D.M.); (C.C.)
| | - Martina Rossano
- Pediatric Immunorheumatology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (L.A.B.); (M.R.)
| | | | - Alfonso Piciocchi
- GIMEMA Data Center, Fondazione GIMEMA Franco Mandelli Onlus, 00182 Rome, Italy;
| | - Amelia Licari
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (R.C.); (A.L.); (G.L.M.)
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Gian Luigi Marseglia
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (R.C.); (A.L.); (G.L.M.)
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Rita Consolini
- Section of Clinical and Laboratory Immunology, Pediatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Viviana Moschese
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Rome Tor Vergata, 00133 Rome, Italy; (M.S.); (E.D.D.); (S.G.); (G.M.F.M.)
- Department of System Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (G.D.M.); (C.C.)
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Holma P, Pesonen P, Karjalainen MK, Järvelin MR, Väyrynen S, Sliz E, Heikkilä A, Seppänen MRJ, Kettunen J, Auvinen J, Hautala T. Low and high serum IgG associates with respiratory infections in a young and working age population. EBioMedicine 2023; 94:104712. [PMID: 37453363 PMCID: PMC10366395 DOI: 10.1016/j.ebiom.2023.104712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND We investigated health consequences and genetic properties associated with serum IgG concentration in a young and working age general population. METHODS Northern Finland Birth Cohort 1966 (NFBC1966, n = 12,231) health data have been collected from birth to 52 years of age. Relationships between life-long health events, medications, chronic conditions, lifestyle, and serum IgG concentration measured at age 46 years (n = 5430) were analysed. Regulatory mechanisms of serum IgG concentration were considered. FINDINGS Smoking and genetic variation (FCGR2B and TNFRSF13B) were the most important determinants of serum IgG concentration. Laboratory findings suggestive of common variable immunodeficiency (CVID) were 10-fold higher compared to previous reports (73.7 per 100,000 vs 0.6-6.9 per 100,000). Low IgG was associated with antibiotic use (relative risk 1.285, 95% CI 1.001-1.648; p = 0.049) and sinus surgery (relative risk 2.257, 95% CI 1.163-4.379; p = 0.016). High serum IgG was associated with at least one pneumonia episode (relative risk 1.737, 95% CI 1.032-2.922; p = 0.038) and with total number of pneumonia episodes (relative risk 2.167, 95% CI 1.443-3.254; p < 0.001). INTERPRETATION CVID-like laboratory findings are surprisingly common in our unselected study population. Any deviation of serum IgG from normal values can be harmful; both low and high serum IgG may indicate immunological insufficiency. Critical evaluation of clinical presentation must accompany immunological laboratory parameters. FUNDING Oulu University Hospital VTR, CSL Behring, Foundation for Pediatric Research.
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Affiliation(s)
- Pia Holma
- Research Unit of Internal Medicine and Biomedicine, University of Oulu and Oulu University Hospital, Division of Infectious Diseases, Oulu, Finland
| | - Paula Pesonen
- Northern Finland Birth Cohorts, Arctic Biobank, Infrastructure for Population Studies, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Minna K Karjalainen
- Northern Finland Birth Cohorts, Arctic Biobank, Infrastructure for Population Studies, Faculty of Medicine, University of Oulu, Oulu, Finland; Research Unit of Population Health, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Marjo-Riitta Järvelin
- Research Unit of Population Health, Faculty of Medicine, University of Oulu, Oulu, Finland; Department of Epidemiology and Biostatistics, MRC Center for Environment & Health, School of Public Health, Imperial College London, London, UK
| | - Sara Väyrynen
- Research Unit of Internal Medicine and Biomedicine, University of Oulu and Oulu University Hospital, Division of Infectious Diseases, Oulu, Finland
| | - Eeva Sliz
- Research Unit of Population Health, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Anni Heikkilä
- Research Unit of Population Health, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Mikko R J Seppänen
- Rare Disease Center and Pediatric Research Center, Children and Adolescents, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Johannes Kettunen
- Research Unit of Population Health, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Juha Auvinen
- Research Unit of Population Health, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Timo Hautala
- Research Unit of Internal Medicine and Biomedicine, University of Oulu and Oulu University Hospital, Division of Infectious Diseases, Oulu, Finland.
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Sgrulletti M, Costagliola G, Giardino G, Graziani S, Del Duca E, Di Cesare S, Di Matteo G, Consolini R, Pignata C, Moschese V. The Evolutionary Scenario of Pediatric Unclassified Primary Antibody Deficiency to Adulthood. J Clin Med 2023; 12:4206. [PMID: 37445241 DOI: 10.3390/jcm12134206] [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: 05/17/2023] [Revised: 06/17/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Unclassified primary antibody deficiency (unPAD) is a relatively novel inborn error of immunity (IEI) condition that can vary with time to more defined entities. Since long-term follow-up (FU) studies are scarce, we aimed to provide insight into the evolutionary clinical and immunological scenario of unPAD children to adulthood and identification of biomarkers of primary immune deficiency (PID) persistence. METHODS A total of 23 pediatric unPAD patients underwent clinical and immunological FU for a mean time of 14 years (range 3-32 years, median 16 years). RESULTS UnPAD diagnosis may change over time. At the last FU, 10/23 (44%) children matched the diagnosis of transient hypogammaglobulinemia of infancy and 13/23 (56%) suffered from a persistent PID. In detail, an unPAD condition was confirmed in 7/23 (30%) patients, whereas 3/23 (13%), 2/23 (9%), and 1/23 (4%) were reclassified as common variable immunodeficiency, selective IgA deficiency, and isolated IgM deficiency, respectively. Low IgA, low specific antibody response to pneumococcus, and lower respiratory tract infections at diagnosis were independently associated with IEI persistence. CONCLUSIONS Long-term monitoring of unPAD patients is required to define their outcome and possible evolution towards a definitive IEI diagnosis.
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Affiliation(s)
- Mayla Sgrulletti
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Tor Vergata, 00133 Rome, Italy
- Ph.D. Program in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Giorgio Costagliola
- Section of Clinical and Laboratory Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Giuliana Giardino
- Pediatric Section, Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy
| | - Simona Graziani
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Tor Vergata, 00133 Rome, Italy
| | - Elisabetta Del Duca
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Tor Vergata, 00133 Rome, Italy
| | - Silvia Di Cesare
- Department of Systems Medicine, University of Tor Vergata, 00133 Rome, Italy
| | - Gigliola Di Matteo
- Department of Systems Medicine, University of Tor Vergata, 00133 Rome, Italy
| | - Rita Consolini
- Section of Clinical and Laboratory Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Claudio Pignata
- Pediatric Section, Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy
| | - Viviana Moschese
- Pediatric Immunopathology and Allergology Unit, Policlinico Tor Vergata, University of Tor Vergata, 00133 Rome, Italy
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Diem L, Evangelopoulos ME, Karathanassis D, Natsis V, Kamber N, Hammer H, Friedli C, Chan A, Helbling A, Penner IK, Salmen A, Walther S, Stegmayer K, Hoepner R. Hypogammaglobulinemia: A contributing factor to multiple sclerosis fatigue? Mult Scler Relat Disord 2022; 68:104148. [PMID: 36063730 DOI: 10.1016/j.msard.2022.104148] [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: 06/18/2022] [Revised: 08/04/2022] [Accepted: 08/25/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Fatigue is one of the most disabling and difficult to treat symptoms of autoimmune diseases and frequently presents in people with multiple sclerosis (PwMS). Hypogammaglobulinemia for immunoglobulin G (IgG) affects approximately 8-25% of PwMS. We performed a retrospective analysis to investigate the association of MS-fatigue and IgG hypogammaglobulinemia. METHODS PwMS, treated at Eginition University Hospital Athens or at the University Hospital Bern, were included (n = 134 patients (Bern n = 99; Athens n = 35)). Mann Whitney U-test (MWT), ANOVA test, Chi2 test and multivariable linear regression models were run. RESULTS 97/134 (72.4%) PwMS reported fatigue. In the multivariable linear regression analysis, IgG serum concentration (-1.6, 95%CI -2.7 - -0.5, p = 0.006), daytime sleepiness (0.8, 95%CI 0.2-1.4, p = 0.009), and a depressive mood (1.1, 95%CI 0.8-1.4, p < 0.001) were significantly associated with fatigue. The impact of IgG serum concentration (-2.9 95%CI -4.7 - -1.1, p = 0.002) remained significant also in the subcohort of PwMS without depressive symptoms or daytime sleepiness. CONCLUSIONS We found an association between IgG hypogammaglobulinemia and fatigue in PwMS (Level of Evidence IV), which might be translated to other autoimmune diseases. It bears a potential therapeutic consequence considering IgG supplementation strategies, if our finding can be validated prospectively.
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Affiliation(s)
- L Diem
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland.
| | - M E Evangelopoulos
- Department of Neurology, Aiginitio University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - D Karathanassis
- Department of Neurology, Aiginitio University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - V Natsis
- Department of Neurology, Aiginitio University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - N Kamber
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - H Hammer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - C Friedli
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - A Chan
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - A Helbling
- Department of Pulmonary Medicine and Allergology, Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - I K Penner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - A Salmen
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
| | - S Walther
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Bern, Switzerland
| | - K Stegmayer
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Bern, Switzerland
| | - R Hoepner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Freiburgstrasse, Bern, Switzerland
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Janssen LMA, Reijnen ICGM, Milito C, Edgar D, Chapel H, de Vries E. Protocol for the unclassified primary antibody deficiency (unPAD) study: Characterization and classification of patients using the ESID online Registry. PLoS One 2022; 17:e0266083. [PMID: 35333892 PMCID: PMC9045688 DOI: 10.1371/journal.pone.0266083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background Primary antibody deficiencies (PADs) without an identified monogenetic origin
form the largest and most heterogeneous group of primary immunodeficiencies.
These patients often remain undiagnosed for years and many present to
medical attention in adulthood after several infections risking structural
complications. Not much is known about their treatment, comorbidities, or
prognosis, nor whether the various immunological forms (decreased total IgG,
IgG subclass(es), IgM, IgA, specific antibody responses, alone or in
combination(s)) should be considered as separate, clearly definable
subgroups. The unclassified primary antibody deficiency (unPAD) study aims
to describe in detail all PAD patients without an
identified specific monogenetic defect regarding their demographical,
clinical, and immunological characteristics at presentation and during
follow-up. In constructing these patterns, the unPAD study aims to reduce
the number of missed and unidentified PAD patients in the future. In
addition, this study will focus on subclassifying unPAD to support the
identification of patients at higher risk for infection or immune
dysregulation related complications, enabling the development of
personalized follow-up and treatment plans. Methods and analysis We present a protocol for a multicenter observational cohort study using the
ESID online Registry. Patients of all ages who have given informed consent
for participation in the ESID online Registry and fulfill the ESID Clinical
Working Definitions for ‘unclassified antibody deficiency’, ‘deficiency of
specific IgG’, ‘IgA with IgG subclass deficiency’, ‘isolated IgG subclass
deficiency’, ‘selective IgM deficiency’, ‘selective IgA deficiency’ or
‘common variable immunodeficiency’ will be included. For all patients, basic
characteristics can be registered at first registration and yearly
thereafter in level 1 forms. Detailed characteristics of the patients can be
registered in level 2 forms. Consecutive follow-up forms can be added
indefinitely. To ensure the quality of the collected data, all data will be
fully monitored before they are exported from the ESID online Registry for
analysis. Outcomes will be the clinical and immunological characteristics of
unPAD at presentation and during follow-up. Subgroup analyses will be made
based on demographical, clinical and immunological characteristics.
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Affiliation(s)
- Lisanne M. A. Janssen
- Department of Tranzo, TSB, Tilburg University, Tilburg, the
Netherlands
- Department of Pediatrics, Amalia Children’s hospital, Nijmegen, the
Netherlands
| | | | - Cinzia Milito
- Department of Molecular Medicine, Sapienza University of Rome, Rome,
Italy
| | - David Edgar
- Department of Immunology, St James’s Hospital, Dublin & (ii) Trinity
College, Dublun, Ireland
| | - Helen Chapel
- Primary Immunodeficiency Unit, Nuffield Department of Medicine,
University of Oxford, Oxford, United Kingdom
| | - Esther de Vries
- Department of Tranzo, TSB, Tilburg University, Tilburg, the
Netherlands
- Laboratory of Medical Microbiology and Immunology, Elisabeth-Tweesteden
Hospital, Tilburg, the Netherlands
- * E-mail:
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Melo KMD, Alves LM, Valente CFC, Tavares FS. One-year intravenous immunoglobulin replacement therapy: efficacy in reducing hospital admissions in pediatric patients with Inborn Errors of Immunity. J Pediatr (Rio J) 2022; 98:190-195. [PMID: 34273274 PMCID: PMC9432171 DOI: 10.1016/j.jped.2021.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES To compare the frequency of hospitalization in children with Inborn Errors of Immunity with antibody deficiency previous to intravenous immunoglobulin (pre- IVIG) with a one-year period after initial IVIG (post-IVIG). METHODS Medical reports of 45 patients during an eight-year period were reviewed from 2018 to 2019. Wilcoxon-test was used for related samples. RESULTS Forty-five children were included in the study, aged 29-249 months of age, and most of them (64.4%) were males. Median ages at onset symptoms and at diagnosis were 6 and 73 months old, respectively. Specific antibody deficiency and unclassified hypogammaglobulinemia were the predominant diagnoses (31.1% and 17.8%, respectively). X-linked agammaglobulinemia, Hyper IgE syndrome, Hyper IgM, transient hypogammaglobulinemia of infancy, and Common Variable Immunodeficiency (CVID) were also reported, in a low frequency. Forty-four (97.8%) patients were hospitalized before IVIG, and 10 patients (22.2%) after. Annual mean hospital admission reduced from 2.5 to 0.5, pre and post-IVIG, respectively (p < 0.0001). Mean length of stay (LOS) reduced from 71 to 4.7 days/year (p < 0.0001) in general ward and in the PICU from 17.2 days/year to zero (p < 0.0002). Pneumonia was the main cause of hospital admission with a reduction in the number of episodes per patient from an average of 2.2-0.1 per year (p < 0.001). Concomitant use of antibiotic prophylaxis did not influence the number of hospital admission. CONCLUSION One-year intravenous IVIG significantly decreased the number of hospitalizations and length of stay in children with impaired antibody production. Social and economic impacts would be required.
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Affiliation(s)
- Karina Mescouto de Melo
- Hospital da Criança de Brasília José Alencar, Clínica de Alergia e Imunologia, Brasília, DF, Brazil.
| | - Lucas Macedo Alves
- Universidade de Brasília (UNB), Faculdade de Medicina, Brasília, DF, Brazil
| | | | - Fabíola Scancetti Tavares
- Hospital da Criança de Brasília José Alencar, Clínica de Alergia e Imunologia, Brasília, DF, Brazil; Hospital Universitário de Brasília (HUB), Brasília, DF, Brazil
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Wågström P, Nilsdotter-Augustinsson Å, Nilsson M, Björkander J, Dahle C, Nyström S. Fatigue Is Common in Immunoglobulin G Subclass Deficiency and Correlates With Inflammatory Response and Need for Immunoglobulin Replacement Therapy. Front Immunol 2022; 12:797336. [PMID: 35082787 PMCID: PMC8785394 DOI: 10.3389/fimmu.2021.797336] [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: 10/18/2021] [Accepted: 12/14/2021] [Indexed: 11/14/2022] Open
Abstract
Purpose Individuals with immunoglobulin G deficiency (IgGsd) often complain of fatigue. The correlation between systemic inflammation and fatigue is unknown. In this study perceived quality of life (QoL) and fatigue in individuals with IgGsd, on and off immunoglobulin replacement therapy (IgRT) were correlated to inflammatory markers in plasma to identify the subgroup that benefits from IgRT. Method Thirty-five IgGsd-patients were sampled on three occasions: at baseline, after being on IgRT for at least 18 months, and 18 months after discontinuation of IgRT. Short form 36, EQ-5D-5L visual analogue scale and fatigue impact scale questionnaires were used for evaluation of QoL and fatigue. Furthermore, a panel of 92 inflammatory markers were analysed in plasma. Thirty-two gender- and age-matched healthy individuals were included as controls and sampled on one occasion. Results QoL was lower and perceived fatigue higher in IgGsd compared to the controls. Severe fatigue and low QoL were associated with the need to restart IgRT (which is considered in IgGsd-individuals with a high burden of infections in Sweden). Twenty-five inflammatory factors were dysregulated in IgGsd and the plasma protein patterns were similar regardless of whether IgRT was ongoing or not. Enrichment analysis indicated IL-10 signalling as the most affected pathway. Severe fatigue was associated with decreased levels of the neurotrophic factors VEGFA and CSF-1. Conclusion Fatigue is a major contributory factor to impaired health-related QoL in IgGsd and is related to the need for IgRT. Low-grade systemic inflammation is a potential driver of fatigue. In addition to the burden of infections, we suggest the degree of fatigue should be considered when the decision to introduce IgRT is made.
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Affiliation(s)
- Per Wågström
- Department of Infectious Diseases, Ryhov County Hospital, Jönköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Åsa Nilsdotter-Augustinsson
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Infectious Diseases, The Vrinnevi Hospital, Norrköping, Sweden
| | - Mats Nilsson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Futurum, Academy of Health and Care, Region Jönköping County, Jönköping, Sweden
| | - Janne Björkander
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Wetterhälsan, Health Care Centre, Jönköping, Sweden
| | - Charlotte Dahle
- Division of Clinical Immunology and Transfusion Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Sofia Nyström
- Division of Clinical Immunology and Transfusion Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Division of Molecular Medicine and Virology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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8
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Sowers KL, Gayda-Chelder CA, Galantino ML. Self-reported cognitive impairment in individuals with Primary Immunodeficiency Disease. Brain Behav Immun Health 2021; 9:100170. [PMID: 34589905 PMCID: PMC8474660 DOI: 10.1016/j.bbih.2020.100170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 11/18/2022] Open
Abstract
Individuals with Primary Immunodeficiency Disease (PID) have increased risk for infection, autoimmune conditions, and inflammatory disorders. Cognitive impairment, also referred to as brain fog, has been recognized in other medical conditions and as a side-effect of treatments; however, it has not been previously reported in individuals with PID. The phenomenon of brain fog is recognized in other autoimmune or inflammatory conditions, including lupus, multiple sclerosis, chronic fatigue syndrome, and has resulted from chemotherapy treatment for cancer. This research investigates the self-reported memory function of individuals with a diagnosis of PID. Respondents completed a survey which used reliable and valid questionnaires: Memory Functioning Questionnaire, Beck’s Depression Inventory II, and Beck’s Anxiety Inventory. Of the 292 completed surveys, 133 did not report any comorbid neurological diagnosis or incident of concussion (both of which could influence perceived memory function). When compared to normative scores, the respondents in this study were found to have significantly greater perceived memory impairment. The respondents had a significant higher score for anxiety and depression as compared to non-anxious and non-depressed normative values. This study finds that individuals with a diagnosis of PID have a greater degree of perceived memory impairment, or brain fog, in addition to greater levels of anxiety and depression. Individuals with a diagnosis of PID would benefit from prospective surveillance through a comprehensive neuropsychological assessment to track cognitive status and implement corrective measures, should any decline be identified.
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Affiliation(s)
- Kerri L. Sowers
- Stockton University, 101 Vera King Farris Drive, Galloway, NJ, 08205, USA
- Corresponding author.
| | | | - Mary Lou Galantino
- Stockton University, University of Pennsylvania, University of Witwatersrand, Johannesburg, South Africa
- 101 Vera King Farris Drive, Galloway, NJ, 08205, USA
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Janssen LMA, van den Akker K, Boussihmad MA, de Vries E. Which triggers could support timely identification of primary antibody deficiency? A qualitative study using the patient perspective. Orphanet J Rare Dis 2021; 16:289. [PMID: 34187500 PMCID: PMC8243743 DOI: 10.1186/s13023-021-01918-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/13/2021] [Indexed: 11/23/2022] Open
Abstract
Background Patients with predominantly (primary) antibody deficiencies (PADs) commonly develop recurrent respiratory infections which can lead to bronchiectasis, long-term morbidity and increased mortality. Recognizing symptoms and making a diagnosis is vital to enable timely treatment. Studies on disease presentation have mainly been conducted using medical files rather than direct contact with PAD patients. Our study aims to analyze how patients appraised their symptoms and which factors were involved in a decision to seek medical care. Methods 14 PAD-patients (11 women; median 44, range 16-68 years) were analyzed using semi-structured interviews until saturation of key emergent themes was achieved. Results Being always ill featured in all participant stories. Often from childhood onwards periods of illness were felt to be too numerous, too bad, too long-lasting, or antibiotics were always needed to get better. Recurrent or persistent respiratory infections were the main triggers for patients to seek care. All participants developed an extreme fatigue, described as a feeling of physical and mental exhaustion and thus an extreme burden on daily life that was not solved by taking rest. Despite this, participants tended to normalize their symptoms and carry on with usual activities. Non-immunologists, as well as patients, misattributed the presenting signs and symptoms to common, self-limiting illnesses or other ‘innocent’ explanations. Participants in a way understood the long diagnostic delay. They know that the disease is rare and that doctors have to cover a broad medical area. But they were more critical about the way the doctors communicate with them. They feel that doctors often don’t listen very well to their patients. The participants’ symptoms as well as the interpretation of these symptoms by their social environment and doctors had a major emotional impact on the participants and a negative influence on their future perspectives. Conclusions To timely identify PAD, ‘pattern recognition’ should not only focus on the medical ‘red flags’, but also on less differentiating symptoms, such as ‘being always ill’ and ‘worn out’ and the way patients cope with these problems. And, most important, making time to really listen to the patient remains the key. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01918-x.
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Affiliation(s)
- Lisanne M A Janssen
- Department of Tranzo, TSB, Tilburg University, PO Box 90153, 5000 LE, Tilburg, The Netherlands.,Department of Pediatrics, Amalia Children's Hospital, Nijmegen, The Netherlands
| | | | | | - Esther de Vries
- Department of Tranzo, TSB, Tilburg University, PO Box 90153, 5000 LE, Tilburg, The Netherlands. .,Jeroen Bosch Academy Research, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.
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10
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Janssen LMA, van der Flier M, de Vries E. Lessons Learned From the Clinical Presentation of Common Variable Immunodeficiency Disorders: A Systematic Review and Meta-Analysis. Front Immunol 2021; 12:620709. [PMID: 33833753 PMCID: PMC8021796 DOI: 10.3389/fimmu.2021.620709] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/24/2021] [Indexed: 12/22/2022] Open
Abstract
Background Diagnostic delay in common variable immunodeficiency disorders (CVID) is considerable. There is no generally accepted symptom-recognition framework for its early detection. Objective To systematically review all existing data on the clinical presentation of CVID. Methods PubMed, EMBASE and Cochrane were searched for cohort studies, published January/1999-December/2019, detailing the clinical manifestations before, at and after the CVID-diagnosis. Results In 51 studies (n=8521 patients) 134 presenting and 270 total clinical manifestations were identified. Recurrent upper and/or lower respiratory infections were present at diagnosis in 75%. Many patients had suffered severe bacterial infections (osteomyelitis 4%, meningitis 6%, septicemia 8%, mastoiditis 8%). Bronchiectasis (28%), lymphadenopathy (27%), splenomegaly (13%), inflammatory bowel disease (11%), autoimmune cytopenia (10%) and idiopathic thrombocytopenia (6%) were also frequently reported. A bimodal sex distribution was found, with male predominance in children (62%) and female predominance in adults (58%). 25% of CVID-patients developed other manifestations besides infections in childhood, this percentage was much higher in adults (62%). Immune-dysregulation features, such as granulomatous-lymphocytic interstitial lung disease and inflammatory bowel disease, were more prominent in adults. Conclusions The shift from male predominance in childhood to female predominance in adults suggests differences in genetic and environmental etiology in CVID and has consequences for pathophysiologic studies. We confirm the high frequency of respiratory infections at presentation, but also show a high incidence of severe bacterial infections such as sepsis and meningitis, and immune dysregulation features including lymphoproliferative, gastrointestinal and autoimmune manifestations. Early detection of CVID may be improved by screening for antibody deficiency in patients with these manifestations.
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Affiliation(s)
- Lisanne M A Janssen
- Department of Tranzo, Tilburg University, Tilburg, Netherlands.,Department of Pediatrics, Amalia Children's Hospital, Nijmegen, Netherlands
| | - Michiel van der Flier
- Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Esther de Vries
- Department of Tranzo, Tilburg University, Tilburg, Netherlands.,Laboratory of Medical Microbiology and Immunology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
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11
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Kim JH, Jang JH, Lee SH, Yang EM, Jang SH, Jung KS, Park HS. Specific Antibody Deficiency in Adult Patients With IgG or IgG Subclass Deficiency. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2021; 13:271-283. [PMID: 33474861 PMCID: PMC7840874 DOI: 10.4168/aair.2021.13.2.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/24/2020] [Accepted: 07/31/2020] [Indexed: 11/23/2022]
Abstract
Purpose Specific antibody deficiency (SAD) involves a deficient response to a polysaccharide vaccine despite having normal immunoglobulin levels. The failure of the polysaccharide response can be observed as a component of various primary antibody deficiencies. However, only a few studies have described the clinical and immunological profiles in SAD and/or other primary immunodeficiencies (PIDs) in adults. Methods A total of 47 patients who had a clinical history suggestive of antibody deficiency or had already been diagnosed with various antibody deficiencies were enrolled. Polysaccharide responses to 7 pneumococcal serotypes (4, 6B, 9V, 14, 18C, 19F and 23F) were measured using the World Health Organization enzyme-linked immunosorbent assay (WHO-ELISA), and postvaccination immunoglobulin G (IgG) titers were compared to clinical and laboratory parameters. Results Based on the American Academy of Allergy, Asthma, and Immunology (AAAAI) criteria for the WHO-ELISA, 11 (23.4%) patients were diagnosed as having SAD. Sixteen-three percent of them had combined with other types of PID, such as IgG subclass deficiency and hypogammaglobulinemia. Postvaccination IgG titers for the serotypes 4/9V/18C correlated with IgG2 (P = 0.012, P = 0.001, and P = 0.004) and for 6B/9V/14 with IgG3 (P = 0.003, P = 0.041, and P = 0.036, respectively). The IgG3 subclass levels negatively correlated with forced expiratory volume in 1 second (FEV1, %) and FEV1/forced vital capacity (P < 0.001 and P = 0.001, respectively). Conclusion SAD can be diagnosed in patients with normal IgG levels as well as in those deficient in IgG or the IgG3 subclass, implicating that restricted responses to Streptococcus pneumoniae polysaccharide antigens commonly exist in patients with predominantly antibody deficiency.
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Affiliation(s)
- Joo Hee Kim
- Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jae Hyuk Jang
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - So Hee Lee
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Eun Mi Yang
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Seung Hun Jang
- Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Ki Suck Jung
- Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hae Sim Park
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.
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12
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Hanitsch L, Baumann U, Boztug K, Burkhard-Meier U, Fasshauer M, Habermehl P, Hauck F, Klock G, Liese J, Meyer O, Müller R, Pachlopnik-Schmid J, Pfeiffer-Kascha D, Warnatz K, Wehr C, Wittke K, Niehues T, von Bernuth H. Treatment and management of primary antibody deficiency: German interdisciplinary evidence-based consensus guideline. Eur J Immunol 2020; 50:1432-1446. [PMID: 32845010 DOI: 10.1002/eji.202048713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/25/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022]
Abstract
This evidence-based clinical guideline provides consensus-recommendations for the treatment and care of patients with primary antibody deficiencies (PADs). The guideline group comprised 20 clinical and scientific expert associations of the German, Swiss, and Austrian healthcare system and representatives of patients. Recommendations were based on results of a systematic literature search, data extraction, and evaluation of methodology and study quality in combination with the clinical expertise of the respective representatives. Consensus-based recommendations were determined via nominal group technique. PADs are the largest clinically relevant group of primary immunodeficiencies. Most patients with PADs present with increased susceptibility to infections, however immune dysregulation, autoimmunity, and cancer affect a significant number of patients and may precede infections. This guideline therefore covers interdisciplinary clinical and therapeutic aspects of infectious (e.g., antibiotic prophylaxis, management of bronchiectasis) and non-infectious manifestations (e.g., management of granulomatous disease, immune cytopenia). PADs are grouped into disease entities with definitive, probable, possible, or unlikely benefit of IgG-replacement therapy. Summary and consensus-recommendations are provided for treatment indication, dosing, routes of administration, and adverse events of IgG-replacement therapy. Special aspects of concomitant impaired T-cell function are highlighted as well as clinical data on selected monogenetic inborn errors of immunity formerly classified into PADs (APDS, CTLA-4-, and LRBA-deficiency).
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Affiliation(s)
- Leif Hanitsch
- Institute for Medical Immunology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Ulrich Baumann
- Department of Paediatric Pulmonology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Kaan Boztug
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Department of Pediatrics and Adolescent Medicine and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | | | - Maria Fasshauer
- ImmunoDeficiencyCenter Leipzig (IDCL), Hospital St. Georg gGmbH Leipzig, Academic Teaching Hospital of the University of Leipzig, Leipzig, Germany
| | | | - Fabian Hauck
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Gerd Klock
- Technische Universität Darmstadt, Clemens-Schöpf-Institut für Organische Chemie & Biochemie, Darmstadt, Germany
| | - Johannes Liese
- Pediatric Immunology, Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Oliver Meyer
- Institute of Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Rainer Müller
- Klinik und Poliklinik für HNO-Heilkunde, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Jana Pachlopnik-Schmid
- Division of Immunology, University Children's Hospital Zurich and University of Zurich, Switzerland
| | | | - Klaus Warnatz
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Chronic Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Wehr
- Center for Chronic Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kirsten Wittke
- Institute for Medical Immunology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Tim Niehues
- Department of Pediatrics, Helios Klinikum Krefeld, Krefeld, Germany
| | - Horst von Bernuth
- Department of Immunology, Labor Berlin Charité - Vivantes GmbH, Berlin, Germany.,Berlin Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
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13
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Immunological and Clinical Phenotyping in Primary Antibody Deficiencies: a Growing Disease Spectrum. J Clin Immunol 2020; 40:592-601. [PMID: 32239366 DOI: 10.1007/s10875-020-00773-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/20/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Although common variable immunodeficiency (CVID) is considered the most prevalent symptomatic primary antibody deficiency (PAD), there is a population with symptomatic PADs that do not meet criteria for CVID. We analyzed clinical and immunological profiles of patients with different PADs to better understand the differences and similarities between CVID and other PADs. METHODS We extracted clinical and laboratory data of patients with PADs from electronic medical records. Patients were categorized into CVID, IgG subclass 2 deficiency (IgG2D), IgG deficiency (IgGD), and specific antibody deficiency (sAbD) based on basal immunoglobulin levels and pneumococcal vaccine responses. We compared clinical and immunological characteristics in these groups. RESULTS All patients, regardless of PAD types, showed similar frequencies of infections, bronchiectasis, and interstitial lung disease (ILD). Hematopoietic malignancies were more frequently found in the CVID than in the IgG2D, IgGD, and sAbD groups, while the latter groups trended towards an increased frequency of connective tissue diseases (CTD). Low counts of natural killer (NK) cells were associated with malignancy, autoimmunity, and ILD in CVID but not in other PAD groups. CONCLUSIONS Higher frequency of hematopoietic malignancy in CVID than in the other PADs and association of lower NK cell counts with non-infectious complications in CVID suggest a relationship between immune alterations and the development of non-infectious manifestations in PADs.
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14
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Janssen LMA, Heron M, Murk JL, Leenders ACAP, Rijkers GT, de Vries E. Focusing on Good Responders to Pneumococcal Polysaccharide Vaccination in General Hospital Patients Suspected for Immunodeficiency. A Decision Tree Based on the 23-Valent Pneumococcal IgG Assay. Front Immunol 2019; 10:2496. [PMID: 31749801 PMCID: PMC6848064 DOI: 10.3389/fimmu.2019.02496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/07/2019] [Indexed: 12/15/2022] Open
Abstract
Background and Aim: Recently, the 23-valent IgG-assay was suggested as screening assay to identify poor responders to pneumococcal polysaccharide (PnPS)-vaccination with the serotype-specific assay as a second-line test. However, in a low pre-test probability general hospital setting predicting good responders could be more valuable to reduce the number of samples needing serotyping. Methods: Serotype-specific PnPS antibody-assays were performed for suspected immunodeficiency in two Dutch general hospitals (Jeroen Bosch Hospital, 's-Hertogenbosch; Elisabeth Tweesteden Hospital, Tilburg). 23-Valent PnPS antibody-assays were subsequently performed in archived material. Data were analyzed using receiver operating characteristic curves (AUC) and agreement indices (ICC). Results: Sera of 284 patients (348 samples) were included; 23-valent IgG-titres and the corresponding sum of PnPS-serotype specific antibodies showed moderate correlation (ICC = 0.63). In 232 conjugated-pneumococcal-vaccine-naïve patients (270 samples), a random 23-valent IgG-titer could discriminate between samples with and without ≥7/11, ≥7/13, or ≥6/9 pneumococcal serotypes when both cut-off values 0.35 and 1.0 μg/ml were used (AUC 0.86 and 0.92, respectively). All patients with a pre-immunization-titer ≥38.2 μg/ml and/or post-immunization-titer ≥96.1 μg/ml and none with a post-immunization-titer ≤38.5 μg/ml exhibited a good response to PnPS vaccination. Using these breakpoints as screening test to predict good responders, only 24% of patients would require further serotyping, as opposed to 68% if breakpoints to predict poor responders would have been used. Conclusion: In a low pre-test probability setting, the 23-valent IgG-assay proved to be a reliable screening test for good responders in conjugated-pneumococcal-vaccine-naïve patients, reducing the overall number of patient samples needing further serotyping, thus reducing overall costs of pneumococcal vaccination response assessment.
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Affiliation(s)
- Lisanne M A Janssen
- Department of Tranzo, Tilburg University, Tilburg, Netherlands.,Department of Pediatrics, Amalia Children's Hospital, Nijmegen, Netherlands
| | - Michiel Heron
- Laboratory of Medical Microbiology and Immunology, St. Elisabeth Hospital Tilburg, Tilburg, Netherlands
| | - Jean-Luc Murk
- Laboratory of Medical Microbiology and Immunology, St. Elisabeth Hospital Tilburg, Tilburg, Netherlands
| | | | - Ger T Rijkers
- Laboratory of Medical Microbiology and Immunology, St. Elisabeth Hospital Tilburg, Tilburg, Netherlands.,Science Department, University College Roosevelt, Middelburg, Netherlands
| | - Esther de Vries
- Department of Tranzo, Tilburg University, Tilburg, Netherlands.,Laboratory of Medical Microbiology and Immunology, St. Elisabeth Hospital Tilburg, Tilburg, Netherlands
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15
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Pimenta FMCA, Palma SMU, Constantino-Silva RN, Grumach AS. Hypogammaglobulinemia: a diagnosis that must not be overlooked. ACTA ACUST UNITED AC 2019; 52:e8926. [PMID: 31618370 PMCID: PMC6787951 DOI: 10.1590/1414-431x20198926] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/27/2019] [Indexed: 12/18/2022]
Abstract
Humoral immunological defects are frequent and important causes of hypogammaglobulinemia, leading to recurrent infections, autoimmunity, allergies, and neoplasias. Usually, its onset occurs in childhood or during the second and third decades of life; however, the diagnosis is made, on average, 6 to 7 years afterwards. As a consequence, antibody defects can lead to sequelae. Here we describe the clinical-laboratory characteristics, treatment, and prognoses of patients with hypogammaglobulinemia. An observational, cross-sectional, and retrospective study of patients attending the recently established outpatient group of Clinical Immunology between 2013 and 2018 was carried out. Patients with IgG levels below 2 standard deviations from the mean values for the age and/or impaired antibody response were included. Eight patients (3 F and 5 M; median age=41 years (16–65), average symptom onset at 25 years (1–59), and time to diagnosis of 10 years were included. The main infections were: sinusitis in 7/8, pneumonia in 6/8, otitis in 2/8, tonsillitis and diarrhea in 2/8, and diarrhea in 2/8 patients. Hypothyroidism was identified in 4/8 (50%) patients. Rhinitis was found in 7/8 (87.5%) and asthma in 3/8 (37.5%) patients. The tomographic findings were consolidations, atelectasis, emphysema, ground glass opacity, budding tree, bronchial thickening, and bronchiectasis. Immunoglobulin reposition was used between 466 and 600 mg/kg monthly (514.3 mg·kg-1·dose-1). Prophylactic antibiotic therapy was included in 7/8 (87.5%) patients. Airway manifestations prevailed in patients with hypogammaglobulinemia. There is a need for educational work to reduce the time of diagnosis and initiation of treatment, avoiding sequelae.
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Affiliation(s)
- F M C A Pimenta
- Pós-graduação em Ciências da Saúde, Faculdade de Medicina do ABC (FMABC), Santo André, SP, Brasil
| | - S M U Palma
- Departamento de Pediatria, Faculdade de Medicina do ABC (FMABC), Santo André, SP, Brasil
| | - R N Constantino-Silva
- Laboratório de Imunologia Clínica, Faculdade de Medicina do ABC (FMABC), Santo André, SP, Brasil
| | - A S Grumach
- Disciplina de Imunologia Clínica, Faculdade de Medicina do ABC (FMABC), Santo André, SP, Brasil
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16
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Ameratunga R, Ahn Y, Steele R, Woon ST. The Natural History of Untreated Primary Hypogammaglobulinemia in Adults: Implications for the Diagnosis and Treatment of Common Variable Immunodeficiency Disorders (CVID). Front Immunol 2019; 10:1541. [PMID: 31379811 PMCID: PMC6652801 DOI: 10.3389/fimmu.2019.01541] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 06/20/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Adults with primary hypogammaglobulinemia are frequently encountered by clinicians. Where IgG levels are markedly decreased, most patients are treated with subcutaneous or intravenous immunoglobulin (SCIG/IVIG), because of the presumed risk of severe infections. The natural history of untreated severe asymptomatic hypogammaglobulinemia is thus unknown. Similarly, there are no long-term prospective studies examining the natural history of patients with moderate reductions in IgG. Methods: In 2006, we began a prospective cohort study of patients with symptomatic and asymptomatic reductions in IgG who were not immediately commenced on SCIG/IVIG. Over the course of 12 years, 120 patients were enrolled in the NZ hypogammaglobulinemia study (NZHS) including 59 who were asymptomatic. Results: Five patients with profound primary hypogammaglobulinemia (IgG < 3 g/l), who were not on regular SCIG/IVIG have remained well for a mean duration of 139 months. This study has also shown most asymptomatic patients with moderate hypogammaglobulinemia (IgG 3.0–6.9 g/l) have been in good health for a mean observation period of 96 months. We have only identified one asymptomatic patient with moderate hypogammaglobulinemia who experienced progressive decline in IgG levels to <3 g/l and was accepted for IVIG replacement. Prospective monitoring has shown that none have suffered catastrophic infections or any of the severe autoimmune or inflammatory sequelae associated with Common Variable Immunodeficiency Disorders (CVID). Unexpectedly, 18.1% of asymptomatic and 41.6% of symptomatic hypogammaglobulinemic patients spontaneously increased their IgG into the normal range (≥7.0 g/l) on at least one occasion, which we have termed transient hypogammaglobulinemia of adulthood (THA). In this study, vaccine challenge responses have correlated poorly with symptomatic state and long-term prognosis including subsequent SCIG/IVIG treatment. Conclusions: In spite of our favorable experience, we recommend patients with severe asymptomatic hypogammaglobulinemia are treated with SCIG/IVIG because of the potential risk of severe infections. Patients with moderate asymptomatic hypogammaglobulinemia have a good prognosis. Patients with symptomatic hypogammaglobulinemia are a heterogeneous group where some progress to SCIG/IVIG replacement, while many others spontaneously recover. This study has implications for the diagnosis and treatment of CVID.
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Affiliation(s)
- Rohan Ameratunga
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand.,Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand
| | - Yeri Ahn
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - Richard Steele
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
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