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Taghizadeh N, Mohammadi S, Abolhassani H, Shokri S, Nabavi M, Fallahpour M, Bemanian MH. From variant of uncertain significance to likely pathogenic in two siblings with atypical RAG2 Deficiency: a case report and review of the literature. BMC Pediatr 2024; 24:116. [PMID: 38350907 PMCID: PMC10863182 DOI: 10.1186/s12887-024-04597-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/26/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Severe combined immunodeficiencies (SCIDs) are hereditary disorders characterized by impaired T and B cell function, resulting in significant immune system dysfunction. Recombination-activating gene (RAG) mutations account for a substantial proportion of SCID cases. Here, we present two sibling cases of SCID caused by a novel RAG2 gene mutation. CASE PRESENTATION The index case was an 8-year-old boy who had a history of recurring infections. After a comprehensive immunological workup, the initial diagnosis of agammaglobulinemia was revised to combined immunodeficiency (CID). The patient underwent hematopoietic stem cell transplantation (HSCT) but succumbed to cytomegalovirus (CMV) infection. His brother, a 4-month-old boy, presented with CMV chorioretinitis. Leaky SCID was diagnosed based on genetic tests and immunological findings. The patient received appropriate treatment and was considered for HSCT. Both siblings had a homozygous RAG2 gene variant, with the first case classified as a variant of uncertain significance (VUS). The presence of the same mutation in the second brother, and the clinical phenotype, supports considering the mutation as likely pathogenic. CONCLUSIONS This case report highlights a novel RAG2 gene mutation associated with CID. The classification of a VUS may evolve with accumulating evidence, and additional studies are warranted to establish its pathogenicity. Proper communication between genetic counselors and immunologists, accurate documentation of patient information, increased public awareness, and precise utilization of genetic techniques are essential for optimal patient management.
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Affiliation(s)
- Nima Taghizadeh
- School of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Soha Mohammadi
- School of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Division of Immunology, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Sima Shokri
- Department of Allergy and Clinical Immunology, School of Medicine, Iran University of Medical Sciences (IUMS), Rasool-e-Akram Hospital, Mansoori ave, Sattarkhan street, Tehran, 14456 13131, Iran.
| | - Mohammad Nabavi
- Department of Allergy and Clinical Immunology, School of Medicine, Iran University of Medical Sciences (IUMS), Rasool-e-Akram Hospital, Mansoori ave, Sattarkhan street, Tehran, 14456 13131, Iran
| | - Morteza Fallahpour
- Department of Allergy and Clinical Immunology, School of Medicine, Iran University of Medical Sciences (IUMS), Rasool-e-Akram Hospital, Mansoori ave, Sattarkhan street, Tehran, 14456 13131, Iran
| | - Mohammad Hassan Bemanian
- Department of Allergy and Clinical Immunology, School of Medicine, Iran University of Medical Sciences (IUMS), Rasool-e-Akram Hospital, Mansoori ave, Sattarkhan street, Tehran, 14456 13131, Iran
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2
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Jauch AJ, Bignucolo O, Seki S, Ghraichy M, Delmonte OM, von Niederhäusern V, Higgins R, Ghosh A, Nishizawa M, Tanaka M, Baldrich A, Köppen J, Hirsiger JR, Hupfer R, Ehl S, Rensing-Ehl A, Hopfer H, Prince SS, Daley SR, Marquardsen FA, Meyer BJ, Tamm M, Daikeler TD, Diesch T, Kühne T, Helbling A, Berkemeier C, Heijnen I, Navarini AA, Trück J, de Villartay JP, Oxenius A, Berger CT, Hess C, Notarangelo LD, Yamamoto H, Recher M. Autoimmunity and immunodeficiency associated with monoallelic LIG4 mutations via haploinsufficiency. J Allergy Clin Immunol 2023; 152:500-516. [PMID: 37004747 PMCID: PMC10529397 DOI: 10.1016/j.jaci.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 02/24/2023] [Accepted: 03/06/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Biallelic mutations in LIG4 encoding DNA-ligase 4 cause a rare immunodeficiency syndrome manifesting as infant-onset life-threatening and/or opportunistic infections, skeletal malformations, radiosensitivity and neoplasia. LIG4 is pivotal during DNA repair and during V(D)J recombination as it performs the final DNA-break sealing step. OBJECTIVES This study explored whether monoallelic LIG4 missense mutations may underlie immunodeficiency and autoimmunity with autosomal dominant inheritance. METHODS Extensive flow-cytometric immune-phenotyping was performed. Rare variants of immune system genes were analyzed by whole exome sequencing. DNA repair functionality and T-cell-intrinsic DNA damage tolerance was tested with an ensemble of in vitro and in silico tools. Antigen-receptor diversity and autoimmune features were characterized by high-throughput sequencing and autoantibody arrays. Reconstitution of wild-type versus mutant LIG4 were performed in LIG4 knockout Jurkat T cells, and DNA damage tolerance was subsequently assessed. RESULTS A novel heterozygous LIG4 loss-of-function mutation (p.R580Q), associated with a dominantly inherited familial immune-dysregulation consisting of autoimmune cytopenias, and in the index patient with lymphoproliferation, agammaglobulinemia, and adaptive immune cell infiltration into nonlymphoid organs. Immunophenotyping revealed reduced naive CD4+ T cells and low TCR-Vα7.2+ T cells, while T-/B-cell receptor repertoires showed only mild alterations. Cohort screening identified 2 other nonrelated patients with the monoallelic LIG4 mutation p.A842D recapitulating clinical and immune-phenotypic dysregulations observed in the index family and displaying T-cell-intrinsic DNA damage intolerance. Reconstitution experiments and molecular dynamics simulations categorize both missense mutations as loss-of-function and haploinsufficient. CONCLUSIONS This study provides evidence that certain monoallelic LIG4 mutations may cause human immune dysregulation via haploinsufficiency.
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Affiliation(s)
- Annaïse J Jauch
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland
| | | | - Sayuri Seki
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Marie Ghraichy
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ottavia M Delmonte
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Valentin von Niederhäusern
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Rebecca Higgins
- Division of Dermatology and Dermatology Laboratory, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland
| | - Adhideb Ghosh
- Division of Dermatology and Dermatology Laboratory, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland; Competence Center for Personalized Medicine, University of Zürich/Eidgenössische Technische Hochschule, Zurich, Switzerland
| | - Masako Nishizawa
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Mariko Tanaka
- Department of Pathology, The University of Tokyo, Tokyo, Japan
| | - Adrian Baldrich
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland
| | - Julius Köppen
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland
| | - Julia R Hirsiger
- Translational Immunology, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland
| | - Robin Hupfer
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland
| | - Stephan Ehl
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty for Medicine, University of Freiburg, Freiburg, Germany
| | - Anne Rensing-Ehl
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty for Medicine, University of Freiburg, Freiburg, Germany
| | - Helmut Hopfer
- Institute for Pathology, University Hospital Basel, Basel, Switzerland
| | | | - Stephen R Daley
- Centre for Immunology and Infection Control, School of Biomedical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland
| | - Florian A Marquardsen
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland
| | - Benedikt J Meyer
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland
| | - Michael Tamm
- Department of Pneumology, University Hospital Basel, Basel, Switzerland
| | - Thomas D Daikeler
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland; University Center for Immunology, University Hospital Basel, Basel, Switzerland
| | - Tamara Diesch
- Division of Pediatric Oncology/Hematology, University Children's Hospital Basel, Basel, Switzerland
| | - Thomas Kühne
- Division of Pediatric Oncology/Hematology, University Children's Hospital Basel, Basel, Switzerland
| | - Arthur Helbling
- Division of Allergology and clinical Immunology, Department of Pneumology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Caroline Berkemeier
- Division Medical Immunology, Laboratory Medicine, University of Basel and University Hospital of Basel, Basel, Switzerland
| | - Ingmar Heijnen
- Division Medical Immunology, Laboratory Medicine, University of Basel and University Hospital of Basel, Basel, Switzerland
| | - Alexander A Navarini
- Division of Dermatology and Dermatology Laboratory, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland; University Center for Immunology, University Hospital Basel, Basel, Switzerland
| | - Johannes Trück
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jean-Pierre de Villartay
- Laboratory of Genome Dynamics in the Immune System, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherché 1163, Université Paris Descartes Sorbonne Paris Cité, Institut Imagine, Paris, France
| | - Annette Oxenius
- Institute of Microbiology, Eidgenössische Technische Hochschule, Zurich, Switzerland
| | - Christoph T Berger
- Translational Immunology, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland; University Center for Immunology, University Hospital Basel, Basel, Switzerland
| | - Christoph Hess
- University Center for Immunology, University Hospital Basel, Basel, Switzerland; Immunobiology Laboratory, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland; Cambridge Institute of Therapeutic Immunology and Infectious Disease, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Hiroyuki Yamamoto
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland; AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan.
| | - Mike Recher
- Immunodeficiency Laboratory, Department of Biomedicine, University of Basel and University Hospital of Basel, Basel, Switzerland; University Center for Immunology, University Hospital Basel, Basel, Switzerland.
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Chitty Lopez M, Yilmaz M, Diaz-Cabrera NM, Saco T, Ishmael L, Sotoudeh S, Bindernagel C, Ujhazi B, Gordon S, Potts DE, Danziger R, Bosticardo M, Kenney H, Illes P, Lee S, Harris M, Cuellar-Rodriguez J, Patel KN, Csomos K, Dimitrova D, Kanakry JA, Notarangelo LD, Walter JE. Separating the Wheat From the Chaff in Asthma and Bronchiectasis: The Saga Trajectory of a Patient With Adult-Onset RAG1 Deficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1972-1980. [PMID: 37088379 PMCID: PMC10332246 DOI: 10.1016/j.jaip.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 04/25/2023]
Affiliation(s)
- Maria Chitty Lopez
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, Tampa, Fla; Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Fla
| | - Melis Yilmaz
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, Tampa, Fla; Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Fla
| | - Natalie M Diaz-Cabrera
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Tampa, Fla
| | - Tara Saco
- Windom Allergy, Asthma and Sinus, Sarasota, Fla
| | - Leah Ishmael
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Tampa, Fla
| | - Shannon Sotoudeh
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, Tampa, Fla; Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Fla
| | | | - Boglarka Ujhazi
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, Tampa, Fla
| | - Sumai Gordon
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, Tampa, Fla
| | - David Evan Potts
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, Tampa, Fla; Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Fla
| | | | - Marita Bosticardo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Md
| | - Heather Kenney
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Md
| | - Peter Illes
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, Tampa, Fla
| | - Sena Lee
- Riverchase Dermatology and Cosmetic Surgery, Suncity Center, Fla
| | - Megan Harris
- Infectious Disease Associates of Tampa Bay, Tampa, Fla
| | - Jennifer Cuellar-Rodriguez
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Md
| | - Kapil N Patel
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of South Florida, Tampa, Fla
| | - Krisztian Csomos
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, Tampa, Fla
| | - Dimana Dimitrova
- Center for Immuno-Oncology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Md
| | | | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Md
| | - Jolan E Walter
- Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, Tampa, Fla; Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Fla; Massachusetts General Hospital for Children, Boston, Mass.
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4
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Walter JE, Ziegler JB, Ballow M, Cunningham-Rundles C. Advances and Challenges of the Decade: The Ever-Changing Clinical and Genetic Landscape of Immunodeficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:107-115. [PMID: 36610755 DOI: 10.1016/j.jaip.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 01/06/2023]
Abstract
In the past 10 years, we have witnessed major advances in clinical immunology. Newborn screening for severe combined immunodeficiency has become universal in the United States and screening programs are being extended to severe combined immunodeficiency and other inborn errors of immunity globally. Early genetic testing is becoming the norm for many of our patients and allows for informed selection of targeted therapies including biologics repurposed from other specialties. During the COVID-19 pandemic, our understanding of essential immune responses expanded and the discovery of immune gene defects continued. Immunoglobulin products, the backbone of protection for antibody deficiency syndromes, came into use to minimize side effects. New polyclonal and monoclonal antibody products emerged with increasing options to manage respiratory viral agents such as SARS-CoV-2 and respiratory syncytial virus. Against these advances, we still face major challenges. Atypical is becoming typical as phenotypes of distinct genetic disease overlap whereas the clinical spectrum of the same genetic defect widens. Therefore, clinical judgment needs to be paired with repeated deep immune phenotyping and upfront genetic testing, as technologies rapidly evolve, and clinical disease often progresses with age. Managing patients with organ damage resulting from immune dysregulation poses a special major clinical challenge and management often lacks standardization, from autoimmune cytopenias, granulomatous interstitial lung disease, enteropathy, and liver disease to endocrine, rheumatologic, and neurologic complications. Clinical, translational, and basic science networks will continue to advance the field; however, cross-talk and education with practicing allergists/immunologists are essential to keep up with the ever-changing clinical and genetic landscape of inborn errors of immunity.
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Affiliation(s)
- Jolan E Walter
- Division of Pediatric Allergy and Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston, Mass.
| | - John B Ziegler
- School of Women's and Children's Health, UNSW Sydney, Sydney, New South Wales, Australia; Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Mark Ballow
- Department of Pediatrics, Division of Allergy and Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St Petersburg, Fla
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5
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Csomos K, Ujhazi B, Blazso P, Herrera JL, Tipton CM, Kawai T, Gordon S, Ellison M, Wu K, Stowell M, Haynes L, Cruz R, Zakota B, Nguyen J, Altrich M, Geier CB, Sharapova S, Dasso JF, Leiding JW, Smith G, Al-Herz W, de Barros Dorna M, Fadugba O, Fronkova E, Kanderova V, Svaton M, Henrickson SE, Hernandez JD, Kuijpers T, Kandilarova SM, Naumova E, Milota T, Sediva A, Moshous D, Neven B, Saco T, Sargur R, Savic S, Sleasman J, Sunkersett G, Ward BR, Komatsu M, Pittaluga S, Kumanovics A, Butte MJ, Cancro MP, Pillai S, Meffre E, Notarangelo LD, Walter JE. Partial RAG deficiency in humans induces dysregulated peripheral lymphocyte development and humoral tolerance defect with accumulation of T-bet + B cells. Nat Immunol 2022; 23:1256-1272. [PMID: 35902638 PMCID: PMC9355881 DOI: 10.1038/s41590-022-01271-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 06/16/2022] [Indexed: 12/22/2022]
Abstract
The recombination-activating genes (RAG) 1 and 2 are indispensable for diversifying the primary B cell receptor repertoire and pruning self-reactive clones via receptor editing in the bone marrow; however, the impact of RAG1/RAG2 on peripheral tolerance is unknown. Partial RAG deficiency (pRD) manifesting with late-onset immune dysregulation represents an ‘experiment of nature’ to explore this conundrum. By studying B cell development and subset-specific repertoires in pRD, we demonstrate that reduced RAG activity impinges on peripheral tolerance through the generation of a restricted primary B cell repertoire, persistent antigenic stimulation and an inflammatory milieu with elevated B cell-activating factor. This unique environment gradually provokes profound B cell dysregulation with widespread activation, remarkable extrafollicular maturation and persistence, expansion and somatic diversification of self-reactive clones. Through the model of pRD, we reveal a RAG-dependent ‘domino effect’ that impacts stringency of tolerance and B cell fate in the periphery. Patients with partial recombination-activating gene (RAG) deficiency (pRD) present variable late-onset autoimmune clinical phenotypes. Walter and colleagues identified a restricted primary B cell antigen receptor repertoire enriched for autoreactivity and clonal persistence in pRD. They described dysregulated B cell maturation with expansion of T-bet+ B cells revealing how RAG impacts stringency of tolerance and B cell fate in the periphery.
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Affiliation(s)
- Krisztian Csomos
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.
| | - Boglarka Ujhazi
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Peter Blazso
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - Jose L Herrera
- Cancer and Blood Disorders Institute and Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher M Tipton
- Department of Medicine, Division of Rheumatology, Emory University, Atlanta, GA, USA
| | - Tomoki Kawai
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Sumai Gordon
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Maryssa Ellison
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Kevin Wu
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Matthew Stowell
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Lauren Haynes
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Rachel Cruz
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Bence Zakota
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Johnny Nguyen
- Department of Pathology & Laboratory Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
| | | | | | | | - Joseph F Dasso
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Jennifer W Leiding
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Grace Smith
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Waleed Al-Herz
- Department of Pediatrics, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Mayra de Barros Dorna
- Department of Pediatrics, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Olajumoke Fadugba
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, USA
| | - Eva Fronkova
- Childhood Leukemia Investigation Prague, Department of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Veronika Kanderova
- Childhood Leukemia Investigation Prague, Department of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Michael Svaton
- Childhood Leukemia Investigation Prague, Department of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Sarah E Henrickson
- Allergy Immunology Division, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Institute for Immunology, the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph D Hernandez
- Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, CA, USA
| | - Taco Kuijpers
- Deptartment of Pediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands
| | | | - Elizaveta Naumova
- Department of Clinical Immunology, University Hospital Alexandrovska, Medical University, Sofia, Bulgaria
| | - Tomas Milota
- Department of Immunology, Second Faculty of Medicine Charles University and University Hospital Motol, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, Second Faculty of Medicine Charles University and University Hospital Motol, Prague, Czech Republic
| | - Despina Moshous
- Université de Paris, Paris, France.,Pediatric Hematology-Immunology and Rheumatology Unit, Necker-Enfants Malades Université Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Laboratory of Genome Dynamics in the Immune System, INSERM UMR1163, Institut Imagine, Paris, France
| | - Benedicte Neven
- Université de Paris, Paris, France.,Pediatric Hematology-Immunology and Rheumatology Unit, Necker-Enfants Malades Université Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM UMR1163, Institut Imagine, Paris, France
| | - Tara Saco
- Windom Allergy, Asthma and Sinus, Sarasota, FL, USA
| | - Ravishankar Sargur
- Department of Immunology and Allergy, Sheffield Teaching Hospitals, Sheffield, UK
| | - Sinisa Savic
- Department of Clinical Immunology and Allergy, St James's University Hospital, Leeds, UK.,National Institute for Health Research-Leeds Musculoskeletal Biomedical Research Centre and Leeds Institute of Rheumatic and Musculoskeletal Medicine, St James's University Hospital, Leeds, UK
| | - John Sleasman
- Division of Allergy, Immunology and Pulmonary Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Gauri Sunkersett
- Cancer and Blood Disorder Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Brant R Ward
- Division of Allergy and Immunology, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA, USA
| | - Masanobu Komatsu
- Cancer and Blood Disorders Institute and Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stefania Pittaluga
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Attila Kumanovics
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Manish J Butte
- Division of Immunology, Allergy, and Rheumatology, Department of Pediatrics and Jeffrey Modell Diagnostic and Research Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Michael P Cancro
- Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, USA
| | - Shiv Pillai
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of technology and Harvard University, Cambridge, MA, USA
| | - Eric Meffre
- Department of Immunobiology, Yale University, New Haven, CT, USA.,Section of Rheumatology, Allergy and Clinical Immunology, Yale School of Medicine, New Haven, CT, USA
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Jolan E Walter
- Division of Pediatric Allergy/Immunology, University of South Florida at Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA. .,Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston, MA, USA.
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6
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Yilmaz M, Potts DE, Geier C, Walter JE. Can we identify WHIM in infancy? Opportunities with the public newborn screening process. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2022; 190:215-221. [PMID: 36210583 DOI: 10.1002/ajmg.c.32002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 06/16/2023]
Abstract
Newborn screening (NBS) for severe combined immunodeficiency (SCID) utilizing T-cell receptor excision circles (TRECs) has been implemented in all 50 states as of December 2018 and has been transformative for the clinical care of SCID patients. Though having high sensitivity for SCID, NBS-SCID has low specificity, therefore is able to detect other causes of lymphopenia in newborns including many inborn errors of immunity (IEIs). In a recent study, three of six newborns later diagnosed with Warts, Hypogammaglobulinemia, Infections, and Myelokathexis (WHIM) syndrome were found to have a low TRECs and lymphopenia at birth. This presents an opportunity to increase the detection and diagnosis of WHIM syndrome by NBS-SCID with immunological follow-up along with a combination of flow cytometry for immune cell subsets, absolute neutrophil count, and genetic testing, extending beyond the conventional bone marrow studies. Coupled with emerging technologies such as next-generation sequencing, transcriptomics and proteomics, dried blood spots used in NBS-SCID will promote earlier detection, diagnosis, and therefore treatment of IEIs such as WHIM syndrome.
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Affiliation(s)
- Melis Yilmaz
- Division of Allergy and Immunology, Department of Pediatrics and Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - David Evan Potts
- Division of Allergy and Immunology, Department of Pediatrics and Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Christoph Geier
- Department of Rheumatology and Clinical Immunology, University Medical Center Freiburg, Freiburg, Germany
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg, Freiburg, Germany
| | - Jolan E Walter
- Division of Allergy and Immunology, Department of Pediatrics and Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
- Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston, Massachusetts, USA
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Chan SWB, Zhong Y, Lim SCJ, Poh S, Teh KL, Soh JY, Chong CY, Thoon KC, Seng M, Tan ES, Arkachaisri T, Liew WK. Implementation of Universal Newborn Screening for Severe Combined Immunodeficiency in Singapore While Continuing Routine Bacille-Calmette-Guerin Vaccination Given at Birth. Front Immunol 2022; 12:794221. [PMID: 35046952 PMCID: PMC8761728 DOI: 10.3389/fimmu.2021.794221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/07/2021] [Indexed: 12/30/2022] Open
Abstract
Introduction Severe Combined Immunodeficiency (SCID) is generally fatal if untreated; it predisposes to severe infections, including disseminated Bacille-Calmette-Guerin (BCG) disease from BCG vaccination at birth. However, delaying BCG vaccination can be detrimental to the population in tuberculosis-endemic regions. Early diagnosis of SCID through newborn screening followed by pre-emptive treatment with anti-mycobacterial therapy may be an alternative strategy to delaying routine BCG vaccination. We report the results of the first year of newborn SCID screening in Singapore while continuing routine BCG vaccination at birth. Method Newborn screening using a T-cell receptor excision circle (TREC) assay was performed in dried blood spots received between 10 October 2019 to 9 October 2020 using the Enlite Neonatal TREC kit. Patients with low TREC had lymphocyte subset analysis and full blood count performed to determine the severity of lymphopenia and likelihood of SCID to guide further management. Results Of the 35888 newborns screened in 1 year, no SCID cases were detected, while 13 cases of non-SCID T-cell lymphopenia (TCL) were picked up. Using a threshold for normal TREC to be >18 copies/μL, the retest rate was 0.1% and referral rate to immunologist was 0.04%. Initial low TREC correlated with low absolute lymphocyte counts (ALC), and subsequent normal ALC corresponded with increases in TREC, thus patients with normal first CD3+ T cell counts were considered to have transient idiopathic TCL instead of false positive results. 7/13 (54%) had secondary TCL (from sepsis, Trisomy 21 with hydrops and stoma losses or chylothorax, extreme prematurity, or partial DiGeorge Syndrome) and 6/13 (46%) had idiopathic TCL. No cases of SCID were diagnosed clinically in Singapore during this period and for 10 months after, indicating that no cases were missed by the screening program. 8/9 (89%) of term infants with abnormal TREC results received BCG vaccination within the first 6 days of life when TREC and ALC were low. No patients developed BCG complications after a median follow-up of 17 months. Conclusion Newborn screening for SCID can be implemented while continuing routine BCG vaccination at birth. Patients with transient TCL and no underlying primary immunodeficiency are able to tolerate BCG vaccination.
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Affiliation(s)
- Su-Wan Bianca Chan
- Rheumatology and Immunology Service, Department of Pediatric Subspecialties, Kadang Kerbau (KK) Women's and Children's Hospital, Singapore, Singapore.,Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore
| | - Youjia Zhong
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore.,Khoo Teck Puat - National University Children's Medical Institute, National University Health System, Singapore, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Soon Chuan James Lim
- Biochemical Genetics and National Expanded Newborn Screening, Department of Pathology and Laboratory Medicine, Kadang Kerbau (KK) Women's and Children's Hospital, Singapore, Singapore
| | - Sherry Poh
- Biochemical Genetics and National Expanded Newborn Screening, Department of Pathology and Laboratory Medicine, Kadang Kerbau (KK) Women's and Children's Hospital, Singapore, Singapore
| | - Kai Liang Teh
- Rheumatology and Immunology Service, Department of Pediatric Subspecialties, Kadang Kerbau (KK) Women's and Children's Hospital, Singapore, Singapore.,Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore
| | - Jian Yi Soh
- Khoo Teck Puat - National University Children's Medical Institute, National University Health System, Singapore, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chia Yin Chong
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Infectious Diseases Service, Department of Pediatric Subspecialties, Kadang Kerbau (KK) Women's and Children's Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Koh Cheng Thoon
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Infectious Diseases Service, Department of Pediatric Subspecialties, Kadang Kerbau (KK) Women's and Children's Hospital, Singapore, Singapore
| | - Michaela Seng
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore.,Hematology Oncology Service, Department of Pediatric Subspecialties, Kadang Kerbau (KK) Women's and Children's Hospital, Singapore, Singapore
| | - Ee Shien Tan
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore.,Genetics Service, Department of Pediatrics, Kadang Kerbau (KK) Women's and Children's Hospital, Singapore, Singapore
| | - Thaschawee Arkachaisri
- Rheumatology and Immunology Service, Department of Pediatric Subspecialties, Kadang Kerbau (KK) Women's and Children's Hospital, Singapore, Singapore.,Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Woei Kang Liew
- Rheumatology and Immunology Service, Department of Pediatric Subspecialties, Kadang Kerbau (KK) Women's and Children's Hospital, Singapore, Singapore
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Lee K, Abraham RS. Next-generation sequencing for inborn errors of immunity. Hum Immunol 2021; 82:871-882. [PMID: 33715910 DOI: 10.1016/j.humimm.2021.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 12/27/2022]
Abstract
Inborn errors of immunity (IEIs) include several hundred gene defects affecting various components of the immune system. As with other constitutional disorders, next-generation sequencing (NGS) is a powerful tool for the diagnosis of these diseases. While NGS can provide molecular confirmation of disease in a patient with a suspected or classic phenotype, it can also identify new molecular defects of the immune system, expand gene-disease phenotypes, clarify mechanism of disease, pattern of inheritance or identify new gene-disease associations. Multiple clinical specialties are involved in the diagnosis and management of patients with IEI, and most have no formal genetic training or expertise. To effectively utilize NGS tools and data in clinical practice, it is relevant and pragmatic to obtain a modicum of knowledge about genetic terminology, the variety of platforms and tools available for high-throughput genomic analysis, the interpretation and implementation of such data in clinical practice. There is considerable variability not only in the technologies and analytical tools used for NGS but in the bioinformatics approach to variant identification and interpretation. The ability to provide a molecular basis for disease has the potential to alter therapeutic management and longer-term treatment of the disease, including developing personalized approaches with molecularly targeted therapies. This review is intended for the clinical specialist or diagnostic immunologist who works in the area of inborn errors of immunity, and provides an overview of the need for genetic testing in these patients (the "why" aspect), the various technologies and analytical approaches, bioinformatics tools, resources, and challenges (the "how" aspect), and the clinical evidence for identifying which patients might be best served by such testing (the "when" aspect).
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Affiliation(s)
- Kristy Lee
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Roshini S Abraham
- Diagnostic Immunology Laboratory, Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pathology, The Ohio State University College of Medicine, Columbus, OH, USA.
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