1
|
Rippel N, Wong J, Hussein S, Kalac M. Idiopathic CD4+ T-lymphocytopaenia with FLT1 mutation complicated by progressive multifocal leucoencephalopathy and EBV+ polymorphic lymphoproliferative disorder. BMJ Case Rep 2023; 16:e253105. [PMID: 37643816 PMCID: PMC10465919 DOI: 10.1136/bcr-2022-253105] [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] [Indexed: 08/31/2023] Open
Abstract
We describe a unique case of idiopathic CD4+T cell lymphocytopaenia complicated by viral-associated disorders in a patient with a heterozygous FLT1 mutation. A previously healthy woman presented with left-sided neurological deficits. Workup revealed a severe HIV-seronegative CD4+T cell deficiency and white matter brain lesions; brain biopsy confirmed progressive multifocal leucoencephalopathy (PML). Six years later, she represented with a tender mandibular lesion, with pathology diagnostic for EBV+polymorphic post-transplant-like lymphoproliferative disorder. A heterozygous FLT1 P1127L mutation was detected on peripheral blood and mandibular lesion next-generation sequencing. Concern for PML reactivation with rituximab-based therapy and the presence of localised disease led us to offer radiotherapy, resulting in significant symptom relief and marked therapeutic response on repeat imaging.
Collapse
Affiliation(s)
- Noa Rippel
- Internal Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Joshua Wong
- Pathology, Molecular and Cell Based Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Shafinaz Hussein
- Pathology, Molecular and Cell Based Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Matko Kalac
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, California, USA
| |
Collapse
|
2
|
Vijayakumar S, Viswanathan S, Aghoram R. Idiopathic CD4 Lymphocytopenia: Current Insights. Immunotargets Ther 2020; 9:79-93. [PMID: 32548074 PMCID: PMC7239889 DOI: 10.2147/itt.s214139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022] Open
Abstract
Idiopathic CD4 lymphocytopenia is a condition characterized by low CD4 counts. It is rare and most of the information about this illness comes from case reports. Presentation is usually in the 4th decade of life with opportunistic infections, autoimmune disease or neoplasia. The pathophysiology of this condition is not well understood. Management revolves around treatment of the presenting condition and close follow-up of these patients. This review presents a narrative summary of the current literature on idiopathic CD4 lymphocytopenia.
Collapse
Affiliation(s)
| | - Stalin Viswanathan
- General Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India
| | - Rajeswari Aghoram
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India
| |
Collapse
|
3
|
Perez-Diez A, Liu X, Sheikh V, Roby G, Stroncek DF, Sereti I. Humanized mouse models reveal an immunologic classification of idiopathic CD4 lymphocytopenia subtypes. JCI Insight 2019; 4:127802. [PMID: 31341106 DOI: 10.1172/jci.insight.127802] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/05/2019] [Indexed: 12/21/2022] Open
Abstract
Idiopathic CD4 lymphocytopenia (ICL) is a clinically heterogeneous immunodeficiency disorder defined by low numbers of circulating CD4+ T cells and increased susceptibility to opportunistic infections. CD8+ T cells, NK, and/or B cells may also be deficient in some patients. To delineate possible pathogenic cellular mechanisms in ICL, we compared immune system development and function in NOD-RAGKO-γcKO (NRG) mice transplanted with hematopoietic stem cells from patients with ICL or healthy controls. CD34+ hematopoietic stem cells from healthy controls and patients with ICL reconstituted NRG mice equally well. In contrast, PBMC transfers into NRG mice identified 2 ICL engraftment phenotypes, reconstituting and nonreconstituting (NR), based on the absence or presence of donor lymphopenia. For patients in the NR group, the distribution of lymphocyte subsets was similar in the peripheral blood of both the patient and the corresponding humanized mice. The NR-ICL group could be further divided into individuals whose CD3+ T cells had defects in proliferation or survival. Thus, ICL cellular pathogenesis might be classified by humanized mouse models into 3 distinct subtypes: (a) T cell extrinsic, (b) T cell intrinsic affecting proliferation, and (c) T cell intrinsic affecting survival. Humanized mouse models of ICL help to delineate etiology and ultimately to guide development of individualized therapeutic strategies.
Collapse
Affiliation(s)
- Ainhoa Perez-Diez
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, and
| | - Xiangdong Liu
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, and
| | - Virginia Sheikh
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, and
| | - Gregg Roby
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, and
| | - David F Stroncek
- Department of Transfusion Medicine, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Irini Sereti
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, and
| |
Collapse
|
4
|
Ménétrier-Caux C, Ray-Coquard I, Blay JY, Caux C. Lymphopenia in Cancer Patients and its Effects on Response to Immunotherapy: an opportunity for combination with Cytokines? J Immunother Cancer 2019; 7:85. [PMID: 30922400 PMCID: PMC6437964 DOI: 10.1186/s40425-019-0549-5] [Citation(s) in RCA: 159] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 02/27/2019] [Indexed: 12/12/2022] Open
Abstract
Quantitative lymphocyte alterations are frequent in patients with cancer, and strongly impact prognosis and survival. The development of cancers in immunosuppressed patients has demonstrated the contribution of different T cell populations, including CD4+ cells, in the control of cancer occurrence.Whereas absolute numbers of neutrophils, platelets and red blood cells are routinely monitored in clinic following treatments, because of possible short-term complications, absolute lymphocyte counts (ALC), their subpopulations or diversity (phenotype, TCR) are rarely analyzed and never used to choose therapy or as prognostic criteria. The recent identification of immune checkpoint inhibitors (ICPi) as powerful therapeutic agents has revitalized immunotherapy of cancer in a broader group of diseases than anticipated. The status of the immune system is now recognized as an important biomarker for response to these novel treatments. Blood ALC values, along with tumor infiltration by CD8+T cells, and ICPi and ICPi-ligand expression, are likely to be a potential marker of sensitivity to anti-ICPi therapy.In this article, we review the current knowledge on the incidence and significance of lymphopenia in cancer patients, and discuss therapeutic strategies to restore lymphocyte numbers.
Collapse
Affiliation(s)
- Christine Ménétrier-Caux
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS 5286, Cancer Research Center of Lyon (CRCL), Centre Léon Bérard, F-69008, Lyon, France. .,Innovation in Immuno-monitoring and Immunotherapy Platform (PI3), Centre Léon Bérard, F-69008, Lyon, France.
| | | | - Jean-Yves Blay
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS 5286, Cancer Research Center of Lyon (CRCL), Centre Léon Bérard, F-69008, Lyon, France.,Medical Oncology department, Centre Léon Bérard, F-69008, Lyon, France
| | - Christophe Caux
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS 5286, Cancer Research Center of Lyon (CRCL), Centre Léon Bérard, F-69008, Lyon, France.,Innovation in Immuno-monitoring and Immunotherapy Platform (PI3), Centre Léon Bérard, F-69008, Lyon, France
| |
Collapse
|
5
|
Sheikh V, Porter BO, DerSimonian R, Kovacs SB, Thompson WL, Perez-Diez A, Freeman AF, Roby G, Mican J, Pau A, Rupert A, Adelsberger J, Higgins J, Bourgeois JS, Jensen SMR, Morcock DR, Burbelo PD, Osnos L, Maric I, Natarajan V, Croughs T, Yao MD, Estes JD, Sereti I. Administration of interleukin-7 increases CD4 T cells in idiopathic CD4 lymphocytopenia. Blood 2016; 127:977-88. [PMID: 26675348 PMCID: PMC4768432 DOI: 10.1182/blood-2015-05-645077] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 12/07/2015] [Indexed: 01/08/2023] Open
Abstract
Idiopathic CD4 lymphopenia (ICL) is a rare syndrome defined by low CD4 T-cell counts (<300/µL) without evidence of HIV infection or other known cause of immunodeficiency. ICL confers an increased risk of opportunistic infections and has no established treatment. Interleukin-7 (IL-7) is fundamental for thymopoiesis, T-cell homeostasis, and survival of mature T cells, which provides a rationale for its potential use as an immunotherapeutic agent for ICL. We performed an open-label phase 1/2A dose-escalation trial of 3 subcutaneous doses of recombinant human IL-7 (rhIL-7) per week in patients with ICL who were at risk of disease progression. The primary objectives of the study were to assess safety and the immunomodulatory effects of rhIL-7 in ICL patients. Injection site reactions were the most frequently reported adverse events. One patient experienced a hypersensitivity reaction and developed non-neutralizing anti-IL-7 antibodies. Patients with autoimmune diseases that required systemic therapy at screening were excluded from the study; however, 1 participant developed systemic lupus erythematosus while on study and was excluded from further rhIL-7 dosing. Quantitatively, rhIL-7 led to an increase in the number of circulating CD4 and CD8 T cells and tissue-resident CD3 T cells in the gut mucosa and bone marrow. Functionally, these T cells were capable of producing cytokines after mitogenic stimulation. rhIL-7 was well tolerated at biologically active doses and may represent a promising therapeutic intervention in ICL. This trial was registered at www.clinicaltrials.gov as #NCT00839436.
Collapse
Affiliation(s)
- Virginia Sheikh
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Brian O Porter
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Rebecca DerSimonian
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Stephen B Kovacs
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD
| | - William L Thompson
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Ainhoa Perez-Diez
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Alexandra F Freeman
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Gregg Roby
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - JoAnn Mican
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Alice Pau
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Adam Rupert
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Joseph Adelsberger
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Jeanette Higgins
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Jeffrey S Bourgeois
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Stig M R Jensen
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - David R Morcock
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, MD
| | - Peter D Burbelo
- Dental Clinical Research Core, National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD
| | - Leah Osnos
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Irina Maric
- Hematology Section, Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD; and
| | - Ven Natarajan
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Therese Croughs
- Cytheris Inc., Subsidiary of Cytheris S.A., Issy les Moulineaux, France
| | - Michael D Yao
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Jacob D Estes
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, MD
| | - Irini Sereti
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| |
Collapse
|
6
|
Abstract
PURPOSE OF REVIEW Idiopathic CD4⁺ lymphocytopenia (ICL) is defined by the reduction of the main lymphocyte subtype in peripheral blood and CD4⁺ T cells below 300/μl in the absence of any secondary known causes of lymphopenia, including viral causes. The present review aims to state the latest available data on clinical, pathological and therapeutic aspects related to ICL, published from 1990 to 2014. The last observed clinical presentation and complications of ICL patients are described. The latest findings and possible mechanisms involved in the development of ICL features are included in the present review; however, pathogenesis of ICL has remained mainly obscured. Finally, recent therapeutic efforts considered in ICL patients are discussed. RECENT FINDINGS In spite of the serious complications ICL has on the patients' quality of life, data on clinical, etiopathological and therapeutic behavior for ICL are very limited. On one side, an abnormal blood cell count may be the sole presentation; however, occurrence of disseminated malignant tumors is not uncommon in patients. Recent findings highlight the role of cytokines, especially interleukin-2, on features such as phenotype severity and responsiveness of the condition to therapy. In addition, some studies have suggested that a defect in hematopoietic stem cells may be involved in disease progression, an idea that is supported by the success of bone marrow transplantation in acquiring persistent remissions in ICL patients. SUMMARY ICL is a hematologic condition of increasing importance due to its diverse clinical and pathological spectrum. Molecular studies have shown the presence of mutations involved in lymphocyte development as potential factors that may contribute to ICL occurrence. ICL patients could present either with common infections or really serious malignant conditions. The role of cytokines, especially interleukin-2, has emerged as one of the main possible mechanisms involved in clinical and pathological behavior of ICL. Today, the main therapeutic approaches are controlling life-threatening infections and underlying disorders along with efforts to cure ICL through rising CD4⁺ cell counts using cytokine interventions and transplantation.
Collapse
|
7
|
Ahmad DS, Esmadi M, Steinmann WC. Idiopathic CD4 Lymphocytopenia: Spectrum of opportunistic infections, malignancies, and autoimmune diseases. Avicenna J Med 2013; 3:37-47. [PMID: 23930241 PMCID: PMC3734630 DOI: 10.4103/2231-0770.114121] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Idiopathic CD4 lymphocytopenia (ICL) was first defined in 1992 by the US Centers for Disease Control and Prevention (CDC) as the repeated presence of a CD4+ T lymphocyte count of fewer than 300 cells per cubic millimeter or of less than 20% of total T cells with no evidence of human immunodeficiency virus (HIV) infection and no condition that might cause depressed CD4 counts. Most of our knowledge about ICL comes from scattered case reports. The aim of this study was to collect comprehensive data from the previously published cases to understand the characteristics of this rare condition. We searched the PubMed database and Science Direct for case reports since 1989 for Idiopathic CD4 lymphocytopenia cases. We found 258 cases diagnosed with ICL in 143 published papers. We collected data about age, sex, pathogens, site of infections, CD4 count, CD8 count, CD4:CD8 ratio, presence of HIV risk factors, malignancies, autoimmune diseases and whether the patients survived or died. The mean age at diagnosis of first opportunistic infection (or ICL if no opportunistic infection reported) was 40.7 ± 19.2 years (standard deviation), with a range of 1 to 85. One-sixty (62%) patients were males, 91 (35.2%) were females, and 7 (2.7%) patients were not identified whether males or females. Risk factors for HIV were documented in 36 (13.9%) patients. The mean initial CD4 count was 142.6 ± 103.9/mm3 (standard deviation). The mean initial CD8 count was 295 ± 273.6/mm3 (standard deviation). The mean initial CD4:CD8 ratio was 0.6 ± 0.7 (standard deviation). The mean lowest CD4 count was 115.4 ± 87.1/mm3 (standard deviation). The majority of patients 226 (87.6%) had at least one infection. Cryptococcal infections were the most prevalent infections in ICL patients (26.6%), followed by mycobacterial infections (17%), candidal infections (16.2%), and VZV infections (13.1%). Malignancies were reported in 47 (18.1%) patients. Autoimmune diseases were reported in 37 (14.2%) patients.
Collapse
Affiliation(s)
- Dina S Ahmad
- Department of Internal Medicine, University of Missouri School of Medicine, Columbia, MO, USA
| | | | | |
Collapse
|