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Deepak P, Kim W, Paley MA, Yang M, Carvidi AB, Demissie EG, El-Qunni AA, Haile A, Huang K, Kinnett B, Liebeskind MJ, Liu Z, McMorrow LE, Paez D, Pawar N, Perantie DC, Schriefer RE, Sides SE, Thapa M, Gergely M, Abushamma S, Akuse S, Klebert M, Mitchell L, Nix D, Graf J, Taylor KE, Chahin S, Ciorba MA, Katz P, Matloubian M, O'Halloran JA, Presti RM, Wu GF, Whelan SPJ, Buchser WJ, Gensler LS, Nakamura MC, Ellebedy AH, Kim AHJ. Effect of Immunosuppression on the Immunogenicity of mRNA Vaccines to SARS-CoV-2 : A Prospective Cohort Study. Ann Intern Med 2021; 174:1572-1585. [PMID: 34461029 PMCID: PMC8407518 DOI: 10.7326/m21-1757] [Citation(s) in RCA: 220] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients with chronic inflammatory disease (CID) treated with immunosuppressive medications have increased risk for severe COVID-19. Although mRNA-based SARS-CoV-2 vaccination provides protection in immunocompetent persons, immunogenicity in immunosuppressed patients with CID is unclear. OBJECTIVE To determine the immunogenicity of mRNA-based SARS-CoV-2 vaccines in patients with CID. DESIGN Prospective observational cohort study. SETTING Two U.S. CID referral centers. PARTICIPANTS Volunteer sample of adults with confirmed CID eligible for early COVID-19 vaccination, including hospital employees of any age and patients older than 65 years. Immunocompetent participants were recruited separately from hospital employees. All participants received 2 doses of mRNA vaccine against SARS-CoV-2 between 10 December 2020 and 20 March 2021. Participants were assessed within 2 weeks before vaccination and 20 days after final vaccination. MEASUREMENTS Anti-SARS-CoV-2 spike (S) IgG+ binding in all participants, and neutralizing antibody titers and circulating S-specific plasmablasts in a subset to assess humoral response after vaccination. RESULTS Most of the 133 participants with CID (88.7%) and all 53 immunocompetent participants developed antibodies in response to mRNA-based SARS-CoV-2 vaccination, although some with CID developed numerically lower titers of anti-S IgG. Anti-S IgG antibody titers after vaccination were lower in participants with CID receiving glucocorticoids (n = 17) than in those not receiving them; the geometric mean of anti-S IgG antibodies was 357 (95% CI, 96 to 1324) for participants receiving prednisone versus 2190 (CI, 1598 to 3002) for those not receiving it. Anti-S IgG antibody titers were also lower in those receiving B-cell depletion therapy (BCDT) (n = 10). Measures of immunogenicity differed numerically between those who were and those who were not receiving antimetabolites (n = 48), tumor necrosis factor inhibitors (n = 39), and Janus kinase inhibitors (n = 11); however, 95% CIs were wide and overlapped. Neutralization titers seemed generally consistent with anti-S IgG results. Results were not adjusted for differences in baseline clinical factors, including other immunosuppressant therapies. LIMITATIONS Small sample that lacked demographic diversity, and residual confounding. CONCLUSION Compared with nonusers, patients with CID treated with glucocorticoids and BCDT seem to have lower SARS-CoV-2 vaccine-induced antibody responses. These preliminary findings require confirmation in a larger study. PRIMARY FUNDING SOURCE The Leona M. and Harry B. Helmsley Charitable Trust, Marcus Program in Precision Medicine Innovation, National Center for Advancing Translational Sciences, and National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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Affiliation(s)
- Parakkal Deepak
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Wooseob Kim
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Michael A Paley
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Monica Yang
- University of California San Francisco, San Francisco, California (M.Y., A.B.C., E.G.D., D.P., N.P., J.G., K.E.T., P.K., M.M.)
| | - Alexander B Carvidi
- University of California San Francisco, San Francisco, California (M.Y., A.B.C., E.G.D., D.P., N.P., J.G., K.E.T., P.K., M.M.)
| | - Emanuel G Demissie
- University of California San Francisco, San Francisco, California (M.Y., A.B.C., E.G.D., D.P., N.P., J.G., K.E.T., P.K., M.M.)
| | - Alia A El-Qunni
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Alem Haile
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Katherine Huang
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Baylee Kinnett
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Mariel J Liebeskind
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Zhuoming Liu
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Lily E McMorrow
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Diana Paez
- University of California San Francisco, San Francisco, California (M.Y., A.B.C., E.G.D., D.P., N.P., J.G., K.E.T., P.K., M.M.)
| | - Niti Pawar
- University of California San Francisco, San Francisco, California (M.Y., A.B.C., E.G.D., D.P., N.P., J.G., K.E.T., P.K., M.M.)
| | - Dana C Perantie
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Rebecca E Schriefer
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Shannon E Sides
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Mahima Thapa
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Maté Gergely
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Suha Abushamma
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Sewuese Akuse
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Michael Klebert
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Lynne Mitchell
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Darren Nix
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Jonathan Graf
- University of California San Francisco, San Francisco, California (M.Y., A.B.C., E.G.D., D.P., N.P., J.G., K.E.T., P.K., M.M.)
| | - Kimberly E Taylor
- University of California San Francisco, San Francisco, California (M.Y., A.B.C., E.G.D., D.P., N.P., J.G., K.E.T., P.K., M.M.)
| | - Salim Chahin
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Matthew A Ciorba
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Patricia Katz
- University of California San Francisco, San Francisco, California (M.Y., A.B.C., E.G.D., D.P., N.P., J.G., K.E.T., P.K., M.M.)
| | - Mehrdad Matloubian
- University of California San Francisco, San Francisco, California (M.Y., A.B.C., E.G.D., D.P., N.P., J.G., K.E.T., P.K., M.M.)
| | - Jane A O'Halloran
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Rachel M Presti
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Gregory F Wu
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Sean P J Whelan
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - William J Buchser
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Lianne S Gensler
- University of California San Francisco and San Francisco VA Health Care System, San Francisco, California (L.S.G., M.C.N.)
| | - Mary C Nakamura
- University of California San Francisco and San Francisco VA Health Care System, San Francisco, California (L.S.G., M.C.N.)
| | - Ali H Ellebedy
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
| | - Alfred H J Kim
- Washington University School of Medicine, St. Louis, Missouri (P.D., W.K., M.A.P., A.A.E., A.H., K.H., B.K., M.J.L., Z.L., L.E.M., D.C.P., R.E.S., S.E.S., M.T., M.G., S.A., S.A., M.K., L.M., D.N., S.C., M.A.C., J.A.O., R.M.P., G.F.W., S.P.W., W.J.B., A.H.E., A.H.K.)
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Deepak P, Kim W, Paley MA, Yang M, Carvidi AB, El-Qunni AA, Haile A, Huang K, Kinnett B, Liebeskind MJ, Liu Z, McMorrow LE, Paez D, Perantie DC, Schriefer RE, Sides SE, Thapa M, Gergely M, Abushamma S, Klebert M, Mitchell L, Nix D, Graf J, Taylor KE, Chahin S, Ciorba MA, Katz P, Matloubian M, O'Halloran JA, Presti RM, Wu GF, Whelan SPJ, Buchser WJ, Gensler LS, Nakamura MC, Ellebedy AH, Kim AHJ. Glucocorticoids and B Cell Depleting Agents Substantially Impair Immunogenicity of mRNA Vaccines to SARS-CoV-2. medRxiv 2021:2021.04.05.21254656. [PMID: 33851176 PMCID: PMC8043473 DOI: 10.1101/2021.04.05.21254656] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Individuals with chronic inflammatory diseases (CID) are frequently treated with immunosuppressive medications that can increase their risk of severe COVID-19. While novel mRNA-based SARS-CoV-2 vaccination platforms provide robust protection in immunocompetent individuals, the immunogenicity in CID patients on immunosuppression is not well established. Therefore, determining the effectiveness of SARS-CoV-2 vaccines in the setting of immunosuppression is essential to risk-stratify CID patients with impaired protection and provide clinical guidance regarding medication management. METHODS We conducted a prospective assessment of mRNA-based vaccine immunogenicity in 133 adults with CIDs and 53 immunocompetent controls. Blood from participants over 18 years of age was collected before initial immunization and 1-2 weeks after the second immunization. Serum anti-SARS-CoV-2 spike (S) IgG + binding, neutralizing antibody titers, and circulating S-specific plasmablasts were quantified to assess the magnitude and quality of the humoral response following vaccination. RESULTS Compared to immunocompetent controls, a three-fold reduction in anti-S IgG titers (P=0.009) and SARS-CoV-2 neutralization (p<0.0001) were observed in CID patients. B cell depletion and glucocorticoids exerted the strongest effect with a 36- and 10-fold reduction in humoral responses, respectively (p<0.0001). Janus kinase inhibitors and antimetabolites, including methotrexate, also blunted antibody titers in multivariate regression analysis (P<0.0001, P=0.0023, respectively). Other targeted therapies, such as TNF inhibitors, IL-12/23 inhibitors, and integrin inhibitors, had only modest impacts on antibody formation and neutralization. CONCLUSIONS CID patients treated with immunosuppressive therapies exhibit impaired SARS-CoV-2 vaccine-induced immunity, with glucocorticoids and B cell depletion therapy more severely impeding optimal responses.
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Affiliation(s)
- Parakkal Deepak
- Inflammatory Bowel Diseases Center, Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Wooseob Kim
- Division of Immunobiology, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael A Paley
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Monica Yang
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Alexander B Carvidi
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Alia A El-Qunni
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Alem Haile
- Clinical Trials Unit, Washington University School of Medicine, St. Louis, MO, USA
| | - Katherine Huang
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Baylee Kinnett
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Mariel J Liebeskind
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - Zhuoming Liu
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Lily E McMorrow
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Diana Paez
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Dana C Perantie
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Rebecca E Schriefer
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Shannon E Sides
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Mahima Thapa
- Division of Immunobiology, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Maté Gergely
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Suha Abushamma
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael Klebert
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Lynne Mitchell
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Darren Nix
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jonathan Graf
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kimberly E Taylor
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Salim Chahin
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew A Ciorba
- Inflammatory Bowels Diseases Center, Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Patricia Katz
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mehrdad Matloubian
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jane A O'Halloran
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Rachel M Presti
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory F Wu
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA; Division of Immunobiology, Department of Pathology and Immunology, Washington, University School of Medicine, St. Louis, MO, USA; The Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
| | - Sean P J Whelan
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA
| | - William J Buchser
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - Lianne S Gensler
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Arthritis/Immunology Section, San Francisco Veterans Administration Health Care System, San Francisco, CA, USA
| | - Mary C Nakamura
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Arthritis/Immunology Section, San Francisco Veterans Administration Health Care System, San Francisco, CA, USA
| | - Ali H Ellebedy
- Division of Immunobiology, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA; The Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
| | - Alfred H J Kim
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA; Division of Immunobiology, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA; The Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO, USA
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