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Engelhardt KR, Gertz ME, Keles S, Schäffer AA, Sigmund EC, Glocker C, Saghafi S, Pourpak Z, Ceja R, Sassi A, Graham LE, Massaad MJ, Mellouli F, Ben-Mustapha I, Khemiri M, Kilic SS, Etzioni A, Freeman AF, Thiel J, Schulze I, Al-Herz W, Metin A, Sanal Ö, Tezcan I, Yeganeh M, Niehues T, Dueckers G, Weinspach S, Patiroglu T, Unal E, Dasouki M, Yilmaz M, Genel F, Aytekin C, Kutukculer N, Somer A, Kilic M, Reisli I, Camcioglu Y, Gennery AR, Cant AJ, Jones A, Gaspar BH, Arkwright PD, Pietrogrande MC, Baz Z, Al-Tamemi S, Lougaris V, Lefranc G, Megarbane A, Boutros J, Galal N, Bejaoui M, Barbouche MR, Geha RS, Chatila TA, Grimbacher B. The extended clinical phenotype of 64 patients with dedicator of cytokinesis 8 deficiency. J Allergy Clin Immunol 2015; 136:402-12. [PMID: 25724123 DOI: 10.1016/j.jaci.2014.12.1945] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 10/14/2014] [Accepted: 12/01/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mutations in dedicator of cytokinesis 8 (DOCK8) cause a combined immunodeficiency (CID) also classified as autosomal recessive (AR) hyper-IgE syndrome (HIES). Recognizing patients with CID/HIES is of clinical importance because of the difference in prognosis and management. OBJECTIVES We sought to define the clinical features that distinguish DOCK8 deficiency from other forms of HIES and CIDs, study the mutational spectrum of DOCK8 deficiency, and report on the frequency of specific clinical findings. METHODS Eighty-two patients from 60 families with CID and the phenotype of AR-HIES with (64 patients) and without (18 patients) DOCK8 mutations were studied. Support vector machines were used to compare clinical data from 35 patients with DOCK8 deficiency with those from 10 patients with AR-HIES without a DOCK8 mutation and 64 patients with signal transducer and activator of transcription 3 (STAT3) mutations. RESULTS DOCK8-deficient patients had median IgE levels of 5201 IU, high eosinophil levels of usually at least 800/μL (92% of patients), and low IgM levels (62%). About 20% of patients were lymphopenic, mainly because of low CD4(+) and CD8(+) T-cell counts. Fewer than half of the patients tested produced normal specific antibody responses to recall antigens. Bacterial (84%), viral (78%), and fungal (70%) infections were frequently observed. Skin abscesses (60%) and allergies (73%) were common clinical problems. In contrast to STAT3 deficiency, there were few pneumatoceles, bone fractures, and teething problems. Mortality was high (34%). A combination of 5 clinical features was helpful in distinguishing patients with DOCK8 mutations from those with STAT3 mutations. CONCLUSIONS DOCK8 deficiency is likely in patients with severe viral infections, allergies, and/or low IgM levels who have a diagnosis of HIES plus hypereosinophilia and upper respiratory tract infections in the absence of parenchymal lung abnormalities, retained primary teeth, and minimal trauma fractures.
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Affiliation(s)
- Karin R Engelhardt
- Department of Immunology and Molecular Pathology, Royal Free Hospital and University College London, London, United Kingdom; Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg, Freiburg, Germany; Institute of Cellular Medicine, University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom
| | - Michael E Gertz
- National Center for Biotechnology Information, National Institutes of Health, Department of Health and Human Services, Bethesda, Md
| | - Sevgi Keles
- Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, Calif; Division of Pediatric Allergy and Immunology, Konya Necmettin Erbakan University, Konya, Turkey; Division of Immunology, Children's Hospital, Boston, Mass
| | - Alejandro A Schäffer
- National Center for Biotechnology Information, National Institutes of Health, Department of Health and Human Services, Bethesda, Md
| | - Elena C Sigmund
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg, Freiburg, Germany
| | - Cristina Glocker
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg, Freiburg, Germany
| | - Shiva Saghafi
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Pourpak
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ruben Ceja
- Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, Calif; Division of Immunology, Children's Hospital, Boston, Mass
| | - Atfa Sassi
- Laboratory of Immunology, Vaccinology, and Molecular Genetics, Pasteur Institute of Tunis and University of Tunis el Manar, Tunis, Tunisia
| | - Laura E Graham
- Department of Immunology and Molecular Pathology, Royal Free Hospital and University College London, London, United Kingdom
| | | | - Fethi Mellouli
- Department of Pediatrics, Bone Marrow Transplantation Center, Tunis, Tunisia
| | - Imen Ben-Mustapha
- Laboratory of Immunology, Vaccinology, and Molecular Genetics, Pasteur Institute of Tunis and University of Tunis el Manar, Tunis, Tunisia
| | - Monia Khemiri
- Department of Pediatrics, Children's Hospital, Tunis, Tunisia
| | - Sara Sebnem Kilic
- Department of Pediatric Immunology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Amos Etzioni
- Meyer's Children Hospital, Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Alexandra F Freeman
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Md
| | - Jens Thiel
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg, Freiburg, Germany
| | - Ilka Schulze
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg, Freiburg, Germany
| | - Waleed Al-Herz
- Department of Pediatrics, Faculty of Medicine, Kuwait University and Allergy and Clinical Immunology Unit, Department of Pediatrics, Al-Sabah Hospital, Kuwait City, Kuwait
| | - Ayse Metin
- Pediatric Immunology Unit, SB Ankara Diskapi Children's Hospital, Ankara, Turkey
| | - Özden Sanal
- Immunology Division, Hacettepe University, Children's Hospital, Ankara, Turkey
| | - Ilhan Tezcan
- Immunology Division, Hacettepe University, Children's Hospital, Ankara, Turkey
| | - Mehdi Yeganeh
- Immunology Asthma and Allergy Research Institute, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Tim Niehues
- HELIOS Klinikum Krefeld, Zentrum für Kinder- und Jugendmedizin, Krefeld, Germany
| | - Gregor Dueckers
- HELIOS Klinikum Krefeld, Zentrum für Kinder- und Jugendmedizin, Krefeld, Germany
| | - Sebastian Weinspach
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Center of Child and Adolescent Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Turkan Patiroglu
- Department of Pediatrics, Division of Pediatric Hematology and Immunology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Ekrem Unal
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Majed Dasouki
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, Mo
| | | | - Ferah Genel
- Division of Pediatric Immunology, Behcet Uz State Hospital, Izmir, Turkey
| | - Caner Aytekin
- Department of Pediatric Immunology, Dr Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Necil Kutukculer
- Department of Pediatrics, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ayper Somer
- Division of Infectious Diseases and Immunology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | | | - Ismail Reisli
- Division of Pediatric Allergy and Immunology, Konya Necmettin Erbakan University, Konya, Turkey
| | - Yildiz Camcioglu
- Division of Pediatric Allergy-Immunology and Infectious Diseases, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Andrew R Gennery
- Institute of Cellular Medicine, University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom
| | - Andrew J Cant
- Institute of Cellular Medicine, University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom
| | - Alison Jones
- Department of Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Bobby H Gaspar
- Department of Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Peter D Arkwright
- University of Manchester, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Maria C Pietrogrande
- Department of Pediatrics, University of Milan, Fondazione Policlinico IRCCS, Milan, Italy
| | - Zeina Baz
- Department of Pediatrics, St George Hospital University Medical Center, Beirut, Lebanon
| | - Salem Al-Tamemi
- Department of Pediatrics, Sultan Qaboos University, Muscat, Oman
| | - Vassilios Lougaris
- Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, University of Brescia, Spedali Civili di Brescia, Brescia, Italy
| | - Gerard Lefranc
- University Montpellier 2 and CNRS Institute of Human Genetics, Montpellier, France
| | - Andre Megarbane
- Medical Genetics Unit, Saint Joseph University, Beirut, Lebanon
| | - Jeannette Boutros
- Cairo University, Specialized Pediatric Hospital, Primary Immunodeficiency Clinic, Cairo, Egypt
| | - Nermeen Galal
- Cairo University, Specialized Pediatric Hospital, Primary Immunodeficiency Clinic, Cairo, Egypt
| | - Mohamed Bejaoui
- Department of Pediatrics, Bone Marrow Transplantation Center, Tunis, Tunisia
| | - Mohamed-Ridha Barbouche
- Laboratory of Immunology, Vaccinology, and Molecular Genetics, Pasteur Institute of Tunis and University of Tunis el Manar, Tunis, Tunisia
| | - Raif S Geha
- Division of Immunology, Children's Hospital, Boston, Mass
| | - Talal A Chatila
- Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, Calif; Division of Immunology, Children's Hospital, Boston, Mass
| | - Bodo Grimbacher
- Department of Immunology and Molecular Pathology, Royal Free Hospital and University College London, London, United Kingdom; Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg, Freiburg, Germany.
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