Diagnosis of GATA2 Deficiency in a Young Woman with Hemophagocytic Lymphohistiocytosis Triggered by Acute Systemic Cytomegalovirus Infection

BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease characterized by an intense immunologic response that results in multiorgan dysfunction. It typically manifests as a result of a familial genetic immunodeficiency disorder or secondary to a trigger such as an infection, malignancy, or autoimmune disease. The major factors involved in the development of the disease are an individual's genetic propensity to develop HLH, such as rare associated mutations, or inflammatory processes that trigger the immune system to go haywire. CASE REPORT Before the COVID-19 pandemic, a 22-year-old woman with a history of congenital absence of the right kidney, right-sided hearing loss, and leukopenia presented with a 3-week history of generalized malaise, fever, chest pain, cough, and shortness of breath. She developed an acute systemic cytomegalovirus infection further complicated by HLH. Based on her history and clinical course, an underlying primary immunodeficiency was suspected. An immunodeficiency gene panel revealed a monoallelic mutation in GATA2, a gene that encodes zinc-transcription factors responsible for the regulation of hematopoiesis. CONCLUSIONS GATA2 deficiency encompasses a large variety of mutations in the GATA2 gene and leads to disorders associated with hematologic and immunologic manifestations of monocytopenia and B-, and natural killer-cell deficiency. Over time, affected individuals are at high risk of developing life-threatening infections and serious hematologic complications, such as myelodysplastic syndromes and/or leukemias. We aimed to illustrate the importance of identifying an underlying genetic disorder associated with secondary HLH to help guide acute and long-term management.

Use of continuous glucose monitoring in patients with diabetes on peritoneal dialysis: poor correlation with HbA1c and high incidence of hypoglycaemia

BACKGROUND

Achieving adequate glycaemic control in patients with diabetes on peritoneal dialysis is challenging. Traditional assessment of glycaemia using HbA1c is difficult in such patients because of renal anaemia or carbamylation of haemoglobin, and significant glucose excursions may be masked. We describe three patients with diabetes on peritoneal dialysis with similar HbA1c levels, but with very different glucose profiles shown on continuous glucose monitoring.

CASE REPORTS

Patient 1 was treated with gliclazide, and had a number of solutions with high glucose concentration in his dialysis prescription. Continuous glucose monitoring showed glucose levels > 11 mmol/l for > 17 h per day, and < 4 mmol/l for 72 min per day with no symptoms. His HbA1c level was 61 mmol/mol (7.7%). Patient 2 was treated with insulin. Continuous glucose monitoring showed glucose levels > 11 mmol/mol for 3.8 h per day, and < 4 mmol/mol for 3.8 h per day. His HbA1c level was 59 mmol/mol (7.6%). Patient 3 was treated with pioglitazone and gliclazide, and glucose levels were > 11 mmol/l for 8 h per day and < 4 mmol/l for 1.6 h per day. His HbA1c was 62 mmol/mol (7.8%). None of the patients was aware of hypoglycaemia during the periods of low glucose recorded on continuous glucose monitoring.

CONCLUSION

Despite similar HbA1c levels, our three patients had very different glucose profiles. These cases highlight the fact that HbA1c is frequently inadequate in reflecting glucose control in patients with diabetes on peritoneal dialysis, and we suggest that intermittent continuous glucose monitoring may allow safer management of glycaemia in such patients.

Evolution of pattern of breathing during a spontaneous breathing trial predicts successful extubation

PURPOSE

Rapid shallow breathing may occur at any time during spontaneous breathing trials (SBT), questioning the utility of a single determination of the rapid shallow breathing index (RSBI). We hypothesize that change in RSBI during SBT may more accurately predict successful extubation than a single determination.

METHODS

Prospective observational study. Seventy-two subjects were extubated. At 24 h, 63/72 remained extubated (Extubation Success), and 9 were re-intubated (Extubation Failure). Respiratory rate (RR), tidal volume (VT) and RSBI were measured every 30 min during 2-h T-piece SBT. Change in respiratory parameters was assessed as percent change from baseline.

RESULTS

Initial RSBI was similar in Extubation Success and Extubation Failure groups (77.0 +/- 4.8, 77.0 +/- 4.8, p = ns). Nevertheless, RSBI tended to remain unchanged or decreased in the Extubation Success group; in contrast RSBI tended to increase in the Extubation Failure group because of either increased RR and/or decreased VT (p < 0.001 for mean percent change RSBI over time), indicating worsening of the respiratory pattern. Quantitatively, only 7/63 subjects of the Extubation Success group demonstrated increased RSBI >or=20% at any time during the SBT. In contrast, in the Extubation Failure group, RSBI increased in all subjects during the SBT, and eight of nine subjects demonstrated an increase greater than 20%. Thus, with a 2-h SBT the optimal threshold was a 20% increase (sensitivity = 89%, specificity = 89%). Similar results were obtained at 30 min (threshold = 5% increase). Percent change of RSBI predicted successful extubation even when initial values were >or=105.

CONCLUSION

Percent change of RSBI during an SBT is a better predictor of successful extubation than a single determination of RSBI.

Accessory cell function of airway epithelial cells

Oei, Erwin, Thomas Kalb, Prarthana Beuria, Matthieu Allez, Atsushi Nakazawa, Miyuki Azuma, Michael Timony, Zanetta Stuart, Houchu Chen, and Kirk Sperber. Accessory cell function of airway epithelial cells.

We previously demonstrated that airway epithelial cells (AECs) have many features of accessory cells, including expression of class II molecules CD80 and CD86 and functional Fcγ receptors. We have extended these studies to show that freshly isolated AECs have mRNA for cathepsins S, V, and H [proteases important in antigen (Ag) presentation], invariant chain, human leukocyte antigen (HLA)-DM-α and HLA-DM-β, and CLIP, an invariant chain breakdown product. A physiologically relevant Ag, ragweed, was colocalized with HLA-DR in AECs, and its uptake was increased by granulocyte-macrophage colony-stimulating factor and IFN-γ treatments, which had no effect on CD80 and CD86 expression. We demonstrate the presence of other costimulatory molecules, including B7h and B7-H1, on AECs and the increased expression of B7-H1 on AECs after treatment with granulocyte-macrophage colony-stimulating factor and IFN-γ. Finally, we compared T cell proliferation after allostimulation with AECs and dendritic cells (DCs). The precursor frequency of peripheral blood T cells responding to AECs was 0.264% compared with 0.55% for DCs. DCs stimulated CD45RO+, CD45RA+, CCR7+and CCR7−CD4+, and CD8+T cells, whereas AECs stimulated only CD45RO+, CD45RA−, CCR7−, CD4+, and CD8+T cells. There was no difference in cytokine production, type of memory T cells stimulated (effector vs. long-term memory), or apoptosis by T cells cocultured with AECs and DCs. The localization of AECs exposed to the external environment may make them important in the regulation of local immune responses.

Relationship of respiratory symptoms with smoking status and pulmonary function in chronic spinal cord injury

OBJECTIVE

The relationship of respiratory symptoms to pulmonary function parameters and smoking status was assessed in subjects with chronic (>1 year) spinal cord injury (SCI).

METHODS AND PARTICIPANTS

As part of their annual physical examination, subjects were queried regarding respiratory symptoms and underwent pulmonary function studies. The 180 patients who successfully completed pulmonary function testing were evaluated, including 79 subjects with tetraplegia (56 nonsmokers and 23 smokers) and 101 subjects with paraplegia (78 nonsmokers and 23 smokers).

FINDINGS

Logistic-regression analysis revealed the following independent predictors of breathlessness: level of injury (tetraplegia, paraplegia, odds ratio = 3.5, P < 0.0015), cough combined with phlegm and/or wheeze (CPWZ, odds ratio = 3.1, P < 0.015), total lung capacity percentage predicted (TLC <60%, odds ratio = 3.9, P < 0.02), and expiratory reserve volume (ERV < 0.6 L, odds ratio = 2.5, P < 0.05). Independent predictors of CPWZ were current smoking (odds ratio = 3.3, P < 0.004), breathlessness (odds ratio = 2.9, P < 0.03), and forced expiratory volume in 1 second (FEV1 <60%, odds ratio = 3.2, P < 0.01).

CONCLUSION

Altered respiratory mechanics associated with tetraplegia contribute to breathlessness, restrictive ventilatory impairment (low TLC%), and reduced expiratory muscle strength (low ERV). These factors apparently overshadow adverse effects caused by smoking. Conversely, smoking and reduction of airflow (low FEV1%) were predictive of CPWZ, symptoms commonly associated with cigarette use.

Regulation of class II expression in monocytic cells after HIV-1 infection

Human macrophage hybridoma cells were used to study HLA-DR expression after HIV-1 infection. HLA-DR surface expression was lost 2 wk after infection that was associated with decreased mRNA transcription. Transfecting HLA-DR-alpha and HLA-DR-beta cDNA driven by a nonphysiological CMV promoter restored expression, suggesting that regulatory DNA-binding proteins may be affected by HIV-1 infection. There was no protein binding to conserved class II DNA elements (W/Z/S box, X-1 and X-2 boxes, and Y box) in a HIV-1-infected human macrophage hybridoma cell line, 43(HIV), and in primary monocytes that lost HLA-DR expression after HIV-1(BaL) infection. PCR analysis of the HIV-1-infected cells that lost HLA-DR expression revealed mRNA for W/Z/S (RFX-5), X-1 (RFX-5), X-2 (hX-2BP), and one Y box DNA-binding protein (NF-YB), and CIITA, a non-DNA-binding protein necessary for class II transcription. There was no mRNA for the Y box-binding protein, NF-YA. However, HLA-DR expression could be restored by transfection with NF-YA driven by a CMV promoter, although HLA-DR failed to localize in either the late endosomes, lysosomes, or acidic compartments. This was associated with a loss of class II-associated invariant chain peptide and leupeptin-induced protein in the 43(HIV) cells. To address this further, non-HIV-1-infected 43 cells were infected with vaccinia virus containing HIV-1 gag, nef, pol, and env proteins. HLA-DR failed to localize in neither the late endosomes, lysosomes, or acidic compartments in the vaccinia-infected cells containing HIV-1 env protein. HIV-1 appears to have multiple effects on class II expression in monocytic cells that may contribute to the immune defects seen in HIV-1-infected patients.

Antigen uptake and trafficking in human intestinal epithelial cells

Primary intestinal epithelial cells, human colonic adenocarcinoma cell lines (DLD-1, Caco-2, and HT-29), and monocytes were used as model systems to study antigen uptake, antigen-presenting cell properties, as well as the kinetics of antigen uptake in intestinal epithelial cells (IEC). Intracellular staining of fluoresceinated tetanus toxoid was not evident in the IEC until after 30 min of incubation at 37 degrees C, whereas in monocytes intracellular punctate staining of fluoresceinated tetanus toxoid was evident after 5 mins. In polarized Caco-2 cells antigen could be internalized at both the apical and basolateral surfaces with polarized transport. When analyzed by electron microscopy, gold-labeled tetanus toxoid was internalized and found within endosomes and multivesicular bodies, but not within the lysosomal compartments by 60 min. By 2 hrs, gold-labeled tetanus toxoid was evident in the secondary lysosomes. These results demonstrate that tetanus toxoid follows an endocytic pathway in intestinal epithelial cells and that the kinetics of antigen uptake is slower than that of conventional antigen-presenting cells.

Factors affecting antigen uptake by human intestinal epithelial cell lines

We assessed the role of size, solubility, and prophagocytic cytokines interferon-gamma (IFN-gamma), and granulocyte-macrophage colony stimulatory factor (GM-CSF) in antigen uptake and kinetics by intestinal epithelial cells using keyhole limpet hemocyanin and ovalbumin. Both fluoresceinated keyhole limpet hemocyanin (3000-7500 kDa) and fluoresceinated ovalbumin (45 kDa) were internalized by human colonic epithelial cell lines, with kinetics similar to those of fluoresceinated tetanus toxoid, and there was decreased uptake of insoluble immune complexes and no enhancement in the uptake of soluble immune complexes. In addition, neither IFN-gamma nor GM-CSF altered the kinetics of uptake nor enhanced antigen internalization by the intestinal epithelial cell lines. These data suggest that regardless of the size of the soluble antigen, the presence of prophagocytic cytokines, or the formation of soluble immune complexes, fluid phase endocytosis of antigen by intestinal epithelial cells appears to be a relatively stable process.

Antigen trafficking and accessory cell function in respiratory epithelial cells

We investigated accessory cell function, antigen (Ag) trafficking, and uptake of immune complexes in isolated nasal epithelial cells (NEC) and airway epithelial cells (AEC), as well as in the two respiratory epithelial cell lines A549 and BEAS-2B. The NEC and AEC were capable of supporting Ag-specific as well as phytohemagglutinin-induced and anti-CD3 antibody-induced T-cell proliferation. We colocalized fluorescein isothiocyanate (FITC)-labeled Ags with human leukocyte antigen (HLA)-DR in A549 and BEAS-2B, utilizing laser confocal microscopy. Respiratory epithelial cells stimulated and unstimulated with interferon (IFN)-gamma were pulsed with FITC-labeled Ags for varying periods and evaluated for their ability to internalize Ag. In the unstimulated cells, intracellular punctate staining was evident at 60 min and persisted up to 120 min. In the IFN-gamma-stimulated cells (100 U/ml for 48 h), uptake occurred at 30 min, was maximal at 60 min, and diminished at 120 min. We conducted kinetic studies in the A549 and BEAS-2B cells, utilizing electron microscopy with colloidal gold-conjugated Ags (Au-OVA). At 15 min, Au-OVA was evident in the early compartments resembling the compartment of uncoupling of receptor and ligand. At 30 min, multivesicular bodies were labeled with Au-OVA, and by 60 min Au-OVA was present in the primary and secondary lysosomes. The FITC-labeled Ags colocalized with an early endosomal marker (anti-cathepsin D), a late endosomal marker (M6PR), a lysosomal marker (CD63), and with 3-(2, 4-dinitroanilino)-3'-aminomethyldipropylamine, a marker of acidic vesicles. The BEAS-2B and A549 cells, and NEC and AEC, expressed surface Fcgamma receptor and internalized IgG immune complexes. The NEC and AEC also expressed the costimulatory molecules CD80 and CD86 as determined with flow cytometry, the reverse transcription-polymerase chain reaction for RNA, and immunohistochemistry, and T-cell proliferation could be blocked by treating NEC and AEC with anti-CD80 and anti-CD86 antibodies. Our findings suggest that respiratory epithelial cells may have a role in local Ag presentation.

In vivo antagonism of agonist actions at N-methyl-D-aspartate and N-methyl-D-aspartate-associated glycine receptors in mouse cerebellum: studies of 1-hydroxy-3-aminopyrrolidone-2

Intracerebellar injections of either NMDA or D-serine dramatically elevated levels of cGMP in the cerebellum of the mouse, in vivo. These actions were both antagonized by simultaneous injection of the NMDA-associated glycine receptor antagonist, HA-966. Intracerebellar injections of D-serine were also antagonized by peripheral (s.c.) injections of HA-966, demonstrating the bioavailability of this glycine receptor antagonist. Parenteral administration of HA-966 was also effective in antagonizing the actions of intravenously injected harmaline, an activator of the cerebellar climbing fiber pathway, on cGMP in the cerebellum. An evaluation of the parenteral dose-response curve for HA-966, revealed no effect on basal activity within the cerebellum. This contrasts sharply with the abilities of both competitive and non-competitive NMDA antagonists to decrease basal levels of cGMP in the cerebellum. In summary, these studies demonstrate that HA-966 is a bioavailable antagonist of the NMDA-associated glycine receptor and that this compound can limit excessive stimulation of the NMDA receptor by exogenous application of agonist, with minimal effects on basal activity. These data suggest that antagonists of the NMDA-associated glycine receptor may be optimal therapies in the treatment of stroke and epilepsy.

Cholecystokinin attenuates basal and drug-induced increases of limbic and striatal dopamine release

Subcutaneous administration to mice of the sulfated octapeptide of cholecystokinin (CCK; 0.2-1 mg/kg) lowered dopamine release and metabolism in the caudate-putamen and frontal cortex in a dose- and time-related manner. Twelve-fold higher doses of CCK were required to lower dopamine release and metabolism in the olfactory tubercle. Amphetamine-induced increases in dopamine release but not metabolism in the caudate-putamen and olfactory tubercle were attenuated in a dose-related manner by CCK. Increases in dopamine release and metabolism following haloperidol were also attenuated by CCK. These data are consistent with the potential antipsychotic action of CCK receptor agonists. CCK appears to be a suppressor of striatal, limbic and cortical dopamine release, especially when release is augmented.

Dopamine autoreceptors modulate the in vivo release of dopamine in the frontal, cingulate and entorhinal cortices

The regulation by autoreceptors of dopamine release in the rat neocortex was inferred from measurements of 3-methoxytyramine after the peripheral injection of a selective (CGS 15855A) or nonselective (apomorphine) dopamine autoreceptor agonist. Basal levels of dopamine release were greatly decreased in the frontal cortex and caudate putamen after the injection of CGS 15855A or apomorphine. The pargyline-induced accumulations of 3-methoxytyramine in the frontal cortex, cingulate cortex and caudate putamen were attenuated by 52 to 82% after the injection of either agonist. 3-Methoxytyramine accumulations in the entorhinal cortex were attenuated by 68% by apomorphine. Thus, as in the caudate putamen, dopamine autoreceptors modulate the in vivo release of dopamine in the frontal cortex and the turnover of the releasable dopamine pool in the frontal, cingulate and entorhinal cortices.