One Gene, Many Facets: Multiple Immune Pathway Dysregulation in SOCS1 Haploinsufficiency

Background

Inborn errors of immunity (IEI) present with a large phenotypic spectrum of disease, which can pose diagnostic and therapeutic challenges. Suppressor of cytokine signaling 1 (SOCS1) is a key negative regulator of cytokine signaling, and has recently been associated with a novel IEI. Of patients described to date, it is apparent that SOCS1 haploinsufficiency has a pleiotropic effect in humans.

Objective

We sought to investigate whether dysregulation of immune pathways, in addition to STAT1, play a role in the broad clinical manifestations of SOCS1 haploinsufficiency.

Methods

We assessed impacts of reduced SOCS1 expression across multiple immune cell pathways utilizing patient cells and CRISPR/Cas9 edited primary human T cells.

Results

SOCS1 haploinsufficiency phenotypes straddled across the International Union of Immunological Societies classifications of IEI. We found that reduced SOCS1 expression led to dysregulation of multiple intracellular pathways in immune cells. STAT1 phosphorylation is enhanced, comparably with STAT1 gain-of-function mutations, and STAT3 phosphorylation is similarly reduced with concurrent reduction of Th17 cells. Furthermore, reduced SOCS1 E3 ligase function was associated with increased FAK1 in immune cells, and increased AKT and p70 ribosomal protein S6 kinase phosphorylation. We also found Toll-like receptor responses are increased in SOCS1 haploinsufficiency patients.

Conclusions

SOCS1 haploinsufficiency is a pleiotropic monogenic IEI. Dysregulation of multiple immune cell pathways may explain the variable clinical phenotype associated with this new condition. Knowledge of these additional dysregulated immune pathways is important when considering the optimum management for SOCS1 haploinsufficient patients.

Monotherapy in patients with pulmonary arterial hypertension at four German PH centres

Background

Although combination therapy is the gold standard for patients with pulmonary arterial hypertension (PAH), some of these patients are still being treated with monotherapy.

Methods

We conducted a retrospective analysis at four German PH centres to describe the prevalence and characteristics of patients receiving monotherapy.

Results

We identified 131 incident PAH patients, with a mean age of 64 ± 13.8 years and a varying prevalence of comorbidities, cardiovascular risk factors and targeted therapy. As in other studies, the extent of prescribed PAH therapy varied with age and coexisting diseases, and younger, so-called “typical” PAH patients were more commonly treated early with combination therapy (48% at 4–8 months). In contrast, patients with multiple comorbidities or cardiovascular risk factors were more often treated with monotherapy (69% at 4–8 months). Survival at 12 months was not significantly associated with the number of PAH drugs used (single, dual, triple therapy) and was not different between “atypical” and “typical” PAH patients (89% vs. 85%).

Conclusion

Although “atypical” PAH patients with comorbidities or a more advanced age are less aggressively treated with respect to combination therapy, the outcome of monotherapy in these patients appears to be comparable to that of dual or triple therapy in “typical” PAH patients.

Septische Granulomatose als seltene Differenzialdiagnose rezidivierender pulmonaler Infektionen bei Erwachsenen

Die septische Granulomatose (engl.: chronic granulomatous disease, CGD) ist bei Kindern und Jugendlichen mit häufigen Infektionen durch bestimmte Erreger differenzialdiagnostisch zu berücksichtigen.

In vorliegender Kasuistik berichten wir über eine 64-jährige Patientin mit über Jahre zunehmenden bronchopulmonalen Infektionen, teilweise durch seltene Erreger, Autoimmunphänomenen, Malignomen und im weiteren Verlauf rezidivierenden organisierenden Pneumonien (OP) mit Nachweis von Granulomen. Ursächlich wurde bei der Patientin eine septische Granulomatose, Unterform p47phox-Defizienz diagnostiziert. Ein Überleben von Patienten mit einem primären Immundefekt (PID) bis ins hohe Erwachsenenalter wird trotz wiederholter Komplikationen in Einzelfällen beobachtet, insbesondere wenn die defekte Zellstruktur eine Restaktivität aufweist. Bei rezidivierenden bronchopulmonalen Infektionen insbesondere durch bestimmte seltene Erreger und in Kombination mit organisierend-granulomatösen Lungenreaktionen sowie Autoimmunphänomenen ist auch bei älteren Erwachsenen an eine CGD zu denken. Durch eine Diagnoseverzögerung kommt es oft zu einem erheblichen Anstieg der Morbidität und Mortalität.

[Complications after Indwelling Pleural Catheter Implant for Symptomatic Recurrent Benign and Malignant Pleural Effusions]

BACKGROUND

 Implant of indwelling pleural catheters (IPC) represents an established therapy method in addition to pleurodesis for symptomatic recurrent benign and malignant pleural effusions (BPE and MPE).There are only few studies on IPC safety during follow-up, especially with regard to infection and pneumothorax rates.The aim of our investigation was to determine the complication frequency after IPC implant and its predictive factors in patients with BPE vs. MPE.

METHODS

 Retrospective analysis of all IPC implantations in the pneumology department at the University Hospital Dresden during 2015 - 2018.

RESULTS

 An IPC was implanted in 86 patients (43 m/f each; age 66.9 ± 13.3 years) with symptomatic BPE and MPE. BPE and MPE was present in 12.8 % (11/86) and 87.2 % (75/86) of the patients, respectively.A predominantly small and asymptomatic pneumothorax was detectable as an immediate complication in 43/86 (50 %) of patients; 34/43 (79 %) of patients did not require any specific therapy. For 9/43 patients, IPC suction was required for a median period of three days; 8/43 patients had a large pneumothorax with partial or complete regression after a median period of two days.Catheter infection developed in 15.1 % (13/86) of the total group and 36.4 % (4/11) of the BPE vs. 12 % (9/75) of the MPE after a median period of 87 (BPE/MPE 116/87) days. This was more common in BPE (p = 0.035), large pneumothorax (4/8 patients; p = 0.015) and longer catheter dwell times (124 ± 112 vs. 71 ± 112 days; p = 0.07).

CONCLUSION

 Small pneumothoraxes are frequent after IPC implantation, but usually do not require specific therapy. IPC infection was detected in 15.1 % of all patients after a median period of 87 days. This was more common in patients with BPE, longer catheter dwell times and large pneumothorax.

[Large Pneumothorax in a Sleep Apnea Patient with CPAP without Previously Known Lung and Thoracic Diseases - a Case Report]

CPAP is the most common treatment for obstructive sleep apnea.Serious complications from this treatment are very rare. Pneumothorax following lung barotrauma under CPAP therapy has been described in case reports only in patients with pre-existing lung and thoracic diseases.A 68-year-old sleep apnea patient without pre-existing lung or thoracic diseases and with established CPAP therapy since many years was admitted to the hospital after a severe thoracic pain event with persistent shortness of breath. Chest radiograph and computed tomography showed an extensive right-sided pneumothorax with basal bullous emphysema. After surgical treatment of the secondary spontaneous pneumothorax, on the third postoperative day CPAP with reduced pressure was re-introduced with satisfactory sleep apnea findings and without pneumothorax recurrence.As possible cause of pneumothorax in the patient, alveolar inflammatory changes due to over-distention and increased pressure in the alveoli was assumed, which can occur after years of CPAP treatment with gradual pressure increase.In summary, in sleep apnea patients treated with CPAP for years, after sudden onset of thoracic pain and shortness of breath possible spontaneous pneumothorax should be considered.