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Löfstedt A, Jädersten M, Meeths M, Henter JI. Malignancy-associated hemophagocytic lymphohistiocytosis in Sweden: incidence, clinical characteristics, and survival. Blood 2024; 143:233-242. [PMID: 37595287 PMCID: PMC10808245 DOI: 10.1182/blood.2023020715] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/31/2023] [Accepted: 07/31/2023] [Indexed: 08/20/2023] Open
Abstract
ABSTRACT We evaluated malignancy-associated hemophagocytic lymphohistiocytosis (mal-HLH) in Sweden regarding population-based incidence, clinical features, and survival. From 1997 to 2018, we identified 307 adults (≥18 years old) and 9 children (209 males, 107 females; P < .001) with both an HLH-related diagnosis and malignant disease, corresponding to 0.19 per 100 000 adults annually (0.15/100 000 for the entire population), increasing from 0.026 (1997-2007) to 0.34 (2008-2018) (P < .001). In the latest 7-year period (2012-2018), the annual incidence was 0.45 per 100 000 adults (n = 246). This incidence varied between the 6 health care regions in Sweden, from 0.18 to 0.71 (Region Stockholm) per 100 000 adults annually (P < .001), likely due to variable awareness. Mal-HLH was reported in 0.6% of all hematological malignancies, with the highest proportion (2.5%) in young males. Among the 316 patients, the 1-month probability of survival, likely representing the HLH episode, increased significantly from 52% (95% confidence interval [CI], 40-63) (1997-2007) to 71% (95% CI, 65-76) (2008-2018), whereas 2-year survival remained poor (25%; 95% CI, 20-30). Altogether, 52% were lymphomas, 29% leukemias, 8% other hematological malignancies, and 11% solid tumors. Males were more affected than females by mal-HLH, also taking the over-representation of males with hematological malignancies into account (P = .0012). Validation by medical-file reviews revealed 13% over-reporting of HLH. We conclude that the annual mal-HLH incidence has increased 10-fold and was at least 0.71 per 100 000 adults from 2012 to 2018, that is, 0.62 per 100 000 adults considering 13% estimated HLH over-reporting, and that early survival improved significantly, likely due to increased awareness and more HLH-directed therapy.
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Affiliation(s)
- Alexandra Löfstedt
- Department of Women’s and Children’s Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgrens Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Jädersten
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Center for Hematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marie Meeths
- Department of Women’s and Children’s Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgrens Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Jan-Inge Henter
- Department of Women’s and Children’s Health, Childhood Cancer Research Unit, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgrens Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
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2
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Meeths M, Bryceson YT. Genetics and pathophysiology of haemophagocytic lymphohistiocytosis. Acta Paediatr 2021; 110:2903-2911. [PMID: 34192386 DOI: 10.1111/apa.16013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 12/11/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) represents a life-threatening hyperinflammatory syndrome. Familial studies have established autosomal and X-linked recessive causes of HLH, highlighting a pivotal role for lymphocyte cytotoxicity in the control of certain virus infections and immunoregulation. Recently, a more complex etiological framework has emerged, linking HLH predisposition to variants in genes required for metabolism or immunity to intracellular pathogens. We review genetic predisposition to HLH and discuss how molecular insights have provided fundamental knowledge of the immune system as well as detailed pathophysiological understanding of hyperinflammatory diseases, highlighting new treatment strategies.
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Affiliation(s)
- Marie Meeths
- Childhood Cancer Research Unit Department of Women’s and Children’s Health Karolinska Institutet Stockholm Sweden
- Theme of Children’s Health Karolinska University Hospital Stockholm Sweden
| | - Yenan T. Bryceson
- Centre for Hematology and Regenerative Medicine Department of Medicine Karolinska Institute Stockholm Sweden
- Division of Clinical Immunology and Transfusion Medicine Karolinska University Hospital Stockholm Sweden
- Broegelmann Research Laboratory Department of Clinical Sciences University of Bergen Bergen Norway
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3
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Groß M, Speckmann C, May A, Gajardo-Carrasco T, Wustrau K, Maier SL, Panning M, Huzly D, Agaimy A, Bryceson YT, Choo S, Chow CW, Dückers G, Fasth A, Fraitag S, Gräwe K, Haxelmans S, Holzinger D, Hudowenz O, Hübschen JM, Khurana C, Kienle K, Klifa R, Korn K, Kutzner H, Lämmermann T, Ledig S, Lipsker D, Meeths M, Naumann-Bartsch N, Rascon J, Schänzer A, Seidl M, Tesi B, Vauloup-Fellous C, Vollmer-Kary B, Warnatz K, Wehr C, Neven B, Vargas P, Sepulveda FE, Lehmberg K, Schmitt-Graeff A, Ehl S. Rubella vaccine-induced granulomas are a novel phenotype with incomplete penetrance of genetic defects in cytotoxicity. J Allergy Clin Immunol 2021; 149:388-399.e4. [PMID: 34033843 DOI: 10.1016/j.jaci.2021.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/19/2021] [Accepted: 05/05/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Rubella virus-induced granulomas have been described in patients with various inborn errors of immunity. Most defects impair T-cell immunity, suggesting a critical role of T cells in rubella elimination. However, the molecular mechanism of virus control remains elusive. OBJECTIVE This study sought to understand the defective effector mechanism allowing rubella vaccine virus persistence in granulomas. METHODS Starting from an index case with Griscelli syndrome type 2 and rubella skin granulomas, this study combined an international survey with a literature search to identify patients with cytotoxicity defects and granuloma. The investigators performed rubella virus immunohistochemistry and PCR and T-cell migration assays. RESULTS This study identified 21 patients with various genetically confirmed cytotoxicity defects, who presented with skin and visceral granulomas. Rubella virus was demonstrated in all 12 accessible biopsies. Granuloma onset was typically before 2 years of age and lesions persisted from months to years. Granulomas were particularly frequent in MUNC13-4 and RAB27A deficiency, where 50% of patients at risk were affected. Although these proteins have also been implicated in lymphocyte migration, 3-dimensional migration assays revealed no evidence of impaired migration of patient T cells. Notably, patients showed no evidence of reduced control of concomitantly given measles, mumps, or varicella live-attenuated vaccine or severe infections with other viruses. CONCLUSIONS This study identified lymphocyte cytotoxicity as a key effector mechanism for control of rubella vaccine virus, without evidence for its need in control of live measles, mumps, or varicella vaccines. Rubella vaccine-induced granulomas are a novel phenotype with incomplete penetrance of genetic disorders of cytotoxicity.
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Affiliation(s)
- Miriam Groß
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany; Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Carsten Speckmann
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany; Center for Pediatrics and Adolescent Medicine, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Annette May
- Institute for Surgical Pathology, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Tania Gajardo-Carrasco
- Molecular Basis of Altered Immune Homeostasis Laboratory, Institut National de la Santé et de la Recherche Médicale (INSERM), Unite Mixte de Recherche (UMR) 1163, Paris, France; Imagine Institute, Université de Paris, Paris, France
| | - Katharina Wustrau
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Lena Maier
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcus Panning
- Institute of Virology, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Daniela Huzly
- Institute of Virology, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Abbas Agaimy
- Institute of Pathology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Yenan T Bryceson
- Department of Medicine, Center for Hematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden; Broegelmann Research Laboratory, Department of Clinical Sciences, University of Bergen, Bergen, Norway
| | - Sharon Choo
- Department of Allergy and Immunology, The Royal Children's Hospital, Melbourne, Australia
| | - C W Chow
- Department of Anatomical Pathology, The Royal Children's Hospital, Melbourne, Australia
| | - Gregor Dückers
- Helios Klinikum Krefeld, Zentrum für Kinder- und Jugendmedizin, Krefeld, Germany
| | - Anders Fasth
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
| | - Sylvie Fraitag
- Department of Pathology, Necker-Enfants Malades Hospital, Paris, France
| | - Katja Gräwe
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany
| | | | - Dirk Holzinger
- Department of Pediatric Hematology-Oncology, University of Duisburg-Essen, Essen, Germany
| | - Ole Hudowenz
- Department of Rheumatology, Immunology, Osteology, and Physical Medicine, Campus Kerckhoff of Justus-Liebig-University Gießen, Bad Nauheim, Germany
| | - Judith M Hübschen
- World Health Organization European Regional Reference Laboratory for Measles and Rubella, Luxembourg Institute of Health, Department of Infection and Immunity, Esch-sur-Alzette, Luxembourg
| | - Claudia Khurana
- Department of Pediatric Hematology and Oncology, Children's Center Bethel, University Hospital Ostwestfalen-Lippe (OWL)/University Bielefeld, Bielefeld, Germany
| | - Korbinian Kienle
- Max Planck Institute of Immunobiology and Epigenetics, Freiburg, Germany
| | - Roman Klifa
- Immunology and Pediatric Hematology Department, Assistance Publique-Hôpitaux de Paris (AH-PH), Paris, France
| | - Klaus Korn
- Institute of Virology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | | | - Tim Lämmermann
- Max Planck Institute of Immunobiology and Epigenetics, Freiburg, Germany
| | - Svea Ledig
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dan Lipsker
- Faculté de Médecine, Université de Strasbourg and Clinique Dermatologique, Hôpitaux Universitaires, Strasbourg, France
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden; Theme of Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Nora Naumann-Bartsch
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital Erlangen, Erlangen, Germany
| | - Jelena Rascon
- Center for Pediatric Oncology and Hematology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Anne Schänzer
- Institute of Neuropathology, Justus Liebig University Gießen, Gießen, Germany
| | - Maximilian Seidl
- Institute for Surgical Pathology, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany; Institute of Pathology, Heinrich Heine University and University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Bianca Tesi
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Genetics, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Christelle Vauloup-Fellous
- AP-HP, Hôpital Paul-Brousse, Department of Virology, World Health Organization Rubella National Reference Laboratory, Groupe de Recherche sur les Infections pendant la Grossesse, University Paris Saclay, INSERM U1193, Villejuif, France
| | - Beate Vollmer-Kary
- Institute for Surgical Pathology, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Klaus Warnatz
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany; Center for Chronic Immunodeficiency, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Claudia Wehr
- Center for Chronic Immunodeficiency, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany; Department of Medicine I, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Bénédicte Neven
- Imagine Institute, Université de Paris, Paris, France; Pediatric Hematology-Immunology and Rheumatology Department, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Laboratory of Immunogenetics of Pediatric Autoimmunity, INSERM UMR 1163, Imagine Institute, Université de Paris, Paris, France
| | - Pablo Vargas
- Institut Curie, Centre National de la Recherche Scientifique (CNRS) UMR 144 and Institut Pierre-Gilles de Gennes, and INSERM U932 Immunité et Cancer, Institut Curie, Paris Sciences et Lettres Research University, Paris, France
| | - Fernando E Sepulveda
- Molecular Basis of Altered Immune Homeostasis Laboratory, Institut National de la Santé et de la Recherche Médicale (INSERM), Unite Mixte de Recherche (UMR) 1163, Paris, France; Imagine Institute, Université de Paris, Paris, France; Centre National de la Recherche Scientifique (CNRS), Paris, France
| | - Kai Lehmberg
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annette Schmitt-Graeff
- Center for Chronic Immunodeficiency, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Stephan Ehl
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany.
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Horne A, von Bahr Greenwood T, Chiang SC, Meeths M, Björklund C, Ekelund M, Erensjö P, Berg S, Hagelberg S, Bryceson YT, Andersson U, Henter JI. Efficacy of Moderately Dosed Etoposide in Macrophage Activation Syndrome–Hemophagocytic Lymphohistiocytosis. J Rheumatol 2021; 48:1596-1602. [DOI: 10.3899/jrheum.200941] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 11/22/2022]
Abstract
Objective Macrophage activation syndrome (MAS) constitutes 1 subtype of the hyperinflammatory syndrome hemophagocytic lymphohistiocytosis (HLH), and the term MAS-HLH was recently proposed for HLH with underlying autoimmune/autoinflammatory conditions. The mortality of MAS-HLH has been estimated at 5–10%. Here we report our experiences with moderately dosed etoposide in severe MAS-HLH; the objective was to effectively reduce severe hyperinflammatory activity with limited side effects. Methods In addition to conventional antiinflammatory treatment, moderately dosed etoposide was administered to 7 children affected by rapidly progressing MAS-HLH with central nervous system (n = 5) and/ or pulmonary (n = 5) involvement. Three had underlying systemic juvenile idiopathic arthritis (sJIA), 2 had atypical sJIA (no arthritis at diagnosis), and 2 had systemic lupus erythematosus. We performed lymphocyte cytotoxicity analyses in all 7 and genetic analyses in 6. Results All children promptly responded to moderately dosed etoposide (50–100 mg/m2 once weekly), added to conventional MAS-HLH treatment that was considered insufficient. The mean accumulated etoposide dose was 671 mg/m2 (range 300–1050 mg/m2) as compared to 1500 mg/m2 recommended in the first 8 weeks of the HLH-94/HLH-2004 protocols. One child developed neutropenic fever and another neutropenic sepsis (neutrophils 0.3 × 109/L at therapy onset). Five of 7 children had low percentages (< 5%) of circulating natural killer (NK) cells prior to or in association with diagnosis; NK cell activity was pathologically low in 2 of 5 children studied. Disease-causing variants in HLH-associated genes were not found. All children were alive at latest follow-up (2–9 yrs after onset); neurological symptoms had normalized in 4 of 5 affected children. Conclusion Moderately dosed etoposide may be beneficial in severe and/or refractory MAS-HLH.
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5
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Botto LD, Meeths M, Campos-Xavier B, Bergamaschi R, Mazzanti L, Scarano E, Finocchi A, Cancrini C, Zirn B, Kühnle I, Kramm CM, Alanay Y, Jones WD, Irving M, Sabir A, Henter JI, Borgström B, Nordgren A, Hammarsjö A, Putti C, Mozzato C, Zuccarello D, Nishimura G, Bonafè L, Grigelioniene G, Unger S, Superti-Furga A. Chondrodysplasia and growth failure in children after early hematopoietic stem cell transplantation for non-oncologic disorders. Am J Med Genet A 2021; 185:517-527. [PMID: 33398909 DOI: 10.1002/ajmg.a.62021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/10/2020] [Accepted: 11/27/2020] [Indexed: 11/09/2022]
Abstract
Bone dysplasias (osteochondrodysplasias) are a large group of conditions associated with short stature, skeletal disproportion, and radiographic abnormalities of skeletal elements. Nearly all are genetic in origin. We report a series of seven children with similar findings of chondrodysplasia and growth failure following early hematopoietic stem cell transplantation (HSCT) for pediatric non-oncologic disease: hemophagocytic lymphohistiocytosis or HLH (five children, three with biallelic HLH-associated variants [in PRF1 and UNC13D] and one with HLH secondary to visceral Leishmaniasis), one child with severe combined immunodeficiency and one with Omenn syndrome (both children had biallelic RAG1 pathogenic variants). All children had normal growth and no sign of chondrodysplasia at birth and prior to their primary disease. After HSCT, all children developed growth failure, with standard deviation scores for height at or below -3. Radiographically, all children had changes in the spine, metaphyses and epiphyses, compatible with a spondyloepimetaphyseal dysplasia. Genomic sequencing failed to detect pathogenic variants in genes associated with osteochondrodysplasias. We propose that such chondrodysplasia with growth failure is a novel, rare, but clinically important complication following early HSCT for non-oncologic pediatric diseases. The pathogenesis is unknown but could possibly involve loss or perturbation of the cartilage-bone stem cell population.
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Affiliation(s)
- Lorenzo D Botto
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, and Clinical Genetics, Karolinska University Laboratory and Karolinska University Hospital, Stockholm, Sweden.,Theme of Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Belinda Campos-Xavier
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Rosalba Bergamaschi
- Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Laura Mazzanti
- Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Emanuela Scarano
- Department of Pediatrics, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Andrea Finocchi
- Immunology and Infectious Diseases Unit, University-Hospital Pediatric Department (DPUO), Bambino Gesù Children's Hospital, IRCSS, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Caterina Cancrini
- Immunology and Infectious Diseases Unit, University-Hospital Pediatric Department (DPUO), Bambino Gesù Children's Hospital, IRCSS, Rome, Italy.,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Birgit Zirn
- Genetikum Stuttgart, Genetic Counselling and Diagnostics, Stuttgart, Germany
| | - Ingrid Kühnle
- Division of Pediatric Hematology and Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Christof Maria Kramm
- Division of Pediatric Hematology and Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Yasemin Alanay
- Department of Pediatrics, Pediatric Genetics Unit, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Wendy D Jones
- North East Thames Regional Genetics Service, Great Ormond Street Hospital, London, UK
| | - Melita Irving
- Clinical Genetics Department, Guy's and St Thomas' NHS Hospital, London, UK.,Division of Medical and Molecular Genetics, King's College London, UK
| | - Ataf Sabir
- Clinical Genetics Department, Guy's and St Thomas' NHS Hospital, London, UK
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Theme of Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Birgit Borgström
- Department of Oncology-Pathology, Karolinska Institutet, Solna, Sweden
| | - Ann Nordgren
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, and Clinical Genetics, Karolinska University Laboratory and Karolinska University Hospital, Stockholm, Sweden
| | - Anna Hammarsjö
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, and Clinical Genetics, Karolinska University Laboratory and Karolinska University Hospital, Stockholm, Sweden
| | - Caterina Putti
- Pediatric Onco-Hematology Unit, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Chiara Mozzato
- Clinical Genetics and Epidemiology Unit, Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Daniela Zuccarello
- Clinical Genetics and Epidemiology Unit, Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Gen Nishimura
- Center for Intractable Diseases, Saitama Medical University Hospital, Saitama, Japan
| | - Luisa Bonafè
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Giedre Grigelioniene
- Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, and Clinical Genetics, Karolinska University Laboratory and Karolinska University Hospital, Stockholm, Sweden
| | - Sheila Unger
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Andrea Superti-Furga
- Division of Genetic Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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6
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Torralba-Raga L, Tesi B, Chiang SCC, Schlums H, Nordenskjöld M, Horne A, Henter JI, Meeths M, Abdelhaleem M, Weitzman S, Bryceson Y. Diagnostic challenges for a novel SH2D1A mutation associated with X-linked lymphoproliferative disease. Pediatr Blood Cancer 2020; 67:e28184. [PMID: 31994322 DOI: 10.1002/pbc.28184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 12/19/2019] [Accepted: 12/27/2019] [Indexed: 11/10/2022]
Abstract
Mutations in SH2D1A, encoding the intracellular adaptor signaling lymphocyte activation molecule associated protein (SAP), are associated with X-linked lymphoproliferative disease type 1 (XLP1). We identified a novel hemizygous SH2D1A c.49G > A (p.E17K) variant in a 21-year-old patient with fatal Epstein-Barr virus infection-associated hemophagocytic lymphohistiocytosis. Cellular and biochemical assays revealed normal expression of the SAP variant protein, yet binding to phosphorylated CD244 receptor was reduced by >95%. Three healthy brothers carried the SH2D1A c.49G > A variant. Thus, data suggest that this variant represents a pathogenic mutation, but with variable expressivity. Importantly, our results highlight challenges in the clinical interpretation of SH2D1A variants and caution in using functional flow cytometry assays for the diagnosis of XLP1.
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Affiliation(s)
- Lamberto Torralba-Raga
- Department of Medicine, Centre for Hematology and Regenerative Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Bianca Tesi
- Clinical Genetics, Karolinska University Hospital Solna, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Samuel C C Chiang
- Department of Medicine, Centre for Hematology and Regenerative Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Heinrich Schlums
- Department of Medicine, Centre for Hematology and Regenerative Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Magnus Nordenskjöld
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - AnnaCarin Horne
- Department of Women's and Children's Health, Karolinska University Hospital, Stockholm, Sweden.,Paediatric Rheumatology Department, Karolinska University Hospital, Stockholm, Sweden
| | - Jan-Inge Henter
- Clinical Genetics, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Marie Meeths
- Clinical Genetics, Karolinska University Hospital Solna, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mohamed Abdelhaleem
- Department of Paediatric Laboratory Medicine, Hospital for Sick Children, Toronto, Canada
| | - Sheila Weitzman
- Division of Pediatric Hematology/Oncology, The Hospital for Sick Children and the University of Toronto, Toronto, Canada
| | - Yenan Bryceson
- Department of Medicine, Centre for Hematology and Regenerative Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Broegelmann Research Laboratory, Institute of Clinical Sciences, University of Bergen, Bergen, Norway
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7
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Tesch VK, Abolhassani H, Shadur B, Zobel J, Mareika Y, Sharapova S, Karakoc-Aydiner E, Rivière JG, Garcia-Prat M, Moes N, Haerynck F, Gonzales-Granado LI, Santos Pérez JL, Mukhina A, Shcherbina A, Aghamohammadi A, Hammarström L, Dogu F, Haskologlu S, İkincioğulları AI, Köstel Bal S, Baris S, Kilic SS, Karaca NE, Kutukculer N, Girschick H, Kolios A, Keles S, Uygun V, Stepensky P, Worth A, van Montfrans JM, Peters AMJ, Meyts I, Adeli M, Marzollo A, Padem N, Khojah AM, Chavoshzadeh Z, Avbelj Stefanija M, Bakhtiar S, Florkin B, Meeths M, Gamez L, Grimbacher B, Seppänen MRJ, Lankester A, Gennery AR, Seidel MG. Long-term outcome of LRBA deficiency in 76 patients after various treatment modalities as evaluated by the immune deficiency and dysregulation activity (IDDA) score. J Allergy Clin Immunol 2019; 145:1452-1463. [PMID: 31887391 DOI: 10.1016/j.jaci.2019.12.896] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/07/2019] [Accepted: 12/13/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Recent findings strongly support hematopoietic stem cell transplantation (HSCT) in patients with severe presentation of LPS-responsive beige-like anchor protein (LRBA) deficiency, but long-term follow-up and survival data beyond previous patient reports or meta-reviews are scarce for those patients who do not receive a transplant. OBJECTIVE This international retrospective study was conducted to elucidate the longitudinal clinical course of patients with LRBA deficiency who do and do not receive a transplant. METHOD We assessed disease burden and treatment responses with a specially developed immune deficiency and dysregulation activity score, reflecting the sum and severity of organ involvement and infections, days of hospitalization, supportive care requirements, and performance indices. RESULTS Of 76 patients with LRBA deficiency from 29 centers (median follow-up, 10 years; range, 1-52), 24 underwent HSCT from 2005 to 2019. The overall survival rate after HSCT (median follow-up, 20 months) was 70.8% (17 of 24 patients); all deaths were due to nonspecific, early, transplant-related mortality. Currently, 82.7% of patients who did not receive a transplant (43 of 52; age range, 3-69 years) are alive. Of 17 HSCT survivors, 7 are in complete remission and 5 are in good partial remission without treatment (together, 12 of 17 [70.6%]). In contrast, only 5 of 43 patients who did not receive a transplant (11.6%) are without immunosuppression. Immune deficiency and dysregulation activity scores were significantly lower in patients who survived HSCT than in those receiving conventional treatment (P = .005) or in patients who received abatacept or sirolimus as compared with other therapies, and in patients with residual LRBA expression. Higher disease burden, longer duration before HSCT, and lung involvement were associated with poor outcome. CONCLUSION The lifelong disease activity, implying a need for immunosuppression and risk of malignancy, must be weighed against the risks of HSCT.
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Affiliation(s)
- Victoria Katharina Tesch
- Research Unit for Pediatric Hematology and Immunology, Medical University Graz, Graz, Austria; Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Hassan Abolhassani
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden; Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Bella Shadur
- Department of Bone Marrow Transplantation, Hadassah, Hebrew University Medical Centre, Jerusalem, Israel; Garvan Institute of Medical Research, Department of Immunology, Darlinghurst, Australia
| | - Joachim Zobel
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Yuliya Mareika
- Bone Marrow Transplantation Unit, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Svetlana Sharapova
- Research Department, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Elif Karakoc-Aydiner
- Faculty of Medicine, Pediatric Immunology and Allergy Division, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
| | - Jacques G Rivière
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Jeffrey Modell Foundation Excellence Center, Barcelona, Spain
| | - Marina Garcia-Prat
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Jeffrey Modell Foundation Excellence Center, Barcelona, Spain
| | - Nicolette Moes
- Department of Pediatric Gastroenterology, Antwerp University Hospital, Edegem, and Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Filomeen Haerynck
- Primary Immune Deficiency Research Lab and Department of Internal Medicine and Pediatrics, Centre for Primary Immunodeficiency Ghent, Jeffrey Modell Diagnosis and Research Centre, Ghent University Hospital, Ghent, Belgium
| | - Luis I Gonzales-Granado
- Immunodeficiencies Unit, Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (i+12), Madrid, Spain
| | - Juan Luis Santos Pérez
- Infectious Diseases and Immunodeficiencies Unit, Service of Pediatrics, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Anna Mukhina
- Immunology, the Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna Shcherbina
- Immunology, the Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Lennart Hammarström
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Figen Dogu
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Sule Haskologlu
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Aydan I İkincioğulları
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Sevgi Köstel Bal
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria; CeMM Research Center for Molecular Medicine, Austrian Academy of Sciences, Vienna, Austria
| | - Safa Baris
- Faculty of Medicine, Pediatric Immunology and Allergy Division, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
| | - Sara Sebnem Kilic
- Pediatric Immunology-Rheumatology, Medical Faculty Department of Pediatrics, Uludag University Bursa, Bursa, Turkey
| | - Neslihan Edeer Karaca
- Ege University Faculty of Medicine, Department of Pediatric Immunology, Izmir, Turkey
| | - Necil Kutukculer
- Ege University Faculty of Medicine, Department of Pediatric Immunology, Izmir, Turkey
| | - Hermann Girschick
- Children's Hospital, Vivantes Berlin Friedrichshain, Berlin, Germany
| | - Antonios Kolios
- Department of Immunology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Sevgi Keles
- Meram Medical Faculty, Division of Pediatric Allergy and Immunology, Necmettin Erbakan University, Konya, Turkey
| | - Vedat Uygun
- Meram Medical Faculty, Division of Pediatric Allergy and Immunology, Necmettin Erbakan University, Konya, Turkey
| | - Polina Stepensky
- Department of Bone Marrow Transplantation, Hadassah, Hebrew University Medical Centre, Jerusalem, Israel
| | - Austen Worth
- Institute of Child Health, University College London, London, United Kingdom
| | - Joris M van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, Wilhelmina Children's Hospital, UMC Utrecht, The Netherlands
| | - Anke M J Peters
- Department of Pediatric Hematology and Oncology, Center for Pediatrics, Medical Center-University of Freiburg, Freiburg, Germany
| | - Isabelle Meyts
- Department of Pediatrics, University Hospitals Leuven, and the Laboratory for Inborn Errors of Immunity, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Mehdi Adeli
- Sidra Medicine/Hamad Medical Corporation, Doha, Qatar
| | - Antonio Marzollo
- Pediatric Hematology-Oncology Unit, Department of Women's and Children's Health, Azienda Ospedaliera-University of Padova, Padova, Italy
| | - Nurcicek Padem
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Amer M Khojah
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Zahra Chavoshzadeh
- Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Magdalena Avbelj Stefanija
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Shahrzad Bakhtiar
- Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt, Frankfurt, Germany
| | - Benoit Florkin
- Immuno-Hémato-Rhumatologie Pédiatrique, Service de Pédiatrie, CHR Citadelle, Liege, Belgium
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health and Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institute, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Laura Gamez
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bodo Grimbacher
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany; DZIF-German Center for Infection Research, Satellite Center Freiburg, Freiburg, Germany; Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University, Freiburg, Germany; RESIST-Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Freiburg, Germany
| | - Mikko R J Seppänen
- Rare Diseases Center and Pediatric Research Center, Children and Adolescents, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland; Adult Immunodeficiency Unit, Inflammation Center, University of Helsinki, and HUS Helsinki University Hospital, Helsinki, Finland; Translational Immunology, Research Programs Unit and Clinicum, University of Helsinki, Helsinki, Finland
| | - Arjan Lankester
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew R Gennery
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Markus G Seidel
- Research Unit for Pediatric Hematology and Immunology, Medical University Graz, Graz, Austria; Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria.
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8
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Serwas NK, Hoeger B, Ardy RC, Stulz SV, Sui Z, Memaran N, Meeths M, Krolo A, Petronczki ÖY, Pfajfer L, Hou TZ, Halliday N, Santos-Valente E, Kalinichenko A, Kennedy A, Mace EM, Mukherjee M, Tesi B, Schrempf A, Pickl WF, Loizou JI, Kain R, Bidmon-Fliegenschnee B, Schickel JN, Glauzy S, Huemer J, Garncarz W, Salzer E, Pierides I, Bilic I, Thiel J, Priftakis P, Banerjee PP, Förster-Waldl E, Medgyesi D, Huber WD, Orange JS, Meffre E, Sansom DM, Bryceson YT, Altman A, Boztug K. Publisher Correction: Human DEF6 deficiency underlies an immunodeficiency syndrome with systemic autoimmunity and aberrant CTLA-4 homeostasis. Nat Commun 2019; 10:4555. [PMID: 31578334 PMCID: PMC6775104 DOI: 10.1038/s41467-019-12454-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nina K Serwas
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria.,Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Birgit Hoeger
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria.,St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
| | - Rico C Ardy
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Sigrun V Stulz
- Centre for Hematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Zhenhua Sui
- Division of Cell Biology, La Jolla Institute for Allergy & Immunology, La Jolla, CA, 92037, USA
| | - Nima Memaran
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria.,Centre for Paediatrics and Adoloscent Medicine, Hannover Medical School, Hannover, Germany
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Ana Krolo
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Özlem Yüce Petronczki
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Laurène Pfajfer
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria.,Center for Pathophysiology of Toulouse Purpan, INSERM UMR1043, CNRS UMR5282, Paul Sabatier University, Toulouse, France
| | - Tie Z Hou
- Institute of Immunity and Transplantation, Division of Infection & Immunity, School of Life and Medical Sciences, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Neil Halliday
- Institute of Immunity and Transplantation, Division of Infection & Immunity, School of Life and Medical Sciences, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | | | - Artem Kalinichenko
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Alan Kennedy
- Institute of Immunity and Transplantation, Division of Infection & Immunity, School of Life and Medical Sciences, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Emily M Mace
- Department of Pediatrics, Baylor College of Medicine and Center for Human Immunobiology, Texas Children's Hospital, Houston, TX, 77030, USA.,Columbia University Medical Center, Columbia, NY, USA
| | - Malini Mukherjee
- Department of Pediatrics, Baylor College of Medicine and Center for Human Immunobiology, Texas Children's Hospital, Houston, TX, 77030, USA
| | - Bianca Tesi
- Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Anna Schrempf
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Winfried F Pickl
- Institute of Immunology, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Joanna I Loizou
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Renate Kain
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | | | - Jean-Nicolas Schickel
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, 06511, USA
| | - Salomé Glauzy
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, 06511, USA
| | - Jakob Huemer
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Wojciech Garncarz
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Elisabeth Salzer
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Iro Pierides
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Ivan Bilic
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria.,Takeda (Shire), Vienna, Austria
| | - Jens Thiel
- Department of Rheumatology and Clinical Immunology, University Medical Center Freiburg, Freiburg, 79106, Germany
| | - Peter Priftakis
- Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Pinaki P Banerjee
- Department of Pediatrics, Baylor College of Medicine and Center for Human Immunobiology, Texas Children's Hospital, Houston, TX, 77030, USA.,MD Anderson Cancer Center, Houston, TX, USA
| | - Elisabeth Förster-Waldl
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Medical University of Vienna, Vienna, Austria
| | - David Medgyesi
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Wolf-Dietrich Huber
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Jordan S Orange
- Department of Pediatrics, Baylor College of Medicine and Center for Human Immunobiology, Texas Children's Hospital, Houston, TX, 77030, USA.,Columbia University Medical Center, Columbia, NY, USA
| | - Eric Meffre
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, 06511, USA
| | - David M Sansom
- Institute of Immunity and Transplantation, Division of Infection & Immunity, School of Life and Medical Sciences, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Yenan T Bryceson
- Centre for Hematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Amnon Altman
- Division of Cell Biology, La Jolla Institute for Allergy & Immunology, La Jolla, CA, 92037, USA
| | - Kaan Boztug
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria. .,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria. .,St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria. .,Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria. .,St. Anna Kinderspital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria.
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9
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Löfstedt A, Ahlm C, Tesi B, Bergdahl IA, Nordenskjöld M, Bryceson YT, Henter JI, Meeths M. Haploinsufficiency of UNC13D increases the risk of lymphoma. Cancer 2019; 125:1848-1854. [PMID: 30758854 PMCID: PMC6593970 DOI: 10.1002/cncr.32011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/10/2018] [Accepted: 12/27/2018] [Indexed: 12/19/2022]
Abstract
Background Experimental models have demonstrated that immune surveillance by cytotoxic lymphocytes can protect from spontaneous neoplasms and cancer. In humans, defective lymphocyte cytotoxicity is associated with the development of hemophagocytic lymphohistiocytosis, a hyperinflammatory syndrome. However, to the best of the authors’ knowledge, the degree to which human lymphocyte cytotoxicity protects from cancer remains unclear. In the current study, the authors examined the risk of lymphoma attributable to haploinsufficiency in a gene required for lymphocyte cytotoxicity. Methods The authors exploited a founder effect of an UNC13D inversion, which abolishes Munc13‐4 expression and causes hemophagocytic lymphohistiocytosis in an autosomal recessive manner. Within 2 epidemiological screening programs in northern Sweden, an area demonstrating a founder effect of this specific UNC13D mutation, all individuals with a diagnosis of lymphoma (487 patients) and matched controls (1844 controls) were assessed using polymerase chain reaction for carrier status. Results Among 487 individuals with lymphoma, 15 (3.1%) were heterozygous carriers of the UNC13D inversion, compared with 18 controls (1.0%) (odds ratio, 3.0; P = .002). It is interesting to note that a higher risk of lymphoma was attributed to female carriers (odds ratio, 3.7; P = .004). Conclusions Establishing a high regional prevalence of the UNC13D inversion, the authors have reported an overrepresentation of this mutation in individuals with lymphoma. Therefore, the results of the current study indicate that haploinsufficiency of a gene required for lymphocyte cytotoxicity can predispose patients to lymphoma, suggesting the importance of cytotoxic lymphocyte‐mediated surveillance of cancer. Furthermore, the results of the current study suggest that female carriers are more susceptible to lymphoma. In the current study, the authors examine the risk of lymphoma attributable to an inversion disrupting UNC13D, a gene associated with familial hemophagocytic lymphohistiocytosis. The results demonstrate that haploinsufficiency of this gene, which is required for normal lymphocyte cytotoxicity, may predispose patients to lymphoma, signifying the importance of cytotoxic lymphocyte‐mediated surveillance of cancer development.
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Affiliation(s)
- Alexandra Löfstedt
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Clas Ahlm
- Infectious Diseases, Department of Clinical Microbiology, Umeå University, Umeå, Sweden
| | - Bianca Tesi
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Magnus Nordenskjöld
- Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Yenan T Bryceson
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.,Theme of Children's and Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Theme of Children's and Women's Health, Karolinska University Hospital, Stockholm, Sweden
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10
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Seidel MG, Böhm K, Dogu F, Worth A, Thrasher A, Florkin B, İkincioğulları A, Peters A, Bakhtiar S, Meeths M, Stepensky P, Meyts I, Sharapova SO, Gámez-Díaz L, Hammarström L, Ehl S, Grimbacher B, Gennery AR. Treatment of severe forms of LPS-responsive beige-like anchor protein deficiency with allogeneic hematopoietic stem cell transplantation. J Allergy Clin Immunol 2017; 141:770-775.e1. [PMID: 28502825 DOI: 10.1016/j.jaci.2017.04.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 03/24/2017] [Accepted: 04/03/2017] [Indexed: 01/10/2023]
Affiliation(s)
- Markus G Seidel
- Research Unit of Pediatric Hematology and Immunology, Division of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Gwraz, Graz, Austria.
| | - Katrin Böhm
- Research Unit of Pediatric Hematology and Immunology, Division of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Gwraz, Graz, Austria
| | - Figen Dogu
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Austen Worth
- Institute of Child Health, University College London, London, United Kingdom
| | - Adrian Thrasher
- Institute of Child Health, University College London, London, United Kingdom
| | - Benoit Florkin
- Immuno-Hémato-Rhumatologie Pédiatrique, Service de Pédiatrie, CHR Citadelle, Liege, Belgium
| | - Aydan İkincioğulları
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Anke Peters
- Department of Pediatrics and Adolescent Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Shahrzad Bakhtiar
- Division for Pediatric Stem-Cell Transplantation and Immunology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health and Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Polina Stepensky
- Department of Bone Marrow Transplantation, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Isabelle Meyts
- Department of Pediatric Immunology, Microbiology and Immunology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Svetlana O Sharapova
- Research Department, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk Region, Belarus
| | - Laura Gámez-Díaz
- Center for Chronic Immunodeficiency (CCI), Medical Center, University of Freiburg, Freiburg, Germany
| | - Lennart Hammarström
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Stephan Ehl
- Department of Pediatrics and Adolescent Medicine, Medical Center, University of Freiburg, Freiburg, Germany; Center for Chronic Immunodeficiency (CCI), Medical Center, University of Freiburg, Freiburg, Germany
| | - Bodo Grimbacher
- Center for Chronic Immunodeficiency (CCI), Medical Center, University of Freiburg, Freiburg, Germany
| | - Andrew R Gennery
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
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11
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Chiang SCC, Wood SM, Tesi B, Akar HH, Al-Herz W, Ammann S, Belen FB, Caliskan U, Kaya Z, Lehmberg K, Patiroglu T, Tokgoz H, Ünüvar A, Introne WJ, Henter JI, Nordenskjöld M, Ljunggren HG, Meeths M, Ehl S, Krzewski K, Bryceson YT. Differences in Granule Morphology yet Equally Impaired Exocytosis among Cytotoxic T Cells and NK Cells from Chediak-Higashi Syndrome Patients. Front Immunol 2017; 8:426. [PMID: 28458669 PMCID: PMC5394158 DOI: 10.3389/fimmu.2017.00426] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 03/27/2017] [Indexed: 12/31/2022] Open
Abstract
Chediak–Higashi syndrome (CHS) is caused by autosomal recessive mutations in LYST, resulting in enlarged lysosomal compartments in multiple cell types. CHS patients display oculocutaneous albinism and may develop life-threatening hemophagocytic lymphohistiocytosis (HLH). While NK cell-mediated cytotoxicity has been reported to be uniformly defective, variable defects in T cell-mediated cytotoxicity has been observed. The latter has been linked to the degree of HLH susceptibility. Since the discrepancies in NK cell- and T cell-mediated cellular cytotoxicity might result from differences in regulation of cytotoxic granule release, we here evaluated perforin-containing secretory lysosome size and number in freshly isolated lymphocytes from CHS patients and furthermore compared their exocytic capacities. Whereas NK cells from CHS patients generally contained a single, gigantic perforin-containing granule, cytotoxic T cells predominantly contained several smaller granules. Nonetheless, in a cohort of 21 CHS patients, cytotoxic T cell and NK cell granule exocytosis were similarly impaired upon activating receptor stimulation. Mechanistically, polarization of cytotoxic granules was defective in cytotoxic lymphocytes from CHS patients, with EEA1, a marker of early endosomes, mislocalizing to lysosomal structures. The results leads to the conclusion that lysosome enlargement corresponds to loss of distinct organelle identity in the endocytic pathway, which on a subcellular level more adversely affects NK cells than T cells. Hence, vesicular size or numbers do not per se dictate the impairment of lysosomal exocytosis in the two cell types studied.
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Affiliation(s)
- Samuel C C Chiang
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Stephanie M Wood
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Bianca Tesi
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Karolinska University Hospital Solna, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Himmet Haluk Akar
- Faculty of Medicine, Department of Pediatric Immunology, Erciyes University, Kayseri, Turkey
| | - Waleed Al-Herz
- Department of Pediatrics, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Sandra Ammann
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Fatma Burcu Belen
- Izmir Katip Celebi University Medical Faculty, Department of Pediatric Hematology and Oncology, Izmir Tepecik Training and Research Hospital, Izmir, Turkey
| | - Umran Caliskan
- Meram Faculty of Medicine, Department of Pediatric Hematology, Necmettin Erbakan University, Konya, Turkey
| | - Zühre Kaya
- Pediatric Hematology Unit of the Department of Pediatrics, Medical School of Gazi University, Ankara, Turkey
| | - Kai Lehmberg
- Department of Pediatric Hematology and Oncology, Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Turkan Patiroglu
- Faculty of Medicine, Department of Pediatric Immunology, Erciyes University, Kayseri, Turkey
| | - Huseyin Tokgoz
- Meram Faculty of Medicine, Department of Pediatric Hematology, Necmettin Erbakan University, Konya, Turkey
| | - Ayşegül Ünüvar
- Division of Pediatric Hematology and Oncology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Wendy J Introne
- Office of the Clinical Director, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Magnus Nordenskjöld
- Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Hans-Gustaf Ljunggren
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Stephan Ehl
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Konrad Krzewski
- Receptor Cell Biology Section, Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Yenan T Bryceson
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Broegelmann Research Laboratory, Department of Clinical Sciences, University of Bergen, Bergen, Norway
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Tesi B, Priftakis P, Lindgren F, Chiang SCC, Kartalis N, Löfstedt A, Lörinc E, Henter JI, Winiarski J, Bryceson YT, Meeths M. Successful Hematopoietic Stem Cell Transplantation in a Patient with LPS-Responsive Beige-Like Anchor (LRBA) Gene Mutation. J Clin Immunol 2016; 36:480-9. [PMID: 27146671 DOI: 10.1007/s10875-016-0289-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 04/21/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE Autosomal recessive mutations in LRBA, encoding for LPS-responsive beige-like anchor protein, were described in patients with a common variable immunodeficiency (CVID)-like disease characterized by hypogammaglobulinemia, autoimmune cytopenias, and enteropathy. Here, we detail the clinical, immunological, and genetic features of a patient with severe autoimmune manifestations. METHODS Whole exome sequencing was performed to establish a molecular diagnosis. Evaluation of lymphocyte subsets was performed for immunological characterization. Medical files were reviewed to collect clinical and immunological data. RESULTS A 7-year-old boy, born to consanguineous parents, presented with autoimmune hemolytic anemia, hepatosplenomegaly, autoimmune thyroiditis, and severe autoimmune gastrointestinal manifestations. Immunological investigations revealed low immunoglobulin levels and low numbers of B and NK cells. Treatment included immunoglobulin replacement and immunosuppressive therapy. Seven years after disease onset, the patient developed severe neurological symptoms resembling acute disseminated encephalomyelitis, prompting allogeneic hematopoietic stem cell transplantation (HSCT) with the HLA-identical mother as donor. Whole exome sequencing of the patient uncovered a homozygous 1 bp deletion in LRBA (c.7162delA:p.T2388Pfs*7). Importantly, during 2 years of follow-up post-HSCT, marked clinical improvement and recovery of immune function was observed. CONCLUSIONS Our data suggest a beneficial effect of HSCT in patients with LRBA deficiency.
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Affiliation(s)
- Bianca Tesi
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden. .,Clinical Genetics Unit, Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.
| | - Peter Priftakis
- Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Fredrik Lindgren
- Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Department of Clinical Science Intervention and Technology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Samuel C C Chiang
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Nikolaos Kartalis
- Department of Clinical Science Intervention and Technology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Department of Radiology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Alexandra Löfstedt
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Esther Lörinc
- Department of Pathology, University Hospital Karolinska Huddinge, Solna, Sweden.,Department of Pathology, Skåne University Hospital, Lund, Sweden
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Jacek Winiarski
- Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Department of Clinical Science Intervention and Technology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Yenan T Bryceson
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden. .,Clinical Genetics Unit, Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.
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13
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Tesi B, Lagerstedt-Robinson K, Chiang SCC, Ben Bdira E, Abboud M, Belen B, Devecioglu O, Fadoo Z, Yeoh AEJ, Erichsen HC, Möttönen M, Akar HH, Hästbacka J, Kaya Z, Nunes S, Patiroglu T, Sabel M, Saribeyoglu ET, Tvedt TH, Unal E, Unal S, Unuvar A, Meeths M, Henter JI, Nordenskjöld M, Bryceson YT. Targeted high-throughput sequencing for genetic diagnostics of hemophagocytic lymphohistiocytosis. Genome Med 2015; 7:130. [PMID: 26684649 PMCID: PMC4684627 DOI: 10.1186/s13073-015-0244-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/11/2015] [Indexed: 01/06/2023] Open
Abstract
Background Hemophagocytic lymphohistiocytosis (HLH) is a rapid-onset, potentially fatal hyperinflammatory syndrome. A prompt molecular diagnosis is crucial for appropriate clinical management. Here, we validated and prospectively evaluated a targeted high-throughput sequencing approach for HLH diagnostics. Methods A high-throughput sequencing strategy of 12 genes linked to HLH was validated in 13 patients with previously identified HLH-associated mutations and prospectively evaluated in 58 HLH patients. Moreover, 2504 healthy individuals from the 1000 Genomes project were analyzed in silico for variants in the same genes. Results Analyses revealed a mutation detection sensitivity of 97.3 %, an average coverage per gene of 98.0 %, and adequate coverage over 98.6 % of sites previously reported as mutated in these genes. In the prospective cohort, we achieved a diagnosis in 22 out of 58 patients (38 %). Genetically undiagnosed HLH patients had a later age at onset and manifested higher frequencies of known secondary HLH triggers. Rare, putatively pathogenic monoallelic variants were identified in nine patients. However, such monoallelic variants were not enriched compared with healthy individuals. Conclusions We have established a comprehensive high-throughput platform for genetic screening of patients with HLH. Almost all cases with reduced natural killer cell function received a diagnosis, but the majority of the prospective cases remain genetically unexplained, highlighting genetic heterogeneity and environmental impact within HLH. Moreover, in silico analyses of the genetic variation affecting HLH-related genes in the general population suggest caution with respect to interpreting causality between monoallelic mutations and HLH. A complete understanding of the genetic susceptibility to HLH thus requires further in-depth investigations, including genome sequencing and detailed immunological characterization. Electronic supplementary material The online version of this article (doi:10.1186/s13073-015-0244-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bianca Tesi
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden. .,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - Kristina Lagerstedt-Robinson
- Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Samuel C C Chiang
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-14186, Stockholm, Sweden
| | - Eya Ben Bdira
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Miguel Abboud
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon
| | - Burcu Belen
- Department of Pediatric Hematology, Izmir Katip Celebi University Medical Faculty, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Omer Devecioglu
- Department of Pediatric Hematology Oncology, Istanbul Medical School, Istanbul, Turkey
| | - Zehra Fadoo
- Department of Oncology and Pediatrics, Aga Khan University, Karachi, Pakistan
| | - Allen E J Yeoh
- Viva-University Children's Cancer Centre, Department of Paediatric, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Merja Möttönen
- Department of Pediatrics and Adolescence, PEDEGO Research Unit, Oulu University Hospital, Oulu, Finland
| | - Himmet Haluk Akar
- Department of Pediatric Immunology, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Johanna Hästbacka
- Department of Perioperative and Intensive Care, Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - Zuhre Kaya
- Pediatric Hematology Unit of the Department of Pediatrics, Medical School of Gazi University, Ankara, Turkey
| | - Susana Nunes
- Hematology-Oncology Unit, Department of Pediatrics, São João Hospital Center, Oporto, Portugal
| | - Turkan Patiroglu
- Department of Pediatric Immunology, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Magnus Sabel
- Institute of Clinical Sciences, Department of Pediatrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Ebru Tugrul Saribeyoglu
- Department of Pediatric Hematology and Oncology and Bone Marrow Transplantation Unit, Medipol School of Medicine, Medipol University, Istanbul, Turkey
| | - Tor Henrik Tvedt
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ekrem Unal
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Sule Unal
- Department of Pediatrics, Division of Pediatric Hematology, Ankara, Turkey
| | - Aysegul Unuvar
- Division of Pediatric Hematology and Oncology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, SE-17176, Stockholm, Sweden
| | - Magnus Nordenskjöld
- Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Yenan T Bryceson
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-14186, Stockholm, Sweden. .,Broegelmann Research Laboratory, The Gades Institute, University of Bergen, Bergen, Norway.
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14
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Löfstedt A, Chiang SCC, Onelöv E, Bryceson YT, Meeths M, Henter JI. Cancer risk in relatives of patients with a primary disorder of lymphocyte cytotoxicity: a retrospective cohort study. Lancet Haematol 2015; 2:e536-42. [PMID: 26686408 DOI: 10.1016/s2352-3026(15)00223-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 09/22/2015] [Accepted: 10/05/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Mutations in genes for perforin-dependent lymphocyte cytotoxicity are associated with haemophagocytic lymphohistiocytosis, a rare disease of severe hyperinflammation that typically becomes evident in early childhood. It has been suggested that individuals with hypomorphic biallelic mutations in genes associated with haemophagocytic lymphohistiocytosis are at increased risk of developing haematological malignancies. We aimed to assess whether relatives of patients with primary haemophagocytic lymphohistiocytosis (ie, heterozygous carriers of these mutated genes) were more likely to develop cancer. METHODS In this retrospective cohort study, we used a multigeneration registry to identify relatives (parents and grandparents) of 79 Swedish children (<15 years) with primary haemophagocytic lymphohistiocytosis diagnosed between 1971 and 2011. For each relative, we randomly selected eight matched individuals from the Swedish total population registry, stratified for sex, birth year, and birth region. Relatives and matched controls were cross-linked with the Swedish Cancer Registry to establish cancer incidence rate. We then calculated the incidence rate ratio between first-degree and second-degree relatives and the matched controls. Additionally, we assessed natural-killer-cell-mediated cytotoxicity in a subgroup of first-degree relatives using standard 4 h (51)Cr assay and flow cytometry quantification of the upregulation of surface CD107a. FINDINGS We identified 346 first-degree and second-degree relatives from 67 families (67 mothers, 66 fathers, 106 grandmothers, and 107 grandfathers) and 2768 matched controls. Median follow-up was 49 years, range 0-54 years. By death or last follow-up (Dec 31, 2012), first-degree relatives had a significantly increased incidence rate of malignancies than did controls (incidence rate per 1000 person-years 2.78 [95% CI 1.42-4.15] vs 1.56 [1.16-1.95]; incidence rate ratio 1.79 [95% CI 1.06-3.03]; p=0.030). Mothers had a particularly increased risk (incidence rate per 1000 person-years 4.43 [95% CI 1.99-6.87] vs 1.60 [1.08-2.11]; incidence rate ratio 2.78 [95% CI 1.48-5.21]; p=0.0014), whereas no difference was found between fathers and controls (1.24 [0.00-2.51] vs 1.52 [0.89-2.15]; 0.82 [0.29-2.29]; p=0.70) or between grandparents and controls (7.24 [5.44-9.04] vs 6.36 [5.70-7.03]; 1.14 [0.88-1.48]; p=0.33). Functional analysis of heterozygous carriers of mutations associated with haemophagocytic lymphohistiocytosis could not show significantly reduced lymphocyte cytotoxicity. INTERPRETATION Heterozygous mutations in genes associated with haemophagocytic lymphohistiocytosis might be a new risk factor for cancer. The increased risk of cancer might imply haploinsufficiency of cytotoxic lymphocyte-mediated immunosurveillance of cancer in carriers of these mutations. Our findings might support intensified screening for malignancies in relatives of patients with haemophagocytic lymphohistiocytosis. FUNDING Swedish Children's Cancer Foundation, Swedish Research Council, Histiocytosis Association, Swedish Cancer Society, Swedish Cancer and Allergy Foundation, Mary Béve Foundation, Karolinska Institutet Research Foundation, Stockholm County Council (ALF-project).
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Affiliation(s)
- Alexandra Löfstedt
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden; Clinical Genetics Unit, Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Samuel C C Chiang
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Erik Onelöv
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Yenan T Bryceson
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden; Clinical Genetics Unit, Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.
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15
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Tesi B, Chiang SCC, El-Ghoneimy D, Hussein AA, Langenskiöld C, Wali R, Fadoo Z, Silva JP, Lecumberri R, Unal S, Nordenskjöld M, Bryceson YT, Henter JI, Meeths M. Spectrum of Atypical Clinical Presentations in Patients with Biallelic PRF1 Missense Mutations. Pediatr Blood Cancer 2015; 62:2094-100. [PMID: 26184781 DOI: 10.1002/pbc.25646] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 06/02/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Perforin, encoded by PRF1, is a pore-forming protein crucial for lymphocyte cytotoxicity. Biallelic PRF1 nonsense mutations invariably result in early-onset hemophagocytic lymphohistiocytosis (HLH), termed familial HLH type 2 (FHL2). In contrast, biallelic PRF1 missense mutations may give rise to later-onset disease and more variable manifestations. PROCEDURE We retrospectively searched our database for patients from families with siblings carrying biallelic PRF1 missense mutations where at least one sibling did not develop HLH, and for patients with biallelic PRF1 missense mutations and an atypical presentation of disease. We reviewed their clinical, genetic, and immunological characteristics. RESULTS In all, we identified 10 such patients, including three sibling pairs with discordant manifestations. Interestingly, in two families, siblings of late-onset HLH patients developed Hodgkin lymphoma but no HLH. In a third family, one sibling presented with recurrent HLH episodes, whereas the other remains healthy. Of note, the affected sibling also suffered from systemic lupus erythematosus. Additional unrelated patients with biallelic PRF1 missense mutations were affected by neurological disease without classical signs of HLH, gastrointestinal inflammation as initial presentation of disease, as well as a hematological malignancy. Compared to early-onset FHL2 patients, the patients with an atypical presentation displayed a partial recovery of NK cell cytotoxicity upon IL-2 stimulation in vitro. CONCLUSIONS Our findings substantiate and expand the spectrum of clinical presentations of perforin deficiency, linking PRF1 missense mutations to lymphoma susceptibility and highlighting clinical variability within families. PRF1 mutations should, therefore, be considered as a cause of several diseases disparate to HLH.
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Affiliation(s)
- Bianca Tesi
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Samuel C C Chiang
- Department of Medicine, Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Dalia El-Ghoneimy
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Ayad Ahmed Hussein
- Bone Marrow and Stem Cell Transplantation Program, King Hussein Cancer Center, Amman, Jordan
| | - Cecilia Langenskiöld
- Department of Women's and Children's Health, Queen Silviás Childreńs Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Rabia Wali
- Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, Pakistan
| | - Zehra Fadoo
- Department of Oncology and Pediatrics, Aga Khan University, Karachi, Pakistan
| | - João Pinho Silva
- Institute for Research and Innovation on Health and Center for Predictive and Preventive Genetics of the IBMC-Institute for Cell and Molecular Biology, University of Porto, Portugal
| | - Ramón Lecumberri
- Hematology Service, University Clinic of Navarra, Pamplona, Spain
| | - Sule Unal
- Division of Pediatric Hematology, Hacettepe University, Ankara, Turkey
| | - Magnus Nordenskjöld
- Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Yenan T Bryceson
- Department of Medicine, Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
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16
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Meeths M, Horne A, Sabel M, Bryceson YT, Henter JI. Incidence and clinical presentation of primary hemophagocytic lymphohistiocytosis in Sweden. Pediatr Blood Cancer 2015; 62:346-352. [PMID: 25382070 DOI: 10.1002/pbc.25308] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 09/19/2014] [Indexed: 01/26/2023]
Abstract
BACKGROUND Primary hemophagocytic lymphohistiocytosis (HLH) represents a group of inherited hyperinflammatory immunodeficiencies, including familial HLH (FHL), Griscelli syndrome type 2 (GS2), and X-linked lymphoproliferative syndrome (XLP). We previously reported an annual incidence of suspected primary HLH in Sweden 1971-1986 of 0.12 per 100,000 children. Here, we determined if the incidence had increased with concomitant awareness. PROCEDURE Children <15 years old presenting with HLH 1987-2006 in Sweden were identified through the national mortality registry as well as by nation-wide inquiries to all pediatric centers. HLH was diagnosed according to the HLH-2004 diagnostic guidelines (in case of missing data of at least three of the eight diagnostic criteria, fulfillment of four was sufficient for inclusion). We defined primary HLH as patients presenting with HLH requiring transplantation or dying of disease. RESULTS Remarkably, the minimal annual incidence rate of primary HLH remained 0.12 per 100,000 children, equating to 1.8 per 100,000 live births. Notably, an increased overall survival was observed in 1997-2006, relative to the period 1987-1996. During the subsequent 5-year period, 2007-2011, the incidence of genetically and/or functionally verified primary HLH was 0.15 per 100,000 children per year, suggesting that new assays may aid the identification of patients with primary HLH. CONCLUSION The annual incidence of primary HLH in Sweden is 0.12-0.15 per 100,000 children per year. Pediatr Blood Cancer 2015;62:346-352. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - AnnaCarin Horne
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Magnus Sabel
- Department of Women's and Children's Health, University of Gothenburg, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Yenan T Bryceson
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Broegelmann Research Laboratory, Department of Clinical Sciences, Univerisity of Bergen, Bergen, Norway
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
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Hussein AA, Hamadah T, Qandeel M, Sughayer M, Amarin R, Mansour A, Chiang SC, Al-Zaben A, Meeths M, Bryceson YT. Hematopoietic stem cell transplantation of an adolescent with neurological manifestations of homozygous missense PRF1 mutation. Pediatr Blood Cancer 2014; 61:2313-5. [PMID: 25110876 DOI: 10.1002/pbc.25166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 06/10/2014] [Indexed: 11/06/2022]
Abstract
Individuals with biallelic truncating PRF1 mutations typically present with fulminant early-onset familial hemophagocytic lymphohistiocytosis (FHL). We report a 19-year-old male with a 5-year history of recurrent fever and headaches progressing to refractory seizures. Brain imaging revealed multiple ring enhancing lesions. Laboratory investigations demonstrated that the patient displayed defective lymphocyte cytotoxicity and carried a homozygous missense PRF1 mutation, c.394G > A (p.Gly132Arg). The patient was successfully treated with chemo-immunotherapy followed by matched related allogeneic hematopoietic stem cell transplantation (HSCT). Our findings demonstrate that prompt HSCT of late-onset FHL with primarily neurological manifestation can reverse central nervous system symptoms and improve long-term outcome.
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Affiliation(s)
- Ayad Ahmed Hussein
- Bone Marrow and Stem Cell Transplantation Program, King Hussein Cancer Center, Amman, Jordan
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18
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Borte S, Meeths M, Liebscher I, Krist K, Nordenskjöld M, Hammarström L, von Döbeln U, Henter JI, Bryceson YT. Combined newborn screening for familial hemophagocytic lymphohistiocytosis and severe T- and B-cell immunodeficiencies. J Allergy Clin Immunol 2014; 134:226-8. [DOI: 10.1016/j.jaci.2014.04.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 04/24/2014] [Accepted: 04/29/2014] [Indexed: 01/25/2023]
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19
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Cichocki F, Schlums H, Li H, Stache V, Holmes T, Lenvik TR, Chiang SCC, Miller JS, Meeths M, Anderson SK, Bryceson YT. Transcriptional regulation of Munc13-4 expression in cytotoxic lymphocytes is disrupted by an intronic mutation associated with a primary immunodeficiency. ACTA ACUST UNITED AC 2014; 211:1079-91. [PMID: 24842371 PMCID: PMC4042637 DOI: 10.1084/jem.20131131] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A conserved regulatory element in intron 1 of UNC13D regulates Munc13-4 expression. Autosomal recessive mutations in UNC13D, the gene that encodes Munc13-4, are associated with familial hemophagocytic lymphohistiocytosis type 3 (FHL3). Munc13-4 expression is obligatory for exocytosis of lytic granules, facilitating cytotoxicity by T cells and natural killer (NK) cells. The mechanisms regulating Munc13-4 expression are unknown. Here, we report that Munc13-4 is highly expressed in differentiated human NK cells and effector CD8+ T lymphocytes. A UNC13D c.118-308C>T mutation, causative of FHL3, disrupted binding of the ETS family member ELF1 to a conserved intronic sequence. This mutation impairs UNC13D intron 1 recruitment of STAT4 and the chromatin remodeling complex component BRG1, diminishing active histone modifications at the locus. The intronic sequence acted as an overall enhancer of Munc13-4 expression in cytotoxic lymphocytes in addition to representing an alternative promoter encoding a novel Munc13-4 isoform. Mechanistically, T cell receptor engagement facilitated STAT4-dependent Munc13-4 expression in naive CD8+ T lymphocytes. Collectively, our data demonstrates how chromatin remodeling within an evolutionarily conserved regulatory element in intron 1 of UNC13D regulates the induction of Munc13-4 expression in cytotoxic lymphocytes and suggests that an alternative Munc13-4 isoform is required for lymphocyte cytotoxicity. Thus, mutations associated with primary immunodeficiencies may cause disease by disrupting transcription factor binding.
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Affiliation(s)
- Frank Cichocki
- Centre for Infectious Medicine, Department of Medicine; Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden Division of Hematology, Oncology and Transplantation, University of Minnesota Cancer Center, Minneapolis, MN 55455
| | - Heinrich Schlums
- Centre for Infectious Medicine, Department of Medicine; Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden
| | - Hongchuan Li
- Basic Science Program, Leidos Biomedical Research, Inc., Laboratory of Experimental Immunology, SAIC-Frederick Inc., Frederick National Laboratory, Frederick, MD 21702
| | - Vanessa Stache
- Centre for Infectious Medicine, Department of Medicine; Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden
| | - Timothy Holmes
- Centre for Infectious Medicine, Department of Medicine; Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden
| | - Todd R Lenvik
- Division of Hematology, Oncology and Transplantation, University of Minnesota Cancer Center, Minneapolis, MN 55455
| | - Samuel C C Chiang
- Centre for Infectious Medicine, Department of Medicine; Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden
| | - Jeffrey S Miller
- Division of Hematology, Oncology and Transplantation, University of Minnesota Cancer Center, Minneapolis, MN 55455
| | - Marie Meeths
- Centre for Infectious Medicine, Department of Medicine; Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, 171 76 Stockholm, Sweden
| | - Stephen K Anderson
- Basic Science Program, Leidos Biomedical Research, Inc., Laboratory of Experimental Immunology, SAIC-Frederick Inc., Frederick National Laboratory, Frederick, MD 21702
| | - Yenan T Bryceson
- Centre for Infectious Medicine, Department of Medicine; Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden Broegelmann Research Laboratory, Clinical Institute, University of Bergen, N-5021 Bergen, Norway
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20
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Müller ML, Chiang SCC, Meeths M, Tesi B, Entesarian M, Nilsson D, Wood SM, Nordenskjöld M, Henter JI, Naqvi A, Bryceson YT. An N-Terminal Missense Mutation in STX11 Causative of FHL4 Abrogates Syntaxin-11 Binding to Munc18-2. Front Immunol 2014; 4:515. [PMID: 24459464 PMCID: PMC3890652 DOI: 10.3389/fimmu.2013.00515] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 12/27/2013] [Indexed: 01/02/2023] Open
Abstract
Familial hemophagocytic lymphohistiocytosis (FHL) is an often-fatal hyperinflammatory disorder caused by autosomal recessive mutations in PRF1, UNC13D, STX11, and STXBP2. We identified a homozygous STX11 mutation, c.173T > C (p.L58P), in three patients presenting clinically with hemophagocytic lymphohistiocytosis from unrelated Pakistani families. The mutation yields an amino acid substitution in the N-terminal Habc domain of syntaxin-11 and resulted in defective natural killer cell degranulation. Notably, syntaxin-11 expression was decreased in patient cells. However, in an ectopic expression system, syntaxin-11 L58P was expressed at levels comparable to wild-type syntaxin-11, but did not bind Munc18-2. Moreover, another N-terminal syntaxin-11 mutant, R4A, also did not bind Munc18-2. Thus, we have identified a novel missense STX11 mutation causative of FHL type 4. The syntaxin-11 R4A and L58P mutations reveal that both the N-terminus and Habc domain of syntaxin-11 are required for binding to Munc18-2, implying similarity to the dynamic binary binding of neuronal syntaxin-1 to Munc18-1.
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Affiliation(s)
- Martha-Lena Müller
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge , Stockholm , Sweden
| | - Samuel C C Chiang
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge , Stockholm , Sweden
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna , Stockholm , Sweden ; Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital Solna , Stockholm , Sweden
| | - Bianca Tesi
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna , Stockholm , Sweden ; Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital Solna , Stockholm , Sweden
| | - Miriam Entesarian
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna , Stockholm , Sweden ; Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital Solna , Stockholm , Sweden
| | - Daniel Nilsson
- Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital Solna , Stockholm , Sweden ; Science for Life Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm , Sweden
| | - Stephanie M Wood
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge , Stockholm , Sweden
| | - Magnus Nordenskjöld
- Clinical Genetics Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital Solna , Stockholm , Sweden
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna , Stockholm , Sweden
| | - Ahmed Naqvi
- Division of Hematology and Oncology, Hospital for Sick Children , Toronto, ON , Canada
| | - Yenan T Bryceson
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge , Stockholm , Sweden ; Broegelmann Research Laboratory, Institute of Clinical Sciences, University of Bergen , Bergen , Norway
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21
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Entesarian M, Chiang SCC, Schlums H, Meeths M, Chan MY, Mya SN, Soh SY, Nordenskjöld M, Henter JI, Bryceson YT. Novel deep intronic and missenseUNC13Dmutations in familial haemophagocytic lymphohistiocytosis type 3. Br J Haematol 2013; 162:415-8. [DOI: 10.1111/bjh.12371] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
| | - Samuel C. C. Chiang
- Centre for Infectious Medicine; Department of Medicine; Karolinska Institutet; Karolinska University Hospital Huddinge; Stockholm; Sweden
| | - Heinrich Schlums
- Centre for Infectious Medicine; Department of Medicine; Karolinska Institutet; Karolinska University Hospital Huddinge; Stockholm; Sweden
| | | | - Mei-Yoke Chan
- Haematology/Oncology Service; Department of Paediatric Subspecialties; KK Women's and Children's Hospital; Singapore
| | - Soe-Nwe Mya
- Haematology/Oncology Service; Department of Paediatric Subspecialties; KK Women's and Children's Hospital; Singapore
| | - Shui-Yen Soh
- Haematology/Oncology Service; Department of Paediatric Subspecialties; KK Women's and Children's Hospital; Singapore
| | - Magnus Nordenskjöld
- Clinical Genetics Unit; Department of Molecular Medicine and Surgery, and Centre for Molecular Medicine; Karolinska Institutet; Karolinska University Hospital Solna; Stockholm; Sweden
| | - Jan-Inge Henter
- Childhood Cancer Research Unit; Department of Women's and Children's Health; Karolinska Institutet; Karolinska University Hospital Solna; Stockholm; Sweden
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22
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Machaczka M, Klimkowska M, Chiang SCC, Meeths M, Müller ML, Gustafsson B, Henter JI, Bryceson YT. Development of classical Hodgkin's lymphoma in an adult with biallelic STXBP2 mutations. Haematologica 2012; 98:760-4. [PMID: 23100279 DOI: 10.3324/haematol.2012.073098] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Experimental model systems have delineated an important role for cytotoxic lymphocytes in the immunosurveillance of cancer. In humans, perforin-deficiency has been associated with occurrence of hematologic malignancies. Here, we describe an Epstein-Barr virus-positive classical Hodgkin's lymphoma in a patient harboring biallelic mutations in STXBP2, a gene required for exocytosis of perforin-containing lytic granules and associated with familial hemophagocytic lymphohistocytosis. Cytotoxic T lymphocytes were found infiltrating the tumor, and a high frequency of Epstein-Barr virus-specific cytotoxic T lymphocytes were detected in peripheral blood. However, lytic granule exocytosis and cytotoxicity by cytotoxic T lymphocytes, as well as natural killer cells, were severely impaired in the patient. Thus, the data suggest a link between defective lymphocyte exocytosis and development of lymphoma in STXBP2-deficient patients. Therefore, with regards to treatment of familial hemophagocytic lymphohistocytosis patients with mutations in genes required for lymphocyte exocytosis, it is important to consider both the risks of hemophagocytic lymphohistocytosis and malignancy.
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Affiliation(s)
- Maciej Machaczka
- Division of Hematology, Department of Medicine, Karolinska Institutet, and Hematology Center Karolinska, Karolinska University Hospital Huddinge, Stockholm, Sweden.
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23
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Macartney CA, Weitzman S, Wood SM, Bansal D, Steele M, Meeths M, Abdelhaleem M, Bryceson YT. Unusual functional manifestations of a novel STX11 frameshift mutation in two infants with familial hemophagocytic lymphohistiocytosis type 4 (FHL4). Pediatr Blood Cancer 2011; 56:654-7. [PMID: 21298754 DOI: 10.1002/pbc.22676] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 05/05/2010] [Indexed: 02/01/2023]
Abstract
Familial hemophagocytic lymphohistiocytosis (FHL) is typically an autosomal recessive, early-onset, life-threatening immune disorder. Loss-of-function mutations in STX11 have been found to impair NK cell degranulation and cytotoxicity. Here, we describe two unrelated infants of Punjabi descent presenting with FHL and carrying a novel, homozygous STX11 frameshift mutation [c.867dupG]. Western blot analysis indicated absence of syntaxin-11. Unexpectedly, degranulation by NK cells from one of the patients was not impaired, although patient NK cells showed mildly and significantly decreased cytotoxicity, respectively. Importantly, these observations imply that STX11 should be sequenced in HLH patients even when impaired NK cell degranulation is not found.
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Affiliation(s)
- Christine A Macartney
- The Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Sieni E, Cetica V, Santoro A, Beutel K, Mastrodicasa E, Meeths M, Ciambotti B, Brugnolo F, zur Stadt U, Pende D, Moretta L, Griffiths GM, Henter JI, Janka G, Aricò M. Genotype-phenotype study of familial haemophagocytic lymphohistiocytosis type 3. J Med Genet 2011; 48:343-52. [PMID: 21248318 DOI: 10.1136/jmg.2010.085456] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mutations of UNC13D are causative for familial haemophagocytic lymphohistiocytosis type 3 (FHL3; OMIM 608898). OBJECTIVE To carry out a genotype-phenotype study of patients with FHL3. METHODS A consortium of three countries pooled data on presenting features and mutations from individual patients with biallelic UNC13D mutations in a common database. RESULTS 84 patients with FHL3 (median age 4.1 months) were reported from Florence, Italy (n=54), Hamburg, Germany (n=18), Stockholm, Sweden (n=12). Their ethnic origin was Caucasian (n=57), Turkish (n=10), Asian (n=7), Hispanic (n=4), African (n=3) (not reported (n=3)). Thrombocytopenia was present in 94%, splenomegaly in 96%, fever in 89%. The central nervous system (CNS) was involved in 49/81 (60%) patients versus 36% in patients with FHL2 (p=0.001). A combination of fever, splenomegaly, thrombocytopenia and hyperferritinaemia was present in 71%. CD107a expression, NK activity and Munc 13-4 protein expression were absent or reduced in all but one of the evaluated patients. 54 different mutations were observed, including 15 new ones: 19 missense, 14 deletions or insertions, 12 nonsense, nine splice errors. None was specific for ethnic groups. Patients with two disruptive mutations were younger than patients with two missense mutations (p<0.001), but older than comparable patients with FHL2 (p=0.001). CONCLUSION UNC13D mutations are scattered over the gene. Ethnic-specific mutations were not identified. CNS involvement is more common than in FHL2; in patients with FHL3 and disruptive mutations, age at diagnosis is significantly higher than in FHL2. The combination of fever, splenomegaly, thrombocytopenia and hyperferritinaemia appears to be the most easily and frequently recognised clinical pattern and their association with defective granule release assay may herald FHL3.
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Affiliation(s)
- Elena Sieni
- Department of Pediatric Hematology and Oncology, Azienda Ospedaliero-Universitaria Meyer, Florence, Italy
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25
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Meeths M, Bryceson YT, Rudd E, Zheng C, Wood SM, Ramme K, Beutel K, Hasle H, Heilmann C, Hultenby K, Ljunggren HG, Fadeel B, Nordenskjöld M, Henter JI. Clinical presentation of Griscelli syndrome type 2 and spectrum of RAB27A mutations. Pediatr Blood Cancer 2010; 54:563-72. [PMID: 19953648 DOI: 10.1002/pbc.22357] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Griscelli syndrome type 2 (GS2) is an autosomal-recessive immunodeficiency caused by mutations in RAB27A, clinically characterized by partial albinism and haemophagocytic lymphohistocytosis (HLH). We evaluated the frequency of RAB27A mutations in 21 unrelated patients with haemophagocytic syndromes without mutations in familial HLH (FHL) causing genes or an established diagnosis of GS2. In addition, we report three patients with known GS2. Moreover, neurological involvement and RAB27A mutations in previously published patients with genetically verified GS2 are reviewed. PROCEDURE Mutation analysis of RAB27A was performed by direct DNA sequencing. NK cell activity was evaluated and microscopy of the hair was performed to confirm the diagnosis. RESULTS RAB27A mutations were found in 1 of the 21 families. This Swedish family had three affected children with heterozygous compound mutations consisting of a novel splice error mutation, [c.239G>C], and a nonsense mutation, [c.550C>T], p.R184X. The three additional children all carried homozygous RAB27A mutations, one of which is a novel splice error mutation, [c.240-2A>C]. Of note, five of the six patients displayed neurological symptoms, while three out of six patients displayed NK cell activity within normal reference values, albeit low. A literature review revealed that 67% of GS2 patients have been reported with neurological manifestations. CONCLUSIONS Identification of RAB27A mutations can facilitate prompt diagnosis and treatment, and aid genetic counselling and prenatal diagnosis. Since five of six patients studied herein initially were diagnosed as having FHL, we conclude that the diagnosis of GS2 may be overlooked, particularly in fair-haired patients with haemophagocytic syndromes.
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Affiliation(s)
- Marie Meeths
- Childhood Cancer Research Unit, Department of Woman and Child Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.
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26
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Rudd E, Meeths M, Uysal Z, Nordenskjöld M, Henter JI, Fadeel B. Multiple inherited sequence variations in two disease-causing genes in familial haemophagocytic lymphohistiocytosis. Br J Haematol 2009; 146:218-20. [DOI: 10.1111/j.1365-2141.2009.07729.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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27
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Trottestam H, Beutel K, Meeths M, Carlsen N, Heilmann C, Pasić S, Webb D, Hasle H, Henter JI. Treatment of the X-linked lymphoproliferative, Griscelli and Chédiak-Higashi syndromes by HLH directed therapy. Pediatr Blood Cancer 2009; 52:268-72. [PMID: 18937330 DOI: 10.1002/pbc.21790] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Griscelli syndrome type 2 (GS2), the X-linked lymphoproliferative (XLP) and the Chédiak-Higashi (CHS) syndromes are diseases that all may develop hemophagocytic syndromes. We wanted to investigate whether the treatment protocols for hemophagocytic lymphohistiocytosis (HLH) can also be used for these syndromes. PROCEDURE In the HLH-94/HLH-2004 treatment study registries, we evaluated all patients with GS2 (n = 5), XLP (n = 2) or CHS (n = 2) treated between 1994 and 2004. RESULTS All patients responded to the therapy, and all are alive but one (suffering from CHS), with a mean follow-up of 5.6 years. All GS2, one XLP and one CHS patient underwent hematopoietic stem cell transplant. Mean follow-up post transplant was 6.0 years. Six of the seven transplanted children achieved non-active disease status at the time for SCT. Neurological sequelae were reported in all, except for the XLP patients. CONCLUSIONS Our results indicate that HLH treatment can be an effective first line treatment to induce remission in patients with GS2, XLP and CHS that have developed a hemophagocytic syndrome. We suggest that these patients should be included as a separate cohort in the international HLH study.
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Affiliation(s)
- Helena Trottestam
- Childhood Cancer Research Unit, Karolinska University Hospital, Department of Woman and Child Health, Karolinska Institutet, Stockholm, Sweden.
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28
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Chan CB, Abe M, Hashimoto N, Hao C, Williams IR, Liu X, Nakao S, Yamamoto A, Zheng C, Henter JI, Meeths M, Nordenskjold M, Li SY, Hara-Nishimura I, Asano M, Ye K. Mice lacking asparaginyl endopeptidase develop disorders resembling hemophagocytic syndrome. Proc Natl Acad Sci U S A 2009; 106:468-73. [PMID: 19106291 PMCID: PMC2626726 DOI: 10.1073/pnas.0809824105] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Indexed: 11/18/2022] Open
Abstract
Asparaginyl endopeptidase (AEP or legumain) is a lysosomal cysteine protease that cleaves protein substrates on the C-terminal side of asparagine. AEP plays a pivotal role in the endosome/lysosomal degradation system and is implicated in antigen processing. The processing of the lysosomal proteases cathepsins in kidney is completely defective in AEP-deficient mice with accumulation of macromolecules in the lysosomes, which is typically seen in lysosomal disorders. Here we show that mutant mice lacking AEP develop fever, cytopenia, hepatosplenomegaly, and hemophagocytosis, which are primary pathological manifestations of hemophagocytic syndrome/hemophagocytic lymphohistiocytosis (HLH). Moreover, AEP deficiency provokes extramedullary hematopoiesis in the spleen and abnormally enlarged histiocytes with ingested red blood cells (RBCs) in bone marrow. Interestingly, RBCs from AEP-null mice are defective in plasma membrane components. Further, AEP-null mice display lower natural killer cell activity, but none of the major cytokines is substantially abnormal. These results indicate that AEP might be a previously unrecognized component in HLH pathophysiology.
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Affiliation(s)
- Chi-Bun Chan
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322
| | - Michiyo Abe
- Division of Transgenic Animal Science, Advanced Science Research Center, and
| | - Noriyoshi Hashimoto
- Division of Transgenic Animal Science, Advanced Science Research Center, and
| | - Chunhai Hao
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322
| | - Ifor R. Williams
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322
| | - Xia Liu
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322
| | - Shinji Nakao
- Department of Cellular Transplantation Biology, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8640, Japan
| | - Akitsugu Yamamoto
- Department of Bio-Science, Nagahama Institute of Bio-Science and Technology, 1266 Tamura-machi, Nagahama 526-0829, Japan; and
| | - Chengyun Zheng
- Department of Woman and Child Health, Childhood Cancer Research Unit, and
- Department of Molecular Medicine and Surgery, Clinical Genetics Unit, Karolinska Institute, Karolinska University Hospital, SE-141 86 Stockholm, Sweden
| | - Jan-Inge Henter
- Department of Woman and Child Health, Childhood Cancer Research Unit, and
| | - Marie Meeths
- Department of Woman and Child Health, Childhood Cancer Research Unit, and
- Department of Molecular Medicine and Surgery, Clinical Genetics Unit, Karolinska Institute, Karolinska University Hospital, SE-141 86 Stockholm, Sweden
| | - Magnus Nordenskjold
- Department of Molecular Medicine and Surgery, Clinical Genetics Unit, Karolinska Institute, Karolinska University Hospital, SE-141 86 Stockholm, Sweden
| | - Shi-Yong Li
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322
| | - Ikuko Hara-Nishimura
- Department of Botany, Graduate School of Science, Kyoto University, Kitashirakawa, Sakyo-ku, Kyoto 606-8502, Japan
| | - Masahide Asano
- Division of Transgenic Animal Science, Advanced Science Research Center, and
| | - Keqiang Ye
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322
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