Transient immune deficiency accompanied with homozygous CBL rare variant

BACKGROUND

CBL plays a critical role in cellular proliferation. Germline heterozygous CBL variants give rise to CBL syndrome, which is phenotypically similar to RASopathy. Somatic mutations in CBL have been reported in patients with juvenile myelomonocytic leukemia (JMML).

METHODS

Exome analysis was performed in a patient with immunodeficiency who developed Pneumocystis jirovecii pneumonia.

RESULTS

Exome analysis identified a homozygous CBL missense variant. Cell biological analysis of this CBL variant confirmed attenuated function.

CONCLUSION

Spontaneous regression of hematological proliferation has been observed in patients with CBL mutated JMML and in patients with CBL syndrome. Intriguingly, immunological impairment was spontaneously ameliorated by aging in this patient.

Dysregulation of Epstein-Barr Virus Infection in Hypomorphic ZAP70 Mutation

Background

Some patients with genetic defects develop Epstein-Barr virus (EBV)-associated lymphoproliferative disorder (LPD)/lymphoma as the main feature. Hypomophic mutations can cause different clinical and laboratory manifestations from null mutations in the same genes.

Methods

We sought to describe the clinical and immunologic phenotype of a 21-month-old boy with EBV-associated LPD who was in good health until then. A genetic and immunologic analysis was performed.

Results

Whole-exome sequencing identified a novel compound heterozygous mutation of ZAP70 c.703-1G>A and c.1674G>A. A small amount of the normal transcript was observed. Unlike ZAP70 deficiency, which has been previously described as severe combined immunodeficiency with nonfunctional CD4+ T cells and absent CD8+ T cells, the patient had slightly low numbers of CD8+ T cells and a small amount of functional T cells. EBV-specific CD8+ T cells and invariant natural killer T (iNKT) cells were absent. The T-cell receptor repertoire, determined using next generation sequencing, was significantly restricted.

Conclusions

Our patient showed that a hypomorphic mutation of ZAP70 can lead to EBV-associated LPD and that EBV-specific CD8+ T cells and iNKT cells are critically involved in immune response against EBV infection.

Epstein-Barr Virus-Associated γδ T-Cell Lymphoproliferative Disorder Associated With Hypomorphic IL2RG Mutation

Chronic active Epstein-Barr virus (EBV) infection (CAEBV) is an EBV-associated lymphoproliferative disease characterized by repeated or sustainable infectious mononucleosis (IM)-like symptoms. EBV is usually detected in B cells in patients who have IM or Burkitt's lymphoma and even in patients with X-linked lymphoproliferative syndrome, which is confirmed to have vulnerability to EBV infection. In contrast, EBV infects T cells (CD4⁺ T, CD8⁺ T, and γδT) or NK cells mono- or oligoclonally in CAEBV patients. It is known that the CAEBV phenotypes differ depending on which cells are infected with EBV. CAEBV is postulated to be associated with a genetic immunological abnormality, although its cause remains undefined. Here we describe a case of EBV-related γδT-cell proliferation with underlying hypomorphic IL2RG mutation. The immunological phenotype consisted of γδT-cell proliferation in the peripheral blood. A presence of EBV-infected B cells and γδT cells mimicked γδT-cell-type CAEBV. Although the patient had normal expression of CD132 (common γ chain), the phosphorylation of STAT was partially defective, indicating impaired activation of the downstream signal of the JAK/STAT pathway. Although the patient was not diagnosed as having CAEBV, this observation shows that CAEBV might be associated with immunological abnormality.

Clinical and Immunological Characterization of ICF Syndrome in Japan

OBJECTIVE

Immunodeficiency, centromeric instability, and facial anomalies (ICF) syndrome is a rare autosomal recessive primary immunodeficiency. Hypogammaglobulinemia is a major manifestation of ICF syndrome, but immunoglobulin replacement therapy does not seem to be effective for some ICF patients. Therefore, we aimed to reassess the immunological characteristics of this syndrome.

METHODS

Eleven Japanese patients with ICF syndrome were enrolled. We performed whole-exome sequencing in four cases and homozygosity mapping using SNP analysis in two. We evaluated their clinical manifestations and immunological status.

RESULTS

We newly diagnosed six ICF patients who had tentatively been diagnosed with common variable immunodeficiency. We identified two novel mutations in the DNMT3B gene and one novel mutation in the ZBTB24 gene. All patients showed low serum IgG and/or IgG2 levels and were treated by periodic immunoglobulin replacement therapy. Three of the six patients showed worse results of the mitogen-induced lymphocyte proliferation test. Analyses of lymphocyte subpopulations revealed that CD19+CD27+ memory B cells were low in seven of nine patients, CD3+ T cells were low in three patients, CD4/8 ratio was inverted in five patients, CD31+ recent thymic emigrant cells were low in two patients, and CD19+ B cells were low in four patients compared with those in the normal controls. ICF2 patients showed lower proportions of CD19+ B cells and CD16+56+ NK cells and significantly higher proportions of CD3+ T cells than ICF1 patients. T cell receptor excision circles were undetectable in two patients. Despite being treated by immunoglobulin replacement therapy, three patients died of influenza virus, fatal viral infection with persistent Epstein-Barr virus infection, or JC virus infection. One of three dead patients showed normal intelligence with mild facial anomaly. Two patients presented with autoimmune or inflammatory manifestations. Infectious episodes decreased in three patients who were started on trimethoprim-sulfamethoxazole and/or antifungal drugs in addition to immunoglobulin replacement therapy. These patients might have suffered from T cell immunodeficiency.

CONCLUSION

These results indicate that patients with ICF syndrome have a phenotype of combined immunodeficiency. Thus, to achieve a better prognosis, these patients should be treated as having combined immunodeficiency in addition to receiving immunoglobulin replacement therapy.

Droplet Digital PCR-Based Chimerism Analysis for Primary Immunodeficiency Diseases

OBJECTIVE

In the current study, we aimed to accurately evaluate donor/recipient or male/female chimerism in samples from patients who underwent hematopoietic stem cell transplantation (HSCT).

METHODS

We designed the droplet digital polymerase chain reaction (ddPCR) for SRY and RPP30 to detect the male/female chimerism. We also developed mutation-specific ddPCR for four primary immunodeficiency diseases.

RESULTS

The accuracy of the male/female chimerism analysis using ddPCR was confirmed by comparing the results with those of conventional methods (fluorescence in situ hybridization and short tandem repeat-PCR) and evaluating dilution assays. In particular, we found that this method was useful for analyzing small samples. Thus, this method could be used with patient samples, especially to sorted leukocyte subpopulations, during the early post-transplant period. Four mutation-specific ddPCR accurately detected post-transplant chimerism.

CONCLUSION

ddPCR-based male/female chimerism analysis and mutation-specific ddPCR were useful for all HSCT, and these simple methods contribute to following the post-transplant chimerism, especially in disease-specific small leukocyte fractions.

Enhanced AKT Phosphorylation of Circulating B Cells in Patients With Activated PI3Kδ Syndrome

Activated PI3Kδ syndrome (APDS) is a primary immunodeficiency characterized by recurrent respiratory tract infections, lymphoproliferation, and defective IgG production. Heterozygous mutations in PIK3CD, PIK3R1, or PTEN, which are related to the hyperactive phosphoinositide 3-kinase (PI3K) signaling, were recently presented to cause APDS1 or APDS2 (APDSs), or APDS-like (APDS-L) disorder. In this study, we examined the AKT phosphorylation of peripheral blood lymphocytes and monocytes in patients with APDSs and APDS-L by using flow cytometry. CD19⁺ B cells of peripheral blood in APDS2 patients showed the enhanced phosphorylation of AKT at Ser473 (pAKT) without any specific stimulation. The enhanced pAKT in CD19⁺ B cells was normalized by the addition of a p110δ inhibitor. In contrast, CD3⁺ T cells and CD14⁺ monocytes did not show the enhanced pAKT in the absence of stimulation. These findings were similarly observed in patients with APDS1 and APDS-L. Among CD19⁺ B cells, enhanced pAKT was prominently detected in CD10⁺ immature B cells compared with CD10⁻ mature B cells. Enhanced pAKT was not observed in B cells of healthy controls, patients with common variable immunodeficiency, and hyper IgM syndrome due to CD40L deficiency. These results suggest that the enhanced pAKT in circulating B cells may be useful for the discrimination of APDS1, APDS2, and APDS-L from other antibody deficiencies.

Maternal T and B cell engraftment in two cases of X-linked severe combined immunodeficiency with IgG1 gammopathy

X-linked severe combined immunodeficiency (X-SCID), caused by defects in the common gamma chain, is typically characterized by T and NK cell defects with the presence of B cells. T cell dysfunction and impaired class-switch recombination of B cells mean that patients typically have defects in class-switched immunoglobulins (IgG, IgA, and IgE) with detectable IgM. Here, we describe two patients with X-SCID with IgG1 gammopathy, in whom we identified maternal T and B cell engraftment. Exclusively, maternal B cells were found among the IgD^-CD27⁺ class-switched memory B cells, whereas the patients' B cells remained naïve. In vitro stimulation with CD40L+IL-21 revealed that peripheral blood cells from both patients produced only IgG1. Class-switched maternal B cells had restricted receptor repertoires with various constant regions and few somatic hypermutations. In conclusion, engrafted maternal B cells underwent class-switch recombination and produced immunoglobulin, causing hypergammaglobulinemia in patients with X-SCID.

The ubiquitin ligase ZNRF1 promotes caveolin-1 ubiquitination and degradation to modulate inflammation

Caveolin-1 (CAV1), the major constituent of caveolae, plays a pivotal role in various cellular biological functions, including cancer and inflammation. The ubiquitin/proteasomal pathway is known to contribute to the regulation of CAV1 expression, but the ubiquitin ligase responsible for CAV1 protein stability remains unidentified. Here we reveal that E3 ubiquitin ligase ZNRF1 modulates CAV1 protein stability to regulate Toll-like receptor (TLR) 4-triggered immune responses. We demonstrate that ZNRF1 physically interacts with CAV1 in response to lipopolysaccharide and mediates ubiquitination and degradation of CAV1. The ZNRF1-CAV1 axis regulates Akt-GSK3β activity upon TLR4 activation, resulting in enhanced production of pro-inflammatory cytokines and inhibition of anti-inflammatory cytokine IL-10. Mice with deletion of ZNRF1 in their hematopoietic cells display increased resistance to endotoxic and polymicrobial septic shock due to attenuated inflammation. Our study defines ZNRF1 as a regulator of TLR4-induced inflammatory responses and reveals another mechanism for the regulation of TLR4 signalling through CAV1.

Phosphatase and tensin homolog (PTEN) mutation can cause activated phosphatidylinositol 3-kinase δ syndrome-like immunodeficiency

BACKGROUND

Activated phosphatidylinositol 3-kinase δ syndrome (APDS) is a recently discovered primary immunodeficiency disease (PID). Excess phosphatidylinositol 3-kinase (PI3K) activity linked to mutations in 2 PI3K genes, PIK3CD and PIK3R1, causes APDS through hyperphosphorylation of AKT, mammalian target of rapamycin (mTOR), and S6.

OBJECTIVE

This study aimed to identify novel genes responsible for APDS.

METHODS

Whole-exome sequencing was performed in Japanese patients with PIDs. Immunophenotype was assessed through flow cytometry. Hyperphosphorylation of AKT, mTOR, and S6 in lymphocytes was examined through immunoblotting, flow cytometry, and multiplex assays.

RESULTS

We identified heterozygous mutations of phosphatase and tensin homolog (PTEN) in patients with PIDs. Immunoblotting and quantitative PCR analyses indicated that PTEN expression was decreased in these patients. Patients with PTEN mutations and those with PIK3CD mutations, including a novel E525A mutation, were further analyzed. The clinical symptoms and immunologic defects of patients with PTEN mutations, including lymphocytic AKT, mTOR, and S6 hyperphosphorylation, resemble those of patients with APDS. Because PTEN is known to suppress the PI3K pathway, it is likely that defective PTEN results in activation of the PI3K pathway.

CONCLUSION

PTEN loss-of-function mutations can cause APDS-like immunodeficiency because of aberrant PI3K pathway activation in lymphocytes.

The use of IKK inhibitor as a lymphocyte depleting agent (47.4)

Purposes: Transcription factor NF-κB and its activating kinase IκB Kinase β (IKKβ) are critical for inflammation and innate immunity. In our previoius report, MLN120B, an IKKβ inhibitor, would cause neutrophilia in mice but their peripheral blood lymphocyte numbers were not affected. We tried other IKK inhibitors; however, we found that feeding with BMS-345541, a highly selective IKKβ inhibitor, would cause lymphopenia in mice. We explored the possibility of BMS-345541 as a therapeutic agent in depleting lymphocytes. Results: To characterize how BMS-345541 affects lymphocyte homeostatsis, C57BL/6 mice received vehicle, or BMS-345541 oral gavage once daily at different dose (10, 25, 50, and 100 mg/kg body weight in 3% Tween 80), and mice were sacrificed on day 3 or day 5. We collected the peripheral blood for blood cell counts and also collected spleen and lymphnodes for histology examination. The lymphocytes, but not neutrophils, were significantly decreased in mice received BMS-345541. Our preliminary results showed that the effect of BMS-345541 on lymphocytes were through apoptosis rather than trapping the lymphocytes in lymphoid organs. BMS-345541 affected both T cells and B cells. Conclusion: We conclude that oral administration of BMS-345541 would reduce lymphocyte counts and could be helpful in depleting lymphocytes in circulation, which would be useful as a therapeutic agent for lymphoproliferative disorder.

The role of IL-1β on IKKβ inhibitors induced neutrophilia (116.4)

Transcription factor NF-κB and its activating kinase IκB Kinase β (IKKβ) are critical for inflammation and immunity. Pharmacological inhibitors of IKKβ-NF-κB could be used for the treatment of inflammation. It was unexpected that IKKβ inhibitors (MLN120B) cause neutrophilia in mice but the mechanism remained unknown. IL-1β acted as a growth factor for myeloid progenitors and a survival factor for mature neutrophils. We tried to investigate the role of IL-1β on IKKβ inhibitors induced neutrophilia. Using conditional deletion of loxP-flanked Ikbkb alleles in myeloid cells in mice, we found severe neutrophilia after IKKβ deletion. Without any stimulus, Ikkβ-deleted mice produced more circulating IL-1β than age-matched wild-type mice. Isolated Ikkβ-deleted monocytes and macrophages secreted higher amounts of IL-1β than wild-type controls without stimulation. Treatment of wild-type mice with IKKβ inhibitors also led to neutrophilia within 8 days, which would be prevented by concomitant treatment with IL-1 receptor antagonis. Neutrophilia in mice after deletion of IKKβ seems IL-1β dependent. Excessive IL-1β signaling is responsible for the uncontrolled neutrophilia and inflammation in IKKβ-deleted mice. Enhanced IL-1β production represents a compensatory mechanism for maintaining immunity when NF-κB is inhibited and compensates for loss of NF-κB-dependent antibacterial immunity.

Influence of morning or evening administration on absorption of theophylline

BACKGROUND

Bronchoconstriction during the night causing nocturnal and early morning wheezing is recognized as a major problem for asthmatics. Oral sustained-release theophyllines (SRTs) were developed to reduce the symptoms. A circadian variation in theophylline kinetics has been demonstrated with many SRTs. The purpose of this study was to evaluate the differences in serum theophylline concentration (STC) caused by morning or evening dosing of Euphyllin Retard, a brand of SRT, for a period of 36 hours following oral administration.

METHODS

A total of nine non-smoking healthy male volunteers were involved in the study, with a two-period crossover comparison. They were randomly divided into two groups. The first group took a single oral dose of 350 mg Euphyllin Retard at 8:00 A.M. and the second group took it at 8:00 P.M. Blood samples were collected during the 36 hours following administration. Two weeks later, the first group took the drug at night and the second group took it in the morning. The difference in the absorption of theophylline with daytime administration versus night-time administration was assessed using pharmacokinetic parameters derived from the plasma drug concentration vs time curve.

RESULTS

The means of unextrapolated area under the concentration vs time curve (AUC) from time 0 to 24 hours (AUCUN) and of the extrapolated AUC from time 0 to infinity (AUCEX) in the night phase were higher than those in the day phase (62.403 micrograms/ml/hr vs 53.081 micrograms/ml/hr, p = 0.9186; 107.21 micrograms/ml/hr vs 98.879 micrograms/ml/hr, p = 0.8807, respectively). The mean of maximum concentration (Cmax) was higher in the night phase than that in the day phase (4.166 micrograms/dl vs 3.451 micrograms/dl, p = 0.9234). Daytime administration showed a delayed time to maximum concentration (Tmax) when compared to that of night-time administration (6.5 hr vs 5.75 hr, p = 0.6244). The terminal elimination rate constant (Kel) was lower in the day phase than in the night phase (0.053 l/hr vs 0.06 l/hr, p = 0.7601). The day phase and night phase data are combined data from the two night and two day groups. The statistical analysis of the results show that the time of administration does not influence the STC.

CONCLUSIONS

No diurnal variation in theophylline kinetics was found with Euphyllin Retard. This study was performed in a limited number of normal healthy subjects, and the same result is yet to be proved in asthmatic patients and a larger population of normal subjects.