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Gazzin A, Pala F, Bosticardo M, Niemela J, Stoddard J, Biasin E, Quarello P, Carli D, Ferroni F, Delmonte OM, Montin D, Rosenzweig SD, Licciardi F, Notarangelo LD. Mulibrey nanism and immunological complications: a comprehensive case report and literature review. Front Immunol 2023; 14:1303251. [PMID: 38116000 PMCID: PMC10728670 DOI: 10.3389/fimmu.2023.1303251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/20/2023] [Indexed: 12/21/2023] Open
Abstract
Introduction Mulibrey nanism (MUL) is a rare disorder caused by TRIM37 gene variants characterized by growth failure, dysmorphic features, congestive heart failure (CHF), and an increased risk of Wilms' tumor. Although immune system impairment has been documented in MUL, the underlying mechanisms remain poorly understood. Methods We present a case of MUL with progressive lymphopenia and review similar cases from the literature. Results Our patient presented with prenatal onset growth restriction, characteristic dysmorphic features, and Wilms' tumor. She developed progressive lymphopenia starting at 10 years of age, leading to the initiation of intravenous immunoglobulin (IVIG) replacement therapy and infection prophylaxis. Genetic analysis detected a likely pathogenic variant on the maternal allele and copy number loss on the paternal allele in TRIM37. Subsequently a cardiac magnetic resonance imaging was conducted revealing signs of pericardial constriction raising concerns for intestinal lymphatic losses. The cessation of IVIG therapy did not coincide with any increase in the rate of infections. The patient exhibited a distinct immunological profile, characterized by hypogammaglobulinemia, impaired antibody responses, and skewed T-cell subsets with an altered CD4+/CD8+ ratio, consistent with previous reports. Normal thymocyte development assessed by artificial thymic organoid platform ruled out an early hematopoietic intrinsic defect of T-cell development. Discussion The immunological profile of MUL patients reported so far shares similarities with that described in protein-losing enteropathy secondary to CHF in Fontan circulation and primary intestinal lymphangiectasia. These similarities include hypogammaglobulinemia, significant T-cell deficiency with decreased CD4+ and CD8+ counts, altered CD4+/CD8+ ratios, and significantly modified CD4+ and CD8+ T-cell phenotypes toward effector and terminal differentiated T cells, accompanied by a loss of naïve CD45RA+ T lymphocytes. In MUL, CHF is a cardinal feature, occurring in a significant proportion of patients and influencing prognosis. Signs of CHF or constrictive pericarditis have been evident in the case reported here and in all cases of MUL with documented immune dysfunction reported so far. These observations raise intriguing connections between these conditions. However, further investigation is warranted to in-depth define the immunological defect, providing valuable insights into the pathophysiology and treatment strategies for this condition.
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Affiliation(s)
- Andrea Gazzin
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, United States
- Postgraduate School of Pediatrics, University of Torino, Turin, Italy
| | - Francesca Pala
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, United States
| | - Marita Bosticardo
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, United States
| | - Julie Niemela
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Jennifer Stoddard
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Eleonora Biasin
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children’s Hospital, Turin, Italy
| | - Paola Quarello
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children’s Hospital, Turin, Italy
| | - Diana Carli
- Immunogenetics and Transplant Biology Unit, Città della Salute e della Scienza University Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Francesca Ferroni
- Department of Pediatric Cardiology, City of Health and Science University Hospital, Turin, Italy
| | - Ottavia M. Delmonte
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, United States
| | - Davide Montin
- Department of Public Health and Pediatrics, University of Turin, Pediatria Specialistica U, “Regina Margherita” Children Hospital, Turin, Italy
| | - Sergio D. Rosenzweig
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Francesco Licciardi
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy
| | - Luigi D. Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, United States
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Ellsworth S, Balmanoukian A, Kos F, Nirschl CJ, Nirschl TR, Grossman SA, Luznik L, Drake CG. Sustained CD4 + T cell-driven lymphopenia without a compensatory IL-7/IL-15 response among high-grade glioma patients treated with radiation and temozolomide. Oncoimmunology 2014; 3:e27357. [PMID: 24790790 PMCID: PMC4004618 DOI: 10.4161/onci.27357] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 11/27/2013] [Indexed: 11/19/2022] Open
Abstract
Prolonged lymphopenia correlating with decreased survival commonly occurs among glioma patients undergoing radiation therapy (RT) and temozolomide (TMZ) treatment. To better understand the pathophysiology of this phenomenon, we prospectively monitored serum cytokine levels and lymphocyte subsets in 15 high-grade glioma patients undergoing combined radiation and TMZ (referred to as RT/TMZ) treatment. Sufficient data for analysis were acquired from 11 of the patients initially enrolled. Lymphocyte phenotyping data were obtained using cytofluorometric analysis and serum cytokine levels were measured using the a multiplex bead-based assays. Total lymphocyte counts (TLCs) were > 1000 cells per μL peripheral blood in 10/11 patients at baseline, but dropped significantly after treatment. Specifically, after RT/TMZ therapy, the TLCs were found to be < 500 cells/μL in 2/11 patients, 500-1000 cells/μL in 7/11 patients, and > 1000 cells/μL in the remaining 2 patients. Among residual mononuclear blood cells, we observed a proportional drop in B and CD4+ T cells but not in CD8+ T lymphocytes. Natural killer cells remained to near-to-baseline levels and there was a transient and slight (insignificant) increase in regulatory T cells (Tregs). The circulating levels of IL-7 and IL-15 remained low despite marked drops in both the total and CD4+ T lymphocyte counts. Thus, patients with malignant glioma undergoing RT/TMZ treatment exhibit a marked decline in TLCs, affecting both CD4+ T cells and B lymphocytes, in the absence of a compensatory increase in interleukin-7 levels. The failure to mount an appropriate homeostatic cytokine response may be responsible for the prolonged lymphopenia frequently observed in these patients.
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Affiliation(s)
- Susannah Ellsworth
- Department of Radiation Oncology and Molecular Radiation Sciences; Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center; Baltimore, MD USA
| | - Ani Balmanoukian
- Department of Radiation Oncology and Molecular Radiation Sciences; Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center; Baltimore, MD USA
| | | | - Christopher J Nirschl
- Department of Medical Oncology; Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center; Baltimore, MD USA
| | - Thomas R Nirschl
- Department of Medical Oncology; Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center; Baltimore, MD USA
| | - Stuart A Grossman
- Department of Medical Oncology; Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center; Baltimore, MD USA
| | - Leo Luznik
- Department of Medical Oncology; Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center; Baltimore, MD USA
| | - Charles G Drake
- Department of Medical Oncology; Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center; Baltimore, MD USA
- James Buchanan Brady Urological Institute; Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center; Baltimore, MD USA
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