Autosomal Dominant hyper-IgE Syndrome Research Articles

Extracellular Vesicles based STAT3 delivery as innovative therapeutic approach to restore STAT3 signaling deficiency

Extracellular Vesicles (EVs) have been proposed as a promising tool for drug delivery because of their natural ability to cross biological barriers, protect their cargo, and target specific cells. Moreover, EVs are not recognized by the immune system as foreign, reducing the risk of an immune response and enhancing biocompatibility. Herein, we proposed an alternative therapeutic strategy to restore STAT3 signaling exploiting STAT3 loaded EVs. This approach could be useful in the treatment of Autosomal Dominant Hyper-IgE Syndrome (AD-HIES), a rare primary immunodeficiency and multisystem disorder due to the presence of mutations in STAT3 gene. These mutations alter the signal transduction of STAT3, thereby impeding Th17 CD4+ cell differentiation that leads to the failure of immune response. We set up a simple and versatile method in which EVs were loaded with fully functional STAT3 protein. Moreover, our method allows to follow the uptake of STAT3 loaded vesicles inside cells due to the presence of EGFP in the EGFP-STAT3 fusion protein construct. Taken together, the data presented in this study could provide the scientific background for the development of new therapeutic strategy aimed to restore STAT3 signaling in STAT3 misfunction associated diseases like AD-HIES. In the future, the administration of fully functional wild type STAT3 to CD4+ T cells of AD-HIES patients might compensate its loss of function and would be beneficial for these patients, lowering the risk of infections, the use of medications, and hospitalizations.

STAT3 Deficiency Alters the Macrophage Activation Pattern and Enhances Matrix Metalloproteinase 9 Expression during Staphylococcal Pneumonia.

Staphylococcus aureus is a significant cause of morbidity and mortality in pulmonary infections. Patients with autosomal-dominant hyper-IgE syndrome due to STAT3 deficiency are particularly susceptible to acquiring staphylococcal pneumonia associated with lung tissue destruction. Because macrophages are involved in both pathogen defense and inflammation, we investigated the impact of murine myeloid STAT3 deficiency on the macrophage phenotype invitro and on pathogen clearance and inflammation during murine staphylococcal pneumonia. Murine bone marrow-derived macrophages (BMDM) from STAT3 LysMCre+ knockout or Cre- wild-type littermate controls were challenged with S. aureus, LPS, IL-4, or vehicle control invitro. Pro- and anti-inflammatory responses as well as polarization and activation markers were analyzed. Mice were infected intratracheally with S. aureus, bronchoalveolar lavage and lungs were harvested, and immunohistofluorescence was performed on lung sections. S. aureus infection of STAT3-deficient BMDM led to an increased proinflammatory cytokine release and to enhanced upregulation of costimulatory MHC class II and CD86. Murine myeloid STAT3 deficiency did not affect pathogen clearance invitro or invivo. Matrix metalloproteinase 9 was upregulated in Staphylococcus-treated STAT3-deficient BMDM and in lung tissues of STAT3 knockout mice infected with S. aureus. Moreover, the expression of miR-155 was increased. The enhanced inflammatory responses and upregulation of matrix metalloproteinase 9 and miR-155 expression in murine STAT3-deficient as compared with wild-type macrophages during S. aureus infections may contribute to tissue damage as observed in STAT3-deficient patients during staphylococcal pneumonia.

Interventional pulmonary procedures and their outcomes in patients with STAT3 hyper IgE syndrome

BackgroundSTAT3 hyperimmunoglobulin E syndrome (STAT3-HIES) also referred to as autosomal dominant HIES (AD-HIES) is an inborn error of immunity characterized by the classic triad of eczema, frequent opportunistic infections, and elevated serum IgE levels. As a consequence of lung sequels due to repeated infections and impaired tissue healing, patients may require interventional pulmonary procedures.MethodFour patients with dominant-negative STAT3 mutations who had received interventional pulmonary procedures were enrolled. The demographic, clinical, and molecular characteristics were gathered through a medical record search. All reported STAT3-HIES patients in the literature requiring pulmonary procedures as part of their treatment were reviewed.ResultRecurrent episodes of pneumonia and lung abscess were the most prevalent symptoms. The most common non-immunological features were scoliosis, failure to thrive, and dental problems such as primary teeth retention and disseminated decays. Bronchiectasis, lung abscess, pneumatocele, and cavitary lesion were the most prevalent finding on high-resolution computed tomography at the earliest recording. All patients underwent pulmonary surgery and two of them experienced complications.ConclusionPatients with STAT3-HIES have marked pulmonary infection susceptibility which may necessitate thoracic surgeries. Since surgical procedures involve a high risk of complication, surgical options are recommended to be utilized only in cases of drug resistance or emergencies.

New Dominant-Negative IL6ST Variants Expand the Immunological and Clinical Spectrum of GP130-Dependent Hyper-IgE Syndrome

Patients with autosomal dominant (AD) hyper-IgE syndrome (HIES) suffer from a constellation of manifestations including recurrent bacterial and fungal infections, severe atopy, and skeletal abnormalities. This condition is typically caused by monoallelic dominant-negative (DN) STAT3 variants. In 2020, we described 12 patients from eight kindreds with DN IL6ST variants resulting in a new form of AD HIES. These variants encoded truncated GP130 receptors, with intact extracellular and transmembrane domains, but lacking the intracellular recycling motif and the four STAT3-binding residues, resulting in an inability to recycle and activate STAT3. We report here two new DN variants of IL6ST in three unrelated families with HIES-AD. The biochemical and clinical impacts of these variants are different from those of the previously reported variants. The p.(Ser731Valfs*8) variant, identified in seven patients from two families, lacks the recycling motif and all the STAT3-binding residues, but its levels on the cell surface are only slightly increased and it underlies mild biological phenotypes with variable clinical expressivity. The p.(Arg768*) variant, identified in a single patient, lacks the recycling motif and the three most distal STAT3-binding residues. This variant accumulates at the cell surface and underlies severe biological and clinical phenotypes. The p.(Ser731Valfs*8) variant shows that a DN GP130 expressed at near normal levels on the cell surface can underlie heterogeneous clinical presentations, ranging from mild to severe. The p.(Arg768*) variant demonstrates that a truncated GP130 protein retaining one STAT3-binding residue can underlie severe HIES.

Hyper‐IgE syndrome presenting with early life craniosynostosis in monozygotic twin sisters

<scp>Hyper‐IgE</scp> syndrome presenting with early life craniosynostosis in monozygotic twin sisters

A novel STAT3 splice-site variant in a kindred with autosomal dominant hyper IgE syndrome

Background: Dominant negative STAT3 loss-of-function is the most common genetic cause of hyper-IgE syndrome (HIES). Patients may present with a host of both immune and non-immune manifestations, including connective tissue abnormalities, recurrent infections, malignant predisposition, and biochemical evidence of elevated serum IgE or eosinophilia. Aim: To describe a novel splice-site variant in STAT3 resulting in HIES. Methods: Case report of two family members with HIES. Results: A proband and his son presented with neonatal-onset pustular rash, recurrent skin and sinopulmonary infections and elevated serum IgE and were diagnosed with AD-HIES. They were identified to harbor a novel splice-site variant in the DNA-binding domain (DBD) of STAT3: c.1110-3C&gt;G, predicted to result in defective splicing in exon 12. Interestingly, a number of other patients with AD-HIES have mutations affecting the same splice-site, suggesting this may be a hot-spot for mutagenesis. Conclusion: Splice-site mutations in the DBD of STAT3 are increasingly identified as a cause of AD-HIES. Future work is required to delineate whether patients with splice-site mutations have unique clinical characteristics, supporting efforts for genotype-phenotype correlation in this disease. Statement of Novelty: We present a novel splice-site mutation in the DNA-binding domain of STAT3 leading to autosomal dominant hyper-IgE syndrome.

STAT3 mutation-associated airway epithelial defects in Job syndrome

Job syndrome is a disease of autosomal dominant hyper-IgE syndrome (AD-HIES). Patients harboring STAT3 mutation are particularly prone to airway remodeling and airway infections. Airway epithelial cells play a central role as the first line of defense against pathogenic infection and express high levels of STAT3. This study thus interrogates how AD-HIES STAT3 mutations impact the physiological functions of airway epithelial cells. This study created human airway basal cells expressing 4 common AD-HIES STAT3 mutants (R382W, V463del, V637M, and Y657S). In addition, primary airway epithelial cells were isolated from a patient with Job syndrome who was harboring a STAT3-S560del mutation and from mice harboring a STAT3-V463del mutation. Cell proliferation, differentiation, barrier function, bacterial elimination, and innate immune responses to pathogenic infection were quantitatively analyzed. STAT3 mutations reduce STAT3 protein phosphorylation, nuclear translocation, transcription activity, and protein stability in airway basal cells. As a consequence, STAT3-mutated airway basal cells give rise to airway epithelial cells with abnormal cellular composition and loss of coordinated mucociliary clearance. Notably, AD-HIES STAT3 airway epithelial cells are defective in bacterial killing and fail to initiate vigorous proinflammatory responses and neutrophil transepithelial migration in response to an experimental model of Pseudomonas aeruginosa infection. AD-HIES STAT3 mutations confer numerous abnormalities to airway epithelial cells in cell differentiation and host innate immunity, emphasizing their involvement in the pathogenesis of lung complications in Job syndrome. Therefore, therapies must address the epithelial defects as well as the previously noted immune cell defects to alleviate chronic infections in patients with Job syndrome.

Intraoral and maxillofacial abnormalities in patients with autosomal dominant hyper-IgE syndrome.

Autosomal dominant hyper-IgE syndrome (AD-HIES) is an inborn error of immunity (IEI) caused by a dominant-negative mutation in the signal transducer and activator of transcription 3 (STAT 3). This disease is characterized by chronic eczematoid dermatitis, recurrent staphylococcal skin abscesses, pneumonia, pneumatoceles, and extremely high serum IgE levels. Loss-of-function STAT3 mutations may also result in distinct non-immunologic features such as dental, facial, skeletal, and vascular abnormalities, central nervous system malformations and an increased risk for bone fractures. Prophylactic treatment of Candida infections and prophylactic antimicrobial therapy for staphylococcal skin infections and sinopulmonary infections are essential. An awareness of the oral and maxillofacial features of HIES may facilitate early diagnosis with genetic counselling and may improve future patient care. This study describes oral, dental, and maxillofacial manifestations in 14 patients with genetically defined AD-HIES. We also review the literature and propose recommendations for the complex care of patients with this rare primary immunodeficiency.

In Silico Analyses of All STAT3 Missense Variants Leading to Explore Divergent AD-HIES Clinical Phenotypes.

Autosomal dominant hyper-IgE syndrome (AD-HIES) is linked to dominant negative mutations of the STAT3 protein whose molecular basis for dysfunction is unclear and presenting with a variety of clinical manifestations with only supportive treatment. To establish the relationship between the impact of STAT3 mutations in different domains and the severity of the clinical manifestations, 105 STAT3 mutations were analyzed for their impact on protein stability, flexibility, function, and binding affinity using in Silico approaches. Our results showed that 73% of the studied mutations have an impact on the physicochemical properties of the protein, altering the stability, flexibility and function to varying degrees. In particular, mutations affecting the DNA binding domain (DBD) and the Src Homology 2 (SH2) have a significant impact on the protein structure and disrupt its interaction either with DNA or other STAT3 to form a heterodomain complex, leading to severe clinical phenotypes. Collectively, this study suggests that there is a close relationship between the domain involving the mutation, the degree of variation in the properties of the protein and the degree of loss of function ranging from partial loss to complete loss, explaining the variability of clinical manifestations between mild and severe.

RARE CUTANEOUS ADVERSE REACTION TO ROUTINE IMMUNIZATIONS LEADING TO HYPER IGE SYNDROME (HIES) DIAGNOSIS

<h3>Introduction</h3> While injection site reactions are common following immunizations, botryomycosis is an uncommon chronic granulomatous bacterial infection that develops in an area of prior injury, typically the skin. Hyper IgE Syndrome (HIES) is a rare primary immunodeficiency characterized by bacterial infections, elevated IgE and cutaneous manifestations; most commonly eczema, mucocutaneous candidiasis and cold abscesses. This case describes the development of a botryomycosis infection following routine two-month vaccinations, leading to HIES diagnosis. <h3>Case Description</h3> At 2 months of age, a male, previously healthy, term baby received routine immunizations to the anterior thigh without immediate adverse effect. Days later he developed small blisters at the prior injection sites, which were pruritic and progressed to large plaques. He was treated unsuccessfully with topical steroid and antifungal creams. At 4 months of age, a skin biopsy was advised which revealed botryomycosis with <i>Staphylococcus aureus</i> as the causative organism. This rare presentation prompted an immunodeficiency work-up, including blood count, immunoglobulins, and dihydrorhodamine testing. Labs revealed neutropenia (620-800 cells/microliter), IgE 1436 IU/mL, and DHR activity was 85% with a subpopulation of reduced activity. Genetic testing revealed a pathogenic mutation of STAT3, diagnostic of an autosomal dominant HIES. Botryomycosis infection resolved on trimethoprim-sulfamethoxazole. <h3>Discussion</h3> Although vaccination can cause benign local skin reactions, botryomycosis is a rare suppurative infection and to our knowledge, there have not been prior reports of botryomycosis diagnosis after vaccination. HIES and botryomycosis are both exceedingly rare and were described together only once. This case underscores that unusual infections with common pathogens are a hallmark of immunodeficiencies.

Allele-Specific Disruption of a Common STAT3 Autosomal Dominant Allele Is Not Sufficient to Restore Downstream Signaling in Patient-Derived T Cells.

Dominant negative mutations in the STAT3 gene account for autosomal dominant hyper-IgE syndrome (AD-HIES). Patients typically present high IgE serum levels, recurrent infections, and soft tissue abnormalities. While current therapies focus on alleviating the symptoms, hematopoietic stem cell transplantation (HSCT) has recently been proposed as a strategy to treat the immunological defect and stabilize the disease, especially in cases with severe lung infections. However, because of the potentially severe side effects associated with allogeneic HSCT, this has been considered only for a few patients. Autologous HSCT represents a safer alternative but it requires the removal of the dominant negative mutation in the patients’ cells prior to transplantation. Here, we developed allele-specific CRISPR-Cas9 nucleases to selectively disrupt five of the most common STAT3 dominant negative alleles. When tested ex vivo in patient-derived hematopoietic cells, allele-specific disruption frequencies varied in an allele-dependent fashion and reached up to 62% of alleles harboring the V637M mutation without detectable alterations in the healthy STAT3 allele. However, assessment of the gene expression profiles of the STAT3 downstream target genes revealed that, upon activation of those edited patient cells, mono-allelic STAT3 expression (functional haploinsufficiency) is not able to sufficiently restore STAT3-dependent signaling in edited T cells cultured in vitro. Moreover, the stochastic mutagenesis induced by the repair of the nuclease-induced DNA break could further contribute to dominant negative effects. In summary, our results advocate for precise genome editing strategies rather than allele-specific gene disruption to correct the underlying mutations in AD-HIES.

STAT3-confusion-of-function: Beyond the loss and gain dualism

Germline mutations of signal transducer and activator of transcription 3 (STAT3) are responsible for 2 distinct human diseases: autosomal-dominant hyper-IgE syndrome (AD-HIES) caused by STAT3 loss-of-function mutations and STAT3 gain-of-function disease. So far, these entities have been regarded as antithetic, with AD-HIES mainly associated with characteristic infections and a connective tissue phenotype and STAT3 gain-of-function characterized by lymphoproliferation and poly-autoimmunity. The R335W substitution in the DNA-binding domain of STAT3 was initially described in 2 patients with typical AD-HIES, but paradoxically, recent functional analysis demonstrated a gain-of-function effect of this variant. A patient with Sjögren syndrome and features of AD-HIES with this mutation is described and the molecular consequences are further characterized. This study provides a clinical and immunological description of the patient. STAT phosphorylation in primary patient cells was studied and A4 cells transfected with the patient allele were used to study phosphorylation kinetics, transcriptional activity, and target-gene induction. The hybrid clinical features of the patient were associated with normal T_H17 cells. Enhanced and prolonged STAT3 phosphorylation, an increased STAT3 driven luciferase reporter activity upon IL-6 stimulation, but reduced IL-6-induced SOCS3 production were all observed. The germline R335W-STAT3 variant displays a mixed behavior invitro that mainly shows gain-of-function, but also loss-of-function features. This is matched by an ambiguous clinical and immunological phenotype that dismantles the classical antithetic dualism of gain- versus loss-of-function. Germline STAT3 mutation-related disease represents a pathological spectrum with the p.R335W associated phenotype locating between the 2 recognized clinical disease patterns.

Clinical Case of Job Syndrome in Infant

The article presents clinical case of Job syndrome, variant of primary immune deficiency disease confirmed genetically. This case is interesting for its early diagnosis due to comprehensive assessment of anamnestic, clinical, and laboratory data. Such typical phenotypic features as facial dysmorphisms, recurrent localized purulent infections, and laboratory parameters (absolute neutropenia and eosinophilia) were the major signs of autosomal dominant hyper IgE syndrome in a child with normal IgE levels. The combination of 2 heterozygous mutations in STAT3 gene inherited from his father and his mother has played its role in disease clinical features in the child.

Hyper-Ig E syndrome in adult patient: a clinical case and a review of the literature

Hyper-Ig E syndrome (HIES) includes a rare group of primary immunodeficiency conditions with frequently recurrent lung and skin infections. The respiratory system is affected by acute and chronic bronchitis, otitis, recurrent pneumonia, pneumocele, pleurisy, severe and prolonged sinusitis. Cutaneous manifestations are presented with “cold abscesses” and eczema/dermatitis. A pathognomic feature for the syndrome is the increased level of serum Ig E. The etiology of HIES still remains unclear. HIES occurs sporadically or is inherited - as an autosomal dominant HIES or autosomal recessive HIES. The type of inheritance determines the variable clinical picture of the syndrome. The pathogenetic diversity, the absence of specific clinical criteria as well as the presentation of few or minor symptoms in some patients complicate the diagnosis. We report а clinical case of a sporadic hyper-Ig E syndrome in an adult man suffering from atopic dermatitis since childhood presented with recurrent bacterial, viral, fungal and protozoan infections of the respiratory tract, gastrointestinal tract, skin and mucosal surfaces. A brief review of the scientific literature is also included.

A progressing inflammatory pulmonary infiltrate in a patient with hyper IgE syndrome

A young man known with autosomal dominant hyper IgE syndrome and changes on his chest radiograph was presumed to be infected with Aspergillus and treated with antifungal medicine for 11 months without effect. Positron emission tomography/computed tomography imaging was suggestive of Aspergilloma but bronchoalveolar lavage cultures, cytology as well as biochemistry were negative for Aspergillus. Finally, a transthoracic computed tomography-guided biopsy did not support the diagnosis of fungal infection as only chronic inflammatory changes were found. The patient was treated with Prednisolone after which the changes on his chest X-ray regressed.

Defective Toll-Like Receptors Driven B Cell Response in Hyper IgE Syndrome Patients With STAT3 Mutations.

Autosomal dominant hyper-IgE syndrome (AD-HIES) is a rare inherited primary immunodeficient disease (PIDs), which is caused by STAT3 gene mutations. Previous studies indicated a defective Toll-like receptor (TLR) 9-induced B cell response in AD-HIES patients, including proliferation, and IgG production. However, the other TLRs-mediated B cell responses in AD-HIES patients were not fully elucidated. In this study, we systematically studied the B cell response to TLRs signaling pathways in AD-HIES patients, including proliferation, activation, apoptosis, cytokine, and immunoglobulin production. Our results showed that the TLRs-induced B cell proliferation and activation was significantly impaired in AD-HIES patients. Besides, AD-HIES patients had defects in TLRs-induced B cell class switch, as well as IgG/IgM secretion and IL-10 production in B cells. Taken together, we first systematically reported the deficiency of TLRs driven B cell response in AD-HIES patients, which help to have a better understanding of the pathology of AD-HIES.

M164 NOVEL ERBIN VARIANT AND ASSOCIATED SEVERE ECZEMA IN A 3-MONTH-OLD

ERBIN deficiency has recently been reported as a cause of autosomal dominant hyper-IgE syndrome. Loss-of-function mutations in ERBIN result in dysregulation of TGF-β signaling, which leads to increased Tregs, IL-4Rα expression, and IgE. This case discusses an infant who presented with severe eczema and failure to thrive and was found to have an ERBIN mutation.

Relieving job: Dupilumab in autosomal dominant STAT3 hyper-IgE syndrome

Autosomal dominant hyper-IgE syndrome (AD-HIES) was initially described as Job syndrome”1 and renamed because of high IgE levels.2 Heterozygous mutations in STAT3 were initially identified as the genetic cause of AD-HIES.3 Patients exhibit (1) pulmonary infections, mainly owing to Staphylococcus aureus and Streptococcus pneumoniae; (2) bone brittleness and retention of decidual and delayed dentition of permanent teeth; and (3) dermatitis and skin infections with S aureus and Candida spp.4 Although prophylaxis and treatment of infections have advanced, options for HIES-related dermatitis are limited and consist of emollients, topical steroids, and calcineurin inhibitors.

Treatment of severe atopic dermatitis and eosinophilic esophagitis with dupilumab in a 14-year-old boy with autosomal dominant hyper-IgE syndrome

Autosomal dominant hyper-IgE syndrome (AD-HIES), also known as Job syndrome and Buckley syndrome, is characterized by elevated IgE levels, eosinophilia, recurrent cutaneous and internal organ abscesses, pneumonia leading to pneumatoceles, mucocutaneous candidiasis, characteristic facies, delayed shedding of primary teeth, bone fractures due to minor trauma, joint hypermobility, and scoliosis.1 In addition, allergic disorders such as atopic dermatitis (AD), food allergy, and eosinophilic esophagitis (EoE)2 may be associated with AD-HIES.

Rare Case of Adult Onset DOCK8 Mutated Hyper Ige Syndrome

Background: Autosomal dominant hyper IgE syndrome (AD-HIES) is a primary immune deficiency characterized by the classic triad of recurrent skin boils, cyst-forming pneumonias, and extreme elevations of serum IgE. AD-HIES is classically associated with mutations in the signal transducer and the activator of the transcription 3 gene (STAT3) gene. To date, the majority of cases have been caused by de novo pathogenic variants. The dedicator of the cytokinesis 8 gene (DOCK8) has been identified as the cause of many cases with autosomal recessive hyper-IgE syndrome (AR-HIES). The autosomal dominant hyper-IgE syndrome is associated with a cluster of facial, dental, skeletal, and connective tissue abnormalities which are not observable in the recessive type. Here we present a rare case of a patient meeting criteria for AD-HIES but with DOCK8 p.R83Q mutation.Methods: Case study involving retrospective chart review from May 2015 to present.Clinical case: Patient is a 49 yo female with past medical history of moderate eczema, innumerable recurrent sinopulmonary infections, 4 episodes of pneumonia, mild scoliosis, 8 digital fractures with minimal trauma, 5 skin abcesses, recurrent vulvovaginal candidiasis, monthly urinary tract infections who presented to the emergency room in May 2015 with left facial paralysis and progressive paralysis in left upper and lower extremity associated with numbness. Physical examination revealed diffuse scaly pruritic rash, high palate, left facial droop, left sided upper and lower extremity weakness and numbness (Figure 1). MRI of the brain with contrast May 2015 showing scattered periventricular, subcortical and deep white matter FLAIR signal hyperintensities (Figure 2). CSF for viral, fungal, bacterial cultures, Cryptococcus, west nile, flow cytometry, protein electropheresis at that time was normal. She was found to have low IGG 579 mg/dL, normal IGA 191 mg/dL, IGM 111mg/Dl IGD 2.09 mg/dL, and increased IGE (297 IU/mL, currently 807 IU/mL, peak 1171 IU/mL). She had a complete negative workup for infections: Blood cultures, HIV, TB, EBV, CMV, HTLV-1&2, Colorado Tick Fever, Tropheryma Whipplei, Stongyloides, Schistosoma, Toxocara Abs, Ascaris, Plasmodium, Trichinella, Influenza A B, HSV, Hepatitis A B C, Echinococcues, West Nile virus, Cystercercosis, Lyme Disease, Syphilis, Amoebic cultures, Aspergillus, Mucormycosis. Stool was negative for ova & parasites, Shigella, Yersenia, Clostridium, Giardia, E. Coli, Trichome stain. Malignancy evaluation was negative including: CT brain, chest, abdomen, and pelvis, flow cytometry, protein electrophoresis, tumor markers, bone marrow biopsy and aspirate (figure 3), upper & lower endoscopy. Electrolytes, metal screen (arsenic, copper, lead, mercury, zinc), complete chemistries were negative. A complete autoimmune and allergy panel was negative. Immunology profile showed normal CBC (normal PLT size), low CH 50 of 38 U/mL, normal helper CD3% 78%, 1884 cell/mcL, elevated helper CD4% 68.5%, 1601 cell/mcL, low suppressor CD8% of 11% with normal absolute number 249 cell/mcL. IL 6 = 3.1 pg/mL, IL 10 =11.5 pg/mL, IL 12 was undetectable. Genetic analysis revealed normal NOTCH3, SPINK5, STAT3, TYK2 genes. A heterozygous mutation in DOCK8 p.Arg83Gln (R83Q) was discovered in this patient. Based on a clinical scoring system developed by the National Institutes of Health patient has features suggestive of AD-HIES (> 40 is cutoff, our patient scored 52). The patient has been receiving IVIG 40 grams IV every 3 weeks with clinical improvement in infectious symptoms but continued progression of neurological symptoms. Due to rarity of this case the patient is currently being referred to the NIH for further management.Conclusion: Here we present a rare adult onset case with the patient meeting criteria for AD-HIES and symptoms of DOCK8 AR-HIES harboring R83Q variant DOCK8. This patient may likely harbor an undiscovered mutation in another allele. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.