Autosomal Dominant hyper-IgE Syndrome Research Articles

Esophageal and Other GI Manifestations of Autosomal Dominant Hyper IgE Syndrome: The First Reported Disease Causing Secondary Eosinophilic Esophagitis Presidential Poster

Esophageal and Other GI Manifestations of Autosomal Dominant Hyper IgE Syndrome: The First Reported Disease Causing Secondary Eosinophilic Esophagitis Presidential Poster

Immunity to infection in IL‐17‐deficient mice and humans

Mice with defective IL-17 immunity display a broad vulnerability to various infectious agents at diverse mucocutaneous surfaces. In humans, the study of patients with various primary immunodeficiencies, including autosomal dominant hyper-IgE syndrome caused by dominant-negative STAT3 mutations and autosomal recessive autoimmune polyendocrinopathy syndrome type 1 caused by null mutations in AIRE, has suggested that IL-17A, IL-17F and/or IL-22 are essential for mucocutaneous immunity to Candida albicans. This hypothesis was confirmed by the identification of rare patients with chronic mucocutaneous candidiasis (CMC) due to autosomal recessive IL-17RA deficiency and autosomal dominant IL-17F deficiency. Heterozygosity for gain-of-function mutations in STAT1 in additional patients with CMC was recently shown to inhibit the development of IL-17 T cells. Although the infectious phenotype of patients with CMC and inborn errors of IL-17 immunity remains to be finely delineated, it appears that human IL-17A and IL-17F display redundancy for protective immunity in natural conditions that is not seen in their mouse orthologs in experimental conditions.

Ligneous Periodontitis and Conjunctivitis With Hyper‐Immunoglobulin E Syndrome

Introduction: Hyper‐immunoglobulin E syndrome (HIES) is a rare multisystem primary immunodeficiency caused by mutation in signal transducer and activator of transcription gene protein 3, associated with recurrent skin and sinopulmonary infection and high serum levels of immunoglobulin E (IgE). It is mostly sporadic, but familial inheritance with autosomal dominant and autosomal recessive forms are seen. Ligneous periodontitis and conjunctivitis are rare poorly defined conditions, characterized by pseudomembranous inflammation of mucosa. There is accumulation of fibrin in lamina propria mostly as a result of quantitative plasminogen deficiency.Case Presentation: An 18‐year‐old Indian girl with history of newborn rash had generalized pseudomembranous periodontitis, bilateral pseudomembranous conjunctivitis, multiple staphylococcal abscesses on the feet, right radial neck fracture after minor trauma, eosinophilia, and raised IgE. Subepithelial deposition of fibrin was seen in gingival and conjunctival biopsies. The National Institutes of Health scoring system for HIES was calculated to be 42 (HIES score >40 points indicates that the presence of autosomal dominant HIES genotype is highly likely). Segmental gingivectomies, topical heparin, and corticosteroids were not effective in dentate areas of gingiva, whereas edentulous areas healed normally. Oral and topical antibiotics caused resolution of the skin abscesses, whereas lubricating and corticosteroid eye drops caused improvement in conjunctival lesions.Conclusions: Ligneous periodontitis and conjunctivitis are novel manifestations in HIES recalcitrant to various treatments. Optimal therapy would be systemic plasminogen concentrate replacement, which is not commercially available. Extensive investigations and a multidisciplinary approach to diagnosis and management are required.

Signal transducer and activator of transcription 3 (STAT3) controls susceptibility to Epstein-Barr virus reactivation in B cells

Epstein-Barr Virus (EBV) is known to cause malignancies in immunocompromised individuals, including lymphomas and lymphoproliferative disorders. Reactivation of EBV from latency is important in the pathogenesis of such malignancies. Therapeutically, oncolysis of tumors harboring lytic EBV holds promise. However, exposure of latently infected cultured B cells to lytic cycle inducing stimuli results in virus reactivation within only 20% to 50% of cells. Host cell determinants, that govern this susceptibility to lytic reactivat ion within latently infected B cells, are not well understood. Our research has previously identified that higher levels of signal transducer and activator of transcription 3 (STAT3) within cells correlate with resistance to EBV lytic reactivation. We now investigate whether inhibiting function of STAT3 promotes susceptibility of latently infected B cells to known lytic cycle inducing stimuli or results in induction of EBV lytic cycle. We found that pharmacological inhibition of STAT3 phosphorylation by Janus Kinase 2 (JAK2) inhibitors (AG490 or WP1066) in latently infected cells (HH514-16 Burkitt lymphoma and B95-8 lymphoblastoid cells) increased lytic reactivation by chemical stimuli that function by distinct mechanisms. Moreover, functional inhibition of STAT3 alone resulted in lytic reactivation in these cells. EBV-Lymphoblastoid cell lines (LCL) newly generated from healthy individuals also demonstrated increased susceptibility to lytic cycle inducing stimuli in the presence of AG490 but variable susceptibility to lytic reactivation when exposed to AG490 alone. Since this lack of uniform response to AG490 alone could be due to inadequate functional suppression of STAT3, we examined EBV-LCLs derived from patients with Autosomal Dominant Hyperimmunoglobulin-E syndrome (AD-HIES or Job syndrome). Patients with AD-HIES carry a dominant negative mutation in their Stat3 gene resulting in lower basal levels of functional STAT3. When LCLs from AD-HIES patients were exposed to a JAK2 inhibitor alone, we observed a strong increase in lytic reactivation by expression of early and late lytic antigens over LCLs derived from healthy individuals. Lytic reactivation in the presence of AG490 occurred in these cells despite lack of discernable increase from basal levels of expression of ZEBRA, the viral lytic switch protein, when compared to cells not exposed to AG490. Thus, STAT3 is important in determining susceptibility to EBV reactivation. Fully understanding how STAT3 governs such susceptibility can lead to novel therapeutic strategies for EBV-related diseases.

Hyper‐IgE syndrome update

Autosomal dominant hyper-IgE syndrome (AD-HIES) or Job's syndrome is a primary immunodeficiency with a wide array of clinical features caused by dominant negative mutations in STAT3. In recent years, not only the clinical phenotype of the disease has been expanded with recognition of features such as arterial aneurysms, but also our understanding of the pathogenesis of the disease has greatly improved.

An update on the hyper-IgE syndromes

The hyper-IgE syndromes (HIES; originally named Job's syndrome) are a collection of primary immunodeficiency syndromes resulting in elevated serum IgE levels and typified by recurrent staphylococcal skin abscesses, eczema and pulmonary infections. The disorder has autosomal dominant and recessive forms. Autosomal dominant HIES has been shown to be mainly due to STAT3 mutations and additionally results in connective tissue, skeletal, vascular and dental abnormalities. Autosomal recessive HIES has been shown to be mainly due to mutations in DOCK8; these patients are more prone to viral skin infections instead. This review article discusses the common clinical features of the syndrome, the genetic mutations responsible and the pathogenesis of the disease, as well as treatments currently used.

Defects in lymphocyte function and interactions in primary immunodeficiencies: insights into disease pathogenesis

Regulated interactions between immune cells facilitate the generation of successful immune responses, thereby enabling efficient neutralisation and clearance of pathogens, and the establishment of both cell and humoral-mediated immunological memory. The corollary of this is that impediments to efficient cell-cell interactions compromise the differentiation and effector function of immune cells, underlying the clinical features of, and disease pathogenesis in, primary immunodeficiencies (PID). These defects manifest as impaired long-term humoral immunity and susceptibility to infection with specific pathogens in affected individuals. We have been studying lymphocyte development, differentiation and effector function in individuals with defined loss-of-function mutations that result in specific PIDs, such as autosomal dominant and autosomal recessive hyper-IgE syndrome, X-linked and autosomal recessive severe combined immunodeficiency, and X-linked lymphoproliferative disease. This has provided an opportunity to ascribe lineage-specific functions to a variety of genes and to identify defects in lymphocyte biology caused by these mutations. Most importantly, however, these studies have provided mechanistic explanations for the clinical features of several of these conditions, thereby identifying molecules and pathways that could be targeted for intervention to improve immune function in different disease settings.

A Critical Role for STAT3 Transcription Factor Signaling in the Development and Maintenance of Human T Cell Memory

STAT3 transcription factor signaling in specific T helper cell differentiation has been well described, although the broader roles for STAT3 in lymphocyte memory are less clear. Patients with autosomal-dominant hyper-IgE syndrome (AD-HIES) carry dominant-negative STAT3 mutations and are susceptible to a variety of bacterial and fungal infections. We found that AD-HIES patients have a cell-intrinsic defect in the number of central memory CD4(+) and CD8(+) T cells compared to healthy controls. Naive T cells from AD-HIES patients had lower expression of memory-related transcription factors BCL6 and SOCS3, a primary proliferation defect, and they failed to acquire central memory-like surface phenotypes in vitro. AD-HIES patients showed a decreased ability to control varicella zoster virus (VZV) and Epstein-Barr virus (EBV) latency, and T cell memory to both of these viruses was compromised. These data point to a specific role for STAT3 in human central memory T cell formation and in control of certain chronic viruses.

Heterozygous signal transducer and activator of transcription 3 mutations in hyper-IgE syndrome result in altered B-cell maturation

Heterozygous signal transducer and activator of transcription 3 mutations in hyper-IgE syndrome result in altered B-cell maturation

Cutaneous Manifestations of <emph type="ital">DOCK8</emph> Deficiency Syndrome

Mutations in the dedicator of cytokinesis 8 gene (DOCK8) cause a combined primary immunodeficiency syndrome that is characterized by elevated serum IgE levels, depressed IgM levels, eosinophilia, sinopulmonary infections, cutaneous viral infections, and lymphopenia. Many patients with DOCK8 deficiency were previously thought to have a variant of Job's syndrome. Distinguishing between DOCK8 deficiency and Job's syndrome, also referred to as autosomal dominant hyper-IgE syndrome, on the basis of clinical findings alone is challenging. The discovery of the DOCK8 mutation has made it possible to differentiate the cutaneous manifestations of these hyper-IgE syndromes. Twenty-one patients from 14 families with confirmed homozygous or compound heterozygous mutations in DOCK8 were evaluated. Clinical findings included dermatitis, asthma, food and environmental allergies, recurrent sinopulmonary infections, staphylococcal skin abscesses, and severe cutaneous viral infections. Malignant neoplasms, including aggressive cutaneous T-cell lymphoma, anal and vulvar squamous cell carcinomas, and diffuse large B-cell lymphoma, developed in 5 patients during adolescence and young adulthood. DOCK8 deficiency and Job's syndrome share several clinical features, including elevated serum IgE levels, dermatitis, recurrent sinopulmonary infections, and cutaneous staphylococcal abscesses. However, the presence of recalcitrant, widespread cutaneous viral infections, asthma, and food and environmental allergies, as well as the absence of newborn rash and coarse facies, favors the clinical diagnosis of DOCK8 deficiency. Rates of malignancy and overall mortality in patients with DOCK8 deficiency were higher than in those with Job's syndrome, highlighting the value of distinguishing between these conditions and the importance of close monitoring for neoplasia.

Abstract A30: High levels of STAT3 and Epstein-Barr virus latent membrane protein 1 are required for virus-driven proliferation and transformation of B cells

Abstract Epstein-Barr virus (EBV) is associated with lymphocyte and epithelial cell cancers in humans. EBV tumorigenesis requires expression of both viral genes, such as the oncoprotein latent membrane protein 1 (LMP1), and cellular genes. In previous tumorigenesis studies, we identified a B cell surface marker pattern (CD23hiCD58+) that predicts proliferation and subsequent transformation of B cells following EBV infection. To investigate the contribution of signal transducer and activator of transcription 3 (STAT3), a progrowth and survival signaling molecule, in EBV-driven proliferation and transformation of B cells, two approaches were taken: 1) Primary B cells from healthy donors were infected with EBV in the presence of AG490, which inhibits the function of STAT3 by interfering with Janus kinases, and 2) B cells from patients with autosomal-dominant hyper IgE syndrome (AD-HIES or Job syndrome) that have naturally occurring dominant negative mutations in the Stat3 gene were infected with EBV. The effects of chemical inhibition of STAT3 function and those of Stat3 mutations on EBV-driven B cell survival, proliferation, and transformation were examined. Following exposure to EBV, LMP1 + cells and CD23hiCD58+ cells expressed activated STAT3 and high levels of total STAT3. Chemical inhibition of STAT3 activation by AG490 inhibited the emergence of the CD23hiCD58+ population by 10- to 30-fold as compared to control infection. This was accompanied by a fall in the fraction of B cells expressing LMP1 and increased apoptosis of CD23hiCD58+ and LMP1 + cells. A similar pattern was observed following infection of B cells from AD-HIES patients, further supporting a role for STAT3 in survival of B cells following EBV infection. Both AG490 treatment during infection of healthy B cells and infection of B cells from AD-HIES patients resulted in accumulation of extant LMP1 + cells in S phase of the cell cycle. Evaluation of nuclear morphology following AG490 treatment demonstrated an absence of LMP1 + mitotic nuclei but enrichment of LMP1 + cells with small dense nuclei consistent with cells in a resting state, supporting a proliferation defect. Only those cells expressing high levels of STAT3 in addition to high levels of LMP1 progressed to G2/M phase of the cell cycle. Cultures with reduced LMP1 expression or reduced CD23hiCD58+ population also failed to establish transformed cell lines. We conclude that proliferation and subsequent transformation of EBV-infected B cells is dependent on the presence of activated STAT3 and high levels of total STAT3 as well as high levels of LMP1. These findings support a possible role for STAT3 modulation in the treatment of EBV-related cancers, particularly those arising in the context of immunocompromise. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the Second AACR International Conference on Frontiers in Basic Cancer Research; 2011 Sep 14-18; San Francisco, CA. Philadelphia (PA): AACR; Cancer Res 2011;71(18 Suppl):Abstract nr A30.

Fungal Infections in Phagocytic Defects

Delineating the infection susceptibility of primary immunodeficiencies allows insight into host immunity. Filamentous mold infections are seen most frequently in chronic granulomatous disease, a neutrophil disorder characterized by impaired superoxide production. Mucocutaneous candidiasis occurs in disorders of impaired interleukin (IL)-17 and IL-22 signaling, such as seen in autosomal dominant hyper-IgE (Job’s) syndrome and in disorders with autoantibodies to these cytokines. The endemic dimorphic fungi are in part controlled by disorders of the IL-12/interferon (IFN)-γ pathway, such as IFN-γ receptor and STAT1 defects. Understanding the pathways involved in these primary immunodeficiency disorders will also provide insight into these infections in secondary immunodeficiencies and allow guidance for novel therapies.

SH2‐domain mutations in STAT3 in hyper‐IgE syndrome patients result in impairment of IL‐10 function

Autosomal-dominant hyper-IgE syndrome (AD-HIES) is a primary immunodeficiency caused by STAT3 mutations. This inherited condition is characterized by eczema, staphylococcal cold abscesses and recurrent pulmonary infections. Given that STAT3 is involved in IL-10 signaling, we examined the immunoregulatory role of IL-10 in inflammation by studying the effects of IL-10 on monocytes, neutrophils and monocyte-derived DCs from HIES subjects. Analysis of gene expression in PBMCs and neutrophils isolated from HIES patients and stimulated with LPS in the presence of IL-10 showed reduced expression of IL1RN, which encodes IL-1 receptor antagonist (IL-1ra), and SOCS3 mRNA but increased CXCL8 mRNA expression. Moreover, secretion of the anti-inflammatory protein IL-1ra was reduced in AD-HIES patients. DCs from HIES patients secreted higher levels of TNF-α, IL-6 and, to a lesser extent, IL-12 when these cells were cultured in the presence of IL-10. These results suggest that IL-10 activity is affected in myeloid cells (e.g. monocytes, DCs) of HIES patients. Impairment of IL-10 signaling in patients with AD-HIES might result in an altered balance between pro-inflammatory and anti-inflammatory signals and might lead to persistent inflammation and delayed healing after infections.

Cutaneous findings in sporadic and familial autosomal dominant hyper-IgE syndrome: A retrospective, single-center study of 21 patients diagnosed using molecular analysis

Recent identification of STAT3 mutations in autosomal dominant (AD) hyper-IgE syndrome (HIES) has improved the clinical, genetic, and molecular classification of the HIES. We sought to characterize the cutaneous signs observed in molecularly diagnosed AD-HIES. We conducted a retrospective study of 21 patients with AD-HIES and confirmed STAT3 mutations, treated at Necker-Enfants Malades Hospital, Paris, France. A papulopustular rash on the face and scalp before the age of 2 months was observed in 67% of patients. This "early rash" was distinguished from other neonatal pustular eruptions by crusted papules and pustules, rash intensity, and a continuum with chronic dermatitis. An eczematous dermatitis was almost always present before the age of 18 months (95% of patients) and was mainly confined to the face, scalp, chest, and buttocks. All patients presented with infected dermatitis (Staphylococcus aureus) and 59% had chronic candidiasis of the oral mucosa and nails. Cutaneous herpes virus infections were not unusually severe. Coarse facial skin at puberty, and sometimes at a younger age, with prominent follicular ostia resembling atrophoderma vermiculatum was not related to severe acne or facial abscesses. This was a retrospective study with a small number of patients. When associated with serum IgE levels 10 times the age-appropriate level, a neonatal papulopustular rash progressing to a chronic impetiginized eczematous dermatitis that differs from classic atopic dermatitis is highly suggestive of AD-HIES. Early recognition is important for initiation of prophylactic antistaphylococcal and antifungal treatment.

Advances in basic and clinical immunology in 2010

Reports in basic and clinical immunology in 2010 reflected the use of state-of-the-art genetic and immunologic tools to characterize the pathogenesis of immunologic diseases and the development of novel therapies directed to these conditions. B-cell biology has been explained in greater detail, significantly with lessons from the genetic defects found in the humoral immunodeficiencies. Therapeutic mAbs are given for an increasing number of indications, such as anti-CD20 antibodies or rituximab, which was initially developed for non-Hodgkin lymphomas and is currently used in diverse autoimmune and inflammatory disorders. The report of an infant with severe combined immunodeficiency (SCID) in Massachusetts detected by means of newborn screening and successfully treated with hematopoietic stem cell transplantation validated recent efforts toward newborn screening for SCID. Improvement of survival outcomes for patients with primary immunodeficiencies treated with hematopoietic stem cell transplantation was demonstrated in a large European cohort, with significant appreciation of the type of donor graft, particularly the use of HLA-matched unrelated donors for patients with non-SCID. Progress in cellular mechanisms of drug hypersensitivity included the characterization of nitroso-modified drug metabolites as potent T-cell activators and the identification of the relocation of plasmacytoid dendritic cells from blood to skin as a potential risk factor for reactivation of viral disease.

Paucity of genotype-phenotype correlations in STAT3 mutation positive Hyper IgE Syndrome (HIES).

Autosomal dominant HIES (AD-HIES) is a primary immunodeficiency caused by dominant negative mutations in STAT3 clustered in the DNA binding and SH2 domains. Although in vitro differences in mutational constructs are observed, clinical phenotypic correlates of these genetic changes have not been described. We reviewed the charts of 65 AD-HIES patients (DNA binding n=35; SH2 n=30), recorded the components of the NIH HIES clinical scoring system as well as brain and coronary artery abnormalities and analyzed data by mutation region in adults and children. Patients with SH2 domain mutations had increased frequency of high palate, broad inter-alar distance, upper respiratory tract infections and, in the pediatric sub-group, significant scoliosis. There was suggestion of increased mortality for patients with DNA binding mutations. Although subtle differences in phenotype were observed to depend on the STAT3 genotype, overall the clinical phenotypes were similar between individuals with DNA binding and SH2 domain mutations.

The hyperimmunoglobulin E syndrome - clinical manifestation diversity in primary immune deficiency

The hyper-IgE syndromes are rare, complex primary immunodeficiencies characterized by clinical manifestation diversity, by particular susceptibility to staphylococcal and mycotic infections as well as by a heterogeneous genetic origin. Two distinct entities - the classical hyper-IgE syndrome which is inherited in an autosomal dominant pattern and the autosomal recessive hyper-IgE syndrome have been recognized. 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. In the majority of affected patients with autosomal dominant hyper-IgE syndrome a mutation in the signal transducer and the activator of the transcription 3 gene has been identified, leading to an impaired Th17 cells differentiation and to a downregulation of an antimicrobial response. A mutation in the dedicator of the cytokinesis 8 gene has been identified as the cause of many cases with autosomal recessive hyper-IgE syndrome and, in one patient, a mutation in tyrosine kinase 2 gene has been demonstrated. In this paper, the authors provide a review of the clinical manifestations in the hyper-IgE syndromes with particular emphasis on the diversity of their phenotypic expression and present current diagnostic guidelines for these diseases.

Destructive pulmonary staphylococcal infection in a boy with hyper-IgE syndrome: a novel mutation in the signal transducer and activator of transcription 3 (STAT3) gene (p.Y657S)

Hyper IgE syndrome (HIES) is a rare primary immunodeficiency disorder, characterized by eczema, recurrent skin and lung infections, and significantly elevated serum IgE level. It was previously diagnosed based on clinical manifestations and laboratory markers that were not specific to the disease. Recent studies have demonstrated that mutations in signal transducer and activator of transcription 3 (STAT3) cause the autosomal dominant or sporadic HIES, which make the disease definitively characterized at molecular level. Here, we reported a 3-year old Chinese boy with neonatal-onset rash and multiple serious Staphylococcus aureus infections including recurrent skin abscesses, liver abscess, sepsis, and destructive pulmonary infection (pneumonia, multiple pulmonary abscesses, pyopneumothorax, and finally, pneumatocele). Genetic study revealed a heterozygous mutation in exon 21 of STAT3 gene (g.66583 A > C, c.1970A > C) in the boy, which resulted in a substitution of tyrosine at the amino acid position 657 to serine (p.Y657S) in the Src homology 2 (SH2) domain of STAT3. Functional prediction with bioinformatics programs of the Sorting Intolerant from Tolerant (SIFT) and the Polymorphism Phenotyping (PolyPhen) reported "deleterious (SIFT score 0.02)" and "probably damaging (PSIC score difference 2.94)" values, respectively. Further study of family members revealed that neither his parents, nor his twin brother carried the mutation, indicating the mutation was likely to occur de novo in our patient. The mutation,p.Y657S,in SH2 domain of STAT3 is a disease-causing mutation in the boy with HIES.

Successful Long-Term Correction of Autosomal Recessive Hyper-IgE Syndrome due to DOCK8 Deficiency by Hematopoietic Stem Cell Transplantation

Autosomal dominant hyper-IgE syndrome (AD-HIES), characterised by eczema, increased susceptibility to skin and lung infections, elevated IgE and skeletal abnormalities is associated with heterozygous STAT3 mutations. The autosomal recessive variant (AR-HIES) has similar immunological findings but mainly lacks extraimmune manifestations. Several AR-HIES patients have recently been shown to harbour mutations in the gene for dedicator of cytokinesis 8 (DOCK8). Here, we present the long-term outcome of a girl having received a hematopoietic stem cell graft for an at that time genetically undefined combined immunodeficiency associated with severe eczema, multiple food allergies, excessively elevated serum IgE levels and eosinophilia. She was recently found to carry a homozygous nonsense mutation in the DOCK8 gene. HSCT resulted in complete immunological correction, even though mixed donor chimerism occurred. Clinically, the outcome was characterised by disappearance of skin manifestations and severe infections, improvement of pulmonary function and constant decline of IgE levels. Outcome in untransplanted DOCK8 deficient patients is poor because of frequent life-threatening infections, CNS bleeding and infarction, and increased susceptibility to malignancy. This argues for early curative therapeutic approaches, supported by this report of successful long-term outcome after HSCT.

TH2 heterogeneity: Does function follow form?

T(H)2 immune responses are required for the 2 fundamental pathological processes characteristic of allergic disease: IgE-mediated hypersensitivity and eosinophilic inflammation. The 3 established T(H)2 cytokines, IL-4, IL-5, and IL-13, each play a nonredundant role in allergic disease pathology. The recent explosion of T(H) subpopulations combined with the wide availability of polychromatic cytokine staining has facilitated the discovery of T(H)2 lineage heterogeneity. In this article we review T(H)2 heterogeneity and ask the following question: At what point do these subpopulations graduate from in vitro curiosities to immunologically robust therapeutic targets? We propose criteria to establish a T-cell subset as a biologically relevant entity and address the evidence to support these T(H)2 subpopulations having a unique function or specific contribution to allergic pathology or host defense.