Cases Of Severe Congenital Neutropenia Research Articles

Spectrum of Pathogenic Genetic Variants in a Large Cohort of North American Congenital and Cyclic Neutropenia Patients: A Report from the Severe Chronic Neutropenia International Registry

▪Severe congenital neutropenia (SCN) is characterized by persistent neutropenia and risk of invasive, life-threatening infection as well as transformation to hematopoietic malignancy. The closely related syndrome cyclic neutropenia is characterized by recurrent episodic neutropenia accompanied by symptoms including infection. Understanding the genetic etiology of congenital neutropenia can help to direct therapy, guide surveillance and health maintenance strategies, and contribute to our understanding of basic neutrophil biology. Although mutations in ELANE are the most frequent cause of congenital neutropenia, there is a wide and ever-growing list of additional causative variants. Additionally, there appears to be regional genetic variability. For example, mutations in HAX1 are rarely if ever observed in North America while they are more common in Europe. We undertook exome sequencing of a large cohort from the Severe Chronic Neutropenia International Registry (SCNIR) of North America in an effort to define the genetic spectrum of congenital neutropenia and aid in the discovery of new pathogenic variants.We expanded our previously reported study of whole exome sequencing to include 152 cases of chronic neutropenia, comprised of 94 cases of SCN and 58 cases of cyclic neutropenia. We selected cases in which ELANE testing was negative, or in a small minority of cases, where ELANE testing had not yet been performed. Indeed, exome sequencing only identified 7 cases (5 SCN and 2 cyclic) carrying pathogenic ELANE mutations in this cohort. In the remaining 145 cases, we analyzed exomes for the presence of variants in genes previously associated with congenital neutropenia including AK2, AP3B1, CD40LG, CLPB, CSF3R, CXCR2, CXCR4, DNAJC21, DNM2, DOCK2, EFL1, EIF2AK3, ELANE, G6PC3, GATA1, GATA2, GFI1, GINS1, HAX1, IRAK4, JAGN1, KAT6A, KRAS, LAMTOR2, LYST, MYD88, PGM3, PSTPIP1, RAB27A, RAC2, SBDS, SEC61A1, SLC37A4, SMARCD2, SRP54, STK4, TAZ, TCIRG1, TCN2, TLR8, USB1, VPS13B, VPS45, WAS, WDR1 and WIPF1. Pathogenic heterozygous mutations of CLPB that localize to the ATP-binding pocket were identified in 7 cases, making it the second most common cause of congenital neutropenia in North America. We additionally identified 4 cases with G6PC3 pathogenic variants, and one case each with pathogenic variants in JAGN1, CXCR4 (the cause of WHIM syndrome), germline homozygous CSF3R, and GFI1.Interestingly, we identify 2 unrelated individuals (one with SCN and one with cyclic) and 2 siblings with SCN all of whom possess a recently described heterozygous variant in SRP54 (p.T117del). We collected genomic DNA from the affected mother of the 2 siblings, an additional unaffected sibling, and the unaffected grandparents. Through this kinship, we can confirm the de novo appearance of this variant in the second generation and demonstrate that it tracks with disease status (Figure 1). We also identified 2 unrelated individuals with SRP54 variants affecting residue 175 also located within the GTPase domain (p.G175E or p.G175del). Both variants are absent from the gnomAD database, and studies are underway to demonstrate de novo acquisition.In summary, we have defined the spectrum of mutations present in ELANE-wildtype chronic neutropenia cases in North America. Pathogenic or likely pathogenic variants were identified in 26 out of 145 (18%) cases. The most frequently mutated genes were of CLPB, SRP54, and G6PC3, while mutations in HAX1 were not seen. Importantly, some of these mutations are associated with genetic syndromes with extra-hematopoietic findings (for example, CLPB and SRP54) that would warrant additional evaluations and targeted health maintenance. These findings emphasize the importance of sending large panels for genotyping, rather than targeted ELANE testing. [Display omitted] DisclosuresBolyard: X4 Pharmaceuticals: Research Funding. Makaryan: Emendo Biotherapeutic: Research Funding. Dale: X4 Pharmaceuticals: Consultancy, Honoraria, Research Funding.

Heterozygous variants of CLPB are a cause of severe congenital neutropenia

AbstractSevere congenital neutropenia is an inborn disorder of granulopoiesis. Approximately one third of cases do not have a known genetic cause. Exome sequencing of 104 persons with congenital neutropenia identified heterozygous missense variants of CLPB (caseinolytic peptidase B) in 5 severe congenital neutropenia cases, with 5 more cases identified through additional sequencing efforts or clinical sequencing. CLPB encodes an adenosine triphosphatase that is implicated in protein folding and mitochondrial function. Prior studies showed that biallelic mutations of CLPB are associated with a syndrome of 3-methylglutaconic aciduria, cataracts, neurologic disease, and variable neutropenia. However, 3-methylglutaconic aciduria was not observed and, other than neutropenia, these clinical features were uncommon in our series. Moreover, the CLPB variants are distinct, consisting of heterozygous variants that cluster near the adenosine triphosphate-binding pocket. Both genetic loss of CLPB and expression of CLPB variants result in impaired granulocytic differentiation of human hematopoietic progenitor cells and increased apoptosis. These CLPB variants associate with wild-type CLPB and inhibit its adenosine triphosphatase and disaggregase activity in a dominant-negative fashion. Finally, expression of CLPB variants is associated with impaired mitochondrial function but does not render cells more sensitive to endoplasmic reticulum stress. Together, these data show that heterozygous CLPB variants are a new and relatively common cause of congenital neutropenia and should be considered in the evaluation of patients with congenital neutropenia.

Neutrophil Elastase Defects in Congenital Neutropenia.

Severe congenital neutropenia (SCN) is a rare hematological condition with heterogenous genetic background. Neutrophil elastase (NE) encoded by ELANE gene is mutated in over half of the SCN cases. The role of NE defects in myelocytes maturation arrest in bone marrow is widely investigated; however, the mechanism underlying this phenomenon has still remained unclear. In this review, we sum up the studies exploring mechanisms of neutrophil deficiency, biological role of NE in neutrophil and the effects of ELANE mutation and neutropenia pathogenesis. We also explain the hypotheses presented so far and summarize options of neutropenia therapy.

Secondary CNL after SAA reveals insights in leukemic transformation of bone marrow failure syndromes

AbstractAcquired aplastic anemia and severe congenital neutropenia (SCN) are bone marrow (BM) failure syndromes of different origin, however, they share a common risk for secondary leukemic transformation. Here, we present a patient with severe aplastic anemia (SAA) evolving to secondary chronic neutrophilic leukemia (CNL; SAA-CNL). We show that SAA-CNL shares multiple somatic driver mutations in CSF3R, RUNX1, and EZH2/SUZ12 with cases of SCN that transformed to myelodysplastic syndrome or acute myeloid leukemia (AML). This molecular connection between SAA-CNL and SCN progressing to AML (SCN-AML) prompted us to perform a comparative transcriptome analysis on nonleukemic CD34high hematopoietic stem and progenitor cells, which showed transcriptional profiles that resemble indicative of interferon-driven proinflammatory responses. These findings provide further insights in the mechanisms underlying leukemic transformation in BM failure syndromes.

Evaluation of periodontal status and cytokine/chemokine profile of GCF in patients with severe congenital neutropenia.

Severe congenital neutropenia (SCN) is a primary immunodeficiency characterized by defect in neutrophil count. Increased risk of infections in addition to periodontal problems, such as ulcerations of oral mucosa, gingival inflammation, and rapid loss of attachment are common in the course of the disease. The aim of the present study is to define the causal relationship between the severity of periodontal inflammation and severe congenital neutropenia through identification of cytokine profile in gingival crevicular fluid (GCF). A case-control study was performed in patients diagnosed with SCN and healthy controls. Demographic data, the molecular defect, laboratory work-up were gathered from the hospital registry. Periodontal indices were recorded and GCF samples were analyzed using multiplex analysis for the simultaneous measurements of the particular cytokines and chemokines. The present study included 14 patients and 22 control subjects. Both groups were comparable in terms of age and sex. Severity of gingival inflammation measured by the criteria of Löe was higher in the SCN cases (p < 0.05). Moreover, GCF levels of IFN-α, TNF-α, IL-10, IL-13, IL-15, IL-17, IL-2, IL-7, IL-33, IP-10, MIG, MIP-1β were significantly higher in the controls. Decreased cytokine secretion seems to correlate with the decrease in neutrophil counts. The severity of gingival inflammation in SCN patients may be due to the bacterial overgrowth and the change in the content of the oral flora due to the decreased neutrophil counts. Therefore, regular periodontal examinations, the motivation of oral hygiene as well as the compliance with therapy in SCN patients contribute to the periodontal health.

Inducible expression of a disease-associated ELANE mutation impairs granulocytic differentiation, without eliciting an unfolded protein response

Severe congenital neutropenia (SCN) is characterized by a near absence of neutrophils, rendering individuals with this disorder vulnerable to recurrent life-threatening infections. The majority of SCN cases arise because of germline mutations in the gene elastase, neutrophil-expressed (ELANE) encoding the neutrophil granule serine protease neutrophil elastase. Treatment with a high dose of granulocyte colony-stimulating factor increases neutrophil production and reduces infection risk. How ELANE mutations produce SCN remains unknown. The currently proposed mechanism is that ELANE mutations promote protein misfolding, resulting in endoplasmic reticulum stress and activation of the unfolded protein response (UPR), triggering death of neutrophil precursors and resulting in neutropenia. Here we studied the ELANE mutation p.G185R, often associated with greater clinical severity (e.g. decreased responsiveness to granulocyte colony-stimulating factor and increased leukemogenesis). Using an inducible expression system, we observed that this ELANE mutation diminishes enzymatic activity and granulocytic differentiation without significantly affecting cell proliferation, cell death, or UPR induction in murine myeloblast 32D and human promyelocytic NB4 cells. Impaired differentiation was associated with decreased expression of genes encoding critical hematopoietic transcription factors (Gfi1, Cebpd, Cebpe, and Spi1), cell surface proteins (Csf3r and Gr1), and neutrophil granule proteins (Mpo and Elane). Together, these findings challenge the currently prevailing model that SCN results from mutant ELANE, which triggers endoplasmic reticulum stress, UPR, and apoptosis.

Heterozygous Mutations of Clpb As a Newly Identified and Frequent Cause of Severe Congenital Neutropenia

Severe congenital neutropenia (SCN) is an inborn disorder of granulopoiesis characterized by severe chronic neutropenia from birth, premature death secondary to infectious complications, and transformation to myeloid malignancy. Although many cases of SCN are associated with mutations in ELANE, encoding the neutrophil elastase, roughly one-third of cases do not have an identifiable genetic cause. In collaboration with the Severe Chronic Neutropenia International Registry (SCNIR), we performed exome sequencing on 90 cases of congenital neutropenia. Heterozygous missense mutations of CLPB were identified in six patients with SCN. None of these patients had mutations in other genes known to cause SCN. A total of 5 different mutations were identified that clustered within the ATPase domain. Of note, all of these mutations were predicted to be functionally deleterious and had a frequency of &amp;lt;0.002% in the ExAC and gnomAD databases. We subsequently identified heterozygous CLPB mutations in an additional 3 cases of SCN that were not part of our original cohort. Prior studies showed that biallelic mutations of CLPB are associated with a syndrome defined by 3-methylglutaconic aciduria (3-MGA), cataracts, neurologic disease, and variable neutropenia. In our original cohort of 6 SCN patients with heterozygous CLPB mutations, 3-MGA was not present in the three cases where urine samples were available and none had reported cataracts. In total, 3 had neurologic abnormalities (2 seizures and 1 developmental delay). Of note, the CLPB mutations present in syndromic cases were distinct from those seen in our SCN cohort, and none of the mutations in our series are biallelic. CLPB encodes for caseinolytic peptidase B, a protein implicated in protein folding in bacteria and yeast but with an unknown role in human granulopoiesis. Based on these observations, we hypothesize that CLPB is required for normal basal granulopoiesis and that the heterozygous CLPB mutations identified in our study act in a dominant-negative fashion to disrupt granulopoiesis. To test this hypothesis, two complementary genetic approaches were employed. First, we used CRISPR-Cas9 gene editing to generate null mutations in CLPB in human cord blood-derived CD34+ hematopoietic stem/progenitor cells (HSPCs). Using this approach, we are able to achieve greater than 90% editing efficiency as assessed by next generation sequencing. The genetically modified HSPCs were cultured for 14 days under conditions that promote granulocytic differentiation. Modified HSPCs were also seeded into methylcellulose cultures to measure CFU-G. The percentage and absolute number of mature granulocytes, but not early granulocytic precursors (promyelocytes and myelocytes), were significantly reduced in cultures of gene-edited cord blood CD34+ cells. Moreover, the frequency of edited cells decreases over time in our culture system indicating that CLPB-knockout cells have a competitive disadvantage. A significant decrease in CFU-G also was observed. Second, we generated lentivirus expressing all 5 of the neutropenia-associated heterozygous CLPB mutations identified in our SCN cohort (N496K, E557K, R561G, R603H, and R620C). Expression of all of these mutants (except R603H) in cord blood-derived CD34+ cells was associated with a significant decrease in mature neutrophils and corresponding increase in early granulocytic precursors. These four CLPB mutants also resulted in a decrease in CFU-G. Collectively, these data strongly suggest that heterozygous mutations of CLPB are a new cause of congenital neutropenia. Indeed, in the North American population, CLPB mutations appear to be the second most common cause of congenital neutropenia, behind ELANE mutations. Studies are underway to examine the molecular mechanisms by which mutant CLPB disrupts granulopoiesis. Disclosures Dale: Coherus: Consultancy; Beheringer/Ingelheim: Consultancy; Athelas: Equity Ownership; Amgen: Consultancy, Research Funding; Sanofi Aventis: Consultancy, Honoraria; Cellerant: Other: Scientific Advisory Board; Hospira: Consultancy; Prolong: Consultancy; x4pharma: Consultancy, Honoraria, Research Funding.

Inducible Expression of Mutant ELANE Correlates with Disruption of Differentiation Program, but Not the Unfolded Protein Response

Background. Severe congenital neutropenia (SCN) is characterized by a critical reduction in absolute neutrophil count (ANC &amp;lt; 500/μl), which renders the affected individual vulnerable to recurrent, life-threatening infections. A majority of SCN cases arise due to germline mutations in the neutrophil elastase gene (ELANE). Treatment with high dose granulocyte colony stimulating factor (GCSF) increases the number of neutrophils and eliminates the risk of infection. SCN patients are at a significantly high risk of developing myelodysplastic syndrome (MDS) or acute myelogenous leukemia (AML). About 70% of the MDS/AML cases report somatic mutations in the GCSF receptor gene (CSF3R), suggesting a correlation between GCSF treatment and development of MDS/AML. The current favored mechanism for ELANE mutations promoting SCN is induction of an unfolded protein response (UPR), triggering death of neutrophil precursors resulting in neutropenia. However multiple studies of UPR activation reported a requirement of treatment with chemical UPR inducers such as tunicamycin or bortezomib to observe significant changes. The mechanism of mutant ELANE-mediated neutrophil deficit thus remains elusive. In addition, the ability of G-CSF to alleviate neutropenia and its role in progression from SCN to MDS/AML is still a confounding factor in G-CSF therapy for SCN cases. Methods.We created a doxycycline inducible expression system of ELANE, consisting of wild type (wt) and point mutation (G185R) variant associated with SCN, in the murine myeloblast cell line 32D and the human promyelocytic leukemia cell line NB4. We determined the effect of mutant ELANE expression on cell proliferation (Trypan blue exclusion), survival (Trypan blue exclusion, AnnexinV-PI staining) and differentiation (Wright-Giemsa staining, CD11b expression). Underlying molecular changes were investigated using immunoblotting and qPCR based gene expression analysis. Results . Induction of wt or mutant ELANEexpression with doxycycline did not have any detrimental effects on cell proliferation and survival. However, a partial block in differentiation with an accumulation of myeloid progenitors was observed in cells expression mutant ELANE. Profiling of gene expression for markers of differentiation identified reduced expression of key transcriptional factors (Cebpa, Cebpe, Cebpb, Cebpd, Gfi1, Spi1) coupled with reduced levels of other markers of differentiation (e.g., Mpo, Ltf). Increased transcript levels were also observed in some cell cycle genes (Pola1, Ccnd1). We did not observe an increase in expression of UPR genes upon mutant ELANEinduction. Conclusion.Our data demonstrate that expression of mutant ELANE promotes an aberrant differentiation gene expression profile that leads to a partial block in differentiation. In addition, our data also suggest that mutant ELANE expression does not promote UPR. We also show a concomitant upregulation of cell proliferation genes upon mutant ELANE expression. This detour from a differentiation profile may indicate pre-leukemic underpinnings for G-CSF treatment in SCN. Disclosures No relevant conflicts of interest to declare.

Mutation, drift and selection in single-driver hematologic malignancy: Example of secondary myelodysplastic syndrome following treatment of inherited neutropenia

Cancer development is driven by series of events involving mutations, which may become fixed in a tumor via genetic drift and selection. This process usually includes a limited number of driver (advantageous) mutations and a greater number of passenger (neutral or mildly deleterious) mutations. We focus on a real-world leukemia model evolving on the background of a germline mutation. Severe congenital neutropenia (SCN) evolves to secondary myelodysplastic syndrome (sMDS) and/or secondary acute myeloid leukemia (sAML) in 30–40%. The majority of SCN cases are due to a germline ELANE mutation. Acquired mutations in CSF3R occur in >70% sMDS/sAML associated with SCN. Hypotheses underlying our model are: an ELANE mutation causes SCN; CSF3R mutations occur spontaneously at a low rate; in fetal life, hematopoietic stem and progenitor cells expands quickly, resulting in a high probability of several tens to several hundreds of cells with CSF3R truncation mutations; therapeutic granulocyte colony-stimulating factor (G-CSF) administration early in life exerts a strong selective pressure, providing mutants with a growth advantage. Applying population genetics theory, we propose a novel two-phase model of disease development from SCN to sMDS. In Phase 1, hematopoietic tissues expand and produce tens to hundreds of stem cells with the CSF3R truncation mutation. Phase 2 occurs postnatally through adult stages with bone marrow production of granulocyte precursors and positive selection of mutants due to chronic G-CSF therapy to reverse the severe neutropenia. We predict the existence of the pool of cells with the mutated truncated receptor before G-CSF treatment begins. The model does not require increase in mutation rate under G-CSF treatment and agrees with age distribution of sMDS onset and clinical sequencing data.

Extended Genetic Testing in Severe Congenital Neutropenia May Identify Mutations That Inform Therapy

The Severe Chronic Neutropenia International Registry (SCNIR) in cooperation with Washington University has developed a next-generation sequencing assay for the genetic diagnosis of chronic neutropenia. Exome-based sequencing is performed, and genetic alterations in 27 genes implicated in the pathogenesis of severe congenital neutropenia (SCN) are reported. Of note, with consent, patients are enrolled in the SCNIR to collect detailed clinical data and to allow researchers access to the exome sequence data to identify new genetic alterations contributing to disease pathogenesis, severity, and progression to acute myeloid leukemia. Here, we report sequencing results for 61 cases of SCN, 31 cases of cyclic neutropenia, and 3 cases of idiopathic or unclassified neutropenia. The median age of this cohort was 17.2 years (range 0.13 to 78 years). Ninety-eight per cent of the SCN cases received G-CSF with a median dose of 1.85 mg/kg/day (range, 0-99.3), and 87% of cyclic neutropenia cases received G-CSF with a median dose of 0.34 mg/kg/day (range, 0-5.2). ELANE mutation status was previously determined for the majority of these cases. In total, 16 of 95 cases of neutropenia had a known ELANE mutation, and the remainder of the cases had no genetic diagnosis.Initial analyses focused on the following genes previously implicated in SCN pathogenesis: ELANE, AP3B1, CSF3R, CXCR2, CXCR4, G6PC3, GFI1, HAX1, LYST, LAMTOR2, RAB27A, SBDS, SLC37A4, SRP54, TCIRG1, VPS13B, VPS45, USB1, TAZ, and WAS. Heterozygous mutations of ELANE were identified in the 16 previously identified cases, but in no additional cases. Of the remaining 50 cases of SCN, probable pathogenic mutations were identified in 8 (16%). Surprisingly, in the 27 cases of cyclic neutropenia with wildtype ELANE, no probable pathogenic mutations were identified. We identified three cases of SCN (including two family members) with biallelic mutations of G6PC3 and single cases of SCN with N382S GFI or R184C TCIRG1 mutations. A novel homozygous R547X CSF3R mutation was seen in one case of SCN. This truncation mutation in the extracellular domain of the G-CSF receptor is predicted to result in a complete loss-of-function allele. Indeed, this patient was refractory to G-CSF therapy. We also identified a single case of SCN carrying a R338X CXCR4 mutation, the cause of WHIM syndrome. Of note, emerging data suggest that the neutropenia in WHIM syndrome can be effectively treated with CXCR4 antagonists. We identified two cases of SCN carrying heterozygous mutations of SRP54, G175E and T191I, respectively. These SRP54 mutations, although not previously reported, localize to the GTPase domain of SRP54 (similar to previously identified SRP54 mutations), and they have not been identified in over 60,000 individuals in the ExAC database.Conclusions: Extended genetic testing in patients with chronic neutropenia and wildtype ELANE, although identifying a pathogenic mutation in the minority of cases, may impact the choice of therapy. Analyses of the exome sequence data are underway to identify novel candidate genes contributing to neutropenia. DisclosuresDale:Athelas, Inc.: Equity Ownership; Amgen: Consultancy, Research Funding; Sanofi-Aventi: Consultancy, Honoraria; Cellerant: Other: Scientific Advisory Board; Hospira: Consultancy; Prolong: Consultancy; Beheringer-Ingelheim: Consultancy; Coherus: Consultancy.

Molecular Spectrum of CSF3R variants Correlate with Specific Myeloid Malignancies and Secondary Mutations

Molecular Spectrum of CSF3R variants Correlate with Specific Myeloid Malignancies and Secondary Mutations

Case Reports of Severe Congenital Neutropenia Treated With Unrelated Cord Blood Transplantation With Reduced-intensity Conditioning

Allogeneic stem cell transplantation is a curative treatment for severe congenital neutropenia (SCN). However, a standard conditioning regimen and donor source have not been established. We report 3 consecutive cases of SCN who were successfully treated by cord blood transplantation (CBT) with reduced-intensity conditioning consisting of fludarabine, melphalan, and low-dose total body irradiation. All cases achieved complete donor chimerism without severe infectious complications and have maintained normal neutrophil counts for between 3 and 9 years after CBT. These results suggest that CBT with reduced-intensity conditioning can be an alternative therapy for SCN when human leukocyte antigen-matched bone marrow donor is unavailable.

Clinical characteristics of severe congenital neutropenia caused by novel ELANE gene mutations.

Mutations within the ELANE gene, which encodes human neutrophil elastase, are the most common genetic causes of severe congenital neutropenia (SCN). No cases of SCN have been previously described from a Chinese population. Herein, we describe the clinical, hematologic and molecular characteristics of 7 Chinese SCN cases with novel ELANE mutations. Seven Chinese pediatric patients (4 males and 3 females) with suspected SCN were enrolled in this study. Clinical data, peripheral blood, bone marrow and immune function were evaluated for SCN. ELANE genomic DNA and cDNA sequences from patients and potential carriers were analyzed using polymerase chain reaction (PCR) and direct sequencing. All the7 patients experienced recurrent infection (soft tissue, lung, oral cavity) during a period of 120 days. Noninfectious conditions such as anemia and osteopenia were found in most patients, and absolute peripheral neutrophil counts varied. DNA and cDNA sequencing demonstrated that the patients harbored a range of heterozygous ELANE gene mutations, including substitution, deletion, insertion and frame shift alterations. All the mutations had not been reported previously; however, no mutation carriers were identified among the parents or siblings, even in a family with 2 affected offspring. SCN cases were identified for the first time in China, and all patients carried novel ELANE mutations. Granulocyte-colony stimulating factor (G-CSF) was an effective treatment for most of the SCN patients and prevented life-threatening bacterial infections.

Neurological findings and genetic alterations in patients with Kostmann syndrome and HAX1 mutations

To describe the clinical profile and the prevalence of severe congenital neutropenia (SCN) and HAX1 mutations, so-called Kostmann syndrome, in France. Two pedigrees were identified from the French registry. The study included five subjects (three males), which represent 0.7% of the 759 SCN cases registered in France. The age at diagnosis was 0.3 years (range: 0.1-1.2 years) and the median age at the last follow-up was 7.3 years (range: 1.2-17.8 years). A novel large homozygous deletion of the HAX1 gene (exons 2-5) was found in one pedigree; while, a homozygous frameshift mutation was identified in exon 3 (c.430dupG, p.Val144fs) in the second pedigree. Severe bacterial infections were observed in four patients, including two cases of sepsis, one case of pancolitis, a lung abscess, and recurrent cellulitis and stomatitis. During routine follow-up, the median neutrophil value was 0.16 × 10(9)/L, associated with monocytosis (2 × 10(9)/L). Bone marrow (BM) smears revealed a decrease of the granulocytic lineage with no mature myeloid cells above the myelocytes. One patient died at age 2 from neurological complications, while two other patients, including one who underwent a hematopoietic stem cell transplantation (HSCT) at age 5, are living with very severe neurological retardation. SCN with HAX1 mutations, is a rare sub type of congenital neutropenia, mostly observed in population from Sweden and Asia minor, associating frequently neurological retardation, when the mutations involved the B isoform of the protein.

Different Clinical Phenotypes in Familial Severe Congenital Neutropenia Cases with Same Mutation of theELANEGene

Severe congenital neutropenia (SCN) is a heterogeneous group of disorders with a defect in granulopoiesis causing marked neutropenia and severe bacterial infections. A 17-month-old girl (patient 1) was admitted due to cervical lymphadenitis caused by methicillin-resistant Staphylococcus aureus, with neutropenia. She had Pseudomonas aeruginosa sepsis and peritonitis with perforated appendicitis at 8-month of age. Her sister, a 37-month-old girl (patient 2), had recurrent stomatitis with profound neutropenia, and her mother, a 32-yr-old woman (patient 3), had had recurrent stomatitis until her early 20s with neutropenia. We found an ELANE gene mutation (c.597+1G > A) from them in direct DNA sequencing analysis. Patients 1 and 2 did not respond to granulocyte colony stimulating factor and patient 1 was treated with prolonged antibiotics and excision. We demonstrated inherited SCN cases showing different severity even with the same mutation of the ELANE gene in a family.

The Spectrum ofELANEMutations and their Implications in Severe Congenital and Cyclic Neutropenia

Neutrophil elastase gene (ELANE) mutations are responsible for the majority of cases of severe congenital neutropenia (CN) and cyclic neutropenia (CyN). We screened CN (n=395) or CyN (n=92) patients for ELANE mutations and investigated the impact of mutations on mRNA expression, protein expression, and activity. We found 116 different mutations in 162 (41%) CN patients and 26 in 51 (55%) CyN patients, 69 of them were novel. CyN-associated mutations were predicted to be more benign than CN-associated mutations, but the mutation severity largely overlapped. The frequency of acquired CSF3R mutations, malignant transformation, and the need for hematopoietic stem cell transplantation was significantly higher in CN patients with ELANE mutation than in ELANE mutation negative patients. Cellular elastase activity was reduced in neutrophils from CN/CyN patients, irrespective of the mutation status. In CN, enzymatic activity was significantly lower in patients with ELANE mutations compared with those with wild-type ELANE. Despite differences in the spectrum of mutations in CN or CyN, type or localization of mutation only partially determine the clinical phenotype. Specific ELANE mutations have limited predictive value for leukemogenesis; the risk for leukemia was correlated with disease severity rather than with occurrence of an ELANE mutation.

Incidence of severe congenital neutropenia in Sweden and risk of evolution to myelodysplastic syndrome/leukaemia

Severe congenital neutropenia (SCN) is characterized by low blood neutrophil counts, early bacterial infections, and risk of leukaemia development. As yet, no population-based incidence estimates of SCN have been reported. Children less than 16 years of age with SCN were sought in Sweden during the 20-year period 1987-2006 by a questionnaire to all Swedish Departments of Paediatrics and by reviewing the Swedish Health and Welfare Statistical Databases. Thirty-two patients were diagnosed with congenital neutropenia during this period. All received treatment with recombinant granulocyte-colony stimulating factor (G-CSF). Twenty-one patients were diagnosed as SCN or probable SCN, corresponding to 1·0 per 100,000 live births. Nine (43%) had ELANE mutations, four (19%) HAX1 mutations and eight (38%) were children with disease of unknown genetic aetiology. Four out of 21 patients (19%) developed myelodysplastic syndrome/leukaemia and three (14%) died, all with leukaemia. The cumulative incidence of myelodysplastic syndrome/leukaemia was 31%. The observed incidence of SCN in this population-based study was higher than previously estimated, possibly because genetic testing now can identify SCN cases previously thought to be idiopathic or benign neutropenia. The risk of developing myelodysplastic syndrome/leukaemia is considerable. ELANE mutations are the most commonly identified genetic defects.

Cyclic neutropenia and severe congenital neutropenia in patients with a shared ELANE mutation and paternal haplotype: Evidence for phenotype determination by modifying genes

Cyclic neutropenia (CN) and severe congenital neutropenia (SCN) are disorders of neutrophil production that differ markedly in disease severity. Mutations of the ELANE gene (the symbol recently replacing ELA2) are considered largely responsible for most cases of CN and SCN, but specific mutations are typically associated with one or the other. We performed ELANE genotyping on all individuals and paternal sperm in an SCN kindred with eight SCN progeny of a sperm donor and six different mothers. One patient with CN had the same S97L ELANE mutation as seven patients with the SCN phenotype. The mutant allele was detected in the donor's spermatozoa, representing 18% of the ELANE gene pool, but not in DNA from his lymphocytes, neutrophils, or buccal mucosa, indicating gonadal mosaicism. The coexistence of CN and SCN phenotypes in this kindred with a shared paternal haplotype strongly suggests both a role for modifying genes in determination of congenital neutropenia disease phenotypes, and the classification of CN and SCN within a spectrum of phenotypes expressing varying degrees of the same disease process.

Molecular Analysis of Two Cases of Severe Congenital Neutropenia

Severe congenital neutropenia is a rare hematological disease characterized by a selective decrease in circulating neutrophils, maturation arrest of granulocytic precursors at the promyelocyte stage, and recurrence of infections. A 2-month-old male infant (patient A) and a 14-month-old female child (patient B) were referred to our hospital due to severe neutropenia. Sequencing analysis of ELA2 and HAX1 genes was performed. Two single nucleotide polymorphisms of HAX1 gene were found. They were 5,104T-->G point mutation of exon 1 and 5,474A-->G point mutation of intron 1 in HAX1 gene. The mutation of ELA2 gene was not found. The patient A showed a good response to granulocyte colony-stimulating factor (G-CSF) treatment and the absolute neutrophil count recovered to 1,195/microL. But the patient B showed a partial response to G-CSF treatment and experienced several episodes of herpetic gingivostomatitis, oral ulcer, acute pharyngotonsillitis and otitis media during follow-up.

Leukocytoclastic Vasculitis in Patients with Severe Congenital Neutropenia

Leukocytoclastic vasculitis is a rare complication of the use of granulocyte colony-stimulating factor (G-CSF). We present two cases of severe congenital neutropenia (SCN) associated with GCSF use. It is reported that skin rashes and biopsy findings of leukocytoclastic vasculitis following the use of G-CSF.