Cells In Common Variable Immunodeficiency Research Articles

Paucity of gastrointestinal plasma cells in common variable immunodeficiency

Purpose of review Common variable immunodeficiency enteropathy (CVID-E) is a noninfectious complication of CVID caused by chronic inflammation of the gastrointestinal (GI) tract. Based on literature, a paucity or lack of plasma cells, although not obligatory for diagnosis, is a pathognomonic feature of CVID and more frequent in CVID-E. However, there is no consensus on standardized histopathological analysis of this feature in biopsies. In this systematic review, we highlight methods of reproducible plasma cell quantification of biopsies in CVID and describe the plasma cell counts and classes as presented in the literature. Recent findings Reduced plasma cell counts are commonly found over the entire GI tract, except for in the oesophagus. Immunoglobulin A+ (IgA+) plasma cells appear to be the most commonly reduced plasma cell class in CVID, yet there is scarce literature on the predictive value of low IgA+ plasma cell counts in CVID-E. Summary We propose two optimized methodologies of quantification using a cut-of value of <10 plasma cells per HPF at 40× magnification, or a proportion of ≥1–5% of total mononuclear cells, recorded over ≥3 sections, and in ≥2 biopsies, as the most conservative agreeable definitions for a paucity of plasma cells to be used in diagnostics and further research.

Cytomegalovirus drives Vδ1+ γδ T cell expansion and clonality in common variable immunodeficiency

The function and phenotype of γδ T cells in the context of common variable immunodeficiency (CVID) has not been explored. CVID is a primary immunodeficiency disorder characterized by impaired antibody responses resulting in increased susceptibility to infections. γδ T cells are a subset of unconventional T cells that play crucial roles in host defence against infections. In this study, we aim to determine the roles and functions of γδ T cells in CVID. We observe a higher frequency of Vδ1+ γδ T cells compared to healthy controls, particularly in older patients. We also find a higher proportion of effector-memory Vδ1+ γδ T cells and a more clonal T cell receptor (TCR) repertoire in CVID. The most significant driver of the Vδ1+ γδ T cell expansion and phenotype in CVID patients is persistent cytomegalovirus (CMV) viremia. These findings provide valuable insights into γδ T cell biology and their contribution to immune defence in CVID.

ICOS agonist vopratelimab modulates follicular helper T cells and improves B cell function in common variable immunodeficiency

Common variable immunodeficiency (CVID) is an immune defect characterized by hypogammaglobulinemia and impaired development of B cells into plasma cells. As follicular helper T cells (TFH) play a central role in humoral immunity, we examined TFH cells in CVID, and investigated whether an inducible T cell co-stimulator (ICOS) agonist, vopratelimab, could modulate TFH, B cell interactions and enhance immunoglobulin production. CVID subjects had decreased TFH17 and increased TFH1 subsets; this was associated with increased transitional B cells and decreased IgG+ B and IgD−IgM−CD27+ memory B cells. ICOS expression on CVID CD4+ T cells was also decreased. However, ICOS activation of CD4+ T cells by vopratelimab significantly increased total CVID TFH, TFH2, cell numbers, as well as IL-4, IL-10 and IL-21 secretion in vitro. Vopratelimab treatment also increased plasma cells, IgG+ B cells, reduced naïve & transitional B cells and significantly increased IgG1 secretion by CVID B cells. Interestingly, vopratelimab treatment also restored IgA secretion in PBMCs from several CVID patients who had a complete lack of endogenous serum IgA. Our data demonstrate the potential of TFH modulation in restoring TFH and enhancing B cell maturation in CVID. The effects of an ICOS agonist in antibody defects warrants further investigation. This biologic may also be of therapeutic interest in other clinical settings of antibody deficiency.

Gene Signature of Regulatory T Cells Isolated from Children with Selective IgA Deficiency and Common Variable Immunodeficiency.

Selective IgA deficiency (SIgAD) is the most common form and common variable immunodeficiency (CVID) is the most symptomatic form of predominant antibody deficiency. Despite differences in the clinical picture, a similar genetic background is suggested. A common feature of both disorders is the occurrence of autoimmune conditions. Regulatory T cells (Tregs) are the major immune cell type that maintains autoimmune tolerance. As the different types of abnormalities of Treg cells have been associated with autoimmune disorders in primary immunodeficiency (PID) patients, in our study we aimed to analyze the gene expression profiles of Treg cells in CVID and SIgAD patients compared to age-matched healthy controls. The transcriptome-wide gene profiling was performed by microarray technology. As a result, we analyzed and visualized gene expression patterns of isolated population of Treg cells. We showed the differences at the gene level between patients with and without autoimmunizations. Our findings suggest that the gene signatures of Treg cells isolated from SIgAD and CVID patients differ from age-matched healthy controls and from each other, presenting transcriptional profiles enriched in innate immune or Th response, respectively. The occurrence of autoimmunity in both types of PID is associated with down-regulation of class I IFNs signaling pathways. In summary, our findings improve our understanding of Treg dysfunctions in patients with common PIDs and associated autoimmunity.

IgD+IgM- B Cells in Common Variable Immunodeficiency.

Common variable immunodeficiency (CVID) is the most frequent form of primary hypogammaglobulinemia in adults. In addition to recurrent infections and respiratory manifestations, CVID patients may present several non-infection complications such as autoimmune diseases. The mechanisms that lead to immune dysregulation in CVID are not completely understood. Given the role of IgD on naïve B cells in the maintenance of tolerance and secreted IgD in the respiratory mucosa, we evaluated the frequency of IgD+ naïve and IgD+ memory B cells in CVID patients. Here, no differences were observed in the percentages and proliferative responses of anergic IgD+IgM-CD27- B cells between CVID patients, with or without autoimmune disease, and the control group. Interestingly, in the compartment of memory B cells, the percentage of IgD+IgM- cells was higher only in CVID patients with allergic rhinitis/allergic asthma. Our results may indicate that anergic IgD+IgM-CD27- B cells may not be compromised in our CVID cohort. However, IgD+IgM- memory B cells may play a role in the immunopathogenesis of allergic rhinitis/allergic asthma in CVID patients. Further studies are needed to better understand the participation of IgD+IgM- memory B cells in the immunopathogenesis of allergic rhinitis/allergic asthma in CVID patients.

Plasma Levels of mir-34a-5p Correlate with Systemic Inflammation and Low Naïve CD4 T Cells in Common Variable Immunodeficiency

PurposeCommon variable immunodeficiency (CVID) is a primary antibody deficiency that commonly manifests as recurrent infections. Many CVID patients also suffer from immune dysregulation, an inflammatory condition characterized by polyclonal lymphocytic tissue infiltration and associated with increased morbidity and mortality. The genetic cause is unknown in most CVID patients and epigenetic alterations may contribute to the broad range of clinical manifestations. MicroRNAs are small non-coding RNAs that are involved in epigenetic modulation and may contribute to the clinical phenotype in CVID.MethodsHere, we determined the circulating microRNAome and plasma inflammatory proteins of a cohort of CVID patients with various levels of immune dysregulation and compared them to healthy controls. A set of deregulated microRNAs was validated by qPCR and correlated to inflammatory proteins and clinical findings.ResultsLevels of microRNA-34a correlated with 11 proteins such as CXCL9, TNF, and IL10, which were predicted to be biologically connected. Moreover, there was a negative correlation between mir-34 levels and the number of naïve CD4 T cells in CVID.ConclusionCollectively, our data show that microRNAs correlate with the inflammatory response in CVID. Further investigations are needed to elucidate the role of miRNAs in the development of CVID-related immune dysregulation.

Dysregulated PI3K Signaling in B Cells of CVID Patients.

The altered wiring of signaling pathways downstream of antigen receptors of T and B cells contributes to the dysregulation of the adaptive immune system, potentially causing immunodeficiency and autoimmunity. In humans, the investigation of such complex systems benefits from nature’s experiments in patients with genetically defined primary immunodeficiencies. Disturbed B-cell receptor (BCR) signaling in a subgroup of common variable immunodeficiency (CVID) patients with immune dysregulation and expanded T-bethighCD21low B cells in peripheral blood has been previously reported. Here, we investigate PI3K signaling and its targets as crucial regulators of survival, proliferation and metabolism by intracellular flow cytometry, imaging flow cytometry and RNAseq. We observed increased basal but disturbed BCR-induced PI3K signaling, especially in T-bethighCD21low B cells from CVID patients, translating into impaired activation of crucial downstream molecules and affecting proliferation, survival and the metabolic profile. In contrast to CVID, increased basal activity of PI3K in patients with a gain-of-function mutation in PIK3CD and activated PI3K delta syndrome (APDS) did not result in impaired BCR-induced AKT-mTOR-S6 phosphorylation, highlighting that signaling defects in B cells in CVID and APDS patients are fundamentally different and that assessing responses to BCR stimulation is an appropriate confirmative diagnostic test for APDS. The active PI3K signaling in vivo may render autoreactive T-bethighCD21low B cells in CVID at the same time to be more sensitive to mTOR or PI3K inhibition.

Role of rare immune cells in common variable immunodeficiency.

Common variable immunodeficiency disorder (CVID) is a heterogeneous disorder and the most common symptomatic antibody deficiency disease characterized with hypogammaglobulinemia and a broad range of clinical manifestations. Multiple genetic, epigenetic, and immunological defects are involved in the pathogenesis of CVID. These immunological defects include abnormalities in the number and/or function of B lymphocytes, T lymphocytes, and other rare immune cells. Although some immune cells have a relatively lower proportion among total immune subsets in the human body, they could have important roles in the pathogenesis of immunological disorders like CVID. To the best of our knowledge, this is the first review that described the role of rare immune cells in the pathogenesis and clinical presentations of CVID.

Phenotypically defined subpopulations of circulating follicular helper T cells in common variable immunodeficiency.

BackgroundCommon variable immunodeficiency (CVID) is characterized by low immunoglobulin G and IgA/IgM, decreased switched memory B cells, impaired response to vaccine, and an increased susceptibility to infections and autoimmunity. TFH cells play an important role in germinal center reaction where it supports isotype switching, somatic hypermutation, generation of memory B cells, and differentiation of B cells to plasma cells. The objective was to study the distribution of three subsets of TFH cells and their relationship with autoimmune diseases associated with CVID.MethodsTFH cells have been divided into TFH1 (interleukin 21 [IL‐21] and interferon γ), TFH2 (IL‐21 and IL‐4), and TFH17 (IL‐21 and IL‐17) cells. Mononuclear cells from 25 patients with CVID and age and gender‐matched controls were stained with various monoclonal antibodies (anti‐CD4 APC, anti‐CXCR5 FITC, anti‐CCR6 PerCP, and anti‐CXCR3 PE) and isotype controls and analyzed for TFH1 (CD4+CXCR5+CXCR3+CCR6−), TFH2 (CD4+CXCR5+CXCR3−CCR6−), and TFH17 (CD4+CXCR5+CXCR3−CCR6+) cells by multicolor flow cytometry. Twenty thousand cells were acquired and analyzed by FlowJo software. Statistical analysis of comparison of patients and healthy controls was performed by paired t test using PRISM 7 software.ResultsTFH2 and TFH17 cells subpopulations of TFH cells were significantly decreased (P < .003 and P < .006, respectively) in CVID as compared with controls. No significant difference was observed in any of TFH cell subpopulations between CVID with and those without autoimmunity group.ConclusionAlterations in TFH cell subpopulation may play a role in defects in B cell compartment in CVID.

Phenotypic and Functional Analysis of T Follicular Cells in Common Variable Immunodeficiency

Introduction: One of the most frequent abnormalities of B cells in common variable immunodeficiency (CVID) is reduced number of class-switched memory B cells, suggesting an impaired germinal center response. Therefore, due to its pivotal role in regulating the development of humoral immunity, the objective of this study was to evaluate the role of circulating T follicular helper (cT_FH) and circulating T follicular regulatory (cT_FR) cells in the pathogenesis of CVID. Methods: cT_FH and cT_FR cells from CVID patients and healthy subjects were phenotypically characterized by flow cytometry. cT_FH and memory B cells from CVID patients and healthy subjects were isolated and cocultured. Results: Our results showed a reduced proportion of cT_FH17 cells in patients with CVID and an increased ratio of cT_FH/cT_FR cells in CVID patients with autoimmune diseases. Furthermore, the proportion of IL-21-producing cT_FH cells was directly related to the proportion of CD27⁺ IgD⁻ B cells. Interestingly, coculture assay showed that CVID-derived cT_FH cells are able to help memory B cells from healthy controls to produce immunoglobulins. Conclusions: The proportions of cT_FH17 and cT_FR cells are altered in CVID patients; however, the cT_FH function in assisting B cells to produce antibodies in vitro is preserved.

Exhausted phenotype of follicular CD8 T cells in CVID

Exhausted phenotype of follicular CD8 T cells in CVID

Functions of Tfh Cells in Common Variable Immunodeficiency.

Common variable immunodeficiency is the most common clinical primary immunodeficiency in adults. Its hallmarks are hypogammaglobulinemia and compromised B-cell differentiation into memory or antibody-secreting cells leading to recurrent infections. This disease is heterogeneous, with some patients harboring multiple complications such as lymphoproliferative disorders, autoimmune manifestations, or granulomatous inflammation. The mechanisms leading to these complications remain elusive despite numerous associations found in the literature. For instance, although described as a B cell intrinsic disease, numerous abnormalities have been reported in other immune cell compartments. Here, we tuned our attention to follicular helper T cells, a CD4+ T cell population specialized in B cell help, considering the recent publications showing an involvement of these cells in CVID pathogenesis.

Low percentages of regulatory T cells in common variable immunodeficiency (CVID) patients with autoimmune diseases and its association with increased numbers of CD4+CD45RO+ T and CD21low B cells

BackgroundCommon variable immunodeficiency (CVID) is a heterogeneous group of primary antibody deficiencies defined by marked reductions in serum IgG, IgA and/or IgM levels and recurrent bacterial infections. Some patients are associated with defects in T cells and regulatory T cells (Tregs), resulting in recurrent viral infections and early-onset autoimmune disease. MethodsWe analyzed whether there is an association between Tregs cells (CD4+CD25+CD127low and CD4+CD25+FoxP3+); memory T cells (CD4+CD45RO+); memory B cells (CD19+CD27-IgD-); and CD21low B cells (CD19+CD38lowCD21low); as well as autoimmune manifestations in 36 patients with CVID (25 women and 11 men, mean age 24 years), all by flow cytometry. ResultsFourteen patients presented with autoimmune diseases (AI) (39%), including 11 with autoimmune thrombocytopenia (ITP) (31%); two with vitiligo (6%); one with systemic lupus erythematosus (LES) (3%); and one with multiple sclerosis (MS) (3%). CVID patients with AI had a reduced proportion of Tregs (both CD4+CD25+CD127low and FoxP3+ cells) compared with healthy controls. CVID patients with AI had expanded CD21low B cell populations compared with patients who did not have AI. A correlation between increased CD4+CD45RO T cell populations and reduced Tregs was also observed. ConclusionsOur results showed that 39% of patients with CVID had AI and reduced Tregs populations. Research in this area might provide noteworthy data to better understand immune dysfunction and dysregulation related to CVID.

Factors Beyond Lack of Antibody Govern Pulmonary Complications in Primary Antibody Deficiency.

Pulmonary complications occur frequently in primary antibody deficiency (PAD). While the impact of antibody deficiency may appear implicit for certain respiratory infections, immunoglobulin replacement therapy does not completely ameliorate pulmonary complications in PAD. Thus, there may be antibody-independent factors influencing susceptibility to respiratory disease in PAD, but these remain incompletely defined. We harnessed the multicenter US Immunodeficiency Network primary immunodeficiency registry to compare prevalence of asthma, bronchiectasis, interstitial lung disease (ILD), and respiratory infections between two forms of PAD: common variable immunodeficiency (CVID) and x-linked agammaglobulinemia (XLA). We also defined the clinical and immunological characteristics associated with ILD and asthma in CVID. Asthma, bronchiectasis, ILD, pneumonia, and upper respiratory infections were more prevalent in CVID than XLA. ILD was associated with autoimmunity, bronchiectasis, and pneumonia as well as fewer B and T cells in CVID. Asthma was the most common chronic pulmonary complication and associated with lower IgA and IgM in CVID. Age of symptom onset or CVID diagnosis was unrelated with ILD or asthma. Despite having less severe immunoglobulin deficiency than XLA, respiratory infections, ILD, and asthma were more common in CVID. Among CVID patients, ILD was associated with autoimmunity and reduced lymphocytes and asthma with lower immunoglobulins. Though our results are tempered by registry limitations, they provide evidence that factors beyond lack of antibody promote pulmonary complications in PAD. Efforts to understand how genetic etiology, nature of concurrent T cell deficiency, and propensity for autoimmunity shape pulmonary disease may improve treatment of PAD.

Dysregulation of Innate Lymphoid Cells in Common Variable Immunodeficiency.

Common variable immunodeficiency (CVID) is the most prevalent symptomatic primary immune deficiency. With widespread use of immunoglobulin replacement therapy, non-infectious complications, such as autoimmunity, chronic intestinal inflammation, and lung disease, have replaced infections as the major cause of morbidity and mortality in this immune deficiency. The pathogenic mechanisms that underlie the development of these complications in CVID are not known; however, there have been numerous associated laboratory findings. Among the most intriguing of these associations is elevation of interferon signature genes in CVID patients with inflammatory/autoimmune complications, as a similar gene expression profile is found in systemic lupus erythematosus and other chronic inflammatory diseases. Linked with this heightened interferon signature in CVID is an expansion of circulating IFN-γ-producing innate lymphoid cells. Innate lymphoid cells are key regulators of both protective and pathogenic immune responses that have been extensively studied in recent years. Further exploration of innate lymphoid cell biology in CVID may uncover key mechanisms underlying the development of inflammatory complications in these patients and may inspire much needed novel therapeutic approaches.

A Review on Defects of Dendritic Cells in Common Variable Immunodeficiency.

Common variable immunodeficiency (CVID) is the most important primary disorder that is associated with clinical complications including recurrent infections, malignancy and autoimmune diseases. The genetic cause of CVID is mostly unknown and only a few genetic causes are identified. The various options are proposed for determining the etiology of CVID patients, such as T- and B-cell defects, Toll-like receptors (TLRs) impairments, altered cytokine production as well as blemished dendritic cells (DCs). The patients with CVID show a reduction in number and frequency of DCs in blood, an altered expression of cell surface molecules, and defective activation through toll-like receptors (TLRs). Also loss of IFNα has a critical role in B-cell impairments of CVID patients. The aim of this review is to collect under one umbrella, all the recent knowledge about DCs defects of CVID patients. This review covers basic information about physiology of DCs followed by reports of DCs situation in CVID. According to the results of researches assessing DCs frequency and function in CVID, the roll of DCs in the pathogenesis of CVID cannot be ruled out. The article is expected to encourage the researchers to do comprehensive researches about complex connections between DCs and other immune cells in CVID.

Loss of Circulating Mucosal-Associated Invariant T Cells in Common Variable Immunodeficiency Is Associated with Immune Activation and Loss of Eomes and PLZF

Abstract Common variable immunodeficiency (CVID) is characterized by low levels of Igs leading to increased risk of infections. Mucosal-associated invariant T (MAIT) cells are a recently identified population of innate T cells with potent antibacterial activity. We hypothesized that CVID is associated with alterations in MAIT cells. Cryopreserved PBMC from CVID patients and healthy controls were used to study the frequency, phenotype, and response to Escherichia coli stimulation of MAIT cells by flow cytometry. MAIT cell frequency and absolute counts were depressed in CVID. Residual MAIT presented elevated coexpression of CD38 and HLA-DR, and reduced expression of CCR6, whereas levels of CD127 (IL-7 receptor) were unchanged. CVID patients also had an accumulation of MAIT cells lacking the critical transcription factors eomesodermin and promyelocytic leukemia zinc finger protein. MAIT cell frequency was inversely associated with levels of soluble CD14, with coexpression of CD38 and HLA-DR, and accumulation of MAIT cells lacking eomesodermin or promyelocytic leukemia zinc finger protein expression. None of these changes were normalized by IgG replacement therapy. Finally, MAIT cells from CVID patients displayed poor IFN-γ responses to E. coli stimulation, in part due to defective Ag presentation, and these responses were increased by pretreatment with IL-7. Defective MAIT cell response may contribute to the increased incidence of microbial infections seen in CVID patients on IgG replacement therapy.

Enhanced formation of giant cells in common variable immunodeficiency: Relation to granulomatous disease

Peripheral monocytes from patients with common variable immunodeficiency (CVID) had on average a 2 fold greater tendency to form giant cells in medium without additional cytokines. Giant cell formation was faster and 3 to 5 fold higher in most CVID cells compared to normal. Addition of IL4, GMCSF, IFNγ, TNFa and both T cell and monocyte conditioned media promoted monocyte fusion of some CVID individuals over 5 fold the normal average level, with combinations of cytokines and monokines acting synergistically. The reduction of normal giant cell formation by anti-IFNγ antibody and a greater tendency of CVID cells to fuse in immunoglobulin conditioned media suggests that standard IVIg treatment contributes to granuloma formation. CVID and normal giant cells expressed similar levels of phenotypic molecules and had similar phagocytic activity. Monocytes from many CVID patients have an elevated tendency to fuse which may explain the high incidence of granulomatous complications in CVID.

Impaired selective cytokine production by CD4+ T cells in Common Variable Immunodeficiency associated with the absence of memory B cells

Common Variable Immunodeficiency (CVID) is a primary immunodeficiency characterized by B cell dysfunction and decreased serum immunoglobulin. CVID patients are classified by the absence or presence of memory B cells. In addition, T cell defects have been demonstrated in only a proportion of CVID patients. The aim of this study was to evaluate the function of CD4+ T cells from CVID patients and its association with memory B cells. Patients were classified according to their Freiburg groups: group Ia and Ib, with decreased switched memory B cells (<0.4 of PBL), and group II, with normal B cell subsets. Their T cell function was evaluated after stimulation. We observed normal and even increased CD4+ T cell proliferation in group Ia (p=0.0277). The proliferation positively correlated with the clinical severity score (r=0.4796). We observed lower levels of IL-17A and IL-10 in group Ia (p=0.0177, 0.0109) and Ib (p=0.0009, 0.0084) patients. Group Ib patients also had low levels of IL-13 and IL-9 (p=0.0169, 0.010). Group II patients had similar cytokine production to that of the controls. BAFFR expression was reduced in groups Ia (p=0.0001) and Ib (p=0.0002) and showed an inverse correlation with the severity score (p=0.0262; r=0.5371). ICOS expression was reduced in group Ia (p=0.0364), and PD-1 was increased in group Ib (p=0.0432) patients. This study shows a selective impairment in cytokine production in group Ia patients, which was more extensive than in group Ib patients. The impairment was associated with BAFFR expression in B cells, with ICOS and PD-1 in T cells and, remarkably, with the absence of memory B cells and with the disease severity. Our results suggest that the evaluation of cytokine expression by T cells in combination with the study of B cell memory could be important for understand the pathogenesis of CVID patients.

Trying to Understand NK Cell Function in vivo Points towards a Severity Score for CVID Patients

Natural Killer (NK) cells were described 40 years ago as lymphoid cells exerting cytolytic activity against tumor cell lines in vitro (Herberman et al., 1975) and are accounted to the group of innate lymphoid cells. Functionally, they have been associated with anti-viral immunity (esp. herpesviridae) and tumor surveillance. However, NK cells have been less in the research focus compared to other components of the immune system (citations in Pubmed in 2015: ~ 2600 for NK cells compared to ~ 7100, ~ 14,600 and ~ 12,100 for B, T cells and macrophages, respectively). An isolated reduction of NK cells in humans has been suggested to be asymptomatic. Whether this notion somewhat reflects the inattentiveness towards NK cells or if NK cells in humans have only redundant functions in the immune system is still a matter of debate. Eric Vivier and colleagues hypothesized that the function of NK cells in humans might be revealed in immunocompromised subjects and report on a large cohort of patients with common variable immunodeficiency (CVID) registered in the French Registry (DEFI) (Ebbo et al., 2016). They stratified 457 CVID patients according to their NK cell numbers at study inclusion: roughly half of the patients had normal NK cell counts (> 100/μl), one quarter of the patients had slightly reduced NK cell counts (50–99/μl) and almost one quarter had severely reduced NK cell numbers (< 50/μl). CVID patients with severe NK cell lymphopenia exhibited a statistically significant increased rate of invasive bacterial infections defined as septicemia, pneumonia or meningitis: the frequency of invasive infections was 68.7% in severe NK lymphopenia, 60.2% in mild NK lymphopenia and 48.8% in patients with normal NK cell counts. However, there was no correlation of NK cell number and viral infections or malignancies. These results rely on prospectively collected registry data that might be skewed by reporting bias and correlations do not necessarily prove causality. Nonetheless, this observation fits well into the increasingly recognized role of NK cells in adaptive immunity. Apart from insights into NK cell biology the paper by Ebbo et al. reveals interesting aspects of NK cells in CVID. On a clinical basis CVID patients can be separated into patients who suffer from infectious complications as only complaint (“infection-only group”) and those who additionally suffer from non-infectious complications/immune dysregulation with e.g. lymphoproliferation, lung disease, enteropathy and malignancies. Whilst the infection-only group has a close to normal life expectancy when treated with immunoglobulin replacement, patients with immune dysregulation have an elevated mortality (Resnick et al., 2012). It is therefore of crucial interest to identify these patients early in the course of the disease and multiple groups have attempted to identify biomarkers in CVID by different approaches targeting B and/or T cells in the majority of cases (Piqueras et al., 2003, Giovannetti et al., 2007, Moratto et al., 2006, Driessen et al., 2011, Kamae et al., 2013, Wehr et al., 2008, Chapel et al., 2012). Ebbo and co-workers now add NK cells as a potential biomarker to the list as they showed that CVID patients with non-infectious complications are overrepresented amongst the patients with severe NK lymphopenia. This was significant for patients with granulomatous complications (NK cells severely reduced vs mildly reduced vs normal: 25.3% vs 13.6% vs 8.8%, p < 0.001) but there was also a trend towards higher frequencies of lymphoid hyperplasia (35.4% vs 24.6% and 19.2%), enteropathies (41.4% vs 28% vs 24.2%) and autoimmune cytopenia (25.3% vs 12.7% vs 14.6%). The authors also report that severely reduced NK cell counts in CVID are associated with lymphopenia i.e. CD4 + lymphopenia (median 415/μl vs 568 and 691/μl, p = 0.003), reduction of naive CD4 + cells (median 63/μl vs 135 and 183/μl, p = 0.003), CD8 lymphopenia (310/μl vs 431/μl vs 479/μl, p = 0.003) and B lymphopenia (median: 59/μl vs 99/μl and 122/μl, p = 0.003). CVID patients with severe NK lymphopenia also had lower levels of IgG, A and M at initial diagnosis compared to the two other groups. Mortality was higher in CVID with low T cell numbers (T cells < 200/μl) but not in patients with isolated low NK lymphopenia. Whilst other groups have associated low naive CD4 cell counts and expansion of CD21low B cells with a more severe CVID phenotype, Ebbo et al. show a weak, positive correlation between NK cell counts and CD21low B cells (r = 0.13, p = 0.05). Considering the large CVID cohort investigated by Ebbo et al., NK cells will have to be considered in future attempts to stratify CVID patients. Ideally the topic will be approached by a multinational team to unify the multiple attempts and dissect predictive biomarkers in CVID helping to early identify patients at risk from severe manifestations.