CGD Patients Research Articles

Chronic granulomatous disease: A single-center experience in Central Anatolia

BackgroundChronic granulomatous disease (CGD), one of the phagocytic cell defects, is the primary immunodeficiency caused by dysfunction of the NADPH oxidase complex in neutrophils. MethodsThe clinical, demographic and laboratory findings of 17 CGD patients who were followed-up between 2002 and 2021 were obtained retrospectively from the records of the patients. ResultsThe number of male and female patients was 10/7. The median age at diagnosis was 5.3 months (range 4–120) for 3 patients with X-CGD, and 42.4 months (range 8–350) for 14 patients with AR-CGD. We have investigated rare CYBA exon 3–6 deletion in 7 patients and hotspot mutation with delGT at the beginning of exon 2 of NCF1 in 5 patients. The most common clinical findings were pneumonia and lymphadenitis with recurrent fever, respectively (41.2%, 35.3%). A total of 154 microbial infections requiring hospital admission (27 in 3 XL and 127 in 14 AR patients) were detected in the follow-up of the patients and median infection number for a patient was 9 in both groups. Eight of 17 patients had stem cell transplantation and the survival rate was 87.5%. ConclusionsX-CGD patients are more rapidly recognized by family history and severe infections than those with AR-CGD and early prophylaxis may decrease infectious episodes. We have investigated the large deletion suggesting a possible founder effect for CYBA exon 3–6 deletion in Central Anatolia. Additionally, HSCT transplantation leads to a high survival rate for the patients with CGD.

Detection of CYBA Gene Expression by Reverse Transcription PCR as a Diagnostic Tool for Autosomal Recessive Chronic Granulomatous Disease in a Sample of Egyptian Children

Abstract Chronic granulomatous disease (CGD) is an inherited primary immunodeficiency disease caused by functional impairment of the nicotinamide dinucleotide phosphate (NADPH) oxidase complex in neutrophilic granulocytes and monocytes, characterized by recurrent and severe infections, dysregulated inflammation, and autoimmunity. Approximately two-thirds of patients with CGD have defects in Cytochrome Bβ (CYBB), the X-linked gene encoding glycoprotein 91 phagocytic oxidase (gp91phox). Rarer autosomal recessive (AR) forms of CGD are caused by autosomal recessive mutations in CYBA genes encoding protein 22 phagocytic oxidase (p22phox). However, the incidence of autosomal recessive CGD can be higher than X-linked CGD in countries with high rates of consanguineous marriage. In the present study we aimed to diagnose the commonest AR-type of CGD by detection of CYBA gene expression using real time RT-PCR as a cheaper diagnostic method for CGD subtypes categorization among immunodeficient children. This case-control study was conducted on 15 children provisionally diagnosed as CGD patients with DHR stimulation index using phorbol myristate acetate (PMA) < 30% (Group I). The study also included 12 mothers and 8 fathers of the studied patients to detect the genetic mutations in carriers, if any (Group IIa and IIb respectively), and 14 apparently healthy children as a control group (Group III). We found that cases with a fold change of CYBA gene expression less than 0.6 were considered under-expressed. At this cut-off value, from our molecularly studied subjects 1 case and 2 mothers showed under-expression of CYBA gene. In conclusion, we could establish the diagnosis of AR-form of CGD, derives from defects in the CYBA gene, which encodes p22phox of the NADPH oxidase using real time RT-PCR, without the need to use complex and expensive methodologies such as northern blot, slot blot, or genomic DNA sequencing.

Detection of NCF-2 Gene Expression in Egyptian Children with Chronic Granulomatous Disease

Abstract Background Chronic granulomatous disease (CGD) is a rare inherited primary immunodeficiency disorder (PID) which is characterized by enhanced susceptibility to severe bacterial and fungal infections. It results from defects in one of the five polypeptide subunits of the nicotinamide adenine dinucleotide phosphate-oxidase (NADPH) complex; CYBB (gp91-phox), NCF-1 (p47phox), CYBA (p22-phox), NCF-2 (p67-phox), or NCF-4 (p40-phox) with a resulting failure of the phagocytes in generating a variety of microbicidal reactive oxygen radicals during respiratory burst. Objectives This work intended to diagnose autosomal recessive (AR)-type of CGD by detection of NCF-2 gene expression using real time RT-PCR as a cheaper diagnostic method for CGD subtypes categorization among CGD children. Subjects and methods This case-control study was conducted on 15 children provisionally diagnosed as CGD patients by the use of dihydrorhodamine (DHR) stimulation index (Group I) in addition to 12 mothers and 8 fathers of the studied patients (Group IIa and IIb respectively) to detect the genetic mutations in carriers, if any, and 14 apparently healthy children as a control group (Group III). In the present study, cases with a fold change of NCF-2 gene expression less than 0.67 were considered defective for NCF-2 gene expression. At this cut-off value, from our molecularly studied subjects, 2 CGD cases and one mother showed underexpression of NCF-2 gene. In conclusion, defect in the NCF-2 gene, which encodes gp67-phox of the oxidase enzyme could be done by RT-PCR as a cheaper diagnostic method for CGD without the need to use complex and expensive methodologies such as northern blot, or genomic DNA sequencing.

Pulmonary Immunopathogenesis of Granulibacter bethesdensis

Abstract Granulibacter bethesdensis (Gb) is a Gram negative bacterial pathogen reported to cause disease exclusively in patients with Chronic Granulomatous Disease harboring mutations in one of the five subunits of NADPH oxidase complex. The pathogen has been shown to cause chronic as well as recurrent infections in CGD patients that can be fatal. Although systemic and septic infection have been reported, the pathogenesis of Gb in respiratory microenvironment is completely unknown. Here we compared the disease progression and infection outcome of wild-type (WT) and murine CGD model Gp91 −/−mice following intranasal infection with a clinical isolate of Gb. We found that compared to the WT mice, Gp91 −/−CGD mice are highly susceptible to respiratory infection with Gb. While the WT mice displayed transient increase in inflammatory cytokines and moderate leukocyte infiltration characteristic of a mild, resolving infection, CGD mice displayed hypercytokinemia but attenuated antimicrobial function of phagocytic cells. A significant upregulation of Type 2 inflammatory cytokine IFN-γ in lungs Gb infected gp91−/− prompted investigation the its role in GB pathogenesis. Neutralization of this cytokine mitigated the inflammatory response and reduced bacterial burden in infected Gp91−/− CGD mice resulting in significantly improved overall survival. Mechanistically, IFN-γ neutralization improved antimicrobial function of neutrophils. Taken together, our findings suggest that in the absence of a functional superoxide production machinery, G. bethesdensis is capable of causing a chronic respiratory infection with fulminant sepsis and IFN-γ produced during the infection has a detrimental effect on the bacterial clearance.

Father and son are carriers of two different types of human inborn errors of immunity: a case report

IntroductionChronic granulomatous disease (CGD) is an inborn error of immunity (IEI) characterized by recurrent bacterial and fungal infections of skin, airways, liver, brain and bones with the estimated prevalence of 1 in 250,000 live births. CGD can inherited either in an X-linked (allelic variants in the CYBB gene) or autosomal recessive mode (allelic variants in the CYBA, NCF1, NCF2, NCF4, and CYBC1 genes). Wiskott-Aldrich syndrome is an X-linked disorder with an estimated incidence of 1 in 100 000 live male births caused by variants in the WAS gene, characterized by microthrombocytopenia, eczema, recurrent infections, increased risk for autoimmune disease and malignancy. Materials and MethodsIn this case report, we present our experience about two cases of blood relatives diagnosed with different types of human inborn errors of immunity. Genetic analysis of CYBB gene in 2007 was performed by Sanger sequencing and of WAS gene in 2022 by next generation amplicon sequencing. All subjects consented to the study. ResultsThe first case was a 15-year-old male (1992 y.o.b., proband) who was diagnosed as X-linked CGD patient in 2007 due to his clinical history and hemizygote allelic variant in the CYBB gene (NM_000397.4: c.484–1G>T, COSV101059810). The second case was a 2-month-old boy (biological son of proband) who was hospitalized in 2022 due to microthrombocytopenia, low platelet volume, cytomegalovirus infection, mild anemia. Genetic analysis revealed in the DNA sample of the second case the hemizygote allelic variant in the WAS gene (NM_000377.3: c.777 +3_777+6del GAGT). Genetic testing didn’t reveal such variant in the DNA sample of the proband's wife, that's why this variant was classified as “de novo”. ConclusionInborn errors of immunity (IEI) present clinically as increased susceptibility to infections, autoimmunity, autoinflammatory diseases, allergy, bone marrow failure, and/or malignancy. There are now a total of 485 IEI, which are segregating to 10 groups of disorders into overlapping phenotypes. Despite the fact that IEI are rare diseases, we have shown that even in one family two different types of disorders can occur. In our case the second IEI was occur due to spontaneously alterations during the process of DNA replication during cell division.

X-Linked Chronic Granulomatous Disease in a Female Carrier: A Management Challenge

Abstract Chronic granulomatous disease (CGD) is characterized by recurrent bacterial and fungal infections due to reduced nicotinamide adenine dinucleotide phosphate oxidase resulting in impaired production of reactive oxidant species, and aberrant inflammation. X-linked CGD (XL-CGD) is associated with a mutation in the CYBB gene. XL-CGD affects more males, although some females are affected affected due to skewed X-inactivation. Though management guidelines for CGD patients exist, they remain lacking for clinically affected XL-CGD female carriers. A 3 year old female with history of hematochezia, oral ulcers, and recurrent skin infections who presented with fevers and skin pustules. Pustule cultures were positive for B. cepacian, and colonoscopy was non-acute. Immunology had concern for XL-CGD with recent atypical infections and dihydrorhodamine (DHR) flow cytometry was abnormal, 17.7% (normal greater than 95%). DHR 2 months later showed 13% activation. Genetic testing showed a CYBB, c.45+2dup (intronic), heterozygous, VUS, gene mutation affecting the splice site, associated with XL-CGD, and a NOD2, c.3019dup, heterozygous, with a 2–4 fold increased risk for Crohn’s disease. She was started on bacterial prophylaxis only. She is awaiting gp91phox expression for gene sequencing. XL-CGD carriers can be at higher risk for infections, and risk is inversely correlated with %DHR neutrophil counts, but only clinically apparent with %DHR less than 20%, and more as levels are less than 10%. Though our patient was started on Bactrim prophylaxis with her %DHR less than 20%, there remains the question of when and if she should be started on anti-fungal prophylaxis. There remain no clear guidelines on the management of XL-CGD carriers.

CGDilemma: Fitting Together the Puzzle Pieces for Definitive Diagnosis

IntroductionChronic granulomatous disease (CGD) is a rare inherited primary immunodeficiency. ΔGT mutations in NCF1, which encodes phagocyte nicotinamide adenine phosphate (NADPH) p47-phox protein, accounts for 23% of CGD. Oftentimes testing focuses on ΔGT defects. However, 20% of p47 CGD patients have mutations at other sites in NCF1 which can be missed. Further, NCF1 has 2 pseudogenes near chromosomal locus 7q11.23 which may undergo reciprocal crossover between functional genes exceeding expected frequency, complicating diagnosis, especially in atypical presentations. Case PresentationA 4-year-old male from Saudi Arabia presented with a necrotic lesion on his left cheek, unresponsive to antibiotics. Two years prior he had a Rhizopus infection on his right leg necessitating debridement. Biopsy revealed recurrent Rhizopus infection. He received debridement, linezolid, posaconazole and amphotericin. He was discharged on posaconazole and trimethoprim/sulfamethoxazole, after a protracted hospital stay. His wound improved, however margins remained positive.Immune workup revealed an oxidative burst assay with a broad abnormal peak of intermediate granulocyte dihydrorhodamine fluorescence suggesting autosomal recessive CGD. Genetic panels identified no variants in CGD genes. Western blot showed absent p47phox protein, confirming NCF1-deficient CGD. Genetic testing did not show the common ΔGT deletion at the start of exon 2 in 6 copies of NCF1/NCF1 pseudogenes. Sanger sequencing revealed a single nucleotide change distinct to the patient. This coded for NCF1 c.579 G > A, p. Trp193X, a previously reported mutation in NCF1. ConclusionDinucleotide deletion at the beginning of exon 2 of NCF1 pseudogenes leads to a frameshift and stop. When a pseudogene replaces the authentic NCF1, the overall ratio of functional genes to pseudogenes is altered. This potentially masks CGD carriers who possess pseudogene to functional gene ratios that renders them indistinguishable from healthy individuals with most testing. Non-ΔGT mutations occur in ~20% of p47phox patients. Because of the extensive sequence homology of NCF1 with the pseudogenes, Sanger sequencing may be insufficient to determine the underlying defect in NCF1. Therefore, gene panels and even whole genome sequencing may miss p47phox deficiency. This multimodality approach allowed us to identify p47phox-deficient autosomal recessive CGD.

Allogeneic Transplantation for High Risk Patients with Chronic Granulomatous Disease (CGD)

CGD is an immunodeficiency characterized by infections and inflammation, particularly inflammatory bowel disease (IBD) and lung inflammation, resulting from mutations in genes encoding any one of 5 subunits of the phagocyte NADPH oxidase impairing production of microbicidal oxidants. Bone marrow transplantation (BMT) has been shown to be curative of both the predilection for CGD-specific fungal and bacterial infections, and CGD related IBD, and is being offered more frequently to patients with appropriate donors, particularly in younger children with matched related donors. However, older adult patients with CGD, especially those with fungal infection not responding to conventional therapy, those with very severe IBD, and particularly those with inflammatory lung disease characterized by significant hypoxia are often considered ineligible for transplant by many US BMT centers. Furthermore, graft versus host disease (GvHD) and graft rejection following BMT of CGD patients going into the transplant with significant inflammation disease has been a significant problem. We report here the results to date of our ongoing protocol using Campath (1mg/kg divided over 4d), Busulfan (5mg/kg divided over 2d) and TBI (300cGy) combined with post-transplant cyclophosphamide (100mg/kg divided over 2d) and sirolimus for patients with CGD, with outcomes that appear to address these issues. Patients with C-reactive protein >100 were excluded from the standard criteria protocol because this had been shown to be a high mortality risk. However 6 patients whose CRP exceeded this exclusion criteria received exceptions to be treated 'off protocol' because of infections not responding to conventional therapy. Results: Number of patients to date: 30 plus 6 of whom were exceptions treated off protocol, and 1 retransplant; Follow up: 6 months to 5 years Donor types: 34 MUD, 3 MSD Patient Characteristics: Age: Mean 30/Range 6 to 57, Gender: 5F, 33M CGD type: GP91 (29, incl.1 lyonized female carrier), P47 (6), P67 (1), P22 (1) Transplant indications (some had more than one): Hypoxic inflammatory pulmonary disease (7), Colitis (11), Active infection (predominantly fungal) despite prolonged conventional therapy (14). See table Summary: Low dose Busulfan with TBI plus Campath and post-transplant cytoxan followed by sirolimus for BMT of CGD patients with CRP <100 at transplant is well tolerated, and results in improved engraftment rates with minimal GvHD. Patients with severe infections, hypoxic inflammatory lung disease, severe colitis and older age, but who have CRP<100 tolerate this conditioning regimen and benefit from the transplant with resolution of their underlying infection and/or non-infectious lung disease and/or severe IBD, even in patients who would not be considered eligible for transplant at other centers. This NIH non-myeloablative /immune suppressive BMT conditioning regimen not only significantly reduces incidence of graft failure and severe GVHD, but expands the group of CGD patients eligible for transplant to older patients and those with ongoing infection, hypoxic inflammatory lung disease, and/or severe IBD. These patients can be transplanted successfully and achieve cure of infection and/or significant improvement in their inflammatory pulmonary disease and IBD if a matched donor is available with this NIH CGD BMT conditioning regimen. Our studies confirm that patients with CRP>100 at transplant should not be transplanted and going forward are excluded without exception from this protocol. Also of note is that transplanted CGD patients have a high rate of fever, diarrhea and newly elevated CRP, but without hypoxia or hypotension, appearing to be a form of 'engraftment syndrome' that occurs starting at 10-12 days post transplant and resolving about the time that ANC >200-300. In 10 patients this was sufficiently severe to warrant treatment with tocilizumab 4mg/kg, which in all cases promptly resolved the fever. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

S10.5d Disseminated pulmonary infection due to Mortierella wolfii in a 6-year-old patient with X-linked CGD receiving MUD-HSCT

S10.5 Fungal respiratory infections in Cystic Fibrosis, September 24, 2022, 10:30 AM - 12:00 PM ObjectivesInvasive fungal infections represent one of the major limiting factors for the successful outcome of patients receiving hematopoietic stem cell transplantation (HSCT). The identification and successful treatment of pretransplant fungal colonization/infections may allow for risk modifications before or at the time of HSCT. Here, we report a case of disseminated pulmonary infection due to a hyaline non-septate mold, Mortierella wolfii in an X-linked chronic granulomatous disease (X-linked CGD) patient that was successfully treated with a combination of terbinafine and posaconazole antifungal therapy.MethodsA 6-year-old male with X-linked CGD from Sri Lanka was admitted to NIH Clinical Center, Bethesda, MD, USA to receive a matched unrelated donor (MUD) hematopoietic stem cell transplantation (HSCT). During pre-transplant immunosuppressive conditioning, the patient developed complicated pulmonary signs resulting in diffuse lymphadenitis and meningitis. Upon further radiologic evaluation, a lung biopsy was performed. The lung biopsy sample was submitted to Microbiology Service of Department of Microbiology at NIH Clinical Center for Fungal culture. Antifungal susceptibility testing was conducted in accordance with the Clinical and Laboratory Standards Institute CLSI M38-A3 guidelines.ResultsA pure heavy growth of white mold grew within 2 days on Sabouraud's Dextrose Agar. Microscopic examination showed hyaline (non-pigmented), non-septate branched hyphae. Sporangiophore-like structures were also present. The species-level identification of the isolate was confirmed as M. wolfii by PCR-sequencing of the internal transcribed spacer (ITS) region of ribosomal DNA.Minimum inhibitory/effective concentrations (μg/ml) were as follows in increasing order: terbinafine = 0.25, amphotericin B = 1, isavuconazole = 4, micafungin >8, itraconazole >16, voriconazole >16, and posaconazole >16. To evaluate the interactions between antifungal drugs, the activity of the posaconazole in combination with terbinafine were also evaluated M. wolfii using agar diffusion test. A combination of posaconazole and terbinafine, significantly inhibited the mycelial growth, which indicates synergism. The patient’s treatment was started on terbinafine in combination with posaconazole. On several follow-up examinations following treatment on day 30, 90 and 120, the infection had not recurred.ConclusionThe species of M. wolfii a is an environmental mold belongs to the order Mortierellales within the subphylum Mortierellomycotina of Kingdom Fungi. This fungus has been mostly associated with fungal infections leading to abortion in dairy cows feeding moldy hays and ensilage.Although posaconazole exhibited high MICs against M. wolfii, our in vitro combination study demonstrated that posaconazole and terbinafine combined are significantly more potent than either drug alone. As a suggestion, combination therapy could provide an option for the treatment of severe cases of M. wolfii in patients with underlying primary immunodeficiencies.As molecular identification and sequencing techniques continue to develop and become more available, we will likely see more diverse pathogens emerge in patients with underlying primary immunodeficiencies. In this current case. Additional study is warranted to explore insight into human immunity and the efficacy of combination therapy against rare fungal species in CGD patients.

Inborn Errors of Immunity With Fetal or Perinatal Clinical Manifestations.

In this article we revised the literature on Inborn Errors of Immunity (IEI) keeping our focus on those diseases presenting with intrauterine or perinatal clinical manifestations. We opted to describe our findings according to the IEI categories established by the International Union of Immunological Societies, predominantly addressing the immunological features of each condition or group of diseases. The main finding is that such precocious manifestations are largely concentrated in the group of primary immune regulatory disorders (PIRDs) and not in the group of classical immunodeficiencies. The IEI categories with higher number of immunological manifestations in utero or in perinatal period are: (i) diseases of immune dysregulation (HLH, IPEX and other Tregopathies, autosomal recessive ALPS with complete lack of FAS protein expression) and (ii) autoinflammatory diseases (NOMID/CINCA, DIRA and some interferonopathies, such as Aicardi-Goutières syndrome, AGS, and USP18 deficiency). Regarding the other IEI categories, some patients with Omenn syndrome (an atypical form of SCID), and a few X-linked CGD patients present with clinical manifestations at birth associated to immune dysregulation. The most frequent clinical features were hydrops fetalis, intrauterine growth retardation leading to fetal loss, stillbirths, and prematurity, as in HLH and IPEX. Additionally, pseudo-TORCH syndrome was observed in AGS and in USP18 deficiency. The main goal of our review was to contribute to increasing the medical awareness of IEI with intrauterine and perinatal onset, which has obvious implications for diagnosis, treatment, and genetic counseling.

HoxB8‐conditional Neutrophil Progenitor Transplant Provides a Therapeutic Benefit for S. aureusPulmonary Infection in a Murine Model of Chronic Granulomatous Disease (CGD)

CGD is a congenital disease marked by neutrophil dysfunction leading to increased infectious susceptibility. Despite prophylactic treatment with antimicrobial agents, outcomes for CGD patients are troubling with a typical lifespan of 30‐40 years due to breakthrough infections. As we strive to stay ahead of the impacts of drug‐resistant microbes, it is reasonable to consider cellular therapeutics which replace immune cells to treat CGD and other immunodeficiencies. We hypothesize that a conditionally‐immortalized neutrophil progenitor cell line has a translational application as a therapy for immune compromised hosts. This cell line was first generated by Wang, et al. through inducing ectopic expression of the transcription factor HoxB8 in murine bone marrow stem cells. Induction of HoxB8 leads to exponential growth of cells, while withdrawal leads to differentiation into neutrophil‐like cells. We have found that unconditioned transplant of HoxB8 progenitors lead to robust engraftment in the bone marrow. Engrafted progenitor cells differentiate in vivointo donor‐derived neutrophils found circulating in the peripheral blood. Donor neutrophils are also recruited to the lungs of mice infected with Staphylococcus aureus. Using a novel fluorescent killing assay, we demonstrate that donor‐derived neutrophils can kill pulmonary S. aureus both in vitro and in vivo with comparable efficiency to wild type host neutrophils. Strikingly, our results find that treatment with HoxB8‐conditional progenitors improves survival of CGD animals infected with S. aureus from 0% to &gt;50%. This work demonstrates the potential of conditionally‐immortalized neutrophil progenitors as a novel cellular therapy in the context of neutrophil dysfunction.

Phenomic Analysis of Chronic Granulomatous Disease Reveals More Severe Integumentary Infections in X-Linked Compared With Autosomal Recessive Chronic Granulomatous Disease.

BackgroundChronic granulomatous disease (CGD) is an inborn error of immunity (IEI), characterised by recurrent bacterial and fungal infections. It is inherited either in an X-linked (XL) or autosomal recessive (AR) mode. Phenome refers to the entire set of phenotypes expressed, and its study allows us to generate new knowledge of the disease. The objective of the study is to reveal the phenomic differences between XL and AR-CGD by using Human Phenotype Ontology (HPO) terms.MethodsWe collected data on 117 patients with genetically diagnosed CGD from Asia and Africa referred to the Asian Primary Immunodeficiency Network (APID network). Only 90 patients with sufficient clinical information were included for phenomic analysis. We used HPO terms to describe all phenotypes manifested in the patients.ResultsXL-CGD patients had a lower age of onset, referral, clinical diagnosis, and genetic diagnosis compared with AR-CGD patients. The integument and central nervous system were more frequently affected in XL-CGD patients. Regarding HPO terms, perianal abscess, cutaneous abscess, and elevated hepatic transaminase were correlated with XL-CGD. A higher percentage of XL-CGD patients presented with BCGitis/BCGosis as their first manifestation. Among our CGD patients, lung was the most frequently infected organ, with gastrointestinal system and skin ranking second and third, respectively. Aspergillus species, Mycobacterium bovis, and Mycobacteirum tuberculosis were the most frequent pathogens to be found.ConclusionPhenomic analysis confirmed that XL-CGD patients have more recurrent and aggressive infections compared with AR-CGD patients. Various phenotypic differences listed out can be used as clinical handles to distinguish XL or AR-CGD based on clinical features.

Overlapping infection of Nocardia farcinica and Aspergillus fumigatus in a child with X-linked chronic granulomatous disease: a case report

BackgroundChronic granulomatous disease (CGD) is a rare inherited primary immunodeficiency syndrome, manifested as recurrent infections and inflammatory complications. Although prophylactic treatment with antibiotics and antifungals improved the outcome of CGD patients, infections remain the major cause of mortality.Case presentationA boy aged 3 years and 8 months was admitted to hospital complaining of lip swelling with fever for half a month and neck abscess for 11 days. After a thorough examination, severe pneumonia, respiratory failure, oral and maxillofacial space infection, and perianal abscess were confirmed. However, his condition didn’t improve after initial comprehensive therapy. Subsequently, overlapping infections of Nocardia farcinica and Aspergillus fumigatus were identified by metagenomic next-generation sequencing. He was treated with imipenem, linezolid, and voriconazole intravenously, plus taking oral compound sulfamethoxazole. Later, his condition improved. Through whole-exome sequencing, the child was ultimately diagnosed as X-linked chronic granulomatous disease (X-CGD) caused by CYBB gene mutation. Allogeneic hematopoietic stem cell transplantation was the potential sanative approach but there were no available human leukocyte antigen compatible donors for the child. The family requested to transfer to a superior hospital for further treatment. Two months later, we followed up the child’s family. Unfortunately, the child had expired due to severe infection.ConclusionTo our knowledge, this is the first case of overlapping infection of Nocardia farcinica and Aspergillus fumigatus identified by metagenomic next-generation sequencing in a child with X-CGD from China. For infectious pathogens that are hard to diagnosis by traditional detection methods, metagenomic next-generation sequencing is recommended as an adminicle or indispensable approach for microbial identification. Patients with X-CGD have poor prognosis, early diagnosis and intervention of X-CGD may reduce the mortality.

False-positive HIV serology, Candida lusitaniae pneumonia, and a novel mutation in the CYBB gene

BackgroundChronic granulomatous disease (CGD) presents with a myriad of clinical manifestations pertaining to both immunodeficiency and hyperinflammation. Although Candida infection is a signature organism for patients with CGD, C. lusitaniae pneumonia in CGD has rarely been reported. C. lusitaniae is a ubiquitous ascomycete predominantly infecting immunocompromised hosts and has the potential to rapidly develop multi-drug resistance during therapy. Additionally, C. lusitaniae is recognized for its variable resistance against amphotericin B. To date, C. lusitaniae infections in patients with CGD have not been reviewed in detail. False-positive HIV serology, resulting from polyclonal hypergammaglobulinemia, has been reported in association with several infections, auto-immune diseases, and malignancies. Although CGD is often associated with hypergammaglobulinemia, a false-positive HIV serology in CGD has not been reported previously. ProcedureWe report a combination of unique findings in a child with CGD – a false-positive HIV serology, Candida lusitaniae pneumonia, and a novel CYBB mutation. We also provide a detailed review of C. lusitaniae infections in patients with CGD. ResultsIn patients with CGD, C. lusitaniae has been reported to cause lymphadenitis (cervical, abdominal), fungemia, meningoencephalitis, or abscesses in the liver and spleen. Many CGD patients with C. lusitaniae infection have associated inflammatory complications of the gut (inflammatory bowel disease, colitis). Additionally, almost all C. lusitaniae infections in CGD have been reported in young infants or in patients receiving long-term immunosuppressive therapy. This reflects that further immunocompromise (in addition to the underlying immune deficiency in CGD) may specifically predispose to C. lusitaniae infection (unlike other candidal infections). Most of the CGD patients with documented C. lusitaniae infection have X-linked form of the disease which generally has been postulated to have a more severe clinical phenotype than the autosomal recessive forms of the disease. ConclusionsHIV serology may be positive in patients with CGD and other inborn errors of immunity as a result of hypergammaglobulinemia. C. lusitaniae, which may have peculiar and evolving antimicrobial sensitivity patterns, needs to be considered in patients with CGD and pneumonia. Lastly, to reiterate, CGD should to be considered in patients with proven C. lusitaniae infection.

USTEKINUMAB FOR CHRONIC GRANULOMATOUS DISEASE-ASSOCIATED INFLAMMATORY BOWEL DISEASE

Abstract Introduction Chronic granulomatous disease (CGD) is a rare immunodeficiency caused by mutations in the NADPH oxidase complex. Dysregulated immune function may cause inflammatory bowel disease (IBD). Patients with CGD-associated IBD may not respond to or may develop serious infections as a result of traditional IBD therapies such as vedolizumab and infliximab. Ustekinumab is approved for use in Crohn’s disease and ulcerative colitis however there is scarce data on its efficacy and safety in CGD. Aims To evaluate the efficacy and safety of ustekinumab for CGD-associated IBD. Methods A retrospective chart review was conducted on CGD patients followed at a single center who had consented to participate in a natural history study. Clinical, laboratory, and endoscopic data were extracted in those that had received ustekinumab for IBD. Results Eight patients were found. Four were male and four were female. Five were white, one was Asian, one was black, and one was mixed race. Median age at diagnosis of CGD was 3 years (IQR 8) and of IBD was 15.5 years (IQR 20). Median age at initiation of ustekinumab was 27.5 years (IQR 14) and median duration on ustekinumab was 10 months (IQR 7). Six had colonic disease, two had ileocolonic disease, and six had perianal disease. Six failed other biologics (n=5 for vedolizumab, n=1 for infliximab, n=1 for adalimumab). Six patients symptomatically improved whereas two had no improvement. Changes in hemoglobin and C-reactive protein were equivocal. Three patients had improved endoscopic findings, two had unimproved findings, and three patients lacked this data. Overall, four patients achieved clinical remission. However, none of the five patients with endoscopic reevaluation achieved endoscopic remission. Three patients discontinued therapy due to lack of response: two required surgery and one underwent stem cell transplant. Fungal pneumonia (n=2), otitis media (n=1), oral herpes simplex virus 1 (n=1), and viral gastroenteritis (n=1) were reported. One infusion reaction occurred. Discussion In our cohort of eight patients with CGD-associated IBD receiving ustekinumab, results were mixed with four patients experiencing some degree of clinical or endoscopic improvement including four who achieved clinical remission. Multiple CGD-related variables may account for the mixed laboratory findings. Four of the five patients with endoscopic reevaluation had pre-existing strictures that would be unlikely to reverse with medical therapy alone. Of these, two had otherwise resolved endoscopic inflammation. Only two patients had no endoscopic improvement. Two serious infections occurred however CGD confers increased infectious susceptibility and no infections lead to discontinuation of therapy. Given these promising results, further formalized study of ustekinumab in CGD-associated IBD is needed.

B subset cells in patients with chronic granulomatous disease in a Mexican population

IntroductionChronic granulomatous disease (CGD) is a disorder of phagocyte function, characterized by pyogenic infections and granuloma formation caused by defects in NADPH oxidase complex activity. Although the effect of CGD mainly reflects the phagocytic compartment, B cell responses are also impaired in patients with CGD. Materials and methodsFlow cytometric analysis was performed on peripheral blood samples from 35 CGD patients age-matched with healthy controls (HC). The target cells of our study were the naive (IgD+/CD27−), memory (IgD−/CD27+), and B1a (CD5+) cells. Immunoglobulins (Igs) were also measured. This study was performed in a Latin American cohort. ResultsWe found significantly higher levels of naive B cells and B1a cells, but lower levels of memory B cells were found in CGD patients compared to HC. There was no significant difference of cell percentages per inheritance type. DiscussionOur findings suggest that the deficiency of NADPH oxidase components can affect the differentiation of naive B cells to memory B cells. Consequently, memory cells will be low, which also influenced the expression of CD27 in memory B cells and as a result, the percentage of naive cells increases. An altered phenotype of B lymphocytes in CGD patients may contribute to the opportunistic infections and autoimmune disorders that are seen in this disease.

Regulatory T cell features in chronic granulomatous disease.

Chronic granulomatous disease (CGD) is a primary immunodeficiency caused by mutations in any of the genes encoding the phagocyte nicotinamide adenine dinucleotide phosphate (NADPH) oxidase system, responsible for the production of reactive oxygen species (ROS). CGD is marked by invasive bacterial and fungal infections and by autoinflammation/autoimmunity, of which the exact pathophysiology remains elusive. Contributing factors include decreased neutrophil apoptosis, impaired apoptotic neutrophil clearance, increased proinflammatory protein expression and reduced ROS-mediated inflammasome dampening. We have explored a fundamentally different potential mechanism: it has been reported that macrophage-mediated induction of regulatory T cells (Tregs ) depends on ROS production. We have investigated whether numerical or functional deficiencies exist in Tregs of CGD patients. As the prevalence of autoinflammation/autoimmunity differs between CGD subtypes, we have also investigated Tregs from gp91phox -, p47phox - and p40phox -deficient CGD patients separately. Results show that Treg numbers and suppressive capacities are not different in CGD patients compared to healthy controls, with the exception that in gp91phox -deficiency effector Treg (eTreg ) numbers are decreased. Expression of Treg markers CD25, inducible T cell co-stimulator (ICOS), Helios, cytotoxic T lymphocyte antigen 4 (CTLA-4) and glucocorticoid-induced tumor necrosis factor receptor (GITR) did not provide any clue for differences in Treg functionality or activation state. No correlation was seen between eTreg numbers and patients' clinical phenotype. To conclude, the only difference between Tregs from CGD patients and healthy controls is a decrease in circulating eTregs in gp91phox -deficiency. In terms of autoinflammation/autoimmunity, this group is the most affected. However, upon culture, patient-derived Tregs showed a normal phenotype and normal functional suppressor activity. No other findings pointed towards a role for Tregs in CGD-related autoinflammation/autoimmunity.

Health-Related Quality of Life and Emotional Health in X-Linked Carriers of Chronic Granulomatous Disease in the United Kingdom

X-linked chronic granulomatous disease (XL-CGD), a rare primary immunodeficiency due to a defect in the gp91phox NADPH oxidase subunit, results in recurrent, severe infection, inflammation, and autoimmunity. Patients have an absent, or significantly reduced, neutrophil oxidative burst. Due to lyonization, XL-CGD carriers have a dual population of functional and non-functional phagocytes and experience a range of symptoms including increased risk of autoimmunity, fatigue, and infection. Patients with CGD have poorer quality of life (QoL) than normal controls. We evaluated QoL and psychological health in UK XL-CGD carriers. Recruited participants completed the Medical Outcomes Study Short Form 36 version 2 (SF-36 V2), providing an overall score for mental and physical health. Psychological health was assessed using the Hospital Anxiety and Depression Scale (HADS) questionnaire. Seventy-five XL-CGD carriers were recruited from 62 families, median age 43 years (range 3–77). Fifty-six were mothers, 6 grandmothers, and 13 siblings. Sixty-two completed the SF36v2 and had reduced QoL scores compared with adult CGD patients and a UK age-matched female control cohort, indicating a reduced QoL. Sixty-one completed a HADS questionnaire. Over 40% experienced moderate or greater levels of anxiety with only one third being classified as normal. Higher anxiety scores significantly correlated with higher depression scores, lower self-esteem, presence of joint or bowel symptoms, and higher levels of fatigue (p < 0.05). This is the first study to evaluate QoL of XL-CGD carriers, and demonstrates high rates of anxiety and significantly reduced QoL scores. XL-CGD carriers should be considered as potential patients and pro-actively assessed and managed.

Chronic Granulomatous Disease.

Chronic granulomatous disease is a clinical condition that stems from inactivating mutations in NOX2 and its auxiliary proteins. Together, these proteins form the phagocyte NADPH oxidase enzyme that generates superoxide. Superoxide (O2ċ-) and its reduced product hydrogen peroxide (H2O2) give rise to several additional reactive oxygen species (ROS), which together are necessary for adequate killing of pathogens. Thus, CGD patients, with a phagocyte NADPH oxidase that is not properly functioning, suffer from recurrent, life-threatening infections with certain bacteria, fungi, and yeasts. Here, I give a short survey of the genetic mutations that underlie CGD, the effect of these mutations on the activity of the leukocyte NADPH oxidase, the clinical symptoms of CGD patients, and the treatment options for these patients.

Preliminary study on chronic granulomatous disease in Sri Lanka

BackgroundChronic granulomatous disease (CGD) is a rare primary immunodeficiency of the phagocytic cells, which results in absent or diminished levels of microbicidal reactive oxygen species. The disease occurs due to germline mutations in the genes encoding the five subunits of NADPH oxidase complex. The present study is a pilot study to understand the clinical and genetic aspects of CGD in Sri Lanka.MethodsClinical records of thirteen CGD patients were analysed and compared with similar studies performed in different countries and regions to identify patterns in demographics, clinical manifestations and infectious agents. Genomic DNA and cDNA were analysed in eight patients to identify mutations in CYBB and NCF1 genes, thereby to ascertain the potential X-linked and autosomal recessive (AR) CGD patients.ResultsThe onset of symptoms in the patient cohort was very early (mean 4.6 months) compared to 20 months in India and 23.9 months in Latin America. Similarly, the age at diagnosis was lower (mean 1.6 years after birth) compared to other studies; 4.5 years in India and 6.1 years in Europe. Pulmonary manifestations were the most common (85%), followed by skin/subcutaneous infections (77%) and lymphadenopathy (62%). The death rate of local patients (38%) was higher than other countries (India 35%, Europe 20%). Majority (77%) were treated for tuberculosis at some point in life. Genetic analysis confirmed six out of eight patients as X-linked CGD cases with mutations in CYBB gene. A novel splice site mutation was identified in P-07 at position c.141+6 which resulted in the deletion of entire exon 2. Two siblings (P-05 and P-06) from consanguineous parents, were identified with AR-CGD based on the homozygous GT deletion mutation in NCF1 gene.ConclusionsThe clinical presentation, manifestations and genetic subtypes in the local cohort, appear to be comparable with global trends. Mycobacterial infections should be investigated and treated with more prominence. Effective treatment options are required to control the high mortality rate.