Diagnosis Of Chronic Granulomatous Disease Research Articles

A child with chronic granulomatous disease

A four-year-old African-American female with a history of asthma, a Staphylococcus aureus skin abscess, and two prolonged pneumonia episodes presented with a one-week history of productive cough, fever, and night sweats. Chest computed tomography revealed right lung consolidation, cavitation within the right azygoesophageal recess, and an enlarged paratracheal lymph node, and biopsy of the lymph node showed granulomas. Lung tissue culture grew Burkholderia cepacia. A nitroblue tetrazolium test indicated a diagnosis of chronic granulomatous disease (CGD). CGD is a rare primary immunodeficiency in which there is a functional defect in one of the genes encoding nicotinamide adenine dinucleotide phosphate oxidase, which leads to impaired killing of catalase-producing bacteria and fungi within the phagolysosome. CGD presents most commonly as re- current and prolonged pulmonary infections, but may also include repeated episodes of lymphadenitis, cutaneous infections, hepatic abscesses, and osteomyelitis. Staphylococcus aureus is the most commonly isolated organism, but infection with certain other bacteria such as Burkholderia cepacia is highly suggestive of CGD.

LĖTINĖ GRANULIOMINĖ LIGA: LITERATŪROS APŽVALGA IR KLINIKINIŲ ATVEJŲ APRAŠYMAS

Chronic granulomatous disease (CGD) is an inherited X-linked or, less frequently, with somatic mutations linked disorder of phagocytic cells which presents in early childhood as recurrent granulomatous lesions and atypical bacterial or fungal infections of skin, lungs, gastrointestinal tract, liver, spleen or lymph nodes. Some patients remain undiagnosed until adulthood or rarely diagnosis is made post mortem. Haematopoietic stem cell transplantation (HSCT) can cure CGD, thus timely diagnosis is essential for saving life of such patients. We present two complicated clinical cases of children with CGD, diagnosed in Lithuania for the first time. After the history of recurrent epizodes of severe infections, reviewed family history, repeated spontaneous and stimulated nitroblue tetrazolium tests (NBT), CGD diagnosis was confirmed for both patients. Allogeneic HSCT is planned in both cases expecting curative effect. All children with recurrent atypical infections should be checked for immunodeficiency. Multidisciplinary approach is essential for making rapid and correct diagnosis based on life and family history, clinical manifestation, immunologic tests and genetic counseling. CGD is curable by HSCT, thus patients should be referred to a HSCT center without delay

Long-term outcome of patients with p22 (phox) -deficient chronic granulomatous disease on Jeju Island, Korea.

PurposeThis study investigated the long-term clinical outcomes of patients with p22phox-deficient chronic granulomatous disease (CGD) on Jeju Island and retrospectively evaluated the effects of interferon-gamma (IFN-γ) prophylaxis.MethodsThe medical records of 15 patients with CGD were retrospectively reviewed. The efficacy of IFN-γ prophylaxis was evaluated by comparing the frequency of severe infections before and after starting continuous prophylaxis with IFN-γ.ResultsAt the time of the analysis, 14 patients were alive, with a median age of 14.3 years. The diagnosis of CGD was made at a median age of 2.4 years, and the median age at onset of severe infection was 0.3 years. Thirteen of the 15 patients had their first severe infection within the first year of life. The overall incidence of severe infection was 1.36 infections per patient-year; pneumonia, suppurative lymphadenitis, and skin and subcutaneous abscesses were the most common infections. Aspergillus species were the most frequently isolated microorganisms, present in 15.8% of isolates. IFN-γ did not significantly change the rate of severe infection. The survival rate for patients after 2 years of age was 93%; there was a prolonged survival plateau beyond the age of 2.ConclusionCompared with cases of X-linked CGD reported in other studies, patients with CGD on Jeju Island did not show obviously different clinical manifestations, but they had a significantly higher survival rate. Further studies with a substantially longer period of observation, and with more patients under intensive surveillance are necessary to elucidate the prophylactic efficiency of IFN-γ.

Chronic Granulomatosis Disease With Meningitis and Multiple Brain Abscesses

A 3-year-old boy with fever, fatigue, and vomiting was admitted to the hospital after failing to respond to antibiotics. His history included frequent throat infections. His physical examination and laboratory findings revealed high body temperature, hyperemic oropharynx with multiple crypts on the tonsils, and elevated acute phase reactants. During follow-up, his temperature normalized but his vomiting increased. With a suspected diagnosis of meningitis, magnetic resonance imaging (MRI) was performed. The MRI findings suggested multiple abscesses (Figs 1 and 2 )a nd meningitis (Fig 1). At surgery the lesions were consistent with abscesses, but no organisms were identified. Additional studies revealed a positive nitroblue tetrazolium test, leading to diagnosis of chronic granulomatous disease (CGD).

Molecular diagnosis of chronic granulomatous disease

Patients with chronic granulomatous disease (CGD) suffer from recurrent, life-threatening bacterial and fungal infections of the skin, the airways, the lymph nodes, liver, brain and bones. Frequently found pathogens are Staphylococcus aureus, Aspergillus species, Klebsiella species, Burkholderia cepacia and Salmonella species. CGD is a rare (∼1:250 000 births) disease caused by mutations in any one of the five components of the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase in phagocytes. This enzyme generates superoxide and is essential for intracellular killing of pathogens by phagocytes. Molecular diagnosis of CGD involves measuring NADPH oxidase activity in phagocytes, measuring protein expression of NADPH oxidase components and mutation analysis of genes encoding these components. Residual oxidase activity is important to know for estimation of the clinical course and the chance of survival of the patient. Mutation analysis is mandatory for genetic counselling and prenatal diagnosis. This review summarizes the different assays available for the diagnosis of CGD, the precautions to be taken for correct measurements, the flow diagram to be followed, the assays for confirmation of the diagnosis and the determinations for carrier detection and prenatal diagnosis.

Is it X-Linked or autosomal recessive chronic granulomatous disease?

Background Neutrophil oxidative burst (NOB) activity as assessed by dihydrorhodamine-123 flow cytometric assay, is used in the diagnosis of chronic granulomatous disease (CGD) and may provide insight into its inheritance pattern. Case report We present a consanguineous family with complete absence of NOB activity in three male siblings. Each affected sibling suffered a severe form of CGD characterised by clinical manifestations within the first year of life, recurrent bacterial and fungal pneumonia, and death in two siblings by the ages of 3 and 4. This complete absence of NOB activity and severe phenotype is atypical for classic autosomal recessive CGD. The unaffected parents and siblings displayed normal NOB activity. In addition, no bimodal peak was detected in the mother, which is atypical for X-linked CGD. Extreme skewing of lyonisation in the maternal X-chromosome was excluded. CGD mutation analysis was performed by GeneDx (Gaithersburg, USA, 2008) on the proband. A novel autosomal recessive p67-phox (NCF2) homozygous deletion mutation [NM_000433.3(NCF2): c.482delA] was identified. Objective and results A targeted bi-directional PCR sequencing analysis was developed in a local molecular laboratory (Pathology Queensland) to help identify this novel mutation in other members of this family. The heterozygous carrier status in both parents and the homozygous mutation in a newborn male sibling were demonstrated by this analysis. Discussion This case report confirms the autosomal recessive mode of inheritance of this novel c.482delA mutation in the p67-phox (NCF2) gene. The mutation is predicted to result in a frame shift and premature stop codon [NP_000424.2(NCF2): p.Lysl61 Argfs*16], potentially explaining the complete absence of NOB activity and severe clinical phenotype in the affected male siblings. Neutrophil oxidative burst (NOB) activity as assessed by dihydrorhodamine-123 flow cytometric assay, is used in the diagnosis of chronic granulomatous disease (CGD) and may provide insight into its inheritance pattern. We present a consanguineous family with complete absence of NOB activity in three male siblings. Each affected sibling suffered a severe form of CGD characterised by clinical manifestations within the first year of life, recurrent bacterial and fungal pneumonia, and death in two siblings by the ages of 3 and 4. This complete absence of NOB activity and severe phenotype is atypical for classic autosomal recessive CGD. The unaffected parents and siblings displayed normal NOB activity. In addition, no bimodal peak was detected in the mother, which is atypical for X-linked CGD. Extreme skewing of lyonisation in the maternal X-chromosome was excluded. CGD mutation analysis was performed by GeneDx (Gaithersburg, USA, 2008) on the proband. A novel autosomal recessive p67-phox (NCF2) homozygous deletion mutation [NM_000433.3(NCF2): c.482delA] was identified. A targeted bi-directional PCR sequencing analysis was developed in a local molecular laboratory (Pathology Queensland) to help identify this novel mutation in other members of this family. The heterozygous carrier status in both parents and the homozygous mutation in a newborn male sibling were demonstrated by this analysis. This case report confirms the autosomal recessive mode of inheritance of this novel c.482delA mutation in the p67-phox (NCF2) gene. The mutation is predicted to result in a frame shift and premature stop codon [NP_000424.2(NCF2): p.Lysl61 Argfs*16], potentially explaining the complete absence of NOB activity and severe clinical phenotype in the affected male siblings.

Chronic Granulomatous Disease: Two Decades of Experience From a Tertiary Care Centre in North West India

Chronic granulomatous disease (CGD) results from an inherited defect in the phagocytic cells of the immune system. It is a genetically heterogenous disease caused by defects in one of the five major subunits of the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex. There is a paucity of data from India on CGD. We herein describe the clinical features in 17 children with CGD from a single tertiary referral center in India. A detailed analysis of the clinical features, laboratory investigations and outcome of 17 children 7 with X-linked (XL) and 10 with autosomal recessive (AR) form was performed. Diagnosis of CGD was based on an abnormal granulocyte oxidative burst evaluated by either Nitroblue Tetrazolium (NBT) test or flow cytometry based Dihyrorhodamine 123 assay or both. The molecular diagnosis was confirmed by genetic mutation analysis in 13 cases. The mean age at diagnosis and the age at onset of symptoms was significantly lower in children diagnosed with XL- CGD compared those with AR disease. Mutations were detected in CYBB gene in 6 patients with XL-CGD and NCF-1 gene mutations were observed in 7 cases of AR- CGD. The course and outcome of the disease was much worse in children diagnosed with X-linked form of disease compared to AR forms of the disease; 4/7 (57%) children with X-CGD were dead at the time of data analysis. This is one of the largest series on chronic granulomatous disease from any developing country.

The value of repeated follow-up, intravenous and intracavitary contrast-enhanced ultrasonography (CEUS) in an adolescent with chronic granulomatous disease and multiple organ abscesses

Purpose: This case report focuses on the diagnosis and management of multiple abdominal abscesses in the liver, spleen, both kidneys, both psoas muscles and the spine in a 17 year old female with the late initial diagnosis of chronic granulomatous disease (CGD).

Fundus Findings in Chronic Granulomatous Disease

Chronic granulomatous disease (CGD) is a rare primary immunodeficiency disease that has been reported to present with various chorioretinal findings, predominantly in men. We report a case of a 17-year-old girl with a known diagnosis of CGD referred to the ophthalmology clinic for evaluation of an inflamed pingueculum. Upon clinical examination and ophthalmic imaging, high-quality montage fundus photographs demonstrated a wide array of bilaterally asymmetric chorioretinal findings known to be characteristic of the ophthalmic manifestations of CGD, including chorioretinitis and focal subretinal granuloma. This report also adds to the body of evidence that the chorioretinal findings associated with this disease have the potential to worsen over time.

Newly diagnosed chronic granulomatous disease in a 44 year old male presenting with recurrent groin cellulitis and colitis

Background Chronic Granulomatous Disease (CGD) is an inherited deficiency which results from the absence or dysfunction of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase subunits in phagocytic cells. This condition is usually diagnosed in early childhood and presents with recurrent infections at epithelial surfaces such as the skin, lungs, and gut. We present a case of CGD which was diagnosed late in adulthood. Case presentation A forty-four year old male was admitted to hospital with fever, testicular pain and an acute onset of swelling of his penis and scrotum. His past history was significant for Crohn’s disease diagnosed at age sixteen; stable on treatment with mesalamine (Asacol W ). He also had recurrent soft tissue infections of his penis and/or scrotum since childhood, approximately 2 or 3 in total, to his recollection. There was no history of abscesses or sexually transmitted infections. However, the patient did complain of frequent upper respiratory tract infections each winter. He had no family history of primary immunodeficiency disease. During admission, he was assessed by urology and general surgery. Both confirmed the absence of any anatomic abnormalities. An immunologist suggested work up for immunodeficiency. Basic laboratory investigations were normal, with a white blood cell count of 7.8 × 10 9 L. C-reactive protein was elevated at 69.7 mg/L. Both his rheumatoid factor and HIV testing were negative. Serum levels of IgA, IgM and IgG levels were all within normal limits (Table 1 reports full details of his immunology investigations) Blood cultures were negative. A CT scan of the chest was normal. CT scan of the abdomen and pelvis revealed no subcutaneous air to suggest a necrotizing infection. Quantitative dihydrorhodamine (DHR)123 flow cytometry assay revealed the complete absence of an oxidative burst response; this was confirmed three times. This was suggestive of a neutrophil NADPH oxidase deficiency associated with CGD. The patient was treated with intravenous cefazolin and metronidazole and discharged home on clindamycin. His cellulitis resolved within weeks, but he experienced a recurrence approximately 6 months later. He was started on trimethoprim-sulfamethoxazole (TMP-SMX), amoxicillin, and itraconazole as prophylactic therapy to prevent future infections. He was assessed by the Infectious Disease service, who simplified his prophylactic regimen to TMP-SMX 160/800 q Mon/Wed/Fri and Penicillin V K 300mg OD based on risk assessment and previous infective patterns. Interferon-gamma was considered, but based on restricted availability at the time and his relatively stable clinical course to date, we elected to pursue antibiotic prophylaxis and active surveillance alone. Genetic testing, performed by the Hospital for Sick Children in Toronto, confirmed a diagnosis of CGD and revealed a homozygous mutation in the NCFI gene (P47). It was recommended that directly family members receive DHR flow cytometry screening but this was declined.

Pulmonary manifestations of chronic granulomatous disease

Chronic granulomatous disease (CGD) is an inherited disorder, characterized by defects in superoxide-generating NADPH oxidase of phagocytes. The genetic defects in CGD induce failure to activate the respiratory burst in the phagocytes, leading to severe recurrent infections and unexplained prolonged inflammatory reactions that may produce granulomatous lesions. A noble advance in curative therapy for CGD is hematopoietic stem cell transplantation. Since the most common site of involvement in CGD is the lung, the pulmonologists (pediatrics or adult) may be among the first to recognize the pattern of infection, inflammation and granuloma formation, leading to diagnosis of CGD. Pulmonologists need to be aware of different lung manifestations of CGD.

Rapid Detection of Intracellular p47phox and p67phox by Flow Cytometry; Useful Screening Tests for Chronic Granulomatous Disease

Chronic granulomatous disease (CGD) is caused by defects of NADPH oxidase. The diagnosis of CGD can be made by analysis of NADPH oxidase activity, however, identification of the CGD subgroups is required before performing mutation analysis. The membrane-bound subunits, gp91phox and p22phox, can be quickly analyzed by flow cytometry, unlike the cytosolic components, p47phox and p67phox. We evaluated the feasibility of flow cytometric detection of p47phox and p67phox with specific monoclonal antibodies in two patients with p47phox deficiency and 7 patients with p67phox deficiency. Consistent with previous observations, p47phox and p67phox were expressed in phagocytes and B cells, but not in T or natural killer cells, from normal controls. In contrast, patients with p47phox and p67phox deficiency showed markedly reduced levels of p47phox and p67phox, respectively. These techniques will be useful to rapidly assess the expression of the cytosolic components, p47phox and p67phox, and represents important secondary screening tests for CGD.

Recurrent Pneumonia not Always Tuberculosis or Congenital Heart

Chronic granulomatous disease (CGD) is one of the important disorders of the immune system due to phagocytic defect. We report a case of CGD who presented with recurrent respiratory tract infections who was treated like tuberculosis and also in view of rarity of this condition. A two year old girl presented with fever on and off with cough since one year of age. She had been hospitalized two times in the past for recurrent pneumonia. Birth and developmental history was normal. She was immunized till date. There was history of elder sibling death at five years of age due to recurrent pneumonia. Child had hepatosplenomegaly and crepitations in chest. Laboratory investigations revealed leucocytosis with ESR of 62 mm/hr. Mantoux test was negative. CXR showed bilateral infiltrates. CT chest showed a 2 cm cavity in right lower lobe with enlarged mediastinal lymph nodes. She was started on antibiotics and antitubercular treatment. HIV Elisa was negative. Immunodeficiency work up showed a normal Lymphocyte subset and Immunoglobulin assay. Intracellular oxidation dysfunction was demonstrated by standard Nitro-blue tetrazolium test (NBT=0) and confirmed with flow cytometry. Hence the diagnosis of CGD was confirmed. On follow up, child had right cheek abscess and treated with higher antibiotics. Child was subsequently well and was continued on cotrimoxazole prophylaxis.

Variant of X-Linked Chronic Granulomatous Disease Revealed by a Severe Burkholderia cepacia Invasive Infection in an Infant.

Chronic granulomatous disease (CGD) is a primary immunodeficiency characterized by increased susceptibility to bacteria and fungi since early in life, caused by mutations in any of the five genes coding for protein subunits in NADPH oxidase. X-linked variant CGD can be missed during routine evaluation or present later in life due to hypomorphic mutations and a residual superoxide production. The case of a 10-month-old boy who died of pneumonia is reported. The isolation of Burkholderia cepacia from his lung, together with a marginally low nitroblue tetrazolium reduction assay (NBT), made us suspect and pursue the molecular diagnosis of CGD. A postmortem genetic analysis finally demonstrated CGD caused by a hypomorphic missense mutation with normal gp91phox expression. In a patient being investigated for unusually severe or recurrent infection, a high index of suspicion of immunodeficiency must be maintained.

Excellent Survival After Sibling or Unrelated Donor Stem Cell Transplantation for Chronic Granulomatous Disease

CA Martinez, S Shah, WT Shearer. J Allergy Clin Immunol. 2012;129(1):176–183 To determine outcomes and survival in patients with chronic granulomatous disease (CGD) after hematopoietic stem cell transplantation (HSCT) in both HLA-matched related (MRD) and unrelated donor (MUD) transplants. This is a single-center retrospective cohort study of 11 children with a diagnosis of CGD, a history of at least 1 invasive infection, and 70% meeting parameters indicative of high-risk disease. Nine children had X-linked CGD, 1 had autosomal recessive CGD, and 1 did not have an identifiable mutation. Nine of the 11 patients were boys, and …

High‐Performance Liquid Chromatography Under Partially Denaturing Conditions (dHPLC) is a Fast and Cost‐Effective Method for Screening Molecular Defects: Four Novel Mutations Found in X‐Linked Chronic Granulomatous Disease

Implementing precise techniques in routine diagnosis of chronic granulomatous disease (CGD), which expedite the screening of molecular defects, may be critical for a quick assumption of patient prognosis. This study compared the efficacy of single-strand conformation polymorphism analysis (SSCP) and high-performance liquid chromatography under partially denaturing conditions (dHPLC) for screening mutations in CGD patients. We selected 10 male CGD patients with a clinical history of severe recurrent infections and abnormal respiratory burst function. gDNA, mRNA and cDNA samples were prepared by standard methods. CYBB exons were amplified by PCR and screened by SSCP or dHPLC. Abnormal DNA fragments were sequenced to reveal the nature of the mutations. The SSCP and dHPLC methods showed DNA abnormalities, respectively, in 55% and 100% of the cases. Sequencing of the abnormal DNA samples confirmed mutations in all cases. Four novel mutations in CYBB were identified which were picked up only by the dHPLC screening (c.904 insC, c.141+5 g>t, c.553 T>C, and c.665 A>T). This work highlights the relevance of dHPLC, a sensitive, fast, reliable and cost-effective method for screening mutations in CGD, which in combination with functional assays assessing the phagocyte respiratory burst will contribute to expedite the definitive diagnosis of X-linked CGD, direct treatment, genetic counselling and to have a clear assumption of the prognosis. This strategy is especially suitable for developing countries.

Successful use of extracorporeal membrane oxygenation for acute respiratory failure in a patient with chronic granulomatous disease

A 9-year-old boy presented with pneumonia, bilateral pulmonary lesions, and fulminant respiratory failure requiring support with extracorporeal membrane oxygenation (ECMO). Open lung biopsy and subsequent bronchoscopy identified Nocardia cyriacigeorgica and Burkholderia cepacia pneumonia. Chronic granulomatous disease (CGD) was diagnosed by an abnormal neutrophil oxidative burst assay. An aggressive diagnostic and therapeutic strategy, which included ECMO, allowed for patient survival and return to baseline function. No ECMO survivors with CGD have previously been reported. It is now recognized that several forms of CGD exist, and some forms may be compatible with long-term survival. Therefore, the diagnosis of CGD should not necessarily be considered a contraindication to ECMO. This is the first known survivor of CGD-related acute respiratory failure supported by ECMO.

P67-phox (NCF2) Lacking Exons 11 and 12 Is Functionally Active and Leads to an Extremely Late Diagnosis of Chronic Granulomatous Disease (CGD)

Two brothers in their fifties presented with a medical history of suspected fungal allergy, allergic bronchopulmonary aspergillosis, alveolitis, and invasive aspergillosis and pulmonary fistula, respectively. Eventually, after a delay of 50 years, chronic granulomatous disease (CGD) was diagnosed in the index patient. We found a new splice mutation in the NCF2 (p67-phox) gene, c.1000+2T→G, that led to several splice products one of which lacked exons 11 and 12. This deletion was in frame and allowed for remarkable residual NADPH oxidase activity as determined by transduction experiments using a retroviral vector. We conclude that p67-phox which lacks the 34 amino acids encoded by the two exons can still exert considerable functional activity. This activity can partially explain the long-term survival of the patients without adequate diagnosis and treatment, but could not prevent progressing lung damage.

Derivation and functional analysis of patient-specific induced pluripotent stem cells as an in vitro model of chronic granulomatous disease.

Chronic granulomatous disease (CGD) is an inherited disorder of phagocytes in which NADPH oxidase is defective in generating reactive oxygen species. In this study, we reprogrammed three normal unrelated patient's fibroblasts (p47phox and gp91phox) to pluripotency by lentiviral transduction with defined pluripotency factors. These induced pluripotent stem cells (iPSC) share the morphological features of human embryonic stem cells, express the key pluripotency factors, and possess high telomerase activity. Furthermore, all the iPSC lines formed embryoid bodies in vitro containing cells originating from all three germ layers and were capable of teratoma formation in vivo. They were isogenic with the original patient fibroblasts, exhibited normal karyotype, and retained the p47phox or gp91phox mutations found in the patient fibroblasts. We further demonstrated that these iPSC could be differentiated into monocytes and macrophages with a similar cytokine profile to blood-derived macrophages under resting conditions. Most importantly, CGD-patient-specific iPSC-derived macrophages showed normal phagocytic properties but lacked reactive oxygen species production, which correlates with clinical diagnosis of CGD in the patients. Together these results suggest that CGD-patient-specific iPSC lines represent an important tool for modeling CGD disease phenotypes, screening candidate drugs, and the development of gene therapy. Stem Cells 2012; 30:599–611

Classical Pyoderma Gangrenosum Associated with Abnormal Neutrophil Oxidative Burst

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by soft tissue necrosis, most often in the lower extremities. Classical neutrophilic dermatoses in patients with chronic granulomatous disease (CGD) are rare. Here we describe an adult without a known diagnosis of CGD diagnosed with PG and a persistent defect in neutrophil oxidative burst.