Primary Immunodeficiency Disorders Patients Research Articles

Primary Immunodeficiency Disorders (PIDs) and its Rheumatologic Manifestations Mohammad Imnul Islam

The hallmark of Primary Immunodeficiency Disorders (PIDs) is increased susceptibility to recurrent infections, which are often poorly responsive to therapy, prolonged and life-threatening. The infections can involve bones and joints. PIDs may also predispose to allergic, autoimmune, autoinflammatory and malignant disorders. Arthritis is the most common rheumatological manifestation of PIDs. Recurrent septic arthritis, arthritis with increased susceptibility to infection, skeletal changes, autoimmune disease or systemic lupus erythematosus with negative antinuclear antibody (ANA) are the essential clinical clues that could be considered rheumatologic manifestations of PIDs. This is considerable concern that early detection of PIDs patients invariably improves the quality of life and life expectancy through the prompt implementation of appropriate medical intervention. BANGLADESH J CHILD HEALTH 2022; VOL 46 (2) : 82-85

Assessment of Sleep Disturbances and Sleep Disordered Breathing in Primary Immunodeficiency Disorders

IntroductionPatients with primary immunodeficiency disorders (PIDD) have lower health related quality of life (HRQoL) compared to the general population. Fatigue is a predominant symptom for PIDD patients and previous publications have demonstrated increased self-reported measures of fatigue in this population, including PROMIS-29 scores. Fatigue is also seen in patients with sleep related disorders including sleep disordered breathing (SDB). Thus, we examined the prevalence of sleep disturbances and SDB in patients with PIDD. MethodsPatients from our institution with a physician-confirmed diagnosis of PIDD were recruited for this IRB-approved study. Patients under 18 years of age, currently pregnant, or with previous diagnosis of SDB were excluded. Patients completed the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), and Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires via REDCap. Patients then completed a home sleep apnea test (HSAT) using the Watch-PAT One device. ResultsA total of 24 patients with PIDD were enrolled in the study. Median age was 49.4 (range: 22.5–68.7) years, 18/24 (75%) patients were female. 22 out of 24 patients completed the questionnaires. Median values for PSQI, ESS, and FSS were 9.0 (2–18), 7.5 (0–20), and 4.9 (1.0–7.0), respectively. The median PROMIS Fatigue score was 57.9 (33.7–75.8). 14 out of 24 patients completed HSATs at the time of abstract submission. Sleep disordered breathing was defined as having an apnea-hypopnea index (AHI) of 5 events/hour or greater. For patients who completed HSATs, 10 (71%) met the threshold for having SDB. Based on guidelines established by the American Academy of Sleep Medicine, 6 (43%) had mild SDB, 3 (21%) had moderate SDB, and 1 (7%) had severe SDB. ConclusionPatients with an established diagnosis of PIDD, without previously diagnosed SDB, show a higher burden of poor sleep quality, daytime sleepiness, and fatigue based on scoring of self-reported questionnaires as compared to the general population. Overall, these patients were also noted to have a higher burden of sleep disordered breathing. These results provide preliminary evidence that undiagnosed sleep disturbances and SDB may contribute to the increased burden of fatigue in patients with PIDD.

SPECTRUM OF PRIMARY IMMUNODEFICIENCY DISORDERS IN CHILDREN IN KASHMIR

Primary immunodeficiency disorders (PIDs) are a genetically heterogeneous group of disorders that affect distinct components of the innate and adaptive immune system. To date, more than 300 different PIDs have been identified, most of these manifesting by 1 year of life. Recognition of these disorders by the clinician is important because appropriate therapy will not only prevent death but also reduce the long-term morbidity from recurrent infections. There is often under diagnosis of these conditions or a delay in the diagnosis of treatable conditions. Delay in the diagnosis of PID disorders is not only evident in undeveloped or developing countries, but is also reported in developed countries. On the other hand, early diagnosis and easy access to care and treatment play key roles in improving the survival, quality of life, and prognosis of patients with these disorders. Evaluation of immune function should be initiated for children with clinical manifestations for a specific immune disorder or with unusual, chronic, or recurrent infections such as systemic bacterial infections, serious respiratory bacterial infections, liver or brain abscesses, infections with unusual pathogens, and infections with common childhood pathogens but of unusual severity. No study regarding the pattern of diseases, clinical profile, complications and outcomes of primary immunodeficiency diseases has been done in Kashmir, which is geographically, socially, culturally, and ethnically a unique population. This study will through some light on the spectrum of primary immunodeficiency Disorders (PID) in this part of the world and help policy makers to set up an ideal platform for the management of these comparatively ignored but important diseases. Aims And Objectives: To study the clinical profile, disease complications and short-term outcomes of patients over a period of two years with Suspected primary immunodeficiency Disorders (PID) to ascertain the association of immunoglobulin levels and CD counts with PID. Materials And Methods: This Prospective observational study was conducted in the Department of Pediatrics, Government Medical College, Srinagar. A detailed history was taken from each patients attendant after confirming the reliability of the attendant (ideally mother or father) with special reference to the presence/ absence of manifestation of Primary immunodeficiency disorders. A thorough clinical examination was done after obtaining written informed consent from all patients for their inclusion in the study. In this study, 30 patients ,0-18 years of age, who met the inclusion criteria were included.: The duration of the study was two years and three months starting from September 2020-December 2022 (The first 3 months for patient recruitment). Data was compiled using Microsoft 2016 Excel spreadsheet and analyzed by IBMSPSS V.23. Descriptive statistics was computed to describe the sociodemographic characteristics of participants and to summarize the distribution of each of the dependent (outcome) and independent variables. Results: In this study, 30 patients with suspected Primary immunodeficiency disorders (PIDs) were recruited for three months and each patient was followed for two years as per study protocol. About 47% of the patients were products of 3rd degree consanguineous marriage, 33.3% of patients had a family history of Primary immunodeficiency disorders and 6.7% had received blood transfusions presently or in the past.Serum immunoglobulins profile was deranged in more than half of the patients. IgM was seen to be low in 60% of the patients, IgG and IgA were low in 36.7 % of the patients and IgE was high in 26% of the patients with suspected primary immunodeficiency disorder. CD4 and CD19 counts were seen to be low in 20% of patients and 16.7% of patients reported low CD8 count. Other diagnostic tests like Broncho-alveolar lavage (BAL) showed growth in 3.3% of patients, WAS protein was low in 16.7 % of the patients.The association of CD4 Counts was found to be statistically significant with p value <0.002 by Fishers Exact test. Patients with low CD4 count had 83.3% mortality as compared to those having normal counts. There was a strong association seen in patients with low CD8 counts with mortality among PID patients and p valve was highly significant (p valve <0.0005).

Investigating Biomarkers for Primary Immunodeficiency Disorders in Patients with Autoimmune Cytopenia

Introduction: Autoimmune cytopenias (AICs) occur in the setting of immune dysregulation and autoimmunity. AICs are known to precede the classical presentation and subsequent diagnosis of primary immunodeficiency disorders (PIDs) in some cases, with a PID spectrum involving B, T, and Treg dysregulation. Conversely, PID patients are also at a markedly increased risk of AICs and patients co-diagnosed with AICs and PIDs face higher mortality rates likely due to delayed diagnosis or improper/delayed therapy. Further, co-diagnosed patients are often refractory to standard treatment. Early screening and diagnosis of PIDs in the setting of AICs could lead to more targeted therapies and potentially better patient outcomes. We intend to investigate biomarkers that differentiate immune dysregulation among those with or without PID in the setting of AIC. Methods: A retrospective analysis comparing clinical history, including symptoms, presence of PID, genetic testing and diagnosis and treatment outcomes was performed on AIC patients in our hospital from 2016 to 2019. We also performed extensive immune phenotyping by flow cytometric analysis. Patients with expansion of CD19hi CD21lo B cells were further evaluated for Tbet+ CD11chi features for potential autoreactivity. Results: Our original cohort of 103 AIC patients included patients who were diagnosed with AIC only (n=52) or co-diagnosed with AIC-PID (n=51). From this cohort, a total of 43 were evaluated for further immune phenotyping, including 35 AIC-PID patients and 8 AIC only patients. Of the AIC-PID patients, 23 (65.7%) had a genetically coded PID, including pathogenic variants in CTLA4, NFKB1, PI3K or partial DiGeorge, while 12 (34.3%) were diagnosed with CVID/CID. Flow cytometry analysis revealed significantly increased T-follicular helper cell (Tfh) population in the AIC-PID group compared to AIC only (p=0.03) and healthy donor (HD) (p=0.004). We saw a similar expansion of CD19hi CD21lo B cells within the AIC-PID group. Conversely, patients with AIC-PID had decreased percentage of T-regulatory cells (Tregs) when compared to AIC only and HD groups. These differences were amplified within the genetically coded AIC-PID patients in Treg and Tfh populations and maintained in CD19hi CD21lo B cells. Further investigation of clinical history within the symptomatic, genetically coded AIC-PID group yielded 3 (33.3%) patients responsive to treatment and 6 (66.7%) patients unresponsive or partially responsive to therapy. Interestingly, nonresponsive patients showed an increased percentage of CD19hi CD21lo B cells. Conclusions: Our analysis demonstrates the potential utility of biomarkers, notably CD19hi CD21lo B cells and their immunological function for detecting underlying PIDs within the setting of AIC patients. Though this B cell population needs further assessment regarding Tbet and CD11c expression, with studies ongoing, these biomarkers may lead to a screening methodology to increase clinical visibility and detection as well as hasten diagnosis of underlying PID and potentially predict response to therapy, therefore increasing effective treatment outcomes for patients co-diagnosed with AIC PID.

Clinical and laboratory spectrum of inborn errors of immunity in Egypt: Five years of experience at a tertiary care university hospital.

The recognition and diagnosis of primary immunodeficiency disorders (PIDs) is challenging in developing countries. This study aimed to describe the features of PID patients in a tertiary care setting in Egypt and analyse the distribution, clinical features and outcome of PID among paediatric patients. This cross-sectional retrospective study was conducted between January 2016 and January 2021, to evaluate all paediatric patients aged below 18 years with PID that were diagnosed according to the International Union of Immunological Societies 2017 classification. We retrospectively studied the clinical features, diagnostic spectrum, laboratory investigations and relevant immunological workup, and treatment options. A total of 61 PID patients were enrolled in the current study. The median age at diagnosis was 22 months. The overall consanguinity rate was 49.2%, and the family history of PID was 19.7%. Among all PIDs, the combined immunodeficiency with syndromic features predominates with 17 cases, accounting for 27.9% of all cases of PIDs. The predominant antibody deficiency was the second common PID that was diagnosed in 14 patients (23%). Recurrent pneumonia was the most common initial presentation, occurring in 77% of patients, followed by failure to thrive (63.9%), and recurrent otitis media (55.7%). The total deaths were 18 patients (29.5%). Paediatric patients with PIDs are not uncommon in Egypt. There is a need to improve PID diagnosis and treatment, for better estimation of PID and to decrease morbidity and mortality.

A042 TRENDS IN PEDIATRIC PRIMARY IMMUNODEFICIENCY: INCIDENCE, UTILIZATION, HEMATOPOIETIC STEM CELL TRANSPLANTATION, AND MORTALITY

Primary immunodeficiency disorders (PIDD) describe a myriad of diseases caused by inherited defects within the immune system. As the number of identified genetic defects associated with PIDD increases, understanding the incidence and outcomes of PIDD patients becomes imperative.

Trends in Pediatric Primary Immunodeficiency: Incidence, Utilization, Transplantation, and Mortality

Primary immunodeficiency disorders (PIDDs) describe a myriad of diseases caused by inherited defects within the immune system. As the number of identified genetic defects associated with PIDDs increases, understanding the incidence and outcomes of PIDD patients becomes imperative. To characterize the frequency of new diagnoses, patterns of health care utilization, rates of hematopoietic stem cell transplantation (HSCT), and mortality in pediatric patients with PIDDs. A retrospective cohort analysis of the Pediatric Health Information System database from 2004 to 2018 for pediatric inpatients with an International Classification of Diseases, Ninth and 10th Revisions (ICD-9/ICD-10). code associated with PIDD. A total of 17,234 patients with a PIDD were hospitalized from 2004 to 2018. There were 2.8 new PIDD diagnoses and 6.3 PIDD hospitalizations per 1,000 discharges; these metrics were unchanged during the study period. The number of new diagnoses for B-cell and antibody defects significantly increased over time. The number of new PIDD diagnoses significantly increased in adolescents or adults and decreased in infants. T-cell disorders had the highest number of intensive care unit admissions. There were 747 PIDD patients who underwent HSCT; complications of HSCT significantly decreased over time. Mortality rates significantly decreased in all PIDD patients and in patients receiving HSCT. The total hospitalizations and incidence of PIDDs within the hospitalized pediatric population were unchanged. There were significant changes in the class of PIDD diagnosed, the age at diagnosis, and health care utilization metrics. Mortality significantly decreased over time within the PIDD cohort.

The 10th anniversary of the world primary immunodeficiency week: A J Project celebration

The 10^th anniversary of the world primary immunodeficiency week: A J Project celebration

Common variable immunodeficiency disorder associated with bronchiectasis: a case report

Common variable immunodeficiency disorder (CVID) is the commonest type of primary immunodeficiency disorders (PIDs) characterized by hypogammaglobulinemia, defective specific antibody production and increased susceptibility of recurrent infections. Autoimmunity, neoplasm and lymphoproliferative disorders are usually associated with CVID. In most cases, the cause is unknown, but multiple gene mutations (10%) may be associated with CVID. Here, we report an eight years old girl with CVID presented with recurrent infections, growth failure, generalized lymphadenopathy and hepatosplenomegaly. Chest examination and radiological findings of this girl were consistent with bronchiectasis. Lack of awareness among health care providers is the reason for delayed diagnosis of several years for this girl. Therefore, it is essential to raise awareness regarding PID patients among the physicians to improve the quality of life.

Evaluating Safety, Tolerability, and Efficacy of Subcutaneous Human Immunoglobulin 16.5% Administered at Modified Dosing Regimens in Patients with Primary Immunodeficiency Diseases – Study Design

Immunoglobulin (Ig) concentrates have been successfully used to treat patients with primary immunodeficiency disorders (PID). Many patients opt to use subcutaneous route of administration (SCIg) for the convenience, flexibility and minimal systemic side effects. This study plans to evaluate safety, tolerability, and efficacy of a SCIg 16.5% at modified infusion regimens in adult and pediatric PID patients.

Clinical Spectrum and Challenges of Primary Immunodeficiency disorders in Egyptian children

Primary Immunodeficiency Disorders (PID) are inherent defects of the immune system that may present in infants and children. The main presentations include increased susceptibility to infections (a narrow or broad spectrum of pathogens), autoimmunity, autoinflammation, allergy and/or malignancy. PIDs are increasingly diagnosed and may present with different phenotypes that range from subtle to severe ones. They are classified into ten major categories according to the International Union of Immunological Societies (IUIS). Autosomal recessive disorders are noticeably more common because of the high consanguinity rates in the society. The spectrum of PID is highlighted with a brief walk through the challenges of establishing a PID service in a resource limited setting like catching up with the rapidly changing field, provision of state of the art diagnostic services and actual provision of medical care to PID patients. Several opportunities for growth of the field and overcoming obstacles are discussed.

Higher Incidence of B Cell Malignancies in Primary Immunodeficiencies: A Combination of Intrinsic Genomic Instability and Exocytosis Defects at the Immunological Synapse

Congenital defects of the immune system called primary immunodeficiency disorders (PID) describe a group of diseases characterized by a decrease, an absence, or a malfunction of at least one part of the immune system. As a result, PID patients are more prone to develop life-threatening complications, including cancer. PID currently include over 400 different disorders, however, the variety of PID-related cancers is narrow. We discuss here reasons for this clinical phenotype. Namely, PID can lead to cell intrinsic failure to control cell transformation, failure to activate tumor surveillance by cytotoxic cells or both. As the most frequent tumors seen among PID patients stem from faulty lymphocyte development leading to leukemia and lymphoma, we focus on the extensive genomic alterations needed to create the vast diversity of B and T lymphocytes with potential to recognize any pathogen and why defects in these processes lead to malignancies in the immunodeficient environment of PID patients. In the second part of the review, we discuss PID affecting tumor surveillance and especially membrane trafficking defects caused by altered exocytosis and regulation of the actin cytoskeleton. As an impairment of these membrane trafficking pathways often results in dysfunctional effector immune cells, tumor cell immune evasion is elevated in PID. By considering new anti-cancer treatment concepts, such as transfer of genetically engineered immune cells, restoration of anti-tumor immunity in PID patients could be an approach to complement standard therapies.

Intravenous versus Subcutaneous Immunoglobulin in Primary Immunodeficiency: Real-World Evaluation of Safety, Efficacy, and Patient Perceptions

Background: Patients with primary immunodeficiency disorders (PIDD) typically require life-long immunoglobulin (IG) replacement therapy. There are two routes of IG administration: intravenous (IVIG) and subcutaneous (SCIG). To better understand routes of IG administration in the real-world, use in a home infusion setting was evaluated. Objective: To evaluate the safety, efficacy, and perceived responses in PIDD patients on IVIG versus SCIG in a realworld, home infusion setting. Methods: Retrospective data were collected from 2010 to 2018 from a national home infusion pharmacy of PIDD patients receiving IVIG or SCIG therapy for at least 6 months with evaluations for safety, efficacy, and patient perception of response. Results: A total of 149 patients were identified for analysis: IVIG (n=84) and SCIG (n=65). Overall, patients in the SCIG group had higher rates of local adverse reactions, while patients receiving IVIG had higher rates of systemic adverse reactions. Both SCIG and IVIG were effective as the majority of patients had ≤ 1 infection or hospital visit within the study period. However, patients in the SCIG group had fewer hospital visits and lower rates of infections overall. Patients receiving SCIG also perceived a faster speed of response. Conclusion: SCIG infusions are safe, efficacious, and well tolerated when compared to IVIG, providing PIDD patients with an alternative route of IG administration. Notably, hospital visits and infection rates were significantly reduced in patients receiving SCIG. The overall findings of this study contribute to growing evidence that demonstrates the benefits of SCIG in adult and pediatric patients with PIDD.

Rapid Low-Cost Microarray-Based Genotyping for Genetic Screening in Primary Immunodeficiency

Background: Genetic tests for primary immunodeficiency disorders (PIDs) are expensive, time-consuming, and not easily accessible in developing countries. Therefore, we studied the feasibility of a customized single nucleotide variant (SNV) microarray that we developed to detect disease-causing variants and copy number variation (CNV) in patients with PIDs for only 40 Euros.Methods: Probes were custom-designed to genotype 9,415 variants of 277 PID-related genes, and were added to the genome-wide Illumina Global Screening Array (GSA). Data analysis of GSA was performed using Illumina GenomeStudio 2.0, Biodiscovery Nexus 10.0, and R-3.4.4 software. Validation of genotype calling was performed by comparing the GSA with whole-genome sequencing (WGS) data of 56 non-PID controls. DNA samples of 95 clinically diagnosed PID patients, of which 60 patients (63%) had a genetically established diagnosis (by Next-Generation Sequencing (NGS) PID panels or Sanger sequencing), were analyzed to test the performance of the GSA. The additional SNVs detected by GSA were validated by Sanger sequencing.Results: Genotype calling of the customized array had an accuracy rate of 99.7%. The sensitivity for detecting rare PID variants was high (87%). The single sample replication in two runs was high (94.9%). The customized GSA was able to generate a genetic diagnosis in 37 out of 95 patients (39%). These 37 patients included 29 patients in whom the genetic variants were confirmed by conventional methods (26 patients by SNV and 3 by CNV analysis), while in 8 patients a new genetic diagnosis was established (6 patients by SNV and 2 patients suspected for leukemia by CNV analysis). Twenty-eight patients could not be detected due to the limited coverage of the custom probes. However, the diagnostic yield can potentially be increased when newly updated variants are added.Conclusion: Our robust customized GSA seems to be a promising first-line rapid screening tool for PIDs at an affordable price, which opens opportunities for low-cost genetic testing in developing countries. The technique is scalable, allows numerous new genetic variants to be added, and offers the potential for genetic testing not only in PIDs, but also in many other genetic diseases.

Pulmonary Complications in Patients with Primary Immunodeficiency Undergoing Hematopoietic Stem Cell Transplantation

<h3>Introduction</h3> Allogeneic hematopoietic stem cell transplantation (HSCT) is curative therapy for a variety of primary immunodeficiency disorders (PIDs). Patients with PID have high rates of pulmonary disease from infections and immune-mediated lung damage, and post-HSCT pulmonary complications account for considerable morbidity and mortality. It is unknown whether pre-HSCT pulmonary disease places PID patients at higher risk for post-HSCT complications. We hypothesize that PID patients with pre-HSCT pulmonary disease have higher risk of transplant-related mortality (TRM), more pulmonary complications, and lower overall survival (OS) compared to PID patients without pre-HSCT pulmonary disease. <h3>Objectives</h3> The primary aim of this study is to compare TRM in PID patients with and without pre-HSCT pulmonary disease. Secondary aims of the study are to compare OS, incidence of non-infectious and infectious pulmonary disease post-HSCT, ICU transfer for any cause, incidence of acute or chronic GVHD, and immune reconstitution. <h3>Methods</h3> This is a single center, retrospective, chart review. All pediatric patients (ages 0-18 years) who underwent allogeneic HSCT for a diagnosis of a PID at Boston Children's Hospital from January 2007-June 2018 (n=115) were included in the analysis. We defined non-infectious pulmonary disease as either functional lung impairment based on pulmonary function tests (PFTs), radiographic evidence of pulmonary disease, or documentation of a specific pulmonary diagnosis. We defined infectious pulmonary disease as either viral, bacterial, fungal or other infection in conjunction with positive radiographic and/or bronch/BAL findings. <h3>Results</h3> Within our cohort, the most common PIDs were SCID (n=28), DOCK8 deficiency (n=16), Wiskott-Aldrich syndrome (n=15), and chronic granulomatous disease (n=9). Of the 115 patients, 54 (47%) had a pre-HSCT diagnosis of pulmonary disease. Pulmonary infection (n=30) and bronchiectasis (n=11) were the most common diagnoses (Fig. 1A). Compared to patients without pre-HSCT lung disease, patients with pre-HSCT lung disease had higher numbers of pulmonary complications after HSCT, such as the need for non-invasive or mechanical ventilation (23 of 54 patients [43%] vs. 12 of 61 patients [20%]) (Fig. 1B). Amongst patients with pre-HSCT lung disease, 1-year survival was 81% compared with 92% in patients without pre-HSCT lung disease. Overall survival was 76% at a median follow up time of 1.6 years versus 89% at a median follow up of 2.7 years in patients with and without pre-HSCT lung disease, respectively (censored logrank p = 0.05) (Fig. 2). <h3>Conclusion</h3> Within our single center study, PID patients with pre-HSCT lung disease had a trend towards more post-HSCT lung complications and lower OS compared to PID patients without pre-HSCT lung disease. Pulmonary risk factors should be carefully considered in PID patients prior to HSCT.

Intravenous versus Subcutaneous Immunoglobulin in Primary Immunodeficiency: Real-World Evaluation of Safety, Efficacy, and Patient Perceptions

Background: Patients with primary immunodeficiency disorders (PIDD) typically require life-long immunoglobulin (IG) replacement therapy. There are two routes of IG administration: intravenous (IVIG) and subcutaneous (SCIG). To better understand routes of IG administration in the real-world, use in a home infusion setting was evaluated. Objective: To evaluate the safety, efficacy, and perceived responses in PIDD patients on IVIG versus SCIG in a realworld, home infusion setting. Methods: Retrospective data were collected from 2010 to 2018 from a national home infusion pharmacy of PIDD patients receiving IVIG or SCIG therapy for at least 6 months with evaluations for safety, efficacy, and patient perception of response. Results: A total of 149 patients were identified for analysis: IVIG (n=84) and SCIG (n=65). Overall, patients in the SCIG group had higher rates of local adverse reactions, while patients receiving IVIG had higher rates of systemic adverse reactions. Both SCIG and IVIG were effective as the majority of patients had ≤ 1 infection or hospital visit within the study period. However, patients in the SCIG group had fewer hospital visits and lower rates of infections overall. Patients receiving SCIG also perceived a faster speed of response. Conclusion: SCIG infusions are safe, efficacious, and well tolerated when compared to IVIG, providing PIDD patients with an alternative route of IG administration. Notably, hospital visits and infection rates were significantly reduced in patients receiving SCIG. The overall findings of this study contribute to growing evidence that demonstrates the benefits of SCIG in adult and pediatric patients with PIDD.

Mycobacteria-Specific T Cells May Be Expanded From Healthy Donors and Are Near Absent in Primary Immunodeficiency Disorders.

Mycobacterial Infections can be severe in patients with T-cell deficiency or phagocyte disorders, and treatment is frequently complicated by antimicrobial resistance. Restoration of T-cell immunity via stem cell transplantation facilitates control of mycobacterial infections, but presence of active infections during transplantation is associated with a higher risk of mortality. Adoptive T cell immunotherapy has been successful in targeting viruses, but has not been attempted to treat mycobacterial infections. We sought to expand and characterize mycobacterial-specific T-cells derived from healthy donors in order to determine suitability for adoptive immunotherapy. Mycobacteria-specific T-cells (MSTs) were generated from 10 healthy donors using a rapid ex vivo expansion protocol targeting five known mycobacterial target proteins (AG85B, PPE68, ESXA, ESXB, and ADK). MSTs were compared to T-cells expanded from the same donors using lysate from M. tuberculosis or purified protein derivative from M. avium (sensitin). MST expansion from seven patients with primary immunodeficiency disorders (PID) and two patients with IFN-γ autoantibodies and invasive M. avium infections. MSTs expanded from healthy donors recognized a median of 3 of 5 antigens, with production of IFN-γ, TNF, and GM-CSF in CD4+ T cells. Comparison of donors who received BCG vaccine (n = 6) to those who did not (n = 4) showed differential responses to PPE68 (p = 0.028) and ADK (p = 0.015) by IFN-γ ELISpot. MSTs expanded from lysate or sensitin also recognized multiple mycobacterial antigens, with a statistically significant differences noted only in the response to PPE68 (p = 0.016). MSTs expanded from patients with primary immunodeficiency (PID) and invasive mycobacterial infections showed activity against mycobacterial antigens in only two of seven subjects, whereas both patients with IFN-γ autoantibodies recognized mycobacterial antigens. Thus, MSTs can be generated from donors using a rapid expansion protocol regardless of history of BCG immunization. Most tested PID patients had no detectable T-cell immunity to mycobacteria despite history of infection. MSTs may have clinical utility for adoptive immunotherapy in T-cell deficient patients with invasive mycobacterial infections.

Rubella Virus-Associated Cutaneous Granulomatous Disease: a Unique Complication in Immune-Deficient Patients, Not Limited to DNA Repair Disorders.

The association of immunodeficiency-related vaccine-derived rubella virus (iVDRV) with cutaneous and visceral granulomatous disease has been reported in patients with primary immunodeficiency disorders (PIDs). The majority of these PID patients with rubella-positive granulomas had DNA repair disorders. To support this line of inquiry, we provide additional descriptive data on seven previously reported patients with Nijmegen breakage syndrome (NBS) (n = 3) and ataxia telangiectasia (AT) (n = 4) as well as eight previously unreported patients with iVDRV-induced cutaneous granulomas and DNA repair disorders including NBS (n = 1), AT (n = 5), DNA ligase 4 deficiency (n = 1), and Artemis deficiency (n = 1). We also provide descriptive data on several previously unreported PID patients with iVDRV-induced cutaneous granulomas including cartilage hair hypoplasia (n = 1), warts, hypogammaglobulinemia, immunodeficiency, myelokathexis (WHIM) syndrome (n = 1), MHC class II deficiency (n = 1), Coronin-1A deficiency (n = 1), X-linked severe combined immunodeficiency (X-SCID) (n = 1), and combined immunodeficiency without a molecular diagnosis (n = 1). At the time of this report, the median age of the patients with skin granulomas and DNA repair disorders was 9years (range 3-18). Cutaneous granulomas have been documented in all, while visceral granulomas were observed in six cases (40%). All patients had received rubella virus vaccine. The median duration of time elapsed from vaccination to the development of cutaneous granulomas was 48months (range 2-152). Hematopoietic cell transplantation was reported to result in scarring resolution of cutaneous granulomas in two patients with NBS, one patient with AT, one patient with Artemis deficiency, one patient with DNA Ligase 4 deficiency, one patient with MHC class II deficiency, and one patient with combined immunodeficiency without a known molecular etiology. Of the previously reported and unreported cases, the majority share the diagnosis of a DNA repair disorder. Analysis of additional patients with this complication may clarify determinants of rubella pathogenesis, identify specific immune defects resulting in chronic infection, and may lead to defect-specific therapies.

Rapid Multiplexed Proteomic Screening for Primary Immunodeficiency Disorders From Dried Blood Spots.

Background: Primary immunodeficiency disorders (PIDD) comprise a group of life-threatening congenital diseases characterized by absent or impaired immune responses. Despite the fact that effective, curative treatments are available with optimal clinical outcomes when diagnosed early, newborn screening does not exist for the majority of these diseases due to the lack of detectable, specific biomarkers or validated methods for population-based screening. Peptide immunoaffinity enrichment coupled with selected reaction monitoring mass spectrometry (immuno-SRM) is a sensitive proteomic assay, involving antibody-mediated peptide capture, that allows for concurrent quantification of multiple analytes. This assay has promise for use in potential newborn screening of PIDDs that lead to diminished or absent target proteins in the majority of cases.Objective: To determine and evaluate if a multiplex assay based on immuno-SRM is able to reliably and precisely distinguish affected patients with X-linked agammaglobulinemia (XLA), Wiskott-Aldrich Syndrome (WAS), and CD3ϵ-associated severe combined immunodeficiency (SCID) from one another and from unaffected normal control dried blood spot (DBS) samples.Methods: We performed a blinded, multiplexed analysis of proteolytically-generated peptides from WASp, BTK, and CD3ϵ (for WAS, XLA, and SCID, respectively) in DBS samples from 42 PIDD patients, 40 normal adult controls, and 62 normal newborns. The peptide ATPase copper transporting protein (ATP7B) 1056 was simultaneously monitored for quality assurance purposes.Results: The immuno-SRM assays reliably quantified the target peptides in DBS and accurately distinguished affected patients from normal controls. Analysis of signature peptides found statistically significant reduction or absence of peptide levels in affected patients compared to control groups in each case (WASp and BTK: p = 0.0001, SCID: p = 0.05). Intra and inter-assay precision ranged from 11 to 22% and 11 to 43% respectively; linearity (1.39–2000 fmol peptide), and stability (≤ 0.09% difference in 72 h) showed high precision for the multiplexed assay. Inter-laboratory assay comparison showed high concordance for measured peptide concentrations, with R2 linearity ≥ 0.97 for the WASp 274, CD3ϵ 197, BTK 407, and ATP7B 1056 peptides.Conclusion: Immuno-SRM-based quantification of proteotypic peptides from WASp, BTK, and CD3ϵ in DBS distinguishes relevant PIDD cases from one another and from controls, raising the possibility of employing this approach for large-scale multiplexed newborn screening of selective PIDDs.

Targeted next-generation sequencing for genetic diagnosis of 160 patients with primary immunodeficiency in south China.

Primary immunodeficiency disorders (PID) is a group of heterogeneous diseases mainly characterized by severe and recurrent infections and an increased susceptibility to lymphoproliferative, atopic, and autoimmune conditions. The clinical diagnosis should preferably be complemented by a genetic diagnosis. To date, PID-related reports from China seldom attempt to make a genetic test for their patients. Our study aimed to evaluate demographic data, clinical manifestations, and molecular diagnosis of PID patients from southern China. Moreover, by comparison with previous reports, we provide a picture of the current status of PID in mainland China. A total number of 160 pediatric PID patients (106 males and 54 females) were enrolled, and targeted next-generation sequencing was conducted using 269 PID-related genes and subsequently confirmed by Sanger sequencing and familial segregation analysis. The autoinflammatory disease group was the most common subcategory of PID (20%), followed by immune dysregulation (17.5%) and combined immunodeficiencies (16.2%). Antibody deficiency disorders were identified in only 11.9% of the cohort. The putative causative gene was identified in 70 patients (43.8%), and an X-linked pattern was found in 45.7% of the genetically diagnosed patients. The current study provides the first collective study of PID phenotypes and genotypes in south China and provides a strong argument for the diagnostic application of targeted next-generation sequencing panels in patients with suspected PID.