Severe Autoimmunity Research Articles

A Case of a 65-year-old woman with Vitiligo and Diabetes Presenting with Severe Autoimmune Hepatitis

Autoimmune hepatitis (AIH) is a chronic liver disease with diverse clinical presentations and significant global variation in prevalence. AIH predominantly affects females and commonly manifests with nonspecific symptoms such as fatigue and malaise, often accompanied by extrahepatic autoimmune disorders. Here, we present the case of a 65-year-old Hispanic woman with vitiligo, type II diabetes mellitus, and severe AIH. Despite extensive diagnostic workup, including serological testing, the cause of this patient’s hepatitis proved to be a challenge. Eventually, autoimmune testing revealed positive anti-smooth muscle antibodies and an elevated IgG, prompting percutaneous liver biopsy, which confirmed mild to moderate active hepatitis with mixed inflammatory infiltrate. Despite there not being a standardized diagnostic criterion for autoimmune hepatitis, the interdisciplinary hospital team agreed that the most likely diagnosis was autoimmune hepatitis, given her constellation of symptoms, serologic testing, and liver biopsy results. Treatment with prednisone was initiated, leading to clinical improvement. This case underscores the importance of a thorough diagnostic workup in suspected AIH cases, especially in patients with concomitant autoimmune conditions, to facilitate timely management and improve patient outcomes. It also highlights the need for a consensus among diagnostic criteria for autoimmune hepatitis.

Chemical-sensitized MITOGEN-ACTIVATED PROTEIN KINASE 4 provides insights into its functions in plant growth and immunity.

Two mitogen-activated protein kinase (MAPK) cascades with MPK4 and MPK3/MPK6 as the bottommost kinases are key to plant growth/development and immune signaling. Disruption of the MPK4 cascade leads to severe dwarfism and autoimmunity, complicating the study of MPK4 in plant growth/development and immunity. In this study, we successfully rescued the Arabidopsis (Arabidopsis thaliana) mpk4 mutant using a chemical-sensitized MPK4 variant, MPK4YG, creating a conditional activity-null mpk4 mutant named MPK4SR (genotype: PMPK4:MPK4YG mpk4) that could be used to examine the functions of MPK4 in plant growth/development and immunity. We discovered that the duration of the loss of MPK4 activity is important to plant immune responses. Short-term loss of MPK4 activity did not impact flg22-induced ROS burst or resistance against Pseudomonas syringae (Pst). Enhanced Pst resistance was only observed in the MPK4SR plants with stunted growth following prolonged inhibition of MPK4 activity. Transcriptome analyses in plants with short-term loss of MPK4 activity revealed a vital role of MPK4 in regulating several housekeeping processes, including mitosis, transcription initiation, and cell wall macromolecule catabolism. Furthermore, the constitutive weak activation of MPK4GA in the MPK4CA plants (genotype: PMPK4:MPK4GA mpk4) led to early flowering and premature senescence, which was associated with its compromised resistance against Pst. These findings suggest that MPK4 plays important roles in plant growth and development and in maintaining the delicate balance between growth/development and immune adaptation in plants.

Where AIRE we now? Where AIRE we going?

The purpose of the review is to describe the most recent advancement in understanding of the pivotal role of autoimmune regulator (AIRE) gene expression in central and peripheral tolerance, and the implications of its impairment in the genetic and pathogenesis of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) manifestations with insight into possible treatment options. AIRE gene expression has an important role of central and peripheral tolerance. Different AIRE gene mutations cause APECED, whereas polymorphisms and some variants may be implicated in development of other more frequently autoimmune diseases. Impaired negative T cell selection, reduction of T regulatory function, altered germinal center response, activated B cells and production of autoantibodies explain the development of autoimmunity in APECED. Recent data suggest that an excessive interferon-γ response may be the primer driver of the associated organ damage. Therefore, Janus kinase (JAK)-inhibitors may be promising therapies for treatment of broad spectrum of manifestations. AIRE has a pivotal role in immune tolerance. Disruption of this delicate equilibrium results in complex immune perturbation, ranging from severe autoimmunity, like APECED, to more common organ-specific disorders. Therefore, a deeper understanding of the correlation between AIRE function and clinical phenotype is warranted given the potential translational implication in clinical practice.

Maternal Immune Thrombocytopenic Purpura Leading to Severe Neonatal Autoimmune Thrombocytopenia: Report of Two Cases

Introduction: In neonatal intensive care units, neonatal thrombocytopenia is one of the common hematological abnormality seen. Neonatal autoimmune thrombocytopenia should be considered in any neonate who is born to a known case of immune thrombocytopenia purpura (ITP) mother, with early onset thrombocytopenia without any signs of sepsis. Neonatal ITP is a condition of autoantibody mediated platelet destruction. Case details: Two neonates with thrombocytopenia, born to mothers with ITP are described in this report. Lowest platelet count noted was 7000 cells/cmm in one of the neonate. Both neonates received intra venous immunoglobulin (IVIG) while one neonate had persistent and severe thrombocytopenia requiring multiple random donor platelet (RDP) transfusions followed by oral steroid as well. Conclusion: Neonatal thrombocytopenia associated with maternal ITP need close monitoring, early sampling and diagnosis to prevent any possible complications and warrant early initiation of treatment.

6560 Atypical Diabetes Mellitus in a Mother-Son Pair with Multiple Autoimmune Conditions & Pathogenic Variant in BCL11B Inherited from the Mother

Abstract Disclosure: R. Elrajabi: None. N. Gurtunca: None. The etiology of diabetes can be challenging to determine at times and misdiagnosis is common in all age groups. To provide the right treatment and enhance glycemic control, which results in better outcomes and fewer comorbidities, an accurate diagnosis is crucial. We describe a mother-son pair who share a pathogenic variant in BCL11B gene with multiple autoimmune conditions including atypical autoimmune DM. A 13 year old young boy with a history of 33-week prematurity, developmental delay, autoimmune hypothyroidism, and vitiligo presented with concerns for DM given mother’s recent diagnosis of DM treated with Metformin and GLP-1 receptor agonist with poor control of her DM. His mother has a learning disability, hypothyroidism, alopecia totalis, vitiligo and hypertension. Interestingly, he and his mother share a genetic variant in BCL11B gene detected on whole exome sequencing sent as part of the workup of developmental delay. His weight and height were in the 13.5% and 13.9% centiles, respectively. He has vitiligo, but other than that, the physical examination was unremarkable. He is prepubertal. HbA1c was high, 6.4% despite the presence of anemia. An oral glucose tolerance test (OGTT) was consistent with DM as was his repeat HbA1c of 7.1%. He had elevated IA 2, zinc transporter 8, and GAD 65 antibodies, all consistent with autoimmune DM. He was admitted to the hospital and started on both long-acting and short acting insulin via multiple daily injections. BCL11B is a transcription factor that is expressed in all T cells and regulates important processes involved in T cell growth, survival, and function, including Treg cells and Foxp3 activity. Autoimmune diseases have been linked to abnormal Treg activity and Foxp3 deficiency. BCL11B functions as a checkpoint required for T cell lineage commitment while minimizing natural killer cell potential. Impaired BCL11B activity at a young age result in severe whole-body autoimmunity, defined by a fully stimulated immune system similar to animals lacking functioning Treg cells. DM associated with BCL11B variant has not previously been reported. If we follow the theory that autoimmunity affects beta cell function or mass, this patient's and his mother's DM and autoimmune disorders are most likely connected to the BCL11B variation they share. Presentation: 6/2/2024

Multifaceted role of the actin-binding protein WIP: Promotor and inhibitor of tumor progression and dissemination.

Cancer cells depend on actin cytoskeleton reorganization to achieve hallmark malignant functions including abnormal activation, proliferation, migration and invasiveness. (Neural)-Wiskott-Aldrich Syndrome protein ((N-)WASP) binds actin and forms a complex with the WASP-interacting protein (WIP), which plays a critical role in regulating the actin cytoskeleton, through (N)-WASP-dependent and independent functions. Mutations in the WIP gene (WIPF1) lead to severe early onset immunodeficiency in humans and severe autoimmunity and shortened lifespan in mice. This review covers the available evidence about the physiological role of WIP in different tissues and its contribution to human disease, focusing on cancer. In solid tumors overexpression of WIP has mostly been associated with tumor initiation, progression and dissemination through matrix degradation by invadopodia, while a suppressive function has been shown for WIP in certain hematological cancers. Interestingly, a minority of studies suggest a protective role for WIP in specific tumor contexts. These data support the need for further research to fully understand the mechanisms underlying WIP's diverse functions in health and disease and raise important questions for future work.

European Society for Immunodeficiencies guidelines for the management of patients with congenital athymia

Congenital athymia is a life-limiting disorder due to rare inborn errors of immunity causing impaired thymus organogenesis or abnormal thymic stromal cell development and function. Athymic infants have a T-B+NK+ immunophenotype with profound T lymphocyte deficiency and are susceptible to severe infections and autoimmunity. Patients variably display syndromic features. Expanding access to newborn screening for severe combined immunodeficiency (SCID) and T lymphocytopaenia and broad genetic testing, including next-generation sequencing technologies, increasingly facilitate their timely identification. The recommended first-line treatment is allogeneic thymus transplantation, which is a specialized procedure available in Europe and the United States. Outcomes for athymic patients are best with early diagnosis and thymus transplantation before the development of infectious and inflammatory complications. These guidelines on behalf of the European Society of Immunodeficiencies provide a comprehensive review for clinicians who manage patients with inborn thymic stromal cell defects, and offer clinical practice recommendations focused on the diagnosis, investigation, risk stratification and management of congenital athymia, with the aim of improving patient outcomes.

Primary immune regulatory disorders (PIRD): expanding the mutation spectrum in Turkey and identification of sixteen novel variants

Human Inborn Errors of Immunity (IEIs) encompass a clinically and genetically heterogeneous group of disorders, ranging from mild cases to severe, life-threatening types. Among these, Primary Immune Regulatory Disorders (PIRDs) constitute a subset of IEIs characterized by diverse clinical phenotypes, prominently featuring severe atopy, autoimmunity, lymphoproliferation, hyperinflammation, autoinflammation, and susceptibility to malignancies. According to the latest report from the International Union of Immunological Societies (IUIS), PIRDs arise from mutations in various genes including LYST, RAB27A, AP3B1, AP3D1, PRF1, UNC13D, STX11, STXBP2, FAAP24, SLC7A7, RASGRP1, CD70, CTPS1, RLTPR, ITK, MAGT1, PRKCD, TNFRSF9, SH2DIA, XIAP, CD27 (TNFRSF7), FAS (TNFRSF6), FASLG (TNFSF6), CASP10, CASP8, FADD, LRBA, STAT3, AIRE, ITCH, ZAP70, TPP2, JAK1, PEPD, FOXP3, IL2RA, CTLA4, BACH2, IL2RB, DEF6, FERMT1, IL10, IL10RA, IL10RB, NFAT5, TGFB1, and RIPK1 genes. We designed a targeted next-generation sequencing (TNGS) workflow using the Ion AmpliSeq™ Primary Immune Deficiency Research Panel to sequence 264 genes associated with IEIs on the Ion S5™ Sequencer. In this study, we report the identification of 38 disease-causing variants, including 16 novel ones, detected in 40 patients across 15 distinct PIRD genes. The application of next-generation sequencing enabled rapid and precise diagnosis of patients with PIRDs.

Wiskott-Aldrich syndrome: a study of 577 patients defines the genotype as a biomarker for disease severity and survival

AbstractWiskott-Aldrich syndrome (WAS) is a multifaceted monogenic disorder with a broad disease spectrum and variable disease severity and a variety of treatment options including allogeneic hematopoietic stem cell transplantation (HSCT) and gene therapy (GT). No reliable biomarker exists to predict disease course and outcome for individual patients. A total of 577 patients with a WAS variant from 26 countries and a median follow-up of 8.9 years (range, 0.3-71.1), totaling 6118 patient-years, were included in this international retrospective study. Overall survival (OS) of the cohort (censored at HSCT or GT) was 82% (95% confidence interval, 78-87) at age 15 years and 70% (61-80) at 30 years. The type of variant was predictive of outcome: patients with a missense variant in exons 1 or 2 or with the intronic hot spot variant c.559+5G>A (class I variants) had a 15-year OS of 93% (89-98) and a 30-year OS of 91% (86-97), compared with 71% (62-81) and 48% (34-68) in patients with any other variant (class II; P < .0001). The cumulative incidence rates of disease-related complications such as severe bleeding (P = .007), life-threatening infection (P < .0001), and autoimmunity (P = .004) occurred significantly later in patients with a class I variant. The cumulative incidence of malignancy (P = .6) was not different between classes I and II. It confirms the spectrum of disease severity and quantifies the risk for specific disease-related complications. The class of the variant is a biomarker to predict the outcome for patients with WAS.

Overnutrition and Lipotoxicity: Impaired Efferocytosis and Chronic Inflammation as Precursors to Multifaceted Disease Pathogenesis.

Overnutrition, driven by the consumption of high-fat, high-sugar diets, has reached epidemic proportions and poses a significant global health challenge. Prolonged overnutrition leads to the deposition of excessive lipids in adipose and non-adipose tissues, a condition known as lipotoxicity. The intricate interplay between overnutrition-induced lipotoxicity and the immune system plays a pivotal role in the pathogenesis of various diseases. This review aims to elucidate the consequences of impaired efferocytosis, caused by lipotoxicity-poisoned macrophages, leading to chronic inflammation and the subsequent development of severe infectious diseases, autoimmunity, and cancer, as well as chronic pulmonary and cardiovascular diseases. Chronic overnutrition promotes adipose tissue expansion which induces cellular stress and inflammatory responses, contributing to insulin resistance, dyslipidemia, and metabolic syndrome. Moreover, sustained exposure to lipotoxicity impairs the efferocytic capacity of macrophages, compromising their ability to efficiently engulf and remove dead cells. The unresolved chronic inflammation perpetuates a pro-inflammatory microenvironment, exacerbating tissue damage and promoting the development of various diseases. The interaction between overnutrition, lipotoxicity, and impaired efferocytosis highlights a critical pathway through which chronic inflammation emerges, facilitating the development of severe infectious diseases, autoimmunity, cancer, and chronic pulmonary and cardiovascular diseases. Understanding these intricate connections sheds light on potential therapeutic avenues to mitigate the detrimental effects of overnutrition and lipotoxicity on immune function and tissue homeostasis, thereby paving the way for novel interventions aimed at reducing the burden of these multifaceted diseases on global health.

Aberrant RNA sensing in regulatory T cells causes systemic autoimmunity.

Chronic and aberrant nucleic acid sensing causes type I IFN-driven autoimmune diseases, designated type I interferonopathies. We found a significant reduction of regulatory T cells (Tregs) in patients with type I interferonopathies caused by mutations in ADAR1 or IFIH1 (encoding MDA5). We analyzed the underlying mechanisms using murine models and found that Treg-specific deletion of Adar1 caused peripheral Treg loss and scurfy-like lethal autoimmune disorders. Similarly, knock-in mice with Treg-specific expression of an MDA5 gain-of-function mutant caused apoptosis of peripheral Tregs and severe autoimmunity. Moreover, the impact of ADAR1 deficiency on Tregs is multifaceted, involving both MDA5 and PKR sensing. Together, our results highlight the dysregulation of Treg homeostasis by intrinsic aberrant RNA sensing as a potential determinant for type I interferonopathies.

Tristetraprolin promotes survival of mammary progenitor cells by restraining TNFα levels.

Tristetraprolin (TTP) is an RNA binding protein that destabilizes mRNAs of factors involved in proliferation, invasiveness, and inflammation. Disruption of the gene that codes for TTP (Zfp36) led to severe arthritis, autoimmunity, cachexia and dermatitis in mice. It has been shown that these phenotypes were mostly due to excessive TNFα levels in the affected tissues. We have previously reported that TTP expression is required for lactation maintenance. Our results indicated that conditional MG TTP-KO female mice displayed early involution due to the untimely induction of pro-inflammatory pathways led mostly by TNFα overexpression. Here we show that reducing TTP levels not only affects the fully differentiated mammary gland, but also harms morphogenesis of this tissue by impairing the progenitor cell population. We found that Zfp36 expression is linked to mammary stemness in human and mice. In addition, diminishing TTP expression and activity induced apoptosis of stem-like mouse mammary cells, reduced its ability to form mammospheres in culture and to develop into complete glands when implanted into cleared mammary fat pads in vivo. Our results show that survival of the stem-like cells is compromised by increased levels of inflammatory cytokines and stimulation of signaling cascades involving NFκB, STAT3 and MAPK-p38 activation. Moreover, TNFα overexpression and the consequent p38 phosphorylation would be the leading cause of progenitor cell death upon TTP expression restriction. Taken together, our results reveal the relevance of TTP for the maintenance of the mammary progenitor cell compartment by maintaining local TNFα levels at bay.

Hem1 inborn errors of immunity: waving goodbye to coordinated immunity in mice and humans.

Inborn errors of immunity (IEI) are a group of diseases in humans that typically present as increased susceptibility to infections, autoimmunity, hyperinflammation, allergy, and in some cases malignancy. Among newly identified genes linked to IEIs include 3 independent reports of 9 individuals from 7 independent kindreds with severe primary immunodeficiency disease (PID) and autoimmunity due to loss-of-function mutations in the NCKAP1L gene encoding Hematopoietic protein 1 (HEM1). HEM1 is a hematopoietic cell specific component of the WASp family verprolin homologous (WAVE) regulatory complex (WRC), which acts downstream of multiple immune receptors to stimulate actin nucleation and polymerization of filamentous actin (F-actin). The polymerization and branching of F-actin is critical for creating force-generating cytoskeletal structures which drive most active cellular processes including migration, adhesion, immune synapse formation, and phagocytosis. Branched actin networks at the cell cortex have also been implicated in acting as a barrier to regulate inappropriate vesicle (e.g. cytokine) secretion and spontaneous antigen receptor crosslinking. Given the importance of the actin cytoskeleton in most or all hematopoietic cells, it is not surprising that HEM1 deficient children present with a complex clinical picture that involves overlapping features of immunodeficiency and autoimmunity. In this review, we will provide an overview of what is known about the molecular and cellular functions of HEM1 and the WRC in immune and other cells. We will describe the common clinicopathological features and immunophenotypes of HEM1 deficiency in humans and provide detailed comparative descriptions of what has been learned about Hem1 disruption using constitutive and immune cell-specific mouse knockout models. Finally, we discuss future perspectives and important areas for investigation regarding HEM1 and the WRC.

Discovery of Novel, First-in-Class Allosteric Modulators of MALT1 Scaffolding Function with Differentiated Pharmacology for NFκB-Driven Malignancies

Constitutive activation of NFκB is an oncogenic driver for many lymphoid and selected solid tumor malignancies. BTK inhibitors, which affect the upstream NFκB pathway, have been successfully used in some diseases, but their utility is limited. The majority of DLBCL patients, for instance, are insensitive to BTK inhibition, supporting the need for alternative mechanisms to block NFκB-driven tumor progression. Knockdown of MALT1, a key component of the CBMT complex (CARD-BCL10-MALT1-TRAF6) involved in direct signal transduction of NFκB, is able to block NFκB-dependent DLBCL tumor growth in BTKi sensitive or resistant tumors, but pharmacologic modulation has been challenged by the dual-functionality of MALT1 in a complexed signalosome. MALT1 functions as the scaffolding component of the CBMT complex. Activated MALT1 recruits multiple proteins and directly activates NFκB canonical signaling. MALT1 also has protease activity that fine-tunes various signaling pathways including NFκB via the cleavage of many substrates. The scaffolding activity of MALT1 is critical for cancer cell survival. Most MALT1 inhibitors discovered so far only block protease activity, which results in incomplete NFκB inhibition, suboptimal anti-tumor activity, and the induction of severe autoimmunity due to protease inhibition. Using our Smart Allostery platform, we elucidated and then drugged a natural hotspot on MALT1 that selectively impacts scaffolding but not protease function. The series of scaffolding modulators demonstrate potent inhibition of MALT1 scaffolding activity with cellular IC 50 values ranging from 15 to 250 nM, while exerting minimal influence on MALT1 protease function. Unlike protease inhibitors, which only partially affect NFκB activity, scaffolding modulators completely inhibit the NFκB downstream signaling manifested by the suppression of NFκB activity with cellular IC 50 values ranging from 2 to 90 nM. Consequently, scaffolding modulators exhibit a superior and broader anti-proliferation profile compared to MALT1 protease inhibitors and BTK inhibitors in a panel of lymphoma cell lines. Pathway and genetic analyses indicate that B-cell lymphoma lines driven by NFκB are especially sensitive to scaffolding modulators. In vivo studies demonstrate a robust, dose-dependent tumor growth inhibition (TGI) by one representative scaffolding modulator in several B-cell lymphoma xenograft models. In a protease inhibitor sensitive ABC-DLBCL model, OCI-LY10, our scaffolding modulator achieved a maximal TGI of 94%, while a clinical MALT1 protease inhibitor showed 62% maximal TGI (p&amp;lt;0.001). In protease resistant NFκB driven DLBCL models, MALT1 scaffolding modulation resulted in tumor regression or stasis. These findings highlight the differentiated pharmacology of our scaffolding modulators. Distinct from protease inhibitors that suppress T cell activation and Treg population in vivo, scaffolding modulators also did not deplete Treg cells nor suppress T cell activation in a 14-day study. This potentially mitigates the risk of development of autoimmune disease caused by chronic MALT1 protease inhibition. In summary, we have discovered novel, first-in-class allosteric modulators of MALT1 scaffolding activities. These scaffolding modulators drive enhanced and broader anti-tumor effect in models resistant to MALT1 protease or BTK inhibitors and do so without immune dysregulation. Scaffolding modulation represents a potential best-in-class therapeutic opportunity to modulate MALT1 in patients with NFκB-driven malignancies.

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) &amp;lt; 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-1 Gene Expression as a Diagnostic Tool for Autosomal Recessive Chronic Granulomatous Disease among Egyptian Children with Phagocytic Dysfunction

Abstract Background Chronic granulomatous disease (CGD) is an inherited primary immunodeficiency disorder caused by functional impairment of the nicotinamide dinucleotide phosphate (NADPH) oxidase complex in neutrophilic granulocytes and monocytes and characterized by recurrent and severe infections, dysregulated inflammation and autoimmunity. Aim of the Work To diagnose the autosomal recessive (AR) type of CGD among a group of Egyptian pediatric patients with phagocytic dysfunction by detection of Neutrophil Cytosolic Factor-1 (NCF-1) gene expression using reverse transcription polymerase chain reaction (RT-PCR) and to correlate it with other diagnostic tests. Subjects and Methods A case-control study was conducted on 15 provisionally diagnosed CGD pediatric patients (Group I) by the use of DHR test, with the stimulation index using PMA &amp;lt; 30%. They were recruited from different university hospitals in Egypt. The study also included 12 mothers of the studied patients to detect the genetic mutations in carriers, if any, (Group II) and 14 apparently healthy children as a control group (Group III). Full medical history was taken and thorough clinical examination was done. The selected groups underwent testing for phagocytic and lytic indices, measurement of NCF-1 gene expression by real time RT-PCR. Results The comparative statistics between group I and group III as regards the phagocytic index (PI) revealed a high statistical significant difference between both groups. In addition, a statistically significant difference between both groups as regards lytic index (LI) was also revealed. Correlation studies were done between fold change of NCF-1 gene expression and each of PI, LI and DHR and showed no significant statistical correlation between these parameters in the 3 studied groups. Cases with a fold change of NCF-1 gene expression less than 0.48 (cut-off value calculated by the 25th percentile fold change of the control group), are considered having defective NCF-1 gene expression. At this cut-off value 2 out of 15 CGD cases and 3 mothers out of 12 showed NCF-1 gene under-expression. Conclusion Assessment of NCF-1 gene expression which encodes p47phox by real time RT- PCR in the present study could detect defective gene expression only among two CGD children and their mother as well as two other mothers with no correlation to other studied parameters. Since CGD is a genotypically heterogeneous disease; the findings of the present study highlight the importance of molecular testing for diagnosis after screening for NADPH oxidase protein deficiency by flow cytometry.

Systemic Inflammation and Normocytic Anemia in DOCK11 Deficiency

BackgroundIncreasing evidence links genetic defects affecting actin-regulatory proteins to diseases with severe autoimmunity and autoinflammation, yet the underlying molecular mechanisms are poorly understood. Dedicator of cytokinesis 11 (DOCK11) activates the small Rho guanosine triphosphatase (GTPase) cell division cycle 42 (CDC42), a central regulator of actin cytoskeleton dynamics. The role of DOCK11 in human immune-cell function and disease remains unknown.MethodsWe conducted genetic, immunologic, and molecular assays in four patients from four unrelated families who presented with infections, early-onset severe immune dysregulation, normocytic anemia of variable severity associated with anisopoikilocytosis, and developmental delay. Functional assays were performed in patient-derived cells, as well as in mouse and zebrafish models.ResultsWe identified rare, X-linked germline mutations in DOCK11 in the patients, leading to a loss of protein expression in two patients and impaired CDC42 activation in all four patients. Patient-derived T cells did not form filopodia and showed abnormal migration. In addition, the patient-derived T cells, as well as the T cells from Dock11-knockout mice, showed overt activation and production of proinflammatory cytokines that were associated with an increased degree of nuclear translocation of nuclear factor of activated T cell 1 (NFATc1). Anemia and aberrant erythrocyte morphologic features were recapitulated in a newly generated dock11-knockout zebrafish model, and anemia was amenable to rescue on ectopic expression of constitutively active CDC42.ConclusionsGermline hemizygous loss-of-function mutations affecting the actin regulator DOCK11 were shown to cause a previously unknown inborn error of hematopoiesis and immunity characterized by severe immune dysregulation and systemic inflammation, recurrent infections, and anemia. (Funded by the European Research Council and others.)

Extended List of Warning Signs in Qualification to Diagnosis and Treatment of Inborn Errors of Immunity in Children and Young Adults.

Inborn errors of immunity (IEI) refer to genetically determined disorders presenting with recurrent infections, autoimmunity, allergies, and malignancies. IEI is now commonly used, replacing the previously used term primary immunodeficiencies (PID). The 10 warning signs of IEI are widely used in the identification patients with IEI. The aim of the study was to determine and compare the utility of the 10 and 14 warning signs in IEI diagnosing. A retrospective analysis of 2851 patients was performed (98.17% were subjects under 18 years old and 1.83% were adults). All patients were questioned about the 10 warning signs and four additional signs: severe eczema, allergies, hemato-oncologic disorders and autoimmunity. Sensitivity, specificity, positive and negative predictive values, and odds ratio were calculated for the 10 and 14 warning signs. IEI were diagnosed in a total of 896 (31.4%) patients and excluded in 1955 (68.6%). The strongest predictors of IEI were hemato-oncologic disorders (OR = 11.25; p < 0.001) and autoimmunity (OR = 7.74; p < 0.001). The strongest predictors of severe IEI were hemato-oncologic disorders (OR = 89.26; p < 0.001), positive family history (OR = 25.23; p < 0.001), and autoimmunity (OR = 16.89; p < 0.001). There were 20.4% and 14% of IEI patients without any signs from the 10 and 14 warnings signs, respectively (p < 0.001). 20.3% and 6.8% of patients with severe PIDs had no presence of any signs from 10 and 14 signs, respectively (p = 0.012). The 10 warning signs have limited usefulness in identifying IEI. The modified list of 14 warning signs seems to represent an effective diagnostic method for the detection of IEI patients, especially those with severe PIDs.

CTLA4-Ig Effectively Controls Clinical Deterioration and Immune Condition in a Murine Model of Foxp3 Deficiency

PurposeFOXP3 deficiency results in severe multisystem autoimmunity in both mice and humans, driven by the absence of functional regulatory T cells. Patients typically present with early and severe autoimmune polyendocrinopathy, dermatitis, and severe inflammation of the gut, leading to villous atrophy and ultimately malabsorption, wasting, and failure to thrive. In the absence of successful treatment, FOXP3-deficient patients usually die within the first 2 years of life. Hematopoietic stem cell transplantation provides a curative option but first requires adequate control over the inflammatory condition. Due to the rarity of the condition, no clinical trials have been conducted, with widely unstandardized therapeutic approaches. We sought to compare the efficacy of lead therapeutic candidates rapamycin, anti-CD4 antibody, and CTLA4-Ig in controlling the physiological and immunological manifestations of Foxp3 deficiency in mice.MethodWe generated Foxp3-deficient mice and an appropriate clinical scoring system to enable direct comparison of lead therapeutic candidates rapamycin, nondepleting anti-CD4 antibody, and CTLA4-Ig.ResultsWe found distinct immunosuppressive profiles induced by each treatment, leading to unique protective combinations over distinct clinical manifestations. CTLA4-Ig provided superior breadth of protective outcomes, including highly efficient protection during the transplantation process.ConclusionThese results highlight the mechanistic diversity of pathogenic pathways initiated by regulatory T cell loss and suggest CTLA4-Ig as a potentially superior therapeutic option for FOXP3-deficient patients.

Dominant-negative heterozygous mutations in AIRE confer diverse autoimmune phenotypes

Autoimmune polyendocrine syndrome type 1 (APS-1) is an autosomal recessive disease characterized by severe and childhood onset organ-specific autoimmunity caused by mutations in the autoimmune regulator (AIRE) gene. More recently, dominant-negative mutations within the PHD1, PHD2, and SAND domains have been associated with an incompletely penetrant milder phenotype with later onset familial clustering, often masquerading as organ-specific autoimmunity. Patients with immunodeficiencies or autoimmunity where genetic analyses revealed heterozygous AIRE mutations were included in the study and the dominant-negative effects of the AIRE mutations were functionally assessed invitro. We here report additional families with phenotypes ranging from immunodeficiency, enteropathy, and vitiligo to asymptomatic carrier status. APS-1-specific autoantibodies can hint to the presence of these pathogenic AIRE variants although their absence does not rule out their presence. Our findings suggest functional studies of heterozygous AIRE variants and close follow-up of identified individuals and their families.