Severe Immunodeficiency Research Articles

Lung TB diagnosing difficulties in HIV-infected patients

Background. The HIV epidemic had a huge impact on the TB epidemic situation in the XXI century. Tuberculo-sis is developing more and more often in patients with HIV, and this is a serious problem for the society and health care system. When monitoring HIV+ patients, it is important to timely detect tuberculosis, the diagnostics of which may be very difficult. In case of progressing im-munosuppression, specific clinical and radiological fea-tures are seen, often with no bacterial excretion in spu-tum and negative skin tests during immunodiagnostics. Objective of the study. To show the prospects of using the T-SPOT®.TB test using clinical examples. Materials and methods. Two clinical examplesof HIV+ patients in severe immunodeficiency stage are presented, these patients are linked to care at the AIDS center. All pa-tients were examined for tuberculosis with T-SPOT®.TB. Results. At the initial diagnostic stage, minimal changes were detected on CT that could point to tuberculosis, MBT were not detected, but T-SPOT®.TB gave positive results. The diagnosis of tuberculosis has not been con-firmed. Upon further observation, with the same X-ray picture, MBT were detected, and pulmonary tuberculosis verified. In these cases, the positive result of T-SPOT®.TB indicated the activity of tuberculosis infection before the detection of MBT. Conclusion. Clinical cases reflect the difficulties of diagnosing tuberculosis in patients with HIV infection with high level of immunosuppression. The introduction of diagnostic tests based on the ELISPOT technique (T-SPOT®.TB) is highly promising, especially in the absence of bacterial excretion in sputum and limited changes in lung tissue.

735. Trends and Cost Analysis of Aspergillus Galactomannan testing at a Tertiary Medical Center

Background Aspergillus is a fungus spread by inhalation of spores that can lead to invasive (IA), chronic, or allergic aspergillosis. Risk factors for IA include neutropenia, hematological malignancy, allogenic stem cell (HSCT) or solid organ transplant, severe immunodeficiency, or prolonged steroid use. An alternative to invasive tissue sampling, the serum Galactomannan (AGM) test detects a polysaccharide cell wall component of Aspergillus and can be used to determine a probable diagnosis of IA. Accuracy of AGM is related to disease burden and thus has the highest sensitivity and specificity in patients with hematologic malignancy or Hematopoietic stem cell transplantation (HSCT) at 70-82% and 86-92%, respectively. Studies have shown sensitivity to decline in other populations, with solid organ transplants as low as 20%.MethodsWe performed a retrospective study of all patients who received the AGM test at UMMC from January 3, 2013 to December 31, 2019. Patient Cohort Explorer was used to obtain de-identified patient data from EPIC. We obtained the number of encounters and patients on whom the AGM test was performed along with other variables. Billing offices provided the self-pay cost per AGM test.ResultsA total of 6,404 AGM tests were performed on 2,126 patients during 4,315 encounters in the study period. With a total of 499, 574, 984, 1140, 851, 1175 and 1181 tests done respectively from 2013 to 2019, a increasing trend was noted. The patients ages ranged from 1 to 89 with a median age of 52 years. A total of 3,055 tests were ordered in females, and 3,349 were ordered in males.At a cut off value (optical density index) of > 0.5, 183 AGM tests resulted positive in 108 patients and at a cut of > 1.0, 113 tests are positive in 70 patients. The rate of a positive AGM tests at > 0.5 was at 2.85% and at > 1.0 was at 1.76% over the study period. With the self-pay cost of each test at $134.54 in 2019 USD, the total cost of 6,404 tests was $861,594.16.ConclusionTo our knowledge this data set constitutes the largest sample size of AGM testing. From our data, it seems that the rate of ordering this test has increased yearly. Relatively low percentage of these tests are positive, suggesting that it is most likely a large amount of these tests could have been ordered inappropriately or in the wrong clinical context.Disclosures All Authors: No reported disclosures

Clinical Recommendations of the Russian Gastroenterological Association on Diagnosis and Treatment of Infectious Esophagitis

Aim. Current clinical recommendations aim to provide gastroenterologists, general practitioners (family doctors), endoscopists and infectionists with modern methods for diagnosis and treatment of infectious esophagitis.Key points. Infectious esophagitis is an esophageal disease of fungal, viral, bacterial or parasitic origin. Esophagus may be affected per se or conjointly in a common gastrointestinal infection. All patients suspected for infectious esophagitis, unless contraindicated, are advised an esophagogastroduodenoscopy with biopsy to confirm diagnosis. Selected incidents of infectious esophagitis require a histological, immunohistochemical examination or polymerase chain reaction-based diagnosis to verify the infectious agent. Uncomplicated infectious esophagitis requires a conservative therapy, mostly on an outpatient basis. However, cases of severe odynophagia, dysphagia, severe pain syndrome, high complication risks (e.g., esophageal ulcer bleeding in thrombocytopenia), severe immunodeficiency, generalised forms of disease and severe concomitant disorders are considered for hospital care. The clinical recommendations outline criteria for the medical care quality assessment and provide relevant information to the patient.Conclusion. Diagnosis of infectious esophagitis capitalises on the clinical picture (odynophagia, dysphagia), presence of immunosuppression, endoscopic and histological evidence. All patients with infectious esophagitis of verified origin are recommended a suitable etiotropic therapy.

Reconstitution of a functional human thymus by postnatal stromal progenitor cells and natural whole-organ scaffolds

The thymus is a primary lymphoid organ, essential for T cell maturation and selection. There has been long-standing interest in processes underpinning thymus generation and the potential to manipulate it clinically, because alterations of thymus development or function can result in severe immunodeficiency and autoimmunity. Here, we identify epithelial-mesenchymal hybrid cells, capable of long-term expansion in vitro, and able to reconstitute an anatomic phenocopy of the native thymus, when combined with thymic interstitial cells and a natural decellularised extracellular matrix (ECM) obtained by whole thymus perfusion. This anatomical human thymus reconstruction is functional, as judged by its capacity to support mature T cell development in vivo after transplantation into humanised immunodeficient mice. These findings establish a basis for dissecting the cellular and molecular crosstalk between stroma, ECM and thymocytes, and offer practical prospects for treating congenital and acquired immunological diseases.

Stratifying risk of infection and response to therapy in patients with myeloma: a prognostic study

BackgroundMultiple myeloma is a cancer of plasma cells that is associated with severe immunodeficiency and increased numbers of bacterial infections. The Tackling Early Morbidity and Mortality in Myeloma (TEAMM) trial assessed the use of prophylactic levofloxacin in newly diagnosed multiple myeloma patients. Interactions between multiple myeloma disease activity, immunity and infection are central to the TEAMM trial. Active multiple myeloma suppresses immunity and infections delay administration of anti-multiple myeloma therapy. Furthermore, infection-derived inflammation nurtures multiple myeloma activity and resistance to anti-multiple myeloma therapy.ObjectivesThe aim of this study was to measure biomarkers of (1) immune competence to develop risk stratification of patients for infection to personalise the decision to prescribe antibiotics, (2) myeloma activity to sensitively measure speed and depth of myeloma response and (3) inflammation to identify patients who may be at risk of poor treatment responses.MethodSerum samples were collected from 977 TEAMM trial patients (aged 35–90 years) at randomisation, then every 4 weeks for 16 weeks and again at 1 year. Biomarker levels were compared with samples from healthy controls. Multiplex Luminex®assays (R&D Systems, Minneapolis, MN, USA) and enzyme-linked immunosorbent assays were used for the analysis of biomarkers and anti-viral antibodies were measured by a haemagglutination assay.ResultsAt baseline, levels of both polyclonal immunoglobulins and anti-bacterial antibodies were below the normal range in most TEAMM trial patients. This immunoparesis was much more severe for antibodies against specific bacterial targets than for total immunoglobulin levels. Levels of anti-bacterial antibodies were below the threshold of protection for 18 of the 19 bacterial antigens tested. More patients aged < 65 years were protected against meningococcal serotypes,Haemophilus influenzatype b and tetanus, whereas more patients aged ≥ 65 years were protected against pneumococcal serotypes but there was good protection in only 6% of the TEAMM trial patients. Higher levels of polyclonal immunoglobulins, but not specific anti-bacterial antibodies, were found to be associated with a lower risk of infection and a longer survival. At presentation, levels of neutrophil elastase, calprotectin and interleukin 10 were elevated in TEAMM trial patients, compared with healthy controls. Interleukin 10 levels were related to infection during the trial: patients with interleukin 10 levels ≥ 10 pg/ml had a greater risk of infection than patients with interleukin 10 levels < 10 pg/ml. Levels of soluble CD138 were elevated in 72% of TEAMM trial patients and were decreased in response to therapy, with a complete response seen in 40% of TEAMM trial patients by 16 weeks. Of the 76 TEAMM trial patients achieving a free light chain complete response at 16 weeks, only 30% had a soluble CD138 complete response. Overall, responses in the levels of soluble CD138 did not correlate with free light chain and myeloma monoclonal protein (also known as m-protein) responses, consistent with the fact that soluble CD138 responses reflect a separate aspect of disease activity and clonal size. Levels of procalcitonin were elevated in only 50% of patients who had febrile episodes during the TEAMM trial. Although levels of interleukins 6 and 8 at presentation were lower than in a heathy cohort of patients, lower levels of interleukin 6 were identified at baseline in poor responders than in good responders, and in patients who had febrile and non-febrile infections during the trial than in patients who had only non-febrile episodes.ConclusionInformation from this Efficacy and Mechanism Evaluation project can help inform risk stratification and patient identification strategies to be responsive to individual patient needs. Monitoring levels of free light chains and soluble CD138 can help identify non-responders early and monitoring interleukin 10 levels can help stratify patients for risk of infection. Furthermore, immunisation in remission should be tested.LimitationsThe TEAMM trial administered prophylactic antibiotics or placebo for 12 weeks from a new diagnosis of myeloma. Patients were monitored for infections for 16 weeks post diagnosis, with a final set of clinical data gathered at 1 year. Infection data and efficacy of prophylactic antibiotics are available for only the first 16 weeks and survival for the first 52 weeks. This limits long-term data, particularly for progression-free and overall survival.Future workThe TEAMM 2 trial (in preparation) will explore the benefit of prophylactic antibiotics up to 12 months following diagnosis and will explore infection risk post therapy and during remission. Furthermore, some of the key findings will be applied to investigate biomarkers in samples from other UK myeloma trials in which long-term outcome data are available.Trial registrationCurrent Controlled Trials ISRCTN51731976.FundingThis project was funded by the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership, and will be published in full inEfficacy and Mechanism Evaluation; Vol. 7, No. 10. See the NIHR Journals Library website for further project information.

THE COURSE OF A COMBINATION OF HIV INFECTION, TUBERCULOSIS, KAPOSI'S SARCOMA IN A PATIENT WHO ARRIVED FROM THE PENITENTIARY SYSTEM (CLINICAL CASE)

The article discusses the problems of polymorbidity in HIV infection, the causes of the unfavorable course of combined diseases, and the influence of social factors on the outcome of diseases. An epidemic variant of Kaposi's sarcoma develops against the background of immunosuppression and is a clinical marker of AIDS. In the first years of the pandemic, it occurred in every third patient and was one of the most common AIDS indicator diseases. In recent years of the HIV and AIDS epidemic, the incidence of Kaposi's sarcoma has decreased by more than 10 times. The course of HIV-associated Kaposi's sarcoma can vary, from long-term stable, lasting for years, to progressive, leading to the patient's death in a few months. The introduction of ARV therapy into practice has also changed the clinical course of Kaposi's sarcoma, its forms with aggressive malignant course are now rare. However, they do occur. A clinical case of a combination of HIV infection, tuberculosis, Kaposi's sarcoma in a patient who arrived from the penitentiary system is presented. It is emphasized that social status and social maladaptation, including stay in prison, has a significant impact on the outcome of combined pathology, along with other aggravating factors. In a patient who has previously had tuberculosis, from the moment of HIV detection to the manifestation of Kaposi's sarcoma, 4 years passed, from the appearance of the first signs of Kaposi's sarcoma to the fatal outcome – 4 months. The clinical case demonstrates the difficulties of differential diagnosis of disseminated pulmonary tuberculosis with Kaposi's sarcoma in a patient with severe immunodeficiency due to HIV; and reflects the influence of social factors on the rapidly progressive course of the combined pathology.

Immune Reconstitution After Gene Therapy Approaches in Patients With X-Linked Severe Combined Immunodeficiency Disease.

X-linked severe immunodeficiency disease (SCID-X1) is an inherited, rare, and life-threating disease. The genetic origin is a defect in the interleukin 2 receptor γ chain (IL2RG) gene and patients are classically characterized by absence of T and NK cells, as well as presence of partially-functional B cells. Without any treatment the disease is usually lethal during the first year of life. The treatment of choice for these patients is hematopoietic stem cell transplantation, with an excellent survival rate (>90%) if an HLA-matched sibling donor is available. However, when alternative donors are used, the success and survival rates are often lower. Gene therapy has been developed as an alternative treatment initially using γ-retroviral vectors to correct the defective γ chain in the absence of pre-conditioning treatment. The results were highly promising in SCID-X1 infants, showing long-term T-cell recovery and clinical benefit, although NK and B cell recovery was less robust. However, some infants developed T-cell acute lymphoblastic leukemia after the gene therapy, due to vector-mediated insertional mutagenesis. Consequently, considerable efforts have been made to develop safer vectors. The most recent clinical trials using lentiviral vectors together with a low-dose pre-conditioning regimen have demonstrated excellent sustained T cell recovery, but also B and NK cells, in both children and adults. This review provides an overview about the different gene therapy approaches used over the last 20 years to treat SCID-X1 patients, particularly focusing on lymphoid immune reconstitution, as well as the developments that have improved the process and outcomes.

Development of a rabbit model of Wiskott-Aldrich syndrome.

The Wiskott-Aldrich syndrome (WAS) is a severe recessive X-linked immunodeficiency resulting from loss-of-function mutations in the WAS gene. Mouse is the only mammalian model used for investigation of WAS pathogenesis. However, the mouse model does not accurately recapitulate WAS clinical phenotypes, thus, limiting its application in WAS clinical research. Herein, we report the generation of WAS knockout (KO) rabbits via embryo co-injection of Cas9 mRNA and a pair of sgRNAs targeting exons 2 and 7. WAS KO rabbits exhibited many symptoms similar to those of WAS patients, including thrombocytopenia, bleeding tendency, infections, and reduced numbers of T cell in the spleen and peripheral blood. The WAS KO rabbit model provides a new valuable tool for preclinical trials of WAS treatment.

A Case of Viral Pneumonia Caused by Coronavirus 229E

Seven human coronaviruses (HCoVs) have been isolated and identified as of February 2020 ; among these, HCoV-229E is known as a common causative organism of seasonal cold, however, a few cases of severe pneumonia caused by this virus in immunocompromised patients have also been reported. Previous reports have suggested that the majority of pneumonia cases labelled as being of unknown origin have a viral cause, including this virus. Herein, we report a case of pneumonia caused by Human Coronavirus 229E in a 78-year-old man with chronic obstructive pulmonary disease (COPD) who had been undergoing medical treatment for Behcetʼs disease as an outpatient. He presented to our hospital complaining of chills, excessive sputum, and cough. At the time of consultation, we suspected the possibility of viral pneumonia caused by SARS-CoV-2 (COVID-19),which had sporadically occurred in Japan by that time. Chest x-ray showed ground glass opacities in the periphery of the middle and lower right lung field and computed tomographic images showed ground-glass opacities in the right middle and lower lobes ; therefore, the patient was admitted to our hospital for treatment and observation in a depressurized room. Urinary rapid antigen tests for Streptococcus pneumoniae and Legionella pneumophila, the rapid influenza diagnostic test, sputum culture, and blood culture were all negative. Further, the PCR test for SARS-CoV-2 PCR was also negative. However, examination of a nasopharyngeal swab sample by nested multiplex PCR (nmPCR) revealed Coronavirus 229E ; we thus diagnosed the patient as having Coronavirus 229E-related pneumonia. He received supportive care with supplemental oxygen, his symptoms gradually improved, and he was discharged on Day 16. The few cases reported in the past had severe immunodeficiency due to hematological tumors, whereas a case like ours appears to be extremely rare. On the other hand, Coronavirus 229E-related pneumonia, which could have occurred in a larger population in the past may have remained unidentified due to a lack of suitable tests. Reports of cases of viral pneumonia in the future are expected to increase with the increased use of nmPCR tests.

Аntiretroviral therapy for HIV in clinical practice

Objective: this study aims to analyze the use of antiretroviral therapy and its efficacy in HIV-infected patients in 5 regions of Russian Federation.Materials and methods: the research protocol included a retrospective analysis of the regional Centers for the Prevention and Control of AIDS registers and medical records of patients. Inclusion criteria were a verified diagnosis of HIV infection. The first group included patients (n=1161) receiving antiretroviral therapy regimens at the latest by 01/01/2015, the second group included patients with no antiretroviral therapy before 01/01/2015 (n=1366). The groups were compared with each other by socio-demographic indicators and characteristics of HIV infection, including infection routes, stage of the disease and its natural course.Results: Group I showed a higher prevalence of patients with an undetectable viral load (60,7%) comparing to group II (p<0,05) where a low (70,9%) and high (8,5%) viral load was observed. There was a dynamic decrease in patients’ numbers with severe immunodeficiency by 12.6% and an increase in the average amount of CD4+ in group I.

Loss of the DNA Fork Remodeling Protein Smarcal1 Impairs the Replication Stress Response in Proliferating Hematopoietic Cells

Rapidly proliferating hematopoietic cells are particularly prone to threats to genomic integrity through replication stress. The response to replication stress involves complex molecular machinery to prevent replication fork collapse, avoid accumulation of DNA damage, and ensure the completion of DNA synthesis. Smarcal1, a DNA remodeling enzyme, has been linked to the replication stress response through stabilization, repair, and restart of stalled DNA replication forks. In humans, complete loss of function of Smarcal1 leads to the pleiotropic disorder Schimke immuno-osseous dysplasia (SIOD), which is characterized, in part, by a severe lymphoid immunodeficiency that leaves patients susceptible to opportunistic infections. Currently, the mechanisms driving the clinical immunodeficient phenotype of SIOD and the in vivo functions of Smarcal1 in hematopoietic cells remain largely unexplored. We evaluated the contribution of Smarcal1 to normal and stressed/emergency hematopoiesis, using a Smarcal1 knockout mouse model and hematopoietic cell replication stresses such as low-dose radiation, 5-fluorouracil, bone marrow transplantation, and oncogene- driven proliferation. We determined that, while loss of Smarcal1 does not affect hematopoietic stem and progenitor cells (HSPCs) or mature hematopoietic cell populations at a normal "resting" state, Smarcal1 is required in these cells undergoing proliferative stress. Following DNA replication stress, we detected defects in multiple Smarcal1-deficient hematopoietic cell populations. We also observed that loss of Smarcal1 led to significantly increased levels of replication stress, DNA damage, and apoptosis in proliferating cells. Through bone marrow transplantation, we determined that the deficiencies observed were not due to a defect in the bone marrow environment or an inability of the HSPCs to home to the bone marrow. Thus, our results reveal that Smarcal1 is critical to maintaining hematopoietic cell survival and function under conditions of DNA replication stress. Our data also suggest that the immunodeficiency of patients with Smarcal1 mutations may be due to an inability of hematopoietic cells, especially HSPCs, to properly respond to replication stress and proliferate. Since wild-type bone marrow is able to fully reconstitute and function in a Smarcal1-deficient environment, bone marrow transplantation may be an effective therapy for immunodeficient SIOD patients. Disclosures Eischen: AbbVie Inc.: Research Funding.

Correlation of vitamin D levels with CD4+ T cells count in children with HIV infection

Abstract Background: Human immunodeficiency virus (HIV) infection has become a serious issue in the field of child health. Faster disease progression, higher mortality, higher mother-to-child transmission, lower CD4+ T cells, and slower CD4+ increases after antiretroviral use are associated with vitamin D deficiency in HIV infection. Objective: To find out the correlation between vitamin D levels in the blood with CD4+ T cells count in children with HIV infection who received ART at Adam Malik General Hospital Medan. Method: This study used an analytic observational design with a cross-sectional approach to see the correlation between vitamin D levels in the blood and CD4+ T cell counts in children with HIV infection who received ART more than one year. The vitamin D and CD4+ count classification is based on WHO criteria. The data collected was processed and analyzed with a 95% confidence interval and a significance of p <0.05 and analysis with the Pearson and Annova correlation test. Result: Of the 31 research subjects, 17 subjects were male (54.8%) and 14 subjects were female (45.2%). The percentage of male is 9.6% more than that of women. With a standard deviation of 3.7 years, the age of the research subjects had a mean value of 8.8 years. Anthropometric measurements showed that 18 subjects (58.1%) were subjects with good nutritional status, while 13 subjects (41.9%) were malnourished. The CD4+ T cell count had a mean value 25 % and 899 sel/mm2 and mean value of vitamin D mean value 21.8 ng/dl. There was a poor correlation (r 0.152), which was not significantly different (p = 0.141), between vitamin D levels and CD4+ cells count. Conclusion: There was no correlation between vitamin D levels and CD4+ T cells count in children with HIV infection who received ART at Adam Malik General Hospital Medan. Further studies with more severe deficiency or severe immunodeficiency are needed, which cannot be represented in this study.

Fluorescent methods in morphological diagnostics of respiratory tuberculosis in HIV-infected patients

Background. Among the spectrum of respiratory diseases in HIV-infected patients, the leading place is taken by tuberculosis (TB). First of all, difficulties in the morphological diagnostics of TB are associated with the smooth over of its typical histological signs under condition of severe immunodeficiency. To objectify the histological conclusion about the presence of tuberculosis lesion in a morphology a number of specific histochemical and fluorescent methods have been developed, which are based on the direct or indirect detection of M. tuberculosis (MBT) in the affected tissues. Objective – to determine the advisability and effectiveness of using of fluorescent methods in the morphological diagnostics of respiratory tuberculosis in HIV-infected patients. Methods. The morphological study included 37 cases. Two methods were used: the traditional fluorescent method (FM) and immunohistochemical study with a polyclonal antibody to M. Tuberculosis with a fluorescent label (FITC). In the study group, the histological conclusions were compared with the final clinical diagnosis and the results of microbiological investigations. The sensitivity, specificity and effectiveness have been established for each of the methods. Results. At hospitalization only in one third of cases, based on the results of clinical and radiological data and laboratory tests, various forms of respiratory TB were suspected. In 26 cases (70,3 %), with traditional staining of tissue samples with hematoxylin and eosin, a histological diagnosis of tuberculosis infection was established. When performing FM, the largest number of positive results was obtained (16 cases, 84,2 %), whereas with FITC, the MBT was detected only in 11 cases (57,9 %). The specificity of the FITC method was 90,5 %, and FM – 84,6 %. The overall efficiency of the parallel application of 2 fluorescent methods was 69,1 %. The coincidence of the results of both methods was noted in 22 cases of 31 (70,9 %). In total, of the using of morphological fluorescent methods, mycobacterium infection in HIV-infected patients was diagnosed in 29 cases (78,4 %), and in 4 cases (10,8 %) mycobacterium infection was established as a background pathology. Conclusion. At the time of hospitalization, in more than half of patients with HIV infection (59,5 %), the results of clinical laboratory and radiological data do not allow determining the true nature of the pathological process. The traditional study of histological samples stained with hematoxylin and eosin made it possible to diagnose mycobacterial infection in 70,3 % of cases. The use of fluorescent methods increased the efficiency of morphological diagnosis of mycobacterial infection by 10,8 %. The fluorescence method showed a high sensitivity (88,0 %), while indicator of specificity was higher with the immunofluorescence method (90,5 %). The overall efficiency of using fluorescent methods for the histological detection of M. tuberculosis was 69,1 %, which indicates the advisability of using these methods in cases of diagnostics mycobacterial infection.

The E3 ubiquitin ligase UBR5 interacts with TTC7A and may be associated with very early onset inflammatory bowel disease

Very early onset inflammatory bowel disease (VEOIBD) denotes children with onset of IBD before six years of age. A number of monogenic disorders are associated with VEOIBD including tetratricopeptide repeat domain 7A (TTC7A) deficiency. TTC7A-deficiency is characterized by apoptotic colitis in milder cases with severe intestinal atresia and immunodeficiency in cases with complete loss of protein. We used whole exome sequencing in a VEOIBD patient presenting with colitis characterized by colonic apoptosis and no identified known VEOIBD variants, to identify compound heterozygous deleterious variants in the Ubiquitin protein ligase E3 component N-recognin 5 (UBR5) gene. Functional studies demonstrated that UBR5 co-immunoprecipitates with the TTC7A and the UBR5 variants had reduced interaction between UBR5 and TTC7A. Together this implicates UBR5 in regulating TTC7A signaling in VEOIBD patients with apoptotic colitis.

NEONATAL SCREENING IN UKRAINE: THE NEW CHALLENGES

Introduction. The priority of modern pediatrics and neonatology is to improve the organizational forms and methods of providing medical care to children, reducing morbidity, mortality and disability prevention. Severe Combined Immunodeficiency (SCID) is a group of primary immunodeficiency conditions with particularly severe dysfunction or absence of T and B cells, and sometimes NK lymphocytes. Late diagnosis of primary immunodeficiency, namely SCID, leads to the development of severe infectious complications, significantly complicates the further treatment and survival of patients, often leading to death from infancy. Today there are results of SCID treatment, with early diagnosis the effectiveness of therapy and survival of children is more than 90% in the world. A number of countries around the world conduct neonatal screening at the state level for early diagnosis of SCID. Modern neonatal screening in Ukraine is provided for 4 nosologies, while in other countries it covers from 8 to 60 genetic pathologies. The aim of our study is the early detection and diagnosis of severe primary immunodeficiency by neonatal screening, prevention of severe infections and complications in this group of patients, timely radical treatment, improving survival and quality of life of children with severe primary immunodeficiency. Materials and methods. For the first time in Ukraine, it is planned to conduct a pilot study of screening of newborns to detect severe primary immunodeficiencies, which will be based on the determination of T- and B-lymphopenia by TRECs and KRECs. The prevalence of T- and B-lymphopenias among 19 newborns, their importance in the diagnosis of severe combined immunodeficiencies and severe antibody disorders will be determined. Based on the results of the study, a protocol for the detection of primary immunodeficiencies by TRECs and KRECs and further tactics for infection prevention, treatment and surveillance of such children will be developed. For the first time, the clinical and economic feasibility of introducing neonatal screening for severe immunodeficiencies in Ukraine will be substantiated. Expected results. After studying the prevalence of T- and B-lymphopenia in infants, their importance in the diagnosis of SCID and severe antibody disorders will be formulated. Conclusions. Early diagnosis of primary immunodeficiency is extremely important to improve the patient's quality of life, as delayed diagnosis leads to a lack of adequate therapy and, consequently, to further serious infections that interfere with daily life, increasing the risk of various non-infectious complications. It is known that these disorders negatively affect the health of the patient, the quality of life of his family and people caring for him. In addition, existing research in the world proves that early diagnosis and bone marrow transplantation is an effective way to reduce the incidence and mortality of patients with SCID and lymphopenia

Vasculitis as a Major Morbidity Factor in Patients With Partial RAG Deficiency.

Vasculitis can be a life-threatening complication associated with high mortality and morbidity among patients with primary immunodeficiencies (PIDs), including variants of severe and combined immunodeficiencies ((S)CID). Our understanding of vasculitis in partial defects in recombination activating gene (RAG) deficiency, a prototype of (S)CIDs, is limited with no published systematic evaluation of diagnostic and therapeutic modalities. In this report, we sought to establish the clinical, laboratory features, and treatment outcome of patients with vasculitis due to partial RAG deficiency. Vasculitis was a major complication in eight (13%) of 62 patients in our cohort with partial RAG deficiency with features of infections and immune dysregulation. Vasculitis occurred early in life, often as first sign of disease (50%) and was complicated by significant end organ damage. Viral infections often preceded the onset of predominately non-granulomatous-small vessel vasculitis. Autoantibodies against cytokines (IFN-α, -ω, and IL-12) were detected in a large fraction of the cases tested (80%), whereas the majority of patients were anti-neutrophil cytoplasmic antibodies (ANCA) negative (>80%). Genetic diagnosis of RAG deficiency was delayed up to 2 years from the onset of vasculitis. Clinical cases with sole skin manifestation responded well to first-line steroid treatment, whereas systemic vasculitis with severe end-organ complications required second-line immunosuppression and/or hematopoietic stem cell transplantation (HSCT) for definitive management. In conclusion, our data suggest that vasculitis in partial RAG deficiency is prevalent among patients with partial RAG deficiency and is associated with high morbidity. Therefore, partial RAG deficiency should be included in the differential diagnosis of patients with early-onset systemic vasculitis. Diagnostic serology may be misleading with ANCA negative findings, and search for conventional autoantibodies should be extended to include those targeting cytokines.

Cytomegalovirus uveitis in HIV-infected patients: course and outcomes

Cytomegalovirus uveitis is one of the AIDS marker diseases, develops with severe immunodeficiency and is the main cause of blindness in HIV-infected patients.The aim of our work is to study the course and outcomes of CMV uveitis in patients with HIV infection over the past 10 years.Materials and methods. The study was conducted at the St. Petersburg Center for the Prevention and Control of AIDS and Infectious Diseases and at the Department of Ophthalmology of North-Western State Medical University named after I.I. Mechnikov. The analysis of statistical data of HIV Newsletters in St. Petersburg for 2009-2019 was carried out, as well as the Journal of Ophthalmologist Examination of the AIDS Center to assess the long-term dynamics of detection of CMV uveitis, CMV associated retinal detachment, and cases of vision loss.Results. On average, CMV eye damage occurred in 1.65% of patients. In most cases, the involvement of the retina was predominantly peripheral (50-89%). Neuritis, panuveitis, cystic macular edema and retinal detachment were also registered. A positive strong linear relationship was found between the number of new cases of HIV infection already detected in the AIDS stage and new cases of cytomegalovirus damage to the organ of vision. There is a very strong inverse linear relationship between the frequency of detection of CMV uveitis and the amount of antiretroviral therapy provided.Conclusion. Conducting antiretroviral therapy and providing it to an increasing number of patients helps to reduce the incidence of HIV infection in St. Petersburg and probably secondary CMV infection with damage to the organ of vision.

Newborn Screening for SCID and Other Severe Primary Immunodeficiency in the Polish-German Transborder Area: Experience From the First 14 Months of Collaboration.

In 2017, in the Polish-German transborder area of West Pomerania, Mecklenburg-Western Pomerania, and Brandenburg, in collaboration with two centers in Warsaw, a partnership in the field of newborn screening (NBS) for severe primary immunodeficiency diseases (PID), mainly severe combined immunodeficiency (SCID), was initiated. SCID, but also some other severe PID, is a group of disorders characterized by the absence of T and/or B and NK cells. Affected infants are susceptible to life-threatening infections, but early detection gives a chance for effective treatment. The prevalence of SCID in the Polish and German populations is unknown but can be comparable to other countries (1:50,000–100,000). SCID NBS tests are based on real-time polymerase chain reaction (qPCR) and the measurement of a number of T cell receptor excision circles (TREC), kappa-deleting recombination excision circles (KREC), and beta-actin (ACTB) as a quality marker of DNA. This method can also be effective in NBS for other severe PID with T- and/or B-cell lymphopenia, including combined immunodeficiency (CID) or agammaglobulinemia. During the 14 months of collaboration, 44,287 newborns were screened according to the ImmunoIVD protocol. Within 65 positive samples, seven were classified to immediate recall and 58 requested a second sample. Examination of the 58 second samples resulted in recalling one newborn. Confirmatory tests included immunophenotyping of lymphocyte subsets with extension to TCR repertoire, lymphoproliferation tests, radiosensitivity tests, maternal engraftment assays, and molecular tests. Final diagnosis included: one case of T-BlowNK+ SCID, one case of atypical Tlow BlowNK+ CID, one case of autosomal recessive agammaglobulinemia, and one case of Nijmegen breakage syndrome. Among four other positive results, three infants presented with T- and/or B-cell lymphopenia due to either the mother's immunosuppression, prematurity, or unknown reasons, which resolved or almost normalized in the first months of life. One newborn was classified as truly false positive. The overall positive predictive value (PPV) for the diagnosis of severe PID was 50.0%. This is the first population screening study that allowed identification of newborns with T and/or B immunodeficiency in Central and Eastern Europe.

Heterozygous PGM3 Variants Are Associated With Idiopathic Focal Epilepsy With Incomplete Penetrance.

IntroductionIdiopathic focal epilepsy (IFE) is a group of self-limited epilepsies. The etiology for the majority of the patients with IFE remains elusive. We thus screened disease-causing variants in the patients with IFE.MethodsWhole-exome sequencing was performed in a cohort of 323 patients with IFE. Protein modeling was performed to predict the effects of missense variants. The genotype–phenotype correlation of the newly defined causative gene was analyzed.ResultsFour novel heterozygous variants in PGM3, including two de novo variants, were identified in four unrelated individuals with IFE. The variants included one truncating variant (c.1432C > T/p.Q478X) and three missense variants (c.478C > T/p.P160S, c.1239C > G/p.N413K, and c.1659T > A/p.N553K), which had no allele frequency in the gnomAD database. The missense variants were predicted to be damaging and affect hydrogen bonds with surrounding amino acids. Mutations Q478X, P160S, and N413K were associated with benign childhood epilepsy with centrotemporal electroencephalograph (EEG) spikes. P160S and N413K were located in the inner side of the enzyme active center. Mutation N553K was associated with benign occipital epilepsy with incomplete penetrance, located in the C-terminal of Domain 4. Further analysis demonstrated that previously reported biallelic PGM3 mutations were associated with severe immunodeficiency and/or congenital disorder of glycosylation, commonly accompanied by neurodevelopmental abnormalities, while monoallelic mutations were associated with milder symptoms like IFE.ConclusionThe genetic and molecular evidence from the present study implies that the PGM3 variants identified in IFE patients lead to defects of the PGM3 gene, suggesting that the PGM3 gene is potentially associated with epilepsy. The genotype–phenotype relationship of PGM3 mutations suggested a quantitative correlation between genetic impairment and phenotypic severity, which helps explain the mild symptoms and incomplete penetrance in individuals with IFE.

Uncovering DNA-PKcs ancient phylogeny, unique sequence motifs and insights for human disease

DNA-dependent protein kinase catalytic subunit (DNA-PKcs) is a key member of the phosphatidylinositol-3 kinase-like (PIKK) family of protein kinases with critical roles in DNA-double strand break repair, transcription, metastasis, mitosis, RNA processing, and innate and adaptive immunity. The absence of DNA-PKcs from many model organisms has led to the assumption that DNA-PKcs is a vertebrate-specific PIKK. Here, we find that DNA-PKcs is widely distributed in invertebrates, fungi, plants, and protists, and that threonines 2609, 2638, and 2647 of the ABCDE cluster of phosphorylation sites are highly conserved amongst most Eukaryotes. Furthermore, we identify highly conserved amino acid sequence motifs and domains that are characteristic of DNA-PKcs relative to other PIKKs. These include residues in the Forehead domain and a novel motif we have termed YRPD, located in an α helix C-terminal to the ABCDE phosphorylation site loop. Combining sequence with biochemistry plus structural data on human DNA-PKcs unveils conserved sequence and conformational features with functional insights and implications. The defined generally progressive DNA-PKcs sequence diversification uncovers conserved functionality supported by Evolutionary Trace analysis, suggesting that for many organisms both functional sites and evolutionary pressures remain identical due to fundamental cell biology. The mining of cancer genomic data and germline mutations causing human inherited disease reveal that robust DNA-PKcs activity in tumors is detrimental to patient survival, whereas germline mutations compromising function are linked to severe immunodeficiency and neuronal degeneration. We anticipate that these collective results will enable ongoing DNA-PKcs functional analyses with biological and medical implications.