(2) Submission ID#755555
Unexpected Oral Lesions in a Patient with a Novel Cytotoxic T-lymphocyte Antigen-4
(CTLA-4) Variant - A Case Report
Christine Rauscher, MD1, Miguel Reyes-Mugica, MD2, Elaine Cassidy, MD3, Raymond Shupak,
DMD, MD, MBE4, Xiaoyi Zhang, MD, PhD5, Hey Chong, MD, PhD6
1Fellow, Department of Allergy and Immunology/UPMC Children's Hospital of Pittsburgh
2Chief of Pathology and Director of Laboratories/UPMC Children's Hospital of Pittsburgh
3Clinical Director of Rheumatology, Assistant Professor of Pediatrics/UPMC Children's
Hospital of Pittsburgh
4Assistant Professor/UPMC School of Dental Medicine
5Fellow, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition/UPMC
Children's Hospital of Pittsburgh
6Division Director of Allergy and Immunology, Associate Professor of Pediatrics/UPMC
Children's Hospital of Pittsburgh
Abstract/Case Report Text
Oral lichen planus (OLP) is a T-cell mediated chronic inflammatory tissue reaction
in which presentation can range from asymptomatic plaques to painful, erosive, bullous,
or ulcerative lesions. Here, we present a 15 year-old female with a novel CTLA-4 variant,
multiple autoimmune conditions, and unusual tongue lesions. Our patient was healthy
until 9 years of age when she developed Hashimoto’s thyroiditis. At 11, she developed
psoriasis. At 13, she was diagnosed with alopecia totalis and Epstein-Barr virus (EBV)
with resultant and persistent anemia, thrombocytopenia, lymphopenia and neutropenia.
She had chronic abdominal pain and diarrhea since age 13. Esophagogastroduodenoscopy
revealed lymphocytic esophagitis and active duodenal inflammation with increased intraepithelial
lymphocytes. Colonoscopy revealed mildly active chronic colitis with eosinophils.
Whole exome sequencing revealed a heterozygous c.239delA (p.Q80Rfs*2) pathogenic mutation
in exon 2 of CTLA-4. Family history is remarkable: father (splenomegaly and psoriasis)
and brother (autoimmune hemolytic anemia) have CTLA4 haploinsufficiency with the same
mutation. Abatacept was initiated with re-growth of hair, improvement in cytopenias,
improvement in psoriasis, and some reduction of gastrointestinal symptoms. Since her
abdominal pain persisted repeat endoscopies after six months of abatacept revealed
persistent active lymphocytic esophagitis with some improvement in inflammatory injury
in her duodenum and colon. Physical exam revealed glossitis with a gel-like coating
and ulceration on her tongue, xerosis along her face and scalp without other abnormalities
(Figure). She denied recent dental procedures, appliances, or tongue biting. Her WBC
ranged from 3-4 x10^9 cells/L and hemoglobin 9.4-12.7 g/dL. Absolute lymphocyte count
ranged from 1.0- 1.7 x10^9 cells/L. Immunologic evaluation revealed low IgA and pan-low
lymphocyte subsets (Table). EBV PCR ranged from 430-1,700 copies/mL. Tongue scraping
revealed Candida dubliniensis and she responded to 5 days of fluconazole. Two months
later, she developed painful white patches along her tongue and subsequent 4 kilogram
weight loss recalcitrant to viscous lidocaine, antacids, and 14 days of fluconazole.
Incisional tongue biopsy revealed ulceration with underlying granulation tissue with
lymphocyte and plasma cell infiltration consistent with OLP (Figure). Periodic acid-Schiff
diastase stain and Grocott stain were negative. Aerobic culture was normal. No fungus
was isolated within 14 days. Epstein-Barr encoding region in situ hybridization was
negative. Two weeks of topical dexamethasone lead to temporary improvement. Her tongue
lesions waxed and waned over the following months. Due to persistent psoriasis, methotrexate
was initiated without worsening in her tongue lesion. To our knowledge, this is the
first case of OLP reported in a patient with CTLA-4 haploinsufficiency. CTLA-4 haploinsufficiency
may present with variable clinical phenotypes including increased risk of EBV viremia
and malignancies. Therefore, after EBV and malignancy are ruled out, OLP may be a
prudent diagnosis to consider in a CTLA4 insufficient patient with unusual oral lesions.
Informed consent: Informed consent was obtained from all individual participants included
in the study.
IgG (751-1,560 mg/dL)
1,170
IgA (82-453 mg/dL)
45
IgM (40-274 mg/dL)
57
IgE (<88 IU/mL)
4
CD3 (1,400-2,200/cumm)
951
CD4 (640-1,200/cumm)
586
CD8 (640-900/cumm)
321
CD19 (260-510/cumm)
124
CD16/56 (180-340/cumm)
28
Vitamin B12 (211-911 pg/mL)
519
Zinc (0.55-1.50 ug/mL)
0.61
(3) Submission ID#756106
An Adult Female With Disseminated Mycobacterium Avium-Intracellulare Found To Have
Anti-Interferon-Gamma Autoantibody Syndrome
Patrick Gleeson, MD1, Michael Phillips, MD2, Scott Feldman, MD, PhD3, Anne Norris,
MD4, Steven Holland, MD5, Christa Zerbe, MD6
1Allergy and Immunology Fellow/Section of Allergy & Immunology, Hospital of the University
of Pennsylvania, Philadelphia, PA
2Professor of Medicine/Section of Allergy & Immunology, Hospital of the University
of Pennsylvania, Philadelphia, PA
3Assistant Professor of Clinical Medicine/Section of Allergy & Immunology, Hospital
of the University of Pennsylvania, Philadelphia, PA
4Associate Professor of Clinical Medicine/Division of Infectious Diseases, Penn Presbyterian
Medical Center, Philadelphia, PA
5Director, Division of Intramural Research; Chief, Immunopathogenesis Section/Laboratory
of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR),
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH), Bethesda, MD, USA
6Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Immunopathogenesis
Section, National Institute of Allergy and Immunology, National Institutes of Health,
Bethesda, MD
Abstract/Case Report Text
Rationale: Anti-interferon-gamma (IFN-γ) autoantibody syndrome is a rare IFN-γ pathway
defect presenting with non-tuberculous mycobacterial disease and other opportunistic
infections. Onset is usually in the 4th to 6th decade and is likely due to genetic
factors. Here we present an adult female with disseminated mycobacterium avium-intracellulare
(MAI), found to have high titers of anti-IFN-γ autoantibody.
Methods: An anti-IFN-γ autoantibodies screening assay was performed at the National
Institutes of Health.
Results: A 38-year-old female with no past medical history presented with back pain
and was found to have bony lytic lesions. She had anemia with hemoglobin 6.2 g/dL,
leukocytosis to 25/μL, peripheral eosinophilia to 1100/μL, elevated inflammatory markers,
mediastinal lymphadenopathy, and a right sphenoid sinus abnormality. A bronchoscopy
and mediastinoscopy were nondiagnostic. A bone marrow biopsy showed decreased trilineage
hematopoiesis without evidence of malignancy. Nasal secretion and sinus biopsy showed
granulomatous inflammation with MAI. She developed an abscess in her gluteal area
at a site of antibiotic administration, and culture grew MAI. An IFN-γ release assay
was nonreactive. An anti-IFN-γ autoantibodies screening assay performed at the Laboratory
of Clinical Immunology and Microbiology at the National Institutes of Health confirmed
the diagnosis of anti-IFN-γ autoantibody syndrome. She was started on a 4-drug regimen
for treatment of MAI with significant clinical and radiographic improvement.
Conclusion: A range of molecular defects in the IFN-γ signaling pathway can result
in nontuberculous mycobacterial and other opportunistic infections. Anti-IFN-γ autoantibody
syndrome is a rare variant that typically presents in adulthood and can be confirmed
by an anti-IFN-γ autoantibody assay.
(4) Submission ID#767531
Novel BCL6b Variants Are Associated With Immunodeficiency and Immune Dysregulation
David Hagin, MD, PhD1, David Buchbinder, MD, MS2, Lisa Forbes, MD3, Jeffrey Cohen,
MD4, Ivan Chinn, MD5, Jenny Despotovic, DO6, Jamie Frediani, MD7, Tal Freund, BSc8,
Ivan Kirov, MD9, Julie Niemela, MS, MLS10, Susan Price, RN11, Sergio Rosenzweig, MD,
PhD12, V. Koneti Rao, MD13
1Director/Department of Allergy and Immunology, Tel-Aviv Sourasky Medical Center,
Tel-Aviv, Israel
2Staff Physician, Division of Hematology/CHOC Children's Hospital
3Assistant Professor/Department of Pediatrics, Baylor College of Medicine, Houston,
TX, USA and Texas Children’s Hospital, William T. Shearer Center for Human Immunobiology,
Department of Allergy, Immunology, and Retrovirology, Houston, TX, USA.
4Senior Investigator/Laboratory of Infectious Diseases, Medical Virology Section,
National Institutes of Health
5Assistant Professor, Director Immunogenetics Program/Department of Immunology, Allergy
and Rheumatology at Baylor College of Medicine
6Assistant Professor/Department of Pediatric Hematology and Oncology at Baylor College
of Medicine
7Staff Physician/Department of Oncology , CHOC Chldren’s Hospital
8Research Assistant/Department of Allergy and Immunology, Tel-Aviv Sourasky Medical
Center
9Division Chief/Department of Oncology , CHOC Chldren’s Hospital
10Medical Laboratory Technologist/Immunology Service, Department of Laboratory Medicine,
Clinical Center, NIH, USA
11Study Nurse Coordinator/Medical Science and Computing, LLC in support to the Laboratory
of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious
Diseases, National Institutes of Health
12Senior Investigator; Chief/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center, Bethesda, MD, USA
13Staff Clinician/ALPS Unit, Laboratory of Clinical Immunology and Microbiology, National
Institute of Allergy and Infectious Diseases, National Institutes of Health
Abstract/Case Report Text
Introduction: B-cell CLL/lymphoma 6 member B (BCL6b) is a transcriptional repressor
which shares close similarity with BCL6, binds to BCL6 DNA binding targets, and interacts
with as well as requires BCL6 for its repression activity. The precise role and potential
molecular mechanism underlying the involvement of BCL6b in the development of primary
immunodeficiency and immune dysregulation is unknown. Herein we report four patients
with clinical manifestations of immunodeficiency / immune dysregulation, all found
to have rare or novel variants in BCL6b.
Objectives: To describe 4 cases of BCL6b variants and their respective phenotypes.
Methods: The patients were evaluated for possible immune deficiency. A retrospective
chart review was conducted examining medical history, diagnosis, laboratory data,
and therapeutic responses.
Results: Patient 1 is a 19-year-old Ashkenazi Jewish female who presented at 9 years
of age with Neutropenia and later developed immune thrombocytopenia (ITP) and autoimmune
hemolytic anemia and cervical lymphadenopathy (biopsy showed reactive changes). Phenotyping
showed a high percent of plasmablasts and a low percent of follicular helper T cells,
a pattern which could be consistent with abnormal BCL6 function. Treatments included
intravenous immunoglobulin (IVIg), rituximab, mycophenolate mofetil (MMF), plaquenil,
and belimumab. No infections have been documented. A heterozygous rare variant in
BCL6b (c.1348C>T, p.R450W) has been documented.
Patient 2 is a 12-year-old Hispanic male who presented at 5 years of age with chronic
abdominal pain, retroperitoneal adenopathy (biopsy with reactive changes), an abdominal
mass, pulmonary nodule (biopsy with cytomegalovirus [CMV] inclusions), in association
with pancreatitis (biopsy with CMV inclusions) and CMV viremia. Stage IIB Nodular
Lymphocyte Predominant Hodgkin's Lymphoma was diagnosed (11 years of age). Intermittent
CD4 T cell lymphopenia was documented. Treatments included ganciclovir/valganciclovir
(CMV) as well as doxorubicin, bleomycin, vincristine, etoposide, prednisone, and cyclophosphamide
(ABVE-PC) for 4 cycles (lymphoma). A heterozygous rare variant in BCL6b (c.1258C>T,
p.R420C) has been documented.
Patient 3 is a 10-year-old Middle Eastern female who presented at 7 years with refractory
ITP and later developed Evan’s syndrome and splenomegaly. Immunophenotyping showed
B-cell lymphocytosis, low memory CD4 T cells and low NK cells. Treatments included
systemic steroids, IVIg, MMF and romiplostim. A homozygous rare BCL6b variant (c.118C>T;
p.T373M) was identified.
Patient 4 is a 47-year-old Caucasian female who presented at 40 years of age with
recurrent fever, abdominal pain, liver function abnormalities and persistent Epstein-Barr
virus (EBV) viremia. Biopsies showed Epstein-Barr encoding region positive (EBER+)
T cells in the liver, bone marrow and spleen (underwent splenectomy). Naïve CD4 T
cell lymphopenia was documented. Treatments included solumedrol and rituximab. Persistent
EBV viremia was the sole infectious issue noted. A heterozygous rare variant in BCL6b
(c.793T>G, p.F265V) has been documented.
Conclusions:
Mutations of BCL6b appear to be associated with lymphoproliferation and autoimmunity
as well as susceptibility to Herpes virus infections. Additional research focusing
on characterization of DNA binding sites of BCL6b as well as the downstream expression
of associated target genes is needed. These data combined with longitudinal analysis
of additional patients with confirmed BCL6b mutations, will help clarify determinants
of BCL6b pathogenesis and highlight potential therapeutic strategies.
Patient
1
2
3
4
Age
20y/o female (Ashkenazi Jew)
12y/o male (Hispanic)
10y/o female (Middle Eastern)
47 female (Caucasian)
Variant
Mutation
Heterozygous c.1348C>T, p.R450W, 4th Zinc finger
Heterozygousc.1258C>T, p.R420C, 5th Zinc finger
Homozygous c.118C>T; p. T373M, 2nd Zinc finger
Heterozygous c.793T>G, p.F265V
Gnomad AF
0.00003188
0.00006416
0.00002406
0.000008015
Polyphen; SIFT
Probably damaging; Deleterious
Probably damaging; Deleterious
Probably damaging; Deleterious
Benign; tolerated
Onset
Age at onset
9y/o
5y/o
7y/o
40y/o
Presenting symptoms
Weakness, neutropenia, Hashimoto's
Chronic abdominal pain and retroperitoneal mass. Lung lesion. Bx - pancreatitis and
CMV inclusion bodies + CMV pneumonitis.
Refractory ITP
Recurrent fever, abdominal pain, LFT abnormalities
Immune Dysregulation
Hematologic
Neutropenia at 9; ITP at 15.5; AIHA at 16.5
At 5yr - Recurrent abdominal pain with extensive retroperitoneal, periportal and peripancreatic
LAD. At 8yr - Worsening LAD + splenomegaly. Mesenteric LN Bx - paracortical hyperplasia
and atypical T cell infiltration. At 11yr - Mediastinal, hilar, and axillary adenopathy.
LN biopsy showed lymphocyte predominant Hodgkin lymphoma.
Evan’s syndrome, ITP, DAT+ AIHA and pancytopenia, resolved with immunosuppression.
Splenomegaly.
Splenomegaly. Splenectomy showing granulomas.
Skin
Alopecia areata - on and off between 9-15. More recent psoriatic rash (per Bx).
GI
Rec aphthous stomatitis
Intermittent vomiting and diarrhea
Urinary
Age 8yrs - Edema, proteinuria and AKI (Cr-1.6). Bx - Acute tubule-interstitial nephritis
Endocrine / other
Hashimoto's thyroiditis at 9
3 mm nodules in lung bases
Infections
Viral
None
CMV viremia at presentation (6000 copies). Responded to ganciclovir / valganciclovir.
None
Persistent EBV viremia
Immune Evaluation
Lymphocyte Subsets
Normal
Fluctuating lymphopenia (mostly CD4 lymphopenia).
B cell lymphocytosis (24%, 694/uL),
B cell phenotyping
Low CD38lowCD24high memory B cells. High % of plasmablast. Increased BAFF-R MFI, increased
CD27 MFI, Increased % of class-switched memory cells.
High % of CD38high cells (plasmablasts?)
Post rituximab – No B cells
T cell phenotyping
CD4s - Skewing toward CD45RO+CCR7- Teff. CD8s - absent CD45RO+CCR7+ Tcm. High % of
CD45RA+CCR7- Temra cells.
Low CD56+ cells, Low CD45RO+ memory CD4+ T cells.
Reduced naïve CD4 cells
DNT
Normal - 0.97% TCR··+ DNT
Elevated – 7.6% TCR··+ DNT
normal
Antibody levels
2015-2018: Elevated IgG between 1507 to 2079mg/dL. Normal IgM.
Normal IgG. Low IgM in the past.
Normal - IgA 98, IgG 1007, IgM 146
Low IgG and Low IgM, normal IgA (post rituximab)
Autoantibodies
Positive APLA at 12 (resolved)
Positive ANA, anti-dsDNA and anticardiolipin (anti-dsDNA resolved)
Other
Normal Treg phenotyping
Normal mitogen proliferation. Suboptimal vaccine response.
normal mitogen and vaccine titers, normal NK function
Pathology
BM Bx
Normal - 2016
Normal - 2013, 2016
2015 - Megakaryocytic number and maturation compatible with peripheral destruction
Increased EBV+ T cells and granulomas
LN Bx
Reactive - 2016
2015 - Negative for malignancy. 2016 - paracortical hyperplasia + atypical T cell
infiltration. 2018 - HD.
Other
Skin - Early lesion of psoriasis - 2016
2016 - Kidney Bx - Acute tubule-interstitial nephritis
Splenectomy - necrotizing granulomas, EBV+ T cells.,
Liver biopsy - EBV hepatitis with EBV in T cells, erythrophagocytosis
(5) Submission ID#769441
Unexpected Autoimmunity and Infections in A Cohort of Patients with Complement Deficiencies
Iñigo Perez-Heras, MD, PhD1, Nerea Dominguez-Pinilla, MD1, Nerea Salmon-Rodriguez,
MD2, Javier Blas, MD3, Begoña Losada-Pinedo, MD1, Lucia Vigara, MD4, Angela Manzanares,
MD5, Luis Allende, MD, PhD2, Jesus Ruiz-Contreras, MD, PhD6, Veronica Silupu-Rodriguez,
MD7, Luis Gonzalez-Granado, MD,PhD8
1Consultant/Hospital Virgen de la Salud. Toledo.
2Consultant/Hospital 12 octubre. Madrid
3Consultant/Immunology Department. Hospital 12 octubre. Madrid.Spain
4Resident/Hospital Universitario Principe de Asturias
5Resident/Hospital 12 octubre. Madrid
6Consultant/Hospital 12 octubre
7Resident/Instituto Nacional de Salud del Niño. Lima
8Senior Consultant/Hospital 12 octubre. Madrid
Abstract/Case Report Text
Introduction: Patients with complement deficiencies represent globally less than 2%
of all primary immunodeficiencies (PID). Sometimes, diagnosis is not straighforward
and diagnostic delay may cause severe sequelae. We report a case series of 11 patients
with complement deficiencies. Aim: To describe the epidemiology of patients with complement
deficiencies in a single Institution in Spain, clinical characteristics prior to diagnosis,
site of infection and microorganisms involved as well as treatment procedures and
outcomes.
Methods: Retrospective study. Review of clinical charts of patients diagnosed with
complement deficiency (N= 11).
Results: Male 36%. Median age at diagnosis 44 months (+/-SD 37). The distribution
by defect is: C2 (63%), FI (27%), FH (10%). Infections prior to diagnosis were: Pneumoniae
(45.5%, mean 1.5 episodes), meningitis (36%), AOM (36%, mean 1), bacteremia (36%),
cellulitis (27%), mastoiditis (18%), septic arthritis (18%).The microorganisms isolated
were: S. pneumoniae (70%), N. meningitidis (10%), H. influenzae (10%) and N. fowleri
(10%). The patient with complement factor 2 deficiency and N. fowleri infection is
almost intact. In adition, one patient developed chronic lung disease (bronchiectasis)
prior to diagnosis. All patients were vaccinated with antimeningococcal tetravalent
conjugated,MenB, PCV13 and Pneumovax. In adition, all patients were under antibacterial
prophylaxis. Concerning autoimmune manifestations, 2 out of 11 patients, both of them
with complement Factor I deficiency (18%) had recurrent Henoch-Schönlein purpura (HSP).
The reasons for immunological work-up were: recurrent respiratory infections (44%),
affected sibbling (18%), HSP (18%), meningitis (10%), atypical site of infection and/or
microorganism (18%). Currently, all of them are alive and well since diagnosis without
any breakthrough infections.
Conclusion: Not only recurrent infections may lead to diagnosis in PID patients with
complement deficiencies, but also autoimmune manifestations. Despite the fact that
in our population the vast majority of isolations were typical well-known capsulated
microorganisms, we show that Naegleria fowleri infection should prompt assessment
for complement deficiency. As our patient has survived to a primary amebic meningoencephalitis
(PAM) we can speculate on the role of C2 in PAM survival. However, further studies
are needed to unravel the underlying mechanism.
(6) Submission ID#769449
Identification of Novel NLRC4 And Il2RA Variants In A Family Cohort With Juvenile-Onset
Arthritis And Rash
Jessica Bloom, MD1, Megan Curran, MD2, Scott Canna, MD3, Hal Hoffman, MD4, Elena Hsieh,
MD5
1Pediatric Rheumatology Fellow/University of Colorado
2Pediatric Rheumatologist/University of Colorado
3Pediatric Rheumatologist/University of Pittsburgh
4Allergist/Immunologist/University of California San Diego
5Pediatric Allergist/Immunologist/University of Colorado
Abstract/Case Report Text
Introduction: Identification of genetic etiologies of autoinflammatory syndromes can
inform targeted therapy to improve outcomes.
Objectives: We aimed to identify a genetic etiology for an underlying autoinflammatory
syndrome in a 3-year-old boy presenting with failure to thrive, rash, and polyarthritis
since infancy without significant fevers. The patient’s mother and maternal aunt also
had similar symptoms since infancy.
Methods: We obtained a history, exam, routine laboratory evaluation, chromosomal microarray,
immune phenotyping and functional assays, and genetic sequencing of familial autoinflammatory
syndromes via INVITAE.
Results: The patient’s first examination showed small and large joint polyarthritis
and maculopapular rash. Laboratory results included anemia, positive ANA, negative
RF and anti-CCP, mildly raised ferritin, and very elevated platelet level, LDH, ESR,
CRP and IgG. He had recurrent diarrhea and tested positive for Campylobacter. INVITAE’s
autoinflammatory panel showed two heterozygous variants of unknown significance (VUS):
NLRC4, exon 4, c.741_742insAlu (p.Leu247fs) and IL2RA, exon 2, c.76G>C (p.Asp26His).
Genetic testing revealed the same two variants in the patient’s mother and aunt, while
unaffected relatives had one or the other (see Figure 1). The patient and mother are
HLA-B27+ and have the same 2.8 Mb duplication from 3q28 to 3q29 on chromosomal microarray
including IL1RAP. Signal transducer and activator of transcription phosphorylation
(pSTAT5) studies showed increased baseline pSTAT5 induction without IL-2 stimulation
in patient compared to control.
The patient’s arthritis partially improved with naproxen and steroid joint injections.
Given genetic results, subcutaneous anakinra was initiated at 10 mg/kg daily with
significant improvement in arthritis, rash, and fatigue. Labs after one month showed
resolved anemia, normal inflammatory markers, and high IL-18 (7,824 pg/mL, normal
89-540). He switched to 4.29 mg/kg of canakinumab monthly. After one month, he had
mildly active arthritis, occasional fatigue, and stable labs apart from an increase
of IL-18 to 15,329 pg/mL. The mother, who is poorly controlled off therapy, also has
elevated IL-18 (7,176 pg/mL). See Figures 2-4 for physical exam findings and Table
1 for a summary of symptoms and results.
Conclusion: We present a family cohort with juvenile-onset arthritis and rash, found
to have elevated IL-18, VUS in both NLRC4 and IL2RA, and a chromosomal duplication
consistent with a heritable autoinflammatory syndrome. While it appears that both
variants are required for symptomatology, his presentation is most consistent with
an unrecognized gain of function NLRC4 mutation despite lack of recurrent fevers or
enterocolitis. Genetic evaluation led to targeted therapy and improved outcomes, with
additional testing underway to further personalize therapy.
The patient's family consented for publication.
References:
1. Canna SW, et al. An activating NLRC4 inflammasome mutation causes autoinflammation
with recurrent macrophage activation syndrome. Nature Genetics. 2014;46(10):1140-6.
2. Romberg N, et al. Mutation of NLRC4 causes a syndrome of enterocolitis and autoinflammation.
Nature Genetics. 2014;46(10):1135-9.
Informed consent: Informed consent was obtained from all individual participants included
in the study.
(7) Submission ID#769608
Age-Related Transcriptional Modules and TF-miRNA-mRNA Interactions in Neonatal and
Infant Human Thymus
Fernanda Bernardi Bertonha, PhD1, Silvia Yumi Bando, PhD1, Leandro Rodrigues Ferreira,
MSc2, Magda Carneiro-Sampaio, MD, PhD3, Carlos Alberto Moreira-Filho, PhD4
1Scientific Researcher/Department of Pediatrics, Faculdade de Medicina da Universidade
de São Paulo, São Paulo, SP, Brazil
2Laboratory Technician/Department of Pediatrics, Faculdade de Medicina da Universidade
de São Paulo, São Paulo, SP, Brazil
3Full Professor/Department of Pediatrics, Faculdade de Medicina da Universidade de
São Paulo, São Paulo, SP, Brazil
4Associate Professor/Department of Pediatrics, Faculdade de Medicina da Universidade
de São Paulo, São Paulo, SP, Brazil
Abstract/Case Report Text
Background – The human thymus suffers a transient neonatal involution, recovers and
then starts a process of decline between the 1st and 2nd years of life. Age-related
morphological changes in thymus were extensively investigated, but the genomic mechanisms
underlying this process remain largely unknown.
Methods – Through WGCNA and TF-miRNA-mRNA integrative analysis we studied the transcriptome
of neonate and infant thymic tissues grouped by age: 0-30 days (A); 31days-6 months
(B); 7-12 months (C); 13-18 months (D); 19-31months (E). Age-related transcriptional
modules, hubs and high gene significance (HGS) genes were identified, as well as TF-miRNA-hub/HGS
co-expression correlations.
Results – Three transcriptional modules were correlated with A and/or E groups. Hubs
were mostly related to cellular/metabolic processes; few were differentially expressed
(DE) or related to T-cell development. Inversely, HGS genes in groups A and E were
mostly DE. In A (neonate) one third of the hyper-expressed HGS genes were related
to T-cell development, against one-twentieth in E, what may correlate with the early
neonatal depletion and recovery of thymic T-cell populations.
Conclusions – Age-related thymic processes are tightly regulated by TF-miRNA-hub/HGS
interactions that govern differentially cellular and molecular processes involved
in the functioning of the neonate thymus and in the beginning of thymic decline.
FAPESP 2014/50489-9
(8) Submission ID#773934
A Pilot Study on the Use of Diagnostic Exome Sequencing in Premarital Screening for
Primary Immunodeficiency
Farida Almarzooqi, MBBS1, Abdul-Kader Souid, MD, PhD2, Fatma Aljasmi, MD3
1Fellowship/McGill University
2Professor of Pediatrics/Department of Pediatrics, United Arab Emirates University,
3Associate Professor in Metabolic Disease/Department of Pediatrics, United Arab Emirates
University
Abstract/Case Report Text
Consanguineous marriages in tribal cultures, such as that in the United Arab Emirates
significantly increase the prevalence of autosomal recessive disorders. Premarital
genetic screening and counseling, thus, are expected to reduce the frequency of these
diseases.
In this pilot study, diagnostic exome sequencing was used in the premarital screening
program to identify recessive pathologic variants preventable by premarital counseling.
A total of 487 pathologic or likely pathologic variants were identified in 176 studied
Emiratis (88 couples), averaging 2.8 variants per person. Four percent of the persons
had negative diagnostic exome sequencing; the remaining had one to eight variants
per person. Of the 351 distinct variants, 162 (46%) were novel. Twenty (23%) couples
had pathologic or likely pathologic variants of inborn errors of immunity (IEI). Two
couples (10%) had IEI pathologic or likely pathologic heterozygous variants in both
partners imposing risk for autosomal recessive disease in the offspring. Other eighteen
couples (90%) had pathologic/ likely pathologic heterozygous variants present in only
one person of the couple. Total of sixteen (4.5%) IEI variant identified and eight
(50%) were novel. Fourteen known phenotypic IEI diseases were recognized (table. 1).
These preliminary results support a need for nationwide premarital genetic screening,
and primary immunodeficiency registry to identify common and novel pathogenic variants
with high heritability rate. These results will aid adopting a pre- and post-connectional
reproductive carrier counseling to reduce autosomal recessive diseases. Also, it will
assist the diagnosis of these complex diseases in our community.
Table 1
Pathologic or likely pathologic variants of primary immunodeficiency (PID).
Diseases (MIM)
Genes (MIM)
Variants
IMD20 (615707)
FCGR3A (146740)
NM_001127593.1:c.423dupT (p.lle142Tyrfs)
HIES2 (243700)
DOCK8 (611432)
NM_203447.3:c.5287C>T (p.Arg1763fs)
CD8DF (608957)
CD8A (186910)
NM_001145873.1:c.49+2T>G
C7D (610102)
C7 (217070)
NM_000587.3:c.1135G>C (p.Gly379Arg) - VCV000012108
NM_000587.3:c.405delT (p.Asn136Thrfs) - VCV000432759
ADA-SCID (102700)
ADA (608958)
NM_000022.3:c.226C>T (p.Arg76Trp) - VCV000001962
NM_000022.3:c.454C>A (p.Leu152Met) - VCV000001979
IMD28 (614889)
IFNGR2 (147569)
NM_005534.3:c.123C>G (p.Tyr41Ter)
BLS-I (604571)
TAP2 (170261)
NM_000544.3:c.753dupA (p.Arg252Thrfs)
GS2 (607624)
RAB27A (603868)
NM_183235.2:c.514_518delCAAGC (p.Gln172Asnfs)
ISDNA (617425)
EXTL3 (605744)
NM_001440.3:c.1970A>G (p.Asn657Ser) - VCV000417795
CFDD (613912)
CFD (134350)
NM_001928.2:c.285C>A (p.Tyr95fs)
Ficolin 3 deficiency (613860)
FCN3 (604973)
NM_003665.3:c.349del (p.Leu117Serfs) - VCV000005285.1
CDG1 (233700)
NCF1 (608512)
NM_000265.5:c.579G>A (p.Trp193Ter) - VCV000426990
FI SCN7 (617014)
CSF3R (138971)
NM_156039.3:c.1015delG (p.Asp339Thrfs)
NBSLD (613078)
RAD50 (604040)
NM_005732.3:c.2165dupA (p.Glu723Glyfs) - VCV000141045
Bolded variants were not found at https://www.ncbi.nlm.nih.gov/clinvar/ or HGMD® Professional
2019.2; MIM, Mendelian Inheritance in Man; VCV, Variation in ClinVar; rs, Reference
SNP; IMD20, immunodeficiency 20; FCGR3A, Fc fragment of IgG, low affinity IIIa, receptor
for; HIES2, hyper-IgE recurrent infection syndrome 2, autosomal recessive; DOCK8,
dedicator of cytokinesis 8; CD8DF, CD8 deficiency, familial; CD8A, CD8 antigen, alpha
polypeptide; C7D, complement component 7 deficiency; C7, complement component 7; ADA-SCID,
severe combined immunodeficiency, autosomal recessive, T cell-negative, B cell-negative,
NK cell-negative, due to adenosine deaminase deficiency; ADA, adenosine deaminase;
IMD28, immunodeficiency 28; IFNGR2, interferon-gamma receptor 2; BLS-I, bare lymphocyte
syndrome type I, TAP2, transporter, ATP-binding cassette, major histocompatibility
complex, 2; GS2, Griscelli Syndrome, Type 2; RAB27A, RAS-associated protein RAB27A;
ISDNA, immunoskeletal dysplasia with neurodevelopmental abnormalities; EXTL3, exostosin-like
glycosyltransferase 3; CFDD, complement factor D deficiency; CFD, complement factor
D; FCN3, ficolin 3; CDG1, granulomatous disease, chronic, autosomal recessive, cytochrome
b-positive, type I; NCF1, neutrophil cytosolic factor 1; SCN7, neutropenia, severe
congenital, 7, autosomal recessive; CSF3R, colony-stimulating factor 3 receptor, granulocyte;
NBSLD, Nijmegen breakage syndrome-like disorder; RAD50, S. cerevisiae, homolog of;
CDG1H, congenital disorder of glycosylation, type Ih; ALG8, ALG8, S. cerevisiae, homolog
of.
(10) Submission ID#778505
Malignancy in Common Variable Immune Deficiency: Data from the IDEaL Patient Registry
Allyson Checkley, PhD1, Loretta Kristofek, RN, BSN2, Haydan Smith, MS3, William Bolgar,
PharmD4
1Research and Registry Program Advisor/Coram CVS Specialty Infusion Services
2Clinical Service Liaison/Coram CVS Specialty Infusion Services
3Registry Program Consultant/Coram CVS Specialty Infusion Services
4Senior Director of Pharmacy Innovation/Coram CVS Specialty Infusion Services
Abstract/Case Report Text
Introduction: Common variable immune deficiency (CVID) is associated with an increased
risk for development of several types of malignancies including lymphoid and gastrointestinal
cancers. With improvement in overall survival and longevity in this patient population
largely due to the effectiveness of immunoglobulin replacement therapy (IGRT) in reducing
infections, cancer has now emerged as the one of the most significant life-threatening
complications of CVID.
Objective: The purpose of this study was to evaluate the prevalence of cancers in
patients with CVID receiving IGRT in the home.
Methods: Data were analyzed from patients with a diagnosis of CVID (ICD-10 codes:
D83.9, D83.1) that were enrolled in the IDEaL (Immunoglobulin, Diagnosis, Evaluation,
and key Learnings) Patient Registry between 2010 and 2019. This is a prospective,
longitudinal registry study of patients receiving IGRT in the home or ambulatory infusion
suite with one national home infusion provider. Cancer occurrence and type, patient
demographics and IGRT dosing information were obtained from medical charts and nursing
and pharmacy standard of care forms.
Results: Out of 312 patients with CVID, 38 (12.2%) patients developed 41 cancers.
The incidence of hematological malignancies was 6.1% (19 cases) and accounted for
46.3% of all reported cancers. There were 11 (26.8%; 11/41) cases of Non-Hodgkin’s
Lymphoma (NHL), 7 (17.1%; 7/41) cases of Chronic Lymphocytic Leukemia (CLL), and 1
(2.4%; 1/41) case of multiple myeloma. Of the cases of NHL, 2 cases were identified
as gastric mucosa-associated lymphoid tissue (MALT) lymphoma. The incidence of solid
tumors was 7.1% (22 cases). These accounted for 53.7% of all reported cancers and
were heterogeneous in localization. There were 7 (17.1%; 7/41) cases of skin tumors
(3 melanomas, 2 basal cell carcinomas, and 2 in which cell type was not-specified).
There were 4 (9.8%; 4/41) cases of breast cancer, 3 (7.3%; 3/41) cases of lung cancer,
2 (4.9; 2/41) cases of uterine cancer, 2 (4.9% 2/41) cases of prostate cancer, 2 pituitary
tumors (4.9%; 2/41), 1 (2.4%; 1/41) bladder tumor, and 1 (2.4%; 1/41) adrenal carcinoma.
Patients who developed cancer were mostly female: 24 (63.1%), and the median age at
cancer diagnosis was 63 (range 21-75 years). The prevalence of all cancers in this
Registry population was higher than the 5-year, all age, all cancers limited duration
prevalence estimates in the US (1.5%). The median age at time of referral for home
infusion of IGRT was 65 years of age. Of these patients, 55.3% were Ig naïve prior
to starting service with this home infusion company. Most patients received subcutaneous
Ig (71.1%) versus intravenous Ig (28.9%) at start of care with mean doses of 128.6±42.4
mg/kg/wk and 431.0±70 mg/kg/month respectively.
Conclusions: Over 12% of the study population suffered from a malignancy. These data
point to defective immunosurveillance mechanisms in preventing certain cancers in
patients with CVID. Better understanding the occurrence of malignancy in patients
with CVID will help to postulate mechanisms between immune factors and cancer initiation
and progression as well as appropriate screening and treatment patterns for this patient
population including the role of IGRT.
(12) Submission ID#781367
Multiple Dermatofibrosarcoma Protuberans: a Phenotype Unique in ADA deficient SCID
Donald Kohn, MD1, Harry Malech, MD2, Julia Bridge, MD3, Dominique Pichard, MD4, Edward
Cowen, MD, MHSc5, Stefania Pittaluga, MD6, Dolores Lopez-terrada, MD, PhD7, Elizabeth
Garabedian, MSLS, RN8
1Dept. MIMG, Pediatrics,MMP/UCLA
2Chief, Genetic Immunotherapy Section/NIAID, NIH
3Pathologist/Ashion Laboratories
4Special Volunteer, Dermatologist/NIH, NIAMS
5Head, Dermatology Consult Service/Dermatology Branch, NIAMS, NIH
6Senior Pathologist/Laboratory of Pathology, Clinical Center, National Cancer Institute
7Professor of Pathology and Pediatrics, Director of Molecular Oncology and Cancer
Cytogenetics/Baylor College of Medicine, Texas Children's Hospital
8Research Nurse/NIH-NHGRI
Abstract/Case Report Text
DFSP is a rare low-grade cutaneous malignancy. A slowly progressive tumor that rarely
metastasizes but frequently has broad subclinical extension and a high recurrence
rate after excision. DFSP rare in children, but is very common in ADA-deficient SCID
and all patients should have full dermatology screening at least annually. It was
first identified in the ADA population in 2011 and is not seen in X- SCID or other
PID. Protuberant lesions should be referred for Mohs micrographic surgery.
(13) Submission ID#781460
Rare Presentation Of Ataxia-Telangiectasia On Newborn Screen
So Lim Kim, MD1, Gabrielle Lapping-Carr, MD2, Raoul Wolf, MD3
1Internal Medicine Resident/University of Chicago Medicine
2Assistant Professor, Division of Pediatric Hematology and Oncology/University of
Chicago Medicine
3Clinical Professor, Division of Allergy and Immunology/University of Chicago Medicine
Abstract/Case Report Text
Introduction: Ataxia-telangiectasia (AT) is a rare disease of primary immunodeficiency
and has a wide spectrum of immunologic abnormalities. We present a case of a patient
born with low T-cell receptor excision circles (TRECs) with progressive combined immunodeficiency
leading to the diagnosis of T-B-NK-SCID and treatment with bone marrow transplant,
who later presented with L-dopa responsive dystonia and finally was diagnosed with
AT after genetic testing was done in his grandmother that had breast cancer.
Case presentation: A full term male was born with low TRECs (44 copies/uL) on newborn
screen within the first few months of screening in Illinois. He presented to clinic
at 2 months of age, where he was found to have hypogammaglobulinemia and a predominant
B cell deficiency with mildly reduced T cells. He was started on monthly IVIg and
prophylactic antifungals while initiating his evaluation. B cell tyrosine kinase (BTK)
was normal and T/B cell mitogen stimulation testing was normal. However, he had a
steady decline in T and NK cell counts over months. Genetic testing that was available
at that time included ADA, AK2, DCLRE1C, LIG4, NHEJ1, RAC2, RAG1, RAG2 which only
revealed heterozygosity for the V186L variant of the DCLRE1C gene, which was also
carried by his unaffected father and sister. Due to the persistent decline his CD3
counts to 147/uL and CD56/16 counts to 26/uL, at age 10 months he received a matched
sibling bone marrow transplant conditioned with campath. He achieved complete immune
reconstitution by 18 months after the transplant. He had normal development until
age 2 when he presented with occasional falling after walking normally and was diagnosed
with L-dopa responsive dystonia. His grandmother developed breast cancer, and because
of a strong family history of breast cancer had genetic screening that revealed a
mutation in ATM. At this point the patient was evaluated for AT and found to also
be affected.
Discussion: The immunodeficiency in AT can have a wide variety of presentations involving
humoral or cell-mediated deficiency or occasionally both. AT is known to present with
increased NK cells and the immune defects are typically non-progressive in nature.
This patient however had progressive immune deficiency necessitating transplant as
well as reduction in NK cells. AT presenting as T-B-NK-SCID is atypical.
Conclusion: The immunologic defects in AT are exceedingly variable. This case suggests
that AT may present with a picture similar to T-B-NK-SCID. Luckily, the majority of
genetic screening programs have now incorporated ATM into their panels, so most patients
will be captured, as opposed to early on in the era of TREC newborn screening. This
case also highlights the importance of early consideration of AT in patients born
with low TRECs, as syndromic manifestations, including dystonia, may present later
in life.
(14) Submission ID#784536
Chronic Granulomatous Disease With Inflammatory Bowel Disease: Disease Presentation,
Treatment, And Outcomes From The USIDNET Registry
Brenna LaBere, MD1, Maria Gutierrez, MD2, Hannah Wright, MSPH3, Elizabeth Garabedian,
MSLS, RN4, Hans Ochs, MD5, Ramsay Fuleihan, MD6, Elizabeth Secord, MD7, Rebecca Marsh,
MD8, Kathleen Sullivan, MD, PhD9, Charlotte Cunningham-Rundles, MD, PhD10, Luigi Notarangelo,
MD, PhD11, Karin Chen, MD12
1Pediatrics Resident/University of Utah
2Assistant Professor/Johns Hopkins University
3Research Data Analyst/United States Immunodeficiency Network
4Research Nurse/NIH-NHGRI
5Professor of Pediatrics and Immunology/University of Washington and Seattle Children's
Research Institute
6Professor of Pediatrics and Allergy and Immunology/Ann & Robert H. Lurie Children's
Hospital of Chicago
7Clinical Associate Professor of Pediatrics and Division Chief of Allergy, Asthma,
and Immunology/Children's Hospital of Michigan; Wayne State University School of Medicine
8Clinical Director, Primary Immune Deficiency Program/Department of Pediatrics, University
of Cincinnati, Cincinnati, Ohio; Division of Bone Marrow Transplantation and Immune
Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
9Professor of Pediatrics and Chief, Division of Allergy and Immunology/Children's
Hospital of Philadelphia; University of Pennsylvania
10Professor of Medicine and Pediatrics/Icahn School of Medicine at Mount Sinai
11Chief, Laboratory of Clinical Immunology and Microbiology/National Institute of
Allergy and Infectious Diseases, NIAID/National Institutes of Health, NIH
12Assistant Professor/University of Utah School of Medicine
Abstract/Case Report Text
Background: Chronic granulomatous disease (CGD) is a primary immunodeficiency disorder
caused by defects in the phagocytic NADPH oxidase complex, leading to increased susceptibility
to infection and inflammatory or autoimmune disease. Up to 50% of patients have gastrointestinal
(GI) involvement and meet diagnostic criteria for inflammatory bowel disease (CGD-IBD).
Objectives: We analyzed CGD patients from the United States Immunodeficiency Network
(USIDNET) registry to determine whether IBD may change the presentation, treatment,
and outcomes of CGD patients, as compared to those without IBD.
Methods: A retrospective evaluation of CGD cases from the USIDNET registry was completed.
CGD-IBD was defined as the presence of any major physician-reported inflammatory,
non-infectious GI tract disease manifestation, including Crohn disease, ulcerative
colitis, IBD endoscopy findings, GI fistulas, GI strictures, GI obstruction, and proctitis.
Demographic information, genotypes, symptoms and conditions, infections, antimicrobial
therapies, immunomodulator use, and allogeneic hematopoietic stem cell transplantation
(HSCT) data were analyzed.
Results: 194 patients with a diagnosis of CGD were identified. 96 met criteria for
IBD; 98 were categorized in the non-IBD group. Crohn disease and colitis were the
most common GI disease manifestations in the CGD-IBD group (n=79), followed by GI
fistulas (n=22). CGD-IBD patients had an increased average frequency of infections
(10.6 events/patient) compared to the CGD-non-IBD group (5.1 events/patient). In both
groups, lower respiratory tract infections were the most common infection type and
Aspergillus was the most common organism. Enteric organism infections were more common
in IBD patients. Temporal data regarding the timing of infections were not available.
Immunomodulators, including biologics and interferon-gamma, were used at a significantly
higher rate in IBD patients compared to non-IBD patients (80% versus 55%, p = 0.0003).
The presence of IBD, as compared to no IBD, in a CGD patient increased the odds of
immunomodulator use (OR = 3.168) (95% confidence limit 1.669-6.017, p = 0.0004). Patients
who received immunomodulator treatment had a higher average number of infections as
compared to those who did not. Thirty-one percent of all patients underwent HSCT;
8 patients died after undergoing HSCT, of which 4 had CGD-IBD. Of the entire CGD cohort,
17 patients died (8.8%), with a median age of death of 21.8 years (range 2.5-48.1
years), and with no significant difference between IBD and non-IBD patients (p=1.00).
Conclusions: Infectious events, enteric organism infections, and immunomodulator use
were higher in IBD than non-IBD patients, though mortality was not increased. Patients
with CGD and concurrent IBD are at increased risk for complications, supporting the
importance of early recognition and diagnosis. Due to limitations in the available
data, we are unable to conclude whether the increased number of infections in CGD-IBD
patients was due to presence of IBD, or other factors such as age, use of immunomodulators,
or transplant status. The USIDNET data may reflect more effective anti-staphylococcal
prophylaxis and treatment in the current era, as compared to historical data. Our
findings reinforce the frequent coexistence of IBD and CGD, illustrate major phenotypic
features of CGD patients with GI inflammatory conditions, and highlight the need for
further investigations.
(15) Submission ID#785311
Three Copies of Four Interferon Receptor Genes Underlie Type I Interferonopathies
In Down Syndrome
Xiao-Fei KONG, MD, Ph.D1, Lisa Worley, n/a2, Darawan Rinchai, Ph.D3, Vincent Bondet,
Ph.D4, Puthen Jithesh, Ph.D5, marie Goulet, MD6, Emilie Nonnotte, MD6, Nicolas Gürtler,
MD7, Luyan Liu, Ph.D8, Mélanie Migaud, n/a9, Mohammed Elanbari, n/a10, Tanwir Habib,
n/a10, Cindy Ma, PhD11, Jacinta Bustamante, MD, PhD12, Laurent Abel, MD, PhD13, Aimé
Ravel, MD6, Stanislas Lyonnet, MD, PhD14, Darragh Duffy, PhD15, Damien Chaussabel,
Ph.D16, Jean-Laurent Casanova, MD, PhD17, Stuart Tangye, PhD18, Stéphanie Boisson-Dupuis,
PhD19, Anne Puel, PhD12
1Fellow/St.Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller
Branch, The Rockefeller University, New York, NY, USA
2Graduate student/Garvan Institute of Medical Research
3Assistant Professor/Sidra Medical and Research Center
4Post-doc/Institut Pasteur
5Assistant Professor/10. Sidra Medicine, Sidra Medical and Research Center, Doha,
Qatar
6Physician/Institute Jérôme Lejeune, Paris, France, EU
7Professor/University Hospital of Basel, Basel, Switzerland.
8Post-doc/4. Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM
U1163, Necker Hospital for Sick Children, Paris, France, EU
9Technician/4. Laboratory of Human Genetics of Infectious Diseases, Necker Branch,
INSERM U1163, Necker Hospital for Sick Children, Paris, France, EU
10graduate student/Sidra Medicine, Sidra Medical and Research Center, Doha, Qatar
11Assistant Professor/Immunity & Inflammatory Diseases, Garvan Institute of Medical
Research, Darlinghurst, New South Wales, Australia.
12Research Associate/Laboratory of Human Genetics of Infectious Diseases, Necker Branch,
INSERM U1163, Necker Hospital for Sick Children, Paris, France, EU
13Professor/Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM
U1163, Necker Hospital for Sick Children, Paris, France, EU
14Professor/Laboratory of Genetics and Embryology of Congenital Malformation, Imagine
Institute, INSERM U-1163, Université de Paris, F-75015, Paris, France
15Principal Investigator/Immunobiology of Dendritic Cells Unit, Institut Pasteur,
Paris, France, EU
16Assistant Professor/Sidra Medicine, Sidra Medical and Research Center, Doha, Qatar
17Professor/St.Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller
Branch, The Rockefeller University, New York, NY, USA
18Professor/Immunity & Inflammatory Diseases, Garvan Institute of Medical Research,
Darlinghurst, New South Wales, Australia.
19Research Associate/1. St.Giles Laboratory of Human Genetics of Infectious Diseases,
Rockefeller Branch, The Rockefeller University, New York, NY, USA
Abstract/Case Report Text
Down syndrome (DS) is characterized by the occurrence of three copies of human chromosome
21 (HSA21). These patients often develop chronic mucocutaneous candidiasis (CMC) and
autoimmune thyroiditis, mimicking patients with heterozygous gain-of-function (GOF)
STAT1 mutations, which enhance cellular responses to the three types of interferon
(IFN). HSA21 contains a cluster of four interferon receptor (IFN-R) genes: IFNAR1,
IFNAR2, IFNGR2 and IL10RB. A gene dosage effect at these four loci may contribute
to the infectious and autoimmune manifestations observed in individuals with DS. We
report high levels of IFN-αR1, IFN-αR2 and IFN-γR2 expression on the surface of monocytes
and EBV-transformed-B (EBV-B) cells from DS patients. Levels of IFN-ɣR1, encoded by
a gene on chromosome 6, were similar in the immune cells of DS patients and healthy
controls. Total and phosphorylated STAT1 (STAT1 and pSTAT1) levels were constitutively
high in unstimulated and IFN-α- and IFN-γ-stimulated monocytes from DS patients, although
less so than those in patients with GOF STAT1 mutations. Following stimulation with
IFN-α or -ɣ, but not with IL-6 or IL-21, pSTAT1 and IFN-ɣ activation factor (GAF)
DNA binding activities were significantly higher in the EBV-B cells of DS patients
than in controls, this response resembling the dysregulated responses observed in
patients with STAT1 GOF mutations. Plasma type I IFNs concentrations were high in
about 12% of the DS patients tested. A genome-wide transcriptomic analysis involving
principle component analysis and a comparison of interferon modules was performed
on circulating monocytes. It showed that IFN-stimulated genes (ISGs) were expressed
more strongly in DS than in controls. DS monocytes have intermediate levels of IFN-α-
and IFN-γ- induced ISGs relative to monocytes from healthy controls and from patients
with GOF STAT1 mutations. By contrast to patients with GOF STAT1 mutations, circulating
Th17 counts were normal and the proportion of terminally differentiated CD8+ T cells
was high in DS patients. The constitutive upregulation of type I and type II IFN-R,
at least in monocytes of DS patients, may therefore contribute to the autoimmune diseases
observed in these individuals.
(16) Submission ID#785796
Gotta Be More Than Just Warts, GATA 2 Deficiency
Stephanie Vazquez, MD1, Maria Pilar Gutierrez, MD2, Steven Holland, MD3, Hanadys Ale,
MD4
1Pediatric Resident PGY-2/Memorial Healthcare System Joe DiMaggio Children's Hospital
2Attending Physician, . Division of Infectious Diseases/Memorial Healthcare System
Joe DiMaggio's Children Hospital
3Director, Division of Intramural Research; Chief, Immunopathogenesis Section/Laboratory
of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR),
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH), Bethesda, MD, USA
4Attending Physician, Division of Allergy & Immunology/Memorial Healthcare System
Joe DiMaggio Children's Hospital
Abstract/Case Report Text
Background: Warts are benign growths produced by human papilloma virus (HPV) that
largely affect immunocompetent children and adolescences. Warts are common in the
pediatric population due to their naïve immune system that has not yet mounted a protective
response to HPV. Usually by their teenage years most are immune to the virus and warts
have regressed. Though mechanism isn’t exactly known, evidence has shown cellular
immunity specifically T-cells and Natural Killer (NK) cell cytotoxic response is essential
for wart regression. Hence, patients with abundant, recurrent, and unmanageable warts
should warrant further testing for possible underlying immune defect.
Case Presentation: 16-year-old Haitian male with 8-year history of multiple verrucous
lesions on the oral mucosa and lips unresponsive to medical treatments (Acyclovir,
Aldara and cimetidine) and laser therapy. He had no recurrent pneumonias, sinusitis,
otitis media, meningitis, sepsis, deep-seated infections, abscess, recurrent or intermittent
fevers, stomatitis, or autoimmunity. His mother had died of malignancy and is father
and half siblings (paternal side) were alive and well. Physical exam revealed several
verrucous lesions covering the entire lower lip and part of the upper lip, the tongue
and soft palate. Smaller verrucous lesions noted on the fingers. No genital or anal
warts. There was a dry, non-pruritic, mildly scaly, faint rash on the back and chest.
Oral lesions were biopsied and pathology showed epithelial hyperplasia consistent
with HPV. Immune evaluation revealed the following results: CBC with diff relevant
for leukopenia, neutropenia, lymphopenia and monocytopenia. Serum immunoglobulins
were within normal. Lymphocyte subset showed B, NK, CD3+ and CD4+ lymphocytopenia.
Lymphocyte antigen and mitogen proliferation studies significant for low PWM, ConA,
Candida stimulation. He also had low functional antibodies to pneumococcal vaccine
(4/23 protective). GATA2 deficiency was strongly suspected due to the presence of
recurrent and intractable HPV + warts along with severe circulating monocytopenia,
B-cell, NK-cell and CD4 lymphocytopenia. Genetic testing revealed a GATA2 heterozygous
pathogenic variant c.1114G>A due to a missense mutation. Upon his diagnosis, NIH was
contacted and he was enrolled in Dr. Steven Holland’s GATA-2 Clinical Trial.
Conclusions: We report a teenage Haitian boy with indolent HPV + warts and profound
monocytopenia, B-cell, NK-cell and CD4-cell lymphocytopenia found to have a pathogenic
variant on GATA2 exon 5, which reportedly has only been previously observed in five
other individuals affected with GATA2 deficiency, all presenting at different age
of onset with a wide spectrum of manifestations, phenotypes and outcomes. This demonstrates
that even patient’s with same GATA2 mutation do not present with distinguishing features
for a particular pathogenic variant. Our patient’s unique manifestation is just another
step closer in unraveling the complex pathogenesis and diverse phenotypes found in
GATA2 deficiency.
Informed consent was obtained from all individual participants included in the study.
(17) Submission ID#786488
Humoral and Cell Mediated Immune Dysregulation Identified by Newborn Screening
Michael Nevid, MD1, G. Wendell Richmond, MD2, Stephannie Davies, MD2, Aloka Patel,
MD2, Alice Hackett, MD2, Mahboobeh Mahdavinia, MD, PhD2
1Resident Physician/Rush University Medical Center
2Physician/Rush University Medical Center
Abstract/Case Report Text
Introduction Screening for severe combined immunodeficiency (SCID) has been widely
implemented as a part of the newborn screen. Testing is done by measuring T cell receptor
excision circles (TRECs) which are DNA excision fragments that can be used as an indirect
measure of naïve T cell production. The goal of this project was to evaluate all immunologic
conditions identified in infants who have low TREC levels on newborn screen.
Methods A cohort study was conducted for infants treated at Rush University Medical
Center from January 2015 to April 2019 with positive SCID screens (positive screen
defined as TREC values less than 250 units/ul per statewide criteria).
Results Forty nine neonates were identified with low TREC values. 46 (94%) of these
infants had repeat TREC screening, 14 (29%) of which were found to have a positive
second TREC screen. Lymphocyte subsets were evaluated in 23 of these infants and 5
of which were noted to have lymphopenia (defined as absolute lymphocyte count less
than 2500). 2 infants were noted to have low CD4 levels (defined as < 300 cells/ul)
and 6 were noted to have low CD8 levels (defined as less than 500 cells/ul). Of note,
50% of the infants with CD4 and CD8 lymphopenia had normal repeat TREC levels. 14
of the infants were noted to have low B cell levels (defined as < 610 cells/ul). 12
infants had quantitative immunoglobulin levels and of these two were noted to have
IgG levels less than 100. Of note one infant was diagnosed with partial DiGeorge syndrome
via microarray. In our study population, no infants were diagnosed with SCID.
Discussion
Our study shows that testing for TREC levels on newborn screen may be beneficial in
identifying not only SCID, but also other immunologic conditions. Infants in our study
had evidence for both cell mediated and humoral immunodeficiency which necessitated
further workup and follow up from Allergy and Immunology specialists. It may be beneficial
to develop further programs to track infants identified with abnormal TREC levels
on newborn screens to determine if they develop signs of immunodeficiency syndromes
later in life.
(18) Submission ID#787559
A 24-Year-Old Male With Activated Phosphoinositide 3-Kinase Delta Syndrome (APDS)
With Novel Deletion
Katherine D'Astous-Gauthier, MD1, Hugo Chapdelaine, MD2
1Resident in Clinical Immunology and Allergy/Université de Montréal
2Immunologist in the Department of Clinical immunology and Allergy at the CHUM/Université
de Montréal
Abstract/Case Report Text
The patient was transferred to our adult clinical immunology transition clinic for
low IgG and IgA, elevated IgM and B cell lymphopenia, treated with subcutaneous gamma
globulin. His medical history was relevant for recurrent respiratory infections since
two years-old, failure to thrive and developmental delay. He also developed chronic
auto-immune hemolytic anemia (AIHA) at ten years old, accompanied by prominent lymphoid
hyperplasia.
Our initial evaluation at the age of twenty years old showed massive polyadenopathy
and splenomegaly. Work-up confirmed flair-up of AIHA. At that point, the diagnosis
of APDS was raised. He also had mild intellectual impairment and dysmorphic features
such as a mild degree of ocular depression, deep-set eyes, vaguely triangular face,
small chin, but had normal stature. A customized panel for usual genes involved in
classic hyperIgM syndromes, APDS, Noonan and Kabuki syndromes came back negative.
At 23 years old, an urgent coloscopy was performed because of acute abdominal pain
and showed diffuse ileal lymphoid hyperplasia. Biopsies confirmed reactional lymphoid
hyperplasia without infection nor malignancy. A second 232 genes NGS panel associated
with PID identified a heterozygote mutation in TAP1; expression of HLA class 1 was
normal on flow cytometry.
The patient was then started on sirolimus for an “APDS-like syndrome” despite the
lack of genetic confirmation. Six months after introduction of mTOR inhibitor, his
abdominal pain had completely disappeared. TEP scan showed complete resolution of
axillar, retroperitoneal and inguinal lymph nodes and significant regression of splenomegaly.
A third large non-biased 6700+ genes NGS panel revealed a 30 pb de novo deletion that
included the splice site of PIK3R1 exon 11 typically involved in APDS2: c.1392_1425+4del
p.(Asp464Glufs*5) , which was missed by the first two panels. Indeed, oligonucleotide-selective
sequencing technology used for the previous panels was associated to mapping errors
of short reads and difficult detection of large deletions. Interestingly, the patient
also presented some but not all dysmorphic features of SHORT syndrome which is related
to PIK3R1 haploinsufficiency.
In this new era of genetic testing, this case is a reminder that we need to be aware
of the pitfalls of genetic tests and that clinical judgment is still our best diagnostic
tool.
(19) Submission ID#792220
Cancer in Patients with X-Linked Chronic Granulomatous Disease: A Case Report
Jennifer Treat, PA-C1
1Physician Assistant/Medical Science and Computing (MSC)
Abstract/Case Report Text
Intro: Patients with Chronic Granulomatous Disease (CGD) are theorized to have a lower
risk of malignancy related to their lack of free radical formation. There are relatively
few reports of malignancy described in patients with CGD. We report three cases of
malignancies in the large cohort CGD population at the National Institutes of Health
followed between 1972-2018 to add to the seven cases described in the literature.
Case 1: A 48-year-old man with X-linked Chronic Granulomatous Disease with a history
of severe inflammatory bowel disease, who presented with progressive left-sided chest
pain in 2017, decreased appetite and weight loss. Transthoracic lung biopsy showed
atypical cells and a PET/CT showed abnormally dense mesentery and widespread hypermetabolic
abnormalities. A mesenteric biopsy showed metastatic pancreatic adenocarcinoma. Palliative
care was initiated. Patient expired four months after diagnosis.
Case 2: A 24-year-old man with X-linked Chronic Granulomatous Disease and severe inflammatory
bowel disease requiring total proctocolectomy and who had been remotely treated with
infliximab, presented in 2015 with right upper quadrant pain. Abdominal ultrasound
and MRI of the liver showed multiple liver lesions. Biopsy of these lesions revealed
hepatocellular carcinoma. Patient underwent two courses of radiolabeled itrium spherules.
However, his disease progressed and he expired approximately five months after diagnosis.
Case 3: An 18-year-old man with X-linked Chronic Granulomatous Disease and inflammatory
bowel disease who presented in 2007 with fevers, abdominal pain and pancytopenia.
During the course of his hospitalization, he developed sepsis which led to his demise.
On autopsy, an incidental finding of papillary thyroid carcinoma was made.
Discussion: These three patients all had poorly controlled inflammatory bowel disease.
Additionally, patients with CGD are typically exposed to higher doses of radiation,
leading one to expect higher rates of radiation induced malignancies. However, there
are still relatively few case reports of cancer in the CGD population. Tissue biopsy
is necessary for diagnosis. Due to end organ damage secondary to the underlying disease
in the first two cases, treatment options were limited. Managing infections during
chemotherapy can be complex due to drug interactions with chemotherapeutic agents.
Figure 1: Clockwise from top left: A. CT imaging highlighting omental radiodensity,
B. PET/CT showing extensive hypermetabolic activity, C. CT of the liver showing multiple
focal lesions
(20) Submission ID#792474
A Late Presentation of MPO Deficiency
Farah Khan, MD1, Brant Ward, MD, PhD2
1Allergy/Immunology Fellow/Virginia Commonwealth University
2Assistant Professor of Medicine/Virginia Commonwealth University
Abstract/Case Report Text
Myeloperoxidase (MPO) deficiency is the most common inherited defect of phagocytes
that impairs microbial killing since the toxicity of the respiratory burst is dampened
without myeloperoxidase release from the azurophilic granules. A significant portion
of these patients remain asymptomatic, however there is a clinically variable phenotype
that can present if they do become symptomatic. Fungal infections with Candida strains
appear to be the most frequently reported. We present an adulthood case of recurrent
invasive Candidal disease due autosomal recessive myeloperoxidase deficiency from
a pathogenic missense variant in the MPO gene (c.1705C>T (p.Arg569Trp)).
A 23-year-old Caucasian male was in his normal state of health without any major illnesses
until 18 years of age when he was diagnosed with Candida osteomyelitis of the heel,
followed by Cryptococcal meningitis the following year which ultimately required a
ventriculoperitoneal shunt. In 2019, he had a prolonged hospitalization after presenting
with lethargy, headache and vomiting that culminated in seizure activity and prompted
an emergency room visit. Imaging at the time showed ventriculomegaly, and fluid from
the shunt revealed yeast, but no bacteria. He was started on broad spectrum antifungal
therapy and admitted for further management. Cerebral spinal fluid and blood cultures
confirmed invasive Candida albicans meningitis. During this hospitalization, he also
developed sepsis secondary to Serratia marcescens. Because of the pathogens that were
being isolated, our service was consulted. Of note, our patient does not have diabetes
mellitus.
A neutrophil oxidative burst assay showed an absent respiratory burst compared to
control. A primary immunodeficiency panel to identify genetic variants was also sent
to Invitae. Variants in CYBA, CYBB, NCF2, and NCF4 were not identified, making chronic
granulomatous disease less likely.
Peroxidase staining was negative on neutrophils and normal on eosinophils, suggesting
a diagnosis of MPO deficiency. This led to MPO gene sequencing for deletion and duplication
analysis. A homozygous pathogenic variant consistent with a molecular diagnosis of
a MPO related condition was identified. Immunoblotting of patient-derived immune cells
demonstrated an absence of mature enzyme. Although not typically indicated, given
the severity of his presentation, our patient remains on Fluconazole for long term
prophylaxis.
His younger brother also had a history of invasive disease with Candida – osteomyelitis
and meningitis. A neutrophils oxidative burst assay showed similar results in his
brother and similar results with peroxidase staining, also suggesting a diagnosis
of MPO deficiency. Confirmatory genetic testing has not been performed yet. Their
father, who reported severe skin infections with Candida, had peroxidase stains performed
on neutrophils and eosinophils which were both normal.
We have presented a patient without a significant history of diabetes mellitus who
developed invasive disease from Candida and Serratia and was ultimately diagnosed
with myeloperoxidase deficiency.
(21) Submission ID#793733
Systemic Juvenile Xanthogranuloma Involving the Central Nervous System Treated Successfully
with ALK-Pathway Targeted Inhibition
Thomas Michniacki, MD1, Rajen Mody, MD, MS2, Julia Brown, PharmD3, Bailey Anderson,
MPH4, Mark Shamoun, MD5, Kelly Walkovich, MD6
1Clinical Lecturer, Pediatric Hematology/Oncology/University of Michigan, C.S. Mott
Children's Hospital
2Professor, Pediatric Hematology/Oncology/University of Michigan
3Clinical Pharmacist, Pediatric Hematology/Oncology/University of Michigan
4Clinical Research Coordinator/University of Michigan
5Physician, Pediatric Hematology/Oncology and Bone Marrow Transplantation/Children’s
Hospital of Michigan
6Associate Professor, Pediatric Hematology/Oncology/University of Michigan, C.S. Mott
Children's Hospital
Abstract/Case Report Text
Introduction: Juvenile xanthogranuloma (JXG) is an often benign, histiocytic proliferative
disorder of the mononuclear phagocytic system. Patients typically present with localized
cutaneous lesions. Systemic disease, especially central nervous system involvement,
rarely occurs but has significant morbidity and mortality risk. No standard evaluation
nor therapy regimen exists for systemic JXG and little is known about the genomic
alterations underlying its pathology.
Case Report: A full-term male infant presented at 4 months of age with post-prandial
abdominal pain, fevers, altered mental status and weight loss. Abdominal ultrasound
and CT identified renal masses. A chest CT was obtained showing a paraspinal mass
with possible neural foramina extension. MRI brain and total spine was consistent
with diffuse leptomeningeal disease involving the left frontal convexity, brainstem,
cerebellum, and multiple cranial nerves. Abnormal enhancement was also present along
the entire surface of the spinal cord extending into the cauda equina with additional
enlargement of the cervical/upper thoracic cord with intramedullary enhancing masses
and a right paraspinal mass. Renal biopsy yielded a pathologic diagnosis of disseminated
JXG. Integrative clinical sequencing of the mass identified a somatic driving ALK
rearrangement (KIF5B-ALK in-frame fusion). Tumor and matched germline DNA sequencing
did not detect any alterations in the RAS/MAPK pathway. Bone marrow biopsy was negative
for disease with cerebrospinal fluid analysis showing numerous monocytes and macrophages
consistent with JXG.
The patient was started on therapy consisting of systemic dexamethasone, intrathecal
methotrexate/hydrocortisone and systemic intravenous cytarabine. His first cycle was
complicated by Pseudomonas aeruginosa bacteremia and gangrenous cellulitis of the
perianal region, treated with systemic/topical antibiotics and topical GM-CSF. Following
completion of the initial cycle of therapy, the patient was noted to have declining
neurologic status, including seizure-like activity. Repeat MR imaging revealed worsening
CNS disease with new subdural fluid collection and progression of leptomeningeal enhancement
and intramedullary cervical lesion. In light of disease progression, the decision
was made to continue dexamethasone treatment, but add adjunct intrathecal cytarabine,
and transition to targeted ALK inhibition via daily oral ceritinib, given its predicted
CNS penetrance followed by ceritinib in combination with systemic intravenous clofarabine.
Significant clinical and radiographic improvement was noted with the new targeted
treatment regimen. Ceritinib therapy was tolerated well overall after a 25% dosing
reduction made for initial grade 2 gastrointestinal toxicity and grade 4 hypertriglyceridemia
(non-life threatening but level > 1000 mg/dL). Following continued treatment with
daily ceritinib and completion of 12 cycles of clofarabine therapy, our patient experienced
complete disease remission. He continues to do well on daily ceritinib monotherapy
with plan to complete an additional year of therapy.
Conclusion: Our report highlights the potential benefit of real-time integrative clinical
sequencing in the management of systemic histiocytic lesions, specifically non-Langerhans
cell conditions. It has the potential to identify novel somatic genetic alterations,
other than the typical LCH-associated BRAF mutations of the MAPK pathway, that may
be therapeutically targetable. Treatment with 2nd generation ALK-inhibition in our
pediatric disseminated JXG patient was a novel, biologically-rationale management
approach with minimal toxicity and potentially contributed to his complete remission.
(22) Submission ID#795170
Normalization of C3 Following Bortezomib Treatment in a C3 Glomerulonephropathy Patient
Jessica Hui, MD1, Mindy Banks, MD2, Tibor Nadasdy, MD3, Jordan Abbott, MD4
1Fellow/National Jewish Health
2Physician/Rocky Mountain Pediatric Kidney Center
3Physician/Ohio State University
4Physician/National Jewish Health
Abstract/Case Report Text
Background: C3 glomerulonephropathy (C3GN) is a progressive kidney disease with the
predominant pathological feature of C3 deposits around the glomerular capillaries.
C3GN patients suffer from dysregulated activation of the alternative pathway as the
result of autoantibodies or congenital genetic defects that stabilize cleavage of
C3. Despite therapy involving immunosuppression and complement-pathway inhibition,
the prognosis for C3GN is poor. We report a patient with autoantibody-mediated, refractory
C3GN who demonstrated no improvement on rituximab but achieved sustained remission
on bortezomib. Follow up studies after one year demonstrated clearance of the culprit
autoantibody, normalization of C3 levels, and improved pathologic appearance of the
kidneys. This case supports the idea that C3GN is frequently driven by pathogenic
autoantibodies that may not clear with rituximab alone. Plasma cell directed therapy
has the potential to clear these autoantibodies and halt the progression of disease.
Case presentation: We report the case of a Hispanic male with chronic renal dysfunction
initially diagnosed with membranoproliferative glomerulonephritis on renal biopsy
at 12 years of age. Despite cellcept and prednisone, over the next 4 years, he had
worsening proteinuria and an increase in protein-to-creatinine ratio. Renal biopsy
suggested C3GN, and lab studies revealed a factor-H autoantibody and C3 level below
the assay limit of detection. After initiating eculizumab, the proteinuria temporarily
improved; however, the proteinuria eventually worsened, and he was referred to immunology.
We hypothesized that the factor H-binding autoantibody was the cause of dysregulated
C3 cleavage and disease progression, and blocking the terminal complement pathway
with eculizumab would not halt upstream C3-mediated kidney injury. At the age of 20,
rituximab and plasmapheresis were administered to clear the factor-H autoantibody.
Three months after rituximab administration, the factor-H autoantibody level decreased
to the normal range, but he continued to have significant proteinuria with low serum
albumin and undetectable C3 level. We concluded that the relevant autoantibody was
not solely produced by differentiating memory B cells, so we decided to target the
plasma cell compartment. Bortezomib was started at the age of 21, and eculizumab was
continued given his initial response to treatment. After adding bortezomib, Factor
H autoantibody levels dropped below prior levels and serum C3 level normalized. Renal
biopsy at the age of 22 showed evidence of improving C3 deposition and less prominent
glomerular hypercellularity, with stable mesangial hypercellularity, interstitial
fibrosis, tubular atrophy, and sclerotic glomeruli. Although his proteinuria did not
worsen, it remained persistent, suggesting that earlier introduction of bortezomib
could have prevented disease advancement. There has been no further progression of
kidney failure.
Conclusions: The majority of C3GN patients harbor autoantibodies to components of
the alternative pathway of complement. This case provides evidence that at least some
of these autoantibodies are indeed the cause of complement dysregulation, and thus
are prime targets for therapy. B cell targeting therapies may be inadequate to decrease
autoantibody levels for some patients. Early initiation of bortezomib, or other plasma-cell
directed therapy, may effectively induce complement normalization and disease remission
in these cases.
(23) Submission ID#795442
A Case Of Combined IgA And IgG Subclass Deficiency In A MECP2 Duplication Syndrome
Patient
Prudhvi Regula, MD1, Tracy Hwangpo, MD, PhD2, Suthida Kankirawatana, MD3
1Internal Medicine Resident/University of Alabama at Birmingham, Montgomery Internal
Medicine Residency Program
2Instructor/University of Alabama Birmingham
3Assistant Professor/University of Alabama Birmingham
Abstract/Case Report Text
Introduction:
MECP2 Duplication Syndrome (MDS) is a rare, X-linked genetic disorder characterized
by early hypotonia, profound intellectual disability, seizures, and immunodeficiency.
Combined IgA and IgG subclass deficiencies were reported to be associated with this
syndrome.
Case description:
An 18-year-old male with autism, seizure disorder, infantile hypotonia, and asthma
was referred to the immunology clinic for evaluation of recurrent respiratory tract
infections (RTI’s) and methicillin-resistant Staphylococcus aureus (MRSA) skin infections. He
had poorly controlled asthma with multiple exacerbations despite treatment with high
dose inhaled corticosteroid and a long-acting bronchodilator. He has no family history
of immunodeficiencies or congenital disorders.
Computed tomography(CT) chest showed bronchiectasis. His complement studies and isohemagglutinin
titers were also normal. His serum immunoglobulin(IG) and lymphocytes on presentation
are shown in Table 1.
He had a poor response to polysaccharide pneumococcal vaccination. He was diagnosed
with combined IgG2/IgG4 subclass/IgA deficiency and was started on immunoglobulin
replacement therapy and prophylactic rotating antibiotic therapy. Thereafter, his
clinical course markedly improved with a reduction in the frequency of RTI’s as well
as the number of bronchiectasis exacerbations.
There was high suspicion for an underlying genetic disorder based on his constellation
of neurodevelopment disorders and immunodeficiency. Cytogenetic evaluation with array
comparative genomic hybridization(CGH) analysis showed duplication of Xq25 and Xq28
consistent with MDS.
Discussion: MDS is caused by duplications involving the MECP2 gene locus of the X
chromosome at Xq28. It has a 100% penetration rate in males whereas females act as
carriers and are usually unaffected. Rarely, cases of de novo mutations causing MDS
have been reported. Chromosome microarray analysis is currently the best initial clinical
test when MECP2 duplication syndrome is suspected. Management needs a multidisciplinary
approach involving geneticists, neurologists, ophthalmologists, physical medicine
and rehabilitation specialists, psychologists, gastroenterologists, and allergy and
immunology specialists. Prophylactic treatment with IVIG and antibiotics has been
the standard of care for immunodeficiency in these patients. Prognosis is guarded
and most male patients die in the mid to late 20’s because of severe RTI’s secondary
to immunodeficiency.
Conclusions: This case confirms the association of MDS with combined IgA and IgG subclass
deficiencies. Clinicians should consider pursuing genetic evaluation for MDS in patients
with neurodevelopmental disorders and immunodeficiency because the diagnosis of the
syndrome can change the overall approach to management and expectations in prognosis.
(24) Submission ID#795768
Persistently Low C3 Post-Streptococcal Glomerulonephritis, Lipodystrophy, and C3 Nephritic
Factor
Stefani Su, MD1, Vincent Bonagura, MD2, Alissa McInerney, MD1
1Fellow, Division of Allergy and Immunology/Donald and Barbara Zucker School of Medicine
at Hofstra/Northwell
2Chief, Division of Allergy and Immunology/The Feinstein Institute for Medical Research
Hofstra/Northwell School of Medicine
Abstract/Case Report Text
Introduction: C3 nephritic factor is an autoantibody that binds to the alternative
pathway C3 convertase (C3bBb). This results in unchecked overactivation of the alternative
complement pathway, which can lead to renal disease, partial lipodystrophy, retina
disease, and frequent infections. In this case, we present a patient with partial
lipodystrophy and low C3, subsequently found to have C3 nephritic factor.
Case Description: A 5 year old female presented with a 19 month history of low C3
levels. She was diagnosed 21 months ago with post-streptococcal glomerulonephritis
(PSGN) after presenting with hematuria and elevated ASO titers. She had C3 levels
drawn 1-2 months after time of diagnosis and C3 level was low at 27 (normal range
81-157), which was consistent with PSGN. It was rechecked 3 months after time of diagnosis
and was still low. She was referred to Rheumatology at this time and was found to
have a positive ANA titer 1:160. Tests for lupus and anti-phospholipid syndrome were
negative. C3 normalized to the low-normal range at 6 months after time of diagnosis
to 81. Her pediatrician checked to make sure it remained normal around 17 months after
initial diagnosis and C3 was low again at 22. C4 was normal at 26. She was referred
to Immunology for further evaluation.
During this time she was asymptomatic with no fevers, infections, hematuria, rashes,
joint pain, or joint swelling. She has no history of hospitalizations other than the
first for PSGN. Mother denied family history of autoimmune disorders.
Physical Exam: Physical exam was notable for abnormal subcutaneous facial fat with
normal fat distribution in the rest of her body. The rest of the exam was unremarkable
with normal cardiac, pulmonary, abdominal, and skin exam.
Testing:
C3 level was rechecked and low at 26. C3 nephritic factor was elevated at 1.07 (normal
range 0.00-0.26). Alternate pathway complement (AH50) was confirmed twice and was
undetectable, < 10 (normal level greater or equal to 46). Total hemolytic complement
(CH50) was low at 22 (normal level 42-95). Other complement levels were checked and
C1q, C2, C4, C5, C6, C7, C8, and C9 complement were within normal range.
Discussion: The overactivation of the alternative complement pathway by C3 nephritic
factor can result in various clinical manifestations, such as C3 glomerulopathy and
acquired partial lipodystrophy in predominantly the face and the upper torso. The
exact mechanism of how C3 nephritic factor is related to facial and upper body lipodystrophy
is not known. One proposed mechanism is that adipocytes in the face and upper body
produce more Factor D, which is a complement protein utilized by C3 nephritic factor.
Overactivation of the alternative complement pathway on the adipocyte then leads to
formation of the membrane attack complex, resulting in adipocyte lysis.
Eye disease, such as retinitis pigmentosa and macular degeneration can develop. C3
nephritic factor can also lead to more frequent infections and renal disease. Patients
need to be closely monitored. If patients develop C3 glomerulopathy, they may need
to be considered for immunomodulatory therapy, such as steroids and other immunosuppressants.
(25) Submission ID#796038
Early Outcome of a Phase I/II Clinical Trial of Gene-Corrected Autologous CD34+ Hematopoietic
Cells and Low-exposure Busulfan in Patients with Artemis-Deficient Severe Combined
Immunodeficiency
Morton Cowan, MD1, Jason Yu, PhD2, Janelle Facchino, PNP3, Shivali Chag, MS24, Carol
Fraser-Browne, n/a5, Janelle Long-Boyle, PharmD, PhD6, Ukina Sanford, M.S.7, Misako
Kawahara, n/a7, Jess Oh, CLS8, Suan Teoh, CLS9, Divya Punwani, PhD10, Jasmeen Dara,
MD11, Christopher Dvorak, MD12, Lori Broderick, MD, PhD13, Diana Hu, MD14, Holly Miller,
DO15, Aleksandra Petrovic, MD16, Harry Malech, MD17, R. Scott McIvor, PhD18, Jennifer
Puck, MD19’
1Emeritus Professor/UCSF Benioff Children's Hospital
2Senior Research Associate/UCSF Benioff Children's Hospital
3Research Nurse/Benioff Children's Hospital
4Project Manager/UCSF Benioff Children's Hospital
5Senior Clinical Research Associate/UCSF Benioff Children's Hospital
6Associate Professor/Department of Clinical Pharmacy, UCSF
7Staff Research Assistant IV/UCSF Benioff Children's Hospital
8Senior Supervisor/UCSF Benioff Children's Hospital
9Laboratory Specialist/UCSF Benioff Children's Hospital
10Research Specialist/UCSF Benioff Children's Hospital
11Assistant Professor/UCSF Benioff Children's Hospital
12Clinical Professor/UCSF Benioff Children's Hospital
13Assistant Professor/UCSD Rady Children's Hospital
14Staff Pediatrician/Tuba City Indian Health Service
15Staff Pediatrician/Phoenix Children's Hospital
16Associate Professor/Seattle Children's Hospital
17Chief, Genetic Immunotherapy Section/NIAID, NIH
18Professor/University of Minnesota
19Professor/UCSF Benioff Children's Hospital
Abstract/Case Report Text
Background: Artemis-deficient SCID (ART-SCID) represents ~3% of all SCID, but occurs
in 1/2000 births in Navajo and Apache Native Americans. Artemis protein, encoded by
DCLRE1C, is essential for repairing DNA double-stranded breaks, including those generated
during V(D)J recombination of antigen receptor genes as T and B cells develop. Artemis-deficiency
causes not only T-B-NK+ SCID, but also increased sensitivity to alkylating drugs and
radiation. ART-SCID is the most difficult SCID to treat with allogeneic hematopoietic
cell transplantation (HCT) due to high rates of rejection and GVHD, incomplete immune
reconstitution, and toxicity following intensive conditioning regimens. As an alternative,
we developed a self-inactivating lentiviral vector containing the human Artemis promoter
and DCLRE1C cDNA (AProArt). We are evaluating its toxicity and efficacy in a Phase
I/II gene transfer trial in ART-SCID patients.
Methods: Newly diagnosed infants with ART-SCID and older patients with insufficient
immunity despite prior allogeneic HCT were eligible if organ function was acceptable.
Infants needed to have no matched sibling donor and be at least 2 months old at conditioning.
CD34+ cells were isolated from bone marrow or cytokine-mobilized peripheral blood,
cultured with cytokines, transduced x2 with AProArt, and cryopreserved. Patients received
2 daily doses of busulfan, targeted for a cumulative exposure (cAUC) of 20mg*hr/L,
with infusion of thawed cells on the following day.
Results: We treated 5 newly diagnosed infants (ART001-3&007-8) with median age 2.6m
(range 2.3-3.7) and 3 previously-treated patients (ART004-6) (5.5y, 12.7y and 20.9y),
with a median follow-up of 9.6m (range 1.6-17.2). The mean (SD) Bu cAUC was 19.4±1.0
mg*hr/L. Patients received a median of 6.5x106 AProArt-transduced CD34+ cells/kg (range
3.9-12.4). The average vector copy number (VCN) and transduction efficiency in the
marrow grafts exceeded those in the PBSC grafts: 2.1±1.0 copies/cell vs 0.83±0.1 (p=0.02)
and 75±9% vs 59±4.6% (p=0.03), respectively. There were no serious busulfan side effects.
All patients had transduced peripheral blood leukocytes by 4w and 7 of 8 developed
gene marking in T, B, NK and myeloid cells by 8w (Fig. 1). Gene-corrected CD3, CD4,
CD4/45RA/CCR7, CD8 and CD19 cells appeared in 7 of 8 patients (Fig. 2), with ART005
having T, NK and myeloid marking without B cells at 6m post infusion. Normalization
of lymphocyte proliferation to PHA occurred in the 3 evaluable (>12w) infants (Fig.
3), all 3 now outpatients off isolation. Two infants and 1 previously treated child
developed autoimmune hemolytic anemia (AIHA), with 2 requiring immunosuppressive therapy.
Infections included rhinovirus at presentation in ART001 that resolved with T cell
reconstitution. After discharge ART001 acquired and recovered from norovirus and ART002
acquired and recovered from CMV and rotavirus. Analyses of insertion sites and T cell
receptor diversity are pending.
Conclusion: Infusion of AProArt-transduced autologous CD34 cells into ART-SCID patients
pretreated with very low exposure busulfan resulted in multilineage engraftment of
transduced cells with evidence for T and B cell immune development. AIHA, the only
complication to date, occurred early and appears to resolve following restoration
of T cell immunity. These encouraging results suggest potential effectiveness of ex
vivo gene therapy for ART-SCID.
(26) Submission ID#798344
RAS-Associated Autoimmune Leukoproliferative Disorder (RALD) Accounts For A Subset
Of Early-Onset Systemic Lupus Erythematosus
MaiLan Nguyen, MD1, Susan Canny, MD, PhD2, Andrea Ramirez, MD1, Ivan Chinn, MD3, Zeynep
Coban-Akdemir, PhD4, James Lupski, MD, PhD5, Tracey Wright, MD6, Eric Allenspach,
MD, PhD7, Tiphanie Vogel, MD, PhD1
1Assistant Professor/Baylor College of Medicine
2Fellow/University of Washington
3Assistant Professor, Director Immunogenetics Program/Department of Immunology, Allergy
and Rheumatology at Baylor College of Medicine
4Post-doctoral Associate/Baylor College of Medicine
5Professor/Baylor College of Medicine
6Assistant Professor/UT Southwestern Medical Center
7Assistant Professor/University of Washington and Seattle Children's Hospital, Immunology
and Rheumatology
Abstract/Case Report Text
Background: Systemic lupus erythematosus is a heterogeneous disorder of the immune
system. Systematic genetic evaluation of patients with childhood-onset SLE (cSLE)
has begun to identify phenotypic clusters of cSLE patients with classic SLE-causing
genetic variants, as well as revealed unexpected genetic mimics of lupus. We report
3 patients diagnosed with cSLE with similar typical and atypical lupus features, who
were subsequently found to carry pathogenic NRAS variants that are the cause of RAS-associated
autoimmune leukoproliferative disorder (RALD).
Cases: All 3 patients (2 females, 1 male) presented at < 3 years of age (average age
21.7 months, range 17-27 months) with anti-nuclear antibodies, anti-double-stranded
DNA antibodies, autoimmune hemolytic anemia, severe thrombocytopenia, antiphospholipid
antibodies, hypocomplementemia and nephritis. Additionally, the patients all displayed
fevers, organomegaly, lymphadenopathy and hypergammaglobulinemia. Two out of 3 patients
had a malar rash, leukopenia, lymphopenia, anti-Smith antibodies, serositis or arthritis.
No patient had oral or nasal ulcers or photosensitivity. Despite the fevers, lymphoproliferation
and systemic autoimmunity, the patients did not display overwhelming immune dysregulation
(peak ferritin 128-623 ng/mL). Interestingly, the patients were found to have monocytosis
(19-45%), as has previously been reported in RALD. Double negative T cells were within
normal range in the 2 patients in which this was tested. All 3 patients required aggressive
immune modulation for control of their disease manifestations. Two of the 3 developed
severe infections, specifically pneumococcal sepsis, during therapy. Current follow-up
covers an average of 9.2 years (range 0.6 to 17 years). The patients responded to
corticosteroids and were given sequential trials of various steroid-sparing therapies.
In general, they appeared to benefit from both B cell depletion and T cell-directed
modalities (cyclosporine, rapamycin), which are not first line therapy in cSLE. Unfortunately,
1 patient developed a fatal pulmonary infection while on treatment; her underlying
disease was felt to be quiescent. Due to the early-onset of disease, each patient
was selected for genetic evaluation (2 by exome sequencing, 1 by gene panel). This
lead to the discovery of pathogenic NRAS variants (c.38G>A, p.G13D) in all patients,
assumed to be somatic, although this was confirmed in only 1 case.
Conclusion: RAS-associated autoimmune leukoproliferative disorder can present indistinguishable
from cSLE with positive autoantibodies, immune cytopenias, arthritis, nephritis and
hypocomplementemia. Clinicians should consider evaluating for RALD in cSLE patients
who present at an early age ( < 3 years) with predominant features of lymphoproliferation
and hematologic abnormalities, particularly monocytosis. T cell-directed therapy with
cyclosporine or rapamycin should be considered for RALD.
(27) Submission ID#798815
Complex Multi-System Immune Dysregulation and Recurrent Infections in an Adult
Aba Al-Kaabi, MD1, Sid Ganguly, MD2, Joseph McGuirk, MD3, Gulbu Uzel, MD4, Eric Rush,
MD5, Selina Gierer, DO6
1Allergy and Immunology fellow/KUMC
2Professor Medicine Hematology/KUMC
3Division Director, Hematologic Malignancies and Cellular Therapeutics/KUMC
4NIH/NIH
5Volunteer Faculty - Genetics/KUMC
6Program director allergy and immunology/KUMC
Abstract/Case Report Text
Introduction:
Cytotoxic T Lymphocyte Associated Protein 4 (CTLA4) is a crucial downregulator of
immune responses. (1) Human CTLA4 loss-of-function causes dysregulation of FoxP3+
regulatory T (Treg) cells, hyperactivation of effector T cells, and lymphocytic infiltration
of target organs. Patients also exhibit progressive loss of circulating B cells, associated
with an increase of predominantly autoreactive CD21(lo) B cells and accumulation of
B cells in non-lymphoid organs. Inherited human CTLA4 loss-of-function demonstrates
a critical quantitative role for CTLA4 in governing T and B lymphocyte homeostasis.
(2) This case highlights the importance of Next Generation Sequencing (NGS) in diagnosing
and managing complex presentations with multi-system involvement.
Case presentation: Patient was diagnosed with diffuse large B cell lymphoma at age
22 and treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone
(R-CHOP) in 9/2012. He underwent autologous stem cell transplant with preparative
carmustine, etoposide, cytarabine, and melphalan (BEAM) in 10/2012. He subsequently
developed recurrent giant condyloma acuminata following transplantation requiring
9 surgical resections, refractory immune thrombocytopenic purpura (ITP) requiring
aggressive systemic steroids and high dose IVIg at least yearly, experiencing hypogammaglobulinemia,
recurrent sinopulmonary infections, disseminated herpes zoster, and Kaposi sarcoma.
In 6/2014, he underwent CT/PET, revealing extensive hypermetabolic lymphadenopathy
and splenomegaly. Bone marrow biopsies were negative for lymphoma, although showed
a slightly hypocellular marrow (40-60% cellularity), 2% blasts, and eosinophilia without
peripheral eosinophilia. Repeated evaluations for HIV, syphilis, Histoplasma, CMV,
HHV6, HHV8, Bartonella, Coxciella, Brucella, HTLV, toxoplasma were negative. HTLV1
and 2 antibodies had been negative prior to transplantation. Tonsillectomy 12/2015
due to progressive enlargement showed reactive follicular hyperplasia with focal acute
tonsillitis without granulomas or viral inclusions. Repeated lymphocyte enumeration
and proliferation studies were normal. A repeat PET scan 3/2016 revealed persistent
diffuse lymphadenopathy involving the neck, chest, abdomen, and pelvis. Left lung
biopsy revealed non-caseating granulomas without lymphoma. Stains for EBV were negative.
Repeat PET scan 11/2016 indicated disease progression prompting a left axillary excisional
lymph node biopsy, revealing EBV lymphadenitis with large, reactive follicles with
interspersed inflammation and loosely formed granulomas and CD20 positive B cells
within the follicles. EBV blood PCR was negative. AFB and fungal stains were negative
on all biopsies. In 1/2017, his IgG was 615 (762-1488), IgA 33 (70-390), and IgM 58
(38-328) with only 1 out of 23 protective serotypes to pneumococcus post-vaccination
at 1.3 or greater. In 3/2018, IgG was 380 (762-1488).
Custom NGS panel showed a heterozygous missense variant in CTLA4 c.534c>g (p.S178R)
located in the transmembrane domain. This variant of uncertain significance is suspicious
and strongly suggests the diagnosis of CTLA4 -related autoimmune lymphoproliferative
syndrome . Patient was referred to the National Institute of Health, where he received
a bone marrow transplant.
Conclusion:
Primary immunodeficiency diseases comprise a group of highly heterogeneous immune
system diseases and around 300 forms of PID have been described. NGS has recently
become an increasingly used approach for gene identification and molecular diagnosis
of human diseases guiding treatment to patients who may otherwise have poor outcomes.
(3)
(28) Submission ID#799299
Atypical Presentation of C8 Alpha Deficiency In A Congolese Boy
Erik Newman, MD1, Cullen Dutmer, MD2
1Allergy and Immunology Fellow/University of Colorado and Children's Hospital Colorado
2Assistant Professor of Pediatrics/Section of Allergy & Immunology, Children's Hospital
Colorado, University of Colorado School of Medicine, Aurora, CO, USA
Abstract/Case Report Text
Introduction: Inherited defects of the complement system are rare disorders that can
result in unique susceptibility to infections with select bacteria. Patients with
a deficiency of a complement protein early in the complement pathway (affecting C1qrs,
C2, C3, Factor H, or Factor I) have increased susceptibility to infection with encapsulated
bacteria, most notably Streptococcus pneumoniae and Neisseria species. In contrast,
patients with a deficiency of a complement protein at the terminal end of the complement
pathway (affecting C5, C6, C7, C8 alpha/beta/gamma, or C9) almost universally present
with severe, recurrent, or disseminated Neisseria species infections. Most genes encoding
complement proteins are found on autosomes, in which specific complement deficiencies
result from biallelic mutations. Although particular complement deficiencies occur
at higher frequencies in certain populations, the prevalence of specific complement
deficiencies is unknown in many parts of the world, especially in underdeveloped regions,
including Sub-Saharan Africa. Herein, we describe a young Congolese boy with an atypical
presentation of C8 alpha deficiency.
Case Description: A 17-month-old Congolese boy with consanguineous parents (first
cousins) presented with recurrent infections. Prior to an evaluation of his immune
system, he was hospitalized five times. His infections included episodes of acute
otitis media, bacterial pneumonia, and viral pneumonitis. A bronchoscopy revealed
diffusely edematous airways and growth of Candida albicans, Moraxella catarrhalis,
and Streptococcus pneumoniae in bronchoalveolar lavage cultures. Concurrently, his
respiratory PCR panel was positive for adenovirus. His initial immune evaluation included
assessments of his serum immunoglobulin levels, vaccine titers (tetanus, diphtheria,
Haemophilus influenzae, and Streptococcus pneumoniae), neutrophil oxidative burst,
lymphocyte subsets, and CH50, in which only his CH50 was abnormal (16 U/mL). His CH50
remained low on repeat assessment (16 U/mL), at which time an AH50 was pursued and
also returned with a low result (1% of normal). A complement system genetic panel
identified a homozygous intronic variant in C8A (c.856-12G>A). Functional confirmation
of the variant revealed that the patient had a significantly decreased C8 level (18
mcg/mL) and absent C8 function.
Discussion: We present a case of a young Congolese boy with C8 alpha deficiency and
a clinical presentation atypical for defects in terminal complement proteins. Our
patient presented primarily with recurrent respiratory infections, including Streptococcus
pneumoniae pneumonia, but without a preceding history of meningococcal disease. While
it is well established that patients presenting with terminal complement pathway defects
have an increased susceptibility to meningococcal disease, it is less clear if they
have increased susceptibility to pneumococcal infections. Occurring between exons
5 and 6, the homozygous intronic variant in C8A identified in our patient is predicted
to result in abnormal splicing. While the allele frequency of this mutation is relatively
high in the African population (0.017), functional confirmation of the variant demonstrated
a decreased C8 level and absent C8 function that support the pathogenesis of the mutation.
The discrepancy between the allele frequency and reported disease cases could be explained
in part by varying clinical manifestations seen in C8 deficiency or underrecognized
disease in Sub-Saharan Africa.
(29) Submission ID#800795
Long Term Clinical Outcomes of Patients with Severe Combined Immunodeficiency (SCID)
Given Bone Marrow Transplantation without Pre-transplant Chemotherapy or Post-Transplant
GVHD Prophylaxis
Olga Hardin, MD1, Talal Mousallem, MD2, Amy Stallings, MD3, Yuliya Lokhnygina, PhD4,
Rebecca Buckley, MD5
1Fellow in Training/Department of Pediatrics, Duke University Medical Center
2Associate Professor of Pediatrics/Department of Pediatrics, Duke University Medical
Center, Durham, North Carolina 27710
3Assistant Professor of Pediatrics/Department of Pediatrics, Duke University Medical
Center
4Assistant Professor of Biostatistics and Bioinformatics/Duke Clinical Research Institute
5James Buren Sidbury Professor of Pediatrics, in the School of Medicine; Professor
of Immunology/Department of Pediatrics, Duke University Medical Center, Durham, North
Carolina 27710
Abstract/Case Report Text
Rationale: SCID is a syndrome characterized by profound T, B, and (in some cases)
NK cell defects that is universally fatal unless immune reconstitution is achieved.
A total of 177 SCID infants have been given allogeneic bone marrow transplantation
at Duke University Medical Center without pre-transplantation chemotherapy or post-transplantation
graft-versus-host disease (GVHD); 90% received T cell-depleted haploidentical parental
marrow and 47(26%) are known to be deceased. Post-transplantation follow-up ranged
from 22 months to 37 years. The aim of this cross-sectional study is to characterize
the clinical status of a large cohort of survivors treated at a single medical center.
Methods:
Clinical status was assessed by detailed questionnaires delivered by mail or electronically.
Adult (≥ 18 years old) and pediatric questionnaires were based on patients’ age. Patients
were also contacted by telephone and evaluated at clinic visits. Molecular type of
SCID, demographics, type, date and age at transplant were obtained from a clinical
database.
Results:
Fifty questionnaires were completed to date from survivors ranging in age from 5 to
37 years. Twenty-nine/50 were adults ≥18 years at the time of the questionnaire. Genetic
defects were known for all 50 patients- X-linked SCID was the cause in about half
(Figure 1). Twenty-three of 50 patients were on immunoglobulin replacement. Thirty
of 50 reported having received immunizations, and about half of those received live
vaccines. Fifteen of 50 reported they were taking no regular medications; 11 reported
taking prophylactic antibiotics.
>We found substantial scholastic achievement, with 17/29 adult patients reporting
college attendance. Two had post graduate education including doctorate level degrees.
Occupations included physician, nurse, factory worker, musician, teacher, and engineer.
One patient had 3 children. Twenty-seven /29 adult patients shared their height and
weight and 78% (21/27) had a healthy BMI (BMI 18.5-24.9), while 15% (4/27) were overweight,
and 7% (2/27) were underweight (< 18.5). In pediatric patients, the average age and
sex-adjusted BMI was at the 47th percentile and only 3 had a BMI that was < 5th percentile.
Thirty-four/50 patients reported seeing an immunologist regularly. In the adult group,
38% reported no longer seeing an immunologist.
The health conditions reported were similar to those common in the general population,
and included rashes, warts and mouth ulcers. Most reported these were transient, self-resolving
issues. Thirteen of 50 (26%) reported having ADHD, higher than NIH reported rates
which estimate ADHD in 8.1% of adults and 11% of children). Ten of 50 (20%) reported
having anxiety, similar to the NIH reported prevalence of 19.1% in the general population.
34/50 (~68%) reported having no active concerns about their health.
Conclusions:
Overall, our findings are consistent with those in the last update done by Railey
et al, J. Peds. 155:834-840, 2009 in this population. Patients are doing well with
most problems similar to those common in the general population. Most have a healthy
BMI. ADHD had a higher prevalence than in the general population. More than 1/3 of
SCID patients are not seeing an immunologist regularly, and a majority do not have
any active concerns.
Figure 1. Genetic Causes of SCID in the 50 patients whose questionnaire data are presented.
X-linked SCID was the most common, followed by ADA and IL-7R deficient SCID
Figure 2. Health conditions reported in 50 SCID patients who received a bone marrow
transplant without conditioning.
(30) Submission ID#801617
Frequency of Myopathy in Primary Immunodeficiency: Data from the USIDNET Registry
Keith Sacco, MD1, Elizabeth Garabedian, MSLS, RN2, Ramsay Fuleihan, MD3, Luigi Notarangelo,
MD, PhD4
1Clinical Fellow/National Institute of Allergy and Infectious Diseases (NIAID/NIH)
2Research Nurse/NIH-NHGRI
3Professor of Pediatrics and Allergy and Immunology/Ann & Robert H. Lurie Children's
Hospital of Chicago
4Chief, Laboratory of Clinical Immunology and Microbiology/National Institute of Allergy
and Infectious Diseases, NIAID/National Institutes of Health, NIH
Abstract/Case Report Text
Rationale: Myopathy has been occasionally documented in patients with primary immunodeficiency
(PID). However, data on frequency and patient characteristics associated with myopathy
are lacking. We performed a descriptive analysis of patients with primary immunodeficiency
(PID) in the USIDNET having myopathy as a feature of their primary disease.
Methods: The USIDNET registry was queried for the spectrum of myopathic disorders
in PID patients that had been entered into the registry as of November 26, 2019.
Results: A total of 63 PID patients with myopathy were identified, 36 of which (57.1%)
were female. Median age at onset of symptoms related to PID was 4 years (range 0.1-72
years, IQR 0.5-25 years). Median age of diagnosis of PID was 8.3 years (range 0.4-77
years, IQR 3-32.5 years). Age at onset of myopathic disorders was not known. Twenty-eight
(44.4%) patients had a diagnosis of common variable immunodeficiency (CVID), 6 (9.5%)
had agammaglobulinemia, 3 patients each (4.8%) were diagnosed with severe combined
immunodeficiency, hypogammaglobulinemia, or ‘HLH and pigmentary disorders’, while
2 patients (3.2%)were reported in each category of combined immunodeficiency (CID),
autoimmune lymphoproliferative syndrome (ALPS), and autoinflammatory disease. Thirty-five
patients (55.6%) had a causative gene variant identified attributable to PID. The
most common variant identified was BTK (6 patients) followed by AIRE, LYST, CYBB (3
patients each) and PI3KCD (2 patients). Eighteen individual patients had other variants
identified (Figure 1). 15 patients had cellulitis or skin/subcutaneous tissue infection,
7 patients had a ‘skin or subcutaneous tissue abscess’, 2 had pyoderma gangrenosum,
and 1 patient with eczema herpeticum. Within this cohort of 63 patients, the most
common myopathy listed was myositis (18) followed by ‘muscle weakness’ (11), dermatomyositis
(8), myalgia/s (6), myalgia/myositis (4), myopathy (4), polymyositis (2), steroid-induced
myopathy (2). No patient had an infectious myositis or muscle abscess listed. Eighteen
patients (28.6%) had a myopathic disorder at the time of diagnosis of their PID. Thirty-one
patients (49.2%) received prednisone, 11 (17.5%) received hydrocortisone and 2 (3.2%)
received dexamethasone. Two patients had a diagnosis of adrenal insufficiency. Nine
patients (14.3%) underwent hematopoietic stem cell transplantation. Nine patients
(14.3%) died; median age of death 16 years (range 0.4-40.6 years, IQR 3.6-21.1 years).
). One patient with chronic granulomatous disease had myopathy due to Duchenne muscular
dystrophy, which was listed as a cause of death. No other myopathic disorders were
listed as a cause of death for the other patients.
Conclusion: Myopathy and inflammatory myopathic disorders occur at relatively high
frequency in PID, and may be present even at the onset of clinical symptoms. The underlying
etiology can be speculated to be multifactorial. Further subgroup analysis is warranted
to elucidate possible variant-specific or treatment-associated characteristics of
myopathy in PID.
Figure 1 Frequency of monogenic variants identified from 35 patients with myopathy
having gene data in the USIDNET PID registry. Each Individual patient in the ‘Other’
Category (n=18) had the following variants identified: RAG2, STAT1, PI3KR1, CLTA4,
FOXP3, IKBKG, MAP3K14, UNG, ATM, DOCK8, PGM3, PNP, IL2RG, IL7RA, IRF2BP2, TNFRSF13B,
TNFRSF1A, and MEFV (Figure 1).
(31) Submission ID#801755
Clinical Manufacturing and Banking of Virus-Specific T cells
Nan Zhang, PhD1, Alyssa Fatic, BA2, Gelina Sani, BS2, Jay Tanna, MS3, Catherine Bollard,
MD4, Patrick Hanley, PhD5, Michael Keller, MD6
1Staff Scientist/Children's National Health System
2Technician/Children's National Health System
3QA Lead/Children's National Health System
4Professor/Children's National Medical Center
5GMP Director/Children's National Health System
6Assistant Professor/Children's National Health System
Abstract/Case Report Text
Virus specific T cells (VST) have shown promising clinical efficacy in patients with
viral infections after hematopoietic stem cell transplant. Despite being used to treat
over 500 patients worldwide, critical quality attributes and parameters associated
with successful VST products have not been established. Here we report in depth characterization
and parameters established from a total of 81 VST products consisting of either trivirus
(65 products targeting CMV, EBV, adenovirus) or hexavirus (16 products targeting CMV,
EBV, adenovirus, HHV6, parainfluenza, BK virus) VSTs. We define a successful VST product
as meeting release criteria (>70% viability, < 5.0 EU/kg endotoxin, 10 spots above
background/100,000 cells). A median of 76 million (range: 26-404) peripheral blood
mononuclear cells (PBMCs) were isolated from a median of 54mL (range: 17-100) whole
blood from 81 consenting donors. Clinical-grade VSTs were initiated using a median
of 29 million (range: 8-80) PBMCs, stimulated with overlapping peptides derived from
viral antigens (CMV (IE1 and pp65), EBV (LMP2 and EBNA1), Adv (Hexon and Penton) +/-
HHV-6B (U54 and U90) +/-BKV (LgT and VP1) +/-HPIV3 (Matrix and NP)) at 200ng/μL/peptide,
and cultured in G-Rex devices for 10-12 days. Clinically frozen cells yielded a median
of 234 million cells (range: 35.5–780) with a median of 96% (80-100%) viability. 70%
of triviral VST products targeted all 3 viruses by ELISPOT assay, 25% targeted 2,
and 6% targeted 1. 19% of Hexaviral VST products targeted all 6 viruses, 31% targeted
5, 19% targeted 4 and 2, and 6% targeted 1 and 3. A median of 68% (range: 17-95%)
were CD4+ T cells, 27% (83-4%) CD8+ T cells, and 0.4% (4-0%) CD16+CD56+CD3- NK cells.
Sixty-five products met criteria for clinical release. To date, 38 patient-specific
VST products have been infused, and 46 third-party VST infusions have been given from
19 products. In summary, VSTs were successfully manufactured from all donors, and
all patient-specific products facilitated at least 1 dose, independent of donor white
blood cell counts. Parameters associated with the highest expansion, specificity and
in vivo potency are currently being evaluated.
(32) Submission ID#802030
Refractory Autoimmune Hemolytic Anemia Successfully Treated With Daratumumab in a
Patient with MHC Class II Deficiency
Suzanne Ngo, MD1, Taizo Nakano, MD2, Cullen Dutmer, MD3
1Fellow in Training/Section of Allergy & Immunology, Children's Hospital Colorado
2Assistant Professor of Pediatrics, Medical Director of Vascular Anomalies Center/Center
for Cancer and Blood Disorders, Children’s Hospital Colorado, University of Colorado
School of Medicine, Aurora, Colorado, USA
3Assistant Professor of Pediatrics/Section of Allergy & Immunology, Children's Hospital
Colorado, University of Colorado School of Medicine, Aurora, CO, USA
Abstract/Case Report Text
Introduction: Bare lymphocyte syndrome (BLS) type II complementation group B is a
combined immunodeficiency caused by biallelic mutations in RFXANK that result in the
absence of major histocompatibility complex (MHC) class II proteins on the surface
of leukocytes. MHC class II deficiency presents with vulnerability to infection, systemic
autoimmune disease, and, specifically, refractory autoimmune cytopenias. We present
a patient with BLS type II complementation group B whose autoimmune enteritis and
refractory, life-threatening autoimmune hemolytic anemia (AIHA) were successfully
treated with daratumumab (an anti-CD38 IgG1κ human monoclonal antibody).
Case Description: After immigrating to the United States, a young boy of Moroccan
ancestry established care for episodic severe AIHA. His episodes were characterized
by jaundice, fatigue, and pan-reactive autoantibodies, which required a combination
of blood transfusions, corticosteroids, and mycophenolate mofetil to control. His
family history revealed a sister with BLS type II complementation group B. Genetic
testing confirmed that he too was homozygous for c.338-25_338del26 (752delG-25) in
RFXANK – a founder event seen in North African populations and the most frequent mutation
responsible for MHC class II deficiency. Additionally, a younger brother was confirmed
to carry the homozygous mutation. Throughout puberty, his AIHA episodes increased
in frequency and severity and were increasingly refractory to immunosuppressive therapy
including high-dose corticosteroids, mycophenolate mofetil, sirolimus, rituximab,
bortezomib, and high-dose intravenous immunoglobulin. Eventually, he required prolonged
hospital admissions and daily blood transfusions, during which time he developed severe
infections, including recurrent Salmonella enterica bacteremia, polymicrobial gastroenteritis,
and recurrent herpes simplex virus-1 gingivostomatitis. Splenectomy was performed
at 16 years of age, resulting in a 6-month clinical remission. However, transfusion-dependent
AIHA returned in addition to autoimmune enteritis manifesting as diarrhea, malabsorption,
and GI bleeding. As alternative management for AIHA, he was initiated on daratumumab.
Following four weekly doses of daratumumab, his hemoglobin normalized and enteritis
resolved.
Discussion: Autoimmune cytopenias are a frequently encountered manifestation of many
primary immunodeficiency diseases, including MHC class II deficiency. Non-specific
immunosuppressive agents may maintain stability of disease, but risk further susceptibility
for infection. Furthermore, diseases may become refractory to typical treatment regimens.
Here, we describe a patient with BLS type II complementation group B who presented
atypically with moderate AIHA, only worsening to severe AIHA and autoimmune enteritis
after puberty. In comparison, the patient's affected sister died from complications
of infections and autoimmune disease in the first decade of life, and his younger
brother underwent hematopoietic stem cell transplantation (HSCT) for similar complications
at 3 years of age. Following a series of failed treatment regimens and without an
adequate HSCT donor available, his AIHA responded to the anti-CD38 monoclonal antibody
daratumumab (FDA-approved for treatment of multiple myeloma). Non-malignant plasma
cells also express CD38, which has been the basis for using daratumumab to treat AIHA,
particularly in severe cases post-HSCT. This is the first reported case of successful
treatment of AIHA with daratumumab in a patient with MHC class II deficiency, suggesting
it may be a reasonable treatment option in MHC class II deficiency patients and perhaps
other primary immunodeficiency diseases with refractory AIHA.
(34) Submission ID#802398
Clinical Characteristics And Infectious Complications In Patients With Rare Forms
Of Syndromic Immunodeficiency: Data From The USIDNET Registry
So Lim Kim, MD1, Elizabeth Garabedian, MSLS, RN2, Kathleen Sullivan, MD, PhD3
1Internal Medicine Resident/University of Chicago Medicine
2Research Nurse/NIH-NHGRI
3Chief of Allergy Immunology/Children's Hospital of Philadelphia
Abstract/Case Report Text
Background: The spectrum of clinical characteristics, infectious complications, and
immunologic abnormalities in rare forms of syndromic immunodeficiencies is not well
defined. Large registries can improve our understanding of these rare diseases.
Methods: The US Immunodeficiency Network (USIDNET) Registry was utilized to identify
784 patients with syndromic immunodeficiency. DiGeorge syndrome (64.2%) was the most
prevalent, followed by hyper-IgE syndrome (13.4%), Wiskott-Aldrich syndrome (12%),
ectodermal dysplasia with immunodeficiency (3.7%), ataxia telangiectasia (3.6%), undefined
syndromic immunodeficiency (1%), Omenn syndrome (1%), CHARGE syndrome (0.7%), and
dyskeratosis congenita (0.2%). As the focus of this study was to investigate rare
forms of syndromic immunodeficiencies, data was analyzed excluding the well known
example of DiGeorge syndrome.
Clinical characteristics: Out of the 281 patients with a diagnosis of syndromic immunodeficiency
other than DiGeorge syndrome, 66% (n=185) were male and 34% (96) were female. The
average age of disease onset was 1.9 years and average age of diagnosis was 5.8 years.
Diagnostic delay was most prominent in Hyper IgE syndrome, where the age of onset
was 2.9 years and age of diagnosis was 9.3 years. On the other hand, CHARGE syndrome
was diagnosed at a mean age of 0.1 years.
Infectious complications and malignancy: A total of 1782 reported infectious conditions
were sorted by organ system. Pulmonary infections were the most common (27%, n=478)
followed by skin (26%, 470), ENT (21%, 381), gastrointestinal (8%, 147), systemic
(8%, 145), genitourinary (2%, 42), CNS (2%, 33), oral (2%, 32), and musculoskeletal
(2%, 30) infections. Pneumonia was the most commonly reported pulmonary infection
(60%, n=285). Of all ENT infections, otitis media (44%, n = 167) was the most common,
followed closely by sinusitis (42%, 160). A total of 943 infectious pathogens were
recorded, of which 21% were Staphylococcus aureus (n=194), 13% Candida (123), 7% Pseudomonas
(68), 6% Aspergillus (55), 5% common respiratory viruses (47), 4% other Staphylococcus
(34), and 4% Streptococcus pneumoniae (34). Malignancy was diagnosed in 14% of patients
(n=39), of which 51% (20) were lymphoma.
Therapy: Immunoglobulin replacement therapy was reported as done in 58% (n=162), not
done in 35% (97), and was not reported in the rest of the cohort. Twenty-three percent
of the cohort underwent stem cell transplant (n=66), with the highest rates in Omenn
syndrome (7/7 patients, 100%) and the lowest rates in ataxia telangiectasia (0/27,
0%) and undefined syndromic immunodeficiency (0/8, 0%).
Conclusions: USIDNET provides a resource to describe the clinical characteristics
of patients with rare forms of syndromic immunodeficiency. Data from the registry
shows that these patients are susceptible to a wide variety of infectious conditions
and pathogens. In this cohort, more than half received immunoglobulin replacement
therapy and about a quarter received stem cell transplant. The overall diagnostic
delay is about 4 years. This suggests the importance of immunological investigations
in patients with congenital anomalies, syndromic features, or chromosomal aberrations
who have recurrent infections.
(35) Submission ID#802527
Dedicator of Cytokinesis 8 (DOCK8) Deficiency Presenting In a Preterm, 24-Week Gestational
Age Infant
Charles Song, MD1, Manish Butte, MD, PhD2, Virender rehan, MD3, Soina Dargan, MD4,
Monika Foster, MD5, Rachit Chawla, MD5, Kenneth Zangwill, MD3, Lynne Smith, MD3, Katherine
Kuniyoshi, MD6, Guadalupe Padilla, MD6, Sylvia Yeh, MD3, Henry Lin, MD3
1Chief of Pediatric Allergy and Immunology/Harbor-UCLA
2Associate Professor/Division of Allergy, Immunology, and Rheumatology, University
of California Los Angeles
3Professor/Harbor-UCLA
4Associate Clinical Professor/Harbor-UCLA
5Fellow/Harbor-UCLA
6Assistant clinical professor/Harbor-UCLA
Abstract/Case Report Text
INTRODUCTION: DOCK8 deficiency (autosomal recessive hyper IgE syndrome) may present
with features of combined immune deficiency (CID) early in life. Here we report a
premature male infant of 24 weeks gestation who had generalized skin candidiasis within
2 weeks after delivery -- the youngest patient with DOCK8 deficiency ever identified
by genetic testing.
CASE HISTORY: The infant was admitted to the neonatal intensive care unit for extreme
prematurity (birthweight 585 g, vaginal delivery), respiratory failure, and possible
sepsis. He was the first born to non-consanguineous parents without a family history
of immunodeficiency. The infant was placed on a ventilator and given antibiotics for
possible sepsis. During the first 2 weeks, candida skin infection was diagnosed (with
a positive KOH preparation) and treated successfully with topical nystatin. Herpes
simplex virus PCR of the skin and blood cultures for bacteria and fungi were negative.
Subsequently, the infant developed conditions commonly associated with prematurity,
including anemia, hyperbilirubinemia, patent ductus arteriosus, cardiac instability,
acute urinary tract infection, and bilateral grade I intraventricular hemorrhages.
Weight and length trended at 3%. Occurrence of severe candida infection with scalded
skin and intractable unconjugated hyperbilirubinemia prompted whole exome sequencing
(collected on day 10; reported on day 30). Results showed two heterozygous pathogenic
DOCK8 variants, compatible with autosomal recessive hyper IgE syndrome: c.1963C>T
(p.Gln655*) and a ~33.39 kb DOCK8 deletion (exon 1 and intron 1). The mother carries
the p.Gln655* variant. Testing for the ~33.39 kb deletion in parents is pending, to
confirm biallelic DOCK8 variants in the infant. Immune laboratory studies included:
normal newborn Trec screening; normal IgG at 12 weeks (76 mg/dL), and borderline low
T and B cells at 5, 9, and 12 weeks (PMIDs 31220471, 27548364) with an increasing
trend (CD4+ T cells: 944 -> 965-> 1581; CD8+ T cells: 396 -> 519 -> 737; B cells:
234 -> 878 -> 1358). CD4 phenotypes at 9 weeks (by another laboratory) showed normal
distributions of various subtypes including naive, memory (central and effector),
and regulatory T cells.
DISCUSSION: Diagnosis of DOCK8 deficiency so early in life presents a unique opportunity
for anticipatory guidance and treatment. A report (25724123) on 64 patients (median
age 10 years) described bacterial, viral, and fungal infections in 70-84% of patients,
low IgG levels in 3%, low IgM levels in 62%, low CD4 and CD8 in 29%, and a mean IgE
level of 5,201 IU/mL. The infant’s clinical course has been otherwise similar to courses
seen for same gestational age infants. T and B cell counts were on the low side but
followed an expected developmental pattern (27548364). Infection prevention with antibiotic
prophylaxis (viral, fungal), IVIG, and immunizations (avoiding live viral vaccines)
are needed to prevent early morbidity and improve the success of hematopoietic stem
cell transplantation (30466772). Interferon-alpha 2b has shown efficacy against severe
viral infections (24743019). The patient may be a strong candidate for HSCT, because
a recent review reported a high survival rate, especially when done before 8 years
of age (98% vs 78%; 30391550).
(36 Submission ID#802725)
First Identified Case of SCID In Puerto Rico After Implementation Of Mandatory Newborn
Screening Test: A Case Report
Jinette Santos, MD1, Cristina Ramos, MD2
1Pediatric Resident, PGY-3/San Juan City Hospital
2Allergist and Immunologist/UPR School of Medicine
Abstract/Case Report Text
Background: Severe combined immunodeficiency (SCID) is an infantile-onset primary
immunodeficiency in which there is dysfunction of T-cells, B-cells and NK cells. Although
fatal without treatment, newborn screening test (NBS) has made it possible to detect
SCID before affected infants experience severe opportunistic infections and complications.
Currently, NBS is mandatory in all states of United States (US) including Puerto Rico
(PR). Before implementation of the screening, a pilot program in 2011 identified one
patient with SCID in PR that was successfully transplanted. After implementation of
the mandatory test in August 2015, a total of 103,680 newborns in PR were screened
with one case identified and confirmed in October 2019.
Purpose/Objective: Report and describe the data of the first SCID patient diagnosed
in October 2019 after implementation of the mandatory NBS test for SCID in PR.
Method: Retrospective record review of data, laboratories, treatment and management
of the first SCID patient that was identified with NBS test at PR.
Results: The patient had a positive NBS result based on a Real Time PCR analysis for
TREC. Two samples showed undetermined Ct values for TREC amplification indicating
the absence of T cells. Reference gene amplified as expected. Initial immunology evaluation
with lymphocyte subset panel was performed. Results showed the following: CD3: 4 cells/uL
(2%), CD4: 1 (1%), CD8: 4 (2%), NK: 8 (4%), CD19: 167 (90%) and CD45RA was not reported.
Patient laboratory results consistent with T -, B+, NK- SCID. Genetic PID panel was
done. One pathogenic variant, c.670C>T (p.Arg224Trp) in IL2RG that is consistent with
a diagnosis of X-linked SCID was identified. Another three genetics variants were
found; c.1356+4C>T, in CARD14, c.3293T>C (p.Ile1098Thr), in DOCK2 and c.981C>G (p.Asp327Glu),
in ZAP70. All of them with uncertain significance. CXR showed peri-bronchial thickening
concerning for viral pneumonia. Patient was admitted to hospital, isolated and placed
on empiric Cefepime treatment pending blood cultures and repeating images. He received
IVIG and prophylactic doses of TMP/SMX, acyclovir, azithromycin and fluconazole. Repeat
CXR was found to be clear. Cefepime was discontinued once blood cultures had been
negative. During hospitalization patient developed one episode of bloody stools for
which infectious workup was done. Changing in newborn formula resolved patient symptoms.
Case was presented to transplant centers in US and options were broadly discussed
with parents. Bone marrow transplant versus gene therapy were considered. Parents
elected gene therapy at Saint Jude Children’s Hospital. At present, patient is pending
transfer for gene therapy. With this confirmed case, we estimate an incidence in PR
to be 1:100,000 from 2015 to 2019. Overall incidence is consistent with US and represents
the first case in the last 4 years that was identified and confirmed in PR.
Conclusion: We identified one infant with abnormal TRECs that subsequently lead to
the diagnosis of X-linked SCID. Mandatory implementation of NBS for SCID in PR provided
the opportunity to successfully recognize, manage and define best treatment options
for this patient. Early detection creates the opportunity to provide immune reconstitution
with better outcome while infants are healthy and uninfected.
(38) Submission ID#802879
A Novel Immunodeficiency Disease Associated With A Congenital Disorder Of Glycosylation:
MAN2B2 Deficiency
Luigi Notarangelo, MD, PhD1, Jan Verheijen, PhD2, Sunnie Wong, MD, PhD3, Jared Rowe,
MD, PhD4, Kimiyo Raymond, MD, PhD5, Jennifer Stoddard, BS, MLS6, Ottavia Delmonte,
MD, PhD7, Marita Bosticardo, PhD8, Kerry Dobbs, BS9, Julie Niemela, MS, MLS10, Enrica
Calzoni, MD11, Sung-Yun Pai, MD12, Uimook Choi, PhD13, Yasuhiro Yamazaki, MD, PhD14,
Anne Marie Comeau, PhD15, Erin Janssen, MD, PhD16, Lauren Henderson, MD, MMSc17, Melissa
Hazen, MD18, Gerard Berry, MD19, Sergio Rosenzweig, MD, PhD20, Hasan Aldhekri, MD21,
Miao He, PhD22
1Chief, Laboratory of Clinical Immunology and Microbiology/National Institute of Allergy
and Infectious Diseases, NIAID/National Institutes of Health, NIH
2N/A/Center for Individualized Medicine, Department of Clinical Genomics, Mayo Clinic
3N/A/Hayward Genetics Center, Tulane University Medical School
4Fellow/Children's Hospital Boston
5N/A/Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology,
Mayo Clinic College of Medicine
6Medical Laboratory Scientist/Immunology Service, Department of Laboratory Medicine,
NIH, USA
7Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Division of Intramural
Research, National Institute of Allergy and Infectious Diseases, National Institutes
of Health
8Staff Scientist/Laboratory of Clinical Immunology and Microbiology, IDGS, DIR, NIAID,
NIH
9Biologist/Laboratory of Clinical Immunology and Microbiology, Division of Intramural
Research, National Institute of Allergy and Infectious Diseases, National Institutes
of Health
10Medical Laboratory Technologist/Immunology Service, Department of Laboratory Medicine,
Clinical Center, NIH, USA
11PhD student/Laboratory of Clinical Immunology and Microbiology, Division of Intramural
Research
12Associate Professor/Division of Hematology/Oncology, Boston Children’s Hospital
13Staff Scientist/Laboratory of Clinical Immunology and Microbiology, Division of
Intramural Research, National Institute of Allergy and Infectious Diseases, National
Institutes of Health
14Post-doctoral fellow/Laboratory of Clinical Immunology and Microbiology, Division
of Intramural Research, National Institute of Allergy and Infectious Diseases, National
Institutes of Health
15Chief/New England Newborn Screening Program and the Department of Pediatrics, University
of Massachusetts Medical School
16Assistant Professor/Division of Immunology, Boston Children's Hospital
17Instructor/Division of Immunology, Boston Children's Hospital,
18Attending physician/Division of Immunology, Boston Children's Hospital,
19Professor/Division of Genetics and Genomics, Department of Pediatrics, Boston Children’s
Hospital
20Senior Investigator; Chief/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center, Bethesda, MD, USA
21Attending physician/Section of Pediatric Allergy and Immunology, King Faisal Hospital
and Research Center, Riyadh
22N/A/Palmieri Metabolic Disease Laboratory, The Children's Hospital of Philadelphia
Abstract/Case Report Text
Congenital disorders of glycosylation (CDGs) are genetic disorders characterized by
heterogeneous clinical features, often including immune dysregulation. Here, we present
the first case of autosomal recessive deficiency of the mannosidase gene MAN2B2, manifesting
as syndromic combined immune deficiency with immune dysregulation.
A female child born to consanguineous parents, suffered from recurrent pneumonias,
thrush, small vessel vasculitis and arthritis since early in infancy. At 16 months
of life, she had a thrombotic stroke and left hemiparesis. Psychomotor developmental
delay was noted. She continued to have recurrent flares of vasculitis and arthritis,
multiple respiratory infections that required intubation, and chronic diarrhea requiring
total parenteral nutrition. Physical exam revealed microcephaly, low height and weight,
strabismus, beaked nose, hyper-extensible skin, pectus carinatum, and mild hepatomegaly.
She had significant speech delay and was only able to walk with support.
Laboratory studies at 4 years revealed normal IgG/IgA/IgM but markedly elevated serum
IgE (42,550 kU/L), anemia (Hb 8.7 g/dL), thrombocytopenia (78 x109/L) and lymphopenia
(520 cells/L), with low T and B cell counts, very low proportion of naïve T cells,
skewed repertoire of CD8+ T cells, undetectable TREC levels, and impaired T cell proliferation
to mitogens and antigens. There was an elevated percentage of circulating plasmablasts
(7.4%) and of dysreactive CD21low CD38low B cells (53.8%). At the age of 5, HSCT with
reduced intensity conditioning was performed from her phenotypically HLA-matched father,
with improvement of T and B cell count and function.
Whole exome sequencing (WES) identified a homozygous missense variant in the Mannosidase
alpha class 2B member 2 (MAN2B2) gene (p.Asp38Asn), that segregates with disease in
the pedigree. The MAN2B2 Asp38 residue is evolutionary conserved. The p.Asp38Asn allele
has a minor allele frequency of 0.0002687 in gnomAD, with no homozygotes. The CADD
score for this variant is 28.300, significantly higher than the Mutation Significance
Cutoff score (3.313).
MAN2B2 is involved in the lysosomal degradation of glycoproteins and demannosylation
of free N-glycans. In particular, MAN2B2 cleaves Man2GlcNac1 to generate Man1GlcNac1.
Serum N-glycan profiling revealed elevated Man5/Man6 and Man5/Man9 in the patient.
N-linked and free glycan profiling by mass spectrometry (MS) showed accumulation of
Man2GlcNac2, Man2GlcNac1 and Man3GlcNAc1glycans in patient fibroblasts as compared
to control cells, consistent with defective lysosomal glycoprotein degradation.
Lentiviral transduction of wild-type MAN2B2 into patient fibroblasts led to normalization
of the N-linked glycan profile, with reduction of Man2GlcNac2 from 8.4 to 0.9 times
control levels, and of Man2GlcNac1 from 26.9 to 1.5 control levels, indicating rescue
of the impaired deglycosylation (Figure 1A).
Western-blotting demonstrated defective N-glycosylation of LAMP2 and ICAM1 proteins
in patient fibroblasts (Figure 1B), which were corrected upon lentiviral transduction
of wild-type MAN2B2 (Figure 1C). Overall, our results indicate that loss of MAN2B2
enzymatic activity leads to dysregulation of deglycosylation and abnormal mannosylation
of glycans.
In conclusion, we have demonstrated that MAN2B2 deficiency accounts for a novel autosomal
recessive CDG with prominent features of immune deficiency and immune dysregulation.
(39) Submission ID#802956
Heme Oxygenase-1-Deficiency with Asplenia, Recurrent Infections, and Interstitial
Pulmonary Fibrosis
Alice Chau, MD, MSE1, Aaron Rosen, n/a2, Bonnie Cole, MD3, Troy Torgerson, MD, PhD4,
Eric Allenspach, MD, PhD5
1Allergy and Immunology Fellow/University of Washington
2Research Scientist/Seattle Children's Research Institute
3Clinical Associate Professor of Pathology/Seattle Children's Hospital
4Associate Professor/University of Washington, Immunology
5Assistant Professor/University of Washington and Seattle Children's Hospital, Immunology
and Rheumatology
Abstract/Case Report Text
Heme oxygenase-1 (HMOX1) is a rate-limiting enzyme that catalyzes the degradation
of heme to carbon monoxide, ferrous iron, and biliverdin, which becomes bilirubin.
These byproducts are implicated in inflammation, cell homeostasis, and antioxidant
defense(1). HMOX1-deficiency is an extremely rare autosomal recessive disorder with
a complex presentation of a wide spectrum of symptoms, including hemolytic anemia
and hyperinflammation, requiring genetic testing for confirmed diagnosis(2). We report
the fifth known case of HMOX1-deficiency(3-5), a boy who presented at 4 years of age
with aspects of the characteristic phenotype, but also had early onset asplenia, interstitial
lung disease, and previously undocumented immune deficiency.
Patient’s presentation was notable for hyperinflammatory exacerbations triggered by
viral and bacterial infections as well as vaccinations. Episodic flares occurred every
few months lasting weeks to months with fevers of 102-104F, hypoxia, leukocytosis
above 40,000/mm3, hemolytic anemia with negative Coombs, thrombocytosis exceeding
1 million/mm3, transaminitis, hemoglobinuria, hyperferritinemia to 4,000ng/mL, and
elevated LDH to 28,000IU/L.
Immune evaluation revealed normal immunoglobulin levels and adequate vaccine titers
to both protein and carbohydrate antigens. Although class switched populations were
normal, B-cell phenotyping showed absent immature and transitional B-cells, low mature
memory, and reduced CD27+ memory B-cells at 6% (normal >8%). Mitogen stimulation with
phytohemagglutinin and anti-CD3 were decreased (24.7% of control and 21.5% of control,
respectively). T-cell phenotyping demonstrated CD4 population heavily skewed to immaturity
with 65% of cells with naïve phenotype CD45RA+CD27+CCR7+. There were few effector-memory
T cells and the CD8 population was skewed towards immaturity with >65% of the cells
naïve.
Liver biopsy was performed secondary to hepatomegaly yielding mild to moderate sinusoidal
fibrosis. Bone marrow biopsy revealed a normocellular marrow with 3% blasts, increased
megakaryocytes, and extensive hemophagocytosis. Natural killer cell function was very
low, while soluble IL-2Ra level was normal. Further workup for hemoglobinopathies,
metabolic defects, congenital disorders of glycosylation, lysosomal storage disorders,
Wilson’s disease, autoimmune hepatitis, inherited and autoimmune hypercoagulability
disorders, connective tissue disorders, myositis, and myopathies were all unremarkable.
Imaging demonstrated asplenia and Howell-Jolly bodies were present. Hemophagocytic
lymphohistiocytosis (HLH) genetic testing showed no variants.
He was suspected to have systemic juvenile idiopathic arthritis (SoJIA) with episodes
of macrophage activation syndrome. The frequency of his autoinflammatory flares increased
such that he was corticosteroid dependent by age 9, having failed methotrexate, azathioprine,
and anakinra. He was started on tocilizumab with laboratory improvements, but his
lung disease progressed and became oxygen dependent. Lung biopsy confirmed nonspecific
interstitial pneumonitis (NSIP) with cholesterol granulomas also seen in SoJIA. Ultimately,
chronic lung disease led to his death at age 10. Whole exome sequencing yielded a
paternal frame shift HMOX1 and maternal splice donor HMOX1 resulting in absence of
protein. Bone marrow transplantation (BMT) in HMOX1 deficient mice have rectified
phagocytotic defects and thereby their autoinflammatory phenotype, but no human reports
for BMT treatment of HMOX1-deficiency has been described. Here we describe a phenotype
expansion for HMOX1-deficiency to include not only asplenia and hepatomegaly, but
also interstitial lung disease with cholesterol granulomas and inflammatory flares.
(40) Submission ID#802980
Biologics in STAT3 Loss-of-Function Hyper IgE Syndrome: A Report of 3 Cases Demonstrating
Improved Clinical Outcomes
Laura West, MD1, Hey Chong, MD, PhD2
1Allergy/Immunology Fellow/UPMC Children's Hospital of Pittsburgh
2Division Director of Allergy and Immunology, Associate Professor of Pediatrics/UPMC
Children's Hospital of Pittsburgh
Abstract/Case Report Text
Introduction: Mutations in the gene encoding signal transducer and activator of transcription
3 (STAT3) cause autosomal dominant hyperimmunoglobulin E syndrome (AD-HIES) characterized
by recurrent skin and sinopulmonary infections, atopic dermatitis, and elevated serum
immunoglobulin E (IgE) levels. Treatment is largely aimed at controlling symptoms
and preventing infections with no standard of care. There is a paucity of literature
describing the utilization of biologic therapies in the AD-HIES patient population.
We present 3 patients from one family with AD-HIES successfully treated with monoclonal
antibody therapies targeted at Il-5, Il-4 and Il-13.
Case Descriptions:
Patient 1: 13-year-old female with STAT3 LOF c.1003C>T (p.Arg335Trp) with a history
of atopic dermatitis and asthma requiring 2-5 steroid courses per year with frequent
school absences. She developed a severe pruritic rash covering her upper body 18 months
ago that failed to respond to antihistamines and topical antibiotics prescribed by
her primary care provider. Given her poorly controlled asthma and our concern for
a follicular type morphologic variant of atopic dermatitis, dupilumab was initiated.
Her scoring atopic dermatitis (SCORAD) prior to initiation of biologic therapy was
53.8 and improved to 4.5 following 12 doses (24 weeks) of dupilumab with clear dramatic
improvement in her skin and quality of life (Figure 1). She also reports decreased
asthma severity with no steroid courses, reduced albuterol usage, and significant
decline in school absences since initiation of dupilumab.
Patient 2: 17-year-old female with STAT3 LOF c.1003C>T (p.Arg335Trp) who is the sister
of Patient 1. She has a history of severe asthma requiring frequent emergency department
visits, hospitalizations, and 4-5 steroid courses per year despite therapy with high-dose
fluticasone-salmeterol. Spirometry prior to April 2017 demonstrated an obstructive
pattern with an FEV1 ranging from 51-64%. She was initiated on mepolizumab in April
2017. Subsequent spirometry demonstrates an FEV1 average of 115% with a range of 96-126%.
She had one hospitalization in early 2018 but otherwise no hospitalizations for asthma
since initiation of biologic therapy.
Patient 3: 15-year-old female with STAT3 LOF c.1003C>T (p.Arg335Trp) who is the paternal
first cousin of Patients 1&2. She has a history of severe atopic dermatitis with associated
pruritus and picking behaviors, poorly controlled despite daily triamcinolone application.
She previously failed ultraviolet therapy and crisaborole. She also has a history
of severe asthma requiring 2-5 steroid courses per year despite high-dose fluticasone-salmeterol.
Dupilumab was started in May 2019. SCORAD prior to initiation monoclonal antibody
therapy was 80.3 and declined to 21.2 following 13 weeks (7 doses) of dupilumab therapy
with marked improvement in skin appearance and pruritus (Figure 2).
Discussion:
We present three cases of AD-HIES caused by STAT3 loss-of-function mutations treated
successfully with monoclonal antibody therapies targeted at Il-5 or Il-4 and Il-13.
To the best of our knowledge, there is no published data describing the use of these
biologic agents in the treatment of AD-HIES. Future studies are needed to clarify
the role of these cytokines in the pathogenesis of AD-HIES and to elucidate clinical
indications for biologic therapy in this patient population.
Informed consent was obtained from all individual participants included in the study.
(41) Submission ID#803650
A Case of a Novel Presentation of CTLA-4 Haploinsufficiency
Maxwell Norris, MD1, Alicia Johnston, MD2, Louis-Marie Charbonnier, PhD3
1Medicine Pediatrics Resident/Baystate Medical Center
2Attending Physician/Baystate Medical Center
3Immunologist/Boston Children's Hospital/Harvard Medical School
Abstract/Case Report Text
CTLA-4 is a potent inhibitor of T cell proliferation that competes with costimulatory
receptor CD28 for its ligands CD80 and CD86 expressed on antigen presenting cells.
Heterozygous loss-of-function mutations in CTLA-4 have been identified in patients
with lymphocytic infiltration of multiple nonlymphoid organs (Lo et al).
The patient is a 2-year-old Jordanian male born at term to nonconsanguineous parents,
hospitalized at 1 mo for LLL pneumonia, and at 2 mo and at 4 mo he was evaluated in
the ED and diagnosed with non RSV-bronchiolitis with LLL infiltrate thought to be
secondary to atelectasis. At 2 yo he developed LLL pneumonia and respiratory failure
requiring PICU admission. He was treated with ceftriaxone. After discharge, he had
6 weeks of intermittent fever, progressive fatigue, productive cough, and FTT. He
received courses of cefdinir, clindamycin, and TMP-SMX without improvement. Chest
CT revealed left lung consolidation, LLL bronchiectasis, LUL tree in bud opacities,
and hilar lymphadenopathy. Bronchoscopy with BAL revealed no bacterial growth and
no acid-fast bacilli. 16srRNA NGS was positive for H. influenzae. Lung biopsy demonstrated
acute and chronic bronchiolitis with bronchiolitis obliterans and intraluminal polyps,
with lymphocytic infiltration involving the bronchi and bronchioles. The lung parenchyma
showed airspace filling with foamy macrophages and chronic interstitial inflammation.
Acid fast and fungal stains were negative. He was treated with systemic steroids for
bronchiolitis obliterans with noted improvement. The severity of lung disease at such
an early age prompted an immune evaluation. Sweat test, ANCA, anti-PR3 and HIV were
negative. Total immunoglobulins were normal for age, and titers to S. pneumoniae,
diphtheria and tetanus were protective. Lymphocyte enumeration revealed elevated T
and NK cell numbers for age. Lymphocyte proliferation to PHA, PWM, Candida and tetanus
were normal. Dihydrorhodamine assay was normal. B cell phenotyping was normal. There
was normal expression of CD69, HLA-DR and CD25 on activated T cells; of note the patient
was on systemic steroids when tested. Invitae 207 gene PIDD panel revealed a variant
in CTLA4: c.326G>A (p.Gly109Glu) that has been shown to be pathogenic in one patient
(Schawb et al). Flow cytometry showed normal frequency of T follicular helper cells
and T regulatory cells compared with controls, however CTLA-4 expression by T regulatory
cells was lower than control. Due to the severe and progressive nature of the patient’s
lung disease, therapy with 3x weekly azithromycin and Abatacept 50mg SQ weekly was
initiated.
We report a case of CTLA-4 haploinsufficiency presenting with recurrent pneumonia
and bronchiolitis obliterans in a 2-year-old child. Based on patient registry data,
our patient appears to be the youngest child diagnosed with CTLA-4 haploinsufficiency
reported in the literature to date (Schawb et al). Notably, our patient lacks other
features commonly described in CTLA-4 haploinsufficiency, including autoimmune cytopenias,
gastrointestinal disease, lymphoproliferation, and hypogammaglobulinemia. This case
illustrates the importance of consideration of this diagnosis in young children with
severe lung disease without other evidence of immune dysregulation. Our hope is that
prompt recognition and early treatment administration will prevent disease progression
and further decrease in pulmonary function.
(42) Submission ID#803769
Looking Through The Kaleidoscope Of GATA2 Haploinsufficiency: A Novel Case Presenting
With Cytopenias, Splenomegaly, Leukoencephalomyelopathy, Granulomatous Uveitis, And
Recurrent Fungal Infections.
Juan Ruiz, MD1, Kateryna Vostretsova, MD2, Jan Dutz, MD3, Luke Chen, MD4, Robert Carruthers,
MD5, Andre Mattman, MD6, Thomas Nevill, MD7, Peter Phillips, MD8, Helen Cross, MD9,
Persia Pourshahnazari, MD10, Catherine Biggs, MD11
1Allergy and Immunology Fellow/University of British Columbia, Vancouver, Canada.
2Physician/Allergy and Immunology, Vancouver, BC, Canada.
3Professor, Department of Dermatology and Skin Science/University of British Columbia,
Vancouver, BC, Canada.
4Clinical Associate Professor Division of Hematology/University of British Columbia,
Vancouver, BC, Canada.
5Clinical Assistant Professor/Department of Neurology, University of British Columbia,
Vancouver, BC, Canada.
6Clinical Associate Professor, Adult Metabolic Diseases Clinic/Vancouver General Hospital,
Vancouver, BC, Canada.
7Clinical Professor, Leukemia/Bone Marrow Transplant Program of British Columbia/Vancouver
General Hospital, BC Cancer, Vancouver, BC, Canada.
8Clinical Professor/Division of Infectious Diseases, St. Paul's Hospital , Vancouver
, BC , Canada.
9Neurology Fellow/University of British Columbia, Vancouver, BC, Canada.
10Clinical Instructor/Department of Medicine, St. Paul’s Hospital, University of British
Columbia, Vancouver, BC, Canada.
11Clinical Assistant Professor/Department of Pediatrics, British Columbia Children's
Hospital, University of British Columbia, Vancouver, BC, Canada.
Abstract/Case Report Text
Background:
GATA 2 is a zinc finger transcription factor essential for development, hematopoiesis,
and lymphatic angiogenesis. Heterozygous mutations cause haploinsufficiency due to
protein dysfunction or reduced transcription. Clinical phenotypes of GATA2 deficiency
are highly variable; common phenotypes include MonoMac, dendritic cell, monocyte,
B and NK lymphoid (DCML) deficiency, familial AML, and Emberger syndrome. We report
a new variable presentation of the DCML phenotype.
Case: A 55-year-old male with a history of warts as a child was in good health until
age 32, when incidental bloodwork revealed severe thrombocytopenia. Bone marrow biopsy
demonstrated sea-blue histiocytosis with negative workup for Niemann-Pick Disease.
He underwent splenectomy with pathology showing EBV-associated lymphoid hyperplasia.
Despite vaccinations prior to splenectomy, he had an episode of pneumococcal meningitis
at age 35, and sepsis of unknown origin at age 55. Over the past several years he
has developed chronic tinea corporis, onychomycosis, and otitis externa infections
despite numerous antimicrobial regimens.
At age 47, the patient developed urinary retention, walking, and balance difficulties.
He was found to have diffuse white matter changes on MRI, elevated WBC, and positive
oligoclonal bands. Initially, he was diagnosed as progressive MS treated with steroids
with partial improvement. CSF microbiology studies including AFB stains, bacterial,
fungal, mycobacterial cultures, cryptococcal antigen, VDRL, T. pallidum particle agglutination
(TPPA), as well as, PCR for CMV, EBV, VZV, Enterovirus, HSV 1-2, JC virus and T. pallidum
were all negative. Peripheral blood studies included mycobacterial blood culture,
PCR for CMV, EBV, HHV-6, in addition to serology for cryptococcal antigen, and Coccidioides
species, all of which were negative. Additional neurological complications include
granulomatous uveitis and oscillopsia, which he developed around age 47.
Immune evaluation performed at age 51 revealed low IgG2 and IgM, and the patient was
started on 30 grams of monthly IVIG. CBC with differential was notable for normal
monocyte count and thrombocytopenia, mild neutropenia (Table1). Immunophenotyping
revealed absent B cells and NK cells, while the CD8 T cells were elevated. CD4 T cells
were normal (Table 1).
At age 55, whole-exome sequencing identified a heterozygous missense mutation in GATA2
c.1186C>T, p.(Arg396Trp). After the diagnosis of GATA2 haploinsufficiency, he was
found to have Myelodysplastic Syndrome with multilineage dysplasia (MDS-MLD) on bone
marrow biopsy. He is currently awaiting bone marrow transplant
Discussion: We present a 55-year-old male with cytopenias, splenomegaly, leukoencephalomyelopathy,
granulomatous uveitis, and recurrent fungal infections found to have a pathogenic
heterozygous missense mutation in GATA 2. Leukoencephalomyelopathy in GATA 2 haploinsufficiency
has been associated with JC virus and EBV infection. Our patient did not have any
evidence of a chronic CSF infection. To our knowledge, myelopathies have not been
reported with GATA2 c.1186C>T, p.(Arg396Trp). This case highlights the variable nature
of presentation in GATA 2 haploinsufficiency, and the need for clinical awareness
of this entity in order to facilitate early diagnosis and appropriate therapy.
Complete Blood Count
Flow cytometry
Immunoglobulins*
White blood cells 4.3 x10*9 /L (N: 4-11)
CD3 2.40 x10*9 /L (N: 0.65-2.09)
IgG 17.20 g/L (7-16)
Hemoglobin 141 g/L (N: 135-170)
CD4 0.48x10*9 /L (N: 0.41-1.33)
IgA 0.92 g/L (0.7-4)
Platelets 117 x10*9 /L (N:150-400)
CD8 1.85 x10*9 /L (N: 0.20-0.78)
IgM <0.20 g/L (0.4-2.30)
Neutrophils 1.4 x10*9 /L (N: 2-8)
CD56 <0.01 x10*9 /L (N: 0.08-0.75)
Monocytes 0.4x10*9 /L (N: 0.2-1)
CD19 <0.01 x10*9 /L (N: 0.07-0.50)
Table 1. Selected immunological work up results. *Vaccine titres unavailable as patient
is on IVIG.
(44) Submission ID#804168
Central Nervous System Lesions and later Liver Lesions in a 20-year-old male with
PASLI Immunodeficiency
Barbara Ariue, MD1
1Assistant Professor, Attending Physician/Loma Linda University Children's Hospital
Abstract/Case Report Text
Background: In 2013 the PASLI disease (p110 δ activating mutation causing senescent
T cells, lymphadenopathy, and immunodeficiency) also known as Activated phosphoinositide
3-kinase (PI3K) delta syndrome (APDS) was discovered as a combined immunodeficiency.
Case Description: A 20 y.o. male with panhypopituitarism, history of autoimmune hemolytic
with splenectomy, and PASLI (PIK3CD or APDS1) immunodeficiency presented to our Emergency
Department with a three-week complaint of right leg weakness. He also had three -weeks
of constipation and urinary retention.
Magnetic Resonance Imaging (MRI) of the brain and spine showed numerous enhancing
parenchymal nodules (figure one). Brain or spinal biopsy was requested, but not recommended
by our Neurosurgery service. Lumbar puncture evaluation was performed. Cerebral spinal
fluid showed no bacterial or fungal elements. Both quantiferon gold for tuberculosis
and three consecutive sputum cultures for acid fast bacilli were negative. He continued
his Sirolimus and the intravenous immunoglobulin replacement was increased to two
grams/kg. The patient was cleared from respiratory isolation and discharged after
two weeks in our facility with mild improvement in his neurologic status.
Within five days he was sent to a nationally renowned hospital. At this facility,
extensive evaluation for his neurologic deficits were performed including culture
and PCR for bacteria, virus, mycobacteria from CSF bone marrow, lymph node, blood,
and induced sputum. These were noncontributory. He was given high dose corticosteroids
for two days. One of our facility’s sputum cultures was reported with acid fast bacilli.
But sputum mycobacterium tuberculosis PCR was negative. Repeat MRI scans of the brain
and spine showed improvement (figure 2), so no brain biopsy was performed.
He was sent back to our facility with the recommendation to start a targeted PI3Kinase
inhibitor on compassionate grounds as he was not eligible for the clinical trial because
his weight was less than 45 kg. But pretreatment abdominal CT revealed multiple low-density
lesions scattered throughout the liver (figure 3) not previously seen on prior noncontrast
CT four months prior.
Discussion: Although this gain in function mutation of the PI3Kδ signaling pathway
disorder has been well characterized, this is a rare report of a patient with PASLI
immunodeficiency with central nervous system and later liver lesions
(45) Submission ID#804175
MALT Lymphoma in a Patient with Autoimmune Lymphoproliferative Syndrome
Giulia Martone, MD, MSc1, Lehman Heather, MD2, Meghan Higman, MD, PhD3
1Resident, Pediatrics/University at Buffalo
2Clinical Associate Professor and Division Chief, Allergy/Immunology and Rheumatology/University
at Buffalo
3Clinical Assistant Professor, Hematology/Oncology, Pediatrics/University at Buffalo
Abstract/Case Report Text
Background: Autoimmune Lymphoproliferative Syndrome (ALPS) is a rare heritable disorder
of lymphocyte apoptosis. The majority of patients with ALPS have mutations in the
tumor necrosis receptor family 6 gene (FAS) and these mutations are typically located
within the intracellular death domain. Less frequently, FAS mutations outside of the
death domain result in reduced lymphocyte apoptosis and ALPS phenotype. Mucosa-Associated
Lymphoid Tissue (MALT) Lymphoma is a B-cell neoplasm, a type of indolent non-Hodgkin
lymphoma. While patients with ALPS are recognized to have increased risk of various
lymphomas, to date, no association has been reported in the literature with ALPS and
MALT Lymphoma. MALT Lymphoma etiology lies in accumulation of lymphoid tissue in non-traditional
sites, typically secondary to underlying inflammatory stimulus. It has been reported
in patients with chronic infection or autoimmune disorders.
Objective: To present a novel clinical case of ALPS with associated MALT Lymphoma
Results: The patient is a 24-year-old male diagnosed with ALPS clinically at age 8
years. He presented with inguinal and cervical lymphadenopathy, hepatosplenomegaly,
and hemolytic anemia, and was found to have 10.7% double-negative T cells. He originally
had increased total immunoglobulin levels, but from age 16 developed undetectable
IgG and IgA, with elevated IgM. His mother had ALPS phenotype and hypogammaglobulinemia,
and brother has ALPS phenotype with elevated immunoglobulins. Father and another brother
are unaffected. At age 22, the patient was hospitalized following a splenic laceration
in hockey. PET imaging showed subcarinal, mediastinal, retroperitoneal lymphadenopathy,
splenic enlargement to 23cm and bilateral lung nodules (Figure 1). Excisional biopsies
of left axillary and left lower lobe of lung were performed and showed low-grade B-cell
Lymphoma (Mucosal) and underlying lymphoproliferative disease.
Invitae ALPS and CVID panels (37 genes) revealed a heterozygous variant of unknown
significance in exon 3 of FAS (c.323A>G(p.Asp108Gly) Unlike most FAS mutations causing
ALPS, this mutation is in the extracellular region rather than the death domain2.
The c.323A>G variant has been reported in a single patient with ALPS phenotype, affecting
FAS protein function by inhibiting binding to FAS ligand (FAS-L), reducing FAS-L induced
apoptosis2. This FAS c.323A>G mutation was found in ALPS affected brother and was
absent in the unaffected father. The patient’s mother passed away prior to testing.
Since diagnosis, the patient’s MALT Lymphoma has been treated with rituximab weekly
for the first month and then monthly. He continues to receive monthly IVIG for hypogammaglobulinemia.
After two years, CT demonstrates a significant decrease in pulmonary nodules and splenomegaly
(Figure 2). The patient’s Forced Vital Capacity (FVC) improved from 3.78L (67% predicted)
to 4.39L (79% predicted).
Conclusion: We report the first case of MALT Lymphoma seen in a patient with ALPS.
It is unknown whether the unique FAS c.323A>G mutation in the non-death domain contributes
to MALT lymphoma progression. We propose MALT lymphoma is a malignant transformation
of chronic inflammation that has the potential to occur in patients with ALPS. In
the future, improved knowledge of mechanistic pathways of inflammation in lymphoma
development and progression is important in the optimal management of ALPS.
(46) Submission ID#804395
An Evolving Immune Phenotype in a Patient with Heterozygous RAC2 Deficiency
Kelli Williams, MD, MPH1, Michelle Hudspeth, MD2
1Assistant Professor of Pediatrics/Medical University of South Carolina
2Associate Professor of Pediatrics/Medical University of South Carolina
Abstract/Case Report Text
A Caucasian girl was born at 32 weeks gestational age due to preterm labor. The infant’s
initial and repeat TREC was undetectable on state newborn screen. Marked T cell lymphopenia
was confirmed with CD3 57 cells/μL, CD4 40 cells/μL, CD8 13 cells/μL (naïve CD4 7.3%,
naïve CD8 9.8%) and severe B and NK cell lymphopenia was also identified (CD16/CD56
83 cells/μL; CD19 12 cells/μL). Further immunologic evaluation revealed decreased
mitogen proliferation to PHA (63,798; control 96,090-358,179), IgG of 350 and undetectable
IgA and IgM. ADA and PNP were not decreased. The baby was started on atovaquone, fluconazole
and IVIG for prophylaxis. At age 3 weeks, the baby developed an erythematous umbilical
stump, erythematous ulcerative skin patches and plaques in her diaper area, and was
found to have E.coli bacteremia.
Next generation sequencing of a panel of 207 primary immunodeficiency genes was done
(Invitae) and identified a heterozygous variant in Rac2 (D57N), previously reported
to be pathogenic with a similar clinical phenotype of severe bacterial infection,
poor wound healing, umbilical stump abnormality, and severe T cell lymphopenia. Rac2
plays a critical role in neutrophil chemotaxis, rolling, adhesion, phagocytosis and
superoxide production. Experimental studies have shown the D57N missense mutation
a dominant negative effect on Rac2 function. This infant initially had a DHR with
fMLP stimulation that was significantly impaired (6.06% fMLP ox-DHR; MFI fMLP 1.19),
confirming her neutrophil dysfunction. She was switched to Bactrim for prophylaxis
at 8 weeks of life. At age 10 weeks, the patient developed severe neutropenia (ANC
280 cells/μL), which has persisted to this day.
In this rare immunodeficiency, prognosis of patients with Rac2 deficiency is uncertain.
While hematopoietic stem cell transplantation is the only potentially curative treatment
option, little is known about the natural history of this combined immunodeficiency.
This child has undergone transplant evaluation, which identified two 9/10 donors (both
HLA-A mismatches), one 8/10 donor, and one potential 5/6 cord blood unit). At the
current time, parents are not interested in transplantation. The father has been identified
as a possible mosaic with the D57N variant identified. He reports delayed wound healing,
but otherwise clinically well. Dad has deferred laboratory immune evaluation. Now
at age 1, this patient’s T cell counts and function have significantly improved naturally,
now with CD3 1657 cells/μL, CD4 1211cells/μL, CD8 386 cells/μ and normal lymphocyte
proliferation to mitogens. Her NK cells and B cells remain markedly decreased (44
and 91 cells/μL respectively). Her ANC remains severely low (350 cells/μL). Interestingly,
her neutrophil function also has improved somewhat (15.4% fMLP, MFI 1.23). She has
continued on prophylaxis with IVIG, Bactrim, and fluconazole and done well clinically.
She has had no further serious infections but has pronounced pathergy reactions with
any minor skin trauma.
(47) Submission ID#804727
Outcomes of Hematopoietic Stem Cell Gene Therapy for Wiskott-Aldrich Syndrome
Roxane Labrosse, MD1, Julia Chu, MD, MPH2, Myriam Armant, PhD3, Jet Van Der Spek,
MD4, Alexandra Miggelbrink, MD5, Johnson Fong, n/a6, John Everett, PhD7, Hayley Raymond,
n/a8, Lyanna Kessler, n/a8, Colleen Dansereau, MSN, RN, CPN9, Brenda Mackinnon, RN10,
Stephanie Koo, n/a11, Emily Morris, n/a11, Wendy London, PhD12, Ahmet Ozen, MD13,
Safa Baris, MD13, Jenny Despotovic, DO14, Lisa Forbes, MD15, Akihiko Saitoh, MD, PhD16,
Takayuki Takachi, MD17, Alejandra King, MD18, Mai Anh Thi Nguyen, MD19, Uyen Vy Vu
Do, MD19, Frederic Bushman, PhD20, Anne Galy, PhD21, Luigi Notarangelo, MD, PhD22,
David Williams, MD23, Sung-Yun Pai, MD24
1Post-Doctoral Research Fellow/Division of Pediatric Hematology/Oncology, Boston Children's
Hospital
2Assistant Professor/Dana Farber Cancer Institute/Boston Children's Hospital
3Instructor in Pediatrics/Boston Children's Hospital
4Post-Doctoral Fellow/Division of Hematology/Oncology, Boston Children’s Hospital
5Post- Doctoral Fellow /Division of Pediatric Hematology/Oncology, Boston Children's
Hospital
6Research Assistant/Division of Hematology/Oncology, Boston Children’s Hospital
7Bioinformatician/Department of Microbiology, Perelman School of Medicine, University
of Pennsylvania
8Research Assistant/Department of Microbiology, Perelman School of Medicine, University
of Pennsylvania
9Director of Clinical Operations/Gene Therapy Program, Dana-Farber/Boston Children’s
Cancer and Blood Disorders Center
10Research Nurse/Gene Therapy Program, Dana-Farber/Boston Children’s Cancer and Blood
Disorders Center
11Clinical Research Coordinator/Gene Therapy Program, Dana-Farber/Boston Children’s
Cancer and Blood Disorders Center
12Associate Professor of Pediatrics/Division of Pediatric Hematology/Oncology, Dana
Farber/Children's Hospital Cancer Center
13Professor/Marmara University
14Associate Professor/Texas Children's Hospital/Baylor College of Medicine
15Assistant Professor of Pediatrics/Texas Children's Hospital/Baylor College of Medicine
16Professor/Niigata University Graduate School of Medical and Dental Sciences
17Doctor/Department of Hematology and Oncology, Shizuoka Children's Hospital
18Member of the Immunology Unit/Hospital Luis Calvo Mackenna
19Doctor/Department of Hematology/Oncology, City Children's Hospital, Ho Chi Minh
City, Viet Nam
20Professor of Microbiology/Department of Microbiology, Perelman School of Medicine,
University of Pennsylvania
21Inserm Research Director/Genethon
22Chief, Laboratory of Clinical Immunology and Microbiology/National Institute of
Allergy and Infectious Diseases, NIAID/National Institutes of Health, NIH
23Senior Vice President and Chief Scientific Officer, Boston Children's Hospital/Division
of Hematology/Oncology, Boston Children’s Hospital
24Associate Professor/Division of Hematology/Oncology, Boston Children’s Hospital
Abstract/Case Report Text
Background Wiskott-Aldrich syndrome (WAS) is a rare X-linked disorder characterized
by combined immunodeficiency, eczema, microthrombocytopenia, infections, autoimmunity
and increased risk of hematological malignancies. Gene therapy (GT) using autologous
CD34+ cells is an emerging alternative treatment with possible advantages over standard
allogeneic hematopoietic stem cell transplant. We report the outcomes of a phase I/II
clinical trial in which 5 WAS patients underwent GT using a self-inactivating lentiviral
(SIN-LV) vector expressing the human WAS cDNA under the control of a 1.6kB fragment
of the human WAS promoter.
Subjects and Methods: Five patients with severe WAS (clinical score 3-5) were enrolled
(Table 1). CD34+ cells were transduced ex-vivo and re-infused after conditioning with
busulfan and fludarabine. Two subjects (P4, P5) had autoimmunity pre-GT, manifested
as skin vasculitis and autoimmune cytopenias.
Results: All subjects were alive at median follow-up of 5.1 (range 2.8-6.3) years.
Multi-lineage vector gene marking was sustained over time. All had clinical improvement
of eczema, infections and bleeding diathesis. WAS protein (WASP) expression was increased
over baseline but remained below normal levels. Proliferation of T cells in response
to anti-CD3 improved post-GT. Humoral immune deficiency improved, with normalization
of IgM, and independence from Ig replacement and vaccine responses in those tested.
Platelet levels increased to >50 x 103 cells/uL in only the two subjects with a VCN
≥2 in transduced stem cells. Podosome formation in monocyte-derived dendritic cells
was near absent pre-GT and improved in all subjects post-GT, but only reached healthy
control levels in the 2 subjects with highest VCN. In contrast to other trials using
this SIN-LV, two patients (P4 and P5) had flares of autoimmunity post-GT, offering
the opportunity to study the poorly understood mechanistic features of immune dysregulation
in this disease. Self-reactive VH4-34-expressing B cells and CD21lo B cells remained
elevated in most patients. However, despite WASP expression in FOXP3+ Tregs, those
with autoimmunity had poor numerical recovery of T cells and Tregs at the time of
clinical symptoms (Fig 1A). In addition, IL-10 producing regulatory B cells (Bregs)
were highly deficient pre-GT, recovered in subjects who did not experience autoimmunity,
but failed to recover in P4 and P5 (Fig 1B). Moreover, transitional B cells, which
are enriched in Bregs and are potent inducers of Treg populations, also recovered
poorly in those two subjects (Fig 1C).
There have been neither severe GT-related adverse events nor abnormal clonal expansion
in transgene-marked cells to date.
Conclusion
In summary, our data confirm and extend the safety and efficacy of GT in correcting
disease manifestations associated with WAS, with the longest overall follow-up reported
so far in studies using SIN-LV. In addition, our findings suggest that higher VCN
is needed in order to correct myeloid compartments such as platelets and monocytes.
Finally, we report the novel finding of the restoration of Bregs and suggest that
recovery of this compartment, along with Tregs, is protective against development
of autoimmunity post-GT. Overall, these data suggest a mechanism for breakdown of
immune tolerance in WAS with important therapeutic implications and prognostic value.
(48) Submission ID#804746
Recurrent Fever and Interstitial Lung Disease
Elisa Ochfeld, MD1, Megan Curran, MD2, Sergio Chiarella, MD3, Kaveh Ardalan, MD4,
Amer Khojah, MD5
1Fellow, Allergy and Immunology/Northwestern University
2Pediatric Rheumatologist/University of Colorado
3Attending Physician/Mayo Clinic
4Assistant Professor of Pediatrics, Rheumatology/Duke University
5Attending Physician, Assistant Professor/Division of Allergy & Immunology, Ann &
Robert H Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School
of Medicine, Chicago, IL
Abstract/Case Report Text
This is an 8-year-old Hispanic female who initially presented with failure to thrive,
recurrent fevers and intermittent cough with episodes of perioral cyanosis. Symptoms
started at age 6 months and were attributed to recurrent viral and bacterial infections.
At 14 months old, she was hospitalized with fever and hypoxemia (O2 saturations 70%).
CXR showed prominent interstitial lung markings and she was diagnosed with pneumonia.
CT scan confirmed CXR findings and ruled out anatomical anomaly. She was lost to follow
up for 2 years, and re-presented with worsening respiratory status. A repeat CT scan
demonstrated worsening interstitial thickening. Immune workup, including quantitative
immunoglobulins, CH50, lymphocyte subsets and vaccine response titers (pneumococcal
and tetanus), was unremarkable, except for elevated IgG levels. Genetic testing for
surfactant dysfunction mutations was negative. Thoracoscopic lung biopsy revealed
interstitial fibrosis, PAS-positive granular alveolar proteinosis, type II cell hyperplasia,
and lymphoid follicles. At age 6, she was admitted for a pericardial effusion. Rheumatology
was consulted for evaluation frequent fevers and persistently elevated inflammatory
markers, with concern that the pericarditis was autoinflammatory. She had an elevated
ANA (>1:2560 homogeneous pattern), IL-6 (378.88 pg/mL), and IgG (2020 mg/dL) at that
time. She had an atypical ANCA pattern with positive myeloperoxidase antibodies. Anti
dsDNA, Smith and Scl70 were negative. She was treated with steroids and hydroxychloroquine
with some improvement in her oxygen requirement. One year later she had an additional
episode of pericarditis, treated with colchicine. A few months later, she was admitted
with new-onset gross hematuria and elevated serum creatinine (to 2 mg/dl). Kidney
biopsy showed ANCA vasculitis with glomerulonephritis (75% crescents, no scarring
or fibrosis). She provisionally received a diagnosis of microscopic polyangiitis,
with lung and kidney involvement. She did not have peripheral vasculopathy. She was
started on cyclophosphamide, Rituximab, and IV steroid pulses. Cyclophosphamide was
discontinued due to recurrent episodes of posterior reversible encephalopathy syndrome
(PRES) after infusion. Her IgG level decreased as she developed nephrotic range proteinuria.
A primary immunodeficiency genetic panel was sent to evaluate for monogenic immune
dysregulation syndromes and revealed a TMEM173 gene mutation (c.463G>A) which has
previously been reported in 4 other subjects with SAVI (STING-associated vasculopathy
of infancy syndrome). STING is a cytosolic DNA sensor that leads to type I interferon
production upon stimulation. This gain-of-function mutation was confirmed by measuring
interferon signature gene expression at the NIH (Fig 1), and her diagnosis was revised
accordingly. The patient was started on a JAK-inhibitor (Tofacitinib) to block interferon
signaling. Unfortunately, the patient is now deceased, due to overwhelming infection
and multi-organ system failure. Conclusion: Genetic testing can be crucial in aiding
the diagnosis of complex patients with immune dysregulation and can provide an opportunity
for targeted therapy, which should be employed as soon as able to stop disease progression.
(49) Submission ID#804924
Disseminated Histoplasmosis in a Patient with PIK3CD
Amanda Holsworth, DO1, Nicholas Hartog, MD2
1Allergist/Clinical Immunologist/Spectrum Health/Helen DeVos Children's Hospital and
Michigan State University College of Human Medicine
2Attending Physician/Michigan State University College of Human Medicine
Abstract/Case Report Text
Background: Activated phosphoinositide 3-kinase δ syndrome (APDS-1) was first described
in 2013 as a monogenetic immune dysregulation syndrome with a variable phenotype.
Increased sinopulmonary and herpesvirus infections are well described, but fungal
infections such as candidiasis have been rare. To date, disseminated histoplasmosis
has not been described.
History: A 38 yo Caucasian male who was previously diagnosed with common variable
immunodeficiency (CVID) in late childhood due to recurrent sinopulmonary infections
presented with recurrent fever, pancytopenia, severe splenomegaly, and lymphadenopathy.
Urine histoplasmosis antigen and beta-D-glucan were elevated. A bone marrow biopsy
demonstrated granulomatous inflammation. Transbronchial biopsy of a subcarinal lymph
node was consistent with granulomatous disease. This led to a diagnosis of disseminated
histoplasmosis. He was treated with amphotericin B and then 11 months of itraconazole,
with improvement of his symptoms.
He was admitted to the hospital about 7 years later when he presented with fatigue,
fever, chills, dark urine, and scleral icterus. He was found to have an acute worsening
of chronic anemia with a hemoglobin of 4.7 g/dL. Due to elevated LDH, presence of
schistocytes on peripheral smear, and undetectable haptoglobin, he was diagnosed with
autoimmune hemolytic anemia, despite a negative direct Coombs. A bone marrow biopsy
specimen was hypercellular with marked erythroid predominance, with normal flow cytometry
and no blasts identified. Infectious workup was negative.
CT chest during the workup revealed new right hilar and mediastinal lymphadenopathy,
in addition to calcified right hilar and subcarinal lymph nodes, bronchiectasis, and
stable hepatosplenomegaly. Transbronchial biopsy of lymph nodes showed benign lymph
nodes with calcified necrotizing granulomata and presence of non-viable fungal species,
presumably “old” Histoplasmosis.
Family History: Family history was significant for mom dying at 29 years-old from
undefined CNS infection.
Immune Labs:
· Panlymphocytopenia: Absolute lymphocyte count of 380/uL, CD3+ T cells 283/uL, CD4+
174/uL, CD8+ 99/uL, CD19+ 65/uL, CD16+CD56+ 25/uL. CD4+/CD8+ ratio 1.8
· Decreased class-switched memory B cells and plasmablasts
· Elevated T central memory cells and activated (HLA-DR+) CD4+ and CD8+ T cells
· Hemoglobin 10.3 g/dL, platelets 77,000/uL, ANC ranging from 360/uL to 1610/uL
· IgA 107 mg/dL, IgM 273 mg/dL; reportedly had low IgG prior to initiating IVIG in
childhood
· EBV PCR and CMV PCR negative
Genetics:
· PIK3CD (c.3061G>A), consistent with diagnosis of autosomal dominant APDS-1.
Discussion: Gain-of-function variants leading to increased PI3kδ activity have been
shown to cause both B and T cell dysfunction, leading to impaired immunologic responses
to bacterial and viral infections. Recurrent sinopulmonary infections and herpesvirus
infections are commonly seen and while mucocutaneous candidiasis has been reported
in cohorts of patients with PIK3CD, other fungal infections are not common. Severe
disseminated histoplasmosis infections have been described in primary immunodeficiencies
characterized by signaling defects in the IL-12/IFN-γ pathway, STAT3 deficiency, CD40L
deficiency, GATA2 deficiency and in STAT1 gain-of-function mutations. To our knowledge,
disseminated histoplasmosis has not been previously reported in patients with PIK3CD
immunodeficiency.
(50) Submission ID#805384
Novel NBAS Mutation And Autoimmune Enteropathy
Silvia Ricci, MD1, Lorenzo Lodi, MD2, Canessa Clementina, PhD3, Francesca Lippi, PhD4,
Chiara Azzari, PhD5
1University Researcher/Paediatric Immunology Division
2Resident/Paediatric Immunology Division
3Consultant/Paediatric Immunology
4Consultant/Paediatric Immunology Division
5Professor/Paediatric Immunology Division
Abstract/Case Report Text
The reported case represents the first case of NBAS disease detected by newborn screening
program for primary immunodeficiency, based on KREC assay. The patient came to our
attention due to the complete absence of KRECs and normal TRECs on DBS (dried blood
spot) while hospitalized for low weight at birth (1,520 g), intolerance for enteral
feeding, hepatosplenomegaly, slightly elevated liver transaminase, head and face eczematous
dermatitis. During the 1st month, he also presented Klebsiella pneumoniae urinary
tract infection and methicillin-resistant Staphylococcus aureus sepsis. Peculiar phenotypic
features including triangular face, proptosis, flat philtrum, mild retrognatia, hirsutism,
loose and slightly wrinkled skin, and apparent reduction of subcutaneous fat were
noticed at birth. Complete blood count showed lymphocytopenia, marked hypereosinophilia.
Serum immunoglobulin G (IgG) were markedly decreased, IgA and IgM were undetectable.
Extended immune-phenotyping showed complete absence of CD19+ cells, low count of CD8+
lymphocytes, and reduced natural killer (NK) levels. At 9month of age a colonoscopy
was carried out for persistent diarrhea and reduced tolerance to enteral feeding.
The histological examination of mucosal intestinal biopsies showed signs compatible
with autoimmune enteropathy. For this reason immunosuppressive therapy with rapamycin
was started without consistent clinical amelioration. Many CVC-sepsis occurred in
the last months, associated with persistent gastrointestinal symptoms and severe growth
restriction. Despite the absence of experience data in literature for NBAS syndrome,
we retain that HSCT represents the only resolutive therapy for him.
(52) Submission ID#805795
CADINS in an Adult with Chronic Sinusitis and Atopic Disease
Neema Izadi, MD, MS1, Manish Butte, MD, PhD2, Timothy Thauland, PhD3, Joseph Church,
MD4
1Assistant Professor/Division of Clinical Immunology and Allergy, Children’s Hospital
Los Angeles/ Keck School of Medicine of USC
2Associate Professor/Division of Allergy, Immunology, and Rheumatology, University
of California Los Angeles
3Project Scientist/Division of Allergy, Immunology, and Rheumatology, University of
California Los Angeles
4Professor/Division of Clinical Immunology and Allergy, Children’s Hospital Los Angeles/
Keck School of Medicine of USC
Abstract/Case Report Text
Case: A 31-year-old female with asthma and allergies presented to immunology clinic
with a history of chronic fatigue and sinusitis. Fatigue occurred daily every 2-3
weeks and was described as not feeling rested even after 12 hours of sleep. Chronic
sinusitis required 4-5 prolonged antibiotic courses per year. Nasal cultures grew
Methicillin-sensitive and -resistant Staphylococcus aureus and Haemophilus influenzae
type b (Hib). Three separate sinus surgeries over the prior few years reduced her
sinus symptoms. Other infectious history was significant for recurrent urinary tract
infections with E. coli and Klebsiella, recurrent otitis media as a child, and a diagnosis
of transient hypogammaglobulinemia of infancy that resolved at 4 years of age.
Review of systems revealed axillary lymphadenopathy for 2-3 days twice per year not
related to infection. She had longstanding eczema that responded to topical tacrolimus,
multiple environmental allergies, and recently diagnosed asthma that improved with
inhaled Budesonide/Formoterol. As a teenager she received allergy immunotherapy for
a few years but stopped due to frequent adverse reactions. Family history revealed
that father died from cancer. Physical exam was unremarkable.
Laboratory evaluation demonstrated normal IgG 874 mg/dL, IgM 133 mg/dL, IgA 166 mg/dL,
elevated IgE 457 mg/dL, normal T and NK cell enumeration, mildly low total B cells
(180 cells/mcl, 5.6%), and normal B cell subsets (CD19+IgM+CD27- 67%, CD19+IgM+CD27+
17%, CD19+IgM-CD27+ 13%). Tetanus antibody titer was protective, but Hib antibody
titer was undetectable at < 0.15 mcg/mL with marginal response after vaccination (0.53
mcg/mL). Pneumococcal serotype specific IgG levels (Mayo) were mostly undetectable
with 3 of 23 serotypes protective at baseline and only 4 protective post vaccination
with Pneumovax 23. CD3/CD28 blastogenesis was poor. Due to poor antibody response
and continued sinus infections she was started on IgG replacement. Her fatigue and
sinus symptoms improved moderately but she continued to require antibiotics and sinus
CT scans continued to demonstrate significant disease. A focused exome sequencing
panel was pursued and a novel heterozygous CARD11 variant was found (c.215G>T, p.R72L).
Discussion: The CARD11/BCL10/MALT1 (CBM) complex is a critical signaling adapter that
facilitates several downstream immune responses predominately through NF-kB. Mutations
in several different domains of CARD11 result in a clinical entity collectively referred
to as CARD11-associated atopy with dominant interference of NF-kB signaling (CADINS).
CADINS is associated with a broad range of clinical manifestations but most have marked
atopy with infections, poor T cell proliferation, and varying levels of poor antibody
response.
Both our variant (p.R72L) and a previously reported pathogenic variant in the same
amino acid (p.R72G) involve a change from a charged arginine to a non-polar amino
acid in the critical BCL10/CARD11 binding interface. IκBα degradation was not present
in B cells from our patient (Figure 1) confirming the functional defect in NF- kB
signaling. Thus, we present a novel variant that fits CADINS both clinically and genetically.
Clinicians should be aware of CADINS when patients present with recurrent infections
in the setting of significant allergic disease.
Figure 1. Defective NF-kB activation in primary B cells from patient with CARD 11
variant (p.R72L). We performed an IκBα degradation assay for the patient compared
to a control. Unstimulated B cell populations are depicted in the left column. B cells
were stimulated with phorbol 12-myristate 13-acetate (PMA) for 20 minutes depicted
in the middle and right columns. The patient demonstrates absent IκBα degradation
compared to control. (Right column: light blue line = unstimulated, red line = PMA
stimulated).
I B degradation assay.
Stimulation: 200 μL of whole blood was stimulated in a 5 mL FACS tube with 50 ng/mL
phorbol 12-myristate 13-acetate (PMA; Sigma, Cat# P1585) at 37 °C for 5, 10, or 20
min, at which point 4 mL of pre-warmed 1X Lyse/Fix buffer (BD, Cat# 558049) was added.
Cells were fixed for 10 min at 37 °C, centrifuged and washed twice with FACS buffer
(PBS supplemented with 2% FBS and 1 mM EDTA). Staining and permeabilization: Fc receptors
were blocked for 5 min at RT (Human TruStain FcX; Biolegend), followed by a 20 min
stain on ice with anti-CD4 AF647 (clone RPA-T4; Biolegend), and anti-CD19 BV421 (clone
HIB19; Biolegend). Cells were washed with FACS buffer and permeabilized for 30 min
on ice with 1 mL Phosflow Perm Buffer II (BD Biosciences, Cat# 558052) that had been
pre-cooled to -20 °C. After permeabilization, two mL FACS buffer was added and the
samples were centrifuged. After three additional washes, the cells were stained with
anti-IкBα PE (clone 25/IkBa/MAD-3; BD Biosciences) for 30 min at RT. Samples were
washed three times and data were collected on a Cytek DxP10 flow cytometer. Data were
analyzed with FlowJo software.
(54) Submission ID#806340
The Importance Of Considering Monogenic Immune Disorders In Adults: New Diagnosis
Of Wiskott-Aldrich Syndrome In A 32-Year-Old Male
Peter Stepaniuk, MD1, Persia Pourshahnazari, MD2, R Robert Schellenberg, MD3, Catherine
Biggs, MD, MSc4
1Allergy and Immunology Fellow/Department of Medicine, University of British Columbia
2Clinical Instructor/Allergy and Immunology, Department of Medicine, University of
British Columbia
3Professor and Division Head/Allergy and Immunology, Department of Medicine, University
of British Columbia
4Clinical Assistant Professor/Allergy and Immunology, Department of Pediatrics, University
of British Columbia
Abstract/Case Report Text
Introduction: Wiskott-Aldrich Syndrome (WAS) is a rare, but well-defined X-linked
disorder. Loss-of-function mutations in the WAS gene result in classic WAS and X-linked
thrombocytopenia (XLT), while gain-of-function mutations lead to X-linked neutropenia
(XLN). Classic WAS phenotypic features include recurrent infections, microthrombocytopenia
and eczema along with increased susceptibility to autoimmune disorders and malignancy.
Most males with classic WAS are diagnosed in early childhood and early death can result
from its various clinical manifestations.
Case: We present a 32-year-old male who was referred to immunology for hypogammaglobulinemia.
As an infant he had moderate eczema, and at the age of two was diagnosed with immune
thrombocytopenia (ITP) with baseline platelets of 50-60 x 10^9/L. Infectious history
was notable for one episode of pneumosepsis and recurrent otitis media, influenza,
and herpes labialis infections. Around the age of 22, he was diagnosed with common
variable immunodeficiency (CVID) based on the finding of low immunoglobulins. He developed
diffuse large B cell lymphoma at age 26, and was treated with cyclophosphamide, doxorubicin,
vincristine, prednisone and rituximab (CHOP-R). At age 32 he developed abdominal pain
with bloody stools. Investigations confirmed an endoscopic and pathologic diagnosis
of ulcerative colitis. Due to the severity of his disease, he has required maintenance
therapy with vedolizumab. He was again noted to have hypogammaglobulinemia at which
point he was referred to immunology at our centre. There was no significant family
history of immunodeficiency, malignancy or autoimmunity. Blood work was notable for
normal white blood cell and lymphocyte counts, platelets of 60 x 10^9 g/L, low IgG
at 4.82 g/L (7.0-16.0 g/L) with normal IgA, IgM and IgE. Lymphocyte subsets including
T, B and NK cells were within the normal range. Genetic testing was performed and
he was found to have a known pathogenic mutation in the WAS gene (c.1453G>A, p.Asp485Asn)
which has been previously reported in association with WAS and XLT. He has since been
placed on immunoglobulin replacement and has been referred for consideration of hematopoietic
stem cell transplantation.
Discussion: WAS is a rare syndrome that can have a similar phenotype to other immunodeficiency
disorders including CVID, Omenn syndrome and IPEX (immune dysregulation, polyendocrinopathy,
X-linked). Individuals with CVID present with hypogammaglobulinemia and recurrent
infections, and these individuals also have an increased susceptibility to autoimmune
disorders, gastrointestinal disease and malignancies, especially lymphoma. Although
eczema is a common disorder, its presence in addition to features of early onset thrombocytopenia,
immunodeficiency, autoimmunity and/or malignancy in male patients should heighten
the suspicion for WAS. It is important to make the diagnosis of WAS as hematopoietic
cell transplantation and gene therapy are potentially curative treatment options.
(55) Submission ID#806348
Secondary Immune Deficiencies in Hematological Malignancy: Developing International
Consensus on Patient Assessment and Selection for Immunoglobulin Replacement Therapy
(IgRT)
Stephen Jolles, MD, PhD1, Mauricette Michallet, MD2, Carlo Agostini, MD3, Michael
Albert, MD4, David Edgar, MD, FRCP, FRCPath5, Roberto Ria, MD6, Livio Trentin, MD7,
Elisabeth Clodi, PhD8, Vincent Lévy, MD9
1Consultant Clinical Immunologist & Honorary Professor/University Hospital of Wales,
Cardiff, UK
2Clinical Hematologist/Université Claude Bernard Lyon, France
3Department Head, Full Professor of Internal Medicine/Padua Unversity, Ca' Foncello
Internal Medicine 1st and Center for Immunologic and Respiratory Rare Diseases
4Head Pediatric SCT Program/Dr. von Haunersches University Children's Hospital, Munich,
Germany
5Consultant Immunologist & Clinical Associate Professor/St James’s Hospital & Trinity
College Dublin, Ireland
6Associate Professor of Internal Medicine/“Aldo Moro” Medical School, University of
Padua, Italy
7Associate Professor of Hematology/Department of Medicine-DIMED, University of Padua,
Italy
8Senior Global Medical Advisor/Octapharma PPG
9Clinical Hematologist/Hôpitaux Universitaires Paris-Seine-Saint-Denis, France
Abstract/Case Report Text
Secondary immune deficiencies (SID) are caused by varied mechanisms and are common
in patients with hematological malignancies such as chronic lymphocytic leukemia (CLL)
and multiple myeloma (MM). In this setting, both the disease and its treatment (such
as B cell ablation therapy) contribute to the development of secondary antibody deficiency.
Infections remain a major cause of morbidity and mortality in CLL and MM patients.
This underscores the need for early recognition and stratification of risks in order
to guide appropriate treatment, including immunoglobulin replacement therapy (IgRT).
New guidelines for the use of human normal immune globulins in SID patients were implemented
by the European Medicines Agency (EMA) in 2019. Despite these new guidelines, significant
variations remain across European countries in the assessment and approaches aiming
to achieve reduction in infection burden, including different strategies for initiation,
dosing and discontinuation of IgRT. The same is true for North America where IgRT
is widely used off-label to prevent infections in patients with SID due to hematological
disease or other reasons.
In order to address this variability, a Task Force comprising both Immunologists and
Hemato-Oncologists drafted 20 statements aiming to test for consensus. Statements
were related to six major areas: Definition of infections, Measuring IgG levels, Initiating
IgRT, IgRT dosing, SCIg usage and Discontinuing IgRT. This was followed by an international
Delphi consensus exercise in three rounds which aimed to develop recommendations on
how to diagnose, treat and follow-up patients with antibody deficiency associated
with hematological malignancies. The first Delphi round consisted in testing the 20
statements with a panel of SID specialists and subsequently their comments were used
by the Task Force to refine the statements.
In the second Delphi round, the refined statements were presented via phone interviews
to the same panel to assess their level of agreement with each statement (ranging
from 1 “I totally disagree” to 6 “I totally agree”).
Consensus was considered to be reached per statement if 70% of the experts agreed
with each statement overall.
The cut-off for overall agreement was 4 “I somewhat agree”. If the expert chose level
4 or less the reasons underpinning his/her choice were discussed. Consensus was achieved
for all statements on level 4 (“I somewhat agree”). Only 5 statements did not achieve
consensus on level 5 “I mostly agree”.
In Delphi Round 3, panelists who had not “mostly agreed” with these five statements
were given the opportunity to reconsider their assessment based on the feedback from
other panelists, which was shared with them. The panelists then chose to maintain
or refine their assessment.
Analysis of the full results on the six key areas identified by the Task Force will
be presented at the conference to offer recommendations and help guide the management
of SID in patients with hematological malignancies.
(56) Submission ID#806376
Liquid versus Semi-Solid Culture Medium for Differentiation of Human Mast Cells from
Hematopoietic Stem Cells in Bone Marrow
A. Yasemin Göksu-Erol, MD1, Ersin Akıncı, PhD2, Hilmi Uysal, MD3, Devrim Demir Dora,
PhD4, Ozan Salim, MD5
1Assoc. Prof. Dr., MD/Akdeniz University, Faculty of Medicine, Histology and Embryology
Department
2Assist. Prof./Akdeniz University, Faculty of Agriculture, Department of Agricultural
Biotechnology. Head of Enzyme and Microbial Biotechnology Division.
3Prof./Akdeniz University, Faculty of Medicine, Department of Neurology
4Assist. Prof./Akdeniz University, Faculty of Medicine, Department of Pharmacology
5Akdeniz University, Faculty of Medicine, Department of Internal Medicine, Division
of Hematology
Abstract/Case Report Text
Introduction: Mast cells (MCs) are hematopoietic-derived immune cells, whose precursors
migrate within tissues reaching maturation and differentiation. Masitinib, a selective
tyrosine kinase inhibitor, is efficient in controlling the survival, differentiation,
and degranulation of MCs.
Aim: To optimize mast cell-differentiation from human bone marrow (BM) hematopoietic
stem cells, and to find best cell culture conditions for proliferation, differentiation,
and maintenance of MCs, which is important when studying particularly MCs’ response
to cytotoxic compounds.
Material-Methods: To produce MCs in vitro, the first method (M1) we used was a modified
semi-solid culture method (1). Briefly; human BM mononuclear cells (MNCs) were obtained
with Ficoll gradient from BM sample of a patient with idiopathic thrombocytopenic
purpura. Colony-forming unit (CFU)-mast was developed from MNCs in methylcellulose
medium supplemented with SCF (200ng/ml) + IL-6 (50ng/ml), and IL-3 (1ng/ml; only first
week). 5-6 weeks later mast cell colonies were transferred into suspension cultures,
in which MCs matured and multiplied up to 7-8 weeks and were used in experiments till
10th week of culture. On the other hand, in our second method (M2); MNCs were separated
by Ficoll, seeded in 6 well-plates with IMDM containing FBS 2%, Pen/Strep, and a little
amount of methylcellulose, and incubated at 37oC, 5%CO2. Cultures were then supplemented
with IMDM (FBS 1%) + SCF (100ng/ml) + IL-6 (50ng/ml) on day 4; and IMDM (FBS 2%) +
SCF (100ng/ml) + IL-6 (50ng/ml) + IL-3 (1ng/ml) on day 9. Beginning on day 18 till
the end, IMDM (FBS 2%) + SCF (100ng/ml) + IL-6 (50ng/ml) were added to cultures.
For both methods, morphological assessment of colonies/cells were evaluated under
an inverted microscope (Figure 1 and 2). Verification of MCs was performed by immunoflorescence
staining for anti-tryptase and -chymase antibodies, and by toluidine blue staining.
Macrophages were verified by anti-CD-68 immunoflorescence staining. MCs were exposed
to masitinib or DMSO for the evaluation of dose-related effects of masitinib, and
cytotoxicity was evaluated by MTT assay.
Results: In M2, culture conditions were easier to handle compared to M1. In M2, high
amounts of MCs in immature and pre-mature forms were appeared as early as 15-18 days,
and peak levels of proliferation rate was around 2-4 weeks of culture, which was about
3 weeks earlier than M1. Culture could be maintained till 10 weeks in both methods.
Although MCs are non-adherent cells, in liquid method adherent BM cells such as fibroblasts,
endothelial cells and mesenchymal stem cells have adhered to the plate and grown up,
providing an attachment site for MCs and serving as a natural BM nest, mimicking in-vivo
environment, for MCs to grow and proliferate (Figure 2). Attachment of MCs has provided
medium exchange available without changing culture dishes. When MCs were exposed to
masitinib (0.5, 1, and 2 μM/μl), approximate survival rates were 75%, 72%, 69%, respectively.
Discussion: In our liquid medium method, the adherent BM cells not only provided a
natural nest supporting MC development and differentiation, they also served as an
attachment site for MCs. As the cells slightly adhered, when trypsinized shortly,
they easily detached and used for experiments. And we also report for the first time
that adding a little amount of methylcellulose to the liquid medium provides ease
of aggregation of CFUs, and easy development of MCs. We suggest that our liquid culture
may be superior to semi-solid method, that it is faster and easier to handle.
Ref. 1. Ozdemir O. Evaluation of human mast cell-mediated cytotoxicity by DIOC18 target
cell labeling in flow cytometry. Journal of Immunological Methods. 319, 98–103; 2007.
Figures:
Fig. 1 Day 16. Liquid method (M2): Slightly attached massive mast cells in immature
forms are seen (x50).
Fig. 2. Day 28. Liquid method (M2): Slightly attached mast cells in pre-mature and
mature forms are seen. Some attached BM cells are also visible (x400).
(57) Submission ID#806440
Pharmacokinetic Modeling and Simulation of Subcutaneous and Intravenous IgG Dosing
in Primary Immunodeficiency Patients
Graciela Navarro-Mora, PhD1, Joan Alberti, PhD2, Juan Vicente Torres, MSc3, Jaume
Ayguasanosa, MD4, Antonio Paez, MD5, David Vilardell, MD, CPT, MSc & BSc6, Elsa Mondou,
MD7
1PK/PD Modeler/Syntax for Science
2DMPK Director/Syntax for Science
3Senior Statistician, Chief Executive Officer/Syntax for Science
4Senior Manager, Clinical and Medical Affairs/Grifols
5Director of Research/Grifols
6Medical Manager Clinical Trials/Grifols
7Medical Director/Grifols
Abstract/Case Report Text
A population pharmacokinetic (PopPK) analysis was conducted on data from 3 studies
performed in the United States (US) and Canada. In all 3 clinical studies treatment-experienced
primary immunodeficiency (PI) patients received intravenous (IV) doses of Immune Globulin
Injection (Human), 10% Caprylate/Chromatography Purified (IGIV-C 10%) in the Run-in/IV
Phase. In 2 studies subjects crossed over to subcutaneous (SC) IGIV-C 10%, and in
the third study crossover was to Immune Globulin SC (Human), 20% Caprylate/Chromatography
Purified (IGSC 20%).
A total of 95 PI patients from these 3 studies were included in the PopPK analysis
and 1841 serum IgG concentrations were included in the final PK analysis. The PK of
IgG following IV and SC administration was adequately described by a two-compartment
model with first-order elimination from the central compartment. Administration of
IGIV was modeled as an infusion directly into the central compartment. Absorption
of exogenous IgG from the depot site of SC infusions into the central compartment
was modeled as a first-order process with an absorption rate constant (KA). The full
model was constructed by incorporation (forward selection process) of covariates of
interest into the model. After completion of the covariate model development, the
final model showed that IgG PK was not influenced by (a) the IGSC formulation used
in the different studies (10% vs. 20%), (b) gender, and (c) age (pediatric vs. adult).
Body weight was identified as a significant covariate having an effect on clearance
and volume of distribution.
Based on the final PK results, serum clearance of IgG for the reference population
was estimated to be 0.150 L/day. The volume of distribution of the central and peripheral
compartments accounted for 3.06 L and 1.93 L, respectively. The inter-compartmental
clearance was 0.474 L/day, and the absorption constant from the depot (KA) was 0.246
day-1. The absolute bioavailability of IgG after SC administration was calculated
as 70.5%.
The developed method was used to evaluate alternative dosing intervals following SC
administration. The equivalent of a weekly IGSC maintenance dose administered 1, 2,
3, 5, or 7 times per week, or biweekly produced overlapping steady-state concentration–time
profiles and similar area under the concentration versus time curve (AUC), maximum
concentration (Cmax), and minimum concentration (Cmin) values. The results of the
evaluation and simulations for IgG exposure following a switch from IGIV-C 10% dosing
(every 3- or 4-weeks) to SC dosing further suggest that a range of dose-adjustment
factors (DAF), from 1:1 to 1:1.37 would be sufficient to provide clinically effective
trough IgG concentrations throughout the course of treatment at various treatment
frequencies.
Current US product labeling for IGSC 20% specifies a DAF of 1:1.37 for transitioning
immune globulin dosing from IV to SC, and specifies IGSC 20% dosing frequencies of
weekly or more frequently (2-7 times per week).
In this PopPK analysis all SC dosing regimens evaluated theoretically would provide
viable alternative administration options for maintaining adequate immunoprotection
in PI patients with dosing flexibility over a range of regimens.
(58) Submission ID#806511
Canakinumab for the Management of Autoinflammatory and Multifactorial Disorders in
Brazil: A Single Center Retrospective Analysis
Leonardo Mendonca, MD1, Fabio Morato Castro, MD, PhD2
1PhD/Clinica Croce, Institute for Advanced Medicine (IMA-Brazil), São Paulo, São Paulo,
Brazil
2Professor/Clinica Croce, Insitute for Advanced Medicine (IMA-Brazil), São Paulo,
São Paulo, Brazil
Abstract/Case Report Text
Background and aims: The immunological concept of autoinflammation made possible development
of new cytokine target therapies and catalogue Autoinflammatory Diseases (AID). However,
in 50% or more, no causative gene can be found going down to Undefined Inflammatory
Syndromes (UIS). Anti-IL1 drugs (AIL1D) revolutionized some IL-1 mediated diseases,
such as TRAPS, CAPS, Hyper-IgD/MKD and FMF. Nevertheless, treatment response among
disorders are not the same as well as no specific study was designed for UIS. Papa
et al, 2019, recently suggested the use of anakinra for the treatment of UIS, especially
those refractory/intolerant to colchicine with severe or very symptomatic phenotype.
This paper aims to retrospectively report for the first time the experience with canakinumab
in monogenic and multifactorial disorders in a single, private center in Brazil. Patient
and Methods: Patients’s records that received canakinumab from January 2016 to December
2019 at Clinica Croce, IMA-Brazil, were revised. Demographic and clinical data were
extracted and descriptively described. All statistical analysis are presented as:
average (minimal; maximum; standard deviation). Results: A total of 23 patients with
autoinflammatory diseases were enrolled and 65% (n=15) are female. Of them, 65% (n=15)
patients had a monogenic disease: 26% (n=6) CAPS, 21% (n=5 FMF), 4% (n=1) MKD, 4%
(n=1) homozygous NLCR4 and 4% (n=1) PAMI syndrome. Multifactorial disorders were 39%
(n=9) patients : 8% (n=2) Recurrent Idiopatic Pericarditis, 8% (n=2) Schnitizler Syndrome
and 21% (n=5) UIS. The average age of the first symptoms was 12,51 years (0;69;19,78)
and the average age of diagnosis was 24,43 years (0;72;21,76) while the aveage of
diagnosis delay was 11,59 years (1;59;15,16). All patients had used, prior to anti-IL1,
corticosteroids with 100% prevalence of Cushing Syndrome and 69% (n=16) tried at least
one steroid sparing agent without clinical success due to: intolerance or non-effective
disease control or side effects. In the FMF group (n=5) 100% tried colchicine prior
to canakinumab and this drug was not effective to 60% because of amyloidosis status
and in 40% colchicine-induced hepatitis was observed. Canakinumab was effective for
disease control in 75% (n=23) considering: control of clinical manifestations, amyloidosis
reversion and normalization of acute reactants markers. The only side effect observed
during the follow up were acute flu-like symptoms and psicomotor agitation (33,34%
, n = 8). The average time of follow up is of 12,51 months (1;37;12,46). Canakinumab
could be discontinued in just one patient with UIS. Conclusions: This is the first
report of Canakinumab use for autoinflammatory disorders in Brazil. Canakinumab is
an effective and safe drug for monogenic and multifactorial disorders control. No
serious adverse effect could be observed in the 3 years maximum follow up of this
drug. Neither, no specific infectious disease more prevalent in south America, such
as yellow fever, dengue, zika or chikungunya was observed.
(59) Submission ID#806681
Mediastinal Mass in Patient with Hyper-IgM Syndrome Type 2
Tejaswi Dittakavi, DO1, Renee Wakulski, BS2, Javeed Akhter, MD3, Li Yanxia, MD3
1Resident Physician/Advocate Healthcare
2Medical Student/Midwestern College of Osteopathic Medicine
3Physician/Advocate Healthcare
Abstract/Case Report Text
A 21-year-old caucasian male with autosomal recessive Hyper IgM syndrome Type 2 (HIGM2)
due to AICDA mutation, diagnosed at age 1, presented with a newly developed mediastinal
mass. He receives routine IVIG, pulmonary function tests (PFT’s) and chest x-rays.
At age 16, patient was noted to have cervical and inguinal lymphadenopathy. CT scan
indicated left mediastinal, hilar and pleural lymphadenopathy with soft tissue infiltration
around the descending thoracic aorta and esophagus. Biopsy indicated no evidence of
a lymphoma or infection.
5 years after initial workup, routine PFT’s showed a declining diffusion capacity
by 50%. Patient complained of intermittent chest pain but displayed no clinical symptoms
of cough, dyspnea, dysphagia or reflux. CT scan which revealed an extensive ill-defined
soft tissue mass extending from the thoracic outlet to the level of the esophageal
hiatus that encased vascular structures resulting in narrowing and occlusion of left
upper lobe pulmonary artery and left lower lobe pulmonary arteries respectively. Imaging
demonstrated homogenous ventilation to bilateral lungs and decreased perfusion in
the left lung compared to the right lung. Infectious workup was negative for atypical
infections.
Biopsy revealed miced cellular infiltrate with no predominenant cell type or evidence
of malignancy, consistent with previous lymph node biopsy 5 years prior. CD20 and
CD3 stains revealed aggregates and scattered B-cells and T-cells, respectively. Removal
of mass was proposed but due to the ambiguous borders and location, surgical excision
was not possible.
Patient was given 4 doses of Rituximab (75g), 3 doses 10mg/kg pulse steroids 18 hours
apart, and daily sirolimus (level was adjusted based on sirolimus level). Follow-up
CT scan indicated significant interval improvement with 50-60% reduction of the soft
tissue mass. Blood flow in the left lower lobe pulmonary artery has still not returned.
This may be due to collaterals and may be a separate problem from compression due
to the mass.
1177 and 1175:
These two images show the mediastinal mass with extensive fibrosis and chronic lymphocytic
infiltrate composed of small sized lymphocytes, plasma cells, histiocytes and occasional
eosinophils
1178 and 1179:
These two images show a lymph node biopsy with surrounding fibrosis and chronic inflammation
(61) Submission ID#806742
Campylobacter species Infections as a Complication of CTLA4 Haploinsufficiency Associated
Enteropathy
Jenna Bergerson, MD, MPH1, Amy Rump, CRNP2, Kate Howe, PA3, Alexandra Freeman, MD4,
Gulbu Uzel, MD5
1Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Division of Intramural
Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD,
USA
2Nurse Practitioner/Leidos Biomedical Research, Inc.
3Physician Assistant/LCIM/NIAID/NIH
4Senior Clinician/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH
5Staff Clinician/Laboratory of Clinical Immunology and Microbiology (LCIM), Division
of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases
(NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
Abstract/Case Report Text
Introduction:
Cytotoxic T-lymphocyte antigen 4 (CTLA-4) is an inhibitory immune regulator critical
for governing T and B cell homeostasis. Heterozygous CTLA4 mutations can cause a syndrome
of immune dysregulation with a variable clinical phenotype including hypogammaglobulinemia
, autoimmune cytopenia and endocrinopathies, lymphoproliferation, predisposition to
malignancy, tissue specific lymphocytic infiltration of brain, lung and GI tract as
well as colitis.
Methods:
We retrospectively reviewed medical records of all patients with CTLA4 haploinsufficiency
evaluated at the NIH between 2014-2019. A pathologic variant in CTLA4 was confirmed
in all patients. We analyzed frequency of Campylobacter species detected in the stool
samples by PCR based Biofilm Rapid array as well as reflex bacterial stool and blood
cultures when available.
Results:
Forty-six patients aged 8-75 years were evaluated at the NIH between 2014 and 2019.
Six of 46 patients (13%) had at least one episode of Campylobacter species associated
acute or worsening diarrhea, with one patient also having Campylobacter bacteremia.
All patients with positive Campylobacter species in stool samples had clinical histories
and/or endoscopic biopsy findings consistent with enteropathy or colitis predating
the incidence of Campylobacter infection. Two of the six patients (33%) had recurrent
or chronic Campylobacter infection, while four of the six patients (67%) had multiple
gastrointestinal pathogens detected by stool pathogen screening at various times.
Conclusions: Campylobacter species infection of the gastrointestinal tract seem to
occur at an increased incidence in our CTLA4 haploinsufficient cohort. To the best
of our knowledge, this is the initial report for the association between CTLA4 haploinsufficiency
and Campylobacter species infection of the gastrointestinal tract. Although CTLA-4
is a critical immune checkpoint involved in mucosal immune homeostasis and gut microbiota-immune
system cross talk, the underlying mechanism predisposing to Campylobacter infection
in CTLA-4 deficient patients remains to be explored. Our study suggests screening
of stool for Campylobacter species in patients with CTLA4 haploinsufficiency associated
enteropathy.
(62) Submission ID#806771
IKAROS Dimerization Defects Associated With Hematologic Cytopenias and Malignancies
Hye Sun Kuehn, PhD1, Sara Ciullini Mannurita, MSc2, Tala Shahin, n/a3, Julie Niemela,
MS, MLS4, Jennifer Stoddard, BS, MLS5, Mary Hintermeyer, APNP6, Raul Jimenez Heredia,
PhD7, Mary Garofalo, RN8, Laura Lucas, CPNP, MSN, RN9, Annalisa Tondo, MD10, Sylvain
Latour, PhD11, James Verbsky, MD, PhD12, John Routes, MD13, Charlotte Cunningham-Rundles,
MD, PhD14, Kaan Boztug, MD15, Eleonora Gambineri, MD16, Thomas Fleisher, MD. PhD17,
Shanmuganathan Chandrakasan, MD. PhD18, Sergio Rosenzweig, MD, PhD19
1Staff Scientist/Immunology Service, Department of Laboratory Medicine, Clinical Center,
NIH, USA
2Researcher, Lab Technician/Anna Meyer Children's Hospital, Hematology/Oncology Department/
University of Florence, NEUROFARBA Department, Florence, Italy
3Predoctoral Fellow/Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases,
Vienna, Austria
4Medical Laboratory Technologist/Immunology Service, Department of Laboratory Medicine,
Clinical Center, NIH, USA
5Medical Laboratory Scientist/Immunology Service, Department of Laboratory Medicine,
NIH, USA
6Staff Member, Allergy and Clinical Immunology/Children's Wisconsin
7Technical assistant/St. Anna Children's Hospital and Children's Cancer Research Institute,
Department of Pediatrics, Medical University of Vienna, Vienna; Ludwig Boltzmann Institute
for Rare and Undiagnosed Diseases, Vienna; CeMM Research Centre for Molecular Medicine
of the Austrian Academy of Sciences, Vienna, Austria
8Staff Member/Primary Immunodeficiency Clinic, National Institutes of Health, Bethesda,
MD
9Pediatric Nurse Practitioner/Division of Bone Marrow Transplant, Immunedysregulation
and Immuno-hematology Program, Aflac Cancer and Blood Disorders Center, Children's
Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
10Medical Doctor/Anna Meyer Children's Hospital, Hematology/Oncology Department, Florence,
Italy.
11Professor/Laboratory of Lymphocyte Activation and Susceptibility to EBV Infection,
INSERM UMR 1163, Paris, France.
12Associate Professor/Medical College of Wisconsin
13Professor/Medical College of Wisconsin
14Professor of Medicine and Pediatrics/Icahn School of Medicine at Mount Sinai
15Director LBI-RUD/St. Anna Children's Hospital and Children's Cancer Research Institute,
Department of Pediatrics, Medical University of Vienna, Vienna; Ludwig Boltzmann Institute
for Rare and Undiagnosed Diseases, Vienna; CeMM Research Centre for Molecular Medicine
of the Austrian Academy of Sciences, Vienna, Austria; Department of Pediatrics and
Adolescent Medicine, Medical University of Vienna, Vienna, Austria
16Assistant Professor/University of Florence, NEUROFARBA Department/Anna Meyer Children's
Hospital, Hematology/Oncology Department, Florence, Italy
17Former Chief/Immunology Service, Department of Laboratory Medicine, Clinical Center,
NIH, USA
18Assistant Professor/Division of Bone Marrow Transplant, Immunedysregulation and
Immuno-hematology Program, Aflac Cancer and Blood Disorders Center, Children's Healthcare
of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
19Senior Investigator; Chief/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center, Bethesda, MD, USA
Abstract/Case Report Text
IKAROS transcription factor and IKAROS family members are critical for development
of lymphocytes and other blood cell lineages. Full length IKAROS (isoform 1) contains
six C2H2 zinc fingers (ZF), four N-terminal DNA binding ZF and two C-terminal dimerization
ZF. Somatic IKAROS mutations and deletions have been associated with increased predisposition
to B- Acute lymphoblastic leukemia (ALL) as well with poor disease prognosis. Recently,
germline IKAROS mutations affecting the N-terminal DNA binding domain and acting in
a haploinsufficiency or dominant negative manner were reported to be associated with
common variable immunodeficiency (CVID) and combined immunodeficiency (CID), respectively.
Herein we describe a novel set of germline heterozygous IKAROS allelic variants affecting
the C-terminal dimerization domains in four unrelated families. Clinical manifestations
include hematopoietic cytopenias presenting as Evans syndrome, and hematologic malignancies
including T-cell ALL and Burkitt lymphoma; other manifestations observed were B-cell
lymphopenia and hypogammaglobinemia, but recurrent or severe infections were not prevalent
or characteristic. We demonstrate that mutants affecting dimerization abolish IKAROS
homodimerization as well as heterodimerization with IKAROS family members AIOLOS and
HELIOS. These variants also affect DNA binding at dimerization sites and pericentromeric
targeting. Opposed to previous allelic variants reported, dimerization changes alter
post-translational sumoylation and gene transcription regulation. Our data show that
mutations affecting IKAROS dimerization are mainly associated with cytopenias and/or
malignancies, have a different mechanism of action than previously reported variants,
present with incomplete clinical penetrance, and contribute to the growing spectrum
of genotype-phenotype IKAROS associated diseases.
(63) Submission ID#806826
Secondary And Incidental Findings in A Cohort of Patients with Immune-Mediated Disease
Undergoing Exome Sequencing
Michael Setzer, ScM, CGC1, Morgan Similuk, ScM, CGC2, Magdalena Walkiewicz, PhD3,
Steven Holland, MD4
1Genetic Counselor/National Institute of Allergy and Infectious Diseases, National
Institutes of Health; Medical Science and Computing, LLC
2Genetic Counselor/National Institute of Allergy and Infectious Diseases, National
Institutes of Health
3Certified Molecular Geneticist/National Institute of Allergy and Infectious Diseases,
National Institutes of Health
4Director, Division of Intramural Research; Chief, Immunopathogenesis Section/Laboratory
of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR),
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH), Bethesda, MD, USA
Abstract/Case Report Text
Introduction: There has been much discussion regarding the return of secondary findings
in genetic sequencing research. Opinions differ on whether researchers should return
secondary findings to participants at all and if so, what the best method is to do
so. We have opted to systematically identify and return pertinent secondary findings
to participants in our cohort of patients with immune-mediated diseases that undergo
exome sequencing. Additionally, exome sequencing may determine multiple or other genetic
diagnoses in addition to the primary diagnosis, which we call “incidental findings.”
Here, we discuss the secondary and incidental findings discovered in our cohort thus
far.
Methods: Individuals in our protocol underwent consent for exome sequencing, including
a discussion of the possibility of secondary findings. Exome sequencing data was analyzed,
and variant pathogenicity was scored using the ACMG criteria (Richards et al); Variants
determined to be likely pathogenic, pathogenic, or otherwise clinically important
were confirmed via CLIA-certified sanger sequencing. Confirmed variants were returned
to participants. We then queried internal databases for cases involving secondary
and incidental findings.
Results: As of November 2019, exome sequencing, interpretation and reporting had been
completed for 629 participants. We detected a total of 18 secondary findings in 17
(2.7%) participants, including variants in APOB, BRCA1(2), BRCA2 (5), DSP, FBN1, KCNH2,
LDLR, MYBPC3 (2), RYR1, PKP2 (2), and VHL. Additionally, we detected possible dual/multiple
genetic diagnoses in 18 (2.9%) participants, some of which explained an unusual clinical
presentation or symptom. These included individuals with variants in multiple immune-related
genes, including one individual with variants in GATA2 and TNFRSF1A, and those with
variants in genes related to multiple organ systems, including an individual with
variants in IFNGR1 and SCO2.
Discussion: Exome sequencing in this cohort detects not only important secondary findings,
but also discovers a significant portion of individuals with multiple genetic diagnoses.
Notably, exome sequencing may provide further context or explanation for unusual phenotypic
presentation and help determine specific symptom etiology even when a primary genetic
etiology is already known. Additionally, these secondary and incidental finds may
be important to consider when delineating risks and symptoms of novel or recently-discovered
conditions.
(64) Submission ID#806856
Utilizing Advanced Practice Providers In A Multidisciplinary Clinic Focused On Care
Of Patients With Immune Dysregulation And Lymphoproliferative Disorders
Ashley Reiland, MS, APRN, FNP-C1, Lisa Forbes, MD2, Carl Allen, MD3, Chelsey Hood,
RN4, Jacqueline Kuna, RN4, Olive Eckstein, MD5, Nitya Gulati, MD5
1Nurse Practitioner/Texas Children's Hospital/Baylor College of Medicine
2Assistant Professor/Department of Pediatrics, Baylor College of Medicine, Houston,
TX, USA and Texas Children’s Hospital, William T. Shearer Center for Human Immunobiology,
Department of Allergy, Immunology, and Retrovirology, Houston, TX, USA.
3Associate Professor/Baylor College of Medicine/Texas Children's Hospital
4Staff Nurse/Texas Children's Hospital
5Assistant Professor/Baylor College of Medicine/Texas Children's Hospital
Abstract/Case Report Text
Background: Immune dysregulation and lymphoproliferative disorders including ALPS
like disease, HLH EBV driven lymphoproliferative disease leading to rare lymphomas
require a multidisciplinary approach utilizing expertise in Immunology and Hematology/Oncology
to care for these patients as we learn the molecular etiology of their underlying
disorders. At Texas Children’s Hospital, the Immunology Lymphoproliferative evaluation
and diagnostic (iLEAD) clinic was created to provide a comprehensive clinical and
research approach to caring for patients with these rare disorders. In an effort to
streamline care and access, we recently on-boarded an advanced practice provider (APP)
.
Methods: A chart review was conducted 6 months before and after on-boarding the APP
for iLEAD patient visits. We reviewed the following patient care and access parameters
to determine increase in efficient and effective patient care as well as improved
access to the clinic. These parameters included: Referral Process, time of referral
placement to appointment, number of patient visits, wait time in clinic, lab interpretation
and reporting time for disseminating results to families, and collaboration process
with other specialties.
Results: Within 2 months of the APP starting our average wait from placing the referral
to first appointment fell by an average of 45%. In addition, we created an algorithm
to prioritize patients with immediate need to be seen. By streamlining the referral
process and patient priority, we developed a “pre-clinic” conference process by which
all patients are reviewed and preliminary plans are made prior to the patient’s arrival.
This has translated into our ability to increase the number of patients seen in clinic
from 4 to 6 and decreased the wait time in clinic by approximately 30 minutes. Since
the APP started, no patient has been in clinic for more than 60 minutes. This has
also led to an increase in RvU generation. In terms of efficiency in patient care,
all labs are now ordered while in the room with the patient by the APP and physician
providers. In turn, all labs are resulted directly to the APP who reviews labs, collaborates
with physicians for care and reports to families in a timely fashion within 1-2 weeks
of labs being resulted compared to greater than 1 month previously. To improve collaborator
communication and post visit plans, a post-visit clinic summary was created. This
has been effective in reducing the time to other specialty referrals, follow up visits
and effective care for ongoing clinical needs.
Conclusions: The addition of an APP in our iLEAD multidisciplinary clinic which provides
specialized care for patients with immune dysregulation and lymphoproliferative disorders
effectively increases work productivity of providers and enhances patient care by
increasing access to care, decreasing wait time in clinic and time of reporting of
results and future plans. The APP with knowledge and expertise in immunology and immune
dysregulation is a cost effective way to enhance provider and patient support. With
the overwhelmingly positive results, future plans include expanding our multidisciplinary
clinic to other services that care for patients with suspected immune deficiency.
(65) Submission ID#806858
Genomic Characterization of a Pediatric Cohort with Lymphoproliferative Disorders
Lisa Forbes, MD1, Olive Eckstein, MD2, Nitya Gulati, MD2, Erin Peckham-Gregory, PhD3,
Nmazuo Ozuah, MD4, M. Cecilia Poli, MD PhD5, JW Caldwell, DO6, Juan C. Aldave-Becerra,
MD PhD7, Stephen Jolles, MD, PhD8, Francesco Saettini, MD9, Hey Chong, MD, PhD10,
Tiphanie Vogel, MD, PhD11, Emily Mace, PhD12, Jordan Orange, MD, PhD13, Asbjorg Stray-Pedersen,
MD PhD14, Donna M. Muzny, MS15, Shalini N. Jhangiani, PhD16, Richard A. Gibbs, MD
PhD17, Zeynep Coban-Akdemir, PhD18, James Lupski, MD, PhD19, Kenneth L. McClain, MD20,
Carl E. Allen, MD PhD21, Ivan Chinn, MD22
1Assistant Professor of Pediatrics/Texas Children's Hospital/Baylor College of Medicine
2Assistant Professor/Baylor College of Medicine/Texas Children's Hospital
3Assistant Professor of Pediatrics/Baylor College of Medicine
4Assistant Professor of Pediatrics/Baylor College of Medicine, 4. Division of Pediatric
Hematology/Oncology, Texas Children’s Hospital Cancer Center
5Professor/5. Universidad del Desarrollo, Clinica Alemana de Santiago, Santiago, Chile
6Director of Allergy/Immunology/Section of Pulmonary, Critical Care, Allergic and
Immunological Diseases, Wake Forest Baptist Medical Center, Medical Center Boulevard,
Winston-Salem, NC
7physician/7. Division of Allergy and Immunology, Hospital Nacional Edgardo Rebagliati
Martins, Lima, Peru
8Consultant Clinical Immunologist & Honorary Professor/University Hospital of Wales,
Cardiff, UK
9consultant/9. Department of Pediatrics, San Gerardo Hospital, Monza, University of
Milano Bicocca, Milano, Italy
10Division Director of Allergy and Immunology, Associate Professor of Pediatrics/UPMC
Children's Hospital of Pittsburgh
11Assistant Professor, Pediatrics & Medicine/Baylor College of Medicine, Texas Children's
Hospital
12Assistant Professor/Columbia University
13Professor of Pediatrics; Chair, Department of Pediatrics/Columbia University
14Consultant/13. Department of Pediatric and Adolescent Medicine, Oslo University
Hospital, University of Oslo, Oslo, Norway
15Scientist/Human Genome Sequencing Center, Baylor College of Medicine, Department
of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
16Post-Doctoral Associate/15. Department of Molecular and Human Genetics, Baylor College
of Medicine, 16. Baylor-Hopkins Center for Mendelian Genomics, Houston, TX
17Professor/15. Department of Molecular and Human Genetics, Baylor College of Medicine,14.
Human Genome Sequencing Center, Baylor College of Medicine, 16. Baylor-Hopkins Center
for Mendelian Genomics, Houston, TX
18Post-Doctoral Associate/Baylor College of Medicine
19Professor/Baylor College of Medicine
20Profesor/4. Division of Pediatric Hematology/Oncology, Texas Children’s Hospital
Cancer Center, Houston, TX
21Associate Professor/Baylor college of Medicine, 4. Division of Pediatric Hematology/Oncology,
Texas Children’s Hospital Cancer Center, Houston, TX
22Assistant Professor, Director Immunogenetics Program/Department of Immunology, Allergy
and Rheumatology at Baylor College of Medicine
Abstract/Case Report Text
Introduction: Pediatric lymphoproliferative disorders represent a clinically and genetically
heterogeneous group of conditions. Misdiagnosis and delayed diagnosis can contribute
to substantial morbidity and mortality. Identification of molecular etiologies and
underlying disease mechanisms may facilitate timely interventions and guide targeted
or curative therapies.
Methods: The study was performed through retrospective chart reviews in accordance
with all local ethics and IRB committees. The study was designed to investigate a
cohort of pediatric patients who met criteria for non-malignant lymphoproliferative
disorders from Texas Children’s Hospital and collaborating centers for underlying
genetic etiologies.
Results: A total of 51 affected individuals from 47 families met criteria. Distribution
between male and females was nearly equivalent: males (n = 26) and females (n = 25).
Approximately half of the cohort was Hispanic (n = 25). Overall Kaplan Meier survival
was 67% (n = 39). Whole exome sequencing was performed in all subjects and available
family members. Likely disease-causing genetic defects were identified in 29 of 47
families (62%). Within these 29 families, 20 (69%) carried variants in genes in International
Union of Immunological Societies established primary immunodeficiency diseases. Potential
novel genetic causes of immune deficiency or immune dysregulation were also discovered.
Mechanistically, all of the implicated genes had roles in modulating lymphocyte activity;
initial activation, cytoskeletal organization, or apoptosis of lymphocytes; or regulation
of inflammation. All subjects less than one year of age had an identified gene in
one of the three mechanistic categories with the dominant mechanistic genetic category
being defective control of lymphocyte signaling (57%). In addition, 72% of patients
between 1 and 8 years of age were found to have a potential genetic diagnosis underlying
the LPD, with a more equal distribution of mechanistic categories compared to patients
greater than 15 years of age where only 33% have a genetic cause. Other important
disease manifestations identified were EBV-associated disease in 21 subjects (41%)
and 15 subjects (24%) met HLH-2004 criteria.
Conclusion: Primary immunodeficiency diseases and other genetic abnormalities of the
immune system underlie a significant percentage of pediatric lymphoproliferative disorder
cases. Greater than 72% of patients less than 8 years of age have a genetic etiology
underlying the lymphoproliferative disorder. Many of these gene defects can be treated
with targeted therapies or hematopoietic stem cell transplantation. Genetic testing
therefore plays an essential role in the diagnosis and management of children with
these conditions.
(66) Submission ID#806874
More Than Meets the IPEX (Immune dysregulation polyendocrinopathy enteropathy X-linked
syndrome): Finding the Right Source in an Immunosuppressed Patient
Ban Wang, MD1, Brant Ward, MD, PhD2
1Internal Medicine Resident/Virginia Commonwealth University Health Systems
2Assistant Professor of Medicine/Virginia Commonwealth University
Abstract/Case Report Text
A 21-year-old gentleman with a history of immune dysregulation polyendocrinopathy
enteropathy X-linked (IPEX) syndrome with known pathogenic variant in FOXP3 presented
to our emergency department with two witnessed episodes of tonic-clonic seizures earlier
that day. He has had a longstanding history of recurrent infections and autoimmune
conditions since birth, and was being treated with monthly IVIG infusions and sirolimus
while awaiting bone marrow transplantation. His symptoms on admission included foaming
at the mouth, generalized shaking, bladder incontinence, and tongue biting that lasted
about five minutes. Family reported recent sores inside his mouth and lips, but denied
any recent fevers, neck pain, headaches, chest pain, abdominal pain, nausea, vomiting,
and sick contacts. He lives on a farm with livestock and reportedly had recent tick
exposure. His last IVIG infusion was two weeks prior to admission, at which time he
also received inactivated flu vaccine.
In the ED, a third seizure was witnessed by multiple medical providers. He subsequently
received lorazepam and lacosamide with interval improvement. He underwent diagnostic
lumbar puncture, as well as extensive evaluation for infections. He was started on
empiric antibacterial and antiviral meningitis coverage. Analysis of the CSF showed
a lymphocytic pleocytosis; bacterial cultures and HSV 1/2 PCR were negative, as was
a 14-pathogen meningitis/encephalitis panel performed by PCR. EEG was negative for
seizure-like activity, and brain MRI showed mild atrophy without sclerosis in the
left hippocampus. Subsequently, anti-infectious therapy was stopped, and patient was
discharged with outpatient follow-up scheduled for suspected non-infectious aseptic
meningitis that was potentially triggered by flu vaccination versus IVIG. On day four
post-discharge, however, PCR for Ehrlichia chaffeensis in the serum returned positive,
and he was started on oral doxycycline.
Ehrlichiosis is a rare tick-borne illness that may cause various non-specific symptoms
including fever, headaches, myalgias, and generalized malaise. Most prevalent in the
mid-Atlantic regions of the United States, tick-borne Ehrlichia spreads through the
mononuclear phagocytic system and can infiltrate many organs including the kidney,
liver, lungs, and heart. CSF penetration can cause sometimes fatal meningoencephalitis.
Aseptic meningitis due to Ehrlichiosis has been described in recent literature. Cases
in HIV patients and transplant patients on chronic immunosuppressive therapy have
been severe, resulting in organ dysfunction in many instances and death in a few.
However, this case marks the first documented Ehrlichia infection in a patient with
primary immunodeficiency. This patient’s presentation of aseptic meningitis and clear
exposure history fits the clinical picture. His relatively benign course could be
due to preserved T effector function not seen in persons with HIV or transplant patients
with significant immunosuppression.
Patients with IPEX usually present with autoimmunity and allergies, but are also prone
to significant infections. It is important to perform a comprehensive workup, including
testing for atypical infections, in patients with immune dysregulation syndromes who
present with symptoms of unclear etiology. Special attention should be paid to patients
who live in areas with known endemic exposure risks. Empiric antibiotic therapy may
need to be considered early to prevent delays in treatment.
References
1.CDC. Signs and Symptoms - Ehrlichiosis. https://www.cdc.gov/ehrlichiosis/symptoms/index.html.
Published 2019. Accessed November 11, 2019, 2019.
2.Buzzard SL, Bissell BD, Thompson Bastin ML. Ehrlichiosis presenting as severe sepsis
and meningoencephalitis in an immunocompetent adult. JMM Case Rep. 2018;5(9):e005162-e005162.
3.Sekeyova Z, Danchenko M, Filipcik P, Fournier PE. Rickettsial infections of the
central nervous system. PLoS Negl Trop Dis. 2019;13(8):e0007469.
4.Geier C, Davis J, Siegel M. Severe human monocytic ehrlichiosis presenting with
altered mental status and seizures. BMJ Case Rep. 2016;2016.
5.Safdar N, Love RB, Maki DG. Severe Ehrlichia chaffeensis infection in a lung transplant
recipient: a review of ehrlichiosis in the immunocompromised patient. Emerg Infect
Dis. 2002;8(3):320-323.
6.Esbenshade A, Esbenshade J, Domm J, Williams J, Frangoul H. Severe ehrlichia infection
in pediatric oncology and stem cell transplant patients. Pediatr Blood Cancer. 2010;54(5):776-778.
7.Chatila TA. Role of regulatory T cells in human diseases. J Allergy Clin Immunol.
2005;116(5):949-959; quiz 960.
8.Bacchetta R, Barzaghi F, Roncarolo MG. From IPEX syndrome to FOXP3 mutation: a lesson
on immune dysregulation. Ann N Y Acad Sci. 2018;1417(1):5-22.
9.Wang J, Li X, Jia Z, et al. Reduced FOXP3 expression causes IPEX syndrome onset:
An implication from an IPEX patient and his disease-free twin brother. Clin Immunol.
2010;137(1):178-180.
(67) Submission ID#806880
PGM3 Deficiency: A New Spectrum of Phenotypes
Jessica Durkee-Shock, MD1, Megan Fisher, PhD2, Nurcicek Padem, MD3, Melanie Makhija,
MD4, Ahmet Ozen, MD5, Laia Alsina, MD, PhD6, Hana Neibur, MD7, Nicholas Hartog, MD8,
Jennifer Leiding, MD9, Rajesh Kumar, MD10, Erinn Kellner, MD10, Blanka Kaplan, MD11,
Chrysi Kanellopoulou, PhD12, Brianne Navetta-Modrov, MD11, Jenna Bergerson, MD, MPH13,
Yu Zhang, PhD14, Alejandra Prat, MD15, Monserrat Buendia Arellano, PhD16, Angela Deyà-Martinez,
MD, PhD6, Rebeca Perez De Diego, PhD17, Helen Matthews, RN18, Tom DiMaggio, RN19,
Kelly Stone, MD, PhD20, Joshua Milner, MD21, Helen Su, MD, PhD22, Alexandra Freeman,
MD23, V. Koneti Rao, MD24, Jonathan Lyons, MD25
1Clinical Fellow in Allergy and Immunology/National Institute of Allergy and Infectious
Diseases, National Institutes of Health
2Fellow/Laboratory of Allergic Diseases, National Institute of Allergy and Infectious
Diseases
3Clinical Fellow in Allergy and Immunology/Ann and Robert H. Lurie Children's Hospital
4Attending Physician, Division of Allergy and Immunology/Ann and Robert H. Lurie Children's
Hospital
5Attending Physician/Marmara University, Division of Pediatric Allergy/Immunology
6Attending Physician/Clinical Immunology and Primary Immunodeficiencies Unit, Allergy
and Clinical Immunology Department, Hospital Sant Joan de Déu
7Attending Physician/Division of Pediatric Allergy/ Immunology, University of Nebraska
Children's Hospital & Medical Center
8Attending Physician/Michigan State University College of Human Medicine
9Attending Physician/Division of Allergy and Immunology, Department of Pediatrics,
University of South Florida at Johns Hopkins-All Children's Hospital
10Attending Physician/Division of Allergy and Immunology, Ann and Robert H. Lurie
Children's Hospital
11Attending Physician/Division of Allergy and Immunology, Donald and Barbara Zucker
School of Medicine at Hofstra/NorthWell, Great Neck, NY
12Fellow/Laboratory of Clinical Immunology and Microbiology, National Institute of
Allergy and Infectious Diseases, National Institutes of Health
13Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Division of
Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda,
MD, USA
14Staff Scientist/Laboratory of Clinical Immunology and Microbiology, National Institute
of Allergy and Infectious Diseases, National Institutes of Health
15Attending Physician/Dermatology Department, Hospital Sant Joan de Déu
16Scientist/Laboratory of Immunogenetics of Human Diseases, Innate Immunity Group,
IdiPAZ Institute for Health Research, La Paz Hospital
17Head Laboratory of Immunogenetics of Human Diseases/Laboratory of Immunogenetics
of Human Diseases, Innate Immunity Group, IdiPAZ Institute for Health Research, La
Paz Hospital
18Clinical Research Specialist/Laboratory of Immune System Biology, National Institutes
of Allergy and Infectious Diseases, National Institutes of Health
19Clinical Research Nurse/Laboratory of Allergic Diseases, National Institute of Allergy
and Infectious Diseases, National Institutes of Health
20Senior Clinician/Laboratory of Allergic Diseases, National Institute of Allergy
and Infectious Diseases, National Institutes of Health
21Laboratory Chief, Attending Physician/Laboratory of Allergic Diseases, National
Institute of Allergy and Infectious Diseases, National Institutes of Health
22Senior Investigator/Laboratory of Clinical Immunology and Microbiology, National
Institute of Allergy and Infectious Diseases, National Institutes of Health
23Senior Clinician/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH
24Staff Clinician/ALPS Unit, Laboratory of Clinical Immunology and Microbiology, National
Institute of Allergy and Infectious Diseases, National Institutes of Health
25Investigator/Laboratory of Allergic Diseases, National Institute of Allergy and
Infectious Diseases, National Institutes of Health
Abstract/Case Report Text
Introduction
Autosomal recessive hypomorphic mutations in PGM3 have been described to result most
commonly in either hyper-IgE or severe combined immunodeficiency (SCID) clinical phenotypes
in humans, with one report of an individual with combined immunodeficiency without
atopy. Herein, we describe a series of individuals newly diagnosed with PGM3 deficiency
functionally confirmed using lectin-based flow cytometric analysis of peripheral blood
mononuclear cells, that broadens the associated clinical phenotypes to confirm CID
without atopy and childhood Evans syndrome. In addition, we present 3 new disease-causing
PGM3 variants, and functionally confirm the pathogenicity of a fourth (p.I350T).
Classical HIES Phenotype
Cases 1.1 and 1.2 identify 2 sisters of Spanish descent with a classical hyper-IgE
phenotype. The younger sibling demonstrated severe atopic dermatitis, mild-moderate
asthma, multiple food allergies, one episode of ITP, and ADHD. The older sibling demonstrated
atopic dermatitis, skin infections, and C. albicans otomastoiditis. The siblings were
found to have the damaging compound heterozygous variants p.T492I and p.Q506X in PGM3.
Case 2 is a 15 year-old Guatemalan boy with prominent atopy including asthma, allergic
rhinitis, food allergy, elevated IgE, atopic dermatitis, as well as oral HSV who was
found to be homozygous for the damaging PGM3 variant p.I350T.
CID phenotype with a paucity of Atopy
Case 3 is a 10-year-old Turkish girl who is the daughter of a consanguineous union.
She presented with infantile nephrotic syndrome at 6 months of age, and subsequently
developed leukopenia, neutropenia, and low IgG. Complications include bronchiectasis,
sinusitis, Pseudomonas urinary tract infection, and inflammatory skin lesions without
atopy. She was found to be homozygous for the damaging PGM3 variant p.R69H
Evans syndrome
Case 4 is a 5-year-old girl from Guatemala. She developed multilineage autoimmune
cytopenias including immune thrombocytopenic purpura (ITP), autoimmune hemolytic anemia
(AIHA) and autoimmune neutropenia (AIN) at the age of 2 years, refractory to multiple
treatments and finally responding to mycophenylate mofetil. She has a history of mild
eczema but is without other atopy and suffered from multiple invasive bacterial infections.
An additional patient, case 5, was diagnosed with Coombs positive AIHA and ITP at
age 3 years refractory to multiple treatments and finally responsive to cyclosporine.
Cytopenias recurred 1 year later, resulting in hypoxic brain injury. He died of infectious
complications at the age of 7 years. Both patients were found to be homozygous for
the damaging PGM3 variant p.I350T.
Discussion This is the first report of PGM3 deficient individuals presenting with
Evans syndrome as a primary presentation without additional pathology. While disease-associated
mutations appear to cluster around the 4 key conserved domains of the protein, no
clear genotype-phenotype correlation is readily observed. In addition to autoimmune
cytopenias, PGM3 deficient individuals have also been reported with splenomegaly,
lymphoma, and EBV viremia. Thus, in particular for children with lymphoproliferative
disease, PGM3 deficiency should also be considered in the differential diagnosis.
Table 1. Patients identified with validated PGM3 disease-associated mutations.
(69) Submission ID#806915
Invasive Cryptococcal and Moraxella Infections in a Patient with Idiopathic CD4+ T
Cell Lymphopenia
Priya Mehta, MD1, Megan Ford, MD2
1Fellow/Thomas Jefferson University/A.I. DuPont Hospital for Children
2Assistant Professor/Thomas Jefferson University
Abstract/Case Report Text
Introduction: Meningitis is a life-threatening manifestation of Cryptococcus neoformans
(C. neoformans). It occurs in increased frequency in those with impaired cell-mediated
immunity, especially those with HIV/AIDS. Infection with C. neoformans has been seen
in previously healthy individuals diagnosed with idiopathic CD4 lymphopenia (ICL).
ICL is defined by an absolute CD4+ count of less than 300 cells/m3 on multiple occasions,
usually 2 to 3 months apart, without other apparent cause such as HIV infection, immunodeficiency,
or immunosuppressive medications.
Case Description: Our patient is a previously healthy 50-year-old female with Cryptococcus
meningitis and fungemia. Her course was complicated by elevated intracranial pressure
requiring extraventricular drain. She was treated with amphotericin and flucytosine
for 1 month. Notably, the patient was also found to have Moraxella catarrhalis (M.
catarrhalis) bacteremia without identifiable source. She denied history of environmental
risk factors, was not up to date on cancer screening, and recently returned from a
trip to Italy. Initial evaluation revealed lymphopenia (422 cells/uL), low CD3+ (283
cells/uL), CD4+ cells (42 cells/uL), and CD16/56+ (31 cells/uL), but normal CD8+ (234
cells/uL) and CD19+ cells (121 cells/uL). HIV, ANA, leukemia/lymphoma flow cytometry
panel was negative. She also had a normal lymphocyte proliferative responses to PHA
(66.7%), normal CD45RA:RO, and protective tetanus titers (2.31 IU/mL), but only 1/23
protective pneumococcal serotypes. Initial immunoglobulins demonstrated slightly low
IgG (616 mg/dL). Laboratory studies 2 months after presentation demonstrated improved
lymphopenia (800 cells/uL) continued low CD4+ cells (86 cells/uL), but normalized
IgG levels (645 mg/dL). Follow-up labs also demonstrated decreased CD19+ B cells (44
cells/uL) and insufficient response to polysaccharide vaccine (9/23 pneumococcal serotypes).
Three months after discharge, she is continued on daily fluconazole without recurrence
of infections although she still has diplopia and headache.
Discussion: In a review of cryptococcosis in 53 patients with ICL, 7 of them had cryptococcal
infection in both the CNS and blood. Of these 7 patients, 1 was cured, 2 improved,
3 relapsed and then improved, and 1 died. Three of these patients were treated with
amphotericin and flucytosine. Five of these patients had underlying disease and 3
had notable infections with VZV, TB, or HPV, however other infections such as M. catarrhalis
were not mentioned. M. catarrhalis bacteremia has been described in children with
underlying immune dysfunction and respiratory infection as well as secondary to pneumonia
with M. catarrhalis. In 24 cases of M. catarrhalis bacteremia in adults, most had
underlying malignancy and/or neutropenia, predisposing respiratory factors, or source
for infection.
Conclusion: This report of C. neoformans meningitis and M. catarrhalis bacteremia
in the setting of ICL is unusual in that to our knowledge, M. catarrhalis bacteremia
has not been reported in ICL. Cases like this also raise the question as to whether
some laboratory abnormalities are secondary to infection, treatment, or underlying
disease. It is important to report these cases with ICL in order to group disease
phenotypes, as continued monitoring and data collection of these cases may lead to
discovery of new disease processes.
(70) Submission ID#806998
Regulation Of Humoral Immunity By Cytokine-Mediated STAT Signalling - Lessons From
Inborn Errors Of Immunity
Stuart Tangye, PhD1
1Professor/Immunity & Inflammatory Diseases, Garvan Institute of Medical Research,
Darlinghurst, New South Wales, Australia.
Abstract/Case Report Text
Cytokines play critical roles in regulating the development, survival, differentiation
and effector function of immune cells. Cytokines exert their function by binding specific
receptors on the surface of immune cells and typically activating intracellular JAK/STAT
signaling pathways, resulting in induction of specific transcription factors and regulated
expression of target genes. In order to differentiate into an appropriate effector
fate, lymphocytes need to integrate multiple signals often provided concomitantly
by numerous cytokines that activate shared transcription factors. How these signals
are balanced and regulated to yield the optimal class of immune response remains to
be completely determined. Inborn errors of immunity, or primary immunodeficiencies
(PIDs), result from germline mutations in defined genes, leading to loss-of expression,
loss-of function, or gain-of function of the encoded protein. PIDs are characterised
by defects in immune cell development, or their differentiation into effector cells
during immune responses, thereby rendering patients not only highly susceptible to
infectious diseases, but also autoimmunity, autoinflammation, allergy and cancer.
PIDs are thus an unprecedented model to link defined monogenic defects to immune dysregulation
in clinical settings. Indeed, PIDs have unequivocally revealed non-redundant roles
of single genes, molecules, signaling pathways and lymphocyte subsets in host defense
and immune regulation, and formed the basis of better therapies for immunopathologies.
Our indepth analysis of inborn errors of immunity of cytokine signalling pathways
have identified fundamental requirements for generating long-lived humoral immune
responses in humans. Here, I will present data relating to our recent studies of how
inactivating mutations in IL21R, IL6R, ZNF341, STAT1, STAT3, and STAT5, disrupt or
dysregulate the generation and function of human memory B cells and Tfh cells, thereby
precipitating humoral immunity, as well as allergic disease and autoimmunity.
(72) Submission ID#807071
Immunophenotyping of cytologic Specimens by Flow Cytometry in Patients With or Without
Prior Hematologic Malignancy
Shirin Tarafder, MBBS,MPhil1
1Professor/Microbiology and Immunology Department, Bangabandhu Sheikh Mujib Medical
University, Dhaka, Bangladesh
Abstract/Case Report Text
Introduction: Flow cytometry is a powerful diagnostic tool for detecting hematologic
malignancies in a variety of patient specimens including body fluids and lymph node
aspirates. Cytopathologists are frequently confronted with lymphocyte –rich effusions,
and the definite decision of whether the lymphocytosis is of a purely reactive nature
or a presentation of an indolent lymphoma may be an extremely difficult based on microscopy
alone. Moreover, small proportions of malignant cells that may be missed out by routine
morphology can be detected by flow cytometry.
Objective: The purpose of this study was to evaluate the usefulness of multiparametric
flow cytometry Immunophenotyping (FCI) to confirm the presence of leukemia or lymphoma
cells in body fluids and FNA specimens.
Methods: Body fluids and FNA specimens simultaneously obtained for FCI, cytologic
analysis and Real time PCR from 30 patients were submitted to our flow cytometry laboratory
from January 2017 to September 2019. The samples studied were 16 body fluids ( 11
pleural fluids and 5 ascitic fluids) and 14 FNA samples (13 enlarged lymph nodes and
1 lung mass).Four color FCI method was performed and the following fluorescent monoclonal
antibodies were used: CD45, CD19, CD5, CD20, CD22, CD23, CD79b, FMC7, Kappa and Lambda
light chains, CD200, CD123, CD10, CD11c, CD2, CD1a, CD3, CD5, CD7, CD4, CD8, TdT,
CD52, CD25, CD30, CD40, CD56, CD95, BCL2, CD34. FCI analysis was performed on a Beckman
coulter cytomics FC500 flow cytometer using software CXP to analyze data. The cases
were diagnosed as leukemia or lymphoma as per the World Health Organization (WHO)
2008 guideline. Real time PCR was done for detecting Mycobacterium tuberculosis (MTB)
DNA to exclude tuberculosis.
Results: Among 30 cases 27(90%) showed immunophenotype positivity for malignancy,
of which 25/27(83.33%) were hematologic malignancies and 2/27(6.67%) other malignancies.
MTB DNA was positive in 3/30(10%) cases. Pleural fluid (n=11) samples were positive
for diffuse large B-cell lymphoma (DLBCL) (4 cases), angioimmunoblastic T-cell lymphoma
(4 cases), T-lymphoblastic lymphoma (1 case), thymoma (1case), tuberculosis (1 case).
Ascitic fluid (n=5) samples showed positivity for angioimmunoblastic T-cell lymphoma
(4 cases) and DLBCL (1 case). FNA of lymph nodes (n=13) were positive forT-lymphoblastic
lymphoma (2cases), angioimmunoblastic T-cell lymphoma (2 cases), DLBCL (3 cases),
Hodgkin lymphoma (1case), nodular lymphocyte predominant Hodgkin lymphoma (1 case),
peripheral T-cell lymphoma (NOS) (1 case), splenic B-cell marginal zone lymphoma(1
case), tuberculosis (2 cases). One FNA of lung mass were tumor of neural cell origin.
Both immunophenotype and cytomorphology positive for malignancy were in 19/30(63.33%)
cases.Cytomorphology was negative/ suspicious in 11/30(36.67%) cases, of which both
cytomorphology and immunophenotype negative were 3(10%) and cytomorphology negative
but immunophenotype positive cases were 8(26.67%). MTB DNA was detected in pleural
fluid in 1 case and FNA sample in 2 cases.
Conclusion: Multiparametric flow cytometry by using comprehensive panel of monoclonal
antibodies is a useful diagnostic test to evaluate body fluids or FNA as it can demonstrate
small malignant populations that may be missed out by routine cytomorphology.
(73) Submission ID#807087
A New Primary Antibody Deficiency (PAD) Related Human Phenotype Ontology (HPO) Tree
Facilitates the Formation of Homogeneous PAD-Patient Cohorts for Future Research
Esther de Vries, MD, PhD1, Klaus Warnatz, MD2, Siobhan O. Burns, MB PhD MRCPI(Paeds)3,
Raul Jimenez Heredia, PhD4, Kaan Boztug, MD5, Peter Robinson, MD, MSc6, Julia Pazmandi,
MSc7, Matthias Haimel, PhD8, Marielle E. van Gijn, MSc, PhD9
1Professor/Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University,
Tilburg; Laboratory for Medical Microbiology and Immunology, Elisabeth Tweesteden
Hospital, Tilburg, the Netherlands
2Attending physician, principal investigator/Center for Chronic Immunodeficiency,
Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
3Reader and consultant in immunology/Department of Immunology, Royal Free London,
NHS Foundation Trust, London; University College London, Institute of Immunity and
Transplantation, London, United Kingdom
4Technical assistant/St. Anna Children's Hospital and Children's Cancer Research Institute,
Department of Pediatrics, Medical University of Vienna, Vienna; Ludwig Boltzmann Institute
for Rare and Undiagnosed Diseases, Vienna; CeMM Research Centre for Molecular Medicine
of the Austrian Academy of Sciences, Vienna, Austria
5Director LBI-RUD/St. Anna Children's Hospital and Children's Cancer Research Institute,
Department of Pediatrics, Medical University of Vienna, Vienna; Ludwig Boltzmann Institute
for Rare and Undiagnosed Diseases, Vienna; CeMM Research Centre for Molecular Medicine
of the Austrian Academy of Sciences, Vienna, Austria; Department of Pediatrics and
Adolescent Medicine, Medical University of Vienna, Vienna, Austria
6Professor of Computational Biology/Department of Computational Biology, The Jackson
Laboratory for Genomic Medicine, Farmington, CT, USA
7PhD student/St. Anna Children's Hospital and Children's Cancer Research Institute,
Department of Pediatrics, Medical University of Vienna, Vienna; Ludwig Boltzmann Institute
for Rare and Undiagnosed Diseases, Vienna; CeMM Research Centre for Molecular Medicine
of the Austrian Academy of Sciences, Vienna, Austria
8Bioinformatics Lead for Personalised Medicine/St. Anna Children's Hospital and Children's
Cancer Research Institute, Department of Pediatrics, Medical University of Vienna,
Vienna; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna; CeMM
Research Centre for Molecular Medicine of the Austrian Academy of Sciences, Vienna,
Austria
9Clinical Laboratory Geneticist/Department of Genetics, University of Groningen, Groningen,
the Netherlands
Abstract/Case Report Text
The phenotypes of primary antibody deficient (PAD) patients range from milder (e.g.
specific antibody deficiency) to severe (e.g. X-linked agammaglobulinemia) deficiency
of the immune system. PAD patients form a clinically, immunologically as well as genetically
heterogeneous group. Often, the genetic background has not been elucidated; it probably
is not monogenetic in a large subgroup of patients. PAD patients suffer most frequently
from recurrent bacterial infections of the respiratory or gastrointestinal tract due
to immune deficiency, but may also have varying degrees of autoimmune and lymphoproliferative
comorbidities due to immune dysregulation.
Unfortunately, a standardized description of PAD phenotypes is lacking rendering robust
definitions of PAD-subtype diagnoses, including CVID, difficult. This impairs the
formation of homogeneous cohorts that can form the starting point for future clinical
and genetic research.
The PAD subgroup of the Human Phenotype Ontology (HPO) immune mediated disorders consortium
supported by ERN RITA and ESID is addressing the gaps in standardized phenotypic description
of PADs. Using the HPO dataset, literature mining, and ESID, IUIS and OMIM classifications,
we aimed to re-evaluate and complete the PAD-related HPO terms to allow efficient
data exchange and matching of phenotypically similar PAD patients.
As a principle, it was decided to avoid the ongoing variance in PAD-subtype definitions
and to build the PAD-related HPO tree based as much as possible on unambiguously interpretable
items. ‘Hypogammaglobulinemia’ was deleted as HPO term, and replaced by separate HPO
terms such as ‘decreased total IgG in blood’, subdivided in ‘transient’ vs. ‘chronic’,
and ‘(near) absent’ vs. ‘partially decreased’ (the same for IgG1, IgG2, IgG3, IgG4,
IgA and IgM). ‘Decreased specific antibody level in blood’ was specified further into
‘decreased natural antibody level to blood group antigens in blood’, subdivided in
‘(near) complete’ vs. ‘partial’ absence (the same for protein, polysaccharide and
protein-conjugated polysaccharide vaccination). Relevant HPO terms related to infection
and to specific organ manifestations like bronchiectasis, autoimmunity and lymphoproliferation
were re-evaluated and completed, and will be linked to PAD diseases in the HPO online
system by the PAD subgroup experts.
Once finalized, existing PAD cohorts will be classified according to the new HPO PAD-related
terms, and studied by clustering technologies (example of two patients shown in Figure
1; white = absent, color = present).
Acceptance and widespread use of this PAD-related HPO tree for standardized phenotyping
will be essential to empower future multicenter clinical research and related genetic
discoveries as well as support clinicians in diagnosing PAD through the linkage of
HPO terms to PAD disease entities.
(74) Submission ID#807151
Ustekinumab in Leukocyte Adhesion Deficiency Type 1 (LAD1) Patients with Chronic Periodontitis
Beatriz Marciano, MD1, Laurie Brenchley, BS RDH2, Amy Rump, CRNP3, Dawn Shawn, MBA
MN RN4, Christa Zerbe, MD5, Ashleigh Sun, MSN RN6, Gulbu Uzel, MD7, Steven Holland,
MD8, Niki Moutsopoulos, DDS, PhD9
1Staff Scientist/NIH NIAID
2Clinical Research Specialist, Dental Hygienist/NIH NIDCR
3Nurse Practitioner/Leidos Biomedical Research, Inc.
4Protocol Nurse Coordinator II/Leidos Biomedical Research, Inc.
5Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Immunopathogenesis
Section, National Institute of Allergy and Immunology, National Institutes of Health,
Bethesda, MD
6Research Nurse/NIH NIAID
7Staff Clinician/NIH NIAID
8Director, Division of Intramural Research; Chief, Immunopathogenesis Section/Laboratory
of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR),
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH), Bethesda, MD, USA
9Senior Investigator Oral Immunity & Infection Section/NIH/NIDCR
Abstract/Case Report Text
Leukocyte adhesion deficiency type 1 (LAD1) is an autosomal recessive disorder characterized
by the inability of granulocytes to emigrate from the bloodstream to sites of inflammation.
LAD1 is caused by mutations in the ITGB2 gene (21q22.3), encoding the beta-2-integrin,
CD18, which is essential for firm adhesion of leukocytes to the endothelium. In LAD1
survival is compromised, morbidity from inflammatory lesions is high, and treatment
is poor. The moderate form of LAD1 is often managed with antibiotics for prophylaxis
and during acute infections. After infancy severe gingivitis and chronic periodontitis
are universal. Periodontal findings affect primary and permanent teeth, causing intense
oral mucosal (gingival) inflammation and destruction of tooth supporting bone, which
are hallmarks of the disease periodontitis.
Blocking the IL-23/IL 17 cytokines, which are up regulated in LAD1 gingiva, can reduce
bacterial load and resolve inflammatory gingivitis. Ustekinumab binds to the shared
p40 subunit of human IL-12 and IL-23, cytokines that modulate lymphocyte function,
including T helper (TH) 1 cells and TH17 subsets, thereby blocking them.
Objective: Explore the effect of Ustekinumab on LAD1 inflammatory disease.
Method: Prospective study using Ustekinumab for oral inflammation. Patients receive
five doses over 1 year, 45- or 90 mg depending of weight.
Results:
(Two patients have enrolled, P1 is >1 year post treatment, P2 is still on study)
Patient characteristics
· Patient 1: Age at diagnosis, 9yrs.(ITGB2 mutation c.2070delT (null)); CD18(%PMN
control):32.6%; CD11a(%PMN);6.6%.
At the initiation of the protocol (17yrs old) WCC:7.41k/Ul; CRP: 6.10
· Patient 2: Age at diagnosis, 4yrs.(ITGB2 mutation c.850A>G,p.G284S c.809C>T,p.A270V)
CD18(%PMN control): 13%; CD11a(%PMN): 3.9%.
At the initiation of the protocol (17yrs old) WCC:7.41k/Ul; CRP: 6.10
Response:
Patient 1: Oral ulcers before treatment: episodes every two months.
During Ustekinumab therapy:
· Oral ulcers: 1 episode in a year
· Reduction in bleeding on probing: 57.5%
· Gingival Index Reduction: 95%
Patient 2: Oral ulcers before treatment : monthly.
During Ustekinumab therapy:
· Oral ulcers: none in first 4 months
· Reduction in bleeding on probing : 68.3%
· Gingival Index reduction: 37.5%
Safety:
No significant adverse events were documented during the therapy
P1 had a previous skin lesion that flared leading to IV antibiotics.
P2 had a previous sebaceous cyst drain spontaneously.
Discussion:
Two patients showed improvement in chronic periodontitis and a substantial decrease
in oral ulcers while on ustekinumab. No clear safety signals were seen. Durability
of these findings is still unknown. Ustekinumab in LAD1deficiency appears to be safe
and potentially effective.
(75) Submission ID#807153
Expanded Phenotype Evaluation Of Patients With Primary Immunodeficiencies With Dysregulation
María Soledad Caldirola, PhD1, María Paula Martinez, n/a2, Analia Gisela Seminario,
MD3, Liliana Bezrodnik, MD4, María Isabel Gaillard, n/a5
1Post Doctoral Fellow/Servicio de Inmunología, Inst. Multidisciplinario de Investigación
en Patologías Pediátricas (IMIPP), Hospital de Niños Ricardo Gutiérrez.
2Chief Resident/Servicio de Inmunología-Hospital de Niños "Dr. R.Gutierrez"
3Immunologist/Centro de Inmunología Clínica "Dra. Liliana Bezrodnik y equipo"- Servicio
de Inmunología Htal. de Niños "Dr. R.Gutierrez"
4Immunologist/Centro de Inmunología Clínica "Dra. Liliana Bezrodnik y equipo"
5Immunologist/Servicio de Inmunología-Hospital de Niños "Dr. R.Gutierrez"
Abstract/Case Report Text
Introduction: primary immunodeficiencies with dysregulation associate defects in the
immune homeostasis leading to inappropriate immune response (lack or excess) that
causes autoimmunity, allergy and/or inflammation. Impairment of different subsets
of T and B compartments may be associated with these PIDs.
Aim: 1) Describe T and B memory compartment of 18 PID patients (pts) with dysregulation:
1 CD25 deficiency, 3 STAT1 GOF, 1 STAT5b deficiency, 4 CTLA4 variant, 2 PI3KCD variant
and 6 CVID-like (with no molecular defect) and compare them with a group of healthy
donors (HD). 2) Associate cTfh profile with B cell compartment impairment.
Results: 1) Pts showed a significant decrease of Naïve CD4+ T cells (CD45RA+CD27+)
(52,2% vs 17,6%) (p < 0.0001) with expanded central memory T cells (CD45RA-CD27+)
(32.8% vs 60.8%) (p < 0.0001); CD4+ T cells had higher levels of activation markers
(CD4+HLA-DR+) (6,1%vs 27,4%) (p < 0,0001). Pts showed a significant increase of circulating
follicular T cells (cTfh) (CD45RA-CXCR5+) compared with HD (mean 30,5% vs 11,6%) (p
< 0,0001) with PD-1 overexpression (p < 0.0001). STAT1 GOF, CTLA4, PI3KCD and CVID-like
pts showed a skew towards cTfh1 (CXCR3+). Regulatory T cells (CD4+CD25++FOXP3+) were
absent in CD25 and STAT5b deficiency and decreased in the other pts. Within CD8+ cells,
although effector memory (CD45RA-CD27-) (p < 0.002), TEMRA (CD45RA+CD27-) (p < 0.009)
and HLA-DR+ CD8+ (p < 0.002) subsets showed a significant increase compared with HD,
the behaviour was variable between different mutations. Regarding B cell compartment,
pts with STAT1GOF, PI3KCD and CVID-like showed a severe impairment of switched-memory
B cells (Sw-MBL) (CD27+IgD-IgM-); the STAT5b deficient patient had increased frequencies
of this subset, while CTLA4 pts had a variable B defect. 2) lower Sw-MBL values were
significantly associated with lower values of cTfh17 cells (p < 0.007) (r=0.6975).
CD21low B cells were exclusively high in CVID-like pts, and transitional B cells were
increase in PI3KCD and almost all CVID-like pts.
Discussion: In summary, patients with dysregulatory syndromes associate a defect of
T and B homeostasis (survival, activation and differentiation). Specific mutations
can differentially affect the quantity and/or the quality of cTfh. There is a strict
association between the differentiations of Tfh with TH17 profile with the generation
of Sw-MBL. These alterations may play a role in the pathophysiology of primary immunodeficiencies
with B lymphocyte functional impairment. Immune monitoring of lymphocyte subsets of
patient with dysregulation may approach to the diagnosis of specific monogenic mutations.
(76) Submission ID#807168
Identifying Primary Immune Deficiencies in Patients with Autoimmune Cytopenias and
Biomarkers of Disease Activity
Emma WestermannClark, MD1, Rachel Cruz, BS2, Sumai Gordon, B.S3, Cristina Meehan,
BS4, Krisztian Csomos, PhD5, Boglarka Ujhazi, MS6, Ernest Amankwah, PhD7, Panida Sriaroon,
MD8, Jonathan Metts, MD9, Marisol Betensky, MD9, Irmel Ayala, MD9, Jolan Walter, MD,
PhD10
1Assistant Professor, Allergy/Immunology/University of South Florida,
2Resrch Assistant/JHMI
3Research Technician/Division of Allergy & Immunology, Department of Pediatrics and
Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla
4Rsrch asst/JHMI
5Research Associate/Division of Allergy & Immunology, Department of Pediatrics and
Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla
6Research Associate/Department of Pediatrics, University of South Florida, St. Petersburg,
FL, United States
7Statistician/Statistician
8Associate Prof/USF
9Hematologist/JHMI
10Division Chief, Pediatric Allergy/Immunology/University of South Florida and Johns
Hopkins All Children’s Hospital
Abstract/Case Report Text
Objective: The purpose of this study is to increase awareness and improve diagnosis
of primary immune deficiency (PID) in the heterogenous group of patients with autoimmune
cytopenia (AIC) by identifying clinical characteristics and laboratory biomarkers
that distinguish those with underlying PID, disease activity and guide mechanism-based
targeted therapy.
Methods: Patients with AIC (autoimmune hemolytic anemia (AIHA), immune thrombocytopenia
(ITP), or autoimmune neutropenia (AIN)) were referred to our Immune Dysregulation
team and prospectively enrolled during 2016-2019. Detailed immune phenotyping (IgG,
IgA, IgM, lymphocyte subsets, vaccine titers, lymphocyte proliferation to mitogens/antigens),
serum lipopolysaccharide (seLPS) and autoantibodies were measured and/or collected
by chart review and genetic testing for PID was pursued.
Results: From 2016 to 2019, 93 patients were enrolled; two subjects were removed due
to parental request or lack of AIC diagnosis. Of the 91 remaining patients, 43 (46%)
were classified as “AIC-PID” based on genetic testing and/or immune phenotyping; 41
(45%) were classified as AIC-only, and 7 (9%) were asymptomatic family controls. The
patients were predominantly children (ages 1-82 years, average age 17.3 years); 47%
(44/93) were male. Among patients who have had genetic testing to date (n=66)(72%),
pathogenic genetic mutations were confirmed in 23/66 (35%) of patients. Mutations
include FAS/FASL (n=8, including 3 family members without AIC), CTLA4 (n=4), 22q11
(n=4), and one patient each with NFKB1, WAS, POLE-1, PI3K, CASP10, CARD11, and CGD;
the remainder of AIC-PID patients were classified as combined immune deficiency or
common variable immune deficiency based on immune phenotyping. Lymphocyte subsets
(CD4+T, CD8+T, CD19+B, CD56+NK) and immune globulins (IgG, IgA, IgM) tended to be
lower in AIC-PID patients vs AIC-only (p < 0.05). Evans syndrome was more common in
AIC-PID patients (13/43, 30%) compared to AIC-only (4/41, 10%). LPS was elevated in
the serum of AIC patients compared to healthy controls (mean 719 vs 87 pg/mL, p <
0.001). Excluding partial DiGeorge syndrome patients (average LPS 222pg/mL), seLPS
levels were significantly higher in genetically-defined untreated PID patients (average
1463 pg/mL) vs. other PID (average 444 pg/mL)(p=0.02) or patients with AIC alone (average
667 pg/mL)(p=0.03). Studies are ongoing on specific subsets that are linked to immune
dysregulation (switched memory B cells, T-regulatory cells, double negative T cells,
T follicular helper cells) and the use of soluble IL-2 as a biomarker of disease activity.
Conclusions: A high fraction of AIC patient were identified with underlying PID in
our study. Basic immune evaluation with immunoglobulin levels and lymphocyte subsets
expedited diagnosis of PID. Genetic evaluation distinguished a group of patients with
AIC-PID and highly elevated LPS level, reflecting high bacterial load, which may distinguish
them from the rest the AIC cohort. The source of bacterial LPS can be multifactorial
and is yet to be determined. Our studies continue focusing on biomarkers that can
be applied to the heterogenous group of patients with AIC. This will allow early detection
and timely initiation of targeted therapies.
(77) Submission ID#807260
APECED Rash as the First Manifestation of the Syndrome in a 10-Month Old Girl
Elise Ferre, PA-C, MPH1, Chyi-Chia Lee, MD, PhD2, Muthulekha Swamydas, MBBS, PhD3,
Amy Hsu, n/a4, Heidi Kong, MD, MHSc5, Edward Cowen, MD, MHSc6, Michail Lionkais, MD,
ScD7
1Physician Assistant/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH
2Staff Clinician/Laboratory of Pathology, CCR, NCI, NIH
3Biologist/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH
4Biologist/Laboratory of Clinical Immunology and Microbiology
5Investigator/Dermatology Branch, NIAMS, NIH
6Head, Dermatology Consult Service/Dermatology Branch, NIAMS, NIH
7Chief, Fungal Pathogenesis Section/Laboratory of Clinical Immunology and Microbiology,
NIH
Abstract/Case Report Text
Introduction/Background: Autoimmune-Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy
(APECED) is a monogenic autoimmune disease resulting from biallelic mutations in the
AIRE gene. Although typically characterized by the classic triad of chronic mucocutaneous
candidiasis, hypoparathyroidism and adrenal insufficiency, we recently reported that
the clinical spectrum of the syndrome is far broader and that incorporation of an
adjunct triad of APECED rash, intestinal dysfunction, and enamel hypoplasia in the
classic triad could lead to earlier diagnosis (Ferre et al., JCI Insight, 2016). Among
the adjunct triad manifestations, APECED rash occurs in 66% of American APECED patients
by age 3, most often developing in the first year of life.
Objectives: To report and describe the clinical features of APECED rash as the first
manifestation in a 10-month old patient with APECED.
Methods: Following enrollment in a NIAID IRB-approved protocol (11-I-0187) the patient
was evaluated with history and physical examination, AIRE sequencing, measurement
of interferon- autoantibodies, and skin biopsy with immunohistochemical analyses.
Results: A 10-month-old girl with a family history of genetically confirmed APECED
in her 13-year old sister developed discrete circular, maculopapular erythematous
lesions on her torso that spread to the face, arms, and legs while sparing the palms
and soles. The rash was partially blanching, non-painful and non-pruritic and was
preceded by low-grade fever (38□C) without other accompanying symptoms. She had not
received medications or vaccinations prior to the rash onset. The lesions increased
in size with associated central clearing and resolved 2.5 months after onset. The
rash recurred with similar appearance 10 times over 14 months with each recurrence
lasting between 10 days and 2.5 months. As with the first rash episode, recurrences
were often preceded by fever (38-39□C) without accompanying symptoms or inciting factors.
Neither topical nor oral antihistamines improved the rash.
AIRE sequencing identified the same compound heterozygous mutations (c.967_979del13
and c.769C>T) that the sister has. High titers of interferon-□ autoantibodies were
measured in serum. Skin biopsy revealed superficial perivascular chronic inflammation
and intraepidermal lymphocytes composed predominantly of mixed CD4 and CD8 T lymphocytes
with few perivascular B lymphocytes. No eosinophils or vasculitis was observed. Myeloperoxidase
immunostaining revealed extensive karyorrhexis. Laboratory studies revealed normal
white count and ESR, negative anti-IgE receptor antibody, and positive anti-IgE antibody.
At 22 months, she developed oral candidiasis as second manifestation of APECED, thus
reaching a diagnostic dyad when applying our proposed expanded diagnostic criteria.
She has not developed hypoparathyroidism or adrenal insufficiency; thus, she has not
yet reached a classic diagnostic dyad. Systematic screening for these endocrinopathies
will be needed to avoid life-threatening complications of acute endocrine failure.
Conclusions: We report the clinical and histologic features of APECED rash manifesting
as the first disease component of APECED in a 10-month old girl. APECED should be
considered in the differential diagnosis of recurrent erythematous maculopapular urticaria-like
eruptions characterized by mixed lymphocytic and neutrophilic infiltration unresponsive
to antihistamines. Our case illustrates the clinical utility of incorporating the
expanded diagnostic criteria of APECED rash, enamel hypoplasia and intestinal dysfunction
into the classic diagnostic triad, which can lead to earlier APECED diagnosis.
(78) Submission ID#807294
Case of Persistent Neutropenia in a Patient with Hyper IgM Syndrome
Priya Patel, MD1, Scott Feldman, MD, PhD2
1Assistant Professor of Clinical Medicine/University of Pennsylvania
2Assistant Professor of Clinical Medicine/Section of Allergy & Immunology, Hospital
of the University of Pennsylvania, Philadelphia, PA
Abstract/Case Report Text
Patient is a 22 yo with h/o Hyper IgM Syndrome (hemizygous frameshift mutation in
CD40L gene, c189delT) recently transitioned from the Children’s Hospital of Philadelphia
(CHOP) to the Hospital of the University of Pennsylvania (HUP) who presented with
prolonged severe neutropenia despite G-CSF and seven hospitalizations for febrile
neutropenia in the span of ten months. Prior to his neutropenia, patient was on monthly
IVIG, with IgG trough 700-900 in the past year. He was evaluated for BMT in 2015 but
declined.
Patient was first found to be neutropenic in Aug 2017 when he was admitted with Pseudomonas
thigh abscess, HSV stomatitis and rhinovirus infection. He was treated with broad-spectrum
antibiotics with improvement in neutropenia. The following month, he was hospitalized
again with neutropenic fever, left axilla Pseudomonas abscess and rhinovirus infection.
He underwent bone marrow biopsy revealing left shifted myeloids with decreased maturing
forms and T cell predominant lymphoid aggregates, suggestive of autoimmune neutropenia
vs. hyper IgM syndrome associated with neutropenia. Anti-neutrophils antibodies were
negative. He was then admitted the following month (10/2017) with febrile neutropenia
with CXR concerning for viral pneumonitis vs. atypical pneumonia. He was started on
G-CSF therapy with significant initial response in ANC. However, this response was
short-lived as he was again admitted in 12/2017 with febrile neutropenia and upper
respiratory rhinovirus infection. He was continued on daily G-CSF.
Due to persistently normal ANC for approximately three weeks, he was weaned off G-CSF
in 1/2018. In 3/2018 and 4/2018, he had two more hospitalizations for febrile neutropenia.
G-CSF was restarted with dose uptitrated to 8mcg/kg during his hospitalization in
April. He was found to be thrombocytopenic with splenomegaly on abdominal ultrasound.
Anti-platelet antibodies and repeat anti neutrophil antibodies were not detected.
He was discharged with close follow up with Immunology and Hematology. Due to his
age, he was transitioned to Penn Allergy/Immunology in 4/2018. There was close communication
between CHOP Allergy/Immunology, CHOP Hematology and Penn Allergy/Immunology during
this transition period.
Patient was admitted to HUP in 5/2018 with febrile neutropenia (despite higher dose
of G-CSF), rhinovirus infection, Pseudomonas sinusitis and CT chest findings suggestive
of possible fungal pneumonia. Due to persistent neutropenia refractory to G-CSF treatment,
Hematology was consulted and repeat bone marrow biopsy showed hypercellular bone marrow
with markedly left shifted granulocytic hyperplasia, compatible with G-CSF therapy.
Flow cytometry showed no evidence of plasma cell neoplasm. Dose of IVIG was adjusted
and increased based on his weight. Per hematology, he also received an additional
high dose IVIG 1g/kg x 2 days for presumed immune mediated neutropenia with immediate
increase in ANC. Despite ANC of 0 for 8 days, an additional 1g/kg of IVIG improved
his ANC to >1000 within 12 hours of his first dose. Thrombocytopenia also improved
to normal range. Since then, patient has been on monthly 500-600mg/kg IVIG with no
recurrence in neutropenia. This patient’s prolonged persistent neutropenia with immediate
response to high dose IVIG is suggestive of autoimmune neutropenia, which should be
taken into consideration in Hyper IgM patients with persistent neutropenia.
(79) Submission ID#807329
The Association Between T-cell Immune Deficiency and the Risk of Serious Infection
in Children with Thymic Hypoplasia Cared for at Duke University
Jacob Kilgore, MD1, Carolyn Baloh, MD2, Adam Blatt, MD3, Rebecca Young, MS, MS4, M.
Louise Markert, MD, Ph.D5, Michael J. Smith, MD, MSCE6, John W. Sleasman, MD7
1Pediatric Infectious Diseases Fellow (third year)/Duke University
2Allergy/Immunology Post-doctoral Fellow/Duke University
3Pediatric Resident Physician (PGY-2)/Duke University
4Biostatistician for the Division of Pediatric Infectious Diseases/Duke University
5Pediatrics and Immunology/Duke University Medical Center
6Associate Professor of Pediatrics, Pediatric Infectious Diseases, Stewardship Medical
Director/Duke University
7Chief, Div. of Allergy/Immunology, Dr. Glenn A. Kiser & Eltha Muriel Kiser Professor
of Pediatrics/Duke University
Abstract/Case Report Text
Background: Children with DiGeorge Anomaly (DGA) represent a heterogenous group, often
classified as either partial DGA (pDGA) or complete DGA (cDGA) based upon the degree
of thymic hypoplasia. This paucity of T-cell parameters and function has serious implications
for infection risk, autoimmunity, and malignancy. However, there are limited studies
stratifying children with DGA by these subgroups, especially in regard to immune function
and subsequent infection risk.
Study design: Single-center, retrospective cohort analysis evaluating the relationship
between pDGA and cDGA to infection risk with particular focus on infection-related
hospitalization, pathogenic organism identification, and antimicrobial resistance
profiles. The source population includes all pediatric patients < 18 years of age
diagnosed with either pDGA or cDGA while receiving care at Duke University from January
1, 2014 to June 30, 2019. The final analysis sample included 145 patients.
Methods: To evaluate the differences in immune function between DGA subgroups, we
will report the proportion of low ( < 10th percentile for age) T cell immune biomarkers
for both subgroups and compare populations using a chi-squared test. To compare per
year incidence of infection-related hospitalization for DGA subgroups, a Poisson model
with number of hospitalizations per patient as the outcome, an offset equal to the
time at risk for hospitalization, and either pDGA or cDGA diagnosis as the exposure
will be used. Models will be bivariate. We will report an incidence rate ratio (IRR)
and 95% confidence interval (95% CI). To evaluate the impact of cellular and humoral
immune function on infection-related hospitalization, we will use Poisson models where
the outcome is the number of hospitalizations per patient, an offset equal to the
time at risk for hospitalization, and low immune biomarker as the exposure. All models
will be bivariate. We will report an IRR and 95% CI. Infection type and resistance
profiles will be completely descriptive.
Results: As expected, children with cDGA had a significantly higher probability of
a low ( < 10th percentile for age) values for total T cells (CD3+), helper T cells
(CD3+CD4+), cytotoxic T cells (CD3+CD8+), and naïve helper T-cells (CD4+CD45RA+CD62L+)
as well as a significantly lower probability of low pan memory T-cells (CD3+CD45RO+)
compared to children with pDGA. No differences were detected in the percentage of
low natural killer (NK) cells (CD15+CD56+) or B cells (CD19+) between subgroups. cDGA
patients had a significantly higher incidence of hospitalization per year (1.52 (0.61,
3.80)) compared to pDGA patients (0.20 (0.12, 0.32)). The IRR is 7.62 (2.71, 21.3).
Across both subgroups, the incidence of hospitalization was higher in DGA patients
who had low helper and naïve T-cells. There is ongoing analysis into hospital-related
infection and resistance profiles. Notable frequencies include bacteremia ( > 5%),
invasive viral disease ( > 1%), and opportunistic infections ( > 1%).
Conclusions: Children who had cDGA were 662% more likely to have an infection requiring
hospitalization than children who had pDGA, emphasizing the need for thymus transplant
for cDGA. Further analysis of infection type and patient outcomes is critical to enhancing
management of this unique patient population.
(81) Submission ID#807404
Zika Virus Antibody-Positivity Among Symptomatic/Asymptomatic Pregnant Women In Aseer
Region Displays Pre-Exposure To Other Cross-Reactive Flavi Viruses
Ahmed Al-Hakami, MD, MSc, PhD1, Esther Paul, MBBS, MSc, MD2, Riyad Moosa, BSc, MSc3,
Harish C. Chandramoorthy, PhD, FICS1
1Associate Professor/Department of Microbiology and Immunology, College of Medicine,
King Khalid University
2Assistant Professor/Department of Microbiology and Immunology, College of Medicine,
King Khalid University
3Lecturer/Department of Microbiology and Immunology, College of Medicine, King Khalid
University
Abstract/Case Report Text
Antibody cross-reactivity among flavivirus has been documented. In recent times Zika
virus has been emerging in pockets of the mosquito-infested regions, While Southwestern
Saudi Arabia is known for Arthropod-borne viral diseases and we do not know the incidence
or even presence of Zika virus in this region. It is restricted to predict the IgM
and IgG antibody detection ranges owing to limited data and colossal cross-reactivity
among the Zika and other flaviviruses. We tested sera from 217 pregnant women irrespective
of their clinical presentation for Zika and Dengue IgM, IgG respectively. The Zika
positive samples were further confirmed by Plaque reduction neutralization tests (PRNT).
From our results, 3.6% (8) cases were positive for ZIKA IgM against 1.8 % (4) positivity
to IgG. When these samples were assessed for Dengue IgM and IgG, we observed 1.3%
(3) seropositivity for IgM and IgG respectively. There was no single sample positive
for both IgM and IgG of Zika or Dengue. However, we observed one sample positive for
both Zika and Dengue IgM. Upon mapping the overlapping serotiters, there was no significant
correlation observed between the Dengue IgM and IgG. Whereas Zika IgG positive sample
showed high serotiter for Dengue IgG indicating the contribution of cross-reactivity
for observed Zika positivity. Screening for the incidence of Zika, therefore, becomes
particularly hard in a population that has the presence of pre-exposure of Dengue
and this cross-reactivity makes it hard to determine the Zika incubation and antibody
prevalence confounded with other flaviviruses.
(82) Submission ID#807497
One Year Experience Using S. TYPHIM Vi Vaccine To Assess PID In Adults
Yvelise Barrios, PhD, MD1, Ana Alonso-Larruga, Msc2, Paloma Poza-Guedes, PhD, MD2,
Andres Franco, PhD, MD2, Inmaculada Sanchez-Machín, PhD, MD3, M.Jose Rodríguez, MD2,
Isabel Suárez, MD2, Victor Matheu, PhD, MD2
1Consultant/Hospital Universitario de Canarias
2Assistant/Hospital Universitario De Canarias
3Head of Department/Hospital Universitario De Canarias
Abstract/Case Report Text
INTRODUCTION Humoral PID diagnostic protocol includes the analysis of the immune response
to different protein and polysaccharide antigens (Ags)(1). Although the analysis of
the immune response against the polysaccharides vaccine from Pneumococca has been
the standard method, the use of S. Typhim Vi vaccine has appeared as a good alternative
(2). In this report we show the results obtained with the use of S.Typhim Vi in 27
adults patients attending the PID outpatient clinic.
MATERIAL AND METHODS Patients with humoral-suspected PIDs were challenged with Typhoid
polysaccharide vaccine (Typhim Vi®; Sanofi-Pasteur). Serum was obtained on basal and
after 4 weeks of vaccination. Specific IgG levels against S.typhim were measured using
“VaccZyme TM Human Anti-Salmonella typhi Vi IgG Enzyme Immunoassay Kit” (Binding-Site).
RESULTS A total of 90 Adult patients attended the PID clinics during Nov 2018-Nov
2019. From those, 27 patients were fully evaluated using a Humoral-Suspected PID algorithm
that includes the S.Typhi vaccination. In total 13 male and 14 female patients completed
the protocol and were analyzed. Twenty patients were considered as responders (ratio
pre/post >3x) whereas 7 patients were non-responders.
DISCUSSION The main advantage of assessing polysaccharide immune response using S.tyhpim
is the usual lack of specific IgG at the moment of the initial evaluation. In this
serie, just one patient has a high basal level (#2-vaccinated in the past). Thirteen
patients had basal levels below the detection limit of the test (7,4U/mL) and 13 patients
between 7,4 and 23,35U/mL, that has been described as a cut otf level for non-immunised
individuals (personal experience,3,4).
Regarding the polysaccharide immune response as a tool to distinguish PID vs non-PID
patients, the results showed a good correlation between those non-responders with
more clinical relevant PID diagnostics. Seven non-responders patients were subsequently
diagnosed with a primary (* on Table I) and/or secondary ID (** on Table I). Despite
this, there were 16 patients that we could have classified as Strong Responders (ratio
>3x, absolute specific IgG post-vaccination level >100U/mL) and 4 patients considered
as Weak Responders (ratio Post/Pre >3x, absolute specific IgG post-vaccination level
< 100U/mL).
Strong responders were considered non-PID after including other clinical investigations
and laboratory tests (Cell subpopulation study, PCP response) whereas weak responders
group consisted in some “minor” forms of PID, like isolated IgM or Ig subclasses deficits.
More patients are needed to confirm this functional classification of PID patients
regarding their S.Typhi immune response.
REFERENCES
1-Orange J et al. Use and interpretation of diagnostic vaccination in PID. J Allergy
Clin Immunol 2012;130:S1-24.
2-Bausch-Jurken et al. The Use of Salmonella Typhim Vaccine to Diagnose Antibody Deficiency
J Clin Immunol 2017;37(5):427-433
3-Barrios et al. Basal protein and polysaccharide immunity levels on Primary Immunodeficiency
outpatient clinic- - Abstract to WAC 2019
4-Sánchez-Ramón S, et al. Multicenter study for the evaluation of the antibody response
against salmonella typhi vi vaccination (EMPATHY) for the diagnosis of anti-polysaccharide
antibody production deficiency in patients with PID. Clin Immunol. 2016;169:80–4.
Table I: Polysaccharide Immune Response of 27 Patients attending the PID Adult Clinic
Nov2018 -Nov2019
(83) Submission ID#807502
CVID And Dysregulation Syndrome In Three Members Of A Same Family With A New Variant
Of CTLA4 Gene
Analia Gisela Seminario, MD1, Agostina Llarens, MS2, Ileana Moreira, MD2, María Soledad
CALDIROLA, PhD3, Maria Esnaola Azcoiti, na4, Lorena Regairaz, MD5, María Isabel Gaillard,
n/a6, Liliana Bezrodnik, MD7
1Immunologist/Centro de Inmunología Clínica "Dra. Liliana Bezrodnik y equipo"- Servicio
de Inmunología Htal. de Niños "Dr. R.Gutierrez"
2PHYSICIAN/IMMUNOLOGIST
3PostDoctoral fellow/Servicio de Inmunología, Inst. Multidisciplinario de Investigación
en Patologías Pediátricas (IMIPP), Hospital de Niños Ricardo Gutiérrez.
4Biochemistry/IMMUNOLOGIST
5PYSICIAN/IMMUNOLOGIST
6Immunologist/Servicio de Inmunología-Hospital de Niños "Dr. R.Gutierrez"
7Immunologist/Centro de Inmunología Clínica "Dra. Liliana Bezrodnik y equipo"
Abstract/Case Report Text
Introduction: CTLA4 is a negative immune regulator that inhibits Tcell activation
by various suppressive functions. Haploinsufficiency in CTLA4 presents with a diverse
clinical phenotype and laboratory results. Objective: Report a family with diverse
clinical presentation due to CTLA gene variant.Results: Three members of a family
presented a CTLA4 gene variant.
The index case (IC) is a girl 15 years old (yo), with a background of severe varicella
and mononucleosis syndrome during her childhood. Since 11yo suffered from recurrent
oral thrush and Evans Syndrome. She was treated with IVIG, steroids and rituximab,
without improvement. Luckily, cytopenias were controlled by Eltrombopag and Sirolimus.
Laboratory showed: low IgM, IgG and antibody responses could not be evaluated because
of IVIG; T/NK lymphopenia, with an expansion of central memory T cells. Her sister
(18yo) has recurrent respiratory infections (RRI), since she was 1yo and has been
suffering from chronic diarrhea. A bowel biopsy (BB) demonstrated follicular lymphoid
hyperplasia (FLH) and focal active colitis. IBD showed partial response to steroids
(discontinued) and azathioprine. Vedolizumab was added. She was diagnosed with CVID
due to hypogammaglobulinemia and impaired antibody responses. Moreover, she showed
T/NK lymphopenia, low counts of Post-switch B cells and an increase of TCR αβ double
negative T cells. Actually she is under SCIG. Their father (47yo), has been suffering
from RRI since his childhood and oral/genital thrush. He developed a severe goiter
at 18yo. For the past 10 years, he has been switching between diarrhea and constipation.
FLH was found in BB, therefore oral Budesonide was started. He only showed mild T-Lymphopenia.
All of them present low levels of regulatory T cells (Treg) and high levels of circulating
T follicular helper cells (cTfh) with a variable cTfh1/cTfh17 profile. NGS showed
an heterozygous CTLA4 gene variant (p.Leu141Pro). This is not reported in ExAC or
GenomAD. Futhermore, the three patients had low expression of CTLA4 in Tregs. We believe
that this finding could explain the different phenotypes. Both siblings received a
Hematopoietic stem cell transplantation (HSCT): IC with match unrelated donor, and
her older sister with match related donor. Both received a reduced-intensity conditioning
(RIC) regimen based on melphalan and fludarabine associated with antithymocyte globulin
(ATG). Good neutrophils engraftment. Currently, they are in day + 19 IC and in day
+ 27 awaiting immune reconstitution. Discussion: The 3 patients presented symptoms
in second childhood and adolescence. Their clinical manifestations were different.
Both daughters with CVID profile due to hematological and intestinal involvement and
endocrinological involvement in their father, All with low CTLA4 expression in Treg.
This demonstrates the complexity of these patients that lead us to face different
therapeutic paths from the modulation of the treatment to a BMT. HSCT for severe presentation
can be a therapeutic option. However, there are few published reports in the literature.
The great risk in patients who undergo to HSCT is inflammation because of the alloreactivity
development
(84) Submission ID#807577
APDS2 and SHORT Syndrome in a Teenager with PIK3R1 Pathogenic Variant
Lourdes Ramirez, MD1, Wendy Guerra, BS2, Hanadys Ale, MD3, Francis Reynoso Santos,
MD4
1Pediatric Resident/Joe DiMaggio Children's Hospital/Memorial Healthcare System
2Medical Student/Florida International University
3Pediatric Immunologist and Allergist/Joe DiMaggio Children's Hospital
4Attending Physician, Division of Genetics/Memorial Healthcare System Joe DiMaggio
Children's Hospital
Abstract/Case Report Text
Activated PI3Kδ syndrome (APDS) is a primary immunodeficiency characterized by recurrent
respiratory infections, as well as increased risk of chronic viremia with herpes family
viruses, benign lymphadenopathy and B cell lymphoma. It is caused by heterogeneous
germline gain-of-function mutations which ultimately lead to the hyperactivation of
the phosphoinositide-3-kinase δ (PIK3δ). PIK3δ exists as a heterodimer composed of
a catalytic and a regulatory subunit. It interacts with B cell receptors, T cell receptors,
costimulatory and cytokine receptors, and is a key player in a signaling pathway involved
in cell growth, proliferation and survival. APDS1 is caused by mutations in the PIK3CD
gene, affecting its protein product p110 δ (catalytic subunit). APDS2 is caused by
mutations in the PIK3R1 affecting p85a (regulatory subunit).
SHORT syndrome is a rare multisystem disorder characterized by short stature, hypertextensible
joints, ocular depression, Reiger anomaly and tooth eruption delay. The primary causes
of SHORT syndrome are heterozygous loss-of-function mutations in the PIK3R1 gene.
The combination of APDS2 and SHORT syndrome is very rare, with only few cases described
in the literature. In this report we present a teenager with a pathogenic variant
in the PIK3R1 gene, and phenotypic characteristics of both APDS2 and SHORT syndrome.
Our patient is a 17-year-old female with a history of growth delay and short stature,
delay tooth eruption, recurrent sinopulmonary infections and hypogammaglobulinemia.
Evaluation performed at a prior institution for recurrent infections revealed low
IgG levels. She did not initiate therapy at that time and was lost to follow up for
several years. At the time of our initial evaluation she reported continued recurrent
episodes of upper respiratory infections and sinus infections requiring antibiotic
treatment that often did not clear the infections. Her physical exam was relevant
for short stature (1%ile, z=-2.33), low weight for age ( < 1%ile, z=-2.69) and hyperextensibility.
Her facial features were significant for prominent forehead and triangular face.
Given concern for immune deficiency, a complete immune evaluation was obtained. Her
workup revealed low IgG levels, with IgM and IgA within normal limits. She did not
have protective titers to S. pneumoniae, H. Influenza or Diphtheria and Tetanus. After
administration of vaccine boosters, she was able to generate a response to all vaccines
except for Tetanus. She had remarkably low absolute B cells (34 cells/uL) and percentage
(1 %), and low CD4:CD8 ratio (0.84). She was started on Amoxicillin prophylaxis and
monthly IVIG replacement therapy. Invitae immunodeficiency panel genetic testing was
sent and revealed a pathogenic loss of function variant in an intronic splice site
in the gene PIK3R1 (c.1425+1G>C). After initiating treatment with IVIG, her sinus
infections significantly improved and she has not had any further episodes. IgG levels
have remained within normal limits with monthly IVIG therapy.
This pathogenic variant had been previously associated with APDS2; however, it had
not been associated with SHORT syndrome. The mechanisms that link both conditions
is yet to be identified. This case report emphasizes the importance of screening for
comorbidities associated with SHORT syndrome in APDS2 patients, and vice versa.
(85) Submission ID#807746
Diagnostic Findings In Patients Suspected Of Primary Immunodeficiency And Custom Analysis
Of NCF1 To Improve Diagnostic Yield In Patients With Chronic Granulomatous Disease
Päivi Kokkonen, 1, Anni Niskakoski, 1, Inka Saarienen, 2, Johanna Sistonen, 3, Heidi
Junnila, 4, Annakarin Kere, 4, Margarita Andreevskaya, 5, Mikko Muona, 6, Janica Djupsjöbacka,
7, Lotta Koskinen, 8, Hatice Duzkale, 9, Joe Jacher, MS, CGC10, Samuel Myllykangas,
11, Juha Koskenvuo, 12, Tero-Pekka Alastalo, 12
1Geneticist/Blueprint Genetics
2Data Scientist/Blueprint Genetics
3Clinical Development Manager/Blueprint Genetics
4Clinical Development Specialist/Blueprint Genetics
5Clinical Bioinformatics Analyst/Blueprint Genetics
6Clinical Bioinformatics Manager/Blueprint Genetics
7Laboratory Manager/Blueprint Genetics
8Clinical Interpretation Manager/Blueprint Genetics
9Senior Geneticist/Blueprint Genetics
10Genetic Counselor & Marketing Manager/Blueprint Genetics
11Chief Strategy Officer/Blueprint Genetics
12Chief Medical Officer/Blueprint Genetics
Abstract/Case Report Text
Finding the genetic diagnosis for patients with suspicion of primary immunodeficiency
(PID) is becoming increasingly important in the management of primary immunodeficiency
and estimating the risk for family members. We constantly increase the diagnostic
yield for PIDs by improving the sequencing technology, updating the panels with new
genes discovered related to PID, and finding diagnoses from difficult to sequence
regions and regions with high homology. Here we report our experiences with nearly
1700 patients suspected with PID. Moreover, we provide a case example, how we increase
the diagnostic yield by developing unique techniques for specific genes which cannot
be reliably analyzed by NGS alone.
Diagnostic yield including all immunology related panels was 14.9% (253/1698). The
majority of the tested individuals were males (1343/1698, 79.1%) and the most common
age of testing was between 10 to 20 years (468/1698, 27.6%). The highest diagnostic
yield 20.6% (75/364) is in children from ages 0 to 5 years, whereas in patients over
60 years of age the diagnosis was found for only 6.5% (4/62) of the patients. The
diagnostic yield was highly variable between the different panels; diagnostic yield
for Primary Immunodeficiency Panel was 13.3% (138/1036), whereas for Severe Combined
Immunodeficiency Panel it was 46.7% (7/15), and for Bone Marrow Failure Syndrome Panel
21.4 % (36/168). Out of the 296 reported diagnostic sequence variants, 234 (79%) were
unique, and only 7 diagnostic variants were reported over 3 times. Copy number variants
(CNVs), including deletions and duplications, were reported for 19 patients from 17
different genes.
The diagnostic yield for Chronic Granulomatous Disease (CGD) Panel is high (10/21,
48%) although analysis of the NCF1 gene included in this panel is complicated by two
highly homologous pseudogenes NCF1B and NCF1C. Deletion calling from the NGS data
cannot well identify or distinguish potential deletion in the pseudogene or the actual
NCF1 gene. In two patient cases, our CNV detection algorithm indicated a homozygous
deletion in the index patient samples potentially covering the whole NCF1 gene. Additional
bioinformatic analysis targeting specifically two coding positions that differ between
the NCF1 gene and the two pseudogenes showed that all reads in those positions originated
from the pseudogenes. Homozygous deletion in the NCF1 gene was further confirmed by
Sanger sequencing two regions in NCF1 with primers that specifically bind to either
NCF1 or the pseudogenes. While clean NCF1 sequences from both regions were obtained
for a control sample, no NCF1-specific amplification product was obtained for the
index patient samples. Pseudogenes were amplified and sequenced successfully in both
index patient samples and positive control samples. Loss-of-function of NCF1 is a
well-established mechanism leading to CGD and by overcoming the difficulties regarding
NCF1 deletion detection by NGS, we can improve diagnostic rate in individuals affected
with CGD.
(86) Submission ID#807751
Defining Novel Populations of Circulating NK Cells in Human GATA2 Deficiency
Seungmae Seo, PhD1, Everardo Hegewisch Solloa, n/a2, Bérèngere Salome, PhD3, Brandon
Mistretta, n/a4, Sujash Chatterjee, PhD5, Amir Horowitz, PhD6, Courtney DiNardo, MD7,
Bethany Mundy-Bosse, PhD8, Preethi Gunaratne, PhD9, Emily Mace, PhD10
1Postdoctoral researcher/Columbia University
2Graduate student/Columbia University
3Postdoctoral researcher/Icahn School of Medicine at Mt Sinai
4Graduate student/University of Houston
5Research associate/University of Houston
6Assistant Professor/Icahn School of Medicine at Mt Sinai
7Associate Professor/MD Anderson Cancer Center
8Assistant Professor/Ohio State University Med Center
9Professor/University of Houston
10Assistant Professor/Columbia University
Abstract/Case Report Text
Human innate lymphoid cells, including natural killer cells, play a critical role
in the control of viral infection and malignancy. GATA2 deficiency can lead to a broad
spectrum of clinical and hematological phenotypes; in some cases, NK cell deficiency
is the primary manifestation, resulting in a greatly increased susceptibility to viral
infections and malignancy. GATA2-deficient patients, particularly those who suffer
from severe viral infections, have reduced frequencies of peripheral blood NK cells
and loss of function in the existing NK cells. Specific loss of the less mature (CD56^bright)
NK cell subset is a hallmark of the immune phenotype in GATA2 deficiency, suggesting
that generation or survival of NK cell precursors is impaired. Given the remarkable
spectrum of clinical phenotypes in GATA2-deficient patients and the poorly understood
biology underlying their NK cell defect, we sought to characterize circulating NK
cells on a single-cell level.
We performed single-cell (sc)RNASeq of lineage-depleted innate lymphocytes from a
patient with GATA2 deficiency. As expected from flow cytometric phenotyping of peripheral
blood cells from this and other patients, scRNASeq revealed decreased representation
of canonical CD56^bright cells. Within the CD56^dim population, we identified two
NK cell populations that were seemingly unique to the GATA2 deficient patient relative
to a healthy donor. Pathway analysis defined the first of these populations (Population
1) by the expression of genes associated with cellular response to stress, extracellular
stimulus and inflammation, as well as programmed cell death and regulation of proliferation
and apoptosis. The second population (Population 2) was defined by genes associated
with NK cell chemotaxis, cytokine responses and interferon signaling.
To extend our findings, we performed scRNAseq of 6 additional healthy donors and analyzed
an additional GATA2-deficient individual who was clinically asymptomatic (Yang et
al. 2019). Of note, we detected Population 2 in seemingly healthy CMV-negative individuals,
suggesting it was not uniquely a result of GATA2 deficiency but associated with an
inflammatory response and not related to adaptive NK cells generated in response to
CMV infection. Population 1, on the other hand, only appeared in our symptomatic GATA2-deficient
patient. We additionally performed bulk gene expression analyses from an unrelated
GATA2-deficient patient that confirmed the altered expression of genes associated
with both novel cell populations. Current efforts are focused on better defining the
functional response of NK cells in these patients and confirming the identification
of our novel populations by mass cytometry (CyTOF). Together, our data define the
heterogeneity and complexity of NK cells in GATA2 deficient and healthy individuals.
(87) Submission ID#807768
Spontaneous Gastrointestinal Perforations In LOF STAT3 And The Role Of Impaired IL-6
Signaling
Hastings Williamson, n/a1, Sumona Bhattacharya, MD2, Theo Heller, MD3, Amanda Urban,
DNP, CRNP4, Dirk Darnell, MA, RN5, Alexandra Freeman, MD6
1Research Intern/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH
2Clinical Gastroenterology Fellow/NIDDK, NIH
3Senior investigator/Liver Diseases Branch, National Institute of Diabetes & Digestive
& Kidney Diseases, NIH, Bethesda, MD, USA
4Nurse Practitioner/Clinical Research Directorate, Frederick National Laboratory for
Cancer Research in support of NIAID, LCIM
5Clinical Research Nurse/Laboratory Of Clinical Immunology And Microbiology, NIAID,
NIH
6Senior Clinician/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH
Abstract/Case Report Text
Introduction: Dominant negative mutations in STAT3 (LOF STAT3) cause a hyper IgE syndrome
characterized by recurrent skin and lung infections, eczema, mucocutaneous candidiasis,
and connective tissue, vascular and skeletal abnormalities. Intestinal perforations,
spontaneous and with diverticulitis, have been reported in LOF STAT3. Recently, spontaneous
intestinal perforations have been reported with tocilizumab, a monoclonal antibody
of the interleukin 6 (IL-6) receptor, suggesting that IL-6 signaling plays a role
in intestinal wall integrity. As IL-6 signals through STAT3, we sought to investigate
the potential association between LOF STAT3 and intestinal perforations, as well as
the incidence and outcome in our patient cohort.
Methods: We performed a retrospective chart review of patients with LOF STAT3 (n=158)
followed at our institution, looking for those with non-malignancy associated spontaneous
gastrointestinal perforations. The demographic information, STAT3 mutation, co-morbidities
at the time of perforation, clinical presentation, management, and clinical outcomes
were compiled
Results: Ten LOF STAT3 patients were identified as having documented intestinal perforations,
an approximate rate of 6%. One perforation was the initial presentation of diffuse
large B cell lymphoma (DLBCL) of the duodenum and liver, and was excluded from the
rest of the analysis. The other nine perforations occurred between 4 to 60 years old
(mean:26), and 55% were female. STAT3 mutations were localized to the DNA binding
domain (n=4) and the SH2 domain (n=5). Two of the perforations occurred while inpatient
for lung infection. Another occurred while recovering from pneumonia at home. Two
perforations were associated with the initial diagnosis of diverticulitis (at age
26 and 60). One perforation occurred in the terminal ileum, one in the cecum, one
in the transverse colon, and six in the sigmoid. Five patients underwent primary closure
of the bowel. Four patients required a temporary ostomy, with subsequent successful
ostomy reversal. Only one patient has since died of pulmonary hemorrhage, the other
patients are alive with a mean of 6 years post perforation follow-up, with no recurrence
of perforation. One patient with prior sigmoid resection required ileal resection
6 post perforation due to as massive intestinal bleed.
Conclusion: Spontaneous gastrointestinal perforations occurred in our LOF STAT3 cohort
at a rate of approximately 6%. One case was associated with malignant infiltration
of the gastrointestinal tract and two cases were associated with diverticulitis both
known risk factors for perforation. Although the pathogenesis of the perforations
in LOF STAT3 remains unclear, the connective tissue phenotype likely contributes as
well as the association with diminished IL-6 signaling, as has been demonstrated with
the perforations and tocilizumab.
(88) Submission ID#807772
Rituximab-Azathioprine Or Rituximab-Mycophenolate for Treatment of Granulomatous and
Lymphocytic Interstitial Lung Disease in Patients with Common Variable Immunodeficiency
John Routes, MD1, Mary Hintermeyer, APNP2, Pippa Simpson, PhD1, Mingen Feng, MSc3,
Jody Barbeau, BS4, Carlyne Cool, MD5, Antonio Sosa-Lazano, MD6, Dhiraj Baruah, MD6,
Erin Hammelev, MSc7, Alyssa Busalacchi, BS7, Amy Rymaszewski, PhD7, Jeff Woodliff,
PhD8, Shaoying Chen, MD9, Mary Jurken, PhD7, James Verbsky, MD, PhD10
1Professor/Medical College Wisconsin
2Staff member, Allergy and Clinical Immunology/Children's Wisconsin
3Staff member, Department of Quantitative Health Sciences/Medical College Wisconsin
4Staff member,Department of Quantitative Health Sciences/Medical College Wisconsin
5Professor, Department of Pathology and Division of Pulmonary and Critical Care Medicine/University
of Colorado Anschutz Medical Campus and National Jewish Health
6Assistant Professor of Radiology/Medical College Wisconsin
7Staff member, Division of Allergy and Clinical Immunology/Medical College Wisconsin
8Staff member, Division of Allergy and Clinical Immunology/Medical College Wisonsin
9Staff member, Division of Pediatric Rheumatology/Medical College Wisconsin
10Associate Professor/Medical College of Wisconsin
Abstract/Case Report Text
Background Granulomatous and lymphocytic interstitial lung disease (GLILD) is a life-threatening
complication that occurs in patients with common variable immunodeficiency (CVID)
and monogenic CVID-like disorders, but the optimal treatment is unknown.
Objective To determine if the use rituximab and azathioprine (RTX-AZA) or rituximab
and mycophenolate mofetil (RTX-MMF) would improve the radiographic abnormalities as
determined by high-resolution computed tomography (HRCT) of the chest and/or pulmonary
function tests (PFTs) in patients with CVID and GLILD.
Methods This is a retrospective study of patients seen from July 2006 to December
2018 with CVID and GLILD who completed immunosuppressive therapy (RTX (375mg/M2) for
4 weeks, repeated at 6-month intervals for 3 or 4 total courses, and AZA (0.5-2.0
mg/kg/day) or MMF (250mg-1000mg-BID) for 18 months). Complete PFTs and HRCT scans
were performed prior to therapy, at the conclusion of therapy, and periodically thereafter.
HRCT scans were blinded, randomized, and scored independently (in pairs) by two radiologists.
All patients underwent whole exome sequencing (WES). Number (percentage) and median
(interquartile range) were reported for categorical and continuous variables, respectively.
Differences between pre- and post-treatment and between relapse and post-relapse HRCT
scores and PFT parameters were analyzed with Wilcoxon signed ranks test. Kaplan-Meier
survival curves were also done. Unadjusted one-sided p-values < 0.05 were considered
statistically significant.
Results The GLILD cohort (N=39) had a 2:1 female predominance, and age at GLILD diagnosis
was 36 (25-43) years (Table 1). Autoimmunity was present in the majority of patients,
with thrombocytopenia (28 (72%)) the most common manifestation. Enteropathy (3 (8%)),
inflammatory bowel disease (1 (3%)), and nodular regenerative hyperplasia of the liver
(6 (15%)) were also present. Splenomegaly (31 (79%)) was present in the majority,
but polyarthritis (0 (0%)) was notably absent. Twenty (51%) patients had been previously
treated with systemic steroids.
HRCT scores substantially improved between pre- and post-treatment for RTX-MMF (p=0.0005)
and RTX-AZA (p < 0.0001, Figure 1). FEV1 (p=0.019), FVC (p=0.0011), and TLC (p=0.0071)
also improved, but DLCO (p=0.060) was unchanged (Figures 2 and 3). Excluding two (5%)
patients who died 2.3 and 2 years after therapy of respiratory failure (1 (3%)) and
septicemia (1 (3%)) respectively, 9/37 (24%) patients relapsed 3.2 (2.8-3.5) years
following therapy with an estimated 60% relapse rate after 5 years (Figure 4). As
of December 2018, 6 of 9 patients that relapsed showed improvement in HRCT scores
(p=0.031), and the remaining 3 patients are still undergoing retreatment (Figure 5).
Four (10%) pneumonias occurred during immunosuppressive therapy, all with severe restrictive
lung disease . Eight (21%) patients had a damaging mutation in a gene known to predispose
(TNFRSF13B, n=3 (8%)) or cause a CVID-like primary immunodeficiency (CTLA4: 2 (5%);
KMTD2: 2 (5%); BIRC4: 1 (3%)). Immunosuppressive treatment improved the HRCT scores
regardless of the absence (p < 0.0001) or presence of a damaging mutation (p=0.0039)
(Figure 6).
Conclusion Combination chemotherapy appeared to be effective in improving the radiographic
abnormalities and pulmonary function of patients with CVID and GLILD. A majority of
patients had sustained remissions, regardless of the presence or absence of a monogenic
disorder.
Characteristics at pre-treatment
CVID and GLILD
(N=39)
Gender: n (%)
Female
Male
26 (67%)
13 (33%)
Age at GLILD diagnosis, years: median (IQR)
36 (25-43)
Estimated duration of GLILD, years: median (IQR)
2 (1-6)
Age at CVID diagnosis, years: median (IQR)
29 (23-39)
Estimated duration of CVID, years: median (IQR)
8 (3-14)
Mode of Diagnosis: n (%)
VATS
Tbx
MS
35 (90%)
3 (8%)
1 (3%)
Normal PFTs: n (%)
16 (41%)
Prior Steroids: n (%)
20 (51%)
H/O Cytopenias: n (%)
28 (72%)
Splenomegaly: n (%)
31 (79%)
Splenectomy: n (%)
5 (13%)
Liver dz/NRH: n (%)
6 (15%)
Enteropathy: n (%)
3 (8%)
IBD: n (%)
1 (3%)
Polyarthrits: n (%)
0 (0%)
IQR=interquartile range, CVID=common variable immunodeficiency, GLILD=granulomatous
and lymphocytic interstitial lung disease, VATS=video-assisted thoracoscopic surgery,
Tbx=transbronchial biopsy, MS=mediastinoscopy excluding B cell malignancy, PFT=Pulmonary
Function Test, H/O=history of, dz=disease, NRH=nodular regenerative hyperplasia, IBD=inflammatory
bowel disease
Table 1. Baseline patient characteristics
Figure 1 HRCT scores of the chest before and after therapy with RTX/AZA (p<0.0001)
or RTX/MMF (p=0.0005).
Figure 2 FEV1, FVC, TLC and DLCO before and after therapy with either RTX/AZA or RTX/MMF
(FEV1 p=0.0011; FVC p=0.0019; TLC p=0.0071; DLCO p=0.060).
Figure 3. Kaplan-Meier disease-free survival curve after either RTX/AZA or RTX/MMF.
(89) Submission ID#807930
A Novel Mutation in PI3KD Gene in a Patient with Chronic Systemic Inflammation And
Recurrent Abscesses
Oscar Correa-Jimenez, MD, MSc1, Adriana Diaz-Maldonado, MD2, Kelly Marquez-Herrera,
MD3, Maribel Trujillo-Hernandez, MD4, Esteban Patiño-Calderon, MD5, Stephania Peña-Hernandez,
MD6, Olga Rodríguez-Urrego, MD1
1Pediatrician/HOMI Fundación Hospital Pediátrico la Misericordia
2Pediatric Reumatologist/HOMI Fundación Hospital Pediátrico la Misericordia
3Pediatric Infectious Disease Specialist/HOMI Fundación Hospital Pediátrico la Misericordia
4Pediatric Dermatologist/HOMI Fundación Hospital Pediátrico la Misericordia
5Pathologist/HOMI Fundación Hospital Pediátrico la Misericordia
6Pediatric Gastroenterologist/HOMI Fundación Hospital Pediátrico la Misericordia
Abstract/Case Report Text
Introduction/Background: Gain of function mutations in PIK3CD gene have been associated
with Activated PI3K Delta Syndrome. Since its first description the number of cases
has increased progressively [1]. Although described as a predominant antibody deficiency[1],
various complex phenotypes have been associated with mutations in this gene[2].
Case Description.
Female patient with no remarkable history until 2 years old, when she suffers from
a persistent fever associated with purulent abscesses in venipuncture areas and hyperleukocytosis
with neutrophilia, so she was treated for about 8 months in 3 hospitals in the city
of Barranquilla before she was referred to our institution. The patient's clinical
picture consisted of persistent fever unresponsive to broad-spectrum antibiotic treatments,
skin abscesses, left subphrenic abscess and toes osteomyelitis. The microbiological
studies documented a bacteremia by Acinetobacter baumannii and isolation in bone marrow
of Candida parapsilosis. During her care stay in Barranquilla, she was approached
as a chronic granulomatous disease versus Job's syndrome, she received two doses of
immunoglobulin with partial control of symptoms. Due to the recurrence of fever, abscesses
and hyperleukocytosis, they decided to refer to our institution for further studies.
Upon admission to our institution, the patient presented nutritional compromise, with
spontaneous resolution of fever but persistence of high acute phase reactants, with
significant improvement of leukocytosis. All the cutaneous lesions she presented were
debrided at the site of remission. Immunoglobulin levels, lymphocyte populations and
dyhidrorhodamine test were normal. She remained with no weight gain, constipation,
abdominal distension and hepatic involvement with elevated liver enzymes and prolonged
coagulation times. New bone compromise was documented. Inflammatory bowel disease,
neoplastic or chronic infectious disease involvement was ruled out. During the stay
in our institution no microbiological isolation was documented. Skin, colon and bone
tissue biopsies were performed and extra-institutionally performed liver biopsy were
examined, showing as a single common finding leukocytoclastic vasculitis in all tissues.
Given the heterogeneous nature of the condition, the diagnostic possibility of an
immune dysregulation disorder was considered and a therapeutic trial with NSAIDs and
prednisolone at 1mg/kg/day was started, as well as genetic studies by exome sequencing.
The exome results documented a novel mutation in the PIK3CD gene [c.1895T> A (p.Phe632Tyr)]
as probably pathogenic. The patient has presented a clinical improvement and a significant
decrease in inflammation markers. At the moment, we are waiting for the performance
of functional tests to define the definitive therapy for this patient.
Conclusions. This case description highlights the diagnostic difficulties that face
in developing countries, where the non-availability of functional testing has implications
on the diagnosis opportunity and establishment of optimal therapeutic for patients
with complex diseases such as primary immune regulatory disorders.
References:
1. Clin Rev Allergy Immunol. 2019 May 21. doi: 10.1007/s12016-019-08738-9. [Epub ahead
of print]
2. Medicine (Baltimore). 2019 May;98(18):e15329. doi: 10.1097/MD.0000000000015329.
(90) Submission ID#807966
Cyclic Autoinflammatory Syndrome as Observed by Providers and Reported by Parents
Brinda Desai, MD1, John Liu, n/a2, Jessica Haines, n/a2, Bazak Sharon, MD3
1Resident/University of Minnesota
2Undergraduate Student/University of Minnesota
3Assistant professor/University of Minnesota
Abstract/Case Report Text
Background: Autoinflammatory syndromes, a wide family of diseases, defined as attacks
of inflammation that are unprovoked (or triggered by a minor event) and are primarily
related to dysregulation of the innate immune system. Periodic/recurrent fever syndromes
were the former name of these diseases. However, only in two conditions: cyclic neutropenia
(CN) and periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) are
febrile episodes truly periodic. For PFAPA, although diagnostic criteria differ and
there is no consensus research definition, patients are usually not difficult to recognize
based on clinical course and presentation1. High index of suspicion and understanding
the parental experiences and descriptions of febrile episodes is imperative in facilitating
early recognition and timely diagnosis.
Aims: To standardize and summarized the clinical presentation of PFAPA, based on parental
descriptions and providers observation of febrile episodes.
Methods: Utilizing a query for the ICD-10 diagnosis code M04.8(+) we identified a
cohort of children diagnosed and managed for periodic fever, excluding those with
monogenetic mutation (e.g. Blau, Majeed) and those with chronic illness. We reviewed
the charts for documented parental report and provider observation of febrile episodes.
Standardized signs and symptoms were recorded for each patient [Table 1].
Results: A cohort of 75 children, 35 boys (47%) and 40 girls (53%) with documented,
cyclic episodes of fever >101, was identified. The average age at diagnosis was 3.77
+/- 2.34 years. Classic symptoms were reported or observed in 85% of patients (64).
More than half (68%, 51 patients) had documentations of other symptoms, usually reported
by parents to occur sporadically during some fever episodes. Decreased oral intake
and general “ill appearance” was reported by parents in 91% of patients. When reporting
the time intervals, parents usually reported similar length for each episode, typically
between 3-5 days, and regular interludes, typically between 3-4 weeks. The findings
are summarized in table 2.
Discussion: The findings presented here are in concordance with previously published
data describing PFAPA as a syndrome affecting young, generally healthy children with
identical episodes of fever lasting for a few days, recur with regularity. Our data
support the approach that parental observation is fundamental in identifying the unique
pattern of illnesses. Engaging the parents with directed interview is crucial to establish
this clinical diagnosis in a timely fashion, prevent misdiagnoses of future febrile
episodes as presumptive infections, and avert unnecessary antibiotics courses. This
cohort adds the observation that up to 15% of patients who display this identifiable
pattern of illnesses, do not present with aphthous stomatitis, pharyngitis, or adenitis.
These classic symptoms although common, are not the rule. The cyclic chronicity of
febrile episodes associated with general ill appearance (but not lethargy), and decreased
PO, in an otherwise healthy child is the clinical gold-standard of this condition.
1. Harel L, et al. The First International Conference on Periodic Fever, Aphthous
Stomatitis, Pharyngitis, Adenitis Syndrome. In: Journal of Pediatrics. ; 2018. doi:10.1016/j.jpeds.2017.10.034
(+)M04.8: Other autoinflammatory syndromes: Blau syndrome, Deficiency of interleukin
1 receptor antagonist [DIRA], Majeed syndrome, PFAPA, Pyogenic arthritis, pyoderma
gangrenosum, and acne syndrome
Table: Clinical signs and symptoms associated with febrile episodes, as documented
in medical charts
Table 2: Clinical features of febrile episodes in children diagnosed with PFAPA
(91) Submission ID#808074
Hepatitis B Core Antibody Positivity from Immunoglobulin Therapy
Jennifer Xu, MD1, F. Eun-Hyung Lee, MD2, Jennifer Shih, MD3
1Resident Physician/Emory University
2Associate Professor/Emory University
3Assistant Professor/Emory University
Abstract/Case Report Text
Background: Immunoglobulin therapy is used to treat patients who are immunocompromised
from primary immunodeficiency, chemotherapy, and autoimmune diseases. Hepatitis B
serologies are often checked in patients who are immunodeficient and prior to initiating
immunosuppressive therapies. The Hepatitis B Core Ab is a sensitive marker for previous
or current infection and a positive result may prompt anti-viral therapy. We present
a case of passive Hep B Core Ab transfer with immunoglobulin therapy and highlight
the importance of understanding this phenomenon to avoid inappropriate treatment and
misinterpretation of serologies. Previous literature has also presented similar cases,
but awareness is limited.
Case Presentation: A 38 year old Caucasian female with a history of common variable
immunodeficiency complicated with granulomatous interstitial lung disease and liver
disease (nodular regenerative hyperplasia), inflammatory bowel disease, immune thrombocytopenic
purpura presented for follow-up in clinic. She was receiving weekly 12g subcutaneous
immunoglobulin therapy. Her hepatitis B serology in 12/2015 demonstrated Anti-hep
B core positivity. The patient also had elevated liver function tests at the time
with alanine aminotransferase of 70 and aspartate aminotransferase of 57 and alkaline
phosphatase of 464 so the hepatitis surface Ag was checked and was negative. She later
had a liver biopsy for her transaminitis showing nodular regenerative hyperplasia.
In 2/2016 her Anti-hep B core was rechecked and was negative. In 7/2019 there was
possibility of placing patient on rituximab for her lung disease, her Anti hep B core
was checked again and had converted back to positive. Her hep B surface antigen levels
were consistently negative. Her hepatitis B DNA quant was also negative. Our patient
illustrates immunoglobulin therapy may passively transfer hep B c Ab and can result
in conversion of serologies without true hepatitis B infection.
Conclusion: Passive conversion of hepatitis B serologies should be considered in patients
on immunoglobulin therapy. In patients with elevated liver enzymes and anti hep B
core positivity a hepatitis surface antigen and HBV DNA can be checked to verify infection.
Increased awareness of this occurrence can decrease inaccurate diagnosis and unnecessary
therapies.
(92) Submission ID#808132
Characterization of the Clinical and Immunological Phenotype and Management of 157
Individuals with 56 Distinct Heterozygous NFKB1 Mutations
Tiziana Lorenzini, MD1,2, Manfred Fliegauf, PhD1,3, Nils Klammer, cand. med.1, Natalie
Frede, MD1, Michele Proietti, MD, PhD1, Alla Bulashevska, PhD1, Nadezhda Camacho-Ordonez,
MD1, Markku Varjosalo, PhD4, Matias Kinnunen, MSc4, Esther de Vries, MD, PhD5, Jos
W.M. van der Meer, MD, PhD6, Rohan Ameratunga, PhD7, Chaim M. Roifman, MD8, Yael D.
Schejter, MD8, Robin Kobbe, MD9, Timo Hautala, MD, PhD10, Faranaz Atschekzei, MD,
PhD11, Reinhold E. Schmidt, MD11, Claudia Schröder, MSc11, Polina Stepensky, MD12,
Bella Shadur, MBBS, BMedSci, FRACP12,13, Luis A. Pedroza, PhD14, Michiel van der Flier,
MD, PhD15, Mónica Martínez-Gallo, PhD16, Luis Ignacio Gonzalez-Granado, MD17, Luis
M. Allende, PhD18, Anna Shcherbina, MD, PhD19, Natalia Kuzmenko, MD, PhD19, Victoria
Zakharova, PhD20, João Farela Neves, MD21, Peter Svec, MD22, Ute Fischer, PhD23, Winnie
Ip, MD(Res), FRACP24, Oliver Bartsch, MD25, Safa Barış, MD26, Christoph Klein, MD,
PhD27, Raif Geha, MD28, Janet Chou, MD28, Mohammed Alosaimi, MD28, Lauren Weintraub,
MD29, Kaan Boztug, MD30, Tatjana Hirschmugl, MSc30, Maria Marluce Dos Santos Vilela,
MD, PhD31, Dirk Holzinger, MD32, Maximilian Seidl, MD33, Vassilios Lougaris, MD2,
Alessandro Plebani, MD2, Laia Alsina, MD, PhD34, Monica Piquer-Gibert, MD34, Angela
Deyà-Martínez, MD, PhD34, Charlotte A. Slade, MBBS35, Asghar Aghamohammadi, MD, PhD36,
Hassan Abolhassani, MD, PhD36,37, Lennart Hammarström, MD, PhD37, Outi Kuismin, MD,
PhD38, Merja Helminen, MD, PhD39, Hana Lango Allen, PhD40, James E. Thaventhiran,
MRCP, FRCPath, PhD41, Alexandra F. Freeman, MD42, Matthew Cook, MBBS, PhD FRACP, FRCPA43,
Shahrzad Bakhtiar, MD44, Mette Christiansen, PhD45, Charlotte Cunningham-Rundles,
MD, PhD46, Niraj C. Patel, MD47, William Rae, MRCP48, Tim Niehues, MD49, Nina Brauer,
MD49, Jaana Syrjänen, MD, PhD50, Mikko R.J. Seppänen, MD, PhD51, Siobhan O. Burns,
MRCP, PhD52, Paul Tuijnenburg, MD53, Taco W. Kuijpers MD53 on behalf of the NIHR-BioResource
– Rare Diseases Consortium54, Klaus Warnatz, MD1, and Bodo Grimbacher, MD3,55,56,57.
1. Center for Chronic Immunodeficiency, Medical Center University of Freiburg, Faculty
of Medicine, University of Freiburg, Germany.
2. Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department
of Clinical and Experimental Sciences, University of Brescia and ASST- Spedali Civili
of Brescia, Brescia, Italy.
3. CIBSS - Centre for Integrative Biological Signalling Studies, University of Freiburg,
Germany.
4. Institute of Biotechnology, University of Helsinki, Helsinki, Finland.
5. Laboratory for Medical Microbiology and Immunology, Elisabeth Tweesteden Hospital,
and Department of Tranzo, Tilburg University, Tilburg, The Netherlands.
6. Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the
Netherlands.
7. Department of Virology and Immunology and Department of Clinical Immunology, Auckland
City Hospital, Auckland 1010, New Zealand.
8. The Canadian Centre for Primary Immunodeficiency, Immunogenomic Laboratory, Division
of Immunology and Allergy, Department of Pediatrics, The Hospital for Sick Children
and the University of Toronto, Toronto, Ontario, Canada.
9. Department of Pediatrics, University Medical Centre Hamburg, Hamburg, Germany.
10. Department of Internal Medicine, Oulu University Hospital, Oulu, Finland.
11. Division of Immunology and Rheumatology, Hannover Medical University, Hannover,
Germany.
12. Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center,
Jerusalem, Israel.
13. Department of Immunology, Garvan Institute of Medical Research, and University
of New South Wales, Graduate Research School, Sydney, Australia.
14. Colegio de ciencias de la salud-Hospital de los Valles and Instituto de Microbiología,
Universidad San Francisco de Quito, Quito, Ecuador, and Department of Pediatrics,
Section of Immunology, Allergy, and Rheumatology, Baylor College of Medicine, Houston,
TX, USA.
15. Department of Pediatric Infectious Diseases & Immunology and Nijmegen Institute
for Infection, Immunity and Inflammation, Radboud University Medical Centre, Nijmegen,
The Netherlands.
16. Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Vall d'Hebron
Research Institute (VHIR), Department of Cell Biology, Physiology and Immunology,
Autonomous University of Barcelona (UAB), Barcelona, Catalonia, Spain; Jeffrey Model
Foundation Excellence Center, Barcelona, Catalonia, Spain.
17. Primary Immunodeficiencies Unit. Pediatrics. Hospital 12 octubre. School of Medicine,
Complutense University, 12 de Octubre Health Research Institute (imas12), Madrid 28041,
Spain.
18. Immunology Department. Hospital Universitario 12 de Octubre, Madrid, Spain.
19. Department of Clinical Immunology, Dmitry Rogachev Federal Research and Clinical
Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia.
20. Department of Hematopoietic Stem Cell Transplantation, Dmitry Rogachev National
Medical and Research Center of Pediatric Hematology, Oncology and Immunology, Moscow,
Russia.
21. Primary Immunodeficiencies Unit, Hospital Dona Estefania, Centro Hospitalar de
Lisboa Central, Lisbon, Portugal.
22. Department of Paediatric Haematology and Oncology, Haematopoietic Stem Cell Transplantation
Unit, Comenius University Children's Hospital, Bratislava, Slovakia.
23. Department of Paediatric Oncology, Hematology and Clinical Immunology, Center
for Child and Adolescent Health, Medical Faculty, Heinrich Heine University, Düsseldorf,
Germany.
24. Department of Immunology and Molecular and Cellular Immunology Unit, Great Ormond
Street Hospital & University College London (UCL) Great Ormond Street Institute of
Child Health, London, United Kingdom.
25. Institute of Human Genetics, Medical Centre of the Johannes Gutenberg University,
Mainz.
26. Marmara University School of Medicine, Department of Pediatrics, Division of Allergy
and Immunology, Istanbul, Turkey.
27. Department of Pediatrics, Dr von Hauner Children's Hospital, University Hospital,
LMU Munich, Munich, Germany.
28. Division of Immunology, Boston Children’s Hospital and Department of Pediatrics,
Harvard Medical School, Boston, MA, USA.
29. Divisions of Pediatric Hematology/Oncology, Albany Medical Center, Albany, NY,
USA.
30. CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences,
Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Department of Pediatrics
and Adolescent Medicine and St. Anna Kinderspital and Children's Cancer Research Institute,
Department of Pediatrics, Medical University of Vienna, Vienna, Austria.
31. Laboratory of Pediatric Immunology, Center for Investigation in Pediatrics, Faculty
of Medical Sciences, University of Campinas - UNICAMP, Campinas, SP, Brazil.
32. Department of Pediatric Hematology-Oncology, University of Duisburg-Essen, Essen,
Germany.
33. Center for Chronic Immunodeficiency and Molecular Pathology, Department of Pathology,
University Medical Center, University of Freiburg, Freiburg, Germany.
34. Pediatric Allergy and Clinical Immunology Department and Institut de Recerca,
Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain.
35. Department of Clinical Immunology and Allergy, Royal Melbourne Hospital, Melbourne,
Australia.
36. Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's
Medical Center, Tehran University of Medical Science, Tehran, Iran.
37. Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska
Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden.
38. PEDEGO Research Unit, Medical Research Center Oulu, Oulu University Hospital and
University of Oulu and Department of Clinical Genetics, Oulu University Hospital,
Oulu, Finland.
39. Tampere Center for Child Health Research, University of Tampere and Tampere University
Hospital, Tampere Finland.
40. Department of Haematology, University of Cambridge, Cambridge, United Kingdom;
NHS Blood and Transplant Cambridge, Cambridge Biomedical Campus, Cambridge, United
Kingdom.
41. Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
42. Laboratory of Clinical Immunology and Microbiology, NIAID, National Institutes
of Health, Bethesda, MD, USA.
43. Australian National University Medical School and John Curtin School of Medical
Research, Australian National University, Acton, Australia; Department of Immunology,
Canberra Hospital, Canberra, Australia.
44. Division for Pediatric Stem-Cell Transplantation and Immunology, University Hospital
Frankfurt, Frankfurt/Main, Germany.
45. International Center for Immunodeficiency Diseases and Department of Clinical
Immunology, Aarhus University Hospital Skejby, Aarhus, Denmark.
46. Division of Clinical Immunology, Icahn School of Medicine at Mount Sinai, New
York, NY, USA.
47. Department of Pediatrics, Section of Infectious Disease and Immunology, Levine
Children's Hospital, Atrium Health, Charlotte, NC, USA.
48. Southampton NIHR Wellcome Trust Clinical Research Facility and NIHR Biomedical
Research Centre, University Hospital Southampton NHS Foundation Trust, Department
of Allergy, Asthma and Clinical Immunology, University Hospital Southampton, Southampton,
United Kingdom.
49. Department of Pediatric Hematology and Oncology, Helios Klinikum Krefeld, Krefeld,
Germany.
50. Department of Internal Medicine, Tampere University Hospital, Tampere, Finland.
51. Rare Disease Center, New Children’s Hospital and Adult immunodeficiency Unit,
Inflammation Center, University of Helsinki and Helsinki University Hospital, Finland.
52. Department of Immunology, Royal Free London NHS Foundation Trust, University College
London Institute of Immunity and Transplantation, London, United Kingdom.
53. Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Department of
Pediatric Immunology, Rheumatology and Infectious diseases, Meibergdreef 9, Amsterdam,
The Netherlands.
54. NIHR BioResource, Cambridge University Hospitals, Cambridge Biomedical Campus,
Cambridge, CB2 0QQ, UK.
55. Institute of Immunology and Transplantation, Royal Free Hospital and University
College London, London, UK.
56. DZIF (German Center for Infection Research) Satellite Center Freiburg, Germany.
57. Center for Chronic Immunodeficiency, Medical Center University of Freiburg, Faculty
of Medicine, University of Freiburg, Germany. bodo.grimbacher@uniklinik-freiburg.de.
Abstract/Case Report Text
Heterozygous mutations in NFKB1 are frequently identified among immunodeficient patients
with highly variable clinical symptoms. In a world-wide collaborative effort, we characterized
the clinical and cellular phenotype and the management of 251 of these patients harboring
106 distinct NFKB1 variants.
NFKB1 encodes the transcription factor precursor p105 which is processed to p50 (canonical
pathway). Known pathogenic variants cause p50 haploinsufficiency (due to protein decay)
or p105-skipping (with expression of p50-like forms). Most variants however are single
amino acid changes with yet unknown effects. All sequence changes were assessed in
silico for their probability of pathogenicity including 32 variants which were additionally
tested in vitro. These analyses include the sub-cellular protein localization (microscopy),
protein expression, stability and processing (Western blotting), transcription factor
activity (reporter assay) and DNA-binding (EMSA) in HEK293T cells transfected with
synthetic constructs. So far, 56 distinct variants in 157 individuals from 68 unrelated
families indicated a pathogenic relevance.
The NFKB1-associated primary immunodeficiency disorder (PID) is characterized by hypogammaglobulinemia
(88.9%), reduced switched memory B cells (60.3%), and respiratory (82.2%) and gastrointestinal
(29.2%) infections. Incomplete penetrance (70%) and age-dependent severity of the
clinical phenotypes were common. In addition, high frequencies of autoimmunity (57.4%),
lymphoproliferation (52.4%), non-infectious enteropathy (23.1%), opportunistic infections
(15·7%), autoinflammation (29.6%), and malignancy (15.7%) indicate immune dysregulation
and multi-system involvement. Current treatment options include immunoglobulin replacement
and immunosuppressive therapy. Our results suggest that hematopoietic stem cell transplantation
and specific targeting of the NF-κB1 signalling pathways should be considered as alternative
strategies in the future.
(93) Submission ID#808137
Changes in DNA Methylation Levels at the PI3KCD Locus in CVID patients
Nadezhda Camacho-Ordonez, MD, PhD student1, Anne Weiss, PhD student2, Magdeldin Elgizouli,
MBBS, PhD3, Klaus Warnatz, MD4, Bodo Grimbacher, MD5
1PhD student/Center for Chronic Immunodeficiency, Faculty of Medicine, Medical Center
- University of Freiburg, Freiburg, Germany
2MsC/Center for Chronic Immunodeficiency, Faculty of Medicine, Medical Center - University
of Freiburg, Freiburg, Germany
3Attending Physician, PhD/Institute of Human Genetics, University of Zurich, Switzerland.
4Attending physician, principal investigator/Center for Chronic Immunodeficiency,
Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
5Principal Investigator/Center for Chronic Immunodeficiency, Faculty of Medicine,
Medical Center - University of Freiburg, Freiburg, Germany
Abstract/Case Report Text
Background. Common variable Immunodeficiency is the most common symptomatic primary
immunodeficiency characterized by a loss of specific antibody production. Monogenetic
causes have been identified in around 25-40% of patients. Lymphocyte differentiation
is accompanied by demethylation processes. Previous work suggested impaired DNA demethylation
during naïve-to-memory B cell transition in a cohort of 16 CVID patients. We investigated
DNA methylation patterns at previously reported candidate sites at a set of genetically
undefined CVID patients compared to healthy donors.
Methods. PBMCs of 19 patients and 19 healthy controls were sorted into four B-cells
subsets (CD21low, naïve, IgM memory and switched memory) and four T-cell subsets (naïve
CD4+, CD4+ EM, regulatory T cells [Tregs] and CD8+ effector memory RA [TEMRA]). Pyrosequencing
was used to determine the methylation status at five previously reported CpG sites
in the following genes: BCL2L1, PIK3CD, RPS6KB2, KCNC4, and CORO1B/PTPRCAP.
Results. Results from nineteen case-control pairs, matched for sex and age, demonstrated
a significant change in the methylation level in naïve B cells in the CpG island of
PI3KCD. For T cell subsets, we observed significant differences for KCNC4 (in Treg),
CORO1B (in TEMRA cells) and RPS6KB2 (in CD4+EM). A late age-of-onset of CVID was associated
with decreased methylation in PI3KCD in CD21low B cells. Autoimmunity was correlated
with increased methylation levels in PI3KCD in IgM memory B cells and CORO1B in naïve
B cells.
Conclusions. In CVID patients, significant differences were observed in PI3KCD (CpG1),
which is mainly regulated at a transcriptional level. Our work adds evidence that
epigenetic factors need to be taken into account to understand the etiology of CVID.
(94) Submission ID#808142
Infections In Secondary Immunodeficiency Patients Treated With Privigen Or Hizentra:
A Retrospective US Administrative Claims Study In Patients With Haematological Malignancies
Rajiv Mallick, PhD1, B. Douglas Smith, MD2, Stephen Jolles, MD, PhD3, Donald C. Vinh,
MD4, Mitchell DeKoven, MHSA5, Victoria Divino, MSc6
1Director of Global Evidence, Market Access and Pricing/CSL Behring, King of Prussia,
PA, USA
2Professor/Johns Hopkins University School of Medicine, Baltimore, MD, USA
3Consultant Clinical Immunologist & Honorary Professor/University Hospital of Wales,
Cardiff, UK
4Associate Professor/McGill University Health Centre, Montreal, Canada
5Senior Principal - Health Economics and Outcomes Research/IQVIA, Falls Church, VA,
USA
6Associate Principal - Health Economics and Outcomes Research/IQVIA, Falls Church,
VA, USA
Abstract/Case Report Text
Introduction: Infections are a common outcome in patients with secondary immunodeficiency
(SID)/hypogammaglobulinemia with underlying haematological malignancies. These infections
are routinely treated with antibiotics and/or immunoglobulin replacement therapy (IgRT).
This study evaluated the benefit of IgRT (Privigen® or Hizentra®, CSL Behring, King
of Prussia, PA, USA) in terms of (a) occurrence and (b) change in frequency with IgRT
of major/severe infections in patients with haematological malignancies and SID.
Methods: A retrospective database analysis was conducted using the IQVIA Real-World
Data Adjudicated Claims – US Database (study period: January 2010–September 2018).
Patients with an SID diagnosis were identified (diagnosis date) and stratified by
underlying malignancy (chronic lymphocytic leukaemia, multiple myeloma and/or Non-Hodgkin’s
lymphoma). Those who had received Privigen® or Hizentra® (and no other IgRT) for 12-months
following diagnosis date were defined as cases and age- and cancer subtype-matched
patients who did not receive IgRT were defined as controls. Index date was date of
IgRT initiation for cases while a pseudo-index date was assigned to controls (diagnosis
date + days between diagnosis date and index date for matched case). Among cases and
controls: (a) occurrence of major/severe bacterial infections (defined as inpatient
hospitalisation with bacterial infection and/or use of intravenous antibiotics in
an outpatient setting) over the 12-month pre-index period (baseline) and 12 months
post-index and (b) change in frequency of major/severe bacterial infections pre- and
post-index were assessed.
Results: A total of 277 cases were matched to 1,019 controls. Mean age (57.2/56.6
years) and gender split (56.7%/55.5% male) were similar between cases and controls.
At baseline, more cases had antibiotics claims (95.7% vs 87.0%, p < 0.0001) and more
received cancer treatment (56.0% vs 45.9%, p=0.0031). Cases were more likely to have
neutropenia, sinusitis or bronchitis (35.7% vs 27.1%, p=0.0049; 40.8% vs 26.9%, p
< 0.0001; 25.3% vs 18.2%, p=0.0083) respectively, versus controls. Cases also had
significantly higher pre-index healthcare costs ($219,149 vs $153,800; p < 0.0001).
In the 12-month pre-index period, 88.4% of cases versus 72.9% of controls experienced
any bacterial infection (p < 0.0001) and the proportion of patients who experienced
≥1 major/severe bacterial infection was 42.2% for cases versus 31.8% for controls
(p=0.0011). The mean number of major/severe bacterial infections per patient in the
12-month pre-index period was 0.5 for cases versus 0.2 for controls (p=0.0014).
Evaluating post-index outcomes, 21.7% of cases versus 21.2% of controls had major/severe
bacterial infections (Figure 1); the associated unadjusted odds ratio (OR) was not
significant, suggesting IgRT had restored cases to a similar baseline infection risk
as the controls. In a multivariate conditional logistic regression model adjusting
for the significantly higher occurrence of risk factors in cases compared with controls
in the pre-index period, cases were associated with a 31% lower adjusted odds of major/severe
infections in the post-index period versus controls (OR=0.69; p=0.04).
Conclusions: Patients who required treatment with IgRT (Privigen®/Hizentra®) had previously
experienced more major/severe bacterial infections than those not needing treatment
with IgRT. However, IgRT was associated with a reduction in the risk-adjusted odds
of major/severe bacterial infections compared with non-IgRT treated SID patients with
haematological malignancies.
Figure 1. Percentage of patients with ≥1 major/severe bacterial infection pre- and
post-index in cases or controls
(95) Submission ID#808148
Risk Factors For Major/Severe Infections in Secondary Immunodeficiency: A Retrospective
US Administrative Claims Study In Patients With Haematological Malignancies
Stephen Jolles, MD, PhD1, B. Douglas Smith, MD2, Donald C. Vinh, MD3, Rajiv Mallick,
PhD4, Gabriela Espinoza, MD5, Mitchell DeKoven, MHSA6, Victoria Divino, MSc7
1Consultant Clinical Immunologist & Honorary Professor/University Hospital of Wales,
Cardiff, UK
2Professor/Johns Hopkins University School of Medicine, Baltimore, MD, USA
3Associate Professor/McGill University Health Centre, Montreal, Canada
4Director of Global Evidence, Market Access and Pricing/CSL Behring, King of Prussia,
PA, USA
5Director, Global Medical Affairs Immunoglobulin/CSL Behring, King of Prussia, PA,
USA
6Senior Principal - Health Economics and Outcomes Research/IQVIA, Falls Church, VA,
USA
7Associate Principal - Health Economics and Outcomes Research/IQVIA, Falls Church,
VA, USA
Abstract/Case Report Text
Introduction: Real-world data are lacking as far as identifying patients with secondary
immunodeficiency (SID)/hypogammaglobulinemia who may benefit most from interventions
to protect them from potentially fatal infections. This study aimed to identify risk
factors for major/severe infections in patients with SID with underlying haematological
malignancies.
Methods: A retrospective database analysis was conducted using the IQVIA Real-World
Data Adjudicated Claims – US Database (study period: January 2010–September 2018).
Inclusion criteria were adults newly diagnosed with SID (first diagnosis termed the
index date), with ≥12-months continuous health plan enrolment pre-index (baseline
period) and a minimum of 3 months’ data post-index (mean: 615 days), with chronic
lymphocytic leukaemia, multiple myeloma and/or non-Hodgkin’s lymphoma and without
claims for any Ig therapy in the 12-month baseline period. Patient characteristics
in the 12-month baseline period were assessed. Over the post-index period, antibiotic/antiviral
use and frequency of infections were assessed. The frequency of major/severe infections
was determined using diagnosis codes for bacterial, viral, fungal, parasitic, other
or unspecified causal pathogen infections. Major/severe infections were defined as
those requiring inpatient hospitalisation with an infection diagnosis code and/or
use of intravenous (IV) antibiotics or IV antivirals in an outpatient setting. A multivariate
Cox proportional hazards (PH) model evaluated baseline patient characteristics associated
with risk of major/severe infections post-index.
Results: A total of 4,066 patients met the inclusion criteria. The mean age of patients
was 57 years and 56.0% were male. In the 12-month baseline period: 75.6% of patients
received cancer treatments and 87.0% of patients received antibiotics (27.1% IV antibiotics).
A total of 79.5% of patients experienced any infection, 65.6% experienced ≥2 infections
and 30.4% experienced major/severe infections. The mean number of infections over
the baseline 12 months was 9.5 for any infection (at the unique diagnosis code level)
and 0.7 for major/severe infections (unique hospitalisations with any infection diagnosis
code and/or unique days with an outpatient IV antibiotic or IV antiviral). In the
post-SID diagnosis period, 46.4% of patients had major/severe infections; of the major/severe
infections, 34.0% were identified as bacterial, 11.6% were viral, 6.3% were fungal,
while 48.2% did not have a causal pathogen specified. A total of 21.3% of patients
experienced one severe/major infection and 10.5% experienced ≥4 severe/major infections
(Figure 1). The mean annualised number of major/severe infections post-index was 1.5.
Receiver operating characteristic (ROC) curve analysis to optimise sensitivity versus
false positives in identifying those at risk of major/severe infections post-index
identified a cut-off point of three bacterial infections in the baseline pre-index
period as a potential optimal trigger to consider treatment to avoid major/severe
infections post-index (Figure 2). The multivariate Cox PH analysis suggested that
hospitalisations, infections (≥3), or antibiotic use in the 12-months pre-index (prior
to SID diagnosis) were predictive of major/severe infections post-index (post-SID
diagnosis) (all p < 0.0001).
Conclusion: Infections are common in patients with haematological malignancies and
SID. Key baseline predictors for major/severe infections in patients with an SID diagnosis
were a history of infections, hospitalisations or antibiotic use.
Figure 1. Percentage of patients who experienced major/severe infections in the post-SID
diagnosis period, by number of infections
Figure 2. ROC curve for pre-SID diagnosis infections as a predictor of risk of major/severe
infections post-SID diagnosis
(96) Submission ID#808315
Targeted Proteomics Panel for Clinical Diagnosis and Newborn Screening of Primary
Immunodeficiencies from Dried Blood Spots
Christopher Collins, PhD1, Fan Yi, PhD1, Remwilyn Dayuha, BS2, Jeff Whiteaker, PhD3,
Amanda Paulovich, MD, PhD4, Hans Ochs, MD5, Alexandra Freeman, MD6, Helen Su, MD,
PhD7, Gesmar Segundo, MD, PhD8, Troy Torgerson, MD, PhD9, Sihoun Hahn, MD, PhD10
1Research Scientist/Seattle Children's Hospital
2Research Technician/Seattle Children's Hospital
3Research Scientist/Fred Hutchinson Cancer Research Institute
4Principle Investigator/Fred Hutchinson Cancer Research Institute
5Professor of Pediatrics and Immunology/University of Washington and Seattle Children's
Research Institute
6Senior Clinician/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH
7Senior Investigator/Laboratory of Clinical Immunology and Microbiology, National
Institute of Allergy and Infectious Diseases, National Institutes of Health
8Assistant Professor/Universidade Federal de Uberlandia
9Associate Professor/University of Washington, Immunology
10Principle Investigator/Seattle Children's Hospital
Abstract/Case Report Text
Background: Tandem mass spectrometry (MS/MS) is a primary platform for many clinical
and newborn screening laboratories. The application of MS/MS mainly focuses on the
analysis of accumulated metabolites in plasma. Direct quantification of intracellular
proteins would benefit diseases where such metabolites do not exist. Unfortunately,
MS/MS detection is limited by the extremely low (e.g., pmol/L) protein concentrations
in blood cells. Peptide immunoaffinity enrichment coupled to selected reaction monitoring
(immuno-SRM) is a robust method for quantification of low abundance proteins in complex
matrices, including dried blood spots (DBS). In a study of 37 patients, immuno-SRM
reliably identified Wiskott-Aldrich Syndrome (WAS) and X-linked agammaglobulinemia
(XLA) patients using direct quantification of proteins responsible for disease (Front.
Immunol., 2018). We further expanded our approach for X-linked Chronic Granulomatous
Disease (X-CGD), ADA and Dock8 deficiency. Marker proteins representing platelets,
NK cells, and T-Cells have also been analyzed to provide additional information about
disease processes. These results demonstrate the utilization of immuno-SRM as a sensitive
platform for multiplexed signature peptide quantification and its potential for PIDD
newborn screening and clinical diagnosis from DBS.
Methods: Candidate peptides were selected based on MS/MS sensitivity and uniqueness
in the proteome. Anti-peptide monoclonal antibodies (mAbs) were then generated for
peptide enrichment from DBS. Blood from normal controls, XLA, WAS, XL-CGD, Dock8 and
ADA deficiency patients was collected after consent on filter paper, dried, and stored
at -20 °C. Proteins were extracted from DBS, digested with trypsin, and enriched using
mAbs bound to magnetic beads. The enriched peptides were then eluted and analyzed
with a Waters Xevo TQ-XS.
Results: A multiplexed Immuno-SRM panel has been generated for screening eight signature
peptides representing five PIDD-specific and three cell-type specific proteins from
DBS. Limits of detection and quantification were femtomoles of peptide, the assay
showed a broad linear range, and intra-assay and inter-assay coefficients of variation
were < 20%. In samples from 13 XLA, 8 WAS, 3 XL-CGD, 1 Dock8 and 1 ADA deficiency
patients, signature peptides are significantly reduced relative to normal controls
and patient identification had excellent agreement with clinical and molecular diagnosis.
Also included in the multiplex panel are cell specific markers for platelets (CD42),
T-Cells (CD3ɛ), and NK Cells (CD56). Diagnostic cutoffs for each peptide concentration
have been established. In WAS patients, CD42 levels were significantly reduced consistent
with characteristic thrombocytopenia. Immuno-SRM also has the ability demonstrate
the effects of PIDD treatment. A WAS patient analyzed before and after bone marrow
transplant showed normalized WAS protein and CD42 after treatment. Two ADA deficiency
patients showed normal levels of ADA enzyme after RBC transfusion. Finally, a high-throughput
(HT) Immuno-SRM method screens PIDD-specific peptides in a 2.5-minute runtime meeting
high volume NBS workflow requirements. This HT method returned identical results to
the standard Immuno-SRM PIDD panel.
Conclusions: The data herein demonstrate the feasibility of using Immuno-SRM as a
broad clinical diagnostic for identifying and studying PIDD patients from easily collected
and shipped DBS. Significantly, HT immuno-SRM workflows represent a promising potential
option for NBS of PIDDs and other congenital disorders.
(97) Submission ID#808468
Artificial Thymic Organoids Reveal an Early Block in T Cell Differentiation In Patients
Carrying Mutations In IKZF1
Marita Bosticardo, PhD1, Francesca Pala, PhD2, Hye Sun Kuehn, PhD3, Amelie Montel-Hagen,
PhD4, Gay Crooks, MD5, Sergio Rosenzweig, MD, PhD6, Luigi Notarangelo, MD, PhD7
1Staff Scientist/Laboratory of Clinical Immunology and Microbiology, IDGS, DIR, NIAID,
NIH
2Post Doctoral Fellow/Laboratory of Clinical Immunology and Microbiology, IDGS, DIR,
NIAID, NIH
3Staff scientist/Immunology Service, Department of Laboratory Medicine, Clinical Center,
NIH, USA
4Associate Project Scientist/Department of Pathology and Laboratory Medicine, DGSOM,
UCLA, Los Angeles, CA
5Professor/Department of Pathology and Laboratory Medicine, DGSOM, UCLA, Los Angeles,
CA
6Senior Investigator; Chief/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center, Bethesda, MD, USA
7Chief, Laboratory of Clinical Immunology and Microbiology/National Institute of Allergy
and Infectious Diseases, NIAID/National Institutes of Health, NIH
Abstract/Case Report Text
We have previously used the artificial thymic organoid (ATO) system, based on the
3D aggregation and culture of a delta-like canonical Notch ligand 4-expressing stromal
cell line (MS5-Dll4) with CD34+ cells, to study T cell differentiation from CD34+
cells obtained from patients carrying defects that are intrinsic to hematopoietic
cells (RAG1-2, AK2, IL2RG) or that affect thymus development (DiGeorge syndrome).
We now report results of in vitro T cell differentiation of CD34+ cells obtained from
patients with either haploinsufficiency or dominant negative (DN) mutations of the
IKZF1 gene. IKZF1 is an essential transcription factor expressed throughout hematopoiesis
and involved in both lymphocyte and myeloid differentiation. Heterozygous germline
mutations in IKZF1 give rise to distinct clinical phenotypes, depending on the nature
of the mutation. In particular patients with IKZF1 haploinsufficiency present with
common variable immunodeficiency (CVID) associated with B cell immune deficiency,
B-ALL susceptibility, and autoimmune manifestations. No clinical T cell defects are
evident among these patients, except for elevated naive and central memory CD3+CD8+
T cells. In contrast, patients carrying DN IKZF1 mutations present with combined immunodeficiency
(CID) characterized by the presence of an increased proportion of naïve T cells, associated
with defective generation of memory T cells, impaired T cell activation, signaling
and proliferation, reduced T-helper (Th) polarization, and susceptibility to Pneumocystis
pneumonia. Different mouse models of IKZF1 mutations have been developed, however
their phenotype does not fully match what reported in patients, and in some models
indicates a more severe defect in T cell development. To address these controversies
and to gain novel insights into the effects of distinct IKZF1 mutations on human T
cell development, we used the ATO system to analyze progression of T cell development
from CD34+ cells obtained from one patient with IKZF1 haploinsufficiency and one patient
with DN IKZF1 mutation.
Both patients showed a similar early block in T-cell differentiation at pre-T cell
stage. However, the patient with IKZF1 haploinsufficiency showed a more pronounced
leakiness, with a residual production of CD3+TCRab+ cells, which could account for
the milder T-cell phenotype presented in this type of patients. Interestingly, the
DN patient presented an increased accumulation of CD4-CD8b-CD8aa+ cells. These results
show an unexpected role for IKZF1 in humans in early stages of T-cell differentiation
and indicate IKZF1 as a necessary factor for the induction of CD8b expression in T
cells.
Funding: This work was supported by the Division of Intramural Research, NIAID, NIH
(98) Submission ID#808636
Characterization of the Immunological Phenotype in a Patient with Indeterminate Pediatric
Acute Liver Failure (iPALF) and Aplastic Anemia (AA)
Jennifer Yonkof, MD1, Benjamin Prince, MD2, Rajinder Bajwa, MD3, Carol Potter, MD4,
Portia Kreiger, MD5, Scott Canna, MD6, Roshini Abraham, PhD7
1Allergy and Immunology Fellow, PGY-V/Nationwide Children's Hospital & the Ohio State
University Wexner Medical Center
2Assistant Professor, Department of Allergy and Immunology/Nationwide Children's Hospital
3Professor, Department of Hematology and Oncology/Nationwide Children's Hospital
4Professor, Department of Gastroenterology/Nationwide Children's Hospital
5Associate Professor of Clinical Pathology and Laboratory Medicine/The Children's
Hospital of Philadelphia
6Pediatric Rheumatologist/University of Pittsburgh
7Associate Chief of Academic Affairs, DIL Director, Dept. of Pathology and Laboratory
Medicine/Nationwide Children's Hospital
Abstract/Case Report Text
Background: Pediatric acute liver failure without an identifiable cause (indeterminate
PALF/iPALF) is associated with increased rates of liver transplant and mortality.
Aplastic anemia (AA) may develop weeks after the diagnosis. The immunologic mechanisms
that contribute to disease pathogenesis have not been clearly elucidated. We report
detailed Immunophenotyping of a patient with iPALF/AA.
Case: A previously-healthy 7-year-old male was admitted for acute hepatitis presenting
with jaundice and hepatosplenomegaly. Evaluation for infectious, toxic, metabolic,
autoimmune, and rheumatologic disorders was negative. He was pan-lymphopenic (CD45+ALC
445 cells/μL) with an inverted CD4:CD8 ratio of 0.2 on admission.
Liver biopsy showed severe portal, interface, and lobular inflammation characterized
by activated sinusoidal macrophages and perforin-expressing CD8+T-cells. Compared
to a healthy control, the percentage and number of peripheral blood CD8+T-cells expressing
perforin (20%v.94%, 85 v.153 cells/μL) and granzyme-A/B (15%v.90%, 66 v.147 cells/μL)
was also increased, while percentages of perforin+(96%) and granzyme-A/B+(98%) NK
cells were normal. Bone marrow (BM) showed 75% cellularity with rare hemophagocytosis.
Serum cytokine analysis demonstrated IL-18 4052 pg/ml, IL-18-binding-protein 23003
pg/ml, CXCL9 4436 pg/ml, and sIL-2Rα 7979 U/ml, consistent with smoldering hemophagocytic
lymphohistiocytosis (HLH), but he did not meet HLH diagnostic criteria. Genetic sequencing
did not identify pathogenic variants in 207 genes associated with primary immunodeficiencies.
He was diagnosed with iPALF and treated with three doses of anakinra and two weeks
of ruxolitinib, followed by prednisone 1-2 mg/kg/day and intravenous immunoglobulin
1g/kg/month. Immunophenotyping performed after two months of therapy showed persistent
inversion of the CD4:CD8 ratio with small expansions of CD3+CD4-CD8- cells and TCR··+T-cells.
In the CD4+T-cell subset, there was a substantial paucity of naïve cells, with effector
memory T cells (Tem) being more abundant than central memory T cells (Tcm). In the
CD8+T-cell subset, the majority of CD45RO+cells were Tem with no detectable Tcm, and
49% of all CD3+T-cells were CD8+TEMRA. In both CD4+ and CD8+T-cell subsets, activated
(HLA-DR+) and senescent (CD57+) subpopulations were increased, and the majority of
cells expressed the exhaustion marker PD-1. The hepatic inflammatory infiltrate similarly
reflected repetitive antigenic stimulation, with expansion of CD103+CD8+T-cells. Quantitative
immunoglobulins and total memory B-cells and plasmablasts (CD19+CD27+) were normal
for age. However, there were no circulating IgA-memory B-cells and a reduced number
of IgG-switched memory B-cells (Table 1).
Given the severity of his phenotype and BM hypocellularity (5%), allogeneic HCT was
performed using a matched-related-donor (10/10) with conditioning of Flu+Cy+Alemtuzumab.
At D+30, he shows improved liver function but persistent pancytopenia, with transfusion-dependence
for platelets.
Discussion: To our knowledge, this is the first description of detailed immunophenotyping
in blood from a patient with iPALF/AA. Other studies have identified distinguishing
hepatic infiltrates and cytokine/chemokine profiles that suggest excessive activation
of cytotoxic T-lymphocytes and macrophages contribute to disease pathogenesis (Alonso
et al, 2017). Our preliminary data supports this hypothesis and expands the spectrum
of immune dysregulation in the T and B cell compartments, proposing a primary immune
etiology. Immune dysregulation may be concordant with hyperinflammation and cytokine
storm, the latter offering potential therapeutic targets. Early diagnosis and treatment
of immune dysregulation may prevent development of AA.
Table 1. Immunophenotyping of a patient with iPALF and AA refractory to immunosuppressant
therapy.
Immunologic Parameter
P1
Median of >36 Healthy Controls
CD45+/CD14- lymphocytes (cells/mm3)
223
1670
CD3+ T cells (% lymphocytes, cells/mm3)
81, 181
76, 1300
CD3+CD4+ T cells (% lymphocytes, cells/mm3)
6, 14
47, 790
CD3+CD8+ T cells (% lymphocytes, cells/mm3)
64, 142
25, 415
CD3+CD4-CD8- T cells (% lymphocytes)
11
3
TCR ··+ T cells (% CD3+T cells)
16
3
CD19+/CD20+ B cells (% lymphocytes, cells/mm3)
4, 10
11, 160
CD16++/CD56+ NK cells (% lymphocytes, cells/mm3)
13, 30
12, 180
Naive CD4+ T cells, CD4+CD45RA+CD62L+CCR7+ (%CD4+CD45RA+)
0
99
Central Memory CD4+ T cells, CD4+CD45RO+CD62L+CCR7+ (%CD4+CD45RO+)
10
55
Effector Memory CD4+ T cells, CD4+CD45RO+CD62L-CCR7- (%CD4+CD45RO+)
36
15
TEMRA CD4+ T cells, CD4+CD45RA+CD62L-CCR7- (%CD4+CD45RA+)
55
0.2
Naive CD8+ T cells, CD8+CD45RA+CD62L+CCR7+ (%CD8+CD45RA+)
1
78
Central Memory CD8+ T cells, CD8+CD45RO+CD62L+CCR7+ (%CD8+CD45RO+)
0
16
Effector Memory CD8+ T cells, CD8+CD45RO+CD62L-CCR7- (%CD8+CD45RO+)
83
48
TEMRA CD8+ T cells, CD8+CD45RA+CD62L-CCR7- (%CD8+CD45RA+)
87
10
Activated CD4+HLADR+ T cells (%CD4+)
36
4
Activated CD8+HLADR+ T cells (%CD8+)
63
8
Senescent CD4+CD57+ T cells (%CD4+)
44
7
Senescent CD8+CD57+ T cells (%CD8+)
68
27
Exhausted CD4+PD1+ T cells (%CD4+)
95
18
Exhausted CD8+PD1+ T cells (%CD8+)
70
24
Transitional B Cells, CD19+CD24++CD38++ (%CD19+)
11
9
Naive B Cells, CD19+CD27-IgM+IgD+ (%CD19+)
90
71
Total Memory B cells and Plasmablasts, CD19+CD27+ (%CD19+)
10
30
IgM Memory B cells, CD19+CD27+IgM+IgD- (%CD19+CD27+)
27
18
IgA Memory B Cells, CD19+CD27+IgM-IgA+ (%CD19+CD27+)
0
18
IgG Memory B Cells, CD19+CD27+IgM-IgA+ (%CD19+CD27+)
36
26
Marginal Zone B Cells, CD19+CD27+IgM+IgD+ (%CD19+CD27+)
55
30
(99) Submission ID#809417
Nodular Regenerative Hyperplasia in X-Linked Agammaglobulinemia: An Underestimated
And Severe Complication
Cristiane Nunes-Santos, MD1, Christopher Koh, MD, MHSc2, Betty Marciano, MD3, David
Kleiner, MD, PhD4, Jenna Bergerson, MD, MPH5, Maria Rivera, .6, Gregory Constantine,
MD7, Warren Strober, MD8, Gulbu Uzel, MD9, Ivan Fuss, MD10, Steven Holland, MD11,
Theo Heller, MD12, Sergio Rosenzweig, MD, PhD13
1Postdoctoral Visiting Fellow/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center, Bethesda, MD, USA
2Director, Gastroenterology Fellowship Program, Digestive Diseases Branch; Staff Clinician/Liver
Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, NIH,
Bethesda, MD, USA
3Staff scientist/Laboratory of Clinical Immunology and Microbiology, Division of Intramural
Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD,
USA
4Senior Research Physician/Laboratory of Pathology, National Cancer Institute, NIH,
Bethesda, MD, USA
5Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Division of Intramural
Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD,
USA
6Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases,
NIH, Bethesda, MD, USA
7Clinical fellow/National Institute of Allergy and Infectious Diseases Allergy and
Immunology Fellowship Program, NIH, Bethesda, Maryland
8Senior investigator/Mucosal Immunity Section, Laboratory of Host Defenses, National
Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA.
9Staff Clinician/Laboratory of Clinical Immunology and Microbiology (LCIM), Division
of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases
(NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
10Staff Clinician/Mucosal Immunity Section, Laboratory of Host Defenses, National
Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
11Director, Division of Intramural Research; Chief, Immunopathogenesis Section/Laboratory
of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR),
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH), Bethesda, MD, USA
12Senior investigator/Liver Diseases Branch, National Institute of Diabetes & Digestive
& Kidney Diseases, NIH, Bethesda, MD, USA
13Senior Investigator; Chief/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center, Bethesda, MD, USA
Abstract/Case Report Text
Background: X-linked agammaglobulinemia (XLA) is one of the first inborn errors of
immunity identified, with thousands of patients described to date. Infections originally
dominated the clinical phenotype, but early diagnosis and immunoglobulin replacement
allowed for long term survival as well as recognition of late-onset complications.
Nodular regenerative hyperplasia (NRH) of the liver is a silent cause of non-cirrhotic
portal hypertension. NRH underlying pathophysiology remains blurry and the disease
has no specific treatment. NRH has been increasingly reported in primary immunodeficiency
but data in XLA are very limited.
Objectives: To assess and characterize NRH in patients with XLA.
Methods: We retrospectively reviewed the medical records of all XLA patients referred
to the NIH between 1994 and 2019. Hepatology evaluation and liver biopsies were performed
when clinically indicated. Patients were stratified into NRH+ or NRH- groups, according
to their NRH biopsy status (patients with no liver biopsies were classified as Unknown).
Laboratory values are presented as medians. Fisher’s exact test and Mann-Whitney test
were used to compare categorical and continuous variables, respectively.
Results: Twenty-one XLA patient records were reviewed, with a median age at start
of follow-up (f/u) of 17y and a median duration of f/u of 10 years. Eight patients
underwent at least one liver biopsy of whom 6 (29% of NIH XLA cohort) were NRH+. The
median age at NRH diagnosis was 20y (17-31). Among patients who had liver biopsies,
alanine aminotransferase (ALT) levels were mildly elevated in all, while alkaline
phosphatase (ALP) levels were only increased in NRH+ patients (p=0.04). Both NRH+
and NRH- groups had similar aspartate aminotransferase (AST) levels at baseline but
higher values were observed at the end of f/u in the NRH+ group (85 vs. 32 U/L, p=0.04).
Persistently low platelet count ( < 100k/μL for more than 6 months), mildly to highly
elevated hepatic venous pressure gradient (HVPG) and either hepatomegaly and/or splenomegaly
were present in all NRH+ patients. In opposition, neither persistently low platelet
counts, nor hepato- or splenomegaly were present in the two NRH- patients evaluated.
HVPG was normal in the only NRH- patient tested. All-cause mortality was higher among
NRH+ patients (5/6, 83%) than in the rest of the cohort (1/15, 7% among NRH- and Unknown
patients, p=0.002).
Conclusions: Based on our retrospective analysis, NRH appears as an underreported,
frequent and severe late-onset complication in XLA, which is highly associated with
increased mortality. Persistent thrombocytopenia, elevated ALP, elevated HVPG, hepato-
and/or splenomegaly were common in liver biopsy-proven XLA/NRH+ patients and distinguish
them from XLA/NRH- patients. Based on NRH prevalence, severity, lack of specific treatment
and poor outcome in XLA, immune-reconstitution (rather than IgG replacement and infectious
prophylaxis) should be considered early in this population in order to prevent fatal
long term complications.
(100) Submission ID#809505
Hypogammaglobulinemia and Lymphopenia in Barth Syndrome
Neha Agnihotri, MD1, Amer Khojah, MD2
1Fellow, Division of Allergy and Immunology/Northwestern University & Lurie Children's
Hospital
2Attending Physician, Assistant Professor/Division of Allergy & Immunology, Ann &
Robert H Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School
of Medicine, Chicago, IL
Abstract/Case Report Text
Introduction: Barth syndrome (BTHS) is an X-linked recessive disorder caused by a
mutation in the tafazzin (TAZ) gene resulting in an inborn error of cardiolipin phospholipid
metabolism (an important mitochondrial inner membrane lipid). It is commonly characterized
by intermittent neutropenia and cardiac and skeletal myopathies. We present a case
of BTHS with associated lymphopenia and hypogammaglobulinemia, which has not been
previously described in the literature.
Case report: A two-month old male, born full term with normal newborn screening, was
first admitted for RSV bronchiolitis. At this time, patient underwent an echocardiogram
given his older brother with hydrops had died hours after birth and on autopsy was
found to have dilated cardiomyopathy (DCM). Patient was similarly noted to have DCM
and thus had whole exome sequencing done that showed a hemizygous mutation in the
TAZ gene (c.639G>A). This novel variant resulted in early termination of the protein
(p.Trp213Ter) with concern for loss of function. In regard to patient’s first year
of life, he had frequent URI symptoms, 6 episodes of acute otitis media requiring
tympanostomy tubes, but no documented pneumonias or other serious bacterial infections.
Patient also had gross developmental delay, particularly motor, and feeding difficulties
with persistent failure to thrive requiring G tube placement. His absolute neutrophil
count ranged from 900-6800 cells/mm3 in the first year.
At age 13 months, patient was found to be in acute decompensated heart failure with
concern for myocarditis (CK 15,313 U/L, Troponin I 3.006 ng/mL) as well as acute hypoxic
respiratory failure with respiratory cultures growing Pseudomonas. He was incidentally
found to have an IgG level of 188 mg/dL (normal for age 345-1213) and treated empirically
with IVIG. When seen by immunology, further workup showed persistent B cell lymphopenia
(absolute CD19 of 167-377/mm3). He also had a low initial NK cell count (78-84/mm3,
later normal) with normal CD8 and CD4 T cell counts. Tetanus and Hib titers could
not be assessed as he had recently received IVIG. His IgG trended up to 931 mg/dL
a few days after initial IVIG and then subsequently dropped to 632 mg/dL, with a level
of 241 mg/dL two weeks following initial dose. Workup for gastrointestinal or renal
losses of immunoglobulin were negative. He also shortly after developed Enterobacter
bacteremia. His IgG levels at this time continue to remain around 270 mg/dL. He subsequently
required a heart transplant at age 14 months for his DCM. After transplant, he continued
to improve from a cardiac standpoint, but his lymphopenia persisted and each time
he was weaned off IVIG, his hypogammaglobulinemia persisted at 275-372 mg/dL thus
requiring additional IVIG replacement over the course of the next 8 months. The remainder
of immunoglobulins were normal initially, but the IgM slowly dropped over time to
31-33.8 mg/dL. Patient was started on weekly subcutaneous immunoglobulin replacement
at 22 months, doing well clinically at age 24-month follow up.
Conclusion: Here we present a patient with BTHS, with a novel variant, who had B-cell
lymphopenia as part of his presentation with persistent hypogammaglobulinemia requiring
IVIG replacement.
(101) Submission ID#809545
Validation Of STAT1 Gain-Of-Function Mutation With Decreased pSTAT1 In A Patient With
CMV Carditis, CMC, Recalcitrant Thrombocytopenia, M. Abscessus Pneumonia
Christin Deal, MD1, Manish Butte, MD, PhD2, Charles Song, MD3, Luigi Notarangelo,
MD, PhD4, Kerry Dobbs, BS5, Timothy Thauland, PhD6
13nd year Fellow/UCLA
2Associate Professor/Division of Allergy, Immunology, and Rheumatology, University
of California Los Angeles
3Chief of pediatric allergy and immunology/Harbor-UCLA
4Chief, Laboratory of Clinical Immunology and Microbiology/National Institute of Allergy
and Infectious Diseases, NIAID/National Institutes of Health, NIH
5Biologist/Laboratory of Clinical Immunology and Microbiology, Division of Intramural
Research, National Institute of Allergy and Infectious Diseases, National Institutes
of Health
6Project Scientist/UCLA
Abstract/Case Report Text
A 28-year-old female presented for combined immunodeficiency. At 2 years of age she
was diagnosed with RAG1 hypomorphism and started on IVIG. As a child, she was hospitalized
for pneumonias and cryptococcal meningitis. She suffered sinusitis, hepatitis, tooth
abscess, CMV and herpes stomatitis. Later, she experienced recurrent cutaneous abscesses,
UTIs, vaginal yeast infections, and hidradenitis. She twice hospitalized recently
for pneumonias and diagnosed with Mycobacterium abscessus on bronchoscopy. She suffers
onychomycosis, osteomyelitis and oral and esophageal candidiasis with odynophagia.
On exam, she had white plaques on tongue and buccal mucosa. She had hyperpigmented
plaques on forehead and cheeks and thickened nails. Immune evaluation was significant
for lymphopenia with ALC 770 and thrombocytopenia with platelets 102K. B cells were
nearly absent (2 absolute count) and NK cells were low at 19 absolute count. IgE was
absent, IgM 23 mg/dL, IgA 72 mg/dL and IgG 872mg/dL (on replacement). Her total CD3+
count was 791, CD4+ T cells were low at 17%, but CD8+ cells normal at 78%. The CD4+
T cells were mostly memory phenotype, which probably reflects lymphopenia-induced
proliferation of a small number of clones. Her CD8+ T cells also had an elevated amount
of memory cells for age, but still had presence of naive CD8+ T cells. As expected
with perpetual lymphopenia-induced proliferation, there was evidence of terminal memory
(TEMRA) in the CD8+ lineage. Proliferative responses of T cells were modest. CD4+
T cells did respond to pokeweed, but less to PHA and ConA. There were no antigen specific
responses. TRECs were normal. ESR was mildly elevated at 31. Of note, her liver enzymes
were elevated with alkaline phosphatase 556 and AST 116, presumably secondary to prolonged
fluconazole use.
WES revealed a known pathogenic variant in STAT1 (NM_007315.3: c.537C>G (p.N179K))
as well as a heterozygous variant in RAG1 p.M355T. The STAT1 mutation is de novo and
was previously published as a gain of function mutation. However, when we performed
validation studies to evaluate CD4+ cells with stimulation to IFNa, the patient had
decreased pSTAT1 as compared with control. Va7.2 analysis was performed to evaluate
RAG1 defect and showed 12% of T cells with Va7.2 expression confirming that the RAG1
defect is not clinically significant.
She developed severe thrombocytopenia refractory to platelet transfusions and IVIG.
She was started on Ruxolitinib which improved platelet counts. However, she presented
with shortness of breath, persistent tachycardia and was found to have CMV carditis
and hepatitis significant for echocardiogram with EF 23%. CMV PCR is improving with
last check 815 IU/ml after 1 month of therapy with ganciclovir. We now are looking
for evidence of SOCS1 to explain the decreased STAT1 phosphorylation.
Genetic testing is critical when evaluating a patient with immunodeficiency. Our patient
demonstrates that genetic mutations cannot be taken at face value and should be evaluated
and validated fully to optimize patient care.
(102) Submission ID#809613
Multiple Opportunistic Infections In A Hematopoietic Cell Transplant Patient Immunosuppressed
With JAK and Complement Inhibitors
Karl O.A. Yu, MD, PhD, FAAP.1, Mary Kate Mannix, DO2, Arthur Chang, MD2
1Clinical Assistant Professor of Pediatrics/University at Buffalo / Oishei Children's
Hospital
2Fellow/University at Buffalo / Oishei Children's Hospital
Abstract/Case Report Text
Opportunistic infections (OI) are commonly seen in patients undergoing hematopoietic
cell transplantation (HCT). Different strategies for antimicrobial prophylaxis are
often employed in the transplant setting to reduce the likelihood of encountering
infection. The predisposing risks for infections include the expected neutropenia
and lymphopenia following conditioning, prolonged defects in cell-mediated and humoral
immunity during the engraftment period, and iatrogenic immunosuppression by medications
for graft versus host disease (GVHD).
We report the case of a 4-year-old male with acute lymphoblastic leukemia, which relapsed
to chronic myelogenous leukemic blast crisis, and failed a subsequent allogeneic HCT
with central nervous system relapse. He was subjected to a second allogeneic HCT.
His immediate post-second transplant course was complicated with skin and gut GVHD,
and infection and/or reactivation of coronavirus, respiratory adenovirus, Epstein-Barr
virus, and human herpesvirus 6. While the herpesviral infections were controlled with
antivirals and rituximab, adenovirus C1 infection proceeded to involve the gastrointestinal
tract, and proved persistent over several months despite use of cidofovir.
The patient’s GVHD and transplant-associated thrombotic microangiopathy necessitated
use of further immunosuppressants, including the complement protein C5-binding eculizumab
(an inhibitor of formation of the terminal C5b-9 complex), ruxolitinib (a Janus kinase
[JAK] 1/2 inhibitor) and low-dose interleukin-2. His clinical course was further complicated
by Stenotrophomonas maltophilia gut colonization and subsequent bacteremia, as well
as multiple Gram-positive bacteremia courses. At around day +190, there was a life-threatening
pericarditis with pericardial effusion and respiratory distress, associated with Pneumocystis
and Stenotrophomonas being isolated from bronchoalveolar lavage. This occurred despite
the patient being on pentamidine prophylaxis. The patient eventually recovered on
trimethoprim/sulfamethoxazole therapy.
We discuss the various risk factors potentially contributing to each OI in this illustrative
case. In particular, complement and JAK inhibitor therapy are fairly new drugs approved
for other indications, whose off-label use in transplant patients is increasing. Both
have recently been associated with certain OI in the literature, as they are in this
patient.
(103) Submission ID#809642
FAS Copy Number Variants Can Also Lead to ALPS, besides Germline and Somatic Variants
Kathleen Jevtich, BS1, Magdalena Walkiewicz, PhD2, Susan Price, RN3, Morgan Similuk,
ScM, CGC4, Elaine Kulm, CPNP-AC5, Jia Yan, MS, PhD6, Michael Setzer, ScM, CGC7, Leila
Jamal, PhD and ScM4, Luis Franco, MD8, Ghosh Rajarshi, PhD, DABMGG9, V. Koneti Rao,
MD10
1Post-Baccalaureate Intramural Research Training Awardee/National Institute of Allergy
and Infectious Diseases, National Institutes of Health
2Certified Molecular Geneticist/National Institute of Allergy and Infectious Diseases,
National Institutes of Health
3Study Nurse Coordinator/Medical Science and Computing, LLC in support to the Laboratory
of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious
Diseases, National Institutes of Health
4Genetic Counselor/National Institute of Allergy and Infectious Diseases, National
Institutes of Health
5Nurse Practitioner/Leidos Biomedical Research, Inc. in support to the Laboratory
of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious
Diseases, National Institutes of Health
6Operations Manager and Genetic Counselor/National Institute of Allergy and Infectious
Diseases, National Institutes of Health; Medical Science and Computing, LLC
7Genetic Counselor/National Institute of Allergy and Infectious Diseases, National
Institutes of Health; Medical Science and Computing, LLC
8Assistant Clinical Investigator/Laboratory of Immune System Biology, National Institute
of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health
9Certified Clinical Molecular Geneticist/National Institute of Allergy and Infectious
Diseases, National Institutes of Health
10Staff Clinician/ALPS Unit, Laboratory of Clinical Immunology and Microbiology, National
Institute of Allergy and Infectious Diseases, National Institutes of Health
Abstract/Case Report Text
Background: Autoimmune lymphoproliferative syndrome (ALPS) is characterized by chronic
nonmalignant lymphadenopathy, splenomegaly, hepatomegaly, cytopenias, and other autoimmune
manifestations. Typically, the biomarker profile of patients with ALPS includes elevated
TCR αβ+ DNT cells, serum IgG, serum B12, serum IL10 and soluble FAS ligand (sFASL).
HDL cholesterol can also be significantly low. ALPS is caused by lymphocyte accumulation
due to defects in the FAS-mediated apoptosis signaling pathway. These defects cause
resistance to physiological apoptosis in lymphocyte populations that results in chronic
lymphoproliferation. The molecular defect underlying most ALPS etiologies is attributed
to heterozygous germline or somatic (limited to DNT cell subpopulation) pathogenic
single nucleotide variants (SNV) in FAS. We describe copy number variants (CNVs) at
the FAS locus underlying ALPS in 3 unrelated families.
Methods: Through the Centralized Sequencing Initiative at at the National Institute
of Allergy and Infectious Diseases (NIAID), patients undergo genomic workup to identify
molecular defects contributing to clinical phenotypes of immune system disorders.
All patients receive exome sequencing and a subset of patients also receive array-CGH
analysis.
Patients and Results: We performed exome sequencing on 132 patients with a clinical
diagnosis of ALPS. For 30 patients with no molecular defect through exome, we performed
CNV analysis. In this cohort, we identified three patients with a copy number variant
involving the FAS locus. All patients presented with splenomegaly and lymphadenopathy
in childhood with ages of onset ranging from 8 months to 9 years old. All patients
experienced anemia, autoimmune neutropenia, and thrombocytopenia. They had biomarker
evidence showing elevated serum B12 levels, sFasL levels, and elevated αβ+DNT cell
populations. They were found to have very low HDL cholesterol in early childhood ranging
from 5-8mg/dL (38-55 mg/dL). All patients had negative family histories for lymphoproliferative
disorders and immunodeficiency. These patients had clinical presentations and biomarker
profiles similar to ALPS patients with germline and somatic FAS variants.
Patient 1: We detected a ~1.03 Mb copy number loss encompassing all of FAS. Parental
studies were not performed.
Patient 2: We detected a ~1.004 Mb copy number loss encompassing all of FAS. Parental
studies showed this to be maternally inherited. In addition, prior karyotype testing
of the bone marrow showed the same deletion.
Patient 3: We detected a ~0.044 Mb copy number loss encompassing exons 7-9 of FAS.
Parental studies were not performed.
These results are consistent with the pathogenic nature of copy number variant losses
involving FAS. The mechanism of disease in these patients is consistent with haploinsufficiency.
In family 2, the mother harboring the FAS deletion is unaffected. This is consistent
with prior observation of reduced penetrance within a family in ALPS.
Conclusion: These three cases harbored causative deletions in FAS in the presence
of biomarkers indicative of ALPS and negative results for germline and somatic genetic
variant testing. These patients demonstrate that copy number variant analysis should
be pursued if there is robust clinical and biomarker evidence of ALPS as it can lead
to a molecular diagnosis and appropriate treatment when exome or next generation panel
based FAS sequencing is inconclusive.
(104) Submission ID#809650
Lymphocytic Pneumonitis in a Thymoma Patient after Thymectomy
Diana Nichols-Vinueza, MD1, Elise Ferre, PA-C, MPH2, Kevin Fennelly, MD3, Peter Burbelo,
PhD4, Yesim Demirdag, MD5, Michail Lionkais, MD, ScD6, Alexandra Freeman, MD7
1Allergy and Immunology Clinical Fellow/NIAID, NIH
2Physician Assistant/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH
3Senior Research Clinician/Laboratory of Chronic Airway Infection, Pulmonary Branch,
NHLBI, Bethesda, MD 20892, USA.
4Staff Scientist/NIDCR, NIH
5Assistant Professor of Pediatrics in the Division of Pediatric Allergy and Immunology/College
of Physicians and Surgeons of Columbia University
6Chief, Fungal Pathogenesis Section/Laboratory of Clinical Immunology and Microbiology,
NIH
7Senior Clinician/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH
Abstract/Case Report Text
RATIONALE: The thymus is essential for the development of T-cells. Patients with thymoma
have decreased AIRE expression and have an abnormal thymic microenvironment where
the negative selection of T-cells is compromised, resulting in a broad spectrum of
autoimmune-mediated diseases. Besides myasthenia gravis, which is found in 15 to 20%
of patients with thymoma, other autoimmune diseases have been reported including erythroblastopenia,
systemic lupus erythematosus, inflammatory myopathies, thyroid disorders and Good's
syndrome. Recent studies have described additional autoimmune conditions such as pneumonitis
in thymoma patients. We identified a patient who developed chronic cough post-thymectomy
and was found to have lymphocytic pneumonitis with associated autoantibodies against
lung antigen KCNRG and lung immunopathology consistent with APECED pneumonitis, which
implies a common pathogenic mechanism between these conditions.
METHODS: We describe a patient with thymoma who developed autoimmune pneumonitis associated
with KCNRG autoantibodies and a characteristic pattern of immunopathology recently
described in patients with monogenic disorder caused by primary AIRE deficiency (APECED)
and secondary AIRE deficiencies (thymoma, RAG deficiency).
RESULTS: Patient is a 32-year-old male with no significant past medical history who
was in good state of health until age 20 when he was diagnosed with and received treatment
for guttate psoriasis (resolved with UV therapy) and alopecia areata. At age 30, he
developed severe abdominal pain and weight loss. He had an abdominal CT performed
that showed chronic pancreatitis and thymoma. One month later, the patient underwent
thymectomy and subsequently, underwent ERCP and pancreas biopsy, revealing atrophic
pancreatitis with negative staining for lgG and lgG4. At that time, he was started
on pancreatic enzymes with improvement of abdominal symptoms. Following thymectomy,
he developed persistent dry cough and recurrent symptoms of sinusitis which did not
respond to several courses of oral antibiotics to treat his positive culture for Pseudomonas.
He had a negative work up for vocal cord dysfunction and cystic fibrosis, and negative
autoantibodies against IFN-gamma, IL-17A, and GM-CSF. For work up of chronic cough,
the patient underwent CT imaging of the chest which revealed diffuse peri-bronchial
thickening, mucus plugging, and tree-in-bud nodularity through most of his lungs.
He underwent bronchoscopy with BAL which revealed normal bronchial mucosa and airway
neutrophilia. Endobronchial biopsies showed basement membrane thickening and dramatic
lymphocyte infiltration in intraepithelial and submucosal areas. His BAL cultures
revealed Mycobacterium intracellulare/chimaera. Patient was also tested for auto-antibodies
against lung-specific bactericidal/permeability-increasing fold-containing B1 (BPIFB1)
and the potassium channel regulator KCNRG that have been associated with the development
of pneumonitis in patient with APECED, thymoma and RAG deficiency, and was found to
have KCNRG-targeted autoantibodies.
CONCLUSIONS: Thymoma is a disease associated with secondary AIRE deficiency. This
case illustrates common clinical, radiographic, histological, and autoantibody features
in thymoma-associated and APECED-associated pneumonitis, indicating that disorders
with primary and secondary AIRE deficiencies may have common pathogenetic mechanisms.
BPIFB1 and KCNRG should be included in the autoantibody profile testing of patients
with thymoma and lung disease. Immune suppression and anti-mycobacterial antibiotic
treatment are planned.
(105) Submission ID#809688
Activated PI3K Delta Syndrome (APDS) in Two Peruvian Pediatric Patients
Crhistian Toribio-Dionicio, MD1, Dania Cubas-Guzmán, n/a2, Wilmer Córdova-Calderón,
MD3
1Student/Universidad Peruana Cayetano Heredia
2Medical Student/Universidad Nacional Mayor de San Marcos
3Chief Primary Immunodeficiency Unit/Instituto Nacional de Salud del Niño
Abstract/Case Report Text
Introduction/Background: Activated phosphoinositide 3-kinase δ (PI3Kδ) syndrome (APDS)
is a primary immunodeficiency caused by a gain-of-function mutation in the PIK3CD
gene that encodes the p110δ catalytic subunit of PI3Kδ. It is characterized by recurrent
respiratory tract infections, lymphoproliferation, nodular mucosal lymphoid hyperplasia,
enteropathy, EBV and/or CMV infection, reduced T cell function and high levels of
IgM. There is not evidence of this disease in Peruvian patients.
Methods: A case series of two pediatric patients with APDS.
Results: The first patient is a girl of non-consanguineous parents. Family history
shows four maternal uncles died at pediatric ages with unknown diagnosis. At the age
of 2, she presented lymphadenopathy and fever being treated as cat scratch disease
without improvement of symptoms. 8 months later, she was hospitalized due to anemia,
mild hepatosplenomegaly, ascites and chronic diarrhea and diagnosed with gastrointestinal
tuberculosis (TB). A hepatic biopsy only showed reactive hepatitis. However, the patient
did not improve her symptoms despite anti TB treatment. 2 years later, she was hospitalized
for lymphadenopathy, pancytopenia, chronic diarrhea, ascites and severe hepatosplenomegaly.
CMV IgG was positive and lymph node biopsy revealed paracortical and follicular lymphoid
hyperplasia due to EBV infection without neoplastic proliferation. Low CD4+ T and
CD19+ B cells and high IgG levels were found (Table 1). At this time, it was suggested
the diagnosis of APDS which was confirmed by next generation sequencing (NGS) identifying
a heterozygous mutation in the PIK3CD gene (c.3061G>A, p.Glu1021Lys). She was treated
with sirolimus and IVIG for 2 years. The symptoms persisted despite treatment and
died at the age of 6.
The second patient is a 6-year-old girl also of non-consanguineous parents. Family
history includes eczema (father) and colorectal cancer (mother). She has had recurrent
respiratory infections, chronic diarrhea and poor weight gain since 4 months old receiving
symptomatic treatment only. At the age of 3, she was hospitalized for persistent pneumonia
(Pseudomonas positive), lymphadenopathy and mild hepatosplenomegaly. A CT scan showed
bilateral bronchiectasis and the sweat chloride test was negative. Based on this,
a diagnosis of cystic fibrosis was made and treatment was started. However, a genetic
study only showed heterozygous mutations in the CFTR gene (G551D and G542X). 1 year
later, she presented a neck-located skin abscess. At the age of 5, she was hospitalized
for complicated pneumonia, diarrhea, lymphadenopathy, ascites and severe hepatosplenomegaly.
Multiple polyps in the duodenum and colon with lymphoid hyperplasia were detected,
EBV IgM and IgG were positive and a lymph node biopsy showed paracortical hyperplasia
without neoplastic proliferation. CD8+ T cells and IgM levels were increased (Table
1). A diagnosis of APDS was suspected and IVIG was started. NGS showed the same mutation
as the first patient (c.3061G>A, p.Glu1021Lys).
Conclusion: APDS should be considered in patients with recurrent respiratory tract
infections, lymphoproliferation, enteropathy and abnormal immunologic function without
another explanation. NGS is a useful tool to identify these cases in low-income countries.
Acknowledgments: We thank Drs. Raif Geha and Janet Chou, Division of Immunology, Boston
Children’s Hospital, Harvard Medical School for the genetic diagnosis.
Table 1. Immunological profile of the patients
Normal range
Patient 1
Patient 2
Lymphocyte subsets
CD3+, 103 cells/μL
0.9 – 4.5
1.14
4.71
CD3+CD4+, 103 cells/μL
0.5 – 2.4
0.37
0.95
CD3+CD8+, 103 cells/μL
0.3 – 1.6
0.67
3.39
CD19+, 103 cells/μL
0.2 – 2.1
0.17
0.95
CD3-CD56+, 103 cells/μL
0.1 – 1.0
0.11
0.47
Immunoglobulins
IgG, mg/dL
550 – 1020
7218.3
1650
IgM, mg/dL
46 – 150
119.8
552
IgA, mg/dL
54 - 153
167.7
336
Values in bold are outside the reference range
(106) Submission ID#809845
Quantitative Computer-Aided Lung Informatics for Pathology Evaluation and Rating (CALIPER)
assessment: A Newer Modality To Predict Progression in GLILD associated with CVID
Roshini Mullakary, MD1, Brian Bartholmai, MD2, Sanjay Kalra, MD3, Avni Joshi, MD,
MS4
1Allergy/Immunology Fellow/Mayo Clinic
2Chair, Division of Radiology Informatics, Department of Radiology/Mayo Clinic
3Consultant, Division of Pulmonary and Critical Care Medicine/Mayo Clinic
4Consultant, Division of Pediatric Allergy & Immunology/Mayo Clinic
Abstract/Case Report Text
Background: Granulomatous-lymphocytic interstitial lung disease (GLILD) is an increasingly
recognized pulmonary complication associated with common variable immunodeficiency
(CVID) but the natural history and long term prognosis remains poorly defined. Imaging
findings with computed tomography (CT) are heterogeneous and visual features do not
consistently predict a patient’s progression to fibrotic lung disease. Computer-Aided
Lung Informatics for Pathology Evaluation and Rating (CALIPER) provides an objective
analysis of lung parenchymal texture and quantifies the extent of normal lung, along
with abnormal features such as honeycombing, reticular/consolidative and ground-glass
opacity. This may be useful in CVID patients to monitor changes in character or extent
of disease and may facilitate early intervention before the disease becomes more aggressive
or advanced.
Case Description: Our patient is a 46-year-old non-smoking female with CVID who has
been followed for her CVID and associated interstitial lung disease. For more than
twenty years, she has had varying abnormalities found on chest CT and these appear
consistent with GLILD. Specifically, she has had variable regions of mixed consolidation,
ill-defined nodularity and septal thickening. The changing morphology and distribution
made assessment of overall severity and extent of fibrosis versus parenchymal infiltration
inconsistent. For clinical decision support we used CALIPER to analyze the current
CT (2019) and compared CALIPER results for previous CT data. CALIPER provided a comprehensive
analysis of the extent and characteristics of parenchymal features, and objectively
determined normal and abnormal regions, some of which were not visually apparent.
The CALIPER color overlay was able to highlight subtle regions of ground-glass opacity
in areas that visually were regarded as uninvolved lung and quantify the extent of
the reticular densities/consolidation over time. CALIPER does not differentiate reticulation
from consolidation, does not detect nodularity or septal thickening, and CT imaging
cannot distinguish inflammation from fibrosis. However, CALIPER has the power to quantitatively
assess overall disease extent and demonstrate subtle abnormalities that would otherwise
have been dismissed as normal, given relative sparing compared to other regions. CALIPER
may also provide evidence for disease progression or therapeutic response that is
not otherwise radiographically apparent.
Conclusion: CALIPER assessment may be a useful tool as an adjunct for a patient with
GLILD to help quantify the extent and character of lung parenchymal involvement. This
information may serve as an important guide for clinicians in the assessment of successful
management and early intervention to prevent irreversible fibrosis.
(107) Submission ID#809896
Immunodeficiency in patients with SGPL1 mutations Immunodeficiency in patients with
SGPL1 mutations
Tatiana Kalashnikova, n/a1, Nicola Wright, MD2, Julian Midgley, MD3, Francois Bernier,
MD4, Joanne Luider, MsC5
1Research Assistant/Section of Hematology and Immunology, Department of Pediatrics,
Alberta Children’s Hospital, Calgary, Canada
2Clinical Associate Professor, Hematologist/1 Section of Hematology and Immunology,
Department of Pediatrics, Alberta Children’s Hospital, University of Calgary. Calgary,
Canada
3Associate Professor/Section of Nephrology, Department of Pediatrics, Alberta Children’s
Hospital, University of Calgary, Calgary, Canada.
4Head and Professor/Section of Medical Genetics, Department of Pediatrics, Alberta
Children’s Hospital, University of Calgary, Calgary, Canada.
5Laboratory Scientist/Flow cytometry Lab, Calgary Laboratory Services, Calgary, Canada
Abstract/Case Report Text
Objective: Evaluation of the immune system in two patients with recessive mutations
in SGPL1 gene, encoding sphingosine-1-phosphate lyase (S1PL), was performed. Both
patients were diagnosed with steroid-resistant nephrotic syndrome (SRNS), adrenal
insufficiency, anemia, and hypothyroidism.
Methods: Flow cytometry was used for lymphocyte immunophenotyping and mitogen stimulation
assay. The concentrations of total immunoglobulins and specific IgG titers to vaccines
were also measured.
Results: Significant T cell lymphopenia was found in both patients, more pronounced
in Patient 2. However, the patients have cleared respiratory viral infections reasonably
well and have had no opportunistic infections. The T-cell numbers of Patient 2 have
improved over time. Both patients had normal T cell proliferation to mitogens (Table
1). These findings may be explained by the known role of S1PL regulating lymphocyte
trafficking (1).
Both patients have a humoral deficiency with low B cell numbers and immunoglobulins
titers, warranting IgG replacement therapy (Table 1). Despite this deficiency, patients
have had very few bacterial infections and did respond to tetanus and diphtheria vaccines.
The IgG levels have improved over time, perhaps partly secondary to adequate treatment
of SRNS resulting in diminished proteinuria.
Patients had a trial of fingolimod without any beneficial changes in immune status.
Both patients receive Pneumocystis jirovecii pneumonia prophylaxis with Sulfamethoxazole-Trimethoprim.
Conclusions: These results indicate that S1PL deficiency due to SGPL1 mutations is
a syndromic primary immunodeficiency leading to profound lymphopenia and hypogammaglobulinemia.
Our data emphasize the importance of sphingolipid metabolism for an efficient immune
response and the need for more studies to delineate the exact mechanisms on how this
happens in humans.
References
1. Lovric S, Goncalves S, Gee HY, Oskouian B, Srinivas H, Choi WI, Shril S, Ashraf
S, Tan W, Rao J et al.Mutations in sphingosine-1-phosphate lyase cause nephrosis with
ichthyosis and adrenal insufficiency.J Clin Invest. 2017 Mar 1;127(3):912-928.
Table 1. Immunological profile of the patients
Lymphocyte immunophenotyping
Values at 9-12 weeks of age
Values at 3rd year of age
Reference ranges
Patient 1
Patient 2
Reference ranges
Patient 1
Patient 2
WBC
5.0-19.5
6.0
5.1
5.0-19.5
2.1
5.3
Lymphocyte
2.5-16.5
1.4
0.9
2.5-16.5
0.4
0.9
CD3 (x109/L)
2.2-9.2
0.57
0.207
0.85-4.3
0.36
0.37
CD3+CD16/56+ (x109/L)
0.013-0.09
0.08
0.009
0.015-0.25
0.08
0.05
CD3-CD16/56+ (x109/L)
0.097-1.99
0.98
0.189
0.061-0.51
0.19
0.32
CD3+CD4+ (x109/L)
1.6-6.5
0.25
0.135
0.5-2.7
0.18
0.23
CD3+CD8+ (x109/L)
0.3-3.4
0.27
0.045
0.2-1.8
0.13
0.14
CD3+4+CD45RA+CD27+(x109/L)
Naive
1.6-6.0
0.147
2.108
0.3-2.3
0.089
0.2
CD3+4+CD45RA+CD27- (x109/L)
Terminally differentiated
0-0.005
0.008
0.058
0-0.016
0
0.09
CD3+4+CD45RA-CD27+ (x109/L)
Central memory
0.053-2.2
0.074
---
0.16-0.66
0.086
---
CD3+4+CD45RA-CD27- (x109/L)
Effector memory
0.02-0.021
0.021
---
0.004-0.089
0.005
---
CD3+8+CD45RA+CD27+ (x109/L) Naive
0.29-1.65
0.225
0.03
0.053-1.1
0.114
0.12
CD3+8+CD45RA-CD27+(x109/L)
Central memory
0.01-0.19
0.004
---
0.004-0.064
0.008
---
CD3+8+CD45RA-CD27-(x109/L)
Effector memory
0.002-0.4
0.039
---
0.024-0.59
0.002
---
CD3+8+CD45RA+CD27-(x109/L)
Terminally diff
0.013-0.82
0.039
---
0.025-0.53
0.005
---
CD19 (x109/L)
0.52-2.3
0.23
0.504
0.18-1.3
0.04
0.07
B cell- IgD-27+(x109/L)
Memory class, switched
0.01-0.17
0
0.012
0.02-0.22
0
0.01
IgD+27-(x109/L)
Naïve
0.62-2.12
0.21
0.351
0.28-1.33
0.04
0.05
IgD+27+(x109/L)
Memory, non-class switched
0.02-0.2
0
0.019
0.02-0.18
0
0.010
IgA (g/L)
0.2-1.6
0.19
0.64
0.2-1.6
0.35
0.75
IgM (g/L)
0.2-1.6
0.82
0.52
0.2-1.6
0.26
0.2
IgG (g/L)
4-16
0.74
3.17
4-16
2.33
2.16
Specific IgG titers to vaccines
After first DTaP-IPV-Hib vaccination done at age of 9 weeks
First DTaP-IPV-Hib vaccination done at age of 14 weeks
After 4th DTaP-IPV-Hib vaccination
Tetanus Antitoxin (IU/ml)
>0.5-1.1
0.75
---
>0.5-1.1
---
0.83
Diphtheria Antitoxin (IU/ml)
>0.1
<0.010
---
>0.1
------
0.33
Mitogen proliferation assay
Reference ranges
At 4 months of age
At 2 months of age
---
---
---
PHA (Ki67/PCNA %)
58-98
80
83
---
---
---
ConA (Ki67/PCNA %)
62-94
76
86
---
---
---
PWM (Ki67/PCNA %)
15-55
64
68
---
---
---
(109) Submission ID#810163
The Influence of Sample Storage and Handling Conditions on Functional Complement Assessments
using The Binding Site CH50 Assay on the Optilite Analyser
Clare Tange, PhD1, Faye Murphy, n/a2, Dominic Matters, n/a2, Mark Hayes, PhD1, Dale
Kay, n/a3, Stephen Harding, PhD4, Kelly Townsend, PhD5
1Medical Scientific Liaison/The Binding Site
2Systems Verification Manager/The Binding Site
3Head of Production Support/The Binding Site
4Chief Scientific Officer/The Binding SIte
5Medical Scientific Liaison Manager/The Binding Site
Abstract/Case Report Text
Background: The CH50 assay is an important test for the functional assessment of the
classical complement pathway. It acts as a screening test for classical cascade complement
deficiencies, can monitor activation of the classical pathway and is a useful tool
for assessing patients with autoimmune conditions. However, it is widely understood
that appropriate sample handling and storage is pivotal to ensure accurate assessment
of complement activity. Conversely, without a standardised approach to sample storage
and handling, complement activation can occur ex-vivo leading to falsely abnormal
results. Here we report on the stability of the classical complement cascade as measured
by the CH50 liposome assay developed for use on the Optilite® analyser and comment
on the optimal storage methods for reliable result generation.
Methods: Serum was collected from 61 healthy adult donors (self-certification absence
of autoimmune conditions, fever or respiratory illness). For each sample, 6 replicates
were performed on the day of collection (d0) and thereafter in duplicate with samples
stored at either room temperature (~21°C ambient), 4°C or at -20°C (stability at -20°C
was assessed after sequential freeze/thaw cycles). Sample stability was assessed based
on CLSI guideline EP25-A with measurand drift used as the primary metric with an allowable
error of +/-15%. All measurements were determined using the Optilite CH50 assay (The
Binding Site Group Ltd, UK).
Results: The median value for samples at d0 was 65.17 U/ml (range 35.17 to 93.82 U/ml),
with a median within-sample CV of 0.99% (range 0.18 to 6.2%). After 1d at room temperature
there was a median -17% (range -33% to +2%; p < 0.001) change in CH50 activity. Subsequently
there was a continued decrease in activity, which was time dependent; allowable error
adjusted stability data indicated a median room temperature stability of 1d.
After 1d at 4°C there was a median -9% (range -44% to +3%; p=0.017) change in activity.
After 2d -11% (range -48% to +8; p=0.006), 3d -13% (range -55% to +4%; p < 0.001),
4d -16% (-60% to +6%; p < 0.001) and after 7d -21% (-68% to +2% p < 0.001). A 4°C
stability of 3d was determined from the median percentage reduction; total allowable
error adjusted stability data indicated a 4°C stability of 5d.
Samples stored at -20°C following repeat freeze thawing saw a freeze/thaw cycle dependent
decrease in CH50 activity. After 1 freeze/thaw cycle there was a median -9% (range
-22% to +1%; p=0.018) change, 2 cycles -11% (range -26% to +2%; p=0.003), 3 cycles
-13% (range -38% to +2%; p < 0.001), 4 cycles -23% (range -69% to -6%; p < 0.001)
and after 5 cycles -25% (range -68% to -7%; p < 0.001). Allowable error adjusted stability
data indicated a maximum of 3 freeze/thaw cycles.
Conclusion: Sample storage and handling can have a significant impact on functional
complement assessments. Room temperature storage should be avoided unless samples
will be analysed on the day of collection, 4°C storage is tolerable providing that
assessment is within 3d; freezing samples at -20°C with limited freeze/thaw analysis
would be optimal. However, further investigations into longer-term storage at -20°C
and -80°C would be beneficial.
(110) Submission ID#810254
Association of GI status and Autoimmunity in CVID
Hannah Wright, MSPH1, Ramsay Fuleihan, MD2, Charlotte Cunningham-Rundles, MD, PhD3,
Kathleen Sullivan, MD, PhD4, Edith Schussler, MD5
1Research Data Analyst/United States Immunodeficiency Network
2Professor of Pediatrics and Allergy and Immunology/Ann & Robert H. Lurie Children's
Hospital of Chicago
3Professor of Medicine and Pediatrics/Icahn School of Medicine at Mount Sinai
4Chief of Allergy Immunology/Children's Hospital of Philadelphia
5Assistant Professor of Clinical Pediatrics/Weill Cornell Medicine
Abstract/Case Report Text
Background: Common variable immune deficiency (CVID) is a heterogeneous group of conditions
affecting approximately 1:30,000 persons. The GI tract is the largest lymphoid organ
and gastrointestinal (GI) complaints are frequent in CVID, leading in some to increased
morbidity and higher mortality. Autoimmunity (AI) is similarly frequent in CVID patients.
Previous studies have shown an association between AI conditions and CVID enteropathy.
We investigated the relationship of GI status as a whole and autoimmunity among CVID
patients in the USIDNET registry.
Methods: The United States Immunodeficiency Network (USIDNET) Patient Registry contains
clinical data on patients with primary immune deficiencies. Data on 939 patients with
a diagnosis of CVID were analyzed. Patients were considered GI+ if they reported any
condition affecting the GI tract from mouth to anus excluding the spleen. 593 patients
were identified as GI+ and 346 as GI-. Patients were further identified as having
an autoimmune condition (AI+) or not (AI-).
Results: 1,075 autoimmune conditions were reported within the cohort, with some patients
reporting multiple autoimmune diagnoses. Of 939 CVID patients, 39.5% (371) experienced
at least one autoimmune condition. Within the GI subgroups, 45.0% (267) GI+ had at
least one autoimmune condition, vs 30.0% (104) of the GI-. The most frequently reported
autoimmune conditions over the entire cohort were ITP (119 in GI+ cohort, 50 in GI-),
hypothyroidism (GI+ = 50; GI- =15), alopecia (GI+ = 20; GI- =9), psoriasis (GI+ =
20; GI- =9), Evans Syndrome (GI+ = 22; GI- =5), autoimmune anemia (GI+ = 21; GI- =7),
Hashimoto’s (GI+ = 18; GI- =8), celiac (GI+ = 23, GI- =0), rheumatoid arthritis (GI+
=17; GI- =4), and vitiligo (GI+ =13; GI- =6). The odds of being AI+ for GI+vs.GI-
was 1.91 (95%CI: 1.44-2.52, p= < .0001). A sub-analysis indicated that ITP (OR: 1.49,
95%CI: 1.04-2.13, p=.03), hypothyroidism (OR: 2.03, 95%CI: 1.12-3.68, p=.02), and
Evans syndrome (OR: 2.63, 95%CI: .99-7.00, p=.05) showed statistically significant
increased odds in the GI+. Additional sub-analysis removing all GI autoimmune conditions
from the AI+ group still resulted in statistically significant increased odds of autoimmunity
1.63 (95%CI: 1.23-2.16, p < .0007) if GI+.
Conclusions: GI disease is common in CVID affecting 63% of patients in our cohort.
GI+ CVID patients have a higher frequency of autoimmune manifestations than those
without GI complaints. The odds of ITP, hypothyroidism, and Evans syndrome all showed
significantly increased odds in the GI+ group. The results of our study may have implications
for both gastroenterologist and immunologist. Recurrent infections especially those
of the sinopulmonary tract are often the trigger for CVID evaluation. Autoimmune and
GI symptoms however may be the initial presentations of CVID and overlooked until
other more recognizable manifestations evolve. The combination of GI issues and autoimmunity
especially thrombocytopenia, Evans syndrome, and hypothyroidism should include CVID
in the GI differential. For the immunologist, a CBC is standard in the work-up of
CVID and may reveal autoimmune cytopenia. Evaluation for autoimmune disease and in
particular hypothyroidism is not. Given our findings an initial immune work up specifically
for thyroid disease may be indicated.
Association of GI status and Autoimmunity in CVID
Table 1. Top 10 Autoimmune Conditions by GI Status
Autoimmune Condition
GI+
GI-
Total
Thrombocytopenia (ITP)
119
50
169
Hypothyroidism
50
15
65
Alopecia
20
9
29
Psoriasis
20
9
29
Evans Syndrome
22
5
27
Hashimoto’s
18
8
26
Celiac
23
0
23
Autoimmune anemia
21
7
28
Rheumatoid arthritis
17
4
21
Vitiligo
13
6
19
GI sub totals
323
113
436
(111) Submission ID#810400
Disseminated Histoplasmosis in an Autosomal Dominant Hyper-IgE Syndrome Patient
Haoli Jin, MD, PhD1, Julie Flom, MD, MPH1, Hsi-en Ho, MD2, Charlotte Cunningham-Rundles,
MD, PhD3
1Fellow Physician/Mount Sinai Health System
2Assitant Professor/Mount Sinai Health System
3Professor of Medicine and Pediatrics/Icahn School of Medicine at Mount Sinai
Abstract/Case Report Text
Introduction: Autosomal dominant hyper-IgE syndrome (AD-HIES), AKA Job’s syndrome,
is caused by dominant negative mutations in STAT3. Elevated IgE levels, low Th17 cell
number, decreased CD4+ and CD8+ central memory T cells are the cardinal immunology
features in patients, leading to increased susceptibility to bacterial and fungal
infections. Histoplasmosis is an endemic and opportunistic fungal infection that causes
impairment and symptoms in immunocompromised patients, most commonly in AIDS, but
quite rarely in Job’s syndrome.
Case presentation: A STAT3 mutation (c1144C>T) was previously identified in our 22-year
old Hispanic Job’s syndrome patient. He had history of atopic dermatitis, Hodgkin’s
lymphoma, skin cold abscess, and recurrent pneumonia, bronchiectasis, pneumatoceles
with Staph aureus infections, lung Asperilloma, massive hemoptysis, as well as pulmonary
embolism requiring right pneumonectomy. His management consists of prophylactic Bactrim
DS, Voriconazole and monthly IVIG. Unfortunately, he lost insurance for about a year
which prohibited him from specialty follow up and IVIG infusion. He was hospitalized
five times in 2019 due to fatigue, shortness of breath and cough. His chest CT revealed
bilateral bronchiectasis and cavitary lesions in the summer, which persist to date.
BAL cytopathology was highly suspicious for fungal organism. He also had extremely
elevated transaminase (ALT/AST 200-500s, AKP over 1600s) which prompted liver ultrasound
showing liver cysts with cholestasis. Liver biopsy and culture was positive for Histoplasma
capsulatum. Urine but not serum histoplasmosis antigen were positive. He was treated
with intravenous vancomycin and cefepime for 30 days for clinical pneumonia, intravenous
Ambisome B for 14 days for histoplasmosis and Gammunex during his last two admissions
in our hospital. He is currently home on oral Itraconazole with improvement of symptoms.
His potential risk factors for histoplasmosis infection include his travel to the
endemic area Caracas (Venezuela), adoption of a dog early this year, and his inconsistent
compliance to antifungal medication and IVIG infusion.
Discussion: We report an adult AD-HIES patient with disseminated histoplasmosis, identified
by liver abscess culture. It was likely originated from the lung, as suggested by
BAL cytopathology. Nine cases of histoplasmosis in AD-HIES patients have been reported
in literature, eight of which primarily involved gastrointestinal tract. One case
of disseminated histoplasmosis was found in a previously 33 month old child in his
lung and blood. STAT3 is the transcriptional factor for many cytokines such as IL-17,
responsible for T cell and neutrophil defense again fungal infection. STAT3 mutation
leads to defect of neutrophil proliferation and chemotaxis to inflammatory site as
well as production of antimicrobial peptides by respiratory epithelial cells. The
poor tissue repair in the cavitary lesions and bacterial superinfection in patient’s
lung created a culture dish for fungal growth and dissemination. Traveling to the
endemic area and patient’s noncompliance to antifungal prophylactic treatment further
increased the risk of histoplasmosis infection.
(112) Submission ID#810461
Interim Analysis of the Global Postauthorization Safety Study of Facilitated Subcutaneous
Immunoglobulin Treatment in Patients With Primary Immunodeficiency Diseases
Arye Rubinstein, MD, PhD1, Niraj Patel, MS, MD2, H. James Wedner, MD, FACP, FAAAAI3,
Richard L. Wasserman, MD, PhD4, Sudhir Gupta, MD, PhD5, Katharina Fielhauer, MA6,
Shailesh Chavan, MD7, Leman Yel, MD8
1Chief, Division of Allergy & Immunology, Department of Pediatrics/Albert Einstein
College of Medicine and Montefiore Hospital
2Pediatrics (Kids & Teens), Allergy and Immunology, Pediatric Infectious Diseases/Levine
Children's Hospital, Atrium Health, Charlotte, NC
3Professor of Medicine/Barnes-Jewish Hospital, Washington University School of Medicine,
St Louis, MO, USA
4Managing Partner/Allergy Partners of North Texas Research, Dallas, TX, USA
5Professor of Medicine/University of California at Irvine, Irvine, CA, USA
6Associate Clinical Director/The Takeda group of companies, Vienna, Austria
7Senior Medical Director, Clinical Medicine Plasma Development Therapies/The Takeda
group of companies, Cambridge, MA, USA
8Vice President, Head Clinical Medicine, Global Research & Development, Plasma Derived
Therapies BU/The Takeda group of companies, Cambridge, MA, USA
Abstract/Case Report Text
Introduction/Background: fSCIG (immune globulin infusion 10% [human] with recombinant
human hyaluronidase [rHuPH20]) is a subcutaneously administered immunoglobulin (IG)
replacement therapy that is approved for patients who have primary immunodeficiency
diseases (PID). fSCIG allows for enhanced IG distribution and absorption compared
with conventional subcutaneous IG products and is associated with fewer systemic adverse
events (AEs) than intravenous IG.
Objective: To acquire additional data on the long-term safety of fSCIG in patients
who have PID.
Methods: This is an ongoing prospective, non-interventional, open-label, uncontrolled,
multicenter, global postauthorization safety study initiated in the United States
in November 2015 (NCT02593188). Patients aged ≥16 years with PID who have started
fSCIG are followed according to standard clinical practice. Dosage regimen and treatment
schedule are at the discretion of the treating physician. AEs are collected from enrollment
to study completion/discontinuation. The presence of anti-rHuPH20 antibody titers
is evaluated on a voluntary basis.
Results: As of May 2, 2019, enrollment was complete, with 264 patients enrolled at
32 US study sites and 81 patients still under follow-up. Most (79.2%) patients were
female, with a mean (SD) age of 54.7 (15.7) years. No serious AEs (SAEs) related to
fSCIG were reported. Infusions were self-administered at home (60.4%) or at the clinical
site (39.6%), most commonly using 4-week infusion intervals (50.7%). The mean maximum
IG infusion rate was 250.8 mL/h, and the mean IG dose was 400.8 mg/kg/4 weeks. The
mean number of infusion sites used for administration was 1.9, and mean infusion duration
was 3.0 hours. Most (98.1%) infusions were administered without a rate reduction,
interruption, or discontinuation due to AEs. Twenty-seven patients experienced a causally
related non-serious local AE (10.2%; 0.35 events/patient-year, 0.05 events per infusion),
and 37 patients experienced a causally related non-serious systemic AE (14.0%, 0.72
events/patient-year, 0.10 events per infusion). Of the 194 patients with immunogenicity
data, 14 (7.2%) had ≥1 positive binding antibody test to rHuPH20 (titers ≥1:160);
no neutralizing rHuPH20 antibodies were detected.
Conclusion: This interim analysis of 264 patients with PID treated with fSCIG in routine
clinical practice supports previous observations that fSCIG is well tolerated, with
no reports of causally related SAEs or neutralizing anti-rHuPH20 antibodies.
(113) Submission ID#810555
IRAK4 Deficiency Presenting with Severe Viral Infections and Recurrent Kingella Kingae
Sepsis
Alexander Humphrey, MBBS1, Stuart Tangye, PhD2, Kahn Preece, FRACP3
1Pediatric Registrar/John Hunter Children's Hospital
2Professor/Immunity & Inflammatory Diseases, Garvan Institute of Medical Research,
Darlinghurst, New South Wales, Australia.
3Pediatric Immunologist/John Hunter Children's Hospital
Abstract/Case Report Text
We present the case of a 20 month old boy, the first child to his non-consanguineous
parents of European descent. He first presented at 9 months of age with a cellulitis
of his right fourth finger culture positive for Staphylococcus aureus which responded
to a prolonged course of Flucloxacillin. At 12 months he presented with Norovirus
positive gastroenteritis leading to a brief admission and slow resolution. The first
of two severe episodes of oral stomatitis and respiratory distress occurred at 13
months of age. HSV1 was isolated from the oral lesions and blood culture during that
admission was positive for Kingella kingae. No cardiac or bone involvement was identified.
A more severe episode of oral stomatitis occurred two months later (age 16 months)
swab positive for an Enterovirus (not typed). Due to airway compromise and rapid deterioration
he was admitted to the Pediatric Intensive Care Unit. Again, Kingella kingae was cultured
from blood cultures with no obvious focal systemic source.
The only notable clinical finding was rapid deterioration and, in retrospect, the
absence of any significant recorded fever ( < 38oC). CRP elevation was observed (max.
188 mg/L) and neutropenia was found with each of the more severe infectious presentations
but recovered in the interval. Baseline immunological investigations were normal (lymphocyte
subsets, naïve T cell populations, lymphocyte proliferation, serum immunoglobulins
and vaccine responses). Serial measurement of circulating neutrophils did not identify
a cyclical pattern and they were morphologically normal.
A panel of genes relevant to Primary Immunodeficiency (Invitae©) revealed a homozygous
mutation in IRAK4 ((c.877C>T (p.Gln293*)) which leads to a premature stop codon. This
is a known pathogenic mutation leading to disease and is most prevalent in the European
population (allele frequency (gnomAD) = 0.0005). Prophylaxis with Sulfamethoxazole
/ Trimethoprim and Amoxicillin was commenced along with monthly IVIG. He has been
well since diagnosis with no further severe infectious presentations. Functional testing
is underway to assess in vitro host viral defence in our patient and potential novel
mechanisms relevant to this rare innate immunodeficiency.
(114) Submission ID#810715
New Dangers Lurking: Diagnosis and Treatment of Fulminant Mulch Pneumonitis in Chronic
Granulomatous Disease
Samantha Kreuzburg, RN1, Jennifer Treat, PA-C, MSHS2, Christa Zerbe, MD3
1Research Nurse Specialist/National Institutes of Health/National Institute of Allergy
and Infectious Diseases
2Physician Assistant/National Institutes of Health/National Institute of Allergy and
Infectious Diseases/Medical Science & Computing
3Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Immunopathogenesis
Section, National Institute of Allergy and Immunology, National Institutes of Health,
Bethesda, MD
Abstract/Case Report Text
Chronic Granulomatous Disease (CGD) is an inherited primary immunodeficiency (PID)
which results in both inflammatory response dysregulation and susceptibility to certain
bacterial and fungal infections. Fungal pneumonias often have a subacute presentation.
In contrast, fulminant mulch pneumonitis (FMP) secondary to aerosolized fungal and
bacterial exposure can present as an acute respiratory emergency requiring prompt
diagnosis and treatment in the face of high mortality.
Case studies will be presented on the five cases of FMP that were diagnosed and treated
in 2019. Potential exposures were identified in four out of five cases: gardening
exposure in one case and vaping exposure in three cases. All five were male, age range
14-45. Four were gp91 deficient, and one was p47-phox deficient. Historically, the
vast majority of cases of FMP could be traced to a significant gardening exposure
such as lawn mowing or spreading mulch. This was the first year that we saw patients
with no identifiable gardening exposure in the setting of significant vaping exposure.
With vaping at epidemic levels, especially among teenagers and young adults, it is
important to consider that a vaping history is potentially a risk factor for FMP and
counseling regarding the potential risks of vaping should be included in infection
risk modification for all patients with CGD.
(116) Submission ID#810903
Rationale and Design of a Retrospective Chart Review Study on the Usage of CUVITRU
in the United States: REToUCH Study
Kevin Rosenbach, MD1, Michelle Park, n/a2, Colin Anderson-Smits, n/a3, Corinna Hermann,
n/a4, Kenneth Paris, MD, MPH5
1Medical Director/Naples Allergy Center
2Global Medical Product Lead, Immunology IG/The Takeda group of companies, Cambridge,
MA, USA
3Director of Outcomes Research and Epidemiology/The Takeda group of companies, Cambridge,
MA, USA
4Global Medical Team Lead, Immunology IG/The Takeda group of companies, Vienna, Austria
5Associate Professor of Pediatrics/LSU Health Sciences Center, Children’s Hospital,
New Orleans, LA, USA
Abstract/Case Report Text
Introduction/Background: Immunoglobulin (IG) replacement therapy is standard first-line
treatment for most forms of primary immunodeficiency diseases (PID) with defective
antibody production. CUVITRU (Immune Globulin Subcutaneous [Human], 20% Solution;
Ig20Gly) is a highly concentrated formulation that enables subcutaneous infusion of
IG in small volumes and reduces infusion times compared with less-concentrated products.
Clinical trials have demonstrated the efficacy and tolerability of Ig20Gly in patients
who have PID. While studies assessing real-world use of Ig20Gly are underway in other
countries, there are currently no data available describing Ig20Gly use in real-world
conditions in the United States.
Objective: To evaluate real-world patterns of Ig20Gly usage and administration in
adult and pediatric patients in the United States who have PID and have been receiving
Ig20Gly for at least 12 months.
Methods: REToUCh is a retrospective chart review study analyzing longitudinal patient
chart data collected from two centers in the United States. Patients who are aged
≥2 years, have PID, and are incident Ig20Gly users who meet all inclusion criteria,
with data for initial Ig20Gly infusion (index date) and for infusions occurring during
the observation period at 6 and 12 months post-index, will be included in the analysis.
Patients currently enrolled in another study or who had any treatment interruptions
affecting >2 doses of Ig20Gly within the 12-month observation period prior to identification
are being excluded. The planned enrollment size is 60 patients. Patient demographics,
medical and PID treatment histories, reasons for selecting or switching to Ig20Gly,
Ig20Gly infusion parameters (dosing and schedule; infusion rate, volume, and site;
premedications; needle characteristics; administration setting; etc.), tolerability
(defined by the incidence of local or systemic events and/or rate of discontinuation,
interruption or reduction of infusion rate), and patterns of use at index date and
6 and 12 months post-index will be assessed.
Results: The REToUCH study is ongoing; real-world Ig20Gly tolerability and patterns
of usage and administration in enrolled patients will be available for presentation
during the congress.
Conclusion: The REToUCH study is expected to provide a detailed and complete description
of Ig20Gly usage, tolerability, and safety under real-world conditions in patients
who have PID in the United States.
(117) Submission ID#811047
Normal Mesenchymal Cells Can Restore Thymic Tissue Expansion In The Setting of 22q11.2
Deletion Syndrome
Nicolai van Oers, PhD1, Bhalla Pratibha, PhD2, Austin Thompson, BSc3, Christian Wysocki,
MD, PhD4, Igor Dozmorov, PhD5, M. Teresa de la Morena, MD6
1Associate Professor/UT Southwestern Medical Center
2Post-Doctororal Fellow/UT Southwestern Medical Center
3Research Associate/UT Southwestern Medical Center
4Associate Professor/Division of Allergy and Immunology, Departments of Medicine and
Pediatrics, UT Southwestern Medical Center
5Professor/UT Southwestern Medical Center
6Professor/Seattle Children's Research Institute and the University of Washington
Abstract/Case Report Text
BACKGROUND. 22q11.2 deletion syndrome (22q11.2del) is the most common human microdeletion
disorder known, affecting 1/4000 individuals. Patients with 22q11.2del have variable
congenital malformations, including a thymic hypoplasia that results in a T cell lymphopenia.
Some patients will have a T-B+NK+ phenotype, leading to a severe combined immunodeficiency
(SCID). The molecular cause of the thymic hypoplasia is unknown. Candidate cell populations
responsible for thymic tissue expansion include neural crest-derived mesenchymal cells,
thymic epithelial cells (TECs), and endothelial cells.
OBJECTIVE. To determine whether the hypoplastic thymus resulting from 22q11.2 deletion
syndrome can be regenerated.
METHODS. Mouse models of 22q11.2del are used to characterize the embryological changes
during the formation of the thymus within the 3rd pharyngeal pouch. Hypoplastic thymic
lobes, evident as early as e12-e13.5, are isolated and characterized by flow cytometry
and compared with normal tissues. In addition, the various cell populations from normal
and hypoplastic embryonic thymic lobes are sorted by flow cytometry and used in reaggregate
thymic organ cultures (RTOC), using various combinations of cell subsets. RNA sequencing
on mesenchymal cells and single cell RNA-seq are being undertaken to identify transcripts
required for thymic tissue expansion.
RESULTS. Flow cytometric analyses of normal and hypoplastic thymic lobes from e13
embryos revealed that both tissues had similar percentages of mesenchymal, epithelial,
and thymic progenitors. The major difference with the hypoplastic thymus was a reduced
cellularity suggesting a growth/expansion defect. While normal lobes expanded in fetal
thymic organ culture, the hypoplastic lobes disintegrated. In RTOC, replacing 22q11.2del
derived mesenchymal cells with those from normal fetal lobes restored the tissue expansion
of the hypoplastic lobes. RNA Seq and 10X single cell RNA is revealing key transcripts
involved in thymic tissue expansion, and these will be presented.
CONCLUSION. The thymic hypoplasia resulting from 22q11.2del syndrome is caused by
mesenchymal cell defects. Thymic tissue regeneration and thymopoiesis are restored
by the addition of normal mesenchyme.
(118) Submission ID#811053
Serum IgG Profiling of Healthy Toddlers Reveals a Subgroup with Clinically Informative
Reactivities to Pathogens and Autoantigens
Nicolai van Oers, PhD1, Patricia Pichilingue-Reto, MD2, Prithvi Raj, PhD3, Quan-Zhen
Li, MD,PhD1, Igor Dozmorov, PhD4, Nancy Kelly, MD5, M. Teresa de la Morena, MD6
1Associate Professor/UT Southwestern Medical Center
2Clinical Fellow/St. Judes Research Institute
3Assistant Professor/UT Southwestern Medical Center
4Professor/UT Southwestern Medical Center
5Professor/UT Southwestern Medical Center and Children's Health, Dallas
6Professor/Seattle Children's Research Institute and the University of Washington
Abstract/Case Report Text
BACKGROUND. The antibody repertoire in an infant/toddler is shaped by the microbiome,
along with infections, diverse environmental exposures, and vaccinations. Monitoring
the specificity of such antibody responses in normal toddlers will provide indicators
of disease susceptibility.
OBJECTIVE. To determine whether profiling of the serum antibody specificities in toddlers
provides key insights into the development of the immune response to pathogens and
autoantigens.
METHODS. The serum IgG and IgM antibody reactivities in 1- and 2-year-old toddlers
was conducted using an antigen array comprising infectious agents, autoantigens, vaccine
antigens, and allergens. The toddlers were stratified based on their antibody reactivity
to these antigens using a normalized fluorescence intensity measure. Repeat profiling
was performed at year 2 to reveal longitudinal changes in the IgG responses. Clinical
information, along with DNA sequencing, and selected cytokine assays were used to
establish an odds ratio for disease potential among the cohort.
RESULTS. Toddlers exhibited a stratification into low, moderate, and high IgG responder
groups unconnected with total serum IgG levels. The high responder group had elevated
IgG reactions to selected pathogens and autoantigens. This group, representing 17%
of the cohort, had high odds ratios with gestational diabetes, age, and a family history
of asthma. While all toddlers developed strong antibody responses to Measles-Mumps-Rubella
vaccines (MMR), more variation was noted towards other vaccines. In infections to
Molluscum contagiosum, the IgG serum levels were transient regardless of the responder
group. The high responder group had DNA polymorphisms linked to enhanced immune responses
that correlated with elevated cytokine levels and eczema and asthma.
CONCLUSION. A subset of normal “healthy” toddlers has a high potential for immune
system abnormalities and autoimmunity based on higher serum antibody responses to
pathogens and autoantigens, genetic polymorphisms, and elevated cytokine responses.
(120) Submission ID#811088
Expanding The Phenotype Of XMEN disease: MAGT1 deficiency presenting with neurodegenerative
symptoms
Sebastian Ochoa, MD1, Camilo Toro, MD2, Lynne Wolfe, MS, CRNP3, Jessica Durkee-Shock,
MD4, Michael Lenardo, MD5, Kyle Binder, MD, PhD6, Juan Ravell, MD7
1Clinical Fellow in Allergy and Immunology/National Institutes of Allergy and Infectious
Diseases (NIAID), Bethesda, Maryland, USA
2Staff Clinician/National Human Genome Research Institute, NIH, Bethesda, Maryland,
USA
3Nurse Practitioner/National Human Genome Research Institute, NIH, Bethesda, Maryland,
USA
4Clinical Fellow in Allergy and Immunology/National Institute of Allergy and Infectious
Diseases, National Institutes of Health
5Chief/Molecular Development of the Immune System Section; Director, Clinical Genomics
Program; Laboratory of Immune System Biology, NIAID, Bethesda, Maryland, USA
6Clinician/Investigator/Neuroimmunology Branch, National Institute of Neurological
Disorders and Stroke (NINDS), Bethesda, Maryland, USA
7Staff Clinician/Laboratory of Clinical Immunology and Microbiology, NIAID, Bethesda,
Maryland, USA
Abstract/Case Report Text
X-linked immunodeficiency with magnesium defect, Epstein-Barr virus (EBV) infection,
and neoplasia (XMEN) disease is a rare primary immunodeficiency and glycoprotein-selective
congenital disorder of glycosylation (CDG) caused by loss-of-function (LOF) mutations
in the magnesium transporter gene (MAGT1). Patients present with lymphadenopathy,
EBV-associated B cell malignancies, cytopenias, liver disease, elevated serum creatine
kinase, splenomegaly, CD4 T-cell lymphopenia, and dysgammaglobulinemia. MAGT1 is part
of the oligosaccharide transferase (OST) complex which is involved in asparagine-linked
glycosylation of specific proteins. While mutations in other genes in this complex
have been associated with non-syndromic intellectual disability (ID), the vast majority
of XMEN patients have normal development. We report on 2 adult males with XMEN disease
and normal developmental histories who developed progressive neurodegeneration as
young adults, indicating a yet uncharacterized link between MAGT1 and central nervous
system (CNS) degeneration.
Case 1: A 32-year-old male developed progressively worsening mania, dysarthria, recurrent
falls, and ataxia at the age of 26 years. He had a past medical history of inflammatory
liver disease and basal ganglia calcifications. His family history was remarkable
for basal ganglia calcifications in his otherwise healthy mother and B-cell lymphomas
in his brother and maternal uncle. Brain imaging showed bilateral frontal, subcortical
and cerebellar calcifications as well as extensive cortical atrophy. Laboratory and
whole exome sequencing (WES) did not reveal an explanation for his neurodegeneration
or apparently familial basal ganglia calcifications. Surprisingly, he was hemizygous
for a mutation in MAGT1 that results in a premature stop codon leading to nonsense
mediated decay (c.414C>A; p.Tyr138X).
Case 2: A 33-year-old male with a past medical history of recurrent lymphadenopathy
in childhood and complicated mononucleosis developed progressive gait and balance
abnormalities, frequent falls, behavioral changes, seizure-like episodes, and cognitive
decline at around the age of 20 years. Brain MRI showed cortical, cerebellar, and
spinal cord atrophy as well as multifocal white matter lesions. Extensive evaluation
for secondary causes of neurodegeneration was unrevealing. Genetic testing showed
a LOF mutation in the MAGT1 gene (c.444dupT; p.Ala149Cysfs*6). Both patients had decreased
NKG2D surface expression on CD8+ T and NK cells, expanded B cells, and chronic EBV
viremia as determined by whole blood PCR. CSF PCR for EBV was negative on both patients.
Both cases demonstrated abnormal carbohydrate deficient transferrin pattern, indicating
a Type I CDG.
To our knowledge, these are the first cases of XMEN disease presenting with a progressive
neurodegenerative phenotype. Further studies are needed to elucidate the basis of
neurodegeneration and the role of MAGT1 in the central nervous system.
(121) Submission ID#811104
A Case Of Disseminated Cryptococcosis Gattii Due To Granulocyte-Macrophage Colony-Stimulating
Factor (GM-CSF) Autoantibodies
Ivan Lee, MD, PhD1, Seher Anjum, MD2, Anne Liu, MD3, Peter Williamson, MD, PhD4, Steven
Holland, MD5, Yael Gernez, MD, PhD6
1Fellow Physician/Division of Allergy, Immunology, and Rheumatology, Department of
Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
2Staff Physician/Laboratory of Clinical Infectious Diseases, National Institute of
Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892
3Clinical Associate Professor/Division of Allergy, Immunology, and Rheumatology, Department
of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
4Chief, Translational Mycology Section/Laboratory of Clinical Infectious Diseases,
National Institute of Allergy and Infectious Diseases, National Institutes of Health,
Bethesda, MD 20892
5Director, Division of Intramural Research; Chief, Immunopathogenesis Section/Laboratory
of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR),
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH), Bethesda, MD, USA
6Clinical Assistant Professor, Division of Allergy, Immunology, and Rheumatology/Stanford
Abstract/Case Report Text
Background: Granulocyte-macrophage colony-stimulating factor (GM-CSF) plays a critical
role in macrophage and dendritic cell maturation and host defense against fungus.
Autoantibodies to GM-CSF are associated with susceptibility to Cryptococcus and Nocardia
infections as well as pulmonary alveolar proteinosis (PAP) in otherwise healthy individuals.
We report a case of a 23-year-old previously healthy female who presented with cryptococcal
meningitis and was found to have autoantibodies against GM-CSF.
Case Presentation: 6 weeks prior to admission, our previously healthy 23-year-old
Taiwanese female developed a headache associated with tinnitus and visual changes.
The headache worsened over the next few weeks and she developed photophobia, phonophobia,
and severe nausea/vomiting. At presentation, her exam was notable for papilledema,
bilateral CN VI palsy and right foot & left hand paresthesia. MRI Brain showed ring-enhancing
lesions in the anterior frontal lobe, caudate head, and the inferior globus pallidus.
She underwent a diagnostic and therapeutic LP. Opening pressure was elevated at 60
and CSF studies were notable for low glucose, elevated protein, pleiocytosis (94%
lymphocytes) and positive cryptococcal antigen. CSF culture grew Cryptococcus gattii.
CT Chest revealed a right upper lobe and a left lower lobe nodule.
Workup: CBC with Diff was unremarkable. HIV was negative. Lymphocyte subsets were
unremarkable with only mildly decreased NK cells, normal immunoglobulin panel including
IgE, protective titers to tetanus, diphtheria, and PPSV23. Targeted genetic sequencing
did not identify any known mutations in primary immunodeficiency. Notably, Anti-GMCSF
autoantibodies were detected by ELISA and were able to neutralize GM-CSF phosphorylation
of STAT5 detected by flow cytometry. Autoantibodies to IFN-γ were not detected.
Management: Patient was initiated on a 6-week course of liposomal Amphotericin B and
Flucytosine. Her CSF cultures were cleared of Cryptococcus after 20 days of treatment,
but her hospital course was complicated by persistently symptomatic intracranial hypertension,
worsening pleiocytosis, and elevated cytokine levels in the CSF, all of which were
consistent with post-infectious inflammatory syndrome (PIIRS). She received therapeutic
LPs 2-7x/week until subsequent ventriculoperitoneal shunt placement. Concurrently,
methylprednisolone was administered for 7 days with a gradual prednisone taper. These
interventions led to improvements in her symptoms, including diplopia, and reduction
in opening pressures and inflammatory markers in the CSF. Lifelong fluconazole prophylaxis
was recommended. From a pulmonary standpoint, she remained asymptomatic without signs
of PAP and has had normal pulmonary function tests (normal DLCO) and stable chest
imaging.
Conclusion: In otherwise healthy HIV-negative patients presenting with extrapulmonary
Cryptococcus or Nocardia infections, autoantibodies to GM-CSF should be suspected
and testing for functional autoantibodies to GM-CSF (and IFN-γ) should be sent, as
genetic testing will not pick up this disease entity. Genetic testing should be considered
to rule out GATA2 deficiency and X-linked CD40L deficiency. Idiopathic CD4 lymphopenia
can be ruled out with lymphocyte enumeration. Immediate treatment of cryptococcosis
is not necessarily different from patients without GM-CSF autoantibodies. Long-term
prophylaxis (fluconazole if presenting with Cryptococcus; Trimethoprim-sulfamethoxazole
if with Nocardia) is likely warranted in addition to monitoring for the development
of PAP. Recognizing PIIRS in patients with cryptococcal meningitis and management
with corticosteroids are critical steps.
(122) Submission ID#811123
NF-κB-Driven Innate and Adaptive Immune Dysregulation Underlies Complications of Common
Variable Immunodeficiency
Miranda Abyazi, BS1, Kayla Bell, BS1, Gavin Gyimesi, BA2, Michele Pham, MD3, Turner
Baker, BS4, Adeeb Rahman, PhD5, Bertrand Boisson, PhD6, Jean-Laurent Casanova, MD,
PhD7, Andrea Cerutti, MD, PhD8, Charlotte Cunningham-Rundles, MD, PhD9, Huaibin Ko,
MD10, Minji Byun, PhD10, Paul Maglione, MD, PhD11
1Research Associate/Boston University School of Medicine
2Research Associate/Icahn School of Medicine at Mount Sinai
3Assistant Professor/UCSF
4Graduate Student/Icahn School of Medicine at Mount Sinai
5Associate Professor/Icahn School of Medicine at Mount Sinai
6Assistant Professor/Rockefeller University
7Professor/Rockefeller University
8Professor/Icahn School of Medicine at Mount Sinai
9Professor of Medicine and Pediatrics/Icahn School of Medicine at Mount Sinai
10Assistant Professor/Icahn School of Medicine at Mount Sinai
11Assistant Professor/Boston University School of Medicine
Abstract/Case Report Text
Background: Non-infectious complications cause most morbidity and mortality in common
variable immunodeficiency (CVID). CVID with complications (CVIDc) is defined by elevated
T helper 1 (Th1) responses attributed to increased circulating microbial products
resulting from mucosal IgA deficiency. However, complications do not uniformly occur
in those with IgA deficiency.
Objective: We tested whether CVIDc occurs preferentially in those with hyper-responsiveness
to microbial stimuli, manifested by elevated NF-κB-driven cytokines and resultant
Th1 responses in CVID patients with increased circulating microbial products.
Methods: We applied unbiased high-throughput seromics and mass cytometry, cellular
and molecular biology approaches, and clinical record review in a 78 subject CVID
cohort.
Results: CVIDc was defined by increased NF-κB-driven cytokines that promote Th1 immunity
in blood in association with elevated soluble CD14, a marker of circulating microbial
products, and elevated TNF production by peripheral blood mononuclear cells stimulated
with lipopolysaccharide. This cytokine upsurge was associated with mutation of full-length
NFKB1 p105 gene product (1375delT) but not mutations that also involved the NFKB1
p50 product involved in transactivation. Cytokine elevation corresponded with increased
CD14+CD16- monocytes expressing higher CD86 and HLA-DR and more central and effector
memory CD4+ T cells, T cell chemoattractants, and T cell-predominant tissue pathology.
Those with granulomatous or neutrophil-predominant, rather than T cell, pathology
had the highest TNF. TNF antagonism improved neutrophilic gastritis in CVID with NFKB1
1375delT after T cell targeted therapy failed.
Conclusion: NF-κB dysfunction underlies Th1 immunopathology and TNF-associated innate
inflammation in CVIDc. Both forms of NF-κB immune dysregulation may divergently shape
CVID immunopathology.
(124) Submission ID#811150
Daratumumab (anti-CD38) For Treatment of Disseminated Nontuberculous Mycobacteria
in a Patient with Anti-IFN-γ Autoantibodies
Sebastian Ochoa, MD1, Ding Li, MD2, Samantha Kreuzburg, RN3, Jennifer Treat, PA-C,
MSHS4, Steven Holland, MD5, Christa Zerbe, MD6
1Clinical Fellow in Allergy and Immunology/National Institutes of Allergy and Infectious
Diseases (NIAID)
2Biologist/Laboratory of Clinical Immunology & Microbiology, National Institutes of
Health
3Research Nurse Specialist/National Institutes of Health/National Institute of Allergy
and Infectious Diseases
4Physician Assistant/National Institutes of Health/National Institute of Allergy and
Infectious Diseases/Medical Science & Computing
5Director, Division of Intramural Research; Chief, Immunopathogenesis Section/Laboratory
of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR),
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH),
6Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Immunopathogenesis
Section, National Institute of Allergy and Immunology, National Institutes of Health,
Abstract/Case Report Text
Introduction: Patients with autoantibodies to IFN-γ develop severe and progressive
infections with intracellular pathogens, despite aggressive antimicrobial treatment.
We describe the use of daratumumab (anti-CD38, targeting plasma cells) in a patient
with autoantibodies to IFN-γ and progressive disseminated Mycobacterium avium infection.
She had progressive disease despite treatment with multi-drug antimycobacterials rituximab,
and bortezomib.
Methods: Clinical symptoms, total CD19/CD20, anti-IFN-γ autoantibody titers, and specific
imaging were obtained before and after treatment with daratumumab. Anti-IFN-γ autoantibody
titers were determined by serial 10-fold dilutions of plasma and measuring anti-IFN-γ
autoantibody levels by a particle-based technique as previously described.
Results: A 31-year-old Filipino woman had progressive disseminated M. avium with extensive
bone and soft tissue involvement (calvarium, ribs, bilateral arm soft tissue, paraspinal
muscles, bilateral glutei, left inferior pubic ramus, bilateral iliac bones, sacrum,
and bilateral humeri) and a tracheo-esophageal fistula. She received bedaquiline,
azithromycin, ethambutol, tedizolid, moxifloxacin, clofazimine and meropenem as well
as rituximab 1g once monthly for 5 months. Despite these she had progression of clinical
and radiographic disease. Bortezomib 1.3 mg/m2 twice weekly for 8 weeks was added,
but discontinued for AST and ALT elevations. Rituximab was continued to maintain CD20
numbers undetectable but clinical and radiographic disease progressed. While on rituximab,
total IgG level and anti-IFN-γ autoantibody levels decreased from 1521mg/dL to 1069mg/dL
and 3058 to 2504, respectively. While on bortezomib, total IgG levels remained stable
(1031mg/dL to 1051mg/dL) and anti-IFN-γ autoantibody levels fell slightly (2504 to
1275). After starting daratumumab, there was clinical and radiographic improvement,
with reduced pain and disappearance of multiple soft tissue lesions. IgG levels decreased
from 1100mg/dL to 434mg/dL and anti-IFN-γ autoantibody levels decreased from 1275
to 157. Adverse effects of daratumumab were urticaria, pruritus and shortness of breath
after the first infusion and aseptic meningitis after the 5th infusion.
Conclusions: Daratumumab resulted in clinical and radiographic improvement of disseminated
M. avium in a patient with rituximab and bortezimib-refractory autoantibodies to IFN-γ.
Daratumumab is another potentially effective therapeutic agent for anti-IFN-γ autoantibodies.
(125) Submission ID#811206
Supplemental NGS Method for Homologous Genes in Inborn Errors of Immunodeficiency
Gene Panel (IEIGP)
Susan Lagerstedt, n/a1, Attila Kumanovics, MD2, Carlos Sosa, PhD3, Ann Moyer, MD4
1Development Coordinator/Mayo Clinic
2Senior Associate Consultant/Mayo Clinic
3Informatics Specialist/Mayo Clinic
4Consultant/Mayo Clinic
Abstract/Case Report Text
Next-generation sequencing (NGS) is now routinely used as a clinical diagnostic tool.
However, regions of high sequence homology continue to be a major challenge for short-read
technologies. Regions within IKBKG, NCF1, SBDS, C4A, C4B, CORO1A, FCGR3A, FCGR3B,
PMS2, SLFN11, SLFN13, STAT5B, UNC93B1, and UPS18 are not available by standard NGS.
We discuss strategies for analysis of these special regions.
We have developed a strategy for supplementing our disease targeted panels which are
performed using capture chemistry and a standard reference file. The supplemental
method uses gene specific long range amplicon and a special gene specific reference
file for alignment. The genes of interest are separated from their homologous counterparts
using specific long range amplification primers. Multiple amplicons may be pooled
together and prepared for sequencing on an Illumina MiSeq instrument using TruSeq
Nano DNA Library Prep. Bioinformatic analysis proceeds with a custom reference file
in which non-specific regions of homology have been removed. This allows reads to
be uniquely mapped despite significant homology; a requirement for variant calling.
We prepared specific amplicon for several homologous gene targets including the IKBKG
gene and the IKBKG pseudogene (IKBKGP1). Both amplicons were sequenced in separate
reactions and were compared with the standard capture method. Variants which are not
called in the standard-capture method due to poor mapping scores (non-uniquely mapped
reads) are called in the amplicon method. In the capture method, the variants are
visualized in the BAM as a mixture of gene and pseudogene, while gene and pseudogene
variants are clearly separated and identified in the amplicon method.
Due to high variability in alignment, many homologous regions do not provide reliable
Copy Number Variant (CNV) results and must be removed from CNV analysis. However in
some situations, we are able to creatively leverage CNV analysis to identify alleles
that mis-align to the pseudogene. The pathogenic NCF1 GT deletion in Exon 2 appears
to resemble a copy number deletion event when present as reads from one allele mis-align
to the NCF1B and NCF1C pseudogenes.
Complement genes, C4A and C4B, share alignment due to their high homology with each
other. CNV analysis in normal samples represents four alleles rather than two alleles.
CNV events may have a weak signal with no indication of which gene is affected. Variant
frequencies from the capture and supplemental PCR analysis can be used in tandem with
CNV analysis to detect events and may indicate which gene is affected.
We plan to include these strategies in our new Inborn Errors of Immunodeficiency Gene
Panel (IEIGP) which will enable us to provide a more comprehensive analysis than is
currently available.
(127) Submission ID#811256
Inflammatory Manifestations in Children with Chronic Granulomatous Disease
Myris Satiko Shinzato Tatebe, MD1, MAYRA DE BARROS DORNA, MD2, Ana Paula Beltran Moschione
Castro, MD, PhD2, Antonio Carlos Pastorino, MD, PhD2, Magda Carneiro-Sampaio, MD,
PhD3
1Fellow in-training/Department of Pediatrics, Faculdade de Medicina da Universidade
de Sao Paulo, Sao Paulo, Brazil.
2Associate Professor/Department of Pediatrics, Faculdade de Medicina da Universidade
de Sao Paulo, Sao Paulo, Brazil.
3Full Professor/Department of Pediatrics, Faculdade de Medicina da Universidade de
São Paulo, São Paulo, SP, Brazil
Abstract/Case Report Text
Inflammatory manifestations (IM) are increasingly recognized as comorbidities among
patients with Chronic Granulomatous Disease (CGD). The aim of the study is to describe
the different inflammatory manifestations and the clinical and laboratory profile
of patients with CGD who presented them.
Methods: Retrospective analysis of the electronic medical records of all CGD patients
followed at the outpatient clinics of Pediatric Allergy and Immunology Unit at University
of São Paulo Children’s Hospital, between 2008 and 2019. Clinical, laboratory and
histological data of patients with CGD patients who had IM were evaluated. Infectious
or neoplastic causes were excluded.
Results: Thirty patients (28 male) with a median age of 13.1 years (1.2-18.2) in the
last clinical follow-up were included. The diagnosis of CGD was confirmed by oxidation
of Dihydrorhodamine (DHR) or Nitroblue tetrazolium reduction (NBT) assays. The median
age at diagnosis was 1.75 years (0.1-14.7).
Ten of the 30 patients (33%) presented inflammatory manifestations during follow-up.
The median age of diagnosis of CGD of patients with IM was 6.1 years (0.2-12.4) and
the age of onset of IM ranged from 0.2 to 12 years (median 7.1y). In 4 out of the
10 patients, IM occurred before the diagnosis of CGD, with a median time between IM
and the diagnosis of 5.85 years (2.1-7.4).
The IM diagnosed were inflammatory bowel disease-like (n = 5, with perianal fistula
in 2/5), mouth ulcers (n = 1), discoid lupus (n = 1), autoimmune dermatitis (n = 1)
and eczema (n = 1), chronic lung disease (n = 2) and granulomas (pulmonary n = 2;
ocular n = 1; bladder n = 1; oropharynx n = 1). Three patients presented more than
one site of inflammatory disease. All patients were treated with systemic or topical
immunosuppressive or immunomodulatory therapy, most of them corticosteroids. Five
patients underwent hematopoietic stem cell transplantation (HSCT), median age at HSCT
was 13 years (4 - 17), and two died 1 month after HSCT.
Conclusions: Although infections are more frequent and have a major impact on patient
morbidity and mortality, IM are increasingly prevalent in patients with CGD. Awareness
regarding this possible comorbidity is of major importance, since earlier diagnosis
and adequate treatment may be crucial for patients survival and quality of life.
(128) Submission ID#811299
Rheumatological Diseases in Patients with Primary Immunodeficiency Disorders in the
USIDNET Registry
Nurcicek Padem, MD1, Ramsay Fuleihan, MD2, Elizabeth Garabedian, MSLS, RN3, Amer Khojah,
MD4
1Fellow/Division of Allergy & Immunology, Ann & Robert H Lurie Children’s Hospital
of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
2Attending Physician, Professor of Pediatrics/Division of Allergy & Immunology, Ann
& Robert H Lurie Children’s Hospital of Chicago, Northwestern University Feinberg
School of Medicine3Research Nurse/NIH-NHGRI
4Attending Physician, Assistant Professor/Division of Allergy & Immunology, Ann &
Robert H Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School
of Medicine, Chicago, IL
Abstract/Case Report Text
Rationale: There is a gap in clinical knowledge regarding associations between specific
PID and different rheumatological diseases. In this study, we are reporting the incidence
of various rheumatological conditions reported in a large PID population using the
USIDNET (United States Immunodeficiency Network) registry.
Methods: We used the retrospective USIDNet registry to conduct the analysis. We included
all primary immunodeficiency patients with physician diagnosed rheumatological diseases.
Results: The total number of PID patients in our query was 5058. 278 (5.49%) patients
had a diagnosis of rheumatological disease. This cohort included 172 (61.8%) female
and 106 (38.2%) male patients. Rheumatologic complications were highest in the interferonopathies
(66.6%), complement deficiencies (14.2%) and Autoimmune Lymphoproliferative Syndrome
(ALPS) (13.7%). Additionally, disease patterns were noted to be different in each
PID. Dermatomyositis was found to be the most common rheumatologic condition in patients
with X-linked Agammaglobulinemia (XLA) with a rate of 1.65%, which was remarkably
higher than the reported prevalence in the United States (0.005%). ALPS patients had
a higher (6.85%) numbers of Sjogren Syndrome diagnoses as compared to the general
population (0.01-0.09%). Systemic lupus erythematosus was increased in patients with
Mucocutaneous Candidiasis (7.41%) as compared to the general population (0.001%) and
other PIDs. Rheumatoid arthritis (RA) was reported in patients with Specific Antibody
Deficiency (3.66%), Common Variable Immunodeficiency (CVID) (2.93%) and ALPS (2.74%).
Wiskott-Aldrich Syndrome patients had the highest numbers of cases diagnosed with
vasculitis (6.50%). 0.29% of patients with Severe Combined Immunodeficiency (SCID)
had reported rheumatologic disease. Juvenile rheumatoid arthritis (JIA) and systemic
sclerosis were reported in 0.19% of patients with DiGeorge Syndrome.
Conclusions: This study reports that higher numbers of rheumatologic diseases are
diagnosed in PIDs compared to the general population. The incidence of different rheumatological
disease was variable based on the PID diagnosis. Early diagnosis of these diseases
is crucial, given the high risk of irreversible complications. Limitations of our
study include possible selection bias as majority of cases were enrolled from tertiary
care centers.
(129) Submission ID#811309
Hematopoietic Stem Cell Transplantation for Diseases of Immune Dysregulation – The
Journey of the Cure for Hitherto Unrecognized Conditions
Ramya Uppuluri, MD1, Venkateswwaran VS, MD2, Revathi Raj, MRCP, FRCPath1
1Consultant/Apollo Hospitals, Chennai
2Senior Registrar/Apollo Hospitals, Chennai
Abstract/Case Report Text
Background Disorders of immune dysregulation are associated with autoimmune features.
This feature could potentially have an impact on the outcome post hematopoietic stem
cell transplantation (HSCT). HSCT, although curative, can be challenging with the
underlying immune dysregulation resulting in significant morbidity and mortality.
We present the journey through HSCT for these children and the factors affecting the
outcome.
Patients and methods
We analysed the data on children up to the age of 18 years diagnosed to have a disorder
of immune dysregulation through gene mutation analysis and who underwent HSCT at our
centre from 2015 to 2019.
Results 1. XIAP mutation
A 10-year-old boy underwent a haploidentical HSCT from his father using fludarabine,
treosulfan, and 2 Gray radiotherapy with post-transplant cyclophosphamide. After initial
complete chimerism and cytomegalovirus reactivation responsive to valganciclovir,
he developed progressive diarrhoea almost 15 months post-HSCT. A rectal biopsy confirmed
CMV reactivation and features of inflammation. He has since been treated for the same
and is on follow up for inflammatory bowel disease. His chimerism had dropped to 67%
and has remained stable.
The second child is a 1-year-old girl who underwent TCR alpha/beta depleted haplo
SCT and is 12 months post-HSCT, with no features of GvHD or infections, and is doing
well with complete chimerism.
2. IL10R deficiency
Three boys aged eight months, one year, and two years of age, diagnosed to have IL10R
deficiency underwent HSCT. All three children needed nasogastric tube feeding, parenteral
nutrition, and vigilant monitoring for electrolyte disturbances. In the first two
children, we had performed TCR alpha/beta depleted PBSC transplants from their haplo
matched fathers. The 1-year-old engrafted by D+17 and is doing well two years post
HSCT with complete chimerism, no GvHD, and infections. His autoimmunity, including
recurrent skin scarring, has resolved entirely. The 8-month-old, however, had primary
graft failure and succumbed to his illness.
The 2-year-old boy underwent matched unrelated donor HSCT and engrafted by D+14 with
completed chimerism documented on three occasions. He, however, had secondary graft
failure around D+60, and he succumbed to the illness.
3. LRBA deficiency
An 18-month-old girl with LRBA deficiency had presented at four months of age with
excessive sweating, hepatosplenomegaly, and recurrent chest infections. She was started
on monthly intravenous immunoglobulin replacement and Abatacept. She received myeloablative
conditioning with thiotepa, treosulfan and fludarabine and underwent a matched sibling
donor HSCT. She engrafted by D+17 and has been well ten months post HSCT with complete
chimerism, no GvHD, and infections.
Conclusion Disorders of immune dysregulation are a heterogeneous group with a varied
spectrum of immune dysfunction. Myeloablative conditioning is essential, and there
is a high risk of cytokine release syndrome and the need for supportive care. The
autoimmune features need to be followed for progression in organs other than the hematopoietic
system and may require interventions. As long-term data evolves, more precise definitions
for patient and donor selection will enable improving outcomes.
(130) Submission ID#811321
“One size does not fit all” - Hematopoietic Stem Cell Transplantation for Genotypic
Variants of Severe Combined Immune Deficiencies
Ramya Uppuluri, MD1, Venkateswwaran VS, MD2, Revathi Raj, MRCP, FRCPath1
1Consultant/Apollo Hospitals, Chennai
2Senior Registrar/Apollo Hospitals, Chennai
Abstract/Case Report Text
Background We present a series of rare variants of SCID, their spectrum of clinical
presentations, and challenges during hematopoietic stem cell transplantation (HSCT).
Patients and Methods
We performed a retrospective observational analysis of case records of children up
to 18 years of age, diagnosed to have variants of SCID, and underwent HSCT at our
centre from 2002 to 2019.
Results
1. ZAP 70 deficiency
A 6-month-old girl presented with oral thrush and submandibular cellulitis from one
week of life with failure to thrive. She underwent a TCR alpha/beta depleted haploidentical
HSCT. Conditioning included treosulfan/thiotepa/fludarabine/anti-thymocyte globulin.
She engrafted by D+15; now three years post-HSCT with complete donor chimerism without
GvHD or infections.
2. ORAI-1 mutation
A 15-month-old girl presented with failure to thrive, generalized hypotonia, oral
thrush, and recurrent respiratory infections. She underwent haplo-SCT with post-transplant
cyclophosphamide with PBSC from her haplo-matched father. Conditioning included fludarabine/treosulfan.
She had cytokine release syndrome grade 4, which responded to tocilizumab. She had
hypertension throughout the peri-engraftment period and had an episode of PRES with
seizures. Her symptoms abated with neutrophil engraftment by D+17. The post-transplant
period was complicated by grade 2 skin GvHD and cytomegalovirus reactivation. She
has remained disease-free with complete chimerism three years post-HSCT. Her hypotonia
is steadily improving with physiotherapy.
3. Cernunnos-XLF deficiency
A 27-year-old male presented with recurrent infections from 14 years of age, aplastic
anemia diagnosed at 20 years of age, subsequent transformation to acute myeloid leukemia
at 27 years of age. He had developed multiple fusarium abscesses during the neutropenic
period post-chemotherapy for AML. He was referred for a matched sibling sister HSCT
when in remission. Conditioning included fludarabine/treosulfan. He engrafted by D+15
with complete chimerism. He developed progressively worsening skin, gut, and liver
toxicity secondary to chemotherapy and succumbed to the illness two months post-HSCT.
4. IKZF mutation
An 18-month-old girl presented with failure to thrive, massive splenomegaly, persistent
pneumonia, anemia, and thrombocytopenia. She underwent a matched sibling donor PBSC
transplant after myeloablative conditioning with thiotepa/treosulfan/fludarabine.
She engrafted by D+20, following which all her symptoms abated. She had secondary
graft failure two months post-HSCT and succumbed to her illness.
5. MHC Class II deficiency (bare lymphocyte syndrome)
Three children, aged 18 months, two years, and four years underwent matched sibling
donor HSCT. Myeloablative conditioning with thiotepa/treosulfan/fludarabine resulted
in engraftment. The first child died of invasive intestinal aspergillosis 30 days
post-HSCT. The other two children are well 11 months post-HSCT with complete chimerism
without GvHD or infections. The two-year-old girl received one cycle of pre-transplant
immunosuppression with fludarabine/dexamethasone to prevent graft rejection pre-HSCT
as she was referred for a second transplant.
Conclusion
Children with SCID have traditionally been transplanted using reduced intensity (RIC)
conditioning with immunomodulation. SCID variants require myeloablative conditioning
with a vigilant follow up for the detection of graft rejection. Radiation sensitive
SCID associated with DNA breakage repair defects require RIC and close monitoring
for GvHD. Advances in HSCT, including supportive care and haplo-SCT, have provided
a ray of hope for these hitherto rare conditions.
(131) Submission ID#811347
Patient with Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX)
Syndrome Is Safely Treated with Tofacitinib
Lisa Kohn, MD, PhD1, Maria Garcia-Lloret, MD2
1Fellow/UCLA
2Attending/UCLA
Abstract/Case Report Text
Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) (OMIM #304790)
is a monogenic autoimmune disorder that occurs due to loss of function variation in
FOXP3 causing dysfunctional T regulatory cells. Although immunosuppression is a mainstay
of treatment for autoimmunity, IPEX treatment is frequently limited by insufficient
response to therapy or side effects of immune suppression. We present a 28 year old
male with IPEX whose prior immunosuppressive treatment was complicated by inefficacy
and medication side effects, requiring a new approach to treat his colitis and erosive
dermatitis.
He initially presented with infantile diabetes and subsequently developed dermatitis,
squamous cell carcinomas, alopecia totalis, and colitis. His clinical diagnosis of
IPEX was confirmed by FOXP3 sequencing, demonstrating known pathogenic variant c.1150G>A
(p.Ala384Thr). This variant has been described in IPEX affected individuals in multiple
publications (Ref 1). His variant affects at the FRKhead domain of FOXP3 and has been
associated with others with severe psoriasiform dermatisis and alopecia universalis
(Ref 2).
His prior immunosuppressive therapies included at different times combinations of
corticosteroids, tacrolimus, sirolimus, azathioprine, infliximab, adalimumab, rituximab,
dupilumab, and oral mesalamine. The relative efficacy of these agents based on experiences
in a cohort of IPEX patients was reviewed in 2018 (Ref 3), with the exception of duplimab,
which was not listed in that review. For our patient, management of his widespread
autoimmunity has been limited by toxicity or lack of efficacy of medications. Notably,
his dermatitis had no improvement with duplimab, consistent his low total IgE and
lack of allergic manifestations. At age 27, after initiation of treatment with sirolimus,
he had spontaneous colonic perforation requiring descending colectomy.
After stabilization of his colonic perforation, his multi-disciplinary team of allergy-immunology,
gastroenterology, and dermatology initiated tofacitinib. Tofacitinib is small molecule
inhibitor of Janus kinase (JAK) signaling pathways that mediate cytokine driven autoimmune
activation. It is FDA approved to treat Rheumatoid Arthritis, Psoriatic Arthritis
and Ulcerative Colitis. The decision to use this JAK inhibitor was due to its FDA
approved use for ulcerative colitis, to target our patient’s colitis and his other
autoimmune manifestations, specifically his dermatitis. Its off label for primary
immune dyregulatory disorders including CANDLE, STAT1-Gain of function and STAT3-Gain
of function disorders has been published (Ref 4), but thus far its use to treat autoimmunity
due to IPEX has not been published.
He experienced leukopenia while on 15 mg of tofacitinib, which resolved after lowering
his dose. Currently, he has had improvement in his colitis and dermatitis, and partial
improvement in alopecia. He has been on tofacitinib 10mg daily for 11 months, with
only prednisone 10mg daily as additional immune suppression.
As the number and types of selective immune modulators increases, there is continued
need to share the experiences of treating physicians of which therapies have been
successfully able to decrease disease manifestations with tolerable side effect profiles.
We present a 28 year old male with IPEX Syndrome with severe dermatitis and colitis
complicated by colonic perforation despite standard immunosuppressive therapy, who
is safely and effectively being treated with tofacitinib.
(132) Submission ID#811382
Lupus and Lupus-like Autoimmunity in Loss of Function STAT3
Alexandra Freeman, MD1, Brian Dizon, MD2, Amanda Urban, DNP, CRNP3, Rishi Goel, BA4,
Shuichiro Nakabo, BA5, Dirk Darnell, MA, RN6, Lilian Howard, NP7, Meryl Waldman, MD8,
Mariana Kaplan, MD9, Sarthak Gupta, MD10
1Senior Clinician/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH
2Clinical Fellow/NIAMS NIH
3Nurse Practitioner/Clinical Research Directorate, Frederick National Laboratory for
Cancer Research in support of NIAID, LCIM
4Medical Student/University of Michigan
5scientist/NIAMS NIH
6Clinical Research Nurse/Laboratory Of Clinical Immunology And Microbiology, NIAID,
NIH
7Nurse practitioner/NIDDK, NIH
8Staff clinician/NIDDK, NIH
9Principal investigator/NIAMS, NIH
10Staff Clinician/NIAMS NIH
Abstract/Case Report Text
INTRODUCTION Autoimmunity and auto-inflammation are common complications of primary
immune deficiencies, manifesting frequently as inflammatory bowel disease, hepatitis
and cytopenias. Dominant negative mutation in STAT3 (LOF STAT3; AD-HIES) is not frequently
associated with autoimmunity, likely due to impaired IL-6 and IL-17 pathways. However,
in our relatively large cohort of LOF STAT3 patients, we have noted an increased incidence
of systemic lupus erythematosus (SLE) diagnoses and SLE- like symptoms. Herein, we
characterized the clinical and laboratory features of the patients in our cohort with
SLE and SLE-like disease, with the aim to better understand the pathogenesis by evaluating
IFN stimulated genes and neutrophil net formation.
METHODS A retrospective chart review was performed of patients with LOF STAT3 to identify
those with SLE and SLE-like presentations, and included clinical features, laboratories
including inflammatory markers, auto-antibodies, and complement levels. RT-PCR was
performed for interferon stimulated genes (ISGs) from neutrophils and PBMCs of LOF
STAT3 patients with and without SLE, and healthy controls. Neutrophil NET formation
was assessed for LOF STAT3 patients with and without SLE, and healthy controls.
RESULTS Out of a cohort of 158 patients, five patients (ages 12-39) were identified
who carried the diagnosis of SLE, and 4 with SLE-like disease (ages 15-34). For those
with SLE, age of presentation was 8-21 years, 4 of 5 were female. Clinical features
included nephritis (4), alopecia (2), autoimmune cytopenias (2), arthritis (3), discoid
rash (2), and Raynaud (1). All had positive auto-antibodies, and 4 of 5 had low C3
and/or C4. For those with SLE-like disease, age of presentation was 12-24, and 2 of
4 were female. Clinical features included alopecia (1), autoimmune cytopenias (1),
Raynaud(1), and nephritis (2). All had positive autoantibodies, and 1 of 4 had low
complements. LOF STAT3 patients with and without clinical features of SLE had increased
expression of ISGs from both PBMCs and neutrophils. Increased spontaneous NET formation
was observed for LOF STAT3 patients both with and without SLE symptoms.
DISCUSSION
Although autoimmunity is not a common finding in LOF STAT3, we have identified SLE
or SLE-like disease in about 6% of our cohort, with a high incidence of kidney disease,
including one patient who required kidney transplant. The interferon signature and
NET formation were unexpectedly high in both the patients with and without the SLE
features. Ongoing studies include whole exome sequencing for possible second mutations
or modifiers, the role of IgE in the kidney disease, and further autoantibody detection.
The increased IFN signature raises the question about JAK-STAT modulation for therapy.
(133) Submission ID#811400
Differential expression of p67phox/p40phox In Neutrophils from Patients and Carriers
With p67phox (gene NCF2) Chronic Granulomatous Disease By Fluorescence-Activated Cell
Sorting
Douglas Kuhns, PhD1, Karen Lau, MS2, Danielle Fink, MS2, Laura Mendez, n/a3, Debra
Long Priel, MS4, Kimberly Marshal-Batty, PhD5, Jessica Kerr, MS6, Steven Holland,
MD7, Harry Malech, MD8, Gallin John, MD9
1Senior Principal Scientist/Frederick National Lab for Cancer Research
2Research Associate III/Frederick National Lab for Cancer Research
3Research Associate II/Leidos Biomedical Research, Inc
4Scientist II/Frederick National Lab for Cancer Research
5Research Associate II/Frederick National Lab for Cancer Research
6Research Associate I/Frederick National Lab for Cancer Research
7Director, Division of Intramural Research; Chief, Immunopathogenesis Section/Laboratory
of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR),
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH),
8Chief, Genetic Immunotherapy Section/NIAID, NIH
9NIH Associate Director for Clinical Research Chief Scientific Officer of the NIH
Clinical Center/NIAID, NIH
Abstract/Case Report Text
Chronic granulomatous disease (CGD), a rare immunodeficiency with decreased reactive
oxygen species (ROS) production, increased susceptibility to infection, and increased
mortality is caused by mutations in any one of 5 distinct phagocyte oxidase (phox)
components of the NADPH oxidase, NOX2. In the past, identification of the specific
protein defect was primarily determined by immunoblotting using specific antibodies
to the phox proteins. Recently, however, we have shown using fluorescence-activated
cell sorting (FACS) analysis of neutrophils in whole blood permeabilized and stained
with specific anti-p47phox antibody that p47phox protein expression was absent in
p47phox CGD patients and significantly reduced in p47phox CGD carriers [Kuhns et al.
2019. Blood Adv. 3(2):136-147]. These findings demonstrated that determination of
phox protein expression by FACS analysis provide an alternative to immunoblotting
and can aid in the identification of p47phox CGD patients and carriers. We now have
extended these studies to patients and carriers with p67phox CGD. FACS analysis of
p67phox expression in permeabilized neutrophils demonstrated that p67phox expression
was absent in four patients with different mutations in NCF2 [two patients homozygous
for c. E12(+1) G>A, one patient homozygous for c.287_289 del AAG, p.Glu96 del; and
one patient compound heterozygous for the mutations, E3(+1) G>A and c.55_63 del AAGAAGGAC].
Moreover, the expression of p67phox in nine p67phox CGD carriers was significantly
reduced >50% compared to expression in neutrophils from healthy volunteers. Another
cytosolic phox protein, p40phox, has been shown to associate with p67phox in a 1:1
molar ratio [Tsunawaki et al. 1994. Biochem Biophys Res Comm. 199(3): 1378-1387].
The expression of p40phox was reduced in both carriers and patients with mutations
in NCF2. Despite reduced expression of p67phox and p40phox, neutrophils isolated from
carriers of p67phox CGD exhibited normal dihydrorhodamine (DHR) oxidation after stimulation
with phorbol ester and fell within the normal range for ROS production (measured by
luminol-enhanced chemiluminescence) after stimulation with either fMLF, opsonized
zymosan, or phorbol ester with one notable exception. Included in this cohort of p67phox
carriers was a p47phox CGD patient (homozygous for a GT deletion at the start of exon
2 in NCF1) who also carried a heterozygous damaging mutation in NCF2 [c.1256 A>T;
p. Asn419Ile]. Normal ROS production in the presence of reduced p67phox and p40phox
expression suggest that these proteins are not rate-limiting components for maximum
NOX2 activity in neutrophils. Finally, determination of the expression of specific
phox components by FACS analysis of permeabilized neutrophils from whole blood provides
a rapid and alternative approach to immunoblotting to determine the specific protein
defect in CGD, and, importantly, one that could be easily established in most clinical
labs.
Funded by NCI Contract No. 75N910D00024.
(134) Submission ID#811617
Impaired CXCR2-specific Neutrophil Chemotaxis and Elevated STAT1/2 Expression in Neutrophils
and Monocytes from Hyper-IgE Syndrome Patients
Qin Zhou, PhD1, Harry Hill, MD2, Attila Kumanovics, MD3
1Research Associate/University of Utah
2Professor/University of Utah
3Senior Associate Consultant/Mayo Clinic
Abstract/Case Report Text
The original clinical observation that defined patients with Hyper-IgE syndrome (HIES)
was the presentation of cold abscesses (“Job’s syndrome”), which indicated a deficient
inflammatory response. Mutations in the STAT3 gene have now been identified in most
classic autosomal dominant HIES patients, but we do not fully understand how these
mutations cause the clinical presentation. Since the discovery of STAT3 mutations,
research on HIES focused largely on the adaptive arm of the immune system and suggested
that the innate immune defects could be secondary. For example, the discovery that
there is a Th17 cell and IL-17 cytokine deficiency in HIES provided a possible explanation
to the neutrophil chemotaxis defects in HIES, as IL-17 is one of the chemokines critical
for neutrophil recruitment in vivo. The goal of this study was to investigate myeloid
cells from HIES patients.
First we used C5a, fMLP, IL-8, CXCL1, and CXCL2 to study neutrophil chemotaxis in
vitro. Responses to C5a, fMLP, and IL-8 were equally robust in HIES compared to healthy
controls, demonstrating that neutrophils from patients are capable of efficient directed
migration in vitro. Neutrophils from all HIES patients responded to CXCL1 and CXCL2
significantly below that of the healthy controls. CXCL1 and CXCL2 are CXCR2-specific
chemokines. These results indicated a neutrophil intrinsic CXCR2-specific defect.
We also found that patient-derived cells express comparable levels of CXCR2 on the
cell surface, suggesting a CXCR2 chemokine receptor signaling defect.
After identifying a neutrophil defect in HIES, we wanted to get a broader view of
myeloid cells in HIES in addition to identifying the CXCR2-specific defect. STAT3
is a transcriptional regulator, therefore we performed transcriptional profiling of
HIES and healthy control-derived neutrophils and monocytes. As it was shown before,
the expression of STAT3 was not different between patients and controls, since HIES
is usually caused by the decrease in STAT3 activity not by decrease in expression.
We found, however, an increase in STAT1 and STAT2 expression as well as significant
changes in the expression of genes regulated by interferons. Increased expressions
of STAT1/2 in both neutrophils and monocytes likely provide and explanation for the
increase in interferon regulated genes. Multiple genes were identified as potential
regulators of CXCR2 signaling.
The balance between the STAT3 and STAT1 signaling has long known to be a regulator
of immune cell activation, especially in T cells, but less studied in myeloid cells.
STAT3 and STAT1/2 signaling pathways cross-regulate each other in healthy cells. We
propose that in HIES the decreased STAT3 signaling leads to not only changes in expression
of effector (e.g. inflammatory) genes, but also decreases expression of genes in the
regulatory (negative) feed-back loop, which are required for decreasing STAT1/2 activity.
Therefore, the immune cell defects caused by decreased STAT3 activity are compounded
by the increase in STAT1/2 activity. Increase in STAT1/2 signaling can cause pathologies
in the absence of STAT3 defects, as well as further decrease STAT3 signaling, thus
contributing to HIES. Interfering with STAT1/2 signaling in HIES may represent a therapeutic
opportunity.
(136) Submission ID#811689
Comparison of Mortality of Matched Newborn Infants with Low TRECs Levels of Unidentified
Etiology
Jenny Huang, MD1, Isabel Hurden, MPH2, Mary Kleyn, MS3, Karen Andruszewski, BS4, Heather
Wood, MS5, Tayaba Miah, MD6, Mary Ruehle, RN7, Divya Seth, MD8, Patrick Long, PhD9,
Roland Chu, MD10, Sureyya Savasan, MD11, Aly Abdel-Mageed, MD12, Nicholas Hartog,
MD13, Kelly Walkovich, MD14, Mark Vander Lugt, MD15, Thomas Michniacki, MD16, Pavadee
Poowuttikul, MD17, Elizabeth Secord, MD18
1Fellow-In-Training/Department of Allergy/Immunology, Children’s Hospital of Michigan,
Detroit, MI
2Newborn Screening Epidemiologist/Michigan Department of Health and Human Services,
Lifecourse Epidemiology and Genomics Division
3Newborn Screening Program Epidemiologist/Michigan Department of Health and Human
Services, Lifecourse Epidemiology and Genomics Division
4Quality Assurance Coordinator/Michigan Department of Health and Human Services, Lifecourse
Epidemiology and Genomics Division
5Newborn Screening Section Unit Manager/Michigan Department of Health and Human Services,
Lifecourse Epidemiology and Genomics Division
6Pediatric Resident/Department of Pediatrics, Children’s Hospital of Michigan, Detroit,
MI
7Severe Combined Immune Deficiency, Coordinator/Department of Allergy/Immunology,
Children’s Hospital of Michigan, Detroit, MI
8Assistant Professor/Department of Allergy/Immunology, Children’s Hospital of Michigan,
Detroit, MI
9Faculty, Diagnostic Immunology/Wayne State University School of Medicine, Detroit,
MI
10Associate Professor/Department of Hematology/Oncology, Children’s Hospital of Michigan,
Detroit, MI
11Professor of Pediatrics/Department of Hematology/Oncology, Children’s Hospital of
Michigan, Detroit, MI
12Pediatric Hematology/Oncology/Department of Pediatric Bone Marrow Transplant, Helen
DeVos Children’s Hospital, Grand Rapids, MI
13Attending Physician/Michigan State University College of Human Medicine
14Associate Professor, Pediatric Hematology/Oncology/University of Michigan, C.S.
Mott Children's Hospital
15Assistant Professor/7 Department of Pediatrics, Division of Hematology/Oncology,
University of Michigan, Ann Arbor, MI
16Clinical Lecturer/Department of Pediatrics, Division of Hematology/Oncology, University
of Michigan, Ann Arbor, MI
17Associated Professor, Fellowship Program Director, Allergy Immunology/Department
of Allergy/Immunology, Children’s Hospital of Michigan, Detroit, MI
18Clinical Associate Professor of Pediatrics and Division Chief of Allergy, Asthma,
and Immunology/Children's Hospital of Michigan; Wayne State University School of Medicine
Abstract/Case Report Text
Rationale: T-cell receptor excision circles (TRECs) testing on newborn screening (NBS)
has been vital for identifying patients with severe combined immunodeficiency (SCID).
We aimed to determine whether one or more abnormal TRECs result on a NBS might predict
higher mortality rates despite the absence of an identifiable underlying etiology.
Methods: Newborns with a positive TRECs NBS result without the diagnosis of SCID or
22q11.2 deletion syndrome born from October 2011 to December 2014 were included (n=467).
Newborns were divided into three groups: group 1 infants had a subsequent normal repeat
screen (n=375); group 2 infants did not undergo repeat screening as the majority expired
before a repeat screen could be conducted (n=36); group 3 infants had a normal initial
screen but subsequent abnormal screen (n=56). Cases were matched 3:1 to controls on
gestational age, birth weight, NICU status, race, birth quarter, and birth year. NBS
records were linked to birth and death certificate records. Demographic characteristics
were compared and mortality rates were calculated between the groups.
Results: The mortality rate of group 1 was 2.4%, group 2 was 91.7% and group 3 was
46.4%. When compared with matched controls, there was no difference in the mortality
rate of group 1 when compared to the control group. There was a significant difference
in the mortality rate between cases and controls in both group 2 (p < 0.001, 95% CI
0.711, 0.950) and group 3 (p < 0.001, 95% CI 0.256, 0.551). The APGAR scores in group
1 infants were comparable to their matched controls. Infants in group 2 (p = 0.01)
and group 3 (p = 0.003) had significantly lower APGAR scores than the controls. The
majority of the infants in all three groups were less than 37 weeks gestation, however,
group 2 had a higher percentage of infants born very premature (less than 32 weeks).
There was no significant difference in maternal age, maternal education, prenatal
care status, cigarette use, or maternal steroid use between the cases and controls
in all three groups.
Conclusions: Infants with an initial abnormal screen who had a subsequent normal repeat
screen did not have an increased rate of mortality compared to their matched controls
(group 1). However, group 2 infants (with unresolved repeat screen) and group 3 infants
(with a first abnormal value on a repeat screen) did have increased mortality rates
when compared to their controls. Overall, an abnormal TRECs level on NBS without a
confirmed negative repeat screen, was associated with higher mortality in our study
population. Further studies will be needed to determine if the TRECs assay can serve
as a predictor for mortality in newborns with an abnormal screen.
(137) Submission ID#811713
Evaluation of immunoglobulin (Ig) G4 Deficiency in an Outpatient Clinic in Brasilia,
Brazil
Natasha Ferraroni, MD PhD1, Luiza Lobao Silva, n/a2, Gabriela Kei Yoshimoto, n/a2,
Marina Batista, n/a2, Giulia B Santos, n/a3, Rosemeire Constantino-Silva, PhD4
1Director/Clinica Ferraroni Of Allergy And Immunolgy, Brasilia, DF, Brazil.
2Medical Student/UNICEUB (Centro de Ensino Unificado de Brasilia), Brasilia, DF, Brazil.
3Biomedicine Graduate Student/Faculty of Medicine ABC, Santo Andre, SP, Brazil.
4Biologist. Researcher at Immunology Lab./Faculty of Medicine ABC, Santo Andre, SP,
Brazil.
Abstract/Case Report Text
INTRODUCTION: Primary immunodeficiency refers to a heterogeneous group of diseases
characterized by altered function or composition of the immune system, and are grouped
into adaptive or innate system defect. Immunoglobulin G subclass immunodeficiencies
(IgGSCS) are classified as a B-cell-related adaptive system disorder and are therefore
associated with recurrent sinopulmonary infections with encapsulated bacteria, presenting
with pneumonia, recurrent bronchitis, rhinosinusitis, and herpes zoster. Its primary
mechanisms are still unclear, although the cause for this deficiency might be related
to gene deletions, transcription errors, or be an effect of allotype. IgG4 immunodeficiency
reaffirms its association with the patient's clinical condition and is often associated
with IgG2 deficiency.
OBJECTIVE: To evaluate the prevalence of IgG4 immunodeficiency in Ferraroni’s Clinic,
classify it by gender, age, IgG4 dosage and other subclasses, correlate it with IgG2
immunodeficiency and the clinical presentations presented by the patients under analysis.
METHOD Records of 24 patients with IgG4 immunodeficiency whose clinical pictures were
followed throughout 15 years were evaluated, patients aged from 4 to 85 years. All
tests were done at the same laboratory and all patients have consented to be part
of this study, which has been approved by the ethics committee. RESULTS Twenty-four
patients with IgG4 deficiency, 79,16% (n=19) were women and 20,83% (n=5) were male,
with average of 47 and 28 years, respectively. The average of IgG4 was 7.76 mg/dL,
and that of IgG2 was 299 mg/dL. Of the patients evaluated, 62.5% had upper airway
infections (sinusitis, rhinitis, otitis and tonsillitis), 25% herpes simplex, 33.3%
asthma. Less prevalent cases were reported as 4.1% of patients had bronchiectasis,
12.5% candidiasis and 4.1% herpes zoster. 41.67% presented the association of IgG4
and IgG2 deficiency.
DISCUSSION: The role of specific IgG4 deficiency in the infectious setting is still
unknown, but it usually occurs in association with other isotypic deficiencies and
sinopulmonary infections. Furthermore, the IgG4 subclass is relevant on the study
of environmental antigens - suggesting its involvement with allergic disorders - and
has been described in association with other diseases, such as chronic mucocutaneous
candidiasis, ataxia-telangiectasia and allergic colitis. IgG2 deficiency is related
to increased susceptibility to bacterial infections. Studies show a correlation between
IgG2 and IgG4 immunodeficiency that generally imply clinical features characterized
by recurrent infections by encapsulated bacteria. The data obtained through the analysis
of patients' charts corroborated this information, since it was evident that most
of the patients had really similar clinical conditions.
CONCLUSION: IgG4 deficiency has a direct correlation with higher prevalence of upper
airway infections, such as rhinitis, sinusitis and pneumonia, and with an increased
incidence of allergic disorders, here presented by our cohort.
(138) Submission ID#811718
T-Helper 17 Cells as a Diagnostic Indicator for Hyper-IgE Syndrome
Michael Nordness, BS1, Natalia Chaimowitz, MD, PhD2, Monica Lawrence, MD3, Aaron Ver
Heul, MD, PhD4, Brittany Hines, MD5, Jian Zhang, PhD6, Pippa Simpson, PhD7, Cindy
Salm Bauer, MD8, Megan Cooper, MD,PhD9, Larry Borish, MD10, Lisa Forbes, MD11, Kathleen
Sullivan, MD, PhD12, Troy Torgerson, MD, PhD13, John Routes, MD7, James Verbsky, MD,
PhD14
1Medical Student/Medical College Wisconsin
2Fellow/Baylor College of Medicine
3Associate Professor/University of Virginia Medical Center
4Instructor/Washington University School of Medicine
5Fellow/Phoenix Children's Hospital
6Biostatistician/Medical College of Wisconsin
7Professor/Medical College Wisconsin
8Assistant Professor/Phoenix Children's Hospital
9Associate Professor/Department of Pediatrics, Divisions of Rheumatology/Immunology,Washington
University School of Medicine, St. Louis, MO.
10Professor/University of Virginia
11Assistant Professor/Department of Pediatrics, Baylor College of Medicine, Houston,
TX, USA and Texas Children’s Hospital, William T. Shearer Center for Human Immunobiology,
Department of Allergy, Immunology, and Retrovirology, Houston, TX, USA.
12Chief of Allergy Immunology/Children's Hospital of Philadelphia
13Associate Professor/University of Washington, Immunology
14Associate Professor/Medical College of Wisconsin
Abstract/Case Report Text
INTRODUCTION Hyper-IgE syndrome (HIES) caused by STAT3 loss-of-function (LOF) variants
is characterized by eczema, skin abscesses, fungal infections, life-threatening pulmonary
disease, and significantly elevated IgE levels. Small cohort studies demonstrated
a decreased percentage of CD4+ T cells expressing IL-17 (Th17) in HIES; however, decreases
in the percentage of Th17 cells were also seen in atopic disease. Interestingly, these
studies also observed a lower percentage of CD4+ T helper cells expressing IFNg (Th1).
Additionally, research suggests that HIES may cause impaired CD8+ T cell function.
We hypothesized that a low percentage of both Th17 and Th1 cells would be predictive
of HIES and would differentiate HIES from atopic disorders. To evaluate this hypothesis,
we examined the percentage of Th17, Th1, and IFNg+CD8+ T cells, laboratory parameters,
and genetic diagnoses from a large cohort of patients to determine which parameters
distinguish patients with STAT3 loss-of-function variants.
METHODS: We conducted a retrospective, multi-institutional chart review of over 200
patients who received a Th17 assay at the Medical College of Wisconsin Clinical Immunology
Research Laboratory. The Th17 assay is performed by activating PBMCs with PMA/ionomycin/brefeldin
A and staining for CD4, CD8, IFNg and IL-17A. The following parameters were included
in the chart review: the percentage of Th17, Th1, and CD8+IFNg+ cells, immunoglobulin
levels, atopy scores, infectious history, and genetic diagnoses.
RESULTS: Using logistic regression, we demonstrated that the percentage of Th17, CD8+IFNg+,
and Th1 cells were positively correlated with age, and percentage of CD8+IFNg+ cells
was higher in females than males. We found that the percentage of Th17 and Th1 cells
were decreased in both atopic disease and HIES, with HIES having the lowest values.
Interestingly, one subject with a STAT3 gain-of-function (GOF) variant had an elevated
percentage of Th17 and Th1. In addition, we determined that IgE levels were inversely
correlated with the percentage of Th17, CD8+IFNg+, and Th1 cells, while IgA and IgM
were positively correlated with the percentage of Th17 cells. Several different monogenic
defects characterized by increased fungal infections exhibited a low percentage of
Th17 including Tatton-Brown-Rahman syndrome and Cornelia de Lang syndrome.
CONCLUSIONS:
We confirmed that the percentage of Th17 cells is low in both HIES and atopy in a
large cohort of subjects, and that the percentage of Th1 cells may be helpful in distinguishing
HIES from atopic disease. However, since the percentage of Th17, CD8+IFNg+, and Th1
cells correlate with age, caution should be used when testing young children. The
inverse correlation between IgE levels with Th1 and Th17 responses suggests that similar
pathway(s) may drive both HIES and atopy. Additionally, the decreased Th1 responses
in STAT3 LOF and increased Th1 responses in STAT3 GOF HIES raise questions about the
role of STAT3 in regulating IFNg levels. We also identified patients with different
genetic disorders with fungal infections in which the Th17 percentages were low, suggesting
that the Th17 test may be useful in evaluating individuals with unusual fungal infections.
(140) Submission ID#811748
Atypical Autoimmune Neutropenia: Data from The Italian Neutropenia Registry
Francesca Fioredda, MD1, Piero Farruggia, MD2, Andrea Rotulo, MD1, Marta Pillon, MD3,
Angela Trizzino, MD2, Lucia Dora Notarangelo, MD4, Laura Luti, MD5, Tiziana Lanza,
MD6, Marina Lanciotti, MD6, Ceccherini Isabella, PhD7, Grossi Alice, PhD8, Laura Porretti,
MD9, Elena Matrodicasa, MD10, Angelica Barone, MD11, Giovanna Russo, MD12, Sonia Bonanomi,
MD13, Gianluca Boscarol, MD14, Andrea Finocchi, MD15, Marinella Veltroni, MD16, Ugo
Ramenghi, MD17, Daniela Onofrillo, MD18, Federico Verzegnassi, MD19, Baldo Martire,
MD20, Roberta Ghilardi, MD21, Giuseppe Lassandro, MD22, Saverio La Dogana, MD23, Nicoletta
Marra, MD24, Paola Terranova, PhD25, Sabrina Zanardi, MD26, Carlo Dufour, MD26, Maurizio
Miano, MD27
1MD/Hematology Unit IRCCS GianninaGaslini Children's Hospital, Genoa, Italy
2MD/Pediatric Hematology and Oncology Unit, A.R.N.A.S. OspedaleCivico, Palermo, Italy
3MD/Pediatric Onco-Hematology Department, University of Padova, Padova.
4MD/Onco-Haematology and Bone Marrow Transplantation Unit, Children's HospitalSpadaliCivili,
Brescia, Italy.
5MD/5 PediatricHematologyOncology, Bone MarrowTransplant, Azienda Ospedaliero Universitaria
Pisana, S. Chiara Hospital, Pisa, Italy
6PhD/Hematology Unit IRCCS GianninaGaslini Children's Hospital, Genoa, Italy.
7PhD/6 Medical Genetics Unit , IRCCS GianninaGaslini Children's Hospital, Genoa, Italy
8PhD/6 Medical Genetics Unit , IRCCS GianninaGaslini Children's Hospital, Genoa, Italy.
9MD/7 Flow Cytometry Service, Laboratory of Clinical Chemistry and Microbiology, IRCCS
"Ca' Granda" Foundation, Maggiore Hospital Policlinico, Milan, Italy
10MD/Paediatric Onco-Haematology Unit-Ospedale Santa Maria della Misericordia, Perugia-Italy,
11MD/10 Department of Pediatric Onco-Hematology, University Hospital, Parma, Italy.
12MD/11 PediatricHematology and Oncology Unit, Azienda Policlinico-Vittorio Emanuele,
University of Catania, Catania, Italy.
13MD/12 MBBM Foundation, Department of Pediatrics, University of Milano - Bicocca,
Monza, Italy.
14MD/13 Department of Pediatrics, Central Teaching Hospital Bolzano, Bolzano, Italy.
15MD/14 University of Rome Tor Vergata, Rome, Italy.
16MD/15 Department of Pediatric Onco-Hematology, Meyer Children's Hospital, Florence,
Italy.
17MD/16 Department of Pediatric and Public Health Sciences, University of Torino,
Italy
18MD/18 Department of Biomedical Sciences and Human Oncology, Pediatric Section, University
"A. Moro" of Bari, Bari, Italy.
19MD/8 Institute for Maternal and Child Health (I.R.C.C.S) BurloGarofolo, Trieste,
Italy
20MD/Pediatria Generale 'Bruno Trambusti' U.O.C. ONCOLOGIA E EMATOLOGIA ONCOLOGICA
PEDIATRICA , Bari
21MD/20 Department of Pediatrics, Ospedale Maggiore Policlinico IRCCS, Milan, Italy.
22MD/Pediatric Science and Surgery Department, Pediatric Onco-Hematology Unit, Hospital
Policlinico- Giovanni XXIII, Bari, Italy.
23MD/22 Department of Hematology, IRCCS Casa Sollievo della Sofferenza, San Giovanni
Rotondo, Italy
24MD/23 A.O.R.N. SantobonoPausillipon, Naples, Italy.
25PhD/Haematology Unit – IRCCS Istituto Giannina Gaslini, Genoa - Italy,
26MD/Haematology Unit – IRCCS Istituto Giannina Gaslini, Genoa - Italy,
27MD/Hematology Unit- IRCCS Istituto Giannina Gaslini, Genoa- ITALY
Abstract/Case Report Text
Background:Primary and Secondary Autoimmuune Neutropenia (pAN/sAN) are well described
entities. Several Autoimmune Neutropenias do not fit the criteria of either pAN or
sAN showing peculiar characteristics mainly for older age at onset and/or for duration
of the disease; moreover they are not associated , at least at the beginning, with
autoimmune markers/diseases Aim of the study: to describe a cohort of subjects affected
with autoimmune neutropenia, defined as “atypical” (aAN), registered in the Italian
Neutropenia Registry (INR) and to compare these data with those from subjects diagnosed
with pAN still in the INR.
Patient and methods: Subjects with neutropenia and positivity of indirect antibodies
against neutrophils (registered in the INR from 2013 to 2019) lasting for more than
3 years, or diagnosed after 5 years of age ( up to 18 y), without any associated autoimmune,
signs/markers were considered eligible for the present study.
Results: Data from 248 patients were collected: 79/128 subjects (32%) were defined
as aAN and 169/248 (68%) as pAN. Among 79 aAN affected patients 61%, were “long lasting”
aAN, while 39% were defined as “late onset” aAN .The degree of neutropenia in aAN
group was mild in 20 %, moderate 44 % and severe in 36 % of the subjects . Leukopenia
at onset was a common hall mark seen in 46% of aAN patients (median values 3700/mm³
; range 2750-5140/mm³ ) especially in the “late onset” aAN if compared with pAN and
“ long lasting” one ( p=0.003). As for clinical features, almost half of the aAN cohort
suffered from recurrent or “significative infections”, while severe episodes (namely
sepsis, meningitis , osteomyelitis , pneumonia, deep abscess or flemmon) were shown
in 28% being more frequent, but non significantly higher than those reported in the
pAN group (6% )( P=ns) Interestingly, recurrent apthae were significantly more seen
in the “late onset” aAN group if compared with the “long lasting” aAn (P=0.006). During
follow up, markers and/or symptoms of autoimmunity appeared in 31% of the aAN cohort,
being another element of peculiarity in respect to pAN (p < 0.0001).
As for immunological pattern in aAN, immunoglobulin values were lower than the references
for age in 12%,while were above them in 17% of the cohort . Lymphocytes subsets evaluation
showed decreased value of CD3+CD19+ cells in 40% of cases, followed by depletion of
CD3-CD16+CD56+ subtype in 33%, CD3+CD4+ in 24 % of cases and CD3+ CD8+ in 17% . Preliminary
study on B memory and T-reg cells values, showed a quantitative deficiency respectively
of in 59% and 27% of the studied subjects.
Mutation analysis performed by NGS in 20% of the subjects identified pathogenic variants
of : TACI (2), TINF 2 (1) and LRBA(1) .Comparison between pAN and aAN is detailed
in Table 1.
Conclusions Atypical neutropenia in childhood is a disorder which show many difference
with pAN; indeed appears an epiphenomenon of a complex immunological disturbances
rather than a disease itself. Occasionally mutations of genes of immunodeficiency/disimmunity
can be demonstrated
Table 1 Differences between Primary AN and Atypical AN
(141) Submission ID#811749
Increased Rate of Secondary Immune Deficiency In Rheumatoid Arthritis (RA) Patients
Receiving DMARD Therapies
Bob Geng, MD1, Terry Harville, MD, PhD2, Michael Runken, PharmD3, Joshua Noone, PhD4
1Physician/University of California at San Diego
2Professor of Pathology & Lab Services and Internal Medicine/University of Arkansas
for Medical Sciences
3Senior Director Global HEOR/Grifols SSNA
4Research Faculty/University of North Carolina at Charlotte
Abstract/Case Report Text
Background: Medications treating RA typically include systemic corticosteroids used
to treat inflammation flares, and disease modifying therapies (DMARDs). Traditional
DMARDs include methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine. Recently,
biologic/immune-response modifiers have come to the forefront for overall therapeutic
benefit, however, an unfortunate side-effect may be the risk of increased immunosuppression.
This study seeks to determine the occurrence rates of immune deficiencies among patients
initiating RA therapies.
Methods: Using the Pharmetrics Plus commercial claims database from 2012-16, RA patients
(ICD-9 714 and -10 codes: M05, M06) over the age of 18 were indexed on their first
use of a new biologic therapy. All patients were required to have enrollment six-month
pre and one-year post index. Cohorts of patients were grouped by medication: methotrexate,
adalimumab, etanercept, and rituximab. RA patients receiving adalimumab, etanercept,
and rituximab were allowed concomitant use of methotrexate, but could not use any
other biologic medications in the post period. A minimal adherence of 40% was required
of all biologic treated RA patients. An additional cohort of RA patients untreated
with biologic therapies was indexed on their first RA diagnosis within the time window
and used as a control. RA patients with comorbid conditions who would also require
biologic treatment were excluded including Crohn’s disease and ulcerative colitis.
Between group comparisons were made with the no treatment group as the referent. To
account for differences in age, gender, and Elixhauser comorbidity conditions patients
in each cohort were matched 1:1 to the rituximab group.
Results: 52,013 RA patients met inclusion criteria: 6,608 in the methotrexate group,
2,826 receiving etanercept, 2,808 receiving adalimumab, and 467 receiving rituximab.
A total of 12,709 in the treated groups and 39,304 in the no biologic treatment group.
Demographic information including age and gender were significantly different but
numerically similar between the groups, with rituximab group having the highest proportion
of female patients but limited dispersion with the lowest proportion being in the
etanercept group. Healthcare utilization metrics highlighted a significantly higher
average number of office visits (21.18, SD: 13.48 vs no treatment 15.61, SD: 13.29,
p < 0.01) and a higher proportion of rituximab patients being hospitalized (14.35%
vs no treatment 10.37%, p < 0.01). The diagnosis of immune deficiency was highest
among the rituximab group with 7.92% followed by methotrexate 2.91%, adalimumab 2.88%,
etanercept 2.80%, and no treatment 2.80%. After matching, similar rates were seen
for healthcare utilization to the pre-match results. The post-match odds of being
diagnosed with immune deficiency were significantly greater for the rituximab group
(OR 3.76, CI: 1.61-8.85) than the no treatment group.
Conclusions: The purpose of DMARDs is to modulate the immune system and decrease autoimmunity
in RA. However, this treatment may lead to significant immunosuppression. This study
suggests that treatment with certain biologic/immune-response modifier therapies may
be associated with higher rates of healthcare utilization. In particular, the increased
post-treatment diagnostic coding of immune deficiency demonstrates the heightened
awareness among healthcare providers of the chronic immunosuppressive potential of
rituximab. Evaluation of potential secondary immunodeficiency pre- and post-DMARD
use should be incorporated into routine practice.
(142) Submission ID#811751
Autoimmune Lymphoproliferative Syndrome (Alps) Disease and Alps Phenotype: Are Distinct
Entities?
Maurizio Miano, MD1, Elena Palmisani, MD1, Paola Terranova, PhD2, Grossi Alice, PhD3,
Marina Lanciotti, MD1, Tiziana Lanza, MD4, Ceccherini Isabella, PhD5, Michaela Calvillo,
MD6, Filomena Pierri, MD4, Concetta Micalizzi, MD4, Rosario Maggiore, MD4, Sabrina
Zanardi, MD4, Elena Facchini, MD7, Saverio Lagodana, MD8, Elena Matrodicasa, MD9,
Paola Corti, MD10, Giovanna Russo, MD11, Marta Pillon, MD12, Piero Farruggia, MD13,
Simone Cesaro, MD14, Angelica Barone, MD15, Carlo Dufour, MD4, Eugenia Montanari,
MD16, Francesca Fioredda, MD17
1MD/Hematology Unit- IRCCS Istituto Giannina Gaslini, Genoa- ITALY
2PhD/Haematology Unit – IRCCS Istituto Giannina Gaslini, Genoa - Italy,
3PhD/6 Medical Genetics Unit , IRCCS GianninaGaslini Children's Hospital, Genoa, Italy.
4MD/Haematology Unit – IRCCS Istituto Giannina Gaslini, Genoa - Italy,
5PhD/6 Medical Genetics Unit , IRCCS GianninaGaslini Children's Hospital, Genoa, Italy
6MD/Haematology Unit – IRCCS Istituto Giannina Gaslini, Genoa - Italy
7MD/Clinic of Pediatric Hematology Oncology-Policlinico S. Orsola-Malpighi, Bologna-Italy,
8MD/Haematology Unit-IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo-Italy,
9MD/Paediatric Onco-Haematology Unit-Ospedale Santa Maria della Misericordia, Perugia-Italy,
10MD/Clinica Pediatrica- AO San Gerardo - Monza - Italy
11MD/11 PediatricHematology and Oncology Unit, Azienda Policlinico-Vittorio Emanuele,
University of Catania, Catania, Italy.
12MD/Pediatric Onco-Hematology Department, University of Padova, Padova.
13MD/Pediatric Onco-Haematology A.R.N.A.S., Civico di Cristina e Benfratelli, Palermo-Italy,
14MD/Onco-Haematology Unit, Azienda Ospedaliera Integrata, Verona-Italy,
15MD/Pediatric Onco-Haematology, Azienda Ospedaliera di Parma Ospedali Riuniti, Parma-Italy
16MD/Hematology Unit - IRCCS Istituto Giannina Gaslini - Genoa, Italy
17MD/Hematology Unit IRCCS GianninaGaslini Children's Hospital, Genoa, Italy
Abstract/Case Report Text
Introduction: Autoimmune lymphoproliferative syndrome (ALPS) is a rare inherited disorder
of lymphocyte homeostasis due to a FAS-mediated apoptosis and characterized by non-infectious
and non-malignant lymphoproliferation, autoimmunity, and secondary malignancies (National
Institute of Health criteria). In spite of recent progress, one third of ALPS patients
still remain gene orphan and they have been previously categorized as ALPS-U. In some
cases, patients fitting ALPS diagnostic criteria have been shown to carry mutation
on genes involved in other immune-dysregulation syndromes.
Aims: The aim of this study is to compare the clinical and immunological features,
and the outcome of a cohort of ALPS patients with mutations on the typical causing
genes (FAS, FASL, FADD and CASP 10)- here defined as ALPS-G - vs the ones without
a molecular diagnosis or carrying mutations on other genes (both defined as ALPS-U).
Patients and methods The demographic, clinical, biochemical, genetic informations
and details about treatment are derived from the ALPS Italian Network. Search of mutations
was performed with Sanger PCR and/or Next Generation sequencing techniques (extended
to immunodeficiency genes panel).
Results: 68 ALPS patients were registered in our data base; the genetic analysis was
performed in 42 subjects (62%): 14/42 pts (33%) were ALPS-G and the remaining 28 (66%)
ALPS-U. Six-teen out of 28 (57%) ALPS-U patients resulted to carry mutations on other
genes (LRBA, STAT3+CECR, CTLA4, BAFFr, TACI, NMLRC4, IKBKG, Gaucher), and the remaining
12 (43%) were negative.
The ALPS-U subjects showed a more complex phenotype compared to the ALPS-G group,
which was characterized by multi-organ involvement (p=0.003) and positivity of autoimmune
markers (p=0.002). (Table 1). Cytopenia affecting one or more haematopoietic lineages
was present in both groups (69% and 82%) with no significant difference, apart from
lymphocytopenia that was more frequent in ALPS-U group (p=0.03) (Table 1). As for
lymphocyte subets and immunoglobulin dosage no differences were shown within the two
groups. Vitamin B12 and IL-10 were more frequently raised in ALPS-G group (p=0.01,
p=0.001) (table 1). Four out of 42 (9%) patients did not require any treatment. First-line
treatment (steroid or intravenous immunoglobulins) controlled the disease only in
4/38 (10%) cases. The response rate to second line therapy -micofenolate mofetile
(MMF) or rapamycin- was 100% and 40% in ALPS-G and ALSP-U group, respectively. Moreover,
target therapies or drug combinations were more commonly applied in ALPS-U subjects
(p=0.02) (Table 1).
Conclusions: Our study showed that ALPS-U subjects, despite the ALPS phenotype, represent
distinct clinical entities and that genes associated with other immune-dysregulation
syndromes are frequently represented in this group (16/28, 57%). The identification
of such disorders is crucial for the management of second-line treatment and/or the
administration of target therapies
(143) Submission ID#811800
Mechanism(S) Of Prolonged Attenuation of Allergic Responses After Modulation of Idiotypic
Regulatory Network
Reginald Gorczynski, MD PhD1, Tahir Maqbool, MSc2, Geoffrey Hoffmann, PhD3
1Professor Emeritus/University of Toronto & The Toronto Hospital
2Research Associate/Cedarlane Labs
3Senior Scientist, CEO Network Immunology/Network Immunology, Vancouver, BC, Canada
Abstract/Case Report Text
Background: We have shown previously that allergic reactivity to ovalbumin (OVA) could
be regulated in mice following perturbation of immune networks using combinations
of an immune Ig along with anti-idiotypic Ig. We have explored features of this regulation
including: its persistence after cessation of administration of combined Igs; the
ability of heterologous Igs to produce immunoregulation; a role for Treg induction
in regulation; and the ability to attenuate responses in mice pre-sensitized to an
allergic stimulus.
Methods: BALB/c mice were sensitized to OVA. Mice also received 5 weekly injections
of immune Ig or anti-idiotype Ig (at separate sites) from either homologous (mouse)
or heterologous (human) sources. In the latter case pooled IVIG (given IM, hence hereafter
IMIG) was used as a source of anti-idiotype Ig, and human anti-Tet as immune Ig. Injections
of the Ig were given from the time of OVA sensitization (to attenuate development
of immunity), or after pre-sensitization of mice (to attenuate existing allergic responses).
All mice were assayed for development of OVA-specific serum IgE and IgG, as well as
the production of OVA-induced IL-2, IL-4, IL-13, IL-31 and IL-33 in splenocytes cultured
for 72hrs. In studies examining possible mechanism(s) responsible for inhibition of
immunity mice received, in addition to the Ig treatments described, infusion of depleting
anti-CD4, and/or anti-CD8 antibodies, or a mAb to TNFSFR25, known to expand Tregs
implicated in regulation of Allo immunity.
Results: Combinations of both heterologous and homologous immune Igs and anti-idiotype
Igs attenuated OVA allergic responses in both naïve and pre-sensitized mice. This
attenuation persisted in mice greater than 14 weeks after cessation of treatment with
the Igs used. Finally, depletion of either CD4 or CD8 cells ameliorated the suppressive
effect seen, while the combination of anti-CD4 and anti-CD8 essentially abolished
suppression. Suppression was further enhanced by anti-TNFSFR25 mAb.
Conclusions: We conclude that the combine Ig treatment protocols used produced a long-lasting
suppression of allergic immunity, even in pre-sensitized animals. The effects seem
to depend upon induction and expansion of Tregs and represents a novel approach to
treatment of allergic disease in humans and other animals.
(144) Submission ID#811811
T Cells Utilize Somatic Mutations and Epigenetic Silencing To Evade Nuclear-Retained
WASp
Caroline Khanna, BA1, Carole Le Coz, PhD2, Courtney Vaccaro, MS3, Piyush Pillarisetti,
n/a4, Tanner Robertson, BS5, Andrew Sy, MD6, David Buchbinder, MD, MS7, Janis Burkhardt,
PhD8, Neil Romberg, MD9
1Research Assistant/Division of Allergy and Immunology, Children's Hospital of Philadelphia
2Postdoc/Division of Allergy and Immunology, The Children's Hospital of Philadelphia
3Bioinformatics Specialist/Children's Hospital of Philadelphia
4Undergraduate Student/Division of Allergy and Immunology, The Children's Hospital
of Philadelphia
5PhD Candidate/University of Pennsylvania, Children's Hospital of Philadelphia
6Fellow/Children's Hospital of Orange County, Department of Pediatrics, University
of California at Irvine
7Staff Physician, Division of Hematology/CHOC Children's Hospital
8Associate Professor/Division of Pathology and Lab Medicine, Children's Hospital of
Philadelphia
9Assistant Professor/Division of Allergy and Immunology, The Children's Hospital of
Philadelphia
Abstract/Case Report Text
Background Wiskott-Aldrich Syndrome protein (WASp) is found in the cytoplasm of hematopoietic
cells but can transit to T lymphocyte nuclei at distinct developmental timepoints.
WASp deficiency is a rare, X-linked combined immunodeficiency disease. Affected patients
display qualitative but not quantitative T cell defects.
We report two immune deficient subjects with nearly identical exon 11 frameshift mutations
in WAS, the gene encoding WASp. One subject lacked circulating T cells, the other
possessed several distinct CD8 T cell populations each expressing quantitatively different
amounts of WASp.
Objective To determine how similar WAS mutations can cause SCID in one person and
generate B and T cells with heterogenous WASp expression in another.
Methods To identify somatic WAS mutations, we deeply sequenced WAS exons, introns,
promoters and 5’ untranslated regions at 10,000 read depth in genomic DNA from various
B and T cell populations of each subject and their unaffected relatives. We confirmed
genomic variants were transcribed and translated by sequencing WAS transcripts and
analyzing WASp in primary cell lysates, both fractionated and not. To model our subjects’
diseases we transfected primary cells and cell lines with mutant WAS transcripts and
then measured viability and nuclear localization via confocal microscopy.
Results Deep sequencing of genomic DNA revealed all of subject one’s cells carried
the same germline exon 11 frameshift WAS mutation. The mutation was incorporated into
subject one’s WAS transcripts and translated into a truncated form of WASp, which
was relegated primarily to the cell nucleus.
Subject two possessed three distinct CD8 T cell subsets that each carried either the
germline exon 11 frameshift WAS mutation or a variety of somatic mutations that circumvented
frameshift WASp expression. Evasion strategies included exon 11 skipping, adoption
of a cryptic exon 11 splice site and reversion to wild type amino acid sequence. Subject
two incorporated somatic mutations into WAS transcripts which encoded either stable
near full-length proteins or unstable non full-length ones.
Subject one’s sister and subject two’s mother, who both carried the germline exon
11 frameshift mutation, produced only wild type transcripts and proteins.
Conclusion We report two patients with WAS mutations encoding truncated WASp. If expressed,
truncated WASp localized to the cell nucleus, and this was associated with T cell
developmental arrest and Severe Combined Immune Deficiency. If, through a variety
of epigenetic and somatic strategies, T cells could avoid expression of truncated
WASp, they would survive but display phenotypical abnormalities and functional defects.
(145) Submission ID#811815
Paediatric lymphomas: a possible warning sign of Primary Immunodeficiency Disorders
(PIDDs)?
Sara Ciullini Mannurita, MSc1, Annachiara Azzali, MD2, Ebe Schiavo, PhD3, Marialuisa
Coniglio, MSc4, Sergio Rosenzweig, MD, PhD5, Kaan Boztug, MD6, Annalisa Tondo, MD7,
Claudio Favre, MD8, Eleonora Gambineri, MD9
1Researcher, lab technician/Anna Meyer Children's Hospital, Hematology/Oncology Department/
University of Florence, NEUROFARBA Department, Florence, Italy
2Medical doctor/University of Florence, Florence, Italy
3Research fellow/University of Florence, Department of NEUROFARBA - Section of Child's
Health, Florence, Italy
4biologist/Anna Meyer Children's Hospital, Hematology/Oncology Department, Florence,
Italy
5Senior Investigator; Chief/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center,
6Director LBI-RUD/St. Anna Children's Hospital and Children's Cancer Research Institute,
Department of Pediatrics, Medical University of Vienna, Vienna; Ludwig Boltzmann Institute
for Rare and Undiagnosed Diseases, Vienna; CeMM Research Centre for Molecular Medicine
of the Austrian Academy of Sciences, Vienna, Austria; Department of Pediatrics and
Adolescent Medicine, Medical University of Vienna, Vienna, Austria
7medical doctor/Anna Meyer Children's Hospital, Hematology/Oncology Department, Florence,
Italy.
8Head of Department/Anna Meyer Children's Hospital, Hematology/Oncology Department,
Florence, Italy
9Assistant Professor/University of Florence, NEUROFARBA Department/Anna Meyer Children's
Hospital, Hematology/Oncology Department, Florence, Italy
Abstract/Case Report Text
Primary immunodeficiency disorders (PIDDs) and immune dysregulations are rare pathological
conditions associated with a high risk of malignancy. Patients with PIDDs show a higher
susceptibility to hematopoietic malignancies, in particular to Non-Hodgkin lymphomas
(NHL) that, generally, account for approximately 6-7% of paediatric cancers and their
incidence increases with age. Recently new gene defects responsible for PIDDs with
lymphoproliferation as a key clinical sign have been identified.
Our goal is to investigate possible immune-mediated mechanisms underlying malignant
lymphoproliferation in children who did not show other typical symptoms of PIDDs.
We retrospectively selected and reviewed the clinical history of nine patients with
NHL (6 Burkitt lymphoma, 2 large B cell lymphoma and 1 lymphoblastic T cell lymphoma).
Immunophenotyping and exome analysis of known PIDDs genes were performed after lymphoma
remission.
Six out of nine patients showed a mild hypogammaglobulinemia at time of presentation,
not noticed before. Moreover, one patient had history of recurrent respiratory infections,
one of hematologic autoimmunity and two of nine were EBV-positive at diagnosis. Preliminary
results show an aberrant B cell phenotype in four patients; exome analysis reveals
a novel heterozygous genetic variation in IKZF1 gene in one patient with Burkitt lymphoma
and autoimmune cytopenia was identified. Concerning the remaining patients, further
studies are ongoing.
A detailed review of clinical history of paediatric patients affected from NHL as
well as an impaired immunophenotyping can be important indicators of immune-mediated
disorder underlying lymphoproliferation and helpful signs of possible PIDDs that should
promptly be investigated by genetic analysis. This will allow an appropriate diagnosis
and disease management.
(146) Submission ID#811829
Dupilumab for Treatment of Caspase Activation And Recruitment Domain 11 Deficiency-Associated
Atopic Dermatitis
Natalie Diaz-Cabrera, MD1, Stephanie Hudey, MD2, Jennifer Leiding, MD3
1Resident Physician/Department of Internal Medicine, University of South Florida College
of Medicine, Tampa, FL
2Fellow/Division of Allergy and Immunology, Department of Internal Medicine, University
of South Florida College of Medicine, Tampa, FL
3Associate Professor/Division of Allergy and Immunology, Department of Pediatrics,
University of South Florida at Johns Hopkins-All Children’s Hospital, St Petersburg,
FL
Abstract/Case Report Text
Introduction: Caspase activation and recruitment domain 11 (CARD11) encodes a scaffold
protein that links antigen receptor activation to intracellular signaling. Dominant
heterozygous loss of function (LOF) mutations in CARD11 cause a syndrome of severe
atopic dermatitis, elevated IgE, and allergic disease. Atopic dermatitis can be difficult
to control leading to substantial morbidity. Dupilumab is a humanized monoclonal antibody
that blocks IL-4 and IL-13 signaling approved for treatment of refractory atopic dermatitis.
We present a case of a 10-year-old female with CARD11 deficiency successfully treated
with dupilumab.
Case: A 10-year-old Puerto Rican female with history of recurrent sinopulmonary infections
with 5 episodes of pneumonia, moderate persistent asthma, food allergies, recurrent
skin boils, and severe atopic dermatitis was referred for further management and evaluation
for autosomal dominant hyper-IgE syndrome (AD-HIES). Her atopic dermatitis was refractory
to conventional therapy with topical corticosteroids, twice-daily emollient use, and
bleach baths; it was also refractory to immunosuppression with mycophenolate mofetil
and cyclosporine. On exam the patient exhibited coarse facial features and a high
palate. She had eczematous lesions on the face, trunk, and extremities (SCORAD 84).
Laboratory evaluation showed: eosinophilia (1400 cells/uL), elevated IgE (>2000 kU/L),
low IgM (20mg/dL), and elevated IgA (568 mg/dL). Lymphocyte subsets and mitogen response
were normal but antigen-induced proliferation was abnormal. Autosomal dominant hyper
IgE score was 42 indicating a high likelihood of AD-HIES. No mutations in STAT3 were
identified and Th17 cell expression was elevated. Dedicator of cytokinesis 8 (DOCK8)
deficiency was also considered but DOCK8 protein expression was normal. Further genetic
testing revealed an 18 base pair deletion in CARD11 (c.518_535del) predicted to be
pathogenic. The combination of the patient’s phenotype and large deletion was consistent
with CARD11 deficiency. Despite continued immunosuppression with cyclosporine and
aggressive skin care, the patient’s atopic dermatitis was still severe and poorly
controlled. Off label (patient < 12 years) treatment with subcutaneous dupilumab 300mg
every 2 weeks was initiated. At last follow-up, 4 months after dupilumab start, the
patient had substantial improvement in dermatitis with clear skin on the face, trunk,
and extremities (SCORAD 40). Cyclosporine was discontinued and topical medications
were applied less frequently.
Discussion: Hypomorphic heterozygous dominant negative loss of function mutations
in CARD11 have recently been associated with severe atopic dermatitis and allergic
disease. Treatment of atopic dermatitis in CARD11 deficiency remains challenging,
but dupilumab appears to be an effective alternative to refractory disease. Longer
follow-up and a larger cohort of CARD11-LOF patients treated with dupilumab are necessary
to understand the long-term efficacy and safety for use of dupilumab in these patients.
(147) Submission ID#811830
Impaired Monocyte and Langerhans Cell Innate Immunity in Patients with Recurrent Respiratory
Papillomatosis (RRP)
Mohd Israr, PhD1, James DeVoti, PhD2, Lam Fung, BA3, Abramson Allan, MD4, Steinberg
Bettie, PhD5, Vincent Bonagura, MD6
1Research Scientist/The Feinstein Institute for Medical Research Hofstra/Northwell.edu
2Dr. Research Scientist/The Feinstein Institute for Medical Research Hofstra/Northwell.edu
3Research Technician/The Feinstein Institute for Medical Research Hofstra/Northwell.edu
4Otolaryngologist/Long Island Jewish Medical Center Northwell Health
5Provost/The Feinstein Institute for Medical Research Hofstra/Northwell.edu
6Chief, Division of Allergy and Immunology/The Feinstein Institute for Medical Research
Hofstra/Northwell School of Medicine
Abstract/Case Report Text
Purpose: The micromilieu within premalignant respiratory papillomas supports persistent
HPV6/11 infection and disease recurrence in recurrent respiratory papillomatosis (RRP).
These patients show polarized (TH2-/Treg) adaptive immunity in papillomas and blood,
enriched immature Langerhans cell (iLC) numbers, and overexpressed COX2/PGE2 in the
upper airway. To better understand the adaptive and innate dysregulation in RRP, we
studied blood-derived monocytes, iLCs, and tissue-derived iLCs from RRP patients and
controls.
Experimental Design: Monocyte subpopulations were isolated, differentiated into iLCs,
activated, and then assessed by flow cytometry. Monocytes were induced to differentiate
into iLCs with/without added PGE2, and then activated by IL-36γ, PGE2, PGE2+IL36γ,
or LPS. iLC CD83 expression was identified by flow cytometry. Monocyte-derived iLCs,
papilloma, foreskin, and abdomen skin iLCs, were also analyzed by qPCR for select
chemokine/cytokine mRNA expression after isolation, 24 hrs later in culture, and again
after poly(I:C) or TNFα stimulation.
Results: The three monocyte sub-populations differed between patients and controls,
and patients’ monocytes generated fewer iLCs. Classical monocytes generated most,
but not all iLCs. PGE2 levels were higher in RRP plasma, and added PGE2 reduced control,
but not patients’ monocyte-iLC differentiation. PGE2 had no effect on iLC maturation
identified by CD83 expression. Papilloma-derived iLCs expressed low CCL-1, and high
CCL-20 mRNA and were unresponsive to poly(I:C) or TNFα. Tissue-specific cytokine/chemokine
responses between iLCS from papillomas, foreskin and abdominal skin differed. Only
papilloma iLCs expressed IL-36γ after isolation, and they up-regulated CCL1 mRNA 24
hrs later without further stimulation.
Conclusions: Monocyte/iLC innate immunity is impaired in RRP, in part due to increased
PGE2 exposure. The immunosuppressive papilloma micromilieu likely alters iLC responses
that skew, HPV6/11-specific TH2/Treg adaptive immunity in RRP.
(148) Submission ID#811847
Different Phenotypic Expression of the Same Compound Heterozygous Familial Mediterranean
Fever Mutation in Identical Twins
Miriam Samstein, MD PhD1, Vincent Bonagura, MD2
1Fellow/Northwell Health
2Chief, Division of Allergy and Immunology/The Feinstein Institute for Medical Research
Hofstra/Northwell School of Medicine
Abstract/Case Report Text
Introduction: Familial Mediterranean fever is a hereditary auto inflammatory disorder
that typically manifests with recurrent fevers, abdominal pain and in some patients
there is an associated with amyloidosis leading to eventual renal failure. While there
are several common mutations in the MEFV gene that when homozygous give these classic
symptoms, patients with atypical mutations or heterozygous mutations often have a
different clinical course. We present identical twin siblings with compound heterozygous
MEFV mutations but differing clinical phenotypes.
Case Description: The index patient is a 3 year old girl, conceived via IVF, who began
having fevers at age 2.5. Her fevers occurred every 4 weeks for 4 months before she
was referred to immunology for evaluation. Her parents describe her as happy and otherwise
not ill appearing during these episodes. Genetic testing for Familial Mediterranean
Fever revealed compound heterozygous E148Q and P369S mutations in the MEFV Genes.
Initiation of colchicine therapy in the affected sibling has resulted in a complete
resolution of her symptoms. A trial off colchicine resulted in return of cyclic fevers.
Her identical twin sister was also tested, and carries the same mutation, but is still
asymptomatic. This created great concern amongst their parents who had genetic testing
prior to undergoing IVF that revealed no parental mutations in MEFV. In consultation
with genetics the mother was tested again through the same laboratory that had performed
testing on the children. This revealed an identical mutation in mom who is also asymptomatic.
Conclusions: Although classic homozygous MEFV mutations have resulted in well described
fever syndromes, there is considerably less data on heterozygous and compound heterozygous
MEFV mutations. In these two identical siblings only one patient has a classic manifestation
of Familial Mediterranean Fever. While it is possible that the other twin will develop
similar symptoms later on in life, it is also possible that another factor is necessary
to trigger symptoms in this unusual genetic presentation of FMF. In addition this
case highlights the importance of understanding the testing method used by the laboratory
performing the genetic testing. While the mother was initially reported as negative
the laboratory that performed her testing only tested for the most common MEFV mutations.
More complete testing, that included the entire gene sequence, revealed that she did
contain an MEFV mutation in E148Q, which although more rare is thought to be pathologic
when combined when combined with a second mutation.
(149) Submission ID#811884
A De Novo Variant in AKT3 Associated With Megalencephaly and Immunodeficiency
Gehad ElGhazali, MD, PhD1, Wassem Fathallah, MD2, Amal Al Tenaiji, MD3
1Consultant and Service Lead Clinical Immunologist/Sheikh Khalifa Medical City
2Consultant/Mafraq Hospital
3Consultant/Shiekh Khalifa Medical City
Abstract/Case Report Text
There are several lines of evidence that link the PI3K/AKT/mTOR signaling pathway
to primary Immunodeficiencies. Hyperactivation of the PI3K/AKT/mTOR/S6K signaling
pathway in immune cells can be the consequence of dominant gain-of-function mutations
in the genes encoding for PI3Kδ that cause the activated PI3Kδ syndrome (APDS). Patients
with these mutations may develop immunodeficiency and immune dysregulation as well
as neurodevelopmental delay and growth retardation. In addition, mutations of genes
within the PI3K-AKT-mTOR pathway were also known to cause megalencephaly and segmental
cortical dysplasia. Mutations in AKT3, a member of the AKT family of proteins and
a downstream effector of PI3K-mediated signaling, was shown to be associated with
autosomal dominant megalencephaly-associated syndromes.
Here we describe a 4 year old girl, born to consanguineous healthy parents, who presented
with megalencephaly, developmental delay, hypotonia, cervical lymphadenopathy and
hepatosplenomegaly. The patient had recurrent hospital and ICU admissions for idiopathic
thrombocytopenia (treated with IVIG), recurrent laryngitis, recurrent peritonsillar
abscess, preorbital cellulitis, conjunctivitis with purulent discharge, otitis media,
pneumonia with pleural effusion (required drainage), Metapneumovirus pneumonia with
respiratory failure, recurrent skin cellulitis, and abscesses that grew MRSA (required
drainage). In addition, the patient is known to have asthma and allergic rhinitis.
MRI of the brain showed megalencephaly, ventriculomegally, thin and dysplastic Corpus
Callosum, a normal cerebellum, and myelination appropriate for age. Immunoglobulin
levels, lymphocyte subsets and the oxidative burst test were all within normal limits.
CMV and EBV were not detected. Bacterial cultures grew MRSA (skin), Strept. pneumoniae,
H. influenzae, and E. coli (urine). Extensive metabolic workup was done, which was
inconclusive (metabolic/mitochondrial diseases). Whole exome sequencing identified
an AKT3 variant c.958G>A; p.(Asp320Asn) in exon 10. The variant was identified in
the patient but not in the parents and it was confirmed by Sanger sequencing. Further
molecular testing concluded that the variant is caused by a de novo mutation during
early development.
Although pathogenic variants in AKT3 gene were shown to be associated with megaloencephaly-associated
syndromes, no associations with immune deficiency have be reported. Functional studies
will be pursued to confirm the link between the clinical phenotype and the identified
variant in the AKT3 gene.
(150) Submission ID#811900
Biallelic CARD11 Deficiency Impairs B Cell Development And Function Causing Profound
Combined Immunodeficiency And Enteropathy
Henry Lu, BSc1, Mehul Sharma, MSc2, Ashish Sharma, PhD3, Atilano Lacson, MD, FRCPC4,
Ashley Szpurko, MD, FRCPC5, Poonam Dharmani, PhD6, Afshin Shameli, MD6, Joanne Luider,
BSc, ART, MLT7, Gregory Guilcher, MD, FRCPC, FAAP8, Victor Lewis, MD, FRCPC8, Marta
Rojas Vasquez, MD, FRCPC9, Sunil Desai, MBhB10, Lyle McGonigle, MD, FRCPC11, Luis
Murguia-Favela, MD, FRCPC12, Consolato Sergi, MD, PhD, MPH, FRCPC, FCAP, FACSc13,
Eytan Wine, MD, PhD, FCRPC14, Sneha Suresh, MD, FRCPC15, Stuart Turvey, MBBS, DPhil,
FRCPC16
1PhD Candidate/BC Children's Hospital and UBC
2PhD Student/BC Children's Hospital and UBC
3Post-Doctoral Fellow/Case Western Reserve University
4Clinical Professor/Stollery Children's Hospital and University of Alberta
5Physician/University of Calgary
6Clinical Assistant Professor/University of Calgary
7Laboratory Scientist/Calgary Laboratory Services
8Associate Professor/Alberta Children's Hospital and University of Calgary
9Physician/University of Alberta
10Clinical Professor/University of Alberta
11Physician/Alberta Health Services
12Clinical Assistant Professor/Alberta Children's Hospital and University of Calgary
13Professor/University of Alberta
14Associate Professor/University of Alberta
15Assistant Professor/University of Alberta and Alberta Health Services
16Professor/BC Children's Hospital and UBC
Abstract/Case Report Text
Introduction/Background: The caspase recruitment domain family member 11 (CARD11)–B
cell CLL/lymphoma 10 (BCL10)–MALT1 paracaspase (MALT1) [CBM] complex is a critical
signalling adaptor that regulates lymphocyte activation, proliferation, survival,
and metabolism. Primary immunodeficiencies affecting each component (termed ‘CBM-opathies’)
result in broad clinical manifestations ranging from combined immunodeficiency (CID)
to atopic disease or lymphoproliferation. We present the laboratory and clinical findings
of two Canadian First Nations patients found to be homozygous for the same novel CARD11
mutation (c.2509C>T; p.R837*) causing complete CARD11 deficiency.
Results: We recently identified an 8-month-old boy who presented with a severe case
of entero/rhinovirus bronchiolitis with interstitial lung disease and a 17-year-old
boy with a history of severe pulmonary infections with bronchiectasis (including PJP),
chronic sinusitis, candidiasis, invasive bacteremia, and severe ileo-colitis and oral
ulceration requiring total colectomy. Testing of both patients demonstrated absent
Tregs, elevated naïve B cells with absent memory B cells, and panhypogammaglobulinemia.
Next generation sequencing revealed that both patients were homozygous for the same
novel variant of CARD11 (c.2509C>T; p.R837*), which rendered CARD11 protein undetectable
by immunoblot. CARD11 deficiency was confirmed by stimulating patient B cells with
phorbol 12-myristate 13 acetate (PMA) and ionomycin and immunoblotting for signalling
proteins in both the NF-κB (IKKα/β, IκBα, p65) and MAPK (MEK1/2, MKK4, JNK1/2, ERK1/2)
pathways as well as cleavage substrates of the MALT1 paracaspase (RELB, CYLD, BCL10,
HOIL1). NF-κB and JNK activation were completely absent and MALT paracapase activity
was lost. Furthermore, co-immunoprecipitation experiments revealed that CARD11 was
required for optimal MALT1 association with BCL10 in response to stimulation. To define
the impact of CARD11 deficiency on the B cell transcriptome, RNA-Seq experiments were
performed. This revealed an inability to upregulate critical genes involved in immunity
and tolerance (e.g. CD40LG, CTLA4, IL2, IL10), decreased enrichment in cytokine pathways
(e.g. IFN-α, IL-6, TGF-β), and decreased enrichment in MALT1-dependent genes. Furthermore,
RNA-Seq confirmed the developmental block observed in patient B cells and suggested
that B cells were halted at the centroblast to centrocyte transition. Both patients
ultimately underwent hematopoietic stem cell transplantation (HSCT), which restored
lymphocyte signalling and activation as measured by NF-κB, JNK, and MALT1 paracaspase
substrate cleavage.
Conclusions: We have presented the most comprehensive clinical and molecular characterization
of human CARD11 deficiency to date. These two cases highlight the crucial role of
CARD11 in regulating B cell development, function, and humoral responses, as confirmed
by signalling and transcriptomic analyses. Furthermore, HSCT is potentially helpful
for these patients as assays performed on post-transplant cells demonstrated restored
signalling and activation.
(151) Submission ID#811904
Barriers to Transition of Care from Pediatric to Adulthood in Patients with a Primary
Immunodeficiency
Neha Agnihotri, MD1, Aisha Ahmed, MD2
1Fellow, Division of Allergy and Immunology/Northwestern University & Lurie Children's
Hospital
2Attending Physician, Assistant Professor/Division of Allergy & Immunology, Ann &
Robert H Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School
of Medicine, Chicago, IL
Abstract/Case Report Text
Introduction: Primary immune deficiencies (PID) can have a significant impact on the
quality of life of patients and their families. As more patients with PID are surviving
to adulthood, the need to monitor them closely and ensure they are transitioned appropriately
is even more crucial. We compared the perspectives of pediatric and adult immunologists
toward the transition of patients with PID at our institution.
Methods: Pediatric allergy/immunology providers at Lurie Children’s Hospital and adult
allergy/immunology physicians at Northwestern University both in Chicago, IL completed
respective surveys anonymously (www.surveymonkey.com). Questions were derived from
the validated ‘ATTITUDE’ and ‘QUARTT’ instruments for transition. Respondents were
asked to rate their level of agreement on a 5-point Likert scale, ranging from strongly
disagree to strongly agree.
Results: Overall, 9 pediatric and 11 adult providers participated (response rate 71.4%).
Of total respondents, 55% thought the transition process should be initiated at age
18-20. About 36% of the adult immunologists selected 21 and older, whereas pediatric
providers would begin earlier; 33.3% of pediatric providers note they would initiate
transition at age 15-17. Both pediatric and adult immunologists agreed that patients
should be transferred when the provider felt they were ready (80%) and when they were
in stable condition (70%). Both adult and pediatric immunologists selected transfer
of complete medical file as a preferred communication method for transition. Other
strategies preferred by adult providers were a referral letter with brief summary
of medical history (90.9%) and staff meeting with pediatric and adult immunologists
(63.6%), whereas pediatric providers would prefer a joint outpatient dedicated transition
clinic (77.8%). Pediatric and adult immunologists, patient, parent, and transition
liaison were considered the most important active participants in the transition process.
The most prominent barriers to a formal transition were unavailability of a transition
coordinator or nurse specialists (100%) or of all disciplines of the interdisciplinary
team (95%), and limited time (95%). On the other hand, limited demand (too few patients)
was strongly rejected as a barrier. All participants agreed during transition patients
should be educated about medications and their side effects, their condition and related
potential future complications, and symptoms that require seeking health care. Over
95% of participants also agreed that education about how to set up IVIG and further
insurance needs were important. All participants agreed that the transition process
should include assistance on how to promote the patients’ independence and self-management
skills, medication management/adherence, and understanding of immunoglobulin replacement
and side effects. Other important transition components included knowing how frequently
lab draws are required for monitoring (95%) and having a written individualized transition
plan (70%). Pediatric providers also thought having an email or telephone help line
would be beneficial.
Conclusion: This study adds to the growing body of literature examining attitudes
of immunologists toward transition, and it highlights important transition components
and barriers. Further work is ongoing to determine the transition needs identified
by patients and parents and define markers for successful transfer in order to build
a transition policy at our institution specific to immunodeficiency patients.
(152) Submission ID#811989
Immunoglobulin abnormalities are frequent in Adults with non-cystic Fibrosis Bronchiectasis
in Cali, Colombia
Andres Zea-Vera, MD PhD1, Mario A. Chacon-Acevedo, MD2, Maximiliano Parra, MD3, Luis
F. Guerrero, MD3, Raul A Vallejo-Serna, MD3, Ricardo P Mosquera, MD4, Maria A. Garcia-Mafla,
MD5, Anilza Bonelo-Perdomo, MSc, PhD1
1Associate Professor/Universidad del Valle
2MSc Student/Universidad del Valle
3Assistant Professor/Universidad del Valle
4Director/Clinica Neumologica del Pacifico
5Research Fellow/Universidad del Valle
Abstract/Case Report Text
Introduction: Bronchiectasis (BQ) is an abnormal and irreversible dilatation of bronchi
secondary to repeated cycles of airway infection and inflammation. Predominantly antibody
deficiency is the main group of Primary Immunodeficiencies (PID) in adults and had
been reported up 10% of subjects with non-cystic Fibrosis Bronchiectasis (NCFB). Hypergammaglobulinemia
(IgG level higher than 1,600 mg/dL) had been observed in 9.2 % of NCFB cases (retrospective
data). Diagnostic delay and inappropriate management of patients with Predominantly
antibody deficiency can lead to irreversible lung damage or even death from serious
infections. The effect of hypergammaglobulinemia on NCFB is unknown. Here we present
the frequency of immunoglobulin abnormalities (PAD and HyperIgG) in adults with NCFB
in Cali, Colombia.
Methods: We present preliminary data of a descriptive prospective study that will
include 260 patients with NCFB. Women and men >14 and < 65 years old will be included.
All volunteers will be evaluated by a clinical immunologist, complete blood count
and serum IgG, IgA, IgM and IgE levels will be determined. According with clinical
suspicious, IgG subclasses, anti-pneumococcal IgG response and B cell subpopulations
will be performed. The project will be executed in 24 months. Written informed consent
has been obtained for all subjects included. This project count with IRB approvals
at Universidad del Valle and Hospital Universitario del Valle.
Results: A total of 103 NCFB cases have been included in the study. The mean age was
46.7 years (14-65 years) with a Female:Male ratio 64:39. Moderate-severe dyspnea was
observed in 17/103 cases (medical research council –MRC- dyspnea scale 4 to 5). Recurrent
pneumonia was found in 33/103 cases (32%).
The main etiologies of bronchiectasis were: Post-Infection 30/103 (29%); Idiopathic
13/103 (12%); Autoimmunity 12/103 (12%); Primary Immunodeficiency 11/103 (10%) Asthma
11/103 (10%); COPD 4/103 (3.8%); Primary ciliary diskinesia 3/103 (3%); Reflux 3/103
(3%) and others.
Primary Immunodeficiencies, 10.6% of NCFB cases, were classified as: Predominantly
Antibody Deficiency (10cases) including CVID 5 cases, IgM deficiency 2 cases, IgG
subclasses deficiency 1 case, selective IgA deficiency 1 case and Hypogamaglobulinemia
1 case. Combined Immunodeficiency (DOCK8 deficiency) 1 case. Interestingly IgG hypergammaglobulinemia
was observed in 29/103 cases (28.1%) suggesting humoral immune response deregulation.
Conclusion
To the best of our knowledge this is the first prospective study evaluating the etiology
of non-cystic Fibrosis Bronchiectasis (NCFB) in Colombia. Hypergammaglobulinemia and
Predominantly antibody deficiencies affect 39% of adults with NCFB in Colombia. Our
study reinforced the necessity to evaluate humoral immune response in patients with
bronchiectasis.
Conflict of interest: Authors disclosure any potential financial conflict of interest
related to this abstract.
Acknowledgements: This investigator-initiated research was supported with a grant
from Baxalta US Inc, a member of the Takeda group of companies BT16-35583/IIR-COL-BXLT-001923.
(153) Submission ID#812006
The Mayo Experience Of Early Onset Inflammatory Bowel Disease – A Case Series Of 51
Patients
Deepti Vellaichamy Manian, MD1, Michael Stephens, MD2, Avni Joshi, MD, MS3
1Fellow (Allergy and Immunology)/Mayo Clinic
2Division chair, Pediatric GI and Hepatology/Mayo Clinic
3Consultant, Division of Pediatric Allergy & Immunology/Mayo Clinic
Abstract/Case Report Text
Background: Early-onset Inflammatory bowel disease (EOIBD) is defined as IBD diagnosis
in children less than 10 years of age. The occurrence of autoimmune disease in children
(where it is relatively rare, compared to adults) may be caused by a high-risk predisposition
gene (monogenic disorders). Mayo Clinic Children’s Center has a unique care model,
where a patient who is referred for EOIBD meets with a team of physicians, including
gastroenterology, immunology, genetics, and nutrition. We describe our experience
of our EOIBD clinic from an immunologic perspective.
Methods: We conducted a retrospective cohort study through EMR chart review of pediatric
patients who were referred to our EOIBD program (2011 - 2019). First diagnosis of
IBD under the age of 10 was the inclusion criteria. We assessed the presentation,
clinical correlates, and immunologic evaluation. Approval was obtained from Mayo’s
Institutional review board. Data abstraction and analysis was done using the software
JMP.
Results: 51 pediatric patients met the inclusion criteria, with 31(61%) males and
20(39%) females. The median age of IBD diagnosis was 5 years (3-7 years range). Median
values and the distribution of variables used in the nutritional and immune evaluation
were assessed (Fig 1). Nutritional assessment was remarkable for low to low normal
hemoglobin and ferritin levels. Vitamin D and Albumin levels were overall within the
normal range. Growth parameters indicated that the median BMI percentile was 57 (28-77).
With immune and genetic screening, one patient was found to have X linked Chronic
Granulomatous Disease (CGD). Immune evaluation of other patients was overall within
normal limits. Fecal calprotectin served a reliable non-invasive biomarker for inflammation
with the median being 220.5 (62.7-499.3). 41 of these patients underwent GI pathogen
panel testing of which 17 (41%) tested negative, four (10%) tested positive for C.
diff, and two (5%) others to Shiga toxin-producing E. Coli. It was also noted during
the chart review that most patients had poor disease control despite undergoing treatment
with various anti-inflammatory and immunosuppressive drugs. The patient diagnosed
with CGD underwent bone marrow transplantation. A higher proportion of patients referred
to our program in recent years underwent a more comprehensive multispecialty evaluation.
Conclusion: Awareness of monogenic causes of Inflammatory disorders in children has
increased in recent years. It is also important to rule out intestinal infections
that can act as IBD mimic. Identifying monogenic disorders and other IBD mimics helps
with targeted therapy and symptom improvement in these patients who have a difficult-to-treat
disease. The group of children with EOIBD, regardless of whether there is an inborn
error of immunity, suffers from very high morbidity and a high burden of disease.
Comprehensive immune-nutrition assessment of EOIBD patients paves way for further
in-depth immunogenic assessments and allows for global management.
Figure 1: Table with reference range, Median values and Range of distribution (25th
to 75th percentile) for variables.
(154) Submission ID#812007
Chronic Granulomatous Disease and Human Immunodeficiency Virus: A Patient With Dual
Primary And Acquired Immune Deficiencies
Dixie Griffin, MD1, Kathleen May, MD2
1Fellow Allergy and Immunology/Medical College of Georgia at Augusta University, Augusta,
Georgia
2Division Chief Allergy, Immunology, and Pediatric Rheumatology and Associate Professor
of Pediatrics/Medical College of Georgia at Augusta University, Augusta, Georgia
Abstract/Case Report Text
Background: Chronic granulomatous disease (CGD) is a primary immunodeficiency (PID)
affecting the NADPH oxidase system in phagocytes resulting in increased susceptibility
to catalase-positive organisms. Human immunodeficiency virus (HIV) is an acquired
immunodeficiency of T helper cells that increases risk for opportunistic infections.
Combined impact of CGD and HIV has been rarely reported. In 2001, Sereti and Holland
presented the first report of dual impact of CGD and HIV in a patient with disseminated
nocardiosis. Because their CGD patient admitted to history of IV drug use, he was
frequently screened for HIV.
Case: A 19-year-old African American male with known CGD tested positive for HIV1
by Western blot in the ED in 2009 when he presented with complaints of intermittent
fever and cervical lymphadenopathy. His CGD was diagnosed by NBT blood testing at
4 years of age. He had frequent skin infections and fever prior to diagnosis. Clinically,
he did so well that his CGD diagnosis was questioned by his immunologists. However,
CGD was confirmed by 2 additional abnormal NBT tests and, ultimately, DHR flow cytometry
testing.
During his second infectious disease consultation for HIV, at age 19, he disclosed
that he was bisexual. Previously, the patient was screened for HIV1 and HIV2 antibodies
in 2003 due to anal fissure. He was screened again in 2007 for marked cervical and
supraclavicular lymphadenopathy. His CD4+ T cell absolute count was noted to be low
(293/mm3) in 2006 at age 17. Until 2009, his prior HIV screenings were negative.
During his CGD treatment course as an adult, he was known to be variably adherent
with administration of interferon gamma due to adverse effects, particularly pain
at the site of injection and malaise. At the time of his positive HIV Western blot
in 2009, his CD4+ T cell count was 237/mm3. After starting HIV antiretroviral treatment,
his viral load became undetectable. At age 23, he had Burkholderia cepacia pyelonephritis
resulting in left nephrectomy. Sepsis from B. cepacia was fatal (positive blood cultures
without known primary source) in 2019 at age 29. His recent viral load was still undetectable
and CD4+ count was 240/mm3.
Summary: Our case reveals the complexities of treating a patient with both primary
and acquired immune deficiencies. It illustrates the importance of taking a thorough
social and sexual history starting in adolescence, including those patients with PID.
Patients with PID should be followed closely by a primary care physician, in addition
to an allergist-immunologist and infectious diseases specialist, to ensure age appropriate
medical and developmental screening. The recognition of PIDs is improving due to better
screening, awareness, and treatment. Currently, the rate of HIV infection is highest
among young homosexual African American males. It remains important to understand
the epidemiology of primary and acquired immunodeficiencies to best identify those
at highest risk.
(155) Submission ID#812008
Phosphatase and tensin homolog (PTEN) hamartoma tumor syndrome identified by newborn
T cell receptor excision circle screening for severe combined immunodeficiency
Cullen Dutmer, MD1, Tara Sarin, MD2, Christine Wang, MD3, Elena Hsieh, MD4
1Assistant Professor of Pediatrics/Section of Allergy & Immunology, Children's Hospital
Colorado, University of Colorado School of Medicine, Aurora, CO, USA
2Fellow/Section of Allergy & Immunology, Children's Hospital Colorado, University
of Colorado School of Medicine, Aurora, CO, USA
3Fellow/Section of Pediatric Rheumatology, Children's Hospital Colorado, University
of Colorado School of Medicine, Aurora, CO, USA
4Assistant Professor of Pediatrics/Section of Allergy & Immunology, Department of
Immunology & Microbiology, Children's Hospital Colorado, University of Colorado School
of Medicine, Aurora, CO, USA
Abstract/Case Report Text
Introduction: Class IA phosphatidylinositol-3-kinases (PI3Ks) are heterodimers with
both regulatory (p85α, p85β, p55) and catalytic (p110α, β, or δ) subunits that are
critical for cellular signaling. Heterozygous gain-of-function (GOF) mutations in
PIK3CD (encoding p110δ) result in activated PI3K δ syndrome 1 (APDS1), while heterozygous
loss-of-function (LOF) mutations in PIK3R1 (encoding p85α) result in activated PI3K
δ syndrome 2 (APDS2). Given its role as a negative regulator of the PI3K signaling
pathway, heterozygous LOF mutations in PTEN (encoding phosphatase and tensin homolog,
PTEN) result in a clinical phenotype that approximates that of APDS1/APDS2 and is
therefore referred to as activated PI3K δ syndrome-like (APDS-L). However, sequelae
of heterozygous PTEN LOF mutations extend beyond the immune system and include a group
of disorders collectively known as PTEN hamartoma tumor syndrome (PHTS). Although
severe T cell lymphopenia at birth would be unexpected in APDS1, APDS2, or APDS-L,
below normal T cell receptor excision circle (TREC) counts have been reported in APDS1,
but only in individuals outside of the neonatal period. Herein, we describe an infant
girl with a low TREC count at birth who was found to have PHTS.
Case Description: A 1-day-old girl, born at a gestational age of 39 weeks, was found
to have a low TREC count of 22/microliter (normal => 40). A second TREC count obtained
at 2 weeks of age resulted as 16/microliter. Arguing against a diagnosis of severe
combined immunodeficiency (SCID), flow cytometric analyses performed at 3 weeks of
age revealed only a modestly diminished CD3+ T cell count (1599/microliter; 1240 CD4+
and 277 CD8+) with a normal percentage of naïve and memory CD4+ T cells (78% and 22%,
respectively). By 7 months of age, her CD3+ T cell count dropped to 828/microliter,
which was accompanied by a significantly decreased percentage of naïve CD4+ T cells
(56%). Sequencing and deletion/duplication analysis was pursued via a commercially
available 207-gene panel aimed at genetically defined primary immunodeficiency (PID),
in which no clearly pathogenic mutations were identified. Over the following months,
the patient was noted to have macrocephaly, tall stature (99th percentile), axial
hypotonia, and gross motor delays. Sequencing and deletion/duplication analysis was
then pursued via a commercially available 29-gene panel aimed at genetically defined
macrocephaly and overgrowth syndromes, in which a hemizygous pathogenic mutation in
PTEN (c.512A>G, p.Gln171Arg) was identified. Subsequent flow cytometric analyses demonstrated
findings characteristic of APDS-L, including expanded transitional and CD21lo B cells,
decreased isotype switched memory B cells, increased effector memory T cells, a lowered
threshold for intracellular calcium mobilization upon B cell receptor engagement,
and increased basal Akt (protein kinase B) and S6 (ribosomal protein S6) signaling.
Discussion: We report the first case of PHTS identified by newborn TREC screening
for SCID. As PTEN is not included in most commercially available, SCID- or PID-tailored
gene panels, PHTS would be missed by conventional genetic testing. Therefore, analysis
for variants in PTEN should be considered in neonates with low TREC counts, macrocephaly,
developmental delay, and other suggestive sequelae.
(156) Submission ID#812017
Combination Therapy Targeting Interferon Gamma and JAK-Dependent Signals Abrogates
Primary Hemophagocytic Lymphohistiocytosis
Josée-Anne Joly, MSc1, Sara Bourbonnais, MSc2, Alexis Vallée, n/a3, Hélène Decaluwe,
MD PhD FRCPC4
1Master Student/University of Montreal, Sainte-Justine University Hospital Research
Center
2Research Assistante/University of Montreal, Sainte-Justine University Hospital Research
Center
3PhD Student/University of Montreal, Sainte-Justine University Hospital Research Center
4Associate Professor of Pediatrics/University of Montreal, Sainte-Justine University
Hospital
Abstract/Case Report Text
Primary (or familial) hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening
hyper-inflammatory syndrome affecting mainly young children. It is caused by mutations
in genes involved in the granule-dependent cytotoxic pathway, inducing extreme inflammation
and massive tissue infiltration by activated T cells and macrophages. Standard chemotherapy-based
treatment regimens are toxic and induce remission in only 80% of patients. To this
day, HSCT is the only available curative treatment, but the inability to efficiently
control the inflammation in many patients prior to transplantation often leads to
graft failure, with transplant-related mortality around 25%. Thus, the development
of new, more potent and less toxic anti-inflammatory regimens would be a major advancement
in the treatment of HLH. Here, we hypothesize that combination therapies targeting
several JAK-dependent cytokines will be more effective than monotherapy to reduce
the life-threatening symptoms induced by this pathology.
Using a perforin-deficient (PKO) mouse model, we first tested the effects of blocking
antibodies against IFNγ, the dominant cytokine secreted during HLH, in combination
with antibodies targeting other highly elevated cytokines, such as IL-6 and IL-18,
on the manifestations of the disease. We found that anti-IL-6R and anti-IL-18 antibodies,
when used in combination with anti-IFNγ antibodies, did not significantly improve
the symptoms of HLH compare to anti-IFNγ antibodies alone. Further, we found that
targeting the JAK-STAT signaling pathway with ruxolitinib, a specific inhibitor of
JAK1 and JAK2, molecules downstream of IFNγ and IL-6, but not IL-18 signaling, was
as beneficial as anti-IFNγ monotherapy. Next, we tested the efficacy of ruxolitinib
in combination with anti-IL-18 antibody, as this later cytokine is not JAK-dependent
and was shown to drive macrophage activation syndrome in other contexts. Unfortunately,
this combination did not result in better symptom resolution than the use of ruxolitinib
only. In contrast, combination therapy using ruxolitinib and anti-IFNγ antibodies
showed a striking synergistic effect on the resolution of most disease manifestations,
to such an extent that our PKO mice presented a clinical phenotype indistinguishable
than that of a C57BL6 control mice. Our findings demonstrate that JAK-dependent cytokines
are the main cytokines driving the progression of HLH in PKO mice. Collectively, our
results suggest that anti-IFNγ antibodies and ruxolitinib, although effective independently,
should be used in combination to more efficiently suppress HLH progression. These
results are particularly relevant since the emapalumab, an anti-IFNγ monoclonal antibody
was recently approved by the FDA for the treatment of HLH while ruxolitinib will soon
be in clinical trials for this indication. This project was supported by funds from
the Fondation de Cancérologie Charles Bruneau and the Canadian Institutes of Health
Research (MOP-130469).
(157) Submission ID#812054
Runs Of Homozygosity Analysis Of Whole Exome Sequencing Data Revealed A Homozygous
TCF3 Branch Point Sequence Variant In Consanguineous Brothers With Immunodeficiency
Julie Niemela, MS, MLS1, Shubham Goel, PhD2, Hye Sun Kuehn, PhD3, Jennifer Stoddard,
BS, MLS4, Luis Gonzalez-Granado, MD,PhD5, Sergio Rosenzweig, MD, PhD6
1Medical Laboratory Technologist/Immunology Service, Department of Laboratory Medicine,
Clinical Center, NIH, USA
2Postdoc Fellow/Immunology Service, Department of Laboratory Medicine, Clinical Center,
NIH, USA
3Staff scientist/Immunology Service, Department of Laboratory Medicine, Clinical Center,
NIH, USA
4Medical Laboratory Scientist/Immunology Service, Department of Laboratory Medicine,
NIH, USA
5Senior Consultant/Hospital 12 octubre. Madrid
6Senior Investigator; Chief/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center,
Abstract/Case Report Text
Introduction: Transcription Factor 3 (TCF3), also known as Transcription factor E2-alpha
(E2A), is a helix-loop-helix transcription factor which plays a critical role in lymphopoiesis.
TCF3 is required for B and T lymphocyte development. Defects in TCF3 have been associated
with Agammaglobulinemia 8, autosomal dominant, characterized by low levels of immunoglobulin
and early onset recurrent bacterial infections. Deletion or diminished activity of
TCF3 may also play a role in lymphoid malignancies.
Runs of homozygosity (ROH) are contiguous stretches of homozygous genotypes at consecutive
polymorphic DNA marker positions. ROH are important reservoirs of homozygous deleterious
variation. The homozygosity heterogeneous HMM (H3M2) algorithm was specifically developed
for analyzing whole exome sequencing (WES) data.
The branch point sequence (BPS) is an essential splicing signal located ~15-55 bases
upstream of splice acceptor sites. While BPS variants are rare, they may result in
aberrant pre-mRNA splicing and genetic disorders. These variants may be overlooked
by standard WES analysis methods because they are intronic and the mammalian BPS is
a degenerate motif.
Objective: Describe the method used to identify a BPS variant in consanguineous brothers
with immunodeficiency, including early onset recurrent infections and B-ALL, hypogammaglobulinemia,
T and NK lymphocytosis, low B cells, and low naïve T cells.
Methods: WES was performed for all family members. Data were analyzed using standard
read mapping, variant calling and annotation methods. ROH were analyzed using the
H3M2 algorithm (Magi et al. 2014). ROH from the siblings was intersected (BedTools)
and the output was submitted to the Genomic Oligoarray and SNP array evaluation tool
(v3.0). Variants were confirmed by Sanger sequencing.
Results: No candidate disease variants were detected in the coding regions, 5’ or
3’ splice sites, or UTRs for both brothers; however, analysis of intersected ROH revealed
a homozygous TCF3 intronic variant within a putative BPS (TCF3 c.1451-18A>T). Sanger
sequencing of the mutant cDNA revealed activation of a cryptic splice site.
(158) Submission ID#812059
Early Humoral Immune Priming Affects Vaccine Responses In Young Infants
Carolyn Baloh, MD1, Guglielmo Venturi, PhD2, Bernard Fischer, DVM, PhD3, Li Yin, PhD4,
Grace Aldrovandi, MD5, Maureen Goodenow, PhD6, John W. Sleasman, MD7
1Allergy/Immunology Post-doctoral Fellow/Duke University
2Staff PhD/Duke University
3Associate Professor/Duke University
4Staff Scientist/NIH
5Chief of the Division of Infectious Diseases/UCLA
6Chief, Molecular HIV Host Interactions Section, Director, NIH Office of AIDS Research/NIH
7Chief, Div. of Allergy/Immunology, Dr. Glenn A. Kiser & Eltha Muriel Kiser Professor
of Pediatrics/Duke University
Abstract/Case Report Text
Background: The humoral immune system undergoes a critical period of development in
infancy with dramatic shifts in B-cell subsets. Prior to complete humoral immune maturation,
infants receive over 20 vaccinations with most vaccines requiring booster administrations
to generate immunological memory. Vaccination response is related to both environmental
and genetic factors (HLA and non-HLA genes). Heritability for routine childhood vaccines
has been shown to range from 38-89%. The genetic component of vaccine response suggests
we should be able to predict vaccine response in infants with biomarkers.
Methods: Multi-center study of 93 infants born vaginally at full term and followed
through 12 months of life. Cord blood was collected at birth & peripheral blood was
collected at 6 and 12 months of life. Six-month collection was 2 weeks post administration
of routine vaccinations, while 12-month collection was immediately prior to receiving
the 12-month booster vaccines. B cell subsets were analyzed with flow cytometry. Vaccine
titers and cytokines were measured via multi-plex ELISA. Study was IRB approved.
Results: Our data confirmed the immaturity of the newborn humoral immune system with
a lower overall B-cell abundance, a predominance of naïve B cells, an inability to
class-switch and produce IgG or IgA, and a Th2 bias. Maturation was observed over
the first year with increasing overall B-cell abundance, frequency of memory B-cells
producing IgA, IgG, and IgM, and frequency of plasmablasts. sCD14 levels also increased
throughout the first year due to microbial translocation reflecting establishment
of the microbiome. Conversely, cord blood contained high levels of BAFF, APRIL, sCD40L,
IL-4, and IL-21, with levels decreasing thereafter. All infants displayed evidence
of humoral immune system activation after getting 6-month vaccines. Total plasmablast
levels peaked 2 weeks after receipt of 6-month immunizations. A decrease in total
plasmablasts was evident between 6 and 12 months, although levels remained above those
at birth, corresponding with the need for 12-month booster vaccinations to maintain
long-lasting immunity. IL-21 and IFN-gamma had a significant positive correlation
with memory B cells and plasmablasts at subsequent time points suggesting that these
cytokines play a role in B cell differentiation and vaccine response. BAFF and APRIL
cytokines were elevated at birth, consistent with germinal center formation and underwent
a compensatory decrease thereafter. APRIL & sCD163 levels in cord blood significantly
correlated with higher tetanus titers at 12 months suggesting that vaccine response
may be predicted by cytokine biomarkers at birth. Response to vaccines was also dynamic
with IL-2 levels being significantly correlated with tetanus titers at 2 weeks after
receipt of 6 month immunizations. Conversely, sCD40L levels did not correspond to
B cell development consistent with a known B cell hypo-responsiveness to CD40L in
infants.
Conclusion: Humoral immune development is both predictable and dynamic. Biomarkers
in the cord blood, produced by the infant, are predictors of B cell development and
vaccine response in infancy.
(159) Submission ID#812086
A Case of Adult-Onset Immunodeficiency with Anti-IFNɣ Autoantibodies in A Previously
Healthy Adult with Disseminated Mycobacterium Avium Complex Infection
Alexandra Graden, MD1, Crescent Isham, BS2, Amir Sadighi Akha, MD, D.Phil.3, Avni
Joshi, MD, M.S.4
1Allergy & Immunology Fellow/Mayo Clinic
2Developmental Technologist/Mayo Clinic
3Consultant, Division of Clinical Biochemistry & Immunology/Mayo Clinic
4Consultant, Division of Pediatric Allergy & Immunology/Mayo Clinic
Abstract/Case Report Text
Background: Adult-onset immunodeficiency with anti-IFNɣ autoantibodies is a newly
described immunodeficiency syndrome characterized by disseminated nontuberculous mycobacterial
and other opportunistic infections in previously healthy middle-aged individuals typically
from Southeast Asia. It is caused by the presence of autoantibodies directed against
the cytokine IFNɣ, which is required for intracellular pathogen killing by macrophages
as well as phosphorylation of the transcription factor STAT1, which is involved in
cell survival gene expression. Successful treatment of the immunodeficiency has been
described in prior case reports with immunomodulatory therapies, including Rituximab.
However, there are no standard recommendations for dosing or timing of these agents,
or recommendations for long-term monitoring of disease activity.
Case Presentation: A 49-year-old Laotian woman with a history of type 2 diabetes and
possible prior Hepatitis C infection presented to the Immunology Clinic for evaluation
of immunodeficiency. In the two years prior to presentation, the patient was diagnosed
with Mycobacterium avium infection involving the parotid gland and lymph nodes of
the neck, Mycobacterium avium complex bacteremia, Histoplasma capsulatum involving
the lymph nodes of the neck, and leukocytoclastic vasculitis of the lower extremities.
As a child and young adult, she had no severe or recurrent illnesses and did not suffer
from any chronic disease. Preliminary immunologic testing demonstrated normal T, B,
and NK cell subsets, elevated immunoglobulin G, A, and M levels, and protective titers
to tetanus, diphtheria, and 23/23 pneumococcal serotypes. Measurement of anti-IFNɣ
autoantibodies was positive, which led to the diagnosis of adult-onset immunodeficiency
with anti-IFNɣ autoantibodies. The patient was treated with four doses of monthly
Rituximab with resolution of the anti-IFNɣ autoantibodies, restoration of normal STAT1
phosphorylation, and depletion of CD19-positive B cells. After a 4-year period of
being lost to follow-up, during which she continued to receive Rituximab every 6 months
at the direction of a local provider, the patient re-presented to the Immunology Clinic
to re-establish care. At that time, the patient had no evidence of anti-IFNɣ autoantibodies
based on titers and normal STAT1 phosphorylation. CD19-positive B cells remained depleted.
The patient also confirmed subjective clinical improvement and denied any interim
infectious complications.
Conclusion: This case provides an example of successful treatment of a patient with
adult-onset immunodeficiency with anti-IFNɣ autoantibodies with Rituximab. It also
highlights the utility of IFNɣ functional testing with STAT1 phosphorylation, which
may be used to monitor disease activity and to make decisions about ongoing immunomodulatory
treatment.
(160) Submission ID#812101
Immunity after lung transplantation: Detailed monitoring results
Ricardo Sorensen, MD1, Jaime Inostroza, MD2
1Professor Emeritus of Allergy-Immunology, Louisiana State University Health Sciences
Center/Louisiana State University Health Science Center, New Orleans
2Professor/Universidad de la Frontera
Abstract/Case Report Text
OBJECTIVES: Lung transplantation (LT) is performed using mostly histoincompatible
organs and requires strong immunosuppression to avoid transplant rejection. Secondary
hypogammaglobulinemia (HGG) is a common post LT complication. Severe HGG in the first-year
post-transplant (IgG < 400 mg/dL) occurs in a small percentage of patients. It is
associated with recurrent infections. Pre-transplant low IgG predicts post-transplant
HGG. However, it does not reliably predict post-LT infections. It is necessary to
monitor additional immunological markers to refine the diagnosis of a secondary post-LT
immunodeficiency to take preventive measures before infections occur. We sequentially
measured T lymphocytes and antibody-mediated immunity in a 67-year-old male receiving
a lung transplant for idiopathic pulmonary fibrosis to determine which immune indicators
could improve the identification of a secondary immunodeficiency.
METHODS: T and B cell numbers, IgM, IgG, IgA, IgE and IgG subclasses and 13 specific
antibodies to S. pneumonia capsular polysaccharides were assessed over a 5 months-long
post LT period. The clinical progress, infections and pulmonary function were monitored
prior to transplantation and at regular intervals thereafter.
RESULTS: The patient had progressive idiopathic pulmonary fibrosis starting with an
episode of pulmonary hypersensitivity 4 years earlier. He developed increasing respiratory
failure progressing to complete 02 dependency requiring a LT in June 2019. He was
treated with Prednisone, 20mg/day continuously for 3 months, then decreased to 15
mg/day. Other immunosupressants included Mycophenolic acid and Tacrolimus and on/off
antibiotics that eventually led to severe tendinitis at 4-5 months post LT. At 4½-month
post LT he developed an early onset bronchiolitis obliterans syndrome (BOS) that was
controlled by increasing the prednisone dose.
Sequential immunologic evaluation showed his IgG dropping from 1,400 mg/dl to 800
after two weeks and then remaining stable at that level for the rest of the observation
period. IgM and IgA had minor variations and IgE remained very low. IgG2 fell from
700-800mg/ml pre-LT to 180-200 in 2 weeks and remained stable at that level thereafter.
Antibodies against S. pneumoniae polysaccharides started high, between 5-15 ·g/ml
for all 13 serotypes and fell rapidly in the first 2 weeks post LT, then continued
a steady decline with > 50% serotypes falling < 1.3·g/ml at 5 months. Twelve of 13
pneumococcal serotype antibodies increased above 1.3·g/ml after IgG replacement at
5 months.
CD4 T lymphocytes decreased from ±1,000 cells/ul to 500-600 at 1 month, remaining
at that number after that. CD4/TH17 cells increased from 4–32 cells/ul to 178 at 5
months when prednisone was tapered down and then decreased to 12 after increasing
the prednisone dose again. This decrease coincided with a reduction in BOS manifestations.
CONCLUSIONS: Immune monitoring revealed an independent decrease of immunoglobulins
with a stronger decrease in IgG2 and specific pneumococcal antibodies. The role of
TH17 cell increase in developing BOS needs further investigation.
(161) Submission ID#812128
Malignancy in STAT3 Mutated Hyper IgE Syndrome
Amanda Urban, DNP, CRNP1, Christopher Melani, MD2, Dirk Darnell, MA, RN3, Stefania
Pittaluga, MD4, Mark Roschewski, MD5, Wyndham Wilson, MD6, Alexandra Freeman, MD7
1Nurse Practitioner/Clinical Research Directorate, Frederick National Laboratory for
Cancer Research in support of NIAID, LCIM
2Assistant Research Physician/Lymphoid Malignancies Branch, Center for Cancer Research,
National Cancer Institute
3Clinical Research Nurse/Laboratory Of Clinical Immunology And Microbiology, NIAID,
NIH
4Senior Pathologist/Laboratory of Pathology, Clinical Center, National Cancer Institute
5Clinical Director, Lymphoid Malignancies Branch/Lymphoid Malignancies Branch, Center
for Cancer Research, National Cancer Institute
6Head, Lymphoma Therapeutics Section/Lymphoid Malignancies Branch, Center for Cancer
Research, National Cancer Institute
7Senior Clinician/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH
Abstract/Case Report Text
Background: Loss of Function (LOF) STAT3 (AD-HIES; Job’s Syndrome) caused by dominant
negative mutations in STAT3 is a rare primary immunodeficiency characterized by sinopulmonary
infections and eczema as well as connective tissue and vascular complications. STAT3
is a frequent target of cancer therapies due to its role in certain malignancies for
cell proliferation and metastasis. With LOF STAT3, decreased incidence of some cancers
may be expected, however increased rates of lymphoma are described. We sought to describe
the incidence and spectrum of malignancy in our relatively large LOF STAT3 cohort.
Methods: We performed a retrospective analysis of 158 LOF STAT3 patients evaluated
at the NIH clinical center to determine the type of malignancies diagnosed, treatments
received, and outcomes following therapy.
Results: A total of 9 patients with 10 malignancies were identified (cancer incidence
6%). Six patients (4%) were diagnosed with non-Hodgkin lymphoma (NHL); 5 with diffuse
large B-cell lymphoma (DLBCL) and 1 with Burkitt lymphoma (BL) with age at diagnosis
ranging from 4 years to 66 years with median age of 31 years. Pathology staining for
EBV was available in four patients; all of whom were negative by EBER. All 5 DLBCL
patients received DA-EPOCH-R for 3-6 cycles, and all achieved complete remission.
Five of 6 patients with lymphoma are alive and disease-free. One patient died of heart
failure 16 years post chemotherapy without disease relapse. Two patients were diagnosed
with papillary thyroid carcinoma at ages 26 and 27, one of whom was subsequently diagnosed
with NHL. Two other patients were diagnosed with basal cell carcinoma of the skin
at ages 42 and 48; both of whom had prior voriconazole exposure.
Conclusion: Malignancy, most commonly NHL, occurs in patients with LOF STAT3 mutations.
NHL should be considered in patients with progressive lymphadenopathy, and thyroid
carcinoma should be considered in patients with thyroid nodules. Patients treated
with voriconazole are at an increased risk of skin cancer and require careful skin
monitoring. As survival increases, it will be important to monitor the incidence of
malignancies diagnosed, as it is possible that decreased STAT3 signaling may prove
to be protective of some cancers, such as colon and breast carcinoma, in which increased
STAT3 signaling is implicated in pathogenesis.
(162) Submission ID#812133
High Frequency of Primary Immunodeficiencies in Adults with Recurrent Pneumonia in
Colombia
Mario A. Chacon-Acevedo, MD1, Maria A. Garcia-Mafla, MD2, Andres Zea-Vera, MD PhD3
1MSc Student/Universidad del Valle
2Research Fellow/Universidad del Valle
3Associate Professor/Universidad del Valle
Abstract/Case Report Text
Introduction: Recurrent pneumonia is defined as 2 or more episodes of pneumonia in
one year or more than 3 pneumonias throughout life (with radiological resolution between
episodes). In retrospective studies, up to 30% of adult subjects with recurrent pneumonia
coursed with Primary Immunodeficiencies (PID). Prospective studies evaluating the
etiology of recurrent pneumonia are scarce. Diagnostic delay and inappropriate management
of patients with PID (predominantly antibody deficiency for example) could lead to
irreversible lung damage or even death from serious infections. Here we present the
frequency of Primary Immunodeficiencies in adults with recurrent pneumonia in Cali,
Colombia.
Methods: We present preliminary data of a descriptive prospective study that will
include 100 patients with Recurrent Pneumonia. Women and men >14 and < 65 years old
will be included. All volunteers will be evaluated by a clinical immunologist, complete
blood count and serum IgG, IgA, IgM and IgE levels will be determined. According with
clinical suspicious, IgG subclasses, anti-pneumococcal IgG response and B cell subpopulations
will be performed. The project will be executed in 24 months. Written informed consent
has been obtained for all subjects included. This project count with IRB approvals
at Universidad del Valle and Hospital Universitario del Valle.
Results: A total of 52 recurrent pneumonia cases have been included in the study.
The mean age was 38.8 years (14-65 years) with a Female:Male ratio 28:24. Moderate-severe
dyspnea was observed in 4/52 cases (medical research council –MRC- dyspnea scale 4
to 5). Non cystic fibrosis bronchiectasis was found in 33/52 cases (63%).
The main etiologies of recurrent pneumonia were: Primary Immunodeficiency 17/52 (32%);
Asthma 4/52 (7.6%); Autoimmunity 3/52 (5.7%); Primary ciliary diskinesia 3/52 (5.7%)
and others. Hypergammaglobulinemia represented 14/52 (27%) of cases.
Primary Immunodeficiencies, 32% of recurrent pneumonia cases, were classified as:
Predominantly Antibody Deficiency (15cases) including CVID 7 cases, IgM deficiency
3 cases, selective IgA deficiency 2 cases, IgG subclasses deficiency 1 case, Hypogamaglobulinemia
1 case and Agammaglobulinemia 1 case. Combined Immunodeficiency: DOCK8 deficiency
1 case and Ataxia Telangiectasia 1 case.
Conclusion: To the best of our knowledge this is the first prospective study evaluating
the etiology of recurrent pneumonia in Colombia. Predominantly antibody deficiencies
and IgG hypergammaglobulinemia affect 60% of adults with recurrent pneumonia in Colombia.
This study allows us diagnosed more than 10 new cases of adult onset PID. Immunological
evaluation is critical in the assessment of patients with recurrent pneumonia.
Conflict of interest: Authors disclosure any potential financial conflict of interest
related to this abstract.
Acknowledgements: This investigator-initiated research was supported with a grant
from Baxalta US Inc, a member of the Takeda group of companies BT16-35583/IIR-COL-BXLT-001923.
(163) Submission ID#812137
Vaccine-Strain Rubella Infection, Hemophagocytic Lymphohistiocytosis, and Autoimmunity
in Lysinuric Protein Intolerance
Ashley Stoner, MD1, Ludmila Perelygina, PhD2, Polly Ferguson, MD3, Diana Bayer, DO4
1Fellow/Division of Immunology, Department of Internal Medicine, University of Iowa
Carver College of Medicine
2Research Microbiologist/Division of Viral Diseases, Centers for Disease Control and
Prevention
3Professor/Division of Rheumatology and Allergy/Immunology, Department of Pediatrics,
University of Iowa Carver College of Medicine
4Clinical Assistant Professor/Division of Rheumatology and Allergy/Immunology, Department
of Pediatrics, University of Iowa Carver College of Medicine
Abstract/Case Report Text
Introduction: Lysinuric protein intolerance (LPI) is an autosomal recessive metabolic
disorder due to pathogenic mutations in SLC7A7. It is distinguished by decreased plasma
concentrations and increased urinary excretion of lysine, arginine and ornithine and
can present with multiorgan involvement and a spectrum of immune deficiency. We present
a five-year-old female with LPI, early-onset juvenile systemic lupus erythematous
(SLE), hemophagocytic lymphohistiocytosis (HLH), and granulomatous skin lesions that
were positive for vaccine-strain rubella.
Methods: Retrospective chart review was conducted. Laboratory investigations included
lymphocyte immunophenotyping by flow cytometry, lymphocyte proliferation to mitogen,
quantitative serum immunoglobulins, vaccine titers, autoantibodies, metabolic studies,
and genetic evaluation by next generation and whole exome sequencing.
Results: A five-years-old female of mixed Native American and African American race
presented at 3 years of age with severe failure to thrive, history of recurrent fevers,
joint swelling, recurrent skin lesions, severe anemia and neutropenia, and hypergammaglobulinemia.
Upon further evaluation, she demonstrated hyperferritinemia and ANA, RNP, Smith, and
SS-A autoantibodies and was diagnosed with early-onset juvenile SLE. Laboratory immune
evaluation revealed age-appropriate lymphocyte subpopulations and lymphocyte proliferative
responses to mitogens and antigens, markedly elevated IgG, IgA, IgM with no associated
monoclonality, and protective tetanus and pneumococcal titers. Given her severe clinical
manifestations at an early age, concern for immunodeficiency prompted further genetic
evaluation with next generation DCLRE1C sequencing, which was negative, and whole
exome sequencing, which revealed two heterozygous mutations in SLC7A7, consistent
with LPI. Laboratory metabolic evaluation was also consistent with a diagnosis of
LPI. She continued to experience recurrent cutaneous lesions on her upper and lower
extremities. Biopsy findings were consistent with a granulomatous lesion and subsequently
identified by the CDC to have vaccine-strain rubella infection. Due to recurrent pneumonia
and concern for pulmonary alveolar proteinosis (PAP), pulmonology was consulted and
eventually confirmed PAP, and she has required home oxygen supplementation. Given
her history of recurrent infections and vaccine-strain rubella infection, supplemental
IVIG was initiated. Her SLE has been fairly refractory to medical management, including
systemic corticosteroids, mycophenolate, rituximab, and cyclosporine. She recently
developed HLH at 5 years of age and is currently maintained on canakinumab, mycophenolate,
and systemic corticosteroids, yet continues to have SLE and PAP that has been difficult
to control.
Conclusion: The range of clinical and immunologic findings in lysinuric protein intolerance
has varied widely in the literature. Our patient presented with early-onset juvenile
SLE and did not develop HLH and PAP until 2 years after initial presentation. Despite
relatively normal cellular immunity by laboratory evaluation, our patient was identified
to have chronic infection with vaccine-strain rubella virus, indicating severe T cell
dysfunction, and poses challenges for future immunomodulatory treatment.
(164) Submission ID#812145
Spectrum of Malignancy in MAGT1 Deficiency (XMEN)
Anahita Agharahimi, MSN, CRNP1, Juan Ravell, MD2, Ashleigh Sun, MSN, RN3, Jenna Bergerson,
MD, MPH4, Sergio Rosenzweig, MD, PhD5, V. Koneti Rao, MD6, Jeffrey Cohen, MD7, Stefania
Pittaluga, MD8, Isaac Brownell, MD, PhD9, Alexandra Freeman, MD10
1Nurse Practitioner/Laboratory of Clinical Immunology and Microbiology, National Institute
of Allergy and Infectious Diseases, National Institutes of Health
2Staff Clinician/Laboratory of Clinical Immunology and Microbiology, NIAID, Bethesda,
Maryland, USA
3Research Nurse/Laboratory of Clinical Immunology and Microbiology, National Institute
of Allergy and Infectious Diseases, National Institutes of Health
4Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Division of Intramural
Research, National Institute of Allergy and Infectious Diseases, NIH,
5Senior Investigator; Chief/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center,
6Staff Clinician/ALPS Unit, Laboratory of Clinical Immunology and Microbiology, National
Institute of Allergy and Infectious Diseases, National Institutes of Health
7Senior Investigator/Laboratory of Infectious Diseases, Medical Virology Section,
National Institutes of Health
8Senior Pathologist/Laboratory of Pathology, Clinical Center, National Cancer Institute
9Investigator, Dermatology Branch/National Institutes of Health
10Senior Clinician/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH
Abstract/Case Report Text
Introduction: X-linked immunodeficiency with magnesium defect, EBV infection, and
neoplasia (XMEN) disease is caused by loss-of-function (LOF) mutations in the magnesium
transporter 1 (MAGT1) gene. It is a rare X-linked combined immunodeficiency and selective
congenital disorder of glycosylation. Clinical manifestations include chronic EBV
viremia, recurrent bacterial and viral infections, lymphadenopathy, splenomegaly,
autoimmunity, liver and central nervous system (CNS) abnormalities. MAGT1 deficiency
was first noted to result in chronic EBV infection and an increased susceptibility
to EBV+ lymphomas. We recently recognized Merkel Cell carcinoma at a very young age
in two XMEN patients, leading to our review of the malignancies in this cohort.
Methods: We reviewed the records of 25 male patients (22 seen at the NIH) with confirmed
hemizygous LOF mutations in MAGT1 for diagnosis of malignancy, therapy, and outcome.
Results: We identified malignancy in 11 patients of 25 with MAGT1 deficiency (44%).
Four patients had Hodgkin’s lymphoma (HL) (ages 15-29 years), three had Non-Hodgkins
Lymphoma (NHL) (ages 7-57 years), one had Kaposi sarcoma (5years) , one patient developed
EBER-negative liposarcoma (age 27 years) after receiving chemo and radiotherapy for
severe lymphoproliferative disease (LPD) at age 13 years and two had Merkel cell carcinoma
at exceedingly young ages (14 and 22 years). All patients had chronic EBV viremia.
They all received treatment according to established protocols. Currently, all except
for three patients are alive and in remission, including one post-HSCT. Overall malignancy
survival of 73%. It is important to note that three patients who did not have malignancy
had EBV LPD so severe that it warranted treatment with a malignancy protocol, with
one mistaken as having lymphoma.
Conclusion: XMEN immune deficiency, an X-linked glycosylation disorder, is a multisystem
disease associated with increased susceptibility to malignancies. Initially, EBV driven
lymphoproliferation and lymphoma was described with XMEN; however, with increasing
diagnoses, more malignancies are being recognized. All the recognized malignancies
are associated, at least in part, with DNA viruses, including EBV, HHV-8, and Merkel
cell virus. Understanding the clinical phenotype and pathogenesis of this disease
will improve monitoring and early diagnosis of malignancies for patients with MAGT1
deficiency.
(166) Submission ID#812150
Decision Tree and Random Forest Classifiers to Assist the Clinical Diagnosis of Primary
Immune Deficiencies
Saul Lugo Reyes, MD, MS1, Elisa Hierro Cascajares, MD, MS2, Ana Belen Ramírez Lopez,
MD2, Elma Isela Fuentes Lara, MD3, Alfredo Mendez, MSc4, Chiharu Murata, MSc5
1Researcher/Immunodeficiencies Research Unit, National Institute of Pediatrics
2Med student/Immunodeficiencies Research Unit, National Institute of Pediatrics
3Pediatrics Resident/Immunodeficiencies Research Unit, National Institute of Pediatrics
4Researcher/Autonomous Technological Institute of Mexico
5Researcher/Research Methodology Department, National Institute of Pediatrics
Abstract/Case Report Text
BACKGROUND: Primary immune deficiencies (PID) constitute a heterogeneous group of
over 400 individually rare congenital diseases that involve genes coding for proteins
of the immune system, and which result in increased susceptibility to infection, inflammation,
autoimmunity, allergy and cancer. The complexity of the diagnostic task, and the intrinsic
biases and limitations of the human mind, can be aided by computational tools. Among
the available machine learning approaches, decision tree algorithms select the best
node to split based on entropy and information gain; random forests build dozens or
thousands of decision trees randomly to improve accuracy and reduce overfitting.
AIM: To implement a machine learning-assisted clinical decision support system for
the diagnosis of PID.
METHODS: With a local database of patients with suspected IEI, we built a decision
tree using c4.5 DTC, and a Random Forest on Python 2.7 (Jupyter Notebook, SciKit,
MathPlotLib, Pandas, Numpy). The database was obtained by conducting an electronic
search on MedSys of patients with the term “immunodeficiency” in their electronic
medical records, and then hand-picking cases in which a PID had been confirmed or
ruled out. It consisted of 234 patients, of which 185 had been diagnosed with IEI.
We first split the dataset randomly into training (60%) and testing (40%) sets. The
decision tree was tasked with classifying correctly PID or NOT. After running the
algorithm in the training set, we evaluated in the testing set through cross-validation.
RESULTS: Accuracy was greater than 80% for the dataset (PID/Not). 0.819 for the DTC
with 15 levels. The attribute with the lowest Gini coefficient was Low IgA (0.044).
Accuracy for the Random Forest classifier was 0.808 with 25 trees. Feature importance
was highest for Lung infection (0.054), High IgG (0.043), Low IgA (0.041), Skin infection
(0.046), no isolate (0.057), and allergy (0.043); it was lowest for Consanguinity,
High IgM, Central nervous system infection, parasites and no infections. During the
random generation of trees, accuracy reached up to 87%.
DISCUSSION: We built two classification models. Decision trees lend themselves more
easily to learning and deriving rules of thumb from their sequences. Random forests
are more robust and better suited for categoric (as opposed to binary) classification.
We next want to develop a chatbot, currently under construction, that will ask relevant
questions in optimal sequence, and extract undiagnosed patients with suspected IEI,
based on statistical “red flags”. We also have preliminary results of this process
applied to a USIDNET database with over 3,000 patients, and are also working on Multinomial
Logistic Regression and Naïve Bayesian Classifiers for this and other databases.
(167) Submission ID#812164
Intravenous Immunoglobulin Associated With Shorter Length of Stay Among Immunocompromised
Inpatients With Acute Viral Respiratory Infections
Antoine Azar, MD1, Michael Runken, PharmD2, Christopher Blanchette, PhD, MBA3
1Clinical Director, Division of Allergy and Clinical Immunology/Johns Hopkins University
Hospital
2Senior Director Global HEOR/Grifols SSNA
3Research Professor/University of North Carolina at Charlotte
Abstract/Case Report Text
OBJECTIVES: Acute viral respiratory infections (AVRI) are associated with significant
healthcare resource use and cost. The use of intravenous immunoglobulin (IVIG) may
be an effective treatment for immunosuppressed patients and reduce overall healthcare
resource utilization. The goal of this study was to assess hospital resource utilization
associated with IVIG use among patients hospitalized for AVRI.
METHODS: Using data from the 2011-17 Premier Hospital Database, we identified patients
hospitalized with a diagnosis of AVRI [respiratory syncytial virus (RSV), parainfluenza
virus, rhinovirus, or metapneumovirus], and who had an immune deficiency (chemotherapy
treatment, transplant, primary immunodeficiency disorder (PIDD), specific antibody
deficiency, other immunodeficiency, or disorders of the immune or lymphatic systems).
Patients receiving IVIG within the first 48 hours were compared to patients who did
not receive IVIG at all. Due to the nature of the need to better understand the treatment
effect associated with IVIG, we used an Inverse Probability Weight-based Regression
Model. Since there were substantially more controls than cases, we randomly drew 5,000
controls. A logistic regression model was developed to adjust for factors associated
with the probability of IVIG use within 48 hours of admission. This propensity score
was then used to weigh subsequent models to assess length of stay (total and ICU)
using negative binomial models and logistic regression for inpatient death.
RESULTS: A sample of 1,927 immunocompromised inpatients were identified, 65 receiving
IVIG within the first 48 hours of admission and 1,862 who did not receive IVIG. The
IVIG group was older (mean age 54 vs 35, p < 0.001), had more antiviral use (40% vs
22%, p < 0.001), and had less cancer (40% vs 75%, p < 0.001). After adjustment for
immunity type (transplant, cancer), RSV, PIDD, age, prednisone, antiviral use, ribavirin
use, urban hospital setting, teaching status, intubation and lung disease, patients
with IVIG use had 3.24 less days of hospitalization (p=0.027) and 1.83 less days in
the
ICU (p=0.003) than non IVIG users.
CONCLUSIONS: This data analysis suggests that hospital length of stay and ICU length
of stay were significantly shorter for immunocompromised patients hospitalized for
acute viral respiratory infections who were administered IVIG within the first 48
hours of admission, as compared to patients who did not receive IVIG. It is possible
that IVIG use may have an impact on hospital resource utilization and costs. Future
prospective studies would help further assess the role of IVIG in patients hospitalized
with acute viral respiratory infections.
(168) Submission ID#812176
Association of CD8+ T Cell Senescence and Clinical Histories in CD40 ligand deficiency
Junghee Shin, MD, PhD1, Jason Catanzaro, MD2, Jennifer Yonkof, MD3, Srikar Reddy,
n/a4, Min Sun Shin, PhD5, Paula Whittington, MD, PhD1, Gary Soffer, MD6, Peter Mustillo,
MD7, Kathleen Sullivan, MD, PhD8, Roshini Abraham, PhD9, Neil Romberg, MD10, Insoo
Kang, MD11
1Clinical Fellow/Yale University
2Clinical Instructor/Yale University
3Allergy and Immunology Fellow, PGY-V/Nationwide Children's Hospital & the Ohio State
University Wexner Medical Center
4medical student/Yale University
5Scientist/Yale University
6Assitant Professor/Yale University
7clinician/Nationwide Childrens Hospital
8Chief of Allergy Immunology/Children's Hospital of Philadelphia
9Professor/Nationwide childrens
10Assistant Professor/Division of Allergy and Immunology, The Children's Hospital
of Philadelphia
11Associate Professor/Yale University
Abstract/Case Report Text
Background: CD40 ligand deficiency is an X-linked combined immunodeficiency associated
with opportunistic infections and increased risk of malignancies. Expansion of memory
CD8+ T-cells with senescent features is known to be associated with chronic immune
stimulation including aging, chronic infection and malignancy. CD8+ T-cell characteristics
of CD40L deficient (CD40LD) patients in relation to their clinical history have not
been described.
Objective: We studied correlation between CD8+ T-cell senescence with clinical histories
of CD40LD patients.
Methods: We analyzed the frequency and phenotypic characteristics of peripheral CD8+
T-cell subsets in four CD40LD patients (5, 28, 33 and 34 years old (yo)) and healthy
controls (HCs). T cell excision circle (TREC) counts and telomere lengths of the patients
and HCs were measured using quantitative PCR. In-depth analysis of CD8+ T-cells of
the 5 yo patient and HCs was done using high-dimensional Cytometer Time of Flight
analysis (CyTOF).
Results: Three patients (5, 28 and 34 yo) with histories of recurrent infections and
poor compliance with immunoglobulin therapy (IVIG) showed an increased frequency of
effector memory CD8+ T-cells with the senescent phenotype compared to age matched
HCs. Whereas 33 yo patient with excellent IVIG compliance starting at infancy did
not show any senescence phenotypes of the CD8+ T-cells. The telomere length and TREC
count of each patient correlated with the degree of CD8+ T-cell senescence and their
current ages, respectively. In-depth analysis showed similar expression patterns of
molecules related to senescence and cytotoxicity in CD8+ T-cells including CD57, t-Bet,
EOMES, Granzyme B and perforin in the 5 yo patient and mid-elderly HCs.
Conclusion: Our findings suggest that prompt diagnosis and compliance with IVIG starting
at the infancy may prevent early onset CD8+ T-cell senescence in CD40L deficiency.
(169) Submission ID#812193
Eye Guess It’s Just My Eye: A Case of Ocular Immunoglobulin G4-Related Disease Without
Systemic Involvement
Angela Gupta, MD1, Mohamed Alalwani, MD2, Maya Mattar, MD3
1Internal Medicine Resident/Case Western Reserve University/University Hospitals Cleveland
Medical Center
2Rheumatology Fellow/Case Western Reserve University/University Hospitals Cleveland
Medical Center
3Assistant Professor of Medicine, Department of Rheumatology/Case Western Reserve
University/University Hospitals Cleveland Medical Center
Abstract/Case Report Text
Introduction: Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory
condition that affects multiple organs. When IgG4-RD is found in the ocular adnexa,
the term “IgG4-related ophthalmic disease (IgG4-ROD)” is used.
Objective: Our case describes a patient with IgG4-ROD without systemic involvement.
Case: Mr. X is a 46-year-old male with a PMH of CML (on imatinib) and allergic rhinitis
who presented to clinic with orbital swelling for twenty years. His swelling had always
been responsive to steroids, but would return once steroids were tapered. Patient
was diagnosed with biopsy proven CML in 2011 and is currently taking imatinib. Because
his peri-orbital edema persisted, a right lacrimal gland biopsy was done which showed
“marked lymphocytic infiltrate of soft tissue with lymphoid follicles, many plasma
cells, and eosinophils. No atypical histiocytes.” Flow cytometry was negative for
malignancy.
Results: CRP 4.12 mg/L. ESR 14 mm/hr. IgG4 elevated at 655 mg/dL. CT chest from 2013
and CT chest, abdomen, pelvis from 2019 were without fibrotic changes.
Assessment: When diagnosing IgG4-RD, we categorize diagnosis into three levels (possible,
probable, or definite) by three criteria (clinical manifestation, elevated serum IgG4,
and histopathology). This is detailed as follows: clinical exam showing organ specific
swelling or masses, elevated serum IgG4 (>135 mg/dL), and histopathology with either
lymphocyte and plasmacyte infiltration and fibrosis or infiltration of IgG4+ plasma
cells (ratio of IgG4+/IgG+ cells ≧40 % and ≧10 IgG4+ plasma cells per high power field).
Not all these components are required for diagnosis, but meeting histopathologic criteria
makes diagnosis more probable. Our patient’s disease was localized to his eye, and
patients with IgG4-ROD have unique diagnostic criteria. These criteria are similar
to the criteria for IgG4-RD, but emphasize enlargement of the ocular adnexa, less
frequent fibrosis, and ≧50 IgG4+ plasma cells per high power field. Our patient’s
histopathology revealed a lymphoplasmacytic infiltrate, but lacked storiform fibrosis
or obliterative phlebitis. His serum IgG4 level was 655 mg/dL, and his biopsy was
positive for an IgG4+/IgG+ ratio of 50% and more than 100 IgG4+ plasma cells per high
power field. Based on this, he meets criteria for IgG4-ROD.
Conclusion: IgG4-ROD is a rare condition that is usually associated with systemic
organ involvement. Our case is unique, as no systemic disease has been detected. We
also suspect our patient has been living with IgG4-ROD for several years, as his orbital
swelling began in high school. It is important to note that he has been on imatinib,
a tyrosine kinase inhibitor, for treatment of his CML. Imatinib inhibits c-abl and
platelet-derived growth factor receptor, tyrosine kinases involved in profibrotic
pathways. Patient’s lack of fibrosis could also be due to his longstanding use of
this drug. It is also possible that he has a rare form of IgG4-ROD without systemic
involvement. A limited number of such cases have been reported, but no consensus has
been made on why disease course was localized. Our patient was started on rituximab,
and his serum IgG4 decreased to 295 mg/dL after the first cycle. We hope his disease
achieves remission.
Informed consent: Informed consent was obtained from all individual participants included
in the study.
(170) Submission ID#812204
Platelet abnormalities with eosinophilia and immune-mediated inflammatory disease
(PLTEID), an ARPC1B mutation
Bruna Polese Rusig, MD1, Mayra de Barros Dorna, MD2, Renata Resstom Dias, MD1, Ana
Paula Beltran Moschione Castro, MD, PhD3, Antonio Carlos Pastorino, MD, PhD3, Maria
Juliana Rodovalho Doriqui, MD4, Annie Mafra Oliveira, MD5, Magda Carneiro-Sampaio,
MD, PhD6
1Fellow in-training/Departament of Pediatrics, Faculdade de Medicina da Universidade
de São Paulo, São Paulo, Brazil.
2Associate Professor/Departament of Pediatrics, Faculdade de Medicina da Universidade
de São Paulo, São Paulo, Brazil.
3Associate Professor/Department of Pediatrics, Faculdade de Medicina da Universidade
de Sao Paulo, Sao Paulo, Brazil.
4Associate Professor/Departament of Maternity, Hospital Infantil Dr. Juvêncio Mattos,
São Luis, Maranhão.
5Associate Professor/Departament of Pediatrics, Universidade Federal do Maranhão,
São Luis, Maranhão.
6Full Professor/Department of Pediatrics, Faculdade de Medicina da Universidade de
São Paulo, São Paulo, SP, Brazil
Abstract/Case Report Text
Platelet abnormalities with eosinophilia and immune-mediated inflammatory disease
(PLTEID) is a recently discovered combined immunodeficiency with inflammatory and
allergic manifestations with few cases reported. We describe a female patient with
compound heterozygous mutation in ARPC1B gene with suggestive clinical findings of
PLTEID.
A 2-year-old girl presented with chronic diarrhea since neonatal period, with bloody
stools and failure to thrive. She also presented atopic dermatitis, recurrent cutaneous
and mucosal ulcers, recurrent respiratory infections (4 episodes of otitis media,
2 pneumonias) and many episodes of mucocutaneous candidiasis. Family history revealed
a sibling deceased in the second month of life, who presented a similar clinical picture
and a paternal uncle and second degree cousin that died in the first year of life.
There is no history of consanguinity.
Laboratory evaluation revealed peripheral eosinophilia (1000/mm3), normal platelet
numbers with low platelet volume (8,3 fL - reference value 9,4-12,4 fL), normal IgM
levels with elevated IgG (1114 mg/dL- RV 453-916 mg/dL), IgA (517 mg/dL - RV 20-100
mg/dL) and IgE (1141 IU/mL - RV A) associated with PLTEID.
The infant receives antimicrobial prophylaxis with sulfamethoxazole-trimethoprim and
fluconazole, intravenous immunoglobulin replacement and was referred to hematopoietic
stem cell transplantation (HSCT).
This case was the first one described in Brazil and highlights the importance of seeking
for a genetic diagnosis in patients with complex clinical phenotypes. Precise diagnosis
can impact on treatment approach.
(171) Submission ID#812236
Safety Of Yellow Fever Vaccine And Other Live Attenuated Vaccines In Pediatric Patients
With DiGeorge Syndrome
Mayara Lorena de Souza, MD1, Mayra de Barros Dorna, MD2, Gabriela Araújo Toscano Henriques,
MD1, Pedro Henrique Meireles Vieira, MD1, Marcília Sierro Grassi, MD3, Ana Paula Beltran
Moschione Castro, MD, PhD4, Antonio Carlos Pastorino, MD, PhD4, Magda Carneiro-Sampaio,
MD, PhD5
1Allergy and Immunology Fellow in-training/Department of Pediatics, Faculdade de Medicina
da Universidade de Sao Paulo, Sao Paulo, Brazil
2Associate Professor/Departament of Pediatrics, Faculdade de Medicina da Universidade
de São Paulo, São Paulo, Brazil.
3Associate professor/Department of Pediatrics, Faculdade de Medicina da Universidade
de São Paulo, Sao Paulo, Brazil
4Associate Professor/Department of Pediatrics, Faculdade de Medicina da Universidade
de Sao Paulo, Sao Paulo, Brazil.
5Full Professor/Department of Pediatrics, Faculdade de Medicina da Universidade de
São Paulo, São Paulo, SP, Brazil
Abstract/Case Report Text
INTRODUCTION: Patients with DiGeorge Syndrome (DGS) have a variable degree of immunodeficiency
due to thymic hypoplasia. Live vaccines are generally contraindicated in patients
with combined immunodeficiency (CID). However, in less severe CID, such as partial
DGS, those vaccines can be considered depending on the immunologic status of the patient.
There are recommendations regarding to measles, mumps, rubella (MMR) and varicella
vaccines, but yellow fever vaccine (YFV) is generally contraindicated in this population.
Considering the severity of the yellow fever disease and the absence of specific treatment,
the use of this vaccine is an important topic for debate in cases of patients from
endemic areas.
OBJECTIVE: This study aimed to describe the use of YFV and other live attenuated vaccines
in patients with DGS, associating it with their immunological profiles and the presence
of adverse effects.
METHODS: Retrospective study of medical records of patients with DGS confirmed by
MLPA or FISH, followed in a pediatric reference center for primary immunodeficiencies
between 2009 and 2019. Collected data included: demographic characteristics, medical
history, history of immunization with live vaccines, postvaccination adverse reactions
and immunological profile, including immunoglobulins levels, serologic vaccination
responses, lymphocyte immunophenotyping, lymphocyte proliferation responses to mitogens
and prophylactic treatments (antibiotic or immunoglobulins).
RESULTS: Thirty-five patients with confirmed DGS and median age of 12 years (2-21y)
were included (22M:13F). Thirty-three children (94%) received MMR vaccine: nine presented
T lymphopenia. Two of the 9 patients had CD4 < 300, one of them with normal mitogenic
proliferation response and the other was not tested. Three of the 33 patients had
low immunoglobulins levels (2/33 low IgG, 2/33 low IgM and 1/33 low IgA), and one
of them received intravenous immunoglobulin (IVIG). Twenty-nine of 33 had normal serologic
vaccination responses. Adverse effect was only reported by one patient, who had one
episode of fever after the administration of all vaccines.
Yellow fever vaccine was administrated to 14 children (40%): 2 had T cell lymphopenia
(but CD4>500), and another patient had hypogammaglobulinemia and received IVIG and
prophylactic antibiotics. Twelve of 14 showed adequate serologic responses to MMR
and Hepatitis B. Only 1 patient reported mild reaction (tremors) two days after the
YFV administration. The same patient had normal T cells, immunoglobulins and vaccine
responses.
Twenty patients (57%) received bacillus Calmette-Guerin vaccine (BCG), 15 (42%) received
oral polio, 9 (25%) rotavirus and 8 (22%) received varicella vaccine. No severe adverse
events were documented in any patient that received live vaccines, and no patient
developed measles, mumps, rubella or yellow fever diseases as a consequence of administration
of the vaccine.
CONCLUSIONS: In this cohort of pediatric patients with DGS, YFV and other live vaccines
were well tolerated, and no severe adverse events were reported, suggesting that widespread
contraindication of YFV may endanger unvaccinated patients with less severe phenotype
living in endemic areas. Immunological evaluation and individualized decisions are
always recommended, and further studies are needed to assess the safety of the YFV
in this pediatric population.
(172) Submission ID#812245
A Phase 1/2 Study of Lentiviral-mediated Ex-vivo Gene Therapy for Pediatric Patients
with Severe Leukocyte Adhesion Deficiency-I (LAD-I): Initial Results from the First
Treated Patient
Donald Kohn, MD1, Gayatri Rao, MD, JD2, Elena Almarza, PhD3, Dayna Terrazas, RN4,
Eileen Nicoletti, MD5, Augustine Fernandes, PhD6, Caroline Kuo, MD7, Satiro De Oliveira,
MD7, Theodore Moore, MD7, Ken Law, PhD8, Brian Beard, PhD9, Julian Sevilla, MD, PhD10,
Christina Mesa, PhD3, Juan Bueren, PhD3, Jonathan Schwartz, MD11
1Dept. MIMG, Pediatrics,MMP/UCLA
2VP, Regulatory Policy & Patient Advocacy/Rocket Pharmaceuticals, Inc.
3Division of Hematopoietic Innovative Therapies/CIEMAT and CIBERER-ISCIII
4Research Nurse Coordinator/University of California, Los Angeles
5Associate Medical Director/Rocket Pharmaceuticals, Inc.
6Project Scientist/Program Manager/University of California, Los Angeles
7Dept of Pediatrics/University of California, Los Angeles
8Senior Scientist/Rocket Pharmaceuticals, Inc.
9Associate Vice President, CMC-Lentivirus & AAV/Rocket Pharmaceuticals, Inc.
10Pediatric Oncology Hematology and Stem Cell Transplant Department/Hospital Infantil
Universitario Nino Jesus
11Chief Medical Officer/Rocket Pharmaceuticals, Inc.
Abstract/Case Report Text
Introduction: LAD-I is a rare inherited disorder of leukocyte (primarily neutrophil)
adhesion to endothelial cell surfaces, migration, and chemotaxis resulting from ITGB2
gene mutations encoding for the β2-integrin component, CD18. Severe LAD-I (i.e., CD18
expression on < 2% of neutrophils) is characterized by recurrent serious infections,
impaired wound healing, and childhood mortality. Although allogeneic hematopoietic
stem cell transplant (alloHSCT) is potentially curative, its utilization and efficacy
are limited by HLA-matched donor availability and risk of graft-versus-host disease
(GVHD). RP-L201-0318 (clinical trials.gov # NCT03812263) is a phase 1/2 open-label
clinical trial evaluating the safety and efficacy of autologous CD34+ cells transduced
with a lentiviral vector (LV) carrying the ITGB2 gene encoding for CD18 (Chim-CD18-WPRE)
in severe LAD-I.
Methods: Pediatric patients ≥ 3 months old with severe LAD-I (demonstrated by CD18
expression on < 2% neutrophils and at least one prior significant bacterial or fungal
infection) are eligible. Peripheral blood (PB) hematopoietic stem cells are collected
via apheresis after mobilization with granulocyte-colony stimulating factor (G-CSF)
and Plerixafor. CD34+ HSPCs are selected, transduced with Chim-CD18-WPRE LV, and cryopreserved.
Myeloablative conditioning with busulfan (therapeutic drug monitoring (TDM) dosing
with adjustments to enable target area under the curve (AUC)) is administered over
4 days, followed by infusion of the thawed investigational drug product (RP-L201).
Patients are followed for safety assessments including replication competent lentivirus
(RCL) and insertion site analysis (ISA), and for efficacy -- survival to age 2 (24
months) and at least 1-year post-infusion without alloHSCT, increase in neutrophil
CD18 expression, PB vector copy number (VCN), decrease in infections and/or hospitalizations,
and resolution of skin or periodontal abnormalities.
Results: An initial LAD-I patient (age 9 years) with recurrent severe infections and
documented ITGB2 mutations has been treated as of November 2019. Baseline CD18, CD11a,
and CD11b expression were < 1%. Mobilization and apheresis procedures were performed
successfully and busulfan conditioning was administered at the target AUC. Investigational
product was comprised of 4.2x10e6 CD34+ cells/kg with VCN of 3.8 copies/cell (liquid
culture), and was infused without complications. No serious treatment-emergent adverse
events were reported. Neutrophil engraftment (3 consecutive days of ANC ≥ 500) was
observed 18 days post-infusion. PB PMN CD18 expression 3 months post-treatment was
44.9% with comparable CD11a and CD11b expression levels; PB CD15 (myeloid) VCN at
2.5 months was 1.5. Safety and efficacy data 6 months post-treatment will be available
at the time of presentation, in addition to preliminary data regarding a potential
additional patient.
Conclusion: Preliminary evidence demonstrates that RP-L201 enables ITGB2 genetic correction
with robust CD18/CD11 neutrophil expression in this frequently fatal primary immunodeficiency.
(173) Submission ID#812249
Chronic Glomerulonephritis, Autoimmunity and Recurrent Infections In A Patient With
C3 Nephritic Factor
Catherine Freeman, MD1, Benjamin Wright, MD2
1Allergy and Immunology Fellow/Mayo Clinic Arizona
2Allergy and Immunology Attending/Mayo Clinic Arizona
Abstract/Case Report Text
Introduction: The complement system plays an integral role in the innate immune system
and links innate and adaptive immunity. Complement deficiencies, hereditary or acquired,
are rare. Acquired deficiencies are more prevalent, occurring in nephrotic syndrome,
reduced hepatic synthesis or transiently in sepsis/viremia. They are also seen in
the presence of autoantibodies known to cause depletion of complement factors, such
as C3 Nephritic Factor (C3NeF). C3 deficiency is associated with infection susceptibility,
particularly to encapsulated bacteria, and immune complex disease.
Case Description: A 47 year old male was evaluated for recurrent infection. In childhood,
he had recurrent sinusitis, otitis media requiring tympanostomy tube placement and
persistent pharyngitis despite tonsillectomy. As a teenager, he developed glomerulonephritis,
progressing to end stage renal disease and requiring transplant at age 22. The kidney
allograft failed 4 years later, with biopsy demonstrating recurrent glomerulonephritis.
The patient was transitioned to peritoneal dialysis and later hemodialysis, due to
recurrent PD-related infections. His adult course was complicated by recurrent methicillin
sensitive staphylococcal aureus (MSSA) catheter and soft tissue infections (cellulitis
and abscess), sinusitis, sepsis (Streptococcal, MSSA and Tularemia), multifocal pneumonia
and a left below knee amputation for osteomyelitis that required revision surgery.
Patient reported other autoimmune phenomena including a presumptive diagnosis of vasculitis
and possible lupus-like syndrome. The constellation of recurrent infections and autoimmune
features was most concerning for an early complement deficiency. Prior work up was
notable for low C3, CH50 and AH50 with normal C4, Factor H and Factor I.
Extensive laboratory work up revealed normal C1q, C4 level and function, serum immunoglobulins,
vaccine titers, Factor B and Factor D levels. Atypical HUS (aHUS) panel revealed a
heterozygous silent variant in exon 17 of CFH and a heterozygous polymorphism within
an intron in MCP/CD46, seen with increased prevalence in the patient population with
aHUS. WES was notable for a variant of uncertain significance in the VCL gene only.
C3 level and function were markedly decreased, alongside low CH50 and AH50. Both SC5b-9
level and C3 Nephritic Factor were elevated.
A diagnosis of acquired C3 deficiency due to C3NeF was made and patient was started
on Bactrim prophylaxis. He has remained free of serious infection since starting antibiotic
prophylaxis.
Discussion: C3NeF stabilizes the alternative pathway C3 convertase, C3bBb, increasing
its half-life and blocking dissociation. This leads to unregulated consumption of
C3 with subsequent deficiency. C3NeF has been associated with C3 glomerulopathy, infection
and partial lipodystrophy. However, there is marked heterogeneity in clinical phenotypes
with reported asymptomatic individuals. Our patient’s glomerulonephritis likely represents
C3 glomerulopathy. Case reports and series of successful treatment of C3 glomerulopathy
with rituximab and eculizumab have not commented on immune outcomes beyond the kidney.
Other potential therapeutic strategies include plasma cell depletion with either bortezomib
or daratumumab. Further study is needed to evaluate these therapies influence on both
reversal of C3 depletion and overall impact on immune function in the setting of C3NeF.
(174) Submission ID#812255
Progressive Disseminated Histoplasmosis and Associated HLH: Manifestations of an underlying
STAT1 GOF mutation
Saara Kaviany, DO1, James Connelly, MD2, Yasmin Khan, MD3, Donna Hummell, MD4, Sarah
Shoop Neumann, RN5, Debra Friedman, MD6, Jeffrey Rathmell, PhD7, Todd Bartkowiak,
PhD8, Jonathon Irish, PhD9, Daniel Dulek, MD10
1Pediatric Hematology/Oncology Fellow/Vanderbilt Children's Hospital
2Assistant Professor, Pediatric Hem/Onc/BMT/Vanderbilt Children's Hospital
3Assistant Professor Pediatrics AI/Vanderbilt Children's Hospital
4Professor Pediatric Rheumatology/AI/Vanderbilt Children'sHospital
5Pediatric Stem Cell Transplant RN/Vanderbilt Children's Hospital
6Division Chief Pediatric Heme/Onc/BMT/Vanderbilt Children's Hospital
7Associate Director - Vanderbilt Institute for Infection, Immunology and Inflammation,
Professor PMI/Vanderbilt University Medical Center
8PostDoc, Department of PMI/Vanderbilt University Medical Center
9Assistant Professor of Pathology, Microbiology and Immunology/Vanderbilt University
Medical Center
10Assistant Professor Pediatric ID/Vanderbilt Children's Hospital
Abstract/Case Report Text
Introduction: Patients with heterozygous signal transducer and activator of transcription
1 (STAT1) gain of function (GOF) pathogenic variants exhibit an array of phenotypes
including susceptibility to viral, bacterial, fungal and mycobacterial infections,
autoimmunity, and cancer predisposition. Progressive disseminated histoplasmosis (PDH)
is well-described to affect infants. However, no reports have evaluated underlying
monogenic immune dysregulation in previously healthy infants presenting with PDH.
We report an infant who presented with PDH and associated hemophagocytic lymphohistiocytosis
(HLH) leading to the diagnosis of a heterozygous STAT1 GOF mutation.
Case Report: A previously healthy 9-month old male presented with persistent fever,
pancytopenia, transaminitis, elevated ferritin, hepatosplenomegaly and coagulopathy.
His clinical and laboratory evaluations were concerning for HLH syndrome. He had no
prior history of immune hyperactivation or atypical infections. Secondary causes of
HLH were investigated, and patient was diagnosed with PDH based on marked histoplasma
antigenemia. Targeted genetic testing did not reveal a genetic etiology of familial
HLH. He was successfully treated with a pulse and taper of dexamethasone as well as
liposomal Amphotericin B with transition to itraconazole.
Immunologic evaluation at the time of initial presentation demonstrated increased
mean channel fluorescence for both perforin and granzyme noted in his NK cells. His
NK function was decreased; however, he had a normal CD107a degranulation assay. His
B-cell panel demonstrated low non-switched memory B-cells, low switched memory B-cells
and low total memory B-cells.
Given his extreme immune activation with histoplasmosis, abnormal immunologic testing,
and persistent lymphopenia despite resolution of his infection, a primary immunodeficiency
next generation sequencing panel was sent. The results demonstrated a pathogenic variant
in STAT1 (c.800C>T; p.ala267Val). This single nucleotide variant has been previously
shown to be pathogenic (Clinvar).
The patient was enrolled in the Human Immune Disease Initiative at Vanderbilt University,
which allows for immunophenotyping of human leukocytes via CyTOF (mass spectrometry).
His evaluation demonstrated relatively increased naïve B-cell populations, and decreased
plasmablasts and class-switched memory B-cell populations.
Discussion: The development of HLH is an infrequent manifestation of STAT1 GOF mutations
(Faitelson et al, Leiding et al). The mechanism of HLH development in STAT1 GOF is
unknown, but possible means include impaired NK cell function as seen in familial
HLH (Tabellini et al.) and abnormal IFN-ϒ signaling given the dominant role of this
cytokine in driving immune dysregulation in patients with impaired cytoxicity (Ovadia
et al.). We suppose that molecular sequencing of STAT1 should be included in patients
presenting with HLH. Identification of STAT1 mutations in such patients is critical
as JAK/STAT pathway inhibition should be an effective therapy for HLH, potentially
avoiding the toxicity of historic agents such as etoposide.
Treatment recommendations for STAT1 GOF are not well established. They include ruxolitnib
and curative bone marrow transplant, but long-term outcomes with JAK inhibition are
lacking and transplant survival rates to date have been very poor compared to other
immune diseases including familial HLH (Leiding et al). As our patient remains healthy
on itraconazole, viral and Pneumocystis jiroveci pneumonia prophylaxis without new
manifestations of disease, we have deferred these options.
Resources:
Faitelson, Y., Bates, A., Shroff, M., Grunebaum, E., Roifman, C. M., & Naqvi, A. (2014).
A mutation in the STAT1 DNA-binding domain associated with hemophagocytic lymphohistocytosis.
LymphoSign Journal. https://doi.org/10.14785/lpsn-2014-0004
Ovadia, A., Sharfe, N., Hawkins, C., Laughlin, S., & Roifman, C. M. (2018). Two different
STAT1 gain-of-function mutations lead to diverse IFN-γ-mediated gene expression. Npj
Genomic Medicine. https://doi.org/10.1038/s41525-018-0063-6
Sampaio, E. P., Hsu, A. P., Pechacek, J., Bax, H. I., Dias, D. L., Paulson, M. L.,
… Holland, S. M. (2013). Signal transducer and activator of transcription 1 (STAT1)
gain-of-function mutations and disseminated coccidioidomycosis and histoplasmosis.
Journal of Allergy and Clinical Immunology. https://doi.org/10.1016/j.jaci.2013.01.052
Tabellini, G., Vairo, D., Scomodon, O., Tamassia, N., Ferraro, R. M., Patrizi, O.,
… Badolato, R. (2017). Impaired natural killer cell functions in patients with signal
transducer and activator of transcription 1 (STAT1) gain-of-function mutations. Journal
of Allergy and Clinical Immunology. https://doi.org/10.1016/j.jaci.2016.10.051
Zimmerman, O., Olbrich, P., Freeman, A. F., Rosen, L. B., Uzel, G., Zerbe, C. S.,
… Holland, S. M. (2019). STAT1 gain-of-function mutations cause high total STAT1 levels
with normal dephosphorylation. Frontiers in Immunology. https://doi.org/10.3389/fimmu.2019.01433
National Center for Biotechnology Information. ClinVar; [VCV000030084.2], https://www.ncbi.nlm.nih.gov/clinvar/variation/VCV000030084.2
(accessed Dec. 13, 2019).
Leiding, J. W., Okada, S., Hagin, D., Abinun, M., Shcherbina, A., Balashov, D. N.,
… Torgerson, T. R. (2018). Hematopoietic stem cell transplantation in patients with
gain-of-function signal transducer and activator of transcription 1 mutations. Journal
of Allergy and Clinical Immunology. https://doi.org/10.1016/j.jaci.2017.03.049
(175) Submission ID#812256
CTLA4 Mutation: Pathogenic or Not Pathogenic, That Is The Question
Joao Pedro Matias Lopes, MD1, Patrick Maffucci, MD, PhD2, Yuval Itan, PhD3, Charlotte
Cunningham-Rundles, MD, PhD4
1Allergy and Immunology Fellow/Icahn School of Medicine at Mount Sinai
2Resident/Icahn School of Medicine at Mount Sinai
3Assistant Professor/Icahn School of Medicine at Mount Sinai
4Professor of Medicine and Pediatrics/Icahn School of Medicine at Mount Sinai
Abstract/Case Report Text
Introduction: Cytotoxic T lymphocyte antigen-4 (CTLA-4) is known to have an important
role as a negative regulator of immune responses, participating in the control of
regulatory T cells and effector T cells. In mice its absence is associated with fatal
autoimmunity and several CTLA-4 mutations, leading to low or absent CTLA-4 expression,
have been shown in humans to be associated with a phenotype that includes hypogammaglobulinemia
(with recurrent respiratory infections) and several manifestations of autoimmunity
(enteropathy, granulomatous lymphocytic interstitial lung disease, organ infiltration,
splenomegaly, autoimmune cytopenias, lymphadenopathy, amongst others), in an autosomal
dominant mode of transmission. One of the published mutations, c.C257T, that results
in an alanine to valine substitution (p.A86V), with a highly conserved alanine at
that position, had a CADD score of 24 and was associated with the phenotype above,
and was shown to be associated with a low expression of CTLA-4 on regulatory T cells
and with low CTLA-4 function (reduction of CTLA-4-mediated transendocytosis).
Methods: After IRB approval, we searched for CTLA-4 mutations present in the BioMe
BioBank· biorepository, containing whole exome sequencing data on 30845 patients,
with data obtained using Illumina· v4 HiSeq 2500 sequencing platform. Sifting through
all the CTLA4 mutations in the data, we identified four patients with the c.C257T
mutation described above. Extensive chart review of the four patients was performed.
Results: Four patients were found with the CTLA-4 c.C257T mutation. None of them had
any of the described phenotypical characteristics of CTLA-4 deficiency. Patient 1
is a 68-year-old male with history of coronary artery disease, atrial fibrillation,
stroke, hypertension, brain aneurysm, chronic kidney disease, gout and depression.
Patient 2 is a 29-year-old female with history of morbid obesity. Patient 3 is a 51-year-old
female with history of hypertension, obesity, pre-diabetes, dyslipidemia and iron
deficiency anemia. Patient 4 is a 70-year-old female with history of peripheral artery
disease, hypertension, dyslipidemia, chronic kidney disease and lung cancer.
Conclusion: Prior literature has attempted to characterize the clinical penetrance
of CTLA-4 mutations, suggesting it to be around 67%, with that number applying to
45 different mutations in 133 CTLA-4 mutation carriers. We screened a large biorepository
of more than 30 thousand patients for CTLA-4 patients and identified four patients
that carry one of the best described CTLA-4 mutations, previously validated from a
functional standpoint and associated with a severe phenotype. None of the four patients
demonstrated any of the previously described phenotypical characteristics, and all
four have ages above the median age of onset of 11 years. With the increasing use
and broad population application of genetic studies, it is crucial to define the value
of identifying presumed pathogenic variants in the absence of the adequate phenotype,
with all the prognostic, therapeutic and ethical considerations it may imply.
(177) Submission ID#812261
Successful Allogeneic Hematopoietic Stem Cell Transplantation for Management of Multiple
B-Cell Malignancies in A Patient with Primary Intestinal Lymphangiectasia
Taylor Lin, MD1, Hesham Eissa, MD2, Cullen Dutmer, MD3
1Allergy/Immunology Fellow/University of Colorado, Children's Hospital Colorado, Aurora,
CO, USA
2Assistant Professor of Pediatrics, Section of Hematology-Oncology and BMT/University
of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
3Assistant Professor of Pediatrics/Section of Allergy & Immunology, Children's Hospital
Colorado, University of Colorado School of Medicine, Aurora, CO, USA
Abstract/Case Report Text
Introduction: Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized
by dilated intestinal lacteals resulting in leakage of lymph into the intestinal lumen,
causing lymphopenia and hypoproteinemia. For reasons that are incompletely understood,
affected patients are predisposed to developing B-cell malignancies with gastrointestinal
or extra-intestinal localizations. Prior case reports of PIL patients with B-cell
malignancies have discussed treatment regimens with chemotherapy, radiation, and/or
surgery, but neither the use nor the outcomes of allogeneic hematopoietic stem cell
transplantation (HSCT) in the management of recurring B-cell malignancies have been
readily reported.
Case Description: A 21-year-old man with PIL and an accompanying history of lymphopenia,
hypoproteinemia, hypoalbuminemia, and hypogammaglobulinemia was diagnosed with diffuse
large B-cell lymphoma (DLBCL) of the liver following a preceding history of Burkitt
lymphoma of the ileum at 6 years of age and DLBCL of the liver at 16 years of age,
in which each malignancy was genetically distinct. In addition, the patient had a
history of benign nodular adenomatoid hyperplasia of the thyroid at 17 years of age
that required a hemi-thyroidectomy. Treatment considerations for the patient included
chimeric antigen receptor T-cell therapy, autologous HSCT, and allogeneic HSCT, in
which allogeneic HSCT was ultimately pursued. Prior to HSCT, the patient was lymphopenic
(670 cells/microliter) with significant T-cell lymphopenia (290 cells/microliter)
and an increased proportion of memory T-cells (67% of his CD4+ T cells were CD45RO+),
as well as hypogammaglobulinemic (IgG 296 mg/dL; IgA 47 mg/dL; IgM 62 mg/dL). Immediately
following treatment of his DLBCL with rituximab, ifosfamide, carboplatin, and etoposide,
the patient underwent a matched-related sibling donor HSCT with a preparative regimen
of busulfan, thiotepa, and fludarabine. Now 18 months status-post HSCT, the patient
has maintained full-donor chimerism and has no evidence of graft-versus-host disease
or malignancy. As expected, HSCT has not corrected abnormalities in certain parameters
associated with his PIL, as he continues to display significant hypoproteinemia, hypoalbuminemia,
and hypogammaglobulinemia, but he has an improved lymphocyte count (1,530 cells/microliter).
Discussion: There is no definitive or curative treatment for PIL; furthermore, the
genetic etiology of PIL remains unknown. Supportive regimens to help mitigate or offset
manifestations of PIL exist, such as adherence to a low-fat diet with medium-chain
triglyceride supplementation, but there are no therapies available to prevent or reduce
the risk of developing B-cell malignancies in this patient population. Although previous
case reports have detailed successful treatment of B-cell malignancies in PIL patients
with chemotherapy, radiation, and/or surgery, there are no published consensus guidelines
regarding management of B-cell malignancies in the setting of PIL, especially if recurrent
in nature. For non-PIL patients with chemotherapy-refractory disease, or recurrent
disease following autologous HSCT, allogeneic HSCT is a potentially curative option.
Herein, we describe a PIL patient with a history of multiple B-cell malignancies who
underwent a successful allogeneic HSCT, indicating that allogeneic HSCT may be an
effective treatment option for similarly affected patients.
(178) Submission ID#812269
DGAT 1 Deficiency Presenting With Intractable Diarrhea, Severe Anemia and Profound
Hypogammaglobulinemia
Idil Ezhuthachan, MD1, Kanya Ahuja, MD2, Ying Lu, MD3, Martin Bialer, MD, PhD4, Artemio
Jongco, MD, PhD, MPH5
1Fellow/Hofstra Northwell School of Medicine
2Fellow, Pediatric Gastroenterology/Hofstra Northwell School of Medicine
3Attending Physician, Pediatric Gastroenterology/Hofstra Northwell School of Medicine
4Section Head of Clinical Metabolism/Hofstra Northwell School of Medicine
5Assistant Professor/Hofstra Northwell School of Medicine
Abstract/Case Report Text
Introduction Diarrhea in young infants is common and generally self-limited. In persistent
cases, the differential diagnosis is broad and includes infections, food protein-induced
allergic proctocolitis, congenital diarrheas and enteropathies. In addition to monogenic
inflammatory bowel diseases, many cellular, humoral, and combined immunodeficiencies
should be considered, including but not limited to CVID, IPEX and IPEX-like phenotypes,
LAD, dyskeratosis congenita, intestinal lymphangiectasia, Omenn syndrome, cartilage
hair hypoplasia, CGD, IL-10 axis defects, AID deficiency and Wiskott-Aldrich Syndrome.
Case Presentation
A full term infant born after an uncomplicated pregnancy to non-consanguineous Honduran
parents presented with non-bloody, non-bilious vomiting and dehydration at 21 days
of life. The infant later developed frequent loose stools, some of which were bloody,
and failure to thrive. His family and prior medical history, including newborn screen,
were normal.
An extensive workup was initiated which showed:
- Persistent and severe anemia with a hemoglobin nadir of 3.5 mg/dL
- Hypoalbuminemia requiring multiple infusions
- Elevated alpha-1-antitrypsin and calprotectin level in stool
- Profound hypogammaglobulinemia with normal IgA, IgM and IgE for age
- Normal gross and histologic findings on esophagogastroduodenoscopies and colonoscopies
besides a gastric ulcer thought not be the cause of his anemia
- Normal abdominal imaging including ultrasound, CT angiography and MRI
- No source of bleeding on Meckel scan or exploratory laparotomy
- Normal DHR assay, G6PD level and positive myeloperoxidase stain
- Immunophenotyping showing T cell lymphocytosis affecting CD4+ more than CD8+ compartment,
with normal lymphocyte proliferation to mitogens
- Normal sweat chloride level
Genetic testing was initiated with a targeted immunodeficiency panel which showed
variants of unknown significance in ADAR, DOCK8, LYST, PTPRC and TBX1 genes, none
of which adequately explained his presentation. Whole exome sequencing showed that
he was a compound heterozygote in the DGAT1 gene. A pathogenic variant c.751+2T>C
(IVS8 + 2T>C) was inherited from the father and a likely pathogenic variant c.1073G>C
(p.R358P) was inherited from the mother. Patient was diagnosed with DGAT1 deficiency,
an inborn error of lipid metabolism resulting in protein-losing enteropathy (PLE).
Under gastroenterology’s guidance, a low fat diet was initiated, resulting in rapid
improvement in stool consistency, weight gain, albumin level and stool alpha-1-antitrypsin
level. He remains on subcutaneous immunoglobulin replacement therapy for ongoing hypogammaglobulinemia.
Conclusion: Protein-losing enteropathies commonly present with intractable diarrhea
and significant laboratory derangements due to malabsorption including hypogammaglobulinemia.
As a result of these findings and since many of the etiologies are immunologic in
origin, immunologists are an integral part of the evaluation of such cases. In cases
where immune system interrogation reveal normal results, genetic testing is crucial
in guiding the diagnosis. In our case, whole exome sequencing not only provided the
diagnosis but also characterized a variant that was previously of unknown significance
as likely pathogenic. Dietary management provided rapid improvement in growth and
nutritional status. Ongoing monitoring will reveal if this management also assists
in IgG level maintenance and hematologic abnormalities or if even more stringent control
of dietary fat will be required
(179) Submission ID#812278
Immune Dysregulation Polyendocrinopathy X-Linked (IPEX) Symptomatology With A Hemizygous
Variant In The Non-Coding Polyadenylation (polyA) Signal of FOXP3
Alissa McInerney, MD1, Stefani Su, MD1, Daniel Sahm, MD2, Laura Pisani, MD3, Kate
Buzzi, MD4, Jennifer Mait-Kaufman, MD4, Michael Pettei, MD5, Joel Brochstein, MD,
FAAP6, Artemio Jongco, MD, PhD, MPH7
1Fellow, Division of Allergy and Immunology/Donald and Barbara Zucker School of Medicine
at Hofstra/Northwell
2Attending Physician, Division of Pediatric Critical Care/Cohen Children's Medical
Center, Northwell Health
3Assistant Professor of Pediatrics/Hofstra Northwell School of Medicine, Cohen Children's
Medical Center, Division of Medical Genetics
4Assistant Professor of Pediatrics/Hofstra Northwell School of Medicine, Cohen Children's
Medical Center, Division of Gastroenterology and Nutrition
5Associate Professor, Chief Division of Gastroenterology and Nutrition/Hofstra Northwell
School of Medicine, Cohen Children's Medical Center, Division of Gastroenterology
and Nutrition
6Associate Chief for Cellular Therapy Division of Hematology/Oncology and Stem Cell
Transplantation/Cohen Children's Medical Center, Donald and Barbara Zucker School
of Medicine at Hofstra/Northwell
7Assistant Professor/Hofstra Northwell School of Medicine
Abstract/Case Report Text
Background: FOXP3 gene mutations are associated with immune dysregulation polyendocrinopathy
X-linked (IPEX) syndrome, a rare X-linked monogenic disease of immune dysregulation
and autoimmunity. The classic presentation consists of severe enteropathy, dermatitis,
and endocrinopathies (commonly early onset insulin dependent diabetes mellitus). Clinical
presentation and severity can be variable even in family members with the identical
variant. We present a patient with IPEX symptomatology and a hemizygous variant in
the polyadenylation (polyA) signal of FOXP3 that is classified as a variant of uncertain
significance (VUS). This specific variant was reported in a single case study in which
the patient improved after hematopoietic stem cell transplantation (HSCT).
Case Presentation:
A 2 month-old ex 34-week gestation boy was admitted with lethargy, hypovolemia, electrolyte
disturbances, and acute kidney injury. He developed persistent diarrhea and vomiting
after receiving Rotavirus vaccine. His family history is significant for early deaths
of three maternal uncles - one stillborn, one death at 6 months and another at 2 years
from unknown gastrointestinal problems.
He demonstrated peripheral eosinophilia (to 4.26 K/uL), elevated IgE, and anemia requiring
multiple transfusions. He developed severe enteropathy with hypoproteinemia requiring
total parenteral nutrition, continual albumin infusions and maintenance of NPO. He
had generalized edema, respiratory distress requiring high flow nasal cannula, and
repeatedly spiked fevers with negative infectious evaluation. Acute kidney injury
improved but renal ultrasound showed persistent nephrocalcinosis. Endoscopy yielded
biopsies demonstrating duodenitis with severe villous atrophy, scanty isolated intraepithelial
eosinophils and neutrophils, a few crypts with mucin, reactive epithelial changes
and increased lamina propria eosinophils. Colon biopsies showed mucosa with focally
increased lamina propria eosinophils with scanty neutrophils and surface epithelium
without cryptitis. Esophagitis with reactive epithelial changes, spongiosis, and many
intraepithelial eosinophils was also present.
The patient’s lymphocytes showed unremarkable proliferation to PHA and PWM. CD4+ CD25+
T cells demonstrated intracellular FoxP3 expression by flow cytometry. A commercially-available
immunodeficiency targeted panel revealed that he was hemizygous for a VUS in FOXP3
(Exon 12, c.*878A>G non coding). This variant is also referred to as an AAUAAA>AAUAAG
or AATAAA>AATAAG change in the polyA site. He was also heterozygous for VUS at these
additional loci: CD79A c.341C>T (p.Ser114Leu), DOCK8 c.5296C>T (p.Arg1766Trp), MOGS
c.1484G>A (p.Arg495Gln), NOD2 c.2110C>T (p.Gln704*), NOD2 c.2110C>T (p.Gln704*), NOD2
c.2110C>T (p.Gln704*).
Discussion: The polyA signal AAUAAA, located 798 bp downstream from the stop codon
of the FOXP3 gene, triggers polyadenylation of the mRNA, which is crucial for stabilizing
and transport of mRNA. Our patient has a point mutation in this sequence. While currently
classified as a VUS, Dorsey et al. (2009) reported the same variant in an IPEX patient
in whom clinical symptomatology, including enteropathy, resolved post-HSCT. Unlike
our patient, the case report patient had absent FOXP3 expression pre-HSCT. Gambineri
et al. (2018) identified mutations in the FOXP3 polyA site in up to 12% of their cohort
of 173 patients indicating this is not an uncommon area of IPEX-associated mutation.
Given the clinical presentation and the available evidence, we suggest that this mutation
is likely pathologic in our patient.
(180) Submission ID#812316
Immune Reconstitution Inflammatory Syndrome or Atypical DiGeorge Syndrome (DGS) Following
Cultured Thymus Tissue Implantation for Complete DGS
Eyal Grunebaum, MD1, Ryan Smith, BASc, MSc, MB BCh BAO, FRCPC2, Vy Hong-Diep Kim,
MD MScCH FRCPC1, Adelle Atkinson, MD, FRCPC1, Joanna Soscia, MEd, MN, NP-Paeds3, Brenda
Reid, RN,MN4, Jennifer Harrington, MBBS, PhD5, M. Louise Markert, MD, Ph.D6
1Clinical immunology and allergy/Hospital for Sick Children, University of Toronto
2Staff Paediatrician/Orillia Soldiers Memorial Hospital,
3Nurse Practitioner/Hospital for Sick Children
4Clinical Nurse Specialist Immunology/Allergy/Hospital for Sick Children
5Division of Endocrinology/Hospital for Sick Children, University of Toronto
6Pediatrics and Immunology/Duke University Medical Center
Abstract/Case Report Text
Introduction: Implantation of allogeneic cultured thymus, partially depleted ex vivo
of T cells, can result in naïve T cell development in patients with complete DiGeorge
syndrome (DGS). In a few patients, early and transient skin rash, often characterized
as “atypical DGS” or late autoimmune manifestations have been reported following implantation.
Here we describe a patient with complete DGS who developed immune reconstitution inflammatory
syndrome (IRIS) or atypical DGS following thymus implantation.
Case description: A female patient was diagnosed at birth with complete DGS due to
absent T cell receptor excision circles (TREC), hypoplastic thymus, profound hypocalcemia
with hypoparathyroidism and cardiac defects. The patient also had microretrognathia,
oral motor dysfunction, sialorrhea, recurrent aspirations and reflux requiring a gastro-jejunum
feeding tube, low-set ears with right ear microotia, semicircular canals atresia,
alopecia and mal-rotated kidneys. Prior to thymus implantation, the patient was thriving,
had no skin rash, no eosinophilia and no T cells. Detailed genetic analyses, did not
reveal a cause for her syndrome. At 9 months of age pulmonary aspergillosis was diagnosed
presumptively. At 10 months of age the patient received an allogeneic T-cell depleted
thymus implant from a male donor, without prior conditioning or post-implantation
immune suppressive medications. The procedure was uneventful and the patient returned
home after 7 days.
Results: Four months after implantation, a pruritic maculopapular rash appeared on
the head and trunk that spread to the extremities including the palms and soles. There
was no lymphadenopathy or splenomegaly. An infectious etiology could not be found.
Eosinophilia and an increase in liver enzymes were noted. There was an increase of
CD4+ and CD8+ T cells with predominantly memory phenotype, which had been undetectable
1 month earlier. Analysis of T cell diversity showed a restricted repertoire with
expansion of two V-beta families. There was no evidence of donor cells to suggest
graft versus host disease. Skin biopsy showed minimal superficial perivascular inflammatory
infiltrate composed mainly of CD163+ histiocytes and rare CD3+ T cells. The patient
was treated with prednisone and cyclosporine. A liver biopsy was performed 3 weeks
after initiation of treatment that showed moderate and diffuse peri-portal ductular
reaction but no duct associated lymphocytic infiltrate or significant duct epithelial
injury or ductopenia. The skin rash rapidly resolved with desquamation, while the
liver enzyme abnormalities persisted for two more months. Cyclosporine and prednisone
were weaned over 2 months. T cell numbers, their response to stimulation and diversity
have since normalized, as well as TREC and naïve T cell production. The patient is
producing appropriate antibodies to protein and polysaccharide vaccines. Sixteen months
after implantation the patient developed Grave’s disease with markedly elevated free-T4,
undetectable TSH and elevated antibodies to the thyroid receptor, which rapidly normalized
with ongoing methimazole treatment. The patient is currently 30 months after the implantation
and is free of infections, thriving and developing appropriately.
Conclusions: This patient developed atypical DGS or IRIS, often associated with autologous
and allogeneic hematopoietic stem cell transplants, organ transplants or effective
treatment of HIV, after successful thymus implantation for complete DGS.
(181) Submission ID#812317
Defective Glycosylation Leads To Impairment of gp130 Wxpression and gp130-Dependent
STAT3 Signaling in PGM3-Deficient Patients
Mohamed-Ridha Barbouche, MD, PhD1, Leila Ben-Khemis, PhD2, Najla Mekki, MD3, Roukaya
Yaakoubi, MSc2, Chaouki Benabdessalem, PhD4, Imen Ben-Mustapha, MD/MSc5, Meriem Ben-Ali,
PhD3
1Professor, Head of Immunology Department/Institut Pasteur de Tunis, Tunis, Tunisia
2PhD student/Institut Pasteur de Tunis, Tunis, Tunisia
3Associate Professor/Institut Pasteur de Tunis, Tunis, Tunisia
4Assistant Professor/Institut Pasteur de Tunis, Tunis, Tunisia
5Professor/Institut Pasteur de Tunis, Tunis, Tunisia
Abstract/Case Report Text
Congenital disorders of glycosylation are a rare group of genetic disorders due to
defects in protein glycosylation. Phosphoglucomutase 3 (PGM3) is an enzyme necessary
for the synthesis of Uridine Diphosphate N-Acetylglucosamine, an important precursor
for protein glycosylation. Patients with autosomal recessive PGM3 deficiency have
a multi-systemic disorder characterized by a neurologic impairment and clinical features
classically observed in autosomal dominant hyper-IgE syndrome due to STAT3 mutations;
including recurrent pneumonias, skin abscesses, elevated levels of IgE, and abnormalities
in connective tissues and bones.
We hypothesized that gp130, a highly glycosylated protein and co-receptor of the cytokine
IL-6, would be weakly expressed on PGM3-deficient cells, due to impaired glycosylation.
We studied 6 PGM3-deficient patients from 3 kindreds and showed that IL-6-driven STAT3
phosphorylation was impaired in their PBMCs and EBV-transformed B cells. Accordingly,
the induction of SOCS3 target gene was significantly decreased. In contrast, the patients
had normal STAT3 phosphorylation and SOCS3 induction downstream of IL-10, a cytokine
whose signaling is independent of gp130. Flow cytometry and immunoblotting showed
significantly lower gp130 expression in peripheral T-cells and EBV-transformed B cells
from PGM3-deficient patients compared to healthy donors. We did also show that in
vitro inhibition of N-glycosylation, using tunicamycin in EBV-transformed B cell line
from healthy donor, alters gp130-mediated signaling.
Collectively, our findings demonstrate that defective glycosylation in PGM3-deficient
patients results in reduced expression of gp130 and consequently, impaired gp130 dependent
STAT3 phosphorylation and defective IL-6 signaling. This may account for the overlapping
clinical features shared by PGM3 and STAT3 deficient patients.
(182) Submission ID#812339
Outcomes Following the Use of Intravenous Immunoglobulin Versus Non-Intravenous Immunoglobulin
Therapy In The Treatment Of Hospitalized Patients With Respiratory Infections
Eric Moughames, MD1, Sevag Sakayan, n/a2, Laura Prichett, PhD3, Dawn Borst, RN4, Antoine
Azar, MD5
1Internal Medicine Resident/Johns Hopkins University
2Medical Student/University of Cairo
3Senior Research Data Analyst/Johns Hopkins University
4Registered Nurse/Johns Hopkins University
5Clinical Director, Division of Allergy and Clinical Immunology/Johns Hopkins University
Hospital
Abstract/Case Report Text
Introduction: There are no known effective therapeutic modalities for patients hospitalized
with moderate to severe acute viral respiratory infections, and treatment is primarily
supportive. Intravenous immunoglobulin (IVIG) has been reported in limited cases to
be used in this setting, especially in immunocompromised patients. The primary objective
of this retrospective study is to compare clinical and economic outcomes among immunocompromised
patients hospitalized with viral respiratory infections who received IVIG to those
who did not receive IVIG at a large academic center hospital.
Methods: We performed a double-center, retrospective cohort study of all immunocompromised
patients who were hospitalized for acute documented respiratory viral infections between
2011 and 2016. We divided patients into two groups: those who received IVIG therapy
for respiratory infections, and those who did not receive IVIG therapy. Data on age,
gender, immune status, viral type, immunosuppression type, respiratory support, microbiological
data, length of hospital stay (LOS), ICU LOS, as well as death and readmission rates
were extracted from medical records. In order to adjust for severity bias typically
present in observational data such as these, we employed inverse probability weighting
(IPW) using all collected baseline covariates. Outcomes (death, length of stay in
hospital and ICU, readmission) were examined using a series of logistic and Poisson
regression models adjusting for baseline covariates and employing IPW.
Results: A total of 282 individual hospital admissions were analyzed; 99 patients
received IVIG and 183 did not receive IVIG. There were no significant differences
between the two groups in terms of mean age, gender . Average age was 40.3, 50% were
female, 74.5% were transplant patients of which 26.6% had lung transplant, 26.6% had
liver transplant, 23.1% had bone marrow transplants (BMT), 8.5% had kidney transplant,
7.8% had heart transplant and 4.3% had both solid organ and BMT. 32.3% of patients
had a hematologic malignancy, and 2.5% had a primary immunodeficiency. The most common
isolated respiratory virus was rhinovirus (51.4%), followed by RSV (25.9%), Parainfluenza
(11.4%) and Metapneumovirus (10.6%).
Overall, the use of IVIG as associated with a significantly shorter ICU length-of-stay,
with an (OR=-2.46, p=0.001), and a higher hospital readmission rate. In the sub-analysis
of patients who received IVIG within the first 48 hours of hospitalization (n=39),
IVIG use was associated with a significantly shorter ICU LOS (OR=-6.01, p=0.0), significantly
shorter overall hospital LOS (OR=-4.341, p=0.008), and no significant change in readmission
rate.
Conclusions: To our knowledge, this is the first retrospective cohort analysis evaluating
the effect of IVIG in immunocompromised patients hospitalized with respiratory viral
infections. The results suggest that immunocompromised patients receiving IVIG may
have a shorter hospital and ICU LOS, especially if IVIG is provided within the first
48 hours of admission. This may result in reduced healthcare costs. This study is
limited by its retrospective nature, and the potential bias that patients treated
with IVIG are sicker to start with. Future prospective studies are suggested to further
evaluate these findings.
(183) Submission ID#812340
Recurrent Stevens-Johnson Syndrome Associated With Mycoplasma Infection In A 15 Year-Old
Female Patient
Melissa Mendoza Suyo, MD1, Jose Calderon, MD2, Camille Ortega, DO3, Stephania Lairet,
MD1, Vivian Hernandez-Trujillo, MD4
1Pediatric Resident/Nicklaus Children's Hospital
2Attending physician/Nicklaus Children's Hospital
3Past Fellow of Allergy and Immunology at Nicklaus Children's Hospital/Past Fellow
of Allergy and Immunology at Nicklaus Children's Hospital
4Director of Allergy & Immunology fellowship in Nicklaus Children's Hospital/Director
of Allergy & Immunology fellowship in Nicklaus Children's Hospital
Abstract/Case Report Text
Introduction/Background: Stevens-Johnson syndrome (SJS) is an immune-mediated disease
characterized by extensive epidermal necrosis and detachment resulting in mucocutaneous
complications (1, 2). The most common precipitant in children is medication, followed
by infection (2,3). Although a clear association between Mycoplasma pneumoniae and
SJS has been established, there is a scarcity of literature exploring the role of
this infection in recurrent SJS in children (2-4).
Case presentation: A 15-year-old female with prior history of SJS was admitted for
mucosal and skin lesions in the setting of community acquired pneumonia. Her past
medical history included SJS with eye involvement, secondary to Mycoplasma pneumoniae
(Ig M positive), occurring five years prior to this admission. She also had frequent
episodes of acute otitis media and sinusitis in early childhood. Family history was
negative for immunodeficiency. Her clinical presentation included respiratory symptoms
and fever for 8 days treated with ceftriaxone, followed by cefdinir and levofloxacin.
Her fever improved the day prior to admission, but she developed conjunctival injection,
ocular pain, and ulcerative lesions in her mouth and nares. On physical examination,
she had low grade fever with mucosal lesions including conjunctival erythema with
serous discharge, painful blisters and denudated skin in lips, perioral area, nares,
tongue and oropharynx. Initial testing included negative blood HSV PCR, blood culture,
rapid antigen testing for group A Streptococcus and Influenza A/B, and elevated CRP
in 4.4mg/dl and ESR 55mm/hr. Right lower lobe pneumonia was confirmed with a chest
radiograph. Nasopharyngeal PCR and serum IgM were positive for Mycoplasma pneumoniae.
She had a mildly elevated Anti-cardiolipin IgM (17 MPL), a mildly decreased C3 (75
mg/dL) and a negative ANA. She was diagnosed with recurrent SJS secondary to Mycoplasma
pneumonia infection. She completed treatment with levofloxacin for Mycoplasma pneumonia,
and received cyclosporine and high-dose methylprednisolone. She had bilateral amniotic
membrane transplantation to prevent corneal ulceration . She was discharged after
clinical improvement, and recurrent oral lesions were noted at followup. Immunological
work up as an outpatient revealed normal serum immunoglobulins, normal lymphocyte
subsets and low pneumococcal titers with adequate response post-vaccination.
SJS secondary to Mycoplasma pneumonia infection has predominance of mucosal involvement
over rash, which was observed in our patient (1, 2). Some case series reported a recurrence
of SJS up to 18% within a 7-year follow up. Almost half of patients with recurrent
SJS developed multiple sequelae (2, 3). Early diagnosis of SJS, especially in those
with prior history of SJS, helps to provide appropriate supportive care, monitoring
of complications and treatment of possible superinfections (5,6).
Conclusions:
There is limited information in the literature regarding the role of Mycoplasma pneumoniae
associated recurrent SJS in children. It is possible that these episodes are triggered
by and/or immune predisposition. There is ongoing discussion regarding whether these
clinical presentation should be labeled SJS secondary to Mycoplasma pneumonia infection
or, depending of the skin involvement, M. pneumonia-associated mucositis (MPAM) and
M. pneumonia-induced rash and mucositis (MIRM) (5,6,7). Mycoplasma should be treated
appropriately in patients with recurrent SJS.
Bibliography:
Olson D, Watkins LK, Demirjian A, et al. Outbreak of Mycoplasma pneumoniae-Associated
Stevens-Johnson Syndrome. Pediatrics. 2015;136(2):e386–e394
Olson D, Abbott J, Lin C, Prok L, Dominguez SR. Characterization of Children. With
Recurrent Episodes of Stevens Johnson Syndrome. J Pediatric Infect Dis Soc. 2017 Sep
1;6(3):e140-e143.
Wanat KA, Castelo-Soccio L, Rubin AI. Recurrent Stevens-Johnson Syndrome Secondary
to Mycoplasma pneumoniae Infection. Cutis. 2014 April;93(4):E7-E8.
Finkelstein Y, Soon GS, Acuna P, George M, Pope E, Ito S, Shear NH, Koren G, Shannon
MW, Garcia-Bournissen F. Recurrence and outcomes of Stevens-Johnson syndrome and toxic
epidermal necrolysis in children. Pediatrics. 2011. Oct;128(4):723-8
Tsai V, Oman J. Stevens-Johnson Syndrome after Mycoplasma pneumoniae Infection. Journal
of Emergency Medicine, 2011-03-01, Volume 40, Issue 3, Pages 324-327.
Ferrandiz-Pulido C, Garcia-Patos V. A review of causes of Steven-Johnson syndrome
and toxic epidermal necrolysis in children. Arch Dis Child 2013 98: 998-1003.
Canavan TN, Mathes EF, Frieden I, Shinkai K. Mycoplasma pneumoniae-induced rash and
mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme:
a systematic review. J Am Acad Dermatol. 2015 Feb;72(2):239-45
(184) Submission ID#812346
Dual NFKB1 Loss-Of-Function and CXCR4 Missense Variant Presents As Hypogammaglobinemia,
Neutropenia, and HPV Susceptibility
Maria Chitty-Lopez, MD1, Krisztian Csomos, PhD2, Boglarka Ujhazi, MS3, Sumai Gordon,
B.S4, Maryssa Ellison, B.S.5, Rachel Cruz, B.S.5, Marton Keszei, PhD6, Lisa Westerberg,
PhD7, Joao Pereira, PhD8, Matt Goodwin, PharmD9, Lori Neri, MSN, CRNP, CLS10, Henry
Kanarek, MD11, Michael Jaglal, MD12, Johnny Nguyen, MD13, Tarek Ebrahim, MD14, Britt
Johnson, PhD, FACMG15, Lukas Stulik, PhD16, Adriana Badarau, PhD17, Sara Cohen, MD18,
Jolan Walter, MD, PhD19
1Allergy & Immunology Fellow/University of South Florida Morsani College of Medicine
2Research Associate/Division of Allergy & Immunology, Department of Pediatrics and
Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla
3Research Associate/Department of Pediatrics, University of South Florida, St. Petersburg,
FL, United States
4Research Technician/Division of Allergy & Immunology, Department of Pediatrics and
Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla
5Clinical research coordinator/Division of Allergy & Immunology, Department of Pediatrics
and Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla
6Research Associate/Department of Microbiology Tumor and Cell biology, Karolinska
Institutet, Stockholm, Sweden
7Associate Professor/Department of Microbiology Tumor and Cell biology, Karolinska
Institutet, Stockholm, Sweden
8Associate Professor of Immunobiology/Department of Immunobiology, Yale School of
Medicine, Yale University, New Haven, CT
9Director, Medical Affairs/X4 Pharmaceuticals, Cambridge, MA
10Medical Science Liaison/Division of Rare Diseases, X4 Pharmaceuticals, Cambridge,
MA
11Physician/Kanarek Allergy, Asthma & Immunology, Overland Park, KS
12Physician/Division of Hematology Oncology, Department of Internal Medicine, Morsani
College of Medicine, University of South Florida, Tampa, Fla
13Physician/Division of Pathology, Department of Pediatrics, Johns Hopkins All Children's
Hospital, St. Petersburg, Fla
14Vice President, Medical Affairs, Rare Disease at X4 Pharmaceuticals/Division of
Rare Diseases, X4 Pharmaceuticals, Cambridge, MA
15Laboratory Director/Invitae
16Director - Translational Sciences & Preclinical QA/X4 Pharmaceuticals, Cambridge,
MA
17Director/X4 Pharmaceuticals, Cambridge, MA
18Medical Director/Division of Rare Diseases, X4 Pharmaceuticals, Cambridge, MA
19Division Chief, Pediatric Allergy/Immunology/University of South Florida and Johns
Hopkins All Children’s Hospital
Abstract/Case Report Text
Background: Growing access to genetic testing has facilitated the genetic evaluation
of primary immunodeficiencies but has also greatly increased the number of variants
of uncertain significance (VUS) encountered in clinical practice. Interpreting the
significance of VUS requires multiple lines of evidence.
We describe a neutropenic index patient with hypogammaglobulinemia, unusual HPV susceptibility,
and dual heterozygous pathogenic loss-of-function NFKB1 and heterozygous missense
CXCR4 VUS. Family analysis showed the NFKB1 variant was inherited from his mother,
while the novel CXCR4 variant was present in his father and sister. All four patients
presented with recurrent infections, warts, and hypogammaglobulinemia. (Figure 1)
The NF-κB1 gene encodes p50/p105 transcription factor of the canonical NF-κB pathway,
the most common autosomal dominant monogenic cause of common variable immunodeficiency
(CVID).
CXCR4 is a G-protein-coupled chemokine receptor with CXCL12 as cognate ligand. Autosomal
dominant pathogenic gain-of-function CXCR4 variants lead to impaired receptor downregulation
and retention of neutrophils and other leukocytes in the bone marrow defining WHIM
(warts, hypogammaglobinemia, infections, and myelokathexis) syndrome. All CXCR4 pathogenic
variants truncate the carboxyl-tail of the CXCR4 receptor, a region responsible for
receptor internalization, with the exception of one missense non-truncating variant
p.E343K.
Case series: The proband (P1) is a 19-year-old male with history of recurrent bacterial
respiratory tract infections, warts, moderate neutropenia, thrombocytopenia and hypogammaglobulinemia
requiring immunoglobulin replacement therapy (IgRT). Bone marrow biopsy didn’t show
myelokathexis. Next-generation panel sequencing identified a novel heterozygous missense
CXCR4 (c.1022C>A, p.S341Y) VUS. The serine residue is highly conserved up to zebrafish.
This variant was present in heterozygous form in two cases in gnomAD database (277,984
alleles). Additional whole-exome sequencing revealed a heterozygous pathogenic NFKB1
variant (c.980dup, pA328Sfs*12) located in the N-terminal Rel homology domain, consistent
with NFKB1 loss-of-function.
Both, the patient’s sister (P2) and their father (P3), carry the heterozygous CXCR4
VUS but not the pathogenic NFKB1 variant, and have history of warts, hypogammaglobinemia,
and recurrent infections. The HPV susceptibility is particularly striking in P3 manifesting
by genital warts and HPV-positive oropharyngeal cancer. Bone marrow evaluation didn’t
identify myelokathexis in P2 (P3 is pending).
The mother of the index case (P4) has CVID requiring IgRT and immunomodulation. She
shares the NFKB1 variant with P1 but is negative for the CXCR4 VUS.
Extensive T and B cell phenotyping revealed low class-switched memory B cell count
(0-7 counts/ul) in all subjects, and loss of transitional and mature naïve B cells
in P1 and P4 with NFKB1 variant. Proband B cells showed the highest tendency for apoptosis
(35-55%) within the family.
Discussion
We describe members of a family with similar presentation (infections, hypogammaglobinemia,
warts), however variable combination of NFKB1 and CXCR4 variants, where either genetic
defect or their combination could explain the clinical phenotype. Biochemical consequence
of our novel CXCR4 variant is pending. As the proband showed the most severe immune
phenotype and neutropenia, we hypothesize that CXCR4 has a synergistic effect on NKFB1
loss-of-function. The contribution of CXCR4 VUS of the clinical phenotype of the two
other family members is yet to be determined.
Figure 1
(185) Submission ID#812348
Human Phenotype Ontology (HPO) Driven Exploration of Phenotypic Spectrum of A Primary
Immunodeficiency Cohort Referred For Research Exome Sequencing
Ghosh Rajarshi, PhD, DABMGG1, Kyle Webb, MS2, Cathleen Frien, n/a3, Vasu Kuram, MS4,
Daniel Veltri, PhD5, Susan Huse, PhD6, Sandhya Xirasagar, PhD7, Andrew Oler, PhD8,
Michael Setzer, ScM, CGC9, Jia Yan, MS, PhD10, Raphaela Goldbach-Mansky, MD, M.H.S.11,
Gulbu Uzel, MD12, Michail Lionkais, MD, ScD13, V. Koneti Rao, MD14, Christa Zerbe,
MD15, Morgan Similuk, ScM, CGC16, Magdalena Walkiewicz, PhD17, Steven Holland, MD18
1Certified Clinical Molecular Geneticist/National Institute of Allergy and Infectious
Diseases, National Institutes of Health
2Fellow/NIAID
3Protocol Nurse Coordinator II/NIAID
4Data Scientist/NIAID
5Health Scientist (Data Science)/NIAID
6Bioinformatics Scientist/NIAID
7Health Scientist (Data Science)/NIAID (National Institute of Allergy and Infectious
Diseases)
8Senior Bioinformatics Scientist/NIAID (National Institute of Allergy and Infectious
Diseases)
9Genetic Counselor/National Institute of Allergy and Infectious Diseases, National
Institutes of Health; Medical Science and Computing, LLC
10Operations Manager and Genetic Counselor/National Institute of Allergy and Infectious
Diseases, National Institutes of Health; Medical Science and Computing, LLC
11Senior Investigator/Translational Autoinflammatory Disease Section, LCIM, NIAID,
NIH, Bethesda, MD
12Staff Clinician/Laboratory of Clinical Immunology and Microbiology (LCIM), Division
of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases
(NIAID), National Institutes of Health (NIH),
13Chief, Fungal Pathogenesis Section/Laboratory of Clinical Immunology and Microbiology,
NIH
14Staff Clinician/ALPS Unit, Laboratory of Clinical Immunology and Microbiology, National
Institute of Allergy and Infectious Diseases, National Institutes of Health
15Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Immunopathogenesis
Section, National Institute of Allergy and Immunology, National Institutes of Health,
Bethesda, MD
16Genetic Counselor/National Institute of Allergy and Infectious Diseases, National
Institutes of Health
17Certified Molecular Geneticist/National Institute of Allergy and Infectious Diseases,
National Institutes of Health
18Director, Division of Intramural Research; Chief, Immunopathogenesis Section/Laboratory
of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR),
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH),
Abstract/Case Report Text
Background: The yield of diagnosis by exome sequencing for some primary immunodeficiencies
(PID) has been less than the typical diagnostic rate for clinical exome analysis (~30-35%).
The relatively low diagnostic rates for certain subtypes of the PIDs may be attributed
to variable expressivity and/or an incomplete understanding of the genetic basis,
among others. Additionally the extent of multiple diagnoses and phenotypyic expansion
in PID is not well explored. Cohorts with high-resolution clinical and genetic data
are instrumental for exploring these questions. We evaluated the use of human phenotype
ontology (HPO)-annotated datasets to systematically address the prevalence of these
issues using a cohort of 1000 individuals with PID who participated in research exome
sequencing at the NIAID.
Results: We generated a phenotype dataset of 1000 individuals with PIDs by annotating
the clinical features of these subjects obtained from electronic health records (EHR)
with HPO terms. Exome sequencing of these 1000 individuals identified 313 probands
with a pathogenic or likely pathogenic (P/LP) variant in a gene associated with the
respective clinical presentation. We identified 118 probands where the same gene harbored
a P/LP variant in at least three unrelated individuals. We used the clinical and genetic
data of 118 individuals in the following areas:
1) We identified P/LP variants in AIRE, PIK3CD, NLRP3, FAS, CTLA4, GATA2, CYBB, STAT1
and TNFRSF13B in at least ten patients that explained their clinical presentations.
This dataset allowed us to characterize variable expressivity of diseases associated
with these genes by capturing the variability in the observed HPO terms among probands
with P/LP variants in the same gene. Dimensional reduction of clinical features of
probands allowed us to cluster patients sharing similar phenotypic profiles. We found
clinical presentation of individuals with monoallelic P/LP variants in AIRE were relatively
less variable and clustered more compactly compared to that of individuals with GATA2
variants.
2) The extent of multiple diagnoses in PID is not well explored. The benchmark cohort
we developed allowed us to identify candidates for multiple diagnosis or phenotype
expansion by comparing the phenotype profile of each patient expressed in HPO terms
to the HPO terms typically observed for a given PID. For example, we identified gain-of-function
pathogenic variant in PIK3CD in a patient that explained the clinical features of
the PID observed in this patient. However, the patient also displayed developmental
delay, congenital hemiplegia, cerebral palsy and absent speech. These features are
not known to be associated with PIK3CD variants, making this individual a candidate
for >1 genetic diagnoses.
Conclusions: We developed a benchmark dataset where clinical features of patients
were described using HPO terms. This dataset allowed us to quantify variable expressivity
for certain PID subtypes and to systematically identify potential candidates for multiple
diagnosis or phenotypic expansion.
(186) Submission ID#812353
Two First Cases Of WHIM Syndrome in Ukraine
Alla Volokha, MD, PhD1, Anna Hilfanova, MD, PhD2
1Head of Department of Pediatric Infectious Diseases and Pediatric Immunology/Shupyk
National Medical Academy of Postgraduate Education
2Assistant-Professor, Department of Pediatric Infectious Diseases and Pediatric Immunology/Shupyk
National Medical Academy of Postgraduate Education
Abstract/Case Report Text
Warts, hypogammaglobulinemia, recurrent infections and myelokathexis syndrome is a
rare combined immunodeficiency due to autosomal dominant gain-of-function mutations
of CXCR4 chemokine receptor. The late diagnosis of WHIM syndrome in two Ukrainian
adolescents highlights the diagnostic challenges in this disease.
Patient 1, 12 year-old girl, had recurrent pneumonia since the first year of age;
overall she had 7 episodes of pneumonia. She has suffered from chronic bronchitis
for last several years. She had recurrent otitis media and chronic pyelonephritis.
Neutropenia was revealed when she was 3 year old. During episodes of bacterial infections
she occasionally had normal value of neutrophils. The girl does not receive any treatment.
Patient 2, 14 year-old boy, had three episodes of pneumonia when he was 2, 7 and 14
year old. Others symptoms include recurrent herpetic infection, warts on the hands.
Since 2 years of age he has haven persistent low neutrophil counts. The child was
followed by hematologist and since 5 years of age he has received G-CSF (5 mg/kg)
twice a month.
Both children have leukopenia 750 – 1200 cells/mm3, neutropenia – 100 – 300 cells/mm3,
lymphopenia 560-830 cells/mm3, low number of B-cells – 30-50 cells/mm3. Hypogammaglobulinemia
was not prominent in both children, they have slightly decreased level of IgG (7,1
g/l), normal level of IgM (1,16 – 1,44 g/l), patient 1 has low level of IgA 0,24 g/l.
Patient 1 does not have protective level of antibodies to diphtheria and tetanus anatoxin,
and anti-Hbs antibodies were absent despite complete immunization.
Bone marrow aspirate revealed hypercellular marrow with granulocytic hyperplasia which
was characterized by hypersegmented nuclei and cytoplasmic vacuolization of neutrophils.
On molecular analysis of CXCR4, heterozygous mutation c.1000C>T (p.Arg334*), known
as R334X mutation, was detected in both patients, confirming the diagnosis of WHIM
syndrome.
Replacement therapy with intravenous immunoglobulin was started in both children together
with antibacterial prophylaxis and G-SCF. Vaccination with 4-valent vaccine against
HPV infection was recommended for both patients.
WHIM syndrome is very rare immunodeficiency but may be underdiagnosed. The awareness
about rare forms primary immunodeficiency is very important in clinical practice for
early diagnosis and treatment.
(187) Submission ID#812355
Practice Survey of the Initial Diagnostic Evaluation of Patients with Suspected Immune-Mediated
Cytopenias: A NICER Consortium Study
Kelly Walkovich, MD1, David Frame, PharmD2, Harlan McCaffery, MS3, Rakesh Goyal, MD4,
Thomas Michniacki, MD5, James Connelly, MD6, Emma Westermann-Clark, MD7, Angela Weyand,
MD8, Allison Remiker, MD9, Sarah Henrickson, MD, PhD10, Melissa Rose, MD11
1Associate Professor, Pediatric Hematology/Oncology/University of Michigan, C.S. Mott
Children's Hospital
2Assistant Professor, Clinical Pharmacy/University of Michigan, College of Pharmacy
3Statistician Intermediate/Associate/University of Michigan, Center for Human Growth
and Development
4Professor, Pediatric Hem/Onc/BMT/University of Missouri-Kansas City School of Medicine,
Children's Mercy Hospital
5Clinical Lecturer, Pediatric Hematology/Oncology/University of Michigan, C.S. Mott
Children's Hospital
6Assistant Professor, Pediatric Hem/Onc/BMT/Vanderbilt Children's Hospital
7Assistant Professor, Allergy/Immunology/University of South Florida,
8Assistant Professor, Pediatric Hematology/Oncology/University of Michigan, C.S. Mott
Children's Hospital
9Assistant Professor, Pediatric Hem/Onc/BMT/Northwester University, Ann & Robert H.
Lurie Children's Hospital of Chicago
10Assistant Professor/Department of Pediatrics, Allergy Immunology Division, Children’s
Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University
of Pennsylvania, Philadelphia, PA
11Assistant Professor, Pediatric Hematology/Oncology/Ohio State University, Nationwide
Children's Hospital
Collaborators: Nelson RP(1), Jesudas R (2), Forbes LR (3), Walter J (4), Marsh RA
(5), Chong H (6), Hannibal M (7), Grossman JK (8), Ebens C (9), Freeman A (10)
(1) Indiana University, Divisions of Hematology and Oncology
(2) Bleeding and Clotting Disorders Institute
(3) Baylor College of Medicine, Texas Children’s Hospital, Department of Pediatrics,
Immunology/Allergy and Retrovirology, William T Shearer Center for Human Immunobiology
(4) University of South Florida, Department of Allergy/Immunology
(5) University of Cincinnati, Department of Pediatrics
(6) UPMC Children’s Hospital of Pittsburgh, Department of Allergy and Immunology
(7) University of Michigan, Department of Pediatrics, Division of Metabolism and Genomic
Medicine
(8) University of Calgary, Department of Medicine, Division of Hematology
(9) University of Minnesota, Department of Pediatrics, Division of Blood and Marrow
Transplantation
(10) National Institutes of Health, NIAID
Abstract/Case Report Text
Background: Immune-mediated cytopenias, i.e. immune thrombocytopenia (ITP), autoimmune
hemolytic anemia (AIHA), autoimmune neutropenia (AIN) and Evans syndrome (ES), are
recognized as key clinical features in primary immunodeficiencies and immune dysregulatory
syndromes. Upwards of 65% of patients with ES and an uncertain fraction of ITP, AIHA
and AIN have pathogenic variants in an immune-related gene. The initial evaluation
of patients with immune-mediated cytopenias is not standardized, particularly across
sub-specialties. The North American Immuno-Hematology Clinical Education and Research
(NICER) Consortium assessed current practices in the evaluation of immune-mediated
cytopenias.
Methods: Clinical providers recruited from NICER institutions electively completed
web-based survey questions related to provider characteristics as well as initial
diagnostic evaluation of ITP, AIHA, AIN and ES via secureQuestionPro® software. Likert
scales ranging from 1 (“rarely” < 20%), 2 (“sometimes” 21 to 40%), 3 (“half the time”
41% to 60%), 4 (“frequently” 61 to 80%), and 5 (“almost always” 81 to 100%) were used
to ascertain frequency of evaluation for each diagnostic study. Statistical analysis
and plotting was done using Rv3.6.1. Plots were created using packages ggplot2, v3.2.0
and ggiraphExtra v0.2.9. Mean Likert scale scores were calculated for each study for
each suspected disease and plotted on radar charts.
Results: The survey was completed by 93 providers, including Hematology/Oncology (48.6%),
Rheumatology (16.4%), Allergy/Immunology (17.1%) and other sub-specialties (17.9%).
A slight majority of physicians (51%) were fellows or within 5 years of graduation;
physician extenders and clinical pharmacists were also respondents. The majority (62.4%)
of respondents indicated that ≤ 50 new immune-mediated cytopenia patients were seen
at their institution annually. The vast majority of respondents (90.4%) reported evaluating
≤ 25 new ES patients per year at their institution with 60% evaluating ≤ 10 cases
annually. Collated data from all respondents showed that in all disease states, the
primary evaluation was focused on peripheral destruction mechanisms; the majority
of patients are only “sometimes” or “rarely” evaluated for bone marrow failure syndromes,
connective tissue disease, immunodeficiency and non-malignant lymphoproliferative
disorders, but when done were more likely in ES (Figure 1). Evaluations were biased
by sub-specialty with higher degrees of connective tissue focus by Rheumatology and
immunodeficiencies by Allergy/Immunology (Table 1).
Genetic sequencing was “frequently” or “almost always” sent in 4.5% of ITP, 7.0% of
AIHA, 6.2% of AIN and 32.2% of ES patients. Personal or family history of autoimmune/hyperinflammatory
disease, malignancy or cytopenias most strongly influenced the decision to send genetic
testing. Lack of insurance coverage/negative financial impact on the patient and concerns
about the inability to resolve variants of uncertain significance were the biggest
barriers for obtaining genetic testing.
Conclusions: Current practices in the evaluation of immune-cytopenias are heterogeneous
by sub-specialty and globally limited in scope with few patients being evaluated for
underlying etiologies. In particular, despite a known high frequency of pathogenic
variants in ES, less than a third of patients are undergoing sequencing, highlighting
a need to reduce barriers to genetic testing. Development of a consensus guideline
with multi-disciplinary engagement to harmonize an optimal evaluation for patients
with immune-mediated cytopenias is needed.
Table 1. Practice Variation Amongst Subspecialists in Workup of Patients Presenting
with Immune Cytopenias
(188) Submission ID#812369
IRF2BP2 Deficiency: Expanded Phenotype and Genotype-Phenotype Correlations
Amy Hsu, n/a1, Angelika Alberstadt, n/a2, Stefania Pittaluga, MD3, Olivier Gilliaux,
MD4, Emilia Falcone *, MD, PhD, FRCPC5, Will Rae, BSc(Hons) MSc BMBS MRCP6, Karin
Chen, MD7, Joao Farela Neves, MD8, Lauren Smith, MD9, Leen Moens, PhD10, Leif Hanitsch,
MD11, Isabelle Meyts, MD12, Michael Keller, MD13, Steven Holland, MD14
1Biologist/NIAID / NIH
2Student/NIAID / NIH; St. John's College
3Pathologist/Laboratory of Pathology, NCI / NIH
4Post-doctoral Fellow/CHU de Charleroi, Dept of Pediatrics
5Director, Microbiome and Mucosal Defense Research Unit; Assistant Professor/Montreal
Clinical Research Institute (IRCM), Montreal, QC, Canada and Department of Medicine,
Université de Montréal, Montreal, QC, Canada
6Wellcome Trust PhD Fellow/University of Cambridge
7Assistant Professor/University of Utah School of Medicine
8Associate Faculty/Hospital de Dona Estefânia
9Assistant Professor/Children’s Hospital of the King’s Daughters
10Scientific Researcher/KU Leuven
11Physician/Berlin Charite'
12Pediatric Immunologist/University Hospitals Leuven
13Assistant Professor/Children's National Health System
14Director, Intramural Research/National Institute of Allergy and Infectious Diseases
/ NIH
Abstract/Case Report Text
Interferon regulatory factor-2 (IRF2) binding protein-2 (IRF2BP2) was originally identified
as a transcriptional co-repressor of IRF2(1). Mutated IRF2BP2 was identified in a
3-member family with recurrent sinopulmonary infections, progressive hypogammaglobulinemia,
and poor response to protein vaccines(2). We have now identified 10 additional families
(18 subjects) with IRF2BP2 mutations. Clinical histories show an expanded phenotype
with 15/21 having chronic gastrointestinal disease; 7 with gastrointestinal manifestations
as the initial clinical complaint. Five had granulomata in liver(x2), spleen, lung(x2)
and gastrointestinal tract. Five out of six tested had poor pneumococcal vaccine responses
and four patients reported viral infections including Varicella zoster(x2), influenza
A and sapovirus.
IRF2BP2 is a 589 amino acid protein containing a highly conserved C-terminal protein-protein
interaction Ring domain (RD). Constraint metrics from gnomAD indicate mild tolerance
to missense changes and intolerance to loss-of-function alleles. We identified 3 categories
of mutations: RD mutation or deletion (n=9 patients), null alleles (n=3) and non-RD
missense changes (n=9). Functional studies assessing the ability to affect NFAT-driven
luciferase expression were performed. RD mutations (4/5) had more profound loss-of-repression
than wild-type, while missense changes had lesser, but still measurable effects. Further,
mutation categories and functional studies correlated with clinical phenotypes. Of
9 patients with RD mutations, 8/9 had infections as presenting symptoms, 6/6 tested
had hypogammaglobulinemia and 7/9 were diagnosed with CVID. One patient with a missense
RD mutation had only an infectious phenotype (pulmonary Mycobacterium avium) with
slight decrease in immunoglobulins; in functional studies this mutation had the least
effect of the RD mutations. Haploinsufficient patients reported respiratory infections
(3/3), recurrent urinary tract infections (2/3), gastrointestinal disease (2/3) and
hypogammaglobulinemia (3/3). In contrast, 8/9 patients with non-RD missense changes
presented with gastrointestinal complaints while only 2 patients had infections (recurrent
bronchitis, shingles). GI disease prevalence is consistent with high levels of IRF2BP2
expression in the colonic crypt cells (Human Protein Atlas). To confirm this, immunohistochemical
staining of colon biopsies from two patients was performed, identifying epithelial
and glandular cells of the colon.
IRF2BP2 is involved in multiple processes, including the negative regulation of NFAT
signaling(3), TCR signaling(4), inflammatory macrophages(5), and PD-L1 transcription(6).
Interaction with the glucocorticoid receptor affecting anti-inflammatory and metabolic
transcription(7) has also been reported. These observations highlight the IRF2BP2
response to type-I interferons (IRF2) and TCR stimulation (NFAT), regulation of inflammatory
macrophages and co-regulation of glucocorticoid receptor mediated signaling. The expanding
role of IRF2BP2 in multiple biologic systems correlates with the broad clinical presentation
we observed in our patients. Further studies utilizing Irf2bp2 mutation knock-in mice
will help characterize the gastrointestinal, lung and immune pathology seen in our
cohort.
References
(1)Childs KS, Goodbourn S. Nucleic Acids Res. 2003;31:3016-3026
(2)Keller MD, Pandey R, et al. J Allergy Clin Immunol. 2016;138(2):544-550:e4
(3)Carneiro FR, Ramalho-Oliveira R, et al. Mol Cell Biol. 2011’31(14):2889-901
(4)Sécca C, Faget DV, et al. J Leukoc Biol. 2016;100(5):1081-1091.
(5)Chen H-H, Keyhanian K, et al. Circulation Res. 2015;117(8):671-683
(6)Dorand RD, Petrosiute A, Huang AY. Transl Cancer Res. 2017;6(Suppl 9):S1451-S1454.
(7)Lempiäinen JK, Niskanen EA, et al. Mol Cell Proteomics. 2017;16(8):1462-1474.
(189) Submission ID#812373
A Signaling and Phenotypic Analysis of Common Variable Immunodeficiency Patients through
Mass Cytometry
Humza Khan, n/a1, Timothy Thauland, PhD2, Alejandro Garcia, PhD2, Manish Butte, MD,
PhD3
1Undergraduate Researcher/UCLA
2Staff Scientist/UCLA
3Associate Professor/Division of Allergy, Immunology, and Rheumatology, University
of California Los Angeles
Abstract/Case Report Text
Common Variable Immunodeficiency (CVID) is a disorder of antibody deficiency arising
from over 20 genetic lesions. The clinical presentation of patients with CVID varies
from recurrent, severe infections to autoimmunity. The immune dysregulation in CVID
is especially difficult to treat and the lifespans of patients suffering from autoimmunity
are much shorter than those without such complications. Unfortunately, we have no
way to identify which patients fall into which categories, or even know how many sub-categories
of CVID there are. Therefore, the field requires a method to classify patients into
categories to precisely recognize and aggressively treat the more severe phenotypes.
We address this goal by integrating analyses of patient exomes with analyses of cellular
signaling. By analyzing stimulation assays with phospho-protein mass cytometry and
high-dimensional data analytics, we aimed to elucidate signaling and phenotyping deficiencies
in patients with CVID. Importantly, our panel identifies all circulating immune cell
subsets in whole blood. In eosinophils, we found amplified responses of pP38, pSTAT3,
and Cleaved Caspase-3 in response to TLR1/2 stimulation. We found additional amplified
responses of pSTAT3 and pSTAT5 in CD16lo monocytes. This finding suggests a previously
unidentified role for eosinophils and CD16lo monocytes to contribute to the pathophysiology
of CVID. We found abormal numbers of memory B cell counts, total switched B cell counts,
and IgM+, CD38+ B cell (plasmablasts) counts between CVID patients and healthy controls.
CD21 expression on B cells was significantly reduced in CVID patients as well. These
B cell results mirror findings from prior, seminal studies on CVID. Notably, we have
found higher PD-1 expression in the effector CD8 T cells of patients. Integrating
phenotype data, genetic analysis, and mass cytometry data will provide a deeper understanding
of each patient’s phenotype and how the are clustered. We also expect that a better
understanding of alterations in the exomes and functions of the circulating immune
cells of CVID patients will lead to new therapeutic approaches.
(190) Submission ID#812391
A Novel Primary Atopic Disorder Associated With A Homozygous Missense Mutation in
OSMR
Mehul Sharma, MSc1, Christina Michalski, n/a1, Kate L. Del Bel, MSc2, Henry Lu, BSc3,
Ashish Sharma, PhD4, Maja Tarailo-Graovac, PhD5, Bhavi Modi, PhD6, Britt Drogemoller,
PhD7, Géraldine Blanchard Rohner, MD, PhD8, Christof Senger, MD9, Wingfield Rehmus,
MD, MPH10, Julie S. Prendiville, MD11, Colin J. Ross, BSc, MSc, PhD12, Clara DM. Van
Karnebeek, PhD, MD13, Wyeth W. Wasserman, Bsc, PhD14, Margaret L. McKinnon, MD15,
Stuart Turvey, MBBS, DPhil, FRCPC16
1PhD Student/BC Children's Hospital and UBC
2Research Manager/BC Children's Hospital and UBC
3PhD Candidate/BC Children's Hospital and UBC
4Post-Doctoral Fellow/Case Western Reserve University
5Principal Investigator/Alberta Children's Hospital Research Institute, University
of Calgary
6Post-Doctoral Fellow/BC Children's Hospital and UBC
7Post-Doctoral Fellow/Faculty of Pharmaceutical Sciences and UBC
8Head of Clinic/Department of Paediatrics, Children's Hospital of Geneva
9Investigator, Clinical Assistant Professor/Department of Pathology and Laboratory
Medicine, BC Children's Hospital and UBC
10Investigator, Clinical Associate Professor/BC Children's Hospital, Division of Dermatology,
Department of Pediatrics, University of British Columbia
11Division Head/UBC Department of Pediatrics, Dermatology
12Investigator, Assistant Professor/Faculty of Pharmaceutical Sciences, University
of British Columbia
13Principal Investigator/Department of Medical Genetics, British Columbia Children's
Hospital, UBC
14Professor/Department of Medical Genetics, Faculty of Medicine, University of British
Columbia
15Investigator, Clinical Assistant Professor/UBC, Department of Medical Genetics
16Professor/BC Children's Hospital and UBC
Abstract/Case Report Text
Objectives: Primary atopic disorders are monogenic disorders leading to profoundly
dysregulated allergic responses. Studying patients with these disorders has been instrumental
in expanding our understanding of the pathogenesis of allergic inflammation with therapeutic
implications for common polygenic versions of allergic disease.
Clinical findings: We have identified a now 8-year old boy who presented with severe
eczema, extremely high blood eosinophil counts (5.8x109 cells/L, normal range: 0-0.85x109
cells/L) after birth and very high serum IgE levels (2645υg/L, normal range: 0-500ug/L)
since birth. Known allergic disorders and parasitic infections are ruled out. Given
the extreme phenotype, whole exome sequencing was performed on the trio of patient
and parents, and the patient was found to have a homozygous mutation in the evolutionarily
conserved fibronectin III domain of the OSMR gene (c.1307T>A, p.V436D) (Figure 1).
OSMR encodes oncostatin M receptor-beta, a component of both the OSM type II receptor
and the IL31 receptor, and is important for keratinocyte cell proliferation, differentiation,
apoptosis and inflammation. Mutations in OSMR have been reported in association with
familial primary localized cutaneous amyloidosis, however this condition was ruled
out in this patient through skin biopsy which showed no amyloid deposits.
Methods and results: We modelled the c.1307T>A OSMR mutation in HEK293 cells and observed
a loss of expression of the OSMR receptor on the cell surface (with normal intracellular
protein levels). This observation was mirrored in primary fibroblasts obtained from
the patient. Signal transduction through phosphorylation of STAT1 and STAT5 and gene
expression (IL6 and CCL2 measured via qPCR) was absent after stimulation with OSM
in patient fibroblasts. These signaling defects were rescued using a lenti-viral transduction
approach to introduce the wild-type (WT) OSMR gene. Whole transcriptome analysis using
RNA sequencing confirmed that OSM mediated JAK-STAT signalling pathways were deficient
in the patient fibroblasts and were rescued after lenti-viral transduction of WT OSMR.
RNA sequencing analysis also suggested significantly enhanced expression of genes
in the NF-κB signalling pathway (e.g.: IL18 and CXCL1) and decreased expression of
genes in the TGF-β signalling pathway (e.g.: Smad6 and Smad7) in patient fibroblasts
at baseline. This was also rescued upon lenti-viral transduction.
Conclusion and future directions: Our findings shed light into the disease mechanism
of a novel primary atopic disorder, caused by a homozygous missense mutation in OSMR.
Figure 1. Patient pedigree and clinical findings. a Patient family pedigree and (b)
Sequencing of the OSMR c.1307 T>A region in patient blood, patient fibroblasts, mother's
blood and sibling blood. c Patient displayed consistently high eosinophil and lgE
levels since birth.
(191) Submission ID#812398
The Other Side Of STIM1: Chronic Myopathy And Platelet Dysfunction In A Patient With
A Gain Of Function Mutation In STIM1
Christian Wysocki, MD, PhD1, Gulbu Uzel, MD2, Hye Sun Kuehn, PhD3, Stefan Feske, MD4
1Associate Professor/Division of Allergy and Immunology, Departments of Medicine and
Pediatrics, UT Southwestern Medical Center
2Staff Clinician/Laboratory of Clinical Immunology and Microbiology (LCIM), Division
of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases
(NIAID), National Institutes of Health (NIH),
3Staff scientist/Immunology Service, Department of Laboratory Medicine, Clinical Center,
NIH, USA
4Professor/Department of Pathology, NYU Grossman School of Medicine
Abstract/Case Report Text
32-year-old Caucasian female presented to Immunology clinic with hypereosinophilia,
eosinophilic esophagitis, peptic ulcer disease, severe GI bleeds, and chronic hepatitis.
Healthy throughout childhood, with minimal infectious history. In adolescence developed
chronic severe myalgias and NSAID overuse, to which the peptic ulcer disease and bleeding
were attributed. Parents healthy and non-consanguineous. Son with severe bleeding
episodes and small stature. On exam she weighed 82lb, BMI 16. Sclerae anicteric. Tongue
deeply furrowed. Cervical nodes palpable. Heart and lung exam normal. No hepatosplenomegaly.
No clubbing of the digits or edema. Skin was clear.
WBC 11,600/ul, eosinophils 4730/ul, hemoglobin 10g/dL, normal platelet count. However,
platelet aggregation testing abnormal. Bone marrow normocellular, and flow cytometric
and molecular analysis did not show hematolymphoid malignancy, primary hypereosinophilic
syndrome, or systemic mastocytosis. Lymph node biopsies did not show lymphoma or aberrant
T cell populations.
Noted to have chronically elevated creatine phosphokinase, ranging from 706-3164U/L
over two years at our institution. Deltoid muscle biopsy showed non-specific myelopathic
changes. An adult dystrophy immunostaining panel was normal. Ultrastructure examination
showed no abnormal storage material. A genetic panel for metabolic myopathies failed
to reveal a cause.
Total IgG, IgA and IgM normal. IgE elevated at 934kU/L, and IgG subclasses showed
IgG4 elevated at 354mg/dL. Flow cytometry showed normal T, B and natural killer cell
numbers. Normal proportions of naïve, mature and activated T cells. Vaccine response
assessment was normal. Evaluation for autoimmune/rheumatologic diseases was negative.
Liver biopsy demonstrated findings consistent with primary or secondary sclerosing
cholangitis (without increased IgG4 staining).
Given her inflammatory phenotype, additional genetic analysis was sent, assessing
for primary immunologic disorders. This identified heterozygous variants of uncertain
significance in CTLA4 (c.553T>A; pS185T), ZAP70 (c.981C>G; p.D327E), and STIM1 (c.752T>C;
p.L251S). Analysis of the CTLA4 variant in vitro revealed that it was expressed normally.
FoxP3 expressing regulatory T cells were present in normal proportions in vivo and
appeared phenotypically normal. This variant was found in her unaffected father. The
ZAP70 variant is present in population databases (rs201605654, ExAC 0.07%), and was
felt unlikely to be clinically relevant.
The STIM1 L251S variant, although not shown previously in human patients, has been
previously shown in vitro to be a gain of function mutation[1-3]. Furthermore, familial
analysis revealed that this was a de novo mutation arising in the patient, and present
in her son. Humans with other gain of function mutations in STIM1 and the ORAI1 channel
it activates have overlapping syndromes including Storkmorken syndrome, Tubular Aggregate
Myopathy and York Platelet syndrome, characterized by chronic myopathy and platelet
aggregation defects [4]. The STIM1 L251S mutation is predicted to cause constitutive
STIM1 activation and calcium influx and likely provides an explanation for the patient’s
chronic myopathy and abnormal platelet aggregation. Neither eosinophilic disease,
nor cholangitis, have been described previously in STIM1 gain of function-related
diseases. It is unclear whether these issues are related to this novel STIM1 mutation,
or to other genetic or environmental influences. Treatment of diseases caused by overactive
CRAC channels is challenging as no pharmacologic inhibitors are yet clinically available.
References
1.Korzeniowski, M.K., B. Baird, and D. Holowka, STIM1 activation is regulated by a
14 amino acid sequence adjacent to the CRAC activation domain. AIMS Biophys, 2016.
3(1): p. 99-118.
2.Ma, G., et al., Inside-out Ca(2+) signalling prompted by STIM1 conformational switch.
Nat Commun, 2015. 6: p. 7826.
3.Fahrner, M., et al., Communication between N terminus and loop2 tunes Orai activation.
J Biol Chem, 2018. 293(4): p. 1271-1285.
4.Feske, S., CRAC channels and disease - From human CRAC channelopathies and animal
models to novel drugs. Cell Calcium, 2019. 80: p. 112-116.
(192) Submission ID#812409
Early Use Of Anti Il-1 In Neonatal-Onset Multisystem Inflammatory Disease (NOMID/CINCA)
Henriques MT¹; Bardou MLD¹; Pontarolli DA1; Palma SMU1; Mendonça LO2; Grumach AS1
1 – Clinical Immunology, University Center Health ABC, Santo Andre, SP, Brazil
2 – Clinica Croce, Advanced Medical Insitute and Department of Clinical Immunology
and Allergy, University of São Paulo, São Paulo, Brazil
NOMID/CINCA syndrome is one of the periodic syndromes associated with cryopyridines.
It is a defect in the innate immune system causing excessive activation of the inflammasome,
with consequent IL-1 secretion and neutrophil recruitment. Clinically, damage occurs
to organs such as the skin (neutrophilic urticaria), central nervous system (meningitis
and deafness) and joint (arthritis). Levy et al. (2015) evaluated a large series of
136 patients and median onset age was 0.8 years, while the median age at diagnosis
was 15 years, although the symptoms initiate in the first days of life. Treatment
includes corticosteroids, which act by nonspecifically blocking all inflammatory cytokines,
or by blocking IL-1 specifically. If early diagnosis and treatment of the disease
is not made, natural evolution leads to motor and adaptive disability and death in
20% of cases already in adolescence due to infection, neurological complications or
secondary amyloidosis. We report a 10-month-old male child from nonconsanguineous
parents who presented shortly after birth, multiple scaling and erythematous lesions
throughout the body, evolving with following symptoms: abdominal abscess, hepatitis,
meningitis and pioarthritis. Laboratory tests showed elevation of inflammatory tests
(ESR, CRP, amyloid protein A) and leukocytosis. The diagnosis was suspected at the
nursery where the patient remained hospitalized for 51 days. A personalized multigene
panel was requested. It was identified the variant p.Gly309Val, heterozygous for NLRP3
gene, not described in the literature, confirming the diagnosis of CINCA/NOMID Syndrome.
After discharge, it was introduced prednisolone (1,5mg/kg/day) and anti-interleukin-1
(IL-1). After the second dose, skin lesions and joint edema regressed, weight gain,
and neuropsychomotor development improved. This case reports a very early diagnosis
of NOMID/CINCA Syndrome. It warns neonatologists and pediatricians about the need
of precocious recognition of the syndrome, probably improving the prognosis of the
patient.
(193) Submission ID#812416
Mbl And Ficolin 3 as A Factor Influencing the Severity of M. Leprae Disease
Francisca Oliveira, MSc1, Rosemeire Constantino-Silva, PhD2, Giulia Souza, BSc3, Anete
Grumach, MD, PhD4
1Postgraduate Student/Federal University of Maranhao
2Biologist. Researcher at Immunology Lab./Faculty of Medicine ABC, Santo Andre, SP,
Brazil.
3Fellow in Training/University Center Health ABC
4Professor/University Center Health ABC
Abstract/Case Report Text
Background: Leprosy affects more than 208,000 people worldwide. Brazil represents
the 3rd. country in the world in leprosy frequency and Maranhão State is an hyperendemic
region. The city of Imperatriz (MA) stands out as a reference center in the care of
these patients. According to few reports, lectin pathway of complement system may
play a role in susceptibility to leprosy. Mannose binding lectin (MBL) and ficolins
(FCNs) recognize patterns of sugars and acetylated residues (PAMP), respectively,
in a wide variety of pathogens, including M. leprae. High levels of ficolins and MBL
may act unfavorably promoting the spread of M. leprae. The present study evaluated
the role of ficolin 3 and MBL in M.leprae patients and contacts.
Methods: A cross-sectional case-control analytical study was carried out, evaluating
clinical and epidemiological data and serum levels of MBL and FCN3 (ELISA) from July
2018 to April 2019. The study was approved by Ethics Committee and Informed Consent
forms were signed before sample collection. Data analysis was performed using the
SPSS 22.0 for Windows statistics program. Results: We evaluated 169 serum samples
(90 patients and 79 healthy family contacts), 54.4% were female, 32% under 15 years
old, 78% African-Brazilian, 65% of the families had more than 3 contacts at home.
Clinical data showed multibacillary forms in 73.3%; dimorphic (51%) and Virchowian
clinical forms (22.2%), up to 03 affected nerves in 26 (64.4%) and more than 5 lesions
in 38 (42.2%). It was observed that 32 (35.6%) had a reaction, being type 1 (75%)
more predominant. Disability grade 2 was found in 16 patients (17.8%). In children
under 15 years, 62.8% were multibacillary, 48.5% dimorphic and 20% undetermined; 11
(31.4%) also had reactions, 90% type 1 reaction and degree of disability 2 in 11.4%
of children with the disease. The evaluation of serum FCN3 and MBL levels for the
patients (n = 90) and contacts (n = 79) were 363.36ng/ml and 365.81ng/ml, (p = 0.76),
and 3035.91ng/ml (P) and 2744.66ng/ml (C) (p = 0.29), respectively. There were lower
values of FCN3 in patients with type 1 reaction (sudden and intense inflammatory processes)
versus no reaction (337.23 ng/ml vs 372.86 ng/ml) (p = 0.03) and in patients with
disability grade 2 (severe sequelae) versus disability grade 1 (319.74 ng/ml vs 343.25
ng/ml) (p = 0.003). Higher FCN3 values was observed in patients with no disability
(383.82 ng/ml) (p = 002). MBL concentrations were higher for patients above 15 years
in comparison with patients below that age (3482.69 ng/ml vs 2626.04 ng/ml)(p = 0.02))
and correlated with the occurrence of a multibacillary clinical form.
Conclusions: MBL and FCN3 levels were not different in the patients and contacts of
M. leprae, nevertheless the presence of severe forms with sequelae (reaction type
1 and disability grade 2) were associated with lower levels of FCN3. In addition,
it is possible that lower MBL levels could influence the higher frequency of multibacillary
disease below 15 years old.
(194) Submission ID#812437
Hyper IgE Syndrome with Associated Pica
Stephania Lairet, MD1, Melissa Cardenas-Morales, MD2, Jose Calderon, MD3, Vivian Hernandez-Trujillo,
MD4
1Pediatric Resident/Nicklaus Children's Hospital
2Fellow/Nicklaus Children's Hospital
3Attending physician/Nicklaus Children's Hospital
4Director of Allergy & Immunology fellowship in Nicklaus Children's Hospital/Director
of Allergy & Immunology fellowship in Nicklaus Children's Hospital
Abstract/Case Report Text
Introduction: Hyper IgE Syndrome (HIES) is a primary immunodeficiency characterized
by elevated IgE levels. Symptoms can range from severe eczema, recurrent skin infections
or pneumonias, and typical dysmorphic facies. There have been wide non-immunologic
presentations in patients with HIES, including retained primary teeth, scoliosis,
craniosynostosis, arterial aneurysms and joint hyperextensibility. An association
between HIES and autoimmune hemolytic anemia (AIHA) has further been described in
the literature. However, there have been no reported cases of HIES in association
with iron deficiency anemia and concurrent pica. We present a unique case of a patient
with a history of eczema, recurrent skin infections and pica found to have HIES and
iron deficiency anemia.
Case presentation: A 5-year-old boy with a history of allergic rhinitis presented
to the Allergy & Immunology clinic for evaluation of chronic eczema and recurrent
skin infections. The patient had a history of multiple hospitalizations requiring
intravenous antibiotics for cellulitis and superinfected eczema since he was an infant.
Symptoms were refractory to the use of multiple skin barrier ointments and oral antihistamines.
His mother further noted that for the past two months prior to initial evaluation,
he developed a fixation with eating crayons, baby powder and chewing on drywall.
Physical exam was notable for a dysmorphic face, broad based nose, pale nasal mucosa
with ample clear discharge, high-arched palate and lower incisor supernumerary teeth.
His skin was characterized by generalized dryness, lichenification and scaly desquamation
with boils on extensor surfaces of knees and elbows. Initial screening for HIES via
T-helper 17 functional assay was consistent with decreased expression of IL-17. Genetic
testing revealed STAT3 S614G missense pathogenic variant consistent with HIES. CBC
was also notable for decreased hemoglobin at 9.9 g/L and MCV of 69 fL. Patient was
diagnosed with concurrent HIES and pica in the setting of iron deficiency anemia.
Iron supplementation was started and patient’s pica improved.
Discussion and Conclusion:
Our patient with HIES had a peculiar initial presentation with the classic signs and
symptoms of HIES and pica. The diagnosis of HIES can often be delayed due to the wide
range of clinical presentations. To our knowledge, the association of HIES with iron
deficiency anemia and pica has been underreported in literature. Screening for anemia
should be considered when evaluating patients with HIES in order to rule out comorbid
iron deficiency anemia which can be easily treated with iron supplementation.
Citations:
1. Freeman AF, Holland SM. The hyper-IgE syndromes. Immunol Allergy Clin North Am.
2008;28(2):277–viii. doi:10.1016/j.iac.2008.01.005
2. Rael EL, Marshall RT, McClain JJ. The Hyper-IgE Syndromes: Lessons in Nature, From
Bench to Bedside. World Allergy Organ J. 2012;5(7):79–87. doi:10.1097/WOX.0b013e31825a73b2
(195) Submission ID#812441
Novel, Heterozygous Mutations in BLNK and LRBA Resulting in CVID phenotype with GLILD,
Inflammatory and Autoimmune Phenotype
Melissa Cardenas-Morales, MD1, Clara Reyes-Miranda, ARNP2, Vivian Hernandez-Trujillo,
MD3, Jose Calderon, MD4
1Fellow/Nicklaus Children's Hospital
2Nurse Practitioner/Nicklaus Children's Hospital
3Director of Allergy & Immunology Fellowship in Nicklaus Children's Hospital/Director
of Allergy & Immunology fellowship in Nicklaus Children's Hospital
4Attending Physician/Nicklaus Children's Hospital
Abstract/Case Report Text
Introduction: Common variable immunodeficiency is a primary immunodeficiency with
variable and diverse phenotypic presentations. The two main phenotypes include a group
which primarily exhibits recurrent infections and a group with or without infections
and primarily inflammatory and autoimmune complications. The latter, may lead to a
delay in diagnosis and is associated with poorer outcomes and higher morbidity and
mortality. (1) Another group of patients present with T-cell defects, lung disease,
autoimmunity, and infections and may be diagnosed as having CVID but instead can have
mutations in LRBA or PI3 kinase. This subset of patients has been referred to as “CVID-like”
in the literature. (2)
Case Presentation: Patient is an 11 year old female who initially presented to an
outside facility due to 2 days of fatigue, fever, and abdominal pain. Upon presentation,
she was found to have massive splenomegaly, hepatomegaly, and an abnormal chest X-ray
showing mediastinal lymphadenopathy and pleural effusion. Laboratory results demonstrated
pancytopenia, hypogammaglobulinemia, and low B cells, T cells, and NK cells via flow
cytometry. She was transferred to our institution for further work up. She did not
have any prior history of recurrent infections, asthma/lung disease, or autoimmune
conditions. Initial CT of the chest was consistent with granulomatous lymphocytic
interstitial lung disease.
Patient was diagnosed with common variable immunodeficiency with granulomatous lymphocytic
interstitial lung disease and was treated initially with high dose IVIG, corticosteroid
taper, rituximab, and Imuran.
She had interval worsening of PFT and lung disease as shown by CT scan.
Genetic panel for CVID and related conditions revealed 2 variants of unknown significance.
One heterozygous mutation in BLNK gene (c.616G>A) and one heterozygous mutation in
LRBA gene (c.3914G>A). She was started on infliximab with plans to repeat CT scan
in 6 months.
Discussion: Mutations in both BLNK and LRBA have been associated with primary immunodeficiency.
Mutations in BLNK, which is located on chromosome 10, have been associated with autosomal
recessive agammaglobulinemia. Homozygous or compound heterozygous mutations in LRBA
on chromosome 4, can lead to LRBA deficiency which encompasses a wide range of clinical
presentations including hypogammaglobulinemia, autoimmune disease, inflammatory bowel
disease, antibody deficiency, organomegaly, and recurrent infections. (3) Without
genetic testing, the clinical presentation can be difficult to distinguish from common
variable immunodeficiency. The patient presented has clinical features that can be
seen with mutations in both BLNK and LRBA, however she is heterozygous for both mutations.
Further analysis, including measurement of LRBA protein expression, is needed to further
define her underlying immunodeficiency so appropriate treatment can be administered.
(196) Submission ID#812443
Novel nonsense IKBKG Mutation in an Infant Presenting with Pneumocystis Jiroveci Pneumonia
and Disseminated Mycobacterium Szulgai Infection
Rachelle Lo, MD1, Ayelet Rosenthal, MD, MS2, Ami Shah, MD3, Sharon Chen, MD4, Lourdes
Eguiguren, MD2, Aminaa Siddiqi, MD5, Joseph Hernandez, MD, PhD6, David Lewis, MD6
1Fellow/Department of Pediatrics, Division of Allergy, Immunology and Rheumatology,
Stanford University School of Medicine
2Fellow, Pediatric Infectious Diseases/Department of Pediatrics, Division of Pediatric
Infectious Diseases, Stanford University School of Medicine
3Clinical Professor/Department of Pediatrics, Pediatric Division of Stem Cell Transplantation
and Regenerative Medicine, Stanford University School of Medicine
4Clinical Associate Professor/Department of Pediatrics, Division of Pediatric Infectious
Diseases, Stanford University School of Medicine
5Fellow, Allergy and Immunology/Department of Pediatrics, Division of Allergy, Immunology
and Rheumatology, Stanford University School of Medicine
6Clinical Assistant Professor/Department of Pediatrics, Division of Allergy, Immunology
and Rheumatology, Stanford University School of Medicine
Abstract/Case Report Text
A 5 month-old, previously healthy, unvaccinated male presented with one week of diarrhea
and cough and was admitted for dehydration and hypoxemia. His mother and sister both
had a history of incontinenti pigmenti (IP). On physical exam, he was alert, afebrile,
with tachypnea and subcostal retractions. Enterovirus/rhinovirus and parainfluenza
3 were detected, but he became progressively hypoxemic and eventually required intubation
and high-frequency oscillatory ventilation. Chest x-ray showed multifocal bilateral
airspace opacities. Empiric treatment for PJP with trimethoprim/sulfamethoxazole and
glucocorticoids was started. Tracheal aspirate PCR confirmed P. jiroveci. HIV RNA
PCR was negative. IVIG was started due to suspicion for primary immunodeficiency.
Although his respiratory status gradually improved, he subsequently developed multiple
skin lesions. Skin biopsy grew Mycobacterium szulgai. M. szulgai osteomyelitis of
the right fibula and the left nasal bone was also detected, indicating hematogenous
spread of the infection. He was started on four-drug anti-mycobacterial therapy and
interferon-gamma (Actimmune) at doses ranging from 50 μg/m^2 three times weekly to
100 μg/m^2 qod.
Immune work-up revealed T-cell lymphopenia [CD3+/CD4+ 202/μl (1400-5,100/μL) and CD3+/CD8+
222/μl (600-2,200/μl)] with an abnormally increased proportion of memory CD4 T-cells
compared to naïve cells for age. B-cell numbers were normal, and NK cells were decreased
[CD56+CD16+/CD3- 17/μl (100-1000/μL)]. NK cell lytic function by K562 lysis was normal,
whereas CD107a degranulation was decreased. The serum IgM level was normal [93 mg/dL
(31-103 mg/dL) whereas IgA [124 mg/dL (8-83 mg/dL)] and IgG [1020 mg/dL (165-781 mg/dL)]
were elevated. Mononuclear cell cytokine response to ligands for TLR2-TLR1, TLR2-TLR6,
TLR3, TLR4, and TLR7-TLR8 was normal. DNA sequencing revealed a novel nonsense mutation
in exon 5 of the IKBKG (p.Gln201Ter (Q201X) (CAG>TAG): c.601 C>T, confirming the diagnosis
of NEMO deficiency, which was suspected based on the infectious disease presentation
and the maternal history of IP. The diagnosis was further supported by signs of ectodermal
dysplasia of teeth that appeared starting at 10 months of age. He underwent HSCT using
bone marrow from a 10/10 matched unrelated donor after conditioning with ATG, busulfan,
fludarabine and rituximab. Actimmune therapy was continued until 10 days prior to
transplant. For GVHD prophylaxis, he received tacrolimus and low-dose methotrexate.
He achieved full donor chimerism post-transplant and has had no significant GVHD.
Interesting features of this case include the prominence of IP in mother and sister,
which is usually due to female heterozygosity for an IKBKG null allele. Such null
alleles when inherited by the male fetus are embryonic lethal. Our patient’s nonsense
mutation would be expected to result in severely impaired IKBKG protein expression
and function. However, the fact that he had was born at term and initially was healthy
coupled with his preservation of normal TLR function suggests that his IKBKG allele
is likely to be a hypomorphic mutation. Studies are in progress using EBV- transformed
B-cell lines from the patient to evaluate IKBKG expression and function. Also of interest,
our patient was able to tolerate relatively high doses of interferon-gamma therapy
without inflammatory side effects or an adverse impact on engraftment or GVHD.
(197) Submission ID#812451
Autosomal Dominant JAK1 Gain-Of-Function Mutation Drives Myelopoiesis and Dysregulated
T Helper Responses Leading To Severe Allergic Inflammation That Is Clinically Responsive
To Ruxolitinib
Catherine Biggs, MD, MSc1, Elizabeth Lin, BSc2, Kate L. Del Bel, MSc3, Felix Orben,
MSc4, Robert Ragotte, BSc5, Aabida Saferali, PhD6, Sara Mostafavi, PhD7, Katja Weinacht,
MD, PhD8, Lisa Ott de Bruin, MD, PhD9, Mehul Sharma, MSc10, Kevin Shopsowitz, PhD11,
Margaret L. McKinnon, MD12, Suzanne Vercauteren, MD, PhD13, Luigi Notarangelo, MD,
PhD14, Francis Lynn, PhD15, Stuart Turvey, MBBS, DPhil16
1Clinical Assistant Professor/Allergy and Immunology, Department of Pediatrics, University
of British Columbia
2Research Technician/University of British Columbia
3Research Manager/BC Children's Hospital and UBC
4PhD Candidate/Die Technische Universität München
5DPhil Candidate/Oxford University
6Post-doctoral fellow/Harvard Medical School
7Assistant Professor/University of British Columbia
8Assistant Professor, Division of Pediatric Stem Cell Transplantation and Regenerative
Medicine/Stanford University
9Pediatric Resident/Erasmus MC
10PhD Student/BC Children's Hospital and UBC
11Medical Student/University of British Columbia
12Investigator, Clinical Assistant Professor/UBC, Department of Medical Genetics
13Clinical Associate Professor/University of British Columbia
14Chief, Laboratory of Clinical Immunology and Microbiology/National Institute of
Allergy and Infectious Diseases, NIAID/National Institutes of Health, NIH
15Associate Professor/University of British Columbia
16Professor/University of British Columbia
Abstract/Case Report Text
Background: Primary atopic disorders are caused by genetic mutations that skew the
immune system towards severe allergic disease. Germline gain-of-function (GOF) mutations
in JAK1 are a newly described monogenic cause of severe atopy, with affected patients
demonstrating profound eosinophilia and allergic inflammation. Our initial report
of this novel condition identified a dramatic clinical response to the combined JAK1/2
inhibitor ruxolitinib. We aimed to determine the long-term clinical response to ruxolitinib
in patients carrying a germline JAK1 GOF mutation, and to characterize the effect
of enhanced JAK1 signaling on T lymphocyte effector functions and hematopoiesis.
Methods: Clinical outcomes were evaluated in two pediatric patients carrying the c.1901
C>A (p.A634D) GOF mutation in JAK1 after 3.5 years of ruxolitinib treatment. T cell
phenotyping was performed using extracellular surface marker and intracellular cytokine
staining by flow cytometry, and by gene expression signature profiling of RNA sequencing
data. To evaluate the effect of enhanced JAK1 activity on myelopoeisis, we reprogrammed
JAK1 GOF patient-derived peripheral blood mononuclear cells into induced pluripotent
stem cells (iPSC) and performed directed myeloid differentiation. RNA sequencing was
performed on RNA collected during iPSC myeloid differentiation and from whole blood
of affected patients before and after ruxolitinib treatment.
Results: Long-term use of ruxolitinib was associated with improved growth, reduced
eosinophilia, and control of allergic inflammation without significant infectious
complications, however, anemia represented a dose-limiting adverse effect. T cell
immunophenotypic analysis revealed severe T helper (TH) cell skewing towards a TH2
phenotype pre-ruxolitinib treatment, in keeping with the allergic clinical manifestations.
Analysis of myeloid differentiation revealed an increased myeloid to erythroid ratio
in colonies derived from JAK1 GOF iPSCs compared to controls. RNA sequencing analysis
of JAK1 GOF human whole blood and iPSCs compared to controls revealed upregulation
of cytokine and cytokine receptor genes implicated in allergic inflammation and early
eosinophil precursor commitment, including CSF-1 and the interleukin-33 receptor.
Reactome pathway analysis of genes upregulated in both JAK1 GOF iPSC and whole blood
compared to controls showed enrichment of several pathways including interferon alpha/beta,
interleukin-4/-13 and interleukin-33 signaling.
Conclusions: This work demonstrates a critical role for JAK1 in atopic immune dysregulation,
specifically driving a TH2 phenotype and eosinophilia. Combined JAK1/2 inhibition
can reverse much of the allergic inflammation, with dramatic clinical effects. This
has important implications for our understanding of the pathogenesis and potential
therapeutic targets for early life allergic immune dysregulation.
(200) Submission ID#812462
Novel heterozygous dominant activating RAC2 variant in four New Zealand patients with
combined immunodeficiency
Kuang-Chih Hsiao, MBCHB, FRACP1, Imogen Caldwell, MBChB2, See Tarn Woon, PhD3, Louisa
Ashby, PhD4
1Paediatric Immunologist and Allergist/Starship Children's Hospital, Auckland, New
Zealand
2Haematologist/Auckland City Hospital, Auckland, New Zealand
3Scientific officer/LabPLUS, Auckland District Health Board, New Zealand
4Research Fellow/Centre for Free Radical Research, Department of Pathology and Biomedical
Science, University of Otago, Christchurch, New Zealand
Abstract/Case Report Text
RAC2 encodes Ras-related C3 botulinum toxin substrate 2, a member of the Rho family
of GTPases that are essential for regulating cell signalling and actin cytoskeleton
reorganisation. Heterozygous mutations causing dominant activating phenotype were
first described in 2019. To date, the majority of reported patients have had severe
combined immunodeficiency (SCID) and/or severe disease in association with their combined
immunodeficiency (CID) necessitating haematopoietic stem cell transplantation (HSCT).
We present clinical and laboratory features of 4 New Zealand patients from the same
family with a novel heterozygous missense variant in RAC2 [c.62T>G, p.Ile21Ser (I21S)].
The index patient (P1 - age 8 y, M) has a history of infectious gastroenteritis, Staphylococcal
aureus conjunctivitis, recurrent otitis media and recurrent Herpes simplex virus (HSV)-1
cutaneous infections. His 2 siblings (P2 – age 9 y, M; P3 - age 6 y, F) and his mother
(P4 – age 42 y, F) all have a history of recurrent viral (HSV-1) and bacterial (Staphylococcal
aureus, Streptococcal pyogenes) cutaneous infections and/or recurrent sinopulmonary
infections that respond to empiric antimicrobial therapy. Affected family members
have chronic lymphopenia involving predominantly CD4+ T (range 53-361 x106/L) and
B (range 20-181 x106/L) cell compartments. P1, P2 and P3 all have CD4+ naïve (CD45RA+/CD62L+)
T cells (range 40-60% of CD4+ T cells) and normal lymphocyte proliferative response
to mitogens. P1, P2 and P3 all have reduced IgM but normal IgG and IgA. Antibody responses
to protein antigens are preserved. P1 underwent diagnostic laboratory gene panel evaluation
(Blueprint Genetics Primary Immunodeficiency Panel, v3) which identified a heterozygous
missense variant I21S in RAC2. The variant has not been observed in a large reference
population cohort (gnomAD). Sanger sequencing confirmed presence of the variant in
the 3 siblings (P1, P2, P3) and their mother (P4). Affected individuals in this family
all have neutrophil vacuolation and an abnormal neutrophil granulation pattern. Their
neutrophils all had enhanced superoxide production in response to stimulation by fMLP
and PMA as compared to healthy controls’. These findings suggest that RAC2 I21S is
an activating mutation causing notable abnormalities in neutrophil morphology and
NADPH oxidase activation similar to other recently reported mutations.
This novel mutation expands the phenotypic spectrum of RAC2 activating mutations.
Clinical management of affected patients needs to be tailored to their phenotype and
disease severity.
References
1. Hsu AP, Donkó A, Arrington ME, et al. Dominant activating RAC2 mutation with lymphopenia,
immunodeficiency, and cytoskeletal defects. Blood 2019;133:1977-88.
2. Sharapova SO, Haapaniemi E, Sakovich IS, et al. Heterozygous activating mutation
in RAC2 causes infantile-onset combined immunodeficiency with susceptibility to viral
infections. Clinical Immunology 2019;205:1-5.
3. Lagresle-Peyrou C, Olichon A, Sadek H, et al. An Autosomal Dominant SCID Form Due
to a Gain of Function Mutation in the RAC2 Gene. Blood 2019;134:3742-.
(201) Submission ID#812467
Microbiome, metagenomic and metabolomic signatures distinguish patients with enteropathy
associated with inherited CTLA4 haploinsufficiency
Emilia Falcone *, MD, PhD, FRCPC1, Yu Han, PhD2, Drew Jones, PhD3, Caroline Grou,
n/a4, Virginie Calderon, PhD5, Clay Deming, M.Sc.6, Sean Conlan, PhD7, Steven Holland,
MD8, Julia Segre, PhD9, Gulbu Uzel, MD10
1Director, Microbiome and Mucosal Defense Research Unit; Assistant Professor/Montreal
Clinical Research Institute (IRCM), Montreal, QC, Canada and Department of Medicine,
Université de Montréal, Montreal, QC, Canada
2Senior Research Assistant/Laboratory of Clinical Immunology and Microbiology (LCIM),
National Institute of Allergy and Infectious Diseases (NIAID), National Institute
of Health (NIH),
3Director Metabolomics Core Resource Laboratory andAsst. Professor Biochemistry/Molecular
Pharmacolog/NYU Langone Health, New York, NY, USA
4Bioinformatics Analyst/Montreal Clinical Research Institute (IRCM), Montreal, QC,
Canada
5Head of the IRCM Bioinformatics Core Facility/Montreal Clinical Research Institute
(IRCM), Montreal, QC, Canada
6Biologist/National Human Genome Research Institute (NHGRI), National Institutes of
Health (NIH),
7Associate Investigator/National Human Genome Research Institute (NHGRI), National
Institutes of Health (NIH),
8Director, Division of Intramural Research; Chief, Immunopathogenesis Section/Laboratory
of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR),
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH),
9Chief, Translational and Functional Genomics Branch/Chief and Senior Investigator
of the Translational and FunctionaNational Human Genome Research Institute (NHGRI),
National Institutes of Health (NIH),
10Staff Clinician/Laboratory of Clinical Immunology and Microbiology (LCIM), Division
of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases
(NIAID), National Institutes of Health (NIH),
Abstract/Case Report Text
Background and aims: Heterozygous mutations in cytotoxic T-lymphocyte antigen-4 (CTLA4)
are associated with recurrent infections, lymphoproliferation, autoimmunity and lymphocytic
infiltration of target organs. Disease penetrance can be highly variable even among
related family members carrying the same CTLA4 mutation. Our evaluation of a subset
of the CTLA4 patient cohort followed at the National Institutes of Health (NIH) revealed
that 50% of CTLA4 mutation carriers have gastrointestinal (GI) manifestations which
include diarrhea and diffuse lymphocytic enteropathy. Our aim was to determine whether
the intestinal microbiome, metagenome and metabolome could distinguish patients with
CTLA4 haploinsufficiency (CTLA4-H) based on disease severity, and the presence or
absence of GI manifestations.
Methods: Clinical metadata and fecal samples were collected from healthy individuals
(n=16) and patients with CTLA4-H (n=32). Patients with CTLA4-H were classified as
having minimal (n=7, only endocrine and/or dermatological manifestations) or systemic
disease (n=25, hematological and multi-organ involvement). They were further classified
based on whether they had a history of enteropathy (n=18) or active GI disease ( <
2 bowel movements per day and/or blood or mucus in stool) at time of sampling (n=8).
Metabolomic profiling (using a panel of 150 metabolites) and 16S rRNA gene sequencing
(V4 region) was performed on fecal samples (total samples: 62; number of reads/sample:
18,341 to 226,027; median: 74,857). A subset of 20 samples were subjected to shotgun
metagenomic sequencing based on findings from the 16S rRNA gene sequencing analysis.
Results: All patients with CTLA4-H and a history of enteropathy or active GI disease
also had systemic disease. Fecal samples from patients with a history of enteropathy
had a distinct microbial community structure (Fig. 1) which was significantly less
diverse (Fig. 2) compared to healthy individuals and patients with minimal vs. systemic
CTLA4-H. Patients with a history of enteropathy had significantly higher relative
abundance of 5 bacterial taxa including Shigella-Escherichia (Fig. 3). Shotgun metagenomic
sequencing confirmed that samples from patients with a history of enteropathy were
dominated by subsets of 12 identified Escherichia coli strains, all of which share
30 genes coding for specific types of virulence factors such as curli fibers (facilitate
uptake into host cells), flagellar proteins (increase motility) and enterobactins
(increase bacterial iron transport). Meanwhile, samples from patients without active
GI disease at the time of collection were enriched for several taxa including Bacteroides
nordii and Akkermansia muciniphila compared to patients with CTLA4-H and active GI
disease (Fig. 4). Metabolomic analyses showed that asparagine, 3-hydroxybutyrate,
cytosine and cystine were enriched in samples with abundant E. coli, whereas samples
without E. coli were enriched in metabolites involved in pyrimidine (Holm p=0.0005),
purine (Holm p=0.004), and alanine/aspartate/glutamate metabolism (Holm p=0.01) (Fig.
5).
Conclusions: Fecal samples from CTLA4-H patients with a history of enteropathy were
heavily colonized with E. coli strains that are associated with a specific metabolomic
profile and that share virulence factor genes that may facilitate host invasion. These
data suggest that the microbiome and metabolome can distinguish patients with CTLA4-H
and GI disease, and support the potential use of antibiotics or even antimetabolites
to treat CTLA4-H-related enteropathy.
Figure 1. Beta diversity (Jaccard) of fecal samples from healthy individuals and patients
with CTLA4 haploinsufficiency.
Figure 2. Alpha diversity of fecal samples from healthy individuals and patients with
CTLA4 haploinsufficiency.
Figure 3. Differentially represented taxa between patients with CTLA4 haploinsufficiency
and history of enteropathy vs. no history of enteropathy.
Figure 4. Differentially represented taxa between patients with CTLA4 haploinsufficiency
and active GI disease vs. no GI disease at time of sampling.
Figure 5. Volcano plot of metabolites present in fecal samples enriched with E. coli
vs. samples without E. coli.
(202) Submission ID#812475
A novel case of DNA polymerase δ 1 (POLD1) deficiency reveals an important role of
POLD1 in DNA repair and B cell maturation
Ottavia Delmonte, MD, PhD1, Diana Nichols-Vinueza, MD2, Marita Bosticardo, PhD3, Cesar
Rueda, PhD4, Kerry Dobbs, BS5, Katherine Calvo, MD6, Jennifer Stoddard, BS, MLS7,
Julie Niemela, MS, MLS8, Michael Keller, MD9, Sergio Rosenzweig, MD, PhD10, Roshini
Abraham, PhD11, Vanessa Bundy, MD, PhD12, Luigi Notarangelo, MD, PhD13
1Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Division of Intramural
Research, National Institute of Allergy and Infectious Diseases, National Institutes
of Health
2fellow in training/NIH
3Staff Scientist/Laboratory of Clinical Immunology and Microbiology, IDGS, DIR, NIAID,
NIH
4PhD/Nationwide Children's Hospital, Columbus, OH
5Biologist/Laboratory of Clinical Immunology and Microbiology, Division of Intramural
Research, National Institute of Allergy and Infectious Diseases, National Institutes
of Health
6Staff clinician/NIH
7Medical Laboratory Scientist/Immunology Service, Department of Laboratory Medicine,
NIH, USA
8Medical Laboratory Technologist/Immunology Service, Department of Laboratory Medicine,
Clinical Center, NIH, USA
9Assistant Professor/Children's National Health System
10Senior Investigator; Chief/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center,
11Professor/Nationwide childrens
12Assistant Professor/Children's National Hospital, DC
13Chief, Laboratory of Clinical Immunology and Microbiology/National Institute of
Allergy and Infectious Diseases, NIAID/National Institutes of Health, NIH
Abstract/Case Report Text
The DNA polymerase delta (Pol δ) complex is essential for leading and lagging DNA
strand synthesis. Its catalytic subunit (POLD1), carries both polymerase and exonuclease
activities and plays a crucial role in DNA replication and repair. Heterozygous POLD1
mutations have been associated with inherited colorectal cancer and mandibular hypoplasia,
deafness, progeroid features and lipodystrophy (MDPL) syndrome. More recently a biallelic
loss of function mutation in POLD1 (p.R1060C) that impairs the stability of the POL
δ complex, has been reported in 3 related subjects with recurrent infections, deafness
and combined immunodeficiency (CID) with T-cell lymphopenia, CD8+ T cell oligoclonality
but preserved B cell proliferation.
We report here a second family in which a novel biallelic missense mutation in POLD1
gene was associated with CID. The proband is a 9-year-old boy born to consanguineous
Pakistani parents. Since infancy he suffered from failure to thrive and recurrent
infections, including 5 episodes of pneumonias, multiple otitis media, sinusitis,
recurrent cellulitis at the G tube site, BK viruria and shingles. Live and dead vaccines
were well tolerated. At 2 years of age sensorineural hearing loss together with profound
leukopenia (ANC 260 cell/μl, ALC 680 cells/μl) and hypogammaglobulinemia (420 mg/dL)
were identified. Intermittent IVIG replacement and antimicrobial prophylaxis were
initiated.
Immunophenotyping at 9 years of age showed severe T cell lymphopenia (122 CD3+ cells/μl,
68 CD4+ cells/μl, 39 CD8+ cells/μl, 148 CD19+ cells/μl, 25 CD56+CD16+ cell/μl, 9 CD4+CD31+
cells/μl, 13 CD4+CD25hiFoxp3+ cells/μl), and hypogammaglobulinemia (IgM 23 mg/dL,
IgG 276 mg/dL, IgA < 10). Physical exam was remarkable for multiple acquired nevi
in the groin area, teeth abnormalities and global developmental delay.
Whole exome sequencing analysis revealed a homozygous POLD1 missense variant (NM_001256849
c.3175C>G, p.Q1059E) absent in public databases (CADD score of 24). Parents were heterozygous.
TCR-Vβ family expression was normal in both CD4+ and CD8+ T cells, but the proportion
of T cells expressing Vα 7.2 (encoded by the distal TRAV1-2 gene) was markedly reduced
(less than 1%), consistent with impaired VDJ recombination at the TRA locus and/or
with defective thymocyte survival. Constitutive expression of γH2AX was observed in
T and NK cells after 1 h and 24h of culture in unirradiated conditions. At 1 h post-irradiation
(2 Gy), reduced levels of p-ATM were detected in T and NK cells, and lack of ATM,
SMC1 and H2AX phosphorylation was observed in a subset of B cells, suggesting inability
of these cells to mount an effective DNA repair response. Bone marrow examination
showed normal trilineage hematopoiesis but decreased proportion of CD10-CD20+ mature
B cells and increased proportion of pre-B cells.
Conclusion: We report the second mutation associated with autosomal recessive POLD1
deficiency. Our findings broaden the understanding of the mechanisms underlying the
immune defect in this disease to include B cell maturation arrest in the bone marrow
and a DNA repair defect that may support the generation of a restricted TCR repertoire
in the thymus and increased malignancy risk.
Funding: This work was supported by the Division of Intramural Research, NIAID, NIH.
(203) Submission ID#812482
Low T-cell receptor β (TRB) Repertoire Diversity Early Post-transplant for Severe
Combined Immunodeficiency SCID Predicts Subsequent Failure of Immune Reconstitution
Ottavia Delmonte, MD, PhD1, Riccardo Castagnoli, MD2, Catherine Chang, n/a3, Melanie
Dela Cruz, n/a4, Jason Yu, PhD5, Stephen Daley, DVM6, Christopher Dvorak, MD7, Sharat
Chandra, MD8, Blachy Davila Saldana, MD9, Morton Cowan, MD10, Luigi Notarangelo, MD,
PhD11, Jennifer Puck, MD12
1Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Division of Intramural
Research, National Institute of Allergy and Infectious Diseases, National Institutes
of Health
2fellow/NIH-NIAID, Bethesda, MD
3research coordinator/UCSF Benioff Children’s Hospital, San Francisco, CA
4research assistant/UCSF Benioff Children’s Hospital, San Francisco, CA
5Senior research associate/UCSF Benioff Children's Hospital
6Senior research fellow/Monash Biomedicine Discovery Institute, Australia
7Clinical Professor/UCSF Benioff Children's Hospital
8Assistant Professor, Division of Bone Marrow Transplantation and Immune Deficiency/Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH, Department of Pediatrics, University
of Cincinnati College of Medicine
9attending physician/Children’s National Medical Center, Washington, DC
10Emeritus Professor/UCSF Benioff Children's Hospital
11Chief, Laboratory of Clinical Immunology and Microbiology/National Institute of
Allergy and Infectious Diseases, NIAID/National Institutes of Health, NIH
12Professor/UCSF Benioff Children's Hospital
Abstract/Case Report Text
Following allogeneic hematopoietic cell transplantation (HCT) for SCID, the development
of a diverse T cell repertoire is essential for optimal immune recovery. High-throughput
sequencing (HTS) of the TRB repertoire is the best tool for the evaluation of clonotype
dynamics during immune reconstitution as compared to CDR3 spectratyping and staining
of Vβ families. We investigated whether longitudinal HTS analysis of TRB would accurately
assess development of TCR repertoire diversity over time and reflect the quality of
T cell reconstitution following HCT for SCID. We wanted to study the effect of conditioning
regimen, SCID genotype, donor type on TCR diversity post HCT. We hypothesized that
repertoire diversity may represent an early biomarker to predict long-term immune
reconstitution vs. need for a second intervention. We assessed if the TRB repertoire
post-HCT carried a molecular signature of self-reactivity.
Methods: The composition and diversity of TRB repertoire of 27 SCID infants, pre-HCT
and at 100 d, 6 and 12 mo and yearly post-treatment(s) was studied by HTS. Median
time of follow-up was 48 mo. Subjects were part of a prospective study of SCID by
the Primary Immunodeficiency Treatment Consortium. Equal amounts of total RNA extracted
from peripheral blood was used as template to semi-quantitatively amplify TRB rearrangements.
The VDJ statistics file (PAST program) was used to calculate a Shannon entropy (H)
index of repertoire diversity and Simpson (1-D) index of repertoire clonality.
Results: TRB sequence analysis of 27 SCID patients showed poor diversity at baseline,
followed by improvement to normal complexity (H index >8.0) after HCT. Similar kinetics
of development of TRB diversity were seen in patients with IL2RG, JAK3, and IL7R defects
(n=16) as in those with RAG and Artemis defects (n=14). In the latter group, however,
HCT with no conditioning or immune suppression only was associated with persistently
lower diversity than HCT with conditioning (p < 0.01), a difference not found in the
IL2RG/JAK3/IL7R group (Fig.2). HCT from a matched donor (6/13 conditioned) correlated
with higher diversity than HCT from a mismatched donor (5/15 conditioned) (p=0.01).
Having > 500 CD4+ T cells/ul at 6 mo post-HCT correlated with higher TRB diversity
at 24 and 36 mo post-HCT (p < 0.01). The TRB repertoire 100 d post-HCT was enriched
for the presence of central cysteines at the apex of the CDR3 (p < 0.001), a biomarker
of self-reactivity (fig.1). An H-index of 4.7 or lower at 100 d after HCT predicted
need for second intervention (HCT or GT)(Fig.3).
Conclusions: Analysis of TRB diversity allows for detailed assessment of development
of a diverse T cell repertoire following cellular therapies for SCID and confirms
the need for patient-tailored treatment strategies based on SCID genotype. T-cell
repertoire 100 d post-HCT is characterized by a molecular signature that may contribute
to the increased rate of autoimmunity early post-transplant. Furthermore analysis
of TRB diversity at 100 d post-HCT may identify patients at risk for failure of sustained
immune reconstitution, thus prompting a second intervention without delay.
Figure 2. Effect of conditioning regimen on TCR diversity reconstitution based on
SCID genotype
Figure 3. Lower early Shannon diversity score after transplant predicts failed transplant
over long term.
(204) Submission ID#812486
The Role Of Skin Biofilm In Pathogenesis Of Atopic Dermatitis
Abdullah Alkahtani, n/a1
1Assistant Professor/King Khalid University, college of Medicine, department of Microbiology
and Immunology
Abstract/Case Report Text
Background Atopic dermatitis is a chronic, multifactorial, relapsing inflammatory
skin condition which is one of the main known health problem worldwide. Atopic dermatitis
lesions are frequently colonized by Staphylococcus aureus and Staphylococcus epidermidis.
Their susceptibility to form biofilms, ability to form adhesive skin colonies which
lead to extremely resistant to antibiotics and immune responses. Formation of skin
Biofilm resulted in complex bacterial communities that have unique effects on human
keratinocytes, mouse fibroblasts and host immunity.
Aims: The aims of this study to confirm the specificity of S. aureus or its secreted
factors in induction of pro-inflammatory cytokines IL-33, TSLP and toxicity on human
keratinocytes and mouse fibroblast. The second aim to study the inhibitory effect
of co-culture of S. epidermidis with S. aureus in term of production of pro-inflammatory
cytokines and toxicity.
Method and materials:
Human epidermal keratinocytes and mouse embryonic fibroblasts cell lines from 3T3
were used as a control strain to examine production of inflammatory response (IL-33
and TSLP) and cell death induced by S. aureus in the presence and absence of S. epidermidis.
TSLP and IL-33 were detected by ELISA and the apoptosis of S. aureus and S. epidermidis
on these cells was evaluated by flow cytometry.
Result: Recent findings propose the important role of skin biofilms in the pathogenesis
of atopic dermatitis. S. aureus have been found to induce secretion of pro-inflammatory
cytokines and cause apoptosis of human keratinocytes and mouse fibroblasts. Presence
of S. epidermidis as skin biofilm found to protects the human keratinocytes and mouse
fibroblasts from induction of pro-inflammatory cytokines and cytotoxicity.
Conclusions and future work: S. aureus are essential in production of inflammatory
response and cell death of mouse fibroblasts and human keratinocytes. Future work
will be carried out to identify the soluble factors that responsible in induction
of pro-inflammatory cytokines. In addition, more studies are needed to be able to
understand the mechanism by how S. epidermidis reduce the induction and cytotoxicity
caused by S. aureus.
(205) Submission ID#812492
Evaluation of the effect of an Allergy/Immunology (A/I) Training Program on the diagnosis
of antibody deficiencies and the Criteria for the use of Immunoglobulin Replacement
Therapy (IgRT)
Ricardo Sorensen, MD1, Paul Nisbet, PhD2
1Professor Emeritus of Allergy-Immunology, Louisiana State University Health Sciences
Center/Louisiana State University Health Science Center, New Orleans
2Research Consultant/One Research, LLC
Abstract/Case Report Text
OBJECTIVES: Immune globulin replacement therapy (IgRT) is indicated for the treatment
of antibody deficiencies. The decision to initiate IgRT in adult patients, in whom
arbitrarily defined diagnostic criteria for antibody deficiency syndromes are not
fulfilled, is subject to interpretation and decision differences reported by immunologists
world-wide. In this study, we explored whether training in one particular program
would decrease the variability in diagnostic and treatment approaches seen in the
responses to two nationwide questionnaires in the UK and the USA.
METHODS: A 10-minute online survey originally administered to a cross-sectional sample
of 203 US allergists/immunologists (USA/I) in January, 2019, was also answered by
43 A/I subspecialists who had trained in the last 25 years at the Louisiana State
University Health Science Center Allergy Immunology training program in New Orleans
(LAA/I). Respondents were asked questions on patient assessment, antibiotic use, initial
IGRT, and immune response assessment in decision-making to prescribe IgRT. USA/I participants
were recruited from the Dynata physician professional panel. LAA/I participants were
recruited by the Louisiana Primary Immunodeficiency Network (LAPIN).
RESULTS: Overall, LAA/I had consensus responses to the various practice questions
close to 90% of the time, but outliers were always present, as was also observed in
the USA/I. There was a higher frequency in the reported care of patients as described
in the questionnaire by LAA/I.
Over 98% of LAA/I assessed vaccine responses prior to commencing IgG replacement vs
only 90% of USA/I p < 0.5. All LA A/I used the pneumococcal vaccine for assessment
purposes while few used tetanus and Hemophilus influenza, and none used meningitis
or salmonella vaccines. These vaccines were still used by some of USA/I. A high level
of concordance was observed among all respondents in that only few regarded pneumococcal
antibody testing as the definitive test to commence IgRT. High resolution chest CT
scan was used more often by LAA/I before starting IgRT. Assessment of effectiveness
of IgRT was decided after only 3 months by more USA/I, vs LAA/I, who tended to wait
6 months to decide to continue or discontinue IgRT.
CONCLUSIONS: All A/I responders saw a significant number of patients who do not conform
to strict diagnostic criteria for antibody deficiency syndromes. There is diversity
in the approach of USA allergists/immunologists in determining the indication for
IgRT for non-classical antibody deficient patients. LAA/I responses made It obvious
that post graduate influences always play a role in shaping the way A/I practice evolves
after graduation.
Drawing on clinician experiences through questionnaires offers a valid contribution
to developing consent approaches to improve patients’ clinical conditions. Diagnostic
criteria and treatment guidelines would benefit from practice-based realistic recommendations
based on A/I experience.
(206) Submission ID#812494
A PU.1 Reporter Cell Line Models the Transcriptional Impacts Of Human SPI1 Mutations
Piyush Pillarisetti, n/a1, Carole Le Coz, PhD2, Brian Nolan, MD3, Gregory Poon, PhD4,
Neil Romberg, MD5
1Undergraduate Student/Division of Allergy and Immunology, The Children's Hospital
of Philadelphia
2Postdoc/Division of Allergy and Immunology, The Children's Hospital of Philadelphia
3Attending Physician, Rheumatology/Ann & Robert H. Lurie Children's Hospital of Chicago
4Associate Professor/Department of Chemistry, Georgia State University, Atlanta, United
States
5Assistant Professor/Division of Allergy and Immunology, The Children's Hospital of
Philadelphia
Abstract/Case Report Text
Background: PU.1, a member of the ets transcription factor family, is important in
cell fate specification of multipotent hematopoietic progenitors and is encoded by
SPI1. Functionally important domains of PU.1 include its C-terminal Ets DNA-binding
domain and protein-protein interaction-regulating PEST domain. PU.1 exerts its transcriptional
regulation by binding to the purine-rich 5’-GGAA/T-3’ λβ DNA consensus sequence (λβ
DNA) of hematopoietic lineage-specific enhancer sites via its Ets domain. Pathogenic
somatic SPI1 mutations are common in myeloid leukemias and classical Hodgkin lymphoma.
We recently identified several SPI1 variants in patients with novel disease we call
PU.1-mutated agammaglobulinemia (PU.MA).
Objective: To assess the impacts of SPI1 mutants on transcription we sought to developed
PU.1 reporter cell lines.
Methods: To determine if a PU.1 variant proteins could bind-λβ DNA and drive transcription
we transfected HEK293 cells, which lack native PU.1, with two vectors, one contained
mutated IRFP-2A-SPI1 constitutively driven by the CMV promotor and the other contained
EGFP which was placed under control of PU.1-specific λβ promoter/enhancer DNA sequence.
Patient SPI1 variants were introduced via site-directed mutagenesis. To determine
if mutant PU.1 interferes with the transcriptional activitiy of wild-type PU.1, we
created a second PU.1 reporter line transfected with mutated IRFP-2A-SPI1, λβ-EGFP
and unmutated mCHERRY-2A-SPI1.
SPI1 transfection efficiency and EGFP expression were evaluated by flow cytometry.
Stability of PU.1 expressed in lines was confirmed with immunoblots.
Results: We introduced 5 SPI1 mutations identified in immune deficient patients into
IRFP-2A-SPI1. The frequency of EGFP expressing cells from G109Sfs* (6.07%), Y122x
(2.04%) H212P (6.68%), V242G (6.54%), and K246del (10.6%) expressing lines were significantly
decreased compared to WT PU.1 (29.2%) (p < 0.001). Mean geometric fluorescence values
for mutated lines were also similarly diminished (p < 0.05).
The frequency of EGFP expressing cells transfected with unmutated mCHERRY-2A-SPI1
was not significantly altered by co-transfection with mutated IRFP-2A-SPI1.
Western blots of mutant line lysates revealed that PEST-domain PU.1 mutants (G109Sfs*78
and Y122x) were expressed at very minimal levels while Ets-domain PU.1 mutants were
expressed at similar levels as WT PU.1.
Conclusion: Taken together, these data suggest PU.MA SPI1 mutations are damaging and
encode either destabilized truncated proteins or transcriptionally inert full-length
PU.1 with ETS domain amino substitutions. Hence, PU.MA PU.1 mutants exert their effects
through haploinsufficiency.
(207) Submission ID#812498
A Case of Lymphoproliferation with ALPS-like Phenotype
Irina Dawson, MD1, Emma WestermannClark, MD2, Warit Jithpratuck, MD3, Vincent Giusti,
MD4, Boglarka Ujhazi, MS5, Sumai Gordon, B.S6, Krisztian Csomos, PhD7, Maurizio Miano,
MD8, Jolan Walter, MD, PhD9
1Allergy & Immunology Fellow/University of South Florida and Johns Hopkins All Children’s
Hospital
2Assistant Professor, Allergy/Immunology/University of South Florida,
3Physician, Allergy/ Immunology/Allergy Asthma Specialist, P.A
4Chair for the Arnold Palmer Hospital Center for Children’s Cancer and Blood Disorders/Department
of Pediatric Medical Education, Arnold Palmer Medical Center, Orlando Health, Orlando,
Florida, USA
5Research Associate/Department of Pediatrics, University of South Florida, St. Petersburg,
FL, United States
6Research Technician/Division of Allergy & Immunology, Department of Pediatrics and
Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla
7Research Associate/Division of Allergy & Immunology, Department of Pediatrics and
Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla
8MD/Hematology Unit- IRCCS Istituto Giannina Gaslini, Genoa- ITALY
9Division Chief, Pediatric Allergy/Immunology/University of South Florida and Johns
Hopkins All Children’s Hospital
Abstract/Case Report Text
Background: Autoimmune lymphoproliferative syndrome (ALPS) is a rare genetic disorder
secondary to a defective FAS-mediated apoptotic pathway of mature lymphocytes. It
is characterized by chronic non-malignant lymphoproliferation in the form of lymphadenopathy
and/or splenomegaly, autoimmune manifestations such as cytopenias, increased risk
of lymphoma, and expansion of TCRαβ+ CD4-/CD8- (DNT)T-cells. Germline or somatic pathogenic
variants in FAS, FASL, and CASP10 are well described genetic defects associated with
ALPS. The definitive diagnosis for ALPS, based on the revised 2009 NIH diagnostic
criteria, include both required criteria (chronic non-malignant, non-infectious lymphadenopathy,
splenomegaly, or both and elevated TCRαβ+ DNT T-cells) and one of the primary accessory
criteria (defective lymphocyte apoptosis or mutation in the genes mentioned above).
Patients who do not meet the current diagnostic criteria are considered for ALPS-related
disorders.
Case presentation:
We report a 2-year-old male who presented with recurrent infections, splenomegaly
and chronic lymphadenopathy since 8 month of age. Due to its chronicity he was evaluated
by multiple specialists for malignant and infectious causes. Hematological workup
including bone marrow biopsy was unremarkable except for an elevated LDH level. Infectious
workup identified a past CMV infection. Clinical course is pertinent for chronic splenomegaly
which was identified incidentally at 1.5 years of age during an evaluation for intussusception.
Family history is pertinent for a father with recurrent infections, paternal grandmother
with thrombocytopenia of unknown cause requiring platelet transfusions, and paternal
cousin with neutropenia. There is no family history of lymphomas.
History of chronic lymphoproliferation and recurrent infections prompted an evaluation
for lymphoproliferative disorder. Full immune workup was notable for elevated plasma
IL-10 and IL-18, normal immunoglobulin levels, lymphocytes subsets, vitamin B12 level,
soluble FASL, and relative frequency (%) but borderline increased absolute count of
TCRαβ+ (DN) T-cells. In addition, he was noted to have presence of anti-platelet antibodies,
poor lymphocyte proliferation to antigens, and low pneumococcal antibody titers. Genetic
testing with a 207 PID gene panel identified a likely pathogenic heterozygous variant
in PRF1 c.487del (p.His163Thrfs*96), a heterozygous variants of uncertain significance
in CASP10 c.683C>T (p.Pro228Leu) and STIM1 c.304A>G (p.Thr102Ala). The CASP10 variant
is present in 63 alleles in gnomAD (282K total allele count) and reported deleterious
by SIFT.
Discussion: Unlike the typical ALPS presentation, characterized by dominantly lymphoproliferation
and autoimmunity, our patient’s clinical phenotype is striking for recurrent infections,
abnormal T-cell function, and poor antibody response. Our patient does not the meet
diagnostic criteria for ALPS due to normal relative frequency of DN T-cells. However,
presence of elevated of IL-10, IL-18, platelet autoantibodies raise concern for ALPS-related
disorder. In addition, family history of recurrent infections and cytopenias raises
concern for familial autoimmunity and ALPS-like phenotype. Although CASP10 is associated
with autosomal dominant and autosomal recessive ALPS, the role of this VUS is yet
to be determined.
Conclusion: We continue to investigate the pathogenicity of our novel CASP10 VUS.
Further studies include pedigree analysis, Fas apoptosis assay and apoptosis pathway
testing to assess for the etiology of this ALPS-related disorder. (word count 487,
max 500)
Laboratory studies:
Absolute αβ TCR+ DNT
61 cells/ μL
37 cell/uL
Absolute αβ TCR+ DNT B220+
19 cells/ μL
0.0
% αβ TCR+ DNT
2%
0.9%
% αβ TCR+ DNT B220+
0.6%
0.0
Soluble Fas-Ligand
439 pg/mL (69-493)
IL-10
11.8 pg/mL (<2)
IL-18
848 pg/mL (89-540)
Vitamin B12
721 pg/mL (180-914)
(208) Submission ID#812503
Retrospective Analysis of the Immunologic Evaluation in Patients Receiving Ocrelizumab
Nancy Yang, BS1, Jocelyn Farmer, MD, PhD2, Sara Barmettler, MD2
1Clinical Research Coordinator/Massachusetts General Hospital
2Physician/Massachusetts General Hospital
Abstract/Case Report Text
Rationale: Ocrelizumab is a recombinant anti-CD20 monoclonal antibody, which binds
to a different, but overlapping CD20 epitope than rituximab. There have been increasing
reports evaluating hypogammaglobulinemia and morbidity and mortality in patients receiving
rituximab, but there is a paucity of data on hypogammaglobulinemia in patients treated
with ocrelizumab.
Methods: We performed a retrospective review of patients who received ocrelizumab
in our healthcare system. We evaluated the demographics, indication for ocrelizumab,
frequency of immunologic evaluation, and hypogammaglobulinemia pre- and post-ocrelizumab.
Hypogammaglobulinemia was stratified as mild (IgG < 600mg/dL or less than lab reference
range), moderate (IgG < 400mg/dL) or severe (IgG < 200mg/dL).
Results: We identified 185 patients who received ocrelizumab for multiple sclerosis
(average number of ocrelizumab cycles = 4; range 1-9 cycles). There were 120 (65%)
female patients, with a mean age of 49 years old (range 23-74; standard deviation
±13). 135/185 (73%) patients had their immunoglobulins evaluated at any time prior
to ocrelizumab. 154/185 (83%) patients had their immunoglobulins evaluated at any
time following ocrelizumab. Of these, 27/135 (20%) patients had hypogammaglobulinemia
(low IgG) pre-ocrelizumab. The majority of these patients had mild hypogammaglobulinemia
(25/27 [93%]), with only 1/27 (4%) patients having moderate hypogammaglobulinemia,
and 1/27 (4%) patients having severe hypogammaglobulinemia pre-ocrelizumab. Following
ocrelizumab, 35/154 (23%) patients had hypogammaglobulinemia, with again the majority
of patients having mild hypogammaglobulinemia (34/35 patients [97%]), and 1/35 (3%)
patient had moderate hypogammaglobulinemia. In the 116 patients who had both pre-
and post- ocrelizumab immunoglobulins evaluated, immunoglobulin levels decreased post-ocrelizumab
(p=0.0008).
Conclusions: Approximately 1 in 5 patients receiving ocrelizumab have hypogammaglobulinemia
either pre- and/or post-ocrelizumab. There was a statistically significant decrease
in immunoglobulin levels post-ocrelizumab. Future studies are needed to evaluate infectious
outcomes and complications to see if the hypogammaglobulinemia is associated with
inferior outcomes with excess morbidity and mortality.
(209) Submission ID#812509
DOCK8 Deficiency Presenting As Chronic, Diffuse, And Recalcitrant Molluscum Contagiosum
Paulina Tran, DO1, Marissa Perman, MD2, Jennifer Heimall, MD3, Nancy Bunin, MD4, Sarah
Henrickson, MD, PhD5
1Allergy and Immunology Fellow/Childrens Hospital of PhiladelphiaDepartment of Pediatrics,
Allergy Immunology Division, Children’s Hospital of Philadelphia
2Clinical Director, Pediatric Dermatology/Department of Pediatrics, Division of General
Pediatrics, Section of Dermatology, Children’s Hospital of Philadelphia; Perelman
School of Medicine at the University of Pennsylvania
3Clinical Immunologist/Department of Pediatrics, Allergy Immunology Division, Children’s
Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania
4Clinical Oncologist/Department of Pediatrics, Oncology Division, Children’s Hospital
of Philadelphia; Perelman School of Medicine at the University of Pennsylvania
5Assistant Professor/Department of Pediatrics, Allergy Immunology Division, Children’s
Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University
of Pennsylvania, Philadelphia, PA
Abstract/Case Report Text
Introduction: Dedicator of cytokinesis (DOCK) 8 deficiency is an autosomal recessive
hyper-IgE syndrome that typically presents as severe atopy, recurrent Staphylococcus
aureus abscesses, pneumonia, viral cutaneous infections, and malignancies. Here we
present a case of DOCK8 deficiency presenting as chronic, recalcitrant molluscum contagiosum.
Case Description: A 6 y.o. female with severe eczema and a 12-month history of severe
molluscum contagiosum was referred to our office. Of note, she was initially seen
in immunology clinic at age 2 due to an episode of pneumonia requiring hospitalization
and immune evaluation demonstrated mild hypogammaglobulinemia, elevated IgE (8035)
and hypereosinophilia. She was subsequently lost to follow up. Three years later,
she was referred by dermatology to immunology for diffuse and recalcitrant molluscum
contagiosum in the context of challenging to manage eczema, having failed multiple
therapies for molluscum including imiquimod, Zymaderm, cimetidine, and curettage of
roughly 100 lesions under sedation. She had also had frequent bacterial superinfection
of her atopic dermatitis. She was fully immunized and live vaccines were well tolerated.
Her family history was negative for primary immune deficiency and consanguinity, with
multiple healthy siblings. Her presenting physical exam was notable for widespread
eczematous patches and thinly lichenified plaques over her face, chest, arms, back
and legs with innumerable, variably sized (many large), juicy, pearly, pink and skin
colored, umbilicated papules. The constellation of severe and exuberant cutaneous
viral infection, eczema, food allergies, elevated IgE and hypereosinophilia and hypogammaglobulinemia
raised concern for combined immunodeficiency. Her immune profile demonstrated low
CD8T cells, low switched memory B cells, low IgM, reduced vaccine titers, impaired
T cell function by mitogen stimulation and normal count of Th17 cells. A whole exome
sequence revealed compound heterozygous mutations in DOCK8, including a large deletion
and a frameshift mutation in DOCK8 with absent DOCK8 protein by flow cytometry. Bacterial
and fungal prophylaxis and subcutaneous Ig replacement was started. A decision was
made with the family to pursue hematopoetic stem cell transplant (HSCT). Her sibling
was a 10/10 match and she underwent matched sibling donor HSCT conditioned with busulfan,
fludarabine and anti-thymocyte globulin. She is currently 18 months post-transplant
and doing well with 100% engraftment, no symptoms of GVHD, and she is off immune suppression
with normal T, NK and B cell counts, as well as normal IgG, IgA and IgM levels. Her
eczema and Molluscum entirely resolved post-HSCT.
Conclusion: In patients presenting with severe, recalcitrant molluscum contagiosum
in the setting of severe atopic disease it is important to consider primary immunodeficiency
in the differential and genetic testing should be part of the initial evaluation.
(210) Submission ID#812510
Early Onset Autoimmune Enteropathy In An Infant With CTLA4 Haploinsufficiency
Alice Chau, MD, MSE1, Clint Dunn, MD2, Kestutis Aukstuolis, DO1, Katherine Altman,
DO1, Jessica Saunders, MD3, M. Cristina Pacheco, MD4, Marina Panopoulos, MD5, David
Suskind, MD6, Aleksandra Petrovic, MD4, Troy Torgerson, MD, PhD7, Maria Teresa de
la Morena, MD6, Suzanne Skoda-Smith, MD4
1Allergy and Immunology Fellow/University of Washington
2Allergy and Immunology Fellow/University of Washingotn
3Pathology Fellow/Seattle Children's Hospital
4Associate Professor/Seattle Children's Hospital
5Assistant Professor/Seattle Children's Hospital
6Professor/Seattle Children's Hospital
7Associate Professor/University of Washington, Immunology
Abstract/Case Report Text
Rationale: CTLA4 is an inhibitory receptor of T-cell proliferation, integral to immune
homeostasis and tolerance. Germline heterozygous loss-of-function mutations result
in immune dysregulation, immunodeficiency, and lymphoproliferation. Aggregated data
from a cohort of 133 patients found the median symptom onset age was 11 years (range
< 1–59 years); only one patient presented under 1 year old at 3 months with recurrent
respiratory and gastrointestinal infections , .
Methods: Retrospective chart review, including immunology, pathology, and genetic
analysis.
Results: A full-term 6-month-old boy with normal TREC screen and maternal familial
history of CTLA4 haploinsufficiency was hospitalized for failure to thrive (height
and weight < 2%) and refractory diarrhea starting at 4 months. Stool calprotectin
515mg/kg (normalT (p.R51). Endoscopies demonstrated flattened duodenal villi with
biopsies yielding CD3-predominant lymphocytic infiltrates throughout. Expression of
Treg FOXP3 was significantly decreased and CTLA4 expression was also decreased by
flow cytometry.
Diarrhea and weight gain initially improved with continuous elemental formula by nasogastric
tube. At 7 months of age, patient developed Clostridium difficile colitis with clearance
of toxin PCR with a course of metronidazole. A gastronomy tube was placed at eight
months of age, but weight gain remained poor. Although infectious surveillance remained
negative, patient developed hypergammaglobulinemia with IgG level of 1120 mg/dL with
serological autoimmune screens pending. Repeat endoscopy yielded unchanged findings
at 10 months and it is planned to initiate CTLA4-Ig (abatacept) at 10 mg/kg.
Conclusions: CTLA4 haploinsufficiency exhibits a wide variance in phenotypes and age
of onset. We present one of the earliest published patients who developed autoimmunity,
requiring early initiation of CTLA4-Ig. Indications for abatacept therapy as well
as the timing of bone marrow transplant have not been established in very young patients.
Further investigation needed to establish clinical protocols in this age group as
well as the etiology of the variability in disease penetrance and expression.
(211) Submission ID#812513
Inflammatory Cytokine Expression in CD4+ T-cells of Patients with Chronic Granulomatous
Disease
Jacqueline Squire, MD1, Christopher Santarlas, BS2, Valentine Santarlas, BA, BS3,
John Cannon, PhD4, Jennifer Leiding, MD5
1Allergy and Immunology Fellow/University of South Florida - All Children's Hospital
2Research Technician/University of South Florida
3Research Administrator/University of South Florida
4Research Lead/University of South Florida
5Associate Professor/Division of Allergy and Immunology, Department of Pediatrics,
University of South Florida at Johns Hopkins-All Children’s Hospital, St Petersburg,
FL
Abstract/Case Report Text
Background: Chronic granulomatous disease (CGD), due to defects in NADPH oxidase subunits,
is associated with increased susceptibility to severe bacterial and fungal infections.
Along with infections, patients with CGD also suffer from a wide range of inflammatory
conditions including inflammatory bowel disease, inflammatory respiratory disease,
and systemic autoimmune disease. Previous studies have demonstrated increased inflammatory
cytokine production in macrophages, monocytes, neutrophils, and CD4+ T-cells of patients
with CGD. The precise mechanisms for inflammatory disease in CGD and how they correlate
with clinical symptoms are not known. Additionally, there are no established biomarkers
that correlate with inflammatory manifestations or control of disease. We aimed to
determine if increased inflammatory cytokines correlates with clinical symptoms.
Methods: Peripheral blood mononuclear cell (PBMC) aliquots were collected from 12
CGD patients with varied clinical statuses and 5 healthy donors. Samples were prepped,
incubated, stimulated, stained, and fixed before being analyzed via flow cytometry
to determine proportions of the intracellular cytokines IL-6, IL-10, IL-17A, IFNγ,
and TNFα relative to the total CD4+ population per sample. Nine patients had single
time points of intracellular cytokine activity and 3 patients had multiple time points
analyzed. Samples were analyzed and compared to the healthy control group and across
clinical status.
Results: Of the 12 CGD patients, 4 had X-linked and 8 autosomal recessive CGD (6 p47phox
and 2 p22phox mutations). Four CGD patients had active colitis, 3 were being treated
with immunosuppression, including corticosteroids, at the time of PBMC collection.
Patients with CGD demonstrated statistically significant elevations in the percentage
of intracellular IL-6 (0.37% vs. 0.26%, p=0.035) and IL-17A (1.24% vs. 0.71%, p=0.0001)
in stimulated CD4+ T-cells. TNFα, IFNγ, and IL-10 were not statistically different
between CGD patients and healthy controls. TNFα, IFNy, IL-10, and IL-17A expression
in patients with CGD who had active colitis or history of colitis were increased as
compared to CGD patients without a history of colitis but did not reach statistical
significance. In two patients, IL-17A expression that was elevated pre-HCT normalized
post-HCT.
Discussion: The mechanism for increased susceptibility to inflammatory disorders in
patients with CGD has not been well elucidated. Our results agree with previous studies
demonstrating increased IL-6 and IL-17A production from CD4+ T-cells in patients with
CGD indicating a pro-inflammatory state in these patients at baseline. Also, there
appears to be an increase in TNFα, IFNy, IL-10, and IL-17A expression from CD4+ T-cells
that correlates with presence of inflammatory disease vs. those without inflammatory
disease indicating that these cytokine perturbations may be able to serve as biomarkers
of disease activity. A larger sample size with prospective collection will be analyzed
in the future.
Figure 1. Percentage of cytokine producing CD4+ T-cells in patients with chronic granulomatous
disease (CGD) compared to healthy donors. A. Percentage of IL-6 positive CD4+ T-cells,
*p=0.035. B. Percentage of IL-17A positive CD4+ T-cells, **p=0.0001.
(212) Submission ID#812521
A Case of G6PC3 Congenital Neutropenia, Misdiagnosed As Evans Syndrome
Juanita Valdes Camacho, MD1, Rondeep Brar, MD2, Courtney Chapman, MD3, Sebastian Fernandez-Pol,
MD, PhD4, Katja Weinacht, MD, PhD5, Yael Gernez, MD, PhD6
1Allergy and Immunology Fellow/Stanford University HealthCare
2Clinical Associate Professor, Division of Hematology, Medicine, Stanford University/Stanford
3Hematopathology Fellow/Stanford
4Clinical Assistant Professor, Pathology/Stanford
5Assistant Professor, Division of Pediatric Stem Cell Transplantation and Regenerative
Medicine/Stanford University
6Clinical Assistant Professor, Division of Allergy, Immunology, and Rheumatology/Stanford
Abstract/Case Report Text
Background: Glucose-6-phosphatase catalytic subunit 3 (G6PC3) deficiency, is characterized
by severe congenital neutropenia, recurrent bacterial infections, mild intermittent
thrombocytopenia and a high incidence of congenital cardiac and uro-genital defects.
We report the case of a 28-yo male with chronic neutropenia and thrombocytopenia,
who was found to have homozygous pathogenic variants in G6PC3 (c.210del, p.Phe71Serfs*46).
Unique to this case is the patient’s long history of misdiagnosis of Evans syndrome
(chronic autoimmune neutropenia with thrombocytopenia).
Case presentation: A 28-yo male with reported diagnosis of chronic autoimmune neutropenia
and thrombocytopenia since age 7 was referred to our clinic with concern for an underlying
immune dysregulation syndrome. He had a history of oral ulcers, gingivitis, recurrent
bacterial infections (otitis media, pneumonia, skin abscess) concomitant with severe
neutropenia ( < 500 cells/uL), for which he had received treatment with systemic steroids
and G-CSF since he was 9 years old. He also had history of asthma and short stature,
thought to be secondary to his chronic systemic steroid use. His physical exam was
otherwise only notable for mild gingivitis.
Workup: Previous diagnostic studies were negative for Fanconi anemia (by DEB testing)
and mutations in ELANE. Multiple bone marrow aspirates/biopsies showed normal trilineage
hematopoiesis and were otherwise unrevealing. A targeted next-generation-sequencing
panel to assess for actionable mutations in genes recurrently altered in myeloid and
lymphoid neoplasms (heme-STAMP) revealed a likely pathogenic KRAS mutation at 2% variant
allele frequency in peripheral blood. A comprehensive immune work up in our clinic
revealed normal B, T and NK subsets. IgG level was increased at 1980 mg/dl. He had
protective titers to diphtheria, tetanus, varicella and mounted 15/23 protective titers
for pneumococcal (65%). Neutrophil autoantibodies were negative. A repeat bone marrow
biopsy was now hypercellular secondary to a marked hyperplasia with increased myeloid
precursors as well as an accumulation of mature neutrophils, a subset of which showed
pyknotic nuclear alterations. However, despite the myeloid hyperplasia, the patient
was neutropenic. These findings are consistent with myelokathexis, abnormal mature
neutrophil retention in the bone marrow. Work up for genetic causes of immunodeficiency
immune dysregulation revealed homozygous pathogenic variants in G6PC3 (c.210del, p.Phe71Serfs*46),
establishing a molecular diagnosis that matches the clinical presentation of this
patient. Interestingly, repeat heme-STAMP testing on peripheral blood and bone marrow
12 months after the initial studies no longer detected the KRAS-mutated clone.
Management: Upon diagnosis of a congenital neutropenia syndrome, the patient was tapered
off steroids while G-CSF treatment was continued. Cardiac echo and abdominal/pelvic
ultrasound will complete the syndromic work-up. Pros and cons of a hematopoietic stem
cell transplant are currently being evaluated.
Conclusion: Our experience suggests that a diagnosis of congenital neutropenia due
to G6PC3 may not be straightforward in patients with neutropenia and thrombocytopenia.
A high index of suspicion and other syndromic features of G6PC3 may be clues to the
diagnosis. Screening of all combined immune deficiencies including neutropenia may
help to uncover the whole spectrum of patient with G6PC3 deficiency.
(213) Submission ID#812526
Five-Year-Old Boy with Very Early Onset Inflammatory Bowel Disease
Beth Thielen, MD, PhD1, Bazak Sharon, MD2
1Fellow in Adult and Pediatric Infectious Diseases/University of Minnesota
2Assistant Professor/University of Minnesota
Abstract/Case Report Text
The patient is a five-year-old fully immunized boy who presents for immunological
investigation of inflammatory gastritis and enteritis. He was previously healthy until
age three, when he presented to an outside facility with lower extremity edema and
hypoalbuminemia. Endoscopy revealed gastritis and duodenitis with grossly normal esophagus
and colon, resulting in a diagnosis of protein losing enteropathy. Elimination diet
was attempted with variable adherence.
He continued to follow in gastroenterology clinic with ongoing abdominal complaints
including intermittent abdominal pain, abdominal distention, vomiting and alternating
constipation and diarrhea without blood. At initial presentation, his weight was at
14% and height at 25%, but this has decreased over two years to weight < 1% and height
< 5%. Additional past medical history is notable for a documented episode of transient
left ankle swelling at age 44 months. There is no history of fevers, sinopulmonary
infections, skin lesions, invasive bacterial infections, mucocutaneous candidiasis,
recurrent viral infections or endocrine abnormalities. The family is of African-American
and Congolese ancestry. The patient has no siblings, both parents are healthy and
there is no family history of immune disorders, autoimmunity or inflammatory bowel
disease.
Additional studies revealed a normal white blood cell count with elevated monocytes,
normal hemoglobin, platelets >1000 x 109 cells/L, persistent hypoalbuminemia (1.4-2.8
g/dL), elevated C-reactive protein (20-51 mg/L), intermittently elevated erythrocyte
sedimentation rate (12-44 mm/h), negative tissue transglutaminase IgA and consistently
elevated fecal calprotectin and alpha-1-antitrypsin. Initial immune evaluation had
revealed normal dihydrorhodamine flow cytometry; elevated IgE (822) but normal IgM,
IgA, IgG and IgD; and normal T, B and NK cell numbers (CD19+ 737 cells/μL, CD4+ 1441
cells/μL, CD8+ 376 cells/μL, CD16/56+ 390 cells/μL).
Over the following two years, he underwent two additional esophagogastroduodenoscopies
and colonoscopies, which have repeatedly shown ulcerations of the stomach and duodenum
with normal esophagus and colon. Biopsies of the duodenum in at ages 3 and 4 showed
duodenal mucosa with villous blunting, crypt hyperplasia, expansion of the lamina
propria, neutrophilic inflammation, intact goblet and Paneth cells, detectable plasma
cells and absent intraepithelial lymphocytosis. CT revealed hepatosplenomegaly. CT
enterography revealed mild small bowel wall thickening and mucosal hyperenhancement.
Based on clinical history and studies, very early onset inflammatory bowel disease
was suspected. Enteral budesonide was attempted, but patient had difficulty with adherence.
He completed a 5-week course of prednisolone with temporary improvement in symptoms
but recurrence after steroids were tapered.
Due to the concern for a genetic cause of early onset inflammatory bowel disease,
whole exome sequencing was performed of proband and both parents. This revealed a
paternally inherited heterozygous pathogenic mutation in mevalonate kinase (MVK; p.Y116H)
and a maternally inherited variant of uncertain significance in Inducible T Cell Costimulator
(ICOS; p.V151L). Additional functional testing is underway to understand whether this
patient’s variants may play a role in disease pathogenesis or whether additional as-yet
unidentified genetic variants may be responsible for his immune disorder.
(214) Submission ID#812527
Gain-of-Function Mutations in STAT1: A Novel Manifestation with Pulmonary Granulomatous
Disease
Yazmin Espinosa, MD1, Fernanda Cofre, MD2, Evelyn Silva, MD3, Camila Astudillo, MD4,
Valentina Jarur, PhDc5, Cecilia Poli, MD, PhD6
1Pediatrician/Hospital Roberto del Rio
2Pediatrician, Infectious Disease Specialist/Hospital Roberto del Rio
3Immunology/Clinica Alemana
4Pediatritian/Hospital Roberto del RIo
5Graduate Student/Universidad del Desarrollo
6Asistant Profesor/Universidad del Desarrollo
Abstract/Case Report Text
Introduction Signal transducer and activator of transcription (STAT1)1 gain of function
(GOF) mutations result in increased STAT tyrosine phosphorylation and secondarily
increased response to STAT1-signaling cytokines, such as interferons determining defective
Th17 cell development and subsequent susceptibility to infections and, in many cases,
autoimmune manifestations.
Clinical manifestations of patients with STAT1 GOF are characterized by disseminated
or recurrent infections due to s. aureus, herpes viruses, mycobacteria and fungal
infections, characteristically presenting as chronic mucocutaneous candidiasis. In
addition to infectious susceptibility many patients have autoimmune manifestations
including hypothyroidism, thyroiditis, type 1 diabetes mellitus and immune cytopenias.
There is no clear correlation between STAT1 domain-specific mutations and phenotype,
and it remains unclear why GOF mutations in STAT1 result in such a wide spectrum of
clinical presentations.
Case Report Three year old female born to non-consanguineous parents at 3 years of
age is admitted to the hospital for workup of an insidious 4 month episode of persistent
mainly facial and upper limb edema associated to respiratory symptoms including cough
and dyspnea. On her medical history she had one previous episode of oral candidiasis,
one episode of pyelonephritis at 11 months and one otitis media. On exam, she had
normal height and weight for her age remarkable facial edema, pulmonary crackles,
oral thrush and multiple, small cervical, axillae and inguinal lymphadenopathies and
a palpable spleen. High resolution chest CT showed multiple bilateral parenchymal
nodules and confirmed multiple adenopathies. An abdominal US identified mild hepato-splenomegaly.
Bronchoalveolar lavage fluid was positive for S. maltophilia and multiple copies of
EBV; there was no evidence of fungi, parasites, or mycobacteria. A cardiac ultrasound
evidenced mild pericardial effusion. Biopsy of pulmonary nodules was suggestive of
lymphomatoid granulomatosis and biopsy of the pericardium showed nonspecific chronic
inflammation. EBV was positive in lung tissue and pericardial fluid. Tuberculin skin,
mycobacterial cultures in BAL and interferon-gamma release assay (IGRA) were negative
reasonably ruling out mycobacterial infection. Immune workup showed normal blood counts,
immunoglobulins and lymphocyte populations within normal ranges. Additional autoantibody
testing (ANA, ENA, ANCA) were negative. A primary immunodeficiency was suspected and
Genetic testing (Invitae PID panel) revealed a previously associated to gain of function,
heterozygous mutation in STAT1 c.820C>T (p.Arg274Trp). Both parents were negative
for this mutation indicating it occurred de novo. Intravenous immunoglobulin (IVIG)
replacement and prophylactic antibiotics were started. Lymphomatoid granulomatosis
in the setting of persistent EBV infection was treated with 2 doses of Rituximab with
excellent response and clearance of pulmonary nodules and respiratory symptoms.
Conclusions
We present the first Chilean patient with STAT1 GOF immune-dysregulation . Moreover,
to our knowledge this is the first STAT1 GOF patient presenting with lymphomatoid
granulomatosis. This is a severe pulmonary disease in which primary immunodeficiencies
including STAT1 GOF should be considered in the differential. In this case Rituximab
successfully resolved pulmonary nodules and respiratory symptoms.
Figure 1. Hi resolution Chest CT showing multiple bilateral pulmonary nodules and
small bronchiectasis.
(215) Submission ID#812530
Use of recombinant human IL-18 Binding Protein In A Pediatric Patient With X-Linked
Lymphoproliferative Disease Type-2
Jeffrey Balduzzi, MD1, AJ Taxter, MD2, EJ Schiffrin, MD3, EM Behrens, MD4, Rebecca
Marsh, MD5, JW Caldwell, DO6
1Physician Fellow/Section of Pulmonary, Critical Care, Allergic and Immunological
Diseases, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem,
NC
2Assistant Professor/Pediatric Rheumatology Wake Forest Baptist Brenner Children’s
Hospital, Winston-Salem, NC.
3Medical Director/AB2 Bio LTD. EPFL, Lausanne, Switzerland.
4Division Chief of Rheumatology/Children’s Hospital of Philadelphia, Philadelphia,
PA.
5Clinical Director, Primary Immune Deficiency Program/Department of Pediatrics, University
of Cincinnati, Cincinnati, Ohio; Division of Bone Marrow Transplantation and Immune
Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
6Director of Allergy/Immunology/Section of Pulmonary, Critical Care, Allergic and
Immunological Diseases, Wake Forest Baptist Medical Center, Medical Center Boulevard,
Winston-Salem, NC
Abstract/Case Report Text
A 14 year-old male with a history of XLP-2 was diagnosed at age 4 after EBV induced
HLH. A four base deletion mutation was identified in the XIAP/BIRC4 gene. He was evaluated
for consideration of bone marrow transplantation, the decision for which was ultimately
deferred due to both lack of HLA matched donors and anecdotal report of poor outcomes
for HSCT in XIAP patients. The patient recovered from his first HLH. There was persistence
of mild hepatosplenomegaly but otherwise clinical stability and monitored expectantly
until the age of 12. At that time he presented with fever, left knee and ankle arthritis.
He underwent arthrocentesis of the left knee and left ankle, both aspirates were sterile,
with notable leukocytosis with heavy neutrophilic predominance. An extensive rheumatologic
and infectious workup was non-diagnostic. Both sIL-2R and IL-6 were elevated, 5,026
units/mL ( < 1105) and 44pg/mL ( < 6), respectively. He was treated with systemic
corticosteroids, ultimately arthritis resolved after 2 months. At age 13 he presented
for the first time with periorbital pain and conjunctival injection of the left eye
that persisted after minor trauma. He was found to have non-granulomatous uveitis,
which responded ultimately to systemic corticosteroid. He then presented at age 14
with fever and right knee and great toe arthritis. Again he underwent arthrocentesis
which revealed aseptic arthritis, and at that time was started on Anakinra (anti IL-1β)
and prednisone. There was clinical improvement over several weeks followed by return
of right knee arthritis, coupled with onset of symptomatic uveitis of the left eye.
Despite systemic corticosteroids and Anakinra and IL-1 blockade, the patient was again
admitted shortly thereafter to the hospital with arthritis, fevers, rash and abdominal
pain. There was concern for evolving HLH and the patient was ultimately transferred
to Cincinnati Children’s for further evaluation and treatment. Pertinent inflammatory
biomarkers at that time included sIL-2R of 3,394 units/mL and IL-18 level of 9,624
pg/mL. In addition to Anakinra and systemic corticosteroids, the patient was started
on Tadekinig alfa (recombinant human IL-18 binding protein) as part of a prospective
study. HLH flare ultimately resolved without use of antineoplastic agents, and the
patient was discharged home. Soluble IL-2R levels since normalized, and IL-18 levels
decreased to less than 1000 pg/mL. The patient has been doing well on Anakinra and
Tadekinig alfa, though continues to experience mild to moderate right knee effusion.
This case suggests IL-18 inhibition may be an effective therapeutic approach for patients
with XIAP deficiency.
(216) Submission ID#812531
Development of a Clinically Validated Test for Dendritic Cell Enumeration
Crescent Isham, BS1, Attila Kumanovics, MD2, Amir Sadighi Akha, MD, D.Phil.3
1Developmental Technologist/Mayo Clinic
2Assistant Professor of Laboratory Medicine and Pathology/Mayo Clinic
3Consultant, Division of Clinical Biochemistry & Immunology/Mayo Clinic
Abstract/Case Report Text
Dendritic cells (DCs) are a group of circulating and tissue resident cells that play
a critical role in both innate and adaptive immune responses. DCs include two major
subsets: myeloid (or classical) and plasmacytoid, mDC and pDC respectively. These
subsets perform distinct in vivo functions and promote different effector functions
in response to pathogens. mDCs can capture and present antigens to CD4+ T cells and
cross-present them to CD8+ T cells. They are also a source of inflammatory cytokines.
pDCs take part in priming of anti-viral T cells and are the major source of type I
interferons.
DC deficiency is a diagnostic component of several genetically defined immunodeficiencies,
including GATA2 deficiency, IRF8 deficiency, STAT3 GOF, IKZF1 deficiency, HYOU1 deficiency,
reticular dysgenesis due to AK2 mutations and WHIM syndrome. In addition, unexplained
monocytopenia can be a relevant clue in detecting DC deficiency. Currently, the full
range of immune defects caused by DC deficiency is not established, but the availability
of a clinically validated assay can help mitigate the diagnostic challenge.
To address this diagnostic need, we have developed a single platform test to enumerate
mDCs, pDCs and monocytes. The method consists of a whole blood no wash assay with
a laboratory-developed polychromatic monoclonal antibody panel. Addition of flow count
beads allows us to report the absolute count of each evaluated population per microliter
of blood. In this panel, pDCs are defined as CD45+, Lin2neg, HLA-DR+, CD123hi; mDCs
as CD45+, Lin2neg, HLA-DR+, CD11c+; and monocytes as CD45+, CD14+-low. Lineage 2 (Lin2)
consists of CD3, CD14, CD19, CD20 and CD56. Isotype controls to HLA-DR, CD11c, and
CD123 are included in this 4-tube test. A daily in-house normal donor is included
on each run.
In order to establish a reference range for the assay, mDC, pDC and monocyte enumeration
was performed on blood obtained from 227 unique normal donors. This group included
164 adults between 18-78 years of age and 63 pediatric donors from 4 months to 17
years of age. The age of the donors was distributed across the decades of life. Within
the adult population, 52% were female, whereas 60% of the pediatric recruits were
female. Reference ranges were calculated using quantile regression methods with a
95% confidence interval on the middle 95% of the range.
We have confirmed the clinical utility of this test by detecting several patients
with established primary immunodeficiency diagnoses.
We believe that the availability of this clinically validated test at a US clinical
reference laboratory will be beneficial in identifying patients with potential immunodeficiencies
involving dendritic cells and/or monocytes.
(217) Submission ID#812544
Successful Management of Primary Hemophagocytic Lymphohistiocytosis by Ruxolitinib,
a JAK Inhibitor
Louis Marois, MD, PhD1, Fabien Touzot, MD, PhD2, Marie-Paule Morin, MD2, Jean-Jacques
De Bruycker, MD2, Isabel Fernandez, PhD2, Henrique Bittencourt, MD, PhD2, Elie Haddad,
MD, PhD2, Pierre Terra, MD, PhD2, Hélène Decaluwe, MD PhD FRCPC3
1Postgraduate Resident Year 4/Montreal University
2Professor/Montreal University
3Associate Professor of Pediatrics/University of Montreal, Sainte-Justine University
Hospital
Primary hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyper-inflammatory
disease mainly caused by defects in genes of the granule cytotoxic pathway, inducing
extreme inflammation and massive tissue infiltration by activated T cells and macrophages.
Hematopoietic stem cell transplantation (HSCT) is the only available curative treatment
with a an overall survival of 60-70%. As success of HSCT is dependent on complete
control of the disease prior to transplantation, the development of targeted and more
potent anti-inflammatory treatments would be a major advance in the treatment of HLH.
More recently, pre-clinical studies in HLH murine models demonstrated therapeutic
efficacy of ruxolitinib, a Janus Kinase (JAK)-1/2 inhibitor, on HLH manifestations
(1-3). Ruxolitinib is licensed to treat hematological malignancies and its pharmacokinetic
has already been documented in the pediatric population.(Loh Pediatrr Blood Cancer
2015) In June 2019, we evaluated a febrile 15-month old girl for a suspicion of incomplete
Kawasaki disease. She presented with 5 criteria of HLH: (i) prolonged fever > 38.5°
C, (ii) splenomegaly, (iii) profound pancytopenia, (iv) increased triglyceride and
reduced fibrinogen levels, (v) hemophagocytosis in her bone marrow biopsy; but only
modestly elevated ferritin levels (less than 500 ·g/L). Lumbar puncture and brain
MRI were negative. Flow cytometry revealed the presence of activated HLA-DR+ CD8 T
cells and the absence of perforin expression by CD8 T and NK cells. Perforin deficiency
was confirmed genetically with the presence of two rare variants in PRF1 (c.445G>A
and c.116C>A). She was initially treated with solumedrol (1-2 mg/kg/day) which corrected
the anemia, thrombocytopenia and normalized the CRP. In the absence of neurological
involvement and infectious trigger, ruxolitinib was initiated at a dose of 50 mg/m2/day,
in combination with dexamethasone (10 mg/m2/day). This treatment led to rapid normalization
of the neutropenia (48 hours), complete resolution of the splenomegaly (10 days) and
disappearance of HLH biological markers (triglycerides levels in 1 week, activated
HLA-DR+ CD8 T cells in 2 weeks, fibrinogen levels in 1 month), without the need for
etoposide or serotherapy. Dexamethasone was weaned every two-weeks and stopped after
8 weeks. Ruxolitinib was well-tolerated with no side effects. While in complete remission
of her HLH, the patient then received alemtuzumab (0.5 mg/kg total dose) and a fludarabine-based
myeloablative conditioning regimen. Ruxolitinib was weaned over one week, and a 9/10
unrelated transplant was performed with success. The immediate post-transplant period
was complicated by a veno-occlusive disease that responded rapidly to defibrotide
and a corticosteroid-resistant skin and ocular graft-vs-host disease (GVHd) despite
a prophylaxis with ciclosporine and mycophenolate mofetil. GVHd was controlled by
the reintroduction of ruxolitinib. At 3 months post-HSCT, her chimerism is 100% donor.
To our knowledge, this case is the first description of a patient with primary HLH
successfully treated in first intent by a combination of dexamethasone and ruxolitinib
prior to HSCT. Our observation suggests that this targeted and less-toxic treatment
regimen, that does not include etoposide nor high-dose alemtuzumab, is effective,
well-tolerated and could be used in first intent to treat primary HLH.
Acknowledgments: We want to thank Bénédicte Neven, Necker-Enfants Malades, France
and Kim Nichols, St Jude Children’s, USA for fruitful discussion; and the HSCT team
of the CHU Ste-Justine.
References:
Maschalidi S, et al. Blood. 2016;128(1):60-71.
Das R, et al. Blood. 2016;127(13):1666-1675.
Albeituni S, et al. Blood. 2019;134(2):147-159.
(218) Submission ID#812546
Diagnostic Yield of Whole-Exome Sequencing For 55 Patients with Primary Immune Deficiencies
Saul Lugo Reyes, MD, MS1, Ana Eunice Fregoso Zúñiga, MD2, Luis Moisés Silva Goytia,
MD3, Elisa Hierro Cascajares, MD, MS3, Marco antonio Yamazaki-Nakashimada, MD4, Aidé
Tamara Staines Boone, MD5, Selma Cecilia Scheffler Mendoza, MD, MSc.6, Edna Venegas
Martínez, MD7, Juan Carlos Bustamante Ogando, MD, MSc.8, Edgar Alejandro Medina Torres,
PhD1, Mario Ernesto Cruz Muñoz, PhD9, Chiharu Murata, MSc10, Sara Elva Espinosa Padilla,
MD, PhD11
1Researcher/Immunodeficiencies Research Unit, National Institute of Pediatrics
2Fellow/Immunodeficiencies Research Unit, National Institute of Pediatrics
3Med Student/Immunodeficiencies Research Unit, National Institute of Pediatrics
4Head of the PID clinic/Clinical Immunology Service, National Institute of Pediatrics
5Head of department/Clinical Immunology Service, Hospital de Especialidades UMAE 25
IMSS, Monterrey NL, Mexico
6Attending Physician/Clinical Immunology Service, National Institute of Pediatrics
7Attending Physician/Clinical Immunology Service at the Hospital de Especialidades
UMAE 25 IMSS, Monterrey, NL
8Attending Physician/Immunodeficiencies Research Unit, National Institute of Pediatrics
9Head of lab/Laboratory of Molecular Immunology at the Faculty of Medicine, UAEM,
Cuernavaca, Morelos, Mexico
10Researcher/Research Methodology Department, National Institute of Pediatrics
11Head of Lab/Immunodeficiencies Research Unit, National Institute of Pediatrics
Abstract/Case Report Text
INTRODUCTION: The National Institute of Pediatrics (INP) is a national referral center
for PID diseases (PIDD). At the Immunodeficiencies Research Unit we discuss and pursue
the molecular and genetic diagnoses for patients with suspected PID from all around
the country. Starting this year, we are processing and analyzing our own patients’
WES results at the Unit. Evaluating the diagnostic yield of WES, as a measure of effectiveness
or quality control, may result in process optimization and perhaps allow for better
patient selection and resource allocation.
OBJECTIVE: To describe and characterize our patients with suspected PIDD whose DNA
samples were sent out for whole-exome sequencing; to analyze and compare our WES diagnostic
yield after the first 3 batches of patients; to identify patient attributes that may
predict a positive diagnostic WES result.
METHODS: Genomic DNA was obtained from whole-blood samples of patients with suspected
PIDD from hospitals in Mexico City, Monterrey and Puebla. WES was performed using
a NG sequencer (Illumina HiSeq) in New Jersey (Admera Health, LLC), with 90% coverage
and a 50x depth of the IDT Xgen library, Human genome version 38 (December 2013).
Two FASTQ files for each patient sample were transferred back to our Unit, where the
bioinformatic workflow was completed. We used Galaxy in the cloud for quality control,
mapping & alignment, and detection of variants; Variant Effect Predictor to process,
map, annotate and filter variants; and IGV (Broad Institute) and Genome browser (UCSC)
for visualization. We defined diagnostic yield as the proportion of patients with
a genetic diagnosis after analysis of their WES results. We performed multivariate
logistic regression, tree partitioning algorithm and linear discriminant analysis
to explore differences between diagnosed and undiagnosed cases.
RESULTS: A rare, pathogenic variant in a gene known to cause a PIDD that matched the
patient’s clinical and laboratory phenotype was found in 23 of the 55 exomes, for
a diagnostic yield of 42%. Explorations with multivariate linear regression (MLR),
linear discriminant analysis (LDA), and tree partitioning algorithm (TPA) suggested
two attributes nearing statistical significance: Family affected, and Dysgammaglobulinemia.
14 studies that matched their inclusion criteria, in which the diagnostic yield ranged
from 15 to 79%. The percentage of patients who were genetically diagnosed by NGS in
mixed PID groups (our case) ranged from 15 to 46%, with a median of 25%.
DISCUSSION: WES is an effective diagnostic tool. Definitive genetic diagnoses, here
and elsewhere, impact the management, counseling, classification and epidemiology
of rare diseases including PIDD. Here, we describe the results of our first batches
of patients sequenced and analyzed in-house.
(219) Submission ID#812548
Monogenic Diagnoses of Adolescents and Adults at A Primary Immunodeficiency Transition
Clinic in Vancouver, Canada
Stephanie Erdle, MD, FRCPC1, Persia Pourshahnazari, MD2, Catherine Biggs, MD3
1Clinical Fellow/BC Children's Hospital
2Clinical Instructor/Allergy and Immunology, Department of Medicine, University of
British Columbia
3Clinical Assistant Professor/Department of Pediatrics, British Columbia Children's
Hospital, University of British Columbia, Vancouver, BC, Canada
Abstract/Case Report Text
Rationale: Primary immunodeficiencies (PIDs) are a group of genetic disorders with
heterogeneous clinical manifestations affecting both children and adults. Adults with
PIDs face high morbidity and mortality, and the period of transitioning care from
pediatric to adult providers is a particularly vulnerable time for those with chronic
illness. Improved access to genetic sequencing has the potential to improve outcomes
through treatment tailored to the patient’s specific molecular defect. Recognizing
the unique needs of this population, a PID transition clinic was established in Vancouver,
Canada in 2018. Staffed by pediatric and adult immunologists, the clinic serves adolescents
transitioning into adult care, as well as adults with suspected or known PIDs. We
sought to determine the frequency of monogenic PIDs and the impact of genetic diagnosis
on management for patients seen in this clinic.
Methods: A retrospective chart review was performed of the patients who attended the
PID transition clinic between March 2018 and September 2019. Baseline characteristics,
diagnoses of patients who underwent genetic sequencing, and the impact of a genetic
diagnosis on the patient’s treatment plan were evaluated.
Results: The charts of 54 patients were reviewed, 24 of whom had received genetic
sequencing for PID in a clinical lab facility. Seven of the 24 patients who underwent
sequencing were diagnosed with a monogenic PID. The median age at confirmatory genetic
diagnosis was 20 years (range prenatal to 55 years), with 5 patients diagnosed at
age 17 or greater. There was a mean latency of 16.1 years between symptom onset and
the age at genetic diagnosis (range = 0-34 yrs), with family member testing accounting
for 2 patients without latency of symptom onset. There were 17 patients in whom a
diagnosis was not confirmed by sequencing: 11 had variants of uncertain significance,
2 had variants confirmed benign through functional testing, and 4 patients had negative
testing results. The monogenic forms of PID seen in adolescent and adult patients
included ADA2 deficiency, chronic granulomatous disease, X-linked neutropenia, GATA-2
deficiency, X-linked agammaglobulinemia, ALPS-FAS, and STAT3 loss-of-function. Sequencing
results led to changes in treatment plans in 7/7 patients, including referral for
hematopoietic stem cell transplantation (N=1), targeted therapy (N=1), and disease-specific
antimicrobial/immune prophylaxis and/or monitoring (N=7).
Conclusions: Transition clinics allow continuity of care for adolescent PID patients,
as well as reassessment of patients with clinical histories suspicious for PID throughout
adulthood. We identified a long latency period between age at symptom onset and age
at confirmatory genetic diagnosis of patients with monogenic PIDs. It is critical
to consider genetic testing in patients of all ages with histories suspicious for
a PID, as there is a high diagnostic yield and impact on management in this population.
(220) Submission ID#812550
Ulcer of Lipschütz within Hyper IgD syndrome, A Rare Combination
Javier Carbajal, MD1, Cristiane Landim, NP2, Vitoria Crisosto, NP2, Fernanda Ribeiro,
NP2, Pamella Ribeiro, NP2, Luis Gonzales-Tamayo, MD3
1Clinica Alergia e Imunologia Dr. Javier Carbajal/Physician
2Nurse/Clínica Alergia Imunologia Javier Carbajal, Sao Paulo Brazil.
3Science Diretor Clinica Alergia e Imunologia Dr Javier Carbajal/Physician
Abstract/Case Report Text
Presentation A 15-year-old girl, presented in ambulatory consultation, with a 3-year
history of recurrent fever, influenza-like symptoms (sore throat, malaise), associated
with self-limited painful genital ulcers (just within the period of fever). The first
episode was characterized for an Fournier’s infection, requiring in-hospital treatment,
multiple surgical procedures, antibiotics and hyperbaric oxygen therapy. After that
catastrophic debut, she was diagnosed approximately 6 episodes per year pharyngitis
(with fever, malaise and sore throat) treated with corticoids, antibiotics and topic
medication. The last year, noticed that every episode of fever (total of 4) were associated
with one or several genital lesions. The patient had no relevant medical history,
she didn’t receive long-term medication, she received all immunizations, she was sexually
inactive, and hadn’t apply any topic medication or product on the vulva, there was
no trauma history, psychological medical history or sexual abuse. Episodic gynecologic
examination showed her labia minor several lesions, fibrinous, soft ulcerations on
their inner aspect, these lesions had a symmetrical appearance, known as kissing lesions;
no vulvar swelling, vaginal discharge or lymphangitis were noticed. There were no
other skin or mucous membrane lesions (Figure 1).
Investigations
Viral (HIV, HBV, HCV, EBV, CMV) and treponemal (TPHA-VDRL) serologies were negatives.
Erythrocyte sedimentation rate (ESR) and PCR analysis within ulcers episodes were
positive. Specific antibodies (Cardiolipin, Anti RO/SS-A, Anti LA/SS-B, Anti CCP,
Anti ENA, Anti Gliadin, Anti TPO Anti TPO) serologies were negative. Otherwise, important
elevation Immunoglobulin D was observed (9,3 mg/dL, twice the normal value): Mild
elevations of Immunoglobulin M and Immunoglobulin A were observed. Serum subtypes
of immunoglobulin G and immunoglobulin E were normal. Leukocytosis with monocytes
elevation and an increase of Lymphocytes B were present. (Table 1).
Discussion Lipschütz ulcers are uncommon and an often unknown entity for physicians,
but it is important to recognize and include it in the differential diagnosis of vulvar
ulcerations. This condition is characterised by self-limited painful ulcerations of
the vulva or lower vagina in adolescent or young women, non-sexually transmitted,
and usually preceded by influenza or mononucleosis-like symptoms.
Hyperimmunoglobulin D syndrome (HIDS) is characterized for unremitting fever lasting
four to seven days and the presence of palpable tender lymphadenopathy, splenomegaly,
arthralgia/arthritis, abdominal pain, and mucocutaneous manifestations. Laboratory
findings suggestive of HIDS include elevated age-specific serum immunoglobulin D (IgD)
and/or immunoglobulin A (IgA) levels, elevation of acute phase reactants, and urinary
excretion of mevalonic acid during, but not between, attacks. The diagnosis is established
if an elevated age-specific level of IgD is detected. IgA levels are typically measured
at the same time but are not required for diagnosis. Elevated serum IgD is not specific
for HIDS and can occur in patients with certain neoplastic, infectious, heritable,
and idiopathic disorders.
In the present case report, the patient was treated with colchicine, with favorable
evolution and free from new events. Levels of Ig D, platelets and monocytes remain
high.
Conclusion
We describe a young female patient presenting recurrent Lipschütz ulcers, fever and
elevation of serum immunoglobulin D, suggesting that HIDS could be associated with
genitalia ulcers.
(221) Submission ID#812552
Long Term Use of Holder Pasteurized Donor Breastmilk in A Premature Infant with SCID/Athymia,
Without CMV Transmission
Christian Wysocki, MD, PhD1
1Associate Professor/Division of Allergy and Immunology, Departments of Medicine and
Pediatrics, UT Southwestern Medical Center
Abstract/Case Report Text
This is an 8-week old male infant born at 29 weeks, birthweight 1390 g. Mother is
17 years old, G1P1 with history of type 1 diabetes, poorly controlled throughout pregnancy.
Pregnancy was additionally complicated by antepartum hypertension, but not by infection.
Prenatal ultrasound on the day of delivery indicated hypoplastic left ventricle. Echocardiogram
after delivery demonstrated single ventricle with type I truncus arteriosus. He was
also noted to have cleft palate, solitary right kidney, and hypocalcemia. Newborn
screen on day 3 of life noted undetectable TRECs. Per the screening algorithm in our
state, this undetectable result was followed by flow cytometry which showed CD3 positive
cells at 0.5% of total lymphocytes (13/mcL). CD19 positive lymphocytes were 75% (1836/mcL),
and CD16/56+ cells were 21.3% (519/mcL). Chromosomal microarray normal. A next generation
sequencing panel encompassing 105 genes did not identify a primary immunodeficiency.
The child was initially at an outside facility and was being fed with pasteurized
donor breast milk. Mother’s breastmilk had never been used. The facility was instructed
to discontinue donor breastmilk feeds and switch to formula, and preparations were
made to transfer the child to our facility. 24 hours after feeds were changed, the
child developed vomiting, bloody secretions per NG tube and increasing lactate. Abdominal
x-ray showed pneumatosis and portal venous gas. He was diagnosed with necrotizing
enterocolitis (NEC). All enteral feeds were stopped. He completed a course of broad-spectrum
antibiotic. Surgery was not required for his NEC. He was started on IV immunoglobulin,
Bactrim, and fluconazole prophylaxis.
With resolution of NEC, discussions began about re-initiation of enteral feeds. Interestingly,
despite having had donor breastmilk at the outside facility, viral studies including
CMV PCR were negative on admission and remained negative throughout his course to
that point. Maternal CMV serologies were positive, thus her milk could not be used.
Literature was reviewed on the risk of NEC with donor breastmilk versus non-breast
milk-based formulas(1), and the safety of donor breast milk was considered in detail.
Processing of donor milk used at our institution is performed according to HMBANA
guidelines, which include Holder pasteurization (62.5 °C for 30 minutes). Literature
on the effectiveness of Holder pasteurization in eliminating CMV infectivity in vitro(2),
and transmission in vivo in extremely low birth weight infants was considered(3).
Based on these considerations, the risk/benefit was considered favorable for restarting
pasteurized donor breastmilk feeds. Given his small size and young age, we had significant
concerns about using ganciclovir prophylaxis and opted to hold this and monitor weekly
CMV PCR. The child has been titrated up on these feeds, is gaining weight appropriately,
and has had weekly CMV PCRs which are negative x5 since restarting donor breastmilk.
T cells, last checked at 7 weeks of age (37 weeks gestational age) remain essentially
absent. Given the lower risk of NEC in premature infants with breastmilk-based enteral
feeds, a broader, multi-institutional study is warranted to best examine the safety
of pasteurized donor breastmilk in infants with SCID and complete DiGeorge syndrome.
(222) Submission ID#812554
The Costa Rican Registry For Primary Immunodeficiencies (1985-2019)
Oscar Porras, MD, PhD1, Gabriela Ivankovich-Escoto, MD2
1Department chief/Department of Pediatric Immunology and Rheumatology, National Children´s
Hospital "Dr. Carlos Sáenz Herrera"
2Consultant/Department of Pediatric Immunology and Rheumatology, National Children´s
Hospital "Dr. Carlos Sáenz Herrera"
Abstract/Case Report Text
The Costa Rican PID registry was established in 1985. The aim of the registry is to
collect data on epidemiology, molecular diagnosis, mortality, malignancy and treatment
from PID cases diagnosed in Costa Rica.
Methods: We analyzed the registered data from 1985 to 2019 and reported the prevalence
of active patients during the year 2019. The study was approved as CEC-HNN-024-2017.
Results: Costa Rica has a population of five million people (30% with an age below
19 years). In 2011, the Costa Rican PID represented 6% of reported cases among Latin-American
countries.
The overall prevalence of PID in Costa Rica is 3.3/100.000 inhabitants (160 PID).
Ataxia-Telangiectasia is the most prevalent (0.98, n=97), followed by antibody deficiencies
(0.72). During the period of the study, 298 PID were registered (55% males). The distribution
according to phenotype was CID 13% (n=38), CID with Syndromic Features 54% (n=161,
AT 132), Antibody Deficiencies 13% (n=38, XLA 15), Immune Dysregulation 2% (n=6),
Neutrophil Defects 4% (n=12, CGD), Osteopetrosis 13% (n=38), other 4% (FMF 1, C1qD
3). Fifty-five percent of the patients are alive. The highest mortality (68%) was
observed in the CID group. HSCT was done in 6 cases with Reticular Dysgenesis, 9 SCIDs,
1 ADA deficiency, 1 CD40L-, 2 FLH-4 (syntaxin 11 deficiency), 1 IPEX and 8 Osteopetrosis.
Nineteen patients developed malignancies, mainly non-Hodgkin lymphomas among AT patients
(74%). Other malignancies were a case with Buschke Lowenstein in a DOCK8 deficiency,
a hepatocellular carcinoma in a CD40L-, and a lymphoma in some of the FHL-4, Chediak
Higashi and PI3KRI cases.
SCID was registered in 9.8% of all PID. Costa Rica does not have newborn screening
for SCID. Twenty-eight percent of SCID patients were Reticular Dysgenesis, which form
part of the same indigenous, consanguineous family. Two of them died before an HSCT
was considered, 6 received HSCT and 2 died one-month post-transplant (HSCT done at
age older than 3 months). Four patients of this family were successfully transplanted
and are alive.
Among the other SCID cases, one was an ADA deficiency and 20 had an unknown molecular
defect. Sixteen patients died, 9 received HSCT (1 before 3 months of age). The first
SCID was transplanted in 1985. Among the SCID patients, 15 had an HSCT and 8 are alive
(47% mortality). AT is the most common PID in Costa Rica and it represents 44% of
the patients registered. Malignancy presented predominately in AT patients as expected.
It was distributed as 8 non-Hodgkin lymphomas, 1 gastric adenocarcinoma, 2 nasopharyngeal
NHL, 1 T-cell lymphoma, 1 ovarian cancer and 1 hepatoblastoma. Two AT patients had
2 malignancies (non-Hodgkin and Hodgkin lymphoma). Osteopetrosis is also very prevalent
(0.48). Mortality decreased since HSCT is performed using an haploidentical protocol
with mothers as donors (12% mortality).
Conclusions: During the study period, 298 PID were registered, mainly AT and Osteopetrosis
cases. SCID represented 12% and XLA 11% of patients. Treatment included HSCT, restitution
with IVIg, and prophylaxis with TMP/S and Itraconazole. Malignancy was 6% and 55%
of cases are alive.
(223) Submission ID#812556
Intralesional Corticosteroids As Adjunctive Therapy For Refractory Cutaneous Lesions
In Chronic Granulomatous Disease
Michelle Joseph, MD1, Filiz Seeborg, MD2, Lenora Noroski, MD,MPH3, Sarah Nicholas,
MD, MS4, Sara Anvari, MD, MB BCH BAO2, Meera Gupta, MD5, Lisa Forbes, MD6, Ivan Chinn,
MD7, Carla Davis, MD8, Mansi James, DO9, Veronica Diaz, MD9, Roman Deniskin, MD, PhD9,
Nicholas Rider, DO10
1Allergy & Immunology Fellow/Department of Pediatric Immuunology, Allergy, and Retrovirology,
Baylor College of Medicine, William T. Shearer Center for Human Immunobiology
2Assistant Professor/Department of Pediatric Immuunology, Allergy, and Retrovirology,
Baylor College of Medicine, William T. Shearer Center for Human Immunobiology
3Associate Director, Fellowship Program, Allergy and Immunology/Department of Pediatric
Immuunology, Allergy, and Retrovirology, Baylor College of Medicine, William T. Shearer
Center for Human Immunobiology
4Assistant Professor/Baylor College of Medicine, Houston, United States
5Associate Professor, Program Director/Department of Pediatric Immuunology, Allergy,
and Retrovirology, Baylor College of Medicine, William T. Shearer Center for Human
Immunobiology
6Assistant Professor/Department of Pediatrics, Baylor College of Medicine, Houston,
TX, USA and Texas Children’s Hospital, William T. Shearer Center for Human Immunobiology,
Department of Allergy, Immunology, and Retrovirology, Houston, TX, USA.
7Assistant Professor, Director Immunogenetics Program/Department of Immunology, Allergy
and Rheumatology at Baylor College of Medicine
8Associate Professor, Director Food Allergy Program/Department of Pediatric Immuunology,
Allergy, and Retrovirology, Baylor College of Medicine, William T. Shearer Center
for Human Immunobiology
9Fellow/Department of Pediatric Immuunology, Allergy, and Retrovirology, Baylor College
of Medicine, William T. Shearer Center for Human Immunobiology
10Associate Professor/Department of Pediatric Immuunology, Allergy, and Retrovirology,
Baylor College of Medicine, William T. Shearer Center for Human Immunobiology
Abstract/Case Report Text
A 15-year-old male with X-linked Chronic granulomatous disease (CGD) complicated by
severe perianal disease and proctocolitis presented with two weeks of open draining
lesions on the thighs, bilateral inguinal regions, and gluteal cleft. The wounds became
excruciating and prevented normal ambulation. The patient was admitted for IV antimicrobial
therapy, local wound care and systemic steroids. Wound cultures, throughout his course,
yielded growth of Klebsiella pneumonia, Candida parapsilosis, Malassezia globose,
Escherichia coli, Enterococcus faecalis and Staphylococcus epidermidis allowing for
directed antibiotic and antifungal therapies. Despite improvement, the wounds persisted
after several weeks of treatment.
Faced with recalcitrant cutaneous lesions despite aggressive systemic and topical
therapies, we looked to alternative options. Noting that other granulomatous diseases
show response with intralesional corticosteroid therapy, we considered this for our
patient (1, 2). For example, patients with idiopathic granulomatous cheilitis had
a complete response after three monthly injections of intralesional corticosteroids
(3). Sarcoidosis patients also improve with intra-granuloma corticosteroid injection
(4,5). Our patient received 20 mg triamcinolone acetonide injections two separate
occasions, administered in multiple open lesions at eight-week intervals. The cutaneous
lesion improvement was gradual and complete resolution of the first open wound was
noted fifty-two days from initial steroid injection.
To our knowledge, intralesional glucocorticoid therapy has not previously been used
to treat cutaneous disease in CGD patients. We are reporting the first CGD patient
with successful lesion resolution following steroid injection as part of therapy.
As such, we believe this case is significant and suggests that direct lesion injection
with glucocorticoids can add to treatment options for CGD patients with recalcitrant
cutaneous disease.
References:
1. B. Dowlati et al. “Granuloma faciale: successful treatment of nine cases with a
combination of cryotherapy and intralesional corticosteroid injection.” Int J Dermatol
1997 Jul; 36 (7): 548-51
2. DJ. Manst et al. “Intralesional steroid injection: A novel method to treat the
symptoms of idiopathic granulomatous mastitis.” American Association for Caner Research
Publications. Feb 2019
3. S. Fedele et al. “Long-term effectiveness of intralesional triamcinolone acetonide
therapy in orofacial granulomatosis: an observational cohort study.” Br J Dermatol.
2014 Apr; 170(4): 794–801
4. L. Diaz-Cabanas et al. “Sarcoidosis in the periocular scar as the first finding
of systemic sarcoidosis: Clinical-radiological characteristics.” Arch Soc Esp Oftalmol.2019
Sep;94(9):453-459
5. YJ K. et al. “A case of scar sarcoidosis of the eyelid.” Korean J ophtalmol. 2006
Dec;20(4):238-40.
(224) Submission ID#812563
Immunological Features Associated With Mono- And Biallelic Transcription Factor 3
(TCF3) Null Mutations: A Gene Dosage Effect
Shubham Goel, PhD1, Hye Sun Kuehn, PhD2, Julie Niemela, MS, MLS3, Jennifer Stoddard,
BS, MLS4, Magdalena Walkiewicz, PhD5, Morgan Similuk, ScM, CGC6, Steven Holland, MD7,
Luis Gonzalez-Granado, MD,PhD8, Sergio Rosenzweig, MD, PhD9
1Post-Doc Visiting fellow/Immunology Services, Department of Laboratory Medicine,
Clinical centre, NIH,
2Staff scientist/Immunology Service, Department of Laboratory Medicine, Clinical Center,
NIH, USA
3Medical Laboratory Technologist/Immunology Service, Department of Laboratory Medicine,
Clinical Center, NIH, USA
4Medical Laboratory Scientist/Immunology Service, Department of Laboratory Medicine,
NIH, USA
5Certified Molecular Geneticist/National Institute of Allergy and Infectious Diseases,
National Institutes of Health
6Genetic Counselor/National Institute of Allergy and Infectious Diseases, National
Institutes of Health
7Director, Division of Intramural Research; Chief, Immunopathogenesis Section/Laboratory
of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR),
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH),
8Senior Consultant/Hospital 12 octubre. Madrid
9Senior Investigator; Chief/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center,
Abstract/Case Report Text
Transcription factor 3 (TCF3) monoallelic/dominant negative (DN) mutations affecting
E47 but not E12 (the two isoforms of TCF3 protein) were originally described in patients
with absent/low B cells and agammaglobulinemia. Later, a few single patient/family
case reports described biallelic/loss of function mutations in TCF3 with absent/low
B cells, hypogammaglobulinemia and B-ALL. Herein we report an extended in-depth analysis
on immune and clinical penetrance associated with mono- and biallelic TCF3 null mutations.
We studied 3 families (A, B and C) with novel null mutations in TCF3 (NM_003200).
Family “A” consists of three children (A.II.1; 6 y.o./M, A.II.2; 3 y.o./M and A.II.3;
8 mo/F), carrying a biallelic branch point mutation (c.1451-18 A>T; p.G486Lfs*4),
causes addition of 11 intronic nucleotides followed by frameshift, inherited from
consanguineous parents (A.I.1 and A.I.2). Family “B” includes 1 patient (B.I.1; 10
y.o./F) with a de novo monoallelic nonsense mutation (c.1541 C>A; p.S514*). Family
“C” involves an adult patient (C.I.1; 53 y.o./F, familial segregation unknown) carrying
a monoallelic insertion leading to early protein termination mutation (c.599delinsGT;
p.Y200Sfs*54).
Clinical manifestations included upper and lower respiratory infections in 2/7 mutation+
individuals; a monoallelic patient (C.I.1) presented with recurrent sinusitis, and
a biallelic patient (A.II.1) presented with recurrent infections and B-ALL. Rest of
the mutation positive individuals were clinically asymptomatic.
B cell immunophenotyping in the 7 mutation+ individuals (3 bi- and 4 monoallelic)
showed low B cell numbers in 5/7 individuals (3 bi- and 2 monoallelic) while normal
on other two monoallelic patients (A.I.1 and C.I.1), and reduced class switched memory
B cells were observed in all. Serum IgG, alone or in combination with IgA and/or IgM,
were reduced in all patients. T-follicular helper cells were reduced only in patients
carrying biallelic mutations (A.II.1, A.II.2 and A.II.3) but not in any patients with
monoallelic TCF3 null mutation. T cell enumeration and function by means of proliferation
was normal in all mutation+ individuals.
No mutated (truncated) protein expression was detected from patients with either biallelic
or monoallelic TCF3 null mutations. However, wildtype TCF3 protein was detectable
in about half amount in heterozygous patients. cDNA data showed either 0/100 or 50/50
WT/mutated transcripts ratios in homozygous or heterozygous individuals, respectively,
suggesting mutated proteins instability; and all together, protein haploinsufficiency
for the heterozygous cases.
Ex-vivo, CD40L and IL21-induced plasmablast differentiation was found to be reduced
in 4/5 patients tested (1 biallelic patient A.II.2 and 3 monoallelic patients A.I.2,
B.I.1 and C.I.1). Moreover, decreased IgG, IgA and IgM production in vitro correlated
with reduced plasmablast cell differentiation.
In conclusion, all individuals carrying either mono- or biallelic null mutations have
immunological penetrance of the B cell defect. However, while clinical penetrance
was complete in patients with biallelic mutation, it was partial for those with monoallelic
TCF3 null mutation suggesting a gene dosage effect for clinical penetrance. In addition,
our study emphasizes that TCF3 is relevant to the plasmablast differentiation process
as well as for Ig production. Further studies are being conducted to evaluate the
individual roles of E12 and E47 on the immune and clinical features.
(225) Submission ID#812566
Impact of Novel STAT1 Gain-of-function D292E and K388Q mutations on the NK cell function
Alexander Vargas-Hernández1, 2, Monica G. Lawrence3, Christian A. Wysocki4, Lisa R.
Forbes1, 2
1Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
2Texas Children’s Hospital, William T. Shearer Center for Human Immunobiology, Department
of Allergy, Immunology, and Retrovirology, Houston, TX, USA.
3Division of Asthma, Allergy & Immunology University of Virginia, Charlottesville,
VA
4Division of Allergy and Immunology, Departments of Internal Medicine and Pediatrics,
UT Southwestern Medical Center/Children’s Medical Center Dallas, TX.
Background: Heterozygous gain-of-function (GOF) mutations in the STAT1 gene result
in a hyperphosphorylated state where patients develop recurrent or persistent chronic
mucocutaneous candidiasis (CMC), other cutaneous mycosis, bacterial infections, disseminated
dimorphic fungal infections and autoimmune disease. Furthermore, the NK defect we
characterized illustrated an immature CD56dim NK cell subset with decreased expression
of CD16, perforin, CD57, and impaired cytotoxic capacity associated with increased
susceptibility to viral infections observed in these patients.
Methods: In this study, we evaluated 2 patients with novel STAT1 mutations (D292E
mutation, located in Coiled-coil domain and K388Q mutation, located in DNA-binding
domain). A third patient with the previously reported V266I mutation (CCD) was also
recruited for this study. In vitro, PBMCs from these patients were stimulated with
IFN-α for 30, 60, and 120 minutes and levels of phospho-STAT1 on CD56dim NK cell subset
were measured by flow cytometry. The STAT1 activity (firefly and Renilla luciferase
activities) was evaluated in U3A-STAT1 deficient cells transfected with a reporter
plasmid (for luciferase), WT or mutant-STAT1 plasmids. NK cell cytotoxicity was measured
by Cr51 release assay. We used multiparametric immune profiling to dissect the effect
of STAT1-GOF mutations on NK cell developmental phenotype.
Results: Similar to our previous studies, we observed higher levels of STAT1 phosphorylation
after two hours of stimulation from the DBD mutation compared to the CCD mutations.
The STAT1 activity assay confirmed gain of function observed by flow cytometry, but
this activity was higher in K388Q mutant and D292E mutant (CCD-closer to DBD) than
V266I mutant. All patients demonstrated low NK cell lytic unit compared to healthy
donors. Interestingly, we observed a correlation between low lytic unit and lower
numbers of CD56dimPerforin+CD16+ NK cells; much lower in patient with K388Q mutation.
STAT1-GOF patients showed a significant decrease in total NK cell numbers and impaired
NK cell maturation was characterized by low expression of CD57, and higher levels
of immature NK cell markers (CD117, NKG2A, CD158b).
Conclusions: These data suggest that impairment of NK cell function is affected by
the location of the STAT1 mutation and continues to be the case in novel mutations
identified. The identification the genotype/phenotype correlation in the spectrum
of the NK cell defect in STAT1 gain-of-function mutants may help to better understand
the molecular basis for STAT1 activation and/or function to predict clinical manifestations
of disease and ultimately treatment regimens.
(227) Submission ID#812574
Jacobsen Syndrome as a Cause of Abnormal TRECs on Newborn Screen: Immunophenotypes
in a Terminal 11q Deletion Syndrome Cohort
Mansi James, DO1, Sarah Nicholas, MD2, Lisa Forbes, MD3
1Fellow/Baylor College of Medicine
2Clinic Chief, Allergy and Immunology; Director, Solid Organ Transplant Immunology/Department
of Pediatric Immuunology, Allergy, and Retrovirology, Baylor College of Medicine,
William T. Shearer Center for Human Immunobiology
3Assistant Professor/Department of Pediatrics, Baylor College of Medicine, Houston,
TX, USA and Texas Children’s Hospital, William T. Shearer Center for Human Immunobiology,
Department of Allergy, Immunology, and Retrovirology, Houston, TX, USA.
Abstract/Case Report Text
Background: T cell lymphopenia associated with genetic syndromes can be identified
with low T cell receptor excision circle (TRECs) up on the newborn screen for Severe
Combined Immune Deficiency (SCID). Jacobsen syndrome (JS), 11q terminal deletion,
is a rare genetic disorder seen in 1/100,000 births characterized by facial dysmorphisms,
platelet abnormalities, neurologic complications, immune system abnormalities including
T and B cell defects. We report an infant with JS found to have low TRECs on NBS and
review the immune phenotypes of our cohort of 7 patients with JS.
Methods: A retrospective chart review of all patients with JS seen by the Allergy
Immunology service at a large tertiary referral center from 12/1/14-12/1/19 was performed
in accordance with IRB standards.
Result: The index patient had two newborn screens 24 hours after birth and two weeks
later in accordance with Texas state law. The first NBS resulted normal TRECS while
the second NBS had low TRECs. A third NBS was done per protocol and again showed low
TRECs. Subsequently, lymphocyte subsets at 2 months of age showed severe T-cell lymphopenia:
CD3 575 cells/dL (61%), CD4 351 cells/dL (21%), CD8 208 cells/dL, and low recent thymic
emigrants (CD4+CD45RA+CCR7+CD31+) 42 cells/dL (12%) with normal lymphocyte mitogen
proliferation. A chromosomal microarray (CMA) revealed a 11q deletion known to cause
JS.
Over the five year study period we evaluated seven patients with JS referred to our
center. The majority of patients (85%) presented to clinic with history of recurrent
infections including recurrent pneumonia, sinusitis, otitis media, skin abscesses
and warts. T-cell lymphopenia was found in 3 of 7 (43%), 2/7 (29%) had abnormal lymphocyte
proliferation (mitogens and antigens) and 2 met criteria for PJP prophylaxis. In addition,
4/7 (57%) had antibody deficiency requiring IgG replacement therapy. Of the 7 cases
reviewed, only 2 patients were born during the period of time that Texas was performing
the NBS.
Conclusion: Jacobsen Syndrome can present with a spectrum of immune defects most notably
T cell lymphopenia and antibody deficiency. These patients can present at birth with
low TRECs. This cohort analysis highlights the importance of considering chromosomal
genetic syndromes with features of primary immunodeficiency in evaluating patients
with low TRECs. Further evaluation of larger cohorts gathered from neurology or genetics
clinics at multiple centers would be helpful for future study in identifying those
who need close immunology care.
(229) Submission ID#812579
The Key roles of ‘IL-3’ and ‘Supporting Cells’ for In vitro Generation of Mast Cells
and Dendritic Cells from Human Bone Marrow
A. Yasemin Göksu-Erol, MD1, Ersin Akıncı, PhD2, Hilmi Uysal, MD3, Devrim Demir Dora,
PhD4, Ozan Salim, MD5
1Assoc. Prof. Dr., MD/Akdeniz University, Faculty of Medicine, Histology and Embryology
Department
2Assist. Prof./Akdeniz University, Faculty of Agriculture, Department of Agricultural
Biotechnology. Head of Enzyme and Microbial Biotechnology Division.
3Prof./Akdeniz University, Faculty of Medicine, Department of Neurology
4Assist. Prof./Akdeniz University, Faculty of Medicine, Department of Pharmacology
5Akdeniz University, Faculty of Medicine, Department of Internal Medicine, Division
of Hematology
Abstract/Case Report Text
Introduction: Recognized as sentinels of the immune system, Mast Cells (MCs) and Dendritic
Cells (DCs) are both derived from hematopoietic/progenitor stem cells in bone marrow
(BM). The crosstalk and direct contact between these cells have been well documented
and play an important role in modulating immune response. We showed that presence/absence
of IL-3 directs cell fate; whether progenitor cells will be differentiated into MCs
or DCs. We also report an easy method in which in vitro generation of DCs is possible
without external induction of GM-CSF or IL-4.
Material-Methods: To produce MCs and DCs in vitro, briefly BM samples were collected
from patients with Idiopathic Thrombocytopenic Purpura., BM mononuclear cells (MNCs)
were seperated by Ficoll gradient, and seeded in plates with IMDM medium containing
FBS 2%, Pen/Strep, and a little amount of methocult, and incubated in 37oC, 5% CO2
(Day 0).
The treatments on the following days were as follows: Day 4, IMDM (FBS 1%) + SCF (100ng/ml)
+ IL-6 (50ng/ml); Day 9, IMDM (FBS 2%) + SCF (100ng/ml) + IL-6 (50ng/ml) + IL-3 (1ng/ml).
On Day 18, 3 groups were formed: Group I: IMDM (FBS 2%) + SCF (100ng/ml) + IL-6 (50ng/ml)
+ IL-3 (30ng/ml), Group II: IMDM (FBS 2%) + SCF (100ng/ml) + IL-6 (50ng/ml), Group
III: DMEM + FBS 10%. The cultures were evaluated every 2 days under an inverted microscope.
Verification of MCs was performed by toluidin blue and tryptase-immunoflorescence
staining. Macrophages were verified by CD-68 immunoflorescence staining. Dendritic
cells of different stages of maturation were easily recognized microscopically, and
evaluated with their typical appearence and elongation of dendrites.
Results: Adherent cells such as fibroblasts, endothelial and mesenchymal stem cells
have grown up and adhered to the plate, thus providing an attachment site for MCs
and serving as a nest for DCs to grow and proliferate. MCs’ attachment to the cells
at the bottom has provided medium exchange available without changing culture dishes.
As the adherent cells released cytokines, growth factors, and other inflammatory mediators,
they provided a natural environment for development of MCs and DCs. On day 18, when
MCs formed and proliferated well, we seperated wells into 3 groups. After 1 week following
our treatment of IL-3 (30ng/ml) to group I (on day 25), Group I showed proliferating
dendritic cells. Group II continued to generate MCs with a low percentage of macrophages
(Figures a-c) and group III consisted of mesenchymal stem cells (with only few MCs
survived in DMEM) . On day 31, after a very short duration of trypsin treatment, MCs
easily detached, and continued to grow and proliferate in suspension culture for about
3-5 weeks more.
Discussion: Here we report two modified methods to obtain both MCs and DCs. We determined
that IL-3 dosage, and duration of treatment were the critical stimulant factors deciding
the fate of the progenitor cells to differentiate into a mast cell or a dendritic
cell. We also achieved generation of DCs without external induction of GM-CSF and
IL-4, which are usual in vitro inducers for DC formation.
Day 16: Immature mast cells are visible (x200).
Day 25: (Group 1): 1 week after the treatment of IL-3 (30 ng/ml) in addition to SCF
and IL-6, dendritic cells have formed. Dendritic cells in different stages are seen.
(x400)
Day 25 (Group II): Only SCF and IL-6 were treated. Mast cells - immature and mature-
have formed (x100)
(230) Submission ID#812584
Twin Infant with Prenatally Diagnosed Compound Heterozygous ADA Gene Mutations
Deepti Deshpande, MD, MPH1, Yesim Demirdag, MD2, Jordan Orange, MD, PhD3
1Fellow in Training/Columbia Univeristy
2Assistant Professor, Pediatrics/Columbia University
3Professor of Pediatrics; Chair, Department of Pediatrics/Columbia University
Abstract/Case Report Text
Background: Adenosine deaminase-1 (ADA) deficiency classically presents as severe
combined immunodeficiency in early infancy, but delayed, late-onset and partial phenotypes
have been reported. Here, we describe a prenatally diagnosed infant with a unique
compound heterozygous genotype presenting with a normal immunophenotype after birth.
Case Description: The patient is a dichorionic-diamniotic twin-B girl, born at 35
weeks to healthy parents that are known carriers of variants in the ADA gene [mother-c.466C>T
(p.R156C); father-c.452C>A (p.L152M)]. Mutation specific analysis after an amniocentesis
showed that one twin was a carrier (L152M) and the other was a compound heterozygote
(R156C and L152M). After birth, twin A had a mildly low erythrocyte ADA level (12.8
nmol/h/mg; normal range 63+41) with normal metabolites and a normal immunophenotype,
similar to both parents. Twin B showed a normal absolute lymphocyte count and mitogen
proliferation, normal T lymphocyte subsets, mildly low B and NK cells with 85% naïve
T cells and a normal TREC assay. Erythrocyte ADA levels were absent in peripheral
blood, with mildly elevated metabolites [dAXP=0.041 μmol/ml RBC (normal < 0.002) and
%AXP=0.9 (normal < 0.2)]. Weekly recombinant ADA enzyme replacement therapy (ERT)
was started at 1 week of life with subsequent normalization of the metabolites by
week 14. Absolute lymphocyte, T cell subsets were normal at birth but continued to
rise slightly above normal range after starting ERT. B and NK cell counts were mildly
low at birth but normalized by week 3. Genetic testing confirmed the prenatal genotypes
in the twin girls. The patient is now 11 months old and doing well with no history
of infections. Her twin was not an HLA match and family is currently awaiting gene
therapy approval.
Discussion: ADA deficient patients show substantial clinical and metabolic heterogeneity
that tends to correlate with the genotype but phenotypic discordance occurs even within
the same genotype. We describe an infant with prenatally diagnosed compound heterozygous
mutations in the ADA gene (Grade-I: R156C and Grade-II: L152M). ADA alleles are graded
from 0-IV with increasing ADA expression and decreasing severity respectively. There
are reports of children with grade I/III allele combinations with delayed, late and
partial phenotypes. Two siblings have been reported with L152M allele (grade III)
in combination with a different grade I allele (R235Q), presenting with combined immunodeficiency
at 1 and 13 months. The specific allele combination from our patient has not been
previously reported, however, we expected that the Grade-I allele likely would be
more deleterious than the Grade-III allele. In our case, predicting a future phenotype
remains a challenge, creating a dilemma regarding management strategies. However,
with only mild metabolite elevations in our patient after birth, we may speculate
whether the prenatal diagnosis with early ERT precluded the development of a full
immunophenotype and it remains to be seen whether non-immune sequeli may be prevented.
Conclusion: Children with compound heterozygous mutations in the ADA gene can pose
diagnostic and therapeutic challenges, especially due to the associated metabolic
and clinical phenotypic variability. Early recognition and treatment may potentially
alter long-term morbidity and mortality.
(231) Submission ID#812585
Jakinibs: A Bridge to Immune Reconstitution in Gain-Of-Function Signal Transducer
and Activator of Transcription 1 (STAT1) Mutation
Maria Chitty-Lopez, MD1, Carla Duff, CPNP-PC APRN MSN CCRP IgCN2, Jennifer Leiding,
MD3
1Allergy & Immunology Fellow/University of South Florida Morsani College of Medicine
2Adjunct Clinical Faculty, College of Nursing/Division of Allergy & Immunology, Department
of Pediatrics and Medicine, Morsani College of Medicine, University of South Florida,
Tampa, Fla
3Associate Professor/Division of Allergy and Immunology, Department of Pediatrics,
University of South Florida at Johns Hopkins-All Children’s Hospital, St Petersburg,
FL
Abstract/Case Report Text
Background: Autosomal dominant gain-of-function (GOF) mutations in STAT1 cause a syndrome
of infection susceptibility, autoimmunity, and immune dysregulation. A subset of patients
develop immune dysregulation-polyendocrinopathy-enteropathy-X-linked syndrome (IPEX)-like
phenotype. Immunodeficiency is often combined with impairment of the humoral and cellular
compartments.
Hematopoietic cell transplant (HCT) can resolve disease-related manifestations in
STAT1-GOF, but overall survival is poor and there is a high rate of secondary graft
loss in transplanted patients.
Jakinibs are a class of medications that block cytokine-induced JAK/STAT activation.
Ruxolitinib preferentially inhibits JAK1 and JAK2 and has been used as precision-directed
therapy for treatment of STAT1-GOF related manifestations with success in stabilizing
and in some cases reversing organ-specific manifestations. The utility and safety
of jakinibs for long term treatment of STAT1-GOF and in the prevention of disease-related
manifestations is not known. As such, HCT is often pursued for patients once disease-related
manifestations are controlled with jakinibs.
We present a patient with STAT1-GOF mutation with gradual secondary graft loss following
HCT 10 years ago, that has had continued disease progression despite chronic ruxolitinib
treatment.
Case Presentation
This is a 14 years-old male diagnosed with a de novo heterozygous STAT1 mutation (c.983A>G/A)
at age 9, 5 years following HCT for IPEX-like disease. He has been treated with ruxolitinib
for the last three years.
This patient initially presented at 5 months of age with wasting enteropathy, failure
to thrive, early-onset type 1 diabetes and hypothyroidism. He had frequent upper respiratory
infections during childhood including Mycobacterium fortuitum mediastinal lymphadenitis.
At 4 years he underwent 10/10 matched, unrelated bone marrow transplant following
reduced-intensity conditioning. Mixed donor chimerism was present in the first 100
days following HCT, and he continued to have a slow progressive decline of donor chimerism
with full graft loss (0% whole blood donor chimerism) by age 13. At age 11, enteropathy
returned leading to cachexia and TPN dependence. Concurrently, he had recurrent upper
respiratory tract infections, lymphopenia, and hypogammaglobulinemia. Imaging showed
bronchiectasis and lung function was consistent with obstructive lung disease (FEV1:1.88
L FVC:1.96 L DLCO:13.9 ml/min/mmHg). Initiation of ruxolitinib at age 11 resolved
his enteropathy with discontinuation of TPN and >25-pound weight gain. Enteropathy
has not returned. Pulmonary clearance measures have also been employed. DLCO initially
improved (DLCO: 19.11 ml/min/mmHg) but obstructive lung pattern continued (FEV1: 1.91
L FVC: 2.08 L). After initial improvement, DLCO began to decline. Over the last 2
years and despite treatment with ruxolitinib, lung function has deteriorated with
worsened FEV1 (1.64 L), FVC (2.03L), and DLCO (17.91 ml/min/mmHg). With this progressive
decline, the family is now pursuing second HCT.
Discussion
Jakinibs apply precision-directed therapy for immune dysregulatory features of STAT1-GOF.
Their use leads to substantial disease control and clinical improvement but does not
prevent disease progression. Jakinibs should be used as a bridge to definitive therapy
with HCT in patients with STAT1-GOF mutation.
(232) Submission ID#812588
Predicting Infections Among Children With Congenital Heart Disease After Thymectomy
Deepti Deshpande, MD, MPH1, Rebecca Koransky, MD2, Abigail Leathe, MD3, Angela Chan,
MD4, Yesim Demirdag, MD5
1Fellow in Training/Columbia Univeristy
2Allergist/Private Practice
3Medical Student/Columbia University
4Fellow in Training/Columbia University
5Assistant Professor, Pediatrics/Columbia University
Abstract/Case Report Text
Background: The thymus is the primary T-cell maturation site where T-cell proliferation,
T-cell receptor rearrangement, thymocyte differentiation and maturation occur. Thymectomies
are commonly performed during cardiac surgery, altering the architecture and micro-environment
needed for T-cell development. Prior studies have revealed the immune impact of thymectomy,
showing T-cell lymphopenia, decreased proportion of naïve T-cells, and reduced diversity
of the T-cell receptor repertoire. A recent large registry study showed a higher risk
of infections (HR 1.42, 95% C.I 1.33-1.52) in children with thymectomy as compared
to surgery controls, in addition to demonstrating differences in the risk of cancers,
autoimmunity and atopy. Limited small studies have described some risk factors for
altered immune consequences; however, specific predictors of infections among children
with congenital heart disease (CHD) undergoing thymectomies have not been systematically
assessed. Among children with CHD and thymectomy, we sought to characterize children
with and without reported infections within 4 years post-thymectomy and identify predictors
of bacterial and viral infections.
Methods: Using a retrospective chart review (Institutional IRB approved) from 7/2/2013
and 3/31/2017, we identified children with CHD that underwent thymectomy and excluded
any known conditions associated with immunodeficiency and those with less than 6-month
follow-up post-thymectomy. First absolute lymphocyte count (ALC) after thymectomy
was stratified using a cutoff at 50% of the lower limit of age-adjusted normal values
(ALC value < 50% vs ALC value >50% of the lower limit of age-adjusted normal levels).
We sought to assess predictors of reported bacterial (positive blood, cerebrospinal
fluid, respiratory cultures and chest-X-Ray confirmed pneumonia) and viral infections
(positive viral PCR tests) within 4 years post-thymectomy.
Results: We identified 128 children with CHD who had thymectomies, of which, 65% (84/128)
were male. The median age at thymectomy was 6 months (interquartile range 2 months-2.2
years); 51% (66/128) underwent a complete thymectomy; and 3% (4/128) developed a chylothorax
within 1 week post-thymectomy. A substantial proportion of children had an ALC below
50% of the lower limit of age-adjusted normal levels after thymectomy (2% [3/127]
pre-thymectomy vs 65% [82/127] post-thymectomy). Among children with CHD post-thymectomy,
51% (65/128) and 45% (57/128) reported bacterial and viral infections within 4 years,
respectively. Children with post-thymectomy ALC values below 50% of the lower limit
of age-adjusted normal levels had higher odds of reported bacterial (OR 3.44, 95%
C.I 1.37-8.64, p=0.008) and viral (OR 5.86, 95% C.I 2.02-16.96, p=0.001) infections
post-thymectomy as compared to those with an ALC greater than 50% of the lower limit
of age-adjusted normal levels (multivariate logistic regression). There was no association
with the type of thymectomy (partial vs complete), age at thymectomy, weight at thymectomy,
sex or prematurity.
Conclusions: Among children with congenital heart disease with no known immunodeficiency
undergoing thymectomy, ALC below 50% of age-adjusted normal levels post-thymectomy
may be associated with higher odds of bacterial and viral infections. A retrospective
study design with a small sample size poses several limitations; however, this study
suggests that post-thymectomy absolute lymphocyte values may be a potentially useful
marker to identify higher risk patients in this population.
(233) Submission ID#812589
Telomere Length: A Novel Biomarker To Predict The Presence Of Interstitial Lung Disease
In PID
Alyssa Kerber, MD1, Avni Joshi, MD, M.S.2
1Resident/Mayo Clinic
2Consultant, Division of Pediatric Allergy & Immunology/Mayo Clinic
Abstract/Case Report Text
Background: Interstitial Lung L Disease (ILD) is commonly encountered as a complication
of many PIDs, esp. CVID in the setting of GLILD associated with CVID. Currently, there
are no clear guidelines on the assessment and monitoring of interstitial lung disease
in PID patients. Radiological assessments esp. in the CT chest is commonly performed,
but has associated radiation exposure and pulmonary function testing, at times, maybe
insensitive to small changes in lung pathophysiology.
Many PIDs may have overlapping features with Short telomere syndromes (STS) a, which
are accelerated aging syndromes affecting hematopoietic, pulmonary, hepatobiliary
and/or immunological systems, unified by a high cell turnover in these organs. Clinical
assessment of age-appropriate telomere length (TL) is performed using flow cytometry
& fluorescence in-situ hybridization (flowFISH).
Methods: We retrospectively analyzed telomere lengths in lymphocytes and granulocytes
using the flow cytometry and FISH method .FlowFISH testing was done at reference laboratories
in Johns Hopkins University (JHU, USA).Approval was obtained from Mayo’s Institutional
review board. Data abstraction and analysis was done using the software JMP.
Results: 24 patients were included in our analysis with 13 females (54%) and 11 males
(45%).The median lymphocyte count of our cohort was 0.98 (0.51-1.78).The telomere
length was strongly associated with the presence of lung disease (p=0.02*) and the
presence of interstitial lung disease closely paralleled the changes in telomere length
(delta- as compared to age adjusted normal percentiles lengths). Shorter lymphocytic
telomere length was associated with more severe reduction on total Lung capacity (TLC;
P=0.006*).
Conclusion: Shorter Lymphocytic telomere length served as a reliable biomarker for
interstitial lung disease in PID patients. This may open up newer avenues for assessment
of aging pathways in PID and may offer the option of using senolytic therapies in
PIDs.
(234) Submission ID#812591
T-B+NK+ SCID Due to A Mutation in IL2RG
Elizabeth Hicks, MD1, Rebecca Buckley, MD2, Kristina De Paris, PhD3, John W. Sleasman,
MD4, Talal Mousallem, MD5
1Clinical Fellow/Department of Pediatrics, Duke University Medical Center, 2James
Buren Sidbury Professor of Pediatrics, in the School of Medicine; Professor of Immunology/Department
of Pediatrics, Duke University Medical Center
3Associate Professor/Department of Microbiology and Immunology, University of North
Carolina at Chapel Hill
4Chief, Div. of Allergy/Immunology, Dr. Glenn A. Kiser & Eltha Muriel Kiser Professor
of Pediatrics/Duke University
5Associate Professor of Pediatrics/Department of Pediatrics, Duke University Medical
Center
Abstract/Case Report Text
Mutations in the IL-2 receptor common gamma chain gene (IL2RG) result in X-linked
severe combined immunodeficiency (SCID). The common gamma chain is shared by IL-2,
IL-4, IL-7, IL-9, IL-15 and IL-21 receptors. X-linked SCID typically presents with
low or absent T and NK cells and normal or elevated numbers of B cells. We report
a case of X-linked SCID with elevated B and NK cell numbers (T-B+NK+).
The male patient had an abnormal newborn screen for SCID in North Carolina. Lymphocyte
enumeration performed at 12 days of life showed 8 CD3+ cells/mm3, 370 B cells/mm3,
and 997 NK cells/mm3. He had no naïve T cells. Repeat lymphocyte enumeration two weeks
later showed that the CD3+ count had increased to 389/mm3. Only 1.5% (6 cells/mm3)
were CD45RA+ naïve T cells. He continued to have elevated B cell and NK cell numbers.
Chimerism studies revealed the presence of 6% female cells in mitogen-stimulated PBMC
by fluorescence in situ hybridization, indicating the presence of transplacentally
transferred maternal cells. Lymphocyte proliferation responses to PHA and ConA mitogen
stimulation were very low (less than 10% of normal). Immunoglobulin levels were IgG
921mg/dL, IgM 18mg/dL, and undetectable IgA and IgE.
Genetic studies revealed a missense mutation in IL2RG, c.467C>T, resulting in an amino
acid substitution (p.Ala156Val) in the extracellular domain. Family testing showed
that the patient’s mother was a carrier for this variant. The father and the two healthy
older brothers did not have this variant. Of note, the family history was significant
for lateral maternal male early deaths.
At 7 weeks of age, the patient received an unfractionated bone marrow transplant from
his HLA-identical brother without conditioning or GVHD prophylaxis. At the time of
this report’s submission, he is 4 weeks post-transplantation and has had successful
engraftment (whole blood-CD3+ fraction was composed of >95% donor cells). He also
now has normal T cell proliferation in response to mitogens and normal levels of all
immunoglobulins.
Genetic defects that cause primary immunodeficiency can have variable phenotypic presentations.
The patient’s phenotype was atypical in that he had elevated NK cell numbers. To further
evaluate these cells, we checked for STAT4 phosphorylation following IL-12 stimulation
of patient NK cells. The NK cells demonstrated adequate STAT4 phosphorylation, indicating
they may be functional.
Kumaki et al (Blood, 1999) reported the Ala156Val mutation in the IL2RG gene in a
patient presenting with no T cells, normal number of B cells, and normal NK function.
The group showed that T cells expressing the mutant gamma chain had impaired responses
to IL-4 and IL-7. However, responses to IL-2 and IL-15 were maintained.
Mutations in the extracellular domain of IL2RG may result in preservation of certain
signaling pathways, but not others. This may explain the presence of NK cells in this
patient. However, we cannot rule out transplacental transfer of a small percentage
of maternal NK cells.
Reference:
Kumaki S, Ishii N, Minegishi M, Tsuchiya S, Cosman D, Sugamura K, and Konno T. Functional
role of interleukin-4 (IL-4) and IL-7 in the development of X-linked severe combined
immunodeficiency. Blood. 1999; 93(2): 607-612.
(235) Submission ID#812594
The Natural History Of STAT3 GOF Syndrome – The Range Of Clinical Manifestations And
Treatment Options
Jennifer Leiding, MD1, Tiphanie Vogel, MD, PhD2, Valentine Gignon Jadoul, MS3, Rahul
Mhaskar, MPH PhD4, Megan Cooper, MD,PhD5, Michael O'Sullivan, MD6, Lisa Giovanni-Chami,
MD7, Akaluck (Ben) Thatayatikom, MD, RhMSUS8, Cindy Salm Bauer, MD9, Mikko Seppanen,
MD10, Mervi Taskinen, MD11, Sari Hamalainen, MD PhD12, Mehdi Adeli, MD13, Renata Formankova,
MD PhD14, Maximilian Heeg, MD15, Tamara Pozos, MD PhD16, Paul Szabolcs, MD17, Tomohiro
Morio, MD PhD18, Ignatius Chua, MD19, Rosemary Hague, MD20, Sophie Hambleton, MD PhD21,
Stuart Tangye, PhD22, Andrew Gennery, MD PhD21, Charlotte Cunningham-Rundles, MD,
PhD23, Helen Su, MD, PhD24, V. Koneti Rao, MD25, Georgios Sogkas, MD PhD26, Joshua
Milner, MD27, Stephan Ehl, PhD28, Lisa Forbes, MD29
1Attending Physician/Division of Allergy and Immunology, Department of Pediatrics,
University of South Florida at Johns Hopkins-All Children's Hospital
2Assistant Professor, Pediatrics & Medicine/Baylor College of Medicine, Texas Children's
Hospital
3Student/University of South Florida
4Associate Professor/University of South Florida
5Associate Professor/Department of Pediatrics, Divisions of Rheumatology/Immunology,Washington
University School of Medicine, St. Louis, MO.
6consultant/Fiona Stanley Hospital
7Professor/Universités-Praticien Hospitalier, Nice France
8Associate Professor and Pediatric Rheumatology Fellowship Training Program Director/Division
of Pediatric Allergy/Immunology/Rheumatology, Department of Pediatrics, College of
Medicine, University of Florida, Gainesville, FL
9Assistant Professor/Phoenix Children's Hospital
10Professor/Children´s Immunodeficiency Unit, New Children´s Hospital, University
of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
11consultant/Children´s Immunodeficiency Unit, New Children´s Hospital, University
of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
12Consultant/Kuopio University Hospital, Kuopio
13Senior Consultant in Pediatrics Allergy and Immunology/Sidra Medicine, Qatar
14Consultant/University Hospital Motol, Prague Czech republic
15Consultant/University Hospital Freiburg Center for Pediatrics and Adolescent Medicine
CCI - Center for Chronic Immunodeficiency
16Medical Director, Clinical Immunology/Children's Minnesota
17Professor/Division of Blood and Marrow Transplantation and Cellular Therapies, Pediatrics
and Immunology, University of Pittsburgh School of Medicine
18Professor/Tokyo Medical and Dental University
19Consultant/Canterbury Health Laboratories, New Zealand
20Consultant/Affiliation Royal Hospital for Children, Glasgow
21Professor/Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation
and Primary Immunodeficiency Group, Translational and Clinical Research Institute,
Newcastle upon Tyne University, UK
22Professor/Immunity & Inflammatory Diseases, Garvan Institute of Medical Research,
Darlinghurst, New South Wales, Australia.
23Professor of Medicine and Pediatrics/Icahn School of Medicine at Mount Sinai
24Senior Investigator/Laboratory of Clinical Immunology and Microbiology, National
Institute of Allergy and Infectious Diseases, National Institutes of Health
25Staff Clinician/ALPS Unit, Laboratory of Clinical Immunology and Microbiology, National
Institute of Allergy and Infectious Diseases, National Institutes of Health
26Professor/Hannover Medical School Clinic for Immunology and Rheumatology, Hannover
Germany
27Laboratory Chief, Attending Physician/Laboratory of Allergic Diseases, National
Institute of Allergy and Infectious Diseases, National Institutes of Health
28Professor/University Hospital Freiburg Center for Pediatrics and Adolescent Medicine
CCI - Center for Chronic Immunodeficiency
29Assistant Professor of Pediatrics/Texas Children's Hospital/Baylor College of Medicine
Abstract/Case Report Text
Background: STAT3 gain-of-function (GOF) mutations cause a multi-system disease of
early onset autoimmunity and lymphoproliferation, severe post-natal growth restriction,
and recurrent and/or invasive infections. Treatment of the autoimmune and auto-inflammatory
features of STAT3 GOF patients relies heavily on immunosuppression and is often challenging.
The full scope of phenotypes, treatments and outcomes may be broader when analyzing
a substantially larger cohort than those already reported.
Methods: We gathered and analyzed data on 144 patients from 56 centers world-wide
with confirmed GOF mutations in STAT3. Retrospective chart reviews were performed
in accordance with all local ethics and IRB committees to determine clinical manifestations,
immunophenotype, treatment regimens, success of treatment methods, and overall survival.
Funcitonal transcriptional activity was assessed by luciferase reporter assay on each
individual mutation.
Results: Fifty-nine individual mutations were identified and all conferred GOF by
a validated luciferase assay. There were 5 mutations in the N-terminal domain, 17
in the coiled-coil domain, 28 in the DNA binding domain, 6 in the SH2 domain, and
3 in the transactivation domain with the overwhelming majority being missense mutations.
Median age at presentation was approximately 5 years; 56% of subjects are male and
44% are female. Immunodysregulatory features presented in all patients. Autoimmune
cytopenias were the most common occurring in 72% of subjects (n=105), followed by
lymphoproliferation in 69% (n=100) with increased frequencies of double negative (CD4-CD8-)T
cells being found in 71% of of patients tested, enteropathy in 53% (n=76), endocrinopathy
in 35% (n=50), interstitial lung disease in 45% (n=65), dermatitis in 41% (n=42),
and inflammatory brain disease in 6.25% (n=9). Growth failure was present in 54% (n=77)
with half of those patients having concurrent enteropathy. Infections were reported
in 60% of the cohort to include recurrent and/or invasive viral, bacterial, opportunistic,
fungal, and mycobacterial infections. Prominent abnormalities of immunophenotyping
included T cell (54%) and B cell (36%) lymphopenia with reduced T cell proliferation
in response to mitogens or antigens in 30% of those evaluated patients. Fifty-nine
percent of the patients hypogammaglobulinemia while 40% exhibited poor specific antibody
responses to recall antigens. Overall survival was 86% at data collection.Treatment
of STAT3 GOF patients often included multiple agents: IVIG , chronic and pulse steroids,
mTOR inhibitors, calcineurin inhibitors, rituximab, mycophenolate mofetil, alemtuzumab,
tocilizumab, and jakinibs. Those started on JAK inhibition showed improvement in clinical
symptoms and, to date, there are 20 STAT3 GOF patients on targeted JAK inhibition.
Thus far, 18 patients have undergone bone marrow transplant with a 61% survival rate.
Discussion: STAT3 GOF mutations were first reported in 2014 to cause a heterogeneous
syndrome of autoimmunity and lymphoproliferation with immunodeficiency and infection
susceptibility. Earlier treatment with targeted therapy such as Jak inhibitors has
led to reduced disease morbidity. We report the largest cohort of STAT3 GOF patients
collected through a multi-national collaboration of the longitudinal data and natural
history of STAT3 GOF disease. Understanding the heterogeneity of presentation and
key features that will lead to proper diagnosis and early treatment in an effort to
prevent long term disease associated sequelae.
(236) Submission ID#812602
Novel Mutation in Transcription Factor 3 (TCF3) Associated With A Unique Humoral Phenotype
and Severe Thrombocytopenia Responsive To Rapamycin
Manar Abdalgani, MBBS1, Yoav Messinger, MD2, Diana Vilkama, APRN CNP3, Tamara Pozos,
MD PhD4
1Clinical Immunologist/Children's MInnesota
2Oncologist/Children's Minnesota
3Clinical Immunology Nurse Practitioner/Children's Minnesota
4Medical Director, Clinical Immunology/Children's Minnesota
Abstract/Case Report Text
We present the case of 5 month old male with a novel heterozygous mutation in TCF3
and two previously unreported phenotypes: 1) absent circulating CD19+ B cells yet
preserved immunoglobulin synthesis and vaccine responses and 2) significant thrombocytopenia
that improved with immunosuppression. There is also a striking family history of two
half-sisters who died during early infancy with similar clinical and lab findings
and the same genetic change.
The infant boy was born at term with respiratory failure and generalized rash. At
birth he had thrombocytopenia (24k/uL) and lymphopenia (465/uL). Initial absolute
CD3+ T cell count was low (442/uL), yet he had normal thymic output and proliferative
responses to mitogens ruling out SCID. CD19+ B cells were < 5/uL and bone marrow biopsy
revealed decreased hematagones, yet he had a normal IgM level (23.1 mg/dL) elevated
IgA (56 mg/dL), and elevated IgE (27 IU/ml). IgG levels were initially obscured by
maternal IgG and IVIG; in turn he made positive titers to diphtheria and tetanus vaccination.
The infant has maintained his own IgG production.
Rapid genome sequencing revealed a heterozygous predicted deleterious VOUS in TCF3,
in the second transactivation domain (c.1138 C>T, p.Pro380Ser). The same change in
TCF3 was identified in the deceased half-sisters as well as the father: all 3 infants
had different mothers, suggesting autosomal dominant inheritance. The sisters had
similarly severe thrombocytopenia and absent circulating B cells; their causes of
death were not completely understood. The 33 year-old father has normal platelet levels,
very low CD19+ B cells (35/uL), elevated IgG (1,580 mg/dL) and IgE (1,030 IU/mL),
and normal levels of IgA and IgM. The father also has an elevated number of CD3+ T
cells (3,455 /uL) with an increased percentage of T cells expressing HLA-DR (46%).
In the months after birth, the infant boy continued to require frequent platelet transfusions.
Despite the persistent T lymphopenia, there was evidence of increased T cell activation
with elevated levels of soluble IL-2R (2510 pg/ml) and increased percentage of cells
expressing HLA-DR (30%) CD95 (98%), CD25 (86%), CD71 (55%), and CD69 (14%). A 10-day
trial of prednisone was associated with an increase in his platelet count to >100k/ul.
He was switched to rapamycin as a steroid-sparing agent, and his platelet count has
remained > 200k/ul for several weeks without transfusions. Interestingly, his B cell
counts also improved after the steroid trial (50/uL) and his absolute lymphocyte count
is normalizing on rapamycin. A potential mechanism could be rapamycin decreasing T
cell-mediated destruction of platelets or B cells. Reassessments of T cell activation
markers and B cell phenotyping while on rapamycin will be done in the future.
In contrast to multiple published cases of TCF3 mutations associated with complete
agammaglobulinemia and absent B cells, we present a case of an infant with absent
B cells yet preserved humoral function as well as severe thrombocytopenia responsive
to rapamycin. In collaboration with colleagues at NIH, studies are underway to understand
whether/how the unique change in TCF3 is related to either phenotype described above.
(237) Submission ID#812603
ARPC1B Deficiency Presenting in an Adult Female with Lymphadenopathy, Cytopenias,
and Polymorphic Ulcerative, Vasculitic and Epidermodysplasia Verruciformis-like Mucocutaneous
Manifestations
Mark Hannibal, MD, PhD1, Ora Gewurz-Singer, MD2, Anna Kovalszki, MD3, David Frame,
PharmD4, Kelly Walkovich, MD5
1Clinical Associate Professor/University of Michigan, Pediatric Genetics, Metabolism
& Genomic Medicine
2Associate Professor of Internal Medicine/Michigan Medicine, Division of Rheumatology
3Clinical Assistant Professor of Internal Medicine/Michigan Medicine, Division of
Allergy and Clinical Immunology
4Clinical Assistant Professor of Pharmacy and Clinical Pharmacist/Michigan Medicine,
College of Pharmacy
5Associate Professor, Pediatric Hematology/Oncology/University of Michigan, C.S. Mott
Children's Hospital
Abstract/Case Report Text
Background: Childhood-onset, chronic, multi-system inflammatory diseases are increasingly
being characterized as monogenic inborn errors of immunity. ARPC1B deficiency is a
recently described, rare combined immunodeficiency characterized by recurrent/severe
infections, a variety of autoimmune manifestations and platelet defects. We describe
a case of ARPC1B deficiency identified in an adult patient with recurrent ulcers/Bechet-like
disease, non-malignant lymphoproliferation and intermittent microthrombocytopenia.
Patient Case: At 1 year of age, our female patient was diagnosed with Behcet disease
based on a history of bloody stools at 3 months, oral ulcers at 9 months and vulvar
lesions at 1 year. She underwent rheumatology evaluations for inflammatory arthritis,
episcleritis, eczema, vasculitic ulcerating nodules of the trunk, perineum and extremities,
and verrucae forming flat plaques similar to epidermodysplasia verruciformis without
a unifying diagnosis. Other infections include otitis media, sinusitis, Pseudomonas
ecthyma gangrenosum, cervical lymphadenitis, and pneumonia.
At 28 years old, the patient was referred to our Immuno-Hematology Comprehensive Program
Clinic with a concern for malignancy versus a primary immune regulatory disorder (PIRD).
She had a 6-month history of drenching night sweats, urticarial plaques, edema in
her extremities and diffuse cervical, axillary and inguinal lymphadenopathy. Past
complete blood counts showed intermittent mild microthrombocytopenia. Lymph node biopsies
were negative for a neoplastic process but identified plasmacytosis, including focally
increased IgA-kappa+ plasma cells. Expert review of the lymph node biopsy, and further
evaluation excluded multicentric Castleman disease. Consideration was also given to
autoimmunune lymphoproliferative syndrome (ALPS)-like disorders; however, her ALPS
flow cytometry panel was nondiagnostic. Her basic immune evaluation showed severe
T cell lymphopenia (CD3+ 229 cells/cm, CD4+ 222 cells/cm, CD8+ 52 cells/cm) with adequate
B and NK cells, normal lymphocyte proliferation to PHA and PWM, and dysgammaglobulinemia
with IgG 1579 G/dL, IgA 638 G/dL, IgM 50 G/dL and IgE 592 G/dL.
Due to concern of an underlying PIRD, a primary immunodeficiency panel was sent for
207 gene analysis with negative results. However, trio clinical exome sequencing identified
biallelic variants in the gene ARPC1B. One allele has a truncating, nonsense pathogenic
variant in exon 8 denoted as c.898G>T, p.Glu300Ter. The other allele has a likely
pathogenic variant in intron 4 denoted as c.393-2A>G, resulting in disruption of the
canonical splice acceptor for exon 5. This is predicted to cause exon skipping, with
an in-frame deletion of amino acids coded by exon 5.
Conclusion: This case highlights the value for evaluation for PIRDs in patients presenting
with Behcet-like disease, particularly in the context of other autoimmune manifestations
and/or microthrombocytopenia. It also underscores that patients with ARPC1B deficiency
may present with chronic non-malignant lymphoproliferation. Moreover, this patient
emphasizes the value of exhaustive genetic testing for complex immunologic phenotypes.
(238) Submission ID#812605
LIPT1 Defect Associated With Agammaglobulinemia In A Neonate
Elif Dokmeci, MD1
1Associate Prof of Pediatrics, Pediatric Allergy and Immunology/University of New
Mexico
Abstract/Case Report Text
Lipoyltransferase 1 gene defect is associated with severe mitochondrial dysfunction
disrupting lipoic acid biogenesis. Clinical manifestations associated with early seizures,
hypotonia, cardiomyopathy and pulmonary hypertension and encephalopathy. Early neonatal
death due to sepsis and cardiovascular collapse is commonly seen.
The patient is a 36 week preemie male with congenital heart disease who developed
severe intractable lactic acidosis on day of life 1 with increased excretion on organic
acids of 2-methyl-2,3-dihydroxybutyric acid. A mitochondrial disorder , ECHS1 or HIBCH
deficiency was suspected. At 3 mo of age the patient was admitted for apneic spells
and respiratory compromise. He was found to have elevated CRP associated with Rhinovirus
infection and gram-negative bacteremia. Due to the history of failure to thrive and
sepsis, Immunology was consulted. Immunologic work up indicated normal B, T and NK
cells with normal DHR, but showed agammaglobulinemia. The patient was started on ivig
and whole exome sequencing was done. Molecular analysis showed compound heterozygote
mutations in the LIPT1 gene: c.293G>A (p.Arg98Gln) and c.635T>G (pVal212Gly). Subsequent
biochemical analysis also showed biochemical abnormalities consistent with LIPT1 defect.
Lipoyltransferase 1 is an enzyme involved in activation of a number of enzymes requiring
lipoic acid. It is involved in lipoic acid synthesis. Lipoic acid is required for
the activity of pyruvate dehydrogenase, alpha-ketoglutarate dehydrogenase, and branched-chain
alpha-ketoacid dehydrogenase. The literature indicates that most patients with LIPT1
defect have a severe, often fatal course. The patient is now almost 3 years old and
has stable clinical course without any major infections. He certainly has significant
hypotonia and developmental delay.
In conclusion, we are presenting the first case of LIPT1 gene mutations associated
with agammaglobulinemia who responded well to ig supplementation therapy. Our immunologic
findings in this case highlights the importance of immunodeficiency work up in challenging
cases. As we see more cases LIPT1 gene mutations, we will better understand the clinical
spectrum.
(239) Submission ID#812607
Hereditary Alpha Tryptasemia Presenting With Scurvy
Daniel Urschel, MD1, Melissa Cardenas-Morales, MD2, Camile Ortega, DO3, William Blouin,
ARNP4, Vivian Hernandez-Trujillo, MD5
1Allergy/Immunology Fellow/Nicklaus Children's Hospital
2Fellow/Nicklaus Children's Hospital
3Allergist/Immunologist/Allergy and Immunology Care Center of South Florids
4Allergy/immunology Nurse Practitioner/Nicklaus Children's Hospital
5Director of Allergy & Immunology fellowship in Nicklaus Children's Hospital/Director
of Allergy & Immunology fellowship in Nicklaus Children's Hospital
Abstract/Case Report Text
A now 8-year-old male was initially evaluated for concerns regarding food allergy,
eczema, Food Protein-Induced Enterocolitis Syndrome, and failure to thrive. He had
reactions of varying severity to multiple foods. These usually involved immediate
urticaria or prolonged vomiting, diarrhea, and abdominal pain. IgE and skin prick
testing was performed to suspected foods and was positive to milk, egg, pork, wheat,
peanut, pecan, coconut and corn. These foods had historically caused reproducible
immediate symptoms. Testing was negative to other suspected foods. He developed an
oral aversion and extremely restricted diet. Symptoms of abdominal pain, hematochezia,
rashes, arthralgias, headaches, fatigue, dyspnea, and palpitations increased. Urticaria
and severe abdominal pain with vomiting and diarrhea continued intermittently without
identifiable triggers on a restricted diet. Laboratory markers demonstrated elevated
inflammatory markers, anemia, iron deficiency, vitamin B12 deficiency, and vitamin
C deficiency (scurvy). Gastroenterology work up did not identify any pathology. Gastrointestinal
symptoms did not respond to treatment with multiple GERD medications or oral steroids.
Baseline tryptase was elevated. Low histamine diet was initiated and repeat tryptase
remained elevated. Fractionated Tryptase revealed normal mature (beta) tryptase with
elevated total tryptase, negative genetics for c-KIT mutation, normal urine prostaglandins.
Family members had tryptase levels drawn. One parent and sibling had elevated Tryptase
levels, while the other parent’s Tryptase was normal.
Hereditary alpha tryptasemia syndrome is defined by elevated blood tryptase levels
and symptoms involving multiple organ symptoms. Patients with elevated tryptase levels
without symptoms are defined as having Hereditary alpha tryptase trait. There is significant
variability regarding which patients are symptomatic. Organ symptoms that may be involved
include skin, gastrointestinal, neurologic, connective tissue, cardiac, neuropsychiatric.
Severe allergic reactions such as anaphylaxis can occur. Increased blood levels of
the protein tryptase are caused by extra copies of the alpha tryptase gene (TPSAB1).
Treatment is usually directed at specific symptoms, antihistamines, and mast cell
stabilizers. Research continues into additional treatment options.
This patient was started on Cromolyn and long-acting antihistamine. His gastrointestinal
symptoms and rash/urticaria improved, and he began tolerating a small, but increased,
variety of foods. The majority of his constitutional symptoms of fatigue, arthralgias,
weakness resolved as he began gaining weight, and hemoglobin, vitamin C and B12 normalized.
His sibling was evaluated and noted to have food allergy, asthma, abdominal pain,
GERD, and eczema. She was also started on Cromolyn and antihistamines which improved
her gastrointestinal symptoms. Parent with elevated tryptase was recommended to be
evaluated further with Allergist.
This is an example of a patient with elevated Tryptase and multiple organ system involvement.
Some of his signs and symptoms responded to mast cell stabilizing and antihistamine
medications. Patients with history of recurrent episodes of allergic reactions to
foods and multiple constitutional symptoms would benefit from baseline tryptase levels.
Family members should also be tested if the patient has elevated tryptase.
(240) Submission ID#812610
Neonatal Screening for SCID: Development of a TREC newborn screen in Alberta, Canada,
and comparative assessment of SCID demographics before and after screening implementation
Candace Rypien, MD1, Nicola Wright, MD2, Luis Murguia-Favela, MD, FRCPC3, Sneha Suresh,
MD, FRCPC4, Stacey Hume, PhD5, Rhonda Kelln, MSc5, Christine Walker, MSc5
1Pediatrician/Alberta Children's Hospital
2Clinical Assistant Professor/Alberta Children's Hospital
3Clinical Assistant Professor/Alberta Children's Hospital and University of Calgary
4Assistant Professor/University of Alberta and Alberta Health Services
5Scientist/University of Alberta
Abstract/Case Report Text
Introduction : Population based newborn screening for severe combined immunodeficiency
(SCID) has been implemented throughout the United States. Within Canada it is only
available in Ontario and Nunavut (2013), the Maritimes (2016) and Alberta and the
Northwest Territories (2019). Multiple studies have been published looking at the
rates of SCID in the United States. The estimated rate of SCID prior to screening
was 1 per 100 000 live births. Post screening implementation, on average rates of
SCID were found to be closer to 1 in 60 000 live births.
Results : Development of a T cell receptor excision circles (TREC) SCID screen in
Alberta involved the screening of 4000 anonymous term neonates using quantitative
PCR for TRECs. The cycle threshold for the control gene, RNaseP, was set at 30.5 as
95% of our population had a cycle threshold < 30.5 (90% CI [30.4,30.6]). From those
bloods spots with adequate DNA, a final TREC cut off of 40 was chosen, as it would
give an accuracy of 99.6%, and fairly low false positive rate of 0.4% (95% CI [0.002,
0.006]).
Since starting a population based screen for SCID in June of 2019, we have identified
4 cases of SCID and 13 cases of low TREC not caused by SCID. To date we have detected
one case of reticular dysgenesis, 2 cases of ADA SCID and one case of X- linked SCID.
Other causes of lymphopenia in the neonatal period detected with abnormal TRECs include
one syndrome associated with variably affected cellular immunity (CHARGE) and 12 cases
of secondary lymphopenia including four cases of prematurity, three cases of diaphragmatic
hernia or gastroschisis, four patients with underlying cardiac disease, and one patient
with severe hydrops.
Discussion : Canada has multiple unique populations with increased risk of SCID. The
estimated rate of SCID in Canada prior to implementation of a population based screen
was 1.4 per 100 000 live births. The rate within Canada’s First Nations, Métis and
Inuit populations is 4.4 per 100 000 live births.
Prior to SCID screening, Alberta had 13 cases of SCID identified between 2005-2014
with an estimated rate of 1 per 60 000 live births. To date, our screen in Alberta
has identified 4 cases of SCID with a rate of 1 per 7000 live births which is significantly
higher than previously estimated. Given that early diagnosis and definitive management
through bone marrow transplant or gene therapy has been shown to reduce mortality
this screen will help reduce morbidity and mortality in this vulnerable population.
(241) Submission ID#812611
Chromosomal Integration of HHV-6 Masquerading as Viral Susceptibility
Amandeep Sandhu, MD1, Sarah Henrickson, MD, PhD2, Soma Jyonouchi, MD3, Lisa Akhtar,
MD, PhD4, Jason Kim, MD5, Louis Bell, MD6
1Fellow in Training/Children's Hospital of Philadelphia, Division of Allergy and Immunology
2Assistant Professor/Department of Pediatrics, Allergy Immunology Division, Children’s
Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University
of Pennsylvania, Philadelphia, PA
3Attending Physician/Children's Hospital of Philadelphia, Division of Allergy and
Immunology
4Attending Physician/Children's Hospital of Philadelphia, Division of Infectious Diseases
5Now at Merck/Children’s Hospital of Philadelphia, Division of Infectious Diseases
6Attending Physician/Children’s Hospital of Philadelphia, Division of Infectious Diseases
Abstract/Case Report Text
Introduction: Human herpesvirus 6 (HHV-6) has the ability to integrate its genome
into host telomeres. If this integration occurs in gametes, then the virus can be
genetically transmitted and offspring will carry a copy of chromosomally integrated
HHV-6 (ciHHV-6) in each somatic cell. This can lead to false attribution of infectious
and non-infectious presentations of HHV-6, and make the diagnosis of active HHV-6
infection difficult. We present the case of a patient with meningoencephalitis attributed
to HHV-6 and persistently elevated blood levels of HHV-6 by PCR concerning for primary
immunodeficiency who was discovered to have ciHHV-6.
Case Description: A 7-year-old female who carried a past diagnosis of HHV-6 meningoencephalitis
was seen in Immunology clinic for follow up of persistently elevated levels of HHV-6
DNA in her blood by PCR. She was born at 35 weeks and as an infant had failure to
thrive (FTT), anemia and a varicella like rash after varicella immunization. At the
age of 3, she received FluMist vaccine and developed a fever the following day. Over
the next few days, she developed lethargy, altered mental status, headache, photophobia,
seizure, papular rash and oral ulcers. She was admitted to the hospital and CSF studies
were consistent with viral meningoencephalitis (270 WBC, 30L, 63M, 100 RBC) although
HSV, CMV, EBV and enterovirus were negative. She was treated for presumed HSV encephalitis
with 21 days of IV acyclovir and 5 days of high dose steroids.
One week after discharge, she again developed papular rash on feet, headache, oral
ulcers and lethargy. She was admitted and CSF studies this time showed only 3 WBC
but positive HHV-6. Blood and skin swab were also positive for HHV-6. Immunology was
consulted while admitted and work up for primary immunodeficiency was initiated. Her
work up was normal including responses to vaccine titers, complement studies, functional
NK assay, T/B/NK panel, TLR assay, lymphocyte mitogen assay, tetanus antigen stimulation
assay and whole exome sequencing. She was found to have humoral immune deficiency
(low IgG and decreasing IgM) and was started and maintained on scIg replacement. She
was followed over time and her blood remained PCR positive for HHV-6 with viral loads
between 4-7 million copies/ml while asymptomatic. She was referred to Infectious Disease
who noted that her persistently high levels of HHV-6 were concerning for ciHHV-6.
Her father was tested and had a viral load of 1200 copies/ml suggesting inheritance
of ciHHV-6.
Discussion: Chromosomally integrated HHV-6 should be a consideration in cases of persistently
elevated HHV-6 levels. Given that any specimen obtained will contain HHV-6 DNA, this
may lead to misdiagnosis of active HHV-6 infection. In return, this may result in
the patient receiving unnecessary or incorrect treatment or missed diagnosis of other
etiology. It is important to note that HHV-6 levels will oftentimes exceed those seen
during active infection. Viral loads of greater than 1 million copies/ml are especially
concerning for ciHHV-6. Therefore, cases of persistently high HHV-6 levels, especially
when asymptomatic, should prompt the provider to consider ciHHV-6.
(242) Submission ID#812615
Truncating Mutations in SAMD9L Cause an Early-Onset Immune-Dysregulatory Syndrome
of Neutrophilic Panniculitis, Interstitial Lung Disease and Cytopenias
Adriana Almeida de Jesus, MD, PhD1, Bin Lin, PhD2, Katherine R. Calvo, MD, PhD3, Gina
A. Montelagere Sanchez, MD, MHS4, Jacob T. Mitchell, BS5, Bernadette Marrero, PhD6,
Jason Dare, MD7, Jon Burnham, MD8, Alice Chan, MD, PhD9, Yuriy Stepanovskiy, MD10,
Angela Rosen-Wolff, PhD11, Christian M. Hedrich, MD, PhD12, Min Ae Lee-Kirsch, MD13,
Liliana Bezrodnik, MD14, Analia Gisela Seminario, MD15, María Soledad CALDIROLA, PhD16,
Eric Allenspach, MD, PhD17, Troy R. Torgerson, MD, PhD18, Laura Finn, MD19, Alhanouf
A. Alsaleem, MD20, Su Jin Hwang, PhD21, Hye Sun Kuehn, PhD22, Sergio Rosenzweig, MD,
PhD23, Stephen Brooks, PhD24, Zuoming Deng, PhD24, Raphaela Goldbach-Mansky, MD, M.H.S.25
1Staff Scientist/Translational Autoinflammatory Disease Section, LCIM, NIAID, NIH,
Bethesda, MD
2Research Fellow/Translational Autoinflammatory Disease Section, LCIM, NIAID, NIH,
Bethesda, MD
3Staff Clinician/DLM, CC, NIH, Bethesda, MD
4Staff Clinician/Division of Clinical Research, NIAID, NIH, Bethesda, MD
5Post-baccalaureate fellow/Translational Autoinflammatory Disease Section, LCIM, NIAID,
NIH, Bethesda, MD
6Research Fellow/NIAID, NIH, Bethesda, MD
7Pediatric Rheumatologist/University of Arkansas for Medical Sciences
8Pediatric Rheumatologist/Children's Hospital of Philadelphia and the Perelman School
of Medicine at the University of Pennsylvania
9Assistant Professor/UCSF
10Pediatric Rheumatologist/Department of Pediatric Infectious Diseases and Immunology
Shupyk National Medical Academy for Postgraduate Education, Kiev, Ukraine
11Scientist/Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische
Universität Dresden, Dresden, Germany
12Pediatric Rheumatologist/Department of Women's & Children's Health, Institute of Translational
Medicine, University of Liverpool & Department of Paediatric Rheumatology, Alder Hey Children's
NHS Foundation Trust Hospital, Liverpool, UK
13Pediatric Rheumatologist/Department of Pediatrics, Medizinische Fakultät Carl Gustav
Carus, Technische Universität Dresden, Dresden, Germany
14Immunologist/Centro de Inmunología Clínica "Dra. Liliana Bezrodnik y equipo"
15Immunologist/Centro de Inmunología Clínica "Dra. Liliana Bezrodnik y equipo"- Servicio
de Inmunología Htal. de Niños "Dr. R.Gutierrez"
16PostDoctoral fellow/Servicio de Inmunología, Inst. Multidisciplinario de Investigación
en Patologías Pediátricas (IMIPP), Hospital de Niños Ricardo Gutiérrez.
17Assistant Professor/University of Washington and Seattle Children's Hospital, Immunology
and Rheumatology
18Assistant Professor/University of Washington and Seattle Children’s Hospital, Seattle,
WA
19Pathology Department/Children's Hospital of Philadelphia, Philadelphia, PA
20Post-doctoral fellow/Translational Autoinflammatory Disease Section, LCIM, NIAID,
NIH, Bethesda, MD
21Scientist/Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD
22Staff scientist/Immunology Service, Department of Laboratory Medicine, Clinical
Center, NIH, USA
23Senior Investigator; Chief/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center,
24Staff Scientist/NIAMS, NIH, Bethesda, MD
25Senior Investigator/Translational Autoinflammatory Disease Section, LCIM, NIAID,
NIH, Bethesda, MD
Abstract/Case Report Text
Background/Purpose: The Sterile Alpha Motif Domain Containing 9 Like protein that
is encoded by SAMD9L plays a role in endosome fusion, and deletions (haploinsufficiency)
of SAMD9L including loss of the chromosome 7 where SAMD9L is located (monosomy 7)
have been associated with myelodysplasia in humans and mice. Missense mutations in
SAMD9L were described in patients presenting with ataxia-pancytopenia syndrome. Here
we describe 6 patients with de novo frameshift mutations in SAMD9L who present with
early-onset systemic inflammation, variable interstitial lung disease and cytopenias.
Methods: Whole exome/genome sequencing (WES/WGS) on trios using Illumina HiSeq 2000
platform were performed. An interferon-response-gene score was assessed using a customized
Nanostring assay and RNA-seq was performed in patients and healthy controls (HCs).
Toll-like receptor (TLR) stimulation assays and STAT phosphorylation assay were performed
in patients and HCs, PBMCs, monocytes and T cells.
Results: We identified 6 patients with 4 de novo frameshift variants in SAMD9L (c.2626delA,
p.I876Lfs*15; c.2633delA, p.K878Sfs*12; c.2658_2659delTT, p.F886Lfs*11; c.2666delT,
p.F889Sfs*2). All 4 variants detected were not detected in public databases (gnomAD
and 1000G). Somatic reversion restricted to hematopoietic cells was observed in 1
patient. All 6 patients had disease onset between 1 and 7 days of life with generalized
nodular skin rashes, fever and increased inflammatory markers (ESR and CRP). Skin
biopsies from all 6 patients revealed a neutrophilic panniculitis. Four patients had
developed severe interstitial lung disease (ILD) triggered by respiratory viral infections
in infancy, all 4 developed pancytopenia, low B-cell count and hypogammaglobulinemia,
and two of those underwent bone marrow transplant. The other 2 patients developed
leukopenia, a low B cell count, hypogammaglobulinemia and recurrent pulmonary infiltrates
at the age of 3 and 5 years, respectively. Additionally, brain imaging revealed basal
ganglia calcifications and/or demyelinating changes in 5 out of the 6 patients. qRT-PCR
of healthy control cell subsets and tissues showed that SAMD9L mRNA relative expression
is high in B and NK lymphocytes, moderate in T cells, monocytes, neutrophils, lung
and muscle, and low in skin, liver, heart and kidney tissues. Analysis of each individual
gene expression level by nanostring in comparison with healthy controls demonstrated
significantly higher levels of the following IRGs: DDX60, EPSTI1, GBP1, IFI6, ISG15,
LY6E, OAS1, OAS2, OAS3, RSAD2, RTP4 and SOCS1. Whole blood RNA-seq was performed in
3 patients and pathway analysis with the differentially upregulated genes demonstrated
an enrichment of intraluminal vesicle formation and negative regulation of apoptotic
signaling pathways. Stimulation of PBMCs with the TLR ligands poly I:C, ODN, and LPS
induced a 200-fold increase in IFI27 and a 30-fold increase in IFNA1 and IFNB1 transcription
compared to baseline. One patient had constitutive upregulation of STAT1 and STAT6
in monocytes and of STAT1 and STAT3 in T cells.
Conclusion: We describe a novel immunedysregulatory disease caused by de novo truncating
variants in SAMD9L that presents similar to CANDLE with neutrophilic pannicultis and
points to an important role of SAMD9L on regulation of adaptive and innate immune
responses.
Acknowledgements: This work was supported by the NIH IRP of NIAID
(243) Submission ID#812619
Ataxia Telangiectasia with Recurrent urinary tract infections and Sepsis
Yatyng Chang, MD1, Melissa Cardenas-Morales, MD2, Camile Ortega, DO3, William Blouin,
ARNP4, Vivian Hernandez-Trujillo, MD5
1Pediatric Resident/Nicklaus Children's Hospital
2Fellow/Nicklaus Children's Hospital
3Allergist/Immunologist/Allergy and Immunology Care Center of South Florids
4Allergy/immunology Nurse Practitioner/Nicklaus Children's Hospital
5Director of Allergy & Immunology fellowship in Nicklaus Children's Hospital/Director
of Allergy & Immunology fellowship in Nicklaus Children's Hospital
Abstract/Case Report Text
Introduction: Ataxia Telangiectasia (AT) is caused by a defect in the ATM gene which
is responsible for repair of damaged DNA. It is a rare, devastating neurodegenerative
disease that results in ataxia and telangiectasias, particularly of the sclera and
skin. Those with AT are at increased risk for immunodeficiency and cancer. The immunodeficiency
is variable and may result in deficiency in humoral and cellular immunity in some
patients. Here we present a patient with Ataxia Telangiectasia and hypogammaglobulinemia
on immunoglobulin therapy who developed recurrent urinary tract infections (UTI) and
sepsis.
Case Presentation: The patient is a 23-year-old female with Ataxia Telangiectasia
and hypogammaglobulinemia who presented with three episodes of UTI, one of which resulted
in prolonged hospitalization due to sepsis and acute kidney injury (AKI). She presented
with 4 days of flank and back pain and was hospitalized for 3 days for E coli UTI.
She improved on IV antibiotics and was discharged home to complete treatment with
oral Ciprofloxacin. Due to persistent emesis, she was readmitted 2 weeks later with
urosepsis and AKI with a creatinine of 2.06 mg/dL, over 5 times her baseline creatinine.
After additional antibiotics and IV fluids, she improved clinically, renal function
normalized and she was discharged home. Renal ultrasound was unremarkable with no
anatomical abnormalities.
She was relatively healthy prior to this with only one episode of bacterial pneumonia
in 2006. She receives weekly subcutaneous immunoglobulin therapy dosed at 120 mg/kg
with normal IgG levels (1023, 931, 1078 mg/dL). At baseline, she had high IgM (550
mg/dL) and low IgA ( < 4 mg/dL) levels, as well as decreased T cells but normal NK
and B cells (489 cells/uL CD3+, 329 cells/uL CD4+, 107 cells/uL CD8+, 211 cells/uL
CD16+CD56+, and 357 cells/uL CD19+). She has hyperglycemia (on Metformin), hypertriglyceridemia
(on Atorvastatin) and hypertension (on Losartan). She is thin and wheelchair bound
with bilateral telangiectasias to the sclera, neck, and chest. She has occasional
eye bleeding and epistaxis, presumably from her telangiectasias. She has good hygiene
and good adherence to medications. She voids voluntarily, has no indwelling urinary
catheter and is not sexually active.
Discussion: Patients with Ataxia Telangiectasia may have frequent viral and bacterial
infections, most frequently upper and lower respiratory tract infections, as well
as wart and skin infections. Based on our review, this is the first reported case
of Ataxia Telangiectasia with hypogammaglobulinemia on immunoglobulin therapy with
recurrent UTIs complicated by urosepsis and AKI. Despite adequate IgG levels on immunoglobulin
therapy, our patient continued with recurrent UTIs. It is uncertain whether her non-ambulatory
status, hyperglycemia or related immunodeficiency are the causes for her increased
susceptibility to UTIs. The literature reports patients with AT and bladder wall telangiectasias
can result in significant hematuria, and perhaps this may be a source of entry for
bacteria and consequent development of UTI. This suggests that patients with Ataxia
Telangiectasia and recurrent UTIs may benefit from renal ultrasound and possible cystoscopy
to better visualize telangiectasias. We recommend consideration of workup for recurrent
UTIs in patients with Ataxia Telangiectasia.
(244) Submission ID#812624
The Fate of Early Polyreactive B Cells in Partial RAG deficiency
Krisztian Csomos, PhD1, Boglarka Ujhazi, MSc2, Peter Blazso, MD, PhD3, Jolan Walter,
MD, PhD4
1Research Associate/University of South Florida
2Biological Scientist/University of South Florida
3Assistant Professor/University of Szeged
4Division Chief, Pediatric Allergy/Immunology/University of South Florida and Johns
Hopkins All Children’s Hospital
Abstract/Case Report Text
Objectives: Patients with partial Rag deficiency frequently present with humoral autoimmunity
suggesting breach in tolerance mechanisms and subsequent expansion of autoreactive
B cell clones. Here we aim to trace polyreactive B cells and their descendants at
B cell developmental stages through our in-house bioinformatic pipeline, ImmChainTracer
(ICT).
Methods: The B cell receptor (BCR) was expressed as monoclonal antibodies from single
sorted mature naive B cells (n=30-50 per donor) from patients with hypomorphic RAG
deficiency and healthy donors. xThe recombinant monoclonal antibodies were screened
for polyreactivity (dsDNA, insulin, LPS and IFNα) by ELISA. In parallel, IgH repertoires
were deep sequenced from sorted mature naïve, activated naïve and memory B-cell compartments.
Our in-house assembled bioinformatic pipeline called ImmChainTracer (ICT) was applied
to track down the descendants of cloned autoreactive IgH sequences in repertoires
of subsets above.
Results: IgH sequences (n=125 including 45 polyreactive, 80 non-polyreactive clones)
from mature naive B cell from six patients with partial RAG deficiency and 3 healthy
donors (n=91 including 7 polyreactive, 84 non-polyreactive) were analyzed with our
novel in-house bioinformatic approach to track lineage fate in repertoire at specific
developmental stages. Interestingly, 28.8% of the patients’ sequences and their descendants
were identified in their mature naive, activated naive or memory B cell repertoires,
while none of the analyzed healthy donor clones were found at later subsets. Furthermore,
genealogical analyses of related clones revealed lineage expansion and progressive
positive antigen selection of the autoreactive clones in the patients.
Conclusions Our findings demonstrate that peripheral tolerance checkpoint is broken
in hypomorphic RAG patients. Our novel method enables tracing the fate of autoreactive
naive B cells in the effector repertoires. We have shown that impaired B cell tolerance
allows the expansion and persistence of autoreactive, potentially harmful B cell clones.
These clones reach the effector B cell compartments (memory B and plasmacell niches)
resulting in the generation of autoantibodies characteristic to hypomorphic RAG deficiency.
(245) Submission ID#812628
Reduced Toxicity Allogeneic Hct With A Busulfan, Fludarabine Regimen: A Promising
Approach For Non-CGD Primary Immune Deficiencies Requiring Myeloablation?
Sharat Chandra, MD1, Shanmuganathan Chandrakasan, MD. PhD2, Blachy Davila Saldana,
MD3, Jack Bleesing, MD, PhD4, Michael Jordan, MD4, Ashish Kumar, MD, PhD4, Michael
Grimley, MD5, Christa Krupski, DO, MPH6, Stella Davies, MBBS, PhD4, Rebecca Marsh,
MD7
1Assistant Professor, Division of Bone Marrow Transplantation and Immune Deficiency/Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH, Department of Pediatrics, University
of Cincinnati College of Medicine
2Assistant Professor/Division of Bone Marrow Transplant, Immunedysregulation and Immuno-hematology
Program, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta,
Emory University School of Medicine, Atlanta, GA, USA
3attending physician/Children’s National Medical Center, Washington, DC
4Professor of Pediatrics/Division of Bone Marrow Transplantation and Immune Deficiency,
Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, Department of Pediatrics,
University of Cincinnati College of Medicine, Cincinnati, Ohio
5Associate Professor of Pediatrics/Division of Bone Marrow Transplantation and Immune
Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, Department
of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
6Instructor of Pediatrics/Division of Bone Marrow Transplantation and Immune Deficiency,
Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, Department of Pediatrics,
University of Cincinnati College of Medicine, Cincinnati, Ohio
7Clinical Director, Primary Immune Deficiency Program/Department of Pediatrics, University
of Cincinnati, Cincinnati, Ohio; Division of Bone Marrow Transplantation and Immune
Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Abstract/Case Report Text
INTRODUCTION A reduced toxicity busulfan, fludarabine regimen with alemtuzumab or
anti-thymocyte globulin (Gungor et al.) was efficacious in patients undergoing allogeneic
HCT for CGD. We report our experience with a similar approach for patients with non-CGD
primary immune deficiencies needing a reduced toxicity myeloablative approach.
METHODS We retrospectively reviewed records of consecutive patients who underwent
allogeneic HCT for primary immune deficiencies with a preparative regimen containing
busulfan, fludarabine and alemtuzumab or anti-thymocyte globulin(ATG), at three transplant
centers between 2015-2018. Busulfan was given either every 6 hours over 4 days with
target AUC of 875 to 1025 μMol/min (based on q6 hr. dosing) or twice daily over 4
days with target AUC of 1800 to 2000 μMol/min (based on q12 hr. dosing) or once daily
over 4 days with a target AUC of 3600-4400 μMol/min (based on q24 hr. dosing). Fludarabine
150 mg/m2 to 180 mg/m2 was given divided over 4-6 days. Serotherapy included alemtuzumab
0.3 – 1.0 mg/kg or ATG 7.5 mg/kg given divided over 3 days. GVHD prophylaxis consisted
of cyclosporine and mycophenolate mofetil.
RESULTS Forty patients (WAS=12, HLH=10, CD40L deficiency=7, IPEX/VEOIBD=4, SCN=2,
IFNGR1 def./CID/X-SCID/MSN1/LAD=1) received busulfan, fludarabine and alemtuzumab
or ATG for allogeneic HCT (first HCT in 31 patients and second HCT in the 9 patients
with HLH). Median age was 2.0 years (range, 0.25 years – 19.8 years). Patients received
a graft from an HLA-matched related (n=11), unrelated (n=27), or single allele mismatched
related or unrelated donor (n=2). All except one patient engrafted at a median of
13 days (range,11-34 days). One patient developed veno-occlusive disease and two patients
developed diffuse alveolar hemorrhage. Notably, it was the second transplant for all
3 patients. Eight patients (20%) developed grade 2-3 acute GVHD and 2 patients (5%)
developed chronic GVHD. One patient developed primary graft failure and two patients
secondary graft failure. Nineteen patients (48%) maintained full donor (>95%) chimerism
following allogeneic HCT. Twenty patients (50%) developed mixed chimerism, predominantly
in the T-cell lineage, but T-cell donor chimerism progressively increased post-HCT.
At 1-year post-transplant, 15 of 20 patients (75%) with mixed chimerism had donor
myeloid chimerism >90% and T-cell chimerism >75%. Two patients underwent a second
transplant for graft failure. There were 6 deaths in the cohort. Overall survival
was 85%(34 of 40) and event free survival was 80%(32 of 40) at 1 year.
CONCLUSION Our experience suggests that a reduced toxicity busulfan, fludarabine regimen
with alemtuzumab or ATG as serotherapy offers a promising approach with low toxicity,
durable myeloid engraftment, low incidence of grade 2-4 GVHD and excellent survival
and can be considered for a variety of primary immune deficiencies where myeloablative
HCT is desired.
(246) Submission ID#812634
New Treatment Approach To Anti-NMDA Receptor Encephalitis Associated With Catatonia
Elif Dokmeci, MD1, Osman Dokmeci, MD2
1Associate Prof of Pediatrics, Pediatric Allergy and Immunology/University of New
Mexico
2Assistant Professor, Allergy and Immunology/University of New Mexico
Abstract/Case Report Text
This is an 18-year-old patient who has the diagnoses of anti-NMDA receptor encephalitis
with associated catatonia. The patient has history of a pineal gland germinoma diagnosed
in August 2018 after 8 months of double vision. However, after several months, the
patient developed difficulty in sleeping, anxiety and nightmares. The patient presented
to Emergency Department in February 2019 with personality changes. He was diagnosed
with NMDA encephalitis based on the clinical findings as well as presence of elevated
serum and CSF anti-NMDA antibodies. The patient was initially treated with high dose
systemic steroids with poor response. Due to the worsening of his clinical condition,
he was started on plasmapheresis, but had poor response to this therapy as well. These
treatments are known standard treatment options for this condition. During his hospital
stay, different therapies were discussed. Cyclophosphamide was one of the treatment
options, but because of the side effect profile and severe toxicity, we recommended
different treatment modality. We started the patient on rituximab as well as sirolimus
therapy to suppress both T and B-cell responses. After receiving two doses of rituximab
in addition to daily sirolimus, the patient showed improvement of his symptoms. And
declining NMDA receptor antibody titers.
This treatment plan was chosen for autoantibody mediated encephalomyelitis due to
the fact that rituximab has inhibitory effect on naive B cells, but not on the proliferation
of memory B cells and Sirolimus has profoundly inhibiting role on memory B cells as
well as a T-cell responses. Combination of sirolimus and rituximab therapy controlled
his autoantibody production which was an important goal for his autoimmune condition.
We present a new treatment approach for Anti-NMDA receptor encephalitis. Rituximab
was tried on these cases before but the combination of sirolimus and rituximab therapy
was never given before. We now recommended that on refractory cases of Anti-NMDA receptor
encephalitis, combination of Rituximab and Sirolimus therapy can be tried.
(247) Submission ID#812639
Mosaic Variants In Immune Function Genes Identified Through Exome Sequencing
Celine Hong, PhD1, Magdalena Walkiewicz, PhD2, Morgan Similuk, ScM, CGC3, Jia Yan,
MS, PhD4, Amy Hsu, n/a5, Vasu Kuram, MS6, Susan Huse, PhD7, Justin Lack, PhD8, Nathanael
Olson, n/a9, Justin Zook, PhD10, Steven Holland, MD11, Leslie G. Biesecker, MD12
1Staff Scientist/National Human Genome Research Institute, National Institutes of
Health
2Certified Molecular Geneticist/National Institute of Allergy and Infectious Diseases,
National Institutes of Health
3Genetic Counselor/National Institute of Allergy and Infectious Diseases, National
Institutes of Health
4Operations Manager and Genetic Counselor/National Institute of Allergy and Infectious
Diseases, National Institutes of Health; Medical Science and Computing, LLC
5Biologist/Laboratory of Clinical Immunology and Microbiology
6Data Scientist/NIAID
7Bioinformatics Scientist/NIAID
8Lead, NIAID Collaborative Bioinformatics Resource/National Institute of Allergy and
Infectious Diseases
9Researcher/National Institute of Standards and Technology
10Lead, Genome in a Bottle Analysis Team/Genome in a Bottle Consortium, National Institute
of Standards and Technology
11Director, Division of Intramural Research; Chief, Immunopathogenesis Section/Laboratory
of Clinical Immunology and Microbiology (LCIM), Division of Intramural Research (DIR),
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH),
12Distinguished Investigator, Chief, Medical Genomics and Metabolic Genetics Branch/National
Human Genome Research Institute, National Institutes of Health
Abstract/Case Report Text
A mosaic gene variant is one which is present in some, but not all, cells within an
individual. They are increasingly associated with a number of diseases, including
a number of primary immunodeficiency disease (PID). Here we systematically analyzed
mosaic variants in known or putative immunodeficiency genes from exome sequencing
data from 998 individuals. Lofreq was used to identify mosaic variants with a variant
allele fraction (VAF) of 0.05-0.30 (0.50 is the VAF for a non-mosaic, heterozygous
variant). We removed variants from extreme read-depth (> 2 standard deviations), unmappable,
repeat-rich, and duplicated genomic regions. The average number of detected variants
per MB was 3.2 and the total number of genomic locations with variants was 65,446.
Mosaic variants were underrepresented in exonic regions, suggesting that coding variants
may be deleterious. More mosaic variants were detected in saliva exomes compared to
peripheral blood exomes (p-value < 1 x 10-5), suggesting tissue-specific mosaic variants
in buccal epithelial cells and white blood cells of saliva. To understand the clinical
relevance of these findings, the variants were further filtered to include only nonsynonymous
variants found in fewer than 1% of samples, leaving a total of 6,808 variant locations.
Of the remaining variant locations, 40 had a pathogenic assertion in the human gene
mutation database, and 140 were in International Union of Immunological Societies
PID genes. Further variant interpretations and clinical correlations are underway.
These data suggest that mosaic variants in PID genes are common, vary by location
of collection, and may have clinical diagnostic relevance.
(248) Submission ID#812640
A rare case of ARPC1B deficiency causing hemorrhagic gastroenteritis, failure to thrive,
and thrombocytopenia
Melissa Watts, MD MPH1, Amer Khojah, MD2, Abigail Lang, MD1
1Allergy/Immunology Fellow/Northwestern University
2Attending Physician, Assistant Professor/Division of Allergy & Immunology, Ann &
Robert H Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School
of Medicine, Chicago, IL
Abstract/Case Report Text
Introduction/Background: The ARPC1B (actin related protein 2/3 complex subunit 1B)
gene is a protein coding gene prominently expressed in blood cells and is necessary
for the assembly and maintenance of the human actin-related protein 2/3 complex (Arp2/3).
Actin polymerization plays a central role in many immune functions including proliferation
and differentiation of immune cells, migration, intercellular and intracellular signaling
and activation of both innate and adaptive immune responses. Defects in the actin
cytoskeleton affect hematopoietic cells in the bone marrow and the immune response
giving rise to a distinct primary immune deficiency, which is phenotypically similar
to Wiskott-Aldrich Syndrome (WAS). ARPC1B deficiency clinically presents as a severe
multisystem disease which includes platelet abnormalities, recurrent infections, failure
to thrive, inflammatory changes in the intestine, eczema, cutaneous vasculitis, eosinophilia,
and elevated inflammatory markers. ARPC1B deficiency is rare and has only recently
been described in the literature. Here we present a clinical case of a patient found
to have a pathogenic ARPC1B mutation via whole exome sequencing.
Case report: Here we describe a 15 month old Somalian boy who presented to the immunology
team at 9 months of age with hematemesis, hematochezia, melena, failure to thrive,
atopic dermatitis, hypothyroidism, autoimmune thrombocytopenia and recurrent infections
concerning for a primary immune deficiency. Family history was notable for parental
consanguinity and an older sibling with a similar presentation of hemorrhagic gastroenteritis
who died in Kenya around 3 months of age due to complications of his symptoms. The
initial primary immunodeficiency evaluation revealed normal inflammatory makers, normal
IgG and protective vaccine (Prevnar and tetanus) response. IgA and IgE were elevated
at 364 mg/dl and 99.6 KU/L respectively. Flow cytometry was remarkable for T cell
lymphopenia (CD3 1541, CD4 1163, and CD8 363) with reduced naïve CD4 and CD8 T cells.
B and NK cell count were normal. ALPS panel and WAS protein expression was unremarkable.
Whole exome sequencing was performed and revealed homozygotic mutation of ARPC1B c.392T>C,
IVS4+2T>C which was predicted to be a pathological variant. Subsequently, DHR flow
cytometry with fMLP showed significant increase of DHP fluorescent (MFI 9.7 when compared
to control MFI 3.7) consistent with findings from other ARPC1B deficiency patients.
At the time of the most recent clinic visit, the patient has remained stable with
no interim infections and is doing well on thyroid hormone replacement. The current
plan is for the patient to undergo a stem cell transplant for the ARPC1B deficiency
as he is at high risk for recurrent infections and severe disease. Although this gene
mutation is rare, review of the current literature describes patients with this condition
that have undergone stem cell transplant and have done well. At this time, this seems
to be the best option for management, and it may potentially be curative.
(250) Submission ID#812646
Development of Cutaneous T Cell Lymphoma in Common Variable Immunodeficiency: Diagnosing
the Rash
Daniel Colon-Rios, BS1, Mario Rodenas, MD2
1Postgraduate Associate/Department of Therapeutic Radiology, Yale School of Medicine,
New Haven, CT
2Assistant Professor and Section Chief/Section of Allergy & Clinical Immunology, Division
of Rheumatology, Department of Medicine, UF College of Medicine, Gainesville, FL
Abstract/Case Report Text
Introduction: Common variable immunodeficiency (CVID) is a disorder characterized
by impaired immunoglobulin production and frequent or recurrent infections, but also
associated with an increased risk for developing malignancies such as lymphomas. Although
intravenous and subcutaneous immunoglobin G replacement has been successful in reducing
the number of bacterial infections and prolonging survival, it fails to address other
complications that arise from this disorder. We report a case of a patient with CVID
who developed mycosis fungoides (MF). MF is a rare form of cutaneous T-cell lymphoma,
occurring in about 1 in 100,000 to 350,000 individuals, lack of treatment could potentially
be fatal.
Case Presentation: A 44-year-old Caucasian woman with a history of ulcerative colitis,
allergic rhino-conjunctivitis and tonsillectomy was referred to the immunology clinic
for evaluation of low serum immunoglobulins.
There was no family history of infections or immune deficiencies, but paternal grandfather
had colon cancer and maternal grandmother had lung cancer. The patient reported frequent
episodes of bronchitis, and sinus infections. Immunizations were up to date for her
age. Medications included azathioprine, cetirizine, fluticasone nasal spray, hyoscyamine,
montelukast, lactobacillus, omeprazole, and olopatadine ophthalmic solution. No history
of frequent use of systemic steroids.
Initial serum immunoglobulins revealed normal IgE and IgM but low IgA (72 mg/dL, normal
range 81-463 mg/dL) and low IgG (522 mg/dL, normal range 694-1618 mg/dL). CBC with
differential, lymphocyte subsets, C3 and C4 levels were normal. While she had adequate
protective titers against Haemophilus influenza type b, diphtheria and tetanus, titers
against pneumococcus were < 50% protective and she failed to mount an adequate response
to pneumococcal polysaccharide vaccine. Given her diagnosis of CVID, she started SCIG
(500 mg/kg every 2 weeks). A year later, she developed a bilateral nonpruritic rash
in the abdomen and upper trunk. Initial skin biopsy suggested a drug reaction. A subsequent
biopsy revealed a superficial perivascular lymphoid infiltrate with focal epidermotropism
and positive T cell receptor gamma gene rearrangement, consistent with MF. Testing
for cell T receptor Beta gene rearrangement was negative.
While MF treatment consisted of triamcinolone 0.1% ointment, treatment for ulcerative
colitis transitioned from azathioprine to vedolizumab.
Conclusions: Cutaneous T cell lymphomas, although uncommon, can be seen in CVID. There
are several reasons for the increased risk of lymphoma in CVID. The role of chronic
infections and the development of lymphoma as of yet, is not clear. Skin reactions
to SCIG products in the areas of infusion are relatively common and resolve promptly.
High index of suspicion is crucial in obtaining tissue sample to confirm or rule out
malignancy therefore avoiding delaying proper treatment.
(251) Submission ID#812650
LRBA Facilitates Autophagy Through Binding To PIK3R4
laura Gámez-Díaz, PhD1, Bodo Grimbacher, MD2
1Postdoc/Institute for Immunodeficiency, University Medical Center Freiburg
2Principal Investigator/Center for Chronic Immunodeficiency, Faculty of Medicine,
Medical Center - University of Freiburg, Freiburg, Germany
Abstract/Case Report Text
Patients with lipopolysaccharide responsive beige-like anchor protein (LRBA) deficiency
present with a plethora of immune related defects including a defective humoral response
characterized by low numbers of switched memory B cells and plasma cells, as well
as an impaired production of antibodies, leading to recurrent infections. However,
the molecular mechanisms behind the defective B cell response remain unknown. To gain
better insights into the possible roles of LRBA in B cell physiology, we screened
for LRBA-interacting proteins using computational predictions. Twenty-seven proteins
involved in vesicle trafficking and autophagy were identified as potential LRBA-interacting
partners. To validate those potential LRBA interactions, we performed co-immunoprecipitations
and proximity ligation assays (PLA), finding that endogenous LRBA interacts with the
phosphoinositide 3-kinase regulatory subunit 4 (PIK3R4) in B cells. PIK3R4 (aka VPS15)
is the regulatory subunit of VPS34, the catalytic subunit of the PI3K-III complex,
which acts as a positive regulator of autophagy by producing phosphatidyl inositol-3
phosphate (PI(3)P). Autophagy is a catabolic mechanism essential for cell survival
and plasma cell differentiation. In fact, we observed that reduced LRBA impaired the
production of PI(3)P upon autophagy induction. In addition, we observed in both LRBA-deficient
HeLa and B cells reduced mobility, abnormal accumulation and increased size of autophaghosomes,
accompanied by an atypical lysosomal positioning. These abnormalities are due to a
blockade of the autophagosome-lysosome fusion, as detected by reduced LC3-II lipidation
upon autophagy induction in the presence of lysosome inhibitors. Interestingly, LRBA-deficient
HeLa and B cells exhibited enhanced activity of mammalian target of rapamycin complex
1 (mTORC1) signaling, a key suppressor of autophagy whose activation possibly contributes
to defective autophagy. Taken together, B lymphocytes lacking LRBA can form autophagosomes
but they fail to fuse with lysosomes. Thus, we propose a role of LRBA at late stages
of autophagy through the binding to PIK3R4.
(252) Submission ID#812659
Eosinophilic esophagitis in patients with Phosphoinositide 3-Kinase p110δ
Jamie Lawson, RN1, Gulbu Uzel, MD2, Sharon Webster, RN3
1Research Nurse Specialist/National Institute of Allergy and Infectious Disease
2Staff Clinician/Laboratory of Clinical Immunology and Microbiology (LCIM), Division
of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases
(NIAID), National Institutes of Health (NIH),
3Study Nurse Coordinator/Medical Science and Computing, LLC in support to the Laboratory
of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious
Diseases, National Institutes of Health
Abstract/Case Report Text
APDS caused by gain-of-function mutations (GOF) in the genes (PIK3CD and PIK3R1),
encoding for the p110δ and p85 subunits of phosphoinositide 3-kinase δ (PI3Kδ), results
in hyperactivation of the PI3K/AKT/mTOR/S6K pathway and lead to immune dysregulation,
lymphoproliferation and immunodeficiency. APDS manifests with respiratory tract infections,
bronchiectasis, susceptibility to Herpes group viruses, autoimmunity, cytopenia, lymphoproliferation
and lymphoma. Gastrointestinal system manifestations include enteropathy, colitis,
and liver disease. Eosinophilic esophagitis (EoE) or eosinophilic gastrointestinal
disease (EGD) have been under diagnosed in reported APDS cohorts.
Objectives: To review the incidence, demographics and relevant clinical data for eosinophilic
gastrointestinal disease in a single center APDS cohort.
Methods: Review of clinical and laboratory findings from 70 APDS patients followed
at the NIH Clinical Center, from 2005 to 2019.
Results: 12 patients were either historically diagnosed or actively studied at our
center for EGD. Incidence of all EGD is 17 % in our cohort and all patients had mutations
in PIK3CD, none in PIk3R1. Most patients also had multiple GI manifestations.
Conclusion: Immunopathology and genetic predisposition leading to EoE is complex.
Eosinophilic GI disease including EoE appears to represent significant GI pathology
in APDS. This implies that activation of PI3K pathway may be directly involved in
the etiology of EoE.
(253) Submission ID#812666
A Novel Gain of Function Mutation in NLRC4 with Phenotypic Variability in 3 Siblings
Akaluck (Ben) Thatayatikom, MD, RhMSUS1, Ezequiel Borgia, MD2, Sthorn Thatayatikom,
MD, MSc3, Genie Beasley, MD4, Melissa Elder, MD, PhD5
1Associate Professor and Pediatric Rheumatology Fellowship Training Program Director/Division
of Pediatric Allergy/Immunology/Rheumatology, Department of Pediatrics, College of
Medicine, University of Florida, Gainesville, FL
2Pediatric Rheumatology/Immunology Fellow/Division of Pediatric Allergy/Immunology/Rheumatology,
Department of Pediatrics, College of Medicine, University of Florida, Gainesville,
FL
3Assistant Professor/Division of Pediatric Allergy/Immunology/Rheumatology, Department
of Pediatrics, College of Medicine, University of Florida, Gainesville, FL
4Assistant Professor/Division of Pediatric Gastroenterology, Department of Pediatrics,
College of Medicine, University of Florida, Gainesville, FL
5Professor, Chief Division of Pediatric Allergy/Immunology/Rheumatology/Division of
Pediatric Allergy/Immunology/Rheumatology, Department of Pediatrics, College of Medicine,
University of Florida, Gainesville, FL
Abstract/Case Report Text
Introduction: Activation of the NOD-like receptor family CARD-containing 4 protein
(NLRC4) leads to the formation of an inflammasome. The inflammasome, a large cytosolic
multiprotein complex of innate immunity, promotes proteolytic cleavage, maturation,
and secretion of pro-inflammatory cytokines, including IL-1 and IL-18. A gain-of-function
mutation (GOF) in the gene encoding NLRC4 or NLRC4-inflammasomopathy is characterized
by hyperinflammation with persistent elevated IL-18, infantile enterocolitis, and
early-onset macrophage activation syndrome (MAS).
Objectives: To describe phenotypic variation among three siblings with a novel NLRC4
GOF variant and to expand our current understanding of the clinical manifestations
of the disease
Methods: Clinical and laboratory features were studied in three siblings of a Hispanic
family with a novel NLRC4 GOF variant.
Results: A novel variant, c.1475G>A (p.Arg492Gln) on the NLRC4 gene, was identified
in a 3-year-old male with recurrent febrile episodes since one year of age. His laboratory
findings showed highly elevated ESR, CRP, IL-18, and fecal calprotectin. His endoscopic
finding was unremarkable. The recurrent fever partially responded to canakinumab.
A 10-year-old sister with ileocolonic Crohn's disease for two years was found with
the same NLRC4 variant and highly elevated IL-18. Crohn's disease was well controlled
after adding infliximab infusion to methotrexate therapy. A15-year-old sister, who
has been asymptomatic and healthy, was tested with the same positive NLRC4 variant
and highly elevated IL-18. The NLRC4 variant is inherited from their father, who currently
has a diagnosis of psoriasis vulgaris. The IL-18 levels of the three siblings show
in the Figure 1.
Conclusions: We report a novel c.1475G>A (p.Arg492Gln) variant in the NLRC4 gene causing
persistent elevated IL-18 and autoinflammatory syndrome with recurrent fever and Crohn's
disease. The clinical manifestations of the same variant may be variable even in the
same family. In addition to the early onset of enterocolitis and MAS, the NLRC4-inflammasomopathy
should be considered in children with unexplained recurrent fever episodes and persistent
high IL-18.
Fig 1. IL-18 levels of the three siblings with a novel variant, c.1475G>A (p.Arg492Gln)
on the NLRC4 gene
(254) Submission ID#812671
Outcome Of Hematopoietic Stem Cell Transplantation In A Case Of Familial Hemophagocytic
Lymphohistiocytosis With A Syntaxin 11 Gene Mutation, A Non-T-Cell-Depleted Graft
From An Haploidentical Donor
Oscar Porras, MD, PhD1, Gustavo Lazo-Páez, MD2, Gabriela Ivankovich-Escoto, MD2, Dora
Matus-Obregón, MD2
1Department chief/Department of Pediatric Immunology and Rheumatology, National Children´s
Hospital "Dr. Carlos Sáenz Herrera"
2Consultant/Department of Pediatric Immunology and Rheumatology, National Children´s
Hospital "Dr. Carlos Sáenz Herrera"
Abstract/Case Report Text
Familial Hemophagocytic Lymphohistiocytosis type 4 (FLH-4) is an autosomal recessive
disease, that arises from the mutation of STX11. Patients with FLH-4 develop the classic
HLH phenotype early in life, with periods of remission. The pathogenesis is associated
with a defect of perforin-dependent cytotoxicity. T-CTL and NK cells fail to remove
abnormal cells, consequently, an uncontrolled proliferation and activation of CD8+
T cells and macrophages develops and generates an inflammatory cytokine storm and
a solid organs infiltration. Mortality of FHL-4 is very high without treatment; allogeneic
HSCT is the only curative therapy. We report the outcome of a child with FHL-4, four
years after his treatment with an allogeneic HSCT using an HLA haploidentical donor.
Case report: A boy born in December 2007, previously healthy, the only child of parents
without consanguinity. He has a normal family and perinatal history. When he is 7
years old, he begins suffering from with fever, arthralgia, hepatosplenomegaly and
pancytopenia. He meets the diagnostic criteria for Hemophagocytic Lymphohistiocytosis
(HLH) and received treatment with iv methylprednisolone and entered in remission of
its HLH. Six months later, he restarts his clinical picture of HLH and receives treatment
with the HLH-2004 protocol, which leads to remission. A year later he presents a new
episode of HLH that responds to IVIg, cyclosporin A and dexamethasone. The possibility
of primary HLH is then suggested. When he is 8 years old, the molecular diagnosis
is made with the identification of a mutation in the STX11 gene, the case was classified
as FHL-4 due to Syntaxin 11 deficiency. In October 2015, a HSCT was performed. At
the age of 12, his clinical status is evaluated and laboratory studies show that his
immunodeficiency due to Syntaxin 11 deficiency was cured. His 42-year-old mother,
HLA haploidentical was used as a donor and a protocol developed for the treatment
of Osteopetrosis was applied. The HSCT protocol did not use a T-cell depleted graft.
HSTC conditioning was done with Melphalan days -11 and -3, Fludarabine days -7 to
-2, Anti-thymocyte globulin days -7 and -6, and Cyclophosphamide day -2. Prophylaxis
against graft vs host disease was with Tacrolimus, Methylprednisolone, Methotrexate
and Mycophenolate mofetil. Engraftment was detected at day +14, no evidence of graft
vs host disease was detected and he leaves the hospital at day +35.
Outcome: Four years after the HSCT, he is a healthy 12 years old child, which has
not experienced new episodes of HLH. A quimerism test showed 100% of hematopoiesis
from the donor. The hemogram, a lymphocyte distribution in peripheral blood and a
phytohemagglutinin blastic stimulation were normal. There is no clinical evidence
of graft vs host disease. His length and weight are normal for his age, and he attends
school at the level for his age.
Conclusions: The use of HSTC protocols with haploidentical donor and a non-T-cell-depleted
graft is an effective therapy for FHL-4 cases. The outcome of the treatment shows
a complete immunological reconstitution and the absence of graft vs host disease.
(255) Submission ID#812673
Characterization of Cytopenias in Primary Immunodeficiencies in the USIDNET Registry
Deepti Deshpande, MD, MPH1, Angela Chan, MD2, Kathleen Sullivan, MD, PhD3, Yu Joyce,
MD4
1Fellow in Training/Columbia Univeristy
2Fellow in Training/Columbia University
3Chief of Allergy Immunology/Children's Hospital of Philadelphia
4Assistant Professor, Pediatrics/Columbia Univeristy
Abstract/Case Report Text
Background: Patients with primary immunodeficiencies (PID)s often present with cytopenias,
either as a feature of the underlying disease or as a complication. We sought to identify
and characterize the PID patients with and without reported cytopenias enrolled in
the United States Immunodeficiency Network (USIDNET) registry.
Methods: We included all the subjects enrolled in the entire USIDNET registry (n=4005)
through April 2019. PID diagnoses were categorized using 2017 International Union
of Immunological Societies (IUIS) categories. Patients were categorized with cytopenia
if they had one or more of the following diagnoses: such as pancytopenia, lymphopenia,
neutropenia, monocytopenia, anemia, and thrombocytopenia. Those with and without any
reported cytopenias were compared using chi2 tests (Fisher’s exact) for categorical
data and continuous data were compared using non-parametric tests (Mann Whitney Wilcoxon
rank sum test).
Results: The USIDNET registry had 4005 individuals with a median age of 19 years (interquartile
range 8-41 years), and the median age at diagnosis was 8 years (interquartile range
1.4 to 29.9 years). About one-third (30.6%, 1224/4005) individuals had at least one
reported cytopenia and 7.8% (314/4005) had at least one reported immune cytopenia.
The registry had 53.6% (2003/3735) males and 46.4% (1732/4005) females with a similar
distribution among those with reported cytopenias. Most patients identified as White
(86%, 2674/3099) and Black (7%, 206/3099) with a similar distribution among those
with and without cytopenia. The majority of individuals (88%, 1986/2253) were alive
at last visit; however, those with reported cytopenia (19.7%, 161/816) had a higher
mortality than those without cytopenia (7.4%, 106/1437); (p < 0.001). Subjects with
reported cytopenia as compared to those without were more likely to have received
immunoglobulin replacement (77% vs 70.5%, p < 0.001). Individuals in IUIS diagnostic
categories I (14.1%, 172/1215), II (15.2%, 185/1215), III (44.8%, 544/1215) and IV
(11.2%, 136/1215) accounted for the majority (85%) of diagnoses in those subjects
with cytopenia. The individual diagnoses most often reporting cytopenias included
CVID (34.9%), SCID (8.3%), CGD (6.4%), Wiskott Aldrich syndrome (5.8%) and DiGeorge
syndrome (5.4%). Most commonly reported types of cytopenias included anemia (17.2%,
689/4005), thrombocytopenia (11.9%, 476/4005), neutropenia (7.7%, 308/4005) and lymphopenia
(6.3%, 254/4005). Overall reported frequency of malignancies in the registry was 7.6%
(304/4005). However, more malignancies were noted among those with reported cytopenias
(11.8%, 145/1224) as compared to those without reported cytopenias (5.7%, 159/2781);
(p= < 0.001), which was a similar effect when both hematologic and non-hematologic
malignancies were assessed separately. Among those with and without reported immune
cytopenias, there was a higher frequency of hematologic malignancy (6.7% vs 3%, p
< 0.001).
Conclusions: Cytopenias are commonly reported among all subjects with PIDs in the
USIDNET registry; however, differences are seen in the frequencies of reported immune
and non-immune cytopenias within specific diagnoses. Individuals with PIDs and cytopenias
(both immune and non-immune) may have higher mortality and frequency of malignancy
as compared to those individuals without reported cytopenias. A high index of suspicion
and close monitoring may be warranted in this potentially higher risk group of PID
individuals with cytopenias.
(256) Submission ID#812799
Daniel Leung, MBBS 2023, MResMed 20231, Yu-lung Lau, MBChB, MD (Hon), FRCPCH, FHKAM,
FHKCPaed2, Pamela Lee, MBBS (HK), MD (HK), FHKCPaed, FHKAM (Paediatrics)3
1MRes[Med] student/Department of Paediatrics and Adolescent Medicine, The University
of Hong Kong
2Chair Professor of Paediatrics/University of Hong Kong
3Assistant Dean (Clinical Curriculum) Programme Director (Pedagogy and Training),
Bau Institute of Me/University of Hong Kong
Abstract/Case Report Text
Background: Chronic granulomatous disease (CGD) is one of the more common primary
immunodeficiencies (PIDs) in the Asian Primary Immunodeficiency Network (APIN).
Objectives: To describe and analyze the epidemiology, genotype, phenotype and clinical
care of chronic granulomatous disease in the Asia Pacific and beyond.
Methodology: Targeted Sanger sequencing was carried out on 190 referred potential
CGD families, followed by whole exome sequencing when needed in 7 families. Clinical
notes of 90 patients from referrers have been retrieved and could be deep-phenotyped
manually using human phenotype ontology (HPO) vocabulary. Analysis of 12 non-overlapping
Asian CGD cohort studies identified on PubMed was conducted to study the infection
profiles. An online survey was sent to all APIN referring doctors to investigate clinical
practices for CGD.
Results: Preliminary data from the ongoing project are available. Sanger sequencing
resulted in diagnoses of 104 CGD patients, 78 of them X-CGD and 26 AR-CGD, and 50
X-CGD carriers. Follow-up whole exome sequencing for other suspected CGD or PID patients
failed to diagnose any additional cases of CGD despite a review for CYBC mutations
after its discovery. Genotype-wise, there are 78 CYBB, 9 CYBA, 13 NCF1 and 4 NCF2.
Preliminary HPO analysis showed the top 3 phenotypic abnormality HPO terms are abnormality
of the respiratory system HP:0002086 (78%), abnormality of the digestive system HP:0025031
(73%) and abnormality of the integument HP:0001574 (49%). AR-CGD is associated with
fewer applicable phenotypic abnormality HPO terms and fewer applicable total HPO terms
under the phenotypic abnormality subontology by linear regression. Independent samples
T test with selected individual HPO terms revealed that AR-CGD is significantly and
negatively associated with infection following live vaccination HP:0020085, sepsis
HP:0100806 and perianal abscess HP:0009789. In the 12 Asian cohort studies on CGD,
the top 3 implicated microbial genera are mycobacteria (38%), staphylococci (14%)
and Aspergillus (14%). Ecologic analysis revealed that mycobacterium tuberculosis
infection and Candidiasis correlate with higher annual precipitation and higher average
temperature of the study site. 18 responses to the CGD care survey have been collected
from 13 centers in the Asia Pacific and 3 centers in Africa. The centers have collectively
diagnosed 451 CGD patients, including 12 X-CGD carriers with carrier disease and 11
adult CGD patients. Among the 16 centers, biochemical CGD diagnostics (nitroblue tetrazolium
test or dihydrorhodamine 123 test) are available at 10 only. While most centers offer
septrin and itraconazole as prophylactic medication for CGD, 1 center offers itraconazole
only and 1 septrin only. One elected to prescribe IFN-gamma in addition. Only 6 centers
have performed hematopoietic stem cell transplants for CGD.
Reference
1. P. P. Lee, Y. L. Lau, Improving care, education, and research: the Asian primary
immunodeficiency network. Ann N Y Acad Sci 1238, 33-41 (2011).
(258) Submission ID#812919
Title: Patient and Clinical Characteristics of a Large US Sample of Patients With
Primary Immunodeficiency Diseases (PID) Initiating Subcutaneous Immunoglobulin (SCIG)
Therapy
Mary E. Ritchey,1* Colin Anderson-Smits,2 Jordan Orange,3 Michelle Park,2 Zhongwen
Huang,2 J. Bradley Layton1
1RTI Health Solutions; 2Shire US Inc., a Takeda company; 3Columbia University College
of Physicians and Surgeons
*Affiliation at the time of the study
INTRODUCTION/BACKGROUND
Primary immunodeficiency diseases (PID) are a group of rare, heterogenous disorders
caused by an array of genetic abnormalities that impair the immune system. Immunoglobulin
(IG) replacement therapy (IGRT) is standard first-line treatment for most forms of
PID with defective antibody production. Subcutaneous IG (SCIG) is an increasingly
popular route of administration with different options, from highly concentrated 20%
IG (cSCIG) to facilitated 10% IG (fSCIG) delivered with Recombinant Human Hyaluronidase.
Patient and clinical characteristics between PID patients and those who are incident
SCIG users are poorly understood.
OBJECTIVE: Identify and describe demographic, clinical, and treatment characteristics
of patients with PID in the US and those initiating SCIG treatment.
DESIGN/METHODS: This claims-based cohort study identified PID patients and PID patients
who were new users of IGRT from 2012–2018 via diagnosis codes in IBM® Watson HealthTM
MarketScan® Research Databases (Figure). Clinical and demographic characteristics,
including the use of a novel claims-based weighted algorithm (Risk Vital Sign; RVS)
and those initiating IVIG and SCIG, were described. Stratified analysis based on PID
diagnosis codes was performed. Probability of receiving available IG treatments based
on baseline characteristics was evaluated by logistic regression and propensity score
methods.
RESULTS: Selected clinical and demographic characteristics, severity measures, and
previous treatments between the overall PID population (n=382,131), PID patients initiating
SCIG (n=2,604), and PID patients initiating IVIG (n=15,327) are presented in the table.
Patient characteristics and previous treatments tended to be stable, although hypertension,
obesity, and corticosteroid use increased during the study period. New IG users tended
to be older and female, with increased depression, dyslipidemia, and hypertension
than all PID patients. New SCIG users had more diagnoses of respiratory (e.g., asthma,
COPD) and inflammatory (e.g., arthritis, fibromyalgia, inflammatory bowel disease)
comorbidities and less cancer than all PID patients. New SCIG users compared with
new IVIG users had increased asthma and COPD, fibromyalgia, and inflammatory bowel
disease and decreased cancer and peripheral vascular disease.
Previous corticosteroid use was higher in IG users than all PID patients. Among SCIG
users, prior PID treatments of IV antibiotics, and oral high potency antibiotics were
similar to all PID patients. IVIG users had higher IV antibiotic and antifungal use.
RVS was initially developed to identify patients likely to have undiagnosed PID. This
analysis applied RVS to patients diagnosed with PID to assess severity. RVS based
on 1-year history in the overall PID cohort was predominantly Low, with only 18.0%
of patients scoring in the Medium and High ranges. RVS was increased in incident IG
users, with (37.4% Medium/High for SCIG; 46.4% Medium/High for IVIG). In other markers
of severity, SCIG users had more sinusitis and IVIG had more pneumonia than all PID.
IG users had fewer abscesses, cellulitis, and otitis media than the full PID cohort.
CONCLUSIONS: This exploratory analysis showed a trend toward increased hypertension,
inflammatory and respiratory comorbidity, higher RVS, and previous corticosteroid
treatment in patients initiating on IG compared with all PID patients. Results could
be confounded based on PID diagnosis codes used and warrants further research.
Author disclosures: MP, CAS, and ZH are employees and stockholders of the Takeda group
of companies. JO is a consultant to Takeda. JBL is an employee of RTI Health Solutions,
an organization funded by Takeda to conduct this research. MER was an employee of
RTI Health Solutions at the time this research was conducted.
Presenting author: Colin Anderson-Smits
Submission topic: Immunoglobulin Replacement Therapy
Table 1
Clinical and demographic characteristics, severity measures, and previous treatments
for the PID cohort, SCIG initiators, and IVIG initiators
Characteristics
PID Cohort (N = 382,131)
SCIG Initiators (n = 2,604)
IVIG Initiators (n = 15,327)
Age, median (IQR)
46 (34)
48 (34)
54 (30)
Sex, n (%)
Female
226,785 (59.3)
1,787 (68.6)
8,753 (57.1)
Male
155,346 (40.7)
817 (31.4)
6,574 (42.9)
Geographic region, n (%)
North Central
66,736 (17.5)
406 (15.6)
3,022 (19.7)
Northeast
69,027 (18.1)
302 (11.6)
2,179 (14.2)
South
128,933 (33.7)
1,056 (40.6)
5,018 (32.7)
West
51,425 (13.5)
353 (13.6)
2,168 (14.1)
Unknown
66,010 (17.3)
487 (18.7)
2,940 (19.2)
Insurance type, n (%)
Commercial
278,385 (72.9)
1,877 (72.1)
9,658 (63.0)
Medicaid
60,010 (15.7)
456 (17.5)
2,765 (18.0)
Medicare supplementary
43,736 (11.4)
271 (10.4)
2,904 (19.0)
Clinical characteristics, n (%)
Arthritis
87,755 (23.0)
797 (30.6)
4,757 (31.0)
Asthma
96,062 (25.1)
1,533 (58.9)
5,804 (37.9)
Cancer
50,405 (13.2)
282 (10.8)
3,350 (21.9)
Cerebrovascular disease
42,202 (11.0)
348 (13.4)
2,694 (17.6)
COPD
143,829 (37.6)
1,852 (71.1)
8,928 (58.3)
Cytomegalovirus
5,556 (1.5)
32 (1.2)
769 (5.0)
Depression
72,114 (18.9)
792 (30.4)
4,255 (27.8)
Diabetes
73,839 (19.3)
526 (20.2)
3,970 (25.9)
Dyslipidemia
144,892 (37.9)
1,160 (44.6)
7,509 (49.0)
Dysthymia
17,986 (4.7)
224 (8.6)
1,093 (7.1)
Fibromyalgia
51,253 (13.4)
642 (24.7)
2,992 (19.5)
Food allergy
6,478 (1.7)
91 (3.5)
264 (1.7)
Gout
21,573 (5.6)
141 (5.4)
1,071 (7.0)
Hypertension or coronary artery disease
159,651 (41.8)
1,176 (45.2)
8,890 (58.0)
Hepatitis B
2,730 (0.7)
11 (0.4)
113 (0.7)
Hepatitis C
7,767 (2.0)
15 (0.6)
176 (1.2)
HIV
5,779 (1.5)
12 (0.5)
112 (0.7)
Hypothyroidism
76,422 (20.0)
738 (28.3)
4,112 (26.8)
Immune-mediated arthritis
39,191 (10.3)
255 (9.8)
1,102 (7.2)
Inflammatory bowel disease
21,608 (5.7)
318 (12.2)
1,214 (7.9)
Juvenile idiopathic arthritis
2,784 (0.7)
28 (1.1)
83 (0.5)
Leukemia
18,790 (4.9)
52 (2.0)
3,557 (23.2)
Lupus
15,159 (4.0)
127 (4.9)
625 (4.1)
Lymphoma
26,369 (6.9)
123 (4.7)
4,350 (28.4)
Myocardial infarction
13,910 (3.6)
94 (3.6)
853 (5.6)
Obesity
59,906 (15.7)
569 (21.9)
2,896 (18.9)
Peripheral vascular disease
38,981 (10.2)
274 (10.5)
2,500 (16.3)
Pulmonary embolism
9,080 (2.4)
91 (3.5)
745 (4.9)
Deep vein thrombosis
18,858 (4.9)
162 (6.2)
1,518 (9.9)
Psoriasis
12,883 (3.4)
97 (3.7)
455 (3.0)
Scleroderma
2,457 (0.6)
15 (0.6)
148 (1.0)
Markers of PID severity, n (%)
Risk vital sign
Low
313,611 (82.1)
1,630 (62.6)
8,217 (53.6)
Medium
15,104 (4.0)
196 (7.5)
916 (6.0)
High
53,416 (14.0)
778 (29.9)
6,194 (40.4)
Abscess
47,709 (12.5)
125 (4.8)
1,197 (7.8)
Bacterial pneumonia
75,321 (19.7)
590 (22.7)
4,362 (28.5)
Cellulitis
57,282 (15.0)
187 (7.2)
1,438 (9.4)
Lymphadenitis
33,690 (8.8)
107 (4.1)
1,467 (9.6)
Mastoiditis
674 (0.2)
7 (0.3)
27 (0.2)
Osteomyelitis
5,531 (1.4)
23 (0.9)
176 (1.2)
Recurrent otitis media
74,887 (19.6)
337 (12.9)
1,374 (9.0)
Recurrent sinusitis
157,932 (41.3)
1,531 (58.8)
5,861 (38.2)
Prior PID treatments, n (%)
IV antibiotics
95,129 (24.9)
601 (23.1)
4,497 (29.3)
High-potency oral antibiotics
130,153 (34.1)
967 (37.1)
4,720 (30.8)
Systemic high-dose corticosteroids
186,557 (48.8)
1,380 (53.0)
10,196 (66.5)
Antifungals
81,737 (21.4)
656 (25.2)
4,520 (29.5)
Stem cell transplant
3,137 (0.8)
1 (<0.1)
385 (2.5)
Interferon-gamma therapy
6 (<0.1)
0
0
Growth factors
16,421 (4.3)
16 (0.6)
1,569 (10.2)
COPD, chronic obstructive pulmonary disease; HIV, human immunodeficiency virus; IQR,
interquartile range; IV, intravenous; IVIG, intravenous immunoglobulin; PID, primary
immunodeficiency diseases; SCIG, subcutaneous immunoglobulin.
Figure 1. Attrition Due to Application of Eligibility Criteria for the IG Initiation
Cohort
(259) Submission ID#812938
Vascular abnormalities found in Coronary and Cerebral Arteries in LOF STAT3
Seemal Awan, MD1, Mia Wessel, n/a2, Hastings Williamson, n/a3, Amanda Urban, DNP,
CRNP4, Ahmed Gharib, MD5, Alexandra Freeman, MD6
1Clinical Fellow/National Institutes of Health
2Research Intern/NIH
3Research Intern/Laboratory Of Clinical Immunology And Microbiology, NIAID, NIH
4Nurse Practitioner/Clinical Research Directorate, Frederick National Laboratory for
Cancer Research in support of NIAID, LCIM
5Senior Clinical Investigator/National Institutes of Health
6Principal Investigator/National Institutes of Health
Abstract/Case Report Text
Introduction: Dominant negative mutations in STAT3 (LOF STAT3; Job’s syndrome) cause
a primary immune deficiency characterized by eczema, recurrent skin and lung infections,
and connective tissues and skeletal abnormalities. Over the last several years, vascular
abnormalities causing tortuous and aneurysmal middle-sized arteries have increasingly
been recognized. Our institution has been imaging prospectively the coronary and cerebral
arteries since 1999 – 2019 for brain imaging and from 2004-2019 for heart imaging.
The purpose of this review is to provide an update on the extent of clinical manifestations
noted in HIES patients in a larger cohort group and to determine if there are patterns
of disease not previously reported.
Methods: We performed a retrospective chart review of patients with LOF STAT3 (n=81)
followed at the National Institutes of Health. We specifically looked at tortuosity,
aneurysms, and dilation of both coronary and cerebral arteries. Epidemiologic information,
STAT3 mutation, co-morbidities, and laboratory information were reviewed along with
imaging studies, specifically Brain MRI, Brain MRA, Heart MRI, and Coronary CT.
Results: Most recently, patients with HIES are found to have vascular abnormalities
including tortuosity, dilatation, narrowing, and aneurysms of middle sized, cerebral,
and coronary arteries. In an effort to determine the extent of vascular involvement
in addition to miscellaneous organ involvement, we are reviewing a cohort of 81 patients
with HIES who were evaluated at the NIH. Of these 81 patients, 53 are women and 28
are men. Of these 81 patients, two have passed away due to vascular events leading
to their deaths. There are four patients under the age of 20, 43 patients between
the ages of 21 and 40, 33 patients between the ages of 41 and 60, and three patients
above the age of 60 (age range 15-68, mean age 35.6).
Of the 81 patients, five of these patients were found to have abnormal Brain MRI/MRA
at an approximate rate of 6.2%. Two of these patients were found to have at least
one cranial aneurysm, two of these patients were found to have a level of narrowing
or stenosis, and one patient was found to have dilatation.
In terms of coronary abnormalities, 36 of the 81 (44.4%) patients were noted to have
at least one coronary abnormality including dilatation, aneurysm, or tortuosity on
Heart MRI or Coronary CT. Eight patients (9.8%) were found to have dilatation of which
four patients were female and 4 patients were male. Of the 81 patients, ten patients
(12.3%) were found to have at least one aneurysm. There were 30 patients (37%) that
were found to have at least mild tortuosity.
Conclusion: Vascular abnormalities in our LOF STAT3 patients occurred at an exceedingly
high rate- cerebral and coronary artery, 6.2% and 44.4% respectively. Due to this,
patient’s with LOF STAT3 should be considered for screening with brain and heart imaging.
Currently, there are no guidelines which outline the appropriate timeline for screening
in these patients however following these patients over time will allow us to determine
the most appropriate interval for imaging follow up.
(260) Submission ID#812971
PIK3CD VUS In A Patient With Common Variable Immunodeficiency
Ileana Moreira, MD1, Analia Gisela Seminario, MD2, Lorena Regairaz, MD3, María Soledad
CALDIROLA, PhD4, María Isabel Gaillard, n/a5, Liliana Bezrodnik, MD6
1Physician/Immunologist
2Immunologist/Centro de Inmunología Clínica "Dra. Liliana Bezrodnik y equipo"- Servicio
de Inmunología Htal. de Niños "Dr. R.Gutierrez"
3PYSICIAN/IMMUNOLOGIST
4PostDoctoral fellow/Servicio de Inmunología, Inst. Multidisciplinario de Investigación
en Patologías Pediátricas (IMIPP), Hospital de Niños Ricardo Gutiérrez.
5Immunologist/Servicio de Inmunología-Hospital de Niños "Dr. R.Gutierrez"
6Immunologist/Centro de Inmunología Clínica "Dra. Liliana Bezrodnik y equipo"
Abstract/Case Report Text
63 year old woman with personal history of severe and recurrent upper and lower respiratory
infections, chronic pulmonary disease with bilateral bronchiectasis and several micro
nodules, chronic diarrhea without diagnosis (colonoscopy with mild colitis, without
CMV. No bacterias no parasits were found in stools), mild osteopenia, focal lesion
in right hepatic lobe, atopic dermatitis and anemia. She was followed up in other
center and in 1996 she was diagnosed with common variable immunodeficiency (CVID)
and started treatment with intravenous immunoglobulin (IVIG), but with low adherence
to it. She did not have referred history of lymphoproliferation nor significant viral
infections. She had a daughter with spherocytosis who required esplenectomy and also
had bronchiectasis and CVID diagnosis, she deceased at 28 years old due to pulmonary
infection. One 30 years old son has anemia. Her other daughter and son are healthy.
In our first immunologic assessment we found severe hypogammaglobulinemia with absence
of B cells in peripheral blood. She started with high doses of IVIG (800 mg/k/month)
and antibiotic prophilaxis with improvement of the functional respiratory test and
without new infections.
Thinking that her clinical picture could be other than CVID we order a genetic study.
A Nextera Exome Capture and Next Generation Sequence with Illumina HiSEq was made
and an heterozygous VUS in PIK3CD gene (chr1:9. 775. 746, p. P97A) was found. Her
son with anemia also have the same variant. (His immunological studies are still pending).
Now a days she is stable, without infections with IVIG and antibiotic profilaxis but
because of the chronic diarrhea and the pulmonary compromise, she began with sirolimus
but it was suspended because severe intolerance (vomiting and diarrhea that caused
dehydration). In plan to iniciate treatment with mycophenolate mofetil.
Conclusion: Clinical presentations of primary immunodeficiencies are becoming more
complex, and their diagnosis imply a challenge for immunologist nowadays. Studies
with Next Generation Sequence is a very useful tool in undefined cases, especially
when more than one member in the family are involved.
(261) Submission ID#813032
Bortezomib for Treatment of Disseminated Nontuberculous Mycobacteria in a Patient
with Anti-IFN-γ autoantibodies
Christa Zerbe, MD1, Betty Marciano, MD2, Jennifer Treat, PA-C, MSHS3, Samantha Kreuzburg,
BSN,RN4, Janine Daub, NP5, Steven Holland, MD6
1Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Immunopathogenesis
Section, National Institute of Allergy and Immunology, National Institutes of Health,
Bethesda, MD
2Staff scientist/Laboratory of Clinical Immunology and Microbiology, Division of Intramural
Research, National Institute of Allergy and Infectious Diseases, NIH,
3Physician Assistant/National Institutes of Health/National Institute of Allergy and
Infectious Diseases/Medical Science & Computing
4Research Nurse/NIAID
5Nurse Practitioner/NIAID
6Director, Intramural Research/National Institute of Allergy and Infectious Diseases
/ NIH
Abstract/Case Report Text
Autoantibodies to interferon- γ (IFN-γ )are associated with disseminated nontuberculous
mycobacterial (NTM). We have previously published our experience with treatment of
refractory infection with rituximab. We report a case of recurrent infection after
initial response and treatment with rituximab targeting CD20+ cells and progression
of infection despite repeated treatment with rituximab and subsequent successful treatment
with bortezomib.
Patient is 38 years old, Philippine female with history of IFN-γ autoantibodies and
refractory disseminated Mycobacterium avium complex (MAC). At 32 yrs. she presented
with lower back and cervical pain, despite conservative therapy, did not improve,
and was associated with lymphadenopathy and severe myalgias. With the addition of
steroids, the pain improved but rapidly worsened with tapering of steroids. The PET/CT
at that time, showed extensive hypermetabolic areas in lymph nodes, femurs, left acetabulum,
left pubic ramus, right ischium, sacrum, both iliac bones, eight rib, T4 and T8, both
clavicles, both humeral, manubrium, and extension into musculature. Initial biopsies
were culture negative, 16S was positive for MAC. She was referred to the National
Institutes of health where she was diagnosed with autoantibodies to interferon- γ
.
Prior to referral, she initially was treated with azithromycin, ethambutol (need to
discontinue due adverse effects), amikacin, rifampicin, linezolid, with not no evidence
of clinical response. She underwent debridement of epidural anterior abscess to T8.
Surgery involved T8-9 laminectomy, and curettage on several bones. She presented unable
to walk secondary to pain and neuropathies.
Initial Laboratory:
CRP:90mg/L; WC 13.51; Hgb: 8.2g/dL; ANA :4.6(strongly positive) CD20: 373 uL
Her first course of rituximab consisted of 7 doses of 1gm at D0, 14, 42 and monthly
thereafter for a total of 7 doses with clinical and radiographic improvement. She
was maintained on optimal antibiotics therapy – meropenem, rifampin, azithromycin,
moxifloxacin, and clofazimine. Two years after she completed rituximab, she presented
to her home hospital with increased left hip pain and biopsy grew MAC. Retreatment
with rituximab failed to show clinical improvement. Her medical regimen was augmented
with tedizolid and bedaquiline, however no IV antibiotics were added. Rituximab was
reinitiated, after the progression of symptoms despite treatment with rituximab; Bortezomib,
was trialed using the schedule based on the multiple myeloma literature. She completed
5 full cycles (two at the NIH, three at home). She subsequently has had clinical improvement
and is working again and has not had progressive neurologic decline. The titers of
antibodies to interferon-· did not follow the clinical improvement. However, we plan
to keep her CD20+ cells zero and continue the bortezomib given her clinical and radiologic
improvement.
(262) Submission ID#813107
David Nguyen, MD, PhD1, Peixin A. Chen, n/a2, Amy Berger, MD PhD3, Jennifer Puck,
MD4, Alex Marson, MD, PhD5
1Clinical Fellow/Department of Medicine, University of California, San Francisco
2Staff Research Associate/UCSF
3Assistant Professor/UCSF
4Professor/UCSF Benioff Children's Hospital
5Associate Professor/Division of Infectious Diseases, Department of Medicine, University
of California, San Francisco
Abstract/Case Report Text
For patients with primary immunodeficiencies (PID), finding a genetically defined
diagnosis can be critical for prognosis, treatment, and counseling. However, for many
patients, determining a genetic etiology remains elusive despite routine gene panel
and exome sequencing because of an inability to resolve variants of uncertain significance
(VUS). CRISPR-based genome editing could be used to address this need by introducing
patient-derived VUS into primary human immune cells for further study; however, existing
techniques are limited by poor efficiency. We recently developed novel non-viral techniques
for large gene editing in primary human T cells and hematopoietic stem cells (HSCs).
We achieve up to 8-fold greater efficiency than existing tools using CRISPR Cas9 ribonucleoprotein
nanoparticles that are non-covalently linked to homology directed repair (HDR) template
DNA. Whereas mutation analysis has previously been limited to expensive and time-consuming
animal models and transformed cell lines, we now have the ability to rapidly recreate
any mutation in the native gene locus in otherwise healthy primary human cells.
We demonstrate this ability by using our technique to knock-in well characterized
loss-of-function mutations in JAK3 and IL2RG and gain-of-function mutations in JAK3
that are known to cause severe combined immunodeficiency and tumor growth, respectively.
We show that these recreated mutations have the expected effects on T cell proliferation
and intracellular signal transduction in the setting of IL-2 stimulation.
We then use our technique to investigate a prototype case of an adult patient with
the unusual combination of common variable immunodeficiency, inflammatory arthritis
and uveitis, and neutrophilic urticaria. Genetic testing in this patient had previously
revealed heterozygous coding VUS’s in four genes previously associated with a PID
disease, including JAK3, but none of the specific variants have been previously reported.
It is thus not clear which mutation (if not more than one) causes this patient’s dysregulated
cell activation, which limits targeted treatment options with kinase inhibitors or
future gene or cell therapy.
By knocking our patient’s JAK3 variant into primary human T cells and comparing these
cells to those carrying wild-type, known loss-of-function, and known gain-of-function
mutations, we are able to rapidly characterize the functional impact of our patient’s
variant and isolate its effect on his complex phenotype. This in vitro genetic engineering
approach thus allows patient-specific VUS to be modeled directly in primary human
immune cells with a rapid turnaround time that is relevant for clinical applications,
including molecular diagnosis and screening of pharmacologic or gene therapies. Further,
similar strategies could be leveraged as a potential basis for future gene correction
therapy.
(263) Submission ID#813425
Variant of Ataxia Telangiectasia in Colombia Caused By New Splicing Mutation Not Reported
In The Literature
William Marquez, MD1
1Pediatric Immunologist/Fundación Hospital Pediatrico de la Misericordia
Abstract/Case Report Text
Definition : “AT variants" comprise a heterogeneous group characterized by the later
onset of clinical symptoms, a slower progression, a prolonged lifespan compared to
most patients with AT and decreased levels of chromosomal instability and cellular
radiosensitivity. In these patients, telangiectasia and / or immunodeficiency may
be absent, while neurological features are present.(1).
Material and methods :A 4 years old girl, born out of a non- consanguineous parents
with clinical picture consisting in progressive alteration of the march (15 months),
associated to exotropia, no weight gain or height, alteration of balance while she
is sitting, she walks by herself. She has 1 acute bronchiolitis.
Results and Discussion: Brain magnetic resonance without alterations. Abdominal ultrasonography
and CPK normal. Ophthalmologist assessment found exotropia, He did not find telangiectasia.
Motor and sensitive neuro-conduction were reported normal. Alpha fetoprotein 102 ng
/ ml increased.
karyotype XX, non-structural alterations. Normal auditory-visual evoked potentials.
Whole exome sequencing (WES): identified the small homozygous pathogenically deletion
¬c.5496 + 2_5496 + 5del TAAG; p.? have a spelling effect in the splicing. it is not
present in the population database or not as a known variant in the general population.
IgG antibodies for hepatitis B 31.83 iu / l. rubella IgG> 500. LTCD4 169 , LTCD8 62
, LTCD3 247. CD4 / CD8: 2.73 , lymphocytes B 161 , natural killer 314 cell/mm3.
Conclusions: Although the ATM activity corresponding to this new splicing mutation
is unknown, it is presumed that it has some residual function, since splicing mutations
is associated with better neurological prognosis have been reported. (2)
(264) Submission ID#808024
Recurrent Respiratory Viral Infections in a 22q11.2 Deletion Syndrome Patient
Victoria Dimitriades, MD1, Anh Nguyen, MD2
1Associate Professor of Pediatrics/University of California, Davis
2Allergy/Immunology Fellow/University of California, Davis
Abstract/Case Report Text
Background: The 22q11.2 deletion syndrome (22qDS) is a common syndrome occurring in
about 1: 4000 births. The most common phenotypic features are cardiac anomalies, palatal
dysfunction, dysmorphic facial features, and hypoplastic parathyroid glands and thymus.
The main immune deficiency manifestation is T cell lymphopenia, ranging from complete
absence of T cells to normal T cell counts with various functional affectations. Additionally,
humoral dysfunction can be associated with recurrent infection or autoimmunity. Thus
far, intravenous immune globulin (IVIg) has been used for 22qDS patients with recurrent
bacterial infections in whom low antibody levels or poor vaccine responses were found.
However standard management for recurrent viral respiratory infections is currently
not available.
Objective: To describe unique management of recurrent viral respiratory infections
in a 22qDS patient. Case: 5-year-old male with a history of 22qDS complicated by truncus
arteriosus, VSD, hypoparathyroidism, asthma, and autism was followed for a history
of “frequent pneumonias.” He had daily rhinitis and a history of frequent otitis media
which resolved after tympanostomy tube placement at age 3y. However, over the next
two years, he had 11 admissions with various respiratory viral infections resulting
in respiratory distress and prolonged oxygen need. Viruses detected during these separate
admissions varied and included Parainfluenza 3, Metapneumovirus, RSV, B and Coronavirus
NL63, Coronavirus HKU1, and Rhino/Enterovirus (5 times total). He was previously on
a prophylactic course of antibiotics which made no difference in his symptoms.
Laboratory evaluation showed protective adaptive immunity with normal immunoglobulin
numbers for age (IgG 589 mg/dL), along with normal B and T cell numbers. He had protective
pneumococcal titers and mounted a normal mitogen response. While his NK cell numbers
were normal, his NK T cells were low. His TLR functioning also appeared normal.
In order to decrease his overall illness burden and to keep him out of the hospital,
IVIg infusions (~500mg/kg) were initiated monthly. Shortly after initiation of treatment,
his nasal purulence and drainage resolved and his family noted that he became more
active and playful. Treatment was continued for 18 months, during which time he had
only one episode of influenza infection needing inpatient management. He has been
off of IVIg for 12 months without recurrence of his viral infections. Conclusion:
In this patient, severe recurrent viral respiratory infections despite apparently
normal adaptive and cellular immunity presents a unique management dilemma. This was
not an issue of recurrent bacterial infections as prophylaxis did not make a difference
in the frequency of his infections. His NK T cells were low, which could have contributed
to his frequent viral infections as NKT cells are known to play a role in viral immunity.
The successful use of IVIg treatment in his case points to a different use for IVIg,
namely for the anti-respiratory virus antibodies which are presumably contained within
the formulation. Given this finding, it may be prudent to consider IVIg in management
of 22qDS patients, even with normal immune evaluation, in order to decrease risks
of complications associated with severe and recurrent viral respiratory infections.
(265) Submission ID#812438
Myhre Syndrome (SMAD4 Gain of Function) Presents with Hypogammaglobulinemia and Decreased
Memory T and B Cells
Ameera Bukhari, n/a1, Elisa Ochfeld, MD2, Amer Khojah, MD3
1PhD Student/Department of Microbiology and Immunology, Loyola University Chicago
2Fellow, Allergy and Immunology/Northwestern University
3Attending Physician, Assistant Professor/Division of Allergy & Immunology, Ann &
Robert H Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School
of Medicine, Chicago, IL
Abstract/Case Report Text
Introduction: SMAD 4 is a critical downstream signaling molecule for transforming
growth factor-β (TGF-β) and bone morphogenic protein (NMP1). Initially, SMAD4, also
known as DPC4 Deleted in Pancreatic Cancer locus 4, was described as a tumor suppressor
gene, and somatic deletion of the SMAD4 is seen in 90% of pancreatic carcinomas. Subsequently,
a germline point mutation in the SMAD4 gene (p. I500V) was reported to cause Myhre
syndrome (MIM#139210). Myhre syndrome is an autosomal dominant disease characterized
by cognitive impairment, hearing loss, and musculoskeletal anomalies. The immunological
phenotype of these patients has not been previously described, despite the critical
role of TGF-β in regulating T cell response and the prevention of excessive inflammation.
Case report: A 9-year-old boy with Myhre syndrome was referred to immunology clinic
for evaluation of recurrent ear infections. He developed acute otitis media infections
as an infant and had tympanostomy tubes placed at one year of life. He also had a
recurrent sinus infections. At two years of age, he was diagnosed with autism and
sensory neuronal hearing loss. Brain MRI showed a mildly hypoplastic pituitary gland,
and a thickened corpus callosum with decreased myelination. Given these findings,
whole-genome sequencing was performed, which revealed a heterozygous de novo mutation
in SMAD4 (p.I800V / c.1498 A>G) consistent with the diagnosis of Myhre syndrome. Through
age 5, he was in the 5th percentile for height until he was started on growth hormone,
which he responded to robustly. He is now he is in the 50th percentile for height.
He had adenoidectomy due to sleep-disordered breathing at the age of 7 years. He is
maintained on montelukast and inhaled corticosteroids for treatment of rhinitis and
mild persistent asthma. He is on atenolol for the treatment of primary hypertension.
On physical exam, he has facial dysmorphisms, thickened skin, and contraction of the
fingers consistent with Myhre syndrome. Immunologic elevation showed significant hypogammaglobulinemia
(IgG 311 mg/dL), low IgA (11 mg/dl) and normal IgM 50 mg/dl. IgG subclasses showed
low IgG1 and IgG2 at 227 mg/dL and 58 mg/dL respectively. Although he was fully vaccinated,
his tetanus antibody was low at 0.14 IU/ml. However, this improved after repeat vaccination
to 4.38 IU/ml. Total T and B lymphocyte counts were normal; however, his memory CD4
and CD8 T cells were low for age at 2.26% and 0.5%, respectively. Additionally, his
switched memory B cell count was low at 1.9%.
Conclusion: SMAD4 gain of function (Myhre syndrome) can lead to impaired memory T
and B cell formation with significant hypogammaglobulinemia and low IgA. Although
the patient was able to respond to protein vaccination (tetanus), it is not clear
if he will be able to maintain a long-term response. In a previous study, a similar
gain of function mutation of SMAD4 has been shown to increase SMAD phosphorylation
in the nucleus in fibroblasts. Further research is needed to examine the role of this
mutation in T and B lymphocytes, given the interesting immunological phenotype of
this patient.