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Taghizade N, Babayeva R, Kara A, Karakus IS, Catak MC, Bulutoglu A, Haskologlu ZS, Akay Haci I, Tunakan Dalgic C, Karabiber E, Bilgic Eltan S, Yorgun Altunbas M, Sefer AP, Sezer A, Kokcu Karadag SI, Arik E, Karali Z, Ozhan Kont A, Tuzer C, Karaman S, Mersin SS, Kasap N, Celik E, Kocacik Uygun DF, Aydemir S, Kiykim A, Aydogmus C, Ozek Yucel E, Celmeli F, Karatay E, Bozkurtlar E, Demir S, Metin A, Karaca NE, Kutukculer N, Aksu G, Guner SN, Keles S, Reisli I, Kendir Demirkol Y, Arikoglu T, Gulez N, Genel F, Kilic SS, Aytekin C, Keskin O, Yildiran A, Ozcan D, Altintas DU, Ardeniz FO, Dogu EF, Ikinciogullari KA, Karakoc-Aydiner E, Ozen A, Baris S. Therapeutic modalities and clinical outcomes in a large cohort with LRBA deficiency and CTLA4 insufficiency. J Allergy Clin Immunol 2023; 152:1634-1645. [PMID: 37595759 DOI: 10.1016/j.jaci.2023.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 08/01/2023] [Accepted: 08/08/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND LPS-responsive beige-like anchor (LRBA) deficiency (LRBA-/-) and cytotoxic T-lymphocyte-associated antigen-4 (CTLA4) insufficiency (CTLA4+/-) are mechanistically overlapped diseases presenting with recurrent infections and autoimmunity. The effectiveness of different treatment regimens remains unknown. OBJECTIVE Our aim was to determine the comparative efficacy and long-term outcome of therapy with immunosuppressants, CTLA4-immunoglobulin (abatacept), and hematopoietic stem cell transplantation (HSCT) in a single-country multicenter cohort of 98 patients with a 5-year median follow-up. METHODS The 98 patients (63 LRBA-/- and 35 CTLA4+/-) were followed and evaluated at baseline and every 6 months for clinical manifestations and response to the respective therapies. RESULTS The LRBA-/- patients exhibited a more severe disease course than did the CTLA4+/- patients, requiring more immunosuppressants, abatacept, and HSCT to control their symptoms. Among the 58 patients who received abatacept as either a primary or rescue therapy, sustained complete control was achieved in 46 (79.3%) without severe side effects. In contrast, most patients who received immunosuppressants as primary therapy (n = 61) showed either partial or no disease control (72.1%), necessitating additional immunosuppressants, abatacept, or transplantation. Patients with partial or no response to abatacept (n = 12) had longer disease activity before abatacept therapy, with higher organ involvement and poorer disease outcomes than those with a complete response. HSCT was performed in 14 LRBA-/- patients; 9 patients (64.2%) showed complete remission, and 3 (21.3%) continued to receive immunosuppressants after transplantation. HSCT and abatacept therapy gave rise to similar probabilities of survival. CONCLUSIONS Abatacept is superior to immunosuppressants in controlling disease manifestations over the long term, especially when started early, and it may provide a safe and effective therapeutic alternative to transplantation.
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Affiliation(s)
- Nigar Taghizade
- Department of Pediatrics, School of Medicine, Marmara University, Istanbul, Turkey
| | - Royala Babayeva
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Altan Kara
- TUBITAK Marmara Research Center, Gene Engineering and Biotechnology Institute, Gebze, Turkey
| | | | - Mehmet Cihangir Catak
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Alper Bulutoglu
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Zehra Sule Haskologlu
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Idil Akay Haci
- Division of Pediatric Allergy and Immunology, Dr Behcet Uz Children's Education and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Ceyda Tunakan Dalgic
- Department of Allergy and Immunology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Esra Karabiber
- Department of Allergy and Immunology, Marmara University Training and Research Hospital, Ministry of Health, Istanbul, Turkey
| | - Sevgi Bilgic Eltan
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Melek Yorgun Altunbas
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Asena Pinar Sefer
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Ahmet Sezer
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | | | - Elif Arik
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Zuhal Karali
- Division of Pediatric Immunology and Rheumatology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Aylin Ozhan Kont
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Can Tuzer
- Department of Allergy and Immunology, Batman Training and Research Hospital, Ministry of Health, Batman, Turkey
| | - Sait Karaman
- Pediatric Allergy and Immunology, Manisa City Hospital, University of Health Sciences, Manisa, Turkey
| | - Selver Seda Mersin
- Department of Allergy and Immunology, Dr Ersin Arslan Training and Research Hospital, Ministry of Health, Gaziantep, Turkey
| | - Nurhan Kasap
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Enes Celik
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | | | - Sezin Aydemir
- Division of Pediatric Allergy and Immunology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ayca Kiykim
- Division of Pediatric Allergy and Immunology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Cigdem Aydogmus
- Division of Pediatric Allergy and Immunology, Basaksehir Cam and Sakura City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Esra Ozek Yucel
- Division of Pediatric Allergy and Immunology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Fatih Celmeli
- Division of Pediatric Allergy and Immunology, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Emrah Karatay
- Department of Radiology, Marmara University Education and Research Hospital, Istanbul, Turkey
| | - Emine Bozkurtlar
- Department of Pathology, Faculty of Medicine, Marmara University, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Semra Demir
- Department of Allergy and Immunology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ayse Metin
- Division of Pediatric Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Neslihan Edeer Karaca
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Necil Kutukculer
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Guzide Aksu
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Sukru Nail Guner
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Sevgi Keles
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Ismail Reisli
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Yasemin Kendir Demirkol
- Division of Pediatric Genetics, Umraniye Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Tugba Arikoglu
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Nesrin Gulez
- Division of Pediatric Allergy and Immunology, Dr Behcet Uz Children's Education and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Ferah Genel
- Division of Pediatric Allergy and Immunology, Dr Behcet Uz Children's Education and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Sara Sebnem Kilic
- Division of Pediatric Immunology and Rheumatology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Caner Aytekin
- Department of Pediatric Immunology, Dr Sami Ulus Children Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Ozlem Keskin
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Alisan Yildiran
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Dilek Ozcan
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Derya Ufuk Altintas
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Fatma Omur Ardeniz
- Department of Allergy and Immunology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Esin Figen Dogu
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | | | - Elif Karakoc-Aydiner
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Ahmet Ozen
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Safa Baris
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey.
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Liu Y, Armbrister SA, Okeugo B, Mills TW, Daniel RC, Oh JH, van Pijkeren JP, Park ES, Saleh ZM, Lahiri S, Roos S, Rhoads JM. Probiotic-Derived Ecto-5'-Nucleotidase Produces Anti-Inflammatory Adenosine Metabolites in Treg-Deficient Scurfy Mice. Probiotics Antimicrob Proteins 2023; 15:1001-1013. [PMID: 37178405 PMCID: PMC10926147 DOI: 10.1007/s12602-023-10089-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
Probiotic Limosilactobacillus reuteri DSM 17938 (DSM 17938) prolongs the survival of Treg-deficient scurfy (SF) mice and reduces multiorgan inflammation by a process requiring adenosine receptor 2A (A2A) on T cells. We hypothesized that L. reuteri-derived ecto-5'-nucleotidase (ecto-5'NT) activity acts to generate adenosine, which may be a central mediator for L. reuteri protection in SF mice. We evaluated DSM 17938-5'NT activity and the associated adenosine and inosine levels in plasma, gut, and liver of SF mice. We examined orally fed DSM 17938, DSM 17938Δ5NT (with a deleted 5'NT gene), and DSM 32846 (BG-R46) (a naturally selected strain derived from DSM 17938). Results showed that DSM 17938 and BG-R46 produced adenosine while "exhausting" AMP, whereas DSM 17938∆5NT did not generate adenosine in culture. Plasma 5'NT activity was increased by DSM 17938 or BG-R46, but not by DSM 17938Δ5NT in SF mice. BG-R46 increased both adenosine and inosine levels in the cecum of SF mice. DSM 17938 increased adenosine levels, whereas BG-R46 increased inosine levels in the liver. DSM 17938Δ5NT did not significantly change the levels of adenosine or inosine in the GI tract or the liver of SF mice. Although regulatory CD73+CD8+ T cells were decreased in spleen and blood of SF mice, these regulatory T cells could be increased by orally feeding DSM 17938 or BG-R46, but not DSM 17938Δ5NT. In conclusion, probiotic-5'NT may be a central mediator of DSM 17938 protection against autoimmunity. Optimal 5'NT activity from various probiotic strains could be beneficial in treating Treg-associated immune disorders in humans.
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Affiliation(s)
- Yuying Liu
- Department of Pediatrics, Division of Gastroenterology, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.
| | - Shabba A Armbrister
- Department of Pediatrics, Division of Gastroenterology, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Beanna Okeugo
- Department of Pediatrics, Division of Gastroenterology, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Tingting W Mills
- Department of Biochemistry & Molecular Biology, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Rhea C Daniel
- Department of Pediatrics, Division of Gastroenterology, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Jee-Hwan Oh
- Department of Food Science, University of Wisconsin-Madison, Madison, WI, 53706, USA
| | | | - Evelyn S Park
- Department of Pediatrics, Division of Gastroenterology, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Zeina M Saleh
- Department of Pediatrics, Division of Gastroenterology, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Sharmistha Lahiri
- Department of Pediatrics, Division of Gastroenterology, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Stefan Roos
- Department of Molecular Sciences, Uppsala BioCenter, Swedish University of Agricultural Sciences, Uppsala, Sweden
- BioGaia AB, Stockholm, Sweden
| | - JMarc Rhoads
- Department of Pediatrics, Division of Gastroenterology, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
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3
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Hou AN, Wang Y, Pan YQ. A Case Report of IPEX Syndrome with Neonatal Diabetes Mellitus and Congenital Hypothyroidism as the Initial Presentation, and a Systematic Review of neonatal IPEX. J Clin Immunol 2023; 43:979-988. [PMID: 36867340 DOI: 10.1007/s10875-023-01456-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
Immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX) is a serious disorder, which may comprise diabetes, thyroid disease, enteropathy, cytopenias, eczema, and other multi-system autoimmune dysfunction features. IPEX syndrome is caused by mutations in the forkhead box P3 (FOXP3) gene. Here, we report the clinical manifestations of a patient with IPEX syndrome onset in the neonatal period. A de novo mutation at exon 11 of the FOXP3 gene (c.1190G > A, p.R397Q) was found, and its main clinical manifestations included hyperglycemia and hypothyroidism. Subsequently, we comprehensively reviewed the clinical characteristics and FOXP3 mutations of 55 reported neonatal IPEX cases. The most frequent clinical presentation included symptoms of gastrointestinal involvement (n = 51, 92.7%), followed by skin-related symptoms (n = 37, 67.3%), diabetes mellitus (DM) (n = 33, 60.0%), elevated IgE (n = 28, 50.9%), hematological abnormality (n = 23, 41.8%), thyroid dysfunction (n = 18, 32.7%), and kidney-related symptoms (n = 13, 23.6%). In total, 38 variants were observed in the 55 neonatal patients. The most frequent mutation was c.1150G > A (n = 6; 10.9%), followed by c.1189C > T (n = 4; 7.3%), c.816 + 5G > A (n = 3; 5.5%), and C.1015C > G (n = 3; 5.5%), which were reported more than twice. The genotype-phenotype relationship showed that the repressor domain mutations were associated with DM (P = 0.020), and the leucine zipper mutations were associated with nephrotic syndrome (P = 0.020). The survival analysis suggested that treatment with glucocorticoids increased the survival of the neonatal patients. This literature review provides an informative reference for the diagnosis and treatment of IPEX syndrome in the neonatal period.
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Affiliation(s)
- A-Na Hou
- Department of Pediatrics, People's Republic of China, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, People's Republic of China
| | - Yuanyuan Wang
- Department of Anesthesiology, The Fourth Affiliated Hospital, China Medical University, Shenyang, Liaoning Province, People's Republic of China
| | - Yu-Qing Pan
- Department of Pediatrics, People's Republic of China, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, People's Republic of China.
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4
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Liu Y, Armbrister SA, Okeugo B, Mills TW, Daniel RC, Oh JH, Pijkeren JP, Park ES, Saleh ZM, Lahiri S, Roos S, Rhoads JM. Probiotic-derived ecto-5'-nucleotidase produces anti-inflammatory adenosine metabolites in Treg-deficient scurfy mice. RESEARCH SQUARE 2023:rs.3.rs-2781715. [PMID: 37066419 PMCID: PMC10104250 DOI: 10.21203/rs.3.rs-2781715/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
Probiotic Limosilactobacillus reuteri DSM 17938 (DSM 17938) prolonges the survival of Treg-deficient scurfy (SF) mice and reduces multiorgan inflammation by a process requiring adenosine receptor 2A (A 2A ) on T cells. We hypothesized that L. reuteri -derived ecto-5'-nucleotidase (ecto-5'NT) activity acts to generate adenosine, which may be a central mediator for L. reuteri protection in SF mice. We evaluated DSM 17938-5'NT activity and the associated adenosine and inosine levels in plasma, gut and liver of SF mice. We examined orally fed DSM 17938, DSM 17938Δ5NT (with a deleted 5'NT gene), and DSM 32846 (BG-R46) (a naturally selected strain derived from DSM 17938). Results showed that DSM 17938 and BG-R46 produced adenosine while "exhausting" AMP, whereas DSM 17938∆5NT did not generate adenosine in culture. Plasma 5'NT activity was increased by DSM 17938 or BG-R46, but not by DSM 17938Δ5NT in SF mice. BG-R46 increased both adenosine and inosine levels in the cecum of SF mice. DSM 17938 increased adenosine levels, whereas BG-R46 increased inosine levels in the liver. DSM 17938Δ5NT did not significantly change the levels of adenosine or inosine in the GI tract or the liver of SF mice. Although regulatory CD73 + CD8 + T cells were decreased in spleen and blood of SF mice, these regulatory T cells could be increased by orally feeding DSM 17938 or BG-R46, but not DSM 17938Δ5NT. In conclusion, probiotic-5'NT may be a central mediator of DSM 17938 protection against autoimmunity. Optimal 5'NT activity from various probiotic strains could be beneficial in treating Treg-associated immune disorders in humans.
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5
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Sharma D, Ben Yakov G, Kapuria D, Viana Rodriguez G, Gewirtz M, Haddad J, Kleiner DE, Koh C, Bergerson JRE, Freeman AF, Heller T. Tip of the iceberg: A comprehensive review of liver disease in Inborn errors of immunity. Hepatology 2022; 76:1845-1861. [PMID: 35466407 DOI: 10.1002/hep.32539] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 03/30/2022] [Accepted: 04/17/2022] [Indexed: 12/08/2022]
Abstract
Inborn errors of immunity (IEIs) consist of numerous rare, inherited defects of the immune system that affect about 500,000 people in the United States. As advancements in diagnosis through genetic testing and treatment with targeted immunotherapy and bone marrow transplant emerge, increasing numbers of patients survive into adulthood posing fresh clinical challenges. A large spectrum of hepatobiliary diseases now present in those with immunodeficiency diseases, leading to morbidity and mortality in this population. Awareness of these hepatobiliary diseases has lagged the improved management of the underlying disorders, leading to missed opportunities to improve clinical outcomes. This review article provides a detailed description of specific liver diseases occurring in various inborn errors of immunity. A generalized approach to diagnosis and management of hepatic complications is provided, and collaboration with hepatologists, immunologists, and pathologists is emphasized as a requirement for optimizing management and outcomes.
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Affiliation(s)
- Disha Sharma
- Department of Internal MedicineMedStar Washington Hospital Center & Georgetown UniversityWashingtonDCUSA.,Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - Gil Ben Yakov
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA.,26744Center for Liver DiseaseSheba Medical CenterTel HaShomerIsrael
| | - Devika Kapuria
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA.,Department of GastroenterologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Gracia Viana Rodriguez
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - Meital Gewirtz
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - James Haddad
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - David E Kleiner
- 3421Laboratory of PathologyNational Cancer InstituteBethesdaMarylandUSA
| | - Christopher Koh
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - Jenna R E Bergerson
- Laboratory of Clinical Immunology and MicrobiologyNIAID, NIHBethesdaMarylandUSA
| | - Alexandra F Freeman
- Laboratory of Clinical Immunology and MicrobiologyNIAID, NIHBethesdaMarylandUSA
| | - Theo Heller
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
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Capra AP, Chiara E, Briuglia S. Autoimmune hepatitis in genetic syndromes: A literature review. World J Hepatol 2021; 13:1328-1340. [PMID: 34786169 PMCID: PMC8568577 DOI: 10.4254/wjh.v13.i10.1328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/25/2021] [Accepted: 09/06/2021] [Indexed: 02/06/2023] Open
Abstract
Genetic syndromes represent relevant and rare diseases. These conditions include a large amount of epidemiological, pathogenetic and clinical features. However, a systematic approach to genetic syndromes is often prevented by the rareness of these diseases. So, although clinical features are usually precisely defined, nowadays more uncommon associations between genetic syndromes and internal medicine related diseases have been insufficiently studied. Autoimmune hepatitis (AIH) is a chronic liver disease caused by loss of tolerance to hepatocyte-specific auto-antigens. Conversely, a better knowledge about specific genetic syndromes in which AIH is more frequent could be important in the clinical management of patients, both for an early diagnosis and for a prompt therapy. Furthermore, a systematic approach could explain if onset, clinical course, and response to treatment of AIH are typical for specific genetic syndromes. We took in consideration all the scientific articles reported in PubMed in the last 10 years, from 2010 to 2020. The purpose of this review is to explore the prevalence of AIH in genetic syndrome, but also to suggest new classification, that could be useful for pathogenetic hypothesis and clinical approach to genetic syndrome. From the 139 publications selected using keywords “autoimmune hepatitis” and “genetic syndrome”, 30 papers (21.6%) respected the chosen inclusion criteria, reporting the association between AIH in patients with a genetic syndrome. We have collected in all 47 patients with AIH and genetic syndrome, and with median age of 12.6-year-old. We suggest that when a patient presents a clinical picture of cryptogenic chronic hepatitis, that is unexplained, it is useful to explore differential diagnosis of AIH associated with genetic syndrome. Given the clinical relevance of this topic, further reports are needed to demonstrate our hypothesis and collect new evidence in this field.
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Affiliation(s)
- Anna Paola Capra
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Messina 98100, Italy
| | - Emanuele Chiara
- Department of Clinical Pathology, University of Messina, Messina 98100, Italy
| | - Silvana Briuglia
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Messina 98100, Italy
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Abstract
Primary immune regulatory disorders (PIRDs) are a group of diseases belonging to inborn errors of immunity. They usually exhibit lymphoproliferation, autoimmunities, and malignancies, with less susceptibility to recurrent infections. Unlike classical primary immune deficiencies, in autoimmune manifestations, such as cytopenias, enteropathy can be the first symptom of diseases, and they are typically resistant to treatment. Increasing awareness of PIRDs among specialists and a multidisciplinary team approach would provide early diagnosis and treatment that could prevent end-organ damage related to the diseases. In recent years, many PIRDs have been described, and understanding the immunological pathways linked to these disorders provides us an opportunity to use directed therapies for specific molecules, which usually offer better disease control than known classical immunosuppressants. In this review, in light of the most recent literature, we will discuss the common PIRDs and explain their clinical symptoms and recent treatment modalities.
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Affiliation(s)
- Burcu Kolukısa
- Marmara University Faculty of Medicine, Division of Pediatric Allergy and Immunology, İstanbul, Turkey,İstanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, İstanbul, Turkey,The Işıl Berat Barlan Center for Translational Medicine, İstanbul, Turkey
| | - Safa Barış
- Marmara University Faculty of Medicine, Division of Pediatric Allergy and Immunology, İstanbul, Turkey,İstanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, İstanbul, Turkey,The Işıl Berat Barlan Center for Translational Medicine, İstanbul, Turkey
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8
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Consonni F, Ciullini Mannurita S, Gambineri E. Atypical Presentations of IPEX: Expect the Unexpected. Front Pediatr 2021; 9:643094. [PMID: 33614561 PMCID: PMC7892580 DOI: 10.3389/fped.2021.643094] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022] Open
Abstract
Immune dysregulation, polyendocrinopathy, and enteropathy, X-linked (IPEX) syndrome is a rare disorder that has become a model of monogenic autoimmunity. IPEX is caused by mutations in FOXP3 gene, a master regulator of regulatory T cells (Treg). Cases reported in the last 20 years demonstrate that IPEX clinical spectrum encompasses more than the classical triad of early-onset intractable diarrhea, type 1 diabetes (T1D) and eczema. Atypical cases of IPEX include patients with late-onset of symptoms, single-organ involvement, mild disease phenotypes or rare clinical features (e.g., atrophic gastritis, interstitial lung disease, nephropathy etc.). Several atypical presentations have recently been reported, suggesting that IPEX incidence might be underestimated. Immunosuppression (IS) treatment strategies can control the disease, however at the moment allogeneic hematopoietic stem cell transplantation (HSCT) is the only available definitive cure, therefore it is important to achieve a prompt diagnosis. This review aims to describe unusual clinical phenotypes, beyond classical IPEX. Overall, our analysis contributes to increase awareness and finally improve diagnosis and treatment intervention in IPEX in order to ensure a good quality of life.
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Affiliation(s)
- Filippo Consonni
- Anna Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Sara Ciullini Mannurita
- Division of Pediatric Oncology/Hematology, Meyer University Children's Hospital, Florence, Italy
| | - Eleonora Gambineri
- Division of Pediatric Oncology/Hematology, Meyer University Children's Hospital, Florence, Italy.,Department of Neurosciences, Psychology, Drug Research, and Child Health (NEUROFARBA), University of Florence, Florence, Italy
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9
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Barzaghi F, Passerini L. IPEX Syndrome: Improved Knowledge of Immune Pathogenesis Empowers Diagnosis. Front Pediatr 2021; 9:612760. [PMID: 33692972 PMCID: PMC7937806 DOI: 10.3389/fped.2021.612760] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/21/2021] [Indexed: 12/18/2022] Open
Abstract
Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a rare monogenic autoimmune disease with variable clinical manifestations, ranging from early-onset severe autoimmunity, including enteropathy, eczema, and type 1 diabetes, to late-onset or atypical symptoms. Despite the clinical heterogeneity, the unifying feature of IPEX is mutation of the FOXP3 gene, which encodes a transcription factor essential for maintenance of thymus-derived regulatory T cells (Tregs). In IPEX patients, Tregs can be present, although unstable and impaired in function, unable to inhibit proliferation and cytokine production of effector T (Teff) cells. Mutated FOXP3 can also disrupt other compartments: FOXP3-deficient Teff cells proliferate more than the wild-type counterpart, display altered T-cell-receptor signaling response, a reduced T-naïve compartment and a skew toward a Th2 profile. Due to FOXP3 mutations, the frequency of autoreactive B cells is increased and the IgA and IgE production is altered, together with early emergence of tissue-specific autoantibodies. Recently, the awareness of the wide clinical spectrum of IPEX improved the diagnostic tools. In cases presenting with enteropathy, histological evaluation is helpful, although there are no pathognomonic signs of disease. On the other hand, the study of FOXP3 expression and in vitro Treg function, as well as the detection of specific circulating autoantibodies, is recommended to narrow the differential diagnosis. Nowadays, Sanger sequencing should be limited to cases presenting with the classical triad of symptoms; otherwise, next-generation sequencing is recommended, given the cost-effectiveness and the advantage of excluding IPEX-like syndromes. The latter approach could be time spearing in children with severe phenotypes and candidate to advanced therapies.
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Affiliation(s)
- Federica Barzaghi
- Department of Paediatric Immunohematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Passerini
- Mechanisms of Peripheral Tolerance Unit, San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
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10
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Jamee M, Zaki-Dizaji M, Lo B, Abolhassani H, Aghamahdi F, Mosavian M, Nademi Z, Mohammadi H, Jadidi-Niaragh F, Rojas M, Anaya JM, Azizi G. Clinical, Immunological, and Genetic Features in Patients with Immune Dysregulation, Polyendocrinopathy, Enteropathy, X-linked (IPEX) and IPEX-like Syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2747-2760.e7. [PMID: 32428713 DOI: 10.1016/j.jaip.2020.04.070] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/06/2020] [Accepted: 04/15/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a rare inborn error of immunity caused by mutations in the forkhead box P3 (FOXP3) gene. OBJECTIVE In this study, we conducted a systematic review of patients with IPEX and IPEX-like syndrome to delineate differences in these 2 major groups. METHODS The literature search was performed in PubMed, Web of Science, and Scopus databases, and demographic, clinical, immunologic, and molecular data were compared between the IPEX and IPEX-like groups. RESULTS A total of 459 patients were reported in 148 eligible articles. Major clinical differences between patients with IPEX and IPEX-like syndrome were observed in rates of pneumonia (11% vs 31%, P < .001), bronchiectasis (0.3% vs 14%, P < .001), diarrhea (56% vs 42%, P = .020), and organomegaly (10% vs 23%, P = .001), respectively. Eosinophilia (95% vs 100%), low regulatory T-cell count (68% vs 50%), and elevated IgE (87% vs 61%) were the most prominent laboratory findings in patients with IPEX and IPEX-like syndrome, respectively. In the IPEX group, a lower mortality rate was observed among patients receiving hematopoietic stem cell transplantation (HSCT) (24%) compared with other patients (43%), P = .008; however, in the IPEX-like group, it was not significant (P = .189). CONCLUSIONS Patients with IPEX syndrome generally suffer from enteropathy, autoimmunity, dermatitis, eosinophilia, and elevated serum IgE. Despite similarities in their clinical presentations, patients with IPEX-like syndrome are more likely to present common variable immunodeficiency-like phenotype such as respiratory tract infections, bronchiectasis, and organomegaly. HSCT is currently the only curative therapy for both IPEX and IPEX-like syndrome and may result in favorable outcome.
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Affiliation(s)
- Mahnaz Jamee
- Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran; Alborz Office of USERN, Universal Scientific Education and Research Network (USERN), Alborz University of Medical Sciences, Karaj, Iran
| | - Majid Zaki-Dizaji
- Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
| | - Bernice Lo
- Sidra Medicine, Division of Translational Medicine, Research Branch, Doha, Qatar
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Fatemeh Aghamahdi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Mehdi Mosavian
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Zohreh Nademi
- Children's Bone Marrow Transplant Unit, Great North Children's Hospital, Newcastle, United Kingdom
| | - Hamed Mohammadi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | | | - Manuel Rojas
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Gholamreza Azizi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran.
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11
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Park JH, Lee KH, Jeon B, Ochs HD, Lee JS, Gee HY, Seo S, Geum D, Piccirillo CA, Eisenhut M, van der Vliet HJ, Lee JM, Kronbichler A, Ko Y, Shin JI. Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome: A systematic review. Autoimmun Rev 2020; 19:102526. [PMID: 32234571 DOI: 10.1016/j.autrev.2020.102526] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/19/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a monogenic disorder characterized by early onset fatal multi-system autoimmunity due to loss-of-function mutations in the gene encoding the forkhead box P3 (FOXP3) transcription factor which is crucial for the development, maturation, and maintenance of CD4+ regulatory T (T-reg) cells. Various autoimmune phenomena such as enteropathy, endocrinopathies, cytopenias, renal disease, and skin manifestations are characteristic findings in patients affected by IPEX syndrome. OBJECTIVES In this systematic review, we focus on both clinical and demographic characteristics of IPEX patients, highlighting possible genotype-phenotype correlations and address prognostic factors for disease outcome. METHODS We performed a literature search to systematically investigate the case reports of IPEX which were published before August 7th, 2017. RESULTS A total of 75 articles (195 patients) were identified. All IPEX patients included had FOXP3 mutations which were most frequently located in the forkhead domain (n = 68, 34.9%) followed by the leucine-zipper domain (n = 30, 15.4%) and repressor domain (n = 36, 18.4%). Clinical manifestations were as follows: enteropathy (n = 191, 97.9%), skin manifestations (n = 121, 62.1%), endocrinopathy (n = 104, 53.3%), hematologic abnormalities (n = 75, 38.5%), infections (n = 78, 40.0%), other immune-related complications (n = 43, 22.1%), and renal involvement (n = 32, 16.4%). Enteropathic presentations (P = 0.017), eczema (P = 0.030), autoimmune hemolytic anemia (P = 0.022) and food allergy (P = 0.009) were associated with better survival, while thrombocytopenia (P = 0.034), septic shock (P = 0.045) and mutations affecting the repressor domain (P = 0.021), intron 7 (P = 0.033) or poly A sequence (P = 0.025) were associated with increased risk of death. Immunosuppressive therapy alone was significantly associated with increased cumulative survival compared to patients who received no treatment (P = 0.041). CONCLUSIONS We report the most comprehensive summary of demographic and clinical profiles derived from a total of 195 IPEX patients with deleterious mutations in FOXP3. Analysis of our findings provides new insights into genotype/phenotype correlations, and clinical and genetic factors associated with increased risk of death and response to treatment strategies.
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Affiliation(s)
- Jae Hyon Park
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Bokyoung Jeon
- Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Hans D Ochs
- Department of Pediatrics, University of Washington and Seattle Children's Research Institute, Seattle, WA, USA
| | - Joon Suk Lee
- Department of Pharmacology, Brain Korea 21 PLUS Project for Medical Sciences, Yonsei University College of Medicine, Seoul 03772, Republic of Korea
| | - Heon Yung Gee
- Department of Pharmacology, Brain Korea 21 PLUS Project for Medical Sciences, Yonsei University College of Medicine, Seoul 03772, Republic of Korea
| | - Seeun Seo
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dongil Geum
- Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ciriaco A Piccirillo
- Department of Microbiology and Immunology, McGill University, Montréal, QC, Canada; The Research Institute of the McGill University Health Center, Montréal, QC, Canada; FOCiS Centre of Excellence in Translational Immunology (CETI), Montréal, QC H4A 3J1, Canada
| | - Michael Eisenhut
- Luton & Dunstable University Hospital NHS Foundation Trust, Lewsey Road, Luton LU4ODZ, United Kingdom
| | - Hans J van der Vliet
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Jiwon M Lee
- Department of Pediatrics, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Medical University Innsbruck, Innsbruck, Austria
| | - Younhee Ko
- Division of Biomedical Engineering, Hankuk University of Foreign Studies, Gyeonggi-do, Republic of Korea
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea.
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12
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Abstract
The transcription factor FOXP3 controls the immunosuppressive program in CD4+ T cells that is crucial for systemic immune regulation. Mutations of the single X-chromosomal FOXP3 gene in male individuals cause the inherited autoimmune disease immune dysregulation, polyendocrinopathy, enteropathy, and X-linked (IPEX) syndrome. Insufficient gene expression and impaired function of mutant FOXP3 protein prevent the generation of anti-inflammatory regulatory T (Treg) cells and fail to inhibit autoreactive T cell responses. Diversification of FOXP3 functional properties is achieved through alternative splicing that leads to isoforms lacking exon 2 (FOXP3Δ2), exon 7 (FOXP3Δ7), or both (FOXP3Δ2Δ7) specifically in human CD4+ T cells. Several IPEX mutations targeting these exons or promoting their alternative splicing revealed that those truncated isoforms cannot compensate for the loss of the full-length isoform (FOXP3fl). In this review, IPEX mutations that change the FOXP3 isoform profile and the resulting consequences for the CD4+ T-cell phenotype are discussed.
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Affiliation(s)
- Reiner K Mailer
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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13
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He B, Liu Y, Hoang TK, Tian X, Taylor CM, Luo M, Tran DQ, Tatevian N, Rhoads JM. Antibiotic-modulated microbiome suppresses lethal inflammation and prolongs lifespan in Treg-deficient mice. MICROBIOME 2019; 7:145. [PMID: 31699146 PMCID: PMC6839243 DOI: 10.1186/s40168-019-0751-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/24/2019] [Indexed: 05/10/2023]
Abstract
BACKGROUND Regulatory T cell (Treg) deficiency leads to IPEX syndrome, a lethal autoimmune disease, in Human and mice. Dysbiosis of the gut microbiota in Treg-deficient scurfy (SF) mice has been described, but to date, the role of the gut microbiota remains to be determined. RESULTS To examine how antibiotic-modified microbiota can inhibit Treg deficiency-induced lethal inflammation in SF mice, Treg-deficient SF mice were treated with three different antibiotics. Different antibiotics resulted in distinct microbiota and metabolome changes and led to varied efficacy in prolonging lifespan and reducing inflammation in the liver and lung. Moreover, antibiotics altered plasma levels of several cytokines, especially IL-6. By analyzing gut microbiota and metabolome, we determined the microbial and metabolomic signatures which were associated with the antibiotics. Remarkably, antibiotic treatments restored the levels of several primary and secondary bile acids, which significantly reduced IL-6 expression in RAW macrophages in vitro. IL-6 blockade prolonged lifespan and inhibited inflammation in the liver and lung. By using IL-6 knockout mice, we further identified that IL-6 deletion provided a significant portion of the protection against inflammation induced by Treg dysfunction. CONCLUSION Our results show that three antibiotics differentially prolong survival and inhibit lethal inflammation in association with a microbiota-IL-6 axis. This pathway presents a potential avenue for treating Treg deficiency-mediated autoimmune disorders.
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Affiliation(s)
- Baokun He
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China.
- Shanghai Key Laboratory of Pancreatic Disease, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201620, China.
- Division of Gastroenterology, Department of Pediatrics, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, 77030, USA.
| | - Yuying Liu
- Division of Gastroenterology, Department of Pediatrics, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, 77030, USA
| | - Thomas K Hoang
- Division of Gastroenterology, Department of Pediatrics, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, 77030, USA
| | - Xiangjun Tian
- Department of Bioinformatics & Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Christopher M Taylor
- Department of Microbiology, Immunology & Parasitology, Louisiana State University School of Medicine, Children's Hospital, New Orleans, Louisiana, 70118, USA
| | - Meng Luo
- Department of Microbiology, Immunology & Parasitology, Louisiana State University School of Medicine, Children's Hospital, New Orleans, Louisiana, 70118, USA
| | - Dat Q Tran
- Division of Gastroenterology, Department of Pediatrics, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, 77030, USA
| | - Nina Tatevian
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, 77030, USA
| | - J Marc Rhoads
- Division of Gastroenterology, Department of Pediatrics, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, 77030, USA.
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14
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Kiykim A, Ogulur I, Dursun E, Charbonnier LM, Nain E, Cekic S, Dogruel D, Karaca NE, Cogurlu MT, Bilir OA, Cansever M, Kapakli H, Baser D, Kasap N, Kutlug S, Altintas DU, Al-Shaibi A, Agrebi N, Kara M, Guven A, Somer A, Aydogmus C, Ayaz NA, Metin A, Aydogan M, Uncuoglu A, Patiroglu T, Yildiran A, Guner SN, Keles S, Reisli I, Aksu G, Kutukculer N, Kilic SS, Yilmaz M, Karakoc-Aydiner E, Lo B, Ozen A, Chatila TA, Baris S. Abatacept as a Long-Term Targeted Therapy for LRBA Deficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2790-2800.e15. [PMID: 31238161 DOI: 10.1016/j.jaip.2019.06.011] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/03/2019] [Accepted: 06/06/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND LPS-responsive beige-like anchor (LRBA) deficiency presents with susceptibility to infections, autoimmunity, and lymphoproliferation. The long-term efficacy of cytotoxic T-lymphocyte-associated antigen 4-immunoglobulin (abatacept) as targeted therapy for its immune dysregulatory features remains to be established. OBJECTIVE To determine the clinical and immunologic features of LRBA deficiency and long-term efficacy of abatacept treatment in controlling the different disease manifestations. METHODS Twenty-two LRBA-deficient patients were recruited from different immunology centers and followed prospectively. Eighteen patients on abatacept were evaluated every 3 months for long-term clinical and immunologic responses. LRBA expression, lymphocyte subpopulations, and circulating T follicular helper cells were determined by flow cytometry. RESULTS The mean age of the patients was 13.4 ± 7.9 years, and the follow-up period was 3.4 ± 2.3 years. Recurrent infections (n = 19 [86.4%]), immune dysregulation (n = 18 [81.8%]), and lymphoproliferation (n = 16 [72.7%]) were common clinical features. The long-term benefits of abatacept in 16 patients were demonstrated by complete control of lymphoproliferation and chronic diarrhea followed by immune dysregulation, most notably autoimmune cytopenias. Weekly or every other week administration of abatacept gave better disease control compared with every 4 weeks. There were no serious side effects related to the abatacept therapy. Circulating T follicular helper cell frequencies were found to be a reliable biomarker of disease activity, which decreased on abatacept therapy in most subjects. However, high circulating T follicular helper cell frequencies persisted in 2 patients who had a more severe disease phenotype that was relatively resistant to abatacept therapy. CONCLUSIONS Long-term abatacept therapy is effective in most patients with LRBA deficiency.
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Affiliation(s)
- Ayca Kiykim
- Division of Pediatric Allergy and Immunology, Marmara University School of Medicine, Istanbul, Turkey
| | - Ismail Ogulur
- Division of Pediatric Allergy and Immunology, Marmara University School of Medicine, Istanbul, Turkey
| | - Esra Dursun
- Division of Pediatric Allergy and Immunology, Marmara University School of Medicine, Istanbul, Turkey
| | - Louis Marie Charbonnier
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Ercan Nain
- Division of Pediatric Allergy and Immunology, Marmara University School of Medicine, Istanbul, Turkey
| | - Sukru Cekic
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Dilek Dogruel
- Division of Pediatric Allergy-Immunology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Neslihan Edeer Karaca
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Mujde Tuba Cogurlu
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Ozlem Arman Bilir
- Division of Pediatric Hematology, Ankara Children's Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Murat Cansever
- Division of Pediatric Immunology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Hasan Kapakli
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Dilek Baser
- Division of Pediatric Allergy and Immunology, Marmara University School of Medicine, Istanbul, Turkey
| | - Nurhan Kasap
- Division of Pediatric Allergy and Immunology, Marmara University School of Medicine, Istanbul, Turkey
| | - Seyhan Kutlug
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Derya Ufuk Altintas
- Division of Pediatric Allergy-Immunology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Ahmad Al-Shaibi
- Division of Translational Medicine, Research Branch, Sidra Medicine, Doha, Qatar
| | - Nourhen Agrebi
- Division of Translational Medicine, Research Branch, Sidra Medicine, Doha, Qatar
| | - Manolya Kara
- Division of Pediatric Infectious Diseases, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ayla Guven
- Division of Pediatric Endocrinology Clinic, Medical Faculty, Zeynep Kamil Women and Children Hospital, Saglik Bilimleri University, Istanbul, Turkey
| | - Ayper Somer
- Division of Pediatric Infectious Diseases, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Cigdem Aydogmus
- Division of Pediatric Allergy and Immunology, Kanuni Sultan Suleyman Training Hospital, Istanbul, Turkey
| | - Nuray Aktay Ayaz
- Division of Pediatric Rheumatology, Kanuni Sultan Suleyman Training Hospital, Istanbul, Turkey
| | - Ayse Metin
- Division of Pediatric Immunology, Ankara Children's Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Metin Aydogan
- Division of Pediatric Gastroenterology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Aysen Uncuoglu
- Division of Pediatric Gastroenterology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Turkan Patiroglu
- Division of Pediatric Immunology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Alisan Yildiran
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Sukru Nail Guner
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Sevgi Keles
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Ismail Reisli
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Guzide Aksu
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Necil Kutukculer
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Sara S Kilic
- Division of Pediatric Immunology and Rheumatology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Mustafa Yilmaz
- Division of Pediatric Allergy-Immunology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Elif Karakoc-Aydiner
- Division of Pediatric Allergy and Immunology, Marmara University School of Medicine, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
| | - Bernice Lo
- Division of Translational Medicine, Research Branch, Sidra Medicine, Doha, Qatar
| | - Ahmet Ozen
- Division of Pediatric Allergy and Immunology, Marmara University School of Medicine, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
| | - Talal A Chatila
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Safa Baris
- Division of Pediatric Allergy and Immunology, Marmara University School of Medicine, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey.
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15
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Agakidis C, Agakidou E, Sarafidis K, Papoulidis I, Xinias I, Farmaki E. Immune Dysregulation, Polyendocrinopathy, Enteropathy, X-Linked Syndrome Associated With a Novel Mutation of FOXP3 Gene. Front Pediatr 2019; 7:20. [PMID: 30805323 PMCID: PMC6370736 DOI: 10.3389/fped.2019.00020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/17/2019] [Indexed: 12/05/2022] Open
Abstract
The immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a rare, x-linked, recessive disorder characterized by dysfunction of the T regulatory (Treg) lymphocytes leading to autoimmune diseases. Herein we report a male patient with IPEX syndrome who presented with severe diarrhea, eczema, and malabsorption leading to failure to thrive and necessitating total parenteral nutrition, as well as with liver dysfunction. Laboratory investigation showed elevated liver enzymes that declined following treatment with glucocorticosteroids and immunosuppressive drugs, marked eosinophilia, increased total IgE, and decreased Treg cells. DNA analysis revealed that the patient himself was hemizygous and his mother heterozygous for the exon 10, c.1015C>T (p.Pro339Ser) mutation of the FOXP3 gene, which has not been previously reported. The current case indicates that mutations resulting in substitution of a certain amino-acid (i.e., proline 339) by different amino-acids are manifested with different IPEX phenotypes.
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Affiliation(s)
- Charalampos Agakidis
- Pediatric Gastroenterology Section, First Department of Pediatrics, Ippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Agakidou
- First Department of Neonatology, Ippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kosmas Sarafidis
- First Department of Neonatology, Ippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Papoulidis
- Access to Genome P.C., Clinical Genetics Laboratory, Thessaloniki, Greece
| | - Ioannis Xinias
- Pediatric Gastroenterology Section, Third Department of Pediatrics, Ippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelia Farmaki
- Immunology Laboratory, First Department of Pediatrics, Ippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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16
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Gambineri E, Ciullini Mannurita S, Hagin D, Vignoli M, Anover-Sombke S, DeBoer S, Segundo GRS, Allenspach EJ, Favre C, Ochs HD, Torgerson TR. Clinical, Immunological, and Molecular Heterogeneity of 173 Patients With the Phenotype of Immune Dysregulation, Polyendocrinopathy, Enteropathy, X-Linked (IPEX) Syndrome. Front Immunol 2018; 9:2411. [PMID: 30443250 PMCID: PMC6223101 DOI: 10.3389/fimmu.2018.02411] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 09/28/2018] [Indexed: 12/22/2022] Open
Abstract
Background: Immune Dysregulation, Polyendocrinopathy, Enteropathy, X-linked (IPEX) Syndrome is a rare recessive disorder caused by mutations in the FOXP3 gene. In addition, there has been an increasing number of patients with wild-type FOXP3 gene and, in some cases, mutations in other immune regulatory genes. Objective: To molecularly asses a cohort of 173 patients with the IPEX phenotype and to delineate the relationship between the clinical/immunologic phenotypes and the genotypes. Methods: We reviewed the clinical presentation and laboratory characteristics of each patient and compared clinical and laboratory data of FOXP3 mutation-positive (IPEX patients) with those from FOXP3 mutation-negative patients (IPEX-like). A total of 173 affected patients underwent direct sequence analysis of the FOXP3 gene while 85 IPEX-like patients with normal FOXP3 were investigated by a multiplex panel of "Primary Immune Deficiency (PID-related) genes." Results: Forty-four distinct FOXP3 variants were identified in 88 IPEX patients, 9 of which were not previously reported. Among the 85 IPEX-like patients, 19 different disease-associated variants affecting 9 distinct genes were identified. Conclusions: We provide a comprehensive analysis of the clinical features and molecular bases of IPEX and IPEX-like patients. Although we were not able to identify major distinctive clinical features to differentiate IPEX from IPEX-like syndromes, we propose a simple flow-chart to effectively evaluate such patients and to focus on the most likely molecular diagnosis. Given the large number of potential candidate genes and overlapping phenotypes, selecting a panel of PID-related genes will facilitate a molecular diagnosis.
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Affiliation(s)
- Eleonora Gambineri
- Department of NEUROFARBA, University of Florence, Florence, Italy
- Oncology/Hematology Department, “Anna Meyer” Children's Hospital, Florence, Italy
| | - Sara Ciullini Mannurita
- Department of NEUROFARBA, University of Florence, Florence, Italy
- Oncology/Hematology Department, “Anna Meyer” Children's Hospital, Florence, Italy
| | - David Hagin
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
| | - Marina Vignoli
- Department of NEUROFARBA, University of Florence, Florence, Italy
- Oncology/Hematology Department, “Anna Meyer” Children's Hospital, Florence, Italy
| | | | - Stacey DeBoer
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
| | - Gesmar R. S. Segundo
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
| | - Eric J. Allenspach
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
| | - Claudio Favre
- Oncology/Hematology Department, “Anna Meyer” Children's Hospital, Florence, Italy
| | - Hans D. Ochs
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
| | - Troy R. Torgerson
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
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17
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Azizi G, Yazdani R, Rae W, Abolhassani H, Rojas M, Aghamohammadi A, Anaya JM. Monogenic polyautoimmunity in primary immunodeficiency diseases. Autoimmun Rev 2018; 17:1028-1039. [PMID: 30107266 DOI: 10.1016/j.autrev.2018.05.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 05/02/2018] [Indexed: 02/08/2023]
Abstract
Primary immunodeficiency diseases (PIDs) consist of a large group of genetic disorders that affect distinct components of the immune system. PID patients are susceptible to infection and non-infectious complications, particularly autoimmunity. A specific group of monogenic PIDs are due to mutations in genes that are critical for the regulation of immunological tolerance and immune responses. This group of monogenic PIDs is at high risk of developing polyautoimmunity (i.e., the presence of more than one autoimmune disease in a single patient) because of their impaired immunity. In this review, we discuss the mechanisms of autoimmunity in PIDs and the characteristics of polyautoimmunity in the following PIDs: IPEX; monogenic IPEX-like syndrome; LRBA deficiency; CTLA4 deficiency; APECED; ALPS; and PKCδ deficiency.
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Affiliation(s)
- Gholamreza Azizi
- Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran; Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Primary Immunodeficiency Diseases Network (PIDNet), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Reza Yazdani
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Wiliam Rae
- Department of Immunology, MP8, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire SO16 6YD, UK
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Manuel Rojas
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia.
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18
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Respiratory manifestations in LPS-responsive beige-like anchor (LRBA) protein-deficient patients. Eur J Pediatr 2018; 177:1163-1172. [PMID: 29777306 DOI: 10.1007/s00431-018-3171-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/28/2018] [Accepted: 05/08/2018] [Indexed: 02/06/2023]
Abstract
UNLABELLED Lipopolysaccharide (LPS)-responsive beige-like anchor (LRBA) protein deficiency is a rare syndrome of primary immune deficiency and immune dysregulation. In this study, we sought to summarize our experience with respiratory manifestations in LRBA-deficient patients. We conducted a retrospective analysis of the medical records of LRBA-deficient patients treated at Hadassah-Hebrew University Medical Center, Jerusalem, Israel. Data retrieved included pulmonary workup, disease course, treatment, and outcome. Ten patients were included. Mean age at presentation of LRBA deficiency-related symptoms was 4.65 years (range 3 months-14 years). Respiratory symptoms were noted in six patients and consisted of chronic cough. Computed tomography revealed consolidation in five patients, atelectasis and bronchiectasis in two patients each, and diffuse interstitial lung disease in two additional patients. Respiratory tract cultures yielded a bacterial pathogen in five patients. Seven patients required active therapy: intravenous immunoglobulins (six patients), immunosuppressive drugs (five patients), and one was successfully treated with abatacept. Two patients underwent successful bone marrow transplantation. Mean follow-up period was 4.5 (range 0.4-14.4) years. On their latest examination, seven patients had no respiratory symptoms. CONCLUSION Pulmonary manifestations are common in LRBA deficiency. Respiratory characteristics in LRBA-deficient patients should be investigated, monitored, and treated from the time of diagnosis. What is Known: • Lipopolysaccharide-responsive beige-like anchor (LRBA) deficiency is a syndrome of primary immune deficiency and immune dysregulation. • Studies concerning the pulmonary characteristics of LRBA-deficient patients are lacking. What is New: • Respiratory manifestations include infections, bronchiectasis, interstitial lung disease, thoracic lymphadenopathy, and clubbing. • Awareness to pulmonary morbidity in LRBA-deficient patients and involvement of a pulmonologist in the workup and clinical decision-making is important. • Respiratory characteristics in LRBA-deficient patients should be investigated, monitored, and treated from a young age.
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19
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He B, Hoang TK, Tran DQ, Rhoads JM, Liu Y. Adenosine A 2A Receptor Deletion Blocks the Beneficial Effects of Lactobacillus reuteri in Regulatory T-Deficient Scurfy Mice. Front Immunol 2017; 8:1680. [PMID: 29270168 PMCID: PMC5723640 DOI: 10.3389/fimmu.2017.01680] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 11/15/2017] [Indexed: 01/06/2023] Open
Abstract
The lack of a functional Foxp3 transcription factor and regulatory T (Treg) cells causes lethal, CD4+ T cell-driven autoimmune diseases in scurfy (SF) mice and humans. Recent studies have shown that adenosine A2A receptor activation limits inflammation and tissue damage, thereby playing an anti-inflammatory role. However, the role of the adenosine A2A receptor in the development of disease in SF mice remains unclear. Using a genetic approach, we found that adenosine A2A receptor deletion in SF mice (SF⋅A2A-/-) does not affect early life events, the development of a lymphoproliferative disorder, or hyper-production of pro-inflammatory cytokines seen in the Treg-deficiency state. As shown previously, Lactobacillus reuteri DSM 17938 treatment prolonged survival and reduced multiorgan inflammation in SF mice. In marked contrast, A2A receptor deletion completely blocked these beneficial effects of L. reuteri in SF mice. Altogether, these results suggest that although absence of the adenosine A2A receptor does not affect the development of disease in SF mice, it plays a critical role in the immunomodulation by L. reuteri in Treg-deficiency disease. The adenosine A2A receptor and its activation may have a role in treating other Treg dysfunction-mediated autoimmune diseases.
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Affiliation(s)
- Baokun He
- Division of Gastroenterology, Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Thomas K Hoang
- Division of Gastroenterology, Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Dat Q Tran
- Division of Gastroenterology, Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jon Marc Rhoads
- Division of Gastroenterology, Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Yuying Liu
- Division of Gastroenterology, Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
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20
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Alroqi FJ, Charbonnier LM, Keles S, Ghandour F, Mouawad P, Sabouneh R, Mohammed R, Almutairi A, Chou J, Massaad MJ, Geha RS, Baz Z, Chatila TA. DOCK8 Deficiency Presenting as an IPEX-Like Disorder. J Clin Immunol 2017; 37:811-819. [PMID: 29058101 DOI: 10.1007/s10875-017-0451-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 10/09/2017] [Indexed: 12/13/2022]
Abstract
PURPOSE The dedicator of cytokinesis 8 (DOCK8) deficiency is an autosomal recessive-combined immunodeficiency whose clinical spectra include recurrent infections, autoimmunity, malignancies, elevated serum IgE, eczema, and food allergies. Here, we report on patients with loss of function DOCK8 mutations with profound immune dysregulation suggestive of an immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX)-like disorder. METHODS Immunophenotyping of lymphocyte subpopulations and analysis of DOCK8 protein expression were evaluated by flow cytometry. T regulatory (Treg) cells were isolated by cell sorting, and their suppressive activity was analyzed by flow cytometry. Gene mutational analysis was performed by whole-exome and Sanger sequencing. RESULTS Patient 1 (P1) presented at 10 months of age with chronic severe diarrhea and active colitis in the absence of an infectious trigger, severe eczema with elevated serum IgE, and autoimmune hemolytic anemia, suggestive of an IPEX-related disorder. Whole-exome sequencing revealed a homozygous nonsense mutation in DOCK8 at the DOCK-homology region (DHR)-1 (c.1498C>T; p. R500X). Patient P2, a cousin of P1 who carries the same DOCK8 nonsense mutation, presented with eczema and recurrent ear infections in early infancy, and she developed persistent diarrhea by 3 years of age. Patient P3 presented with lymphoproliferation, severe eczema with allergic dysregulation, and chronic diarrhea with colitis. She harbored a homozygous loss of function DOCK8 mutation (c.2402 -1G→A). Treg cell function was severely compromised by both DOCK8 mutations. CONCLUSION DOCK8 deficiency may present severe immune dysregulation with features that may overlap with those of IPEX and other IPEX-like disorders.
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Affiliation(s)
- Fayhan J Alroqi
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Karp Family Building, Room 10-214. 1 Blackfan Street, Boston, MA, 02115, USA
- Department of Pediatrics, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Louis-Marie Charbonnier
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Karp Family Building, Room 10-214. 1 Blackfan Street, Boston, MA, 02115, USA
| | - Sevgi Keles
- Division of Pediatric Allergy and Immunology, Necmettin Erbakan University, Konya, Turkey
| | - Fatima Ghandour
- Department of Pathology, St George Hospital University Medical Center, Beirut, Lebanon
| | - Pierre Mouawad
- Department of Pediatrics, St George Hospital University Medical Center, Beirut, Lebanon
| | - Rami Sabouneh
- Department of Pediatrics, St George Hospital University Medical Center, Beirut, Lebanon
| | - Reem Mohammed
- Department of Pediatrics, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abduarahman Almutairi
- Department of Pediatrics, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Janet Chou
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Karp Family Building, Room 10-214. 1 Blackfan Street, Boston, MA, 02115, USA
| | - Michel J Massaad
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Karp Family Building, Room 10-214. 1 Blackfan Street, Boston, MA, 02115, USA
| | - Raif S Geha
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Karp Family Building, Room 10-214. 1 Blackfan Street, Boston, MA, 02115, USA
| | - Zeina Baz
- Department of Pediatrics, St George Hospital University Medical Center, Beirut, Lebanon
| | - Talal A Chatila
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Karp Family Building, Room 10-214. 1 Blackfan Street, Boston, MA, 02115, USA.
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21
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Louie RJ, Tan QKG, Gilner JB, Rogers RC, Younge N, Wechsler SB, McDonald MT, Gordon B, Saski CA, Jones JR, Chapman SJ, Stevenson RE, Sleasman JW, Friez MJ. Novel pathogenic variants in FOXP3 in fetuses with echogenic bowel and skin desquamation identified by ultrasound. Am J Med Genet A 2017; 173:1219-1225. [PMID: 28317311 DOI: 10.1002/ajmg.a.38144] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 12/05/2016] [Accepted: 12/30/2016] [Indexed: 11/12/2022]
Abstract
Immunodysregulation, Polyendocrinopathy, Enteropathy, X-linked (IPEX) syndrome is a rare, X-linked recessive disease that affects regulatory T cells (Tregs) resulting in diarrhea, enteropathy, eczema, and insulin-dependent diabetes mellitus. IPEX syndrome is caused by pathogenic alterations in FOXP3 located at Xp11.23. FOXP3 encodes a transcription factor that interacts with several partners, including NFAT and NF-κB, and is necessary for the proper cellular differentiation of Tregs. Although variable, the vast majority of IPEX syndrome patients have onset of disease during infancy with severe enteropathy. Only five families with prenatal presentation of IPEX syndrome have been reported. Here, we present two additional prenatal onset cases with novel inherited frameshift pathogenic variants in FOXP3 that generate premature stop codons. Ultrasound findings in the first patient identified echogenic bowel, echogenic debris, scalp edema, and hydrops. In the second patient, ultrasound findings included polyhydramnios with echogenic debris, prominent fluid-filled loops of bowel, and echogenic bowel. These cases further broaden the phenotypic spectrum of IPEX syndrome by describing previously unappreciated prenatal ultrasound findings associated with the disease.
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Affiliation(s)
| | | | | | | | - Noelle Younge
- Duke University School of Medicine, Durham, North Carolina
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22
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He B, Hoang TK, Wang T, Ferris M, Taylor CM, Tian X, Luo M, Tran DQ, Zhou J, Tatevian N, Luo F, Molina JG, Blackburn MR, Gomez TH, Roos S, Rhoads JM, Liu Y. Resetting microbiota by Lactobacillus reuteri inhibits T reg deficiency-induced autoimmunity via adenosine A2A receptors. J Exp Med 2016; 214:107-123. [PMID: 27994068 PMCID: PMC5206500 DOI: 10.1084/jem.20160961] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/17/2016] [Accepted: 11/29/2016] [Indexed: 12/13/2022] Open
Abstract
He et al. show that T reg deficiency markedly induces autoimmunity and shifts gut microbiota. Remodeling microbiota by Lactobacillus reuteri was found to inhibit autoimmunity via the metabolite inosine, which interacts with the adenosine A2A receptor. This finding establishes a link between the gut microbiota, A2A receptors, and autoimmunity induced by T reg cell deficiency. Regulatory T (T reg) cell deficiency causes lethal, CD4+ T cell–driven autoimmune diseases. Stem cell transplantation is used to treat these diseases, but this procedure is limited by the availability of a suitable donor. The intestinal microbiota drives host immune homeostasis by regulating the differentiation and expansion of T reg, Th1, and Th2 cells. It is currently unclear if T reg cell deficiency–mediated autoimmune disorders can be treated by targeting the enteric microbiota. Here, we demonstrate that Foxp3+ T reg cell deficiency results in gut microbial dysbiosis and autoimmunity over the lifespan of scurfy (SF) mouse. Remodeling microbiota with Lactobacillus reuteri prolonged survival and reduced multiorgan inflammation in SF mice. L. reuteri changed the metabolomic profile disrupted by T reg cell deficiency, and a major effect was to restore levels of the purine metabolite inosine. Feeding inosine itself prolonged life and inhibited multiorgan inflammation by reducing Th1/Th2 cells and their associated cytokines. Mechanistically, the inhibition of inosine on the differentiation of Th1 and Th2 cells in vitro depended on adenosine A2A receptors, which were also required for the efficacy of inosine and of L. reuteri in vivo. These results reveal that the microbiota–inosine–A2A receptor axis might represent a potential avenue for combatting autoimmune diseases mediated by T reg cell dysfunction.
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Affiliation(s)
- Baokun He
- Pediatrics Gastroenterology, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030.,Pediatric Research Center, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030
| | - Thomas K Hoang
- Pediatrics Gastroenterology, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030.,Pediatric Research Center, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030
| | - Ting Wang
- Pediatrics Gastroenterology, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030.,Pediatric Research Center, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030
| | - Michael Ferris
- Department of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine, New Orleans, LA 70118
| | - Christopher M Taylor
- Department of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine, New Orleans, LA 70118
| | - Xiangjun Tian
- The Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX 77030
| | - Meng Luo
- Department of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine, New Orleans, LA 70118
| | - Dat Q Tran
- Pediatric Research Center, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030
| | - Jain Zhou
- Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030
| | - Nina Tatevian
- Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030
| | - Fayong Luo
- Department of Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030
| | - Jose G Molina
- Department of Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030
| | - Michael R Blackburn
- Department of Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030
| | - Thomas H Gomez
- Center for Laboratory Animal Medicine and Care, The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Stefan Roos
- Department of Microbiology, Uppsala BioCenter, Swedish University of Agricultural Sciences, 750 07 Uppsala, Sweden.,BioGaia AB, 103 64 Stockholm, Sweden
| | - J Marc Rhoads
- Pediatrics Gastroenterology, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030 .,Pediatric Research Center, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030
| | - Yuying Liu
- Pediatrics Gastroenterology, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030 .,Pediatric Research Center, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX 77030
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23
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Barış HE, Kıykım A, Nain E, Özen AO, Karakoç-Aydıner E, Barış S. The plethora, clinical manifestations and treatment options of autoimmunity in patients with primary immunodeficiency. Turk Arch Pediatr 2016; 51:186-192. [PMID: 28123330 DOI: 10.5152/turkpediatriars.2016.3928] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 06/24/2016] [Indexed: 12/19/2022]
Abstract
AIM Although the association between primary immunodeficiency and autoimmunity is already well-known, it has once again become a topic of debate with the discovery of newly-defined immunodeficiencies. Thus, investigation of the mechanisms of development of autoimmunity in primary immunodefficiency and new target-specific therapeutic options has come to the fore. In this study, we aimed to examine the clinical findings of autoimmunity, autoimmunity varieties, and treatment responses in patients who were genetically diagnosed as having primary immunodeficiency. MATERIAL AND METHODS The files of patients with primary immunodeficiency who had clinical findings of autoimmunity, who were diagnosed genetically, and followed up in our clinic were investigated. The demographic and clinical features of the patients and their medical treatments were evaluated. RESULTS Findings of autoimmunity were found in 30 patients whose genetic mutations were identified. The mean age at the time of the first symptoms was 8.96±14.64 months, and the mean age of receiving a genetic diagnosis was 82.55±84.71 months. The most common diseases showing findings of autoimmunity included immune dysregulation, polyendocrinopathy, enteropathy X-linked syndrome (16.7%); autoimmune lymphoproliferative syndrome (10%); lipopolysaccharide-responsive beige-like anchor protein deficiency (10%); and DiGeorge syndrome (10%). Twelve (40%) patients showed findings of autoimmunity at the time of first presentation. The most common findings of autoimmunity included inflammatory bowel disease, inflammatory bowel disease-like findings (n=14, 46.7%), immune thrombocytopenic purpura (n=11, 36.7%), and autoimmune hemolytic anemia (n=9, 30.0%). A response to immunosupressive agents was observed in 15 (50%) patients. Ten patients underwent hematopoietic stem cell transplantation. Six patients were lost to follow-up due to a variety of complications. CONCLUSION Autoimmunity is frequently observed in patients with primary immunodeficiency. The possibility of primary immunodeficiency should be considered in patients with early-onset manifestations of autoimmunity, and these patients should be carefully monitored in terms of immunodeficiency development. Early diagnosis of primary immunodeficiency may provide favorable outcomes in terms of survival.
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Affiliation(s)
- Hatice Ezgi Barış
- Department of Peditarics, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - Ayça Kıykım
- Department of Peditarics, Division of Allergy and Immunology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - Ercan Nain
- Department of Peditarics, Division of Allergy and Immunology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - Ahmet Oğuzhan Özen
- Department of Peditarics, Division of Allergy and Immunology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - Elif Karakoç-Aydıner
- Department of Peditarics, Division of Allergy and Immunology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - Safa Barış
- Department of Peditarics, Division of Allergy and Immunology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
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24
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Johnson MB, Hattersley AT, Flanagan SE. Monogenic autoimmune diseases of the endocrine system. Lancet Diabetes Endocrinol 2016; 4:862-72. [PMID: 27474216 DOI: 10.1016/s2213-8587(16)30095-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 05/09/2016] [Accepted: 05/12/2016] [Indexed: 12/29/2022]
Abstract
The most common endocrine diseases, type 1 diabetes, hyperthyroidism, and hypothyroidism, are the result of autoimmunity. Clustering of autoimmune endocrinopathies can result from polygenic predisposition, or more rarely, may present as part of a wider syndrome due to a mutation within one of seven genes. These monogenic autoimmune diseases show highly variable phenotypes both within and between families with the same mutations. The average age of onset of the monogenic forms of autoimmune endocrine disease is younger than that of the common polygenic forms, and this feature combined with the manifestation of other autoimmune diseases, specific hallmark features, or both, can inform clinicians as to the relevance of genetic testing. A genetic diagnosis can guide medical management, give an insight into prognosis, inform families of recurrence risk, and facilitate prenatal diagnoses.
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Affiliation(s)
- Matthew B Johnson
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.
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25
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Bacchetta R, Barzaghi F, Roncarolo MG. From IPEX syndrome to FOXP3
mutation: a lesson on immune dysregulation. Ann N Y Acad Sci 2016; 1417:5-22. [DOI: 10.1111/nyas.13011] [Citation(s) in RCA: 210] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/29/2015] [Accepted: 01/06/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Rosa Bacchetta
- Department of Pediatrics; Division of Pediatric Stem Cells, Transplantation and Regenerative Medicine; Stanford University Medical School; Stanford California
| | - Federica Barzaghi
- San Raffaele Telethon Institute for Gene Therapy; Division of Regenerative Medicine; Stem Cells and Gene Therapy; San Raffaele Scientific Institute; Milan Italy
| | - Maria-Grazia Roncarolo
- Department of Pediatrics; Division of Pediatric Stem Cells, Transplantation and Regenerative Medicine; Stanford University Medical School; Stanford California
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26
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Chen CA, Chung WC, Chiou YY, Yang YJ, Lin YC, Ochs HD, Shieh CC. Quantitative analysis of tissue inflammation and responses to treatment in immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome, and review of literature. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2015; 49:775-782. [PMID: 26748735 DOI: 10.1016/j.jmii.2015.10.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 09/24/2015] [Accepted: 10/14/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND/PURPOSE Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a severe autoimmune disease that is caused by regulatory T cell deficiency due to FOXP3 gene mutations. The long-term outcome can be variable depending on the extent of tissue damage caused by autoimmunity and infections, the use of immunosuppressive treatment or sequela of bone marrow transplantation. METHODS We used immunohistochemical staining to analyze cell types infiltrating the tissue of affected organs from a classic IPEX patient with a splicing mutation (c.736-2A>C) in the FOXP3 gene. Expression of transcription factors that are critical for immune responses including T-bet, GATA-3, RORγt, and FOXP3 were evaluated in various tissue samples. For objective analysis of the distribution of different cell types in tissues, we used an automated microscope-based image acquiring system to assess quantitatively the different cell types by investigating the histopathological changes in the patient's biopsy samples obtained from the intestine and the kidneys before and after treatment. RESULTS The percentages of cells expressing the TH2-associated transcription factor GATA3 were higher in the IPEX patient before treatment than in controls, suggesting that TH2-type cells contribute to the tissue inflammation of the gut and kidneys in IPEX syndrome. Immunosuppressive treatment effectively decreased the number of effector cells in the kidneys and intestine of the IPEX patient. CONCLUSION This study provides quantitative evidence that the inflamed intestinal and renal tissues of the IPEX patient contain TH2-type immune effector cells, which decreased in number after immunosuppressive treatment was initiated and the clinical symptoms had improved.
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Affiliation(s)
- Chih-An Chen
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wan-Chen Chung
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Yow Chiou
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yao-Jong Yang
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yung-Chieh Lin
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hans D Ochs
- Seattle Children's Research Institute and Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Chi-Chang Shieh
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Pichard DC, Freeman AF, Cowen EW. Primary immunodeficiency update: Part I. Syndromes associated with eczematous dermatitis. J Am Acad Dermatol 2015; 73:355-64; quiz 365-6. [PMID: 26282794 DOI: 10.1016/j.jaad.2015.01.054] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/20/2015] [Accepted: 01/21/2015] [Indexed: 01/26/2023]
Abstract
In the past decade, the availability of powerful molecular techniques has accelerated the pace of discovery of several new primary immunodeficiencies (PIDs) and revealed the biologic basis of other established PIDs. These genetic advances, in turn, have facilitated more precise phenotyping of associated skin and systemic manifestations and provide a unique opportunity to better understand the complex human immunologic response. These continuing medical education articles will provide an update of recent advances in PIDs that may be encountered by dermatologists through their association with eczematous dermatitis, infectious, and non-infectious cutaneous manifestations. Part I will discuss new primary immunodeficiencies that have an eczematous dermatitis. Part II will focus on primary immunodeficiencies that greatly increase susceptibility to fungal infection and the noninfectious presentations of PIDs.
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Affiliation(s)
- Dominique C Pichard
- National Institutes of Health, National Cancer Institute, Bethesda, Maryland
| | | | - Edward W Cowen
- National Institutes of Health, National Cancer Institute, Bethesda, Maryland.
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Bertelli R, Bonanni A, Di Donato A, Cioni M, Ravani P, Ghiggeri GM. Regulatory T cells and minimal change nephropathy: in the midst of a complex network. Clin Exp Immunol 2015; 183:166-74. [PMID: 26147676 DOI: 10.1111/cei.12675] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2015] [Indexed: 12/16/2022] Open
Abstract
Minimal change nephrosis (MCN) is an important cause of morbidity in children. In spite of successful therapies having been developed in the last three decades, most aspects related to pathogenesis still remain poorly defined. Evolution in basic immunology and results deriving from animal models of the disease suggest a complex interaction of factors and cells starting from activation of innate immunity and continuing with antigen presentation. Oxidants, CD80 and CD40/CD40L have probably a relevant role at the start. Studies in animal models and in human beings also suggest the possibility that the same molecules (i.e. CD80, CD40) are expressed by podocytes under inflammatory stimuli, representing a direct potential mechanism for proteinuria. B and T cells could play a relevant role this contest. Implication of B cells is suggested indirectly by studies utilizing anti-CD20 monoclonal antibodies as the main therapy. The role of regulatory T cells (Tregs ) is supported mainly by results in animal models of nephrotic syndrome (i.e. adriamycin, puromycin, lipopolysaccharide), showing a protective effect of direct Treg infusion or stimulation by interleukin 2 (IL-2). Limited studies have also shown reduced amounts of circulating Tregs in patients with active MCN cells. The route from bench to bedside would be reduced if results from animal models were confirmed in human pathology. The expansion of Tregs with recombinant IL-2 and new anti-CD20 monoclonal antibodies is the beginning. Blocking antigen-presenting cells with cytotoxic T lymphocyte antigen (CTLA-4)-Ig fusion molecules inhibiting CD80 and/or with blockers of CD40-CD40 ligand interaction represent potential new approaches. The hope is that evolution in therapies of MCN could fill a gap lasting 30 years.
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Affiliation(s)
- R Bertelli
- Laboratory on Physiopathology of Uremia, Children's Hospital, Genoa, Italy.,Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - A Bonanni
- Laboratory on Physiopathology of Uremia, Children's Hospital, Genoa, Italy.,Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - A Di Donato
- Laboratory on Physiopathology of Uremia, Children's Hospital, Genoa, Italy.,Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - M Cioni
- Laboratory on Physiopathology of Uremia, Children's Hospital, Genoa, Italy.,Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - P Ravani
- Division of Nephrology, University of Calgary, Calgary, Canada
| | - G M Ghiggeri
- Laboratory on Physiopathology of Uremia, Children's Hospital, Genoa, Italy.,Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
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