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Karaaslan BG, Turan I, Aydemir S, Meric ZA, Atay D, Akcay A, Sari AA, Hershfield M, Cipe F, Aksoy BA, Ersoy GZ, Bozkurt C, Demirkol YK, Ozturk G, Aydogmus C, Kiykim A, Cokugras H. Neurologic Status of Patients with Purine Nucleoside Phosphorylase Deficiency Before and After Hematopoetic Stem Cell Transplantation. J Clin Immunol 2023; 43:2062-2075. [PMID: 37726596 DOI: 10.1007/s10875-023-01585-6] [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] [Received: 07/10/2023] [Accepted: 09/12/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Purine nucleoside phosphorylase (PNP) deficiency is a rare autosomal recessive combined immunodeficiency. The phenotype is profound T cell deficiency with variable B and NK cell functions and results in recurrent and persistent infections that typically begin in the first year of life. Neurologic findings occur in approximately two-thirds of patients. The mechanism of neurologic abnormalities is unclear. Hematopoietic stem cell transplantation (HSCT) is the only curative treatment for PNP deficiency. METHODS We report here six patients from five unrelated families with PNP deficiency treated in two centers in Turkey. We evaluated the neurological status of patients and compared to post-transplantation period if available. Then, we performed PubMed, Google Scholar, and Researchgate searches using the terms "PNP" and "hematopoietic stem cell transplantation" to find all reported cases of PNP transplantation and compared to our cohort. RESULTS Six patients were treated in two centers in Turkey. One patient died from post-transplant complications. The other four patients underwent successful HSCT with good immune reconstitution after transplantation (follow-up 21-48 months) and good neurological outcomes. The other patient with a new mutation is still waiting for a matching HLA donor. DISCUSSION In PNP deficiency, clinical manifestations are variable, and this disease should be considered in the presence of many different clinical findings. Despite the comorbidities that occurred before transplantation, HSCT currently appears to be the only treatment option for this disease. HSCT not only cures immunologic disorders, but probably also improves or at least stabilizes the neurologic status of patients.
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Affiliation(s)
- Betul Gemici Karaaslan
- Department of Pediatric Immunology and Allergy, School of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Isilay Turan
- Department of Pediatric Immunology and Allergy, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Sezin Aydemir
- Department of Pediatric Immunology and Allergy, School of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Zeynep Akyuncu Meric
- Department of Pediatric Immunology and Allergy, School of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Didem Atay
- Department of Pediatric Hematology/Oncology, Bone Marrow Transplantation Unit, School of Medicine, Altunizade Hospital, Acibadem University, Istanbul, Turkey
| | - Arzu Akcay
- Department of Pediatric Hematology/Oncology, Bone Marrow Transplantation Unit, School of Medicine, Altunizade Hospital, Acibadem University, Istanbul, Turkey
| | - Aysun Ayaz Sari
- Department of Pediatric Neurology, School of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Michael Hershfield
- Department of Medicine, Department of Biochemistry, Duke University School of Medicine, Durham, NC, Duke University School of Medicine, Durham, NC, USA
| | - Funda Cipe
- Department of Pediatric Immunology and Allergy, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
- Department of Pediatric Allergy-Immunology & Pediatric Bone Marrow Transplantation Unit Altınbas University, Medical Park Bahcelievler Hospital, Istanbul, Turkey
| | - Basak Adakli Aksoy
- Department of Pediatric Allergy-Immunology & Pediatric Bone Marrow Transplantation Unit Altınbas University, Medical Park Bahcelievler Hospital, Istanbul, Turkey
| | - Gizem Zengin Ersoy
- Department of Pediatric Allergy-Immunology & Pediatric Bone Marrow Transplantation Unit Altınbas University, Medical Park Bahcelievler Hospital, Istanbul, Turkey
| | - Ceyhun Bozkurt
- Department of Pediatric Allergy-Immunology & Pediatric Bone Marrow Transplantation Unit Istinye University, Medical Park Bahcelievler Hospital, Istanbul, Turkey
| | | | - Gulyuz Ozturk
- Department of Pediatric Hematology/Oncology, Bone Marrow Transplantation Unit, School of Medicine, Altunizade Hospital, Acibadem University, Istanbul, Turkey
| | - Cigdem Aydogmus
- Department of Pediatric Immunology and Allergy, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ayca Kiykim
- Department of Pediatric Immunology and Allergy, School of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Haluk Cokugras
- Department of Pediatric Immunology and Allergy, School of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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Habib Dzulkarnain SM, Hashim IF, Zainudeen ZT, Taib F, Mohamad N, Nasir A, Wan Ab Rahman WS, Ariffin H, Abd Hamid IJ. Purine Nucleoside Phosphorylase Deficient Severe Combined Immunodeficiencies: A Case Report and Systematic Review (1975-2022). J Clin Immunol 2023; 43:1623-1639. [PMID: 37328647 DOI: 10.1007/s10875-023-01532-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/03/2023] [Indexed: 06/18/2023]
Abstract
Purine nucleoside phosphorylase deficient severe combined immunodeficiency (PNP SCID) is one of the rare autosomal recessive primary immunodeficiency disease, and the data on epidemiology and outcome are limited. We report the successful management of a child with PNP SCID and present a systematic literature review of published case reports, case series, and cohort studies on PNP SCID listed in PubMed, Web of Science, and Scopus from 1975 until March 2022. Forty-one articles were included from the 2432 articles retrieved and included 100 PNP SCID patients worldwide. Most patients presented with recurrent infections, hypogammaglobulinaemia, autoimmune manifestations, and neurological deficits. There were six reported cases of associated malignancies, mainly lymphomas. Twenty-two patients had undergone allogeneic hematopoietic stem cell transplantation with full donor chimerism seen mainly in those receiving matched sibling donors and/or conditioning chemotherapy before the transplant. This research provides a contemporary, comprehensive overview on clinical manifestations, epidemiology, genotype mutations, and transplant outcome of PNP SCID. These data highlight the importance of screening for PNP SCID in cases presented with recurrent infections, hypogammaglobulinaemia, and neurological deficits.
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Affiliation(s)
- Syarifah Masyitah Habib Dzulkarnain
- Primary Immunodeficiency Diseases Group, Department of Clinical Medicine, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam 13200 Kepala Batas, Pulau Pinang, Malaysia
- Cawangan Pulau Pinang, Fakulti Sains Kesihatan, Universiti Teknologi MARA, Kampus Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia
| | - Ilie Fadzilah Hashim
- Primary Immunodeficiency Diseases Group, Department of Clinical Medicine, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam 13200 Kepala Batas, Pulau Pinang, Malaysia
| | - Zarina Thasneem Zainudeen
- Primary Immunodeficiency Diseases Group, Department of Clinical Medicine, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam 13200 Kepala Batas, Pulau Pinang, Malaysia
| | - Fahisham Taib
- Department of Paediatric, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
- Hospital USM, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Norsarwany Mohamad
- Department of Paediatric, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
- Hospital USM, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Ariffin Nasir
- Department of Paediatric, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
- Hospital USM, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Wan Suriana Wan Ab Rahman
- Hospital USM, 16150 Kubang Kerian, Kelantan, Malaysia
- School of Dental Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Hany Ariffin
- Department of Paediatrics, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Intan Juliana Abd Hamid
- Primary Immunodeficiency Diseases Group, Department of Clinical Medicine, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Bertam 13200 Kepala Batas, Pulau Pinang, Malaysia.
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Grunebaum E, Campbell N, Leon-Ponte M, Xu X, Chapdelaine H. Partial Purine Nucleoside Phosphorylase Deficiency Helps Determine Minimal Activity Required for Immune and Neurological Development. Front Immunol 2020; 11:1257. [PMID: 32695102 PMCID: PMC7338719 DOI: 10.3389/fimmu.2020.01257] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/18/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Complete or near complete absence of the purine nucleoside phosphorylase (PNP) enzyme causes a profound T cell immunodeficiency and neurological abnormalities that are often lethal in infancy and early childhood. We hypothesized that patients with partial PNP deficiency, characterized by a late and mild phenotype due to residual PNP enzyme, would provide important information about the minimal PNP activity needed for normal development. Methods: Three siblings with a homozygous PNP gene mutation (c.769C>G, p.His257Asp) resulting in partial PNP deficiency were investigated. PNP activity was semi-quantitively assayed by the conversion of [14C]inosine in hemolysates, mononuclear cells, and lymphoblastoid B cells. PNP protein expression was determined by Western Blotting in lymphoblastoid B cells. DNA repair was quantified by measuring viability of lymphoblastoid B cells following ionizing irradiation. Results: A 21-year-old female was referred for recurrent sino-pulmonary infections while her older male siblings, aged 25- and 28- years, did not suffer from significant infections. Two of the siblings had moderately reduced numbers of T, B, and NK cells, while the other had near normal lymphocyte subset numbers. T cell proliferations were normal in the two siblings tested. Hypogammaglobulinemia was noted in two siblings, including one that required immunoglobulin replacement. All siblings had typical (normal) neurological development. PNP activity in various cells from two patients were 8-11% of the normal level. All siblings had normal blood uric acid and increased PNP substrates in the urine. PNP protein expression in cells from the two patients examined was similar to that observed in cells from healthy controls. The survival of lymphoblastoid B cells from 2 partial PNP-deficient patients after irradiation was similar to that of PNP-proficient cells and markedly higher than the survival of cells from a patient with absent PNP activity or a patient with ataxia telangiectasia. Conclusions: Patients with partial PNP deficiency can present in the third decade of life with mild-moderate immune abnormalities and typical development. Near-normal immunity might be achieved with relatively low PNP activity.
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Affiliation(s)
- Eyal Grunebaum
- Division of Immunology and Allergy, Hospital for Sick Children, Toronto, ON, Canada.,Developmental and Stem Cell Biology Program, Hospital for Sick Children, Toronto, ON, Canada
| | - Nicholas Campbell
- Department of Medicine, Centre Hospitalier de I'Universite de Montreal, and Montreal Clinical Research Institute, Montreal, QC, Canada
| | - Matilde Leon-Ponte
- Developmental and Stem Cell Biology Program, Hospital for Sick Children, Toronto, ON, Canada
| | - Xiaobai Xu
- Developmental and Stem Cell Biology Program, Hospital for Sick Children, Toronto, ON, Canada
| | - Hugo Chapdelaine
- Department of Medicine, Centre Hospitalier de I'Universite de Montreal, and Montreal Clinical Research Institute, Montreal, QC, Canada
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4
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Schejter YD, Even-Or E, Shadur B, NaserEddin A, Stepensky P, Zaidman I. The Broad Clinical Spectrum and Transplant Results of PNP Deficiency. J Clin Immunol 2019; 40:123-130. [PMID: 31707514 DOI: 10.1007/s10875-019-00698-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/25/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Purine nucleoside phosphorylase (PNP) is a known yet rare cause of combined immunodeficiency with a heterogeneous clinical presentation. We aim to add to the expanding clinical spectrum of disease, and to summarize the available data on bone marrow transplant for this condition. METHODS Data was collected from patient files retrospectively. A review of the literature of hematopoietic stem cell transplantation (HSCT) for PNP deficiency was conducted. RESULTS Four patients were treated in two centers in Israel. One patient died of EBV-related lymphoma with CNS involvement prior to transplant. The other three patients underwent successful HSCT with good immune reconstitution post-transplant (follow-up 8-108 months) and excellent neurological outcomes. CONCLUSION PNP is a variable immunodeficiency and should be considered in various clinical contexts, with or without neurological manifestations. HSCT offers a good treatment option, with excellent clinical outcomes, when preformed in a timely manner.
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Affiliation(s)
- Yael Dinur Schejter
- Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - Ehud Even-Or
- Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Bella Shadur
- Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Immunology Division, Garvan Institute of Medical Research, Sydney, Australia.,Graduate Research School, University of New South Wales, Sydney, Australia
| | - Adeeb NaserEddin
- Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Polina Stepensky
- Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Irina Zaidman
- Bone Marrow Transplantation Department, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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5
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Fekrvand S, Yazdani R, Abolhassani H, Ghaffari J, Aghamohammadi A. The First Purine Nucleoside Phosphorylase Deficiency Patient Resembling IgA Deficiency and a Review of the Literature. Immunol Invest 2019; 48:410-430. [PMID: 30885031 DOI: 10.1080/08820139.2019.1570249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purine nucleoside phosphorylase (PNP) deficiency is a rare autosomal recessive primary immunodeficiency disorder characterized by decreased numbers of T-cells, variable B-cell abnormalities, decreased amount of serum uric acid and PNP enzyme activity. The affected patients usually present with recurrent infections, neurological dysfunction and autoimmune phenomena. In this study, whole-exome sequencing was used to detect mutation in the case suspected of having primary immunodeficiency. We found a homozygous mutation in PNP gene in a girl who is the third case from the national Iranian registry. She had combined immunodeficiency, autoimmune hemolytic anemia and a history of recurrent infections. She developed no neurological dysfunction. She died at the age of 11 after a severe chicken pox infection. PNP deficiency should be considered in late-onset children with recurrent infections, autoimmune disorders without typical neurologic impairment.
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Affiliation(s)
- Saba Fekrvand
- a Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center , Tehran, and the University of Medical Science , Tehran , Iran
| | - Reza Yazdani
- a Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center , Tehran, and the University of Medical Science , Tehran , Iran
| | - Hassan Abolhassani
- a Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center , Tehran, and the University of Medical Science , Tehran , Iran.,b Division of Clinical Immunology, Department of Laboratory Medicine , Karolinska Institute at Karolinska University Hospital Huddinge , Stockholm , Sweden
| | - Javad Ghaffari
- c Department of Pediatrics , Mazandaran University of Medical Sciences , Sari , Iran
| | - Asghar Aghamohammadi
- a Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center , Tehran, and the University of Medical Science , Tehran , Iran
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Yeates L, Slatter MA, Gennery AR. Infusion of Sibling Marrow in a Patient with Purine Nucleoside Phosphorylase Deficiency Leads to Split Mixed Donor Chimerism and Normal Immunity. Front Pediatr 2017; 5:143. [PMID: 28674683 PMCID: PMC5475337 DOI: 10.3389/fped.2017.00143] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 06/06/2017] [Indexed: 12/31/2022] Open
Abstract
Purine nucleoside phosphorylase (PNP) deficiency, a rare autosomal recessive metabolic disease causes combined immunodeficiency and developmental delay, hypotonia, and spasticity. Patients present with recurrent infections associated with T-lymphocytopenia, characteristically presenting later than patients with classical severe combined immunodeficiency (SCID). PNP, with adenosine deaminase (ADA), is part of the purine salvage pathway. The only curative therapy is hematopoietic stem cell transplantation. Myeloablative conditioning is recommended to prevent rejection caused by residual immune function. However, HLA-identical sibling stem cell infusions in ADA-SCID result in some donor stem cell engraftment and long-term thymopoiesis. We report a patient with PNP deficiency, who received HLA-identical sibling marrow without chemotherapy because of disseminated cytomegalovirus (CMV) infection. The patient presented at 14 months of age following recurrent infections, from early infancy, with persistent irritability, developmental delay, and hypotonia. She had neutropenia, pan-lymphocytopenia, and hypogammaglobulinemia with low plasma urate and erythrocyte PNP activity. Diagnosis was confirmed with a homozygous mutation in PNP. The patient was viremic with CMV detected in blood and CSF by PCR. Dual antiviral therapy improved the clinical condition and reduced the viral load. In view of the disseminated CMV infection, the decision was made to infuse stem cells without any pre-conditioning chemotherapy. She received a matched sibling donor unconditioned stem cell infusion at 16 months of age. The post-transplant course was uneventful. Blood PCR became negative for CMV. Global hypotonia persisted, although with significant improvement in irritability. At 4 years of age and 29 months post-transplant, the patient demonstrated normal T-lymphocyte and natural killer cell numbers. Recent thymic emigrants represented 12% of the total T-lymphocyte population. Lymphocyte proliferative responses to phytohemagglutinin were normal. Memory and class-switched B-lymphocytes were present. Immunoglobulin replacement had been discontinued, and there were normal IgG responses to tetanus vaccine, Haemophilus influenzae type B and pneumococcal conjugate vaccine antigens. There was 93% donor T-lymphocytes, 20% donor B-lymphocytes, and 5% donor myeloid cells, indicative of some donor stem cell engraftment. There was no significant infection history despite regular nursery attendance. Height and weight were following the 50th centile. Split mixed donor chimerism has corrected the immunological defect.
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Affiliation(s)
- Laura Yeates
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Mary A Slatter
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Andrew R Gennery
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom
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7
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Brodszki N, Svensson M, van Kuilenburg ABP, Meijer J, Zoetekouw L, Truedsson L, Toporski J. Novel Genetic Mutations in the First Swedish Patient with Purine Nucleoside Phosphorylase Deficiency and Clinical Outcome After Hematopoietic Stem Cell Transplantation with HLA-Matched Unrelated Donor. JIMD Rep 2015; 24:83-9. [PMID: 25967230 DOI: 10.1007/8904_2015_444] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/09/2015] [Accepted: 04/13/2015] [Indexed: 04/07/2023] Open
Abstract
Purine nucleoside phosphorylase (PNP) is an enzyme active in the purine salvage pathway. PNP deficiency caused by autosomal recessive mutations in the PNP gene leads to severe combined immunodeficiency (SCID) and in two thirds of cases also to neurological effects such as developmental delay, ataxia, and motor impairment.PNP deficiency has a poor outcome, and the only curative treatment is allogenic hematopoietic stem cell transplantation (HSCT). We present the first Swedish patient with PNP deficiency with novel mutations in the PNP gene and the immunological results of the HSCT and evaluate the impact of HSCT on the neurological symptoms. The patient presented early in life with neurological symptoms and suffered later from repeated serious respiratory tract infections. Biochemical tests showed severe reduction in PNP activity (1% residual activity). Genetic testing revealed two new mutations in the PNP gene: c.729C>G (p.Asn243Lys) and c.746A>C (p.Tyr249Cys). HSCT was performed with an unrelated donor, resulting in prompt and sustained engraftment and complete donor chimerism. There was no further aggravation of the patient's neurological symptoms at 21 months post HSCT, and appropriate developmental milestones were achieved. HSCT is curative for the immunological defect caused by PNP deficiency, and our case strengthens earlier reports that HSCT is effective as a treatment even for neurological symptoms in PNP deficiency.
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Affiliation(s)
- Nicholas Brodszki
- Childrens Hospital, Skåne University Hospital, Lasarettsgatan 48, SE-221 85, Lund, Sweden.
| | | | - André B P van Kuilenburg
- Academic Medical Center Lab. Genetic Metabolic Diseases, University of Amsterdam, Amsterdam, The Netherlands
| | - Judith Meijer
- Academic Medical Center Lab. Genetic Metabolic Diseases, University of Amsterdam, Amsterdam, The Netherlands
| | - Lida Zoetekouw
- Academic Medical Center Lab. Genetic Metabolic Diseases, University of Amsterdam, Amsterdam, The Netherlands
| | - Lennart Truedsson
- Department of Laboratory Medicine, Section of Microbiology, Immunology and Glycobiology, Lund University, Lund, Sweden
| | - Jacek Toporski
- Childrens Hospital, Skåne University Hospital, Lasarettsgatan 48, SE-221 85, Lund, Sweden
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8
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Balasubramaniam S, Duley JA, Christodoulou J. Inborn errors of purine metabolism: clinical update and therapies. J Inherit Metab Dis 2014; 37:669-86. [PMID: 24972650 DOI: 10.1007/s10545-014-9731-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 05/27/2014] [Accepted: 06/02/2014] [Indexed: 12/20/2022]
Abstract
Inborn errors of purine metabolism exhibit broad neurological, immunological, haematological and renal manifestations. Limited awareness of the phenotypic spectrum, the recent descriptions of newer disorders and considerable genetic heterogeneity, have contributed to long diagnostic odysseys for affected individuals. These enzymes are widely but not ubiquitously distributed in human tissues and are crucial for synthesis of essential nucleotides, such as ATP, which form the basis of DNA and RNA, oxidative phosphorylation, signal transduction and a range of molecular synthetic processes. Depletion of nucleotides or accumulation of toxic intermediates contributes to the pathogenesis of these disorders. Maintenance of cellular nucleotides depends on the three aspects of metabolism of purines (and related pyrimidines): de novo synthesis, catabolism and recycling of these metabolites. At present, treatments for the clinically significant defects of the purine pathway are restricted: purine 5'-nucleotidase deficiency with uridine; familial juvenile hyperuricaemic nephropathy (FJHN), adenine phosphoribosyl transferase (APRT) deficiency, hypoxanthine phosphoribosyl transferase (HPRT) deficiency and phosphoribosyl-pyrophosphate synthetase superactivity (PRPS) with allopurinol; adenosine deaminase (ADA) and purine nucleoside phosphorylase (PNP) deficiencies have been treated by bone marrow transplantation (BMT), and ADA deficiency with enzyme replacement with polyethylene glycol (PEG)-ADA, or erythrocyte-encapsulated ADA; myeloadenylate deaminase (MADA) and adenylosuccinate lyase (ADSL) deficiencies have had trials of oral ribose; PRPS, HPRT and adenosine kinase (ADK) deficiencies with S-adenosylmethionine; and molybdenum cofactor deficiency of complementation group A (MOCODA) with cyclic pyranopterin monophosphate (cPMP). In this review we describe the known inborn errors of purine metabolism, their phenotypic presentations, established diagnostic methodology and recognised treatment options.
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Affiliation(s)
- Shanti Balasubramaniam
- Metabolic Unit, Princess Margaret Hospital, Roberts Road, Subiaco, Perth, WA, 6008, Australia
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9
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Purine nucleoside phosphorylase deficiency presenting as severe combined immune deficiency. Immunol Res 2013; 56:150-4. [DOI: 10.1007/s12026-012-8380-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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10
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Madkaikar MR, Kulkarni S, Utage P, Fairbanks L, Ghosh K, Marinaki A, Desai M. Purine nucleoside phosphorylase deficiency with a novel PNP gene mutation: a first case report from India. BMJ Case Rep 2011; 2011:bcr.09.2011.4804. [PMID: 22669887 DOI: 10.1136/bcr.09.2011.4804] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The authors report a case of purine nucleoside phosphorylase (PNP) deficiency for the first time from India. The case presented with recurrent severe infections, developmental delays, seizures and progressive neurological deterioration. The diagnosis of primary immunodeficiency disorder was delayed in spite of recurrent infection due to predominant neurological symptoms. Sequencing of the PNP gene revealed a novel mutation resulting in a premature stop codon.
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Affiliation(s)
- Manisha Rajan Madkaikar
- Paediatric Immunology and Leukocyte Biology Department, National Institute of Immunohaematology, Mumbai, India.
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Chinen J, Buckley RH. Transplantation immunology: solid organ and bone marrow. J Allergy Clin Immunol 2010; 125:S324-35. [PMID: 20176267 PMCID: PMC2857984 DOI: 10.1016/j.jaci.2009.11.014] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 11/09/2009] [Accepted: 11/11/2009] [Indexed: 12/21/2022]
Abstract
Development of the field of organ and tissue transplantation has accelerated remarkably since the human MHC was discovered in 1967. Matching of donor and recipient for MHC antigens has been shown to have a significant positive effect on graft acceptance. The roles of the different components of the immune system involved in the tolerance or rejection of grafts and in graft-versus-host disease have been clarified. These components include antibodies, antigen-presenting cells, helper and cytotoxic T-cell subsets, immune cell-surface molecules, signaling mechanisms, and cytokines. The development of pharmacologic and biological agents that interfere with the alloimmune response has had a crucial role in the success of organ transplantation. Combinations of these agents work synergistically, leading to lower doses of immunosuppressive drugs and reduced toxicity. Reports of significant numbers of successful solid-organ transplantations include those of the kidneys, liver, heart, and lung. The use of bone marrow transplantation for hematologic diseases, particularly hematologic malignancies and primary immunodeficiencies, has become the treatment of choice in many of these conditions. Other sources of hematopoietic stem cells are also being used, and diverse immunosuppressive drug regimens of reduced intensity are being proposed to circumvent the mortality associated with the toxicity of these drugs. Gene therapy to correct inherited diseases by means of infusion of gene-modified autologous hematopoietic stem cells has shown efficacy in 2 forms of severe combined immunodeficiency, providing an alternative to allogeneic tissue transplantation.
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Affiliation(s)
- Javier Chinen
- Department of Pediatrics, Allergy/Immunology, Baylor College of Medicine, Houston, USA
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12
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Primary Immunodeficiencies. PEDIATRIC ALLERGY, ASTHMA AND IMMUNOLOGY 2008. [PMCID: PMC7121684 DOI: 10.1007/978-3-540-33395-1_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Primary immunodeficiencies (PIDs), once considered to be very rare, are now increasingly recognized because of growing knowledge in the immunological field and the availability of more sophisticated diagnostic techniques and therapeutic modalities [161]. However in a database of >120,000 inpatients of a general hospital for conditions suggestive of ID 59 patients were tested, and an undiagnosed PID was found in 17 (29%) of the subjects tested [107]. The publication of the first case of agammaglobulinemia by Bruton in 1952 [60] demonstrated that the PID diagnosis is first done in the laboratory. However, PIDs require specialized immunological centers for diagnosis and management [33]. A large body of epidemiological evidence supports the hypothesis of the existence of a close etiopathogenetic relation between PID and atopy [73]. In particular, an elevated frequency of asthma, food allergy (FA), atopic dermatitis and enteric pathologies can be found in various PIDs. In addition we will discuss another subject that is certainly of interest: the pseudo-immunodepressed child with recurrent respiratory infections (RRIs), an event that often requires medical intervention and that very often leads to the suspicion that it involves antibody deficiencies [149].
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Delicou S, Kitra-Roussou V, Peristeri J, Goussetis E, Vessalas G, Rigatou E, Psychou F, Salavoura K, Grafakos S. Successful HLA-identical hematopoietic stem cell transplantation in a patient with purine nucleoside phosphorylase deficiency. Pediatr Transplant 2007; 11:799-803. [PMID: 17910661 DOI: 10.1111/j.1399-3046.2007.00772.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PNP deficiency is an autosomal recessive metabolic disorder characterized by severe combined immunodeficiency, autoimmune hemolytic anemia, and by a complex of neurologic manifestations including ataxia, developmental delay, and spasticity. PNP protein catalyzes the phosphorolysis of deoxyinosine and deoxyguanosine. It is found in most tissues of the body but is expressed at the highest levels in lymphoid tissues. This tissue distribution explains why the lymphoid system is predominantly affected in PNP deficiency. We describe a five-yr-old boy with muscular hypertonia, impaired growth, autoimmune hemolytic anemia, and neutropenia who underwent HSCT from his HLA-identical sister. One yr post-HSCT, the boy developed normal immunological functions, and his neurological status improved.
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Affiliation(s)
- Sophia Delicou
- Bone Marrow Transplantation Unit, Athens University Medical School, St Sophia Children's Hospital, Athens, Greece.
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14
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Abstract
Immunodeficiencies in children may be caused by primary immunodeficiency syndromes or can result from secondary disorders of immune regulation. Thoracic complications in immunocompromised children are frequent and may vary according to the type of the immunodeficiency. Imaging plays a pivotal role in detection and distinction of the variety of sequelae. It is important for the radiologist to understand both the spectrum of pediatric immune disorders, and the mechanisms underlying these disorders.
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Affiliation(s)
- Caroline L Hollingsworth
- Division of Pediatric Radiology, Department of Radiology, Duke University Health System, 1905 McGovern-Davison Children's Health Center, Box 3808, Erwin Road, Durham, NC 27710, USA.
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15
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Myers LA, Hershfield MS, Neale WT, Escolar M, Kurtzberg J. Purine nucleoside phosphorylase deficiency (PNP-def) presenting with lymphopenia and developmental delay: successful correction with umbilical cord blood transplantation. J Pediatr 2004; 145:710-2. [PMID: 15520787 DOI: 10.1016/j.jpeds.2004.06.075] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purine nucleoside phosphorylase deficiency is a primary immunodeficiency syndrome characterized by the triad of recurrent infection, neurologic dysfunction, and autoimmunity. This patient presented atypically with few infections and normal T-cell function. Progressive lymphopenia, ataxia, and developmental delay led to diagnosis. Umbilical cord blood transplantation corrected the immunodeficiency.
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Affiliation(s)
- Laurie A Myers
- Division of Allergy and Immunology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina 27710, USA.
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16
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Abstract
In the fifty years since Ogden Bruton discovered agammaglobulinemia, more than 100 additional immunodeficiency syndromes have been described. These disorders may involve one or more components of the immune system, including T, B, and NK lymphocytes; phagocytic cells; and complement proteins. Most are recessive traits, some of which are caused by mutations in genes on the X chromosome, others in genes on autosomal chromosomes. Until the past decade, there was little insight into the fundamental problems underlying a majority of these conditions. Many of the primary immunodeficiency diseases have now been mapped to specific chromosomal locations, and the fundamental biologic errors have been identified in more than 3 dozen. Within the past decade the molecular bases of 7 X-linked immunodeficiency disorders have been reported: X-linked immunodeficiency with Hyper IgM, X-linked lymphoproliferative disease, X-linked agammaglobulinemia, X-linked severe combined immunodeficiency, the Wiskott-Aldrich syndrome, nuclear factor kappaB essential modulator (NEMO or IKKg), and the immune dysregulation polyendocrinopathy (IPEX) syndrome. The abnormal genes in X-linked chronic granulomatous disease (CGD) and properdin deficiency had been identified several years earlier. In addition, there are now many autosomal recessive immunodeficiencies for which the molecular bases have been discovered. These new advances will be reviewed, with particular emphasis on the pulmonary complications of some of these diseases. In some cases there are unique features of lung abnormalities in specific defects. Infections obviously account for most of these complications, but the host reaction to infection often leads to characteristic findings that can be helpful diagnostically. Finally, advances in treatment of the underlying diseases as well as their infectious complications will be covered.
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Affiliation(s)
- Rebecca H Buckley
- Departments of Pediatrics and Immunology, Duke University Medical Center, Durham, NC 27710, USA.
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17
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Buckley RH. A historical review of bone marrow transplantation for immunodeficiencies. J Allergy Clin Immunol 2004; 113:793-800. [PMID: 15100688 DOI: 10.1016/j.jaci.2004.01.764] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Rebecca H Buckley
- Departments of Pediatrics and Immunology, Duke University School of Medicine, Durham, NC 27710, USA
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18
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Tabarki B, Yacoub M, Tlili K, Trabelsi A, Dogui M, Essoussi AS. Familial spastic paraplegia as the presenting manifestation in patients with purine nucleoside phosphorylase deficiency. J Child Neurol 2003; 18:140-1. [PMID: 12693783 DOI: 10.1177/08830738030180021001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report two siblings with purine nucleoside phosphorylase deficiency revealed by isolated spastic paraplegia, whereas symptoms of immune deficiency did not become apparent until 3 years of age. As the concurrence of immunodeficiency and neurologic problems strongly suggests the diagnosis of purine nucleoside phosphorylase deficiency, special attention should be paid to counts of lymphocytes in any infant with spastic paraplegia.
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Affiliation(s)
- Brahim Tabarki
- Service de Pédiatrie, Hôpital Farhat Hached, Sousse, Tunisia.
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19
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Abstract
The discovery of the human MHC in 1967 launched the field of organ and tissue transplantation. More than 800,000 such transplants have been performed during this time. Although matching of donor and recipient for MHC antigens was shown to be of great importance and continues to be so, the development of pharmacologic agents and antilymphocyte antibodies that interfere with the process of graft rejection has had a crucial role in the success of organ transplantation during the past 2 decades. Enormous progress has been made in understanding the immunologic mechanisms of graft rejection and of graft-versus-host disease. The roles of antibodies, antigen-presenting cells, helper and cytotoxic T cells, immune cell surface molecules, and signaling mechanisms and the cytokines they release have been clarified. This understanding is leading to the development of newer immunosuppressive agents targeting various components of the rejection process. Combinations of these agents work synergistically, leading to lower doses and reduced toxicity. Similarly, the development of effective T-cell depletion techniques has been of great importance for bone marrow transplantation when an HLA-identical sibling is not available. The major obstacle to the performance of solid organ transplantation currently is the shortage of donor organs.
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Affiliation(s)
- Rebecca H Buckley
- Department of Pediatrics, Allergy/Immunology, Duke University Medical Center, 362 Jones Building (Campus Box 2898), Durham, NC 27710-0001, USA
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20
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Abstract
Genetic defects in T-cell function lead to susceptibility to infections or to other clinical problems that are more grave than those seen in disorders resulting in antibody deficiency alone. Those affected usually present during infancy with either common or opportunistic infections and rarely survive beyond infancy or childhood. The spectrum of T-cell defects ranges from the syndrome of severe combined immunodeficiency, in which T-cell function is absent, to combined immunodeficiency disorders in which there is some, but not adequate, T-cell function for a normal life span. Recent discoveries of the molecular causes of many of these defects have led to a new understanding of the flawed biology underlying the ever-growing number of defects. Most of these conditions could be diagnosed by means of screening for lymphopenia or for T-cell deficiency in cord blood at birth. Early recognition of those so afflicted is essential to the application of the most appropriate treatments for these conditions at a very early age. The latter treatments include both transplantation and gene therapy in addition to immunoglobulin replacement. Fully defining the molecular defects of such patients is also essential for genetic counseling of family members and prenatal diagnosis.
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Affiliation(s)
- Rebecca H Buckley
- Division of Allergy and Immunology, Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA
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21
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Baguette C, Vermylen C, Brichard B, Louis J, Dahan K, Vincent MF, Cornu G. Persistent developmental delay despite successful bone marrow transplantation for purine nucleoside phosphorylase deficiency. J Pediatr Hematol Oncol 2002; 24:69-71. [PMID: 11902746 DOI: 10.1097/00043426-200201000-00018] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 10-month-old girl with a history of recurrent candidiasis, developmental delay, and a fulminant varicella infection is described. The diagnosis of purine nucleoside phosphorylase (PNP) deficiency was suggested by a reduced level of serum uric acid and confirmed by measurement of PNP activity. A human leukocyte antigen-matched bone marrow transplantation resulted in immune reconstitution, but poor neurodevelopmental progression.
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Affiliation(s)
- Christel Baguette
- Department of Pediatric Hematology and Oncology, Cliniques Universitaires St. Luc, Brussels, Belgium
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22
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Bzowska A, Kulikowska E, Shugar D. Purine nucleoside phosphorylases: properties, functions, and clinical aspects. Pharmacol Ther 2000; 88:349-425. [PMID: 11337031 DOI: 10.1016/s0163-7258(00)00097-8] [Citation(s) in RCA: 334] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The ubiquitous purine nucleoside phosphorylases (PNPs) play a key role in the purine salvage pathway, and PNP deficiency in humans leads to an impairment of T-cell function, usually with no apparent effects on B-cell function. This review updates the properties of the enzymes from eukaryotes and a wide range of prokaryotes, including a tentative classification of the enzymes from various sources, based on three-dimensional structures in the solid state, subunit composition, amino acid sequences, and substrate specificities. Attention is drawn to the compelling need of quantitative experimental data on subunit composition in solution, binding constants, and stoichiometry of binding; order of ligand binding and release; and its possible relevance to the complex kinetics exhibited with some substrates. Mutations responsible for PNP deficiency are described, as well as clinical methods, including gene therapy, for corrections of this usually fatal disease. Substrate discrimination between enzymes from different sources is also being profited from for development of tumour-directed gene therapy. Detailed accounts are presented of design of potent inhibitors, largely nucleosides and acyclonucleosides, their phosphates and phosphonates, particularly of the human erythrocyte enzyme, some with Ki values in nanomolar and picomolar range, intended for induction of the immunodeficient state for clinical applications, such as prevention of host-versus-graft response in organ transplantations. Methods of assay of PNP activity are reviewed. Also described are applications of PNP from various sources as tools for the enzymatic synthesis of otherwise inaccessible therapeutic nucleoside analogues, as coupling enzymes for assays of orthophosphate in biological systems in the micromolar and submicromolar ranges, and for coupled assays of other enzyme systems.
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Affiliation(s)
- A Bzowska
- Department of Biophysics, Institute of Experimental Physics, University of Warsaw, Zwirki i Wigury 93, 02-089 Warsaw, Poland.
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23
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Abstract
For patients with well-characterized, rapidly fatal, nonmalignant immunodeficiency disorders, such as SCID, the decision to proceed with allogeneic SCT is clear-cut. For patients with many other disorders, this decision can be extremely difficult. Disorders such as LAD or CGD have a variable natural history. Each patient must be considered individually, with the risk for SCT-related morbidity and mortality carefully weighed against that of the underlying disease. Significant advances during the past 10 years have made SCT a much safer procedure. Use of nonmyeloablative conditioning regimens as a means of reducing toxicity of high-dose chemotherapy and irradiation hold great promise. Highly immunosuppressive, nonchemotherapeutic agents that inhibit graft rejection or GVHD by blocking the critical costimulatory component of the T-cell receptor-antigen interaction are beginning to emerge and may be ideal for SCT of nonmalignant diseases. Therefore, the risk-benefit equation must be reassessed each year as the severity of patients' disorders is better defined and techniques of SCT improve.
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Affiliation(s)
- M E Horwitz
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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24
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Markert ML, Finkel BD, McLaughlin TM, Watson TJ, Collard HR, McMahon CP, Andrews LG, Barrett MJ, Ward FE. Mutations in purine nucleoside phosphorylase deficiency. Hum Mutat 2000; 9:118-21. [PMID: 9067751 DOI: 10.1002/(sici)1098-1004(1997)9:2<118::aid-humu3>3.0.co;2-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Purine nucleoside phosphorylase deficiency is an inherited disease of purine metabolism characterized clinically as combined immunodeficiency. The molecular defects have been published for 4 different alleles in 3 patients. We report four new mutations including two amino acid substitutions, A174P and G190V, a single codon deletion, delta I129, and a point mutation in intron 3 which leads to aberrant splicing and creation of a premature stop codon in exon 4 (286-18G-->A). Of the previously reported mutations, E89K was found in one additional patient, and R234P was found in 3 unrelated patients, making R234P the most common mutation reported to date in this disease.
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Affiliation(s)
- M L Markert
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina 27710, USA
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25
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Cohen A, Grunebaum E, Arpaia E, Roifman CM. IMMUNODEFICIENCY CAUSED BY PURINE NUCLEOSIDE PHOSPHORYLASE DEFICIENCY. Radiol Clin North Am 2000. [DOI: 10.1016/s0033-8389(22)00184-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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26
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Cohen A, Grunebaum E, Arpaia E, Roifman CM. IMMUNODEFICIENCY CAUSED BY PURINE NUCLEOSIDE PHOSPHORYLASE DEFICIENCY. Immunol Allergy Clin North Am 2000. [DOI: 10.1016/s0889-8561(05)70139-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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Fischer A, Haddad E, Jabado N, Casanova JL, Blanche S, Le Deist F, Cavazzana-Calvo M. Stem cell transplantation for immunodeficiency. SPRINGER SEMINARS IN IMMUNOPATHOLOGY 1998; 19:479-92. [PMID: 9618769 DOI: 10.1007/bf00792603] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A Fischer
- Hôpital Necker-Enfants Malades, Inserm U429, Paris, France
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