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Vijayakumar S, Viswanathan S, Aghoram R. Idiopathic CD4 Lymphocytopenia: Current Insights. Immunotargets Ther 2020; 9:79-93. [PMID: 32548074 PMCID: PMC7239889 DOI: 10.2147/itt.s214139] [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: 02/10/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022] Open
Abstract
Idiopathic CD4 lymphocytopenia is a condition characterized by low CD4 counts. It is rare and most of the information about this illness comes from case reports. Presentation is usually in the 4th decade of life with opportunistic infections, autoimmune disease or neoplasia. The pathophysiology of this condition is not well understood. Management revolves around treatment of the presenting condition and close follow-up of these patients. This review presents a narrative summary of the current literature on idiopathic CD4 lymphocytopenia.
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Affiliation(s)
| | - Stalin Viswanathan
- General Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India
| | - Rajeswari Aghoram
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India
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2
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Fernandes RA, Perez-Andres M, Blanco E, Jara-Acevedo M, Criado I, Almeida J, Botafogo V, Coutinho I, Paiva A, van Dongen JJM, Orfao A, Faria E. Complete Multilineage CD4 Expression Defect Associated With Warts Due to an Inherited Homozygous CD4 Gene Mutation. Front Immunol 2019; 10:2502. [PMID: 31781092 PMCID: PMC6856949 DOI: 10.3389/fimmu.2019.02502] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/07/2019] [Indexed: 12/12/2022] Open
Abstract
Idiopathic T-CD4 lymphocytopenia (ICL) is a rare and heterogeneous syndrome characterized by opportunistic infections due to reduced CD4 T-lymphocytes (<300 cells/μl or <20% T-cells) in the absence of HIV infection and other primary causes of lymphopenia. Molecular testing of ICL has revealed defects in genes not specific to CD4 T-cells, with pleiotropic effects on other cell types. Here we report for the first time an absolute CD4 lymphocytopenia (<0.01 CD4+ T-cells/μl) due to an autosomal recessive CD4 gene mutation that completely abrogates CD4 protein expression on the surface membrane of T-cells, monocytes, and dendritic cells. A 45-year-old female born to consanguineous parents consulted because of exuberant, relapsing, and treatment-refractory warts on her hands and feet since the age of 10 years, in the absence of other recurrent infections or symptoms. Serological studies were negative for severe infections, including HIV 1/2, HTLV-1, and syphilis, but positive for CMV and EBV. Blood analysis showed the absence of CD4+ T-cells (<0.01%) with repeatedly increased counts of B-cells, naïve CD8+ T-lymphocytes, and particularly, CD4/CD8 double-negative (DN) TCRαβ+ TCRγδ- T-cells (30% of T-cells; 400 cells/μl). Flow cytometric staining of CD4 using monoclonal antibodies directed against five different epitopes, located in two different domains of the protein, confirmed no cell surface membrane or intracytoplasmic expression of CD4 on T-cells, monocytes, and dendritic cells but normal soluble CD4 plasma levels. DN T-cells showed a phenotypic and functional profile similar to normal CD4+ T-cells as regards expression of maturation markers, T-helper and T-regulatory chemokine receptors, TCRvβ repertoire, and in vitro cytokine production against polyclonal and antigen-specific stimuli. Sequencing of the CD4 gene revealed a homozygous (splicing) mutation affecting the last bp on intron 7-8, leading to deletion of the juxtamembrane and intracellular domains of the protein and complete abrogation of CD4 expression on the cell membrane. These findings support previous studies in CD4 KO mice suggesting that surrogate DN helper and regulatory T-cells capable of supporting antigen-specific immune responses are produced in the absence of CD4 signaling and point out the need for better understanding the role of CD4 on thymic selection and the immune response.
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Affiliation(s)
- Rosa Anita Fernandes
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Martin Perez-Andres
- Department of Medicine, Cancer Research Centre (IBMCC, USAL-CSIC), Cytometry Service (NUCLEUS), University of Salamanca (USAL), Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain
| | - Elena Blanco
- Department of Medicine, Cancer Research Centre (IBMCC, USAL-CSIC), Cytometry Service (NUCLEUS), University of Salamanca (USAL), Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain
| | - Maria Jara-Acevedo
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain.,Sequencing DNA Service, NUCLEUS, University of Salamanca, Salamanca, Spain
| | - Ignacio Criado
- Department of Medicine, Cancer Research Centre (IBMCC, USAL-CSIC), Cytometry Service (NUCLEUS), University of Salamanca (USAL), Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain
| | - Julia Almeida
- Department of Medicine, Cancer Research Centre (IBMCC, USAL-CSIC), Cytometry Service (NUCLEUS), University of Salamanca (USAL), Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain
| | - Vitor Botafogo
- Department of Medicine, Cancer Research Centre (IBMCC, USAL-CSIC), Cytometry Service (NUCLEUS), University of Salamanca (USAL), Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain
| | - Ines Coutinho
- Dermatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Artur Paiva
- Flow Cytometry Unit-Clinical Pathology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Ciências Biomédicas Laboratoriais, ESTESC-Coimbra Health School, Instituto Politécnico de Coimbra, Coimbra, Portugal.,Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (iCBR), University of Coimbra, Coimbra, Portugal
| | - Jacques J M van Dongen
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Alberto Orfao
- Department of Medicine, Cancer Research Centre (IBMCC, USAL-CSIC), Cytometry Service (NUCLEUS), University of Salamanca (USAL), Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain
| | - Emilia Faria
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Huang S, Wu JH, Lewis DJ, Rady PL, Tyring SK. A novel approach to the classification of epidermodysplasia verruciformis. Int J Dermatol 2018; 57:1344-1350. [PMID: 30156265 DOI: 10.1111/ijd.14196] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 07/22/2018] [Accepted: 07/31/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Epidermodysplasia verruciformis (EV) is a rare genodermatosis that causes disseminated eruptions of hypo- or hyperpigmented macules and wart-like papules that can coalesce and scale. It is uniquely characterized by an increased susceptibility to specific human papillomavirus (HPV) genotypes. Classically, EV is associated with mutations of the EVER1/TMC6 and EVER2/TMC8 genes. The term "acquired" epidermodysplasia verruciformis was coined to describe an EV-like syndrome that can develop in patients with a compromised immune system. Recent discoveries of other genes implicated in EV, including RHOH, MST-1, and CORO1A, have complicated the classification of EV and EV-like syndromes. METHODS We review the available data on epidermodysplasia verruciformis in the literature in order to propose a new classification system to encompass current and future developments on EV and EV-like syndromes. RESULTS We propose classifying EV into: (1) classic genetic EV, (2) non-classic genetic EV, and (3) acquired EV. CONCLUSION The proposed categorization scheme provides a simple and logical way to organize the different cases of EV that have been described in the literature. This system organizes EV by its cause, allowing for a better understanding of the disease and helps differentiate EV from other causes of generalized verrucosis.
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Affiliation(s)
- Simo Huang
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Julie H Wu
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Daniel J Lewis
- School of Medicine, Baylor College of Medicine, Houston, TX, USA.,Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter L Rady
- Department of Dermatology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Stephen K Tyring
- Department of Dermatology, University of Texas Health Science Center at Houston, Houston, TX, USA.,Center for Clinical Studies, Houston, TX, USA
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4
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Kashem SW, Kaplan DH. Skin Immunity to Candida albicans. Trends Immunol 2016; 37:440-450. [PMID: 27178391 DOI: 10.1016/j.it.2016.04.007] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/20/2016] [Accepted: 04/21/2016] [Indexed: 12/20/2022]
Abstract
Candida albicans is a dimorphic commensal fungus that colonizes healthy human skin, mucosa, and the reproductive tract. C. albicans is also a predominantly opportunistic fungal pathogen, leading to disease manifestations such as disseminated candidiasis and chronic mucocutaneous candidiasis (CMC). The differing host susceptibilities for the sites of C. albicans infection have revealed tissue compartmentalization with tailoring of immune responses based on the site of infection. Furthermore, extensive studies of host genetics in rare cases of CMC have identified conserved genetic pathways involved in immune recognition and the response to the extracellular pathogen. We focus here on human and mouse skin as a site of C. albicans infection, and we review established and newly discovered insights into the cellular pathways that promote cutaneous antifungal immunity.
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Affiliation(s)
- Sakeen W Kashem
- Department of Dermatology, Center for Immunology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Daniel H Kaplan
- Departments of Dermatology and Immunology, University of Pittsburgh, Pittsburgh, PA 15216, USA.
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Cheung L, Weinstein M. Idiopathic CD4 T-Cell Lymphocytopenia: A Case Report of a Young Boy With Recalcitrant Warts. J Cutan Med Surg 2016; 20:470-3. [PMID: 26964553 DOI: 10.1177/1203475416638045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
IMPORTANCE Idiopathic CD4 T-cell lymphocytopenia (ICL) is an immunodeficiency disorder that presents with a decrease in CD4(+) T cells without evidence of a human immunodeficiency virus infection. It is most commonly diagnosed after a patient presents with an opportunistic infection and can also be associated with malignancies and autoimmune diseases. This case presentation and literature review highlights the common skin findings in patients with ICL, mainly recalcitrant warts, and discusses the treatment options available. OBSERVATIONS The patient described is the youngest reported with ICL presenting with isolated cutaneous findings of recalcitrant warts and psoriasis. Many treatment options were tried for the warts, with the most significant response to acitretin. CONCLUSIONS AND RELEVANCE This case highlights the importance of considering underlying immunodeficiency in patients with recalcitrant warts as well as developing treatment plans. Such patients require close follow-up by both dermatology and immunology to monitor for the development of other diseases related to ICL.
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Affiliation(s)
- Loretta Cheung
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Miriam Weinstein
- Division of Paediatric Medicine, Section of Dermatology, Hospital for Sick Children, Toronto, ON, Canada
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Ahmad DS, Esmadi M, Steinmann WC. Idiopathic CD4 Lymphocytopenia: Spectrum of opportunistic infections, malignancies, and autoimmune diseases. Avicenna J Med 2013; 3:37-47. [PMID: 23930241 PMCID: PMC3734630 DOI: 10.4103/2231-0770.114121] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Idiopathic CD4 lymphocytopenia (ICL) was first defined in 1992 by the US Centers for Disease Control and Prevention (CDC) as the repeated presence of a CD4+ T lymphocyte count of fewer than 300 cells per cubic millimeter or of less than 20% of total T cells with no evidence of human immunodeficiency virus (HIV) infection and no condition that might cause depressed CD4 counts. Most of our knowledge about ICL comes from scattered case reports. The aim of this study was to collect comprehensive data from the previously published cases to understand the characteristics of this rare condition. We searched the PubMed database and Science Direct for case reports since 1989 for Idiopathic CD4 lymphocytopenia cases. We found 258 cases diagnosed with ICL in 143 published papers. We collected data about age, sex, pathogens, site of infections, CD4 count, CD8 count, CD4:CD8 ratio, presence of HIV risk factors, malignancies, autoimmune diseases and whether the patients survived or died. The mean age at diagnosis of first opportunistic infection (or ICL if no opportunistic infection reported) was 40.7 ± 19.2 years (standard deviation), with a range of 1 to 85. One-sixty (62%) patients were males, 91 (35.2%) were females, and 7 (2.7%) patients were not identified whether males or females. Risk factors for HIV were documented in 36 (13.9%) patients. The mean initial CD4 count was 142.6 ± 103.9/mm3 (standard deviation). The mean initial CD8 count was 295 ± 273.6/mm3 (standard deviation). The mean initial CD4:CD8 ratio was 0.6 ± 0.7 (standard deviation). The mean lowest CD4 count was 115.4 ± 87.1/mm3 (standard deviation). The majority of patients 226 (87.6%) had at least one infection. Cryptococcal infections were the most prevalent infections in ICL patients (26.6%), followed by mycobacterial infections (17%), candidal infections (16.2%), and VZV infections (13.1%). Malignancies were reported in 47 (18.1%) patients. Autoimmune diseases were reported in 37 (14.2%) patients.
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Affiliation(s)
- Dina S Ahmad
- Department of Internal Medicine, University of Missouri School of Medicine, Columbia, MO, USA
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Leiding JW, Holland SM. Warts and all: human papillomavirus in primary immunodeficiencies. J Allergy Clin Immunol 2012; 130:1030-48. [PMID: 23036745 DOI: 10.1016/j.jaci.2012.07.049] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Revised: 06/06/2012] [Accepted: 07/25/2012] [Indexed: 01/19/2023]
Abstract
Infection with human papillomavirus (HPV) is almost universal and eventually asymptomatic, but pathologic infection with HPV is severe, recurrent, and recalcitrant to therapy. It is also an underappreciated manifestation of primary immunodeficiency. Mutations in EVER1, EVER2, GATA2, CXCR4, and dedicator of cytokinesis 8 (DOCK8) are typically associated with extensive HPV infections, whereas several other primary immune defects result in severe HPV much less frequently. We review immunodeficiencies with severe HPV infections and the mechanisms underlying them.
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Affiliation(s)
- Jennifer W Leiding
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892-1684, USA.
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8
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Generalized verrucosis: A review of the associated diseases, evaluation, and treatments. J Am Acad Dermatol 2012; 66:292-311. [DOI: 10.1016/j.jaad.2010.12.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Revised: 12/02/2010] [Accepted: 12/10/2010] [Indexed: 12/23/2022]
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Sharma A, Lal V, Modi M, Khurana D, Bal S, Prabhakar S. Idiopathic CD4 lymphocytopenia presenting as refractory cryptococcal meningitis. Ann Indian Acad Neurol 2010; 13:136-8. [PMID: 20814499 PMCID: PMC2924513 DOI: 10.4103/0972-2327.64646] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Revised: 05/06/2009] [Accepted: 06/26/2009] [Indexed: 11/23/2022] Open
Abstract
Idiopathic CD4 T-lymphocytopenia (ICL) is a syndrome characterized by depletion of CD4 T-cells without evidence of human immunodeficiency virus (HIV) infection. There are a few reported cases of ICL associated with different diseases and clinical conditions, most commonly the opportunistic infections like Tuberculosis, fungal and parasitic diseases which are also seen in HIV-positive patients. We report a case without risk factors or laboratory evidence of HIV infection who presented with refractory cryptococcal meningitis and was found to have ICL.
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Affiliation(s)
- A Sharma
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh-160 012, India
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Salit RB, Hankey KG, Yi R, Rapoport AP, Mann DL. Detection of CD4(+) T-cell antibodies in a patient with idiopathic CD4 T lymphocytopenia and cryptococcal meningitis. Br J Haematol 2007; 139:133-7. [PMID: 17854318 DOI: 10.1111/j.1365-2141.2007.06781.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Idiopathic CD4(+) T lymphocytopenia (ICL) is defined as a CD4(+) T-cell count <0.3 x 10(9)/l or <20% of the total T-cell count on two occasions in the absence of any immunodeficiency disorder or therapy associated with reduced CD4(+) T-cell count. Although several mechanisms of ICL have been reported, the pathophysiology is still largely unknown. This case report describes a patient who presented with cryptococcal meningitis and was subsequently discovered to meet the criteria for ICL. Flow cytometric analysis of the patient's peripheral blood mononuclear cells revealed antibodies coating a much larger proportion of his CD4(+) T cells (33.61%) than the CD4(+) T cells of normal donors (3.94 +/- 1.77%). The reasons behind the development of these autoantibodies are explored.
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Affiliation(s)
- Rachel B Salit
- Department of Internal Medicine, The University of Maryland Medical Center, Baltimore, MD 21201, USA.
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Abstract
PURPOSE OF REVIEW A severe decrease of CD4 T cells predisposes humans to opportunistic infections. In adults, HIV is certainly the most common cause of CD4 lymphocytopenia, but other causes, such as infections, autoimmune diseases, immunosuppressive therapy, lymphoma and idiopathic forms need to be considered. This review summarizes the current knowledge of the poorly understood syndrome of idiopathic CD4 lymphocytopenia. RECENT FINDINGS Little research has tried to systematically dissect this probably heterogeneic syndrome after its initial description in 1992. Numerous cases presenting with opportunistic infections have been reported. Disturbed differentiation of stem cell precursors may contribute to CD4 lymphocytopenia. Because infections and lymphoma may also cause CD4 lymphocytopenia, the distinction between cause and effect may evolve only during follow-up. SUMMARY The manifestation of opportunistic infections calls for the evaluation of the immune system for CD4 lymphocytopenia. The differential diagnosis of this condition in adults comprises primarily HIV infection and less often other diseases or drugs. Idiopathic CD4 lymphocytopenia is very rare. The clinical significance of low CD4 cell counts in HIV negative patients still awaits its systematic analysis. Prophylaxis of opportunistic infections is oriented at the recommendations of HIV-infected individuals and causal treatment remains experimental.
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Affiliation(s)
- Ulrich A Walker
- Division of Rheumatology and Clinical Immunology, Freiburg University Hospital, Freiburg, Germany
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Hochauf K, Bandt D, Pöhlmann C, Monecke S, Toma M, Trautmann S. Fatal varicella zoster virus infection as first manifestation of idiopathic CD4+ T-cell lymphocytopenia. Eur J Clin Microbiol Infect Dis 2006; 24:706-8. [PMID: 16261302 DOI: 10.1007/s10096-005-0033-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- K Hochauf
- Institute of Medical Microbiology and Hygiene, Faculty of Medicine Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
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Bonilla FA, Bernstein IL, Khan DA, Ballas ZK, Chinen J, Frank MM, Kobrynski LJ, Levinson AI, Mazer B, Nelson RP, Orange JS, Routes JM, Shearer WT, Sorensen RU. Practice parameter for the diagnosis and management of primary immunodeficiency. Ann Allergy Asthma Immunol 2005; 94:S1-63. [PMID: 15945566 DOI: 10.1016/s1081-1206(10)61142-8] [Citation(s) in RCA: 295] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Francisco A Bonilla
- Department of Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA
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Pasic S, Minic P, Dzudovic S, Minic A, Slavkovic B. Idiopathic CD4+ lymphocytopenia and juvenile laryngeal papillomatosis. Pediatr Pulmonol 2005; 39:281-3. [PMID: 15668935 DOI: 10.1002/ppul.20173] [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: 11/07/2022]
Abstract
We report on an association of idiopathic CD4+ lymphocytopenia (ICL) and juvenile laryngeal papillomatosis (JLP) in a pediatric-aged patient. Because of a past medical history of recurrent lung infections and severe chickenpox in infancy, immunologic investigations were done at age 6 years. On several occasions, a CD4+lymphocyte count of <300 cells/mm3 was detected, supporting the diagnosis of ICL. During follow-up, both medical (interferon-alpha) and surgical treatments of JLP were only partially efficient. Our patient developed disseminated infection with Mycobacterium avium and died at 10 years of age. Human papillomavirus is an important pathogen in pediatric and adult patients with ICL. In pediatric patients with JLP who develop other unusually severe viral or opportunistic infections, immunological investigations should be considered.
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Affiliation(s)
- Srdjan Pasic
- Pediatric Clinic and Pediatric Surgery Clinic, Mother and Child Health Institute, Belgrade, Serbia and Montenegro.
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15
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Tobin E, Rohwedder A, Holland SM, Philips B, Carlson JA. Recurrent 'sterile' verrucous cyst abscesses and epidermodysplasia verruciformis-like eruption associated with idiopathic CD4 lymphopenia. Br J Dermatol 2003; 149:627-33. [PMID: 14511000 DOI: 10.1046/j.1365-2133.2003.05543.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Rupture of follicular (epidermoid) cysts is believed to be the consequence of bacterial infection. We report a 24-year-old man with idiopathic CD4 lymphopenia and chronic Mycobacterium avium intracellulare infection who developed multiple, recurring painful abscesses over the distal extremities that increased in number and severity when systemic steroid and interferon-gamma treatment was instituted for interstitial lung disease. Cultures were consistently negative for microorganisms, but pathological examination revealed ruptured epidermoid cyst walls with human papillomavirus (HPV) viropathic changes (keratinocytes with perinuclear halos and abundant basophilic keratohyaline granules). Cutaneous examination showed numerous, widespread flat-topped papules and achromic macules over the extremities, head and neck. Nested polymerase chain reaction analysis for HPV DNA revealed that the abscess-related cyst walls harboured epidermodysplasia verruciformis (EV)-associated HPV types 20, 24, alb-7 (AY013872) and 80. His cutaneous lesions harboured HPV types 3, 8 and 80. Similar to past reports, our patient developed an EV-like eruption in the setting of immunodeficiency. In this instance, EV-associated HPV infection of the follicular infundibular epithelium or pre-existing cysts in the setting of immunodeficiency may have led to cystic growth, rupture and subsequent painful inflammation.
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Affiliation(s)
- E Tobin
- Upstate Infectious Disease, 567 New Scotland Ave., Albany, NY 12208, USA
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16
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Gubinelli E, Posteraro P, Girolomoni G. Idiopathic CD4+ T lymphocytopenia associated with disseminated flat warts and alopecia areata. J Dermatol 2002; 29:653-6. [PMID: 12432998 DOI: 10.1111/j.1346-8138.2002.tb00197.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Idiopathic CD4+ T lymphocytopenia is a very rare condition characterized by persistent depletion of circulating CD4+ T lymphocytes, without evidence of HIV or HTLV infection, or other identifiable causes of immunodeficiency. The syndrome can present with dermatological diseases, including viral, fungal and bacterial infections, as well as Kaposi's sarcoma, epithelial cell malignancies, lymphoma and inflammatory dermatoses. We report the case of a 47-year-old woman with idiopathic CD4+ T lymphocytopenia who presented with a 10-year history of disseminated and refractory flat warts from which human papillomavirus type 3 DNA was identified. The patient also had alopecia areata.
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Abstract
BACKGROUND There have been several reports of HIV-negative patients with chronic idiopathic CD4+ T lymphocytopenia, the diagnostic criteria for which are: depressed numbers of circulating T lymphocytes (less than 300/ micro l or less than 20%) on more than one occasion; no laboratory evidence of HIV-1 or HIV-2 infection; and the absence of any defined immunodeficiency or therapy associated with depressed levels of CD4+ T lymphocytes. METHODS We report a patient with disseminated human papillomavirus infection associated with idiopathic CD4+ T-cell lymphocytopenia. A 50-year-old woman presented to the dermatology clinic with a 10-year history of widespread verrucae involving the skin and the cervix. RESULTS Biopsy from the arm revealed a common wart. PCR analysis performed from the paraffin-embedded block was strongly positive for HPV type 2. Other HPV types (including EV-associated HPV 5, 8, 14, 15, 17) were not found. Further laboratory work up revealed T-cell lymphocytopenia, with an absolute CD4 count of 21. HIV tests were repeatedly negative. She was treated with interferon A 8 million units SQ three times per week with partial improvement. The patient underwent a hysterectomy for cervical dysplasia and a vulvectomy for vulvar intraepithelial neoplasia. She developed small-cell lung carcinoma and died. CONCLUSIONS The diagnosis of idiopathic CD4+ T-cell lymphocytopenia should be considered in any patient with widespread viral, fungal, or mycobacterial infection whose HIV test is negative, and appropriate evaluation of the absolute CD4+ counts should be performed.
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Affiliation(s)
- Cloyce L Stetson
- Department of Dermatology, Texas Tech University, Lubbock, Texas 79430, USA.
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Yamauchi PS, Nguyen NQ, Grimes PE. Idiopathic CD4+T-cell lymphocytopenia associated with vitiligo. J Am Acad Dermatol 2002; 46:779-82. [PMID: 12004324 DOI: 10.1067/mjd.2002.119672] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The syndrome of idiopathic CD4+ T lymphocytopenia (ICTL) is defined as the persistent depletion of peripheral blood CD4+ T lymphocytes below 300 cells/mm(3) or less than 20% of the total lymphocytes in the absence of either HIV infection or other known causes of immunodeficiency. To date no known viral origin has been identified. ICTL has a variable clinical course ranging from patients with minimal symptoms to those who have died from opportunistic infections. We report a case of a 32-year-old white man with a long history of vitiligo that is associated with ICTL. He also had incidental psoriasis. The correlation between ICTL and autoimmune vitiligo suggests an aberration in the immune surveillance that leads to an abnormal response of CD4+ T lymphocytes in the host.
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Affiliation(s)
- Paul S Yamauchi
- Division of Dermatology, University of California Los Angeles School of Medicine, USA
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Van Wagoner JA, Khan DA. Selective CD4+ T cell lymphocytopenia and recalcitrant warts in an 8-year-old child. Ann Allergy Asthma Immunol 2001; 87:373-8. [PMID: 11730178 DOI: 10.1016/s1081-1206(10)62917-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- J A Van Wagoner
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas 75390-8859, USA.
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Nisini R, Romagnoli G, Gomez MJ, La Valle R, Torosantucci A, Mariotti S, Teloni R, Cassone A. Antigenic properties and processing requirements of 65-kilodalton mannoprotein, a major antigen target of anti-Candida human T-cell response, as disclosed by specific human T-cell clones. Infect Immun 2001; 69:3728-36. [PMID: 11349037 PMCID: PMC98380 DOI: 10.1128/iai.69.6.3728-3736.2001] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
T-cell-mediated immunity is known to play a central role in the host response to Candida albicans. T-cell clones are useful tools for the exact identification of fungal T-cell epitopes and the processing requirements of C. albicans antigens. We isolated human T-cell clones from an HLA-DRB1*1101 healthy donor by using an antigenic extract (MP-F2) of the fungus. Specific clones were T-cell receptor alpha/beta and CD4(+)/CD8(-) and showed a T-helper type 1 cytokine profile (production of gamma interferon and not interleukin-4). The large majority of these clones recognized both the natural (highly glycosylated) and the recombinant (nonglycosylated) 65-kDa mannoprotein (MP65), an MP-F2 minor constituent that was confirmed to be an immunodominant antigen of the human T-cell response. Surprisingly, most of the clones recognized two synthetic peptides of different MP65 regions. However, the peptides shared the amino acid motif IXSXIXXL, which may be envisaged as a motif sequence representing the minimal epitope recognized by these clones. Three clones recognized natural and pronase-treated MP65 but did not detect nonglycosylated, recombinant MP65 or the peptides, suggesting a possible role for polysaccharides in T-cell recognition of C. albicans. Finally, lymphoblastoid B-cell lines were efficient antigen-presenting cells (APC) for recombinant MP65 and peptides but failed to present natural, glycosylated antigens, suggesting that nonprofessional APC might be defective in processing highly glycosylated yeast proteins. In conclusion, this study provides the first characterization of C. albicans-specific human T-cell clones and provides new clues for the definition of the cellular immune response against C. albicans.
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Affiliation(s)
- R Nisini
- Laboratorio di Batteriologia e Micologia Medica, Istituto Superiore di Sanità, Rome, Italy.
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Warnatz K, Draeger R, Schlesier M, Peter HH. Successful IL-2 therapy for relapsing herpes zoster infection in a patient with idiopathic CD4+ T lymphocytopenia. Immunobiology 2000; 202:204-11. [PMID: 10993296 DOI: 10.1016/s0171-2985(00)80068-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Idiopathic CD4+ T lymphocytopenia (ICL) has been defined by the center of disease control as a rare cause of immunodeficiency with a variable clinical course and an unknown aetiology. Here we describe a 65-year old patient with relapsing generalized herpes zoster infection due to ICL and a severe panlymphocytopenia. In vitro assays revealed an enhanced activation of CD8+ T cells and an increased sensitivity of activated CD4+ T cells for cell death. The clinical outcome was substantially improved after starting the patient on a subcutaneous therapy with IL-2.
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Affiliation(s)
- K Warnatz
- Department of Internal Medicine, University Hospital Freiburg, Germany.
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