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Alrumayyan N, Slauenwhite D, McAlpine SM, Roberts S, Issekutz TB, Huber AM, Liu Z, Derfalvi B. Prolidase deficiency, a rare inborn error of immunity, clinical phenotypes, immunological features, and proposed treatments in twins. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:17. [PMID: 35197125 PMCID: PMC8867623 DOI: 10.1186/s13223-022-00658-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/09/2022] [Indexed: 12/30/2022]
Abstract
Background Prolidase deficiency (PD) is an autosomal recessive inborn multisystemic disease caused by mutations in the PEPD gene encoding the enzyme prolidase D, leading to defects in turnover of proline-containing proteins, such as collagen. PD is categorized as a metabolic disease, but also as an inborn error of immunity. PD presents with a range of findings including dysmorphic features, intellectual disabilities, recurrent infections, intractable skin ulceration, autoimmunity, and splenomegaly. Despite symptoms of immune dysregulation, only very limited immunologic assessments have been reported and standard therapies for PD have not been described. We report twin females with PD, including comprehensive immunologic profiles and treatment modalities used. Case presentation Patient 1 had recurrent infections in childhood. At age 13, she presented with telangiectasia, followed by painful, refractory skin ulcerations on her lower limbs, where skin biopsy excluded vasculitis. She had typical dysmorphic features of PD. Next-generation sequencing revealed pathogenic compound heterozygous mutations (premature stop codons) in the PEPD gene. Patient 2 had the same mutations, typical PD facial features, atopy, and telangiectasias, but no skin ulceration. Both patients had imidodipeptiduria. Lymphocyte subset analysis revealed low-normal frequency of Treg cells and decreased frequency of expression of the checkpoint molecule CTLA-4 in CD4+ TEM cells. Analysis of Th1, Th2, and Th17 profiles revealed increased inflammatory IL-17+ CD8+ TEM cells in both patients and overexpression of the activation marker HLA-DR on CD4+ TEM cells, reflecting a highly activated proinflammatory state. Neither PD patient had specific antibody deficiencies despite low CD4+CXCR5+ Tfh cells and low class-switched memory B cells. Plasma IL-18 levels were exceptionally high. Conclusions Immunologic abnormalities including skewed frequencies of activated inflammatory CD4+ and CD8+ TEM cells, decreased CTLA-4 expression, and defects in memory B cells may be a feature of immune dysregulation associated with PD; however, a larger sample size is required to validate these findings. The high IL-18 plasma levels suggest underlying autoinflammatory processes.
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Affiliation(s)
- Nora Alrumayyan
- Division of Immunology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Drew Slauenwhite
- Division of Immunology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Sarah M McAlpine
- Division of Immunology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Sarah Roberts
- Division of Immunology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Thomas B Issekutz
- Division of Immunology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Adam M Huber
- Division of Rheumatology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Zaiping Liu
- Division of Clinical Biochemistry & Maritime Newborn Screening, Department of Pathology and Laboratory Medicine, Dalhousie University, IWK Health Centre, Halifax, Canada
| | - Beata Derfalvi
- Division of Immunology, Department of Paediatrics, Dalhousie University, IWK Health Centre, Halifax, Canada.
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Haller CN, George-Abraham JK, Peterson RG, Diaz LZ. A case of prolidase deficiency in a male patient. Pediatr Dermatol 2022; 39:94-98. [PMID: 34888915 DOI: 10.1111/pde.14890] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/17/2021] [Accepted: 11/23/2021] [Indexed: 11/27/2022]
Abstract
Prolidase deficiency is an extremely rare, autosomal recessive disorder resulting in defective collagen formation. We report a case of prolidase deficiency in a male child, highlighting the dermatologic features. Early diagnosis is important as these patients encounter significant multisystem comorbidities requiring multispecialty care.
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Affiliation(s)
- Courtney N Haller
- Division of Dermatology, Department of Internal Medicine, Dell Medical School, Austin, Texas, USA
| | - Jaya K George-Abraham
- Division of Genetics, Department of Pediatrics, Dell Medical School, Austin, Texas, USA
| | - Rosemary G Peterson
- Division of Rheumatology, Department of Pediatrics, Dell Medical School, Austin, Texas, USA
| | - Lucia Z Diaz
- Division of Dermatology, Department of Internal Medicine, Dell Medical School, Austin, Texas, USA.,Division of Dermatology, Department of Pediatrics, Dell Medical School, Austin, Texas, USA
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Rossignol F, Duarte Moreno MS, Benoist JF, Boehm M, Bourrat E, Cano A, Chabrol B, Cosson C, Díaz JLD, D'Harlingue A, Dimmock D, Freeman AF, García MT, Garganta C, Goerge T, Halbach SS, de Laffolie J, Lam CT, Martin L, Martins E, Meinhardt A, Melki I, Ombrello AK, Pérez N, Quelhas D, Scott A, Slavotinek AM, Soares AR, Stein SL, Süßmuth K, Thies J, Ferreira CR, Schiff M. Quantitative analysis of the natural history of prolidase deficiency: description of 17 families and systematic review of published cases. Genet Med 2021; 23:1604-1615. [PMID: 34040193 DOI: 10.1038/s41436-021-01200-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Prolidase deficiency is a rare inborn error of metabolism causing ulcers and other skin disorders, splenomegaly, developmental delay, and recurrent infections. Most of the literature is constituted of isolated case reports. We aim to provide a quantitative description of the natural history of the condition by describing 19 affected individuals and reviewing the literature. METHODS Nineteen patients were phenotyped per local institutional procedures. A systematic review following PRISMA criteria identified 132 articles describing 161 patients. Main outcome analyses were performed for manifestation frequency, diagnostic delay, overall survival, symptom-free survival, and ulcer-free survival. RESULTS Our cohort presented a wide variability of severity. Autoimmune disorders were found in 6/19, including Crohn disease, systemic lupus erythematosus, and arthritis. Another immune finding was hemophagocytic lymphohistiocytosis (HLH). Half of published patients were symptomatic by age 4 and had a delayed diagnosis (mean delay 11.6 years). Ulcers were present initially in only 30% of cases, with a median age of onset at 12 years old. CONCLUSION Prolidase deficiency has a broad range of manifestations. Symptoms at onset may be nonspecific, likely contributing to the diagnostic delay. Testing for this disorder should be considered in any child with unexplained autoimmunity, lower extremity ulcers, splenomegaly, or HLH.
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Affiliation(s)
- Francis Rossignol
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Marvid S Duarte Moreno
- Reference Centre for Inherited Metabolic Diseases, Assistance Publique Hôpitaux de Paris, Hôpital universitaire Robert-Debré, Université de Paris, Paris, France
| | - Jean-François Benoist
- Reference Centre for Inherited Metabolic Diseases, Assistance Publique Hôpitaux de Paris, Hôpital universitaire Necker-Enfants malades, Université de Paris, Paris, France
| | - Manfred Boehm
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Emmanuelle Bourrat
- Reference Center for Genodermatoses MAGEC Saint Louis, Assistance Publique Hôpitaux de Paris, Hôpital universitaire Saint Louis, Paris, France
| | - Aline Cano
- Reference Center for Inherited Metabolic Disorders, Assistance Publique Hôpitaux de Marseille, Centre Hospitalier Universitaire de La Timone Enfants, Marseille, France
| | - Brigitte Chabrol
- Reference Center for Inherited Metabolic Disorders, Assistance Publique Hôpitaux de Marseille, Centre Hospitalier Universitaire de La Timone Enfants, Marseille, France
| | - Claudine Cosson
- Laboratoire de Biochimie, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | | | - Arthur D'Harlingue
- Benioff Children's Hospital Oakland, University of California, San Francisco, Oakland, CA, USA
| | - David Dimmock
- Project Baby Bear, Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - Alexandra F Freeman
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - María Tallón García
- Hospital Álvaro Cunqueiro, Universidad de Santiago de Compostela, Vigo, Spain
| | - Cheryl Garganta
- Division of Genetics and Metabolism, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Tobias Goerge
- Department of Dermatology, University Hospital Münster, Münster, Germany
| | - Sara S Halbach
- University of Chicago Medicine, University of Chicago, Chicago, IL, USA
| | - Jan de Laffolie
- University Children's Hospital, Justus-Liebig-University, Giessen, Germany
| | - Christina T Lam
- Seattle Children's Hospital, Seattle, WA, USA.,Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA
| | - Ludovic Martin
- Centre Hospitalier Universitaire d'Angers, Angers, France
| | | | - Andrea Meinhardt
- University Children's Hospital, Justus-Liebig-University, Giessen, Germany
| | - Isabelle Melki
- General Pediatrics, Infectious Disease and Internal Medicine Department, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, Reference Center for Rheumatic, Autoimmune and Systemic Diseases in Children (RAISE), Paris, France.,Pediatric Hematology-Immunology and Rheumatology Department, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Reference Center for Rheumatic, Autoimmune and Systemic Diseases in Children (RAISE), Paris, France.,Laboratory of Neurogenetics and Neuroinflammation, Imagine Institute, Paris, France
| | - Amanda K Ombrello
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Noémie Pérez
- Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Dulce Quelhas
- Centro de Genética Médica Doutor Jacinto Magalhães, Centro Hospitalar Universitário do Porto, Unit for Multidisciplinary Research in Biomedicine, ICBAS, UP, Porto, Portugal
| | - Anna Scott
- Seattle Children's Hospital, Seattle, WA, USA.,Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA
| | - Anne M Slavotinek
- Division of Medical Genetics, Department of Pediatrics, Benioff Children's Hospital San Francisco, University of California, San Francisco, San Francisco, CA, USA
| | | | - Sarah L Stein
- University of Chicago Medicine, University of Chicago, Chicago, IL, USA
| | - Kira Süßmuth
- Department of Dermatology, University Hospital Münster, Münster, Germany
| | - Jenny Thies
- Seattle Children's Hospital, Seattle, WA, USA
| | - Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Manuel Schiff
- Reference Centre for Inherited Metabolic Diseases, Assistance Publique Hôpitaux de Paris, Hôpital universitaire Robert-Debré, Université de Paris, Paris, France.,Reference Centre for Inherited Metabolic Diseases, Assistance Publique Hôpitaux de Paris, Hôpital universitaire Necker-Enfants malades, Université de Paris, Paris, France.,INSERM U1163, Institut Imagine, Paris, France
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Razmi T M, Jindal AK, Arora K, Joshi V, Suri D, De D. Refractory leg ulcers in prolidase deficiency with antiphospholipid antibody positivity responding to aspirin-hydroxychloroquine-vitamin C combination therapy. Dermatol Ther 2020; 33:e14156. [PMID: 32927500 DOI: 10.1111/dth.14156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/29/2020] [Accepted: 08/02/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Muhammed Razmi T
- Department Dermatology, IQRAA International Hospital and Research Centre, Calicut, India
| | - Ankur Kumar Jindal
- Allergy Immunology Unit, Departments of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kanika Arora
- Allergy Immunology Unit, Departments of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vibhu Joshi
- Allergy Immunology Unit, Departments of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepti Suri
- Allergy Immunology Unit, Departments of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dipankar De
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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