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Yazdanpanah N, Rezaei N. Autoimmune disorders associated with common variable immunodeficiency: prediction, diagnosis, and treatment. Expert Rev Clin Immunol 2022; 18:1265-1283. [PMID: 36197300 DOI: 10.1080/1744666x.2022.2132938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency. Due to the wide spectrum of the CVID manifestations, the differential diagnosis becomes complicated, ends in a diagnostic delay and increased morbidity and mortality rates. Autoimmunity is one of the important complications associated with CVID. While immunoglobulin replacement therapy has considerably decreased the mortality rate in CVID patients, mainly infection-related mortality, other complications such as autoimmunity appeared prevalent and, in some cases, life threatening. AREAS COVERED In this article, genetics, responsible immune defects, autoimmune manifestations in different organs, and the diagnosis and treatment processes in CVID patients are reviewed, after searching the literature about these topics. EXPERT OPINION Considering the many phenotypes of CVID and the fact that it remained undiagnosed until older ages, it is important to include various manifestations of CVID in the differential diagnosis. Due to the different manifestations of CVID, including autoimmune diseases, interdisciplinary collaboration of physicians from different fields is highly recommended, as discussed in the manuscript. Meanwhile, it is important to determine which patients could benefit from genetic diagnostic studies since such studies are not necessary for establishing the diagnosis of CVID.
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Affiliation(s)
- Niloufar Yazdanpanah
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran.,School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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2
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Czech T, Shah P, Lee G, Watanabe G, Ogasawara C, Noh T. Cerebral toxoplasmosis in a patient with combined variable immunodeficiency. Surg Neurol Int 2022; 13:354. [PMID: 36128152 PMCID: PMC9479566 DOI: 10.25259/sni_532_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/24/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Cerebral toxoplasmosis is an opportunistic infection in patients but has rarely been described in the setting of compromised humoral immunodeficiency. Prompt diagnosis and treatment of the infection is critical in the care of these patients. Medical management is the mainstay of treatment of the infection. There have been very few reports of surgical management of cerebral toxoplasmosis. Case Description: We describe the case of a 40-year-old male who presented with headache, memory deficits, weight loss, and left-sided weakness in the setting of a known but undiagnosed brain lesion identified 1 month prior. Imaging demonstrated a right basal ganglia lesion which was initially presumed to be malignancy. On further workup including a positive serum test and biopsy including polymerase chain reaction analysis, diagnosis was confirmed as toxoplasmosis. On further investigation, he was found to have deficiencies in immunoglobulins consistent with common variable immunodeficiency (CVID). The patient underwent craniotomy with surgical debulking as repeat imaging showed increased size of mass with new satellite lesions and worsening hydrocephalus. Conclusion: Cerebral toxoplasmosis is an important differential to consider in cases of intracerebral lesions and should not necessarily be excluded in the absence of compromised cellular immunity. In cases where there is no immunocompromised state and malignancy cannot immediately be established, CVID should be considered as an etiology. Due to the subtlety of CVID diagnosis, careful attention should be paid to history taking and workup for CVID should be considered as soon as possible. Surgical removal of these lesions in conjunction with medications is an effective treatment option.
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Affiliation(s)
- Torrey Czech
- Department of Internal Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, United States
| | - Parthav Shah
- Department of Internal Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, United States
| | - Gunnar Lee
- Department of Neurological Surgery, John A. Burns School of Medicine, Honolulu, Hawaii, United States
| | - Gina Watanabe
- Department of Medicine, John A. Burns School of Medicine, Honolulu, Hawaii, United States
| | - Christian Ogasawara
- Department of Medicine, John A. Burns School of Medicine, Honolulu, Hawaii, United States
| | - Thomas Noh
- Neurosurgery, John A. Burns School of Medicine, Honolulu, Hawaii, United States
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van Stigt AC, Dik WA, Kamphuis LSJ, Smits BM, van Montfrans JM, van Hagen PM, Dalm VASH, IJspeert H. What Works When Treating Granulomatous Disease in Genetically Undefined CVID? A Systematic Review. Front Immunol 2021; 11:606389. [PMID: 33391274 PMCID: PMC7773704 DOI: 10.3389/fimmu.2020.606389] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/17/2020] [Indexed: 12/29/2022] Open
Abstract
Background Granulomatous disease is reported in at least 8–20% of patients with common variable immunodeficiency (CVID). Granulomatous disease mainly affects the lungs, and is associated with significantly higher morbidity and mortality. In half of patients with granulomatous disease, extrapulmonary manifestations are found, affecting e.g. skin, liver, and lymph nodes. In literature various therapies have been reported, with varying effects on remission of granulomas and related clinical symptoms. However, consensus recommendations for optimal management of extrapulmonary granulomatous disease are lacking. Objective To present a literature overview of the efficacy of currently described therapies for extrapulmonary granulomatous disease in CVID (CVID+EGD), compared to known treatment regimens for pulmonary granulomatous disease in CVID (CVID+PGD). Methods The following databases were searched: Embase, Medline (Ovid), Web-of-Science Core Collection, Cochrane Central, and Google Scholar. Inclusion criteria were 1) CVID patients with granulomatous disease, 2) treatment for granulomatous disease reported, and 3) outcome of treatment reported. Patient characteristics, localization of granuloma, treatment, and association with remission of granulomatous disease were extracted from articles. Results We identified 64 articles presenting 95 CVID patients with granulomatous disease, wherein 117 different treatment courses were described. Steroid monotherapy was most frequently described in CVID+EGD (21 out of 53 treatment courses) and resulted in remission in 85.7% of cases. In CVID+PGD steroid monotherapy was described in 15 out of 64 treatment courses, and was associated with remission in 66.7% of cases. Infliximab was reported in CVID+EGD in six out of 53 treatment courses and was mostly used in granulomatous disease affecting the skin (four out of six cases). All patients (n = 9) treated with anti-TNF-α therapies (infliximab and etanercept) showed remission of extrapulmonary granulomatous disease. Rituximab with or without azathioprine was rarely used for CVID+EGD, but frequently used in CVID+PGD where it was associated with remission of granulomatous disease in 94.4% (17 of 18 treatment courses). Conclusion Although the number of CVID+EGD patients was limited, data indicate that steroid monotherapy often results in remission, and that anti-TNF-α treatment is effective for granulomatous disease affecting the skin. Also, rituximab with or without azathioprine was mainly described in CVID+PGD, and only in few cases of CVID+EGD.
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Affiliation(s)
- Astrid C van Stigt
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine, Division of Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
| | - Willem A Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
| | - Lieke S J Kamphuis
- Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Pulmonary Medicine, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Bas M Smits
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Centre (UMC), Utrecht, Netherlands
| | - Joris M van Montfrans
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Centre (UMC), Utrecht, Netherlands
| | - P Martin van Hagen
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine, Division of Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
| | - Virgil A S H Dalm
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine, Division of Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hanna IJspeert
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
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4
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Ameratunga R, Ahn Y, Tse D, Woon ST, Pereira J, McCarthy S, Blacklock H. The critical role of histology in distinguishing sarcoidosis from common variable immunodeficiency disorder (CVID) in a patient with hypogammaglobulinemia. Allergy Asthma Clin Immunol 2019; 15:78. [PMID: 31827542 PMCID: PMC6886192 DOI: 10.1186/s13223-019-0383-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 11/05/2019] [Indexed: 12/23/2022] Open
Abstract
Background Common variable immunodeficiency disorders (CVID) are a rare group of primary immune defects, where the underlying cause is unknown. Approximately 10–20% of patients with typical CVID have a granulomatous variant, which has closely overlapping features with sarcoidosis. Case presentation Here we describe a young man who sequentially developed refractory Evans syndrome, cauda equina syndrome and most recently renal impairment. Following immunosuppression, he has made a recovery from all three life-threatening autoimmune disorders. As the patient was hypogammaglobulinemic for most of the time while on immunosuppression, vaccine challenges and other tests were not possible. Histological features were in keeping with sarcoidosis rather than the granulomatous variant of CVID. In the brief period when immunosuppression was lifted between the cauda equina syndrome and renal impairment, he normalised his immunoglobulins, confirming sarcoidosis rather than CVID was the underlying cause. Conclusion We discuss diagnostic difficulties distinguishing the two conditions, and the value of histological features in our diagnostic criteria for CVID in identifying sarcoidosis, while the patient was hypogammaglobulinemic. The key message from this case report is that the characteristic histological features of CVID can be very helpful in making (or excluding) the diagnosis, particularly when other tests are not possible.
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Affiliation(s)
- Rohan Ameratunga
- 1Department of Virology and Immunology, Auckland City Hospital, Park Rd, Grafton, Auckland, 1010 New Zealand.,4Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Yeri Ahn
- 1Department of Virology and Immunology, Auckland City Hospital, Park Rd, Grafton, Auckland, 1010 New Zealand
| | - Dominic Tse
- 2Department of Neurology, Auckland City Hospital, Park Rd, Grafton, Auckland, 1010 New Zealand
| | - See-Tarn Woon
- 1Department of Virology and Immunology, Auckland City Hospital, Park Rd, Grafton, Auckland, 1010 New Zealand.,4Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jennifer Pereira
- 2Department of Neurology, Auckland City Hospital, Park Rd, Grafton, Auckland, 1010 New Zealand
| | - Sinead McCarthy
- 3Department of Histopathology, Auckland City Hospital, Park Rd, Grafton, Auckland, 1010 New Zealand
| | - Hilary Blacklock
- 4Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,5Department of Haematology, Middlemore Hospital, Auckland, New Zealand
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5
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Autoimmunity and infection in common variable immunodeficiency (CVID). Autoimmun Rev 2016; 15:877-82. [PMID: 27392505 DOI: 10.1016/j.autrev.2016.07.011] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 06/05/2016] [Indexed: 11/23/2022]
Abstract
Common variable immunodeficiency (CVID) is a heterogeneous group of diseases, characterized by primary hypogammaglobulinemia. B and T cell abnormalities have been described in CVID. Typical clinical features of CVID are recurrent airway infections; lymphoproliferative, autoinflammatory, or neoplastic disorders; and autoimmune diseases among which autoimmune thrombocytopenia (ITP) is the most common. The coexistence of immunodeficiency and autoimmunity appears paradoxical, since one represents a hypoimmune state and the other a hyperimmune state. Considering both innate and adaptive immune response abnormalities in CVID, it is easier to understand the mechanisms that lead to a breakdown of self-tolerance. CD21(low) B cells derive from mature B cells that have undergone chronic immune stimulation; they are increased in CVID patients. The expansion of CD21(low) B cells is also observed in certain autoimmune diseases. We have studied CD21(low) B cells in patients with CVID, CVID, and ITP and with ITP only. We observed a statistically significant increase in the CD21(low) population in the three pathological groups. Moreover, we found statistical differences between the two groups of CVID patients: patients with ITP had a higher percentage of CD21(low) cells. Our data suggest that CD21(low) cells are related to autoimmunity and may represent a link between infection and autoimmunity.
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Tashtoush B, Memarpour R, Ramirez J, Bejarano P, Mehta J. Granulomatous-lymphocytic interstitial lung disease as the first manifestation of common variable immunodeficiency. CLINICAL RESPIRATORY JOURNAL 2016; 12:337-343. [PMID: 27243233 DOI: 10.1111/crj.12511] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/18/2016] [Accepted: 05/29/2016] [Indexed: 12/15/2022]
Abstract
Common variable immunodeficiency (CVID) is one of the most common primary immunodeficiencies, which is characterized by reduced serum immunoglobulin levels and B-lymphocyte dysfunction. There are many clinical manifestations of this disease, the most common of which are recurrent respiratory tract infections. Among the most recently recognized autoimmune manifestation of CVID is a disease described as granulomatous-lymphocytic interstitial lung disease (GLILD), where CVID coexists with a small airway lymphoproliferative disorder, mimicking follicular bronchiolitis, or lymphocytic interstitial pneumonitis (LIP) on histology specimens. We herein describe the clinical and radiological features of GLILD in a 55-year-old woman where the diagnosis of CVID was actively pursued and eventually confirmed after her lung biopsy showed characteristic features of GLILD. The patient had dramatic response to treatment with IVIG and corticosteroids for 3 months followed by Mycophenolate mofetil for maintenance therapy.
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Affiliation(s)
- Basheer Tashtoush
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Roya Memarpour
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Jose Ramirez
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Pablo Bejarano
- Department of Pathology, Cleveland Clinic Florida, Weston, Florida
| | - Jinesh Mehta
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
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Gargiulo C, Pham VH, Nguyen KC, Kim ND, Van TN, Tuan AL, Abe K, Shiffman M. Toxoplasmosis Gondii Infection and Diabetes Mellitus Type 2 Treated by Using Autologous Peripheral Blood Stem Cells a Unique Case Report of a Caucasian 83 Year Old Lady. BIOMEDICAL RESEARCH AND THERAPY 2015. [DOI: 10.7603/s40730-015-0019-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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8
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Abstract
Lymphomatoid granulomatosis (LG) is a B-cell type lymphoproliferative disease. It mainly affects the lungs but may have extrapulmonary manifestations, especially in the central nervous system. The purpose of this study was to review the pediatric cases in the literature and add 2 new cases to the existing literature. A review of the literature was performed on children (0 to 18 years of age at diagnosis) with pathologically proven LG. We found 47 case reports, which, together with 2 new cases, were systematically analyzed. The median age was 12 years. The main symptoms were general, pulmonary, and neurological. Approximately one third of the patients were immunocompromised. High mortality rate was observed. Pediatric LG is a rare disease, which appears to be more frequently seen in immunocompromised patients, especially patients with leukemia. The disease has a high mortality rate; therefore, aggressive therapy according to a high-grade B-cell lymphoma protocol is justified.
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9
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Unger S, Seidl M, Schmitt-Graeff A, Böhm J, Schrenk K, Wehr C, Goldacker S, Dräger R, Gärtner BC, Fisch P, Werner M, Warnatz K. Ill-defined germinal centers and severely reduced plasma cells are histological hallmarks of lymphadenopathy in patients with common variable immunodeficiency. J Clin Immunol 2014; 34:615-26. [PMID: 24789743 DOI: 10.1007/s10875-014-0052-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 04/21/2014] [Indexed: 11/28/2022]
Abstract
Given the severely reduced numbers of circulating class-switched memory B cells and plasmablasts in patients with common variable immunodeficiency (CVID) the germinal center (GC) reaction as the source of both populations is expected to be disturbed in many CVID patients. Therefore immunohistochemical studies were performed on lymph node (LN) biopsies from ten CVID patients with benign lymphoproliferation. According to the Sander classification the majority of patients presented with reactive lymphoid hyperplasia (7/10), 6/10 showed granulomatous inflammation. All cases showed some normal GCs but in 9/10 these concurred to a varying degree with hyperplastic, ill-defined GCs in the same LN. The percentage of ill-defined GCs correlated significantly with the percentage of circulating CD21(low) B cells suggesting a common origin of both immune reactions. In 9/10 CVID LNs significantly higher numbers of infiltrating CD8+ T cells were found in GCs of CVID patients compared to controls, but no HHV-8 and only in 2/10 LNs EBV infection was detected. Class switched plasma cells (PCs) were severely reduced in 8/10 LNs and if present, rarely found in the medulla of the LN. Based on the presence of large GCs in all examined patients, the reduction of circulating memory B cells and PCs points towards a failure of GC output rather than GC formation in CVID patients with lymphadenopathy.
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Affiliation(s)
- Susanne Unger
- Center for Chronic Immunodeficiency, University Medical Center Freiburg and University of Freiburg, Breisacher Str.117, 79106, Freiburg, Germany
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10
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Pavic M, Pasquet F, Fieschi C, Malphettes M, Sève P. Granulomatoses au cours des déficits immunitaires primitifs de l’adulte. Rev Med Interne 2013; 34:154-8. [DOI: 10.1016/j.revmed.2012.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Accepted: 02/14/2012] [Indexed: 12/13/2022]
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Baldovino S, Montin D, Martino S, Sciascia S, Menegatti E, Roccatello D. Common variable immunodeficiency: crossroads between infections, inflammation and autoimmunity. Autoimmun Rev 2012; 12:796-801. [PMID: 23219764 DOI: 10.1016/j.autrev.2012.11.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Common variable immunodeficiency is a collection of diseases characterized by primary hypogammaglobulinemia. The causes of CVID are extremely heterogeneous and may affect virtually every pathway linked to B cell development and function. Clinical manifestations of CVID mainly include recurrent bacterial infections, but autoimmune, gastrointestinal, lymphoproliferative, granulomatous, and malignant disorders have also been frequently reported as associated conditions. We aimed to focus on the state of the art of the relationship between infections, inflammation and autoimmunity in CVID.
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Affiliation(s)
- Simone Baldovino
- Centro Universitario di Ricerche di Immunologia Clinica, Immunopatologia e Documentazione su Malattie Rare (CMID), Università di Torino, Ospedale G. Bosco, Turin, Italy.
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12
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Granulomatous Disease in CVID: Retrospective Analysis of Clinical Characteristics and Treatment Efficacy in a Cohort of 59 Patients. J Clin Immunol 2012; 33:84-95. [DOI: 10.1007/s10875-012-9778-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 08/21/2012] [Indexed: 10/27/2022]
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13
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Case report and review of the literature: Toxoplasma gondii encephalitis in a 40-year-old woman with common variable immunodeficiency and a new diagnosis of large granular lymphocytic leukemia. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2011; 19:309-10. [PMID: 19436513 DOI: 10.1155/2008/614279] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2007] [Accepted: 04/10/2008] [Indexed: 11/18/2022]
Abstract
Toxoplasma gondii has been well-documented to cause central nervous system infections in immunodeficient patients. The present study describes a case of central nervous system toxoplasmosis in a patient with common variable immunodeficiency and newly diagnosed large granular lymphocytic leukemia, with a review of the literature for this association.
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14
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De Somer L, Wouters C, Morren MA, De Vos R, Van Den Oord J, Devriendt K, Meyts I. Granulomatous skin lesions complicating Varicella infection in a patient with Rothmund-Thomson syndrome and immune deficiency: case report. Orphanet J Rare Dis 2010; 5:37. [PMID: 21143835 PMCID: PMC3009952 DOI: 10.1186/1750-1172-5-37] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 12/08/2010] [Indexed: 01/25/2023] Open
Abstract
Rothmund-Thomson syndrome (RTS)(OMIM 268400) is a rare autosomal recessive genodermatosis characterized by poikiloderma, small stature, skeletal and dental abnormalities, cataract and an increased risk of cancer. It is caused by mutations in RECQL4 at 8q24. Immune deficiency is not described as a classical feature of the disease. Here we report the appearance of granulomatous skin lesions complicating primary Varicella Zoster Virus infection in a toddler with Rothmund Thomson syndrome and immune deficiency. Although granulomatous disorders are sometimes seen after Herpes zoster, they are even more rare after Varicella primary infection. Granulomas have hitherto not been described in Rothmund-Thomson syndrome. With this report we aim to stress the importance of screening for immune deficiency in patients with Rothmund-Thomson syndrome.
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Affiliation(s)
- Lien De Somer
- Department of Pediatric, University Hospitals Leuven, Leuven, Belgium
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15
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Chen X, Remotti F, Tong GX, Gorczyca E, Hamele-Bena D. Fine-needle aspiration cytology of subcutaneous toxoplasmosis: A case report. Diagn Cytopathol 2009; 38:716-20. [PMID: 20014129 DOI: 10.1002/dc.21281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Toxoplasmosis is a common opportunistic infection in patients with AIDS in whom it typically presents as encephalitis, pneumonia, lymphadenitis, and myocarditis. Skin involvement is very rare and, to our best knowledge, Toxoplasma gondii forming a subcutaneous mass has not been reported. Here, we report the findings of an interesting case of subcutaneous toxoplasmosis with the cytological appearance of an inflammatory fibrovascular lesion in a HIV-positive patient and discuss the differential diagnosis.
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Affiliation(s)
- Xiaowei Chen
- Department of Pathology, Columbia University Medical Centre, New York, NY 10032, USA.
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16
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Ardeniz O, Cunningham-Rundles C. Granulomatous disease in common variable immunodeficiency. Clin Immunol 2009; 133:198-207. [PMID: 19716342 DOI: 10.1016/j.clim.2009.05.001] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 04/23/2009] [Accepted: 05/04/2009] [Indexed: 11/19/2022]
Abstract
Granulomatous disease occurs in 8-22% of patients with common variable immunodeficiency (CVID). We examined the clinical and immunologic information of all 37 of 455 (8.1%) CVID subjects with this complication. The median age at diagnosis of CVID was 26 (2-59). 14 had granulomas 1-18 years before diagnosis of CVID. In 6 detection of granulomas coincided with this diagnosis; for 17, granulomas were documented later. 54% had lung granulomas, 43% in lymph nodes and 32% in liver. 54% of the group had had autoimmune diseases, mostly immune thrombocytopenia and hemolytic anemia. 24% had had a splenectomy. Nineteen (51.3%) required steroid treatment for granulomas; other immune suppressants were used in some. Over 25 years 28.5% died (median age 37.5), but not significantly more when compared to our CVID patients without granulomas (19.8%). Those with lung granulomas had similar mortality to those with granulomas in other tissues.
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Affiliation(s)
- Omür Ardeniz
- Ege University Medical Faculty, Department of Internal Medicine, Division of Allergy and Clinical Immunology, Izmir, Turkey
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17
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Deane S, Selmi C, Naguwa SM, Teuber SS, Gershwin ME. Common variable immunodeficiency: etiological and treatment issues. Int Arch Allergy Immunol 2009; 150:311-24. [PMID: 19571563 PMCID: PMC2814150 DOI: 10.1159/000226232] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
One of the great advances in clinical medicine was the recognition of the pleomorphism of the immune response and the multiple afferent and efferent limbs of antigen processing and responsiveness. A significant contribution to this understanding was derived from studies of human immunodeficiency states, including both inherited and acquired syndromes. Amongst these syndromes, one of the most common, and least understood, is common variable immune deficiency (CVID). CVID is a syndrome that leads to a reduction in serum immunoglobulins and complications including recurrent infections. Management includes immunoglobulin replacement therapy; however, patients with CVID are at risk for complications of exogenous immunoglobulin administration as well as CVID-associated diseases such as autoimmune processes and malignancies. To assess the current state of knowledge in the field, we performed a literature review of a total of 753 publications covering the period of 1968 until 2008. From this list, 189 publications were selected for discussion. In this review, we demonstrate that while the molecular basis of CVID in many cases remains incompletely understood, significant strides have been made and it is now clear that there is involvement of several pathways of immune activation, with contributions from both T and B cells. Furthermore, despite the current gaps in our knowledge of the molecular pathogenesis of the syndrome, there have been dramatic advances in management that have led to improved survival and significantly reduced morbidity in affected patients.
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Affiliation(s)
| | | | | | | | - M. Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California
at Davis School of Medicine, Davis, Calif., USA
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18
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Malphettes M, Oksenhendler E, Galicier L, Fieschi C. [Granulomatous disease in common variable immunodeficiency]. Rev Med Interne 2007; 29:28-32. [PMID: 18054123 DOI: 10.1016/j.revmed.2007.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Accepted: 10/02/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE Common variable immunodeficiency (CVID), defined by defective production of immunoglobulins, is the most common primary immunodeficiency in adulthood requiring a medical follow-up. Repeated bacterial infections and/or autoimmune manifestations and/or benign lymphoproliferation (including follicular hyperplasia and/or granulomatous disease) are the hallmark of the disease. This review aims at describing recent advances in the understanding and treatment of granulomatous disease in CVID. CURRENT KNOWLEDGE AND KEY POINTS Clinical features of granulomatous disease in CVID can mimic sarcoidosis, remarkable by the low levels of circulating immunoglobulins. Granulomas may be found in several organs in a single patient, and the main features are pulmonary, lymphoid, cutaneous, hepatic or splenic. The features of CVID is remarkable by the high frequency of autoimmune diseases complicating the immunodeficiency. Some immunological abnormalities have been described in such patients, including lymphopenia, decreased T-cells proliferations to mitogens and antigens. Rare polymorphisms in the gene encoding TNFalpha (Tumor Necrosis Factor) have been identified in CVID patients with granulomatous disease. FUTURE PROSPECTS AND PROJECTS The evolution of the disease is severe, particularly when the lung is involved. Treatment consists in immunoglobulins substitution, immunosuppressive agents (corticosteroids, cyclophosphamide) and anti-TNFalpha antibodies. These treatments are difficult to manage in such immunocompromised patients.
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Affiliation(s)
- M Malphettes
- Département d'immunologie clinique, hôpital Saint-Louis, 1 avenue Claude-Vellefaux, Paris, France
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Busse PJ, Farzan S, Cunningham-Rundles C. Pulmonary complications of common variable immunodeficiency. Ann Allergy Asthma Immunol 2007; 98:1-8; quiz 8-11, 43. [PMID: 17225714 DOI: 10.1016/s1081-1206(10)60853-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To review pulmonary complications of common variable immunodeficiency (CVID) and summarize data available on the use of replacement antibody treatment to protect against lung changes. DATA SOURCES Relevant articles regarding CVID and pulmonary disease identified from PubMed and reference lists of review articles. STUDY SELECTION Key articles were selected by the authors. RESULTS Patients with CVID often develop acute sinopulmonary infections that can lead to chronic airway inflammation, which can produce substantial morbidity and mortality. Replacement immunoglobulin treatment significantly reduces the reoccurrence of lower airway infections, but the effect on the development of chronic lung damage is not yet clear. Screening examinations, such as pulmonary function testing and high-resolution computed tomography of the chest, can be used to evaluate pulmonary status. Patients with abnormal findings may benefit from more aggressive treatment, including larger doses of immune globulin and the use of prophylactic antibiotics. CONCLUSIONS Pulmonary complications present a significant comorbidity in CVID; monitoring may indicate which patients require more aggressive treatment.
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Affiliation(s)
- Paula J Busse
- Allergy and Immunology, Mt Sinai Hospital, New York, New York 10029, USA
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Fernández-Ruiz M, Guerra-Vales JM, Francisco-Javier CF, Yolanda RG, Miguel-Ingel MG, Cristina GC, Jesús RC. Fever of unknown origin in a patient with common variable immunodeficiency associated with multisystemic granulomatous disease. Intern Med 2007; 46:1197-202. [PMID: 17675769 DOI: 10.2169/internalmedicine.46.6414] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Non-caseating epithelioid granulomas have been described in a small number of patients with common variable immunodeficiency (CVID). We report a 26-year-old woman diagnosed with CVID nine years earlier, who developed non-caseating granulomas in the liver, bone marrow and skin. She was referred to our department for a fever of more than one year duration without apparent focus. Extensive search for underlying malignancy or occult infection was unremarkable. Empirical treatment with prednisone was begun and the patient showed a marked improvement. The literature on the association between CVID and non-caseating granulomatous disease, and the differential diagnosis of hepatic granulomas as a cause of fever of unknown origin, is also reviewed.
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Abstract
Primary immunodeficiencies are important disorders because they typically cause severe illness in affected patients. In addition, these diseases provide a unique glimpse at the underpinnings of the immune system in humans. Susceptibility to infections, including those caused by parasites, is a hallmark of these immune defects. Understanding the association between primary immunodeficiencies and parasitic infections will likely improve our grasp on the mechanisms of defense against these pathogens.
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Affiliation(s)
- C S Subauste
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0560, USA.
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Morimoto Y, Routes JM. Granulomatous disease in common variable immunodeficiency. Curr Allergy Asthma Rep 2006; 5:370-5. [PMID: 16091208 DOI: 10.1007/s11882-005-0008-x] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Common variable immunodeficiency (CVID) is a primary immunodeficiency of unknown etiology characterized by low levels of immunoglobulin (Ig)G, failure to make specific antibodies in response to infection or immunization, and variable T-cell abnormalities. Multisystemic granulomatous disease is a well-documented complication of CVID, and its presence is associated with significant morbidity and early mortality. Although the lung is the most common organ system affected, granulomas are also found frequently in other organs, including skin, liver, spleen, and the gastrointestinal tract. Autoimmune disorders are common in these patients, and there appears to be an increased propensity to develop lymphoproliferative disorders. Common physical, radiographic, and laboratory abnormalities in patients with CVID and granulomatous disease include splenomegaly, hilar and mediastinal lymphadenopathy with ground glass or nodular opacities in the lung parenchyma, and reduced T-cell numbers and function. The etiology of granulomatous disease in patients with CVID is unknown, and optimal treatment of granulomatous disease in CVID remains to be established. Further studies are needed to elucidate the underlying etiology of granulomatous lymphoproliferative interstitial lung disease and to delineate appropriate treatments for this disease.
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Affiliation(s)
- Yoshikazu Morimoto
- Department of Medicine, National Jewish Medical and Research Center, 1400 Jackson Street, Denver, CO 80206, USA
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Thatayatikom A, Thatayatikom S, White AJ. Infliximab treatment for severe granulomatous disease in common variable immunodeficiency: a case report and review of the literature. Ann Allergy Asthma Immunol 2005; 95:293-300. [PMID: 16200822 DOI: 10.1016/s1081-1206(10)61228-8] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Granulomatous disease resembling sarcoidosis is a well-described condition associated with common variable immunodeficiency (CVID). Its treatment remains problematic, and new therapeutic options are needed. OBJECTIVES To report the efficacy of treatment with infliximab, a chimeric anti-tumor necrosis factor alpha monoclonal antibody, in a patient with granulomatous CVID and to review the literature on the treatment of patients with granulomatous CVID. METHODS A 22-year-old white man with CVID developed acute multiorgan failure, with granulomatous inflammation on lung and liver biopsy specimens. He was initially treated with antibiotics, intravenous immunoglobulin, and corticosteroids for 5 weeks without improvement. High-dose infliximab was then infused weekly for 6 weeks and then monthly for 9 months. The response to infliximab was determined by changes on clinical examination, imaging studies, and histologic studies. RESULTS The patient's condition dramatically improved after 1 dose of infliximab infusion, with decreasing hepatosplenomegaly, ventilatory support requirements, and pulmonary infiltrates. Ventilatory support was successfully discontinued within 3 weeks. The corticosteroid dose was tapered without reactivation of the disease. After 9 months of therapy, follow-up imaging studies showed resolution of pulmonary infiltrates, no hepatosplenomegaly, and no portal hypertension, and a percutaneous liver biopsy revealed no granulomas; then, infliximab use was discontinued. The patient remains free of granulomatous disease after 18 months of follow-up. CONCLUSIONS To our knowledge, this is the first report of severe visceral granulomatous CVID successfully treated with infliximab. Infliximab may be an effective therapy for granulomas in CVID. Further studies of infliximab and other tumor necrosis factor a antagonist therapies in granulomatous CVID are warranted.
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Affiliation(s)
- Akaluck Thatayatikom
- Division of Immunology/Rheumatology, Department of Pediatrics, St Louis Children's Hospital and Washington University School of Medicine, St Louis, Missouri 63110, USA
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