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Biggs SE, Gilchrist B, May KR. Chromosome 22q11.2 Deletion (DiGeorge Syndrome): Immunologic Features, Diagnosis, and Management. Curr Allergy Asthma Rep 2023; 23:213-222. [PMID: 36897497 PMCID: PMC9999075 DOI: 10.1007/s11882-023-01071-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE OF REVIEW This review focuses on immunologic findings, relationships among immunologic findings and associated conditions of autoimmunity and atopy, and management of immunologic disease in chromosome 22q11.2 deletion syndrome (22q11.2DS, historically known as DiGeorge syndrome). RECENT FINDINGS The implementation of assessment of T cell receptor excision circles (TRECs) in newborn screening has led to increased detection of 22q11.2 deletion syndrome. While not yet applied in clinical practice, cell-free DNA screening for 22q11.2DS also has the potential to improve early detection, which may benefit prompt evaluation and management. Multiple studies have further elucidated phenotypic features and potential biomarkers associated with immunologic outcomes, including the development of autoimmune disease and atopy. The clinical presentation of 22q11.2DS is highly variable particularly with respect to immunologic manifestations. Time to recovery of immune system abnormalities is not well-defined in current literature. An understanding of the underlying causes of immunologic changes found in 22q11.2DS, and the progression and evolution of immunologic changes over the lifespan have expanded over time and with improved survival. An included case highlights the variability of presentation and potential severity of T cell lymphopenia in partial DiGeorge syndrome and demonstrates successful spontaneous immune reconstitution in partial DiGeorge syndrome despite initial severe T cell lymphopenia.
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Affiliation(s)
- Sarah E Biggs
- Division of Allergy-Immunology & Pediatric Rheumatology, Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Bailee Gilchrist
- Division of Allergy-Immunology & Pediatric Rheumatology, Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Kathleen R May
- Division of Allergy-Immunology & Pediatric Rheumatology, Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, GA, USA.
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Chen C, Zhang C, Deng Y, Du S, Wang H, Li D. Thymic hypoplasia induced by copy number variations contributed to explaining sudden infant death based on forensic autopsies. Forensic Sci Int 2022; 336:111323. [DOI: 10.1016/j.forsciint.2022.111323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/24/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022]
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3
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Drozdov D, Petermann K, Dougoud S, Oberholzer S, Held L, Güngör T, Hauri-Hohl M. Dynamics of recent thymic emigrants in pediatric recipients of allogeneic hematopoetic stem cell transplantation. Bone Marrow Transplant 2022; 57:620-626. [PMID: 35140350 DOI: 10.1038/s41409-022-01594-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 01/11/2022] [Accepted: 01/19/2022] [Indexed: 11/09/2022]
Abstract
After allogeneic hematopoietic stem cell transplantation (allo-HSCT), the recurrence of recent thymic emigrants (RTE) and self-tolerant T cells indicate normalized thymic function. From 2008 to 2019, we retrospectively analyzed the RTE-reconstitution rate and the minimal time to reach normal age-specific first percentiles for CD31+CD45RA+CD4+T cells in 199 pediatric patients after allo-HSCT for various malignant and non-malignant diseases. The impact of clinically significant graft-versus-host disease (GvHD), age at transplantation, underlying disease and cumulative area under the curve of busulfan on RTE-reemergence was assessed in multivariable longitudinal analysis. RTE-reconstitution (coefficient -0.24, 95% CI -0.33 to -0.14, p < 0.001) was slowed down by GvHD and the time to reach P1 was significantly longer (Event Time Ratio 1.49, 95% CI 1.25 to 1.78, p < 0.001). Older age at transplantation was also associated with a slower RTE-reconstitution (coefficient -0.028, 95% CI -0.04 to -0.02, p < 0.001) and time to reach P1 was significantly longer (Event Time Ratio 1.03, 95% CI 1.02 to 1.05, p < 0.001). RTE-reconstitution velocity was not influenced by underlying disease or cumulative busulfan exposure. In summary, duration until thymic reactivation was independent of both conditioning intensity and underlying disease and was negatively influenced by older age and GvHD.
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Affiliation(s)
- Daniel Drozdov
- Division of Stem Cell Transplantation and Children's Research Center, University Children's Hospital Zurich, University of Zürich, Zürich, Switzerland. .,Division of Oncology-Hematology, Department of Pediatrics, Kantonsspital Aarau, Aarau, Switzerland.
| | - Katrin Petermann
- Epidemiology, Biostatistics, and Prevention Institute (EBPI), University of Zürich, Zürich, Switzerland.,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Svetlana Dougoud
- Department of Cardiology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Sibylle Oberholzer
- Division of Stem Cell Transplantation and Children's Research Center, University Children's Hospital Zurich, University of Zürich, Zürich, Switzerland
| | - Leonhard Held
- Epidemiology, Biostatistics, and Prevention Institute (EBPI), University of Zürich, Zürich, Switzerland
| | - Tayfun Güngör
- Division of Stem Cell Transplantation and Children's Research Center, University Children's Hospital Zurich, University of Zürich, Zürich, Switzerland
| | - Mathias Hauri-Hohl
- Division of Stem Cell Transplantation and Children's Research Center, University Children's Hospital Zurich, University of Zürich, Zürich, Switzerland
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Deya-Martinez A, Flinn AM, Gennery AR. Neonatal thymectomy in children-accelerating the immunologic clock? J Allergy Clin Immunol 2020; 146:236-243. [PMID: 32169378 DOI: 10.1016/j.jaci.2020.02.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/25/2020] [Accepted: 02/26/2020] [Indexed: 12/29/2022]
Abstract
The thymus is critical for central tolerance and diverse T-lymphocyte repertoire development, to provide lifelong defense against pathogens while maintaining self-tolerance. Peak thymic output occurs in utero, during infancy, and in early childhood, diminishing throughout life. Infants with congenital heart disease requiring sternotomy often undergo thymectomy to clear the surgical field. The long-term effects of early thymectomy are just being appreciated. Many patients remain asymptomatic despite immunologic findings mirroring those of immunosenescence. Few develop increased infection or lymphoreticular malignancy risk. When considering the effects of infant thymectomy, patients with partial DiGeorge syndrome or hypomorphic recombination-activating gene (RAG) mutations may be instructive. These patients are lymphocytopenic, with increased early-onset infection and autoimmunity risk that is not seen in most patients who underwent thymectomy during infancy. The thymic structure of patients with partial DiGeorge syndrome or hypomorphic RAG is abnormal, with disrupted architecture inclining to perturbation of central tolerance. Similar findings may be seen in patients with myasthenia gravis, although disrupted peripheral tolerance may play a greater role in autoimmunity development. In conclusion, thymectomy during infancy may increase future risk of infection or autoimmunity, with premature immunosenescence mediated through disruption of central and peripheral tolerance mechanisms initiated by early cessation or diminution of thymic output. Ideally, some thymic tissue should be preserved at the time of surgery.
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Affiliation(s)
- Angela Deya-Martinez
- Functional Unit of Clinical Immunology and Primary Immunodeficiencies, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, University of Barcelona, Pediatric Research Institute Sant Joan de Déu, Barcelona, Spain
| | - Aisling M Flinn
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Childrens' Hospital, Newcastle upon Tyne, United Kingdom
| | - Andrew R Gennery
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Childrens' Hospital, Newcastle upon Tyne, United Kingdom; Primary Immunodeficiency Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
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5
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Sullivan KE. Chromosome 22q11.2 deletion syndrome and DiGeorge syndrome. Immunol Rev 2019; 287:186-201. [PMID: 30565249 DOI: 10.1111/imr.12701] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/30/2018] [Indexed: 12/19/2022]
Abstract
Chromosome 22q11.2 deletion syndrome is the most common microdeletion syndrome in humans. The effects are protean and highly variable, making a unified approach difficult. Nevertheless, commonalities have been identified and white papers with recommended evaluations and anticipatory guidance have been published. This review will cover the immune system in detail and discuss both the primary features and the secondary features related to thymic hypoplasia. A brief discussion of the other organ system involvement will be provided for context. The immune system, percolating throughout the body can impact the function of other organs through allergy or autoimmune disease affecting organs in deleterious manners. Our work has shown that the primary effect of thymic hypoplasia is to restrict T cell production. Subsequent homeostatic proliferation and perhaps other factors drive a Th2 polarization, most obvious in adulthood. This contributes to atopic risk in this population. Thymic hypoplasia also contributes to low regulatory T cells and this may be part of the overall increased risk of autoimmunity. Collectively, the effects are complex and often age-dependent. Future goals of improving thymic function or augmenting thymic volume may offer a direct intervention to ameliorate infections, atopy, and autoimmunity.
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Affiliation(s)
- Kathleen E Sullivan
- The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Nain E, Kiykim A, Ogulur I, Kasap N, Karakoc-Aydiner E, Ozen A, Baris S. Immune system defects in DiGeorge syndrome and association with clinical course. Scand J Immunol 2019; 90:e12809. [PMID: 31322747 DOI: 10.1111/sji.12809] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 06/27/2019] [Accepted: 07/05/2019] [Indexed: 12/11/2022]
Abstract
We evaluated 18 DiGeorge syndrome (DGS) patients and aimed to investigate the immunological changes in this population. DGS patients with low naive CD4+ T and CD8+ T cells were defined as high-risk (HR) patients, whereas patients with normal numbers of naive CD4+ and CD8+ T cells were defined as standard risk (SR) patients. Level of serum IgM, CD3+ T cell counts and percentages of class-switched memory B cells were significantly low in HR group compared to SR ones. Severe infections and persistent hypoparathyroidism were detected significantly higher in HR group. Patients with reduced percentages of class-switched B cells had earlier onset of infection, lower blood IgM, lower CD4+ and CD8+ T counts than patients with normal class-switched memory B cells. Decreased levels of IgM were associated with low numbers of naive CD4+ and recent thymic emigrants T cells. Monitoring the immune changes of patients with DGS would be useful to predict the severe phenotype of disease.
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Affiliation(s)
- Ercan Nain
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey
| | - Ayca Kiykim
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey
| | - Ismail Ogulur
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey
| | - Nurhan Kasap
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey
| | - Elif Karakoc-Aydiner
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey.,Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
| | - Ahmet Ozen
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey.,Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
| | - Safa Baris
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey.,Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
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7
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Clinical and immunological features in a cohort of patients with partial DiGeorge syndrome followed at a single center. Blood 2019; 133:2586-2596. [PMID: 31015189 DOI: 10.1182/blood.2018885244] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/03/2019] [Indexed: 02/06/2023] Open
Abstract
DiGeorge syndrome (DGS) is a primary immunodeficiency characterized by various degrees of T-cell deficiency. In partial DGS (pDGS), other risk factors could predispose to recurrent infections, autoimmunity, and allergy. The aim of this study was to assess the effect of different factors in the development of infections, autoimmunity, and/or allergy in patients with pDGS. We studied 467 pDGS patients in follow-up at Great Ormond Street Hospital. Using a multivariate approach, we observed that palatal anomalies represent a risk factor for the development of recurrent otitis media with effusion. Gastroesophageal reflux/dysphagia and asthma/rhinitis represent a risk factor for the development of recurrent upper respiratory tract infections. Allergy and autoimmunity were associated with persistently low immunoglobulin M levels and lymphopenia, respectively. Patients with autoimmunity showed lower levels of CD3+, CD3+CD4+, and naïve CD4+CD45RA+CD27+ T lymphocytes compared with pDGS patients without autoimmunity. We also observed that the physiological age-related decline of the T-cell number was slower in pDGS patients compared with age-matched controls. The age-related recovery of the T-cell number depended on a homeostatic peripheral proliferation of T cells, as suggested by an accelerated decline of the naïve T lymphocytes in pDGS as well as a more skewed T-cell repertoire in older pDGS patients. These evidences suggest that premature CD4+ T-cell aging and lymphopenia induced spontaneous peripheral T-cell proliferation might contribute to the pathogenesis of autoimmunity in patients with pDGS. Infections in these patients represent, in most of the cases, a complication of anatomical or gastroenterological anomalies rather than a feature of the underlying immunodeficiency.
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Neonatal Levels of T-cell Receptor Excision Circles (TREC) in Patients with 22q11.2 Deletion Syndrome and Later Disease Features. J Clin Immunol 2015; 35:408-15. [DOI: 10.1007/s10875-015-0153-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
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9
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Cancrini C, Puliafito P, Digilio MC, Soresina A, Martino S, Rondelli R, Consolini R, Ruga EM, Cardinale F, Finocchi A, Romiti ML, Martire B, Bacchetta R, Albano V, Carotti A, Specchia F, Montin D, Cirillo E, Cocchi G, Trizzino A, Bossi G, Milanesi O, Azzari C, Corsello G, Pignata C, Aiuti A, Pietrogrande MC, Marino B, Ugazio AG, Plebani A, Rossi P. Clinical features and follow-up in patients with 22q11.2 deletion syndrome. J Pediatr 2014; 164:1475-80.e2. [PMID: 24657119 DOI: 10.1016/j.jpeds.2014.01.056] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 12/17/2013] [Accepted: 01/28/2014] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To investigate the clinical manifestations at diagnosis and during follow-up in patients with 22q11.2 deletion syndrome to better define the natural history of the disease. STUDY DESIGN A retrospective and prospective multicenter study was conducted with 228 patients in the context of the Italian Network for Primary Immunodeficiencies. Clinical diagnosis was confirmed by cytogenetic or molecular analysis. RESULTS The cohort consisted of 112 males and 116 females; median age at diagnosis was 4 months (range 0 to 36 years 10 months). The diagnosis was made before 2 years of age in 71% of patients, predominantly related to the presence of heart anomalies and neonatal hypocalcemia. In patients diagnosed after 2 years of age, clinical features such as speech and language impairment, developmental delay, minor cardiac defects, recurrent infections, and facial features were the main elements leading to diagnosis. During follow-up (available for 172 patients), the frequency of autoimmune manifestations (P = .015) and speech disorders (P = .002) increased. After a median follow-up of 43 months, the survival probability was 0.92 at 15 years from diagnosis. CONCLUSIONS Our data show a delay in the diagnosis of 22q11.2 deletion syndrome with noncardiac symptoms. This study provides guidelines for pediatricians and specialists for early identification of cases that can be confirmed by genetic testing, which would permit the provision of appropriate clinical management.
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Affiliation(s)
- Caterina Cancrini
- University Department of Pediatrics, Bambino Gesù Children's Hospital and Tor Vergata University, Rome, Italy.
| | - Pamela Puliafito
- University Department of Pediatrics, Bambino Gesù Children's Hospital and Tor Vergata University, Rome, Italy
| | | | - Annarosa Soresina
- Pediatrics Clinic and Institute of Molecular Medicine "A. Nocivelli," University and Spedali Civili, Brescia, Italy
| | | | | | - Rita Consolini
- Department of Pediatrics and Reproductive Medicine, University of Pisa, Pisa, Italy
| | - Ezia Maria Ruga
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Padua, Padua, Italy
| | - Fabio Cardinale
- Department of Allergy and Pulmonology, Pediatric Hospital Giovanni XXIII, University of Bari, Bari, Italy
| | - Andrea Finocchi
- University Department of Pediatrics, Bambino Gesù Children's Hospital and Tor Vergata University, Rome, Italy
| | - Maria Luisa Romiti
- University Department of Pediatrics, Bambino Gesù Children's Hospital and Tor Vergata University, Rome, Italy
| | - Baldassarre Martire
- Department of Pediatrics "Federico Vecchio" and Department of Biomedicine of the Development Age, University of Bari, Bari, Italy
| | - Rosa Bacchetta
- Pediatric Immunology San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Hospital, Milan, Italy
| | | | - Adriano Carotti
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | | | - Davide Montin
- Department of Pediatrics, University of Turin, Turin, Italy
| | - Emilia Cirillo
- Department of Pediatrics, "Federico II" University of Naples, Naples, Italy
| | - Guido Cocchi
- Department of Pediatrics and Neonatology, University of Bologna, Bologna, Italy
| | - Antonino Trizzino
- Department of Pediatric Oncology and Hematology, G. Di Cristina Children's Hospital, Palermo, Italy
| | - Grazia Bossi
- Department of Pediatrics IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Ornella Milanesi
- Department of Pediatrics, Division of Pediatric Cardiology, University of Padua Medical School, Padua, Italy
| | - Chiara Azzari
- Department of Pediatrics, Anna Meyer Children's Hospital, University of Florence, Florence, Italy
| | | | - Claudio Pignata
- Department of Pediatrics, "Federico II" University of Naples, Naples, Italy
| | - Alessandro Aiuti
- University Department of Pediatrics, Bambino Gesù Children's Hospital and Tor Vergata University, Rome, Italy; Pediatric Immunology San Raffaele Telethon Institute for Gene Therapy (TIGET), San Raffaele Hospital, Milan, Italy
| | | | - Bruno Marino
- Department of Pediatrics, "La Sapienza" University, Rome, Italy
| | - Alberto Giovanni Ugazio
- Division of Rheumatology, Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessandro Plebani
- Pediatrics Clinic and Institute of Molecular Medicine "A. Nocivelli," University and Spedali Civili, Brescia, Italy
| | - Paolo Rossi
- University Department of Pediatrics, Bambino Gesù Children's Hospital and Tor Vergata University, Rome, Italy
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Ferrando-Martínez S, Lorente R, Gurbindo D, De José MI, Leal M, Muñoz-Fernández MA, Correa-Rocha R. Low thymic output, peripheral homeostasis deregulation, and hastened regulatory T cells differentiation in children with 22q11.2 deletion syndrome. J Pediatr 2014; 164:882-9. [PMID: 24461789 DOI: 10.1016/j.jpeds.2013.12.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 10/29/2013] [Accepted: 12/06/2013] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To perform an extensive analysis of the immune status of asymptomatic children with the 22q11.2 deletion syndrome, with special emphasis on the regulatory T cells (Treg) population. STUDY DESIGN Analysis of thymic function, frequency and absolute counts of immune subsets, and phenotype of Treg were performed in 10 asymptomatic children bearing the 22q11.2 deletion and compared with 12 age-matched, healthy children. RESULTS Children with 22q11.2 deletion syndrome showed a curtailed thymic output, lower T-cell levels, and a homeostatic deregulation in the CD4 T-cell compartment, characterized by a greater proliferative history in the naïve CD4 T-cell subset. Treg numbers were markedly reduced in children with 22q11.2 deletion syndrome, and remaining Treg showed mostly an activated phenotype. CONCLUSIONS Reduced thymic output in children with 22q11.2 deletion syndrome could be related with an increased proliferation in the naïve CD4 T-cell compartment and the consequent Treg activation to ensure that T-cell expansion remains under control. Deregulated peripheral homeostasis and loss of suppressive capacity by Treg could compromise the integrity of T-cell immunity during adulthood and play a relevant role in the increased incidence of autoimmune diseases reported in patients with the 22q11.2 deletion syndrome.
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Affiliation(s)
- Sara Ferrando-Martínez
- Laboratory of Molecular Immunobiology, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain; Laboratorio de Inmunovirología, Instituto de Biomedicina de Sevilla (IBIS), Unidad clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
| | - Raquel Lorente
- Laboratory of Molecular Immunobiology, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
| | - Dolores Gurbindo
- Sección de Inmunopediatría, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ma Isabel De José
- Servicio de Enfermedades Infecciosas Infantil, Hospital Universitario "La Paz", Madrid, Spain
| | - Manuel Leal
- Laboratorio de Inmunovirología, Instituto de Biomedicina de Sevilla (IBIS), Unidad clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
| | - Ma Angeles Muñoz-Fernández
- Laboratory of Molecular Immunobiology, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain; Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | - Rafael Correa-Rocha
- Laboratory of Molecular Immunobiology, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain.
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Davies EG. Immunodeficiency in DiGeorge Syndrome and Options for Treating Cases with Complete Athymia. Front Immunol 2013; 4:322. [PMID: 24198816 PMCID: PMC3814041 DOI: 10.3389/fimmu.2013.00322] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 09/23/2013] [Indexed: 11/13/2022] Open
Abstract
The commonest association of thymic stromal deficiency resulting in T-cell immunodeficiency is the DiGeorge syndrome (DGS). This results from abnormal development of the third and fourth pharyngeal arches and is most commonly associated with a microdeletion at chromosome 22q11 though other genetic and non-genetic causes have been described. The immunological competence of affected individuals is highly variable, ranging from normal to a severe combined immunodeficiency when there is complete athymia. In the most severe group, correction of the immunodeficiency can be achieved using thymus allografts which can support thymopoiesis even in the absence of donor-recipient matching at the major histocompatibility loci. This review focuses on the causes of DGS, the immunological features of the disorder, and the approaches to correction of the immunodeficiency including the use of thymus transplantation.
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Affiliation(s)
- E Graham Davies
- Centre for Immunodeficiency, Institute of Child Health, University College London and Great Ormond Street Hospital , London , UK
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Abstract
PURPOSE G6PC3 deficiency presents as a complex and heterogeneous syndrome that classically associates severe congenital neutropenia with cardiac and urogenital developmental defects. Here we investigate the findings of T cell lymphopenia and inflammatory bowel disease in a child with G6PC3 deficiency due to compound heterozygous mutations in intron 3 (c.IVS3-1 G>A) and exon 6 (c.G778G/C; p.Gly260/Arg). METHODS Histological examination was conducted on all biopsy specimens. Immunophenotyping and lymphocyte proliferation assays were performed. Immunoglobulin levels and vaccine responses were measured. RESULTS The patient showed persistent global T cell lymphopenia, with only 8 to 13 % of thymic naive CD31(+)CD45RA(+) cells among CD4 T cells (normal range 27-60 %). Proliferation assays and vaccine responses were within normal limits. The gastrointestinal inflammatory lesions were very closely related to those of glycogen storage disease type 1b, with a Crohn's-like appearance but without granuloma or increased cryptic abscesses. The gastrointestinal disease responded to infliximab therapy. These findings were associated with a polyclonal hypergammaglobuliemia G. CONCLUSION G6PC3 deficiency may present with inflammatory bowel disease and T cell lymphopenia. The diagnosis should thus be considered in a patient with chronic congenital neutropenia and gastrointestinal symptoms. Patients with confirmed disease should also undergo T cell phenotyping to rule out cellular immunodeficiency.
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Gennery AR. Immunological aspects of 22q11.2 deletion syndrome. Cell Mol Life Sci 2012; 69:17-27. [PMID: 21984609 PMCID: PMC11114664 DOI: 10.1007/s00018-011-0842-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 09/13/2011] [Accepted: 09/13/2011] [Indexed: 12/16/2022]
Abstract
Chromosome 22q11 deletion is the most common chromosomal deletion syndrome and is found in the majority of patients with DiGeorge syndrome and velo-cardio-facial syndrome. Patients with CHARGE syndrome may share similar features. Cardiac malformations, speech delay, and immunodeficiency are the most common manifestations. The immunological phenotype may vary widely between patients. Severe T lymphocyte immunodeficiency is rare-thymic transplantation offers a new approach to treatment, as well as insights into thymic physiology and central tolerance. Combined partial immunodeficiency is more common, leading to recurrent sinopulmonary infection in early childhood. Autoimmunity is an increasingly recognized complication. New insights into pathophysiology are reviewed.
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Affiliation(s)
- A R Gennery
- Institute of Cellular Medicine, Old Children's Outpatients, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK.
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Hirasaki S, Murakami K, Mizushima T, Ohmori K, Fujita S, Hanayama Y, Kanamori T, Yokota R, Ebara H, Kusano N, Kudo C, Yamaguchi T, Akagi T, Koide N. Successful treatment of sepsis caused by Staphylococcus lugdunensis in an adult with 22q11.2 deletion syndrome. Intern Med 2012; 51:377-80. [PMID: 22333372 DOI: 10.2169/internalmedicine.51.6257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 27-year-old woman visited our hospital because of high fever. She had been diagnosed as 22q11.2 deletion syndrome (22q11.2DS) due to her cardiac history (tetralogy of Fallot), thymic hypoplasia and 22q11.2 deletion. She had a normal CD4/CD8 ratio, a slightly decreased lymphocyte count and normal serum immunoglobulin levels. Blood cultures were positive for Staphylococcus lugdunensis (S. lugdunensis). Infection route of S. lugdunensis in this case was unclear. The patient was successfully treated with several intravenous antibiotics. Infection should be considered when managing patients with 22q.11.2DS. regardless of whether their immune system is impaired.
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Affiliation(s)
- Shoji Hirasaki
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan.
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Newborn screening for severe combined immunodeficiency; the Wisconsin experience (2008-2011). J Clin Immunol 2011; 32:82-8. [PMID: 22068910 DOI: 10.1007/s10875-011-9609-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 10/06/2011] [Indexed: 01/10/2023]
Abstract
Severe combined immunodeficiency is a life-threatening primary immune deficiency characterized by low numbers of naïve T cells. Early diagnosis and treatment of this disease decreases mortality. In 2008, Wisconsin began newborn screening of infants for severe combined immunodeficiency and other forms of T-cell lymphopenia by the T-cell receptor excision circle assay. In total, 207,696 infants were screened. Seventy-two infants had an abnormal assay. T-cell numbers were normal in 38 infants, abnormal in 33 infants, and not performed in one infant, giving a positive predictive value for T-cell lymphopenia of any cause of 45.83% and a specificity of 99.98%. Five infants with severe combined immunodeficiency/severe T-cell lymphopenia requiring hematopoietic stem cell transplantation or other therapy were detected. In summary, the T-cell receptor excision circle assay is a sensitive and specific test to identify infants with severe combined immunodeficiency and severe T-cell lymphopenia that leads to life-saving therapies such as hematopoietic stem cell transplantation prior to the acquisition of severe infections.
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Lima K, Abrahamsen TG, Foelling I, Natvig S, Ryder LP, Olaussen RW. Low thymic output in the 22q11.2 deletion syndrome measured by CCR9+CD45RA+ T cell counts and T cell receptor rearrangement excision circles. Clin Exp Immunol 2010; 161:98-107. [PMID: 20491792 DOI: 10.1111/j.1365-2249.2010.04152.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Thymic hypoplasia is a frequent feature of the 22q11.2 deletion syndrome, but we know little about patients' age-related thymic output and long-term consequences for their immune system. We measured the expression of T cell receptor rearrangement excision circles (TREC) and used flow cytometry for direct subtyping of recent thymic emigrant (RTE)-related T cells in 43 patients (aged 1-54 years; median 9 years) from all over Norway and in age-matched healthy controls. Thymic volumes were estimated by ultrasound in patients. TREC levels correlated well with RTE-related T cells defined by co-expression of CD3, CD45RA and CCR9 (r=0.84) as well as with the CD4+ and CD8+ T cell subtypes. RTE-related T cell counts also paralleled age-related TREC reductions. CD45RA+ T cells correlated well with absolute counts of CD4+ (r=0.87) and CD8+ (r=0.75) RTE-related T cells. Apart from CD45RA- T cells, all T cell subsets were lower in patients than in controls. Thymic volumes correlated better with RTE-related cells (r=0.46) than with TREC levels (r=0.38). RTE-related T cells and TREC levels also correlated well (r=0.88) in patients without an identifiable thymus. Production of RTEs is impaired in patients with a 22q11.2 deletion, and CCR9 appears to be a good marker for RTE-related T cells.
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Affiliation(s)
- K Lima
- Section of Endocrinology, Faculty Division Akershus University Hospital, University of Oslo, Oslo, Norway.
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