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Ragab I, Makkeyah S, Hassan N, Botros M, Da Costa L, Aly NH. Immunodeficiency in children with Diamond Blackfan and Diamond Blackfan like anemia. Blood Cells Mol Dis 2025; 111:102911. [PMID: 39923319 DOI: 10.1016/j.bcmd.2025.102911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2024] [Revised: 01/23/2025] [Accepted: 02/04/2025] [Indexed: 02/11/2025]
Abstract
BACKGROUND Diamond-Blackfan anemia Syndrome (DBAS) is a ribosomopathy with erythroid failure. DBA-like picture occurs with non-ribosomal mutation and a normal rRNA maturation. Immunodeficiency in patients with DBAS is not adequately studied. We aimed to study the frequency of infections and immunoglobulins levels in children with DBAS. METHODS Children and adolescents with DBAS were included. Infections were scored according to the immunodeficiency related score (IDR). Total serum immunoglobulin A (IgA), IgG and IgM were measured. Molecular studies were done to a group of patients. RESULTS Thirty-four patients had a median age at diagnosis of 3.6 month-old. Fourteen (41 %) patients had an IDR score of ≥6, and 4 of them (28.6 %) had low immunoglobulin levels. Patients with IDR score > 6 had significantly lower IgG (471 versus 1057 mg/dl, p = 0,032) and serum IgA (24 versus 98.5 mg/dl, p = 0.015) than IDR < 6 group. We report mortality in 8 (23.5 %) patients, two of them were related to infection. Molecular analyses were performed in 8 probands and 17 relatives (5 families); 7 of the probands carried CECR1/ADA2 gene mutation and one patient carried a pathogenic variant in RPL36 gene. CONCLUSION We highlight the presence of underlying immunodeficiency in a group of patients with DBA and DBA-like disease.
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Affiliation(s)
- Iman Ragab
- Pediatric Hematology and Oncology, Children's Hospital, Ain Shams University, Cairo, Egypt; IbnSina National College for Medical Studies, Jeddah, Saudi Arabia.
| | - Sara Makkeyah
- Pediatric Hematology and Oncology, Children's Hospital, Ain Shams University, Cairo, Egypt.
| | - Noura Hassan
- Pediatric Hematology and Oncology, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Michael Botros
- Pediatric Hematology and Oncology, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Lydie Da Costa
- Hematology Diagnostic Laboratory, Bicêtre Hospital, F-94270 Le Kremlin-Bicêtre, France; Paris-Saclay University; U1770 Inserm, Gustave Roussy institute, LABEX GR-Ex, Villejuif, France.
| | - Nihal Hussien Aly
- Pediatric Hematology and Oncology, Children's Hospital, Ain Shams University, Cairo, Egypt
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2
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Gutierrez MJ, Nino G, Sun D, Restrepo-Gualteros S, Sadreameli SC, Fiorino EK, Wu E, Vece T, Hagood JS, Maglione PJ, Kurland G, Koumbourlis A, Sullivan KE. The lung in inborn errors of immunity: From clinical disease patterns to molecular pathogenesis. J Allergy Clin Immunol 2022; 150:1314-1324. [PMID: 36244852 PMCID: PMC9826631 DOI: 10.1016/j.jaci.2022.08.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/17/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022]
Abstract
In addition to being a vital organ for gas exchange, the lung is a crucial immune organ continuously exposed to the external environment. Genetic defects that impair immune function, called inborn errors of immunity (IEI), often have lung disease as the initial and/or primary manifestation. Common types of lung disease seen in IEI include infectious complications and a diverse group of diffuse interstitial lung diseases. Although lung damage in IEI has been historically ascribed to recurrent infections, contributions from potentially targetable autoimmune and inflammatory pathways are now increasingly recognized. This article provides a practical guide to identifying the diverse pulmonary disease patterns in IEI based on lung imaging and respiratory manifestations, and integrates this clinical information with molecular mechanisms of disease and diagnostic assessments in IEI. We cover the entire IEI spectrum, including immunodeficiencies and immune dysregulation with monogenic autoimmunity and autoinflammation, as well as recently described IEI with pulmonary manifestations. Although the pulmonary manifestations of IEI are highly relevant for all age groups, special emphasis is placed on the pediatric population, because initial presentations often occur during childhood. We also highlight the pivotal role of genetic testing in the diagnosis of IEI involving the lungs and the critical need to develop multidisciplinary teams for the challenging evaluation of these rare but potentially life-threatening disorders.
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Affiliation(s)
- Maria J Gutierrez
- Division of Pediatric Allergy, Immunology and Rheumatology, Johns Hopkins University, Baltimore, Md.
| | - Gustavo Nino
- Division of Pediatric Pulmonary and Sleep Medicine, Children's National Hospital, Washington, DC; Department of Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Di Sun
- Division of Pediatric Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Sonia Restrepo-Gualteros
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia; Division of Pediatric Pulmonology, Fundacion Hospital La Misericordia, Bogotá, Colombia
| | - Sarah C Sadreameli
- Division of Pediatric Pulmonology and Sleep Medicine, Johns Hopkins University, Baltimore, Md
| | - Elizabeth K Fiorino
- Departments of Science Education and Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Eveline Wu
- Division of Pediatric Allergy, Immunology and Rheumatology, University of North Carolina, Chapel Hill, NC
| | - Timothy Vece
- Division of Pediatric Pulmonology, University of North Carolina, Chapel Hill, NC
| | - James S Hagood
- Division of Pediatric Pulmonology, University of North Carolina, Chapel Hill, NC
| | - Paul J Maglione
- Division of Allergy and Immunology, Boston University, Boston, Mass
| | - Geoffrey Kurland
- Division of Pediatric Pulmonology and Sleep Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Anastassios Koumbourlis
- Division of Pediatric Pulmonary and Sleep Medicine, Children's National Hospital, Washington, DC; Department of Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Kathleen E Sullivan
- Division of Pediatric Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pa
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3
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Artificial Intelligence in Clinical Immunology. Artif Intell Med 2022. [DOI: 10.1007/978-3-030-64573-1_83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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4
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Brock I, Prendergast W, Maitland A. Mast cell activation disease and immunoglobulin deficiency in patients with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorder. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2021; 187:473-481. [PMID: 34747107 DOI: 10.1002/ajmg.c.31940] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/16/2021] [Indexed: 12/17/2022]
Abstract
Mast cell activation disease (MCAD) includes single organ disease such as asthma, urticaria, and gastroenteritis, as well as multiorgan system involvement such as mast cell activation syndrome and anaphylaxis. Reports link MCAD with hypermobile Ehlers-Danlos syndrome (hEDS), hypermobility spectrum disorder (HSD), and with primary immune deficiencies such as complement and immunoglobulin deficiencies (Ig Def). This study assesses the concurrence of these syndromes. We undertook a cohort analysis of patients seen in a community-based Allergy/Immunology clinic from 2015 to 2019. We searched for diagnostic codes for Ig Def disorders, hypermobility syndrome, hypermobile/Ehlers-Danlos syndrome, and MCADs. Of 974 patients with suspected MCAD, 449 (46%) had a diagnosis of MCAD; 496 (51%) of cases had a combination of at least two of hEDS/HSD, MCAD, and Ig Def. Ig Def was present in 417 (43%) of patients; 188 (19.3%) had hEDS/HSD with an Ig Def with or without MCAD and accounted for 45% of all the cases with Ig Def. Of 974 cases, 101 (10%) had hEDS/HSD and MCAD; 207 (21%) had Ig Def and MCAD; 7 (0.7%) had Ig Def and hEDS/HSD; and 181 (19%) had a combination of all three syndromes. Most patients (74%) with these comorbidities were female. The presence of MCAD and Ig Def should be explored in patients with hEDS/HSD. Identifying underlying contributors to recurrent/chronic inflammation and tissue injury is needed to tailor and personalize therapies. This, in turn, can reduce tissue damage, iatrogenic intervention, and optimize health outcomes.
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Affiliation(s)
- Isabelle Brock
- Comprehensive Asthma and Allergy, Tarrytown, New York, USA.,Qolify, New York, New York, USA.,Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Anne Maitland
- Comprehensive Asthma and Allergy, Tarrytown, New York, USA.,Department of Neurology, Mount Sinai-South Nassau, Hewlett, New York, USA
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5
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Zama D, Conti F, Moratti M, Cantarini ME, Facchini E, Rivalta B, Rondelli R, Prete A, Ferrari S, Seri M, Pession A. Immune cytopenias as a continuum in inborn errors of immunity: An in-depth clinical and immunological exploration. IMMUNITY INFLAMMATION AND DISEASE 2021; 9:583-594. [PMID: 33838017 PMCID: PMC8127541 DOI: 10.1002/iid3.420] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/01/2021] [Accepted: 02/17/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Immune thrombocytopenia (ITP), autoimmune hemolytic anemia (AIHA), and autoimmune neutropenia (AIN) are disorders characterized by immune-mediated destruction of hematopoietic cell lineages. A link between pediatric immune cytopenias and inborn errors of immunity (IEI) was established in particular in the combined and chronic forms. OBJECTIVE Aim of this study is to provide clinical-immunological parameters to hematologists useful for a prompt identification of children with immune cytopenias deserving a deeper immunological and genetic evaluation. METHODS We retrospectively collected 47 pediatric patients with at least one hematological disorder among which persistent/chronic ITP, AIHA, and AIN, aged 0-18 years at onset of immune cytopenias and/or immune-dysregulation. The cohort was divided into two groups (IEI+ and IEI-), based on the presence/absence of underlying IEI diagnosis. IEI+ group, formed by 19/47 individuals, included: common variable immune deficiency (CVID; 9/19), autoimmune lymphoproliferative syndrome (ALPS; 4/19), DiGeorge syndrome (1/19), and unclassified IEI (5/19). RESULTS IEI prevalence among patients with ITP, AIHA, AIN, and Evans Syndrome was respectively of 42%, 64%, 36%, and 62%. In IEI+ group the extended immunophenotyping identified the presence of statistically significant (p < .05) specific characteristics, namely T/B lymphopenia, decrease in naїve T-cells%, switched memory B-cells%, plasmablasts%, and/or immunoglobulins, increase in effector/central memory T-cells% and CD21low B-cells%. Except for DiGeorge and three ALPS patients, only 2/9 CVID patients had a molecular diagnosis for IEI: one carrying the pathogenic variant CR2:c.826delT, the likely pathogenic variant PRF1:c.272C> and the compound heterozygous TNFRSF13B variants p.Ser144Ter (pathogenic) and p.Cys193Arg (variant of uncertain significance), the other one carrying the likely pathogenic monoallelic variant TNFRSF13B:p.Ile87Asn. CONCLUSION The synergy between hematologists and immunologists can improve and fasten diagnosis and management of patients with immune cytopenias through a wide focused clinical/immunophenotypical characterization, which identifies children worthy of IEI-related molecular analysis, favouring a genetic IEI diagnosis and potentially unveiling new targeted-gene variants responsible for IEI phenotype.
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Affiliation(s)
- Daniele Zama
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mattia Moratti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maria E Cantarini
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Elena Facchini
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Beatrice Rivalta
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Roberto Rondelli
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Arcangelo Prete
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Simona Ferrari
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Seri
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 522] [Impact Index Per Article: 130.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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7
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Artificial Intelligence in Clinical Immunology. Artif Intell Med 2021. [DOI: 10.1007/978-3-030-58080-3_83-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Toms K, Gkrania‐Klotsas E, Kumararatne D. Analysis of scoring systems for primary immunodeficiency diagnosis in adult immunology clinics. Clin Exp Immunol 2021; 203:47-54. [PMID: 32990325 PMCID: PMC7744492 DOI: 10.1111/cei.13526] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 11/29/2022] Open
Abstract
Failure to spot the signs of primary immunodeficiency (PID) often results in delayed diagnosis. Scoring systems to identify PID exist, such as the immunodeficiency disease-related (IDR) score. This research aims to analyse and improve the diagnostic sensitivity and specificity of the IDR scoring system in a small preselected group of adult patients referred to immunology with clinical suspicion of a PID. Records of all patients presenting for the first time to an adult immunology clinic in 2018 at Addenbrooke's Hospital, Cambridge, were scored using the unmodified IDR score and modified versions of it. Included records were searched for a subsequent diagnosis of PID, and the diagnostic sensitivity and specificity of the scoring systems were analysed. Of 400 patients, 213 were excluded: 141 due to secondary immunodeficiency, 69 due to no clinical suspicion of a PID, and hence no investigation for PID, and three due to ongoing diagnostic investigations. Of 187 included patients, 71 were found to have a clinically significant PID. The unmodified IDR score was useful in discriminating between those with and without PID. Modification of the scoring system with seven additional criteria improved the sensitivity and specificity for PID diagnosis to the greatest extent. A modified IDR score with seven additional criteria validated in adults referred to immunology with suspicion of a PID could be used clinically to aid PID diagnosis, although further validation in different patient cohorts is required before it is used in other contexts.
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Affiliation(s)
- K. Toms
- School of Clinical MedicineUniversity of CambridgeCambridgeUK
| | | | - D. Kumararatne
- Clinical ImmunologyCambridge University HospitalsCambridgeUK
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9
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Chen R. Primary Immunodeficiency. Rare Dis 2020. [DOI: 10.5772/intechopen.89624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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10
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Bush A, Floto RA. Pathophysiology, causes and genetics of paediatric and adult bronchiectasis. Respirology 2019; 24:1053-1062. [PMID: 30801930 DOI: 10.1111/resp.13509] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/16/2019] [Indexed: 02/06/2023]
Abstract
Bronchiectasis has historically been considered to be irreversible dilatation of the airways, but with modern imaging techniques it has been proposed that 'irreversible' be dropped from the definition. The upper limit of normal for the ratio of airway to arterial development increases with age, and a developmental perspective is essential. Bronchiectasis (and persistent bacterial bronchitis, PBB) is a descriptive term and not a diagnosis, and should be the start not the end of the patient's diagnostic journey. PBB, characterized by airway infection and neutrophilic inflammation but without significant airway dilatation may be a precursor of bronchiectasis, and there are many commonalities in the microbiology and the pathology, which are reviewed in this article. A high index of suspicion is essential, and a history of chronic wet or productive cough for more than 4-8 weeks should prompt investigation. There are numerous underlying causes of bronchiectasis, although in many cases no cause is found. Causes include post-infectious, especially after tuberculosis, adenoviral or pertussis infection; aspiration syndromes; defects in host defence, which may solely affect the airways (cystic fibrosis, not considered in this review, and primary ciliary dyskinesia); and primary ciliary dyskinesia or be systemic, such as common variable immunodeficiency; genetic syndromes; and anatomical defects such as intraluminal airway obstruction (e.g. foreign body), intramural obstruction (e.g. complete cartilage rings) and external airway compression (e.g. by tuberculous lymph nodes). Identification of the underlying cause is important, because some of these conditions have specific treatments and others genetic implications for the family.
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Affiliation(s)
- Andrew Bush
- Department of Paediatrics, Imperial College, London, UK.,Department of Paediatric Respirology, National Heart and Lung Institute, London, UK.,Royal Brompton Harefield NHS Foundation Trust, London, UK
| | - R Andres Floto
- Department of Respiratory Biology, University of Cambridge, Cambridge, UK.,Cambridge Centre for Lung Infection, Royal Papworth Hospital, Cambridge, UK
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12
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Primary Immune Deficiencies in the Adult: A Previously Underrecognized Common Condition. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 4:1101-1107. [PMID: 27836059 DOI: 10.1016/j.jaip.2016.09.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/01/2016] [Accepted: 09/09/2016] [Indexed: 12/21/2022]
Abstract
The large majority of classified primary immune deficiency (PID) diseases present in childhood. Yet, most patients with PID are adults, with a large proportion experiencing onset of symptoms beyond their childhood years. Most of these are diagnosed predominantly with antibody defects, but cellular and other disorders are increasingly being identified in older patients as well. Moreover, advances in clinical immunology are allowing pediatric patients, even those with severe disease, to reach adulthood. Because of differences in the physiology and pathophysiology of children and adults, the presentation, diagnosis, and management of a complex chronic disease could differ significantly between these patient populations and therefore require modifications in approach.
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13
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Halderman A, Lane AP. Genetic and Immune Dysregulation in Chronic Rhinosinusitis. Otolaryngol Clin North Am 2017; 50:13-28. [PMID: 27888910 DOI: 10.1016/j.otc.2016.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic rhinosinusitis (CRS) is a prevalent condition that is heterogeneous in disease characteristics and multifactorial in cause. Although sinonasal mucosal inflammation in CRS is often either reversible or well-managed medically and surgically, a significant proportion of patients has a refractory form of CRS despite maximal therapy. Two of the several described factors thought to contribute to disease recalcitrance are genetic influences and dysfunction of the host immune system. Current evidence for a genetic basis of CRS is reviewed, as it pertains to putative abnormalities in innate and adaptive immune function. The role of systemic immunodeficiencies in refractory CRS is discussed.
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Affiliation(s)
- Ashleigh Halderman
- Department of Otolaryngology - Head and Neck Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Andrew P Lane
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Outpatient Center, Johns Hopkins School of Medicine, 6th Floor, 601 North Caroline Street, Baltimore, MD 21287-0910, USA.
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14
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Abstract
PURPOSE OF REVIEW Diagnostic delay is a major problem for rare diseases including primary antibody deficiency (PAD). The aim of this review is to discuss the opportunities and challenges of current and future screening approaches for antibody deficiency, to reduce the delay and its impact on patients. (Figure is included in full-text article.) RECENT FINDINGS Diagnostic delay in PAD is known to result in increased morbidity, mortality, and permanent functional impairment. Approaches to prevent this have been only partially successful and the delay may still be many years as the clinical presentation of PAD is highly variable and may be at any age, making screening difficult. Patients often have numerous healthcare encounters generating repeated cycles of laboratory and clinical data before the diagnosis is made. Low immunoglobulin levels result in alterations in laboratory tests not directly aimed at measuring immunoglobulins. We describe these and highlight the growing evidence in support of using calculated globulin which is part of the liver function test profile as a screening tool for antibody deficiency. Additional approaches include using embedded algorithms to analyse data generated by repeated clinical encounters (e.g. infections, antibiotics, cytopenias), potentially in combination with laboratory results such as calculated globulin, to help bring forward the diagnosis of PAD in patients in whom this has not yet been considered. SUMMARY There is a strong case for the use of calculated globulin in screening for antibody deficiency. Further work is required to integrate laboratory results with clinical data to reduce diagnostic delay in patients with hitherto unsuspected antibody deficiency.
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15
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Mazza JM, Lin SY. Primary immunodeficiency and recalcitrant chronic sinusitis: a systematic review. Int Forum Allergy Rhinol 2016; 6:1029-1033. [PMID: 27187624 DOI: 10.1002/alr.21789] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 03/08/2016] [Accepted: 03/15/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND A subset of patients with chronic rhinosinusitis (CRS) has disease refractory to standard therapies. Primary immunodeficiency should be considered in this group. Past literature has demonstrated an association between immunodeficiency and chronic sinusitis. METHODS A systematic literature search was performed using OVID, MEDLINE, EMBASE, and Cochrane databases to identify English language papers containing original human data on subjects with primary immunodeficiency and chronic sinusitis. A total of 39 studies met inclusion criteria. Data was collected pertaining to immune dysfunction in patients with chronic sinusitis, the clinical workup for these patients, and the effectiveness of medical and surgical treatments. The studies were assessed to determine their level of evidence. RESULTS The majority of studies were supported by Level 4 evidence. Up to 50% of patients with recalcitrant CRS were found to have immune dysfunction. The most frequent primary immunodeficiencies studied were common variable immunodeficiency (CVID) and X-linked agammaglobulinemia (XLA). Common collected data included measurement of serum immunoglobulins and functional antibody responses. Treatments reviewed include immunoglobulin replacement, long-term antibiotics and endoscopic sinus surgery. CONCLUSION Patients with recalcitrant CRS should be evaluated for primary immunodeficiency. This should include as assessment of quantitative serum immunoglobulin levels as well as functional antibody responses. Medical therapy, particularly immunoglobulin replacement therapy, appears to be most effective when administered at high doses early in the disease course. The addition of surgery is less clearly supported, but may also provide benefit if performed early.
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Affiliation(s)
- Jill M Mazza
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Sandra Y Lin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM, Batra PS, Bernal-Sprekelsen M, Bhattacharyya N, Chandra RK, Chiu A, Citardi MJ, Cohen NA, DelGaudio J, Desrosiers M, Dhong HJ, Douglas R, Ferguson B, Fokkens WJ, Georgalas C, Goldberg A, Gosepath J, Hamilos DL, Han JK, Harvey R, Hellings P, Hopkins C, Jankowski R, Javer AR, Kern R, Kountakis S, Kowalski ML, Lane A, Lanza DC, Lebowitz R, Lee HM, Lin SY, Lund V, Luong A, Mann W, Marple BF, McMains KC, Metson R, Naclerio R, Nayak JV, Otori N, Palmer JN, Parikh SR, Passali D, Peters A, Piccirillo J, Poetker DM, Psaltis AJ, Ramadan HH, Ramakrishnan VR, Riechelmann H, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Senior BA, Sindwani R, Stankiewicz JA, Stewart M, Tan BK, Toskala E, Voegels R, Wang DY, Weitzel EK, Wise S, Woodworth BA, Wormald PJ, Wright ED, Zhou B, Kennedy DW. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2016; 6 Suppl 1:S22-209. [DOI: 10.1002/alr.21695] [Citation(s) in RCA: 333] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 02/06/2023]
Affiliation(s)
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- Royal National Throat Nose and Ear Hospital; London UK
| | - Amber Luong
- University of Texas Medical School at Houston
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Sathkumara HD, De Silva NR, Handunnetti S, De Silva AD. Genetics of common variable immunodeficiency: role of transmembrane activator and calcium modulator and cyclophilin ligand interactor. Int J Immunogenet 2015; 42:239-53. [DOI: 10.1111/iji.12217] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 04/27/2015] [Accepted: 05/25/2015] [Indexed: 12/25/2022]
Affiliation(s)
- H. D. Sathkumara
- Genetech Research Institute; Colombo Sri Lanka
- Institute of Biochemistry, Molecular Biology and Biotechnology; University of Colombo; Colombo Sri Lanka
| | | | - S. Handunnetti
- Institute of Biochemistry, Molecular Biology and Biotechnology; University of Colombo; Colombo Sri Lanka
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Doctors' awareness concerning primary immunodeficiencies in Brazil. Allergol Immunopathol (Madr) 2015; 43:272-8. [PMID: 25796303 DOI: 10.1016/j.aller.2014.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 09/25/2014] [Accepted: 09/30/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND PIDs are a heterogeneous group of genetic illnesses, and delay in their diagnosis is thought to be caused by a lack of awareness among physicians concerning PIDs. The latter is what we aimed to evaluate in Brazil. METHODS Physicians working at general hospitals all over the country were asked to complete a 14-item questionnaire. One of the questions described 25 clinical situations that could be associated with PIDs and a score was created based on percentages of appropriate answers. RESULTS A total of 4026 physicians participated in the study: 1628 paediatricians (40.4%), 1436 clinicians (35.7%), and 962 surgeons (23.9%). About 67% of the physicians had learned about PIDs in medical school or residency training, 84.6% evaluated patients who frequently took antibiotics, but only 40.3% of them participated in the immunological evaluation of these patients. Seventy-seven percent of the participating physicians were not familiar with the warning signs for PIDs. The mean score of correct answers for the 25 clinical situations was 48.08% (±16.06). Only 18.3% of the paediatricians, 7.4% of the clinicians, and 5.8% of the surgeons answered at least 2/3 of these situations appropriately. CONCLUSIONS There is a lack of medical awareness concerning PIDs, even among paediatricians, who have been targeted with PID educational programmes in recent years in Brazil. An increase in awareness with regard to these disorders within the medical community is an important step towards improving recognition and treatment of PIDs.
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Dantas EDO, Aranda CS, Nobre FA, Fahl K, Mazzucchelli JTL, Felix E, Friedlander-Del Nero DL, Nudelman V, Sano F, Condino-Neto A, Damasceno E, Costa-Carvalho BT. Medical awareness concerning primary immunodeficiency diseases in the city of São Paulo, Brazil. EINSTEIN-SAO PAULO 2014; 11:479-85. [PMID: 24488388 PMCID: PMC4880386 DOI: 10.1590/s1679-45082013000400013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 11/07/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate medical knowledge of primary immunodeficiency in the city of São Paulo (SP). METHODS A 14-item questionnaire about primary immunodeficiency was applied to physicians who worked at general hospitals. One of the questions presented 25 clinical situations that could be associated or not with primary immunodeficiency, and the percentage of appropriate answers generated a knowledge indicator. RESULTS Seven hundred and forty-six participated in the study, among them 215 pediatricians (28.8%), 244 surgeons (32.7%), and 287 clinicians (38.5%). About 70% of the physicians responded that they had learned about primary immunodeficiency in graduate school or in residency training. Treatment of patients that use antibiotics frequently was reported by 75% dos physicians, but only 34.1% had already investigated a patient and 77.8% said they did not know the ten warning signs for primary immunodeficiency. The knowledge indicator obtained showed a mean of 45.72% (±17.87). Only 26.6% if the pediatricians and 6.6% of clinicians and surgeons showed a knowledge indicator of at least 67% (equivalent to an appropriate answer in two thirds of the clinical situations). CONCLUSION There is a deficit in medical knowledge of primary immunodeficiency in the city of São Paulo, even among pediatricians, despite having greater contact with the theme over the last few years. The improvement of information on primary immunodeficiency in the medical community is an important step towards the diagnosis and treatment process of these diseases.
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Kobrynski L, Powell RW, Bowen S. Prevalence and morbidity of primary immunodeficiency diseases, United States 2001-2007. J Clin Immunol 2014; 34:954-61. [PMID: 25257253 DOI: 10.1007/s10875-014-0102-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 09/17/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE Few studies have estimated population prevalence and morbidity of primary immunodeficiency diseases (PIDD). We used administrative healthcare databases to estimate the prevalence of PIDD diagnoses in the United States from 2001 to 2007. METHODS MarketScan databases compile claims from commercial health insurance plans and Medicaid, recording individual diagnoses for outpatient encounters and hospital stays. We used a cross sectional survey to estimate prevalence of PIDD using related ICD-9 codes (279.0, 279.1, 279.2, 279.8, 279.9, 288.1 and 288.2). Persons with secondary immunodeficiency diagnoses were excluded from analysis. RESULTS Between 2001 and 2007, prevalence of any PIDD diagnosis increased from 38.9 to 50.5 per 100,000 among privately insured and from 29.1 to 41.1 per 100,000 among publicly insured persons. B cell defects predominated. Prevalence was more than twice as high among Whites as among Blacks or Hispanics. CONCLUSION In this large database, we found a higher prevalence of diagnosed PIDD than has been reported previously from registries. Increased awareness may have contributed to the increasing prevalence.
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Affiliation(s)
- Lisa Kobrynski
- Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Dr., Atlanta, GA, 30322, USA,
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21
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Ryan MW. AAOA allergy primer: immunodeficiency. Int Forum Allergy Rhinol 2014; 4 Suppl 2:S74-8. [DOI: 10.1002/alr.21379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 07/01/2014] [Accepted: 07/02/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Matthew W. Ryan
- Department of Otolaryngology; University of Texas Southwestern Medical Center; Dallas TX
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Aldırmaz S, Yücel E, Kıykım A, Çokuğraş H, Akçakaya N, Camcıoğlu Y. Profile of the patients who present to immunology outpatient clinics because of frequent infections. TURK PEDIATRI ARSIVI 2014; 49:210-6. [PMID: 26078665 PMCID: PMC4462295 DOI: 10.5152/tpa.2014.1810] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 04/17/2014] [Indexed: 11/22/2022]
Abstract
AIM We aimed to determine the rate of primary immune deficiency (PID) among children presenting to our immunology outpatient clinic with a history of frequent infections and with warning signs of primary immune deficiency. MATERIAL AND METHODS The files of 232 children aged between 1 and 18 years with warning signs of primary immune deficiency who were referred to our pediatric immunology outpatient clinic with a complaint of frequent infections were selected and evaluated retrospectively. RESULTS Thirty-six percent of the subjects were female (n=84) and 64% were male (n=148). PID was found in 72.4% (n=164). The most common diagnosis was selective IgA deficiency (26.3%, n=61). The most common diseases other than primary immune deficiency included reactive airway disease and/or atopy (34.4%, n=22), adenoid vegetation (12.3%, n=8), chronic disease (6.3%, n=4) and periodic fever, aphtous stomatitis and adenopathy (4.6%, n=3). The majortiy of the subjects (90.5%, n=210) presented with a complaint of recurrent upper respiratory tract infection. PID was found in all subjects who had bronchiectasis. The rates of the diagnoses of variable immune deficiency and Bruton agammaglubulinemia (XLA) were found to be significantly higher in the subjects who had lower respiratory tract infection, who were hospitalized because of infection and who had a history of severe infection compared to the subjects who did not have these properties (p<0.05 and p<0.01, respectively). Growth and developmental failure was found with a significantly higher rate in the patients who had a diagnosis of severe combined immune deficiency or hyper IgM compared to the other subjects (p<0.01). No difference was found in the rates of PID between the age groups, but the diagnosis of XLA increased as the age of presentation increased and this was considered an indicator which showed that patients with XLA were being diagnosed in a late period. CONCLUSIONS It was found that the rate of diagnosis was considerably high (72.4%), when the subjects who had frequent infections were selected by the warning signs of PID.
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Affiliation(s)
- Sonay Aldırmaz
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Esra Yücel
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Ayça Kıykım
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Marmara University Faculty of Medicine, İstanbul, Turkey
| | - Haluk Çokuğraş
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Necla Akçakaya
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Yıldız Camcıoğlu
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
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Primary Immunodeficiency May Be Misdiagnosed as Cow's Milk Allergy: Seven Cases Referred to a Tertiary Pediatric Hospital. ISRN PEDIATRICS 2013; 2013:470286. [PMID: 24198970 PMCID: PMC3806379 DOI: 10.1155/2013/470286] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 08/27/2013] [Indexed: 12/12/2022]
Abstract
Introduction. The presence of eczema and gastrointestinal manifestations are often observed in cow's milk allergy (CMA) and also in some primary immunodeficiency diseases (PID). Objective. To describe 7 patients referred to a tertiary allergy/immunology Center with a proposed diagnosis of CMA, who were ultimately diagnosed with PID. Methods. This was a retrospective study based on clinical and laboratory data from medical records. Results. Seven patients (6 males) aged between 3 mo and 6 y were referred to our clinic with a proposed diagnosis of CMA. They presented with eczema and/or gastrointestinal symptoms. Five were receiving replacement formula. All patients presented with other clinical features, including severe/recurrent infections unrelated to CMA, and two of them had a positive family history of PID. Laboratory tests showed immune system dysfunctions in all patients. Hyper-IgE and Wiskott-Aldrich syndromes, CD40L deficiency, severe combined immunodeficiency, X-linked agammaglobulinemia, transient hypogammaglobulinemia of infancy, and chronic granulomatous disease were diagnosed in these children. In conclusion, allergic diseases and immunodeficiency are a result of a different spectrum of abnormalities in the immune system and may be misdiagnosed. Educational programs on PID among clinical physicians and pediatricians can reduce the occurrence of this misdiagnosis.
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Resnick ES, Bhatt P, Sidi P, Cunningham-Rundles C. Examining the use of ICD-9 diagnosis codes for primary immune deficiency diseases in New York State. J Clin Immunol 2013; 33:40-8. [PMID: 22941512 PMCID: PMC3690548 DOI: 10.1007/s10875-012-9773-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 08/14/2012] [Indexed: 01/04/2023]
Abstract
PURPOSE To use International Classification of Disease Codes (ICD-9) codes to investigate primary immune deficiency (PID) in New York State. METHODS We investigated the diagnosis of Primary Immune Deficiency (PID) in New York State (NYS) using the Statewide Planning and Research Cooperative System (SPARCS) database, a comprehensive data reporting system that collects ICD-9 codes for each patient hospitalized in NYS. RESULTS From 2000-2004 there were 13,539,358 hospitalizations for 4,777,295 patients; of these, 2,361 patients (0.05 %) were diagnosed with one or more of the ICD-9 codes for PID. Antibody defects were the most common diagnoses made. The PID population had significantly more Caucasians, and fewer African American or Hispanic subjects compared to the general population. Subjects with PID codes were younger, had longer hospitalizations, were less likely to have Medicare and more likely to have Medicaid or Blue Cross insurance. Most hospitalizations were due to respiratory and infectious diseases. Most patients resided in the most populous counties, Kings, New York and Queens, but the distribution of home zip codes was not proportional to county populations. CONCLUSIONS These data provide useful information on incidence and complications of selected PID diagnoses in one large state.
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Affiliation(s)
- Elena S Resnick
- Mount Sinai School of Medicine, Immunology Institute, New York, NY 10029, USA.
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Reda SM, El-Ghoneimy DH, Afifi HM. Clinical predictors of primary immunodeficiency diseases in children. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2012; 5:88-95. [PMID: 23450209 PMCID: PMC3579097 DOI: 10.4168/aair.2013.5.2.88] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 07/09/2012] [Accepted: 07/23/2012] [Indexed: 12/22/2022]
Abstract
Purpose To promote awareness of primary immunodeficiency (PID), the "10 warning signs" of PID and an immunodeficiency-related (IDR) score were developed. However, their efficiency in identifying PID cases was not sufficiently evaluated in clinical practice. The objective of this study was to test the validity of the 10 warning signs and IDR score in identifying PID among children with recurrent infections at a tertiary pediatric hospital in Egypt. Methods A retrospective analysis of the medical records of 204 patients was performed. Of these patients, 92 had defined PID diseases and 112 were considered non-PID cases because investigations were inconclusive. Results Demonstrating two warning signs and an IDR score of 6 led to sensitivities of 94 and 66%, respectively, and specificities of 64 and 75%, respectively, in identifying PID cases. The strongest predictor of PID was family history that, if combined with the need for intravenous antibiotics, recurrent deep-seated infections, and failure to thrive, could identify 81% of PID patients. A family history of PID, sibling death, and/or parental consanguinity would predict 92% of combined immunodeficiencies, 92% of phagocyte defects, 87% of well-identified immunodeficiency syndromes, and 84% of antibody deficiency if the need for intravenous antibiotics is considered in the latter. Conclusions The 10 warning signs and IDR score do not aid in an early diagnosis of severe PID. Educational campaigns should target pediatricians aiming to increase PID awareness and to address family history of PID, parental consanguinity, and previous sibling death as key predictors of PID in communities with a high prevalence of consanguineous marriages.
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Affiliation(s)
- Shereen M Reda
- Department of Pediatric Allergy and Immunology, Children's Hospital, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Srinivasa BT, Alizadehfar R, Desrosiers M, Shuster J, Pai NP, Tsoukas CM. Adult primary immune deficiency: what are we missing? Am J Med 2012; 125:779-86. [PMID: 22682795 DOI: 10.1016/j.amjmed.2012.02.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 01/31/2012] [Accepted: 02/03/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND More than 200 primary immune deficiencies have been described. In adults, their identification can be difficult. The lack of timely referrals, diagnostic facilities, and available expertise often delay appropriate treatment. Because an increasing number of adults are now diagnosed with immune deficiencies, there is a need to better understand the immune deficits in this age group. The study objective was to analyze the diagnostic spectrum of adults with primary immune deficiency and to determine the presumptive diagnostic accuracy of the referring physicians. METHODS We conducted a retrospective chart review over a 10-year period of all individuals referred to a dedicated center for adults with primary immune deficiency. Suspected cases were confirmed using standard clinical criteria and state of the art immune assays. RESULTS Of the 381 individuals studied, 244 were diagnosed as immune deficient. Of these, 210 had primary immune deficiency classified as novel, defined, and undefined. Forty-three patients had a prior diagnosis and were referred for follow-up care, and 201 patients were newly diagnosed. Most patients had common variable immune deficiency. Despite an apparent high index of suspicion in initiating the referrals, only one third of these patients had a prior quantitative assessment of serum immunoglobulins. CONCLUSIONS In this first known analysis of a large cohort of adults with suspected immune deficiency using established diagnostic criteria, we confirmed the diagnosis in two thirds of all patients. Our findings highlight the wide spectrum of primary immune deficiency states seen in adult medical practices and the need for increased awareness of their existence.
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Affiliation(s)
- Bharat T Srinivasa
- Division of Allergy and Clinical Immunology, McGill University Health Centre, Montreal, Quebec, Canada
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MacGinnitie A, Aloi F, Mishra S. Clinical characteristics of pediatric patients evaluated for primary immunodeficiency. Pediatr Allergy Immunol 2011; 22:671-675. [PMID: 21449988 DOI: 10.1111/j.1399-3038.2011.01167.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE When to evaluate a child for possible immune deficiency is a challenge, as many children have frequent infections for which they are treated with antibiotics. We aimed to describe the clinical characteristics of children evaluated for possible primary immunodeficiency in a specialist clinic. We specifically aimed to evaluate widely promulgated 'warning signs of primary immunodeficiency' and to evaluate the relationship between primary immunodeficiency and atopy. METHODS A retrospective analysis of 141 children who underwent testing for possible primary immunodeficiency was undertaken. RESULTS Thirty-two (23%) children were diagnosed with an underlying primary immunodeficiency, and published warning signs were neither sensitive nor specific for primary immunodeficiency. Patients with allergy as determined by the presence of antigen-specific IgE were more likely to be diagnosed with immunodeficiency. CONCLUSIONS Widely promulgated warning signs did not distinguish between patients with and without primary immunodeficiency. Likewise, primary immunodeficiency and allergy may coexist.
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Affiliation(s)
- Andrew MacGinnitie
- Division of Pulmonary Medicine, Allergy and Immunology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA. Andrew.MacGinnitie@Childrens
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Merritt TH, Segreti J. The Role of the Infectious Disease Specialist in the Diagnosis and Treatment of Primary Immunodeficiency Disease. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2011. [DOI: 10.1097/ipc.0b013e318214b068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Wasserman RL, Manning SC. Diagnosis and treatment of primary immunodeficiency disease: the role of the otolaryngologist. Am J Otolaryngol 2011; 32:329-37. [PMID: 20724030 DOI: 10.1016/j.amjoto.2010.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Accepted: 05/10/2010] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The objective of the study was to review the diagnosis and treatment of primary immunodeficiency disease (PID) and the role of otolaryngologists in the management of PID. METHODS A search was conducted of PubMed and the Web sites of organizations for PID patients for literature pertaining to the diagnosis and treatment of PID, with an emphasis on the role of otolaryngologists. The reference lists of selected articles were reviewed for additional articles. RESULTS Patients with PID commonly present with respiratory tract infections (eg, recurrent ear, nose, or throat infections) and chest disease. Diagnostic delays or inadequate treatment of PID may lead to significant morbidity and premature mortality. Immunoglobulin (Ig) replacement is the cornerstone of therapy for most patients with PID. Although intravenous Ig is the most popular route of administration in the United States, subcutaneous Ig administration may be appropriate for patients with poor venous access, those who are unable to tolerate intravenous Ig, or those who prefer the independence and flexibility of self-administration. CONCLUSIONS Recognition and diagnosis of PID by otolaryngologists are critical to optimizing patient outcomes. Several therapeutic regimens for Ig replacement are now available that offer patients increased flexibility and independence.
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Infektanfälligkeit. Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-010-2330-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Leiva LE, Bezrodnik L, Oleastro M, Condino-Neto A, Costa-Carvalho BT, Grumach AS, Espinosa-Rosales FJ, Franco JL, King A, Inostroza J, Quezada A, Porras O, Sorensen RU. Primary immunodeficiency diseases in Latin America: proceedings of the Second Latin American Society for Immunodeficiencies (LASID) Advisory Board. Allergol Immunopathol (Madr) 2011; 39:106-10. [PMID: 21345576 DOI: 10.1016/j.aller.2010.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 10/26/2010] [Indexed: 11/28/2022]
Abstract
Early diagnosis and appropriate therapy are essential for the best prognosis and quality of life in patients with primary immunodeficiency diseases (PIDDs). Experts from several Latin American countries have been meeting on a regular basis as part of an ongoing effort to improve the diagnosis and treatment of PIDD in this region. Three programmes are in development that will expand education and training and improve access to testing facilities throughout Latin America. These programmes are: an educational outreach programme (The L-Project); an immunology fellowship programme; and the establishment of a laboratory network to expand access to testing facilities. This report provides the status of these programmes based on the most recent discussions and describes the next steps toward full implementation of these programmes.
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Affiliation(s)
- L E Leiva
- Department of Pediatrics, LSU Health Sciences Center, New Orleans, LA, USA
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Kobrynski LJ, Mayer L. Diagnosis and treatment of primary immunodeficiency disease in patients with gastrointestinal symptoms. Clin Immunol 2011; 139:238-48. [PMID: 21489888 DOI: 10.1016/j.clim.2011.01.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Revised: 01/18/2011] [Accepted: 01/19/2011] [Indexed: 12/12/2022]
Abstract
An estimated 250,000 individuals in the Unites States have been diagnosed with a primary immunodeficiency disease (PIDD). Early diagnosis and treatment of PIDD are critical to minimizing morbidity and improving quality of life. Patients with certain subtypes of PIDD may present with gastrointestinal complaints such as chronic or acute diarrhea, malabsorption, gastrointestinal pain, and inflammatory bowel diseases. Therefore, gastroenterologists are well positioned to help identify patients with PIDD. The hallmarks of PIDD include recurrent or persistent infections, infections due to microorganisms that rarely cause significant disease in immunocompetent people, unusually severe or life-threatening infections, and either low or persistently high white blood cell counts. An assessment for PIDD involves detailed patient and family histories, a physical examination, and diagnostic screening tests. Immunoglobulin replacement therapy is the cornerstone of treatment for most subtypes of PIDD.
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Affiliation(s)
- L J Kobrynski
- Division of Pulmonary, Allergy/Immunology, Cystic Fibrosis and Sleep Apnea, Emory Children's Center, Atlanta, GA, USA.
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Aghamohammadi A, Bahrami A, Mamishi S, Mohammadi B, Abolhassani H, Parvaneh N, Rezaei N. Impact of delayed diagnosis in children with primary antibody deficiencies. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2011; 44:229-34. [PMID: 21524619 DOI: 10.1016/j.jmii.2011.01.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Revised: 06/10/2010] [Accepted: 08/04/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Primary antibody deficiencies (PADs) are heterogeneous group of disorders, characterized by hypogammaglobulinemia and increased susceptibility to recurrent infections. To evaluate the diagnostic delay in Iranian PADs in association with their infections, we scored such manifestations to find an association between such delay and the scoring system. METHODS Forty-eight patients with PADs, who were referred to our center during a 25-year period, were enrolled in this study. Each episode of infection, before making the PADs diagnosis, got a score of 5 or 10 based on the severity of infections. RESULTS The diagnosis was made with median delay of 34.5 months, when the patients had mean score of 94.48 ± 52.89. There was a significant direct association between this scoring system and delay diagnosis. The score of 50 was considered as the cutoff point in our patient group. In this score, the suspicions to PADs in more than 90% of patients true positively lead to diagnosis of PADs. CONCLUSION Although diagnosis delay significantly decreased over time, PADs still continue to be diagnosed late. Based on the results of this study, the assessment of immune system should be performed in the patients with 50 total score or about 25 score per year.
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Affiliation(s)
- Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
Primary immune deficiency diseases (PIDs) are a heterogeneous group of inherited diseases characterized by variable genetic immune defects, conferring susceptibility to recurrent infections. They have a vast array of manifestations some of which involve the gastrointestinal and hepatobiliary systems. These complications can be the consequence of five different factors, namely, infection, autoimmune process, unregulated inflammation, malignancies and complications of therapeutic intervention. They may precede the PID diagnosis and, once developed, they pose high risk of morbidity. Untrained clinicians may treat these manifestations only at the level of their presentation, leaving the PIDs dangerously undiagnosed. In fact, early diagnosis of PIDs and accompanied gastrointestinal and hepatic complications clearly require appropriate treatment, and in-turn lead to an improved quality of life for the patient. To improve the awareness of gastroenterologists and related health care providers about these diseases, we have reviewed herein the complications of different PIDs focusing on gastrointestinal and hepatic manifestation.
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Affiliation(s)
- Saleh Z. Al-Muhsen
- Prince Naif Center for Immunology Research, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Address for correspondence: Dr. Saleh Z. Al-Muhsen, Department of Pediatrics, King Khaled University Hospital, King Saud University, King Faisal Specialist Hospital and Research Center, P.O. Box 2925, Riyadh 11461, Saudi Arabia. E-mail:
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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: 2.0] [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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Llobet MP, Soler-Palacin P, Detkova D, Hernández M, Caragol I, Espanol T. Common variable immunodeficiency: 20-yr experience at a single centre. Pediatr Allergy Immunol 2009; 20:113-8. [PMID: 18798799 DOI: 10.1111/j.1399-3038.2008.00744.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency. It can present at any age in patients with a history of recurrent bacterial infections, with or without a family history of other primary immunodeficiencies (PID), and shows a wide range of clinical manifestations and immunological data. Diagnosis is based on low IgG, IgM and/or IgA levels. Delayed diagnosis and therapy can lead to bronchiectasis and malabsorption. The aim of this study was to describe a paediatric population diagnosed of CVID and its evolution in the population. Memory B-cell (MB) classification carried out in these patients was correlated with clinical manifestations and outcome. Clinical and immunological data of 22 CVID children under 18 yr treated at our centre between 1985 and 2005 are presented. Immunological studies included those for diagnosis and MB quantification. Differences in form of presentation, familial incidence and MB classification were reviewed. A statistical descriptive analysis was made. Infections were the commonest manifestation, affecting mainly respiratory (19/22) and gastrointestinal (10/22) tracts. Bronchiectasis was present in seven cases, and detected prior to CVID diagnosis in five. Replacement therapy led to a significant reduction in the number of infections. Severe complications appeared mostly in patients without MB. Patients of the same family share the same MB group. Family members had also been diagnosed of CVID in seven cases. Early diagnosis and therapy are essential to improve outcome in these patients. MB studies are useful in children to orient prognosis and further genetic studies.
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Affiliation(s)
- M Pilar Llobet
- Paediatric Immunodeficiencies and Immunology Units, Vall d'Hebron Hospital, Barcelona, Spain.
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Wilson NW, Hogan MB. Otitis media as a presenting complaint in childhood immunodeficiency diseases. Curr Allergy Asthma Rep 2008; 8:519-24. [PMID: 18940144 DOI: 10.1007/s11882-008-0095-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Otitis media is one of the most common childhood infections and may result from a variety of underlying problems. Suspicion of immunodeficiency should increase when ear infections are frequent; suppurative; unresponsive to antibiotics; caused by unusual organisms; or seen in the context of other frequent infections, severe eczema, or failure to thrive. Humoral immune deficiencies, particularly with an inability to make antibody to encapsulated organisms, are the immunodeficiencies most likely to cause increased otitis media. Immune system evaluation should concentrate on humoral immunodeficiency disorders, but the presenting history and physical findings also should be considered when designing the work-up. Treating the underlying immune deficiency is usually necessary to adequately control the ear infections.
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Affiliation(s)
- Nevin W Wilson
- Department of Pediatrics, Section of Allergy, Immunology, and Pulmonology, University of Nevada School of Medicine, 343 Elm Street, Suite 201, Reno, NV 89503, USA.
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Reda SM, Afifi HM, Amine MM. Primary Immunodeficiency Diseases in Egyptian Children: A Single-Center Study. J Clin Immunol 2008; 29:343-51. [DOI: 10.1007/s10875-008-9260-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2008] [Accepted: 10/20/2008] [Indexed: 10/21/2022]
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Abstract
OBJECTIVE To report various primary immune deficiencies diagnosed in children at a tertiary care hospital, their clinical manifestations and laboratory profile. METHODS Case records of children diagnosed to have primary immunodeficiency disorders over a period of 24 months at a tertiary care hospital in northern India were evaluated. RESULTS Twenty-seven children (M: F=3.5: 1) with mean age of 5.4 +/- 4.6 yrs (2 mo-16 yr) were diagnosed to have primary immunodeficiency. Thirteen children had chronic granulomatous disease (CGD), 4 had severe combined immunodeficiency (SCID), 4 had hypogammaglobulinemia, 2 had Ataxia telangiectasia, and one each had DiGeorge syndrome, Wiskott Aldrich syndrome, hyper IgM syndrome and leukocyte adhesion defect. Common mode of presentation were recurrent/ persistent pneumonia in 19, recurrent/ persistent diarrhea in 10, deep seated abscesses in 8, allergy in 3, disseminated tuberculosis infection in 2, extensive fungal infections in 2 and 1 each of disseminated cytomegalovirus (CMV) infection, disseminated BCG disease, otitis media and meningitis. Family history of sibling deaths was elicited in 2 families. Infectious agents were isolated in 16 cases. CONCLUSION From a single center 27 patients with primary immune deficiency could be identified by chart review, suggesting need for high index of suspicion for diagnosis of primary immune deficiency in India. Though the exact prevalence is not known there is need to make a registry to document the magnitude of problem of these disorders.
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Mehra A, Sidi P, Doucette J, Estrella L, Rouvelas H, Cunningham-Rundles C. Subspecialty evaluation of chronically ill hospitalized patients with suspected immune defects. Ann Allergy Asthma Immunol 2007; 99:143-50. [PMID: 17718102 DOI: 10.1016/s1081-1206(10)60638-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The diagnosis of primary immunodeficiency is suggested by recurrent or unusual infections and inflammatory and autoimmune conditions. Because the diversity of immune defects and clinical presentations poses a diagnostic challenge in hospital populations, a computer algorithm was devised to help identify patients. OBJECTIVE To assess use of pertinent subspecialty clinics by patients with clinical features of immunodeficiency. METHODS Using a validated algorithm based on International Classification of Diseases, Ninth Revision (ICD-9), codes applied to The Mount Sinai Hospital billing records, we investigated hospitalized patients, 60 years or younger, who had been diagnosed as having conditions associated with immunodeficiency, excluding those with confounding medical conditions. Immunodeficiency-related disease codes were given a weighted score based on relative severity and expressed as a sum for admissions between January 1, 1999, and December 31, 2003. Demographic features, subspecialty care, and clinic attendance were determined. RESULTS The 296 computer-identified patients with illnesses characteristic of immunodeficiency were 35.8% Hispanic, 27.0% African American, and 21.6% white; their median age was 13.3 years. Patients were hospitalized 1,261 times, or a median of 4.2 times each (range, 1-42 times), and had 5,700 diagnoses. Of the patients, 75.0% received primary care at The Mount Sinai Hospital. Although the most common diagnosis was pneumonia (n = 243), 45% of patients never received allergy/immunology or pulmonary subspecialty care. CONCLUSION Despite receiving primary medical care at the same hospital, many frequently hospitalized subjects with features of immunodeficiency do not receive medical care in appropriate subspecialty clinics.
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Affiliation(s)
- Ami Mehra
- Department of Medicine, The Mount Sinai Medical Center, New York City, New York, USA
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Estrella L, Foley ME, Cunningham-Rundles C. X-linked agammaglobulinemia in a 10-year-old child: a case study. ACTA ACUST UNITED AC 2007; 19:205-11. [PMID: 17430541 DOI: 10.1111/j.1745-7599.2007.00213.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To discuss the advanced practice nurse's diagnosis and management of an unsuspected primary immunodeficiency (PI) disease, X-linked agammaglobulinemia (XLA), in a child. DATA SOURCES Review of historical and current scientific literature, practice guidelines, and a case study. CONCLUSIONS While a diagnosis of XLA is most commonly made in the first 3 years of life, this case study presents a 10-year-old boy's circuitous route to this diagnosis. A diagnosis of an immune defect should be considered for patients with chronic, recurrent, or unusual infections. For patients who lack immune globulins and antibodies, intravenous immune globulin, given monthly and continued throughout life, is the standard of care. IMPLICATIONS FOR PRACTICE Diagnosis of children and adults with primary immune deficiency diseases may be delayed if practitioners fail to find the root cause of recurrent infections. Nurses as patient advocates should recognize the need for a referral in clinical cases where immunodeficiency may not be suspected. Evaluation of the immune system is performed by a panel of blood tests. There is a need to increase awareness of PI, their manifestations, and treatment among nurses both at the bedside and in advanced practice settings.
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Affiliation(s)
- Lissette Estrella
- Division of Clinical Immunology, Mount Sinai School of Medicine, New York, New York 10029-6574, USA.
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