1
|
Chen R, Lukianova E, van der Loeff IS, Spegarova JS, Willet JDP, James KD, Ryder EJ, Griffin H, IJspeert H, Gajbhiye A, Lamoliatte F, Marin-Rubio JL, Woodbine L, Lemos H, Swan DJ, Pintar V, Sayes K, Ruiz-Morales ER, Eastham S, Dixon D, Prete M, Prigmore E, Jeggo P, Boyes J, Mellor A, Huang L, van der Burg M, Engelhardt KR, Stray-Pedersen A, Erichsen HC, Gennery AR, Trost M, Adams DJ, Anderson G, Lorenc A, Trynka G, Hambleton S. NUDCD3 deficiency disrupts V(D)J recombination to cause SCID and Omenn syndrome. Sci Immunol 2024; 9:eade5705. [PMID: 38787962 DOI: 10.1126/sciimmunol.ade5705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 04/24/2024] [Indexed: 05/26/2024]
Abstract
Inborn errors of T cell development present a pediatric emergency in which timely curative therapy is informed by molecular diagnosis. In 11 affected patients across four consanguineous kindreds, we detected homozygosity for a single deleterious missense variant in the gene NudC domain-containing 3 (NUDCD3). Two infants had severe combined immunodeficiency with the complete absence of T and B cells (T -B- SCID), whereas nine showed classical features of Omenn syndrome (OS). Restricted antigen receptor gene usage by residual T lymphocytes suggested impaired V(D)J recombination. Patient cells showed reduced expression of NUDCD3 protein and diminished ability to support RAG-mediated recombination in vitro, which was associated with pathologic sequestration of RAG1 in the nucleoli. Although impaired V(D)J recombination in a mouse model bearing the homologous variant led to milder immunologic abnormalities, NUDCD3 is absolutely required for healthy T and B cell development in humans.
Collapse
Affiliation(s)
- Rui Chen
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - Elena Lukianova
- Wellcome Sanger Institute, Wellcome Genome Campus, CB10 1SA Hinxton, UK
| | - Ina Schim van der Loeff
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, NE1 4LP Newcastle upon Tyne, UK
| | | | - Joseph D P Willet
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - Kieran D James
- Institute of Immunology and Immunotherapy, University of Birmingham. B15 2TT Birmingham, UK
| | - Edward J Ryder
- Wellcome Sanger Institute, Wellcome Genome Campus, CB10 1SA Hinxton, UK
| | - Helen Griffin
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - Hanna IJspeert
- Department of Immunology, Erasmus University Medical Center, Rotterdam 3000 CA, Netherlands
| | - Akshada Gajbhiye
- Biosciences Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - Frederic Lamoliatte
- Biosciences Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - Jose L Marin-Rubio
- Biosciences Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - Lisa Woodbine
- Genome Damage and Stability Centre, University of Sussex, BN1 9RQ Brighton, UK
| | - Henrique Lemos
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - David J Swan
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - Valeria Pintar
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - Kamal Sayes
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | | | - Simon Eastham
- Wellcome Sanger Institute, Wellcome Genome Campus, CB10 1SA Hinxton, UK
| | - David Dixon
- Biosciences Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - Martin Prete
- Wellcome Sanger Institute, Wellcome Genome Campus, CB10 1SA Hinxton, UK
| | - Elena Prigmore
- Wellcome Sanger Institute, Wellcome Genome Campus, CB10 1SA Hinxton, UK
| | - Penny Jeggo
- Genome Damage and Stability Centre, University of Sussex, BN1 9RQ Brighton, UK
| | - Joan Boyes
- Faculty of Biological Sciences, University of Leeds, LS2 9JT Leeds, UK
| | - Andrew Mellor
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - Lei Huang
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - Mirjam van der Burg
- Department of Immunology, Erasmus University Medical Center, Rotterdam 3000 CA, Netherlands
| | - Karin R Engelhardt
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - Asbjørg Stray-Pedersen
- Norwegian National Unit for Newborn Screening, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo 0424, Norway
| | - Hans Christian Erichsen
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo 0424, Norway
| | - Andrew R Gennery
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, NE1 4LP Newcastle upon Tyne, UK
| | - Matthias Trost
- Biosciences Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
| | - David J Adams
- Wellcome Sanger Institute, Wellcome Genome Campus, CB10 1SA Hinxton, UK
| | - Graham Anderson
- Institute of Immunology and Immunotherapy, University of Birmingham. B15 2TT Birmingham, UK
| | - Anna Lorenc
- Wellcome Sanger Institute, Wellcome Genome Campus, CB10 1SA Hinxton, UK
| | - Gosia Trynka
- Wellcome Sanger Institute, Wellcome Genome Campus, CB10 1SA Hinxton, UK
- Open Targets, Wellcome Genome Campus, CB10 1SA Hinxton, UK
| | - Sophie Hambleton
- Translational and Clinical Research Institute, Newcastle University, NE2 4HH Newcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, NE1 4LP Newcastle upon Tyne, UK
| |
Collapse
|
2
|
Immune dysregulation in patients with RAG deficiency and other forms of combined immune deficiency. Blood 2020; 135:610-619. [PMID: 31942628 DOI: 10.1182/blood.2019000923] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 09/25/2019] [Indexed: 12/12/2022] Open
Abstract
Traditionally, primary immune deficiencies have been defined based on increased susceptibility to recurrent and/or severe infections. However, immune dysregulation, manifesting with autoimmunity or hyperinflammatory disease, has emerged as a common feature. This is especially true in patients affected by combined immune deficiency (CID), a group of disorders caused by genetic defects that impair, but do not completely abolish, T-cell function. Hypomorphic mutations in the recombination activating genes RAG1 and RAG2 represent the prototype of the broad spectrum of clinical and immunological phenotypes associated with CID. The study of patients with RAG deficiency and with other forms of CID has revealed distinct abnormalities in central and peripheral T- and B-cell tolerance as the key mechanisms involved in immune dysregulation. Understanding the pathophysiology of autoimmunity and hyperinflammation in these disorders may also permit more targeted therapeutic interventions.
Collapse
|
3
|
Abstract
Recombination-activating genes (
RAG)
1 and
RAG2 initiate the molecular processes that lead to lymphocyte receptor formation through VDJ recombination. Nonsense mutations in
RAG1/
RAG2 cause the most profound immunodeficiency syndrome, severe combined immunodeficiency (SCID). Other severe and less-severe clinical phenotypes due to mutations in
RAG genes are now recognized. The degree of residual protein function may permit some lymphocyte receptor formation, which confers a less-severe clinical phenotype. Many of the non-SCID phenotypes are associated with autoimmunity. New findings into the effect of mutations in
RAG1/2 on the developing T- and B-lymphocyte receptor give insight into the development of autoimmunity. This article summarizes recent findings and places the genetic and molecular findings in a clinical context.
Collapse
Affiliation(s)
- Andrew Gennery
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Childrens' Hospital, Newcastle upon Tyne, UK.,Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
4
|
Villa A, Notarangelo LD. RAG gene defects at the verge of immunodeficiency and immune dysregulation. Immunol Rev 2019; 287:73-90. [PMID: 30565244 PMCID: PMC6309314 DOI: 10.1111/imr.12713] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/21/2018] [Indexed: 12/18/2022]
Abstract
Mutations of the recombinase activating genes (RAG) in humans underlie a broad spectrum of clinical and immunological phenotypes that reflect different degrees of impairment of T- and B-cell development and alterations of mechanisms of central and peripheral tolerance. Recent studies have shown that this phenotypic heterogeneity correlates, albeit imperfectly, with different levels of recombination activity of the mutant RAG proteins. Furthermore, studies in patients and in newly developed animal models carrying hypomorphic RAG mutations have disclosed various mechanisms underlying immune dysregulation in this condition. Careful annotation of clinical outcome and immune reconstitution in RAG-deficient patients who have received hematopoietic stem cell transplantation has shown that progress has been made in the treatment of this disease, but new approaches remain to be tested to improve stem cell engraftment and durable immune reconstitution. Finally, initial attempts have been made to treat RAG deficiency with gene therapy.
Collapse
Affiliation(s)
- Anna Villa
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), Division of Regenerative Medicine, Stem Cell and Gene Therapy, San Raffaele Scientific Institute, Milan, Italy
- Milan Unit, Istituto di Ricerca Genetica e Biomedica, Consiglio Nazionale delle Ricerche, Milan, Italy
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| |
Collapse
|
5
|
Gennery AR. Advances in genetic and molecular understanding of Omenn syndrome - implications for the future. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1478287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Andrew R Gennery
- Clinical Resource Building, Floor 4, Block 2, Great North Children’s Hospital, Newcastle Upon Tyne, UK
| |
Collapse
|
6
|
Abstract
Hypomorphic Rag mutations in humans cause Omenn Syndrome (OS) a severe immunodeficiency associated with autoimmune-like manifestations mediated by oligoclonal activated T and B cells. The clinical and immunological spectrum of OS presentation is extremely broad. However, the role played by environmental triggers in the disease pathogenesis remains largely unknown. We have recently shown in a murine model that gut microbiota has a substantial role in determining the distinctive immune dysregulation of OS. Here, we describe how dysbiosis and loss of T cell tolerance to commensals influence the expression of autoimmunity at the barrier site and beyond, and the disease hallmark hyper-IgE. We discuss how commensal antigens and gut-derived pathogenic T cells could potentially modulate skin immunity to determine cutaneous degenerations in OS. These mechanisms may have broader implications for a deeper understanding of the role of gut microbes in influencing barriers integrity and host physiology.
Collapse
Affiliation(s)
- Rosita Rigoni
- Milan Unit, Istituto di Ricerca Genetica e
Biomedica, Consiglio Nazionale delle Ricerche, Milan,
Italy,Humanitas Clinical and Research
Center, Rozzano, Milan, Italy
| | - Fabio Grassi
- Istituto Nazionale Genetica Molecolare,
Department of Medical Biotechnology and Translational Medicine, University of
Milan, Milan, Italy,Institute for Research in
Biomedicine, Bellinzona, Switzerland
| | - Anna Villa
- Milan Unit, Istituto di Ricerca Genetica e
Biomedica, Consiglio Nazionale delle Ricerche, Milan,
Italy,Telethon Institute for Gene Therapy, Division
of Regenerative Medicine, Stem Cells and Gene Therapy, Istituto di Ricovero e Cura a
Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan,
Italy
| | - Barbara Cassani
- Milan Unit, Istituto di Ricerca Genetica e
Biomedica, Consiglio Nazionale delle Ricerche, Milan,
Italy,Humanitas Clinical and Research
Center, Rozzano, Milan, Italy,CONTACT Barbara Cassani Humanitas Clinical and Research Center, via Manzoni
56, 20089 Rozzano (Mi), Italy
| |
Collapse
|
7
|
Abstract
The recombination-activating gene 1 (RAG1) and RAG2 proteins initiate the V(D)J recombination process, which ultimately enables the generation of T cells and B cells with a diversified repertoire of antigen-specific receptors. Mutations of the RAG genes in humans are associated with a broad spectrum of clinical phenotypes, ranging from severe combined immunodeficiency to autoimmunity. Recently, novel insights into the phenotypic diversity of this disease have been provided by resolving the crystal structure of the RAG complex, by developing novel assays to test recombination activity of the mutant RAG proteins and by characterizing the molecular and cellular basis of immune dysregulation in patients with RAG deficiency.
Collapse
|
8
|
Gao Y, Workman S, Gadola S, Elliott T, Grimbacher B, Williams AP. Common variable immunodeficiency is associated with a functional deficiency of invariant natural killer T cells. J Allergy Clin Immunol 2014; 133:1420-8, 1428.e1. [PMID: 24582167 DOI: 10.1016/j.jaci.2013.10.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 10/18/2013] [Accepted: 10/22/2013] [Indexed: 01/17/2023]
Abstract
BACKGROUND Common variable immunodeficiency (CVID) is the commonest symptomatic primary antibody disorder, with monogenic causes identified in less than 10% of all cases. X-linked proliferative disease is a monogenic disorder that is associated with hypogammaglobulinemia and characterized by a deficiency of invariant NKT (iNKT) cells. We sought to evaluate whether a defect in iNKT cell number or function was associated with CVID. OBJECTIVE An evaluation of the function and number of iNKT cells in CVID. METHODS Six-color flow cytometry enumerated iNKT cells in 36 patients with CVID and 50 healthy controls. Their proliferative capacity and cytokine production (IFN-γ, IL-13, IL-17) was then investigated following activation with CD1d ligand alpha-galactosylceramide. RESULTS A reduction in the number of iNKT cells (31 iNKT cells/10(5) T cells) in patients with CVID compared with healthy controls (100 iNKT cells/10(5) T cells) was observed (P < .0001). Two cohorts could be discerned within the CVID group: group 1 with an abnormal number of iNKT cells (n = 28) and group 2 with a normal number of iNKT cells (n = 8). This segregation coassociated with the proliferative capacity of iNKT cells between the 2 groups. However, differences in the function of iNKT cells were noted in group 2, in which an increase in IFN-γ (P = .0016) and a decrease in IL-17 (P = .0002) production was observed between patients with CVID and controls. Finally, a significant association was seen between the number of iNKT cells and the percentage of class-switched memory B cells and propensity to lymphoproliferation (P = .002) in patients with CVID. CONCLUSION iNKT cells are deficient and/or functionally impaired in most of the patients with CVID.
Collapse
Affiliation(s)
- Yifang Gao
- Faculty of Medicine, Cancer Sciences Division, University of Southampton, Southampton, United Kingdom
| | - Sarita Workman
- Department of Clinical Immunology and Molecular Pathology, Royal Free Hospital, London, United Kingdom; University College London, London, United Kingdom
| | - Stephan Gadola
- Faculty of Medicine, Clinical and Experimental Sciences Division, University of Southampton, Southampton, United Kingdom
| | - Tim Elliott
- Faculty of Medicine, Cancer Sciences Division, University of Southampton, Southampton, United Kingdom
| | - Bodo Grimbacher
- Department of Clinical Immunology and Molecular Pathology, Royal Free Hospital, London, United Kingdom; University College London, London, United Kingdom
| | - Anthony P Williams
- Faculty of Medicine, Cancer Sciences Division, University of Southampton, Southampton, United Kingdom.
| |
Collapse
|
9
|
Abstract
Patients with the dedicator of cytokinesis 8 (DOCK8) immunodeficiency syndrome suffer from recurrent viral and bacterial infections, hyper-immunoglobulin E levels, eczema, and greater susceptibility to cancer. Because natural killer T (NKT) cells have been implicated in these diseases, we asked if these cells were affected by DOCK8 deficiency. Using a mouse model, we found that DOCK8 deficiency resulted in impaired NKT cell development, principally affecting the formation and survival of long-lived, differentiated NKT cells. In the thymus, DOCK8-deficient mice lack a terminally differentiated subset of NK1.1(+) NKT cells expressing the integrin CD103, whereas in the liver, DOCK8-deficient NKT cells express reduced levels of the prosurvival factor B-cell lymphoma 2 and the integrin lymphocyte function-associated antigen 1. Although the initial NKT cell response to antigen is intact in the absence of DOCK8, their ongoing proliferative and cytokine responses are impaired. Importantly, a similar defect in NKT cell numbers was detected in DOCK8-deficient humans, highlighting the relevance of the mouse model. In conclusion, our data demonstrate that DOCK8 is required for the development and survival of mature NKT cells, consistent with the idea that DOCK8 mediates survival signals within a specialized niche. Accordingly, impaired NKT cell numbers and function are likely to contribute to the susceptibility of DOCK8-deficient patients to recurrent infections and malignant disease.
Collapse
|
10
|
Late-onset combined immune deficiency associated to skin granuloma due to heterozygous compound mutations in RAG1 gene in a 14 years old male. Hum Immunol 2012; 74:18-22. [PMID: 23085344 DOI: 10.1016/j.humimm.2012.10.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 09/26/2012] [Accepted: 10/03/2012] [Indexed: 11/22/2022]
Abstract
We report a male with atypical severe combined immunodeficiency caused by heterozygous compound mutations c.256-257del and c.C1331T in RAG1 gene. The patient presents with recurrent bronchopneumonias with obstruction, chronic fibrosing alveolitis, complicated by respiratory failure, pulmonary hypertension and hepatosplenomegaly. He was diagnosed with agammaglobulinemia at the age of 9. His condition was complicated by granulomatous skin disease at the age of 12 despite regular IVIg substitution. Immunological presentation included profound hypogammaglobulinemia and absence of B cells. Under immunoglobulin substitution for 5 years patient has permanent lymphopenia, skewed phenotype of T cells and diminished number of recent thymic emigrants.
Collapse
|
11
|
Zeissig S, Blumberg RS. Primary immunodeficiency associated with defects in CD1 and CD1-restricted T cells. Ann N Y Acad Sci 2012; 1250:14-24. [PMID: 22276638 DOI: 10.1111/j.1749-6632.2011.06380.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
CD1 is a family of atypical MHC class I molecules that present various endogenous and exogenous lipid antigens to CD1-restricted T cells. While little is known about the function of CD1a-, CD1b-, and CD1c-restricted lipid-reactive T cells due to their absence in mice, CD1d-restricted natural killer T (NKT) cells have been extensively studied since their description almost 20 years ago. NKT cells, effector memory cells that share characteristics of innate and adaptive lymphocytes, are among the earliest responders in immune reactions and have broad effects on the activation of other immune cell lineages, including NK cells, T cells, and B cells. Accordingly, studies in mice have revealed critical roles of NKT cells in infectious, malignant, and autoimmune diseases. The recent description of primary immunodeficiencies associated with defects in CD1 and CD1-restricted T cells has provided a unique opportunity to study the biological role of lipid antigen presentation in human disease. Intriguingly, these studies revealed that defects in lipid immunity are associated with susceptibility to selected infectious and malignant diseases but not with broad immunodeficiency.
Collapse
Affiliation(s)
- Sebastian Zeissig
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | | |
Collapse
|
12
|
|
13
|
Acquired Omenn-like syndrome, a novel posttransplant autoaggression syndrome reversed by rapamycin. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2011; 19:109-12. [PMID: 22089244 DOI: 10.1128/cvi.05456-11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Graft-versus-host disease is uncommon in autologous hematopoietic cell transplantation (HCT) and is typically brief and mild. We report unusual, protracted, and severe Omenn syndrome-like autoaggression following autologous HCT. We identified a profound FOXP3(+) regulatory T cell defect that coincided with hyperinflammatory T cell responses which were reversible with rapamycin in vitro.
Collapse
|
14
|
Palendira U, Low C, Chan A, Hislop AD, Ho E, Phan TG, Deenick E, Cook MC, Riminton DS, Choo S, Loh R, Alvaro F, Booth C, Gaspar HB, Moretta A, Khanna R, Rickinson AB, Tangye SG. Molecular pathogenesis of EBV susceptibility in XLP as revealed by analysis of female carriers with heterozygous expression of SAP. PLoS Biol 2011; 9:e1001187. [PMID: 22069374 PMCID: PMC3206011 DOI: 10.1371/journal.pbio.1001187] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 09/16/2011] [Indexed: 11/18/2022] Open
Abstract
X-linked lymphoproliferative disease (XLP) is a primary immunodeficiency caused by mutations in SH2D1A which encodes SAP. SAP functions in signalling pathways elicited by the SLAM family of leukocyte receptors. A defining feature of XLP is exquisite sensitivity to infection with EBV, a B-lymphotropic virus, but not other viruses. Although previous studies have identified defects in lymphocytes from XLP patients, the unique role of SAP in controlling EBV infection remains unresolved. We describe a novel approach to this question using female XLP carriers who, due to random X-inactivation, contain both SAP(+) and SAP(-) cells. This represents the human equivalent of a mixed bone marrow chimera in mice. While memory CD8(+) T cells specific for CMV and influenza were distributed across SAP(+) and SAP(-) populations, EBV-specific cells were exclusively SAP(+). The preferential recruitment of SAP(+) cells by EBV reflected the tropism of EBV for B cells, and the requirement for SAP expression in CD8(+) T cells for them to respond to Ag-presentation by B cells, but not other cell types. The inability of SAP(-) clones to respond to Ag-presenting B cells was overcome by blocking the SLAM receptors NTB-A and 2B4, while ectopic expression of NTB-A on fibroblasts inhibited cytotoxicity of SAP(-) CD8(+) T cells, thereby demonstrating that SLAM receptors acquire inhibitory function in the absence of SAP. The innovative XLP carrier model allowed us to unravel the mechanisms underlying the unique susceptibility of XLP patients to EBV infection in the absence of a relevant animal model. We found that this reflected the nature of the Ag-presenting cell, rather than EBV itself. Our data also identified a pathological signalling pathway that could be targeted to treat patients with severe EBV infection. This system may allow the study of other human diseases where heterozygous gene expression from random X-chromosome inactivation can be exploited.
Collapse
MESH Headings
- Antigens, CD/immunology
- B-Lymphocytes/pathology
- B-Lymphocytes/virology
- CD48 Antigen
- CD8-Positive T-Lymphocytes/immunology
- CD8-Positive T-Lymphocytes/pathology
- CD8-Positive T-Lymphocytes/virology
- Dendritic Cells/immunology
- Epstein-Barr Virus Infections/genetics
- Epstein-Barr Virus Infections/immunology
- Epstein-Barr Virus Infections/virology
- Female
- Genotype
- Herpesvirus 4, Human/immunology
- Herpesvirus 4, Human/pathogenicity
- Humans
- Immunoglobulin Class Switching
- Influenza, Human/immunology
- Influenza, Human/virology
- Intracellular Signaling Peptides and Proteins/genetics
- Intracellular Signaling Peptides and Proteins/immunology
- Leukocytes, Mononuclear/immunology
- Leukocytes, Mononuclear/pathology
- Leukocytes, Mononuclear/virology
- Lymphoproliferative Disorders/genetics
- Lymphoproliferative Disorders/immunology
- Lymphoproliferative Disorders/pathology
- Lymphoproliferative Disorders/virology
- Orthomyxoviridae/immunology
- Orthomyxoviridae/pathogenicity
- Receptors, Cell Surface/immunology
- Receptors, Immunologic/immunology
- Signal Transduction
- Signaling Lymphocytic Activation Molecule Associated Protein
- Signaling Lymphocytic Activation Molecule Family
- Signaling Lymphocytic Activation Molecule Family Member 1
- X Chromosome Inactivation
Collapse
Affiliation(s)
- Umaimainthan Palendira
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Carol Low
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Anna Chan
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Andrew D. Hislop
- School of Cancer Sciences and MRC Centre for Immune Regulation, University of Birmingham, Edgbaston, United Kingdom
| | - Edwin Ho
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Tri Giang Phan
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Elissa Deenick
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Matthew C. Cook
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
- John Curtin School of Medical Research, Canberra, Australian Capital Territory, Australia
- Department of Immunology, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - D. Sean Riminton
- Department of Immunology, Concord Hospital, Sydney, New South Wales, Australia
| | - Sharon Choo
- Department of Allergy and Immunology, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Richard Loh
- Department of Clinical Immunology, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Frank Alvaro
- Pediatric Hematology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Claire Booth
- Centre for Immunodeficiency, Molecular Immunology Unit, UCL Institute of Child Health, London, United Kingdom
| | - H. Bobby Gaspar
- Centre for Immunodeficiency, Molecular Immunology Unit, UCL Institute of Child Health, London, United Kingdom
| | - Alessandro Moretta
- Dipartimento di Medicina Sperimentale, Università di Genova, Genova, Italy
| | - Rajiv Khanna
- Tumour Immunology Laboratory, Division of Immunology, Queensland Institute of Medical Research, Brisbane, Queensland, Australia
| | - Alan B. Rickinson
- School of Cancer Sciences and MRC Centre for Immune Regulation, University of Birmingham, Edgbaston, United Kingdom
| | - Stuart G. Tangye
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
- * E-mail:
| |
Collapse
|
15
|
Banovic T, Yanilla M, Simmons R, Robertson I, Schroder WA, Raffelt NC, Wilson YA, Hill GR, Hogan P, Nourse CB. Disseminated varicella infection caused by varicella vaccine strain in a child with low invariant natural killer T cells and diminished CD1d expression. J Infect Dis 2011; 204:1893-901. [PMID: 22043019 DOI: 10.1093/infdis/jir660] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Live attenuated varicella vaccine is considered a safe vaccine with serious adverse effects reported only in immunocompromised children. We describe a severe life-threatening infection with varicella vaccine virus causing rash and pneumonitis in a 6-year-old boy with no apparent immunodeficiency. METHODS AND RESULTS Polymerase chain reaction (PCR) analysis of vesicle swab samples demonstrated varicella zoster virus (VZV). Sequencing of the PCR product demonstrated 100% homology with human herpesvirus 3 strain VZV-Oka ORF62 gene. Routine immunologic investigations failed to demonstrate any abnormality. Total leukocyte, lymphocyte, and neutrophil counts and lymphocyte subsets were normal. Immunoglobulins, C3, C4, and CH50 were intact. Specific IgG to protein and polysaccharide antigens and to Epstein-Barr virus and cytomegalovirus were present. Normal lymphocyte proliferation to phytohemagglutinin and VZV antigens was detected. Neutrophil function and natural killer (NK) cell activity were normal. The analysis of invariant NK T (iNKT) cell numbers and function revealed diminished iNKT cells, reported once previously and unique to our patient, deficient expression of the cognate receptor, CD1d. CONCLUSIONS This report provides a further link between deficiency of the iNKT/CD1d pathway and increased susceptibility to varicella vaccine virus, suggesting an important role of this innate pathway in host defense against yet another member of the herpesvirus family.
Collapse
Affiliation(s)
- Tatjana Banovic
- Laboratory for Bone Marrow Transplantation, The Queensland Institute of Medical Research, Herston, Australia.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Felgentreff K, Perez-Becker R, Speckmann C, Schwarz K, Kalwak K, Markelj G, Avcin T, Qasim W, Davies EG, Niehues T, Ehl S. Clinical and immunological manifestations of patients with atypical severe combined immunodeficiency. Clin Immunol 2011; 141:73-82. [PMID: 21664875 DOI: 10.1016/j.clim.2011.05.007] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 05/18/2011] [Accepted: 05/20/2011] [Indexed: 12/17/2022]
Abstract
Hypomorphic mutations in genes associated with severe combined immunodeficiency (SCID) or Omenn syndrome can also cause milder immunodeficiencies. We report 10 new patients with such "atypical" SCID and summarize 63 patients from the literature. The patient groups with T(low)B(low) (n=28), T(low)B(+) (n=16) and ADA (n=29) SCID variants had similar infection profiles but differed in the frequency of immune dysregulation, which was observed predominantly in patients with recombination defects. Most immunological parameters were remarkably similar in the three groups. Of note, 19/68 patients with "atypical" SCID had normal T cell counts, 48/68 had normal IgG and 23/46 had at least one normal specific antibody titer. Elevated IgE was a characteristic feature of ADA deficiency. This overview characterizes "atypical" SCID as a distinct disease with immune dysregulation in addition to infection susceptibility. Lymphopenia, reduced naïve T cells and elevated IgE are suggestive, but not consistent features of the disease.
Collapse
Affiliation(s)
- Kerstin Felgentreff
- Centre of Chronic Immunodeficiency, University Hospital Freiburg, Breisacher Str. 117, D-79106 Freiburg, Germany
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Paust S, Gill HS, Wang BZ, Flynn MP, Moseman EA, Senman B, Szczepanik M, Telenti A, Askenase PW, Compans RW, von Andrian UH. Critical role for the chemokine receptor CXCR6 in NK cell-mediated antigen-specific memory of haptens and viruses. Nat Immunol 2010; 11:1127-35. [PMID: 20972432 PMCID: PMC2982944 DOI: 10.1038/ni.1953] [Citation(s) in RCA: 530] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 09/28/2010] [Indexed: 12/29/2022]
Abstract
Hepatic natural killer (NK) cells mediate antigen-specific contact hypersensitivity (CHS) in mice deficient in T cells and B cells. We report here that hepatic NK cells, but not splenic or naive NK cells, also developed specific memory of vaccines containing antigens from influenza, vesicular stomatitis virus (VSV) or human immunodeficiency virus type 1 (HIV-1). Adoptive transfer of virus-sensitized NK cells into naive recipient mice enhanced the survival of the mice after lethal challenge with the sensitizing virus but not after lethal challenge with a different virus. NK cell memory of haptens and viruses depended on CXCR6, a chemokine receptor on hepatic NK cells that was required for the persistence of memory NK cells but not for antigen recognition. Thus, hepatic NK cells can develop adaptive immunity to structurally diverse antigens, an activity that requires NK cell-expressed CXCR6.
Collapse
Affiliation(s)
- Silke Paust
- Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Niehues T, Perez-Becker R, Schuetz C. More than just SCID--the phenotypic range of combined immunodeficiencies associated with mutations in the recombinase activating genes (RAG) 1 and 2. Clin Immunol 2010; 135:183-92. [PMID: 20172764 DOI: 10.1016/j.clim.2010.01.013] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 01/23/2010] [Accepted: 01/25/2010] [Indexed: 01/08/2023]
Abstract
Combined immunodeficiencies with impaired numbers and function of T- and B-cells can be attributed to defects in the recombinase activating genes (RAG). The products of these genes, the RAG1 and 2 proteins, are key players in the V(D)J recombination process leading to the assembly of antigen receptor genes. Complete RAG deficiency (RAGD) with no V(D)J (<1% recombination activity of wild type) is associated with classical SCID and absence of T- and B-cells. In RAGD with residual V(D)J activity (>1% recombination activity of wild type), several clinical and immunological subtypes have been described: RAGD with skin inflammation and alphabeta T-cell expansion (classical Omenn syndrome), RAGD with skin inflammation and without T-cell expansion (incomplete Omenn syndrome), RAGD with gammadelta T-cell expansion and RAGD with granulomas. Engraftment of maternal T-cells can add to variation in phenotype. The potential role of epigenetic factors that influence the emergence of these phenotypes is discussed. Thorough assessment and interpretation of clinical and immunological findings will guide treatment modalities as intense as hematopoietic stem cell transplantation.
Collapse
Affiliation(s)
- Tim Niehues
- HELIOS Klinikum Krefeld, Center for Child and Adolescent Health, Krefeld, Germany.
| | | | | |
Collapse
|
19
|
Cassani B, Poliani PL, Moratto D, Sobacchi C, Marrella V, Imperatori L, Vairo D, Plebani A, Giliani S, Vezzoni P, Facchetti F, Porta F, Notarangelo LD, Villa A, Badolato R. Defect of regulatory T cells in patients with Omenn syndrome. J Allergy Clin Immunol 2010; 125:209-16. [DOI: 10.1016/j.jaci.2009.10.023] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Revised: 09/22/2009] [Accepted: 10/16/2009] [Indexed: 01/21/2023]
|
20
|
Fulcher DA, Avery DT, Fewings NL, Berglund LJ, Wong S, Riminton DS, Adelstein S, Tangye SG. Invariant natural killer (iNK) T cell deficiency in patients with common variable immunodeficiency. Clin Exp Immunol 2009; 157:365-9. [PMID: 19664144 DOI: 10.1111/j.1365-2249.2009.03973.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Common variable immunodeficiency (CVID) is a B cell immunodeficiency disorder characterized frequently by failure of memory B cell development and antibody secretion. A unifying cellular pathogenesis for CVID has not been forthcoming, but given the immunoregulatory role of invariant NK (iNK) T cells and their absence in several other immunodeficiencies, we quantified these cells in the blood of 58 CVID patients. There was a marked decrease in the proportion of iNK T cells in CVID patients compared with controls. This was particularly notable in those with low isotype-switched memory B cells, but subset analysis demonstrated no difference when stratified by specific clinical features. We propose that the decreased proportion of iNK T cells in CVID might be linked to the failure of memory B cell generation, which may contribute to reduced antibody production in these patients.
Collapse
Affiliation(s)
- D A Fulcher
- Immunology Unit, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, Sydney, NSW 2145, Australia.
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Karaca NE, Aksu G, Genel F, Gulez N, Can S, Aydinok Y, Aksoylar S, Karaca E, Altuglu I, Kutukculer N. Diverse phenotypic and genotypic presentation of RAG1 mutations in two cases with SCID. Clin Exp Med 2009; 9:339-42. [PMID: 19458910 DOI: 10.1007/s10238-009-0053-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Accepted: 04/17/2009] [Indexed: 11/25/2022]
Abstract
Severe combined immunodeficiencies (SCID) comprise a spectrum of genetic defects that involve both humoral and cellular immunities. Defects in recombinating activating gene 1 (RAG1), RAG2, Artemis, or LIG4 can disrupt V(D)J recombination. Defective V(D)J recombination of the T and B cell receptors is responsible for T(-)B(-)NK(+)SCID. Amorphic mutations in RAG1 and RAG2 cause T(-)B(-)NK(+)SCID, whereas hypomorphic mutations cause an immunodeficency characterized by oligoclonal expansion of TCRgammadelta T cells, severe CMV infection and autoimmunity. First patient is a typical T(-)B(-)NK(+)SCID with clinical and immunologic findings while the second is atypical with normal immunoglobulin levels, CD4 lymphopenia, elevated TCRgammadelta T cells, persistent CMV infection, and autoimmune hemolytic anemia. These cases are presented to emphasize that mutations in RAG1 gene may lead to a diverse spectrum of clinical and immunologic findings while hypomorphic mutations may be related with autoimmunity and refractory CMV infection during infancy.
Collapse
Affiliation(s)
- Neslihan Edeer Karaca
- Department of Pediatrics, Faculty of Medicine, Ege University, 35100, Bornova, Izmir, Turkey.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Locci M, Draghici E, Marangoni F, Bosticardo M, Catucci M, Aiuti A, Cancrini C, Marodi L, Espanol T, Bredius RGM, Thrasher AJ, Schulz A, Litzman J, Roncarolo MG, Casorati G, Dellabona P, Villa A. The Wiskott-Aldrich syndrome protein is required for iNKT cell maturation and function. ACTA ACUST UNITED AC 2009; 206:735-42. [PMID: 19307326 PMCID: PMC2715111 DOI: 10.1084/jem.20081773] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The Wiskott-Aldrich syndrome (WAS) protein (WASp) is a regulator of actin cytoskeleton in hematopoietic cells. Mutations of the WASp gene cause WAS. Although WASp is involved in various immune cell functions, its role in invariant natural killer T (iNKT) cells has never been investigated. Defects of iNKT cells could indeed contribute to several WAS features, such as recurrent infections and high tumor incidence. We found a profound reduction of circulating iNKT cells in WAS patients, directly correlating with the severity of clinical phenotype. To better characterize iNKT cell defect in the absence of WASp, we analyzed was(-/-) mice. iNKT cell numbers were significantly reduced in the thymus and periphery of was(-/-) mice as compared with wild-type controls. Moreover analysis of was(-/-) iNKT cell maturation revealed a complete arrest at the CD44(+) NK1.1(-) intermediate stage. Notably, generation of BM chimeras demonstrated a was(-/-) iNKT cell-autonomous developmental defect. was(-/-) iNKT cells were also functionally impaired, as suggested by the reduced secretion of interleukin 4 and interferon gamma upon in vivo activation. Altogether, these results demonstrate the relevance of WASp in integrating signals critical for development and functional differentiation of iNKT cells and suggest that defects in these cells may play a role in WAS pathology.
Collapse
|
23
|
Abstract
V(D)J recombination not only comprises the molecular mechanism that insures diversity of the immune system but also constitutes a critical checkpoint in the developmental program of B- and T-lymphocytes. The analysis of human patients with Severe Combined Immune Deficiency (SCID) has contributed to the understanding of the biochemistry of the V(D)J recombination reaction. The molecular study V(D)J recombination settings in humans, mice and in cellular mutants has allowed to unravel the process of Non Homologous End Joining (NHEJ), one of the key pathway that insure proper repair of DNA double strand breaks (dsb), whether they occur during V(D)J recombination or secondary to other DNA injuries. Two NHEJ factors, Artemis and Cernunnos, were indeed discovered through the study of human V(D)J recombination defective human SCID patients.
Collapse
|
24
|
Pitt LA, Hubert FX, Scott HS, Godfrey DI, Berzins SP. NKT cell development in the absence of the autoimmune regulator gene (Aire). Eur J Immunol 2008; 38:2689-96. [PMID: 18828139 DOI: 10.1002/eji.200838553] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Autoimmune regulator gene (Aire)-deficient mice develop an array of autoimmune lesions that reflect failures of immune tolerance. Negative selection is clearly compromised in these mice, but there is evidence to suggest that other mechanisms of tolerance might also be affected, including a possible impairment of regulatory T cell (Treg) development. Studies to date have failed to demonstrate any significant impact on the development or function of the FOXP3+ Treg compartment, but NKT cells represent a distinct regulatory cell lineage that also develop in the thymus and which are known to influence self-tolerance. Aire-related defects coincide with NKT cell deficiencies in a number of animal models, but the direct consequence of Aire-deficiency on NKT cell development has not been established. In this study, we demonstrate that the frequency, distribution and cytokine production of NKT cells and their subsets is principally normal in Aire-deficient mice. We conclude that Aire has little or no effect on regulatory T cell development in general and NKT cells in particular.
Collapse
Affiliation(s)
- Lauren A Pitt
- Department of Microbiology and Immunology, University of Melbourne, Parkville, Victoria, Australia
| | | | | | | | | |
Collapse
|
25
|
Ohm-Laursen L, Nielsen C, Fisker N, Lillevang ST, Barington T. Lack of nonfunctional B-cell receptor rearrangements in a patient with normal B cell numbers despite partial RAG1 deficiency and atypical SCID/Omenn syndrome. J Clin Immunol 2008; 28:588-92. [PMID: 18592361 DOI: 10.1007/s10875-008-9210-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2008] [Accepted: 05/19/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION A 2.5-month old boy presented with recurrent wheezing, protracted diarrhea, erythrodermia, and failure to thrive. METHODS AND RESULTS Laboratory analysis showed lymphocytopenia with severely reduced T-cell numbers but normal numbers of B and NK cells. Serum IgE was increased and the patient had eosinophilia. These presentations are consistent with atypical severe combined immunodeficiency (SCID)/Omenn Syndrome and the diagnosis was confirmed by demonstration of homozygosity for the R841W mutation in the catalytic core of RAG1. Comparison of the patient's immunoglobulin heavy chain rearrangements to those of age-matched controls, cord blood, and adults revealed an almost total lack of nonproductive rearrangements (2.7% versus 14.7%, 27.6%, and 19.8% in the controls, respectively) indicating failure to correct out-of-frame rearrangements by a second rearrangement on the homologous chromosome 14. CONCLUSION We hypothesize that the R841W mutation causes a malfunction of RAG1 that has differential outcome on V(D)J recombination in B and T cells, as the patient had normal B cell numbers but suffered severe alpha-beta T-cell immunodeficiency.
Collapse
Affiliation(s)
- Line Ohm-Laursen
- Department of Clinical Immunology, Odense University Hospital, 5000 Odense, Denmark
| | | | | | | | | |
Collapse
|
26
|
Of Omenn and mice. Trends Immunol 2008; 29:133-40. [PMID: 18255337 DOI: 10.1016/j.it.2007.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2007] [Revised: 11/29/2007] [Accepted: 12/03/2007] [Indexed: 11/22/2022]
Abstract
Omenn syndrome (OS) is a peculiar immunodeficiency in which profound T and B cell defects are associated with severe autoimmune manifestations. Although the molecular and biochemical bases of OS have been elucidated, the mechanisms leading to T cell infiltration of peripheral tissues such as skin and gut still remain unsolved. Two murine models with hypomorphic mutations in rag genes reproducing OS features and a murine model of lymphopenia-derived autoimmunity with similar immunopathology were recently described. The aim of this review is to integrate clues regarding the roles of impaired thymic development and lymphopenia into the pathogenesis of autoimmunity.
Collapse
|