Eye involvement in hyperimmunoglobulinemia E (Job's) syndrome

Herpes Simplex Conjunctivitis and Recurrent Chalazia in a Patient DOCK8 Deficiency

PURPOSE

To report a case of recurrent chalazia and Herpes Simplex conjunctivitis in a patient with DOCK8 deficiency.

CASE REPORT

We report the case of a 15-year-old male patient with genetically diagnosed DOCK8 deficiency who presented with a left lower eyelid mass and left eye conjunctivitis. The lesion did not resolve despite aggressive measures, including topical steroids, topical antibiotics, and multiple debulking procedures but eventually resolved after the initiation of intravenous acyclovir. The diagnosis of HSV infection was supported by pathology findings from the eyelid mass.

CONCLUSION

Patients with DOCK8 deficiency can present with a variety of cutaneous viral infections. In our case, a DOCK8-deficient patient with chalazia and conjunctivitis resistant to antibiotics, steroids and debulking responded to intravenous acyclovir.

STAT3 Hyper-IgE Syndrome-an Update and Unanswered Questions

The hyper-IgE syndromes (HIES) are a heterogeneous group of inborn errors of immunity sharing manifestations including increased infection susceptibility, eczema, and raised serum IgE. Since the prototypical HIES description 55 years ago, areas of significant progress have included description of key disease-causing genes and differentiation into clinically distinct entities. The first two patients reported had what is now understood to be HIES from dominant-negative mutations in signal transduction and activator of transcription 3 (STAT3-HIES), conferring a broad immune defect across both innate and acquired arms, as well as defects in skeletal, connective tissue, and vascular function, causing a clinical phenotype including eczema, staphylococcal and fungal skin and pulmonary infection, scoliosis and minimal trauma fractures, and vascular tortuosity and aneurysm. Due to the constitutionally expressed nature of STAT3, initial reports at treatment with allogeneic stem cell transplantation were not positive and treatment has hinged on aggressive antimicrobial prophylaxis and treatment to prevent the development of end-organ disease such as pneumatocele. Research into the pathophysiology of STAT3-HIES has driven understanding of the interface of several signaling pathways, including the JAK-STAT pathways, interleukins 6 and 17, and the role of Th17 lymphocytes, and has been expanded by identification of phenocopies such as mutations in IL6ST and ZNF341. In this review we summarize the published literature on STAT3-HIES, present the diverse clinical manifestations of this syndrome with current management strategies, and update on the uncertain role of stem cell transplantation for this disease. We outline key unanswered questions for further study.

Giant Chalazia in the Hyperimmunoglobulinemia E (Hyper-Ige) Syndrome

Purpose

To report the occurrence of recurrent multiple giant chalazia in the hyperimmunoglobulin E syndrome (hyper-IgE syndrome or Job syndrome).

METHODS

Two patients with hyperimmunoglobulinemia E (>500 IU/ml) had ophthalmologic examination and surgical treatment for chalazia of the eyelids.

Results

The hyper-IgE syndrome is a rare immunodeficiency and multisystem disorder characterized by recurrent skin and pulmonary abscesses, connective tissue abnormalities, and elevated levels of serum IgE. In two patients with the hyper-IgE syndrome, multiple giant chalazia were seen in upper and lower eyelids. Despite surgical incision new giant chalazia arose.

CONCLUSIONS

Recurrent multiple giant chalazia may occur as an ophthalmic feature of the hyper-IgE syndrome.

Recurrent giant chalazia in hyperimmunoglobulin E (Job's) syndrome

Hyperimmunoglobulinemia E (Job's) syndrome is a rare autosomal dominant disorder appearing early in life with recurrent skin and pulmonary infections, characterized by markedly increased serum immunoglobulin E (IgE) levels. We describe a 50-year-old man with a 4-year history of recurrent, multiple giant chalazia in all eyelids. Medications and surgical intervention had produced only transient improvement. The patient had also had pulmonary and scalp infection. Laboratory tests disclosed elevated serum IgE (>1,000 IU/ml) and eosinophilia. As a result, based on the patient's history and clinical and laboratory findings, a diagnosis of Job's syndrome was made. Even though rarely, recurrent multiple giant chalazia may occur as an ophthalmic feature of Job's syndrome. Hyperimmunoglobulinemia E syndrome should be suspected in any case of recurrent giant chalazia, regardless of the patient's age. Measurement of serum IgE and eosinophils, along with internal evaluation, is essential to establish a proper diagnosis.

Hyper-IgE syndromes

The hyper-immunoglobulin E (IgE) syndromes (HIES) are primary immunodeficiencies characterized by the clinical triad of recurrent staphylococcal abscesses, recurrent cyst-forming pneumonia, and an elevated serum IgE level of >2000 IU/ml. Most cases are sporadic; however, multiplex families displaying autosomal dominant (AD) and autosomal recessive (AR) inheritance have been described. In most sporadic and AD cases, the HIES clinical triad is part of a multisystem disorder including abnormalities of the soft tissue, skeletal, and dental systems. In contrast, those with AR-HIES have severe molluscum contagiosum and other viral infections and may develop severe neurological complications. Unlike patients with sporadic HIES and AD-HIES, those with AR-HIES lack skeletal or dental involvement and do not develop lung cysts. Additional variants of HIES are discussed in this review. The etiology of HIES is still unresolved. Recent research points toward a skewed T helper 1 (Th1) cell/Th2 cell ratio and the involvement of chemokines. Therapy for HIES is directed at prevention and management of infections by using sustained systemic antibiotics and antifungals along with topical therapy for eczema and drainage of abscesses. Anti-staphylococcal antibiotic prophylaxis is useful. Interferons, immunoglobulin supplementation, or low-dose cyclosporine A have been reported to benefit selected patients, but they are not generally indicated.

Recurrent Staphylococcus aureus chalazia in hyperimmunoglobulinemia E (Job's) syndrome

PURPOSE

To report a case of recurrent Staphylococcus aureus chalazia in a patient with hyperimmunoglobulinemia E syndrome (Job's Syndrome).

DESIGN

Case report.

METHODS

Three separate surgical incisions and curettages of multiple, recurrent chalazia of the right upper eyelid were performed over a course of 3 months. Cultures and pathologic specimens were obtained. Postoperative treatment consisted of oral erythromycin and amoxicillin/clavulonate, topical tobramycin/dexamethasone ointment, and warm compresses.

RESULTS

Pathology of the tarsus confirmed the diagnosis of multiple chalazia. Cultures of the chalazia contents were positive for Staphylococcus aureus. No further recurrence was observed following the third surgical procedure over a 3-month follow-up period.

CONCLUSION

Characteristic Staphylococcus aureus skin infections in immunodeficient patients with hyperimmunoglobulinemia E syndrome can involve the eyelids and may be recurrent despite appropriate medical and surgical therapy.