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García-Solís B, Tapia-Torres M, García-Soidán A, Hernández-Brito E, Martínez-Saavedra MT, Lorenzo-Salazar JM, García-Hernández S, Van Den Rym A, Mayani K, Govantes-Rodríguez JV, Gervais A, Bastard P, Puel A, Casanova JL, Flores C, Pérez de Diego R, Rodríguez-Gallego C. IgG4-related disease and B-cell malignancy due to an IKZF1 gain-of-function variant. J Allergy Clin Immunol 2024:S0091-6749(24)00330-0. [PMID: 38579942 DOI: 10.1016/j.jaci.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 03/15/2024] [Accepted: 03/22/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Monoallelic loss-of-function IKZF1 (IKAROS) variants cause B-cell deficiency or combined immunodeficiency, whereas monoallelic gain-of-function (GOF) IKZF1 variants have recently been reported to cause hypergammaglobulinemia, abnormal plasma cell differentiation, autoimmune and allergic manifestations, and infections. OBJECTIVE We studied 7 relatives with autoimmune/inflammatory and lymphoproliferative manifestations to identify the immunologic disturbances and the genetic cause of their disease. METHODS We analyzed biopsy results and performed whole-exome sequencing and immunologic studies. RESULTS Disease onset occurred at a mean age of 25.2 years (range, 10-64, years). Six patients suffered from autoimmune/inflammatory diseases, 4 had confirmed IG4-related disease (IgG4-RD), and 5 developed B-cell malignancies: lymphoma in 4 and multiple myeloma in the remaining patient. Patients without immunosuppression were not particularly prone to infectious diseases. Three patients suffered from life-threatening coronavirus disease 2019 pneumonia, of whom 1 had autoantibodies neutralizing IFN-α. The recently described IKZF1 GOF p.R183H variant was found in the 5 affected relatives tested and in a 6-year-old asymptomatic girl. Immunologic analysis revealed hypergammaglobulinemia and high frequencies of certain lymphocyte subsets (exhausted B cells, effector memory CD4 T cells, effector memory CD4 T cells that have regained surface expression of CD45RA and CD28-CD57+ CD4+ and CD8+ T cells, TH2, and Tfh2 cells) attesting to immune dysregulation. Partial clinical responses to rituximab and corticosteroids were observed, and treatment with lenalidomide, which promotes IKAROS degradation, was initiated in 3 patients. CONCLUSIONS Heterozygosity for GOF IKZF1 variants underlies autoimmunity/inflammatory diseases, IgG4-RD, and B-cell malignancies, the onset of which may occur in adulthood. Clinical and immunologic data are similar to those for patients with unexplained IgG4-RD. Patients may therefore benefit from treatments inhibiting pathways displaying IKAROS-mediated overactivity.
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Affiliation(s)
- Blanca García-Solís
- Laboratory of Immunogenetics of Human Diseases, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Interdepartmental Group of Immunodeficiencies, Madrid, Spain
| | - María Tapia-Torres
- Department of Hematology, La Palma University Hospital, Breña Alta, Spain
| | - Ana García-Soidán
- Department of Immunology, University Hospital of Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Spain
| | - Elisa Hernández-Brito
- Department of Immunology, University Hospital of Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Spain
| | | | - José M Lorenzo-Salazar
- Genomics Division, Instituto Tecnológico y de Energías Renovables (ITER), Santa Cruz de Tenerife, Spain
| | | | - Ana Van Den Rym
- Laboratory of Immunogenetics of Human Diseases, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Interdepartmental Group of Immunodeficiencies, Madrid, Spain
| | - Karan Mayani
- Department of Hematology, La Palma University Hospital, Breña Alta, Spain
| | | | - Adrian Gervais
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, Paris, France; Paris Cité University, Imagine Institute, Paris, France
| | - Paul Bastard
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, Paris, France; Paris Cité University, Imagine Institute, Paris, France; St Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY; Hematology-Immunology and Rheumatology Unit, Necker Hospital for Sick Children, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Anne Puel
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, Paris, France; Paris Cité University, Imagine Institute, Paris, France; St Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY
| | - Jean-Laurent Casanova
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, Paris, France; Paris Cité University, Imagine Institute, Paris, France; St Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY; Howard Hughes Medical Institute, New York, NY; Department of Pediatrics, Necker Hospital for Sick Children, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Carlos Flores
- Genomics Division, Instituto Tecnológico y de Energías Renovables (ITER), Santa Cruz de Tenerife, Spain; Research Unit, Hospital Universitario Ntra. Sra. de Candelaria, Santa Cruz de Tenerife, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Department of Clinical Sciences, University Fernando Pessoa Canarias, Las Palmas de Gran Canaria, Spain
| | - Rebeca Pérez de Diego
- Laboratory of Immunogenetics of Human Diseases, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Interdepartmental Group of Immunodeficiencies, Madrid, Spain.
| | - Carlos Rodríguez-Gallego
- Department of Immunology, University Hospital of Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Spain; Department of Clinical Sciences, University Fernando Pessoa Canarias, Las Palmas de Gran Canaria, Spain; Department of Medical and Surgical Sciences, School of Medicine, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain.
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Alsaidalani AA, García-Solís B, Bukhari E, Van Den Rym A, López-Collazo E, Sánchez-Ramón S, Corvillo F, López-Lera A, de Andrés A, Martínez-Barricarte R, Perez de Diego R. Inherited Human BCL10 Deficiencies. J Clin Immunol 2023; 44:13. [PMID: 38129623 DOI: 10.1007/s10875-023-01619-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/26/2023] [Indexed: 12/23/2023]
Abstract
Human BCL10 deficiency causes combined immunodeficiency with bone marrow transplantation as its only curative option. To date, there are four homozygous mutations described in the literature that were identified in four unrelated patients. Here, we describe a fifth patient with a novel mutation and summarize what we have learned about BCL10 deficiency. Due to the severity of the disease, accurate knowledge of its clinical and immunological characteristics is instrumental for early diagnosis and adequate clinical management of the patients.
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Affiliation(s)
- Ashwag A Alsaidalani
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, 22252, Jeddah, Saudi Arabia
| | - Blanca García-Solís
- Laboratory of Immunogenetics of Human Diseases, IdiPAZ Institute for Health Research, La Paz University Hospital, 28046, Madrid, Spain
- Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz University Hospital, 28046, Madrid, Spain
- Interdepartmental Group of Immunodeficiencies, Madrid, Spain
| | - Esraa Bukhari
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, 22252, Jeddah, Saudi Arabia
| | - Ana Van Den Rym
- Laboratory of Immunogenetics of Human Diseases, IdiPAZ Institute for Health Research, La Paz University Hospital, 28046, Madrid, Spain
- Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz University Hospital, 28046, Madrid, Spain
- Interdepartmental Group of Immunodeficiencies, Madrid, Spain
| | - Eduardo López-Collazo
- Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz University Hospital, 28046, Madrid, Spain
| | - Silvia Sánchez-Ramón
- Interdepartmental Group of Immunodeficiencies, Madrid, Spain
- Clinical Immunology Department and IdSSC, San Carlos Clinical Hospital, 28040, Madrid, Spain
| | - Fernando Corvillo
- IdiPAZ Institute for Health Research, La Paz University Hospital, CIBERER U-754, 28046, Madrid, Spain
| | - Alberto López-Lera
- IdiPAZ Institute for Health Research, La Paz University Hospital, CIBERER U-754, 28046, Madrid, Spain
| | - Ana de Andrés
- Immunology Department, Hospital Ramon y Cajal, 28034, Madrid, Spain
| | - Rubén Martínez-Barricarte
- Division of Genetic Medicine, Department of Medicine, Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
- Division of Molecular Pathogenesis, Department of Pathology, Microbiology, and Immunology, Vanderbilt Center for Immunobiology, Immunology, and Inflammation, Vanderbilt Institute for Infection, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Rebeca Perez de Diego
- Laboratory of Immunogenetics of Human Diseases, IdiPAZ Institute for Health Research, La Paz University Hospital, 28046, Madrid, Spain.
- Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz University Hospital, 28046, Madrid, Spain.
- Interdepartmental Group of Immunodeficiencies, Madrid, Spain.
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3
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García-Solís B, Van Den Rym A, Martinez-Martínez L, Franco T, Pérez-Caraballo JJ, Markle J, Cubillos-Zapata C, Marín AV, Recio MJ, Regueiro JR, Navarro-Zapata A, Mestre-Durán C, Ferreras C, Martín Cotázar C, Mena R, de la Calle-Fabregat C, López-Lera A, Fernández Arquero M, Pérez-Martínez A, López-Collazo E, Sánchez-Ramón S, Casanova JL, Martínez-Barricarte R, de la Calle-Martín O, Pérez de Diego R. Inherited human ezrin deficiency impairs adaptive immunity. J Allergy Clin Immunol 2023; 152:997-1009.e11. [PMID: 37301410 PMCID: PMC11009781 DOI: 10.1016/j.jaci.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Inborn errors of immunity (IEI) are a group of monogenic diseases that confer susceptibility to infection, autoimmunity, and cancer. Despite the life-threatening consequences of some IEI, their genetic cause remains unknown in many patients. OBJECTIVE We investigated a patient with an IEI of unknown genetic etiology. METHODS Whole-exome sequencing identified a homozygous missense mutation of the gene encoding ezrin (EZR), substituting a threonine for an alanine at position 129. RESULTS Ezrin is one of the subunits of the ezrin, radixin, and moesin (ERM) complex. The ERM complex links the plasma membrane to the cytoskeleton and is crucial for the assembly of an efficient immune response. The A129T mutation abolishes basal phosphorylation and decreases calcium signaling, leading to complete loss of function. Consistent with the pleiotropic function of ezrin in myriad immune cells, multidimensional immunophenotyping by mass and flow cytometry revealed that in addition to hypogammaglobulinemia, the patient had low frequencies of switched memory B cells, CD4+ and CD8+ T cells, MAIT, γδ T cells, and centralnaive CD4+ cells. CONCLUSIONS Autosomal-recessive human ezrin deficiency is a newly recognized genetic cause of B-cell deficiency affecting cellular and humoral immunity.
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Affiliation(s)
- Blanca García-Solís
- Laboratory of Immunogenetics of Human Diseases, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Interdepartmental Group of Immunodeficiencies, Madrid, Spain
| | - Ana Van Den Rym
- Laboratory of Immunogenetics of Human Diseases, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Interdepartmental Group of Immunodeficiencies, Madrid, Spain
| | | | - Teresa Franco
- Immunology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jareb J Pérez-Caraballo
- Division of Genetic Medicine, Department of Medicine, Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tenn; Division of Molecular Pathogenesis, Department of Pathology, Microbiology, and Immunology, Vanderbilt Center for Immunobiology, Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, Tenn
| | - Janet Markle
- Division of Genetic Medicine, Department of Medicine, Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tenn; Division of Molecular Pathogenesis, Department of Pathology, Microbiology, and Immunology, Vanderbilt Center for Immunobiology, Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, Tenn
| | - Carolina Cubillos-Zapata
- Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Centre for Biomedical Research Network, CIBEres, Madrid, Spain
| | - Ana V Marín
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, and 12 de Octubre Health Research Institute (imas12), Madrid, Spain
| | - María J Recio
- Interdepartmental Group of Immunodeficiencies, Madrid, Spain; Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, and 12 de Octubre Health Research Institute (imas12), Madrid, Spain
| | - José R Regueiro
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, and 12 de Octubre Health Research Institute (imas12), Madrid, Spain
| | - Alfonso Navarro-Zapata
- Translational Research in Paediatric Oncology, Haematopoietic Transplantation and Cell Therapy, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain
| | - Carmen Mestre-Durán
- Translational Research in Paediatric Oncology, Haematopoietic Transplantation and Cell Therapy, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain
| | - Cristina Ferreras
- Translational Research in Paediatric Oncology, Haematopoietic Transplantation and Cell Therapy, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain
| | - Carla Martín Cotázar
- Translational Research in Paediatric Oncology, Haematopoietic Transplantation and Cell Therapy, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain
| | - Roció Mena
- Institute of Medical and Molecular Genetics (INGEMM), Hospital Universitario La Paz, Universidad Autónoma de Madrid, IdiPAZ, Madrid, Spain
| | | | - Alberto López-Lera
- IdiPAZ Institute for Health Research, La Paz University Hospital, CIBERER U-754, Madrid, Spain
| | - Miguel Fernández Arquero
- Interdepartmental Group of Immunodeficiencies, Madrid, Spain; Clinical Immunology Department, San Carlos Clinical Hospital, Madrid, Spain
| | - Antonio Pérez-Martínez
- Translational Research in Paediatric Oncology, Haematopoietic Transplantation and Cell Therapy, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain
| | - Eduardo López-Collazo
- Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain
| | - Silvia Sánchez-Ramón
- Interdepartmental Group of Immunodeficiencies, Madrid, Spain; Clinical Immunology Department, San Carlos Clinical Hospital, Madrid, Spain
| | - Jean-Laurent Casanova
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale U1163, Paris, France; St Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY; Imagine Institute, University Paris Descartes, Paris, France; Howard Hughes Medical Institute, New York, NY
| | - Rubén Martínez-Barricarte
- Division of Genetic Medicine, Department of Medicine, Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tenn; Division of Molecular Pathogenesis, Department of Pathology, Microbiology, and Immunology, Vanderbilt Center for Immunobiology, Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, Tenn
| | | | - Rebeca Pérez de Diego
- Laboratory of Immunogenetics of Human Diseases, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Innate Immunity Group, IdiPAZ Institute for Health Research, La Paz University Hospital, Madrid, Spain; Interdepartmental Group of Immunodeficiencies, Madrid, Spain.
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4
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Mestre-Durán C, Martín-Cortázar C, García-Solís B, Pernas A, Pertíñez L, Galán V, Sisinni L, Clares-Villa L, Navarro-Zapata A, Al-Akioui K, Escudero A, Ferreras C, Pérez-Martínez A. Ruxolitinib does not completely abrogate the functional capabilities of TLR4/9 ligand-activated NK cells. Front Immunol 2023; 13:1045316. [PMID: 36685552 PMCID: PMC9851469 DOI: 10.3389/fimmu.2022.1045316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/16/2022] [Indexed: 01/06/2023] Open
Abstract
Introduction Natural killer (NK) cells are lymphocytes from the innate immune system part of the first defense barrier against infected and transformed cells, representing 5%-15% of peripheral blood lymphocytes. The cytotoxic capacity of NK cells is controlled by a balance between inhibitory and activating NK receptors expressed on their surface, which recognize and interact with the ligands on stressed cells. The cytokines involved in NK cell activation, proliferation, survival, and cytotoxicity are signaled mainly through the Janus kinase and signal transducer and activator of transcription proteins (JAK/STAT) pathway. NK cells are also activated in response to pathogens through Toll-like receptors (TLRs) expressed on their surface. Ruxolitinib is a specific JAK1/2 inhibitor approved for treating myelofibrosis and for steroid-refractory acute and chronic graft-versus-host disease (SR-GvHD). Methods Purified NK cells from healthy donors were stimulated with two TOLL-like receptor ligands, LPS and CpG, in the presence of different concentrations of Ruxolitinib. Results This study showed the effects of ruxolitinib on TLR4 and TLR9 ligand-activated NK cells from healthy donors. Ruxolitinib did not completely inhibit STAT3 phosphorylation and had a moderate effect on NK cell cytokine activation via the TLR pathway. Only the highest doses of ruxolitinib led to a decrease in the pro-inflammatory cytokines tumor necrosis factor α, interferon-γ, interleukin-6, and interleukin-1β. The cytotoxic capacity of stimulated NK cells versus K562, SEM, and MV-4-11 cell lines was reduced by increasing doses of ruxolitinib, but it was not completely abolished and we observed no major changes in degranulation capacity. Phenotypic changes were observed in activated NK cells in the presence of ruxolitinib. In a small cohort of pediatric patients treated with ruxolitinib for SR-GvHD, we observed no decrease in NK cell counts; however, further prospective studies with larger cohorts are necessary to confirm this finding. Discussion In summary, our results showed that the functional capabilities and phenotype of NK cells activated through TLR4/9 agonists were not completely abolished by the inhibition of the JAK-STAT pathway by ruxolitinib.
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Affiliation(s)
- Carmen Mestre-Durán
- Translational Research in Pediatric Oncology, Hematopoietic Transplantation and Cell Therapy Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Carla Martín-Cortázar
- Translational Research in Pediatric Oncology, Hematopoietic Transplantation and Cell Therapy Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Blanca García-Solís
- Laboratory of Immunogenetics of Human Diseases, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Alicia Pernas
- Department of Genetics, Institute of Medical and Molecular Genetics (INGEMM), La Paz University Hospital, Madrid, Spain
| | - Lidia Pertíñez
- Translational Research in Pediatric Oncology, Hematopoietic Transplantation and Cell Therapy Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Víctor Galán
- Pediatric Hemato-Oncology Department, La Paz University Hospital, Madrid, Spain
| | - Luisa Sisinni
- Pediatric Hemato-Oncology Department, La Paz University Hospital, Madrid, Spain
| | - Laura Clares-Villa
- Translational Research in Pediatric Oncology, Hematopoietic Transplantation and Cell Therapy Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Alfonso Navarro-Zapata
- Translational Research in Pediatric Oncology, Hematopoietic Transplantation and Cell Therapy Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Karima Al-Akioui
- Translational Research in Pediatric Oncology, Hematopoietic Transplantation and Cell Therapy Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Adela Escudero
- Translational Research in Pediatric Oncology, Hematopoietic Transplantation and Cell Therapy Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
- Department of Genetics, Institute of Medical and Molecular Genetics (INGEMM), La Paz University Hospital, Madrid, Spain
| | - Cristina Ferreras
- Translational Research in Pediatric Oncology, Hematopoietic Transplantation and Cell Therapy Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Antonio Pérez-Martínez
- Translational Research in Pediatric Oncology, Hematopoietic Transplantation and Cell Therapy Group, Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
- Pediatric Hemato-Oncology Department, La Paz University Hospital, Madrid, Spain
- Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
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