1
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Sharabati I, Ayesh BM, Qafesha RM, Rasras H, Abunejma FM, Abdulrazzak M, Jobran AW. Central retinal artery occlusion in a child with ADA2 deficiency: a case report. Ann Med Surg (Lond) 2024; 86:2343-2347. [PMID: 38576931 PMCID: PMC10990381 DOI: 10.1097/ms9.0000000000001857] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/12/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction and importance Deficiency of ADA2 (DADA2) is the first molecularly described monogenic vasculitis syndrome. During the past decade, DADA2's clinical spectrum has expanded significantly as the number of reported cases has increased. Case presentation A 5-year-old boy with DADA2 who experienced sudden onset left-sided vision loss due to unilateral central retinal artery occlusion. The patient had a history of recurrent fever and arthralgia with high inflammatory markers (C-reactive protein and erythrocyte sedimentation rate). Brain MRI showed mild limbic encephalitis, and MRA was normal. His gene sequencing results demonstrated substitutions mutation in ADA2, and the diagnosis of DADA2 was eventually confirmed. Clinical discussion Central retinal artery occlusion (CRAO) in paediatrics is a very rare condition. Typically, DADA2 presents in childhood as systemic inflammation, vasculitis, humoral immunodeficiency, and/or haematologic abnormalities. The most common phenotype described in the literature is vasculitis, which typically affects the skin and central nervous system, but other systems can also be affected. Ophthalmic manifestations are less common and highly variable. Conclusions DADA2 manifests rarely with central retinal artery occlusion; therefore, physicians should be aware of this manifestation.
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Affiliation(s)
| | | | | | - Heba Rasras
- Faculty of Medicine, Al Quds University, Jerusalem
| | - Fawzy M. Abunejma
- Ahli Hospital, PRCS Hebron Hospital, Hebron University, Hebron, Palestine
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2
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Verschoof MA, van Meenen LCC, Andriessen MVE, Brinkman DMC, Kamphuis S, Kuijpers TW, Leavis HL, Legger GE, Mulders-Manders CM, de Pagter APJ, Rutgers A, van Well GTJ, Coutinho JM, Hak AE, van Montfrans JM, Klouwer FCC. Neurological phenotype of adenosine deaminase 2 deficient patients: a cohort study. Eur J Neurol 2024; 31:e16043. [PMID: 37584090 DOI: 10.1111/ene.16043] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/22/2023] [Accepted: 08/11/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND PURPOSE Patients with adenosine deaminase 2 (ADA2) deficiency can present with various neurological manifestations due to vasculopathies and autoinflammation. These include ischaemic and hemorrhagic stroke, but less clearly defined neurological symptoms have also been reported. METHODS In this cohort study, patients with confirmed ADA2 deficiency from seven university hospitals in the Netherlands were included. The frequency and recurrence rates of neurological manifestations before and after initiation of tumor necrosis factor α (TNF-α) inhibiting therapy were analyzed. RESULTS Twenty-nine patients were included with a median age at presentation of 5 years (interquartile range 1-17). Neurological manifestations occurred in 19/29 (66%) patients and were the presenting symptom in 9/29 (31%) patients. Transient ischaemic attack (TIA)/ischaemic stroke occurred in 12/29 (41%) patients and was the presenting symptom in 8/29 (28%) patients. In total, 25 TIAs/ischaemic strokes occurred in 12 patients, one after initiation of TNF-α inhibiting therapy and one whilst switching between TNF-α inhibitors. None was large-vessel occlusion stroke. Two hemorrhagic strokes occurred: one aneurysmatic subarachnoid hemorrhage and one spontaneous intracerebral hemorrhage. Most neurological symptoms, including cranial nerve deficits, vertigo, ataxia and seizures, were caused by TIAs/ischaemic strokes and seldom recurred after initiation of TNF-α inhibiting therapy. CONCLUSIONS Neurological manifestations, especially TIA/ischaemic stroke, are common in patients with ADA2 deficiency and frequently are the presenting symptom. Because it is a treatable cause of young stroke, for which antiplatelet and anticoagulant therapy are considered contraindicated, awareness amongst neurologists and pediatricians is important. Screening for ADA2 deficiency in young patients with small-vessel ischaemic stroke without an identified cause should be considered.
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Affiliation(s)
| | - Laura C C van Meenen
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Valérie E Andriessen
- Department of Pediatric Immunology and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daniëlle M C Brinkman
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylvia Kamphuis
- Department of Pediatric Rheumatology, Sophia Children's Hospital, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Taco W Kuijpers
- Department of Pediatric Immunology and Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Helen L Leavis
- Department of Rheumatology and Clinical Immunology, University Medical Center and Utrecht University, Utrecht, The Netherlands
| | - G Elizabeth Legger
- Department of Pediatric Rheumatology and Immunology, University Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Catharina M Mulders-Manders
- Department of Internal Medicine, Radboud Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anne P J de Pagter
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Abraham Rutgers
- Department of Rheumatology and Clinical Immunology, University Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gijs T J van Well
- Division of Pediatric Infectious Diseases, Immunology & Rheumatology, Department of Pediatrics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Elisabeth Hak
- Departments of Internal Medicine and Rheumatology and Clinical Immunology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris M van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Femke C C Klouwer
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pediatric Neurology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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3
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Celikel E, Aydin F, Tekin ZE, Kurt T, Sezer M, Tekgoz N, Karagol C, Coskun S, Kaplan MM, Kurt ANC, Acar BC. Deficiency of adenosine deaminase 2 as an unrecognized cause of early-onset stroke and cranial nerve palsy. North Clin Istanb 2023; 10:411-417. [PMID: 37719263 PMCID: PMC10500243 DOI: 10.14744/nci.2022.45380] [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: 09/15/2021] [Revised: 02/02/2022] [Accepted: 06/30/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The aim of this study is to evaluate the clinical, laboratory, and radiological findings and prognosis of patients with adenosine deaminase 2 deficiency (DADA2) and to highlight the conditions that DADA2 should be considered in the differential diagnosis in patients with neurological findings. METHODS A case series of six DADA2 patients was presented in this retrospective, descriptive study. Clinical and laboratory data, treatment protocols, and prognosis of the patients were recorded. A diagnosis of DADA2 was established by ADA2 enzyme activity assay and/or ADA2 gene sequencing. RESULTS Six patients with DADA2 were included in the study. The median age at symptom onset was 6.5 years (range 3.5-13.5 years). The median time to diagnosis from the initial presentation was 9 (3-72) months. Consanguinity was present in the families of 4 cases. The skin, nervous system, and musculoskeletal system were the most commonly involved systems. Vasculitis mimicking polyarteritis nodosa (PAN) was the predominant phenotype (n=4) in our case series. Four patients with PAN-like features had neurological involvement. Ischemic strokes were found in 3 patients, cranial nerve palsy in 2 patients, and seizures in 2 patients. The CECR1 gene was analyzed in all patients. We analyzed plasma ADA2 enzyme activity only in one patient. Anti-tumor necrosis factor (TNF)-α therapy was initiated. Inflammation was suppressed and remission was achieved in all patients. CONCLUSION DADA2 should be considered in patients with PAN-like disease, a history of familial PAN/vasculitis, early-onset strokes/neurological involvement with systemic inflammation. Furthermore, anti-TNF-α therapy appears to be beneficial for the treatment of DADA2.
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Affiliation(s)
- Elif Celikel
- Department of Pediatric Rheumatology, Ankara City Hospital, Ankara, Turkiye
| | - Fatma Aydin
- Department of Pediatric Rheumatology, Ankara City Hospital, Ankara, Turkiye
| | - Zahide Ekici Tekin
- Department of Pediatric Rheumatology, Ankara City Hospital, Ankara, Turkiye
| | - Tuba Kurt
- Department of Pediatric Rheumatology, Ankara City Hospital, Ankara, Turkiye
| | - Muge Sezer
- Department of Pediatric Rheumatology, Ankara City Hospital, Ankara, Turkiye
| | - Nilufer Tekgoz
- Department of Pediatric Rheumatology, Ankara City Hospital, Ankara, Turkiye
| | - Cuneyt Karagol
- Department of Pediatric Rheumatology, Ankara City Hospital, Ankara, Turkiye
| | - Serkan Coskun
- Department of Pediatric Rheumatology, Ankara City Hospital, Ankara, Turkiye
| | | | - Aysegul Nese Citak Kurt
- Department of Pediatric Neurology, Yildirim Beyazit University Faculty of Medicine, Ankara, Turkiye
| | - Banu Celikel Acar
- Department of Pediatric Rheumatology, Ankara City Hospital, Ankara, Turkiye
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4
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Duhamel N, Queyrel V, Tieulié N, Comont T. [Multiple strokes in a 17-year-old woman]. Rev Med Interne 2023; 44:388-390. [PMID: 37236869 DOI: 10.1016/j.revmed.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023]
Affiliation(s)
- N Duhamel
- Service de rhumatologie, hôpital Pasteur 2, CHU de Nice, 30, voie Romaine, CS 51069 06001 Nice cedex 1, France.
| | - V Queyrel
- Service de rhumatologie, hôpital Pasteur 2, CHU de Nice, 30, voie Romaine, CS 51069 06001 Nice cedex 1, France
| | - N Tieulié
- Service de rhumatologie, hôpital Pasteur 2, CHU de Nice, 30, voie Romaine, CS 51069 06001 Nice cedex 1, France
| | - T Comont
- Service de médecine interne, oncopôle, CHU de Toulouse, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
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5
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Wu Z, Rajput RV. Novel pathogenic ADA2 mutations: alert to diagnosis challenge of ADA2 deficiency. Transl Pediatr 2023; 12:110-112. [PMID: 36891360 PMCID: PMC9986784 DOI: 10.21037/tp-23-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 01/16/2023] [Indexed: 02/12/2023] Open
Affiliation(s)
- Zhijie Wu
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Roma V Rajput
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.,Department of Pediatric Hematology and Oncology, Children's National Hospital, Washington, DC, USA
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6
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Cho S, Park S, Lee JS, Ju YS, Choi YJ, Lee S. Adenosine Deaminase 2 Deficiency Caused by Biallele Variants Including Splicing Variant: The First Case in Korea. J Rheum Dis 2022; 29:254-260. [PMID: 37476427 PMCID: PMC10351412 DOI: 10.4078/jrd.21.0046] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/30/2021] [Accepted: 11/04/2021] [Indexed: 07/22/2023]
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is an autoinflammatory disease caused by pathogenic variants of the ADA2 gene and has similar clinical features to polyarteritis nodosa (PAN). We, herein, report a case of DADA2 in Korea that was diagnosed in a patient with childhood-onset PAN. The patient had a truncal ataxia and facial palsy caused by thalamic infarction at 34 months of age. Livedo reticularis with Raynaud phenomenon and abdominal pain with fever were followed. Radiologic examination showed multiple infarctions in brain and kidney. She was diagnosed with PAN using skin biopsy and angiography. She had severe hemorrhagic strokes despite medical treatments. Her disease activity was controlled after adding a tumor necrosis factor-α inhibitor. Molecular analysis revealed compound heterozygous pathogenic variants of ADA2 gene. This is the first case of DADA2 in Korea. Genetic analysis for ADA2 gene should be considered in patients with childhood-onset PAN.
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Affiliation(s)
- Sun Cho
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
| | | | | | - Young Seok Ju
- GENOME INSIGHT Inc., Daejeon, Korea
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Yun Jung Choi
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
- Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Soyoung Lee
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
- GENOME INSIGHT Inc., Daejeon, Korea
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7
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Yap JY, Moens L, Lin MW, Kane A, Kelleher A, Toong C, Wu KHC, Sewell WA, Phan TG, Hollway GE, Enthoven K, Gray PE, Casas-Martin J, Wouters C, De Somer L, Hershfield M, Bucciol G, Delafontaine S, Ma CS, Tangye SG, Meyts I. Intrinsic Defects in B Cell Development and Differentiation, T Cell Exhaustion and Altered Unconventional T Cell Generation Characterize Human Adenosine Deaminase Type 2 Deficiency. J Clin Immunol 2021; 41:1915-1935. [PMID: 34657246 PMCID: PMC8604888 DOI: 10.1007/s10875-021-01141-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/22/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Deficiency of adenosine deaminase type 2 (ADA2) (DADA2) is a rare inborn error of immunity caused by deleterious biallelic mutations in ADA2. Clinical manifestations are diverse, ranging from severe vasculopathy with lacunar strokes to immunodeficiency with viral infections, hypogammaglobulinemia and bone marrow failure. Limited data are available on the phenotype and function of leukocytes from DADA2 patients. The aim of this study was to perform in-depth immunophenotyping and functional analysis of the impact of DADA2 on human lymphocytes. METHODS In-depth immunophenotyping and functional analyses were performed on ten patients with confirmed DADA2 and compared to heterozygous carriers of pathogenic ADA2 mutations and normal healthy controls. RESULTS The median age of the patients was 10 years (mean 20.7 years, range 1-44 years). Four out of ten patients were on treatment with steroids and/or etanercept or other immunosuppressives. We confirmed a defect in terminal B cell differentiation in DADA2 and reveal a block in B cell development in the bone marrow at the pro-B to pre-B cell stage. We also show impaired differentiation of CD4+ and CD8+ memory T cells, accelerated exhaustion/senescence, and impaired survival and granzyme production by ADA2 deficient CD8+ T cells. Unconventional T cells (i.e. iNKT, MAIT, Vδ2+ γδT) were diminished whereas pro-inflammatory monocytes and CD56bright immature NK cells were increased. Expression of the IFN-induced lectin SIGLEC1 was increased on all monocyte subsets in DADA2 patients compared to healthy donors. Interestingly, the phenotype and function of lymphocytes from healthy heterozygous carriers were often intermediate to that of healthy donors and ADA2-deficient patients. CONCLUSION Extended immunophenotyping in DADA2 patients shows a complex immunophenotype. Our findings provide insight into the cellular mechanisms underlying some of the complex and heterogenous clinical features of DADA2. More research is needed to design targeted therapy to prevent viral infections in these patients with excessive inflammation as the overarching phenotype.
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Affiliation(s)
- Jin Yan Yap
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia
| | - Leen Moens
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium
| | - Ming-Wei Lin
- Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia.,Department of Clinical Immunology and Immunopathology, Westmead Hospital, Westmead, NSW, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Alisa Kane
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia.,Department of Immunology, Liverpool Hospital, Allergy and HIV, Liverpool, Sydney, Australia.,HIV and Immunology Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, Sydney, NSW, Australia
| | - Anthony Kelleher
- HIV and Immunology Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia.,The Kirby Institute for Infection and Immunity in Society, Sydney, Australia
| | - Catherine Toong
- Department of Immunology, Liverpool Hospital, Allergy and HIV, Liverpool, Sydney, Australia
| | - Kathy H C Wu
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,St Vincent's Clinical Genomics, St Vincent's Hospital Darlinghurst, Darlinghurst, NSW, Australia.,School of Medicine, UNSW Sydney, Sydney, Australia.,Discipline of Genetic Medicine, University of Sydney, Sydney, Australia.,School of Medicine, University of Notre Dame, Fremantle, Australia
| | - William A Sewell
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, Sydney, NSW, Australia
| | - Tri Giang Phan
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia.,HIV and Immunology Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Georgina E Hollway
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia
| | - Karen Enthoven
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia
| | - Paul E Gray
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, Australia.,School of Women's and Children's Health, UNSW Sydney, Sydney, NSW, Australia
| | - Jose Casas-Martin
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium
| | - Carine Wouters
- Department of Microbiology and Immunology, Herestraat 49, 3000, Leuven, EU, Belgium.,Department of Pediatrics, University Hospitals Leuven, Leuven, EU, Belgium
| | - Lien De Somer
- Department of Microbiology and Immunology, Herestraat 49, 3000, Leuven, EU, Belgium.,Department of Pediatrics, University Hospitals Leuven, Leuven, EU, Belgium
| | - Michael Hershfield
- Department of Medicine and Biochemistry, Duke University Medical Center, Durham, NC, USA
| | - Giorgia Bucciol
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium.,Department of Pediatrics, Division of Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, EU Leuven, Belgium
| | - Selket Delafontaine
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium.,Department of Pediatrics, Division of Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, EU Leuven, Belgium
| | - Cindy S Ma
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, Sydney, NSW, Australia
| | - Stuart G Tangye
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia. .,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia. .,Faculty of Medicine, St Vincent's Clinical School, Sydney, NSW, Australia.
| | - Isabelle Meyts
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium. .,Department of Medicine and Biochemistry, Duke University Medical Center, Durham, NC, USA.
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8
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Nihira H, Izawa K, Ito M, Umebayashi H, Okano T, Kajikawa S, Nanishi E, Keino D, Murakami K, Isa-Nishitani M, Shiba T, Honda Y, Hijikata A, Yasu T, Kubota T, Hasegawa Y, Kawashima Y, Nakano N, Takada H, Ohga S, Heike T, Takita J, Ohara O, Takei S, Takahashi M, Kanegane H, Morio T, Iwaki-Egawa S, Sasahara Y, Nishikomori R, Yasumi T. Detailed analysis of Japanese patients with adenosine deaminase 2 deficiency reveals characteristic elevation of type II interferon signature and STAT1 hyperactivation. J Allergy Clin Immunol 2021; 148:550-562. [PMID: 33529688 DOI: 10.1016/j.jaci.2021.01.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [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: 07/05/2020] [Revised: 01/15/2021] [Accepted: 01/21/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive inflammatory disease caused by loss-of-function mutations in both alleles of the ADA2 gene. Most patients with DADA2 exhibit systemic vasculopathy consistent with polyarteritis nodosa, but large phenotypic variability has been reported, and the pathogenesis of DADA2 remains unclear. OBJECTIVES This study sought to assess the clinical and genetic characteristics of Japanese patients with DADA2 and to gain insight into the pathogenesis of DADA2 by multi-omics analysis. METHODS Clinical and genetic data were collected from 8 Japanese patients with DADA2 diagnosed between 2016 and 2019. ADA2 variants in this cohort were functionally analyzed by in vitro overexpression analysis. PBMCs from 4 patients with DADA2 were subjected to transcriptome and proteome analyses. Patient samples were collected before and after introduction of anti- TNF-α therapies. Transcriptome data were compared with those of normal controls and patients with other autoinflammatory diseases. RESULTS Five novel ADA2 variants were identified in these 8 patients and were confirmed pathogenic by in vitro analysis. Anti-TNF-α therapy controlled inflammation in all 8 patients. Transcriptome and proteome analyses showed that upregulation of type II interferon signaling was characteristic of DADA2. Network analysis identified STAT1 as a key regulator and a hub molecule in DADA2 pathogenesis, a finding supported by the hyperactivation of STAT1 in patients' monocytes and B cells after IFN-γ stimulation. CONCLUSIONS Type II interferon signaling and STAT1 are associated with the pathogenesis of DADA2.
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Affiliation(s)
- Hiroshi Nihira
- Department of Pediatrics, Kyoto University, Kyoto, Japan
| | - Kazushi Izawa
- Department of Pediatrics, Kyoto University, Kyoto, Japan.
| | - Moeko Ito
- Department of Pharmacy, Hokkaido University of Science, Sapporo, Japan
| | | | - Tsubasa Okano
- Department of Pediatrics and Development Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Etsuro Nanishi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Dai Keino
- Division of Hematology/Oncology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Kosaku Murakami
- Department of Rheumatology and Clinical Immunology, Kyoto University, Kyoto, Japan
| | | | - Takeshi Shiba
- Department of Pediatrics, Tenri Hospital, Tenri, Japan
| | | | - Atsushi Hijikata
- Department of Bioscience, Nagahama Institute of Bio-Science and Technology, Nagahama, Japan
| | - Tadateru Yasu
- Department of Pediatrics, Nagasaki Medical Center, Omura, Japan
| | - Tomohiro Kubota
- Department of Pediatrics, Kagoshima University, Kagoshima, Japan
| | - Yoshinori Hasegawa
- Department of Applied Genomics, Kazusa DNA Research Institute, Kisarazu, Japan
| | - Yusuke Kawashima
- Department of Applied Genomics, Kazusa DNA Research Institute, Kisarazu, Japan
| | - Naoko Nakano
- Department of Pediatrics, Ehime University, Toon, Japan
| | - Hidetoshi Takada
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshio Heike
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Junko Takita
- Department of Pediatrics, Kyoto University, Kyoto, Japan
| | - Osamu Ohara
- Department of Applied Genomics, Kazusa DNA Research Institute, Kisarazu, Japan
| | - Syuji Takei
- Department of Pediatrics, Kagoshima University, Kagoshima, Japan
| | - Makio Takahashi
- Department of Neurology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hirokazu Kanegane
- Department of Child Health and Development, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Development Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Yoji Sasahara
- Department of Pediatrics, Tohoku University, Sendai, Japan
| | - Ryuta Nishikomori
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
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9
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Saettini F, Fazio G, Corti P, Quadri M, Bugarin C, Gaipa G, Penco F, Moratto D, Chiarini M, Baronio M, Gazzurelli L, Imberti L, Paghera S, Giliani S, Cazzaniga G, Plebani A, Badolato R, Lougaris V, Gattorno M, Biondi A. Two siblings presenting with novel ADA2 variants, lymphoproliferation, persistence of large granular lymphocytes, and T-cell perturbations. Clin Immunol 2020; 218:108525. [PMID: 32659374 DOI: 10.1016/j.clim.2020.108525] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/26/2020] [Accepted: 07/07/2020] [Indexed: 12/25/2022]
Abstract
The presence of large granular lymphocytes has been reported in patients with ADA2 deficiency and T-LGL leukemia. Here we describe two siblings with novel ADA2 variants, expanding the mutational spectrum of ADA2 deficiency. We show that lymphoproliferation, persistence of large granular lymphocytes, T-cell perturbations, and activation of PI3K pathway, measured by means of phosphorylation levels of S6, are detectable in DADA2 patients without T-LGL leukemia.
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Affiliation(s)
- F Saettini
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy.
| | - G Fazio
- Centro Ricerca Tettamanti, University of Milan Bicocca, Monza, Italy
| | - P Corti
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
| | - M Quadri
- Centro Ricerca Tettamanti, University of Milan Bicocca, Monza, Italy
| | - C Bugarin
- Centro Ricerca Tettamanti, University of Milan Bicocca, Monza, Italy
| | - G Gaipa
- Centro Ricerca Tettamanti, University of Milan Bicocca, Monza, Italy
| | - F Penco
- Center for Autoinflammatory disease and Immunodeficiencies, IRCCS G. Gaslini, Genova, Italy
| | - D Moratto
- Flow cytometry Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - M Chiarini
- Flow cytometry Laboratory, Diagnostic Department, ASST Spedali Civili di Brescia, Brescia, Italy
| | - M Baronio
- Pediatrics Clinic and Institute of Molecular Medicine A. Novicelli, Department of Clinical and Experimental Sciences, University of Brescia, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - L Gazzurelli
- Pediatrics Clinic and Institute of Molecular Medicine A. Novicelli, Department of Clinical and Experimental Sciences, University of Brescia, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - L Imberti
- Centro di Ricerca Emato-oncologica AIL (CREA), ASST Spedali Civili, Brescia, Italy
| | - S Paghera
- Centro di Ricerca Emato-oncologica AIL (CREA), ASST Spedali Civili, Brescia, Italy
| | - S Giliani
- Pediatrics Clinic and Institute of Molecular Medicine A. Novicelli, Department of Clinical and Experimental Sciences, University of Brescia, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - G Cazzaniga
- Centro Ricerca Tettamanti, University of Milan Bicocca, Monza, Italy; Department of Medicine and Surgery, University of Milan Bicocca, Monza, Italy
| | - A Plebani
- Pediatrics Clinic and Institute of Molecular Medicine A. Novicelli, Department of Clinical and Experimental Sciences, University of Brescia, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - R Badolato
- Pediatrics Clinic and Institute of Molecular Medicine A. Novicelli, Department of Clinical and Experimental Sciences, University of Brescia, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - V Lougaris
- Pediatrics Clinic and Institute of Molecular Medicine A. Novicelli, Department of Clinical and Experimental Sciences, University of Brescia, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - M Gattorno
- Center for Autoinflammatory disease and Immunodeficiencies, IRCCS G. Gaslini, Genova, Italy
| | - A Biondi
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy; Centro Ricerca Tettamanti, University of Milan Bicocca, Monza, Italy
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10
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Barzaghi F, Minniti F, Mauro M, Bortoli MD, Balter R, Bonetti E, Zaccaron A, Vitale V, Omrani M, Zoccolillo M, Brigida I, Cicalese MP, Degano M, Hershfield MS, Aiuti A, Bondarenko AV, Chinello M, Cesaro S. ALPS-Like Phenotype Caused by ADA2 Deficiency Rescued by Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2019; 9:2767. [PMID: 30692987 PMCID: PMC6339927 DOI: 10.3389/fimmu.2018.02767] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/12/2018] [Indexed: 11/13/2022] Open
Abstract
Adenosine deaminase 2 (ADA2) deficiency is an auto-inflammatory disease due to mutations in cat eye syndrome chromosome region candidate 1 (CECR1) gene, currently named ADA2. The disease has a wide clinical spectrum encompassing early-onset vasculopathy (targeting skin, gut and central nervous system), recurrent fever, immunodeficiency and bone marrow dysfunction. Different therapeutic options have been proposed in literature, but only steroids and anti-cytokine monoclonal antibodies (such as tumor necrosis factor inhibitor) proved to be effective. If a suitable donor is available, hematopoietic stem cell transplantation (HSCT) could be curative. Here we describe a case of ADA2 deficiency in a 4-year-old Caucasian girl. The patient was initially classified as autoimmune neutropenia and then she evolved toward an autoimmune lymphoproliferative syndrome (ALPS)-like phenotype. The diagnosis of ALPS became uncertain due to atypical clinical features and normal FAS-induced apoptosis test. She was treated with G-CSF first and subsequently with immunosuppressive drugs without improvement. Only HSCT from a 9/10 HLA-matched unrelated donor, following myeloablative conditioning, completely solved the clinical signs related to ADA2 deficiency. Early diagnosis in cases presenting with hematological manifestations, rather than classical vasculopathy, allows the patients to promptly undergo HSCT and avoid more severe evolution. Finally, in similar cases highly suspicious for genetic disease, it is desirable to obtain molecular diagnosis before performing HSCT, since it can influence the transplant procedure. However, if HSCT has to be performed without delay for clinical indication, related donors should be excluded to avoid the risk of relapse or partial benefit due to a hereditary genetic defect.
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Affiliation(s)
- Federica Barzaghi
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Department of Systems Medicine, Tor Vergata University, >Rome, Italy
| | - Federica Minniti
- Paediatric Hematology-Oncology, Ospedale della Donna e del Bambino, Verona, Italy
| | - Margherita Mauro
- Paediatric Hematology-Oncology, Ospedale della Donna e del Bambino, Verona, Italy
| | | | - Rita Balter
- Paediatric Hematology-Oncology, Ospedale della Donna e del Bambino, Verona, Italy
| | - Elisa Bonetti
- Paediatric Hematology-Oncology, Ospedale della Donna e del Bambino, Verona, Italy
| | - Ada Zaccaron
- Paediatric Hematology-Oncology, Ospedale della Donna e del Bambino, Verona, Italy
| | - Virginia Vitale
- Paediatric Hematology-Oncology, Ospedale della Donna e del Bambino, Verona, Italy
| | - Maryam Omrani
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Zoccolillo
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Department of Systems Medicine, Tor Vergata University, >Rome, Italy
| | - Immacolata Brigida
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Pia Cicalese
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Degano
- Biocrystallography Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michael S Hershfield
- Department of Medicine and Biochemistry, Duke University School of Medicine, Durham, NC, United States
| | - Alessandro Aiuti
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Anastasiia V Bondarenko
- Department of Pediatric Infectious Diseases and Immunology, Medical Academy of Postgraduate Education, Kiev, Ukraine
| | - Matteo Chinello
- Paediatric Hematology-Oncology, Ospedale della Donna e del Bambino, Verona, Italy
| | - Simone Cesaro
- Paediatric Hematology-Oncology, Ospedale della Donna e del Bambino, Verona, Italy
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11
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Alsultan A, Basher E, Alqanatish J, Mohammed R, Alfadhel M. Deficiency of ADA2 mimicking autoimmune lymphoproliferative syndrome in the absence of livedo reticularis and vasculitis. Pediatr Blood Cancer 2018; 65. [PMID: 29271561 DOI: 10.1002/pbc.26912] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 11/06/2017] [Accepted: 11/08/2017] [Indexed: 12/15/2022]
Abstract
Adenosine deaminase-2 (ADA2) deficiency (DADA2) is associated with early onset polyarteritis nodosa and vasculopathy. Classic presentation includes livedo reticularis, vasculitis, and stroke. However, the phenotype and disease severity are variable. We present a 5-year-old female who presented with features that mimicked autoimmune lymphoproliferative syndrome (ALPS) in the absence of classic features of DADA2. Exome sequencing identified a novel homozygous splicing variant in ADA2 c.882-2A > G. Patient responded to anti- tumor necrosis factor medication and is in complete remission. Hematologists should be aware of various hematological presentations of DADA2, including ALPS-like disorder, that might lack vasculitis and livedo reticularis to prevent delay in initiating optimal therapy.
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Affiliation(s)
- Abdulrahman Alsultan
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Enas Basher
- Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Jubran Alqanatish
- Department of Pediatrics, King Abdullah Specialist Children's Hospital and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Reem Mohammed
- Department of Pediatrics, King Abdullah Specialist Children's Hospital and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Majid Alfadhel
- Department of Pediatrics, King Abdullah Specialist Children's Hospital and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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