Staphylococcus aureus and Hyper-IgE Syndrome

Hyper-immunoglobulin E syndrome (HIES) is a primary immunodeficiency disease characterized by recurrent Staphylococcus aureus (S. aureus) infections, eczema, skeletal abnormalities and high titers of serum immunoglobulin E. Although the genetic basis of HIES was not known for almost a half century, HIES most frequently exhibits autosomal dominant trait that is transmitted with variable expressivity. Careful genetic studies in recent years identified dominant-negative mutations in human signal transducer and activator of transcription 3 (STAT3) gene as the cause of sporadic and dominant forms of HIES. The STAT3 mutations were localized to DNA-binding, SRC homology 2 (SH2) and transactivating domains and disrupted T helper 17 (T_H17) cell differentiation and downstream expression of T_H17 cytokines IL-17 and IL-22. Deficiency of IL-17 and IL-22 in turn is responsible for suboptimal expression of anti-staphylococcal host factors, such as neutrophil-recruiting chemokines and antimicrobial peptides, by human keratinocytes and bronchial epithelial cells. T_H17 cytokines deficiency thereby explains the recurrent staphylococcal lung and skin infections of HIES patients.

STAT3 modulates reprogramming efficiency of human somatic cells; insights from autosomal dominant Hyper IgE syndrome caused by STAT3 mutations

Human induced pluripotent stem cell (iPSC) technology has opened exciting opportunities for stem-cell-based therapy. However, its wide adoption is precluded by several challenges including low reprogramming efficiency and potential for malignant transformation. Better understanding of the molecular mechanisms of the changes that cells undergo during reprograming is needed to improve iPSCs generation efficiency and to increase confidence for their clinical use safety. Here, we find that dominant negative mutations in STAT3 in patients with autosomal-dominant hyper IgE (Job's) syndrome (AD-HIES) result in greatly reduced reprograming efficiency of primary skin fibroblasts derived from skin biopsies. Analysis of normal skin fibroblasts revealed upregulation and phosphorylation of endogenous signal transducer and activator of transcription 3 (STAT3) and its binding to the NANOG promoter following transduction with OKSM factors. This coincided with upregulation of NANOG and appearance of cells expressing pluripotency markers. Upregulation of NANOG and number of pluripotent cells were greatly reduced throughout the reprograming process of AD-HIES fibroblasts that was restored by over-expression of functional STAT3. NANOGP8, the human-specific NANOG retrogene that is often expressed in human cancers, was also induced during reprogramming, to very low but detectable levels, in a STAT3-dependent manner. Our study revealed the critical role of endogenous STAT3 in facilitating reprogramming of human somatic cells.

Case report of an unusual presentation of Staphylococcus aureus induced toxic shock syndrome/hyperimmunoglobulinemia E syndrome

RATIONALE

Toxic shock syndrome (TSS) typically is an acute onset multi-organ infection caused by TSS toxin-1 producing Staphylococcus aureus. Herein we describe a highly unusual case report.

PATIENT CONCERNS

A male patient self-referred to the University of Minnesota Hospital with a chronic history of S aureus infection with accompanying fever, hypotension, and nonhealing, football-sized lesion on his leg.

DIAGNOSIS

An unusual case presentation of TSS/hyperimmunoglobulin E syndrome is described. The patient had a leg wound from which TSS toxin-1 S aureus was isolated. The patient exhibited characteristic skewing of T cells to those with variable region, β-chain T cell receptor-2. Other patients have been seen with related presentations.

INTERVENTIONS

The following therapeutic regimen was instituted: vigorous antibacterial scrubs several times daily plus intravenous Ancef 3 days each month; intravenous infusions of immunoglobulin G infusions (28 gm) every 3 weeks; and weekly subcutaneous injections of recombinant granulocyte colony-stimulating factor.

OUTCOME

Improvement was obvious within 3 months: no further cellulitic episodes occurred; the patient regained 95 pounds in 9 months; blanching and cyanosis of fingers disappeared within 3 months as did intractable pain although mild hypesthesias continued for 2 years; erythroderma resolved, and repeat skin biopsies performed after 2 years no longer demonstrated T cell receptor skewing. Although IgE levels have not completely returned to normal, the patient remains in excellent health.

LESSONS

We propose that staphylococcal TSST-1 was responsible for the serious problems suffered by this patient as suggested by the following features: rapid onset of chronic, life-threatening, disorder that began with an episode of staphylococcal sepsis; the extraordinary elevation of IgE levels in this previously non-atopic individual; the acquired severe granulocyte chemotactic defect that accompanied this hyperimmunoglobulinemia ("Job Syndrome") with its accompanying wound-healing defect; and the striking diffuse erythroderma, including palmar erythema ("Red Man Syndrome") with hypotension and fever that also characterizes TSS.

Human hyper-IgE syndrome: singular or plural?

Spectacular progress has been made in the characterization of human hyper-IgE syndrome (HIES) over the last 50 years. HIES is a primary immunodeficiency defined as an association of atopy in a context of very high serum IgE levels, characteristic bacterial and fungal diseases, low-level clinical and biological inflammation, and various non-hematopoietic developmental manifestations. Somewhat arbitrarily, three disorders were successively put forward as the underlying cause of HIES: autosomal dominant (AD) STAT3 deficiency, the only disorder corresponding to the original definition of HIES, and autosomal recessive (AR) DOCK8 and PGM3 deficiencies, in which atopy and high serum IgE levels occur in a context of manifestations not seen in patients with typical HIES. Indeed, these three disorders disrupt different molecular pathways, affect different cell types, and underlie different clinical phenotypes. Surprisingly, several other inherited inborn errors of immunity in which serum IgE levels are high, sometimes almost as high as those in HIES patients, are not considered to belong to the HIES group of diseases. Studies of HIES have been further complicated by the lack of a high serum IgE phenotype in all mouse models of the disease other than two Stat3 mutant strains. The study of infections in mutant mice has helped elucidate only some forms of HIES and infection. Mouse models of these conditions have also been used to study non-hematopoietic phenotypes for STAT3 deficiency, tissue-specific immunity for DOCK8 deficiency, and cell lineage maturation for PGM3 deficiency. We review here the history of the field of HIES since the first clinical description of this condition in 1966, together with the three disorders commonly referred to as HIES, focusing, in particular, on their mouse models. We propose the restriction of the term "HIES" to patients with an AD STAT3-deficiency phenotype, including the most recently described AR ZNF341 deficiency, thus excluding AR DOCK8 and PGM3 deficiencies from the definition of this disease.

Hyperimmunoglobulin E syndrome-like symptoms in a hemodialysis patient who developed multiple subcutaneous Staphylococcus aureus abscesses

Hyperimmunoglobulin E syndrome (HIES) is sporadically triggered by de novo genetic mutations of the signal transducer and activator of transcription 3 (STAT3). Dialysis patients frequently exhibit HIES-like symptoms including elevated IgE levels and recurrent bacterial infections. We herein report the case of a 74-year-old man on hemodialysis (HD) who developed marked IgE elevation and multiple subcutaneous cold Staphylococcus aureus abscesses. We are the first to report that a dialysis patient presented with HIES-like symptoms without the characteristic facies or bone and connective tissue abnormalities. A STAT3 gene analysis was conducted as part of the differential diagnosis.

[Hyper IgE syndrome. Opportune diagnosis and management]

The hyperimmunoglobulin E syndrome was discribed for Buckley, and it also called the Job syndrome. There are two types: dominant autosomal and recessive autosomal. It is a primary, rare and complex immunodeficiency, characterized clinically by recurrent skin abscesses for Staphylococcus aureus, recurrent pneumonia, and pneumatoceles, hypereosinophylia, high serum levels of immunoglobulin E (> 2,000 Ul/mL), early eczema and late loss of primary dentition. Recently a STAT3 mutation has been described as origin of dominant autosomal hyperimmunoglobulin E syndrome. Since 1972, 250 cases have been reported around the world. The diagnosis is done with the Grimbacher criteria and the prognosis depends on the opportune diagnosis and treatment. The incidence is same in women and men. The differential diagnosis is with allergic bronchopulmonary aspergillosis, chronic granullomatose disease, T cell lymphoma, and atopic dermatitis. The treatment is with prophylactic antibiotic, intravenous immunoglobulin or recombinant INF gamma.

Hyperimmunoglobulin E syndrome (Job's syndrome)

Hyperimmunoglobulin E (Hyper IgE) syndrome, also described as Job's syndrome, is a rare primary immunodeficiency disease characterized by recurrent skin and respiratory tract infections, chronic eczematous dermatitis, skeletal abnormalities associated with markedly elevated serum IgE levels. Variable impaired T cell function is described in this disease, but no direct association between IgE levels or clinical manifestations with these abnormalities does exist. We report a case of a patient with recurrent staphylococcal cold abscesses, eczematous dermatitis and high serum IgE levels in which the treatment with Cyclosporine A seems to have a favorable effect.

Hyper IgE in New Zealand black mice due to a dominant-negative CD23 mutation

Immunoglobulin E (IgE) plays a critical role in both resistance to parasitic infection and allergy to environmental antigens. The IgE response is in turn regulated by the B-cell co-receptor CD23, and CD23-deficient mice show exaggerated IgE responses and airway hyper-responsiveness. In this report, we show that New Zealand black (NZB) mice express a variant CD23 allele, with mutations in both the C-lectin-binding domain and stalk region, which fails to bind IgE at high affinity and has reduced expression on the cell surface. Expression of the variant CD23 chain interferes with trimerisation of the receptor and has a dominant-negative effect leading to reduced IgE binding in crosses between NZB and other strains. Genetic mapping shows that the variant CD23 leads to an exaggerated primary IgE response, which is independent of other strain-specific effects. These results suggest that NZB mice or mice carrying the variant allele will be useful models for studying both allergy and quantitative traits associated with atopy. The exaggerated IgE response provides an explanation for the natural resistance of NZB mice to parasitic infection by Leishmania.

Cow's milk allergy in a patient with hyper-IgE syndrome

BACKGROUND

Both hyper-IgE syndrome and food allergies can result in the early onset of skin rash, eosinophilia, and markedly elevated serum IgE. Occasionally, it can be difficult to distinguish the 2 disorders. Most patients with hyper-IgE syndrome do not have food allergy.

OBJECTIVE

To describe a child with cow's milk allergy associated with hyper-IgE syndrome manifesting as failure to thrive (FTT).

METHODS

Epicutaneous skin prick test to cow's milk, CAP radioallergosorbent test, atopy patch tests, and double-blind, placebo-controlled milk challenge (DBPCMC) were performed.

RESULTS

During initial presentation at 3 weeks of age, the circulating eosinophil count increased from 13,800/mm3 to 44,254/mm3 within 2 weeks while taking cephalexin. Despite treatment, he had worsening rash and FTT at 10 weeks of age with an IgE level of 8,454 U/mL. After changing from an infant milk formula with whey protein to an amino acid-based formula in combination with oral antibiotic treatment, his rash and growth velocity improved markedly within 2 months. IgE decreased to 2,747 U/mL. He remained clinically well for 12 months. He subsequently developed additional food and inhalant allergies with an increase in IgE to 12,150 U/mL. Cow's milk allergy was confirmed by epicutaneous skin prick test, atopy patch test, and DBPCMC.

CONCLUSIONS

Traditional prophylactic antistaphylococcal antibiotics, in combination with Neocate formula, were effective in treating the early skin manifestations of hyper-IgE syndrome and FTT in this infant. Cow's milk protein allergy should be considered in patients with hyper-IgE syndrome and FTT.

Acute myocarditis with transient eosinophilia and serum hyper-IgE-emia in a patient with atopic dermatitis

A 14-year-old girl with acute myocarditis, transient eosinophilia, and hyper-IgE-emia associated with atopic dermatitis is described. The patient was admitted because of severe heart failure and shock, and severe atopic dermatitis was seen. Blood examinations showed moderate eosinophilia (1917/mm3) and hyper-IgE-emia (830IU/ml). The response to treatment with dopamine was excellent, and the congestive heart failure was gradually ameliorated, followed by improvement in her atopic dermatitis. In addition, rapid improvement in eosinophilia and hyper-IgE-emia was observed. Histopathological examination of the right ventricular myocardium obtained by endomyocardial biopsy showed mild interstitial fibrosis and mild infiltrations of inflammatory cells, indicating myocarditis. We speculated that the transient eosinophilia and hyper-IgE-emia in the present case indicated that an allergen induced strong allergic reactions, including type 1 allergy, and caused both acute myocarditis and deterioration of the atopic dermatitis; specifically noteworthy is that the patient's disease rapidly improved without corticosteroid treatment.

Hyperimmunoglobin E syndrome: a sign of TH1/TH2 imbalance?

We report on a patient with hyperimmunoglobulin E syndrome, who developed pruritic vesiculopapules from the age of six months and also had recurrent episodes of skin abscesses and oral thrush. Serum IgE was extremely elevated at 59,514 IU/ml and specific IgE antibody to Staphylococcus aureus was positive. Histological examination from a vesiculopapule on the face revealed that eosinophil-rich infiltration involved hair follicles, similar to eosinophilic pustular folliculitis. We also examined cytokine profiles of circulating CD4+ T cells by intracellular cytokine staining and flow cytometry. The ratio of cells positive for interferon-gamma was significantly reduced compared with a control. Several reports have shown decreased interferon-gamma production by peripheral blood mononuclear cells of patients with hyperimmunoglobulin E syndrome. We think that this cytokine profile and the histological findings of our patient support the hypothesis that TH1/TH2 imbalance is involved in hyperimmunoglobulin E syndrome.

Kimura's disease associated with bronchial asthma presenting eosinophilia and hyperimmunoglobulinemia E which were attenuated by suplatast tosilate (IPD-1151T)

A 29-year-old man developed atopic bronchial asthma in association with eosinophilia and hyperimmunoglobulinemia E (hyper-IgE). A biopsy specimen from an inguinal lymph node showed changes consistent with Kimura's disease. IPD-1151T (suplatast tosilate), an anti-allergy drug, attenuated eosinophilia and hyper-IgE as well as the serum level of eosinophil cationic protein (ECP). The drug, however, did not affect the positivity for specific IgE antibodies against common allergens or the bronchial hyperresponsiveness to acetylcholine. Interleukin (IL)-2, IL-4, IL-5, interferon (IFN)-gamma, and tumor necrosis factor (TNF)-alpha were measured to be undetectable in serum before or during therapy. However, the expressions of mRNAs for IL-2, IL-4, IL-5, IFN-gamma, and TNF-alpha in peripheral blood T-lymphocytes and the expression of IL-5 mRNA in peripheral blood eosinophils were detected before and during therapy, which were unchanged by therapy with IPD-1151T. The present results suggest that different mechanisms other than the predominance of type 2 helper (T(H2))-like T-lymphocytes may underlie Kimura's disease and atopic bronchial asthma regarding the findings of eosinophilia and hyper-IgE, which could be modulated by IPD-1151T.