Morning ConferenceJuly 22, 2009

Araya Tangwitoon, MD

HistoryHistory

•• A 14A 14--yearyear--old girl old girl presented with chronic presented with chronic

rhinosinusitisrhinosinusitis and recurrent and recurrent otitisotitis media. media.

•• She had a She had a history of recurrent history of recurrent otitisotitis media since media since

88--yryr--old & a history of recurrent old & a history of recurrent rhinosinusitisrhinosinusitis since since

1010--yryr--old, which not respondedold, which not responded to treatment with to treatment with

various antibioticsvarious antibiotics..

• Nasal discharge culture (1st): P. aeruginosaSensitivity to ciprofloxacin

• Nasal discharge culture (2nd): M. morganiiSensitivity to amikacin, ceftazidime, cefoxitin, imipenem

•• CBC: CBC: HbHb 12.8 mg/12.8 mg/dLdL HctHct 39.2% 39.2%

WBC 8100 /mmWBC 8100 /mm33 N 67% L 26% M 4% Eo1.4%N 67% L 26% M 4% Eo1.4%

PltPlt 216,000 /mm216,000 /mm33

•• Serum Serum IgGIgG 12.4 mg/12.4 mg/dLdL (600(600--1600)1600)

IgMIgM <18.6 mg/<18.6 mg/dLdL (40(40--160)160)

IgAIgA <5.91 mg/<5.91 mg/dLdL (80(80--480)480)

Problem ListsProblem Lists

• A 14-yr-old girl with CRS

• Recurrent sinopulmonary tract infections

• Panhypogammaglobulinemia

•• Secondary Secondary hypogammaglobulinemiahypogammaglobulinemia

•• Primary ImmunodeficiencyPrimary Immunodeficiency

Physical ExaminationPhysical Examination

•• A Thai girl, good consciousness, well coA Thai girl, good consciousness, well co--operateoperate

•• BW 48 kg (P50BW 48 kg (P50--75), Ht 158 cm (P5075), Ht 158 cm (P50--75)75)

•• HEENT: not pale, no jaundiceHEENT: not pale, no jaundice

RtRt ear: TM perforation with opacity & ear: TM perforation with opacity & mucoidmucoid

dischargedischarge

Nose: purulent discharge both nostrils, Nose: purulent discharge both nostrils, Inferior turbinate 3+ bothInferior turbinate 3+ both

Tonsils: 1+, Tonsils: 1+, mucopurulentmucopurulent postnasal drippostnasal drip

•• Heart: normal S1S2, no murmurHeart: normal S1S2, no murmur

•• Lungs: Clear, Lungs: Clear, RtRt = Lt= Lt

•• AbdAbd: soft, not tender, spleen: just palpable, : soft, not tender, spleen: just palpable,

no no hepatomegalyhepatomegaly

•• Ext: normalExt: normal

•• Flow Flow cytometrycytometry: :

WBC 9,050/ul WBC 9,050/ul

Absolute total lymphocyte 2,054/ulAbsolute total lymphocyte 2,054/ul

Lymphocyte 22.7%Lymphocyte 22.7%

%CD3%CD3 92%92% Absolute CD3 1,890 /Absolute CD3 1,890 /ulul

%CD4%CD4 55%55% Absolute CD4 1,130 /Absolute CD4 1,130 /ulul

%CD8%CD8 34%34% Absolute CD8 698 /Absolute CD8 698 /ulul

%CD19%CD19 2%2%

%CD56%CD56 6%6%

•• Serum Serum IgGIgG < 7.3 mg/< 7.3 mg/dLdL (600(600--1600)1600)

IgMIgM < 18.6 mg/< 18.6 mg/dLdL (40(40--160)160)

IgAIgA < 5.91 mg/< 5.91 mg/dLdL (80(80--480)480)

•• Flow Flow cytometrycytometry: WBC 6,150: WBC 6,150 //ulul

ALC 1,550/ul ALC 1,550/ul Lymphocyte 25.2%Lymphocyte 25.2%

%CD3%CD3 91%91% Absolute CD3 1,411 /Absolute CD3 1,411 /ulul

%CD4%CD4 54%54% Absolute CD4 837 /Absolute CD4 837 /ulul

%CD8%CD8 34%34% Absolute CD8 527 /Absolute CD8 527 /ulul

%CD19%CD19 1%1%

%CD56%CD56 5%5%

Problem ListsProblem Lists

• A 14-yr-old girl with CRS

• Recurrent sinopulmonary tract infections

• Panhypogammaglobulinemia

• Low number of circulating B cell

•• Secondary Secondary hypogammaglobulinemiahypogammaglobulinemia

•• Primary ImmunodeficiencyPrimary Immunodeficiency

–– AutosomalAutosomal AgammaglobulinemiaAgammaglobulinemia

–– XX--Linked Linked AgammaglobulinemiaAgammaglobulinemia

–– Common Variable ImmunodeficiencyCommon Variable Immunodeficiency

Secondary hypogammaglobulinemia

• Drug-induced

– Anticonvulsants (e.g., carpamazepineand phenytoin)

– Gold salts

– Penicillamine

– Antimalarial agents

– Methotrexate

• Excessive loss of immunoglobulins

– Protein-losing enteropathy

– Nephrotic range proteinuria

– Severe burns

• Malignancy

– Chronic lymphocytic leukemia

– Non-Hodgkin's B-cell lymphoma

• Infectious diseases

– Epstein-Barr virus

XLA or AR Agammaglobulinemia CVID

Age at onset XLA: 6-12 monthsAR: younger than XLA

Any ages; peak in first & third decades

Sex XLA: malesAR: males and females

males and females

Clinical manifestations

recurrent infections; more severe in AR agammaglobulinemia

recurrent infections,autoimmune manifestations,lymphoma & other selected cancers.

Lymphoid tissue hypoplasia or absent Normal-sized or Enlarged

profound hypogammaglobulinemia(IgG, IgA and IgM)

Peipheral B Cells almost complete absence ofperipheral B cells, as defined byCD19 & CD20 expression (<2%)

normal or low number

XLA; BTK mutationAR; μ heavy chain, Igα, Igß,

λ5/VpreB, BLNK

Serum Ig level Decreased IgG, IgAand/or IgM

Molecular analysis ICOS, CD19, TACI, BAFF-R, Msh5

XLA

AR Agammaglobulinemia

CVID

Berek C et al. Clinical Immunology Principles and Practice.3rd Edition.

Autosomal Recessive Agammaglobulinemia

• When compared with XLA

– an earlier onset of disease

– more severe complications

• Females with early onsetinfections, profoundhypogammaglobulinemia andabsent B cells

• Male patients with negative BTKmutation analysis results

Schroeder HW Jr. Clinical Immunology Principles and Practice.3rd Edition.Aghamohammadi A et al. Primary Immunodeficiency Diseases: Definition, Diagnosis, and Management 1st edition.

S Ferrari et al.Genes and Immunity 2007;8:325–33.

•• 4 pts: homozygous 4 pts: homozygous mutation in IGHMmutation in IGHM

•• 2 pts: 2 pts: compoundcompoundheterozygousheterozygous variationsvariationsinin VpreBVpreB11 genegene

•• SeveralSeveral newnew singlesinglenucleotidenucleotidepolymorphismspolymorphisms bothboth ininthethe μμHCHC andand inin thethe λλ55--likelike//VpreBVpreB--codingcoding genesgeneswerewere identifiedidentified..

Clinical findings in AR agammaglobulinemia

Lopez-Granados E, Porpiglia A, Hogan MB, et al. J Clin Invest 2002; 110:1029-35.

• A 10-month-old Japanese girl with frequent respiratory infectionsand otitis media (onset of infections: 8-month-old)

• Her father was diagnosed as having XLA.

• Her serum IgG 6 mg/dL, IgA 1 mg/dL, IgM 5 mg/dL

• Flow cytometric analysis

– the lack of peripheral B cells with the block of B-cell differentiation in the stages between pro-B cells and pre-B cells in the bone marrow

– the defect of the Bruton tyrosine kinase (BTK) expression on monocytes

Takada H et al. Blood. 2004;103:185-187.

Defect of BTK and block of B-cell differentiation.

Takada H et al. Blood. 2004;103:185-187

PatientPatient Healthy Healthy controlcontrol

PatientPatient Healthy controlHealthy control

PtPt MotherMother FatherFather

Paternal Paternal Grand Grand mommom BrotherBrother

• Maternally derived X chromosome was exclusively inactivated in peripheral blood & oral mucosal cells.

Takada H et al. Blood 2004;103:185-187.

XLA

(Heterozygous abnormality of the BTK gene &

nonrandom X inactivation of maternally derived X chromosome in which normal

BTK gene is located.)

Problem ListsProblem Lists

• A 14-yr-old girl with CRS

• Recurrent sinopulmonary tract infections

• Panhypogammaglobulinemia

• Low number of circulating B cell

•• Secondary Secondary hypogammaglobulinemiahypogammaglobulinemia

•• Primary ImmunodeficiencyPrimary Immunodeficiency

–– AutosomalAutosomal AgammaglobulinemiaAgammaglobulinemia

–– XX--Linked Linked AgammaglobulinemiaAgammaglobulinemia

–– Common Variable ImmunodeficiencyCommon Variable Immunodeficiency

Physical ExaminationPhysical Examination

•• A Thai girl, good consciousness, well coA Thai girl, good consciousness, well co--operateoperate

•• BW 48 kg (P50BW 48 kg (P50--75), Ht 158 cm (P5075), Ht 158 cm (P50--75)75)

•• HEENT: not pale, no jaundiceHEENT: not pale, no jaundice

RtRt ear: TM perforation with opacity & ear: TM perforation with opacity & mucoidmucoid

dischargedischarge

Nose: purulent discharge both nostrils, Nose: purulent discharge both nostrils, Inferior turbinate 3+ bothInferior turbinate 3+ both

Tonsils: 1+,Tonsils: 1+, mucopurulentmucopurulent postnasal drippostnasal drip

•• Heart: normal S1S2, no murmurHeart: normal S1S2, no murmur

•• Lungs: Clear, Lungs: Clear, RtRt = Lt= Lt

•• AbdAbd: soft, not tender, : soft, not tender, spleen: just palpablespleen: just palpable, ,

no no hepatomegalyhepatomegaly

•• Ext: normalExt: normal

Common Variable Immunodeficiency

CVIDCVID• The most common symptomatic PID

• A group of genetically, immunologically &

clinically heterogeneous disorders

• Hypogammaglobulinemia & recurrent

infections

• Complicated by autoimmunity,

granulomatous inflammation,

lymphoproliferation & malignancy

• Inherited in 10-20% of patients

• Associated genetic defects: ICOS, TACI,

CD19, BAFF-R and Msh-5

CVID: CVID: DefinitionDefinition

• Hypogammaglobulinaemia of

> 2 immunoglobulin isotypes

(significant reduction of IgG (>2SD),

reduction of IgA or IgM)

• Recurrent infections

• Impaired functional antibody responses

• Exclusion of other primary antibody

deficiency syndromes & secondary

causes of hypogammaglobulinemia

www.ESID.org

Clinical Features of

CVID patients

CVID: Age at onset & diagnosisNo. of CVID

patients

Age at evaluation; year

Age at onset; year

Age at Diagnosis; year

Delay Diagnosis;

year

Chapel H et al. Blood 2008;112:277-86.

334 mean±SD: 49.4±16.3

(11-90)

mean±SD:

47±17

(10-84)

Median: 44

(12-87)

< 18

Llobet et al.

Pediatr Allergy Immunol2009: 20: 113–118.

22 < 18 NA Median: 7.8

(2.5-16)

NA

Mean: 26.3 median: 24

Mean: 33.5 median: 33

NA

Wehr C et al.

Blood 2008;111:77-85.

303 mean±SD: 27±17

mean±SD:

35±16

NA

Oksenhendler E et al.

Clinical InfectiousDiseases2008;46:1547–54

252 Median: 19 Median: 33.9 Median: 6.9

(0-55)

URSCHEL S et al. J Pediatr 2009;154:

888-94.

32 NA Median:

10.4±4.3

(1.1-17.4)

Median:

5.8±4.2

(0.2-14.3)

Park MA et al. Lancet 2008;372:489-502.

Infectious complications

in CVID patients

Oksenhendler E et al. Clinical Infectious Diseases 2008;46:1547–54.

Chapel H and Cunningham-Rundles C. British Journal of Haematology 2009;145:709–727.

(originally published in Blood. Chapel H. et al. Blood 2008;112:277–286.)

Chapel H et al. Blood 2008;112: 277-86.

a noninfectious complication (with or without breakthrough infections).only breakthroughinfections

Lymphocytic infiltration: n=38Autoimmunity: n=72Enteropathy: n=7Malignancy: n=1

lymphocytic infiltration+autoimmunity: n=28Enteropathy+lymphocytic infiltration: n=8lymphocytic infiltration+malignancy: n=1Enteropathy+autoimmunity: n=3Autoimmunity+malignancy: n=2

Autoimmunity+lymphocytic infiltration+enteropathy: n=9Autoimmunity+lymphocytic infiltration+malignancy: n=4Lymphocytic infiltration+enteropathy+malignancy: n=1

autoimmunity,lymphocytic infiltration,enteropathy,malignancy: n=1

Chapel H et al. Blood 2008;112: 277-86.

Disease complication prevalences

WEHR et al.(Blood 2008; 111:77-85.)

CHAPEL et al(Blood. 2008;112:277-86.)

No. of CVID patients 303 334

Splenomegaly, % 40.5 30

Lymphadenopathy, % 26.2 15

Granulomatous disease, % 11.6 8

Autoimmune phenomena*, % 20.3 25

Autoimmune cytopenia, % 20.2 12

*not include autoimmune *not include autoimmune cytopeniacytopenia

Wehr C et al. Blood 2008;111:77-85.

Chapel H et al. Blood 2008;112: 277-86.

URSCHEL S et al. J Pediatr 2009;154:888-94.

Immunological analysis of

CVID patients

Serum

Immunoglobulin

at diagnosis

Chapel H and Cunningham-Rundles C.British Journal of Haematology 2009;145:709–727.

European cohort

United States Cohort

Serum IgG < 1 g/L

Serum IgG 1.1-3 g/L

Serum IgG >3, <6.5 g/L

URSCHEL S et al. J Pediatr 2009;154:888-94.

Pediatric population diagnosed of CVID

Serum level in each patient at first diagnosis

IgG

IgM

IgA

Peripheral B Cells

Chapel H et al. Blood 2008;112: 277-286.

NNo o significantsignificant associationsassociations withwith clinicalclinical phenotypesphenotypes

Wehr C et al. Blood 2008;111:77-85.

Association of clinical phenomena with dysregulated B-cell subpopulations.

Llobet et al. Pediatr Allergy Immunol 2009: 20: 113–118.

Pediatric population diagnosed of CVID

URSCHEL S et al. J Pediatr 2009;154:888-94.

Classification systems for CVID

Peripheral blood B-cell subsets

Park MA et al. Lancet 2008;372:489-502.

Expert Review of Clinical Immunology 2009.

Classification

systems

for

CVID

Evaluation of the Paris and Freiburg classification scheme.

Wehr C et al. Blood 2008;111:77-85.

P = 0.03

P = 0.02

P = 0.04

P < 0.001

P = 0.02

Wehr C et al. Blood 2008;111:77-85.

P < 0.001

P < 0.01

P = 0.002

P = 0.009

P = 0.049

P = 0.03

P = 0.016

P < 0.001

Genetics of CVID

Genetics for CVIDGenetics for CVID

• ICOS

• CD19

• TACI (TNFRSF13B)

• BAFF-R (TNFRSF13C)

• Msh5

The inducibleinducible costimulator (ICOS) gene

Park MA et al. Lancet 2008;372:489-502.

• Germinal center formation • Memory B cell development• Provide T-cell dependent antibody response for B cell

Fig. 1. Inducible co-stimulator molecule (ICOS) : ICOS-L signalling can results in multiple pathways.

C. Bacchelli et al. Clinical and Experimental Immunology 2007;149: 401–9.

ICOS DeficiencyICOS Deficiency

• About 2% of patients with CVID

• Inherited as autosomal recessive trait

• 9 CVID patients from 4 apparently unrelatedfamilies descended from a common founder

• Geographical location: along the river Danube

• Serum IgG & IgA levels were markedlyreduced in all patients

– IgG < 1.9-2.55 g/L

– IgA < 0.06-0.58 g/L

• Serum IgM level

– reduced in 6/9 patients

– low normal values in 3/9 patients

C. Bacchelli et al. Clinical and Experimental Immunology 2007, 149: 401–409.

Yong et al. Immunological Reviews 2009;229: 101–113.Park MA et al. Lancet 2008;372:489-502.

• Marked impairment of germinal center formation

• The clinical phenotype shows nearly all complication

(autoimmunity, benign lymphoproliferation, chronic

granulomatous inflammation & malignancy).

C. Bacchelli et al. Clinical and Experimental Immunology 2007;149: 401–409.Yong et al. Immunological Reviews 2009;229: 101–113.

• Circulating B cells

– Markedly reduced in 5/9 patients

– Slightly elevated in 2/9 patients

• Switched memory B cells: absent in all patients

• Few abnormalities in T-cell phenotype & function

– 3 patients had an inverted CD4⁄CD8 ratio.

– Normal in vitro proliferation responses when stimulated with

mitogens & antigens

Yong et al. Immunological Reviews 2009;229: 101–113.

The B cell receptor signaling complex

Park MA et al. Lancet 2008;372:489-502Schaffer AA et al. Current Opinion in Genetics & Development 2007, 17:201–12.

CD19 Deficiency•• 44 patients patients with with homozygoushomozygous mutationsmutations inin thethe CDCD1919 genegene,,

fromfrom 22 unrelatedunrelated familiesfamilies

–– increasedincreased susceptibilitysusceptibility toto infectioninfection

–– hypogammaglobulinemiahypogammaglobulinemia

–– normalnormal numbersnumbers ofof CD20+CD20+ B B cellscells

–– expressionexpression ofof CDCD 1919 onon B B cellscells

•• unundetectabledetectable in 1/4 patientsin 1/4 patients

•• barelybarely detectabledetectable in 3/4 patientsin 3/4 patients

van Zelm MC, Reisli I, van der Burg M et al. N Engl J Med 2006;354:1901-12.

•• Numbers of CD27+ memory B cells & CD5+ B cellsNumbers of CD27+ memory B cells & CD5+ B cells

•• Normal germinal center formationNormal germinal center formation

•• Poor antibody response to rabies vaccinationPoor antibody response to rabies vaccination

•• NNo o autoimmuneautoimmune featuresfeatures oror signssigns ofof lymphoproliferationlymphoproliferation

van Zelm MC, Reisli I, van der Burg M et al. N Engl J Med 2006;354:1901-12.

Park MA et al. Lancet 2008;372:489-502

The APRIL–BAFF network

InteractionsInteractions ofof BBAFF, APRIL with AFF, APRIL with theirtheir receptorsreceptors

C. Bacchelli et al. Clinical and Experimental Immunology 2007;149: 401–9.

• Prevalence: 10-20% of CVID patients

• Risk factors, not solely disease-causing in CVID

• Associated with

– Lymphoproliferation

• splenomegaly

• tonsillar hyperplasia

• follicular nodular hyperplasia of GI

– Autoimmunity

• hemolytic anaemia

• autoimmune thrombocytopaenia

• thyroiditis

TACI MutationTACI Mutation

Park MA et al. Lancet 2008;372:489-502.Young PFK et al. Immunol Allergy Clin N Am 2008;28:367-86.

C. Bacchelli et al. Clinical and Experimental Immunology 2007;149: 401–409.

• A multicenter study involving 564 unrelatedCVID patients

• 8.8% (50/564) of the patients carriedat least 1 mutated TACI allele.

– 4% (2/50): homozygous mutations

– 14% (7/50): compound heterozygous mutations

– 82% (41/50): heterozygous mutations

Salzer U et al. Blood 2009;113:1967-76.

TACI MutationTACI Mutation

•• TACITACI C104C104RR && A181EA181E

–– mutationalmutational ''hotspotshotspots‘‘

–– ApproximatelyApproximately 80%80% ofof thethe sequencesequence variantsvariants inin TACITACI

–– presentpresent inin a a heterozygousheterozygous statestate inin 2% 2% ofof 675675 healthy healthy

controlscontrols

Salzer U et al. Blood 2009;113:1967-76.

Salzer U et al. Blood 2009;113:1967-76.

Zhang et al. 2007

• 7.3% (13/176) of subjects had HeterozygousTACI mutations.

• Autoimmune thrombocytopenia

– 46% of subjects with mutations

– 12% of subjects without mutations

• Mutations in TACI significantly predispose toautoimmunity and lymphoid hyperplasia in CVID.

• Splenomegaly and splenectomy weresignificantly increased (P 5 .012; P 5 .001).

• 8 first-degree relatives from 5 families had thesame mutations but were not immune-deficient.

Zhang et al. J Allergy Clin Immunol 2007;120:1178-85

Zhang et al. J Allergy Clin Immunol 2007;120:1178-85.

Immunologicphenotype of

TACI-deficientpatients.

Salzer U et al. Blood 2009;113:1967-76.

Autoimmunity &lymphoproliferationin TACI deficiency

Salzer U et al. Blood 2009;113:1967-76.

36% (18/50)

60% (30/50)

BAFFBAFF--R R DeficiencyDeficiency

• Described in only 1 patient

• a 60-year-old male with

hypogammaglobulinaemia

• Profound reduction of both class switch

(CD27+, IgM-, IgD-) & non-switched memory

(CD27+, IgM+, IgD+)

• Transitional B cell (CD38+++, IgM++)

• Plasmablasts (CD38+++, IgM-)

Park MA et al. Lancet 2008;372:489-502.C. Bacchelli et al. Clinical and Experimental Immunology 2007;149: 401–409.

MutSMutS 5 5 ((MMshsh55))

• A gene encoded in the central

MHC class III region

• A critical role in regulating meiotic

homologous recombination

• A role in class switch recombination

• Msh5 Mutation: associated with CVID

and selective IgA deficiency.

Sekine et al. Proc Natl Acad Sci U S A. 2007 ;104(17):7193-8.Young PFK et al. Immunol Allergy Clin N Am 2008;28:367-86.

Gene (chromosomal

location)

Frequency (%) Inheritance Phenotype B-cell phenotype Clinical phenotype

ICOS (2q33) 2

8-20

1

< 1

CVID Low numbers ofB-cell & memory B cells

Recurrent respiratoryinfections,autoimmunity,granulomata andmalignancy

AR

TNFRSF13B/ TACI

(17p11.2)

AD • CVID, • IgGsubclass deficiency• sIgAD

No specific B-cellphenotype

Recurrent respiratoryinfections, increasedrates of benignlymphoproliferation andincreased rates ofautoimmunity

ARCD19(16p11.2)

CVID Decrease in classswitched memory B cells, low CD21expression on B cells, normalnumbers of CD20+mature B cells inperipheral blood

Recurrent respiratoryinfections

TNFRSF13C/ BAFF-R

(22q13.1-q13.31)

AR CVID Low B-cell numbers,relative increase intransitional B cellsand low numbersof memory B cells

Recurrent respiratoryinfections

Expert Review of Clinical Immunology, March 2009, Vol. 5, No. 2, Pages 167-180 al. Lancet 2008;372:489-502.Park MA et

TherapeuticTherapeutic ManagementManagement

• Prevention of recurrent and chronic

infections by Immunoglobulin therapy

• Antibiotic therapy of breakthrough

infections

• Treatment of associated disease

complications and sequelae

Common Variable Immunodeficiency

• A 14-yr-old girl with CRS

• Recurrent sinopulmonary tract infections

• Panhypogammaglobulinemia

• Low number of circulating B cell

• Splenomegaly

Management

• Treatment of infections

• Intravenous immunoglobulin

replacement therapy

• Genetic Testing

• Surveillance for autoimmunity and

malignancy

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