Virtual, April 14-17
Sponsorship: Publication of this supplement was funded by the Clinical Immunology
Society. All content was reviewed and approved by the Program Committee, which held
full responsibility for the abstract selections.
All contributors have provided original material as submitted for publication in the
Journal of Clinical Immunology.
01 Oral Presentations
(1) A new manufacturing process to remove thrombogenic factors (II, VII, IX, X, and
XI) from intravenous immunoglobulin gamma preparations
Alan Huber, PharmD MBA1, Dong Hwarn Park, PhD2, Gil Bu Kang, PhD3, Dae Eun Kang, MSc4,
Ki Yong Kim, PhD4, Jeung Woon Hong, PhD5, Min Gyu Lee, PhD6, Jeung Whan Han, PhD7
1Director of Medical Affairs US/GC Mogam Inc
2Head, Research and Development/GC Corporation
3Deputy Director, Research and Development/GC Corporation
4Research and Development/GC Corporation
5Director of Bioassay/GC Corporation
6Faculty, School of Pharmacy/Sungkyunkwan University
7Faculty, School of Medicine/SungkyunKwan University
Coagulation factors (II, VII, IX, X, and particularly XIa) remaining in high concentrations
in intravenous immunoglobulin (IVIG) preparations can form thrombi, causing thromboembolic
events, and in serious cases, death. Therefore, manufacturers of biological products
must investigate the ability of their production processes to remove procoagulant
activities. Previously, we were able to remove coagulation factors II, VII, IX, and
X from our IVIG preparation through ethanol precipitation, but factor XIa, which plays
an important role in thrombosis, remained in the intermediate products. Therefore,
our objective was to develop and test a process to remove factor XIa from IVIG.
The study samples were cleared cryo-poor plasma. A chromatographic process using a
new cation-exchange (CEX) resin that binds with high capacity to IgG and removes procoagulant
activities was added in a sequential step to the standard removal/inactivation process.
Testing of the samples was performed using the standard process alone and then with
sequential addition of the new CEX process. Procoagulant activity was tested using
several standard methods, including, thrombin generation assay, chromogenic FXIa assay,
non-activated partial thromboplastin time (NaPTT), and FXI/FXIa ELISA. We further
spiked our samples with additional coagulation factor XIa, in amounts exceeding any
variability that may be caused due to sample differences, and tested these samples
for procoagulant activity using the same methods.
The procoagulant activities were reduced to low levels as determined by the thrombin
generation assay: < 1.56 mIU/mL, chromogenic FXIa assay: < 0.16 mIU/mL, NaPTT: >250
s, FXI/FXIa ELISA: < 0.31 ng/mL. Even after spiking with FXIa at a concentration 32.5
times higher than the concentration in normal specimens, the procoagulant activities
were below the detection limit ( < 0.31 ng/mL).
We successfully removed the coagulation factors FII, FVII, FIX, and FX through cold
ethanol precipitation, and removed FXIa using chromatography. Using this novel technology
can potentially reduce future thromboembolic events with IVIG since FXIa is virtually
eliminated.
These results demonstrate the ability of our manufacturing process to remove procoagulant
activities to below the detection limit (except by NaPTT), suggesting a reduced risk
of thromboembolic events that may be potentially caused by our IVIG preparation.
Keywords: immunoglobulin, chromatography, Factor Xia
Disclosures: All authors indicated they had no financial relationships to disclose.
(2) CARMIL2 Deficiency And Various Clinical Phenotypes: Warning Signs For Early Diagnosis
Burcu Kocamis Kolukisa, MD1, Nurhan Kasap, MD1, Sevgi Bilgic Eltan, MD2, Dilek Baser,
MSc2, Gamze Akgun,2, Asena Pınar Sefer, MD1, Yasemin Kendir Demirkol, MD3, Elif Karakoc
Aydiner, MD4, Ekrem Unal, MD5, Ahmet Ozen, MD4, Safa Baris, MD4
1Clinical Fellow/Marmara University Hospital, Department of Pediatric Immunology and
Allergy
2Marmara University Hospital, Department of Pediatric Immunology and Allergy
3Umraniye Research and Training Hospital, Department of Pediatric Genetic Diseases
4Professor of Pediatrics/Marmara University Hospital, Department of Pediatric Immunology
and Allergy
5Erciyes University, Department of Pediatric Hematology and Oncology
CARMIL2(RLTPR) gene regulates CD28 co-signalization and cytoskeletal dynamics of immune
cells. Immune deficiency caused by homozygous mutations in CARMIL2 has been linked
to a broad range of manifestations, including allergies of the skin and respiratory
tract; serious bacterial, fungal and viral infections such as disseminated warts and
molluscum; EBV-related smooth muscle tumors; chronic diarrhea and growth retardation.
We present a single center experience on CARMIL2 patients.
We studied seven patients (1 Male, 6 Females; current age: 16.7 years) from 4 independent
families. Mean age at onset of symptoms was 48,8 months. P1 and P2 presented with
chronic abdominal pain and bloody diarrhea. P3 and P4, sisters, had eczema, recurrent
respiratory and skin infectins including warts and molluscum. P5 presented with early-onset
IBD and wheezing. P6 and P7, cousins, had recurrent skin and airway infections, eczema
and warts. Eosinophilia was observed in 3/6 patients. Serum immunoglobulins were normal
in half, low IgG in two, high IgG, IgA, IgM in one patient. Protein antibody responses
were poor in all patients. Flow cytometry revealed low NK-cells in 5 of 6 subjects;
elevated naïve CD4+ T cells in 3 of 6, and reduced memory B cells in 2 of 6. Regulatory
T-cells (Tregs) and induction of CTLA4 were reduced in all patients. Defective CD28
T-cell stimulation and cytokine production was confirmed in 2 patients (P3 and P7).
CARMIL2 deficiency may present with early onset-IBD, viral infections, eczema and
malignancies. Increased naive T cells, observed in majority of patients suggests defective
differentiation. Knowledge of diverse manifestations related to CARMIL2 deficiency
should be envisaged for timely diagnosis.
This work was supported by the Scientific and Technological Research Council of Turkey
(318S202).
Keywords: CARMIL2, combined immunodeficiency, Treg
Disclosures: All authors indicated they had no financial relationships to disclose.
(3) Excess IL-18 and perforin deficiency distinctly and synergistically promote pathologic
CD8 T-cell activation and experimental Hemophagocytic Lymphohistiocytosis
Emily Landy, B.S.1, Scott Canna, MD2
1PhD Candidate/University of Pittsburgh
2Assistant Professor/University of Pittsburgh, UPMC Childrens Hospital
Hemophagocytic Lymphohistiocytosis (HLH) and Macrophage Activation Syndrome (MAS)
are life-threatening hyperinflammatory cytokine storm syndromes. Familial HLH is associated
with genetic impairment of cytotoxic function (e.g. perforin deficiency), and Prf1-/-
mice succumb to typically-mild LCMV infection via CD8 T-cell/IFNγ-mediated immunopathology.
MAS is clinically similar to HLH, but occurs in certain rheumatic/autoinflammatory
diseases and has been associated with extraordinarily and chronically elevated serum
IL-18. Improved understanding of their pathogenesis could significantly alter patient
screening, diagnosis, and management.
Using mice with excess IL-18 (Il18tg) to model a state of susceptibility to MAS, we
found some baseline abnormalities included decreased IL-18 receptor expression on
NK cells and increased PD-1+ CD8 T-cells. Il18tg mice, but not Prf1-/- mice, developed
more severe immunopathology in the TLR9-triggered model of MAS. Il18tg mice also developed
MAS-like immunopathology upon infection with LCMV (Armstrong), which was largely mediated
through CD8 T cells and IFNγ. As with LCMV-infected Prf1-/- mice, CD8 T cells from
LCMV-infected Il18tg mice showed increased activation and cytokine production, but
did not exhibit cytotoxic impairment or persistent antigen presentation. They retained
KLRG1+ terminal effector differentiation and their transcriptional program was more
comparable to WT than Prf1-/- mice in their absence of an exhaustion signature.
Mounting evidence suggests heterozygous mutations in cytotoxicity-related genes like
PRF1 may promote hyperinflammatory responses in MAS patients, who also have highly
elevated IL-18 levels. Though neither excess IL-18 nor perforin-deficiency individually
cause immunopathology without inflammatory challenge, we observed lethal spontaneous
hyperinflammation in Il18tg;Prf1-/- mice. We even observed subclinical MAS in Il18tg
mice heterozygous for Prf1. These mice showed expansion of a splenic PD-1+, TIGIT+,
and Tim-3+ CD8 T-cell population, yet show increased IFNg production. Additionally,
spontaneous immunopathology was partially abrogated by CD8 depletion or IFNg neutralization.
Together, these data suggest that IL-18 and cytotoxicity can independently and synergistically
drive pathologic CD8 T-cell activation and life-threatening immunopathology in HLH
and MAS.
Figure 1: Dysregulation of the immune systems response to antigen/infection can lead
to hyperinflammation. Excess free IL-18 (as seen in MAS) can hyperactivate CD8 T cells.
Perforin deficiency (as seen in fHLH) can also lead to hyperactivated CD8 T cells
along with lack of antigen removal. Together these factors can combine to cause spontaneous
hyperinflammation in mice.
Keywords: HLH, MAS, IL-18, Perforin Deficiency, CD8 T cell, activation
Disclosures: Scott Canna received research grants from AB2Bio Ltd and IMMvention Therapeutix.
Emily Landy had no financial relationships to disclose.
(4) Long-term Safety Data from Pregnant Women Treated with Facilitated Subcutaneous
Immunoglobulin (fSCIG) in a Pregnancy Registry Study
Michael Borte, Prof. Dr. med.1, Stefan Raffac, MUDr.2, Martin Hrubisko, MD, PhD3,
Karina Jahnz-Rozyk, MD, PhD4, Milada Cvackova, MD5, Enrique Garcia, MD, MBA6, Andras
Nagy, MD7, Barbara McCoy, PhD8, Leman Yel, MD9
1Director, Clinic for Child and Adolescent Medicine/St. Georg Hospital
2Clinic of Clinical Immunology and Allergology/RAFMED s.r.o.
3Department Head, Clinical Immunology and Allergy/Oncology Institute of St. Elisabeth
4Head, Department of Internal Diseases, Pneumonology, Allergology & Clinical Immunology/Military
Institute of Medicine
5Faculty Hospital Kralovske Vinohrad/3rd Medical Faculty of Charles University
6Senior Medical Director, GSL/Takeda Pharmaceutical Company Limited
7Associate Medical Director, Clinical Development/Baxalta Innovations GmbH, a Takeda
company
8Senior Clinical Director/Baxalta Innovations GmbH, a Takeda Company
9Vice President, Head Clinical Medicine, Global Research & Development, PDT/Baxalta
US Inc., a Takeda company, University of California
fSCIG is an immunoglobulin G (IgG) replacement therapy comprised of a dual-vial unit
of IgG 10% and recombinant human hyaluronidase (rHuPH20). A postauthorization registry
conducted in the United States and Europe assessed safety data on the courses/outcomes
of pregnancy in women ever treated with fSCIG treatment and assessed the growth/development
of their infants (NCT02556775; EUPAS5798).
Women pregnant during or after fSCIG exposure who provided informed consent participated
in this non-interventional, 2-arm, prospective, uncontrolled, open-label, multicenter
registry study. During pregnancy, women received alternative treatment (Arm 1) or
continued fSCIG (Arm 2) as determined by their physician. Assessments were performed
per standard of care. Data were obtained from medical records. Infants were followed
for up to 2 years postdelivery.
The study included 9 mothers (Arm 1: n=2; Arm 2: n=7) and 7 infants between Dec 2015
and Dec 2019. Thirteen adverse events (AEs) occurred among 4 mothers (1 in Arm 1,
3 in Arm 2), including 2 serious AEs (SAEs; thrombocytopenia and preeclampsia) in
Arm 2. None of these were considered treatment-related by the investigator, or led
to fSCIG treatment changes. No local or immunologic AEs were recorded. No discontinuations
of fSCIG occurred during pregnancy, and fSCIG was not associated with labor/delivery
complications. All pregnancies with known outcomes (n=8) resulted in live births (mean
gestational age [weight]: 38.7 weeks [3.1 kg]). Of the 7 infants enrolled, all had
normal appearance, pulse, grimace, activity, and respiration (APGAR) scores. Seventeen
AEs, all unrelated to the mothers’ treatment, occurred in 6 infants (1 in Arm 1, 5
in Arm 2). Among these, 2 were SAEs (cleft lip and talipes calcaneovalgus, both of
mild severity) assessed as incidental findings in 2 infants in Arm 2 who had normal
growth and development during the 2-year follow-up. All anti-rHuPH20 binding antibody
results (from 4 mothers, 2 in each arm) were negative (titers < 160).
No AEs related to fSCIG were reported in this pregnancy registry in women ever treated
with fSCIG treatment or their infants. All infants had normal APGAR scores.
Funding: Baxalta US Inc. (a Takeda company) funded this study and medical writing
support.
Keywords: immunoglobulin replacement therapy, safety, pregnancy, infant, real-world
data, primary immunodeficiency diseases, facilitated immunoglobulin
Disclosures: Steffan Raffac received speaker honoraria from Takeda. Karina Jahnz-Rozyk
received speaker honoraria from Alyogen, AstraZeneka, Chiesi, CSL Behring, GSK, Novartis,
Sanofi, and Takeda. Enrique Garcia, Barbara McCoy and Leman Yel are employees of Takeda.
All other authors had no financial relationships to disclose.
(5) Long-term Outcomes after Gene Therapy for Adenosine Deaminase Severe Combined
Immune Deficiency (ADA SCID)
Donald Kohn, M.D.1, Omar Habib, n/a2, Bryanna Reinhardt, n/a2, Kit Shaw, PhD3, Elizabeth
Garabedian, MSN4, Dayna Terrazas, RN5, Beatriz Campo Fernandez, PhD6, Satiro De Oliveira,
MD7, Theodore Moore, MD7, Alan Ikeda, MD7, Barbara Engel, MD,PhD8, Gregory Podsakoff,
MD9, Roger Hollis, PhD6, Augustine Fernandes, PhD10, Connie Jackson, n/a10, Sally
Shupien, n/a10, Suparna Mishra, PhD11, Alejandra Davila, MS11, Jack Mottahedeh, PhD11,
Andrej Vitomirov, n/a11, John Everett, PhD12, Aoife Roche, n/a12, Pascha Hokama, n/a12,
Shantan Reddy, n/a12, Xiaoyan Wang, PhD13, Kenneth Cornetta, MD14, Michael Hershfield,
MD15, Robert Sokolic, MD16, Harry Malech, MD17, Frederick Bushman, PhD12, Fabio Candotti,
MD18
1Distinguished Professor/University of California, Los Angeles
2Research Associate/University of California, Los Angeles
3Project Scientist/Dana Farber Cancer Center
4Research Nurse/National Genome Research Institute
5Research Nurse/University of California, Los Angeles
6Project Scientist/University of California, Los Angeles
7Clinical Investigator/University of California, Los Angeles
8Regulatory Administration/Children's Hospital of Philadelphia
9Regulatory Administration/Children's Hospital of Philadelphia
10Regulatory Administration/University of California, Los Angeles
11GMP Lab Scientist/University of California, Los Angeles
12Bioinformatician/University of Pennsylvania
13Biostatistican/University of California, Los Angeles
14Vector Manufacturing/Indiana University
15Investigator/Duke University School of Medicine
16Clinical Investigator/Brown University
17Clinical Investigator/National Institute of Allergy and Infectious Disease, NIH
18Clinical Investigator/University of Lausanne
Patients lacking functional adenosine deaminase activity suffer from severe combined
immunodeficiency (ADA SCID), which can be treated with ADA enzyme replacement therapy
(ERT), allogeneic hematopoietic stem cell transplantation (HSCT), or autologous HSCT
with gene-corrected cells (gene therapy-GT). A cohort of 10 ADA SCID patients, aged
3 months to 15 years, underwent GT in a Phase II clinical trial between 2009 and 2012.
Autologous bone marrow CD34+ cells were transduced ex vivo with the MND-ADA gamma-retroviral
vector (gRV) and infused following busulfan reduced intensity conditioning. These
patients were monitored in a long-term follow-up protocol over 8-11 years. Nine of
ten patients have sufficient immune reconstitution to protect against serious infections,
and have not needed to resume ERT or proceed to secondary allogeneic HSCT. ERT was
restarted 6 months after GT in the oldest patient who had no evidence of benefit from
GT. Four of nine evaluable patients with the highest gene marking and B cell numbers
remain off immunoglobulin replacement therapy and responded to vaccines. There were
broad ranges of responses, in terms of normalization of ADA enzyme activity and adenine
metabolites in blood cells, and levels of cellular and humoral immune reconstitution.
These outcome parameters were generally better in younger patients and those receiving
higher doses of gene-marked CD34+ cells. No patient experienced a leukoproliferative
event after GT, despite persisting prominent clones with vector integrations adjacent
to proto-oncogenes. These long-term findings demonstrate enduring efficacy of GT for
ADA SCID, but risks of genotoxicity with gRVs.
(Clinicaltrials.gov #NCT00794508)
Keywords: ADA SCID, Gene Therapy, Long-term Follow-up, Gamma-retroviral vector
Disclosures: Donald Kohn was a consultant for Leadiant Biosciences. Kit Shaw was a
consultant for Orchard Therapeutics. Roger Hollis is an employee of ImmunoVec. All
other authors had no financial relationships to disclose.
(6) Common Variable Immunodeficiency in a young male uncovers Nuclear Factor 훋B-1
(NFKB1) haploinsufficiency with variable phenotype in several relatives: the importance
of pursuing a genetic diagnosis
Maria Chitty Lopez, MD1, Farnaz Tabatabaian, MD2, Hana Niebur, MD3, Erinn Kellner,
MD4, Gulbu Uzel, MD5, Jennifer Leiding, MD6
1Physician Fellow/Division of Allergy and Immunology, Department of Pediatrics, University
of South Florida, Tampa, FL, USA
2Assistant Professor/Division of Allergy & Immunology, Department of Internal Medicine,
Morsani College of Medicine, University of South Florida, Tampa, Fla
3Assistant Professor/Division of Allergy and Immunology, Department of Pediatrics,
University of Nebraska, Omaha, NE, USA
4Assistant Professor/Division of Allergy and Immunology, Department of Pediatrics,
University of Cincinnati, Cincinnati, OH, USA
5Physician scientist/Laboratory of Clinical Immunology and Microbiology, National
Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda,
Maryland, USA
6Associate Professor/Division of Allergy and Immunology, Department of Pediatrics,
University of South Florida at Johns Hopkins-All Children’s Hospital, St Petersburg,
FL
Common Variable Immunodeficiency (CVID) is a genetically heterogeneous disorder characterized
by increased susceptibility to infections and humoral immunodeficiency. Monogenic
CVID accounts for 10% of cases and is often associated with immunodysregulation. NFKB1
haploinsufficiency is a monogenic cause of CVID complicated by early-onset infection
susceptibility, cytopenias, lymphoproliferative disease, autoimmunity, and malignancy.
We present a young male with CVID, autoimmunity, and non-malignant lymphoproliferation
who was found to have NFKB1 haploinsufficiency, leading to subsequent diagnosis in
several previously undiagnosed family members.
Clinical details regarding proband and relatives were obtained. NFKB1 variant was
identified by whole-exome sequencing (WES) and confirmed by Sanger sequencing in the
proband and by variant-based Sanger sequencing in relatives.
A 14-year-old male with sinopulmonary infections, persistent cervical and abdominal
lymphadenopathy, splenomegaly, Crohn's-like colitis, and idiopathic thrombocytopenic
purpura (ITP) presented for evaluation. Family history showed father with CVID, ITP,
splenomegaly post-splenectomy, and autoimmune hepatitis; paternal uncle with CVID
deceased from lymphoma; paternal aunt with autoimmune hemolytic anemia (AIHA) and
psoriatic arthritis; and paternal cousin with refractory thrombocytopenia post-splenectomy
(Figure-1, Table-1).
Initial immunophenotyping revealed poor antibody responses to tetanus, diphtheria,
and pneumococcus.; low IgM, normal IgG and IgA, T-cell lymphopenia, platelet-antibody-positive
thrombocytopenia, and elevated double-negative-T-cells (DNTs), (Table-2). Bone marrow
biopsy showed trilineage hematopoiesis; lymph node biopsy showed reactive hyperplasia.
Immunoglobulin replacement therapy (IgRT) decreased the frequency of infections and
improved platelet count. The use of rapamycin further controlled thrombocytopenia
and lymphoproliferation. Infliximab improved his colitis. After several genetic evaluations,
at age 21, WES identified a novel pathogenic heterozygous nonsense variant in NFKB1
(c.538C>T, p.Gln180Ter). The same pathogenic variant was found in the proband’s father,
paternal aunt, cousin, and deceased paternal uncle. NFKB1 variant was also present
in the proband’s asymptomatic sister and paternal uncle with a known daughter with
ITP (Figure-1).
NFKB1 haploinsufficiency is a monogenic cause of CVID with a high incidence of immunodysregulatory
features and variable penetrance leading to diverse immunophenotypes even amongst
subjects of the same family. Clinicians should pursue genetic testing in the evaluation
of CVID patients especially when symptoms of immune dysregulation or significant family
history are present as this case series illustrates.
Table 1: Clinical Phenotype of Family Members
Figure-1. Variable clinical phenotype of NFKB1 haploinsufficiency in a single-family.
Table 2: Immunophenotype of Proband at Presentation
Keywords: Common Variable Immunodeficiency, NFKB1 loss of function, Monogenic CVID
Disclosures: Hana Niebur was a member of Horizon Therapeutics Advisory Board. Jennifer
Leiding received speaker honoraria from CSL Behring and Horizon Therapeutics and was
an advisory board member for Pharming. All other authors had no financial relationships
to disclose.
(7) A novel primary atopic disorder associated with a homozygous missense variant
in OSMR
Mehul Sharma, MSc1, Christina Michalski, BSc1, Kate Del Bel, MSc2, Henry Lu, PhD3,
Ashish Sharma, PhD4, Maja Tarailo-Graovac, PhD5, Bhavi Modi, PhD3, Britt Drogemoller,
PhD6, Géraldine Blanchard Rohner, MD7, Christof Senger, MS8, Wingfield Rehmus, MD
MPH9, Julie Prendiville, MD10, Colin Ross, PhD11, Clara van Karnebeek, MD, PhD12,
Wyeth Wasserman, PhD13, Pascal Lavoie, MD PhD11, Margaret McKinnon, MD8, Stuart Turvey,
MBBS, DPhil13
1Trainee/University of British Columbia
2Research Coordinator/University of British Columbia
3Post Doctoral Research Fellow/University of British Columbia
4Instructor/Emory University
5Assistant Professor/University of Calgary
6Assistant Professor/University of Manitoba
7Physician/University Hospitals of Geneva
8Clinical Assistant Professor/University of British Columbia
9Clinical Associate Professor/University of British Columbia
10Physician/University of British Columbia
11Associate Professor/University of British Columbia
12Professor/University of Amsterdam
13Professor/University of British Columbia
Primary atopic disorders are monogenic disorders characterized by profound dysregulated
allergic responses. Studying patients with these disorders has been instrumental in
expanding our understanding of the pathogenesis of allergic inflammation with therapeutic
implications for common polygenic versions of allergic disease.
Clinical findings: We describe a 9-year old boy who presented with severe eczema,
high blood eosinophil counts (5.8x109 cells/L, normal range: 0-0.85x109 cells/L) and
high serum IgE levels (2645υg/L, normal range: 0-500ug/L) since birth. After ruling
out known allergic disorders and parasitic infections are ruled out, whole exome sequencing
was performed on patient and his parents trio. The patient was found to have a homozygous
variant in the evolutionarily conserved fibronectin III domain of the OSMR gene (c.1307T>A,
p.V436D). OSMR encodes oncostatin M receptor-beta, a component of both the OSM type
II and the IL31 receptor, and is important for keratinocyte cell proliferation, differentiation,
apoptosis and inflammation. Variants in OSMR have been reported in association with
familial primary localized cutaneous amyloidosis, however this condition was ruled
out in this patient as skin biopsies were absent for amyloid deposits.
We transfected the c.1307T>A OSMR variant in both HEK293 cells and primary fibroblasts
obtained from the patient, and observed a loss of expression of the mutated OSMR receptor
on the cell surface. Signal transduction through phosphorylation of STAT1 and STAT5
was absent and phosphorylation of STAT3 was significantly reduced after stimulation
with OSM in patient fibroblasts. These signaling defects were “rescued” upon lenti-viral
transduction of the wild-type (WT) OSMR gene (Figure 1). RNAseq analysis confirmed
that OSM mediated JAK-STAT and interferon signalling pathways were deficient in the
patient fibroblasts and were rescued with WT OSMR. Furthermore, an enhanced atopic
dermatitis gene expression signature was observed in patient fibroblasts at baseline
which was also rescued upon lenti-viral transduction (Figure 1) or upon treatment
with dexamethasone (by qPCR).
Our findings shed light on the disease mechanism of a novel primary atopic disorder,
caused by a homozygous missense variant in OSMR.
Figure 1. Patient pedigree and clinical findings. (A) Patient family pedigree. (B)
Patient displayed consistently high eosinophil and lgE levels since birth. (C) Impaired
STAT1 and STAT5 signaling was observed in patient fibroblasts upon OSM stimulation,
which was “rescued” with WT OSMR. (D) RNAseq showed high baseline expression of barrier
disruption and inflammation genes in patient fibroblasts compared to healthy controls
(HC1, HC2, HC3) and “rescued” fibroblasts.
Keywords: Primary Immunodeficiency, Atopic Dermatitis, Allergy, Eosinophilia, Primary
Atopic Disorder
Disclosures: Wingfield Rehmus was an advisory board member of Leo Pharma Inc and Pfizer
Canada. All other authors had no financial relationships to disclose.
(8) Mortality in Combined Immunodeficiency: Data From the USIDNET Registry
Jessica Durkee-Shock, MD1, Hua Liang, PhD2, Hannah Wright, MSPH3, Elizabeth Garabedian,
MSN4, Rebecca Marsh, MD5, Kathleen Sullivan, MD, PhD6, Michael Keller, MD7
1Clinical Fellow in Allergy and Immunology/National Institute of Allergy and Infectious
Diseases/ Children's National Medical Center
2Professor of Statistics/George Washington University Department of Statistics
3Research Data Analyst/The United States Immunodeficiency Network (USIDNET)
4Research Nurse/National Genome Research Institute
5Attending Physician/Division of Bone Marrow Transplantation and Immune Deficiency,
Cincinnati Children’s Hospital Medical Center
6Professor of Pediatrics, Chief of the Division of Allergy and Immunology/The Children’s
Hospital of Philadelphia, Philadelphia, PA, USA
7Assistant Professor/Children's National Research Institute, Program for Cell Enhancement
and Technologies for Immunotherapy
Combined Immunodeficiency (CID) is a broad category of inborn errors of immunity.
Improved understanding of the determinants of early mortality may help to identify
patients who will benefit from early definitive therapy.
The USIDNET database was queried for participants with a diagnosis of CID or a genetic
diagnosis consistent with CID as defined by IUIS genetic classification. Participants
with primary thymic defects, SCID, and Wiskott-Aldrich syndrome were excluded. Akaike
Information Criterion (AIC) was used for variable selection for multivariate analysis
of factors associated with mortality.
337 participants met the inclusion criteria, with a median age of symptom onset of
0.5 years (IQR 0.1years-4.0years), and a median age of diagnosis of 3.6 years (IQR
0.3years-15 years). Of this population, 38 of 332 individuals for whom data was available
were deceased (11%), with a median age at death of 20.7 years. Lower mean values of
absolute lymphocyte count, CD3+, CD4+, or CD8+ T cells were not statistically significantly
associated with increased mortality. The most common genetic variants in the deceased
participants regardless of transplant status were CD40L (17%), GATA2 (14%), DOCK8
(14%), NEMO (8%) and CTLA4 haploinsufficiency (8%). The most common genetic variants
in those patients who were deceased and remained un-transplanted at time of death
were CTLA4 haploinsufficiency, CD40L, ATM, STAT3, and RMRP. AIC model selection found
statistically significantly decreased odds of survival for participants with variants
in CTLA4 (OR 0.13), DOCK8 (OR=0.02), CD40L (OR 0.11) and ATM (OR 0.02); as well as
participants with renal disease (OR 0.24), bone abnormalities (OR 0.19), invasive
bacterial (OR 0.30), viral (OR 0.1) and fungal (OR 0.13) infections . Cognitive (OR
4.8), Mucocutaneous fungal (OR 14.4), and localized viral (OR 4.8) were statistically
significantly associated with an increased odds of survival. Other variables selected
for the AIC model included RMRP, NEMO, and neurologic comorbidities.
We identified multiple genetic variants, comorbidities, and infectious complications
which appear to impact survival in CID. Determining patients at risk for increased
mortality and poor outcome may influence the decision to proceed to early definitive
therapy, such as hematopoietic stem cell transplant and thereby improve outcomes.
Keywords: Combined Immunodeficiency, USIDNET, Mortality
Disclosures: Kathleen Sullivan was a consultant of the Immune Deficiency Foundation.
Michael Keller was an advisory board member of Enzyvant Sciences. All other authors
had no financial relationships to disclose.
(9) Mosaic And Germline Gain-Of-Function Variants In TLR8 Leading To Immunodeficiency
With Lymphoproliferation And Bone Marrow Failure
Jahnavi Aluri,1, Alicia Bach, MD2, Saara Kaviany, D.O.3, Luana Chiquetto Paracatu,
PhD4, Maleewan Kitcharoensakkul, M.D., MSCI5, Magdalena Walkiewicz, PhD6, Christopher
Putnam, Ph.D.7, Marwan Shinawi, MD8, Nermina Saucier, MS9, Elise Rizzi, BA10, Michael
Harmon, BA11, Molly Keppel, MS12, Michelle Ritter, RN, BSN13, Morgan Similuk, MS14,
Elaine Kulm, C.R.N.P.15, Michael Joyce, MD16, Adriana De Jesus, MD, PhD17, Raphaela
Goldbach-Mansky, MD18, Yi-Shan Lee, MD,PhD19, Marina Cella, MD20, Peggy Kendall, MD21,
Mary Dinauer, MD,PhD20, Jeffrey Bednarski, MD,PhD22, Christy Bemrich-Stolz, MD23,
Scott Canna, MD24, Shirley Abraham, MD25, Matthew Demczko, MD26, Jonathan Powell,
MD27, Stacie Jones, MD28, Amy Scurlock, MD29, Suk See De Ravin, MD,PhD30, Jack Bleesing,
MD31, James Connelly, MD32, V. Koneti Rao, MD30, Laura Schuettpelz, MD,PhD22, Megan
Cooper, MD,PhD33
1Postdoctoral Research Associate/Washington University in St. Louis
2Clinical Fellow/Department of Pediatrics, Division of Hematology/Oncology, Washington
University School of Medicine, St. Louis, MO.
3Instructor/Pediatric Hematology Oncology, Vanderbilt University Medical Center, Nashville,
TN Pediatric Hematology Oncology, Vanderbilt University Medical Center, Nashville,
TN
4Postdoctoral Research Associate/Department of Pediatrics, Division of Hematology/Oncology,
Washington University School of Medicine, St. Louis, MO
5Assistant Professor/Department of Pediatrics, Division of Rheumatology/Immunology
and Allergy and Pulmonary Medicine, Washington University School of Medicine, St.
Louis, MO,
6Certified Molecular Geneticist/Division of Intramural Research (DIR), NIAID, National
Institutes of Health, Bethesda, MD
7Assistant Professor/Department of Medicine, University of California School of Medicine,
San Diego, La Jolla, CA, and San Diego Branch, Ludwig Institute for Cancer Research,
La Jolla, CA
8Professor/Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington
University School of Medicine, St. Louis, MO
9Research Technician/Department of Pediatrics, Division of Rheumatology/Immunology,
Washington University School of Medicine, St. Louis, MO.
10Research Technician/Department of Medicine, Division of Allergy and Immunology,
Washington University School of Medicine, St. Louis, MO
11Undergraduate Research assistant/Department of Pediatrics, Division of Rheumatology/Immunology,
Washington University School of Medicine, St. Louis, MO
12Researcher/Department of Pediatrics, Division of Rheumatology/Immunology, Washington
University School of Medicine, St. Louis, MO
13Research Nurse Coordinator/Department of Pediatrics, Division of Rheumatology/Immunology,
Washington University School of Medicine, St. Louis, MO
14Genetic counselor/Centralized Sequencing Initiative and Division of Intramural Research
(DIR), NIAID, National Institutes of Health, Bethesda, MD
15Pediatric Nurse Practitioner/Clinical Research Directorate, Frederick National Laboratory
for Cancer Research sponsored by the National Cancer Institute,Frederick, MD
16Assistant professor/Nemours Children's Specialty Care, Jacksonville
17Staff Scientist/Translational Autoinflammatory Disease Section (TADS), Laboratory
of Clinical Investigation and Microbiology (LCIM), NIAID, NIH
18Chief/Translational Autoinflammatory Diseases Section, NIAID, National Institutes
of Health, Bethesda, MD,
19Assistant Professor/Department of Pathology and Immunology, Division of Anatomic
and Molecular Pathology, Washington University School of Medicine, St. Louis, MO
20Professor/Department of Pediatrics, Division of Hematology/Oncology, Washington
University School of Medicine, St. Louis, MO
21Associate Professor/Department of Medicine, Division of Allergy and Immunology and
Department of Pathology and Immunology,Division of Immunology, Washington University
School of Medicine, St. Louis, MO
22Assistant Professor/Department of Pediatrics, Division of Hematology/Oncology, Washington
University School of Medicine, St. Louis, MO
23Assistant Professor/Department of Pediatrics, Division of Hematology and Oncology,
University of Alabama School of Medicine, Birmingham, AL
24Assistant Professor/University of Pittsburgh, UPMC Childrens Hospital
25Assistant Professor/Department of Pediatrics, Division of Hematology and Oncology,
University of New Mexico, Albuquerque, NM
26Physician/Department of Pediatrics, Division of Diagnostic Referral, Nemours Alfred
I. DuPont Hospital for Children, Wilmington, DE, 19803
27Physician/Department of Pediatrics, Division of Pediatric Hematology/Oncology, Nemours
Alfred I. DuPont Hospital for Children, Wilmington, DE, 19803
28Professor/Department of Pediatrics, Division of Allergy & Immunology, University
of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR
29Associate Professor/Department of Pediatrics, Division of Allergy & Immunology,
University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little
Rock, AR
30Staff Clinician/Laboratory of Clinical Immunology and Microbiology, Division of
Intramural Research, National Institute of Allergy and Infectious Diseases, National
Institutes of Health, Bethesda, MD
31Professor/Division of Bone Marrow Transplantation and Immunodeficiency, Cincinnati
Children's Hospital Medical Center, Cincinnati, OH
32Assistant Professor Pediatric Hem/Onc/BMT/Vanderbilt University Medical Center,
Nashville, TN
33Associate Professor/Department of Pediatrics, Division of Rheumatology/Immunology,
Washington University School of Medicine, St. Louis, MO
Inborn errors of immunity (IEI) are a genetically heterogeneous group of disorders
that affect the development and/or function of one or more components of the immune
system. We describe a cohort of six unrelated male patients with a clinical and immunological
presentation of recurrent infections, severe neutropenia, humoral defects, and lymphoproliferation
with hepatosplenomegaly and lymphadenopathy. Multiple patients had a relatively poor
response to therapeutic or high doses of GCSF. Anti-neutrophil antibody testing was
performed in 3 patients and was positive in 2 cases. Three patients required hematopoietic
stem cell transplantation. Exome sequencing identified novel missense variants in
TLR8 gene. Five patients were mosaic for the variants, with four patients sharing
the same variant. Patients with mosaic variants had less than 30% mosaicism, with
similar allele frequencies in sorted immune cells, saliva and fibroblast lines. The
sixth patient harbored a de-novo germline variant. All variants result in a gain-of-function
(GOF) of the encoded protein in a TLR8-deficient NF-κB reporter cell line. Immune
phenotyping revealed the presence of activated T cells, including the presence of
T cell clones in some cases and large granular lymphocytic leukemia (T-LGL) in 1 patient.
Multiple patients required IgG replacement therapy due to low B cells numbers and
antibody defects. Analysis of serum cytokines demonstrated significantly increased
levels of TNFα, IL-1β, IFNg, BAFF, IL-2Rα, IL-12/23 p40 and IL-18. The functional
consequence of the GOF variants on primary cells was established using patient-derived
iPSCs. Differentiation of myeloid cells from patient-derived iPSCs identified cells
with the variant as having increased phosphorylation of NF-κB to low doses of TLR8
stimulation. Additionally, enhanced production of pro-inflammatory cytokines like
IL-6, TNF-α, and IL-1β was also identified, supporting the presence of cytokine-driven
mechanism of disease pathogenesis. Our finding of 3 novel variants in TLR8 gene in
six unrelated patients suggests a novel monogenic TLR8-associated PID.
Keywords: Inborn errors of immunity, neutropenia, toll-like receptor
Disclosures All authors indicated they had no financial relationships to disclose.
(10) Autoantibodies against type I IFNs in Patients With Life-Threatening Disease
Due To Yellow Fever Live Attenuated Vaccine
Paul Bastard, n/a
1
1MD-PhD Student/Laboratory of human genetics of infectious diseases, Imagine Institute
Yellow fever virus (YFV) live attenuated vaccine can rarely cause life-threatening
disease, typically in patients with no history of severe viral illness. Autosomal
recessive (AR) complete IFNAR1 deficiency was reported in one 14-year-old patient.
Here, we studied eight other, previously healthy patients aged 13 to 68 years, with
unexplained life-threatening YFV vaccine-associated disease. One 13-year-old patient
had AR complete IFNAR2 deficiency. Three other patients vaccinated at the ages of
47, 62, and 64 years, had high titers of circulating auto-Abs against at least 14
of the 17 individual type I IFNs, a condition recently shown to underlie at least
10% of cases of life-threatening COVID-19 pneumonia. The auto-Abs were neutralizing
in vitro, blocking the protective effect of IFN-a2 against YFV vaccine strains. AR
IFNAR1 or IFNAR2 deficiency and neutralizing auto-Abs against type I IFNs thus account
for more than half the cases of life-threatening YFV vaccine-associated disease studied
here. Apparently healthy subjects could be tested for both deficiencies before vaccination
against YFV.
Keywords: Yellow fever vaccine, Type I intereferons, autoantibodies
Disclosures: The author had no financial relationships to disclose.
(11) Patient, Parent, and Provider Perceived Barriers in Primary Immunodeficiency
Transition of Care
Neha Agnihotri, MD1, Aisha Ahmed, MD2
1Assistant Professor of Medicine/University of Illinois at Chicago
2Attending Physician, Allergy and Immunology/Ann and Robert H Lurie Children's Hospital
of Chicago
We explored the perspectives of primary immunodeficiency (PID) patients and their
parents/guardians toward transition of care from pediatric to adult providers. We
also compared how transition components were perceived by immunologists at our institution.
Using ICD-9/10 codes, patients with a PID were identified at Lurie Children’s Hospital
(LCH) in Chicago, IL. Patients and their parents/guardians were sent separate surveys
with questions derived from the validated ‘ATTITUDE’ and ‘QUARTT’ instruments for
transition. Pediatric and adult immunologists at LCH and Northwestern Hospital completed
respective surveys anonymously (www.surveymonkey.com). Respondents were asked to rate
their level of agreement on a 5-point Likert scale, ranging from strongly disagree
to strongly agree.
Overall, 17 patients, 18 parents, 9 pediatric immunologists and 11 adult immunologists
participated. Regarding the current transition process, 71% of patients reported satisfaction
(mean score 3.82, SD 1.33) compared to 31% of parents (mean score 2.94, SD 1.18).
All parents, providers, and over 88% of patients agreed that during transition patients
should be educated about medications, patient condition, and symptoms that require
seeking health care. A transition coordinator was preferred by 94.1% of patients and
77.8% of parents. About 82.4% of patients and 72.2% of parents indicated a written
individualized plan for transition should be provided; 70% of providers favored this.
All parents and 94% of patients wanted an adult program to have phone access to a
nurse. The majority of patients and parents preferred a joint appointment with pediatric
and adult immunologists during transition; providers communicating directly without
patient/parent present was strongly rejected. About 53% of patients and 56% of parents
indicated that providers should prepare PID patients for transition around ages 15-17;
in comparison, 47% of patients, 37.5% of parents, and 55% of total providers indicated
transition preparation to start when 18 or older.
This study highlights key transition components. Families identified clear communication
among all involved parties and specific elements (written transition plan, phone access)
as being important. Interestingly, there were differences between current recommendations
regarding age of transition preparation initiation and patient/parent perspectives.
Further large-scale work is needed to build transition guidelines for the PID population.
Keywords: transition, primary immunodeficiency, adolescents, immunology provider
Disclosures: All authors indicated they had no financial relationships to disclose.
(12) COVID-19 in 3 patients with CLTA4 haploinsufficiency and absence of autoantibodies
to type 1 interferons
Sebastian Ochoa, MD1, Lindsey Rosen, BS2, Michail Lionakis, MD, ScD3, Gulbu Uzel,
MD4, Daniel Suez, MD5
1Clinical Fellow/Laboratory of Clinical Immunology and Microbiology, National Institute
of Allergy and Infectious Diseases/National Institutes of Health, Bethesda, MD, USA
2Investigator/Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda,
MD
3Chief, Fungal Pathogenesis Section/Laboratory of Clinical Immunology and Microbiology,
National Institute of Allergy and Infectious Diseases/National Institutes of Health,
Bethesda, MD, USA
4Physician scientist/Laboratory of Clinical Immunology and Microbiology, National
Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda,
Maryland, USA
5Past President of the Consortium of Independent Immunology Clinics/Allergy, Asthma
& Immunology Clinic PA
Despite a worldwide increase in COVID-19 cases, clinical experience with SARS-COV2
in primary immunodeficiency diseases remains limited. Recent studies showed patients
with defects in type 1 interferon (INF)-related pathways or those with auto-antibodies
(auto-Abs) against type 1 interferons developed severe COVID-19. We report the clinical
course of three patients with CTLA4 haploinsufficiency and COVID-19, and interrogated
for autoantibodies to type 1 interferons at baseline.
Data was obtained via patient interview and chart review. Screening for anti-INF auto-Abs
was carried out using a multiplex particle-based. Auto-Abs were tested for their neutralizing
activity.
Patient characteristics and COVID-19 disease course are shown in table 1. Patients
were adults (ages 20-34), had multiple autoimmune manifestations of CLTA4 haploinsufficiency,
and were managed with mTOR inhibitors, IVIG replacement, and abatacept. All patients
had a known close contact with COVID-19 and tested positive via nasopharyngeal rapid
antigen or PCR. Most common symptoms were nasal congestion and anosmia. Patients 1
and 2 received monoclonal antibodies (mAb) to SARS CoV2 within four days of symptom
onset and had mild disease course with no hypoxemia or need for hospitalization. Patient
3 received remdesivir and dexamethasone on day 7 (day 0 is defined as the first day
of symptoms), was admitted due to bilateral pulmonary infiltrates and an a SaO2 of
92%. He was discharged after 3 days with delayed resolution of shortness of breath
and fatigue after 4 weeks. Patients 1, 2 and 3 tested negative for SARS CoV2 at day
22, 30 and 19, respectively. Qualitative SARS CoV-19 IgG/IgM serologies obtained on
day 103 (patient 1) and day 31 (patient 3) were negative. All patients were negative
for autoantibodies to IFN-α, IFN-β and IFN-ω at baseline.
To our knowledge, this is the first report of COVID-19 in patients with CLTA4 haploinsufficiency.
Unlike reported patients with autoantibodies to type 1 interferons at baseline, 2
of our patients (patients 1 and 2) who had an early therapeutic intervention with
anti SARS-COV2 mAb had a benign disease course. Whether this is related to the early
therapeutic intervention and/or absent autoantibodies to type 1 interferons remains
to be elucidated.
Keywords: CTLA4, COVID19, Coronavirus, Interferon, SARS CoV2, CTLA4 haploinsufficiency,
Primary immunodeficiency, Type 1 interferon, COVID-19, Autoantibodies to interferon
Disclosures: All authors indicated they had no financial relationships to disclose.
(13) Dupilumab Therapy in STAT3 Deficient Hyper IgE Syndrome
Pavan Nataraj, MD1, Jenna Bergerson, MD, MPH2, Shashi Kumar, MD3, Kimberly Risma,
MD, PhD4, Michelle Sabo, MD, PhD5, Amanda Urban, CRNP6, Alexandra Freeman, MD7
1Resident Physician/George Washington University
2Staff Clinician/LCIM, NIAID, NIH
3Attending Physician/Alabama Asthma, Allergy & Immunology Center
4Associate Professor/Division of Allergy and Immunology, Cincinnati Children's Hospital
Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine,
Cincinnati, OH
5Assistant Professor of Medicine/University of Washington
6Nurse Practitioner/Clinical Research Directorate, Frederick National Laboratory for
Cancer Research
7Director, Primary Immune Deficiency Clinic/Laboratory of Clinical Immunology and
Microbiology, National Institute of Allergy and Infectious Diseases, National Institute
of Health
Dupilumab is a humanized monoclonal antibody blocking IL-4 and IL-13 signaling, approved
to treat atopic dermatitis (AD), asthma, and nasal polyps from chronic sinusitis.
Patients with dominant negative STAT3 mutations (LOF STAT3; Job’s syndrome) express
increased IL-4R suggesting dupilumab may treat some clinical manifestations. We examined
the clinical response and safety of dupilumab in LOF STAT3 patients treated for dermatitis,
asthma, and/or allergic bronchopulmonary Aspergillus (ABPA).
We reviewed the charts of 10 LOF STAT3 patients treated with dupilumab. We reviewed
age at initiation, length of therapy, indication, subjective clinical response, and
IgE level, absolute eosinophil count (AEC) and FEV1 prior to initiation and on therapy.
Dupilumab was initiated in 10 patients (7 female), aged 10 to 41 years. Indications
included AD (6 patients), asthma (1 patient), AD and asthma (1 patient), and ABPA
(2 patients). Pre-dupilumab IgE (516 to 41,336 IU/ml) was increased compared to IgE
on dupilumab (available for 6 patients; 458 to 12,233IU/mL); average percent decrease
in IgE was 24.7% (n=6). Baseline AEC (40 to 3320 cells/uL) was lower than AEC on dupilumab
(available for 6 patients; 70 to 5480 cells/uL); average percent change 14.5% increase
(n=5). FEV1 was unchanged pre- and post-therapy for the one patient with asthma and
available data. All patients treated at least 2 months endorsed significant improvement
in dermatitis, with decreased or discontinuation of topical steroids. One patient
had severe AD flare during a treatment interruption. One asthmatic patient endorsed
significant improvement in chest tightness and need for rescue inhaler, while the
other reported no symptom changes. One patient treated for ABPA had significant improvement
in cough, decreased sputum production, and improved radiographic findings. The second
ABPA patient developed difficulties with mental clarity and discontinued use. Dupilumab
was otherwise well tolerated.
Dupilumab administration in LOF STAT3 appears clinically promising and safe for treatment
of AD, with mixed results treating asthma and ABPA thus far. Preliminary studies showed
a decrease in serum IgE, but an increase in eosinophilia. Further studies are needed
to better evaluate the safety and efficacy in this population, as well as the mechanism
behind the improvement.
Keywords: Dupilumab, STAT3, Job's Syndrome, IL-4 receptor α inhibition, asthma, atopic
dermatitis, allergic bronchopulmonary aspergillus, ABPA, eczema, Hyper IgE Syndrome
Disclosures: All authors indicated they had no financial relationships to disclose.
(14) Investigating the Impact of Germline STAT3 Gain-of-Function on Regulatory T Cells
Erica Schmitt, M.D., Ph.D.1, Molly Keppel, MS2, Nermina Saucier, MS3, Kelsey Toth,
B.A.4, Tiphanie Vogel, M.D, Ph.D.5, Peter Vogel, DVM, Ph.D.6, Megan Cooper, MD,PhD7
1Clinical Fellow Pediatric Rheumatology/Washington University School of Medicine in
St. Louis
2Researcher/Department of Pediatrics, Division of Rheumatology/Immunology, Washington
University School of Medicine, St. Louis, MO
3Research Technician/Department of Pediatrics, Division of Rheumatology/Immunology,
Washington University School of Medicine, St. Louis, MO.
4Graduate Student/Washington University School of Medicine
5Assistant Professor, Division of Rheumatology, Department of Pediatrics & Medicine/Texas
Children’s Hospital, Baylor College of Medicine
6Director, Veterinary Pathology Core Laboratory/St Jude Children’s Research Hospital
7Associate Professor/Department of Pediatrics, Division of Rheumatology/Immunology,
Washington University School of Medicine, St. Louis, MO
Autosomal dominant germline gain-of-function variants in STAT3 result in immune dysregulation
and a broad spectrum of clinical features. A decreased frequency of Foxp3+ regulatory
T (Treg) cells has been observed in the peripheral blood of STAT3 GOF patients. STAT3
signaling is involved in both pro- and anti-inflammatory pathways and in the regulation
and balance of the Treg/Th17 cell polarization axis. To investigate the pathogenesis
of disease we developed a mouse model of STAT3 GOF with a protein variant discovered
in patients, p.G421R. STAT3 GOF mice heterozygous for the G421R mutation have a normal
or increased frequency of Treg cells, and similar expression of canonical Treg markers
and Treg suppressive capacity in vitro. However, in vitro induction of iTreg cells
is significantly impaired in these mice. With aging, STAT3 GOF mice develop progressive
lymphoproliferation. There is an increased frequency of activated CD4+ T cells and
increased IFN-gamma secretion from splenocytes re-stimulated ex-vivo. To further investigate
the implications of STAT3 GOF in T cells we utilized the T cell transfer model of
colitis. Naïve T cells were isolated from WT or STAT3 GOF mice and adoptively transferred
into C57BL/6 Rag1-/- mice. Weight loss, survival, and intestinal pathology were similar.
However, phenotypic analysis of the transferred T cells after 28 days demonstrated
an increased frequency of IFN-gamma positive cells, but not IL-17A-producing cells,
in the intestine lamina propria and mesenteric lymph nodes of mice receiving STAT3
GOF T cells. Mice with colitis induced by STAT3 GOF T cells had a significant reduction
in the frequency of peripherally-induced Treg cells in the mesenteric lymph nodes
and intestine lamina propria, suggesting decreased formation of iTreg cells in vivo.
Interestingly though, preliminary data suggest that treatment of colitis mice with
STAT3 GOF Treg cells is sufficient to allow for weight gain and survival, inferring
that Treg function may not be significantly altered in STAT3 GOF. Collectively, these
data may imply an altered function of effector T cells due to STAT3 GOF early in the
disease course of mice with colitis, and in aged STAT3 GOF mice, with a pathogenic
Th1 phenotype potentially dominating.
Keywords: immune dysregulation, STAT3, regulatory T cells
Disclosures: All authors indicated they had no financial relationships to disclose.
(15) Germline-encoded loss of RHOG specifically abrogates human lymphocyte cytotoxicity
and cause HLH
Artem Kalinichenko
1, Giovanna Casoni, n/a2, Loïc Dupré, PhD3, Luca Trotta, PhD4, Jakob Huemer, MSc5,
Donatella Galgano, PhD6, Yolla German, MSc7, Ben Haladik, MSc5, Julia Pazmandi, MSc5,
Marini Thian, MSc5, Özlem Petronczki, PhD8, Samuel Chiang, PhD6, Mervi Taskinen, MD,
PhD9, Anne Hekkala, PhD10, Saila Kauppila, MD, PhD11, Outi Lindgren, MD, PhD11, Terhi
Tapiainen, MD, PhD12, Michael Kraakman, PhD13, Kim Vettenranta, Prof, MD, PhD14, Alexis
Lomakin, PhD15, Janna Saarela, MD, PhD16, Mikko Sepanenn, n/a17, Yenan Bryceson, PhD18,
Kaan Boztug, MD, PhD19
1Postdoctoral fellow/St. Anna Children’s Cancer Research Institute / St. Anna Kinderkrebsforschung
(CCRI)
2Pre-doctoral fellow/Center for Hematology and Regenerative Medicine, Department of
Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
3Principal Investigator/Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases,
Vienna, Austria
4Postdoctoral Fellow/6Institute for Molecular Medicine Finland, University of Helsinki,
Finland
5Pre-doctoral fellow/St. Anna Children’s Cancer Research Institute, Vienna, Austria
6Postdoctoral Fellow/Center for Hematology and Regenerative Medicine, Department of
Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
7Pre-doctoral fellow/Center for Pathophysiology of Toulouse Purpan, INSERM UMR1043,
CNRS UMR5282, Paul Sabatier University, Toulouse, France
8Staff scientist/St. Anna Children’s Cancer Research Institute, Vienna, Austria
9Consultant/8Oulu University Hospital and University of Oulu, Oulu, Finland
10Postdoctoral Fellow/Oulu University Hospital and University of Oulu, Oulu, Finland
11Staff scientist/Oulu University Hospital and University of Oulu, Oulu, Finland
12Consultant/Oulu University Hospital and University of Oulu, Oulu, Finland
13Postdoctoral Fellow/St. Anna Children’s Cancer Research Institute, Vienna, Austria
14Consultant/Rare Disease and Pediatric Research Centers, University of Helsinki and
Helsinki University Hospital, Helsinki, Finland
15Program Leader and Deputy Lab Head/St. Anna Children’s Cancer Research Institute,
Vienna, Austria
16Director/Institute for Molecular Medicine Finland, University of Helsinki, Finland
17Rare Disease and Pediatric Research Centers, Hospital for Children and Adolescents,
and Adult Immuno/Unit, Inflammation Center, University of Helsinki and HUS Helsinki
University Hospital, Helsinki, Finland
18Principal Investigator/Center for Hematology and Regenerative Medicine, Department
of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
19Director/St. Anna Children’s Cancer Research Institute, Vienna, Austria
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized
by immune dysregulation and massive, aberrant hyperactivation of cytotoxic T cells
and macrophages. The molecular pathologies underlying HLH are diverse. The monogenic
or primary form of HLH is caused by mutations selectively disrupting perforin-mediated
cytotoxicity in human lymphocytes.
We studied a patient with early-onset HLH who fulfilled all diagnostic criteria, including
almost absent killing activity of NK cells. Targeted NGS-based panel sequencing did
not reveal any germline mutations in established HLH-associated genes. Using exome
sequencing and genome-wide SNP array, we identified biallelic germline mutations in
RHOG. Genetic ablation of the RHOG gene in a model cell line and primary cytotoxic
T lymphocytes (CTLs) from healthy individuals confirmed its crucial role in lymphocyte
cytotoxicity. Notably, despite the severe defect in exocytosis, RhoG-deficient lymphocytes
showed normal activation, proliferation, and cytokine production.
To decipher the molecular pathomechanism of the RhoG deficiency, we performed interaction
proteomics analysis and defined the molecular partners of RhoG in human lymphocytes.
In addition to the strong association with the cytoskeleton regulators, this analysis
also revealed a direct link of RhoG with the exocytosis machinery. Hence, we discovered
that RhoG interacts with the regulator of cytotoxic granule (CG) release Munc13-4
and regulates docking of Munc13-4-positive CGs to the plasma membrane. This step is
required for subsequent fusion of the membranes to release cytolytic cargo toward
target cells. Using molecular biology and biochemical approaches, we showed that RhoG
is essential for the proper function of hematopoietic Munc13-4, assisting it in binding
to the membrane phospholipids. We further confirmed that this requirement for the
RhoG assistance is unique for Munc13-4, which lacks the C1 membrane-binding domain
present in other Munc13 isoforms. Collectively, our work i) discovers a novel Mendelian
disease affecting human immune function and homeostasis, potentially representing
familial HLH type 6; ii) defines a molecular pathomechanism of the discovered disorder;
iii) identifies a novel layer of exocytosis regulation unique for cytotoxic lymphocytes.
Keywords: Cytotoxic lymphocytes, Hemophagocytic lymphohistiocytosis, regulated exocytosis
Disclosures: All authors indicated they had no financial relationships to disclose.
(16)
Immunometabolic Phenotyping in Father-Daughter Pair with GATA2 Haploinsufficiency
James Maiarana, MD1, Saara Kaviany, D.O.2, Todd Bartkowiak, Phd3, Yasmin Khan, MD4,
Daniel Dulek, MD5, Sarah Neumann, RN6, Jeffrey Rathmell, PhD7, Jonathan Irish, PhD8,
James Connelly, MD9
1Intern/Vanderbilt University Medical Center
2Instructor/Pediatric Hematology Oncology, Vanderbilt University Medical Center, Nashville,
TNPediatric Hematology Oncology, Vanderbilt University Medical Center, Nashville,
TN
3Postdoctoral Scholar/Vanderbilt University
4Assistant Professor Pediatrics AI/Vanderbilt University Medical Center
5Assistant Professor Pediatric ID/Vanderbilt University Medical Center
6Pediatric BMT Case Manager/Vanderbilt University Medical Center
7Associate Director - Vanderbilt Institute for Infection, Immunology and Inflammation,
Professor PMI/Vanderbilt University
8Associate Professor of Cell and Developmental Biology/Vanderbilt University
9Assistant Professor Pediatric Hem/Onc/BMT/Vanderbilt University Medical Center, Nashville,
TN
The transcription factor GATA2 is required for hematopoietic stem cell homeostasis
and lymphangiogenesis (1,2,3). Heterozygous mutations in GATA2 result in haploinsufficiency
leading to a spectrum of clinical phenotypes: susceptibility to viral and bacterial
infections, cytopenias, pulmonary alveolar proteinosis, lymphedema, and myelodysplasia
(2,4,5). We present a father-daughter pair with heterozygous GATA2 (c.890del, p.Asn297Thr*29)
variants leading to haploinsufficiency and their distinct clinical phenotypes. Using
mass cytometry (CyTOF), we performed comparative immune-profiling of peripheral blood,
demonstrating immune phenotypic and metabolic characteristics.
The daughter presented at 15 years old with cytopenias and recurrent urinary tract
infections. Bone marrow biopsies revealed hypocellularity, dyserythropoiesis, karryohexis,
and erythrocyte and granulocyte atypia. An NGS myeloid panel revealed a c.890del variant
in GATA2 with a 47% allelic frequency. She has recently developed recurrent panniculitis
and lower extremity lymphedema.
The same variant was present in the father who presented with more severe clinical
features, including HPV-associated squamous cell carcinoma, T-cell large granular
lymphocytic leukemia, and recurrent viral and bacterial infections.
Patients were enrolled in the Human Immune Discovery Initiative (HIDI) at Vanderbilt
University permitting immunophenotyping of human leukocytes using CyTOF. Cytometric
evaluation revealed that the patients with GATA2 haploinsufficiency had systemically
perturbed peripheral immunity compared to healthy controls including 1) increased
frequencies of TEMRA, 2) 8-fold reduction in myeloid cells 3) inverted CD4:8 ratios,
4) increased expression of markers of activation (CD44, CD95, CXCR3, and CD57) and
metabolism (ATP5a, CPT1a, GLUT1, GLUT3) in T- and B-cell subsets, and 5) increased
expression of markers of glycolysis (GLUT1, GLUT3) in monocytes.
GATA2 haploinsufficiency leads to a spectrum of clinical illness with monocytopenia,
and decreased frequencies of B- and NK-cells. Utilizing CyTOF, we have gained a more
complete understanding of immunity in patients with known or suspected inborn errors
of immunity (IEIs). Our findings are consistent with reports of known GATA2 haploinsufficiency
(6,7); however, this is the first analysis, to our knowledge, of the immunometabolic
profile of patients with GATA2 haploinsufficiency. Our data suggests an undescribed
metabolic activation across lymphoid and myeloid lineages in our patients.
Figure 1:
Immunometabolic phenotyping of T cells in patients with Gata2 Haploinsufficiency compared
to healthy control
Keywords: GATA2 Haploinsufficiency, Immunometabolism, Mass Cytometry
Disclosures: All authors indicated they had no financial relationships to disclose.
(17) Unusual presentation of subcutaneous panniculitis-like T cell lymphoma in patients
with BENTA disease
Bradly Bauman, MS1, Stefania Pittaluga, MD, PhD2, Yu Zhang, PhD3, Sergio Rosenzweig,
MD, PhD4, Ronald Anderson, MD5, Gregory Gulcher, MD6, Iwona Auer, MD7, Renee Perrier,
MD8, Martin Campbell, MBSS Msc9, Magdalena Schelotto, MD10, Nicola Wright, MD, MSc,
FRCPC5, Helen Su, MD PhD11, Andrew Snow, PhD12
1Graduate Student/Department of Pharmacology and Molecular Therapeutics, Uniformed
Services University of the Health Sciences, Bethesda, MD, USA
2Senior Research Physician/Lab of Pathology, National Cancer Institute, Bethesda,
MD, USA.
3Staff Scientist/Laboratory of Clinical Immunology & Microbiology, National Institute
of Allergy and Infectious Diseases, National Institutes of Health
4Senior Investigator/Immunology Service, Department of Laboratory Medicine, NIH Clinical
Center, Bethesda, MD, USA
5Clinical Associate Professor/Department of Pediatrics, Alberta Children's Hospital,
University of Calgary, Calgary, AB, Canada
6Associate Professor/Department of Pediatrics, Alberta Children's Hospital, University
of Calgary, Calgary, AB, Canada
7Clinical Associate Professor/Alberta Precision Laboratories, University of Calgary,
Calgary, AB, Canada
8Clinical Associate Professor/Department of Medical Genetics, University of Calgary,
Calgary, AB, Canada
9Consultant Oncologist/Children's Cancer Centre, Royal Children's Hospital, Melbourne,
Australia
10Clinical Investigator/Department of Pediatric Hematology and Oncology, Fundación
Pérez Scremini, Hospital Pereira Rossell, Montevideo, Uruguay
11Senior Investigator/Laboratory of Clinical Immunology & Microbiology, National Institute
of Allergy and Infectious Diseases, National Institutes of Health
12Associate Professor/Department of Pharmacology and Molecular Therapeutics, Uniformed
Services University of the Health Sciences, Bethesda, MD
Subcutaneous panniculitis-like T cell lymphoma (SPTCL) is a rare form of non-Hodgkin’s
lymphoma, comprised of neoplastic CD8+ TCRalpha/bet+ cytotoxic T cells that surround
adipocytes in the panniculus. Primary SPTCL is frequently associated with hemophagocytic
lymphohistiocytosis (HLH) and germline, biallelic loss-of-function mutations in HAVCR2,
which encodes for the immunomodulatory receptor T cell immunoglobulin mucin 3 (TIM-3).
In contrast, atypical lymphocytic lobular panniculitis (ALLP) or secondary SPTCL can
occur in the context of infection or autoimmune disease, often accompanied by somatic
mutations in infiltrating T cells, and can be difficult to distinguish from primary
SPTCL. Here we describe two unrelated patients with confirmed B cell Expansion with
NF-□B and T cell Anergy (BENTA) disease and a novel presentation of SPTCL/ALLP. Patient
1 presented early in life with recurrent infections and transitional B cell lymphocytosis,
linked to a novel gain-of-function (GOF) mutation in the lymphocyte-specific scaffold
protein caspase activation and recruitment domain 11 (CARD11, p.Lys238del), consistent
with BENTA disease. By age 2, he developed SPTCL-like lesions and membranoproliferative
glomerulonephritis / nephrotic syndrome. Following relapse after initial CHOP chemotherapy,
the patient was successfully treated with cyclosporine A and has remained in remission
since, with prophylactic TMP-SMX and no infections. Subsequent histopathological analyses
of skin biopsies suggested lupus-associated ALLP with no clonality and normal TIM-3
expression. Patient 2 presented with splenomegaly, lymphadenopathy, elevated naïve
B cells, and confirmed SPTCL at 18 months, with widespread cutaneous involvement and
evidence of HLH. Genetic analysis revealed two de novo, in cis germline GOF mutations
in the LATCH domain of CARD11 (p.Glu121Asp, p.Gly126Ser), confirming a diagnosis of
BENTA disease. No HAVCR2 mutations were detected. After a poor response to multiple
rounds of chemotherapy, she required autologous bone marrow transplant and has been
in remission since, with no infectious complications. These cases illuminate an unusual
pathological manifestation for BENTA disease, and further suggest that CARD11 GOF
mutations can contribute to the development of cutaneous T cell dyscrasias and/or
malignancies involving both CD4+ (Sézary syndrome) and CD8+ (SPTCL) lineages, or both
(ALLP).
Keywords: CARD11, SPTCL, BENTA, lobular panniculitis, B cell lymphocytosis, ALLP
Disclosures: Gregory Gulcher received a research grant from Blue Bird Bio. All other
authors had no financial relationships to disclose.
(18) Clinically Unsolvable Autoinflammatory Disorder Diagnosed by RNA and Long Read
Sequencing
Jessica Nguyen, MD1, Marietta M. DeGuzman, MD2, Jessi Xu, n/a3, Stephen Wu, n/a3,
Patricia Rosillo, MD2, Caridad Martinez, MD4, Judith Campbell, MD5, Sarah Nicholas,
M.D.6, Jill Rosenfield, MS7, Fan Xia, PhD8, Lindsay Burrage, MD, PhD9, Medhat Mahmoud,
n/a10, Fritz Sedlazeck, PhD11, Undiagnosed Disease Network, n/a12, Eric Hanson, MD13,
M. Cecilia Poli, MD, PhD14, David Murdock, MD7, Tiphanie Vogel, M.D, Ph.D.15
1Resident/Baylor College of Medicine
2Division of Rheumatology, Department of Pediatrics Associate Professor/Baylor College
of Medicine/Texas Children's Hospital
3Division of Rheumatology, Department of Pediatrics/Indiana University School of Medicine
4Division of Hematology and Oncology, Department of Pediatrics Associate Professor/Baylor
College of Medicine/Texas Children's Hospital
5Division of Infectious Diseases, Department of Pediatrics Attending Physician/Baylor
College of Medicine/Texas Children's Hospital
6Assistant Professor, Division of Immunology, Allergy and Retrovirology, Department
of Pediatrics/Texas Children's Hospital, Baylor College of Medicine
7Department of Molecular and Human Genetics Assistant Professor/Baylor College of
Medicine
8Department of Molecular and Human Genetics Associate Professor/Baylor College of
Medicine
9Assistant Professor/Baylor College of Medicine
10Human Genome Sequencing Center Postdoctoral Associate/Baylor College of Medicine
11Human Genome Sequencing Center Assistant Professor/Baylor College of Medicine
12Undiagnosed Disease Network/Undiagnosed Disease Network
13Division of Rheumatology, Department of Pediatrics Associate Professor/Indiana University
School of Medicine
14Director of the Immunogenetics and Translational Immunology Program; Assistant Professor/Universidad
del Desarrollo; Baylor College of Medicine/ Texas Children's Hospital
15Assistant Professor, Division of Rheumatology, Department of Pediatrics & Medicine/Texas
Children’s Hospital, Baylor College of Medicine
IKBKG on chromosome X encodes NEMO, a critical regulator of NF-κB and interferon signaling.
Hypomorphic NEMO mutations cause anhidrotic ectodermal dysplasia with immunodeficiency
in males. Recently, NEMO deleted exon 5 autoinflammatory syndrome (NEMO-NDAS) was
reported in both males and females, characterized by infantile-onset fevers, panniculitis,
and immunodysregulation. We report a case of NEMO-NDAS and the evaluation necessary
for the diagnosis.
The patient presented at age 6 weeks with fevers and rash; inflammatory markers were
elevated. Infectious etiologies were excluded and she responded to corticosteroids,
but symptoms returned with tapers. Extensive clinical investigations pursuing an etiology
were most notable for granuloma formation (in bone marrow, stomach, liver, and dura
mater) and low B cells with hypogammaglobulinemia. Clinical trio exome sequencing
(ES) was negative. Research analysis suggested dysregulated interferon responses in
patient-derived cells. RNA-sequencing from fibroblasts revealed a deletion of IKBKG
exon 5, present in 97% of transcripts, consistent with skewed X-inactivation. Targeted
exome analysis of IKBKG was uninformative due to a nearby pseudogene. Nanopore long
read sequencing was then done and identified a presumed de novo IKBKG splice site
variant, c.519-2A>C, originating on the paternal allele. Fibroblast protein electrophoresis
confirmed 95% of the patient’s NEMO protein was the shorter form.
Her predominate clinical features have been recurrent fever and wide-spread panniculitis.
She has also developed multiple infections in the setting of chronic immunosuppression,
requiring IVIG replacement and anti-microbial prophylaxis, including frequent upper
respiratory and urinary infections, Pneumocystis pneumonia, HSV-1 and BK viremia,
and disseminated candidiasis. She has trialed numerous immunomodulatory treatments
(anti-TNF, IL-1, IL-6R, and IL-12/23 agents, costimulatory blockade, JAK inhibition).
However, her disease is refractory to all steroid-sparing attempts and she has remained
on corticosteroids since presentation. She exhibits multiple sequelae of chronic illness
and steroid use including adrenal insufficiency, hypertension, short stature, osteoporosis,
and papilledema. She is now 10 years old and undergoing evaluation for bone marrow
transplant.
NEMO-NDAS is a new monogenic autoinflammatory disease characterized by an interferon
signature. Thorough genetic evaluation for NEMO-NDAS should be considered in cases
of early-onset fevers, severe immune dysregulation and panniculitis if clinical ES
is unrevealing.
Keywords: IKBKG, NEMO, immune dysregulation, genetics, case report
Disclosures: Jill Rosenfield, Fan Xia, Lindsay Burrage, and David Murdock work for
the Human Genetics Laboratory at Baylor College of Medicine which receives revenue
from clinical genetic testing completed at Baylor Genetics Laboratory. All other authors
had no financial relationships to disclose.
(19) Splice Site Variants in IKBKG Detected by a Customized Next-Generation Sequencing
Analysis Cause an Early-onset Autoinflammatory Syndrome of Panniculitis and Cytopenias
in Male and Female Patients
Adriana De Jesus, MD, PhD1, Bin Lin, PhD2, Eric Karlins, MSc3, Andrew Oler, PhD4,
Sofia Torreggiani, MD5, Andre Rastegar, BS6, Dana Kahle, BS6, Jacob Mitchell, BS6,
Eric Hanson, MD7, Magdalena Walkiewicz, PhD8, Sara Alehashemi, MD, MHS9, Kader Cetin-Gedik,
MD9, Cassandra Holmes, MS, CRNP, FNP-C10, Kat Uss, RN, BSN11, Eveline Wu, MD12, Christiaan
Scott, MD13, Timothy Leahy, MD, PhD14, Emma MacDermott, MD15, Orla Killeen, MD16,
Thaschawee Arkachaisri, MD17, Scott Canna, MD18, Seza Ozen, MD19, Zoran Gucev, MD20,
Kathryn Cook, DO21, Vafa Mammadova, MD, PhD22, Gulnara Nasrullayeva, MD22, Amer Khojah,
MD23, Timothy Moran, MD, PhD24, Raphaela Goldbach-Mansky, MD25
1Staff Scientist/Translational Autoinflammatory Disease Section (TADS), Laboratory
of Clinical Investigation and Microbiology (LCIM), NIAID, NIH
2Staff Scientist/Translational Autoinflammatory Disease Section, NIAID, NIH
3Bioinformatics Scientist/Bioinformatics and Computational Biosciences Branch, Office
of Cyber Infrastructure and Computational Biology, NIAID, NIH
4Senior Bioinformatics Scientist/Bioinformatics and Computational Biosciences Branch,
Office of Cyber Infrastructure and Computational Biology, NIAID, NIH
5Post-doctoral visiting fellow/Translational Autoinflammatory Disease Section (TADS),
Laboratory of Clinical Investigation and Microbiology (LCIM), NIAID, NIH
6Post-baccalaureate fellow/Translational Autoinflammatory Disease Section (TADS),
Laboratory of Clinical Investigation and Microbiology (LCIM), NIAID, NIH
7Division of Rheumatology, Department of Pediatrics Associate Professor/Indiana University
School of Medicine
8Certified Molecular Geneticist/Division of Intramural Research (DIR), NIAID, National
Institutes of Health, Bethesda, MD
9Clinical Fellow/Translational Autoinflammatory Disease Section (TADS), Laboratory
of Clinical Investigation and Microbiology (LCIM), NIAID, NIH
10Clinical Trials Research Nurse Practitioner/Translational Autoinflammatory Disease
Section (TADS), Laboratory of Clinical Investigation and Microbiology (LCIM), NIAID,
NIH
11Research Nurse/Translational Autoinflammatory Disease Section (TADS), Laboratory
of Clinical Investigation and Microbiology (LCIM), NIAID, NIH
12Associate Professor/University of North Carolina School of Medicine
13Associate Professor/University of Cape Town, Red Cross War Memorial Children's Hospital
14Consultant in Paediatric Immunology and Infectious Diseases/CHI at Crumlin
15Consultant Pediatric Rheumatologist/CHI at Crumlin
16Consultant Adolescent and Pediatric Rheumatologist/CHI at Crumlin
17Associate Professor/KK Women's and Children's Hospital
18Assistant Professor/University of Pittsburgh, UPMC Childrens Hospital
19Professor/Division of Rheumatology, Department of Pediatrics, Hacettepe University
Faculty of Medicine
20Professor of Pediatrics/University Children's Hospital, Medical Faculty Skopje
21Pediatric Rheumatologist/Akron Children’s Hospital
22Pediatric Immunologist/Azerbaijan Medical University
23Attending Physician, Allergy, Immunology, and Rheumatology/Ann & Robert H. Lurie
Children's Hospital of Chicago/ Northwestern University Feinberg School of Medicine
24Assitant Professor/University of North Carolina School of Medicine
25Chief/Translational Autoinflammatory Diseases Section, NIAID, National Institutes
of Health, Bethesda, MD,
Loss-of-function mutations in the X-linked gene, IKBKG, encoding NEMO, cause immunodeficiency
with ectodermal dysplasia in males and incontinentia pigmenti in females. Previously,
we identified 4 patients with gain-of-function splice site variants in IKBKG using
targeted sequencing. These variants caused in-frame splicing-out of exon 5 and a novel
chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature
(CANDLE)-like autoinflammatory disease (AID) called NEMO-deleted exon 5 autoinflammatory
syndrome (NEMO-NDAS). Because an IKBKG pseudogene (IKBKGP1) complicates genetic diagnosis
of NEMO-NDAS by standard methods, we sought to develop a customized bioinformatics
approach to identify disease-causing splice site variants in IKBKG.
A bioinformatics pipeline to computationally mask the IKBKGP1 pseudogene was used
in whole exome/genome sequencing (WES/WGS) from patients with undifferentiated AIDs
enrolled in an IRB-approved protocol. Western blot, cDNA sequencing, RNA-seq and an
interferon (IFN) response gene (IRG) score (Nanostring) were performed.
Out of 682 individuals, including patients with undiagnosed AIDs and their parents,
13 patients (9 females and 4 males) with 8 different de novo splice-site variants
in IKBKG were identified. All patients had early-onset disease (2 days to 3 years
old), panniculitis, systemic inflammation and elevated IFN signatures. Other manifestations
(>70%) included failure to thrive, lipodystrophy, hepatosplenomegaly, thrombocytopenia
and B-cell lymphopenia. All patients were steroid-dependent and partially responded
to anti-TNF (n=8) or JAK-inhibition (n=5) therapies. One patient died from opportunistic
infections and another from sudden cardiac arrest. cDNA sequencing showed exon 5 skipping
in the 10 patients tested and Western blot confirmed the splice product in 5/5 patients.
RNA-seq showed a high frequency of exon 5 skipping in the 6 patients tested. The IFN
scores had higher expression of IRG’s harboring NF-kB binding sites (CXCL10, GBP1
and SOCS1) than IRG’s without. Screening of IKBKG exon 5 splice-site variants in internal
and public WES/WGS databases with more than 2,000 subjects is ongoing.
We describe a novel CANDLE-like autoinflammatory disease caused by de novo splice-site
variants in IKBKG. Our bioinformatics pipeline masking the pseudogene provides a diagnostic
tool for the diagnosis of WES/WGS data and early recognition may allow for better
outcomes.
Acknowledgements: This work was supported by the NIH-NIAID-IRP
Keywords: IKBKG, NEMO, autoinflammatory disease, NEMO-deleted exon 5 autoinflammatory
syndrome, panniculitis, cytopenia, bioinformatics
Disclosures: All authors indicated they had no financial relationships to disclose.
(20) Thymus Hypoplasia Resulting from 22q11.2 Deletion Syndrome Corrected by Reconstitution
with Normal Mesenchymal Cells
Pratibha Bhalla, PhD1, Igor Dozmorov, PhD2, Christian Wysocki, PhD, MD3, Ashwani Kumar,
n/a4, Chao Xing, n/a5, Ondine Cleaver, PhD6, Mary Louise Markert, MD PhD7, M. Teresa
De La Morena, MD8, Nicolai van Oers, PhD6
1Postdoctoral Researcher/UT Southwestern Medical Center
2Associate Professor/UT Southwestern Medical center
3Pediatric Immunologist. Assistant Professor/UT Southwestern Medical center
4Computational Biologist/Bioinformatics Lab , UT Southwestern Medical Center
5Director/Bioinformatics Lab , UT Southwestern Medical Center
6Professor/UT Southwestern Medical Center
7Professor/Department of Immunology, Duke University, Durham
8Allergist/Division of Immunology, Department of Pediatrics, University of Washington
and Seattle Children’s Hospital
Thymus hypoplasia occurs in many clinical conditions including particular congenital
disorders, 22q11.2 Deletion Syndrome (22q11.2DS), Down syndrome, and individuals with
autosomal recessive FOXN1 mutations. 22q11.2 deletion syndrome (22q11.2del) is the
most common human microdeletion disorder known, affecting ~1/4000. Thymus tissues
that were obtained from 22q11.2DS patients are size-restricted. This results in reduced
T cell output, measured as low TRECs. This is very similar for patients with autosomal
recessive FOXN1 mutations. In both clinical settings, an allogenic thymus tissue graft
is a preferred treatment option to resolve the stromal cell defects characteristic
for 22q11.2DS and FOXN1 mutations. To determine the molecular mechanisms contributing
to a small thymus size caused by 22q11.2del, we compared the development of the thymus
in embryos from mouse models of 22q11.2del relative to those from normal controls
and from Foxn1 mutant mice. Reaggregate fetal thymic organ culture assays established
that mesenchymal cells were causal to the formation of a small thymus in the setting
of 22q11.2. Experimentally, replacing mesenchymal cells from 22q11.2del hypoplastic
lobes with equivalent numbers of normal ones restored thymus tissue growth and thymopoiesis.
Normal thymic epithelial cells could not support this tissue regeneration. This is
distinct from the Foxn1 mutant mice, wherein the thymic epithelial cells cause the
thymus hypoplasia/aplasia. Single-cell RNA sequencing of normal and hypoplastic thymus
lobes revealed a differential gene expression that primarily impacted 5 distinct mesenchymal
cell subsets. Differential expression of transcripts involved in cell-cell interactions,
collagen matrices, and growth factors were evident in the hypoplastic lobes. This
contrasted the transcriptome differences using hypoplastic lobes from Foxn1 mutant
mice, wherein TECs are primarily impacted. Taken together, these findings suggest
novel approaches for restoring thymus function in various clinical settings.
Keywords: DiGeorge Syndrome, Thymus Hypoplasia, Low TRECs, 22q11.2 Syndrome, Chromosomal
Microdeletion
Disclosures: All authors indicated they had no financial relationships to disclose.
(21) Constrained chromatin accessibility in PU.1-mutated agammaglobulinemia patients
Carole Le Coz, PhD1, David Nguyen, MD PhD2, Amy Stiegler, PhD3, Amy Rymaszewski, PhD4,
Jennifer Puck, MD5, Kathleen Sullivan, MD, PhD6, John Routes, MD7, Joud Hajjar, MD8,
Sarah Nicholas, M.D.9, Prescott Atkinson, MD, PhD10, James Verbsky, MD, PhD11, Ivan
Chinn, MD12, Alexander Marson, MD PhD13, Neil Romberg, MD14
1Research Associate/Children's Hospital of Philadelphia
2Assistant Adjunct Professor/UCSF
3Research Associate & Scientist/Yale university
4Research Associate/Medical College of Wisconsin
5Attending Physician/Pediatric Allergy, Immunology, and Blood and Marrow Transplant
Division, University of California San Francisco Benioff Children’s Hospital
6Professor of Pediatrics, Chief of the Division of Allergy and Immunology/The Children’s
Hospital of Philadelphia, Philadelphia, PA, USA
7Professor of Pediatrics, Medicine, Microbiology and Immunology/Medical College of
Wisconsin
8Assistant Professor of Immunology, Allergy, and Rheumatology/Baylor College of Medicine
9Assistant Professor, Division of Immunology, Allergy and Retrovirology, Department
of Pediatrics/Texas Children's Hospital, Baylor College of Medicine
10Professor of Pediatrics/Division of Pediatric Allergy & Immunology University of
Alabama at Birmingham
11Associate Professor of Pediatrics, Medicine, Microbiology and Immunology/Medical
College of Wisconsin
12Assistant Professor/Baylor College of Medicine/ Texas Children's Hospital
13Associate Professor/UCSF, Gladstone Institutes
14Assistant Professor of Pediatrics, Perelman School of Medicine at the University
of Pennsylvania/Children's Hospital of Philadelphia
PU.1 is a pioneer transcription factor that determines hematopoietic cell fate by
decompacting stem cell heterochromatin, regulating expression of PU.1-controlled genes
and recruiting non-pioneer transcription factors to otherwise inaccessible nucleotides.
Although PU.1 deficiency fatally arrests lymphopoiesis and myelopoiesis in mice and
PU.1 mutations are common in human myeloid leukemias, primary PU.1-mediated diseases
have yet not been described. Here, we identify six unrelated, agammaglobulinemic subjects
each harboring novel, non-synonymous heterozygous mutations (four de novo, two unphased)
in SPI1, the gene encoding PU.1.
To determine if and how SPI1 mutations cause PU.1-mutated agammaglobulinemia (PU.MA).
PU.MA subject DNA, peripheral blood and bone marrow samples were analyzed with whole
exome sequencing, Cellular Indexing of Transcriptomes and Epitopes by Sequencing (CITE-Seq),
flow cytometry and immunohistochemistry. The transcriptional capacity, tertiary stability,
nuclear localization and DNA binding strength of PU.1 mutants were assessed with reporter
lines, confocal microscopy, electrophoretic mobility shift assays, circular dichroism
spectroscopy and quantitative fluorescence polarization. Hematopoiesis was modelled
in vitro using genetically edited RS4;11 pro-B cell lines and human hematopoietic
stem cells (HSCs).
All PU.MA subjects lacked circulating B cells and were deficient of PU.1-high expressing
conventional dendritic cells. CITE-seq analysis of PU.MA marrow displayed developmental
arrest between the pro and pre-B cell stages when there was a rising demand for PU.1
and PU.1-dependent gene products like BTK, FCRLA and IGLL5. In vitro HSCs genetically
edited to carrying patient-similar SPI1 mutations, failed to differentiate into B
cells. When overexpressed in HEK293 lines, three of six mutant, patient SPI1 alleles
failed to produce detectable protein. The three detectable PU.1 mutants failed to
drive transcription in reporter cells but also did not interfere with wild type PU.1’s
ability to do so. Of these, one PU.1 mutant failed to localize to the nucleus and
two mutants localized but could not bind target DNA. In SPI1-excised RS4;11 lines,
PU.1 loss constrained chromatin access for non-pioneer TFs critical for B-cell development.
Our findings identify and molecularly describe a novel form of autosomal dominant
agammaglobulinemia. PU.MA agammaglobulinemia underscores the essential, dose-dependent
role of PU.1 in human B-cell lymphopoiesis.
Keywords: agammaglobulinemia, hematopoiesis, Pioneer Transcriptional Factor, PU.1,
B cells
Disclosures: John Routes had contracted research at CSL Behring and Evolve Biologics.
Joud Hajjar received research grants from Amplimmune, Arcus Biosciences, ARMO BioSciences,
Atterocor/Millendo, Baxalta, BMS, Calithera Biosciences, Chao Physician-Scientist
Foundation, CytomX Therapeutics, Eli Lilly, EMD Serono, Healios Onc, Immune Deficiency
Foundation, ImmuneOncia, Incyte, Jeffrey Modell Foundation, Karyopharm, Kymab, MedImmune,
Merck, National Cancer Institute, NeoImmuneTech, Neon Therapeutics, Novartis, OncoSec
KEYNOTE-695, Pfizer, PsiOxus, Regeneron, Surface Oncology, The Texams Medical Center
Digestive Diseases Center and Top Alliance; she was an Advisory Board member of Alfaisal
University, Genome & Company, Horizon, and Pharming. All other authors had no financial
relationships to disclose.
(22) Results of 105 patients who received cultured thymus tissue implants
Mary Markert, MD, PhD1, Stephanie Gupton, CPNP2, Elizabeth McCarthy, RN, MSN3
1Professor of Pediatrics/Department of Pediatrics and Department of Immunology, Duke
University Medical Center, Durham, North Carolina, USA
2Nurse Practitioner/Duke University Medical Center
3Research Program Leader, Senior/Duke University Medical Center
Congenital athymia results in high early mortality due to infection and immune dysregulation.
One hundred and three children with congenital athymia and 2 with severe combined
immune deficiency received cultured thymus tissue implantation (CTTI) over 27 years
at a single center.
Objectives: Objectives of the study were to assess survival, T cell numbers and function,
adverse events, and infections.
The 105 patients received CTTI under one of 10 IRB approved protocols. Ninety-five
patients with athymia met the eligibility criteria for complete DiGeorge anomaly or
FOXN1 and had naïve T cells < 50/mm3. Ten additional patients were enrolled in an
expanded access protocol and were evaluated separately. Ninety-five patients were
included in the Efficacy Analysis Set (EAS); 10 additional patients were included
in the Full Analysis Set (FAS).
The EAS shows Kaplan-Meier estimated survival rates at year 1 and year 2 post-implantation
of 77% and 76% respectively. The median follow-up time for the EAS is 7.6 years and
ranged from 0 to 25.5 years. The median CD3 T cell counts in the EAS were >600/mm3
2 years post implantation and remained below the 10th percentile for age. After developing
naïve T cells, the patients were able to clear disseminated infections such as mycobacteria
and parainfluenza III virus. The proliferative response to phytohemagglutinin was
normal. In the first year of life, there were adverse events such as autoimmune disease,
fever, and respiratory, gastrointestinal, and central line infections. Infections
were responsible for 12 deaths, all during the first year post implantation. Of the
10 additional patients in the FAS, there were 3 deaths with a survival similar to
the EAS.
The use of CTTI in athymic infants led to an excellent survival based on the Kaplan
Meier Curve of the EAS analysis set. Of 95 patients, there are 70 survivors whose
median age is 12.7 years post CTTI. All deaths related to poor immunity occurred in
the first 2 years post CTTI. The development of T cell immunity enabled the patients
to fight off infection. In summary, CTTI is a life-saving investigational therapy
for congenital athymia.
Keywords: Thymus Transplantation, congenital athymia, athymia, complete DiGeorge,
CHARGE, 22q11.2 deletion
Disclosures: Mary Markert received a research grant from Enzyvant Therapeutics, GmbH.
All other authors had no financial relationships to disclose.
(23) Somatic reversion of pathogenic DOCK8 variants alters lymphocyte differentiation
and function to effectively cure DOCK8 deficiency
Stuart Tangye, PhD1
1Theme Leader/Garvan Institute of Medical Research
Inborn errors of immunity cause monogenic immune dysregulatory conditions such as
severe and recurrent pathogen infection, inflammation, allergy and malignancy. Somatic
reversion refers to the spontaneous repair of a pathogenic germline genetic variant
and has been reported to occur in a number of inborn errors of immunity with a range
of impacts on clinical outcomes of these conditions. DOCK8 deficiency due to bi-allelic
inactivating mutations in DOCK8 causes a combined immunodeficiency characterised by
severe bacterial, viral and fungal infections, as well as allergic disease and some
cancers. Here, we describe the clinical, genetic and cellular features of three patients
with bi-allelic DOCK8 variants who, following somatic reversion in multiple lymphocyte
subsets, exhibited improved clinical features, including complete resolution of infection
and allergic disease, cure over time. Acquisition of DOCK8 expression restored defective
lymphocyte signalling, survival and proliferation, as well as CD8+ T cell cytotoxicity,
CD4+ T cell cytokine production, and memory B cell generation compared to typical
DOCK8-deficient patients. Our temporal analysis of DOCK8-revertant and DOCK8-deficient
cells within the same individual established mechanisms of clinical improvement in
these patients following somatic reversion and revealed further non-redundant functions
of DOCK8 in human lymphocyte biology. Lastly, our findings have significant implications
for future therapeutic options for the treatment of DOCK8 deficiency.
Keywords: DOCK8, Somatic reversion, lymphocyte effector function, inborn errors of
immunity
Disclosures: The author had no financial relationships to disclose.
(24) LRBA facilitates autophagy through binding to PIK3R4
Laura Gamez-Diaz, PhD1, Bodo Grimbacher, Prof. Dr. med.2
1Postdoc/Center for Chronic Immunodeficiency, Faculty of Medicine, Medical Center
of the University Hospital, University of Freiburg, Freiburg, Germany
2Head of the laboratory/Center for Chronic Immunodeficiency, Medical Center, University
of Freiburg, Germany
Patients with lipopolysaccharide responsive beige-like anchor protein (LRBA) deficiency
present with a plethora of immune related defects including low numbers of switched
memory B cells and plasma cells, as well as an impaired production of antibodies,
leading to recurrent infections. However, the molecular mechanisms behind the defective
B cell response remain unknown. To gain better insights into the possible roles of
LRBA in B cell physiology, we screened for LRBA-interacting proteins using in silico
analysis. Following validation by co-IP and PLA, we identified that endogenous LRBA
interacts through its WD40 domain to the phosphoinositide 3-kinase regulatory subunit
4 (PIK3R4) in B cells. PIK3R4 (aka VPS15) is the regulatory subunit of VPS34, the
catalytic subunit of the PI3K-III complex, which acts as a positive regulator of autophagy
by producing phosphatidyl inositol-3 phosphate (PI(3)P). In fact, we observed that
reduced LRBA impaired the production of PI(3)P upon autophagy induction leading to
a blockade of the autophagosome-lysosome fusion, and resulting in a reduced mobility,
abnormal accumulation and increased size of autophaghosomes, accompanied by an atypical
lysosomal positioning, altogether causing an overall impaired autophagy flux and a
decreased degradation of cargo material. Interestingly, LRBA-deficient cells exhibited
enhanced activity of mTORC1 signaling, a key suppressor of autophagy whose activation
possibly contributes to defective autophagy. Taken together, B lymphocytes lacking
LRBA can form autophagosomes but they fail to fuse with lysosomes. Thus, we propose
a role of LRBA at late stages of autophagy through the binding to PIK3R4, which is
essential for plasma cell differentiation.
Keywords: LRBA, autophagy, B cells, primary immunodeficiency, mTOR, PIK3R4
Disclosures: Bodo Grimbacher received a research grant from Baxalta. The other author
had no financial relationship to disclose.
02 Poster Presentations
(25) The origins of IL18 in models of Macrophage Activation Syndrome
Vinh Dang, B.S.1, Lauren Van Der Kraak, PhD2, Corinne Schneider, BS3, Timothy Hand,
Phd4, Scott Canna, MD4, Emily Landy, B.S.5
1Research Technician/University of Pittsburgh
2Post Doctoral/University of Pittsburgh
3Lab Manager/University of Pittsburgh
4Principal Investigator/University of Pittsburgh
5PhD Candidate/University of Pittsburgh
Macrophage Activation Syndrome (MAS) is a life threatening hyperinflammatory complication
of systemic juvenile idiopathic arthritis (sJIA) and other rheumatic diseases. IL-18
is an inflammasome-activated cytokine associated with augmenting the production of
Th1 cytokines like IFNg and promoting cellular cytotoxicity. IL-18 is naturally and
potently inhibited by IL-18 Binding Protein (IL-18BP). Serum IL-18 levels correlate
strongly and specifically with MAS, particularly in the context of activating mutations
in the NLRC4 inflammasome. What induces IL18 production and where it comes from in
MAS remain unknown. Mice with excess IL-18 signaling (IL18BP KO) develop more severe
TLR9 driven MAS. However, in a model of murine NLRC4 inflammasome hyperactivation,
excess serum IL-18 comes from intestinal epithelial cells but, is not sufficient to
exacerbate the TLR9 driven model of MAS. By contrast, the intestinal microbiota are
critical for the development of TLR9-MAS in WT mice. We treated WT and IL-18BP KO
mice with broad spectrum antibiotics prior to TLR9 stimulation with CpG and found
that antibiotics were minimally protected in IL-18BP KO mice, suggesting that the
microbiota may not be necessary for pathogenic IL-18 induction. Indeed, mice colonized
with immunostimulatory microbes (Segmented Filamentous bacteria or Tritrichomonous)
were not more susceptible to TLR9-MAS. Furthermore, increased IL-18 in TLR9-MAS did
not derive from intestinal microbiota, suggesting it may derive from myeloid cells.
We queried publicly available transcriptional data and found that IL18 transcription
was frequently stimulated by Interferon signaling and strongly correlated with PPARg
transcription in macrophages. Overall, these data suggest that although the intestine
is a rich source of IL-18, gut-derived IL-18 may not be efficient at promoting MAS.
Understanding the signals that drive IL-18, potentially including IFN and PPARg may
help us to understand susceptibility to MAS.
Keywords: Macrophage Activation Syndrome, Hyperinflammation, IL-18, Cytokine, PPARg,
Interferon, Microbiome, Antibiotics
Disclosures: All authors indicated they had no financial relationships to disclose.
(26) Recurrent inflammatory episodes, urticaria, and severe T-cell lymphopenia due
to a novel heterozygous CD48 mutation
Laura Ann Wang, MD, MPH1, Vijaya Knight, MD, PhD2, Kaylee Dollerschell, MS, CGC3,
Jordan Abbott, MD, MA4, Cullen Dutmer, MD4
1Allergy & Immunology Fellow/Children's Hospital Colorado, University of Colorado
School of Medicine, Aurora, CO, USA
2Associate Professor of Pediatrics/Section of Allergy & Immunology, Children's Hospital
Colorado, University of Colorado School of Medicine, Aurora, CO, USA
3Instructor of Pediatrics/Section of Genetics & Metabolism, Children's Hospital Colorado,
University of Colorado School of Medicine, Aurora, CO, USA
4Assistant Professor of Pediatrics/Section of Allergy & Immunology, Children's Hospital
Colorado, University of Colorado School of Medicine, Aurora, CO, USA
CD48 is a glycosylphosphatidylinositol (GPI)-anchored protein of the signaling lymphocytic
activation molecule (SLAM) family that is expressed on the surface of hematopoietic
cells and plays an important role in lymphocyte activation and differentiation. Volkmer
et al recently described a 24-year-old man with a history of recurrent inflammatory
disease in which a de novo S220Y mutation in the GPI-anchor region of CD48 was reported
as causative.1 Herein, we describe a young man with a novel CD48 mutation affecting
the same codon (S220F), resulting in a similar clinical phenotype.
A 17-year-old male presented with a 14-year history of recurrent fever, fatigue, and
atypical urticaria. Episodes lasted 4-7 days. The episodes occurred as frequently
as monthly but became less frequent. Two severe episodes required hospitalization,
where lymphopenia and thrombocytopenia were observed. His infection history included
2 episodes of norovirus gastroenteritis, 1 episode of rotavirus gastroenteritis, and
1 influenza A (2009-H1N1) infection, all of which triggered inflammatory episodes.
His inter-episode diagnostic evaluation revealed severe T-cell lymphopenia (214 cells/mcL),
high sCD25 (1233 pg/mL), high triglycerides (171 mg/dL), low IgM (19 mg/dL), and Streptococcus
pneumoniae antibody deficiency. T-cell proliferation to phytohemagglutinin, NK-cell
cytotoxicity (chromium release), ESR, CRP, and ferritin were normal. Trio whole-exome
sequencing identified a de novo heterozygous variant in CD48 (c.659C>T, p.S220F) and
flow cytometric analyses demonstrated reduced T-cell, B-cell, and monocyte surface
CD48 expression.
We report a novel, de novo, heterozygous variant in CD48 associated with recurrent
inflammatory episodes and severe T-cell lymphopenia that recapitulates the clinical
phenotype induced by another aromatic amino acid substitution at codon 220.1 Serine
220 is the site of covalent GPI anchor attachment, and loss of that attachment point
is proposed to result in reduced surface membrane CD48. The precise mechanism of pathogenicity
remains to be determined.
References: 1. Volkmer B, Planas R, Gossweiler E, et al. Recurrent inflammatory disease
caused by a heterozygous mutation in CD48. J Allergy Clin Immunol. 2019;144(5):1441-1445.e17.
doi:10.1016/j.jaci.2019.07.038
Keywords: CD48, T-cell lymphopenia, Recurrent fever
Disclosures: All authors indicated they had no financial relationships to disclose.
(27) BTK inhibitors for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2):
A Systematic Review
Michael Stack, BS1, Keith Sacco, MD2, Alicia Livinski, MPH, MLS3, Luigi Notarangelo,
MD4, Michail Lionakis, MD, ScD5
1Postbaccalaureate Fellow/Laboratory of Clinical Immunology and Microbiology, National
Institute for Allergy and Infectious Diseases, NIH, Maryland, USA
2Clinical Fellow/Lab of Clinical Immunology and Microbiology, Immune Deficiency Genetics
Section, NIAID, NIH, Bethesda, MD, USA
3Biomedical Librarian/Informationist/National Institutes of Health Library, Division
of Library Services, Office of Research Services
4Chief/Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy
and Infectious Diseases, National Institutes of Health
5Chief, Fungal Pathogenesis Section/Laboratory of Clinical Immunology and Microbiology,
National Institute of Allergy and Infectious Diseases/National Institutes of Health,
Bethesda, MD, USA
Bruton tyrosine kinase (BTK) regulates B cell and macrophage signaling, and activation.
Blood monocytes from patients with severe COVID-19 showed increase in BTK activation
and production of interleukin-6 correlating with systemic inflammation. Inhibiting
BTK has been hypothesized to prevent lung injury in COVID-19 patients, alike to its
protective effect in mice for lethal influenza-induced acute lung injury. Our aim
was to evaluate BTK inhibitor (BTKi) use during acute COVID-19 infection and assess
whether BTK inhibitors are associated with specific clinical outcomes.
Our primary aim was to describe clinical outcomes following BTKi use in acute SARS-CoV-2.
We searched PubMed, Embase, Web of Science, MedRxiv, BioRxiv and 5 clinical trials
registries on 30 December, 2020. Clinical studies with at least 5 patients were included.
Case reports and reviews were excluded.
126 unique articles were identified, of which 6 met our inclusion criteria. Sample
size ranged from 6 to 126. Patient populations observed included subjects hospitalized
with COVID-19 (6/6) and admitted to ICU (5/6). Patient age range was between 35 and
98 years among the pooled 6 studies. 4 studies followed patient cohorts that were
on BTKi for treatment of their lymphoproliferative disease -1 cohort of Waldenstrom’s
macroglobulinemia and 3 studies of leukemia patients (Table 1). The most common clinical
outcomes measured were oxygen requirements (4/6) and hospitalization (3/6), secondary
clinical outcomes included length of intubation and most aggressive method of oxygenation.
Standard of care reflected not only the date of study, but also the pre-existing conditions
of the cohort. Studies used full doses of acalabrutinib (3/6) and/or ibrutinib (2/6).
Three studies found favorable hospitalization rate/duration in those on full-dose
BTK inhibitors. One study did not find any significant difference in survival for
those on BTKi.
BTK inhibition shows promise for ameliorating hyper-inflammation in patients with
severe COVID-19. Randomized Clinical trials assessing three BTK inhibitors (ibrutinib,
acalabrutinib, zanubrutinib) in patients with severe SARS-CoV-2 are underway.
Acknowledgment: This research was supported by the Intramural Research Program of
the NIH.
Table 1. Summary of studies evaluating clinical outcomes following BTK inhibitor use
in acute SARS-CoV-2.
Keywords: COVID-19, Bruton's tyrosine Kinase (BTK), X-linked agammaglobulinemia (XLA),
Systematic Review, Clinical Outcomes, BTK inhibitors
Disclosures: All authors indicated they had no financial relationships to disclose.
(28) A case of Spondyloenchondrodysplasia with immune dysregulation presenting as
Systemic Lupus Erythematous
Juanita Valdes Camacho, MD1, Deepika Singh, MD2, Rosa Bacchetta, MD3, Kenneth Weinberg,
MD4, Alma-Martina Cepika, MD, PhD5, Mansi Narula, MS6, David B Lewis, MD7, Yael Gernez,
MD, PhD8, Katja Weinacht, MD, PhD9
1Allergy and Immunology Fellow/Stanford University HealthCare
2Pediatric Rheumatologist/Valley Children's Hospital Madera
3associate Professor (Research) of Pediatrics (Stem Cell Transplantation)/Stanford
4Professor of Pediatrics - Stem Cell Transplantation/Stanford
5Instructor - Pediatric Stem Cell Transplantation/Stanford
6Life Science Research Professional/Stanford
7Chief, Department of Pediatrics, Division of Allergy, Immunology and Rheumatology/Stanford
8Assistant Professor of Pediatric Allergy and Immunology/Stanford University
9Assistant Professor of Pediatric Stem Cell Transplantation/Stanford University
Monogenic lupus is a form of systemic lupus erythematosus that occurs in patients
with a single gene defect. This rare variant of lupus generally presents with early
onset severe disease, often with recalcitrant autoimmune cytopenias, renal or neurologic
disease. Spondyloenchondrodysplasia with immune dysregulation (SPENCDI) is a rare
type I interferonopathy, caused by biallelic mutations in the ACP5 gene. Clinically,
SPENCDI is characterized by the triad of skeletal dysplasia, autoimmunity and variable
neurologic findings, ranging from asymptomatic brain calcifications to severe developmental
delay with spasticity. SPENCDI has been implicated in monogenic lupus, however, therapeutic
considerations targeting the underlying mechanism have never been described.
A 7 year old girl with history of short stature and developmental delay, was diagnosed
in 2017 with SLE characterized by petechial and purpuric rash, hematologic involvement
with anemia, thrombocytopenia and splenomegaly, with elevated inflammatory markers
(ESR 78mm/h, CR 1.2), hypergammaglobulinemia with secondary complement deficiency
(CH50 = 0 mg/dl mg/dl, reduced C2 function, C3 41 mg/dl, C4 < 2.9 mg/dl), positive
high titer ANA >1:1280, elevated dsDNA >300 IU/ml, elevated MPO antibody, without
evidence of renal involvement. Initially, she had a favorable response to steroids,
however, cytopenias immediately flare once steroids were withdrawn. The patient received
rituximab and IVIG with transient effect, and was started on Mycophenolate to achieve
disease control.
Extended immune function testing was not suggestive of a primary immunodeficiency.
Work up for genetic causes of refractory Evans syndrome revealed biallelic mutations
in the ACP5 gene, including one previously reported pathogenic variant and one variant
of undetermined significance. Hands and spine radiographs demonstrated the characteristic
radiolucent metaphyseal and vertebral lesions of spondyloepimetaphyseal dysplasia
establishing the diagnosis of SPENCDI.
SPENCDI is a type I interferonopathy. Based on the favorable therapeutic response
of patients with other type I interferonopathies Janus kinase (JAK) inhibitors, a
therapeutic trial with the JAK inhibitor ruxolinitib has been initiated.
SPENDCI is a monogenic disease which can present with refractory cytopenias and other
clinical features of SLE. Although SLE is a clinical diagnosis, vigilance for underlying
genetic defects is warranted and may have important implications on management
Keywords: ACP5, SPENCDI, Monogenic Lupus, Interferonopathy, JAK inhibitor
Disclosures: All authors indicated they had no financial relationships to disclose.
(29) Severe scabies In Two Patients with Gain-of-function mutations in Signal transducer
and activator of transcription 1
Sara Van Meerbeke, MD1, Robin Gehris, MD2, Brian Campfield, MD3, Hey Chong, MD, PhD4
1Allergy & Immunology Fellow/UPMC Children's Hospital of Pittsburgh
2Clinical Associate Professor of Dermatology and Pediatrics/UPMC Children's Hospital
of Pittsburgh
3Assistant Professor of Pediatrics, Division of Infectious Diseases/UPMC Children's
Hospital of Pittsburgh
4Associate Professor of Pediatrics, Division of Allergy & Immunology/UPMC Children's
Hospital of Pittsburgh
Gain-of-function mutations in STAT1 are the most common syndromic cause of chronic
mucocutaneous candidiasis and can lead to a wide spectrum of infections and autoimmune
conditions as well as predispose to cerebral aneurysms and malignancy. Norwegian scabies,
or crusted scabies, is characterized by infestation with millions of Sarcoptes scabei
mites and thick, hyperkeratotic crusted skin and linked with immunosuppression most
notably HIV although not classically STAT1 mutation.
Patient 1 is a 26-year-old female who presented at 22 years of age with recurrent
oral candidiasis, hypothyroidism, and persistent hyperkeratotic skin rash. She later
developed pulmonary Cryptococcal infection. Her immune evaluation revealed the following
results: Serum immunoglobulins with elevated IgG but normal IgM and IgA. Lymphocyte
subset showed CD3+, CD4+, and NK lymphocytopenia (691, 322 and 33 respectively). Lymphocyte
proliferative response normal to PHA and PWM. Pt underwent punch biopsy which was
consistent with Norwegian scabies treated with oral ivermectin and topical permethrin.
Family genetic testing revealed STAT1 pathogenic variant c.820C>T (p.Arg274Trp).
Patient 2 is an 11-year-old male with chronic mucocutaneous candidiasis, who presented
at 7 years of age with several week history of erythematous, pruritic rash across
trunk and legs. His immune evaluated revealed elevated IgG at 1320 but normal IgA
and IgM. Lymphocyte subset showed CD3+, CD4+, CD8+, B and NK lymphocytopenia (960,
446, 379, 103 and 24 respectively). WES revealed STAT1 c.1256C>G, p.T419R and c.1874(-8)C>T
mutations. Microscopic exam of a skin scraping showed evidence of mites consistent
with Norwegian scabies treated with oral ivermectin and topical permethrin.
While Norwegian scabies can be associated with immunosuppression, there is no clear
association with defects in STAT1 pathway. We report two patients with STAT1 GOF who
developed persistent hyperkeratotic skin crusts and ultimately diagnosed with Norwegian
scabies. Literature review also reveals a case report by Sampaio et al. of patient
with STAT1 GOF mutation who developed disseminated Rhodococcus infection, chronic
mucocutaneous candidiasis, hypothyroidism and Norwegian scabies. These three cases
suggest that in patients with STAT1 GOF, Norwegian scabies should be considered as
etiology of skin rash. Further studies are needed to further elucidate underlying
susceptibility to scabies infection.
Keywords: STAT1 GOF, Norwegian scabies, Skin rash
Disclosures: All authors indicated they had no financial relationships to disclose.
(30) The effect of critical illness on flow cytometric testing in identifying primary
immune deficiency
Ali Hemyari, MD1, Liyun Zhang, MS2, Jenny Andres, MBA, BSN, RN3, John Routes, MD4,
Ke Yan, PhD2, James Verbsky, MD, PhD5
1Pediatric Critical Care Fellow/Medical College of Wisconsin
2Biostatistician/Medical College of Wisconsin
3Quality and Outcomes Manager/Children's Wisconsin
4Professor of Pediatrics, Medicine, Microbiology and Immunology/Medical College of
Wisconsin
5Associate Professor of Pediatrics, Medicine, Microbiology and Immunology/Medical
College of Wisconsin
Flow Cytometry is used often in the diagnosis of primary immune deficiencies. Often
these tests are sent in patients in varying states of health while in outpatient and
inpatient settings, and it is unknown how clinical status can affect flow cytometric
results.
We retrospectively analyzed flow cytometry results from the Clinical Immunology Research
Laboratory at the Medical College of Wisconsin, a CLIA approved reference laboratory,
and included any subject with two or more flow cytometric tests. Each test measured
the absolute counts of up to four lymphocyte subsets: CD3+CD4+, CD3+CD8+, CD19+, and/or
CD56+16+. Tests results were designated a percentage of the measurements that were
normal. We then identified which clinical division ordered the test and the final
diagnosis. A generalized linear mixed model with Maximum Likelihood Estimation was
used to compare the tests ordered by clinical areas after considering the repeated
measures within patients. Statistical significance was set at p < 0.05.
Of a total of 6,462 tests from 1,515 patients, 11% of all tests had measurements which
were 100% normal, and only 42 patients (2.7% of total patients) had every test with
100% normal measurements. Of the 1,370 patients who had tests with < 100% normal measurements
(an abnormal test), 224 patients had testing that “normalized” in future testing.
When the mean percent normal measurements were ranked by the eight clinical divisions
(after excluding tests from the bone marrow transplant, oncology, solid organ transplant,
and HIV divisions), tests ordered by the Allergy division had the highest percent
normal measurements and tests ordered in the ICU had the lowest percent normal measurements.
Both were statistically significant when compared with other clinical divisions (Table
1).
These results confirm that flow cytometry can be greatly affected by the clinical
status of the patient, as supported by the high rate of abnormal tests in the ICU,
while outpatient testing had higher rates of normal tests. These data would argue
that flow cytometric testing to identify primary immune deficiency during critical
illness may result in a high false positive rate, and that this testing should be
delayed until the clinical status has improved.
Table 1. Percent normal measurements for each ordering clinical area
Keywords: Primary Immunodeficiency testing, Flow Cytometric Testing, Critical Illness,
Lymphocyte Subset Testing
Disclosures: John Routes had contracted research with CSL Behring and Evolve Biologics.
All other authors had no financial relationships to disclose.
(31) Child with hyperinflammatory syndrome and aplastic anemia with CD247 pathogenic
variant
Lourdes Ramirez, MD1, Carmen Ballestas, MD2, Maria Pilar Gutierrez, MD3, Luigi Notarangelo,
MD4, Hanadys Ale, MD5
1Pediatric Resident/Joe DiMaggio Children's Hospital/Memorial Healthcare System
2Attending Physician/Joe DiMaggio Children's Hospital, Division of Pediatric Hematology
and Oncology
3Attending Physician/Joe DiMaggio Children's Hospital, Division of Pediatric Infectious
Diseases
4Chief/Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy
and Infectious Diseases, National Institutes of Health
5Attending Physician/Joe DiMaggio Children's Hospital, Division of Pediatric Immunology
and Allergy
Severe combined immunodeficiency (SCID) as a result of mutations in the invariant
homodimer CD247 (CD3-zeta) lead to mild T-cell lymphopenia, in contrast to more severe
forms of SCID. CD247 is also expressed in NK cells, and mutations in CD247 have been
linked to NK cell hypo-responsiveness, even in heterozygous carriers. The full clinical
manifestations of these patients however, have not been clearly described. Here we
present a case of a patient with a pathogenic variant in CD247 who developed hyperinflammatory
syndrome and refractory aplastic anemia.
A 12-year-old female with Noonan syndrome with multiple lentigines, associated prolonged
QT syndrome, unrepaired VSD, recurrent sinopulmonary infections and hypogammaglobulinemia
of unknown etiology, presented with a 4-day history of jaundice, abdominal pain and
emesis. Evaluation demonstrated leukopenia, thrombocytopenia, transaminitis and direct
hyperbilirubinemia. She developed fevers with hyperferritinemia, hypertriglyceridemia,
elevated lactate dehydrogenase and worsening transaminitis. Soluble IL-2 receptor-α
was significantly elevated at 12,340 pg/mL at its peak. Immunologic profiling revealed
low IgG, significant T-cell lymphopenia, and borderline low NK cells with depressed
NK-cell function. Invitae primary immunodeficiency panel revealed a heterozygous pathogenic
variant in CD247 (c.301C>T p.Gln101*). Bone marrow (BM) biopsy initially showed normal
cellularity without evidence of malignancy. She was treated with IVIG and high dose
steroids with clinical improvement. Upon weaning steroids, she developed worsening
cytopenias with a follow-up BM biopsy demonstrating aplastic anemia. Rituximab was
started without improvement of cell counts. She was transferred to an outside institution
where she received immunosuppressive therapy for aplastic anemia with Eltrombopag,
cyclosporine and ATG. That hospital course was complicated by neutropenic fevers,
multiple deep-seated infections and respiratory failure. Since failing immunosuppressive
therapy, she is undergoing palliative management while awaiting BM transplantation.
Heterozygous carriers of CD247 pathologic variants have not been reported to exhibit
CD247 disease. This report, however, suggests that perhaps the carrier status may
contribute to this patients’ underlying immunodeficiency characterized by hypogammaglobulinemia,
low NK cells, and absent NK function and T cell lymphopenias; ultimately leading to
a hyperinflammatory state and aplastic anemia. These patients may require BM transplantation
as definitive treatment early in their presentation.
Keywords: Primary immunodeficiency, aplastic anemia, hyperinflammatory syndrome, CD247
Disclosures: All authors indicated they had no financial relationships to disclose.
(32) Cortico-resistant Seronegative Autoimmune hepatitis
Eunice Sandoval-Ramirez
1, Nery Eduardo Solis-Perales, MD2, Juan Manuel Alcántar-Fierros, MD3, Luis-Humberto
Cruz-Contreras, MD4, Ignacio Camacho-Meza, MD1
1Pediatric Allergy/Hospital de Especialidades Pediatrico Leon
2Pediatric Gastroenterology/Hospital de Especialidades Pediatrico Leon
3Pediatric Surgery/Hospital de Especialidades Pediatrico Leon
4Pathologist/Hospital Materno Infantil Irapuato
Autoimmune hepatitis is characterized by chronic, progressive inflammation of liver
with the presence of autoantibodies, hypergammaglobulinemia and interface hepatitis
in the histological study, it presents several phenotypes, we focus on the seronegative;
patients present a characteristic clinical picture, compatible laboratory and histological
findings without the presence of "standard" antibodies, with a frequency of presentation
between 1 and 5% of all reported cases, the association with thrombocytopenia is rare
(1.4%).
The case of an 11-year-old patient is described, who begins suffering jaundice, hepatic
pain, elevated liver enzymes and direct bilirubin. She was admitted to our hospital
with ascites, hepatomegaly, anemia, and thrombocytopenia (52 thousand / μL platelets).
No dilation of the bile duct or presence of stones was found. Negative viral serology,
anti-KLM 18.6 antibodies, anti-smooth muscle, anti-mitochondrial, rheumatoid factor,
Anti DNA, antinuclear and VDRL antibodies were negative, serum IgG 2780mg / dL, with
a biopsy report of severe chronic active hepatitis and 60% necrosis, severe activity
3 of 4, mild fibrosis stage EFE1 DF4.
After excluding viral, toxic or hereditary causes of hepatitis, in the presence of
another autoimmune disease, the most likely cause is a hepatic autoimmune process,
despite not finding standard immunological markers but meeting criteria of the international
group of autoimmune hepatitis. management begins with steroid and azathioprine without
complete remission of the biochemical markers of hepatitis, so alternative treatment
with mycophenolate mofetil at a dose of 1gr / day and increase in the dose of Azathioprine
to 150 mg / day and prednisone 0.75mg / kg / day.
Upon evaluation 6 weeks later, we found a decrease in the values of liver enzymes
and platelets 103 thousand / μL. Currently, it continues with the alternative management
established with mycophenolate mofetil (MMF) associated with standard treatment of
azatiprine and steroid with adequate response at the hepatic and hematological level.
Figure 1. Nejib trichrome (40x) Panoramic view showing viable parenchyma areas marked
with (*) alternating with large areas of necrosis.
Figure 2. Nejib and PAS trichrome (100x). Interface hepatitis is shown with a predominance
of lymphocytic infiltrate with severe inflammatory activity and necrosis, rosette
formation (arrows) is observed. We can also observe moderate intracellular and canalicular
cholestasis.
Keywords: Autoimmune, Hepatitis, Seronegative, Cortico-resistan
Disclosures: All authors indicated they had no financial relationships to disclose.
(33) X-linked agammaglobulinemia incidentally identified during pre-surgical ABO blood
cross-matching: case report and review of the literature
Jennifer Blase, MD, PhD1, Kelly Walkovich, MD2, Thomas Michniacki, MD3, Mark Hannibal,
MD, PhD4
1Fellow Physician, Pediatric Hematology & Oncology/University of Michigan
2Associate Professor, Pediatric Hematology & Oncology/University of Michigan
3Assistant Professor, Pediatric Hematology & Oncology/University of Michigan
4Associate Professor, Genetics, Metabolism & Genomic Medicine/University of Michigan
Mismatch between forward and reverse blood group typing, i.e. ABO typing discrepancy,
is most commonly caused by cold agglutinins or weak/missing antibodies due to age
or use of immunosuppressive agents. However, inborn errors of immunity with humoral
defects can also result in ABO typing discrepancy. While more commonly diagnosed following
frequent or unusual infections, we describe a case of X-linked agammaglobulinemia
(XLA) where ABO typing discrepancy served as the primary trigger for diagnosis as
well as a related literature review.
The medical record of the patient case was reviewed. A literature review was conducted
using the keywords “immunodeficiency” and either “ABO typing” or “isoagglutinin” in
Pubmed, with review of English articles published between 1958 and 2020.
We describe a 6-year-old male patient with a history of left knee septic arthritis
and sinopulmonary infections who presented with fever, cough, rhinorrhea, left knee
arthralgia and edema. He was found to have leukocytosis, severe thrombocytopenia,
elevated inflammatory markers, and left knee effusion, consistent with recurrent septic
arthritis. He was initially transfused with O negative platelets urgently for epistaxis.
However, subsequent type and screen performed prior to left knee irrigation and debridement
revealed type B blood group with forward typing but no evidence of anti-A antibodies
during reverse typing. This prompted an immunodeficiency workup, revealing hypogammaglobulinemia
and B cell deficiency. Bruton tyrosine kinase (BTK) protein expression was decreased,
and a hemizygous pathogenic variant in BTK gene, c.1775C>A (p.Ser592Tyr), diagnostic
of XLA, was found. IVIG supplementation was initiated.
A literature search, as above, yielded 202 articles, seven of which detailed immunodeficiency
cases with abnormal blood bank testing. This included case reports of common variable
immunodeficiency (CVID), XLA, selective IgM immunodeficiency (SIgMID), Good’s syndrome,
and Wiskott-Aldrich syndrome (WAS). This revealed only a small number of published
cases detailing ABO typing discrepancies in patients with primary immunodeficiency
syndromes (Table 1).
This case and subsequent literature review demonstrate the utility of inter-specialty
communication and highlight the need for a high index of clinical suspicion for primary
immunodeficiencies in cases of ABO typing discrepancy.
Keywords: X-linked agammaglobulinemia, ABO typing discrepancy, Immunodeficiency
Disclosures: Kelly Walkovich is a consultant for Sobi Pharmaceuticals. All other authors
had no financial relationships to disclose.
(34) G6PD deficiency with recurrent infections in a pediatric case
Tyrone Coyle, MD1, Sherry Farzan, MD2, Artemio Jongco, MPH, MD, PhD, FACP, FACAAI,
FAAAAI2
1Allergy/Immunology fellow/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
2Assistant Professor of Medicine and Pediatrics/Donald and Barbara Zucker School of
Medicine at Hofstra/Northwell
Glucose-6-phosphate dehydrogenase (G6PD) is a critical enzyme for erythrocytes and
neutrophils. G6PD reduces NADP+ to NADPH which protects erythrocytes from oxidative
injury and is a key substrate for neutrophil respiratory burst. G6PD deficiency is
a congenital X-linked disorder. Clinical manifestations are often absent but various
triggers can precipitate episodes of acute hemolytic anemia. Usually, diminished G6PD
levels will not cause neutrophil dysfunction unless enzyme levels are below 5% of
normal.
A 6-year-old Turkish male with history of asthma and chronic neutropenia was seen
in an outpatient setting. He had a prolonged history of frequent infections characterized
by fever, cough, diarrhea and myalgias. He was regularly treated with courses of antibiotics
but no known bacterial infections were reported. Family history was significant for
a brother, aunt and cousin with cystic fibrosis. Prior chloride sweat test and CFTR
genetic testing were normal.
Initial immunodeficiency workup showed normal levels of immunoglobulins, T and B cells,
CH50, MBL, mitogen proliferation, myeloperoxidase stain, DHR assay and negative anti-granulocyte
antibodies. Vaccination titers were protective to all tested vaccines except varicella.
Abnormal labs included CBC with neutropenia (range 1100 – 1700cells/μL), mildly decreased
AH50 (40) and undetectable G6PD level. A commercial targeted primary immunodeficiency
panel showed a hemizygous pathogenic c.563C>T (p.Ser188Phe) G6PD variant, confirming
G6PD deficiency. He was also heterozygous for variants of uncertain significance in
C8B, C9, CIITA, COL7A1, FANCA, PRKDC, RNASEH2B, and SPINK5.
The diagnosis of G6PD deficiency was initially surprising given the normal DHR assay
and no prior clinical history suggestive of hemolysis. Despite the normal DHR assay,
G6PD deficiency in conjunction with neutropenia is the suspected etiology of recurrent
infections for our patient. The DHR assay has proven less sensitive than other modalities
such as nitroblue tetrazolium (NBT) for assessing oxidative burst in G6PD. Severe
G6PD deficiency can closely mimic chronic granulomatous disease (CGD) with recurrent
bacterial and fungal infections, due to impaired reactive oxygen species dependent
neutrophil extracellular trap (NET) formation, which occurs in the absence of NADPH.
Given the similar pathogenesis, he may benefit from prophylactic antimicrobials which
has proven effective in reducing morbidity in CGD.
Keywords: G6PD deficiency, recurrent infections, neutropenia, DHR assay, Pediatrics,
NADPH, chronic granulomatous disease, neutrophil extracellular trap
Disclosures: All authors indicated they had no financial relationships to disclose.
(35) Clinical and Treatment History of Patients with Partial DiGeorge Syndrome and
Autoimmune Cytopenia at a Tertiary Center
Priya Patel
1, Emma Emma Westermann-Clark, MD2, Sonia Joychan, MD3, Ahmad Shaker, MD4, Boglarka
Ujhazi, BS5, Cristina Meehan, BS6, Maryssa Ellison, n/a7, Krisztian Csomos, PhD8,
Sumai Gordon, B.S.9, Daime Nieves, APRN10, Anthony Nguyen, MSPH11, Irmel Ayala, MD12,
Jolan Walter, MD, PhD13, Panida Sriaroon, MD14
1Resident/Johns Hopkins All Children's Hospital
2Assistant Professor/Division of Allergy and Immunology, University of South Florida
Morsani College of Medicine
3Physician/Dearborn Allergy & Asthma Clinic, P.C.
4Physician/Baycare Medical Group
5Senior Biological Scientist/University of South Florida
6Medical student/University of Alabama
7Department of Pediatrics/University of South Florida
8PhD/Massachusetts General Hospital
9B.S./University of South Florida
10APRN/University of South Florida
11Biostatistician/Johns Hopkins All Children's Hospital
12Physician/Johns Hopkins All Children's Hospital
13Division Chief and associate professor/Johns Hopkins All Children’s Hospital; Department
of Pediatrics, Division of Allergy and Immunology, University of South Florida Morsani
College of Medicine
14Medical Director and Associate Professor/Johns Hopkins All Children’s Hospital;
Department of Pediatrics, Division of Allergy and Immunology, University of South
Florida Morsani College of Medicine
Partial DiGeorge Syndrome (pDGS) presents with a wide phenotypic heterogeneity. Patients
with pDGS can present with immune dysregulation, most commonly autoimmune cytopenia
(AIC). The clinical spectrum, treatment outcome, and biomarkers for AIC in patients
with pDGS are not well understood, and a standardized treatment pathway is needed.
The aim of this project is to characterize the natural history and immune phenotype
of the heterogeneous population of pDGS with AIC, ranging from manageable to severe,
and biomarkers predicting refractory AIC in pDGS.
Data on clinical presentation, disease severity, immunological phenotype, treatment
selection and response for patients with pDGS with AIC were collected via retrospective
chart review.
Of 69 pDGS patients, 28 (40%) had a history of cytopenia. 10 of 28 patients with cytopenia
had AIC (14% of cohort) at our tertiary academic center. Seven patients had multi-lineage
AIC (Evans syndrome (ES)) and 3 had immune thrombocytopenia alone. Five of the 7 pDGS
patients with ES had refractory cytopenias requiring second line therapy beyond steroids
and high dose immunoglobulin. Six of the 7 patients with ES were considered refractory
for repeated hospitalizations and requiring multiple different combinations of treatments
for stabilization. These 6 refractory patients had lower average nadir of hemoglobin
(6.35 g/dL), white blood cell count (2.92x103/μL), and platelet (14x103/μL) count
during acute AIC episodes compared to the 4 patients who were not refractory to initial
therapy (11.9 g/dL, 9.15 x103/μL, and 77 x103/μL respectively). Those 6 patients with
refractory AIC also had both evidence of antibody deficiency syndrome (ADS) and lower
naïve T cell counts, compared to pDGS patients with mild AIC and the general population.
Three of the 6 refractory patients received rituximab; other agents included mycophenolate
mofetil, cyclophosphamide, and azathioprine. One patient is stabilized on sirolimus
and high dose subcutaneous immunoglobulin.
AIC is common in pDGS and often treatment-refractory. The findings of this study suggest
that lower naïve T cell count and ADS with need for high dose immunoglobulin replacement
therapy distinguish pDGS patients with severe refractory AIC. Long term T cell therapy
may improve AIC for these patients after initial treatment with rituximab.
Table 1 and Figure 1
Keywords: partial DiGeorge Syndrome, Autoimmune, Cytopenia
Disclosures: All authors indicated they had no financial relationships to disclose.
(36) Novel Use of Dupilumab in the Treatment of Recurrent Bacterial Scalp Infections
and Axillary Lymphadenitis in a Patient with Hyper-IgE Syndrome
Jason Moraczewski, MD1, Katherine Tison, MD2, Lisa Kobrynski, MD, MPH3
1Pediatrics Resident/Emory University and Children's Healthcare of Atlanta
2Fellow/Emory University and Children's Healthcare of Atlanta
3Professor of Pediatrics, Marcus Professor of Immunology, Section Chief Allergy-Immunology/Emory
University and Children's Healthcare of Atlanta
Hyper-IgE syndrome (HIES) is a primary immunodeficiency associated with elevated serum
immunoglobulin E (IgE), bacterial pneumonias complicated by pneumatoceles, recurrent
skin abscesses, and early-onset allergic manifestations, including an eczematous,
impetiginized, pruritic rash similar to atopic dermatitis. Here we describe the successful
treatment of bacterial skin infections and secondary axillary lymphadenitis with dupilumab
in a 13-year-old African American female with HIES. By 2 years of age, she had recurrent
staphylococcal infections of her scalp requiring incision and drainage procedures,
otitis media requiring myringotomy tube placement, and recurrent pneumonia requiring
hospitalization. Serum IgE levels were markedly elevated at 14,000 kU/mL, and she
was subsequently diagnosed with HIES based on clinical features and the NIH scoring
system. Further genetic testing revealed a STAT3 loss-of-function mutation. At 13
years of age, the patient presented with suppurative infections of her scalp, sinusitis,
and left axillary lymphadenitis despite multiple courses of antimicrobial therapy
and adequate intravenous immunoglobulin replacement. After 3-months of doxycycline
therapy followed by a course of culture-directed antimicrobial and antifungal therapy
status post axillary lymph node incision and drainage, she continued to have progression
of her scalp involvement and worsening left axillary lymphadenitis. Due to refractory
symptoms despite appropriate antibiotic treatment, the decision was made to initiate
dupilumab. Dupilumab is an IgG4 human monoclonal antibody that inhibits IL-4 and IL-13
signaling by binding to the IL-4Rα subunit, thus preventing the release of proinflammatory
cytokines, chemokines, nitric oxide, and IgE. She received the pediatric weight-based
dosing for children ≥6 years for moderate to severe atopic dermatitis with initial
600mg dose followed by a maintenance dose of 300mg every other week. At follow-up
3 weeks after starting dupilumab, she had significant clearing of her scalp lesions
and a decrease in her reactive left axillary lymphadenitis. While dupilumab has been
used to treat severe atopic dermatitis in patients with HIES, this is a novel case
where its use resulted in clinical improvement in skin infections and secondary lymphadenitis.
This case suggests that dupilumab may be an effective treatment for the secondary
bacterial infections that develop due to skin pathology in patients with HIES.
Keywords: HIES, Hyper-IgE syndrome, Dupilumab, Biologic therapy, Recurrent infections,
STAT3 mutations, Atopic dermatitis
Disclosures: All authors indicated they had no financial relationships to disclose.
(37) TNFAIP3: Evolving clinical picture from Autoinflammatory syndrome to Autoimmune
lymphoproliferative syndrome
Esosa Adah, MD1, Mary Nguyen, MD2, Nikita Raje, MD3, Voytek Slowik, MD4, Julia Harris,
MD5
1Pediatric Resident/Children's Mercy Hosp. Kansas-City
2Allergy & Immunology Fellow/Children's Mercy Hosp. Kansas-City
3Allergy & Immunology Attending/Children's Mercy Hosp. Kansas-City
4Gastroenterology Attending/Children's Mercy Hosp. Kansas-City
5Rheumatology Atttending/Children's Mercy Hosp. Kansas-City
Autoimmune lymphoproliferative syndrome (ALPS) is a rare genetic disorder of the immune
system that affects children and adults. It can present with lymphoproliferation to
lymphoid organs with the development of neutropenia, lymphopenia, and thrombocytopenia.
Most cases are caused by either a germline or somatic mutation in the FAS, FASLG,
or CASP10 genes that are involved in cell apoptosis. Tumor Necrosis Factor Alpha,
Induced Protein 3 (TNFAIP3) is a protein coding gene associated with A20 haploinsufficiency.
A 3-year-old female presented at 4-months old to the intensive care unit in shock
with a vesiculopustular skin rash & indurated plaques on her extremities. Upon presentation,
she was febrile and in respiratory failure requiring intubation. Infectious workup
was unrevealing. Following discharge, genetic evaluation revealed heterozygous TNFAIP3
c.475del, p.Tyr159Metfs*57. Brain MRI/MRA/MRV were normal, EGD/colonoscopy showed
chronic gastritis with normal biopsy, and eye exam showed no ocular inflammation.
Immunology evaluation revealed T cell lymphopenia: CD3 1576 mm^3, CD4 1182 mm^3, CD8
368 mm^3, CD4−CD8− TCRαβ+ T cells (1.6 % T cells) with normal CD 19, NK cells, immunoglobulins,
hib/tetanus titers, oxidative burst and lymphocyte proliferation to mitogen. At the
age of 2, patient developed elevated AST/ALT (~300s-700 units/L) & pancytopenia 8
months later with physical findings of recurrent oral ulcers. Abdominal ultrasound
remarkable for splenomegaly. Liver biopsy showed acute & chronic hepatitis with lymphocyte
predominance, bile duct injury and bridging fibrosis. Bone marrow biopsy was negative
for malignancy. Flow cytometry on peripheral blood had elevated CD4−CD8− TCRαβ+ (4.7%
T cells ), suggestive of ALPS. Fas mediated assay, sFASL, IL-10, IL-18 were obtained
& pending.
TNFAIP3 is known to present with autoinflammatory symptoms. Our case shows that patients
with TNFAIP3 variants can have an evolving clinical picture that can include a spectrum
of autoimmune lymphoproliferative syndrome -like disease. A hallmark finding of ALPS
is a high proportion of CD4−CD8− TCRαβ+ T cells, called double-negative T cells. A
2017 case report revealed a 1 year old male with findings of bilateral cervical lymphadenopathy
and hepatosplenomegaly. TNFAIP3, A20 was identified in this patient showing the ALPS-like
phenotype with elevated double-negative T cells (5.1% T cells). (https://doi.org.10.1016/i.iaci.2016.09.038)
Keywords: TNFAIP3, ALPS, autoinflammatory, lymphoproliferation, autoimmune
Disclosures: All authors indicated they had had no financial relationships to disclose.
(38) Post-operative absolute lymphocyte counts in pediatric patients with congenital
heart disease
Katie Kennedy, MD1, Kathryn Dodds, MSN, CRNP2, Jack Rychik, MD1, Jennifer Heimall,
MD3
1Attending Physician/The Children's Hospital of Philadelphia
2Advanced nurse practitioner/The Children's Hospital of Philadelphia
3Assistant Professor/Division of Allergy and Immunology, Children’s Hospital of Philadelphia
Previous studies regarding T-cell excision circle (TREC) screening in newborns report
a high proportion of false positive findings in infants with congenital heart disease
(CHD). These observations are postulated to be secondary to removal of thymus tissue
during routine cardiac surgery. We aimed to describe the absolute lymphocyte counts
(ALC) trend over time of infants born at our institution with CHD requiring surgical
intervention and subsequent thymectomy.
We performed a retrospective chart review of 441 infants born with CHD at our institution
from September 2012 through August 2015. Absolute lymphocyte counts over time were
analyzed in addition to cardiac defects, genetic diagnoses and effect of surgical
intervention. Exclusion criteria included known chylous loss or post-natal administration
of immune modulating medications such as high dose corticosteroids or chemotherapy.
The majority of subjects were male (57%) and born full term (85%). Genetic diagnoses
were noted in 13%, most commonly 22q11.2 deletion syndrome (3.7%), Trisomy 21 (3.5%)
and Turner Syndrome (1.6%). The most common cardiac defects included hypoplastic left
heart syndrome (15.6%), transposition of the great arteries (15.3) and tetralogy of
fallot (13.5%). No significant difference was found between average ALC at birth in
infants with CHD who later underwent thymectomy and those that did not (p>.9999).
Similar findings were present when comparing average ALC 6 months post-operatively
and 15 months post-operatively (p>.9999, p>.9999 respectively). Of note, all newborn
screen studies for severe combined immunodeficiency sent in Pennsylvania following
thymectomy were normal.
In this large retrospective cohort, removal of thymus tissue did not affect ALC up
to 15 months post-operatively. These findings suggest that the cause of lymphopenia
in these patients is not due to routine thymectomy during cardiac surgery. Further
study is necessary to elucidate infection risk in these patients as well as late follow
up of ALC.
Keywords: lymphopenia, trec, newborn screen, congenital heart disease
Disclosures: All authors indicated they had no financial relationships to disclose.
(39) Yield of Genetic Testing in a Large Autoinflammatory Disease Cohort
Amanda Salih, MD, MPH1, Bo Yuan, PhD, FACMG2, Anaid Reyes, BA3, Justin Branch, BA4,
Gina Cahill, MPH3, W. Blaine Lapin, MD5, Jennifer Rammel, MD, MPH6, Martha Curry,
MS, RN, C-PNP7, Lisa Forbes-Satter, MD8, Joud Hajjar, MD, MS8, Nicholas Rider, DO8,
M. Cecilia Poli, MD, PhD9, Zeynep Coban Akdemir, PhD10, James Lupski, M.D., Ph.D.,
D.Sc.11, Ivan Chinn, MD8, Tiphanie Vogel, M.D, Ph.D.12
1Fellow/Baylor College of Medicine/ Texas Children's Hospital
2Assistant Director/Seattle Children's
3Research Coordinator/Baylor College of Medicine/ Texas Children's Hospital
4Research Technician/Baylor College of Medicine/ Texas Children's Hospital
5Assistant Professor/Connecticut Children's
6Assistant Professor/UF Jacksonville
7Instructor/Baylor College of Medicine/ Texas Children's Hospital
8Assistant Professor/Baylor College of Medicine/ Texas Children's Hospital
9Director of the Immunogenetics and Translational Immunology Program; Assistant Professor/Universidad
del Desarrollo; Baylor College of Medicine/ Texas Children's Hospital
10Postdoctoral Associate/Baylor College of Medicine/ Texas Children's Hospital;
11Professor/Baylor College of Medicine/ Texas Children's Hospital
12Assistant Professor, Division of Rheumatology, Department of Pediatrics & Medicine/Texas
Children’s Hospital, Baylor College of Medicine
Systemic autoinflammatory diseases (SAIDs) represent a heterogenous group of disorders
characterized by dysregulated activation of the innate immune system and a pathogenic
inflammatory response. Genetic advances have identified a rapidly expanding number
of monogenic SAIDs, and many can be diagnosed using commercial gene panels. Although
most patients with autoinflammation do not have monogenic disease, identifying those
who do is important to inform treatment, and is particularly advantageous in atypical
presentations. We aimed to investigate genetic etiologies in a large cohort of patients
with autoinflammation.
We identified 74 patients with autoinflammation and clinical genetic sequencing. Clinical
sequencing was diagnostic for 30 patients (41%). The remaining 44 patients with non-diagnostic
clinical sequencing included 16 exomes and 28 targeted panels, containing a range
of 7-207 genes. These patients were further investigated using research exome sequencing
(ES) and bioinformatic evaluation with a candidate gene approach.
Our cohort is 52% male and 67% Caucasian; 20% of the patients are Hispanic. The median
age of onset is 2.2 years old. Fever episodes ranged from 1-10 days with an average
periodicity of 3-6 weeks. Predominant clinical features include fatigue (84%), rash
(69%), lymphadenopathy (61%), abdominal pain (60%), and arthritis (51%). Elevations
in C-reactive protein (74%) and erythrocyte sedimentation rate (59%) were noted during
flares, but no patients demonstrated elevated inflammatory markers outside of flares.
A majority of patients (76%) demonstrated symptom improvement with steroids. Most
patients (96%) required a controller medication, either colchicine (24%) or a biologic
agent (72%). Research ES yielded no additional cases of known monogenic autoinflammatory
diseases. Variants of uncertain significance (VUSes) in known or suspected primary
immunodeficiency (PID) genes were identified in 46% of patients. Interestingly, 47%
of patients with a VUS in a PID-associated gene carried heterozygous NLRP12 VUSes.
Identification of genetic causes of SAIDs is of critical importance for rapid disease
diagnosis, targeted therapeutic selection, and family counseling for recurrence risk.
Use of clinically available expanded genetic panels was sufficient to diagnose known
diseases in 40% of our autoinflammatory cohort. Research investigations are ongoing
into the VUSes identified in our patients.
Keywords: periodic fever syndromes, recurrent fevers, autoinflammation, genetics
Disclosures: Bo Yuan works for the Department of Molecular and Human Genetics at Baylor
College of Medicine which receives revenue form clinical genetic testing completed
at Baylor Genetics Lab. Lisa Forbes-Satter is a Consultant at ADMA and Grifols, and
is an Advisory Board member at CSL Behring, Horizon, and Takeda. Joud Hajjar received
research grants from Amplimmune, Arcus Biosciences, ARMO BioSciences, Atterocor/Millendo,
Baxalta, BMS, Calithera Biosciences, Chao Physician-Scientist Foundation, CytomX Therapeutics,
Eli Lilly, EMD Serono, Healios Onc, Immune Deficiency Foundation, ImmuneOncia, Incyte,
Jeffrey Modell Foundation, Karyopharm, Kymab, MedImmune, Merck, National Cancer Institute,
NeoImmuneTech, Neon Therapeutics, Novartis, OncoSec KEYNOTE-695, Pfizer, PsiOxus,
Regeneron, Surface Oncology, The Texams Medical Center Digestive Diseases Center and
Top Alliance; she was an Advisory Board member of Alfaisal University, Genome & Company,
Horizon, and Pharming. Nicholas Rider is an Advisory Board member at CSL Behring,
Pharming, Takeda; received a research grant from The Jeffrey Modell Foundation; Royalties
from UpToDate and Wolters Kulwer Publishing. James Lupski has ownership interested
in 23andMe and Regeneron and is an employee of the Department of Molecular and Human
Genetics at Baylor College of Medicine All other authors had no financial relationships
to disclose.
(40) Gain-of-function mutations in JAK3 in CVID and Interstitial Lung Disease
Michael Nordness, B.S.1, Amy Rymaszewski, PhD2, Jeffrey Woodliff, PhD3, Shaoying Chen,
MD2, John Routes, MD4, James Verbsky, MD, PhD5
1Medical Student/Medical College of Wisconsin
2Research Associate/Medical College of Wisconsin
3Clinical Immunology Research Laboratory Manager/Medical College of Wisconsin
4Professor of Pediatrics, Medicine, Microbiology and Immunology/Medical College of
Wisconsin
5Associate Professor of Pediatrics, Medicine, Microbiology and Immunology/Medical
College of Wisconsin
Common variable immune deficiency (CVID) is a primary immune deficiency characterized
by hypogammaglobulinemia, poor specific antibody responses, and infectious and non-infectious
complications.
We evaluated a 64-year-old male with CVID, recurrent sinopulmonary infections, and
progressive interstitial lung disease (ILD). He exhibited a chronic lymphocytosis
(~13K cells/mm3), and flow cytometry demonstrated increased numbers of T cells (CD4:
3820 cells/mm3, CD8: 7163 cells/mm3) and NK cells (3104 cells/mm3), but an absence
of B cells. The percentage of activated (HLA-DR+) CD4 and CD8 T cells was markedly
increased, and there was a decreased percentage of naïve T cells. Open lung biopsy
demonstrated lymphocytic interstitial pneumonitis (LIP) (CD4+>CD8+ T cells), an absence
of B cells or granulomas, and severe pulmonary fibrosis. HIV-1 RNA was negative. Despite
immunoglobulin replacement, he experienced repeated episodes of pneumonia requiring
IV antibiotics and chronic CMV viremia.
Whole exome sequencing (WES) was conducted. JAK3 plasmids underwent site-directed
mutagenesis and were transfected into an IL-2/IL-15 responsive HEK reporter line (Quanti-Blue).
Cells were simulated with IL-2 in the presence or absence of a JAK3 inhibitor (tofacitinib).
Peripheral blood mononuclear cells (PBMCs) and HEK cells were stimulated with IL-15,
and phospho-STAT5 was assessed with flow cytometry.
WES demonstrated two rare, damaging variants in JAK3: S835C and R925S. No other known
CVID-causing variants were detected. JAK3 cDNA cloning demonstrated cis orientation
of these variants. To evaluate variant function, wild type (WT) JAK3, S835C/R925S,
and a known gain-of-function (GOF) variant A573V were transfected into an IL-2/IL-15
responsive reporter line and stimulated with IL-15. WT JAK3 increased phospho-STAT5
levels and transcriptional activity versus controls, while S835C/R925S further increased
phospho-STAT5 activity comparable to A573V. IL-15 stimulation of the patient’s PBMCs
demonstrated delayed STAT5 dephosphorylation.
The dual presence of S835C and R925S variants in JAK3 caused STAT5 activation in reporter
cell lines and delayed STAT5 dephosphorylation consistent with a GOF. We speculate
that the GOF S835C and R925S mutations in JAK3 led to a chronic T-cell lymphocytosis
and T cell predominant LIP and CVID. This is the first report of GOF mutations in
JAK3 in a patient with CVID and an unusual form of ILD.
Keywords: CVID, JAK3 GOF, Interstitial Lung Disease
Disclosures: John Routes has contracted research with CSL Behring and Evolve Biologics.
All other authors had no financial relationships to disclose.
(41) Multicentric Castleman Disease revealing STAT1 deficiency
Camille Beaufils, M.D.1, Marie-Paule Morin, M.D.. Ph.D.2, Jean Jacques De Bruycker,
MD3, Lorie Marchitto, M.Sc.4, Isabel Fernandes, PhD5, Sonia Cellot, M.D. Ph.D.6, Philippe
Ovetchkine, M.D. Ph.D.7, Jean-François Soucy, M.D.8, Luc Oligny, M.D. Ph.D.9, Elie
Haddad, MD, Phd2, Fabien Touzot, M.D. Ph.D.2
1Clinical Fellow/Immunology-Rheumatology Division, Department of Pediatrics, University
of Montreal
2Attending physician/Immunology-Rheumatology Division, Department of Pediatrics, University
of Montreal
3Assistant clinical professor, division of Pediatric Immunology and Rhumatology/CHU
Sainte-Justine
4Ph.D student/CHU Sainte-Justine Research Center, University of Montreal
5Professor/Immunology-Rheumatology Division, Department of Pediatrics, University
of Montreal
6Attending Physician/Hematology Oncology Division, Department of Pediatrics, University
of Montreal
7Attending Physician/Infectious Disease Division, Department of Pediatrics, University
of Montreal
8Attending Physician/Genetic Division, Department of Pediatrics, University of Montreal
9Attending Physician/Pathology Division, Department of Pediatrics, University of Montreal
Castleman disease (CD), first described in 1956, is a rare lymphoproliferative disorder
characterized by enlargement of lymphoid tissue with follicular hyperplasia, vascular
proliferation, and plasmocytosis. Multicentric Castleman Disease (MCD) is an infrequent
pathology in the pediatric population and is often reported in regions where HHV-8
is endemic. We report an 11-month-old girl who presented with 6 criteria of hemophagocytic
lymphohistiocytosis (HLH): (i) prolonged fever > 38.5° C, (ii) splenomegaly, (iii)
bicytopenia with severe thrombocytopenia and anemia, (iv) increased triglycerides
and decreased fibrinogen, (v) hyperferritinemia (vi) increased circulating activated
HLA-DR+ CD8 T. Additional remarkable features were a tumoral syndrome (multiple diffuse
adenopathies, hepatomegaly), jaundice secondary to mild hepatitis with cholestasis,
eosinophilia and an extensive rash. All the infectious workup was negative. A PET-scan
revealed diffuse hypermetabolic adenopathies, hepatomegaly and splenomegaly). Bone
marrow biopsy also excluded malignant hematological disease. An axillary lymph node
biopsy was consistent with the diagnosis of MCD in its hyaline-vascular form. Immunohistochemistry
for HHV-8 was negative. Perforin expression and NK degranulation were normal, excluding
familial HLH. The patient was treated with 2 mg/kg/day prednisolone, 4 infusions of
rituximab (375 mg/m2 per dose), and sirolimus (for trough level between 10-15 ng/mL).
Despite an initial response to therapy, the patient relapse during steroid tapering
(at 1 mg/kg/day) with recurrence of fever, skin rash, and eosinophilia. Meanwhile,
the whole genome sequencing results were obtained and evidenced a maternal unidisomy
of chromosome 1, resulting in a homozygous deletion encompassing exon 5 to 9 of STAT1.
STAT1deficiency was confirmed in our patient through western blot and functional testing
of STAT1 phosphorylation by flow cytometry. We decided to introduce subcutaneous Ig
replacement and substitute sirolimus with ruxolitinib, given the initial HLH presentation
and reports showing imbalanced STAT3 pathway activation in STAT1 deficiency. Modification
of therapy allowed to maintain a sustainable remission of the disease and a complete
withdrawal of steroids. While in complete remission, our patient underwent hematopoietic
stem cell transplantation with a match unrelated donor.
Keywords: Primary Immunodeficiency, STAT1 deficiency, Multicentric Castleman Disease,
Hemophagocytic Lymphohistiocytosis, ruxolitinib
Disclosures: Elie Haddad is a consultant for Jasper Therapeutics and Rocket Pharma.
All other authors had no financial relationships to disclose.
(42) Newborn Screening for Severe Combined Immunodeficiency in New Jersey from 2014
to 2017
Amandeep Sandhu, MD1, Jennifer Heimall, MD2, Miriam Schachter, PhD3
1Allergy and Immunology Fellow/Children’s Hospital of Philadelphia
2Attending Physician/Children's Hospital of Philadelphia
3Research Scientist/New Jersey Department of Health
New Jersey department of health (NJ DOH) initiated newborn screening (NBS) for severe
combined immunodeficiency (SCID) in July 2014. The NBS uses a T-cell receptor excision
circle (TREC) assay reported as cycle threshold (CT) to evaluate for SCID but also
identifies other causes of T-cell lymphopenia. The objective of this study was to
report outcomes of abnormal NBS for SCID in NJ from its initiation in 2014 through
December 2017.
Retrospective chart review of infants with abnormal NBS for SCID were identified by
New Jersey Department of Health (NJ-DOH). The data reviewed included demographics,
TREC CT, lymphocyte enumeration, lymphocyte proliferation to mitogens, quantitative
immunoglobulins, genetic analysis, family history and clinical history. The TREC CT
parameters for a presumptive positive screen is 35.8, while the test is repeated if
the CT is between 34.5 and 35.7.
Two hundred and thirteen infants were referred for flow cytometry and 146 of these
subsequently had a normal evaluation. Fifty-three patients expired prior to further
evaluation for SCID. Fourteen patients (6.6%) were diagnosed with either SCID or T-cell
lymphopenia: 4 patients (1.9%) with SCID, 2 patients (0.9%) with 22q11.2 deletion
syndrome, and 8 patients (3.8%) with idiopathic T-cell lymphopenia. Of the 4 patients
with SCID, a genetic mutation was identified in all and included the following genotypes:
ADA (n=2), RAG1 (n=1), MSN (n=1). Demographic information, TREC cycle threshold values
and lymphocyte enumeration data are summarized in tables 1 and 2.
NBS for SCID in NJ was one of the first in the US to use TREC-CT rather than TREC
count as a reporting strategy. Most SCID cases detected in NJ were autosomal recessive
genotypes, rather than the x-linked IL2RG genotype most commonly reported to cause
SCID. In addition, female and non-Caucasian infants comprised half the population
identified via NJ-DOH NBS to have significant lymphopenia. These data further support
the value of population based NBS for SCID and significant T cell lymphopenia utilizing
TREC CT reporting to detect these conditions in populations previously less likely
to be detected prior to symptom onset.
Table 1: Demographic information for infants with SCID or T-cell lymphopenia identified
on NJ NBS
Table 2: Initial lymphocyte enumeration for infants with SCID or T-cell lymphopenia
identified on NJ NBS
Keywords: Newborn screening, Severe combined immunodeficiency (SCID), T-cell Lymphopenia,
TREC, DiGeorge, Cycle threshold, 22q11.2 deletion syndrome
Disclosures: Jennifer Heimall is an advisory board member of CIRM; received research
grants from Regeneron and CSL Behring; and received speaker honoraria from Horizon.
All other authors had no financial relationships to disclose.
(43) IRAK 4 deficiency diagnosed in a 14-year-old male presenting with bacterial meningitis
Paulina Tran, DO1, Juhee Lee, MD2
1Fellow Physician/Childrens Hospital of Philadelphia
2Attending Physician/Childrens Hospital of Philadelphia Department of Pediatrics,
Allergy Immunology Division, Children’s Hospital of Philadelphia
IRAK4 (Interleukin-1 receptor-associated kinase 4) deficiency is an autosomal recessive
innate immune defect involving the toll-like receptor pathway. The majority of patients
present in infancy with pyogenic bacterial infections due to Staphylococcus aureus,
Streptococcus pneumoniae, Pseudomonas aeruginosa, or less commonly Neisseria Meningitidis.
(1) Common clinical manifestations include meningitis, osteomyelitis, skin abscesses,
lymphadenitis, sinopulmonary infections, and bacteremia. Patients tend to have milder
disease later in life. In one series, no patients beyond age 14 years developed invasive
bacterial infection or death.(1) This improvement with age is a unique feature of
IRAK4 deficiency and thought to be due to a maturing adaptive immune system. We report
the first case of IRAK4 deficiency diagnosed in an adolescent male with meningococcal
meningitis.
A 15-year-old male presented with sudden onset of severe headache with photophobia,
nausea, vomiting, and low-grade fever. Cerebral spinal fluid culture gram stain and
culture confirmed Neisseria meningitidis infection. Prior infectious history included
bilateral lymphadenitis with lymph node removal at 7 years of age and recurrent sinus
infections that improved after sinus surgery and allergen immunotherapy. Immune work
up revealed an abnormal TLR assay with a decreased response in TLR2-TLR1, TLR3, TLR5,
TLR7-TLR8, TLR4 and normal responses to TLR2-TLR6. Complement studies showed a reduced
alternative complement response (AH50 = 59 units/mL) and normal classical pathway
testing. Pneumococcal titers were 60% protective and meningococcal titers were protective
to 3/4 serotypes. His immunoglobulin levels were normal. Whole exome sequencing was
pursued and revealed IRAK4 deficiency with a pathogenic variant that results in a
premature stop codon and loss of protein expression. The patient fully recovered from
his infection and has not any further infectious issues. He has since completed the
MCV4 and Serogroup B vaccination series and continues on daily amoxicillin prophylaxis.
To our knowledge this is the first case of IRAK4 deficiency that developed an invasive
bacterial infection after the age of 14. Although rare, it is important to consider
innate immune defects in older patients presenting with invasive pyogenic disease.
Reference: 1.) PMID: 21057262
Keywords: IRAK 4 deficiency, Invasive bacterial disease, Neisseria meningitidis, Adolescence,
Innate Immunity, Toll Like Receptor Pathway
Disclosures: All authors indicated they had no financial relationships to disclose.
(44) Transcriptional dysregulation of CVID patients harboring C104R TNFRSF13B mutation
Neftali Ramirez, MSc1, Niko Langer, MTA2, Nils Klammer, graduate degree3, Alla Bulashevska,
PhD4, Bärbel Keller, PhD4, Claudia Bossen, PhD5, Bodo Grimbacher, Prof. Dr. med.6
1PhD Sstudent/University Clinic Freiburg, CCI
2MTA/University Clinic Freiburg, CCI
3MD student/University Clinic Freiburg, CCI
4Postdoc/University Clinic Freiburg, CCI
5Group leader/University Clinic Freiburg, CCI
6Head of the laboratory/Center for Chronic Immunodeficiency, Medical Center, University
of Freiburg, Germany
To determine additional factors contributing to the development of common variable
immunodeficiency (CVID), we investigated the perturbations of transcription factor
binding and transcriptome profiles in CVID patients harboring the C104R mutation in
TNFRSF13B. The C104R mutation in TNFRSF13B however, has a prevalence of approx. 1%
in the healthy population.
Assay for transposase accessible chromatin-sequencing (ATAC-seq) was performed on
naïve and class switched memory B cells of six CVID patients heterozygous for the
C104R mutation, six of their healthy relatives carrying the same heterozygous mutation,
and eight healthy wild-type donors. In addition, ATAC-seq was performed on naïve CD4+
T cells of two C104R-heterozygous CVID patients, their unaffected relatives, and three
healthy wild-type donors. RNA-sequencing was performed on three C104R-heterozygous
CVID patients, their unaffected relatives, and three healthy donors. For functional
validation, intra-cellular staining was performed by flow cytometry.
Our analysis revealed 25 % less accessible chromatin in class-switched memory B cells
from TNFRSF13B-mutant carriers compared to healthy donors. 1.356 and 1.069 differential
accessible regions were detected in naïve and class-switched memory B cells from mutation
carriers compared to healthy donors, respectively. The most enriched transcription
factor binding motif was for NF-kB in both B cell subsets, but not observed for the
T cell population. IkBa expression (downstream of NF-kB) was significantly increased
in patients, as determined by flow cytometry. RNA-seq analysis revealed 687 dysregulated
genes in naïve B cells and 617 in class-switched B cells from CVID patients, respectively.
Gene ontology analysis highlighted the NF-kB signaling and systemic lupus erythematosus
pathway in naïve- and class-switched memory B cells, respectively. Integration of
ATAC- and RNA-seq data pointed towards a dysregulation MAP3K8. Flow cytometry analysis
of pERK (downstream of MAP3K8) confirmed this trend.
Here we showed the transcriptional dysregulation of naïve- and class-switched memory
B cells of individuals with the C104R mutation in TNFRSF13B. The most enriched transcription
factor binding motif was for NF-kB, confirmed by transcriptome analysis, and the increase
of IkBa expression. NF-kB is essential for regulating immune response to infections.
Thus, its changes may lead to variety of disease-causing differences. Furthermore,
the data suggest NF-kB dysregulation is B cell intrinsic.
Keywords: CVID, TNFRSF13B, epigenetics, NF-kB
Disclosures: Bodo Grimbacher received a research grant from Baxalta. All other authors
had no financial relationships to disclose.
(45) Using switchable NF-κB signaling to uncover the molecular defects of pathogenic
NFKB1 and NFKB2 variants
Manfred Fliegauf
1, Bodo Grimbacher, Prof. Dr. med.2
1Researcher/Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical
Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany; CIBSS
– Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University,
Freiburg, Germany
2Head of the Laboratory/Center for Chronic Immunodeficiency, Medical Center, University
of Freiburg, Germany
Common variable immunodeficiency (CVID) represents the most prevalent symptomatic
primary antibody deficiency with heterozygous NFKB1 and NFKB2 mutations collectively
accounting for up to 20% of the monogenetic forms. NFKB1 encodes the transcription
factor precursor p105, which is processed to p50 (canonical NF-κB signaling pathway),
while NFKB2 encodes p100/p52 (non-canonical pathway). Known pathogenic variants either
cause (haplo)insufficiency, precursor-skipping or non-processable p100, while most
of the identified missense changes have yet unknown effects.
The disease-causing mechanisms presumably originate from imbalanced p105/p50 and p100/p52
ratios and altered NF-κB signaling dynamics. To assess the pathogenic relevance of
NFKB1 and NFKB2 variants, we first analyze the localization, expression and processing,
DNA-binding activity and reporter gene activation of mutant NF-κB proteins in transfected
HEK293T cells. We then test their functional capabilities following experimentally
induced precursor-processing, IκB-mediated cytoplasmic retention, nuclear translocation
and DNA-binding competition, respectively. To accomplish NF-κB manipulation, we use
switchable models based on co-expression of the NF-κB proteins together with diverse
upstream kinases, natural and synthetic IκBs, Rel interaction partners, competitors
and the combination thereof. With these tools, we aim at exploring the NF-κB signaling
defects associated with diseases of the immune system.
Keywords: NFKB1, NFKB2, NF-kappaB, CVID
Disclosures: Bodo Grimbacher received a research grant from Baxalta. The other author
had no financial relationships to disclose
(46) Effects of Aging on Immune parameters In Patients with STAT3 Hyper IgE Syndrome
Jennifer Heimall, MD1, Amanda Urban, CRNP2, Hastings Williamson, n/a3, Jean Ulrick,
CRNP4, Alexandra Freeman, MD5
1Assistant Professor/Division of Allergy and Immunology, Children’s Hospital of Philadelphia
2Nurse Practitioner/Clinical Research Directorate, Frederick National Laboratory for
Cancer Research
3Research Assistant/NIAID
4CRNP/NIAID
5Director, Primary Immune Deficiency Clinic/Laboratory of Clinical Immunology and
Microbiology, National Institute of Allergy and Infectious Diseases, National Institute
of Health
Patients with Hyper IgE Syndrome (HIES) due to dominant negative STAT3 mutations (STAT3
HIES) have recurrent skin and lung infections, eczematous dermatitis, and connective
tissue changes. Laboratory abnormalities include elevated serum IgE, elevated absolute
eosinophil count (AEC), lower memory T lymphocytes, and lower switched memory B lymphocytes.
We sought to describe the change in immune function parameters with age in this population.
METHODS: We retrospectively reviewed 157 patients with STAT3 HIES, with a focus on
clinically obtained immune parameters. These included cells counts (AEC, CD19, CD20/CD27/IgM+,
Cd20/CD27/IgM-, CD3-/CD16+ and/or CD56+, CD3, CD3/CD4, CD3/CD8, CD4/CD62L+/ CD45RA+/CD3+,
CD3/CD4/CD62L+/CD45RA-, CD3/CD4/CD62L-/CD45RA-, CD8/CD62L+/ CD45RA+/CD3+, CD3/CD8/CD62L+/CD45RA-,
CD3/CD8/CD62L-/CD45RA-) and levels of IgG, IgA, IgM, IgE. Patients were clustered
by age groups of 0-5 years of age, 6-10 years of age, 11-15 years of age, 16-30 years
of age, 31-45 years of age, and >45 years of age. We assessed median level of each
parameter in each age cluster. Most patients only were represented in one cluster.
RESULTS: Results are summarized in Table 1. As expected, median IgE was elevated,
but was higher in children, adolescents and young adults as compared to toddlers and
older adults. Median IgG, IgA and IgM were normal. Surprisingly, median AEC was at
the high end of normal and stable across age groups. Overall, CD19, CD3, and CD3-/CD16+
and/or CD56+ cell counts were slightly lower than expected for age across all categories.
Naïve B cell populations did decrease with age, but there was not a commensurate increase
in switched or unswitched memory B cell populations over time leading to progressive
total B cell number decline. T cell populations demonstrated an appropriate 2:1 ratio
of CD4:CD8 cells that was maintained over time; increased DNT were not seen. Naïve
T cell populations did decrease with age, but there was not a commensurate increase
in memory T cell populations over time leading to decreasing total T lymphocytes with
age.
Further study is needed to correlate clinical outcomes with variations from these
median immunologic parameters in patients with STAT3 HIES.
Table 1: Median Values of immune parameters by age
Keywords: Primary Immunodeficiency, Aging, Hyper IgE Syndromes, Immunophenotyping
Disclosures: All authors indicated they had no financial relationships to disclose.
(47) Chronic Granulomatous Disease presenting with Early Onset Chronic Recurrent Multifocal
Osteomyelitis
Christopher Costin, MD1, Amer Khojah, MD2, Michael Miller, MD3
1Pediatric Rheumatology Fellow/Ann & Robert H. Lurie Children's Hospital of Chicago/
Northwestern University Feinberg School of Medicine
2Attending Physician, Allergy, Immunology, and Rheumatology/Ann & Robert H. Lurie
Children's Hospital of Chicago/ Northwestern University Feinberg School of Medicine
3Clinical Practice Director, Division of Rheumatology/Ann & Robert H. Lurie Children’s
Hospital of Chicago
Chronic Recurrent Multifocal Osteomyelitis (CRMO) is a rare autoinflammatory bone
disease presenting with pain and noninfectious osteomyelitis. The pathophysiology
of CRMO remains unclear; however, bone metabolism, IL-10 and IL-1 pathways have been
linked in its pathogenesis. CRMO may present as distinct clinical entity or may be
associated with other disease: such as Crohn’s disease, HLA B27 associated diseases.
Early onset CRMO is typically linked to monogenic syndromes such as Majeed syndrome
or Deficiency of the interleukin-1 receptor antagonist (DIRA). Rarely chronic granulomatosis
disease (CGD) has been associated with CRMO. Here we present a case of CGD presenting
with early onset CRMO.
A 3-year-old boy presented to the ED for left sided facial swelling. An MRI of the
face showed left sided hemimaxilla enhancement. A whole-body MRI showed additional
hyperintensity of the left ulna and radius concerning for CRMO. A bone biopsy of hemimaxilla
showed fibroproliferative lesion with chronic inflammation consistent with CRMO. Infectious
studies were negative. He was discharged home on scheduled NSAIDs with eventual resolution
of his swelling and pain.
From ages 5-8 he then developed recurrent facial sores and skin infections that resolved
with clindamycin or mupirocin. He developed a gluteal abscess requiring oral antibiotics.
He was seen by dermatology and diagnosed with a Serratia facial infection. Oxidative
burst testing was obtained and resulted low at 2.4. He was diagnosed with chronic
granulomatous disease.
CRMO is a relatively rare disease. It typically presents in females ages 7-12. This
case highlights the importance of considering monogenic autoinflammatory diseases
in patients with early onset CRMO such as CGD, Majeed Syndrome and DIRA.
Keywords: CRMO, CGD, osteomyelitis, Chronic, granulomatous, Disease
Disclosures: All authors indicated they had no financial relationships to disclose.
(48) A pediatric case of trisomy 8 mosaicism with periodic fevers
Tyrone Coyle, MD1, Sujatha Rajan,, MD2, Artemio Jongco, MPH, MD, PhD, FACP, FACAAI,
FAAAAI3
1Allergy/Immunology fellow/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
2Pediatrics Infectious Disease/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
3Assistant Professor of Medicine and Pediatrics/Donald and Barbara Zucker School of
Medicine at Hofstra/Northwell
Trisomy is the most common aneuploidy or defect with an abnormal number of chromosomes.
Full trisomies are often lethal in utero. Trisomy mosaicism increases survivability
but also leads to high variability in phenotypes. Trisomy 8 Mosaicism (T8M), or Warkany
syndrome, occurs in 1:25,000 to 1:50,000 of live births, with 3:1 male predominance.
An 8-year-old Asian male was seen in an outpatient setting for evaluation of recurrent
high grade fevers (to 103°F) for 3 years. A fever log showed episodes every 24-28
days, lasting for 3 days and then spontaneously resolving. Episodes were associated
with abdominal pain, vomiting, diarrhea and chills. Initially, fevers were treated
with antibiotics and antipyretics which were ineffective. A thorough infectious disease
evaluation detected no infectious etiology. The synchronicity of fevers were highly
suspicious for a periodic fever syndrome.
Preliminary workup revealed neutropenia (1200cells/μL), mild eosinophilia (520 cells/μL),
thrombocytosis (458K/μL) and mild macrocytosis (MCV 100.2). Otherwise, screening of
cellular immunity, complement, humoral immunity and for periodic fevers with IgD level
and periodic fever syndromes panel (ELANE, LPIN2, MEFV, MVK, NLRP3, PSTPIP1, TNRFSF1A)
were unremarkable.
A commercial targeted primary immunodeficiency panel showed copy number variants (CVNs)
of uncertain significance (VUS) in ANGPT1, ASAH1, CHD7, DGAT1, EXTL3, GTF2E2, IKBKB,
LYN, MCM4, NBN, PRKDC, TONSL, VPS13B, and heterozygous VUS in AP3B1, CTC1, FANCI,
FCHO1, IL17RC, LRBA, PEPD, POLD1, SLC39A7, SPINK5, TTC37. All CVNs were on chromosome
8. A chromosomal microarray confirmed diagnosis of trisomy 8.
T8M can present with an array of clinical findings. Several articles from predominantly
Asian adult cohorts show an association amongst T8M, myelodysplastic syndrome (MDS)
and Behçet disease (BD)-like symptoms, and one Japanese review proposes a designation
of “trisomy 8 syndrome” (T8S) for such cases. Several Japanese adults with T8S were
reported to have periodic fevers that are reminiscent to the clinical presentation
seen in our pediatric case. While our patient has not shown clinical signs of BD or
MDS, prior Japanese reports of T8S were exclusively in adults. Periodic fevers could
be the initial insult, prior to developing clinical signs of T8S.
Keywords: Trisomy 8, periodic fevers, Mosaicism, Warkany syndrome, pediatric, neutropenia,
Behçet disease, myelodysplastic syndrome
Disclosures: All authors indicated they had no financial relationships to disclose.
(49) Suspected Lymphocytic Variant Hypereosinophilic Syndrome with Concomitant Immune
Thrombocytopenia
Susamita Kesh, MD1, Ian Slack, MD2, Juan Abonia, MD3, Kimberly Risma, MD, PhD3, Stephanie
Ward, MD4
1Allergy/immunology fellow/Cincinnati Children's Hospital Medical Center
2Clinical Fellow/Division of Allergy and Immunology, Cincinnati Children's Hospital
Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine,
Cincinnati, OH
3Associate Professor/Division of Allergy and Immunology, Cincinnati Children's Hospital
Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine,
Cincinnati, OH
4Assistant Professor/Division of Allergy and Immunology, Cincinnati Children's Hospital
Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine,
Cincinnati, OH
Hypereosinophilic syndrome (HES) is a rare condition which can lead to irreversible
end organ damage with various manifestations. Here we describe a unique case of suspected
lymphocytic-variant hypereosinophilic syndrome (L-HES) with concomitant immune thrombocytopenia
(ITP).
A previously healthy 19-year-old Asian male who presented with a six-week history
of bilateral lower extremity rash, angioedema, weight loss, and fatigue was admitted
with thrombocytopenia (13,000 platelets/mcL) and leukocytosis (44,800 cells/mcL) with
severe eosinophilia of 33,700 cells/mcL. Additional disease sequelae included decreased
ejection fraction (50%), acute kidney injury, transaminitis, and hepatic vein thrombosis.
Skin biopsy demonstrated eosinophilic panniculitis; rheumatologic and infectious workups
were unrevealing. Bone marrow biopsy demonstrated eosinophilic hyperplasia (70-80%)
with normal eosinophil morphology and unremarkable flow cytometry. Genetic workup
for myeloproliferative variants including chronic eosinophilic leukemia were unremarkable
including FISH (negative BCR/ABL1, JAK2, PDGFRA, PDGFRB, CHIC2, FGFR1), normal karyotype,
microarray SNP, and no genetic alterations on FoundationOne heme next-generation sequencing.
Peripheral flow cytometry was significant for an inverted CD4:CD8 ratio with increased
CD3+/CD4+ γ/δ cells (21%) and minimal elevations of IL5 and IL6. Additional evaluation
for a lymphocytic clonal process revealed no evidence of T or B cell clonality. Workup
for his thrombocytopenia identified GpIIb/IIIa antibodies. Without any clear evidence
for malignancy or immunodeficiency, he was started on systemic steroids which were
escalated for recalcitrant thrombocytopenia with a nadir platelet count that was undetectable
despite initial eosinophil normalization. He subsequently started mepolizumab 300
mg subcutaneously every 4 weeks allowing a slow taper of systemic steroids
Although cytogenetic testing can categorize patients into myeloproliferative HES,
the diagnosis of L-HES, as in this case, is often challenging as a subset of patients
can have clones which are difficult to identify. We suspect L-HES based on the increased
γ/δ T cells, evidence of additional adaptive immune dysfunction (ITP), and lack of
other findings to suggest a myeloproliferative variant. To our knowledge, this is
the only reported case of HES with GpIIb/IIIa positive antibody ITP. Our patient is
undergoing serial laboratory monitoring for end organ damage. Repeat bone marrow biopsy
is planned for oncologic surveillance as well as risk of HES recurrence.
Keywords: hypereosinophilic syndrome, immune thrombocytopenia, malignancy
Disclosures: All authors indicated they had no financial relationships to disclose.
(50) Pneumococcal Antibody(PA) Levels Are Decreased in Subjects with Allergic Sensitization
Charles Song, M.D.1, Diana Chernikova, MD, Phd2, Dennys Estevez, MSc3
1Chief of pediatric allergy and immunology/Harbor-UCLA
2Resident/Harbor-UCLA
3Statistician/Harbor-UCLA
In the previous study of 313 subjects with recurrent respiratory symptoms aged 6-70
years, we reported allergic skin sensitization was significantly increased in those
with inadequate baseline pneumococcal antibody levels. 1 We extended the study to
include the 57 children under 6 years of age to further investigate the relationship
between allergy and pneumococcal antibody (PA) levels.
We investigated 313 subjects aged 6 to 70 years and 57 subjects aged 2 to 5 years
with recurrent respiratory symptoms for atopy and pneumococcal antibody; Inclusion
criteria were: persistent cough >4 weeks, persistent rhinitis>4 weeks, otitis media
> 4/year, sinusitis > 1x/year, chronic sinusitis ≥12 weeks. Exclusion criteria were
the history of incomplete vaccination, primary immune deficiency, autoimmune disorders,
and malignancy. Diagnostic studies included allergy skin test, IgE, IgG, IgA, IgM,
and pneumococcal antibody levels. Pneumococcal antibodies were considered protective
(adequate) if ≥50% of the tested serotypes were in a protective range (≥1.3 mg/dL)
for ages 2 to 5 and ≥70% for ages 6 to 70.
The prevalence of adequate baseline PA among 194 patients aged 6-70 years with positive
allergic skin sensitization was significantly lower compared to the 119 patients with
negative skin sensitization (15% vs. 24%, P < 0.05). The prevalence of adequate baseline
PA among 35 patients aged 2-5 years with positive allergic skin sensitization also
showed lower trend compared to the 22 patients with negative skin sensitization (20%
vs. 36%, P =0.29) (Figure 1).
Our findings demonstrated a strong association between the baseline PA and allergic
sensitization. This raises the hypothesis that allergic propensity (Th2 pathway) may
have an initial suppressive effect on the immunological response (IgM/G) to polysaccharide
antigens (Th1 pathway). Patients with recurrent respiratory symptoms need to be checked
both for allergic sensitization and PA levels.
Reference:
1. Song CH, Estevez D, Chernikova D, et al. Low baseline pneumococcal antibody titers
predict specific antibody deficiency, increased upper respiratory infections, and
allergy sensitization. Allergy and Rhinology . 2020; 11;1-10
Figure 1 : Percentage of adequate (protective) pneumococcal antibody levels among
allergic and non-allergic subjects.
Keywords: Pneumococcal antibody deficiency, allergy, recurrent respiratory symptoms
Disclosures: All authors indicated they had no financial relationships to disclose.
(51) Worsening Cough in Patient with CVID and GILD - what we least expected
Ana Luiza Graneiro, MD1, Yatyng Chang, MD2, Vivian Hernandez-Trujillo, MD3
1Pediatric Resident/Nicklaus Children’s Hospital
2Allergy and Immunology Fellow/Nicklaus Children's Hospital
3Allergy Immunology Attending/Nicklaus Children's Hospital
Antidegradation agents used to enhance rubber products include paraphenylenediamine
(PPD), among others, known collectively as black rubber mix. This can also be found
in some hair products. The rationale for their use stems from the fact that when oxidized,
PPD turns hair a darker color. The substance can also cause allergic reactions. Here,
we present an adult with primary immunodeficiency and chronic cough with acute exacerbation
likely due to hair dye.
To describe a case of allergic reaction manifesting as worsening cough in a patient
with CVID and GILD due to exposure to black rubber mix in hair dye.
This patient had a history of CVID and GILD on subcutaneous gamma globulin replacement,
granulomatous interstitial lung disease, congenital heart disease, allergic rhinitis,
chronic sinusitis and contact dermatitis, who presented with a dry cough for months.
During this time, she was followed by multiple specialties including pulmonology for
her history of stable basilar pulmonary fibrosis, who suspected her cough was upper
respiratory in nature. A CT scan of the sinus was normal. Over the prior months, she
also developed skin rashes to tape, jewelry and leads from EKG. Patch testing showed
positive results to nickel, gold, Cl+Me-Isothiazolinone and black rubber mix. Skin
prick testing was positive only to feathers. She was treated with cefdinir for three
weeks for suspected sinus infection. Despite the treatment with allergy medications,
her cough persisted. One day, patient went to the hair salon to have her hair done
and had an acute worsening of her symptoms. She had not dyed her hair in over one
year.
In patients with primary immunodeficiency and chronic lung disease presenting with
acute exacerbation of cough, uncommon causes should be considered. For patients with
persistent cough, who have eliminated pertinent environmental allergens and are on
appropriate treatment, clinicians should consider infection versus products that may
contain contact allergens such as PPD/black rubber mix as potential causes. We recommend
consideration of testing for contact allergens. Patients should read labels carefully,
eliminate hair products with black rubber mix/PDD or opt for natural hair products
without these chemicals.
Keywords: Paraphenylenediamine, Black rubber mix, CVID, GILD
Disclosures: Vivian Hernandez-Trujillo is an advisory board member of Covis, CSL Behring,
DBV, Kaleo, Takeda, and US WORLD MEDS. All other authors had no financial relationships
to disclose.
(52) Hematopoietic Stem Cell Transplant Outcomes in Adolescent and Young Adults with
Immune Disorders
Andrea Bauchat, DO1, Laura Lucas, NP2, Debbie Leavenworth, RN3, Suhag Parikh, MD4,
Shanmuganathan Chandrakasan, MD5
1Bone Marrow Transplant Fellow/Aflac Cancer and Blood Disorders Center, Children's
Healthcare of Atlanta
2Nurse Practitioner/Children's Healthcare of Atlanta
3RN/Children's Healthcare of Atlanta
4Attending Physician/Division of Bone Marrow Transplant, Aflac Cancer and Blood Disorders
Center, Children’s Healthcare of Atlanta, Emory University School of Medicine
5Pediatric Hematologist/Oncologist/Children's Healthcare of Atlanta
Hematopoietic stem cell transplantation (HSCT) is an effective therapy for immune
dysregulations and immunodeficiencies. The adolescent and young adult (AYA) patients
in this diagnostic group pose unique challenges as their pre-HSCT course may be characterized
by recurrent infections, inflammatory manifestations, atopy, and autoimmunity, increasing
post-HSCT complication risks.
We performed a chart review at a single institution for HSCT outcomes of AYA patients
with immune disorders.
We identified 22 patients aged 11 to 20 years (median 14 years) who received HSCT
between 2005 and 2020. Indications for HSCT include Hemophagocytic Lymphohistiocytosis(n=6),
Combined Immune Deficiency with autoimmunity(n=5), Common Variable Immune Deficiency(n=2),
chronic granulomatous disease(n=3), GATA2 haploinsufficiency(n=2), SCID for second
HSCT(n=1), CD40 Ligand deficiency(n=1), IPEX(n=1), and CTLA4 haploinsufficiency(n=1).
Conditioning regimens included Busulfan with Fludarabine (45%), Busulfan with Cytoxan
(14%), and low-dose TBI (23%). Donors were matched siblings (36%), matched unrelated
(27%) mismatched unrelated (14%) or haploidentical (23%). Graft sources included bone
marrow (77%), peripheral blood (14%), and cord blood (5%).
Overall survival is 86% with 14% transplant related mortality. All patients achieved
engraftment. Post-HSCT median follow-up is 3 years (range 1-10years). At last follow-up,
45% had complete donor chimerism in T cell and myeloid lineages. 32% had mixed T cell
chimerism (31-91% donor). 9% had mixed myeloid chimerism (50-92% donor). A CGD patient
had combined mixed chimerism of 83% donor T cell and 1% donor myeloid but remains
clinically well. Acute graft versus host disease (GVHD) occurred in 50% (18% grade
III-IV) and chronic GVHD in 22% (8.7% severe). Causes of death include a CID patient
from intracranial hemorrhage due to autoimmune vasculitis (day+40) and 2 HLH patients
from septic shock with respiratory failure (day+62) and respiratory failure with ADV
colitis, CMV reactivation and EBV viremia (day+133) both without evidence of HLH recurrence.
Among survivors, 90% are off immunoglobulin replacement and 95% have normal or significantly
improved lymphocyte subsets.
This study documents HSCT outcomes in a complex cohort of patients with a high risk
of developing therapy complications. Increased reporting of HSCT outcomes in AYA patients
with immune disorders is critical to understanding the challenging areas for clinical
improvement.
Keywords: Hematopoietic Stem Cell Transplant, Immune disorders, Immune dysregulation,
Bone marrow transplant outcomes, Adolescent and young adult
Disclosures: All authors indicated they had no financial relationships to disclose.
(53) Type I interferon signature in RALD mimicking inflammatory CVID
Riccardo Papa, MD1, Marta Rusmini, PhD2, Sara Signa, MD1, Maria Cristina Coccia, MD3,
Roberta Caorsi, MD1, Francesca Schena, PhD4, Giovanni Spirito, PhD5, Remo Sanges,
PhD5, Diego Vozzi, PhD6, Andrea Cavalli, PhD6, Stefano Gustincich, PhD6, Elisabetta
Traggiai, PhD7, Isabella Ceccherini, PhD8, Marco Gattorno, MD9, Stefano Volpi, MD,
PhD1
1Pediatrician/Autoinflammatory Diseases and Immunodeficiencies Centre, IRCCS Istituto
Giannina Gaslini, Genoa, Italy
2Geneticist/UOC Medical Genetics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
3Pathologist/UO Pathology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
4Biologist/Autoinflammatory Diseases and Immunodeficiencies Centre, IRCCS Istituto
Giannina Gaslini, Genoa, Italy
5Geneticist/Area of Neurobiology, SISSA, Trieste
6Geneticist/RNA Central lab, IIT, Genova
7Biologist/Novartis Institutes for Biomedical Research, Basel 4056, Switzerland
8Head, Geneticist/UOC Medical Genetics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
9Head, Pediatrician/Autoinflammatory Diseases and Immunodeficiencies Centre, IRCCS
Istituto Giannina Gaslini, Genoa, Italy
RAS-associated autoimmune leukoproliferative disease (RALD) is a rare immune dysregulation
syndrome caused by somatic gain-of-function mutations of either NRAS or KRAS gene
in a subset of hematopoietic cells. We describe a patient with atypical RALD displaying
hypogammaglobulinemia, multi-organ autoimmunity and liver failure.
Immune and genetic analyses were conducted as part of the patient's clinical workup
and in the contest of a research project on pediatric autoimmune diseases approved
by our hospital institutional ethics committee.
The patient is a 27-year-old boy who presented at 5 months of age with EBV infection,
followed by episodes of recurrent otitis media and lymphadenopathy. During childhood,
he developed polyarthritis, nephrotic syndrome with minimal change disease, growth
and pubertal delay, pulmonary fibrosis, autoimmune hypothyroidism, alopecia, celiac
disease, anemia and hypogammaglobulinemia. Immunological studies showed normal lymphocyte
subpopulations including CD4/CD8 double negative T cells and Fas-mediated apoptotosis.
Peripheral blood type I interferon signature was positive. Partial control of the
disease was obtained during the years with oral steroids, hydroxichloroquine, and
mofetil mycophenolate, together with IVIG prophylaxis. Since 18 years of age, regenerative
nodular hyperplasia of the liver was detected, causing hepatopulmonary syndrome Whole
exome sequencing analysis revealed the heterozygous p.Gly13Asp missense mutation in
the NRAS gene. As reported, the mutation was demonstrated to be somatic, being absent
at Sanger sequencing of oral swab, urine sediment and hair follicle DNA.
Our report highlights the possibility of detecting somatic NRAS gene variants in patients
with inflammatory CVID. NRAS-dependent type I interferon pathways activation may be
involved in the multi-organ autoimmunity of RALD. Life-threatening complications,
as end-stage liver failure, can occur in case of a prolonged diagnostic delay.
Keywords: CVID, Interferon, NRAS, SLE, RALD
Disclosures: All authors indicated they had no financial relationships to disclose.
(54) Heterozygous transcription factor 3 gene (TCF3) mutation is associated with absent
B cells, normal immunoglobulin levels and function and severe thrombocytopenia, which
responded well to Rapamycin
Manar Abdalgani, MBBS1, Tam Pozos, MD PhD2, Diana Vilkama, APRN CNP3, Yoav Messinger,
MD4
1Clinical Immunologist/Children's Hospitals and Clinics of Minnesota
2Medical Director of Immunology/Children's Hospitals and Clinics of Minnesota
3Immunology Nurse Practitioner/Children's Hospitals and Clinics of Minnesota
4Medical Director-Hematology Oncology/Children's Hospitals and Clinics of Minnesota
We present the case of 17 month old male with a novel heterozygous mutation in TCF3
and previously unreported phenotype: absent circulating CD19+ B cells and significant
thrombocytopenia that improved with immunosuppression. There is also a family history
of two half-sisters who died during early infancy with similar phenotype.
The male index case was born with respiratory failure and generalized rash. At birth,
he had thrombocytopenia (24k/uL) and lymphopenia (465/uL). Initial absolute CD3 T
cell count was low (442/uL), yet he had normal thymic output. CD19+ B cells were <
5/uL and bone marrow biopsy revealed decreased hematagones, yet he had initially preserved
humoral function. He later developed low IgG levels requiring replacement.
Rapid genome sequencing revealed a heterozygous, predicted deleterious VOUS in TCF3,
in the second transactivation domain (c.1138 C>T, p Pro380Ser). His deceased half-sisters
and the father showed the same mutation: all 3 children had different mothers, suggesting
an autosomal dominant inheritance pattern. An infant sister was born 5 months ago
to the same parents as the index case, with a similar immunophenotype yet her TCF3
targeted gene sequencing is normal.
In the months after birth, the index case continued to require frequent platelet transfusions.
He demonstrated increased T cell activation with elevated levels of soluble IL-2R
(2510 pg/ml) and increased percentage of T cells expressing HLA-DR, CD95, CD25, CD71,
and CD69 activation markers. A 10-day trial of prednisone resulted in significant
improvement of his thrombocytopenia. He was switched to rapamycin, and his platelet
count has remained normal since then. His B cell counts and lymphopenia almost normalized
on rapamycin. His 5-month-old sister’s thrombocytopenia also resolved on rapamycin.
In this abstract, we present a case of an infant with absent B cells as well as severe
thrombocytopenia responsive to rapamycin. The lack of TCF3 mutation in the 5-month-old
sister calls into question the relevance of this mutation to the index case and his
older half-sisters despite the established role of TCF3 in early B cell development.
In collaboration with colleagues at NIH, studies are underway to evaluate if there
is a contribution of TCF3 to this family’s phenotype.
Keywords: Thrombocytopenia, TCF3, Absent B cells
Disclosures: Tamara Pozos is employed by Smiths Medical. All other authors had no
financial relationships to disclose.
(55) Skin disease related to NFKB1 abnormality improve by anti IL1 treatment
Elma Nievas, Hospital Pediátrico A Fleming1, Leonardo Mannino, n/a2, Natalia Tamburri,
n/a3, Diego Cristal, n/a4, Mikko Sepanenn, n/a5, Silvina Denita, n/a6
1Pediatric Inmunologist/Hospital Pediátrico A Fleming
2Pediatric Infetology/Hospital Pediatrico A Fleming
3Pediatric Surgery/Hospital Pediátrico A Fleming
4Peditric Nursery/Hospital Alexander Fleming
5Rare Disease and Pediatric Research Centers, Hospital for Children and Adolescents,
and Adult Immuno/Unit, Inflammation Center, University of Helsinki and HUS Helsinki
University Hospital, Helsinki, Finland
6Molecular Biologist/Biogenotec Lab
14 years old male, born from non consanguineous couple. Past history of deep necrotizing
ocular cellulitis at 2 years old associated to fever, neutrophilia and increased inflammatory
markers. Lesion’s microscopy: inflammatory infiltration, abscess areas, mononuclear
infiltration associated with medium vessels vasculitis, necrobiosis on epidermis.
Panniculitis with vasculitis assumed and managed as pyoderma gangrenosum
He was followed up for dermatologist for 8 years, and received several oral steroids
treatment after minimal traumatism because of pathergy phenomena.
On April 2019 was admitted on our Hospital because of prolonged fever of unknown etiology.
He presented abdominal pain, severe leukocytosis and increase CRP. Pneumonia was diagnosed
after chest-X-ray. After 3 days of intravenous antibiotics pleural effusion was observed
and thoracentesis was made without any result but presented complications: diaphragm
damage and secondary stomach ulcer by puncture. After gastroraphy, he developed dehiscence
of the abdominal skin incision as post-surgery gangrenosum pyoderma
CT chest scan was made after surgical complications: nodules, consolidation, bilateral
pleural effusion and ground glass opacity were the main findings. Laboratory assay:
ANA, ANCA and antiphospholipid antibody were negative. Normal level of Immunoglobulins
(IgG 1193, IgA 171, IgM213, IgE 40,8) Normal response to vaccines. Total Lymph: 3840
CD3:77% CD4:45% CD8: 29% CD19-20:12%. CD16-56: 11%. CD4/RA: 61% CD4/RO :39% CD19+
CD27 +: 9,6%. CD19+ C27+ IgD+: 5,3% CD19+CD27+IgD-: 4,3% . Normal DHR Test.Elevated
serum amyloid
Corticosteroid was indicated and continued after 6 weeks to high dose (2mg/kg/day)
with good results. In order to tapper steroids and look for long term mainstay treatment
anti Il 1 (canakinumab 4 mg / kg / dose each 4 weeks) was indicated suspecting autoinflammatory
disease.
Abdominal postsurgical incision pyoderma demonstrated improvement and the wound healed
after high dose of steroids, local care and canakinumab. Nowadays he is on anti -
IL 1 treatment and diaphragm damage resolved and stomach fistula healed. Pulmonary
abnormalities improved too. Inflammatory parameters normalized. Genetic test by NGS
was made and an NFKB1 p.(Arg156Pro) pathogenic variant was found, confirmed by sanger
sequencing. Genetic test on parents are ongoing.
Keywords: NFKB1, ANTI IL1, PYODERMA GANGRENOSUM
Disclosures: All authors indicated they had no financial relationships to disclose.
(56) Risk of TNF-alpha Inhibitor Use in Patients with Undiagnosed Mendelian Susceptibility
to Mycobacterial Disease
Jacqueline Squire, MD1, Jared Nelson, MD2, Lisa Brumble, MD1, Claudia Libertin, MD1,
Federico Laham, MD3, Jennifer Leiding, MD4
1Physician/Mayo Clinic
2Infectious Disease Fellow/Mayo Clinic
3Physician/Orlando Health Arnold Palmer Hospital for Children
4Associate Professor/Division of Allergy and Immunology, Department of Pediatrics,
University of South Florida at Johns Hopkins-All Children’s Hospital, St Petersburg,
FL
Tumor necrosis factor-alpha (TNF-alpha) is a proinflammatory cytokine that has become
a target for therapeutic blockade in the treatment of rheumatic and inflammatory conditions.
Infection, particularly reactivation of latent tuberculosis (TB) or nontuberculous
mycobacterium (NTM), is the most notable risk. We present two patients with undiagnosed
Mendelian susceptibility to mycobacterial disease (MSMD) that developed disseminated
mycobacterial infection following use of TNF-alpha inhibitors.
Case 1: A 4-year-old African American female presented with persistent fever and progressive
cervical lymphadenopathy. She was diagnosed with juvenile idiopathic arthritis a year
prior and was being treated with methotrexate and infliximab. On admission, she also
had a scalp abscess with osteolytic skull lesion. Skull biopsy showed acute osteomyelitis,
lymph node biopsies demonstrated non-caseating granulomas. All cultures grew Mycobacterium
avium complex (MAC). Genetic testing revealed a heterozygous pathogenic IFNGR1, c.819_822del
(p.Asn274Hisfs*7) mutation consistent with autosomal dominant IFNGR1 deficiency. Treatment
with anti-mycobacterial agents and IFN-gamma has led to substantial improvement.
Case 2: A 50-year-old Caucasian female presented with retroperitoneal lymphadenopathy,
splenomegaly, and right infrahilar pulmonary mass during evaluation for 50-pound weight
loss. Lymph node and infrahilar mass biopsy demonstrated necrotizing granulomas, cultures
negative. She was treated with prednisone and then infliximab for idiopathic granulomatous
disease. After starting infliximab, she developed panniculitis and worsening right
lower lobe pulmonary opacity, BAL positive for MAC. Immune evaluation demonstrated
panlymphopenia with markedly reduced NK cells 0-1 cells/mcL (ref:101-678 cells/mcL),
B-cells 6-10 cells/mcL (ref:99-527 cells/mcL), and monocytes .02x109/L (ref:0.26-0.81x109/L).
Genetic testing revealed heterozygous pathogenic mutation in GATA2, c.1192C>T (p.Arg398Trp).
Now improving on anti-mycobacterial treatment and undergoing evaluation for HCT.
Blockade of TNF-alpha is effective in treating inflammation associated with autoimmune
conditions. While generally well tolerated, there are known risks with use, most notably
TB or NTM infection. Complicating the diagnosis, disseminated mycobacterial infections
can mimic systemic inflammatory syndromes which can delay diagnosis and appropriate
treatment. Evaluation for underlying or latent infection prior to starting therapy
with TNF-alpha inhibitors is indicated. Underlying immune deficiency, particularly
MSMD, should be suspected in the right clinical context prior to initiating treatment
with TNF-alpha inhibitors due to the risks of disseminated, life-threatening mycobacterial
disease.
Keywords: Mendelian susceptibility to mycobacterial disease, TNF- alpha inhibitor,
Disseminated mycobacterial disease, GATA2, IFNGR1 deficiency
Disclosures: Federico Laham is an advisory board member of Tyme, Inc. Jennifer Leiding
is an advisory board member and received speaker honoraria from CSL Behring; an advisory
board member of Phamring; and received speaker honoriaria and a research grant from
Horizon Therapeutics. All other authors had no financial relationships to disclose.
(57) X-linked Hyper IgM Syndrome (HIGM): A novel pathogenic variant causing decreased
function of CD40L
Arjola Cosper, DO1, Rachel Eisenberg, MD2, Arye Rubinstein, MD PhD3
1Fellow In training/Albert Einstein College of Medicine/Children's Hospital at Montefiore
2Attending in Allergy and Immunology/Montefiore Medical Center
3Professor of Pediatrics, Microbiology and Immunology Attending in Medicine Chief
Division of Aller/Albert Einstein College of Medicine
X linked HIGM due to hemizygous pathogenic variants in CD40L present in the first
two years of life with recurrent upper and lower respiratory infections. Typical lab
findings include neutropenia and elevated IgM in the setting of low IgA and IgG consistent
with a defect in class switching.
An 18-month-old male presented with recurrent acute otitis media, sinusitis, and pneumonia.
Initial work up revealed an IgG of 333mg/dL, IgA of 5mg/dL and IgM of 122mg/dL with
no protective titers to measles, mumps, or rubella. B-cell phenotyping was notable
for increased naive B-cells, low class switched memory B-cells and decreased memory
B- cells. His infection burden and immunoglobulin levels did not improve over time
and replacement immunoglobulin was initiated at 4 years of age. A 207 gene primary
immunodeficiency panel (Invitae) was notable for a maternally inherited hemizygous
variant of uncertain significance (VUS) in CD40L c.373 C>T (p. His125Tyr). While this
missense substitution has not been observed in X-linked HIGM, in silico analysis all
suggested this variant to likely be disruptive. Functional validation showed decreased
expression of CD40L on 32% of CD4 stimulated T cells (normal range 86-98%). Additionally,
CD40-Ig FP stimulated, measuring the binding capability of CD40L protein, was decreased
to 29% (normal range 73-98%). Our patient’s milder phenotype can possibly be explained
by the finding of reduced instead of aberrant expression of CD40L. In addition, typically
CD40-Ig FP will not be able to bind mutated CD40L protein, however the variant in
our patient allowed for some function of CD40L. The variant was soon after reclassified
as pathogenic by Invitae.
HIGM due to CD40L pathogenic variants should be considered in any male patient presenting
with low IgG and normal or elevated IgM with recurrent infections. These patients
need to be followed for possible complications of abdominal tumors, PJP risk during
infancy and pure red cell aplasia when infected with parvovirus. In some cases, HSCT
(hematopoietic stem cell transplant) is performed however the risk/benefit assessment
may not be in favor in cases with milder phenotype of CD40L deficiency like our patient.
Keywords: Hyper IgM, CD40 Ligand, novel variant
Disclosures: All authors indicated they had no financial relationships to disclose.
(58) Post COVID-19 multisystem inflammatory syndrome in adults; a case series
Sibel Buabeng Atmaca, s.atmaca@erasmusmc.nl1, Jasper Schuurbiers, MD2, C.A. Den Uil,
MD3, V.A.S.H. Dalm, MD,Phd4, P.M. van Hagen, Proffesor4, K Caliskan, MD, Phd5, S.M.
Rombach, MD6
1Resident internal medicine/Erasmus Medical Centre
2resident intensive care medicine/Erasmus Medical Centre
3Intensivist-Cardiologist/Erasmus Medical Centre
4internist immunologist/Erasmus Medical Centre
5Cardiologist/Erasmus Medical Center
6Internist- immunologist/Erasmus Medical Center
Since the start of the COVID-19 pandemic multiple reports have been published about
a new disease entity called multisystem inflammatory syndrome in children (MIS-C).
The World Health Organization published the case definition of MIS-C as children and
adolescents younger than 19 years old, presenting with fever > 38°C for > 3 days,
multi organ (>2) ) life-threatening inflammation following SARS-CoV2 infection. Clinical
data about MIS in adults is rare. We present a descriptive study of five adult patients
with life-threatening cardiac insufficiency after COVID-19, meeting the criteria for
MIS-C turning the diagnosis into MIS-in adults (MIS-A).
We included 5 adults admitted at the intensive care unit of the Erasmus Medical Center,
25-58 years of age who otherwise met the case definition of MIS-C. Prior and during
treatment we performed routine blood test to monitor the course of cardiac damage
and systemic inflammation. These include, CRP, ferritin, sIL-2R, interleukin 6, NT-Pro-BNP
and Trop T. Cardiac function was monitored by ultrasound.
All patients were treated with intravenous immunoglobulins (IVIG) 2 g/kg bodyweight
and methylprednisolone 2 mg/kg bodyweight in addition to medication for hemodynamic
and cardiac support. In case of a good response we tapered MPS to zero within three
weeks. We also performed whole exome sequencing in order to identify genetic determinants
which may predict the development of MIS-A.
Within one week after start of treatment, routine inflammatory markers of all patients
decreased with 87-96% and cardiac function improved significantly on cardiac ultrasound.
Three patients could be discharged from the hospital after 7, 10 and 12 days after
diagnosis. They recovered completely without significant residual disease. One patient
had a prolonged hospital stay because of delayed recovery because of muscle weakness
and the other patient because of neurological complications after coronary artery
angiography.
The adult variant of MIS warrants early recognition and the start of high dose IVIG
and methylprednisolone treatment. This resulted in our series in rapid improvement
of cardiac function and systemic inflammatory parameters. WES results are pending,
hopefully these contribute to more insights in the genetic determinants of MIS-A.
Keywords: Case series, MIS-A, Sars-CoV-2, kawasaki like disease, intravenous immunoglobulins
(IVIG), methylprednisolone, cardiogenic shock, myocardial biopsy, COVID 19
Disclosures: V.A.S.H. Dalm has contracted research with CSL Behring and Takeda. P.M.
van Hagen has contracted research with CSL Behring and Takeda. All other authors had
no financial relationships to disclose.
(59) Fulminant Renal Failure in a Patient with Autosomal Dominant Hyper IgE Syndrome
Jason Moraczewski, MD1, Safia Nawaz, MD2, Tricia Lee, MD3
1Resident/Emory University School of Medicine/Children's Healthcare of Atlanta
2Fellow/Emory University School of Medicine/Children’s Healthcare of Atlanta
3Assistant Professor/Emory University School of Medicine/Children's Healthcare of
Atlanta
Hyper IgE syndrome (HIES) is a primary immunodeficiency characterized by elevated
serum IgE, recurrent bacterial pulmonary and cutaneous infections, eczema, and various
connective tissue and craniofacial anomalies. The autosomal dominant variant of HIES
is due to a loss of function (LOF) mutation in STAT3. Here we describe a 12-year-old
male with autosomal dominant HIES who presented with acute renal failure requiring
dialysis.
The patient was diagnosed in early childhood following multiple abscesses requiring
drainage and recurring episodes of pneumonia resulting in partial right upper lobectomy.
At age 8, he was diagnosed with cutaneous Fusarium solani and received intermittent
amphotericin B infusions for 6 months. This resulted in acute kidney injury with improvement
in renal function following completion of therapy. Two months prior to presentation
the patient was restarted on Bactrim prophylaxis, which he had previously tolerated.
At age 12, he presented to the ED with emesis, dizziness, and blood pressure of 151/105.
Laboratory workup revealed pancytopenia, hyperkalemia, hypocalcemia, hyperphosphatemia,
hyperparathyroidism, elevated BUN, and markedly elevated creatine at 16.8 mg/dL, prompting
concern for chronic kidney disease. Renal ultrasound revealed increased echogenicity
bilaterally with no evidence of obstruction. Renal biopsy revealed immune complex
deposition and immunofluorescence was positive for deposits of IgM, IgG, C1q, and
C3c. Autoimmune workup yielded positive ANA (1:80, speckled), low C3, and negative
dsDNA IgG, while elevated LDH, decreased haptoglobin, anemia, and absence of schistocytes
suggested autoimmune hemolytic anemia. Malignancy was ruled out with no masses visualized
on chest x-ray or abdominal ultrasound. The patient was stabilized following initiation
of dialysis for his end-stage renal disease.
The rare presentation of fulminant renal failure in a patient with HIES suggests immune
dysregulation as a primary contributing factor, but the correlation between STAT3
LOF and said dysregulation has only sparsely been alluded to in previous literature.
A small portion of patients with STAT3 LOF have been seen to present with a lupus-like
picture with predominant renal involvement. There may be a role for screening these
patients for lupus-like disease in an attempt to mitigate disease burden and allow
for targeted therapies.
Keywords: Hyper IgE, Renal failure, STAT3 LOF, Immune dysregulation
Disclosures: All authors indicated they had no financial relationships to disclose.
(60) Mass Cytometry Reveals Immune Cellular-Signaling Defects in Common Variable Immunodeficiency
with Granulomatous Lymphocytic Interstitial Lung Disease
Victor Lui
1, Ryan Baxter, MSc2, Amy Rymaszewski, PhD3, Shaoying Chen, MD3, Tusharkanti Ghosh,
PhD4, James Verbsky, MD, PhD5, John Routes, MD6, Elena Hsieh, MD7
1Student/University of Colorado Anschutz Medical Center
2Senior Professional Research Assistant/University of Colorado Anschutz Medical Center
3Research Associate/Medical College of Wisconsin
4Postdoctoral Fellow/University of Colorado Anschutz Medical Center
5Associate Professor of Pediatrics, Medicine, Microbiology and Immunology/Medical
College of Wisconsin
6Professor of Pediatrics, Medicine, Microbiology and Immunology/Medical College of
Wisconsin
7Assistant Professor/Department of Pediatrics, Section of Allergy and Immunology,
University of Colorado, Anschutz School of Medicine; Children’s Hospital Colorado;
Department of Immunology and Microbiology, University of Colorado, Anschutz School
of Medicine, Aurora, CO
Common Variable Immunodeficiency (CVID) is a clinical, immunological, and genetically
heterogenous primary immunodeficiency (PID) characterized by hypogammaglobulinemia,
failure to make specific antibodies, and recurrent infections. However, due to the
immune-dysregulation in CVID, non-infectious complications such as B cell lymphomas,
GI tract disorders, autoimmune cytopenias and granulomatous lymphocytic interstitial
lung disease (GLILD) are the most common causes of morbidity and mortality in this
disorder. The immunopathogenesis of GLILD, the pulmonary component of multisystemic
granulomatous and lymphoproliferative disorder, is poorly understood. To further investigate
the underlying immunological mechanisms leading to the development of GLILD within
CVID, we utilized mass cytometry to identify unique immune cellular and signaling
signatures from patients’ peripheral blood cells. We report that patients with CVID
(n=25) or CVID with GLILD (n=20) had increased frequency of HLADR+ CD4+ T cells, CD57+
CD8+ T cells, and CD21lo B cells in the periphery compared to healthy controls (n=25).
Within these cellular populations in CVID patients with GLILD, engagement of T and
B cell receptors (respectively) results in an asynchronous downstream signaling response
when compared to CVID patients without GLILD. In CVID patients with GLILD, CD21lo-B
cells show perturbed protein kinase B (Akt) and extracellular signal-regulated kinase
(ERK) activation, while HLADR+ CD4+ T cells and CD57+ CD8+ T cells display disrupted
activation of kinases most proximal to the antigen receptor. These findings likely
represent altered T/B receptor signaling responses in exhausted lymphocyte subsets
in these patient groups, and may contribute to our understanding of the mechanisms
of immune dysregulation in CVID with GLILD.
Keywords: Common Variable Immunodeficiency, Granulomatous Lymphocytic Interstitial
Lung Disease, Mass Cytometry
Disclosures: John Routes has contracted research with CSL Behring and Evolve Biologics.
Elena Hsieh is a consultant for Enzyvant. All other authors had no financial relationships
to disclose.
(61) A Case Report of Hyper-IgM syndrome with Normal Serum IgA Level
Ameera Bukhari
1, Amer Khojah, MD2
1PhD Student/Loyola University Chicago
2Attending Physician, Allergy, Immunology, and Rheumatology/Ann & Robert H. Lurie
Children's Hospital of Chicago/ Northwestern University Feinberg School of Medicine
CD40L deficiency is an X-linked primary immunodeficiency disorder representing the
most common form of hyper-IgM syndromes. CD40 and CD40L interaction is critical for
the initiation of T cell-dependent B cell class switching. Therefore, patients with
CD40L deficiency typically have no or low IgA and IgG. We present a case of CD40L
defect who had normal IgA.
A 20-month-old boy with a history of congenital subglottic stenosis who presented
with failure to thrive, developmental delay, recurrent fever, and oral ulcers. He
had a low-grade fever (100.4-101) almost every two weeks for the last few months with
recurrent mouth ulcers. He had four bilateral ear infections in the past six months
but no recent pneumonia or sinus infections. He also had intermittent watery, non-bloody
diarrhea lasting 2-3 days per episode with normal stools in between for many months.
He also has delayed motor function (although he was sitting at the age of 8 months,
he cannot walk yet) and speech delay. His laboratory evaluation was notable for intermittent
elevated CRP (0.3-21 mg/dl), intermittent neutropenia (ANC 190 /uL), anemia and negative
stool cryptosporidium Ag. His Immunoglobulin levels showed elevated IgM (397 mg/dl),
normal IgA (78 mg/dl) and low IgG (51 mg/dl). He has undetectable antibody response
Hib, tetanus, measles, and all streptococcus pneumonia serotypes. Whole exome testing
showed likely pathological hemizygotes variant in the CD40LG (c.674 T>C, P.L225S)
inherited from his mother. This variant has not been observed in large cohorts such
as Gnomad or ExAC. CD40L expression is markedly decreased on the stimulated T cell
( 5%, and the reference range is more than 85%) with intact ICOS expression.
Although hyper-IgM syndromes classically present with absent serum IgA and IgG due
to class switch defect, the diagnosis should not be excluded just because the patient
has a normal serum IgA level. Of note, T cell-independent B cells IgA class switch
has been reported in the intestinal mucosa after APRIL stimulation.
Keywords: Hyper-IgM syndrome, CD40L deficiency, class switching
Disclosures: All authors indicated they had no financial relationships to disclose.
(62) Increased detection of genetic mutations in patients with Common Variable Immunodeficiency
(CVID) and associated pulmonary involvement
Emily Haltigan, MD1, Zerka Wadood, MD2, Divya Patel, DO3, Diana Gomez-Manjarres, MD4,
Lyda Cuervo-Pardo, MD5
1Resident Physician/Department of Medicine, University of Florida
2Fellow/Division of Pulmonary, Critical Care and Sleep Medicine; University of Florida
3Clinical Assistant Professor/Division of Pulmonary, Critical Care and Sleep Medicine;
University of Florida
4Assistant Professor of Medicine/Division of Pulmonary, Critical Care and Sleep Medicine;
University of Florida
5Assistant Professor of Medicine/Division of Rheumatology, Allergy, and Clinical Immunology,
University of Florida
Common Variable Immunodeficiency (CVID) is the most common symptomatic immunodeficiency.
It is characterized by both B and T-cell abnormalities, predisposition to infections,
and noninfectious complications in in nearly 50% of patients. Pulmonary involvement
has been documented in up to 46% of cases. Even though etiology is still unknown,
CVID is considered a polygenic disorder, with multiple genes implicated in its pathogenesis.
Genetic testing is advocated in the evaluation of patients, as results may have implications
on diagnosis, prognosis, and treatment. The objective of this study is to characterize
common pulmonary manifestations and genetic mutations in patients with CVID.
A retrospective chart review of CVID patients evaluated at the University of Florida
between 2012 and 2019 was performed. Patients with diagnosis of primary CVID by consensus
from our immunology and pulmonary departments were included. We collected demographic,
clinical, physiological, radiographic, pathologic and genetic testing results.
Fifty patients were included in the analysis. Genetic testing data was available for
twenty patients. Pathogenic mutations were identified in 55%. Variants of unknown
significance were present in 70%. The most common genetic mutation identified was
TNFRSF13B (TACI mutation) in 20%. Lung parenchymal involvement on chest imaging was
present in 78% of patients. The most common CT findings were: nodules (38%), bronchiectasis
(32%), and ground glass opacities (22%). Eight patients had a lung biopsy. Pathology
showed lymphoid aggregates in most patients (78%). Granulomas and bronchiolitis were
also seen (44%).
We described characteristics of genetic mutations and pulmonary manifestations among
CVID patients at our institution. Prevalence of lung disease in this cohort emphasizes
the importance of screening asymptomatic patients with chest imaging for early detection.
Even though most cases of CVID have no clear associated genetic defect, and monogenic
causes are thought to account only for 10% of cases, our data documented pathogenic
mutations in 55% of cases. Genetic testing, especially in patients with pulmonary
involvement should be advocated, which could result in a higher yield. Efforts to
characterize disease phenotype may lead to early detection of organ involvement and
potentially allow for earlier intervention and improved outcomes.
Keywords: CVID, genetics, lung disease, immunodeficiency, PID, genetic testing
Disclosures: All authors indicated they had no financial relationships to disclose.
(63) Hyper IgM Syndrome in Toddler with 18p Deletion
Erin Dennis, MD1, Jason Caldwell, DO2
1Fellow PGY4/Wake Forest Baptist Medical Center
2Fellowship Director/Wake Forest Baptist Medical Center
An 18 month old male with 18p deletion presented following low immunoglobulin levels
in setting of history of previous chylothorax, worsening bronchiectasis, and recurrent
infections concerning for primary immunodeficiency. His immunoglobulin levels revealed
an IgG of < 75 , IgA of < 10, and IgM of 55 at 3 months of age in the setting of chylothorax.
Repeat immunoglobulins at 18 months old continued to demonstrate low IgG, undetectable
IgA and IgE, and normal IgM. Although the chylothorax resolved, he continued to show
abnormal antibody levels, as well as experience infections requiring hospitalization.
Given his picture, primary immunodeficiency is being considered, particularly Hyper
IgM Syndrome. Initial evaluation showed an absence of switched memory B cells. There
are relatively normal T, B, and NK cell populations. He did have protective titers
to tetanus and diphtheria, although maternal antibodies may still be present. His
streptococcal titers showed adequate response. The lymphocyte response to mitogens
was normal, but he had markedly reduced lymphocyte responses to both tetanus and Candida.
An assay to evaluate the presence of CD40L was normal. A literature search revealed
that none of the known genes associated with Hyper IgM Syndromes are located on chromosome
18 . (1)
While 18p deletion is associated with Selective IgA deficiency (2), this patient’s
immune pattern is concerning for a more significant immunodeficiency. It is likely
he has an unrelated primary immunodeficiency based on known gene associations with
Hyper IgM Syndrome. Phenotypically the patient has an immune evaluation that meets
the criteria for Hyper IgM Syndrome. Absent switched memory B cells supports this
diagnosis. His normal CD40L study suggests a mutation outside the CD40 or CD40L genes.
Genetic tests will help confirm this diagnosis as well as better classify his phenotype
for a more tailored treatment approach.
References: 1. Yazdani R, Fekrvand S, Shahkarami S, Azizi G, Moazzami B, Abolhassani
H, Aghamohammadi A. The hyper IgM syndromes: Epidemiology, pathogenesis, clinical
manifestations, diagnosis and management. Clin Immunol. 2019 Jan;198:19-30. doi: 10.1016/j.clim.2018.11.007.
Epub 2018 Nov 13.
2. Browning MJ. Specific polysaccharide antibody deficiency in chromosome 18p deletion
syndrome and immunoglobulin A deficiency. J Investig Allergol Clin Immunol. 2010;20(3):263-6.
Keywords: Hyper IgM Syndrome, 18 p deletion, chromosome abnormality, primary immunodeficiency,
chylothorax
Disclosures: All authors indicated they had no financial relationships to disclose.
(64)
Efficacy and safety of administration of cutaquig (16.5% IGSC) in pediatric patients
with primary immunodeficiencies (PI): Data from two phase 3 studies
Roger Kobayashi, MD1, Jose Fernando Mandujano, MD2, Syed Rehman, MD3, Ai Lan Kobayashi,
MD4, Bob Geng, MD5, Elisabeth Clodi, PhD6, Eva Turpel-Kantor, MD7, Sudhir Gupta, MD,
PhD8
1Allergist Immunologist/Allergy, Asthma, and Immunology Associates PC
2Pediatric Pulmonologist/Pediatric Pulmonary Associates of North Texas, P.A.
3Allergist Immunologist/Asthma and Allergy Center
4Allergist Immunologist/Midlands Pediatrics PC
5Allergist Immunologist/Rady's Children's Hospital San Diego
6Senior Global Medical Advisor/Octapharma PPG
7Clinical Project Manager/Octapharma Pharm. ProduduktionsgesmbH
8Professor of Medicine, Pathology & Laboratory Medicine, and Microbiology & Molecular
Genetics/University of California, Irvine
Cutaquig is a 16.5% immunoglobulin solution for subcutaneous administration, currently
approved for adult subjects with PI.
Two prospective, open-label, non-controlled, non-randomized, multicenter trials including
pediatric patients with PI have recently been completed.
The pivotal study (65 weeks long, NCT01888484) assessed the pharmacokinetics (PK),
efficacy and safety of Cutaquig in pediatric and adult patients with PI and was followed
by an extension study (NCT03907241) assessing the medium-to-long-term safety and efficacy
(max. treatment 168 weeks).
The pivotal study included 38 pediatric patients (76% male) in 3 subgroups: 12 young
children (aged 2 to 5yrs), 14 older children (6 to 11yrs) and 12 adolescents (12 to
16yrs). Ten pediatric subjects continued in the extension study (2 young, 4 older
children, 4 adolescents). Pediatric patients received a total of 3,283 cutaquig infusions.
PK data from 19 pediatric subjects were collected. Weekly cutaquig administration
resulted in flat PK profiles with lower fluctuations at steady state after cutaquig
administration than after IGIV. No patient had IgG trough levels below 5 g/L.
Clinical efficacy of cutaquig was confirmed by zero SBI (serious bacterial infection)
reported in pediatric patients in either study. Overall rate of infections was similar
across the age groups at between 2 and 4 infections/person-year in the pivotal study
with the highest rate in young children (4.2). In the 10 pediatric patients in the
extension study the rate of infections/person year was highest in the adolescent group
(2.9). Most common infections were respiratory infections. The number of days absent
from school/person-year was 8.5 in the youngest, 3 in older children and 4 days in
adolescents in the pivotal study. Similar results were seen in the extension study.
Cutaquig administration was well tolerated with no related serious adverse reactions
reported in pediatric patients in either study and 5 related adverse reactions in
both studies (none in the youngest subjects). Infusion site reactions were reported
in 25 (66%) pediatric patients during the pivotal study and in 7 (70%) in the extension
study (all except one of mild/moderate intensity).
Data from both studies demonstrate similar efficacy and safety of cutaquig administration
in pediatric patients as in adults.
Keywords: IgG, SCIG, Efficacy, subcutaneous, primary immune deficiency, pediatric
patient, safety, PI, immunoglobulin
Disclosures: Roger Kobayashi received speaker honoraria from IgNS and a research grant
and speaker honoraria from Octapharma. Syed Rehman received contracted research and
speaker honoraria from Astra Zeneca, Genentech, and Takeda; contracted research with
Kedrion, Novartis, Sagent, Sanofi, Takeda, and TEVA; speaker honoraria from GSK. Ai
Lan Kobayashi received a research grant from Octapharma. Bob Geng was an advisory
board member for Biocryst and received speaker honoraria from Grifols, GSK, Horizon,
Kedrion, Octapharma, Optinose, Regeneron, Sanofi, and Takeda; he was a consultant
for RMS. Elizabeth Clodi, Eva Turpel-Kantor are employees of Octapharma PPG. Sudhir
Gupta received research grants from Octapharma and Takeda. All other authors had no
financial relationships to disclose.
(65) Increased susceptibility to allergic and autoimmune diseases in patients with
activated phosphoinositide 3-kinase (PI3K) delta syndrome (APDS)
Stephanie Kubala, MD1, Marjohn Rasooly, MSN, CRNP2, Gulbu Uzel, MD3, Pamela Frischmeyer-Guerrerio,
MD, PhD4
1Clinical Allergy/Immunology Fellow/Laboratory of Allergic Diseases, National Institute
of Allergy and Infectious Diseases, NIH
2Family Nurse Practitioner/Laboratory of Allergic Diseases, National Institute of
Allergy and Infectious Diseases, NIH
3Physician scientist/Laboratory of Clinical Immunology and Microbiology, National
Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda,
Maryland, USA
4Chief/Laboratory of Allergic Diseases, National Institute of Allergy and Infectious
Diseases, NIH
Activated phosphoinositide 3-kinase (PI3K) delta syndrome (APDS) is caused by gain-of-function
mutations (GOF) in the genes PIK3CD and PIK3R1, encoding for the p110δ and p85 subunits
of phosphoinositide 3-kinase δ (PI3Kδ). Hyperactivation of the PI3K/AKT/mTOR/S6K pathway
leads to immune dysregulation, lymphoproliferation, and immunodeficiency. Additionally,
PI3K is a central regulator of mast cell, T follicular helper cell and Th2 cell function.
Therefore, we hypothesize that patients with APDS would be predisposed to allergic,
as well as autoimmune disease.
Thirty-seven patients (18 male; median age 17 years, range 6-54) with confirmed PI3K
activating mutations were evaluated in a prospective natural history study. Twenty-eight
patients had peripheral blood obtained to evaluate hematologic variables, immunoglobulins,
total and allergen specific IgE, and tryptase.
Thirty-two of the thirty-seven patients had a positive allergic history; 23 had allergic
rhinitis, 15 atopic dermatitis, 5 chronic urticaria, 1 chronic angioedema, and 16
physician-diagnosed asthma. Five patients had IgE-mediated food allergies with avoidance
encompassing peanuts, tree nuts, eggs, and milk. Five had biopsy-proven eosinophil-associated
gastrointestinal disorders. All patients denied contact dermatitis. Eleven patients
reported autoimmune disorders including granulomatosis with polyangiitis, ulcerative
colitis, hashimoto's, sjogren's, lupus, autoimmune hemolytic anemia, immune thrombocytopenic
purpura, and other immune cytopenias. White blood cell counts were within normal limits
(median 5.58 K/uL, range 2.12-15.05 K/uL) with absolute lymphocyte counts trending
low (median 1.28 K/uL, range 0.45-3.07 K/uL). Median total IgE and eosinophil counts
were within normal limits (20.3 IU/mL; range < 1–54276 IU/mL and 0.14 K/uL; range
0-1.84 K/uL, respectively) but varied widely. All other immunoglobulins were within
normal limits. Of the 16 patients who had vaccine titers drawn, 4 had decreased responses.
Median baseline serum tryptase level was 5 ng/ml (range 1.5-14.3 ng/ml). Seven out
of twenty-eight patients had detectable specific IgE to common food allergens. Patients
were most likely to be sensitive to milk (6 patients), egg (4 patients), peanut (3
patients), and wheat (3 patients). No patients were sensitized to finned fish or shellfish.
Patients with PI3K activating mutations exhibit an increased prevalence of atopic
and autoimmune disorders, demonstrating an important role for PI3K in tolerance development
in humans.
Keywords: PI3K, PIK3CD, APDS, allergy, autoimmunity
Disclosures: All authors indicated they had no financial relationships to disclose.
(66) Use of emapalumab and cyclophosphamide in a patient with X-linked lymphoproliferative
disease and EBV-associated hemophagocytic lymphohistiocytosis complicated by retinal
vasculitis
Sebastian Ochoa, MD1, Sameeya Ahmed-Winston, CPNP-PC2, Michael Keller, MD3, Blachy
Blachy Dávila Saldaña, MD4
1Clinical Fellow/Laboratory of Clinical Immunology and Microbiology, National Institute
of Allergy and Infectious Diseases/National Institutes of Health, Bethesda, MD, USA
2Pediatric Nurse Practitioner/Division of Blood and Marrow Transplantation, Children's
National Health System, Washington, DC, USA
3Pediatric Immunologist/Division of Allergy and Immunology, Children's National Health
System, Washington, DC, USA
4Pediatric Hematologist/Oncologist/Division of Blood and Marrow Transplantation, Children's
National Health System, Washington, DC, USA
A 15-year-old boy was admitted due to worsening fever, adenopathy, and splenomegaly
after diagnosis of infectious mononucleosis. Diagnostic workup showed cytopenias (absolute
neutrophil count of 0.3k/μL, platelets 83k/μL), AST 277 units/L, ALT 416 units/L,
ferritin 1832.6ng/mL, fibrinogen 144mg/dL, soluble CD25 1606 (NR <=1033pg/mL), and
borderline decreased NK cell activity. Bone marrow biopsy showed decreased marrow
cellularity and hemophagocytosis, thus meeting criteria for hemophagocytic lymphohistiocytosis
(HLH). Quantitative EBV polymerase chain reaction (PCR) analysis demonstrated 103,409
copies/mL. Cerebrospinal fluid (CSF) studies showed 25 WBCs/mm3 (86% lymphocytes,
14% monocytes) and CSF EBV PCR 11,137 copies/mL. Immunologic testing was notable for
normal IgG (1280mg/dL), elevated IgA (442mg/dL) and IgM (317mg/dL); elevated CD3 (2958,
NR 820-2035 cells/μL) and CD8 (2589, NR 262-864 cells/μL) and low CD4 (319, NR 527-1380
cells/μL) and NK cells (123, NR 160-390 cells/μL). Genetic analysis revealed a pathogenic
variant in chromosome X SH2DIA (c.23A>C, p.His8pro) and NK and CD8 SAP expression
by flow cytometry was undetectable, uncovering the diagnosis of X-linked lymphoproliferative
disease type 1 (XLP-1). He was treated for HLH with CNS disease with I.V. methylprednisolone
and etoposide, as well as intrathecal (IT) methotrexate (MTX) and methylprednisolone,
in addition to ganciclovir and rituximab. A search for a potential stem cell transplant
donor was initiated. Due to refractory disease and elevated CXCL9 (671 pg/mL, NR <=121pg/mL),
he was started on emapalumab 150mg (2.718 mg/kg) once weekly. Following 4 doses of
IT therapy and 5 doses of rituximab, he was continued on Decadron and emapalumab.
He had onset of retinal vasculitis prompting resumption of IT chemotherapy, addition
of cyclophosphamide, and an increase in emapalumab to twice weekly dosing, resulting
in clinical improvement, with minimal residual visual field loss. He underwent successful
hematopoietic stem cell transplant from a matched unrelated donor 6 months after initial
HLH diagnosis, which was complicated by EBV-PTLD, treated with rituximab and third-party
EBV-specific T-cell therapy. Retinal vasculitis is an uncommon manifestation of XLP-1,
and there are only a few cases reported in the literature. We report the use of emapalumab
and cyclophosphamide in a patient with XLP-1 and EBV-associated HLH complicated by
retinal vasculitis, resulting in clinical improvement.
Keywords: XLP-1, XLP, Duncan syndrome, SAP deficiency, Retinitis, Vasculitis, Emapalumab,
Cyclophosphamide, HLH, hemophagocytic lymphohistiocytosis
Disclosures: Sameeya Ahmed-Winston received speaker honoraria from Jazz Pharmaceuticals.
Michaek Keller is an advisory board member of Enzyvant. All other authors had no financial
relationships to disclose.
(67) Rituximab-induced Hypogammaglobulinemia and Infection Risk in Pediatric Patients
Roxane Labrosse, MD, MMSc1, Sara Barmettler, MD2, Beata Derfalvi, MD., PhD3, Annaliesse
Blincoe, MBChB4, Guilhem Cros, MD5, Jonathan Lacombe-Barrios, MD1, Julie Barsalou,
MD1, Nancy Yang, n/a6, Nora Alrumayyan, MD7, Jan Sinclair, MBChB4, Mei-Sing Ong, PhD8,
Carlos Camargo, MD/DrPH2, Jolan Walter, MD, PhD9, Elie Haddad, MD, Phd10
1Physician/CHU Sainte-Justine
2Physician/Massachusetts General Hospital
3Associate Professor/Dalhousie University/IWK Health Centre
4Physician/Starship Children’s Hospital
5Physician/Centre Hospitalier de l'Université de Montréal
6Clinical Research Coordinator II/Massachusetts General Hospital
7clinical fellow/Division of Immunology, Department of Paediatrics, Dalhousie University,
IWK Health Centre
8Assistant Professor/Harvard Medical School and Harvard Pilgrim Health Care Institute
9Division chief and associate professor/Johns Hopkins All Children’s Hospital; Department
of Pediatrics, Division of Allergy and Immunology, University of South Florida Morsani
College of Medicine
10Attending Physician/Immunology-Rheumatology Division, Department of Pediatrics,
University of Montreal
Rituximab (RTX) is a B-cell depleting agent used in B-cell malignancies and autoimmune
diseases. A subset of adult patients may develop prolonged and symptomatic hypogammaglobulinemia
following RTX. However, this phenomenon has not been well delineated in the pediatric
population.
Our objective was to determine the prevalence, risk factors and clinical significance
of hypogammaglobulinemia following RTX therapy in children.
We conducted a multi-center, retrospective cohort study and extracted clinical and
immunological data from pediatric patients who received RTX. Patients were excluded
if they had a prior diagnosis of primary immune deficiency (PID) or if they received
RTX after having undergone hematopoietic stem cell transplant (HSCT).
The cohort was comprised of 207 patients (median age 12.0 years). Compared to baseline
values, there was a significant increase in reported hypogammaglobulinemia post-RTX,
with an increase in prevalence of hypo-IgG (28.7% to 42.6%, p=0.009), hypo-IgA (11.1%
to 20.4%, p=0.02) and hypo-IgM (20.0% to 62.0%, p < 0.0001). Additionally, low IgG
levels at any time post-RTX were associated with a higher risk of serious infections
(34.4% vs 18.9%; OR 2.3, 95% CI 1.1-4.8, p=0.03). Persistent IgG hypogammaglobulinemia
(PH-IgG) was observed in 27 (26.7%) of 101 evaluable patients in whom IgG levels were
measured beyond a year after RTX initiation. Significant risk factors for PH-IgG included
low IgG and IgA levels pre-RTX and co-administration of prednisone. Nine patients
(4.3%) within the study were subsequently diagnosed with a PID, seven of whom received
RTX for autoimmune cytopenia. Genetic confirmation was present in 4 of the 9 patients
(44.4%).
In the largest pediatric cohort described thus far, we found that hypogammaglobulinemia
post-RTX was frequently diagnosed, and that low IgG levels were associated with a
significant increase in serious infections. Our results highlight the importance of
immunologic monitoring both before and after RTX therapy, and suggest that immunoglobulin
replacement therapy should be considered in these patients. Furthermore, underlying
PIDs were relatively common in children receiving RTX, particularly in those with
autoimmune cytopenia. In patients with a suspected PID, genetic testing may help distinguish
between iatrogenic (secondary) and primary immunodeficiency.
Keywords: rituximab, B-cell depleting therapy, hypogammaglobulinemia, infection, children,
primary immunodeficiency, secondary immunodeficiency, IgG, IgA, IgM
Disclosure:. Elie Haddad was a consultant for Jasper Therapeutics and Rocket Pharma
All other authors had no financial relationships to disclose
(68) Use Of Rituximab And Brentuximab Vedotin To Treat EBV-Associated Lymphoproliferative
Disease Resembling Classical Hodgkin Lymphoma In A Patient With Ataxia Telangiectasia
Joshua Goldman, MD1, Amer Heider, MD2, Thomas Michniacki, MD3
1Pediatric Hematology/Oncology Fellow/University of Michigan
2Associate Professor of Pathology/University of Michigan
3Clinical Assistant Professor/University of Michigan
Patients with DNA repair disorders, such as ataxia telangiectasia (AT), both are at
an increased risk for malignancy and experience low survival with standard cytotoxic
chemotherapy given increased treatment toxicity. Median survival for AT patients with
Hodgkin disease is approximately three months. We report novel use of rituximab and
brentuximab vedotin (BV) to treat an EBV-associated lymphoma resembling classical
Hodgkin disease in a patient with AT that resulted in prolonged overall survival compared
to standard therapy while maintaining a good quality of life.
A 14-year old with AT presented with fever, night sweats, and hypoxia. MR chest/abdomen
revealed pulmonary nodules, paratracheal/mediastinal adenopathy, and hepatic lesions.
Liver biopsy showed an EBV-associated lymphoproliferative disorder resembling classical
Hodgkin lymphoma with CD30+/CD20- cells (previously given rituximab dose for EBV viremia).
The patient’s family declined cytotoxic chemotherapy, so treatment was initiated with
rituximab 375 mg/m2 days 1/8/15/22 and BV 1.2 mg/kg days 1/8/15 mirroring a protocol
for immunocompromised adults with EBV+ and/or CD30+ lymphomas. A partial response
was noted following induction. Four additional weekly doses of 375 mg/m2 rituximab
were completed with BV therapy moved to a more traditional dosing regimen of 1.8 mg/kg
every 3 weeks. Given occurrence of peripheral neuropathy and exacerbation of the patient’s
baseline tremor, therapy was transitioned to maintenance cycles of dose-reduced BV
1.2 mg/kg q3weeks and rituximab 375 mg/m2 q6weeks. Therapy was additionally augmented
with prednisone 20 mg/m2 BID during Week 1 of Cycles 3-5. No convincing evidence of
lymphoma was noted following Cycle 7. Therapy was well tolerated other than neuropathic
pain managed with gabapentin and an episode of osteomyelitis. Unfortunately, the patient
then experienced disease progression and rising EBV titers after 9 months of therapy
and is attempting salvage therapy with additional chemotherapy-sparing agents.
Combination rituximab and brentuximab therapy should be considered for EBV+/CD30+
lymphomas in immunodeficient patients who poorly tolerate cytotoxic chemotherapy.
Table 1. Summary of administered therapy
Keywords: Primary immune deficiency, lymphoma, ataxia telangiectasia, rituximab, brentuximab,
EBV
Disclosure: All authors had no financial relationships to disclose
(69) Combined Immunodeficiency With Autoimmunity Due Rag1 Mutation In A Preschooler
With Systemic Lupus Erythematosus, Systemic Sclerosis, Antiphospholipid Syndrome,
Vitiligo And Cytomegalovirus Infection
Oscar Moreno-Laflor, MD1, Lyuva Ramirez-Devars, MD2, Omar Saucedo-Ramirez, MD3, Blanca
Del Rio-Navarro, MD, MSc4
1Allergy and Immunology fellow-in-training/Hospital Infantil de México
2Dermatology fellow in-training/Hospital Infantil de México
3Pediatric Allergy and Immunology/Hospital Infantil de México
4Pediatric Allergy and Immunology Training Program Director/Hospital Infantil de México
Immune dysregulation is emerging as a key feature of patients with human inborn error
of immunity. RAG mutations with higher residual recombination activity are more likely
to result in immune dysregulation and they have been identified in patients presenting
later in childhood or in young adulthood with combined immunodeficiency with granulomas
and/or autoimmunity (CID-G/AI).
METHODS : A 4 years and 5 months female infant with history of Vitiligo at 1 year
3 months old, Systemic Sclerosis (SSc) at 2 years 8 months old, Systemic Lupus Erythematosus
(Overlap syndrome SLE/SSc) at 3 years 7 months, Antiphospholipid Syndrome at 4 years
1 month old and asymptomatic cytomegalovirus infection. The mother has a history about
threatened miscarriage during pregnacy. The patient has not history about recurrent
or severe infections. Laboratory evaluation for human inborn errors of immunity was
made, lymphocyte subsets showed decreased T and B cells and normal count of NK cells:
CD3+ 374.66mm3, CD8+ 146.1mm3, CD4+ 214.12mm3, CD16/56 110.8mm3, CD19+ 82mm3, CD4+CD45RA
105.3mm3, CD4+CD45RO 108.34mm3, CD8+CD45RA 103.6mm3, CD8+CD45RO 42.37mm3, CD4:CD8
1.36. Serum immunoglobins with decreased IgA: IgA 24 mg/dl, IgM 140 mg/dl, IgG 1210
mg/dl, IgE 42.9 mg/dl. It was started monthly intravenous gammaglobulin (IVIG) therapy.
She is currently in treatment with mycophenolate mofetil, hydroxychloroquine, tocilizumab,
acetylsalicylic acid and antibiotic prophylaxis.
Whole exome secuencing revealed a missense variant in RAG1 gene: c.1822G>A, p.(Val608Met).
Exon 2/2. The tools that predict the effect of missense variants consider the change
observed in this patient is deleterious. The variant found in this patient is located
in the RNase H domain. The variant found in the patient is close to the active site,
alters the function of the RAG1-RAG2 complex, reducing its activity and, therefore,
the efficiency of the V(D)J recombination process.
RAG mutations show a diversity of clinical and immunological phenotypes. A broad range
of serum autoantibodies has been demonstrated in patients with CID-G/AI, which is
consistent with the diverse spectrum of clinical manifestations of autoimmunity. Our
patient is currently in the program for hematopoietic stem-cell transplantation. This
is the first case report about patient with four autoimmune diseases and primary inmunodeficiency.
Table 1: Lymphocytes subsets
Keywords: combined immunodeficiency, RAG mutation, Immune dysregulation, Vitiligo,
autoimmune disease
Disclosure: All authors had no financial relationships to disclose
(70) The clinical coarse and outcome of SARS-COVID 19 in patients with inborn error
of immunity , does it relate to the type of the immune defects
Roya Sherkat, M.D , Suspecialist1, Paria Bolourinejad, MD2, Negin Salemi, MD2, Farhoodeh
Rahmati, PHd3, Hamid Aria, PHd3, Mahdieh Azizi, PHd4, Mahbubeh Jafari, MSc2, Somayeh
Najafi, MSc2
1Associate Prof/Acquired Immunodeficiency Research Center, Isfahan University of Medical
Sciences , Isfahan , Iran
2Research Fellow/Acquired Immunodeficiency Research Center, Isfahan University of
Medical Sciences , Isfahan , Iran
3Research Fellow/Acquired Immunodeficiency Research Center, Immunology Department
, Isfahan University of Medical Sciences , Isfahan , Iran
4Research Fellow/Acquired Immunodeficiency Research Center, Immunology Department
,Isfahan University of Medical Sciences , Isfahan , Iran
There are still enigmas about the impact of SARS-CoV-2 infection in individuals with
inborn errors of immunity (IEI) and potential genetic effects on host immune response
that may leading to increased susceptibility to SARS-CoV-2 infection. Understanding
the pathways would help not only in unraveling disease pathogenesis, but also in suggesting
targets for therapy and prophylaxis. It seems risk factors predisposing to severe
disease and mortality in patients with IEI are related to the type of immune defects.
During a prospective study among our registry of IEI’s at Isfahan Immunodeficiency
Research Center,14 cases with COVID19 declared their primary symptoms through tele-visit
and clinical and immunological diagnosis made according to the PCR and laboratory
tests. The clinical courses, treatment, and outcome of SARS-CoV-2 infection were followed
in relation with the immunodeficiency disorders.
Among 14 patients, 7 (50%) were female, five patients (35.7%) suffer from Bruton Disease,
three (21.4%) Common Variable Immunodeficiency, two (14.3%) Combined Immunodeficiency
(CID), one (7.1%) Autosomal Recessive Hypogammaglobinemia, one (7.1%) CID with syndromic
features, one (7.1%) IgM deficient and one (7.1%) Severe Congenital Neutropenia and
the median age was 27 years. 10 (71.4%) patients were controlled and treated as outpatients
via remote management, 3 (21.4%) required ward hospitalization and oxygen administration
and one CID case (7.1%) admitted to the ICU without intensive ventilation.
This study showed IEI’s does not predispose all patients to severe COVID19 or related
mortality. Among enrolled patients 9 (64.2%) of patients experienced moderate infection
with satisfactory outcomes and 5(35.7%) suffered from severe COVID19 infection but
were handled well. It seems that the course of infection and appearance of real cytokine
storm is not the same as normal population but to find out about the best management
and therapy in IEI’s more study has to be planned.
Table 1: Summary of patients Manifestations
Keywords: inborn error in immunity, SARS - covid19, clinical presentations
Disclosure: All authors had no financial relationships to disclose
(71) The evaluation of radiosensitivity in patients with STAT3 deficiency
Sukru Cekic, n/a1, Huzeyfe Huriyet, n/a2, Melika Hortoglu, n/a2, Safa Baris, MD3,
Ayşe Metin, MD4, Ahmet Ozen, MD3, Elif Karakoç Aydıner, MD5, Candan Abakay, n/a6,
Tolga Cavas, n/a7, Sara Kilic, n/a8
1Dr./Uludag University Faculty of Medicine, Pediatric Immunology
2Research Asistant/Faculty of Sciences and Letters, Biology Department, Uludag University,
Bursa, Turkey.
3Professor of Pediatrics/Marmara University Hospital, Department of Pediatric Immunology
and Allergy
4Prof. Dr./Ankara City Hospital
5professor/Marmara University Pendik Research and Training Hospital
6Assoc. Prof./Department of Radiation Oncology, Uludag University Faculty of Medicine,
Bursa, Turkey.
7Prof./Faculty of Sciences and Letters, Biology Department, Uludag University, Bursa,
Turkey.
8Prof./Uludag University Faculty of Medicine, Pediatric Immunology
The aberrant activity of STAT3, a powerful oncogene, leads to persistent activation
of upstream regulators, such as cytokine and growth factor receptors. Therefore, a
number of oncogenic pathways is up-regulated to promote aggressive tumor growth and
migration. A relationship between abnormal STAT3 expression and increased radiosensitivity
has been reported.
The aim was to investigate the radiation sensitivity in patients with STAT3 deficiency.
Twelve patients diagnosed with STAT3 LOF and age/sex-matched 11 healthy control were
included in the study. Radiation sensitivity was evaluated by the Comet test. In the
Comet test; the extents of spontaneous (0Gy), initial (immediately after 2Gy irradiation),
and residual (2h after irradiation) DNA damage was evaluated by quantifying the Olive
Tail Moment under an epifluorescence microscope using a computer-based image analysis
system (Kameram Komet Module, Micro System Ltd. Turkey). Experiments were performed
in triplicate and the obtained data is presented as the mean ± standard error of the
mean.
The female/male ratio in patients STAT3 LOF is 1.4 (7/5). The age of patients diagnosed
with STAT3 LOF is between 3.6 and 40.6 years old. There is no patient who did not
develop cancer. The lymphocyte subgroups and immunoglobulin levels were normal in
all patients. However, 10 of 12 patients with STAT3 LOF were treated with IVIG because
of recurrent skin and pulmonary infections. The extent of initial DNA damage induced
by 2Gy radiation was significantly higher in the patient’s lymphocytes in comparison
with the control. On the other hand, after 2h of recovery, the level of DNA damage
was low in control cells, whereas the extent of DNA damage increased in the patient’s
lymphocytes, compared to initial values (table 1, and figure 1).
DNA repair mechanisms were impaired in all patients compared to controls. Impaired
tumor immunosurveillance contributes to the high rate of malignancies in PID. Genetic
defects that lead to impairment in DNA repair mechanisms can result in cancer. In
this study, we showed an impairment in the DNA repair mechanisms in patients with
LOF-STAT3 defects. This is the first study to disclose the increase sensitivity to
radiation in these patient groups.
Table 1. The differences between Olive Tail Moments of patients with STAT3 LOF and
healthy controls
Figure 1. The Olive Tail Moment of STAT3 LOF patients and healthy controls
Keywords: STAT3 LOF, Cancer, Radiosensitivity, DNA impairment
Disclosure: All authors had no financial relationships to disclose
(72) The phenomenon of high cytotoxic activity of the T-cell component of the immune
system in patients with X-linked agammaglobulinemia
Lyudmila Sizyakina, PhD1, Irina Andreeva, PhD2
1Head. Dep. Clinical Immunology and Allergology/Rostov State Medical University
2professor of the Department of Clinical Immunology and Allergology/Rostov State Medical
University
Primary immunodeficiency is an ideal natural model for studying the possibilities
of functioning of the immune system with a defect of one of its links. In this regard,
the primary immunodeficiency of the humoral type,which allows to evaluate the potential
of the cell-based system in the whole is very informative. The analysis of the examination
results of patients with X-linked agammaglobulinemia (XLA) was carried out to reveal
the features of the functioning of the T-cell component of the adaptive immune response
in the conditions of genetic antibody disorder.
12 men at the age of 10-25 years were under the supervision. The disease debuted in
all patients in the first year of life and bacterial infections of the respiratory
tract became a clinical manifestation. The diagnosis was confirmed by the detection
of a genetic defect of BTK and/or a characteristic family history. The results of
immunological testing after the detection of XLA before the replacement therapy were
analyzed.
Expression of surface receptors and intracellular lymphocyte proteins were studied
by flow cytometry. Healthy blood donors were examined as a comparison group. In patients
with XLA an increase in the number of mature T-lymphocytes was revealed (91,40±2,5%,
in the control 68.88±0.38%, p=0.03). The increase in the total pool of T- cells was
mediated by increase of CD8+effectors (40.80±3.44%, in the control of 21.88 ±0.33%,
p=0.001) with the strengthening of their cytolytic resources (CD8+Gr+ 32.60±3.84,
in control of 9.38 ±2.21% , p < 0.0001). Changes in CD4+T-cells are associated with
a decrease in the peripheral circulation of part of naive CD4+CD45RA+lymphocytes (12.6±5.3%,
in the control 29.2±6.1%) and CD4+CD25+FoxP3+Treg (0.40±0.01%, in the control 1.3±0.3%,
p=0.001).
Thus, the genetically determined absence of mature B-cells and complete antibody genesis
contributes to the increase of quantitative and functional parameters of T-effectors
of adaptive immunity with the involvement of immunoregulatory mechanisms which support
their high potential.
Keywords: X-linked agammaglobulinemia, T-cells, immunoregulatory mechanisms
Disclosure: All authors had no financial relationships to disclose
(73) Second tier test options in newborn screening for inborn errors of immunity
Maartje Blom, MD1, Ingrid Pico-Knijnenburg, n/a2, Sandra Imholz, n/a3, Janika Schulze,
Phd4, Jeannette Werner, Phd5, Mirjam van der Burg, PhD6
1Clinical Researcher/Leiden University Medical Center (LUMC)
2Research technician/Leiden University Medical Center (LUMC)
3Research technician/National Institute for Public Health and the Environment (RIVM)
4Senior Scientist/Epiume GmbH
5Scientist/Epiume GmbH
6Associate Professor Primary Immunodeficiencies/Leiden University Medical Center (LUMC)
Newborn screening (NBS) for severe combined immunodeficiency (SCID) and X-linked agammaglobulinemia
(XLA) are based on the detection of indirect markers for newly formed T-lymphocytes
i.e. T-cell receptor excision circles (TRECs) and B-lymphocytes i.e. kappa-deleting
recombination excision circles (KRECS). There is a range of neonatal disorders and
conditions that lead to low T- and/or B-lymphocytes around birth, causing NBS for
SCID and XLA to be accompanied by secondary findings and false positive referrals.
The main objective was to explore different second tier options after TREC/KREC analysis
in order to reduce the number of secondary findings, increase the positive predictive
value for NBS for SCID/XLA and reduce the emotional impact for parents that is associated
with a referral procedure.
NBS cards of newborns with low TRECs (N=56) and KRECs (N=110) measured with the SPOT-it
kit (ImmunoIVD) were analyzed with a second TREC/KREC assay (NeoMDx PerkinElmer).
Epigenetic immune cell counting (Epimune GmbH) based on unique DNA methylation markers
was used for relative quantification of CD3+ T-cells and B-cells in NBS cards of healthy
controls (N=311), newborns with low TRECs (N=58) and low KRECs (N=103). DNA was isolated
for TREC region sequencing from NBS cards of healthy controls (N=12), idiopathic lymphocytopenia
cases (N=4) and false positive referrals (N=8).
When analyzed with the second TREC/KREC assay, 25/56 newborns with low TRECs and 16/110
newborns with low KRECs had TREC/KREC levels above cut-off. With epigenetic qPCR,
15/58 newborns with low TRECs and 18/103 newborns with low KRECs had relative T-cell/B-cell
counts within the 99.9% CI ellipse of healthy controls. A SNP was found in the TREC
region of four false positive cases (14-22475276-G-T (GRCh38)) leading to a primer/probe
mismatch and no TREC amplification with the SPOT-it kit.
All second tier options have the potential to reduce the number of referrals and secondary
findings in NBS for SCID and XLA. Second tier testing with NGS with a SCID gene panel
or BTK gene analysis are currently being explored as well. Sensitivity, specificity,
costs, feasibility for the screening laboratories and throughput time should be further
evaluated before second tier options can be implemented.
Keywords: second tier test, newborn screening, inborn errors of immunity, SCID, XLA,
TRECs, KRECs, epigenetic immune cell counting, sequencing
Disclosure: All authors had no financial relationships to disclose
(74) A Heterozygous Pathogenic Mutation in FOXN1 in a patient with CVID
Michell Lozano Chinga, MD1, John Bohnsack, MD2, Angelica Putnam, MD3
1Pediatric Hematology-Oncology Fellow/University of Utah
2Professor and Chief - Division of Allergy and Immunology/University of Utah
3Associate Professor - Pathology/Department of Pathology, University of Utah, Salt
Lake City, UT, USA
FOXN1 heterozygous mutations have been associated to thymic hypoplasia and T-cell
lymphopenia. We report a case of a female teenager with CVID and mild T-cell lymphopenia
found to have a pathogenic heterozygous FOXN1 mutation.
A 16-year-old female presented with an enlarging left neck mass and shortness of breath
with exertion. Her medical history was remarkable for one episode of warm AIHA that
resolved with prednisone. PE showed splenomegaly in addition to cervical and supraclavicular
lymphadenopathy. Her CBC exhibited mild leukopenia with lymphopenia. CT of the neck
and chest showed cervical, supraclavicular and mediastinal lymphadenopathy, and multiple
pulmonary nodules. Biopsy of the cervical lymphadenopathy showed non-caseating granulomas.
Cultures were negative, as was PCR for bacterial, fungal, and mycobacterial RNA. PFTs
were consistent with mild persistent asthma.
Additional workup included low CD3, low normal CD4 and CD8 cells, low CD45RA, absent
class-switched memory and increased transitional B-cells, with associated diffuse
hypogammaglobulinemia. All IgG subclasses were low except for IgG3. Serum antibodies
to pneumococcal polysaccharide, diphtheria and tetanus toxoids, and rubeola were below
protective levels. The absolute number of peripheral blood T-regs were normal. ANA
and ANCA were negative, and serum ACE was normal. Fluid obtained by BAL was negative
for malignancy, Aspergillus species and pneumocystis by PCR, and culture was negative
for routine pathogens, Legionella, Nocardia and AFB.
The InVitae 207 gene Immunodeficiency panel showed a pathogenic heterozygous mutation
in FOXN1 gene, exon 4, c.823del (p.Ser275Profs*27) and heterozygous VUS in LYST and
VPS13B.
The patient was diagnosed with CVID with lymphocytic interstitial lung disease and
granulomatous lymphadenopathy. She is being treated with scIG replacement, inhaled
albuterol and budesonide.
CVID is characterized by impaired B cell function with secondary hypogammaglobulinemia
and variable defects in T cell function. Homozygous LOF FOXN1 mutations cause SCID
with alopecia, while heterozygous LOF FOXN1 is associated with thymic hypoplasia,
nail dystrophy and T-cell lymphopenia. There are no reports describing CVID in patients
with FOXN1 mutation and only one patient has been described to have autoimmunity.
Our patient has immunologic features of CVID. We suspect that her heteroxygous LOF
in FOXN1 contributes to her immunologic phenotype.
Keywords: common variable immunodeficiency, FOXN1 mutation, lymphopenia
Disclosure: John Bohnsack has ownership interst in General Electric. All other authors
had no financial relationships to disclose.
(75) Hypomorphic phenotype of XLA a Case Report
Cristina Vo, MD1, Stephen McGeady, MD2
1First year Allergy/Immunology fellow/Thomas Jefferson University and Nemours Children's
Hospital
2Attending physician/Thomas Jefferson University and Nemours Children's Hospital
X-linked agammaglobulinemia (XLA) occurs 1 in 200,000 individuals (1), and results
from mutations of Bruton’s tyrosine kinase (BTK) (1). The defect prevents precursor
B cells in the bone marrow from forming mature B-lymphocytes, capable of differentiating
into antibody producing plasma cells resulting in greatly diminished levels of all
immunoglobulin isotypes (2). Individuals with XLA are susceptible to invasive encapsulated
bacteria (2).
A 5 year old male presented with 2 episodes of bacterial pneumonia, one complicated
by streptococcus pneumococcal bacteremia, skin abscess requiring drainage, and recurrent
viral infections. Immune evaluation at 6 years of age revealed decreased CD19+ cells
with an absolute count of 4 cells/mcL (normal 310 – 1120) and a CD19 percentage of
0% (normal 14-33). At age 6 years there was no detectable antibody to diphtheria,
tetanus, or pneumococcal antigens but normal quantitative immunoglobulins. At 7 years
old, he had normal IgG, elevated IgA 756mg/dL (normal 89-559), and low IgM 12 mg/dL
(normal 24-98) and persistently low absolute CD19 count of 3 cells/mcL (normal 270-860).
Following vaccine boosters for tetanus, diphtheria, and 23 pneumococcal serotypes,
there was a normal recall response to tetanus, but no response to diphtheria and protective
antibody titers to 6/23 pneumococcal serotypes. Genetic testing revealed a c.-31+5G>A
mutation, in the BTK gene which was reported to be of unknown clinical significance.
Flow cytometry for BTK expression was not possible in B cells due to the low numbers,
but showed diminished monocyte expression (MFI =1.5 vs. normal control MFI= 5.05).
He was also found to be heterozygous for UNC93B. The BTK mutation, greatly diminished
B cell numbers, weak antibody responses and clinical history strongly suggestive of
antibody deficiency, are felt likely to be due to the mutation of BTK resulting in
a hypomorphic phenotype of XLA. Normal levels of IgG and IgA, with low IgM have been
described in patients with hypomorphic mutations of BTK (3). The association of mutations
in BTK with a UNC93B mutation, is previously unreported to our knowledge, but might
suggest unusual susceptibility to herpesvirus meningoencephalitis. The BTK mutation
in this patient has previously been reported in Korean patients with XLA(4).
Keywords: Hypomorphic phenotype of XLA, Bruton’s tyrosine kinase, UNC93B mutation,
antibody deficiency
Disclosure: All authors had no financial relationships to disclose
(76) X-linked CGD Presenting with Candida lusitaniae Fungemia and Hemophagocytic Lymphohistiocytosis
Nivedita Muralidhar, MD1, Mia Chandler, MD, MPH2, Alicia Johnston, MD3
1Clincial Fellow/Boston Children's Hospital
2Clinical Fellow/Boston Children's Hospital
3Infectious Disease Attending Physician/Boston Children's Hospital
Chronic granulomatous disease (CGD) results from defective neutrophil and monocyte
bacterial and fungal killing associated with mutations in NADPH oxidase including
CYBB that results in X-linked CGD. Excessive cytokine release may lead to hemophagocytic
lymphohistiocytosis (HLH) and this can be associated with infection. We report two
infants with X-linked CGD presenting with Candida lusitaniae fungemia and HLH.
Case 1: A 5 wo term male presented with fever, diarrhea and rash. Labs revealed elevated
inflammatory markers and transaminases. Blood cultures grew C. lusitaniae. The patient
developed pancytopenia, adenopathy, hepatosplenomegaly, hyperferritinemia, and elevated
soluble IL2 consistent with HLH. Dihydro-rhodamine assay showed no neutrophil oxidative
burst. CYBB sequencing revealed a hemizygous mutation: c.253-8A>G or IVS3-8A>G. He
was treated with liposomal amphotericin, caspofungin, decadron and IVIG with clearance
of candidemia and resolution of HLH. The patient underwent a single allele HLA-B mismatched
unrelated donor HSCT at 10 mo with peripheral blood chimerism demonstrating 97% donor
engraftment and neutrophil oxidative index (NOI) of 275 (nl >100) in all neutrophils.
Case 2: A 6 wo term male presented with fever, bloody diarrhea, mesenteric adenopathy
and splenomegaly. Pancytopenia, hyperferritinemia, elevated inflammatory markers,
transaminases, and soluble IL2, CXCL9, and IL18 led to a diagnosis of HLH. IVIG and
anakinra were initiated. Up-trending ferritin prompted the addition of decadron and
emapalumab. Blood cultures grew C. lusitaniae. Emapalumab was held and liposomal amphotericin,
micafungin and fluconazole were initiated. WES revealed a variant in CYBB: c.469C>T,
p.R157X resulting in a nonsense mutation and the NOI was 1. Fungemia resolved after
daily granulocyte infusions, however HLH persisted. Treatment with ruxolitinib led
to clinical improvement and HSCT is planned.
C. lusitaniae represents 1-2% of all candida infections. While C. lusitaniae sepsis
has been reported in very premature infants; it is rare in term infants without risk
factors. Five cases of CGD and C. lusitaniae have been reported; two were fatal. Fourteen
patients with CGD and HLH have been reported; including one infant with C. lusitaniae
fungemia and HLH. We report two additional cases. C. lusitaniae fungemia and/or HLH
in an infant without known risk factors should prompt an evaluation for CGD.
Keywords: Chronic Granulomatous Disease, Candida Lusitaniae, Primary Immunodeficiency,
Fungemia, Hemophagocytic lymphohistiocytosis
Disclosure: All authors had no financial relationships to disclose
(77) Prolidase deficiency, a rare inborn error of immunity, presents with different
phenotypes, immunological features, and proposed treatment modalities in twins
Beata Derfalvi, MD., PhD1, Nora Alrumayyan, MD2, Sarah M McAlpine, PhD3, Thomas Issekutz,
MD4, Drew Slauenwhite, PhD5, Adam M Huber, MD4, Zaiping Liu, MD6
1associate Professor/Dalhousie University/IWK Health Centre
2clinical Fellow/Division Of Immunology, Department Of Paediatrics, Dalhousie University,
IWK Health Centre
3research Associate/Division Of Immunology, Department Of Paediatrics, Dalhousie University,
IWK Health Centre
4professor/Division Of Immunology, Department Of Paediatrics, Dalhousie University,
IWK Health Centre
5postdoctoral Fellow/Department Of Paediatrics, Dalhousie University, IWK Health Centre
6associate Professor/Division Of Clinical Biochemistry & Maritime Newborn Screening,
Department Of Pathology And Laboratory Medicine, Dalhousie University, IWK Health
Centre
Prolidase deficiency (PD) is an autosomal recessive disorder of defective collagen
synthesis caused by mutations in the PEPD gene encoding the enzyme prolidase D. PD
typically presents with recurrent infections, intellectual disabilities, dysmorphic
features, splenomegaly, and increased proline metabolites in urine. PD was recently
classified under the immune dysregulation subgroup within inborn errors of immunity,
however, detailed immunological assessments have not been reported. PD is also characterized
as a “lupus-mimic” with intractable skin ulceration and systemic autoimmunity; thrombocytopenia,
hypocomplementemia, and hypergammaglobulinemia are frequent laboratory findings. Standard
therapies for PD have not yet been described.
We report teenage twin females of non-consanguineous asymptomatic carrier parents
exhibiting variable severity of the phenotype caused by novel compound heterozygous
mutations (c.977G>A, c.550C>T; premature stop codons) in the PEPD gene discovered
using PID panel NGS. Clinically, twin A presented with more severe disease phenotype,
including elevated inflammatory parameters, thrombocytopenia, autoimmune thyroiditis,
and “livedoid vasculopathy”, characterized by debilitating skin ulceration that prevented
ambulation for a year. Twin B has atopic symptoms of allergic rhinitis, eczema and
asthma, and recently painful skin ulceration. Both patients have slightly dysmorphic
facial features, learning difficulties, recurrent upper respiratory tract infections
(URTI) and massive imidodipeptiduria. Immunological assessment revealed low memory
B cell counts with IgG2 subclass deficiency and normal antibody responses to vaccines.
Lupus specific autoantibodies were not present. In twin A, regulatory T (Treg) cell
counts were low, possibly contributing to the more severe inflammatory symptoms. In
both patients, lymphocyte proliferation was normal, whereas NK cell cytotoxicity was
low in twin B. Both patients have MBL complement deficiency, possibly contributing
to the frequent URTI. Both twins had normal serum amyloid A, but highly increased
plasma IL-18 levels. A new therapeutic regimen included immunomodulatory IVIG, microcirculation-improving
low-molecular-weight heparin, red cell filterability increasing pentoxifylline, and
collagen synthesis cofactor vitamin C combined with topical proline and tacrolimus,
leading to resolution of twin A’s skin ulcers, allowing her to walk again.
PD may feature defects in memory B cells and Tregs. Profoundly high IL-18 plasma levels
suggest underlying autoinflammatory processes. Ulcer improvement has been seen with
the current regimen.
Keywords: prolidase deficiency, inborn error of immunity, immune dysregulation, ulcer
Disclosure: Beata Derfalvi has contracted research with CSL Behring and is an advisory
board member of SOBI. All other authors had no financial relationships to disclose
(78) Dupilumab successfully controls severe eczema in a child with hyper-IgE syndrome:
a case report
Tejas Joshi, B.S.1, Sara Anvari, MD2, Meera Gupta, MD3, Carla Davis, MD4, Joud Hajjar,
MD5
1Medical Student/Baylor College of Medicine
2Assistant Professor/Baylor College of Medicine
3Associate Professor/Baylor College of Medicine
4Professor/Baylor College of Medicine
5Assistant Professor of Immunology, Allergy, and Rheumatology/Baylor College of Medicine
Managing the severe atopic manifestations in Hyper-IgE syndromes (HIES) is challenging.
Although dupilumab has been approved to treat severe asthma and atopic dermatitis,
its effectiveness in HIES is unknown, especially in children. We present the case
of a child with HIES who achieved remarkable control of his eczema and recurrent skin
infections with dupilumab.
Our patient is a 12-year-old Caucasian male. He developed eczema in infancy, which
became severe at 8-years, with a scoring atopic dermatitis (SCORAD) score of 91.7/103.
Despite excellent skincare, he developed multiple Staphylococcus aureus skin infections,
requiring systemic antibiotics and hospitalizations. He also developed herpes simplex
skin infections and recurrent generalized lymphadenopathy. Furthermore, he experienced
vernal keratoconjunctivitis of both eyes requiring amniotic membrane transplantation.
Labs showed elevated IgE (>50,000 kU/L), normal IgG/A/M levels, and normal responses
to protein/polysaccharide-based vaccines. He had occasional lymphocytosis with normal
lymphocyte subsets, and low-normal intracellular IL-17 in CD4+T-cells upon stimulation.
Chromosomal Microarray Analysis showed a gain of 9p24.3 involving the dedicator of
cytokinesis 8 (DOCK8) gene, of unclear significance. DOCK8 protein expression on peripheral
blood mononuclear cells was normal. Trio whole exome sequencing revealed a heterozygous
c.7339C>T (p.Arg2447Ter) change in the Filaggrin gene inherited from father. Although
genetic workup was not definitive, our patient’s clinical phenotype is that of HIES
and not simply severe eczema and atopy.
Treatment regimen included cyclosporine 2-3 mg/kg, trimethoprim/sulfamethoxazole,
and omalizumab 300 mg. The latter provided skin improvement, but our patient developed
anaphylaxis. He was also started on intravenous immunoglobulin 1g/kg, which helped
decrease infections and recurrent lymphadenitis. At 12-years, he was started on dupilumab
300 mg subcutaneously every 2 weeks, which led to considerable improvement in his
skin infections and eczema (SCORAD score of 23.95/103). IgE levels decreased to 5,820
IU/mL, and CD4+T-cell induction of intracellular IL-17 normalized (Table 1). Moreover,
he no longer needed systemic steroids, and his growth chart improved significantly.
Our case suggests that dupilumab might be used to treat the severe atopic symptoms
seen in HIES. The steroids sparing effect led to improved patient’s symptoms, quality
of life, and growth.
Table 1: Humoral immunity panel and CD4 T cell induction of intracellular IL-17 both
before and after treatment: patient had elevated IgE levels but normal IgG/M/A and
normal responses to protein and polysaccharide-based vaccines prior to treatment.
Patient showed markedly reduced IgE levels following treatment. Also, treatment led
to normalization of CD4 T cell induction of intracellular IL-17 following stimulation.
Abbreviations: IgE, immunoglobulin E; IgG, immunoglobulin G; IgM, immunoglobulin M;
IgA, immunoglobulin A
Keywords: Hyper IgE syndrome (HIES), dupilumab, eczema, primary immunodeficiency
Disclosure: Meera Gupta is an advisory board member of Sanofi Genzyme. Joud Hajjar
received research grants from Amplimmune, Arcus Biosciences, ARMO BioSciences, Atterocor/Millendo,
Baxalta, BMS, Calithera Biosciences, Chao Physician-Scientist Foundation, CytomX Therapeutics,
Eli Lilly, EMD Serono, Healios Onc, Immune Deficiency Foundation, ImmuneOncia, Incyte,
Jeffrey Modell Foundation, Karyopharm, Kymab, MedImmune, Merck, National Cancer Institute,
NeoImmuneTech, Neon Therapeutics, Novartis, OncoSec KEYNOTE-695, Pfizer, PsiOxus,
Regeneron, Surface Oncology, The Texams Medical Center Digestive Diseases Center and
Top Alliance; she was an Advisory Board member of Alfaisal University, Genome & Company,
Horizon, and Pharming. All other authors had no financial relationships to disclose
(79) Global T-cell lymphopenia and hypogammaglobulinemia in a 15-month-old patient
with Takenouchi-Kosaki syndrome (CDC42 mutation)
Lydia Zhang, MD1, Jean Jacques De Bruycker, MD2, Yves Pastore, MD3, Jean-François
Soucy, M.D.4, Marie-Paule Morin, M.D.. Ph.D.5, Elie Haddad, MD, PhD5
1Fellow-in-Training/McGill University
2Assistant clinical professor, division of Pediatric Immunology and Rhumatology/CHU
Sainte-Justine
3Associate Professor in Pediatrics, department of pediatrics, hematology-oncology
division/Centre hospitalier universitaire Sainte-Justine
4Attending Physician/Genetic Division, Department of Pediatrics, University of Montreal
5Attending physician/Immunology-Rheumatology Division, Department of Pediatrics, University
of Montreal
Human CDC42, an intracellular member of the Rho-family GTPases, is a small GTPase
that is highly conserved among eukaryotes and plays a crucial role for cell cycle
development and actin cytoskeleton formation as it acts as a regulator of cell polarity.
While there is a growing evidence of genotype-phenotype correlation, more data are
needed to better characterize the role of CDC42 mutations on immune system dysfunction.
Here, we describe a case of Takenouchi-Kosaki syndrome presenting with transposition
of the great arteries, microcephaly and club feet. Arterial switch post-operative
course was complicated by a sternal wound dehiscence but no infectious complications.
Additionally, neutropenia and global T-cell lymphopenia with decreased numbers of
recent thymic migrant cells and hypogammaglobulinemia were present without thrombocytopenia.
Whole genome sequencing was pursued after a normal CGH array and revealed a de novo
mutation (NM_001791.3: c.68 A>G p.Tyr23Cys) in CDC42 affecting the N-terminal α-helix,
corresponding to Takenouchi-Kosaki Syndrome. This mutation is known to cause an amino
acid substitution at the highly conserved Tyr23 position, which is part of a cavity
on the CDC42 surface that accommodates the CDC42/RAC-interacting binding motif that
allows binding to effector proteins such as TAK1, WASP and FMNL2. PAK1 is responsible
for cell motility and contraction, WASP is important for cell migration and cell cycle
progression, whereas FMNL2 has a role in cell division, cell polarity and migration.
This mutation can therefore explain the various clinical manifestations of our patient,
including the absence of thrombocytopenia. However, the associated T-cell lymphopenia
is not typical of the described amino acid substitution Tyr23 in the literature. In
our patient, global T-cell lymphopenia with decreased numbers of recent thymic migrant
cells could have been worsened by a partial thymectomy during cardiac surgery.
This report suggests that even with a better knowledge of phenotype-genotype correlation,
close follow up in immunology clinic is warranted to address indication of pneumocystis
pneumonia prophylaxis and immune globulin replacement treatment.
Keywords: CDC42, Takenouchi-Kosaki Syndrome, Congenital cardiac defect, Microcephaly,
T-cell lymphopenia, Hypogammaglobulinemia
Disclosure: Yves Pastore has contracted research with Novartis and Principia, and
is an advisory board member of Pfizer. Elie Haddad is a consultant with Jasper Therapeutics
and Rocket Pharma. All other authors had no financial relationships to disclose
(80) Severe Congenital Neutropenia due to G6PC3 Deficiency with Autoinflammatory Complications
Monica Bray, MD1, MaiLan Nguyen, MD2
1Fellow Physician/Baylor College of Medicine
2Assistant Professor/Baylor College of Medicine
Severe congenital neutropenia (SCN) due to pathogenic variants in glucose-6-phosphatase
catalytic subunit 3 (G6PC3) have been associated with the extra-hematopoietic features
of cardiac abnormalities, urogenital malformation, and venous angiectasis. Patients
typically present in infancy with failure to thrive and severe infections. A French
cohort of 14 patients revealed 3 with diagnoses of inflammatory bowel disease (IBD)
and 2 patients with polyarthritis. We aim to add to the existing body of knowledge
of autoinflammatory conditions that can be associated with pathogenic variants in
G6PC3.
The patient is a 4-year-old Hispanic male with a history of prematurity (born at 34
weeks gestation) and atrial septal defect. He required hospitalization at birth for
respiratory distress and at 5 months of age for failure to thrive. He was admitted
3 times at 6 months of age for recurrent infectious myositis. On third admission it
was noted that his absolute neutrophil count (ANC) had been low since birth and he
was diagnosed with SCN. He was started on G-CSF with normalization of his ANC. Genetic
testing confirmed inherited compound heterozygous pathogenic variants in G6PC3: c.210delC
(p.F71fs) and c.778G>C (p.G260R). His weight improved from < 0.01 percentile to the
50th percentile by 1 year of age. From age 3 to 4, his weight decreased from the 50th
percentile to the 10th percentile. At 4 years of age, he developed fatigue, abdominal
pain, anorexia, oral ulcers, and splenomegaly. Bone marrow biopsy was negative for
malignancy. He was referred to gastroenterology for the poor weight gain and intermittent
abdominal pain. Biopsies from colonoscopy revealed surface erosion with reactive lymphonodular
hyperplasia and were not consistent with IBD. He was also noted to have a persistent
bilateral ankle swelling and limited range of motion, which was confirmed by rheumatology
to be consistent with inflammatory arthritis. The bilateral ankle arthritis did not
resolve with intra-articular steroid injections, so the decision was made to start
adalimumab and methotrexate. His care team is also hopeful this treatment regimen
may benefit his non-specific colonic inflammation. This case report demonstrates increasing
recognition that autoinflammatory conditions can complicate primary immunodeficiency.
Figure 1. Absolute Neutrophil Count Over Time
Keywords: autoinflammatory, severe congenital neutropenia, immune dysregulation, rheumatology,
arthritis
Disclosure: All authors indicated they had no financial relationships to disclose.
(81) Atypical presentation of T-/B+/NK+ SCID with Omenn-like phenotype attributable
to a hemizygous variant in IL2RG
Abigail Lang, MD1, Nashmia Qamar, DO2, Aaruni Khanolkar, MBBS, PhD3, Kai Lee Yap,
PhD3, Aisha Ahmed, MD4, Amer Khojah, MD5
1Fellow Physician/Ann and Robert H. Lurie Children's Hospital of Chicago
2Attending Physician/Ann and Robert H. Lurie Children's Hospital of Chicago
3Assistant Professor/Ann and Robert H. Lurie Children's Hospital of Chicago
4Attending Physician, Allergy and Immunology/Ann and Robert H Lurie Children's Hospital
of Chicago
5Attending Physician, Allergy, Immunology, and Rheumatology/Ann & Robert H. Lurie
Children's Hospital of Chicago/ Northwestern University Feinberg School of Medicine
Defects in interleukin-2 receptor gamma (IL2RG) lead to X-linked severe combined immunodeficiency
(SCID). The common gamma chain is utilized by multiple interleukin receptors important
for T and NK cell survival, and defects typically lead to T-/B+/NK- SCID phenotype.
We present a case of T-/B+/NK+ SCID with Omenn-like phenotype attributable to a hemizygous
variant in IL2RG.
Case Report: A full-term Caucasian male born to non-consanguineous parents was evaluated
after Illinois newborn screen was positive for SCID with 0 TRECs/μL. The infant was
transferred to the NICU for poor feeding and diffuse erythematous desquamating rash.
The initial complete blood count demonstrated white blood cell count of 21.7 103/μL
[reference range (RR): 9.4-34.4 103/μL], eosinophil count of 9.76 103/μL (RR: 0-2.04
103/μL), and lymphocyte count of 1.085 103/μL (RR: 3.38-15.64 103/μL). Flow cytometry
demonstrated T cell lymphopenia (CD3 count: 763/mm3, RR: 1375-7129/mm3), elevated
B cells (CD19 count: 1687/mm3, RR: 104-1448/mm3) and elevated NK cells (CD3-CD16/CD56
count: 642/mm3, RR: 60-434/mm3). T cell subsets demonstrated a predominance of memory
CD4 T cells with absent naïve T cells and recent thymic emigrants. Lymphocyte proliferation
to PHA was sub-optimal, and NK cell function was reduced by lytic assay. TCR V-beta
repertoire analysis revealed polyclonal T cells, and chimerism studies ruled out maternal
engraftment.
Expedited genetic testing for a gene subset (CD247, CD3D, CD3E, CORO1A, IL7R, PTPRC)
associated with T-/B+/NK+ SCID was negative. An expanded panel revealed a likely pathologic
hemizygous variant in IL2RG (NM_000206.2, p.Tyr125Cys, c.374A>G). Flow cytometry demonstrated
normal expression of CD127 (IL-7R) and CD132 (common gamma chain). Functional assays
showed reduced STAT-5 phosphorylation after stimulation with IL-2, 7, and 15 consistent
with common gamma chain defect.
Treatment with corticosteroids and cyclosporine resulted in normalization of eosinophilia
and rash. The infant underwent a matched unrelated hematopoietic stem cell transplantation
without major complications.
We present a case of atypical T-/B+/NK+ SCID with Omenn-like phenotype attributable
to a hemizygous missense variant in IL2RG. The hypomorphic variant likely contributed
to normal NK cell number with abnormal function. This case highlights the need for
rapid genetic diagnostics followed by functional testing to confirm variant pathogenicity.
Keywords: Severe Combined Immunodeficiency, SCID, Omenn's syndrome, IL-2 receptor,
Common gamma chain
Disclosure: All authors indicated they had no financial relationships to disclose.
(82) First reported complete C6 deficiency in Chinese patients
Valerie Chiang, MBBS1, WILLIAM WONG, PHD2, EVELYN LEUNG, MSc3, ELAINE AU, MBBS; MRCP;
FHKCP; FHKAM; FRCPA; FHKCPath; FHKAM; D (ABMLI)4, PHILIP LI, MBBS, MRes(Med), PDipID,
MRCP, FHKCP, FHKAM5
1Resident/Queen Mary Hospital, Hospital Authority
2Scientific Officer/Queen Mary Hospital, Hospital Authority
3Medical Technologist/Queen Mary Hospital, Hospital Authority
4Consultant/Queen Mary Hospital, Hospital Authority
5Clinical Assistant Professor/The University Of Hong Kong
Complete C6 deficiency (C6Q0) is a rare primary immunodeficiency leading to increased
susceptibility to recurrent Neisseria infections. Patients with C6Q0 have mostly been
reported in individuals of African ancestry previously, but never in Chinese. We identify
the first Chinese patients with C6Q0 through family screening of an index case presenting
with recurrent Neisseria meningitis with septicaemia.
Three C6Q0 patients had near‐absent C6 levels, and absent CH50/AH50 activity. Genetic
testing identified them to be compound heterozygous for two nonsense mutations in
the C6 gene: NM_000065.4:c.1786C>T (p.Arg596Ter) and NM_000065.4:c.1816C>T (p.Arg606Ter).
Neither mutations have been reported to be pathogenic previously. Two other family
members who were heterozygous for either only p.Arg596Ter or p.Arg606Ter had intermediate
C6 levels but preserved CH50/AH50 activity. These two loss‐of‐function mutations showed
a strong genotype–phenotype correlation in C6 levels; both nonsense mutations likely
lead to abolishment of C6 protein level and function.
We demonstrate that heterozygous family members with subtotal C6 levels had preserved
complement haemolytic function and demonstrate a threshold effect of C6 protein level.
In this study, even about half the level of normal C6 levels was sufficient to maintain
normal haemolytic activity as demonstrated by normal CH50/AH50 assays (i.e. a threshold
effect of C6 protein level). These single heterozygotes develop C6SD without the classical
predisposition to recurrent meningococcal disease seen in C6Q0.
A high prevalence of C6 deficiency has been reported among African Americans. In South
Africa, where C6Q0 seems most prevalent, four common frameshift defects in the C6
gene account for the vast majority of cases. To the best of our knowledge, this is
the first pedigree with C6Q0 deficiency reported in Chinese and the first TCC deficiency
reported in Hong Kong. It is likely that C6Q0 patients of different ethnic and geographic
backgrounds carry distinct mutations, hence the significance in detecting these two
mutations in our reported pedigree. It is likely that the genetic causes of C6Q0 (and
other PIDs) in Chinese may vary significantly compared with other populations and
highlights the importance of future immunology studies dedicated to specific ethnicities.
Figure 1: Family tree and summary of C6 genotypes
Keywords: c6, complement, deficiency, neisseria, immunodeficiency, chinese, pedigree
Disclosure: All authors indicated they had no financial relationships to disclose.
(83) Clinical Outcomes of SARS-CoV2 infection in STAT3 Deficiency
Muhammad Khalid, MD1, Amanda Urban, CRNP2, Dirk Darnell, RN3, Alexandra Freeman, MD4
1Clinical Fellow/National Institute of Allergy and Infectious Diseases, National Institute
of Health
2Nurse Practitioner/Clinical Research Directorate, Frederick National Laboratory for
Cancer Research
3Senior Clinical Research Nurse/National Institute of Allergy and Infectious Diseases,
National Institute of Health
4Director, Primary Immune Deficiency Clinic/Laboratory of Clinical Immunology and
Microbiology, National Institute of Allergy and Infectious Diseases, National Institute
of Health
With the continued global spread of SARS-CoV2, we continue to learn immunological
responses and clinical outcomes in immunocompetent hosts. Our understanding is far
more limited in patients with an underlying immune dysregulation.
The objective is to describe clinical outcomes of SARS-CoV2 infection in patients
with HyperIgE immunophenotype due to STAT3 loss of function (LOF) mutations.
We tele-interviewed five patients with confirmed or clinically suspected SARS-CoV2
infection and assessed for nature, duration, and severity of symptoms.
All patients had confirmed STAT3 LOF and were on antimicrobial prophylaxis during
the period of SARS-CoV2 infection. Two patients had SARS-CoV2 PCR confirmed infection,
and three had suspected disease with a PCR-positive household family contact and compatible
symptoms. Four of these five patients suffered from mild disease and fully recovered.
They ranged in age from 14-45 years and included three males. Two had underlying mild
parenchymal lung disease. Symptoms included fever, myalgias, fatigue, congestion,
cough, dyspnea on exertion, diarrhea, anosmia, and ageusia. The duration of symptoms
ranged from 6 to 20 days, except one patient had persistent fatigue for additional
21 days. One patient received additional antibiotics due to clinical worsening with
resultant improvement.
One of the 5 patients suffered from fatal disease. This patient was a 41-year-old
male who also had history of severe bronchiectasis with chronic Pseudomonas colonization,
smoking history, coronary artery aneurysm with focal area of cardiac hypokinesis,
hypertension, prolonged corticosteroid therapy, and class-1 obesity. He was admitted
to the hospital after 2 days of fever and shortness of breath and was found to be
SARS-CoV2 PCR-positive. He subsequently developed hypoxic respiratory failure with
Pseudomonas pulmonary infection, requiring mechanical ventilation and blood pressure
support, further complicated by kidney failure. Despite treatment with broad-spectrum
antibiotics and corticosteroids, he died after 26 days of illness.
While four of five patients with STAT3 LOF completely recovered, one patient with
additional co-morbidities and bacterial co-infection succumbed to COVID-19. This underscores
the need for research to understand differences in immunological responses when compared
to the healthy population.
Figure 1: Duration and outcomes of COVID-19 illness in patients with underlying HyperIgE
Syndrome due to STAT 3 Loss of function.
Keywords: STAT3 Loss of Function, SARS-CoV2, HyperIgE Syndrome, COVID-19
Disclosure: All authors indicated they had no financial relationships to disclose.
(84) Infodemiological study on primary immunodeficiency disorders: A global report
Umair Ahmed Bargir, MBBS,DCP1, Manisha Madkaikar, MD2
1Clinical Scientist/ICMR-National Institute of Immunohaematology
2Director/ICMR National Institute of Immunohaematology
Primary immunodeficiency disorder (PID) now known as inborn errors of immunity is
a group of more than 430 monogenic defects presenting with a wide phenotype from recurrent
infections to autoimmune, autoinflammatory, and other immune dysregulatory features.
Infodemiological studies apply user-generated data from various search engines and
social media to analyze and explore the trend of different diseases and to speculate
human behaviour towards distinct health topics. We investigated a Google Trends (GT)
based approach to monitor selected PID globally. Relative search volume for ‘Severe
Combined Immunodeficiency Disorder’ (SCID), ‘Ataxia-Telangiectasia’ (AT), ‘Digeorge
Syndrome’ (DGS), ‘Hyper IgE Syndrome’ (HIGE), ‘Common Variable Immunodeficiency Disorder’
(CVID), ‘Chronic Granulomatous Disease’ (CGD), ‘Hemophagocytic Lymphohistiocytosis’
(HLH), ‘Familial Mediterranean Fever’ (FMF), ‘Hyper IgD syndrome’ (HIGD) and ‘PFAPA
Syndrome’ disorders was extracted from Google Trends since its inception till 30 June
2020 to study the trend and across different countries. We also analysed the number
of publications published per year using Web of Science. Our analysis shows a decreasing
trend for SCID, AT, HIGE, CGD, and HIGD and an increasing trend for DGS, HLH, and
PFAPA syndrome. No trend was observed for CVID. The peaks observed for seasonality
signify the importance of awareness programs and educational conferences. The geographical
distribution of different PID matches with the search interest. We report for the
first time an infodemiological study on PIDs with a global perspective. GT acts as
a valuable tool to understand the trend and seasonality and geographical distribution
based on the search interest of different PIDs. This may help in tracing the impact
of awareness programs and advocacy measures to promote newborn screening.
Figure 1: Search interest expressed as relative search volumes. A Trend for SCID.
B, Trend for AT. C, Trend for DGS. D, Trend for HIGE (X=RSV, Y=Year)
Figure 2: Choropleth maps for relative search volumes of A, SCID. B, AT. C, DGS. D,
HIGE
Figure 3: No of publications per year for A-SCID, B-AT, C-DGS, D- HIGE
Keywords: Infodemiology, Google Trends, SCID, Primary immunodeficiency disorders,
Time series analysis, Forecast
Disclosure: All authors indicated they had no financial relationships to disclose.
(85) Effects of HDAC activity modulation on disease pathogenesis in mice infected
with Influenza – implications for rheumatic disease interventions
Milena Leseva, PhD1, Lora Simeonova, PhD2, Kalin Stoyanov, MD1, Petya Dimitrova, PhD3
1Researcher/The Stephan Angeloff Institute of Microbiology, Laboratory of Experimental
Immunotherapy
2Assistant Professor/The Stephan Angeloff Institute of Microbiology, Laboratory of
Experimental chemotherapy of Influenza
3Associate Professor/The Stephan Angeloff Institute of Microbiology, Laboratory of
Experimental chemotherapy of Influenza
HDACs are epigenetic regulators with a role in infection, inflammation and autoimmunity.
Their inhibition or activation can alter the host’s response to infection, but the
specific effects on flu pathogenesis remain largely unexplored. Sirtuins, classified
as class III HDACs, target a remarkably large set of proteins and are involved in
numerous cellular processes with an impact on immune cell activity and function: from
transcriptional and metabolic regulation, to cell differentiation. We are interested
in new therapeutic approaches for rheumatoid arthritis (RA). Because patients with
RA are susceptible to infections, we are focused on RA complicated by the flu. We
have observed that modulation of Sirt1 activity alleviates joint swelling and inflammation
in mouse models of RA in part through ligand-CXCR2 pathways, mobilization of neutrophils
from the bone marrow and reduced cartilage destruction. Based on our data and on reports
that sirtuins have a conserved anti-viral activity, we hypothesized that SRT2183 -
an activator specific for Sirt1 – can be used for treating both RA and infections
with Influenza. SRT2183 was administered subcutaneously at different doses, selected
for their protective effects against RA-mediated inflammation and joint tissue damage.
We used an adapted IAV H3N2 virus in two different experimental settings: high- and
low-multiplicity of infection. Treatment with SRT2183 in the context of a severe infection
did not alleviate the disease; it did not increase survival time, nor did it decrease
the lung viral titers. On the contrary, lung tissue damage was exacerbated in mice
treated with SRT2183 compared to controls treated with oseltamivir, a clinically relevant
anti-viral. This effect was dose-dependent. Moreover, we observed a massive infiltration
of mature neutrophils in the bronchoalveolar lavage of SRT2183 – treated infected
mice. However, during a mild infection low-dose SRT2183 treatment exhibited some protective
effect by extending the mean survival time by 1.2 days compared to controls.
Activation of Sirt1 using natural or synthetic compounds can be beneficial for RA
complicated with the flu. However, it should be done with caution, especially during
the flu season, since the effects depend on the severity of the infection.
Project funding from Bulgarian National Science Fund (DN11/5_2017).
Keywords: Rheumatoid arthritis, Influenza, autoimmunity, innate immunity, infection,
sirtuins, Sirt1
Disclosure: All authors indicated they had no financial relationships to disclose.
(86) The other side of the coin: immunodysregulation in primary immunodeficiency.
Analysis of the United States Immunodeficiency Network (USIDNET) database
Maria Chitty Lopez, MD1, Rahul Mhaskar, MPH, PhD2, Hannah Wright, MSPH3, Rebecca Marsh,
MD4, Elizabeth Garabedian, RN, MSLS5, Ramsay Fuleihan, MD6, Kathleen Sullivan, MD,
PhD7, Jennifer Leiding, MD8
1Physician Fellow/Division of Allergy and Immunology, Department of Pediatrics, University
of South Florida, Tampa, FL, USA
2Director of College of Medicine Office of Research/Center for Evidence Based Medicine
and Health Outcomes Research, USF Morsani College of Medicine, Tampa, Florida
3Research Data Analyst/The United States Immunodeficiency Network (USIDNET)
4Attending Physician/Division of Bone Marrow Transplantation and Immune Deficiency,
Cincinnati Children’s Hospital Medical Center
5Research Nurse/Office of the Clinical Director, National Human Genome Research Institute,
NIH, Bethesda, MD
6Professor of Pediatrics/Division of Allergy and Immunology, Department of Pediatrics,
Columbia University, New York, NY, USA
7Professor of Pediatrics, Chief of the Division of Allergy and Immunology/The Children’s
Hospital of Philadelphia, Philadelphia, PA, USA
8Associate Professor/Division of Allergy and Immunology, Department of Pediatrics,
University of South Florida at Johns Hopkins-All Children’s Hospital, St Petersburg,
FL
Substantial effort has been devoted to characterizing infectious susceptibility in
patients with primary immunodeficiencies diseases (PIDD). Immunodysregulation, autoimmunity,
and auto-inflammation are increasingly identified as major PIDD features. We aim to
describe the frequency of immunodysregulatory conditions in a large US PIDD cohort.
The USIDNET is a national research consortium with 43 contributing academic and private
centers (Figure1). Data from PIDD patients is collected in a registry after obtaining
informed consent. Patients were grouped by their diagnosis according to the IUIS 2019
classification (Table1). Immunodysregulatory conditions were categorized by affected
organ system by investigators (Table2). The frequency of immunodysregulatory conditions
and organ systems affected were determined within each IUIS category. Association
between immunodysregulatory conditions and survival was investigated using Chi-square
or Fisher’s exact test.
4,182 subjects with a diagnosis of PIDD were identified. Median-age-of diagnosis and
death (n=259) were 8 and 17years respectively. Male:female ratio was 1.2:1. Of surviving
patients (n=3.672), 57.8% had ≥1 organ systems affected; 9.4% had ≥3 affected. Within
IUIS categories, the most common systems affected were respiratory (30.6%), integumentary
(19.3%), gastrointestinal (18.4%), immune (13.9%), and hematopoietic (11.5%). The
most frequent IUIS categories to have immunodysregulatory conditions associated were
Diseases of Immune Dysregulation (76.4%), and Defects of the Innate Immune System
(73.0%). Specific conditions segregated within IUIS categories: hematologic dyscrasias
(34.3%) were most common within Diseases of Immune Dysregulation, gastrointestinal
conditions (32.5%) within Congenital Defects of Phagocytes, and respiratory conditions
(38.1%) within Predominantly Antibody Deficiency. Immunodysregulatory conditions affecting
cardiovascular (p=0.014), endocrine (p=0.046), gastrointestinal (p < 0.0001), hematopoietic
(p < 0.0001), and immune systems (p < 0.0001), were associated with death. Within
each organ system affected, specific immunodysregulatory conditions were associated
with worse survival (Table3).
More than half of patients within the USIDNET PIDD cohort had immunodysregulatory
conditions associated with their diagnosis. Hematologic, GI, and respiratory conditions
had the most negative effect on survival. This large cohort of patients was predominantly
contributed by academic centers which may have influenced the observations, towards
more severe phenotypes. Given the high frequency of immunodysregulatory features,
recognition of autoimmunity and auto-inflammatory symptoms should be used to guide
surveillance strategies for recognition and diagnosis of PIDD.
Keywords: primary immunodeficiencies diseases, immunodysregulation, PIDD, autoimmunity,
auto-inflammation, USIDNET
Disclosure: Jennifer Leiding is an advisory board member and received speaker honoraria
from CSL Behring; an advisory board member of Phamring; and received speaker honoriaria
and a research grant from Horizon Therapeutics.
(87) Damaging Biallelic Variants in OSBPL5 are associated with T Cell Immunodeficiency
in Humans
Amy O'Connell, MD, PhD1, Monica Wojcik, MD, PhD2, Casie Genetti, MS, CGC3, Jill Madden,
PhD, MSc, CGC3, David Breault, MD, PhD4, Pankaj Agrawal, MBBS, MMSC4
1Assistant Professor/Boston Children's Hospital/Harvard Medical School
2Instructor/Boston Children's Hopsital/Harvard Medical School
3Genetic Counselor/Boston Children's Hospital
4Associate Professor/Boston Children's Hospital/Harvard Medical School
A male infant born at 24 5/7 weeks’ gestation developed fulminant necrotizing enterocolitis
with multiple intestinal perforations at 1 month of age. The patient initially had
normal TREC levels. He had a prolonged recovery complicated by Candida parapsilosis
septicemia. At 4 months the patient died from Klebsiella sepsis. Immunologic testing
at 41 weeks postmenstrual age demonstrated CD4 and CD8 T cell lymphopenia despite
a normal absolute lymphocyte count with diminished naïve CD4 T cells, a paucity of
switched memory B cells, and an abnormal T cell response to stimulation with anti-CD3
and Candida antigen. The family was enrolled in a research study and trio exome sequencing
was performed. Bialellic missense variants in OSBPL5 were identified in a conserved
region. The maternal variant, (GRCh38) chr11:3129108 C>T; c.41G>A, p.Cys14Tyr (NM_020896.4)
is absent from gnomAD. The paternal variant (GRCh38) chr11:3129114 G>T; c.35C>A, p.Ser12Tyr
(NM_020896.4) had a gnomAD frequency of 0.000019 (one heterozygote in gnomAD exomes,
none in genomes). Both variants were assessed by in silico predictors as probably
damaging (Polyphen), damaging (SIFT), and disease causing (Mutation Taster). OSBPL5
encodes ORP5, which is known to be involved in membrane trafficking of phospholipids
and has been sown to be important for cell proliferation via mTOR signaling. Highest
tissue mRNA expression of ORP5 is found in the liver and spleen, and CD4 T cells have
the highest cellular mRNA expression. Shortly after we began investigating this result,
a mechanistic study (Xu et al. J Immunol 2020) showed that ORP5 is responsible for
calcium trafficking in T cells by facilitating PIP2 hydrolysis and potentiates T cell
activation, confirming our suspicion about the genotype-phenotype correlation. This
case report suggests ORP5 deficiency as a novel cause of inborn error of immunity
in humans; ongoing functional evaluation in the laboratory seeks to further understand
the impacts of ORP5 deficiency. The case also highlights that TREC screening alone
does not identify all T cell functional disorders and emphasizes the clinical point
that immunologic evaluation is challenging in premature infants. Further, premature
infants with clinical symptoms of abnormal immunity deserve prompt genetic evaluation.
Table 1: Immunologic testing at 4 months of age (41 weeks postmenstrual age).
Keywords: Immunodeficiency, T cell, OSBPL5, Inborn error of immunity, lipid transfer,
prematurity, proliferation
Disclosure: All authors indicated they had no financial relationships to disclose.
(88) Validation of APECED Expanded Diagnostic Criteria in Independent Patient Cohorts
Elise Ferre, PA-C, MPH1, Monica Schmitt, CRNP2, Michail Lionakis, MD, ScD3
1Physician Assistant/Fungal Pathogenesis Section, Laboratory of Clinical Immunology
and Microbiology, National Institute of Allergy and Infectious Diseases/National Institutes
of Health, Bethesda, MD, USA
2Nurse Practitioner/Fungal Pathogenesis Section, Laboratory of Clinical Immunology
and Microbiology, NIAID, NIH, Bethesda, MD, USA
3Senior Investigator/Fungal Pathogenesis Section, Laboratory of Clinical Immunology
and Microbiology, NIAID, NIH, Bethesda, MD, USA
Autoimmune-Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy (APECED), caused by
AIRE mutations, is typically diagnosed with any dyad among the classic triad manifestations
of chronic mucocutaneous candidiasis, hypoparathyroidism, and adrenal insufficiency.
We previously evaluated 35 American APECED patients (Ferré et al., JCI Insight, 2016),
and reported APECED’s clinical spectrum is far broader, and identified an adjunct
triad of APECED rash, intestinal dysfunction, and enamel hypoplasia, which upon incorporation
within the classic criteria, could accelerate clinical diagnosis.
To validate the expanded diagnostic criteria in independent APECED cohorts from the
Americas and Europe.
American (n=57) and European (n=12) APECED patients were enrolled in an IRB-approved
prospective natural history protocol (11-I-0187) at the NIH Clinical Center and underwent
uniform comprehensive clinical evaluation.
American patients reached a clinical APECED diagnosis 4.2 years earlier with the expanded
diagnostic criteria (i.e., reaching any dyad among the six classic and adjunct manifestations)
compared to the classic diagnostic criteria (mean age at diagnosis, 4.6 versus 8.8
years, respectively). Similarly, European patients reached a clinical APECED diagnosis
4 years earlier with the expanded diagnostic criteria compared to the classic diagnostic
criteria (mean age at diagnosis, 3.8 versus 7.8 years, respectively). A total of 10
genetically-confirmed American and European APECED patients who have not yet reached
a diagnosis based on the classic diagnostic criteria meet a clinical diagnosis by
the expanded diagnostic criteria. APECED rash, intestinal dysfunction, and enamel
hypoplasia were the three most common early-onset manifestations occurring before
reaching diagnosis by the classic diagnostic criteria. Expanded diagnostic criteria-based
diagnosis could have prevented acute life-threatening endocrine failure complications
(i.e., adrenal crisis, hypocalcemic seizures) as presenting manifestations of unsuspected
APECED in a total of 28 (41%) American and European patients.
Incorporation of APECED rash, intestinal dysfunction, and enamel hypoplasia into the
classic diagnostic criteria can accelerate APECED diagnosis in both American and European
patients. Earlier diagnosis based on utilization of expanded diagnostic criteria can
a) facilitate early screening for endocrinopathies that would ameliorate acute life-threatening
endocrine failure complications and b) promote early recognition and treatment for
non-endocrine manifestations such as pneumonitis, hepatitis, and keratoconjunctivitis.
Keywords: APECED, APS-1, Expanded Diagnostic Criteria
Disclosure: All authors indicated they had no financial relationships to disclose.
(89) Mycophenolate-induced colitis in APECED patients: A case series
Monica Schmitt, CRNP1, Michail Lionakis, MD, ScD2, Elise Ferre, PA-C, MPH3, Theo Heller,
MD4
1Nurse Practitioner/Fungal Pathogenesis Section, Laboratory of Clinical Immunology
and Microbiology, NIAID, NIH, Bethesda, MD, USA
2Chief, Fungal Pathogenesis Section/Laboratory of Clinical Immunology and Microbiology,
National Institute of Allergy and Infectious Diseases/National Institutes of Health,
Bethesda, MD, USA
3Physician Assistant/Fungal Pathogenesis Section, Laboratory of Clinical Immunology
and Microbiology, National Institute of Allergy and Infectious Diseases/National Institutes
of Health, Bethesda, MD, USA
4Senior Investigator/Translational Hepatology Section, Liver Diseases Branch, National
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD
20892, USA
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is an autoimmune
disorder that often requires immunomodulation to prevent end-organ damage. Mycophenolic
acid (MPA) is the active metabolite of mycophenolate mofetil (MMF) and mycophenolate
sodium (MPS), which have been used to treat autoimmune manifestations in APECED. Mycophenolate
can cause colitis in 2-9% of treated patients.
To describe the clinical and histological features of biopsy-proven mycophenolate-induced
colitis in 3 APECED patients.
Patients were enrolled in an NIH IRB-approved protocol (11-I-0187) and were evaluated
with history, physical examination, laboratory testing, and colonoscopy with biopsies
and pathology evaluation.
Patient 1 is a 19-year-old woman with tubulointerstitial nephritis treated with MPS
(540 mg twice daily). Seven months after MPS initiation, she developed persistent
watery diarrhea (4-5 times daily), periumbilical cramping, and foul-smelling flatulence
with significant nocturnal symptoms. Colonoscopy revealed diffuse macroscopic ulcerations
and histological evidence of chronic colitis with crypt destruction and an increased
number of eosinophils in the lamina propria. Patient 2 is a 14-year-old girl with
autoimmune hepatitis and pneumonitis who was treated with MMF. Two weeks upon increase
of MMF dosing to 1000 mg twice a day, she experienced 5-6 episodes of diarrhea per
day. Colonoscopy demonstrated chronic active colitis with focal cryptitis, apoptotic
bodies, and a lymphoplasmacytic infiltrate within the lamina propria. Patient 3 is
a 10-year-old girl with tubulointerstitial nephritis who was treated with MMF (500
mg twice daily). Eight months later, she developed vomiting, abdominal pain and weight
loss. Colonoscopy revealed increased apoptosis in the ileum and transverse colon.
Abdominal symptoms resolved in all 3 patients within 1-3 weeks of MPS or MMF discontinuation,
and colitis resolution was confirmed by colonoscopy in one of the patients.
Among 104 evaluated APECED patients, mycophenolate was used for autoimmune end-organ
involvement in 10 patients. Three (30%) of them developed biopsy-proven mycophenolate-induced
colitis, which was reversible upon drug discontinuation. Mycophenolate-induced colitis
appears to be a common complication affecting the autoimmune syndrome APECED and clinicians
should maintain a high index of suspicion in recognizing the development of this complication
in mycophenolate-treated APECED patients.
Keywords: Mycophenolate, colitis, APECED
Disclosure: All authors indicated they had no financial relationships to disclose.
(90) Case Series of Pediatric Patients with Kabuki Syndrome
Elisa Ochfeld, MD1, Aisha Ahmed, MD2, A. Kyle Mack, MD3, Robert Liem, MD3, Allison
Remiker, MD3, Amer Khojah, MD4
1Fellow/Northwestern University/ Lurie Childrens Hospital
2Attending Physician, Allergy and Immunology/Ann and Robert H Lurie Children's Hospital
of Chicago
3Attending, Hematology/ Oncology/Lurie Children's Hospital of Chicago
4Attending Physician, Allergy, Immunology, and Rheumatology/Ann & Robert H. Lurie
Children's Hospital of Chicago/ Northwestern University Feinberg School of Medicine
Introduction: Kabuki syndrome (KS) is a rare multi-organ system disorder that can
present with distinct facial features, developmental delay/ intellectual disability,
short stature, congenital heart disease, skeletal anomalies, and recurrent infections.
KS is associated with genetic mutations in KMT2D (autosomal dominant inheritance)
and KDM6A (X-linked inheritance), which encode histone-modifying proteins. The phenotype
of Kabuki syndrome is heterogenous and can also involve endocrine dysfunction, autoimmune
cytopenias, neurosensory abnormalities and immunodeficiency. Immunodeficiency associated
with KS is variable but can resemble CVID, with hypogammaglobulinemia, low IgA and/
or impaired specific antibody responses. Methods: This is a retrospective case series
from one pediatric academic institution including eight patients with Kabuki syndrome.
Results: 5/8 patients were male, 3/8 female. All patients had characteristic facial
features of KS. Age at genetic diagnosis of KS had a bimodal distribution, either
occurring prior to age 3 (n=4) or from age 9-13 (n=4). All patients displayed developmental
delay, 5/8 had hearing impairment, 3/8 had endocrine dysfunction, 3/8 had congenital
cardiac abnormalities, 3/8 had autoimmune cytopenia. All associated variants were
in KMT2D, and no patients had relevant family histories. Those with parental genetic
testing showed de-novo variants. Recurrent infections were most commonly frequent
AOMs in childhood which improved as the patient aged or after tympanostomy tube placement.
None have required IgG replacement or prophylactic antibiotics for hypogammaglobulinemia
with recurrent infections. Of patients with complete evaluations, 6/6 displayed robust
vaccine response to protein and polysaccharide antigens, with no evidence of specific
antibody dysfunction. Mild hypogammaglobulinemia was present in 3/8 patients, and
7/8 display low IgA (though detectable). Interestingly, 2/8 displayed T cell lymphopenia
(though one of these patients had a significant cardiac history), and 3/8 had low
NK cell levels. Conclusion: Kabuki syndrome is a highly heterogenous multi-system
disorder with a variable immunologic phenotype. While humoral immunodeficiency is
most commonly reported in KS, patients may display other immunologic abnormalities
including T or NK cell lymphopenia, and should undergo a broad immunologic evaluation.
Poor specific antibody response was not a hallmark of our population. Recurrent infections
were typically mild and none of these patients have required IVIG replacement or prophylactic
antibiotics.
Keywords: Kabuki Syndrome, Case Series, Immunologic phenotypes, Recurrent infections
Disclosure: All authors indicated they had no financial relationships to disclose.
(91) Neurologic Manifestations reported in Autoinflammatory Disorders and Immune Dysregulatory
Diseases from the USIDNET Registry
Elizabeth Wagman
1, Dana O’Toole, MD2, Hannah Wright, MSPH3, Elizabeth Garabedian, MSN4, Ramsay Fuleihan,
MD5, Devorah Segal, MD6, Elizabeth Feuille, MD7
1Student/Emory University
2Assistant Professor of Clinical Pediatrics/Weill Cornell Medicine
3Research Data Analyst/The United States Immunodeficiency Network (USIDNET)
4Research Nurse/National Genome Research Institute
5Professor of Pediatrics/Division of Allergy and Immunology, Department of Pediatrics,
Columbia University, New York, NY, USA
6Assistant Professor of Clinical Pediatrics/NYU Langone Health
7Assistant Professor of Pediatrics/Weill Cornell Medicine
Autoinflammatory and immune dysregulatory conditions may be associated with various
neurologic manifestations including seizures, behavioral and developmental psychiatric
conditions, fatigue, and headache. Here we aim to identify the types and frequencies
of neurologic manifestations among patients in the USIDNET (United States Immunodeficiency
Network) Registry with immune dysregulatory and autoinflammatory conditions.
Demographic and clinical data were obtained and described for patients in the USIDNET
Registry with neurologic manifestations who had a genetic diagnosis of an autoinflammatory
or immune dysregulatory disorder as defined by the International Union of Immunological
Societies.
Among those patients with an immune dysregulatory disorder who reported neurologic
symptoms (N=101), the most commonly reported was seizures (32%), followed by behavioral/psychiatric
(23%), fatigue/pain (22%), headache (19%), and developmental conditions (18%). Among
those patients (N=17) with an autoinflammatory disorder who reported neurologic symptoms,
the most commonly reported were behavioral/psychiatric (30%), followed by fatigue/pain
(24%), ophthalmic/visual (24%), auditory complications (24%), and developmental conditions
(18%). Genetic mutations most commonly associated with neurologic conditions are listed
in Table 1.
Various neurologic conditions may arise in patients with immune dysregulatory and
autoinflammatory conditions, either as a direct manifestation of disease, as a consequence
of infections, or as a complication of treatments. Knowledge of neurologic conditions
associated with immune dysregulatory and autoinflammatory conditions may aid practitioners
in suspecting and making a diagnosis and in anticipating neurologic complications
that may arise as a consequence of these conditions.
Table 1. Genetic mutations associated with neurologic manifestations of patients in
the USIDNET Registry
Table 2. Neurological manifestations of patients with autoinflammatory disorders and
diseases of immune dysregulation in the USIDNET registry
Keywords: Autoinflammatory disorders, Diseases of immune dysregulation, Nervous system
Disclosure: All authors indicated they had no financial relationships to disclose.
(92) Treatment Of COVID-19 With Convalescent Plasma in a Patient With X-linked Agammaglobulinemia
Yashu Dhamija, MD1, Susan Xie, MD2, Simin Zhang, MD1, Bridget Wilson, MD3, Paul Spearman,
MD4, Grant Paulsen, MD4, Lara Danziger-Isakov, MD4, Amal Assa'ad, MD5
1Fellow/University of Cincinnati
2Fellow/Cincinnati Children's Hospital Medical Center
3Resident/Cincinnati Children's Hospital Medical Center
4Attending Physician/Cincinnati Children's Hospital Medical Center
5Attending Phsyician/Cincinnati Children's Hospital Medical Center
X-linked agammaglobulinemia (XLA) is a primary immunodeficiency consisting of humoral
deficiency and subsequent respiratory and gastrointestinal infections. Convalescent
plasma contains immunoglobulins of patients who recovered from a specific infection.
The US Food and Drug Administration has approved emergency use of convalescent plasma
during the COVID-19 pandemic.
A 24-year-old white man with XLA adherent to intravenous immunoglobulin (IVIG) every
3 weeks presented with 1 week of nasal congestion and sore throat, followed by 3 days
of fever, night sweats, productive cough, chest pain, and diarrhea. On presentation
to the emergency department (ED), his COVID-19 PCR was positive. Chest x-ray showed
right upper lobe pneumonia, and he was started empirically on IV ceftriaxone. IgG
was 1,480 mg/dL (3 days after IVIG). He received convalescent plasma on the day of
admission. His symptoms resolved over the next 2 days, and he remained afebrile and
normoxic throughout admission, and he was discharged on a 10-day course of amoxicillin
for pneumonia. SARS-CoV-2 IgG was 1:800 on day of discharge, indeterminate 8 days
after discharge, and negative 14 days after discharge. The patient returned to the
ED one month after admission with nasal congestion and cough. Chest X-ray showed worsening
right upper lobe pneumonia; PCR testing was negative for COVID-19 but positive for
rhinovirus. He was admitted overnight and discharged in stable condition on a course
of amoxicillin/clavulanate and azithromycin for recrudescent community acquired pneumonia.
In patients with humoral immunodeficiencies, use of convalescent plasma provides passive
immunity. In this case report, a patient with XLA was treated with early convalescent
plasma for an acute COVID-19 infection with good response and maintenance of quality
of life. Recurrence of this patient’s symptoms of fevers and cough suggest bacterial
pneumonia may have been the preeminent infection. While there are no data on the half-life
of COVID-19 convalescent plasma products, the half-life of IgG is thought to be 21
days. This patient displayed rapid loss of passive immunity. Antibody age in plasma
products cannot be guaranteed. Research on use of early convalescent plasma in immunodeficient
patients will provide further clarity on outcome measures.
Keywords: COVID-19, X-linked agammaglobulinemia, primary immunodeficiency, convalescent
plasma, pneumonia
Disclosure: Lara Danziger-Isakov has contracted research with Ansun BioPharma, Astellas,
Merck, Takeda and Viracor. All other authors had no financial relationship to disclose.
(93) 22q11.2 deletion and biomarkers of autoimmunity
Terrence Blaine Crowley, BA1, Daniel McGinn, BA2, Emily Liebling, MD3, Michele P Lambert,
MD MSTR4, Katz Lorraine, MD5, Donna McDonald McGinn, MS LCGC6, Kathleen Sullivan,
MD, PhD7
1Analyst/Children's Hospital of Philadelphia
2Research Assistant/Children's Hospital of Philadelphia
3Assistant Professor/Children's Hospital of Philadelphia
4Associate Professor/Children's Hospital of Philadelphia
5Professor of Pediatrics/Children's Hospital of Philadelphia
6Director of the 22q and You Center/Children's Hospital of Philadelphia
7Professor of Pediatrics, Chief of the Division of Allergy and Immunology/The Children’s
Hospital of Philadelphia, Philadelphia, PA, USA
Chromosome 22q11.2 deletion syndrome is strongly associated with autoimmunity with
a frequency that increases over time. There are recent reports suggesting that greater
compromise in thymic production is associated with at least some specific types of
autoimmune diseases in 22q11.2 deletion syndrome. Yet, there are other studies that
suggest the autoimmunity is seen predominantly in patients with an altered B cell
compartment. We undertook this retrospective analysis of the trajectory of laboratory
features in our carefully phenotyped cohort of >1500 patients with 22q11.2 deletion
syndrome to understand possible associations with autoimmunity. Three subcohorts with
autoimmunity were identified after manual chart review to validate the diagnosis initially
extracted by ICD codes. 25 patients with autoimmune thyroid disease with 80 available
immunologic studies, 5 patients with idiopathic thrombocytopenia purpura (ITP) who
had 24 immunologic evaluations and 5 patients with JIA with 13 immunologic evaluations
were included in the study along with 668 patients with no autoimmune diagnosis who
had 1207 immunologic evaluations. We found that ITP was associated with significantly
lower CD4 counts. This same finding was not observed in the patients with autoimmune
thyroid disease or JIA, suggesting a different mechanism for solid organ autoimmunity.
We further looked at CD4 CD45RA as a common clinical marker for naïve T cells and
found the lowest levels at all ages in the subcohort with ITP. The subcohort with
ITP had on average CD4CD45RA counts of 327 cells/mm3 less than the non-autoimmune
comparator group (p=0.0034). These findings support the hypothesis that the patients
with the greatest compromise in thymic T cell production are at the highest risk of
ITP. These results pave the way for emerging risk stratification for patients with
22q11.2 deletion syndrome.
Keywords: 22q11.2 deletion syndrome, DiGeorge syndrome, T cells
Disclosure: Michele P Lambert received research grants from Novartis, Octapharma,
Principia, and Rigel; is a consultant for Dova; and Advisory board member and consultant
for Argenx. Kathleen Sullivan is a consultant for Enzyvant and an advisory board member
of the Immune Deficiency Foundation. All other authors had no financial relationship
to disclose.
(94) A challenging case of recurrent idiopathic hemophagocytic lymphohistiocytosis
(HLH) initially presenting in an infant with Pneumocystis jirovecii pneumonia
Benjamin Solomon, MD, PhD1, Jay Balagtas, MD2, May Chien, MD3, Rajdeep Pooni, MD,
MS4, Imelda Balboni, MD, PhD5, Katja Weinacht, MD, PhD6, Yael Gernez, MD, PhD7
1Pediatric Resident Physician/Stanford University
2Associate Professor of Pediatric Hematology-Oncology/Stanford University
3Assistant Professor of Pediatric Hematology-Oncology/Stanford University
4Pediatric Rheumatology Instructor/Stanford University
5Associate Professor of Pediatric Rheumatology/Stanford University
6Assistant Professor of Pediatric Stem Cell Transplantation/Stanford University
7Assistant Professor of Pediatric Allergy and Immunology/Stanford University
Here, we report the case of a one-year-old girl with HLH who initially presented at
3 months of age with Pneumocystis jirovecii pneumonia (PJP) requiring intubation for
hypoxemic respiratory failure. She developed anemia, neutropenia, and splenomegaly,
which improved with treatment of her infection. She had hypogammaglobulinemia, but
no evidence of malignancy or lymphocyte abnormalities and her newborn screen was normal.
After discharge, a genetic panel identified a single copy variant of unknown significance
(VUS) in STXBP2.
While the patient had no further infections, she had recurrent splenomegaly with severe
cytopenias requiring repeat admissions. At 6 months of age, she met 7/8 of the HLH-2004
criteria (maximum ferritin of 1,189 ng/mL) and improved with methylprednisone (1 mg/kg).
While on a prolonged steroid taper, she experienced another HLH flare at 9 months
of age (maximum ferritin of 6,862 ng/mL) which ultimately required high-dose steroids
in combination with anakinra (4mg/kg) to induce remission. The patient was discharged
on anakinra and a steroid taper and remains well at 10 months of age.
Despite her unusual presentation, our patient’s immune evaluation has been relatively
normal. She had persistent hypogammaglobulinemia with low isohemagglutinin and hepatitis
B titers and was started on IVIG. She had moderately low CD27+IgM+ B-cells (1.2 cells/uL),
though the rest of her lymphocyte phenotyping was normal, as was her T-cell proliferation
to cytokines, TCR spectratyping, and CD40 genetic testing. Targeted genetic and whole
exome sequencing did not identify an underlying genetic cause.
This patient posed a diagnostic and therapeutic challenge due to the absence of a
clear HLH etiology. Her initial episode of PJP was suspicious for an immunodeficiency,
though only a mild humoral impairment was found. Though her young age, history of
a severe opportunistic infection, and two HLH flares suggest an underlying genetic
predisposition to immune dysregulation, her single copy STXBP2 VUS alone does not
account for her condition. She is currently being evaluated for possible allogenic
hematopoietic stem cell transplantation. The inability to categorize our patient as
primary vs. secondary HLH complicated coordination of her care and highlights the
importance of interdisciplinary teams in management of HLH.
Keywords: Hemophagocytic lymphohistiocytosis (HLH), Macrophage activation syndrome
(MAS), Primary immune deficiency (PID), Pneumocystis jirovecii pneumonia (PJP), Anakinra
Disclosure: All authors indicated they had no financial relationships to disclose.
(95) Diagnostic Utility of Genomic Testing in Disorders of the Immune System
Amber Begtrup, PhD, FACMG1, Ushna Ahmad, MS2, Rashmi Chikarmane, MsC, CGC3, Jane Juusola,
PhD, FACMG4
Inborn errors of the immune system (IEI) are caused by monogenic germline variants
that lead to disruption of immune function. Rapid gene discovery over the past decade
has resulted in over 400 different genes now recognized to cause an IEI. Due to the
large degree of genetic heterogeneity, and overlapping clinical features of many IEI,
genomic sequencing, defined as exome or genome sequencing, is a cost-effective diagnostic
tool to assist with diagnosis and management of individuals with IEI. To better understand
the utility of genomic sequencing, we performed a retrospective review of our experience
with individuals with IEI in our clinical laboratory. Our cohort included 2,624 patients,
with trio (62%), duo (10%), singleton (23%), or other (5%) clinical exome testing
strategies. Our cohort had an age range from 5 days to 76 years, with 74% of patients
under 18 years. Overall, we found 14% of cases had a diagnostic finding, 47% with
a nondiagnostic finding, and 38% with no findings reported. Patients < 2 years of
age had the highest diagnostic rate (25%) and diagnostic yield decreased with increasing
age of patients (6% in >40 years). Including family members in the testing strategy
increased diagnostic rates and reduced the number of nondiagnostic variants reported
in both the pediatric and adult patients. We identified 378 patients with diagnostic
results, 176 (47%) with a diagnostic gene consistent with an IEI, 164 (42%) with a
non-IEI diagnostic finding, and 38 cases with a diagnostic multigene CNV (10%). The
most frequently observed diagnostic IEI genes were STAT1 (10), KMT2D (8), and PIK3CD
(7). Our diagnostic cases included 97 distinct IEI genes and 133 non-immune gene findings,
highlighting the genetic heterogeneity of this cohort. Additionally, over 300 distinct
candidate genes with emerging associations to disease were reported in this cohort,
suggesting that the rapid pace of identification of new genetic causes of IEI is likely
to continue with the use of clinical genomic sequencing.
Keywords: genomics, gene discovery, diagnostics
Disclosure: All authors are employed by GeneDx.
(96) Developing threshold parameters to administer live vaccines in cellular immunodeficiency:
A survey of practicing clinical immunologists
Justine Ade, MD1, Avni Joshi, MD, MS2
1Allergy Immunology Fellow/Mayo Clinic
2Allergist-Immunologist/Mayo Clinic
Live vaccines are contraindicated in patients with severe cellular immunodeficiencies.
Guidelines regarding the administration of live vaccines in patients with more mild
disease, however, are ill-defined. We sought to decipher different parameters used
by practicing immunologists for the administration of live vaccines in cellular immunodeficiency
patients.
A 27-question survey assessing clinical and laboratory threshold parameters used in
the administration of live vaccines to immunodeficient patients was distributed amongst
members of the Clinical Immunology Society (CIS) listserv after approval. Variables
including CD3, CD4, CD8 counts and T-cell functional studies were used to inquire
about thresholds for the administration of three live vaccines - measles, mumps and
rubella (MMR), varicella, and rotavirus vaccines.
There were 83 survey respondents, 65% identified as female, and 71% were based in
the United States. Allergy / Immunology and Immunodeficiency were the most common
identified specialties, accounting for 84% of respondents. Most clinicians did administer
live vaccines to patients with humoral (54/67; 80.6%), cellular (41/67; 61.2%), and
combined diseases (37/67; 55.2%). Most clinicians who administer live vaccines to
patients with immune deficiencies considered a threshold CD4 count of □ 400 cells/mm3
(MMR 48/60 [80%], Varicella 42/53 [79%], Rotavirus 40/45 [88.89%]), a CD8 count of
□ 250 cells/mm3 (MMR 30/39 [76.92%], Varicella 29/37 [78.34%], Rotavirus 27/34 [79.41%]),
and normal mitogen function (MMR 44/53 [83.02%], Varicella 40/48 [83.33%], Rotavirus
37/40 [92.5%]).
More than half of clinicians who care for immune deficient patients included in this
survey do administer live vaccines to patients with cellular immunodeficiency. The
most commonly used parameters used in clinical decision making include numeric and
functional assessments of the T cell compartment. Using these results, we propose
a treatment threshold of using CD4 count of □ 400 cells/mm3, a CD8 count of □ 250
cells/mm3 and normal mitogen function testing. Future studies are needed to determine
clinical efficacy and safety using these thresholds.
Keywords: live vaccine, primary immunodeficiency, cellular immunodeficiency
Disclosure: All authors indicated they had no financial relationships to disclose.
(97) Common variable immunodeficiency revised: expanding the spectrum of IRF2BP2 deficiency
Julia Körholz, MD1, Henrike Sczakiel, MD2, Livia Schulze, n/a3, Timm Amendt, Phd4,
Anastasia Gabrielyan, Phd5, Matin Laass, MD6, Daniela Aust, Prof.7, Joachim Roesler,
PD6, Axel Roers, Prof.8, Catharina Schuetz, Prof.6
1Resident/Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische
Universität Dresden, Dresden, Germany
2resident/Institute of Medical Genetics and Human Genetics, Charité - Universitätsmedizin
Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Berlin 13353, Germany.
3Technician/Institute of Immunology, Medizinische Fakultät Carl Gustav Carus, Technische
Universität Dresden, Dresden, Germany
4Researcher/Institute of Immunology, University Hospital Ulm, Ulm, Germany
5Postdoc/Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische
Universität Dresden, Dresden, Germany.
6Chief resident/Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus,
Technische Universität Dresden, Dresden, Germany.
7Assistant head of institute/Institute of Pathology, Medizinische Fakultät Carl Gustav
Carus, Technische Universität Dresden, Dresden, Germany.
8Head of institute/Institute of Immunology, Medizinische Fakultät Carl Gustav Carus,
Technische Universität Dresden, Dresden, Germany.
Interferon regulatory factor-2 binding protein 2 (IRF2BP2) is a nuclear protein that
has been described as important transcriptional cofactor. It interacts with interferon
regulatory factor 2 (IRF2) as transcriptional repressor and has recently been described
as positive and negative regulator of gene expression. It impacts on different cellular
functions influencing macrophage regulation, lymphocyte activation and angiogenesis
especially in cancer development. In humans dominant IRF2BP2 deficiency is associated
with an inborn error of immunity (IEI). Although IRF2BP2-deficiency is mentioned in
almost every classification of monogenic CVID there has only been one family described
to date with a CVID phenotype associated with a variant in IRF2BP2. The phenotypic
spectrum was characterized by hypogammaglobulinaemia and infections but also psoriasis,
colitis and type 1 diabetes.
We present a 32-year old male with a history of recurrent infections since childhood
including sinusitis, bronchitis, pneumonia and otitis media attributed to hypogammaglobulinaemia.
Immunoglobulin substitution significantly reduced susceptibility to infections although
IgG remained low. Colonoscopy revealed inflammation of the intestinalgut mucosa with
chronic lymphocytic and focal granulocytic infiltration similar to inflammatory bowel
disease but with remarkableabscence of plasma cells. This may point to the cause underlying
low Ig levels. At age 25, the patient developed a rheumatoid factor negative chronic
active and erosive polyarthritis, resulting in progressive stiffness and severely
restricted mobility within 2-3 years despite treatment with methotrexate.
Immunophenotyping revealed decreased memory B cells with an impairment of class-switch
and a lack of plasmablasts. T-cell numbers, subpopulations and function were normal.
Whole exome sequencing (and Sanger confirmation) revealed a de novo nonsense mutation
in IRF2BP2,c.1618C>T, p.(Q540*) (ACMG class IV). This mutation may result in expression
of a truncated IRF2BP2 protein lacking some highly conserved amino acids and leading
to the inability to properly form the RING domain. This domain was also affected in
the family described by Keller et al.
This report adds to the described spectrum of human IRF2BP2 deficiency expanding the
phenotype of this rare monogenic CVID. Further functional investigations and patient
cohort studies will broaden the understanding of this deficiency, its role for B-cell
development and support tailored therapeutic management.
Keywords: IRF2BP2, CVID, Erosive polyarthritis, Hypogammaglobulinaemia
Disclosure: Axel Roers has contracted research with Celgene and Roche. All other authors
had no financial relationship to disclose
(98) Reliability of shipped dried blood spot samples for IgG trough level monitoring
in patients with primary immunodeficiency disease
Hanna Haberstroh, MSc1, Ulrich Salzer, MD2, Bodo Grimbacher, Prof. Dr. med.3, Sigune
Goldacker, MD4, Aleksandra Hirsch, MD5, Arianna Troilo, MD, PhD6, Monika Erler, n/a7,
Martina Eigenbrod-Damerau, n/a7, Norbert Zessack, n/a8, Klaus Warnatz, MD9
1technician/Center for Chronic Immunodeficiency, MedicalCenter, University of Freiburg,
Germany
2Research group leader/University Clinic Freiburg, CCI
3Head of the laboratory/Center for Chronic Immunodeficiency, Medical Center, University
of Freiburg, Germany
4Physician for internal medicine and rheumatology/Center for Chronic Immunodeficiency,
Medical Center, University of Freiburg, Germany
5Physician/Center for Chronic Immunodeficiency, Medical Center, University of Freiburg,
Germany
6Resident in Rheumatology/Department of Rheumatology and Clinical Immunology, Medical
Center - University of Freiburg. Faculty of Medicine, University of Freiburg, Germany
7Study assistants/Department of Rheumatology and Clinical Immunology, Medical Center
- University of Freiburg. Faculty of Medicine, University of Freiburg, Germany
8Associate Director, Country Medical Lead Immunology/Shire Deutschland GmbH
9Head of Division/Center for Chronic Immunodeficiency, Medical Center, University
of Freiburg, Germany
Primary immunodeficiency disease (PID) and concomitant antibody deficiencies are effectively
treated with immunoglobulin G (IgG) administered either intravenously (IVIG) at a
medical facility or subcutaneously as home self-therapy (SCIG). One drawback of home-based
SCIG is the lack of easy options for monitoring IgG levels. We and others have previously
shown that IgG levels can be analyzed from dried blood spots (DBS) using a standard
nephelometric assay. The aim of this study was to test the reliability of this method
under real life conditions comparing sampling on-site and from shipped DBS cards with
standard serum measurement.
IgG levels in DBS eluates from shipped and on-site samples and serum from 100 prospectively
enrolled patients on IVIG or SCIG therapy were tested by nephelometry (BN Prospec,
Siemens, Germany). All patients provided informed consent (IRB University of Freiburg
#514/18) to the study (DRKS-ID: DRKS00020522)
We found a highly significant correlation of both on-site and shipped DBS samples
with serum samples (n=100, Figure 1A and B; p < 0.0001) as well as within non-shipped
and shipped DBS samples (n=100, Figure 1C; p < 0.0001). However, mean IgG levels determined
from DBS samples were consistently slightly lower than those from serum samples for
both non-shipped and shipped DBS samples (mean IgGserum: 10.07 g/l versus mean IgGon-site
DBS 8.768 g/L, mean %CVon-site DBS vs serum: 10.54; or versus mean IgGshipped DBS
8.754 g/L, mean %CVshipped DBS vs serum: 10.77), whereas there was no significant
difference between non-shipped and shipped DBS samples (mean %CVon-site DBS vs shipped:
4.552; Wilcoxon teston-site DBS vs shipped DBS: p= 0.6983).
Our data show that patient-friendly, home-based monitoring of IgG levels from DBS
is reliable and the results not influenced significantly by shipment of DBS cards,
confirming the applicability of the method in routine clinical practice. Slightly
lower IgG levels were consistently found in DBS samples when compared with serum.
It is currently unclear if this is related to the DBS sampling procedure or different
properties of capillary blood itself. Therefore, reference ranges specific for IgG
derived from capillary DBS samples might be necessary.
Figure 1. Correlations between on-site and shipped DBS sample and serum sample IgG
Levels
Keywords: immunoglobulin, assay, primary immunodeficiency disease, dried blood spot
Disclosure: Hanna Haberstroh received a travel grant from Baxalta/Takeda. Ulrich Salzer
is an advisory board member of Baxalta. Bodo Grimbacher received a research grant
from Baxalta. Norbert Zessack is employed by Takeda. Klaus Warnatz received speaker
honoraria from Baxalta/Takeda. All other authors had no financial relationship to
disclose.
(99) Recurrent pneumonia and sinusitis: an interplay of alcoholism and selective IgM
deficiency
Minh Nguyen, DO1, Taylor Cable, MD1, Ricardo de Castro, MD1, Ali Shah, MBBS1, Mark
Loehrke, MD2
1Resident Physician/Western Michigan University School of Medicine
2Attending Physician/Western Michigan University School of Medicine
Selective immunoglobulin M deficiency (sIgMD) is a rare immune disorder, defined as
IgM levels below two standard deviations of the mean with normal IgG and IgA and exclusion
of other causes of immune deficiencies. Most patients with sIgMD present with frequent
infections. Here, we detail a patient with recurrent pneumonia (PNA) and sinusitis;
and a workup consistent with sIgMD. Further, his course is complicated by alcoholism.
Chronic alcohol use is linked with changes in the immune system, leading to higher
risk of infections. This case represents a clinical conundrum involving alcoholism
and sIgMD.
A 42-year-old man with a history of homelessness, severe alcoholism, and recurrent
PNA presented with worsening dyspnea and cough. He required oxygen supplementation
on arrival. Chest XR revealed left basilar PNA. His CBC and CMP were unremarkable.
Chart review revealed seven admissions related to PNA during the last 12 months. Imaging
studies demonstrated opacities/infiltrates involving varying lobes: right lower, middle,
lingula and upper lobes, and left lower lobe (figure 1). He reported multiple hospitalizations
as a child for PNA. Since 2017, multiple brain CT scans showed sinus disease (figure
2). The patient confirmed recurrent sinusitis. Immunologic workup revealed IgM of
29 mg/dL (ref range 53-334) on two separate checks, IgE of 51 kU/L (ref range < 41),
NK cells of 38 cells/uL (ref range 59-513) and normal IgG, IgA, IgG subclass, total
complement, CD3, CD4, CD8 and CD19 cells. HIV antibodies were negative. ANA titers
were less than 1:40. Vaccine titers were not obtained, as the patient left against
medical advice.
The patient’s recurrent sinusitis and PNA involving various lobes suggested an underlying
immunological condition. His workup is consistent with sIgMD. Concurrent alcohol abuse
plays a role in his ongoing infections, as chronic alcohol use has profound effects
on immune response. It is arguable that his recurrent PNA is partly due to inadequate
treatment in the setting of noncompliance, although this is less likely with PNA occurring
in varying lobes and recurrent PNA in childhood. Overall, the interplay of his alcoholism
and an underlying immunological disorder, most likely sIgMD, contributed to a prolonged
course of PNA and sinusitis.
Figure 1: A) Computed tomography of chest taken in 1/2020 showed multifocal patchy
groundglass opacities involving the lingula. B) Chest X-ray (CXR) on 4/2020 demonstrated
right lung base consolidation. C) CXR on 12/2020 revealed left basilar infiltrates.
Figure 1: A) Computed tomography (CT) of brain in 8/2017 showed moderate amount of
mucosal thickening involving the paranasal sinuses (red arrow). B) Brain CT in 8/2020
again demonstrated moderate opacification of the paranasal sinuses (red arrows).
Keywords: Selective IgM Deficiency, Alcoholism, Recurrent pneumonia, Recurrent Sinusitis
Disclosure: All authors indicated they had no financial relationships to disclose.
(100) Real-world healthcare resource utilization in untreated congenital athymia:
A medical chart audit study
Megan Cooper, MD,PhD1, Cathleen Collins, MD, PhD2, Julie Kim-Chang, MD3, Shruti Nambiar,
PhD4, Matthew O'Hara, MBA5, Sarah Kulke, MD6, Elena Hsieh, MD7
1Associate Professor/Department of Pediatrics, Division of Rheumatology/Immunology,
Washington University School of Medicine, St. Louis, MO
2Assistant Professor/Department of Pediatrics, Division of Allergy Immunology, University
of California San Diego; Rady Children’s Hospital, San Diego, CA
3Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics,
Duke University School of Medicine, Durham, NC
4Senior Consultant/Trinity Life Sciences, Waltham, MA
5Managing Director/Trinity Life Sciences, Waltham, MA
6Vice President, Medical Affairs/Enzyvant, Cambridge, MA
7Assistant Professor/Department of Pediatrics, Section of Allergy and Immunology,
University of Colorado, Anschutz School of Medicine; Children’s Hospital Colorado;
Department of Immunology and Microbiology, University of Colorado, Anschutz School
of Medicine, Aurora, CO
Congenital athymia is an ultra-rare disorder characterized by absence of a thymus
at birth. These patients lack naïve T-cells critical to immune regulation and defense
against infections, and typically die within two to three years of life if they do
not receive treatment to establish T-cell immunity.
To estimate the healthcare resource utilization (HCRU) associated with congenital
athymia for patients receiving supportive care prior to cultured thymic tissue implantation
(CTTI; if received) using medical charts.
Board-certified physicians participated in an IRB-approved online survey abstracting
HCRU data from medical charts for living or deceased patients with congenital athymia
(defined by naïve T-cell count < 100 cells/mm^3 recorded at birth or diagnosis). Data
was collected for at least 12 continuous months starting from birth to three years
of age, until either CTTI or death. Descriptive statistics were conducted to estimate
the average annual HCRU in the first three years of life for future application as
inputs in a model to estimate cost of care for congenital athymia from birth to age
three.
Interim results from the ongoing survey (n=5 charts) are reported here; complete results
will be reported in the presentation. Two patients were born to diabetic mothers,
one had DiGeorge syndrome, one had CHARGE syndrome and one had no known associated
conditions. Before age three, three patients received CTTI, and two patients died.
Annual mean length of inpatient stay was 120.4 days, with maximum stay as high as
365 days. All patients required immunoglobulin replacement therapy on a weekly or
monthly basis. All patients received prophylactic antibiotics and antifungals. Patients
required multiple procedures such as feeding tube placement (100%), central line placement
(80%), bronchoscopy (60%), skin biopsy (60%), and ventilators (60%). All patient charts
reported abnormal T-cells counts, and 80% reported more than one infection type. Sepsis
was reported in 60% of patients.
Congenital athymia is associated with high HCRU in the initial three years of life
prior to CTTI, placing a significant burden on healthcare systems, providers, patients
and their families.
Keywords: thymic aplasia, congenital athymia, real-world evidence, healthcare resource
utilization, cultured thymic tissue implantation
Disclosure: Megan Cooper, Cathleeen Collins, Shruti Nambiar, Matthew O’Hara and Elena
Hsieh are all consultants for Enzyvant. Sarah Kulke is employed by Enzyvant.
(101) Age isn’t just a number when it comes to genetic testing: diagnostic yields
across age groups for patients with PIDDs
Hui Yu, PhD1, Jennifer Holle, MS, CGC2, Rebecca Truty, PhD3, Shiloh Martin, MD, PhD1,
Jessica Connor, MS, LCGC1, Lauren Bryl, MS, CGC1, Olga Sarmento, PhD1, Britt Johnson,
PhD, FACMG, HCLD(ABB)4
1Clinical Genomics Scientist/Invitae
2Genetic Counselor/Invitae
3Bioinformatic Analyst/Invitae
4Medical Director, Metabolic Genetics and Immunology,Medical Affairs Director, Biopharma
Partnerships/Invitae Corporation, San Francisco, CA
The clinical presentations of individuals with inborn errors of immunity may be complicated
by developmental stages and environmental exposures during life. Those with early
presentations are typically considered more likely to test positive than older patients,
while some primary immunodeficiencies and immune dysregulatory diseases (PIDDs) may
be more commonly diagnosed in patients of different age groups. To better understand
the genetic contribution to clinical presentations, we examined the diagnostic yield
of genetic testing panels across PIDD patients of different age groups at a commercial
laboratory over a 2.5 year period. Patients were divided into 3 cohorts based on testing
age: < 3 years; 3-17 years; ≥18 years.
During the studied period 10,864 unrelated patients were tested with immunology panels
with an overall positive rate of 6.22% (n=676). Among them, 2,003 patients were infants
younger than 3 years, 4,876 were age 3-17 years, and 3,985 were adult patients ≥ 18
years. The < 3 age group had the highest positive rate (12.13%). The 3-17 group had
a 5.46% positive rate. Adults had the lowest diagnostic yield: 4.19%. Similar trends
were seen when results were separated by type of PID panel. The severe/combined immunodeficiencies
(SCID/CID) panels were most frequently ordered (n=137) in the < 3 age group with a
positive rate of 40.15%, compared to a 5% positive rate in the 3-17 group (n=20),
and a 4.76% positive rate in adults (n=21). The large 207-gene PID panel accounted
for over half of the tests ordered throughout all age groups, and its diagnostic yield
correlated with the overall positive rates: 11.77%, 6.54%, and 4.32%, respectively.
Several factors are likely contributing to the different diagnostic yields among age
groups. In very young patients, PIDD presentations tend to be classic, severe and
less likely to escape diagnosis than in older individuals. Clinical manifestations
in adult patients are frequently mild or moderate, involving nonspecific features.
Adult patients with complex histories are more likely to undergo genetic testing for
the purpose of “ruling out” primary immunodeficiency. Understanding the expected positive
rate for a given patient in a specific age group is valuable for setting appropriate
expectations for clinicians and families.
Keywords: genetic testing, diagnostic yields, primary immunodeficiencies and immune
dysregulatory diseases
Disclosure: All authors are employed by Invitae.
(102) Diagnostic efficacy of next-generation sequencing panel testing in the diagnosis
of inherited bone marrow failure syndromes
Alicia Scocchia, MS, LCGC1, Päivi Kokkonen, PhD2, Elina Hirvonen, PhD2, Emma Mårtensson,
PhD2, Hatice Duzkale, MD, MPH, PhD, FACMG, CGMB3, Kim Gall, MSc, CGC4, Joe Jacher,
MS, CGC5, Inka Saarinen, MSc6, Johanna Sistonen, PhD7, Juha Koskenvuo, MD, PhD8, Lotta
Koskinen, PhD9, Tero-Pekka Alastalo, MD, PhD10
1Clinical Liaison, Licensed and Certified Genetic Counselor/Blueprint Genetics
2Geneticist/Blueprint Genetics
3Senior Geneticist/Blueprint Genetics
4Clinical Liaison, Certified Genetic Counselor/Blueprint Genetics
5Certified Genetic Counselor and Marketing Manager/Blueprint Genetics
6Data Scientist/Blueprint Genetics
7Clinical Development Manager/Blueprint Genetics
8Executive Director, Medical & Lab Director/Blueprint Genetics
9Clinical Interpretation Manager/Blueprint Genetics
10Executive Director, Medical/Blueprint Genetics
Inherited bone marrow failure syndromes (IBMFS), recently classified as inborn errors
of immunity, represent a genetically heterogenous group of conditions characterized
by aplastic anemia, congenital malformations, and increased risk to develop malignancies.
Identifying the molecular etiology of IBMFS can allow for personalized management,
surveillance, and risk estimation for the patient and their family members. Comprehensive
next-generation sequencing (NGS) panel testing can be a useful molecular diagnostic
tool, where broad inclusion of genes associated with IBMFS along with robust analysis
of both multigenic and intragenic copy number variation (CNV) are expected to significantly
contribute to diagnostic yield. To determine the diagnostic efficacy of a broad panel
test including robust CNV analysis, we conducted a retrospective review of test results
from patients with suspected IBMFS.
We reviewed clinical reports from consecutive patients with an indication of suspected
IBMFS who underwent panel testing at Blueprint Genetics (a CLIA-certified diagnostic
laboratory). The Bone Marrow Failure Syndrome panel was utilized for testing, which
contains 135 genes and includes sequence variant, CNV, and targeted noncoding variant
analysis. CNV analysis was performed bioinformatically from NGS data using two variant
calling algorithms, including a proprietary method specific for small, intragenic,
exon-level CNVs. Variant interpretation was performed according to ACMG guidelines.
A molecular diagnosis was defined as identification of a pathogenic or likely pathogenic
variant consistent with the patient’s reported phenotype and with known associated
disease inheritance.
The median age of patients at testing was 14 years (ranging from fetal to 90 years).
A molecular diagnosis was established in 82 of 442 tested patients (18.6%). CNVs ranged
from 241 bp to 2.2 Mb and contributed to the diagnosis of 17.1% (14/82) patients;
64.3% (9/14) of these CNVs were intragenic. Diagnostic variants were identified in
34 genes, with nearly half of these genes (15, 44.1%) identified in a single patient
in this cohort. The most commonly reported genes in diagnostic reports include FANCA
(n=17, 20.7%) associated with Fanconi anemia and SBDS (n=12, 14.6%) associated with
Shwachman-Diamond syndrome.
This study demonstrates that next-generation sequencing panel testing that includes
robust CNV detection can contribute to the diagnostic yield among patients with IBMFS.
Keywords: Bone marrow failure, Next-generation sequencing, Genetic testing, Molecular
diagnostics, Copy number variant
Disclosure: All authors are employeed by Blueprint Genetics.
(103) Trends in pediatric primary immunodeficiency: incidence, healthcare utilization,
hematopoietic stem cell transplantation, and mortality
Taylor Eddens, MD/PhD1, Molly Mack, MD2, Meghan McCormick, MD3, Ramasubramanian Kalpatthi,
MD4
1Allergy/Immunology Fellow/UPMC Children’s Hospital of Pittsburgh
2Pediatrics Resident/UPMC Children’s Hospital of Pittsburgh
3Assistant Professor/Pediatric Hematology/Oncology, UPMC Children's Hospital of Pittsburgh
4Associate Professor/UPMC Children’s Hospital of Pittsburgh, Hematology/Oncology
The term ‘primary immunodeficiency’ (PID) encompasses a myriad of diseases caused
by inherited defects within the immune system. As the number of identified genetic
defects associated with PID increases, understanding the incidence and outcomes of
patients with PID becomes imperative.
The objective is to characterize the frequency of new diagnoses (i.e. incidence),
patterns of healthcare utilization, rates of hematopoietic stem cell transplantation,
and mortality over time in pediatric patients with PID.
A retrospective cohort analysis of pediatric inpatients from 2004-2018 with an ICD9/ICD10
diagnosis code associated with primary immunodeficiency using the Pediatric Health
Information System (PHIS) database. Causes of secondary immunodeficiency were excluded.
Incidence was calculated using first-time hospitalization.
There were a total of 17,234 patients hospitalized with a primary immunodeficiency
from 2004-2018. There were 2.8 new PID diagnoses and 6.3 PID hospitalizations per
1,000 discharges; these metrics were unchanged during the study period. The number
of new diagnoses for B cell and antibody defects significantly increased over time.
The number of new PID diagnoses significantly increased in adolescents/adults and
decreased in infants. T cell disorders had the highest number of ICU admissions. There
were 747 patients that received hematopoietic stem cell transplantation (HSCT); complications
of HSCT significantly decreased over time. Mortality significantly decreased in all
PID patients and in the subgroup of patients receiving HSCT.
The total hospitalization rate and incidence of PID within the hospitalized pediatric
population was stable. There were significant changes in the class of PID diagnosed,
the age at diagnosis, and healthcare utilization metrics. Mortality significantly
decreased over time within the PID cohort.
Keywords: Primary immunodeficiency, Hematopoietic stem cell transplantation, Pediatrics,
incidence, Mortality
Disclosure: All authors indicated they had no financial relationships to disclose.
(105) Endocrine-Specific Autoimmunity in Primary Immunodeficiencies: a Report from
the USIDNET Registry
Teresa Pelletier, MD1, Hannah Wright, MSPH2, Elizabeth Garabedian, MSN3, Ramsay Fuleihan,
MD4, Elizabeth Feuille, MD5
1Resident/Weill Cornell Medicine- New York Presbyterian
2Research Data Analyst/The United States Immunodeficiency Network (USIDNET)
3Research Nurse/National Genome Research Institute
4Professor of Pediatrics/Division of Allergy and Immunology, Department of Pediatrics,
Columbia University, New York, NY, USA
5Assistant Professor of Pediatrics/Weill Cornell Medicine
Primary Immunodeficiencies (PIDs) are typically thought of as presenting with susceptibility
to infection, but may also manifest with other immune dysregulatory processes including
autoimmunity which may be systemic or organ-specific. Subspecialists who evaluate
these patients and may be the first point-of-contact with such patients may not be
aware of the breadth and types of autoimmunity associated with PID. Here we report
the numbers and types of endocrine-organ associated autoimmune conditions found in
the USIDNET Registry, as well as the PIDs most often associated with endocrine-organ
associated autoimmunity.
Investigators obtained clinical data for the patients within the USIDNET Registry
with endocrine-organ autoimmunity. Frequency of endocrine-organ associated autoimmunity
among various immune defects were reported. Of note, due to high probability of having
iatrogenic cause, those with adrenal insufficiency that were not specifically reported
as Addison’s Disease were excluded. In addition, patient’s with DiGeorge Syndrome
and unspecific hypoparathyroidism were also excluded.
Among the 5486 patients in the USIDNET Registry with PIDs, 521 patients (9.5%) were
found to have a condition associated with endocrine-organ autoimmunity. The most commonly
reported endocrine-specific conditions among patients in the USIDNET Registry are
thyroid specific, found in 356 patients (6.5% of registry patients); this is followed
by pancreatic (N=105, 1.9%), parathyroid (N=82, 1.5%), ovarian (N=19, 0.3%, where
6 of these patients had undergone stem cell transplant), Addison’s (N=16, 0.3%), polyglandular
(N=4, 0.1%), and testicular (N=1, 0.02%). The PID entities associated with more endocrine-organ
associated autoimmunity were Mucocutaneous Candidiasis (affecting 60.9% of the 69
patients with Mucocutaneous Candidiasis) and Autoimmune Lymphoproliferative Syndrome
(49.2% of 59, with majority affected by parathyroid disease), followed by Interferonopathy
(23.1% of 13), Combined Immune Deficiency (14.2% of 106), and Common Variable Immune
Deficiency (12.8% of 1820).
Endocrine-specific autoimmune conditions are common among patients with PIDs. Further
study is needed to determine the impact of therapeutics on the development of endocrine-associated
autoimmunity. This information may help guide clinicians to suspect PID in certain
patients with endocrine-organ associated autoimmunity and/or to monitor for endocrine-organ
autoimmunity in patients with certain PIDs.
Keywords: Primary Immunodeficiencies, Autoimmunity, Endocrine-Specific Autoimmunity
Disclosure: All authors indicated they had no financial relationships to disclose.
(106) Quality of Life in Adult and Pediatric Patients with Chronic Granulomatous Disease
Grace Gleason, BS, BA1, Samantha Kreuzburg, RN, BA2, Jennifer Treat, PA-C, MSHS, MPH3,
Ericka Garrett, RN4, Dawn Shaw, MBA, MN, RN5, Betty Marciano, MD6, Christa Zerbe,
MD7
1Post-Baccalaureate IRTA/National Institutes of Health
2Research Nurse Specialist/National Institutes of Health
3Physician Assistant/National Institutes of Health
4Nurse/National Institutes of Health
5Nurse Coordinator II/Leidos Biomedical Research, Inc.
6Staff Scientist/National Institutes of Health
7Director, Clinical Patient Services/National Institutes of Health
Chronic Granulomatous Disease (CGD) is an inherited primary immunodeficiency (PID)
which results in both inflammatory response dysregulation and an increase in susceptibility
to certain bacterial and fungal infections. Chronic disease can involve physical,
psychological and social effects on a patient’s quality of life. In order to expand
our understanding of CGD’s effects on quality of life, a six-month study of CGD patients
began October 2019. The study was concluded in March 2020 due to concerns over the
potential significant effect of the COVID-19 pandemic on patients’ quality of life.
All patients (inpatient/outpatient) were consented and administered either the WHO
QOL-BREF instrument (26 years and older) or the PEDS-QL instrument (2-25 years old)
enrolled on NIH protocol 93-I-0119 (NCT00404560). The WHO QOL-BREF is a validated
questionnaire comprised of 26 items, encompassing: physical health, psychological
health, social relationships and environment. The PEDS-QL is a validated questionnaire
comprised of 23 items encompassing: physical, emotional, social, and school functioning.
The PEDS-QL includes a module to assess the impact of CGD on the family for patients
under 18. Each item in the WHO QOL-BREF and PEDS-QL is rated on a 5-point Likert scale.
The surveys were interview-administered to 32 adult patients (16 males, 16 females)
and 21 pediatric patients (17 males, 4 females) with genetically confirmed CGD. The
age range was 4 - 62 years old (mean 31.4 years) with a distribution of 31% x-linked
CGD, 22% CGD-carrier, and 47% autosomal recessive CGD among adult patients and a distribution
of 76% x-linked CGD, 10% CGD-carrier, and 14% autosomal recessive CGD among pediatric
patients. The WHO QOL-BREF domain scores were as follows: physical =14.14, psychological
=14.38, social =16.63, environmental =16.69. The PEDS-QL domain scores were physical
=74.63, emotional =67.32, social =78.93, school =38.22. Overall, adult domains showed
an unexpected high score compared to the US general population; while pediatric domains
showed a lower score, especially in school functioning. Perhaps being pulled out of
school, frequent hospitalizations and illness impact the quality of life in pediatrics
for this population more than it affects the quality of life in adults.
Keywords: Chronic Granulomatous Disease, Quality of Life, WHO QOL-BREF, PEDS-QL, Psychosocial,
Inherited Primary Immunodeficiency
Keywords: Primary antibody deficiency, Screening algorithm, Diagnostic delay, Primary
care
Disclosure: Mariannae A. Messelink, Roos-Marjin Berbers and Helen L. Leavis received
research grants from Takeda. Joris van Montfrans is an advisory board member for Takeda.
Giovanna Devercelli has ownership interest in Amgen and Takeda and is employed by
Takeda. All other authors had no financial relationship to disclose.
(109) Efficacy and Safety of PlasmaCap IG, A New 10% Intravenous Immunoglobulin Manufactured
Using an Innovative Chromatography Process, in Adults and Children with Primary Immunodeficiency
Disorders
Richard Wasserman, MD, PhD1, Jennifer Leiding, MD2, William Lumry, MD3, Mark Scarupa,
MD4, Daniel Suez, MD5, Sudhir Gupta, MD, PhD6, John Routes, MD7, Tina Zecca, MD8
1Medical Director, Pediatric Allergy / Immunology/Medical City Children's Hospital
2Associate Professor/Division of Allergy and Immunology, Department of Pediatrics,
University of South Florida at Johns Hopkins-All Children’s Hospital, St Petersburg,
FL
3Clinical Professor/University of Texas Southwestern Medical School
4Clinical Faculty/Johns Hopkins Asthma & Allergy Center
5Past President of the Consortium of Independent Immunology Clinics/Allergy, Asthma
& Immunology Clinic PA
6Professor of Medicine, Pathology & Laboratory Medicine, and Microbiology & Molecular
Genetics/University of California, Irvine
7Professor of Pediatrics, Medicine, Microbiology and Immunology/Medical College of
Wisconsin
8Clinical Director/Allergy & Asthma Associates of Monmouth County
Primary immunodeficiency disorder (PIDD) patients require life-long immunoglobulin
(IG) replacement therapy to minimize recurrent infections, especially serious bacterial
infections (SBIs). Ongoing shortages of IG have exposed the need for increased manufacturing
efficiency to meet growing global demand. PlasmaCap IG, a new 10% intravenous immunoglobulin
(IGIV), is prepared from > 1000 donor plasma pools through an innovative chromatography
process that can enable higher yields of certain plasma proteins, including IG, compared
to traditional cold ethanol plasma fractionation. A clinical study evaluated the safety
and efficacy of PlasmaCap IG in PIDD patients.
The primary efficacy outcome was the number of SBIs. Secondary endpoints included
(among others) tolerability and safety, number of days missed at work or school, number
of days hospitalized due to infections or with fever, and days of antibiotic therapy.
A Phase 3, prospective, open-label, multicenter study was conducted at 12 sites in
the United States and Canada. Participants received 300-900 mg/kg of PlasmaCap IG
either every 21 or 28 days for a period of one year.
A total of 57 of 63 participants (90.5%) completed the study and received 839 infusions.
Six adults discontinued prior to study completion due to withdrawal of informed consent
(4 subjects [8.3%]) and adverse events (2 subjects [4.3%]). Adults, age 20-70 years
(median 51.0 years) and children age 2-16 years (median 9.0 years) were enrolled.
No SBIs occurred in either group. Quality of life measures comprising days absent
from work or school due to an infection (mean 6.5 days/patient/year), hospitalization
due to infection (mean 0.2 days/patient/year), or febrile days > 38.5ºC, (mean 0.9
days/patient/year), were all low. Antibiotic use was also low. The most common treatment-related
adverse events were headache, fatigue, and nausea; > 97% of all treatment-related
adverse events reported were mild or moderate. No subject experienced a treatment-related
serious adverse event (SAE), hemolysis, thromboembolism, or renal failure.
This study demonstrated that PlasmaCap IG is safe and effective in the treatment of
adult and pediatric patients with PIDD.
Keywords: Intravenous Immunoglobulin, Primary Immunodeficiency Disorder, PlasmaCap
IG, Chromatography, IGIV, PIDD
Disclosure: Richard Wasserman received research grants from CSL Behring, Evolve Biologics,
Grifols, Kedrion, Korean Green Cross, and Takeda. Jennifer Leiding received speaker
honoraria from CSL Behring; research grant and speaker honoraria from Horizon Therapeutics;
and is an advisory board member for Pharming Therapeutics. William Lumry received
a research grant from ADMA, ALK, BioCryst, Grifols, Ionis, Kedrion, Shire/Takeda,
and Therapure; speaker honoraria from Astra Zeneca, CSL Behring, Grifols, GSK, Pharming,
Sanofi/Regeneron; and is a consultant for Biomarin, Fresenius Kabi, Intellia, Kalyista,
Phavarus and US Hereditary Angioedema Assocation. Mark Scarupa received a research
grant from ALK, AstraZeneca, BioCryst, CSL Behring, Genentech, Grifols, Novartis,
Octapharma, Pfizer, Regeneron and Takeda. John Routes has contracted research with
CSL Behring and Evolve Biologics. All other authors had no financial relationship
to disclose.
(110) Cross-sectional, caregiver-assessed burden of congenital athymia in patients
without treatment in the first years of life
Cathleen Collins, MD, PhD1, Julie Kim-Chang, MD2, Bhagyashree Oak, PhD3, Matthew O'Hara,
MBA4, Sarah Kulke, MD5, Elena Hsieh, MD6
1Assistant Professor/Department of Pediatrics, Division of Allergy Immunology, University
of California San Diego; Rady Children’s Hospital, San Diego, CA
2Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics,
Duke University School of Medicine, Durham, NC
3Senior Consultant/Trinity Life Sciences, Waltham, MA
4Managing Director/Trinity Life Sciences, Waltham, MA
5Vice President, Medical Affairs/Enzyvant, Cambridge, MA
6Assistant Professor/Department of Pediatrics, Section of Allergy and Immunology,
University of Colorado, Anschutz School of Medicine; Children’s Hospital Colorado;
Department of Immunology and Microbiology, University of Colorado, Anschutz School
of Medicine, Aurora, CO
Congenital athymia is an ultra-rare disorder characterized by the absence of a thymus
in utero (naïve T-cell count < 100 cells/mm^3 at diagnosis); without treatment patients
typically die within two to three years of life due to recurring infections and sequelae
of immune dysregulation. Congenital athymia is associated with genetic/syndromic disorders,
including DiGeorge Syndrome, 22q11.2 deletion, CHARGE syndrome, FOXN1 deficiency,
diabetic embryopathy, and maternal alcohol exposure.
The objective was to characterize the economic, humanistic, and clinical burden of
illness of congenital athymia on patients receiving supportive care prior to cultured
thymic tissue implantation (CTTI; if received), and caregivers/families.
This cross-sectional study enrolled adult caregivers of patients with congenital athymia.
Caregivers of patients who have not received a CTTI responded to questions about congenital
athymia in the patient’s most recent 12 months (or patient’s lifetime, if < 12 months).
Additionally, the caregiver proxy version of the PedsQL Generic instrument was administered.
For caregivers of patients who had received CTTI at the time of participation, questions
were asked to consider only the time prior to treatment.
Interim quantitative results from the survey (n=18) are reported here; insights from
qualitative interviews will be reported in the poster. The sample included caregivers
of seven patients who never received CTTI [mean age (SD): 1.7 (0.8) years] and eleven
patients that received CTTI [8.8 (6.2) years]. The impact of congenital athymia on
patients and caregivers was significant across many characteristics including the
need to live in isolation (100% of respondents), financial hardship (78%), inability
to meet family/friends (72%), high burden of medical care, and impact on siblings/families
(67% each). Caregivers reported the impact on their own lives on a scale from 1-7,
7 being “very high impact” for a list of potential dimensions. Responses were rated
highly, with all nearly > 6; “Ability to plan for the future” was reported with the
highest average burden [mean: 6.9]. Caregiver-reported (n=7) PedsQL summary scores
indicated low quality of life across domains.
Conclusion: Caregivers of patients with congenital athymia reported high emotional,
social, financial, and clinical burden on patients and their families as a result
of the disease.
Keywords: congenital athymia, burden of illness, real-world evidence, cultured thymic
tissue implantation
Disclosure: Cathleen Collins, Bhagyashree Oak, Matthew O’Hara and Elena Hsieh are
consultants for Enzyvant. Sarah Kulke is employed by Enzyvant.
(111) WES 102: Whole-exome sequencing analysis and diagnostic yield in 100 patients
with recurrent infections and immune alterations
Saul Lugo Reyes, MD, MS1, Lina M Castano-Jaramillo, MD2, Luis Moises Silva Goytia,
MD3, Edgar A Medina Torres, PhD4, Marco Antonio Yamazaki-Nakashimada, MD5, Aide Tamara
Staines Boone, MD6, Selma C Scheffler Mendoza, MD, MSc.7, Ana Eunice Fregoso Zuñiga,
MD8, Francisco Rivas Larrauri, MD9, Alonso Gutierrez Hernandez, MD9, Nideshda Ramirez
Uribe, MD10, Juan Carlos Bustamante Ogando, MD, MSc11, Maria Edith Gonzalez Serrano,
MD, MSc11, Laura Berron Ruiz, PhD11, Hector Gomez Tello, MD12, David Muzquiz Zermeño,
MD13, Maria del Mar Saez de Ocariz Gutierrez, MD, MSc14, Melissa Espinosa Navarro,
MD15, Leticia Hernandez Nieto, MD16, Rosa Maria Cortes Grimaldo, MD17, Ana Paola Macias
Robles, MD18, Diana G Ramirez Vasquez, MD19, Kannelva M Gomez Castillo, MD20, Sandra
Rajme Lopez, MD21, Joel Barroso Santos, MD22, Rosa Martha Covarrubias Carrillo, MD23,
Aristoteles Alvarez Cardona, MD24, Beatriz A Llamas Guillen, MD25, Edna Venegas Montoya,
MD26, Ana Isabel Jimenez Romero, MD27, Carmen Zarate Hernandez, MD28, Mario Ernesto
Cruz Muñoz, PhD29, Chiharu Murata, MSc30, Sara Elva Espinosa Padilla, MD, PhD31
1Researcher/National Institute of Pediatrics
2Fellow in training/National Institute of Pediatrics
3General practitioner/Immune deficiencies lab, National Institute of Pediatrics
4Senior researcher/Immune deficiencies Lab, National Institute of Pediatrics
5Researcher/Clinical Immunology department, National Institute of Pediatrics
6Researcher/Hospital de Especialidades UMAE 25 IMSS Monterrey
7Attending/Clinical Immunology department, National Institute of Pediatrics, Mexico
City
8Attending physician/Immunology department, Hospital Angeles Morelia, Michoacan
9Attending physician/Clinical Immunology Department, National Institute of Pediatrics
10Attending physician/Transplantation Department, National Institute of Pediatrics
11Researcher/Immune deficiencies lab, National Institute of Pediatrics
12Attending physician/Clinical Immunology Service, Hospital del Niño Poblano
13Attending physician/Clinical Immunology Department, Hospital de Especialidades,
UMAE 25 IMSS Monterrey, NL
14Researcher/Dermatology Service, National Institute of Pediatrics
15Consulting physician/Immunology Department, Escuela Nacional de Ciencias Biologicas,
Instituto Politecnico Nacional
16Attending physician/Allergy and Immunology, Secretaria de Salud, Hospital Juarez
de Mexico
17Head/Clinical Immunology Service, Hospital de Especialidades, Centro Medico Nacional
de Occidente, Guadalajara, Jalisco
18Head/Immunology Service, Hospital de Pediatria, Centro Medico Nacional de Occidente
IMSS, Guadalajara, Jalisco
19Head of Pediatrics/Allergy and Immunology service, Hospital de la Niñez Oaxaqueña,
Oaxaca
20Attending physician/Allergy and Immunology service, Hospital de Especialidades El
Mirador
21Resident/Instituto Nacional de Nutricion y Ciencias Medicas
22Attending physician/Allergy and Immunology, Hospital del Niño DIF Pachuca, Hidalgo
23Physician/Immunology Department, Hospital General de Zacatecas
24Attending physician/Allergy and Immunology, Universidad Autonoma de Aguascalientes
25Attending/Immunology Department, Hospital del Niño Morelense
26Attending physician/Clinical Immunology Service, Hospital de Especialidades UMAE
25 IMSS Monterrey
27Head/Immunology Department, Hospital Angeles Leon
28Attending/Immunology Department, Hospital Universitario de Monterrey
29Head/Molecular Immunology Lab, Faculty of Medicine, Universidad Autonoma del Estado
de Morelos
30Researcher/Research Methodology Department, National Institute of Pediatrics
31Head/Immune deficiencies lab, National Institute of Pediatrics, Mexico City
At a national referral center we discuss and pursue the molecular and genetic diagnoses
of patients with suspected inborn errors of immunity (IEI) from all around the country.
Since two years ago, we process and analyze our own whole-exome sequencing (WES) results
at the lab. Assessing our diagnostic yield as a measure of performance and quality
control might help optimize processes, improve patient selection and resource allocation.
We aimed to characterize our patients with suspected inborn errors of immunity and
WES, to compare our diagnostic yield, and to identify attributes that might predict
a positive diagnosis.
We extracted gDNA from whole blood of patients with suspected IEI in Mexico. Exome
was sequenced in New Jersey using Illumina HiSeq with a 90% coverage and 50-100x raw
depth of the IDT Xgen library, human genome version 38. We obtained two FASTQ files
per patient to complete the bioinformatic workflow using Galaxy on the cloud for quality
control, mapping & alignment of the reads, as well as variant detection, annotation
and filtering; Ensembl Variant Effect Predictor to analyze said variants; Broad Institute
IGV and UCSC Genome Browser to visualize them. We defined diagnostic yield as the
proportion of patients with a genetic diagnosis after WES results analysis. Through
multivariate logistic regression and tree partitioning algorithm we explored differences
between diagnosed and undiagnosed cases.
We found a rare pathogenic variant in at least one gene known to cause IEI, and matching
the patient phenotype in 42 of 100 exomes, and of other monogenic causes in 5, for
a total yield of 47%. Statistical explorations suggested some predictingn features:
family history, dysgammaglobulinemia, hemophagocytosis, etc.
We describe our experience analyzing our first 100 exomes at home. Our results compare
well with those from other centers. A recent systematic review found 14 NGS studies
for IEI, and for mixed groups like ours the dx yield was 15-46%, a median of 25%.
Genetic diagnoses impact management, counseling, classification and epidemiology of
rare diseases, including IEI. WES is a powerful and cost-effective diagnostic tool.
Keywords: whole-exome sequencing, inborn errors of immunity, diagnostic yield
Disclosure: All authors indicated they had no financial relationships to disclose.
(112) Chronic Granulomatous Disease with Associated IgG4-Related Disease Masquerading
as Pulmonary Pseudotumor
Mahnaz Jamee, MD1, Mazdak Fallahi, MD2, Javad Enayat, MD2, Zahra Chavoshzadeh, MD3
1Medical Doctor, Research Assistant/Pediatric Nephrology Research Center, Research
Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran,
Iran
2Medical Doctor, Fellowship/Immunology and Allergy Department, Mofid Children's Hospital,
Shahid Beheshti University of Medical Sciences, Tehran, Iran
3Medical Doctor, Professor/Immunology and Allergy Department, Mofid Children's Hospital,
Shahid Beheshti University of Medical Sciences, Tehran, Iran
The association between IgG4-related disease (IgG4RD) and inborn errors of immunity
(IEI) is barely understood. Herein, we presented the first report of pediatric IgG4RD
and chronic granulomatous disease (CGD).
An 8.5-year-old male presented with complaints of dyspnea. He was the third child
of non-consanguineous parents and the family history was unremarkable.
He was hospitalized two years ago with exertional dyspnea, mild cough, chest pain,
and nocturnal sweating and was found to have a tumor-like mass in the right lung.
In the chest MRI obtained at the last admission, the mass had a diameter of 52*15*61
millimeters with invasion to atria, completely obstructing right upper lobe bronchus
and both right pulmonary veins. The histopathologic findings were consistent with
non-necrotizing granulomatous inflammation, central neutrophilic micro-abscess, and
extensive peripheral fibrosis without any evidence for acid-fast bacilli or fungal
elements.
Treatment with prednisolone resulted in considerable symptom resolution. After 15
months, following the discontinuation of prednisolone by the patient, symptoms recurred,
gradually exacerbated, and he developed anorexia and weight loss.
On the physical examination, respiratory distress, absent sound on auscultation and
dullness on percussion of the right lung were detected. The chest spiral CT scan showed
a large mass in the right lung, right lung collapse, and mediastinal metastasis. The
abdominal ultrasound and CT scan were normal.
In laboratory evaluation, the complete blood count, leukocyte differentiation, lactate
dehydrogenase, and liver function tests were normal, however, inflammatory markers
(ESR: 112, CRP:108) were high. In immunologic workup, lymphocyte subsets were normal
and serum immunoglobulin levels included IgG: 2530, IgM: 178, IgA: 151, IgG1: 1885,
IgG2: 561, IgG3: 32, and IgG4: 311 (normal range: 2.3-189). The NBT test was zero
in two consecutive evaluations. In virtue of high IgG4 level, the immunostaining of
lung specimen was performed which was inconclusive for IgG4+ cells, and staining for
CD138 was not available.
He was eventually diagnosed with concurrent CGD and IgG4RD, but progressed to respiratory
failure and died despite the reinstitution of steroid therapy.
Further studies to investigate IgG subsets among IEI patients with pulmonary manifestations
can help elucidate clinicopathological correlations between IgG4RD and IEIs.
Keywords: Inborn Error of Immunity, IgG4-related Disease, Chronic Granulomatous Disease,
Pulmonary manifestations
Disclosure: All authors indicated they had no financial relationships to disclose.
(113) An easily available score to detect patients at risk of death after COVID19
infection
Javier Carbone, MD, PhD1, Jimena Gomez-Perez, MD2, Elizabeth Sarmiento, MD, PhD3
1Consultant Clinical Immunologist/Clinical Immunology Department. Hospital General
Universitario Gregorio Marañón
2Immunology registrar/Clinical Immunology Department. Hospital General Universitario
Gregorio Marañon
3Consultant Clinical Immunologist/Laboratory Medicine Department. Hospital Universitario
La Paz
Background. COVID19 severe disease is associated with high mortality. There are no
widely accepted proved therapeutic interventions that decrease mortality rates. So,
all the efforts to detect patients at higher risk of developing severe disease are
of utmost importance because this could aid to select patients for intervention. Taking
into account that COVID19 is a pandemic infection biomarkers should be easily available
all around the world including developing countries.
Objectives. We aimed to evaluate an easily available laboratory profile of progression
to death at time of admission for COVID19 pneumonia that could be easily introduced
into clinical practice.
Methods. The proposed basic profile to assess the risk of progression to COVID19 related
death was the assessment at hospital admission of neutrophil count, lymphocyte count,
total proteins and albumin concentration. 100 adult COVID19 patients with positive
PCR to SARS-CoV-2 were prospectively evaluated at the time of admission at the Gregorio
Marañón Hospital in Madrid, Spain, during the first wave (March-May 2020). During
follow-up 14 patients (14%) died after admission.
Results. Patients who died were found to have higher levels of neutrophils and neutrophil
to lymphocyte ratio as compared with survivors (6469±4522 vs 4302±2965 cells/ul, p=0.026
and 8.29±6.41 vs 5.00±4.34, p=0.020, respectively). Using ROC curves we identified
cut-offs. Patients with neutrophil to lymphocyte ratio >4 and albumin < 3.3 g/dL were
at higher risk of death (odds ratio, OR 4.16; 95%CI 1.06-16.27, p=0.04 and OR 7.49,
95%CI 1.22-45.94, p=0.029, respectively). Patients with both factors were at even
higher risk of death (OR 12.99, 2.06-81.90, p=0.0063). Calculated globulin (difference
between total protein and albumin results) at admission < 1.9 g/dL was not associated
with risk of death.
Conclusions. An easily available laboratory profile (neutrophil to lymphocyte ratio
>4 and albumin < 3.3 g/dL) was useful to assess the risk of death in COIVID19 patients.
Multivariate analysis in greater number of patients is the next stept to further evaluate
the independence of this potential predictor of death in hospitalized COVID19 patients.
This profile has real potential to be introduced in the routine for better selection
of patients for early therapeutical interventions.
Keywords: COVID19, Risk factors of death, Prediction
Disclosure: All authors indicated they had no financial relationships to disclose.
(114) High Dose Intravenous Immunoglobulin. The next step in therapy for severe COVID19
infection?
Maria Alejandra Mejia, MD1, Marisa di Natale, MD2, Hector Balastegui, MD3, Jimena
Gomez-Perez, MD1, Elena Seoane, MD4, Javier Carbone, MD, PhD2
1Immunology Registrar/Clinical Immunology Department. Hospital General Universitario
Gregorio Marañon
2Consultant Clinical Immunologist/Clinical Immunology Department. Hospital General
Universitario Gregorio Marañón
3Immunology Registrar/Clinical Immunology Department
4Consultant Immunologist/Allegology Department, Hospital General Universitario Gregorio
Marañon
COVID-19 disease is associated with high mortality among high-risk patients. Up today
the only widely accepted interventions for hospitalized patients are enoxaparin and
dexamethasone. All new information in this field is important. Distintc immunebased
therapies are under investigation in clinical trials. We report a case serie of 5
patients admitted in our hospital with COVID-19 pneumonia who were treated with high-dose
intravenous immunoglobulin (IVIG). Severely ill COVID-19 patients were treated with
high-dose IVIG. Results. Patient 1 with previous history of lymphoma, secondary IgG
hypogammaglobulinemia and persistence of SARS-Cov2 viremia (more than 3 months), received
high-dose IVIG, 0.5 g/kg for 5 days (total 150 grams). Previous therapy included corticosteroids,
tocilizumab, anakinra, lopinavir/ritonavir, remdesivir and 2 sesions of convalescent
plasma. Low and transitory maintenance of SARS-Cov2 IgG antibodies was observed after
plasma infusions. Patient 2 was treated with 0.4 g/kg for 3 days (total 150 grams).
Obesity (120 kg), hypertension and diabetes were risk factors. Previous therapy included
lopinavir/ritonavir. Due to severe bacterial infection corticosteroids and tocilizumab
were not added as therapy. Patient 3 with severe pneumonia received therapy with remdesivir.
High dose IVIG was added at a dose of 2 g/kg. Patient 4 was a CVID patient that demostrated
bad radiological evolution soon after admission in hospital and received therapy with
1 g/kg of IVIG. Patient 5 was a 17 years-old women with previous history of myeloid
leukemia. Previous therapy included tocilizumab, remdesivir and convalescent plasma.
High dose IVIG was added at a dose of 2 g/kg (1gr/kg during 2 days). Biomarkers associated
with bad prognosis (including high IL6) were observed in all cases. High-dose IVIG
prevented deterioration of clinical symptoms and progression to mechanical ventilation
in 4 cases and coincided with extubation a few days after addition of IVIG in patient
5. After high-dose IVIG was completed 4 patients were discharged from the hospital
with a stable clinical condition in a few days and 1 patient was discharged from ICU.
Infusions were tolerated well. DVT was observed in patient 2. Conclusion. High-dose
IVIG can improve clinical condition and prevent progression to ICU usage in COVID-19
patients with severe symptoms.
Keywords: COVID19, Therapy, High dose intravenous immunoglobulin
Disclosure: All authors indicated they had no financial relationships to disclose.
(115)
A Self-Limited Qualitative Complement Deficiency in Infancy
Ian Slack, MD1, Stephanie Ward, MD2, Kimberly Risma, MD, PhD3
1Clinical Fellow/Division of Allergy and Immunology, Cincinnati Children's Hospital
Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine,
Cincinnati, OH
2Assistant Professor/Division of Allergy and Immunology, Cincinnati Children's Hospital
Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine,
Cincinnati, OH
3Associate Professor/Division of Allergy and Immunology, Cincinnati Children's Hospital
Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine,
Cincinnati, OH
Complement deficiencies are a rare cause of innate immune defects with variable phenotypes
depending on the particular component deficiency. While these deficiencies may be
inherited or acquired, patients presenting in young childhood typically have a genetic
etiology. Here we present a case of a young infant with initial near-absent complement
activity who recovered function after 6 months with no underlying genetic difference
identified.
A previously healthy 3-month old boy was hospitalized for prolonged fever and respiratory
symptoms and diagnosed with necrotizing pneumonia. He responded to antibiotic therapy
and surgical drainage. Immunology was consulted due to the severity of infection.
His workup revealed normal lymphocyte subsets apart from expansion of terminally differentiated
CD8 T cells suggesting recent systemic viral infection; HIV testing was negative.
Additionally, he demonstrated normal neutrophil oxidative burst and normal IgM/IgA
levels. However, his CH50 returned decreased at 5 CH50 units (normal range 101-300
units). On recheck one month later, his CH50 remained depressed at 2 CH50 units. Alternative
pathway functional assay and lectin pathway functional assay at that time showed undetectable
activity ( < 10% and < 4%, respectively). Based on these results, a defect in C3 or
terminal complement was suspected (figure 1). Complement component levels did not
identify quantitative complement defects. Workup for qualitative complement defects
included normal C3 and C5 functional assays, as well as a normal next-generation sequencing
panel encompassing 80 genes and C5 Sanger sequencing. At 9 months of age (6 months
after his initial complement screen), both CH50 and AH50 recovered to normal levels.
The patient was placed on amoxicillin prophylaxis upon initial diagnosis of complement
deficiency and has not had additional serious infections.
This case highlights an unusual recovery of complement function in infancy. Although
the inciting etiology for decreased complement activity was not identified in our
patient, his course suggests that some infants without identified genetic differences
in the complement system may regain function.
Figure 1. The complement cascade can be triggered by 1 of 3 pathways: lectin, classical,
or alternative. These pathways converge with the assembly of a C3 convertase and ultimately
the formation of the membrane attack complex. Complement deficiencies can be interrogated
by measuring function of the 3 distinct pathways. The patient had deficient function
in all 3 pathways, suggesting a C3 or terminal complement deficiency. Complement cascade
schematic adapted from: Murphy, Kenneth, and Casey Weaver. Janeway's Immunobiology.
Garland science, 2016
Keywords: Innate Immunity, Complement Deficiency, Complement System
Disclosure: All authors indicated they had no financial relationships to disclose.
(116) Missing in Plain Sight: Chromosomal Microdeletion and GATA2 Deficiency
Catherine Freeman, MD1, Cindy Bauer, MD2, Holly Miller, DO3, Benjamin Wright, MD4
1Allergy and Immunology Fellow/Mayo Clinic Arizona
2Section Chief, Allergy and Immunology/Phoenix Children's Hospital
3Divison of Hematology and Oncology/Phoenix Children's Hospital
4Division of Allergy, Asthma and Clinical Immunology/Mayo Clinic Arizona
The relationship between chromosomal deletion and immunodeficiency is best established
in 22q11.2 deletion syndrome. Widespread availability of genetic testing has resulted
in a greatly increased number of recognized chromosomal deletion and microdeletion
syndromes. Deletions, especially on the X chromosome, have been ascribed to immunodeficiency
states including X-linked chronic granulomatous disease, Wiskott-Aldrich syndrome
and X-linked SCID. However, the association between chromosomal deletions and immunodeficiency
remains incompletely characterized.
A six-year-old girl was evaluated for recurrent sinopulmonary and urinary tract infections.
Medical history was notable for developmental delay with a de novo 3q13.33-q21.3 deletion
and vesicoureteral reflux. Surgical history was remarkable for adenotonsillectomy
age three. Physical examination demonstrated dysmorphic facies, microcephaly and low
set ears. Laboratory evaluation revealed B and T-cell lymphopenia (CD4+ cells 351/mm3,
CD8+ cells 312/mm3, CD19+ cells 247/mm3). Absolute monocyte count was normal. IgG
was low for age at 381mg/dL but with normal IgM and IgA. Oxidative burst, total complement
and vaccine titers were protective. The patient underwent ureteral reimplantation
in conjunction with trimethoprim/sulfamethoxazole prophylaxis and was asymptomatic
thereafter. Following discontinuation of antibiotic prophylaxis, her course was complicated
by viral gastroenteritis and recurrent pneumonia. Genetic sequencing revealed a heterogeneous
pathogenic mutation in GATA2, with the entire coding sequence missing. Bone marrow
biopsy showed no evidence of dysplasia and computerized tomography of the chest was
without findings suggestive of bronchiectasis or pulmonary alveolar proteinosis. The
patient is currently managed on immunoglobulin replacement therapy and daily azithromycin
prophylaxis, with improvement in infection frequency and severity.
GATA2 is a zinc finger transcription factor essential for hematopoiesis and lymphatic
angiogenesis. GATA2 deficiency is caused by mutations in the GATA2 gene and follows
an autosomal dominant pattern of inheritance. Patients are susceptible to infection
(mycobacterial, viral and fungal), marrow failure and myeloid leukemias, lymphedema
and pulmonary alveolar proteinosis. Disease onset, clinical features and outcomes
are heterogenous. The GATA2 gene is located at 3q21.3 and has not previously been
reported in microdeletion syndromes affecting chromosome 3. Meticulous review of the
genes encompassed in a chromosomal microdeletion is critical in immunodeficiency evaluation
as it can allow for earlier detection of primary immunodeficiency.
Keywords: GATA2 Deficiency, chromosomal deletions, primary immunodeficiency, microdeletions,
gene deletions
Disclosure: All authors indicated they had no financial relationships to disclose.
(117) PATH4WARD: A Genetic Testing Program for Primary Immunodeficiencies With Neutropenia
Including WHIM Syndrome
Britt Johnson, PhD, FACMG, HCLD(ABB)1, James Connelly, MD2, Sarah Cohen, MD3, Lukas
Dillinger, PhD4, Adriana Badarau, MSc, PhD5, Swaroop Aradhya, Ph.D., FACMG6, Ana Morales,
MS, CGC7, Peter Newburger, MD8
1Medical Director, Metabolic Genetics and Immunology,Medical Affairs Director, Biopharma
Partnerships/Invitae Corporation, San Francisco, CA
2Assistant Professor Pediatric Hem/Onc/BMT/Vanderbilt University Medical Center, Nashville,
TN
3Medical Director, Rare Disease/X4 Pharmaceuticals Inc, Boston, MA
4Director, Translational Sciences & Preclinical QA/X4 Pharmaceuticals Inc, Boston,
MA
5Discovery Director/X4 Pharmaceuticals Inc, Boston, MA
6Medical Director/Invitae, San Francisco, CA
7Medical Affairs Liaison/Invitae Corporation, San Francisco, CA
8Physician/University of Massachusetts Medical School, Worcester, MA
PATH4WARD is a no-charge, sponsored genetic testing program utilizing a next-generation
targeted sequencing panel to provide early and accurate diagnosis for patients with
suspected congenital neutropenia (CN) including WHIM (Warts, Hypogammaglobulinemia,
Infections, Myelokathexis) syndrome, a condition with a therapeutic option currently
under investigation in clinical trials. Patients with WHIM present with heterogeneous
symptoms that include neutropenia, increased susceptibility to infections, and persistent
warts. Early diagnosis of CN is key to reduce progression of long-term morbidities
and improve quality of life. We report methods and demographics for initial utilization
of the PATH4WARD program from July 2019–September 2020.
At the time of data acquisition, PATH4WARD utilized a 23-gene CN panel, with reflex
to a 207-gene primary immunodeficiency (PID) panel. Patients with a clinical presentation
compatible with congenital or chronic idiopathic neutropenia and history of chronic
severe neutropenia (absolute neutrophil count [ANC] ≤500/μL) were eligible. Analysis
was performed at Invitae using multiple algorithms to identify single nucleotide variants,
small/large indels, structural variants, and exon-level copy number variants. Sequencing
was performed at an average depth of 350X (minimum 50X). Variants were classified
per Sherloc, Invitae’s score-based refinement of recent guidelines.[1]
PATH4WARD was utilized by 156 unique physicians, most frequently by specialists in
pediatric hematology/oncology (52.5%), followed by adult hematology (14.6%), clinical
genetics (12.0%), other pediatric (9.5%), allergy/immunology (8.2%), and medical oncology
(3.2%). The median age of patients tested was 5 years (range, 0–81).
The PATH4WARD program, sponsored by X4 Pharmaceuticals and Invitae, is a valuable
tool for facilitating early genetic evaluation of patients with suspected PIDs with
neutropenia, including WHIM. Pediatric hematology/oncology physicians most commonly
referred patients, and a pediatric focus was highlighted by the age those enrolled.
Owing to the success of PATH4WARD and the greater opportunity to help additional patients
with CN, inclusion criteria were broadened in September 2020 to include patients with
ANC ≤750 cells/μL, and the panel was extended, without need for reflex, to analyze
407 genes associated with PIDs including many associated with CN or neutropenia acquired
in the context of an inborn error of immunity.[2]
References:
1. Nykamp K et al. Genet Med. 2017;19(10):1105-1117.
2. PATH4WARD Program.
https://www.invitae.com/en/path4ward/
Keywords: WHIM Syndrome, Primary Immunodeficiency, PATH4WARD
Disclosure: Britt Johnson, Swaroop Aradhava, and Ana Morales is an employee of Invitate.
Sarah Cohen received financial and material support from Clinical and Laboratory Standards
institute and is employed by X4 Pharmaceuticals. Lukas Dillinger is employed by X4
Pharmaceuticals and UCB Pharma GmbH. Adriana Badarau is employed by X4 Pharmaceuticals.
All authors indicated they had no financial relationships to disclose. Peter Newburger
is an advisory board member of X4 Pharmaceuticals.
(118) Immune Dysregulation With Mucocutaneous Ulceration in a Large Cohort Due to
A Novel Pathogenic RELA Variant.
Kelsey Lecerf, MD1, Hyesun Kuehn, PhD2, Jennifer Yonkof, MD3, Daniel Koboldt, MS4,
Theresa Mihalic Mosher, MS, LGC5, Mari Mori, MD6, Scott Hickey, MD7, Shoghik Akoghlanian,
MD8, Vidya Sivaraman, MD8, Sergio Rosenzweig, MD, PhD9, Roshini Abraham, PhD10
1Allergy and Immunology Fellow/The Ohio State University Wexner Medical Center/Nationwide
Children's Hospital, Columbus, OH
2Staff Scientist/Immunology Service, Department of Laboratory Medicine, NIH Clinical
Service, Bethesda, MD, USA
3Allergy and Immunology Physician/ProMedica Physicians Allergy and Immunology, Toledo,
OH
4Principal Investigator, Institute for Genomic Medicine/Nationwide Children's Hospital,
Columbus, OH
5Licensed Genetic Counselor/Institute for Genomic Medicine, Nationwide Children's
Hospital, Columbus, OH
6Clinical and Biochemical Geneticist, Division of Genetic & Genomic Medicine/Nationwide
Children's Hospital, Columbus, OH
7Clinical Geneticist, Division of Genetic & Genomic Medicine/Nationwide Children's
Hospital, Columbus, OH
8Pediatric Rheumatologist/Nationwide Children's Hospital, Columbus, OH
9Senior Investigator/Immunology Service, Department of Laboratory Medicine, NIH Clinical
Center, Bethesda, MD, USA
10Director of the Diagnostic Immunology Laboratory/Department of Pathology and Laboratory
Medicine, Nationwide Children’s Hospital, Columbus, OH
NFκB includes a family of inducible transcription factors important for immune regulation.
One of the key components of the canonical pathway of NFκB is p65 (RELA gene). Here,
we report four patients, from a large family kindred, with chronic mucocutaneous disease
with a novel frameshift variant in RELA (c.1044dupC, p.Tyr349LeufsTer13).
The objective was to assess the functional impact of this RELA variant on the canonical
NFκB pathway.
Immunoblotting for the canonical NFκB pathway components was performed after LPS stimulation
of cells PBMCs from four affected individuals and healthy controls. Immunophenotyping
of T and B cell subsets was performed.
WES on P3 and P4, which revealed the previously mentioned novel variant, which segregated
with disease. This RELA variant results in premature truncation of the protein before
the serine (S) 536 residue, which is a key phosphorylation site, which could result
in enhanced degradation of the protein. Immunoblotting revealed significantly decreased
phosphorylated (p) p65 with increased levels of native IKBα and decreased pERK. The
levels of pIKKα and pIKKβ (and native IKKα and IKKβ), along with pIKBα were comparable
to controls. The decrease in phosphorylated p65 in the patients suggests reduced heterodimer
formation between p50/p65 [NFκB1/RelA]. Extensive T cell immunophenotyping revealed
decreased CD4+ and CD8+ CD45RA+ T cells with increased memory CD4+ T cells in one
of the 4 patients (P1). This patient also had increased CD4+25+ activated T cells,
and senescent CD57+CD4+ and CD57+CD8+ T cells. B cell phenotyping was unremarkable.
Cellular apoptosis and death was evaluated at baseline, 4 hours and 24 hours after
stimulation with 100 ng LPS and showed no evidence of increased apoptosis or death
in lymphocytes in any of the patients after stimulation.
Family members with this novel RELA variant have a clinical phenotype similar to other
reported RELA cases with predominant chronic mucocutaneous ulceration, however, the
clinical phenotype is expanded to include Behçet’s disease and inflammatory bowel
disease (IBD, Crohn’s). There is impairment of the canonical pathway of NFκB. These
findings will improve our understanding of the pathogenesis of early-onset or familial
Behçet’s, and IBD, and may direct therapeutic/management decisions for these patients.
Figure 1. RELA Variant Pedigree
Table 1. Demographics and Clinical Features of Affected Patients
Keywords: Immune Dysregulation, Primary immunodeficiency, RELA, NFkB, Mucocutaneous
ulceration
Disclosure: All authors indicated they had no financial relationships to disclose.
(119) A novel pathogenic variant in FANCA uncovers a previously undiagnosed case of
Fanconi Anemia (FA) in a 22-year-old woman
Hannie Zomer, MD1, Arye Rubinstein, MD, PhD2, Rachel Eisenberg, MD3, Robert Marion,
MD4, Monisha Sebastin, MS, CGC5
1Fellow/Montefiore Medical Center
2Chief of the Pediatrics Division of the Department of Allergy & Immunology/Montefiore
Medical Center
3Attending in Allergy and Immunology/Montefiore Medical Center
4Chief of the Divisions of Genetics and of Development Medicine/Montefiore Medical
Center
5Certified Genetic Counselor/Montefiore Medical Center
FA is an autosomal recessively inherited condition characterized by physical features,
bone marrow failure and increased risk of malignancy. We present a 22-year-old female
with multiple medical issues in whom a Primary Immunodeficiency (PID) panel led to
an unexpected diagnosis of FA.
TC was referred because of recurrent upper respiratory infections with fevers, abnormal
liver enzymes since childhood, and chronic fatigue. Past history revealed megaloblastic
anemia non-responsive to vitamin B12 and growth failure unresponsive to growth hormone.
Immune evaluation revealed normal serum immunoglobulins, protective titers to measles,
mumps, rubella, and absent response to streptococcus pneumoniae (14/14 titers were
< 0.5mcg/mL). Pan-activation was noted on a cytokine panel along with elevated double
positive T-cells of unknown significance (23% CD3+CD4+CD8+ T – cells). A PID panel
(Invitae) demonstrated a heterozygous deletion of one FANCA allele and two variants
(c.3539T>A and c.4199G>A) noted by the lab to be of unknown significance in the second
allele. Based on in-silico analysis, the c.4199G>A variant was suspected to likely
be pathogenic. Diepoxybutane assay demonstrated chromosome breakage in TC that was
3-10 times greater than control, confirming the diagnosis of FA. Further proband and
maternal genetic studies, including microarray, revealed maternal inheritance of a
16q24.3 deletion encompassing FANCA. Further studies are needed to confirm that the
second variant (c.4199G>A) is paternally inherited. Bone marrow biopsy was within
normal limits. A multi-gene molecular profiling assay covering genes implicated in
the pathogenesis of solid and/or hematological malignancies was within normal limits.
The patient is currently undergoing evaluation for allogenic-hematopoietic stem cell
transplantation.
We describe a 22-year-old woman with FA in whom a variant in FANCA (c.4199g>A) previously
described as a VUS was determined to be pathogenic. In retrospect, TC had multiple
findings seen in FA, including macrocytosis, growth failure, horseshoe kidney, multiple
café-au-lait macules, and abnormal left thumb. Individuals with FA often exhibit immune
activation early in life leading to neoplastic disease. In TC, diagnosis was delayed
until the third decade because of the mild nature of her symptoms. We suspect this
is because the c.4199G>A variant produced partial protein function. We are closely
following her course.
Keywords: Fanconi Anemia, Immune activation, Pathogenic variant
Disclosure: All authors indicated they had no financial relationships to disclose.
(120) Early T-cell Development in Twins with Heterozygous FOXN1 Mutations
Saara Kaviany, DO1, Todd Bartkowiak, PhD2, Kelsey Voss, PhD3, Yasmin Khan, MD4, Daniel
Dulek, MD5, Sarah Neumann, RN6, Jeffrey Rathmell, PhD7, Jonathan Irish, PhD8, James
Connelly, MD9
1Pediatric Hematology/Oncology/BMT Instructor/Vanderbilt University Medical Center
2Research Fellow, Department of CDB/Vanderbilt University
3Research Fellow, Department of PMI/Vanderbilt University
4Assistant Professor Pediatrics AI/Vanderbilt University Medical Center
5Assistant Professor Pediatric ID/Vanderbilt University Medical Center
6Pediatric BMT Case Manager/Vanderbilt University Medical Center
7Associate Director - Vanderbilt Institute for Infection, Immunology and Inflammation,
Professor PMI/Vanderbilt University
8Associate Professor of Cell and Developmental Biology/Vanderbilt University
9Assistant Professor Pediatric Hem/Onc/BMT/Vanderbilt University Medical Center, Nashville,
TN
The transcription factor FOXN1 plays an essential role in thymic epithelial development,
mediating selection of maturing thymocytes1. Heterozygous loss-of-function FOXN1 variants
are associated with low T-cell receptor excision circles (TRECs) and T-cell lymphopenia
at birth1. CD4+ T-cell reconstitution is not completely understood, but a lower proportion
of naïve T-cells in adult patients has suggested a role for homeostatic proliferation1.
We present fraternal twins with low TRECs at birth, found to have a pathogenic heterozygous
variant in FOXN1. Using 40+ plex single-cell mass cytometry (CyTOF) we performed extensive
immune-profiling to understand T-cell development in newborn patients with lymphopenia.
Increased understanding of the immune milieu will guide potential need for therapeutics,
and risk for infection or autoimmunity over time.
The twins presented at birth with severely low TRECs by newborn screen and T-cell
lymphopenia with quantitatively normal B- and NK- cells.
Genetics- Targeted primary immunodeficiency testing revealed two heterozygous variants
of unknown significance: in DOCK8 (C.277G>T, p.Val93Leu), and FOXN1 (c.1205del, p.Pro402Leufs*148).
The FOXN1 variant found shares a similar frameshift mutation to reported patients2,
affecting the transactivation domain necessary for increasing DNA affinity in a DNA
binding assay3.
Immunophenotype- The patients were enrolled in the Human Immune Disease Initiative
(HIDI) at Vanderbilt University, combining multidimensional cytometry and genomics
to gain deeper insight into inborn errors of immunity. Key findings (depicted in Figure
1) include an expansion of terminally differentiated CD4+ TEMRA cells and contraction
of the CD8+ naïve (CD45RA+ CCR7+) T-cells in peripheral blood of the patients with
FOXN1 mutations relative to healthy controls. Both patients had increased CD38 and
ICOS expression, suggesting a T-cell activation state.
Through deeper immunophenotyping of this variant, our findings suggest that defective
FOXN1 expression may impact peripheral T-cell differentiation, potentially through
impaired thymic selection and subsequent early peripheral expansion and maturation
in a lymphopenic environment. We present HIDI as a platform capable of high-dimensional
immune phenotyping to provide further understanding of pediatric inborn errors of
immunity. Our findings support a future focus exploring T-cell development and the
role of CD4+ TEMRA cells in patients with severe lymphopenia, such as the FOXN1 heterozygous
variants.
Figure 1: Deep phenotyping of CD45+ CD3+ T-cells from FOXN1 heterozygous twins and
a healthy donor using mass cytometry and t-SNE: t-SNE plots from mass cytometric data
demonstrating greater frequencies of CD4+ TEMRA cells (red) and fewer CD8+ naïve T
cells (green) observed in the T cell compartment of the FOXN1 twins than in the healthy
reference.
Keywords: lymphopenia, mass cytometry, immunophenotyping, FOXN1, CD4+ TEMRA
Disclosure: Jeffrey Rathmell received research grants from Incyte, Kadmon, and Tempest;
advisory board member of Caribou Biosciences, Nirogy, Sitryx; and is a consultant
for Mitobridge. All other authors had no financial relationship to disclose.
(121) The lockdown in 2020 has opened a new path in the genetic diagnosis of patients
with hereditary angioedema.
Irina Guryanova, Phd student1, Ekaterina Polyakova, PhD student2, Iryna Ausianik3,
Andrei Salivonchik4, Valeria Pugacheva1, Yulia Zharankova, Phd student5, Mikhail Belevtsev,
PhD6
1Bench scientist/Belarusian research center for pediatric oncology, hematology and
immunology
2PhD student,Research in the field of genetics of PIDS, determination of TREC /KREC/Belarusian
Research Center for Pediatric Oncology, Hematology and Immunology,clinical research
laboratory of the scientific department
3President of HAE Belarus/Belarussian National Public Organization "HAE Patients Care"
4Physician/Republican Scientific and Practical Center of Radiation Medicine and Human
Ecology
5Physician/Belarusian research center for pediatric oncology, hematology and immunology
6PhD/Belarusian Research Center for Pediatric Oncology, Hematology and Immunology,
Deputy Director for Research
Hereditary angioedema (HAE) is a rare, but potentially life-threatening genetic disorder,
characterized by acute, recurring, and self-limiting edematous episodes of the face,
extremities, trunk, genitals, upper airways, or the gastrointestinal tract. HAE due
to C1-inhibitor deficiency (Type I) or dysfunction (Type II) occurs in about 1 in
10,000 to 1 in 50,000 people without racial or gender differences.
In 2020 due to the COVID-19, we started using the Dry Blood Spot (DBS) method for
the genetic diagnostic for 33 blood relatives of previously diagnosed HAE patients
(8 were symptomatic and 25 were asymptomatic), who were not able to come to the Center.
Patients sent their DBS using postal envelopes. Genetic analysis was performed by
Sanger sequencing.
In all symptomatic patients, we identified family mutations. 20 from 25 asymptomatic
blood relatives were wild type for the family mutations and 5 patients were diagnosed
before their first attacks. Thus, there are now 85 genetically confirmed HAE patients
in Belarus (50 females): 64 are type I (75.3%) and 21 - type II (24.7%). Based on
these results, the estimated minimal prevalence of HAE in Belarus is 1: 110 700 (0.90
in 100 000).
Since HAE attacks can start without any reason or can be caused by the trigger (stress,
trauma, etc.) patients are afraid of moving within the country for diagnostic purposes.
Thanks to the DBS method, we diagnosed 13 patients, some of whom could not come to
the Belarusian research center for pediatric oncology, hematology and immunology for
more than 5 years. We are confident that the DBS method has received high evaluation
and response among HAE patients, primarily due to its simplicity and convenience.
Keywords: Hereditary angioedema (HAE), c1 inhibitor deficiency, genetic diagnosis,
Dry Blood Spot, Belarus
Disclosure: All authors indicated they had no financial relationships to disclose.
(122) A novel semi-quantitative ELISA for measuring circulating SARS-CoV-2 neutralizing
antibody levels in human plasma or serum that correlates with a plaque reduction cell-based
neutralization assay
Andrew Gibson
1, Wm Pat Leinert2, Dima Decker, PhD3, Gene Wetzstein, PharmD, BCOP4, James Mond,
MD/PhD5
1Manager Assay Development/Leinco Technologies, Inc
2President and CEO/Leinco Technologies, Inc
3Associate Director of Medical Affairs/ADMA Biologics
4Executive Director & Head of Scientific Engagement/ADMA Biologics
5Chief Scientific Officer/Chief Medical Officer/ADMA Biologics
The protective quality of convalescent plasma and vaccine efficacy is reflected in
a large part by the level of neutralizing antibodies (NAbs). The gold standard for
detecting NAbs against viruses is the plaque reduction cell-based neutralization assay
(PRNT) that requires specialized facilities, is costly and takes several days. To
overcome these challenges, we have developed a rapid, semi-quantitative ELISA that
measures COVID-19 NAbs, correlates closely with the live virus plaque reduction assay
and can be used for high throughput screening of samples.
Results obtained from the ELISA were compared to the results from PRNT for positive
percent agreement (PPA) and negative percent agreement (NPA) with 115 samples (95%
confidence interval [CI] was calculated using the Wilson Method). Cross-reactivity
to antibodies against 11 viruses including the common coronaviruses NL63, 2293, OC43
and HKU1 was analyzed with this ELISA.
When comparing the ELISA and PRNT PPA for the 115 samples, there was a very close
correlation between the extent of neutralization in these two assays. ELISA specificity
was demonstrated, as there was no cross-reactivity with the 55 potentially cross reactive
samples tested. In addition, of the 531 negative plasma samples collected from healthy
donors prior to the COVID-19 outbreak, 527 samples were negative for NAbs resulting
in 99.3% specificity. Furthermore, when screening 100 convalescent plasma donor samples,
only 61% of the samples contained COVID-19 NAbs. Eighty percent of these exhibited
low to moderate neutralization and only 20% contained high neutralization activity.
We have developed a rapid high throughput ELISA assay that measures COVID-19 NAbs
and has demonstrated a significant correlation to PRNT. This assay can be used to:
1) screen donor plasma units for NAbs prior to their inclusion in the manufacture
of IG to achieve a plasma pool with the highest level of NAbs, 2) test vaccinated
subjects to ensure that they have mounted a protective NAb titer to COVID-19 and 3)
continue to monitor the vaccinated population for sustained levels of protective NAbs.
Keywords: ELISA, COVID-19, SARS-CoV-2, convalescent plasma
Disclosure: Andrew Gibson and Wm Pat Leinert are employed by Leinco Technologies,
Inc. Dima Decker, Gene Wetzstein and James Mond are employed by ADMA Biologics.
(123) A Case of Zhu‐Tokita‐Takenouchi‐Kim (ZTTK) Syndrome in a Child With Significant
Hypogammaglobulinemia and Poor Vaccine Response
Lauren Gunderman, MD1, Aisha Ahmed, MD2, Amer Khojah, MD3
1Allergy and Immunology Fellow/Northwestern McGaw and Ann and Robert H Lurie's Hospital
2Attending Physician, Allergy and Immunology/Ann and Robert H Lurie Children's Hospital
of Chicago
3Attending Physician, Allergy, Immunology, and Rheumatology/Ann & Robert H. Lurie
Children's Hospital of Chicago/ Northwestern University Feinberg School of Medicine
Zhu‐Tokita‐Takenouchi‐Kim (ZTTK) Syndrome is a rare, congenital anomaly syndrome caused
by de novo variants in the SON gene located on 22q22.11. Given the heterogeneity of
variants, there is no clinical diagnostic criteria, but patients often have intellectual
disability, brain malformation, facial dysmorphia, musculoskeletal abnormalities,
and visceral malformations. We present a case of ZTTK Syndrome with significant hypogammaglobulinemia
and need for immunoglobulin replacement.
A 2-year-old girl with known ZTTK syndrome, diagnosed on whole exome sequencing (WES),
complicated by subglottic stenosis, hypothyroidism, hypoglycemia, developmental delay,
dysphagia with GJ tube dependence, and left ventricular dysfunction, presented to
the emergency department (ED) in respiratory failure. The patient was intubated with
concern for aspiration and found to be rhinovirus/enterovirus positive. She was admitted
to the pediatric intensive care unit (PICU), and required prolonged intubation for
five days. Immunology was consulted given a past medical history significant for 4
episodes of acute otitis media, multiple viral infections (rhinovirus/enterovirus,
norovirus and rotavirus), hypovolemic shock secondary to E. faecalis urosepsis and
recurrent fevers without a clear infectious trigger. Pertinent Immunology labs included
a severely low IgG of 150 mg/dL, low IgM of 29 mg/dl, normal IgA and poor antibody
response to both Streptococcus pneumonaie(only 1 out 23 serotype was >1.3) and Tetanus
( < 0.1IU/ml). T and B cell lymphocyte enumeration was within normal limits. In the
setting of hypogammaglobulinemia, concern for poor vaccine responses and recurrent
infections, the child received Intravenous Immunoglobulin (IVIG) with an appropriate
increase of her IgG. The patient was discharged home with plans for continued IVIG,
unfortunately she continued to have ED visits and admissions for emesis and died a
month later after an episode of emesis, choking and exhaustion of Cardiopulmonary
Resuscitation (CPR).
ZTTK Syndrome is a rare congenital anomaly syndrome characterized by multiple congenital
anomalies, including facial dysmorphia, musculoskeletal abnormalities and visceral
abnormalities. Our patient’s presentation was further complicated by having a humoral
immunodeficiency and the need for replacement Immunoglobulin. In their approach to
children with ZTTK Syndrome and recurrent infections, clinicians should consider investigating
for immunodeficiency.
Keywords: Zhu‐Tokita‐Takenouchi‐Kim (ZTTK), hypogammaglobulinemia, CVID
Disclosure: All authors indicated they had no financial relationships to disclose.
(124) The interrelationship of CVID gastrointestinal manifestations, autoimmunity,
splenomegaly and lymphoproliferative disease.
Hannah Wright, MSPH1, Ramsay Fuleihan, MD2, Charlotte Cunningham Rundles, MD3, Kathleen
Sullivan, MD, PhD4, Edith Schussler, MD5
1Research Data Analyst/The United States Immunodeficiency Network (USIDNET)
2Professor of Pediatrics/Division of Allergy and Immunology, Department of Pediatrics,
Columbia University, New York, NY, USA
3David S. Gottesman Professor of Immunology/Mount Sinai School of Medicine
4Professor of Pediatrics, Chief of the Division of Allergy and Immunology/The Children’s
Hospital of Philadelphia, Philadelphia, PA, USA
5Assistant Professor/Weill Cornell Medicine
The GI tract is the largest lymphoid organ and gastrointestinal (GI) complaints are
frequent in CVID, leading in some to increased morbidity and higher mortality. Previous
studies have shown associations between autoimmunity(AI), lymphoproliferation (LP),
Splenomegaly(SM) and CVID enteropathy, however results have been varied. We suggest
this variation may be due to the variable definitions of enteropathy used in these
evaluations. We investigated the relationship of GI status as a whole as well as the
most common GI complaints to AI, LP and SM in CVID patients in the USIDNET registry.
Data on 939 patients with a diagnosis of CVID in the United States Immunodeficiency
Network (USIDNET) Patient Registry were analyzed. GI+ was defined as any condition
affecting the GI tract from mouth to anus excluding the spleen. Evaluation of the
most common GI complaints was used to further delineate which manifestations are most
associated with AI and LP, and SM.
Results: CVID GI disease showed significant associations with autoimmunity (OR 2.04,
95% CI:1.53-2.71, p < 0.001), lymphoproliferation (OR 2.44, 95% CI:1.67-3.54, p <
0.0001) and splenomegaly (OR 2.26, 95% CI:1.441-3.528, p < 0.0004). When looking at
the most common GI manifestations the only significant association was between aphthous
ulcers and AI (p=0.03), although chronic diarrhea approached statistical significance
(p=0.06). Chronic diarrhea was significantly associated with lymphoproliferation (OR
1.55, 95% CI:1.03-2.34, p=0.04), and splenomegaly (OR 1.94, 95% CI:1.22-3.09, p=0.005),
while infectious diarrhea was not. Abdominal pain was significantly associated with
lymphoproliferation (OR 1.7, 95% CI:1.15-2.5, p=0.007), but not lymphadenopathy or
splenomegaly. Non-IBD colitis was significantly associated with lymphoproliferation
(OR 1.86, 95% CI:1.20-2.90, p=0.006), lymphadenopathy (OR 2.01, 95% CI:1.22-3.29,
p=0.006), but not splenomegaly. Infectious colitis was not associated with LP, LA
or SM.
Conclusions: GI disease is common in CVID affecting 65% of patients in our cohort.
GI+ CVID patients have a higher frequency of AI manifestations, LP and SM than those
without GI complaints. We found that specific GI complaints were very specifically
associated with autoimmunity, lymphoproliferation and/or splenomegaly. These results
suggest that specific GI symptoms/manifestations rather than groupings may be useful
in the evaluation of CVID.
Keywords: CVID, Gastrointestinal, Autoimmune, Lymphoproliferative, Splenomegaly
Disclosure: Kathleen Sullivan is a consultant for the Immune Deficiency Foundation.
Edith Schussler is an advisory board member for Horizon Therapeutics. All other authors
had no financial relationship to disclose.
(125) Chronic Epstein-Barr virus infection and atypical sarcoidosis vs. granulocytic/lymphocytic
interstitial lung disease in a child hemizygous for a pathogenic variant on SKIV2L
Arthur Chang, M.D.1, Danielle Goetz, M.D.2, Teresa Hennon, M.D.3, Rafal Kozielski,
M.D.4, Gail Deutsch, M.D.5, Karl O.A. Yu, M.D., Ph.D., F.A.A.P.3
1Fellow/University at Buffalo / Oishei Children's Hospital
2Clinical Associate Professor of Pediatrics/University at Buffalo / Oishei Children's
Hospital
3Clinical Assistant Professor of Pediatrics/University at Buffalo / Oishei Children's
Hospital
4Clinical Assistant Professor of Pathology/University at Buffalo
5Professor of Pathology/University of Washington / Seattle Children's Hospital
A 9-year-old female with asthma and allergic rhinitis was admitted to the intensive
care unit for 3 weeks of cough, intermittent fever and malaise. Her exam was remarkable
for diffuse lymphadenopathy, hepatosplenomegaly and clubbing. She was hypoxic when
febrile, intermittently requiring oxygen by nasal cannula. Symptoms slowly improved
without targeted therapy. After discharge, she had slow improvement in lymphadenopathy
and splenomegaly, but continued to have dyspnea on exertion and mild intermittent
cough. Approximately 4 months after discharge, she developed fever, dyspnea and cough.
This responded well to corticosteroid therapy.
Laboratories showed pancytopenia, mildly elevated inflammatory markers, and Epstein
Barr viremia. Imaging showed bilateral pulmonary infiltrates, diffuse adenopathy and
hepatosplenomegaly. On biopsy, bone marrow was mildly hypocellular with intact trilineage
hematopoiesis. An inguinal lymph node had non-necrotizing epithelioid granulomas.
A lung needle biopsy showed lymphocytic and lymphohistiocytic infiltrates with few
multinucleated giant cells but no well-formed granulomas. A pathologic diagnosis of
granulocytic/lymphocytic interstitial lung disease (GLILD) versus a clinical diagnosis
of atypical sarcoidosis are considered.
The patient’s viremia is persistent (now > 6 months), with negative IgM but positive
IgG against viral capsid antigen, and seropositivity against early and nuclear antigens.
This suggests an aberration on the cellular immunologic capacity for herpesvirus control.
She had intact antibody responses to common vaccine antigens. Flow cytometry showed
an exaggerated CD4:CD8 ratio and a mild B lymphocytopenia.
Targeted panel sequencing uncovered a heterozygous pathogenic mutation in SKIV2L,
p.Arg374*. SKIV2L encodes a helicase component of the RNA exosome complex, and is
itself a negative regulator of Rig-1 like receptors and their associated antiviral/interferon
response. Homozygous deficiency of SKIV2L causes trichohepatoenteric syndrome (syndromic
diarrhea, Stankler syndrome), a rare condition characterized by intractable diarrhea
in infancy, syndromic facies, and skin, hair, liver, intellectual and immunologic
abnormalities.
Unpublished anecdotal reports on individuals hemizygous for SKIV2L pathogenic variants
have identified them as either having trichohepatoenteric syndrome (presumed unidentified
second defect) or being phenotypically normal (these patients’ parents). As GLILD
is well-described in several primary immunodeficiencies, this report suggests that
study is needed to determine if there may be a haploinsufficiency phenotype for this
genetic defect.
Keywords: interstitial lung disease, Epstein Barr infection, RNA exosome
Disclosure: All authors indicated they had no financial relationships to disclose.
(126) Newly diagnosed chronic granulomatous disease in a 52 year-old male presenting
with fulminant pulmonary aspergillosis
Louis Marois, MD, PhD1, David Drouin, MD2, Isabel Fernandes, PhD3, Charles Leduc,
MD4, Hélène Manganas, MD4, Hugo Chapdelaine, MD4, Emilia Liana Falcone, MD, PhD4,
Guilhem Cros, MD4
1Postgraduate Resident Year 6/Montreal University
2Postgraduate Resident Year 3/Montreal University
3Professor/Immunology-Rheumatology Division, Department of Pediatrics, University
of Montreal
4Professor/Montreal University
Background: Chronic granulomatous disease (CGD) is caused by inherited NADPH (nicotinamide
adenine dinucleotide phosphate) oxidase 2 defects resulting in severely reduced phagocyte-derived
superoxide production that manifest clinically as recurrent infections and autoinflammation.
Although the majority of patients with CGD are diagnosed before 10 years of age, only
a handful of patients with autosomal recessive CGD have been diagnosed after the fourth
decade of life. We present a 52 year-old male diagnosed with autosomal recessive (p47phox-deficient)
CGD after an episode of fulminant pulmonary aspergillosis (a.k.a. mulch pneumonitis).
Case presentation: 52-year-old male excavator with no significant past medical history
was admitted with fever, nausea, and headaches. Blood tests revealed a c-reactive
protein (CRP) of 238 mg/L and a WBC count at 13 x109/L, while cerebral spinal fluid
(CSF) analyses were within normal range. A chest X-Ray showed small multicentric consolidation
and empirical treatment for community acquired pneumonia was begun along with corticosteroids.
Despite initial improvement, the patient's respiratory condition rapidly deteriorated
along with an increase in inflammatory parameters (CRP 299 mg/L, WBC 24 x109/L) leading
to his transfer to the intensive care unit on day 3 of hospitalization. A lung biopsy
revealed an extensive granulomatous inflammation, along with a massive presence of
Aspergillus spp, confirmed by culture.. He was empirically started on voriconazole
and caspofungin. Despite antifungal treatment, the patient developed refractory acute
respiratory distress syndrome requiring extracorporeal membrane oxygenation (ECMO).
A dihydrorhodamine 123 (DHR) assay was performed and demonstrated a marked reduction
in neutrophil superoxide production. The patient was promptly started on anakinra
(IL-1 receptor antagonist). However, the patient succumbed within 28 days of hospitalization.
Genetic analysis showed a homozygous NCF1 (p47phox) deletion, confirming the diagnosis
of CGD in this previously asymptomatic man.
Conclusion: Autosomal recessive CGD can present beyond the fourth decade of life with
fulminant pulmonary aspergillosis in a previously completely asymptomatic individual.
The severity and rapidly progressive clinical course in this seemingly healthy older
individual demonstrates the importance of maintaining a high index of suspicion for
primary immune defects in adults with atypical clinical presentation or evolution
of infections.
Keywords: pulmonary aspergillosis, chronic granulomatosis disease, late-onset primary
immunodeficiency
Disclosure: All authors indicated they had no financial relationships to disclose.
(127) Opportunistic Infections in non-HIV associated CD4+ T-cell Lymphopenia
Sara Barmettler, MD1, Nancy Yang, BS2, Jocelyn Farmer, MD/PhD1, Jolan Walter, MD/PhD3,
Carlos Camargo, MD/DrPH1, Mei-Sing Ong, PhD4
1Physician/Massachusetts General Hospital
2Clinical Research Coordinator/Massachusetts General Hospital
3Department of Pediatrics/University of South Florida at Johns Hopkins All Children's
Hospita
4Assistant Professor/Harvard Medical School and Harvard Pilgrim Health Care Institute
The most common clinical manifestations of CD4+ T-cell lymphopenia are opportunistic
infections (OIs). Published literature on human immunodeficiency virus (HIV) shows
that OIs are associated with significant morbidity and mortality, but data are lacking
from patients with non-HIV associated CD4+ lymphopenia. Clinicians currently extrapolate
from HIV guidelines to manage patients with non-HIV associated CD4+ lymphopenia.
We performed a retrospective review of patients with CD4+ lymphopenia
in our healthcare system. We evaluated demographics, severity of CD4+ lymphopenia,
and incidence of OIs. CD4+ lymphopenia was defined by an absolute CD4+ T-cell count
of < 300 cells/microL or < 20% of total T cells on more than one occasion, without
evidence of HIV infection. We further stratified CD4+ lymphopenia as mild (CD4+ T-cells
201 to < 300 cells/microL), moderate (CD4+ T-cells 101 to ≤200 cells/microL), severe
(CD4+ T-cells 51 to ≤100 cells/microL), and very severe (CD4+ T-cells ≤50 cells/microL).
OIs of interest included pneumocystis jirovecii, toxoplasma gondii, mycobacterium
avium complex, cryptococcus neoformans, coccidioidomycosis and histoplasmosis. We
examined the association between severity of lymphopenia and risk of OI, and used
logistic regression to identify risk factors for OIs.
We identified 366 patients with non-HIV associated CD4+ lymphopenia. The mean age
was 44 years; there were 256 (70%) men. 38 (10%) patients had mild CD4+ lymphopenia,
22 (6%) moderate, 7 (2%) severe, and 299 (82%) very severe lymphopenia. 55/366 (15%)
patients had one or more OIs, including pneumocystis jirovecii (n=31), toxoplasma
gondii (n=14), mycobacterial infection (n=10), cryptococcus neoformans (n=10), and
disseminated mycobacterium avium-intracellulare complex (n=5). Almost all cases of
OIs occurred in those with very severe disease (n=51/55=93%). Very severe CD4+ lymphopenia
was associated with a higher risk of OIs (OR 1.14; 95%CI, 1.04-1.25). Age and sex
were not associated with OIs. Most infections (n=44/55=80%) required inpatient treatment.
15% of patients with CD4+ lymphopenia developed OIs. Severity of CD4+ lymphopenia
was associated with a higher risk of OIs. Future studies on non-HIV associated CD4+
lymphopenia are needed to better understand risk factors for OIs, as well as the safety
and efficacy of antibiotic prophylaxis.
Keywords: T-cell lymphopenia, opportunistic infections, immune deficiency
Disclosure: Jocelyn Farmer received a research grant from Bristol Myers Squibb and
X4 Pharmaceuticals. All other authors had no financial relationship to disclose.
(128) Immunomodulatory Therapy with Doxycycline and Hydroxychloroquine Allows Excisional
Debridement of Cutaneous Granulomas in a Patient with Ataxia Telangiectasia
Luis Murguia-Favela, MD, FRCPC1, Michele Ramien, MDCM, MSc, FRCPC2, Alan Harrop, MD,
MSc (Exp Surg), MSc (Epi), FRCSC, FACS3
1Clinical Assistant Professor, Pediatric Immunology, Section of Hematology/Immunology/Department
of Pediatrics, Alberta Children's Hospital, University of Calgary
2Clinical Associate Professor, Pediatric and Adult Dermatology/Departments of Pediatrics
and Medicine, Alberta Children's Hospital, University of Calgary
3Clinical Professor, Section Head of Plastic Surgery, Department of Surgery/Alberta
Children's Hospital, University of Calgary
Rubella virus vaccine strain-induced cutaneous granulomas are now a well-recognized
pathologic feature in patients with inborn errors of immunity, including ataxia telangiectasia
and other combined immunodeficiencies. These lesions can become persistent with high
risk of tissue loss and infections.
There are no specific therapies and topical and systemic corticosteroids, nitazoxanide,
anti-tumor necrosis factor agents, and interferon-alfa have been used with inconsistent
results. In addition, patients usually require multiple courses of antibiotics for
bacterial superinfections.
Immunomodulatory properties of doxycycline have been studied. These include inhibition
of matrix metalloproteinases, downregulation of pro-inflammatory cytokines, inhibition
of leukocyte chemotaxis, and inhibition of granuloma formation. Likewise, hydroxychloroquine
has been shown to have anti-granulomatous effects, namely reduced toll-like receptor
signaling resulting in decreased activation of dendritic cells and production of pro-inflammatory
cytokines.
We present a 10-year-old boy with Ataxia Telangiectasia with skin granulomas since
he was 3 years old. Biopsy materials from the two main lesions allowed for RT-PCR
detection and sequencing analysis confirming the presence of the Wistar RA27/3 vaccine
strain rubella virus.
Over the years, these lesions had a pattern of acute ulceration during the winter
and slow healing over 8-12 weeks. The granulomatous inflammation would persist and
each year the ulcerations would be larger and extend deeper into the subcutaneous
tissues. Many courses of oral and intravenous antibiotics for bacterial secondary
infections were required. Failed therapies included topical steroids, tacrolimus,
and many types of dressings. Access to nitazoxanide therapy was not possible.
During the most recent episode of ulceration, combination therapy with doxycycline
(4mg/Kg/day divided twice daily) and hydroxychloroquine (4mg/Kg/day) was trialed.
The ulcerations fully closed within 4 weeks, without visible residual inflammation
and no side effects. Three months later, both residual lesions were excised, and the
wounds healed completely.
The immunomodulatory effects of doxycycline and hydroxychloroquine, a combination
therapy repurposed from treatment of inflammatory granulomas, contributed to a faster
healing of ulcers in rubella vaccine-strain-induced cutaneous granulomas in a patient
with ataxia telangiectasia. This allowed for a complete surgical excision and may
prevent recurrences. More studies are needed to fully evaluate the efficacy of this
therapeutic approach.
Keywords: immunomodulation, cutaneous granulomas, ataxia telangiectasia, doxycycline,
hydroxychloroquine
Disclosure: Michele Ramien is an advisory board member for Abbvie and Eli Lilly, a
consultant for Pfixer, and received a research grant from Sanofi-Genzyme. All other
authors had no financial relationship to disclose.
(129) Enzymatic Activity of Neutrophil Elastase (NE) and Myeloperoxidase (MPO); Putting
it into Clinical Practice
Devora Eisenberg, MS41, Ronit Elhasid, MD2, Silvia Baron, Phd3
1Fourth year medical student/Tel Aviv University- Sackler School of Medicine
2Director of Pediatric Hemato-oncology/Dana-Dwek Children’s Hospital
3Senior Scientist/Pediatric Hemato-Oncology Research Laboratory, Tel Aviv Sourasky
Medical Center affiliated to the Sackler Faculty of Medicine
Introduction: Neutrophil extracellular trap formation (NETosis), a potent method for
killing extracellular pathogens, plays an important role in many inflammatory diseases
such as juvenile idiopathic arthritis (JIA) and even cancer. However, the evaluation
of NETosis is based on microscopy, a labor-intensive and subjective technique. In
the previous study of our group, the activity of key enzymes of NETs formation, neutrophil
elastase (NE) and myeloperoxidase (MPO), showed linear correlation to NETosis(1).
Therefore, we suggested that the easy and fast measurements of NE activity could serve
as a surrogate marker for NETosis. The aim of this study was to determine the reference
range of NE and MPO activity to enable clinicians to use the activity of these enzymes
to easily estimate NETosis in different pathological conditions.
Methods: 93 healthy volunteers between the ages of 18-62 (median age: 30) were recruited.
Neutrophils were isolated by immunomagnetic negative selection kit from StemCell Technologies.
Subsequently, cells were lysed by Triton X-100 and then incubated with chromogenic
peptide MeOSuc-Ala-Ala-Pro-Val-pNA for 90 min at 37 °C for NE activity or with o-phenylenediamine
and hydrogen-peroxide for 20 min at room temperature for MPO activity measurements.
Enzymatic activity was measured with an iMark Microplate Absorbance Reader at 415
nm or at 450 nm respectively for NE and MPO. Calibration curves were set up using
varying amounts of purified NE and MPO respectively.
Results: Enzyme activity level for NE ranged between 1.7 and 10.0 mU (mean 4.5 ± 1.9;
N=89) and for MPO ranged between 0.22 and 2.53 mU (mean 0.91 ± 0.46; N=93). Both NE
and MPO enzymatic activity was mildly higher in females than males, but there was
no significant difference for NE or MPO values respectively PNE=0.77 and PMPO=0.82.
Conclusions: In this study, as opposed to our previous study, we used immunomagnetic
negative selection for isolation of neutrophils, which contains milder treatments
causing less activation of the cells resulting in a more reliable reference range.
Future studies will involve data collection from elderly (over 60 years old) and children
(below 18 years old), as well as the application of this assay in disease states.
Keywords: Neutrophil, Neutrophil extracellular trap, Neutrophil elastase, Myeloperoxidase
Disclosure: All authors indicated they had no financial relationships to disclose.
(130 The associations of T cell subsets, serum cytokines (IL-23, IL-17, TNF-α) and
IL-23R and IL-12B gene polymorphisms with disease activity in patients with psoriasis
Shirin Tarafder, MBBS, MPhil1, Sabia Shahin Sultana, MBBS, MD2, Ismet Nigar, MBBS,
FCPS3, ATM Asaduzzaman, MBBS, FCPS4
1Professor/Microbiology and Immunology Department, Bangabandhu Sheikh Mujib Medical
University, Dhaka, Bangladesh
2Lecturer/Microbiology Department, Shaheed Suhrawardy Medical College, Dhaka, Bangladesh
3Assistant Professor/Microbiology and Immunology Department, Bangabandhu Sheikh Mujib
Medical University, Dhaka, Bangladesh
4Associate Professor/Dermatology and Venereology Department, Bangabandhu Sheikh Mujib
Medical University, Dhaka, Bangladesh
Psoriasis is a genetically regulated, T lymphocyte mediated autoimmune skin disease.
Monoclonal antibodies targeting p19 subunit inhibits IL-23, a “master regulator” of
Th17 cell development, offer potential disease control for long term disease management.
Objective: This study aims to demonstrate the T cell subsets, cytokines (IL-17, IL-23
and TNF-α) and polymorphisms in IL-12B and IL-23R genes in psoriasis patients to investigate
their possible relationship with susceptibility to psoriasis.
Blood samples from 35 clinically diagnosed psoriatic patients and 35 healthy controls
analysed at our laboratory between March 2019 and February 2020. T cell subsets were
detected by flow cytometric immunophenotyping using monoclonal antibodies, serum cytokines
levels by ELISA and gene polymorphism by Real-Time PCR.
The mean percentage of Th1, Th17, T-reg and pT-reg cells were significantly more in
psoriatics than in controls (P < 0.05). In contrast mean percentage of tT-reg cells
were decreased significantly in psoriatics (P < 0.0001). A significant difference
was seen between psoriatics and healthy controls, for IL-17 (150 Vs 84.10, P=0.002),
IL-23 (231.70 Vs 13.97, P < 0.0001) and TNF-α (534.68. Vs 84.26, P=0.002). IL-17 and
IL-23 level showed difference among groups according to disease severity (IL-17, P=
0.03; IL-23, P=0.42). The allelic frequency of the major variant C of IL23R rs11805303
was 27 (77.10%) in patients and 18 (51.4%) in controls (P=0.02). The frequency of
homozygous genotype AA of IL23R rs2201841 was 45.70% and 22.90% in patients and healthy
controls respectively (P= 0.043). Predominant presence of AA genotype of rs10889677
and TT genotype of rs11805303 of IL-23R were statistically significant, suggesting
a risk of developing psoriasis with these genotypes. Of 35 psoriasis patients, 23
(65.71%) had AA genotype of IL23R rs10889677 gene, along with increased number of
all T cell subsets and increase serum cytokine level which corresponds with disease
severity (PASI>10) and duration (>10 years).
This is the first study in Bangladesh showing association of mean IL-23 level with
AA genotype of IL23R rs10889677 gene polymorphism provides evidence that IL-23 pathway
can be an appropriate target for intervention in psoriasis as higher concentration
of IL-23 are associated with severity of disease and duration.
Keywords: Psoriasis, T cell subsets, cytokines, gene polymorphisms, IL-23, IL-23R,
IL-12B
Disclosure: All authors indicated they had no financial relationships to disclose.
(131) New homozygous activating RAC2 mutation causing combined immune deficiency with
pulmonary, skin and neoplastic manifestations
Louis Marois, MD, PhD1, Agnes Donkò, PhD2, Géraldine Gosse, MSc3, Amy P Hsu, MD, PhD4,
Thomas L Leto, PhD5, Hugo Chapdelaine, MD6, Emilia Liana Falcone, MD, PhD6, Guilhem
Cros, MD6
1Postgraduate Resident Year 6/Montreal University
2Post-doctoral Fellow/Laboratory of Clinical Immunology and Microbiology, National
Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda,
MD.
3Genetic consellor/Institut de recherches cliniques de Montréal
4Professor/3Laboratory of Clinical Immunology and Microbiology, National Institute
of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.
5Senior Investigator/3Laboratory of Clinical Immunology and Microbiology, National
Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda,
MD.
6Professor/Montreal University
Ras-related C3 botulinum toxin substrate 2 (RAC2) is a member of the rho family of
GTPases that is strictly expressed in hematopoietic cells, and involved in superoxide
(O-2) production and actin remodeling. Dominant negative RAC2 mutations result in
phagocyte defects, whereas heterozygous dominant activating mutations manifest as
combined immune deficiencies (CID). We present a 44-year old woman diagnosed with
a novel homozygous activating mutation in RAC2, and functionally evaluate the mutation
in vitro.
A 44-year-old woman was evaluated following the resection of an anal epidermoid cancer.
The patient was from a consanguineous French-Canadian family and her past medical
history was significant for recurrent pneumonias and severe asthma leading to bronchiectasis
at 9 years of age, as well as recurrent tonsilitis resulting in tonsillectomy. As
a teenager, she suffered from recurrent cold sores and persistent warts on her hands
and genitals which have persisted into adulthood. Her immune tests were significant
for moderate hypogammaglobulinemia and lymphopenia. She was treated with intravenous
immunoglobulins for presumed common variable immunodeficiency (CVID). She underwent
a hysterectomy at age 40 for high grade cervical and vaginal intraepithelial neoplasia,
which was followed by the resection of a perianal epidermoid cancer at age 44. At
this time, her lymphocyte phenotyping demonstrated moderate T and B lymphopenia with
marked reduction in naive T lymphocytes (Table 1). A homozygous mutation in RAC2 (c.202C>T,
p.R68W) was identified using a gene panel. The patient’s family history was only significant
for recurrent pneumonias in her mother and HPV mediated oropharyngeal cancer in her
father.
Stimulated HEK cells transfected with plasmids carrying the R68W mutation showed a
greater than 3-fold increase in O-2 production compared to controls. Interestingly,
COS-7 cells transfected with the mutant plasmid showed decreased (presumably unstable)
RAC2 protein expression associated with increased phosphorylated AKT (pAKT, marker
of RAC2 activity) by Western blot analysis (Figure 1).
We present a novel homozygous RAC2 gain-of-function mutation resulting in a relatively
moderate phenotype and family history compared to reported patients with heterozygous
RAC2 dominant activating mutations likely due to RAC2 protein instability associated
with our patient’s mutation.
Keywords: RAC2, Reactive oxygen species, Combined immunodeficiency
Disclosure: All authors indicated they had no financial relationships to disclose.
(132) Novel coronavirus immunoglobulin G in a four-month-old infant
Melissa Mendoza Suyo, MD1, Yatyng Chang, MD2, Jose Calderon, MD3, Vivian Hernandez-Trujillo,
MD3
1Pediatric Resident/Nicklaus Children's Hospital
2Allergy Immunology Fellow/Nicklaus Children's Hospital
3Allergy Immunology Attending/Nicklaus Children's Hospital
The COVID-19 pandemic has been a challenge for public health. There is scarce literature
regarding the immune response to SARS-CoV-2 in the pediatric population. We present
the case of a 4-month-old infant with positive IgG anti-SARS-CoV-2 antibodies.
4-month-old male with positive IgG anti-SARS-CoV-2 antibodies. When he was 2 months
of age both parents were diagnosed with COVID-19, after they presented with anosmia
and cough, and positive for SARS-CoV-2 PCR. He became symptomatic one week after his
parents were diagnosed with COVID-19, with cough and rhinorrhea lasting for 2 weeks
with an uncomplicated course. He was born full term via cesarean section. Mother was
asymptomatic around the time of delivery. He has been breastfed since birth.
We present a 4-month-old infant with positive IgG anti-SARS-CoV-2 antibodies, who
may be one of the youngest patients with positive antibodies reported in the literature.
Although the positive antibodies could represent an adaptive immune response to SARS-CoV-2,
the interpretation of this positive serology presents a diagnostic challenge for a
variety of reasons. First, cross-reactivity between antibodies to SARS-CoV-2 and alpha
(NL63 and 229E) and beta (OC43 and HKU1) coronaviruses has been reported in the literature.
In fact, the adult population can have a prevalence of positive antibodies as high
as 90% which might represent a high false positive rate. Second, there is the possibility
of mother-to-fetus transplacental IgG passage of antibodies to common human coronaviruses.
The duration of circulating maternal antibodies in the infant cannot be firmly established.
Despite the lack of symptoms in his mother prior to delivery, there is a possibility
of perinatal transmission of antibodies to SARS-CoV-2 or common human coronaviruses.
Lastly, the role of breastfeeding should be considered. Animal studies have suggested
the breast milk IgG can cross the gut barrier, although SARS-CoV-2 RNA has not been
found in breast milk, and transmission through human breast milk has not been described.
In conclusion, this case describes a young infant with positive IgG anti-SARS-CoV-2
antibodies and the caveats to consider when interpreting this test in patients of
this age group.
Keywords: Novel coronavirus, SARS-CoV-2 antibodies, Infancy
Disclosure: Vivian Hernandez-Trujillo is an advisory board member of Covis, CSL Behring,
DBV, Kaleo, Takeda, and US WORLD MEDS. All other authors had no financial relationships
to disclose.
(133) Novel STAT3-variant found in a family with presumed Hyper-IgE syndrome in four
generations of women.
Camilla Drabe, Dr.1, Tania Masmas, MD, Phd2, Hanne Marquart, MD, Phd3, Jens Lundgren,
MD, Phd4, Isabel Forss, Phd5, Line Borgwardt, MD, Phd6, Terese Katzenstein, MD, Phd,
MSc7
1Clinical research assistant/Dept. of Infectious Diseases, Rigshospitalet, Copenhagen
University hospital, Copenhagen, Denmark
2Consultant/Pediatric hematopoietic stem cell transplantation and immunodeficiency,
The Child and Adolescent Clinic, Rigshospitalet, Copenhagen University Hospital
3Cunsultant/Dept. of Clinical Immunology, Rigshospitalet, Copenhagen University Hospital
4Professor, Consultant/Department of Infectious Diseases, PERSIMUNE, Centre of Excellence
for Personalised Medicine of Infectious Complications in Immune Deficiency, Rigshospitalet,
Copenhagen University Hospital, Denmark
5Molecular biologist/Center for Genomic Medicine, University Hospital of Copenhagen,
Rigshospitalet, Denmark
6Consultant/Center for Genomic Medicine, University Hospital of Copenhagen, Rigshospitalet,
Denmark
7Consultant/Department of Infectious Diseases, Rigshospitalet, Copenhagen University
Hospital, Denmark
Variants in the signal transducer and activator of transcription 3 (STAT3) gene cause
autosomal dominant hyper-IgE syndrome (AD-HIES) also known as Job’s syndrome. Here
we present a family of four generations of women with a medical history compatible
with AD-HIES, where we identified a novel variant in STAT3 in the two youngest generations.
A four-year-old girl was referred for evaluation of primary immunodeficiency due to
recurring severe staphylococcus abscesses in the last two years. Her mother also suffered
recurring abscesses whereas her grandmother had eczema, allergy, and lung-disease,
and died at an early age. The great-grandmother had a similar phenotype and died young
too. Reportedly the mother and grand-mother had been clinically diagnosed with Job’s
syndrome elsewhere in the past, but for unknown reasons the mother was not followed
for her immunodeficiency. No connective tissue, skeletal or dental abnormalities were
found or reported. Both the girl and her mother initiated Co-Trimoxazole prophylaxis
with a markedly reduction of abscesses.
The girl and her mother had significantly elevated levels of IgE. By whole-genome
sequencing a heterozygote missense variant in the DNA-binding domain of STAT3 (c.1250G>C,
p.(Arg417Thr)) was found in the child and mother. The variant was confirmed by Sanger
sequence.
The identified STAT3 variant has not been previously reported in the literature in
conjunction with AD-HIES or in population databases. It resides in the DNA-binding
domain of STAT3, where other pathogenic missense variants have previously been reported
in AD-HIES patients. The family history and phenotype are highly suggestive for AD-HIES.
As the two oldest generations are deceased, it was not possible to further illuminate
co-segregation in family members. The functional impact of the variant remains to
be determined. We suspect that the identified variant is disease-causing, however
according to the American College of Medical Genetics and Genomics (ACMG) classifications,
we classify the variant as of uncertain significance (class 3).
Keywords: Hyper-IgE, HIES, Jobs syndrome, Immunodeficiency, STAT3, Whole Genome Sequencing,
WGS, Genetics, Diagnostics
Disclosure: Camila Drabe received speaker honoraria from Takeda. Terese Katzenstein
received speaker honoraria from CSL Behring, Takeda, Baxalta, Janssen, Shire; a research
grant from Gilead; and is an advisory board member of ViiV/GSK, MSD, Chiesi. All other
authors had no financial relationships to disclose.
(134) Analysis of soluble mediators of promotion and suppression of the immune response
in patients with the 22q11.2 deletion syndrome
Diogo Soares, MD, PhD1, Chong Kim, MD, PhD2, Leuridan Torres, PhD3, Anelisa Dantas,
PhD4, Natalia Nunes, MSc5, Maria Isabel Melaragno, PhD6, Magda Carneiro-Sampaio, MD,
PhD7
1Researcher/Faculdade de Medicina da Universidade de São Paulo
2Associate Professor/Faculdade de Medicina da Universidade de São Paulo
3Head of Research Department/Instituto de Medicina Integral Prof. Fernando Figueira
4Researcher/Universidade Federal de São Paulo
5PhD Student/Universidade Federal de São Paulo
6Full Professor/Universidade Federal de São Paulo
7Full Professor/Faculdade de Medicina da Universidade de São Paulo
22q11.2 deletion syndrome (22q11.2DS) is the most common human microdeletion syndrome,
with an estimated prevalence of 1:4000 live births. It has a wide phenotypic variability,
with more than 180 different related manifestations. Among the clinical findings,
immune abnormalities are present in approximately 75% of the cases and includes recurrent
infections, atopy and/or autoimmune diseases, suggesting that it is a disease of dysregulation
of the immune system. OBJECTIVE: to evaluate soluble mediators of promotion and suppression
of the immune response in 22q11.2DS patients. Fifteen patients with a confirmed diagnosis
of 22q11.2DS and 15 healthy patients without a family history of 22q11.2DS, major
congenital malformations or a clinical history suggestive of immunodeficiencies were
enrolled in the study. Through the sample of peripheral blood, analyzes of mediators
related to immune regulation were performed, using techniques of Cytometric Bead Array
(CBA) and enzyme-linked immunosorbent assay (ELISA). The study comprised a total of
15 22q11.2DS patients (15.5 years ± 8.4; 4 women and 11 men) and 15 healthy individuals
(17.5 years ± 7.2; 7 men and 8 women). When comparing 22q11.2DS patients with healthy
individuals, the patients presented higher levels of TREM1, MCP1, IL8 and reduced
levels of sOX40 and RANTES. When comparing 22q11.2DS patients with and without autoimmune
disease, the group with autoimmune disease has increased levels of sTREM1, s4-1BB,
IP10, RANTES, sPD1 and reduced levels of sOX40 and sPDL1. 22q11.2DS patients have
defects in the production of soluble mediators involved in the promotion and suppression
of the inflammatory response, being essential to maintain the physiological balance
of the immune system, regardless of exposure to external factors that may trigger
the activation of the immune response. The mediators evaluated can be used as biomarkers
to predict autoimmunity in patients with 22q11.2DS.
Keywords: 22q11.2 deletion syndrome, DiGeorge syndrome, autoimmunity
Disclosure: All authors indicated they had no financial relationships to disclose.
(135) Spectrum of COVID-19 in patients with secondary immunodeficiency
Jessica Galant-Swafford, MD1, Lori Broderick, MD, PhD2, Marc Riedl, MD, MS3
1Clinical Fellow, Allergy/Immunology/University of California San Diego/Division of
Rheumatology, Allergy & Immunology
2Assistant Professor of Pediatrics/University of California San Diego/Division of
Rheumatology, Allergy & Immunology
3Professor of Medicine/University of California San Diego/Division of Rheumatology,
Allergy & Immunology
Little is known about the spectrum of COVID-19 in patients with secondary/acquired
immunodeficiency diseases, such as those arising from immunosuppressive medications
and/or hematologic malignancies. We hypothesized that those with hypogammaglobulinemia
may be at particular risk due to a decreased ability to produce protective antibodies.
Methods: In this retrospective analysis, patients were identified who had been diagnosed
with hypogammaglobulinemia via ICD-10 code and had a positive SARS-COV-2 PCR or antibody
test. Descriptive information about each patient’s clinical history, course of SARS-COV-2
infection, and relevant laboratory data were obtained.
A total of 11 patients with secondary immunodeficiency were identified as COVID-19
positive: 27.2% female, median age 55 years (25-80). Seven had a history of malignancy,
1 with autoimmune disease, 2 with history of transplant, and 1 with hypogammaglobulinemia
of unknown etiology. All had received chemotherapy or immunosuppressive therapy. Less
than half were prescribed routine immunoglobulin (Ig) replacement. Median IgG level
at COVID diagnosis was 607 mg/dL (446-862). The most common subjective symptom was
fever (87.5%), followed by cough/shortness of breath (75%), however less than one-third
of these had objective temperature >100.4°C. Approximately 73% of patients were hospitalized,
45% received supplemental oxygen, 18% were intubated, and 27.2% died. Five patients
received remdesivir, 2 received dexamethasone, and 1 received additional Ig replacement.
Lymphopenia and decrease in absolute lymphocyte count from baseline, but not baseline
IgG, were predictors for severe disease. The mortality rate among those on routine
Ig replacement was 25%, compared to 28.6% in those without routine replacement. Similar
rates of hospitalization, oxygen administration, and ICU admission were observed in
the two groups. Of the 3 deceased patients, two had multiple myeloma and one had acute
myeloid leukemia.
Particular subtypes of secondary immunodeficiency may be more predisposed to severe
disease from COVID-19, specifically those arising from hematologic malignancy. A larger
sample size is needed to determine wither routine Ig replacement has a protective
effect on COVID-19-associated mortality in this group. Examining the course of COVID-19
in patients with immunodeficiency can promote greater understanding of the pathogenesis
of SARS-COV-2 infection, protective and deleterious immune responses, and protective
strategies for susceptible patients.
Keywords: COVID-19, Immunodeficiency, Hypogammaglobulinemia, Secondary immunodeficiency
Disclosure: Lori Broderick received financial or material support from IFM Pharmaceuticals.
Marc Redl is a consultant for Adverum, Attune, Biocryst, Biomarin, CSL Behring, Ionis,
Kalvista, Pfizer, Pharming, Pharvaris, RegenexBio, Shire/Takeda; received a research
grant from Biocryst, CSL Behring, Ionis, and Shire/Takeda; and speaker honoraria from
CSL Behring, Pharming, and Shire/Takeda. All other authors had no financial relationship
to disclose.
(136) A case of disseminated Mycobacterium flavescens in a child with a novel combination
of compound heterozygous variants in IFNGR1 leading to complete IFNGR1 deficiency
Elizabeth Christian, MD1, Brenna LaBere, MD2, Alicia Johnston, MD3
1Infectious Disease Fellow/Boston Children's Hospital and Beth Israel Deaconess Medical
Center
2Allergy and Immunology fellow/Boston Children's Hospital
3Infectious Disease Attending Physician/Boston Children's Hospital
Mendelian susceptibility to mycobacterial diseases (MSMD) is a rare condition characterized
by predisposition to infection with weakly virulent mycobacteria, salmonella, candida,
and other intracellular organisms. Pathogenic variants have been described in nine
genes involved in IFNγ-dependent immunity: IFNGR1, IFNGR2, STAT1, IL12B, IL12RB1,
ISG15, IRF8, NEMO, and CYBB. Autosomal recessive (AR) complete IFNGR1 deficient patients
are at risk for severe disseminated mycobacterial disease in early childhood, with
fewer than 20% surviving beyond 12 years. Hematopoietic stem cell transplant (HSCT)
may be curative. To date, there have been fewer than 40 cases described worldwide.
The patient presented at 16 months of age with fever, leukocytosis and elevated inflammatory
markers. CT revealed diffuse lymphadenopathy concerning for lymphoma. Bone marrow
biopsy revealed normocellular marrow, while cervical lymph node biopsy showed a reactive
lymph node without granulomas. Flow cytometry from both samples was negative for a
lymphoproliferative process. AFB stains were negative, however lymph node culture
grew an AFB positive organism, later identified as Mycobacterium flavescens by 16s
rRNA sequencing. Isolation of a low virulence organism prompted an immune evaluation.
The patient’s immunologic profile was generally reassuring, though with significant
elevation in IFNγ. Prevention Genetics PID panel revealed two heterozygous variants
in IFNGR1: C523del, p.Tyr175Metfs*2 and C.200+1G>A. Both have been shown to be pathogenic
as homozygous variants. Parental sequencing revealed that each parent was heterozygous
for one variant. Parents are non-consanguineous. Functional studies revealed no expression
of CD119/IFNγR1 on monocytes and no activation of pSTAT1 in monocytes following IFNγ
stimulation, supporting the diagnosis of AR complete IFNGR1 deficiency. The patient
received linezolid, isoniazid, ciprofloxacin and azithromycin with resolution of fever
and lymphadenopathy, and normalization of inflammatory markers and IFNγ levels. Parents
are considering HSCT with 9/10 A or B mismatched unrelated donors versus HSCT following
IVF with preimplantation genetic diagnosis.
We report a novel combination of heterozygous variants in IFNGR1 leading to complete
IFNGR1 deficiency, identified after presentation with disseminated M. flavescens,
a rarely pathogenic scotochromogenic mycobacterium. To our knowledge this is the first
report of M. flavescens infection in a patient with MSMD.
Keywords: Mendelian susceptibility to mycobacterial disease, Primary immunodeficiency,
Non-tuberculous mycobacterium, IFNGR1 deficiency
Disclosure: All authors indicated they had no financial relationships to disclose.
(137) Retroprotenial fibrosis is arare immunlogical disease that cause heamaturia
in young pateints
Awatif Alobeid
1, Mawia Hassan, MD2, Hani Aldien, MD2
1Dr/Clinical immunology
2Urologist/Sudanese urlogy association
Retroperitoneal fibrosis is characterized by development of extensive fibrosis throughout
the retroperitonium .its thought to be apart of IGg related autoimmune diseas,and
its responding to steroid and immunesupressive therapy.This is a case of 16 years
old male patient who was presented with haematuria,CTKUB showed retroperitoneal mass.
Keywords: Retroperitoneal fibrosis, Heamaturia, IGg related disease, Autoimmune
Disclosure: All authors indicated they had no financial relationships to disclose.
(138) Utility of expanded molecular testing for primary immunodeficiencies: disease-specific
panels may miss diagnoses
Jessica Connor, MS, LCGC1, Rebecca Truty, PhD2, Jennifer Holle, MS, CGC3, Shiloh Martin,
MD, PhD1, Hui Yu, PhD1, Olga Sarmento, PhD4, Britt Johnson, PhD, FACMG, HCLD(ABB)5
1Clinical Genomics Scientist/Invitae
2Bioinformatic Analyst/Invitae
3Genetic Counselor/Invitae
4Clinical Genomics Scientist/Inviate
5Medical Director, Metabolic Genetics and Immunology,Medical Affairs Director, Biopharma
Partnerships/Invitae Corporation, San Francisco, CA
Primary immunodeficiency disorders (PIDs) exhibit “phenotype expansion” in which genes
previously thought to be associated with specific phenotypes have an increasing circle
of clinical presentations. Traditionally, genetic testing for PIDs is phenotype-specific,
guided by genes associated with a given clinical presentation. A disease-specific
panel may not include the actual causative gene in a patient with a suspected PID,
making a phenotype-agnostic panel a more powerful test.
This study compared the diagnostic value of a 207 gene PID panel to smaller, disease-focused
panels. Patient phenotypes were compared to keywords and ICD.10 codes corresponding
to each focused panel and each requisition was assigned a virtual focused panel. Positive
diagnoses on the expanded panel and the focused panel were compared for each requisition
to determine the frequency of missed diagnoses if only the focused panel had been
ordered.
Our commercial diagnostic laboratory performed 6,257 expanded PID panels between April
2017 and October 2019. A virtual focused panel could be assigned based on clinical
indication for 3,384 unique orders. Of the 2,573 cases in which a focused panel could
not be assigned, 623 (18%) had no clinical information provided and 1,950 had information
not useful for analysis. Of the 3,384 unique orders, 105 had positive results. Positive
results would have been missed in 24.8% (26/105) of cases had the expanded panel not
been ordered. The Combined T/B Cell Deficiencies panel missed three positive results
(14%) while the Antibody Deficiencies panel missed 17 positive results (42.5%). The
Autoinflammatory Syndromes panel missed four results (25%) and for orders that indicated
both the Antibody Deficiencies panel and Autoinflammatory Syndromes panel, 2 positive
results were missed (16%). For example, an infant presented with failure to thrive
and perirectal abscess. Two of her older siblings are deceased, one of whom had a
genetic diagnosis of hemophagocytic lymphohistiocytosis, an autoinflammatory syndrome.
The expanded PID panel identified a homozygous MALT1 truncation, which is consistent
with a diagnosis of combined immunodeficiency. These results indicate the importance
of ordering an expanded panel or having the option to re-requisition to an expanded
panel for conditions with overlapping symptoms.
Keywords: primary immunodeficiency, genetic testing, diagnostic yield
Disclosure: All authors are employed by Invitae.
(139) Isolated CNS HLH during adolescence as the initial manifestation of Griscelli
Syndrome type 2 due to a novel homozygous mutation in RAB27A
Miriah Gillispie-Taylor, MD1, Philip Roehrs, MD2, Sharat Chandra, MD3
1Assistant Professor/Atrium Health/Levine Children's Hospital
2Associate Professor/Atrium Health/Levine Children's Hospital
3Associate Professor/Cincinnati Children's Hospital
Primary/familial HLH is an inherited syndrome of immune dysregulation caused by impairment
of the cytotoxic function of NK and T cells leading to uncontrolled immune cell activation,
and multi-organ immunopathology. While CNS involvement is common in primary HLH, presentation
with isolated CNS HLH without any systemic manifestations is rare. We report isolated
CNS HLH as the initial manifestation of Griscelli Syndrome type 2 due to a novel homozygous
mutation in RAB27A.
A 17-year-old Pakistani-American female was admitted for evaluation of headache, fever,
and left sided weakness. Her medical history was significant for altered mental status
and status epilepticus at the age of 13 years. Exam then was significant for hypopigmented
skin lesions. She is the product of a consanguineous marriage. CSF studies revealed
pleocytosis and elevated protein, as well as anti-NMDAr antibodies in serum that led
to the diagnosis of anti-NMDAr encephalitis and treatment followed BrainWorks protocol.
Recurrence of CNS symptoms at age 17 prompted repeat admission. CSF studies showed
elevated protein and pleocytosis. Spine MRI showed a demyelinating lesion at the level
of C6/7. She developed status epilepticus and was treated with high dose steroids,
rituximab and IVIG for a presumed autoimmune neuroinflammatory process, but repeat
serum and CSF encephalitis panels were negative. She developed respiratory distress
and chest CT showed parenchymal opacities. Due to worsening clinical status she underwent
brain and lung biopsies. Brain pathology shows leptomeningeal infiltration of T cells
and lymphohistiocytes and lung pathology showed organizing/fibrinous pneumonia with
histiocytic infiltration. Further evaluation revealed minimal elevation in soluble
IL-2 and ferritin, but impaired T cell degranulation. She was diagnosed with HLH and
started on HLH therapy which led to clinical response. HLH genetic panel revealed
a novel homozygous variant in RAB27A (p. Trp113Arg), predicted to be pathogenic. She
underwent allogeneic HCT and successfully engrafted with 100% donor chimerism. She
is currently 3 months post BMT and doing well.
Our report suggests that Griscelli syndrome type 2 due to homozygous mutation in RAB27A
can present with isolated CNS HLH. This case highlights the importance of evaluating
for isolated CNS-HLH in any patient with neuroinflammation of unclear etiology.
Keywords: HLH, CNS, seizure
Disclosure: Philip Roehrs received speaker honoraria from Sobi Pharmaceuticals and
is a consultant for Spark Therapeutics. All other authors had no financial relationship
to disclose.
(140) ICF Type 2: A Novel Mutation
Priyanka Seshadri, MD1, Hilary Gordon, MD2, Stephen McGeady, MD2
1Fellow in Training/Thomas Jefferson University Hospital/ Nemours A.I. DuPont Hospital
for Children
2Attending/Thomas Jefferson University Hospital/ Nemours A.I. DuPont Hospital for
Children
Immunodeficiency, centromeric instability, and facial dysmorphism Type 2 (ICF Type
2) is a rare primary immunodeficiency resulting from abnormalities in the ZBTB24 gene
involved in DNA methylation . Patients often present with global developmental delays
and either humoral or combined immunodeficiencies that can be progressive. The mortality
rate is high with a majority of patients succumbing to opportunistic infections. Therapies
that have been used include immune globulin replacement and hematopoietic stem cell
transplant. We describe a novel genetic mutation leading to ICF Type 2 and address
the ethics of declining treatment when no standard of care has been established.
A 3 month old female presented with severe hypotonia and dysmorphic facial features.
Family history is significant for consanguinity in parents (1st cousins) and a sister
deceased due to sepsis at 2 years of age. Whole Exome Sequencing revealed 2 mutations
in the ZBTB24 exome, one previously unreported (p.Arg398Ter: c.1192C>T) and one in
which functional studies demonstrate moderate to no damaging effects (p.Gly486Asp:c.1457).
Immune evaluation at age 4 months revealed hypogammaglobulinemia (IgG 128mg/dL normal
228-636, IgA 3mg/dL normal 27-72, IgM 7mg/dL normal 26-60) and reduced isotype-switched
memory B cells on flow cytometry (normal is 5-30%). Lymphocyte subsets and lymphocyte
mitogen proliferation were normal. At age 6 months, the patient had no infections
nor required any anti-microbials however, she remained hypogammaglobulinemic (IgG
134mg/dL normal 228-636mg/dL, IgA 2mg/dL normal 27-72mg/dL, IgM 9mg/dL normal 25-60mg/dL).
Immunoglobulin replacement was recommended but the family declined treatment due to
concerns about inflicting pain with IV placement and the religious belief that it
would be wrong to prolong life if the quality would be poor. An ethics committee was
consulted due to the child’s significant hypogammaglobulinemia and posed the question
of whether immune globulin replacement as a life sustaining therapy could ethically
be refused. The committee concluded it would be unethical to refuse immune globulin
replacement if the immunology department considered IVIG life-sustaining. The family
ultimately consented to immune globulin replacement.
This case highlights a novel mutation in a rare primary immunodeficiency and addresses
the ethics of declining treatment when no standard of care has been established.
Keywords: ICF Type 2, IVIG, Ethics
Disclosure: All authors indicated they had no financial relationships to disclose
(141) Moderate to severe CARD11 Loss of Function-associated atopic dermatitis treated
with biologic modifiers
Natalie Diaz-Cabrera, MD1, Bradly Bauman, MS2, Mildred Iro, MD, PhD3, Gina Dabbah,
BS4, Vered Molho-Pessach, MD5, Abraham Zlotogorski, MD6, Oded Shamriz, MD7, Yael Dinur-Schejter,
MD8, Tatyana Dubnikov Sharon, PhD9, Polina Stepensky, MD10, Yuval Tal, MD, PhD11,
Eli Eisenstein, MD12, Joshua Milner, MD13, Anthony Williams, PhD14, Gil Armoni-Weiss,
MD15, Andrew Snow, PhD16, Jennifer Leiding, MD17
1Fellow Physician/Division of Allergy and Immunology, Department of Internal Medicine,
University of South Florida College of Medicine, Tampa, FL
2Graduate Student/Department of Pharmacology and Molecular Therapeutics, Uniformed
Services University of the Health Sciences, Bethesda, MD, USA
3NIHR Academic Clinical Lecturer/Faculty of Medicine and Institute for Life Sciences,
University of Southampton, Southampton, United Kingdom
4Graduate Student/Department of Pharmacology & Molecular Therapeutics, Uniformed Services
University of the Health Sciences, Bethesda, MD
5Senior Lecturer/Pediatric Dermatology Service, Department of Dermatology and Venereology,
The Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem,
Israel
6Associate Professor/Department of Dermatology and Venereology, Hadassah Medical Center,
Jerusalem, Israel
7Fellow Clinical Immunologist/Clinical Immunology and Allergy Unit, Hadassah-Hebrew
University Medical Center; The Lautenberg Center for Immunology and Cancer Research,
Institute of Medical Research Israel-Canada, Hebrew University-Hadassah Medical School,
Jerusalem, Israel
8Staff Clinical Immunologist/Department of Bone Marrow Transplantation and Cancer
Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel
9Head of Immunodiagnostics lab/Department of Bone Marrow Transplantation and Cancer
Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel
10Professor, Director of Bone Marrow Transplantation Cancer Immunotherapy & Immunobiology
Research Cen/Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah
University Medical Center, Jerusalem, Israel
11Associate Professor/Clinical Immunology and Allergy Unit, Hadassah-Hebrew University
Medical Center, Jerusalem, Israel
12Pediatric Rheumatologist/Department of Pediatrics, Hadassah-Hebrew University Medical
Center,Mount Scopus, Jerusalem, Israel
13Professor/Laboratory of Allergic Diseases, National Institute of Allergy and Infectious
Diseases, National Institutes of Health, Bethesda, MD, USA
14Professor/Faculty of Medicine and Institute of Life Sciences, University of Southampton,
Southampton, United Kingdom
15Dermatologist/Department of Dermatology and Venereology, Hadassah Medical Center,
Jerusalem, Israel
16Associate Professor/Department of Pharmacology and Molecular Therapeutics, Uniformed
Services University of the Health Sciences, Bethesda, MD
17Associate Professor/Division of Allergy and Immunology, Department of Pediatrics,
University of South Florida at Johns Hopkins-All Children’s Hospital, St Petersburg,
FL
The caspase activation and recruitment domain 11 (CARD11) gene encodes a scaffold
protein required for lymphocyte antigen receptor signaling. Dominant negative, loss-of-function
(LOF) mutations in CARD11 are associated with common variable immune deficiency, cutaneous
and respiratory infections, neutropenia, and atopy. Nearly 90% of patients display
severe atopic disease such as atopic eczema, allergic rhinitis, food allergies, and
eosinophilic esophagitis. Omalizumab and dupilumab are two humanized monoclonal antibodies
directed against free circulating IgE and the interleukin-4 receptor, respectively,
successfully used in the treatment of refractory allergic asthma, idiopathic urticaria,
and atopic dermatitis. Data is limited regarding their safety and efficacy in patients
with CARD11 LOF.
We assessed the response to dupilumab in two patients and omalizumab in one patient
with severe atopic disease. CARD11 mutations were validated for pathogenic potential
using a T cell transfection assay to assess impact on activation-induced signaling
to NF-kB, JNK, and mTORC1.
This series included 3 unrelated females with a mean age of 20 years; all had novel
heterozygous LOF variants in CARD11 that were shown to disrupt wild-type CARD11 signaling
(Table 1). All 3 presented with atopic disease in infancy and susceptibility to infections.
Patients 1 and 2 were treated with dupilumab for treatment-refractory atopic dermatitis
and patient 3 was treated with omalizumab for treatment-refractory chronic urticaria.
Patients 1 and 2 experienced substantial improvement in atopic dermatitis following
therapy with dupilumab. SCORing Atopic Dermatitis (SCORAD) for patient 1 reduced from
84 to 40 and Eczema Area and Severity Index (EASI) score reduced from 21.75 to 4.0
in patient 2, both within a few months of therapy. Chronic urticaria improved substantially
in patient 3. Additional atopic conditions improved as well: asthma, allergic rhinitis,
and food sensitivities. There were no complications or adverse effects from use of
dupilumab or omalizumab.
Treatment with dupilumab and omalizumab for severe, refractory atopic disease in patients
with CARD11-associated atopy with dominant interference of NF-kB signaling (CADINS)
disease appears to be effective and well tolerated in our cohort. Further follow-up
and larger sample sizes are required to determine additional efficacy and safety data.
Keywords: CARD11, atopic dermatitis, dupilumab, omalizumab, urticaria
Disclosure: Jennifer Leiding received speaker honoraria from CSL Behring and Horizon
Therapeutics and was an advisory board member for Pharming. All other authors had
no financial relationships to disclose.
(142) MHC Class II deficiency: up-and-down road from the diagnosis to the follow-up
Claudia Rita
1, Ignacio Iturrieta-Zuazo, PhD2, Paloma Lapuente Suanzes, MD2, Ana García-Soidan,
MD2, Ana De Andrés, MD3
1Immunology resident/Hospital Universitario Ramón y Cajal
2Immunology resident/Ramón y Cajal University Hospital
3Immunologist/Ramón y Cajal University Hospital
MHC II deficiency is caused by a mutation in the genes encoding transcription factors
of MHC II. Most cases have been reported from consanguineous marriages.
Herein, we report a twenty-three-year-old Spanish boy from a consanguineous family.
He was referred to our centre for a highly inverted CD4/CD8 ratio, chronic diarrhoea
and early onset of recurrent and severe respiratory tract infections. Since the first
year of life, he presented with frequent upper and lower respiratory tract infections.
More than 20 hospital admission for bacterial pneumonia and gastroenteritis were recorded.
Besides he had history if septic arthritis of the knee complicated with osteomyelitis,
two episodes of immune thrombocytopenic purpura and at the age of 15 years, bronchiectasis
was identified needing oxygen therapy. In family history, one brother and one sister
have demised during the first year of life for septicaemia. One sister presented with
recurrent otitis media and respiratory tract infections being diagnosed with IgA deficiency.
Laboratory findings revealed IgG2 deficiency and IgG hypogammaglobulinemia with normal
levels of IgA and IgM. T-cell compartment showed a T CD4+ lymphopenia (224 cell/μL)
and inverted CD4/CD8 ratio (0,12),. T-cell proliferation to antigens (Candida albicans)
was decreased but normal to mitogens (OKT3 and PHA), delayed-type hypersensitivity
was negative for purified protein derivative (PPD) and candidin. Flow cytometry revealed
no expression of HLA-DR antigen on resting monocytes and B-cells and absence of inducible
expression of MHC class II molecules after interferon-gamma stimuli on B-cells, T-cells
or monocytes. Genetic analysis revealed a homozygous mutation in RFXANK gene. During
the study of the family, one sister showed the same homozygous mutation, while six
siblings showed heterozygous mutation and one had no mutation.
According to the high risk of transplant-related mortality and significant comorbidities
hematopoietic cell transplantation was not accepted by the family. He was treated
for 22 years with prophylactic cotrimoxazole and intravenous immunoglobulin. During
the following years, the frequency and severity of infectious episodes diminished
until he develop nephrotic syndrome requiring to stop immunoglobulins and dying for
sepsis.
Unknown factors may influence the residual innate or CD8+ T cell–mediated immunity,
which potentially contributes to this more favourable outcome.
Figure 2: Pedigree of the family. The index patient is pointed by an arrow.
Keywords: MHC class II deficiency, bafe lymphocyte syndrome, primary immunodeficiency
Disclosure: All authors indicated they had no financial relationships to disclose.
(143) Novel Compound Heterozygous variants in IKBKB associated with Autoimmunity and
Autoinflammation
Nouf Alsaati, MD1, Keith Sacco, MD2, Lauren Smith, MD3, Sameeya Ahmed-Winston, CPNP-PC4,
Blachy Blachy Dávila Saldaña, MD5, Hyesun Kuehn, PhD6, Sergio Rosenzweig, MD, PhD7,
Michael Keller, MD8
1Resident Physician/Division of Allergy and Immunology, Children's National Health
System, Washington, DC, USA
2Clinical Fellow/Lab of Clinical Immunology and Microbiology, Immune Deficiency Genetics
Section, NIAID, NIH, Bethesda, MD, USA
3Assistant Professor of Pediatrics/Children's Hospital of the King's Daughters, Eastern
Virginia Medical School, Norfolk, VA, USA
4Pediatric Nurse Practitioner/Division of Blood and Marrow Transplantation, Children's
National Health System, Washington, DC, USA
5Pediatric Hematologist/Oncologist/Division of Blood and Marrow Transplantation, Children's
National Health System, Washington, DC, USA
6Staff Scientist/Immunology Service, Department of Laboratory Medicine, NIH Clinical
Center, Bethesda, MD, USA
7Senior Investigator/Immunology Service, Department of Laboratory Medicine, NIH Clinical
Center, Bethesda, MD, USA
8Pediatric Immunologist/Division of Allergy and Immunology, Children's National Health
System, Washington, DC, USA
Homozygous null mutations of IKBKB encoding IKK2 are known to cause severe combined
immunodeficiency (SCID) with normal peripheral T cell and B cell counts, and hypogammaglobulinemia.
Heterozygous missense mutations in the same gene were described to cause an autosomal
dominant combined immunodeficiency. To our knowledge, a phenotype of autoinflammation
with organ-specific autoimmunity has not been described.
A 6-week-old ex-full term male developed a self-limiting episode of rash, fever, and
autoimmune hemolytic anemia (AIHA) – hemoglobin (hgb) 10.4 g/dL, platelets 407k/mcL,
and absolute neutrophil count (ANC) 3321/mcL at presentation. Symptoms recurred at
7 weeks (hgb 6.5 g/dL, platelets 702k/mcL, ANC 8474/mcL) with serological testing
being positive for anti-D antibodies and anti-neutrophil antibodies, requiring packed
red cell transfusion. His rash was clinically described as erythematous papules coalescing
into plaques scattered on the arms, legs, trunk, and diagnosed by biopsy as Sweet
syndrome. Serum immunoglobulins were not decreased (IgG 493 mg/dL, IgM 278 mg/dL and
IgA 55.2 mg/dL). The patient developed a fever after receiving scheduled vaccinations
at 2 months which led to a third autoimmune crisis. He had received the second dose
of Hepatitis B, and first doses of Diphtheria, Tetanus, Pertussis, Haemophilus influenzae
type b, inactivated Polio vaccine, pneumococcal conjugate vaccine (PCV13), and Rotavirus.
A targeted primary immunodeficiency gene panel identified two IKBKB variants in trans
(IKBKB: c.1552G>A, p.D518K; c.1676 C>T, p.T559M). Variant c.1676 C>T, p.T559M had
a low minor allele frequency of 5.24e-5 (Gnomad®) while c.1552G>A, p.D518K was absent
from major gene databases. Functional assays showed decrease in IkBα degradation in
patient’s PBMCs following TNFα stimulation, as well as elevation of baseline phospho-AKT.
Our case is the first to demonstrate a clinical phenotype of autoinflammation with
organ-specific autoimmunity due to novel compound heterozygous variants in IKBKB.
Though the specific consequences of these individual IKBKB variants remains unknown,
the phenotype could suggest dysfunctional signaling of the canonical NF-κB pathway
affecting its interaction with NLRP3, TNFα, and IL-1β. These findings suggest that
a IKBKB mutations should be considered in the setting of disease manifesting with
features of autoinflammation or autoimmune dysregulation.
Keywords: IKBKB, NfKB signaling, Immune dysregulation, Combined immunodeficiency,
Autoimmunity, Autoinflammation
Disclosure: Sameeya Ahmed-Winston received speaker honoraria from Jazz Pharmaceuticals.
Michael Keller is an advisory board member of Enzyvant. All other authors had no financial
relationship to disclose.
(144) Improvement of SLC29A3 spectrum disorder-related sensorineural hearing loss
after initiation of IL-6 inhibitor
Hallie Carol, MD1, Amer Khojah, MD2, Nurcicek Padem, MD3, Taher Valika, MD4
1Resident Physician/McGaw Medical Center of Northwestern University/ Ann & Robert
H. Lurie Children's Hospital
2Attending Physician, Allergy, Immunology, and Rheumatology/Ann & Robert H. Lurie
Children's Hospital of Chicago/ Northwestern University Feinberg School of Medicine
3Attending Physician, Allergy and Immunology/Riley Children's Hospital
4Attending Physician, Otorhinolaryngology-Head & Neck Surgery/Ann & Robert H. Lurie
Children's Hospital of Chicago/ Northwestern University Feinberg School of Medicine
SLC29A3 spectrum disorder is an autosomal recessive, autoinflammatory syndrome, that
is characterized by mutations in the SLC29A3 gene, which encodes the human equilibrative
nucleoside transporter 3 (hENT3). This defect precipitates as a multisystem autoinflammatory
disorder with a wide spectrum of severity and presentations, commonly including hyperpigmentation,
hypertrichosis, hepatosplenomegaly, heart anomalies, hearing loss, hypogonadism, low
height, and hyperglycemia in the setting of immune mediated diabetes. Interleukin
6 (IL-6) is a cytokine that plays an important role in the regulation of the immune
response and inflammation, and over production has been linked to the etiologyof inflammatory
diseases such as rheumatoid arthritis.. Therefore, IL-6 inhibitors havebeen used in
the treatment of autoinflammatory diseases with great success.
A 15 month old boy initially presented to immunology clinic with increased inflammatory
markers and sensorineural hearing loss in the setting of a SLC29A3 mutation (homozygous
pathogenic variant c.1309 G>A p.G437R). Of note, this variant has been reported in
the published literature to cause SLC29A3 related disorders. Family history was significant
for parental consanguinity and a maternal aunt with hearing loss secondary to Rosai
Dorfman syndrome. His inflammatory markers were elevated (ESR 31-43 mm/hr and CRP
2-10.4 mg/dl).The patient’s sensorineural hearing loss was progressive and presumed
secondary to his underlying autoinflammation. In the hopes of slowing the progression
of his hearing loss, he was started on an IL-6 inhibitor (tocilizumab 162mg subcutaneously,
every 21 days) at age 25 months. Continued follow up has shown improvement in his
hearing and overall down-trending inflammatory markers (ESR 1mm/hr CRP < 0.1).
This case provides insight into the use of Il-6 inhibitors to slow the progression
and potential reversal of autoinflammatory related hearing loss associated with SLC29A3
spectrum disorders.
Keywords: SLC29A3, L-6 inhibitor, sensorineural hearing loss
Disclosure: Taher Valika has ownership interest in Save My Scope, Inc. All other authors
had no financial relationship to disclose.
(145) A Compare and Contrast of COVID-19 Disease Progression in Two Siblings with
APECED in Relation to the Timing of Treatment Initiation
Alyssa James, MD1, Monica Schmitt, CRNP2, Sebastian Ochoa, MD1, Elise Ferre, PA-C,
MPH3, Thomas Dimaggio, RN4, Michail Lionakis, MD, ScD5
1Allergy/Immunology Clinical Fellow/National Institute of Allergy and Infectious Diseases/National
Institutes of Health, Bethesda, MD, USA
2Certified Registered Nurse Practitioner/Fungal Pathogenesis Section, Laboratory of
Clinical Immunology and Microbiology, National Institute of Allergy and Infectious
Diseases/National Institutes of Health, Bethesda, MD, USA
3Physician Assistant/Fungal Pathogenesis Section, Laboratory of Clinical Immunology
and Microbiology, National Institute of Allergy and Infectious Diseases/National Institutes
of Health, Bethesda, MD, USA
4Nurse/Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology,
National Institute of Allergy and Infectious Diseases/National Institutes of Health,
Bethesda, MD, USA
5Chief, Fungal Pathogenesis Section/Laboratory of Clinical Immunology and Microbiology,
National Institute of Allergy and Infectious Diseases/National Institutes of Health,
Bethesda, MD, USA
Early treatment of COVID-19 in patients with high-risk primary immunodeficiencies
(PIDs) is of critical importance. Here we discuss two siblings with autoimmune polyendocrinopathy-candidiasis-ectodermal
dystrophy (APECED) who developed distinct severities of COVID-19 associated with differential
timing of treatment initiation.
Methods: Two COVID-19 positive siblings with APECED provided consent and were studied
using an NIH IRB approved protocol. Their charts were reviewed.
Siblings are Caucasian with APECED caused by compound heterozygous deletions in AIRE
[c.967_979del13 (p.L323SfsX51) and c.190_226del37 (p.S64TfsX71)] with positive autoantibodies
to IFN-α and IFN-ω, which are associated with high risk COVID-19 disease. Sibling
1 is a 48 year old woman with chronic mucocutaneous candidiasis (CMC), hypoparathyroidism,
adrenal insufficiency, hypothyroidism, primary ovarian failure, and Sjogren’s syndrome.
Sibling 2 is a 45 year old man with CMC, hypoparathyroidism, adrenal insufficiency,
hypothyroidism, autoimmune gastritis, intestinal malabsorption, alopecia, vitiligo,
B12 deficiency, and end stage renal disease secondary to hypertensive nephropathy.
Sibling 1 tested positive for COVID-19 by SARS-CoV-2 PCR in March 2020 after developing
fever, cough and shortness of breath. She was treated with hydroxychloroquine, but
developed respiratory failure requiring intubation for nine days. She was treated
with high dose corticosteroids, extubated and made a full recovery. Sibling 2 tested
positive for COVID-19 by SARS-CoV-2 PCR in October 2020 after developing fever, congestion
and cough. He was admitted and treated with remdesivir and high dose corticosteroids
given CT chest findings of bilateral ground glass opacities and mild hypoxemia (95%
on room air). A bronchoalveolar lavage was positive for SARS-CoV-2 PCR with negative
bacterial and fungal cultures. He developed acute pulmonary emboli involving the distal
pulmonary arterial branches to the right lower lobe and was treated with apixaban.
Throughout his 2-week hospitalization, he remained on room air.
We describe siblings with APECED with the same genetic profile who experienced distinct
clinical courses of COVID-19. Sibling 2 was treated in the beginning of his course
with corticosteroids and remdesivir which may have prevented the development of respiratory
failure like in his sibling. This report highlights the importance of prompt therapeutic
intervention in patients with certain PIDs that confer high risk for severe COVID-19.
Keywords: APECED, COVID-19, Primary Immunodeficiency, Early Treatment
Disclosure: All authors indicated they had no financial relationships to disclose.
(146) case of activated phosphoinositide 3-kinase (PI3K) delta syndrome associated
with growth hormone deficiency, aseptic arthritis, nephromegaly, and asthma
Megan Craig, MD1, Mateja Cernelc-Kohan, MD2, Kristen Wigby, MD3, Susan Phillips, MD4,
Bob Geng, MD5
1Resident Physician/Department of Pediatrics, University of California San Diego,
Rady Children’s Hospital
2Assistant Professor/Department of Respiratory Medicine, University of California
San Diego, Rady Children's Hospital
3Clinical Geneticist, Assistant Clinical Professor of Pediatrics/Division of Genetics,
Department of Pediatrics, University of California San Diego, Rady Children's Hospital
4Assistant Professor/Department of Endocrinology, University of California San Diego,
Rady Children's Hospital
5Assistant Professor of Pediatrics and Medicine/Divisions of Adult and Pediatric Allergy
& Immunology, University of California San Diego, Rady Children's Hospital
We report the case of a 9-year-old boy with a heterozygous de novo variant in PIK3CD
(p.E1021K) resulting in activated PI3K delta syndrome (APDS), a rare form of primary
immunodeficiency. Our patient exhibits classic findings of this syndrome, including
recurrent sinusitis and bronchitis, bronchiectasis, mild developmental delay (DD),
splenomegaly, and lymphadenopathy. His laboratory abnormalities include immune cytopenias
and specific antibody deficiency requiring subcutaneous immunoglobulin replacement
therapy.
In addition to the previously described features, he is also affected by growth hormone
(GH) deficiency, aseptic arthritis, asthma, and nephromegaly. He showed marked growth
deceleration by age 5 (short stature is seen in APDS2). GH provocative testing with
arginine-clonidine revealed low peak GH consistent with deficiency. Subsequent pituitary
MRI demonstrated mildly hypoplastic adenohypophysis with thinning and hypoplasia of
the infundibular stalk. He started GH therapy with an excellent growth response.
He underwent evaluation of chronic cough and asthma at age 7. Despite appropriate
therapy and normalization of PFTs, chronic wet cough persisted, and further work-up
was notable only for bronchiectasis. Taken together with his other clinical symptoms,
there was increasing suspicion for a syndrome that would provide a unifying diagnosis,
and he was referred to genetics. Whole exome sequencing (WES) revealed APDS.
Since GH signals through the PI3K pathway, his diagnosis prompted concern that GH
could increase risk of malignancy. However, he was allowed to continue as the pathway
was considered constitutively active at baseline and he had been tolerating GH for
over three years prior to diagnosis.
Shortly after diagnosis, he was admitted for acute on chronic left hip pain. Laboratory
studies revealed mild leukocytosis with normal inflammatory markers. MRI showed moderate
left hip effusion with synovial enhancement, moderately prominent inguinal and iliac
lymph nodes, and no avascular necrosis. He underwent arthrocentesis and was diagnosed
with aseptic arthritis. Symptoms resolved spontaneously soon after the procedure.
This patient’s unique findings add to the clinical information available for this
rare form of primary immunodeficiency and illustrate the importance of a multidisciplinary
collaborative approach in managing this complex syndrome. WES was instrumental in
obtaining a timely diagnosis, especially as targeted therapies are being developed.
Keywords: activated phosphoinositide 3-kinase (PI3K) delta syndrome, whole exome sequencing,
growth hormone deficiency, pituitary abnormality, aseptic arthritis, asthma, nephromegaly
Disclosure: Bob Geng was an advisory board member for Biocryst and received speaker
honoraria from Grifols, GSK, Horizon, Kedrion, Octapharma, Optinose, Regeneron, Sanofi,
and Takeda; he was a consultant for RMS. All other authors had no financial relationship
to disclose.
(147) Diagnosis and treatment of hepatopulmonary syndrome in an adolescent patient
with partial DiGeorge syndrome
Minh Nguyen, DO1, Nicholas George, MD1, Katherine Scott, MD2, Roua Azmeh, MD3
1Resident Physician/Western Michigan University School of Medicine
2Attending Physician/Bronson Pediatric Oncology & Hematology Specialists (A Bronson
Methodist Hospital facility)
3Attending Physician/Western Michigan University School of Medicine
Chromosome 22q11.2 deletion syndrome, or DiGeorge syndrome (DGS), is the most common
chromosome deletion syndrome. Immunodeficiency is one of the key features. Hepatopulmonary
syndrome (HPS) is characterized by hypoxemia caused by intrapulmonary vascular dilatation
in patients with liver disease. Here, we present an adolescent with DGS and immune
dysregulation who developed HPS.
The patient was a 13-year-old girl with partial DGS, immune dysregulation (low IgG,
IgA, T, B, natural killer, helper and suppressor cells along with poor response to
vaccinations), Evans’ syndrome, and hemodynamically insignificant cardiac anomalies.
During an outpatient IVIG infusion, she was found to be hypoxemic on room air. A chest
CT showed pulmonary hypertension, splenomegaly along with enlarged splenic and portal
veins, concerning for portal hypertension (figure 1). An echocardiogram with bubble
study suggested pulmonary arteriovenous malformations (pAVMs) (figure 2). A cardiac
catherization identified pAVMs which were not amenable to intervention. Genetic testing
for hereditary hemorrhagic telangiectasia was negative. A high-resolution chest CT
reported no signs of parenchymal diseases. A liver biopsy showed epithelioid granulomas
without evidence of fibrosis. A diagnosis of HPS was made. Her clinical course was
notable for persistent hypoxemia and multiple intensive care unit admissions. Liver
transplant was not feasible due to her comorbidities. Altogether, she enrolled in
hospice care. In light of her immune dysregulation, rituximab was considered, but
held due to side effects and the patient’s frail status. Instead, high dose prednisone
was initiated and slowly tapered. After one year, she improved, and supplemental oxygen
was discontinued. She was discharged from hospice.
Although HPS is typically associated with cirrhosis, her case was related to granulomatous
liver disease secondary to DGS. Granulomas are inflammatory infiltrates occurring
as a result of immune dysregulation and have been described in primary immunodeficiency
disorders such as chronic granulomatous disease and common variable immunodeficiency.
Her liver epithelioid granulomas caused poor clearance of angiogenic factors and resulted
in the development of AVMs in the lungs, with subsequent shunting and hypoxemia.
To our knowledge, this is the first reported case of HPS in a DGS patient. The case
also offers a potential treatment for HPS associated with immunodysregulation.
Figure 2: Echocardiogram with bubbly study, apical 4-chamber view. (A) demonstrates
the atria and ventricles prior to the injection of saline. After the injection, (B)
shows the presence of the saline in the right side of the heart (yellow arrow), which
is a normal finding. After 4 cardiac cycles, (C) indicates the saline (red arrows)
in the left heart. This finding is positive for intrapulmonary shunting, consistent
with pulmonary arteriovenous malformations. RA: right atrium. RV: right ventricle.
LA: left atrium. LV: left ventricle. R: right heart. L: left heart.
Keywords: DiGeorge Syndrome, Hepatopulmonary syndrome, Granulomatous disease
Disclosure: All authors indicated they had no financial relationships to disclose.
(148) Organizing pneumonia in a Down syndrome child with T cell lymphopenia
Minh Nguyen, DO1, Roua Azmeh, MD2, Mariam Ischander, MBChB2
1Resident Physician/Western Michigan University School of Medicine
2Attending Physician/Western Michigan University School of Medicine
Organizing pneumonia (OP) is a rare but distinct clinical and pathologic entity, characterized
by the formation of organized buds of granulation tissue. These lead to obstruction
of the alveolar lumen and bronchioles. This inflammatory process occurs in response
to an injury, which can be primary or secondary to other causes. We describe a rare
case of OP secondary to chronic aspiration exacerbated by rhinovirus infection in
a pediatric patient.
A 5-year-old female with Down Syndrome (DS) and chronic aspiration presented with
shortness of breath and was hypoxic on room air. A nasal swab tested positive for
rhino/enterovirus. CXR revealed bibasilar pulmonary opacities, suspicious for a community
acquired pneumonia. She was started on a course of amoxicillin. At 3-day follow-up,
she was again hypoxic. Repeat CXR showed worsening bilateral opacities (figure 1).
Chest CT showed bilateral patchy ground-glass opacities distributed along bronchovascular
bundles in the lower lung zones, concerning for a secondary OP (figure 2). Lung biopsy
was not pursued as the patient improved with a prolonged course of steroids. After
she completed her steroid course, immunologic workup revealed low T lymphocyte counts
(CD45, CD3, and CD4).
OP is rare in pediatric patients. OP typically manifests as dyspnea and cough. Biopsy
is the gold standard for diagnosis. Histology is defined by buds of granulation issue
located in the distal airspaces. The classic radiologic features of OP, as in this
case, are areas of focal consolidation and ground glass opacities. The radiographic
findings consistent with OP and our patient’s improvement with corticosteroids persuaded
against a biopsy. Her chronic pulmonary aspiration is also a predisposing factor for
development of OP. Further, patients with DS can have high rates of infections, particularly
of the respiratory tract. Their disease courses are often complicated, attributed
to T and B cell dysfunction and deficiencies, as found in our patient. This rare case
of pediatric OP in the setting of DS, T cell lymphopenia and chronic pulmonary aspiration
highlights the need for a high index of suspicion when evaluating respiratory symptoms
in patients with DS or other conditions associated with immune deficiency.
Figure 1: Chest X-Ray (CXR) (A) from the first hospital admission showing bibasilar
pulmonary opacities. Repeat CXR (B) five days later showing increasing bilateral lower
lobe opacities.
Figure 2: Axial view of lung (A) computed tomography (CT) with patchy consolidation
in lower lobes, right middle lobe, and the lingual. Coronal view of lung CT (B) with
patchy consolidation in both lower lobes, right middle lobe, and the lingula.
Keywords: Organizing pneumonia, T cell lymphopenia, Down syndrome
Disclosure: All authors indicated they had no financial relationships to disclose.
(149) Comparing Hemophagocytic Lymphohistiocytosis Between Adult and Pediatric Patients:
Perspectives from a Tertiary Care Institution
Minh Nguyen, DO1, Tahnee Spoden, MD1, Gisel Rivera, MD1, Melissa Baker, DO1, Roua
Azmeh, MD2
1Resident Physician/Western Michigan University School of Medicine
2Attending Physician/Western Michigan University School of Medicine
Hemophagocytic lymphoshistiocytosis (HLH) describes a rare syndrome resulting from
immune system overactivation. This retrospective observational study characterizes
adult and pediatric patients diagnosed with HLH at our small tertiary care center
in order to further our understanding of the condition.
A report was generated via the EMR of all patients with the ICD-10 code D76.1 for
HLH and D89.42 for macrophage activation syndrome in their problem list or encounter
diagnoses seen between March 2007 and May 2020.
15 patients fulfilled the HLH-2004 diagnostic criteria. Of these, 9 were adult patients
with an average age of 44.6 years and a mean time to diagnosis of 6.7 days. Causes
included 4 cases of viral-induced (EBV, HIV, and CMV), 1 case of T-cell lymphoma,
1 case of familial HLH, and 3 idiopathic cases. The survival rate in adult patients
was 66.7%. For our pediatric population, 6 met diagnostic criteria, their average
age being 4.7 years with a mean time to diagnosis of 11.5 days. Causes included 5
cases of viral-induced (HSV-2, HHV-6 and CMV), 1 case of malignancy (B-cell leukemia)
and 2 cases of familial HLH. The survival rate was 83.3% in this population. Diagnostic
criteria of prolonged fever were met in 14 patients. Elevated serum ferritin above
500 ng/mL was present in all patients. Time to diagnosis was shorter in adults by
5 days. However, one complicated case of HLH of the liver took 46 days to diagnose.
Treatment with etoposide and dexamethasone was used in 9 patients. Bone marrow transplant
was performed in two children and two adults. Two patients died while receiving treatment
and one was transitioned to comfort care.
HLH remains rare as 15 cases were identified out of 875,690 patients. Viral causes
were the most common etiology in both groups, in contrast to prior studies that found
malignancy as the most common inciting factor in adults. Shorter time to diagnosis
was seen in adults, along with a higher mortality rate. Overall, diagnosing HLH requires
a high index of clinical suspicion, with treatment being dependent on the cause of
immune overstimulation.
Keywords: Hemophagocytic Lymphohistiocytosis, Macrophage activation syndrome, Retrospective
observational study
Disclosure: All authors indicated they had no financial relationships to disclose.
(150) Immune-mediated chronic macrothrombocytopenia, musculoskeletal abnormalities,
and dysmorphic features in a patient with Takenouchi-Kosaki Syndrome
Leigh Stubbs, MD1, Amanda Grimes, MD2, Lisa Forbes, MD3, Lindsay Burrage, MD, PhD2,
Tiphanie Vogel, MD, PhD2, Maria Pereira, MD2
1Rheumatology Fellow/Baylor College of Medicine
2Assistant Professor/Baylor College of Medicine
3Assisant Professor/Baylor College of Medicine
CDC42 is a Rho-family GTPase important for proper cell polarization and migration.
A spectrum of human disease has been associated with heterozygous, autosomal dominant
mutations in CDC42, ranging from neurodevelopmental to hyperinflammatory phenotypes.
Takenouchi-Kosaki syndrome (TKS) is a rare, multisystemic disorder associated with
CDC42 mutations and typically characterized by delayed psychomotor development, dysmorphic
features, brain malformations, macrothrombocytopenia, and lymphedema. We describe
a patient with TKS that presented with chronic macrothrombocytopenia responsive to
corticosteroids.
A 17-year-old male presented for evaluation and management options for chronic macrothrombocytopenia
prior to surgical release of a tethered spinal cord. He had a history of global developmental
delay, short stature, asymptomatic external hydrocephalus, bilateral sensorineural
hearing loss, recurrent inguinal hernias, obstructive sleep apnea and a left lower
lobectomy in infancy for congenital lobar emphysema. Physical examination was significant
for dysmorphic features including biparietal prominence, high forehead, upslanting
palpebral fissures, low-set ears with thick helices, a long and smooth philtrum, a
thin upper lip, midface hypoplasia, and mandibular prognathia. Musculoskeletal examination
showed limited abduction of the shoulders, limited extension of the elbows, camptodactyly
of the 5th digits, decreased rotation of the hips, severe thoracic dextroscoliosis,
and a leg length discrepancy with no sign of inflammatory arthritis. His platelets
ranged from 40-60 x 10^3/uL at baseline. Exome sequencing revealed a presumed de novo
pathogenic mutation in CDC42 (c.203G>A, p.Arg68Gln). Subsequently, extensive immune
phenotyping and a hyperinflammation evaluation were unremarkable. It is not clear
if thrombocytopenia in TKS is associated with an increased risk of bleeding. However,
due to his planned surgery a trial of 4 mg/kg/day of prednisone was given, to which
his platelets promptly responded. He was managed peri-operatively with a short course
of corticosteroids.
TKS should be considered in the differential for patients with neurodevelopmental
disorders, dysmorphic features, and thrombocytopenia. The chronic macrothrombocytopenia
in our TKS patient was rapidly responsive to glucocorticoids, suggesting an immune-mediated
component which is consistent with the expanding immune phenotypes reported in patients
with CDC42 mutations. As additional patients are described, it may allow clarification
of genotype-phenotype associations between CDC42 variants and the role of immunomodulation
for these patients.
Keywords: CDC42, Takenouchi-Kosaki syndrome, case report, thrombocytopenia
Disclosure: Lisa Forbes-Satter is a Consultant at ADMA and Grifols, and is an Advisory
Board member at CSL Behring, Horizon, and Takeda. Lindsay Burrage works at the Baylor
Genetics Laboratory which receives revenue from clinical genetic testing completed
at Baylor Genetics Laboratory. All other authors had no financial relationship to
disclose.
(151) Developing a Rag1-mutant Murine Model of Rubella vaccine-associated Granulomatous
Inflammation
Keith Sacco, MD1, Marita Bosticardo, PhD2, Francesca Pala, PhD3, Stefania Pittaluga,
MD, PhD4, Cristina Corsino, .5, LiJuan Hao, PhD6, Ludmila Perelygina, PhD7, Luigi
Notarangelo, MD8
1Clinical Fellow/Lab of Clinical Immunology and Microbiology, Immune Deficiency Genetics
Section, NIAID, NIH, Bethesda, MD, USA
2Staff Scientist/Lab of Clinical Immunology and Microbiology, Immune Deficiency Genetics
Section, NIAID, NIH, Bethesda, MD, USA.
3Postdoctoral Fellow/Lab of Clinical Immunology and Microbiology, Immune Deficiency
Genetics Section, NIAID, NIH, Bethesda, MD, USA.
4Senior Research Physician/Lab of Pathology, National Cancer Institute, Bethesda,
MD, USA.
5Research Technician/Lab of Clinical Immunology and Microbiology, Immune Deficiency
Genetics Section, NIAID, NIH, Bethesda, MD, USA.
6Biologist/Viral Vaccine Preventable Diseases Branch. National Center for Immunization
& Respiratory Diseases, Centers for Disease Control & Prevention (CDC), Atlanta, GA,
USA
7Senior Researcher/Viral Vaccine Preventable Diseases Branch. National Center for
Immunization & Respiratory Diseases, Centers for Disease Control & Prevention (CDC),
Atlanta, GA, USA
8Chief/Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy
and Infectious Diseases, National Institutes of Health
Mutated RA27/3 viral sequences (termed Immunodeficiency-related vaccine derived rubella
viruses [iVDRVs]) have been identified in granulomas of patients with combined immunodeficiencies.
Mice carrying Rag1 hypomorphic mutations (R972Q and R972W) replicate the phenotype
of combined immune deficiency with granulomas and/or autoimmunity (CID-G/AI) seen
in patients. We used the R972Q and R972W mice to investigate the quality and kinetics
of an inflammatory response to iVDRV recovered from skin granuloma.
The Rag1 R972Q mouse is the leakiest model of CID-G/AI. We intramuscularly (IM) injected
4-6-week-old R972Q and WT mice with 10^3 pfu/mouse iVDRV in 50uL followed by an IM
injection at week +4 of iVDRV 10^7 pfu/mouse in 50uL. Age-and-sex matched R972Q and
WT control mice were injected with equal volume of PBS. Serum was collected at baseline,
week +4, +9 and +20, and titer of anti-rubella virus antibodies was measured. Serum
cytokines were analyzed at week +20. Mice were euthanized at week +22, and tissue
was sent for histology, RNA extraction, and splenic tissue immunophenotyping. In a
second experiment, we injected WT and Rag1 R972W mice with 2 doses of 10^7 pfu/mouse
iVDRV in 50uL 4 weeks apart. In parallel, R972W and WT control mice were injected
with 50 uL of PBS as a control.
No significant weight changes were observed. Titers of anti-rubella virus antibodies
at 4 weeks were negative in WT and R972Q mice, however they became positive at +9
weeks (following 2 doses). Mean titer OD values were higher for WT males (2.5) and
WT females (2.74) versus R972Q males (0.77) and R972Q females (1.48). In the second
experiment, titers were positive in WT mice after 1 dose of 10^7 pfu however remained
absent in R972W after the second 10^7 pfu dose. No granulomas were observed on histology.
iVDRV RNA was extracted from bone marrow and lymph nodes of WT mice but was weakly
positive by PCR (Ct 34-36) in bone marrow and lymph nodes of R972Q mice.
Higher iVDRV doses may be required to produce an inflammatory phenotype. iVDRV in
bone marrow suggests a role for development and persistence of immunological memory.
Keywords: Combined Immunodeficiency, Granuloma, Rubella vaccine, Chronic Rubella Infection
Disclosure: All authors indicated they had no financial relationships to disclose.
(152) Fluctuations in Quality of Life and Immune Responses During the Intravenous
Immunoglobulin Infusion Cycles
Jordan Abbott, MD, MA1, Sanny Chan, MD, PhD2, Morgan Macbeth, BS3, James Crooks, PhD2,
Cathy Hancock, RN4, Vijaya Knight, MD, PhD5, Erwin Gelfand, MD6
1Associate Professor/University of Colorado Aschutz Medical Campus, Children's Hospital
colorado
2Assistant Professor/National Jewish Health
3Professional Research Assistant/University of Colorado School of Medicine
4Research Coordinator/National Jewish Health
5Associate Professor of Pediatrics/Section of Allergy & Immunology, Children's Hospital
Colorado, University of Colorado School of Medicine, Aurora, CO, USA
6Distinguished Professor/National Jewish Health, University of Colorado School of
Medicine
Despite adequate infection prophylaxis, decline in self-reported quality of life throughout
the IVIG infusion cycle is a widely reported but infrequently studied phenomenon.
Objective: To better understand this phenomenon, 18 antibody-deficient subjects receiving
replacement doses of IVIG were studied over 3 infusion cycles.
Questionnaire data from 6 time points spread over 3 IVIG infusions cycles (infusion
day and 7 days after each infusion) assessing well-being were analyzed in conjunction
with monitoring the number of regulatory T-cells (Treg) and levels of 40 secreted
analytes: primarily cytokines, chemokines, and growth factors at 9 time points over
the same time period (immediately before the infusion, 1 hour after infusion completion,
and 7 days after the infusion for 3 cycles).
Across all subjects and all infusion cycles, a statistically significant increase
in well-being (visual analog scale, VAS, p=0.001) between the day of infusion and
7 days following the infusion was shown. The percentage of CD4+ T-cells that had a
Treg phenotype increased from before the infusion to 7 days following the infusion
but did not correlate with VAS score improvement. Cytokine level changes were significant
between the pre-infusion measurement and 1 hour after infusion and included increases
in CCL4 (MIP-1b), CCL3 (MIP-1a), CCL2 (MCP-1), CCL20, TNF-alpha, granzyme B, IL-10,
IL-1RA, IL-8, and IFN-gamma and decreases in IL-17E and EGF. These cytokine changes
were more dramatic in subjects receiving IVIG for the first time (naïve), and additional
increases in IL-6, GM-CSF, and decreases in EGF and CD40L were observed in this group.
Non-naïve subjects experienced a decrease in IL-17E that was not seen in the IVIG-naïve
group. The decrease in IL-17E was detectable 7 days following the infusion, indicating
the impact of IVIG on this cytokine lasts beyond the week following infusion.
The data demonstrate that following IVIG infusion, patients experience significant
immediate changes in multiple blood cytokine levels, particularly in those receiving
IVIG for the first time. In addition, increases in quality of life and blood Tregs
arose 1 week after infusion. The relationships between these observed perturbations
remain to be elucidated in further studies.
Keywords: IVIG, Quality of Life, Cytokines, Tregs, IVIG-Naive, CVID, Hypogammaglobulinemia
Disclosure: Sanny Chan received a research grant from CSL Behring. All other authors
had no financial relationship to disclose.
(153) Immune implications of SARS-CoV-2 in Nasopharynx
Jose Ordovas-Montanes, PhD1, Carly Ziegler, BS2, Haley Williams, MS3, George Abraham,
MD4, Tanya Robinson, PhD5, Michal Senitko, MD5, Meredith Sloan, MD6, Anna Owings,
MD6, Hannah Laird, BS7, Taylor Christian, BS7, Adam Parker, MD8, Yilianys Pride, MHA9,
Andrew Navia, BS10, Vincent Miao, BS10, Ying Tang, PhD11, Bruce Horwitz, MD12, Alex
Shalek, PhD13, Sarah Glover, DO14
1Assistant Professor of Pediatrics/Boston Children's Hospital
2Graduate Student/Massachusetts Institutes of Technology
3Research Specialist/University of Mississippi Medical Center
4Associate Professor/University of Mississippi Medical Center
5Assistant Professor/University of Mississippi Medical Center
6Chief Resident/University of Mississippi Medical Center
7Medical Student/University of Mississippi Medical Center
8Gastroenterology Fellow/University of Mississippi Medical Center
9Division Business Administrator/University of Mississippi Medical Center
10Graduate Student/Massachusetts Institute of Technology
11Post Doctorate Assistant/Boston Children's Hospital
12Associate Professor of Pediatrics/Boston Children's hospital
13Associate Professor/Massachusetts Institute of Technology
14Division Chief/University of Mississippi Medical Center
COVID-19 presents with respiratory symptoms including sore throat, cough and congestion,
and can progress to multi-organ system involvement. Nasopharyngeal (NP) epithelial
cells express the SARS-CoV-2 spike protein receptor, angiotensin-converting enzyme
2 (ACE2), and infection of the NP appears to be an obligate step in the development
of COVID-19. Immune responses initiated in the NP are almost certainly crucial for
directing viral clearance but may also play a role in the generation of inflammatory
injury observed in a subset of patients infected with the virus. While several studies
have identified infected cells within the respiratory epithelium of the lung, neither
the target cells for SARS-CoV-2 infection nor the response of target and bystander
cells within the nasal mucosa have been characterized in detail. We have previously
presented preliminary results employing single-cell RNA sequencing to evaluate cellular
composition and targets of viral infection using material isolated on nasal swabs
obtained from a cohort of adults with severe COVID-19. Here we report on an extended
cohort that includes patients with mild disease as well as those that have recovered
from acute disease. We have identified cellular targets of infection including subsets
of ciliated and secretory epithelial cells. Further, we have identified a potent type
1 interferon response within a subset of ciliated cells that appears to be a direct
response to viral infection, as well secondary anti-viral responses in several diverse
cell populations. Finally, we will present initial correlations between cellular targets
of infection, cellular subset composition, and gene expression profiles with the severity
of COVID-19. These studies provided a framework for understanding the cellular and
transcriptional response to viral infection within both epithelial and immune cells
of the nasal mucosa, and lay the groundwork for understanding protective cellular
immune responses to this disease.
Keywords: COVID-19, SARS-CoV-2, single cell RNA sequencing
Disclosure: All authors indicated they had no financial relationships to disclose.
(154) Granulocyte Transfusions in Patients with Chronic Granulomatous Disease Undergoing
Hematopoietic Cell Transplantation or Gene Therapy
Danielle Arnold, MD1, Deepak Chellapandian, MD2, Suhag Parikh, MD3, Kanwaldeep Mallhi,
MD4, Rebecca Marsh, MD5, Jennifer Heimall, MD6, Debra Grossman, BS7, Maria Chitty
Lopez, MD8, Luis Murguia-Favela, MD9, Andrew Gennery, MBChB, MD10, Farid Boulad, MD11,
Erin Arbuckle, MS12, Morton Cowan, MD13, Christopher Dvorak, MD13, Linda Griffith,
MD, MHS, PhD14, Elie Haddad, MD, Phd15, Luigi Notarangelo, MD16, Sung-Yun Pai, MD17,
Jennifer Puck, MD13, Michael Pulsipher, MD18, Troy Torgerson, MD, PhD19, Elizabeth
Kang, MD20, Harry Malech, MD20, Jennifer Leiding, MD21
1Assistant Research Physician/National Cancer Institute
2Attending Physician/Center for Cell and Gene Therapy for Non-Malignant Conditions,
Blood and Marrow Transplant Program, John Hopkins All Children’s Hospital
3Attending Physician/Division of Bone Marrow Transplant, Aflac Cancer and Blood Disorders
Center, Children’s Healthcare of Atlanta, Emory University School of Medicine
4Attending Physician/Fred Hutchinson Cancer Research Center, Seattle Children’s Hospital,
The University of Washington School of Medicine
5Attending Physician/Division of Bone Marrow Transplantation and Immune Deficiency,
Cincinnati Children’s Hospital Medical Center
6Assistant Professor/Division of Allergy and Immunology, Children’s Hospital of Philadelphia
7Contract Worker/Genetic Immunotherapy Section, Laboratory of Clinical Immunology
and Microbiology, National Institute of Allergy and Infectious Diseases, National
Institutes of Health
8Fellow Physician/Division of Allergy and Immunology, Department of Pediatrics, John
Hopkins All Children’s Hospital, University of South Florida
9Attending Physician/Section of Hematology/Immunology, Department of Pediatrics, Alberta
Children's Hospital, Cumming School of Medicine, University of Calgary
10Attending Physician/Translational and Clinical Research Institute, Newcastle University
and Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North
Children's Hospital
11Attending Physician/Department of Pediatrics, BMT Service, Memorial Sloan Kettering
Cancer Center
12Clinical Research Coordinator/Department of Pediatrics, Duke University
13Attending Physician/Pediatric Allergy, Immunology, and Blood and Marrow Transplant
Division, University of California San Francisco Benioff Children’s Hospital
14Attending Physician/Division of Allergy, Immunology and Transplantation, National
Institute of Allergy and Infectious Diseases, National Institutes of Health
15Attending Physician/Immunology-Rheumatology Division, Department of Pediatrics,
University of Montreal
16Chief/Laboratory of Clinical Immunology and Microbiology, National Institute of
Allergy and Infectious Diseases, National Institutes of Health
17Attending Physician/Immune Deficiency-Cellular Therapy Program, National Cancer
Institute, National Institutes of Health
18Attending Physician/Blood and Marrow Transplant Program, Division of Hematology,
Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Keck
School of Medicine, University of Southern California
19Attending Physician/Experimental Immunology, Allen Institute
20Attending Physician/Genetic Immunotherapy Section, Laboratory of Clinical Immunology
and Microbiology, National Institute of Allergy and Infectious Diseases, National
Institutes of Health
21Associate Professor/Division of Allergy and Immunology, Department of Pediatrics,
University of South Florida at Johns Hopkins-All Children’s Hospital, St Petersburg,
FL
Granulocyte transfusions are sometimes used as an adjunctive therapy for the treatment
of infection in patients with chronic granulomatous disease (CGD). However, granulocyte
transfusions can be associated with alloimmunization, and their role in CGD patients
undergoing allogeneic hematopoietic cell transplantation (HCT) and gene therapy (GT)
is unknown.
We conducted a retrospective survey of 27 CGD patients who received granulocyte transfusions
as a bridge to (within 3 months of) HCT or GT and/or post-HCT using a spreadsheet
questionnaire and the Primary Immune Deficiency Treatment Consortium (PIDTC) database.
Median age at HCT or GT was 12 (range 2-25) years. Twelve patients received granulocyte
transfusions pre- +/- post-HCT or GT, and 15 patients received granulocyte transfusions
post-HCT only (Table 1). Patients received a median of 11 (range 4-75) granulocyte
transfusions. Overall response rate was 50% in patients who received granulocytes
as a bridge to HCT or GT. Six of 10 (60%) patients for whom testing was performed
developed anti-HLA antibodies, and 3 (25%) patients had autoimmune cytopenia within
the first 100 days post-HCT or GT. HLA antibodies were not checked for any of the
15 patients who received granulocyte transfusions post-HCT only, but there were no
cases of early autoimmune cytopenia. HCT and GT characteristics are shown in Table
2. Five of 25 (20%) patients who underwent HCT experienced primary graft failure.
Three of the patients with primary graft failure received granulocyte transfusions
pre-HCT. One of the three patients received a graft from a 5/10 HLA-matched related
donor and was found to have donor-specific antibodies. The other two patients had
high anti-HLA antibody levels but did not have donor-specific antibodies identified.
Overall and event-free survival were 36% (CI 11-63%) and 33% (CI 10-59%) in patients
who received granulocytes pre- +/- post-HCT or GT versus 100% (p < 0.001) and 87%
(CI 56-97%, p=0.005) in patients who received them post-HCT only (Figure 1).
Granulocyte transfusions pre-HCT or GT are associated with a high rate of alloimmunization
and may increase the risk of primary graft failure and early severe autoimmune cytopenia
post-HCT or GT. Granulocyte transfusions post-HCT appear to be safe.
Keywords: granulocyte transfusions, chronic granulomatous disease, alloimmunization,
hematopoietic cell transplantation, graft failure
Disclosure: Morton Cowan is an advisory board member of Bluebird Bio, Leadiant, Rocket
Pharma; ownership interest in Homology Medicine; and other financial material support
from UpToDate. Christopher Dvorak is a consultant for Alexion Inc., Omeros Corp. Elie
Haddad is a consultant for Jasper Therapeutics and Rocket Pharma. Michael Pulsipher
received other financial material support from Adaptive and Miltenvi; is an advisory
board member of Mesoblast; and received speaker honoraria from Novartis. Troy Torgerson
is a consultant for CSL Behring and Grifols; received speaker honoraria from Takeda
and X4 Pharmaceuticals; and is an advisory board member of Enzyvant. Jennifer Leiding
received speaker honoraria from CSL Behring and Horizon Therapeutics and was an advisory
board member for Pharming. All other authors had no financial relationship to disclose.
(155) A Case of Undetectable T-cell Receptor Excision Circle (TREC) and Multiple Congenital
Anomalies
B. Paige DePriest, MD1, Mamatha Mandava, MD1, Michelle Hudspeth, MD2, Mary Markert,
MD, PhD3, Elie Haddad, MD, Phd4, Kelli Williams, MD, MPH2
1Pediatric Hematology & Oncology Fellow/Department of Pediatrics, Medical University
of South Carolina, Charleston, South Carolina, USA
2Associate Professor of Pediatrics/Department of Pediatrics, Medical University of
South Carolina, Charleston, South Carolina, USA
3Professor of Pediatrics/Department of Pediatrics and Department of Immunology, Duke
University Medical Center, Durham, North Carolina, USA
4Attending Physician/Immunology-Rheumatology Division, Department of Pediatrics, University
of Montreal
A Caucasian girl was born at 32 weeks to a G3P3 mother with type II diabetes. Prenatal
ultrasound revealed ventriculomegaly. Postnatally she had ventriculomegaly, PDA, left
renal agenesis, rib anomalies, lumbar scoliosis, hypoparathyroidism with associated
hypocalcemia. Initial NBS had inconsistent TREC and repeat was undetectable. Lymphocyte
phenotyping revealed T-B+NK+ with CD3+ 26cells/mcl (1484-5327), CD4 15 cells/mcl (733-3181),
CD8 6 cells/mcl (370-2555), CD56 681 cells/mcl, CD19 >1000 cells/mcl. CD4 recent thymic
emigrants revealed 1% naïve and 99% memory CD4 cells. Mitogen proliferation to phytohemagglutinin
was decreased, whereas proliferation to pokeweed mitogen was essentially normal. Serum
immunoglobulins were IgG 563, IgA 49, IgM 179, and IgE 25.4 mg/dL. Genetics identified
a normal karyotype and microarray. Next generation sequencing primary immunodeficiency
panel (Invitae) and subsequently whole exome sequencing failed to identify any pathogenic
mutation. At 4 weeks, the patient developed a diffuse maculopapular rash. Skin biopsy
was consistent with maternal engraftment, confirmed by chimerism assay (16% maternal
cells). By 8 weeks old, her T cells increased (CD3 104, CD4 91, CD8 undetectable).
At 4 months, she developed recurrence of her diffuse maculopapular rash, marked diffuse
lymphadenopathy, tachypnea, thrombocytopenia and eosinophilia. IgE was now >10,000
IU/mL and T cells increased (CD3 1897, CD4 1740, CD8 undetectable). TCR Vb repertoire
identified 25 oligoclonal populations. Lymph node biopsy showed predominant histiocytes
with small follicles. Clinically, presentation was most consistent with atypical complete
DiGeorge Syndrome associated with maternal diabetes. Research evaluation confirmed
normal in vitro differentiation of CD34+ hematopoietic stem cells into T cells on
3D organoid, consistent with functional athymia. The patient clinically decompensated
and had immune dysregulation, so she received systemic steroids followed by alemtuzumab
with improvement. At 11 months, the patient’s IgE increased to >10,000 IU/mL with
intermittent exfoliative rash. A second treatment with alemtuzumab has been ordered.
She is currently awaiting cultured thymus tissue implantation and continues on prophylaxis
with intravenous immunoglobulin, azithromycin, trimethoprim-sulfamethoxazole, and
voriconazole.
This case highlights the impact maternal diabetes can have on the immune system and
its association with complete DiGeorge Syndrome. Additionally it further expands the
differential diagnoses to consider with an abnormal TREC on NBS.
Keywords: T-cell receptor excision circles (TRECs), Newborn screen (NBS), Congenital
athymia
Disclosure: Michelle Hudspeth is an advisory board member of Mesoblast. Mary Markert
received a research grant and has patent/intellectual property with Ezyvant Therapeutics.
Elie Haddad is a consultant for Jasper Therapeutics and Rocket Pharma. Kelli Williams
is an advisory board member of Horizon Therapeutics and Kenota Health and received
a research grant from Regeneron Pharmaceuticals. All other authors had no financial
relationships to disclose.
(156) Anti-TNF-α therapy leads to recurrent and invasive S. aureus infections in patient
with compound heterozygous NOD2 variants
Nissim Stolberg, DO1, James Verbsky, MD, PhD2, John Routes, MD3, Amy Rymaszewski,
PHd4, Shaoying Chen, MD5, Jeffrey Woodliff, PhD6, Adrian Miranda, MD7
1Rheumatology Fellow/Medical Collège of Wisconsin
2Associate Professor of Pediatrics, Medicine, Microbiology and Immunology/Medical
College of Wisconsin
3Professor of Pediatrics, Medicine, Microbiology and Immunology/Medical College of
Wisconsin
4Research Associate II/Medical College of Wisconsin
5Research Associate/Medical College of Wisconsin
6Clinical Immunology Research Laboratory Manager/Medical College of Wisconsin
7Professor/Medical College of Wisconsin
NOD2 gain of function (GOF) variants result in Blau syndrome and loss of function
(LOF) variants result in Crohn’s disease. NOD2 facilitates the detection of S. aureus
and generation of inflammatory cytokines (i.e. IL-1β, IL-6 and TNF-α) which promotes
recruitment of neutrophils and other immune cells required to resolve infection. Herein
we describe a case of severe recurrent S. aureus infection following TNF-α inhibition
in a patient with compound heterozygous NOD2 variants.
Exome sequencing was performed with Sanger confirmation of subject and parents. NOD2
expression plasmid were modified by site-directed mutagenesis, transfected into HEK293T
cells, stimulated with IL-1β and MDP, and IL-8 production measured. PBMCs were stimulated
with MDP and IL-8 and TNF-α detected.
A 10-year-old Caucasian male diagnosed with Crohn’s colitis was started on infliximab
and within 2 weeks developed recurrent cellulitis, lymphadenitis (12 episodes), and
abscesses involving his neck, psoas muscle, axilla, and perianal region due to S.
aureus. Psoriasiform skin lesions developed and resolved upon transition to adalimumab,
however S. aureus infections continued. Transition to Ustekinumab resolved his colitis
and infections.
Exome sequencing revealed two NOD2 variants: Leu1007Profs*2, a known LOF variant associated
with Crohn’s disease; and Lys421Asn, a novel variant in NOD2 located in the nucleotide
binding domain usually associated with Blau syndrome. Sanger sequencing confirmed
the variants, and sequencing of parents demonstrating compound heterozygous inheritance.
Transfection studies confirmed LOF of the Leu1007Profs*2 variant, but the Lys421Asn
variant was functional. However, stimulating patients PBMCs with MDP resulted in complete
loss of IL-8 and TNF-α production, demonstrating loss of function of NOD2.
This case illustrates the important role of NOD2 in defense against S. aureus, as
complete loss of NOD2 function, combined with TNF-α blockade, resulted in recurrent
and severe S. aureus infections. It remains unclear how the Lys421 variant, which
is in the nucleotide binding domain and close to other GOF variants, results in NOD2
unresponsiveness. We propose that TNF-α blockade inhibited redundant inflammatory
pathways that are critical in sensing S. aureus in the setting of NOD2 deficiency.
These results may have implications in the treatment of Crohn’s disease.
Keywords: NOD2, CARD15, Crohn's, Anti-TNF-α, Staphylococcus aureus
Disclosure: John Routes has contracted research with CSL Behring and Evolve Biologics.
All other authors had no financial relationship to disclose.
(157) Facilitated Subcutaneous Immunoglobulin (fSCIG) Usage in Children and Adolescents
with Primary or Secondary Immunodeficiency Diseases: A Retrospective Chart Study (RAHPP)
Ulrich Baumann, Prof. Dr. med.1, Maria Fasshauer, Dr. Med2, Christine Pausch, Dr.
Med3, Corinna Hermann, Dr. Med4, David Pittrow, Prof. Dr. med.5, Michael Borte, Prof.
Dr. med.6
1Department of Paediatric Pulmonology, Allergy and Neonatology/Hannover Medical School
2Senior Physician, Paediatrics and Adolescent medicine/St. Georg Hospital
3Pharmacoepidemiology/GWT-TUD GmbH
4Global Medical Team Lead Immunology IG/Baxalta Innovations GmbH, a Takeda company
5Clinical Research/Pharmacoepidemiology/Technical University of Dresden
6Director, Clinic for Child and Adolescent Medicine/St. Georg Hospital
Pediatric patients ( < 18 years) included in a phase 3 trial of fSCIG in primary immunodeficiency
diseases (PID; NCT00814320) showed low rates of infection and systemic reactions with
fSCIG treatment. The RAHPP study (DRKS-ID: DRKS00015436) assessed real-world fSCIG
utilization in pediatric patients with PID or secondary immunodeficiency diseases
(SID) in Germany.
This multicenter retrospective chart review study enrolled pediatric patients ( <
18 years) with PID or SID on fSCIG for ≥6 months from 3 German centers. Informed consent
was obtained for all patients. Patient characteristics, immunoglobulin treatment history,
and reason for initiating fSCIG were collected at fSCIG initiation. fSCIG administration
and experience parameters and adverse drug reaction (ADR) reporting were collected
at fSCIG initiation and 6 months. Data were analyzed for the overall population and
by age subgroup (children: 0– < 12 years; adolescents: 12– < 18 years).
Thirty patients (16 male/14 female; mean [SD] age: 11.1 [4.9] years) with PID (n=26)
or SID (n=4) were enrolled. While 90.0% of patients received their first fSCIG infusion
at a hospital/doctor’s office, by 6 months all received infusions at home, with >95.0%
of patients infusing every 3–4 weeks. The median dose (volume) was 10.0 g (100.0 mL)
at initiation and 15.0 g (150.0 mL) at 6 months. At both timepoints, patients used
a median of 1 infusion site. Four local ADRs occurred at initiation, and 6 local and
2 systemic ADRs occurred at 6 months. No serious ADRs or technical infusion issues
were reported. The median monthly dose at 6 months was 0.4 g/kg in both children (n=14;
mean age: 6.6 years) and adolescents (n=16; mean age: 15.1 years). Most patients in
both age groups received their first infusion from a nurse (84.6% and 87.5%, respectively),
while at 6 months, children primarily (85.7%) received treatment via caregiver, and
adolescents primarily (75.0%) self-administered treatment. This real-world study confirms
the feasibility and tolerability of administering fSCIG at home every 3–4 weeks to
pediatric patients with PID or SID, with administration parameters similar to clinical
trials.
Funding: Takeda Pharmaceuticals International AG funded this study. Baxalta US Inc.
(a Takeda company) funded writing support.
Keywords: hypogammaglobulinemia, immunoglobulin, pediatric, real-world study, primary
immunodeficiency diseases, secondary immunodeficiency diseases
Disclosure: Ulrich Baumann received speaker Honoria from Takeda, CSL Behring and Octapharma.
Corinna Hermann is employed by Baxalta Innovations GmbH – part of Takeda. David Pittrow
is a consultant for Actelion Amgen, Baxalta, Biogen and Daiichi Sankyo. All other
authors had no financial relationship to disclose.Michael Borte: No financial relationships
or conflicts of interest
(158) Persistently Positive SARS-CoV-2 RT-PCR Testing in a Pediatric Patient with
X-Linked Agammaglobulinemia
Aaron Westreich, MD1
1Fellow/National Jewish Health
Limited information is available regarding SARS-CoV-2 infection in patients with primary
immunodeficiency and the effect this has on disease course and duration. Recommendations
for self-isolation after SARS-CoV-2 infection have been informed by retrospective
studies that examined the duration of viral shedding and infectivity in patients.
Though immunosuppressed patients were included in these studies, patients with primary
immunodeficiency were not specifically studied. I present a case of a pediatric patient
with X-linked agammaglobulinemia (XLA) who had persistently positive SARS-CoV-2 RT-PCR
testing as well as prolonged symptoms.
Our patient was a 12-year-old male with XLA with known hemizygous A523V mutation in
the BTK gene. His infection history included recurrent acute otitis media, chronic
conjunctivitis and possible sinus disease. Patient was diagnosed with SARS-CoV-2 infection
by RT-PCR 3 days after he began developing symptoms including sore throat, nausea,
vomiting, headache, dyspnea, non-productive cough and chest pain. He also developed
a fever which was not typical of his previous infections. During the first week of
illness, he was diagnosed with acute otitis media and conjunctivitis for which he
was treated with standard courses of oral and ophthalmic antibiotics, respectively.
On day 25 of illness, patient was admitted for persistent symptoms and dehydration
and discharged the following morning. He received an IVIG infusion while admitted
as his routine monthly infusion had been delayed by 3 weeks. He continued to report
persistent symptoms over the next several weeks, particularly fatigue and nausea.
His workup during this time included normal inflammatory and cardiac biomarkers, ECG,
echocardiogram and chest x-ray. A chest CT revealed diffuse mild bronchiectasis and
an 8mm ground-glass nodule in his left upper lobe of unclear etiology. Repeat SARS-CoV-2
RT-PCR testing revealed persistently positive results until 46 days after symptom
onset with negative results after 53 days. He was discharged from isolation on day
57 from symptom onset after his second negative PCR test. A significant improvement
in symptoms was noted approximately 58 days from symptom onset.
This case highlights the limitations of applying generalized isolation protocols to
patients with primary immunodeficiency where the significance of prolonged viral shedding
is unknown.
Fig. 1. Cycle threshold (Ct) values of N gene (a nucleocapsid protein) on SARS-CoV-2
real-time reverse transcription polymerase chain reaction are shown in blue. The horizontal
dashed red line represents the cutoff for positivity at 40, with undetectable values
presented below this line.
Keywords: Immunodeficiency, COVID-19, SARS-CoV-2, Coronavirus, Viral shedding, Immunosuppression,
X-linked agammaglobulinemia
Disclosure: The author had no financial relationship to disclose.
(159) Immunoglobulin Initiation Among Patients with Primary Immunodeficiency Diseases
(PIDD): A Retrospective Claims-based US Cohort Study
Colin Anderson-Smits, MPH1, Jordan Orange, MD, PhD2, Michelle Park, PharmD3, Zhongwen
Huang, PhD4, J. Bradley Layton, PhD5, Mary E. Ritchey, PhD6
1Director Outcomes Research & Epidemiology/Shire US Inc., A Takeda company
2Vagelos College of Physicians and Surgeons/Columbia University Irving Medical Center
3Director, Global Medical Affairs, Rare Immunology/Shire US Inc., A Takeda company
4Sr. Principal Statistician/Takeda Pharmaceuticals International Co.
5Senior Research Epidemiologist/RTI Health Solutions
6RTI Health Solutions/Med Tech Epi, LLC
Immunoglobulin (IG) replacement therapy, administered intravenously (IVIG) or subcutaneously
(SCIG), is standard first-line treatment for most forms of PIDD with defective antibody
production. SCIG allows for home administration of highly concentrated 20% IG or facilitated
10% IG delivered with recombinant human hyaluronidase. Limited data exist regarding
characteristics of patients with PIDD initiating IVIG and SCIG.
To identify and describe demographic, clinical, and treatment characteristics of patients
with PIDD in the United States initiating IVIG and SCIG.
This claims-based cohort study identified patients initiating IVIG or SCIG from 2012
to 2018, via diagnosis codes, in IBM® MarketScan® Research Databases. Clinical and
demographic characteristics were documented and described for IVIG and SCIG initiators.
Risk Vital Sign (RVS), a claims-based weighted algorithm for PIDD risk, was used to
assess disease severity.
The study population comprised 15,327 IVIG (57% female, median age 54 years) and 2604
SCIG initiators (69% female, median age 48 years). Compared with IVIG initiators,
SCIG initiators were more likely to have asthma (59% vs 38%), chronic obstructive
pulmonary disease (71% vs 58%), fibromyalgia (25% vs 20%), and inflammatory bowel
disease (12% vs 8%), but less likely to have cancer (11% vs 22%), coronary artery
disease/hypertension (45% vs 58%), and peripheral vascular disease (11% vs 16%). Compared
with IVIG initiators, SCIG initiators had greater use of high-potency oral antibiotics
(37% vs 31%) but lower use of IV antibiotics (23% vs 29%), systemic high-dose corticosteroids
(53% vs 67%), antifungals (25% vs 29%), and growth factors (1% vs 10%). Markers of
disease severity differed: A greater proportion of IVIG initiators had RVS predicted
risks in the medium/high range (46% vs 37%) and pneumonia (28% vs 23%), while recurrent
sinusitis was less common compared with SCIG initiators (38% vs 59%).
This exploratory analysis suggests differences between characteristics of patients
with PIDD who initiated SCIG versus IVIG with respect to comorbidities, markers of
PIDD severity, and previous PIDD treatments. Misclassification of PIDD status was
possible, which warrants further research.
Funding: Baxalta US Inc. (a Takeda company) funded this study and writing support.
Keywords: subcutaneous, intravenous, immunoglobulin, primary immunodeficiency
Disclosure: Colin Anderson-Smits, Michelle Park and Zhongwen Huang are employed by
Takeda. Joran Orange is a consultant for CSL, Enzyvant, Grifols, Takeda, and an advisory
board member of ADMA. J. Bradley Layton is employed by RTI Health Solutions. Mary
E. Ritchey has contracted research with AbbVie, Boehringer-Ingelheim, Gilead, Pasage
Bio, Regeneron, Takeda and Urovant; consultant of Johnson and Johnson and UCB; and
ownership interest in Procter & Gamble.
(160) Model-Based Simulation of Varied Subcutaneous Immune Globulin (Human), 20% (Ig20Gly)
Loading and Maintenance Dosing Regimens in Immunoglobulin-Naïve Patients with Primary
Immunodeficiency Diseases
Zhaoyang Li, PhD1, Todd Dumas, PharmD2, Barbara McCoy, PhD3, N. Seth Berry, PharmD4,
Leman Yel, MD5
1Senior Director, Clinical Pharmacology, Clinical Medicine, PDT/Shire US Inc., a Takeda
company
2Director, Research Pharmacometrics, Decision Sciences/IQVIA
3Senior Clinical Director/Baxalta Innovations GmbH, a Takeda Company
4Senior Director, Clinical PK-PD Modeling and Simulation/IQVIA
5Vice President, Head Clinical Medicine, Global Research & Development, PDT/Baxalta
US Inc., a Takeda company, University of California
While the pharmacokinetic (PK) profile of Ig20Gly is well characterized in immunoglobulin
(IG)-experienced patients with primary immunodeficiency diseases (PIDD), information
in IG-naïve patients is limited. This study used population PK modeling to simulate
serum IgG profiles and trough levels of Ig20Gly in IG-naïve patients with different
dosing regimens for treatment initiation and maintenance in PIDD.
Simulations of Ig20Gly PK profiles in IG-naïve patients were performed using a validated
population PK model developed from two pivotal phase 2/3 trials of weekly Ig20Gly
in PIDD (NCT01412385, NCT01218438). Two scenario sets were simulated: 1) a 400-mg/kg
loading dose and 100-mg/kg weekly maintenance dose, and 2) an 800-mg/kg loading dose
and 200-mg/kg weekly maintenance dose. Endogenous IgG baseline levels of 1.5, 2.0,
4.0, and 6.0 g/L for IG-naïve patients were evaluated. Dosing regimens were simulated
to determine the time to achieve the therapeutic target IgG trough level (7 g/L).
Across various loading and maintenance regimens, irrespective of endogenous baseline
IgG levels, serum IgG approached steady state around Week 12. The time to achieve
the target median IgG trough level was dependent on endogenous baseline IgG level
and Ig20Gly loading scheme. Achievement of target IgG trough levels was faster when
the loading dose was dispensed over 1 week vs 2 weeks. Patients with endogenous IgG
< 4 g/L may require the 800-mg/kg loading dose given within 1 week to achieve target
IgG levels within 1 to 2 weeks. Both maintenance regimens sustained serum IgG levels
above the target level.
These simulations suggest that attainment of serum IgG levels above a protective target
threshold (assumed 7 g/L in this study) in IG-naïve patients with PIDD can be achieved
within 1 to 2 weeks using appropriate loading-dose regimens and that, after the loading
phase, a 400- or 800-mg/kg/month maintenance regimen is adequate to maintain stable
IgG levels. Regular serum IgG trough-level monitoring should guide subsequent dose
adjustments and dosing intervals.
Funding: Baxalta US Inc. (a Takeda company) funded this study and writing support.
Keywords: subcutaneous immunoglobulin G, pharmacokinetic, primary immunodeficiency
diseases, treatment-naïve, Immune Globulin Subcutaneous (Human) 20% Solution
Disclosure: Barbara McCoy and Leman Yel are employed by Takeda. N. Seth Berry is employed
by IQVIA. The other authors had no financial relationship to disclose.
(161) The assessment of brain evoked potentials in patients with CAPS
Sukru Cekic1, Aylin Bican Demir2, Sara Kilic
3
1Dr./Uludag University Faculty of Medicine, Pediatric Immunology
2Dr./Uludag University Faculty of Medicine, Neurology
3Prof./Uludag University Faculty of Medicine, Pediatric Immunology
CAP syndromes are extremely rare, affecting about one person in every one million
people. Sensorinoral complications of the disease reduce the quality of life of patients.
Evoked potentials such as ABR and VEP are non-invasive methods used to measure the
electrophysiological response of the central nervous system. They have been used in
the diagnosis and monitoring of many immune and inflammatory diseases that affect
central nervous system. We aimed to assess the neurological involvement and outcome
of nine patients with CAPS.
Material and methods: We enrolled nine patients with CAPS from the same family. Visual
evoked potentials (VEP) and auditory brainstem responses (ABR) were performed in all
patients using Neuropack S1 MEB 9402, Nihon Kohden, Tokyo, Japan.
Results: The female to male ratio was 1.25. The median age at the diagnosis was 25
years (9–65), and the median duration of delay in diagnosis was 24 years (2–58). Six
patients were treated with canakinumab and three patients with anakinra. In ABR tests,
three cases (6 ears) considered acoustic nerve damage because no brainstem activity
occurred at 90 and 95 dB. The prolongation of P100 latency in VEP was detected in
five cases (bilateral in two cases,).
Conclusion: There was no previously reported data on the nervous system evoked potentials
such as ABR and VEP in patients with CAPS. Supporting audiometry with ABR is more
convenient than audiometry alone in recognizing hearing loss. Besides, VEP is also
a useful method to monitor the visual acuity of the patients. Subsequent studies are
needed to clarify this issue.
Keywords: CAPS, hearing loss, brain evoked potentials
Disclosure: The authors had no financial relationship to disclose.
(162) Which triggers could help to enhance timely identification of primary antibody
deficiency (PAD) – a qualitative study from the perspective of the patients
Lisanne M.A. Janssen, MD, MSc1, Kim van den Akker, MD, MSc2, Mohamed A. Boussihmad,
BSc3, Esther de Vries, MD, PhD4
1PhD student/Tilburg University
2Pediatric resident/Radboud UMC
3Master student/Radboud University
4Professor, Physician researcher in immunology/Tranzo, Tilburg School of Social and
Behavioral Sciences, Tilburg University, Tilburg; Laboratory for Medical Microbiology
and Immunology, Elisabeth Tweesteden Hospital, Tilburg, the Netherlands
Patients with predominantly (primary) antibody deficiencies (PADs) commonly develop
recurrent respiratory infections which can lead to bronchiectasis, long-term morbidity
and increased mortality. Recognizing symptoms and making a diagnosis is vital to enable
timely treatment. Studies on disease presentation have mainly been conducted using
medical files rather than direct contact with PAD patients. In order to ascertain
how patients appraised their symptoms and which factors were involved in a decision
to seek medical care, we conducted semi-structured interviews with 14 PAD-patients
(11 women, median 44, range 16-68yrs) until saturation of key emergent themes was
achieved.
Being always ill featured in all participant stories. Often from childhood onwards
periods of illness were felt to be too numerous, too bad, too long-lasting, or antibiotics
were always needed to get better. Recurrent or persistent respiratory infectious episodes
were the main triggers for patients to seek care. All participants developed an extreme
fatigue, described as a feeling of physical and mental exhaustion and thus an extreme
burden on daily life that was not solved by taking rest. Despite this, participants
tended to normalize their symptoms and carry on with usual activities. Non-immunologists,
as well as patients, misattributed the presenting signs and symptoms to common, self-limiting
illnesses or other ‘innocent’ explanations.
Participants in a way understand the long diagnostic delay. They know that the disease
is rare and that doctors have to cover a broad medical area. But they are more critical
about the way the doctors communicate with them. They feel that doctors often don’t
listen very well to their patients. The participants’ symptoms as well as the interpretation
of these symptoms by their social environment and doctors had a major emotional impact
on the participants and a negative influence on their future perspectives.
In conclusion, to timely identify PAD, ‘pattern recognition’ should not only focus
on the medical ‘red flags’, but also on less differentiating symptoms, such as ‘being
always ill’ and ‘worn out’ and the way patients cope with these problems. And, most
important, really listening to the patient, and remembering that things are not always
what they seem remains the key.
Keywords: primary antibody deficiency, qualitative research, timely diagnosis, trigger
Disclosure: The authors had no financial relationship to disclose.
(163) Real-World Safety and Tolerability of Facilitated Subcutaneous Immunoglobulin
in Pediatric Patients with Primary Immunodeficiency Diseases: Interim Analysis from
a Post-authorization Study in Europe
Peter Ciznar, MD, PhD1, Marion Roderick, MD2, Helena Schneiderová, MUDr.3, Milos Jesenak,
MD, PhD4, Gergely Kriván, MD, PhD5, Nicholas Brodszki, MD, PhD6, Stephen Jolles, MD,
PhD7, Katharina Fielhauer, n/a8, Shumyla Saeed-Khawaja, MD9, Barbara McCoy, PhD10,
Leman Yel, MD11
1Associated Professor of Pediatrics/Children University Hospital Bratislava, National
Institute of Children’s Diseases
2Department of Paediatric Immunology/Bristol Royal Hospital for Children
3Department of Pediatrics/Faculty of Medicine Masaryk University
4Department of Pediatrics/Jessenius Faculty of Medicine, Comenius University in Bratislava,
University Hospital in Martin
5Department of Pediatric Hematology & Stem Cell Transplantation/Szent László Hospital
6Department of Pediatric Oncology/Hematology/Immunology/Skåne University Hospital
7Clinical Lead – Immunodeficiency Centre for Wales/University Hospital of Wales
8Associate Clinical Director/Baxalta Innovations GmbH, a Takeda company
9Associate Clinical Director/Baxalta US Inc., a Takeda company
10Senior Clinical Director/Baxalta Innovations GmbH, a Takeda Company
11Vice President, Head Clinical Medicine, Global Research & Development, PDT/Baxalta
US Inc., a Takeda company, University of California
In a phase 3 trial in primary immunodeficiency diseases (PIDD; NCT00814320), facilitated
subcutaneous immunoglobulin (fSCIG), a dual-vial unit containing immunoglobulin G
(IgG) 10% and recombinant human hyaluronidase (rHuPH20), was effective and bioequivalent
to intravenous immunoglobulin with fewer systemic adverse events. This ongoing phase
4, prospective, European post-authorization study is evaluating fSCIG safety, tolerability,
and immunogenicity in pediatric patients with PIDD (NCT03116347).
Patients aged 2 to < 18 y with PIDD receiving immunoglobulin therapy from 16 European
centers enrolled with informed consent and received fSCIG for up to 3 years (Epoch
2). fSCIG-pretreated and fSCIG-naïve (new starters) patients were included. New starters
initiated fSCIG with a ramp-up of up to 6 weeks (Epoch 1). fSCIG safety, immunogenicity,
tolerability, use, and IgG trough-level data were collected approximately every 3
months. An interim analysis was preplanned for when 75% of patients completed 1 year
in Epoch 2 (data cut-off: May 14, 2020).
Of 42 patients (81.0% male) enrolled, 23 were fSCIG-naïve and 19 were fSCIG-pretreated
(mean age: 10.3 and 11.7 y, respectively). At interim analysis, patients received
a mean of 12.5 infusions. A total of 42 treatment-related adverse events occurring
after first fSCIG dose (AEs), excluding infections, were reported in 12 patients;
most AEs were mild. Treatment-related AEs occurred more frequently in fSCIG-naïve
(33 local, 3 systemic treatment-related AEs in 10 patients; 1.7 events/patient-year
[PY]) than fSCIG-pretreated (2 local, 4 systemic-related AEs in 2 patients; 0.3 events/PY).
No serious treatment-related AEs were reported. No patients developed positive anti-rHuPH20
antibody titers (≥1:160). Patients received a median of 1.2 infusions/month, with
fSCIG-pretreated receiving higher median infusion volumes/site than fSCIG-naïve (150
vs 80 mL/site) and fewer interrupted/adjusted/stopped infusions (4.9% vs 9.3% of infusions).
Mean IgG trough levels at enrolment and 12 months were 9.6 and 8.2 mg/dL, respectively.
This interim analysis supports the long-term safety of fSCIG in pediatric patients
with PIDD, with a safety and tolerability profile consistent with previous clinical
studies, and indicates that incidence of local AEs declines with fSCIG treatment duration.
Funding: Baxalta US Inc. (a Takeda company) funded this study and writing support.
Keywords: hypogammaglobulinemia, immunoglobulin, pediatric, safety, immunogenicity,
primary immunodeficiency diseases
Disclosure: Peter Ciznar received speaker honoraria from Shire/Takeda. Stephen Jolles
is an advisory board member of Biocryst, Biotest, Grifols, LFB, Pharming; received
a research grant from CSL Behring and Takeda; and speaker honoraria from Octapharama,
Takeda, UCB Pharma; and has ownerhip interest in Zarodex. Katharina Fielhauer, Shumyla
Saeed-Khawai, Barbara McCoy and Leman Yel are employed by Takeda. The other authors
had no financial relationship to disclose.
(164) A Case of Drug Allergy – Or is it?
Yatyng Chang, MD1, Stephania Lairet, MD2, Jose Calderon, MD3, Vivian Hernandez-Trujillo,
MD3
1Allergy Immunology Fellow/Nicklaus Children's Hospital
2Pediatric Resident/Nicklaus Children's Hospital
3Allergy Immunology Attending/Nicklaus Children's Hospital
The Jarisch-Herxheimer reaction is a systemic inflammatory reaction secondary to the
release of endotoxins. It results in high levels of TNF훂, IL6, and IL8. Symptoms are
similar to anaphylaxis and occur immediately after administration of antibiotics,
thereby often being confused as a drug allergy. Here we present a child with E. coli
urosepsis and likely Jarisch-Herxheimer reaction.
To describe a case of systemic cytokine release and septic shock not responding to
treatment for anaphylaxis.
This patient initially presented with 2 days of fever, back pain, and dysuria. She
was found to have left pyelonephritis and treated with cefotaxime. Soon after antibiotic
administration, she developed tachycardia, difficulty breathing, rash, and hypotension.
She was given multiple doses of epinephrine and transferred to the PICU. Given concern
for drug allergy, she was changed to meropenem and developed hypotension requiring
epinephrine. She was subsequently labeled as allergic to penicillins, cephalosporins,
and meropenem. When consulted, the allergy team diagnosed septic shock and suspected
Jarisch-Herxheimer reaction, as the patient was not improving despite aggressive treatment
for anaphylaxis. She improved clinically once treatment for septic shock was initiated.
In this age of growing antibiotic resistance, a misdiagnosis of drug allergy, especially
in a child, can greatly affect and restrict patient care. It can turn simple outpatient
treatments into long inpatient stays. We believe that in patients not responding to
appropriate treatment for anaphylaxis, septic shock and Jarisch-Herxheimer reaction
should be considered. The patient should be followed closely with consideration of
antibiotic testing and/ or reintroduction.
Keywords: Jarisch-Herxeimer, Drug allergy, Drug reaction
Disclosure: Disclosures: Vivian Hernandez-Trujillo is an advisory board member of
Covis, CSL Behring, DBV, Kaleo, Takeda, and US WORLD MEDS. All other authors had no
financial relationships to disclose.
(165) A Novel Intronic Genetic Variant in an Adolescent with Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal
Dystrophy Syndrome
Mohamed Ebrahim, MD1, Rachel Eisenberg, MD2, Melissa Wasserstein, MD3, Katie Gallagher,
MS, C.G.C.4, Arye Rubinstein, MD, PhD5
1Allergy and Immunology fellow in Ttraining/Montefiore medical center
2Attending in Allergy and Immunology/Montefiore Medical Center
3Chief of the department of Pediatric Genetic Medicine/Montefiore medical center
4Certified Genetic Counselor/Montefiore medical center
5Chief of the Pediatrics Division of the Department of Allergy & Immunology/Montefiore
Medical Center
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare
autosomal recessive disease caused by bi-allelic pathogenic variants in the Autoimmune
Regulator (AIRE) gene. AIRE is a transcriptional regulator, critical in the expression
of tissue-specific antigens (TSAs). Thymocytes with high affinity to TSAs undergo
apoptosis, thereby eliminating escape of self-reactive T cells to the periphery. Aberrations
in this process lead to multiorgan autoimmunity, commonly in endocrine tissues and
susceptibility to chronic mucocutaneous candidiasis. We describe a boy with classic
features of APECED whose diagnosis was confirmed 16 years later by whole genome sequencing
(WGS).
A 17-year-old male of mixed European, including Finnish, ancestry presented at 14
months, with a hypotensive crisis and severe hyponatremia and was diagnosed with adrenal
insufficiency. Over the years, he developed esophageal candidiasis, hypothyroidism,
hypoparathyroidism, vitiligo, enamel dysplasia, alopecia, uveitis, autoimmune hepatitis
and poor bowel motility. His management included antifungal therapies, calcium supplementation,
oral fludrocortisone and tacrolimus. At 11 years, he developed recurrent sinopulmonary
infections. Chest imaging showed interstitial pneumonitis, bilateral nodular ground
glass and tree-in-bud opacities, mild bilateral lower lobe bronchial wall thickening
and eventual bronchiectasis. Immune work up revealed poor response to streptococcus
pneumonia vaccines. His infection burden improved with gammaglobulin replacement.
The bowel motility abnormality led to failure to thrive requiring gastro-jejunal tube
insertion and a cecostomy.
Genetic testing as a young child demonstrated a heterozygous, maternally inherited,
pathogenic variant (c.769C>T) in AIRE. Whole exome sequencing (WES) at age 16 years
did not identify any additional pathogenic variants. At 17 years, he enrolled in NYCKidSeq,
an NIH funded WGS, that identified a second, paternally inherited, intronic AIRE variant
of uncertain significance (c.1504-818G>A). The Genome Aggregation Database (gnomAD)
supports the rarity of this allele, and in silico tools predict conflicting evidence
of pathogenicity. However, In the setting of bi-allelic variants in a patient with
a consistent clinical diagnosis, it highly likely that they are causative of APECED.
In this era of evolving genetic testing, this case is a reminder of the limitations
of genetic panels and WES. In patients with highly suspicious clinical findings, follow
up with WGS may be of imperative significance.
Keywords: APECED, AIRE, Intronic, gene, Autoimmune polyendocrinopathy-candidiasis-ectodermal
dystrophy
Disclosures: Melissa Wasserstein has contracted research with BioMarin, National Niemann
Pick Disease Foundation, Orchard Therapeutics, Retrophin, Sanofi Genzyme and Ultragenyx.
All other authors had no financial relationships to disclose.
(166) Utilizing Newborn Screening to Facilitate Immunologic Diagnosis of 22q11.2 Deletion
Syndrome
Erika Cherk, MD1, Victoria Dimitriades, MD, FAAAAI, FACAAI2
1Resident Physician/UC Davis Medical Center
2Clinical Professor of Pediatrics; Division Chief, Pediatric Allergy, Immunology &
Rheumatology/UC Davis Medical Center
Historically, 22q11.2 deletion syndrome has been underdiagnosed. However, since initiation
of Severe Combined Immune Deficiency newborn screening (SCID-NBS) in California in
2010, immunologists have become involved in earlier identification of cases of 22q11.2
deletion syndrome.
A clinically well-appearing 10 month-old, ex-28 WGA male diagnosed with 22q11.2 deletion
syndrome after a positive SCID NBS prompted further immunological workup. He did not
have any of the cardiac (congenital heart disease), facial (cleft palate, hypertelorism,
posteriorly rotated ears), or endocrinologic abnormalities (hypoparathyroidism) commonly
associated with 22q11.2 deletion syndrome.
SCID NBS (measuring numbers of T cell receptor excision circles [TRECs]), CBC, flow
cytometry, tracking lymphocyte subpopulations (from birth until diagnosis), Primary
Immunodeficiency panel genetic testing
On day 16 of life, the patient was found to have positive SCID newborn screening with
low TREC numbers. Subsequent immunologic testing showed mild hypogammaglobulinemia
(which resolved over time) and T cell lymphopenia (which persisted over time). Genetic
testing identified a pathogenic deletion in TBX1, a gene associated with 22q11.2 deletion
syndrome.
Without SCID newborn screening and immunologic follow-up, this case of 22q11.2 deletion
syndrome without typical clinical features may not have been detected. Ultimately,
earlier detection of 22q11.2 deletion syndrome will greatly improve health and quality
of life for affected children, allowing them to receive appropriate preventative care
(e.g. associated disease tracking, developmental assessments, infection prevention)
prior to developing complications related to their genetic disorder.
Keywords: 22q11.2 deletion syndrome, primary immunodeficiency, SCID newborn screening,
genetic testing
Disclosures: Victoria Dimitriades is received speaker honoraria from Grifols and is
an advisory board member of Horizon Therapeutics. The other author had no financial
relationships to disclose.
(167) Dysregulation of multiple cytokine signaling pathways underlies the pleiotropy
of SOCS1 haploinsufficiency
Julia Körholz1, Anastasia Gabrielyan, PhD2, John Sowerby, PhD3, Felix Boschann, Dr.
med.4, Lan-Sun Chen, PhD5, Diana Paul6, Karsten Conrad, PD. Dr. med7, Nadja Roeber8,
Min Ae Lee-Kirsch, Prof. Dr. med.9, Ken Smith, Prof.10, Alexander Dalpke, Prof. Dr.
med.11, Catharina Schütz, Prof. Dr. med.12, William Rae, MSc13
1Resident/Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische
Universität Dresden, Dresden, Germany
2PostDoc/Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische
Universität Dresden, Dresden, Germany
3Postdoctoral Research Associate/Cambridge Institute of Therapeutic Immunology and
Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus,
Cambridge, UK. / Department of Medicine, University of Cambridge, Cambridge Biomedical
Campus, Cambridge, UK.
4Physician/Institute of Medical Genetics and Human Genetics, Charité - Universitätsmedizin
Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health
5PostDoc/Institute of Medical Microbiology and Hygiene, Medizinische Fakultät Carl
Gustav Carus, Technische Universität Dresden, Dresden, Germany
6Lab Assistant/Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus,
Technische Universität Dresden, Dresden, Germany.
7Head of the laboratory, scientific staff/Institute of Immunology, Medizinische Fakultät
Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
8Scientific Staff/Institute of Immunology, Medizinische Fakultät Carl Gustav Carus,
Technische Universität Dresden,
9Head of the clinical research group 249/Department of Pediatrics, Medizinische Fakultät
Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
10Professor of Medicine/Cambridge Institute of Therapeutic Immunology and Infectious
Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, University
of Cambridge, Cambridge, UK / Department of Medicine, University of Cambridge, Cambridge
Biomedical Campus, Cambridge, UK.
11Head of Infection & Immunity, Microbiome Studies/Institute of Medical Microbiology
and Hygiene, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden,
Dresden, Germany
12Professor at the Department of Pediatric immunology/Department of Perdiatrics, Uniklinikum
Carl Gustav carus Dresden
13PhD Student/Cambridge Institute of Therapeutic Immunology and Infectious Disease,
Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK. / Department
of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.
Inborn errors of immunity (IEI) present diagnostic and therapeutic challenges, as
they are characterized by highly diverse phenotypic spectrums, genetic heterogeneity
and incomplete penetrance (1,2). Suppressor of cytokine signaling 1 (SOCS1) is a key
negative regulator of cytokine signaling, limiting phosphorylation of different targets,
including signal transducer and activator of transcription (STAT) 1 (3). SOCS proteins
exert their action by interacting with Janus kinase (JAK) and non-receptor tyrosine
kinase-2 (TYK2) kinases with varying affinities across different cell surface cytokine
receptors3. SOCS1 haploinsufficiency was recently identified as an autosomal dominant
monogenic IEI (4-6).
We assessed impacts of reduced SOCS1 expression across multiple immune cell pathways
utilizing patient cells and CRISPR/Cas9 edited primary human T cells. We conducted
molecular genetics analysis, measurements of interferon signature, immunoblotting
and flow cytometric analysis.
SOCS1 haploinsufficiency phenotypes straddle across the International Union of Immunological
Societies classification of IEI. Reduced SOCS1 expression leads to dysregulation of
multiple intracellular pathways in immune cells. STAT1 phosphorylation is enhanced,
comparably with STAT1 gain-of-function mutations, and STAT3 phosphorylation is similarly
reduced with concurrent reduction of Th17 cells. Furthermore, nuclear factor 'kappa-light-chain-enhancer'
of activated B-cells (NF-κB)1 activity appears increased in SOCS1 haploinsufficient
cells. Reduced E3 ligase functions of SOCS1 lead to increased focal adhesion kinase
(FAK) in immune cells resulting in increased AKT (protein kinase B) and p70 ribosomal
protein S6 kinase phosphorylation. We also find increased Toll-like receptor responses
in SOCS1 haploinsufficient patients.
SOCS1 haploinsufficiency is a pleiotropic monogenic IEI. Dysregulation of multiple
immune cell pathways may explain the variable clinical phenotype associated with this
new condition. Knowledge of these additional dysregulated immune pathways is important
when considering the optimum management for SOCS1 haploinsufficient patients.
References:
1. Bousfiha A, et al. J Clin Immunol. 2017.
2. Gruber C, Bogunovic D. Human Genetics. 2020.
3. Yoshimura, A. et al. Front Immunol. 2012.
4. Thaventhiran J, et al. Nature. 2020.
5. Lee PY, et al. J Allergy Clin Immunol. 2020.
6. Hadjadj J, et al. Nat Commun. 2020.
Keywords: Inborn error of immunity, primary immunodeficiency, SOCS1
Disclosures: All authors indicated they had no financial relationships to disclose.
(168) CTLA-4 and CVID: Analysis of USIDNET Patients
Sara Ghannam, MD1, John McDonnell, MD, FAAP1, Seth Rotz, MD2, James Fernandez, MD,
PhD3
1Allergy Immunology Fellow/Cleveland Clinic Foundation
2Staff, Pediatric Hematology Oncology and Blood and Bone Marrow Transplant/Cleveland
Clinic Foundation
3Staff, Allergy and Clinical Immunology/Cleveland Clinic Foundation
Common variable immunodeficiency disorder (CVID) is common, affecting up to 1 in 25,000
patients. Improvements in medical science have led to the discovery of several monogenic
defects of this clinical syndrome, which is broadly characterized by decreased antibody
levels, decreased antibody function, and immune dysregulation. One recently described
monogenic defect of CVID is a pathogenic mutation in cytotoxic T lymphocyte associated
protein four (CTLA-4), a soluble factor produced by regulatory T cells.
To examine clinical characteristics of a cohort of subjects in the United States Immunodeficiency
Network (USIDNET) registry with known CTLA-4 mutations.
USIDNET is a registry of data from multiple participating sites concerning patients
with primary immune deficiencies in the US and Canada. Information was obtained on
patients diagnosed with CTLA-4 mutations and entered into the registry through 2019.
There were a total of 22 subjects with diagnosed CTLA-4 mutations in the registry,
all born between 1944 and 2018. Of these, 13 were male (59.1%). The vast majority
were white (90.9%). The average age of onset of symptoms was 13.5 years, and the average
time to molecular diagnosis was 11.4 years. 68.2% of patients had a family history
of primary immunodeficiency and 95% of subjects had a single pathogenic mutation (CTLA-4).
The most common infections reported were sinopulmonary (49.3%), cutaneous (25.4%),
and diarrheal (9.4%). The top immunomodulators prescribed by category included m-tor
inhibitors (33%), abatacept (24.7%), and corticosteroids (15.3%). Other immunomodulators
used include rituximab, colony stimulators, mycophenolate, calcineurin inhibitors,
phosphodiesterase-4 inhibitors and antimalarials. One subject underwent a stem-cell
transplant, and 4 subjects died during the period of observation.
Data from the USIDNET registry summarizes the currently reported clinical characteristics
of patients with CTLA-4, a monogenic cause of CVID.
Figure 1: Demographic data presented as mean (SD) for continuous measures, and percent
(%) for categorical measures.
Figure 2: Infection types in CTLA-4 patients
Keywords: CTLA4, CVID, Primary Immunodeficiency, USIDNET
Disclosures: All authors indicated they had no financial relationships to disclose.
(169) Medium-to-Long-Term Safety, Efficacy, and Tolerability of Subcutaneous Human
Immunoglobulin 16.5% in Patients with Primary Immunodeficiencies
Syed Rizvi, PharmD1, Sudhir Gupta, MD, PhD2, Roger Kobayashi, MD3, Ai Lan Kobayashi,
MD4, Isaac Melamed, MD5, Jose Fernando Mandujano, MD6, Bob Geng, MD7, Syed Rehman,
MD8, Bruce Ritchie, MD, FRCPC9, Shardae Young, PharmD10
1Associate Director Medical Affairs, Immunology/Octapharma
2Professor of Medicine, Pathology & Laboratory Medicine, and Microbiology & Molecular
Genetics/University of California, Irvine
3Allergist Immunologist/Allergy, Asthma, and Immunology Associates PC
4Allergist Immunologist/Midlands Pediatrics PC
5Allergist Immunologist/IMMUNOe Research Centers
6Pediatric Pulmonologist/Pediatric Pulmonary Associates of North Texas, P.A.
7Allergist Immunologist/Rady's Children's Hospital San Diego
8Allergist Immunologist/Asthma and Allergy Center
9Hematologist/University of Alberta
10Medical Science Liaison, Immunology/Octapharma
Patients with primary immunodeficiencies (PID) require life-long replacement therapy
with immunoglobulins (Ig) to prevent severe infections and irreversible complications.
In this follow-up study, medium-to-long term safety, efficacy and tolerability of
a subcutaneous human normal immunoglobulin 16.5% were evaluated in adult and pediatric
PID patients.
Methods: A prospective, open-label, non-controlled, single-arm, multicenter phase
3 study involving 27 adult and pediatric patients with PID was conducted in North
America to assess medium-to-long term safety, efficacy and tolerability of SCIg 16.5%
as a follow-up extension study to the pivotal Phase 3 study. PID patients received
weekly or bi-weekly doses of SCIg 16.5% (Cutaquig) with the option of increased infusion
volume (up to 60 mL/site) and rate (up to 240 mL/hr/all sites) over a 42-month period.
Twenty-seven patients with a mean age of 39.26 years receiving a total of 2,777 SCIg
infusions were included in the Full Analysis Set. The mean actual dose administered
was 0.169 g/kg. One serious bacterial infection was recorded in 1 adult patient, for
an overall rate of 0.018 SBIs per person-year. Among the 119 other infections observed,
only 2 (1.7%) were graded as severe (pyrexia of unknown origin and E.coli bacteremia).
All other infections were mild (61.3%) or moderate (37%) in intensity. Two patients
had to be hospitalized on 3 occasions due to infection for an overall rate of hospitalization
of 0.185 days. Of the 204 reported adverse events (excluding infusion site reactions
and infections), only 7 (headache, nausea, chills, pyrexia) were assessed as being
related to the study drug; all of which were non-serious. Overall, 44.4% of patients
experienced infusion site reactions, with most being mild-to-moderate in intensity.
In the majority of infusions (96.6%), there were no infusion site reactions.
: The efficacy of this SCIg 16.5% product was confirmed by an overall rate of 0.018
SBIs which is far below the FDA requested threshold of 1. The product was well tolerated,
with 96.6% of all infusions having no infusion site reactions.
This study demonstrated that subcutaneous human normal immunoglobulin 16.5% is well-tolerated,
safe and effective for long-term use in patients with primary immunodeficiency diseases.
Keywords: Primary immunodeficiency, Subcutaneous immunoglobulin, infections, immunoglobulins
Disclosures: Syed Rizvi and Shardae Young are employed by Octapharma. Sudhir Gupta
and Isaac Melamed received contract research from Octapharma and Shire. Bob Geng was
an advisory board member for Biocryst and received speaker honoraria from Grifols,
GSK, Horizon, Kedrion, Octapharma, Optinose, Regeneron, Sanofi, and Takeda; he was
a consultant for RMS. Roger Kobayashi received speaker honoraria from IgNS and a research
grant and speaker honoraria from Octapharma. Ai Lan Kobayashi received a research
grant from Octapharma. Bruce Ritchie is a consultant for Octapharma.
(170) Inflammatory Markers Correlate with Clinical Response to Immunomodulatory Agents
in MIS-C: A Case Series
Sylwia Nowak, MD1, Andrew McGurn, MD2, Latania Logan, MD3, Colleen Nash, MD, MPH3,
Julie Wohrley, MD3, Sindhura Bandi, MD3
1Allergy/Immunology Fellow/Rush University Medical Center
2Resident/Rush University Medical Center
3Attending/Rush University Medical Center
Multisystem Inflammatory Syndrome in Children (MIS-C) is a potentially severe disease
with a varied clinical presentation, elevated markers of inflammation, and temporal
relationship to a previous SARS-CoV-2 infection.
We report on 4 pediatric cases of multi-system inflammatory dysfunction in setting
of SARS-CoV-2 positive IgG titers.
Patient 1 is a previously healthy 5-year-old who rapidly decompensated with cardiogenic
shock and respiratory failure after presenting with a 2-day history of infectious
gastroenteritis. He received IVIG and corticosteroids, with continued fever, organ
involvement, and persistent elevation of inflammatory markers. Anakinra was administered
with reduction in inflammatory markers and clinical improvement.
Patient 2 is an ex-24 week 18-month-old with history of IVH and BPD who presented
with status epilepticus, hypotensive shock, and respiratory failure in the setting
of 3-day history of fevers. She received IVIG and corticosteroids with clinical improvement
and downtrending inflammatory markers thereafter.
Patient 3 is a previously healthy 7-year-old who presented with 5-day history of fevers,
worsening abdominal and chest pain, altered mental status, and purpura requiring VA-ECMO
and CRRT. After treatment with IVIG due to continued organ dysfunction, he was treated
with anakinra and methylprednisolone that led to eventual improvement in inflammatory
markers and clinical status.
Patient 4 is a previously healthy 12-year-old who presented with a 4-day history of
fever, headache, and myalgias who developed persistent hypotension and troponin leak.
She clinically improved after treatment with IVIG and methylprednisolone with normalization
of her troponin and other inflammatory markers.
Patients with hyperinflammation and organ dysfunction due to MIS-C necessitate a guideline-driven
multidisciplinary approach, which incorporates a stepwise approach to initiation of
immunomodulatory agents specific to each patient’s clinical course, laboratory trends,
and response to treatment.
Keywords: MIS-C, SARS-CoV-2, multidisciplinary, immunomodulatory
Disclosure: All authors indicated they had no financial relationships to disclose.
(171) Heterozygous AIRE Mutation in a Family with Multiple Autoimmune Organ Involvement
Asena Pınar Sefer, MD1, Burcu Kocamis Kolukisa, MD1, bengü akçam, pHd2, Yasemin Kendir
Demirkol, MD3, Elif Karakoç Aydıner, MD4, ahmet Ozen, MD4, Safa Baris, MD5
1Clinical Fellow/Marmara University Hospital, Department of Pediatric Immunology and
Allergy
2PhD/Marmara University Pendik Research and Training Hospital
3./Umraniye Research and Training Hospital, Department of Pediatric Genetic Diseases
4professor/Marmara University Pendik Research and Training Hospital
5Professor of Pediatrics/Marmara University Hospital, Department of Pediatric Immunology
and Allergy
The AIRE (Autoimmune regulatory) gene plays an important role in controlling immune
tolerance and preventing autoimmunity. APS -1 (Autoimmune polyendocrinopathy syndrome)
is a syndrome that is caused by autosomal recessive mutations in the AIRE gene and
presented with multiple autoimmune tissue and organ involvement. Recently, it is unveiled
that autosomal dominant heterozygous mutations in the AIRE gene have also been cause
autoimmune diseases like autoimmune thyroiditis, adrenal insufficiency, pernicious
anemia and vitiligo like APS-1 but occurring at a older age.
A 16-year-old male patient who had symptoms of celiac disease, autoimmune hepatitis,
vitiligo, and muscle weakness was immunologically evaluated due to his history of
frequent fever and lymphopenia. The patient's immunoglobulin levels were normal and
lymphocyte subgroup examination was ; CD3: 74% (absolute: 592-low), CD3CD4: 35% (absolute:
280-low), CD3CD8: 35% (absolute: 80-low), CD19: 12% (absolute: 96-low), CD16- 56:
10% (absolute: 80-low). Anti-parietal antibody positivity was detected in the autoimmune
panel. The regulatory T cell ratios of the patient were lower than the control. Genetic
analysis was done and C.926T> C, p.Ile309 * heterozygous change in the AIRE gene was
detected. Sanger sequence analysis was performed to the patient's family. Similar
heterozygous changes were detected in the AIRE gene of the mother who had no complaints,
but lymphopenia and anti-thyroid autoantibody positivity were detected in her examinations.
AIRE gene mutations can cause multiple autoimmune organ involvement in addition to
autoimmune polyendocrinopathy syndrome. In these patients, autosomal dominant transition,
which is the rare, can be detected. This work was supported by the Scientific and
Technological Research Council of Turkey to (318S202).
Keywords: AIRE, autoimmunity, heterozygous mutation, APDS
Disclosure: All authors indicated they had no financial relationships to disclose.
(172) Activated Phosphoinositide 3-Kinase Delta Syndrome 1: clinical and immunological
data from an Italian cohort of eight patients
Giulio Tessarin, MD1, Manuela Baronio, PhD2, Stefano Rossi, MD1, Luisa Gazzurelli,
PhD3, Michael Colpani, MD1, Fabio Cardinale, MD4, Baldassarre Martire, MD5, Letizia
Brescia, MD6, Giorgio Costagliola, MD7, Laura Luti, MD8, Gabriella Casazza, MD8, Maria
Cristina Menconi, MD8, Francesco Saettini, MD9, Raffaele Badolato, MD10, Marco Chiarini,
MSc11, Daniele Moratto, MSc12, Antonella Meini, MD13, Maria Pia Bondioni, MD14, Silvia
Giliani, MD15, Alessandro Plebani, MD, PhD16, Vassilios Lougaris, MD17
1Pediatric Resident/Pediatrics Clinic and “A. Nocivelli” Institute for Molecular Medicine,
Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali
Civili of Brescia, Brescia, Italy
2PhD/Pediatrics Clinic and “A. Nocivelli” Institute for Molecular Medicine, Department
of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili
of Brescia
3PhD/Pediatrics Clinic and “A. Nocivelli” Institute for Molecular Medicine, Department
of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili
of Brescia, Brescia, Italy
4Professor of Pediatrics/Allergy, Immunology and Pediatric Pulmonology Unit, “Policlinico-Giovanni
XXII” Hospital, University of Bari, Bari, Italy;
5MD/Pediatrics Unit, Monsignor Dimiccoli Hospital, Barletta, Italy
6MD/Pediatric Oncohematology Unit, Ospedale Santissima Annunziata, Taranto, Italy
7Pediatric Resident/Division of Pediatrics, University of Pisa, Pisa, Italy
8MD/Pediatric Oncology and Hematology, University of Pisa, Pisa, Italy
9MD/Pediatric Hematology Oncology Unit, Department of Pediatrics, University of Milano
Bicocca, MBBM Foundation, Monza, Italy
10Full Professor of Pediatrics/Pediatrics Clinic and “A. Nocivelli” Institute for
Molecular Medicine, Department of Clinical and Experimental Sciences, University of
Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
11Msc/Clinical Chemical Analysis Central Laboratory, ASST Spedali Civili of Brescia,
Brescia, Ital
12MSc/Clinical Chemical Analysis Central Laboratory, ASST Spedali Civili of Brescia,
Brescia, Italy
13MD/Pediatrics Clinic, ASST-Spedali Civili of Brescia, Brescia, Italy
14MD/Pediatric Radiology, University of Brescia, ASST Spedali Civili di Brescia, Brescia,
Italy;
15Assistant Professor/Cytogenetic and Medical Genetics Unit and “A. Nocivelli” Institute
for Molecular Medicine, Department of Molecular and Translational Medicine, University
of Brescia, ASST Spedali Civili of Brescia, 25123 Brescia,
16Full Professor of Pediatrics/ediatrics Clinic and “A. Nocivelli” Institute for Molecular
Medicine, Department of Clinical and Experimental Sciences, University of Brescia,
ASST Spedali Civili of Brescia, Brescia, Italy
17Assistant Professor of Pediatrics/ediatrics Clinic and “A. Nocivelli” Institute
for Molecular Medicine, Department of Clinical and Experimental Sciences, University
of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
Activated Phosphoinositide 3-Kinase Delta Syndrome 1 (APDS-1) is a recently described
primary combined immunodeficiency caused by gain-of-function mutations in the PIK3CD
gene.
The methods used were a review of medical records and laboratory data of APDS-1 patients
regularly followed by three Italian Immunology Units.
We report on eight APDS-1 patients. All patients are alive. Ages at clinical onset
and molecular diagnosis were variable (0.5 to 20.5; 2.2 to 43.2 years). Recurrent
sinopulmonary infections were the most common initial feature of disease requiring
medical evaluation. At onset or during follow-up, seven patients presented lymphoproliferative
disease, one case complicated by HLH (Table 1). Immunohistochemical analysis of bioptic
specimens showed reactive non-infective non-neoplastic lymphoproliferation. Only one
patient presented an atypically mild clinical course: besides the B cell lymphopenia,
she presented occasional respiratory infections, without signs of lymphoproliferation.
Among our cohort, reduced CD4+ T-cells count with low Recent Thymic Emigrants, increased
CD8+ effector-memory, raised CD8+CD57+ and hypogammaglobulinemia were common findings.
Genetic analysis of PIK3CD gene revealed three novel variants: functional testing
evaluating the phosphorylation pattern of S6K confirmed their activating nature (Table
2 and Figure 1). In the remaining five patients, the previously reported mutations
p.E1021K (n=4) and p.E525A (n=1) were identified. Six patients were started on immunoglobulin
replacement treatment (IgRT). In two patients, Sirolimus was used to control lymphoproliferation.
One patient successfully underwent HSCT, with good chimerism and no GVHD at 16 months
after-HSCT.
APDS-1 is a combined immunodeficiency with a wide variety of clinical manifestations
and a complex immunological presentation. Besides IgRT, specific therapies targeting
the PI3Kδ pathway will most likely become a valid aid for the amelioration of patients’
clinical management and their quality of life.
Table 2. Genetic analysis and phospo-S6K evaluation of eight APDS-1 patients
Figure 1. phospo-S6 kinase (pS6K) levels in peripheral T cells from Activated Phosphoinositide
3-Kinase Delta Syndrome-1 (APDS-1) patients (Pts). Summarized data for pS6K levels
from patients harbouring the Y524D, P658L and R108L PIK3CD mutations are shown for
CD4+ T cells (a) and CD8+ T cells (b) after anti-CD3 stimulation and/or CAL-101 treatment.
(Data were summarized from n = 3 experiments from the index patients and four different
healthy controls (HCs); statistical analysis was performed using the Student’s t-test
(* p < 0.05)
Keywords: inborn errors of immunity, p110delta, lymphoproliferation, apds-1, PIK3CD,
HSCT, Sirolimus, activated PI3K
Disclosure: All authors indicated they had no financial relationships to disclose.
(173) Reduction of Infusion Time Using a 10% Immunoglobulin Product During Staffing
Shortages Due to COVID-19
Christine Miller, PharmD1, Timothy Walton, MHS, CCRP2, Barbara Prosser, RPh3, Craig
Vollmer, BA4, David Luckey, MBA5, Drew Doyle, RPh6
1Manager, Health Economics and Outcomes Research/Soleo Health
2Director of Data Quality, Health Outcomes and Research/Soleo Health
3VP, Health Economics and Outcomes Research/Soleo Health
4Chief Commercial Officer/Soleo Health
5Director of Business Applications/Soleo Health
6Vice President, Sales & Market Development/Soleo Health
The recent healthcare crisis due to the novel Coronavirus disease 2019 (COVID-19)
has created an increased demand for infusions administered within the home environment.
Patients with immunodeficiencies who are receiving intravenous immune globulin (IVIg)
are at greater risk for contracting infections, like COVID-19. Hospital and outpatient
clinics providing scheduled infusions have referred patients to specialty pharmacy
organizations in order to make availability for critically ill patients and reduce
COVID-19 exposure risk to patients and employees. Due to increased demand for home
infusion, it has become imperative to reduce nurse visit times to minimize COVID-19
exposure risk to nurses and patients while meeting these increased demands. The purpose
of this study is to determine if a 10% immune globulin (Ig) product with a 15-minute
titration protocol has a shorter total infusion time and could therefore reduce the
amount of time spent in a patient’s home.
A retrospective review of patient medical records was conducted by a multidisciplinary
team over a 30-month period. Customized reports identified patients receiving Gammaplex
10% after previously receiving other Ig products. This allowed for a comparison of
infusion times for all Ig products pre and post transition to Gammaplex 10%.
A total of twenty-three patients met the inclusion criteria. Thirteen had an average
infusion reduction time of 35 minutes per episode, with a maximum of 1 hour 15 minutes.
Five patients had an average infusion increase time of 36 minutes per episode and
five had no change per episode. 56% of patients experienced zero adverse events post-transition.
The most frequent adverse events reported (>10% patients) included headache and fatigue.
Fatigue may also have been attributed to premedication with diphenhydramine, which
was taken by 83% of patients.
Conclusions: The home environment is an important site of care to help reduce the
risk of exposure to COVID-19, especially for those with immunodeficiencies and receiving
Ig infusions. Using a 10% Ig product with a 15-minute titration protocol with a shorter
infusion time is one strategy to help reduce the amount of time a visiting nurse spends
with a patient and allows greater flexibility with nursing scheduling.
Keywords: COVID, Immunoglobulin, Infusion Time, IVIG, Specialty Pharmacy, Staffing
Shortage
Disclosure: All authors indicated they had no financial relationships to disclose.
(174) Exploring the Effects of BMI and Route of Administration on Efficacy of Immunoglobulin
G Replacement Therapy - a Preliminary Report
Nikki Kimura, MD1, Miriam Samstein, MD, PhD2, Brianne Navetta-Modrov, MD3, David Rosenthal,
DO, PhD4, Blanka Kaplan, MD4, Vincent Bonagura, MD5, Artemio Jongco, MPH, MD, PhD,
FACP, FACAAI, FAAAAI4
1Resident Physician/Zucker School of Medicine at Hofstra/Northwell Residency Program
in Internal Medicine at North Shore University Hospital and Long Island Jewish Medical
Center (NS/LIJ)
2Assistant Professor of Clinical Pediatrics/Weill Cornell Medicine
3Assistant Professor of Medicine/Stony Brook University School of Medicine
4Assistant Professor of Medicine and Pediatrics/Donald and Barbara Zucker School of
Medicine at Hofstra/Northwell
5Chief, Division of Allergy/Immunology/Donald and Barbara Zucker School of Medicine
at Hofstra/Northwell
There is a paucity of information about whether and how BMI and administration route
may affect infection rate in patients on IgG replacement therapy (IGRT). Our prior
work suggested that mean infection rate did not differ by BMI when adjusting for administration
route, but that IVIG patients have a lower infection rate compared to SCIG patients
when adjusting for BMI (P < 0.01).
The overall study objective is to elucidate the relationship between BMI, dose, and
route of administration in primary immunodeficiency patients receiving IGRT. Here,
we build upon our prior work by expanding the original sample size and study time
frame.
We performed a retrospective chart review at an outpatient, tertiary care, academic
medical center allergy & immunology clinic from 1/1/2000 through 12/31/2019. Administration
route, dose, infection history, IgG levels, height, weight, demographics, and diagnosis
requiring IGRT were analyzed. BMI categories were based on height and weight upon
study entry.
The study included a total of 177 subjects compared to 63 from the previous study.
The median age was 41 years (range 11 months – 91 years), 45.1% (n=80) were male.
Racial and ethnic demographics were as follows: 84.7% (n= 150) White, 6.2% (n=11)
Hispanic or Latino, 6.2% (n=11) Other or Multiracial, 1.7% (n=3) Black or African
American, and 1.1% (n=2) Asian. 5.1% (n=9) were underweight, 42.4% (n=75) had normal
BMI, 24.3% (n=43) were overweight, and 28.2% (n=50) were obese. 59.3% (n=105) of subjects
used SCIG. The diagnoses were distributed as follows: 54.2% (n=96) Common Variable
Immunodeficiency, 28.8% (n=51) hypogammaglobulinemia, 6.2% (n=11) X-linked agammaglobulinemia,
2.8% (n=5) Specific Antibody Deficiency, 2.3% (n=4) Hyper IgM, 1.7% (n=3) Severe Combined
Immunodeficiency, and 4.0% (n=7) other. At study start, median age (P=0.14), number
of visits (P=0.35) or number of infections (P=0.37) did not differ among the four
BMI cohorts.
The current study more than doubled the prior sample. Our cohort was mostly white
middle-aged females, 52.5% of whom were overweight or obese, 54.2% of whom have CVID,
with 59.3% on SCIG. Ongoing analyses with the larger cohort will help clarify the
relationship between BMI, dose, and route of administration.
Keywords: Immunoglobulin Replacement Therapy, Infections in PIDs, Phenotypic and Molecular
Spectrum of Primary Immune Deficiency
Disclosure: Nikki Kimura and Artemio Jongco received support from Takeda. All other
authors indicated they had no financial relationships to disclose.
(175) Agranulocytosis and Severe Infection Secondary to Metimazole
Daniel Urschel, MD1, Vivian Hernandez-Trujillo, MD2, Jose Calderon, MD2
1Allergy/Immunology Fellow/Nicklaus Children's Hospital
2Allergy Immunology Attending/Nicklaus Children's Hospital
An eleven-month-old, previously healthy, vaccinated male traveled with family to Cuba.
He developed fever and oral lesions after arrival. Patient was diagnosed with viral
stomatitis and treated with an over the counter antipyretic. Symptoms worsened to
include frequent drooling, decreased oral intake, cough, and intermittent stridor
leading to multiple ER visits and admission after returning to the United States.
Laboratory evaluation demonstrated neutropenia and leukopenia, with normal hemoglobin
and platelet counts. Concerning imaging included unilateral infiltrate on chest x-ray
and epiglottitis on CT of neck. Immunologic laboratory evaluation pertinent for borderline
low IgG for age, normal IgM and IgA, significant T cell lymphopenia, normal B cell
and NK cell lines, normal antibody/antitoxin titers to S.Pneumoniae, H.Influenzae
B, Diphtheria and Tetanus.
Our patient was started on antibiotics, antifungals, steroids, IVIG and supplemental
oxygen. Symptoms dramatically improved within one week of admission. Laboratory values,
including complete blood count with differential, repeat lymphocyte subsets including
T cell subsets, all normalized one week after admission. Blood cultures were negative.
A skin lesion tested positive for Pseudomonas. Viral testing was positive for Rhinovirus/Enterovirus
only. Newborn screen confirmed to be normal. Further history after admission revealed
the antipyretic the patient had been treated with prior to severe symptom onset was
Dipyrone (Metamizole). He remained well following discharge. Subsequent testing including
complete blood counts with differentials and immunoglobulin levels were normal at
follow up.
Dipyrone is a commonly used analgesic, antipyretic, antispasmodic, and anti-inflammatory
throughout the world. The mechanism of agranulocytosis secondary to Dipyrone is not
fully understood, although it is believed to be immune mediated via anti-neutrophil
antibody production. Illness secondary to agranulocytosis can be severe and life threatening.
Concern in the case of an infant presenting with severe illness, leukopenia, T cell
lymphopenia and neutropenia initially were for a primary immunodeficiency such as
severe combined immunodeficiency. Identifying the underlying cause of these lab abnormalities
in a severely ill infant without a significant medical history is challenging. Infections,
primary immunodeficiencies, malignancies, idiosyncratic drug reactions, autoimmune
and genetic conditions must be considered. This represents the importance of thorough
history taking and awareness of secondary immunodeficiencies.
Keywords: Other Topics Related To Immune Deficiency and/or Dysregulation, Secondary
Immunodeficiency, Agranulocytosis
Disclosure: Vivian Hernandez-Trujillo is an advisory board member of Covis, CSL Behring,
DBV, Kaleo, Takeda, and US WORLD MEDS. All other authors had no financial relationships
to disclose.
All other authors indicated they had no financial relationships to disclose.
(176) Psychosocial insights of parents of pediatric primary immune deficient (PID)
patients who had genetic testing
Smriti Singh, BS1, Lauren Lichten, MS2, Nadia Ali, PhD2, Christopher Gray, MS3, Hong
Li, MD, PhD4, Shanmuganathan Chandrakasan, MD5
1Graduate Student/Emory University Genetic Counseling Training Program, Atlanta, Georgia
2Department of Human Genetics/Emory University, Atlanta, Georgia
3Genetic Counselor/Roberts Individualized Medical Genetics Center and the Division
of Human Genetics at Children's Hospital of Philadelphia
4Associate Professor and Medical Geneticist/Department of Human Genetics and Pediatrics,
Emory University, Atlanta, Georgia
5Pediatric Hematologist/Oncologist/Children's Healthcare of Atlanta
Primary immunodeficiency syndromes (PIDs) are a group of immune conditions with variable
severity and age of onset. Given PIDs include 400+ conditions, genetic testing utilizing
next generation sequencing can shorten the diagnostic odyssey and can influence management.
While psychosocial challenges of raising a child with a PID are significant, psychosocial
challenges surrounding genetic testing for these patients are relatively unexplored.
We performed a qualitative study to evaluate experiences of 9 negative and 9 positive
result families who had a child undergo panel (14) or exome (4) genetic testing for
a PID at Children’s Healthcare of Atlanta’s Immune Dysregulation Clinic in the last
three years. Eighteen qualitative semi-structured interviews were adopted from validated
genomics outcome and psychosocial assessment scales and interpreted using thematic
analysis.
Preliminary findings indicate genetic result disclosures left questions, concerns,
or uncertainty in many parents regarding financial costs of testing, and adaption
to understanding of results as related to patients’ long-term outcomes. Some disclosures
took several months or were learned via a web portal/the advocacy of parents seeking
results. Few participants were referred to genetic counseling, yet they demonstrated
needs involving a) a variety of emotional reactions to results/long-term coping, b)
support groups, c) planning next steps, and/or d) needing a central provider such
as a genetic counselor to coordinate communication between all involved providers
and the family. Approximately half of parents also desired help with a) follow-up
testing regarding at-risk/symptomatic family members, b) realistically assessing genetic
testing’s ability to end patients’ diagnostic odysseys or alter treatment/management
plans, and c) anticipatory guidance for psychosocial challenges, including distress
from uncertain results. Despite anticipated concerns being realized, a majority of
parents viewed genetic testing for PIDs in a positive light, cognizant of benefits
it provided for current/future care of their children.
For pediatric immunology providers offering genetic testing, a unified protocol or
pre-/post-test counseling is suggested. A PID genetic testing protocol/counseling
can be adapted using Rolland & Williams’ Family Systems Genetic Illness model (FSGI)
to encompass comprehensive consent, timely/informed testing and result disclosure,
and parent-friendly resources such as summary letters for patients’ multiple specialty
providers.
Keywords: PID, Genetic, Testing, Psychosocial, Resources, Panel, Exome, Counseling,
Coping, Pediatric
Disclosure: Nadia Ali received a research grant from Amicus Therapeutics, BioMarin,
Pfizer, Sanofi Genzyme, Shire/Takeda and speaker honoraria from Vitaflo. All other
authors indicated they had no financial relationships to disclose.
(177) Immunodeficiency of Kabuki Syndrome: A Case Series
Stefani Su, MD1, Alissa McInerney, MD2, Artemio Jongco, MPH, MD, PhD, FACP, FACAAI,
FAAAAI3
1Allergy Immunology Fellow in Training/Donald and Barbara Zucker School of Medicine
at Hofstra/ Northwell Health
2Allergy Immunology Fellow in Training/Donald and Barbara Zucker School of Medicine
at Hofstra/Northwell Health
3Assistant Professor of Medicine and Pediatrics/Donald and Barbara Zucker School of
Medicine at Hofstra/Northwell
Kabuki syndrome is a rare syndrome characterized by dysmorphic facies, intellectual
disability, anatomic malformations and recurrent infections. We present two cases
of Kabuki syndrome.
(Patient 1): A 22 month old female with developmental delay, ex-35 week gestation,
hypocalcemia at birth and multiple refractory complex febrile seizures presented for
immune evaluation. Hematology evaluation showed anemia and thrombocytopenia, requiring
multiple transfusions and oral steroids. Bone marrow biopsy was consistent with Autoimmune
Myelofibrosis. She had one episode each of urinary tract infection and otitis media.
Physical exam demonstrated long palpebral fissures with eversion of lower eyelid,
prominent ears and frontal bossing, flat nasal tip, prominent fingertip pads, café-au-lait
spots, and expressive language delay.
Whole Exome Sequencing revealed heterozygous pathogenic variant c. 1234 dupCpL412PfsX4
in KMT2D, consistent with Kabuki Syndrome. She was also heterozygous for likely pathogenic
variant c.1511 C>A p.T504N in PCDH19 so she was diagnosed with PCDH19-Related Epilepsy
Disorder. Initial testing showed normal numbers of CD4+ and CD8+ T-cells and CD19+
B-cells. Subsequent testing showed CD8+ T-cell lymphopenia as well as B-cell lymphopenia
likely due to Rituximab administration.
(Patient 2): A 4 year old male with history of hypocalcemia at birth, microcephaly,
severe developmental delay, and eczema presented for immune evaluation. He had multiple
pneumonias requiring hospitalization and chronic ear infections. He was diagnosed
with Evans syndrome at age two due to thrombocytopenia, which improved with Rituximab.
Physical exam demonstrated elongated palpebral fissures, arched and broad eyebrows,
and prominent ears.
He was diagnosed with Kabuki Syndrome at age four after genetic testing revealed a
mutation in KMT2D. Immune labs done prior to Rituximab showed normal immunophenotype
as well as normal immunoglobulins. Labs 1 year post-Rituximab showed continued normal
numbers of T-cells, B-cell lymphopenia, as well as profound hypogammaglobinemia. He
started on subcutaneous immunoglobulin replacement therapy with decreased frequency
and severity of sinopulmonary infections.
The immunodeficiency associated with Kabuki syndrome is variable and can include humoral
and cellular defects as well as autoimmunity. The most common infections seen in patients
is otitis media. Further information on the immunologic manifestations of the syndrome
is needed.
Keywords: Kabuki syndrome, Immunodeficiency, KMT2D
Disclosure:. All authors indicated they had no financial relationships to disclose.
(178) Common Variable Immune Deficiency in a patient with a heterozygous mutation
in IRF2BP2
Alissa McInerney, MD1, Stefani Su, MD2, Artemio Jongco, MPH, MD, PhD, FACP, FACAAI,
FAAAAI3
1Allergy Immunology Fellow in Training/Donald and Barbara Zucker School of Medicine
at Hofstra/Northwell Health
2Allergy Immunology Fellow in Training/Donald and Barbara Zucker School of Medicine
at Hofstra/ Northwell Health
3Assistant Professor of Medicine and Pediatrics/Donald and Barbara Zucker School of
Medicine at Hofstra/Northwell
Common Variable Immune Deficiency (CVID) is a common primary immune deficiency, although
a genetic cause is found in only a small minority of patients. We present a case with
a heterozygous variant of uncertain significance in IRF2BP2, a gene that has been
associated with autosomal dominant CVID in one family.
A 60-year-old woman with frequent sinopulmonary infections, chronic diarrhea, and
fatigue presented for immune evaluation. She had a history of IgA deficiency and a
family history of malignancy and autoimmune disease.
Laboratory evaluation revealed low IgG, IgM, IgA with elevated IgA antibodies. Non
protective titers to measles, mumps, rubella, varicella, tetanus, and diphtheria were
found. Immunophenotype revealed increased number of B cells and decreased switched
memory B cells (CD27+IgM-IgD-). Commercially available immune deficiency genetic panel
revealed a heterozygous mutation IRF2BP2 c.1688C>T(p. Pro563Leu), classified as a
VUS.
The heterozygous variant of IRF2BP2 c.1654G>A(p. Ser551Asn), located in the carboxyl
terminal ring domain, was reported by Keller et al., 2016 in 3 members of a single
family and shown to be likely a cause of autosomal dominant CVID. In vitro, this mutation
impacted B cell maturation and differentiation of plasmablasts. Our patient’s mutation
is just downstream and within the ring domain, which interacts with nuclear factor
of activated T-cells 1 (NFAT1), a transcription factor important in immune responses.
This interaction strongly inhibits transcriptional activity of cytokine genes preventing
differentiation of B cells in animal models. Based on the similar clinical presentation
and the available information we suggest that this mutation is pathologic in our patient.
Functional validation studies are underway to further characterize this patient's
variant.
Keywords: Common Variable Immune Deficiency, IRF2BP2, CVID
Disclosure:. All authors indicated they had no financial relationships to disclose
(179) A patient with X-linked agammaglobulinemia and COVID-19 infection treated with
remdesivir and convalescent plasma
Aled Iaboni, MD1, Stephen Betschel, MD2
1Resident/Allergy/Immunology
2Staff Physician/Allergy/Immunology
This 28 year-old male with X-linked agammaglobulinemia (XLA) presented to hospital
with a one-week history of fevers, hyposmia and cough. He had received a throat swab
prior to presentation that was positive for COVID-19. On presentation, he was tachycardic,
tachypnic and mildly hypoxic. A chest X-ray showed bilateral airspace opacities suggestive
of pneumonia. He had hyponatremia, leukopenia, thrombocytopenia, transaminitis and
elevated inflammatory markers (Table 1).
The patient was admitted and treated with dexamethasone 6mg daily. By day 4, his hypoxia
had worsened and he began a 5-day course of Remdesivir. On day 5, he was transferred
to the intensive care unit and received 500mL of convalescent plasma (CP). By day
9, he began to improve clinically and had less oxygen requirements. By day 11, he
had been completely weaned off of oxygen. He was was discharged on day 13 with near
complete symptom resolution.
Patients with primary immunodeficiencies are suspected to be at elevated risk for
more severe infections due to COVID-19. Two early studies reported 4 patients with
agammaglobulinemia and 5 patients with common variable immunodeficiency (CVID) that
had COVID-19 infection. Compared with CVID, patients with agammaglobulinemia had very
mild courses. This led to a hypothesis that B-lymphocytes may be involved in COVID-19
related inflammation. However, a more recent study described 3 XLA patients who required
more protracted hospital courses. Similar to our patient, these patients rapidly recovered
after receiving CP. These cases suggest that XLA patients remain at risk of severe
complications from COVID-19.
The rapid recoveries seen in XLA patients following administration of CP suggests
antibodies are important for viral neutralization. However, a recent randomized trial
of 334 adult patients with severe COVID-19 pneumonia showed administration of CP compared
to placebo resulted in no difference in clinical outcomes or mortality. Whether CP
has a unique mechanism of effect in patients with absence of B-lymphocytes remains
unknown. The rapid response to CP in our patient suggests that humoral immunity is
an important factor in recovery from COVID-19. The observed response to CP may be
unique to patients who lack B-lymphocytes and this requires further study.
Keywords: PID, XLA, COVID-19, remdesivir, convalescent plasma, agammaglobulinemia
Disclosure:. All authors indicated they had no financial relationships to disclose.
(180) Confirmed SARS-COV-2 Infection In A Cohort Of Children And Young Adults With
Moderate Or Severe Primary Immunodeficiencies
Angela Deyà-Martínez, MD, PhD1, Anna P. García-García, MD2, Alexandru Vlagea, MD,
PhD3, Yolanda Jordan, MD, PhD4, Victoria Fumado, MD, PhD5, Claudia Fortuny, MD, PhD5,
Marta Español, MD6, Azucena Gonzalez, MD,PhD6, anna Esteve-Solé, MD, PhD7, Manel Juan,
MD, PhD8, Mariona Pascal, MD, PhD9, Laia Alsina, MD, PhD10
1Attending/Clinical Immunology and Primary Immunodeficiencies Unit. Pediatric Allergy
and Clinical Immunology Department. Hospital Sant Joan de Déu, Barcelona, Spain. Institut
de Recerca Sant Joan de Déu, Barcelona, Spain.4. Clinical Immunology Unit Hospital
Sant Joan de Déu-Hospital Clínic Barcelona
2Attending/Clinical Immunology and Primary Immunodeficiencies Unit. Pediatric Allergy
and Clinical Immunology Department. Hospital Sant Joan de Déu, Barcelona, Spain
3Attending/Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic Barcelona,
Barcelona, Spain. Department of Immunology-CDB, Hospital Clínic-IDIBAPS, Universitat
de Barcelona, Barcelona, Spain.
4Attending/Hospital Sant Joan de Deu, Pediatric Intensive Care, esplugues llobregat,
Spain
5Attending/Hospital Sant Joan de Deu, Pediatric Infectious Disease Unit, Esplugues
llobregat, Spain
6Attending/Department of Immunology-CDB, Hospital Clínic-IDIBAPS, Universitat de Barcelona,
Barcelona, Spain
7Post-Doctoral researcher/Clinical Immunology and Primary Immunodeficiencies Unit.
Pediatric Allergy and Clinical Immunology Department. Hospital Sant Joan de Déu, Barcelona,
Spain. Institut de Recerca Sant Joan de Déu, Barcelona, Spain.
8Head of the Unit/Universitat de Barcelona, Spain. Clinical Immunology Unit Hospital
Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain. Department of Immunology-CDB,
Hospital Clínic-IDIBAPS, Universitat de Barcelona, Barcelona, Spain. Immunotherapy
Platform, Hospital Sant Joan de Déu-Hospital Clínic, Universitat de Barcelona, Barcelona,
Spain.
9Head of the Unit/Universitat de Barcelona, Spain; Clinical Immunology Unit Hospital
Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain; Department of Immunology-CDB,
Hospital Clínic-IDIBAPS, Universitat de Barcelona, Barcelona, Spain. Immunotherapy
Platform, Hospital Sant Joan de Déu-Hospital Clínic, Universitat de Barcelona, Barcelona,
Spain.
10Head of the Unit/Clinical Immunology and Primary Immunodeficiencies Unit. Pediatric
Allergy and Clinical Immunology Department. Hospital Sant Joan de Déu, Barcelona,
Spain Institut de Recerca Sant Joan de Déu, Barcelona, Spain. Universitat de Barcelona,
Spain. Clinical Immunology Unit Hospital Sant Joan de Déu-Hospital Clínic Barcelona,
Barcelona, Spain
In December of 2019, an outbreak caused by SARS-CoV-2 started in Wuhan causing a worldwide
pandemic. Evidence indicates lower incidence and milder clinical course in children,
but there is a lack of information about primary immunodeficiency (PID) as a possible
risk factor. The objective of the study is to determine de prevalence of SARS-CoV-2
infection in a cohort of children and young adults with a moderate or severe primary
immunodeficiency using different immune assays and describe their clinical expression.
Cross-sectional study developed in a single-centre between May 2020- June 2020. Children
and young adults, from 0-21 years old, with moderate-severe PID and with signed informed
consent, were included. Patients' information was collected from the medical chart,
focusing into presence of past COVID 19-related symptoms (from patients and household
contacts) during epidemic period (January 2020-June 2020). In order to confirm the
infection the following assays were performed: SARS-CoV-2 PCR, specific IgA/IgM/IgG
serology and specific spike protein SARS-CoV-2 ELISpot* (* only in those patients
with positive household contacts).
A total of 65 patients have been included (median age 12.3 (2-21.1); 58.5% males)
from 7 different PID groups (IUIS classification). 18% of the patients had confirmed/highly
suspected household contact. Five patients had confirmed infection (4/5 positive serology;
1/5 positive PCR), only 1/5 with symptoms (mild cough). Twelve patients had positive
household contacts: 3/12 positive serology; 9/12 negative serology or PCR neither
positive results in ELISpot assay.
The prevalence of COVID19 in the studied paediatric cohort of moderate-severe PID
patients, was 7.7% (5/65), similar to that observed in Catalonia at that time (6.1%;
5.2-7.2). Of these, only 1/5 was symptomatic (mild symptoms; Jacobsen Syndrome + CVID-like
phenotype). In the subgroup with higher SARS-CoV-2 exposure and negative PCR or serology,
SARS-CoV-2 protein S ELISpot did not improve infection diagnosis.
Keywords: Primary immunodeficiencies, Paediatric, SARS-CoV-2 infection, Diagnosis,
COVID19
Disclosure:. All authors indicated they had no financial relationships to disclose.
(181) Comparative cost-effectiveness of hematopoietic stem cell transplantation versus
lifetime immunoglobulin replacement for congenital agammaglobulinemia
Di Sun, MD1, Nancy Bunin, MD2, Jennifer Heimall, MD3, Neil Romberg, MD4
1Allergy/Immunology Fellow/Children's Hospital of Philadelphia
2Professor of Pediatrics, Perelman School of Medicine at the University of Pennsylvania/Children's
Hospital of Philadelphia
3Attending Physician/Children's Hospital of Philadelphia
4Assistant Professor of Pediatrics, Perelman School of Medicine at the University
of Pennsylvania/Children's Hospital of Philadelphia
To prevent severe infections, the mainstay of treatment for congenital agammaglobulinemia
is lifelong immunoglobulin (Ig) replacement. Although hematopoietic stem cell transplantation
(HSCT) is associated with significant morbidity and mortality, this therapy offers
a one-time cost when compared to lifelong intravenous or subcutaneous Ig replacement.
This study evaluates the cost-effectiveness of HSCT compared to Ig replacement for
treatment of agammaglobulinemia in the United States (US).
The base-case scenario of a 12 month-old child with agammaglobulinemia receiving Ig
replacement therapy compared with either matched sibling donor (MSD) or matched unrelated
donor (MUD) HSCT was represented using a Markov model from the healthcare perspective
over an 80-year time horizon. The model was populated through extensive analysis of
published literature. Cohort analysis and microsimulations were used to determine
the incremental cost-effectiveness ratio (ICER) expressed in 2020 US dollars (USD)
per quality-adjusted life year (QALY) gained. One-way sensitivity and probabilistic
uncertainty analyses were performed across plausible ranges.
For treatment of agammaglobulinemia, MSD and MUD HSCT yield a lower cost of $1,322,563
and $1,417,499 respectively when compared to Ig replacement ($3,743,107), but Ig replacement
generates more QALYs (48.34) compared to MSD (36.12) and MUD (36.07) HSCT. Overall,
Ig replacement results in an ICER of $198,056 and $189,532 per QALY gained when compared
to MSD and MUD HSCT respectively, which is higher than the willingness-to-pay (WTP)
threshold of $100,000 (per capita GDP of the US). In microsimulation analysis (n=10,000),
compared to HSCT, Ig replacement costs less and is more effective only 5.98% of the
time. The cost-effectiveness of Ig replacement therapy is highly dependent on the
annual cost of Ig replacement; in fact, when annual cost of Ig replacement therapy
is lower than $30,474, this strategy falls below the WTP threshold of $100,000.
Under current conditions, HSCT is more cost-effective than Ig replacement therapy
but Ig replacement is more effective (generating greater QALYs). Importantly, when
the annual cost of Ig replacement is reduced, this therapy falls below the WTP threshold
of $100,000. In this reduced cost scenario, Ig therapy would be the preferred long-term
treatment strategy for agammaglobulinemia in the US.
Keywords: Agammaglobulinemia, Cost-effectiveness analysis, Hematopoietic stem cell
transplantation, Health economics
Disclosure:. ennifer Heimall is an advisory board member of CIRM; received research
grants from CSL Behring and Regeneron; and speaker honoraria from Horizon. All other
authors indicated they had no financial relationships to disclose.
(182) Monitoring of post-transplant naïve lymphocytes reconstitution in PID patients
using TREC and KREC quantification
Ekaterina Polyakova, PhD student1, Maria Stegantseva, PhD2, Mikhail Belevtsev, PhD3
1PhD student,Research in the field of genetics of PIDS, determination of TREC /KREC/Belarusian
Research Center for Pediatric Oncology, Hematology and Immunology,clinical research
laboratory of the scientific department
2PhD/Belarusian Research Center for Pediatric Oncology, Hematology and Immunology,
laboratory of genetic biotechnology, scientific department
3PhD/Belarusian Research Center for Pediatric Oncology, Hematology and Immunology,
Deputy Director for Research
In this study the dynamics of TRECs and KRECs positive cells in PID patients after
hematopoietic stem cell transplantation was evaluated.
Quantity of TREC and KREC were determined using RQ-PCR in 11 patients from 3 months
to 12.3 years old (median age – 1.95 years). Following diagnoses were genetically
confirmed: SCID-4, WAS-4, CGD-1, HLH-1, HLA-DR II deficiency-1). The number of CD3+
and CD19+ cells were determined in the routine immunogram after HSCT.
It was found that 2 SCID patients reconstituted the number of TREC-positive cells
to day 180, when others keep undetectable TREC during the all follow-up. All of them
reached normal KREC count closer to day 45 - 60, except one (day 180). Among the WAS
patients three restored TREC level between 100-245 days and KREC level to day 60.
Only one had both negative results during all monitoring period. HLH patient had the
longest time of recovery: TREC –day 245, KREC – day 145. Patients with CGD and HLA-DR
II deficiency had similar results: TREC reconstituted to day 180 and KREC between
30-45 days. The dynamics of TREC- and KREC molecules correlated with the CD3+CD45RA+
T-lymphocytes and differed from total population of CD3+ and CD19+ lymphocytes. The
high quantity of TREC on the 15-30 days is caused by the presence of naïve T-cells
in the transplant and is not related to thymopoiesis reconstitution.
Quantity of TREC and KREC molecules can be useful markers to assess the reconstitution
of naïve lymphocytes after HSCT
Keywords: TRECs KRECs, RQ-PCR, Hematopoietic stem cell transplantation, PIDs, Reconstitution
of naïve lymphocytes
Disclosure:. All authors indicated they had no financial relationships to disclose.
(183) Hypogammaglobulinemia, macrocytosis, and pancytopenia in a patient with LIG1
deficiency
Angela Chun, M.D.1, Juan C. Bernini, M.D.2, Tiphanie Vogel, M.D, Ph.D.3, Sarah Nicholas,
M.D.4
1Clinical Fellow, Division of Rheumatology, Department of Pediatrics/Texas Children’s
Hospital, Baylor College of Medicine
2Professor, Division of Hematology-Oncology, Department of Pediatrics/Vannie E. Cook
Jr. Children's Cancer and Hematology Clinic, Baylor College of Medicine
3Assistant Professor, Division of Rheumatology, Department of Pediatrics & Medicine/Texas
Children’s Hospital, Baylor College of Medicine
4Assistant Professor, Division of Immunology, Allergy and Retrovirology, Department
of Pediatrics/Texas Children's Hospital, Baylor College of Medicine
DNA ligase 1 (LIG1) is critical for proper DNA replication and repair, and LIG1-deficient
cells are prone to chemical and radiation-induced DNA damage. Deleterious biallelic
mutations in LIG1 have been reported in only rare patients with primary immunodeficiency,
varying from mild antibody deficiency to severe combined immunodeficiency. These patients
exhibited variable growth retardation and hematologic abnormalities, including hypogammaglobulinemia,
erythroid macrocytosis, and lymphopenia. We describe a patient with compound heterozygous
variants in LIG1, who presented with short stature, hypogammaglobulinemia, macrocytosis,
and pancytopenia.
A 15-year-old neurodevelopmentally normal male presented with chronic fatigue and
a history of recurrent fevers responsive to empiric antibiotics. He was found to have
growth retardation ( < 1st percentile). Laboratory evaluation revealed pancytopenia
(nadir WBC 2.02 x 103/□L, ANC 0.33 x 103/□L, hemoglobin 8.2 g/dL, platelets 22 x 103/□L),
macrocytosis (peak MCV 120 fL), and marked hypogammaglobulinemia (IgG < 7 mg/dL, IgA
< 6 mg/dL, IgM 72 mg/dL). Retrospective review noted the patient was first documented
to have macrocytosis at 5-years-old, without associated anemia. He was subsequently
lost to follow up and experienced frequent infections (pneumonia, acute otitis media,
gingivitis) during childhood, twice requiring hospitalization for pneumonia. At the
time of evaluation, lymphadenopathy and marked hepatosplenomegaly was noted. Liver
biopsy demonstrated diffuse lymphohistiocytic inflammation and multifocal hepatocyte
necrosis and lymph node biopsy showed paracortical T-cell expansion and diminished
B-cell follicles without germinal center formation. He had normocellular bone marrow,
with moderate erythroid hyperplasia and dysplastic features. Peripheral evaluation
revealed increased CD3+ T-cells with a low CD4:CD8 ratio, and a relative decrease
in mature B- and NK-cells. His lymphocytes demonstrated impaired responses to mitogens.
Telomere length was markedly shortened in T- and NK-cell populations, but normal in
granulocytes, indicating replicative stress. Exome sequencing revealed novel compound
heterozygous variants (c.1049G>T, p.G350V; c.2636G>A, p.R879H) in LIG1. Functional
validation was not performed, but he was diagnosed with LIG1-deficiency based on the
remarkable phenotypic match. He has been treated successfully with immunoglobulin
replacement.
Defects in LIG1 can result in variable clinical phenotypes. Hallmark features include
hypogammaglobulinemia and macrocytosis. Our patient is unique in his hepatosplenomegaly,
neutropenia, and thrombocytopenia. Bone marrow transplant and splenectomy are being
explored.
Keywords: LIG1 deficiency, Pediatric, Primary immunodeficiency, Macrocytosis, Hypogammaglobulinemia
Disclosure:. All authors indicated they had no financial relationships to disclose.
(184) Management Dilemmas as Newborn Screening for Severe Combined Immunodeficiency
also Detects Newborns with T cell Lymphopenia: A Review of University of California,
Los Angeles 2019-2020
Lisa KLohn, MD, PhD1, Alexis Stephens, BS2, Manish Butte, MD, PhD3
1Fellow/UCLA
2Research Coordinator/UCLA
3Associate Professor/Division of Allergy, Immunology, and Rheumatology, University
of California Los Angeles
Since 2008, newborn screening (NBS) measuring T cell receptor excision circles (TRECs)
has been used to detect patients with severe combined immunodeficiency (SCID) prior
to the onset of infections or other complications. Published reviews demonstrate that
in addition to detecting newborns with SCID, TREC screening also identifies infants
with other potential immunodeficiencies.
From January 2019 through December 2020, UCLA treated 24 infants who were referred
for low TRECs ( < 18 TREC/μL), all of whom underwent further diagnosis by flow cytometry
to assess CD3+ T cells/μL, % of CD4+ that are CD45RA+ T cells (naive), CD19+ B cell/μL,
and CD56+ NK/μL.
Of the 24 infants, six met criteria for typical SCID, with TRECs 0-2/μL and CD3+ T
cells/μL < 300 (at initial or subsequent evaluation). Genetic testing identified variants
in genes associated with SCID (IL2RG, JAK3, DCLRE1C, or RAG1) or cartilage hair hypoplasia
with profound lymphopenia (RMRP). All patients have either undergone or are awaiting
hematopoietic stem cell transplant or gene therapy, and the cohort has 100% survival
at short-term follow up.
Of the remaining 18 patients detected on TREC screening without typical SCID, four
exhibit syndromic immunodeficiency (partial DiGeorge, trisomy 22); three had T cell
loss (chylothorax); two had lymphopenia secondary to other issues (extreme prematurity,
maternal medication); one patient’s work-up remains pending; and eight infants had
T cell lymphopenia (300-1500/μL).
Of the eight lymphopenic patients, three had low B cells (1500/μL) at birth and none
had low NK cells. None have known pathogenic variations in immune-associated genes,
but all patients had at least one variation of unknown significance (VUS). One patient
has variation in RASGRP1, a gene associated with both lymphopenia and EBV driven lymphoproliferation
and is undergoing evaluation for possible HSCT. Live vaccines were held in all patients,
until 12-month pending re-evaluation of T cells and antibody response to non-live
vaccines. Thus far, two of the patients have resolved T cell lymphopenia (>1500/μL).
This new cohort of T lymphopenic infants of unclear underlying diagnosis pose a management
dilemma, requiring long-term follow-up and additional genetic investigations in order
for us to provide well-informed prognoses and potential interventions.
Uploaded File(s)
Figure 1: Correlation of TREC level with initial CD3+ T cell count, grouped by underlying
diagnosis
Keywords: Severe Combined Immunodeficiency, T cell Lymphopenia, Newborn Screen, T
cell Recombination Excision Circle (TREC)
Disclosure:. Manish Butte received research grant from Horizon, Regeneron and Takeda
and speaker honoraria from CSL. All other authors indicated they had no financial
relationships to disclose.
(185) A Proposed Targeted Treatment for Omenn Syndrome – A Case Report
Terrie Ahn, MD1, Gloria Sheng, MD, PhD1, Maria Garcia-Lloret, MD2, Manish Butte, MD,
PhD2
1Allergy & Immunology Fellow/Division of Allergy, Immunology, and Rheumatology, University
of California Los Angeles
2Associate Professor/Division of Allergy, Immunology, and Rheumatology, University
of California Los Angeles
Omenn Syndrome (OS) is a type of severe combined immunodeficiency (SCID) most commonly
caused by hypomorphic mutations in recombination-activating gene 1 (RAG1) or RAG2.
It is characterized by presentation in infancy with cellular immunodeficiency, scaling
erythroderma, diarrhea, lymphadenopathy and hepatosplenomegaly resulting from autoreactive,
oligoclonal T cells. Prognosis in OS has improved with hematopoietic stem cell transplant
(HSCT), but remains suboptimal often due to poor clinical status pre-transplant. Herein,
we describe a patient with OS and comment on a possible targeted treatment.
A two-month-old male born to consanguineous parents presented with a positive SCID
newborn screen. Immunophenotyping showed a T-B-NK-low profile with poor mitogen proliferation.
We found a homozygous missense mutation in RAG1 (c.2867T>C, p.Ile956Thr) previously
associated with OS.
At one month of age, he developed scaling erythroderma with concerning lymphocyte
count (ALC 4,200 cells/μL), eosinophilia (AEC 4,800 cells/μL), and elevated IgE (9,421
mg/dL). There was no evidence of maternal T cell engraftment. T-helper cell profiling
showed a strong Th2-skewing compared to control (Figure 1) consistent with previous
reports.
We considered blocking Th2 cytokines to treat OS. In vitro, the patient’s CD4+ helper
T cells showed modest decrease in IL-4 and IL-5 expression when cultured with dupilumab
(IL-4 receptor-alpha blocker, IL-4Rɑ), whereas the reduction was more robust after
IL-12 stimulation (Figure 2).
He received topical tacrolimus and systemic steroids with rapid resolution of his
cutaneous disease, and currently awaits HSCT.
In OS, systemic immunosuppression against autoreactive T lymphocytes provides benefit,
but often has associated adverse effects. Tailored therapies downregulating type 2
immunity may provide a novel approach to OS management. Interestingly, CD4+ helper
T cells showed a weaker response to dupilumab in terms of IL-4 reduction as compared
to control, but notably showed a robust decrease in both IL-4 and IL-5 expression
with IL-12 stimulation. This could suggest that activated T cells in OS may not require
IL-4 signaling for ongoing production of Th2 cytokines. Further studies of therapeutics
directed against the Th2 pathway (such as IL-4 or IL-5 blockade) in conjunction with
strategies for IL-12 augmentation are needed to fully understand their potential in
OS.
Keywords: Omenn Syndrome, Immunodeficiency, Type 2 immunity, Dupilumab, Hypomorphic
RAG1
Disclosure:. Manish Butte received research grant from Horizon, Regeneron and Takeda
and speaker honoraria from CSL. All other authors indicated they had no financial
relationships to disclose.
(186) X-linked Agammaglobulinemia and Massive Thoracic Lipoma: Not so Benign?
Aaron Chin, MD1, Nicholas Rider, DO2
1Resident Physician/Baylor College of Medicine
2Associate Professor/Texas Children's Hospital and the Baylor College of Medicine
X-linked agammaglobulinemia (XLA) is primary immunodeficiency resulting from mutations
in the Bruton tyrosine kinase (BTK) gene which disrupt the development of humoral
immunity. Although infectious complications of XLA are well characterized, risk of
malignancies and tumors may also be a concern. We present a case of a 20 year old,
stable XLA patient presenting with a massive thoracic lipoma.
The patient was initially diagnosed after suffering multiple serious bacterial infections
within the first 2 years of life prompting evaluation. The patient, his brother, and
maternal grandfather were ultimately diagnosed via sequencing of BTK and all have
absent B-cells. He was started promptly on weekly subcutaneous immunoglobulin therapy
will minimal recurrent infections and stable normal IgG levels since. During a hospitalization
for pericarditis and 25-pound weight loss a right axillary mass was detected measuring
16 x 7 x 6 cm. Initial core needle biopsy revealed monomorphic mature fat with no
MDM2 amplification consistent with lipoma. The patient underwent resection requiring
radical axillary dissection to extricate the tumor from his brachial plexus. Notably,
the patient also had multiple subcutaneous nodules above his patella the in years
preceding this presentation which were self-revolved and also found to be benign lipomas.
To our knowledge this is the first case of a patient with XLA presenting with multiple
lipomas including a massive thoracic lipoma. The association between XLA and malignant
neoplasms has been well-documented; however, this case raises the possibility of unusual
benign neoplasms as an additional complication of XLA. The understood relationship
between XLA and benign neoplasms is limited but may still have important clinical
implications. For example, thymolipomas, are reported in patients with hypogammaglobulinemia
and suggest a potential relationship between adipose tissue and humoral deficiency.
An association with colorectal and gastric polyps is also observed in patients with
XLA with increased risk of later undergoing malignant transformation. Generally, patients
with humoral deficiencies have a high incidence of benign lymphoproliferative hyperplastic
growths that may increase susceptibility of developing a lymphoid malignancy. Our
case highlights the need for further characterization of “benign” neoplasms in patients
with XLA so they may be appropriately distinguished from malignancies.
Keywords: X-linked agammaglobulinemia, Lipoma, benign neoplasm, primary immunodeficiency,
XLA
Disclosure:. Nicholas Rider is an advisory board member for CSL Behring, Horizon Therapeutics
and Takeda. All other authors indicated they had no financial relationships to disclose.
(187) Molecular Diagnosis Of A Chinese Boy With X-Linked Agammaglobulinaemia
Jenny Ho, PhD1, Stephen Cheung, PhD1, Pamela Lee, MD2, Janette Kwok, MD PhD3
1Scientific Officer/Queen Mary Hospital
2Associate Professor/Department of Paediatrics and Adolescent Medicine,The University
of Hong Kong
3Consultant/Queen Mary Hospital
X-linked agammaglobulinaemia (XLA) is characterised by recurrent bacterial infections
in affected males in the first few years of life. Mutations in the Bruton Tyrosine
Kinase (BTK) gene have been found to be associated with the clinical presentation
of XLA. We investigated a Hong Kong Chinese 6-year old boy presenting with severe
E. coli sepsis, pleural effusion and purulent pericardial effusion. Laboratory investigations
found absence of IgG/A/M and lymphocyte subset confirmed absence of B-cells which
were in concordance with the absence of KREC in the peripheral blood with the KREC
assay by quantitative PCR. Nucleotide substitution c.3G>T of exon 2 in the BTK gene
has revealed a start-loss variant p.Met1Ile of the BTK protein. Carrier status in
the mother and the two maternal aunts has been confirmed. Family study has found the
mutation was inherited from one of the biggest hindred of the Hong Kong Chinese XLA
family reported in the 90s with different nomenclature as 135G>T. The family has only
been tested with basic serology tests e.g. IgG/A/M levels as screening while molecular
diagnosis was not widely available at the time. Retrospective or early molecular diagnosis
is warranted to review previous similar family screening and hence reduce related
complication and allow prompt medical intervention.
Keywords: BTK, XLA, molecular diagnosis, KREC
Disclosure:. All authors indicated they had no financial relationships to disclose.
(188) Systems biology reveals biomarkers and pathways involved in autoimmunity in
22q11.2 deletion syndrome
Carolyn Baloh, MD1, Guglielmo Venturi, Phd2, Bernard Fischer, DMV, Phd3, John Sleasman,
MD4
1Fellow/Post-doc/Duke
2Staff Scientist/Duke
3Associate Professor/Duke
4Professor of Pediatrics, Chief of Division of Allergy, Immunology, and Pulmonary
Medicine/Duke
Autoimmunity is common in 22q11.2 deletion syndrome (22q11.2DS) but biomarkers associated
with its risks have not been identified. Typically, autoimmunity develops 8 years
after 22q11.2DS diagnosis with up to 25% experiencing at least 1 autoimmune complication.
We sought to identify novel biomarkers of autoimmunity and determine if they shed
light on the mechanism of autoimmunity in 22q11.2DS.
Single site, retrospective chart review of clinical outcomes of 71 children with 22q11.2
deletion followed at Duke University Immunology Clinic from 2008 to 2020. Additional
prospective assessment of immune biomarkers included flow cytometry of naive T regulatory
cells, Th17 T cells, and total T and B cell subsets done on selected participants.
Multiplex ELISA and RNA-sequencing were also performed. Results between 22q11.2 deletion
participants and age balanced healthy controls were compared using Kruskal Wallis
and Benjamini Hochberg correction. The study was approved by the Duke University IRB.
Results: Seventy-one patients with 22q11.2DS were identified with 19 of 71 (26.8%)
having physician diagnosis of at least one autoimmune disease. The most common autoimmune
diagnoses were hematologic cytopenias. Autoimmunity occurred only in children with
22q11.2DS who had absolute lymphocyte counts < 2680 cells/ul. In a subpopulation of
21 participants with 22q11 DS (7/24 had autoimmunity) and 4 healthy controls, those
with 22q11.2DS and autoimmunity had significantly lower percentage CD3+ CD31+ naive
T cells, a lower percentage CD4+CD25+CD127loCD45RA+ Naive T regulatory cells, and
a shift of T regulatory cells away from Th17 pathways (CD4+CD25+CD127loCXCR3-CCR6-),
when compared to 22q11.2 without autoimmunity and healthy controls. Analysis of plasma
samples from 24 participants with 22q11.2DS (17/24 had autoimmunity) and 12 healthy
controls revealed 3 cytokines (ST2, BAFF, and IFN-beta) that differed significantly
based on whether or not the participants had 22q11.2DS. An additional 3 cytokines
(MMP3, APRIL, and haptoglobin) differentiated those with autoimmunity. STRING analysis
of these 6 cytokines converged on type 1 interferon pathways. Exploratory RNA-seq
of a smaller subset identified ST2 as an upregulated gene among children with 22q11.2DS
and autoimmunity.
Conclusion: Children with 22q11.2DS and autoimmunity have characteristic immune profiles
involving Treg polarization, upregulation of ST2 signaling, and trends toward Type
1 interferon pathways.
Keywords: 22q11.2 deletion syndrome (22q11.2DS), DiGeorge Syndrome, Autoimmunity
Disclosure:. All authors indicated they had no financial relationships to disclose.
(189) Juvenile Sjögren’s Syndrome With Extraglandular Manifestations Mimicking Immunodeficiency
Diseases
Akaluck Thatayatikom, MD1, Sthorn Thatayatikom, MD, MSc2, Silvana Carr, MD2, Dima
Ezmigna, MD2, Luciana Paim-Marquest, MD, PhD3, Indraneel Bhattacharyya, DDS, MSD4,
Seunghee Cha, DDS, PhD4
1Associate Professor/Department of Pediatrics, University of Florida
2Assistant Professor/Department of Pediatrics, University of Florida
3Fellow-in-training/Department of Pediatrics, University of Florida
4Professor/College of Dentistry, University of Florida
Juvenile Sjögren’s syndrome (jSS) is a rare and poorly defined systemic autoimmune
disorder affecting children and adolescents. jSS is characterized by chronic lymphocytic
infiltrates in the exocrine glands and positive autoantibodies. The clinical phenotype
varies from benign glandular disease to aggressive systemic extraglandular manifestations.
In the absence of jSS-specific diagnostic criteria, timely diagnosis of jSS is challenging.
We present a single case report of a young boy who was evaluated for possible immunodeficiency
but later diagnosed with jSS.
A nine-year-old boy was hospitalized for failure to thrive, oral thrush, fungal skin
infections, chronic cough, abdominal distension with chronic diarrhea, and hyperpigmented
rash of two years duration. Physical examinations revealed Tinea faceii, Tinea capitis,
generalized erythematous gingiva, desquamative oral mucosa, angular cheilitis, cervical
lymphadenopathy, fine crackles in both lungs, abdominal distension and generalized
well-demarcated papules. While EBV on PCR, ANA (1:2560), SSA-52, and enterocyte antibodies
were positive, normal CBC, immunoglobulins, lymphocyte subsets, lymphocyte mitogen
stimulation, NK cell function, HIV PCR, XIAP, FoxP3, IL-18, and CF variants were found.
Chest CT revealed bronchiectasis with diffuse peribronchial thickening and left lower
lobe consolidation. A labial minor salivary gland biopsy was positive with a focus
score >2. A cytologic smear and skin biopsies indicated oral candidiasis and lichen
planus, respectively. Esophageal candidiasis and autoimmune enteropathy with decreased
pancreatic enzymes were uncovered. Chronic hepatitis by a liver biopsy with negative
CMV and EBV in situ hybridization tests and early lymphocytic interstitial pneumonia
with subpleural and interstitial T and B lymphocytic infiltrates by a thoracoscopic
lung biopsy were detected. A heterozygous variant of an uncertain significance in
IL17RA (c.2428 G>A, p.E810K) was discovered by whole exome sequencing. The patient
responded well to pulse methylprednisolone, rituximab, mycophenolate, antifungals,
and pancreatic enzyme replacement.
We report the perplexing jSS with overlapping features of primary immunodeficiency
including EBV infection, persistent oral and esophageal candidiasis and aggressive
extraglandular manifestations, such as autoimmune enteropathy, exocrine pancreatic
insufficiency, pulmonary and hepatic involvement and lichen planus. Future studies
should investigate any potential association between IL17RA variant with jSS and establish
jSS-specific diagnostic criteria to avoid a delay in jSS intervention.
Keywords: Juvenile Sjögren’s syndrome, Immunodeficiency, Candidiasis, ANA, autoimmune
enteropathy, Bronchiectasis, Pancreatic insufficiency, Anti-SSA autoantibodies, Epstein-Barr
virus, IL17RA
Disclosure:. All authors indicated they had no financial relationships to disclose.
(190) Lower IgG trough and CD4 count may lead to hospitalization for COVID-19 infection
in patients on IgG maintenance therapy.
John Kuster, MD1, Serhan Unlu, MD2, Michael Simonov, MD3, Ryan Steele, DO4, Ida Hsu,
MD5, Christina Price, MD6, Insoo Kang, MD7, Junghee Shin, MD8
1Clinical Fellow/Division of Allergy and Immunology, Section of Rheumatology, Allergy
and Immunology, Department of Internal Medicine, Yale University School of Medicine
2Postdoctoral Research Fellow/Division of Allergy and Immunology, Section of Rheumatology,
Allergy and Immunology, Department of Internal Medicine, Yale University School of
Medicine
3Instructor; Director of Informatics, Clinical and Translational Research Accelerator
(CTRA)/Department of Internal Medicine, Yale University School of Medicine
4Assistant Professor; Program Director, Contact Dermatitis Program/Division of Allergy
and Immunology, Section of Rheumatology, Allergy and Immunology, Department of Internal
Medicine, Yale University School of Medicine
5Assistant Professor of Clinical Medicine; Training Program Director: Allergy & Immunology
Fellowship/Division of Allergy and Immunology, Section of Rheumatology, Allergy and
Immunology, Department of Internal Medicine, Yale University School of Medicine
6Assistant Professor of Medicine; VA Medical Center Section Chief Allergy and Clinical
Immunology/Division of Allergy and Immunology, Section of Rheumatology, Allergy and
Immunology, Department of Internal Medicine, Yale University School of Medicine
7Professor; Director of Allergy & Immunology, Internal Medicine/Division of Allergy
and Immunology, Section of Rheumatology, Allergy and Immunology, Department of Internal
Medicine, Yale University School of Medicine
8Instructor/Division of Allergy and Immunology, Section of Rheumatology, Allergy and
Immunology, Department of Internal Medicine, Yale University School
Immunoglobulin G (IgG) therapy is a pooled donor IgG preparation used in the treatment
of antibody deficiency, autoimmune disease, rheumatologic disorders, and chronic infection.
IgG therapy has also been utilized in COVID-19 infection to modulate inflammatory
response with some benefit, however, studies on the effect of IgG maintenance therapy
for IgG replacement or immune-modulation on COVID-19 infection is limited. Here, we
hypothesized that IgG maintenance therapy implemented a vital role in protecting immune
deficient and dysregulated patients from poor outcomes of COVID-19 infection.
To test this hypothesis, we performed a retrospective chart review of COVID-19 positive
patients in the Yale-New Haven Health System from March 2020 to October 2020. We collected
their demographics, Elixhauser comorbidities, home medications including IgG maintenance
therapy and immunosuppressive therapy, laboratory data, and clinical outcome of COVID-19
infection.
We identified total of 14,359 patients who were COVID-19 positive in Yale-New Haven
Health System. From this cohort, fourteen patients were found to be on IgG maintenance
therapy. Of these, three and six patients met the criteria for Common Variable Immune
deficiency (CVID) and IgG deficiency, respectively. Five patients had diagnosed autoimmune
disorders. The outcome of COVID-19 infection of the fourteen patients showed that
eight were hospitalized and there were no deaths. The IgG trough level (743.40 +/-
192.00mg/dL vs 1054.33 +/- 79.84mg/dL, p=0.02) and baseline CD4 counts (344.75 +/-
181.92cell/ul vs 733.85 +/- 94.54cell/ul, p=0.009 ) were found to be significantly
lower in the hospitalized patients compared to those who were treated as outpatients,
respectively. Their diagnosis for IgG maintenance therapy, 48 Elixhauser comorbidities,
use of immunosuppressive therapies, CD8, CD19 and NK cell counts were similar between
patients who were hospitalized vs. monitored as outpatients.
Our findings suggest that targeting higher IgG trough level (such as 1000 mg/dL) during
the COVID-19 pandemic period may reduce the need for hospitalization of COVID-19 infection
for patients on IgG maintenance therapy. Monitoring T cell subsets may serve as screening
for high risk patients for hospitalization with COVID-19 infection in immune-deficient
and -dysregulated patients.
Keywords: IVIG, COVID-19, immunoglobulin G maintenance therapy, autoimmune disease,
IgG deficiency
Disclosure:. All authors indicated they had no financial relationships to disclose.
(191) Neurological Manifestations as a Sole Presentation of a Novel Gain-Of-Function
Mutation in NLRC4
Sthorn Thatayatikom, MD, MSc1, Akaluck Thatayatikom, MD2
1Assistant Professor/Department of Pediatrics, University of Florida
2Associate Professor/Department of Pediatrics, University of Florida
Inflammasomes are cytosolic multiprotein complexes that sense microbial infections
or host cell damage, triggering pro-inflammatory cytokine production including IL-1beta
and IL1-8, and leading to cell death. A gain-of-function mutation (GOF) in the gene
encoding NLRC4 leads to over activation of NLRC4 inflammasome and autoinflammatory
syndrome characterized by persistent elevated IL-18. A recent study demonstrated a
potential role of NLRC4 inflammasome activation related to neuroinflammation and neuropathology
in animals and in human brain with multiple sclerosis.
A sixteen-year-old Hispanic female presented with intermittent severe throbbing frontal
headache twice a week for several months. Her headache typically lasts for 30 minutes
but may continue throughout the day without auras, hypersensitivity to light or sounds,
nausea or vomiting, diarrhea, fever, skin rash, joint symptoms or signs of infections.
She was previously asymptomatic and found with a novel gain-of-function mutation in
NLRC4, c.1475G>A (p.Arg492Gln) without clinical symptoms and signs of inflammatory
disease. The genetic test was obtained since the mutation was found in three family
members including the father, 3-year-old brother and 12-year-old sister who were diagnosed
with NLRC4 associated autoinflammatory disease. While abnormal laboratory tests including
persistent highly elevated IL-18 in the range of 2234-2297 pg/ml, positive thyroid
autoantibodies, and ANA (1:160) were detected, normal CBC, ESR, CRP, T4, TSH and cytokines
studies including IL-1beta, IL-2, IL-6, IL-8, IL12, IFN-gamma, TNF-alpha, were uncovered.
A brain MRI revealed mild to moderate generalized atrophy. Since an IL-18 inhibitor
has not been approved by FDA, a trial of canakinumab, an IL-1 inhibitor was considered.
We report a teenager female with gain-of-function mutation in NLRC4 who developed
severe headache with imaging evidence of brain pathology. This case highlights that
neurological symptoms can be the only clinical manifestation of NLRC4 associated autoinflammatory
disease and the deleterious effect of NLRC4 inflammasome activation in the brain development.
Future evaluation of the role of NLRC4 inflammasome and the development of central
nervous system in children is warranted.
Keywords: NLRC4, Autoinflammatory syndrome, IL-18, Headache, inflammasome
Disclosure:. All authors indicated they had no financial relationships to disclose.
(192) ARGINASE + MYELOID-DERIVED SUPPRESSOR CELLS ARE IMPORTANT IN THE PATHOPHYSIOLOGY
OF SEVERE COVID-19.
Augusto Ochoa, MD1, matthew Dean, PhD2, Juan Ochoa, MD3, Maria Sanchez-Pino, PhD4,
zabaleta Jovanny, PhD5, Jone Garai, PhD6, Luis Del Valle, MD, PhD7, Dorota Wyczechowska,
PhD8, Lyndsey Buckner, PhD9, Phaethon Philbrook, MD, PhD Candidate10, Rinku Majumder,
PhD11, Richard Vander Heide, MD12, Logan Dunkenberger, student13, Ramesh Thyllur,
PhD6, Bobby Nossaman, MD14, W. Mark Roberts, MD15, Andrew Chapple, PhD4, Jack Collins,
PhD16, Brian Luke, PhD17, Randall Johnson, PhD17, Claudia Morris, MD18, Julia Garcia
Diaz, MD19
1Professor Pediatrics, Director LSU Cancer Center/Louisiana State University Health
- New Orleans, Louisiana
2Postdoctoral Fellow/LSU Health
3Director, Surgical Intensive Care Unit/Ochsner Medical Center
4Assistant Professor/LSU Health
5Associate Professor, Director Genomics Core/LSU Cancer Center
6Postdoctoral Fellow/LSU Cancer Center
7Associate Professor/LSU Cancer Center
8Instructor/LSU Cancer Center
9Supervisor, Biorepository/Ochsner Medical Center
10Student/LSU Cancer Center
11Professor Biochemistry/LSU Health
12Professor, Pathology/LSU Health
13Research Associate/LSU Cancer Center
14Anesthesiologist - ICU/Ochsner Health
15Dean of Research/Ochsner Health
16Director, Advanced Biomedical Computational Science/Frederick National Laboratory
for Cancer Research
17Investigator/Frederick National Laboratory for Cancer Research
18Professor of Pediatrics and Emergency Medicine/Emory University School of Medicine
19Director, COVIS-19 Clinics/Ochsner health
Approximately 35% of COVID-19 patients are asymptomatic, while 20% develop severe
respiratory and coagulation complications. The mechanisms differentiating these presentations
is unclear. Severe COVID-19 is associated with uncontrolled inflammation including
a cytokine storm, increased granulocytes and decreased T cells. Genomic studies suggested
the importance of granulocytes and two reports showed the presence of myeloid-derived
suppressor cells (MDSC). MDSC produce arginase and deplete arginine which impairs
T cell and endothelial cell function, and increases reactive oxygen species (ROS).
We compared the type of MDSC among patients with different stages of COVID-19, tested
arginase expression and its effect on arginine levels, T cells and endothelial cells.
We also aimed to determine if MDSC might play a role in respiratory complications
of severe COVID-19. Transcriptomic signatures of MDSC between COVID-19 patients at
different stages were compared.
A prospective observational study was conducted with 24 severe, 5 asymptomatic, and
26 convalescent COVID-19 patients, and 15 normal controls. Autopsy samples from 5
patients who perished from severe COVID-19 were also tested. All samples were tested
for MDSC subpopulations, T cells and NK cells. Plasma was tested for arginine, nitrates,
cytokines and markers for endothelial cell dysfunction. Transcriptomes of purified
MDSC were compared using RNAseq.
Severe COVID-19 patients had a highly significant increases in circulating Arginase+
granulocytic-MDSC (Arg+G-MDSC), compared to other groups. High Arg+G-MDSC resulted
in decreased plasma arginine, decreased numbers of T cells and NK cells and increased
markers of endothelial cell dysfunction. Large accumulations of Arg+G-MDSC expressing
NOX1 and NOX2, were found infiltrating lungs of patients who died from severe COVID.
Transcriptome comparison showed that Arg+G-MDSC from asymptomatic patients had increased
expression of Type I IFN genes and associated downstream pathways, while severe COVID-19
patients had increased expression of granulocyte functions. Statistical analysis suggests
that G-MDSC may identify patients at risk for developing severe COVID-19.
Arg+G-MDSC play an important role in the pathophysiology of severe COVID-19. Arginine
depletion can cause T cell and endothelial cell dysfunction, while infiltration of
lungs by Arg+G-MDSC expressing NOX-1 and NOX-2 may produce ROS resulting in extensive
pulmonary inflammation and damage and respiratory distress.
Keywords: Myeloid-derived suppressor cells (MDSC), Arginase 1, T cell receptor z chain,
COVID-19
Disclosure:. Claudia Morris is a consultant for Pfizere. All other authors indicated
they had no financial relationships to disclose.
(193) Immunodeficiency Identified In Organ Donor
Eszter Lazar-Molnar, PhD1, Archana Agarwal, MD2, Attila Kumanovics, MD3
1Assistant Professor/University of Utah
2Associate Professor/University of Utah
3Clinical Consultant/Mayo Clinic
Offer for an import kidney was received for a sensitized, 99% cPRA re-transplant patient.
Prospective crossmatch performed using donor lymphocytes from whole blood revealed
a compatible T cell crossmatch, however, the B cell crossmatch could not be interpreted
due to very low number of B cells (130 B cells, 0.4% of enriched lymphocytes). Follow-up
on the 34y old male donor’s history revealed that the cause of death was bacterial
meningitis and pneumonia, laboratory results indicated increased white cell count,
and cultures were positive for Streptococcus pneumoniae. The donor chart indicated
a history of IgM deficiency, however, the presence of encapsulated bacteria in the
context of the low B cells suggested the possibility of an immunodeficiency affecting
IgG levels. Indeed, serum immunoglobulin test showed decreased levels of both IgM
and IgG, and very low levels of Streptococcus pneumoniae antibodies (11 out of 23
serotypes above 1ug/ml, 4 over 1.3ug/ml).
Histological analysis of the residual spleen tissue indicated that the spleen was
severely depleted of B cells, with markedly attenuated follicles and expansion of
red pulp.
Whole exome sequencing of residual donor DNA from the donor identified a pathogenic
R288Q variant of Bruton’s tyrosine kinase (Btk) enzyme, which was also confirmed by
Sanger sequencing. Pathogenic variants of Btk are known to cause X-linked agammaglobulinemia.
Identification of a pathogenic Btk variant in this deceased donor explained the observed
dramatically decreased B cell numbers in whole blood and spleen, and provided explanation
for the fatal sensitivity to infection with encapsulated bacteria. The results of
the findings were communicated to the originating Organ Procurement Organization to
be used for informing and counseling the donor family.
Keywords: agammaglobulinemia, B cell, Bruton's tyrosine kinase
Disclosure:. All authors indicated they had no financial relationships to disclose.
(194) Combination Treatment with Cromolyn Sodium and Masitinib Displays Cell-Protective
Effect and Shows Additive Anti-Oxidative Actions on an in vitro Neurodegenerative
Model
A. Yasemin Göksu Erol, MD1, Fatma Gonca Kocanci, Phd2, Devrim Demir-Dora, Phd3, Hilmi
Uysal, MD4
1Assoc. Prof. Dr./1- Akdeniz University, Department of Gene and Cell Therapy / 2-
Faculty of Medicive, Department of Histology and Embryology
2Asst. Prof./Alaaddin Keykubat University, Division of Medical Techniques, Department
of Medical Laboratory Techniques
3Asst. Prof. Dr./Akdeniz University, Faculty of Medicine, Department of Medical Pharmacology
4Prof. Dr./Akdeniz University, Faculty of Medicine, Department of Neurology
Neuroinflammation plays a key role in occurrence and development of neurodegenerative
diseases. Microglia, the resident immune cells in the brain, have been recognized
to contribute to neuroinflammation. Cromolyn sodium, which is an FDA-approved mast
cell-stabilizer drug used in the treatment of asthma and known to prevent mast cells
from triggering the immune response, has a neuroprotective and anti-inflammatory effect
on microglial cells, as well. Masitinib [1] is an orally administered selective tyrosine
kinase inhibitor which is developed for neurological (i.e. amyotrophic lateral sclerosis),
inflammatory and oncological diseases. It modulates the activity of mast cells and
macrophages for immunity, and can exert a neuroprotective effect in some neurodegenerative
diseases by its activity on mast cells and microglia.
In our previous studies, we found that masitinib inhibits neuronal cell death on 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine
(MPTP) degenerated- differentiated (d)-SH-SY5Y human neuroblastoma cell model. In
this study we tested the synergistic neuroprotective effects of cromolyn sodium and
masitinib when applied together on the same model.
First, (d)-SH-SY5Y cells, with or without MPTP, were exposed to different doses of
cromolyn sodium. MTT assay was used to detect cell survival rates. Spectrophotometric
measurements of total oxidant capacity (TOC)/total antioxidant capacity (TAC) ratios
in CM of (d)-SH-SY5Y cells were performed.
When (d)-SH-SY5Y cells were exposed to MPTP, a dose-dependent decrease in cell viability
rates was observed. High doses of cromolyn ameliorated decreased viability rates (p
< 0.05) (Fig 1). When cromolyn (6.25 μM) and masitinib (0.5 μM) were applied as combination
treatment on d-SH-SY5Y cells, with or without MPTP (d)-SH-SY5Y cell viability was
found to be increased (Fig 2), and TOC/TAC ratios in CM of d-SH-SY5Y cells were measured
to be significantly decreased (p < 0.05) (Fig 3). These agents reduced TOC/TAC ratios
more effectively when applied together, compared to their mono-treatments.
Combined therapy with cromolyn sodium and masitinib showed an additive effect on decreasing
oxidative stress, and protecting cells against neurotoxin applications. Beneficial
effects of this combined treatment should be considered in future investigations.
References
1- Dubreuil P, Letard S, Ciufolini M, Gros L, Humbert M, et al. Masitinib (AB1010),
a potent and selective tyrosine kinase inhibitor targeting KIT. PloS One 2009;4(9):e7258
Figure 1: Dose dependent effects of cromolyn sodium treatment on with or without MPTP
(d)-SH-SY5Y cell viability.
Figure 2. Effects of cromolyn sodium (6.25 μM) and masitinib (0.5 μM) treatment on
with or without MPTP (d)-SH-SY5Y cell viability.
Keywords: Masitinib, Cromolyn sodium, Neurodegeneration, Neuroinflammation, Combined
therapy, Cell culture, Oxidative stress, Total antioxidant capacity, SH-SY5Y cells,
MPTP
Disclosure:. All authors indicated they had no financial relationships to disclose.
(195) A case of subcutaneous panniculitis-like T-cell lymphoma with hemophagocytic
lymphohistiocytosis independent of germline variants in HAVCR2
Gloria Sheng, MD, PhD1, Maria Garcia-Lloret, MD2, Manish Butte, MD, PhD2
1Allergy & Immunology Fellow/Division of Allergy, Immunology, and Rheumatology, University
of California Los Angeles
2Associate Professor/Division of Allergy, Immunology, and Rheumatology, University
of California Los Angeles
Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is an unusual type of non-Hodgkin
skin lymphoma characterized by subcutaneous infiltration of pleomorphic alpha/beta
T cells mimicking panniculitis. Patients have a good survival rate unless they develop
hemophagocytic lymphohistiocytosis (HLH), which occurs in 20% of cases. A germline
mutation in the hepatitis A virus-cellular receptor gene (HAVCR2) causing loss of
function of T cell immunoglobulin mucin 3 (TIM-3) has been identified in 60-85% of
SPTCL-HLH cases. Patients with wild-type HAVCR2 can develop SPTCL-HLH, albeit with
a lower incidence and typically in the setting of underlying autoimmune disease. Herein
we report a previously healthy 40 year old male who presented with a 4 year history
of persistent fevers, lymphadenopathy, subcutaneous nodularities, seizures without
apparent cause, found to have splenomegaly and pancytopenia. He underwent an extensive
workup at an outside institution that was negative for infectious and autoimmune etiologies.
He had numerous lymph and bone marrow biopsies, all of which were unrevealing. Upon
transfer to our institution, patient met diagnostic criteria for HLH (including elevated
ferritin, elevated soluble IL-2 receptor, hemophagocytosis on repeat bone marrow biopsy)
with marginally elevated EBV titers. Skin biopsy of a lower extremity subcutaneous
nodule was also consistent with SPTCL. Immune workup was notable for persistently
low IgG, otherwise unremarkable. Cytokine panel was consistent with a dysregulated
IFN-gamma-inducible inflammatory host response. Molecular assays were negative for
chronic granulomatous disease and X-linked lymphoproliferative disease type 1/2. Whole
exome sequencing did not identify a primary immunodeficiency associated with increased
susceptibility to HLH (including no variants in HAVCR2). However, patient was found
to have a heterozygous c.169G >A variant in the MCM4 gene, which may be associated
with NK cell deficiency and EBV lymphoproliferative disease. Further work is needed
to determine the significance of this variant and its possible relationship with SPTCL-HLH,
as well as reanalysis of his exome to determine if he has an alternative variant which
may affect TIM-3 expression or downstream pathways. While the patient has improved
on etoposide and dexamethasone, he may require maintenance therapy with an immunomodulator
to target this immune checkpoint inhibitor or its effectors.
Keywords: hemophagocytic lymphohistiocytosis, subcutaneous panniculitis-like T-cell
lymphoma, dysgammaglobulinemia, immune overactivation, MCM4
Disclosure: Manish Butte received research grant from Horizon, Regeneron and Takeda
and speaker honoraria from CSL. All other authors indicated they had no financial
relationships to disclose.
(196) No association of viral infection with CTLA-4 insufficiency onset
Noriko Mitsuiki, MD, PhD1, Máté Krausz, MD2, Laura Gamez-Diaz, PhD3, Nadezhda Camacho,
MD4, Hartmut Hengel, MD, PhD5, Bodo Grimbacher, Prof. Dr. med.6
1Physician/Center for Chronic Immunodeficiency, Faculty of Medicine, Medical Center
of the University Hospital, University of Freiburg, Freiburg, Germany AND Department
of Pediatrics, Tokyo Medical and Dental University, Tokyo, Japan.
2Physician scientist/Centre for Chronic Immunodeficiency
3Postdoc/Center for Chronic Immunodeficiency, Faculty of Medicine, Medical Center
of the University Hospital, University of Freiburg, Freiburg, Germany
4PhD student/Center for Chronic Immunodeficiency, Faculty of Medicine, Medical Center
of the University Hospital, University of Freiburg, Freiburg, Germany.
5Medical Director- Institute of Virology/Institute of Virology, Medical Center of
the University Hospital, University of Freiburg, Freiburg, Germany.
6Head of the laboratory/Center for Chronic Immunodeficiency, Medical Center, University
of Freiburg, Germany
Cytotoxic-T-lymphocyte-antigen-4 (CTLA-4) insufficiency is an immune deficiency and
immune dysregulation syndrome caused by heterozygous mutations in CTLA4. Aiming to
determine the influence of viral infections as triggers of the disease onset that
explain the incomplete penetrance characteristically observed in CTLA-4 insufficiency
patients, we evaluated the seroprevalence of antibodies against HSV (Herpes simplex
virus), CMV (cytomegalovirus), EBV (Epstein Barr Virus), and human parvo virus B19.
We collected serum samples and corresponding clinical data from wild-type CTLA4 healthy
individuals (n=12) and patients with CTLA-4 insufficiency, including affected CTLA4
mutation carries (n=5) and unaffected CTLA4 mutation carriers (n=7). The later showing
normal immunoglobulin production or dysgammaglobulinemia. Following the seroprevalence
evaluation of antibodies against HSV, CMV, EBV, and human parvo virus B19, we performed
a Fc gamma receptor (FcγR) activation assay for EBV to measure the ability of the
IgG against EBV to bind to viral antigens and to stimulate and activate FcγR. The
FcγR activity was estimated by IL-2 levels produced by human FcrR-expressing BW5147
cells.
Affected CTLA4 mutation carriers did not present higher seroprevalence of any of the
four pathogens evaluated, in comparison to unaffected CTLA4 mutation carriers and
wild-type healthy individuals. In addition, the FcrR activation assay demonstrated
that all of the unaffected CTLA4 mutation carriers showed normal FcγR activation,
while two out of five affected CTLA4 mutation carriers showed low activity, suggesting
that affected CTLA4 mutation carriers possess IgG with abnormal functionality. No
history of severe EBV-associated diseases in these patients were reported.
Our data suggest that HSV, CMV, EBV and human parvo virus B19 do not trigger the disease
onset in the context of CTLA-4 innsufficiency.
Keywords: CTLA4, Viral infections, Primary immunodeficiency, EBV, CMV, HSV
Disclosure: Bodo Grimbacher received research grant from Baxalta. All other authors
indicated they had no financial relationships to disclose.
(197) Recurrent Infections and Profound Autoimmune Disease in a Patient with a Heterozygous
TNFSF12 Variant
Daniel Cerrone, MD1, Manish Butte, MD, PhD2
1Clinical Fellow/Division of Allergy, Immunology, and Rheumatology, University of
California Los Angeles
2Associate Professor/Division of Allergy, Immunology, and Rheumatology, University
of California Los Angeles
TNFSF12 (TWEAK) has been implicated as a very rare, autosomal dominant cause of common
variable immune deficiency (CVID). We present a case of a 63-year old female diagnosed
with a TNFSF12 variant in the setting of recurrent infections and numerous comorbid
autoimmune conditions.
Our patient first came to medical attention in childhood where she was noted to suffer
from numerous episodes of otitis media, bacterial pharyngitis, and bacterial pneumonia.
She developed bouts of oral thrush even aside from antibiotic use. At age 24 years
she developed her first of two lifetime cases of optic neuritis. She was also diagnosed
with hyperparathyroidism in setting of osteoporosis and numerous fractures. She had
three children, with one diagnosed with type 1 diabetes and rheumatoid arthritis.
Her infections persisted and she was referred to an immunologist at 57 years of age,
who noted a mildly low IgG of 612 mg/dL and IgA of 75 mg/dL. Her response to the pneumococcal
polysaccharide vaccine was inadequate and she would be diagnosed with CVID. Of note,
both TPO and cardiolipin antibodies were elevated at time of diagnosis. She has received
subcutaneous immunoglobulin since diagnosis, however, despite maintaining a treatment
IgG level consistently above 1100 mg/dL, she has required hospitalization for treatment
of Listeria bacteremia and treatment of submandibular cellulitis. She has also been
diagnosed with granulomatous-lymphocytic interstitial lung disease.
At 63 years of age genetic testing revealed a single heterozygous missense variant
in TNFSF12 (NM_003809:c.716T>C (p.Phe239Ser)). This variant is located in the conserved
TNF homology domain. More recent immune testing revealed a B-cell count of 127 cells/μL
but a relatively low switched memory B-cell count and percentage (6.8% of B cells,
8.6 cells/μL).
TNFSF12 encodes TWEAK, which promotes proliferation, fibrosis, and chronic inflammation
in autoimmune diseases. Previous investigations have shown that R145C-variant TWEAK
signals appropriately through its receptor, but forms aberrant oligomers with BAFF
and perturbs B-cell signaling. Our case highlights not only the infections consequences
of TNFSF12 mutations but also a profound autoimmune phenotype.
Keywords: TNFSF12, TWEAK, CVID
Disclosure: Manish Butte received research grant from Horizon, Regeneron and Takeda
and speaker honoraria from CSL. All other authors indicated they had no financial
relationships to disclose.
(198) HLA-typing analysis of patients with CTLA-4 insufficiency
Noriko Mitsuiki, MD, PhD1, Charlotte Schwab, MD, PhD2, Laura Gamez-Diaz, PhD3, Veronika
Soetedjo, MSc4, Florian Emmerich, MD5, Bodo Grimbacher, MD6
1Physician/Center for Chronic Immunodeficiency, Faculty of Medicine, Medical Center
of the University Hospital, University of Freiburg, Freiburg, Germany AND Department
of Pediatrics, Tokyo Medical and Dental University, Tokyo, Japan.
2Resident/Center for Chronic Immunodeficiency, Faculty of Medicine, Medical Center
of the University Hospital, University of Freiburg, Freiburg, Germany.
3Postdoc/Center for Chronic Immunodeficiency, Faculty of Medicine, Medical Center
of the University Hospital, University of Freiburg, Freiburg, Germany
4PhD Student/Institute of Medical Biometry and Statistics, Freiburg Center for Data
Analysis and Modeling (FDM), IMBI/ZKS, Freiburg, Germany.
5Principal Investigator- Laboratory for Immunogenetics/Institute for Transfusion Medicine
and Gene Therapy, University Medical Center Freiburg, University of Freiburg, Freiburg,
Germany.
6Principal Investigator -Genetic Basis of Immunodeficiency/Center for Chronic Immunodeficiency,
Faculty of Medicine, Medical Center of the University Hospital, University of Freiburg,
Freiburg, Germany.
Heterozygous mutations in Cytotoxic-T-lymphocyte-antigen-4 (CTLA4) causes an immune
deficiency and immune dysregulation syndrome known as CTLA4 insufficiency, which is
characterized by a heterogeneous clinical phenotype and an incomplete disease penetrance.
Aiming to identify a disease modifier, we investigated the correlation of the HLA-type
of CTLA4 patients with several clinical and baseline characteristics, as HLA type
is known to be an underlying mechanism of autoimmune diseases and immune dysregulation.
We evaluated a total of seven families composed of 43 individuals carrying heterozygous
mutations in CTLA4. Among them, 25 patients were clinically affected whereas 18 were
unaffected. Genotype analyses at 4-digit-level of the HLA locus, HLA-A, -B, -C, -DRB1,
and -DQB1 were performed in all patients. Statistical analysis using the method of
generalized estimating equations (GEE) allowed us to estimate HLA-types with statistically
significant odds ratio (OR).
Following multiple comparisons analyses of HLA-typing with different variables (including
clinical features and age), we found that affected CTLA4 mutation carriers presented
HLA-DRB1 *13:01 with a higher OR (OR 1.73; p value= 0.024) in comparison to unaffected
CTLA4 mutation carriers. In addition, patients with CTLA-4 insufficiency who developed
autoimmune diseases and lymphoproliferation had significantly more often HLA-DRB1
*15:01 (OR 3.71; p value= 0.013), and HLA-DRQ1 *06:02 (OR 4.82; p value=0.023). HLA-DRB1
*15:01 and -DRQ1 *06:02 are predicted to form a haplotype.
Our results showed that CTLA-4-insufficient patients with autoimmune diseases and
lymphoproliferation who were categorized with a severe immune dysregulation phenotype,
presented the haplotype HLA-DRB1 *15:01 and -DQB1 *06:02 with higher frequency. Further
studies focused on the association of HLA-typing and CTLA-4 insufficiency onset should
be performed.
Keywords: CTLA4, HLA type, primary immunodeficiency
Disclosure: All authors indicated they had no financial relationships to disclose.
(199) Two Unrelated Cases of Familial Hemophagocytic Lymphohistocytosis Presented
as Severe Combined Immunodeficiency
Khaled Hazzazi, MD1, Bandar Al-Saud, MD2, Reem Mohammed, MD2
1Fellow in Pediatric Allergy/immunology/King Faisal Specialist Hospital and Research
Centre
2Consultant Allergist/Immunologist/King Faisal Specialist Hospital & Research Centre
There is a growing data on primary immune deficient patients presenting with hemophagocytic
lymphohistocytosis (HLH). On the other hand, It is less often reported for a patient
with a known genetic mutation causing familial HLH to present clinically as severe
combined immunodeficiency (SCID).
We present two unrelated Saudi patients with familial HLH presenting as SCID. The
first child was a 6-month-old male, who presented with severe pneumonia at age of
4 months, requiring mechanical ventilation. His preliminary laboratory assessment
showed severe lymphopenia and hypogammaglobulinemia. His lymphocytes markers confirmed
a T-B-NK- SCID phenotype. At 8 months of age, he developed persistent fever and progressive
cytopenia despite broad spectrum antimicrobials. His laboratory testing showed pancytopenia,
hyperferritinemia, transaminitis and hypertriglyceridemia. A diagnosis of HLH was
suspected and confirmed with bone marrow biopsy. Genetic testing revealed a homozygous
missense mutation c.3145C>G p.(Pro1049Ala) in UNC13D gene.
The second case is a 2-year-old female presented at age of 9 months with recurrent
skin abscesses and febrile neutropenia. Her initial lab showed neutropenia and severe
lymphopenia. Immunological workup revealed severely depressed lymphocyte function
and markedly low T and B lymphocytes markers consistent with T-B-NK+ SCID. Genetic
testing showed a homozygous mutation variant c.1229G>C (p.Arg410Pro) in PRF1 gene.
This case series of familial HLH presenting with SCID phenotype adds to the spectrum
of clinical presentation of familial HLH and highlights the importance of early genetic
diagnosis in improving patients’ outcome.
Keywords: hemophagocytic lymphohistocytosis, FHL, combined immunodeficiency, mutation
in UNC13D, PRF1
Disclosure: All authors indicated they had no financial relationships to disclose.
(200) Hereditary Angioedema Type 1, Pregnancy, and Acute SARS-CoV-2 Infection
Amanda Salih, MD, MPH1, Manisha Gandhi, MD2, Amir Shamshirsaz, MD3, Joud Hajjar, MD4
1Fellow/Baylor College of Medicine/ Texas Children's Hospital
2Associate Professor, Division of Maternal Fetal Medicine, Department of Obstetrics
and Gynecology/Baylor College of Medicine
3Assistant Professor, Division of Maternal Fetal Medicine/Surgical Critical Care/Baylor
College of Medicine
4Assistant Professor of Immunology, Allergy, and Rheumatology/Baylor College of Medicine
Hereditary angioedema (HAE) and coronavirus disease 2019 (Covid-19) have pathophysiologic
overlap via the activation of complement, contact, and coagulation systems, and production
of proinflammatory cytokines. Both HAE and Covid-19 can lead to an exaggerated inflammatory
response. Common pathway blockade through C1 esterase inhibitor (C1-INH) may dampen
inflammation and improve outcomes.
We report a case of a patient with HAE Type I, pregnant in her second trimester, who
developed Covid-19.
SERPING1 sanger sequencing was performed by GeneDx. SARS-CoV-2 PCR was performed by
Texas Children’s Hospital Laboratory.
A 20-year-old Caucasian female with known HAE type 1 (SERPING1 c.707 T>C) presented
at 22-weeks gestation with abdominal pain and extremity swelling. She had been maintained
on subcutaneous C1-INH (Haegarda®) at 60 IU/Kg with disease control prior to presentation.
Routine nasal swab surveillance screening in the emergency department for Covid-19
by PCR was positive. She experienced no fever, chills, nasal congestion, or dyspnea
symptoms. Later, she reported loss of taste and smell. She was admitted to the hospital
and received 2500 IU of intravenous human C1-INH. Following the abortive therapy,
her swelling and abdominal pain resolved. No signs of fetal distress occurred despite
flare. She was discharged 24 hours after admission. Her pregnancy progressed to 36
weeks and she delivered a healthy newborn. Repeat Covid-19 testing 2 days prior to
delivery was negative.
Pregnancy is an independent risk factor in both Covid-19 and HAE. Pregnant women infected
with Covid-19 are at increased risk for both intensive care unit admission and mechanical
ventilation requirements. Elevated estrogen during pregnancy can trigger an angioedema
flare. Despite having two independent risk factors for poor outcomes, our patient
fared well. Her mild clinical course might be attributed to C1-INH therapy that blunted
the inflammatory response associated with Covid-19.
While further studies are currently being conducted to investigate the effectiveness
of C1-INH in decreasing severe inflammation associated with Covid-19, our case highlights
the importance of maintaining adequate therapy in HAE patients, particularly during
pregnancy.
Keywords: Hereditary Angioedema Type 1, SERPING1, Covid-19, SARS-CoV-2, Pregnancy,
C1-INH, Angioedema
Disclosure: Joud Hajjar received research grants from Amplimmune, Arcus Biosciences,
ARMO BioSciences, Atterocor/Millendo, Baxalta, BMS, Calithera Biosciences, Chao Physician-Scientist
Foundation, CytomX Therapeutics, Eli Lilly, EMD Serono, Healios Onc, Immune Deficiency
Foundation, ImmuneOncia, Incyte, Jeffrey Modell Foundation, Karyopharm, Kymab, MedImmune,
Merck, National Cancer Institute, NeoImmuneTech, Neon Therapeutics, Novartis, OncoSec
KEYNOTE-695, Pfizer, PsiOxus, Regeneron, Surface Oncology, The Texams Medical Center
Digestive Diseases Center and Top Alliance; she was an Advisory Board member of Alfaisal
University, Genome & Company, Horizon, and Pharming. All other authors indicated they
had no financial relationships to disclose.
(201) At Both Ends of the Spectrum: A Case Report of an Infant with Anauxetic Dysplasia
and Severe Combined Immunodeficiency
Lindsay Zayia
1, Hana Niebur, MD2, Danita Velasco, MD3
1Medical Student/Creighton University School of Medicine, Omaha, NE
2Assistant Professor/Division of Allergy and Immunology, Department of Pediatrics,
University of Nebraska, Omaha, NE, USA
3Assistant Professor/Division of Genetic Medicine, Munroe-Meyer Institute for Genetics
and Rehabilitation, University of Nebraska Medical Center, Omaha, NE
Cartilage-Hair Hypoplasia-Anauxetic Dysplasia (CHH-AD) spectrum disorder includes
a range of phenotypes related to biallelic variants in RMRP, the untranslated RNA
component of mitochondrial RNA processing endoribonuclease. This spectrum includes
severe short-limbed short stature and vertebral anomalies, with limited extraskeletal
features in AD to combined immunodeficiency, sparse hair, anemia, gastrointestinal
abnormalities, and metaphyseal dysplasia without vertebral involvement or even normal
stature in CHH. While CHH is a rare cause of severe combined immunodeficiency (SCID),
AD is not typically associated with SCID. Herein, we describe a case of an infant
with skeletal features consistent with AD and SCID.
Next-generation sequencing was obtained with follow-up parental testing confirming
biallelic inheritance.
A term female infant with prenatally detected micromelia and limb bowing suggestive
of thanatophoric dysplasia presented with abnormal TREC assay on day of life 5. Prenatal
genetic testing including FGFR3 was unrevealing. After birth, the infant had profound
lymphopenia, and anemia, requiring a PRBC transfusion. While anemia improved, lymphopenia
continued, and the infant developed moderate neutropenia. Flow cytometry demonstrated
profound B- and T-cell lymphopenia with absent naïve T-cells. IgG, A, and M were low
to absent. A skeletal survey showed characteristic features of AD including platyspondyly,
hypoplastic iliac bones, and shortened, bowed femurs, humeri, radii, and ulnae. MRI
demonstrated a small foramen magnum with an attenuated CSF signal at the cervicomedullary
junction and upper cervical spinal cord. Genetic testing showed biallelic variants
in RMRP with a known pathogenic variant in the promoter region (n.-19_-3dup) and a
novel variant in the transcribed region (n.223C>T). The infant was referred for hematopoietic
stem cell transplantation.
Conclusions: To our knowledge, this is the first reported case of an infant with both
the severe skeletal findings of AD and extraskeletal features of CHH including SCID.
This novel case demonstrates the importance of immunological screening in all individuals
presenting with features consistent with a CHH-AD spectrum disorder, regardless of
the severity of the skeletal dysplasia and expands the phenotype of CHH-AD spectrum
disorders.
Keywords: Severe Combined Immunodeficiency, Cartilage Hair Hypoplasia, Anauxetic Dysplasia
Disclosure: All authors indicated they had no financial relationships to disclose.
(202) Seropositive IgG Responses to Coronaviruses in Children Pre-COVID-19 Provides
Cross-Protection Against SARS-CoV-2
Nicolai van Oers, PhD1, Quan-Zhen Li, MD, Phd2, Fatma Coskun, BSc3, Prithvi Raj, Phd4,
Patricia Pichilingue-Reto, MD, Phd5, Igor Dozmorov, PhD2, Jeffrey Kahn, MD, Phd1,
Christian Wysocki, PhD, MD6
1Professor/UT Southwestern Medical Center
2Associate Professor/UT Southwestern Medical Center
3Graduate Student/UT Southwestern Medical Center
4Assistant Professor/UT Southwestern Medical Center
5Medical fellow/UT Southwestern Medical Center
6Pediatric Immunologist. Assistant Professor/UT Southwestern Medical center
The antibody repertoire forms in response to infections, the microbiome, vaccinations
and environmental exposures. The specificity of such antibody responses was compared
among a cohort of toddlers to identify associations between seropositive responses
to SARS-CoV-2 relative to other infectious agents and vaccinations.
The serum IgG antibody reactivities in children and adults prior to and during the
COVID-19 pandemic was compared with a microfluidic array containing 110 distinct antigens.
Seropositivity to RNA and DNA viruses, including multiple Coronaviruses together with
SARS-CoV-2 was compared. Neutralization assays were performed on individuals with
seropositivity to SARS-CoV-2. A stratification was developed based on quantitative
variations in the IgG responses. Clinical presentations were investigated in relation
to IgG responses.
Approximately 5% of toddlers seen prior to the COVID-19 pandemic had seropositive
antibody responses to the Spike protein from diverse Coronaviruses. Some of these
IgG responses provided cross-protection against SARS-CoV-2 in a neutralization assay.
This was in spite of limited IgG responses to the SARS-CoV-2 nucleocapsid protein.
Current analyses are examining whether the SARS-CoV-2 responses are associated with
enhanced IgG responses to different Coronaviruses along with diverse live-attenuated
viral vaccines. Taken together, our findings suggest that prior Coronavirus infections
in children may afford some protection against COVID-19. This may account for the
less severe conditions seen in some the younger age group relative to adults, who
may have diminished serospecific antibody responses.
Keywords: SARS-CoV-2, serum IgG profiling, Coronaviruses, vaccines, children antibody
responses
Disclosure: All authors indicated they had no financial relationships to disclose.
(203) Heterozygous ATM Mutation Associated with Immunodeficiency and Recurrent Malignancy
Daniel Tcheurekdjian
1, Shan Shan Wu, DO2, Devi Jhaveri, DO3, Robert Hostoffer, DO4, Haig Tcheurekdjian,
MD4
1Visiting Student/Allergy/Immunology Associates, Inc.
2Attending Physician/University Hospitals of Cleveland
3Clinical Instructor/Case Western Reserve University
4Associate Clinical Professor/Case Western Reserve University
Ataxia-Telangiectasia is an early-onset autosomal recessive disorder caused by mutations
in the Ataxia-Telangiectasia Mutated gene (ATM). It is characterized by immunodeficiency,
predisposition to malignancy, and neurodegeneration. We present a patient with a heterozygous
ATM mutation displaying adult-onset immunodeficiency and recurrent malignancies without
neurodegeneration or telangiectasia.
A 51 year old male presented with a 10 year history of recurrent shingles, sinusitis,
bronchitis and pneumonia. Physical examination was normal except for bilateral rhonchi
and rales on pulmonary examination. Neurologic examination was normal, and there were
no telangiectasia on the skin or ocular tissues. The complete blood count was normal
with an absolute lymphocyte count of 1282 cells/μL (850-3900 cells/μL). The peripheral
lymphocyte phenotyping demonstrated a low T-cell count of 764 cells/μL (840-3060 cells/μL),
with absolute CD4 and CD8 counts of 443 cells/μL (490-1740 cells/μL) and 277 cells/μL(180-1170
cells/μL), respectively. The quantitative immunoglobulins demonstrated an IgG of 892
mg/dL (692-1618 mg/dL), IgA of 226 mg/dL (81-463 mg/dL), and IgM of 28 mg/dL (48-271
mg/dL). The pneumococcal titers were protective against 2/14 serotypes. Both unconjugated
and conjugated polysaccharide pneumococcal immunization led to no change in titers.
The patient was started on intravenous immunoglobulin therapy with a decrease in the
number and severity of infections. He subsequently developed a diffuse large B-cell
lymphoma in the retroperitoneum two years later, which was successfully treated with
R-CHOP. He later developed a left occipital mass. An excisional biopsy revealed an
ectopic salivary gland neoplasm. Excision was curative. Three years later there was
a recurrence of a diffuse large B-cell lymphoma in the retroperitoneum and the liver
which was successfully treated with an autologous stem cell transplantation. Whole
exome sequencing was obtained because of the patient's history of unusual and recurrent
malignancy in association with immunodeficiency identifying a heterozygous pathogenic
mutation in ATM (c.2098 C>T, p.Q700X).
Heterozygous ATM mutations may cause an ATM-related disorder manifesting with immunodeficiency
and predisposition to malignancy without neurodegeneration.
Keywords: Ataxia-Telangiectasia, ATM mutation, Immunodeficiency, Malignancy
Disclosure: All authors indicated they had no financial relationships to disclose.
(204) Serum proteomic analysis of inflammatory complications in common variable immunodeficiency
Hsi-en Ho, MD1, Lin Radigan, MD2, Charlotte Cunningham Rundles, MD3
1Assistant Professor/Mount Sinai School of Medicine
2Researcher/Icahn School of Medicine at Mount Sinai
3David S. Gottesman Professor of Immunology/Mount Sinai School of Medicine
Inflammatory complications in Common variable immunodeficiency (CVID) are heterogeneous,
and together they lead to increased morbidity/mortality. The shared immune pathways
underlying such heterogeneous manifestations are not fully identified.
We employed a proteomic-approach to identify the serum immune signatures that marked
CVID subjects with autoimmune/inflammatory complications (“CVID+”) from those without.
\We performed Olink Protein Extension Assays, covering 92 inflammation-related proteins,
in serums from 30 well-characterized CVID subjects (CVID+, n=20).
Among CVID+ subjects in this cohort, the clinical manifestations included interstitial
lung disease (45%), granulomas (25%), nodular regenerative hyperplasia of liver (25%),
enteropathy (50%), lymphoproliferations (90%), and a history of hematologic autoimmunity
(65%). Our analysis identified five immune signatures, consist of (A) type 2 interferon
and associated factors, (B) chemokines, (C) pro-inflammatory cytokines (IL-6, TNF-a/b),
(D) immune-regulatory proteins (IL-10), and (E) hematopoietic growth factors (M-CSF),
which were all significantly elevated in CVID+ compared to CVID subjects without inflammatory
manifestations (FDR < 0.05). Signature A was notable for elevated circulating IFN-g,
along with its associated cytokines, IL-12 and IL-18. Additionally, elevated IFN-g
positively correlated with multiple circulating factors, including PD-L1, MMP-10,
CDCP1, TNF-a/b, and IL-15RA (Spearman r=0.50-0.76, FDR < 0.05). Signature B included
chemokines typically highly expressed in lymph nodes (CCL19), small intestines (CCL25),
and lung/liver (CCL23). In addition, it included multiple chemokines that were significantly
correlated with serum IFN-g levels in this cohort: CXCL9, CCL19, CXCL10 (Spearman
r=0.54-0.73, FDR < 0.05).
Our serum proteomic analysis of CVID revealed common immune signatures that characterized
those with inflammatory manifestations. Our data extend upon the IFN transcriptional
signature previously noted in CVID+ subjects and identified dysregulated immune pathways
and markers that may be of clinical and therapeutic importance.
Keywords: common variable immunodeficiency, proteomics, immune dysregulation
Disclosure: All authors indicated they had no financial relationships to disclose.
(205) Two types of independent malignancies in a patient with selective IgM deficiency
Yesim Demirdag, MD1, Linda Doan, MD2, Sudhir Gupta, MD3
1Director, Allergy and Immunology Fellowship Program Associate Professor of Clinical
Medicine/Division of Basic and Clinical Immunology Department of Medicine University
of California Irvine
2Assitant Clinidal Professor/University of California in Irvine
3Professor of Medicine/University of California in Irvine
Selective IgM deficiency (SIGMD), defined as IgM < 2 SD of age-adjusted levels, is
a rare primary immunodeficiency. Although it is usually asymptomatic, individuals
with selective IgM deficiency may present with recurrent respiratory tract infections
and atopic tendency. Here we present a 76-year-old man with IgM deficiency associated
with IgG2 subclass deficiency. In addition to infections, the patient developed melanoma
as well as angiosarcoma, a rare and aggressive form of soft tissue malignancy with
a poor prognosis. To our knowledge this is the first reported case of selective IgM
deficiency who developed angiosarcoma, and, this is also the first case of selective
IgM deficiency who developed two different types of malignancies.
Case: The patient was initially evaluated in our immunology clinic at age 73 because
of recurrent shingles and a history of prolonged recovery from infections. His past
medical history was significant for trauma-induced quadriplegia at age 29, neurogenic
bladder causing recurrent urinary tract infections, and neurogenic colon requiring
colostomy at age 64 which was complicated by perforation and sepsis. He also has type
2 diabetes, gout, and a history of melanoma on the right upper chest which was fully
resected without any further therapy at age 72. Immunology evaluation revealed normal
complete blood counts and differentials, normal IgG and IgA levels, but very low IgM
levels (17 mg/dl, normal: 65-230 mg/dl). Lymphocyte subsets and IgG subclasses were
normal and antibody response to pneumococcal polysaccharide vaccine was adequate.
During follow-up, IgM levels stayed low and IgG2 level slightly decreased (227 mg/dl,
normal: 242-700 mg/dl). In May 2019, he was diagnosed with aggressive angiosarcoma
( Figure 1) which was located on the right side of the umbilicus. It was resected
and he was started on radiotherapy followed by chemotherapy.
Summary: While selective IgM deficiency is associated with a wide clinical spectrum
from an asymptomatic state to recurrent infections and/or atopy, malignancies are
rarely reported. We describe a patient with SIGMD with 2 different types of malignancies
one of which is a rare and aggressive type.
Figure 1: The skin biopsy shows extravasated blood in the dermis with inflammatory
cells and the suggestion of vascular channels (black arrows).
Figure 2: The tumor cell nuclei show strong positive staining with ERG
Figure 3: The tumor cell nuclei show negative staining for Melanin
Keywords: Selective IgM deficiency, Angiosarcoma, Melanoma
Disclosure: All authors indicated they had no financial relationships to disclose.
(206) A Phase 1/2 Study of Lentiviral-mediated Ex-vivo Gene Therapy for Pediatric
Patients with Severe Leukocyte Adhesion Deficiency-I (LAD-I): Interim Results
Donald Kohn, MD1, Gayatri Rao, MD, JD2, Elena Almarza, PhD3, Dayna Terrazas, RN4,
Eileen Nicoletti, MD5, Augustine Fernandes, PhD6, Caroline Kuo, MD7, Satiro De Oliveira,
MD8, Theodore Moore, MD9, Ken Law, PhD10, Brian Beard, PhD11, Julian Sevilla, MD,
PhD12, Cristina Mesa-Nunez, PhD13, Claire Booth, MBBS, MSc, PhD14, Adrian Thrasher,
MBBS, PhD15, Juan Bueren, PhD16, Jonathan Schwartz, MD17
1Distinguished Professor, Microbiology, Immunology & Molecular Genetics/University
of California, Los Angeles
2Vice President, Global Program Head, LAD-1 Program/Rocket Pharmaceuticals, Inc.
3Senior Scientist/Rocket Pharmaceuticals, Inc.
4Study Coordinator/University of California, Los Angeles
5Medical Director/Rocket Pharmaceuticals, Inc.
6Administrative Director/University of California, Los Angeles
7Assistant Professor of Pediatrics/University of California, Los Angeles
8Clinical Instructor, Pediatrics/University of California, Los Angeles
9Professor of Pediatrics, Chief of Pediatric Hematology/Oncology/University of California,
Los Angeles
10Associate Director, CMC/Rocket Pharmaceuticals, Inc.
11Associate Vice President, CMC/Rocket Pharmaceuticals, Inc.
12Hematologist/IB Hospital Infantil Universitario Niño Jesús, and Centro de Investigación
Biomédica en Red de Enfermedades Raras (CIBERER-ISCIII )
13Scientist/entro de Investigaciones Energéticas Medioambientales y Tecnológicas (CIEMAT)
and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER-ISCIII);
IIS-FJD/UAM
14Senior Clinical Lecturer/UCL Great Ormond Street (GOS) Institute of Child Health
15Professor/UCL Great Ormond Street (GOS) Institute of Child Health
16Professor/entro de Investigaciones Energéticas Medioambientales y Tecnológicas (CIEMAT)
and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER-ISCIII);
IIS-FJD/UAM
17Chief Medical Officer/Rocket Pharmaceuticals, Inc.
LAD-I is a rare disorder of leukocyte (primarily neutrophil) adhesion resulting from
ITGB2 gene mutations encoding for the β2-integrin component, CD18. Severe LAD-I (i.e.,
CD18 expression on < 2% of PMNs) is characterized by severe infections, impaired wound
healing, and childhood mortality. Although allogeneic hematopoietic stem cell transplant
(alloHSCT) is potentially curative, utilization and efficacy are limited by donor
availability and risk of graft-versus-host disease (GVHD). RP-L201-0318 (NCT03812263)
is a phase 1/2 open-label clinical trial evaluating the safety and efficacy of RP-L201,
consisting of autologous CD34+ cells transduced with a lentiviral vector (LV) carrying
the ITGB2 gene encoding for CD18 (Chim-CD18-WPRE) in severe LAD-I.
Pediatric patients ≥ 3 months old with severe LAD-I are eligible. Peripheral blood
(PB) HSCs are collected via apheresis after mobilization with granulocyte-colony stimulating
factor (G-CSF) and Plerixafor and transduced with Chim-CD18-WPRE LV. Myeloablative
busulfan conditioning is followed by RP-L201 infusion. Patients are followed for safety
and efficacy (i.e., survival to age 2 and at least 1-year post-infusion, increase
in PMN CD18 expression to at least 10%, PB vector copy number (VCN), decrease in infections/hospitalizations,
and resolution of skin or periodontal abnormalities).
Four patients (ages 7 months to 9 years) have been treated with RP-L201 with follow-up
ranging from 6 weeks to 12 months. RP-L201 cell doses ranged from 2.8x106 to 6.5x106
CD34+ cells/kg with VCNs from 1.83 to 3.8 copies/cell (liquid culture). No serious
treatment-emergent adverse events were reported. Neutrophil engraftment was observed
in ≤ 5 weeks. PB PMN CD18 expression in Patient 1 12-months post-treatment was 40%
(sustained from 47% at 6-months, vs. < 1% at baseline), with PB VCN of 1.2. Skin lesions
present at baseline resolved with no new lesions reported. Patient 2 PB PMN CD18 expression
6-months post-treatment was 23% with PB VCN at 0.75. Patients 3 and 4 PB PMN CD18
expression were 74% at 3-months and 59% at 6-weeks post-treatment, respectively. No
new infections have been reported in patients post-infusion.
These results demonstrate that RP-L201 leads to durable neutrophil CD18 expression
and improved clinical course. Additional patient treatment is planned for early 2021.
Keywords: Primary Immunodeficiency, Gene Therapy, Leukocyte Adhesion Deficiency Type
1, Rare Disease
Disclosure: Donald Kohn is an advisory board member of Allogene Therapeutics, MyoGene
Bio and Orchard Therapeutics. Gayatri Rao, Elena Almarza, Eileen Nicoletti, Ken Law,
Brian Beard are employees of Rocket Pharmaceuticals. Julian Sevilla has ownership
interest in Rocket Pharmaceuticals, and is a consultant at Amgen, Miltenyi Biotec
and Sobi. Claire Booth received educational honoraria from GSK, Orchard, Rocket, SOBI,
and Takeda. Adrian Thrasher is a consultant at 4BioCapital, Generation Bio, Orchard,
and Rocket Pharma. Juan Bueren and Jonathan Schwartz have ownership interest in Rocket
Pharmaceuticals. All other authors indicated they had no financial relationships to
disclose.
(207) Observed Treatment Adjustments and Complications in an Ovarian Cancer Patient
with Inborn Error of Immunity
Jamila Mammadova
1, Anna Redden2, Rachel Cruz1, Maryssa Ellison3, Tyra Gatewood, PharmD, BCOP4, Carla
Duff, MSN3, Charurut Somboonwit, MD, FACP, FIDSA5, Chakrapol Sriaroon, MD5, Jolan
Walter, MD/PhD6, Roohi Ismail-Khan, MD, MSc7
1Medical Student/University of South Florida
2Student/University of Southern California
3Department of Pediatrics/University of South Florida
4Clinical Pharmacist/H. Lee Moffitt Cancer Center and Research Institute
5Department of Medicine/University of South Florida
6Department of Pediatrics/University of South Florida at Johns Hopkins All Children's
Hospita
7Co-Director, Cardio-Oncology Program, Moffitt/USF/H. Lee Moffitt Cancer Center and
Research Institute
Inborn errors of immunity (IEI) prone patients to increased risk of developing cancer.
However, there is sparse literature on optimizing their cancer treatment.
We present a patient with specific antibody deficiency (SAD), immune dysregulation
(AI) and stage III high grade ovarian carcinoma, whose treatment regimen needed modification
secondary to ongoing infections.
This is a retrospective chart review on the patient's cancer treatment course.
Our patient with SAD and AI (ANA+, polyarthralgia, autoimmune neutropenia) was diagnosed
with stage III ovarian carcinoma at age 60. After robot-assisted laparoscopic primary
debulking surgery she underwent 6 cycles of chemotherapy. Prior to cycle 1, routine
immunoglobulin replacement therapy was adjusted from 40 mg of IVIG every two weeks
to 80 mg of IVIG every 3 weeks (1.3 g/kg/3 weeks, wt 60 kg), administered 1 week prior
to each chemo cycle. Chemo doses were lowered for all cycles: Carboplatin (area under
the curve (AUC) 4 instead of standard 5), Paclitaxel (Taxol 150 mg/m^2 instead of
standard 175 mg/m^2) and Avastin (15 mg/kg). Colony-stimulating factor pegfilgrastim
throughout prevented febrile neutropenia. After cycle 1, the patient developed pulmonary
mycobacterium avium-intracellulare (MAI) infection, hyperbilirubinemia, elevated liver
enzymes, and urinary retention. Liver evaluation was reassuring. For post-cycle-1
adjustment, the IVIG dose was reduced to 60 mg (1g/kg/4 weeks, wt 50 kg). During cycle
2 and 3, the patient developed urinary tract infection (UTI) caused by Klebsiella
pneumoniae, treated with Rocephin and Ciprofloxacin. Throughout cycles 4-6, UTI was
prevented with prophylactic Bactrim and Azithromycin and received Myrbetriq for symptoms
of urinary incontinence. The patient completed all 6 cycles. For MAI lung scarring
and recurrent cough, she had repeat bronchoscopy that was unrevealing. Post-chemo
CT scan revealed no evidence of cancer, therefore she will continue with 1-year maintenance
therapy of Avastin (15 mg/kg). Cancer genetic analysis revealed no targetable markers,
primary immunodeficiency gene panel (207 genes) was unrevealing.
Patients with IEI with cancer may require a modified treatment course and multidisciplinary
team approach. Larger studies are needed on how to adjust therapy to decrease risk
of infection but still treat cancer aggressively for optimal long-term outcomes.
Keywords: Primary immunodeficiency, Ovarian cancer, Inborn error of immunity, Treatment
adjustment, Complications
Disclosure: All authors indicated they had no financial relationships to disclose.
(208) A rare case of Chronic Granulomatous Disease and Fanconi's Anemia
Candace Rypien, MD1, Luis Murguia-Favela, MD2, Tony Truong, MD3, Sneha Suresh, MD4,
Nicola Wright, MD, MSc3
1Pediatrician/Alberta Children's Hospital
2Attending Physician/Section of Hematology/Immunology, Department of Pediatrics, Alberta
Children's Hospital, Cumming School of Medicine, University of Calgary
3Associate Professor/Alberta Children's Hospital
4Clinical Assistant Professor/Stollery Children's Hospital
Chronic granulomatous disease (CGD) is a primary immunodeficiency leading to increased
risk of life threatening infections with catalase positive bacteria and fungus, and
inflammatory complications associated with poorly functioning neutrophils. In North
America, the most common cause of CGD is mutations in CYBB (X-linked), however, CGD
can be caused by mutations in any of the components of the NADPH oxidase complex (CYBB,
NCF1, CYBA, NCF2, NCF4). In populations with higher rates of consanguinity, the recessive
forms of CGD can be more common.
Regular use of prophylactic antimicrobials has decreased the rate of infections; however,
patients continue to have significant morbidity in the form of inflammatory complications
and ongoing risk of infections. Growing evidence supports the use of Hematopoietic
Stem cell transplant (HSCT) in patients with CGD to prevent long term complications
of infection and inflammation.
This patient presented at 3 months of age with chronic cough, congestion and failure
to thrive since birth. Due to ongoing oxygen requirements, she had a chest CT which
found multiple scattered pulmonary nodules leading to a bronchoalveolar lavage being
performed which grew Aspergillus fumigatus. Immune investigations demonstrated an
absence normal neutrophil oxidative burst on flow cytometry. A primary immunodeficiency
genetic panel was sent which came back demonstrating homozygous stop codon variant
in CYBA as well as a homozygous splice variant causing Fanconi’s anemia. She was started
on voriconazole for treatment of pulmonary Aspergillosis and required admission to
the PICU with respiratory failure requiring intubation.
Patients with a history of consanguinity are at increased risk of recessive monogenetic
diseases. The identification of a second recessive disease, Fanconi’s Anemia, lead
to significant changes to the conditioning regiment and bone marrow donor selection.
Both parents were suboptimal bone marrow donors as they were carriers of Fanconi’s
anemia. Given the unusual ethnic background and lack of sibling donor, a mismatched
unrelated cord had to be utilized for transplant. The conditioning regiment had to
be modified given the radio-sensitivity of the patient due to their underlying Fanconi’s
anemia. This patient demonstrates a unique HSCT challenge and outlines the importance
of genetic sequencing when preparing for bone marrow transplant.
Keywords: Chronic Granulomatous Disease, Fanconi's Anemia, Hematopoietic Stem Cell
Transplant, Pulmonary Aspergillosis
Disclosure: Tony Truong is a consultant at Jazz Pharmaceutical. Sneha Suresh received
speaker honoraria from Abbvie. Nicola Wright received speaker honoraria from Sobi
Canada Inc. All other authors indicated they had no financial relationships to disclose.
(209) Post-COVID-19 Hemophagocytic Lymphohistiocytosis in an Infant with Trisomy 21
Taya Carpenter, DO1, Melissa Gans, MD2
1Resident Physician in Pediatrics/Westchester Medical Center
2Attending in Allergy and Immunology/Boston Children's Health Physicians
An 8 month-old ex-35 week baby girl with trisomy 21, atrioventricular canal defect
status post repair, pulmonary hypertension, oxygen dependence, and nasogastric tube
feed dependence was admitted to the pediatric intensive care unit for respiratory
failure secondary to COVID-19 pneumonia. She was treated with remdesivir, COVID-19
convalescent plasma, and dexamethasone. Over the next several weeks, she had waxing
and waning respiratory distress and was also diagnosed with a Klebsiella urinary tract
infection, for which she completed treatment. She was afebrile for 5 consecutive days
at the end of week 1 to beginning of week 2 of her treatment course, but soon her
fevers returned accompanied by elevated inflammatory markers, anemia, thrombocytopenia,
elevated ferritin, hypertriglyceridemia, low fibrinogen, and elevated liver function
tests. Multisystem inflammatory syndrome in children was considered as a diagnosis
and she was treated with immunoglobulin and dexamethasone with no improvement in symptoms.
Further laboratory testing revealed elevated IL-2 receptor, low Natural Killer cell
function, and normal perforin/granzyme B. Her clinical presentation was believed to
be more consistent with hemophagocytic lymphohistiocytosis, even though her bone marrow
aspiration did not show hemophagocytosis. The patient was started on HLH94 dexamethasone
dosing regimen with a response to treatment evidenced by improvement in clinical status
and some laboratory markers. Etoposide and other immunosuppressive agents were held
due to clinical improvement on dexamethasone alone. Immune evaluation revealed lymphopenia
(ALC 2679 lymphocytes per microliter) with normal distribution of lymphocyte subsets
and normal IgA and IgM. Genetic analysis of 407 genes associated with primary immunodeficiency
was unrevealing. Trisomy 21 is an underrecognized immune dysregulatory disorder and
we believe that this underlying inborn error of immunity likely triggered her hemophagocytic
lymphohistiocytosis after COVID-19. This case also demonstrates the diagnostic difficulty
in discerning multisystem inflammatory syndrome in children from hemophagocytic lymphohistiocytosis.
Bone marrow aspiration could distinguish the two disorders, but our patient had a
negative aspiration, possibly due to partial treatment of her hemophagocytosis by
her previous course of dexamethasone or bone marrow sampling error. Additionally,
viruses, particularly Epstein-Barr virus, are well known triggers of hemophagocytic
lymphohistiocytosis and this case demonstrates COVID-19 as a potential trigger as
well.
Keywords: Trisomy 21, Hemophagocytic Lymphohistiocytosis, Immune Dysregulation, COVID-19
Disclosure: All authors indicated they had no financial relationships to disclose.
(210) Immune cell profiling and fitness in WHIM syndrome
Maryssa Ellison
1, Ulrich Salzer, MD2, Christoph Geier, MD, MSc3, Mei-Sing Ong, PhD4, Rachel Cruz5,
Sumai Gordon, B.S.6, Boglarka Ujhazi, BS7, Marton Keszei, PhD8, Svetlana Sharapova,
PhD9, Morna Dorsey, MD10, Mica Muskat, Nurse Practitioner11, Amer Khojah, MD12, Eyal
Grunebaum, MD, M.Sc. Paeds13, Oliver Wegehaupt, MD14, Klaus Warnatz, MD15, Krisztian
Csomos, PhD16, Joao Pereira, PhD17, Jolan Walter, MD/PhD18
1Department of Pediatrics/University of South Florida
2Research group leader/University Clinic Freiburg, CCI
3MD, MSc/Immunology Outpatient Clinic, Vienna, Austria
4PhD/Department of Population Medicine, Harvard Medical School and Harvard Pilgrim
Health Care Institute, Boston, MA, USA
5Medical student/University of South Florida
6B.S./University of South Florida
7Senior Biological Scientist/University of South Florida
8PhD/Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Sweden
9PhD/Belarusian Research Center for Pediatric Oncology and Hematology
10Director, Allergy/Immunology Program/University of California, San Francisco
11Ped-Immuno Nurse Practitioner, Pediatrics/University of California, San Francisco
12Attending Physician, Allergy, Immunology, and Rheumatology/Ann & Robert H. Lurie
Children's Hospital of Chicago/ Northwestern University Feinberg School of Medicine
13Co-director Food Allergy and Anaphylaxis Program, Division of Immunology and Allergy/SickKids
14MD/Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical
Center University of Freiburg Faculty of Medicine, University of Freiburg, Freiburg,
Germany
15Head of Division/Center for Chronic Immunodeficiency, Medical Center, University
of Freiburg, Germany
16Research Associate/University of South Florida
17Associate Professor of Immunobiology/Yale
18Department of Pediatrics/University of South Florida at Johns Hopkins All Children's
Hospita
CXCR4 gain-of function is the most common molecular basis for immunodeficiency in
warts, hypogammaglobulinemia, infections, myelokathexis syndrome (WHIM) manifesting
as both defect in innate immunity, but also variable levels of antibody deficiency.
In our current retrospective international cohort of 59 WHIM patients, 37 (62%) had
a diagnosis of hypogammaglobulinemia. There has been limited data on characterization
of lymphocyte profile and fitness and its relationship to variability in antibody
deficiency.
We aim to evaluate lymphocyte phenotype, function, and survival in a cohort of patients
with WHIM syndrome.
Flow cytometry-based assay to assess extended immune phenotype, function, and fitness
of peripheral lymphocytes (T, B and NK cell subsets).
We had seven patients available for immune studies from our international cohort of
WHIM syndrome. The majority of patients have history of hypogammaglobulinemia. Immune
phenotype was notable for decreased fraction of memory B, naïve CD4+ and CD8+ and
central memory T cells in patients when compared to age matched healthy controls.
In vitro differentiation of naïve B cells revealed early activation and decreased
ability for expansion. BAFF levels were found to be increased (n=6). Regarding lymphocyte
fitness, an increase in apoptosis was found in several lymphocyte subsets, but most
prominently in total CD19+ B cell population post 24-hour incubation.
Our study has shown lymphocyte abnormalities in WHIM syndrome, specifically regarding
development, function, and survival of B cells. Early activation may explain B cell
apoptotic tendencies, but further investigation is warranted to understand the mechanisms
and its link to variable phenotype of antibody deficiency in WHIM syndrome. Further
investigation of the B cell immune phenotype, function and apoptosis could help with
the development of biomarkers to predict the need for antibody replacement therapy
in WHIM syndrome.
Keywords: WHIM Syndrome, lymphocyte, immune phenotype, apoptosis
Disclosure: Ulrich Salzeer is an advisory board member at Baxalta. Klaus Warnatz received
speaker honoraria from Baxalta/Takeda. All other authors indicated they had no financial
relationships to disclose.
(211) Neuroblastoma amplified sequence related disease manifesting with complex immune
cytopenias
Dilawar Khokhar, MD1, Mark Hannibal, MD, PhD2, Lauren DeMeyer, MS3, Laura Howe, MD4,
Beth Kurt, MD, MS5, Yelena Kier, DO, FACOI6, Kristle Habrichter, DO7, Kelly Walkovich,
MD8
1Allergy and Immunology Fellow/University of Michigan
2Associate Professor, Genetics, Metabolism & Genomic Medicine/University of Michigan
3Genetic Counselor/University of Michigan
4Allergist/Bayside Allergy
5Section Chief, Pediatric Hematology and Oncology/Spectrum Health Helen DeVos Children’s
Hospital
6Hematologist, Oncologist/Cowell Family Cancer Center
7Pathologist/Grand Traverse Pathology, PLLC
8Associate Professor, Pediatric Hematology & Oncology/University of Michigan
Neuroblastoma amplified sequence (NBAS)-associated disease is a multisystem disorder
that may involve the liver, nervous system, immune system, retina, connective tissue
and bone. The most commonly reported immunologic aberrations are hypogammaglobulinemia
and NK cell deficiency. Hematologic features of isolated ITP or AIHA are rare, although
the Pelger-Huet anomaly is frequently visualized on peripheral smear.
We present a 25-year-old male diagnosed with CVID requiring immunoglobulin replacement
at age 8 years and Evans syndrome (ES) with ITP and warm AIHA at age 16 years. His
ES required treatment with corticosteroids, vincristine, danazol, rituximab and splenectomy,
with an ongoing need for chronic steroids to manage hemolysis. Additionally, he has
legal blindness secondary progressive optic nerve atrophy, short stature, liver disease,
type 1 diabetes mellitus and lymphopenia. He was referred for further evaluation due
to serious recurrent infections despite adequate IgG supplementation (IgG > 1000 mg/dL)
and refractory ES. Laboratory testing showed severe lymphopenia (CD3+ T cells 128
cells/mcL; CD4+ T cells 62 cells/mcL; CD8+ T cells 65 cells/mcL; CD19+ B cells 0 cells/mcL;
CD16/56+ NK cells 39 cells/mcL) as well as undetectable IgA and IgM. His DAT showed
2+ IgG, negative C3; anti-platelet antibody screening was not obtained. His peripheral
smear demonstrated easily appreciable neutrophils with the Pelger-Huet anomaly.
Genetic testing for immune disorders identified a pathogenic heterozygous variant
in NBAS c.2827G>T, p.Glu943Ter, along with a heterozygous missense variant of uncertain
significance in NBAS c.5740C>T, p.Arg1914Cys, consistent with the NBAS-associated
disease. This missense variant occurs in the c-terminal region, at the same codon
as the Yakut founder variant, NBAS c.5741G>A, p.1914His. C-terminal missense variants,
in conjunction with null variants, define a phenotype-genotype group characterized
by highly penetrant, pleiotropic, multisystem features.
Immune-mediated cytopenias, particularly in association with hypogammaglobulinemia,
liver disease, optic atrophy and/or the presence of the Pelger-Huet anomaly, should
prompt consideration for NBAS-associated disease as the underlying etiology. Additionally,
this case underscores the value of genetic testing in adult patients with unexplained
hypogammaglobulinemia as well as review of the peripheral blood smear as a diagnostic
aid.
Keywords: NBAS, hypogammaglobulinemia, Evans Syndrome, Pelger Huet Anomaly
Disclosure: Kelly Walkovich is a consultant for Sobi Pharmaceuticals. All othre authors
indicated they had no financial relationships to disclose.
(212) Improving Diagnosis of Immunodeficiency in the Premature Population
Lauren Frazer, MD, PhD1, Maureen Schnur, DNP, RN, CPN2, Rylee Kerper, MPH3, Vanessa
Young, RN. BA2, Amy O'Connell, MD, PhD4
1Clinical Fellow/Boston Children's Hospital
2Clinical Research Nurse/Boston Children's Hospital
3Clinical Research Assistant/Boston Children's Hospital
4Assistant Professor/Boston Children's Hospital/Harvard Medical School
Newborn screening for severe combined immunodeficiency (SCID) leads to earlier detection
and saves lives. Testing in premature neonates, however, is significantly complicated
by the relative T cell lymphopenia common in very premature and extremely premature
infants. Previous work by our group and others has shown the T cell receptor excision
circle (TREC) screening is not highly specific in premature infants, and current diagnostic
algorithms may be missing cases of primary immunodeficiency in premature infants.
Meanwhile, a subset of extremely premature infants has lasting T cell lymphopenia
even at term postmenstrual age, a phenomenon we are calling prematurity-related immune
dysfunction (PRID). We are interested in improving detection and management of immunodeficiency
in premature infants, both for primary immunodeficiency disorders and PRID. In the
first phase of this project, we are using T cell receptor repertoire sequencing (RepSeq)
to determine whether we can utilize RepSeq to enhance test specificity for premature
infants with low TRECs. Using discard or small volume blood samples, we can generate
diverse T cell repertoire sequencing outputs in premature infants and newborns. Patients
with SCID and some combined immunodeficiencies are known to have abnormal diversity
in the T cell repertoire, and repertoire diversity and skewing should be less affected
by lymphopenia than flow cytometry, which is the current standard reflex test for
low TRECs. We are currently testing whether RepSeq can be used as an effective second
step test to improve specificity after an abnormal TREC screen in very and extremely
premature infants. Our long-term project goal is to improve identification of SCID
and other forms of PID in premature infants.
Keywords: TREC, SCID, Prematurity, Repertoire, Diagnosis, Newborn Screening, Immunodeficiency
Disclosure: All authors indicated they had no financial relationships to disclose.
(213) Deciphering The Genetic Diagnosis Of 325 Patients with Primary Antibody Deficiency
By Targeted Next Generation Sequencing At The CCI In Freiburg.
Jessica Rojas-Restrepo, MSc1, Andrés Caballero-García de Oteyza, Phd2, Katrin Hübscher3,
Hanna Haberstroh, MSc3, Michele Proietti, Dr. med.4, Bodo Grimbacher, Prof. Dr. med.5
1PhD student/Center for Chronic Immunodeficiency, Medical Center, University of Freiburg,
Germany
2Postdoctoral scientist/Center for Chronic Immunodeficiency, Medical Center, University
of Freiburg, Germany
3Research assistant/Center for Chronic Immunodeficiency, Medical Center, University
of Freiburg, Germany
4Head of the laboratory/Department of Rheumatology and Immunology, Hannover Medical
University, Hannover, Germany
5Head of the laboratory/Center for Chronic Immunodeficiency, Medical Center, University
of Freiburg, Germany
Primary antibody deficiencies (PAD) are chronic disorders with an often markedly reduced
quality of life and, if left untreated, also reduced life expectancy. A timely diagnosis
has been shown to be associated with a significantly improved prognosis.
Here, we report on our experiences with targeted panel sequencing employing Agilent’s
HaloPlex or SureSelect and Illumina’s MiSeq technologies in a group of 325 patients
with common variable immunodeficiency, hypogammaglobulinemia and agammaglobulinaemia.
In total, we have detected over 50 relevant mutations in ADA, BTK, CECR1, CTLA4, CXCR,
IL2RG, LRBA, NFKB1, NFKB2, STAT3, TNFRSF13B. Overall, a genetic diagnosis could be
made in up to 21.8% leading to a definite or possible molecular diagnosis in 71 out
of the 325 evaluated patients. Based on the type of variant we could identified 89
missense, 11 nonsense, 5 splice-site, 11 insertion or deletion and 3 frameshift. The
most frequent mode of inheritance in our cohort was autosomal dominant (in 5 genes
due to a loss of function or gain of function mutations), followed by autosomal recessive
(in 4 genes) and in 2 genes were found X-linked mutations. Moreover, functional testing
was performed in patients who had candidate variants for instance in CTLA4 and LRBA.
This large genetic cohort analysis highlights once again that the primary antibody
deficiencies have a diverse genetic background and genotype-phenotype correlation
is often poor, although certain clinical features may hint towards a specific group
of defects.
Employing targeted sequencing panels proves to be a very time-and cost-efficient,
yet reliable, method for the establishment of a genetic diagnosis of PAD. In case
of negative screening results by panel sequencing, further work-up including whole
exome sequencing should be considered for patients with complex disease, a positive
family history, or an early onset of disease.
Keywords: PAD, NGS, Targeted gene panel, Genetics, Sequencing
Disclosure: Bodo Grimbacher received a research grant from Baxalta. All other authors
indicated they had no financial relationships to disclose.
(214) Epigenetic Immune Cell Quantification For Diagnosis and Monitoring of Patients
with Inborn Errors of Immunity, Primary Immune Deficiencies, and Immune Regulatory
Disorders
Neftali Ramirez, MSc1, Steffi Walter, Diploma2, Jeannette Werner, Phd3, Christoph
Sachsenmaier, Phd4, Bodo Grimbacher, MD, Phd5, Ulrich Salzer, MD5, Janika Schulze,
Phd6
1PhD student/University Clinic Freiburg, CCI
2Clinical Research Scientist/Epiume GmbH
3Scientist/Epiume GmbH
4Vice President Business Development/Epiume GmbH
5Research group leader/University Clinic Freiburg, CCI
6Senior Scientist/Epiume GmbH
Quantitative immune cell enumeration is important in all inborn errors of immunity,
and all primary and secondary immune deficiencies. Within this study, the application
of a new in vitro diagnostic test for the epigenetic quantification of CD3+, CD4+,
and CD8+ T cells, B cells and NK cells from as little as 40 μl of fresh or frozen
whole blood as well as dried blood spots is described. The method has been shown to
yield identical results when compared to flow cytometry from fresh blood samples of
a healthy donor cohort, with the advantage of being more sensitive with minimal sample
requirements.
Using this in vitro diagnostic test, 247 whole blood samples of different patients
with Primary Immune Deficiencies (PID) or Inborn Errors of Immunity (IEI) were analyzed
and compared to flow cytometric data obtained in an independent diagnostic laboratory.
Spearman correlation of > 0.9 was observed for all immune cell types analyzed except
for NK cells. With regard to NK cells, the epigenetic analysis shows an overestimation
of the cell percentages, but the correlation of 0.73 was still robust.
To demonstrate the utility of the epigenetic quantification method, we extended the
immune cell panel to regulatory T cells (Treg), Th17 cells, Tfh cells, PD-1+ cells,
memory B cells, monocytes and granulocytes. Data of these additional markers will
be presented at the meeting.
This study underscores the suitability of epigenetic immune cell quantification for
the accurate measure of multiple immune cell types from PID and IEI patients. We propose
this method as uniquely suitable for novel molecular diagnostic applications in settings
with limited fresh blood sample or limited cell number, at the point of care, as well
as for newborn screening.
Figure 1: Comparison of epigenetic analysis and flow cytometric analysis in lymphocytes,
CD3+, CD4+, and CD8+ T cells, B cells and NK cells from 247 patients with Primary
Immune Deficiencies (PID) or Inborn Errors of Immunity (IEI). Spearman correlation
for each cell type is indicated in the corresponding plot.
Keywords: epigenetics, diagnostic, lymphocyte subsets
Disclosure: Steffi Walter, Jeanette Werner, Christoph Sachsenmaier and Janika Schulze
are all employed by Epimune GmbH. Bodo Grimbacher received a research grant from BMBF,
Bristol Myers Squibb GmbH & Co. KgaA, CSL Behring, DFG, Merck KGaA, Novartis Pharma
AG, Takeda Pharma Veeertrieb GmbH & Co. KG and is a consulstant at Atheneium Partners
GmbH, Epimune GmbH, GigaGen Inc., Janssen-Cilag GmbH, Octapharma, UCB Pharma S.A.
All other authors indicated they had no financial relationships to disclose.
(215) High-throughput CRISPR knock-in functional screening in primary human T cells
to predict functionally pathologic mutations in the IL2RG gene
David Nguyen, MD PhD1, Peixin A. Chen, BS2, Charlotte Hui Wang, n/a3, Eric Shifrut,
PhD4, Jennifer Puck, MD5, Alexander Marson, MD PhD6
1Assistant Adjunct Professor/UCSF
2Staff Research Associate/UCSF
3Undergraduate/Emory
4Postdoc/UCSF
5Attending Physician/Pediatric Allergy, Immunology, and Blood and Marrow Transplant
Division, University of California San Francisco Benioff Children’s Hospital
6Associate Professor/UCSF, Gladstone Institutes
X-linked severe combined immunodeficiency (X-SCID) is a rare inborn error of immunity
caused by loss of function (LOF) mutations in the IL2RG gene, encoding the cytokine
receptor common gamma chain, □c. Newborn screening (NBS) for T cell excision circles
(TRECs) in California identified 50 patients with SCID between 2010 and 2017 [Amatuni
et al Pediatrics 2019]. IL2RG was most frequently mutated, affecting 14 patients,
5 of whom had mutations in Exon 5. NBS also missed one individual with a hypomorphic
mutation in IL2RG exon 5 (Arg222Cys) who developed pneumonia at age 7 months. Hypomorphic
mutations in IL2RG cause diminished, but not absent STAT5 phosphorylation and a “leaky”
phenotype with susceptibility to infection, low but not absent T cells, and delayed
clinical presentation.
While over 200 unique mutations have been observed in X-SCID across the IL2RG gene,
additional characterization is required to understand the functional consequences
of all possible variants; and patients with new variants continue to be found [Lebet
et al, Genet in Med 2008]. We utilized high efficiency CRISPR knock-in editing to
create every potential single nucleotide variant (SNV) across the 163 bases of Exon
5 in primary human T cells from healthy males. In a pooled screening format, we then
assessed the impact of each SNV on cell proliferation, survival, and □c surface expression
over 14 days of cell culture in vitro. Sequencing of cDNA from cells fluorescently-sorted
for □c expression revealed preferential dropout of nonsense mutations (eg Ser201*)
and other mutations (eg Arg226His/Cys) previously associated with X-SCID. We identified
additional missense mutations (eg c.720G>A; Trp240*) with deleterious effects annotated
with presumed LOF in the ClinVar database but never previously described in patients.
We also noted a characteristic intolerance of missense mutations in the WSEWX motif
(aa237-241) predicted to be critical for protein folding.. Further, certain variants
had minimal effect, including p.Glu239Gln not listed in databases. More expansive
functional annotation of IL2RG (and other genes associated with immunodeficiencies)
could be leveraged to permit confident rapid interpretation of previously undescribed
mutations. Further, these studies lay a foundation to overwrite pathogenic mutations
with healthy code for corrective gene therapy.
Keywords: CRISPR, Human, IL2RG, High throughput screen, SCID
Disclosure: All authors indicated they had no financial relationships to disclose.
(216) Genetic analysis of a cohort of 275 patients with a hyper-IgE phenotype
Natalie Frede, MD1, Jessica Rojas-Restrepo, MSc2, Andrés Caballero-García de Oteyza,
Phd3, Mary Buchta4, Katrin Hübscher4, Michele Proietti, Dr. med.5, Shiva Saghafi,
MD6, Zahra Chavoshzadeh, MD7, Nermeen Galal, MD8, Zineb Jouhadi, MD, PhD9, Bodo Grimbacher,
Prof. Dr. med.10
1Resident Doctor/University Medical Center Freiburg, Dept of Rheumatology & Clinical
Immunology
2PhD student/Center for Chronic Immunodeficiency, Medical Center, University of Freiburg,
Germany
3Postdoctoral scientist/Center for Chronic Immunodeficiency, Medical Center, University
of Freiburg, Germany
4Technician/Center for Chronic Immunodeficiency, Medical Center, University of Freiburg,
Freiburg
5Head of the laboratory/Department of Rheumatology and Immunology, Hannover Medical
University, Hannover, Germany
6Medical Doctor/Immunology Asthma and Allergy Research Institute Tehran, University
of Medical Sciences Tehran, Iran
7Medical Doctor, Professor/Immunology and Allergy Department, Mofid Children's Hospital,
Shahid Beheshti University of Medical Sciences, Tehran, Iran
8Medical Doctor/Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo,
Egypt
9Medical Doctor/Department of pediatric infectious diseases, Children’s hospital CHU
Ibn Rochd, University Hassan 2, Casablanca, Morocco
10Head of the laboratory/Center for Chronic Immunodeficiency, Medical Center, University
of Freiburg, Germany
Hyper IgE syndromes (HIES) and chronic mucocutaneous candidiasis (CMC) constitute
rare primary immunodeficiency syndromes with an overlapping clinical phenotype. During
recent years a growing number of underlying genetic defects have been identified.
To characterize the underlying genetic defects in a large international cohort of
275 patients, of whom 211 had been clinically diagnosed with hyper IgE syndrome and
64 with chronic mucocutaneous candidiasis, targeted panel sequencing was performed
relying on Agilent HaloPlex and Illumina MiSeq technologies.
This approach allowed us to identify 86 mutations in 77 patients, which translates
into a diagnostic hit rate of 28%. Specifically, mutations in DOCK8 (25 patients),
STAT3 (22), STAT1 (15), CARD9 (6), AIRE (3), IL17RA (2), SPINK5 (3), ZNF341 (2), CARMIL2/RLTPR
(1), IL12RB1 (1) and WAS (1) have been detected. Genetic data were correlated with
clinical presentations. The most common clinical findings were elevated IgE (81.5%),
eczema (71.7%) and eosinophilia (62.9%). Regarding infections, 54.7% of patients had
a history of radiologically-proven pneumonia, while 28.3 % reportedly had other serious
infection(s). 53% of patients had a history of fungal infection or chronic mucocutaneous
candidiasis and 52.9% had at least one skin abscess. 46.2% of patients had skeletal
or dental abnormalities with a characteristic face being the most commonly reported
item (23.1%), followed by retained primary teeth reported in 18.9% of patients. The
NIH HIES score was available for 122 patients with a clinical hyper IgE phenotype
and averaged at 34.0 points, in contrast to on average 9.75 points in CMC patients.
Individual clinical features proved to be largely unspecific and not predictive of
detection of an underlying monogenic defect in general, likely due to clinical heterogeneity
of hyper IgE phenotypes and associated genetic defects.
Targeted panel sequencing provides a cost-effective first-line genetic screening method.
This approach has allowed us to identify mutations in patients with atypical clinical
presentations, highlighting the importance of a genetic diagnosis, which has important
implications for counseling the patient regarding treatment, prognosis and family
planning.
Keywords: hyper IgE syndrome, chronic mucocutaneous candidiasis, targeted panel sequencing,
genetics
Disclosure: Bodo Grimbacher received a research grant from Baxalta. All other authors
indicated they had no financial relationships to disclose.
(217) Variant X-Linked Chronic Granulomatous Disease Associated with A409E Mutation
in CYBB
S Deane, MD1, John Belko, MD2, Chioma Enweasor, MD3, Harry Hill, MD4
1Senior Physician; Assistant Clinical Professor of Medicine/The Permanente Medical
Group; University of California, Davis, School of Medicine
2Senior Physician/The Permanente Medical Group
3Clinical Fellow/University of California, Davis, School of Medicine
4Professor of Pathology, Pediatrics and Medicine; Medical Director, ARUP Laboratories/University
of Utah, School of Medicine
Variant X-linked chronic granulomatous disease (XLCGD) can present with atypical patterns
on dihydrorhodamine (DHR) testing (PMID: 19483518). We present an adolescent male
with serial DHR assays initially reported as normal, who was subsequently reclassified
after a high index of suspicion led to further genetic testing and reanalysis of the
DHR data. The case highlights the potential for variable expressivity of disease in
patients with A409E missense mutations in CYBB and the potential for variant patterns
that may be seen on DHR assays.
The patient is a 16-year-old male who developed his first serious infection, a lobar
pneumonia and empyema requiring decortication, at approximately 34 months of age;
cultures were unrevealing. He had episodic otitis media and respiratory infections
starting at 6 months of age, and lymphadenitis at 15 months of age. Pneumonia requiring
hospitalization reoccurred at age 4. At age 11, he developed recurrent lymphadenitis,
rib, spine, and lung lesions, with both caseating and noncaseating granulomas found.
Necrotizing granulomatous lung inflammation recurred at age 14, with granulomatous
dermatitis and nodulocystic acne by age 16. Excepting hospitalizations for his two
early pneumonias, he had largely done well with outpatient treatment. Multiple DHR
assays were all initially reported as normal. However, CYBB sequencing revealed a
A409E missense mutation. Subsequent review of his most recent DHR assay demonstrated
abnormalities in the flow cytometry data, with a borderline stimulation index of 36,
a population of cells that failed to demonstrate respiratory burst signal and a broad,
irregular histogram peak in the population of cells that did, consistent with variant
XLCGD.
DHR assays are commonly used to diagnose or exclude CGD in patients with compatible
presentations. An A409E mutation causing CGD has been described previously (PMID:
27666509), with DHR findings and a clinical course typical of XLCGD. Our patient has
had milder manifestations both clinically and in respiratory burst activity, resulting
in serial DHR assays being initially reported as “normal.” This case highlights the
importance of patient specific analysis of raw DHR flow cytometry data to identify
variant XLCGD and the potential for variable expressivity of A409E mutations in CYBB.
Figure 1: Control Unstimulated DHR
Figure 2: Control Stimulated DHR
Figure 3: Patient Stimulated DHR
Keywords: Chronic Granulomatous Disease, CGD, CYBB, Variant CGD, DHR, Dihydrorhodamine,
Necrotizing Lymphadenitis, Primary Immune Deficiency, Granulomatous Disease, A409E
Disclosure: Sean Deane is employed but Sutter Medical Group and The Permanente Medical
Group. Harry Hill received speaker honoraria from Horizon Pharm. All other authors
indicated they had no financial relationships to disclose.
(218) Nodular regenerative hyperplasia in X-linked agammaglobulinemia: an underestimated
and severe complication
Cristiane Nunes dos Santos, MD1, Christopher Koh, MD, MHSc2, Anjali Rai, MD3, Keith
Sacco, MD4, Betty Marciano, MD5, David Kleiner, MD, PhD6, Michael Stack, BS7, Jenna
Bergerson, MD, MPH8, Gregory Constantine, MD9, Warren Strober, MD10, Gulbu Uzel, MD11,
Ivan Fuss, MD12, Luigi Notarangelo, MD13, Steven Holland, MD14, Sergio Rosenzweig,
MD, PhD15, Theo Heller, MD16
1Postdoctoral Visiting Fellow/Immunology Service, Department of Laboratory Medicine,
National Institutes of Health (NIH) Clinical Center, Bethesda, MD, USA
2Director, Gastroenterology Fellowship Program, Digestive Diseases Branch; Staff Clinician/Liver
Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, NIH,
Bethesda, MD, USA
3Pediatric Gastroenterology Fellow/John's Hopkins Children's Center
4Clinical Fellow/Lab of Clinical Immunology and Microbiology, Immune Deficiency Genetics
Section, NIAID, NIH, Bethesda, MD, USA
5Staff Scientist/National Institutes of Health
6Senior Research Physician/Laboratory of Pathology, National Cancer Institute, NIH,
Bethesda, MD, USA
7Postbaccalaureate Fellow/Laboratory of Clinical Immunology and Microbiology, National
Institute for Allergy and Infectious Diseases, NIH, Maryland, USA
8Staff Clinician/LCIM, NIAID, NIH
9Assistant Research Physician/National Institutes of Health
10Senior Investigator/Mucosal Immunity Section, Laboratory of Host Defenses, National
Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA.
11Physician scientist/Laboratory of Clinical Immunology and Microbiology, National
Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda,
Maryland, USA
12Staff Clinician/Mucosal Immunity Section, Laboratory of Host Defenses, National
Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
13Chief/Laboratory of Clinical Immunology and Microbiology, National Institute of
Allergy and Infectious Diseases, National Institutes of Health
14Scientific Director – Division of Intramural Research/Laboratory of Clinical Immunology
and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda,
MD, USA
15Senior Investigator/Immunology Service, Department of Laboratory Medicine, NIH Clinical
Center, Bethesda, MD, USA
16Senior Investigator/Translational Hepatology Section, Liver Diseases Branch, National
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH, Bethesda, MD
20892, USA
Late-onset complications in X-linked agammaglobulinemia (XLA) are increasingly recognized.
Nodular regenerative hyperplasia (NRH) has been reported in primary immunodeficiency
but data in XLA are very limited. Objective: To assess and characterize NRH in patients
with XLA. Methods: We retrospectively reviewed the medical records of all XLA patients
referred to the NIH between 1994 and 2019. Liver biopsies were performed when clinically
indicated. Patients were stratified into NRH+ or NRH- groups, according to their NRH
biopsy status. Fisher’s exact test and Mann-Whitney test were used for statistical
comparisons. Results: Twenty-one XLA patient records were reviewed, with a median
age at start of follow-up (f/u) of 21y and a cumulative follow-up of 129 patient-years.
Eight patients underwent at least one liver biopsy of whom 6 (29% of NIH XLA cohort)
were NRH+. The median age at NRH diagnosis was 20y (17-31). Among patients who had
liver biopsies, alanine aminotransferase (ALT) levels were mildly elevated in all,
while alkaline phosphatase (ALP) levels were only increased in NRH+ patients (p=0.04).
Both NRH+ and NRH- groups had similar aspartate aminotransferase (AST) levels at baseline
but higher values were observed at the end of f/u in the NRH+ group (85 vs. 32 U/L,
p=0.04). Persistently low platelet count ( < 100k/μL for more than 6 months), mildly
to highly elevated hepatic venous pressure gradient (HVPG) and either hepatomegaly
and/or splenomegaly were present in all NRH+ patients. In opposition, persistently
low platelet counts were not seen in NRH- patients, and hepatosplenomegaly observed
in one NRH- patient. HVPG was normal in the only NRH- patient tested. All-cause mortality
was higher among NRH+ patients (5/6, 83%) than in the rest of the cohort (1/15, 7%
among NRH- and Unknown patients, p=0.002). Conclusion: NRH is an underreported, frequent
and severe late-onset complication in XLA, which is highly associated with increased
mortality. Persistent thrombocytopenia, elevated ALP, elevated HVPG, hepato- and/or
splenomegaly were common in liver biopsy-proven XLA/NRH+ patients and distinguished
them from XLA/NRH- patients. Based on NRH prevalence, lack of specific treatment and
poor outcome in XLA, immune-reconstitution should be considered early in this population
in order to prevent fatal long term complications.
Keywords: X-linked agammaglobulinemia, Nodular regenerative hyperplasia, mortality,
morbidity
Disclosure: All authors indicated they had no financial relationships to disclose.
(219) Hematopoietic stem cell transplantation using non-genotoxic anti-CD117 immunotoxin
conditioning corrects immune deficiencies and restores immune function in ataxia telangiectasia
mice
Athena Russell
1, Chengyu Prince2, Deepak Kumar, PhD3, Kristopher Knight4, Sruti Rayaprolu, PhD3,
Hailian Xiao2, Srikant Rangaraju, MBBS5, H. Trent Spencer, PhD6, Christopher Doering,
PhD7, Shanmuganathan Chandrakasan, MD8
1Doctoral Candidate/Emory University
2Research Technologist/Emory University
3Postdoctoral Fellow/Emory University
4Graduate Student/Emory University
5Associate Professor/Emory University
6Director of Gene and Cell Therapy/Children's Healthcare of Atlanta
7Professor/Emory University
8Pediatric Hematologist/Oncologist/Children's Healthcare of Atlanta
Ataxia telangiectasia (AT) is a chromosomal instability syndrome caused by mutation
in ATM kinase, a protein critical for DNA double strand break repair and cell cycle
control. AT is characterized by cerebellar neurodegeneration, immune dysfunction and
predisposition to malignancy. Like several other immune deficiency disorders with
DNA repair defect, AT patients could benefit from HSCT and immune reconstitution with
ATM-competent cells. Additionally, we hypothesized that correction of underlying immune
defects could delay inflammation-enhanced neurodegeneration. However, increased sensitivity
to DNA damaging agents and progressive cerebellar degeneration are major barriers
precluding HSCT for AT. Conditioning with an antibody-based, non-genotoxic immunotoxin
targeting CD117 on hematopoietic stem cells may offer a safer approach to allogeneic
HSCT in this setting. We conditioned Atm-/- mice with CD117-saporin immunotoxin, then
transplanted GFP+ Atm+/+ whole bone marrow or fetal liver cells. We analyzed multilineage
donor chimerism, body weight, leukocyte counts, immunoglobulins, cytokine levels,
and immunization responses in transplanted Atm-/- mice versus Atm+/+ and non-transplanted
Atm-/- controls. CD117-saporin conditioning enabled high-level myeloid chimerism (97.5
+/- 0.8%) within six weeks that was sustained for 26 weeks. Chimerism reached 80.1
+/- 0.9% and 93.6 +/- 1.0% in T and B cell compartments, respectively. Atm-/- mice
have a growth defect that was not corrected by HSCT. However, CD4+ and CD8+ T cells
were increased in transplanted mice compared with age-matched Atm-/- controls and,
following immunization with a T cell-dependent immunogen, mounted effective IgM and
IgG immune responses after HSCT similar to Atm+/+ mice, whereas Atm-/- controls could
not. IgA and IgG1 levels were low in Atm-/- controls but were significantly increased
after transplant. Additionally, Atm-/- controls had low levels of cytokines known
to be important for innate and adaptive immunity such as M-CSF, MIP-1a, and MIP-2,
and these returned to Atm+/+ levels after HSCT. One mouse that received HSCT after
CD117-saporin conditioning developed host-derived T cell leukemia. We are currently
exploring non-genotoxic host lymphocyte depletion to complement CD117-saporin conditioning
to prevent lymphoid malignancy caused by residual Atm-/- T cells. Additionally, the
role of donor myeloid derived microglial-like cell reconstitution in brain and its
effects on decreasing neuroinflammation and neurodegeneration are being evaluated.
Keywords: Ataxia telangiectasia, hematopoietic stem cell transplantation, non-genotoxic
conditioning, immunotoxin, immune deficiency, neurodegeneration, neuroinflammation
Disclosure: H. Trent Spencer and Christopher Doering have ownership interest in Expression
Therapeutics. All other authors indicated they had no financial relationships to disclose.
(3) Late-Breaking Oral Abstracts
(220) A germline AIOLOS variant is associated with abnormal T and B differentiation,
pneumocystis pneumonia and increased risk for chronic lymphocytic leukemia
Hye Sun Kuehn, PhD1, Motoi Yamashita, MD, PhD2, Julie E. Niemela, MS3, Jennifer L.
Stoddard, BS4, Ryan Baxter, MSc5, Elena Hsieh, MD6, Mary Garofalo, RN, BSN7, Thomas
A. Fleisher, MD, PhD8, Tomohiro Morio, MD, PhD9, Cullen M. Dutmer, MD10, Sergio Rosenzweig,
MD, PhD11
1Senior Associate Scientist, Immunology Service, Department of Laboratory Medicine,
NIH Clinical Center, Bethesda, MD, USA
2Scientist, Department of Pediatrics and Developmental Biology, Graduate School of
Medical and Dental Sciences, Tokyo Medical and Dental University
3Research Biologist, Immunology Service, Department of Laboratory Medicine, Clinical
Center, NIH
4Molecular Biologist, Immunology Service, Department of Laboratory Medicine, Clinical
Center, NIH
5Senior Professional Research Assistant, University of Colorado Anschutz Medical Center
6Assistant Professor, Department of Pediatrics, Section of Allergy and Immunology,
University of Colorado, Anschutz School of Medicine; Children’s Hospital Colorado;
Department of Immunology and Microbiology, University of Colorado, Anschutz School
of Medicine, Aurora, CO
7Research Nurse, National Institutes of Health National Institute of Allergy and Infectious
Diseases
8Executive Vice President, American Academy of Allergy, Asthma and Immunology
9Vice President / Deputy Director, Department of Pediatrics and Developmental Biology,
Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
10Assistant Professor of Pediatrics, Section of Allergy & Immunology, Children's Hospital
Colorado, University of Colorado School of Medicine, Aurora, CO, USA
11Senior Investigator, Immunology Service, Department of Laboratory Medicine, NIH
Clinical Center, Bethesda, MD, USA
AIOLOS, encoded by IKZF3, is a member of the IKAROS family of proteins. Both Aiolos
and Ikaros have been shown to be important regulators of lymphocyte development and
differentiation. In Aiolos deficient mice, abnormal B cell differentiation and functions
were observed including increased number of B cell precursors, breakdown in B cell
tolerance, spontaneous autoantibody production, and the development of B cell lymphomas,
suggesting the important role of Aiolos in murine B cell differentiation and development.
Previously, germline IKAROS (IKZF1) mutations have been associated with common variable
immunodeficiency (CVID) and combined immunodeficiency (CID). Here we describe a novel
immunodeficiency due to an IKZF3 mutation in a family presenting with CID, Pneumocystis
jirovecii pneumonia (PJP) and/or chronic lymphocytic leukemia (CLL). Individuals carrying
IKZF3 c.479A>G p.N160S heterozygous variant displayed impaired humoral immune responses
as well as abnormal B cell development with a high percentage of CD21low B cells.
In addition, T cell development was also affected, with increased naïve T cells, abnormal
T cell differentiation, and impaired CD40L upregulation following activation. Further
in-vitro studies demonstrated that the mutant protein failed to bind to its DNA target
sequence as well as to undergo pericentromeric localization. Mechanistically, the
mutant was fully penetrant and had a dominant negative effect over AIOLOS wildtype
function. Our findings demonstrate that AIOLOS plays a key role in T and B cell development
in humans and also associates abnormal AIOLOS function with CID, PJP and potential
development of CLL.
Keywords: AIOLOS, IKZF3, chronic lymphocytic leukemia, pneumocystis pneumonia, combined
immunodeficiency
Disclosures: Elena Hsieh is a consultant for Enzyvant. All other authors had no financial
relationships to disclose.
(221) Germline SAMD9L truncation variants trigger global translational repression
Eric J. Allenspach, MD, PhD1, Frank Soveg, BS2, Laura Finn, MD3, Lomon So, PhD4, Jacquelyn
Gorman, PhD4, Aaron Rosen, BS5, Suzanne Skoda-Smith, MD6, Marsha Wheeler, PhD4, Jason
Debley, MD, MPH6, Michael Bamshad, MD7, Deborah Nickerson, PhD7, Ram Savan, PhD7,
Troy Torgerson, MD, PhD8, David Rawlings, MD7
1Assistant Professor of Pediatrics, University of Washington
2Graduate Student, University of Washington
3Professor, University of Pennsylvania
4Post-Doctoral Fellow, University of Washington
5Research Scientist, Seattle Children's Research Institute
6Associate Professor, University of Washington
7Professor, University of Washington
8Attending Physician, Experimental Immunology, Allen Institute for Immunology
SAMD9L is an interferon-induced tumor suppressor implicated in a spectrum of multi-system
disorders including risk for myeloid malignancies and immune deficiency. We identified
a heterozygous de novo frameshift variant in SAMD9L in an infant with B cell aplasia
and clinical autoinflammatory features who died from respiratory failure with chronic
rhinovirus infection. Autopsy demonstrated absent bone marrow and peripheral B cells
as well as selective loss of Langerhans and Purkinje cells. The frameshift variant
led to expression of a truncated protein with interferon treatment. This protein exhibited
a gain-of-function phenotype resulting in interference in global protein synthesis
via inhibition of translational elongation. Using a mutational scan, we identified
a region within SAMD9L where stop-gain variants trigger a similar translational arrest.
SAMD9L variants that globally suppress translation had no effect or increased mRNA
transcription. The complex reported phenotype likely reflects lineage dominant sensitivities
to this translation block. Taken together, our findings indicate that interferon-
triggered SAMD9L gain-of-function variants globally suppress translation.
Keywords: SAMD9L, Translation, Autoinflammatory, B cell Aplasia
Disclosures: Jason Debley received a research grant from the NIH. Troy Torgerson is
a consultant for CSL Behring and Grifols; received speaker honoraria from Takeda and
X4 Pharmaceuticals; and is an advisory board member of Enzyvant. All other authors
had no financial relationships to disclose.
(222) New machine learning approaches to estimate the functional consequence of mutations
in diverse human populations
Yuval Itan, PhD1, Yiming Wu, PhD2, Cigdem Sevim Bayrak, PhD2
1Assistant Professor, Icahn School of Medicine at Mount Sinai
2Postdoctoral Researcher, Icahn School of Medicine at Mount Sinai
The genome of a patient with a genetic disease contains about 20,000 non-synonymous
variations, of which only one (or a few) is disease-causing. Current computational
methods cannot predict the functional consequence of a mutation: whether it results
in gain-of-function (GOF) or loss-of-function (LOF). Moreover, computational predictions
of mutation pathogenicity are still lacking specificity when analyzing diverse human
genetic data. Here we present two novel approaches to address these shortcomings:
(1) a machine learning study to computationally differentiate GOF from LOF mutations,
using natural language processing (NLP) and feature selection to generate the first
large-scale human inherited GOF and LOF mutation database; and (2) a deep learning
neural network approach to classify mutations by the human phenotype ontology (HPO)
disease group. We demonstrate the utility of our combining our state-of-the-art with
gold standard methods in case-control studies across different diseases including
susceptibility to severe COVID-19 and inflammatory bowel disease (IBD), where we discovered
novel genetic etiologies.
Keywords: Mutation and gene predictions, Next generation sequencing, Computational
methods, Disease genomics, Machine learning, Case-control associations, Phenome-wide
associations, Polygenic risk score
Disclosure: All authors indicated they had no financial relationships to disclose.