Immunodeficiency Immunodeficiency diseases diseases Xinhua Hospital Xinhua Hospital Shanghai Institute for Pediatric Shanghai Institute for Pediatric Research Research Tong-Xin Chen Tong-Xin Chen Paediatrics teaching ppt
Jan 11, 2016
Immunodeficiency Immunodeficiency diseasesdiseases
Xinhua HospitalXinhua Hospital Shanghai Institute for Pediatric ResearShanghai Institute for Pediatric Resear
chchTong-Xin ChenTong-Xin Chen
Paediatrics teaching ppt
Development of Immune System Up to normal adults level
From mother mainly
Achieve to 60% of adults level when 1 year old , an
d 100% of adults level when 6 years old
IgG could be subdivided into IgG1 、 IgG2 、 IgG3
and IgG4
Age dependent changes of serum IgG level synthesiz
ed by themselves : IgG1(5y) ; IgG3(10y) ; IgG2
and IgG4(14y)
Development of IgG in Newborn Infant
Cord blood IgG level ≥ IgG from mother(>10% of IgG f
rom mother )
IgG from mother are catabolized gradually after born
IgG from mother disappeared completely when 6 mont
hs , serum IgG levels of 3~6 months infant are lowest ,
especially IgG2 and IgG4
IgM from mother can not pass placenta, ser
um IgM of fetuses synthesis when born <20
0-300mg/L
Normal neonatal IgM increase rapidly afte
r born 4-7 days,is likely to be associated wit
h the response of IgM to intestinal
bacteria
If increasing , implicating neonates are sti
mulated by “nonself” antigen in uterus
Development of IgM in Newborn Infant
Development of IgA in Newborn Infant
Can not pass placenta, serum IgA level achieve to 20% of
adults level when 1 year old , and 100% of adults level
when 12 years old
Cord blood IgA level ≤50mg/L , increasing of IgA implic
ates the possibility of infections in uterus
IgA is detectable in tears and saliva of 2-3 weeks neonate
The biological function of IgA is defend against some loca
l mucous infections
Cellular Immunity of Newborn Infant
Number of T lymphocytes are usually normal
CD4+T cells are relatively higher , CD4/CD8 up t
o 3~4 , consequently, are susceptible to infections
Function of Th2 cells are relatively stronger,are sus
ceptible to allergic diseases
CD45RA+T cells are more , CD45RO+T cells are
less
Deficiency of Cytokine : IFN-γ 、 IL-4 , and so
on
Immunodeficiency diseasesImmunodeficiency diseases ,, IDID A group of disorders characterized A group of disorders characterized
by an impaired ability to produce nby an impaired ability to produce normal immune response. Most of thormal immune response. Most of these disorders are cased by mutationese disorders are cased by mutations in genes involved in the developms in genes involved in the development and function of immune organs,ent and function of immune organs, cells, and molecules. cells, and molecules.
• Primary and acquired
Antibody or B cells deficiency ( 50% )
Combined immunodeficiency ( 20% )
Phagocytic dysfunction ( 18% )
Cellular or T cell deficiency ( 10% )
Complement deficiency ( 2% )
Immunodeficiency with other important charac
teristics
Immunodeficiency with or acquired other cong
enital or hereditary diseases
Classification of Primary Immunodeficiency Diseases(7 main Categories)
The incidence of PID Calculated by alive infants : 1/10000
( Japan 1981 and Australia 1983 ) Hongkong report : 1/8000 There is no statistics report in mainland s
o far According to the incidence of 1/10000 , 2
500/25000000 nerborn infants every year i
n our country , cases add up to 3~8 ten t
housands at least More than 100 cases in our hospital since
1970
Clinical featuresClinical features
Recurrent infectionRecurrent infection
High risk of autoimmune High risk of autoimmune
diseasesdiseases
High risk of malignancyHigh risk of malignancy
Severe infection 、 Refractory infection 、 Recurrent infection 、 Opportunistic pathogens infection 、 Recurrent diarrhea 、
InfectioInfectionn
Autoimmunity diseases
Immunodeficiency Immunodeficiency associated with autoimmuneassociated with autoimmune
X-Linked AgammaglobulinemiaX-Linked AgammaglobulinemiaSelective IgA DeficiencySelective IgA DeficiencyCVIDCVIDThymic hypoplasiaThymic hypoplasiaImmunodeficiency with hyperIgMImmunodeficiency with hyperIgMChronic granulomatosisChronic granulomatosisComplement deficiencyComplement deficiencyWiskott-Aldrich SyndromeWiskott-Aldrich Syndrome
Autoimmune disease suspiAutoimmune disease suspiciouscious
ArthritisSLE , JRAThrombocytopenia ITPNeutropenia Crohn’s deseaseSLEHemolytic anemia
Children with Children with immunodeficiency immunodeficiency have higher risk of have higher risk of autoimmune than autoimmune than normal(0.01%~14%)normal(0.01%~14%)
TumorChildren with immunodeficiChildren with immunodeficiency have higher risk of cancency have higher risk of cancer than normal(100~300 fold)er than normal(100~300 fold)
Tympanitis more than 8 times per yearSevere nose sinusitis more than 2 times per yearPneumonia more than 2 times per yearDeep infection in abnormal position more than 2 ti
mes Recurrent infection in deep skin or visceraInfection eliminated with antibiotics by intravenou
s injectionRare or opportunistic pathogens infection Family PID history
Primary immunodeficiency suspicious
History
Growth development deficiency
Lymph nodes or tonsil deficiency
Skin changes:capillary vessel expand, petechia
Skin mildew, lupus erythematosus-like tetter
Ataxia(A-T)
Thrush after 1 year old
Oral ulear
Clinical features
Laboratory analysis :
Serum IgG , IgM , IgA ( B cell function ) CD3 , CD4 , CD8 ( T cell subsets ) CD19 ( number of B cell ) CD56/16 ( NK cell ) White blood cell count or nitroblue tetrazolium
( NBT ) test
Complement
IgG subclasses ( 1~4 )
Thymus : X -ray
Cytokine : IL-2 , IL2R , IFN , IFNR
Cell surface molecular : CD18
Gene analysis : BTK , CD40L , WASP
Combined immunodeficiency ( 14 )Antibody or B cells deficiency ( 10 )Cellular or T cell deficiency ( 9 )Immunodeficiency with other important characteristics ( 3 )Phagocytic dysfunction ( 12 )Complement deficiency ( 16 )Immunodeficiency with or acquired other congenital or hereditary diseases
( 41 )
Common primary immunodeficiency diseases
X-linked agammaglobulinaemia
Selective IgA deficiencySelective IgA deficiency Thymic hypoplasiaThymic hypoplasia Combined immunodeficiencyCombined immunodeficiency
X-linked agammaglobulinaemia ( XLA ) Also named as Bruton disease ( described in 1952 ) Discovered that the disease was associated with mutati
on of the gene coding pre B-cell cytoplasmic tyrosine k
inase ( btk ) in1993
Mutation lead to block in signal transduction of B cell
development , block in maturation after the pre-B ce
ll stage ,lead to decreaseing of mature B cell
The patterns of mutations are diverse , more than 11
8 cases are reported so far
Male
Onset during 4~6 months of age
Recurrent Pyogenic bacterial infection
Respiratorty tract infections are typical ,
as well as systemic infections
Clinical features
Can hardly produce antibody , all kinds of Ig are m
arkedly reduced
IgG < 2g/L ( <200mg/dl )
IgA <0.02g/L ( <2mg/dl )
IgM <0.1g/L ( <10mg/dl )
Circulating B cells are markedly decreased , usuall
y less than 0.5% of total lymphocytes
Numbers and function of T lymphocytes are normal
Btk gene located on Xq21.3-22 is deficiency
Immunological characteristics :
Alteration of T cell subsets
Alteration of B cell and NK cell
62145-62155
62155-62145
Exon10R
Exon10F
Mutation of Btk gene
cDNA mutation:
989_999delTGA
CTCGGAGTins
GGTGGTATTC
CAAA
Codon change:
MTRS286_289R
WYSK
Mother status:
carrier
Differential diagnosis :
Characteristics
Age
IgM
IgG
IgAMolecular deficiency
B cell
IgG replacement?
XLA
congenital (> 6m )reduced
absent/ reduced
absent/ reduced
BTK
absent/ reduced
yes
infantile transient
hypogammaglobulinemia
1~2y
normal
reduced
normal
unclear
presence
no
A heterogeneous group of diseases characteri
zed by antibody defects
Late-appearing immunodeficiency
Immunological characteristics of CVID
Common Variable Immunodeficiency ( CVID )
• Antibody deficiency IgG <2.5g/L ( <250mg/dl )
IgA usually is reduced
IgM usually is reduced
• Circulating B cells usually are normal or decreased
• Cellular immunity : normal or help function deficiency
Recurrent infection Recurrent infection ( ( bacterial infectionbacterial infection )) with onset at any age, with onset at any age,
affects both males and femalesaffects both males and females
High risk of gastrointestinal infectionsHigh risk of gastrointestinal infections ,, usually chronic giardiasiusually chronic giardiasi
s s
Lymphoma and gastric carcinoma occur with increased frequencyLymphoma and gastric carcinoma occur with increased frequency
Increased incidence of autoimmune disease(hemolytic anemia Increased incidence of autoimmune disease(hemolytic anemia 、、
pernicious anemiapernicious anemia 、 、 thrombocytopenia,et al)thrombocytopenia,et al)
lymphoproliferationlymphoproliferation ,, splenomegaliasplenomegalia ,, lymphoid hyperplasialymphoid hyperplasia
Clinical manifestations :
X-linked agammaglobulinaemia
Selective IgA deficiencySelective IgA deficiency Thymic hypoplasiaThymic hypoplasia Combined immunodeficiencyCombined immunodeficiency
Incidence : Caucasian1/500~1500 , Japanese1/18500 , C
hinese1/5000~10000
Associated with maladjustment of Th2 cell to B cell produce
IgA
Both males and females, often coincide in same family
Mild form is asymptomatic
Recurrent infections in infancy ( respiratory 、 intestinal a
nd urinary infections ) Be associated with autoimmune diseases 、 asthma and intes
tinal malabsorption
Serum IgA less than 0.05g/L , IgM 、 IgG nor
mal or increased
sIgA markedly reduced
Serum IgA could increase to normal level in so
me cases
Should not be treated with IVIG , since capab
le of forming anti-IgA antibodys subsequent al
lergy
X-linked agammaglobulinaemia
Selective IgA deficiencySelective IgA deficiency Thymic hypoplasiaThymic hypoplasia Combined immunodeficiencyCombined immunodeficiency
Thymic hypoplasia also is called DiGeor
ge syndrome ( 1964 年)
It is known now that 80%~90% Digeorg
e syndrome have minor deletion of gen
e located at 22q11
Minor deletion of gene located at 22q11
included a group of disease , now calle
d CATCH22 syndrome
CATCH 22
Cardiac defects
Abnormal facies
Thymus hypoplasia
Cleft palate
Hypocalcemia
Thymus hypoplasia
Parathyroid hypoplasia
Ⅲ-Ⅳpharyngeal arch hypoplasia
Ⅰ-Ⅱpharyngeal arch hypoplasia
Clinical features :
T cell reduced
Recurrent infections ( virus infections )
Hypocalcemia
Tetany
Cardiac defects
Tetralogy of Fallot and aorta abnormal ( eg.arcus aortae break off )
Abnormal facies
Cleft palate 、short philtrum and low-set ears
Number of peripheral blood lymphocytes
reduced ( <1000 个 /mm2 )
CD3+T cell markedly reduced
Serum Ig normal or reduced , whereas I
gE increased
Serum calcium Serum calcium reduced , serum phosphserum phosph
orusorus increased , parathyroidhormone parathyroidhormone r
educed
Chest radiograph: thymus absence
Laboratory analysis :
Boy
14months
Bronchopneumonia
Congenital heart disease
Immunodeficiency
Hypocalcemia
Nearside facial paralysis
DiGeorge syndrome:
Normal Thymus
Thymus shadow of infant(<6m) is visible , usually>10g
If invisible(< 4g ) ,implicated thymus hypoplasia
DiGeorge syndrome
Thymus absence
X-linked agammaglobulinaemia
Selective IgA deficiencySelective IgA deficiency Thymic hypoplasiaThymic hypoplasia Combined immunodeficiencyCombined immunodeficiency
A group of diseases , occurs both males and females in autosom
al recessive SCID , only males in X-linked recessive SCID
Recurrent infections with fungi, bacteria, virus, mycobacterium,
protozoa
Typical features: chronic diarrhea 、 pneumonia and persistent f
ungal infections ( especially thrush )
Sometimes morbilliform rash is the only symptom of SCID in neo
natal period , may caused by GVHR
Usually succumb to overwhelming infection whithin the first year
of life
Severe combined immunodeficiency ( SCID )
T- B+NK-Ig-
Approximately 50%~60% SCID are X-linked forms ,the most common genetics alteration is mutation of rec
eptor c of IL-2 、 IL-4 、 IL-7 、 IL-9 and IL-15
Autosomal recessive SCID usually have JAK3 gene defi
ciency,JAK3 coded a tyrosine protein kinase which is a
ssociated with signal transduction initiated by c
Autosomal recessive SCID may have mutations of R
AG-1 and RAG-2 , affects antigen receptor on T 、
B cells surface
In addition , approximately 50% autosomal recess
ive SCID have adenosine deaminase ( ADA ) defi
ciency
T- B-NK+Ig-
Figure 8 photo of a patient with SCID : candida albicans in the mouth
Boy , 8months
Recurrent pneumonia 、 thrush
One of his uncle died at 6months un
known cause
T-B+NK-Ig ↓
Figure 8-2 photo of a patient with SCID : GVHD and BCG vaccination
Boy , 4.5monthsFever , pneumonia ,hepatosplenomegaly ,Have abscess after inoculating BCG vaccine 3 months , rash and diarrhea after transfusion
Alteration of T cell subsets
Alteration of B cell and NK cell
Molecular Diagnosis of X-SCID in Patient 1 Molecular Diagnosis of X-SCID in Patient 1 IL2RG gene PCR direct sequencingIL2RG gene PCR direct sequencing
IVS6-17
Deletion in patient
Normal control: Intron 6
IVS7-11
Deletion in patient
Normal control: Intron 7
487bp deletion
Patient 1: deletion between Intron 6 and intron 7
Deletion mutation from Deletion mutation from intron 6 to 7 including exon intron 6 to 7 including exon 7 and 2 primer site (IVS6-71 7 and 2 primer site (IVS6-71 to IVS7-11del487) to IVS7-11del487)
Predicted frameshift start at Predicted frameshift start at arginine 285 with stop codon arginine 285 with stop codon (TAA)created at position 342, (TAA)created at position 342, predicted premature predicted premature termination (R285fsX342)termination (R285fsX342)
Carrier diagnosis in IL2RG deletion (XSCID) – Carrier diagnosis in IL2RG deletion (XSCID) – Patient 1Patient 1
PCR-agarose gel electrophoresis PCR-agarose gel electrophoresis
Causative gene: IL2RG Causative gene: IL2RG in X-chromosomein X-chromosome
PCR amplified for each PCR amplified for each exon for sequencingexon for sequencing
No PCR product for No PCR product for amplification of exon 6, amplification of exon 6, 7 and 87 and 8
Suspected large Suspected large deletion, try other deletion, try other primer pairs primer pairs combinationcombination
Deletion mutation Deletion mutation including exon 7 and 2 including exon 7 and 2 primer site found (IVS6-primer site found (IVS6-71 to IVS7-11del487) 71 to IVS7-11del487)
Mother diagnosed as Mother diagnosed as heterozygous carrier by heterozygous carrier by PCR directlyPCR directly
Primer PairExon 6F/8R
Primer Pair Exon 5F/8R
-ve control
Patie
nt Moth
er Norm
al
-ve control
Patie
nt Moth
er Norm
al
Hyper IgM syndrome ( HIGM )
T+CD40L-B+IgM↑IgG↓
Four types , most common type is X-linked f
orm (Hyper IgM syndrome type )Ⅰ
Approximately 70% , caused by mutations o
f the CD40L gene
Diagnosis: CD40L expression on T cell reduc
ed in vitro lymphocyte cultivation
B cell
T cell
Isotype switching
CD40
CD40L TCR
MHC-Ag
cytokine
IgM
IgGIgAIgE
IL-2IFN-γ
Infections
Extracellular pathoge
ns
Introcellular pathoge
ns
T-B cell interaction
patient control
CD40L
Fig1. CD40 ligand expression induced by PMA+IM in paitent with HIGM
CD40 ligand gene mutations identified in this study
Exon5
cDNA mutation:
672-675delCTCA
Codon change:
L205fsX240
Mother status:
not carrier
11319495-11319494
11319492-11319495
Immunodeficiency SCID
X-linked or JAK3 deficiency
RAG-1 or RAG-2 deficiency
Omenn‘s syndrome
ADA deficiency
ZAP-70 deficiency
Ⅱnake lymphocyte syndrome
Combined T cell and B cell deficiency
PNP deficiency
Ataxia-telangiectasia
Wiskott-Aldrich Syndrome
Selective T cell deficiency
DiGeorge Syndrome
Total number
↓
↓
↓
-
+
+
↓
↓
↓
↓
T
-
-
↓
-
+
+
-
↓
↓
↓
CD4
-
-
↓
-
+
↓
-
↓
↓
↓
CD8
-
-
↓
-
-
+
-
+
↓
↓
B
↑
-
-
-
+
+
+
+
+
+
NK
-
+
+
-
+
+
-
+
+
+
IgG
-
-
-
-
-
↓
±
IgG2 ↓
+
+
IgM
↓
-
↓
-
+
±
±
+
↓
+
IgA
-
-
-
-
+
↓
±
↓
↑
+
IgE
-
-
↑
-
-
↓
-
↓
↑
+
Circulating lymphocyte Serum Ig
Phenotype
Laboratory features of some primary Tcell immunodeficiency
Wiskott Aldrich Syndrome Patient Photo
thrombocytopenic purpura eczema
Ataxia-telangiectasia Patient Photo
Conjunctiva telangiectasia Appearance of this patient
Treatment :General management Strengthen publicizing and nursing , prevent infections
Antibiotics
Specific treatment : thrombocyte for WAS , calcium and V
it D for thymic hypoplasia
Avoid live vaccines to patients with T cell deficiency
Avoid fresh blood productions transfusion to patients with
T cell deficiency in case of GVHR , if necessary , should
be treated by ray ( 2000~3000rad ) Screen CMV strictly in blood productions , avoiding CMV i
nfections
B cell deficiency : IVIG
T cell deficiency : Thymic hormones , stem cell
transplantation
Phagocytic dysfunction : stem cell transplantatio
n
Complement deficiency : Replacement therapy :
plasma
Gene therapy : ADA , SCID ( 11cases )
Specific treatment to immunodeficiency
Replacement therapy
IVIG replacement therapy :
80% patients have different degree IgG or other a
ntibodys deficiency
400mg/kg/m
Serum IgG should be increased more than 5g/L in
principle
Side effect:anaphylaxis 、 blood transmitted dise
ases
Enzyme replacement : ADA-PEG : 15~30u/ug 1~2/week , sub
cutaneous injection
Washing erythrocytes for PNP 、 ADA
Cytokine : IL-2 for SCID
Immune Immune
reconstitutionreconstitution Bone marrow transplantationBone marrow transplantation
Allogenetic homozygote bone marrow transplantatAllogenetic homozygote bone marrow transplantat
ion ion (( HLA completely matchingHLA completely matching ))
Allogenetic hemizygote bone marrow transplantatiAllogenetic hemizygote bone marrow transplantati
on on (( HLA half matchingHLA half matching ))
Unrelated donor bone marrow transplantationUnrelated donor bone marrow transplantation
Thymus transplantation
<16week fetal thymus transplantation
Apply to cellular immunity deficiency ,
mostly thymic hypoplasia
Stem cell transplantation ( pure stem cell C
D34+ ) Cord blood stem cell transplantation
Peripheral blood stem cell transplantation
Gene Gene therapytherapy
Mutant geneMutant gene
CloneClone identify location of mutation identify location of mutation
Gene transformationGene transformation
Target gene fragment stem cell genome of patientsTarget gene fragment stem cell genome of patients
Transgenic cell mitosisTransgenic cell mitosis ,,
gene transformation fragment replicategene transformation fragment replicate
insert
ADA
XL-SCID ( 11cases ) ZAP70
JAK3
LAD
WAS
PNP
MHC II
CGD
XLA
Effect of gene therapy :
good
good
goodgoodgood
good
bad
bad
bad
uncertainty