Transcript Advanced Tests

Primary
immunodeficiencies
Prof.Dr. Yıldız
Camcıoğlu
10 Signs and symptoms of PID
1- More than 8 infections per year
2- More than 2 sinus infections per year
3- Uneffective antibiotic treatment more than 2 months
4- More than 8 pneumonias per year
5- Growth retardation
6- Recurrent deep tissue or organ abscesses
7- Persistant mucosal or skin fungal infections after first year
of age
8- Need for IV antibiotic therapy
9- More than 2 deep tissue infections per year
10- PID in family
Spesific signs
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Telangiectasia
Ataxia
Short-limped dwarftism
Cartilage-hair hypoplasia
Idiopatic endocrinopathy
Partial albinism
Trombocytopeni
Tetany
Eczema
Assessment General
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Patient and family history
Physical examination
Laboratory assesment
Treatment
The family history
• PID in the family; familial occurrence of
similar symptoms (affected males related by
the female line, or another clear pattern of
inheritance)
• Unexplained early infant deaths, deaths due
to infection
• Consanguinity in the (grand) parents (known
or suspected)
• Autoimmune disease or haematological
malignancy in several family members
Physical examination
• Skin and appendages
• Abnormal hair or teeth. Eczema. Neonatal erythroderma. (Partial) albinism.
Pale skin. Incontinentia pigmenti. Nail dystrophy.
• Extensive warts or molluscae. Congenital alopecia. Vitiligo. Petechiae (early
onset, chronic). Cold abscesses. Telangiectasia.
• Absence of sweating
• Oral cavity Gingivostomatitis (severe). Periodontitis. Aphthae (recurrent). Giant
oral ulcers. Thrush. Dental crowding. Conical incisors.
• Enamel hypoplasia. Persistent deciduous teeth
• Eyes Retinal lesions. Telangiectasia
• Lymphoid tissue Absence of lymph nodes and tonsils. Lymphadenopathy
(excessive). Asplenia. Organomegaly (liver, spleen)
• Neurological Ataxia. Microcephaly. Macrocephaly
• Other Angioedema (without urticaria). Digital clubbing. Dysmorphism. Stunted
growth or disproportional growth
Primary Immunodeficiency Diseases
International Union of Immunological Societies
Primary Immunodeficiency Diseases Classification
I-Combined T- and B-cell immunodeficiencies
II-Predominantly antibody deficiencies
III-Other well-defined immunodeficiency syndromes
IV-Diseases of immune dysregulation
V-Congenital defects of phagocyte number,
function, or both
VI-Defects in innate immunity
VII-Autoinflammatory disorders
VIII-Complement deficiencies
I-Predominantly antibody deficiencies
• 1. Severe reduction in all serum Ig isotypes with
absent B cells
(a) Btk deficiency (b) m heavy chain
deficiency (c) l 5 deficiency (d) Igα
deficiency (e) BLNK deficiency (f) Thymoma
with immunodeficiency
• 2. Severe reduction in at least 2 serum Ig isotypes
with normal or low numbers of B cells
(a) Common variable immunodeficiency
disorders (b) ICOS deficiency (c) CD19
deficiency (d) TACI deficiency(e) BAFF receptor
deficiency
Predominantly antibody deficiencies
• 3. Severe reduction in serum IgG and IgA with
increased IgM and normal numbers of B cells
(a) AID deficiency(b) UNG deficiency
• 4. Isotype or light chain deficiencies with normal
numbers of B cells (a) Ig heavy chain
deletions (b) κ Chain deficiency (c) Isolated IgG
subclass deficiency (d) IgA with IgG subclass
deficiency (e) Selective IgA deficiency
• 5. Specific antibody deficiency with normal Ig
concentrations and numbers of B cells
• 6. Transient hypogammaglobulinemia of infancy
B-Cell defects; clinical findings
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Infections onsets after 6 months of age
Adenoids and tonsils are rudimentary
Lymph nodes are reduced in size
Chronic pulmonary diseases
Recurrent otitis media
Bronchiectasia
Encapsulated microorganisms
S.pneumoniae
H.influenzae typ b
N.meningitidis
X-linked agammaglobulinemia (XLA)
• XLA is the first primary immunodeficiency
disease reported by Bruton in1952
• Affected persons develop severe, recurrent
sinus and pulmonary infections and
septicemias with bacteria usually during
the first year of life
• Patients have a few antibody-producing B
cells
• Antibody production is defective
Common variable Immunodeficiency
• CVID is characterized by variably low levels of
immunoglobulin G (IgG), immunoglobulin M (IgM),
and IgA,
• Antibody responses after vaccination is
suboptimal
• Patients usually experience recurrent bouts of
pneumonia and infections of the joints, bones, and
skin
• These persistent infections lead to organ damage,
often resulting in disability or death from chronic
lung disease
• CVID had increased risk for lymphomas
Isolated IgA deficiency
• IgA deficieny has a wide clinical spectrum
• Certain persons are asymptomatic whereas other
have recurrent infections
• Some patients also have IgG subclass
deficiencies
• The incidence of allergy or autoimmune disease
is increased among patients with selective IgA
deficiency
• IgA-deficient persons might have severe or fatal
anaphylactic reactions to blood or blood-products
containing IgA
IgG Subclass deficiency
• IgG1 deficiency; CVID, isolated IgA
deficiency
• IgG2 deficiency; with or without IgG4
deficiency, with isolated IgA deficiency
• IgG3 deficiency; with or without IgG1
deficiency
Laboratory Tests
General approach; WBC, Lymphocyte ,
neutrophil count
Microbiologic studies ; culture
Humoral immune deficiencies;
Serum IgG, IgM. IgA levels
Isohemaggulitinin titers
Spesific antibody response
(tetanus,dyphteria,Hib)
WBC, Leucocyte morphology,
trombocyte, reticulocyte count
Haemolytic anemia
G6PD deficiency
Anormal neutrophil granul+ partial albinis
Chediak-Higashi Syndrome
Anormal neutrophil granuls(Pelger-Huet anomalisi)
Spesific Granul deficiency
Howell-Jolly bodies
Asplenia
Trombocytopenia+Eczema
Wiskott-Aldrich Sendromu
Neutrophil count1500
Neutropenia, cyclic neutropenia
NORMAL
B-Cell Function
Screening Tests
• Serum immunoglobulin levels
• Serum specific antibody titers
• Antibody response to booster immunization
• Flow cytometry to enumerate B cells
• In vitro immunoglobulin production in response
to mitogen
• In vitro immunoglobulin production in response
to anti-CD40 and cytokines
Immunoglobulin levels
IgG+A+M 400mg/dL
Normal, or  2SD
Mildly low  400mg/dL
T.protein, albumin
response
Specific antibody
(TT, İsohemagglutinin, PPS)
IgG subclassews
Normal
Low
immunised
Low production
Primary
Immune Def..
IgG half life
Abnormal
Low
Sekondary Imm. Def.
İnfections with IgG subclass
Antibody def.
RicardoSorensen: Pediatric Clinics of North America, 2000
Normal
IgG, IgG subclasses,IgM, IgA,IgE levels
Antibody levels( tetanus, dyphteria, H.influenzae)
Low immunoglobulins
Normal immunoglobulins levels
XLA
Antibody deficiency syndrome
CVI
IgA deficiency
IgG subclass deficiency
IgM deficiency
Transient hypogammaglobulinemia
of infancy
High immunoglobulins
Hyper IgE
Hyper IgM Syndrome
AIDS
B-Cell Defects
Agammaglobulinemia
Transient
HypogammaGlobulinemia of
infancy(THI)
Common variable
immune deficiency
(CVID)
B cell
0-2 %
IgG 100 mg/dl
IgA 0-10 mg/dl
IgM 0-20
B cell
10-20 %
IgG 250 mg/dl
IgA 10 mg/dl
IgM 20 mg/dl
B cell
10-20%
IgG 250 mg/dl
IgA 20 mg/dl
IgM 60 mg/dl
Management of Humoral
immunodeficiencies
• Intravenous immunoglobulin (IVIG)
replacement therapy
• Avoidance of live viral vaccines
• Systemic antibiotics
• Patient/parent education and genetic
counseling
IVIG Therapy
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X-linked Agammaglobulinemia
THI(rarely)
CVID
Hyper IgM Syndrome
Isolated IgA deficiency(Caution?)
IgG subclass deficiencies
Antibody response deficiency
CID
II-Severe Combined
immunodeficiencies (SCID)
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Infections onsets at early life
Failure to thrive
Persistant oral and mucosal fungal infections
Chronic CMV, P.Carinii, toxoplasmosis
Opportunistic infections
Lymphocyte count, Delayed type skin testleri( candidin, tetanus,
mumps, tricophyton, streptokinase-streptodornase)
Total B and T cell; CD19,CD3,CD4+, CD8+, CD4+/CD8+,CD56
T Lymphocyte proliferation test
Timus X ray
SCID
Lymphopenia ( < 1500/mm3),
Peripheral CD3 (+) , T cell count < 20 %(< 500/mm3)
B and NK cell counts variable
Poor Lymphocyte proliferation response to PHA or mitogen
Hypogammaglobulinemia ( <150mg/dl IgG)
Cellular Immune Function
Screening Tests
• Flow cytometry to enumerate T cells and natural killer cells
• Cutaneous delayed hypersensitivity
Advanced Tests
• Enzyme assays (adenosine deaminase [ADA], purine
nucleoside phosphorylase [PNP])
• Fluorescent in situ hybridization (FISH) for 22q11 and
10p11 deletion
• In vitro proliferative response to mitogens and antigens
• Natural killer cell cytotoxicity
• Cytokine production in response to mitogen or antigen
stimulation
• Expression of surface markers after mitogen stimulation
Combined T- and B-cell immunodeficiencies (SCID)
T-B-NK- T-B-NK+ T-B+NK- T-B+NK+
Adenosine
deaminase
deficiency
Reticular
dysgenesis
IgG
IgA
IgM
IgE
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X-SCID
JAK3
RAG 1 /2
deficiency
Omenn
syndrome
Navajo
SCID
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IL-7 R
ZAP-70
deficiency
deficiency
deficiency
PNP
CD3
deficiency
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deficiency
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T+B+
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N, ,
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Tip2 BLS
IL-2
deficiency
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Management of combined
immunodeficiencies
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HLA-identical (sibling) bone marrow transplantation
IVIG
Avoidance of nonirradiated blood or products
Avoidance of live viral vaccines
Pneumocystis prophylaxis
Avoidance of cytomegalovirus (CMV)-positive blood
or cells
• Antifungal agents
• Anti-mycobacterial therapy
• Patient education and genetic counseling
III. Other well-defined immunodeficiency
syndromes
• 1. Wiskott-Aldrich syndrome
• 2. DNA repair defects
• (a) Ataxia-telangiectasia (b) Ataxia-like
syndrome (c) Nijmegen breakage
syndrome (d) Bloom syndrome
• 3. Thymic defects Di George anomaly
• 4. Immuno-osseous dysplasias (a) Cartilage hair
hypoplasia (b) Schimke syndrome
• 5. Hermansky-Pudlak syndrome type 2
• 6. Hyper-IgE syndrome
• 7. Chronic mucocutaneous candidiasis
IV. Diseases of immune dysregulation
1. Immunodeficiency with hypopigmentation
(a) Chediak-Higashi syndrome (b) Griscelli syndrome, type 2
2. Familial hemophagocytic lymphohistiocytosis (FHL)
syndromes (a) Perforin deficiency (b) Munc 13-D
deficiency (c) Syntaxin 11 deficiency
3. X-linked lymphoproliferative syndrome (XLP)
4. Syndromes with autoimmunity
(a) Autoimmune lymphoproliferative syndrome (ALPS)
(i) CD95 (Fas) defects, type 1a (ii) CD95L (Fas ligand)
defects, ALPS type 1b (iii) Caspase 10 defects, ALPS type
2a (iv) Caspase 8 defects, ALPS type 2b
(b) APECED, autoimmune polyendocrinopathy with candidiasis
and ectodermal dystrophy
(c) IPEX, immune dysregulation, polyendocrinopathy, enteropathy
X-linked)
V. Congenital defects of phagocyte number, function,
or both
1.-3.Severe congenital neutropenias
4.Kostmann syndrome
5.Cyclic neutropenia
6.X-linked neutropenia/myelodysplasia
7.Leukocyte adhesion deficiency type 1
8.Leukocyte adhesion deficiency type 2
9.Leukocyte adhesion deficiency type 3
10.Rac 2 deficiency
11.β-Actin deficiency
12.Localized juvenile periodontitis
V. Congenital defects of phagocyte number, function,
or both
13.Papillon-Lefèvre syndrome
14.Specific granule deficiency
15.Shwachman-Diamond syndrome
16.X-linked chronic granulomatous disease (CGD)
17.-19.Autosomal CGDs20.Neutrophil G-6PD deficien.
21.IL-12 and IL-23 receptor β1 chain deficiency
22.IL-12p40 deficiency
23.IFN-γ receptor 1 deficiency
24.IFN-γ receptor 2 deficiency
25.STAT1 deficiency (2 forms)
Chronic granulomatous disease (CGD)
• Caused by a defect in intracellular killing of
bacteria by phagocytes
• It can be inherited as an X-linked or
autosomal-recessive defect
• Affected persons experience frequent and
severe infections of the skin, lungs, and
bones and tumor-like masses called
granulomas
Leukocyte adhesion defect
(LAD),
• Phagocytes lack an essential adhesion
molecule, preventing them from migrating
to sites of infection
• The result is recurrent, life-threatening
infections, especially of the soft tissues.
Phagocytic Cell Function
Screening Tests
• Blood cell count with differential <500
• Neutrophil staining, morphology
Advanced Tests
• Oxidase function (nitroblue tetrazolium,
chemiluminescence)
• Flow cytometry for adhesion molecules
• Chemotaxis
• Phagocytosis
• Enzyme assays (myeloperoxidase, glucose-6phosphate dehydrogenase ((G6PDH))
• Bacterial or fungal killing
Nitroblue tetrazolium(NBT) test
Superoxide O2 investigation
Chemotaxis
Rebuck skin window test
Abnormal NBT test
Abnormal chemotaxis
Chronic Granulamatous diseases
Complement deficiency
LAD
Chediak-Higashi Syndrome
Specific Granule deficiency
NORMAL
Management of phagocytic cell
disorders
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Avoidance of live bacterial vaccines
Antibiotic prophylaxis
Interferon gamma
Surgical or dental debridement
Granulocytic transfusions
Antifungals
G-CSF
BMT
VI. Defects in innate immunity
Anhidrotic ectodermal dysplasia with
immunodeficiency (EDA-ID)
Anhidrotic ectodermal dysplasia with
immunodeficiency (EDA-ID)
IL-1 receptor–associated kinase 4 (IRAK4)
deficiency
WHIM (warts, hypogammaglobulinemia infections,
myelokathexis) syndrome
Epidermodysplasia verruciformis
VII. Autoinflammatory disorders
• Familial Mediterranean fever
• TNF receptor–associated periodic syndrome
(TRAPS)
• Hyper-IgD syndrome
• Muckle-Wells syndrome
• Familial cold autoinflammatory syndrome
• Neonatal-onset multisystem inflammatory disease
(NOMID) or chronic infantile neurologic cutaneous
and articular syndrome (CINCA)
• Pyogenic sterile arthritis, pyoderma gangrenosum,
acne (PAPA) syndrome
• Blau syndrome
VIII. Complement deficiencies
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C1q deficiency
C1r deficiency
C4 deficiency
C2 deficiency
C3 deficiency
C5 deficiency
C6 deficiency
C7 deficiency
C8a deficiency
C8b deficiency
C9 deficiency
•C1 inhibitor deficiency
•Factor I deficiency
•Factor H deficiency
•Factor D deficiency
•Properdin deficiency
•MBP deficiency
•MASP2 deficiency
Complement Function
Screening Tests
1.CH50 (total hemolytic complement activity)
2.AH50 (alternative pathway hemolytic activity)
Advanced Tests
1.Level or function of individual complement
components
2.Chemotactic activity of complement
split products
Complement Deficiency
• Patients have recurrent and severe
infections with encapsulated bacteria,
• frequently meningitis
• a susceptibility to autoimmune diseases
• Terminal complement protein (C6-8)
deficiencies are associated with severe
infections with Neisseria meningitidis and
N. gonorrhoeae
Management of complement
deficiencies
• Pneumococcal vaccine
• Meningococcal vaccine
• Antibiotic therapy
Other
Advanced Tests
1.Molecular methods including Southern,
Northern, and Western blots,
2.polymerase chain reaction/single-strand
conformational polymorphism
(PCR/SSCP), DNA fingerprinting, and
nucleotide sequencing