Immunodeficiency diseases Xinhua Hospital Shanghai Institute for Pediatric Research Shanghai...

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 ：

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

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

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

Immunodeficiency diseases Xinhua Hospital Shanghai Institute for Pediatric Research Shanghai...

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