Unknown combined Unknown combined immunodeficiencyimmunodeficiency

with T cell lymphopenia with T cell lymphopenia

Vilnius University Children’s Vilnius University Children’s Hospital Hospital Pediatric CentePediatric Centerr, Lithuania, LithuaniaRR..Duobiene Duobiene

Medical historyMedical history

X.Y., male, DOB: 26.02.2000X.Y., male, DOB: 26.02.2000

the the second childsecond child, , non consanguineous parents.non consanguineous parents.MMaternal uncleaternal uncle’s’s son – CF in susp., son – CF in susp., ssweat chlorine weat chlorine 65 mmol/l, genetic testing not confirmed CF65 mmol/l, genetic testing not confirmed CF..

normal gestationnormal gestation, b, birth weigh irth weigh - - 4250 g, hight 55 4250 g, hight 55 cm. cm.

Vaccinations: BCG, HB1 at birth, Vaccinations: BCG, HB1 at birth, DTPaDTPa1-2-31-2-3-4-4+IPV+IPV1-2-31-2-3-4-4, Hib, Hib11-2-2, , DTDT55, OPV, OPV55, HA, HA from 2 from 2 year old without complicationsyear old without complications. .

An.morbiAn.morbi At theAt the 2 weeks 2 weeks of age – of age – pemphigus pemphigus

neonatorumneonatorum;;

5 months5 months - - sepsissepsis:: pneumonia, enterocolitis, pneumonia, enterocolitis, hepatosplenomegalyhepatosplenomegaly, mucocutaneus fungal , mucocutaneus fungal infections, piodermia.infections, piodermia. ((Staph.aureusStaph.aureus from the pus from the pus and stool culture)and stool culture)

6 months6 months - - sepsissepsis:: toxic-septic shock, bilateral toxic-septic shock, bilateral pneumonia with r. atelectasis Spneumonia with r. atelectasis S 6, 9, 10, DIC , DIC syndrome, liver‘s abscess in susp. syndrome, liver‘s abscess in susp. ((mechanical ventilation for 2 weeks and non irradiated mechanical ventilation for 2 weeks and non irradiated blood component‘s transfusions (EM, TM, plasma)blood component‘s transfusions (EM, TM, plasma);;

((Staph. aureus, Staph. aureus, Pseudomonas aeruginosaPseudomonas aeruginosa, Str. , Str. pneumonia, Candida sp.pneumonia, Candida sp. from intubation tube). from intubation tube).

An.morbiAn.morbi 7-8 months7-8 months

- - pneumoniapneumonia with bronchial obstruction and pur with bronchial obstruction and pur. . mucus, mucus,

- - hepatosplenomegalyhepatosplenomegaly..

10 months10 months –– cystic fibrosiscystic fibrosis due to recurrent chest due to recurrent chest infections, viscid mucus in the small airwaysinfections, viscid mucus in the small airways, , malabsorbtion, failure to thrive, cholestasis. malabsorbtion, failure to thrive, cholestasis. ((Moraxella Moraxella cath., Strept. cath., Strept. hemolyticus, Candida hemolyticus, Candida from BAL)from BAL)

1-2 years1-2 years- - recurrent fevering, repeated episodes of cough with recurrent fevering, repeated episodes of cough with purulentpurulent

sputum, persistentsputum, persistent changes in the right lung, changes in the right lung, - - cholestatic hepatitischolestatic hepatitis, , hepatohepatosplenomegalysplenomegaly.. Portal hypertensionPortal hypertension was excluded by sonography, was excluded by sonography, EGDF.EGDF.

An.morbiAn.morbi 2-3 years:2-3 years: recurrent purulent skin recurrent purulent skin

diseases, diseases, flegmona, flegmona, furunculosis (furunculosis (Staph.aureusStaph.aureus) ) prolonged wound healing, prolonged wound healing,

22 episodes episodes of of bone bone fractures,fractures,

hhyperextensibilityyperextensibility,, ggingivostomatitisingivostomatitis ( (Candida spCandida sp)),, rec. pneumoniarec. pneumonia ((StrepStreptt..

pneumonia, Moraxella, pneumonia, Moraxella, H. H. influenzainfluenza))

Splenomegaly

The The spleen biopsyspleen biopsy (5 years) histology: (5 years) histology: reactive hyperplasia of lymphoid follicles, reactive hyperplasia of lymphoid follicles, signs of splenitis, signs of splenitis, extramedular focus of haemopoesis.extramedular focus of haemopoesis.

4 - 5 4 - 5 years:years:

An.morbiAn.morbi

5 - 6 years:5 - 6 years: chr.chr. ddiarrheaiarrhea ( ( steatorrhea, steatorrhea, llactose intoleranceactose intolerance), ), mucositis, esophagitismucositis, esophagitis (Candida sp.), (Candida sp.), urinary tract infection urinary tract infection (E.coli, Klebsiella (E.coli, Klebsiella

pneumonia),pneumonia), pneumonia (pneumonia (Moraxella, Staph.aureus, Moraxella, Staph.aureus,

Pseudomonas aeruginosa IBLPseudomonas aeruginosa IBL, Strept.pneumonia, , Strept.pneumonia, Staph. epidermidisStaph. epidermidis, fungal in susp.), fungal in susp.)

6 y: 6 y: sepsissepsis: : enterocolitisenterocolitis ((PseudomonasPseudomonas aeruginosaaeruginosa IBL IBL,, Candida, Campilobacter jejuniCandida, Campilobacter jejuni)), , bilateral polisegmental pneumonia, otitis, DIC bilateral polisegmental pneumonia, otitis, DIC syndrome, hepatosplenomegaly (fatal outcome).syndrome, hepatosplenomegaly (fatal outcome).

Patanatomical findingsPatanatomical findings

Mb. princ.Mb. princ.:: Primary combined immunodeficiency (D81.9).Primary combined immunodeficiency (D81.9).

ComplicationsComplications:: SSepsis: epsis: bilateral bilateral pneumonia, pneumonia, rr. . lung’s lung’s abscesabscessesses, , non non exudativeexudative pleurit pleuritiis, dis, diffffuusese alveol alveoles’es’ lesion lesion ssyyndromndromee, , oesophagitis ulcerosaoesophagitis ulcerosa,,

ulcerated ulcerated enteroenteroccolitolitiis, splenomegals, splenomegalyy. . Hepatic Hepatic ccirirrhrhoosissis..

SpleenLymphnode

0

100

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300

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500

600

700

800

900

1000

AST

2000 2001 2002 2003 2004 2005 2006

ALTALT

ASTAST0

100

200

300

400

500

600

700

800

900

-GT-GT

0

20

40

60

80

100

120

140

160

180

GGT

2000 2001 2002 2003 2004 2005 2006

Alkaline phosphatase (AP) level was normal Alkaline phosphatase (AP) level was normal (N: (N: 250-950 U/L)250-950 U/L)Serum bilirubin levels were normal, except one episode of increased total Serum bilirubin levels were normal, except one episode of increased total and direct bilirubin at 2 year old (2002). (TB- and direct bilirubin at 2 year old (2002). (TB- 56,456,4; ; DB-DB-21,921,9 mmol/lmmol/l, N:, N: <17/<4,5)<17/<4,5)

Abdominal USAbdominal US 6 month6 month - enlargement of liver- enlargement of liver, , increased echogenicity, increased echogenicity,

regular surfaceregular surface,, normal vascularization normal vascularization.. Hypodensic focuses, Hypodensic focuses, ~1-2 cm in diameter with fluid inclusions in the right hepatic ~1-2 cm in diameter with fluid inclusions in the right hepatic lobe.lobe. CTCT: A hypodensic focus, ~1.6 x 0.7 cm in diameter, was seen in the : A hypodensic focus, ~1.6 x 0.7 cm in diameter, was seen in the

right hepatic lobe by CT. Liver’s ducts not dilatated. right hepatic lobe by CT. Liver’s ducts not dilatated.

1 - 5 year1 - 5 year of age - nonhomogenous internal liver’s structure of age - nonhomogenous internal liver’s structure, , v.portae v.portae branches were infiltrativebranches were infiltrative,, increased echogenicity increased echogenicity of of intrahepatic ducts’ walls. Sintrahepatic ducts’ walls. Splenomegaly.plenomegaly. EGDF – nEGDF – normalormal. . Sonography of v. portae system – Sonography of v. portae system – PH excluded PH excluded

(2001.12).(2001.12).

66 yearyear of age - of age - hepatomegaly - right lobe 13,0 -17,4 cm (N: hepatomegaly - right lobe 13,0 -17,4 cm (N: 6,0-7,4 cm), 6,0-7,4 cm), increased echogenicity,increased echogenicity, nonhomogenous nonhomogenous structure; structure; splenomegaly -147- 200 mm (N: 49-58 mm), splenomegaly -147- 200 mm (N: 49-58 mm), homogenous homogenous structure.structure. Ascites.Ascites.

Laboratory analysisLaboratory analysis

Sweat chlorine 47 mmol/l Sweat chlorine 47 mmol/l (N)(N)CF genetic testing: F 508 CF genetic testing: F 508 del (-)del (-)(R 553X, G542G, G551D, (R 553X, G542G, G551D, H 1303K, CFTR dele 23 H 1303K, CFTR dele 23 (21 hb) will be done)(21 hb) will be done)

NNormal ormal -1 antitrypsin -1 antitrypsin level 2,2 g/l ( N:0,9-2,0 level 2,2 g/l ( N:0,9-2,0 g/l).g/l).

Bone marrow Bone marrow investigation – normal.investigation – normal.

Total protein level: 71-52-Total protein level: 71-52-61-67-57 61-67-57 - - 3737g/L g/L (N: 66-(N: 66-

83),83), Albumin 29,2 g/l Albumin 29,2 g/l (N:38-54). (N:38-54).

amilaseamilase 57 U/L (57 U/L (N:N:0-0-220220)) CK CK 163 U/L 163 U/L (N:24-170)(N:24-170)

LDH LDH 2966-997-615 U/L 2966-997-615 U/L (N<1100)(N<1100)

KK++, Na, Na++, Ca, Ca++++, Cl, Cl-- , , glucose – normal.glucose – normal.

Laboratory analysisLaboratory analysis

Serology for hepatitis A, B, C, HSV, Serology for hepatitis A, B, C, HSV,

HIV(-), HIV(-), toxoplasmosis (-),toxoplasmosis (-), CMV IgM (-), IgG (+)(1.16, pos.> CMV IgM (-), IgG (+)(1.16, pos.>

0.2), 0.2), RPR screening test RPR screening test negative.negative. Mantoux test negative.Mantoux test negative.

anti-dsDNR anti-dsDNR (-), CIC (-)(-), CIC (-) A (II), Rh D+, A (II), Rh D+, D.CooD.Coombs test mbs test

positivepositive..

Bacteriologically:Bacteriologically:

Staph. aureus, Staph. aureus,

Pseudomonas Pseudomonas aeruginosaaeruginosa,,

Str. pneumonia, Str. pneumonia,

H. influenza, H. influenza,

Klebsiella Klebsiella pneumonia,pneumonia,

Campilobacter Campilobacter jejuni, jejuni,

Candida sp.Candida sp.

Laboratory analysisLaboratory analysis

WBC: 6.9-WBC: 6.9- 14.1-14.1- 3.4-3.4- 20.6 (max)-20.6 (max)- 4.3-4.3- 12.0-12.0- 5.55.5 ..- ..- 2.3-1.7-3.9 2.3-1.7-3.9 x109/L, x109/L,

lymphopenia ( 27-lymphopenia ( 27- 31-31- 31-31- 24.6-24.6- 23-23- 16.416.4 -15.. – 17--15.. – 17-11-6%11-6%/0.82..-0,2/0.82..-0,2 x10x1099), ),

normal eosinophil count,normal eosinophil count,

PLTPLT: : 83 to 23883 to 238 x10x1099/L, /L,

aanemia (Hb 131-62-123-59-114-107 g/L, decreased nemia (Hb 131-62-123-59-114-107 g/L, decreased MCV, MCH), MCV, MCH),

decreased level of serum ferum (1.5 mmol/L). decreased level of serum ferum (1.5 mmol/L).

Parameter Result18.10.2000 / ~7m. old

Result29.01.2002 / ~2y old

Result26.02.2003/ 3y old

Result28.01.2005 /~5y old

Normal value1-6 y

Absolute lymphocytes count

819 1156 1520 23 828 38-53% / 2900-5100 mm3

CD3+ 61 199 73 844 82 1246 89 737 62-69% / 1800-3000 mm3

CD3+CD4+ 37 303 15 173 14 213 26 215 30-40% / 1000-1800 mm3

CD3+CD8+ 22 180 56 647 67 1018 63 522 25-32% / 800-1500 mm3

CD4/CD8 1,68 0,27 0,21 0,41 1,0 – 1,6

CD16+/CD56+ 7 57 7 81 7 106 2 17 8-15% / 200-600 mm3

CD19+ 31 278 16 185 13 198 9 75 21-28% / 700-1300 mm3

CD3+/CD25+ 3 2 4 2 8-12%

CD3+CD45RO+ (naïve) 73

CD3-CD45RO 3

CD3+CD45RA+(memory) 30

CD3-CD45RA 7

Lymphocytes’ subpopulationsLymphocytes’ subpopulations

0

200

400

600

800

10001200

1400

1600

1800

normal 8m 2y 3y 5y 6y

0

500

1000

1500CD8+

0

500

1000

1500

2000

2500

3000no

rmal 8m 2y 3y 5y 6y

CD3+

0

200

400

600

800

1000

1200

1400

Normal 8m 2y 3y 5y 6y

CD4+

CD19+

ImmunoglobulinsImmunoglobulins 2000-2006 y2000-2006 y

0

2

4

6

8

10

12

IgA g/l IgG g/l IgM g/l

normal 2000 2000

2000 2005 2005

2006 2006

Parameter ~7m. old ~2y old

3y old ~5y old

Normal value1-6 y

Lymphocytes transformation test against PHA

- 37 31 3 30-40%

Lymphocytes transformation test against PWM

- - 3 3 8-10%

Lymphocytes transformation test against tuberculin

negative - 7 n.i. negative (< 5%)

Neutrophyl respiratory burst spontaneous

50 40 - 16 15-25%

Neutrophyl respiratory burst PMA stimulation

36,5 43 93 45-65%

Neutrophyls‘ activity with latex‘s particles

76 15-20%

CIC 0,045 0,037 < 0,08

Lymphocytes’ proliferation, Lymphocytes’ proliferation, NBTNBT

Discussion. Diagnosis?Discussion. Diagnosis?

PID PID (T cell deficiency)(T cell deficiency) – –- sepsis (umbilical?), - sepsis (umbilical?), toxic-septic shock, vein toxic-septic shock, vein

thrombosisthrombosis ? - ? -

- portopulmonary hypertension - splenomegaly - - portopulmonary hypertension - splenomegaly -

- persistent cholestatic hepatitis - hepatic cirrhosis -- persistent cholestatic hepatitis - hepatic cirrhosis -

- sepsis. - sepsis. or secondary ID or secondary ID ((cystic fibrosis, liver cystic fibrosis, liver

disease…) disease…) ??

What’s your comments?What’s your comments?

Thank you for attentionThank you for attention

CD3+HLA-DR 8 65 5 58 28 246 44 364 6-16%

(CD14+)HLA-DR+ 57 56 87 65-85%

CD3+/CD25+ 3 2 4 2 8-12%

CD3+/CD71+ 27 1,5-2,0%

CD3+/CD54+ 68 2,0-4,5%

CD3+/CD69+ 10 1,0-2,0%

CD3+/CD11b+ 57 20-40%

CD3+/CD57+ 0 3 2-5%

CD8+/CD57+ 2 48? 6-15%

CD8+/CD38+ 59 5-9%

CD8+/HLA-DR+ 51 3-5%

CD4+/HLA-DR+ 18 3-5%