A Homozygous STIM1 Mutation Impairs Store-Operated Calcium
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J ALLERGY CLIN IMMUNOL LETTERS TO THE EDITOR 955 VOLUME 137, NUMBER 3 Kejian Zhang, MDb recessive AI and hypohidrosis by using autozygosity mapping Stella Davies, MBBS, PhD, MRCPa and clonal sequencing. A homozygous rare missense mutation a Alexandra H. Filipovich, MD in STIM1 (p.L74P) in the EF-hand domain was identified (see From the Divisions of aBone Marrow Transplantation and Immune deficiency and the Methods and Results sections in this article’s Online Reposi- bHuman Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, tory at www.jacionline.org). Ohio. E-mail: [email protected]. The family was re-evaluated, with particular attention paid to Disclosure of potential conflict of interest: The authors declare that they have no relevant conflicts of interest. features associated with recessive STIM1 mutations (Table I and see Tables E1-E3 in this article’s Online Repository at www.jacionline. org). The 2 affected cousins (18 and 11 years old, respectively) did REFERENCES 1. Bennett CL, Christie J, Ramsdell F, Brunkow ME, Ferguson PJ, Whitesell L, et al. not have overt clinical immunodeficiency. Further evaluation of The immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome their immune systems showed a normal immunoglobulin profile (IPEX) is caused by mutations of FOXP3. Nat Genet 2001;27:20-1. with an adequate specific antibody response to both nonlive (pneu- 2. Barzaghi F, Passerini L, Bacchetta R. Immune dysregulation, polyendocrinopathy, mococcus, tetanus and, Hib) and live (mumps, measles, and enteropathy, x-linked syndrome: a paradigm of immunodeficiency with autoimmu- nity. Front Immunol 2012;3:211. rubella) vaccinations. In addition, both subjects had detectable 3. Baud O, Goulet O, Canioni D, Le Deist F, Radford I, Rieu D, et al. Treatment of the IgG against varicella zoster virus after a previous uncomplicated immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome primary infection. The younger cousin was also found to have (IPEX) by allogeneic bone marrow transplantation. N Engl J Med 2001;344:1758-62. IgG against EBV viral capsid antigen, suggesting previous expo- 4. Rao A, Kamani N, Filipovich A, Lee SM, Davies SM, Dalal J, et al. Successful sure, but neither showed any evidence of acute infection or previous bone marrow transplantation for IPEX syndrome after reduced-intensity condition- ing. Blood 2007;109:383-5. exposure to cytomegalovirus. 5. Burroughs LM, Torgerson TR, Storb R, Carpenter PA, Rawlings DJ, Sanders J, Lymphocyte studies showed stable CD8 T-cell depletion in the et al. Stable hematopoietic cell engraftment after low-intensity nonmyeloablative older affected subject only. Other lymphocyte subsets, including conditioning in patients with immune dysregulation, polyendocrinopathy, enterop- CD4 T, natural killer (NK), and B cells, were within the normal athy, X-linked syndrome. J Allergy Clin Immunol 2010;126:1000-5. 6. Nademi Z, Slatter M, Gambineri E, Mannurita SC, Barge D, Hodges S, et al. Sin- range (Table I). However, despite normal PHA and anti-CD3 gle centre experience of haematopoietic SCT for patients with immunodysregula- simulation responses, T-lymphocyte and NK cell SOCE was tion, polyendocrinopathy, enteropathy, X-linked syndrome. Bone Marrow grossly abnormal, which is consistent with disruption of the Transplant 2014;49:310-2. Ca21-binding EF-hand and in keeping with previous reports for 7. Wildin RS, Smyk-Pearson S, Filipovich AH. Clinical and molecular features of the recessive STIM1 mutations (see Fig E1, A, in this article’s Online immunodysregulation, polyendocrinopathy, enteropathy, X linked (IPEX) syn- 1-3 drome. J Med Genet 2002;39:537-45. Repository at www.jacionline.org). The defect in NK cell 8. Marsh RA, Vaughn G, Kim MO, Li D, Jodele S, Joshi S, et al. Reduced-intensity SOCE was associated with impaired NK cell effector function, conditioning significantly improves survival of patients with hemophagocytic lym- as shown by assays of granule exocytosis and intracellular phohistiocytosis undergoing allogeneic hematopoietic cell transplantation. Blood IFN-g production in response to K562 tumor cells (see Fig E1, 2010;116:5824-31. 9. Burroughs LM, Nemecek ER, Torgerson TR, Storer BE, Talano JA, Domm J, et al. B). After recently published mouse studies, which confirmed Treosulfan-based conditioning and hematopoietic cell transplantation for nonma- the importance of STIM1 to neutrophil SOCE and associated lignant diseases: a prospective multicenter trial. Biol Blood Marrow Transplant functions,4 we also evaluated neutrophil function. This was found 2014;20:1996-2003. to be within normal limits. Despite abnormal immune system SOCE, the affected subjects Available online November 11, 2015. http://dx.doi.org/10.1016/j.jaci.2015.09.030 in this case appear to be able to compensate for this deficit and avoid overt immunodeficiency. It is possible that the relative preservation of T-cell function might compensate for NK cell A homozygous STIM1 mutation dysfunction. Neither might yet have encountered a pathogen impairs store-operated calcium that would expose this particular immune system limitation (see entry and natural killer cell Table E2). An ability to mount a partial response to viral effector function without clinical infections was reported in a family with clinical immunodefi- immunodeficiency ciency and a history of viral infections caused by a homozygous missense R429C change affecting the STIM1 cytoplasmic To the Editor: domain.2 A mouse model characterized by conditional knockout Stromal interaction molecule 1 (STIM1) is a transmembrane of Stim1 and Stim2 in both CD41 and CD81 T cells has recently protein pivotal to store-operated calcium entry (SOCE) that provided further insight into the importance of Stim1 in immune localizes to either the cell or endoplasmic reticulum (ER) system development and virus-specific memory and recall membranes, with the N-terminus in either the extracellular space responses, which prevent acute viral infections from becoming or the ER, respectively. Plasma membrane ORAI calcium 5 21 chronic. release–activated calcium modulator 1 (ORAI1) Ca channels Recessive STIM1 mutations can be associated with other are activated by STIM1. Families previously described with immune dysregulations, including autoimmune disease. The recessive STIM1 mutations (MIM #612783) had life-threatening older cousin had a transient episode of idiopathic thrombocyto- viral, bacterial, and fungal infections; developmental myopathy; penic purpura when 2 years old that might have been unrelated hypohidrosis; and amelogenesis imperfecta (AI; generalized 1-3 to the STIM1 mutations. There were no other clinical or serologic developmental enamel abnormalities). We investigated a markers consistent with autoimmune disease, and regulatory consanguineous family, segregating a novel syndrome of T-cell numbers were normal. Ó 2015 The Authors. Published by Elsevier Inc. on behalf of the American Academy of Both cousins were intolerant of warm environments and aware Allergy, Asthma & Immunology. This is an open access article under the CC BY license of their inability to sweat normally. This limited the older cousin’s (http://creativecommons.org/licenses/by/4.0/). ability to participate in sport. There was no clinical or serologic 956 LETTERS TO THE EDITOR J ALLERGY CLIN IMMUNOL MARCH 2016 TABLE I. Summary of the main clinical and clinical immunologic features in subjects with either homozygous or heterozygous STIM1 c.221T>C mutations Feature V:3 IV:4 IV:3 V:2 STIM1 genotype Homozygous c.221T>C Heterozygous c.221T>C Heterozygous c.221T>C Homozygous c.221T>C Age at evaluation (y) 18-21 45-48 41 9-12 Persistent infections None None None None Other infections Infancy: repeated chest No reported issues No reported issues Infancy: chest, urinary infections but not thereafter tract, gastrointestinal tract, ear, and eye infections but not thereafter Autoimmune disorder Transient ITP aged 2.5 y None Sjogren syndrome None Lymphocytes Total (3109/L [1.00-2.80]) 1.50 2.30 2.64 2.34 CD4 (absolute; 3 109/L 0.841 1.091 1.502 0.908 [0.300-1.400]) CD8 (absolute; 3 109/L 0.055 0.236 0.415 0.488 [0.200-0.900]) CD4/CD8 (1.07-1.87) 15.29 4.62 3.62 1.86 NK (absolute; 3 109/L 0.238 0.581 0.252 0.252 [0.090-0.600]) Immunization history Full schedule without adverse Not assessed Not assessed Full schedule without events adverse events Musculoskeletal Muscle bulk, tone, power, and No issues evident; not No issues evident; Muscle bulk, tone, power, reflexes normal; hypermobility formally examined not formally examined and reflexes normal; in upper and lower limbs; hypermobility in upper CK normal and lower limbs; CK normal Pupil reaction Normal Normal Normal Normal Sweating Diminished sweating recognized No reported issues No reported issues Diminished sweating from infancy onward; insufficient recognized from infancy sample for sweat test analysis onward; reduced sweating on starch and iodine testing Dental enamel Generalized hypomineralized AI Enamel within normal Enamel within normal Generalized hypomineralized AI limits limits Development Global development normal Not assessed Not assessed Global development normal Height, 156 cm (<0.4th percentile) Height, 122 cm (0.4th-2nd Weight, 40.3 kg (<0.4th percentile) percentile) Head circumference, 51.5 cm Weight 24 kg (2nd-9th (<0.4th percentile) percentile) Head circumference, 50 cm (0.4th percentile) Further details are presented in Tables E1-E3. Values in boldface are outside the reference ranges. CK, Creatine