Established: 1959. The year 2009 is the 50th anniversary of continuous publication
ISSN 0036-4665 ISSN 1678-9946 on line EDITOR‑IN‑CHIEF EDITORS EMERITUS Prof. Dr. Thales F. de Brito Prof. Dr. Luis Rey (Founding Editor) Associate Editors: Prof. Dr. Marcello Fabiano de Franco Prof. Dr. Carlos da Silva Lacaz Prof. Dr. Pedro Paulo Chieffi
EDITORIAL BOARD Alan L. de Melo (Belo Horizonte, MG) Gil Benard (S. Paulo, SP) Mario Mariano (S. Paulo, SP) Alberto Duarte (S. Paulo, SP) Gioconda San-Blas (Caracas, Venezuela) Mirian N. Sotto (S. Paulo, SP) Angela Restrepo M. (Medellin, Colombia) Govinda Visvesvara (Atlanta, USA) Moisés Goldbaum (S. Paulo, SP) Anna Sara S. Levin (S. Paulo, SP) Heitor F. Andrade Jr. (S. Paulo, SP) Moysés Mincis (S. Paulo, SP) Antonio A. Barone (S. Paulo, SP) Henrique L. Lenzi (Rio de Janeiro, RJ) Moysés Sadigursky (Salvador, BA) Antonio Carlos Nicodemo (S. Paulo, SP) Hiro Goto (S. Paulo, SP) Myrthes T. Barros (S. Paulo, SP) Antonio Sesso (S. Paulo, SP) Ises A. Abrahamsohn (S. Paulo, SP) Nilma Cintra Leal (Recife, PE) Antonio W. Ferreira (S. Paulo, SP) João Carlos Pinto Dias (Belo Horizonte, MG) Paulo C. Cotrim (São Paulo, SP) Barnett L. Cline (New Orleans, USA) José Eduardo Levi (S. Paulo, SP) Paulo M. Z. Coelho (Belo Horizonte, MG) Carlos F. S. Amaral (Belo Horizonte, MG) José M. R. Zeitune (Campinas, SP) Pedro Morera (San José, Costa Rica) Celso Granato (S. Paulo, SP) Julia Maria Costa-Cruz (Uberlândia, MG) Regina Abdulkader (S. Paulo, SP) Cesar A. Cuba Cuba (Brasília, DF) Julio Litvoc (S. Paulo, SP) Ricardo Negroni (B. Aires, Argentina) César Naquira V. (Lima, Peru) Luiz Caetano da Silva (S. Paulo, SP) Robert H. Gilman (Baltimore, USA) Claudio S. Pannuti (S. Paulo, SP) Luiz Carlos Severo (P. Alegre, RS) Roberto Martinez (Rib. Preto, SP) Cláudio Santos Ferreira (S. Paulo, SP) Luiz Jacintho da Silva (Campinas, SP) Semíramis Guimarães F. Viana (Botucatu, SP) Dalton L. F. Alves (Belo Horizonte, MG) Luiz T. M. Figueiredo (Rib. Preto, SP) Silvino A. Carvalho (S. Paulo, SP) Eridan Coutinho (Recife, PE) Lygia B. Iversson (S. Paulo, SP) Silvio Alencar Marques (Botucatu, SP) Ernesto Hofer (Rio de Janeiro, RJ) Marcos A. Rossi (Ribeirão Preto, SP) Sumie Hoshino‑Shimizu (S. Paulo, SP) Euclides A. Castilho (S. Paulo, SP) Marcos Boulos (S. Paulo, SP) Thelma S. Okay (S. Paulo, SP) Eufrosina S. Umezawa (S. Paulo, SP) M. A. Shikanai‑Yasuda (S. Paulo, SP) Tsutomu Takeuchi (Tokyo, Japan) Fan Hui Wen (S. Paulo, SP) Maria I. S. Duarte (S. Paulo, SP) Venâncio A. F. Alves (S. Paulo, SP) Fernando A. Corrêa (S. Paulo, SP) Maria L. Higuchi (S. Paulo, SP) Vicente Amato Neto (S. Paulo, SP) Fernando Montero‑Gei (San José, Costa Rica) Mario E. Camargo (S. Paulo, SP) Zilton A. Andrade (Salvador, BA) Flair J. Carrilho (S. Paulo, SP)
Executive Board ‑ Librarians: Maria do Carmo Berthe Rosa; Sonia Pedrozo Gomes; Maria Ângela de Castro Fígaro Pinca
The Revista do Instituto de Medicina Tropical de São Paulo is abstracted and/or indexed in: Index Medicus, Biological Abstracts, EMBASE/Excerpta Medica, Hepatology/Rapid Literature Review, Tropical Diseases Bulletin, Referativnyi Zhurnal: All-Russian Institute of Scientific and Technical Information (VINITI), Periódica ‑ Índice de Revistas Latinoamericanas en Ciencias, Helminthological Abstracts, Protozoological Abstracts, Review of Medical and Veterinary Mycology, PubMed, UnCover, HealthGate, OVID, LILACS, MEDLINE, New Jour, ExtraMED, Free Medical Journals, ISI (Institute for Scientific Information), BIOSIS Previews, Scopus, Science Citation Index Expanded (SciSearch), Journal Citation Reports/Science Edition, Current Contents®/Clinical Medicine and Index Copernicus. ON LINE ACCESS ‑ http://www.imt.usp.br/revista/rimtsp.htm ‑ FREE PDF ACCESS TO ALL PAST ISSUES (1959-1989). http://www.scielo.br/rimtsp ‑ FULL TEXT, SINCE 1990. E‑mail: [email protected] Reprints may be obtained from Pro Quest Inf. and Learning, 300 North Zeeb Road, Ann Arbor, Michigan 48106‑1346 ‑ USA. The Revista do Instituto de Medicina Tropical de São Paulo is supported by: Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Universidade de São Paulo and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). This issue was financed by: CNPq Proc. 402584/2008-2. Desktop Publishing by: Hermano - e-mail: [email protected] - Printed by: Copy Service Indústria Gráfica Ltda, Rua Goes Raposo, 1550, 04182-000 São Paulo, SP, Brazil. Phone: 55.11.2215-5800.
UNIVERSIDADE DE SÃO PAULO - BRAZIL FACULDADE DE MEDICINA Instituto de Medicina Tropical de São Paulo Director: Prof. Dr. Claudio Sergio Pannuti I The purpose of the “Revista do Instituto de Medicina Tropical de São Paulo” (Journal of the São Paulo Institute of Tropical Medicine) is to publish the results of research which contribute significantly to knowledge of all transmissible diseases.
REVISTA DO INSTITUTO DE MEDICINA TROPICAL DE SÃO PAULO (JOURNAL OF THE S. PAULO INSTITUTE OF TROPICAL MEDICINE). São Paulo, SP-Brasil, 1959 - v. ilust. 28 cm
1959-2008, 1-50 1973-2002 (supl. 1-12) 2003 (supl. 13 - on-line only) 2005-2009 (supl. 14-15) 2009, 51 (1-5)
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II International Symposium on Primary Immunodeficiencies - SIDEP
September 30th through October 03rd, 2009 Rebouças Convention Center São Paulo – SP – Brazil
ADDRESS SUBSCRIPTIONS INSTITUTO DE MEDICINA TROPICAL DE SÃO PAULO FOREIGN COUNTRIES Av. Dr. Enéas de Carvalho Aguiar, 470 One year (six issues)...... U$ 200.00 05403-000 São Paulo, SP - Brazil Single issue...... U$ 50.00 Phone/Fax: 55.11.3062.2174; 55.11.3061-7005 e-mail: [email protected] III ISSN 0036-4665 ISSN 1678-9946 on line
SPONSORSHIP
Shire Human Genetic Therapies Farmacêutica Ltda Grifols Brasil Ltda Octapharma Brasil S/A Baxter Healthcare Brasil Fundação Coord. de Aperfeiçoamento Pessoal de Nível Superior – CAPES Fundação de Amparo à Pesquisa do Estado de São Paulo – FAPESP Fundação Faculdade de Medicina – FFM
INSTITUTIONAL SUPPORT
Sociedade de Pediatria de São Paulo Sociedade Brasileira de Medicina Tropical Sociedade Brasileira de Infectologia Associação Brasileira de Alergia e Imunopatologia Sociedade Brasileira de Imunizações Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-facial Sociedade Brasileira de Clínica Médica Sociedade Brasileira de Patologia Clinica Sociedade Brasileira de Pneumologia e Tisiologia Grupo Brasileiro de Imunodeficiências Sociedade Brasileira de Dermatologia (RESP)
SUPPORT
Shire Human Genetic Therapies Farmacêutica Ltda Grifols Brasil Ltda Baxter Hospitalar Ltda Octapharma Brasil Ltda Sanofi-Aventis Farmacêutica Ltda Wyeth Indústria Farmacêutica Ltda Bristol-Myers Squibb Farmacêutica S/A Livraria Balieiro Ltda DBR Com. Imp. Mat. Med. Hospitalares Ltda.
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COORDINATION
Laboratório de Investigação em Dermatologia e Imunodeficiências (Unidade LIM 56) Depto. de Dermatologia, Depto. de Pediatria e Depto. de Patologia da Faculdade de Medicina da Universidade de São Paulo Faculdade de Medicina da Universidade de São Paulo Hospital das Clínicas – FMUSP Diretoria Executiva dos LIM’s – HC – FMUSP Fundação Faculdade de Medicina Instituto de Medicina Tropical de São Paulo
ORGANIZING COMMITTEE
Alberto J. S. Duarte (SP) – President Anete S. Grumach (SP) Cristina Miuki Abe Jacob (SP) Dewton de Moraes Vasconcelos (SP) Magda M. S. Carneiro Sampaio (SP)
SCIENTIFIC COMMITTEE
Maria Marluce dos Santos Vilela (SP) - Coordinator Aluce Ouricuri (RJ) – Hospital dos Servidores do Estado do Rio de Janeiro Antonio Condino Neto (SP) – Instituto de Ciências Biomédicas - USP Antonio Zuliani (SP) – Faculdade de Medicina de Botucatu - UNESP Angela Bueno Ferraz Fomin (SP) – Instituto da Criança do Hospital das Clínicas da FMUSP Antonio Carlos Pastorino (SP) - Instituto da Criança do Hospital das Clínicas da FMUSP Beatriz Tavares C. Carvalho (SP) – Escola Paulista de Medicina – Universidade Federal de São Paulo Cristina Maria Kokron (SP) - Hospital das Clínicas da FMUSP Eduardo Finger (SP) – Santa Casa de Misericórdia de São Paulo Fátima Rodrigues Fernandes (SP) – Hospital do Servidor Público Estadual - IAMSPE Jorge Andrade Pinto (MG) – Hospital das Clínicas da Universidade Federal de Minas Gerais Luis Eduardo Coelho Andrade (SP) - Escola Paulista de Medicina – Universidade Federal de São Paulo Luiz Fernando Job Jobim (RS) - Hospital de Clínicas de Porto Alegre. Luiz Vicente Rizzo (SP) - Instituto de Ciências Biomédicas - USP Mônica de Freitas Leitão (SP) – PUC Campinas Myrthes Anna Maragna Toledo Barros (SP) – Hospital das Clínicas da FMUSP Nelson Augusto Rosário Filho (PR) – Universidade Federal do Paraná Pérsio Roxo Júnior (SP) – Hospital das Clínicas de Ribeirão Preto – USP
EXECUTIVE SECRETARIAT
In Time Promoções e Eventos Av. Dr. José Maciel, 618 – T. da Serra – São Paulo – SP – Brazil – 06763-270 PABX: (55 11) 2147-8177 – Fax: (55 11) 2147-8155 [email protected] - www.intimeeventos.com.br/sidep2009
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INVITED SPEAKERS
INTERNATIONAL Andrew Cant - Newcastle General Hospital - Newcastle/England Anne Durandy - Hôpital Necker-Enfants Malades - Paris/France Daniel Suez – The University of Texas Southwestern Medical School at Dallas - Texas/USA Hans Ochs - Seattle Children’s Research Institute - Seattle/USA Jacinta Bustamante - Faculté de Médécine Necker - Paris/France Jean-Laurent Casanova - University of Paris René Descartes - Paris/France João Bosco de Oliveira Filho - National Institutes of Health - Bethesda/USA Marco Cicardi - Università Degli Studi di Milano - Milano/Italy Michael Kirschfink- Universitaet Heidelberg - Heidelberg/Germany Sergio Crovella - Università degli Studi di Trieste Sergio Rosenzweig - National Institutes of Health - Bethesda/USA Steven Holland - National Institutes of Health - Bethesda/USA Sudhir Gupta - University of California – Irvine/USA Thomas Fleisher - National Institutes of Health - Bethesda/USA
BRAZILIAN Adriana Seber (SP) - Instituto de Oncologia Pediátrica - UNIFESP Alberto José da Silva Duarte (SP) – Faculdade de Medicina da USP Aluce Loureiro Ouricuri (RJ) - Hospital dos Servidores do Estado do Rio de Janeiro Andrea Cohon (SP) - Médica Assistente do Serviço de Imunologia Clinica e Alergia do HC Anete Sevciovic Grumach (SP) - Médica pesquisadora do Laboratório de Investigação Médica em Dermatologia e Imunodeficiências do Depto. de Dermatologia FMUSP e médica do Depto. de Pneumologia da FMABC Angela Bueno F. Fomin (SP) - Médica Assistente da Unidade de Alergia e Imunologia do Depto. de Pediatria - FMUSP Antonio Carlos Pastorino (SP) - Médico Assistente da Unidade de Alergia e Imunologia do Depto.de Pediatria - FMUSP Antonio Condino Neto (SP – Campinas) - / Pediatria - Área de Alergia Antonio Zuliani (Botucatu - SP) - Pediatria da Faculdade de Medicina de Botucatu – UNESP Beatriz Tavares Costa Carvalho (SP) – Professora Adjunta do Depto. de Pediatria da EPM- UNIFESP Cristina Maria Kokron (SP) – Professora Colaboradora Médica HC-FMUSP; Ambulatório de Imunodeficiências Primárias do HC-FMUSP Cristina Miuki Abe Jacob (SP) – Profª Associada e Livre Docente do Depto. Pediatria da Faculdade de Medicina USP Dalton Luis Bertolini (SP) – Laboratório de Investigação em Dermatologia e Imunodeficiências (LIM-56) Dewton de Moraes Vasconcelos (SP) – Responsável pelo Ambulatório de Manifestações Dermatológicas das Imunodeficiências do HCFMUSP; Pesquisador Associado ao Laboratório de Investigação Médica em Dermatologia e Imunodeficiências (LIM-56) do Depto de Dermatologia FMUSP
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Eduardo Finger (SP) – Prof. Voluntário da Fac. de Ciências Médicas da Santa Casa de Misericórdia de São Paulo Eitan Berezin (SP) - Prof. Assoc. da Fac. de Ciências Médicas da Santa Casa de Misericórdia de São Paulo Ekaterini Goudouris (RJ) - Department of Pediatrics of Federal University of Rio de Janeiro (UFRJ) Eliana Toledo (S.J. Rio Preto–SP) – Serv. de Alergia e Imunol. Clín do Depto.de Pediatria e Cirurgia Ped. da FAMERP Fabíola Scancetti (DF) - Mestre em Ciências aplicadas à Pediatria pela UNIFESP/EPM Faradiba Sarquis (ES) - Profa. Assistente de Clínica Médica da EMESCAM; Coord. da Disc. de Imunol. da UNIVIX Fátima Rodrigues Fernandes (SP) – Serv. de Alergia e Imunol. Clínica do Hospital do Servidor Público Estadual-FMO Helena Keico Sato (SP) – Vigilância Sanitária da Secretaria de Estado da Saúde de São Paulo Jorge de Andrade Pinto (MG) - Universidade Federal de Minas Gerais – UFMG – Pediatria José Marcos Cunha (RJ) - Professor Adjunto da Faculdade de Medicina - UFRJ Juliana Folloni Fernandes (SP) - Médica do Serviço de Oncologia do Instituto da Criança - HCFMUSP; Médica da Unidade de Hematologia e Transplante de Medúla Óssea do Hospital Israelita Albert Einstein Katya Rocha (SP) – Farmacêutica da FMABC Loreni Kovalhuk (PR) – Depto de Pediatria da UFPR. Mestre em Pediatria; Espec. em Alergia e Imunologia pela ASBAI Lourdes Isaac (SP) – Imunodeficiências das Proteínas do Complemento Humano – ICB/USP Luis Eduardo Coelho Andrade (SP) - Professor do Depto. de Reumatologia da EPM- UNIFESP Luiz Fernando Jobim (RS) - Prof. Associado de Medicina Interna da UFRGS; Chefe do Serviço de Imunologia do HCPA Luiz Vicente Rizzo (SP) – Professor Titular de Imunologia do Instituto de Ciências Biomédicas – USP. Superintendente do Centro de Ensino e Pesquisa do Hospital Albert Einstein Luiza Helena F. R. Carvalho (SP) – Prof. Titular de Pediatria da UNIMES e Inst. de Infect. Emílio Ribas (SP) Magda Mª Sales Carneiro Sampaio (SP) – Professora Titular de Pediatria da Faculdade de Medicina da USP Maria do Socorro Ferrão (SP) - Especialização Infectologia e Pediatria e Instituto de Infectologia Emílio Ribas Maria Elisa Bertocco de Andrade (SP) - Mestre em Imunol. pela UNIFESP e Hosp. do Serv. Públ. Est.- FMO Maria Helena Kiss (SP) - Professora Associada da Faculdade de Medicina da USP Maria Ignez Elsas (RJ) - Fundação Oswaldo Cruz, Instituto Fernandes Figueira, Departamento de Pediatria. Maria Marluce S. Vilela (Campinas-SP) – Professora Titular de Ped. e Imunol. / Centro de Invest. em Ped.– UNICAMP Maria Notomi Sato (SP) - Faculdade de Medicina da USP Marinella Della Negra (SP) - Supervisora da 6ªunidade de Internação do II Emilio Ribas; Profa. Adj. Mol. Infecc. e Paras. da Fac. de Ciências Méd. da Santa Casa de São Paulo Mirian Nacagami Sotto (SP) – Professora Associada da Faculdade de Medicina da USP Mônica de Freitas Leitão (Valinhos – SP) – Professora Titular da PUC de Campinas Myrthes Anna Maragna Toledo Barros (SP) - Médica Superv. do Serv. de Imunol. Clin. e Alergia do HC-FMUSP; Doutora em Microb. e Imunol. - UNIFESP Nelson Augusto Rosário Filho (PR) - Professor Titular de Pediatria - UFPR Pérsio Roxo Júnior (Rib. Preto – SP) - Co-resp. Serv. de Imunol., Alergia e Reumat. Ped. do HC de Rib. Preto - USP Rosana Richtman (SP) – Médica Infectologista do Instituto de Infectologia Emilio Ribas Solange Rodrigues do Valle (RJ) – Mestre em Imunologia e Diretora Secretária da ASBAI - RJ Tatiana Cristina Lawrence (SP) – Mestre em Infectologia Pediátrica; Médica da EPM/UNIFESP Terezinha Martire (RJ) – Universidade do Rio de Janeiro
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Vicente Odone Filho (SP) – Professor Titular de Oncologia Pediátirca da Faculdade de Medicina da USP Victor Nudelman (SP) - Mestre Associado da Disciplina de Alergia, Imunologia, Reumatologia do Depto de Pediatria da UNIFESP; Imunologista da ClÍnica de Especialidades Pediátricas do Hospital Israelita Albert Eisntein Virginia Ferriani (SP) - Professora Associada do Depto. de Pediatria da Faculdade de Medicina de Ribeirão Preto Wilma Neves Forte (SP) – Coord. e Profa. Adj. da Disc. de Imunol. da Fac. de Ciências Méd. da Santa Casa de SP Wilmar Dias da Silva (SP) - Professor Titular, Universidade Estadual do Norte Fluminense - Darcy Ribeiro.
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EDITORIAL
Dear Colleagues,
It is indeed a great honor to present to you the program of “The 2nd International Symposium on Primary Immunodeficiencies – II SIDEP”. This meeting will be held on September 30 - October 3, 2009 at the Rebouças Convention Center, in São Paulo, Brazil.
Like the previous program, this symposium is designed to provide the most up-to-date information about primary immunodeficiency diseases and to highlight the significance of integrated health care via a multidisciplinary approach. The faculties of this symposium are the most outstanding authorities in their fields and have extensive experience in sharing their evidence-based scientific knowledge with the participants. The program starts with a selection of pre-symposium lectures presented by Brazilian experts followed by the “Opening Ceremony” and “International section of the Symposium”
New this year, II SIDEP kicks off on Wednesday with a full day of education, directed to two different populations: 1: Physicians and basic scientists / trainees updating on primary immunodeficiencies, 2: Nurses and healthcare personnel, with a course directed to improve the knowledge of general aspects of primary immunodeficiencies and the specific training on the characteristics, preparation and adverse effects usually observed during the administration of Intravenous immunoglobulin (IVIg).
There is no doubt that the implementations of the currently available “state-of-the-art” possibilities in primary immunodeficiencies diagnosis and therapy are a major challenge among medically underserved populations. This summit will focus on the implications of specialized health care delivery beyond the financial issues, trying to minimize the issues of limited human knowledge of the inherited immunodeficiencies in our country and the implications of more late-stage diagnosis and the consequent need for more aggressive and expensive therapeutics.
The II SIDEP brings together these researchers and clinicians from around the world, working in basic and clinical immunology. The meeting is also an opportunity to bring together affiliated biotechnology, pharmaceutical and tool companies in a forum where attendees can share their work and ideas. The organization is growing and broadening its scope in pursuit of its mission: to improve human health through immunology. Our symposium has achieved the status of an accredited educational program that helps keep our trainees and colleagues abreast of the dramatic advances in our field.
This symposium is the product of four years of planning with participation of highly committed colleagues across the world. The program is sponsored by the Faculdade de Medicina da Universidade de São Paulo. Please join me in extending my most sincere thanks to the members of the II SIDEP Organizing Committee for their time, energy and expertise. Thank you for taking part in this meeting and for helping to further the mission of this symposium, which promises to be a not-to-be-missed event.
We are looking forward to welcoming you to São Paulo, Brazil in September – October 2009.
Prof. Dr. Alberto José da Silva Duarte President of the Symposium
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Wednesday – September 30, 2009
Pre-Symposium Courses UPDATE COURSE IN IMMUNODEFICIENCIES Location: Rebouças Convention Center- Yellow Room
Moderator: Andrea Cohon (SP) and Eliana Toledo (SP) 08:30 to 09:00 AM: The immune response - Maria Notomi Sato (SP) 09:00 to 09:30 AM: Development of the immune system in children and when to suspect immunodeficiency? - Ekaterini Simões Goudouris (RJ) 09:30 to 10:00 AM: Laboratorial evaluation of the immune response - Dewton de Moraes Vasconcelos (SP) 10:00 to 10:30 AM: Discussion
10:30 to 11:00 AM: Coffee break
Moderator: Maria Cristina Kokron (SP) and Marinella Della Negra (SP) 11:00 to 11:30 AM: Predominantly humoral immunodeficiencies - Beatriz Costa Carvalho (SP) 11:30 AM to 12:00 PM: Cellular and combined immunodeficiencies - Jorge Andrade Pinto (MG) 12:00 to 12:30 PM: Discussion
12:30 - 2:00 PM: Lunch
Moderator: Wilma Carvalho Neves Forte (SP) and Maria do Socorro Carneiro Ferrão (SP) 2:00 to 2:30 PM: Disorders of phagocytes and complement - Mônica de Freitas Leitão (SP) 2:30 to 3:00 PM: Vaccination in immunodeficient patients - Maria Marluce of Santos Vilela (SP) 3:00 to 3:30 PM: Nutritional aspects of immunodeficiency - Cristina MiukiAbe Jacob (SP) 3:30 to 3:45 PM: Discussion
3:45 - 4:15 PM: Coffee break
Moderators: Victor Nudelman (SP) and Maria Elisa Bertocco Andrade (SP) 4:15 to 4:55 PM: Autoimmunity in Primary Immunodeficiency Diseases – Sudhir Gupta (USA) 4:55 to 5:25 PM: Treatment of immunodeficiencies - Fátima Rodrigues Fernandes (SP) 5:25 to 6:05 PM: Bone marrow transplantation in primary immunodeficiencies -Adriana Seber (SP) and Juliana Folloni Fernandes (SP) 6:05 PM: Discussion
Wednesday – September 30, 2009
Pre-Symposium Courses TRAINING COURSE FOR NURSES Location: Rebouças Convention Center - Red Auditorium
Moderators: Aluce Loureiro Ouricuri (RJ) and Katya Rocha (SP) 08:30 to 09:00 AM: The Immune Response - Eduardo Finger (SP) 09:00 to 09:30 AM: When to suspect immunodeficiency? - Antonio Carlos Pastorino (SP) 09:30 to 10:00 AM: How to diagnose immunodeficiencies? - Tatiana Cristina Lawrence (SP) 10:00 to 10:30 AM: Discussion
10:30 to 11:00 Coffee break
Moderators: Antonio Zuliani (SP) and Faradiba Sarquis (ES) 11:00 to 11:30 AM: Classification and main immunodeficiencies - José Marcos Cunha (RJ) 11:30 AM to 12:00 PM: Treatment of Immunodeficiencies and indications of immunoglobulins - Persio Roxo Junior (SP) 12:00 to 12:30 PM: Discussion
12:30 - 13:30 Lunch
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Moderators: Terezinha Martire (ES) and Solange Valle (RJ) 1:30 to 2:00 PM: Characteristics of Immunoglobulins for intravenous use and adverse effects - Fabiola Scancetti (DF) 2:00 to 3:30 PM: Preparation and administration of immunoglobulins - Daniel Suez (USA)
3:30 to 4:00 Coffee break
Moderators: Loreni Kovalhuk (PR) and Dalton Luis Bertolini (SP) 4:00 to 4:30 PM: Orientation of patients and complications arising from the use of gamma globulin - Daniel Suez (USA) 4:30 to 5:30 PM: Discussion
Thursday, October 01st, 2009
Symposium Program Location: Rebouças Convention Center - Grand Auditorium
08:30 to 08:45 AM: OPENING. Alberto J. S. Duarte (SP)
Chairs: Alberto J. S. Duarte (SP) and Nelson Rosário (PR) 08:50 to 09:30 AM: Historical view of Primary Immunodeficiency Diseases - PIDs - Hans Ochs (EUA) 09:30 to 10:10 AM: Sensing microbes - Steven Holland (EUA)
10:10 to 10:30 AM: Coffee Break and visiting to expositors
Chairs: Luiz Fernando Jobim (RS) and Maria Ignez Elsas (RJ) 10:30 to 11:10 AM: Flow cytometry for the diagnosis of Primary Immunodeficiencies - Thomas Fleisher (EUA) 11:10 to 11:50 AM: Molecular diagnosis of PIDs - João Bosco de Oliveira Filho (EUA)
11:50AM to 12:50 PM: Baxter Satellite symposium
12:30 to 2:30 PM: POSTER PRESENTATION AND LUNCH Evaluators: Michael Kirschfink (Alemanha), Marco Cicardi (Itália), Sergio Crovella (Itália), Steven Holland (EUA), Hans Ochs (EUA) and Jacinta Bustamante (França)
Chairs: Mirian N. Sotto (SP) and David Uip (SP) 2:30 to 3:10 PM: Dermatological manifestations of PIDs - Dewton de Moraes Vasconcelos (SP) 3:10 to 3:50 PM: Defects on Innate Immunity - Jean Laurent Casanova (França) 3:50 to 4:30 PM: Diagnostic Approach to patients with susceptibility to Mycobacteria - Sergio Rosenzweig (EUA)
4:30 to 4:50 PM: Coffee Break and visiting to expositors
4:50 to 5:30 PM: Vaccines for Primary Immunodeficient Patients Chairs: Luiza Helena Carvalho (SP) and Eitan Berezin (SP) Speakers: Anete S. Grumach (SP), Jean Laurent Casanova (França), Rosana Richtman (SP), Sergio Rosenzweig (EUA) and Steven Holland (EUA)
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Friday, October 02nd, 2009
Symposium Program Location: Rebouças Convention Center - Grand Auditorium
Chairs: Daniel Suez (EUA) and Lourdes Isaac (SP) 08:30 to 09:10 AM: Laboratorial diagnosis of complement deficiencies - Michael Kirschfink (Alemanha) 09:10 to 09:50 AM: New acquisitions on Hereditary Angioedema - Marco Cicardi (Itália)
09:50 to 10:10 AM: Coffee Break and visiting to expositors
Chairs: Wilmar Dias da Silva (SP) and Virginia Ferriani (SP) 10:10 to 10:50 AM: Clinical relevance of the lectin pathway of complement - Sergio Crovella (Itália) 10:50 to 11:30 AM: Complement deficiencies in Brazil - Anete S. Grumach (SP)
12:10 to 2:30 PM: POSTER PRESENTATION AND LUNCH Evaluators: Jean Laurent Casanova (França), Thomas Fleisher (EUA), Anne Durandy (França), Sergio Rosenzweig (EUA) and João Bosco de Oliveira Filho (EUA)
Chairs: Beatriz Costa Carvalho (SP) and Myrthes Toledo Barros (SP) 2:30 to 3:10 PM: Diagnosis of class-switch defects - Anne Durandy (França) 3:10 to 3:50 PM: New findings on combined immunodeficiencies - Andrew Cant (Inglaterra)
3:50 to 4:10 PM: Coffee Break and visiting to expositors
Chairs: Jorge Andrade Pinto (MG) and Maria Marluce Santos Vilela (SP) 4:10 to 4:30 PM: Symptoms and signs for PID diagnosis in infants - Magda M. S. Carneiro Sampaio (SP) 4:30 to 5:10 PM: Phagocyte defects and infections: what’s new? - Steven Holland (EUA)
Chairs: Pérsio Roxo Júnior (SP) and Ekaterine Goudouris (RJ) 5:10 to 5:50 PM: Immunoglobulin replacement for Primary Immunodeficiencies -Andrew Cant (Inglaterra), Anne Durandy (França), Dewton de Moraes Vasconcelos (SP), Hans Ochs (EUA) and Thomas Fleisher (EUA)
Saturday, October 03rd, 2009
Symposium Program Location: Rebouças Convention Center - Grand Auditorium
Chairs: Maria Helena Kiss (SP) and Antonio Condino Neto (SP) 08:30 to 09:10 AM: Autoinflammatory syndromes - João Bosco de Oliveira Filho (EUA) 09:10 to 09:50 AM: Diagnosis of NF-kB axis defects - Jacinta Bustamante (França) 09:50 to 10:30 AM: The spectrum of IPEX and APECED - Hans Ochs (EUA)
10:30 to 11:00 AM: Coffee Break and visiting to expositors
Chairs: Vicente Odone Filho (SP) and Alberto José da Silva Duarte(SP) 11:00 to 11:40 AM: Stem-cell transplantation and gene therapy - Andrew Cant (Inglaterra) 11:40 to 12:20 AM: What have we learned about PIDs? - Jean Laurent Casanova (França) 12:20 AM to 12:50 PM: Closing remarks – Alberto José da Silva Duarte (SP)
XII ISSN 0036-4665 ISSN 1678-9946 on line
CONTENTS
Summary of The Lectures...... 1 Immune response: interplay between innate and adaptive immunity...... 1 Development of the immune system in children and when to suspect of primary immunodeficiency diseases...... 3 Laboratorial evaluation of the immune response...... 5 Humoral deficiencies...... 6 Cellular and Combined Immunodeficiencies...... 8 Disorders of phagocytes and complement...... 9 Nutritional aspects of primary immunodeficiencies...... 10 Management of primary immunodeficiencies...... 11 Allogeneic stem-cell transplantation for primary immune deficiency diseases...... 12 The immune system...... 14 When there is suspicion of immunodeficiency?...... 15 How to diagnose Immunodeficiency patients?...... 16 Treatment of immunodeficiencies and indication of immunoglobulins -...... 18 Characteristics and adverse effects of available intravenous immunoglobulins...... 19 Flow Cytometry for the Diagnosis of Primary Immunodeficiencies...... 22 Dermatological manifestations of primary immunodeficiencies...... 22 Laboratorial diagnosis of complement deficiencies...... 24 New acquisitions on Hereditary Angioedema...... 24 Clinical relevance of the lectin pathway of complement...... 26 Complement deficiencies in Brazil...... 28 Immunoglobulin class switch recombination defects...... 29 New Findings on Combined Immunodeficiencies...... 31 Diagnosis of NF-kB axis defects...... 32 The Spectrum of IPEX and APECED...... 32 Stem Cell Transplantation and Gene Therapy...... 33 Posters Case Reports – PCR...... 34 Posters Immunological Investigation – PII...... 45 Author Index...... 61
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SUMMARY OF THE LECTURES
IMMUNE RESPONSE: INTERPLAY BETWEEN INNATE AND ADAPTIVE IMMUNITY
Maria Notomi Sato Laboratory of Investigation in Dermatology and Immunodeficiencies- LIM 56 School of Medicine – University of São Paulo
The immune system is one of the most complex cellular organizations Other families of PRR have been described, as RLHs (RIG-like that exist in the body. This system is composed of multiple cell types helicases) and NLRs (NOD-like receptors). These families consist of that are arranged in distinct organs or circulate through the blood and soluble proteins that survey the cytoplasm for signs the presence of peripheral tissues. The multifaceted purpose of the immune system is intracellular invader. The RIG-I-like receptors constitute a family of necessary to establish strategies to block or to destroy an infectious agent, cytoplasmic RNA helicases that are critical for host antiviral responses. afterwards to keeping the homeostasis of the system. The lymphocytes RIG-I (retinoic-acid-inducible protein 1or Ddx58) and MDA-5 (Helicard) possess important peculiarities in order to maintain all the information were identified as cytoplasmic, viral RNA sensors. Upon viral stimulation, received throughout their life, with the ability to react quickly after contact NFkB and IRF3/7 are activated, inducing the production of type I with the pathogen, confer protective immunity against re-infections. The interferons. The RLH play essential roles in the recognition of RNA immune system properties, includes the ability to discriminate between viruses in various cells, while plasmacytoid dendritic cells utilize TLR self and foreign antigens, specificity for distinct antigens, diversity for detecting virus invasion. of antigen recognition, memory for antigen exposure, self-limitation NOD-Like Receptors (NLRs or CATERPILLERs) constitute a family and immunoregulatory control mechanism. Failures of one of these of intracellular PRRs, which their primary role is to recognize cytoplasmic mechanisms may lead to disease with deficient or excessive immunity. PAMPs and/or endogenous danger signals also called damage-associated The immune system allows their cells to recognize the antigenic molecular patterns (DAMPs), inducing immune responses. NLRs are mosaics expressed by the infectious agents and to eliminate them, characterized by a tripartite-domain organization with a conserved based on the limited number of germline encoded receptors called nucleotide binding oligomerization domain (NOD) and leucine-rich pattern-recognition receptors (PRRs) and mainly by the large repertoires repeats. NOD1 senses the D-γ-glutamyl-meso-DAP dipeptide which is of unique antigenic receptors of B and T lymphocytes (1014 and 1018, found in proteoglican of all Gram-negative and certain Gram-positive respectively). From the recognition of the antigen by antigen-presenting bacteria while NOD2 recognizes the muramyl dipeptide structure found cells (APC) to the lymphocytes, series of cellular events are generated, in almost all bacteria. Some of the NLRs also sense nonmicrobial danger culminating in the differentiation and proliferation of antigen-specific signals and form large cytoplasmic complexes called inflammasomes effector cells able to produce specific antibodies and/or specialized that link the sensing of microbial products and metabolic stress to the functions. The resolution of an infection is a dynamic process that proteolytic activation of the proinflammatory cytokines IL-1β and IL-18. depends on factors derived from the microorganism as well as from the Caspase-1 participates in the processing and subsequent release of these host, which may determine the outcome of the infection. cytokines. Three prototypes of inflammasomes: the NALP1, NALP3 The elements that participate in the innate immunity include and the IPAF. For several NALPs, there is evidence for their roles as components of complement system, inflammatory mediators, chemokines, scaffolding proteins of inflammasomes. It is assumed that the PYD of cytokines, PRRs recognizing conserved pathogen-associated molecular NALPs interacts and recruits the adaptor ASC (apoptosis associated patterns (PAMPs), anti-microbial peptides, cellular populations, etc. The speck-like protein containing a caspase recruitment domain) via PYD- ability of the innate immune system to recognize and respond to microbial PYD interaction. ASC contains an N terminal PYD and a C-terminal components has been attributed to the PRRs. A group of proteins that CARD and is an essential component for inflammasome formation. comprise the Toll or Toll-like family of receptors (TLRs) are the most NALP3 mediates caspase-1 activation in response to a wide variety intensively studied. These receptors are expressed mainly on APCs such of stimuli: whole bacteria (Listeria monocytogenes, Staphylococcus as monocytes, macrophages and dendritic cells (DC) and show an ability aureus), bacterial RNA, synthetic purine-like compounds (R848, R837), to discriminate distinct PAMPs. Ten human and twelve murine TLRs uric acid crystals, extracellular ATP and pore-forming toxins (nigericin, have been characterized, each of them recognizing conserved PAMPs. For maitotoxin). The understanding of the biology of NLRs will help to example, TLR4 is triggered by lipopolysaccharide (LPS), TLR3 by double- elucidate their role in host responses to infectious agents and to danger stranded RNA, TLR5 by bacterial flagellin and TLR9 by unmethylated signals, but also will certainly contribute to the development of novel oligodinucleotide (CpG). TLRs recognizing nucleic acids (TLR3, TLR7, types of anti-inflammatory drugs. TLR8 and TLR9) are primarily or completely contained in intracellular Dendritic cells monitor their surrounding environment and coordinate membranes and unavailable for interaction with extracellular ligands. an appropriate response during both steady-state and inflammatory Stimulation of TLRs by PAMPs initiates signaling cascades that involves conditions. DC are central to T lymphocyte activation and differentiation a number of proteins, such as MyD88, TRIF and IRAK, leading to the into T helper type 1 (Th1), Th2, Th17 cells and cytotoxic T lymphocyte activation of transcription factors, such as AP-1, NF-κB and IRFs inducing (CTL) effectors. DCs have been categorized in two broadest categories the secretion of pro-inflammatory cytokines that direct the adaptive immune being conventional DC (cDC) and plasmacytoid dendritic cells (pDC). response. TLR signaling trigger DC maturation, increasing expression of Upon activation immature cDC may differentiate and migrate via the major histocompatibility complex (MHC) molecules and costimulatory afferent lymphatics into draining lymph nodes. Upon maturation, cDC molecules, bridging innate and adaptive immunity. downregulate their ability to capture antigen and enhanced ability
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to stimulate T cells to present the antigenic peptides on the relevant CD4+ T cell precursors and Th1, Th2 and Th17 T helper cell subsets, to MHC molecules. This process involves phagocytosis, upregulation of adopt overlapping functional profiles or potentially to switch from one costimulatory and MHC molecules, secretion of cytokines and chemokines lineage to another. In addition, as TGF-b also induces differentiation and antigen presentation by DCs. The pDCs circulate through the blood, of naive T cells into CD4+CD25+Foxp3+ regulatory T cells (Tregs) in lymph nodes and the spleen and, upon stimulation, migrate to the T-cell the peripheral immune compartment, the participation of TGF-b in the area of lymphoid organs producing robust type I interferons secretion, differentiation of Th17 cells places the Th17 lineage in close relationship important in the context of systemic viral or bacterial infections, but also with Foxp3+ Tregs. exerting a tolerogenic effect on the immune system. cDCs migrate to T Immune response regulation includes homeostatic mechanisms cell areas seek out antigen-specific T cells and induce their activation intrinsic to the activation and differentiation of antigen-triggered and differentiation into effector cells, initiating antigen-specific immune immunocompetent cells and extrinsic mechanisms mediated by responses, or immunological tolerance. DCs provide the naïve T cells regulatory cells. The suppressor cells were reborn as regulatory T cells, with two signals required to their activation. The first signal is the result when it was identified several T cell subsets that had the ability to of binding of the T-cell receptor (TCR) to peptide presented by the MHC inhibit proliferation of others cells, mainly by cell-to-cell contacts and molecule. secretion of cytokines. IL-10-secreting T regulatory type I (Tr1) cells and Antigen processing and presentation are processes performed by TGF-b-secreting T helper cells (Th3) were postulated to be involved in APCs, as DCs, macrophages and B lymphocytes. Pathways of assembly the maintenance of tolerance to dietary antigen and to prevent chronic of MHC molecules ensure that class II molecules preferentially display intestinal inflammation. A naturally occurring subset of CD4+CD25+ peptides that are derived from extracellular proteins and taken up in to regulatory T cells are mainly thymus derived and are central in regulating vesicles in APCs, and class I molecules present peptides from cytosolic self-reactive T cells and preventing autoimmune disease. These cells can proteins. The intersection of the endosomal system with the endoplasmic be shown to be dependent of cell-cell contact, and the transcription factor reticulum in macrophages and DC may acts as an organelle optimized for Foxp3 was identified as a control gene that define this subset. Deficiency MHC class I–restricted cross-presentation of exogenous antigens (cross- or dysfunction of these cells can be a cause of autoimmune disease. A presentation). Class II MHC molecules interact or present peptides for mutation in the gene encoding Foxp3, a helix family of transcription CD4+ lymphocytes due to the affinity between these molecules, as well factors, was identified as the genetic defect underlying autoimmune as class I MHC molecules to CD8+ cells. and inflammatory disease in scurfy mice. This mutation is also found The second signal is provided by the costimulatory molecules such in humans with IPEX (immune dysregulation, polyendocrinopathy, as B7.1 (CD80) and B7.2 (CD86), which are expressed by DC and which enteropathy X-linked syndrome) and XLAAD (X-linked autoimmunity trigger CD28 expressed on naïve T cells. Interaction of costimulatory allergic dysregulation syndrome). Natural Treg cells may limit the molecules with their ligants in APCs, such as CD40/CD40L and CD28/ magnitude of effector responses, which may result in failure to adequately B7, and interaction of adhesion molecules, CD2/LFA-3 and ICAM-1/ control infection. However, natural Treg cells also help limit collateral LFA-1, are essential to achieve full activation responses. In contrast to tissue damage caused by vigorous antimicrobial immune responses. The CD28, CTLA-4 (cytotoxic T-lymphocyte antigen 4, CD152) up-regulation immune regulatory cells are central in the control of immune reactivity. following T cell activation is thought to be negative regulator of T cell Both autoimmunity and chronic inflammatory responses can be attributed activation, by inhibition of IL-2 receptor expression and restriction of to failures of immunoregulatory control mechanisms. normal cell cycle progression. Programmed death-1 (PD-1) receptor, an inhibitory costimulatory molecule found on activated T cells, has REFERENCES been demonstrated to play a role in the regulation of immune responses and peripheral tolerance. In the absence of costimulatory signal, T Medzhitov R, Janeway C. Innate Immunity. NEJM 343:338-344, 2000. lymphocytes may be deleted by apoptosis or become anergic. Martinon F, Mayor A, Tschopp J. The Inflammasomes: Guardians of the Body. Annu. Rev. Immunol. 27:229–265, 2009. The avidity of the T-cell receptor to the antigen/MHC complex, the Mosmann TR, Cherwinski H, Bond MW, Giedlin MA, Coffman RL. Two types of murine nature of costimulatory molecules and the cytokine environment all helper T cell clone. I. Definition according to profiles of lymphokine activities and influence the fate of a Th precursor cell. DCs represent a critical source of secreted proteins. J. Immunol. 136:2348–2357, 1986. IL-12, that plays a key role in innate responses and drives Th1 polarization Murphy E, Shibuya K, Hosken N, Openshaw P, Maino V, Davis K, Murphy K, O’Garra A. as well as for CTL responses. Generation of CTL responses to viral Reversibility of T helper 1 and 2 populations is lost after long-term stimulation. J. Exp. Med. 183:901–913, 1996. infections, organ transplants or tumor cells, require cytokines, such as Zheng W, Flavell RA. The transcription factor GATA-3 is necessary and sufficient for Th2 IL-2 and IFN-g, but also IL-12 produced by APCs. Antigen-activated cytokine gene expression in CD4 T cells. Cell 89:587, 1997. CD8+ T cells differentiate into functional CTLs, which lyse target cells Weiner, H. L. Induction and mechanisms of action of transforming growth factor-b secreting expressing specific antigen-MHC complexes. Th3 regulatory T cells. Immunological Reviews 182:207-214, 2001 CD4 T cells have been divided into several subsets as defined by their Reis e Sousa, C. Dendritic cells in a mature age. Nat. Rev. Immunol. 6, 476–483, 2006. Shortman, K., Liu, Y.J. Mouse and human dendritic cell subtypes. Nat. Rev. Immunol. 2, cytokine products and functions after their activation, including Th1, Th2, 151–161, 2002. and Th17 cells. 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Mucida D, Park Y, Kim G, Turovskaya O, Scott I, Kronenberg M, Cheroutre H. Reciprocal Lee, YK, Turner H, Maynard CL, Oliver JR, Chen D, Elson CO, Weaver CT. Late TH17 and regulatory T cell differentiation mediated by retinoic acid. Science developmental plasticity in the T helper 17 lineage. Immunity.30:92–107, 2009. 317:256, 2007.
DEVELOPMENT OF THE IMMUNE SYSTEM IN CHILDREN AND WHEN TO SUSPECT OF PRIMARY IMMUNODEFICIENCY DISEASES.
Ekaterini Simões Goudouris Department of Pediatrics of Federal University of Rio de Janeiro (UFRJ) Allergy and Immunology Clinics of IPPMG – UFRJ
INTRODUCTION increasing protein, which binds to lipid A portion of LPS, directly killing the bacteria and acting as an opsonin. Here we will talk about the so called physiologic immunodeficiency Mononuclear cells - The number of monocytes and macrophages of immaturity and its consequences, as well as the initial manifestations of newborns is normal. of primary immunodeficiency disorders. The phagocytic and the microbicidal activities of macrophages seem Term newborns present a series of quantitative and functional to be compromised, as demonstrated in studies with macrophages of the disorders of many components of the immune system. Premature bronchoalveolar lavage. It is possible that local (pulmonary) alterations newborns, those small for gestational age, and those submitted to stress jeopardize the function of these cells. present even more important disorders. We used to think that the neonatal The exit of monocytes from blood to tissues and consequent period was characterized for absence of immune response. Now we know inflammatory response are reduced in the neonatal period, with a well that this response might be deficient, but not absent, and in account of known alteration of the late response intradermic tests, which persists the immaturity of the immune mechanisms and/or absence of antigen during the early childhood. There is a smaller chemotaxis and a smaller exposition. The “normalization” of these disorders, reaching adult´s production of chemokines. The phagocytic and microbicidal activities parameters, varies depending on the immune system compartment studied are apparently normal. and from one individual to another. The majority of studies have revealed that the newborn’s monocytes Neutrophils – The number of circulating neutrophils´ precursors in produce less proinflammatory cytokines, but this is counterbalanced by fetus and newborns is 10 to 20 times higher than in adults. The neonatal a reduced production also of anti-inflammatory cytokines. This may bone marrow has also a huge number of precursors. The proliferative not be true for the pulmonary macrophages, which may have an even index of neutrophil precursors is next to the maximum, the reason why smaller capacity to produce anti-inflammatory cytokines, favoring there is a small capacity to increase the G-CSF in face of an infectious the development of inflammatory pulmonary diseases. The smaller process. The limitation of the reserve pool and the smaller capacity to production of cytokines probably occurs because of a smaller production increase the number of cells, and not a deficiency of G-CSF, is responsible of IFN-g by T and NK cells. for the neutropenia usually seen in newborns with sepsis, especially the Humoral mediators of inflammation and opsonization – There is premature ones. no placental transference of the Complement system components. The There are evidences of alterations in function of neutrophils in vitro. AP50 activity is mildly reduced and CH50 is little reduced in newborns, The ability to migrate to tissues is diminished, and that occurs probably mainly in the premature ones. There´s also an important deficiency of because of problems with adhesion or with chemotaxis. The adhesion the final components of the Complement, chiefly of C9. There is also to activated endothelium is reduced, probably due to smaller expression smaller production of C5a which has quemotatic activity for neutrophils. of L-selectin and to the smaller ability to bind to P-selectin of the The fibronectin levels are diminished, mainly in the premature baby and endothelium. The chemotaxis of newborns´ neutrophils, especially the in sepsis they may fall even more. The production of C-reactive Protein is premature ones, is clearly smaller when compared to the one of adults. normal in newborns and it may be used in the diagnosis of sepsis, even in the This may happen because of a reduced response to chemotatic molecules. neonatal period. The Mannan-Binding Lectin (MBL) levels are diminished There is also description of a reduced deformability, particularly in the by 50% of adults´ levels, but only in premature babies. Surfactant immature cells, and a decreased capacity to reorganize the cytoskeleton apoproteins A and D are members of the same family of MBL, with the in response to stimulation. same opsonization action and are synthesized by type II alveolar epithelial Apparently, the neutrophils of term and premature newborns are cells. Therefore, in premature newborns, the deficiency of surfactant is one able to efficiently bind and ingest bacteria. Nevertheless, as we will see more reason to have a greater risk for pulmonary infections. ahead in this text, there is, at least in premature newborns, a deficient These alterations provoke a minor ability to opsonize, especially in opsonization (because of reduced IgG and complement molecules), face of low levels of specific antibodies. impairing the phagocytosis. The reduction of neutrophils´ Fcg receptors NK cells - The NK cells present in normal numbers in the neonatal and receptors for complement molecules is discrete and may not be period, but 50% of them are CD56-, a marker of immaturity. The cytotoxic responsible for the diminished opsonization. function is therefore impaired: both the antibody independent and the The capacity of intracellular digestion is jeopardized in premature ADCC (antibody dependent cellular cytotoxicity). newborns, but not in term newborns. The generation of superoxide anions Antigen presentation – Despite the minor expression of MHC class I is normal, with a diminished generation of hydroxyl radicals. Azurophilic molecules, apparently there´s no major loss in antigen presentation. It has granules of newborns has a smaller content of bactericidal permeability been demonstrated a limited role of B lymphocytes as antigen presenting
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cells in the neonatal period. Cord blood (CB) dendritic cells (DCs) seem susceptibility for virus and intracellular microbes can occur in account of to be less effective than adult DCs in supporting proliferation of T cells alterations of NK cells´ functions, in production of cytokines, in activity in response to antigenic stimulation. There´s a predominance of type II of macrophages, in lymphocytes T cytotoxicity, besides ADCC (antibody dendritic cells or plasmocytoid cells. The presentation of antigens by these dependent). there are several mechanisms that might operate to produce cells propitiates a Th2 effector response, by activating naive CD4+ cells. the relative immunodeficiency that is seen in neonatal period. We also This may be the reason why there is a preponderance of Th2 response in don´t know the exact mechanisms responsible for many of the alterations newborns in face of environmental antigens, and a limited response to described. Much is to be studied. intracellular pathogens (limited Th1 response), as well as the maintenance It´s probable that these observed alterations are responsible, at least of fetal-maternal tolerance during the gestation period and the low risk in part, for a major susceptibility of young children to various infectious of graft- versus- host disease after cord blood transplantation. diseases. So, when should we suspect of a primary immunodeficiency T cells – There is no transference of maternal specific T cell immunity disease? to the fetus. The thymus increases since the second trimester of gestation Not all the primary immunodeficiency diseases present early in until he reaches his maximum size at ten years old. It is responsible for life, just the most severe ones do, especially the combinated defects of the maintenance of the peripheral T cells compartment. In the neonatal T and B cells. Severe diarrhea, extensive mucocutaneous candidiasis, period there is a huge number of circulating T cells, but a preponderance opportunistic agents infections (P. jeroveci), severe reaction to BCG, of naïve T cells, with lesser memory/effector cells. It´s been described vaccine-related poliomyelitis, cutaneous manifestations of graft-versus- a lesser expression of CD40 ligand; that means the preponderance of host disease or the absence of thymus image in thorax radiography lead cells with a minor ability to produce cytokines and properly perform to a suspicion of this type of immunodeficiency. One of these combined the cellular interaction process. The T cells cytotoxicity, the activation defects which have more distinctive and early clinical manifestations is of B cells and the late phase cutaneous response are also jeopardized. Omenn Syndrome, a severe and extense eczema, similar to hystiocytosis B cells and immunoglobulins – There are well known milestones associated to hepatoesplenomegaly and lymphadenomegaly. of the humoral immunity development (figure 1). It´s important to The predominantly antibody deficiencies rarely produce clinical emphasize that IgA is the last immunoglobulin to reach adults´ levels manifestations in the neonatal period, on account of the maternal and that there is a minor production of anti-polysaccharide antibodies transference of IgG via placenta. The diagnosis of selective deficiency until 2 or 3 years old. These alterations probably occur because of B of IgA can only be done after 4 years of age. The reduced response cells immaturity and a jeopardized interaction with T cells. In newborns, to polysaccharide antigens that occurs in children less than 2 years of reduced levels of CD21 expression and low complement activity result in age makes the evaluation of number and severity of common bacterial a lack of CD21/BCR synergy and contribute to defective B-cell activation. infections, as otitis and pneumonias, extremely important to suspect of Newborns are protected by maternal IgG placental transference, primary immunodeficiency disorders. which occurs mainly in the last trimester of pregnancy. Therefore, the In the group of other well defined immunodeficiency syndromes, the premature newborns, mainly those born before 34 weeks, have a humoral ones that can initiate their manifestations early in life are: the Wiskott - defense significatively diminished. Aldrich syndrome (eczema, thrombocytopenia), chronic mucocutaneous candidiasis and DiGeorge Syndrome (hypocalcemia, abnormal facies and congenital cardiac disorders). The immune dysregulation diseases that can initiate their manifestations early in life are Chédiak–Higashi syndrome and Griscelli syndrome (partial albinism), APECED (autoimmune polyendocrinopathy with candidiasis and ectodermal dystrophy) e IPEX (immune dysregulation, polyendocrinopathy, enteropathy X-linked). In the congenital defects of phagocytes group, a delayed umbilical cord detachment may suggest leukocyte adhesion deficiencies, and onphalitis may suggest chronic granulomatous disease. The presence of suggestive or positive familiar history for primary immunodeficiency diseases must lead to an immediate investigation, Figure 1 - from Morena & Shackelford – Immunologic Development and Susceptibility to independent of the presence of clinical manifestations. Presently, it´s Infection in Long: Principles and Practice of Pediatric Infectious Diseases. 3rd. Ed, 2008, even possible to make a prenatal diagnosis, using fetal tissue after tenth Elsevier. week of gestation, or fetal blood after 22th week of gestation. We must be very alert when evaluating results of laboratory exams PRIMARY IMMUNODEFICIENCY DISEASES (PID) in children, especially the younger ones. We must always have in mind the non pathologic alterations usually described in small children. Unanswered questions concern the time required for maturation of The major relevance of this theme resides in the fact that the earliest innate immunity to adult-like functions and the potential physiological the diagnosis and the treatment, the smaller the morbidity and the role of the limitation of innate immunity in the maternal-fetal and mortality of this group of diseases. early-life context. We don´t know for sure how much the alterations in immune system observed in small children, when compared to adults, REFERENCES can be clinically relevant, but we know that these components of immune system are important to the opsonin-phagocytic death of E.coli and Durandy, A & Griscelli, C. – Prenatal diagnosis of severe and hereditary immunodeficiencies. group B streptococcus, as well as fungi as Candida sp. Similarly, the Ann Pediatr (Paris), 1989;86(6):403-7.
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Edwards, M.S. & Baker, C.J. – Sepsis in the Newborn in Gershon: Krugman´s Infectious grown up? Immunology Today, 2000; 21(1);35-41. Diseases of Children, 2004, 11th Edition, Mosby inc., chapter 31. Morena, M. de la – Immunologic Development and Susceptibility to Infection in Long: Kovarik, J & Siegrist, C. Immunity in early life. Immunology Today, 1998; 19(4):151-3. Principles and Practice of Pediatric Infectious Diseases, 2008, 3rd. Edition, Elsevier, Lewis, D.B. & Tu, W – The physiologic immunodeficiency of immaturity in Stiehm, Ochs, chapter 10. Winkelstein – Immunologic Disorders in Infants & Children, 2004, 5th Edition, Schroeter,C.H.; Gibbons, F.K.; Finn, P.W. Development of the early immune system: Elsevier Saunders, chapter 22. impact on allergic diseases. Immunol Allergy Clin N Am, 2002; 22:713– 36. Maródi, L. Innate cellular immune responses in newborns. Clinical Immunology, 2006; Stiehm, E.R., Ochs, H.D. and Winkelstein, J.A. – Immunodeficiency Disorders: General 118:137 – 44. Considerations in Stiehm, Ochs, Winkelstein – Immunologic Disorders in Infants & Marshall-Clarke, S; Reen, D.; Tasker, L.; Hassan, J. Neonatal immunity: how well has it Children, 2004, 5th Edition, Elsevier Saunders, chapter 12.
LABORATORIAL EVALUATION OF THE IMMUNE RESPONSE
Dewton de Moraes Vasconcelos; Laboratory of Investigation in Dermatology and Immunodeficiencies (LIM-56) and Dermatological Manifestations of Primary Immunodeficiencies Outpatient Unit ADEE-3003; Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo.
Recent advances in immunologic evaluation techniques, developed of the complement cascade are: hereditary angioedema, the deficiency from the increasing availability of new diagnostic molecular genetics of C1 esterase inhibitor; lupus-like syndrome and glomerulonephritis in and immunologic tools, are allowing physicians to confirm the diagnosis deficits of the early components of the classical pathway (C1, C2, C4); of a disease early and efficiently and to prevent sequels by identifying and finally recurrent infections by encapsulated bacteria, especially of and quantifying physiological markers that precede the disease itself. the genus Neisseria in the deficiencies of components of the alternative Moreover, many diseases can be adequately monitored by laboratory tests. pathway and the membrane attack complex. These data allow a better treatment to match the patient’s condition. The The humoral immunity disorders vary in severity depending on laboratory examinations may also set the parameters for healing, essential the degree of involvement in the production of different isotypes for either drug discontinuation or changes of the dose of medication, of immunoglobulins, as well as its role in facing different types of allowing the best use of a therapeutic and less risk of unwanted effects. In antigens. For example, IgA-deficient individuals can have a normal life, particular, the evaluation of immunological parameters is used to address occasionally diagnosed by the presence of immunodeficiency in the various infectious and inflammatory processes and disorders arising family or even analysis of donor blood banks. Moreover, people with from imbalance of the immune system, such as immune deficiencies, more severe disorders involving several immunoglobulin isotypes show autoimmune diseases and allergic diseases. frequent and more severe signs of infections. The immune response is now known as a compartmentalized set Finally, patients with disorders of cellular immunity usually present of mechanisms and an intricate network of communications. The great processes commonly known as opportunistic infections by intracellular complexity and interaction of different cell types and molecules involved agents of low pathogenicity or neoplasms. Importantly, because of the in inflammatory and immune response allow many possibilities of genetic regulatory function of T cells on the humoral and phagocyte branches, defects of immunity, generically designated primary immunodeficiencies many of the disorders of T lymphocytes are characterized by a combined (PIDs). PIDs can be didactically classified according to the compartments immunodeficiency, ie, affecting more than one branch of the immune of host defense: response. • Phagocyte Thus, we conclude that the new immunological and genetic • Complement research tools allow us to assess in detail the existing defects in • Humoral (B lymphocytes and antibodies) immunodeficiencies, whether primary or secondary. So, a group • Cellular (T lymphocytes) of professionals, including general practitioners and clinical Thus, by applying a strategic approach to the immunological immunologists, and other consultants such as geneticists, should be evaluation, most cases of supposedly immunocompromised patients involved in the diagnosis, counseling, treatment and care of patients can be diagnosed efficiently and at reasonable cost through standard with immune deficiencies. Importantly, despite the fact that the primary laboratory tests. For the cases considered as real immune deficiencies, immunodeficiency diseases are relatively rare, their knowledge and the assessment requires a sophisticated immunology laboratory, and a research allow a better diagnosis and therefore an appropriate treatment specialized team to obtain and interpret the results. for these usually serious disorders that, if not recognized quickly and Thus, the clinical defects of phagocytes, whether numerical or efficiently, present high morbidity and mortality. functional present susceptibility to infections, usually by bacteria or fungi affecting the barriers to the environment, ie the skin and mucous REFERENCES membranes, and are often suppurative infections highly prone to spread. The complement cascade is responsible for opsonization, chemotaxis, 1. Janeway Jr., C.A.: How the immune system protects the host from infection. Microbes and bactericidal activities by the sequential activation of the classical and infection 2001, 3: 1167 – 1171. 2. Campos, R.A.; Moraes-Vasconcelos, D.; Bellinati-Pires, R.; Ferriani, V.P.L.: Avaliação pathway (activated by immune complexes), the alternative pathway laboratorial da resposta imune. In: Grumach, A. S.: In: Alergia e imunologia na (triggered by the activation of C3 by mechanisms independent of infância e adolescência. Atheneu, São Paulo, SP, 2001, pgs. 357 – 394. antibodies, as endotoxin, cell wall fragments, or immunoglobulin 3. Chapel H, Geha R, Rosen F; IUIS PID (Primary Immunodeficiencies) Classification aggregate) or mannose-binding protein dependent pathway (activated committee: Primary immunodeficiency diseases: an update. Clin Exp Immunol 2003, by fungal or bacterial cell wall oligosaccharides). Examples of disorders 132: 9 – 15.
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4. Moraes-Vasconcelos, D.: Imunodeficiências primárias combinadas. In: Grumach, A. S.: 11. Pilch, H., Hohn, H., Freitag, K., Neukirch, C., Necker, A., Haddad, P., Tanner, B., In: Alergia e imunologia na infância e adolescência. Atheneu, São Paulo, SP, 2001, Knapstein, P.G., and Maeurer, M.J. 2002. Improved assessment of T-cell receptor pgs. 445 – 466. (TCR) VB repertoire in clinical specimens: combination of TCR-CDR3 spectratyping 5. Candotti, F.; Notarangelo, L.; Visconti, R.; O’Shea, J.: Molecular aspects of primary with flow cytometry-based TCR VB frequency analysis. Clin. Diagn. Lab Immunol. immunodeficiencies: lessons from cytokine and other signaling pathways. J. Clin. 9:257-266. Invest. 2002, 109: 1261 – 1269. 12. Chan, K., and Puck, J.M. 2005. Development of population-based newborn screening 6. Fischer, A.: Primary immunodeficiency diseases: an experimental model for molecular for severe combined immunodeficiency. J. Allergy Clin. Immunol. 115:391-398. medicine. Lancet 2001, 357: 1863 – 1869. 13. Al-Harthi, L., Marchetti, G., Steffens, C.M., Poulin, J., Sekaly, R., and Landay, A. 2000. 7. Lowell, C.: Clinical Laboratory Methods for Detection of Antigens and Antibodies. In: Detection of T cell receptor circles (TRECs) as biomarkers for de novo T cell synthesis Parslow, T.G.; Stites, D.P.; Terr, A.I.; Imboden, J.B.: Medical Immunology, 10th using a quantitative polymerase chain reaction-enzyme linked immunosorbent assay Edition, Appleton & Lange, 2001, 215 – 233. (PCR-ELISA). J. Immunol. Methods 237:187-197. 8. Lowell, C.: Clinical Laboratory Methods for Detection of Cellular Immunity. In: Parslow, 14. Przybylski, G.K., Kreuzer, K.A., Siegert, W., and Schmidt, C.A. 2007. No recovery T.G.; Stites, D.P.; Terr, A.I.; Imboden, J.B.: Medical Immunology, 10th Edition, of T-cell receptor excision circles (TRECs) after non-myeloablative allogeneic Appleton & Lange, 2001, 234 – 249. hematopoietic stem cell transplantation is correlated with the onset of GvHD. J. 9. Oliveira, J.B., and Fleisher, T.A. 2005. Principles of flow cytometry. In Textbook of Appl. Genet. 48:397-404. Hematology. N.Young, Gerson,N., and High,K., editors. Elsevier. Philadelphia. 15. Vowells, S.J., Sekhsaria, S., Malech, H.L., Shalit, M., and Fleisher, T.A. 1995. Flow 1310-1325. cytometric analysis of the granulocyte respiratory burst: a comparison study of 10. Fleisher, T.A., and Oliveira, J.B. 2004. Functional and molecular evaluation of fluorescent probes. J. Immunol. Methods 178:89-97. lymphocytes. J. Allergy Clin. Immunol. 114:227-234.
HUMORAL DEFICIENCIES
Beatriz Tavares Costa Carvalho Profa Adjunta da Disciplina de Alergia, Imunologia Clínica e Reumatologia Do Departamento de Pediatria da UNIFESP-EPM
Predominant antibody deficiencies are the most common of the protein or markedly reduced numbers of B lymphocytes in their blood primary immunodeficiencies and in particular the IgA deficiency. The [<2%] and hypogammaglobulinemia), or 3) markedly reduced numbers clinical manifestations vary from asymptomatic - which is the case in of B lymphocytes in their blood (<2%) and hypogammaglobulinemia. some patients with IgA deficiency - to severe infections in patients with Clinical manifestations usualy start in the first year of life. Respiratory XLA. These deficiencies can be grouped into three categories: infections are the predominant here in Brasil and also in others countries Profound antibodies deficiency: X-linked agammaglobulinemia such as USA, Italy, Korea, Iran and Argentina etc.. The most common (XLA), common variable immunodeficiency (CVID) and Hyper-IgM. infections in our clinics are otitis (58%), pneumonia (51%), sinusitis All of them are treated with intravenous immunoglobulin (IVIG). (32%) and diarrhea (30%). The delay in diagnosis in our country is approx Common but less severe antibody deficiencies: transient 5 years. Encapsulated bactéria, as S.pneumoniae, Haemophilus influenzae hypogammaglobulinemia of infancy, IgA deficiency, IgG subclass and Pseudomonas are the main etiologic agents causing infections in these deficiency and impaired polysaccharide resposiveness. IVIG is rarely patients. Giardia lamblia is frequent in XLA patients with gastrointestinal used in these groups. symptoms and wild polio was related in a few patients. Although the Unusual and usually less severe antibody deficiencies: Transcobalamin characteristic of the disease is low immunoglobulin levels, some patients deficiency, selective IgM deficiency and drug-induced antibody present one isotype within normal levels. Treatment must be done with deficiencies. regular infusion of intravenous immunoglobulin. Antibody deficiencies such as XLA, Hyper-IgM and CVID are characterized by low levels of serum immunoglobulins and impaired CVID antibody production. CVID is the most frequent symptomatic primary immunodeficiency XLA in adults. It is usually diagnosed in patients who present with low immunoglobulin levels and a clinical history of recurrent and severe X-linked agammaglobulinemia is caused by mutations in the gene for infections, mostly affecting the respiratory tract and caused by Bruton tyrosine Kinase (BTK) that result in the deficient development of encapsulated bacteria. To confirm a diagnosis of CVID it is mandatory B lymphocytes. Affected individuals have hypogammaglobulinemia and to exclude other primary antibody deficiency syndromes and secondary markedly reduced numbers of B cells. As a result, they have an increased causes of hypogammaglobulinemia. susceptibility to a variety of encapsulated bacteria and enteroviruses, A significant number of CVID patients also suffer from GI tract microorganisms for which antibodies play an especially critical role in infections caused by Giardia lamblia, Campylobacter or Salmonella spp. host defense. Incidence is approx 1/200000 male births per year. Some patients present an inflammatory disease such as Crohn’s disease Diagnosis must be done according to PAGID criteria: Patients were or ulcerative colitis in its clinical presentation. considered to have XLA if they had 1) a mutation in the BTK gene and/ Approximately 20-30% of CVID patients show autoimmune or defective expression of the BTK protein, or 2) a positive family history phenomena and/or develop manifest autoimmune disease. The of a maternally related lateral male relative with XLA (for example, dysregulation of the immune system often seems paradoxical; while either a mutation of the BTK gene or defective expression of the BTK antibody production in response to pathogens and vaccines is severely
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impaired or even lacking, the generation of autoantibodies might, at the the second most abundant seric immunoglobulin but it’s role in systemic same time, be excessive. In our clinic, the frequency of autoimmune immunity is still not understood. The prevalence of IgA deficiency ranges disease is approx 30% with a predominancy in female patients similar from 1:200 to 1:3000. In our country the prevalence is approx 1:1000 in to other centers. healthy blood donors and 1:50 among asthmatic patients. IgA deficieny In some patients, CVID manifests with additional complications such is defined as a level of less than 7 mg/dL, in children over four years old as granulomatous inflammation or malignancy. with the other Igs in normal levels. Some individuals diagnosed as IgA Classification system for CVID has been proposed according to deficient may produce secretory IgA. percentage of memory B cells and switched memory cells. The aims of Despite the fact that most IgA-deficient subjects are not ill, IgA classification are the subdivision of these patients into approximately deficiency has been associated with specific disorders. homogeneous groups, who share clinical phenotypes. Another objective is Recurrent sinopulmonary infections are the most frequent and are the identification of predictive immunophenotypic markers. For example, more likely to occur when associated with IgG2 subclass deficiency. In a severe reduction of memory B cells is associated with an increased risk our clinic, from 21 patients with IgA deficiency, 20,2% had history of of splenomegaly and granulomatous disease. pneumonia and 17,5% sinusitis. Gastrointestinal disease was present Genetic defects: a) ICOS (inducible costimulator) deficiency: ICOS in 14% of our patients. Different gastrointestinal diseases such as belongs to the CD28 family of costimulatory T-cell molecule and is only giardiasis, nodular lymphoid hyperplasia, celiac disease, food allergy expressed on activated T cells. It coinduces secretion of some cytokines and inflammatory bowel disease have been related. and is pivotal for the induction of IL-10; b) TACI (transmembrane Autoimmunity (AI) may represent the most common association activator and calcium modulating cyclophilin ligand interactor) with IgA deficiency. The most common of these conditions are juvenile deficiency: constitutes a complex signaling network responsible for B-cell idiophatic arthritis, systemic lupus erythemathous, vitiligo, haemolytic survival and differentiation; c) CD19 deficiency: this molecule forms a anemia, idiopathic thrombocytopenia purpura etc… Three (14%) from receptor complex with CD21, CD81 and CD225 which amplifies B-cell our IgA deficiency patients present AI disease. On the other hand, we receptor signals after antigen binding and d) BAFF-R deficiency: the evaluated 72 patients with AI disease and none of them presented IgA BAFF-BAFF-R interaction mediates signals important for B-cell survival levels < 7mg/dL. and regulates peripheral B-cell homeostasis. IgA deficiency has been associated with the development of allergy XLA and CVID patients present recurrent respiratory bacterial and IgE levels are often increased in these patients. Many clinicians infections, even with appropriate treatment, particularly those by believe that IgA deficient subjects with asthma have more refractory encapsulated bacteria such as Haemophilus influenzae, Streptococcus diseases; perhaps their susceptibility to secondary respiratory infections pneumoniae and Staphylococci. A high proportion of these patients have aggravates the associated inflammation. Approx 70% of our IgA deficient experienced at least one episode of pneumonia before diagnosis, and patients presented allergy disease, rhinitis being the most frequent many, multiple episodes. In fact, respiratory infections are responsible for (71.4%) followed by asthma (66%), atopic dermatitis (9.5%) and only chronic symptoms, reduction in quality of life, frequent use of antibiotics, 4.7% presented food allergies. hospitalizations and anatomical lung abnormalities being one of the A fundamental defect in IgA deficiency is the failure of IgA-bearing principal causes of death in these patients. B lymphocytes to mature into IgA- secreting plasma cells. It appears to The early diagnosis of chronic pulmonary diseases in patients be a defect of stem cells, since IgA deficiency can be transferred by bone with XLA and CVID is essential in preventing further infections and marrow engraftment. There are some patients who also don’t produce complications. Lung function (LF) tests and imaging are the most adequate pneumococcal antibodies after immunization and clinical suitable tools for this investigation. Chest computed tomography (CCT) symptoms are more severe. has shown to be more sensitive than traditional X-rays in detecting lung abnormalities, such as bronchiectasis. TREATMENT WITH INTRAVENOUS IMMUNOGLOBULIN Analyzing thirty patients (22 males over 6 years of age) from our clinic (IVIG) with diagnosis of XLA and CVID who presented recurrent pneumonia, we observed that the mean number of pneumonias was 5 episodes per IVIg is indicated as replacement therapy for patients with primary and patient. Three of the patients referred had had approximately 10 episodes selected secondary immunodeficiency diseases characterized by absence of pneumonia before diagnosis and two of them were the patients with or deficient antibody production and, in most cases, recurrent or unusually the most severe pulmonary sequel. CCT scan was performed on all 30 severe infections. Because currently available IGIV preparations are patients and 53% (16) of them presented abnormalities: bronchiectasis produced from human plasma by using a number of preparatory steps, (12/16); peribronchial thickening (3/16); air trapping (5/16); lung volume supply of products is finite, and its use should be carefully considered. The reduction (4/16); atelectasis (2/16), follicular bronchiolitis and ground- administration of IGIV can lead to numerous side effects and potential glass abnormality (2/16) and parenchymal nodule (1/16). Bronchiectasis additional adverse consequences. Despite this, the appropriate use of was seen most frequently in the right middle lobe (66.7%). Seven patients immunoglobulin can be life-saving. were diagnosed as having more than one abnormality on CCT. The respiratory system is the main target of infections in patients with Pneumonia being the most common severe infection before the IVIG IGA DEFICIENCY replacement and sinusitis the major one after administration. Although the replacement of IVIG has significantly decreased the frequency and It is the predominant immunoglobulin that is secreted in the mucosa severity of infections in patients with CVID, progression of pulmonary and here it can neutralize viruses, bind toxins, agglutinate bacteria, sequel still occurs despite recommended treatment. prevent bacteria from binding to mucosal epithelial cells and bind to After deficient antibody production has been diagnosed, IVIG various food antigens preventing entry into the general circulation. It’s infusions are recomended every 3 to 4 weeks at an initial dose of 0.4 to
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0.6 g/kg, titrating the dose and interval between infusions to achieve IgG was a marked decrease in the number of infections after treatment: level at least greater than 500 mg/dL in agammaglobulinemic patients pneumonias were reduced from 88% to 40% in patients, diarrhea were In our clinic all patients with XLA or CVID have been receiving reduced from 52% to 36%, otitis media were reduced from 44% to 20% intravenous immunoglobulin since diagnosis. Infusions are given at and skin infections were reduced from 24% to 12%. Side effects were intervals of 3 to 4 weeks at doses that vary from 320 to 711 mg/kg. present in 64% of patients mostly mild. Approx 70% from our patients keep IgG levels above 600mg/dL. There
CELLULAR AND COMBINED IMMUNODEFICIENCIES
Jorge A. Pinto, MD, DSc Associate Professor, Head of Immunology Division, Department of Pediatrics, Federal University of Minas Gerais, Brazil
Cellular and combined immunodeficiencies comprise a diverse group disseminated tuberculosis, cryptococosis, mucocutaneous candidiasis of diseases with clinical manifestations usually more severe than those and relapsing herpes zoster. Other manifestations include vasculitis, seen in isolated antibody deficiencies. Affected individuals present with progressive multifocal leukoencephalopathy, inflammatory demyelinating common or opportunistic infections and very high mortality rates in their polyneuropathy and malignancies such as non-Hodgkin lymphoma first years of life. Early identification and prompt treatment is critical for and mycosis fungoides. Laboratory criteria for the diagnosis of ICD4L the survival of these individuals. requires persistently low CD4 counts (<300 céls/mm3) and no evidence This review will describe some of the most important primary of HIV or other retroviral infection by both serological and molecular immunodeficiencies affecting T cells and combined T- and B-cell methods. Selected antimicrobial prophylaxis and IL-2 may be used in defects. For a more comprehensive list of cellular and combined the treatment of individuals with ICD4L. immunodeficiencies readers should refer to Bonnila et al [1] and Notarangelo et al [2]. COMBINED IMMUNODEFICIENCIES
CELLULAR IMMUNODEFICIENCIES Severe Combined Immunodeficiency (SCID) The SCID syndromes are a group of disorders in which a disturbance Defects of the IFN-γ/IL-12 Axis in the development of both T and B cells is seen. Patients with SCID Individuals with defects in the IFN-γ/IL-12 axis present increased present in the first months of life with recurrent severe infections, failure susceptibility to mycobacteria, Salmonella and herpeviruses (CMV, to thrive, diarrhea and skin rashes. Due to the severity and immediate HSV and VZV). Defects in type I cytokine pathways result from life-threatening nature of infections, diagnosis of an infant with genetic mutations in genes encoding IFN-γRα, IFN-γRβ, the IL-12 p40 suspicion of SCID is a medical emergency. The laboratory abnormalities subunit, IL-12Rβ1 and STAT-1. Most of these conditions are inherited as observed in SCID include severe, age-adjusted lymphopenia and autosomal recessive. Screening evaluation tests for humoral and cellular panhypogammaglobulinemia, one or more reduced or absent major immune function are normal in this group of patients. Marked increase lymphocyte subpopulations, and absent or profoundly reduced T-cell (>80 pg/mL) in serum IFN-γ measured by ELISA is found in patients proliferation to mitogens and antigens. With the exception of adenosine with IFN-γR defects and can be used as a screening test to prompt further deaminase deficiency, which may be treated with enzyme replacement, evaluation [1]. Subcutaneous treatment with IFN-γ may be considered the only available curative therapy for most forms of SCID is BMT. as an adjunctive therapy in patients with mycobacterial disease. Bone Gene therapy is a possible alternative in some forms of SCID, such as marrow transplantation (BMT) with a HLA-identical sibling may be ADA-SCID and X-linked SCID. considered for patients with IFN-γR mutation. Wiskott-Aldrich Syndrome (WAS) Chronic Mucocutaneous Candidiasis (CMCC) WAS is an X-linked recessive syndrome characterized by eczema, The diagnosis of CMCC applies to a heterogeneous group of patients thrombocytopenic purpura with small platelets and increased susceptibility with unusual susceptibility to candida infections of the skin and mucous to infections. Infections are usually caused by pneumococcus and other membranes. Invasive or systemic candidiasis is rare. In most patients the encapsulated bacteria. Patients that survive through infancy may occurrence is sporadic with no definite pattern of inheritance. There is an present autoimmune cytopenias and vasculitis. Humoral immunologic autosomal recessive form of CMCC due to AIRE gene mutations with abnormalities in WAS include dysgammaglobulinemia and impaired the clinical phenotype of multiple endocrinopathy, ectodemral dystrophy specific antibody production. Cellular immunologic abnormalities include and candidiasis. Laboratory abnormalities in CMCC include defective T lymphocytopenia, impaired in vitro and in vivo T-cell responses, and cutaneous or in vitro T-cell response to Candida antigens and low NK decreased NK cell activity. The mutated gene responsible for WAS was cell count and/or function. Prolonged treatment with antifungal agents designated WASP (WAS protein) and is found with limited expression are usually required. in megakaryocytic and lymphocytic lineages of affected individuals. A large number of mutations in the WASP gene has been identified in Idiopathic CD4 Lymphocytopenia (ICD4L) patients with WAS and some mutant WASP genotypes have prognostic ICD4L is a rare disease in which patients present with AIDS-like values [3]. The only curative treatment for WAS is BMT. opportunistic such as Pneumocystis jirovecci pneumonia, histoplasmosis,
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Ataxia-Telangiectasia (A-T) CD4/CD8 ratio, and diminished T-cell proliferative responses to A-T is a complex combined immunodeficiency syndrome mitogens and antigens in vitro. There is also often a striking decrease with associated neurologic, endocrinologic, hepatic and cutaneous in NK cell cytotoxicity. The defective gene responsible for this disease abnormalities. Gait ataxia, oculocutaneous telangiectasias, growth encodes the protein SAP (signaling lymphocyte activation molecule retardation, and immune deficiency are the most prominent clinical associated protein). The mutated protein may be involved in regulation features of A-T. Ataxia is apparent shortly after the child starts walking. of the intense CD8 T cell cytotoxicity stimulated by acute EBV infection Telangiectasias develop between 3 and 6 years of age. Recurrent [4]. Intravenous immunoglobulin (IVIG) should be given to XLP patients sinopulmonary infections are present in approximately 80% of the with hypogammaglobulinemia, disgammaglobulinemia or infections. patients. There is a high rate of malignancies in A-T patients, mostly BMT can cure XLP. lymphomas. Immunologic abnormalities in A-T include low or elevated immunoglobulin levels, IgG subclass deficiencies, impaired specific CD40 and CD40 Ligand Deficiencies antibody production, and alterations in lymphocyte populations. Most cases of hyper-IgM (HIGM) are X-linked and result from a Inheritance of A-T follows an autossomal recessive pattern. Chromosomal mutation in the gene encoding the T cell surface molecule CD40 ligand. translocations that involve immunoglobulin and T-cell receptor loci are Clinical features of CD40 and CD40L deficiencies include presentation highly characteristic in lymphocytes of patients with A-T and other related in infancy with recurrent and severe bacterial upper and lower respiratory disorders, such as Nijmegen breakage syndrome ot A-T-like disorder. tract infections, gastrointestinal infections, opportunistic infections such Antibiotic prophylaxis and/or immunoglobulin replacement may be as Pneumocistis jirovecci pneumonia and disseminated fungal infections, indicated for A-T and related disorders. A coordinated multidisciplinary neutropenia, chronic anemia due to parvovirus, and cholangitis due to approach is recommended for these patients. Cryptosporidium. The main laboratory findings of HIGM are low levels of IgG and IgA in combination with normal or elevated concentrations of DiGeorge Syndrome (DGS) IgM. The failure to express CD40L may be assessed by flow cytometry Thymic dysplasia, cardiovascular structural defects, and on activated T-cells. IVIG infusion is beneficial for these patients. hypoparathyroidism mark the triad of congenital defects in DGS. A Pneumocystis jirovecci prophilaxis should be instituted. BMT is curative variable degree of thymic and parathyroid gland hypoplasia (partial for this disease. DGS) is more common than complete aplasia. Patients with complete In conclusion, cellular and combined immunodeficiencies are life- DGS are more susceptible to opportunistic infections and graft-versus- threatening conditions that usually manifest in early infancy and require host disease (GVHD) from non-irradiated blood products. Patients with immediate diagnosis and management. Bone marrow transplantation, partial DGS are usually only mild lymphopenic. DGS has occurred in gene therapy and immunoglobulin replacement are the mainstay of both female and male patients. No immunologic treatment is required therapy. Most of these conditions could be diagnosed by newborn for partial DGS. BMT is indicated in complete DGS. screening [5] and the application of this approach in a populational scale has the potential to save many lifes. X-Linked Lymphoproliferative Disease (XLP) Boys with XLP characteristically present with fulminant infectious REFERENCES mononucleosis, lymphoma or disgammaglobulinemia. Onset of disease is variable but usually manifests around age 5 to 10 years. In approximately 1.Bonilla FA, Bernstein L, and Khan DA, Practice parameter for the diagnosis and two thirds of the patients disease manifestation will be triggered by a management of primary immunodeficiency. Annals of Allergy, Asthma and Immunology, 2005. 94(May): p. S1-S63. Epstein-Barr virus (EBV) infection. The immunologic findings in 2.Notarangelo L, Casanova JL, and Fischer A, Primary immunodeficiency diseases: An update. XLP are variable and depend on EBV exposure. Before EBV Journal of Allergy and Clinical Immunology, 2004. 114: p. 677-87. exposure, immunologic laboratory abnormalities are limited mainly 3.Rong SB and Vihinen M, Structural basis of Wiskott-Aldrich syndrome causing mutation in to hypogammaglobulinemia, one or more low IgG subclasses, or the WH1 domain. Journal of Mollecular Medicine, 2000. 78: p. 530-7. elevated IgA and IgM levels. Following EBV infection, there may be 4.Howie D, Sayos J, and Terhorst C, The gene defective in X-linked lymphoproliferative disease controls T cell dependent immune surveillance against Epstein-Barr virus. hypogammaglobulinemia with impaired specific antibody production, Current Opinion Immunology, 2000. 12: p. 474-479. an inverted 5.Chan K and Puck JM, Development of population-based newborn screening for severe combined immunodeficiency. J Allergy Clin Immunol, 2005. 115: p. 391-397.
DISORDERS OF PHAGOCYTES AND COMPLEMENT
Mônica de Freitas Leitão (SP) Professora Titular da PUC de Campinas
The phagocytes are the first line defense of our organism. They are the patients present infections of recurrence in the barrier organs, lymph responsible for the phagocytosis of microorganisms, liberation of free nodes and profound abscesses. It is common to have infections caused by radicals and activation of lysosome enzymes with microbicidal activity. bacteries as Staphylococcus aureus/epidermidis, Serratia marcencens, The phagocytes disturbances are described in a frequency which Enterobacteria, Pseudomonas ssp and Mycobacteria. In these patients it is varies from 6 to 20% of the primary immunodeficiencies. They may also observed infections caused by fungus like Aspergillus and Candida. occur because of the quantitative or qualitative alterations. Clinically, Examples of quantitative deficiencies are Reticular Dysgenesis,
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Kostmann syndrome and Familiar Neutropenia. The qualitative antimicrobial defence. deficiencies may occur due to the changes in the adhesion-dependent The primary immune deficiencies of the complement system are functions (LAD-1 and LAD-2), deficiencies in the chemotaxis (Hyper too rare, with a variation from 1 to 7% in the population. Their clinical IgE Syndrome) and deficiencies in the microbicidal activities (Chronic manifestations are correlated to the infections by encapsulated bacteria, granulomatous disease, Chédiak-Higashi syndrome). specially the meningococcus. Autoimmune disease is frequently also The complement system consists of aproximately 35 proteins. The observed. In the deficiency of C1 inhibitor the clinical signs are related functions of the system include control of inflammatory reaction and to episodes of angioedema with an autosomal dominant inheritance. chemotaxis, clearance of immune complexes, cellular activation and
NUTRITIONAL ASPECTS OF PRIMARY IMMUNODEFICIENCIES
Cristina Miuki Abe Jacob Professora Associada e Livre Docente do Depto Pediatria da Faculdade de Medicina USP
Nutrition is an important factor that influences immunity and infection and liver involvement. malnutrition is a principal cause of secondary immunodeficiency. On Among the phagocyte disorders, the patients with chronic the other hand, impaired nutritional status has been reported in primary granulomatous disease frequently presented malnutrition secondary to immunodeficient patients. chronic suppurative infection associated to prolonged hospitalization. Primary Immunodeficiencies (PIDs) include a large and heterogeneous The delay for diagnosis probably contributed for this finding. A study group of many different diseases that became patients very susceptible carried out by Carnide et al at Instituto da Criança do HCFMUSP, about to infections. Currently, more than 150 different diseases were described 44% of patients presented impaired nutritional status. and with the development of genetic approach many others will be Among all PID, the patients with severe combined immunodeficiency describe in the future. (SCID) certainly showed the most important interference with the The early diagnosis is essential and represents a challenging task for nutritional status. The malnutrition was a characteristic of this group health professional. Although the high susceptibility to infections was the and its control is very difficult in consequence of chronic diarrhea and most common finding associated to PIDs, it is important to point out that recurrent infections. These cases represented a immunological emergency many others clinical findings may be observed in these patients. Among and the bone marrow transplantation is the treatment of choice. The them, the failure to thrive is frequently found in PID, mainly when the nutritional therapy frequently included parenteral nutrition and correction cellular or phagocyte immunity are affected. This clinical manifestation of many metabolic disturbs. is very important and was included among the 10 warning signs proposed Currently at Instituto da Criança do HCFMUSP, a study developed by the American Red Cross and the Jeffrey Modell Foundation which by Afonso et al have been evaluating 78 PID patients, aged from 3 to have definitely facilitated the PID diagnosis. Many factors may affect 18 years. Among all patients, those with cellular and phagocyte PID the nutritional status: recurrent or chronic infections, chronic diarrhea present the most affected nutritional status. In this study, a curious with gastrointestinal tract malabsorption, metabolic diseases associated, finding detected was the high cholesterol level observed in the cellular among others. PID patients, in spite of the malnutrition diagnosed. This fact need to be In the last decade, with the development of many kinds of therapy, carefully analysed because it may indicated that the actual nutritional including the bone marrow transplantation was possible to improve treatment may be not adequate for these patients, contributing to survival of patients with primary immunodeficiency diseases. This fact metabolic unbalance. leads to new needs, such as the approach of nutritional deficits, which The relationship between chronic infection and atherosclerotic if not adequately treated may contribute to the reduced immunological diseases has been evaluated in adults, but many others situations may response. reproduced this phenomena. The immune response against heat shock Unfortunately this object is not much discussed in the literature, protein 60 (HSP60) derived from pathogens causing chronic infections except in particular classes of PID. In the experience of the Children’s is thought to be an important pro-atherogenic mechanism because high Medical Center of Tehran University of Medical Science with 38 primary serum levels of antibodies against HSP60 have been associated with antibody deficiency patients (CVID, XLA, IgA deficiency, IgG subclass atherosclerotic diseases, such as coronary artery diseases, or cerebro- deficiency, and hyper IgM) the ages varied from 2 to 18 years. The vascular events. In PID patients there is a continue inflammatory process measurements evaluated were: body mass index (BMI), height-for-age and many metabolic alterations may be occurring, including the alteration (HAZ), weight-for-height (WHZ) and weight-for-age (WAZ). Based observed in our cellular PID patients here described. If this observation on BMI index, 21.1% of patients had malnutrition. According to HAZ, means that these patients with failure to thrive present specific metabolic 13.2%, 13.2% and 36.8% had severe, moderate and mild malnutrition, alterations, the nutritional treatment should be tailored according the respectively. Of note, about 50% of patients were CVID disease. Among metabolic profile of patients and not the same for all. the PID with antibody deficiency, CVID was the most affected probably in consequence of many cases with gastrointestinal involvement and REFERÊNCIAS BIBLIOGRÁFICAS malabsorption, besides the chronic pulmonary disease. The Hyper IgM syndrome was frequently associated to impaired Ayada K, Yokota K, Kobayashi K, Shoenfeld Y, Matsuura E, Oguma K. Chronic infections nutritional status, mainly in patients presenting Cryptosporidium chronic and atherosclerosis. Clin Rev Allergy Immunol. 2009;37(1):44-8
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Cunninghan-Rundles C, Bodian C. Common Variable Immunodeficiency: Clinical and Lamon BD, Hajjar DP.Inflammation at the molecular interface of atherogenesis: an Immunological Features of 248 patients. Clinical Immunology,1999; 92: 34-48. anthropological journey. Am J Pathol. 2008;173(5):1253-64 Geha RS, Notarangelo L, Casanova JL, Chapel H, Conley ME, Fischer A, Hammarström Llobet MP, Soler-Palacin P, Detkova D, Hernandez M, Caragol I, Espanhol T. Common L, Nonoyama S, Ochs HD, Puck JM, Roifman C, Seger R, Wedgwood J. Primary Variable Immunodeficiency: 20-yr experience at a single centre. Pediatr Allergy immunodeficiency diseases: an update from the International Union of Immunological Immunol 2009;20(2):113-8 Societies Primary Immunodeficiency Diseases Classification Committee. J Allergy Muscaritoli M, Fanfarillo F, Luzi G, Sirianni C, Iebba F, Laviano A, Russo M, Aiuti F, Fanelli Clin Immunol. 2007;120:776-94. FR. Impaired nutritional status in common variable immunodeficiency patients Katona P, Katona-Apte J. The Interaction between Nutrition and Infection. Clin Infect Dis correlates with reduced levels of serum IgA and of circulating CD4+ T lymphocytes. 2008,46:1582-8 Eur J Clin Invest 2001; 31(6): 544-549 Kouhkan A, Pourpak Z, Moin M, Dorosty AR, Safaralizadeh R, Teimorian S, Farhoudi A, Wilkesntein JA, Marino MC, Ochs H, Fuleihan R, Scholl PR, Geha R. The X-linked hyper- Aghamohammadi A, Mesdaghi M, Kazemnejad A. A Study of Malnutrition in Iranian IgM syndrome: clinical and immunologic features of 79 patients. Medicine 2003; Patients with Primary Antibody Deficiency. Iran J Allergy Asthma Immunol. 2004 82: 183-204 Dec;3(4):189-196
MANAGEMENT OF PRIMARY IMMUNODEFICIENCIES
Fátima Rodrigues Fernandes Hospital do Servidor Público Estadual - IAMSPE
Introduction: Primary immunodeficiencies (PIDs) are a genetically before therapy is selected or initiated. heterogeneous group of disorders that affect distinct components of the Environmental Control: Immunodeficient patients must be innate and adaptive immune system, with more than 120 distinct genes recommended to avoid agglomerations or contact with individuals with identified, whose abnormalities account for more than 150 different forms any contagious disease. Nurseries and daycare schools are risk factors to of PID, frequently misdiagnosed1,2,9. The approaches to proper diagnosis acquire infections. Contact with tobacco smokers, air pollution and pets and treatment of these complex disorders change as new information should be avoided. Damp places and mold exposure may predispose to emerges. By contrast with the progress of molecular genetics and the fungal infections and should also be avoided 8. continuing discovery of new primary immunodeficiency disorders, Antibody Production Defects: In the primary antibody deficiency many patients continue to be ill and die early because of misdiagnosis syndromes the respiratory tract is the major target for infections and and inadequate treatment. Thus, rapid advances in the knowledge of the their sequelae. The strongest predictor of mortality is the presence of pathogenesis, diagnosis, and treatment of these disorders may contributes chronic lung disease at diagnosis, while early diagnosis and timely to widened the gap between researches and the application in everyday intervention predicts good outcome 12. With the exceptions of selective clinical practice 6,10. Regrettably, the cost of late diagnosis added a IgA deficiency and transient hypogammaglobulinemia of infancy, patients considerable disease burden to the patient. Most patients (61%) reported with an identified antibody deficiency disorder are generally treated on being hospitalized before diagnosis, with a quarter being hospitalized 4 a periodic basis throughout life with replacement immune globulin, times or more. Almost 37% of patients with PIDs reported some type of intravenously or subcutaneously 4,5,7. Typical total monthly doses are permanent functional impairment before diagnosis, with almost a quarter in the range of 400 to 800 mg/kg body weight. Dose adjustments may (23%) reporting permanent loss of lung function7. be necessary during childhood related to normal growth or during PIDs management: PIDs are characterized by unusual susceptibility pregnancy. Ig replacement reduces acute and chronic infections to infection, but they may also have associated autoimmune or allergic and their sequelae in agammaglobulinaemia, CVID and hyper-IgM manifestations. The infections are usually recurrent and caused by syndromes. Also, Ig therapy may still be helpful in selected patients unusual pathogens that rarely cause problems in healthy people. Because with partial antibody deficiencies such as IgG subclass deficiency or most of these are lifelong conditions, it is very important to perform a specific antibody deficiency 12. Many patients with antibody production detailed diagnostic evaluation before initiating therapies that will be disorders also benefit from the use of prophylactic antibiotics, mainly continued in an open-ended fashion. The principal modes of therapy for against extracellular, encapsulated bacteria (amoxicillin with or without patients with the primary immunodeficiency disorders are: 1,4,8 clavulanate or macrolides, in full treatment doses), especially if there 1. protective isolation, is evidence of chronic infection or permanent damage to the lungs 2. antibiotics for the eradication or prevention of bacterial and (bronchiectasis) or sinuses. Bronchopulmonary hygiene measures are fungal infections. Early recognition of fevers and prompt evaluation recommended, and pulmonary rehabilitation may be useful in this (including blood cultures) is very important, and immunodeficient patients. To detect the risk of developing chronic lung disease, an annual patients often require more aggressive and prolonged antimicrobial assessment of pulmonary function, chest x-rays or high resolution C-T therapy, scans must be done. 3. replacement of missing humoral or cellular immunologic Cellular or Combined Defects: There are no replacement therapies functions. that are routinely effective for the cellular deficiencies. Treatment focuses Besides that, the adequate control of immunodeficient patients principally on aggressive treatment of infectious complications as they includes diet, hygiene measures, personal habits and growth monitoring. occur and preventive treatment when appropriate. However, IVIG is The complexities of both the immunodeficiency diseases and their an important component of therapy for combined immunodeficiencies treatment emphasize the need for all such patients to be evaluated in such as SCID, WAS, A-T and hyper-IgM syndrome. IVIG should also centers where detailed studies of immune function can be conducted be administered to all patients with SCID while they are prepared for
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definitive 3. However, bone marrow transplantation has remained the known for many of the primary immunodeficiency diseases, including only hope for long-term survival in patients with SCID and the majority some of the most common disorders, making it difficult to accurately of these disorders. Depending on the age at transplantation, the type determine inheritance patterns and risk to other family members. of SCID, and the type of donor (identical versus haploidentical versus This makes it difficult to offer widely prenatal diagnostic options 4,7. unrelated), success rates vary from approximately 50% to almost 100% 5. Concluding remarks: Recent decades have witnessed an explosive Gene therapy has been tried with notable success in SCID, but there have advance in the molecular understanding of many previously unknown been serious adverse events. This form of treatment is less commonly used immunodeficiency disorders. Along the way, we have gained a wealth of at present, with the general availability of bone marrow transplantation knowledge of immune system biology and advances for novel therapies 3. Only irradiated CMV-negative, leukocyte-depleted blood products not only for the immunodeficiencies themselves but also for a variety of should be used in managing the patient with SCID or other suspected T autoimmune-, inflammatory-, or transplantation-related disorders. This cell deficiencies. In SCID, patients should be placed on PJP prophylaxis must be translated in the clinical practice to better outcome for patients. with trimethoprim/sulfamethoxazole, besides anti-fungal (itraconazole) and anti-viral (acyclovir, gancyclovir) prophylaxis. REFERENCES Phagocytic Cell Immune Defects: In individuals with a primary immunodeficiency disease affecting phagocytic cells, prophylactic 1. Bonilla FA, Bernstein L, Khan DA, Ballas ZK, Chinen J, Frank MM, Kobrynski antibiotics may be appropriate. For chronic granulomatous disease LJ, Levinson AI, Mazer B, Nelson Jr RP, Orange JS, Routes JM, Shearer WT, Sorensen RU. Practice parameters for the diagnosis and management of primary (CGD) current prophylaxis with trimethoprim/sulfamethoxizole or immunodeficiency. Ann Allergy, Asthma & Immunol 2005; 94: S1-61 cephalexin and itraconazole is indicated. In selected cases additional 2. Bonilla FA & Geha RS. Are you immunodeficient? J Allergy Clin Immunol 2005; interferon gamma is efficient with some clinical benefit (e.g. reduced 116:423-5 number of serious infections) 11. Some patients with CGD have been 3. Bonilla FA & Geha RS. Primary immunodeficiency diseases. J Allergy Clin Immunol treated successfully with bone marrow transplantation, when there is a 2003;111:S571-81 3 4. Buckey RH. Diagnostic and Clinical Care Guidelines for Primary Immunodeficiency matched sibling donor . Patients with Kostmann’s Syndrome or CD40 Diseases. Immune Deficiency Foundation, Towson, Maryland, 2006. Disponível na ligand deficiency may be responsive to granulocyte colony stimulating Internet : http//:www.primaryimmune.org. (acessed in August 28, 2009) factor (G-CSF). 5. Buckley RH. Primary immunodeficiency diseases: dissectors of the immune system. Complement Defects: Complement deficiencies may be difficult Immunological Reviews 2002; 185: 206–219 to treat. Complications of complement deficiency include autoimmune 6. Casanova J-L & Abel L. Primary Immunodeficiencies: A Field in Its Infancy Science 2007; 317(3): 617-9 disease, especially systemic lupus erythematosus, lupus-like syndromes, 7. Dinakar C. Practical aspects of ambulatory diagnoses and management of glomerulonephritis, and infections. The concomitant autoimmune immunodeficiency disorders. Ann Allergy, Asthma & Immunol 2007; 99: 201 phenomena may be resistant to immunosuppressive therapy. Patients 8. Fernandes FR. Tratamento das Imunodeficiências. Cuidados Gerais. In: Grumach AS. should be thoroughly immunized with respect to common pathogens, Alergia e imunologia na infância e na adolescência. 2 ed. São Paulo: Editora Ateneu, for meningococcal pneumococcal infection prevention 1. If patients have 2009 9. Geha RS et al. Primary immunodeficiency diseases: An update from the International frequent infections, antibiotic prophylaxis may be considered 3. Union of Immunological Societies Primary Immunodeficiency Diseases Classification Practical Aspects of Genetic Counseling: Some primary Committee. J Allergy Clin Immunol 2007;120:776-94 immunodeficiency diseases follow autosomal dominant inheritance. 10. Marodi L, Casanova J-L. Primary immunodeficiency diseases: the J Project. The Lancet Unlike autosomal recessive inheritance, only one copy of the gene defect 2009; 373 June 27 needs to be present for the condition to be expressed in an individual and 11. Seger RA. Modern management of chronic granulomatous disease. British Journal of Haematology 2008; 140: 255–266 individuals affected with these disorders have a 50% chance of passing the 12. Tarzi MD, Grigoriadou S, Carr SB, Kuitert LM, Longhurst HJ. An approach to the gene defect on to each of their children, regardless of gender. However, management of pulmonary disease in primary antibody deficiency. Clinical and some of these disorders occur as new mutations in the affected individual Experimental Immunology 2008; 155: 147–155 and a family history may be negative. Also, the genetic basis is still not
ALLOGENEIC STEM-CELL TRANSPLANTATION FOR PRIMARY IMMUNE DEFICIENCY DISEASES
Juliana Folloni Fernandes Médica do Serviço de Oncologia do Instituto da Criança - HCFMUSP; Médica da Unidade de Hematologia e Transplante de Medúla Óssea do Hospital Israelita Albert Einstein
Primary immunodeficiency diseases (PID) are rare inherited disorders other had Wiskott-Aldrich syndrome) received allogeneic bone marrow characterized by impairment of innate or adaptive immunity, that often cells from their HLA-identical brothers and had their immune function have severe and lethal complications. The most severe disorders, as recovered. Since that time, several PID have been successfully treated severe combined immunodeficiencies (SCID), are generally fatal in the with HSCT (table 1). first year of life if untreated. Transplantation of hematopoietic stem cells from an allogeneic donor can cure most of the lethal forms of immune Principles of hematopoietic stem cell transplantation (HSCT) deficiencies. The first reports of successful allogeneic hematopoietic The objective of allogeneic HSCT is to replace defective or stem cell transplantation (HSCT) appeared shortly after the major malignant cells of the recipient with normal hematopoietic cells. human histocompatibility system (HLA) was discovered in 1968. Two Normal bone marrow contains self-replicating cells that can give rise to patients with severe immune deficiency diseases (one had SCID and the erythrocytes, granulocytes, cells of the monocyte-macrophage lineage,
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Table 1. Immunodeficiencies treated by hematopoietic stem cell mismatched family donors (MMRD), usually one of the parents. With transplantation the improvement of supportive care and T-depletion techniques, overall survival of mismatched related transplants reported in the literature is Severe Combined Immune deficiencies (SCID) around 70% for severe combined immunodeficiency patients and about T-B+ (common gamma-chain, JAK-3, IL-7Rα) 50% for other severe T-cell deficiencies. However, these transplants have T-B- (RAG-1/2, Artemis, reticular dysgenesis) some particular characteristics: T-cell reconstitution is delayed, reflecting Enzyme deficiencies (ADA, PNP) the absence of expandable mature T cells and the time required for Severe T-cell deficiencies thymic maturation; patients undergo a period of profound and continued Zap-70 deficiency immunological incompetence; and donor cell engraftment may be MHC class II deficiency restricted to T cells, with many patients remaining without effective B Omenn syndrome cell immunity and requiring immunoglobulin substitution. Wiskott-Aldrich syndrome Phagocyte disorders HSCT from unrelated donors Chronic granulomatous disease Successful transplantation for PID with HLA-matched unrelated Leukocyte adhesion deficiency marrow donors has been reported since 1990. Although these reports Disorders of immune regulation usually don’t have a large number of patients, results look comparable IPEX syndrome to those of MMRD transplants. Given the fact that SCID treatment Hemophagocytic syndromes is considered an emergency, for these patients, the time spent in an Familial hemophagocytic lymphohistiocytosis unrelated donor search may be not justified. Cord blood transplantation Chediak-Higashi syndrome (CBT) was first reported in 1989 in a child with Fanconi anemia. Since Griscelli syndrome then, more than 14000 cord blood transplants have been performed X-linked lymphoproliferative disease worldwide, mainly for hematological disorders. One of the advantages of cord blood as a stem cell source is to permit a higher degree of HLA mismatch without increasing the incidence of GVHD, characteristic that megakaryocytes, and immunocompetent T, B, and NK cells. The success improves the chances of finding unrelated donors in the international of this therapy is directly related to the availability of a hematopoietic donor registries. In the recent literature, several series of patients with stem cell donor and to the degree of HLA compatibility between patient primary immunodeficiencies receiving unrelated cord blood transplants and donor. In HSCT, immunocompetent cells in both the recipient and have been reported, showing that unrelated CBT is a feasible alternative in the donor graft have the potential of rejecting each other, resulting to these patients. Recently, a study of the Eurocord registry (unpublished in graft rejection (host versus graft direction) and graft-versus-host data) with 93 patients with PID transplanted with single unrelated cord disease (GVHD). Therefore, to avoid rejection, patients are submitted blood units found an overall survival of 68% at 2 years. A critical endpoint to a preparatory treatment with chemotherapy and/or radiotherapy; and after HSCT for primary immunodeficiencies is the immune reconstitution. to prevent GVHD, prophylaxis with immunossupressant agents may be Despite the improvement in overall survival in the last years, delayed maintained up to 1 or 2 years after transplant. T-cell reconstitution and incomplete cellular and humoral immunity recovery is still a major question, accounting for an important morbidity HSCT from an identical sibling donor over the years after transplant. In transplants with unmanipulated Transplantation from an identical sibling donor is currently the marrow grafts, there are mature T-lymphocytes that rapidly expand treatment of choice for PIDs corrected by HSCT. In SCID patients, some in the recipient, with an early reconstitution of the cellular immunity remarkable features characterize the stem cell transplantation process. (memory T-cells) that may protect the patient from infections present in Due to the absence of immunocompetent cells able to reject foreign cells, the time of transplantation. In T-cell depleted grafts, circulating T-cells marrow grafts from HLA-identical siblings may be infused without any may be undetectable for a long period, appearing only about the 3rd or 4th preparative conditioning, acute and chronic GVHD are rare, and there is months and attaining normal range generally between 6-12 months after a rapid development of T- and B-cell function post transplant. Another transplantation. In cord blood transplants, infused T-cells are functionally particularity of these transplants is the fact that only donor lymphoid cells immature, and post-transplant immune reconstitution is also described engraft, the erythroid, granulocytic and megakaryocytic lineages remain as delayed, with naïve T-cells appearing at the same time described for of recipient origin. In patients with other PID a preparative regimen is MMRD transplants. necessary to avoid graft rejection, increasing the treatment-associated morbidity and mortality. Results of HSCT in PID Since the first transplant performed successfully for a PID in 1968, HSCT from mismatched family donors during the last 4 decades, close collaboration between transplant centers Unfortunately, only about 25% the patients will have a matched allowed the accumulation of significant experience on transplants for such sibling donor available. Since the early 80’s, the development of rare diseases. To date, the larger study published shows the outcomes techniques to remove mature T-cells from bone marrow showed the of 919 patients transplanted between 1968 and 1999 in 37 European feasibility of using HLA-partially compatible donors for HSCT. T-cell centers. Four hundred forty-four patients had SCID and 512 patients had depletion decreased the high risk of GVHD associated with these other severe primary immune deficiency (Wiskott Aldrich syndrome, transplants, otherwise prohibitive; and extended the possibility to find a n=103; phagocytic cell disorders, n=48; and hemophagocytic syndromes, donor to virtually all patients with severe primary immunodeficiencies. n=90). Two hundred and fifty-two transplants were performed with The type of donor most frequently used for these transplants are HLA-identical sibling donors, 470 with MMRD and 108 with unrelated
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donors. In SCID patients, 3-year overall survival (OS) was of 77% 3. Antoine C, Müller S, Cant A, Cavazzana-Calvo M, Veys P, Vossen J, Fasth A, Heilmann C, after HLA-identical donor transplant, compared to 54% after MMRD Wulffraat N, Seger R, Blanche S, Friedrich W, Abinun M, Davies G, Bredius R, Schulz A, Landais P, Fischer A; European Group for Blood and Marrow Transplantation; transplants (p=0.002). Besides the type of donor, other variables with European Society for Immunodeficiency. Long-term survival and transplantation of statistically significant impact on the OS, conferring poorer prognosis: haemopoietic stem cells for immunodeficiencies: report of the European experience B (-) phenotype, the absence of protected environment and the presence 1968-99. Lancet. 2003 Feb 15;361(9357):553-60. of pulmonary infection before transplantation. In patients with other 4. Dvorak C C, Cowan M J. Hematopoietic stem cell transplantation for primary severe PID, survival was significantly better after HLA-matched than immunodeficiency disease. Bone Marrow Transplant. 2008; 41(4):119-126. 5. Bertrand Y, Landais P, Friedrich W, Gerritsen B, Morgan G, Fasth A, Cavazzana-Calvo after HLA-mismatched transplantation. 3-year overall survival after M, Porta F, Cant A, Espanol T, Müller S, Veys P, Vossen J, Haddad E, Fischer A. matched sibling donor, MMRD or unrelated donor was 71%, 42% and Influence of severe combined immunodeficiency phenotype on the outcome of HLA 59%, respectively (p=0.0006). non-identical, T-cell-depleted bone marrow transplantation: a retrospective European survey from the European group for bone marrow transplantation and the European Future approaches society for immunodeficiency. J Pediatr. 1999 Jun;134(6):740-8. 6. Bhattacharya A, Slatter MA, Chapman CE, Barge D, Jackson A, Flood TJ, Abinun M, Cant Improvements in tissue typing, advances in stem cell manipulation, AJ, Gennery AR. Single centre experience of umbilical cord stem cell transplantation new chemotherapy conditioning regimens, and new methods for detecting for primary immunodeficiency. Bone Marrow Transplant. 2005 Aug;36(4):295-9. and treating viral and fungal infections have led to improving survival and 7. Slatter MA, Gennery AR. Umbilical cord stem cell transplantation for primary cure by HSCT over the past 2 decades. However, the treatment related immunodeficiencies. Expert Opin Biol Ther. 2006 Jun;6(6):555-65. mortality is still an issue. Recently, an alternative therapeutic option 8. Knutsen AP, Wall DA. Umbilical cord blood transplantation in severe T-cell immunodeficiency disorders: two-year experience. J Clin Immunol. 2000 based on retroviral gene delivery has been used to correct X-linked severe Nov;20(6):466-76. combined immune deficiency (SCID-X1) and adenosine deaminase 9. Notarangelo LD, Forino C, Mazzolari E. Stem cell transplantation in primary deficiency. Autologous CD34-positive hemopoietic bone-marrow stem immunodeficiencies. Curr Opin Allergy Clin Immunol. 2006 Dec;6(6):443-8. cells are transduced ex vivo with the defective gene and returned to 10. Mazzolari E, Forino C, Guerci S, Imberti L, Lanfranchi A, Porta F, Notarangelo LD. the patients without preceding cytoreductive chemotherapy, restoring Long-term immune reconstitution and clinical outcome after stem cell transplantation for severe T-cell immunodeficiency. J Allergy Clin Immunol. 2007 Oct;120(4):892-9. their immune system successfully. In one trial of gene therapy for Epub 2007 Sep 7. X-linked SCID, 4 cases of leukemia developed as a result of insertional 11. Buckley RH. A historical review of bone marrow transplantation for immunodeficiencies. mutagenesis. These findings have raised concerns regarding the toxicity J Allergy Clin Immunol. 2004 Apr;113(4):793-800. of retroviral vector-based gene delivery. New vectors are being developed 12. Kook H, Goldman F, Giller R, Goeken N, Peters C, Comito M, Rumelhart S, Holida M, in order to try to avoid these severe side effects. Lee N, Trigg M. Reconstruction of the immune system after unrelated or partially matched T-cell-depleted bone marrow transplantation in children: functional analyses of lymphocytes and correlation with immunophenotypic recovery following REFERENCES transplantation. Clin Diagn Lab Immunol. 1997 Jan;4(1):96-103. 13. Grunebaum E, Mazzolari E, Porta F, Dallera D, Atkinson A, Reid B, Notarangelo LD, 1. Fischer A. Allogeneic hematopoietic stem transplantation for congenital immune Roifman CM. Bone marrow transplantation for severe combined immune deficiency. deficiencies; In: Clinical bone marrow and stem cell transplantation. Atkinson K. JAMA. 2006 Feb 1;295(5):508-18. 2004: 947-962. 14. Fischer A, Hacein-Bey-Abina S, Cavazzana-Calvo. Gene therapy for immunodeficiency 2. Buckley R. Transplantation; In: Immunologic disorders in infants and children. Stiehm diseases.. Semin Hematol. 2004 Oct;41(4):272-15. E R, Ochs H D, Winkelstein J A. 2004: 1400-48.
THE IMMUNE SYSTEM
Eduardo Finger Professor Voluntário da Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo
The immune system of higher mammals can be didactically divided by epitopes (little pieces of protein from the pathogen), presented to into 2 compartments denominated innate and adaptive immune systems. them by antigen presenting cells (APCs). One of the most important The innate immune response is primarily orchestrated by macrophages APCs is the dendritic cell who after being activated by the same stimuli and neutrophils who were evolutionarily equipped with surface receptors that triggers the innate immune response, migrates to the lymph node to to recognize and respond to substances evolutionarily eliminated from activate pathogen specific CD4 T cells. These activated cells organize mammalian organismal economy. Characteristically, the innate response the different arms of the adaptive immune system (humoral and cellular) initiates almost instantaneously upon contact with these substances, and into a diverse and sophisticated strategy that most of the time, manages follows a pattern that is almost always identical. If this first effort fails to to destroy the pathogen with minimal collateral tissue damage. destroy the pathogen, it keeps it sequestered until the vast resources of The purpose of this course is to present the progression of a normal the adaptive immune system can be mobilized to eradicate it. immune response in order to understand the role played by each The adaptive immune system is controlled by CD4 T cells activated compartment in the maintenance of health or promotion of disease.
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WHEN THERE IS SUSPICION OF IMMUNODEFICIENCY?
Antonio Carlos Pastorino Mestre e Doutor em Ciências pela Faculdade de Medicina da Universidade de São Paulo Médico Assistente da Unidade de Alergia e Imunologia – Departamento de Pediatria da Faculdade de Medicina da Universidade de São Paulo
Primary immunodeficiencies (PIDs) are disorders of inheritance of child grows and their immune system matures, the number of infections immune system function and more than 150 distinct genetic disorders is reduced. The susceptibility to infections is not only due to immaturity have been identified until now. The hallmarks of PIDs are recurrent of the immune system and other causes may be related: the early exposure or unusual infections. Autoimmune disease, allergies and malignancy to environments containing many infectious agents such as kindergartens, are also often seen in a variety of immunodeficiencies. PID average schools or having more siblings in the home, exposure to pollutants and prevalence may reach 1 in 2,000 live births, but variations of 1 to 300 cigarette smoke of which negatively influence the mucociliar clearance (IgA deficiency) or even 1 in every 200.000 (Chronic Granulomatous of the airways, lack of adequate nutrition and low socioeconomic level Disease - CGD) live births may occur. with all its implications. Added to these factors an allergic disease of The body’s immune response is made up of a diverse network the upper airways (rhinitis, conjunctivitis) and also of the lower airways of defenses, including physical barriers, cellular components, and (asthma) may provide an increased number of airway infections in 30% soluble mediators. The normal immune system has two “arms”: first, of children with recurrent infections. it mounts rapid, nonspecific responses (innate immune responses) to The main problem for the pediatrician is to discriminate normal initial infection; later, it mounts adaptive immune responses specific to children with high respiratory infections frequency related to an a particular pathogen. Together, those arms work to maintain normal augmented exposure to environmental risk factors from children affected host function and resistance to infection. Disruption of any part of by other underlying pathological conditions (immunological or not), the orchestrated immune response can result in an inability to control predisposing to infectious diseases. So, it is important to recognize how infection and subsequent illness (figure 1). The innate immune system many infections are considered normal in children and adults. Between comprises the cells and mechanisms that defend the host from infection 1 and 3 years of age children have up to 12 colds a year with symptoms in a non-specific manner. This means that the cells of the innate system lasting less than 10 days, without needing antibiotics. Schwartz et al. recognize and respond to pathogens in a generic way, but unlike the described 8 upper respiratory infections for children under one year, 6 adaptive immune system, it does not confer long-lasting or protective for children between two and three years and 3 infections to five years. immunity to the host. Innate immune system provides immediate defense In relation to otitis this number varies between 4 episodes under de first against infection, and are found in all classes of plant and animal life. year to 0.3 episodes to five years old. Many PIDs patients present the The elements of the innate (non-specific) immune system included: same kinds of infections that normal people, including otitis, sinusitis anatomical barriers (skin, internal epithelial layers), the movement of the and pneumonia, but their infections are more frequently, more severe, intestines, the oscillation of bronchopulmonary cilia, proteins (lysozyme, too prolonged, and unusual and have many complications, needing a defensine, lactoferrin, transferring, fibronectin, complement, interferons) variety of antibiotics to improve. An infection recurring in a single site and cellular components) macrophages, neutrophils, natural killer (NK) is generally not indicative of a primary immunodeficiency disease and and lymphokine activated killer (LAK) cells). rather it suggests an anatomic abnormality. On the other hand, several types of infections affecting various organ systems may be indicative of an underlying immunologic deficiency. The guidelines for determining if a patient has too many infections include: · More than four courses of antibiotics treatment per year in children or more that two times per year in adults · More than four new ear infections per year after four years of age · More than two pneumonia in any time · More than three episodes of bacterial sinusitis in one year or pres‑ ence of chronic sinusitis · Use of preventive antibiotics to reduce the number of infections · Severe infections or infections caused by unusual bacteria that do not usually cause problems in normal people at same age.
Figure 1 – Overview of the immune system In an attempt to facilitate the recognition of patients with possible primary immunodeficiencies the Jeffrey Modell Foundation in Cells that make up the adaptive (specific) immune system include the association with the Red Cross developed a group of 10 warning signs. B, T lymphocytes, and their humoral products (immune globulins and This warning signs were modified by the Brazilian Group of Primary cytokines). The hallmarks of the specific immune system are memory Immunodeficiency Disorders (BRAGID) in according with our country and specificity. characteristics and included: A child borned with immature and vulnerable immune system can 1. Two or more episodes of pneumonia in the last year cause many infections mainly in the neonatal period and infancy. As the 2. Four or more ear infections in the last year
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Table 1. Characteristic infections of the primary immunodeficiencies
Component Primary pathogen Primary site Clinical example
intracellular bactéria, viruses, T-cells non-specific SCID, DiGeorge protozoa, fungi, opportunistic agents
IgG, IgM deficiency Pneumococcus, Streptococcus, lung, skin, CNS Haemophilus IgG, IgM deficiency B-cells enteric bactéria, viruses, Giardia GI, nasal, eye IgA deficiency lamblia
Staphylococcal, Klebsiella lung, skin, regional chronic granulomatous disease Phagocytes Pseudomonas, fungi lymph node (CGD)
CNS Neisseria, Haemophilus, C3, Factors I and H, late C Complement lung Pneumococcus, Streptococcus components skin SCID – severe combined immunodeficiency CNS – central nervous system GI - gastrointestinal
3. Recurrent gingivitis (mouth ulcers) and oral candidiasis (thrush) for with staphyloccoccal, fungal, and gram-negative organisms. Complement more than two months disorders are associated by neisserial infections (Table 1). 4. Recurrent deep-seated infections or ecthyma 5. One serious episode of systemic infections (meningitis, osteoarthri‑ References tis, sepsis) 6. Recurrent gastrointestinal infection or chronic diarrhea 1. Schwartz B, Giebink GS, Henderson FW, Reichler MR, Jereb J, Collet JP. Respiratory 7. Severe asthma, auto-immune or collagen diseases infections in day care. Pediatrics 1994;94:1018-20. 2. De Martino M, Ballotti S. The child with recurrent respiratory infections: normal or not? 8. Adverse reactions after BCG vaccine or mycobacteria infection Pediatr Allergy Immunol 2007; Suppl 18:13-8. 9. Phenotypic characteristics suggesting associated immunodeficien‑ 3. Carvalho BTC, Lawrence TC. Quando investigar imunodeficiências: sinais de alerta. In: cies Alergia e Imunologia para o pediatra. Jacob CMA, Pastorino AC. Barueri, SP. Ed 10. Family history of primary immunodeficiency Manole, 2009, pp 32-44 . 4. Jacob CMA, Pastorino AC. Desenvolvimento do sistema imunológico. In: Alergia e Imunologia para o pediatra. Jacob CMA, Pastorino AC. Barueri, SP. Ed Manole, Infections in immunodeficiency have a characteristic cause depending 2009, pp 3-16. on the nature of the immune deficiency. Antibody deficiencies are 5. Carneiro-Sampaio MMS, Jacob CMA, Ribeiro LMA, Pastorino AC. Aspectos gerais do associated with infections with gram-positive infections. Cellular immune sistema imune e relação parasita-hospedeiro. In: Alergia e Imunologia para o pediatra. deficiencies are associated with mycobacterial, protozoan, fungus, virus, Jacob CMA, Pastorino AC. Barueri, SP. Ed Manole, 2009, pp17-31. and opportunistic bacterial infection. Phagocytic disorders are associated 6. Grupo Brasileiro de Imunodeficiências Primárias (BRAGID). www.bragid.org.br. Fundação Jeffrey Modell. www.info4pi.org
HOW TO DIAGNOSE IMMUNODEFICIENCY PATIENTS?
Tatiana Cristina Lawrence Mestre em Infectologia Pediátrica; Médica da EPM/UNIFESP
Before the correct diagnosis it is important to have an important 7. Severe asthma, Collagenosis or autoimmune disease suspicion of the patient for primary immunodeficiency. At this point the 8. Adverse effect to BCG and/or Mycobacterium infection 10 warning sings are the best protocol to follow. 9. Clinical phenotype of syndrome associated to immunodeficiency 1. Two or more pneumonias within a year 10. Family history of immunodeficiency 2. Four or more new ear infections within a year 3. Persistent thrush or fungus infection in the mouth for more than There are more than 200 primary immunodeficiencies divided in two months 8 major groups: Humoral (antibody deficiency), Combined (Cellular 4. Skin abscess or ecthyma and Humoral deficiency), Phagocytes deficiency, Innate immunity 5. One deep-seated infection (meningitis, osteoarthritis, sepsis) defects, Complement deficiency, Other well defined immunodeficiency 6. Recurrent gut infections / chronic diarrhea syndromes, Disease of immune dysregulation and Autoinflammatory
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disorders. Specific pathogens are more frequent in each individual Laboratorial exams are Complete blood count, Immunoglobulin (IgG, category and can help you to get the right direction. IgA and IgM), DHR and evaluation of the toll like receptors.
Humoral deficiency: Complement deficiency: Patients presenting with recurrent upper and lower airway infections Patients presented with meningitis by Neisseria meningitis and/or by encapsulated bacteria as Streptococus pneumoniae. recurrent upper and lower airway infections by encapsulated bacteria. Laboratorial findings are low immunoglobulins (IgG, IgA and/or Lab exams show low Complement fractions and the most frequent IgM) and low specific antibody production. pathology is Hereditary angioedema. The most frequent presentation is immunoglobulin deficiency as Laboratory exams are Complete blood count, Immunoglobulins Agammaglobulinemia, Common variable immunodeficiency, IgA (IgG, IgA and IgM), CH100, AS100, dosage of C1 inhibitor and other deficiency, specific antibody deficiency. factors if need. Laboratorial exams that help to confirm the diagnosis are: Complete blood count, Immunoglobulins (IgG, IgA and IgM), vaccine specific Other well defined immunodeficiency syndromes: antibody production, and subclass of Immunoglobulin, CH50 and CD19 Patients presenting with a specific syndrome that is associated with (B cell) counts. immunodeficiency. Recurrent upper and lower airway infections by These exams will exclude other pathologies that have resembled extracellular bacteria as Streptococcus pneumoniae, and Staphylococcus presentation as Complement deficiency, HIV, Neutropenias, Chronic aureus or intracellular germs. granulomatous disease and Wiskott-Aldrich syndrome. Laboratorial findings can be low immunoglobulins (IgG, IgA and/or Combined Cellular and Humoral deficiency: IgM), low specific antibody production and lymphopenia. Characterized by failure to thrive within the first year of life, and The most frequent presentation is specific antibody deficiency in the severe/recurrent infections induced by any kind of germs, including syndromes as Ataxia-teleangiectasia, Hyper IgE, Chronic Mucocutaneous opportunistic pathogens. candidiasis, Di George and immuno-osseous dysplasia. Laboratorial findings are low number of lymphocytes and low levels Laboratorial exams that will help to confirm the diagnosis are: of Immunoglobulin. Hemogram, Immunoglobulins (IgG, IgA and IgM), vaccine specific The most frequent presentations are severe combined antibody production, subclasses of Immunoglobulin, Lymphocytes immunodeficiency (SCID), T cells deficiency, Wiskott-Aldrich syndrome subpopulation and lymphoproliferation. and CD40L deficiency. Laboratorial exams necessary for diagnosis are: Complete blood Disease of immune dysregulation: count (important Lymphocytes, neutrophils and platelets counts), This group can present variable phenotypes of unbalance in specific Immunoglobulins (IgG, IgA and IgM), subpopulation of lymphocytes antibody production, inflammation, apoptosis and lymphoproliferation (CD3, CD4, CD8, CD19, CD16/56), HIV, PPD and Candidin as after virus infection. first screening followed specific vaccine antibody production, The syndromes associated with immune dysregulation are Lymphoproliferation, expression of WASP protein and CD40L. Immunodeficiency with hypopigmentation, Familial Hemophagocytic SCIDs are medical emergencies and should get immediate treatment. histiocytosis, Lymphoproliferative and autoimmunity syndromes. Necessary Laboratorial exams are Complete blood count, Phagocytes deficiency: Immunoglobulins (IgG, IgA and IgM), vaccine specific antibody Characterized by recurrent pyogenic infections, fungal infections production, specific lymphocytes subpopulation (double negative T cell, (Candida, Aspergillus), Mycobacterium infections and pulmonary NK …), autoantibodies and lymphoproliferation. abscesses. Laboratorial exams can be presented by low neutrophils counts, Autoimflamatory disorders: - elevated IgE levels, faulty O2 production and deregulation in the IFNγ/ Patients are presented with inflammatory signs as recurrent fever, IL12-23 cytokine production. urticaria and inflammation in the bowel, skin and joints. The most frequent presentations are Neutropenias, Granulomatous The most common onset is Familial Mediterranean fever and Familial disease, IFNγ/IL12-23 receptor deficiency, STAT1 deficiency and Hyper cold autoinflammatory syndrome. IgE syndrome. Laboratorial exams to confirm the diagnosis are very specific in Necessary Laboratorial exams are Complete blood count (neutrophils monocytes and Polomorphonuclear cells but the initial screening is counts), Immunoglobulins (IgG, IgA, IgM and IgE), Dihydrorhodamine normal with Complete blood count, Immunoglobulins (IgG, IgA and (DHR) and evaluation of the IFNγ/IL12-23 axis. IgM) and vaccine specific antibody production. For a correct diagnosis it is more important to bring up the hypothesis Innate Immunity defects: of primary immunodeficiency than send the patient to a specialist who Characterized by pyogenic infections associated or not with will get the specific laboratory exams to elucidate the case. mycobacterium infections, or herpes simplex infection. Patients can present a specific phenotype of anhydrotic ectodermal BIBLIOGRAPHY dysplasia (EDA) with low Immunoglobulins levels or normal screening exams. Jeffrey Modell Foundation and Red cross 10 warning sings for primary immunodeficiency. The most frequent pathologies are EDA with immunodeficiency, www.jmfworld.org Geha et al. Jounal Allergy and clinical Immunology 2007, 120(4): 776-794. IRAK4 deficiency and Herpes simplex encephalitis.
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TREATMENT OF IMMUNODEFICIENCIES AND INDICATION OF IMMUNOGLOBULINS -
Pérsio Roxo Júnior Hospital das Clínicas de Ribeirão Preto – USP
Primary immunodeficiencies (PID) are a group of rare diseases with · Reestablishment of nutritional and micronutrient conditions. heterogeneous expression, usually resulting from genetic defects of the · Diets without raw or poorly cooked foods. immunological system and its development. In the early 1950’s and · Avoiding agglomerations. 1960’s, the discovery of congenital agamma-globulin, of the DiGeorge · Frequent nasal washes with physiological saline. syndrome and of severe combined immunodeficiency was a milestone · Drainage of secretions by means of respiratory physiotherapy. for the division of specific immunity into antibody-mediated response Mucolytic drugs such as N-acetyl-cysteine may eventually be used by the (humoral) and cell-mediated response (cellular) 15 years before the inhalatory route depending on the degree of viscosity of the secretions. discovery of B and T lymphocytes. Similarly, the importance of defects · Avoiding vaccines consisting of attenuated live agents (BCG, in natural killer cell function and of the signaling of the so-called toll-like Sabin, rotavirus, triple viral, yellow fever, and chicken pox) in some PID, receptors has been recently attracting attention in PID. especially severe cell immunity deficiencies and agammaglobulinemias. The clinical phenotypes derived from a given genotype can vary In these cases, relatives or other dwellers living in the patient’s widely depending on different factors. Thus the relationship between domicile should not receive the Sabin or rotavirus vaccine due to the genetic characteristics and clinical phenotypes is not linear, but is a risk of transmission of vaccinal strains. On the other hand, vaccines complex expression of molecular defects regulated by endogenous consisting of inactivated agents or subunits can be administered safely and exogenous factors, a fact that may justify the wide genotypic to immunodeficient patients, although their efficacy is lower. Patients heterogeneity observed. Over the last few years, a substantial number with deficiencies of the terminal components of the complement system of genes involved in immunity and in its functions have been identified may benefit from immunization against encapsulated bacteria, especially by the study of PID patients. Although traditionally these diseases are Neisseria meningitidis. considered to predispose to infections caused by a large number of · When necessary, blood derivatives should be infused only after different pathogens, a growing number of immunodeficiencies involving being irradiated in order to prevent graft-versus-host disease. high susceptibility to infections cased by specific germs have been · Aggressive and early treatment of infections with antimicrobial described. agents, based, whenever possible, on the previous isolation of the PID is usually diagnosed late, probably due to the limited knowledge pathogens by culture of organic fluids and on the antibiogram. Severe of physicians about these diseases, with a consequent increased risk of conditions should be preferentially treated in the hospital using complications and death secondary to infections and other co-morbidities. intravenous antibiotic therapy. The use of prophylactic antibiotic (with In addition, many cases have been diagnosed in an incorrect manner, rotation every 3 months) is indicated for some PID in patients presenting resulting in the adoption of inappropriate therapeutic measures. susceptibility to infections by specific agents. Although considered to be diseases of rare incidence, PID are · Treatment of co-morbidities and their complications. estimated to occur in more than 1 in 2000 births. According to Conley and Stiehm (1996), in the pediatric age range approximately half the patients Specific therapeutic measures should be applied only when the with recurrent respiratory infections are healthy, 30% have allergies, 10% diagnosis has been well established and they vary according to each PID. have chronic diseases, and 10% may have immunodeficiency. The main procedures available and their indications are: Case series from many parts of the world have pointed out humoral · Bone marrow or stem cell transplantation: this is the treatment immunodeficiencies as the most frequent occurrences, accounting for of choice for severe cellular and combined immunodeficiencies. approximately half the cases, and deficiencies of the components of the · Immunomodulators: these are cytokines of great clinical complement system as the rarest. applicability in some immunodeficiencies, such as interferon-gamma The more typical clinical manifestations of PID are repeated for chronic granulomatous disease and granulocyte colony stimulating infections. This high predisposition occurs in one or more clinical factor in patients with congenital neutropenia. dimensions of the infections, such as pathogen virulence, site of infection · Enzyme replacement therapy: successfully used in a form of (localized or generalized), severity (degree of tissue injury), persistence severe combined immunodeficiency denoted adenosine deaminase (ADA) or resistance to treatment, and frequency of recurrence or of re-infection. deficiency. Infections due to specific microorganisms or to germs of low virulence · Gene therapy represents the most promising procedure for most predominate. Although their clinical expression may be low, in most cases severe PID. There are reports of patients with X-linked severe combined infectious conditions have a severe and prolonged course, an inadequate immunodeficiency, ADA deficiency, and X-linked chronic granulomatous response to habitually employed antibiotic therapy, and high risks of disease who benefited from this treatment modality. complications and hospitalizations. · Immunoglobulin replacement therapy is the treatment of Treatment of PID should be instituted as soon as the diagnosis is choice for patients with some humoral immunodeficiencies. According confirmed in order to prevent possible complications. It may be classified to the Committee of Clinical Immunology of the International Union of as general or specific. Immunology Societies and to the World Health Organization, gamma- The general therapeutic measures include: globulin has a well-defined indication for defects in immunoglobulin · Rigorous environmental and personal hygiene. production such as X-linked agammaglobulinemia, variable common · Education of patients and relatives about the disease. immunodeficiency, hyper-IgM syndrome, immunodeficiency with
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thymomas, and severe combined immunodeficiency. Possible indications 6. Geha RS, Notarangelo LD, Casanova JL, Chapel H, Conley ME, Fischer A et al. The of gamma-globulin replacement therapy include deficiencies of one or more International Union of Immunological Societies (IUIS) Primary Immunodeficiency Diseases (PID) Classification Committee. Primary immunodeficiency diseases: immunoglobulin classes, antibody deficiency with normal immunoglobulin an update from the International Union of Immunological Societies Primary levels, and transitory hypogammaglobulinemia with recurrent infections. Immunodeficiency Diseases Classification Committee. J Allergy Clin Immunol 2007; Treatment with gamma-globulin is not recommended for asymptomatic 120: 776–94. patients with mild forms of immunoglobulin deficiency or with transitory 7. Guzman D, Veit D, Knerr V, Kindle G, Gathmann B, Eades-Perner AM et al. The ESID hypogammaglobulinemia, although these patients should be followed Online Database network. Bioinformatics 2007; 23: 654-5. 8. IUIS/WHO notice. Appropriate uses of human immunoglobulin in clinical practice. Clin up clinically in a rigorous manner. Patients with severe primary T cell Exp Immunol. 1983;52(2):417-22. deficiencies such as ataxia telangiectasia, Wiskott-Aldrich syndrome, 9. Morimoto Y, Routes JM. Immunodeficiency overview Prim Care Clin Office Pract 2008; severe combined immunodeficiency, and DiGeorge syndrome may benefit 35: 159–73. from gamma-globulin replacement therapy as an adjuvant treatment. The 10. Notarangelo L, Casanova JL, Conley ME, Chapel H, Fischer A, Puck J et al. The route of administration could be intravenous (more used) or subcutaneous. International Union of Immunological Societies (IUIS) Primary Immunodeficiency Diseases (PID) Classification Committee. Primary immunodeficiency diseases: The preparations contain neutralizing antibodies against a wide variety of An update from the International Union of Immunological Societies Primary bacterial and viral pathogens, reflecting the immunological memory of the Immunodeficiency Diseases Classification Committee Meeting in Budapest, 2005. donors. J Allergy Clin Immunol 2006; 117: 883-96. Finally, gamma-globulin has proved to be safe and highly effective 11. Orange JS, Levy O, Brodeur SR, Krzewski K, Roy RM, Niemela JE et al. Human nuclear in reducing the incidence of respiratory infections and hospitalization factor kappa B essential modulator mutation can result in immunodeficiency without ectodermal dysplasia. J Allergy Clin Immunol 2004; 114: 650-6. rates in a significant manner, with a consequent reduction of morbidity 12. Ott MG, Schmidt M, Schwarzwaelder K, Stein S, Siler U, Koehl U et al. Correction of and mortality. X-linked chronic granulomatous disease by gene therapy, augmented by insertional activation of MDS1-EVI1, PRDM16 or SETBP1. Nat Med 2006; 12: 401–9. REFERENCES 13. Pourpak Z, Aghamohammadi A, Sedighipour L, Farhoudi A, Movahedi M, Gharagozlou M et al. Effect of regular intravenous immunoglobulin therapy on prevention of 1. Bonilla FA, Bernstein IL, Khan DA, Ballas ZK, Chinen J, Frank MM et al. American pneumonia in patients with common variable immunodeficiency. J Microbiol Immunol Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma Infect 2006; 39: 114–20. and Immunology; Joint Council of Allergy, Asthma and Immunology. Practice 14. Roxo Júnior P, Costa carvalho BT, Tavares FS. Infecções de repetição: o que é importante parameter for the diagnosis and management of primary immunodeficiency. Ann para o pediatra. Rev Paul Pediatr 2009 (in press). Allergy Asthma Immunol 2005; 94 (5 Suppl 1): S1–63. 15. Roxo Júnior P, Menezes UP, Ferriani. VPL. Relative frequency between primary 2. Booth C, Hershfield M, Notarangelo L, Buckley R, Hoenig M, Mahlaoui N et al. immunodeficiency groups in the primary immunodeficiency ward of Ribeirão Preto Management options for adenosine deaminase deficiency: proceedings of the EBMT Clinics Hospital-USP, from 1994 to 2005. Clinics 2005; 60 (1): S 55. satellite workshop (Hamburg, March 2006). Clin Immunol 2007; 123: 139–47. 16. Roxo Júnior P, Sorensen RU. Imunodeficiências predominantemente humorais. In: Roxo 3. Buckley RH. Primary immunodeficiency or not? Making the correct diagnosis. J Allergy Júnior P, editor. Alergia e imunodeficiências em pediatria – abordagem prática. Clin Immunol 2006; 117: 756–8. Ribeirão Preto: Tecmedd, 2006. p. 237-70. 4. Buckley RH. Variable phenotypic expression of mutations in genes of the immune system. 17. Simon HU, Spath PJ. IVIG: mechanisms of action. Allergy 2003; 58: 543–52. J Clin Invest 2005; 115, 2974–76. 18. Vasconcelos DM, Nudelman V. Imunodeficiências predominantemente celulares. In: 5. Conley ME, Stiehm ER. – Immunodeficiency disorders: general considerations. Roxo Júnior P, editor. Alergia e imunodeficiências em pediatria-abordagem prática. In: Stiehm ER, editor. Immunologic disorders in infants and children. 4ed Ed. Ribeirão Preto: Tecmedd, 2006. p. 271-307. Philadelphia: W B Saunders; 1996. p. 201-49.
CHARACTERISTICS AND ADVERSE EFFECTS OF AVAILABLE INTRAVENOUS IMMUNOGLOBULINS
Fabíola Scancetti Tavares Hospital Universitário de Brasília, Hospital de Base do Distrito Federal, Brazil
1. INTRODUCTION 2. CHARACTERISTICS
Disease prevention and treatment by passive immunization has been During the last two decades, many advances in large scale polyclonal a medical practice since the early 1900s. But widespread use of human intravenous immunoglobulin (IVIG) production have taken place. immune globulin became possible only after World War II.1 Many steps are followed during IVIG manufacturing to reduce disease The first report of an immune deficient patient who benefited from transmission and maximize tolerability. immune serum globulin replacement occurred in 1952.2 Since then, Improvement of virus inactivation and removal procedures include: immunoglobulin (Ig) supplementation has resulted in a significant cold ethanol precipitation and depth filtration, pasteurization, low pH reduction in morbidity and mortality in primary immune deficient (PID) treatment, proteases treatment, nanofiltration and so on. Donor screening patients.3 test amelioration involves tests for new pathogens and increasing Commercial Igs were restricted to intramuscular or subcutaneous sensitivity tests to eliminate window period infections. Aggregation injections until the early 1980s. Later, new preparations could be used of IgG molecules is prevented by adding stabilizing agents such as safely intravenously.4 carbohydrates. And products differ in composition: some contain glucose, others maltose or sucrose, and some have no sugar added. Yet, all the resulting intravenous (IV) solutions contain sodium in various amounts.4,5
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Table 1 - Characteristics of IVIG available preparatio Brand name Concentration Form pH Sugar Content Sodium Content IgA Content IgM Content Osmolarity (%) (μg/mL) (mOsmol/L) Gamunex® 10 Liquid 4.0-4.5 None Trace Amounts 46 Trace Amounts 258
Endobulin®/ 10 Liquid 4.5-5.1 None None ≤ 14 Trace Amounts 240-300 Kiovig®/ Gammagard® Privigen® 10 Liquid 4.6-5.0 None Trace Amounts ≤ 25 Trace Amounts 240-440
Gammagard® – Powder 6.4-7.2 20 mg/mL 8.5 mg/mL < 2.2 Trace Amounts 636 glucose
Carimune® NF – Powder 6.4-6.8 1.67 mg < 20 mg/g of protein 720 Trace Amounts 192 (5%)-1074 sucrose/g of (10%) protein Octagam® 5 Liquid 5.1-6.0 100 mg/mL ≤ 30 mMol/L ≤ 200 Trace Amounts 310-380 maltose Flebogamma® 5 Liquid 5.0-6.0 50 mg/mL < 3.2 mEq/L ≤ 50 Trace Amounts 240-350 sorbitol Carimune®/ 12 Liquid 5.3 None < 10 mMol/L ≤ 15 Trace Amounts 360 Sandoglobulin®/ Redimune® NF Polygam® – Powder 6.8 Glucose 0.145 mEq/mL < 2.2 Trace Amounts 636 (5%)-1250 (5% solution) (10%) 0.28 mEq/mL (10% solution)
There are premixed solutions and lyophilized powders which need adverse event frequency is in the order of 10% or less. Infusional or reconstitution, with their final concentrations ranging from 3% to 12%. temporally associated adverse events can occur from 30 minutes to 72 Between 15,000 and 60,000 donors are recommended to obtain adequate hours post infusion.4 Table 2 summarizes some common and rare IVIG product antibody diversity. Obviously, regional peculiarities can be found side effects.1,4,5,18-23 but do no pose any disadvantage. Preparations must have 90% or more monomeric IgG and only traces of aggregates. They may also contain Table 2 - Common and rare IVIG side effects IgG subclasses in similar concentrations as in normal plasma.6 The final osmolarity varies from 253 mOsm/L for a 5% IgG product Common Rare to 1250 mOsm/L for a 10% one. Another variability is the solution fatigue, malaise, fever, myalgia, aseptic meningitis, anaphylaxis, IgA amount, ranging from trace levels to 720mg/mL. The half-life of arthralgia, joint swelling, chills, pleural effusion, myocardial intravenously administered IgG is around 22 days. A few characteristics flushing, headache, migraine, infarction, tubular damage, renal of some IVIG available preparations are summarized in Table 1.7-14 cough, “flu-like sumptoms”, failure, alopecia, dyspnea, shock, The availability of higher protein concentration IVIG solutions may nausea, vomiting, anorexia, wheezing, anxiety, erythema benefit patients who use large doses frequently. In addition, a low pH hypertension, hypotension, multiforme, hepatic enzymes formulation favors product stability, so carbohydrate and sodium chloride dizziness, pruritus, urticaria, increase, blood glucose false are no longer required to prevent IgG aggregation.5 nonspecific skin eruption, positive, thrombotic phenomena, Since the 1990s, IVIG has been found to be useful in a variety backache, chest discomfort, respiratory failure, neutropenia, of clinical conditions other than PID.6,15 For example, there are some tachycardia, diarrhea transient hemolytic anemia, reports of IgM enriched IVIG product infusions used as adjuvant TRALI*, sense of impending therapy in septic patients.16,17 And when IVIG is used in higher doses for doom, anaphylactoid reactions, immunomodulatory purposes, unusual but severe adverse events have Stevens-Johnson syndrome been noticed more frequently. *TRALI: Transfusion Related Acute Lung Injury 3. ADVERSE EFFECTS Fortunately, most adverse reactions to IVIG are infusion-related, generally mild and self-limiting. They can often be solved by Reactions during IgG supplementation were already observed when infusion slowing or stopping and by symptomatic treatment. Actually, it was given intramuscularly and have continued to be of concern with premedication with antipyretics, nonsteroidal anti-inflammatory agents, IVIG therapy. At replacement doses in patients with PID, IVIG associated antihistamines, IV hydration, or low dose IV corticosteroids may avoid
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infusion related side effects. Headache is the most commonly reported to promptly treat anaphylaxis. If adverse reactions persist, premedication symptom, occurring in 5% to 20% of infusions. Mild-to-moderate with corticosteroids, antihistamines, antipyretics, nonsteroidal anti- reactions occur in 5% to 15% of all infusions. In spite of this, severe inflammatory agents, and/or IV hydration is frequently effective, along reactions occur in less than 1% of patients. 6,18,22,23 with decreasing the infusion rate. But, if a patient experiences severe The pathogenesis of IVIG associated adverse reactions is variable and adverse reactions to a licensed IVIG product, a different brand or depends on product type, amount, rate of infusion, as well as patient’s subcutaneous IgG should be tried.19,21 clinical features. Several factors predispose patients to a higher rate of Delaying infusion because of infection presence is considered systemic reactions: presence of infection, initiation of therapy, high dose, counterproductive and is rarely indicated. Some clinical situations dictate change in IVIG product, high concentration product, and rapid infusion individualization of the product used. For example, sucrose containing rate.18 Children are not more likely to experience IVIG associated adverse preparations must be avoided in patients with risk of renal damage reactions than adults.19 However, due to underlying morbidity, elderly and maltose in diabetic ones, whose glucose monitors might give false patients receiving IVIG are more prone to side effects. Elderly patients readings because of that sugar.22 with diabetes or preexisting renal function impairment are especially at risk of thromboembolic events and acute renal failure.22 4.4. DOCUMENTATION Of interest, there are reports of severe anaphylactic reactions in Before each IVIG infusion, product brand, batch, dosage and IgA deficient patients who still produce IgE. True anaphylaxis occurs expiration date should be registered in the patients’ records as well as rarely but may be life threatening. Severe adverse reactions are rare but the patients’ weight. Registering patients’ infectious, hematological, unpredictable and can even occur in patients who have tolerated IVIG hepatic, and renal function baseline is recommended before initiating therapy for months or years.23 IVIG therapy. And these parameters should be periodically reassessed during continuous treatment. 4. RECOMMENDATIONS 5. CONCLUDING REMARKS Some useful recommendations for IVIG therapy found in current literature are listed as follows. Immunoglobulin replacement therapy has represented a major advance in the treatment of PID patients. Production advances have 4.1. INFUSION MONITORING improved IVIG safety and tolerability. The first three infusions should ideally be given in a qualified center Actually, IVIG preparations are not biologically equivalent. These for monitoring severe adverse reactions. This is also recommended when diversities have a clinical impact and may lead to unpredictable individual changing the IVIG brand.6,18,20 differences in product tolerance. Therefore, the most appropriate product Before beginning any infusion, the patient should be reassessed. selection should be individualized for each patient considering outcomes Adverse effects occurring for up to 72 hours after the previous infusion like: age, morbidities, diagnosis, among others. should be noted. It is important to note any signs/symptoms of chronic Moreover, side effects have become more frequent as IVIG or acute infection. Reaction risk may be reduced by making sure patients indications have expanded. Favorably, IVIG adverse events are mostly are afebrile and that active infections are being treated before beginning mild and rare. IVIG therapy. Vital signs should be checked before the beginning and Nowadays IVIG is an important tool in order to reduce PID patient frequently during IVIG infusions.4,18 morbidity and mortality. And the variety of available preparations provides the opportunity for better clinical approaches that are focused 4.2. INFUSION RATE on each patients’ peculiarities. In order to reduce rate related adverse effects, infusions should be started at rates not above 0.01 mL/kg/minute (0.5 mg/kg/minute of 5% 6. REFERENCES solution or 1 mg/kg/minute of the 10% one). If the patient remains stable, infusion rate may be increased in a stepwise manner, (15 to 30 minute 1. Eibl MM. History of immunoglobulin replacement. Immunol Allergy Clin N Am intervals), up to the maximum tolerated (not surpassing a 0.08 mL/kg/ 2008;28:737-64. 2. Bruton OC. Agammaglobulinemia. Pediatrics 1952;9:722-7. minute infusion rate). Therefore, vital signs and patient’s condition 3. Boyle ML, Scalchunes C. Impact of intravenous immunoglobulin (IVIG) treatment among 4,6 should be recorded before and 5 to 10 minutes after each rate change. patients with primary immunodeficiency diseases. Pharmaceuticals Policy and Law Additionally, close patient monitoring is necessary when switching 2008;10:133-46. products, as infusion rates may need adjustment. Premedication should 4. Berger M. Principles of and advances in immunoglobulin replacement therapy for primary be used every time the patient receives a different brand from his usual immunodeficiency. Immunol Allergy Clin N Am 2008;28:413-37. 20 5. Hooper, JA. Intravenous immunoglobulins : evolution of commercial IVIG preparations. one and for the first two infusions in naïve patients. Immunol Allergy Clin N Am 2008;28:765-78. When facing a mild infusion rate side effect, IVIG administration 6. Orange JS, Hossny EM, Weiler CR, Ballow M, Berger M, Bonilla FA et al. Use of must be stopped. Usually symptoms begin to subside within 30 minutes intravenous immunoglobulin in human disease: a review of evidence by members and infusion can be restarted. A restarting rate of half the previous one of the primary immunodeficiency committee of The American Academy of Allergy, is recommended. Although most patients can tolerate administration Asthma and Immunology. J Allergy Clin Immunol 2006;117:S525-53. 7. Stein MR, Nelson RP, Church JA, Wasserman RL, Borte M, Vermylen C et al. Safety and of IVIG over three to four hours, the infusion rate may need to be efficacy of Privigen®, a novel 10% liquid immunoglobulin preparation for intravenous 6 individualized. use, in patients with primary immunodeficiencies. J Clin Immunol (2009) 29:137-44. 8. Poelsler G, Berting A, Kindermann J, Spruth M, Hämmerle T, Teschner W et al. A new 4.3. GENERAL liquid intravenous immunoglobulin with three dedicated virus reduction steps: virus Any practitioner or facility that administers IVIG must be equipped and prion reduction capacity. Vox Sanguinis 2008;94:184-92.
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9. Church JA, Leibl H, Stein MR, Melamed IR, Rubinstein A, Schneider LC et al. Efficacy, microbiological aetiology and severity of sepsis. J Int Med 2006;260:509-16. safety and tolerability of a new 10% liquid intravenous immune globulin [IGIV 10%] 17. Neilsona AR, Burchardib H, Schneidera H. Cost-effectiveness of immunoglobulin M– in patients with primary immunedeficiency. J Clin Immunol 2006;26(4):388-95. enriched immunoglobulin (Pentaglobin) in the treatment of severe sepsis and septic 10. Ochs HD, Pinciaro PJ, and The Octagam Study Group. Octagam® 5%, an intravenous IgG shock. Journal of Critical Care 2005;20:239-50. product, is efficacious and well tolerated in subjects with primary immunodeficiency 18. Bonilla FA. Intravenous immunoglobulin: adverse reactions and management. J Allergy diseases. J Clin Immunol 2004;24(3):309-14. Clin Immunol 2008;122:1238-9. 11. Berger M, Cunningham-Rundles C, Bonilla FA, Melamed I, Bichler J, Zenker O et al. 19. Garcia-Lloret M, SeanMcGhee, Chatila TA. Immunoglobulin replacement therapy in Carimune NF liquid is a safe and effective immunoglobulin replacement therapy in children. Immunol Allergy Clin N Am 2008;28:833-49. patients with PID. J Clin Immunol 2007;27(5):503-9. 20. Brennan VM, Salomé-Bentley NJ, Chapel HM. Prospective audit of adverse reactions 12. Berger M, Pinciaro PJ, and Flebogama® 5% Investigators. Safety, efficacy, and occurring in 459 primary antibody-deficient patients receiving intravenous pharmacokinetics of Flebogamma® 5% [Immune Globulin Intravenous (Human)] immunoglobulin. Clin Exp Immunol 2003;133:247-51. for replacement therapy in primary immunodeficiency diseases. Journal of Clinical 21. Quinti I, Soresina A, Agostini C, Spadaro G, Matucci A, Sfika I et al. Prospective Immunology, 2004 July;24(4):389-96. study on CVID patients with adverse reactions to intravenous or subcutaneous IgG 13. Talecris Biotherapeutics, Inc. Immune Globulin Intravenous (Human) Gamunex® 10% administration. J Clin Immunol 2008;28:263-7. Product Information Available at: http://www.talecris-pi.info. Accessed July 26,2009. 22. Vo AA, Cam V, Toyoda M, Puliyanda DP, Lukovsky M, Bunnapradist S et al. Safety 14. National Bioproducts Institute (Manufacturer of human immunoglobulin in South Africa). and adverse events profiles of intravenous gammaglobulin products used for Polygam® Polyvalent human normal immunoglobulin powder - Product information. immunomodulation: a single-center experience. Clin J Am Soc Nephrol 2006;1:844- Available at: www.nbi-kzn.org.za. Accessed July 29,2009. 52. 15. Nimmerjahn F, Ravetch JV. Anti-inflammatory actions of IVIG. Annu. Rev. Immunol. 23. Immune Deficiency Foundation. 2003 Treatment experiences and preferences of patients 2008;26:513-33. with primary immune deficiency diseases: first Immune Deficiency Foundation 16. Norrby-Teglund A, Haque KN, Hammarstön L. Intravenous polyclonal IgM-enriched national survey. Available at: http://www.primaryimmune.org/pid/survey.htm. immunoglobulin therapy in sepsis: a review of clinical efficacy in relation to Accessed July 27, 2009.
FLOW CYTOMETRY FOR THE DIAGNOSIS OF PRIMARY IMMUNODEFICIENCIES.
Thomas A. Fleisher, M.D., NIH Clinical Center, National Institutes of Health, Bethesda, MD, USA
The utility of flow cytometry in the evaluation of possible primary flow cytometric screening test usually will detect protein based on the immunodeficiency (PID) has expanded significantly as the range of binding of the monoclonal antibody and thus, would fail to identify the applications of this technology has increased. The application of this presence of the disease. In many PIDs there are biological effects that methodology includes evaluation based on surface antigen detection result from the underlying disorder and examples of these include failure for the absence of specific cell populations or subpopulations that are to generate memory B cells or T cells, failure to undergo isotype class characteristic of selected PIDs. These studies are particularly useful in switch and oligoclonal T cell antigen receptor expression. In each of those the setting of possible congenital agammaglobulinemia where B cells are situations, flow cytometry can be used to verify the biological effect of absent or very low and in severe combined immunodeficiency (SCID) the underlying PID. Finally, the evolution of functional flow cytometry where T cell development is defective but the abnormality in B cells and has provided additional means of screening for PIDs. Examples of this NK cells vary. The capacity to specifically quantify extracellular and application include evaluating for STAT phosphorylation in response intracellular proteins has provided additional utility for flow cytometry to specific cytokine stimulation to screen for defects in the IL-12/ as a screen for PIDs associated with a defect in a cellular protein to which IFN-gamma pathway and evaluation of granulocyte oxidative burst to a monoclonal antibody has been developed (e.g.CD40L, CD18, BTK, diagnose chronic granulomatous disease. Flow cytometry has emerged WASP). This allows screening patient cells for protein absence that would as an important tool in the evaluation of patients for possible PID and clarify the specific diagnosis. However, there are also situations where in selected settings can actually provide the definitive diagnosis in an a protein is present but it is functionally defective and in this setting the accurate and very timely fashion.
DERMATOLOGICAL MANIFESTATIONS OF PRIMARY IMMUNODEFICIENCIES.
Dewton de Moraes Vasconcelos; Anete Sevciovic Grumach; Maurício Domingues Ferreira; Noac Chuffi-Barros; Elisabete Cordeiro; Alberto José da Silva Duarte. Ambulatório de Manifestações Dermatológicas das Imunodeficiências do HCFMUSP; Laboratório de Investigação Médica em Dermatologia e Imunodeficiências (LIM-56) do Depto de Dermatologia FMUSP
SUMMARY: Primary immunodeficiency disorders comprise serious may realize something is wrong with the immunity of their patient and rare diseases, predominantly in children (Morimoto and Routes, and prompt diagnosis of the defect can lead to lifesaving treatment. 20081). The skin may be involved in a primary immunodeficiency and Since atypical presentations of well known dermatoses are common in the cutaneous alterations such as infections, eczematous dermatitis, immunodeficiency disorders, histopathology and bacterial, fungal or erythroderma, autoimmune dermatoses and vasculitis may be the basis viral tests of the skin lesions are often indispensable. Our experience for the ultimate diagnosis (Berron-Ruiz et al, 20001). Dermatologists of nine years in this outpatient unit of the Department of Dermatology
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showed that there are PIDs characterized by cutaneous manifestations, and chronic granulomatous disease (2.8% each), specific polysaccharide but other PIDs might occasionally be associated to skin features. The antibody deficiency (SPAD) (1.9%), xeroderma pigmentosum (XP), knowledge of skin findings in primary immunodeficiency diseases may immunodeficiency with thymoma (Good syndrome) and X linked help dermatologists to play a role in the early detection of these diseases. agammaglobulinemia (XLA) (1.4% each) and several other PIDs such as Netherton and hyper IgE syndromes, epidermodysplasia verruciformis, Keywords: Primary immunodeficiencies; skin; cutaneous IgG subclass and CD3 epsilon deficiencies, Bloom syndrome, CD18, manifestations. ZAP-70 and purine nucleoside phosphorylase (PNP) deficiencies (less than 1% each). These phenotypes were diagnosed mostly in the last 5 Running title: Dermatological manifestations of Primary years of the survey. Associated diseases, found in 40% of patients, were Immunodeficiency diseases. mostly allergic conditions followed by autoimmune and neoplastic disorders. BACKGROUND: Primary immunodeficiency disorders include a Among the other diseases not classified yet as PIDs there were: severe variety of diseases that render patients more susceptible to infections furunculosis (39.6%), extensive mucocutaneous candidiasis (16.4%), (Geha et al, 20073). To determine the percentage of different primary extensive dermatophytosis (6.7%), disseminated mycobacteriosis and immunodeficiency disorders diagnosed in the Cutaneous Manifestations recurrent onychomycosis (6.0% each), recurrent aphtae and herpes of Primary Immunodeficiencies Outpatient Unit (ADEE-3003) of the simplex (4.5% each), HPV associated verrucosis and deep mycoses Clinics Hospital affiliated to the University of São Paulo in Brazil, we (3.0% each), pyoderma gangrenosum / inflammatory bowel disease and retrospectively reviewed the charts of the patients being referred to our erythroderma ictiosiformis congenitae (2.2%), extensive molluscum hospital for immunologic evaluation of recurrent infections during a nine contagiosum, decalvating folliculitis, severe periodontitis and cutaneous year period. Advances in immunologic techniques in recent years have mastocytosis (1.5% each). led to increased recognition of primary immunodeficiency disorders, with immunoglobulin deficiencies being the most common phenotype reported DISCUSSION: Primary immunodeficiencies are challenging by most registries. There have also been reports of increased associated diagnoses in primary care settings, where clinicians often encounter incidence of autoimmunity, allergy, and other diseases. patients with a history of recurrent infection. With advances in diagnostics and therapeutics, these disorders have been better understood and more OBJECTIVES: We wished to determine the percentage of successfully treated, yet their prognosis depends on early recognition different primary immunodeficiency disorders seen in a specialized of the disorder and initiation of the appropriate management. Because dermatology outpatient unit and to determine the association of primary the primary care physician is most often the first physician encountered immunodeficiency disorders with other diseases – mainly dermatological by a patient with immunodeficiency, primary care practitioners - that are not part of classic immunodeficiency diseases. should be familiar with these rare but important disorders. This is particularly true for dermatologists, which are usually the one and only METHODS: We performed a retrospective review of the patients physician evaluating patients presenting cutaneous infections. Primary referred to our immunology clinic for immunologic evaluation of recurrent immunodeficiency diseases are considered rare disorders, but often infections during an 9-year period (1999-2008). We also reviewed lead to serious consequences. Therefore an early diagnosis is critical. pathology reports with postmortem diagnosis of immunodeficiencies The variety in the clinical presentation, the complexity of the immune not identified while patients were alive. system and the ongoing discovery of new defects render it a difficult area for the involved physician. Due to the often imprecise complaint of RESULTS: Of the 1049 patients followed-up in the dermatological a weak immune system the primary task is the identification of patients manifestations of primary immunodeficiencies outpatient unit, 116 with true immunodeficiency. Subsequently, the immune defect needs (11.1%) presented primary immunodeficiency disorders (PIDs) with to be identified in collaboration with a center for immunodeficiency dermatological manifestations, 109 (10.4%) PIDs without cutaneous disorders, such as our outpatient unit in the Department of Dermatology. features, 161 patients (15.2%) presented possible (not confirmed) PID The diagnostic procedure is dependent on the pattern of infections and with dermatological manifestations, 405 patients (38.7%) presented follows a defined series of steps. This procedure should prevent costly other types of diseases (autoimmunity, allergy, and other diseases) and diagnostic evaluation, which are usually not indicated, and also prevent 258 individuals (24.6%) didn’t have any immunological abnormality. In the delayed diagnosis of patients with manifest immunodeficiency relation to the genders, 598 (57%) were females and 451 (43%) males. disease. The present manuscript provides an overview of the casuistry Contrasting to the majority of the PID services, our service follows of our outpatient unit, specialized in the evaluation of dermatological children and adults as well: 482 patients (46%) were 0-20 years old manifestations of primary immunodeficiencies and located in the and 567 (54%) were 21-80 years old. According to the type of defect, Department of Dermatology of the School of Medicine of the University we observed predominantly antibody deficiencies (46%); cellular or of São Paulo. The study reveals that in our outpatient unit there was combined (13%); phagocytic (12%) complement (11%); associated to a little predominance of antibody deficiencies, being IgA deficiency major defects (3%) and others (15%). The most common phenotype was and CVID the most frequently diagnosed primary immunodeficiency IgA deficiency (17.5%), followed by common variable immunodeficiency disorder in our patient population. Nevertheless following these more (CVID) (14.7%), chronic mucocutaneous candidiasis (CMC) and common diseases, cellular and complement disorders are extremely hereditary angioedema (11.8% each). Following these, idiopathic CD4 prevalent in our casuistry, possibly denoting a sample bias due to the lymphocytopenia (6.2%), Mendelian susceptibility to Mycobacterial expertise in the diagnosis of cellular and complement disturbances by diseases (4.3%), Complement, IgM and G6PD deficiencies (3.8% each), the main researchers of the group (Moraes-Vasconcelos and Grumach, cyclic neutropenia (3.3%), Transient hypogammaglobulinemia of infancy respectively), leading to the diagnosis of rare diseases. We have already
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established in our associated laboratory the phenotypical and molecular constitute specific skin symptoms combined with unusual or severe biology tests to diagnose most of the more common diseases and even infections. Our study shows some differences with other results and several disorders rarely observed. It is important to stress that there are other registries devoted to primary immunodeficiencies due to the special genetic background factors that influence the distribution of the diverse characteristic of our service evaluating PID patients with dermatological types of PIDs. It also indicates that immunodeficiency disorders should manifestations. be considered in patients with other abnormalities like allergic and syndromic/chromosomal disorders that present with recurrent infections. BIBLIOGRAPHY Moreover, the skin may be involved in a primary immunodeficiency and the cutaneous alterations such as infections, eczematous dermatitis, 1. Morimoto Y. Routes JM. Immunodeficiency Overview. Primary Care: Clinics in Office erythroderma, autoimmune dermatoses and vasculitis may be the basis Practice, 2008; 35(1): 159-173. 2. Berron-Ruiz A, Berron-Perez R, Ruiz-Maldonado R. Cutaneous markers of primary for the ultimate diagnosis. Dermatologists may realize something is immunodeficiency diseases in children. Pediatr Dermatol. 2000; 17(2): 91-6. wrong with the immunity of their patient and prompt diagnosis of the 3. Geha RS, Notarangelo LD, Casanova JL, Chapel H, Conley ME, Fischer A, Hammarström defect can lead to lifesaving treatment. Since atypical presentations of L, Nonoyama S, Ochs HD, Puck JM, Roifman C, Seger R, Wedgwood J; International well-known dermatoses are common in immunodeficiency disorders, Union of Immunological Societies Primary Immunodeficiency Diseases Classification histopathology and bacterial, fungal or viral tests of the skin lesions are Committee. Primary immunodeficiency diseases: an update from the International 4 Union of Immunological Societies Primary Immunodeficiency Diseases Classification often indispensable. (Sillevis Smith et al, 2005 ). The knowledge of skin Committee. J Allergy Clin Immunol. 2007; 120(4): 776-94. findings in primary immunodeficiency diseases may help dermatologists 4. Sillevis Smitt JH, Wulffraat NM, Kuijpers TW. The skin in primary immunodeficiency to play a role in the early detection of these diseases. Key findings disorders. Eur J Dermatol. 2005; 15(6): 425-32.
LABORATORIAL DIAGNOSIS OF COMPLEMENT DEFICIENCIES
Michael Kirschfink Institute of Immunology, University of Heidelberg, Germany
The discovery of individuals with complement deficiencies has greatly age related macular degeneration, paroxysmal nocturnal hemoglobinuria contributed to our knowledge on the importance of the complement system and the relatively more frequent hereditary angioedema. With the in host defence. The identification of an increasing number of individuals availability of screening assays that are much easier to perfom than the with selective deficiencies of complement components and regulators has standard haemolytic tests, more and more individuals with complement led to the recognition that bacterial infections and autoimmune diseases deficiency are expected to be found. are the clinical conditions most frequently associated with complement An overview will be given on the current status of complement defects. Complement analysis in the clinic is usually associated with analysis, including assays for complement activity and complement C3 and C4 quantification, measurement of C1inhibitor and screening activation products, genetic methods for the detection of deficiencies as for complement activity, parameter that have been available in routine well as mutations and polymorphisms. diagnostics for decades. In recent years this field has considerably The implementation of new techniques and the development of new expanded, introducing novel assays to detect complement activation and diagnostic tools in complement analysis will help to further elucidate expanding to genetic analysis to reveal complement deficiency, as well as its mechanisms of action and effects. Using these new approaches in a mutations and polymorphisms related to defined diseases such as atypical collaborative way between research and clinic it will be ultimately possible haemolytic uremic syndrome, membranoproliferative glomerulonephritis, to find therapeutic strategies for diseases in which complement is involved.
NEW ACQUISITIONS ON HEREDITARY ANGIOEDEMA.
Marco Cicardi and Andrea Zanichelli Department of Clinical Sciences, University of Milan, Ospedale Luigi Sacco, Milan, Italy
Introduction mucosa that represent angioedema. (1) A form of hereditary angioedema The majority of subjects with hereditary angioedema (HAE) have with normal C1-INH, which frequently occurs just in women and can C1inhibitor (C1-INH) functional levels in plasma lower than 50% be associated with mutations in factor XII has been recently described, of normal. C1-INH inactivates C1r, C1s and MASP 1 and 2 in the but will not be discussed here.(2) complement system, Factor XII and kallikrein in the contact system, Factor XI and thrombin in the coagulation system, tPA and plasmin in Etiology of C1-INH defect the fibrinolytic system. Subjects with C1-INH deficiency are exposed to C1-INH deficiency can be genetic or acquired. The genetic form is develop local, self limiting, reversible increase of vascular permeability due to mutations in one of the two alleles of C1-INH gene that result in in the deeper layers of the skin and/or the gastrointestinal and laryngeal reduced protein levels in plasma (hereditary angioedema, HAE, type I)
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or in normal protein levels, but reduced function (HAE type II) . attenuated derivatives. (11) On high doses they increase C1-INH plasma The mutated allele and C1-INH deficiency segregate into HAE levels, but much lower doses that do not change the plasma levels of C1- families according to Mendelian law and nearly 200 different mutations INH, are clinical effective. Thus it is possible that the therapeutic effect causing HAE have been described so far. (3) of androgens on HAE is independent from the effect on C1-INH levels The kallikrein kinin system and the pathophysiology of angioedema provided recent evidence that they may facilitate kinin catabolism acting in C1-INH deficiency on aminopeptidase P. (5) Studies in patients’ plasma, in vitro studies and studies in C1-INH Starting from the early seventies, preparations of C1-INH partially K.O. animals provide strong evidence that angioedema due to C1- purified from pooled human plasma became available as substitution INH deficiency is mediated by the nine aminoacids peptide hormone therapy in deficient patients. Evidence for the efficacy of C1-INH bradykinin (BK). BK acts in a paracrine mode and activates adjacent G concentrates comes from a few controlled studies and from a clinical protein-coupled receptors of the B2 type (B2R) that are constitutively experience of nearly 30 years. (12) Available data provide sufficient expressed on different cells. BK can induce endothelial hyperpermeability evidence to consider C1-INH concentrate the treatment of choice for acute via the nitric oxide pathway. (4) BK remains in the circulation just for attacks in HAE patients. This has certainly been true until now, but it may a few seconds and it is rapidly metabolized, mainly by angiotensin change in the coming years based on the results of the trials aimed to I–converting enzyme (ACE) and aminopeptidase P (APP), whereas demonstrate efficacy and safety of three different new drugs in treatment carboxypeptidase N (CPN) transforms BK into its active metabolite, of angioedema attacks in patient with HAE due to C1-INH deficiency. des-Arg9-BK. Changes in the BK catabolism may influence angioedema Pharming, a Dutch biotech company, has developed a method for which occurs as side effect of treatment with inhibitors of the ACE and production of recombinant human C1 inhibitor (rhC1-INH) from the milk which can be influenced by the levels of APP. (5) of transgenic rabbits. A favorable safety profile and biologic activity were BK is produced by the kallikrein-kinin system (KKS), which is proved in a phase I study. The efficacy in treating angioedema in HAE formed by three zymogen, plasma prekallikrein (PK), Factor XII (FXII) was initially assessed in an open label study in which 10 attacks resolved and Factor XI (FXI), and by the non enzymatic cofactor high molecular faster compared to untreated attacks. (13) Phase III studies have then weight kininogen (HK). (6) Classically, activation of the KKS starts when been recently completed with apparently good results communicated in FXII gets activated to become the enzyme FXIIa, which then activates PK meetings and press releases, but not yet published. (14) complexed with HK, eventually leading to formation of BK. Despite a The 2 other new compounds are not based on C1-INH: the plasma long list of candidates proposed over the years, the physiological activator kallikrein inhibitor Dx-88 (Ecallantide) (Dyax Corp.) and the bradykinin of FXII in vivo has remained unknown. B2 receptor antagonist Icatibant (Jerini A.G.). Dx88 is a recombinant peptide of 7054 kD, produced in Pichia The clinic and diagnosis of HAE Pastoris. (15) Five clinical studies with Dx-88 have been completed and Patients with HAE suffer from a characteristic triad of symptoms the results communicated to meetings indicate that Dx88 is effective in defined as self limiting, recurrent angioedema of the cutaneous, reverting HAE attacks given either intravenous (IV) or subcutaneous gastrointestinal and pharyngo-laryngeal tissues. Fifty percent of them (SC). (16) The safety profile seems to be generally good, a few acute become symptomatic within the first decade of life and less than 10% dosing reactions (rhinitis, flushing, and/or nausea) and one anaphylactoid after the second. Depending on the location, angioedema are disfiguring, reaction have been reported. (17) cause abdominal pain mimicking acute surgical emergencies and cause Icatibant is a potent, specific and selective peptidomimetic bradykinin asphyxia becoming lifethreatening. At any location, angioedema can B(2)-receptor antagonist. An open labelled pilot study showed that highly impair daily activities and severely impact the patients’ quality Icatibant, either i.v. or s.c., considerably shortened the duration of attacks of life. (7) Frequency and severity of recurrences determine the burden compared with similar untreated attacks in the same patients. (18) Phase of the disease which varies from patient to patient. Such variability does III clinical studies (FAST 1 and FAST 2) to prove the safety and efficacy not segregate with C1-INH defect and thus does not depend on C1-INH have been completed and the results are expected to be published. In mutation. At the present time we have no clue to the understanding of the April 2008 the European Medicines Agency’s (EMEA) Committee for mechanisms governing such variability and we just begin to recognize Medicinal Products for Human Use (CHMP) adopted positive opinion markers to distinguish patients in the different disease phases. (8) recommending the granting of a marketing authorization, for icatibant The disease, suspected based on the recurrent symptoms and on with the name of Firazyr for the treatment of hereditary angioedema in the family history, present in 75% of the subjects (9), is biochemically adults with C1-INH deficiency. In July the European Commission has diagnosed by the detection of plasma levels of C1-INH function granted the company marketing authorization for Firazyr® (Icatibant) in below 50% of normal. A major limit to the biochemical diagnosis the treatment of acute attacks of hereditary angioedema (HAE). Firazyr® is the poor availability of the functional C1-INH test and the lack of has now been, or is being, introduced in European Union’s 27 member standardization. (10) Reduction in C1-INH and C4 antigen, widely states, and is the first product to be approved in all EU countries for the available measurements, provide diagnostic support, but do not identify treatment of HAE. all patients. Genetic testing for C1-INH mutations is rarely necessary for diagnosis and may be needed for the few patients in who inherited REFERENCES and acquired C1-INH deficiency can not be otherwise distinguished. (7) 1. DiSanto JP, Bonnefoy JY, Gauchat JF, Fischer A, de Saint Basile G. CD40 ligand mutations The treatment of C1-INH deficiency in x-linked immunodeficiency with hyper-IgM. Nature 1993;361:541-3. 2. Ferrari S, Giliani S, Insalaco A, Al-Ghonaium A, Soresina AR, Loubser M, Avanzini Angioedema attacks are disabling and lifethreatening, an adequate MA, Marconi M, Badolato R, Ugazio AG, Levy Y, Catalan N, Durandy A, Tbakhi A, treatment has always represented a critical priority. The first drugs that Notarangelo LD, Plebani A. Mutations of CD40 gene cause an autosomal recessive positively changed the life of HAE patients were androgens and their form of immunodeficiency with hyper IgM. Proc Natl Acad Sci U S A 2001;98:12614-9.
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3. Doffinger R, Smahi A, Bessia C, Geissmann F, Feinberg J, Durandy A, Bodemer C, lymphomas. Oncogene 2003 22(35), 5381–5386 Kenwrick S, Dupuis-Girod S, Blanche S, Wood P, Rabia SH, Headon DJ, Overbeek 11 Stavnezer J, Guikema JE, Schrader CE. Me chanism and regulation of class switch PA, Le Deist F, Holland SM, Belani K, Kumararatne DS, Fischer A, Shapiro R, recombination. Annu Rev Immunol. 2008;26:261-92. Conley ME, Reimund E, Kalhoff H, Abinun M, Munnich A, Israel A, Courtois G, 12 Péron S, Metin A, Gardès P, Alyanakian MA, Sheridan E, Kratz CP, Fischer A, Durandy Casanova JL. X-linked anhidrotic ectodermal dysplasia with immunodeficiency is A Human PMS2 deficiency is associated with impaired immunoglobulin class switch caused by impaired NF-kappaB signaling. Nat Genet 2001;27:277-85. recombination. J Exp Med. 2008;205(11):2465-72. 4. Cerutti A.The regulation of IgA class switching. Nat Rev Immunol. 2008 ;6:421-34 13. Pan-Hammarström Q, Lähdesmäki A, Zhao Y, Du L, Zhao Z, Wen S, Ruiz-Perez VL, 5. Grimbacher B, Hutloff A, Schlesier M, Glocker E, Warnatz K, Drager R, Eibel H, Fischer Dunn-Walters DK, Goodship JA, Hammarström L. Disparate roles of ATR and ATM B, Schaffer AA, Mages HW, Kroczek RA, Peter HH. Homozygous loss of ICOS in immunoglobulin class switch recombination and somatic hypermutation. J Exp is associated with adult-onset common variable immunodeficiency. Nat Immunol Med. 2006;203(1):99-110.A, 2003;4:261-8. 14. Etzioni A, Ben-Barak A, Peron S, Durandy A. Ataxia-telangiectasia in twins presenting 6. Revy P, Muto T, Levy Y, Geissmann F, Plebani A, Sanal O, Catalan N, Forveille M, as autosomal recessive hyper-immunoglobulin M syndrome. Isr Med Assoc J. 2007; Dufourcq-Labelouse R, Gennery A, Tezcan I, Ersoy F, Kayserili H, Ugazio AG, 5:406-7 Brousse N, Muramatsu M, Notarangelo LD, Kinoshita K, Honjo T, Fischer A, Durandy 15 Buck D, Malivert L, de Chasseval R, Barraud A, Fondanèche MC, Sanal O, Plebani A, A. Activation-induced cytidine deaminase (AID) deficiency causes the autosomal Stéphan JL, Hufnagel M, le Deist F, Fischer A, Durandy A, de Villartay JP, Revy recessive form of the Hyper-IgM syndrome (HIGM2). Cell 2000;102:565-75. P Cernunnos, a novel nonhomologous end-joining factor, is mutated in human 7. Durandy A, Peron S, Taubenheim N, Fischer A. Activation-induced cytidine deaminase: immunodeficiency with microcephaly Cell. 2006;124(2):287-99. structure-function relationship as based on the study of mutants.Hum Mutat. 2006; 16. Pan-Hammarström Q, Jones AM, Lähdesmäki A, Zhou W, Gatti RA, Hammarström 27 (12) :1185-8. L, Gennery AR, Ehrenstein MR.Impact of DNA ligase IV on nonhomologous end 8. Imai K, Zhu Y, Revy P, Morio T, Mizutani S, Fischer A, Nonoyama S, Durandy A. Analysis joining pathways during class switch recombination in human cells. J Exp Med. of class switch recombination and somatic hypermutation in patients affected with 2005;201(2):189-94. autosomal dominant hyper-IgM syndrome type 2. Clin Immunol 2005;115:277-85. 17. Taubenheim N, Peron S, Fischer A. Pathophysiology of B-cell intrinsic immunoglobulin 9. Imai K, Slupphaug G, Lee WI, Revy P, Nonoyama S, Catalan N, Yel L, Forveille M, Kavli class switch recombination deficiencies. Adv Immunol 2007;94:275-306. B, Krokan HE, Ochs HD, Fischer A, Durandy A. Human uracil-DNA glycosylase 18. Peron S, Pan-Hammarstrom Q, Imai K, Du L, Taubenheim N, Sanal O, Marodi L, deficiency associated with profoundly impaired immunoglobulin class-switch Bergelin-Besancon A, Benkerrou M, de Villartay JP, Fischer A, Revy P, Durandy recombination. Nat Immunol 2003;4:1023-8. A. A primary immunodeficiency characterized by defective immunoglobulin class 10. Nilsen, H., Stamp, G., Andersen, S., Hrivnak, G., Krokan, H. E., Lindahl, T., and Barnes, switch recombination and impaired DNA repair. J Exp Med 2007;204:1207-16. D. E. Gene targeted mice lacking the ung Uracil-DNA glycosylase develop B cell
CLINICAL RELEVANCE OF THE LECTIN PATHWAY OF COMPLEMENT
Sergio Crovella Department of Genetics, Federal University of Pernambuco
Mannose-binding lectin (MBL) is a plasma glycoprotein synthesized now recognized to have a role in different processes, as complement in the liver and it is an important constituent of the innate immune system activation, promotion of complement-independent opsonophagocytosis, with a structure similar to the complement C1q . MBL structure has been modulation of inflammation, recognition of altered self-structures and studied extensively and consists of multimers of an identical polypeptide apoptotic cell clearance (3). chain of 32 kDa. Each chain comprises four distinct regions encoded by MBL deficiency has been reported and is largely explained by three different exons of the MBL2 gene. Each chain has a C-terminal, calcium- single nucleotide polymorphisms (SNP) at codons 52, 54 and 57 of exon 1 dependent carbohydrate-recognition domain (CRD); a short, α-helical, in the MBL2 gene. These mutations are frequently referred to as variants D, hydrophobic neck region (in the so-called coiled-coil configuration); B and C, respectively, with A indicating wild-type. The B variant mutation a collagene-like region and a cysteine-rich N-terminal region. Three occurs in 22–28% of Eurasian populations, whereas the C variant mutation polypeptide chains form a triple helix within the collagenous region, is characteristic of sub-Saharan African populations in whom it reaches stabilized by hydrophobic interactions and interchain disulphide bonds frequencies of 50–60%. The D mutation reaches frequencies of 14% in within the N-terminal cysteine-rich region (1). European populations but can be much lower elsewhere. In serum, MBL consists of oligomers ranging from dimers to The exon 1 mutations in the MBL2 gene are believed to impair hexamers, and X-ray crystallographic studies demonstrated that in this oligomerisation and lead to a functional deficiency. In the case of the form the oligomers show a bouquet-like structure due to an interruption B and C mutations, critical axial glycines of the triple collagenous in the collagenous region, giving rise to a slight bending of the triple helix are replaced by dicarboxylic acids, which would be expected to helix structure. Clustering of the structural subunits allows binding of distort the helix. In the case of the D variant, the effect of the mutation MBL to the arrays of repeating sugar groups on microbial surfaces. is to replace an arginine residue by a cysteine and it has been claimed Although the binding affinity of each individual interaction between that the presence of this extra cysteine residue causes the formation of the carbohydrate-recognition domain and the sugar is relatively low, the adventitious disulphide bonds, dramatically reducing the formation of formation of higher order oligomers provides a way for MBL to bind to higher order oligomers. In addition to the above structural gene mutations, the bacterial sugars with high avidity (2). several polymorphisms have been described in the promoter region of MBL is a major pattern-recognition molecule of the innate immune the MBL2 gene. These are the H/L, X/Y and P/Q allele at positions system that primarily recognizes specific sugar groups on the surface of −550, −221 and +4 of the MBL2 gene. These promoter polymorphisms a wide range of bacteria, viruses, fungi and protozoa. The understanding combine to form haplotypes that are in strong linkage disequilibrium with of MBL function has grown rapidly over the past three decades. It is the exon 1 mutations, resulting in seven common extended haplotypes,
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namely HYPA, LYPA, LYQA, LXPA, HYPD, LYPB and LYQC. Other MBL2 allele (allele 0) and HIV-1 infection in perinatally exposed rare haplotypes have also been descrive (4,5). children. The presence of the allele 0 conferred a relative risk of 1.37 The combination of structural gene and promoter polymorphisms (95% confidence limits 1.02–1.84) for HIV-1 infection through vertical results in a dramatic variation in MBL concentration in apparently transmission (7). In a previous study on Italian perinatally infected HIV-1 healthy individuals of up to 1000-fold (Caucasian: range <20–10,000 positive children the presence of the 0 allele has been associated with a ng/ml). Approximately one-third of the Caucasian population possesses rapid progression to AIDS (8). genotypes conferring low levels of MBL, with approximately 5% having We also investigated the role of the polymorphisms in the first exon of very low levels. MBL2 gene in the susceptibility to HCV infection and disease progression The high frequency of variant alleles observed in certain populations in a Northeastern Brazilian population. The 0 allele was significantly was initially puzzling since it suggests that functional MBL deficiency more frequent in the HCV positive group than the healthy controls (34% may well be advantageous. Similarities have been proposed between the vs. 20%, p<0.01, respectively) and was associated to an increased risk of MBL genetic system and the role of the hemoglobin gene mutation that HCV-1 infection (O.R.=2.1; C.I. 1.41–3.19). Also genotypes frequencies leads to sickle cell anemia in protection against malaria. The argument were significantly different in HCV positive subjects when compared runs as follows: certain intracellular parasites use C3 opsonization and to healthy controls with the 0/0 and A/0 genotypes being significantly C3 receptors on monocytes/macrophages to enter their host. Therefore, overrepresented in HCV infected subject (15% and 37%, respectively) any reduction in complement-activating function of the host may reduce as compared to healthy subjects (6% and 27%, respectively, p<0.01) (9). the probability of parasitizing. In support of this notion is a study on We then studied the association between high-risk human papillomavirus patients with visceral leishmaniosis, which revealed that such patients (HPV) infection and MBL2 functional polymorphisms in a group of 180 are more likely to have high MBL levels than uninfected controls. high-risk HPV-infected women and 180 healthy control subjects. No A small study of Ethiopian patients with lepromatous or borderline differences in MBL2 genotype or in allelic or haplotype frequencies lepromatous leprosy also found that their MBL levels were significantly were found between HPV patients who developed cervical uterine cancer higher than those of healthy blood donors. An alternative explanation and those who did not. When considering combined genotypes grouped of the unexpectedly high frequency of low MBL phenotype individuals according to MBL production (designated as high, low, and deficient found in many tropical regions is that excessive complement activation producers), we detected a significant difference between healthy controls can result in immunopathologically mediated host damage; therefore, and high-risk HPV-positive patients, the latter group showing increased any mechanism that reduces complement activation may be beneficial. frequencies of deficient-producer genotypes (10). The identification of MBL deficiency as the cause of the so-called In another study performed on an Italian group of gynecological common opsonic defect has been followed by a plethora of disease patients, we demonstrated an association of MBL2 polymorphisms with association studies aimed at defining the precise role of this protein. A high risk HPV infection in women without squamous cell carcinoma of number of the early studies concentrated on pediatric populations and the cervix (SCC), who showed increased presence of the mutant MBL2 0 MBL was suggested to provide substitute ‘antibody-like’ activity during allele and 0/0 genotype when compared to women with SCC and healthy the ‘window of vulnerability’ (approximately 6–24 months), when controls. No correlation with MBL2 functional polymorphisms was found maternal immunoglobulin G (IgG) antibody levels have waned but the in women who developed cancer Therefore, we proposed that MBL2 infant’s own adaptive immune response is still immature. Nevertheless, polymorphisms responsible for defective production of MBL protein studies in adults suggested that there might be a role for MBL throughout play a role in the augmented susceptibility for high risk HPV infection life, notwithstanding the majority of individuals possessing a variant but not for cervical cancer onset and development. (11). MBL allele apparently suffers no ill effects and remains essentially Moreover we performed several studies analyzing the possible healthy. Nevertheless, MBL deficiency has been shown to be associated association between MBL2 functional polymorphisms and the risk of with increased susceptibility to many infectious diseases such as developing autoimmune diseases. bacterial diseases in neutropenic patients, meningococcal meningitis, We investigated the relationship between polymorphisms in the first invasive fungal infections, and viral infections Several reports suggest exon of the MBL2 gene, and celiac disease. MBL2 allele and genotype that MBL can also modulate the disease severity and can be used as a frequencies varied significantly between celiac patients and healthy marker to predict the therapeutic efficacy in some disorders, e.g. the controls. The frequencies of the 0 allele were 28% in DQ2 or DQ8 response to interferon treatment in patients with type C chronic hepatitis. celiac patients, 36% in HLA atypical celiac patients, and 22% in healthy Interestingly, it has been shown that individuals with mutations in the controls. Interestingly, the MBL2 0/0 genotype was present in 7 of 33 MBL2 gene are at increased risk of having autoimmune diseases such as HLA atypical celiac patients (21%) and in 13 of 116 HLA typical celiac systemic lupus erythematosus, celiac disease and rheumatoid arthritis (3). patients (13%) but in only 7 of 147 healthy controls (5%). Furthermore, Here we present several studies, performed in different ethnic groups we found that MBL2 genotype is strongly associated with the occurrence reporting the association of MBL2 functional polymorphims with distinct of secondary autoimmune diseases. Immunohistochemistry and TUNEL diseases including infectious diseases such as HIV, HCV and HPV findings support a role of MBL2 in the clearance of apoptotic cells (12). infection as well as autoimmune diseases such as type 1 diabetes (T1D), In another study we investigated the possible role of MBL2 autoimmune tiroiditis and celiac disease. polymorphisms in the augmented susceptibility to develop other autoimmune We evaluated the frequency of the polymorphisms in the first exon of diseases in presence of type 1 diabetes (T1D) in a group of Brazilian patients. the MBL2 gene in an HIV-1-infected pediatric Brazilian cohort, sampled Patients were stratified for the presence of autoimmune diseases known to from impoverished areas in the proximity of Recife (Pernambuco, Brazil). be associated with T1D, such as autoimmune thyroid disease (AITD) and The population was derived from an admixture of African, Caucasian celiac disease (CD), and compared with healthy controls (HC). Our findings and native American populations estimated, respectively, at 44, 34 and suggested that MBL2 functional SNPs are more closely related to AITD 22% (6). We found an association between the presence of the mutated than to T1D, being MBL2 SNPs frequencies in T1D patients not affected by
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AITD comparable to the healthy controls ones, while significantly different disease associations. Rev Immunogenet 2000; (2):305-322,. between AITD patients and patients not affected by the disease. Thus, the 2. Petersen SV, Thiel S, Jensenius JC. The mannan-binding lectin pathway of complement activation: biology and disease association. Mol Immunol. 2001; 38(2-3):133-49. association between MBL2 polymorphisms and T1D seemed to result from 3. Bouwman LH, Roep BO, Roos A. Mannose-binding lectin: clinical implications for the stronger association of MBL2 SNPs with another autoimmune disease, infection, transplantation, and autoimmunity. Hum Immunol. 2006; 67(4-5):247-56. the AITD, frequently associated with T1D. (13). 4. Garred P, Larsen F, Seyfarth J, Fujita R, Madsen HO. Mannose-binding lectin and its We investigated as well if MBL2 functional allelic variants were genetic variants.Genes Immun. 2006 Mar;7(2):85-94. responsible for increased risk of developing atopic dermatitis in Brazilian 5. Boldt AB, Culpi L, Tsuneto LT, de Souza IR, Kun JF, Petzl-Erler ML. Diversity of the MBL2 gene in various Brazilian populations and the case of selection at the mannose- children. Genotyping of A/0, H/L and X/Y polymorphisms allowed us binding lectin locus. Hum Immunol. 2006 ;67(9):722-34. to build up MBL2 combined genotypes. MBL2 combined genotypes 6. Alves-Silva J, da Silva Santos M, Guimaraes PE, Ferreira AC, Bandelt HJ, Pena SD, et associated with a deficient production of MBL were more frequent in al. The ancestry of Brazilian mtDNA lineages. Am J Hum Genet 2000; 67:444-461. AD patients than controls. While the role of MBL in the development 7. Boniotto M., Braida L., Pirulli D., Arraes L., Amoroso A., Crovella S, MBL2 of AD is still debated in the literature, we were able to demonstrate that polymorphisms are involved in HIV-1 infection in Brazilian perinatally infected children. AIDS 2003, 17:779–790. the presence of an MBL defective producer genotype is associated to an 8. Amoroso A, Berrino M, Boniotto M, Crovella S, Palomba E, Scarlatti G, Serra C, Tovo increased susceptibility to AD in Brazilian children (14). PA, Vatta S. Polymorphism at codon 54 of mannose-binding protein gene influences All the studies presented here show association between MBL2 AIDS progression but not HIV infection in exposed children. AIDS. 1999 May functional polymorphisms, leading to a reduction of MBL levels, and 7;13(7):863-4. infectious or autoimmune diseases. A predisposition role for these 9. Segat L, Silva Vasconcelos L.R., Montenegro de Melo F., Santos Silva B., Arraes L.C., Moura P., Crovella S. Association of polymorphisms in the first exon of mannose polymorphisms has been hypothesized. binding lectin gene (MBL2) in Brazilian patients with HCV infection. Clin Immunol. Our research group also described an association of MBL2 2007 Jul;124(1):13-7. polymorphisms leading to low circulating MBL levels and the protection 10. Guimaraes V., Guimaraes R., Brandao L, Piffer Tomasi Baldez da Silva M.F. , Milanese against development of thrombocytopenia associated with severe dengue M., Segat L. , Castelletti H., Bruneska D., de Lima Filho J.L., de Freitas A.C., phenotype. The genotypes of 110 well-characterized dengue-positive Arraes L.C., Rocha, C. Crovella S. Association between MBL2 gene functional polymorphisms and high-risk human papilloma virus infection in Brazilian women. patients were statistically analyzed to establish possible correlations Human Immunology, 2008. between MBL2 polymorphisms and parameters such as sex, type of 11. Segat L, Crovella S, Comar M, Milanese M, Zanotta N, Fabris A, Trevisiol C, Rossi T, infection (primary or secondary response), race/ethnicity, course of De Seta F, Campello C. MBL2 gene polymorphisms are correlated with high-risk infection, and age. We found significant correlations between wild-type human papillomavirus infection but not with human papillomavirus-related cervical A/A MBL2 genotype and age as associated risk factors for development cancer. Hum Immunol. 2009 Jun;70(6):436-9. 12. Boniotto M., Braida L., Baldas V., Not T., Ventura A., Vatta S., Radillo O., Tedesco F., of dengue-related thrombocytopenia (15). Percopo S., Montico M., Amoroso A., Crovella S. Evidence of a correlation between As reported for our findings obtained analyzing MBL2 polymorphisms mannose binding lectin and celiac disease: a model for other autoimmune diseases. in patients with dengue severe phenotype, not always a genetic variation J Mol Med (2005) 83: 308–315. leading to a reduced MBL production is plays a negative role in the 13. Araujo J, Segat L, Guimarães RL, Brandão LA, Souza PE, Santos S, Soares TS, Falcão development of a pathology. The presence of high serum MBL levels can EA, Rodrigues F, Carvalho R Jr, de Lima-Filho JL, Arraes LC, Crovella S. Mannose binding lectin gene polymorphisms and associated auto-immune diseases in type 1 be also associated with pathological conditions, evidencing the “double diabetes Brazilian patients. Clin Immunol. 2009 May;131(2):254-9. face”of the MBL able to both protect from infection but also capable of 14. Brandão LA, Guimarães RL, Carrera M, Milanese M, Segat L, Luiz de Lima-Filho commencing an excessive immunological response. J, Arraes LC, Crovella S. MBL2 functional allelic variants and increased risk for the development of atopic dermatitis in Brazilian children. Arch Dermatol. 2008 REFERENCES Mar;144(3):412-3. 15. Acioli-Santos B, Segat L, Dhalia R, Brito CA, Braga-Neto UM, Marques ET, Crovella S. MBL2 gene polymorphisms protect against development of thrombocytopenia 1. Turner MW, Hamvas RM: Mannose-binding lectin: structure, function, genetics and associated with severe dengue phenotype. Hum Immunol. 2008 Feb;69(2):122-8.
COMPLEMENT DEFICIENCIES IN BRAZIL
Anete Sevciovic Grumach Laboratory of Medical Investigation in Dermatology and Immunodeficiencies LIM56, Dept of Dermatology, University of São Paulo. Immunologist of Dept of Pneumology, Faculty of Medicine ABC. Physician of Center of Disease Control, Immunization, São Paulo Health Secretary.
The immunologic disturbances of Complement system secondary to several diseases as, for example, trauma, systemic inflammatory reaction syndrome, hyperacute graft rejection, autoimmune diseases, are frequent. The main complement functions are immune complexes dissociation, However, primary immunodeficiencies due to complement deficiencies bacterial lysis and interaction between innate and adaptive immune are considered rare in comparison with other defects. The frequency of system. Complement system is activated by three pathways: classical, primary complement deficiencies has been reported from 2% up to 6% alternative and lectin pathways. All the three lead to the formation of in most National reports (5,9). Looking back to those studies, several of a Membrane attack complex called terminal pathway. The absence of them had not screened for complement deficiencies. Regarding Brazilian activity of any component of complement system results in variable experience with complement deficiencies, we have found few case reports clinical manifestations (4,7). in the literature with increasing interest in the last years. The most frequent complement deficiency described had been
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C2 deficiency, affecting 1 in 20000 individuals. In Japan, 1 in 1000 Screening in 166 lupus patients detected 4 partial deficiencies in this individuals presents C9 deficiency. MBL deficiency had been described group without relationship with disease severity. as detected in 5% of the population. So, there is a wide range of incidence Regarding control proteins of complement system, the diagnosis of due to the capacity of screening for complement deficiency and ethnic C1 inhibitor (C1-INH) deficiency improved in the last years in Brazil. variability. Our belief is that complement deficiencies are underdiagnosed We have an informal register of patients with more than 220 confirmed not only in Brazil but elsewhere (5,8,9). diagnoses. Most of the patients were identified as Hereditary Angioedema The impairment of complement system is associated with type 1 (91,7%), probably due to the restricted access to the laboratorial autoimmune diseases, recurrent infections and hereditary angioedema. diagnosis of functional C1-INH activity. The mean time for identification Most of the infections are not severe and caused by capsulated bacteria: has been 11 years. The disease is associated with subcutaneous, Streptococcus, Haemophilus and Neisseria and affecting more frequently respiratory and gastrointestinal edema. Frequent unnecessary abdominal the respiratory airways. Neisseria meningitidis as well as gonorrhea surgeries are indicated in those patients and asphyxia is one of the most are associated with terminal pathway and properdin deficiencies (4,7). severe complications (25-40%) (3,6). Laboratorial evaluation confirmed C4 levels as a good screening for HAE but a recent report showed that it is not present in all patients. More recently, HAE type III or without C1- INH deficiency has been described and several cases have been reported with 1/3 presenting factor XII deficiency (1,2). Considering the resumed overview, we believe that complement deficiencies are more common than reported due to the restricted access to laboratorial diagnosis. Another issue is that few epidemiologic studies have been developed looking for complement deficiencies even in autoimmune diseases. The restricted knowledge about HAE or Acquired Angioedema results in poor and late identification of the patients in our country. Although new drugs have been delivered for HAE, we don´t have access to them in Brazil. Figure 1 – Main clinical manifestations and complement proteins deficiencies associated. REFERENCES Meningococcal meningitis occurs during the adolescence, caused by uncommon serogroups (W135 and Y), recurrent and with better 1. Bork, K.; Gül, D.; Dewald, G. Hereditary Angioedema With Normal C1 Inhibitor in a prognosis than not deficient patients. We had developed a screening in Family Affected Women and Men. Br J Dermatol. 154:542-545. 2006 all suspected meningococcal patients for 10 years and 5% of patients 2. Bork K, Siedlecki K, Bosch S, Schopf RE, Kreuz W. Asphyxiation by laryngeal edema in patients with hereditary angioedema. Mayo Clin Proc. 2000;75(4):349-54. presented complement deficiencies. C2 and C6 deficiencies were detected 3. Cicardi M, Zingale L, Zanichelli A, Pappalardo E, Cicardi B C1 inhibitor: molecular and and it was caused by types B and C serogroups instead of rare ones. It clinical aspects. Springer Semin Immunopathol. 2005;27(3):286-98. is well described that immunization for meningococcus prevents further 4. Densen P. Complement deficiencies and infection. In: Volanakis JE, Frank MM. The episodes. We concluded that screening for complement deficiencies Human Complement System in Health and Disease. New York: Marcel Dekker; should be established for every patient above 5 years of age (considering 1998.p 409-21. 5. Grumach AS, Kirschfink M Deficiência de Complemento IN Grumach AS Alergia e ontogeny of antibody response) with meningococcal meningitis, even Imunologia na Criança e Adolescente, Atheneu, Rio de Janeiro, 2008, pp678. after the first episode. The familial history of consanguinity is relevant 6. Nzeako UC, Frigas E, Tremaine WJ. Hereditary Angioedema: A broad review for clinicians because most of complement deficiencies are inherited by autosomal . Arch Intern Med 2001, 161:2417-27. recessive mode. 7. Ross SC, Densen P. Complement deficiency states and infection: epidemiology, Autoimmunity is associated with the first components of classical pathogenesis and consequences of neisserial and other infections in na immune deficiency. Medicine. 1984;63:243-73. pathway. C1q deficiency causes clinical manifestations in more than 95% 8. Sorensen R, Thiel S, Jensenius JC. Mannan-binding-lectin-associated serine proteases, of the individuals. The finding of C4 and C2 deficiency is not always characteristics and disease associations. Springer Semin Immunopathol. 2005 linked with clinical manifestations. Araujo et al reported the evaluation for Nov;27(3):299-319. Epub 2005 Nov 11. C2 deficiency in Brazilian blood donors and they found 8 heterozygous 9. Sullivan KE; Winkelstein JA. Genetically determined deficiencies of the complement and one homozygous out of 1503 deficient individuals (1,2:10000) . system. In: Ochs HD; Edvard Smith CI; Puck JM. Primary Immunodeficiency Diseases: A molecular and Genetic approach. New York: Oxford;1999. p 397-416.
IMMUNOGLOBULIN CLASS SWITCH RECOMBINATION DEFECTS
Anne Durandy Hôpital Necker-Enfants Malades - Paris/France
Ig class switch recombination (Ig CSR)-deficiencies, also named molecular defect, the Ig CSR-deficiency is associated or not with a defect in hyper-IgM syndromes, are rare diseases (1/200,000 births), characterized by the generation of somatic hypermutation (SHM) in the Variable region of the normal or increased serum IgM levels, contrasting with the drastic decrease Ig, a process required for increased affinity maturation. Ig-CSR deficiency or complete lack of other isotypes (IgG, IgA and IgE). According to the syndrome is heterogeneous and several molecular causes have been defined.
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Two main subgroups can be distinguished, one caused by defective that are easily controlled by regular Ig substitution, and therefore their T/B cell cooperation, the other linked to an intrinsic defect of B prognosis is much better than that of CD40L or CD40-deficient patients. lymphocytes. However, they very often suffer also from lymphadenopathies, and auto- immune complications can be life-threatening. Moreover, some of these A. DEFECTIVE T/B COOPERATION syndromes can be associated to cancer occurence.
I- CD40 ligand-deficiency I. Activation-Induced cytidine Deaminase-deficiency The X-linked CD40-ligand (CD40L)-deficiency is the most frequent It is the most frequent Ig-CSR deficiency due to an intrinsic B cell cause of Ig CSR deficiency (50% of all cases). CD40L is a molecule defect (25% of all Ig CSR-deficiencies). It is transmitted as an AR transiently expressed on follicular helper T lymphocytes (TFh) in germinal disorder. It is caused by mutations in AICDA gene which encodes the centres of the secondary lymphoid organs. It interacts with its receptor, Activation Induced cytidine Deaminase (AID), a B cell specific molecule. the CD40 molecule constitutively expressed on B and dendritic cells. At the Ig locus, AID introduces the DNA lesion (replacement of a dC by CD40-stimulation of B lymphocytes, in association with interleukines a dU) which is the first step required for both CSR and SHM. Therefore, (IL) in germinal centres, induces B cell proliferation, Ig CSR and SHM, AID-deficiency is characterized by a complete lack of CSR and SHM 6. through NF-kB activation and nuclear translocation. The humoral defect However, few mutations located at the C ter part of AID (respecting (associating defective Ig-CSR and SHM) caused by CD40L-deficiency the cytidine deaminase domain) lead to a complete CSR defect, without is charaterized by recurrent bacterial infections, but also severe affecting the SHM process7. This observation suggests that AID is not opportunistic infections due to defective T/dendritic cell cooperation only a cytidine deaminase enzyme but plays a further role in CSR, likely and cellular immunodeficiency 1. by recruiting a CSR-specific cofactor by its C ter domain 6. Interestingly, Treatment of this Ig-CSR deficiency is regular Ig substitution, some heterozygous mutations located in the nuclear export signal of antibiotics prophylaxis and, whenever possible (HLA-matched donor), AID are responsible for a variable defect in Ig CSR with an autosomal bone-marrow transplantation. dominant transmission8.
II. CD40-deficiency II. Uracil-DNA Glycosylase-deficiency It is a very rare form of Ig-CSR deficiency (1%) transmitted as This very rare Ig CSR-deficiency (<1%) is transmitted as an AR an autosomal recessive (AR) disorder. The phenotype and treatment disease. It is caused by deleterious mutations in the gene encoding the are identical to those of CD40L-deficiency 2. However, neurological Uracil-DNA glycosylase (UNG), which is able to recognize and withdraw impairment can worsen the prognosis and refute bone-marrow the dU misintegrated by AID on Ig locus DNA. This step is followed by transplantation. DNA breaks and repair. Patients present with a typical Ig CSR-deficiency, SHM are not absent but abnormal with a skewed nucleotide substitution III. NEMO-deficiency 9. As all ung-deficient mice present B cell lymphomas when ageing 10, this A defect in the NF-kB essential modulator (NEMO), responsible complication, although not yet reported, could occur in human patients. for the X-linked anhydrotic ectodermal dysplasia, can be associated to a defect in Ig CSR-deficiency, that could be the main symptom 3. The III. Ig-CSR deficiencies associated to a DNA repair defect defective CD40-induced NF-kB activation leads to a defect in CSR and Besides the occurrence of cancers observed in all patients with SHM, however very variable, according to the NEMO misense mutations. DNA repair defects, Ig CSR deficiency is a frequent complication ; it is Treatment depends on the severity of the humoral defect : Ig substitution, due to abnormal processing or repair of the CSR-induced DNA breaks. antibiotics prophylaxis or bone-marrow transplantation. In contrast, SHM are found normal since CSR and SHM use different These three defects clearly indicate the essential role for CD40 mechanisms for processing and repair of the same AID/UNG DNA activation of B cells in both Ig-CSR and SHM processes. Interestingly induced lesions 11. Different DNA repair disorders are known to be enough, some of the patients do have normal IgA levels and SHM, associated to an Ig CSR-deficiency : suggesting an alternative pathway (via TACI or Toll Like Receptor activation ?) 4. a) Post-meiotic segregation 2 The Post Meiotic Segregation 2 (PMS2) belongs to the Mismatch IV. ICOS-deficiency repair pathway which is able to repair the mismatch residues intingrated Recently, the defect in the Inducible COStimulator (ICOS), a on DNA (such as the dU:dC induced by AID). Because of this impairment molecule also expressed on activated TFH lymphocytes, has been described of the repair mechanism, the rare patients who carry bi-allelic mutations as a very rare AR form of common variable immunodeficiency (CVID)5. in PMS2 gene are prone to cancers from the first years of age. However, However, normal IgM levels observed in the few described patients an Ig CSR deficiency, affecting mostly the IgG subclasses IgG2 and 4, suggest an in vivo Ig CSR deficiency, likely due to abnormal IL production and IgA, is found in all patients and can be a main symptom, requiring 12 by TFH lymphocytes in germinal centres. Ig substitution .
B. INTRINSIC DEFECT OF B LYMPHOCYTES b) Ataxia-Telangiectasia Ataxia-Telangiectasia, a frequent AR disorder due to ATM The description of the Ig CSR-deficiencies caused by an intrinsic mutations, is characterized by cerebellar ataxia, telangiectasia, variable defect of B lymphocytes has been essential for a better understanding of immunodeficiency and tumor occurence. ATM has been shown to be the complex molecular mechanisms underlying CSR and SHM. Patients involved in DNA repair during CSR 13, and ATM patients can present for affected by such defects present with recurrent bacterial infections many years as affected by a typical Ig CSR-deficiency 14 .
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In these two DNA repair defects (PMS2 and ATM), the Ig CSR Conley ME, Reimund E, Kalhoff H, Abinun M, Munnich A, Israel A, Courtois G, deficiency can be the main and unique feature for years, before the Casanova JL. X-linked anhidrotic ectodermal dysplasia with immunodeficiency is caused by impaired NF-kappaB signaling. Nat Genet 2001;27:277-85. occurrence of any other symptoms. Therefore, it is much important 4. Cerutti A.The regulation of IgA class switching. Nat Rev Immunol. 2008 ;6:421-34 to check for these etiologies in patients with Ig CSR-deficiencies due 5. Grimbacher B, Hutloff A, Schlesier M, Glocker E, Warnatz K, Drager R, Eibel H, Fischer to an intrinsic B cell defect which is not related to either AID or UNG B, Schaffer AA, Mages HW, Kroczek RA, Peter HH. Homozygous loss of ICOS mutations. is associated with adult-onset common variable immunodeficiency. Nat Immunol 2003;4:261-8. 6. Revy P, Muto T, Levy Y, Geissmann F, Plebani A, Sanal O, Catalan N, Forveille M, c) Non Homologous End Joining Dufourcq-Labelouse R, Gennery A, Tezcan I, Ersoy F, Kayserili H, Ugazio AG, Although Non Hologous End Joining (NHEJ) drastic defects lead Brousse N, Muramatsu M, Notarangelo LD, Kinoshita K, Honjo T, Fischer A, Durandy to severe combined immunodeficiency15, hypomorphic mutations wich A. Activation-induced cytidine deaminase (AID) deficiency causes the autosomal allow some T and B cell development lead frequently to a phenotype of recessive form of the Hyper-IgM syndrome (HIGM2). Cell 2000;102:565-75. Ig-CSR deficiency with normal SHM15,16. 7. Durandy A, Peron S, Taubenheim N, Fischer A. Activation-induced cytidine deaminase: structure-function relationship as based on the study of mutants.Hum Mutat. 2006; These natural mutants have clearly shown the roles of these molecules 27 (12) :1185-8. in the processing (PMS2) and repair (ATM, NHEJ) of the AID/UNG- 8. Imai K, Zhu Y, Revy P, Morio T, Mizutani S, Fischer A, Nonoyama S, Durandy A. Analysis induced DNA breaks during the CSR process in humans. of class switch recombination and somatic hypermutation in patients affected with autosomal dominant hyper-IgM syndrome type 2. Clin Immunol 2005;115:277-85. IV. Undefined Ig-CSR deficiencies 9. Imai K, Slupphaug G, Lee WI, Revy P, Nonoyama S, Catalan N, Yel L, Forveille M, Kavli B, Krokan HE, Ochs HD, Fischer A, Durandy A. Human uracil-DNA glycosylase Half of the Ig-CSR deficiencies due to an intrinsic B cell defect deficiency associated with profoundly impaired immunoglobulin class-switch are still undefined on a molecular basis ; according to the phenotype of recombination. Nat Immunol 2003;4:1023-8. patients, one of them is very likely caused by a defect in the putative 10. Nilsen, H., Stamp, G., Andersen, S., Hrivnak, G., Krokan, H. E., Lindahl, T., and Barnes, CSR-specific AID cofactor 17 (which binds AID C ter-see above), the other D. E. Gene targeted mice lacking the ung Uracil-DNA glycosylase develop B cell by a defect in a new DNA repair factor 18. Both of these conditions are lymphomas. Oncogene 2003 22(35), 5381–5386 11 Stavnezer J, Guikema JE, Schrader CE. Me chanism and regulation of class switch complicated by bacterial infections and require Ig substitution, but in the recombination. Annu Rev Immunol. 2008;26:261-92. lattest B cell lymphomas do occur in more than 10% of cases. 12 Péron S, Metin A, Gardès P, Alyanakian MA, Sheridan E, Kratz CP, Fischer A, Durandy The ongoing delineation of inherited CSR-deficiencies is essential A Human PMS2 deficiency is associated with impaired immunoglobulin class switch for accurate diagnosis (including prenatal diagnosis), prognosis, recombination. J Exp Med. 2008;205(11):2465-72. treatment and follow-up of patients: indeed, patients with defects in 13. Pan-Hammarström Q, Lähdesmäki A, Zhao Y, Du L, Zhao Z, Wen S, Ruiz-Perez VL, Dunn-Walters DK, Goodship JA, Hammarström L. Disparate roles of ATR and ATM T/B cooperation are prone to severe opportunistic infections due to a in immunoglobulin class switch recombination and somatic hypermutation. J Exp cellular immunodeficiency, that are not controlled by Ig substitution. Med. 2006;203(1):99-110.A, Patients with DNA repair defects are prone to cancers, especially 14. Etzioni A, Ben-Barak A, Peron S, Durandy A. Ataxia-telangiectasia in twins presenting lymphomas, a complication that requires a careful follow-up. Moreover, as autosomal recessive hyper-immunoglobulin M syndrome. Isr Med Assoc J. 2007; the characterisation of these disorders strongly enlightens our knowledge 5:406-7 15 Buck D, Malivert L, de Chasseval R, Barraud A, Fondanèche MC, Sanal O, Plebani A, of the complex mechanisms involved in both CSR and SHM. Stéphan JL, Hufnagel M, le Deist F, Fischer A, Durandy A, de Villartay JP, Revy P Cernunnos, a novel nonhomologous end-joining factor, is mutated in human REFERENCES immunodeficiency with microcephaly Cell. 2006;124(2):287-99. 16. Pan-Hammarström Q, Jones AM, Lähdesmäki A, Zhou W, Gatti RA, Hammarström 1. DiSanto JP, Bonnefoy JY, Gauchat JF, Fischer A, de Saint Basile G. CD40 ligand mutations L, Gennery AR, Ehrenstein MR.Impact of DNA ligase IV on nonhomologous end in x-linked immunodeficiency with hyper-IgM. Nature 1993;361:541-3. joining pathways during class switch recombination in human cells. J Exp Med. 2. Ferrari S, Giliani S, Insalaco A, Al-Ghonaium A, Soresina AR, Loubser M, Avanzini 2005;201(2):189-94. MA, Marconi M, Badolato R, Ugazio AG, Levy Y, Catalan N, Durandy A, Tbakhi A, 17. Taubenheim N, Peron S, Fischer A. Pathophysiology of B-cell intrinsic immunoglobulin Notarangelo LD, Plebani A. Mutations of CD40 gene cause an autosomal recessive class switch recombination deficiencies. Adv Immunol 2007;94:275-306. form of immunodeficiency with hyper IgM. Proc Natl Acad Sci U S A 2001;98:12614- 18. Peron S, Pan-Hammarstrom Q, Imai K, Du L, Taubenheim N, Sanal O, Marodi L, 9. Bergelin-Besancon A, Benkerrou M, de Villartay JP, Fischer A, Revy P, Durandy 3. Doffinger R, Smahi A, Bessia C, Geissmann F, Feinberg J, Durandy A, Bodemer C, A. A primary immunodeficiency characterized by defective immunoglobulin class Kenwrick S, Dupuis-Girod S, Blanche S, Wood P, Rabia SH, Headon DJ, Overbeek switch recombination and impaired DNA repair. J Exp Med 2007;204:1207-16. PA, Le Deist F, Holland SM, Belani K, Kumararatne DS, Fischer A, Shapiro R,
NEW FINDINGS ON COMBINED IMMUNODEFICIENCIES
Andrew Cant Newcastle General Hospital - Newcastle/England
Molecular and biological studies define an ever growing range of T Janus associated kinase JAK-3 causing autosomal recessive B+ S.C.I.D., cell disorders including at least 10 forms of SCID, T cell activation and and a defect in one of the recombinase activating gene causing Omenn’s signalling defects, DNA repair disorders, thymic defects and immuno- syndrome in some cases of T- B- S.C.I.D, and in the Artermis DNA repair osseous dysplasias, a defect in the common gamma chain of receptors gene in others. Patterns of infection give important diagnostic clues; for interleukin 2, 5, 7 and 9 causing X-linked B+ S.C.I.D., a defect in the PCP almost always indicates a T cell deficiency, as does severe Human
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Herpes virus infection, diarrhoea and failure to thrive with persistent intracellular architectural integrity in haemopoietic cells. Bone marrow enteric virus infection. Cryptosporidium is an important pathogen which transplantation is now more frequently indicated. Di George syndrome may be only detected by PCR tests of stool. A detailed family history is associated with a deletion of a homeobox gene at chromosome 22q11, is so helpful and many conditions such as the DNA repair disorders are whilst children with CMC suffer persistent candida infections and also associated with dysmorphic features, but these non-immunological clues auto immune disease later in life. are easily overlooked. Enumeration of T, B and NK numbers together Once a diagnosis is made management needs to be pro-active; with T cell proliferation studies are useful in diagnosing SCID but can be watching and hoping a problem will resolve rarely works. The overall misleadingly normal in other T cell disorders. More detailed flow cytometry prognosis should be determined in the light of clinical registry data on to look for naïve T cells, class switched memory B cells, as well as TCR children with the same defect. Infections should be treated promptly Vβ family studies and spectrotyping can help substantiate a diagnosis using antiviral agents such as Ganciclovir, Foscarnet and Cidofovir of T cell deficiency, but ultimately tests to look for abnormal protein or where indicated. Cotrimoxazole prophylaxis should be given and some gene expression are usually needed to make a diagnosis. Evidence of patients benefit from immunoglobulin replacement despite seemingly auto-immunity both organ specific and non-specific should be sought, good specific antibody responses. Nutrition should be optimised. Precise remembering auto-antibodies to red cells are particularly common. Lymph diagnosis, assessment of damage to lungs and liver, and data on results node biopsies can be helpful, for example in Omenn’s syndrome. for Haemopoietic Stem Cell Transplantation (HSCT) should be carefully T cell immunodeficiencies are a heterogeneous group including reviewed and discussed with the child and family. A treatment plan based Wiskott Aldrich syndrome, Ataxia Telangiectasia, Di George syndrome on least risk should then be devised. Increasingly good results from HSCT and Chronic Mucocutaneous Candidiasis. Wiskott Aldrich syndrome for intrinsic T cell disorders mean that many patients can be treated in is characterised by eczema, thrombocytopenia and bacterial infections this way. However, for those with thymic disorders HSCT is unlikely to and is caused by a defect in a gene whose protein product is vital for be beneficial and thymic transplantation is now a possibility.
DIAGNOSIS OF NF-kB AXIS DEFECTS
Jacinta Bustamante1,2, Capucine Picard1,2,3,4, Anne Puel1,2 and Jean-Laurent Casanova1,2,3,4,5 1. Laboratory of Human Genetics of Infectious Diseases, Institut National de la Santé et de la Recherche Médicale, U550, Necker Branch, 75015 Paris, France, EU 2. Paris René Descartes University, Necker Medical School, 75015 Paris, France, EU 3. Center for the Study of Primary Immunodeficiencies, Necker Hospital, 75015 Paris, France, EU 4. Pediatric Hematology-Immunology Unit, Necker Hospital, 75015 Paris, France, EU 5. Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA
The transcription factors of NF-κB family are involved in the of Toll and interleukin-1 receptor (TIR)-interleukin receptor-associated development and the function of the immune system. Genetic studies kinase (IRAK) signalling pathway. The infectious phenotypes associated performed in model animals demonstrated an important role in immunity with each of genetics disorders are markedly differents. The EDA-ID against pathogens. The human primary immunodeficiencies (PID) phenotypes is associated with susceptibility to various bacteria, including involving the NF-κB signalling pathway were recently described and the mycobacteria, and occasionally other microbes such as fungi and viruses. susceptibility to pyogenic bacteria is associated. The affected patients bear In contrast, patients with IRAK-4 or MyD88 deficiencies seem to be mutations in NEMO, IKBA, IRAK4 and MYD88. Patients with anhidrotic specifically prone to few pyogenic bacterial diseases in otherwise healthy ectodermal dysplasia with immunodeficiency (EDA-ID) syndrome carry individuals, in particular pneumococcal and staphylococcal diseases. An either X-linked recessive hypomorphic mutations in NEMO or autosomal understanding of the molecular basis of these new immunodeficiences has dominant hypermorphic mutations in IKBA. Other patients with provided detailed insight into the pathogenesis of infections in affecting autosomal recessive amorphic mutations in IRAK4 or MYD88 present a patients, paving the genetics counselling and the rational treatment design. more restricted, purely immunological defect, with specific impairement
THE SPECTRUM OF IPEX AND APECED
Hans Ochs Seattle Children’s Research Institute - Seattle/USA
The observation that several single-gene defects result in multiple lymphocytes and autoantibodies. Patients with Immune dysregulation, autoimmune disorders have strengthened the concept that immune Polyendocrinopathy, Enteropathy, X-Linked (IPEX) syndrome may dysregulation interferes with the carefully orchestrated development of an present early in life with Type 1 diabetes, autoimmune thyroiditis, severe immune system that recognizes and eliminates not only infectious agents diarrhea caused by villous atrophy, dermatitis and antibody induced and malignant cells, but also prevents the generation of autoaggressive hemolytic anemia, neutropenia and thrombocytopenia. Most affected
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boys die before the age of three years, but milder cases have been observed patients present with alopecia, nail dystrophy and enamel hypoplasia, who live to their teenage years. Characteristic findings at autopsy include hypoparathyroidism, adrenal and ovarian failure and infrequently, insulin lymphocytic infiltrates of the lungs, endocrine organs such as pancreas dependent diabetes mellitus. APECED is caused by mutations in the and thyroid and the skin. Therapy with immunosuppressive drugs AutoImmune REgulator (AIRE), a transcription factor expressed in the provides some benefit, but the only curative treatment for IPEX patients medullary thymic epithelial cells and the monocyte/dendritic cell lineage is hematopoietic stem cell transplantation. IPEX is caused by mutations of the thymus. AIRE induces these cells to promiscuously express a wide in the transcription factor FOXP3, which is required for the generation array of tissue restricted antigens derived from nearly all organs in the of regulatory CD4+ T cells (Tregs) both in the thymus and the periphery. body. Thus, epithelial cells and monocyte/dendritic cells play a major Tregs suppress effector T cells including autoaggressive lymphocytes. role in the establishment of self-tolerance by eliminating autoreactive The transcription factor FOXP3 exerts transcriptional repression of T cells through negative selection. Lack of AIRE leads to reduced the promoters of key cytokine genes, most likely by inhibiting NFAT2 expression of tissue specific antigens in the thymus, allowing the escape expression in T cells. Autoimmune PolyEndocrinopathy Candidiasis of autoreactive T cell clones into the periphery. These rare disorders of and Ectodermal Dystrophy (APECED) is a rare autosomal recessive immune regulation might provide new insights into mechanisms that disorder with prevalence in certain isolated populations. Affected allow immune homeostasis.
STEM CELL TRANSPLANTATION AND GENE THERAPY
Andrew Cant Newcastle General Hospital - Newcastle/England lead normal lives with complete immunity, off IVIG and antibiotic Since Severe Combined Immune Deficiency (SCID) was first prophylaxis. Cord blood transplants are successful in over 80% of cases cured by HLA-id HSCT in 1968, now the availability of unrelated and mismatched transplants in 70%. Using low intensity conditioning donors (URDs), Cyclosporin as GvHD prophylaxis, T cell depletion of and URDs, 90% survival is achieved. Chronic GvHD is very unlikely, mismatched marrow, reduced intensity conditioning, cord blood stem there is little late chemotherapy toxicity; as total body irradiation (TBI) cells, have greatly increased survival, so HSCT is now also indicated is not used, growth is not impaired. for CD40 Ligand Deficiency, Wiskott Aldrich Syndrome, Chronic Gene therapy has been attempted for X-linked SCID, Adenosine Granulomatous Disease, combined immunodeficiencies, and severe Deaminase Deficiency and CGD, but 4/10 Paris X-SCID patients auto-immune diseases. developed leukaemia. Gene therapy for ADA Deficiency and CGD needs European data for HLA-id SCID transplants show survival increased pre-transplant chemotherapy; from 2008 the results for ADA look more from 70% to 97% since 2000, and from 45% to 77% for mismatched encouraging, but the transfected genes have been extinguished in the HSCT. In Newcastle, 36 of 41 SCID patients have survived (88%), 8 of 9 CGD patients. Wiskott Aldrich patients (89%), 18 of 20 CGD patients (90%) and 8 of 12 Stem cell and gene therapy research should yield even better results. CD40 Ligand patients (67%). Non survivors were already very damaged Successful HSCT for immune disorders depends on teamwork and by infection; patients transplanted early do very well; all 7 Newcastle attention to detail, and the special skills and expertise that develop from CD40 Ligand patients (100%) transplanted since 2000 survived. Most these.
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POSTERS CASE REPORTS – PCR
PCR 01 - IMPAIRED CYTOTOXICITY ACTIVITY AND LOW PCR 02 – ROBUST gd+ T CELL AND LOW TCD4+ EXPANSION CD3-CD16+CD56+ CELL COUNT IN A PATIENT WITH IN A BOY WITH ATAXIA-TELANGIECTASIA VACCINATED RECURRENT INFECTIONS AT BIRTH WITH BCG.
Authors: Abramczuk, B.M.; Pedroza, L.A.; Ramalho, V.D.; da Silva, Authors: Ana Karina C. Labbate, Maria Marluce dos Santos Vilela, Marcos M.T.N.; Vilela, M.M.S. Tadeu Nolasco da Silva
Institution: Center for Investigation in Pediatrics, Pediatrics Depart‑ Institution: Hospital das Clínicas - HC- Unicamp - State University of ment, Faculty of Medical Sciences, University of Campinas. UNICAMP Campinas - Faculty of Medical Sciences, Campinas, São Paulo, Brazil. - Campinas-SP Ataxia-Telangectasia (A-T) is characterized by cellular and humoral Background: Natural killer (NK) cells are generally defined as large immunodeficiency, with variable clinical expression. In spite of the high granular lymphocytes that express CD16 and/or CD56 and are negative for prevalence of laboratory immunologic abnormalities, systemic bacterial, pan-T and B-cell markers. NK plays an integral role in the innate immune severe viral, and opportunistic infections are uncommon in A-T. The response, with a cell contact-dependent cytolysis of virally infected and objective of this study is to report a case of a patient with A-T, his transformed cells and provides help to adaptive responses through cytokine development and immunological abnormalities. The main immunological secretion. investigations were the measurement of serum immunoglobulins and IgG Aim: We report here an eleven year old male patient with a history of subclasses, serum complement, lymphocyte immunophenotyping, a-feto recurrent infections since his first year of life, characterized by: episodes protein levels, and flow-based lymphocyte proliferation to antigens and of otitis, pneumonia, urinary tract infections, enteritis with dehydration, mitogens. The patient has humoral immunodeficiency (low IgG levels stomatitis, persistent oral candidiasis, BCGitis at site of BCG vaccine, and low proportion of CD19+ cells) and normal specific cellular immunity Herpes simplex and Herpes zoster infections. to BCG antigen, 7 years after vaccination, either regarding total CD3 Methods: Chemotaxis: Polymorphonuclear cells and monocytes were Blasts and the TCR gd subpopulation. Expansion of the TCR gd subset is incubated with normal human serum + LPS and with the patient serum recognized as an important feature in response to mycobacteria.
+ LPS for 2h in a 5% CO2 atmosphere and analyzed after the staining procedure. Proliferation: Peripheral blood mononuclear cells (PBMC) were stimulated for 6 days with PHA or BCG or medium alone at 37◦C with 5% PCR 03 - PROBABLE ICOS DEFICIENCY IN A COMMON CO2 in round-bottomed 96-well tissue culture plates. After harvesting with VARIABLE IMMUNODEFICIENCY (CVID) PATIENT 20mM ethylene diamine tetracetic acid (EDTA), samples were incubated with human immunoglobulin and then stained with anti-human CD3, Authors: Collanieri A.C., Soares, M.C.P.; Pires-Oliveira, T.; Duarte, A.J.S.; CD4, CD8 and TCR γδ fluorescent antibodies before acquisition in a flow Moraes Vasconcelos D. Primary cytometer. Toll like receptors (TLRs) function: PBMC were incubated with specific stimuli for TLRs and TNF – alpha was determined in the Institution: Immunodeficiencies Outpatient Unit – ADEE3003 and Labo‑ supernatant of the culture. Cytotoxicity activity: PBMC in three different ratory of Medical Investigation in Dermatology and Immunodeficiencies concentrations were incubated at 37 ºC for 2 and 3 hours in a 5% CO2 (LIM-56), Department of Dermatology, University of São Paulo Medical atmosphere with target cell K562 labeled with PKH2 (Sigma, EUA). School Propidium iodide (Sigma, EUA) was added and the cell lysis percentage was acquired in a flow cytometer. Immunophenotyping: samples of 100μL Common variable immunodeficiency (CVID) is a primary of whole blood were incubated for 20 minutes at room temperature with immunodeficiency defined by the decrease of at least two immunoglobulin the following fluorochrome-conjugated monoclonal antibodies: anti-CD3 isotypes below two standard deviations of the reference to age, lack of (FITC)/anti-CD16+anti-CD56 (PE). The red blood cells were lysed and antibody response to immunization and the exclusion of other causes of washed, and data were acquired in a flow cytometer. primary hypogammaglobulinemia. Due to the quantitative and qualitative Results: The child showed normal TLR function but low migration deficiency of antibodies (IgG, IgA and less frequently IgM) these ability of PMN cells. The proliferation of CD4+ cells for PHA and of patients develop recurrent bacterial infections in the respiratory tract and TCR γδ for BCG was impaired. The PBMC activity against K562 cells gastrointestinal tract, which may lead to pulmonary and gastrointestinal and the CD3-CD16+CD56+ counts were very low. An increase in the pathological changes. Several cases of non-infectious granulomas have concentration of effector cells or in the incubation period did not change also been described in CVID patients. the killing of target cells. In the last 4 years, several studies now report the influence of Conclusion: The clinical and laboratory aspects of the child are mutations in certain genes such as TACI, BAFF-R, CD19 and ICOS in the consistent with a defect in the function of natural killer cells. development of CVID. ICOS is a co-stimulating molecule expressed only Financial support: FAPESP and CNPq. on activated T cells that interacts with ICOS-L expressed on the surface of B cells and antigen-presenting cells. The binding of ICOS to its ligand (ICOS-L) results in the release of interleukin 10 (IL-10) by T cells in germinal centers, triggering the process of B cell isotype switching. The
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loss of expression of ICOS results in deficient terminal differentiation of There are important evidences demonstrating that cellular immune B lymphocytes and hypogammaglobulinemia. response is responsible to the resistance to cutaneous fungal infections. In this case report, we describe a patient with CVID, followed in The evaluation of our patient showed that he presented an important T, B, the primary immunodeficiencies outpatient unit ADEE-3003, with and NK lymphocytopenia. This alteration could justify his susceptibility to changes in the phenotypic expression of the molecule ICOS. Unlike the dermatophytosis. ous fungus. Other hypothesis that might be the production individual’s control, the patient showed a high reduction in the expression of prostaglandin E2 by Schistosoma. This susceptibility seemed to be of ICOS on previously stimulated T cells (patient: 1.87% and control: punctual, due to the fact that the patient has not presented other fungal 11.96%), however the intensity of fluorescence showed no significant infections such as candidiasis or bacterial, viral and parasitic infections. changes (patient: 114.46 and: control 117.44). No additional change in B lymphocytes (CD19: 25.13%, CD20: 24.65%, CD21: 20.72%, CD27 + CD19 +: 1.65) and T (CD3: 69.49%, CD4: 39. 1%, CD8: 24.5%) cells were PCR 05 – CD79A DEFICIENCY: CASE REPORT observed, and their cellular function (Lymphoproliferation - PHA: 105.18; OKT3: 37.55; PWM: 139.57, CMA: 5.24, PPD: 2.55, tetanus toxoid: 1.18 Authors: Pires-Oliveira, T; Soares, M.C.P; Bressani V.O.; Santi T.N.; *) was also normal. Knowing that ICOS is closely related to the expression Collanieri A.C.; Chuffi-Barros, N.; Grumach A.S.; Vilela, M.M.S.; Duarte of CD154 (CD40L) on activated T cells, we evaluated the expression of A.J.S.; Moraes Vasconcelos D. this molecule in patient’s cells, where we observed a significant reduction in the expression of the molecule (control: 49.09% and patient: 19.82%). Institution: Primary Immunodeficiencies Outpatient Unit – ADEE3003 We are nowadays sequencing the ICOS gene in order to know the defect and Laboratory of Medical Investigation in Dermatology and Immunode‑ at the genomic level. ficiencies (LIM-56), Department of Dermatology, University of São Paulo Medical School; Department of Pediatrics – State University of Campinas.
PCR 04 – PUNCTUAL IMMUNE CELLULAR DEFICIENCY The B lymphocyte antigen receptor is a multimeric complex that CHARACTERIZED BY CHRONIC DERMATOPHYTOSIS includes the antigen-specific component, surface immunoglobulin (Ig). IN A PATIENT WITH CHRONIC HEPATOSPLENIC Surface Ig non-covalently associates with two other proteins, Ig-alpha SCHISTOSOMIASIS. COULD MANSONIC SCHISTOSOMIASIS (CD79a) and Ig-beta (CD79b), which are necessary for expression and LEAD TO IMMUNODEFICIENCY ? function of the B-cell antigen receptor. This gene encodes the Ig-alpha protein of the B-cell antigen component. CD79 deficiency occurs in the Authors: Collanieri A.C.; Domingues-Ferreira, M.; Negri-Santi, T.; Soares, absence or failure of CD79a or Ig-g (the gene products of mb-I) and Ig-b M.C.P.; Duarte, A.J.S.; Moraes-Vasconcelos, D. (CD79b, the product of the gene B29) in mature B cells. Ig-a as well as Ig-b consists of an extracellular domain, a Institution: Primary Immunodeficiencies Outpatient Unit – ADEE3003 transmembrane domain and a cytoplasmic domain associated to an ITAM and Laboratory of Medical Investigation in Dermatology and Immuno‑ motif. Mouse with knockout of Ig-a and Ig-b, and patients with null deficiencies (LIM-56), Department of Dermatology, University of São mutations of Ig-a, result in total blockade of the transition of pro-B to Paulo Medical School pre-B cells. Ig-a binds and activates molecules of Src family. There were only two reported cases of CD79a deficiency in Turkey. Schistosomiasis or bilharzia is a tropical disease caused by worms of JVAM, 2 years and 6 months-old, born to non-consanguineous parents, the genus Schistosoma. The transmission cycle requires contamination of 7 siblings, (1 male brother died of pneumonia with 1y8m-old). The parents surface water by excreta, specific freshwater snails as intermediate hosts, report several episodes of acute middle otites, and one hospitalization with and human water contact. The main disease-causing species in Brazil is S. 1y 8m due to pneumonia with pleural effusions by Staphylococcus. He had mansoni. Immunopathological reactions against schistosome eggs trapped another severe pneumonia at 2y4m old. After ambulatorial treatment with in the tissues lead to inflammatory and obstructive disease in the intestines, three different antibiotic schemes without resolution, he was sent to ER hepatosplenic inflammation, and liver fibrosis. Portal hypertension leads with face edema and hepatomegaly, resulting in hospitalization (ICU) due ultimately to hypersplenism and cytopenias (mainly thrombocytopenia to drug-induced hepatitis. After 4 days he went to ward, where sustained and neutropenia). tachydyspnea, led to the suspicion of Pneumocystosis and co-trimoxazole GMC, 37 years old, male, Causasian and African origins, was born in the was introduced with improvement of the clinical features. Laboratory rural area of the state of Minas Gerais, Brazil. There is no consanguinity in exams were collected and evidenced severe hypogammaglobulinemia, his family. He had a normal health during childhood up to 21 year old, when when IgIV infusions began. The patient was sent to our service, keeping he began to have extensive and chronic dermatophytosis in the trunk, legs, the use of Bactrim and IgIV 3/3 weeks. Immunophenotyping by flow feet, gluteus, inguinal and perinea region. The occurrence was intermittent, cytometry for CD3, CD4, CD8, CD19, CD20, BTK, CD79a, and CD179 but 6 year ago the lesions became persistent, more extensive and refractory to showed: IgM and IgD presence, CD19 and CD20 expression decreased, topic treatments. Four years ago he felt his abdomen getting bigger. He was absence of CD79a and normal expression of BTK, CD79a, and CD179. investigated by the infectious diseases department and a hepatosplenic form The patient was hospitalized again in another hospital, progressing of schistosomiasis was diagnosed. He was treated and sent to our service for to death after 1 month of follow up in our clinic. Despite the fact that investigation of a possible immunodeficiency, due to the uncommon behavior his brother and maternal cousin history of infections strongly suggested of the dermatophytosis. The patient has never had story of respiratory or a X-linked hypogammaglobulinemia, normal expression of BTK on gastrointestinal infections. During clinical evaluation, splenomegaly and T monocytes and absent expression of CD79a are highly suggestive of a cell lymphocytopenia were noted. Probably chronic dermatophytosis was CD79a deficiency. related to lymphopenia, possibly secondary to splenomegaly.
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PCR 06 - GOOD’S SYNDROME – CASES REPORT Institution: (1) Medical Investigation Laboratory Unit 56 (LIM/56): University of São Paulo Medical School; (2) Primary Immunodeficiency Authors: Soares, M.C.P.1; Santi T.N.1; Bressani, V.O.1; Collanieri A.C.1; Outpatient Unit (ADEE-3003): University of São Paulo Medical School; Duarte A.J.S.1: Moraes-Vasconcelos (3) Hematology Division: University of São Paulo Medical School; (4) Institute of Infectology Emílio Ribas; (5) Address correspondence and Institution: D.1,2,3. (1) Medical Investigation Laboratory Unit 56 (LIM/56): reprint requests to Dr. Dewton de Moraes Vasconcelos: Av. Dr. Enéas de University of São Paulo Medical School; (2) Primary Immunodeficiency Carvalho Aguiar, 470, Building 2, 3rd floor, CEP: 05403-000, São Paulo, Outpatient Unit (ADEE-3003): University of São Paulo Medical School; SP, Brazil. E-mail address: [email protected] 3) Address correspondence and reprint requests to Dr. Dewton de Moraes Vasconcelos: Av. Dr. Enéas de Carvalho Aguiar, 470, Building 2, 3rd floor, Leukocyte adhesion deficiency type 1 (LAD 1 - CD18 deficiency) is a CEP: 05403-000, São Paulo, SP, Brazil. E-mail address: [email protected] rare primary combined immunodeficiency characterized by a predominant disturbance of phagocyte function associated to a less severe cellular INTRODUCTION: Robert Good, in 1954, reported a case of and humoral dysfunction. Characteristically the infections are indolent, hypogammaglobulinemia associated to thymoma, that it´s known as Good´s necrotic, and tend to recur. In contrast to the striking difficulties in defense Syndrome. This rare syndrome has an approximately 3-6% incidence against bacterial and fungal microorganisms, LAD 1 patients do not exhibit among thymoma patients. The patients are high susceptible to opportunistic a marked susceptibility to viral infections and neoplasias. infection and hypogammaglobulinemia, with low or absent B cells. The 20 years old female, without consanguinity, presenting recurrent mechanisms that lead to these clinical features are not known. Therefore, infections by Candida spp. since 8 years of age. At 18 years of age she the higher the number of cases reported might facilitate the development presented acute genital herpetic lesions requiring a long-lasting treatment of etiological hypothesis to explain this syndrome. with acyclovir and antibiotics. At that time she had leukocytosis with CASES REPORT: APM, female, 75 years old. She presented neutrophilia (between 30000 and 70000 neutrophils/mL), depending on several symptons of respiratory and gastric intestinal infections, 2 CMV her clinical status. Monocytes and lymphocyte subsets were normal. A retinitis episodes. Immunophenotyping showed normal counts of T cells, biopsy of the vulvar lesion showed a leukocytoclastic vasculitis with a absence of B cells in blood and severely reduced IgM. She did not present poor neutrophilic infiltrate in the tissue, contrasting to the high counts of autoimmunity. leukocytes inside the blood vessels. Her myelogram was normal, excluding RSFCM, female, 32 years old. Presented pure red cell aplasia, bone the diagnosis of leukemia. The expression of CD11a, CD11b and CD18 on marrow Erythrovirus B19 infection that get remission with gammaglobulin lymphocytes and monocytes were very low. Nevertheless she went back IV use and Cyclosporin. In January 2001 a Thymoma was diagnosed, that to her city being misdiagnosed and treated as a Behçet’s disease. A blood was surgically removed on February of the same year. Her exams showed: cell count obtained one year later presented besides leukocytosis also low levels of CD4+ T and high CD8+ T cells, low B cells counts. She thrombocytosis suggesting a myeloproliferative syndrome not evident at presented a moderate hypogammaglobulinemia. that time. After two years she returned for reevaluation in a septic state MOO, female, 61 years old. Presented initially recurrent upper and lower and severely pancytopenic. Her myelogram had a strikingly low cellularity respiratory infections. During an episode of pneumonia, she performed a without blasts. The peripheral blood lymphocyte phenotyping showed a computerized tomography that revealed a thymoma in 2002. After this she depletion of all subsets of T cells and a severe B cell decrease. After some presented an autoimmune hemolytic anemia. The immunophenotyping days, still pancytopenic, a few blasts appeared in the peripheral blood. showed normal values of CD19+ cells, as well as CD3+ and CD8+, A bone marrow biopsy showed an acute myeloid leukemia of the M7 and reduced CD4+ T cells. YF, female, 64 years old. She had clinical type: Precursor cells (CD34+) of myeloid (CD117+, CD13+, CD33+) intense and recurrent diarrhea, recurrent CMV retinitis and respiratory and megakaryocytic lineages (CD41+, CD61+) were detected. She was infections. A thymoma was diagnosed and thymectomy was performed. treated with MEC (Mitoxantrone, Etoposide and Ara-C) chemotherapy, Her immunological evaluation demonstrated a CD3+ count increase, with without adequate response to therapy and a poor bone marrow replacement, low CD4+ and high CD8+ T cells, and absence of CD19+ B cells. Several impeding a more aggressive chemotherapy, quickly evolving to death years later she presented a EGF-R mutated lung adenocarcinoma, treated due to dissemination of the leukemia. Due to the fact that integrins are with erlotinib with an adequate response but she eventually progressed to involved in processes such as inflammation, cellular growth, differentiation, death after two years of the diagnosis of the lung carcinoma. junction formation and polarity, it is conceivable that the deficiency of CONCLUSIONS: Good’ s syndrome is a important differential accessory adhesion molecules could lead to an enhancement of the spread diagnosis of CVID and other hypogammaglobulinemic syndromes of adult of neoplastic cells patients, presenting as a whole a more severe clinical course.
PCR 08 – ASSOCIATION OF COMBINED PCR 07 - CD18 DEFICIENCY EVOLVING TO IMMUNODEFICIENCY WITH GM1-GANGLIOSIDOSIS MEGAKARYOCYTIC (M7) ACUTE MYELOID LEUKEMIA: FIRST CASE REPORT Authors: Toledo, EC, Moscardini AC, Albuquerque RA
Authors: Moraes-Vasconcelos, Dewton 1,2,5; Soares, Maria Cecília Pereira1; Institution: Faculdade de Medicina de São José do Rio Preto - FAMERP Grumach, Anete Sevciovic 1,2; Beitler, Beatriz 3; Martinez, Gracia A.3: Pereira, Juliana 3; Amigo Filho, José Ulysses 3; Klautau, Giselle Burlamaqui BACKGROUND: GM1-gangliosidosis is an autosomal recessive 4; Lian, Yu Cheng 4; Della Negra, Marinella 4; Collanieri, Anna Cristina1; lysosomal storage disorder (LSD) due to deficiency of the beta- Duarte, Alberto José da Silva1: galactosidase enzyme. This deficiency results in accumulation of GM1
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gangliosides in the lysosomes leading to cellular damage, and organ dihidrorodamine oxidation test. Patient was discharged to the hospital dysfunction1. in use of prophylactic sulfamethoxazole-trimetroprim and itraconazole GM1-gangliosidosis can be classified into three clinical phenotypes and remained well and free of any major infections. This case report of according to the time of onset: infantile, juvenile and adult form, where the disseminated tuberculosis as the initial presentation of CGD in a teenager infantile form is the most common, severe and lethal. Beta-galactosidase patient emphasizes the need for investigation of Primary Immunodeficiency deficiency is also responsible for Morquio disease type B characterized Disease in atypical tuberculosis presentation or evolution even in endemic by marked skeletal abnormalities, corneal clouding, cardiac involvement, areas. but no CNS degeneration. The clinical manifestations of GM1-gangliosidosis result from the massive storage of GM1 ganglioside and related glycoconjugates PCR 10 – INFECTIVE DERMATITIS AND MESANGIAL in different tissues and particularly in the central nervous system. The PROLIFERATIVE GLOMERULONEPHRITIS ASSOCIATED cardinal feature of infantile form GM1 gangliosidosis are psychomotor WITH HTLV-1 INFECTION: CASE REPORT regression (100%), coarse facial features (87%), cherry-red macula (59%), hepatosplenomegaly (85%), skeletal dysostosis (82%)1. Authors: Soares DCQ, Souza ES, Ribeiro JPM Lysosomal function has central importance to normal cellular function that can be appreciated by examining the various pathologies BACKGROUND: Infective dermatitis is a distinct clinical entity that arise in LSDs. Recent studies have revealed that several LSDs also associated with HTLV-1 infections among children and might participate have irregularities in the function of the immune system, could cause as in the pathogenesis and immune dysfunction. Nonstreptococcal much immunosuppression (e.g., Gaucher disease, Niemann-Pick disease, glomerulonephritis is associated with some infections and histologic α-mannosidosis, and mucopolysaccharidosis VII), as immune system findings might differ depending on the cause. Human T-cell lymphotropic hyperactivity or autoimmune response (e.g., GM2 gangliosidosis, globoid virus-1-associated renal disease has been described in two Jamaican cell leukodystrophy, Niemann-Pick disease type C1 and juvenile neuronal children and among chronic kidney patients. ceroid lipofuscinosis). Antigen presentation and processing by antigen OBJECTIVE: This case-report document some long-term follow-up presenting cells, secretion of perforins by cytotoxic-T lymphocytes, and outcomes of a HTLV-1 infected boy followed during 13 years at IMIP´s release of pro-inflammatory mediators by mast cells are among the many Hospital in Recife, Northeastern, Brazil. crucial immune system functions in which the lysosome plays a central role1. METHODS: We reviewed the immunology and nephrology clinical We report a case of GM1-gangliosidosis presenting with combined records, laboratory and histological data of a 3 years old black boy admitted immunodeficiency. A review of the literature showed no cases reported at IMIP due to skin infections since the first year of life. previously. RESULTS: The boy at the beginning of follow-up had diagnosis of atopic dermatitis that did not respond to current treatment guidelines. When he was 6 years old the presumption of infective dermatitis was PCR 09 – CHRONIC GRANULOMATOUS DISEASE arisen and confirmed by presence of antibodies against HTLV-1 in PRESENTING AS PULMONARY AND PERITONEAL blood samples of the patient and his mother, who breastfed the boy TUBERCULOSIS IN A TEENAGER: CASE REPORT. during two years. When he was 9 years old, he had diagnosis of acute poststreptococcal glomerulonephritis and arterial hypertension (AH). Authors: Cunha LAO, Minafra FG, Fusaro GV, Nunes JB, Ibiapina CC, These comorbities led to use of different approaches to control AH and Alvim CG, Pinto JÁ. microalbuminuria. At age of 16 years old, he was submitted to a kidney biopsy that revealed histological lesions compatible with focal and Institution: Division of Immunology, Hospital das Clínicas – Federal segmentar mesangioproliferative glomerulonephritis. Actually, he is using University of Minas Gerais. antihypertensive drugs, corticosteroids and cyclosporine with good control and health associated quality of life. Brief communication: CONCLUSION: Kidney involvement should be ruled out and Background: Chronic Granulomatous Disease (CGD) is a rare verified periodically in HTLV-1 infected children with the purpose of early disorder of phagocytic oxidative burst leading to recurrent pyogenic diagnosis that might influence prognosis and outcome. infections. Affected individuals are more prone to infections caused by KEY-WORDS: HTLV-1; infective dermatitis; glomerulonephritis Staphylococci, Salmonella, Candida and Aspergillus. A high incidence of Mycobacterium infections has also been observed. We report a case of a previously healthy twelve-years old boy admitted to the hospital with PCR 11 – SEVERE PULMONARY HISTOPLASMOSIS prolonged fever, loss of appetite, weight loss, weakness and abdominal IN A PATIENT WITH CHRONIC MUCOCUTANEOUS and iliac fossa pain. Two courses of antibiotics for bacterial pneumonia CANDIDIASIS: A CASE REPORT were done without improvement. Exploratory laparotomy revealed ascites, diffused peritoneal granulomatous reaction, spleen abscess and Authors: Dorna, M.B.; Bressani, V.O; Oliveira, G.M.; Duarte, A.J.S.; splenomegaly. The thoracic CT scan shows apical and posterior cavitations Moraes Vasconcelos, D. and homogeneous opacity with bronchiectasis at medium lobe. Cultures and BAAR of ascitic material, lymph nodes and sputum smears were Institution: Primary Immunodeficiencies Outpatient Unit – ADEE3003 negatives. Antituberculosis treatment was iniciated with isoniazid, rifampin and Laboratory of Medical Investigation in Dermatology and Immuno‑ and pirazynamid with clinical improvement, weight gain and regression deficiencies (LIM-56), Department of Dermatology, University of São of lesions. Immunological investigation revealed no respiratory burst at Paulo Medical School.
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INTRODUCTION: Chronic mucocutaneous candidiasis (CMC) is a with no abnormalities found. Six months of acetazolamide and two months rare primary T-cell immunodeficiency of unknown etiology characterized of steroid therapies resulted in fewer headaches and the disappearance of by persistent or recurrent Candida infections of the skin, nails and mucous papilledema and probably the steroids contributed to an improvement in membranes without Candida albicans sepsis. There is evidence that the the nephrotic syndrome. immune defect could be the result of altering patterns of proinflammatory The patient has normal development without severe infections. The cytokine production, resulting in insufficient interleukin-2 and interferon-γ serum levels of IgG were low and IgA and IgM were normal. The number release in response to Candida infections. of the lymphocyte subpopulation and the proliferative response to PHA Histoplasmosis is one of the most common endemic mycosis causing and BCG were normal. Genetic analysis found polymorphisms: 1628a > human infection throughout the world. Similar to the other fungi in this C3’UTR SNP (homozygote); 1662t > C3’UTR SNP (homozygote); 1729t category, initial exposure to Histoplasma capsulatum occurs through > C3’UTR SNP (homozygote). We show that this patient has a mutation the respiratory tract and, once inhaled, the organism readily spreads in in the EDAAR gene. New studies of immune functions will be performed macrophages throughout the reticuloendothelial system. The ability to to provide more data to further understand this case. contain infection is almost entirely mediated by cell-mediated immunity. In most patients, infection is associated with no symptoms or with only mild pulmonary symptoms. People who have either intrinsic or secondary PCR 13 – HEMOPHAGOCYTIC SYNDROME ASSOCIATED TO defects in cell-mediated immunity, however, are at risk for development NK CELLS DEFICIENCY: A CASE REPORT of severe disseminated histoplasmosis. Authors: Dorna M, Jacob CMA, Sztajnbok J, Giorno E, Moraes-Vascon‑ CASE REPORT: RAAR is a 40 years-old female who presents celos D, Carneiro-Sampaio MMS chronic mucocutaneous candidiasis since the age of 6 months. After the age of 21, she has been presenting recurrent episodes of pneumonia (20 Institution: Unit of Allergy and Immunology - Pediatrics Department episodes) leading to the development of bronchiectasis. Recently, she LIM – 56 Laboratório de Investigação Médica Faculty of Medicine - Uni‑ presented an asthmatic episode followed by persistently symptomatic versidade de São Paulo - São Paulo – Brasil pneumonia despite many antibiotic treatments. She was hospitalized after worsening of clinical symptoms and hemoptysis, with the identification INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a of a severe pneumopathy with pleural effusion and multiple cavities in puzzle disease. It may be inherited as an autosomal recessive trait, usually the medium pulmonary lobe. She was submitted to pulmonary biopsy, manifested in infancy and early childhood and usually fatal if not treated. lobectomy and pleural drainage. Microbiological studies diagnosed a The secondary form may be a result of strong activation of the immune pulmonary histoplasmosis. The patient was discharged after 2 months of system by infection, malignancies or rheumatologic diseases. The main hospitalization and treatment with amphotericin followed by itraconazole clinical criteria for the diagnosis are: fever, splenomegaly, cytopenias, and cotrimoxazole. hypertriglyceridemia, hypofibrinogenemia, hemophagocytosis, low NK- cell activity, hyperferritinemia, and high levels of sIL-2r. NK cell deficiency CONCLUSION: Chronic mucocutaneous candidiasis can lead to a is a rare disorder clinically manifested by recurrent or severe infections defect in cell-mediated immunity that can cause lower or even no production by herpes virus, which can be a trigger to the activation of the immune of proinflammatory cytokines. This may be one of the mechanisms leading system, eventually leading to hemophagocytic syndrome. to an increased susceptibility to Histoplasma spp. infections. CASE REPORT: RSS is a 10 month-old, previously healthy female hospitalized for the treatment of urinary tract infection. During hospitalization she developed a febrile hepatosplenomegaly and was PCR 12 – ANHIDROTIC ECTODERMAL DYSPLASIA: referred for investigation. During the hospitalization she presented chronic POLYMORPHISM WITH NEUROLOGICAL AND RENAL diarrhea, pancytopenia, digestive bleeding with a positive PCR to CMV, MANIFESTATION IN A BRAZILIAN CHILD. beginning the treatment with Gancyclovir. The bone marrow smear showed hemophagocytosis and the PCR to CMV in the bone marrow was negative. Authors: Riccetto AGL; Oliveira JB; da Silva MTN; Labbate AKC; Rama Hyperferritinemia, hypertriglyceridemia, hypofibrinogenemia and TF; Vilela MM. sustained pancytopenia supported the HLH diagnosis. The immunological investigation showed very low number of NK cells. No specific treatment Institution: Center for Investigation in Pediatrics, Pediatrics Department. for the hemophagocytic syndrome was initiated since the patient State University of Campinas Medical School. UNICAMP-Campinas SP, experienced spontaneous remission of the signs and symptoms. Brazil. CONCLUSION: A high clinical suspicion of HLH is essential to allow early diagnosis and treatment, avoiding severe sequels. Brief Report: Ectodermal Dysplasia Syndrome (EDS) is a group of congenital diseases, some of them with defects in innate immunity, affecting NF-κB protein. We describe a boy, aged five and white, with PCR 14 – NEW MUTATION IN EXON FIVE OF CD40 LIGAND Anhydrotic Ectodermal Dysplasia (AED). He has congenital alopecia, DEFICIENT PATIENT WITH SEVERE NEUTROPENIA anhydrosis, small teeth, hypertrophic gums and moderate rhinitis. After age three, the patient developed nephrotic syndrome, with episodes of Authors: Jobim M1, Daudt LE1, Monteiro L1, Stotlz J1, Schlottfeldt J1, mild facial edema and normal renal function, despite persistent hematuria Nava TR1, Hammarstrom L2, Portela P1, Salim PH1 & Jobim L1,3 and proteinuria. After age four, the patient had intense headaches and papilledema and was investigated with CT, NMR and spinal fluid punction Institution: 1, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul,
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Brazil 2 University Hospital of Karolinska, Stockholm, Sweden 3 Univer‑ was investigated with peroral jejunal biopsy and quantitative analysis of sidade Federal do Rio Grande do Sul, Brazil serum immunoglobulins. The results have shown villous atrophy and crypt hyperplasia in the small intestine and low IgA levels, respectively. Minor Introduction: Hyper-IgM syndromes (HIGM) is the term used to clinical improvement was seen after gluten-free diet. Several months later he describe a group of diseases with immunoglobulin deficiencies related to developed steatorrhea and insulin-dependent diabetes mellitus, with marked class-switch recombination and somatic hyper mutation. The patients have weight loss. Progressive recovery was achieved after glycemic control, normal number of B lymphocytes and low concentration of IgG, IgA, IgE, empiric therapy for giardiasis and proper enteral nutrition. Six years later but with normal or high IgM levels. he was referred for immunological evaluation due to recurrent infections The most common type of inheritance is the X-linked recessive which (extensive cellulitis, pneumonias, sinusitis and sepsis). The laboratory is considered a combined form of immunodeficiency disease. The main evaluation showed reduced levels of IgG, IgA and IgM was well as low defect is related to mutations in the CD40 ligand gene (CD40L or CD154). CD4+ T-cell counts in peripheral blood. The clinical picture and laboratory The CD40L deficiency is considered to be a disease resulting in the data were consistent with common variable immunodeficiency and IVIG failure of T-cell signaling to B cells in order to complete their maturation was started (400-600 mg/Kg/month). The patient remained well for several program by undergoing (Ig)-isotype switching. In normal individuals this months but gastrointestinal cytomegalovirus (CMV) infection was disclosed contact induces the production of specific antibodies after the class switch during an investigation for daily low grade fever. Conventional therapy from original IgM to IgG, IgA and IgE immunoglobulin. In patients with with gancyclovir was used for several cycles, due to relapses. In 2009 mutations in the CD40L gene, the immunoglobulin production could be (27-years-old) he presented chronic diarrhea and significant weight loss. The affected leading to an immunodeficiency state. investigation protocol revealed chronic pancreatitis, gastric CMV disease Case Report : T.C is a 2 years old boy, from Brazil, that came to and conspicuous inflammation of the esophagus, stomach, duodenum, ileum our Immunology Service at an age of 8 months, when presenting since and colon. The most striking histopathological features were the absence birth, recurrent bacterial infections. At that time, he presented with cyclic of goblet cells throughout the gastrointestinal tract, the atrophic changes neutropenia and low levels of IgG and IgA, and high levels of IgM. We in the gastric mucosa and duodenal mucosa (particularly villous atrophy suggested the possibility of primary immunodeficiency and he started with crypt hyperplasia) and the presence of increased numbers of apoptotic immunoglobulin infusion. epithelial cells. The initial therapy consisted of gancyclovir, enteral nutrition Methods: We continued the investigation with bone marrow biopsy with oligomeric formulas and aminoacids and steroids (methylprednisolone, showing no alterations. HLA typing was also done (A02, A30, B42, B49, 2 mg/Kg), besides IVIg and supportive care. After two weeks of treatment, HLA-DRB1 030201, DRB1 110201). DNA sequencing showed a new and no significant clinical response was found in spite of negative PCR for rare mutation in exon 5 (A to G) in Y169C, for CD40L CMV. Infliximab (5 mg/kg, every two weeks) was then added, with gradual steroid tapering, with excellent clinical response, as judged by weight gain, control of diarrhea, lowered serum levels of pancreatic enzymes and reduced inflammatory infiltrates in gastric and duodenal biopsies. These results suggest that anti-TNF therapy is a valid option for generalized autoimmune gut disorder in common variable immunodeficiency patients.
PCR 16 – AORTIC ANEURYSM IN A PATIENT WITH AUTOSOMAL-DOMINANT CHRONIC MUCOCUTANEOUS CANDIDIASIS
Authors: MORAES VASCONCELOS D, GRUMACH AS, FERREIRA MD, DUARTE AJS
Institution: Laboratory of Medical Investigation in Dermatology and Conclusion: The interest of this case report is the diagnosis of a CD40L Immunodeficiencies (LIM/56) and Primary Immunodeficiency Outpatient patient with severe neutropenia and low immunoglobulin levels. The DNA Unit (ADEE-3003) – Department of Dermatology and Pediatrics - Uni‑ sequencing showed a rare mutation in exon 5 (A to G) in Y169C. We found versity of São Paulo Medical School an HLA identical donor in the family, and the patient recovered well after a bone marrow transplant. Background: Chronic mucocutaneous candidiasis (CMC) is a rare disease, characterized by persistent and refractory infections of the skin, nails and mucous membranes, with yeasts of the genus Candida, PCR 15 – ANTI-TNF THERAPY FOR SEVERE AUTOIMMUNE infrequently evolving to systemic disease or septicemia. ENTEROPATHY ASSOCIATED WITH COMMON VARIABLE Case report: We report a family with three CMC patients of a IMMUNODEFICIENCY. non-consanguineous family beginning in childhood, with lesions in skin, nails and mucosa, improving with time, being the mucosal lesions Authors: Cunha, JMT, Francioni, E; Fagundes, FVB; Neves, L; Wakim, refractile to therapy. The family members affected by CMC are the mother VL; Taboada, G & Madi, K. (propositus), and her two daughters that have classical CMC, one of them with autoimmune thyroiditis. A 17-years-old man, presenting with chronic diarrhea and malnutrition Patient 1: Female, 38 years old, Caucasian, born to non-consanguineous
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parents. She was 2 years old when she started to present recurrent severe oral chorea, arching dental and enamel dental alterations, coeliac disease and candidiasis that led to failure to thrive. When she was 3 years old, ungueal and skin pigmentar alteration on the face. Patients with a history of coeliac cutaneous candidiasis, associated to alopecia, appeared. With 18 years old she disease are associated with an increased prevalence of developmental developed arthralgias and arthritis in large joints. She showed high titers of enamel defects. Some erupted teeth were affected, with a non – anti-DNA (1/600), leading to the diagnosis of systemic lupus erythematosus. homogeneous color distribution, ranging from opaque white-orange to She was treated by high dose corticosteroids and azathioprine, worsening brownish color. Clinical appearance of typical hypocalcification was her infectious manifestations and leading to medullar hypoplasia. At that observed with no changes in morphology. The disturbances presented by time CMC was diagnosed, corticosteroid and azathioprine were withdrawn, the patient’s teeth are symmetrical. Other uncommon feature in this patient and G-CSF introduced. Her clinical picture stabilized and 200mg/day of is the presence of neurologic manifestations. ketoconazole was introduced to control the candidiasis. One year after Over the years, the classic triad of APECED – hypoparathyroidism, the patient presented hepatitis, probably by ketoconazole. This drug was hypoadrenalism, and CMC – has been expanded to a highly variable replaced by fluconazole and the patient got better. When she was 26 years combination of autoimmune diseases affecting endocrine and non- old she presented a segmentar and focal glomerulonephritis. She was initially endocrine organs, including the parathyroid glands, adrenal cortex, gonads, treated with 60 mg of prednisone until the remission of the renal and articular pancreatic β-cells, and gastric parietal cells. This expanded phenotype is manifestations, with subsequent tapering of the drug. In the same year she often associated with ectodermal manifestations such as dystrophic dental presented hepatitis again, and fluconazole was replaced by itraconazole. enamel and nails. A new finding in APECED patients is the presence of Clinical course was satisfactory with control of the symptoms, but she autoantibodies directed to cytokines. As Aire is of paramount importance continued to have oral and esophageal candidiasis. In 1998 she presented in the regulation of central tolerance to tissue restricted antigens, and jugular and subclavian thrombosis due to anti-phospholipid antibodies. Sydenham chorea is associated to antibodies directed to tubulin and She was treated and evolved satisfactorily without sequelae. The patient phospholypids it is possible to hypothesize that the chorea presented by was submitted to several endoscopies with biopsies due to the esophageal our patient could be related to the immune dysregulation associated to candidiasis. She needed to be submitted to anterograde esophageal dilation the syndrome. because of an esophageal stenosis in 2004. The result was good. Nowadays she is stable with itraconazole 100 mg/day and 5 mg prednisone/day. Earlier in 2008 a routine CT evaluation showed a dilation of the aorta leading to a PCR 18 – DISSEMINATED INTRACELLULAR INFECTIONS IN cardiac surgery with implantation of a stent, substitution of the aortic valve A PATIENT WITH MYELOPEROXIDASE DEFICIENCY and dislocation of the coronary ostium. Conclusions: To our knowledge, this is the first report of an ascending Authors: Domingues-Ferreira, M.; Moraes-Vasconcelos, D.; Pereira, J.; aortic aneurysm in CMC, as well as the association of SLE and CMC Poli-Neto, A.; Oshiro, M.; Benard, G.; Duarte, A.J.S. have not been described in the literature. The association of uncommon complications in an autosomal dominant CMC suggests that this patient Institution: Primary Immunodeficiencies Outpatient Unit – ADEE3003 may have a different variant with systemic autoimmunity and aortic and Laboratory of Medical Investigation in Dermatology and Immuno‑ aneurysm not described until now. deficiencies (LIM-56), Department of Dermatology, University of São Paulo Medical School
PCR 17 – ATYPICAL CLINICAL FEATURES IN A PATIENT Paracoccidioidomycosis is the most important and prevalent WITH APECED systemic mycosis of Latin America. It is caused by the dimorphic fungus Paracoccidioides brasiliensis. A functional neutrophil deficiency against Authors: Domingues-Ferreira, M.; Nascimento-Filho, E.; Pieri,P.; P. brasiliensis in susceptible individuals has been demonstrated. Carneiro-Sampaio,M.; Moraes-Vasconcelos,D.; Duarte, A.J.S. Mycobacterium tuberculosis pathogenicity is related to its ability to escape killing by macrophages. In this case M. tuberculosis resides in Institution: Department of Preventive Medicine – UNIFESP; Primary phagosomes, which is not acidified into lysosomes. Immunodeficiencies Outpatient Unit – ADEE3003 and Laboratory of Myeloperoxidase enzyme (MOP) is present in granules of neutrophils Medical Investigation in Dermatology and Immunodeficiencies (LIM-56), and in the lysossomes of monocytes. MOP catalyzes the conversion of Department of Dermatology, University of São Paulo Medical School hydrogen peroxide and chloride ions into hypochlorous acid. Hypochlorous acid is a very potent microbial killing mechanism and is fundamental to Chronic mucocutaneous candidiasis (CMC) is a clinical syndrome with the process of phagocytosis. selectively altered immune responses against Candida. Patients with CMC LGC, female, caucasian, 20 year old, not consanguineous. She had display recurrent or persistent yeast infections of the skin, nails, and mucous a normal health during childhood up to 13 year old. At that time she membranes caused by organisms of the genus Candida, mainly Candida developed cervical, axillar and inguinal polyadenopathy and weight loss, albicans. Several unique syndromes are part of this entity based on the for about 6 months. She was submitted to a biopsy and juvenile form extent and locations of the Candida infections and characteristic associated Paracoccidioidomycosis was diagnosed. She was treated with fluconazole findings such as polyendocrinopathies, autoimmune disorders, thymoma, 600mg/day and has being treated up to now. One year later, she developed and interstitial keratitis. Frequently, CMC is associated with endocrine and ascitis, weight loss and vomiting. Peritoneal tuberculosis was diagnosed autoimmune disorders, such as autoimmune polyendocrinopathy candidiasis- by biopsy and rifampin, isoniazide and pirazinamide were introduced. ectodermal dystrophy (APECED) syndrome. She was treated for 1 year and the symptoms remitted. Then she was We describe a patient with APECED, female, 34 year old with oral referred to our department to investigate a possible immunodeficiency. chronic candidiasis, diabetes mellitus, hypoparathyroidism, epilepsy, She is HIV-, presents normal T, B and NK cells, IL12-23 and its receptor,
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and IFN-gamma receptors. She presents normal activity of the oxidative Diphosphate. The patient presented a new period of seizures and decrease burst, G6PD activity, and normal response to PHA, OKT3, PWM, gp43 of the consciousness at the beginning of 2004. A new stereotaxic biopsy (Paracoccidioides brasiliensis antigen), Candidin, PPD, Toxoplasma, of the brain was performed and cerebral nocardiosis was detected. He was Tetanus Toxoid and CMV. Her Immunoglobulin levels, ferritin and treated with co-trimoxazole. After multiple central nervous system infections glycemia are normal. She presents abnormal level of myeloperoxidase he got important sequelae: dementia, paraparesis and neurogenic bladder. in neutrophils. 97% of her Neutrophils have low activity of peroxidase. The immunological evaluation showed: Glucose: 85 mg/dl; Anti-HIV 1/2: Our patient presented two consecutive systemic granulomatous negative; Toxoplasmosis, Varicella, Epstein Barr vírus, Cytomegalovirus: IgG infections; Peritoneal Tuberculosis and a ganglionar form of positive; IgM negative; C3,C4 ,CH50 and APH50: normal; IgA 960mg/dL Paracoccidioidomycosis. The systemic characteristics of both infections (NR:69-382); IgG: 146mg/dL (NR:952-1538 mg/dL); IgM 249 mg/dL (NR: suggest some immunological defect. During the investigation no 73-171mg/dL); Kappa: 90 mg/dL (NR 138-375 mg/dL); Lambda: 86mg/dL abnormality of the expression of IL-12/23/IFN-gamma axis receptors was (NR:93-242 mg/dL); Normal and stable number of lymphocytes and their found. Other immunological parameters, such as lymphoid proliferation subsets (CD3+, CD4+, CD8+, CD19+, CD3-CD56+, CD3+CD56+, CD4+/ to mitogens and antigens, were normal, including the response to gp43 CD45RA, CD4+/CD45RO). and PPD. The unique important abnormality was the low myeloperoxidase Normal response to PHA, OKT3, PWM, Candida, Tetanus Toxoid, activity. PPD, Cytomegalovirus, Varicella, and Toxoplasma antigens was observed. We report a patient with deficient myeloperoxidase and disseminated DHR stimulated by PMA: 36,55%; control: 90,8% (Normal range: 90 – Tuberculosis and Paracoccidioidomycosis. The normal functions of the 100%); G6PD: 1.0 IU/g Hb/min 37oC (Reference value: 12.1+/-2.09); IL-12/23/IFN-gamma, oxidative burst and lymphoproliferation suggests Genomic analysis diagnosed an african mutation (codon 212); Neutrophil that myeloperoxidase deficiency is the central cause of her susceptibility. chemotaxis with patient’s serum: Patient: 55,25µm; Control: 102,35µm (Normal range: 91,48 - 137,22µm); Superoxide anion was normal in neutrophils and decreased in Monocytes. That could explain our patient PCR 19 – DEFICIENCY OF G6PD AND INTRACELLULAR recurrent infection on central nervous system. NEMO (IkBKg) sequencing INFECTIONS – DISCUSSION OF A VERY UNCOMMON showed two mutations in exon 10: 22565A>C and 22599T>G. NEMO PATIENT mutation associated with G6PD deficiency can be the main cause of this very uncommon immunodeficiency. To our knowledge this is the first Authors: Ferreira, M.D.1; Barros NC. 1 Oshiro, M.3; Saad, S.O.4; Condino, described case of NEMO mutation associated with G6PD deficiency and A.5; Grumach, A.S. 1,2; Duarte, A.J.S. 2; Moraes-Vasconcelos, D.1,2. recurrent intracellular infection in the central nervous system.
Institution: Dermatological Manifestations of Primary Immunodeficien‑ cies Outpatient Unit (ADEE-3003)1 and Laboratory of Medical Investi‑ PCR 20 – PERSISTENT GANGLIONAR TUBERCULOSIS – gation in Dermatology and Immunodeficiency (LIM-56)2 Department of UNCOMMON EVOLUTION Dermatology – Faculty of Medicine - University of São Paulo; Hematology Laboratory, Adolfo Lutz Institute, São Paulo3; Hematology Department, Authors: Ferreira, M.D.1; 5; Grumach, A.S. 1,2; Duarte, A.J.S. 2; Moraes- State University of Campinas4; Pediatrics Department, State University Vasconcelos, D.1,2. of Campinas5;. Institution: Dermatological Manifestations of Primary Immunodeficien‑ Case Report: The patient is a 31 year-old African-Caucasian male cies Outpatient Unit (ADEE-3003)1 and Laboratory of Medical Investi‑ patient, born to a non-consanguineous couple, with normal neuropsychomotor gation in Dermatology and Immunodeficiency (LIM-56)2 Department of and pondero-statural development. He did not have important health Dermatology – Faculty of Medicine - University of São Paulo; problems up to 25 years old, when he lost 10 Kg and had 3 pneumonias. Some weeks later he was admitted again at the hospital with progressive MT, african caucasian origens, was Born in Bahia state- northeastern headache, vomiting, fever, seizures and decrease of the consciousness level. of Brazil. She had not have important healthy problems up to 18 years old, At that time a CT scan and peritoneal biopsy were performed, leading to when she started to developed important chronic edema in inferior limbs. the diagnosis of Neurological and peritoneal tuberculosis. As sequelae It was diagnosed lymphangioedema. Some months later she developed he acquired spastic paralysis and chronic intracranial hypertension. He fever, weight loss and polyadenomegaly. It was diagnosed by biopsy was submitted twice to ventricular-peritoneal shunting and treated with ganglionar tuberculosis by Mycobacterium tuberculosis. She was treated RIP for 9 months. Later on, Amitryptillin, phenytoin and phenobarbital by isoniazid and rifampin for 8 months and the symptoms remitted. During were introduced. In the end of 2001 he had seizures and decrease of the 2 years she kept asymptomatic when she had a new episode of ganglionar consciousness level. He was submitted to stereotaxic biopsy. The diagnosis tuberculosis, diagnosed by biopsy. She was treated again for 6 months of Mucormycosis was established. He was treated with amphotericin and with isoniazid and rifampin. The clinical features remitted and after 1 got better, but with sequelae (paraparesis and bladder paralysis). During month without medication the symptoms returned. Isoniazid and rifampin the treatment the patient had esophageal candidiasis twice. The next year were introduced again for more 8 month and the symptoms disappeared. he had recurrent urinary infections due to bilateral nephrolithiasis. He was After this period isoniazid was removed and she used just rifampin. After submitted to left nephrectomy due to chronic renal failure of left kidney. some day the ganglionar tuberculosis returned. It was reintroduced again The patient had another series of seizures and decrease of the consciousness the both drugs and the symptoms ended. She has been using these drugs level. At that time Toxoplasmosis was diagnosed. He was treated with continuously until 2006, when she stopped to use isoniazid. The ganglionar pyrimethamine and sulfadiazine. Later on, HBV+ active chronic hepatitis was tuberculosis reappeared. Both drugs were reintroduced again and the diagnosed by liver biopsy and he has been treated with 3TC and Adefovir-5’ symptoms remitted. She uses both drugs up to now. She has never had
41 II Simpósio Internacional de Imunodeficiências Primárias - SIDEP. São Paulo, 30 de setembro a 3 de outubro de 2009. Rev. Inst. Med. trop. S. Paulo, 51(supl. 15), 2009.
bacterial infections such as pneumonia, sinusitis and others. Nowadays lesion revealed lymphohistiocytic inflammatory infiltrate along with she is taking sulfametoxazole and trimetoprim, fluconazole, isoniazide and poorly formed granulomas containing vacuolated macrophages, with a rifampin. CT scan demonstrates a bilateral pleural effusion. Leucocytes perivascular, periadnexal and perineural distribution. Staining for acid-fast 3650, Lymphocytes 212, CD3+ 99, CD4+ 37, CD8+ 60, CD19+ 31, bacilli (Fite-Faraco) resulted positive (+++/6+), exhibiting isolated and CD3-CD16+CD56+ 40, CD3+CD16+CD56+ 11, CD4+/CD8+ 0,56. HIV in globi solid bacilli. Laboratory examination revealed normal complete negative, expression of IL-12 and IFN-gamma receptors were normal. blood count, liver and renal function tests, as did the glucose-6-phosphate Myelogram was normal. IgG 496 mg/dl; IFN-gamma Elispot presented a dehydrogenase dosage. Abnormal laboratory tests included: parathormone lower response to mycobacterium antigens. Albumin stained with Cr 51 131 pg/mL (normal range 16-87 pg/mL), total serum calcium 11,5 mg/mL to evaluate protein loss by the intestines demonstrated an important loss. (8,6-10,2 mg/dL) and ionized calcium 6,2 mg/dL (4,6-5,3mg/mL), serum She loses 930 ml/serum/day RV (lower than 30 ml/plasma/day). This phosphorus 2,7 mg/dL (2,7-4,5 mg/dL), osteocalcin 124,1 ng/mL (11-43 report demonstrates a patient with chronic ganglionar tuberculosis that ng/mL), P1NP (N-terminal propeptide of type 1 procollagen) 222 ng/mL is controlled by isoniazid and rifampin, but not cured. This situation is (15,1-58,6 ng/mL), CTX (serum carboxy-terminal collagen crosslinks) probably due to the chronic T cell lymphopenia. What is remarkable is the 1,77 ng/mL (< 0,57 ng/mL). 25-hydroxyvitamin-D, thyroid function, cause of the lymphopenia. That is probably due to the loss of lymphocytes prolactin, ACTH, cortisol, GH, insulin, gastrin and sex hormones were by the gut mucosa. It was diagnosed an important protein loss from the within normal range.MEN I predisposes to endocrine and nonendocrine intestines. Probably this patient suffers from Intestinal lymphangiectasia, tumors as well cutaneous diseases, like angiofibromas, lipomas and which is a rare condition characterized by severe edema, thickening of the collagenomas (13), however, it is unknown whether the development small-bowel wall, protein-losing enteropathy, ascites, and pleural effusion. of leprosy in the case reported was influenced or not by the syndrome. If lymphatic fluid and proteins are lost into the gastrointestinal tract, patients Although many leprosy susceptibility genes have been described, none present with generalized edema due to hypoproteinemia. The condition of these is associated with MEN1 gene. There is evidence that vitamin may be primary, resulting from a congenital lymphatic vascular disorder, D receptor polymorphisms, one of possible mechanisms of susceptibility or secondary, as a consequence of inflammatory or neoplastic involvement to leprosy, is associated with sporadic hyperparathyroidism, but not with of the lymphatic system. These patients often lose lymphocytes from their MEN I-related hyperparathyroidism (14). In conclusion, the association intestine. Probably our patient is losing lymphocytes from her intestine. of leprosy with MEN I described in this report was probably an incidental This situation caused a persistent lymphopenia, the probable cause of the case of an endemic disease in a susceptible individual with a rare syndrome. ganglionar tuberculosis.
PCR 22 – OSTEOLYTIC LESION DUE TO BCG IN A PCR 21 – LEPROSY AND MULTIPLE ENDOCRINE DOMINANT-NEGATIVE IFN-GAMMA RECEPTOR NEOPLASIA TYPE I: A CASE REPORT DEFICIENCY PATIENT
Authors: Liliane Akemi Ayabe1, Ilana Halpern1, Maria Angela Bianconcini Authors: Nadai, T.R.; Orii, N.M.; Soares, M.C.P.; Litvoc, M.; Souza, M.I.; Trindade1,2 Almeida, M.C.S.; Duarte, A.J.S.; Moraes-Vasconcelos, D.
Institution: 1Departamento de Clínica Dermatológica do Hospital das Institution: Primary Immunodeficiencies Outpatient Unit ADEE3003 and Clínicas da Faculdade de Medicina da Universidade de São Paulo; 2Instituto Laboratory of Medical Investigation in Dermatology and Immunodefi‑ de Saúde, Secretaria de Estado da Saúde de São Paulo, Brazil ciencies (LIM-56), Department of Dermatology, Department of Thoracic Surgery and Department of Infectious Diseases University of São Paulo Multiple endocrine neoplasia type I (MEN I) is a rare, hereditary School of Medicine. syndrome, expressed by a combination of endocrine and nonendocrine tumors. Diagnosis is based on the occurrence of at least two of the three Introduction: BCG (Mycobacterium bovis attenuated strain Bacillus main MEN I-associated endocrine tumors: parathyroid adenoma, entero- Calmette-Guérin) vaccination is routinely indicated for all the Brazilian pancreatic endocrine tumor and pituitary tumor. Leprosy is a chronic children in the neonatal period to prevent the severe forms of tuberculosis, infectious disease, endemic in developing countries as India and Brazil, an endemic disease in our country. Despite its good safety profile, caused by Mycobacterium leprae. We report a case of multibacillary leprosy complications related to the vaccination occur, ranging from local to in a 16-year-old female patient with multiple endocrine neoplasia type I disseminated disease. Defects in any of the mechanisms involved in the (MEN I) syndrome, an association never described in literature. immune response to mycobacteria may impair the child to deal with the A 16-year-old white female reported a 5-month history of multiple attenuated M. bovis BCG and develop pottencially fatal complications. asymptomatic cutaneous lesions on her trunk and limbs. She had a Mendelian susceptibility to mycobacterial diseases is a rare congenital medical history of asymptomatic multiple endocrine neoplasia type I – as syndrome conferring a predisposition to infections caused by weakly the patient had a family history of MEN I, she underwent genetic testing virulent mycobacteria, such as BCG vaccines and nontuberculous and screening for endocrine tumors: genetic analysis resulted positive environmental mycobacteria (EM). Affected individuals are also vulnerable for MEN I mutation, laboratory tests revealed a hyperparathyroidism to the more virulent mycobacterial species Mycobacterium tuberculosis. and magnetic resonance imaging found a pituitary microadenoma. Mendelian susceptibility to mycobacterial diseases (MSMD) displays a Physical examination revealed erythematous and infiltrated papules and high level of genetic heterogeneity. There are 6 MSMD-causing genes, plaques on her trunk and extremities, foveolar lesions on elbows, as well including 1 X-linked gene (nuclear factor-κB–essential modulator as facial erythema. Neither had she presented neural enlargement, nor [NEMO]) and 5 autosomal genes (IFN-γ receptor 1 [IFNGR1], IFN-γ sensory or motor loss. Histopathological examination of an abdominal receptor 2 [IFNGR2], signal transducer and activator of transcription 1
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[STAT1], IL-12 p40 subunit [IL12P40], and IL-12 receptor β-subunit Institution: Universidade Federal de São Paulo – São Paulo – Brazil [IL12RB1]). Case report: GLT, 6 years-old, male, developed a tumor in the Introduction: CVID (Common Variable Immunodeficiency) usually retrosternal region for 1 year without fever, poor general condition and presents with a typical history of recurrent infections in the mucous / or weight loss. Associated pain and tumor presented also in the right membranes due to a marked hypogammaglobulinemia in serum. 60% of arm. Radiography showed a lytic lesion in the right humerus and in the patients present gastrointestinal symptoms. Although T cell dysfunction 3rd right rib. Biopsy of the bone lesion showed a granulomatous pattern is a common feature observed in CVID patients, opportunistic infections plenty of acid fast bacilli. Previous history of BCGitis after birth, treated with cytomegalovirus are rare. with isoniazide for 6 months with improvement. Immunological evaluation Case report: FHM, 31-year-old, male, diagnosed with CVID in 2002 showed normal T, B, and NK cells, as well as dyhidrorhodamine (DHR) whose main symptom was diarrhea. At that time he started treatment with reduction; Normal expression of IL-12 R beta 1 and extremely high intravenous immunoglobulin (dose of 560mg/Kg, every 4 weeks) and expression of IFN-gamma R alpha chain by flow cytometry. We are maintains the serum IgG level around 518mg/dl. He had recurrent Giardia nowadays sequencing IFN-gR1 gene searching for the mutation that led lamblia infections treated successfully. There were no other relevant to a dominant-negative effect and disseminated BCGitis infections. In June 2009 he started having abdominal pain, sensation of Conclusion: This case shows the extremely high susceptibility to low fullness of stomach, vomiting and loss of appetite. His symptoms worsened pathogenenicity Mycobacteria in MSMD patients. and he lost 8Kg (15% of his weight) in 4 weeks. During hospital admission for investigation, severe erosive gastritis was diagnosed by upper digestive endoscopy. Biopsy revealed cytomegalovirus. Gancyclovir was used for PCR 23 – PERSISTENT B CELLS DEPLETION AND the treatment (5mg/Kg/day) for 21 days successfully. He has gained weight HYPOGAMMAGLOBULINEMIA AFTER USE OF RITUXIMAB and had no further symptoms. FOR THE TREATMENT OF AUTOIMMUNE HEMOLYTIC Conclusion: Cytomegalovirus infection needs to be considered a ANEMIA – CASE REPORT. differential diagnosis of gastrointestinal infections in patients with CVID.
Authors: Nobre FA, França VV, Santos TC, Loureiro GL, Surian BR, Santos-Valente EC, Costa-Carvalho BT. PCR 25 – DISSEMINATED MYCOBACTERIUM TUBERCULOSIS IN A PATIENT WITH IFNg-IL12 AXIS DEFICIENCY Institution: Universidade Federal de São Paulo, São Paulo – SP, Brazil Authors: França VV, Loureiro GL, Santos TC, Surian BR, Nobre FA, Introduction: Rituximab is a chimeric monoclonal antibody targeting Lawrence TC, Moraes-Pinto MI, Diniz LC, Costa–Carvalho BT the CD20 molecule expressed on B cells. In this study, we demonstrate a persistent hypogammaglobulinemia and B cells depletion some years after Institution: Universidade Federal de São Paulo-SP, Brasil, Universidade the use of Rituximab for immune cytopenias. Católica de Goiás-GO Case report: BDBZ, male, 16 years old, diagnosed with autoimmune hemolytic anemia at 1 year old. He had recurrent hemolysis, treated with Mendelian susceptibility to mycobacterial diseases is a rare congenital systemic corticosteroids, until he was 12 years old. In 2004 (age of 12 syndrome conferring a predisposition to infections caused by weakly years old) he had his first treatment with Rituximab (dose of 427.5 mg/m2, virulent mycobacteria, such as BCG vaccines and nontuberculous once a week, for 4 weeks), with good results. Because of the recurrence environmental mycobacteria. Affected individuals are also vulnerable to of hemolysis, this treatment was repeated twice: in January 2005 and the more virulent mycobacterial species as Mycobacterium tuberculosis. December 2005. Following this, he had only one hemolysis crisis (February Objective: to investigated an absence of response to M. tuberculosis 2007) and was treated with intravenous immunoglobulin. After using after intensive treatment. Rituximab, his B cells were drastic reduced, and he also had a decrease Case report: KRL, male, 5 y old. At the age of 1y11m he presented in immunoglobulin (IgG, IgM, IgA) levels. Today, 3 years and half after with an abscess in the left psoas muscles with BAAR+ in secretions and the last administration of Rituximab, he still has an extremely low count culture was positive for M. tuberculosis. He was treated for M. tuberculosis of B cells (12,2 cells/mm3 or 1,3% of the total lymphocytes); also he has with Rifampin, Isoniazid, and Pyrazinamide for 6 months. This abscess also hypogammaglobulinemia. He has not had infections and is been being disseminated to the right side and recurred on 8 different occasions despite treated with intravenous immunoglobulin. continuous treatment. He was referred to our clinic at the age of 3 years old Conclusion: Rituximab has been used successfully for the treatment for treatment, and neurotuberculosis was diagnosed at that time. Despite of some autoimmune diseases. However, this medication could cause B continous treatment with Rifampin and Isoniazid for 2 years and 3 months, cells depletion and hypogammaglobulinemia over a prolonged period. Streptomycin for 3 months, Ethambutol and Clarithromycin for 1 year and 4 months, Ciprofloxacin for 2 months, the psoas and neural abscesses went uncontrolled. Lab exams showed low production of IL12p40 and IL 12 PCR 24 – CYTOMEGALOVIRUS GASTROINTESTINAL p70 after activation in vitro, with normal production of IFNg and IL10. INFECTION IN A PATIENT WITH COMMON VARIABLE Conclusion: patients with IFNg-IL12 axis deficiency can present IMMUNODEFICIENCY – CASE REPORT disseminated infection by M.tuberculosis without improvement after intensive treatment. Authors: VV França, Surian BR, Loureiro GL, Santos TC, Nobre FA, Melo, K, Pimentel CFMG, Rullo, VEV, Costa-Carvalho, BT.
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PCR 26 – HYPER - IgE SYNDROME WITH Peritoneal tuberculosis was diagnosed and RIP therapy was introduced. She HYPOGAMMAGLOBULINEMIA - A CASE REPORT was treated for 1 year and the symptoms remitted. Laboratorial evaluation showed HIV-, normal T, B and NK cells, normal IL12 and IFN-gamma Authors: Gonzalez, IG; Nobre FA; Lessa-Mazzucchelli, JT; Costa- receptors and normal G6PD activity. She presents normal DHR oxidation Carvalho, BT and normal response to PHA, OKT3, PWM, Candidin, PPD, gp43 of Pb, Toxoplasmosis, Tetanus Toxoid and CMV. Her Immunoglobulins, ferritin Institution:Universidade Federal de São Paulo- São Paulo- Brazil and glycemia are normal. 97% of her Neutrophils have low peroxidase activity. Introduction: The Hyper-IgE syndromes (HIES) are primary immune Discussion and conclusions: The great number of neutrophils found deficiencies characterized by elevated IgE, dermatitis, and recurrent skin in P. brasiliensis granulomas demonstrates the importance of these cells and lung infections. There are two forms of HIES: an autosomal dominant during this mycosis. Neutrophils from healthy human donors can ingest and (AD) form and an autosomal recessive (AR) form. The AD form is kill the fungus. There are evidences of the importance of the oxidative burst characterized by skeletal, connective tissue, and pulmonary abnormalities in of neutrophils and their ability to inhibit Pb growth in susceptible (B10.A) addition to recurrent infections and eczema. The AR form lacks the somatic and resistant (A/J) mice. The combination of two intracellular infections features and has marked viral infections and neurologic complications. In in which granulomas are important for the resistance and clearance of this study we describe a probable case of autosomal dominant HIES with the pathogens suggest that the deficient myeloperoxidase of our patient hypogammaglobulinemia. might explain her susceptibility to PCM and her peritoneal tuberculosis Case Report: RRS, male, born october/2002, first presented a (uncommon form of tuberculosis). newborn rash, after two months he was hospitalized for pneumonia. At three years old, he had a second hospitalization due to pneumonia and lung abscess, being submitted to right lobectomy. At 5 years old, he PCR 28 – WALDENSTRÖM HYPERGLOBULINEMIC presented the third pneumonia episode and at 6 years old, he was again PURPURA IN A PATIENT WITH CHRONIC hospitalized for treatment of a left lung abscess and pneumatocele, he MUCOCUTANEOUS CANDIDIASIS was submitted to thoracoscopy and received antibioticotherapy plus IVIg. Physical examination showed his coarse facies, moderate eczema in trunk, Authors: MORAES VASCONCELOS D, VASCONCELOS R, CRIADO hiperextensibility of the joints and onychomycosis on his hands. Laboratory PR, GRUMACH AS, FERREIRA MD, DUARTE AJS tests showed IgE> 3000mg/dl, IgA = 125mg/dl, IgM = 73mg/dl, IgG = 685mg/dl. Based on the Score system established by Grimbacher et al, Institution: Laboratory of Medical Investigation in Dermatology and 1999, this patient has: newborn rash = 4 points, 4 episodes of pneumonia Immunodeficiencies (LIM/56) and Primary Immunodeficiency Outpatient over lifetime = 8 points, parenchymal lung anomalies (pneumatocele) = Unit (ADEE-3003) – Department of Dermatology and Pediatrics - Uni‑ 8 points, coarse facies = 5 points, moderate eczema in trunk = 2 points, versity of São Paulo Medical School hiperextensibility of the joints = 4 points, onychomycosis on his hands = 2 points, IgE> 3000mg/dl = 10 points, with the final total-point assignments Background: Chronic mucocutaneous candidiasis (CMC) is a rare of 43 points, hence this patient is likely to carry an HIES genotype. disease, characterized by persistent and refractory infections of the Conclusion: This case report describes a classical case of HIES, skin, nails and mucous membranes, with yeasts of the genus Candida, in which the patient presents most of the clinical criteria established by infrequently evolving to systemic disease or septicemia. Grimbacher et al for its diagnosis. Although serum IgG, IgA and IgM Case report: Female, 20 years old, Caucasian, born to non- typically are normal in HIES, this patient showed low levels of IgG and consanguineous parents. She was 2 years old when she started to present IgM. Therefore, IVIg therapy may be beneficial. recurrent severe oral candidiasis that led to failure to thrive. When she was 3 years old, ungueal and cutaneous candidiasis appeared. With 19 years old she developed signs of purpura mainly in lower extremities, which PCR 27 – DISSEMINATED PARACOCCIDIOIDOMYCOSIS improved after longer resting periods. She showed positive ANA 1/320 AND TUBERCULOSIS IN MYELOPEROXIDASE DEFICIENCY (fine speckled cytoplasmic pattern) and rheumatoid factor, c-ANCA1/20, anti smooth muscle 1/40, anti-thyroglobulin 252 U/ml (<35); leading to the Authors: Mauricio Domingues Ferreira; Juliana Pereira; Alberto José da diagnosis of an overlap autoimmune syndrome. The investigation of cellular Silva Duarte; Dewton de Moraes Vasconcelos. immunity showed normal immunophenotyping and lymphoproliferative responses to T and B cell mitogens, as well as to recall antigens (Candida, Paracoccidioidomycosis (PCM), caused by the dimorphic fungus tetanus toxoid and M. tuberculosis PPD). The antibody memory to protein Paracoccidioides brasiliensis (Pb), is the most prevalent systemic mycosis antigens is preserved (positive IgG to CMV, EBV and hepatitis A). The of Latin America, with Brazil accounting for 80% of the reported cases. quantification of immunoglobulins showed IgA: 465, IgG: 7634, IgM: 201 mg/dl and IgE: 92 IU/ml, C4: 29 and C3: 346 mg/dl (90-180). Case report: Female, caucasian, 20 years old, without consanguinity. Conclusions: To our knowledge, this is the first report of a She had normal development without important diseases up to 13 years old. hyperglobulinemic purpura in CMC, as well as the association of an At that time she presented polyadenopathy (cervical, axillar and cervical) overlap autoimmune syndrome and CMC have not been described in the and weight loss without fever. She was submitted to a biopsy that showed literature. The association of uncommon complications in CMC suggests disseminated PCM. She was treated with fluconazole and the symptoms that this patient may have a different variant with systemic autoimmunity subsided. One year later, she developed ascites, weight loss and vomiting. not described until now.
44 II Simpósio Internacional de Imunodeficiências Primárias - SIDEP. São Paulo, 30 de setembro a 3 de outubro de 2009. Rev. Inst. Med. trop. S. Paulo, 51(supl. 15), 2009.
POSTERS IMMUNOLOGICAL INVESTIGATION – PII
PII 01 - THE ROLE OF NUCLEAR FACTOR KAPPA B (NF-kB) CONCLUSION: NF-kB, IFNGR1 and IFNGR2 are necessary for NCF1 AND THE IL-12/23-IFN-g AXIS IN THE ACTIVATION OF THE and NCF2 gene expression and activation of the human NADPH oxidase NADPH OXIDASE SYSTEM in this model system.
Authors: WALMIR CUTRIM ARAGÃO-FILHO1; CAROLINA PRAN‑ FINANCIAL SUPPORT: FAPESP, CNPq. DO2; JEAN-LAURENT CASANOVA3; PETER E. NEWBURGER4; Key words: NF-kB; EDA-ID; IL-12/23-IFN-g axis defects; NADPH ANTONIO CONDINO-NETO1. oxidase.
Institution: 1Department of Immunology, Institute of Biomedical Sci‑ ences, University of São Paulo, Brazil. 2Laboratory of Human Genetics PII 02 - REDUCED FREQUENCY OF CD4+CD25HIGHFOXP3+ of Infectious Diseases, The Rockefeller University, New York, NY, CELLS AND DIMINISHED FOXP3 EXPRESSION USA. 3Laboratory of Human Genetics of Infectious Diseases, Institut IN PATIENTS WITH COMMON VARIABLE National de la Santé et de la Recherche Médicale, U550, University of IMMUNODEFICIENCY: A LINK TO AUTOIMMUNITY? Paris René Descartes, Necker Medical School, Pediatric Hematology- Immunology Unit, Necker Hospital, 75015 Paris, France. 4Department Authors: GENRE JULIETA1, ERRANTE PAOLO RUGGERO1 KOK‑ of Pediatrics and Cancer Biology, University of Massachusetts Medical RON CRISTINA MARIA2,3, TOLEDO-BARROS MYRTHES2,3, CÂ‑ School, Worcester, MA, USA. MARA NIELS OLSEN SARAIVA1,4 AND RIZZO LUIZ VICENTE 1,2,3,5
INTRODUCTION AND OBJECTIVES: We investigated the Institution:1 Department of Immunology, Biomedical Sciences Institute, NF-kB and the IL-12/23-IFN-g axis defects consequences on the CYBA, University of São Paulo, Brazil. 2Division of Clinical Immunology and NCF1, NCF2 and NCF4 gene regulation of the human NADPH oxidase Allergy, University of São Paulo Medical School, Brazil. 3Laboratory system. Cell models: myeloid (wild type U937 cells (U937) or transfected of Medical Investigation (LIM) – 60, University of São Paulo Medical with a NF-kB repressor (U937 IkBa-S32A/S36A) or transfected with School, Brazil. 4Nephrology Division, Federal University of São Paulo, the empty vector (U937 pCMV3)) and lymphocytic (B EBV cells from UNIFESP, Brazil. 5Albert Einstein Jewish Institute for Education and patients with EDA-ID, or with CGD due to mutations in NADPH genes, Research, São Paulo, Brazil or from patients with IL-12/23-IFN-g axis defects) cells. METHODS: Cells were cultured in RPMI medium supplemented with inactivated Introduction and aim: Common Variable Immunodeficiency bovine fetal serum (10%), L-glutamine (2mM), streptomycin (100U/ (CVID) is considered the most prevalent primary immune deficiency mL), 2-mercaptoethanol (50mM), humid atmosphere (5% of CO2). in humans requiring medical attention, being the main clinical U937 cells were cultured for 48 hrs with or without IFN-g (100U/ features hypogammaglobulinemia and consequent recurrent infections mL, R&D-285-IF-100)/TNF-a (1000U/mL, R&D-210-TA); B EBV of the gastrointestinal and respiratory tracts. CVID is a disease of cells with IL-12/23-IFN-g axis defects were treated or not with IFN-g unknown etiology, although several defects in the innate and adaptive (103UI/mL) for 15 min. Total cellular RNA was acquired by TRIzol® compartments of the immune system have been observed, contributing (INVITROGEN15596-026) method. cDNAs were made by SuperScriptTM to the heterogeneous clinical manifestations presented by these patients. III (INVITROGEN18080-044). Real-time PCR (SYBR Green Master Noteworthy, CVID patients are prone to autoimmunity and malignancy. Mix, Applied Biosystems) was performed. ECR browser tool (http:// Although regulatory T cells have been shown to downmodulate immune ecrbrowser.dcode.org) was used in search for NF-kB binding sites. responses to auto antigens, allergens, pathogens and cancer cells, and to Statistics: Mann Whitney or ANOVA one-tailed, followed by Tukey test; mediate peripheral transplantation tolerance in mice, controversial views p<0.05; Medium ± S.D. n = at least 5. RESULTS: U937 IkBa-S32A/ exist about whether defects in this T cell population directly contribute S36A showed decrease in NCF1 expression compared to U937 cells to the pathogenesis of human autoimmune disorders. The principal aim (9.88 ± 2.66, 16.18 ± 0.63, respectively; p<0.05) as in NCF2 expression of this study was to investigate whether autoimmune disease in a subset (8.38 ± 0.71, 14.95 ± 2.11; p<0.001) in same comparison. NCF1 gene of CVID patients correlates with altered peripheral regulatory T cell expression in EDA-ID IkBa-S32I (heterozygous hypermorphic mutation) homeostasis. was lower than in healthy controls (0.06 ± 0.03, 1; p<0.001) as was in Methods: Peripheral blood mononuclear cells of CVID patients and EDA-ID NEMO/IKKg-X420W (hemizygous hypomorphic mutation) control subjects were obtained from fresh heparinized venous blood by (0.37 ± 0.21, 1; p<0.01) cells in same comparison. In the NCF1 and NCF2 Isolymph density gradient centrifugation and stained with FITC and upstream intergenic regions we found 8 and 3 specific sites for p50/p65 PE- conjugated antibodies against human CD4 and CD25, respectively. NF-kB subunits, respectively, conserved among the human and other For intracellular staining of FOXP3, cells were fixed and permeabilized species (ECR browser tool). IFNGR1 complete defect decreased NCF1 according to the manufacturer’s instructions before incubation APC- gene expression in both basal (0.2 ± 0.1) and IFN-g stimulated (0.81 ± conjugated FOXP3. For all markers, appropriate isotype controls were 0.48) cells compared to respective controls (1, 2.09 ± 0.54; p<0.001). used. For analysis, 100,000 events were recorded for each sample within Two distinct IFNGR2 complete defects prevent increase of NCF1 gene a CD4+ T cells gate. Quantitative analysis of CD4+CD25highFOXP3+ expression in IFN-g stimulated cells. Complete and partial IFNGR1 cells and their FOXP3 mean fluorescence intensity (MFI) were performed defects prevent the increase of IFN-g stimulated NCF2 gene expression. by flow cytometry technique and compared to clinical characteristics.
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Results: Thirty three CVID patients were enrolled following Ambulatory of Alergy and Infantile Immunology, Brazil; 3Department of the clinical and laboratory criteria established by the Pan-American Medical Clinics, Medical Science Faculty, State University of Campinas, Group of Immunodeficiency (PAGID), the European Society for UNICAMP, Brazil; 4Albert Sabin Infantile Hospital, Fortaleza, Brazil. Immunodeficiencies (ESID) and the Clinical Immunology Committee of 5Department of Pediatrics, Federal University of São Paulo, UNIFESP, the International Union of Immunological Societies (IUIS). Autoimmunity Brazil. was diagnosed following clinical and laboratory guidelines for each of the diseases presented by the patients. As controls, 30 sex- and age- INTRODUCTION: Hyper IgM Syndrome (HIGM) is a group matched individuals with no history of CVID or autoimmune disease of primary immunodeficiency with estimated incidence of 1/500.000 were recruited. Our results report that CVID patients with autoimmune newborns characterized by normal or elevated IgM levels, and reduction disorders show a lower frequency of CD4+CD25HIGHFOXP3+ cells in or absence of IgG, IgA and IgE, resulting in recurrent infections. their peripheral blood than patients without autoimmunity (1.43 ± 0.60% Defects in AID (Activation-Induced Cytidine Deaminase) and UNG vs. 2.18 ± 0.74%; p=0.0067), accompanied by a decreased intensity of (Uracil DNA Glicosilase) molecules cause distinct Autosomal HIGM FOXP3 expression (46.05 ± 5.77 vs. 67.05 ± 6.18 ; p<0.0001). Notably, (A-HIGM). OBJECTIVES: The aim of this work was to investigate although CVID patients in whom autoimmunity was not diagnosed had the phenotype of Brazilian patients with history of A-HIGM and a reduced frequency of CD4+CD25HIGHFOXP3+ cells when compared phenotype of UNG and AID deficiency. METHODS: Analyses of to healthy controls (2.18 ± 0.74 vs. 3.32 ± 0.83%; p<0.0001), FOXP3 clinical features. RESULTS: We studied 13 patients with clinical expression levels did not show statistical differences (68.57 ± 11.62 vs diagnostic of A-HIGM. They presented recurrent infections since the 67.05 ± 6.18). first months of life, such as pneumonias (100%), medium acute otitis Conclusion: We demonstrate for the first time that CVID (90%), diarrheas (70%), lymphoid hyperplasia (40%), sinusitis (30%), patients with autoimmune disease show reduced frequencies of amygdalates (20%), stomatitis (10%), cutaneous mycobacteriosis CD4+CD25HIGHFOXP3+ cells in the peripheral blood accompanied (10%), the most requiring internment. In 20% of the patients were by decreased FOXP3 expression. Our results suggest that in addition identified the presence of opportunistic pathogens (Staphylococcus to genetic background and environmental factors, altered peripheral epidermidis and Herpes zoster). The age of the first symptoms ranged regulatory T cell homeostasis and possible subsequent attenuation in between 3 and 7 months, clinical diagnostic ranged between 5 months the function of this population, could be associated with the outcome and 8 years. The 13 patients were diagnosed with HIGM after dosage of of autoimmune diseases in a subset of CVID patients. Remarkably, serum Immunoglobulins. According with the percentills 97, 50 and 3. 9 FOXP3 MFI values displayed an almost mutually exclusive stratification these patients presented high levels of IgM and 4 had normal levels, all of CVID patients´ subgroups. This reduced expression of FOXP3 in presented low levels of IgG, 3 had normal levels of IgA and 10 had low the peripheral blood of patients with autoimmune disorders could levels. The analysis of family historic of the patients showed a standard either result from its lower expression in all FOXP3+ cells, or selective of primary immunodeficiency with autosomal recessive inheriance. elimination of FOXP3HIGH cells. Since patients without autoimmunity After the replacement of intravenous gammaglobulin the number of have FOXP3 MFI values similar to those of healthy controls, analysis infections decrease in all patients. CONCLUSION: In that cases where of FOXP3 MFI may be a useful diagnostic tool to identify and follow the patients present high or normal levels of IgM, low IgG and IgA individuals at risk for developing autoimmune disorders. Notably, the levels and recurrent infections a genetic diagnosis is required to genetic functional consequences of reduced FOXP3+ cells may be amplified in counseling and screening of future newborns so that they can be treated individuals with inverted CD4/CD8 ratios since in these patients the total before the development of symptoms of HIGM. numbers of FOXP3+ cell would be further decreased. Taken together, FINANCIAL SUPPORT: FAPESP, CNPq. our findings might offer a way to improve CVID patient stratification Key-words: A-HIGM; AID; UNG. and prompt the development of therapies targeting regulatory T cells in CVID autoimmunity. PII 04 – IDENTIFICATION OF MUTATIONS OF BRUTON’S Financial support by FAPESP, CNPQ, CAPES and Millennium TYROSINE KINASE GENE (BTK) IN BRAZILIAN PATIENTS Institute. WITH X – LINKED AGAMMAGLOBULINEMIA
Authors: Ramalho,V.D.1; Oliveira Junior, E. B.1; Roxo Júnior, P.2; PII 03 - STUDY OF BRAZILIAN CHILDREN WITH D’Souza-Li, L.1; Vilela, M. M. S.1 PHENOTYPE OF AUTOSOMAL HYPER-IgM SYNDROME Institution: 1Center for Investigation in Pediatrics and Department of Authors: STEFANIE GOMES KLAVER1, OTÁVIO CABRAL Pediatrics, State University of Campinas; Medical School, Campinas, MARQUES1; WALMIR CUTRIM ARAGÃO-FILHO1; PAULO VÍTOR Brazil. 2Department of Pediatrics, Faculty of Medicine, State University SOEIRO PEREIRA1; ÂNGELA FALCAI1; CHRISTINA ARSLA‑ of São Paulo, Ribeirão Preto, Brazil. NIAN1; PAOLO RUGGERO ERRANTE1; JOSIAS BRITO FRAZÃO1; FABÍOLA SCANCETTI TAVARES2; ELI MANSUR3; JANAÍRA FER‑ KEY WORDS: XLA; X-linked agammaglobulinemia; BTK; Bruton NANDES S. FERREIRA4; BEATRIZ COSTA CARVALHO5; ANTONIO tyrosine kinase; mutational analysis; Brazilian. CONDINO-NETO1. BACKGROUND: Mutations in the gene encoding for Bruton’s Institution: 1Department of Immunology, Institute of Biomedical Sci‑ tyrosine kinase (BTK) are responsible for most of the X-linked ences, University of São Paulo, Brazil; 2Federal District Base Hospital, agammaglobulinemia (XLA) which is characterized by markedly reduced
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numbers of blood B cells (<2%) and all immunoglobulin isotypes. We essential for transcriptional activity, this interaction between p65 and CBP evaluated 3 XLA Brazilian patients from unrelated families. is crucial prerequisite for efficient transcription by NF-kB (10, 11, 12). MATERIALS AND METHODS: DNA was prepared from the In this study we investigate the production of cytokines and patients peripheral blood cells. SSCP (single-strand conformation chemokines, and the NFkB protein expression and p65 activation in polymorphism) analysis was performed for the entire BTK gene, neutrophils fromRTS patients. We have studied 8 unrelated RTS patients including the exon-intron boundaries and the promoter region. The (2M and 6F, range 8-24 years) and healthy control (range 18-30 years). The BTK protein expression was assessed in monocytes of patients and diagnosis was done by a pediatric geneticist using clinical criteria. Normal their mothers by flow cytometry. RESULTS: We identified two novel karyotype, at 450 bands resolution, was identified in 7 patients, whereas (Ala347fsX55, I355T) and one recurrent mutations (Q196X). Mutations one patient presented t(2;16). All patients presented recurrent respiratory Ala347fsX55 and I355T were found in the Src homology domain 2 infections in the first decade of life. The NF-kB protein expression and (SH2) that is involved in phosphotyrosyl peptide binding, and Q196X p65 activation in neutrophils were determined using Western blot and in the Tec homology (TH) domain a proline-rich region (PRR) capable Electrophoretic Mobility Shift Assay (EMSA), respectively. The assays of interacting with several SH3 domains. Flow cytometric evaluation of were performed before and after lipopolysaccharide (LPS) stimulation BTK expression in monocytes revealed that BTK deficiency was present in neutrophil culture. In the supernatant of the culture, the expression in patients and importantly, a mosaic pattern of BTK expression was of cytokine- tumor necrosis factor-α (TNF-α), interleukin-1ra (IL-1ra), obtained from mothers, indicating that they were obligate XLA carriers. interleukin-1β (IL-1β), and interleukin – 8 (IL-8) was measured by CONCLUSIONS: The mutations responsible for XLA allowed us to do enzyme-linked immunosorbent assay (ELISA) (DuoSet, R&D System, definitive diagnosis and genetic counseling. A flow cytometric assay of Minneapolis, MN, USA). The RTS patients presented high activation BTK protein expression may be clinically useful for the detection of levels of transcription factor NF-kB/p65 in neutrophils, before and XLA and its carrier state. after LPS stimulation, while healthy controls showed a high activation level only after LPS stimulation. The patients presented normal NF-kB Financial support: FAPESP and CAPES. protein concentration in neutrophils, high levels of cytokines IL-1RA and IL-1b before and after LPS stimulation and increased production of TNF-a and IL-8 after LPS stimulation. The patients presented higher PII 05 – STUDY OF NFkB PROTEIN EXPRESSION AND p65 levels of all cytokines before and after stimulation when compared to ACTIVATION IN NEUTROPHILS FROM PATIENTS WITH healthy controls.The results indicate that the neutrophils of the patients RUBINSTEIN-TAYBI SYNDROME do not need to be stimulated with substances that induce the NF-k B/p65 activation, since they are activated in basal conditions (without stimulus). Authors: Leuridan Cavalcante Torres1, Marco Aurelio R. Vinolo2, Rui The high production of cytokines IL-1RA and IL-1b before and after LPS Curi2, Ricardo Ambrósio Fock3, Sofia Mizuho Miura Sugayama1, Magda stimulation could be caused by the high level of NFkB/p65 activation Carneiro-Sampaio1 in neutrophils in basal conditions. We conclude that the genetic defects responsible for RTS do not cause defects of NF-kB protein expression Institution: 1Department of Pediatrics, Faculty of Medicine, University and p65 activation in neutrophils. Financial support: FAPESP. of São Paulo, São Paulo, Brazil; 2Department of Physiology and Biophys‑ ics, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil; 3Experimental Hematology Laboratory, School of Pharmaceutical PII 06 – JUVENILE SYSTEMIC LUPUS ERYTHEMATOSUS Sciences, University of São Paulo, São Paulo, SP, Brazil. FREQUENTLY DEVELOPS IN A BACKGROUND OF PRIMARY IMMUNODEFICIENCIES Rubinstein-Taybi syndrome (RTS) [OMIM 1808499] is an autosomal dominant disorder characterized by craniofacial dysmorphisms, broad Authors: Jesus AA1, Liphaus BL1, Silva CA1, Andrade LEC2, Coutinho thumbs and toes, mental and structural deficiency, and recurrent A3, Carneiro-Sampaio M1 respiratory infections (1). In 45-56% of the RTS patients, mutations of the CREB-binding protein (CREBBP or CBP) have been identified on Institution: USP, Departamento de Pediatria do Instituto da Criança, Av. chromosome 16p13.3 (2, 3). Mutations of the EP300 gene, located on Dr Eneas C. Aguiar, 647; 2. UNIFESP, Departamento de Reumatologia, chromosome 22q13.3, were identified in four RTS patients (4). CBP and Rua Borges Lagoa; 3. IGC, Instituto Gulbenkian de Ciência, Rua da its paralogue, p300, are believed to activate gene expression by interacting Quinta Grande, 6 with components of the general transcriptional machinery (5, 6, 7) and by acetylating chromatin (8). NF-kB activation is crucial for many important Objective: To evaluate the frequency of complement and antibody biological processes, including immunity (9). NF-kB transcription factors primary immunodeficiencies (PIDs) in Juvenile Systemic Lupus are induced by a variety of surface and cytoplasmic receptors (e.g., Toll Erythematosus (JSLE) patients and to compare lupus patients with like receptors, IL1/IL18 receptors, and TNF-a receptors) and lead to and without PID regarding demographic data, clinical features, disease the transcription of numerous genes (e.g., proinflammatory cytokines activity and damage, treatment and occurrence of severe sepsis. and chemokines) (9). The CBP and NF-kBp65 can form two distinct Methods: Seventy-two JSLE (ACR criteria) patients (1 to 16 interations: a phosphorylation-independent interaction that involves yrs at diagnosis) were analyzed for early components of the classical the C-terminal region of p65 and the N-terminal region of CBP, and a complement pathway (C1q, C1r/C1s, C4, C2, C3) and immunoglobulin phosphorylation-dependent interaction that requires phosphorylation levels (IgG, IgA, IgM, IgE, and IgG2 subclass). Anti-C1q antibody was of serine 276 of p65 and KIX region CBP (10, 11, 12). These authors detected by ELISA (Inova Diagnostics - QUANTA LiteTM Anti-C1q, San suggested that recruitment of CBP to p65-containing NF-kB complexes is Diego, California, USA). Statistical analysis was carried out according
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to Fisher´s exact test, Mann-Whitney test and Backward Stepwise multifocal aseptic osteomyelitis. We describe the first two and unrelated multivariate analysis. Brazilian cases of DIRA, both presenting the same deletion on IL1RN, Results: Nineteen patients (26%) had underlying primary causing severe but distinct clinical phenotypes. immunodeficiencies (PIDs). Complement PIDs were: 5 cases of C2 Patient 1 is a 12 month-old girl that was born to healthy but deficiency and 2 of C4 deficiency (all with persistently very low values consanguineous parents (second degree cousins). She was noted to have in the presence of normal levels of other complement components, and disseminated pustular cutaneous lesions just after birth. Laboratorial SLEDAI < 4), and 2 cases with complete C1q deficiency. All PID patients exams showed hemoglobin 7.9 g/dl, white blood cell count 21.300 cells/ had normal C3 levels. Immunoglobulin deficiencies were: 4 cases with mm3 (88% neutrophils), platelet count 681.000 cells/mm3 erythrocyte IgG2 deficiency (<20mg%), 3 with IgA deficiency (<7mg%), and 3 with sedimentation rate (ESR) 51 mm 1st/hour and C-reactive protein (CRP) IgM deficiency (<35mg%). All patients with immunoglobulin deficiencies 54 mg/dl. Several antibiotic courses were initiated without remission were identified after 10-years of age and had normal or high total IgG of skin lesions. At the age of one month, the patient presented pain on levels. One IgA deficient patient also presented C4 and C2 deficiencies. manipulation. Bone scintigraphy revealed acute osteomyelitis in left A clear gender bias was observed, since 54% of the boys (7/13) and 20% clavicle and right 7th and 9th costal archs. Bone cultures for bacteria, (12/59) of the girls presented an underlying PID (p=0.032; RR: 3.25; CI: fungi and mycobacteria were negative. Primary immunodeficiencies 1.25 – 8.46). The 2 cases of infantile SLE (age at onset <2 years) were investigation was done and lymphocytes immunophenotyping, both males (one with C1q deficiency and other with IgM deficiency). A dihydrorhodamine, immunoglobulins levels, CD40 and CD40 ligand remarkably higher frequency of severe sepsis was observed in the PIDs axis and IL-12 and IFN-g axis were all normal. Her skin biopsy showed group (31% vs 7.5%; p=0.017; RR: 4.2; CI: 1.32 – 13.2). Specific lupus epidermal parakeratosis and subcorneal pustula, very similar to a clinical features (cutaneous, mucosal, neuropsychiatric, cardiopulmonary, psoriasis pustulosa skin pathology. A clinical suspicion of a pyogenic renal, hematological and articular manifestations and antiphospholipid auto-inflammatory disease was done and prednisolone was started (2mg/ syndrome) were not significantly different in patients with and without kg/day). The patient had an initially impressive improvement of pain on PIDs. On the other hand, the median of the cumulative damage related manipulation and skin rash and a significant decrease of CRP (21 mg/ to SLE (SLICC/ACR-DI) was significantly higher in immunodeficient dl) three days after starting corticosteroids. Despite prednisolone use, subjects [1(0 - 5) vs 0 (0 - 3); p=0.0075]. Logistic regression showed patient maintained a recurrent cutaneous picture and acitretin (0.2 mg/ that male gender and (odds ratio=4.7; 95% CI=1.2 – 19.2; p=0.034) and kg/day) was initiated and progressively increased (1.0 mg/kg/day) with SLICC/ACR-DI (odds ratio=2.5; 95% CI=1.13 – 4.8; p=0.007) were a remarkable improvement of cutaneous rash. Her cutaneous picture is independent risk factors for PID (Nagelkerke R2=0.26). controlled; she has not presented osteomyelitis or significantly abnormal Additionally, 44% of JSLE patients (30/68) had high IgE levels, inflammatory markers. Current physical examination reveals weight which were at least twice the frequency of the general population for (6.500 g) and height (63 cm) below 3rd percentile for age, sparse pustules this age. Conclusions: An exceedingly high frequency of antibody on head, chest and extremities without secondary infection or abscesses. and complement deficiency was observed amongst JSLE patients, Mutational screening of IL1RN identified a homozygous in-frame suggesting that these immunologic defects may contribute to the disease deletion (15bp) and both parents are heterozygous for the same mutation. development. Our results command that these two groups of PIDs should Patient 2 is a 15 month-old girl, born from non-consanguineous be systematically investigated in early onset lupus. parents. She developed a respiratory discomfort in the first 24 hours of life and remained in neonatal intensive care until 25 days of age due to oxygen dependence. At 30 days of life, she presented papular and pustular PII 07 – DEFICIENCY OF INTERLEUKIN-1- RECEPTOR diffuse cutaneous lesions that were treated with antibiotics. Laboratorial ANTAGONIST: DESCRIPTION OF TWO BRAZILIAN CASES exams showed Hb 7g/dl, white blood cell count 24.100 cells/mm3 (53% OF A NOVEL AUTOINFLAMMATORY DISEASE WITH neutrophils), platelet count 853.000 cells/mm3 erythrocyte sedimentation NEONATAL-ONSET rate (ESR) 47 mm 1st/hour and C-reactive protein (CRP) 21 mg/dl. Skin biopsy demonstrated mixed superficial perivascular dermatitis Authors: Adriana Almeida Jesus1, Clovis Artur Almeida Silva1,2, Débora with neutrophils, eosinophils and subcorneal pustula. At 2 months of Romeo Bertola3, Magda Carneiro-Sampaio4, Hatem El-Shanti5 age, patient presented fever and pain on manipulation and left radial and several ribs osteomyelitis was diagnosed by computed tomography Institution: 1Pediatric Rheumatology Unit, 2Division of Rheumatology, (CT). She remained hospitalized for 2 months and received several IV 3Genetic Clinic Unit and 4Immunology Unit of Faculdade de Medicina antibiotics courses with no change in clinical picture. Additionally, lytic da Universidade de São Paulo, Sao Paulo, Brazil. 5Shafallah Medical lesions of T1 and T2 vertebral bodies resulted in fracture of spine and in Genetics Center, Doha, Qatar a chronic inflammatory process with perivertebral fibrosis. Since the age of 5 months, she has presented hypoxemia and dyspnea crises needing Key-words: Deficiency of Interleukin-1-Receptor Antagonist, autoin‑ respiratory physiotherapy and domiciliary oxygen therapy. Moreover, a flammatory disease, neonatal severe and persistent anemia led to seven blood transfusions until now. Current physical examination reveals weight (5.500 g) and height (65 Introduction. Auto-inflammatory syndromes (AS) are caused by cm) below 3rd percentile for age, small pustules on head and chest and monogenic defects in innate immunity proteins. Recently, a novel AS central cyanosis when crying. Family history was remarkable for her named Deficiency of Interleukin-1-Receptor Antagonist (DIRA) was mother with juvenile idiopathic arthritis polyarticular onset and course described in 10 patients. The syndrome is caused by mutations of IL1RN, since the age of 8 years. Mutational screening of IL1RN was performed encoding the interleukin-1-receptor antagonist (IL1Ra), and characterized and revealed a homozygous inframe deletion (15bp). The parents are by early-onset (mainly neonatal-onset) of pustular dermatitis and heterozygous for the same mutation.
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Conclusion. We report two rare cases of a new AS named DIRA. North East Brazil. To our knowledge, this is the first study that reports the These patients presented the same deletion on IL1RN gene, causing severe frequency of MASP-2 D371Y polymorphism in a Brazilian population. cutaneous and bone manifestations. Despite that both probands showed #Supported by FAPESP and FACEPE. the same mutation, the clinical phenotype was variable: case 1 presented with florid skin abnormalities and case 2 showed a more pronounced bone involvement. It is possible that other gene(s) and/or environmental PII 09 – BCGOSIS: A WARNING SIGN FOR PRIMARY factors should be modulating their phenotypes. IMMUNODEFICIENCY
Authors: Dorna, MB; Grumach, AS; Chuffi-Barros, N; Domingues- PII 08 – MANNOSE-BINDING LECTIN (MBL2) AND Ferreira, M; Pessoa, FGP; Giliani, S; Orii, NM; Bressani, VO; Oliveira, MANNOSE-BINDING LECTIN-ASSOCIATED SERINE GM; Duarte, AJS; Moraes Vasconcelos D. PROTEASE-2 (MASP-2) GENE POLYMORPHISMS IN A BRAZILIAN POPULATION Institution: Primary Immunodeficiencies Outpatient Unit ADEE3003 and Laboratory of Medical Investigation in Dermatology and Immu‑ Authors: N. Ferraroni1, S. Crovella2,3, R. L. Guimarães3, L. A. C. nodeficiencies (LIM-56), Department of Dermatology, University of Brandão3, L. Segat2,3, R. N. Constantino-Silva1, C. Alves1, I. Siqueira4, São Paulo; Department of Pediatrics and Angelo Nocivelli Institute for C. Loja4, A. J. S. Duarte1, A. S. Grumach1; Molecular Medicine, University of Brescia, Italy.
Institution: 1Faculty of Medicine, University of São Paulo, São Paulo, Introduction: BCG (Mycobacterium bovis attenuated strain BRAZIL, 2IRCCS Burlo Garofolo, Trieste, ITALY, 3Federal University Bacillus Calmette-Guérin) vaccination is routinely indicated for all the of Pernambuco, Recife, BRAZIL, 4Hospital dos Servidores do Estado Brazilian children in the neonatal period to prevent the severe forms do Rio de Janeiro, Rio de Janeiro, BRAZIL. of tuberculosis, an endemic disease in our country. Despite its good safety profile, complications related to the vaccination occur, ranging RATIONALE: Mannose-binding lectin (MBL) is a C-type lectin from local to disseminated disease. Defects in any of the mechanisms encoded by the MBL2 gene. The activation of the lectin pathway of involved in the immune response to mycobacteria may impair the child Complement system is mediated by MBL in association with serine to deal with the attenuated M. bovis BCG and develop pottencially proteases, named MASPs (-1,-2,-3). The MBL/MASP-2 complex, fatal complications. The search for immunological defects in children in particular, is able to generate the C3 convertase and activate the developing complications related to BCG vaccination is important, since Complement cascade. it can be the first manifestation of an immunodeficiency. Single nucleotide polymorphisms (SNPs) in the first exon of MBL2 Methods: Retrospective evaluation of 11 patients (4M:7F) referred gene, as well as in the promoter region, are known to be associated with for immunological investigation after a complication of BCG vaccination. infective and autoimmune diseases. To a lesser extent, also MASP-2 The age for the first clinical signs of BCGosis ranged from 5 days to 6 polymorphisms have been described and related with autoimmune months and the age of the diagnosis of BCGosis ranged from 3 to 10 diseases. months. One patient presented a relapse after 5 years. Three of them METHODS: 200 blood donors from Hospital dos Servidores do presented only regional lymphadenopathies. Immunological defects Estado do Rio de Janeiro (median age 36 years (range 18-63); 56/200 were not found in two of them and one is still under investigation. Eight (28.0%) females and 144/200 (72.0%) males) were enrolled and patients developed a disseminated form of disease and seven of them genotyped for MBL2 exon 1 polymorphisms (at codons 52, 54 and 57) presented immunological deficiencies: IL12RB1 deficiency in 2/7; and for MASP-2 D371Y polymorphism. Genomic DNA was extracted by Dominant-negative IFN-gR1 deficiency in 1/7 ; SCID in 4/7 (2 IL7Ra using the QIAamp blood kit (QIAgen). MBL2 genotyping was performed deficiency, 1 RAG1 deficiency, 1 T-B+NK+ not molecularly defined). by using a Melting Temperature Assay (MTA) based on SYBR Green Conclusions: Since BCG vaccine is administered in the neonatal chemistry in a Rotor Gene RG 3000 (Corbett Research) Real Time PCR period in our country, it can represent the first infectious challenge for a platform. The three variant alleles at codons 52, 54 and 57 of the MBL2 child. Complications related to the vaccination should be a warning sign gene were grouped together as allele ‘O’ while the wild type is called for immunological investigatio allele ‘A’. The analysis of MASP-2 D371Y polymorphism (rs12711521) was performed by using TaqMan pre-developed assay. RESULTS: MBL2 and MASP-2 SNPs frequencies were in PII 10 – MALIGNANCIES IN PRIMARY Hardy-Weinberg equilibrium in the population analyzed. MBL2 allele IMMUNODEFICIENCY PATIENTS frequencies were A=79.0% and O=21.0%. The frequencies of MBL2 genotypes were 61% A/A (122/200), 35.5% A/O (71/200) and 3.5% O/O Authors: Dorna, M.B.; Moraes Vasconcelos, D.; Grumach, A.S.; Ferreira, (7/200) and did not differ between females and males. MASP-2 D371Y M.D.; Chuffi-Barros, N.; Bressani, V.O.; Oliveira, G.M.; Duarte, A.J.S. allele frequencies were A=60.0%, C=40.0%; genotypes were 38.0% A/A (76/200), 44.5% A/C (89/200) and 17.5% C/C (35/200). Institution: Primary Immunodeficiencies Outpatient Unit – ADEE3003 CONCLUSIONS: The prevalence of MBL2 O/O genotypes in the and Laboratory of Medical Investigation in Dermatology and Immuno‑ Southeast Brazilian population (3.5%) was similar to the prevalence deficiencies (LIM-56), Department of Dermatology, University of São for both northern Europeans (3%) and indigenous groups (2% to 4%) Paulo Medical School. in Greenland and Canada while some differences were found when comparing our findings with previous reports on MBL2 frequencies in Introduction: Primary immunodeficiencies (PIDs) are genetic
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disorders that predispose to frequent and severe infections, autoimmunity Non-Hodgkin T cell Lymphoma was confirmed. and cancer. NK cells, macrophages and mainly cytotoxic T cells are Case 2: L.G.V.R, male, diagnosed with CVID at age 23 and receiving involved in the destruction of tumoral cells. Transformation of a cell IgIV monthly This patient developed weight loss and anemia at age 43 and to one with malignant potential in an immunodeficient host may allow was investigated for malignancy. It were performed scans of the abdomen clonogenic expansion and eventually clinical cancer. and chest and an endoscopy with gastric biopsy which revealed MALT Material and Methods: Retrospective evaluation of the 301 patients Lymphoma. Bone marrow aspiration revealed infiltration in this location. (129M:172F) that have been followed-up for primary immunodeficiencies Case 3: L.A.S., 9 years, male, admitted in our service to (PID) in the unit. Description of 12 of those patients (8M:4F) that have immunological investigation because of recurrent respiratory infections. developed malignancies during the follow-up. On physical examination, this patient presented hepatomegaly, Results: Two out of the 12 patients were diagnosed idiopathic CD4 splenomegaly and lymph node enlargement. Realized immunologic lymphocytopenia and both developed a B cell EBV positive lymphoma investigation, diagnosed CVID. Referred to hematological investigation, (1/2 non Hodgkin nodal B cell lymphoma; 1/2 primary pulmonary B biopsy lymph node diagnosed Non-Hodgkin T cell Lymphoma. cell lymphoma). One patient who presented Bloom syndrome developed Conclusion: In this cohort of CVI the incidence of TCL was 50-fold colon adenocarcinoma and a second one developed a myelodysplastic higher than what is observed in the general population (9,80/1,000 p-y vs. syndrome characterized as a refractory anemia with excessive number 0.16/1,000 p-y). Early identification of patients with CVID, aggressive of blasts. One patient was diagnosed IgM deficiency and presents a T treatment of infections and intravenous immunoglobulin therapy have gd cells leukemia. One patient presenting Good´s syndrome progressed prevented long-term complications and dramatically improved the quality to lung adenocarcinoma. An IFNR1 deficient patient progressed of life of these patients. However, the medical staff should be aware of to a myelodysplastic syndrome and acute myeloid leukemia. One the increased risk for development neoplastic diseases. patient with Common Variable Immunodeficiency developed stomach adenocarcinoma. A patient presenting epidermodysplasia verruciformis showed a perianal epidermoid carcinoma. A male with chronic PII 12 – CLINICAL AND LABORATORIAL EVOLUTION OF mucocutaneous candidiasis progressed to esophageal squamous cell THREE ALPS PATIENTS. carcinoma. A female suspected of partial CD18 deficiency developed an acute M7 myeloid leukemia. One patient with CD3ε deficiency developed Authors: Riccetto AGL; da Silva MTN; Oliveira JB; Labbate AKC; a Hodgkin lymphoma. Rama TF; Vilela MM. Conclusion: Many PIDs are related to a predisposition to the development of malignancies. Our casuistry shows some classical Institution: Center for Investigation in Pediatrics and Pediatrics De‑ associations such as Bloom’s and Good’s syndrome but some new partment. State University of Campinas Medical School. UNICAMP, observations such as CD18 and CD3e deficiencies. Surveillance is Campinas, SP, Brazil important for early diagnosis and treatment, reducing the mortality. Autoimmune lymphoproliferative syndrome (ALPS) is a rare human disorder associated with defects in lymphocyte apoptosis. Most PII 11 – LYMPHOID MALIGNANCY IN PATIENTS WITH patients bear heterozygous mutations in the TNFRSF6 gene (encoding COMMON VARIABLE IMMUNODEFICIENCY Fas) located on the chromosome 10q24.1; over 70 different mutations have been described so far; there is a complex relationship between Authors: Nunes, J.; Minafra, F.G.; Fusaro, G.V.; Cunha, L.A.O.; Pinto, genotype, phenotype and disease penetrance. Double-negative CD4- J.A CD8- TCR alpha/beta+ T cells are reliable markers of autoimmune lymphoproliferative syndrome (ALPS) associated with FAS loss of Institution: Immunology Division, School of Medicine, Federal Uni‑ function. versity of Minas Gerais We report here the clinical and laboratorial evolution of three patients with ALPS all of whom have Fas gene mutation, but with Introduction: The major clinical manifestation of primary different phenotypes. The first patient was female, 14 years old, with immunodeficiency (PID) is the increased susceptibility to infections. cervical and axillary lymphadenopathy, a high level of IgG; with no However, malignancies and auto-immune diseases also occur with cytopenias or splenomegaly found. At the present moment, she is well, increased frequency in a variety of PID disorders. In evaluating a patient without any medication. The second patient was male, 13 years old, with PID it is necessary to be aware of possible malignancies. with cervical, axillary and inguinal lymphadenopathy, low levels of Objective: To describe the incidence of lymphoid malignancy (LM) IgA and IgM and thrombocytopenia. He was treated for 18 months with among patients with common variable immunodeficiency (CVID) in mycophenolate mofetil for thrombocytopenia control. Submandibullar follow up at a referral center. lymph node surgical exeresis was carried out. The third patient was male, Results: During a 6-year period, 3 out of 51 patients with CVID 19 years old, with lymphadenopathy, splenomegaly, hemolytic anemia, developed LM. The overall incidence of LM in this cohort was 9,80/1,000 immunoglobulin abnormalities (high level of IgA, low level of IgG and persons-year. The three cases are described below. IgM) and mesangial proliferative glomerulonephritis (IgA nephropathy). Case 1: D.L.O., female, 8 years, was admitted to our service because With the use of mycophenolate and prednisone, at the present moment, of recurrent respiratory infections. Immunological investigation was the patient is free of cytopenia, hematuria or splenomegaly. These three compatible with CVID. During regular follow up, this patient presented cases show different phenotypes for similar Fas gene mutation. lymph node enlargement, hepatomegaly, splenomegaly and pancitopenia. She was referred to hematological investigation and the diagnosis of
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PII 13 – CASE SERIES OF PRIMARY diseases (4,7%), severe combinated immunodeficiency (4,7%), chronic IMMUNODEFICIENCIES AT A REFERRAL SERVICE IN mucocutaneous candidiasis (2,0%), hereditary angioedema (12,2%), MINAS GERAIS – BRAZIL ataxia-telangiectasia (2,0%), Sindrome diGeorge (0,6%), ALPS (0,6%) and IPEX (0,6%). The median age at onset of symptoms was 1 year. The Authors: Minafra, F.G.; Cunha, L.A.O.; Fusaro, G.V.; Miranda, L.B.C.; patients showed high frequency of infeccious diseases, hospitalizations Pinto, J.A and often requiring intensive care. Allergic, autoimmune and chronic inflammatory manifestations (beyond malignancy diseases) occurred in Institution:Division of Immunology, Department of Pediatrics, School a significant proportion of cases. of Medicine, Federal University of Minas Gerais
Objectives: To monitor, portray and describe the practice of the HC- PII 14 – AUTOIMMUNITY IN A BRAZILIAN COHORT OF UFMG on the follow up of patients with primary immunodeficiences PARTIAL IgA DEFICIENT PATIENTS (PID) accompanied in this specific ambulatory. Introduction: Primary Immunodeficiencies (PID) are inherited Authors: Oliveira, AKB; Rizzo, LV; Kokron, CM; Kalil, J; Rivas,JJ; disorders of humoral immunity (B cell function) and cell-mediated Barros, MT immunity (T cell function). This malfunction of the immune system predispose affected individuals to increased rate and severity of infections, Institution: Division of Clinical Immunology and Allergy and Labora‑ immune deregulation with auto immune diseases and malignancies. We tory of Clinical Immunology and Allergy (LIM-60), Institute of Inves‑ describe a case series of patients with PID at the Hospital das Clinicas – tigation in Immunology iii, University of São Paulo Medical School, Federal University of Minas Gerais (HC-UFMG), Brazil. São Paulo, Brazil. Methods: The patients with PID usually are sent to the specific ambulatory by other physicians that suspect an immunodeficiency. When Introduction and Objectives: IgA Deficiency (IgAD) is the most admitted at HC-UFMG, was applied a questionnaire and were classified common primary immunodeficiency. It is defined as serum IgA levels according to the International Consensus Criteria. lower than 7 mg/dL. The etiology is still unknown. A subgroup of patients, with serum IgA more than 7 mg/dL but less than 30 mg/dL are defined as Immunodeficiency Patients Male Female partial IgA deficiency (pIgAD). IgA deficient patients are characterized by increased incidence of infections, mainly in respiratory and intestinal CVID 46 19 27 tracts, as well as presence of atopy and autoimmunity. Yet, most of the XLA 22 22 - patients are asymptomatic. On the other hand, the meaning of pIgAD is not established. The objective of this study is to report the clinical SIGAD 32 14 18 manifestations observed in our cohort of 40 pIgAD patients followed IGGSD 3 2 1 between 1994 and 2008 in the Division of Clinical Immunology and CGD 7 7 0 Allergy of University of São Paulo Medical School. Methods and Results: Forty patients (60% females) were diagnosed SCID 8 3 5 as having partial IgA deficiency. Age ranged between 4 and 62 years CMCC 3 3 - at the time of diagnosis and between 13 and 66 years at the end of the HA 18 4 14 study (only one patient was under 18 years). During the follow up serum IgA levels reached normal values in 5 patients. Atopic diseases were AT 3 1 2 detected in 21 patients (52.5%) and recurrent infections only in 7 of SAD 3 1 2 them (17.5%). Autoimmune manifestations were observed in 19 pIgAD DGS 1 - 1 patients (47.5%) and the diseases detected were: thyroiditis (8), systemic ALPS 1 1 lupus erythematosus (5), autoimmune hemolytic anemia (2), idiopathic thrombocytopenic purpura (1), celiac disease (1), Behcet’s disease (1), IPEX 1 1 Sjögren’s disease (1), rheumatoid arthritis (1), and antinuclear antibodies without disease (2). The most prevalent diseases were thyroiditis CVID: Common variable immunodeficiency; XLA: X-linked (20.0%) and systemic lupus erythematosus (12.5%). In 3 pIgAD patients agamaglobulinemia; SIGAD: selective IgA deficiency; IGGSD: IgG presented more than one autoimmune disease. In partial IgAD patients, subclasses deficiency; CGD: chronic granulomatous diseases; SCID: autoimmunity diseases were detected 2.7 times more times than recurrent severe combinated immunodeficiency; CMCC: chronic mucocutaneous infections (17.5%). candidiasis; AH: Hereditary angioedema; AT: Ataxia-Telangiectasia; Conclusion: In partial IgA deficient patients the prevalence of DGS: Syndrome diGeorge ; ALPS: Syndrome of Linfoproliferative , autoimmunity was high and similar to that of atopic diseases. Our data IPEX; SAD:specific antibody deficiency suggest that patients with partial IgA deficiency do have an immune dysregulation being prone to develop autoimmune diseases therefore Results: A total of 147 patients diagnosed with PID are currently in these diseases should be investigated in these patients. follow-up at our service. The following diseases were found: common variable immunodeficiency (31,2%), X-linked agammaglobulinemia (14,9%), selective IgA deficiency (21,7%), IgG subclasses deficiency (2,0%), specific antibody deficiency (2%), chronic granulomatous
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PII 15 – EVALUATION OF A COHORT OF SELECTIVE PII 16 – FOLLOW UP OF HEPATIC ABSCESS IN CHRONIC IgM DEFICIENT PATIENTS FOLLOWED IN A PRIMARY GRANULOMATOUS DISEASE (CGD): CLINICAL IMMUNODEFICIENCY DISEASES CLINIC. EXPERIENCE OF A BRAZILIAN REFERENCE CENTER IN PRIMARY IMMUNODEFICIENCY (PID) Authors: OLIVEIRA, AKB; BARROS, MT; RIZZO, LV; KALIL, J; KOKRON, CM. Authors: Watanabe LA, Pastorino AC, Castro APM, Fomin ABF, Carneiro-Sampaio MMS, Jacob CMA Institution: Division of Clinical Immunology and Allergy, Laboratory of Clinical and Allergy Immunology (LIM-60) and Institute of Investiga‑ Institution: Unit of Allergy and Immunology- Pediatrics Department tion in Immunology iii , University of São Paulo Medical School - São - Faculty of Medicine-Universidade de São Paulo - São Paulo – Brasil Paulo - Brasil. Rational: CGD is a severe PID that leads to infections especially Introduction: Selective IgM immunodeficiency (SIgMID) is a by S aureus and intracellular pathogens and hepatic abscess can be a dysgammaglobulinemia characterized by an isolated low level of serum complication with unique characteristics. In this report it was described IgM, usually <20 mg/dL in infants and children or <2 standard deviations the follow up of CGD patients with hepatic abscesses. or 10% below age adjusted means. Usually, serum IgM levels are <10–20 Methods: From 22 CGD patients (20M) followed in a reference mg/dL. The prevalence of selective IgM deficiency is 0.03% in healthy center for PID, five boys presented hepatic abscess, three of them with individuals and 0.2 to 3% in hospitalized patients. In the literature this two episodes. condition is associated to recurrent infections as well as atopic and Results: All patients developed fever and abdominal pain, four autoimmune diseases. presented hepatomegaly, one loss of weight and other vomiting. Diagnosis Objective: To describe the clinical features of adult IgM deficient was done less than one week after the beginning of symptoms in four patients followed at the Primary Immunodeficiency outpatient clinic of patients and lasted 20 days for diagnosis in one. Ultrasound detected the the Division of Clinical Immunology and Allergy of Hospital das Clínicas, abscess in all patients and abscesses size varied from 2.0 to 9.0 cm. The University of São Paulo Medical School. first episode occurred in average with 6,75 years (median = 9 years) and Methods: We reviewed the medical records of 38 adult IgM deficient second one 11,8 years. Pathogens were not detected through blood culture patients followed at our clinic. SIgMID is diagnosed when IgM serum but were positive in two abscess culture (Enterobacter aerogenes and S levels were <40 mg/dL, excluded other antibody deficiencies (IgG, IgA, aureus). Antibiotic therapy was performed in all, focusing in catalase- IgE). Present clinical symptoms, concurrent conditions, and clinical positive bacteria and four received also anti-fungi drugs. Treatment last course were evaluated. from 20 to 108 days. Four patients had their abscess surgically drained. Results: Mean serum IgM level was 26 mg/dL. The mean age at Two patients developed sepsis and one died from its complications. CGD the time of the diagnosis was 51 years. Serum IgA and IgG levels were had already been diagnosed in three patients and, in two, diagnosis was normal in all patients. There were 18 males and 20 females identified in suspected only after the first episode. our cohort. Recurrent infections were observed in 22 patients (57.9%) Conclusion: Hepatic abscess in CGD patients demands a high index in the following order of frequency: bronchopneumonia, sinusitis, of suspicion but symptoms can be unspecific. It is important to be aware tonsillitis and otitis. Furthermore, chronic axillary hydrosadenitis about specific pathogens and precocious diagnosis and intervention. caused by S. epidermidis, recurrent furunculosis, stomatitis, pulmonary tuberculosis, ganglionar tuberculosis, and genital human papillomavirus infection were seen in distinct patients. Chronic diarrhea was observed PII 17 – LABORATORY AND CLINICAL DESCRIPTION in 4 individuals (one of them diagnosed as irritable bowel syndrome), OF DI GEORGE SYNDROME PATIENTS FOLLOWED AT A bronchiectasis in 4 patients, and atopic diseases in 14 (36.8%) patients. REFERENCE CENTER: PRELIMINARY DATA Malignancies (basal cell carcinoma, bladder cancer, lymphoma, and lung cancer) were detected in 4 (7.9%) patients. The autoimmune diseases Authors: Asanuma MD, Jacob CMA, Carneiro-Sampaio MMS, Kaiser (9 patients – 23.7%) observed were: systemic lupus erythematosus (4 C, Arismendi I, Fomin ABF patients), thyroiditis (2 patients) and vasculitis (2 patients). At the time of the diagnosis, chronic use of systemic corticosteroid was observed in 6 Institution: Unit of Allergy and Immunology - Pediatric Department patients and the use of antiepileptic drugs (carbamazepine and phenytoin) - Faculty of Medicine, Universidade de São Paulo - São Paulo – Brasil in 2 of them. Chronic mercury poisoning was well established in 4 patients (10.5%). Neither patient died of serious infections, malignancies Introduction: DiGeorge’s syndrome (DGS) may be defined by the or complications of autoimmune disease. presence of congenital heart disease, hypocalcemia, facial dysmorphism Conclusion: Corroborating with literature findings, we observed and lymphopenia. Deletion of chromosome 22q11.2 is present in about a heterogeneous group of clinical manifestations related to diminished 35-90% of patients but other chromosomes may be involved. Its incidence serum IgM levels in our cohort. Decreased levels of IgM have been is approximately 1:3000 live births and immunological changes depend associated with episodes of recurrent infections, thymic hypoplasia, on the degree of thymic involvement. celiac disease, autoimmune disease and malignancies. The role of the Rational: To describe the clinical features and immunological selective IgM deficiency remains uncertain but it certainly needs to be abnormalities found in patients with DGS followed-up at a reference addressed for further understanding of its role center. Methods: We included patients who fulfilled the PAGID/ESID diagnostic criteria. A standardized protocol was applied, including
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clinical and laboratorial data, including humoral and cellular PII 19 – CHRONIC GRANULOMATOUS DISEASE AND immunological evaluation. INFECTIOUS PROFILE Results: Until now, 14 patients were evaluated (M:F = 1.8). The cardiac defects were the most frequent findings, present in 12 patients. Authors: Rezende DGC, Watanabe LA, Pastorino AC, Fomin ABF, Facial dysmorphism was observed in 11 patients. The evaluation of Carneiro-Sampaio MMS, Jacob CMA humoral immunity detected five patients with IgM values below -2DS, 8 non responsive to hepatitis B vaccine and 6 non responsive to measles. Institution:Unit of Allergy and Immunology - Pediatric Department Lymphocyte subpopulations were analysed in six patients: reduced - Faculty of Medicine-Universidade de São Paulo - São Paulo – Brasil CD4+ count (n=2), lymphopenia and low NK cell count (n=2) The lymphoproliferative response to mitogens and antigens was performed in CGD is a severe PID which affects 1/200.000 to 1/250.000 individuals two patients with decreased proliferation in both cases. The quantification in USA, and leads to a high susceptibility to S. aureus and Aspergillus of TREC was performed in 5 patients and the comparison between the sp infections. Main clinical findings are pyodermitis, pneumonias, medians of the quantification of TREC patients and controls showed a lymphadenitis, abscesses and osteomyelitis. Infections can be insidious statistically significant difference. and the early diagnosis is essential to avoid serious complications. Conclusion: The DGS should be investigated in patients with METHODS: Retrospective study with 20 CGD patients followed cardiac conotruncal anomalies, hypocalcemia, associated with facial at the specialized Unit for the last 20 years. The study was based on dysmorphism or even in the absence of these phenotypes. The high patient’s medical records concerning infectious episodes and its agents. known prevalence showed probably a failure to recognize this disease RESULTS: Twenty patients were included (3F:17M). The age of in a significant proportion of patients. CGD diagnosis ranged from 1mo to 16yr1mo (median 1yr11mo); six male patients belonged to the same family. The reasons for immunological evaluation were: recurrent infections (n=11) mainly pneumonias, PII 18 – TRANSIENT HYPOGAMAGLOBULINEMIA OF lymphadenitis and skin abscesses; family history of CGD (n=4); INFANCY: A REVIEW OF CLINICAL FINDINGS AND hepatic abscesses (n=2); adverse reactions to BCG (n=1); persistent EVOLUTION OF PATIENTS pneumonia (n=1) and tuberculous lymphadenitis (n=1) All patients received prophylactic TMP-SMX and itraconazole. Five patients died Authors: Esteves, IC; Jacob CMA, Pastorino AC, Dorna M, Castro by severe infections. APBM, Fomin ABF,Carneiro-Sampaio MMS. Pneumonia was the most common infection (17/20), followed by lymphadenitis (12/20) and skin abscesses (12/20). The number Institution: Unit of Allergy and Immunology - Pediatric Department of pneumonia’s episodes ranged from 1 to 15 per patient (median: 4 - Faculty of Medicine-Universidade de São Paulo - São Paulo – Brasil episodes/patient), while the number of lymphadenitis episodes and skin abscesses ranged from 1 to 6 per patient (median: 3 episodes/patient). Abstract: Transient hypogammaglobulinemia of infancy (HTI) is a Other infections frequently described were: otitis (11/20), pyodermitis disorder characterized by a maturation delay in immunoglobulin synthesis (11/20) and urinary tract infection (7/20). Sepsis occurred in 8 patients that is usually believed to recover between two to four years of age. and hepatic abscess in other five. Abscesses were also detected in The authors aimed to analyze the clinical and immunologic evaluation lungs (2/20), spleen (2/20), oral mucosa (2/20) and kidney (1/20). Two of patients with HTI. patients had frequent stomatitis (at least 1 episode/year). One patient had Twenty eight children followed at a tertiary teaching reference pericardial empyema. The main causes of hospitalization were pneumonia center presenting with an IgG level at least 2 SDs bellow the age- and deep abscesses. Fever was the main cause for visiting the emergency related mean and absence of clinical or laboratory features of other room and in the majority of patients the site of infection was found after immunodeficiencies, where retrospectively reviewed. complementary exams (image and laboratory investigations). Of the 28 included children, the mean age at referral was 33,2 months Of note, although culture was obtained from almost all infectious and 60% were boys. Patients presented most frequently with recurrent episodes, only 46 cultures of many sources were positive: bronchoalveolar upper (57%) or lower (39%) respiratory infections and 4 patients had a lavage (11/46), skin abscess secretion (8/46), blood (8/46), urine (6/46), significant family history of immunodeficiency. Two patients developed lymphnode (6/46), liver abscess (3/46), ear secretion (3/46) and pericardic bronchiectasis. empyema (1/46). The most frequent isolated microorganism was S. aureus Nineteen patients recovered of hypogammaglobulinemia (mean (11/46), followed by Serratia marcescens (6/46), Aspergillus sp (6/46) and age: 63,4months), four lost follow-up and five developed other coagulase negative Staphylococcus (4/46). Proteus mirabilis was isolated in dysgammaglobulinemias: 1 case of selective IgA deficiency and 4 cases three urine cultures. Other isolated microorganisms were Candida albicans presented low IgA and/or IgM levels. Five patients received prophylactic (2/46), Enterobacter aerogenes (2/46), Pseudomonas aeruginosa (2/46), antibiotics and four, intravenous immunoglobulin. S. epidermidis (2/46) and Streptococcus mitis (2/46). E. coli, Klebsiella THI is not always a benign clinical entity. It probably includes a pneumoniae, M. morganii, S. pneumoniae, S. viridans, Salmonella spp, heterogeneous group of patients. Clinicians need to be aware of the Streptococcus viridans group, Streptococcus sanguinis were isolated in one need of careful follow-up of these patients to provide earlier detection culture each. M. bovis was isolated from BCG lymphadenitis in one patient. of imunodeficiencies and establishment of treatment to avoid infectious CONCLUSION: It is important to emphasize that infections like complications. hepatic abscess, empyema, mycobacteriosis and aspergillosis must be a warning sign for the CGD investigation, especially in male patients with familial history of similar infectious conditions. Besides, infectious symptoms especially fever in CGD patients should be promptly
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investigated and treated, since infections remain the main cause of Institution: 1 Laboratory of Investigation in Dermatology and Immu‑ morbi-mortality in this disease. nodeficiencies, LIM-56, School of Medicine, University of São Paulo. 2 Department of Pediatrics, School of Medicine, University of São Paulo
PII 20 – NEW TREATMENT RECOMMENDATION FOR Selective IgA deficiency (sIgAD) is the most common primary THE HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS antibody deficiency, highy associated to autoimmune diseases. Natural SYNDROME autoantibodies (NAb) are important components to the immunological homeostasis, characteristically multireactive and consisting the Authors: Mariana Jobim1, Beatriz Chamun Gil1, Larissa Siqueira Penna1, majority of circulating immunoglobulins. To evaluate the profile of Patrícia Hartstein Salim1, Liane Daut3, Otávio Pietcher4, Eliana Trotta5, natural autoantibody reactivity to self and non- self antigens related Luiz Shozo Ozaki6, Luiz Fernando Jobim1,2 to phosphorylcholine (PC) molecules in sIgAD, associated or not to autoimmune diseases. Patients with sIgAD were enrolled (n=28, mean Institution: 1Serviço de Imunologia, Hospital de Clínicas de Porto of age: 21.5 years-old, 21 female, 07 male), with clinical manifestation Alegre (HCPA). 2Dep. de Med. Interna (FAMED-UFRGS) 3Serviço de of autoimmune diseases (13) or not (15); normal healthy samples were Hematologia e de 4Otorrinolaringologia, HCPA 5UTI Pediátrica, HCPA. employed as control (n=36, mean of age: 23.4 years-old, 26 female, 10 6Virginia Commonwealth University, Richmond, VA, USA male). The results revealed a similar profile of IgM antibody reactivity against the panel of autoantigens evaluated [PC, phosphatidylserine Introduction: The Hemophagocytic Lymphohistiocytosis Syndrome (PS), cardiolipin, C-reative protein, lipopolyssacharide] in both patients (HLH) is a group of diseases with macrophage proliferation induced by and controls. IgG reactivity was more pronounced in patients, in both a “storm of lymphokines” leading to the destruction of several cellular autoimmune and non-autoimmune subgroup than controls except for lineages. The primary form occurs early in children less than one year anti-cardiolipin IgG antibodies. Fourteen percent of patient serum was old and is usually fatal. Bone marrow transplantation is the treatment polyreactive able to binding up to 5 autoantigens while six percent of of choice for most patients. The secondary form starts later in life and control samples recognized two autoantigens. Evidence of anti-IgA IgG is associated with infections and malignancies. Treatment is performed Ab (35 %) in sIgAD patients were detected in both, autoimmune and with ciclosporin A and etoposide and the survival rate is 85%. Five non-autoimmune subgroups. The results showed an equilibrate IgM NAb symptoms for the diagnosis of HLH must be present: fever, splenomegaly, pattern in the sIgAD associated with high IgG autoantibodies reactivity to cytopenia, hypertriglyceridemia and hemophagocytosis in bone marrow, PC, present on the bacterial wall and as an abundant self-antigens. This spleen and lymph nodes. finding suggested that deficiency of dominant humoral mucosal immunity Case Report: Five years old male patient showed at beginning component, such as IgA Nab, evoke a disturbance of peripheral tolerance signs of tonsillitis, high fever, abdominal pain and diarrhea. Later he mechanism, favoring the development of autoimmune phenomena. presented enterorrhagia, jaundice and progressive leucopenia. Invasive Financial support: FAPESP, LIM-HC/FMUSP. Aspergillosis was detected in biopsies of paranasal sinus and liver. Changes in hepatic functions tests and triglycerides were observed as well as hypofibrinogenemia and positive EBV serology. PII 22 – PEDIATRIC AND ADULT PRIMARY Treatment: The following antimicrobial scheme was administered: IMMUNODEFICIENCY DISEASES IN A SINGLE TERTIARY Meropenem, Vancomycin and Amphotericin with added Ciprofloxacin, UNIVERSITY HOSPITAL IN SÃO PAULO, BRAZIL. Co-trimoxazole, Gancyclovir and Caspofungin. After debridement of affected sinus Caspofungin administration was suspended. Amphotericin Authors: 1Dewton Moraes-Vasconcelos, 2Myrthes Toledo-Barros, was maintained and later substituted by Itraconazole. With uncontrolled 3Cristina M A Jacob, 2Cristina Kokron, 1Anete Grumach, 3Antonio C symptoms and impending death we opted for two blood volumes Pastorino, 3Angela Fomin, 3Mayra Dorna, 1Maurício D Ferreira, 2Luiz V plasmapheresis and infusion of immunoglobulin in high dose. Rizzo, 1Alberto Duarte, 2Jorge Kalil, 3Magda Carneiro-Sampaio (magda. Result: With the final treatment the patient reacted slowly but steadily [email protected]) and is now fully recovered. Conclusion: The final treatment was performed as we reasoned that the Institution: 1Department of Dermatology, 2Division of Immunology, phagocytosis stimulating lymphokines should be cleared from circulation Department of Internal Medicine, 3Immunology and Allergy Unit, De‑ together with enhanced immunomodulation. There are no reasons for partment of Pediatrics, Hospital das Clínicas da Faculdade de Medicina immunosuppression in a patient already highly immunodeppressed. We da Universidade de São Paulo, Brazil thus suggest such a treatment for patients with HLS. Primary Immunodeficiency Diseases (PIDs) have been classically considered as pediatric diseases. Nevertheless, nowadays an increase in PII 21 – PROFILE OF NATURAL AUTOANTIBODY the diagnosis among adults has been observed. With the advances in PID REACTIVITY TO PHOSPHORYLCHOLINE IN THE diagnosis and management, the survival has significantly increased, and IgA DEFICIENCY WITH AUTOIMMUNE OR NON- currently we have many patients who reached adulthood in reasonable AUTOIMMUNE MANIFESTATIONS health conditions. Besides these classical diseases there are entities recognized only in adulthood. Authors: Ana Elisa Fusaro1, Kristine Fahl2, Cristina Miuki Abe Jacob2, Here we describe the 30-year experience of a tertiary teaching hospital Magda Carneiro-Sampaio2, Alberto José da Silva Duarte1, Maria Notomi at São Paulo, with both adult and pediatric PID patients. HC-FMUSP is the Sato1 largest public hospital in the country and represents a national reference
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center for rare and complex diseases. Our patients have an interesting Objective: The aim of this report is to select the main signs dealing to mixed ethnic background, that is typical of Brazilian population, and most PID diagnosis based on a prospective evaluation of hospitalized patients. of them live under low socio-economic conditions. In addition to classical Methodology: A prospective evaluation of inpatients was performed immune competence evaluation, in the last 8 years we developed laboratory for a 8 year period. All the patients with clinical symptomatology not methods for phenotypic diagnosis of PID, and in the last 2 years, techniques well elucidated were referred to the immunologist. A comprehensive for genetic diagnosis (for 25 genes). immunological evaluation was available and the laboratorial tests were PATIENT SERIES: In our Hospital we have followed up performed according to the clinical manifestations. 929 patients with well characterized PIDs. The most common Results: 462 patients (1.4 M: 1 F) were evaluated and the main diagnoses are: Symptomatic IgA deficiency-272 patients; CVID-171 symptoms were: prolonged fever (3.5%), hepatosplenomegaly (2%), ; Hereditary angioedema-67; Chronic mucocutaneous candidiasis-42; uncommon infections (67%), recurrent infections (4.3%), unexpected Transient hypogammaglobulinemia-42; IgM deficiency-41; complications (18.2%), suggestive auto-immunity (3.7%), complications Chronic granulomatous disease-36; DiGeorge syndrome (sy)-30; due to vaccines (0.7%), allergy (2.2%). PIDs were identified in 18 Agammaglobulinemia-25; Ataxia-telangiectasia-21; Idiopathic CD4 patients. No PID was diagnosed among patients complaining of fever lymphocytopenia-19; Complement deficiencies (excluding HAE)-19; and hepatosplenomegaly and the final diagnosis were tumor and auto- IgG subclass deficiencies-13; Chédiak-Higashi sy-13; X-SCID-13; Cyclic immune diseases. neutropenia-12; Defects of the IL-12/23-IFN- axis-11; Hyper IgM-10; Conclusions: The following criteria could be used as warning Phagocyte G6PD deficiency-10; Specific Polysaccharide Antibody signs for hospitalized patients: recurrent infections, meningococcal Deficiency (SPAD)-9; Hyper IgE-7; Good sy-7; APECED-5; IPEX-5; meningitis above 5 years old, complicated infections caused by common Xeroderma pigmentosum-4; Epidermodysplasia verruciformis-4; Bloom pathogens, uncommon pathogens in HIV negative patients and vaccinal syndrome-4; Wiskott-Aldrich-3; CD127 deficiency-3; CD3 epsilon-3; complications. Netherton sy-2; Griscelli sy-2; NEMO-2; LAD1-2; ALPS-1; RAG1-1; ZAP70-1; PNP-1 patient. Of these patients, 56 died mainly due to septic episodes and neoplasias (lymphomas / leukemias and adenocarcinoma PII 24 – MUTATIONS IN THE C1 ESTERASE INIHIBITOR of colon). The distribution between genders is: males: 309; females: GENE IN A BRAZILIAN FAMILY LEADING TO TYPE I AND 352. There are 516 infants and children; and 413 adults (above 20 II OF HEREDITARY ANGIOEDEMA years old); As a whole there are more than 1500 patients in follow-up, with 360 patients with probable PID not well characterized until now. Authors: Correia AP1, Costa EP1, Rangel-Santos, AC1, Komninakis, SV2, Among the patients with severe immunoglobulin deficits, 171 receive Constantino RN1, Duarte AJS1, Grumach AS1 IVIg replacement therapy. DISCUSSION AND CONCLUSIONS: Our series shows an Institution: 1Laboratory of Medical Investigation in Dermatology and extreme diversity of cases, with several rare diagnoses. The possibility Immunodeficiencies and Outpatient Group of Dermatologic Manifesta‑ of an interchange between pediatric and adult clinic units leads to a tions of Primary Immunodeficiencies, Dept of Dermatology, University of joint for working with PID patients since the childhood until adulthood, São Paulo (USP). 2Laboratory of Molecular Biology – Federal University evaluating the course as well as the natural history of some diseases. of São Paulo (UNIFESP). The interface with the dermatologic immunology unit provides the diagnoses of patients presenting mainly dermatological manifestations. Hereditary Angioedema (HAE) is a rare disease of autosomal PIDs as a whole comprise an important health problem considering that dominant inheritance, caused by deficiency of the C1 inhibitor (C1INH), their frequency is comparable to hematological cancer or cystic fibrosis. a serinoprotease responsible by complement and contact system control. The main clinical manifestations are related to edema of subcutaneous tissue, gastrointestinal and respiratory tract and it is potentially fatal due PII 23 – WARNING SIGNS FOR PRIMARY to laringeal edema causing asphyxia. More than 200 mutations in C1INH IMMUNODEFICIENCIES INVESTIGATION IN gene (SERPING1) have been described in HAE patients affecting the HOSPITALIZED PATIENTS protein structure and protease recognition. There are two phenotypic variants: HAE type I, with reduced plasma antigen levels and HAE type Authors: BARROS NC, MORAES-VASCONCELOS D, GRUMACH II with normal antigen levels and reduced functional C1 inhibitor activity. AS, FERRÃO MS, DELLA NEGRA M, CAMPEAS A, KHOURY Z, There are no previous studies assessing the gene defects in Brazilian DUARTE AJS patients, correlating with clinical and laboratorial findings. We evaluated 15 members (9M:6F) of the same family with clinical symptoms Institution: Outpatient group of Cutaneous Manifestations of Primary suggestive of HAE and 15 normal controls by a genetic screening strategy Immunodeficiencies and Laboratory of Medical Investigation in Der‑ of the C1 inhibitor activity. This family was analysed by haemolytic assay matology and Immunodeficiencies (LIM56), Dept of Dermatology, for classical pathway (CH50), C4 and C1INH levels (nephelometry) and University of Sao Paulo Medical School, Institute of Infectology Emilio functional C1INH (colorimetric assay). The mutations were evaluated Ribas, Sao Paulo, Brazil for the 8 exons applying polymerase chain reaction (PCR) and genomic DNA sequencing. Normal CH50 was verified in 15/15, decreased levels Background: It has been published a higher prevalence of PID in of antigenic activity of C1-INH and C4 (13/15) and functional C1INH hospitalized patients. Nevertheless, most of the recommendations for the was reduced in all the members. Among the 8 exons of C1-INH gene, identification of PID are based on retrospective reports or in outpatients mutations were detected in intronic and exonic regions and the exons 4, 7 groups. and 8 were mutated in this family. No mutations were found in exons 3, 5
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and 6 and the same pattern was observed in all the generations evaluated. improvement, replaced by interferon alpha. After 6 months of treatment Overall two novel mutations were detected possibly responsible for mild improvement was noted, and acitretin was introduced, showing the disease: missense (type II) and splice site defect (type I). A better striking improvement of the lesions. The immunological parameters were comprehension of the gene mutations and their correlation with clinical inalterated. Patient 2, male, 25 years old, presented respiratory infections manifestations will provide data to understand of specific functional since 4 years of age, followed by disseminated warts and chronic sinusitis. implication of the structure of the protein and the disease as well. When he was 18 years old he was directed to our clinic for follow-up. At that time he already had CD4 lymphopenia and decreased lymphocyte proliferation. Afterwards the warts became bigger throughout all skin PII 25 – SECONDARY IMMUNODEFICIENCY DUE TO surfaces, when we decided to treat with IFN-alpha, leading to a significant CONGENITAL HEART DISEASE CORRECTION improvement of the lesions. Nevertheless he presented dryness of the eyes and the therapy was withdrawn. The warts had a partial relapse Authors: Elias1, P.F.; Jatene1,I.B. ; Souza1,L.C.B.; Jatene,M.B1.; Carneiro- and he presented an EBV+ B cell non-Hodgkin lymphoma treated with Sampaio,M.M2.; Duarte, A.J.S.1,2, . chemotherapy with an adequate response. Although the patient presented an important CD4 lymphopenia, the absence of more severe infections Institution: 1Hospital do Coração, SP; 2Faculdade de Medicina da USP besides the warts suggests that the normal activity of NK cells might (LIM 56 e Instituto da Criança), play a role in the protection of the patient.
Heart defects are common congenital malformations (8:1,000 live births). High pressure in inferior vena cava is observed before and/or PII 27 – LEPROSY AND TUBERCULOSIS CO INFECTION IN after corrective surgery in some conditions, results in protein-losing A COHORT OF DERMATOLOGICAL PATIENTS enteropathy (PLE).We report 3 PLE cases with immune alterations as complication of heart defect/corrective surgeries. Case 1: an 11-m girl with Authors: Denise Miyamoto, Neusa Yuriko Sakai Valente, Dewton de left atrial isomerism was submitted at 4 m to an atrium-septoplasty. She Moraes Vasconcelos; Maria Angela Bianconcini Trindade developed PLE and had difficult follow-up, dying at 12 m due to sepsis. Immunological tests: IgG 320 mg/dl, IgM 75, IgA 45, lymphocytopenia, Leprosy and tuberculosis are endemic diseases in Brazil, and 29,317 reduced CD4+ (647 cells/mm3), nl CD8 (1360), CD4/CD8 ratio 0.50, nl B and 43,242 new cases were recorded in 2008, respectively. Both diseases (488) and NK cells(297). Case 2: a 12 year boy with Ebstein anomaly had are caused by aerobic Gram positive acid-fast bacilli and are clinically tricuspid valve replaced at 5 years-old, and developed PLE, ascitis, without manifested in a spectrum, according to the immunity of the host. However, infections. Laboratory tests: IgG 161, IgM 60, IgA 17, lymphocytopenia, there are few reports of co infection of mycobacterioses in our country low CD3+ (652), CD4+(231), CD8+ (331), CD4/CD8 ratio 0.70, B ( 283) and its cause remains unknown. cells. Case 3: a 25 year-old male with tricuspid atresia was submitted at The existence of cross-immunity between leprosy and tuberculosis 2-years to Blalock-Taussig surgery and atrio-pulmonary Bjork-surgery was defended by Chaussinand et al, who suggested that when the acquired one year later, and developed PLE, portal hypertension, arrhyithmias, and immune response against Mycobacterium tuberculosis protect against ascitis at 13-years. Severe varicella-zoster infection was observed. At 25 infection by Mycobacterium leprae. Therefore, pulmonary tuberculosis years he had a surgery to cavopulmonar deviation and died due to cardiac occurs more frequently in individuals with leprosy than leprosy in and renal failure. Blood tests: IgG 885, IgM 64, IgA 90, lymphocytes ( individuals with tuberculosis. 576), low CD3+ (309), low CD4+ (230) and CD8+ (91) cells, CD4/CD8 The co infection in human archaeological samples was demonstrated ratio 2.54. Our observations suggest that a systematic evaluation of immune later by Donoghue et al by detection of DNA of M. leprae and M. competence must be performed in children submitted to heart surgery for tuberculosis, which concluded that a deficient cellular immune response congenital anomalies. Supported by CNPq, LIM-HC-FMUSP is associated with the development of both diseases. Thus, individuals that after infection by M. tuberculosis develops the disease have a poor cellular immune response against the intracellular pathogen. These PII 26 – DISSEMINATED COMMON WARTS IN IDIOPATHIC patients present a predominance of humoral response and are unable to CD4 LYMPHOCYTOPENIA PATIENTS: RESPONSE TO contain the proliferation of mycobacteria. TREATMENT WITH INTERFERON-ALPHA With respect to leprosy, individuals who present a Th2 pattern of immune response are also unable to eliminate the mycobacteria and Authors: Dewton de Moraes Vasconcelos; Noac Chuffi Barros; Elisabete develop the multibacillary form of the disease. Systemic corticosteroid Cordeiro; Maurício Domingues Ferreira, Anete Sevciovic Grumach; therapy used in the treatment of Hansenic reactional states also appears Alberto José da Silva Duarte to contribute to a poor cellular immune response, favoring the infection or reactivation of tuberculosis. This study reported two cases of association Idiopathic CD4 lymphopenia (ICL) is a rare disease characterized by between leprosy and tuberculosis. an absolute CD4+ number < 300 / dl or less than 20% of T lymphocytes in more than one occasion, in the absence of HIV infection or any known cause of lymphopenia. Case 1: Male, 24 years old, without PII 28 – VITAMIN A DEFICIENCY IN COMMON VARIABLE consanguinity, with common warts for 4 years mainly on hands, elbows, IMMUNODEFICIENCY PATIENTS legs and face. The immunological evaluation showed significant CD4 lymphopenia with reduced response to mitogens and antigens, but with Authors: Elisangela Calheiro dos Santos-Valente1, Rosangela da Silva1,2, normal activity of NK cells. Difenciprone 1% therapy was started without Fabíola Isabel Suano de Souza1, Maria Isabel de Moraes-Pinto1, Roseli
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Oselka Saccardo Sarni1, Beatriz Tavares Costa-Carvalho1 beta-carotene in patients with A-T. Methods: The study was approved by the Ethics Committee from Institution: 1Department of Pediatrics – Federal University of Sao UNIFESP and was conducted in the Division of Clinical Immunology Paulo - UNIFESP/EPM 2Federal University of Alfenas - UNIFAL-MG – Federal University of Sao Paulo (UNIFESP). Fourteen patients were enrolled. Plasma levels of retinol and beta-carotene were analyzed Introduction: Common Variable Immunodeficiency (CVI) is and cut-off points for the deficiency were 1,05µmol/L and 0,3µmol/L, characterized by recurrent infections, hypogammaglobulinemia and respectively. Results: The mean age was 13,2 ± 4,8 years and 78,6% impaired antibody responses. Some CVI patients present gastrointestinal (11/14) of the patients were male. The mean BMI was 16,2 ± 3,1 kg/m2 (GI) symptoms, including weight loss. Vitamin A deficiency (VAD) and 7 out of 14 patients (50%) were mildly or severely mal-nourished. also leads to GI manifestations and it is a public health problem in Body composition analysis revealed 27,9 ± 13,6% of mean body fat and Brazil. Patients with hypogammaglobulinemia present higher rates of 46,1% (6/13) of the patients showed fat percentage above the 95th centile. VAD compared with healthy population. Therefore, CVI patients could The median plasma levels of retinol and beta-carotene were 1.45 µmol/L evidence high frequency of VAD, worsening their nutritional status. (range 1.0- 4,2) and 0,25µmol/L (range 0,1- 1,7), respectively; 7.1% Objective: To evaluate nutritional status and plasma levels of retinol (1/14) and 50% (7/14) of the patients presented Vitamin A deficiency and beta-carotene in CVI patients and in healthy control subjects. and beta-carotene deficiency, respectively. The majority (71.4% (5/7) Methods: CVI outpatients from the Division of Clinical Immunology of patients with beta-carotene deficiency showed a high percentage of from UNIFESP and healthy control subjects were evaluated using weight, body fat. height and body mass index. Plasma levels of retinol and beta-carotene Conclusion: A high percentage of the A-T patients were mal- were analyzed and cut-off points for the deficiency were 1,05 µmol/L e 0,3 nourished according to the BMI. However, they had adequate or µmol/L, respectively. The subjects were divided in 4 groups as follows: elevated body fat. This fact clearly demonstrates a loss of lean mass. G1- malnourished patients, G2- eutrophic patients, G3- overweight The median plasma level of beta-carotene seems to be related to the patients and G4- healthy control subjects. body fat percentage. Results: Seventeen CVI outpatients and 8 healthy subjects were enrolled in this study. The mean age of the patients and the health controls were 28.41±11.22 and 25.54±7.58 years, respectively, with no significant PII 30 – AUTOIMMUNE MANIFESTATIONS IN PATIENTS statistical difference. 47% of the patients and 62.5% of the controls were WITH IDIOPATHIC CD4 LYMPHOCYTOPENIA male. 41.2% of the patients were considered malnourished, 17.7% were overweight and the controls were eutrophic. The median retinol plasma Authors: Moraes-Vasconcelos, D; Grumach, A.S.; Almeida, A.; Fer‑ level was 1.7 µmol/L (range 0.9-2.3) in G1, 2.0 µmol/L (range 1.7-3.6) reira, M.D.; Collanieri, A.C.; Orii, N.M.; Ogusuku, S.; Oliveira-Filho, in G2, 2.4 µmol/L (1.8-2.6) in G3 and 2.25 µmol/L (1.0-4.0) in G4. The J.B.; Duarte, A.J.S. median beta-carotene plasma levels were 0.3 µmol/L (range 0.1-0.9), 0.3 µmol/L (0.1-0.4), 0.3 µmol/L (0.1-0.7) and 0.45 µmol/L (0.3-2.0) Institution: Laboratory of Medical Investigation in Dermatology and for G1 to G4, respectively. There was significant statistical difference Immunodeficiencies (LIM/56) and Dermatological Manifestations of in the median retinol plasma level between G1 vs G2+G3 (p= 0.019), in Primary Immunodeficiencies Outpatient Unit (ADEE-3003) – Depart‑ median beta-carotene plasma level between G2+G3 vs G4 (p= 0.027) ment of Dermatology - University of São Paulo Medical School and between G1+G2+G3 vs G4, p=0.016. Conclusion: High percentage of the patients was malnourished Idiopathic CD4 lymphocytopenia (ICL) is a rare disease characterized while all controls were eutrophic. The median retinol plasma level seems by an unexplained T cell deficit, leading to infections by intracellular to be related to the nutritional status of the subject. On the other hand, pathogens. ICL is defined by an absolute CD4+ number < 300 / dL beta-carotene plasma level seems to be related more to the presence of or less than 20% of T lymphocytes in more than one occasion, in the the disease. absence of HIV infection or any known cause of lymphocytopenia. Infections by protozoa, fungi or intracellular bacteria are the most frequent clinical features among those individuals. Neoplasias are also PII 29 – PLASMA LEVELS OF RETINOL AND BETA- frequent, particularly of the connective or lymphohematopoietic tissues; CAROTENE IN ATAXIA-TELANGIECTASIA PATIENTS one case each of neurodegenerative disorder and autoimmune disease are described. The basic immune defect of this syndrome remains unknown. Authors: Rosangela da Silva, Elisângela Calheiro dos Santos Valente, This syndrome can be associated with substantial mortality. It is important Flavia Burim Scomparini, Roseli Oselka Saccardo Sarni, Beatriz Tavares to stress that current treatment of ICL only deals to the prevention or Costa Carvalho. treatment of infections. Patient 1, male, 22 years of age had presented upper and lower Institution: Department of Pediatrics – Federal University of Sao Paulo respiratory infections since 2 years of age, which improved after - UNIFESP/EPM pneumococcal vaccination by 10 years old. At that time he already had low CD4+ counts (<300 cells/mL). At 20 years old, he developed Introduction: Ataxia-telangiectasia (A-T) is an autosomal recessive an autoimmune hemolytic anemia (AIHA) with positive polyreactive disease caused by a mutation in ATM gene on the chromosome 11q22-33. Coombs test, treated with IVIg. At that time, he was receiving co- As a result of this mutation, the incidence of malnourishment can be up trimoxazole as primary prophylaxis for Pneumocystis jiroveci and the to 70% in these patients. Vitamin A deficiency (VAD) is a public health drug was interrupted. AIHA relapsed two more times after 6 months, problem in Brazil. Objectives: To evaluate plasma levels of retinol and one episode possibly associated to a Mycoplasma pneumoniae infection
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(IgM and IgG serology positive). A few months later a lung nodule was protein of the family to TNF-R, expressed in lymphocyte B surface. BAFF detected and the biopsy showed a high-grade extra-nodal Epstein-Barr is specific to BAFF-R, however other molecule, TACI, also binds to the virus positive B cell lymphoma. Despite adequate chemotherapy, brain same receptor. The role of BAFF-R changes according to the ligand. and spinal cord metastasis developed, leading to death. When BAFF binds to BAFF-R, B lymphocytes trigger the survival signal, Patient 2, female, 16 years of age, presented upper and lower denominated positive regulation. However, TACI has an antagonic role, respiratory infections in the first years of life, spontaneously improving because it’s binding to BAFF-R trigger the negative regulation of the cell. and persisting asymptomatic until 12 years old, when she presented BAFF and BAFF-R deficiencies result in development blockage of the an idiopathic thrombocytopenic purpura (ITP). One year later, she stage of transitional B cell, reducing follicular B cell. Mutations in BAFF- presented fever, signs of meningoencephalitis, nostril obstruction and receptor result in a CVID phenotype with a distinct phenotype of B cells: a fistula in the hard palate, associated to osteoarticular pain in several patients with BAFF-R deficiency have reduced total number of B cells but locations and followed by a pathological fracture of the 4th digit of the an expansion of transitional B cells, since BAFF signal is a survival signal left hand. Biopsies of the nasal mucosa and bone showed Histoplasma specific to B cells after transitional stage. capsulatum. At that time she presented very low CD4+ T cell counts and CASE REPORTS: In this abstract, we report three CVID a severe immunological dysfunction. Relapses of fungal disease were patients of ADEE-3003, with reduction in expression of BAFF-R. accompanied by decreased platelet counts. Immunophenotypic evaluation by flow cytometry in whole blood Patient 3, male, 46 years old, presented neurocryptococcosis when 41 demonstrated a decreased number of cells expressing the receptor, when years of age, being treated with amphotericin B followed by fluconazole compared with healthy individuals. The same result can be observed (400 mg per day) and co-trimoxazole (Pneumocystis jiroveci primary by the evaluation of median fluorescence intensity (MFI). All patients prophylaxis). He had a previous diagnosis of neurolues (?) due to positive expressed normal cell counts and MFI to T and B lymphocytes markers VDRL and TPHA, not responsive to classical treatment. Approximately (CD19, CD20, CD21, CD40 and CD3). 1 year ago he started to develop Evans’ syndrome (autoimmune Because of the variable etiology of CVID, the understanding of several hemolytic anemia + thrombocytopenic purpura) with high levels of anti- mechanisms that would lead to development of this immunodeficiency is phospholypid antibodies, needing corticosteroid therapy. obscure. Therefore, the data presented here, showing correlations between The immunological evaluation showed normal immunoglobulin clinical aspects of CVID patients and its immunophenotypic aspects, must levels; negative HIV serology; positive Coombs (polyreactive) in patient be taken into account in order to better understanding CVID. 1, IgG anti cardiolypin during idiopathic trombocytopenia in patient 2 and antiphospholypid antibodies in patient 3; no additional auto antibodies were found in all patients. All ICL patients presenting hematological PII 32 – “ADVERSE REACTIONS AFTER BCG autoimmune manifestations presented severe immunodeficiency. VACCINATION IN PATIENTS WITH SEVERE COMBINED IMMUNODEFICIENCY (SCID): A RETROSPECTIVE STUDY OF 20 PATIENTS IN BRAZIL.” PII 31 – BAFF RECEPTOR EXPRESSION DEFICIENCY IN B LYMPHOCYTES OF COMMON VARIABLE Authors: JT Lessa-Mazzucchelli 1, F Tavares 2, A Seber 3, MI Moraes- IMMUNODEFICIENCY (CVID) PATIENTS Pinto5, CS Bonfim 4, BT Costa-Carvalho1.
Authors: Collanieri, A.C.; Soares, M.C.P.; Duarte, A.J.S.; Moraes- Institution: 1Division of Allergy, Clinical Immunology and Rheumatol‑ Vasconcelos, D ogy, Department of Pediatrics, Federal University of Sao Paulo, Brazil; 2Hospital de Base do Distrito Federal, Brasilia, Brazil; 3Institute of Pedi‑ Institution: Laboratory of Medical Investigation in Dermatology and atric Oncology, Federal University of Sao Paulo, Brazil; 4Bone Marrow Immunodeficiencies (LIM/56) and Dermatological Manifestations of Transplantation Service, Hospital de Clinicas, Federal University of Primary Immunodeficiencies Outpatient Unit (ADEE-3003) – Depart‑ Parana, Curitiba, Brazil; 5Division of Infectious Diseases, Department ment of Dermatology - University of São Paulo Medical School of Pediatrics, Federal University of Sao Paulo, Brazil
INTRODUCTION: Common variable immunodeficiency (CVID) Introduction: SCID patients usually present early in life and their is a primary immunodeficiency, characterized by decrease of two clinical picture of failure to thrive, rash, diarrhea, and severe infections immunoglobulin isotypes below two “standard deviations”, in relation that frequently require medical care tends to be very dramatic. In spite to age; absence of antibody response to vaccines and exclusion of the of that, because of amongst other things its rare incidence within the diagnosis of other primary immunodeficiencies. CVID usually appears general population along with an enormous lack of awareness concerning between the ages of 6 to 10 and 26 to 40 years old, respectively. Depending SCID among medical care providers, most of these patients receive the of the genetic background, the prevalence of CVID can vary from 1:25 000 live BCG vaccine, which contains the Moreau/Brazil/Rio de Janeiro to 1:66 000. Because of the antibody deficits (IgG, IgA and infrequently strain of Mycobacterium bovis, either at birth or at completion of their IgM) these patients develop recurrent infections by encapsulated bacteria 1st month of life, intradermally at the deltoid muscle, in accordance in the respiratory and gastrintestinal tracts, that may lead to pathologic with Brazil’s national BCG vaccination policy, before the diagnosis of alterations in these systems. Recently, several reports of non-infectious SCID has been made. This scenario of unwitting exposure of a severe granulomas were associated to CVID. In the last two years, several groups immunocompromised host to a live mycobacterium creates the conditions reported the influence of mutations in specific genes as TACI, BAFF-R, for adverse reactions that can range from local reaction to a situation of ICOS and CD19, associated with the development of CVID. B-cell disseminated mycobacterial disease combined with a treatment challenge. activation factor of the TNF family (BAFF-R) is a type III transmembrane Objectives: Evaluate a number of referred SCID patients who had
58 II Simpósio Internacional de Imunodeficiências Primárias - SIDEP. São Paulo, 30 de setembro a 3 de outubro de 2009. Rev. Inst. Med. trop. S. Paulo, 51(supl. 15), 2009.
received BCG vaccine and presented an adverse reaction to BCG. Institution: 1Department of Pediatrics UNIFESP-EPM- São Paulo/ Methods: We surveyed some of the major referral centers for primary Brazil, immunodeficiencies and bone marrow transplantation in Brazil regarding their experience with patients diagnosed with SCID who had had adverse Common Variable Immunodeficiency (CVID) is the most frequent reactions to BCG. symptomatic primary immunodeficiency (PID) characterized by Results: In the past 10 years, 20 patients were diagnosed with SCID hypogammaglobulinemia and specific antibody productiondeficiecy. in these centers. 15 of them had received the BCG vaccine and 9 had Patients present a higher risk of autoimmunity, splenomegaly, adverse reactions (one a local reaction, all other eight had systemic granulomatous disease and cancer. Classification of this disease according dissemination). Out of these cases, 4 cases of death occurred due to the to B cell subsets has been proposed. We analyzed 31 patients, 15 males, adverse reactions to BCG. from 8 to 53 years old who were being followed up at the UNIFESP- EPM. Mean age of diagnosis was 19.6 y (6-47 y old) and the mean of Conclusion: We have observed a very high frequency of adverse delay in diagnosis was 6.6 years (1-23.7 years). Absolute numbers and reactions to BCG in our SCID patients. percentages of B cells (CD19+) were normal but percentage of memory B cells (CD19+CD27+) were reduced with a higher percentage of CD21low compared to controls (p=0,003). The expression of the CD86 PII 33 – HEREDITARY ANGIODEMA: CLINICAL (B7.2) molecule and the CD80 (B7.1) molecule were higher in memory CHARACTERISTICS OF 58 PATIENTS IN FOLLOW-UP AT A than in naïve (CD19+CD27-) B cells. We observed a lower expression SINGLE CENTER of CD5 memory B cells than in controls (p=0,002). Analyzing B cells (CD19+CXCR5+), we observed a subset of CD38high in naive B cells Authors: Fusaro, GV; Cunha, LAO; Minafra, FG; Nunes, JBS; Pinto, JA not present in memory B cells. Apoptosis of naïve (CD19+/CD27-/ Caspase+) and memory B cells (CD19+/CD27+/Caspase+) showed that Institution: Division of Immunology, Department of Pediatrics, School the latter has a higher percentage of apoptosis than the former (13.06% of Medicine, Federal University of Minas Gerais and 48.53%, respectively). These alterations observed in B cells from these patients could be a piece of this puzzle. INTRODUCTION: Hereditary angioedema (HAE) is an autosomal dominant disease characterized by recurrent episodes of potentially life- threatening angioedema. The prevalence of HAE is not known for certain PII 35 – LOWER EXPRESSION OF CO-STIMULATORY but has been estimated to range from 1:10000 to 1:150000 in the general (CD28) IN T CD8 + CELLS FROM PATIENTS WITH population. Because of the significant morbidity and mortality associated COMMON VARIABLE IMMUNODEFICIENCY with HAE, careful treatment of acute attacks as well as strategies to prevent HAE attacks are essential for the management of these patients. Authors: Tatiana C. Lawrence1, Juliana T. Lessa-Mazzucchelli1, Mariste‑ METHODS: This study describes the clinical and demographic la Miyamoto1, Maria Isabel de Moraes-Pinto2, Beatriz T. Costa-Carvalho1. characteristics of patients with HAE in follow-up at the Immunodeficiency Unit, Hospital das Clínicas – Universidade Federal de Minas Gerais. Institution: 1Department of Pediatrics UNIFESP-EPM- São Paulo/ RESULTS: A total of 58 patients with confirmed diagnosis of HAE Brazil. are currently in follow-up, 35 female and 23 male, and age range: 4 to 60 years. These patients are clustered in 8 families. Overall, initial symptoms Common Variable Immunodeficiency (CVID) is the most frequent were noticed within the second decade of life. The diagnosis of HAE symptomatic primary immunodeficiency (PID) characterized by low was established from 1 and ½ year to 48 years after initial symptoms. levels of IgG, IgA or IgM, and deficient specific antibody production Trauma, pressure and emotional stress precipitated attacks in 95% which has a higher risk for autoimmunity, splenomegaly, granulomatous patients. Skin swellings were presented in 86.2% (50/58) patients and disease and cancer than the normal population. Differences in peripheral abdominal pain attacks were related by all patients. Respiratory symptoms levels of T cell, memory /naïve B cells have been reported. Surface were experienced by 31.0% (18/58) patients and 15.5% (9/58) of then markers were analyzed from T cell subsets according to activation and presented laryngeal edema. Low levels of C4 were present in all patients. apoptosis status. We analyzed 31 patients, 15 males, from 8 to 53 years Prophylactic treatment with attenuated androgens was administered old being followed up at the UNIFESP-EPM. Mean age of diagnosis in 98% of patients with satisfactory control of symptoms in all cases. was 19.6 y (6-47 y old) and the mean time in delay of diagnosis was Treatment-associated side effects occurred in 35.1% (20/57) of patients. 6.6 years (1-23.7 years). CD4+ T cells were normal in absolute and % CONCLUSION: HAE tended to occur in family clusters. The numbers compared to normal people. The same results were observed prophylactic treatment with attenuated androgens was effective in for naïve (CD4+/CD45RA+/CCR7+) and central memory TCD4+ controlling clinical manifestations, but was associated with a high rate of cells (CD4+/CD45RA-/CCR7+). There wasn’t any difference between adverse events. There is still a significant delay in the diagnosis of HAE. TCD4+ numbers from CVID patients with and without autoimmune disease. Absolute numbers and percentages of TCD8+ cells from CVID patients were higher than controls, although percentages of naïve (CD8+/ PII 34 – B LYMPHOCYTE SUBSETS IN COMMON VARIABLE CD45RA+/CCR7+) and central memory (CD8+/CD45RA-/CCR7+) IMMUNODEFICIENCY BRAZILIAN PATIENTS cells were normal. Analysing co-stimulatory molecules we observed that patients with CVID had a lower expression of the CD28 molecule Authors: Tatiana C. Lawrence1, Juliana T. Lessa-Mazzucchelli1, Mariste‑ in the TCD8+ cells (p=0,000) associated with higher numbers and la Miyamoto1, Maria Isabel de Moraes-Pinto2, Beatriz T. Costa-Carvalho1. percentages of the CD38 receptor expression (p=0,000) and apoptosis
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(p=0,039) than controls. Impairment in the co-stimulatory molecules of PII 37 – CONFUSING PRIMARY IMMUNODEFICIENCY these patients could be a reason (among many) to explain the impairment (PID) WITH COW’S MILK PROTEIN ALLERGY of the immune system and the lower or absent antibody response after contact with microorganisms. Authors: Karina M. Melo1, Victor Nudelman1; Ellen Dantas1; Tatiana Lawrence1, Márcia C Malozzi,1. Beatriz T. Costa-Carvalho1
PII 36 – A FOLLOW-UP OF 25 PATIENTS WITH Institution: 1- Department of Pediatrics – Universidade Federal de São HYPOGAMMAGLOBULINEMIA BEING TREATED WITH Paulo UNIFESP/EPM -Brazil IVIg Introduction: The presence of eczema and gastrointestinal Authors: Nobre, FA, Gonzalez IG, Melo, K, Rullo, VE, Lawrence, TC, manifestations is frequent in some Primary Immunodeficiency diseases Dantas, E, Nudelman, V, Costa-Carvalho, BT. (PID). The diagnosis of cow’s milk protein allergy (CMPA) is based on a detailed clinical history, positive allergy tests and, if required, milk Institution: Universidade Federal de São Paulo – São Paulo – Brazil. challenges. Objective: To describe 5 patients referred to our clinic with a Introduction: Patients with primary X-linked agammaglobulinemia diagnosis of CMPA, and who have PID. (XLA) or Common Variable Immunodeficiency (CVI) are treated with Methods: Retrospective study based on clinical and laboratory data regular infusions of intravenous immunoglobulin (IVIG). This medication from medical records. provides passive antibodies for a great number of antigens avoiding severe Results: Five male patients aged between 3mo and 6y5mo were infections in these patients. referred to our clinic with a diagnosis of CMPA resulting in eczema Objective: To analyze the number of severe/recurrent infections in and/or gastrointestinal symptoms. Two were on a diet of hydrolyzed patients with XLA and CVI being treated with regular infusions of IVIG. formula. They also presented: pneumonia (4 / 5), sepsis (4 / 5), otitis Material and Methods: A descriptive study, based on a retrospective (3 / 5), celulitis (1/5), meningitis (1/5) and urinary tract infection analysis of 25 patients (18 with CVI and 7 with XLA). Patient´s data were (1 / 5). Two patients have a positive family history of PID. Lab obtained from medical records at Immunology Department of UNIFESP. exams showed: hypogammaglobulinemia (4/5), lymphopenia (2/5), Results: A total of 25 patients were studied, 18 with CVI (7 male and thrombocytopenia (1/4) and, three patients had negative specific IgE 11 female, mean age = 21.7 years, from 3 to 53 years) and 7 with XLA (RAST) against whole-milk-antigens and fractions. Among the patients (mean age = 14.4 years, from 6 to 28 years). The mean age of onset of with hypogammaglobulinemia one of them had B lymphocyte less than symptoms was 9.8 and 1.6 years for CVI and XLA respectively. The mean 2% (X linked Agammaglobulinemia), the second boy had IgE serum age at diagnosis was 17.7 years for CVI with a delay of diagnosis of 7.9 level > 3000 IU/ml, and a classic phenotype of Hyper IgE Syndrome; the years and mean age of diagnosis was 5.4 years with a delay of 3.8 years third patient had Hyper IgM syndrome and, the fourth patient had marked for XLA. Pneumonia was the most common initial clinical presentation lymphopenia and eosinophilia (SCID). The only patient with normal IgG (52%), followed by recurrent diarrhea (16%), sinusitis (12%), otitis levels presented low IgM and high IgA levels plus anemia, lymphopenia, media (8%) and others. The average IgG, IgM and IgA levels at diagnosis thrombocytopenia with small platelets and, absence of WASP (Wiskott were 308.8, 27.9, 31.0 mg/dl, respectively. All of the patients have been - Aldrich syndrome). All patients presented other symptoms, including receiving intravenous immunoglobulin since diagnosis. Infusions are severe/recurrent infections unrelated to CMPA and lab exams that showed given at intervals of 4 weeks at doses that vary from 320 to 711 mg/kg. immune system dysfunction. Mean IgG levels are 714.3 mg/dl for CVI and 597.7 mg/dl for XLA. 18 Conclusion: Allergic diseases and immunodeficiency are result of patients (72%) keep IgG levels above 600mg/dL. There was a marked abnormalities in the immune system and, sometimes the symptoms are decrease in the number of infections after treatment: pneumonias were confusing. The knowledge of PID sign’s can avoid this mix up. reduced from 88% to 40% of patients, diarrhea were reduced from 52% to 36% of patients, otitis media were reduced from 44% to 20% of patients and skin infections were reduced from 24% to 12% of patients. Side effects were present in 64% of patients most mild. Conclusion: IVIG treatment provides a remarkable reduction of infection in hypogammaglobulinemia patients.
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AUTHOR INDEX
Abramczuk, B.M. PCR01 D’Souza Li, L. PII04 Albuquerque, R.A. PCR08 Duarte, A.J.S. PCR03, PCR04, PCR05, PCR06, Almeida, A. PII30 PCR07, PCR11, PCR16, PCR17, Almeida,M.C.S. PCR22 PCR18, PCR19, PCR20, PCR21, Alves, C. PII08 PCR22, PCR27, PCR28, PII08, Alvim, C.G. PCR09 PII09, PII10, PII21, PII22, PII23, Amigo-Filho, J.U. PCR07 PII24, PII25, PII26, PII30, PII31 Andrade, L.E.C. PII06 Elias, P.F. PII25 Aragão-Filho, W.C. PII01, PII03 El-Shanti, H. PII07 Arismendi, I. PII17 Errante, P.R. PII02, PII03 Arslanian, C. PII03 Esteves, I.C. PII18 Asanuma, M.D. PII17 Fagundes, F.V.B. PCR15 Ayabe, L.A. PCR21 Fahl, K. PII21 Beitler, B. PCR07 Falcai, A. PII03 Benard, G. PCR18 Ferrão, M.S.C. PII23 Bertola, D.R. PII07 Ferraroni, N. PII08 Bonfim, C.S. PII32 Ferreira, J.F.S. PII03 Brandão, L.A.C. PII08 Fock, R.A. PII05 Bressani V.O. PCR05, PCR06, PCR11, PII09, Fomin, A.B.F. PII16, PII17, PII18, PII19, PII22 PII10 França, V.V. PCR23, PCR24 Câmara, N.O.S. PII02 Francioni, E. PCR15 Campeas, A. PII23 Frazão, J.B. PII03 Carneiro-Sampaio, M.M.S. PCR13, PCR17, PII05, PII06, Fusaro, A.E. PII21 PII07, PII16, PII17, PII18, PII19, Fusaro, G.V. PCR09, PII11, PII13, PII33 PII21, PII22, PII25 Genre, J. PII02 Casanova, J-L. PII01 Gil, B.C. PII20 Castro, A.P.M. PII16, PII18 Giliani, S. PII09 Chuffi-Barros, N. PCR05, PCR19, PII09, PII10, Giorno, E. PCR13 PII23, PII26 Gonzalez, I.G. PCR25, PII36 Collanieri A.C. PCR03, PCR04, PCR05, PCR06, Grumach, A.S. PCR05, PCR06, PCR07, PCR16, PCR07, PII30, PII31 PCR19, PCR20, PCR27, PII08, Condino-Neto, A. PCR19, PII01, PII03 PII09, PII10, PII22, PII23, PII24, Constantino-Silva, R.N. PII08, PII24 PII26, PII30, Cordeiro, E. PII26 Guimarães, R.L. PII08 Correia, A.P. PII24 Halpern, I. PCR21 Costa, E.P. PII24 Hammarstrom, L. PCR14 Costa-Carvalho, B.T. PCR23, PCR25, PII03, PII28, Ibiapina, C.C. PCR09 PII29, PII32, PII34, PII35, PII36 Jacob, C.M.A. PCR13, PII16, PII17, PII18, PII19, Coutinho, A. PII06 PII21, PII22 Criado, P.R. PCR28 Jatene, I.B. PII25 Crovella, S. PII08 Jatene, M.B. PII25 Cunha, J.M.T. PCR15 Jesus, A.A. PII06, PII07 Cunha, L.A.O. PCR09, PII11, PII13, PII33 Jobim, L.F. PCR14, PII20 Curi, R PII05 Jobim, M. PCR14, PII20 da Silva, M.T.N. PCR01 Kalil, J. PII14, PII15, PII22 da Silva, M.T.N. PCR12, PII12, Kayser, C PII17 Dantas, E. PII36, PII37 Khoury, Z PII23 Daudt, L.E. PCR14, PII20 Klautau, G.B. PCR07 Della-Negra, M. PCR07, PII23, Klaver, S.V. PII03 Domingues-Ferreira, M. PCR04, PCR05, PCR06, PCR16, Kokron, C.M. PII02, PII14, PII15, PII22 PCR17, PCR18, PCR19, PCR20, Komninakis, S.V. PII24 PCR27, PCR28, PII09, PII10, Labbate, A.K.S PCR02, PCR12, PII12 PII22, PII23, PII26, PII30 Lawrence. T.C. PII34, PII35, PII37 Dorna, M.B. PCR11, PII09, PII10, PII18, PII22 Lessa-Mazzucchelli, JT PCR25, PII32, PII34, PII35
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Lian, Y.C. PCR07 Poli-Neto, A PCR18, PCR19 Liphaus, B.L. PII06 Portela, P. PCR14 Litvoc, M. PCR22 Prando, C. PII01 Loja, C. PII08 Rama, T.S. PCR12, PII12, Loureiro, G.L. PCR23, PCR24 Ramalho, V.D. PCR01, PII04 Madi, K. PCR15 Rangel-Santos, A.C. PII24 Mallozzi, M.C. PII37 Rezende, D.G.C. PII19 Mansur, E. PII03 Ribeiro, J.P.M. PCR10 Marques, O.C. PII03 Riccetto, A.G.L. PCR12, PII12, Martinez, G.M. PCR07 Rivas, J.J. PII14 Melo, K.M. PCR24, PII36, PII37 Rizzo, L.V. PII02, PII14, PII15, PII22 Minafra, F.G. PCR09, PII11, PII13, PII33 Roxo-Júnior, P. PII04 Miranda, L.B.C. PII13 Rullo, V.E.V. PCR24, PII36 Miyamoto, D PII27 Saad, S.T.O. PCR18, PCR19 Miyamoto, M. PII34, PII35 Salim, P.H. PCR14, PII20 Monteiro, L. PCR14 Santos, T.C. PCR23, PCR24 Moraes-Pinto, M.I. PII28, PII32, PII34, PII35 Santos-Valente, E.C. PCR23, PII28, PII29 Moraes-Vasconcelos, D PCR03, PCR04, PCR05, PCR06, Sarni, R.O.S. PII28, PII29 PCR07, PCR11, PCR16, PCR17, Sato, M.N. PII21 PCR18, PCR19, PCR20, PCR21, Schlottfeldt, J. PCR14 PCR22, PCR27, PCR28, PII09, Scomparini, F.B. PII29 PII10, PII22, PII23, PII26, PII27, Seber, A PII32 PII30, PII31 Segat, L. PII08 Moscardini, A.C. PCR08 Silva, C.A.A. PII06, PII07 Nadai, T.R. PCR22 Silva, R. PII28, PII29 Nascimento-Filho, E. PCR17 Siqueira, I. PII08 Nava, T.R. PCR14 Soares, D.C.Q. PCR10 Negri-Santi, T. PCR04, PCR05, PCR06, Soares, M.C.P. PCR03, PCR04, PCR05, PCR06, Neves, L. PCR15 PCR07, PCR21, PII31 Nobre, F.A. PCR23, PCR24, PCR25, PII36 Souza, E.S. PCR10 Nolasco da Silva, M.T. PCR02 Souza, F.I.S. PII28 Nudelman, V. PII36, PII37 Souza, L.C.B. PII25 Nunes, J.B.S. PCR09, PII11, PII33 Souza, M.I. PCR22 Ogusuku,S. PII30 Stotlz, J. PCR14 Oliveira, A.K.B PII14, PII15 Sugayama, S.M.M. PII05 Oliveira, G.M. PCR11, PII09, PII10 Surian, B.R. PCR23, PCR24 Oliveira, J.B. PCR12, PII12, PII30+B15 Sztajnbok, J. PCR13 Oliveira-Júnior,E.B. PII04 Taboada, G. PCR15 Orii, N.M. PCR13, PCR22, PII09, PII30 Tavares, F.S. PII03, PII32 Oshiro, M. PCR18, PCR19 Toledo, E.C. PCR08 Ozaki, L.S. PII20 Toledo-Barros, M.A.M. PII02, PII14, PII15, PII22 Pastorino, A.C. PII16, PII18, PII19, PII22 Torres, L.C. PII05 Pedroza, L.A. PCR01 Trindade, M.A.B. PCR21, PII27 Penna, L.S. PII20 Trotta, E. PII20 Pereira, J. PCR07, PCR18, PCR27 Valente, N.Y.S. PII27 Pereira, P.V.S. PII03 Vasconcelos, R. PCR28 Pessoa, F.G.P PII09 Vilela, M.M.S. PCR01, PCR02, PCR05, PCR12, Pieri, P. PCR17 PII04, PII12 Pietcher, O. PII20 Vinolo, M.A.C. PII05 Pimentel, C.F.M.G. PCR24 Wakim, V.L. PCR15 Pinto, J.A. PCR09, PII11, PII13, PII33 Watanabe, L.A. PII16, PII19 Pires-Oliveira, T. PCR03, PCR05,
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