State of art in Emerging Fungal Infections

COMMON VARIABLE IMMUNODEFICIENCY – a complex disorder of the immune system © by author Prof. Dr. Victor Cristea, Dr. Nicolae Miron, Dr. Mirela-Mihaela Miron, Department of Immunology, University of Medicine and Pharmacy „Iuliu Haţieganu” Cluj Napoca ESCMID Online Lecture Library Immunodeficiencies

• Immune system integrity is essential for the defence against infections and against tumours, being therefore essential for survival.

• Defects of one/more components of the immune system can lead to serious diseases – sometimes© fatal by – authorIMMUNODEFICIENCIES .

ESCMID Online Lecture Library Immunodeficiencies

• Immunodeficiencies – two main categories : – Primary immunodeficiencies (congenital) – caused by genetic defects; – Secondary immunodeficiencies (acquired) – consequence of other pathological conditions© :by malnutrition author, malignant diseases, immunosppressive therapies, or infection of the immune system cells (especially HIV infection ). ESCMID Online Lecture Library ETIOLOGY OF PRIMARY IMMUNODEFICIENCIES

1. Gene defect (deletions and/or rearrangements of genes, usually X- linked and autosomal recessive inherited) 2. Biochemical and/or metabolic defect (e.g. adenosin-deaminase) 3. Vitamin© and by oligoelement author deficiencies (biotin (vit. B7), vit. B12, Zn) 4. Embryogenesis anomalies ESCMID Online Lecture Library ETIOLOGY OF SECONDARY IMMUNODEFICIENCIES

1. Viral infections (rubella, measles, herpesvirus, cytomegalovirus, hepatitis viruses) 2. Transfusions 3. Nutritional deficits 4. Prolonged drug use 5. Alcoholism 6. Radiotherapy 7. Immunosuppressive therapies 8. Chronic renal© by disease author requiring dialysis 9. Neoplasias 10. AIDS – Acquired Immunodeficiency ESCMIDSyndrome Online Lecture Library IMMUNE DEFICIENCY

• Partial – affecting only certain

cell populations, humoral factors or soluble mediators.

• Total – affecting both cellular © by author and humoral immune responses.

ESCMID Online Lecture Library Primary immunodeficiencies, PID – old classification

• Humoral immunodeficiencies (B-cell PID) – Agammaglobulinemia, hypogammaglobulinemias • Cellular immunodeficiencies (T-cell PID) – DiGeorge syndrome, deficiencies of T-cell development and maturation etc. • Combined immunodeficiencies – SCID, bare lymphocyte syndrome, Wiskott-Aldrich syndrome,© ataxia by telangiectasiaauthor etc. • Deficiencies of unspecific defense mechanisms – Phagocyte function defects, complement deficiencies. ESCMID Online Lecture Library Primary immunodeficiencies – 2009 classification

1. Combined T-cell and B-cell immunodeficiencies; 2. Predominantly antibody deficiencies; 3. Other well defined immunodeficiency syndromes; 4. Diseases of immune dysregulation; 5. Congenital defects of phagocyte number, function, ©or both;by author 6. Defects in innate immunity; 7. Autoinflammatory disorders; ESCMID8. Complement Online deficiencies.Lecture Library Number of PID cases reported in Europe (ESID)

© by author

ESCMID Online Lecture Library PID distribution across age groups in Europe (ESID)

© by author

ESCMID Online Lecture Library Main PID types (ESID)

© by author

ESCMID Online Lecture Library Adult-onset PID

• PID onset can occur at the adult age:

– Bruton„s disease; – Bare lymphocyte syndrome; – Tapasin deficiency; – CD8 deficiency; – Chronic granulomatous disease; – Idiopathic CD4 lymphopenia; – Adenosin© deaminaby authorse deficiency; – Selective immunodeficiency against Mycobacteria and/or Salmonella; ESCMID– CVID Online etc. Lecture Library DIAGNOSTIC CRITERIA FOR IMMUNE DEFICIENCY

Major criteria: • Increased frequency of infections (bacterial, viral, fungal, parasitic). • Severe infections. • Occurrence of complications or of unusual manifestations. • Incomplete© by therapeutical author response – partial remissions. • Frequent opportunistic infections. ESCMID Online Lecture Library DIAGNOSTIC CRITERIA FOR IMMUNE DEFICIENCY

Moderate criteria: • Cutaneous eruption: eczema, candidiasis. • Chronic diarrhea. • Growth delay. • Recurrent abscesses or osteomyelitis. • The presence© by authorof autoimmune manifestations. • Hepatosplenomegaly. ESCMID Online Lecture Library DIAGNOSTIC CRITERIA FOR IMMUNE DEFICIENCY

Criteria that make possible an association with immunodeficiency (especially primary):

• ataxia • telangiectasias • disharmonic nanism • cartilage and hair hypoplasia • idiopathic© endocrinopathiesby author • partial albinism • isolated thrombocytopenia • chronic, recurrent eczema ESCMID• spasmophilia Online Lecture Library Predominantly antibody deficiencies

• Agammaglobulinemia with absent B cells • Hypogammaglobulinemia with normal/decreased number of B cells (common variable immunodeficiency) • Deficiencies of Ig class recombination • Selective IgA deficiency (SIGAD) • Other deficiencies© by author of Ig isotypes or light chains • Specific antibodies deficiencies with normal levels of Ig • Transient hypogammaglobulinemia of infancy ESCMID Online Lecture Library Common variable immunodeficiency, CVID

• One of the most common adult-onset PID (1:25.000 – 1:60.000), with no gender preference. • Adult onset more frequent than childhood onset. • A heterogeneous group (genotype and phenotype)© of by humoral author immunodeficiencies, characterized by hypogammaglobulinemia, affecting at least two types of Ig (IgA and IgG), with normal or decreased number of B cells. ESCMID Online Lecture Library CVID onset according to age

© by author

ESCMIDTwo peaks Online of incidence: Lecture the first Library and third decade CVID clinical picture

• Frequent bacterial – sinopulmonary or gastrointestinal – infections.

• Less frequent: infections with enteroviruses of CNS (central nervous system).

• Helicobacter© bypylori author is often isolated from CVID patients, as etiological agent of dyspeptic syndromes or chronic gastritis. ESCMID Online Lecture Library Frequency of infections in CVID patients

Type of infection Frequency (%)

Recurrent bronchitis, sinusitis and otitis 98 Pneumonia 76,6 Viral hepatitis 6,5 Severe herpes zoster infections 3,6 Giardia lamblia enteritis 3,2 Pneumocystis carinii infections 2,8 Mycoplasma pneumoniae pneumonias 2,4 Chronic mucocandidiasis© by author 1,2 Salmonella gastroenteritis 1,2 Sepsis (caused by Pseudomonas, pneumococci, H. 1,2 Influenzae, Listeria) ESCMIDCampylobacter Online enteritis Lecture Library 1,2 Non-infectious manifestations in CVID patients

• Inflammatory gastrointestinal diseases: diarrhea, malabsorb tion and weight loss.

• Gastrointestinal disease can present as: nodular lymphoid hyperplasia, colitis or ulcerative proctitis, Crohn disease, gluten enteropathy. © by author • Other digestive diseases in CVID: primary biliary cirrhosis, idiopathic hepatitis. ESCMID Online Lecture Library Non-infectious manifestations in CVID patients

• Lymphoproliferative diseases: – Malignant lymphomas (almost 30 times higher incidence than general population), – But more frequently – benign lymphoproliferation, manifested as: splenomegaly and/or diffuse lymphadenopathy, but also with other locations: gut, lung, nasopharingeal or bone marrow. © by author • Development of non-caseous granulomas (8– 22 % of patients) in lungs, lymph nodes, skin, bone marrow, spleen or liver. ESCMID Online Lecture Library Non-infectious manifestations in CVID patients

• Autoimmune disorders: – Autoimmune hemolitic anemia, – Idiopathic thrombocytopenic purpura, – Autoimmune neutropenia, – Pernicious anemia, – Autoimmune tiroiditis, – Rheumatoid© by author arthritis, – Systemic lupus erythematosus, – Vitiligo, ESCMID– OnlineSjögren syndrome Lecture etc. Library CVID – immune phenotype

• CVID was initially explained by a defect of B-cell differentiation and maturation. • Now, the humoral deficiency is also considered a consequence of inadequate T cell – B cell cooperation.

© by author

ESCMID Online Lecture Library B cell anomalies in CVID

• CD19 deficiency (CD 19 is important for B cell survival and regulation of B-cell response to Ag); • Mutations of the gene encoding the TACI receptor (transmembrane activator and calcium-modulator and cyclophilin ligand interactor), essential for immunoglobulin class switching, terminal differentiation of B cells, and T-cell independent antibody production; • Increased B© cell by apoptosis, author associated with overexpression of CD95 (Fas); • Functional deficiency of proteinkinase C; ESCMID• Loss ofOnline L-selectin Lecture expression Library.

T cell anomalies in CVID

• Decreased expression of the CD40 ligand (CD40L); • Decreased lymphocyte proliferation responses to mitogen and antigen stimulation; • Increased apoptosis of the CD45RA+ naive T-cell subtype; • Decreased numbers of CD4+ T cells (overexpression of Fas) and decreased CD4+/CD8+ ratio; • Polarization© toward by authorthe T helper 1 phenotype (through increased production of IL-12), with consequent reduction of the T helper 2 response, required for antibody synthesis. ESCMID Online Lecture Library Case 1 – CVID associated with T1DM

• Our patients belong to the “F2” and “F3” generations of the family below: mother and son, suffering from CVID and, respectively, T1DM (type 1 diabetes mellitus). Diabetes was diganosed around the age of 12-14, in all the affected family members.

CVID F0 T1DM

F1 © by author F2

ESCMID Online Lecture Library F3 CVID diagnosis in the mother

• The mother was diagnosed with CVID at 45 years old, in the context of recurrent infections (rhinosinusitis, pneumonias) and globally decreased values of serum Ig (IgA, IgG and IgM).

• Her fasting© blood by glucoseauthor and OGTT (oral glucose tolerance test) were normal.

ESCMID Online Lecture Library Diabetes diagnosis in the son

• The son was diagnosed with T1DM at the age of 12, based on a polyuric-polydipsic syndrome with weight loss, lethargy, and ketosis. • Laboratory tests revealed the presence of anti- islet cell and anti-GAD (glutamic acid decarboxylase), with absent postprandial C- peptide (marker of endogenous insulin secretion). • The absence of endogenous insulin correlated with the presence© by authorof anti-islet cell antibodies pleaded for a T1DM. • Immunoglobulin values were within the normal range, but IgA and IgG were at the lower ESCMIDnormal Online limit. Lecture Library Discussion

• There is an obvious familial aggregation of T1DM, but the pedigree does not plead for a mendelian inheritance pattern, thus excluding a monogenic diabetes. • We can observe a most interesting familial co- existence of diabetes and CVID. • Both CVID and T1DM are caused by immune dysfunctions. • It is already known that CVID can associate with T1DM in the© same by authorperson, from CVID onset or later during disease evolution. • Border values of Ig in the boy might suggest that he is at risk for developing hypogammaglobulinemia in ESCMIDthe future Online. Lecture Library Possible etiologic links between CVID and T1DM

• Genetic studies have identified a number of HLA or non-HLA loci involved in the appearance of both CVID and T1DM. • The DQB1*0201 (DQ2) allele is associated with a high risk for T1DM and also for CVID. • The IL-12p40 gene is associated with T1DM predisposition (IDDM18 – insulin dependent diabetes mellitus© by locusauthor 18 – 5q31.1-q33.1). And.. • An increased IL-12 synthesis by monocytes, with high serum levels of IL-12p40, is present ESCMIDin some Online CVID patients Lecture. Library Case 2 – CVID associated with primary amylodosis

© by authorCVID and primary amyloidosis CVID, chronic urticaria

Recurrent pyelonephritis ESCMID Online Lecture Library CVID and primary amyloidosis

• Father: • 56 years old, with cardiovascular medical history, treated with beta blockers, coronary dilators, diuretics, and antiplatelet agents. • For 2 years: progressive muscular asthenia, echymosis and petechiae on the neck and thorax, appeared after minimal trauma, increased© cutaneous by author fragility, and 0.5 cm pale-red nodules.

ESCMID Online Lecture Library CVID and primary amyloidosis

• Father: • IgG = 400,2 g/dl (800-1800) • IgM = 56,7 (60-280) • IgA = 105,5 (70-400) • ESR = 32-61, Hgb = 10,8 g/dl, normal WBC • Proteinuria = 6g/24h, leucocituria, hematuria • BUN = 83,73 mg/dl (15-45), serum creatinine = 2,1 g/dl (0,5-1,2)© by author • Serum albumin = 3,4 g/dl (3,5-5,2), total serum proteins = 6,1 g/dl (6,2-8) ESCMID• CIC = Online6000 U/dl (Lecture<150) Library CVID and primary amyloidosis

• Father: • Electrophoresis of urine proteins with immunofixation: kappa chains – present, lambda chains – absent. • Skin biopsy: epidermal atrophy with dermal amyloid deposits© by author(Red Congo stain examined under polarized light).

ESCMID Online Lecture Library CVID and primary amyloidosis

• Father: • Bone marrow examination: normal • Echocardiography: concentric moderate left ventricular hypertrophy, with diastolic dysfunction. Infiltrative cardiomyopathy. • Final diagnosis: Primary amyloidosis with skin, cardiac and renal involvement. Infiltrative cardiomyopathy© by with author diastolic dysfunction, stage II. Symptomatic orthostatic hypotension. Effort angina due to microvascular disease (class II CCS). Congestive heart failure NYHA II. Nephrotic ESCMIDsyndrome Online. Lecture Library CVID and primary amyloidosis

• Father: • Therapy: 1) First line – Melfalan associated with dexamethasone, 3 months, with no effect (kappa chains still present in urine) 2) Second line – Bortezomib, a proteasom inhibitor© approvedby author by FDA for multiple myeloma treatment, was effective – kappa chain negativation in urine and improvement of the nephrotic syndrome. ESCMID Online Lecture Library CVID and primary amyloidosis

• Daughter - CVID: • 25 years old, suffers for 2 years from: frequent episodes of diarrhea, upper tract respiratory infections, moderate-severe allergic rhinitis, chronic urticaria, migratory arthritis of© upper by authorlimbs joints with cca. 2 weeks-long evolution.

ESCMID Online Lecture Library CVID and primary amyloidosis

• Daughter – CVID: • IgG = 450 g/dl (800-1800) • IgM = 178 g/dl (60-280) • IgA = 35 g/dl (70-400) • IgE = 16 UI/ml (<50) • C4 = 17 mg/dl© by (16 author-35) • C3 = 76 mg/dl (90-180) • Rheumatoid factor, ANA, anti-cardiolipin ESCMIDantibodies, Online anti Lecture-CCP antibodies Library – normal.

CVID and primary amyloidosis

• Daughter – CVID: • Complete blood count, renal function – normal. • Electrophoresis of serum and urine proteins: no kappa chains. • Comparative© byhand author X-ray: minor soft tissue tumefaction in the vicinity of the left radiocarpal joint. • Treatment: substitution with IVIG (intravenous ESCMIDimmunoglobulin). Online Lecture Library CVID and primary amyloidosis

• Possible link between CVID and primary amyloidosis

• It is speculated that amyloidosis could be the result of hypogammaglobulinemia, which leads to prolonged infections, with tissue deposits of amyloid resulted from the serum amyloid A (SAA) protein....© by Secondary author amyloidosis. • But in our case, kappa-chain primary amyloidosis is associated with familial hypogammaglobulinemia. The molecular basis ESCMIDfor such Online an association Lecture is yet Library unknown. Case 3 – CVID associated with SLE and SIGAD

CVID

SIGAD

SLE

© by author

ESCMID Online Lecture Library CVID associated with SLE and SIGAD

• CVID – female, 35 years old, diagnosed in 2008 with CVID, after 11 years of clinical evolution, with: chronic generalized lymhadenopathy, recurrent urticaria, nausea, asthenia, cough, dispnoea, thoracic pain.

• SIGAD – ©the bypatient‟s author son, 7 years old, diagnosed with selective IgA deficiency – SIGAD, (IgA = 2 mg/dl), is yet asymptomatic. ESCMID Online Lecture Library CVID associated with SLE and SIGAD

• SLE – 2 female patients in the same family. – One patient died at 40 years as a result of a soft tissue infection; – One patient died at 30 years. • The CVID – SLE association was described before. On a 18 case series, it was observed that the majority were young female patients with a median age of 24 years. In 50% of cases, CVID was diagnosed© by within author 5 years of the SLE diagnosis. • A recent study mentioned MBL (mannose-binding lectin) gene polymorphisms as basis for the CVID ESCMID– SLE Online association Lecture. Library Other CVID cases under our observation

• CVID associated with celiac disease in a 10 year-old girl; • CVID associated with vitiligo in a 34 year-old young woman; • We are monitoring a single case with CVID, in a 16 year-old ©teenager, by author in which hypogammaglo- bulinemia is the only immunologic disorder, in the patient‟s medical history or in his family. ESCMID Online Lecture Library Conclusions

• CVID is the expression of a complex immune disorder.

• The CVID hypogammaglobulinemia frequently represents just a part of a paradoxical clinical picture, based on the coexistence© by of immunodeficiencyauthor and immunologic hiperactivity, in the form of autoimmunity, allergy, or ESCMIDlymphoproliferative Online Lecture disease. Library New perspectives for immunodeficiencies in Romania

• Recently, the Regional Institute of Gastroenterology and Hepatology „Prof. Dr. Octavian Fodor” Cluj-Napoca has been appointed, by a Ministry of Health order, as the national technical coordinator for The National Programme of Health regarding the diagnosis and treatment of primary immunodeficiency sindromes (PID) in adults.

• We intend to create a National Registry for PID in adults. © by author

• We intend to enroll these patients in the european ESCMIDregistry Online for PID. Lecture Library

New perspectives in immunodeficiencies in Romania

• We want to invest in young people, to become specialists in immunodeficiencies, to have the necessary expertise, in both clinical and laboratory field.

• We intend to implement new laboratory investigations, specific for the diagnosis of primary immunodeficiencies.© by author

ESCMID Online Lecture Library THANK YOU!

© by author

ESCMID Online Lecture Library