Do Ribosomopathies Explain Some Cases of Common Variable Immunodeficiency?Cei 4280 96..103
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Clinical and Experimental Immunology ORIGINAL ARTICLE doi:10.1111/j.1365-2249.2010.04280.x Do ribosomopathies explain some cases of common variable immunodeficiency?cei_4280 96..103 S. Khan,*† J. Pereira,‡ P. J. Darbyshire,§ Summary S. Holding,¶ P. C. Doré,¶ The considerable clinical heterogeneity of patients with common variable W. A. C. Sewell† and A. Huissoon** immunodeficiency disorders (CVID) shares some similarity with bone- *Department of Immunology, Frimley Park Hospital, Frimley, Surrey, †Centre for marrow failure disorders such as Diamond–Blackfan anaemia (DBA) and Immunoglobulin Therapy, Scunthorpe General Shwachman–Diamond syndrome (SDS), now recognized as defects in ribo- Hospital, Scunthorpe, §Paediatric Oncology and some biogenesis or ribosomopathies. The recognition of a patient with DBA Haematology, Birmingham Children’s Hospital, who subsequently developed CVID lends support to our previous finding of a **Department of Immunology, Birmingham heterozygous mutation in the SBDS gene of SBDS in another CVID patient, Heartlands Hospital, Birmingham, ¶Department suggesting that ribosome biogenesis defects are responsible for a subset of of Immunology, Hull Royal Infirmary, Hull, UK, CVID. Genetic defects in the ribosomal translational machinery responsible and ‡Centro Hospitalar de Coimbra, Unidade de for various bone marrow failure syndromes are recognized readily when they Hematologia Molecular, Coimbra, Portugal manifest in children, but diagnosing these in adults presenting with complex phenotypes and hypogammaglobulinaemia can be a challenge. In this per- spective paper, we discuss our clinical experience in CVID patients with ribosomopathies, and review the immunological abnormalities in other con- ditions associated with ribosomal dysfunction. With genetic testing available for various bone marrow failure syndromes, our hypothesis that ribosomal abnormalities may be present in patients with CVID could be proved in future Accepted for publication 14 September 2010 studies by testing for mutations in specific ribosomal genes. New knowledge Correspondence: S. Khan, Department of might then be translated into novel therapeutic strategies for patients in this Immunology, Frimley Park Hospital NHS group of immunodeficiency disorders. Foundation Trust, Portsmouth Road, Frimley, Camberley, Surrey GU16 7UJ, UK. Keywords: bone marrow failure, common variable immunodeficiency, E-mail: [email protected] Diamond–Blackfan anaemia, ribosome, ribosomopathy insufficiency [4]. There is emerging evidence that loss of Introduction Shwachman–Bodian–Diamond syndrome (SBDS) protein Common variable immunodeficiency disorders (CVID) affects haematopoeisis and numbers of circulating B lym- comprise a range of hypogammaglobulinaemias, for which a phocytes [5]. Craniofacial malformation syndromes such as small number of genetic defects have been identified [1–3]. Treacher–Collins syndrome, caused by haploinsufficiency of However, these account for only a small proportion of cases the treacle protein, also affect the cells of the immune system of CVID, and the majority of patients have no identified [6], and a broader immunological defect has been described genetic cause. A number of bone marrow failure syndromes in the congenital anaemia of Diamond–Blackfan syndrome are now recognized to be due to defects in ribosome biogen- (Diamond–Blackfan anaemia: DBA) [7]. The 5q- syndrome, esis with mutations in genes coding for ribosomal proteins. a somatically acquired deletion of chromosome 5q and a Various immunological abnormalities are evident in these subtype of myelodysplastic syndrome, leads to haploinsuffi- syndromes and provide proof that failure of optimal ribo- ciency of a ribosomal protein that is also implicated in DBA. some function, ‘ribosomopathies’, can also affect cells of the The active eukaryotic ribosome, the site of protein synthe- immune system. sis, is composed of 40S and 60S subunits. Formation of the These syndromes are heterogeneous in their clinical active complex requires synthesis and assembly of core ribo- presentations: for example, patients with Shwachman– somal proteins, ribosomal RNAs, small nucleolar RNAs and Diamond syndrome (SDS) with confirmed mutations in the several other associated proteins (see Fig. 1). This process SBDS gene (Chr7q11) may not have all the characteristic begins in the nucleolus and the preribosomal units are features of neutropenia, skeletal defects and pancreatic exported into the cytoplasm for final steps in the maturation 96 © 2010 The Authors Clinical and Experimental Immunology © 2010 British Society for Immunology, Clinical and Experimental Immunology, 163: 96–103 Ribosomopathies and common variable immunodeficiency complete deletion of one RPS19 allele) generated enormous interest in the clinical effects of disordered ribosome biosyn- thesis [8,9]. Mutations in the RPS19 gene prevent assembly of the 40S ribosomal subunit, but account for only 25% of DBA patients [9]. However, to our knowledge, there have been no reports of failure of antibody production in DBA. We present our clinical experience with the report of the first case of DBA who subsequently developed antibody deficiency, consistent with a new diagnosis of CVID, with complications of bronchiectasis and managed on immuno- globulin therapy. The previous case of CVID with mutation in the SBDS gene of SDS has been discussed briefly with additional data, as a detailed report was published in a pre- vious issue of this Journal [10]. In the final part of this perspective paper, we review the immunological abnormali- Fig. 1. An overview of the biogenesis of the eukaryotic ribosome. ties beginning to emerge in ribosomopathy syndromes. Synthesis of ribosomal proteins and assembly of the mature eukaryotic ribosome has several step: (1) DNA transcription and RNA processing; (2) translation of ribosomal RNA (rRNA); (3) Clinical experience of ribosomopathies and modification and processing by small nucleolar RNPs (snoRNPs) and hypogammaglobulinaemia Rnase; (4) formation of immature large and small ribosomal subunits and exit from nucleolus; and (5) formation of mature eukaryotic DBA and CVID ribosome[8]. The 60S subunit has a cleft for tRNA and amino acids Clinical synopsis including investigations. A 22-year-old from the endoplasmic reticulum (ER) are translated into protein. rRNA, ribosomal RNA; mRNA, messenger RNA; tRNA, transfer RNA; female presented with bronchiectasis and hypo- AAA, amino acids. gammaglobulinemia. DBA had been diagnosed at 1 year of age and required treatment with corticosteroids and blood transfusions until the age of 6 years. There were no associ- of ribosomes [8]. The exact functions of many of these pro- ated skeletal, cardiac or congenital defects. Over the next 3 teins remain unknown. Some ribosomal proteins are now years she suffered from recurrent sinusitis, otitis media, chest known to have extraribosomal functions; for example, the infections (sputum cultures positive for Moraxella catarrha- SBDS protein has a role in stabilizing the mitotic spindle. lis and Haemophilus species) and viral warts. Immunological abnormalities in ribosomopathies may She has a sister with features of DBA – low haemoglobin at therefore provide clues as to how ribosomal proteins can 10·4 g/dl, raised mean corpuscular volume (MCV), lym- shape the immune system. phopenia, elevated fetal haemoglobin (HbF) (3%), high According to internationally accepted criteria, the diagno- erythrocyte adenosine deaminase (eADA) levels, mildly sis of CVID remains one of exclusion. The currently identi- reduced T cell numbers and slight reduction in proliferative fied four genetic mutations (ICOS, CD19, TACI, BAFFR) responses to standard mitogens. The sister’s immunoglobu- account for fewer than a fifth of cases, with no consensus on lin levels, including functional antibody levels, are normal which genetic testing should be undertaken in most cases and she has not required any specific therapy for her [1]. The current European Society of Immunodeficiency anaemia. (ESID)/Pan-American Group for Immunodeficiency Investigations in infancy showed a normocytic anaemia, (PAGID) criteria for CVID include:‘probable’ CVID in those normal serum immunoglobulins [IgG 7·3 g/l (normal range aged > 2 years with low immunoglobulin (Ig)G and another 3·0–10·5), IgA 0·28 g/l (0·1–1·2), IgM 1·07 g/l (0·3–1·5)] and low isotype level (IgA or IgM) with absent vaccine responses; good vaccine responses to conjugated Haemophilus influen- and ‘possible’ CVID in those with low immunoglobulin of zae type b and unconjugated pneumococcal polysaccharide any isotype with absent vaccine responses where other vaccines. By the age of 9, serum IgG levels had dropped to causes of hypogammaglobulinaemia have been excluded [2]. 4·94 g/l (normal range 6·0–13·0). Lymphocyte proliferation Additional similarities with ribosomopathies and CVID responses to phytohaemagglutinin, pokeweed mitogen, patients include heterogeneous presentations with T cell OKT3, tetanus, varicella and herpes antigens were reduced. defects, cytopenias and malignancies [1–3]. Intravenous immunoglobulin (IVIG) replacement therapy The initial description of DBA was of a congenital eryth- was commenced, and stopped after 8 years for reassessment roblastopenia characterized by an early arrest of pre- of immune function. Four years later, she had persistent erythroblast differentiation. The first report of loss-of- anaemia (Hb 10·0 g/dl, MCV 95·6fl) and low IgG (3·37 g/l), function mutations in a gene coding for a ribosomal protein