J Clin Immunol (2014) 34:304–308 DOI 10.1007/s10875-014-9991-9
ORIGINAL RESEARCH
Severe Combined Immunodeficiency in Serbia and Montenegro Between Years 1986 and 2010: A Single-Center Experience Srdjan Pasic & Dragana Vujic & Dobrila Veljković & Bojana Slavkovic & Marija Mostarica-Stojkovic & Predrag Minic & Aleksandra Minic & Goran Ristic & Silvia Giliani & Anna Villa & Cristina Sobacchi & Desa Lilić & Mario Abinun
Received: 9 September 2013 / Accepted: 20 January 2014 / Published online: 1 February 2014 # Springer Science+Business Media New York 2014
Abstract Severe combined immunodeficiency (SCID), including the ‘variant’ Omenn syndrome (OS), represent a heterogeneous group of monogenic disorders characterized by defect in differentiation of T- and/or B lymphocytes and susceptibility to infections since birth. In the period of 25 years, between January 1986 and December 2010, a total of 21 patients (15 SCID, 6 OS) were diagnosed in Mother & Child Health Institute of Serbia, a tertiary-care teaching University hospital and a national referral center for patients affected with primary immunodeficiency (PID). The diagnoses were based on anamnestic data, clinical findings, and immunological and genetic analysis. The median age at the S. Pasic : D. Vujic : D. Veljković : B. Slavkovic : P. Minic : A. Minic : G. Ristic Pediatric Clinic, Mother & Child Health Institute “Dr Vukan Čupić”, Belgrade, Serbia M. Mostarica-Stojkovic Institute for Microbiology and Immunology, Medical Faculty, University of Belgrade, Belgrade, Serbia S. Giliani Clinica Pediatrica, Spedali Civili, Brescia, Italy A. Villa : C. Sobacchi Istituto per Technologie Biologiche Avanzzate, Segrate, Milan, Italy D. Lilić Institute of Cellular Medicine, Medical School, University of Newcastle, Newcastle upon Tyne, UK M. Abinun Department of Paediatric Immunology, Great North Children’s Hospital, Newcastle upon Tyne, UK S. Pasic (*) Mother and Child Health Institute, Medical Faculty, University of Belgrade, Radoja Dakića 8, 11070 Belgrade, Serbia e-mail:
[email protected]
onset of the first infection was the 2nd month of life. Seven (33 %) patients had positive family history for SCID. Out of five male infants with T-B+NK- SCID phenotype, mutation analysis revealed interleukin-2 (common) gamma-chain receptor (IL2RG) mutations in 3 with positive X-linked family history, and Janus-kinase (JAK)-3 gene defects in the other two. Six patients had T-B-NK+ SCID phenotype and further 6 features of OS, 11 of which had recombinase-activating gene (RAG1or RAG2) and 1 Artemis gene mutations. One child with T+B+NK+ SCID phenotype as well had proven RAG mutation. One child each with T-B+NK+ SCID phenotype, CD8 lymphopenia and unknown phenotype remained without known underlying genetic defect. Of the eight patients who underwent hematopoetic stem cell transplant (HSCT) 5 survived, the other 13 died between 2 days and 12 months after diagnosis was made. Early diagnosis of SCID, before onset of severe infections, offers possibility for HSCT and cure. Education of primary-care pediatricians, in particular including awareness of the risk of using live vaccines and nonirradiated blood products, should improve prognosis of SCID in our setting. Keywords Severe combined immunodeficiency . Omenn syndrome . RAG deficiency
Introduction Severe combined immunodeficiency (SCID), including the Omenn syndrome (OS), represents a group of rare, monogenic diseases with profound defect of T and/or B cell differentiation [1–4]. We undertook a retrospective study with aim to investigate clinical characteristics, molecular diagnosis and outcome in infants who were diagnosed with SCID or OS in Serbia and Montenegro in the period of 25 years, between January 1986 to December 2010.
J Clin Immunol (2014) 34:304–308
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Methods
Results
Diagnosis of SCID was established by finding of lymphopenia (except for OS) and early onset of infections. Patients with proven congenital infections (rubella, cytomegalovirus), complete DiGeorge syndrome or HIV infection were excluded.
Patients Age at the Time of Diagnosis The median age at onset of infections in our patients was 45 days of life (range, 30 days–6 months). Mean age at the time of diagnosis was 4th month of life, with an average 2 months of diagnostic delay (up to 5.5 months) since the onset of first infections.
Immunological Investigations Serum concentrations of immunoglobulins IgG, IgA and IgM were evaluated by nephelometry, and serum IgE by ELISA. Since 1990, relative and absolute numbers of peripheral blood T- and B lymphocytes and NK-cells were measured by flow-cytometry using monoclonal antibodies (CD3, CD4, CD8, CD19, CD16, CD25, CD45RA, CD45RO, CD56, HLA-DR, TCR-αβ, TCR-γδ; Becton Dickinson, San Јоsе, USA). T cell function was evaluated by in vitro stimulation of peripheral blood lymphocytes with mitogens (phytohemagglutinin-PHA and/or Concavalin A) [4]. Activity of adenosine deaminase was evaluated by biochemical methods. Phenotypic classification of SCID was performed by flowcytometry method enumerating relative and absolute counts of peripheral blood T- and B lymphocyte subpopulations and natural killer (NK)-cells. Clinical and laboratory diagnosis of OS was based on the following criteria: a) atopic/seborrhoic dermatitis and/or erythroderma; b) increased numbers of circulating T-lymphocytes expressing activation markers (CD45RO, CD25, HLA-DR); c) proof of autologous Tlymphocytes by using genotyping at the highly polymorphic D1S80 and DQ loci as previously described [5]. Adenosine deaminase deficiency (ADA)-SCID was excluded by normal enzyme activity. Molecular Diagnosis Since 1999, sequencing of several genes known to cause SCID and OS was performed in two specialized laboratories in Italy (Istituto molecolare “A. Nocivelli”, Spedali Civili, Brescia; Istituto per technologie biologiche avanzzate, Segrate, Milano). In male patients with T-B+NK-SCID and X-linked mode of inheritance (X-SCID; positive family history) mutational analysis of IL2RG was performed [6], in those with presumed autosomal-recessive SCID and T-B+NK- and/or T-B+NK+ phenotype, JAK3 or interleukin 7 receptor alpha (IL-7RA) genes were analysed [7, 8], and in those with T-B-NK+SCID or OS, as well as in the one case of T+B+NK+SCID, RAG1, RAG2 and/or Artemis genes were sequenced [9, 10].
Clinical Manifestations Infections with opportunistic agents such as Bacillus Calmette-Guérin (BCG), Pneumocystis jiroveci (PJ), cytomegalovirus (CMV) or Candida speciaes were present in 19 (90 %) patients at the time of diagnosis, in particular persistent lung infections/pneumonitis was present in 15 (71 %) (5 PJP, 3 CMV, 2 BCG, 5 other respiratory viral pathogens such as parainfluenza, adenovirus, respiratory syncytial virus-RSV) (Fig. 1). Laboratory Investigations Immunological investigations are presented in Table I. Fourteen (66 %) patients were lymphopenic (absolute lymphocyte count-ALC
