[PAGID] unusual SCIDs

[Aly.Mageed at devoschildrens.org]

Thank you very much for the offer and very helpful suggestions. I already did a couple of skin biopsies so we will grow and send fibroblasts for radiation sensitivity to Dr Notarangelo (please send method of shipment,..).  It is great that you can also do mutation analysis despite being on research basis ( which one, type of tubes,...). This way I can do RAG1/2 for now (most likely mutation) at a CLIA lab to save time and money, then if  any other is +, we'll confirm that while we are looking for a donor. We will do spectratyping at Mayo's and CFSE as a research test. The lesions on the face do look similar to the NEJM but they are (at least so far) not nodular, we'll see histo tomorrow for granulomas.
Thanks


Aly Mageed, MD, MBA
Division Chief, Pediatric Blood & Marrow Transplant Program
Director, Stem Cell Engineering Laboratory
Helen DeVos Children's Hospital, Spectrum Health
Associate Professor of Pediatrics, Michigan State University
Grand Rapids, MI 
(616)-391-3962
aly.mageed at spectrum-health.org
 

-----Original Message-----
From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Notarangelo, Luigi
Sent: Wednesday, October 28, 2009 2:48 PM
To: pagid at list.clinimmsoc.org
Subject: Re: [PAGID] unusual SCIDs

I agree with Tom Fleisher's comment that spectratyping would help. I do believe it is very likely that this is a leaky SCID. Importantly, TREC levels are undetectable also in patients with leaky SCID who develop a fairly decent number of memory T cells. The DNT cells are likely to be in vivo activated T cells that downregulate CD4 and CD8.
I could help with mutation analysis on a research basis, but you would then have to confirm using a CLIA-approved lab. Radiation sensitivity would be important, but can best be done on fibroblasts. Again, I could help is a skin biopsy is made available (at the time of placing a central line?). Also, activated T cells in patients with leaky SCID die of activation-induced cell death following mitigen stimulation. You may want to consider CFSE staining and analysis of annexin V staining following in vitro activation to pick up such a possibility.
In my personal experience, these patients do require imune suppression to control erythroderma/organ damage (which I would assume is due to infiltrating T cells). This patient may need a transplant pretty soon, no matter whether a mutation is found or not.

Luigi D. Notarangelo


Luigi D. Notarangelo, M.D.
Jeffrey Modell Chair of Pediatric Immunology Research in Boston Director, Research and Molecular Diagnosis Program on Primary Immunodeficiencies Division of Immunology, Children's Hospital Professor of Pediatrics and Pathology, Harvard Medical School Karp Building, 9th floor, Rm 09210
1 Blackfan Circle
Boston, MA 02115
USA

(tel) (617)-919-2276
(fax) (617)-730-0709


Secretary: Luisa Raleza
email: luisa.raleza at childrens.harvard.edu





On 10/28/09 2:14 PM, "Aly.Mageed at devoschildrens.org" <Aly.Mageed at devoschildrens.org> wrote:

I would like to get the groups' opinion regarding a 5 months old white male who presented at 3 months with recurrent URIs and eczematous rash. IgG was 62, IgA<8, IgM was 5, and IgE was 33.  WBC was 15,000 with 16% lymphs and 44% Eos. Flow data: 2418 lymphs, CD19= 1 cell, CD3 =1812 and CD16=585. Diagnosed as potential Bruton's and started on I g replacement and Btk genetic testing (full-gene sequencing of all 19 exons with intron-exon boundaries and UTRs) was performed and did not reveal any mutations and Btk protein was also normal by intracellular flow cytometry on monocytes. No transfusions and no sibs.

Recent flow shows CD3= 5020, CD8= 2655 and CD4=1613 cells/uL with 14.41% DNT cells.  ALPS screening (despite lack of classic ALPS presentation) revealed only 0.5% of the DNT cells expressed the alpha-beta TCR (were also B220 negative).  The remaining DNT cells were negative for ab TCR, and may presumably be gd+ T cells.  Mitogen stim showed only 2% PHA, 40% PWM and 1% ConA relative to the normal control.  TRECs were undetectable.  CD4 RTE (CD4+CD31+CD45RA+) was 0.2% (only 3 cells/uL).  Next to zero naïve CD45RA+ T cells and the majority of the CD4 T cells express CD45RO (~99%).  The CD8 RTE (CD8+CD103+CD62L+CD45RO-) showed an apparent increase due to the overall CD8 lymphocytosis, however, again on examination of the CD45RA gate, there were hardly any CD45RA+ CD8 T cells present, the majority were CD45RO+ (>99%).  Therefore, in reality, CD8 RTE is also absent.

Now, he is in house with staph bactremia. Thriving at 8 Kg with some diarrhea once started on Bactrim a month ago. Rash has its ups and downs with increasing erythroderma and what looks like age/sunspots  that are increasing in #, which will be biopsied. Has mild splenomegaly and some inguinal and cervical adenopathy. IgG is 522 (gets IG which will be increased) and IgE is 14, Eos = 13%. No cytopenias. XX/XY probe surprisingly show all male XY cells with no evidence of maternal engraftment.

It is unclear as to how there can be such a substantial population of T cells with a memory phenotype (CD45RO+) in the blood of this infant along with a sizable population of DNT cells that are ab TCR-negative, if there is no external source, such as maternal engraftment, i.e. where are these cells originating from, especially since thymic output appears to be non-existent.  There certainly seems to be a reasonable amount of data in the literature to support extrathymic maturation and TCR rearrangement in the human gut (both gd and ab TCR+) but the question remains as to whether that is indeed what is happening in this patient.  We are trying to look at RAG1/2, Artemis and JAK3 but so far unsuccessful as he is Medicaid and social worker is still working on these issues. HLA is pending for UCB/MUD search. Is this Omenn's ? Any further testing - would gamma delta rearrangement analysis (clonality assessment), TCR V beta analysis to look for oligoclonal populations be worthwhile? Radiation sensitivity pathway? Additional thoughts??"
Thanks


Aly Mageed, MD, MBA
Division Chief, Pediatric Blood & Marrow Transplant Program Director, Stem Cell Engineering Laboratory Helen DeVos Children's Hospital, Spectrum Health Associate Professor of Pediatrics, Michigan State University Grand Rapids, MI
(616)-391-3962
aly.mageed at spectrum-health.org <mailto:aly.mageed at spectrum-health.org><mailto:aly.mageed at spectrum-health.org>
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