Predominantly antibody deficiency: case report / Deficiência predominantemente de anticorpos: relato de caso

Abstract Objectives: present a case of Inborn errors of immunity (IEI) as a potential diagnosis in pediatric patients with recurrent infections. Description: male patient, 13 years old, since he was eight months old had recurrent diarrhea, sinusitis, otitis, abscesses and urinary tract infections. At the age of ten, he presented mastoiditis progressing to meningitis, he was admitted to a tertiary hospital, where an immunological evaluation was performed, which led to the diagnosis of Predominantly Antibody Deficiency (PAD), with suspected X-linked Agammaglobulinemia (XLA). Treatment was initiated with administration of intravenous gamma globulin 400 mg/kg every four weeks, with a significant improvement of the condition. Discussion: usually, the diagnosis of XLA tends to be made in the first three years of life. However, in this report, although the first manifestations started at eight months of age, there was a delay of ten years before starting the treatment. In fact, the diagnosis of children and adults with IEI can be delayed if healthcare professionals are unable to find the true cause of recurrent infections. Therefore, the relevance of considering such pathologies in the presence of risk signs is highlighted, as early diagnosis being essential in treating and preventing morbidities.

Resumo Objetivos: apresentar um caso de Erro Inato da Imunidade (EII) como diagnóstico em potencial de pacientes pediátricos com infecções de repetição. Descrição: paciente masculino, 13 anos, desde os oito meses de idade apresentou quadros repetidos de diarreias, sinusites, otites, abscessos e infecções do trato urinário; destacando-se a otite, sinusite e diarreia pela maior recorrência. Aos dez anos, quando apresentou mastoidite evoluindo para meningite, foi internado em um hospital terciário, onde foi realizada avaliação imunológica, a qual levou ao diagnóstico de Deficiência Predominantemente de Anticorpos (DPAs), tendo como suspeita a agamaglobulinemia ligada ao cromossomo X (ALX). Foi iniciado tratamento com administração de gamaglobulina endovenosa 400 mg/kg a cada quatro semanas, ocorrendo melhora significativa do quadro. Discussão: normalmente, o diagnóstico da ALX tende a ser feito nos primeiros três anos de vida. Neste relato, entretanto, embora as primeiras manifestações tenham iniciado aos oito meses de idade, ocorreu um atraso de dez anos até o início do tratamento. De fato, o diagnóstico de crianças e adultos com EII pode ser retardado se os profissionais de saúde não conseguirem encontrar a causa das infecções recorrentes. Destaca-se, portanto, a relevância de se considerar tais patologias na vigência de sinais de riscos, pois o diagnóstico precoce é fundamental para tratar e prevenir morbidades.

Diagnóstico genético de pacientes con agammaglobulinemia primaria atendidos en centros peruanos de tercer nivel / Genetic diagnosis of patients with primary agammaglobulinemia treated at third level peruvian centers

Las agammaglobulinemias primarias (AP) resultan de alteraciones específicas en las células B, lo cual, conduce a baja producción de anticuerpos. La sospecha diagnóstica se establece con el antecedente de infecciones a repetición, inmunoglobulinas bajas y la ausencia linfocitos B CD19+. El diagnóstico se confirma mediante el análisis genético y la detección de una mutación ligada en el cromosoma X o autosómico recesiva o dominante. En Perú, no hay literatura sobre AP ni reportes sobre el genotipo de los pacientes con sospecha de AP. Bajo este escenario, se realizó un estudio que describió el genotipo de pacientes con sospecha de AP. Se encontraron 20 pacientes con mutaciones en el gen BTK y una mutación autosómica recesiva IGHM. Se hallaron 13 mutaciones hereditarias y siete mutaciones de novo. Se concluye que las AP son, en su mayoría, mutaciones en el gen BTK que corresponden con AP ligadas al cromosoma X.

Primary agammaglobulinemia result from specific alterations in B cells, which lead to low antibody production. Diagnostic suspicion is established with a history of repeated infections, low immunoglobulins, and absence of CD19+ B lymphocytes. The diagnosis is confirmed by genetic analysis and the detection of a mutation linked to the X or autosomal recessive or dominant chromosome. In Peru, there is no literature on primary agammaglobulinemia and no reports on the genotype of patients with suspected primary agammaglobulinemia. Under this scenario, a study was performed to describe the genotype of patients with suspected primary agammaglobulinemia. Twenty (20) patients were found with mutations in the BTK gene and an autosomal recessive IGHM mutation. Thirteen (13) hereditary mutations and seven de novo mutations were found. It is concluded that the group of primary agammaglobulinemia are mostly mutations in the BTK gene, corresponding to X-linked agammaglobulinemia.

Hypogammaglobulinemia: a diagnosis that must not be overlooked

Humoral immunological defects are frequent and important causes of hypogammaglobulinemia, leading to recurrent infections, autoimmunity, allergies, and neoplasias. Usually, its onset occurs in childhood or during the second and third decades of life; however, the diagnosis is made, on average, 6 to 7 years afterwards. As a consequence, antibody defects can lead to sequelae. Here we describe the clinical-laboratory characteristics, treatment, and prognoses of patients with hypogammaglobulinemia. An observational, cross-sectional, and retrospective study of patients attending the recently established outpatient group of Clinical Immunology between 2013 and 2018 was carried out. Patients with IgG levels below 2 standard deviations from the mean values for the age and/or impaired antibody response were included. Eight patients (3 F and 5 M; median age=41 years (16-65), average symptom onset at 25 years (1-59), and time to diagnosis of 10 years were included. The main infections were: sinusitis in 7/8, pneumonia in 6/8, otitis in 2/8, tonsillitis and diarrhea in 2/8, and diarrhea in 2/8 patients. Hypothyroidism was identified in 4/8 (50%) patients. Rhinitis was found in 7/8 (87.5%) and asthma in 3/8 (37.5%) patients. The tomographic findings were consolidations, atelectasis, emphysema, ground glass opacity, budding tree, bronchial thickening, and bronchiectasis. Immunoglobulin reposition was used between 466 and 600 mg/kg monthly (514.3 mg·kg-1·dose-1). Prophylactic antibiotic therapy was included in 7/8 (87.5%) patients. Airway manifestations prevailed in patients with hypogammaglobulinemia. There is a need for educational work to reduce the time of diagnosis and initiation of treatment, avoiding sequelae.

Inmunodeficiencias primarias en niños gravemente enfermos: a propósito de 3 casos clínicos / Primary immunodeficiencies in seriously ill children: Report of 3 clinical cases

Las inmunodeficiencias primarias (IDP) son enfermedades congénitas causadas por alteraciones cuantitativas o funcionales de la respuesta inmunitaria. Se caracterizan por predisposición a infecciones, autoinmunidad, alergia y enfermedades linfoproliferativas. Objetivo: Reportar 3 casos de lactantes menores con IDP que se manifestaron como infecciones graves de curso inhabitual. Casos clínicos: Se presentan 3 pacientes diagnosticados como IDP en su estadía en la Unidad de Paciente Crítico Pediátrico. El primero corresponde a un lactante de 4 meses con neumonía multifocal extensa a quien se diagnosticó un síndrome de inmunodeficiencia combinada severa ligada a X; el segundo es un lactante de 8 meses que se manifestó como una adenitis mesentérica por Candida lusitaniae y que correspondió a enfermedad granulomatosa crónica, y el tercero se trata de un lactante de 6 meses que se presentó con un ectima por Pseudomona y se diagnosticó una agammaglobulinemia ligada a X. Conclusión: El diagnóstico de IDP debe sospecharse en presencia de una infección de evolución arrastrada que no responde a tratamiento habitual. Se discuten los casos y se presenta una puesta al día de las patologías diagnosticadas.

Primary immunodeficiency diseases (PID) are congenital disorders secondary to an impaired immune response. Infections, autoimmune disorders, atopy, and lymphoproliferative syndromes are commonly associated with this disorder. Objective: To present and discuss 3 infants diagnosed with PID. Clinical cases: The cases are presented of three patients with PID diagnosed during their first admission to a Paediatric Intensive Critical Care Unit. The first patient, a 4-month-old infant affected by a severe pneumonia, and was diagnosed as a Severe Combined Immunodeficiency Disease. The second patient was an 8-month-old infant with Candida lusitaniae mesenteric adenitis, and diagnosed with a Chronic Granulomatous Disease. The last patient, a 6-month-old infant presented with ecthyma gangrenosum and X-linked agammaglobulinaemia. Conclusion: PID should be suspected when an infectious disease does not responde to the appropriate therapy within the expected period. An update of each disease is presented.

Primary hypogammaglobulinemia: The impact of early diagnosis in lung complications / Hipogamaglobulinemia primária: o impacto do diagnóstico precoce nas complicações pulmonares

Summary Objective: To describe clinical features, tomographic findings and pulmonary function in pediatric patients with primary hypogammaglobulinemia (PH). Method: A retrospective cohort study of children with PH who received intravenous immunoglobulin (IVIG) and prophylactic antibiotics between 2005 and 2010. Epidemiological and clinical features, computed tomography (CT) findings, and spirometric data were compared, assuming a 5% significance level. Results: We evaluated 30 patients with PH. After the start of IVIG replacement, there was a decline in the frequency of pneumonia (p<0.001). The 11 patients with bronchiectasis in their first CT scan were older at diagnosis (p=0.001) and had greater diagnostic delay (p=0.001) compared to patients without bronchiectasis. At the end of the study, 18 patients had bronchiectasis and 27 also had other lung disorders, alone or in combination. The Bhalla score was applied to the last CT scan of 16 patients, with a median score of 11 (range 7-21), with a positive correlation between the score and the number of pneumonias after the start of treatment (r=0.561; p=0.024). The score was also correlated with forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) values in 13/16 patients, with negative correlation to FEV1 previously to bronchodilator (r=-0.778; p=0.002) and after bronchodilator (r =-0.837; p<0.001) and FVC (r=-0.773; p=0.002). Conclusion: Pulmonary complications were common in this cohort, despite the decrease in the frequency of pneumonia with treatment. Early investigation of patients with recurrent infections for primary immunodeficiencies can reduce the frequency of these complications. The monitoring of changes in spirometry may indicate the need to carry out radiological investigation.

Resumo Objetivo: descrever características clínicas, tomográficas e de função pulmonar em pacientes pediátricos com hipogamaglobulinemia primária (HP). Método: estudo de coorte retrospectivo de crianças com HP que recebiam gamaglobulina endovenosa (GEV) e antibiótico profilático entre 2005 e 2010. As características epidemiológicas, clínicas, os achados de tomografia e espirometria foram comparadas adotando níveis de significância de 5%. Resultados: foram avaliados 30 pacientes com HP. Após o início da reposição de GEV, houve redução da frequência de pneumonias (p<0,001). Os 11 pacientes que apresentavam bronquiectasias na primeira tomografia computadorizada (TC) eram mais velhos ao diagnóstico (p=0,001) e tiveram maior atraso no diagnóstico (p=0,001) quando comparados aos pacientes sem bronquiectasias. Ao final do estudo, 18 pacientes apresentavam bronquiectasias e 27/30 também apresentaram outras alterações pulmonares, isoladas ou concomitantes. O escore de Bhalla foi aplicado à última TC de 16/30 pacientes, com mediana do escore de 11 (variação 7-21), com correlação positiva entre o escore e o número de pneumonias após o início do tratamento (r=0,561; p=0,024). O escore foi ainda correlacionado com valores de volume expiratório forçado no primeiro segundo (VEF1) e capacidade vital forçada (CVF) obtidos por espirometria de 13/16 pacientes, com correlação negativa com VEF1 pré- (r=-0,778; p=0,002) e pós-broncodilatador (r=-0,837; p<0,001) e CVF (r=-0,773; p=0,002). Conclusão: complicações pulmonares foram frequentes nesta coorte, apesar da diminuição na frequência de pneumonias com o tratamento. A investigação precoce de pacientes com infecções de repetição para imunodeficiências primárias pode reduzir a frequência dessas complicações. A monitorização de alterações na espirometria pode indicar a necessidade de investigação radiológica.

Disseminated bronchiectasis in an adult with common variable immunodeficiency / Bronquiectasias diseminada en un adulto con inmunodeficiencia común variable

Primary immunodeficiencies (PID) are traditionally considered childhood diseases; however, adults account for 35% of all patients with PID. Antibody deficiencies, especially Common Variable Immunodeficiency (CVID), which have their peak incidence in adulthood, require a high suspicion index. Even though the estimated frequency of CVID is not high (1:25,000), high rates of under diagnosis and under reporting are very likely. The delay in diagnosis increases the morbidity and mortality; therefore, adult physicians should be able to suspect, identify and initiate management of individuals with PID. Here we report the case of a 37 year-old man presenting to the emergency room with dyspnea, fever and cough; he developed respiratory failure requiring mechanical ventilation. He complained of recurring pneumonia associated with widespread bronchiectasis since he was 18 years old. Serum immunoglobulins quantification showed severe hypogammaglobulinemia (total IgG <140 mg/dL; total IgA, 2.9 mg/dL; and total IgM <5 mg/dL). Treatment with Human Intravenous Immunoglobulin (IVIG) 10% was started, and with antibiotic treatment for severe pneumonia (during 14 days) was also prescribed. His clinical evolution has been favorable after one year follow-up. Common Variable Immunodeficiency (CVID) diagnosis was made.

Las inmunodeficiencias primarias (IDP) son patologías que tradicionalmente se consideran de la niñez sin embargo los adultos representan el 35% del total de pacientes con IDP. Las deficiencias de anticuerpos, en especial la Inmunodeficiencia Común Variable (IDCV) tienen su pico de incidencia en la edad adulta, requiere un alto índice de sospecha y si bien su frecuencia estimada no es alta (1:25,000), es muy posible que el subregistro y subdiagnóstico si lo sean. El retraso en el diagnóstico aumenta la morbi-mortalidad razón por la cual los médicos de adultos deben estar en capacidad de sospechar, identificar e iniciar el manejo de las personas con IPD. Presentamos el caso de un hombre de 37 años de edad atendido en la sala de urgencias con disnea, fiebre y tos, desarrolla falla respiratoria requiriendo ventilación mecánica. Refería neumonías a repetición desde los 18 años de edad asociadas con bronquiectasias generalizadas. La cuantificación de inmunoglobulinas séricas evidenció hipogammaglobulinemia severa (IgG total <140 mg/dL, IgA total 2.9 mg/dL, IgM total <5 mg/dL), se inició inmunoglobulina humana endovenosa (IGIV) al 10%, y recibió tratamiento antibiótico por 14 dias para neumonía severa, su evolución clínica ha sido favorable hasta ahora (un año de seguimiento), se estableció el diagnostico de Inmunodeficiencia Común Variable (IDCV).

Spectrum of primary immune deficiency at a tertiary care hospital.

OBJECTIVE: To report various primary immune deficiencies diagnosed in children at a tertiary care hospital, their clinical manifestations and laboratory profile. METHODS: Case records of children diagnosed to have primary immunodeficiency disorders over a period of 24 months at a tertiary care hospital in northern India were evaluated. RESULTS: Twenty-seven children (M: F=3.5: 1) with mean age of 5.4 +/- 4.6 yrs (2 mo-16 yr) were diagnosed to have primary immunodeficiency. Thirteen children had chronic granulomatous disease (CGD), 4 had severe combined immunodeficiency (SCID), 4 had hypogammaglobulinemia, 2 had Ataxia telangiectasia, and one each had DiGeorge syndrome, Wiskott Aldrich syndrome, hyper IgM syndrome and leukocyte adhesion defect. Common mode of presentation were recurrent/ persistent pneumonia in 19, recurrent/ persistent diarrhea in 10, deep seated abscesses in 8, allergy in 3, disseminated tuberculosis infection in 2, extensive fungal infections in 2 and 1 each of disseminated cytomegalovirus (CMV) infection, disseminated BCG disease, otitis media and meningitis. Family history of sibling deaths was elicited in 2 families. Infectious agents were isolated in 16 cases. CONCLUSION: From a single center 27 patients with primary immune deficiency could be identified by chart review, suggesting need for high index of suspicion for diagnosis of primary immune deficiency in India. Though the exact prevalence is not known there is need to make a registry to document the magnitude of problem of these disorders.

Dificient expression of brouton's tyrosine kinase in monocytes from x linked agmmaglobulinemia as evaluated by a flow cytometric analysis and its clinical application to carrier detection

The B-cell defect in X-linked agammaglobulinemia [XLA] is caused by mutations in the gene for Bruton's tyrosine kinase [BTK]. BTK mutations result in deficient expression of BTK protein in peripheral blood monocytes. Using the anti-BTK monoclonal antibody [48-2H], a flow cytometric analysis of intra cytoplasmic BTK protein expression in monocytes was performed to identify Iranian patients with XLA phenotype. To examine the possible identification of XLA patients and female carriers by this assay, we studied 13 XLA families. The flow cytometric assay showed deficient expression of the BTK protein in 12 [92%] families. One patient exhibited a normal level of BTK expression. The cellular mosaicism of BTK expression in monocytes from obligate carriers was clearly shown in 9 of 12 [75%] families. The results suggested that most XLA patients have deficient expression of the BTK protein; therefore we conclude that deficient expression of BTK protein can be evaluated by a flow cytometric assay

Imunodeficiências primárias: agamaglobulinemias: série de casos / Immunodeficiencys would excel: agamaglobulinemias: series of cases

Os autores descrevem uma série de casos de agamaglobulinemia ligada ao X e fazem uma breve revisão da literatura sobre esta desordem imunológica. Salientam os sinais e sintomas para que o pediatra generalista tenha condições de realizar um diagnóstico mais precoce que permita melhor manuseio clínico e terapêutico para os pacientes portadores desta doença

Agamaglobulinemia ligada ao cromossomo X em nove pacientes: revisäo de literatura / X-linked agammaglobulinemia in nine patients: review literature

A Agamaglobulinemia ligada ao X (ALX) e uma imunodeficiencia rara, caracterizada pela ausencia ou diminuicao acentuada de todos os isotipos de imunoglobulinas sericas e maior suscetibilidade a infecçöes, principalmente apos o sexto mes de vida. Os autores apresentam nove pacientes portadores de ALX, com processos infecciosos recorrentes (pneumonias 7/9, otites 7/9, sinusites 5/9, diarreias 3/9, artrites infecciosas 3/9, meningites 3/9, piodermites 3/9, encefalite viral 1/9), com inicio dos sintomas em media aos nove meses de vida. Os exames laboratoriais mostraram ausencia de resposta de anticorpos, com imunidade celular normal. Os pacientes receberam gamaglobulina com controle dos processos infecciosos. Cinco crianças receberam antibioticoterapia profilatica para controle de sinusites...

Relaciones entre niveles de inmunoglobulinas y patrones electroforéticos del suero / Relationship between immunoglobulin levels and serum electrophoretic pattern

La cuantificación de inmunoglobulinas séricas es el examen más importante en la evaluación de inmunodeficiencias humorales primarias o secundarias. La electroforesis de proteínas séricas (EFPs) da información cualitativa y semicualitativa de la Igs a través de la separación de las proteínas mediante un campo eléctrico. Por la gran variedad de información que aporta, tiene gran utilidad clínica. La relación entre ambos exámenes es más estrecha en medicina interna, en que se recomienda hacer ambas determinaciones. Para estudiar las relaciones que existen entre la determinación específica de niveles de Igs séricas por inmunodifusión radial (IDR) y un examen de screening que engloba a las Igs como la EFPs en soporte de agarosa o acetato de celulosa, se analizó una muestra de 441 pacientes mayores de 10 años que tuvieran determinación de ambos exámenes. Se descartaron los exámenes con componente monoclonal electroforético. Al relacionar los valores de Igs y los de fracción gammaglobulinas mediante el coeficiente de correlación lineal se determinó en todas un valor significativo, que correspondió a 0,7 para IgG, 0,34 para IgM y 0,25 para IgA. Esto corresponde a una buena correlación para IgG y moderada para IgA e IgM. La capacidad predictiva de concentraciones altas y bajas de Igs mediante el nivel de gammaglobulinas se estudió por el odds ratio o razón de probabilidades; la que fue de 32 para IgG baja e hipogammaglobulinemia severa; 7 para IgG baja e hipogammaglobulinemia; 19 para IgG alta e hipergammaglobulinemia; 26 para concentraciones bajas de IgG, A o M e hipogammaglobulinemia severa; 6 para IgA alta e hipergammaglobulinemia y 2 para IgG, A o M bajas e hipogammaglobulinemia. La hipogammaglobulinemia severa demostró ser una prueba de gran específicdad y buena sensibilidad para detectar tanto valores bajos de IgG como disminuciones de algunas de las Igs: G, M o A. Menos específico pero más sensible mostró ser la hipogammaglobulinemia en valores bajos de IgG. Sin embargo, la hipogammaglobulinemia no mostró buena sensibilidad para detectar valores bajos de IgG, A o M; debido principalmente a su poca variación cuando una de estas dos últimas Igs disminuye. La hipergammaglobulinemia mostró buena sensibilidad y específicidad para aumentos policlonales de IgG e IgA

Hipogamaglobulinemia común, variable del adulto: a propósito de un caso clínico / Common variable hypogammaglobulinemia of the adult: apropos of a case

La Hipogamaglobulinemia común variable del adulto es una afección poco frecuente. Sus manifestaciones clínicas son similares a los de la hipogamaglobulinemia congénita, destacándose la presencia de bronquiectasias adquiridas por infecciones respiratorias reiteradas. El hallazgo de otras anomalías inmunitarias, en particular, alteraciones cuanti y cualitativas de los linfocitos T, ponen en la pista del diagnóstico de esta afección. A propósito de este caso, se repasan las causas más frecuentes de bronquiectasias en el adulto, su metodología de estudio y su relación con alteraciones del sistema inmune. Se señala además el hallazgo de mutaciones vinculadas con la mucovisidosis como una interrogante en la interpretación patogénica de todo el cuadro

Diarréia crônica e infecçöes repetidas em adulto / Chronic diarrhea and repeated infections in an adult

Um caso de infecçäo por Shigella flexneri em uma mulher de 34 anos de idade com hipogamaglobulinemia e diarréia é apresentado; o problema diagnóstico representado por diarréia no paciente com hipogamaglobulinemia é discutido. A revisäo de 7 outros pacientes com hipogamaglobulinemia tratados no HCRP é apresentado e é enfatizado que vários agentes patogênicos podem causar diarréia nesses pacientes

The prediction of serum IgG levels by scanning densitometry.

A novel approach has been described. In this method the serum IgG level can be predicted with a fair degree of accuracy by scanning densitometry and total serum protein values. This approach might be useful as a screening procedure for hypogammaglobulinemia.