1. Morning Conference
July 22, 2009
Araya Tangwitoon, MD

2. History
• A 14-year-old girl presented with chronic
rhinosinusitis and recurrent otitis media.
• She had a history of recurrent otitis media since
8-yr-old & a history of recurrent rhinosinusitis since
10-yr-old, which not responded to treatment with
various antibiotics.

3. • Nasal discharge culture (1st): P. aeruginosa
Sensitivity to ciprofloxacin
• Nasal discharge culture (2nd): M. morganii
Sensitivity to amikacin, ceftazidime, cefoxitin, imipenem
• CBC: Hb 12.8 mg/dL Hct 39.2%
WBC 8100 /mm3 N 67% L 26% M 4% Eo1.4%
Plt 216,000 /mm3
• Serum IgG 12.4 mg/dL (600-1600)
IgM <18.6 mg/dL (40-160)
IgA <5.91 mg/dL (80-480)

4. Problem Lists
• A 14-yr-old girl with CRS
• Recurrent sinopulmonary tract infections
• Panhypogammaglobulinemia
• Secondary hypogammaglobulinemia
• Primary Immunodeficiency

5. Physical Examination
• A Thai girl, good consciousness, well co-operate
• BW 48 kg (P50-75), Ht 158 cm (P50-75)
• HEENT: not pale, no jaundice
Rt ear: TM perforation with opacity & mucoid
discharge
Nose: purulent discharge both nostrils,
Inferior turbinate 3+ both
Tonsils: 1+, mucopurulent postnasal drip
• Heart: normal S1S2, no murmur
• Lungs: Clear, Rt = Lt
• Abd: soft, not tender, spleen: just palpable,
no hepatomegaly
• Ext: normal

6. • Flow cytometry:
WBC 9,050/ul
Absolute total lymphocyte 2,054/ul
Lymphocyte 22.7%
%CD3 92% Absolute CD3 1,890 /ul
%CD4 55% Absolute CD4 1,130 /ul
%CD8 34% Absolute CD8 698 /ul
%CD19 2%
%CD56 6%

7. • Serum IgG < 7.3 mg/dL (600-1600)
IgM < 18.6 mg/dL (40-160)
IgA < 5.91 mg/dL (80-480)
• Flow cytometry: WBC 6,150 /ul
ALC 1,550/ul Lymphocyte 25.2%
%CD3 91% Absolute CD3 1,411 /ul
%CD4 54% Absolute CD4 837 /ul
%CD8 34% Absolute CD8 527 /ul
%CD19 1%
%CD56 5%

8. Problem Lists
• A 14-yr-old girl with CRS
• Recurrent sinopulmonary tract infections
• Panhypogammaglobulinemia
• Low number of circulating B cell
• Secondary hypogammaglobulinemia
• Primary Immunodeficiency
– Autosomal Agammaglobulinemia
– X-Linked Agammaglobulinemia
– Common Variable Immunodeficiency

9. Secondary hypogammaglobulinemia
• Drug-induced • Excessive loss of immunoglobulins
– Anticonvulsants – Protein-losing enteropathy
(e.g., carpamazepine – Nephrotic range proteinuria
and phenytoin) – Severe burns
– Gold salts
– Penicillamine • Malignancy
– Antimalarial agents – Chronic lymphocytic leukemia
– Methotrexate – Non-Hodgkin's B-cell lymphoma
• Infectious diseases
– Epstein-Barr virus

10. XLA or AR
CVID
Agammaglobulinemia
Age at onset XLA: 6-12 months Any ages; peak in first & third
AR: younger than XLA decades
Sex XLA: males males and females
AR: males and females
Clinical recurrent infections; recurrent infections,
manifestations more severe in AR autoimmune manifestations,
agammaglobulinemia lymphoma & other selected cancers.
Lymphoid tissue hypoplasia or absent Normal-sized or Enlarged
Serum Ig level profound hypogammaglobulinemia Decreased IgG, IgA
(IgG, IgA and IgM) and/or IgM
Peipheral B Cells almost complete absence of normal or low number
peripheral B cells, as defined by
CD19 & CD20 expression (<2%)
Molecular analysis XLA; BTK mutation ICOS, CD19, TACI, BAFF-R, Msh5
AR; μ heavy chain, Igα, Igß,
λ5/VpreB, BLNK

11. AR Agammaglobulinemia
XLA CVID
Berek C et al. Clinical Immunology Principles and Practice.3rd Edition.

12. Autosomal Recessive Agammaglobulinemia
• When compared with XLA
– an earlier onset of disease
– more severe complications
• Females with early onset
infections, profound
hypogammaglobulinemia and
absent B cells
• Male patients with negative BTK
mutation analysis results
Schroeder HW Jr. Clinical Immunology Principles and Practice.3rd Edition.
Aghamohammadi A et al. Primary Immunodeficiency Diseases: Definition, Diagnosis, and Management 1st edition.

13. • 4 pts: homozygous
mutation in IGHM
• 2 pts: compound
heterozygous variations
in VpreB1 gene
• Several new single
nucleotide
polymorphisms both in
the μHC and in the λ5-
like/VpreB-coding genes
were identified.
S Ferrari et al.
Genes and Immunity 2007;8:325–33.

15. Clinical findings in AR agammaglobulinemia
Lopez-Granados E, Porpiglia A, Hogan MB, et al. J Clin Invest 2002; 110:1029-35.

16. • A 10-month-old Japanese girl with frequent respiratory infections
and otitis media (onset of infections: 8-month-old)
• Her father was diagnosed as having XLA.
• Her serum IgG 6 mg/dL, IgA 1 mg/dL, IgM 5 mg/dL
• Flow cytometric analysis
– the lack of peripheral B cells with the block of B-cell
differentiation in the stages between pro-B cells and pre-B
cells in the bone marrow
– the defect of the Bruton tyrosine kinase (BTK) expression on
monocytes
Takada H et al. Blood. 2004;103:185-187.

17. Defect of BTK and block of B-cell differentiation.
Patient Healthy control
Patient Healthy
control
Paternal
Grand
mom Pt Mother Brother Father
Takada H et al. Blood. 2004;103:185-187

18. • Maternally derived X chromosome was
exclusively inactivated in peripheral blood
& oral mucosal cells.
XLA
(Heterozygous abnormality of the BTK gene &
nonrandom X inactivation of maternally
derived X chromosome in which normal
BTK gene is located.)
Takada H et al. Blood 2004;103:185-187.

19. Problem Lists
• A 14-yr-old girl with CRS
• Recurrent sinopulmonary tract infections
• Panhypogammaglobulinemia
• Low number of circulating B cell
• Secondary hypogammaglobulinemia
• Primary Immunodeficiency
– Autosomal Agammaglobulinemia
– X-Linked Agammaglobulinemia
– Common Variable Immunodeficiency

20. Physical Examination
• A Thai girl, good consciousness, well co-operate
• BW 48 kg (P50-75), Ht 158 cm (P50-75)
• HEENT: not pale, no jaundice
Rt ear: TM perforation with opacity & mucoid
discharge
Nose: purulent discharge both nostrils,
Inferior turbinate 3+ both
Tonsils: 1+, mucopurulent postnasal drip
• Heart: normal S1S2, no murmur
• Lungs: Clear, Rt = Lt
• Abd: soft, not tender, spleen: just palpable,
no hepatomegaly
• Ext: normal

21. Common Variable
Immunodeficiency

22. CVID
• The most common symptomatic PID
• A group of genetically, immunologically &
clinically heterogeneous disorders
• Hypogammaglobulinemia & recurrent
infections
• Complicated by autoimmunity,
granulomatous inflammation,
lymphoproliferation & malignancy
• Inherited in 10-20% of patients
• Associated genetic defects: ICOS, TACI,
CD19, BAFF-R and Msh-5

23. CVID: Definition
• Hypogammaglobulinaemia of
> 2 immunoglobulin isotypes
(significant reduction of IgG (>2SD),
reduction of IgA or IgM)
• Recurrent infections
• Impaired functional antibody responses
• Exclusion of other primary antibody
deficiency syndromes & secondary
causes of hypogammaglobulinemia
www.ESID.org

24. Clinical Features
of
CVID patients

25. CVID: Age at onset & diagnosis
No. of Delay
Age at Age at Age at
CVID Diagnosis;
evaluation; year onset; year Diagnosis; year
patients year
Chapel H et al. 334 mean±SD: Mean: 26.3 Mean: 33.5 NA
Blood 2008;112: 49.4±16.3 median: 24 median: 33
277-86. (11-90)
Wehr C et al. 303 mean±SD: mean±SD: mean±SD: NA
Blood 2008;111:77-85. 47±17 27±17 35±16
(10-84)
Oksenhendler E et al. 252 Median: 44 Median: 19 Median: 33.9 Median: 6.9
Clinical Infectious (12-87) (0-55)
Diseases2008;46:1547–54
URSCHEL S et al. 32 < 18 NA Median: Median:
J Pediatr 2009;154: 10.4±4.3 5.8±4.2
888-94. (1.1-17.4) (0.2-14.3)
Llobet et al. 22 < 18 NA Median: 7.8 NA
Pediatr Allergy Immunol (2.5-16)
2009: 20: 113–118.

26. Park MA et al. Lancet 2008;372:489-502.

27. Infectious complications
in CVID patients
Oksenhendler E et al.
Clinical Infectious Diseases 2008;46:1547–54.

28. Chapel H and Cunningham-Rundles C. British Journal of Haematology 2009;145:709–727.
(originally published in Blood. Chapel H. et al. Blood 2008;112:277–286.)

29. Chapel H et al.
Blood 2008;112: 277-86.

30. only breakthrough a noninfectious complication (with or without breakthrough infections).
infections
Lymphocytic infiltration: n=38
Autoimmunity: n=72
Enteropathy: n=7
Malignancy: n=1
lymphocytic infiltration+autoimmunity: n=28
Enteropathy+lymphocytic infiltration: n=8
lymphocytic infiltration+malignancy: n=1
Enteropathy+autoimmunity: n=3
Autoimmunity+malignancy: n=2
autoimmunity,
lymphocytic infiltration,
enteropathy,
malignancy: n=1
Autoimmunity+lymphocytic infiltration+enteropathy: n=9
Autoimmunity+lymphocytic infiltration+malignancy: n=4
Lymphocytic infiltration+enteropathy+malignancy: n=1
Chapel H et al. Blood 2008;112: 277-86.

31. Disease complication prevalences
WEHR et al. CHAPEL et al
(Blood 2008; 111:77-85.) (Blood. 2008;112:277-86.)
No. of CVID patients 303 334
Splenomegaly, % 40.5 30
Lymphadenopathy, % 26.2 15
Granulomatous disease, % 11.6 8
Autoimmune phenomena*, % 20.3 25
Autoimmune cytopenia, % 20.2 12
*not include autoimmune cytopenia

32. Wehr C et al. Blood 2008;111:77-85.

33. Chapel H et al. Blood 2008;112: 277-86.

35. URSCHEL S et al. J Pediatr 2009;154:888-94.

36. Immunological analysis
of
CVID patients

37. European cohort
Serum
Immunoglobulin
at diagnosis
Serum IgG < 1 g/L
Serum IgG 1.1-3 g/L
Serum IgG >3, <6.5 g/L
United States Cohort
Chapel H and Cunningham-Rundles C.
British Journal of Haematology 2009;145:709–727.

38. Pediatric population
diagnosed of CVID
Serum level in each patient at first diagnosis
IgG
IgM
IgA
URSCHEL S et al. J Pediatr 2009;154:888-94.

39. Peripheral B Cells
No significant associations with clinical phenotypes
Chapel H et al. Blood 2008;112: 277-286.

40. Association of clinical phenomena with dysregulated B-cell subpopulations.
Wehr C et al. Blood 2008;111:77-85.

41. Pediatric population diagnosed of CVID
Llobet et al. Pediatr Allergy Immunol 2009: 20: 113–118.

42. URSCHEL S et al.
J Pediatr 2009;154:888-94.

43. Classification systems
for CVID

44. Peripheral blood B-cell subsets
Park MA et al. Lancet 2008;372:489-502.

45. Classification
systems
for
CVID
Expert Review of Clinical Immunology 2009.

46. Evaluation of the Paris and Freiburg classification scheme.
P < 0.001
P = 0.03
P = 0.04
P = 0.02 P = 0.02
Wehr C et al. Blood 2008;111:77-85.

47. P < 0.001
P = 0.002
P < 0.01
P = 0.009 P = 0.03
P < 0.001
P = 0.049
P = 0.016 Wehr C et al. Blood 2008;111:77-85.

48. Genetics of CVID

49. Genetics for CVID
• ICOS
• CD19
• TACI (TNFRSF13B)
• BAFF-R (TNFRSF13C)
• Msh5

50. The inducible costimulator (ICOS) gene
• Germinal center formation
• Memory B cell development
• Provide T-cell dependent antibody response for B cell
Park MA et al. Lancet 2008;372:489-502.

51. Fig. 1. Inducible co-stimulator molecule (ICOS) : ICOS-L signalling can results in multiple pathways.
C. Bacchelli et al. Clinical and Experimental Immunology 2007;149: 401–9.

52. ICOS Deficiency
• About 2% of patients with CVID
• Inherited as autosomal recessive trait
• 9 CVID patients from 4 apparently unrelated
families descended from a common founder
• Geographical location: along the river Danube
• Serum IgG & IgA levels were markedly
reduced in all patients
– IgG < 1.9-2.55 g/L
– IgA < 0.06-0.58 g/L
• Serum IgM level
– reduced in 6/9 patients
– low normal values in 3/9 patients
Yong et al. Immunological Reviews 2009;229: 101–113.
Park MA et al. Lancet 2008;372:489-502.
C. Bacchelli et al. Clinical and Experimental Immunology 2007, 149: 401–409.

53. • Circulating B cells
– Markedly reduced in 5/9 patients
– Slightly elevated in 2/9 patients
• Switched memory B cells: absent in all patients
• Few abnormalities in T-cell phenotype & function
– 3 patients had an inverted CD4⁄CD8 ratio.
– Normal in vitro proliferation responses when stimulated with
mitogens & antigens
• Marked impairment of germinal center formation
• The clinical phenotype shows nearly all complication
(autoimmunity, benign lymphoproliferation, chronic
granulomatous inflammation & malignancy).
Yong et al. Immunological Reviews 2009;229: 101–113.
C. Bacchelli et al. Clinical and Experimental Immunology 2007;149: 401–409.

55. The B cell receptor signaling complex
Park MA et al. Lancet 2008;372:489-502
Schaffer AA et al. Current Opinion in Genetics & Development 2007, 17:201–12.

56. CD19 Deficiency
• 4 patients with homozygous mutations in the CD19 gene,
from 2 unrelated families
– increased susceptibility to infection
– hypogammaglobulinemia
– normal numbers of CD20+ B cells
– expression of CD 19 on B cells
• undetectable in 1/4 patients
• barely detectable in 3/4 patients
• Numbers of CD27+ memory B cells & CD5+ B cells
• Normal germinal center formation
• Poor antibody response to rabies vaccination
• No autoimmune features or signs of lymphoproliferation
van Zelm MC, Reisli I, van der Burg M et al. N Engl J Med 2006;354:1901-12.

57. van Zelm MC, Reisli I, van der Burg M et al. N Engl J Med 2006;354:1901-12.

58. The APRIL–BAFF network
Park MA et al. Lancet 2008;372:489-502

59. Interactions of BAFF, APRIL with their receptors
C. Bacchelli et al. Clinical and Experimental Immunology 2007;149: 401–9.

60. TACI Mutation
• Prevalence: 10-20% of CVID patients
• Risk factors, not solely disease-causing in CVID
• Associated with
– Lymphoproliferation
• splenomegaly
• tonsillar hyperplasia
• follicular nodular hyperplasia of GI
– Autoimmunity
• hemolytic anaemia
• autoimmune thrombocytopaenia
• thyroiditis
Park MA et al. Lancet 2008;372:489-502.
Young PFK et al. Immunol Allergy Clin N Am 2008;28:367-86.
C. Bacchelli et al. Clinical and Experimental Immunology 2007;149: 401–409.

61. TACI Mutation
• A multicenter study involving 564 unrelated
CVID patients
• 8.8% (50/564) of the patients carried
at least 1 mutated TACI allele.
– 4% (2/50): homozygous mutations
– 14% (7/50): compound heterozygous
mutations
– 82% (41/50): heterozygous mutations
Salzer U et al. Blood 2009;113:1967-76.

62. • TACI C104R & A181E
– mutational 'hotspots‘
– Approximately 80% of the sequence variants in TACI
– present in a heterozygous state in 2% of 675 healthy
controls
Salzer U et al. Blood 2009;113:1967-76.

63. Salzer U et al. Blood 2009;113:1967-76.

64. Zhang et al. 2007
• 7.3% (13/176) of subjects had Heterozygous
TACI mutations.
• Autoimmune thrombocytopenia
– 46% of subjects with mutations
– 12% of subjects without mutations
• Mutations in TACI significantly predispose to
autoimmunity and lymphoid hyperplasia in CVID.
• Splenomegaly and splenectomy were
significantly increased (P 5 .012; P 5 .001).
• 8 first-degree relatives from 5 families had the
same mutations but were not immune-deficient.
Zhang et al. J Allergy Clin Immunol 2007;120:1178-85

65. Zhang et al. J Allergy Clin Immunol 2007;120:1178-85.

66. Immunologic
phenotype of
TACI-deficient
patients.
Salzer U et al. Blood 2009;113:1967-76.

67. 36% (18/50)
Autoimmunity &
lymphoproliferation
in TACI deficiency
60% (30/50)
Salzer U et al. Blood 2009;113:1967-76.

68. BAFF-R Deficiency
• Described in only 1 patient
• a 60-year-old male with
hypogammaglobulinaemia
• Profound reduction of both class switch
(CD27+, IgM-, IgD-) & non-switched memory
(CD27+, IgM+, IgD+)
• Transitional B cell (CD38+++, IgM++)
• Plasmablasts (CD38+++, IgM-)
Park MA et al. Lancet 2008;372:489-502.
C. Bacchelli et al. Clinical and Experimental Immunology 2007;149: 401–409.

69. MutS 5 (Msh5)
• A gene encoded in the central
MHC class III region
• A critical role in regulating meiotic
homologous recombination
• A role in class switch recombination
• Msh5 Mutation: associated with CVID
and selective IgA deficiency.
Young PFK et al. Immunol Allergy Clin N Am 2008;28:367-86.
Sekine et al. Proc Natl Acad Sci U S A. 2007 ;104(17):7193-8.

70. Gene
Frequency
(chromosomal Inheritance Phenotype B-cell phenotype Clinical phenotype
(%)
location)
ICOS (2q33) 2 AR CVID Low numbers of Recurrent respiratory
B-cell & memory B infections,
cells autoimmunity,
granulomata and
malignancy
TNFRSF13B/ 8-20 AD • CVID, No specific B-cell Recurrent respiratory
TACI • IgG phenotype infections, increased
(17p11.2) subclass rates of benign
deficiency lymphoproliferation and
• sIgAD increased rates of
autoimmunity
CD19 1 AR CVID Decrease in class Recurrent respiratory
(16p11.2) switched memory B infections
cells, low CD21
expression on B
cells, normal
numbers of CD20+
mature B cells in
peripheral blood
TNFRSF13C/ <1 AR CVID Low B-cell numbers, Recurrent respiratory
BAFF-R relative increase in infections
(22q13.1- transitional B cells
q13.31) and low numbers
of memory B cells
Park MA et al. Lancet 2008;372:489-502. Expert Review of Clinical Immunology, March 2009, Vol. 5, No. 2, Pages 167-180

71. Therapeutic Management
• Prevention of recurrent and chronic
infections by Immunoglobulin therapy
• Antibiotic therapy of breakthrough
infections
• Treatment of associated disease
complications and sequelae

72. • A 14-yr-old girl with CRS
• Recurrent sinopulmonary tract infections
• Panhypogammaglobulinemia
• Low number of circulating B cell
• Splenomegaly
Common Variable Immunodeficiency

73. Management
• Treatment of infections
• Intravenous immunoglobulin
replacement therapy
• Genetic Testing
• Surveillance for autoimmunity and
malignancy

74. …THANK YOU…