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Genetic Defects of Griscelli Syndrome Type 2 in Saudi Arabia
Abstracts AB155
J ALLERGY CLIN IMMUNOL VOLUME 129, NUMBER 2
Asthma Severity in Aspirin Exacerbated Respiratory Disease K. S. Farnam, D. D. Stevenson; Scripps Clinic, San Diego,
CA. RATIONALE: Aspirin Exacerbated Respiratory Disease (AERD) is characterized by chronic rhinosinusitis, nasal polyposis, and asthma that is exacerbated with ingestion of aspirin. AERD has been associated with severe asthma. Our hypothesis was that standard markers of severity would be the same in both groups. METHODS: One hundred AERD asthmatics were compared with one hundred non-AERD asthmatics, the latter recruited as new or continuing care patients in the Scripps Allergy Division. A simple survey questionnaire was administered to both groups. Two sample T test was used for analysis. RESULTS: The two populations did not have significant differences in baseline characteristics (age, sex and baseline FEV1 values). Unscheduled visits for asthma exacerbations were higher in the AERD group (0.53/yr vs 0.18/yr p50.009). Uses of medications were the same for low and medium dose inhaled corticosteroids and use of bursts or continuous systemic corticosteroids. However, high dose inhaled corticosteroids (33 vs 19 p50.009), long acting bronchodilators (73 vs 46 p50.003) and leukotriene receptor antagonists (77 vs 25 p<0.0001) were used more frequently in the AERD patients. Abnormal sinus imaging results were characteristic of the AERD patients and were compared to the non-AERD control asthmatics: pansinusitis (100 vs 10), any sinus opacification (100 vs 26) and nasal polyps (100 vs 7). History of any "sinusitis" was recorded in 100 AERD patients and 43 non-AERD patients. p values for all were <0.0001. CONCLUSIONS: Asthma in AERD patients has more markers of severity and striking differences in upper airway disease when compared to asthma in a heterogeneous non-AERD patient population.
584
DiGeorge Syndrome Immune Reconstitution and CMV Elimination by Bone Marrow Transplant S. K. Chan1, R. Krance1, W. W. Stafford2, R. Lee3, D. K. Nguyen4, G. Harrison1, I. C. Hanson1; 1Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, 2Driscoll Childrens Hospital, Corpus Christi, TX, 3Texas Department of State Health Services, Austin, TX, 4Houston Allergy Asthma Associates, Houston, TX. RATIONALE: Complete DiGeorge Syndrome (cDGS) patients are completely athymic and exhibit a T-B+NK+ severe combined immunodeficiency (SCID) phenotype with inability to eliminate viral infections. We report the progressive functional immune reconstitution of a cDGS infant with resolution of persistent CMV viremia following bone marrow transplant (BMT). METHODS: Retrospective chart review. RESULTS: A term male infant born without DGS-associated genetic deletions presented with multiple congenital abnormalities including athymia, right kidney agenesis, butterfly vertebrae, hypocalcemia, and congenital heart disease. Initial evaluation revealed virtual absence of T cell markers (CD4+: 7 cells/ mm3, CD4+CD45 RA+: 4 cells/ mm3, absent TRECs) and absent phytohemagglutinin lymphoproliferative response. CMV viremia detected by PCR reached over 4 million copies/ mL at 6 weeks old and persisted despite aggressive antiviral treatment with 500 copies/ mL at 4 months old immediately prior to BMT. Thymic transplantation was unavailable, so he received unmanipulated BMT from his HLA matched brother without pre-transplant conditioning. CMV viremia has been undetectable off antiviral treatments since 9 months post transplant. Serial lymphocyte studies demonstrate sustained CD4+CD45 RO+ cell recovery with good lymphoproliferative responses. Immunoglobulin titers to vaccines allowed him to wean off of IVIG. At >2 years since transplant, he has no evidence of chronic graft versus host disease. CONCLUSIONS: BMT in cDGS patients is a viable option to establish long term functional immune reconstitution and eradication of life threatening viral infections.
585
Genetic Defects of Griscelli Syndrome Type 2 in Saudi Arabia H. Al-Mousa1,2, A. Al-Ghonaium1, H. Al-Dhekri1, S. Al-Muhsen1, B. Al-Saud1, R. Arnaout1, N. Ades1, S. Alhisi1, A. Hawwari1; 1King Faisal Specialist Hospital and Research Center, Riyadh, SAUDI ARABIA, 2 Alfaisal university, Riyadh, SAUDI ARABIA. RATIONALE: Griscelli syndrome type 2 is a rare autosomal recessive disorder that results in a characteristic pigmentary dilution of the skin and the hair associated with an immune defect, leading to episodes of a lifethreatening uncontrolled T lymphocyte and macrophage activation syndrome known as accelerated phase or hemophagocytic lymphohisticytosis (HLH). We aimed to present the clinical and the underlying genetic defects of eleven Saudi patients. METHODS: Griscelli syndrome type 2 was diagnosed based on the characteristic irregular large melanin clumps in hair shafts viewed by light microscopy, the hypopigmented skin and HLH picture. All patients were screened for mutations in RAB27A gene. RESULTS: Six mutations identified in the eleven patients screened from nine families. Four were novel mutations (W73X, A92fsX7, K134Q and Q172X) identified in four patients from four families. A two known mutations causing disease (R200X and R50fsX33) were identified in seven patients from five families. Parents of all patients were confirmned as carriers of the respective mutation. No similar mutations were found among 96 DNA samples derived from normal Saudi blood donors. CONCLUSIONS: RAB27 gene defects are responsible for all Griscelli syndrome type 2 in Saudi Arabia. Novel and known mutations were identified that expected to result into impaired protein function with severe clinical phenotype.
586
Histone-3-lysine-4 (H3K4) Methylation Defects in an Adult Female Kabuki Syndrome Patient with Pan-Hypogammaglobinemia A. W. Lindsley1, J. Bernstein2, M. Wills-Karp1; 1Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, 2University of Cincinnati, College of Medicine, Division of Immunology Allergy & Rheumatology, Cincinnati, OH. RATIONALE: Kabuki Syndrome (KS, Niikawa-Kuroki Syndrome, OMIM 147920) is a rare congenital condition characterized by distinct dysmorphic faces, intellectual disabilities, renal & cardiac abnormalities, and humoral immune deficiency. Autosomal-dominant, loss-of-function mutations in the Mixed Lineage Leukemia-2 (MLL-2/ALR) gene were recently associated with KS. MLL2/ALR is a histone methyl-transferase enzyme that adds gene-activating H3K4 modifications to promoter-associated histones. Given that the primary feature of KS-related immune deficiency is poor antibody production, we hypothesized that B cell H3K4 methylation patterns may be altered in KS patients. Here we describe our immune evaluation a 21yr old Female with clinically-diagnosed KS and pan-hypogammaglobinemia. METHODS: DNA sequencing of MLL2/ALR locus. Quantification of T, B, and NK cells. Anti-H3K4 Chromatin-immunoprecipitation (ChIP) on stimulated mature na€ıve B cells. RESULTS: DNA sequencing revealed a heterozygous T nucleotide insertion in exon10 of patient’s MLL2 gene, resulting in a premature stop codon. Immune phenotyping revealed deficient production of IgA, IgG1-4, and IgM. Lymphocyte subpopulation analysis revealed normal T (CD4+ & CD8+), B (CD19+), and NK cell (CD56+) counts. B cell cytometry identified normal counts of immature B cells (CD10+), transitional B cells (CD21+), and plasma cells (CD38+/CD138+), but reduced peripheral memory B cells (CD27+) and class-switched memory cells (CD27+ IgD-) counts. ChIP was performed on patient-derived B cells which revealed altered H3K4 methylation at the IL-6 promoter, a critical B cell survival cytokine. CONCLUSIONS: Our results suggest that hypogammaglobinemia in an MLL2 mutation positive KS patient may be secondary to altered H3K4 methylation patterns in activated B cells.
MONDAY
583
J ALLERGY CLIN IMMUNOL VOLUME 129, NUMBER 2
Asthma Severity in Aspirin Exacerbated Respiratory Disease K. S. Farnam, D. D. Stevenson; Scripps Clinic, San Diego,
CA. RATIONALE: Aspirin Exacerbated Respiratory Disease (AERD) is characterized by chronic rhinosinusitis, nasal polyposis, and asthma that is exacerbated with ingestion of aspirin. AERD has been associated with severe asthma. Our hypothesis was that standard markers of severity would be the same in both groups. METHODS: One hundred AERD asthmatics were compared with one hundred non-AERD asthmatics, the latter recruited as new or continuing care patients in the Scripps Allergy Division. A simple survey questionnaire was administered to both groups. Two sample T test was used for analysis. RESULTS: The two populations did not have significant differences in baseline characteristics (age, sex and baseline FEV1 values). Unscheduled visits for asthma exacerbations were higher in the AERD group (0.53/yr vs 0.18/yr p50.009). Uses of medications were the same for low and medium dose inhaled corticosteroids and use of bursts or continuous systemic corticosteroids. However, high dose inhaled corticosteroids (33 vs 19 p50.009), long acting bronchodilators (73 vs 46 p50.003) and leukotriene receptor antagonists (77 vs 25 p<0.0001) were used more frequently in the AERD patients. Abnormal sinus imaging results were characteristic of the AERD patients and were compared to the non-AERD control asthmatics: pansinusitis (100 vs 10), any sinus opacification (100 vs 26) and nasal polyps (100 vs 7). History of any "sinusitis" was recorded in 100 AERD patients and 43 non-AERD patients. p values for all were <0.0001. CONCLUSIONS: Asthma in AERD patients has more markers of severity and striking differences in upper airway disease when compared to asthma in a heterogeneous non-AERD patient population.
584
DiGeorge Syndrome Immune Reconstitution and CMV Elimination by Bone Marrow Transplant S. K. Chan1, R. Krance1, W. W. Stafford2, R. Lee3, D. K. Nguyen4, G. Harrison1, I. C. Hanson1; 1Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, 2Driscoll Childrens Hospital, Corpus Christi, TX, 3Texas Department of State Health Services, Austin, TX, 4Houston Allergy Asthma Associates, Houston, TX. RATIONALE: Complete DiGeorge Syndrome (cDGS) patients are completely athymic and exhibit a T-B+NK+ severe combined immunodeficiency (SCID) phenotype with inability to eliminate viral infections. We report the progressive functional immune reconstitution of a cDGS infant with resolution of persistent CMV viremia following bone marrow transplant (BMT). METHODS: Retrospective chart review. RESULTS: A term male infant born without DGS-associated genetic deletions presented with multiple congenital abnormalities including athymia, right kidney agenesis, butterfly vertebrae, hypocalcemia, and congenital heart disease. Initial evaluation revealed virtual absence of T cell markers (CD4+: 7 cells/ mm3, CD4+CD45 RA+: 4 cells/ mm3, absent TRECs) and absent phytohemagglutinin lymphoproliferative response. CMV viremia detected by PCR reached over 4 million copies/ mL at 6 weeks old and persisted despite aggressive antiviral treatment with 500 copies/ mL at 4 months old immediately prior to BMT. Thymic transplantation was unavailable, so he received unmanipulated BMT from his HLA matched brother without pre-transplant conditioning. CMV viremia has been undetectable off antiviral treatments since 9 months post transplant. Serial lymphocyte studies demonstrate sustained CD4+CD45 RO+ cell recovery with good lymphoproliferative responses. Immunoglobulin titers to vaccines allowed him to wean off of IVIG. At >2 years since transplant, he has no evidence of chronic graft versus host disease. CONCLUSIONS: BMT in cDGS patients is a viable option to establish long term functional immune reconstitution and eradication of life threatening viral infections.
585
Genetic Defects of Griscelli Syndrome Type 2 in Saudi Arabia H. Al-Mousa1,2, A. Al-Ghonaium1, H. Al-Dhekri1, S. Al-Muhsen1, B. Al-Saud1, R. Arnaout1, N. Ades1, S. Alhisi1, A. Hawwari1; 1King Faisal Specialist Hospital and Research Center, Riyadh, SAUDI ARABIA, 2 Alfaisal university, Riyadh, SAUDI ARABIA. RATIONALE: Griscelli syndrome type 2 is a rare autosomal recessive disorder that results in a characteristic pigmentary dilution of the skin and the hair associated with an immune defect, leading to episodes of a lifethreatening uncontrolled T lymphocyte and macrophage activation syndrome known as accelerated phase or hemophagocytic lymphohisticytosis (HLH). We aimed to present the clinical and the underlying genetic defects of eleven Saudi patients. METHODS: Griscelli syndrome type 2 was diagnosed based on the characteristic irregular large melanin clumps in hair shafts viewed by light microscopy, the hypopigmented skin and HLH picture. All patients were screened for mutations in RAB27A gene. RESULTS: Six mutations identified in the eleven patients screened from nine families. Four were novel mutations (W73X, A92fsX7, K134Q and Q172X) identified in four patients from four families. A two known mutations causing disease (R200X and R50fsX33) were identified in seven patients from five families. Parents of all patients were confirmned as carriers of the respective mutation. No similar mutations were found among 96 DNA samples derived from normal Saudi blood donors. CONCLUSIONS: RAB27 gene defects are responsible for all Griscelli syndrome type 2 in Saudi Arabia. Novel and known mutations were identified that expected to result into impaired protein function with severe clinical phenotype.
586
Histone-3-lysine-4 (H3K4) Methylation Defects in an Adult Female Kabuki Syndrome Patient with Pan-Hypogammaglobinemia A. W. Lindsley1, J. Bernstein2, M. Wills-Karp1; 1Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, 2University of Cincinnati, College of Medicine, Division of Immunology Allergy & Rheumatology, Cincinnati, OH. RATIONALE: Kabuki Syndrome (KS, Niikawa-Kuroki Syndrome, OMIM 147920) is a rare congenital condition characterized by distinct dysmorphic faces, intellectual disabilities, renal & cardiac abnormalities, and humoral immune deficiency. Autosomal-dominant, loss-of-function mutations in the Mixed Lineage Leukemia-2 (MLL-2/ALR) gene were recently associated with KS. MLL2/ALR is a histone methyl-transferase enzyme that adds gene-activating H3K4 modifications to promoter-associated histones. Given that the primary feature of KS-related immune deficiency is poor antibody production, we hypothesized that B cell H3K4 methylation patterns may be altered in KS patients. Here we describe our immune evaluation a 21yr old Female with clinically-diagnosed KS and pan-hypogammaglobinemia. METHODS: DNA sequencing of MLL2/ALR locus. Quantification of T, B, and NK cells. Anti-H3K4 Chromatin-immunoprecipitation (ChIP) on stimulated mature na€ıve B cells. RESULTS: DNA sequencing revealed a heterozygous T nucleotide insertion in exon10 of patient’s MLL2 gene, resulting in a premature stop codon. Immune phenotyping revealed deficient production of IgA, IgG1-4, and IgM. Lymphocyte subpopulation analysis revealed normal T (CD4+ & CD8+), B (CD19+), and NK cell (CD56+) counts. B cell cytometry identified normal counts of immature B cells (CD10+), transitional B cells (CD21+), and plasma cells (CD38+/CD138+), but reduced peripheral memory B cells (CD27+) and class-switched memory cells (CD27+ IgD-) counts. ChIP was performed on patient-derived B cells which revealed altered H3K4 methylation at the IL-6 promoter, a critical B cell survival cytokine. CONCLUSIONS: Our results suggest that hypogammaglobinemia in an MLL2 mutation positive KS patient may be secondary to altered H3K4 methylation patterns in activated B cells.
MONDAY
583