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Granulomatous and Lymphocytic Interstitial Lung Disease (GLILD) Associated with KMT2D Gene Mutation in Kabuki Syndrome
AB118 Abstracts
384
Granulomatous and Lymphocytic Interstitial Lung Disease (GLILD) Associated with KMT2D Gene Mutation in Kabuki Syndrome
Juan A. Adams, MD, Joel L. Gallagher, MD, Mary Hintermeyer, APNP, James W. Verbsky, MD, PhD, John M. Routes, MD, FAAAAI; Medical College of Wisconsin, Milwaukee, WI. RATIONALE: Granulomatous and lymphocytic interstitial lung disease (GLILD) is a known complication of CVID. Humoral immunodeficiency associated with Kabuki syndrome is increasingly recognized. Here we present a patient with Kabuki syndrome, due to a mutation in lysine (K)specific methyltransferase 2D (KMT2D), complicated by GLILD. METHODS: Chart review of flow cytometry results, clinical lab results, and lung pathology are presented. RESULTS: A 13-year-old male with Kabuki syndrome presented with recurrent otitis media, immune thrombocytopenic purpura, and psoriasis. Workup for ITP (platelets 27 K/uL) revealed panhypogammaglobulinemia (IgG 241 mg/dL, IgA <5 mg/dL, IgM 65 mg/dL). Further evaluation showed deficient vaccine titers to mumps, tetanus, diphtheria and pneumococcal antigens. Lymphocyte subsets revealed a low CD4 T-cell count (314/mm3; nl 500-1300), low total memory (7.8/mm3; nl 50-200) and switched memory B-cells (1.3/mm3; nl 30-110). HRCT of the chest and abdomen revealed mediastinal lymphadenopathy; bronchiectasis; bilateral, lower-lobe predominant ground glass nodular abnormalities and splenomegaly. Lung biopsy showed follicular bronchiolitis, lymphocytic interstitial pneumonia, and non-necrotizing granulomas; immunohistochemistry showed a CD4 T-cell predominant infiltrate (CD4>CD8) with a smaller B-cell population. Collectively, these findings are consistent with GLILD. Infectious workup (CMV, EBV, AFB, fungus and routine bacterial cultures) was negative. CONCLUSIONS: This is the first case report of a patient with Kabuki syndrome due to a KMT2D mutation and with biopsy-proven GLILD. This case illustrates that GLILD is not a complication limited to CVID. In fact, GLILD is well described in an increasing number of monogenic defects associated with immunodeficiency and immunodysregulation such as CTLA4 haploinsufficiency, LRBA deficiency and hypomorphic RAG1 mutations.
SUNDAY
385
A Novel Mutation in the CYBB Gene, Thr343Lys, in a Male Infant with X-Linked Chronic Granulomatous Disease with a Rare Presentation of Bilateral Parotiditis
Wei Te Lei, MD; Division of Allergy, Immunology, Rheumatology Disease, Department of Pediatrics, Mackay Memorial Hospital, Hsinchu, Taiwan. RATIONALE: Chronic granulomatous disease (CGD) is a rare primary immunodeficiency disease that is characterized by defects in NADPH oxidase causing inability of phagocyte to destroy certain invading pathogens. Patients are vulnerable to catalase-positive microorganisms and are easily to get infections over lungs, skin. Here we described a 11month-old male infant with X-linked CGD who carried a novel mutation, 1028A>C(Thr343Lys) missense mutation in the CYBB gene with a rare presentation of bilateral parodititis. METHODS: DNA RT-PCR and sequencing of CYBB were performed. RESULTS: This patient was initially hospitalized for 14 days due to pseudomonas oryzihabitans bacteremia at 1 month. He got sequential parotiditis over bilateral sides with right side abscess formation at 10 months and 11 months and was hospitalized for 7 days and 14 days, respectively. He accepted 2 times of debridement and thereafter responded well to oxacillin therapy. IgG, IgA, IgM, IgE and cell surface markers were normal. Laboratory data revealed dysfunction of PMN bacterial killing: tests over a period of 30 mins, 1hr, 2 hrs were: 7.3%, 12.2%, 12.2% (control: 57.4%, 65.2%, 81.7%). CYBB gene analysis revealed a missense mutation in exon 9 [c. 1028C>A, amino acid change p.Thr343Lys]. CONCLUSIONS: We believe this is the first reported case of bilateral parodititis in a infant with CGD. Our patient’s missense mutation has not been previously reported. This novel CYBB gene mutation may be helpful to elucidate correlations between genotype and phenotype in patients with CGD.
J ALLERGY CLIN IMMUNOL FEBRUARY 2016
386
B Cell Function in Immunodeficiency with Normal Immunoglobulins
Hillary Gordon, MD1,2, Stacey Galowitz, DO1,2, Kishore Alugupalli, PhD1, Gregory Dickinson, PhD1, Stephen J. McGeady, MD, FAAAAI1,2; 1Thomas Jefferson University Hospital, Philadelphia, PA, 2 Nemours/AI duPont Hospital for Children, Wilmington, DE. RATIONALE: Patients with normal immunoglobulins but impaired antibody production to polysaccharide antigens may experience recurrent sinopulmonary infections. The immune dysfunction leading to this syndrome is poorly understood, but intrinsic B cell deficits are presumed since polysaccharides are T cell-independent antigens. METHODS: The B cells of three patients with recurrent infections and decreased antibody responses to polysaccharide vaccines were studied for response to specific B cell stimuli. Peripheral blood mononuclear cells (PBMC) were separated using density gradient centrifugation. Mature B cells (CD20+) excluding CD27+ (memory) and CD10+ (immature) cells were identified by flow cytometry. PBMCs were stimulated with various concentrations of F(ab’)2 anti-human IgG and IgM to initiate B cell antigen receptor (BCR) stimulation and with Imidazoquinoline to stimulate toll like receptors 7 & 8 (TLR 7/8). Mature B cell responses to these stimuli were assessed by flow cytometric analysis of the expression of the B cell activation marker CD86, and compared to stimulated cells from controls. RESULTS: Compared to controls, B cells of patients with impaired polysaccharide-specific antibody responses showed markedly lower CD86 expression at all concentrations of anti-BCR stimulation. In two patients, the CD86 expression following exposure to Imidazoquinoline was considerably lower compared to normal subjects. CONCLUSIONS: Three patients unresponsive to polysaccharide antigens showed evidence of diminished activation in response to BCR stimulation. Two patients were also refractory to activation via TLR 7/8 pathways. It is plausible that these impaired activation pathways are responsible for the failure of these patients to respond to polysaccharide vaccines, but the defect may be heterogeneous.
387
Sema4C Expression Characterization and Downstream Signaling in HEK Cells and B Cell Lines
David Wu; McGill University, Montreal, QC, Canada. RATIONALE: Semaphorin 4C (Sema4C) is an axonal guidance molecule that is expressed following Th2 activation on human memory B-cells. It is unknown if Sema4C can induce signal transduction in human B-cells following interaction with its ligand Plexin B2. We characterized Sema4C expression on B-cell lines and studied Plexin B2 induced Sema4C downstream signaling using Sema4C-expressing human embryonic kidney cells (HEK) cells and human B cell lines. METHODS: The expression of Sema4C was measured by Flow cytometry and immunofluorescence (IF). Sema4C transfected HEK (tHEK) and B-cells were stimulated with hrPlexinB2 and p38 phosphorylation was measured by flow cytometry from 1-60 minutes following activation. RESULTS: We detected Sema4C expression by FACS and IF on 6 immortalized B-cell lines including Ramos, U266 and IM9. We observed an increase in p38 phosphorylation following addition of Plexin B2 to tHEK after 1 min of stimulation, maximizing after 5 minutes and decreasing after 15 min. This was confirmed using the immortalized Bcell lines. CONCLUSIONS: Sema4C is present on activated and immortalized human B-cells. Addition of its ligand, Plexin B2, induces p38 MAPK downstream signaling in Sema4C transfected HEK cells and B cell lines. This data suggests that Semaphorin-PlexinB2 interaction can play a role in mature, memory B–cell function.
384
Granulomatous and Lymphocytic Interstitial Lung Disease (GLILD) Associated with KMT2D Gene Mutation in Kabuki Syndrome
Juan A. Adams, MD, Joel L. Gallagher, MD, Mary Hintermeyer, APNP, James W. Verbsky, MD, PhD, John M. Routes, MD, FAAAAI; Medical College of Wisconsin, Milwaukee, WI. RATIONALE: Granulomatous and lymphocytic interstitial lung disease (GLILD) is a known complication of CVID. Humoral immunodeficiency associated with Kabuki syndrome is increasingly recognized. Here we present a patient with Kabuki syndrome, due to a mutation in lysine (K)specific methyltransferase 2D (KMT2D), complicated by GLILD. METHODS: Chart review of flow cytometry results, clinical lab results, and lung pathology are presented. RESULTS: A 13-year-old male with Kabuki syndrome presented with recurrent otitis media, immune thrombocytopenic purpura, and psoriasis. Workup for ITP (platelets 27 K/uL) revealed panhypogammaglobulinemia (IgG 241 mg/dL, IgA <5 mg/dL, IgM 65 mg/dL). Further evaluation showed deficient vaccine titers to mumps, tetanus, diphtheria and pneumococcal antigens. Lymphocyte subsets revealed a low CD4 T-cell count (314/mm3; nl 500-1300), low total memory (7.8/mm3; nl 50-200) and switched memory B-cells (1.3/mm3; nl 30-110). HRCT of the chest and abdomen revealed mediastinal lymphadenopathy; bronchiectasis; bilateral, lower-lobe predominant ground glass nodular abnormalities and splenomegaly. Lung biopsy showed follicular bronchiolitis, lymphocytic interstitial pneumonia, and non-necrotizing granulomas; immunohistochemistry showed a CD4 T-cell predominant infiltrate (CD4>CD8) with a smaller B-cell population. Collectively, these findings are consistent with GLILD. Infectious workup (CMV, EBV, AFB, fungus and routine bacterial cultures) was negative. CONCLUSIONS: This is the first case report of a patient with Kabuki syndrome due to a KMT2D mutation and with biopsy-proven GLILD. This case illustrates that GLILD is not a complication limited to CVID. In fact, GLILD is well described in an increasing number of monogenic defects associated with immunodeficiency and immunodysregulation such as CTLA4 haploinsufficiency, LRBA deficiency and hypomorphic RAG1 mutations.
SUNDAY
385
A Novel Mutation in the CYBB Gene, Thr343Lys, in a Male Infant with X-Linked Chronic Granulomatous Disease with a Rare Presentation of Bilateral Parotiditis
Wei Te Lei, MD; Division of Allergy, Immunology, Rheumatology Disease, Department of Pediatrics, Mackay Memorial Hospital, Hsinchu, Taiwan. RATIONALE: Chronic granulomatous disease (CGD) is a rare primary immunodeficiency disease that is characterized by defects in NADPH oxidase causing inability of phagocyte to destroy certain invading pathogens. Patients are vulnerable to catalase-positive microorganisms and are easily to get infections over lungs, skin. Here we described a 11month-old male infant with X-linked CGD who carried a novel mutation, 1028A>C(Thr343Lys) missense mutation in the CYBB gene with a rare presentation of bilateral parodititis. METHODS: DNA RT-PCR and sequencing of CYBB were performed. RESULTS: This patient was initially hospitalized for 14 days due to pseudomonas oryzihabitans bacteremia at 1 month. He got sequential parotiditis over bilateral sides with right side abscess formation at 10 months and 11 months and was hospitalized for 7 days and 14 days, respectively. He accepted 2 times of debridement and thereafter responded well to oxacillin therapy. IgG, IgA, IgM, IgE and cell surface markers were normal. Laboratory data revealed dysfunction of PMN bacterial killing: tests over a period of 30 mins, 1hr, 2 hrs were: 7.3%, 12.2%, 12.2% (control: 57.4%, 65.2%, 81.7%). CYBB gene analysis revealed a missense mutation in exon 9 [c. 1028C>A, amino acid change p.Thr343Lys]. CONCLUSIONS: We believe this is the first reported case of bilateral parodititis in a infant with CGD. Our patient’s missense mutation has not been previously reported. This novel CYBB gene mutation may be helpful to elucidate correlations between genotype and phenotype in patients with CGD.
J ALLERGY CLIN IMMUNOL FEBRUARY 2016
386
B Cell Function in Immunodeficiency with Normal Immunoglobulins
Hillary Gordon, MD1,2, Stacey Galowitz, DO1,2, Kishore Alugupalli, PhD1, Gregory Dickinson, PhD1, Stephen J. McGeady, MD, FAAAAI1,2; 1Thomas Jefferson University Hospital, Philadelphia, PA, 2 Nemours/AI duPont Hospital for Children, Wilmington, DE. RATIONALE: Patients with normal immunoglobulins but impaired antibody production to polysaccharide antigens may experience recurrent sinopulmonary infections. The immune dysfunction leading to this syndrome is poorly understood, but intrinsic B cell deficits are presumed since polysaccharides are T cell-independent antigens. METHODS: The B cells of three patients with recurrent infections and decreased antibody responses to polysaccharide vaccines were studied for response to specific B cell stimuli. Peripheral blood mononuclear cells (PBMC) were separated using density gradient centrifugation. Mature B cells (CD20+) excluding CD27+ (memory) and CD10+ (immature) cells were identified by flow cytometry. PBMCs were stimulated with various concentrations of F(ab’)2 anti-human IgG and IgM to initiate B cell antigen receptor (BCR) stimulation and with Imidazoquinoline to stimulate toll like receptors 7 & 8 (TLR 7/8). Mature B cell responses to these stimuli were assessed by flow cytometric analysis of the expression of the B cell activation marker CD86, and compared to stimulated cells from controls. RESULTS: Compared to controls, B cells of patients with impaired polysaccharide-specific antibody responses showed markedly lower CD86 expression at all concentrations of anti-BCR stimulation. In two patients, the CD86 expression following exposure to Imidazoquinoline was considerably lower compared to normal subjects. CONCLUSIONS: Three patients unresponsive to polysaccharide antigens showed evidence of diminished activation in response to BCR stimulation. Two patients were also refractory to activation via TLR 7/8 pathways. It is plausible that these impaired activation pathways are responsible for the failure of these patients to respond to polysaccharide vaccines, but the defect may be heterogeneous.
387
Sema4C Expression Characterization and Downstream Signaling in HEK Cells and B Cell Lines
David Wu; McGill University, Montreal, QC, Canada. RATIONALE: Semaphorin 4C (Sema4C) is an axonal guidance molecule that is expressed following Th2 activation on human memory B-cells. It is unknown if Sema4C can induce signal transduction in human B-cells following interaction with its ligand Plexin B2. We characterized Sema4C expression on B-cell lines and studied Plexin B2 induced Sema4C downstream signaling using Sema4C-expressing human embryonic kidney cells (HEK) cells and human B cell lines. METHODS: The expression of Sema4C was measured by Flow cytometry and immunofluorescence (IF). Sema4C transfected HEK (tHEK) and B-cells were stimulated with hrPlexinB2 and p38 phosphorylation was measured by flow cytometry from 1-60 minutes following activation. RESULTS: We detected Sema4C expression by FACS and IF on 6 immortalized B-cell lines including Ramos, U266 and IM9. We observed an increase in p38 phosphorylation following addition of Plexin B2 to tHEK after 1 min of stimulation, maximizing after 5 minutes and decreasing after 15 min. This was confirmed using the immortalized Bcell lines. CONCLUSIONS: Sema4C is present on activated and immortalized human B-cells. Addition of its ligand, Plexin B2, induces p38 MAPK downstream signaling in Sema4C transfected HEK cells and B cell lines. This data suggests that Semaphorin-PlexinB2 interaction can play a role in mature, memory B–cell function.