Diagnostic and therapeutic challenges in a child with complete Interferon-γ Receptor 1 deficiency

Depósito de investigación de la Universidad de Sevilla https://idus.us.es/ Esta es la versión aceptada del artículo publicado en: This is a accepted manuscript of a paper published in: Pediatric Blood & Cancer (2015): 14 July DOI: 10.1002/pbc.25625 Copyright: Wiley Periodicals, Inc. El acceso a la versión publicada del artículo puede requerir la suscripción de la revista. Access to the published version may require subscription. “This is the peer reviewed version of the following article: Olbrich P, Martínez- Saavedra MT, Perez-Hurtado JM, Sanchez C, Sanchez B, Deswarte C, Obando I, Casanova JL, Speckmann C, Bustamante J, Rodriguez-Gallego C, Neth O. Diagnostic and therapeutic challenges in a child with complete interferon-γ receptor 1 deficiency. Pediatr Blood Cancer. 2015 Nov;62(11):2036-9. doi: 10.1002/pbc.25625. Epub 2015 Jul 14. Erratum in: Pediatr Blood Cancer. 2016 Feb;63(2):377. doi: 10.1002/pbc.25888. 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For Peer Review Diagnostic and therapeutic challenges in a child with complete Interferon-γ Receptor 1 deficiency Journal: Pediatric Blood & Cancer Manuscript ID: PBC-15-0401 Wiley - Manuscript type: Brief Report Date Submitted by the Author: 12-Apr-2015 Complete List of Authors: Olbrich, Peter; Hospital Universitario Virgen del Rocio, Pediatric Infectious Diseases and Immunopathology Martinez-Saavedra, Maria Teresa; Dr. Negrín University Hospital, Department of Immunology PEREZ-HURTADO, JOSE MARIA; HOSPITAL UNIVERSITARIO VIRGEN DEL ROCIO, Pediatric hematology Sánchez, Cristina; Hospital Universitario Virgen del Rocio, Pediatric Infectious Diseases and Immunopathology Sanchez, Berta; Hospital Universitario Virgen del Rocio, Department of Immunology Deswarte, Carolina; Paris Descartes University, Imagine Institute, ; Necker Hospital for Sick Children, Laboratory of Human Genetics of Infectious Diseases Obando, Ignacio; Hospital Universitario Virgen del Rocio, Pediatric Infectious Diseases and Immunopathology Casanova, Jean-Laurent; Laboratory of Human Genetics of Infectious Diseases, Institut National de la Santé et de la Recherche Médicale Speckmann, Carsten; University Medical Centre Freiburg, Center for Pediatrics and Adolescent Medicine; University Medical Centre Freiburg, Center of Chronic Immunodeficiency Bustamante, Jacinta; Laboratory of Human Genetics of Infectious Diseases, Institut National de la Santé et de la Recherche Médicale Rodriguez-Gallego, Carlos; Dr. Negrín University Hospital, Department of Immunology; School of Medicine, University of Las Palmas de Gran Canaria, Department of Medical and Surgical Sciences neth, olaf; Hospital Universitario Virgen del Rocio, Pediatric Infectious Diseases and Immunopathology Keywords: Immunodeficiency, congenital (not HIV), Infections in imunocompromised hosts, BMT, Transplantation, Immunocompromised hosts, Atypical mycobacteria, Interferon gamma receptor John Wiley & Sons Pediatric Blood & Cancer For Peer Review 1 Diagnostic and therapeutic challenges in a child with complete Interferon-γ γγ γ 1 Receptor 1 deficiency 2 Peter Olbrich 1 , MD, María Teresa Martínez-Saavedra 2 , PhD, José María Perez 3 Hurtado 3 , MD, Cristina Sanchez 1 , MD, Berta Sanchez 4 , PhD, Carolina Deswarte 5,6 , 4 PhD, Ignacio Obando 1 , MD, PhD, Jean-Laurent Casanova 5-9 , MD, PhD, Carsten 5 Speckmann 10 , MD, PhD, Jacinta Bustamante 5,6,11 , MD, PhD, Carlos Rodriguez- 6 Gallego 2,12 , MD, PhD and Olaf Neth 1** , MD, PhD. 7 1 Pediatric Infectious Diseases and Immunodeficiency Unit, Hospital Virgen del Rocio, 8 Instituto de Biomedicina de Sevilla, Spain 9 2 Department of Immunology, Gran Canaria Dr. Negrín University Hospital, Las Palmas 10 de Gran Canaria, Spain 11 3 Pediatric Hematology Unit, Hospital Virgen del Rocio, Sevilla, Spain 12 4 Department of Immunology, Hospital Virgen del Rocio, Sevilla, Spain 13 5 Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM 14 U1163, Necker Hospital for Sick Children, Paris, France 15 6 Paris Descartes University, Imagine Institute, Paris, France 16 7 Pediatric Hematology-Immunology Unit, Necker Hospital for Sick Children, AP-HP, 17 Paris, France 18 8 St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller branch, the 19 Rockefeller University, New York, NY, USA 20 9 Howard Hughes Medical Institute, New York, USA 21 10 Center for Chronic Immunodeficiency, University of Freiburg, Germany 22 11 Center for the Study of Primary Immunodeficiencies, Necker Hospital for Sick 23 Children, AP-HP, Paris, France 24 Page 1 of 17 John Wiley & Sons Pediatric Blood & Cancer For Peer Review 2 12 Department of Medical and Surgical Sciences, School of Medicine, University of Las 25 Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain 26 Address correspondance to: 27 Olaf Neth, Pediatric Infectious Diseases and Immunodeficiency Unit, Hospital Virgen 28 del Rocio, Instituto de Biomedicina de Sevilla 29 Av. Manuel Siurot, s/n. 41013, Sevilla, Spain; Phone: +34 622488740; 30 [olaf[email protected]] 31 Word count: 83 (abstract), 1200 (main text) 32 Number of tables: 0 33 Number of Figures: 2 34 Number of Supplemental Files: 1 (Figure 3) 35 Short running title: Challenges in the management of IFN-γ R1 deficiencies 36 Abbreviations: 37 AR Autosomal recessive GVHD Graft-versus-host-disease HSCT Hematopoietic stem cell transplantation IFN- γR1 Interferon-γ Receptor1 TMP-SMX Trimethoprim-Sulfamethoxazole 38 Keywords: Primary immunodeficiency, atypical mycobacteria, interferon gamma 39 receptor, transplantation, infant 40 41 Page 2 of 17 John Wiley & Sons Pediatric Blood & Cancer For Peer Review 3 Abstract 42 43 Autosomal recessive (AR) complete Interferon-γ Receptor1 (IFN-γR1) deficiency is a 44 rare variant of Mendelian susceptibility to mycobacterial disease (MSMD). Whilst 45 hematopoietic stem cell transplantation (HSCT) remains the only curative treatment, 46 outcomes are heterogeneous; delayed engraftment and/or graft rejection being 47 commonly observed. This case report and literature review expands the knowledge 48 about this rare but potentially fatal pathology, providing details regarding diagnosis, 49 antimicrobial treatment, transplant performance and outcome that may help to guide 50 physicians caring for patients with AR complete IFN-γR1 or IFN-γR2 deficiency. 51 52 Introduction: 53 Autosomal recessive (AR) complete Interferon-γReceptor1 (IFN-γR1) deficiency is a 54 rare variant (8%) of Mendelian susceptibility to mycobacterial disease (MSMD) [1,2]. 55 To date 32 patients with 26 different mutations have been reported [3, 4]. AR complete 56 IFN-γR1 deficiency is characterized by a lack of cytokine production such as 57 Interleukin-12 (IL-12) or tumor necrosis factor α (TNF-α) in response to IFN-γ 58 activation in vitro and high levels of circulating IFN-γ [3,5]. Clinical penetrance is 59 complete with disseminated infections in early childhood, most commonly caused by 60 BCG [3] or atypical mycobacteria including M.avium complex, M.abscessus 61 M.chelonae, M.fortuitum, M.mageritense, M.peregrinum, M.smegmatis and 62 M.scrofulaceum [3,5,6]. Other pathogens, such as Listeria monocytogenes, Salmonella 63 spp and Toxoplasma spp as well as viral pathogens have also been described to cause 64 disease in these patients [3]. Complete IFN-γR1 deficiency is fatal within the first two 65 decades of life despite antibiotic treatment [3,5,7]. Hematopoietic stem cell 66 Page 3 of 17 John Wiley & Sons Pediatric Blood & Cancer For Peer Review 4 transplantation (HSCT) remains the only curative treatment option; however, outcomes 67 are heterogeneous [8-12]. Delayed engraftment and/or graft rejection are common 68 observations [9]. The presence of high IFN-γ plasma levels of IFN-γR1 deficient 69 patients might explain these potentially severe complications, as IFN-γ has been shown 70 to have anti-hematopoietic properties in vivo [13,14]. We describe the clinical 71 presentation, diagnosis, and successful transplant of a child with AR complete IFN-γR1 72 deficiency and review the current experience of this rare disorder. 73 74 75 Case Report 76 A 4-year-old boy born to non-consanguineous parents was admitted with generalized 77 lymphadenopathy, rash and night sweats. Family history was unremarkable; personal 78 medical history included a Salmonella gastroenteritis aged 12 months, requiring 79 intravenous antibiotics. He had not received BCG vaccine. 80 A full blood count revealed neutrophilia (45.000/mm 3 ) and raised C-reactive protein 81 (CRP, 308 mg/l). Repeated blood cultures and an infectious disease screening including 82 Mantoux tuberculin skin test, Brucella, Rickettsia, Bartonella, Coxiella, Leishmania, 83 Cytomegalovirus, Epstein-Barr virus, viral hepatitis panel and HIV serology were 84 negative. Immunological studies showed raised serum immunoglobulin (IgG 85 1890mg/dl, IgA 227mg/dl, IgM 260mg/dl), whilst lymphocyte subsets, T cell response 86 to mitogens and neutrophil respiratory burst test using dihydrorhodamine flow 87 cytometry were normal for his age. Due to persistent fever and respiratory distress 88 despite intravenous antibiotic therapy, bone marrow aspirates, lymph node and lung 89 biopsies were performed, showing non-specific reactive changes, without signs of 90 malignancy, hemophagocytosis or infectious agents despite prolonged culturing, acid- 91 Page 4 of 17 John Wiley & Sons Pediatric Blood & Cancer For Peer Review 5 fast bacilli testing and molecular biology methods. Broad-spectrum antibiotics including 92 Trimethoprim-Sulfamethoxazole (TMP-SMX), liposomal Amphotericin B, and 93 Imipenem resulted in disappearance of fever and respiratory symptoms and subsequent 94 hospital discharge. 95 Three months later he represented with fever, generalized lymphadenopathies, hepato- 96 splenomegaly, disseminated rash and a marked edema of the right lower extremity 97 (Figure 1A-D). Blood tests revealed high inflammatory parameters: neutrophilia: 98 54380/mm 3 , subsequently 120000/mm 3 , ESR: 102mm/h, CRP: 107mg/l, IgG: 99 4744mg/dl, soluble CD25: 15241U/ml (normal 158-623). Cultures of a repeated lymph 100 node biopsy grew Mycobacterium fortuitum. Subsequently, treatment was initiated with 101 Azithromycin (10mg/kg/day), TMP-SMX (TMP 10mg/kg/d), and Ciprofloxacin 102 (30mg/kg/d). 103 The atypical pathogen identification in context with the clinical picture led to functional 104 studies of the IFN-γ axis showing markedly raised IFN-γ plasma levels (275pg/ml, 105 normal<10) and normal IFN-γ production after whole blood stimulation with 106 phytohaemagglutinin in the presence or absence of IL-12 (data not shown). However, 107 whole blood culture cells showed no response to increasing doses of IFN-γ in vitro, in 108 terms of IL-12p70 production (Figure 2A). Flow cytometry confirmed a marked 109 decrease in the expression of IFN-γR1 in polymorphonuclear granulocytes (Figure 2B), 110 compared with healthy controls suggesting a complete IFN-γR1 deficiency. Sequencing 111 of the IFNGR1 gene identified a known compound heterozygous mutations 112 (c.523delT/c.652del3) confirming the diagnosis of AR complete IFN-γR1 deficiency 113 (Figure 3 supplements) [3]. Complete clinical recovery was achieved within two weeks 114 of triple antibiotic therapy and IFN-γ plasma levels were normal 4 and 2 months pre- 115 HSCT. 116 Page 5 of 17 John Wiley & Sons Pediatric Blood & Cancer For Peer Review 6 A fully myeloablative conditioning regimen included Cyclophosphamide and Busulfan 117 (BUCY-200). Graft-versus-host-disease (GVHD) prophylaxis consisted of Cyclosporine 118 A (pre dose serum levels 200-300ng/ml) and four doses of Methotrexate (15mg/m 2 119 day+1, 10mg/m 2 on days+3, +6 and +11 post HSCT). A non–T-cell-depleted HSCT 120 from a fully matched sibling donor was performed (cell dose 5.3x10 6 /kg CD34 + HSCs). 121 Neutrophil (>1000cells/mm3) and platelets recovery (>50.000cells/mm3) occurred on 122 day+15; early engraftment studies revealed >98% donor cells on day+17 post HSCT. M. 123 fortuitum triple therapy was maintained during transplant with temporary substitution of 124 TMP-SMX for Amikacin during the aplastic phase. The patient did not suffer from 125 fever or infections during and post HSCT. Donor chimerism was maintained >90% and 126 IFN-γ plasma levels were <10pg/ml at 1, 2, 3 and 4 months post HSCT. In vitro cellular 127 responses to increasing concentrations of IFN-γ were repeatedly measured at 4 and 8 128 months after HSCT showing similar IL-12p70 induction as his donor (Figure 2C). IFN- 129 γR1 expression 4 months post HSCT was normal in 95% of patient’s CD14 + monocytes 130 and 99% of CD15 + polymorphonuclear granulocytes and equal in donor and recipient 131 CD19 + B cells (Figure 2D). Thirteen months after HSCT the patient is in an excellent 132 clinical shape, with no signs of GVHD and a stable donor chimerism of 97%. GVHD 133 prophylaxis was reduced at six and finally stopped at 10 months after HSCT. Treatment 134 against M. fortuitum was maintained 12 months post HSCT. 135 136 Discussion: 137 Mutations conferring a complete defect in IFN-γ response, e.g. AR IFN-γR1 and IFN- 138 γR2 deficiency, lead to potentially fatal mycobacterial infections [1-7]. The detection of 139 IFN-γR1 expression on nucleated cells and the performance of functional tests for 140 Page 6 of 17 John Wiley & Sons Pediatric Blood & Cancer For Peer Review 7 analyzing IFN-γ responses facilitate targeted gene sequencing and the prediction of 141 effectiveness of adjuvant therapies such as exogenous IFN-γ. Patients with AR complete 142 IFN-γR1 deficiency require HSCT [5,15]. However, HSCT does not completely correct 143 this pathology as the IFN-γR is also expressed on cells and tissue types not directly 144 derived from lymphoid tissue or bone marrow (16). Malignancies such as lymphoma, 145 Kaposi sarcoma and a pineal germinoma have been reported [6,17,18]. Tumor 146 surveillance seems reasonable for all patients with IFN-γR deficiency independently of 147 their transplant status. 148 Our patient was diagnosed in the context of disseminated M. fortuitum infection, which 149 was controlled by combined and long-term antibiotic therapy. Immunological results 150 suggested AR complete IFN-γR1 deficiency allowing directed candidate gene 151 sequencing thus saving time and economic resources. 152 To date, ten patients underwent HSCTs, all but one from HLA matched family donors 153 [8-12]. Four of these patients died within the first 8 months of transplant, two survived 154 despite autologous reconstitution and in four patients HSCT was curative [8,9,11,12]. 155 Importantly, all these four patients received long-term antibiotic therapy, myeloablative 156 conditioning, as well as non-T-cell-depleted grafts with good nucleated cell counts 157 [8,9,11,12]. 158 Pre-transplant, normalization of IFN-γ levels is warranted, as raised levels have been 159 associated with graft rejections [13,14]. HSCT was only performed in our patient, once 160 IFN-γ levels had normalized using a complete myeloablative-conditioning regimen 161 from a HLA identical brother. GVHD prophylaxis was maintained for 10 and 162 antimycobacterial treatment for 12 months, respectively. This approach resulted in a fast 163 and sustained engraftment without major complications. Follow up evaluations include 164 Page 7 of 17 John Wiley & Sons Pediatric Blood & Cancer For Peer Review 14 (B) Automated sequencing profile showing the mutations IFNGR1 gene in DNAg 289 extracted from the patient, brother, parents and comparison with the sequence obtained 290 from a healthy control. An arrow indicates the corresponding mutations. 291 292 Page 14 of 17 John Wiley & Sons Pediatric Blood & Cancer For Peer Review Figure 1! ! Page 15 of 17 John Wiley & Sons Pediatric Blood & Cancer For Peer Review HC Patient GIR94 GIR208 B A 0 50 100 150 LPS IFN-γ (IU/mL) - - + - + 102 + + 103 104 IL-12p70 (pg/mL) 0 200 400 600 LPS IFN-γ (IU/mL) - - + - + 102 + + 103 104 IL-12p70 (pg/mL) C Figure 2! B cells Monocytes Granulocytes Fluorescence Number of cells Page 16 of 17 John Wiley & Sons Pediatric Blood & Cancer For Peer Review Exon 4 : c.523del T! Patient! Mother! Healthy control! Father, Brother ! Patient! Father, Brother! Healthy control! Mother! Exon 5: c.652del3! Figure 3! ! 1!2! 1!2! I! II! c.523delT/WT!c.652del3/WT! c.652del3/WT! c.652del3/! c.523delT! A B Page 17 of 17 John Wiley & Sons Pediatric Blood & Cancer