Defective natural killer–cell cytotoxic activity in NFKB2-mutated CVID-like disease
2015; Elsevier BV; Volume: 135; Issue: 6 Linguagem: Inglês
10.1016/j.jaci.2014.11.038
ISSN1097-6825
AutoresVassilios Lougaris, Giovanna Tabellini, Massimiliano Vitali, Manuela Baronio, Ornella Patrizi, Giacomo Tampella, Augusto Biasini, Daniele Moratto, Silvia Parolini, Alessandro Plebani,
Tópico(s)Immune Cell Function and Interaction
ResumoCommon variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency characterized by low immunoglobulin serum levels, low vaccine responses, and recurrent infections. The clinical presentation of CVID comprises a variable mixture of recurrent infections, autoimmune phenomena, granulomatous disease, and lymphoproliferation. The underlying genetic mechanisms have been elucidated in the last few years in less than 10% to 15% of the cases and involve mutations in CD19, MS4A1 (CD20), CR2 (CD21), ICOS, TNFRSF13C, TNFRSF13B, PLCG2 (phospholipase Cg2), CD81, LRBA, and PRKCD (protein kinase Cd).1Cunningham-Rundles C. Human B cells in perspective.Immunol Res. 2012; 54: 227-232Crossref PubMed Scopus (23) Google Scholar, 2Salzer U. Warnatz K. Peter H.H. Common variable immunodeficiency—an update.Arthritis Res Ther. 2012; 14: 223Crossref PubMed Scopus (116) Google Scholar, 3Lougaris V. Tampella G. Baronio M. Vitali M. Plebani A. The genetic heterogeneity of common variable immunodeficiency (CVID): an update.J Vaccines Vaccin. 2014; 5: 223Crossref Scopus (2) Google Scholar Recently, germline heterozygous mutations in NFKB2 were identified in 10 patients to be associated with early-onset CVID with autoimmunity in most cases,4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar profound B-cell deficiency,6Lee C.E. Fulcher D.A. Whittle B. Chand R. Fewings N. Field M. et al.Autosomal dominant B-cell deficiency with alopecia due to a mutation in NFKB2 that results in non-processible p100.Blood. 2014; 124: 2964-2972Crossref PubMed Scopus (69) Google Scholar or a CVID-like phenotype.7Lindsley A.W. Qian Y. Valencia C.A. Shah K. Zhang K. Assa'ad A. Combined immune deficiency in a patient with a novel NFKB2 mutation.J Clin Immunol. 2014; 34: 910-915Crossref PubMed Scopus (48) Google Scholar All affected patients had hypogammaglobulinemia with variable association of the following clinical and immunologic features: central adrenal insufficiency (ACTH insufficiency), alopecia totalis or areata, trachyonychia, variable natural killer (NK) cell numbers, and defects in peripheral T and B cells. We report on a male patient with early-onset CVID who carried the heteroyzgous p.Arg853* mutation in NFKB2 and later developed central adrenal insufficiency (ACTH insufficiency), alopecia totalis, and trachyonychia. An extensive immunologic work-up was performed that, besides confirming the presence of T- and B-cell defects, revealed, as a novel finding, impaired NK-cell cytotoxic activity in vitro, despite normal NK cell counts.The index patient was born to Italian nonrelated parents. Routine laboratory investigation was performed at age 15 months for growth delay and showed profound hypogammaglobulinemia—IgG, 95 mg/dL (normal values for age, 264-1509 mg/dL); IgA, less than 5 mg/dL (normal values for age, 17-178 mg/dL); IgM, less than 5 mg/dL (normal values for age, 48-337 mg/dL)—in the presence of normal peripheral B-cell counts (CD19+, 16.5%). Immunoglobulin replacement treatment was initiated. During follow-up, the patient presented with occasional infections of the upper respiratory tract. He developed alopecia totalis at the age of 4 years, followed by the development of trachyonychia. Endocrinological evaluation following a hypoglycemic episode (blood glycemic level, 26 mg/dL) revealed ACTH and cortisol insufficiency for which he was placed on replacement treatment with hydrocortisone. During adolescence, he developed hypothyroidism and required hormone replacement therapy. On the identification of hypogammaglobulinemia, a more extensive immunologic work-up revealed abnormalities of both T and B cells, namely, an accumulation of T cells in the early stages of differentiation with reduction of the terminal stages of T-cell development, for both CD4 and CD8 subsets, and the typical peripheral B-cell block of CVID with reduction in memory B cells, both switched and IgM memory ones, and lack of plasma cells (Table I). Proliferative responses to mitogens were normal (Table I).Table IImmunologic profile from the index patient mutated in NFKB2Lymphocyte subsetsIndex patient (%)Normal range for age (%)T cells (CD3+)89.860.5-79.8CD3+CD4+63.830.3-48.3 Naive (CD45RA+CCR7+)85.834.3-74.6 RTE (CD45RA+CCR7+CD31+)66.521.1-63.5 Central memory (CD45RA−CCR7+)8.513.0-43.5 Effector memory (CD45RA−CCR7−)4.48.5-28.1 Terminally differentiated (CD45RA+CCR7−)1.20.7-6.6CD3+CD8+22.313.8-37.5 Naive (CD45RA+CCR7+)92.026.7-72.9 Central memory (CD45RA−CCR7+)1.81.2-11.6 Effector memory (CD45RA−CCR7−)4.06.0-53.6 Terminally differentiated (CD45RA+CCR7−)2.33.9-72.0 TCR γ/δ1.70.5-21.5B cells (CD19+)4.85.7-19.7 RBE (CD38hiCD21dim/loCD27−)31.415.0-35.3 Naive (CD38dim/loCD21hiCD27−)60.533.8-79.6 CD19hiCD21lo1.91.1-10 Switched memory (IgD−CD27+)0.42.7-20.6 IgM memory (IgD+CD27+)2.03.5-24.1 Terminally differentiated (CD38hiCD27hiCD21lo)0.170.16-8.70 Plasma cells (CD38hiCD20−CD138+)0.000.04-3.20NK cells (CD3−CD16+CD56+)4.54.6-27.8Proliferation (cpm)Index patientHealthy controlCD3227,00077,000CD3 + IL2200,000152,000PHA116,000120,000PMA + Ionomycin418,000285,000Background4,0007,000PMA, Phorbol 12-myristate 13-acetate; RBE, recent bone marrow emigrants; RTE, recent thymic emigrants; TCR, T-cell receptor. Open table in a new tab On the description of NFKB2 mutations associated with early-onset CVID, ACTH insufficiency, alopecia totalis, and trachyonichia,4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar direct gene sequencing for NFKB2 was performed for the index patient. A c.2557C>T substitution was found, leading to the non-sense mutation p.Arg853* (Fig 1). This is a de novo mutation because the patient's parents were wild type for this mutation. Interestingly, all patients described so far to be mutated in NFKB2, with the exception of 3 family members carrying a missense mutation,6Lee C.E. Fulcher D.A. Whittle B. Chand R. Fewings N. Field M. et al.Autosomal dominant B-cell deficiency with alopecia due to a mutation in NFKB2 that results in non-processible p100.Blood. 2014; 124: 2964-2972Crossref PubMed Scopus (69) Google Scholar carry de novo mutations.4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar, 7Lindsley A.W. Qian Y. Valencia C.A. Shah K. Zhang K. Assa'ad A. Combined immune deficiency in a patient with a novel NFKB2 mutation.J Clin Immunol. 2014; 34: 910-915Crossref PubMed Scopus (48) Google Scholar The p.Arg853* mutation is disease-causing and was identified in the first description of NFKB2 mutations in CVID.4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar The index patient here described is the 11th patient to be affected with this genetic defect and the second one to carry the p.Arg853* mutation. Interestingly, the index patient is the first patient with germline NFKB2 mutation to develop clinically relevant hypothyroidism, underlying the clinical heterogeneity of this disorder. By reviewing the clinical data of the reported patients,4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar, 6Lee C.E. Fulcher D.A. Whittle B. Chand R. Fewings N. Field M. et al.Autosomal dominant B-cell deficiency with alopecia due to a mutation in NFKB2 that results in non-processible p100.Blood. 2014; 124: 2964-2972Crossref PubMed Scopus (69) Google Scholar, 7Lindsley A.W. Qian Y. Valencia C.A. Shah K. Zhang K. Assa'ad A. Combined immune deficiency in a patient with a novel NFKB2 mutation.J Clin Immunol. 2014; 34: 910-915Crossref PubMed Scopus (48) Google Scholar it is evident that some clinical features are common to all patients, whereas others are sporadic (see Table E1 in this article's Online Repository at www.jacionline.org). Furthermore, the clinical and immunologic phenotype appears more severe in the presence of non-sense4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar, 7Lindsley A.W. Qian Y. Valencia C.A. Shah K. Zhang K. Assa'ad A. Combined immune deficiency in a patient with a novel NFKB2 mutation.J Clin Immunol. 2014; 34: 910-915Crossref PubMed Scopus (48) Google Scholar rather than missense6Lee C.E. Fulcher D.A. Whittle B. Chand R. Fewings N. Field M. et al.Autosomal dominant B-cell deficiency with alopecia due to a mutation in NFKB2 that results in non-processible p100.Blood. 2014; 124: 2964-2972Crossref PubMed Scopus (69) Google Scholar mutations in NFKB2. Mutations in nuclear factor kappa B (NF-κB) essential modifier , a component of the NF-κB cascade, result in a complex form of immunodeficiency with variable clinical and immunologic severity depending on the type of mutations and have been previously reported to result in impaired NK-cell cytotoxicity.8Orange J.S. Brodeur S.R. Jain A. Bonilla F.A. Schneider L.C. Kretschmer R. et al.Deficient natural killer cell cytotoxicity in patients with IKK-gamma/NEMO mutations.J Clin Invest. 2002; 109: 1501-1509Crossref PubMed Scopus (177) Google Scholar Although NF-κB essential modifier is part of the canonical pathway, recent experimental data on NFKB2-mutated mice suggested that there may be overlap in the function of NF-κB members in canonical and noncanonical pathway signaling.9Tucker E. O'Donnell K. Fuchsberger M. Hilton A.A. Metcalf D. Greig K. et al.A novel mutation in the Nfkb2 gene generates an NF-kappaB2 "super repressor".J Immunol. 2007; 179: 7114-7122Crossref Scopus (63) Google Scholar Because herpes viral susceptibility and numerical NK-cell abnormalities have been reported in NFKB2-mutated patients,4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar we decided to evaluate whether mutations in NFKB2 could also affect NK-cell cytotoxic activity. NK-cell functional evaluation revealed defective NK-cell cytotoxic activity in vitro, which could not be restored by the addition of hr-IL-2 (Fig 1, B). Then, we further characterized the patient's NK cells by examining the expression pattern of activating and inhibitory NK receptors, including natural cytotoxicity receptors, NKG2D and killer cell immunoglobulin-like receptors molecules, chemokine receptors (CXCR1 and CCR7), and activation marker (CD69) on CD56+ CD3− gated cells by flow cytometry. Patient's NK-cell subsets, both immature (CD56bright) and mature (CD56dim), showed normal expression of different NK receptors when compared with healthy donors (see Fig E1 in this article's Online Repository at www.jacionline.org). The expression of CD57, an NK-cell maturation marker, and the intracellular levels of perforin in CD56dim CD16+KIR+ cells, the more differentiated and cytotoxic NK-cell population, were normal, ruling out a maturational defect (see Fig E1). On the contrary, the expression of CD69 on CD56dimCD16+ in patient's NK cells was increased, suggesting an activated steady state of unknown cause (Fig 1, C).Impaired NK-cell activity has been reported in numerous forms of primary immunodeficiencies.10Orange J.S. Natural killer cell deficiency.J Allergy Clin Immunol. 2013; 132: 515-525Abstract Full Text Full Text PDF PubMed Scopus (331) Google Scholar This is the first description of impaired NK-cell activity associated with NFKB2 mutations. These findings broaden the immunologic defects in NFKB2 deficiency, confirm the heterogeneous and complex immunologic and clinical phenotype in disorders in which NF-κB components are defective, and underline an important role for NF-κB in NK-cell cytotoxic activity. Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency characterized by low immunoglobulin serum levels, low vaccine responses, and recurrent infections. The clinical presentation of CVID comprises a variable mixture of recurrent infections, autoimmune phenomena, granulomatous disease, and lymphoproliferation. The underlying genetic mechanisms have been elucidated in the last few years in less than 10% to 15% of the cases and involve mutations in CD19, MS4A1 (CD20), CR2 (CD21), ICOS, TNFRSF13C, TNFRSF13B, PLCG2 (phospholipase Cg2), CD81, LRBA, and PRKCD (protein kinase Cd).1Cunningham-Rundles C. Human B cells in perspective.Immunol Res. 2012; 54: 227-232Crossref PubMed Scopus (23) Google Scholar, 2Salzer U. Warnatz K. Peter H.H. Common variable immunodeficiency—an update.Arthritis Res Ther. 2012; 14: 223Crossref PubMed Scopus (116) Google Scholar, 3Lougaris V. Tampella G. Baronio M. Vitali M. Plebani A. The genetic heterogeneity of common variable immunodeficiency (CVID): an update.J Vaccines Vaccin. 2014; 5: 223Crossref Scopus (2) Google Scholar Recently, germline heterozygous mutations in NFKB2 were identified in 10 patients to be associated with early-onset CVID with autoimmunity in most cases,4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar profound B-cell deficiency,6Lee C.E. Fulcher D.A. Whittle B. Chand R. Fewings N. Field M. et al.Autosomal dominant B-cell deficiency with alopecia due to a mutation in NFKB2 that results in non-processible p100.Blood. 2014; 124: 2964-2972Crossref PubMed Scopus (69) Google Scholar or a CVID-like phenotype.7Lindsley A.W. Qian Y. Valencia C.A. Shah K. Zhang K. Assa'ad A. Combined immune deficiency in a patient with a novel NFKB2 mutation.J Clin Immunol. 2014; 34: 910-915Crossref PubMed Scopus (48) Google Scholar All affected patients had hypogammaglobulinemia with variable association of the following clinical and immunologic features: central adrenal insufficiency (ACTH insufficiency), alopecia totalis or areata, trachyonychia, variable natural killer (NK) cell numbers, and defects in peripheral T and B cells. We report on a male patient with early-onset CVID who carried the heteroyzgous p.Arg853* mutation in NFKB2 and later developed central adrenal insufficiency (ACTH insufficiency), alopecia totalis, and trachyonychia. An extensive immunologic work-up was performed that, besides confirming the presence of T- and B-cell defects, revealed, as a novel finding, impaired NK-cell cytotoxic activity in vitro, despite normal NK cell counts. The index patient was born to Italian nonrelated parents. Routine laboratory investigation was performed at age 15 months for growth delay and showed profound hypogammaglobulinemia—IgG, 95 mg/dL (normal values for age, 264-1509 mg/dL); IgA, less than 5 mg/dL (normal values for age, 17-178 mg/dL); IgM, less than 5 mg/dL (normal values for age, 48-337 mg/dL)—in the presence of normal peripheral B-cell counts (CD19+, 16.5%). Immunoglobulin replacement treatment was initiated. During follow-up, the patient presented with occasional infections of the upper respiratory tract. He developed alopecia totalis at the age of 4 years, followed by the development of trachyonychia. Endocrinological evaluation following a hypoglycemic episode (blood glycemic level, 26 mg/dL) revealed ACTH and cortisol insufficiency for which he was placed on replacement treatment with hydrocortisone. During adolescence, he developed hypothyroidism and required hormone replacement therapy. On the identification of hypogammaglobulinemia, a more extensive immunologic work-up revealed abnormalities of both T and B cells, namely, an accumulation of T cells in the early stages of differentiation with reduction of the terminal stages of T-cell development, for both CD4 and CD8 subsets, and the typical peripheral B-cell block of CVID with reduction in memory B cells, both switched and IgM memory ones, and lack of plasma cells (Table I). Proliferative responses to mitogens were normal (Table I). PMA, Phorbol 12-myristate 13-acetate; RBE, recent bone marrow emigrants; RTE, recent thymic emigrants; TCR, T-cell receptor. On the description of NFKB2 mutations associated with early-onset CVID, ACTH insufficiency, alopecia totalis, and trachyonichia,4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar direct gene sequencing for NFKB2 was performed for the index patient. A c.2557C>T substitution was found, leading to the non-sense mutation p.Arg853* (Fig 1). This is a de novo mutation because the patient's parents were wild type for this mutation. Interestingly, all patients described so far to be mutated in NFKB2, with the exception of 3 family members carrying a missense mutation,6Lee C.E. Fulcher D.A. Whittle B. Chand R. Fewings N. Field M. et al.Autosomal dominant B-cell deficiency with alopecia due to a mutation in NFKB2 that results in non-processible p100.Blood. 2014; 124: 2964-2972Crossref PubMed Scopus (69) Google Scholar carry de novo mutations.4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar, 7Lindsley A.W. Qian Y. Valencia C.A. Shah K. Zhang K. Assa'ad A. Combined immune deficiency in a patient with a novel NFKB2 mutation.J Clin Immunol. 2014; 34: 910-915Crossref PubMed Scopus (48) Google Scholar The p.Arg853* mutation is disease-causing and was identified in the first description of NFKB2 mutations in CVID.4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar The index patient here described is the 11th patient to be affected with this genetic defect and the second one to carry the p.Arg853* mutation. Interestingly, the index patient is the first patient with germline NFKB2 mutation to develop clinically relevant hypothyroidism, underlying the clinical heterogeneity of this disorder. By reviewing the clinical data of the reported patients,4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar, 6Lee C.E. Fulcher D.A. Whittle B. Chand R. Fewings N. Field M. et al.Autosomal dominant B-cell deficiency with alopecia due to a mutation in NFKB2 that results in non-processible p100.Blood. 2014; 124: 2964-2972Crossref PubMed Scopus (69) Google Scholar, 7Lindsley A.W. Qian Y. Valencia C.A. Shah K. Zhang K. Assa'ad A. Combined immune deficiency in a patient with a novel NFKB2 mutation.J Clin Immunol. 2014; 34: 910-915Crossref PubMed Scopus (48) Google Scholar it is evident that some clinical features are common to all patients, whereas others are sporadic (see Table E1 in this article's Online Repository at www.jacionline.org). Furthermore, the clinical and immunologic phenotype appears more severe in the presence of non-sense4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar, 7Lindsley A.W. Qian Y. Valencia C.A. Shah K. Zhang K. Assa'ad A. Combined immune deficiency in a patient with a novel NFKB2 mutation.J Clin Immunol. 2014; 34: 910-915Crossref PubMed Scopus (48) Google Scholar rather than missense6Lee C.E. Fulcher D.A. Whittle B. Chand R. Fewings N. Field M. et al.Autosomal dominant B-cell deficiency with alopecia due to a mutation in NFKB2 that results in non-processible p100.Blood. 2014; 124: 2964-2972Crossref PubMed Scopus (69) Google Scholar mutations in NFKB2. Mutations in nuclear factor kappa B (NF-κB) essential modifier , a component of the NF-κB cascade, result in a complex form of immunodeficiency with variable clinical and immunologic severity depending on the type of mutations and have been previously reported to result in impaired NK-cell cytotoxicity.8Orange J.S. Brodeur S.R. Jain A. Bonilla F.A. Schneider L.C. Kretschmer R. et al.Deficient natural killer cell cytotoxicity in patients with IKK-gamma/NEMO mutations.J Clin Invest. 2002; 109: 1501-1509Crossref PubMed Scopus (177) Google Scholar Although NF-κB essential modifier is part of the canonical pathway, recent experimental data on NFKB2-mutated mice suggested that there may be overlap in the function of NF-κB members in canonical and noncanonical pathway signaling.9Tucker E. O'Donnell K. Fuchsberger M. Hilton A.A. Metcalf D. Greig K. et al.A novel mutation in the Nfkb2 gene generates an NF-kappaB2 "super repressor".J Immunol. 2007; 179: 7114-7122Crossref Scopus (63) Google Scholar Because herpes viral susceptibility and numerical NK-cell abnormalities have been reported in NFKB2-mutated patients,4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar we decided to evaluate whether mutations in NFKB2 could also affect NK-cell cytotoxic activity. NK-cell functional evaluation revealed defective NK-cell cytotoxic activity in vitro, which could not be restored by the addition of hr-IL-2 (Fig 1, B). Then, we further characterized the patient's NK cells by examining the expression pattern of activating and inhibitory NK receptors, including natural cytotoxicity receptors, NKG2D and killer cell immunoglobulin-like receptors molecules, chemokine receptors (CXCR1 and CCR7), and activation marker (CD69) on CD56+ CD3− gated cells by flow cytometry. Patient's NK-cell subsets, both immature (CD56bright) and mature (CD56dim), showed normal expression of different NK receptors when compared with healthy donors (see Fig E1 in this article's Online Repository at www.jacionline.org). The expression of CD57, an NK-cell maturation marker, and the intracellular levels of perforin in CD56dim CD16+KIR+ cells, the more differentiated and cytotoxic NK-cell population, were normal, ruling out a maturational defect (see Fig E1). On the contrary, the expression of CD69 on CD56dimCD16+ in patient's NK cells was increased, suggesting an activated steady state of unknown cause (Fig 1, C). Impaired NK-cell activity has been reported in numerous forms of primary immunodeficiencies.10Orange J.S. Natural killer cell deficiency.J Allergy Clin Immunol. 2013; 132: 515-525Abstract Full Text Full Text PDF PubMed Scopus (331) Google Scholar This is the first description of impaired NK-cell activity associated with NFKB2 mutations. These findings broaden the immunologic defects in NFKB2 deficiency, confirm the heterogeneous and complex immunologic and clinical phenotype in disorders in which NF-κB components are defective, and underline an important role for NF-κB in NK-cell cytotoxic activity. We thank Fondazione Camillo Golgi and Comunità Bresciana, Brescia, Italy. We also thank the patients, their families, and the nurses for all their efforts. We thank Alessandro Moretta for providing mAbs anti–NK-cell receptors, produced in his Laboratory of Dipartimento di Medicina Sperimentale, Università di Genova, Italy. AppendixFig E1Flow cytometry analysis was performed on CD56+CD3- gated cells derived from patient (left columns) and from healthy donor (right columns). Activating NK cell receptors (CD16, NKp46, NKP30, NKG2D), maturation markers of CD56dim NK cell population (CD57 and perforin content), HLA class I specific NK cell receptors (NKG2A, KIR molecules), CD56dim and CD56bright NK cell chemokine receptors (CXCR1 and CCR7 respectively) are shown. The slight differences regarding KIRs molecule expression between the index patient and the healthy donor fall within the physiologic variability.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table E1Clinical features of patients with germline NFKB2 mutations∗Chen et al.4FeaturePatient 1∗Chen et al.4Patient 2∗Chen et al.4Patient 3∗Chen et al.4Patient 4∗Chen et al.4Patient 5†Liu et al.5Patient 6†Liu et al.5Patient 7‡Lindsley et al.6Patient 8§Lee et al.7Patient 9§Lee et al.7Patient 10§Lee et al.7Patient 11Index patient.SexFemaleFemaleMaleMaleFemaleMaleMaleFemaleMaleMaleMaleMutationp.Lys855Serfs∗Chen et al.47p.Lys855Serfs∗Chen et al.47p.Lys855Serfs∗Chen et al.47p.Arg853∗Chen et al.4p.Asp865Valfs∗Chen et al.417p.Asp865Valfs∗Chen et al.417p.A867Cfs∗Chen et al.419p.Asp865Glyp.Asp865Glyp.Asp865Glyp.Arg853∗Chen et al.4Age at diagnosis30 y6 y3 y10 y9 y7 y2.5 y40 y20 yInfancy4 yURTI+++++++++++LRTI+−+++−++−−−Recurrent herpes infections+++−−−−−−−−Alopecia universalis−+−+−−++ (Alopecia areata)+ (Alopecia areata)+ (Alopecia areata)+ACTH deficiency++++−−−−−−+Hypothyroidism−−−−−−−−−+Trachyonychia−+−+−−+−−−+Onychomycosis−+−−−−−−−−−Asthma++++−−−−−−−In all cases, except for patients 8, 9, and 10, the mutations are de novo mutations.LRTI, Lower respiratory tract infection; URTI, upper respiratory tract infection.∗ Chen et al.4Chen K. Coonrod E.M. Kumánovics A. Franks Z.F. Durtschi J.D. Margraf R.L. et al.Germline mutations in NFKB2 implicate the noncanonical NF-kB pathway in the pathogenesis of common variable immunodeficiency.Am J Hum Genet. 2013; 93: 812-824Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar† Liu et al.5Liu Y. Hanson S. Gurugama P. Jones A. Clark B. Ibrahim M.A. Novel NFKB2 mutation in early-onset CVID.J Clin Immunol. 2014; 34: 686-690Crossref PubMed Scopus (57) Google Scholar‡ Lindsley et al.6Lee C.E. Fulcher D.A. Whittle B. Chand R. Fewings N. Field M. et al.Autosomal dominant B-cell deficiency with alopecia due to a mutation in NFKB2 that results in non-processible p100.Blood. 2014; 124: 2964-2972Crossref PubMed Scopus (69) Google Scholar§ Lee et al.7Lindsley A.W. Qian Y. Valencia C.A. Shah K. Zhang K. Assa'ad A. Combined immune deficiency in a patient with a novel NFKB2 mutation.J Clin Immunol. 2014; 34: 910-915Crossref PubMed Scopus (48) Google Scholar|| Index patient. Open table in a new tab In all cases, except for patients 8, 9, and 10, the mutations are de novo mutations. LRTI, Lower respiratory tract infection; URTI, upper respiratory tract infection.
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