Plasmacytoid dendritic cell depletion in DOCK8 deficiency: Rescue of severe herpetic infections with IFN-α 2b therapy
2014; Elsevier BV; Volume: 133; Issue: 6 Linguagem: Inglês
10.1016/j.jaci.2014.03.032
ISSN1097-6825
AutoresSevgi Keleş, Haifa H. Jabara, İsmail Reisli, Douglas R. McDonald, Işıl Barlan, Rima Hanna‐Wakim, Ghassan Dbaibo, Marie‐Paule Lefranc, Waleed Al‐Herz, Raif S. Geha, Talal A. Chatila,
Tópico(s)Parvovirus B19 Infection Studies
ResumoDedicator of cytokinesis 8 (DOCK8) deficiency is a primary combined immune deficiency characterized by profound T-cell lymphopenia and impaired humoral antibody responses, increased serum IgE levels, and eosinophilia.1Zhang Q. Davis J.C. Lamborn I.T. Freeman A.F. Jing H. Favreau A.J. et al.Combined immunodeficiency associated with DOCK8 mutations.N Engl J Med. 2009; 361: 2046-2055Crossref PubMed Scopus (531) Google Scholar, 2Engelhardt K.R. McGhee S. Winkler S. Sassi A. Woellner C. Lopez-Herrera G. et al.Large deletions and point mutations involving the dedicator of cytokinesis 8 (DOCK8) in the autosomal-recessive form of hyper-IgE syndrome.J Allergy Clin Immunol. 2009; 124: 1289-1302.e4Abstract Full Text Full Text PDF PubMed Scopus (383) Google Scholar DOCK8 encodes a guanine nucleotide exchange factor that coordinates the actin cytoskeleton response to mitogenic and chemokine signals through the reversible activation of small G proteins, including cell division cycle 42.3Harada Y. Tanaka Y. Terasawa M. Pieczyk M. Habiro K. Katakai T. et al.DOCK8 is a Cdc42 activator critical for interstitial dendritic cell migration during immune responses.Blood. 2012; 119: 4451-4461Crossref PubMed Scopus (169) Google Scholar Subjects with DOCK8 deficiency are particularly susceptible to viral infections, especially with herpes simplex virus (HSV), varicella-zoster virus, human papillomavirus, molluscum contagiousum virus, and JC viruses. Overall, these infections represent a major cause of morbidity and at times mortality in DOCK8 deficiency. We here describe 2 patients with DOCK8 deficiency and severe, progressive oral herpes labialis infection refractory to therapy with acyclovir and its analogue valacyclovir who were successfully treated with systemic IFN-α 2b (IFN-α 2b). Importantly, analysis revealed profound deficiency of plasmacytoid dendritic cells (pDCs), the major immune cell population involved in IFN-α production, in DOCK8-deficient subjects.The demographic and genetic findings of the 2 patients are detailed in Table E1 and the immunologic findings in Table E2 in the Online Repository at www.jacionline.org. The first patient is a Turkish girl with a homozygous splice acceptor mutation in intron 16 of DOCK8 (c.1869 –1 G>C) who first presented at age 5 years with herpes labialis, confirmed by a positive Tzanck smear at age 5 years. Her infection initially resolved with oral acyclovir treatment but later recurred, leading to her placement on oral acyclovir prophylaxis. At the age of 6½ years, and despite prophylaxis, breakthrough disease recurred and progressively worsened with tissue destruction despite high acyclovir and later valacyclovir therapy (1500 mg/m2 and 150 mg/kg/d, respectively) (Fig 1, A and B). Pegilated IFN-α 2b was applied topically to little effect. Subcutaneous pegilated IFN-α 2b was then started on a weekly dose of 40 μg/m2, and the dose was increased stepwise over 4 months to 80 μg/m2/wk. Clinical response was noted after reaching a dose of 60 μg/m2/wk during the second month of therapy, and complete remission was achieved at 6 months of therapy (Fig 1, C). The patient continues to be maintained on IFN-α 2b at 80 μg/m2/wk with no recurrence of disease and no complications of therapy.The second case is a Turkish girl with a homozygous deletion in DOCK8, encompassing exon 26 through the 3′ end of the gene, who was hospitalized at age 6 years with a 4-week history of purulent otitis media resistant to oral antibiotics, a left ear ulceration, and oral vesicular lesions that were positive on Tzanck smears, consistent with herpes labialis. She was hospitalized with intravenous antibiotics and acyclovir. Intravenous immunoglobulin prophylaxis was restarted (0.5 g/kg every 3 weeks). Oral herpes labialis persisted with increasing severity and tissue destruction despite acyclovir and valcyclovir therapy (Fig 1, D and E). Subcutaneous pegilated IFN-α 2b was started at 40 μg/m2 and escalated up to 80 μg/m2 followed by weekly maintenance therapy, as detailed for the first patient, with complete and sustained remission of her lesions (Fig 1, F).pDCs play a key role in the innate immune response to viral infections, including HSV, by virtue of their capacity to produce copious amounts of type I IFN on activation.4Reizis B. Bunin A. Ghosh H.S. Lewis K.L. Sisirak V. Plasmacytoid dendritic cells: recent progress and open questions.Annu Rev Immunol. 2011; 29: 163-183Crossref PubMed Scopus (452) Google Scholar pDCs sense virus nucleoside-based products derived from DNA viruses including herpes through Toll-like receptor 9 (TLR9) and the TLR adaptor MyD88, a pathway that is profoundly impaired in DOCK8 deficiency, leading us to examine the capacity of patient pDCs to produce IFN-α in response to unmethylated CpG dinucleotides.5Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (45) Google Scholar To that end, we first analyzed the population of pDCs present in the peripheral blood of a group of DOCK-deficient as compared with control subjects. Details of the clinical and genetic findings of the DOCK8-deficient subjects we tested are provided in Table E1. Flow cytometric analysis of pDCs, identified by the markers CD123 and BDCA-4, revealed that their severe deficiency in the peripheral blood is a common attribute of DOCK8-deficient subjects (Fig 2, A and B). We further examined the capacity of PBMCs to produce IFN-α in vitro in response to CpG-A DNA (ODN 2216) treatment, as measured by ELISA. IFN-α production was profoundly depressed in patients than in control subjects, consistent with the markedly decreased number of pDCs in the former group (Fig 2, C). There was also decreased IFN-α production on per-cell basis down to one third of control values that did not achieve significance (P = .1), suggesting that this poor responsiveness to viral DNA may potentially compound pDC deficiency as a cause of decreased IFN-α production in this disease (Fig 2, D).Fig 2A, Representative FACS analysis for BDCA-4+ CD123+ pDCs in the lymphocyte gate of PBMCs from a control and a DOCK8-deficient subject. B, Total number of pDCs/106 cells in controls (C, n = 10) and patients (Pt, n = 9). C, IFN-α production in supernatants of CpG-stimulated PBMCs from controls (n = 9) and patients (n = 8). D, Production of IFN-α/pDC in controls and patients (n = 7 each). *P < .05. FACS, Fluorescence-activated cell sorting; ns, nonsignificant.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The mechanisms by which DOCK8 deficiency compromises the pDC compartment are presently unclear, and may include aberrant development, peripheral sequestration, and/or poor survival. DOCK8 regulates interstitial DC migration in response to chemotactic factors, suggesting that impaired mobilization of pDCs may also be a contributing mechanism.3Harada Y. Tanaka Y. Terasawa M. Pieczyk M. Habiro K. Katakai T. et al.DOCK8 is a Cdc42 activator critical for interstitial dendritic cell migration during immune responses.Blood. 2012; 119: 4451-4461Crossref PubMed Scopus (169) Google ScholarIFN-α 2b therapy may act by inhibiting viral replication and also by activating effector lymphocytes, including natural killer (NK) and cytotoxic T cells.4Reizis B. Bunin A. Ghosh H.S. Lewis K.L. Sisirak V. Plasmacytoid dendritic cells: recent progress and open questions.Annu Rev Immunol. 2011; 29: 163-183Crossref PubMed Scopus (452) Google Scholar Its utility in DOCK8 deficiency may extend beyond HSV infections to include other viral pathogens. IFN-α has previously been used in a child with Heck's disease, associated with chronic oral and vulvar human papillomavirus infection, later documented to have DOCK8 deficiency due to deletion in exon 38.2Engelhardt K.R. McGhee S. Winkler S. Sassi A. Woellner C. Lopez-Herrera G. et al.Large deletions and point mutations involving the dedicator of cytokinesis 8 (DOCK8) in the autosomal-recessive form of hyper-IgE syndrome.J Allergy Clin Immunol. 2009; 124: 1289-1302.e4Abstract Full Text Full Text PDF PubMed Scopus (383) Google Scholar, 6Ozarmagan G. Didem Yazganoglu K. Agacfidan A. Hyper-IgE syndrome with widespread premalign oral papillomas treated with interferon alpha2b.Acta Derm Venereol. 2005; 85: 433-435Crossref PubMed Scopus (15) Google Scholar IFN-α 2b therapy markedly improved the papillomatosis.Besides circulating pDC deficiency, other mechanisms have been invoked to explain the unusual susceptibility to viral infections in DOCK8-deficient subjects. These include poor CD8+ cytotoxic T-cell memory responses, deficiency of NK T cells, impaired NK cell function, and defective DOCK8 and MyD88-dependent TLR signaling.5Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (45) Google Scholar, 7Crawford G. Enders A. Gileadi U. Stankovic S. Zhang Q. Lambe T. et al.DOCK8 is critical for the survival and function of NKT cells.Blood. 2013; 122: 2052-2061Crossref PubMed Scopus (55) Google Scholar, 8Randall K.L. Chan S.S. Ma C.S. Fung I. Mei Y. Yabas M. et al.DOCK8 deficiency impairs CD8 T cell survival and function in humans and mice.J Exp Med. 2011; 208: 2305-2320Crossref PubMed Scopus (141) Google Scholar, 9Mizesko M.C. Banerjee P.P. Monaco-Shawver L. Mace E.M. Bernal W.E. Sawalle-Belohradsky J. et al.Defective actin accumulation impairs human natural killer cell function in patients with dedicator of cytokinesis 8 deficiency.J Allergy Clin Immunol. 2013; 131: 840-848Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar These defects may synergistically interact to precipitate severe, persistent viral infections in DOCK8-deficient patients.In summary, deficiency of circulating pDCs and its attendant decreased IFN-α production are previously undescribed attributes of DOCK8 deficiency that likely contribute to the heightened susceptibility to severe viral infections, especially those affecting the mucocutaneous compartment. Systemic IFN-α therapy may be beneficial in those DOCK8-deficient subjects who prove unresponsive to conventional antiviral chemotherapies. Dedicator of cytokinesis 8 (DOCK8) deficiency is a primary combined immune deficiency characterized by profound T-cell lymphopenia and impaired humoral antibody responses, increased serum IgE levels, and eosinophilia.1Zhang Q. Davis J.C. Lamborn I.T. Freeman A.F. Jing H. Favreau A.J. et al.Combined immunodeficiency associated with DOCK8 mutations.N Engl J Med. 2009; 361: 2046-2055Crossref PubMed Scopus (531) Google Scholar, 2Engelhardt K.R. McGhee S. Winkler S. Sassi A. Woellner C. Lopez-Herrera G. et al.Large deletions and point mutations involving the dedicator of cytokinesis 8 (DOCK8) in the autosomal-recessive form of hyper-IgE syndrome.J Allergy Clin Immunol. 2009; 124: 1289-1302.e4Abstract Full Text Full Text PDF PubMed Scopus (383) Google Scholar DOCK8 encodes a guanine nucleotide exchange factor that coordinates the actin cytoskeleton response to mitogenic and chemokine signals through the reversible activation of small G proteins, including cell division cycle 42.3Harada Y. Tanaka Y. Terasawa M. Pieczyk M. Habiro K. Katakai T. et al.DOCK8 is a Cdc42 activator critical for interstitial dendritic cell migration during immune responses.Blood. 2012; 119: 4451-4461Crossref PubMed Scopus (169) Google Scholar Subjects with DOCK8 deficiency are particularly susceptible to viral infections, especially with herpes simplex virus (HSV), varicella-zoster virus, human papillomavirus, molluscum contagiousum virus, and JC viruses. Overall, these infections represent a major cause of morbidity and at times mortality in DOCK8 deficiency. We here describe 2 patients with DOCK8 deficiency and severe, progressive oral herpes labialis infection refractory to therapy with acyclovir and its analogue valacyclovir who were successfully treated with systemic IFN-α 2b (IFN-α 2b). Importantly, analysis revealed profound deficiency of plasmacytoid dendritic cells (pDCs), the major immune cell population involved in IFN-α production, in DOCK8-deficient subjects. The demographic and genetic findings of the 2 patients are detailed in Table E1 and the immunologic findings in Table E2 in the Online Repository at www.jacionline.org. The first patient is a Turkish girl with a homozygous splice acceptor mutation in intron 16 of DOCK8 (c.1869 –1 G>C) who first presented at age 5 years with herpes labialis, confirmed by a positive Tzanck smear at age 5 years. Her infection initially resolved with oral acyclovir treatment but later recurred, leading to her placement on oral acyclovir prophylaxis. At the age of 6½ years, and despite prophylaxis, breakthrough disease recurred and progressively worsened with tissue destruction despite high acyclovir and later valacyclovir therapy (1500 mg/m2 and 150 mg/kg/d, respectively) (Fig 1, A and B). Pegilated IFN-α 2b was applied topically to little effect. Subcutaneous pegilated IFN-α 2b was then started on a weekly dose of 40 μg/m2, and the dose was increased stepwise over 4 months to 80 μg/m2/wk. Clinical response was noted after reaching a dose of 60 μg/m2/wk during the second month of therapy, and complete remission was achieved at 6 months of therapy (Fig 1, C). The patient continues to be maintained on IFN-α 2b at 80 μg/m2/wk with no recurrence of disease and no complications of therapy. The second case is a Turkish girl with a homozygous deletion in DOCK8, encompassing exon 26 through the 3′ end of the gene, who was hospitalized at age 6 years with a 4-week history of purulent otitis media resistant to oral antibiotics, a left ear ulceration, and oral vesicular lesions that were positive on Tzanck smears, consistent with herpes labialis. She was hospitalized with intravenous antibiotics and acyclovir. Intravenous immunoglobulin prophylaxis was restarted (0.5 g/kg every 3 weeks). Oral herpes labialis persisted with increasing severity and tissue destruction despite acyclovir and valcyclovir therapy (Fig 1, D and E). Subcutaneous pegilated IFN-α 2b was started at 40 μg/m2 and escalated up to 80 μg/m2 followed by weekly maintenance therapy, as detailed for the first patient, with complete and sustained remission of her lesions (Fig 1, F). pDCs play a key role in the innate immune response to viral infections, including HSV, by virtue of their capacity to produce copious amounts of type I IFN on activation.4Reizis B. Bunin A. Ghosh H.S. Lewis K.L. Sisirak V. Plasmacytoid dendritic cells: recent progress and open questions.Annu Rev Immunol. 2011; 29: 163-183Crossref PubMed Scopus (452) Google Scholar pDCs sense virus nucleoside-based products derived from DNA viruses including herpes through Toll-like receptor 9 (TLR9) and the TLR adaptor MyD88, a pathway that is profoundly impaired in DOCK8 deficiency, leading us to examine the capacity of patient pDCs to produce IFN-α in response to unmethylated CpG dinucleotides.5Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (45) Google Scholar To that end, we first analyzed the population of pDCs present in the peripheral blood of a group of DOCK-deficient as compared with control subjects. Details of the clinical and genetic findings of the DOCK8-deficient subjects we tested are provided in Table E1. Flow cytometric analysis of pDCs, identified by the markers CD123 and BDCA-4, revealed that their severe deficiency in the peripheral blood is a common attribute of DOCK8-deficient subjects (Fig 2, A and B). We further examined the capacity of PBMCs to produce IFN-α in vitro in response to CpG-A DNA (ODN 2216) treatment, as measured by ELISA. IFN-α production was profoundly depressed in patients than in control subjects, consistent with the markedly decreased number of pDCs in the former group (Fig 2, C). There was also decreased IFN-α production on per-cell basis down to one third of control values that did not achieve significance (P = .1), suggesting that this poor responsiveness to viral DNA may potentially compound pDC deficiency as a cause of decreased IFN-α production in this disease (Fig 2, D). The mechanisms by which DOCK8 deficiency compromises the pDC compartment are presently unclear, and may include aberrant development, peripheral sequestration, and/or poor survival. DOCK8 regulates interstitial DC migration in response to chemotactic factors, suggesting that impaired mobilization of pDCs may also be a contributing mechanism.3Harada Y. Tanaka Y. Terasawa M. Pieczyk M. Habiro K. Katakai T. et al.DOCK8 is a Cdc42 activator critical for interstitial dendritic cell migration during immune responses.Blood. 2012; 119: 4451-4461Crossref PubMed Scopus (169) Google Scholar IFN-α 2b therapy may act by inhibiting viral replication and also by activating effector lymphocytes, including natural killer (NK) and cytotoxic T cells.4Reizis B. Bunin A. Ghosh H.S. Lewis K.L. Sisirak V. Plasmacytoid dendritic cells: recent progress and open questions.Annu Rev Immunol. 2011; 29: 163-183Crossref PubMed Scopus (452) Google Scholar Its utility in DOCK8 deficiency may extend beyond HSV infections to include other viral pathogens. IFN-α has previously been used in a child with Heck's disease, associated with chronic oral and vulvar human papillomavirus infection, later documented to have DOCK8 deficiency due to deletion in exon 38.2Engelhardt K.R. McGhee S. Winkler S. Sassi A. Woellner C. Lopez-Herrera G. et al.Large deletions and point mutations involving the dedicator of cytokinesis 8 (DOCK8) in the autosomal-recessive form of hyper-IgE syndrome.J Allergy Clin Immunol. 2009; 124: 1289-1302.e4Abstract Full Text Full Text PDF PubMed Scopus (383) Google Scholar, 6Ozarmagan G. Didem Yazganoglu K. Agacfidan A. Hyper-IgE syndrome with widespread premalign oral papillomas treated with interferon alpha2b.Acta Derm Venereol. 2005; 85: 433-435Crossref PubMed Scopus (15) Google Scholar IFN-α 2b therapy markedly improved the papillomatosis. Besides circulating pDC deficiency, other mechanisms have been invoked to explain the unusual susceptibility to viral infections in DOCK8-deficient subjects. These include poor CD8+ cytotoxic T-cell memory responses, deficiency of NK T cells, impaired NK cell function, and defective DOCK8 and MyD88-dependent TLR signaling.5Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (45) Google Scholar, 7Crawford G. Enders A. Gileadi U. Stankovic S. Zhang Q. Lambe T. et al.DOCK8 is critical for the survival and function of NKT cells.Blood. 2013; 122: 2052-2061Crossref PubMed Scopus (55) Google Scholar, 8Randall K.L. Chan S.S. Ma C.S. Fung I. Mei Y. Yabas M. et al.DOCK8 deficiency impairs CD8 T cell survival and function in humans and mice.J Exp Med. 2011; 208: 2305-2320Crossref PubMed Scopus (141) Google Scholar, 9Mizesko M.C. Banerjee P.P. Monaco-Shawver L. Mace E.M. Bernal W.E. Sawalle-Belohradsky J. et al.Defective actin accumulation impairs human natural killer cell function in patients with dedicator of cytokinesis 8 deficiency.J Allergy Clin Immunol. 2013; 131: 840-848Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar These defects may synergistically interact to precipitate severe, persistent viral infections in DOCK8-deficient patients. In summary, deficiency of circulating pDCs and its attendant decreased IFN-α production are previously undescribed attributes of DOCK8 deficiency that likely contribute to the heightened susceptibility to severe viral infections, especially those affecting the mucocutaneous compartment. Systemic IFN-α therapy may be beneficial in those DOCK8-deficient subjects who prove unresponsive to conventional antiviral chemotherapies. MethodsFlow cytometryFor the detection of pDCs, PBMCs were stained with anti-human CD123 (AC145) and BDCA-4 (AD5-17F6) mAbs (Miltenyi Biotec, San Diego, Calif) with the appropriate isotype controls as described before.E1Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (171) Google Scholar Standard flow cytometric methods were used for staining. Data collected with a LSRFortessa cell analyzer (BD Biosciences, San Diego, Calif) were analyzed in the lymphocyte gate with FlowJo software (TreeStar, Ashland, Ore).IFN-α productionTable E1Clinical and genotypic features of DOCK8-deficient subjectsClinical findingsGenotyping (reference sequence NM_203447.3)ReferencePatientAge (y)SexViral infections1∗Patients treated with IFN-α 2b.5FHSVHomozygous IVS16splice acceptor site mutation: c.[1869 –1 G>C]; [1869 –1 G>C]This report2∗Patients treated with IFN-α 2b.4FHSVHomozygous deletion encompassing exons 26-48: c.[3121 –?_7340+?del]; [3121 –?_7340+?del]This report31FHomozygous deletion encompassing exons 1-23: c.[1 –?_ 2874+?del]; [1 –?_ 2874+?del]This report49FHPVHomozygous deletion encompassing exons 26-48: c.[3121 –?_7340+?del]; [3121 –?_7340+?del]This report54MMCVHomozygous deletion encompassing exon 27: c.[3235 –?_3390+?del]; [3235 –?_3390 +?del]Jabara et al5Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (45) Google Scholar66MMCVHomozygous deletion encompassing exons 1 and 2: c.[1 –?_156 +?del]; [1 –?_156+?del]Jabara et al5Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (45) Google Scholar78FHSV, HPV, MCVHomozygous deletion encompassing exons 28-35: c.[3391 –?_4473+?del]; [3391 –?_4473+?del]Jabara et al5Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (45) Google Scholar810FHSV, VZVHomozygous nonsense mutation: c.[2248G>T]; [2248G>T]Engelhardt et al2Engelhardt K.R. McGhee S. Winkler S. Sassi A. Woellner C. Lopez-Herrera G. et al.Large deletions and point mutations involving the dedicator of cytokinesis 8 (DOCK8) in the autosomal-recessive form of hyper-IgE syndrome.J Allergy Clin Immunol. 2009; 124: 1289-1302.e4Abstract Full Text Full Text PDF PubMed Scopus (383) Google Scholar97MHomozygous IVS44 splice donor site mutation: c.[5817 +1 G>A]; [5817 +1 G>A]Janssen et alE2Janssen E. Tsitsikov E. Al-Herz W. Lefranc G. Megarbane A. Dasouki M. et al.Flow cytometry biomarkers distinguish DOCK8 deficiency from severe atopic dermatitis.Clin Immunol. 2014; 150: 220-224Crossref PubMed Scopus (26) Google Scholar10†Deceased.8MHSVHomozygous IVS44 splice donor site mutation: c.[5817+1 G>A]; [5817 +1 G>A]This reportNote. Patients' demographic characteristics, viral infections, and DOCK8 genotypes are listed. The genotypes of patients 9 and 10 are described in Janssen et al.E2Janssen E. Tsitsikov E. Al-Herz W. Lefranc G. Megarbane A. Dasouki M. et al.Flow cytometry biomarkers distinguish DOCK8 deficiency from severe atopic dermatitis.Clin Immunol. 2014; 150: 220-224Crossref PubMed Scopus (26) Google ScholarF, Female; HPV, human papillomavirus; M, male; MCV, molluscum contagiousum virus; VZV, varicella-zoster virus.∗ Patients treated with IFN-α 2b.† Deceased. Open table in a new tab Table E2Hematologic and immunologic findings in DOCK8-deficient patients treated with IFN-α 2bPeripheral blood cellsPatient 1 at diagnosisPatient 1 before IFN-α 2b therapyPatient 1 2 mo into IFN-α 2b therapyPatient 2 at diagnosisPatient 2 before IFN-α 2b therapyPatient 2 2 mo into IFN-α 2b therapyWhite blood cells (mm3)11,50015,40010,70017,10025,00011,900Neutrophils (mm3)6,04012,8008,9996,4809,5008,150Lymphocytes (mm3)2,2901,8101,4902,4001,9991,680Eosinophils (mm3)3,50087278,0008061,100Hemoglobin (g/dL)9.911.39.7910.113.113.8Platelets (mm3)719,000435,000847,000825,000374,000392,000Serum immunoglobulins IgE (IU/mL)3341,33014,0002,450 IgA (mg/dL)9494.1176199 IgM (mg/dL)36.563.184.560.9 IgG (mg/dL)1,2809942,1001,230Lymphocyte subset analysis CD3+ (%)405454585153 CD3+4+ (%)292428272833 CD3+8+ (%)123433302419 CD19+ (%)471920152224 CD3–CD16+CD56+ (%)102418272420 Open table in a new tab Flow cytometryFor the detection of pDCs, PBMCs were stained with anti-human CD123 (AC145) and BDCA-4 (AD5-17F6) mAbs (Miltenyi Biotec, San Diego, Calif) with the appropriate isotype controls as described before.E1Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (171) Google Scholar Standard flow cytometric methods were used for staining. Data collected with a LSRFortessa cell analyzer (BD Biosciences, San Diego, Calif) were analyzed in the lymphocyte gate with FlowJo software (TreeStar, Ashland, Ore). For the detection of pDCs, PBMCs were stained with anti-human CD123 (AC145) and BDCA-4 (AD5-17F6) mAbs (Miltenyi Biotec, San Diego, Calif) with the appropriate isotype controls as described before.E1Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (171) Google Scholar Standard flow cytometric methods were used for staining. Data collected with a LSRFortessa cell analyzer (BD Biosciences, San Diego, Calif) were analyzed in the lymphocyte gate with FlowJo software (TreeStar, Ashland, Ore). IFN-α productionTable E1Clinical and genotypic features of DOCK8-deficient subjectsClinical findingsGenotyping (reference sequence NM_203447.3)ReferencePatientAge (y)SexViral infections1∗Patients treated with IFN-α 2b.5FHSVHomozygous IVS16splice acceptor site mutation: c.[1869 –1 G>C]; [1869 –1 G>C]This report2∗Patients treated with IFN-α 2b.4FHSVHomozygous deletion encompassing exons 26-48: c.[3121 –?_7340+?del]; [3121 –?_7340+?del]This report31FHomozygous deletion encompassing exons 1-23: c.[1 –?_ 2874+?del]; [1 –?_ 2874+?del]This report49FHPVHomozygous deletion encompassing exons 26-48: c.[3121 –?_7340+?del]; [3121 –?_7340+?del]This report54MMCVHomozygous deletion encompassing exon 27: c.[3235 –?_3390+?del]; [3235 –?_3390 +?del]Jabara et al5Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (45) Google Scholar66MMCVHomozygous deletion encompassing exons 1 and 2: c.[1 –?_156 +?del]; [1 –?_156+?del]Jabara et al5Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (45) Google Scholar78FHSV, HPV, MCVHomozygous deletion encompassing exons 28-35: c.[3391 –?_4473+?del]; [3391 –?_4473+?del]Jabara et al5Jabara H.H. McDonald D.R. Janssen E. Massaad M.J. Ramesh N. Borzutzky A. et al.DOCK8 functions as an adaptor that links TLR-MyD88 signaling to B cell activation.Nat Immunol. 2012; 13: 612-620Crossref PubMed Scopus (45) Google Scholar810FHSV, VZVHomozygous nonsense mutation: c.[2248G>T]; [2248G>T]Engelhardt et al2Engelhardt K.R. McGhee S. Winkler S. Sassi A. Woellner C. Lopez-Herrera G. et al.Large deletions and point mutations involving the dedicator of cytokinesis 8 (DOCK8) in the autosomal-recessive form of hyper-IgE syndrome.J Allergy Clin Immunol. 2009; 124: 1289-1302.e4Abstract Full Text Full Text PDF PubMed Scopus (383) Google Scholar97MHomozygous IVS44 splice donor site mutation: c.[5817 +1 G>A]; [5817 +1 G>A]Janssen et alE2Janssen E. Tsitsikov E. Al-Herz W. Lefranc G. Megarbane A. Dasouki M. et al.Flow cytometry biomarkers distinguish DOCK8 deficiency from severe atopic dermatitis.Clin Immunol. 2014; 150: 220-224Crossref PubMed Scopus (26) Google Scholar10†Deceased.8MHSVHomozygous IVS44 splice donor site mutation: c.[5817+1 G>A]; [5817 +1 G>A]This reportNote. Patients' demographic characteristics, viral infections, and DOCK8 genotypes are listed. The genotypes of patients 9 and 10 are described in Janssen et al.E2Janssen E. Tsitsikov E. Al-Herz W. Lefranc G. Megarbane A. Dasouki M. et al.Flow cytometry biomarkers distinguish DOCK8 deficiency from severe atopic dermatitis.Clin Immunol. 2014; 150: 220-224Crossref PubMed Scopus (26) Google ScholarF, Female; HPV, human papillomavirus; M, male; MCV, molluscum contagiousum virus; VZV, varicella-zoster virus.∗ Patients treated with IFN-α 2b.† Deceased. Open table in a new tab Table E2Hematologic and immunologic findings in DOCK8-deficient patients treated with IFN-α 2bPeripheral blood cellsPatient 1 at diagnosisPatient 1 before IFN-α 2b therapyPatient 1 2 mo into IFN-α 2b therapyPatient 2 at diagnosisPatient 2 before IFN-α 2b therapyPatient 2 2 mo into IFN-α 2b therapyWhite blood cells (mm3)11,50015,40010,70017,10025,00011,900Neutrophils (mm3)6,04012,8008,9996,4809,5008,150Lymphocytes (mm3)2,2901,8101,4902,4001,9991,680Eosinophils (mm3)3,50087278,0008061,100Hemoglobin (g/dL)9.911.39.7910.113.113.8Platelets (mm3)719,000435,000847,000825,000374,000392,000Serum immunoglobulins IgE (IU/mL)3341,33014,0002,450 IgA (mg/dL)9494.1176199 IgM (mg/dL)36.563.184.560.9 IgG (mg/dL)1,2809942,1001,230Lymphocyte subset analysis CD3+ (%)405454585153 CD3+4+ (%)292428272833 CD3+8+ (%)123433302419 CD19+ (%)471920152224 CD3–CD16+CD56+ (%)102418272420 Open table in a new tab Note. Patients' demographic characteristics, viral infections, and DOCK8 genotypes are listed. The genotypes of patients 9 and 10 are described in Janssen et al.E2Janssen E. Tsitsikov E. Al-Herz W. Lefranc G. Megarbane A. Dasouki M. et al.Flow cytometry biomarkers distinguish DOCK8 deficiency from severe atopic dermatitis.Clin Immunol. 2014; 150: 220-224Crossref PubMed Scopus (26) Google Scholar F, Female; HPV, human papillomavirus; M, male; MCV, molluscum contagiousum virus; VZV, varicella-zoster virus.
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