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Clinical and Immunological Phenotype of Patients With Primary Immunodeficiency Due to Damaging Mutations in NFKB2

2019; Frontiers Media; Volume: 10; Linguagem: Inglês

10.3389/fimmu.2019.00297

1664-3224

Christian Klemann, Nadezhda Camacho-Ordóñez, Linlin Yang, Zoya Eskandarian, Jessica Rojas‐Restrepo, Natalie Frede, Alla Bulashevska, Maximilian Heeg, Moudjahed Saleh Al-Ddafari, Julian Premm, Maximilian Seidl, Sandra Ammann, Roya Sherkat, Nita Radhakrishnan, Klaus Warnatz, Susanne Unger, Robin Kobbe, Anja Hüfner, Timothy Ronan Leahy, Winnie Ip, Siobhan O. Burns, Manfred Fliegauf, Bodo Grimbacher,

Immune Cell Function and Interaction

Non-canonical NF-κB-pathway signaling is integral in immunoregulation. Heterozygous mutations in NFKB2 have recently been established as a molecular cause of common variable immunodeficiency (CVID) and DAVID-syndrome, a rare condition combining deficiency of anterior pituitary hormone with CVID. Here, we investigate 15 previously unreported patients with primary immunodeficiency (PID) from eleven unrelated families with heterozygous NFKB2-mutations including eight patients with the common p.Arg853* nonsense mutation and five patients harboring unique novel C-terminal truncating mutations. In addition, we describe the clinical phenotype of two patients with proximal truncating mutations. Cohort analysis extended to all 35 previously published NFKB2-cases revealed occurrence of early-onset PID in 46/50 patients (mean 5.5 yrs, median 2 yrs). ACTH-deficiency occurred in 44%. Three mutation carriers have deceased, four developed malignancies. Only two mutation carriers were clinically asymptomatic. In contrast to typical CVID, most patients suffered from early-onset and severe disease manifestations, including clinical signs of T cell dysfunction e.g. chronic-viral or opportunistic infections. In addition, 80% of patients suffered from autoimmune (AI) phenomena (alopecia > various lymphocytic organ-infiltration > diarrhea > arthritis > AI-cytopenia). Lymphoproliferation was not a hallmark of disease. Immunophenotyping showed largely normal quantities of naïve and memory CD4+ or CD8 + T-cells and normal T-cell proliferation. NK-cell number and function were also normal. In contrast, impaired B-cell differentiation and hypogammaglobinemia were consistent features of NFKB2-associated disease. In addition, an array of lymphocyte subpopulations such as regulatory T cell, Th17-, cTFH-, NKT-, and MAIT-cell numbers were decreased. We conclude that heterozygous damaging mutations in NFKB2 represent a distinct PID entity exceeding the usual clinical spectrum of CVID. Impairment of the non-canonical NF-κB pathways affects function and differentiation of numerous lymphocyte-subpopulations and thus causes a heterogeneous, more severe form of PID phenotype with early-onset. Further characteristic features are multifaceted, primarily T cell-mediated autoimmunity such as alopecia, lymphocytic organ infiltration, and frequently ACTH-deficiency.