Common variable immunodeficiency

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Common variable immunodeficiency
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Common variable immunodeficiency (CVID) is an immune disorder characterized by recurrent infections and low antibody levels, specifically in immunoglobulin (Ig) types IgG, IgM and IgA. [1] Generally symptoms include high susceptibility to foreign invaders, chronic lung disease, and inflammation and infection of the gastrointestinal tract. [1] However, symptoms vary greatly between people. "Variable" refers to the heterogeneous clinical manifestations of this disorder, which include recurrent bacterial infections, increased risk for autoimmune disease and lymphoma, as well as gastrointestinal disease. [2] CVID is a lifelong disease.

Contents

The cause of CVID is poorly understood. Deletions in genes that encode cell surface proteins and cytokine receptors, such as CD19, CD20, CD21, and CD80, is a likely cause. [3] A deletion is a mutation in which part of the chromosome is lost during DNA replication which may include several genes, or as few as a single base pair. Additionally, the disease is defined by T cell defects, namely reduced proliferative capacity. [4] The disease is hard to diagnose, taking on average 6–7 years after onset. [3] [5] CVID is a primary immunodeficiency. [3]

Treatment options are limited, and usually include lifelong immunoglobulin replacement therapy. [5] This therapy is thought to help reduce bacterial infections. This treatment alone is not wholly effective, and many people still experience other symptoms like lung disease and noninfectious inflammatory symptoms.

CVID was first diagnosed over 60 years ago, and since has emerged as the predominant class of primary antibody deficiencies. CVID is formally diagnosed by levels of IgG and IgA more than two standard deviations below the norm, and no other cause for hypogammaglobulinemia, an abnormally low level of immunoglobulins in the blood. It is thought to affect between 1 in 25,000 to 1 in 50,000 people worldwide.

Signs and symptoms

The symptoms of CVID vary between people affected. Its main features are hypogammaglobulinemia and recurrent infections. Hypogammaglobulinemia manifests as a significant decrease in the levels of IgG antibodies, usually alongside IgA antibodies; IgM antibody levels are also decreased in about half of people. [6] Infections are a direct result of the low antibody levels in the circulation, which do not adequately protect them against pathogens. The microorganisms that most frequently cause infections in CVID are bacteria Haemophilus influenzae, Streptococcus pneumoniae and Staphylococcus aureus. Pathogens less often isolated from people include Neisseria meningitidis, Pseudomonas aeruginosa and Giardia lamblia. Infections mostly affect the respiratory tract (nose, sinuses, bronchi, lungs) and the ears; they can also occur at other sites, such as the eyes, skin and gastrointestinal tract. These infections respond to antibiotics but can recur upon discontinuation of antibiotics. Bronchiectasis can develop when severe, recurrent pulmonary infections are left untreated.

In addition to infections, people with CVID can develop complications. These include:

Anxiety and depression can occur as a result of dealing with the other symptoms. [7]

CVID patients generally complain of severe fatigue. [8]

Causes

The underlying causes of CVID are largely obscure. [5] Genetic mutations can be identified as the cause of disease in about 10% of people, while familial inheritance accounts for 10-25% of cases. [9] Rather than arising from a single genetic mutation, CVID seems to result from variety of mutations that all contribute to a failure in antibody production.

Mutations in the genes encoding ICOS, TACI, CD19, CD20, CD21, CD80 and BAFFR have been identified as causative of CVID. [9] [10] [11] Susceptibility to CVID may also be linked to the Major Histocompatibility Complex (MHC) of the genome, particularly to DR-DQ haplotypes. [12] A mutation in the NFKB2 gene has recently been shown to cause CVID-like symptoms in a murine model. The frequency of this NFKB2 mutation in the CVID population is, however, yet to be established. [13]

Diagnosis

According to a European registry study, the mean age at onset of symptoms was 26.3 years old. [14] As per the criteria laid out by ESID (European Society for Immunodeficiencies) and PAGID (Pan-American Group for Immunodeficiency), CVID is diagnosed if: [15]

Diagnosis is chiefly by exclusion, i.e. alternative causes of hypogammaglobulinemia, such as X-linked agammaglobulinemia, must be excluded before a diagnosis of CVID can be made.

Diagnosis is difficult because of the diversity of phenotypes seen in people with CVID. For example, serum immunoglobulin levels in people with CVID vary greatly. Generally, people can be grouped as follows: no immunoglobulin production, immunoglobulin (Ig) M production only, or both normal IgM and IgG production. [3] Additionally, B cell numbers are also highly variable. 12% of people have no detectable B cells, 12% have reduced B cells, and 54% are within the normal range. [15] In general, people with CVID display higher frequencies of naive B cells and lower frequencies of class-switched memory B cells. Frequencies of other B cell populations, such as IgD memory B cells, transitional B cells, and CD21 B cells, are also affected, and are associated with specific disease features. Although CVID is often thought of as a serum immunoglobulin and B cell-mediated disease, T cells can display abnormal behavior. Affected individuals typically present with low frequencies of CD4+, a T-cell marker, and decreased circulation of regulatory T cells and iNKT cell. Notably, approximately 10% of people display CD4+ T cell counts lower than 200 cells/mm3; this particular phenotype of CVID has been named LOCID (Late Onset Combined Immunodeficiency), and has a poorer prognosis than classical CVID.

Types

Type OMIM Gene
CVID1 607594 ICOS
CVID2 240500 TACI
CVID3 613493 CD19
CVID4 613494 TNFRSF13C
CVID5 613495 CD20
CVID6 613496 CD81

The following types of CVID have been identified, and correspond to mutations in different gene segments.

Treatment

Treatment consists of immunoglobulin replacement therapy, which replenishes Ig subtypes that the person lacks. This treatment is given at frequent intervals for life, and is thought to help reduce bacterial infections and boost immune function. [16] Before therapy begins, plasma donations are tested for known blood-borne pathogens, then pooled and processed to obtain concentrated IgG samples. Infusions can be administered in three different forms: intravenously (IVIg):, [17] subcutaneously (SCIg), and intramuscularly (IMIg).

The administration of intravenous immunoglobulins requires the insertion of a cannula or needle in a vein, usually in the arms or hands. Because highly concentrated product is used, IVIg infusions take place every 3 to 4 weeks. Subcutaneous infusions slowly release the Ig serum underneath the skin, again through a needle, and takes place every week. [18] Intramuscular infusions are no longer widely used, as they can be painful and are more likely to cause reactions.

People often experience adverse side effects to immunoglobulin infusions, including:

In addition to Ig replacement therapy, treatment may also involve immune suppressants, to control autoimmune symptoms of the disease, and high dose steroids like corticosteroids. [15] In some cases, antibiotics are used to fight chronic lung disease resulting from CVID. [19] The outlook for people varies greatly depending on their level of lung and other organ damage prior to diagnosis and treatment.

Epidemiology

CVID has an estimated prevalence of about 1:50,000 in caucasians. [20] The disease seems to be less prevalent amongst Asians and African-Americans. Males and females are equally affected; however, among children, boys predominate. [3] A recent study of people in European with primary immunodeficiencies found that 30% had CVID, as opposed to a different immunodeficiency. [9] 10-25% of people inherited the disease, typically through autosomal-dominant inheritance. Given the rarity of the disease, it is not yet possible to generalize on disease prevalence among ethnic and racial groups. CVID shortens the life-span; but no study currently has a median age recorded. One study suggests the median age of death for men and women is 42 and 44 years old, respectively but most patients involved in the study are still alive. [5] Those people with accompanying disorders had the worst prognosis and those people with CVID only had frequent infections had the longest survival rates, with life expectancy almost equalling that of the general UK population. [21] Additionally, people with CVID with one or more noninfectious complications have an 11 times higher risk of death as compared to people with only infections.

History

[15] Charles Janeway Sr. is generally credited with the first description of a case of CVID in 1953. [22] The case involved a 39-year-old who had recurrent infections, bronchiectasis, and meningitis. [9] Though described in 1953, there was no standard definition for CVID until the 1990s, which caused widespread confusion during diagnosis. During the 1990s, the European Society for Immunodeficiency (ESID) and Pan-American Group for Immunodeficiency (PAGID) developed diagnostic criteria, including minimum age of diagnosis and the need to exclude other conditions, to describe the disease. These criteria were published in 1999 and since that time, some aspects, like increasing the minimum age, have been changed.

Research

Current research is aimed at studying large cohorts of people with CVID in an attempt to better understand age of onset, as well as mechanism, genetic factors, and progression of the disease. [3]

Funding for research in the US is provided by the National Institutes of Health. Key research in the UK was previously funded by the Primary Immunodeficiency Association (PiA) until its closure in January 2012, [23] and funding is raised through the annual Jeans for Genes campaign. Current efforts are aimed at studying the following: [15]

Related Research Articles

Immunodeficiency, also known as immunocompromisation, is a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent. Most cases are acquired ("secondary") due to extrinsic factors that affect the patient's immune system. Examples of these extrinsic factors include HIV infection and environmental factors, such as nutrition. Immunocompromisation may also be due to genetic diseases/flaws. An example here is SCID.

Wiskott–Aldrich syndrome

Wiskott–Aldrich syndrome (WAS) is a rare X-linked recessive disease characterized by eczema, thrombocytopenia, immune deficiency, and bloody diarrhea. It is also sometimes called the eczema-thrombocytopenia-immunodeficiency syndrome in keeping with Aldrich's original description in 1954. The WAS-related disorders of X-linked thrombocytopenia (XLT) and X-linked congenital neutropenia (XLN) may present with similar but less severe symptoms and are caused by mutations of the same gene.

X-linked agammaglobulinemia

X-linked agammaglobulinemia (XLA) is a rare genetic disorder discovered in 1952 that affects the body's ability to fight infection. As the form of agammaglobulinemia that is X-linked, it is much more common in males. In people with XLA, the white blood cell formation process does not generate mature B cells, which manifests as a complete or near-complete lack of proteins called gamma globulins, including antibodies, in their bloodstream. B cells are part of the immune system and normally manufacture antibodies, which defend the body from infections by sustaining a humoral immunity response. Patients with untreated XLA are prone to develop serious and even fatal infections. A mutation occurs at the Bruton's tyrosine kinase (Btk) gene that leads to a severe block in B cell development and a reduced immunoglobulin production in the serum. Btk is particularly responsible for mediating B cell development and maturation through a signaling effect on the B cell receptor BCR. Patients typically present in early childhood with recurrent infections, in particular with extracellular, encapsulated bacteria. XLA is deemed to have a relatively low incidence of disease, with an occurrence rate of approximately 1 in 200,000 live births and a frequency of about 1 in 100,000 male newborns. It has no ethnic predisposition. XLA is treated by infusion of human antibody. Treatment with pooled gamma globulin cannot restore a functional population of B cells, but it is sufficient to reduce the severity and number of infections due to the passive immunity granted by the exogenous antibodies.

Hypogammaglobulinemia is a problem with the immune system in which not enough gamma globulins are produced in the blood. This results in a lower antibody count, which impairs the immune system, increasing risk of infection. Hypogammaglobulinemia may result from a variety of primary genetic immune system defects, such as common variable immunodeficiency, or it may be caused by secondary effects such as medication, blood cancer, or poor nutrition, or loss of gamma globulins in urine, as in nonselective glomerular proteinuria. Patients with hypogammaglobulinemia have reduced immune function; important considerations include avoiding use of live vaccines, and take precautionary measures when traveling to regions with endemic disease or poor sanitation such as receiving immunizations, taking antibiotics abroad, drinking only safe or boiled water, arranging appropriate medical cover in advance of travel, and ensuring continuation of any immunoglobulin infusions needed.

X-linked severe combined immunodeficiency

X-linked severe combined immunodeficiency (X-SCID) is an immunodeficiency disorder in which the body produces very few T cells and NK cells.

Selective immunoglobulin A deficiency

Selective immunoglobulin A (IgA) deficiency (SIgAD) is a genetic immunodeficiency, a type of hypogammaglobulinemia. People with this deficiency lack immunoglobulin A (IgA), a type of antibody that protects against infections of the mucous membranes lining the mouth, airways, and digestive tract. It is defined as an undetectable serum IgA level in the presence of normal serum levels of IgG and IgM, in persons older than 4 years. It is the most common of the primary antibody deficiencies. Most such persons remain healthy throughout their lives and are never diagnosed.

Hyper IgM syndrome Primary immune deficiency disorders

Hyper IgM syndrome describes a group of primary immune deficiency disorders characterized by defective CD40 signaling; via B cells affecting class switch recombination (CSR) and somatic hypermutation. Immunoglobulin (Ig) class switch recombination deficiencies are characterized by elevated serum Immunoglobulin M (IgM) levels and a considerable deficiency in Immunoglobulins G (IgG), A (IgA) and E (IgE). As a consequence, people with HIGM have decreased concentrations of serum IgG and IgA and normal or elevated IgM, leading to increased susceptibility to infections.

Hyper-IgM syndrome type 2 Primary immune deficiency disorder

Hyper IgM Syndrome Type 2 is a rare disease. Unlike other hyper-IgM syndromes, Type 2 patients identified thus far did not present with a history of opportunistic infections. One would expect opportunistic infections in any immunodeficiency syndrome. The responsible genetic lesion is in the AICDA gene found at 12p13.

Hyper-IgM syndrome type 5 Primary immune deficiency disorder

The fifth type of hyper-IgM syndrome has been characterized in three patients from France and Japan. The symptoms are similar to hyper IgM syndrome type 2, but the AICDA gene is intact.

Primary immunodeficiencies are disorders in which part of the body's immune system is missing or does not function normally. To be considered a primary immunodeficiency (PID), the cause of the immune deficiency must not be secondary in nature. Most primary immunodeficiencies are genetic disorders; the majority are diagnosed in children under the age of one, although milder forms may not be recognized until adulthood. While there are over 430 recognized PIDs as of 2019, most are very rare. About 1 in 500 people in the United States are born with a primary immunodeficiency. Immune deficiencies can result in persistent or recurring infections, auto-inflammatory disorders, tumors, and disorders of various organs. There are currently limited treatments available for these conditions; most are specific to a particular type of PID. Research is currently evaluating the use of stem cell transplants (HSCT) and experimental gene therapies as avenues for treatment in limited subsets of PIDs.

An immune disorder is a dysfunction of the immune system. These disorders can be characterized in several different ways:

Humoral immune deficiency

Humoral immune deficiencies are conditions which cause impairment of humoral immunity, which can lead to immunodeficiency. It can be mediated by insufficient number or function of B cells, the plasma cells they differentiate into, or the antibody secreted by the plasma cells. The most common such immunodeficiency is inherited selective IgA deficiency, occurring between 1 in 100 and 1 in 1000 persons, depending on population. They are associated with increased vulnerability to infection, but can be difficult to detect in the absence of infection.

Hyper-IgM syndrome type 3 Primary immune deficiency disorder

Hyper-IgM syndrome type 3 is a form of hyper IgM syndrome characterized by mutations of the CD40 gene. In this type, Immature B cells cannot receive signal 2 from helper T cells which is necessary to mature into mature B cells.

Hyper-IgM syndrome type 4

Hyper-IgM syndrome type 4 is a form of Hyper IgM syndrome which is a defect in class switch recombination downstream of the AICDA gene that does not impair somatic hypermutation.

Thymoma with immunodeficiency is a rare disorder that occurs in adults in whom hypogammaglobulinemia, deficient cell-mediated immunity, and thymoma may develop almost simultaneously.Most reported cases are in Europe, though it occurs globally.

DOCK8 deficiency

DOCK8 deficiency, also called DOCK8 immunodeficiency syndrome, is the autosomal recessive form of hyperimmunoglobulin E syndrome, a genetic disorder characterized by elevated immunoglobulin E levels, eosinophilia, and recurrent infections with staphylococcus and viruses. It is caused by a mutation in the DOCK8 gene.

Immunoglobulin therapy, also known as normal human immunoglobulin (NHIG), is the use of a mixture of antibodies (immunoglobulins) to treat a number of health conditions. These conditions include primary immunodeficiency, immune thrombocytopenic purpura, chronic inflammatory demyelinating polyneuropathy, Kawasaki disease, certain cases of HIV/AIDS and measles, Guillain-Barré syndrome, and certain other infections when a more specific immunoglobulin is not available. Depending on the formulation it can be given by injection into muscle, a vein, or under the skin. The effects last a few weeks.

Granulomatous–lymphocytic interstitial lung disease (GLILD) is a lung complication of common variable immunodeficiency disorders (CVID). It is seen in approximately 15% of patients with CVID. It has been defined histologically as the presence of (non-caseating) granuloma and lymphoproliferation in the lung. However, as GLILD is often associated with other auto-immune features such as splenomegaly, adenopathy and cytopenias, a definition based on abnormalities on lung imaging together with evidence of granulomatous inflammation elsewhere has also been employed.

Nuclear factor-kappa B Essential Modulator (NEMO) deficiency syndrome is a rare type of primary immunodeficiency disease that has a highly variable set of symptoms and prognoses. It mainly affects the skin and immune system but has the potential to affect all parts of the body, including the lungs, urinary tract and gastrointestinal tract. It is a monogenetic disease caused by mutation in the IKBKG gene. NEMO is the modulator protein in the IKK inhibitor complex that, when activated, phosphorylates the inhibitor of the NF-κB transcription factors allowing for the translocation of transcription factors into the nucleus.

References

  1. 1 2 "Common Variable Immune Deficiency". Genetics Home Reference. Retrieved 8 February 2016.
  2. Cunningham-Rundles, C. Clinical manifestations, epidemiology, and diagnosis of common variable immunodeficiency in adults. In: UpToDate, Notarangelo, LD, Feldweg, AM (Eds), UpToDate, Waltham, MA, 2020. Retrieved April 08, 2020.
  3. 1 2 3 4 5 6 Abbott, Jordan K.; Gelfand, Erwin W. (2015). "Common Variable Immunodeficiency: Diagnosis, Management, and Treatment". Immunol Allergy Clin N Am. 35 (4): 637–658. doi:10.1016/j.iac.2015.07.009. PMID   26454311.
  4. Strober, Warren; Chua, Kevin (2000). "Common Variable Immunodeficiency". Clinical Reviews in Allergy and Immunology. 19 (2): 157–181. doi:10.1385/criai:19:2:157. PMID   11107500. S2CID   32349345.
  5. 1 2 3 4 Resnick, Elena S.; Cunningham-Rundles, Charlotte (2012). "The many faces of the clinical picture of common variable immune deficiency". Current Opinion. 12 (6): 595–601. doi:10.1097/aci.0b013e32835914b9. PMID   23026770. S2CID   205435779.
  6. Herriot R, Sewell WA (2008). "Antibody deficiency". Journal of Clinical Pathology. 61 (9): 994–1000. doi:10.1136/jcp.2007.051177. PMID   18755724. S2CID   25106807.
  7. Sanger, David E. "An Investigation of Coping and Psychosocial Functioning in Persons with Common Variable Immunodeficiency (CVID)" Archived 2003-07-28 at Archive.today , Barts and The London NHS Trust, 2003, accessed August 7, 2011.
  8. "PatientsLikeMe - Symptoms". www.patientslikeme.com. Retrieved 14 April 2018.
  9. 1 2 3 4 Park, Miguel A; Ti, James T; Hagan, John B; Maddox, Daniel E; Abraham, Roshini S (2008). "Common variable immunodeficiency: a new look at an old disease". The Lancet. 372 (9637): 9–15. doi:10.1016/s0140-6736(08)61199-x. PMID   18692715. S2CID   205951889.
  10. Salzer U, Neumann C, Thiel J, et al. (2008). "Screening of functional and positional candidate genes in families with common variable immunodeficiency". BMC Immunol. 9 (1): 3. doi:10.1186/1471-2172-9-3. PMC   2268914 . PMID   18254984.
  11. Blanco-Quirós A, Solís-Sánchez P, Garrote-Adrados JA, Arranz-Sanz E (2006). "Common variable immunodeficiency. Old questions are getting clearer". Allergol Immunopathol (Madr). 34 (6): 263–75. doi:10.1157/13095875. hdl:10261/71519. PMID   17173844. Archived from the original on 2009-05-21. Retrieved 2008-03-01.
  12. O Olerup, O; Smith, CI; Björkander, J; Hammarström, L (Nov 15, 1992). "Shared HLA class II-associated genetic susceptibility and resistance, related to the HLA-DQB1 gene, in IgA deficiency and common variable immunodeficiency". PNAS. 89 (22): 10653–10657. Bibcode:1992PNAS...8910653O. doi:10.1073/pnas.89.22.10653. PMC   50399 . PMID   1438261.
  13. Chen, Karin; Emily M. Coonrod; Attila Kumánovics; Zechariah F. Franks; Jacob D. Durtschi; Rebecca L. Margraf; Wilfred Wu; Nahla M. Heikal; Nancy H. Augustine; Perry G. Ridge; Harry R. Hill; Lynn B. Jorde; Andrew S. Weyrich; Guy A. Zimmerman; Adi V. Gundlapalli; John F. Bohnsack; Karl V. Voelkerding (17 October 2013). "Germline Mutations in NFKB2 Implicate the Noncanonical NF-κB Pathway in the Pathogenesis of Common Variable Immunodeficiency". The American Journal of Human Genetics. 93 (5): 812–24. doi:10.1016/j.ajhg.2013.09.009. PMC   3824125 . PMID   24140114.
  14. Bonilla, Francisco A.; Geha, Raif S. (2009). "Common Variable Immunodeficiency". Pediatric Research. 65 (5): 13R–19R. doi:10.1203/pdr.0b013e31819dbf88. PMID   19190529. S2CID   9361175.
  15. 1 2 3 4 5 Chapel, Helen; Cunningham-Rundles, Charlotte (2009). "Update in understanding common variable immunodeficiency disorders (CVIDs) and the management of patients with these conditions". British Journal of Haematology. 145 (6): 709–727. doi:10.1111/j.1365-2141.2009.07669.x. PMC   2718064 . PMID   19344423.
  16. "Primary immunodeficiency". Mayo Clinic. Retrieved 17 February 2016.
  17. Pourpak Z, Aghamohammadi A, Sedighipour L, et al. (2006). "Effect of regular intravenous immunoglobulin therapy on prevention of pneumonia in patients with common variable immunodeficiency". J Microbiol Immunol Infect. 39 (2): 114–20. PMID   16604243. Archived from the original (abstract) on 2008-09-29. Retrieved 2008-03-01.
  18. Schwartz, Robert A; Modak, Rohit; Modak, Prema. "Common Variable Immunodeficiency Treatment and Management". Medscape. Retrieved 17 February 2016.
  19. "Common Variable Immune Deficiency". Immune Deficiency Foundation. Retrieved 16 February 2016.
  20. Common Variable Immunodeficiency : Article by Robert A Schwartz at eMedicine
  21. Chapel, Helen; Cunningham-Rundles, Charlotte (2009-06-01). "Update in understanding common variable immunodeficiency disorders (CVIDs) and the management of patients with these conditions". British Journal of Haematology. 145 (6): 709–727. doi:10.1111/j.1365-2141.2009.07669.x. ISSN   1365-2141. PMC   2718064 . PMID   19344423.
  22. Janeway CA, Apt L, Gitlin D (1953). "Agammaglobulinemia". Trans Assoc Am Physicians. 66: 200–2. PMID   13136263.
  23. "Archived copy". Archived from the original on 2012-09-13. Retrieved 2012-10-26.CS1 maint: archived copy as title (link)
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