Background: Systemic autoinflammatory diseases (SAID) are rare inherited disorders involving gene... more Background: Systemic autoinflammatory diseases (SAID) are rare inherited disorders involving genes regulating innate immune signaling and are characterized by periodic or chronic multi-systemic inflammation.Objective: To describe spectrum of clinical, immunological, molecular features, and outcomes of patients with SAID in India.Methods: Request to share data was sent to multiple centers in India that are involved in care and management of patients with Inborn Errors of Immunity. Six centers provided requisite data that were compiled and analyzed.Results: Data on 107 patients with SAID were collated—of these, 29 patients were excluded due to unavailability of complete information. Twelve patients (15%) had type 1 interferonopathies, 21 (26%) had diseases affecting inflammasomes, 30 patients (41%) had non-inflammasome related conditions and 1five patients (19%) had Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA). Type1 interferonopathies identified in the cohort in...
BackgroundThere is paucity of literature on XLA from developing countries. Herein we report the c... more BackgroundThere is paucity of literature on XLA from developing countries. Herein we report the clinical and molecular profile and outcome in a multicenter cohort of patients with XLA from India.MethodsData on XLA from all regional centers supported by the Foundation for Primary Immunodeficiency Diseases (FPID), USA and other institutions providing care to patients with PIDs were collated. Diagnosis of XLA was based on European Society for Immunodeficiencies (ESID) criteria.ResultsWe received clinical details of 195 patients with a provisional diagnosis of XLA from 12 centers. At final analysis, 145 patients were included (137 ‘definite XLA’ and eight ‘probable/possible XLA’). Median age at onset of symptoms was 12.0 (6.0, 36.0) months and median age at diagnosis was 60.0 (31.5, 108) months. Pneumonia was the commonest clinical manifestation (82.6%) followed by otitis media (50%) and diarrhea (42%). Arthritis was seen in 26% patients while 23% patients developed meningitis. Bronchie...
BackgroundWiskott Aldrich syndrome (WAS) is characterized by bleeding manifestations, recurrent i... more BackgroundWiskott Aldrich syndrome (WAS) is characterized by bleeding manifestations, recurrent infections, eczema, autoimmunity, and malignancy. Over the last decade, improved awareness and better in-house diagnostic facilities at several centers in India has resulted in increased recognition of WAS. This study reports collated data across major primary immunodeficiency diseases (PID) centers in India that are involved in care of children with WAS and highlights the varied clinical presentations, genetic profile, and outcomes of patients in India.MethodsRequest to share data was sent to multiple centers in India that are involved in care and management of patients with PID. Six centers provided requisite data that were compiled and analyzed.ResultsIn this multi-institutional cohort, clinical details of 108 patients who had a provisional diagnosis of WAS were received. Of these, 95 patients with ‘definite WAS’ were included Fourteen patients were classified as XLT and 81 patients as...
Introduction:Hyper-IgE Syndrome (HIES) is a rare inborn error of immunity (IEI) characterized by ... more Introduction:Hyper-IgE Syndrome (HIES) is a rare inborn error of immunity (IEI) characterized by a constellation of symptoms related to susceptibility toStaphylococcalskin and pulmonary infections, eczema, raised serum IgE (>2,000 IU/ml), craniofacial anomalies, and recurrent bone fractures. Data on HIES from the Indian subcontinent is scarce and restricted to small case series and case reports. This is the first compilation of national data on HIES.Materials and Methods:A total 103 cases clinically diagnosed and treated as HIES were analyzed from nine centers. Cases with clinical and/or molecular diagnosis of DOCK8 deficiency were not included. Patients were divided into two groups: group I for whom a heterozygous rare variant of STAT3 was identified, and group II, with clinical features similar to those of AD STAT3 deficiency, but without any genetic diagnosis.Results:Genetic diagnosis was available in 27 patients (26.2%) and all harbored rare variants in the STAT3 gene. Majori...
Prenatal Diagnosis (PND) forms an important part of primary preventive management for families ha... more Prenatal Diagnosis (PND) forms an important part of primary preventive management for families having a child affected with primary immunodeficiency. Although individually sparse, collectively this group of genetic disorders represents a significant burden of disease. This paper discusses the prenatal services available for affected families at various centers across the country and the challenges and ethical considerations associated with genetic counseling. Mutation detection in the index case and analysis of chorionic villous sampling or amniocentesis remain the preferred procedures for PND and phenotypic analysis of cordocentesis sample is reserved for families with well-characterized index case seeking PND in the latter part of the second trimester of pregnancy. A total of 112 families were provided PND services in the last decade and the presence of an affected fetus was confirmed in 32 families. Post-test genetic counseling enabled the affected families to make an informed de...
Indian Journal of Hematology and Blood Transfusion, 2020
To study the clinical course of patients with sickle cell anemia and coinherited hematological di... more To study the clinical course of patients with sickle cell anemia and coinherited hematological disorders. Retrospective analysis of clinical data of patients enrolled at our hospital over last 7 years was performed. Eighty four patients of symptomatic sickling disorders were registered during this period, comprising of HbSS (n = 49), HbS-b thalassemia (n = 28), HbS-HbD disease (n = 5), HbS-b thalassemia with G6PD deficiency (n = 1) and HbS-hemophilia A (n = 1). Among HbS-b thalassemia, 18% suffered from occasional pain crises and 27% required occasional blood transfusion. 40% patients with HbS-HbD disease required occasional blood transfusions, one patient was transfusion dependent, while none suffered from crisis episodes. Patient with HbS-b thalassemia with G6PD deficiency had increased transfusion requirement during first 3 years of life, which decreased after that. Patient with HbS and severe hemophilia A had only one episode of severe bleeding, suffered from 1 crisis episode. In conclusion, HbA reduces severity of HbS in HbS-b ? thalassemia. HbS-HbD disease can manifest as a transfusion dependent illness. HbSS reduces severity of G6PD deficiency after first few years of life. HbSS and hemophilia coinheritance ameliorates symptoms of hemophilia.
inheritance. CGD is characterized by neutrophils and monocytes capable of normal chemotaxis, inge... more inheritance. CGD is characterized by neutrophils and monocytes capable of normal chemotaxis, ingestion and degranulation, but unable to kill catalase-positive microorganisms due to defects in one of the 5 major subunits of NADPH oxidase. Method and material: The medical records of 38 patients diagnosed with CGD were reviewed and analysed with respect to demographic data, age at presentation and diagnosis, clinical features, laboratory investigations, organisms isolated, treatment & prophylaxis given and clinical course. Results: Our study had 28 males and 10 females with 13 having history of consanguinity. Their mean age at presentation and diagnosis was 1.32yr and 2.5yr respectively. The most common manifestations at presentation were failure to thrive (100%) and lymphadenopathy (100%) followed by hepatomegaly (72%) and splenomegaly (48%). The commonest infection was pneumonia (84%) followed by abscesses (55%) involving lungs, liver, subcutaneous tissue; osteomyelitis (15%); urinary tract infections; otitis media and CNS infections. Organisms isolated from blood, stool and pus of infected lesions included bacteria-Mycobacterium tuberculae (50%), Staphylococci (24%), Klebsiella (16%) and fungi-Aspergillus (13%), Candida (26%). Biopsies done in 36% patients from lymph node, skin, lung and liver showed non caseating granulomatous inflammation. Diagnosis was based on reduced nitroblue tetrazolium test (NBT) between 0-5% in all patients and confirmed by dihydrorhodamine (DHR) assay in 84% patients. 18 families were screened. All patients received antibiotics, 80% received AKT, 76% received Antifungals and all received antifungal and antibacterial prophylaxis. 4 patients have succumbed to the illness and 13 patients are lost to follow-up. 7 patients inherited CGD in an X-linked recessive fashion. Genetic mutation analysis has been done in 22 patients. Conclusion: CGD is a not uncommon in India. The commonest mode of presentation was Pneumonia, skin and subcutaneous abscesses, lymphadenitis and osteomyelitis. Mycobacteria, Staphylococcus Aureus, Klebsiella, Aspergillus, Candida, and Gram negative bacilli were the commonest organism isolated in our series. Infection with Aspergillus, Burkholderia Cepacia, Serratia Marcescens, Nocardia should prompt work up for CGD. All children with CGD should be given routine chemoprophylaxis with Septran and Itraconazole. Families should be screened and counselled during future conceptions.
(BENTA) disease characterized by excessive B cell lymphocytosis presenting in early childhood, wi... more (BENTA) disease characterized by excessive B cell lymphocytosis presenting in early childhood, with associated splenomegaly and lymphadenopathy. BENTA disease is genetically defined by germ line-encoded, heterozygous GOF mutations in CARD11. CARD11 is expressed primarily in lymphocytes and functions as a scaffold molecule that bridges engagement of the antigen receptor. Phenotyping reveals accumulation of both immature transitional and mature naïve polyclonal B cells, while T cell fall within normal pediatric ranges. BENTA patients exhibit several hallmarks of primary immunodeficiency with Sino pulmonary and ear infections other "opportunistic" viral infections with insufficient humeral immune responses in response to polysaccharide-based vaccines. Conclusion: BENTA disease represents different spectrum of ALPS disorder with similar presentation but different molecular mechanism and lack of typical feature of autoimmune phenomenon. Also traditional test DNT not useful for a diagnosis of BENTA disease hence to diagnose such a disease precise molecular tests are require if clinical background firmly suggestive of disease.
(BENTA) disease characterized by excessive B cell lymphocytosis presenting in early childhood, wi... more (BENTA) disease characterized by excessive B cell lymphocytosis presenting in early childhood, with associated splenomegaly and lymphadenopathy. BENTA disease is genetically defined by germ line-encoded, heterozygous GOF mutations in CARD11. CARD11 is expressed primarily in lymphocytes and functions as a scaffold molecule that bridges engagement of the antigen receptor. Phenotyping reveals accumulation of both immature transitional and mature naïve polyclonal B cells, while T cell fall within normal pediatric ranges. BENTA patients exhibit several hallmarks of primary immunodeficiency with Sino pulmonary and ear infections other "opportunistic" viral infections with insufficient humeral immune responses in response to polysaccharide-based vaccines. Conclusion: BENTA disease represents different spectrum of ALPS disorder with similar presentation but different molecular mechanism and lack of typical feature of autoimmune phenomenon. Also traditional test DNT not useful for a diagnosis of BENTA disease hence to diagnose such a disease precise molecular tests are require if clinical background firmly suggestive of disease.
inheritance. CGD is characterized by neutrophils and monocytes capable of normal chemotaxis, inge... more inheritance. CGD is characterized by neutrophils and monocytes capable of normal chemotaxis, ingestion and degranulation, but unable to kill catalase-positive microorganisms due to defects in one of the 5 major subunits of NADPH oxidase. Method and material: The medical records of 38 patients diagnosed with CGD were reviewed and analysed with respect to demographic data, age at presentation and diagnosis, clinical features, laboratory investigations, organisms isolated, treatment & prophylaxis given and clinical course. Results: Our study had 28 males and 10 females with 13 having history of consanguinity. Their mean age at presentation and diagnosis was 1.32yr and 2.5yr respectively. The most common manifestations at presentation were failure to thrive (100%) and lymphadenopathy (100%) followed by hepatomegaly (72%) and splenomegaly (48%). The commonest infection was pneumonia (84%) followed by abscesses (55%) involving lungs, liver, subcutaneous tissue; osteomyelitis (15%); urinary tract infections; otitis media and CNS infections. Organisms isolated from blood, stool and pus of infected lesions included bacteria-Mycobacterium tuberculae (50%), Staphylococci (24%), Klebsiella (16%) and fungi-Aspergillus (13%), Candida (26%). Biopsies done in 36% patients from lymph node, skin, lung and liver showed non caseating granulomatous inflammation. Diagnosis was based on reduced nitroblue tetrazolium test (NBT) between 0-5% in all patients and confirmed by dihydrorhodamine (DHR) assay in 84% patients. 18 families were screened. All patients received antibiotics, 80% received AKT, 76% received Antifungals and all received antifungal and antibacterial prophylaxis. 4 patients have succumbed to the illness and 13 patients are lost to follow-up. 7 patients inherited CGD in an X-linked recessive fashion. Genetic mutation analysis has been done in 22 patients. Conclusion: CGD is a not uncommon in India.
Familial hemophagocytic lymphohistiocytosis (FHL) is an autosomal recessive disease of early chil... more Familial hemophagocytic lymphohistiocytosis (FHL) is an autosomal recessive disease of early childhood characterized by nonmalignant accumulation and multivisceral infiltration of activated T lymphocytes and histiocytes (macrophages). Cytotoxic T and natural killer (NK) cell activity is markedly reduced or absent in these patients, and mutations in a lytic granule constituent, perforin, were recently identified in a number of FHL individuals. Here, we report a comprehensive survey of 34 additional patients with FHL for mutations in the coding region of the perforin gene and the relative frequency of perforin mutations in FHL. Perforin mutations were identified in 7 of the 34 families investigated. Six children were homozygous for the mutations, and one patient was a compound heterozygote. Four novel mutations were detected: one nonsense, two missense, and one deletion of one amino acid. In four families, a previously reported mutation at codon 374, causing a premature stop codon, was identified, and, therefore, this is the most common perforin mutation identified so far in FHL patients. We found perforin mutations in 20% of all FHL patients investigated (7/34), with a somewhat higher prevalence, ∼30% (6/20), in children whose parents originated from Turkey. No other correlation between the type of mutation and the phenotype of the patients was evident from the present study. Our combined results from mutational analysis of 34 families and linkage analysis of a subset of consanguineous families indicate that perforin mutations account for 20%-40% of the FHL cases and the FHL 1 locus on chromosome 9 for ∼10%, whereas the major part of the FHL cases are caused by mutations in not-yet-identified genes.
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of immune dysregulation characterized by h... more Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of immune dysregulation characterized by hyperactivation of the immune system, excessive cytokine secretion and severe systemic inflammation. HLH is classified as familial (FHL) when associated with mutations in PRF1, UNC13D, STX11, and STXBP2 genes. There is limited information available about the clinical and mutational spectrum of FHL patients in Indian population. This study is a retrospective analysis of 101 molecularly characterized FHL patients over the last 10 years from 20 different referral centers in India. FHL2 and FHL3 together accounted for 84% of cases of FHL in our cohort. Patients belonging to different FHL subtypes were indistinguishable based on clinical and biochemical parameters. However, flow cytometry-based assays viz. perforin expression and degranulation assay were found to be specific and sensitive in diagnosis and classification of FHL patients. Molecular characterization of respective genes revealed 7...
The energy metabolism of myeloid cells depends primarily on glycolysis. 1,5-anhydroglucitol (1,5A... more The energy metabolism of myeloid cells depends primarily on glycolysis. 1,5-anhydroglucitol (1,5AG), a natural monosaccharide is erroneously phosphorylated by glucose-phosphorylating enzymes to produce 1,5-anhydroglucitol-6-phosphate (1,5AG6P), a powerful inhibitor of hexokinases. The endoplasmic reticulum transporter (SLC37A4/G6PT) and the phosphatase G6PC3 co-operate to dephosphorylate 1,5AG6P. Failure to eliminate 1,5AG6P is the mechanism of neutrophil dysfunction and death in G6PC3-deficient mice. SLGT2-inhibitor reduces 1,5AG level in the blood and restores the neutrophil count in G6PC3-deficient mice. In the investigator-initiated study, a 30 year-old G6PC3-deficient woman with recurrent infections, distressing gastrointestinal symptoms and multi-lineage cytopenia was treated with an SLGT2-inhibitor. A significant increase in all the hematopoietic cell lineages and substantial improvement in the quality of life was observed.
was present in 42(20.8%):lungs-28/42(66.6%),bones-15/ 42(35.7%),lymphnodes-5/42(11.9%),alone or c... more was present in 42(20.8%):lungs-28/42(66.6%),bones-15/ 42(35.7%),lymphnodes-5/42(11.9%),alone or combined. At a median follow up of 28 months(range 6-71months), 3-year EFS and OS of whole cohort is 67.6%(95%CI:59.5-74.4)and 76.4%(95%CI:68.9-82.3)and for localized and metastatic cohorts is 73.6%(
Background Chronic granulomatous disease (CGD) is characterized by mutation in any one of the fiv... more Background Chronic granulomatous disease (CGD) is characterized by mutation in any one of the five genes coding NADPH oxidase components that leads to functional abnormality preventing the killing of phagocytosed microbes by affecting the progression of a respiratory burst. CGD patients have an increased susceptibility to infections by opportunistic and pathogenic organisms. Though initial diagnosis of CGD using a nitroblue tetrazolium (NBT) test or dihydrorhodamine (DHR) test is relatively easy, molecular diagnosis is challenging due to involvement of multiple genes, presence of pseudogenes, large deletions, and GC-rich regions, among other factors. The strategies for molecular diagnosis vary depending on the affected gene and the mutation pattern prevalent in the target population. There is a paucity of molecular data related to CGD for Indian population. Method This report includes data for a large cohort of CGD patients (n = 90) from India, describing the diagnostic approach, mutation spectrum, and novel mutations identified. We have used mosaicism in mothers and the expression pattern of different NADPH components by flow cytometry as a screening tool to identify the underlying affected gene. The techniques like Sanger sequencing, next-generation sequencing (NGS), and Genescan analysis were used for further molecular analysis. Result Of the total molecularly characterized patients (n = 90), 56% of the patients had a mutation in the NCF1 gene, 30% had mutation in the CYBB gene, and 7% each had mutation in the CYBA and NCF2 genes. Among the patients with NCF1 gene mutation, 82% of the patients had 2-bp deletion (DelGT) mutations in the NCF1 gene. In our cohort, 41 different mutations including 9 novel mutations in the CYBB gene and 2 novel mutations each in the NCF2, CYBA, and NCF1 genes were identified. Conclusion Substantial number of the patients lack NCF1 gene on both the alleles. This is often missed by advanced molecular techniques like Sanger sequencing and NGS due to the presence of pseudogenes and requires a simple Genescan method for confirmation. Thus, the diagnostic approach may depend on the prevalence of affected genes in respective population. This study identifies potential gene targets with the help of flow cytometric analysis of NADPH oxidase components to design an algorithm for diagnosis of CGD in India. In Indian population, the Genescan method should be preferred as the primary molecular test to rule out NCF1 gene mutations prior to Sanger sequencing and NGS.
Background: Systemic autoinflammatory diseases (SAID) are rare inherited disorders involving gene... more Background: Systemic autoinflammatory diseases (SAID) are rare inherited disorders involving genes regulating innate immune signaling and are characterized by periodic or chronic multi-systemic inflammation.Objective: To describe spectrum of clinical, immunological, molecular features, and outcomes of patients with SAID in India.Methods: Request to share data was sent to multiple centers in India that are involved in care and management of patients with Inborn Errors of Immunity. Six centers provided requisite data that were compiled and analyzed.Results: Data on 107 patients with SAID were collated—of these, 29 patients were excluded due to unavailability of complete information. Twelve patients (15%) had type 1 interferonopathies, 21 (26%) had diseases affecting inflammasomes, 30 patients (41%) had non-inflammasome related conditions and 1five patients (19%) had Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA). Type1 interferonopathies identified in the cohort in...
BackgroundThere is paucity of literature on XLA from developing countries. Herein we report the c... more BackgroundThere is paucity of literature on XLA from developing countries. Herein we report the clinical and molecular profile and outcome in a multicenter cohort of patients with XLA from India.MethodsData on XLA from all regional centers supported by the Foundation for Primary Immunodeficiency Diseases (FPID), USA and other institutions providing care to patients with PIDs were collated. Diagnosis of XLA was based on European Society for Immunodeficiencies (ESID) criteria.ResultsWe received clinical details of 195 patients with a provisional diagnosis of XLA from 12 centers. At final analysis, 145 patients were included (137 ‘definite XLA’ and eight ‘probable/possible XLA’). Median age at onset of symptoms was 12.0 (6.0, 36.0) months and median age at diagnosis was 60.0 (31.5, 108) months. Pneumonia was the commonest clinical manifestation (82.6%) followed by otitis media (50%) and diarrhea (42%). Arthritis was seen in 26% patients while 23% patients developed meningitis. Bronchie...
BackgroundWiskott Aldrich syndrome (WAS) is characterized by bleeding manifestations, recurrent i... more BackgroundWiskott Aldrich syndrome (WAS) is characterized by bleeding manifestations, recurrent infections, eczema, autoimmunity, and malignancy. Over the last decade, improved awareness and better in-house diagnostic facilities at several centers in India has resulted in increased recognition of WAS. This study reports collated data across major primary immunodeficiency diseases (PID) centers in India that are involved in care of children with WAS and highlights the varied clinical presentations, genetic profile, and outcomes of patients in India.MethodsRequest to share data was sent to multiple centers in India that are involved in care and management of patients with PID. Six centers provided requisite data that were compiled and analyzed.ResultsIn this multi-institutional cohort, clinical details of 108 patients who had a provisional diagnosis of WAS were received. Of these, 95 patients with ‘definite WAS’ were included Fourteen patients were classified as XLT and 81 patients as...
Introduction:Hyper-IgE Syndrome (HIES) is a rare inborn error of immunity (IEI) characterized by ... more Introduction:Hyper-IgE Syndrome (HIES) is a rare inborn error of immunity (IEI) characterized by a constellation of symptoms related to susceptibility toStaphylococcalskin and pulmonary infections, eczema, raised serum IgE (>2,000 IU/ml), craniofacial anomalies, and recurrent bone fractures. Data on HIES from the Indian subcontinent is scarce and restricted to small case series and case reports. This is the first compilation of national data on HIES.Materials and Methods:A total 103 cases clinically diagnosed and treated as HIES were analyzed from nine centers. Cases with clinical and/or molecular diagnosis of DOCK8 deficiency were not included. Patients were divided into two groups: group I for whom a heterozygous rare variant of STAT3 was identified, and group II, with clinical features similar to those of AD STAT3 deficiency, but without any genetic diagnosis.Results:Genetic diagnosis was available in 27 patients (26.2%) and all harbored rare variants in the STAT3 gene. Majori...
Prenatal Diagnosis (PND) forms an important part of primary preventive management for families ha... more Prenatal Diagnosis (PND) forms an important part of primary preventive management for families having a child affected with primary immunodeficiency. Although individually sparse, collectively this group of genetic disorders represents a significant burden of disease. This paper discusses the prenatal services available for affected families at various centers across the country and the challenges and ethical considerations associated with genetic counseling. Mutation detection in the index case and analysis of chorionic villous sampling or amniocentesis remain the preferred procedures for PND and phenotypic analysis of cordocentesis sample is reserved for families with well-characterized index case seeking PND in the latter part of the second trimester of pregnancy. A total of 112 families were provided PND services in the last decade and the presence of an affected fetus was confirmed in 32 families. Post-test genetic counseling enabled the affected families to make an informed de...
Indian Journal of Hematology and Blood Transfusion, 2020
To study the clinical course of patients with sickle cell anemia and coinherited hematological di... more To study the clinical course of patients with sickle cell anemia and coinherited hematological disorders. Retrospective analysis of clinical data of patients enrolled at our hospital over last 7 years was performed. Eighty four patients of symptomatic sickling disorders were registered during this period, comprising of HbSS (n = 49), HbS-b thalassemia (n = 28), HbS-HbD disease (n = 5), HbS-b thalassemia with G6PD deficiency (n = 1) and HbS-hemophilia A (n = 1). Among HbS-b thalassemia, 18% suffered from occasional pain crises and 27% required occasional blood transfusion. 40% patients with HbS-HbD disease required occasional blood transfusions, one patient was transfusion dependent, while none suffered from crisis episodes. Patient with HbS-b thalassemia with G6PD deficiency had increased transfusion requirement during first 3 years of life, which decreased after that. Patient with HbS and severe hemophilia A had only one episode of severe bleeding, suffered from 1 crisis episode. In conclusion, HbA reduces severity of HbS in HbS-b ? thalassemia. HbS-HbD disease can manifest as a transfusion dependent illness. HbSS reduces severity of G6PD deficiency after first few years of life. HbSS and hemophilia coinheritance ameliorates symptoms of hemophilia.
inheritance. CGD is characterized by neutrophils and monocytes capable of normal chemotaxis, inge... more inheritance. CGD is characterized by neutrophils and monocytes capable of normal chemotaxis, ingestion and degranulation, but unable to kill catalase-positive microorganisms due to defects in one of the 5 major subunits of NADPH oxidase. Method and material: The medical records of 38 patients diagnosed with CGD were reviewed and analysed with respect to demographic data, age at presentation and diagnosis, clinical features, laboratory investigations, organisms isolated, treatment & prophylaxis given and clinical course. Results: Our study had 28 males and 10 females with 13 having history of consanguinity. Their mean age at presentation and diagnosis was 1.32yr and 2.5yr respectively. The most common manifestations at presentation were failure to thrive (100%) and lymphadenopathy (100%) followed by hepatomegaly (72%) and splenomegaly (48%). The commonest infection was pneumonia (84%) followed by abscesses (55%) involving lungs, liver, subcutaneous tissue; osteomyelitis (15%); urinary tract infections; otitis media and CNS infections. Organisms isolated from blood, stool and pus of infected lesions included bacteria-Mycobacterium tuberculae (50%), Staphylococci (24%), Klebsiella (16%) and fungi-Aspergillus (13%), Candida (26%). Biopsies done in 36% patients from lymph node, skin, lung and liver showed non caseating granulomatous inflammation. Diagnosis was based on reduced nitroblue tetrazolium test (NBT) between 0-5% in all patients and confirmed by dihydrorhodamine (DHR) assay in 84% patients. 18 families were screened. All patients received antibiotics, 80% received AKT, 76% received Antifungals and all received antifungal and antibacterial prophylaxis. 4 patients have succumbed to the illness and 13 patients are lost to follow-up. 7 patients inherited CGD in an X-linked recessive fashion. Genetic mutation analysis has been done in 22 patients. Conclusion: CGD is a not uncommon in India. The commonest mode of presentation was Pneumonia, skin and subcutaneous abscesses, lymphadenitis and osteomyelitis. Mycobacteria, Staphylococcus Aureus, Klebsiella, Aspergillus, Candida, and Gram negative bacilli were the commonest organism isolated in our series. Infection with Aspergillus, Burkholderia Cepacia, Serratia Marcescens, Nocardia should prompt work up for CGD. All children with CGD should be given routine chemoprophylaxis with Septran and Itraconazole. Families should be screened and counselled during future conceptions.
(BENTA) disease characterized by excessive B cell lymphocytosis presenting in early childhood, wi... more (BENTA) disease characterized by excessive B cell lymphocytosis presenting in early childhood, with associated splenomegaly and lymphadenopathy. BENTA disease is genetically defined by germ line-encoded, heterozygous GOF mutations in CARD11. CARD11 is expressed primarily in lymphocytes and functions as a scaffold molecule that bridges engagement of the antigen receptor. Phenotyping reveals accumulation of both immature transitional and mature naïve polyclonal B cells, while T cell fall within normal pediatric ranges. BENTA patients exhibit several hallmarks of primary immunodeficiency with Sino pulmonary and ear infections other "opportunistic" viral infections with insufficient humeral immune responses in response to polysaccharide-based vaccines. Conclusion: BENTA disease represents different spectrum of ALPS disorder with similar presentation but different molecular mechanism and lack of typical feature of autoimmune phenomenon. Also traditional test DNT not useful for a diagnosis of BENTA disease hence to diagnose such a disease precise molecular tests are require if clinical background firmly suggestive of disease.
(BENTA) disease characterized by excessive B cell lymphocytosis presenting in early childhood, wi... more (BENTA) disease characterized by excessive B cell lymphocytosis presenting in early childhood, with associated splenomegaly and lymphadenopathy. BENTA disease is genetically defined by germ line-encoded, heterozygous GOF mutations in CARD11. CARD11 is expressed primarily in lymphocytes and functions as a scaffold molecule that bridges engagement of the antigen receptor. Phenotyping reveals accumulation of both immature transitional and mature naïve polyclonal B cells, while T cell fall within normal pediatric ranges. BENTA patients exhibit several hallmarks of primary immunodeficiency with Sino pulmonary and ear infections other "opportunistic" viral infections with insufficient humeral immune responses in response to polysaccharide-based vaccines. Conclusion: BENTA disease represents different spectrum of ALPS disorder with similar presentation but different molecular mechanism and lack of typical feature of autoimmune phenomenon. Also traditional test DNT not useful for a diagnosis of BENTA disease hence to diagnose such a disease precise molecular tests are require if clinical background firmly suggestive of disease.
inheritance. CGD is characterized by neutrophils and monocytes capable of normal chemotaxis, inge... more inheritance. CGD is characterized by neutrophils and monocytes capable of normal chemotaxis, ingestion and degranulation, but unable to kill catalase-positive microorganisms due to defects in one of the 5 major subunits of NADPH oxidase. Method and material: The medical records of 38 patients diagnosed with CGD were reviewed and analysed with respect to demographic data, age at presentation and diagnosis, clinical features, laboratory investigations, organisms isolated, treatment & prophylaxis given and clinical course. Results: Our study had 28 males and 10 females with 13 having history of consanguinity. Their mean age at presentation and diagnosis was 1.32yr and 2.5yr respectively. The most common manifestations at presentation were failure to thrive (100%) and lymphadenopathy (100%) followed by hepatomegaly (72%) and splenomegaly (48%). The commonest infection was pneumonia (84%) followed by abscesses (55%) involving lungs, liver, subcutaneous tissue; osteomyelitis (15%); urinary tract infections; otitis media and CNS infections. Organisms isolated from blood, stool and pus of infected lesions included bacteria-Mycobacterium tuberculae (50%), Staphylococci (24%), Klebsiella (16%) and fungi-Aspergillus (13%), Candida (26%). Biopsies done in 36% patients from lymph node, skin, lung and liver showed non caseating granulomatous inflammation. Diagnosis was based on reduced nitroblue tetrazolium test (NBT) between 0-5% in all patients and confirmed by dihydrorhodamine (DHR) assay in 84% patients. 18 families were screened. All patients received antibiotics, 80% received AKT, 76% received Antifungals and all received antifungal and antibacterial prophylaxis. 4 patients have succumbed to the illness and 13 patients are lost to follow-up. 7 patients inherited CGD in an X-linked recessive fashion. Genetic mutation analysis has been done in 22 patients. Conclusion: CGD is a not uncommon in India.
Familial hemophagocytic lymphohistiocytosis (FHL) is an autosomal recessive disease of early chil... more Familial hemophagocytic lymphohistiocytosis (FHL) is an autosomal recessive disease of early childhood characterized by nonmalignant accumulation and multivisceral infiltration of activated T lymphocytes and histiocytes (macrophages). Cytotoxic T and natural killer (NK) cell activity is markedly reduced or absent in these patients, and mutations in a lytic granule constituent, perforin, were recently identified in a number of FHL individuals. Here, we report a comprehensive survey of 34 additional patients with FHL for mutations in the coding region of the perforin gene and the relative frequency of perforin mutations in FHL. Perforin mutations were identified in 7 of the 34 families investigated. Six children were homozygous for the mutations, and one patient was a compound heterozygote. Four novel mutations were detected: one nonsense, two missense, and one deletion of one amino acid. In four families, a previously reported mutation at codon 374, causing a premature stop codon, was identified, and, therefore, this is the most common perforin mutation identified so far in FHL patients. We found perforin mutations in 20% of all FHL patients investigated (7/34), with a somewhat higher prevalence, ∼30% (6/20), in children whose parents originated from Turkey. No other correlation between the type of mutation and the phenotype of the patients was evident from the present study. Our combined results from mutational analysis of 34 families and linkage analysis of a subset of consanguineous families indicate that perforin mutations account for 20%-40% of the FHL cases and the FHL 1 locus on chromosome 9 for ∼10%, whereas the major part of the FHL cases are caused by mutations in not-yet-identified genes.
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of immune dysregulation characterized by h... more Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of immune dysregulation characterized by hyperactivation of the immune system, excessive cytokine secretion and severe systemic inflammation. HLH is classified as familial (FHL) when associated with mutations in PRF1, UNC13D, STX11, and STXBP2 genes. There is limited information available about the clinical and mutational spectrum of FHL patients in Indian population. This study is a retrospective analysis of 101 molecularly characterized FHL patients over the last 10 years from 20 different referral centers in India. FHL2 and FHL3 together accounted for 84% of cases of FHL in our cohort. Patients belonging to different FHL subtypes were indistinguishable based on clinical and biochemical parameters. However, flow cytometry-based assays viz. perforin expression and degranulation assay were found to be specific and sensitive in diagnosis and classification of FHL patients. Molecular characterization of respective genes revealed 7...
The energy metabolism of myeloid cells depends primarily on glycolysis. 1,5-anhydroglucitol (1,5A... more The energy metabolism of myeloid cells depends primarily on glycolysis. 1,5-anhydroglucitol (1,5AG), a natural monosaccharide is erroneously phosphorylated by glucose-phosphorylating enzymes to produce 1,5-anhydroglucitol-6-phosphate (1,5AG6P), a powerful inhibitor of hexokinases. The endoplasmic reticulum transporter (SLC37A4/G6PT) and the phosphatase G6PC3 co-operate to dephosphorylate 1,5AG6P. Failure to eliminate 1,5AG6P is the mechanism of neutrophil dysfunction and death in G6PC3-deficient mice. SLGT2-inhibitor reduces 1,5AG level in the blood and restores the neutrophil count in G6PC3-deficient mice. In the investigator-initiated study, a 30 year-old G6PC3-deficient woman with recurrent infections, distressing gastrointestinal symptoms and multi-lineage cytopenia was treated with an SLGT2-inhibitor. A significant increase in all the hematopoietic cell lineages and substantial improvement in the quality of life was observed.
was present in 42(20.8%):lungs-28/42(66.6%),bones-15/ 42(35.7%),lymphnodes-5/42(11.9%),alone or c... more was present in 42(20.8%):lungs-28/42(66.6%),bones-15/ 42(35.7%),lymphnodes-5/42(11.9%),alone or combined. At a median follow up of 28 months(range 6-71months), 3-year EFS and OS of whole cohort is 67.6%(95%CI:59.5-74.4)and 76.4%(95%CI:68.9-82.3)and for localized and metastatic cohorts is 73.6%(
Background Chronic granulomatous disease (CGD) is characterized by mutation in any one of the fiv... more Background Chronic granulomatous disease (CGD) is characterized by mutation in any one of the five genes coding NADPH oxidase components that leads to functional abnormality preventing the killing of phagocytosed microbes by affecting the progression of a respiratory burst. CGD patients have an increased susceptibility to infections by opportunistic and pathogenic organisms. Though initial diagnosis of CGD using a nitroblue tetrazolium (NBT) test or dihydrorhodamine (DHR) test is relatively easy, molecular diagnosis is challenging due to involvement of multiple genes, presence of pseudogenes, large deletions, and GC-rich regions, among other factors. The strategies for molecular diagnosis vary depending on the affected gene and the mutation pattern prevalent in the target population. There is a paucity of molecular data related to CGD for Indian population. Method This report includes data for a large cohort of CGD patients (n = 90) from India, describing the diagnostic approach, mutation spectrum, and novel mutations identified. We have used mosaicism in mothers and the expression pattern of different NADPH components by flow cytometry as a screening tool to identify the underlying affected gene. The techniques like Sanger sequencing, next-generation sequencing (NGS), and Genescan analysis were used for further molecular analysis. Result Of the total molecularly characterized patients (n = 90), 56% of the patients had a mutation in the NCF1 gene, 30% had mutation in the CYBB gene, and 7% each had mutation in the CYBA and NCF2 genes. Among the patients with NCF1 gene mutation, 82% of the patients had 2-bp deletion (DelGT) mutations in the NCF1 gene. In our cohort, 41 different mutations including 9 novel mutations in the CYBB gene and 2 novel mutations each in the NCF2, CYBA, and NCF1 genes were identified. Conclusion Substantial number of the patients lack NCF1 gene on both the alleles. This is often missed by advanced molecular techniques like Sanger sequencing and NGS due to the presence of pseudogenes and requires a simple Genescan method for confirmation. Thus, the diagnostic approach may depend on the prevalence of affected genes in respective population. This study identifies potential gene targets with the help of flow cytometric analysis of NADPH oxidase components to design an algorithm for diagnosis of CGD in India. In Indian population, the Genescan method should be preferred as the primary molecular test to rule out NCF1 gene mutations prior to Sanger sequencing and NGS.
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Papers by Mukesh Desai