J Clin Immunol

DOI 10.1007/s10875-014-9997-3

ORIGINAL RESEARCH

Chronic Granulomatous Disease in Morocco: Genetic,

Immunological, and Clinical Features of 12 Patients
from 10 Kindreds
Laila Ait Baba & Fatima Ailal & Naima El Hafidi & Marjorie Hubeau & Fabienne Jabot-Hanin &
Noufissa Benajiba & Zahra Aadam & Francesca Conti & Caroline Deswarte & Leila Jeddane &
Ayoub Aglaguel & Ouafaa El Maataoui & Ahmed Tissent & Chafiq Mahraoui & Jilali Najib &
Ruben Martinez-Barricarte & Laurent Abel & Norddine Habti & Rachid Saile &
Jean-Laurent Casanova & Jacinta Bustamante & Hanane Salih Alj & Ahmed Aziz Bousfiha

Received: 11 November 2013 / Accepted: 6 February 2014

# Springer Science+Business Media New York 2014

Abstract onwards. From 2009 to 2013, 12 cases of CGD were diag-

Purpose Chronic granulomatous disease (CGD) is character- nosed in Morocco. We describe here these Moroccan cases of
ized by an inability of phagocytes to produce reactive oxygen CGD.
species (ROS), which are required to kill some microorgan- Methods We investigated the genetic, immunological and
isms. CGD patients are known to suffer from recurrent bac- clinical features of 12 Moroccan patients with CGD from 10
terial and/or fungal infections from the first year of life unrelated kindreds.

Fatima Ailal and Naima Hafidi contributed equally to the study.

Jacinta Bustamante, Hanane Salih Alj and Ahmed Aziz Bousfiha share
senior coauthorship.
L. A. Baba : Z. Aadam : R. Saile : H. Salih Alj L. Jeddane
Laboratory of Biology and Health URAC34—Metabolic and Biochemistry, Immunology Laboratory, University Mohamed V
Immunologic pathology Research Team, Faculty of Science of Ben agdal, Rabat, Morocco
M’sik, King Hassan II University, Casablanca, Morocco

F. Ailal : J. Najib : A. A. Bousfiha A. Aglaguel

Clinical Immunology Unit, Department of Pediatric Infectious Laboratory of Immunology, Faculty of Sciences and Technology,
Diseases, Averroes University Hospital, King Hassan II King Hassan II University, Mohammedia, Morocco
University-Aïn Chok, Casablanca, Morocco

N. El Hafidi : C. Mahraoui O. El Maataoui

Department of Pediatric, Pneumo-allergologic and Infectious Immunology Laboratory, Averroes University Hospital, University
Diseases, Avicennes University Hospital, Rabat, Morocco King Hassan II-Aïn Chok Casablanca, Casablanca, Morocco

M. Hubeau : F. Jabot-Hanin : F. Conti : C. Deswarte : L. Abel : A. Tissent : N. Habti

J.<L. Casanova : J. Bustamante (*) Laboratory of Genetics and Cellular Enegineering–Faculty of
Laboratory of Human Genetics of Infectious Diseases, Necker Medicine and Pharmacy of Casablanca, Casablanca, Morocco
Branch, Institut National de la Santé et de la Recherche Médicale,
U980, Imagine institute, Paris, France
e-mail: [email protected] R. Martinez-Barricarte : L. Abel : J.<L. Casanova
St. Giles Laboratory of Human Genetics of Infectious Diseases,
M. Hubeau : F. Jabot-Hanin : F. Conti : C. Deswarte : L. Abel : Rockefeller Branch, The Rockefeller University, New York, NY,
J.<L. Casanova : J. Bustamante USA
Necker Medical School, Paris Descartes University, Paris, France

N. Benajiba J. Bustamante
Department of Pediatrics, Al Farabi Hospital, Mohamed VI Center for the Study of Primary Immunodeficiencies, Assistance
University Hospital, Oujda, Morocco Publique–Hôpitaux de Paris AP-HP, Enfants-Malades, Paris, France
 J Clin Immunol

Results All patients were children suffering from recurrent syndrome with Duchenne muscular dystrophy [10], and
bacterial and/or fungal infections. All cases displayed im- retinitis pigmentosa [11]. CGD can be diagnosed biologi-
paired NADPH oxidase activity in nitroblue tetrazolium cally, by assessing the production of reactive oxygen
(NBT), dihydrorhodamine (DHR) or 2′,7′ dichlorofluorescein species (ROS) by neutrophils. Various blood tests, such
diacetate (DCFH-DA) assays. Mutation analysis revealed the as the NBT slide test, the chemiluminescence test, the
presence of four different mutations of CYBB in four kindreds, quantification of superoxide anion O2− formation (cyto-
a recurrent mutation of NCF1 in three kindreds, and a new chrome-c reduction) and flow cytometry assays with
mutation of NCF2 in three patients from a single kindred. A DHR or other fluorochromes, can confirm the diagnosis
large deletion of CYBB gene has detected in a patient. The [4]. Since 1997, 327 cases of Primary Immunodeficiencies
causal mutation in the remaining one kindred was not (PID) have been diagnosed in Morocco and 10 % of these
identified. patients present a congenital phagocyte defect [12, and
Conclusion The clinical features and infectious agents found unpublished data]. We report here the genetic, immuno-
in these patients were similar to those in CGD patients from logical and clinical features of CGD patients diagnosed in
elsewhere. The results of mutation analysis differed between Morocco.
kindreds, revealing a high level of genetic and allelic hetero-
geneity among Moroccan CGD patients. The small number of
patients in our cohort probably reflects a lack of awareness of Materials and Methods
physicians. Further studies on a large cohort are required to
determine the incidence and prevalence of the disease, and to Patients
improve the description of the genetic and clinical features of
CGD patients in Morocco. The study was conducted in accordance with the Hel-
sinki Declaration, with informed consent obtained from
Keywords Chronic granulomatous disease . primary each patient or the patient’s family. Patients were re-
immunodeficiency disease . NADPH oxidase . recurrent cruited at the Clinical Immunology Unit (CIU) in Casa-
infection blanca and the Department of Pediatrics of Rabat Chil-
dren’s Hospital, between 2009 and 2013. The clinical
diagnosis of CGD was based on a history of recurrent
Introduction infections and/or a history of the disease in other family
members. The referring physicians carried out structured
Chronic granulomatous disease (CGD) is a primary immu- interviews to collect demographic and clinical data for
nodeficiency disease (PID) caused by an impairment of the patients. The clinical features of the patients are
the activity of nicotinamide adenine dinucleotide phosphate shown in Table I.
(NADPH) oxidase components in all phagocytic cells
(neutrophils, eosinophils, monocytes, and macrophages) Assays of Neutrophil Function
[1–3]. Patients with CGD suffer from severe recurrent
bacterial and/or fungal infections and display granuloma A diagnosis of CGD was accepted when the clinical
formation in various tissues [1–4]. Defects of gp91phox manifestations and at least one laboratory test result
(encoded by the CYBB gene, located on chromosome X: were consistent. The diagnosis of CGD was confirmed
Xp21.1) are the most common, accounting for about 75 % biologically by NBT slide tests and/or flow cytometry
of cases in Europe and North America. These defects are with DHR or 2′7′-dichlorofluorescein diacetate
transmitted as an X-linked recessive (XR) trait [5–8]. (DCFDA) assays. The NBT slide test with lipopolysac-
Defects of the other four components—p47phox (NCF1 charide (LPS, 840 W Sigma-Aldrich) from E. coli was
gene, located on chromosome 7: 7q11.23), p67 phox developed in the laboratory. Heparin-treated whole
(NCF2 gene, located on chromosome 1:1q25), p40phox blood was incubated with NBT reagent and LPS at
(NCF4 gene, located on chromosome 22: 22q13. 1) and 37 °C for 15 min. Red blood cells were lysed by
p22phox (CYBA gene, located on chromosome 16: 16q24) incubation with distilled water for 1 min. Isotonicity
define the autosomal recessive forms (AR) of CGD [9]. was then restored by adding 3.4 % NaCl. The cell
Almost 800 mutations have been identified in the five suspension was centrifuged for 15 min at 400×g. Slides
genes known to cause CGD, and many different types of were stained with 1 % fuchsine solution and observed
causal mutations have been described: missense, nonsense, under a microscope equipped with an oil immersion
splice site, regulatory, and structural mutations (small objective. NBT screening test results were considered
deletions/insertions) [5, 9]. Large deletions of the CYBB normal if the cells took up dye (purple formazan de-
gene can also affect proximal genes, as seen in McLeod posits) and as abnormal if they failed to take up the
Table I Genetic and clinical features of CGD patients

Patient 1 2 3 4 5 6

Kindred 1 2 3 4 4 4
J Clin Immunol

Code II.1 II.1 II.2 II.1 II.2 II.3

Sex M M M M F M
Age at diagnosis (years) 0.16 1.66 5 5.5 0.67 0.25
Age at onset (years) 0.036 0.5 0.5 1.16 0.33 0.25
Consanguinity No No Yes Yes Yes Yes
Clinical manifestations Liver abscess Lymphadenopathy Chronic osteomyelitis Pneumonia Pneumonia Lymphadenopathy
Skin abscess Pneumonia Lymphadenopathies Diarrhea Septicemia
Septicemia Osteitis Macrophage activation syndrome
Bronchiectasis
Bacteria Enterobacter spp. Klebsiella spp. Staphylococcus spp. Salmonella spp. – Klebsiella spp.
Klebsiella spp.
Fungi – Aspergillus spp. Aspergillus spp. Aspergillus spp. – Candida albicans
Candida dubliniens
Diagnosis test NBT NBT NBT NBT NBT NBT
Mutation CYBB CYBB CYBB NCF2 NCF2 NCF2
? large deletion c.1678G>T c.257+1G>A c.257+1G>A c.257+1G>A
Outcome Deceased Deceased Alive Alive Deceased Alive

Patient 7 8 9 10 11 12

Kindred 5 6 7 8 9 10
Code II.1 II.3 II.3 II.1 II.2 II.5
Sex M M M M M M
Age at diagnosis (years) 1.83 0.92 0.25 0.83 13 11
Age at onset (years) 0.83 0.042 0.020 0.16 10 5
Consanguinity No No No Yes Yes No
Clinical manifestations Lymphadenopathy Lymphadenopathy Skin abscess Lymphadenopathy Skin abscess Skin abscess
Skin abscess Skin abscess Liver abscess Pleuralempyema
Pleuralempyema Meningitis
Brain abscess
Septicemia
Bacteria Serratia spp. Serratia spp. Serratia marcescens Staphylococcus spp. – –
M.bovis-BCG M.bovis-BCG
Fungi – – – – – Trichosporum
Diagnosis test NBT NBT +DHR NBT +DHR NBT NBT NBT+ DCFDA
Mutation CYBB CYBB NCF1 CYBB NCF1 NCF1
c.676C>T c.674+5G>A c.75_76delGT c.897+1G>T c.75_76delGT c.75_76delGT
Outcome Alive Alive Alive Alive Alive Deceased

Abbreviation DCFDA 2′,7′7dichlorofluorescein diacetate

 J Clin Immunol

dye. The patient was considered to have a carrier Genetic Analysis

profile if both types of cell behavior were observed
simultaneously. Genomic DNA was purified by phenol-chloroform extraction.
The DHR assay was performed with 1 ml of heparin- Total RNA was extracted with Trizol reagent (Invitrogen, Life
treated blood. Briefly, the red blood cells were lysed and the Technologies), according to the manufacturer’s instructions,
leukocytes were incubated with DHR (D1054-Sigma-Al- and used to generate cDNA. The cDNA was stored at −20 °C.
drich) for 7 min at 37 °C and then activated by incubation Polymerase chain reaction (PCR) amplification was carried
with 4-beta-phorbol 12-beta-myristate 13-alpha-acetate out with the AmpliTaq DNA polymerase (Applied
(PMA, Sigma-Aldrich) for 15 min at 37 °C. The cells were Biosystems, Foster City, CA) and the GeneAmp PCR 9700
then placed on ice to stop the reaction and the conversion of system (Applied Biosystems). The primers and conditions
DHR into rhodamine was assessed by considering 104 events used for PCR amplification of the coding exons, including
by flow cytometry on a FACSCanto II or a FACS Callibur the flanking intron sequences and the cDNAs of all the causal
(Becton Dickinson) machine, with CellQuest Pro software. genes of CGD are available upon request. Amplified PCR
The results of the DHR assay were considered normal if all the products were checked by electrophoresis in a 1 % agarose gel
cells converted DHR (non fluorescent) to rhodamine 123 and cleaned up by the EXO-SAP protocol. PCR products
(fluorescent) after stimulation with PMA. For the DCFDA were sequenced by dideoxynucleotide termination, with the
assay, the cells were stimulated by incubation with PMA or BigDye Terminator kit v3.1 (Applied Biosystems) and appro-
E. coli for 10 min at 37 °C, then incubated with DCFDH-DA priate primers. Sequencing products were purified by centri-
for 10 min at 37 °C. fugation through Sephadex G-50 Superfine resin (GE
Healthcare) on multiscreen MAHV-N45 (Millipore,
Molsheim, France) filter plates, or with the BigDye X Termi-
Expression of NADPH Subunits
nator purification kit (Applied Biosystems) and analyzed on
an ABI Prism 310 or 3130xl apparatus (Applied Biosystems).
Flow Cytometry Evaluation of Flavocytochrome b558
Sequence files and chromatograms were analyzed with
Expression
GENALYS software (CNG, France; http://software.cng.fr).
Leukocytes were incubated for 30 min at 4 °C with the 7D5
Copy Number Variation (CNV) Analysis
mAb (D162-3; MBL) or an isotype-matched control antibody
(mouse immunoglobulin G1; M075-3; MBL; BD
Potential genomic copy number variations were detected by
Pharmingen) at a concentration of 5 μg/ml. Cells were ana-
using Affymetrix Genome-Wide Human SNP Array 6.0,
lyzed with a FACS Canto II machine (Becton Dickinson). We
analysed by an algorithm based on an hidden markov model
collected 104 cells from each sample and analyzed them with
(PennCNV). The array consisted in particular of 744,000 copy
CellQuest software (BD Pharmingen).
number probes, evenly spaced along the genome, with addi-
tional 202,000 probes targeting 5,677 CNV regions from the
Western-Blot Analysis of NADPH Oxidase Components Toronto Database of Genomic Variants.

Proteins for western blotting were extracted from peripheral

blood granulocytes or Epstein-Barr virus-transformed B cells Results
(EBV-B cells). Granulocytes were purified by Ficoll–
Hypaque gradient centrifugation followed by red blood cell Clinical Features, Biological Diagnosis and Outcome
lysis. A protein extract was then prepared by incubation in
extraction buffer (20 mM Tris–HCl, 150 mM NaCl 1 % Between 2009 and 2013, 12 patients from 10 unrelated fam-
Triton, 1 mM EDTA) supplemented with protease inhibitors ilies in Morocco were identified as having CGD on the basis
(0.1 % PMSF, 0.1 % AEBSF, 0.1 % chymostatin, and 0.1 % of their clinical signs and the absence or impairment of phago-
leupeptin, Sigma Aldrich). The proteins in the cell lysate were cyte NADPH complex activity. Eleven of these patients were
resolved by SDS-PAGE in a 12 % polyacrylamide gel and male and one was female. Only one multiplex family, with
electroblotted onto PVDF membranes. The membranes were three affected siblings, was identified. All the remaining cases
blocked in 1 % BSA solution and then incubated overnight were sporadic (Fig. 1). The parents were consanguineous in
with a mAb against gp91phox (54.1, Santa Cruz). Polyclonal four of the 10 kindreds (40 %, kindreds 3, 4, 8 and 9).
antibodies from Santa Cruz were used for the analysis of However, XR-CGD was confirmed in kindreds 3 and 8.
p22phox (sc-20781), p47phox (sc-14015), p67phox (sc-7663), The biological diagnosis of CGD was made at a mean age
and α-tubulin (sc-5546). Immunoblot signals were visualized of 5.1 years (range: 0.16–13 years). All index cases were
with an enhanced chemiluminescence detection system. identified as having CGD on the basis of a lack of NBT
J Clin Immunol

4. 5. 6.
1. 2. 3.
I

II

7. 8. 9. 10.
I

II
Fig. 1 Pedigrees of 10 families with CGD disease. Each kindred is (each individual studied is identified by these 3 numbers, organized from
designated by an integer (1–10), each generation is designated by a roman left to right). The double lines connecting the parents indicate known or
numeral (I, II) and each individual is designated by an Arabic numeral presumed consanguinity. Index cases are indicated by an arrow

reduction after stimulation with LPS, with confirmation of the in patients with CGD. No autoimmune or autoinflammatory
diagnosis, when possible, by DHR or DCFDA oxidation in complications were found in this cohort.
the neutrophils after stimulation with PMA (Table I). For the Treatment was based essentially on antibacterial drugs
mothers of patients P2 and P8, we observed two different cell according to the pathogen causing the infection and antifungal
populations after stimulation, suggesting an X-linked pattern drugs for pulmonary aspergillosis. Trimethoprim and
of inheritance. Sulphamethoxazole were used as antibacterial prophylaxis.
The clinical signs were dominated by lymphadenopathy Itraconazol was used as antifugal prophylaxis. Patients with
(n=6) at several sites [cervical (n=3), inguinal (n=2), sub- BCG-itis were treated with antimycobacterial drugs. Treat-
mandibular (n=2), axillary (n=2)], with multiple sites affected ment with interferon gamma (IFN-γ) was not used in this
in some patients. Skin abscesses (n=6) were the second most cohort.
common sign. The microorganisms isolated from these infec- Four patients diagnosed with CGD diagnosis died during
tions were Klebsiella spp. (n=3), Serratia spp. (n=3) and the follow-up period (mortality 33.33 %). The mean age at
Staphylococcus aureus (n=2), Candida (n=1). Pulmonary diagnosis for the patients that died was 3.37 years. The causes
involvement was observed in four cases, including two cases of death were refractory pulmonary aspergillosis for P2 (at
of pleural empyema with negative cultures. Two cases of 3.5 year old), septicemia in P5 (at 8 months old), a neurolog-
pulmonary aspergillosis were complicated by sternal osteo- ical infection for P12 (at 11 year old) and an accident unrelated
myelitis (n=1) or bronchiectasis (n=1). Liver abscesses with to the clinical complications of CGD for P1 (at2.5 year old).
negative cultures were found in two cases.
All patients were vaccinated with Mycobacterium bovis Genetic Analysis
BCG. Only two (P8 and P10) of the 12 patients developed
axillary lymphadenitis after vaccination with BCG (BCG- We identified 12 patients from 10 kindreds. The disease was
itis). In both cases, mycobacterial infection was associated familial in one kindred (kindred 4) and sporadic in the other
with pyogenic infections (orbital cellulitis, chronic multifocal nine kindreds. Unfortunately, no biological material was avail-
osteomyelitis with Aspergillus spp. and Staphylococcus spp., able for P1, and only genomic DNA was available for P2, P3,
respectively, Table I). P4 suffered diarrhea with Salmonella P5 and P7. All results of mutation analysis are summarized in
enteritidis complicated by sepsis, and this infection triggered a Table I.
macrophage activation syndrome characterized by the occur- Four patients (42 %) had a hemizygous mutation of the
rence of a decrease in platelet counts (27,000/mm3) and fi- CYBB gene and all these patients had classical XR forms of
brinogen concentration (0.89 g/l) and an increase in levels of CGD (absence of NADPH activity and no gp91phox protein
ferritin (1,013 μg/l) and triglyceride (4.03 g/l) concentrations, production). For P2, we obtained no amplicon on genomic
hepatomegaly and abnormal liver function test results. Finally, DNA amplification for any of the coding exons of CYBB or
P12 was reported to have meningitis complicated by a brain for the flanking intron regions. However, all the coding exons
abscess due to Trichosporum, an organism found only rarely of the four autosomal genes implicated in CGD were
 J Clin Immunol

amplified. A large deletion in the X-chromosome was detect- homozygous splice site mutation of NCF2, c.257 + 1G > A.
ed in P2 (hg18 of UCSC: 37,036,086 to 37,615,465). This An analysis of p67phox cDNA from EBV-B cell lines showed
deletion includes CYBB, DYNLT3, LANCL3, PRRG1, XK that the NCF2 cDNA differed in size from that of healthy
genes. P3 has a previously unknown mutation of the CYBB controls, with 200 bp corresponding to exon 2 (data not
gene, c.1678G > T, resulting in a premature stop codon at shown). Both parents were carriers of this same mutation in
amino-acid position 560 of the gp91phox protein. The genomic the heterozygous state. This mutation results in an absence of
DNA sequencing results for both parents and sisters showed a p67phox protein (data not shown). P9, P11 and P12 have a well
wild-type sequence, suggesting that this patient has a novo known recurrent mutation in exon 2 of NCF1
mutation of CYBB. Both SIFT and POLYPHEN 2 predicted (c.75_76delGT), which is present in the homozygous state
that this mutation would be damaging. Unfortunately, only and has been identified in a number of unrelated patients from
genomic DNA was available for this patient. P7 has a nonsense different populations (9). Immunoblots of lysate proteins from
mutation, c.676C > T in exon 7 of the CYBB gene, resulting in P11 showed p47phox to be absent (Fig. 2b), as previously
a premature stop codon at amino-acid position 226 of gp91phox. reported.
P8 has a mutation in the CYBB gene, c.674 + 5G > A, affecting
the splicing donor site and resulting in the skipping of exon 6.
His mother was heterozygous at this locus. These two muta- Discussion
tions have been reported before (5). P10 had a known splice
donor defect mutation, c.897 + 1G > T, in exon 8 of CYBB and We describe here a series of 12 patients from 10 unrelated
his mother was wild-type for this gene. CGD-affected kindreds from Morocco. This constitutes the
The expression of cytochrome b558 (gp91phox and p22phox) first clinical, genetic and molecular characterization of this
on the plasma membrane was monitored in P8, by flow PID in Morocco. The clinical and immunological findings
cytometry with the monoclonal antibody (mAb) 7D5, which reported here were obtained at the only two reference centers
recognizes the motifs Ile-Lys-Asn-Pro (amino acids 160–163) in this country.
and Arg-Ile-Val-Arg-Gly (amino acids 226–230) on gp91phox The clinical features observed and the microorganisms
dimerized with p22phox. Cytochrome b558 was undetectable on isolated, all of which are known to be major pathogens in
neutrophils from P8. The mother of P8 had two cell popula- CGD, were consistent with CGD [1, 4]. All patients had an
tions (data not shown). We carried out western blots with impaired respiratory burst, as confirmed by NBT, DHR or
whole protein extract from the neutrophils of P8 and P10, DCFDA assays. Molecular studies showed that 50 % of the
comparing the results obtained with those for healthy controls patients had AR-CGD, whereas 41, 7 % had XR-CGD. No
(Fig. 2a). We detected no gp9phox in patients P8 and P10; genetic analysis was carried out for one patient. In this study,
p22phox was also absent from both these patients, as expected, we detected no mutations of the CYBA and NCF4 genes. The
because the expression of this protein is dependent on the results of this study contrast with reports from Tunisia, Iran
presence of gp91phox (Fig. 2a). and Turkey, in which AR forms predominated [13–15].
Three patients with AR forms of CGD had a new germline The number of patients included in this cohort clearly does
mutation of NCF2 (P4, P5 and P6), and another three patients not reflect the true number of individuals with the disease in
had identical mutations of the NCF1gene (P9, P11 and P12). Morocco. From 1997 to 2009, only one case of CGD was
P4, P5 and P6 are from the same family and all have a diagnosed in Morocco [16]. More cases have been reported

a C1 C2 P10 P8 b
C1 C2 P11
p47phox
gp91phox
α-tubulin

p22phox
α-tubulin
Fig. 2 Expression of NADPH subunits. a Neutrophils were isolated from anti-gp91phox, anti-p22phox and α-tubulin. b Immunoblot analysis of
healthy controls (C1, C2) and patients (P8 and P10); cells were lysed and lysates of neutrophils from healthy controls (C1, C2) and a patient
analyzed by SDS-PAGE and immunoblotting with antibodies against (P11). The data shown are representative of two independent experiments
J Clin Immunol

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biochemical, and clinical features of chronic granulomatous disease.
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Acknowledgments We would particularly like to thank the patients
associated with expression of Duchenne muscular dystrophy, chronic
and their families, whose trust, support, and cooperation were essential
granulomatous disease, retinitis pigmentosa, and McLeod syndrome.
for the collection of the data used in this study. We thank Naim Btissam,
Am J Hum Genet. 1985;37(2):250–67.
Abdellah Mouden, Khattane Rachida and Labied Driss for technical
11. Watkins CE, Litchfield J, Song E, Jaishankar GB, Misra N, Holla N,
support. We also thank the Hospital Biology Center (le Centre de Biologie
et al. Chronic granulomatous disease, the McLeod phenotype and the
des Hôpitaux; CBH) in Morocco for technical support for the NBT test.
contiguous gene deletion syndrome-a review. Clin Mol Allergy.
We thank the members of the Laboratory of Human Genetics of Infec-
2011;9(1):13.
tious Diseases in Paris for secretarial and technical assistance. We thank
12. Bousfiha AA, Jeddane L, Ailal F, Benhsaien I, Mahlaoui N,
the Moroccan PID Society and Hajar, the Association to Help Moroccan
Casanova J-L, et al. Primary immunodeficiency diseases worldwide:
Children with Primary Immunodeficiencies (www.hajar-maroc.org) for
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financial support. The Laboratory of Human Genetics of Infectious
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Diseases is supported by institutional grants to INSERM and The
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Rockefeller University, and grants from the Agence Nationale de la
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, HOMITUB E08153KK and NEOTIM (018736). Laila Ait Baba was
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supported by a PhD grant from the National Center for Technical Scien-
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