Utility of Screening for Chronic Granulomatous Disease in Patients with Inflammatory Bowel Disease
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- Jaggi, P., Scherzer, R., Knieper, R. et al. J Clin Immunol (2012) 32: 78. doi:10.1007/s10875-011-9608-5
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Chronic granulomatous disease (CGD), a genetically heterogeneous primary X-linked or autosomal recessive immunodeficiency, can manifest with gastrointestinal symptoms, including colitis or Crohn’s disease. The frequency of CGD carriers among those with chronic colitis/inflammatory bowel disease is unknown. We underwent a pilot study examining the value of prospectively screening patients with chronic colitis/inflammatory bowel disease (IBD) for either CGD or the carrier state of CGD. No carriers of CGD or patients with CGD were detected among 120 patients. Three patients had inconclusive results and the assay was normal on repeat testing. We conclude that routine screening for CGD was not instructive in this cohort of chronic colitis or IBD patients.
KeywordsChronic granulomatous diseaseinflammatory bowel diseasecolitis
Chronic granulomatous disease
Inflammatory bowel disease
Systemic lupus erythematosus
Chronic granulomatous disease (CGD) is a genetically heterogeneous primary immunodeficiency due to defective nicotinamide adenine dinucleotide phosphate (NADPH) oxidase activity by neutrophils. The estimated minimal incidence of the disease is 1 in 200–250,000 . Approximately 65% of patients have X-linked disease due to defects in gp91phox and the remainder have autosomal recessive disease due to defects in p47phox, p67phox, p40phox, or p22phox. The impaired phagocyte respiratory burst in CGD renders affected patients with recurrent catalase-positive bacterial and fungal infections; current treatment for CGD includes prophylactic trimethoprim–sulfamethoxazole, interferon gamma, and itraconazole to reduce the risk of infection in these patients [1–3]. Early diagnosis is crucial as treatment and counseling can prevent critical and/or fatal illness . CGD is easier to recognize in those presenting with an unusual infection but can be more challenging to diagnose in patients with noninfectious manifestations.
We previously reported two cases of children with unrecognized CGD who initially presented with eosinophilic inflammatory conditions prior to developing an unusual infection . In one case, a 4-year-old child was treated with long-term corticosteroids for more than 1 year for eosinophilic colitis prior to eventually presenting with an Aspergillus chest wall abscess and subsequently was diagnosed with CGD. Others have also reported similar cases of inflammatory bowel disease-like symptoms as the first presentation of CGD [6, 7]. Carriers of CGD are usually asymptomatic, but have been reported to have inflammatory bowel disease (IBD) [8, 9] and have a higher incidence of systemic lupus erythematosus (SLE); the frequency of CGD carriers among those with IBD is unknown. This prompted two hypotheses: that some children being evaluated for colitis/IBD may actually have undiagnosed CGD and that there may be a higher frequency of CGD carriers among those with chronic colitis/IBD than the general population. Colitis can occur in up to 20% of patients with CGD and is difficult to distinguish on colonic biopsy from two major clinical entities: eosinophilic colitis and IBD [10–12]. We underwent a pilot study examining the value of prospectively screening patients with IBD or chronic indeterminate colitis for either CGD or the carrier state of CGD.
Patients eligible for the study included children aged 12 months to 21 years who did not already have a diagnosis of CGD and who had received a diagnosis of inflammatory bowel disease (ulcerative colitis or Crohn’s disease), indeterminate colitis, or eosinophilic colitis. With institutional review board approval, we prospectively collected data from patients at a routine gastroenterology clinic visit or in the infusion clinic. With written informed consent and IRB approval, 3–5 cc of fresh blood was drawn and was heparinized. Blood was processed and analyzed within 24 h of sample collection at the Cincinnati Children’s Hospital Immunology Laboratory. Samples were tested using the dihydrorhodamine assay (DHR) using flow cytometry for the carrier or disease state. Clinical and demographic data were prospectively collected including the patient’s age, sex, and race. In addition, past medical history of abscess or other infections such as pneumonia, liver abscess, or other infections was recorded. Family history, including the aforementioned infections, pneumonia, and family history of IBD, CGD, or SLE was also collected. When available, colonoscopy reports were retrieved to note presence of features typically seen in CGD-related colitis [10–12].
Power analysis for this study was based on the Bayes’ rule and binomial distribution, which assess the relation between two conditional probabilities. We estimated a sample size of 220 patients at an α level of 0.05 to detect one positive CGD patient or four CGD carriers among patients with chronic colitis/IBD.
One hundred and twenty patients were prospectively screened by survey and DHR. Mean age was 14.8 years (range 2–21 years, SD 4 years). Fifty-five percent of the patients were male, 88% were Caucasian, 8% African-American, and 4% were either of mixed or of another descent. Ninety-one (76%) had received a diagnosis of Crohn’s disease, 23 (19%) with ulcerative colitis, and 6 (5%) were classified as having indeterminate colitis.
Characteristics of patients screened
Number (n = 120)
Mean age at screening (years)
TNF alpha blocker
Family history of IBDa
Family history of SLEa
Past medical history
Asthma, allergy or eczema
Gastric outlet obstruction
Peri-anal abscess, fistula or fissure
n = 95
Pigmented macrophages within the gastrointestinal lamina propria
Abundance of eosinophils in the lamina propria
Langhans type giant cells
In summary, during routine screening for over 100 patients with chronic colitis or inflammatory bowel disease, we did not find any patients who were diagnosed with chronic granulomatous disease or found to be carriers of the disease. To our knowledge, this is the first study of prospective screening for CGD among those with chronic colitis or any form of IBD. We conclude from our experience that an inconclusive DHR (or one that indicates a carrier state) should be repeated.
Colitis is only one gastrointestinal (GI) manifestation of CGD and GI symptoms can occur in up to 50% of CGD patients, particularly in males with X-linked disease . These manifestations include colitis (in about 20%) as mentioned previously, but also gastric antral narrowing and obstruction, small bowel obstruction, diarrhea, anal fissure, and perirectal abscess . There are similarities between CGD-related colitis and inflammatory bowel disease, both clinically and histopathologically [11, 12]. The histopathologic overlap between IBD and CGD colitis includes the presence of crypt abscesses. However, the pathology of CGD colitis in retrospective pathologic reviews tends to show a paucity of neutrophils, increased numbers of eosinophils in the lamina propria, eosinophilic crypt abscesses and cryptitis, pigmented macrophages, and granulomas when compared to other patients with inflammatory bowel disease [10–13].
Several other primary immunodeficiencies can manifest with GI inflammation, including common variable immune deficiency as well as other diseases that result in altered neutrophil number or function, including leukocyte adhesion deficiency and glycogen storage disease type 1b. Neutrophil dysfunction has been speculated to play a role in the development of GI inflammation due to bacterial overgrowth and subsequent antigen sensitization. Yu et al. found that 96% of 59 patients (58 CGD patients and one CGD carrier) possessed serum antibodies to intestinal microbial antigens suggesting chronic antigenic stimulation , though higher antibody levels were not associated with clinically diagnosed colitis.
Historically, the diagnosis of CGD was made by the nitroblue tetrazolium test. This was a simple and rapid (but largely qualitative) determination of phagocyte NADPH oxidase activity. Most academic centers now use the quantitative determination of phagocyte reactive oxygen production using flow cytometry (DHR) for provisional diagnosis of CGD. There are several advantages to this assay. It is able to differentiate oxidase-positive from oxidase-negative phagocyte subpopulations in CGD carriers as well as identify the disease state , and thus, we chose to use it for the primary assay in this investigation.
Females have been reported to have symptomatic X-linked CGD. This is thought to occur secondary to skewed lyonization (X inactivation) [16–18]. In addition, female kindred of X-linked CGD patients have been shown to have a higher incidence of systemic lupus erythematosus [1, 19, 20]. Females who are X-linked CGD carriers also have a reported history of inflammatory bowel disease, but whether there is an association between these two clinical entities is unknown [8, 21]. Using the estimated incidence of CGD disease of 1 in 200,000 in the Hardy–Weinberg equation, we estimate the frequency of CGD carriers in the population to be approximately 1 in 387 (autosomal recessive) and 1 in 150,000 carrier females for X-linked disease. The true X-linked carrier rate is likely lower after accounting for de novo mutations.
Our study had several limitations. Most patients with CGD are diagnosed within the first 5 years of life. We did not selectively screen younger children only. Accordingly, we cannot obtain conclusions concerning the value of screening for CGD in a large number of children in this age group with chronic colitis/IBD. The infections were self-reported, and we were unable to accurately record the timing of infection in relation to the initiation of therapy with immunosuppressive agents. We were unable to reach the desired number of patients due to resource limitations and the inconclusive results of the interim analysis. One other study has been reported screening 71 patients with Crohn’s disease for CGD using the DHR assay and also reported that no CGD carriers or patients with CGD were found , bringing the total number of known IBD patients screened for CGD to 191. Assuming that there was a higher prevalence of CGD among those with IBD versus the general population, using a sample size of 191 patients, there would be a 91% chance of finding either a CGD patient or a carrier of CGD. CGD-associated colitis remains on the differential diagnosis for IBD and should be considered especially if a significant infection, such as liver abscess or gram-negative lymphadenitis, has been diagnosed.
This work was supported by the Children’s Research Institute at Nationwide Children’s Hospital.