Abstract
Background
Patients with partial DiGeorge syndrome (pDGS) can present with immune dysregulation, the most common being autoimmune cytopenia (AIC). There is a lack of consensus on the approach to type, combination, and timing of therapies for AIC in pDGS. Recognition of immune dysregulation early in pDGS clinical course may help individualize treatment and prevent adverse outcomes from chronic immune dysregulation.
Objectives
Objectives of this study were to characterize the natural history, immune phenotype, and biomarkers in pDGS with AIC.
Methods
Data on clinical presentation, disease severity, immunological phenotype, treatment selection, and response for patients with pDGS with AIC were collected via retrospective chart review. Flow cytometric analysis was done to assess T and B cell subsets, including biomarkers of immune dysregulation.
Results
Twenty-nine patients with the diagnosis of pDGS and AIC were identified from 5 international institutions. Nineteen (62%) patients developed Evan’s syndrome (ES) during their clinical course and twenty (69%) had antibody deficiency syndrome. These patients demonstrated expansion in T follicular helper cells, CD19hiCD21lo B cells, and double negative cells and reduction in CD4 naïve T cells and regulatory T cells. First-line treatment for 17/29 (59%) included corticosteroids and/or high-dose immunoglobulin replacement therapy. Other overlapping therapies included eltrombopag, rituximab, and T cell immunomodulators.
Conclusions
AIC in pDGS is often refractory to conventional AIC treatment paradigms. Biomarkers may have utility for correlation with disease state and potentially even response to therapy. Immunomodulating therapies could be initiated early based on early immune phenotyping and biomarkers before the disease develops or significantly worsens.
Similar content being viewed by others
Data Availability
All data and material are organized into databases and available.
Change history
29 February 2024
A Correction to this paper has been published: https://doi.org/10.1007/s10875-024-01677-x
References
McDonald-McGinn DM, Sullivan KE. Chromosome 22q11.2 deletion syndrome (DiGeorge syndrome/velocardiofacial syndrome). Medicine (Baltimore). 2011;90(1):1–18.
Sullivan KE. Chromosome 22q11.2 deletion syndrome and DiGeorge syndrome. Immunol Rev. 2019;287(1):186–201.
Seidel MG. Autoimmune and other cytopenias in primary immunodeficiencies: pathomechanisms, novel differential diagnoses, and treatment. Blood. 2014;124(15):2337–44.
Benn P, et al. Pediatric healthcare costs for patients with 22q11.2 deletion syndrome. Mol Genet Genomic Med. 2017;5(6):631–8.
Gennery AR, et al. Antibody deficiency and autoimmunity in 22q11.2 deletion syndrome. Arch Dis Child. 2002;86(6):422–5.
Teachey DT, Lambert MP. Diagnosis and management of autoimmune cytopenias in childhood. Pediatr Clin North Am. 2013;60(6):1489–511.
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) - a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81.
Westermann-Clark E, et al. Primary immunodeficiency in children with autoimmune cytopenias: retrospective 154-patient cohort. Front Immunol. 2021;12:649182.
Thalhammer J, et al. Initial presenting manifestations in 16,486 patients with inborn errors of immunity include infections and noninfectious manifestations. J Allergy Clin Immunol. 2021;148(5):1332-1341e5.
Montin D, et al. Immunophenotype anomalies predict the development of autoimmune cytopenia in 22q11.2 deletion syndrome. J Allergy Clin Immunol Pract. 2019;7(7):2369–76.
Giardino G, et al. Clinical and immunological features in a cohort of patients with partial DiGeorge syndrome followed at a single center. Blood. 2019;133(24):2586–96.
Hadjadj J, et al. Pediatric Evans syndrome is associated with a high frequency of potentially damaging variants in immune genes. Blood. 2019;134(1):9–21.
Tison BE, et al. Autoimmunity in a cohort of 130 pediatric patients with partial DiGeorge syndrome. J Allergy Clin Immunol. 2011;128(5):1115-71e1-3.
Soldatou A, et al. Transient effect of anti-CD20 therapy in a child with 22q11.2 deletion syndrome and severe steroid refractory cytopenias: a case report. J Pediatr Hematol Oncol. 2013;35(4):311–4.
Seidel MG. Treatment of immune-mediated cytopenias in patients with primary immunodeficiencies and immune regulatory disorders (PIRDs). Hematol Am Soc Hematol Educ Program. 2020;2020(1):673–9.
Neunert C, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv. 2019;3(23):3829–66.
Neven B, et al. A survey of 90 patients with autoimmune lymphoproliferative syndrome related to TNFRSF6 mutation. Blood. 2011;118(18):4798–807.
Martin JR, Pattee CJ. Complications observed during ACTH and cortisone therapy. Can Med Assoc J. 1953;68(2):146–52.
Rao VK. Approaches to managing autoimmune cytopenias in novel immunological disorders with genetic underpinnings like autoimmune lymphoproliferative syndrome. Front Pediatr. 2015;3:65.
Grimes AB, et al. Refractory autoimmune cytopenias in pediatric Evans syndrome with underlying systemic immune dysregulation. Eur J Haematol. 2021;106(6):783–7.
Bride KL, et al. Sirolimus is effective in relapsed/refractory autoimmune cytopenias: results of a prospective multi-institutional trial. Blood. 2016;127(1):17–28.
Biggs SE, Gilchrist B, May KR. Chromosome 22q11.2 deletion (DiGeorge syndrome): immunologic features, diagnosis, and management. Curr Allergy Asthma Rep. 2023;23(4):213–22.
Lawrence S, et al. Thrombocytopenia in patients with chromosome 22q11.2 deletion syndrome. J Pediatr. 2003;143(2):277–8.
Acknowledgements
The authors would like to acknowledge Dr. Joseph F. Dasso for his contributions to the manuscript.
Funding
The authors received funding from the Johns Hopkins All Children’s Foundation.
Author information
Authors and Affiliations
Contributions
All authors listed in the byline have agreed to the byline order and to submission of the manuscript in its current form. All authors listed have contributed significantly to the work through substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work and drafting the work or revising it critically for important intellectual content and agreeing to be accountable for all aspects of the work.
Corresponding author
Ethics declarations
Ethics Approval
The planning, conduct, and reporting of human research reported in this manuscript are in accordance with the Helsinki Declaration as revised in 2013. This project received IRB approval (IRB00103900).
Consent to Participate
Written consent was obtained from all patients.
Consent for Publication
Written consent was obtained from all patients.
Conflict of Interest
The authors declare no competing interests.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Patel, P.K., Chinga, M.L., Yilmaz, M. et al. Clinical and Treatment History of Patients with Partial DiGeorge Syndrome and Autoimmune Cytopenia at Multiple Centers. J Clin Immunol 44, 42 (2024). https://doi.org/10.1007/s10875-023-01607-3
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s10875-023-01607-3