Primary Immunodeficiencies Flashcards
What is the most common inheritance pattern of the primary immunodeficiencies?
Usually AR, but there are a few x-linked
X-linked: anhidrotic ectodermal dysplasia w/ immunodeficiency, chronic granulomatous disease, severe combined immunodeficiency syndrome, Wiskott-Aldrich, Bruton’s agammaglobulinemia, and IPEX syndrome
What signs should increase your concern for primary immunodeficiency?
Increased frequency and duration of bacterial, viral, and/or fungal infections
- Opportunistic infections like atypical mycobacteria or deep fungal infections
- Failure to thrive
What cutaneous infections can be seen in primary immunodeficiencies?
Recurrent staph/other bacterial pyodermas, extensive viral infxn (warts, molluscum, and HSV), widespread dermatophyte infections, mucocutaneous candidiasis
When is hematopoietic stem cell transplantation indicated?
Severe combined immunodeficiencies, chronic granulomatous disease, Wiskott-Aldrich syndrome, IPEX, hemophagocytic lymphohistiocytosis (Chediak-Higashi and Griscelli), MonoMAC syndrome
What primary immunodeficiencies show erythroderma?
Omenn syndrome > other SCID, lennier
What primary immunodeficiencies show atopic phenotype (eczematous dermatitis and elevated eosinophils with IgE
Wiscott-Aldrich syndrome, Hyper IgE syndrome (STAT3>DOCK8), IgA deficiency, Omenn syndrome, IPEX syndrome
What primary immunodeficiencies show noninfectious cutaneous granulomas?
Ataxia-telangiectasia, SCID (RAG1), common variable immunodeficiency, chronic granulomatous disease
What primary immunodeficiencies show pigmentary dilution (Silvery hair and hypopigmentation)?
Griscelli syndrome, Chediak-Higashi syndrome
What is the gene mutation in Leiner’s disease?
C5 gene mutation –> complement deficiency
What is the disease presentation of Leiner’s disease?
- Get erythrodermic seborrheic dermatitis
- See recurrent infections, diarrhea, failure to thrive
- Increased risk of meningococcal meningitis
What genes are mutated in Omenn syndrome?
RAG1/RAG2
What are the characteristic infections in Omenn syndrome?
Any (t-cells are auto-reactive too)
Distinct cutaneous findings in Omenn syndrome?
Erythroderma, alopecia, can see acute GVHD
What gene mutations are seen in SCID? What are the inheritance patterns
IL2RG (IL-2Rgamma chain) = most common, XLR inheritance
- ADA = increased adenosine leads to lymphocyte toxicity; AR inheritance
- ZAP70
- JAK3; AR inheritance
What characteristic infections are seen in SCID?
Any
- Can see candida, staph and strep infections, sepsis, viral diarrhea, otitis media, pneumonias (PCP and parainfluenza, in addition to bacteria
Most characteristic skin findings seen in SCID?
Erythroderma (less common), GVHD-like presentation (you get materno-fetal GVHD –> maternal transfer of T-cells, and they get rejected
No palpable lymph nodes, no tonsilar buds/lymphoid tissue
Failure to thrive
What is the gene mutation and inheritance pattern seen in Wiskott-Aldrich?
XLR, gene mutated is WAS (involved in actin filament assembly)
What infections are seen in Wiskott-Aldrich?
Recurrent encapsulated bacterial infections (otitis media, penumonia, and meningitis), HSV (as eczema herpeticum), HPV and PCP
Infections can lead to death in first decade in this syndrome
Characteristic cutaneous findings in in Wiskott-Aldrich?
Eczematous dermatitis (scalp, face, and flexures w/ secondary infections)
Extra cutaneous findings in Wiskott-Aldrich?
Thrombocytopenia (petechiae/purpura/epistaxis), small platelets, and bloody diarrhea
- Food allergies/asthma/urticaria
- Increased IgA, IgD, and IgE (decreased IgM)
- Increased risk of non-Hodgkin’s lymphomas and other hematologic malignancies
What is the gene is mutated in ataxia-telangiectasia?
ATM gene
Characteristic skin findings in ataxia-telangiectasia?
Telangiectasias of skin and conjunctivae, noninfectious granulomas
Extracutaneous findings in ataxia-telangiectasia?
Truncal>peripheral ataxia
- Sensitivity to ionizing radiation
- Increased risk of hematologic malignancies
- Females heterozygotes at increase risk for breast cancer
- Decreased IgA, IgG, and IgE
What is the mutation seen in autosomal dominant hyper IgE syndrome?
STAT3
What are the characteristic infections seen in autosomal dominant hyper IgE syndrome?
Pyodermas, cellulitis, furuncles, abscesses, and paronychia
- staph, candida, and strep common
- 30% of abscesses are cold
- Bronchitis, otitis media, empyemas, sinusitis, pneumotoceles, lung abscesses and pneumonia can lead to early death
Characteristic cutaneous findings in autosomal dominant hyper IgE syndrome?
Course facial features, broad nasal bridge and big nose
- Diffuse dermatitis
- Retention of primary teeth
Extracutaneous finidngs in autosomal dominant hyper IgE syndrome?
Retained primary teeth and issues with secondary teeth.
- Osteopenia –> fractures, scoliosis, and hyperextensibility
- Increased IgE and eos
What is the gene involved in autosomal recessive hyper IgE?
DOCK8
What infections are seen with AR hyper IgE?
Any, but mycobacterial, severe viral, and results HPV and SCC can be seen
Cutaneous findings in AR hyper IgE?
None
What is the mutation in IgA deficiency?
IGAD1
What are the characteristic infections in IgA deficiency?
Sinopulmonary bacterial infections and giardia gastroenteritis
What are the cutaneous findings in IgA deficiency?
eczematous dermatitis and autoimmune conditions
Extracutaneous findings in in IgA deficiency?
It is the most common immunoglobulin deficiency
- Must check before given any patient IVIG
What is common variable immunodeficiency?
Many genes (ICOS, CD19, CD20, CD21, CD8, LRBA1, TACI, BAFFR, NFKB2, IL21, PRKCD) which lead to hypogammaglobinemia
- can see increased bacterial infections
- In the skin can see non-infectious granulomas and autoimmune conditions
- There is an increased risk for hematologic conditions
What gene causes Bruton’s hypogammaglobinemia?
BTK
What is the clinical phenotype of Bruton’s hypogammaglobinemia?
Helicobacter bilis associated pyoderma gangrenosum, you can see non-infectious granulomas, and there is an increased risk for hematologic malignancies
Which immunodeficiency can aphthous ulcers be seen in?
Common variable immunodeficiency
What skin findings can be seen in female carriers of the chronic granulomatous disease genes?
Discoid lupus, aphthous stomatitis, and Raynaud’s
What are the two primary genes mutated in chronic granulomatous disease?
CYPBB (p91-phagocyte oxidase beta subunit)
CYPBA
others: NCF1, NCF2, NCF4
What infections are seen in chronic granulomatous disease?
Pneumonia (Nocardia, apsergilosis, and staph), perianal abscesses, perioral dermatitis, and pyodermas due to catalase + organisms (staph aureus #1 )
Cutaneous features in chronic granulomatous disease?
Noninfectious granulomas (cutaneous and extracutaneous esp in the GI tract), gingivitis/stomatitis
Extracutaneous findings in chronic granulomatous disease?
Hepatosplenomegaly, diarrhea, and lymphadenopathy (large)
- Abscess/fistula, granulomas of lung/liver/GU/GI
How can you test for chronic granulomatous disease?
Nitroblue tetrazolium test (normally turns blue, turns yellow in this condition)
What gene is mutated in leukocyte adhesion deficiency type I?
ITGB2
What infections are typical in leukocyte adhesion deficiency type I?
Pyodermas, bacterial ulcerations can mimic pyoderma gangrenosum
Characteristic cutaneous findings in leukocyte adhesion deficiency type I?
Delayed separation of the umbilical cord
Poor wound healing
At what point are you concerned about umbilical separation being abnormal?
After 1-2 weeks
What gene is mutated in Chediak-Higashi?
LYST
What infections are seen in Chediak-Higashi?
Pyodermas, bacterial ulcerations that can mimic pyoderma gangrenosum
What cutaneous findings are seen in Chediak-Higashi?
Pigmentary dilution, silvery hair and hypopigmentation of skin, hyperpigmentation may develop in acral sun-exposed areas
What are some extracutaneous findings in Chediak-Higashi?
Accelerated lymphohistiocytic phase
- Neurologic deterioration
- Giant granules or melanosomes in leukocytes and melanocytes
What is the gene mutations seen in Griscelli?
Rab27A
What infections are seen in Griscelli?
Pyodermas
distinct cutaneous and extracutaneous findings in Griscelli?
Pigmentary dilution (silvery hair and hypopigmentation of skin)
- Accelerated lymphohistiocytic phase
- Neurologic deterioration (primarily with MYO5A mutation)
What gene is mutated in hypohidrotic ectodermal dysplasia with immunodeficiency?
NEMO
Findings in hypohidrotic ectodermal dysplasia with immunodeficiency?
Conical incisors decrease or absence of sweat glands and hair follicles
- Allelic to incontinentia pigmenti
What genes are mutated in chronic mucocutaneous candidiasis/familial candidiasis?
CARD9, IL-17RA, IL-17F, CLEC7A, STAT1, TRAF3IP2
What pathway is defective in chronic mucocutaneous candidiasis/familial candidiasis?
IL-17 and the Th17 cell function
Cutaneous findings in chronic mucocutaneous candidiasis/familial candidiasis?
Mucocutaneous candidiasis and deep dermatophytosis
What is the gene mutated in WHIM?
CXCR4 (neuts get stuck in bone marrow)
What are the findings in WHIM?
HPV (with extensive verrucae)
- Myelokathexis: peripheral neutropenia w/ retention of neutrophils in the bone marrow
What are the genes mutated in EDV (epidermal dysplasia verruciformis)?
EVER1/EVER2
Findings in EDV (epidermal dysplasia verruciformis)?
Caused by HPV 5,8,10,14,20,21,25
- Extensive verruca plana along with thicker verrucous warts
- Can see malignant transformation of warts to SCC
Which HPV subtypes are implicated in EDV?
Caused by HPV 5,8,10,14,20,21,25
What gene is mutated in Monomac?
GATA2
What infections are seen in monomac?
HPV, atypical mycobacteria, and deep fungal infections
- Pulmonary alveolar proteinosis is seen
- Increased risk of hematologic malignancies
What is the mutation in immunodeficiency, polyendocrinopathy, and x-linked (IPEX)?
FOXP3
Findings in immunodeficiency, polyendocrinopathy, and x-linked (IPEX)?
Eczematous dermatitis
- Severe diarrhea
- type I diabetes Mellitus, hypothyroidism
- Autoimmune hemolytic anemia