Citations

Objectives: Systemic beta-blockers are highly effective for the management of infantile hemangiomas (IH), but little is known about infants who do not adequately respond. We aimed to describe the characteristics and outcomes of suboptimal responders to standard-dose systemic beta-blockers in infants with IH. Methods: This is a multicenter retrospective cohort study to evaluate demographics, IH lesion characteristics, and treatment specifics of infants with IH with suboptimal response to baseline standard-dose propranolol treatment. Clinical response was used to assess the outcome after a therapeutic change. Results: Twenty-five infants were included in this study. Seven (28%) had segmental IH, 16 (64%) focal, and 2 (8%) indeterminate. The IHs were located on the head and neck in 21 (84%) infants, with 24 (96%) having a deep or combined component. Therapy changes after standard-dose propranolol treatment failure, most commonly by escalating propranolol dose to ≥2.5 mg/kg/d (59%) or surgical interventions (29%), were associated with good therapeutic effects. Conclusion: Among suboptimal responders to standard-dose systemic propranolol, IHs with a deep or combined component and located on the head and neck were the most common. This retrospective study was largely descriptive in nature with additional exploratory analyses. However, it is still encouraging that for patients with a suboptimal clinical response, higher propranolol doses of ≥2.5–3 mg/kg/d or second-line treatments with surgical interventions or systemic steroids can be considered as potentially safe and effective alternatives. Level of evidence: Level 4 (case series).

Background Bruton tyrosine kinase (BTK) is a protein-coding gene crucial for B cell development. It is found on Xq21.3-Xq22 of the long arm of the X chromosome and belongs to the Tec family of cytoplasmic protein tyrosine kinases consisting of 5 structural domains: PH, TH, Src3, Src2, and TK. Pathogenic variants in the BTK gene can fully or partially block B cell development. BTK has been linked to various antibody deficiencies beyond agammaglobulinemia, including CVID. In hypomorphic BTK variants, there are detectable B cells in the periphery that may result in variable levels of serum immunoglobulins and clinical phenotype. Objective Investigate the impact of a missense pathogenic hypomorphic BTK variant (p.Arg525Gln) observed in a large kindred. Results We plan to assess by flow cytometry BTK protein expression in specific B cell subsets in hypomorphic XLA patients in this kindred. The flow cytometry revealed a uniformly reduced BTK expression in B cells (B cells evaluation is limited by low cell counts). BTK expression was decreased with an unexpected bimodal distribution in monocytes. Since both patients were male, XXY syndrome was initially considered but deemed less likely. The unexpected monocyte expression pattern in the current patient suggests possible somatic mosaicism or other genetic factors, or the two peaks are related to BTK protein degradation, and this may differ in specific cellular compartments or change with age, warranting further investigation. Conclusions This highlights the challenges of diagnosing hypomorphic XLA, especially in patients with detectable B cell counts and atypical BTK expression. Flow cytometric analysis of two patients with BTK mutations identified bimodal mosaic patterns of BTK expression in monocytes. This bimodal expression pattern may reflect cellular mosaicism like in mothers who are obligate carriers of XLA. BTK biology with hypomorphic variants remains incompletely understood, particularly how these variants affect B cell development and result in milder antibody deficiency phenotypes, warranting further investigation. This emphasizes the importance of genetic screening in kindreds with XLA and the need for increased awareness of partial XLA among healthcare providers to ensure timely diagnosis and treatment.

Introduction Loss of interferon-γ (IFN-γ) function through the development of neutralizing autoantibodies results in a late-onset immunodeficiency characterized by disseminated opportunistic infection. While rare, there is a higher prevalence in patients of Southeast Asian ancestry. Treatment is aimed at B cell depletion; however, relapse is common. Here we describe two cases of anti–IFN-γ autoantibody-associated immunodeficiency. Case Descriptions Patient 1: A 42-year-old female originally from Laos presented with a 30-lb weight loss and fatigue over the course of 8 months. Cultures grew Mycobacterium hassiacum. Testing by National Jewish was positive for anti–IFN-γ autoantibody via ELISA and for IFN-γ neutralizing ability via pSTAT1 phosphorylation. Autoantibodies were treated with rituximab 375 mg/m2 weekly for 4 weeks. She had subsequent negative autoantibody levels for 6 months until positive autoantibodies were again detected. She was treated with an additional 3 rituximab 375 mg weekly infusions and maintained remission for an additional 15 months until autoantibody levels were again positive without associated symptoms or infection (see table for timeline). She is currently undergoing additional 4 rituximab infusions. Table Patient 2 A 59-year-old female originally from Laos who presented for an immunodeficiency workup with a history of disseminated Mycobacterium avium infection, with pulmonary, lymph node, and parotid gland involvement. Anti–IFN-γ autoantibody testing from National Jewish was positive. She was treated with rituximab 375 mg/m2 weekly for 4 weeks. Autoantibody levels were negative 3 months later, and she has maintained remission since by serial monitoring. Discussion In our experience, anti–IFN-γ autoantibody-associated secondary immunodeficiency should be suspected in middle-aged patients with disseminated opportunistic infection, especially women of Southeast Asian ancestry. Rituximab rapidly depletes autoantibody levels; however, maintenance of remission is variable. The average duration of response in patient 1 was 10.5 months compared with persistent remission in patient 2. Thus, serial monitoring with autoantibody levels, markers of inflammation, and symptom assessments should be performed with consideration for repeated doses of rituximab.

Introduction Very early-onset inflammatory bowel disease (VEO-IBD) involves children less than 6 years of age presenting with IBD. These patients are more likely to have inborn errors of immunity. We present a child with VEO-IBD, found to have compound heterozygous variants in the DUOX2 gene that expands on the rare association of VEO-IBD with DUOX2 insufficiency. Case Description A 5-year-old male presented with six months of watery diarrhea, with labs notable for thrombocytosis, elevated CRP, and fecal calprotectin to 1430 [ref ≤ 49 μg/g]. Endoscopy and colonoscopy with biopsy revealed intraepithelial lymphocytosis in the duodenum, eosinophilic infiltrate in the stomach, esophagitis without eosinophilia, and chronic active ileitis with eosinophils of 65/hpf in the terminal ileum, consistent with a diagnosis of Crohn’s disease. The patient underwent immune phenotyping given his young age, which revealed elevated sIL2R, IL-17, IL-5, IL-13, IL-10, and IL-6, T cell lymphocytosis, and a normal neutrophil oxidative burst. Targeted genetic sequencing revealed two heterozygous variants in the DUOX2 gene: one maternally inherited likely pathogenic splice site variant, c.2922-14_2925del; and one paternally inherited variant of uncertain significance (VUS), c.1528C>T (p.Arg510Trp). The VUS is within the peroxidase-like region of the gene, which plays a crucial role in enzyme function, has a high CADD score of 25, and has a GnomAD allelic frequency of only 0.001%, suggesting possible pathogenicity. The patient is currently doing well on infliximab, with interval normalization of his cytokines. Discussion The DUOX2 gene encodes for dual NADPH oxidase (DUOX), which is responsible for the release of hydrogen peroxide as part of the innate immune defense of gut epithelial cells. In mice, DUOX2 has been shown to play an integral role in maintaining immune homeostasis in the gut biome, with knockout models showing elevated IL-17C levels in the ileum. There are few reported cases describing the association of compound heterozygous variants in DUOX2 in patients with VEO-IBD, with this being the fourth patient, to the best of our knowledge. This case highlights the importance of further research to better understand the role of this gene in the development of inflammatory bowel disease. Table 1.DiagnosticsValueCytokine panelIL-2 <2.1 (ref range ≤ 2.1)IL-2R 2259.3 (ref range 175.3 - 858.2)IL-12 <1.9 (ref range ≤ 1.9)INF- γ <4.2 (ref range ≤ 4.2)IL-4 <2.2 (ref range ≤ 2.2)IL-5 19.1 (ref range ≤ 2.1)IL-10 11.1 (ref range ≤ 2.8)IL-13 2.5 (ref range ≤ 2.3)IL-17 5.5 (ref range ≤ 5.5)IL-1β <6.5 (ref range ≤ 6.7)IL-6 6.3 (ref range ≤ 2.0)TNF-α 2.5 (ref range ≤ 7.2)ImmunoglobulinsIgA – 69 (ref range 21 – 144)IgE – 4680 (ref range 2 – 524)IgG – 734 (498 – 1332)IgM – 82 (ref range 31 – 63)Lymphocyte subset panelAbsolute CD3 3080 (ref range 1400 – 3700)Absolute CD4 1969 (ref range 700 – 2200)Absolute CD8 876 (ref range 490 – 1300)Absolute CD45RA 1505 (ref range 430 – 1500)Absolute CD45RO 652 (ref range 220 – 660)Absolute HLADR 660 (ref range 50 – 180)Absolute CD19 594 (ref range 390 – 1400)Absolute CD20 552 (ref range)Absolute NK 170 (ref range 130 – 720)EGD/ColonoscopyDuodenum - Intraepithelial lymphocytosisEsophagus mid and distal – esophagitis up to 2 eos/hpfEsophagus upper – esophagitis up to 1 eos/hpfChronic active ileitis with eosinophils (up to 65/hpf)Neutrophil oxidative burstNormal granulocyte dihydrohodamine fluorescence suggesting normal NADPH oxidase activityPrimary immunodeficiency panel1. DUOX2a. c.2922-14_2925del (splice site). Het. Likely pathogenic. GnomAD AC 99. CADD 31.b. c.1528C>T (p.Arg510Trp). Het. VUS. GnomAD AC 3. CADD 25. Peroxidase-like region (mediates peroxidase activity).2. FOXI3a. c.713G>A (p.Arg238Gln). Het. VUS. GnomAD AC 3. CADD 28.8. Associated with T cell lymphopenia. Not clinically relevant.3. MS4A1a. c.352A>C (p.Ile118Leu). Het. VUS. CADD 17.01. Conflicting in silico prediction models. GnomAD AC 71. Associated with CVID. Not clinically relevant.4. POLD1a. c.520C>T (p.Arg174Trp). Het. VUS. Associated with AD mandibular hypoplasia, deafness, progeroid features and lipodystrophy and AR T cell immunodeficiency. GnomAD AC 12. Not clinically relevant.

Aim Vedolizumab is a humanized monoclonal antibody that binds to α4β7 integrin expressed on most leukocytes and is used for treatment of inflammatory bowel disease. The objective of this study was to assess the effect of recombinant anti-vedolizumab treatment in vitro on allogeneic T and B cell flow cytometry crossmatches (FCXM) in solid organ transplantation. Methods Serum samples from kidney transplant recipients that received parenteral therapeutic vedolizumab monoclonal antibody injection 5 days prior to collection were used in the study. All serum samples were tested for the presence of HLA donor-specific antibodies (DSA) by Luminex single antigen beads assay (Thermo Fisher-One lambda). FCXM were performed using surrogate lymphocytes and sera were treated with heat inactivation (HI, 56°C for 30 mins), dithiothreitol (DTT, 5 mM at 37°C for 15 mins), and inhibitory anti-idiotypic recombinant anti-vedolizumab antibodies (HCA292, Bio-Rad, at 0.1, 0.05, and 0.025 mg/ml at room temperature for 30 min). Results Parenteral administration of therapeutic vedolizumab monoclonal antibodies caused false-positive allogeneic T and B cell FCXM in the absence of HLA DSA. HI and DTT treatment of sera had no effect on the false-positive T and B cell FCXM. However, recombinant anti-vedolizumab antibodies successfully abrogated the false-positive T and B cell FCXM at 0.1 mg/ml and 0.05 mg/ml concentrations (Table 1). Anti-vedolizumab antibodies at 0.1 mg/ml concentration had no effect on the negative and positive crossmatch control serum. Table 1.Serum treatmentFlow cytometry crossmatchT cellB cellHeat inactivationpositivepositiveDTTpositivepositiveAnti-vedoluzimab 0.1mg/mlnegativenegativeAnti-vedoluzimab 0.05mg/mlnegativenegativeAnti-vedoluzimab 0.025mg/mlpositivepositive Conclusions This is the first report showing that therapeutic administration of vedolizumab monoclonal antibodies cause false-positive T and B cell FCXM in absence of HLA DSA, which can preclude from proceeding with allogeneic transplantation. In addition, recombinant anti-vedolizumab antibodies abrogated false-positive allogeneic T and B cell FCXM.

Introduction STAT1 gain-of-function (GOF) mutations result in a broad clinical spectrum characterized by complex phenotypic manifestations. In addition to the hallmark chronic mucocutaneous candidiasis (CMC), patients are predisposed to bacterial and viral infections, autoimmunity, endocrinopathies, lymphoproliferative disorders, and malignancies. Severe complications, including invasive infections, cerebral aneurysms, and malignancies, are significant predictors of poor outcomes. Understanding genotype–phenotype correlations is critical for optimizing management in this challenging patient population. Methods We conducted a retrospective review of electronic medical records for five patients diagnosed with STAT1 GOF mutations at Mayo Clinic, Rochester, MN. This case series included data on demographics, clinical history, immunologic evaluations, genetic testing results, disease manifestations, treatments, and outcomes. Results The cohort included five patients (1 male, 4 females; mean age at diagnosis: 21.7 years) with heterozygous STAT1 GOF mutations. Three patients had c.1154C>T (p.Thr385Met), one had c.1310C>T (p.Thr437Ile) in the DNA-binding domain (DBD), and one had c.856A>G (p.Lys286Glu) in the coiled-coil domain (CCD). Universal features included CMC and recurrent sinopulmonary infections. Patients with c.1154C>T presented with early-onset infections, severe autoimmunity (e.g., pancytopenia and enteropathy), and bronchiectasis, requiring ruxolitinib in all three cases. The patient with c.1310C>T had a late childhood onset of symptoms, later complicated by persistent histoplasmosis. The c.856A>G case experienced severe multidrug-resistant infections, splenomegaly, coagulopathy, neurological complications, poor response to ruxolitinib, and died from complications of MSSA pneumonia and monkeypox. Conclusion Genotype–phenotype correlations in STAT1 GOF mutations highlight a diverse clinical spectrum driven by mutation-specific mechanisms. DBD mutations are associated with more severe outcomes, including early-onset immunodeficiency, invasive infections, and autoimmunity, due to faster nuclear accumulation and impaired dephosphorylation of STAT1. CCD mutations present with multisystem involvement, further emphasizing the heterogeneity of clinical manifestations. These variations underscore the importance of genetic insights for prognostication and tailored management. Early interventions, including hematopoietic stem cell transplantation for severe cases, and emerging therapies like JAK inhibitors show promise; however, ruxolitinib's need for individualized dosing, vigilant monitoring, continuous treatment to maintain benefits, and lack of epigenetic correction warrant further evaluation.

Background Cytokines play an important role in Th1 and Th2 inflammation. Both Th1 and Th2 cytokines can be utilized for evaluation and treatment response in many different disorders, including inborn errors of immunity. The role of broad cytokine panel testing in inborn errors of immunity is not well described. Objective To analyze broad cytokine panel testing in clinical practice. Methods A retrospective review of cytokine panel testing performed at Mayo Clinic was performed. Data were collected from patients at Mayo Clinic Rochester, Mayo Clinic Jacksonville, and Mayo Clinic Health System. Serum cytokine panel testing included the following cytokines: tumor necrosis factor (TNF), IL-6, IFN-β, IL-10, monocyte chemoattractant protein-1 (MCP-1), IL-1β, IFN-γ, macrophage inflammatory protein-1 alpha (MIP-1α), granulocyte-monocyte colony-stimulating factor (GM-CSF), IL-2 receptor α soluble, IFN-α, and IL-18. Data collection ranged from 03/2021 to 09/2024. The study was funded by Mayo CCaTS grant number UL1TR002377. Results A total of 88 cytokine panel tests were performed during the study period on 80 total patients. There was at least 1 elevated cytokine level in 70/88 (80%) tests performed. There was elevation in each individual cytokine level as follows: TNF (49), IL-2 receptor α soluble (40), IFN-α (0), IL-18 (26), IL-6 (33), IFN-β (4), IL-10 (13), MCP-1 (18), IL-1β, IFN-γ (11), MIP-1α (12), and GM-CSF (6). 18 patients that underwent cytokine panel testing had common variable immune deficiency (CVID), and 10 of those patients had granulomatous lymphocytic interstitial lung disease. 6 patients with early onset inflammatory bowel disease, 5 patients with autoimmune lymphoproliferative syndrome, 2 patients with Myhre syndrome, 2 patients with Hyper IgE syndrome, 1 patient with hypereosinophilic syndrome, 1 patient with autoimmune polyglandular syndrome type 1, 1 patient with XIAP deficiency, 1 patient with X-linked chronic granulomatous disease, and 1 patient with STAT 1 gain of function were tested. Other patients tested had other medical diagnoses or were undergoing immunodeficiency evaluation. There was no significant increase noted in any individual cytokine level when compared with the whole cohort. Conclusion Cytokine panel testing could be a potential diagnostic tool in evaluation of inborn errors of immunity. Further research is needed to better characterize the importance of cytokine panel testing in inborn errors of immunity.