Pediatric Specialty Conference Case 2 Presentation

Transcription

1 Pediatric Specialty Conference Case 2 Presentation Michele Paessler Children s Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania Department of Pathology and Laboratory Medicine

2 Case Presentation 9 month old male presents to the ER with pneumonia and fever Further history reveals: Two weeks prior there was a mouth ulcer. Wound culture showed normal flora. Dentist thought trauma from teething 2 small abscesses on the back that were lanced by the pediatrician (MSSA cultured) several months prior History of 1 ear infection No other infectious history. No history of prior or recurrent fevers. Robust weight gain, no hospitalizations or surgeries. No diarrhea, no eczema Fully immunized No medications.

3 Case History Family History No consanguinity. No PID. No early deaths. 2 healthy older siblings (1 sister and 1 brother) Social History no daycare. Exam in ER: Febrile Normal vitals. Happy, well-nourished 2mm ulcer inside lower lip Tonsils present Decreased breathe sounds No HSM No skin lesions

4 CBC Component White Blood Cell Count Red Blood Cell Count Hemoglobin Hematocrit Mean Corpuscular Volume Mean Corpuscular Hgb Mean Corpus Hgb Conc Red Distribution Width Platelet Count Mean Platelet Volume Eosinophils Lymphocytes Monocytes Total Cells Counted Differential Method Anisocytosis Hypochromia Microcytosis Platelet Estimate Result (L) 30.1 (L) (H) 677 (H) (H) MANUAL INCREASED Range & Units THOU/uL MIL/uL g/dl % fl pg g/dl % THOU/uL fl 0-4 % % 4-10 % 100 MANUAL INCREASED ANC=0 ALC=10620

5 Hematology/Oncology Consult Concern for malignancy specifically leukemia Peripheral blood smear was reviewed no circulating blasts were identified Bone marrow aspirate and biopsy were obtained

6 Bone Marrow Aspirate Slide 2A

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12 Flow Cytometry Bone Marrow Aspirate Slide 2G

13 Slide 2H Slide 2I Slide 2J

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16 Syndromes Associated with Neutropenia Constitutional neutropenia syndromes usually associated with myeloid hypoplasia/aplasia Shwachman-Diamond syndrome Severe congenital neutropenia & Kostmann syndrome Cyclic Neutropenia Bone marrow failure disorders Fanconi anemia Dyskeratosis congenita Immunodeficiencies Common variable immunodeficiency (CVID) Hyper IgM syndrome X linked agammaglobulinemia Reticular dysgenesis

17 Syndromes Associated with Neutropenia Storage disorders Glycogen storage disorder type 1b Trafficking disorders Chediak Higashi Gricelli syndrome, type 2 Other Myelokathexis/WHIM Barth syndrome Cohen syndrome

18 Differential Diagnosis Congenital Neutropenia Severe congenital neutropenia & Kostmann Syndrome Cyclic neutropenia Shwachman Diamond Syndrome Autoimmune neutropenia Immunodeficiency work up is recommended including immunoglobulins Infectious (viral) Malignancy Leukemia Drug induced

19 Other Laboratory Values Antineutrophil antibodies negative Flow cytometry consistent with hematogones Molecular studies for ELA2 mutation negative Laboratory test for CGD negative

20 B cell Panel B-Cell Panel: - CD19+/CD40+ = 1989 cells/ul - CD19+/IgD+/IgM + = 1796 cells/ul (naïve B-cells) - CD19+/CD27+/IgD- = 4 cells/ul (switched memory) - CD19+/CD27+/IgM- = 4 cells/ul (switched memory)

21 Lab Values Immunoglobulin levels IgM - mildly elevated IgG, IgA, and IgE - decreased IgG 31, IgA 8, IgM 184 Diptheria and Tetanus Ab undetectable 2 pneumococcal serotypes positive (1, 9V)

22 Flow Cytometry CD40L absent O'Gorman MR, Zaas D, Paniagua M, Corrochano V, Scholl PR, Pachman LM. Development of a rapid whole blood flow cytometry proedure for the diagnosis of X-linked hyper-igm syndrome patients and carriers.clin Immunol Immunopathol Nov;85(2):

23 Diagnosis.. X-linked Hyper IgM Syndrome Mutation analysis confirmed X-linked HIGM - deletion of adenine and cytosine at position 460/461 - frameshift mutation

24 Hyper IgM Syndrome Pathophysiology Immunodeficiency with elevated (or normal) IgM. Most common form is inherited as an X-linked recessive trait due to mutations in CD40 ligand. CD40L is on T lymphocytes and interacts with CD40 on B cells to induce class switching from IgM to IgG, IgD and IgA (the IgM is functional).

25 X-Linked Hyper IgM T-cell ligand defect leads to defective stimulatory signaling. CD40L on T-cells interacts with CD40 receptor on B-cells, macrophages, and dendritic cells. - B-cell proliferation, CSR, SHM - Activation of macrophages and dendritic cells

26 HIGM Type 1 HIGM Type 3 HIGM Type 6 HIGM Type 2 HIGM Type 2 HIGM Type 5 HIGM Type 4

27 HIGM Syndrome SHM and CSR occur in germinal center Thought to need CD40L on T cells and CD40 on B cells CD27+ B cells are memory cells that have successfully undergone SHM and lack of CD27 B cells is the result of defective generation of memory cells This is not the case as in HIGM2 there are CD27+ B cells with no SHM

28 Most HIGM Syndromes show Lack of Memory B cells SHM and CSR occur in germinal center Thought to need CD40L on T cells and CD40 on B cells CD27+ B cells are memory cells that have successfully undergone SHM and lack of CD27 B cells is the result of defective generation of memory cells This is not the case as in HIGM2 there are CD27+ B cells with no SHM S gr1.jpg

29 Hyper Ig M Clinical Manifestations Symptoms develop 1st-2nd year of life Classically patients have recurrent pyogenic infections bacterial infections and opportunistic infections (P carinii, histoplasmosis, toxoplasmosis). Other clinical manifestations include autoimmune disease and malignancies.

30 X-Linked Hyper IgM Recurrent respiratory infections with pyogenic bacteria. Opportunistic infections PCP (Why?) Low IgG, IgA, IgE IgM normal or elevated Absent specific IgG antibody responses Low switched memory B-cells T-cell subsets and mitogens normal Defective Th1 response w/ decreased IFN-Gamma secretion and failure of APCs to make IL-12 >50% of patients have intermittent or chronic neutropenia - arrest at the myelocyte-promyelocyte stage Autoimmunity common AHA, thrombocytopenia, autoimmune hepatitis, inflammatory bowel disease. Hodgkin s lymphoma, malignancies of the liver and GI tract.

31 Neutropenia and HyperIgM Syndrome It is common for Hyper IgM patients to have neutropenia. Neutropenia is often chronic and occasional cyclical in nature. Pathophysiology of neutropenia not definitively known. Possibly autoimmune etiology however autoantibodies in hyper IgM patients have not been demonstrated. Possibly due to defect in CD40L on stromal cells leading to defective synthesis of G-CSF.

32 Primary Immunodeficiencies Associated with Neutropenia X-Linked Agammaglobulinemia (XLA) Hyper IgM IgA deficiency Wiskot Aldrich Syndrome (WAS) Chediak-Higashi Syndrome Dyskeratosis Congenita Reticular Dysgenesis WHIM (warts, hypogammaglobulinemia, infections, Myelokathexis) CVID (common variable immunodeficiency)

33 Bone Marrow Findings in HIGM Normal to decreased myeloid elements Myeloid series shows an arrest at the promyelocyte to myelocyte stage of development No dysplasia Other lineages are normal

34 How would you treat this patient? Option #1: - Monthly IVIG - Bactrim prophylaxis for PCP - GCSF for neutropenia - Other antibiotic prophylaxis Option #2: - Bone marrow transplant - Haploidentical vs. full HLA match Median survival of patients who do not receive BMT is less than 25 years - PCP - infancy - GI malignancy - adult Levy et al. 1997

35 Conclusion In pediatric population neutropenia may be associated with: Congenital Neutropenias Severe congenital neutropenia, Kostman syndrome, cyclic neutropenia and Shwachman Diamond syndrome Bone Marrow Failure Fanconi anemia Dyskeratosis Congenita Immunodeficiencies Hyper IgM syndrome X-linked agammagloblinemia CVID Reticular dysgenesis WHIM/myelokathexis Chediak Higashi Syndrome Molecular tests are available for specific diseases as well as screening tests for bone marrow failures ELA2 SCN and cyclic neutropenia SBDS mutation testing for Shwachman Diamond Syndrome Telomere length for DKC and subsequent TERC/TERT/Dyskerin gene testing Chromosome breakage for FA Hematogones can mimic acute leukemia

36 References Allen RC, Armitage RJ, Conley ME, et al: CD40 ligand gene defects responsible for X linked Hyper-IgM syndrome. Science 259: Aruffo A, FarringtonM, Hollenbaugh D, et al: The Cd40 ligand, gp39, is defective in activated T cells from patients with X-linked hyper-igm syndrome. Cell72: Berliner N, Horwitz M, Loughran TP, Jr. Congenital and acquired neutropenia. Hematology (Am Soc Hematol Educ Program) 2004;63-69 Bone Marrow Pathology, 3 rd Edition, Volume 2, Foucar, K, Reichard K, Czuchlewski D, 2013 ASCP Press Boxer L, Dale DC. Neutropenia: Causes and consequences. Semin Hematol 2002;39:75-81 Boxer LA, Stein S, Buckley D, et al. Strong evidence for autosomal dominant inheritances of severe congenital neutropenia associated with ELA2 mutations. J Pediatr 2006;148: Cham B, Bonilla MA, Winkelstein J.Neutropenia associated with primary immunodeficiency syndromes. Semin Hematol 2002;39: Dale DC, Cottle TE, Fier CJ, et al. Severe chronic neutropenia: Treatment and follow-up of patients in the Severe Chronic Neutropenia International Registry. Am J Hematol 2003; 72:82-93 Dale DC, Hammond WP. Cyclic neutropenia: A clinical review. Blood Rev 1988; 2: Doffinger R, Smahi A, Bessia C, et al: X-linked anhidrotic ectodermal dysplasia with immunodeficiency is caused by impaired NK-kappa B signaling. Nature Genet 27: , 2001 Horwitz M, Benson KF, Person RE, et al. Mutations in ELA2, encoding neutrophil elastase, define a 21-day biological clock in cyclic haematopoiesis. Nat Genet 1999;23:

37 References JP, Bonnefow JY, Gauchat JF, et al: CD40 ligand mutations in X-linked immunodeficiency with hyper-igm. Nature 361: , 1993 Klein C, Grudzien M, Appaswamy G, et al. HAX1 deficiency causes autosomal recessive severe congenital neutropenia (Kostmann disease). Nat Genet 2006:39:86-92 Levy J, Espanol-Boren T, Thomas C, et al: Clinical spectrum of X-linked hyper IgM syndrome. J Pediatr 131:47-54, 1997 Levy, J. Clinical Spectrum of X-linked Hyper IgM syndrome. J. Pediatrics. 1997; Mavroudi I and Papadaki HA. The Role of CD40/CD40L Interactions in Bone Marrow Granulopoiesis. Review. The Scientific World Journal 2011;11: Notarangelo Ld, Duse M, Ugazio AG: Immunodeficiency with hyper-igm. Immunodef Rev 3: , 1992 O Gorman MR, Zollett J, Bensen N. Flow cytometry assays in primary immunodeficiency disease. Methods Mol Biol. 2011;699: O'Gorman MR, Zaas D, Paniagua M, Corrochano V, Scholl PR, Pachman LM. Development of a rapid whole blood flow cytometry procedure for the diagnosis of X- linked hyper-igm syndrome patients and carriers.clin Immunol Immunopathol Nov;85(2):

38 References Revy P, Muto T, Levy Y, et al: Activation induced cytidine deaminase (AID) deficiency causes the autosomal recessive form of the hyper-igm syndrome. Cell 102: , 2000 Rezaei N, Aghamohammadi A, Ramyar A, et al. Severe Congenital Neutropenia or HyperIgM Syndrome? A Novel Mutation of CD30 Ligand in Patient with Severe Neutropenia. Int Arch of Allergy and Immunol 2008;147: Skokowa J, Germeshausen M, Zeidler C, et al. Severe congenital neutropenia: Inheritance and pathophysiology. Curr Opin Hematol 2007;14:22-28 Wang Wc, CordobaJ, Infante AJ, et al: Successful treatment of neutropenia in the hyper immunoglobulin M M syndrome with granulocyte colony-stimulating factor. Am J Pediatr Hematol Oncol 16: , 1994 Ward AC, van Aesch YM, Gits J, et al. Novel point mutation in the extracellular domain of the granulocyte colony-stimulating factor (G-CSF) receptor in a case of severe congenital neutropenia hyporesponsive to G-CSF treatment. J Exp Med 1999; 190: Winkelstein J, Marino M, Ochs H, et al. The X-linked Hyper-IgM Syndrome: Clinical and Immunology Features of 79 Patients. Medicine. 2003;82(6): Winkelstein JA, Marino MC, Ochs H. et al. The X-linked hyperigm syndrome. J Pediatr 1997;131:47-54.

39 The End Thank You