Publications by authors named "John I Gallin"

63 Publications

An immune-based biomarker signature is associated with mortality in COVID-19 patients.

JCI Insight 2021 01 11;6(1). Epub 2021 Jan 11.

Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA.

Immune and inflammatory responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) contribute to disease severity of coronavirus disease 2019 (COVID-19). However, the utility of specific immune-based biomarkers to predict clinical outcome remains elusive. Here, we analyzed levels of 66 soluble biomarkers in 175 Italian patients with COVID-19 ranging from mild/moderate to critical severity and assessed type I IFN-, type II IFN-, and NF-κB-dependent whole-blood transcriptional signatures. A broad inflammatory signature was observed, implicating activation of various immune and nonhematopoietic cell subsets. Discordance between IFN-α2a protein and IFNA2 transcript levels in blood suggests that type I IFNs during COVID-19 may be primarily produced by tissue-resident cells. Multivariable analysis of patients' first samples revealed 12 biomarkers (CCL2, IL-15, soluble ST2 [sST2], NGAL, sTNFRSF1A, ferritin, IL-6, S100A9, MMP-9, IL-2, sVEGFR1, IL-10) that when increased were independently associated with mortality. Multivariate analyses of longitudinal biomarker trajectories identified 8 of the aforementioned biomarkers (IL-15, IL-2, NGAL, CCL2, MMP-9, sTNFRSF1A, sST2, IL-10) and 2 additional biomarkers (lactoferrin, CXCL9) that were substantially associated with mortality when increased, while IL-1α was associated with mortality when decreased. Among these, sST2, sTNFRSF1A, IL-10, and IL-15 were consistently higher throughout the hospitalization in patients who died versus those who recovered, suggesting that these biomarkers may provide an early warning of eventual disease outcome.
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http://dx.doi.org/10.1172/jci.insight.144455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7821609PMC
January 2021

Low Plasma Gelsolin Concentrations in Chronic Granulomatous Disease.

Inflammation 2021 Feb 4;44(1):270-277. Epub 2020 Sep 4.

Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.

Plasma gelsolin (pGSN) is the secreted isoform of an intracellular actin remodeling protein found in high concentrations in human plasma. Clinical studies demonstrate reduced pGSN concentrations in several disease states, including severe trauma, burns, and sepsis. Markedly decreased pGSN concentrations in these conditions precede and predict adverse clinical outcomes. In this study, we measured pGSN in patients with chronic granulomatous disease (CGD), a primary immunodeficiency characterized by recurrent infections and dysregulated inflammation. pGSN was quantified using a sandwich ELISA in plasma from healthy volunteers, clinically stable CGD patients, and X-linked CGD carriers and in sera from 12 CGD patients undergoing bone marrow transplantation. pGSN was also quantified in healthy volunteers challenged with intravenous endotoxin. pGSN concentrations were lower in CGD patients without active infection or systemic inflammation compared with healthy control subjects. In CGD patients undergoing bone marrow transplantation, pGSN concentrations increased significantly following successful transplant. X-linked carriers of CGD had normal pGSN. Despite reduction of pGSN in CGD patients, we did not detect significant changes in pGSN over 24 h following challenge of healthy volunteers with intravenous endotoxin (4 ng/kg) that elicited a febrile response. We describe, for the first time, significantly lower pGSN in clinically stable patients with CGD compared with age- and sex-matched healthy volunteers. Low pGSN levels in CGD patients significantly increased following bone marrow transplantation. X-linked carriers of CGD had normal pGSN. In healthy volunteers challenged with intravenous endotoxin, pGSN is not an acute phase reactant.
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http://dx.doi.org/10.1007/s10753-020-01330-wDOI Listing
February 2021

Neutrophil activation in systemic capillary leak syndrome (Clarkson disease).

J Cell Mol Med 2019 08 18;23(8):5119-5127. Epub 2019 Jun 18.

Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, NIAID/NIH, Bethesda, Maryland.

Systemic capillary leak syndrome (SCLS; Clarkson disease) is a rare orphan disorder characterized by transient yet recurrent episodes of hypotension and peripheral oedema due to diffuse vascular leakage of fluids and proteins into soft tissues. Humoral mediators, cellular responses and genetic features accounting for the clinical phenotype of SCLS are virtually unknown. Here, we searched for factors altered in acute SCLS plasma relative to matched convalescent samples using multiplexed aptamer-based proteomic screening. Relative amounts of 612 proteins were changed greater than twofold and 81 proteins were changed at least threefold. Among the most enriched proteins in acute SCLS plasma were neutrophil granule components including bactericidal permeability inducing protein, myeloperoxidase and matrix metalloproteinase 8. Neutrophils isolated from blood of subjects with SCLS or healthy controls responded similarly to routine pro-inflammatory mediators. However, acute SCLS sera activated neutrophils relative to remission sera. Activated neutrophil supernatants increased permeability of endothelial cells from both controls and SCLS subjects equivalently. Our results suggest systemic neutrophil degranulation during SCLS acute flares, which may contribute to the clinical manifestations of acute vascular leak.
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http://dx.doi.org/10.1111/jcmm.14381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6653644PMC
August 2019

(p47)-deficient chronic granulomatous disease: comprehensive genetic and flow cytometric analysis.

Blood Adv 2019 01;3(2):136-147

Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.

Mutations in (p47) cause autosomal recessive chronic granulomatous disease (CGD) with abnormal dihydrorhodamine (DHR) assay and absent p47 protein. Genetic identification of mutations is complicated by adjacent highly conserved (>98%) pseudogenes ( and ). has GTGT at the start of exon 2, whereas the pseudogenes each delete 1 GT (ΔGT). In p47 CGD, the most common mutation is ΔGT in (c.75_76delGT; p.Tyr26fsX26). Sequence homology between and its pseudogenes precludes reliable use of standard Sanger sequencing for mutations and for confirming carrier status. We first established by flow cytometry that neutrophils from p47 CGD patients had negligible p47 expression, whereas those from p47 CGD carriers had ∼60% of normal p47 expression, independent of the specific mutation in We developed a droplet digital polymerase chain reaction (ddPCR) with 2 distinct probes, recognizing either the wild-type GTGT sequence or the ΔGT sequence. A second ddPCR established copy number by comparison with the single-copy telomerase reverse transcriptase gene, We showed that 84% of p47 CGD patients were homozygous for ΔGT The ddPCR assay also enabled determination of carrier status of relatives. Furthermore, only 79.2% of normal volunteers had 2 copies of GTGT per 6 total () copies, designated 2/6; 14.7% had 3/6, and 1.6% had 4/6 GTGT copies. In summary, flow cytometry for p47 expression quickly identifies patients and carriers of p47 CGD, and genomic ddPCR identifies patients and carriers of ΔGT , the most common mutation in p47 CGD.
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http://dx.doi.org/10.1182/bloodadvances.2018023184DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341190PMC
January 2019

TNF overproduction impairs epithelial staphylococcal response in hyper IgE syndrome.

J Clin Invest 2018 08 23;128(8):3595-3604. Epub 2018 Jul 23.

Laboratory of Clinical Immunology and Microbiology, and.

Autosomal dominant hyper IgE syndrome (AD-HIES), or Job's syndrome, is a primary immune deficiency caused by dominant-negative mutations in STAT3. Recurrent Staphylococcus aureus skin abscesses are a defining feature of this syndrome. A widely held hypothesis that defects in peripheral Th17 differentiation confer this susceptibility has never been directly evaluated. To assess the cutaneous immune response in AD-HIES, we induced suction blisters in healthy volunteers (HVs) and patients with AD-HIES and then challenged the wound with lethally irradiated bacteria. We show that cutaneous production of IL-17A and IL-17F was normal in patients with AD-HIES. Overproduction of TNF-α differentiated the responses in AD-HIES from HVs. This was associated with reduced IL-10 family signaling in blister-infiltrating cells and defective epithelial cell function. Mouse models of AD-HIES recapitulated these aberrant epithelial responses to S. aureus and involved defective epithelial-to-mesenchymal transition (EMT) rather than a failure of bacterial killing. Defective responses in mouse models of AD-HIES and primary keratinocyte cultures from patients with AD-HIES could be reversed by TNF-α blockade and by drugs with reported modulatory effects on EMT. Our results identify these as potential therapeutic approaches in patients with AD-HIES suffering S. aureus infections.
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http://dx.doi.org/10.1172/JCI121486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063472PMC
August 2018

Inherited p40phox deficiency differs from classic chronic granulomatous disease.

J Clin Invest 2018 08 6;128(9):3957-3975. Epub 2018 Aug 6.

Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, Paris, France.

Biallelic loss-of-function (LOF) mutations of the NCF4 gene, encoding the p40phox subunit of the phagocyte NADPH oxidase, have been described in only 1 patient. We report on 24 p40phox-deficient patients from 12 additional families in 8 countries. These patients display 8 different in-frame or out-of-frame mutations of NCF4 that are homozygous in 11 of the families and compound heterozygous in another. When overexpressed in NB4 neutrophil-like cells and EBV-transformed B cells in vitro, the mutant alleles were found to be LOF, with the exception of the p.R58C and c.120_134del alleles, which were hypomorphic. Particle-induced NADPH oxidase activity was severely impaired in the patients' neutrophils, whereas PMA-induced dihydrorhodamine-1,2,3 (DHR) oxidation, which is widely used as a diagnostic test for chronic granulomatous disease (CGD), was normal or mildly impaired in the patients. Moreover, the NADPH oxidase activity of EBV-transformed B cells was also severely impaired, whereas that of mononuclear phagocytes was normal. Finally, the killing of Candida albicans and Aspergillus fumigatus hyphae by neutrophils was conserved in these patients, unlike in patients with CGD. The patients suffer from hyperinflammation and peripheral infections, but they do not have any of the invasive bacterial or fungal infections seen in CGD. Inherited p40phox deficiency underlies a distinctive condition, resembling a mild, atypical form of CGD.
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http://dx.doi.org/10.1172/JCI97116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6118590PMC
August 2018

The Changing Paradigm of Management of Liver Abscesses in Chronic Granulomatous Disease.

Clin Infect Dis 2018 04;66(9):1427-1434

Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health (NIH), Bethesda, Maryl.

Background: Chronic granulomatous disease (CGD) is a rare genetic disorder causing recurrent infections. More than one-quarter of patients develop hepatic abscesses and liver dysfunction. Recent reports suggest that disease-modifying treatment with corticosteroids is effective for these abscesses. Comparison of corticosteroid therapy to traditional invasive treatments has not been performed.

Methods: Records of 268 patients with CGD treated at the National Institutes of Health from 1980 to 2014 were reviewed. Patients with liver involvement and complete records were included. We recorded residual reactive oxygen intermediate (ROI) production by neutrophils, nicotinamide adenine dinucleotide phosphate (NADPH) oxidase germline mutation status, laboratory values, imaging characteristics, time to repeat hepatic interventions, and overall survival among 3 treatment cohorts: open liver surgery (OS), percutaneous liver-directed interventional radiology therapy (IR), and high-dose corticosteroid management (CM).

Results: Eighty-eight of 268 patients with CGD suffered liver involvement. Twenty-six patients with a median follow-up of 15.5 years (8.5-32.9 years of follow-up) had complete records and underwent 100 standard interventions (42 IR and 58 OS). Eight patients received a treatment with high-dose corticosteroids only. There were no differences in NADPH genotype, size, or number of abscesses between patients treated with OS, IR, or CM. Time to repeat intervention was extended in OS compared with IR (18.8 vs 9.5 months, P = .04) and further increased in CM alone (median time to recurrence not met). Impaired macrophage and neutrophil function measured by ROI production correlated with shorter time to repeat intervention (r = 0.6, P = .0019).

Conclusions: Treatment of CGD-associated liver abscesses with corticosteroids was associated with fewer subsequent hepatic interventions and improved outcome compared to invasive treatments.
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http://dx.doi.org/10.1093/cid/cix1012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248449PMC
April 2018

A Brief Historical Perspective of Cancer Rehabilitation and Contributions From the National Institutes of Health.

PM R 2017 Sep;9(9S2):S297-S304

Rockville, MD(#).

People who have cancer diagnoses often need care throughout their lives through all stages of their illness. These stages include diagnosis, primary treatment, survivorship, and end of life. The management of people with cancer, now a common and chronic illness with long-term survival improving, is complex, challenging, and rapidly changing. Rehabilitation for people with cancer diagnoses is a new specialty and is charged with providing care throughout the trajectory of illness and wellness to maximize potential for function and mitigate disability. Rehabilitation interventions include the application of physical and occupational therapeutics, speech and language interventions, and physical medicine in order to help patients reach their individual goals and to promote life satisfaction. The Department of Rehabilitation in the Clinical Center of the National Institutes of Health has pioneered this field through research and clinical care models over the past 40 years. Staff of this department has supported clinical research investigators at the National Institutes of Health in their exploration of new treatments using chemotherapies, surgery, radiation, and psychosocial interventions. They have also engaged in research specific to rehabilitation to devise and improve functional outcome measures, design exercise interventions, devise orthotics, and prosthetic devices for adaptation to functional loss. Collectively, the staff has published widely in oncology textbooks and professional journals in order to share findings and improve the quality of cancer rehabilitation treatment across the continuum of care.
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http://dx.doi.org/10.1016/j.pmrj.2017.07.005DOI Listing
September 2017

X-linked carriers of chronic granulomatous disease: Illness, lyonization, and stability.

J Allergy Clin Immunol 2018 01 18;141(1):365-371. Epub 2017 May 18.

Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md. Electronic address:

Background: Chronic granulomatous disease (CGD) is characterized by recurrent life-threatening bacterial and fungal infections and aberrant inflammation. Mutations in CYBB cause X-linked CGD and account for 65% to 70% of cases in Western countries.

Objective: We sought to understand the clinical manifestations associated with the X-linked CGD carrier state.

Methods: We undertook a comprehensive retrospective study of 162 affected female subjects. We examined dihydrorhodamine 123 (DHR) oxidation data for percentage of X-chromosome inactivation. We correlated lyonization (%DHR) with clinical features. Where possible, we followed %DHR values over time.

Results: Clinical data were available for 93 female subjects: %DHR values were 46% (mean) and 47% (median; SD, 24). Using the %DHR value as the criterion for X inactivation, 78% of patients had levels of inactivation of 20% to 80%, suggesting random inactivation that was independent of age. In contrast, carriers with CGD-type infections had median %DHR values of 8% (n = 14; range, 0.06% to 48%), and those with only autoimmune or inflammatory manifestations had median %DHR values of 39% (n = 31; range, 7.4% to 74%). Those with both infections and autoimmunity had low %DHR values (n = 6; range, 3% to 14%). A %DHR value of less than 10% was strongly associated with infections (odds ratio, 99). Strong association persisted when %DHR values were less than 20% (odds ratio, 12). Autoimmunity was not associated with %DHR values. In 2 sets of identical twins, the %DHR populations tracked closely over time. Although the %DHR populations were very similar between sisters, those between mothers and daughters were unrelated.

Conclusions: A low %DHR value strongly predicts infection risk in X-linked CGD carriers, and the carrier state itself is associated with autoimmunity.
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http://dx.doi.org/10.1016/j.jaci.2017.04.035DOI Listing
January 2018

Early Intracellular Trafficking of Granulibacter bethesdensis in Human Macrophages.

Infect Immun 2017 06 23;85(6). Epub 2017 May 23.

Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA

is a Gram-negative bacterium that infects patients with chronic granulomatous disease (CGD), a primary immunodeficiency marked by a defect in NOX2, the phagocyte NADPH oxidase. Previous studies have shown that NOX2 is essential for killing of by neutrophils and monocytes and that the bacteriostatic activity of monocyte-derived macrophages (MDM) requires NOX2 and gamma interferon (IFN-γ) pretreatment. To determine whether evades phagolysosomal killing, a host defense pathway intact in both normal and CGD MDM, or whether it occupies a distinct intracellular niche in CGD MDM, we assessed the trafficking patterns of this organism. We observed colocalization of with an early endosome antigen 1 (EEA1)-positive compartment, followed by colocalization with lysosome-associated membrane protein 1 (LAMP1)-positive and LysoTracker-positive late phagosomes; these characteristics were similar in both normal and CGD MDM. Despite localization to acidified late phagosomes, viable cells were recovered from viable MDM in numbers greater than in the initial input up to 6 days after infection. remains, and in some cases appears to divide, within a membrane-bound compartment for the entire 6-day time course. These findings indicate that this organism resists both oxygen-dependent and oxygen-independent phagolysosomal antimicrobial systems of human macrophages.
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http://dx.doi.org/10.1128/IAI.00847-16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5442635PMC
June 2017

NADPH Oxidase-2 and Atherothrombosis: Insight From Chronic Granulomatous Disease.

Arterioscler Thromb Vasc Biol 2017 02 8;37(2):218-225. Epub 2016 Dec 8.

From the Division of I Clinica Medica, Policlinico Umberto I, Sapienza University, Rome, Italy (F.V., L.L., P.P.); Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy (R.C.); and Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (J.I.G.).

The phagocytic cell enzyme NADPH oxidase-2 (Nox2) is critical for killing micro-organisms via production of reactive oxygen species and thus is a key element of the innate immune system. Nox2 is also detectable in endothelial cells and platelets where it has vasoconstrictive and aggregating properties, respectively. Patients with X-linked chronic granulomatous disease with hereditary Nox2 deficiency not only have impaired bacterial killing but, in association with loss of Nox2 function, also have enhanced carotid artery dilation, impaired platelet-related thrombosis, and reduced carotid atherosclerotic burden. Experimental studies corroborated these reports in chronic granulomatous disease by demonstrating (1) Nox2 is upregulated in atherosclerotic plaque, and this upregulation significantly correlates with oxidative stress and (2) pharmacological inhibition of Nox2 is associated with a delayed atherosclerotic progression in animal models. Furthermore, the role of Nox2 in platelet-associated thrombosis was substantiated by experiments showing impaired platelet activation in animals treated with a Nox2 inhibitor or impaired platelet aggregation along with reduced platelet-related thrombosis in the mouse knockout model of Nox2. Interestingly, in chronic granulomatous disease patients and in the mouse knockout model of Nox2, no defects of primary hemostasis were detected. This review analyses experimental and clinical data suggesting Nox2 is a potential target for counteracting the atherothrombotic process.
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http://dx.doi.org/10.1161/ATVBAHA.116.308351DOI Listing
February 2017

Cytoskeletal abnormalities and neutrophil dysfunction in WDR1 deficiency.

Blood 2016 10 24;128(17):2135-2143. Epub 2016 Aug 24.

Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD.

Cell motility, division, and structural integrity depend on dynamic remodeling of the cellular cytoskeleton, which is regulated in part by actin polymerization and depolymerization. In 3 families, we identified 4 children with recurrent infections and varying clinical manifestations including mild neutropenia, impaired wound healing, severe stomatitis with oral stenosis, and death. All patients studied had similar distinctive neutrophil herniation of the nuclear lobes and agranular regions within the cytosol. Chemotaxis and chemokinesis were markedly impaired, but staphylococcal killing was normal, and neutrophil oxidative burst was increased both basally and on stimulation. Neutrophil spreading on glass and cell polarization were also impaired. Neutrophil F-actin was elevated fourfold, suggesting an abnormality in F-actin regulation. Two-dimensional differential in-gel electrophoresis identified abnormal actin-interacting protein 1 (Aip1), encoded by WDR1, in patient samples. Biallelic mutations in WDR1 affecting distinct antiparallel β-strands of Aip1 were identified in all patients. It has been previously reported that Aip1 regulates cofilin-mediated actin depolymerization, which is required for normal neutrophil function. Heterozygous mutations in clinically normal relatives confirmed that WDR1 deficiency is autosomal recessive. Allogeneic stem cell transplantation corrected the immunologic defect in 1 patient. Mutations in WDR1 affect neutrophil morphology, motility, and function, causing a novel primary immunodeficiency.
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http://dx.doi.org/10.1182/blood-2016-03-706028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5084607PMC
October 2016

Thoracic Surgery in Chronic Granulomatous Disease: a 25-Year Single-Institution Experience.

J Clin Immunol 2016 10 6;36(7):677-83. Epub 2016 Aug 6.

Thoracic and Gastrointestinal Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.

Introduction: Chronic granulomatous disease (CGD) is a genetic disorder in which phagocyte dysfunction leads to recurrent infection. Persistent pulmonary infections sometimes require thoracic surgical intervention. We reviewed our 25-year experience to identify outcomes and prognostic factors associated with thoracic surgery in these patients.

Methods: A retrospective single-institution review of all patients with CGD from 1990 through 2015 was performed. Univariate analysis identified prognostic variables to include in a Cox model. Overall survival was estimated by the Kaplan-Meier method.

Results: We identified 258 patients who had 2221 admissions (both scheduled and emergent). During the period examined, 51 thoracic operations were performed in 13.6 % (35/258) of patients and 2.3 % (35/2221) of overall admissions. Patients undergoing surgery did not have statistically significant differences in disease genotype compared to those that did not require surgery. Pathogens were identified from 67 % (34/51) of specimens. Complications occurred in 27 % (14/51), including 10 % (5/51) with wound and 12 % (6/51) with pulmonary infections. Mortality at 30 and 90 days was 0 and 6 % (3/51), respectively. Overall survival probabilities were 75 and 62 % at 5- and 10-year follow-up (median potential follow-up: 16.5 years), respectively. Undergoing thoracic surgery was associated with an increased hazard ratio for death of 3.71 (p < 0.0001). Both chest wall resection and EBL > 500 mL were negative prognostic factors (p < 0.05).

Conclusions: A minority of CGD patients required thoracic surgery for infections refractory to antibiotic or antifungal therapy. Patients who had these operations had significant morbidity and relatively poor long-term survival, particularly in the cases of chest wall resection or significant blood loss.
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http://dx.doi.org/10.1007/s10875-016-0319-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6329290PMC
October 2016

Outcomes From the NIH Clinical Research Training Program: A Mentored Research Experience to Enhance Career Development of Clinician-Scientists.

Acad Med 2016 12;91(12):1684-1690

F.P. Ognibene is deputy director, Educational Affairs and Strategic Partnerships, National Institutes of Health (NIH) Clinical Center, and former director, NIH Clinical Research Training Program, NIH, Bethesda, Maryland. J.I. Gallin is director, NIH Clinical Center, associate director for clinical research, and associate director for clinical research training, NIH, Bethesda, Maryland. B.J. Baum is former director, NIH Medical Research Scholars Program, and scientist emeritus, National Institute of Dental and Craniofacial Research, Bethesda, Maryland. R.G. Wyatt is deputy director, NIH Office of Intramural Research, Bethesda, Maryland. M.M. Gottesman is NIH deputy director for intramural research, Bethesda, Maryland.

Purpose: Clinician-scientists are considered an endangered species for many reasons, including challenges with establishing and maintaining a career pipeline. Career outcomes from yearlong medical and dental students' research enrichment programs have not been well determined. Therefore, the authors assessed career and research outcome data from a cohort of participants in the National Institutes of Health (NIH) Clinical Research Training Program (CRTP).

Method: The CRTP provided a yearlong mentored clinical or translational research opportunity for 340 medical and dental students. Of these, 135 completed their training, including fellowships, from 1997 to January 2014. Data for 130 of 135 were analyzed: time conducting research, types of public funding (NIH grants), and publications from self-reported surveys that were verified via the NIH Research Portfolio Online Reporting Tools Web site and PubMed.

Results: Nearly two-thirds (84 of 130) indicated that they were conducting research, and over half of the 84 (approximately one-third of the total cohort) spent more than 25% of time conducting research. Of those 84, over 25% received grant support from the NIH, and those further in their careers published more scholarly manuscripts.

Conclusions: Data suggest that the CRTP helped foster the careers of research-oriented medical and dental students as measured by time conducting research, successful competition for federal funding, and the publication of their research. Longer follow-up is warranted to assess the impact of these mentored research experiences. Investments in mentored research programs for health professional students are invaluable to support the dwindling pipeline of biomedical researchers and clinician-scientists.
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http://dx.doi.org/10.1097/ACM.0000000000001245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5501747PMC
December 2016

Gastrointestinal Features of Chronic Granulomatous Disease Found During Endoscopy.

Clin Gastroenterol Hepatol 2016 Mar 9;14(3):395-402.e5. Epub 2015 Nov 9.

National Institutes of Health, Bethesda, Maryland. Electronic address:

Background & Aims: Chronic granulomatous disease (CGD) is an inherited disorder of the reduced nicotinamide adenine dinucleotide phosphate oxidase complex within phagocytic cells that predisposes people to bacterial and fungal infections. Approximately 40% of patients with CGD have gastrointestinal involvement. We aimed to characterize the endoscopic features of gastrointestinal CGD and define the role of endoscopy in patients.

Methods: We created a database of all patients with CGD seen at the National Institutes of Health from 1990 through 2010. We identified patients who had an endoscopy, and collected information from those with CGD-associated inflammatory bowel disease. We analyzed clinical data (demographic information and symptoms), endoscopic data (indication, preparation quality, degree of inflammation, mucosal findings, and complications), and pathologic data.

Results: A total of 211 endoscopies (96 esophagogastroduodenoscopies, 82 colonoscopies, and 33 flexible sigmoidoscopies) were performed at the National Institutes of Health on 78 patients with CGD. Esophageal, gastric, and duodenal inflammation were detected in 21%, 74%, and 37% of patients, respectively. Esophageal dysmotility and structural abnormalities were noted in 26%. Of the patients who had colonic CGD-inflammatory bowel disease, 74% had skip lesions and 93% had anorectal disease. Enteric fistulae were found in 18% of patients; 73% of these were perianal. Colonic strictures were observed in 24% of patients; 80% were in the anorectal area.

Conclusions: Based on an analysis of clinical and endoscopic data from 78 patients, CGD-inflammatory bowel disease is a distinct entity, primarily involving the anus and rectum, with skip lesions in the remaining bowel. Bowel strictures and fistulae are present in a significant number of patients. Upper gastrointestinal tract inflammatory disease is common, although typically not as severe as colonic disease. Upper and lower endoscopies are important in characterizing the gastrointestinal features of CGD.
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http://dx.doi.org/10.1016/j.cgh.2015.10.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5553864PMC
March 2016

Simultaneous Host-Pathogen Transcriptome Analysis during Granulibacter bethesdensis Infection of Neutrophils from Healthy Subjects and Patients with Chronic Granulomatous Disease.

Infect Immun 2015 Nov 17;83(11):4277-92. Epub 2015 Aug 17.

Laboratory of Host Defenses, NIAID, NIH, Bethesda, Maryland, USA

Polymorphonuclear leukocytes (PMN) from patients with chronic granulomatous disease (CGD) fail to produce microbicidal concentrations of reactive oxygen species (ROS) due to mutations in NOX2. Patients with CGD suffer from severe, life-threatening infections and inflammatory complications. Granulibacter bethesdensis is an emerging Gram-negative pathogen in CGD that resists killing by PMN of CGD patients (CGD PMN) and inhibits PMN apoptosis through unknown mechanisms. Microarray analysis was used to study mRNA expression in PMN from healthy subjects (normal PMN) and CGD PMN during incubation with G. bethesdensis and, simultaneously, in G. bethesdensis with normal and CGD PMN. We detected upregulation of antiapoptotic genes (e.g., XIAP and GADD45B) and downregulation of proapoptotic genes (e.g., CASP8 and APAF1) in infected PMN. Transcript and protein levels of inflammation- and immunity-related genes were also altered. Upon interaction with PMN, G. bethesdensis altered the expression of ROS resistance genes in the presence of normal but not CGD PMN. Levels of bacterial stress response genes, including the ClpB gene, increased during phagocytosis by both normal and CGD PMN demonstrating responses to oxygen-independent PMN antimicrobial systems. Antisense knockdown demonstrated that ClpB is dispensable for extracellular growth but is essential for bacterial resistance to both normal and CGD PMN. Metabolic adaptation of Granulibacter growth in PMN included the upregulation of pyruvate dehydrogenase. Pharmacological inhibition of pyruvate dehydrogenase by triphenylbismuthdichloride was lethal to Granulibacter. This study expands knowledge of microbial pathogenesis of Granulibacter in cells from permissive (CGD) and nonpermissive (normal) hosts and identifies potentially druggable microbial factors, such as pyruvate dehydrogenase and ClpB, to help combat this antibiotic-resistant pathogen.
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http://dx.doi.org/10.1128/IAI.00778-15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4598409PMC
November 2015

Common severe infections in chronic granulomatous disease.

Clin Infect Dis 2015 Apr 23;60(8):1176-83. Epub 2014 Dec 23.

Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda.

Background: Chronic granulomatous disease (CGD) is due to defective nicotinamide adenine dinucleotide phosphate oxidase activity and characterized by recurrent infections with a limited spectrum of bacteria and fungi as well as inflammatory complications. To understand the impact of common severe infections in CGD, we examined the records of 268 patients followed at a single center over 4 decades.

Methods: All patients had confirmed diagnoses of CGD, and genotype was determined where possible. Medical records were excerpted into a standard format. Microbiologic analyses were restricted to Staphylococcus, Burkholderia, Serratia, Nocardia, and Aspergillus.

Results: Aspergillus incidence was estimated at 2.6 cases per 100 patient-years; Burkholderia, 1.06 per 100 patient-years; Nocardia, 0.81 per 100 patient-years; Serratia, 0.98 per 100 patient-years, and severe Staphylococcus infection, 1.44 per 100 patient-years. Lung infection occurred in 87% of patients, whereas liver abscess occurred in 32%. Aspergillus incidence was 55% in the lower superoxide-producing quartiles (quartiles 1 and 2) but only 41% in the higher quartiles (rate ratio, <0.0001). Aspergillus and Serratia were somewhat more common in lower superoxide producing gp91phox deficiency. The median age at death has increased from 15.53 years before 1990 to 28.12 years in the last decade. Fungal infection carried a higher risk of mortality than bacterial infection and was the most common cause of death (55%). Gastrointestinal complications were not associated with either infection or mortality.

Conclusions: Fungal infections remain a major determinant of survival in CGD. X-linked patients generally had more severe disease, and this was generally in those with lower residual superoxide production. Survival in CGD has increased over the years, but infections are still major causes of morbidity and mortality.
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http://dx.doi.org/10.1093/cid/ciu1154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4400412PMC
April 2015

An AAVS1-targeted minigene platform for correction of iPSCs from all five types of chronic granulomatous disease.

Mol Ther 2015 Jan 7;23(1):147-57. Epub 2014 Oct 7.

Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA.

There are five genetic forms of chronic granulomatous disease (CGD), resulting from mutations in any of five subunits of phagocyte oxidase, an enzyme complex in neutrophils, monocytes, and macrophages that produces microbicidal reactive oxygen species. We generated induced pluripotent stem cells (iPSCs) from peripheral blood CD34(+) hematopoietic stem cells of patients with each of five CGD genotypes. We used zinc finger nuclease (ZFN) targeting the AAVS1 safe harbor site together with CGD genotype-specific minigene plasmids with flanking AAVS1 sequence to target correction of iPSC representing each form of CGD. We achieved targeted insertion with constitutive expression of desired oxidase subunit in 70-80% of selected iPSC clones. Neutrophils and macrophages differentiated from corrected CGD iPSCs demonstrated restored oxidase activity and antimicrobial function against CGD bacterial pathogens Staphylococcus aureus and Granulibacter bethesdensis. Using a standard platform that combines iPSC generation from peripheral blood CD34(+) cells and ZFN mediated AAVS1 safe harbor minigene targeting, we demonstrate efficient generation of genetically corrected iPSCs using an identical approach for all five genetic forms of CGD. This safe harbor minigene targeting platform is broadly applicable to a wide range of inherited single gene metabolic disorders.
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http://dx.doi.org/10.1038/mt.2014.195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4426805PMC
January 2015

Assessment of atherosclerosis in chronic granulomatous disease.

Circulation 2014 Dec 19;130(23):2031-9. Epub 2014 Sep 19.

From the Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center (C.T.S., A.Z., A.C.K., E.B.T., D.A.B.), Laboratory of Host Defenses (T.E., P.B.S., A.K.R.S., H.L.M., K.A.Z., J.I.G.), Biostatistics Research Branch (C.-Y.H.), and Laboratory of Clinical Infectious Diseases (S.M.H.), National Institute of Allergy and Infectious Diseases and National Heart, Lung, and Blood Institute (A.T.R.), National Institutes of Health, Bethesda, MD.

Background: Patients with chronic granulomatous disease (CGD) experience immunodeficiency because of defects in the phagocyte NADPH oxidase and the concomitant reduction in reactive oxygen intermediates. This may result in a reduction in atherosclerotic injury.

Methods And Results: We prospectively assessed the prevalence of cardiovascular risk factors, biomarkers of inflammation and neutrophil activation, and the presence of magnetic resonance imaging and computed tomography quantified subclinical atherosclerosis in the carotid and coronary arteries of 41 patients with CGD and 25 healthy controls in the same age range. Univariable and multivariable associations among risk factors, inflammatory markers, and atherosclerosis burden were assessed. Patients with CGD had significant elevations in traditional risk factors and inflammatory markers compared with control subjects, including hypertension, high-sensitivity C-reactive protein, oxidized low-density lipoprotein, and low high-density lipoprotein. Despite this, patients with CGD had a 22% lower internal carotid artery wall volume compared with control subjects (361.3±76.4 mm(3) versus 463.5±104.7 mm(3); P<0.001). This difference was comparable in p47(phox)- and gp91(phox)-deficient subtypes of CGD and independent of risk factors in multivariate regression analysis. In contrast, the prevalence of coronary arterial calcification was similar between patients with CGD and control subjects (14.6%, CGD; 6.3%, controls; P=0.39).

Conclusions: The observation by magnetic resonance imaging and computerized tomography of reduced carotid but not coronary artery atherosclerosis in patients with CGD despite the high prevalence of traditional risk factors raises questions about the role of NADPH oxidase in the pathogenesis of clinically significant atherosclerosis. Additional high-resolution studies in multiple vascular beds are required to address the therapeutic potential of NADPH oxidase inhibition in cardiovascular diseases.

Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT01063309.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.113.006824DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258873PMC
December 2014

Persistence of the bacterial pathogen Granulibacter bethesdensis in chronic granulomatous disease monocytes and macrophages lacking a functional NADPH oxidase.

J Immunol 2013 Sep 16;191(6):3297-307. Epub 2013 Aug 16.

Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA.

Granulibacter bethesdensis is a Gram-negative pathogen in patients with chronic granulomatous disease (CGD), a deficiency in the phagocyte NADPH oxidase. Repeated isolation of genetically identical strains from the same patient over years, and prolonged waxing and waning seropositivity in some subjects, raises the possibility of long-term persistence. G. bethesdensis resists killing by serum, CGD polymorphonuclear leukocytes (PMN), and antimicrobial peptides, indicating resistance to nonoxidative killing mechanisms. Although G. bethesdensis extends the survival of PMN, persistent intracellular bacterial survival might rely on longer-lived macrophages and their precursor monocytes. Therefore, we examined phagocytic killing by primary human monocytes and monocyte-derived macrophages (MDM). Cells from both normal and CGD subjects internalized G. bethesdensis similarly. G. bethesdensis stimulated superoxide production in normal monocytes, but to a lesser degree than in normal PMN. Normal but not CGD monocytes and MDM killed G. bethesdensis and required in vitro treatment with IFN-γ to maintain this killing effect. Although in vitro IFN-γ did not enhance G. bethesdensis killing in CGD monocytes, it restricted growth in proportion to CGD PMN residual superoxide production, providing a potential method to identify patients responsive to IFN-γ therapy. In IFN-γ-treated CGD MDM, G. bethesdensis persisted for the duration of the study (7 d) without decreasing viability of the host cells. These results indicate that G. bethesdensis is highly resistant to oxygen-independent microbicides of myeloid cells, requires an intact NADPH oxidase for clearance, and can persist long-term in CGD mononuclear phagocytes, most likely relating to the persistence of this microorganism in infected CGD patients.
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http://dx.doi.org/10.4049/jimmunol.1300200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3769460PMC
September 2013

Gastrointestinal histopathology in chronic granulomatous disease: a study of 87 patients.

Am J Surg Pathol 2013 Sep;37(9):1365-72

*Laboratory of Pathology, National Cancer Institute, National Institutes of Health †National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases ‡National Institutes of Health, National Cancer Institute §National Institutes of Health, National Institute of Allergy and Infectious Diseases, Bethesda, MD.

Gastrointestinal (GI) involvement in chronic granulomatous disease (CGD), a rare genetic immunodeficiency, mimics other inflammatory bowel diseases. We report GI pathology from 87 CGD patients seen at the NIH Clinical Center, with vague to severe clinical symptoms, in whom biopsies (313) had been evaluated (esophagus [23], stomach [71], small bowel [52] including duodenum [39], ileum [12], and jejunum [1], and colon [167]). Additionally reviewed was GI tissue from 15 autopsies. In our patient cohort, the mean age was 22 years (age range, 3 to 44 y; 2:1 male to female ratio). There were pathologic changes in 83/87 (95%) patients; with colon being the most commonly involved site and esophagus the least. There were microgranulomas in 53/87 (61%), pigmented macrophages in 64/87 (74%), tissue eosinophilia in 31/87 (36%), and chronic and/or acute inflammation in 57/87 (66%) patients. A subset of patients had villous shortening in the duodenum (8/39) and ileum (5/12). We identify microgranulomas in 76/167 (46%) colon, 12/52 (23%) small bowel, and 4/71 (6%) gastric biopsies; pigmented macrophages in 109/167 (65%) colon and 7/52 (13%) small bowel biopsies and 14/15 autopsies; chronic and/or acute inflammation in 97/167 (58%) colon, 13/52 (25%) small bowel, 42/71 (59%) gastric, and 5/23 (22%) esophageal biopsies; tissue eosinophilia in 43/167 (26%) colon, 7/52 (13%) small bowel, and 2/71 (3%) gastric biopsies. Only 4/87 (5%) patients had normal histology. No infectious etiology was identified in the majority of inflammatory lesions. We found that mild to severe GI pathology was common in CGD. In addition, microgranulomas, pigmented macrophages, and eosinophilia are not associated with acute (neutrophilic) inflammation.
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http://dx.doi.org/10.1097/PAS.0b013e318297427dDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3787986PMC
September 2013

B-cell activating factor (BAFF) is elevated in chronic granulomatous disease.

Clin Immunol 2013 Aug 22;148(2):258-64. Epub 2013 May 22.

Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.

Chronic Granulomatous Disease (CGD) is an inherited defect in superoxide production leading to life-threatening infections, granulomas, and, possibly, abnormal immunoglobulin concentrations. We investigated whether factors controlling antibody production, such as B-cell activating factor (BAFF), were altered in CGD. CGD subjects had significantly increased mean (2.3-fold, p < 0.0001) plasma concentrations of BAFF compared to healthy donors. Patients on IFN-γ treatment had significantly higher BAFF concentrations compared with CGD patients not taking IFN-γ (1.6-fold, p < 0.005). Leukocytes from CGD subjects produced normal amounts of BAFF in response to IFN-γ or G-CSF in vitro. Expression of BAFF-R and TACI was significantly reduced on CGD B cells. Elevated BAFF in CGD correlated with CRP (R = 0.44), ESR (R = 0.49), and IgM (R = 0.47) and increased rapidly in healthy subjects following intravenous endotoxin administration. These findings suggest that elevated BAFF in CGD subjects and healthy donors is a consequence of acute and chronic inflammation.
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http://dx.doi.org/10.1016/j.clim.2013.05.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774275PMC
August 2013

Intermediate phenotypes in patients with autosomal dominant hyper-IgE syndrome caused by somatic mosaicism.

J Allergy Clin Immunol 2013 Jun 25;131(6):1586-93. Epub 2013 Apr 25.

Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md., USA.

Background: Autosomal dominant hyper-IgE syndrome (AD-HIES) is caused by mutations in signal transducer and activator of transcription 3 (STAT3). We describe 2 subjects in whom somatic mosaicism was associated with intermediate phenotypes.

Objective: Somatic mosaics might shed light on the pathogenesis of dominant STAT3 mutations and the mechanisms behind the immunologic and nonimmunologic features of the disease.

Methods: Clinical evaluations were conducted. Mutant STAT3 was amplified from different tissues and sequenced, and the percentage of mosaicism in various cell types was calculated. Flow cytometry was performed to determine percentages of IL-17(+) cells, IL-22(+) cells, or both. Suction blisters were induced in 1 subject, and exudate fluid was analyzed for whether emigrating neutrophils were STAT3 mutant or wild-type; neutrophils from peripheral blood were simultaneously examined.

Results: The 2 subjects with STAT3 somatic mosaicism had intermediate phenotypes and were found to have preserved TH17 cell compartments and apparently normal CD8 cells. However, they still had infections, including mucocutaneous candidiasis. The percentage of STAT3 mutant neutrophils migrating into blisters at 16 hours was the same as in peripheral blood, suggesting normal chemotaxis.

Conclusion: STAT3 mosaicism accounts for a milder phenotype and allows for further investigation into the pathogenesis of AD-HIES. Despite having a preserved TH17 cell compartment, both subjects with mosaicism had chronic mucocutaneous candidiasis, suggesting that candidiasis in subjects with AD-HIES is not driven solely by low TH17 cell numbers. The percentage of STAT3 mutant neutrophils emigrating into a suction blister at 16 hours was the same as the percentage in peripheral blood, suggesting that early chemotaxis of STAT3 neutrophils is normal in vivo.
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http://dx.doi.org/10.1016/j.jaci.2013.02.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103905PMC
June 2013

Serologic reactivity to the emerging pathogen Granulibacter bethesdensis.

J Infect Dis 2012 Sep 10;206(6):943-51. Epub 2012 Jul 10.

Laboratory of Clinical Infectious Diseases, Bethesda, MD, USA.

Background: Granulibacter bethesdensis is a recently described member of the Acetobacteraceae family that has been isolated from patients with chronic granulomatous disease (CGD). Its pathogenesis, environmental reservoir(s), and incidence of infection among CGD patients and the general population are unknown.

Methods: Detected antigens were identified by mass spectroscopy after 2-dimensional electrophoresis and immunoaffinity chromatography. The prevalence of Granulibacter immunoreactivity was assessed through immunoblotting and enzyme-linked immunosorbent assay (ELISA).

Results: Methanol dehydrogenase (MDH) and formaldehyde-activating enzyme were recognized during analysis of sera from infected patients. Unique patterns of immunoreactive bands were identified in Granulibacter extracts, compared with extracts of other Acetobacteraceae species. By use of criteria based on these specific bands, specimens from 79 of 175 CGD patients (45.1%) and 23 of 93 healthy donors (24.7%) reacted to all 11 bands. An ELISA that used native MDH to capture and detect immunoglobulin G was developed and revealed high-titer MDH seroreactivity in culture-confirmed cases and 5 additional CGD patients. Testing of samples collected prior to culture-confirmed infection demonstrated instances of recent seroconversion, as well as sustained seropositivity. Infection of CGD mice with G. bethesdensis confirmed acquisition of high-titer antibody-recognizing MDH.

Conclusions: These serologic tests suggest that Granulibacter immunoreactivity is more common among CGD patients and, perhaps, among healthy donors than was previously suspected. This finding raises the possibility that clinical presentations of Granulibacter infection may be underappreciated.
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http://dx.doi.org/10.1093/infdis/jis431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3501152PMC
September 2012

Innate immunity against Granulibacter bethesdensis, an emerging gram-negative bacterial pathogen.

Infect Immun 2012 Mar 19;80(3):975-81. Epub 2011 Dec 19.

Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA.

Acetic acid bacteria were previously considered nonpathogenic in humans. However, over the past decade, five genera of Acetobacteraceae have been isolated from patients with inborn or iatrogenic immunodeficiencies. Here, we describe the first studies of the interactions of the human innate immune system with a member of this bacterial family, Granulibacter bethesdensis, an emerging pathogen in patients with chronic granulomatous disease (CGD). Efficient phagocytosis of G. bethesdensis by normal and CGD polymorphonuclear leukocytes (CGD PMN) required heat-labile serum components (e.g., C3), and binding of C3 and C9 to G. bethesdensis was detected by immunoblotting. However, this organism survived in human serum concentrations of ≥90%, indicating a high degree of serum resistance. Consistent with the clinical host tropism of G. bethesdensis, CGD PMN were unable to kill this organism, while normal PMN, in the presence of serum, reduced the number of CFU by about 50% after a 24-h coculture. This finding, together with the observations that G. bethesdensis was sensitive to H(2)O(2) but resistant to LL-37, a human cationic antimicrobial peptide, suggests an inherent resistance to O(2)-independent killing. Interestingly, 10 to 100 times greater numbers of G. bethesdensis were required to achieve the same level of reactive oxygen species (ROS) production induced by Escherichia coli in normal PMN. In addition to the relative inability of the organism to elicit production of PMN ROS, G. bethesdensis inhibited both constitutive and FAS-induced PMN apoptosis. These properties of reduced PMN activation and resistance to nonoxidative killing mechanisms likely play an important role in G. bethesdensis pathogenesis.
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http://dx.doi.org/10.1128/IAI.05557-11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3294668PMC
March 2012

Brief report: genotype, phenotype, and clinical course in five patients with PAPA syndrome (pyogenic sterile arthritis, pyoderma gangrenosum, and acne).

Arthritis Rheum 2012 Jun 12;64(6):2022-7. Epub 2011 Dec 12.

National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA.

Objective: To describe the genotypes, phenotypes, immunophenotypes, and treatments of PAPA syndrome (pyogenic sterile arthritis, pyoderma gangrenosum, and acne), a rare autoinflammatory disease, in 5 patients.

Methods: Clinical information was gathered from medical records and through interviews with 5 patients from 4 kindreds. PSTPIP1 (CD2BP1) exon 10 and exon 11 sequencing was performed in each patient. Neutrophil granule content and cytokine levels were determined in plasma and stimulated peripheral blood mononuclear cells (PBMCs) from patients and controls.

Results: We identified 2 previously described PAPA syndrome-associated PSTPIP1 mutations, A230T and E250Q, and a novel change, E250K. Disease penetrance was incomplete, with variable expressivity. The cutaneous manifestations included pathergy, cystic acne, and pyoderma gangrenosum. Interleukin-1β (IL-1β) and circulating neutrophil granule enzyme levels were markedly elevated in patients compared to those in controls. PBMC stimulation studies demonstrated impaired production of IL-10 and enhanced production of granulocyte-macrophage colony-stimulating factor. Good resolution of pyoderma gangrenosum was achieved in 3 patients with tumor necrosis factor α (TNFα) blockade treatment.

Conclusion: This analysis of 5 patients demonstrates that mutations in PSTPIP1 are incompletely penetrant and variably expressed in the PAPA syndrome. Neutrophil granule proteins are markedly elevated ex vivo and in the plasma, and elevated levels might be compatible with a diagnosis of PAPA syndrome. TNFα blockade appears to be effective in treating the cutaneous manifestations of PAPA syndrome.
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http://dx.doi.org/10.1002/art.34332DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3737487PMC
June 2012

The NIH Clinical Center and the future of clinical research.

Authors:
John I Gallin

Nat Med 2011 Oct 11;17(10):1221-3. Epub 2011 Oct 11.

Clinical Center, National Institutes of Health, Bethesda, Maryland, USA.

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http://dx.doi.org/10.1038/nm.2466DOI Listing
October 2011

Residual NADPH oxidase and survival in chronic granulomatous disease.

N Engl J Med 2010 Dec;363(27):2600-10

Clinical Services Program, SAIC-Frederick, Frederick, Maryland, USA.

Background: Failure to generate phagocyte-derived superoxide and related reactive oxygen intermediates (ROIs) is the major defect in chronic granulomatous disease, causing recurrent infections and granulomatous complications. Chronic granulomatous disease is caused by missense, nonsense, frameshift, splice, or deletion mutations in the genes for p22(phox), p40(phox), p47(phox), p67(phox) (autosomal chronic granulomatous disease), or gp91(phox) (X-linked chronic granulomatous disease), which result in variable production of neutrophil-derived ROIs. We hypothesized that residual ROI production might be linked to survival in patients with chronic granulomatous disease.

Methods: We assessed the risks of illness and death among 287 patients with chronic granulomatous disease from 244 kindreds. Residual ROI production was measured with the use of superoxide-dependent ferricytochrome c reduction and flow cytometry with dihydrorhodamine oxidation assays. Expression of NADPH oxidase component protein was detected by means of immunoblotting, and the affected genes were sequenced to identify causal mutations.

Results: Survival of patients with chronic granulomatous disease was strongly associated with residual ROI production as a continuous variable, independently of the specific gene affected. Patients with mutations in p47(phox) and most missense mutations in gp91(phox) (with the exception of missense mutations in the nucleotide-binding and heme-binding domains) had more residual ROI production than patients with nonsense, frameshift, splice, or deletion mutations in gp91(phox). After adolescence, mortality curves diverged according to the extent of residual ROI production.

Conclusions: Patients with chronic granulomatous disease and modest residual production of ROI have significantly less severe illness and a greater likelihood of long-term survival than patients with little residual ROI production. The production of residual ROI is predicted by the specific NADPH oxidase mutation, regardless of the specific gene affected, and it is a predictor of survival in patients with chronic granulomatous disease. (Funded by the National Institutes of Health.).
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http://dx.doi.org/10.1056/NEJMoa1007097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3069846PMC
December 2010

Clinical features and outcome of patients with IRAK-4 and MyD88 deficiency.

Medicine (Baltimore) 2010 Nov;89(6):403-425

From Study Center of Primary Immunodeficiencies, Assistance Publique Hôpitaux de Paris (CP); Necker Hospital, Paris, France. Laboratory of Human Genetics of Infectious Diseases (CP, HvB, PG, MC, CLK, L. Abel, AP, JLC), Necker Branch, INSERM U980, Paris, France. Paris Descartes University (CP, HvB, PG, MC, CLK, L. Abel, AP, JLC), Paris, France. Department of Pediatric Pneumology and Immunology (HvB), Charité Hospital-Humboldt University, Berlin, Germany. Prince Naif Center for Immunology Research (PG, SAM, SAH, AAG, JLC), College of Medicine, King Saud University, Riyadh, Saudi Arabia. Division of Infectious Diseases (OL); and Division of Immunology (DM, RSG), Children's Hospital Boston (OL), Boston, Massachusetts. Harvard Medical School (OL, DM, RSG), Boston, Massachusetts. University of Manchester (PDA), Royal Manchester Children's Hospital, Manchester, United Kingdom. Department of Pediatrics (HT, TH), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. Department of Pediatrics (JCK, CBC), Division of Pediatric Infectious Diseases, Vanderbilt University, Nashville, Tennessee. Centre of Chronic Immunodeficiency (SE), University of Freiburg, Freiburg, Germany. Department of Infectious and Pediatric Immunology (LM), Medical and Health Science Center, University of Debrecen, Debrecen, Hungary. Department of Pediatrics (SAM, SAH, AAG), King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. Department of Pediatrics (NKDG), Division of Allergy and Immunology, University of South Florida and All Children's Hospital, St. Petersburg, Florida. Laboratory of Clinical Infectious Diseases (SMH, JIG), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland. University of Oxford and Oxford Radcliffe Hospital (HC), Oxford, United Kingdom. Division of Infectious and Immunological Diseases (DPS), Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada. Department of Immunology (CRG), Dr Negrin University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Spain. Department of Pediatrics (EC), Unit of Infectious Diseases, Insular-Materno-Infantil University Hospital, Las Palmas de Gran Canaria, Spain. Schneider Children's Medical Center (BZG), Petah Tiqva, Israel. Division of Immunology and Allergy (C. Roifman), Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. Department of Neurology (HY), Miyagi Children's Hospital, Sendai, Japan. Department of Pediatrics (SN), National Defense Medical College, Saitama, Japan. Pediatrics, Microbiology and Immunology (JD), SUNY Upstate Medical University, Syracuse, New York. Dalhousie University (ACI), Halifax, Nova Scotia, Canada. Royal Children's Hospital (MT, JS), Parkville, Victoria, Australia. University Children Hospital Ljubljana (SEZ), Ljubljana, Slovenia. Unité transversale d'Allergologie, Néphrologie et Immunologie Clinique (CH), Centre hospitalier universitaire de Tours, Tours, France. Department of Clinical Biochemistry and Immunology (DSK, RD), Addenbrookes Hospital, Cambridge, United Kingdom. Paediatric Immunology and Molecular Immunology Unit (AJT), Institute of Child Health, London, United Kingdom. Department of Clinical Immunology (EGD), Great Ormond St Hospital, London, United Kingdom. Immunology Department (CB), Derriford Hospital,Plymouth, United Kingdom. University Hospital Archet 2 (NS), Nice, France. Lenval Foundation (DDR), Children's Hospital, Nice, France. Cerrahpasa Medical School (YC), Istanbul University, Istanbul, Turkey. Clinical Pathology and Pediatric Department (JV, MG), General Hospital of Santo António, Porto, Portugal. Pediatric Department (ABV), Hospital S. João, Porto, Portugal. Pediatric Department (C. Rodrigo, FA, MM), Germans Trias i Pujol Hospital,Barcelona Autonomous University, Barcelona, Spain. Immunology Department-CDB (JIA), Hospital Clínic-IDIBAPS, Barcelona University, Barcelona, Spain. Pediatric Department (L. Alsina, CF), Hospital Sant Joan de Deu, Barcelona University, Barcelona, Spain. Immunology Department (JR), Universitäts-Kinderspital Zürich, Zürich, Switzerland. Pediatrics and Microbiology and Molecular Genetics (JMV), Medical College of Wisconsin, Milwaukee, Wisconsin. Experimental Laboratory Medicine (XB), Department of Medical Diagnostic Sciences, Biomedical Science Group, Catholic University Leuven, Leuven, Belgium. St. Giles Laboratory of Human Genetics of Infectious Diseases (JLC), Rockefeller Branch, The Rockefeller University, New York, New York. Pediatric Hematology-Immunology Unit (JLC), Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.

Autosomal recessive interleukin-1 receptor-associated kinase (IRAK)-4 and myeloid differentiation factor (MyD)88 deficiencies impair Toll-like receptor (TLR)- and interleukin-1 receptor-mediated immunity. We documented the clinical features and outcome of 48 patients with IRAK-4 deficiency and 12 patients with MyD88 deficiency, from 37 kindreds in 15 countries.The clinical features of IRAK-4 and MyD88 deficiency were indistinguishable. There were no severe viral, parasitic, and fungal diseases, and the range of bacterial infections was narrow. Noninvasive bacterial infections occurred in 52 patients, with a high incidence of infections of the upper respiratory tract and the skin, mostly caused by Pseudomonas aeruginosa and Staphylococcus aureus, respectively. The leading threat was invasive pneumococcal disease, documented in 41 patients (68%) and causing 72 documented invasive infections (52.2%). P. aeruginosa and Staph. aureus documented invasive infections also occurred (16.7% and 16%, respectively, in 13 and 13 patients, respectively). Systemic signs of inflammation were usually weak or delayed. The first invasive infection occurred before the age of 2 years in 53 (88.3%) and in the neonatal period in 19 (32.7%) patients. Multiple or recurrent invasive infections were observed in most survivors (n = 36/50, 72%).Clinical outcome was poor, with 24 deaths, in 10 cases during the first invasive episode and in 16 cases of invasive pneumococcal disease. However, no death and invasive infectious disease were reported in patients after the age of 8 years and 14 years, respectively. Antibiotic prophylaxis (n = 34), antipneumococcal vaccination (n = 31), and/or IgG infusion (n = 19), when instituted, had a beneficial impact on patients until the teenage years, with no seemingly detectable impact thereafter.IRAK-4 and MyD88 deficiencies predispose patients to recurrent life-threatening bacterial diseases, such as invasive pneumococcal disease in particular, in infancy and early childhood, with weak signs of inflammation. Patients and families should be informed of the risk of developing life-threatening infections; empiric antibacterial treatment and immediate medical consultation are strongly recommended in cases of suspected infection or moderate fever. Prophylactic measures in childhood are beneficial, until spontaneous improvement occurs in adolescence.
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http://dx.doi.org/10.1097/MD.0b013e3181fd8ec3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3103888PMC
November 2010