Predominantly antibody deficiencies (PAD) are the most common type of primary immunodeficiency diseases (PID). PAD is a large group of diseases which may vary widely from having a complete absence of B cells and decrease in all immunoglobulins to having deficiency in specific immunoglobulins. Depending on the phenotype, agammaglobulinemia or CVID, patients can present either in infancy or adulthood.The main clinical characteristic of patients with PAD is recurrent bacterial infections, low levels of immunoglobulin (ranging from agammaglobulinemia to hypogammaglobulinemia), and impaired response to vaccines and antigens. Treatment is by intravenous or subcutaneous immunoglobulins and treatment of infections by antibiotics.
It is an X linked disease, first described by Bruton in 1952.
It is caused by the mutation of BTK gene (present on the long arm of X chromosome) which encodes for the protein Bruton tyrosine kinase,which is associated with the maturation and differentiation of the pre B cell.[1]
The disruption of this protein can lead to significant decrease in all antibody isotypes, due to failure of Ig heavy chain rearrangement.[2]
Affected individuals generally present between 3 months to 3 years of age, with almost 90% becoming symptomatic by 5 years of age.[3]
Presence of maternal immunoglobulins provide transient protection, concealing symptoms of the disease and preventing early detection.
Physical examination typically shows absence of lymph nodes.
Patients are susceptible to recurrent infections with encapsulated organisms and enteroviruses, primarily effecting respiratory and gastrointestinal tracts.
Laboratory findings show defect in humoral immunity with absence or negligible amount of IgM, IgG, and IgA, as well as <2% of B cells lymphocytes. Neutropenia can also be seen.[4][1][5]
It is caused by mutation of µ heavy chain (IGHM) on chromosome 14.[7]
This mutation is phenotypically similar to X-linked agammaglobulinemia, but unlike X-linked agammaglobulinemia can also be seen in females, yet there has been a study that provides data showing clinically significant difference between the two.[8]
PIK3R1 gene encodes for the p85α subunit of class IA phosphoinositide 3-kinases (PI3Ks).[15]
Patients present with history of recurrent bacterial infections and positive family history, similar to clinical features seen in X-linked agammaglobulinemia.[16]
Also known as activated phosphoinositide 3-kinase δ syndrome (APDS).
Autosomal dominant gain of function (GOF) mutation of PIK3CD gene, which encodes for P110δ subunit of phosphoinositide 3-kinase (PI3K) and loss of function (LOF) mutation of PIK3R1 gene, which encodes the p85α subunit of PI3K.
Mutations in PIK3CD gene leads to clinical features similar to mutation in PIK3R1 gene.[21]
Patients with mutations of gene for PIK3R1 show characteristics similar to that of patients carrying gain-of-function mutations of PIK3CD gene.
Transmembrane activator and calcium-modulator and cyclophilin ligand interactor (TACI) is a part of tumor necrosis factor family and involved in B cell class switching.
Missense mutation of one allele of TNFRSF13B gene encoding for TACI leads to CVID like immunodeficiency.[28]
Mutation of B-cell activating factor receptor (BAFF-R) prevents maturation of transitional B cell, leading to a CVID type adult onset immunodeficiency.
Incomplete maturation leads to hypogammaglobulinemia, but can in a few cases not manifest to clinical disease, with recurrent infections.
Mannosyl-oligosaccharide glucosidase (MOGS) deficiency causes a congenital disorder of glycosylation type IIb (CDG-IIb), also known as MOGS-CDG.
MOGS deficiency leads to improper processing of immunoglobulins, which shortens their half-life in circulation.
Few studies show that unlike most antibody deficiencies MOGS deficiency does not lead to clinical features of hypogammaglobulinemia like recurrent infections.
This is because cells with MOGS deficiency have altered glycosylation which prevents productive infection of multiple enveloped viruses.[34][35]
Tetratricopeptide Repeat Domain 37 (TTC37) deficency is an autosomal recessive disease causing syndromic diarrhea/tricho-hepato-enteric syndrome (SD/THE) which has a similar immune phenotype to CVID.
TTC37 is involved in aberrant mRNAs decay.
Patient presents in infancy with low IgG and poor antigen-stimulation to vaccine.
Clinical features show infantile onset refractory diarrhea, hair and facial anomalies.[36][37]
Interferon Regulatory Factor 2 Binding Protein 2 (IRF2BP2) mutation leads to impaired differentiation of B cells.
Few studies show that most patients with this mutation are diagnosed with CVID in childhood.
Disease is characterized by recurrent infections,low levels of IgG, IgA and IgM , and decreased number of memory B cells. There is no T cell dysfunction.[38]
CD20 is essential for T cell independent antibody response.
Deficiency of CD20 therefore leads to reduced ability to mount an antibody response.
Patients have increased risk of infections by encapsulated bacteria, hypogammaglobulinemia, due to decrease somatic hypermutation, and normal B cell numbers; but a decrease in number of circulating memory B cells.[41]
Unlike patients with CD19 and CD20 deficiency patients with CD 21 have less sever clinical phenotype, and are able to mount specific antibody response to vaccines but not very well with polysaccharide vaccines.[42]
Treatment is by curative antibiotics to treat recurrent infections.[20]
Patients typically have normal or increased IgM, but lack IgG and IgA.
Immunodeficiency is complicated by autoimmune disorders, gastric illnesses due to impaired IgA production, and recurrent bacterial infections of the upper respiratory system.
Uracil-N glycosylase (UNG) removes uracil in DNA plays a role in suppressing GC-to-AT transition mutations.[57]
UNG removes uracil residues leading to DNA breaks that helps initiate class switching.
UNG deficiency has an autosomal recessive mutation, this leads to an normal or increased serum IgM concentrations with low or absent serum IgG, IgA, and IgE concentrations.
MSH6 plays an important role in induction and repair of DNA double-strand breaks in immunoglobulin isotype switch regions, and is also involved in somatic hypermutation.[61]
Several genetic mutations are associated with SIgAD which suggest its polygenic nature but most commonly it is due to a maturation defect in B cells to produce IgA.[63]
B cells arrested at a stage where they coexpress surface IgM, IgD as well as IgA and donot develop into IgA secreting plasma cells.[64].
Majority of the individuals are asymptomatic, but may present with recurrent respiratory and gastrointestinal infections (mucosal infections), autoimmune diseases, atopy and anaphylaxis to IgA containing products.[62]
IgA levels should be periodically monitored in asymptomatic patients.
There is no specific treatment for selective IgA deficiency. Individuals can be managed based on their symptoms as the presentation varies.
Antibiotics are used to treat bacterial infections in patients with SIgAD.
Prophylactic antibiotics can be used for recurrent infections.
If prophylactic antibiotics fail, a trial of intravenous or subcutaneous immunoglobulin replacement therapy with minimal component of IgA may be tried.
Serum IgA antibodies should always be checked in such patient before administration of IVIG to prevent the risk of anaphylaxis.
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