Single Gene defects,

Immune Dysregulation, Infections,

Autoimmunity – and more

APSR, 15th Congress, Manado, 2019

Hans D. Ochs
University of Washington, Department of Pediatrics, and
Seattle Children’s Research Institute, Seattle, Washington
 Immune deficiency syndromes
• Cognate Immune deficiencies
Defects in T and B cells
infections, autoimmunity/dysregulation
• Innate Immune deficiencies
Defects in neutrophils, complement
Toll-like receptor signaling,
regulatory T cells,
infections, autoimmunity/dysregulation
Mechanisms of Immune Tolerance

Central

Peripheral
Thymic T Cell Maturation

95%
APECED (APS-1)
(Autoimmune PolyEndocrinopathy Candidiasis Ectodermal Dysplasia)

• Autoimmune Parathyroid Disease (Ca++ problems)

may affect tooth enamel & nails (ED)
• Adrenal Insufficiency
• Mucocutaneous Candidiasis
• Gonadal Failure
• May also have Diabetes, Thyroiditis, etc.

Caused by defects in:

AIRE-1 Transcription factor
Mechanisms of Immune Tolerance

Central

Peripheral
 Scurfy Mouse
Wild type Scurfy
• X-linked recessive inheritance
• Lethality at 21-25 days
• Wasting syndrome
• Exfoliative dermatitis
• Small, thickened ears
Wild type Scurfy
• Hepatosplenomegaly
• Lymphadenopathy
• Lymphocytic infiltrates
• Elevated cytokines (GM-CSF,
IL-2, -4, -5,-6,-7,-10, IFN-γ, TNFα)
Immune dysregulation Polyendocrinopathy
Enteropathy X- linked

Clinical syndrome described by Powell et al (1982).

Thymic T Cell Maturation
 IPEX Syndrome
(IPEX)
• Early onset enteropathy
– watery diarrhea
– villus atrophy
• Early onset Type I DM
• Thyroiditis
• Eczema

Pancreas (low) Pancreas (high) Pancreas (insulin) Bowel Striated Muscle

IPEX Clinical Features
IPEX (%)
Enteropathy 98
Villous Atrophy 53
Failure to thrive 65
Food Allergies 33
Endocrinopathy 69
Diabetes Mellitus 55
Thyroid disease 33
Skin manifestations 91
Eczema 87
Alopecia 13
Other manifestations 73
Hematologic 48
Nephropathy 29
Hepatitis 16
Neurologic 24
Pulmonary 11
 FOXP3 for the Development of TREG Cells

IPEX Normal
FOXP3

CD25
 FOXP3 Mutations in IPEX

Symbol Mutation Type Number

R337Q
Point 27 5/88 (5.7%)
Deletion (inframe) 2
Deletion (frameshift) 8 250delK A384T
251delE 11/88 (12.5%)
Splice site 15
Complex 1
Identified in Seattle
Identified elsewhere
10/88 (11.4%)
IPEX-Like
 IPEX Genotyping
David Hagin – Fellow
Cohort: 400+ patients Eric Allenspach – Fellow
Clinical phenotype suggestive of IPEX Gesmar Segundo – Fellow
Sarah Baxter - Resident
Stephanie Anover-Sombke
IPEX: FOXP3 – 84 patients Mary Hackett

Troy Torgerson, Hans Ochs

Eleonora Gambineri
IPEX-like: CD25 UW – CMG
STAT5b Debbie Nickerson
Mike Bamshad
STAT1-GOF
STAT3-GOF
CTLA4 Haploinsufficiency
34% of
LRBA patients in
TTC37 IPEX-like
TTC7A cohort
RAG1/2
DOCK8
MYO5B
Signaling From IL-2
 IL-10 Receptor Defects

1. Severe, early onset (< 1y/o), fistulating

enterocolitis, poorly responsive to a
variety of therapies. No other
autoimmune diseases

2. Early onset Folliculitis

3. Some infections: pneumonia, otitis

media, and renal abscess caused by E.
Coli
(IL-10 deficiency causes similar symptoms)
 IL-10 Receptor Deficiency
Normal IL10RA def
X X
X

IL-10
IL-23
No Stim
pSTAT3

IL10 Receptor Deficiency

• Mutations identified in both IL10R1 (2 patients) and IL10R2 (2
patients)
• Bone marrow transplantation effective
• Other immunosuppressants ineffective
IL10 Deficiency
• 2 unrelated patients with a similar clinical phenotype but lacking
mutations in IL10R1 or IL10R2
• Bone marrow transplantation effective
 Defective apoptosis – ALPS
Lymphadenopathy, splenomegaly
Autoimmunity, Lymphoma
Multiple autoantibodies
IL-10, sFASL, B12 are elevated
Mutations in FAS, FAS-ligand;
Caspase-8,10;
can be AD, AR or somatic mutations
 Autoimmune LymphoProlifrative Syndrome
Lymph Node

Strauss SE et al. Ann. Int. Med. 130:591-601 (1999)

Genotypic Overlap with Other PIDs

Leaky/
Variant SCID

RAG1/2
CD25 TTC7A
STAT5B DOCK8 IPEX
FOXP3 IPEX-Like
LRBA
STAT1-GOF
STAT3-GOF
hCTLA4

CVID ALPS
 Lab
Mary Hackett
Stacey Rylaarsdam
Nick Hubbard
Sarah Wagner
Lam-Ha Dang
Larissa Rogge

Visiting Scientists: Paulina Ferrada

Rodrigo Carrasco, David Hagan,
Sandro Perazzio, Gesmar Secundo
Dawn Mary Hong Yen
 Diagnosis

Red= AD gain-of–function; CMC

Green=AD partial STAT1 deficiency; MSMD
Brown = AR complete STAT1 deficiency, intracellular infections
Blue = AR partial STAT1 deficiency, mild intracellular infections

STAT1 sequencing revealed a heterozygous missense mutation (866A>G,

p.Y289C) within the coiled-coil domain in both the index patient and his
mother. This is presumed to be a hypermorphic (gain-of-function) protein.
His unaffected brother had wildtype STAT1.

Figure Reference: Boisson-Dupuis S, Kong XF, Okada S, Cypowyj S, Puel A, Abel L, Casanova JL. Inborn errors of human STAT1: allelic heterogeneity governs the diversity of
immunological and infectious phenotypes. Curr Opin Immunol. 2012 Aug;24(4):364-78. PMID: 22651901.
Persistent STAT1 phosphorylation
In IPEX-like STAT1-GOF patients
STAT1 Dimer bound to DNA
STAT1 Gain-of-Function Mutations in
IPEX-Like Syndrome
 IPEX IPEX-like with STAT1 gain of
function mutation
(normal # or Tregs)
FOXP3

CD25
 CD25 Deficiency: clinical phenotype

• 2 patients reported to date, early onset of:

• Hepatosplenomegaly, lymphadenopathy
• Lymphocytic infiltrates in multiple organs
e.g. gut, liver
• eczema
• Autoantibodies
• Infections (CMV, thrush)
• Failure to reject allogeneic skin graft
 STAT5b Deficiency

• Few patients described:

• Dwarfism - Normal growth hormone level
- Very low plasma IGF-1 & IGFBP-3
- Elevated plasma Prolactin
• Prominent forehead, saddle nose
• Immune deficiency: T cell defect – viral infections
Interstitial lung disease
• Low NK cell numbers, low gamma/delta T cells
• Autoimmunity
• - Early onset diarrhea
- Eczema
• Splenomegaly
 Single Gene defects, Autoimmunity
and more

Pediatric Forum, Shenzhen, 2017

Hans D. Ochs
University of Washington, Department of Pediatrics,
and Seattle Children’s Research Institute, Seattle,
Washington
 Single Gene defects, Autoimmunity
and more

Summer School. Moscow, 2018

Hans D. Ochs
University of Washington, Department of Pediatrics,
and Seattle Children’s Research Institute, Seattle,
Washington
 Ig Replacement -Therapy
• IVIG: 400 mg/kg/month
– 100 mg/kg/week
– Infusions every 2 – 4 weeks
• SCIG: 100 mg/kg/week
• and/or
• Prophylactic antibiotics
– Bronchiectasis
– Chronic sinusitis
• Immunosuppression
– Autoimmune disorders (colitis)
 Single Gene defects,
Immune Dysregulation, Autoimmunity
and more

Children’s Research Institute USF,

Department of Pediatrics,Nov/26, 2018

Hans D. Ochs
University of Washington, Department of Pediatrics, and
Seattle Children’s Research Institute, Seattle, Washington
Acquisition of FOXP3+ Regulatory T cells
Post-HCT in IPEX
 IPEX vs. IPEX-Like patients – Clinical

IPEX (%) IPEX-like

(n=55) IPEX-подобные (%)(n=55) P-value
Enteropathy 100 98.2
Villous Atrophy 52.7 35.7
Failure to thrive 65.4 69.6
Food Allergies 32.7 3.6 <.001
Endocrinopathy 69.1 58.9
Diabetes Mellitus 54.5 28.6 0.01

Thyroid disease 32.7 41.1

Skin manifestations 90.7 75 0.03
Eczema 87.3 66.1 <.01
Alopecia 12.7 19.6
Other manifestations 72.7 66.1
Hematologic 47.3 33.9
Nephropathy 29.1 17.9
Hepatitis 16.4 16.1
Neurologic 23.6 21.4
Pulmonary 10.9 16.1

Enteropathy, Endocrine, & Skin

63.6 44.6 0.045
 Regulatory T Cells (Treg)
Direct Suppression Bystander Suppression
- CTLA4, etc. - IL-10, TGFβ, etc.
CD25

GITR
CD4 Teff
(-)
CD103
CTLA4 Treg Treg
FOXP3

(-)
Characteristics of Tregs Teff

Mechanisms of Treg Suppression

38
 Bacteriophage testing

Humoral response to Bacteriophage ΦX174 revealed a normal initial B cell

dependent primary response but poor T cell dependent amplification of
both the primary and secondary responses and poor immunoglobulin class-
switching.
Signaling From IL-2 via STAT5
Development of Immune Tolerance

Central

Both
ALPS

Peripheral
ALPS
(Autoimmune Lymphoproliferative Syndrome)

Diagnosis:
• Elevated double negative (CD4-CD8-) T cells (>1%)
• Decreased Fas-mediated lymphocyte apoptosis
 Single Gene defects,
Immune Dysregulation, Autoimmunity
and more

Hem/Onc/Immunol Congress
SOCHI, April 2019

Hans D. Ochs
University of Washington, Department of Pediatrics, and
Seattle Children’s Research Institute, Seattle, Washington
Skin Disease in IPEX

Nieves DS, et al., Arch. Derm. (2004)

McGinnis JL, et al., J. Am. Acad. Derm. (2006)
 IPEX and IPEX-like
“Responders” (Effector T cells) ↑
Tregs↓

Tolerance
Cancer?
Inflammation
Autoimmunity

Tregs ↑
Treg Intrinsic vs. Extrinsic Mechanisms
CD25

GITR
FOXP3 CD4

CD103
CTLA4
FOXP3
CD25 Direct Suppression Bystander Suppression
- CTLA4, etc. - IL-10, TGFβ, etc.
STAT5B
STAT1-GOF
STAT3-GOF Teff
CTLA4 Haploins. (-)
LRBA Treg Treg
TTC37
TTC7A (-)
MYO5B Teff

RAG1/2
Mechanisms of Treg Suppression
DOCK8
 Immunology Referral – Age 3 years
• Relevant family history:
• Mother with chronic mucocutaneous candidiasis (CMC) – Limited immune workup as a
teenager revealed poor T cell response to candida by antigen stimulation.
• 70 yo Maternal Grandmother with recurrent vaginal yeast infections
• 2 year old brother is in good health
• No concerning paternal immunologic history
• No consanguinity

• Unremarkable Physical Exam