Wiskott-Aldrich syndrome

INTRODUCTION

Wiskott-Aldrich syndrome (WAS, MIM #301000) is an X-linked disorder caused by mutations in

the gene that encodes the Wiskott-Aldrich syndrome protein (WASp). The originally described
features of WAS include susceptibility to infections (subsequently associated with adaptive and
innate immune deficiency), microthrombocytopenia, and eczema [1,2]. However, there is a
wide spectrum of disease severity due to WAS gene mutations, ranging from severe phenotype
(classic form) of WAS associated with bacterial and viral infections, severe eczema
autoimmunity, and/or malignancy to a milder form characterized by thrombocytopenia and less
severe or sometimes absent infections and eczema, called X-linked thrombocytopenia (XLT), to
X-linked neutropenia (XLN).

EPIDEMIOLOGY

WAS is a rare syndrome with an estimated incidence of approximately 1:100,000 live births [3].
As an X-linked disorder, it is seen almost exclusively in males. Approximately 50 percent of
patients with WAS gene mutations have the WAS phenotype, and the other half have the X-
linked thrombocytopenia (XLT) phenotype (figure 1 and figure 2). WAS gene mutations causing
X-linked neutropenia (XLN) are very rare, with <12 patients in four families reported to date.

PATHOGENESIS

Wiskott-Aldrich syndrome protein (WASp) is a member of a distinct family of cytoplasmatic

proteins that link signaling pathways to actin cytoskeleton reorganization by activating actin
polymerization mediated by actin-related protein (Arp) 2/3. A small amount of WASp is located
in the nucleus, where it regulates RNA polymerase II-dependent transcription in cells of the
hematolymphoid lineage [4]. The WASp family of proteins is characterized by a C-terminal
domain containing a common actin monomer-binding motif, a verprolin homology domain, a
central acidic region that is capable of binding and activating the Arp-2/3 complex, and an N-
terminal domain containing the pleckstrin homology/enabled VASP homology 1 (PH/EVH1)
domain and the WASP interacting protein (WIP) binding region (figure 1) [5].

WASp is expressed exclusively in the cytoplasm of hematopoietic cells and plays a crucial role in
actin cytoskeleton remodeling [6]. Its absence impacts the formation of the immunologic
synapse, the site of interaction between T cells and antigen-presenting cells such as dendritic
cells [7] that depends upon the generation of so-called lipid rafts, which provide a platform to
recruit crucial molecules to ensure the stability of the immunologic synapse [8]. Thus, T cell
function is defective due to abnormal cytoskeletal reorganization, leading to impaired
migration and adhesion and insufficient interaction with other cells due to abnormal synapse
formation. B cell homeostasis is perturbed due to the abnormalities in T cell function, resulting
in the depletion of circulating mature B cells, splenic marginal zone precursors, and marginal
zone B cells [9,10]. The phenomenon of lymphocyte numbers declining over time is possibly
due to accelerated cell death [11].

Circulating natural killer (NK) cell numbers are normal or increased, but cytotoxicity of WASp-
deficient NK cells is impaired as a result of defective immune synapse formation on the cell
surface, a process requiring WASp [12,13]. Interleukin (IL) 2 can, at least in part, restore
cytotoxicity in NK cells [13] by inducing expression of a functionally related protein, WASp
family verprolin-homologous 2 (WAVE2) [14]. Invariant natural killer T (iNKT) cells are thought
to play an important role in protection against autoimmunity and in cancer
immunosurveillance. iNKT cells are completely absent in patients with WAS and reduced in
patients with X-linked thrombocytopenia (XLT) [15]. In mice, WASp is required for late-stage
thymic iNKT cell development and egress [16].

WASp-deficient humans and mice have regulatory T (Treg) cells that fail to suppress effector
cells in vitro and that are incapable of controlling autoimmunity in several mouse models [17-
20]. While WASp does not seem to be required for the thymic generation of natural Treg cells,
it appears to play a crucial role in peripheral homeostasis of these cells [18]. The suppressive
effect of Tregs on effector T cells requires direct cell-to-cell contact. The failure of WASp-
deficient Tregs to form synapses with effector T cells may explain their decreased function.

WASp-deficient myeloid lineage cells exhibit impaired phagocytosis and chemotaxis [21,22]. In
addition, monocytes, macrophages, and dendritic cells from WASp-deficient patients and mice
demonstrate almost completely abrogated assembly of podosomes (actin-rich structures on the
outer surface of cells) [23,24]; the formation of lamellipodia (sheet-like, actin-containing
extensions) and filopodia (hairlike projects [microspikes] that extend beyond the leading edge
of the lamellipodia) at the migrating edge of macrophages and dendritic cells is defective; and
chemotaxis to specific chemoattractants is impaired [23,25,26]. Defective migration and
homing of several cell lineages may be a significant pathogenic mechanism in WAS.

Thrombocytopenia has been explained by increased clearance, ineffective thrombocytopoiesis

[22], reduced platelet survival due to intrinsic platelet abnormalities, and/or immune-mediated
events [27,28].

Mechanisms for the high incidence of autoimmunity in WAS include inadequate Treg cell
function [17-19], B cell-intrinsic loss of tolerance via positive selection of self-reactive
transitional B cells [29], expansion of autoreactive B cells [30] and production of autoantibodies
[31], impaired Fas-mediated apoptosis of self-reactive lymphocytes [32], and defective
phagocytosis of apoptotic cells resulting in chronic inflammation [33].

Whereas "loss-of-function" mutations in the WAS gene cause either XLT or WAS, unique "gain-
of-function" missense mutations in the guanosine triphosphate hydrolase (GTPase) cell division
control protein 42 homolog (Cdc42)-binding domain of WASp impair the autoinhibitory
conformation of the molecule and lead to increased actin polymerization, resulting in
congenital neutropenia.

GENETICS

Mutations of the WAS gene on the X chromosome (figure 1 and figure 2) are responsible not
only for classic WAS, but also for X-linked thrombocytopenia (XLT) and, in rare instances,
congenital X-linked neutropenia (XLN) [34-37]. Biallelic mutations of the WIPF1 gene on
chromosome 2, which encodes WAS protein (WASp)-interacting protein (WIP), a cytoplasmic
protein required to stabilize WASp, can also cause a WAS phenotype [38,39].

WAS/XLT/XLN have in common mutations in the WAS gene, located on the short arm of the X
chromosome (figure 1). The WAS gene consists of 12 exons spanning approximately 9 kb of
genomic DNA [34] and encodes a 502 amino acid protein, designated WASp. Many
different WAS gene mutations can cause WAS, although several mutational hotspots have been
identified (figure 1). Certain types of mutations at particular locations are more likely to cause
XLT than classic WAS, and mutations in the cell division control protein 42 homolog (Cdc42)-
binding domain (GTPase-binding domain, GBD) result in XLN (figure 2).

The analysis of affected members of 270 unrelated WAS families from three large referral
centers (United States, Italy, Japan) revealed a total of 158 unique WAS gene mutations [40,41].
Most common were missense mutations, followed by splice-site mutations, short deletions,
and nonsense mutations. Insertions, complex mutations, and large deletions were less
frequent. Most deletions and insertions involved fewer than 10 nucleotides, resulting in frame
shift and early termination of transcription. Amino acid substitutions are typically located in
exons 1 to 4.

Splice-site mutations occur predominantly in the downstream half of the WAS gene (introns 6
to 11) (figure 1 and figure 2). Mutations affecting variant splice sites may result in multiple
splicing products, which often include normal amounts of WAS gene cDNA (eg, c.559+5G>A).

Six mutational hotspots, defined as occurring in >2.5 percent of the WAS/XLT population, have
been identified. Three of these hotspots represent point mutations (T45M; R86C/H/L/S; R211X)
within the coding regions, whereas the other three involve splice sites (c.559+5G>A;
c.777+1G>N; c.777+1 to 6 del GTGA) [42]. These six hotspot mutations accounted for 25.6
percent of the entire cohort [40,41].

Spontaneous somatic reversions of the causative mutations restore WASp expression in a

fraction of the lymphocytes in up to 10 percent of patients with WAS. Somatic reversions and
mosaicism observed in patients with classic WAS usually affect natural killer (NK) cells and
differentiated T cell subsets, most often CD8+ T cells, but do not seem to influence the clinical
phenotype [43-45]. Thus, the clinical benefit observed in association with reversion and
expansion of reverted lymphocytes is minimal at best [46,47].

CLINICAL PHENOTYPES

Mutations in the WAS gene result in variable clinical phenotypes that correlate with the type of
mutation and its effect on WAS protein (WASp) expression [40,41]. Affected patients are
categorized into three major groups: classic WAS, X-linked thrombocytopenia (XLT), and X-
linked neutropenia (XLN) (table 1).

While there is a considerable phenotype/genotype correlation, there are exceptions, making it

difficult in individual cases to accurately predict the clinical course based solely on the type of
mutations of the WAS gene. The most consistent phenotype/genotype correlation is observed
when patients are divided into two categories: WASp+ for patients whose mutated,
nonfunctional protein is expressed, although often in reduced quantities and of normal size,
and WASp- for patients whose mutated protein is absent or truncated [40,41]. Patients with
mutations that allow the expression of normal-sized mutated protein develop the XLT
phenotype, with few exceptions (figure 2). In contrast, patients with lymphocytes that do not
express WASp or express only truncated WASp are more likely to have the classic WAS
phenotype (figure 1).

A WAS disease severity scoring system (table 1) facilitates the clinical categorization of patients
and may be useful in predicting disease severity and outcome of hematopoietic cell
transplantation (HCT) [48]. The clinical phenotype of the disease evolves over time and is often
incomplete in boys younger than two years of age. Thus, WAS scores should not be used to
predict disease severity in infancy.

A score of 1 or 2 defines patients with XLT, a score of 3 to 4 identifies patients with classic WAS,
and a score of 5 is reserved for patients with either XLT or WAS who develop autoimmunity
and/or malignancies. A modified scoring system also assigns a score of 5 to patients with severe
refractory thrombocytopenia since these patients are at increased risk for hemorrhage with
associated morbidity and mortality [49]. However, progression of the disease can occur at a
later age. Thus, some patients originally diagnosed with XLT (score of 1 to 2) may develop
autoimmunity or cancer later in life (score of 5) [50].

The WAS score reflects the severity of the clinical phenotype without taking into account the
type of mutation or whether WASp is expressed. However, most patients with missense
mutations in exon 1, 2, and 3 of the WAS gene express mutated, nonfunctional WASp, often in
decreased amounts, and tend to have a milder disease phenotype (figure 1 and figure 2)
[40,41,50].

X-linked neutropenia — XLN is one of several distinct phenotypes presenting as severe,

congenital neutropenia. Patients with XLN suffer from infections characteristic for neutropenia
but may also develop infections associated with lymphocyte dysfunction [36,51-53]. These
patients are also at increased risk for myelodysplasia. Severe congenital neutropenia is
discussed in greater detail separately.

X-linked thrombocytopenia — This less severe variant of WAS presents as congenital

thrombocytopenia [35] that is sometimes intermittent (IXLT) [54-56]. Eczema, if present, is
mild. These patients generally have a benign disease course, compared with classic WAS, and
good long-term survival, although they still carry an increased risk (lower than that for WAS) for
severe events such as life-threatening infections (especially postsplenectomy), serious
hemorrhage, autoimmune complications, and cancer [50]. XLT must be differentiated from
immune thrombocytopenia (ITP), which does not have an increased risk of malignancies. Any
male with thrombocytopenia and small platelets should be evaluated for WASp expression
and WAS gene mutations.

Classic (severe) Wiskott-Aldrich syndrome — The phenotype originally described by Wiskott is

often referred to as classic WAS [1]. Affected boys present in early childhood with a
hemorrhagic diathesis due to thrombocytopenia; recurrent bacterial, viral, and fungal
infections; and extensive eczema. Lymphadenopathy is frequently present, especially in those
WAS patients with chronic eczema, and hepatosplenomegaly is common. In contrast, adenoid
tissue on lateral neck radiographs is often absent [57]. Patients with classic WAS tend to
develop autoimmune disorders and lymphoma or other malignancies, often leading to early
death [58].

There are a few case reports of females with the WAS phenotype due to either a
heterozygous WAS mutation with skewed X-chromosome inactivation [59-62] or a homozygous
nonsense mutation in WIPF1 that encodes WASp-interacting protein (WIP), a protein that
stabilizes WASp [38,39].

Specific clinical manifestations

Bleeding — Thrombocytopenia is present at birth, and almost 90 percent of patients have

manifestations of thrombocytopenia at the time of diagnosis. Affected patients may present in
the first days of life with petechiae and/or prolonged bleeding from the umbilical stump or
after circumcision. Other manifestations may include purpura, hematemesis, melena, epistaxis,
hematuria, and such life-threatening symptoms as oral, gastrointestinal, and intracranial
bleeding. A subset of infants ≤2 years of age may present with "severe refractory
thrombocytopenia," possibly due to antiplatelet autoantibody, a complication that is associated
with poor prognosis [49].

Immunodeficiency — The severity of the immunodeficiency in patients with WAS depends

largely upon the mutation and its effect on protein expression [40,41]. Patients with severe
WAS phenotype may have recurrent infections in early infancy, but, in most patients with WAS,
the frequency of infections increases with age.

Patients are particularly susceptible to such organisms as Streptococcus pneumoniae, Neisseria

meningitidis, and Haemophilus influenzae. Manifestations include otitis media, sinusitis,
pneumonia, meningitis, sepsis, and colitis. Splenectomy, which is occasionally performed to
decrease the risk of bleeding, further increases the risk of severe infections and sepsis [63].

Opportunistic infections with Pneumocystis jirovecii, Molluscum contagiosum, as well as

systemic varicella and cytomegalovirus infection, are also common. Fungal infections are
relatively rare (10 percent), consisting primarily of mucocutaneous infection due to Candida
albicans [58].

Eczema — Eczema of varying severity, often with superinfection, develops in approximately

one-half of WAS patients during the first year of life and resembles classical atopic dermatitis
(picture 1) [48,64].

Autoimmune manifestations — Autoimmune diseases have been reported in 26 to 70 percent

of WAS patients [58,65,66] and include hemolytic anemia, neutropenia, vasculitis involving both
small and large vessels, inflammatory bowel disease, and renal diseases. A broad spectrum of
autoantibodies has been observed both in classic WAS and in XLT [31], supporting the
hypothesis that altered B cell tolerance leads to positive selection of self-reactive transitional B
cells [29].

Malignancies — Malignancies can occur during childhood but are most frequently observed in
adolescent and young adult males with the classic WAS phenotype [41,58]. B cell lymphoma
(often Epstein-Barr virus positive) and leukemia are common in classic WAS but do occur,
although less frequently, in XLT [50].

Laboratory findings

Immunology — Abnormal immunologic findings in patients with WAS include [22,58,67]:

●Decreased number and function of T cells

●Abnormal immunoglobulin isotypes, notably low to normal immunoglobulin G (IgG)

and immunoglobulin M (IgM) and high immunoglobulin A (IgA) and immunoglobulin E
(IgE)

●Defective antibody responses to some vaccine antigens

●Normal to increased natural killer (NK) cell numbers, but reduced cytotoxicity [12,13]

●Decreased function of regulatory T (Treg) cells [17,18]

●Impaired chemotaxis of phagocytic cells [22]

Absolute lymphocyte counts are usually normal during infancy, but T and B cell numbers
decrease later in life in patients with classic WAS [22]. Decreased lymphocyte proliferation in
response to mitogens occurs in approximately 50 percent of patients. Delayed-type
hypersensitivity skin testing is abnormal in 90 percent of affected individuals [58]. In vitro
proliferation of T cells to specific antigens is also reduced.

Morphologically, WAS lymphocytes are relatively devoid of microvillus projections (picture 2)

[68]. Upon in vitro activation with an anti-CD3 antibody, patient lymphocytes proliferate poorly
and fail to undergo normal cytoskeleton rearrangements, producing very long filopodial
projections instead [69]. This reduced lymphocyte proliferation to anti-CD3 antibody has also
been observed in patients with XLN.

Variations in the levels of immunoglobulin have been described, including normal levels of
serum IgG, decreased levels of IgM, and elevated levels of IgA and IgE [70,71]. Consistent
findings in WAS patients are low isohemagglutinin titers, decreased antibody responses to
polysaccharide antigens (eg, unconjugated pneumococcal polysaccharide vaccine) and the T-
dependent neoantigen bacteriophage phi X174, normal antibody responses to diphtheria and
tetanus toxoid, and rapid IgG catabolism [22,72].

The number and phagocytic activity of neutrophils are normal. However, chemotactic
responses are defective [22].

Histopathology — Abnormal findings in lymphoreticular tissue are commonly observed:

●Most patients have varying degrees of T cell zone depletion in lymph nodes and the
spleen, as well as decreased number of follicles and abnormal follicular formation
devoid of marginal zone, and regressive or "burned out" germinal centers [73-75].

●Abnormalities observed in the thymus vary from a small-sized thymus with normal
architecture and corticomedullary differentiation [76] to a completely atrophic thymus
[77].

Thrombocytopenia and platelet abnormalities — Thrombocytopenia associated with small

platelet volume is a consistent finding in patients with WAS gene mutations, except for those
presenting with an XLN phenotype due to missense mutations within the Cdc42-binding domain
[36]. Platelet counts are generally 20,000 to 50,000/mm3 but may drop below 10,000/mm3. The
mean platelet volume is 3.8 to 5.0 femtoliter (fL) compared with 7.1 to 10.5 fL in normal
subjects [22]. Normal platelet size or macrothrombocytopenia has been reported in rare cases
of WAS [78-80]. Patients with a WAS phenotype due to WIP deficiency have thrombocytopenia
with normal platelet volume [38,81].

DIAGNOSIS

The diagnosis of WAS or X-linked thrombocytopenia (XLT) should be considered in any male
patient presenting with petechiae, bruises, and congenital or early-onset thrombocytopenia
associated with small platelet size (table 2). To confirm the diagnosis, a deleterious mutation in
the WAS gene (other than mutations in the cell division control protein 42 homolog (Cdc42)
binding domain that cause X-linked neutropenia [XLN]) is required. Presence of mild or severe
eczema supports the diagnosis. Infections and immunologic abnormalities may be absent, mild,
or severe. Autoimmune diseases and malignancies develop more often in patients with classic
WAS than in those with XLT.

Screening for presence/absence of WAS protein (WASp) can be performed in lymphocytes by

flow cytometry using an anti-WASp antibody [82]. However, this testing may miss patients with
WAS (including classic WAS) who have expression of mutated, nonfunctional, or hypofunctional
WASp. Sequence analysis of the WAS gene with identification of a deleterious mutation is
essential to confirm the diagnosis. A combination of these two methods may aid in estimating
the severity of the disease and long-term outcome [40,41,50].

WASp-interacting protein (WIP) deficiency should be suspected in patients with features of

WAS in whom WASp is absent but WAS sequence and messenger RNA (mRNA) levels are
normal. The diagnosis of WIP deficiency is confirmed by sequencing WIPF1 [38,39,81].

The diagnosis of XLN should be considered in any male patient presenting with severe
congenital neutropenia [36,51-53]. Male infants with this form of severe, congenital
neutropenia have missense mutations in the Cdc42-binding domain (exon 7 to 8).

Wiskott-Aldrich syndrome/X-linked thrombocytopenia in females — A few symptomatic

female patients have been identified who are heterozygous for mutations of the WAS gene.
They presented with either a classic WAS phenotype [59,60] or an XLT phenotype [61,62,83-
85]. In all cases, the symptomatic females were found to have markedly skewed X-chromosome
inactivation in favor of the X chromosome with the WAS gene mutation. The WAS phenotype in
a female may also be caused by WIP deficiency [38,81].

Carrier detection and prenatal diagnosis — Carrier females can be identified with certainty by
mutation analysis if the WASgene mutation is known. Prenatal diagnosis of a male fetus at risk
for WAS or XLT can be performed by DNA analysis with chorionic villi sampling or cultured
amniocytes as the source of genomic DNA [86].

DIFFERENTIAL DIAGNOSIS

Several syndromes presenting with eczema, elevated serum IgE, and susceptibility to infections
may resemble WAS/X-linked thrombocytopenia (XLT) including:

●Omenn syndrome due to hypomorphic mutations in genes associated with severe

combined immunodeficiency (SCID; eg, recombinase-activating genes 1 and 2
[RAG1/2], adenosine deaminase [ADA], interleukin [IL] 7 receptor [IL7R], Artemis, IL-2
receptor gamma [IL-2R-gamma]; RNA component of mitochondrial RNA processing
endoribonuclease [RMRP])

●Immune dysregulation, polyendocrinopathy, X-linked (IPEX) due to mutations in

forkhead box P3 (FOXP3) [87]

●Netherton syndrome due to mutations of serine peptidase inhibitor, Kazal type 5

(SPINK5) [88]
 ●Hyper-IgE syndrome due to heterozygous signal transducer and activator of
transcription 3 (STAT3) mutations [89]

●Dedicator of cytokinesis 8 (DOCK8) deficiency [90]

●Atopic dermatitis

None of these molecularly defined syndromes present with thrombocytopenia (except some
IPEX patients with immune thrombocytopenia [ITP]) or small platelets.

ITP is a frequent misdiagnosis of patients with XLT [91]. The fact that WAS/XLT platelets are
consistently, with few exceptions [78-80], small and ITP platelets are large is useful for
differentiating these two conditions. Automated platelet counting, unfortunately, does not pick
up very small platelets, and the platelet size difference determined by Colter counter is less
impressive than when manual counts using blood smears are performed.

WAS protein (WASp)/XLT belongs to a large group of disorders affecting actin

polymerization/depolymerization, a process that controls actin cytoskeletal remodeling
required for cell motility, synapse formation, and cell-cell interaction [92]. Several of these
actinopathies are associated with thrombocytopenia. Deficiency of WIP, a cytoplasmic protein
that stabilizes WASp, results in a WAS/XLT phenotype with autosomal-recessive inheritance,
including microthrombocytopenia, eczema, and recurrent viral and bacterial infections [39].
Biallelic mutations in the actin-related protein 2/3 complex subunit 1B gene (ARPC1B) are
associated with early-onset bacterial and viral infections reflecting combined
immunodeficiency, skin rashes due to small-vessel vasculitis, and microthrombocytopenia [93];
ARPC1B is a crucial component of the actin-related protein 2/3 complex (ARP2/3), which,
following interaction with WASp, initiates actin polymerization. Biallelic mutations in WDR1, the
gene encoding the actin-interacting-protein 1 (AIP1), which plays an important role in actin
depolymerization, result in combined immunodeficiency, autoinflammation, and
thrombocytopenia with normal-size or large platelets [94].

The neutropenia associated with WAS gene mutations (X-linked neutropenia [XLN]) is
congenital and has to be differentiated from cyclic neutropenia due to elastase, neutrophil
expressed (ELANE, also known as ELA2) mutations; severe congenital neutropenia due to HCLS1
associated protein X-1 (HAX1) mutation (Kostmann disease), ELANE mutations, G6PC3
mutations, or VPSO5 mutations; warts, hypogammaglobulinemia, infections, myelokathexis
(WHIM) syndrome due to mutations in the C-X-C motif chemokine receptor 4 (CXCR4) gene;
Hermansky-Pudlak syndrome due to mutations in AP3B1 [95]; or mutations in the granulocyte
colony-stimulating factor (G-CSF) receptor.

TREATMENT

Treatment of WAS and X-linked thrombocytopenia (XLT) is discussed below. Treatment of X-

linked neutropenia (XLN) is discussed in detail separately.

Conventional treatment and supportive care — Conventional treatment and supportive care
include:

●Prophylactic antibiotics, such as trimethoprim-sulfamethoxazole, to prevent P.

jirovecii pneumonia in infants and children less than three to four years of age with
classic WAS.

●Prophylactic acyclovir in patients with recurrent herpes simplex virus (HSV) infections.

●Platelet transfusions to treat major bleeding episodes, such as acute central nervous
system hemorrhage or gastrointestinal bleeding, or to prevent excessive blood loss
during surgery (platelet transfusions are not recommended as routine prophylaxis or for
minor hemorrhages).
 ●Blood products should be irradiated and tested for cytomegalovirus.

Intravenous immune globulin therapy — Intravenous immune globulin (IVIG) therapy is

indicated in WAS/XLT patients with significant antibody deficiency. The dose is usually higher
than that used for other primary immunodeficiencies due to an increased catabolic rate
observed in WAS patients (eg, 400 to 600 mg/kg every three weeks) [72]. Immune globulin may
also be given subcutaneously. However, this route of administration must be used with caution
in this patient population because of bleeding tendency.

Low-dose IL-2 therapy — Low-dose interleukin (IL) 2 therapy, explored in a phase-I trial
conducted in a cohort of patients with WAS and XLT, achieved a modest increase in platelet
counts and a trend toward higher T, B, and natural killer (NK) cell numbers and increased
regulatory T (Treg) cell percentages [97].

Eltrombopag, an oral thrombopoietin receptor agonist approved for the treatment of immune
thrombocytopenia (ITP), may be useful in preventing bleeding in patients with WAS who are
awaiting hematopoietic cell transplantation (HCT) [98], but it is less effective in raising the
platelet count in these patients than in patients with ITP [99].

Immunosuppressive treatment — Immunosuppressive treatment may be required for

autoimmune manifestations. Autoimmune cytopenias often respond to a monoclonal antibody
targeting the B cell–specific CD20 antigen (rituximab), which is relatively safe for those patients
already being treated with IVIG.

Splenectomy — Elective splenectomy has been advocated in selected patients with WAS/XLT to
reverse the thrombocytopenia and arrest the bleeding tendency by increasing the number of
circulating platelets [63]. Splenectomy markedly increases the risk of septicemia [50] and is not
routinely recommended, especially not for those patients who might undergo HCT. WAS/XLT
patients who undergo splenectomy require lifelong antibiotic prophylaxis.

Hematopoietic cell transplantation — HCT is the only readily available curative treatment, with
excellent results for patients with human leukocyte antigen (HLA)-matched family or unrelated
donors (URDs) or partially matched cord-blood donors [100-108], achieving 100 percent overall
survival in a 2018 report of 34 transplanted patients with WAS/XLT [109]. Outcomes have been
less satisfactory for other donor types, although a retrospective study reports improved survival
for recipients of mismatched-related-donor transplants [105,106]. Haploidentical HCT using
posttransplant cyclophosphamide [110] or T cell alpha beta receptor (TCR-alpha-beta) and
CD19 depletion can achieve sustained engraftment and early immune recovery and has a low
risk of graft-versus-host disease [111,112].

Reduced-intensity conditioning, although associated with a reduction in adverse and chronic

events, is not recommended in patients with WAS, because this approach may result in graft
rejection or lead to mixed chimerism that is often associated with an increased incidence of
autoimmune manifestations [103]. Mixed chimerism affecting the myeloid compartment may
result in persistent thrombocytopenia. Thus, allogeneic HCT from an HLA genotypically identical
sibling, a 9/10 or 10/10 allele-matched URD, or a 4 to 6/6 cord blood is the standard of care for
any patient with WAS who has clinically significant disease (score 3 to 5) or who has absent
WAS protein (WASp) expression. If no such donor is available, a haploidentical donor, usually a
parent, is a viable alternative.

The decision to perform HCT in a patient with XLT is less urgent because these patients have a
more favorable long-term outcome with only supportive treatment [50]. However, HCT is a
reasonable treatment option if an HLA-identical sibling is available. The outcomes of 24 patients
with XLT identified worldwide who have undergone HCT are similar to those of patients with
classic WAS [107]. Of the four posttransplant deaths reported, two were attributed to sepsis
related to pretransplant splenectomy.

Gene therapy — Gene therapy is an alternative, potentially curative therapy under

investigation for WAS. A normal WAS gene copy is introduced into hematopoietic CD34+ stem
cells isolated from a patient with WAS. These manipulated cells are then reinfused into the
same patient after conditioning with submyeloablative doses of busulfan. Long-term follow-up
is necessary to determine if this experimental therapy is safe and will result in long-term cure,
as is the case for HCT.

The first retroviral-based gene therapy trial involved two patients and resulted in sustained
expression of WASp in hematopoietic stem cells, lymphocytes, myeloid cells, and platelets and
functional correction of T, B, and NK cells and monocytes [113]. The condition of both patients
markedly improved, with resolution of hemorrhagic diathesis (although platelets remained
somewhat low), eczema, autoimmunity, and predisposition to severe infection. Eight additional
WAS patients subsequently underwent retroviral-based gene therapy at the same site
(Hannover, Germany). One patient with insufficient gene-treated cells failed to respond and
underwent successful HCT. Seven of the remaining nine successfully corrected patients
developed leukemia (four patients affected with T cell acute lymphoblastic leukemia [T-ALL],
two with T-ALL and secondary acute myeloid leukemia [AML], and one with primary AML). The
dominant clones revealed vector integration at the LM02, MDS1, and MN1 loci [114].

Lentiviral-based gene therapy trials were subsequently initiated, with early reports showing
encouraging results. All three WAS patients receiving autologous gene-corrected hematopoietic
stem cells (using a lentiviral vector under the endogenous promoter) after reduced-intensity
myeloablative conditioning showed WASp expression in myeloid and lymphoid cells and
platelets. They were protected from bleeding, severe infections, and eczema [115]. In a more
recent report, seven patients who underwent this form of gene therapy for WAS were alive at a
median follow-up of 27 months [116]. One patient died from a pre-existing herpes virus
infection that was drug resistant. All surviving patients demonstrated sustained clinical benefit,
with resolved eczema and susceptibility to infections and improved autoimmunity and
manifestations of thrombocytopenia. No evidence of lymphoproliferative disease was seen in
the surviving patients of either of the two clinical trials. One report illustrates the safety and
success of this treatment in a 30-year-old patient with a severe WAS phenotype [117].
Following lentiviral-mediated gene therapy, serum immunoglobulin levels normalized, the B cell
compartment repopulated, B cell subsets were normally distributed, and B cell tolerance was
restored [118,119]. In a follow-up report of eight patients with WAS who underwent lentiviral
gene therapy (median interval of 3.6 years posttreatment), survival was 100 percent; T and B
cell function had normalized; and all patients tolerated discontinuation of immune
globulin replacement therapy [120]. While WASp-positive donor platelet counts remained low
(<100x103), no severe bleeding events occurred post-gene therapy.

PROGNOSIS

Life expectancy of patients with classic WAS not treated with hematopoietic cell transplantation
(HCT) or gene therapy is reduced, with premature death resulting from infections, hemorrhage,
autoimmune disease, and malignancies. Bleeding is the main cause of death [58]. Malignancies
in patients with classic WAS are often fatal. In one study, only 1 of 21 patients who developed a
malignancy was alive more than two years after diagnosis [58].

In contrast, life expectancy of patients with X-linked thrombocytopenia (XLT) is close to that of
the normal male population in a developed country [50], even though event-free survival is
reduced (median 10.2, range 0.1 to 74 years) [50].

SOCIETY GUIDELINE LINKSLinks to society and government-sponsored guidelines from selected

countries and regions around the world are provided separately.

SUMMARY

●Wiskott-Aldrich syndrome (WAS) is defined as an X-linked hereditary disorder associated with

adaptive and innate immune deficiency, microthrombocytopenia, eczema, and an increased
risk of autoimmune disorders and malignancy.
●WAS protein (WASp) is a member of a distinct family of proteins that link signaling pathways
to actin cytoskeleton reorganization. "Loss-of-function" mutations of the WAS gene are
responsible not only for classic WAS, but also for X-linked thrombocytopenia (XLT) (figure
1 and figure 2). More rarely, "gain-of-function" mutations result in congenital X-linked
neutropenia (XLN).

●The phenotype originally described by Wiskott is often referred to as classic WAS. Affected
boys present in early childhood with hemorrhagic diathesis due to thrombocytopenia; recurrent
bacterial, viral, and fungal infections; and extensive eczema. Patients with classic WAS tend to
develop autoimmune disorders and lymphoma or other malignancies, leading to early death.

●XLT is a less severe variant of WAS that presents with congenital thrombocytopenia,
sometimes intermittently, and mild, if any, eczema. The disease course is generally benign,
although these patients still carry an increased risk for severe events such as life-threatening
infections (especially postsplenectomy), serious hemorrhage, autoimmunity, and cancer.

●Patients with XLN (congenital neutropenia) present with infections characteristic for
neutropenia but may also develop infections associated with lymphocyte dysfunction and are at
increased risk for myelodysplasia.

●The diagnosis of WAS/XLT should be considered in any male patient presenting with
petechiae, bruises, and congenital or early-onset thrombocytopenia associated with small
platelet size (table 2). Screening for WASp expression is performed by flow cytometry using an
anti-WASp antibody. However, this testing may miss patients with expression of mutated,
nonfunctional WASp. Sequence analysis of the WAS gene is essential to confirm the diagnosis.

●Conventional treatment and supportive care include the use of prophylactic antimicrobials
and platelet transfusions to stop life-threatening hemorrhages. Intravenous immune
globulin (IVIG) therapy is indicated in patients with significant antibody deficiency.
Immunosuppressive treatment may be required for autoimmune manifestations.
Hematopoietic cell transplantation (HCT) is the only available curative treatment, but gene
therapy is under investigation and is showing promising results.

●Life expectancy of patients with classic WAS is reduced, with premature death resulting from
infections, hemorrhage, autoimmune disease, and malignancies. In contrast, life expectancy of
patients with XLT is near normal.