Different clinical phenotypes in common variable immunodeficiency.

Summary: Background. We aimed to describe the clinical heterogeneity (infectious and noninfectious manifestations) and the impact of immunoglobulin replacement therapy on the reduction of infections in patients given a diagnosis of common variable immunodeficiency. Methods. This was a descriptive case series study. Medical charts were retrospectively reviewed based on demographics, clinical presentation, immunoglobulin replacement therapy and laboratory findings at diagnosis. Results. Thirty six common variable immunodeficiency patients were enrolled. Nineteen of them were male (53%). The median age at onset of symptoms was 8 years and at common variable immunodeficiency diagnosis was 19 years. Family history for immunodeficiency was observed in 2 patients (5%). Recurrent infections were present in 35 patients (97%) and they were the first clinical manifestations in 31 patients (86%). Respiratory infections were the most frequent, followed by gastrointestinal infections. Noninfectious manifestations were present in 32 patients (89%), including bronchopulmonary disease, allergy, autoimmunity, lymphoproliferation, gastrointestinal disorders and malignancy. Chronic pulmonary disease and lymphoproliferation were the most common. There was an important reduction of infections 1 year after begining immunoglobulin replacement therapy, mainly pneumonia and sinusitis. Conclusions. Although the diagnosis of common variable immunodeficiency has improved over the last decade, many patients are still being referred and diagnosed late. Physicians must recognize that both infectious and noninfectious manifestations can be the initial signs of common variable immunodeficiency and are very common in these patients. Immunoglobulin replacement therapy significantly reduces respiratory infections.

Diamine oxidase levels in different chronic urticaria phenotypes.

BACKGROUND: Diamine oxidase (DAO) is a polyamine-degrading enzyme also implicated in histamine metabolism. Chronic urticaria (CU) has a wide spectrum of clinical presentations and causes. Anisakis sensitisation associated chronic urticaria (CU+) has been characterised as a phenotype with different clinical and immunological characteristics and possibly associated with previous acute parasitism. We aimed to analyse serum DAO levels in different CU phenotypes. We further analysed the possible association of DAO with fish eating habits. METHODS: We studied 35 CU+ patients and 39 non-sensitised CU patients (CU-) as well as 19 controls. We analysed fish-eating frequency as well as fish intake associated exacerbation of CU (FIAE) or gastro-intestinal complaints (GI). DAO levels were further analysed with respect to lymphoproliferative responses, cytokine and specific IgE production. RESULTS: DAO levels were not different between CU and controls, but were significantly higher in CU+ than in CU-. CU+ patients with FIAE had lower DAO levels, but no differences were detected in patients with GI. DAO levels correlated positively with oily and canned fish consumption in CU-. In CU+, DAO levels correlated positively with specific Anisakis IgE, percentages of proliferation in Anisakis stimulated peripheral blood lymphocytes, serum IL-2 and IL-6, but correlated negatively with mitogen stimulated TGF-ß in supernatants. CONCLUSIONS: DAO levels in CU depend on fish-eating habits and in CU+ on the amount of specific IgE production. In the CU+ phenotype, lower levels of DAO predispose to urticaria exacerbation after fish intake, probably due to a relative insufficient enteric availability of this enzyme.

Positive associations between infections of Toxoplasma gondii and seropositivity with Anisakis simplex in human patients suffering from chronic urticaria.

Toxoplasma gondii is a food-borne and orofecal microorganism which produces chronic infection, and attempts have been made to prove its negative association with atopy in the context of the hygiene hypothesis. Anisakis simplex is a fish parasite associated with chronic urticaria (CU) in endemic regions. We analysed the relationship between both infectious agents in CU. We included 42 patients with chronic urticaria (18 patients with CU associated with A. simplex sensitization and 24 not sensitized CU patients). Patients were assessed for atopy by a skin prick test (SPT) against common aeroallergens and for respiratory symptoms. Anisakis simplex sensitization was assessed by SPT and specific IgE by CAP fluoro-enzyme immunoassay (CAP-FEIA). Anti-T. gondii IgG levels were measured by enzyme-linked immunosorbent assay (ELISA). CU patients were analysed with respect to T. gondii seropositivity, A. simplex sensitization, atopy and immigrant status. The seroprevalence of T. gondii was 40.5% in CU patients and 42.1% in the control group. Immigrants were more frequently infected by T. gondii (41.2% versus 12%; P =0.036). Anti-T. gondii IgG antibodies were associated with past A. simplex parasitism (odds ratio 6.73; P =0.03) and independently with atopic sensitization (odds ratio 5.85; P =0.04). In CU patients, T. gondii has no protective effect on atopic sensitization or A. simplex sensitization.

Specific IgG4: possible role in the pathogenesis and a new marker in the diagnosis of Anisakis-associated allergic disease.

IgG4 and IgE are immunoglobulin isotypes which are mediated by the same Th2-mediated mechanism. The postulated pathogenic and protective function of IgE or IgG4, respectively, in allergic disease is opposite in parasitic infection. The possible role of IgG4 against recombinant major allergens on the appearance of different forms of Anisakis simplex-associated allergic disease was studied. Gastro-allergic anisakiasis (GAA) and Anisakis-sensitization-associated chronic urticaria (CU+) were compared for specific IgE, IgG4 and the respective recognition of Ani s 1 and Ani s 7. Gastro-allergic anisakiasis showed higher IgE and IgG4 levels against crude extract and both recombinant allergens. Whereas IgE recognition of Ani s 7 did not differ and supports both clinical entities to be associated with previous acute parasitism, the IgE recognition rates of Ani s 1 and IgG4 recognition of both Ani s 1 and Ani s 7 were higher in GAA. IgG4 levels were associated with IgE, but also with age, time to last parasitic episode and frequency of fish intake. Logistic regression analysis showed that the presence of specific IgG4 against Ani s 7 was an independent marker associated with GAA. In the diagnosis of Anisakis-associated allergic disease phenotypes (GAA versus CU+), measurement of specific IgG4 against recombinant allergens could be useful. Further, evaluation of specific IgE and IgG4 facilitates more insight into the protective versus pathogenic potential of IgE and IgG4.

The effect of anti-Anisakis simplex antibody levels on C3 and C4 complement components in human sera.

Previously, an in vitro effect was observed on the complement system not only of the excretory-secretory products but also of somatic antigens from L3 Anisakis simplex larvae. In the present work the effect of anti-A. simplex specific antibodies on C3 and C4 levels in human sera was investigated. Up to 309 samples of sera were tested to determine levels of C3 and C4 and anti-A. simplex antibodies, including immunoglobulins IgG, IgM, IgA and IgE. Significant differences were observed between levels of C3 and C4 and all immunoglobulins except for IgE. In the case of immunoglobulins, the probability that an anti-A. simplex positive subject has a C3 deficiency was 3.8 times higher than a subject without specific antibodies. In conclusion, an association between elevated levels of anti-A. simplex antibodies and C3 and C4 deficiency was demonstrated.

Different serum cytokine levels in chronic vs. acute Anisakis simplex sensitization-associated urticaria.

The knowledge on immune mechanisms of chronic urticaria (CU) at the cytokine level is widely scarce. We compared pro- and anti-inflammatory as well as Th1- and Th2-associated serum cytokine levels in two phenotypes of CU: associated with (CU+) and without (CU⁻) sensitization against Anisakis simplex, a ubiquitous fish parasite, that has been associated with acute urticaria in gastro-allergic anisakiasis (GAA) and with CU+. Thirteen CU+ and 19 CU⁻ patients were compared with 13 GAA patients and 15 control subjects for cytokines, measured by cytometric bead array. Urticaria activity score was positively correlated with IL-6 in CU⁻. Serum levels of IL-10 were lower in CU+ and CU⁻ with respect to the control group. Median IFN-γ was lower in all urticaria groups. Patients with previous parasitism by A. simplex displayed higher TGF-ß levels than subjects without previous parasitism. The main finding was lower levels of IL-17 in CU+ with respect to GAA or controls, with a further tendency to even lower levels in CU⁻. Different urticaria phenotypes are associated with distinct serum cytokine levels.

Study of the effect of Anisakis simplex larval products on the early and late components in the classical complement pathway.

In previous studies, we have reported that the larval products (crude extract [CE] and excretory-secretory [ES]) of Anisakis simplex showed a dose-dependent inhibition of the lysis mediated by classical (CP) and alternative pathways (AP) of the human complement system, with the major inhibition on the CP rather than on AP. This inhibition of hemolysis is due to the consumption of complement factors because the assays performed shortening the preincubation period result in a significant decrease of the inhibitory effect on the lysis of the larval products compared with the standard time. Likewise, we found that the larval products reduce the inhibitory percentages in the CP using C3-deficient sera, but not in the AP, which could indicate that other complement components are implicated in the inhibitory effect in the CP. Hence, we have studied the activity of the larval products of A. simplex on individual components in the CP, using different complement-deficient sera. The investigated complement molecules were C1q, C2, C4, C5, C6, C7, C8, and C9. The larval products showed activity at the C2 level but failed to have a significant effect on the other components. Therefore, CE and ES products from A. simplex interact with C3 and C2 complement proteins, which are early components of the complement system, but not with the late complement components.

Follow-up of antibody avidity in BALB/c mice infected with Toxocara canis.

In human Toxocara canis infection, an association has been shown between high IgG avidity in the chronic phase and low IgG avidity in recently acquired toxocarosis. The evolution of the antibody response in terms of avidity has been carried out through a T. canis infection in BALB/c mice. Infection with T. canis embryonated eggs (EE) was carried out with single doses (SD) of 6, 12, 50, 100, 200 or 1000 EE/mouse and with multiple doses (MD) of 200 and 1000 EE. Specific antibodies against T. canis (IgM+G, IgG, IgG1 and IgM) were detected by ELISA and Western Blot (WB) techniques in the presence and absence of urea. With the ELISA method, an increase in the avidity index (AI) of around 50% was detected from days 40-80 p.i. to the end of the study, with all the doses studied. The WB method showed the presence of high avidity antibodies bound to 100 kDa and 75 kDa T. canis proteins in all the cases when the IgM+G and the IgG1 antibodies were investigated. Antibodies of variable avidity were observed in those sera that recognized the group of low molecular weight proteins, between 37 kDa and 25 kDa.

Anisakis simplex and Kudoa sp.: evaluation of specific antibodies in appendectomized patients.

High prevalence and intensity of infection with anisakid larvae has been reported in commercially important fish in Spain. Likewise, Kudoa-infected fish have lately been detected in both fresh and frozen fish. In the present study the possible relation between appendectomy and specific antibodies to these fish parasites was investigated. One hundred and sixty patients were enrolled in this study. They were divided into two groups of eighty patients each and matched for sex and age: Group 1 (appendectomized) and Group 2 (control group). Total immunoglobulins (Ig's), IgG, IgM, IgA and IgE against Anisakis simplex or Kudoa sp. antigens were analysed by ELISA. The mean values of the specific antibodies were lower in the appendectomy group, although significant differences were not observed in the case of IgG, IgA and IgE anti-A. simplex and IgE anti-Kudoa sp. In summary, appendectomy significantly decreased serum specific immunoglobulin levels against these food borne parasite antigens. This decrease was detectable from three months to three years post-appendectomy. It is necessary to study the influence of the surgical removal of other important parts of the GALT on these anti-parasite humoral immune responses.

ADA2 deficiency: case report of a new phenotype and novel mutation in two sisters.

The objective of this paper is to: describe the phenotype compound heterozygote for mutations in CECR1 in two children. We describe the clinical and immunological phenotype, including the assessment of ADA2 activity, cytokine expression, interferon-stimulated and neutrophil-stimulated gene signatures, and the results of CECR1 sequencing. The first patient presented with intermittent fever, cutaneous vasculitis, myalgia and muscle inflammation on MRI leading to a provisional diagnosis of periarteritis nodosa. Subsequently, two cerebral lacunar lesions were identified following a brain stroke. Clinical features improved on anti-tumour necrosis factor therapy. The first patient's sister demonstrated early-onset, long-lasting anaemia with mild biological inflammation; at the ages of 3 and 5 years, she had presented 2 acute, transient neurological events with lacunar lesions on MRI. CECR1 sequencing identified both sisters to be compound heterozygous for a p.Tyr453Cys mutation and a previously undescribed deletion of exon 7. ADA2 activity was reduced by 50%. Neutrophil-stimulated genes were not overexpressed, but interferon-stimulated genes were. The expression of a panel of other cytokine transcripts was not significantly altered. In conclusion, searching for CECR1 mutation or assessing ADA2 activity should be considered in patients with an atypical presentation of inflammatory disease.

Specific IgE induced by Kudoa sp. (Myxosporea: Multivalvulida) antigens in BALB/c mice.

The majority of Kudoa species infect the somatic muscle of fish establishing cysts. As there is no effective method to detect infected fish without destroying them, these parasited fish reach the consumer. We have developed this work to determine whether this parasite contains antigenic compounds capable of provoking an immune response in laboratory animals, in order to consider the possible immunopathological effects in man by the ingestion of Kudoa infected fish. BALB/c mice were injected by the subcutaneous route with the following extracts suspended in aluminium hydroxide: Group 1 (black Kudoa sp. pseudocyst extract), group 2 (white Kudoa sp. pseudocyst extract). Specific IgE levels were measured by ELISA. IgE detected in both groups 1 and 2 showed the possible allergenic nature of some of the components of the parasitic extracts.

[Ocular complications after treatment with intravenous cidofovir for cytomegalovirus retinitis]. / Complicaciones oculares por cidofovir intravenoso en el tratamiento de las retinitis por citomegalovirus.

PURPOSE: To describe the ocular changes observed in six patients treated with intravenous cidofovir for cytomegalovirus retinitis. METHODS: We have studied six patients (12 eyes) treated with intravenous cidofovir. A complete ophthalmologic examination was performed before and after each dose during the follow-up period, paying special attention to intraocular pressure changes. RESULTS: Three cases of non-granulomatous anterior uveitis with good response to conventional treatment were detected. The intraocular pressure decreased after the administration of the two first doses of the drug (p<0.01), and was followed by stabilization of the intraocular pressure with the next doses. In two of the eyes (16.7%), the decrease in the intraocular pressure was more than 50% in comparison to the measurements at the onset of treatment. In three eyes (18.7%), we detected acute anterior uveitis, which responded well to conventional treatment. CONCLUSIONS: The intravenous administration of cidofovir for the treatment of cytomegalovirus retinitis is associated with important ocular changes that must be carefully observed in the follow-up of these patients.

Ani s 1 and Ani s 7 recombinant allergens are able to differentiate distinct Anisakis simplex-associated allergic clinical disorders.

Diagnosis in gastro-allergic anisakiasis (GAA) is straightforward, when clinical history is combined with further allergological evaluation of specific IgE by means of skin prick test and serum specific IgE. In Anisakis simplex sensitisation associated chronic urticaria (CU+), clinical evaluation of possible previous parasitism is difficult, and positive serum specific IgE could be due to cross-reactivity or other unknown factors. In this study, we evaluated the association between IgE seropositivity to the recombinant allergens Ani s 1 and Ani s 7 and several A. simplex-associated allergic disorders. Twenty-eight patients with GAA and 40 patients with CU+ were studied and their IgE responses were compared with a control group composed of patients with chronic urticaria not sensitized to A. simplex (CU-) according to the skin prick test, as well as a group of 15 healthy subjects not referring urticaria or currently A. simplex associated symptoms. 82.1% of GAA patients and 42.5% of CU+ patients were positive for Ani s 1 (P < 0.001), while the Ani s 7 allergen was recognized by 92.9 and 92.5% of sera from patients with GAA and CU+, respectively. The combined positivity obtained for both allergens reached 100% in GAA, and 95% in CU+. IgE determinations to Ani s 1 and Ani s 7 allergens are useful to diagnose the Anisakis infections and to differentiate among several A. simplex-associated allergic disorders. The IgE responses to Ani s 1 are mainly associated with GAA, while this molecule cannot be considered a major allergen in CU+ patients.

Diagnosing human anisakiasis: recombinant Ani s 1 and Ani s 7 allergens versus the UniCAP 100 fluorescence enzyme immunoassay.

Commercially available serological methods for serodiagnosis of human anisakiasis either are poorly specific or do not include some of the most relevant Anisakis allergens. The use of selected recombinant allergens may improve serodiagnosis. To compare the diagnostic and clinical values of enzyme-linked immunosorbent assay (ELISA) methods based on Ani s 1 and Ani s 7 recombinant allergens and of the UniCAP 100 fluorescence enzyme immunoassay (CAP FEIA) system, we tested sera from 495 allergic and 25 non-food-related allergic patients. The decay in specific IgE antibodies in serum was also investigated in 15 positive patients over a period of 6 to 38 months. Considering sera that tested positive by either Ani s 1 or Ani s 7 ELISA, the CAP FEIA classified 25% of sera as falsely positive, mainly in the group of patients with the lowest levels of anti-Anisakis IgE antibodies, and 1.28% of positive sera as falsely negative. Considering allergens individually, the overall sensitivities of Ani s 7 ELISA and Ani s 1 ELISA were 94% and 61%, respectively. The results also showed that anti-Anisakis IgE antibodies can be detected in serum for longer with Ani s 1 ELISA than with Ani s 7 ELISA and CAP FEIA (P < 0.01). Our findings suggest that ELISA methods with Ani s 7 and Ani s 1 allergens as targets of IgE antibodies are currently the best option for serodiagnosis of human anisakiasis, combining specificity and sensitivity. The different persistence of anti-Ani s 1 and anti-Ani s 7 antibodies in serum may help clinicians to distinguish between recent and old Anisakis infections.

Seroprevalence of anti-Gymnorhynchus gigas (Trypanorhyncha, Gymnorhynchidae) antibodies in a Spanish population.

The somatic products released from ingested larvae of Gymnorhynchus gigas parasitizing fish induce a Th2 response capable of causing allergic disorders. The objective of the present work was to evaluate the prevalence of anti-Gymnorhynchus gigas antibodies in a Spanish population and established a possible relationship with fish consumption habits. We studied 305 residents in Madrid, with neither clinical symptoms suggestive of gastrointestinal or allergic disorders, nor pathologies related to ingestion of fish that could cause disease. Specific antibody levels were measured by ELISA: 11.8%, 20%, 15.7%, 21%, and 7.5% of the total studied sera were IgA, Ig's, IgG, IgM, and IgE positive, respectively. Seropositivity was not more prevalent among fresh fish consumers and did not increase with frequency of fish consumption. IgE values were lower in the group that never ingested smoked fish. Anti-G. gigas antibody levels were higher in the group that reported frequent consumption of marinated fish. The use of cooking methods with the least heating efficacy (frying, or frying in batter, and microwaving) did not affect seropositivity percentages among consumers. Infection with live plerocercoids is not necessary for seropositivity, and the antibody production, in this case, is due to the absorption of antigens from the parasite following the digestion process. The human health risks of allergic reactions due to parasite antigens remain active after freezing the fish.

Differential effect of appendectomy and tonsillectomy on anti-Kudoa sp. antibodies in patients with MALTectomy.

We found an association between tonsillectomized patients and subsequent appendicitis. We also observed that MALTectomy significantly decreased secretory IgA levels in serum of patients, being this decrease more pronounced when both operations (tonsillectomy and appendectomy) had been performed. The elevated humoral responses detected previously by us in BALB/c mice immunized with Kudoa sp. pseudocyst extracts and the high IgG1 and IgE levels induced by the oral administration of Kudoa sp. pseudocysts to BALB/c mice showed the possible immunopathological effects in man from the ingestion of Kudoa sp. infected fish. We use the ELISA method to investigate the possible relationship between MALTectomy (tonsillectomy and appendectomy) and specific antibody levels to Kudoa sp. Both anti-Kudoa sp. specific antibody levels and the number of patients that recognized Kudoa sp. antigens were greater in tonsillectomy patients when compared to the control and the other studied groups (appendectomized and appendectomized+tonsillectomies patients). Tonsillectomy was associated to a switch in the class of immunoglobulins involved in these responses and these responses may be abrogated by appendectomy. Tonsils and appendix may respond in different ways to Kudoa sp. antigens and these different reactions may be involved in some immunopathological reactions.