Trasplante de médula ósea haploidéntico en un paciente pediátrico con síndrome de Wiskott-Aldrich. A propósito de un caso / Haploidentical bone marrow transplantation in a pediatric patient with Wiskott-Aldrich syndrome. A case report

El síndrome de Wiskott-Aldrich es un error innato de la inmunidad de herencia ligada al cromosoma X, producido por variantes en el gen que codifica la proteína del síndrome de Wiskott-Aldrich (WASp). Reportamos el caso clínico de un paciente de 18 meses con diagnóstico de Wiskott-Aldrich que no presentaba donante antígeno leucocitario humano (HLA) idéntico y recibió un trasplante de células progenitoras hematopoyéticas (TCPH) con donante familiar haploidéntico. La profilaxis para enfermedad de injerto contra huésped incluyó ciclofosfamida (PT-Cy). El quimerismo del día +30 fue 100 % del donante y la evaluación postrasplante de la expresión de la proteína WAS fue normal. Actualmente, a 32 meses del trasplante, presenta reconstitución hematológica e inmunológica y quimerismo completo sin evidencia de enfermedad injerto contra huésped. El TCPH haploidéntico con PT-Cy se mostró factible y seguro en este caso de síndrome de WiskottAldrich en el que no se disponía de un donante HLA idéntico.

Wiskott-Aldrich syndrome (WAS) is an X-linked genetic disorder caused by mutations in the gene that encodes the Wiskott-Aldrich syndrome protein (WASp). Here, we report the clinical case of an 18-month-old boy diagnosed with Wiskott-Aldrich syndrome, who did not have an HLA-matched related or unrelated donor and was treated successfully with a hematopoietic stem cell transplant (HSCT) from a haploidentical family donor. Graft-versus-host disease (GvHD) prophylaxis included post-transplant cyclophosphamide (PT-Cy). At day +30, the peripheral blood-nucleated cell chimerism was 100% and the WAS protein had a normal expression. Currently, at month 32 post-transplant, the patient has hematological and immune reconstitution and complete donor chimerism without evidence of GvHD. HSCT with PT-Cy was a feasible and safe option for this patient with WAS, in which an HLA matched donor was not available.

Haploidentical bone marrow transplantation in a pediatric patient with Wiskott-Aldrich syndrome. A case report. / Trasplante de médula ósea haploidéntico en un paciente pediátrico con síndrome de Wiskott-Aldrich. A propósito de un caso.

Wiskott-Aldrich syndrome (WAS) is an X-linked genetic disorder caused by mutations in the gene that encodes the Wiskott-Aldrich syndrome protein (WASp). Here, we report the clinical case of an 18-month-old boy diagnosed with Wiskott-Aldrich syndrome, who did not have an HLA-matched related or unrelated donor and was treated successfully with a hematopoietic stem cell transplant (HSCT) from a haploidentical family donor. Graft-versus-host disease (GvHD) prophylaxis included post-transplant cyclophosphamide (PT-Cy). At day +30, the peripheral blood-nucleated cell chimerism was 100% and the WAS protein had a normal expression. Currently, at month 32 post-transplant, the patient has hematological and immune reconstitution and complete donor chimerism without evidence of GvHD. HSCT with PT-Cy was a feasible and safe option for this patient with WAS, in which an HLA matched donor was not available.

El síndrome de Wiskott-Aldrich es un error innato de la inmunidad de herencia ligada al cromosoma X, producido por variantes en el gen que codifica la proteína del síndrome de Wiskott-Aldrich (WASp). Reportamos el caso clínico de un paciente de 18 meses con diagnóstico de Wiskott-Aldrich que no presentaba donante antígeno leucocitario humano (HLA) idéntico y recibió un trasplante de células progenitoras hematopoyéticas (TCPH) con donante familiar haploidéntico. La profilaxis para enfermedad de injerto contra huésped incluyó ciclofosfamida (PT-Cy). El quimerismo del día +30 fue 100 % del donante y la evaluación postrasplante de la expresión de la proteína WAS fue normal. Actualmente, a 32 meses del trasplante, presenta reconstitución hematológica e inmunológica y quimerismo completo sin evidencia de enfermedad injerto contra huésped. El TCPH haploidéntico con PT-Cy se mostró factible y seguro en este caso de síndrome de WiskottAldrich en el que no se disponía de un donante HLA idéntico.

Who's your data? Primary immune deficiency differential diagnosis prediction via machine learning and data mining of the USIDNET registry.

PURPOSE: There are currently more than 480 primary immune deficiency (PID) diseases and about 7000 rare diseases that together afflict around 1 in every 17 humans. Computational aids based on data mining and machine learning might facilitate the diagnostic task by extracting rules from large datasets and making predictions when faced with new problem cases. In a proof-of-concept data mining study, we aimed to predict PID diagnoses using a supervised machine learning algorithm based on classification tree boosting. METHODS: Through a data query at the USIDNET registry we obtained a database of 2396 patients with common diagnoses of PID, including their clinical and laboratory features. We kept 286 features and all 12 diagnoses to include in the model. We used the XGBoost package with parallel tree boosting for the supervised classification model, and SHAP for variable importance interpretation, on Python v3.7. The patient database was split into training and testing subsets, and after boosting through gradient descent, the predictive model provides measures of diagnostic prediction accuracy and individual feature importance. After a baseline performance test, we used the Class Weighting Hyperparameter, or scale_pos_weight to correct for imbalanced classification. RESULTS: The twelve PID diagnoses were CVID (1098 patients), DiGeorge syndrome, Chronic granulomatous disease, Congenital agammaglobulinemia, PID not otherwise classified, Specific antibody deficiency, Complement deficiency, Hyper-IgM, Leukocyte adhesion deficiency, ectodermal dysplasia with immune deficiency, Severe combined immune deficiency, and Wiskott-Aldrich syndrome. For CVID, the model found an accuracy on the train sample of 0.80, with an area under the ROC curve (AUC) of 0.80, and a Gini coefficient of 0.60. In the test subset, accuracy was 0.76, AUC 0.75, and Gini 0.51. The positive feature value to predict CVID was highest for upper respiratory infections, asthma, autoimmunity and hypogammaglobulinemia. Features with the highest negative predictive value were high IgE, growth delay, abscess, lymphopenia, and congenital heart disease. For the rest of the diagnoses, accuracy stayed between 0.75 and 0.99, AUC 0.46-0.87, Gini 0.07-0.75, and LogLoss 0.09-8.55. DISCUSSION: Clinicians should remember to consider the negative predictive features together with the positives. We are calling this a proof-of-concept study to continue with our explorations. A good performance is encouraging, and feature importance might aid feature selection for future endeavors. In the meantime, we can learn from the rules derived by the model and build a user-friendly decision tree to generate differential diagnoses.

[Wiskott-Aldrich syndrome with platelets of normal size and c.295C>T mutation of the WAS gene. Case report]. / Síndrome de Wiskott-Aldrich con plaquetas de tamaño normal y mutación c.295C>T en el gen WAS. Informe de caso.

BACKGROUND: Wiskott-Aldrich syndrome is an Inborn Error of Immunity characterized by thrombocytopenia, small platelets, severe eczema, recurrent infections, tendency to autoimmune diseases and neoplasms. The diagnosis of the syndrome can be difficult, especially when platelets are of normal size. CASE REPORT: A three-year-old male patient was referred to a specialized sector of university hospital for presenting acute otitis media that progressed to sepsis by Haemophilus influenzae. At one month of age, he had been diagnosed with autoimmune thrombocytopenia, and splenectomy was performed at two years of age. During follow-up, three hospitalizations were necessary: an infection by Streptococcus pneumoniae, which progressed to sepsis; one due to exacerbation of eczema, isolating S. epidermidis; another due to fever of undetermined origin. The tests showed normal number of platelets after splenectomy, platelets always with normal size. At age four, tests were performed: IgE 3128 Ku/L; IgA, IgG, and normal anti-polysaccharide antibodies; decreased IgM; decrease CD19, TCD4, naïve T and B; increased TCD8; normal NK. A diagnostic hypothesis of "probable" WAS was made. Genetic research has identified the c.295C>T mutation in the WAS gene. CONCLUSIONS: The case reported expressed a new mutation in the SWA gene, characterized by clinical manifestations of the mild phenotype of Wiskott-Aldrich syndrome, with thrombocytopenia, platelets of normal size, and X-linked inheritance. It is important to establish the early diagnosis and treatment to offer a better quality of life in these patients.

ANTECEDENTES: El síndrome de Wiskott-Aldrich es un error innato de la inmunidad, distinguido por trombocitopenia, plaquetas pequeñas, eccema severo, infecciones recurrentes, y susceptibilidad a enfermedades autoinmunes y neoplasias. El diagnóstico es difícil de establecer, especialmente cuando las plaquetas son de tamaño normal. REPORTE DE CASO: Paciente masculino de 3 años, enviado al Hospital Universitario da Santa Casa de São Paulo, Brasil, por otitis media aguda, con evolución a sepsis por Haemophilus influenzae. Al mes de edad fue diagnosticado con trombocitopenia autoinmune, y a los 2 años se llevó a cabo explenectomía. Durante el seguimiento requirió tres hospitalizaciones: una por infección por Streptococcus pneumoniae, que evolucionó a sepsis; otra por exacerbación de eccema, aislándose S. epidermidis, y la última por fiebre de origen indeterminado. Las pruebas de laboratorio informaron: concentración de plaquetas dentro de los valores de referencia después de la esplenectomía, y de tamaño normal. A los 4 años se efectuaron nuevas pruebas, que reportaron: IgE 3128 kU/L; IgA, IgG y anticuerpos anti-polisacáridos normales; disminución de IgM y de CD19, TCD4, T y B vírgenes; aumento de TCD8; NK normales. Se sospechó el diagnóstico de síndrome de Wiskott-Aldrich. Mediante estudios de genética se identificó la mutación c.295C>T en el gen WAS. CONCLUSIONES: El caso aquí expuesto expresó una nueva mutación en el gen SWA, caracterizado por manifestaciones clínicas de fenotipo leve del síndrome de Wiskott-Aldrich, con trombocitopenia, plaquetas de tamaño normal y herencia ligada al cromosoma X. Es importante establecer el diagnóstico y tratamiento oportunos para ofrecer una mejor calidad de vida en estos pacientes.

Guillain-Barré Syndrome and Hydrocephalus in an infant with Wiskott-Aldrich Syndrome. / Síndrome de Guillain Barré e hidrocefalia en un lactante con Síndrome de Wiskott Aldrich.

INTRODUCTION: Guillain-Barre Syndrome (GBS) is rarely diagnosed in the first year of life. The association of GBS with Wiskott-Aldrich syndrome (WAS) is even less frequent and has been previously reported in only two children to our knowledge. Hydrocephalus is a known but rare complication of GBS. OBJECTIVE: To describe the case of an infant in which GBS, WAS and hydrocephalus appear clinically associated. CLINICAL CASE: A nine-months-old male infant with a history of WAS was admitted to our ICU with acute hypotonia and poor general condition. He developed flaccid paralysis, absent deep tendon reflexes, and respiratory failure. A lumbar puncture showed albuminocytologic dissociation. GBS was suspected and an electromyography was performed, showing a demyelinating polyneuropathy. He was successfully treated with intravenous immunoglobulins. During hospitalization, he presented intermittent bradycardia, so a brain CT scan was performed, showing acute hydrocephalus which was managed through an external ventricular drain achieving favorable response. In the long term, the patient underwent bone marrow transplant and had to be reoperated due to valve-related complications. However, his psychomotor development is normal, with no obvious neurological sequelae. CONCLUSION: We present the third case of GBS in a patient with WAS, which is the first infant younger than one year. Additionally, he presented acute hydrocephalus as a complication of GBS. We suggest considering these three comorbidities since their early diagnosis and prompt management allow bet ter neurological recovery and avoid potentially lethal complications.

[Aortic aneurysm in a patient with Wiskott-Aldrich syndrome]. / Aneurisma aórtico en un paciente con síndrome de Wiskott-Aldrich.

BACKGROUND: The Wiskott-Aldrich syndrome is a combined immunodeficiency associated with a syndrome linked to the X chromosome, which is characterized by eczema, recurrent infections, and thrombocytopenia. Other manifestations include autoimmune disorders such as hemolytic anemia or thrombocytopenic purpura mediated by the immune system, increased susceptibility to malignant tumors, including lymphoma or leukemia. CLINICAL CASE: A 7-year-old male patient with a diagnosis of Wiskott-Aldrich syndrome who was treated with intravenous gamma globulin, antimicrobial prophylaxis with trimethoprim/sulfamethoxazole, and fluconazole, as well as with prednisone and cyclosporine due to hemolytic anemia and uveitis. Suddenly, he presented a deviation of the left labial commissure, so he was hospitalized. The studies showed a giant aneurysm of the aorta root, ascending aorta, descending aorta, and right coronary aorta, with insidious cardiac symptoms; therefore, he was referred to the vascular surgery department. CONCLUSION: Vasculitis in Wiskott-Aldrich syndrome is rare and it is usually asymptomatic in early stages, so an annual cardiovascular evaluation should be performed in order to avoid the complications of an aneurysm, which can be deleterious in this type of immunodeficiency where the possibility of death from bleeding is high.

Antecedentes: El síndrome de Wiskott-Aldrich es una inmunodeficiencia combinada asociada al síndrome ligado al cromosoma X, que se caracteriza por eccema, infecciones de repetición y trombocitopenia. Otras manifestaciones son los trastornos autoinmunes como anemia hemolítica o púrpura trombocitopénica mediada por el sistema inmunológico y susceptibilidad incrementada a tumores malignos, como linfoma o leucemia. Caso clínico: Niño de siete años, con diagnóstico de síndrome de Wiskott-Aldrich, en quien se estableció tratamiento con gammaglobulina intravenosa, profilaxis antimicrobiana con trimetoprima-sulfametoxazol y fluconazol, así como prednisona y ciclosporina debido a anemia hemolítica y uveítis. De forma súbita presentó desviación de la comisura labial izquierda, por lo que fue hospitalizado. Los estudios indicaron aneurisma gigante de la raíz de la aorta, aorta ascendente, descendente y coronaria derecha, con sintomatología cardiaca insidiosa, por lo que fue referido al servicio de cirugía vascular. Conclusiones: La vasculitis en el síndrome de Wiskott Aldrich es poco común y suele ser asintomática en las fases iniciales, por ello debe realizarse evaluación cardiovascular anual para evitar complicaciones propias de un aneurisma, que pueden ser deletéreas en este tipo de inmunodeficiencia, en las cuales existe mayor riesgo de muerte por sangrado.

[Ileitis as presentation of lymphoma in Wiskott-Aldrich syndrome]. / Ileítis como presentación de linfoma en síndrome de Wiskott-Aldrich.

Wiskott-Aldrich syndrome is a rare X chromosome-linked primary immunodeficiency syndrome associated with an increased incidence of infections, autoimmune disorders and neoplasms. We present the case of a 41-year-old man with a diagnosis of Wiskott-Aldrich syndrome with ileitis as a form of presentation of a lymphoproliferative syndrome. The ileitis, in the context of the patient, represents a clinical challenge given the large number of differential diagnoses (inflammatory bowel disease, infections, neoplasms and lymphoproliferative diseases), so it usually requires anatomopathological diagnosis and particular considerations regarding the subsequent specific treatment.

El síndrome de Wiskott-Aldrich (SWA) es un raro síndrome de inmunodeficiencia primaria ligado al cromosoma X que se asocia con aumento de incidencia de infecciones, trastornos autoinmunes y neoplasias. Se presenta el caso de un varón de 41 años con diagnóstico de síndrome de Wiskott-Aldrich y cuadro de ileítis como forma de presentación de un síndrome linfoproliferativo. La ileítis, en el contexto del paciente, representa un problema clínico dado el gran número de diagnósticos diferenciales (enfermedad inflamatoria intestinal, infecciones, neoplasias y enfermedades linfoproliferativas) por lo que suele requerir diagnóstico anatomopatológico y consideraciones particulares respecto al posterior tratamiento específico.

Ileítis como presentación de linfoma en síndrome de Wiskott-Aldrich / Ileitis as presentation of lymphoma in Wiskott-Aldrich syndrome

El síndrome de Wiskott-Aldrich (SWA) es un raro síndrome de inmunodeficiencia primaria ligado al cromosoma X que se asocia con aumento de incidencia de infecciones, trastornos autoinmunes y neoplasias. Se presenta el caso de un varón de 41 años con diagnóstico de síndrome de Wiskott-Aldrich y cuadro de ileítis como forma de presentación de un síndrome linfoproliferativo. La ileítis, en el contexto del paciente, representa un problema clínico dado el gran número de diagnósticos diferenciales (enfermedad inflamatoria intestinal, infecciones, neoplasias y enfermedades linfoproliferativas) por lo que suele requerir diagnóstico anatomopatológico y consideraciones particulares respecto al posterior tratamiento específico.

Wiskott-Aldrich syndrome is a rare X chromosome-linked primary immunodeficiency syndrome associated with an increased incidence of infections, autoimmune disorders and neoplasms. We present the case of a 41-year-old man with a diagnosis of Wiskott-Aldrich syndrome with ileitis as a form of presentation of a lymphoproliferative syndrome. The ileitis, in the context of the patient, represents a clinical challenge given the large number of differential diagnoses (inflammatory bowel disease, infections, neoplasms and lymphoproliferative diseases), so it usually requires anatomopathological diagnosis and particular considerations regarding the subsequent specific treatment.

Síndrome de Guillain Barré e hidrocefalia en un lactante con Síndrome de Wiskott Aldrich / Guillain-Barré Syndrome and Hydrocephalus in an infant with Wiskott-Aldrich Syndrome

Resumen: Introducción: El Síndrome de Guillain-Barré (SGB) es raramente diagnosticado en lactantes menores de 1 año. Su asociación con el Síndrome de Wiskott Aldrich (SWA), es aún menos frecuente, y ha sido previa mente reportada sólo en dos pacientes a nuestro conocimiento. La hidrocefalia, es una complicación conocida, pero infrecuente del SGB. Objetivo: presentar el caso clínico de un lactante en el que se asocian las patologías de SGB, SWA e hidrocefalia. Caso Clínico: varon de 9 meses, portador de SWA hospitalizado en unidad de cuidados intensivos por hipotonía aguda y compromiso del estado gene ral. Evolucionó con parálisis fláccida, falla ventilatoria y arreflexia generalizada. Una punción lumbar mostró disociación albuminocitológica, y el estudio electrofisiológico mostró signos de polineuropatía desmielinizante severa. Se trató con inmunoglobulina, evolucionando en forma satisfactoria. Por bradicardia intermitente, se realizó tomografla axial computada cerebral (TAC), que mostró signos de una hidrocefalia aguda, manejada mediante válvula derivativa ventrículo peritoneal con favorable respuesta. En el largo plazo, se sometió a trasplante de médula ósea y debió ser reintervenido por complicaciones valvulares, sin embargo, su desarrollo psicomotor es normal sin secuelas neurológi cas evidentes hasta los 3 años. Conclusión: Presentamos el tercer caso de SGB en un paciente porta dor de SWA, destacando ser el primero de ellos en un lactante menor de 1 año. Adicionalmente, este niño presentó una hidrocefalia aguda como complicación del SGB. Consideramos relevante tener presente estas comorbilidades, debido a que su pronto diagnóstico y manejo oportuno, permiten una mejor recuperación neurológica y evitan complicaciones potencialmente letales.

Abstract: Introduction: Guillain-Barre Syndrome (GBS) is rarely diagnosed in the first year of life. The association of GBS with Wiskott-Aldrich syndrome (WAS) is even less frequent and has been previously reported in only two children to our knowledge. Hydrocephalus is a known but rare complication of GBS. Objective: To describe the case of an infant in which GBS, WAS and hydrocephalus appear clinically associated. Clinical Case: A nine-months-old male infant with a history of WAS was admitted to our ICU with acute hypotonia and poor general condition. He developed flaccid paralysis, absent deep tendon reflexes, and respiratory failure. A lumbar puncture showed albuminocytologic dissociation. GBS was suspected and an electromyography was performed, showing a demyelinating polyneuropathy. He was successfully treated with intravenous immunoglobulins. During hospitalization, he presented intermittent bradycardia, so a brain CT scan was performed, showing acute hydrocephalus which was managed through an external ventricular drain achieving favorable response. In the long term, the patient underwent bone marrow transplant and had to be reoperated due to valve-related complications. However, his psychomotor development is normal, with no obvious neurological sequelae. Conclusion: We present the third case of GBS in a patient with WAS, which is the first infant younger than one year. Additionally, he presented acute hydrocephalus as a complication of GBS. We suggest considering these three comorbidities since their early diagnosis and prompt management allow bet ter neurological recovery and avoid potentially lethal complications.

Síndrome de Wiskott-Aldrich com plaquetas de volume normal / Wiskott-Aldrich syndrome with normal-sized platelets

A Síndrome de Wiskott-Aldrich (WAS) é uma imunodeficiência congênita ligada ao cromossomo X, caracterizada por mutações no gene WAS, responsável pela proteína WASP. As principais manifestações clínicas são trombocitopenia com plaquetas de volume reduzido, eczema, infecções recorrentes e maior incidência de doenças autoimunes e neoplasias. Relatamos o caso de um paciente do sexo masculino com sintomas clássicos desta síndrome (eczema, trombocitopenia e infecções recorrentes), porém com plaquetas de volume normal. Existem poucos relatos desta síndrome em pacientes com plaquetas de volume normal, o que atrasou o encaminhamento do paciente ao imunologista, o qual foi tratado como portador de Síndrome de Evans e dermatite atópica até os quatro anos de idade. A confirmação diagnóstica foi por teste genético. O diagnóstico precoce possibilita profilaxia com antibioticoterapia e uso de imunoglobulina endovenosa, devido ao risco de infecções graves, e encaminhamento para transplante de células-tronco hematopoiéticas, que até o momento é o único tratamento curativo. A suspeita clínica deve existir em pacientes com trombocitopenia inexplicável, mesmo se as plaquetas tiverem o tamanho normal, associada às outras manifestações da doença.

Wiskott-Aldrich syndrome (WAS) is an X-linked congenital immunodeficiency characterized by mutations in the WAS gene of the WASP protein. The main clinical manifestations are thrombocytopenia with small-sized platelets, eczema, recurrent infections and a higher incidence of autoimmune diseases and cancer. We report the case of a male patient with classical symptoms of this syndrome (eczema, thrombocytopenia and recurrent infections), however presenting platelets with normal size. There are few reports of this syndrome in patients with normal-sized platelets, which delayed our patient's referral to the immunologist. The patient received treatment for Evans syndrome and atopic dermatitis until he was four years old. Confirmation of WAS diagnosis was made by genetic testing. Early diagnosis allows prophylactic treatment with antibiotics and the use of intravenous immunoglobulin due to the risk of serious infections, in addition to referral for hematopoietic stem cell transplantation, which is the only curative treatment available so far. WAS should be suspected when patients develop unexplained thrombocytopenia even with normal-sized platelets, especially in the presence of other manifestations.

Síndrome de Wiskott-Aldrich. Dificultades diagnósticas y terapéutucas de un paciente con inmunodeficiencia primario / Wiskott - Aldrich syndrome. Therapeutic and Diagnosis Difficulties in a patient with primary immunodeficiency

Introducción. Las inmunodeficiencias primarias son un grupo de enfermedades de origen genético que implican altera - ciones asociadas a la respuesta inmunológica. El infra diagnóstico de estas conlleva al retraso de tratamiento, evitables en gran parte; Entre estas existe el síndrome de Wiskott-Aldrich; es un trastorno raro, ligado al cromosoma X, recesivo, que se caracteriza por trom - bocitopenia, eczema e inmunodeficiencia donde su tratamiento curativo es el trasplante de medula ósea. CASO CLÍNICO : Paciente de 10 años, con antecedentes de múltiples hospitalizaciones por procesos infecciosos importantes: neumonías recurrentes, menin - gitis, diarreas, erupción cutánea generalizada y trombocitopenia de hasta 9,000 mm³. Después de múltiples estudios realizados, se confirma el diagnóstico de síndrome de Wiskott -Aldrich por inmunogenetica (mutación del gen WAS) y mediante colaboración médica internacional, se realiza trasplante de médula ósea con posterior resolución de su enfermedad. DISCUSION: Las inmunodeficiencias primarias son patologías más comunes de lo que se creía (prevalencia de hasta 1/1200), la evidencia de aparición y su importancia clínica deben ser tomadas en consideración. En este caso de Síndrome de Wiskot-Aldrich en donde el diagnóstico definitivo es in - munogenetico, (actualmente el país no cuenta), además de tratamiento inmuno-oncológico adecuado, el paciente pudo sobrevivir y mejorar su calidad de vida gracias a soporte investigativo y terapéutico multinacional. Existen colaboraciones multicentricas como el consorcio de tratamiento inmunodeficiencias primarias, que tienen como objetivo colaborar activamente en el diagnóstico y tratamien - to estos casos, salvaguardando la vida de estos pacientes y ayudando a comprender estas enfermedades raras...(AU)

[Wiskott-Aldrich syndrome: Case report]. / Síndrome de Wiskott-Aldrich: Caso clínico.

The Wiskott-Aldrich syndrome is a rare X-linked recessive immunodeficiency, with an estimated incidence of 3.5 to 5.2 cases per million males. It is characterized by immunodeficiency, microthrombocytopenia and eczema. We present a 5-year-old Hispanic male, with a medical history of numerous infectious diseases, compromised health, chronic malnutrition, language delay and failure to thrive. An infrequent mutation in the Wiskott-Aldrich syndrome gene was found.

Disruption of hSWI/SNF complexes in T cells by WAS mutations distinguishes X-linked thrombocytopenia from Wiskott-Aldrich syndrome.

Wiskott-Aldrich syndrome (WAS), an immunodeficiency disorder, and X-linked thrombocytopenia (XLT), a bleeding disorder, both arise from nonsynonymous mutations in WAS, which encodes a hematopoietic-specific WASp. Intriguingly, XLT evolves into WAS in some patients but not in others; yet the biological basis for this cross-phenotype (CP) effect remains unclear. Using human T-helper (TH) cells expressing different disease-causing WAS mutations, we demonstrated that hSWI/SNF-like complexes require nuclear-WASp to execute their chromatin-remodeling activity at promoters of WASp-target, immune function genes during TH1 differentiation. Hot-spot WAS mutations Thr45Met and Arg86Cys, which result in XLT-to-WAS disease progression, impair recruitment of hBRM- but not BRG1-enriched BAF complexes to IFNG and TBX21 promoters. Moreover, promoter enrichment of histone H2A.Z and its catalyzing enzyme EP400 are both impaired. Consequently, activation of Notch signaling, a hBRM-regulated event, and its downstream effector NF-κB are both compromised, along with decreased accessibility of nucleosomal DNA and inefficient transcription-elongation of WASp-target TH1 genes. In contrast, patient mutations Ala236Gly and Arg477Lys that manifest in XLT without progressing to WAS do not disrupt chromatin remodeling or transcriptional reprogramming of TH1 genes. Our study defines an indispensable relationship between nuclear-WASp- and hSWI/SNF-complexes in gene activation and reveals molecular distinctions in TH cells that might contribute to disease severity in the XLT/WAS clinical spectrum.

Síndrome de Wiskott Aldrich. Presentación de un caso / Wiskott Aldrich Syndrome. Presentation of a Case

El síndrome de Wiskott Aldrich es una inmunodeficiencia primaria clasificada dentro del grupo de las bien definidas, se hereda con carácter recesivo ligado al X, el gen mutado codifica para una proteína citoplasmática presente en linfocitos y megacariocitos importante en la regulación de la polimerización de la actina y traducción de señales necesarias para la reorganización del citoesqueleto celular. Las manifestaciones clásicas están dadas por sangramientos, infecciones y eczemas; sus primeros síntomas pueden aparecer al nacimiento con hemorragia petequial, diarreas con sangre; mientras las infecciones y el eczema se desarrollan durante el primer año de edad, la otitis media es la infección que se presenta con mayor frecuencia. Desde el punto de vista inmunológico se caracteriza por tener niveles de inmunoglobulina M bajos, las inmunoglobulinas A y E son elevadas, mientras la inmunoglobulina G puede ser normal a lo que se une trombocitopenia. El diagnóstico de esta enfermedad se realizó en un niño de tres meses de edad, el cual permaneció ingresado por largo tiempo en cuidados intensivos y falleció a los dos años de edad por sepsis generalizada.(AU)

The Wiscott Aldrich Syndrome is a well-defined primary immunodeficiency X- linked recessive disorder, the mutated gene encodes a cytoplasmatic protein in lymphocytes and megakaryocytes which is important in actin polymerization and cytoskeletal reorganization .The classic manifestations involve bleeding, infections and eczema. The first symptoms may appear at birth with petechial hemorrhage, diarrhea with blood, while infections and eczema are present during the first year of age, otitis media is an infection that occurs more frequently. From the immunological point of view it is characterized by low levels immunoglobulin M, immunoglobulin A and E are high, while immunoglobulin G may be normal together with thrombocytopenia. This disorder was diagnosed in a three- year- month infant who was admitted at intensive care unit for a long period of time. The patient died when he was two years old due to generalized infection.(AU)

Estudo de células T regulatórias em camundongos deficientes em WASP / T Cell study regulatory in mice disabled in wasp

A Síndrome de Wiskott-Aldrich (WAS) é uma imunodeficiência associada a infecçõesrecorrentes, câncer e autoimunidade. Ela é causada por mutações no gene que codifica amolécula WASP (“Wiskott-Aldrich syndrome protein”), envolvida na reorganização docitoesqueleto de actina em células de origem hematopoiética. Camundongos deficientes emWasp (WKO) apresentam migração leucocitária e proliferação linfocitária deficientes, edesenvolvem colite. Esse processo inflamatório está associado a eventos deimunodesregulação importantes, como participação exacerbada de células Th2 e diminuiçãode células T regulatórias (Treg) no timo e baço desses animais. Assim, esse trabalho visacaracterizar as células Treg tímicas e avaliar os mecanismos potencialmente relacionados àdiminuição dessas células no timo de camundongos WKO. Nas análises de CD25 e CD122,importantes para a diferenciação de células Treg, observamos uma diminuição na expressãode CD25 na população de células CD4+CD8-Foxp3+, além de uma diminuição no númeropercentual dessa população. As células Treg tímicas de animais WKO apresentaram níveisnormais de CD122 e de moléculas de ativação, mas mostraram uma diminuição na expressãoda molécula funcional CD39, responsável pela hidrólise tecidual de ATP. Saliente-se aindaque estudos sobre a morte celular ex-vivo, a transmigração in vitro mediada por S1P e alocalização intratímica de células Treg não revelaram diferenças significativas na comparaçãoentre animais WKO e seus controles. De forma interessante, precursores tímicos de célulasTreg CD4+CD8-CD25+Foxp3-também se apresentaram diminuídos em WKO, assim como ascélulas Treg Helios...

The Wiskott-Aldrich syndrome (WAS) is an immunodeficiency associated with recurrentinfections, malignancies and autoimmunity. It is caused by mutations in the gene encodingWASP (Wiskott-Aldrich syndrome protein), a molecule involved in the actin cytoskeletonrearrangements in hematopoietic cells. Wasp deficient mice (WKO) show impaired leukocytemigration and lymphocyte proliferation, and also develop colitis. This inflammatory processis associated with important immunodysregulation events, such as exacerbated participationof Th2 cells and decreased numbers of regulatory T cells (Treg) in the thymus and spleen ofthese animals. Thus, this study aims to characterize the thymic Treg cells and evaluate thepotential mechanisms involved in the decreased number of these cells in the thymus of WKOmice. In the analysis of CD25 and CD122, important molecules for the differentiation of Tregcells, we observed a decreased expression of CD25 in the CD4+CD8-Foxp3+ cells, and adecrease in the percentage number of this population. WKO Treg cells showed normal levelsof CD122 and activation molecules, but present a decreased expression of the functionalmarker CD39, molecule responsible for ATP hydrolysis in the tissues. Also, it is important topoint out that studies about ex vivo cell death, S1P-mediated in vitro transmigration andintratymic localization of Treg cells revealed no significant differences between WKOanimals and their controls. Interestingly, both CD4+CD8-CD25+Foxp3- Treg precursors andHelios+ Treg cells are reduced in WKO thymus. More over, we also observed an importantincrease in the basal expression of pSTAT-5 in Treg cells of WKO mice and their precursors.Altogether, our results indicate an important role of Wasp in thymic Treg cell development,and point to the necessity of further studies on the mechanisms involved in the generation ofTreg cells in WKO mice...

Cutaneous manifestations in patients with Wiskott-Aldrich syndrome submitted to haematopoietic stem cell transplantation.

INTRODUCTION: Wiskott-Aldrich syndrome (WAS) is an X-linked primary immunodeficiency caused by a mutation of the WAS protein gene. This protein actively participates in important cellular processes, and its presence is related to diverse clinical manifestations, including cutaneous alterations. The classical triad of WAS consists of recurrent infections, thrombocytopaenia with small platelets and atopic dermatitis (AD)-like lesions. OBJECTIVE: To evaluate the frequencies of cutaneous manifestations in patients with WAS prior to haematopoietic stem cell transplantation (HSCT). RESULTS: Twenty-four boys diagnosed with WAS and treated with HSCT between 1992 and 2007 were included. The characteristic triad of WAS occurred in 46% of patients. Before HSCT, the most frequent cutaneous manifestations included eczema similar to AD (71%), followed by petechiae and/or ecchymosis (58%) and cutaneous infections (17%). CONCLUSIONS: Cutaneous manifestations in patients with WAS are frequent, especially those similar to the eczema found in AD.

Urgent minimal invasive treatment of a dental trauma in a child with Wiskott-Aldrich syndrome.

Wiskott-Aldrich syndrome (WAS) is an X-linked recessive disorder characterized by thrombocytopenia with microplatelets, eczema, recurrent infections, and predisposition to autoimmune disease and malignancy. The aim of this study is to report an urgent minimal invasive treatment of a dental trauma in a pediatric patient with WAS. The conservative management was a success and did not cause any local nor systemic complications.

[Wiskott Aldrich syndrome associated to vasculitis: a therapeutic challenge]. / Síndrome de Wiskott Aldrich asociado con vasculitis: un desafÌo terapéutico.

Wiskott Aldrich syndrome (WAS) is an X-linked primary immunodeficiency, associated with WASP gene mutation that causes severe immunological abnormalities and alterations in platelet function. A seven year old male patient with WASP, began with acute abdominal pain, fever and knee swelling. The diagnosis of septic arthritis was made, and he was treated with broad-spectrum antibiotics and human gammaglobulin. During treatment he presented digestive tract bleeding with hypovolemic shock; after 72 hours palpable purpura in upper and lower extremities appeared. Then Henoch-Schönlein purpura with abdominal vasculitis was suspected, and later confirmed by histopathology. Methylprednisolone pulses were initiated, showing improvement within 24 hours. The patient had a severe inflammatory reaction, caused by a serious infectious disease, but the clinical evolution suggested an autoimmune disease such as Henoch-Schönlein purpura. Up to 20% of patients with WAS have autoimmune manifestations of vasculitis. An early diagnosis of autoimmunity in WAS is important for a favorable clinical outcome.

Síndrome de Wiskott-Aldrich / Wiskott - Aldrich syndrome

Objetivo: Descrever um caso de síndrome de Wiskott-Aldrich, enfatizandoa importância do diagnóstico precoce de uma imunodeficiênciarara, para seu tratamento adequado.Descrição do caso: Criança do sexo masculino, que aos seismeses de idade apresentou eczema em face e pescoço. Três mesesapós, evoluiu com piora, sendo internado com infecção secundária doeczema. Aos dez meses foi novamente internado por otite média comsecreção sanguinolenta, sangramento oral e lesões em pele com sufusõeshemorrágicas. Com um ano foi internado pela terceira vez, devidoà diarreia sanguinolenta, evoluindo com sepse. Exames laboratoriaisevidenciaram plaquetopenia e anemia, além de número reduzido delinfócitos T CD4+ e CD8+. A pesquisa para proteína da síndrome deWiskott-Aldrich foi ausente.Discussão: A Síndrome de Wiskott-Aldrich (WAS) é uma imunodeficiênciarara, ligada ao X, com manifestações clínicas característicasque incluem trombocitopenia com plaquetas pequenas, eczema, infecçõesrecorrentes e incidência aumentada de manifestações autoimunese malignidades. O diagnóstico precoce é muito importante para umtratamento adequado. Até o momento, a única terapia curativa é otransplante de células tronco.

Objective: Describe a case of Wiskott-Aldrich syndrome, emphasizingthe importance of early diagnosis of a rare immunodeficiency, for itsappropriate treatment.Case description: Male child, who at six months of age presentedeczema in face and neck. Three months later, progressed to worse,being admitted with secondary infection of the eczema. At ten monthswas again hospitalized due to otitis media with drainage of blood, oralbleeding and skin lesions with hemorrhagic suffusions. With one yearold was hospitalized for the third time, due to bloody diarrhea, evolvingto sepsis. Laboratory tests showed anemia and thrombocytopenia, andreduced number of CD4 and CD8 T lymphocytes. The search for theWiskott-Aldrich syndrome protein was absent.Discussion: The Wiskott-Aldrich Syndrome (WAS) is a rareimmunodeficiency, X-linked, with clinical features that includethrombocytopenia with small platelets, eczema, recurrent infections andincreased incidence of autoimmune manifestations and malignancies.Early diagnosis is very important for appropriate treatment. So far, theonly curative therapy is the transplantation of stem cells.