Rapid molecular diagnostics of severe primary immunodeficiency determined by using targeted next-generation sequencing.

BACKGROUND: Primary immunodeficiency diseases (PIDDs) are inherited disorders of the immune system. The most severe form, severe combined immunodeficiency (SCID), presents with profound deficiencies of T cells, B cells, or both at birth. If not treated promptly, affected patients usually do not live beyond infancy because of infections. Genetic heterogeneity of SCID frequently delays the diagnosis; a specific diagnosis is crucial for life-saving treatment and optimal management. OBJECTIVE: We developed a next-generation sequencing (NGS)-based multigene-targeted panel for SCID and other severe PIDDs requiring rapid therapeutic actions in a clinical laboratory setting. METHODS: The target gene capture/NGS assay provides an average read depth of approximately 1000×. The deep coverage facilitates simultaneous detection of single nucleotide variants and exonic copy number variants in one comprehensive assessment. Exons with insufficient coverage (<20× read depth) or high sequence homology (pseudogenes) are complemented by amplicon-based sequencing with specific primers to ensure 100% coverage of all targeted regions. RESULTS: Analysis of 20 patient samples with low T-cell receptor excision circle numbers on newborn screening or a positive family history or clinical suspicion of SCID or other severe PIDD identified deleterious mutations in 14 of them. Identified pathogenic variants included both single nucleotide variants and exonic copy number variants, such as hemizygous nonsense, frameshift, and missense changes in IL2RG; compound heterozygous changes in ATM, RAG1, and CIITA; homozygous changes in DCLRE1C and IL7R; and a heterozygous nonsense mutation in CHD7. CONCLUSION: High-throughput deep sequencing analysis with complete clinical validation greatly increases the diagnostic yield of severe primary immunodeficiency. Establishing a molecular diagnosis enables early immune reconstitution through prompt therapeutic intervention and guides management for improved long-term quality of life.

Approach to patients with suspected hypersensitivity to local anesthetics.

Adverse reactions to local anesthetics are relatively common, but true IgE-mediated hypersensitivity is extremely rare. Fortunately, the vast majority of adverse reactions occur via nonimmunologic means, but considerable confusion still exists among providers. We conducted a review of the literature to determine if earlier estimates of IgE-mediated allergy are consistent with current reports and whether current management strategies are consistent with these findings. We identified several confounding variables involved in the evaluation, including the roles of preservatives/additives, epinephrine, latex, and inadequate testing procedures. These problems may cause significant diagnostic challenges for clinicians. It is in fact much more likely that there is an alternate diagnosis, and in many cases clinicians can begin the evaluation in the office. When local anesthetic allergy is still suspected, the patient should be referred to an allergist for testing to determine if the suspected culprit drug can be safely used, or, if necessary, identify a suitable alternative.

Management of patients with a history of allergy to beta-lactam antibiotics.

Patients with a history of penicillin allergy pose a treatment dilemma. Unnecessary avoidance of this relatively nontoxic class of drugs exposes the patient to potentially more toxic drugs, increases health care costs, and contributes to the development of antibiotic resistance. Yet for those who truly have allergy or other serious adverse reactions to beta-lactams, the use of alternate drugs is a must. This article reviews current management strategies to determine which patients are good candidates for reintroduction of beta-lactams and which patients should continue avoidance.

Allergic and nonallergic drug reactions.

Allergic drug reactions may be difficult to distinguish from nonallergic reactions. In this article, we review a pragmatic approach to the management of adverse drug reactions on the basis of knowledge of the classification and patterns of these reactions. Algorithms for management of patients with a previous adverse drug reaction who require treatment for the same indication, and the approach to a patient who experiences a drug reaction while on multiple drugs, are presented.

Allergic reactions to Triatoma bites.

BACKGROUND: Triatoma bugs are best known in the medical community as vectors of trypanosomiasis (Chagas disease). However, bites of Triatoma bugs are a cause of local cutaneous reactions and anaphylaxis, mainly in the western and southwestern United States. The reactions typically occur at night during sleep, and the bite may not be recognized. There is continuing public interest in medical complications of bites of these bugs, although the scope of the problem remains undefined. OBJECTIVE: To review the relevant medical literature, identify present knowledge, and determine future research goals for allergy to Triatoma. DATA SOURCES: Computerized databases were used to search the medical literature for articles in the English language on Triatoma bites, allergy and entomology, and Chagas disease. STUDY SELECTION: Almost all identified articles on Triatoma allergy were used. Only selected articles on Triatoma bites and entomology were pertinent to the objectives. Articles on Chagas disease were limited to cases in the United States. RESULTS: Bites of Triatoma bugs have been known to cause anaphylaxis for more than a century. These insects inhabit a large area of the United States, but to date most reports of allergic reactions to their bites have originated in the West and Southwest. The reactions typically occur at night during sleep following a bite on uncovered skin and may be unrecognized. Procalin has been identified as the major salivary allergen of Triatoma protracta and was recently cloned and expressed through recombinant technique. Allergenic reactivity has been demonstrated to salivary gland extracts of 2 species. The extracts of these 2 species have not shown immunologic cross-reactivity. Immunotherapy using a salivary gland extract appeared to be beneficial in a small number of patients; however, no commercial testing or treatment allergen is available. CONCLUSIONS: Triatoma bites appear to be an important cause of anaphylaxis, especially in the western and southwestern United States. Because exposure to these insects often occurs during sleep, the incidence of allergic reactions to them is unclear. An epidemiologic study should be performed to determine the incidence, prevalence, and range of allergic responses to the bites of these insects. The lack of commercial antigen limits diagnostic and treatment capabilities. The development of an allergen under the Orphan Drug Act should be encouraged.