Severe combined immunodeficiency: Wikis

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Severe Combined Immune Deficiency
Classification and external resources
ICD-10 D81.0-D81.2
ICD-9 279.2
DiseasesDB 11978
eMedicine med/2214
MeSH D016511

Severe combined immunodeficiency (SCID), or Boy in the Bubble Syndrome, (also known as "Alymphocytosis," "Glanzmann–Riniker syndrome," "Severe mixed immunodeficiency syndrome," and "Thymic alymphoplasia"[1]) is a genetic disorder in which both "arms" (B cells and T cells) of the adaptive immune system are crippled, due to a defect in one of several possible genes. SCID is a severe form of heritable immunodeficiency. It is also known as the "bubble boy" disease because its victims are extremely vulnerable to infectious diseases. The most famous case is that of David Vetter.

Chronic diarrhea, ear infections, recurrent Pneumocystis jirovecii pneumonia, and profuse oral candidiasis commonly occur. These babies, if untreated, usually die within 1 year due to severe, recurrent infections. However, treatment options are much improved since David Vetter.

Contents

Prevalence

The most commonly quoted figure for the prevalence of SCID is around 1 in 100,000 births, although this is regarded by some to be an underestimate of the true prevalence[2]; and a figure of about 1 in 65,000 live births has been reported for Australia.[3]

Recent studies indicate that one in every 2,500 children in the Navajo population inherit severe combined immunodeficiency. This condition is a significant cause of illness and death among Navajo children. [4] Ongoing research reveals a similar genetic pattern among the related Apache people.[5]

Types

Type Description
X-linked severe combined immunodeficiency Most cases of SCID are due to mutations in the gene encoding the common gamma chainc), a protein that is shared by the receptors for interleukins IL-2, IL-4, IL-7, IL-9, IL-15 and IL-21. These interleukins and their receptors are involved in the development and differentiation of T and B cells. Because the common gamma chain is shared by many interleukin receptors, mutations that result in a non-functional common gamma chain cause widespread defects in interleukin signalling. The result is a near complete failure of the immune system to develop and function, with low or absent T cells and NK cells and non-functional B cells.
The common gamma chain is encoded by the gene IL-2 receptor gamma, or IL-2Rγ, which is located on the X-chromosome. Therefore, immunodeficiency caused by mutations in IL-2Rγ is known as X-linked severe combined immunodeficiency. The condition is inherited in an X-linked recessive pattern.
Adenosine deaminase deficiency The second most common form of SCID after X-SCID is caused by a defective enzyme, adenosine deaminase (ADA), necessary for the breakdown of purines. Lack of ADA causes accumulation of dATP. This metabolite will inhibit the activity of ribonucleotide reductase, the enzyme that reduces ribonucleotides to generate deoxyribonucleotides. The effectiveness of the immune system depends upon lymphocyte proliferation and hence dNTP synthesis. Without functional ribonucleotide reductase, lymphocyte proliferation is inhibited and the immune system is compromised.
Omenn syndrome The manufacture of immunoglobulins requires recombinase enzymes derived from the recombination activating genes RAG-1 and RAG-2. These enzymes are involved in the first stage of V(D)J recombination, the process by which segments of a B cell or T cell's DNA are rearranged to create a new T cell receptor or B cell receptor (and, in the B cell's case, the template for antibodies).
Certain mutations of the RAG-1 or RAG-2 genes prevent V(D)J recombination, causing SCID.[6]
Bare lymphocyte syndrome MHC class II is not expressed on the cell surface of all antigen presenting cells. Autosomal recessive. The MHC-II gene regulatory proteins are what is altered, not the MHC-II protein itself.
JAK3 Janus kinase-3 (JAK3) is an enzyme that mediates transduction downstream of the γc signal. Mutation of its gene also causes SCID.[7]
Artemis/DCLRE1C Mortan Cowan, MD, director of the Pediatric Bone Marrow Transplant Program at the University of California-San Francisco, noted that although researchers have identified about a dozen genes that cause SCID, the Navajo and Apache population has the most severe form of the disorder. This is due to the lack of a gene designated Artemis. Without the gene, children's bodies are unable to repair DNA or develop disease-fighting cells. [4][5]

Detection

Several US states are performing pilot studies to diagnose SCID in newborns through the use of T-cell recombinant excision circles. Wisconsin and Massachusetts (as of February 1, 2009) screen newborns for SCID.[8][9]

Despite these pilot programs, standard testing for SCID is not currently available in newborns due to the diversity of the genetic defect. Some SCID can be detected by sequencing fetal DNA if a known history of the disease exists. Otherwise, SCID is not diagnosed until about six months of age, usually indicated by recurrent infections. The delay in detection is because newborns carry their mother's antibodies for the first few weeks of life and SCID babies look normal.

Treatment

The most common treatment for SCID is bone marrow transplantation, which has been successful using either a matched related or unrelated donor, or a half-matched donor, who would be either parent. The half-matched type of transplant is called haploidentical and was perfected by Memorial Sloan Kettering Cancer Center in New York and also Duke University Medical Center which currently does the highest number of these transplants of any center in the world. [10] David Vetter, the original "bubble boy", had one of the first transplantations but eventually died because of an unscreened virus, Epstein-Barr (tests were not available at the time), in his newly transplanted bone marrow from his sister. Today, transplants done in the first three months of life have a high success rate. Physicians have also had some success with in utero transplants done before the child is born and also by using cord blood which is rich in stem cells.

More recently gene therapy has been attempted as an alternative to the bone marrow transplant. Transduction of the missing gene to hematopoietic stem cells using viral vectors is being tested in ADA SCID and X-linked SCID. The first gene therapy trials were performed in 1990, with peripheral T cells. In 2000, the first gene therapy "success" resulted in SCID patients with a functional immune system. These trials were stopped when it was discovered that two of ten patients in one trial had developed leukemia resulting from the insertion of the gene-carrying retrovirus near an oncogene. In 2007, four of the ten patients have developed leukemias [11]. Work is now focusing on correcting the gene without triggering an oncogene. No leukemia cases have yet been seen in trials of ADA-SCID, which does not involve the gamma c gene that may be oncogenic when expressed by a retrovirus.

Trial treatments of SCID have been gene therapy's only success; since 1999, gene therapy has restored the immune systems of at least 17 children with two forms (ADA-SCID and X-SCID) of the disorder.

SCID in animals

SCID mice were and still are used in disease, vaccine, and transplant research, especially as animal models for testing the safety of new vaccines or therapeutic agents in people with weakened immune systems.

An animal variation of the disease, an autosomal recessive gene with clinical signs similar to the human condition, also affects the Arabian horse. In horses, the condition remains a fatal disease, as the animal inevitably succumbs to an opportunistic infection within the first four to six months of life.[12] However, carriers, who themselves are not affected by the disease, can be detected with a DNA test. Thus careful breeding practices can avoid the risk of an affected foal being produced.[13]

Another animal with well-characterized SCID pathology is the dog. There are two known forms, an X-linked SCID in Basset Hounds that has similar ontology to X-SCID in humans[14], and an autosomal recessive form seen in one line of Jack Russell Terriers that is similar to SCID in Arabian horses and mice.[15]

References

  1. ^ Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 1-4160-2999-0.  
  2. ^ http://www.cga.ct.gov/2008/rpt/2008-R-0564.htm
  3. ^ Yee A, De Ravin SS, Elliott E, Ziegler JB (2008). "Severe combined immunodeficiency: A national surveillance study". Pediatr Allergy Immunol 19: 080130211941085. doi:10.1111/j.1399-3038.2007.00646.x. PMID 18221464. http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0905-6157&date=2008&volume=&issue=&spage=.  
  4. ^ a b "News From Indian Country - A rare and once-baffling disease forces Navajo parents to cope". http://indiancountrynews.net/index.php?option=com_content&task=view&id=2109&Itemid=1. Retrieved 2008-03-01.  
  5. ^ a b Li L, Moshous D, Zhou Y, et al. (2002). "A founder mutation in Artemis, an SNM1-like protein, causes SCID in Athabascan-speaking Native Americans". J. Immunol. 168 (12): 6323–9. PMID 12055248. http://www.jimmunol.org/cgi/pmidlookup?view=long&pmid=12055248.  
  6. ^ Haq IJ, Steinberg LJ, Hoenig M, et al. (2007). "GvHD-associated cytokine polymorphisms do not associate with Omenn syndrome rather than T-B- SCID in patients with defects in RAG genes". Clin. Immunol. 124 (2): 165–9. doi:10.1016/j.clim.2007.04.013. PMID 17572155. http://linkinghub.elsevier.com/retrieve/pii/S1521-6616(07)01181-3.  
  7. ^ Pesu M, Candotti F, Husa M, Hofmann SR, Notarangelo LD, O'Shea JJ (2005). "Jak3, severe combined immunodeficiency, and a new class of immunosuppressive drugs". Immunol. Rev. 203: 127–42. doi:10.1111/j.0105-2896.2005.00220.x. PMID 15661026. http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0105-2896&date=2005&volume=203&spage=127.  
  8. ^ "Wisconsin First State in Nation to Screen All Newborns for Severe Combined Immune Deficiency (SCID) or "Bubble Boy Disease"". http://www.slh.wisc.edu/news/scid_080402.dot.  
  9. ^ "NEWBORN SCREENING FOR PRIMARY IMMUNODEFICIENCY DISEASE". http://www.cga.ct.gov/2008/rpt/2008-R-0564.htm.  
  10. ^ "Severe Combined Immunodeficiency (SCID): Immunodeficiency Disorders: Merck Manual Professional". http://www.merck.com/mmpe/sec13/ch164/ch164l.html. Retrieved 2008-03-01.  
  11. ^ Press release from the European Society of Gene Therapy
  12. ^ FOAL.org, an organization promoting research into genetic lethal diseases in horse
  13. ^ "The New DNA Test for Severe Combined Immunodeficiency (SCID) in Arabian Horses"
  14. ^ Henthorn PS, Somberg RL, Fimiani VM, Puck JM, Patterson DF, Felsburg PJ (1994). "IL-2R gamma gene microdeletion demonstrates that canine X-linked severe combined immunodeficiency is a homologue of the human disease" (abstract only). Genomics 23 (1): 69–74. doi:10.1006/geno.1994.1460. PMID 7829104. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WG1-45PMSC1-FK&_user=409397&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000019483&_version=1&_urlVersion=0&_userid=409397&md5=30a567571392ace6f5a8bac4114b2fd5.  
  15. ^ Perryman LE (2004). "Molecular pathology of severe combined immunodeficiency in mice, horses, and dogs". Vet. Pathol. 41 (2): 95–100. doi:10.1354/vp.41-2-95. PMID 15017021.  

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