Identification of novel compound heterozygous LRBA mutations associated with recurrent hemophagocytic lymphohistiocytosis and CNS manifestations

Publication: LymphoSign Journal
30 March 2023

Abstract

Background: Lipopolysaccharide-responsive beige-like anchor (LRBA) is an intracellular protein that regulates the recycling of cytotoxic T lymphocyte-associated protein 4 (CTLA4), an immune checkpoint molecule which prevents ongoing activation of T cells. Deficiency of LRBA results in increased trafficking and degradation of CTLA4, and consequently, uncontrolled T cell responses. The phenotypic spectrum of LRBA deficiency arising from biallelic loss-of-function typically includes recurrent infections, autoimmunity, lymphoproliferation, chronic diarrhea, hypogammaglobulinemia, and cytopenia.
Aim: To report an atypical presentation of LRBA deficiency arising from a set of compound heterozygous LRBA variants, encompassing recurrent hemophagocytic lymphocytosis (HLH) and neurological manifestations.
Methods: Clinical data was gathered through retrospective chart review. Expanded genetic analysis including whole exome sequencing was performed.
Results: Our patient initially presented at age 15 months with fever, seizures, and encephalopathy. HLH-work-up showed bicytopenia, elevated ferritin and triglyceride, and low fibrinogen, however, he did not yet meet the diagnostic criteria for HLH. MRI brain and EEG at diagnosis was suggestive of acute necrotizing encephalopathy of childhood. He responded to pulsed IV methylprednisolone treatment with minimal residual neurological deficit on follow-up. At 36 months of age, he had a repeat presentation and rapidly deteriorated. He developed severe encephalopathy with fixed dilated pupils. Whole exome sequencing revealed a set of compound heterozygous missense variants in the LRBA gene, a novel c.2206A>T (p.R736W) and c.5989C>T (p.R1997C) variant.
Conclusion: Compound heterozygous mutations in the LRBA gene caused an atypical presentation of recurrent HLH with central nervous system (CNS) manifestations in our patient.
Statement of Novelty: We herein report a novel set of compound heterozygous mutations in LRBA with atypical presentation of recurrent HLH with CNS manifestations, thus expanding the known phenotypic spectrum of LRBA deficiency.

Formats available

You can view the full content in the following formats:

REFERENCES

Alkhairy O.K., Abolhassani H., Rezaei N., Fang M., Andersen K.K., Chavoshzadeh Z., Mohammadzadeh I., El-Rajab M.A., Massaad M., Chou J., Aghamohammadi A., Geha R.S., and Hammarström L. 2016. Spectrum of Phenotypes Associated with Mutations in LRBA. J. Clin. Immunol. 36: 33–45.
Bashiri F.A., Johani S.A., Hamad M.H., Kentab A.Y., Alwadei A.H., Hundallah K., Hasan H.H., Alshuaibi W., Jad L., Alrifai M.T., Hudairi A, Sheikh R.A., Alenizi A., Alharthi N.A., Abdelmagid T.A., Ba-Armah D., Salih M.A., and Tabarki B. Oct 2020. Acute Necrotizing Encephalopathy of Childhood: A Multicenter Experience. Front. Pediatr. 8: 526.
Cagdas D., Halaçlı S.O., Tan Ç., Lo B., Çetinkaya P.G., Esenboğa S., Karaatmaca B., Matthews H., Balcı-Hayta B., Arıkoğlu T., Ezgü F., Aladağ E., Saltık-Temizel İ.N., Demir H., Kuşkonmaz B., Okur V., Gümrük F., Göker H., Çetinkaya D., Boztuğ K., Lenardo M., Sanal Ö., and Tezcan İ. 2019. A Spectrum of Clinical Findings from ALPS to CVID: Several Novel LRBA Defects. J. Clin. Immunol. 39: 726–738.
Gámez-Díaz L., August D., Stepensky P., Revel-Vilk S., Seidel M.G., Noriko M., Morio T., Worth A.J.J., Blessing J., de Veerdonk F.V., Feuchtinger T., Kanariou M., Schmitt-Graeff A., Jung S., Seneviratne S., Burns S., Belohradsky B.H., Rezaei N., Bakhtiar S., Speckmann C., Jordan M., and Grimbacher B. (2016). The extended phenotype of LPS-responsive beige-like anchor protein (LRBA) deficiency. J. Aller. Clin. Immunol. 137(1): 223–230.
Henter J.-I., Horne A., Aricó M., Egeler R.M., Filipovich A.H., Imashuku S., Ladisch S., McClain K., Webb D., Winiarski J., and Janka G. 2007. HLH-2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr. Blood Cancer, 48(2): 124–131.
Jamee M., Hosseinzadeh S., Sharifinejad N., Zaki-Dizaji M., Matloubi M., Hasani M., Baris S., Alsabbagh M., Lo B., and Azizi G. 2021. Comprehensive comparison between 222 CTLA-4 haploinsufficiency and 212 LRBA deficiency patients: a systematic review. Clin. Exp. Immunol. 205: 28–43.
Kim M.-M., Yum M-S., Choi H-W., Ko T-S., Im H.J., Seo J-J., and Koh K-N. 2012. Central nervous system (CNS) involvement is a critical prognostic factor for hemophagocytic lymphohistiocytosis. Korean J. Hematol. 47(4): 273–280.
Kiykim A., Ogulur I., Dursun E., Charbonnier L.M., Nain E., Cekic S., Dogruel D., Karaca N.E., Cogurlu M.T., Bilir O.A., Cansever M., Kapakli H., Baser D., Kasap N., Kutlug S., Altintas D.U., Al-Shaibi A., Agrebi N., Kara M., Guven A., Somer A., Aydogmus C., Ayaz N.A., Metin A., Aydogan M., Uncuoglu A., Patiroglu T., Yildiran A., Guner S.N., Keles S., Reisli I., Aksu G., Kutukculer N., Kilic S.S., Yilmaz M., Karakoc-Aydiner E., Lo B., Ozen A., Chatila T.A., and Baris S. 2019. Abatacept as a Long-Term Targeted Therapy for LRBA Deficiency. J Aller. Clin. Immunol. Pract. 7(8): 2790–2800.
Kostel Bal S., Haskologlu S., Serwas N.K., Islamoglu C, Aytekin C., Kendirli T., Kuloglu Z., Yavuz G., Dalgic B., Siklar Z., Kansu A., Ensari A., Boztug K., Dogu F., and Ikinciogullari A. 2017. Multiple Presentations of LRBA Deficiency: a Single-Center Experience. J. Clin. Immunol. 37(8): 790–800.
Lo B., Zhang K., Lu W., Zheng L., Zhang Q., Kanellopoulou C., Zhang Y., Liu Z., Fritz J.M., Marsh R., Husami A, Kissell D., Nortman S., Chaturvedi V., Haines H., Young L.R., Mo J., Filipovich A.H., Bleesing J.J., Mustillo P, Stephens M., Rueda C.M., Chougnet C.A., Hoebe K., McElwee J., Hughes J.D., Karakoc-Aydiner E., Matthews H.F., Price S., Su H.C., Rao V.K., Lenardo M.J., and Jordan M.B. 2015. Patients with LRBA deficiency showCTLA4 loss and immune dysregulationresponsive to abatacept therapy. Science, 349(6246): 436–440.
Lopez-Herrera G., Tampella G., Pan-Hammarström Q., Herholz P., Trujillo-Vargas C.M., Phadwal K., Simon A.K., Moutschen M., Etzioni A., Mory A., Srugo I., Melamed D., Hultenby K., Liu C., Baronio M., Vitali M., Philippet P., Dideberg V., Aghamohammadi A., Rezaei N., Enright V., Du L., Salzer U., Eibel H., Pfeifer D., Veelken H., Stauss H., Lougaris V., Plebani A., Gertz E.M., Schäffer A.A., Hammarström L., and Grimbacher B. 2012. Deleterious Mutations in LRBA Are Associated with a Syndrome of Immune Deficiency and Autoimmunity. Am. J. Human Gen. 90: 986–1001.
Mo W., Wei W., Sun Y., Yang Y., Guan Z., Li M., Zhu P., and Chi Z. 2019. Application of blood and immunodeficiency gene detection in the diagnosis of hemophagocytic lymphohistiocytosis patients. Exper. Hematol. 78: 62–69.
Neilson D.E., Adams M.D., Orr C.M.D., Schelling D.K., Eiben R.M., Kerr D.S., Anderson J., Bassuk A.G., Bye A.M., Childs A-M., Clarke A., Crow Y.J., Rocco M.D., Dohna-Schwake C., Dueckers G., Fasano A.E., Gika A.D., Gionnis D., Gorman M.P., Grattan-Smith P.J., Hackenberg A., Kuster A., Lentschig M.G., Lopez-Laso E., Marco E.J., Mastroyianni S., Perrier J., Schmitt-Mechelke T., Servidei S., Skardoutsou A., Uldall P., der Knaap M.S.V., Goglin K.C., Tefft D.L., Aubin C., de Jager P., Hafler D., and Warman M.L. 2009. Infection-triggered familial or recurrent cases of acute necrotizing encephalopathy caused by mutations in a component of the nuclear pore, RANBP2. Am. J. Hum. Genet. 84(1): 44–51.
Ren Y., Xiao F., Cheng F., Huang X., Li J., Wang X., Lang W., Zhou X., Lan J., and Tong H. (2021). Whole exome sequencing reveals a novel LRBA mutation and clonal hematopoiesis in a common variable immunodeficiency patient presented with hemophagocytic lymphohistiocytosis. Exper. Hematol. Oncol. 10(1): 38.
Sham M., Zhu R., and Pasternak Y. 2022. Whole exome sequencing identifies causative compound heterozygous variants in PRF1 in late-onset familial hemophagocytic lymphohistiocytosis. LymphoSign J. 9(4).
Suri M. 2010. Genetic basis for acute necrotizing encephalopathy of childhood. Dev. Med. Child Neurol. 52(1) 4–5.
Yao J., Gu H., Mou W., Chen Z., Ma J., Ma H., Li N., Zhang R., Wang T., Jiang J., and Wu R. 2022. Various phenotypes of LRBA gene with compound heterozygous variation: A case series report of pediatric cytopenia patients. International Journal of Immunopathology and Pharmacology 36: 3946320221125591.

Information & Authors

Information

Published In

cover image LymphoSign Journal
LymphoSign Journal
Volume 10Number 1March 2023
Pages: 20 - 26

History

Received: 24 March 2023
Accepted: 30 March 2023
Accepted manuscript online: 30 March 2023

Authors

Affiliations

Marina Sham
Canadian Centre for Primary Immunodeficiency, The Hospital for Sick Children, Toronto, ON
Division of Clinical Immunology and Allergy, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON
Daniele Merico
Vevo Therapeutics, 953 Indiana Street, San Francisco, CA 94107, USA
The Centre for Applied Genomics (TCAG), The Hospital for Sick Children, Toronto, ON
Myra Pereira
Division of Clinical Immunology and Allergy, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON
Chaim M. Roifman
Canadian Centre for Primary Immunodeficiency, The Hospital for Sick Children, Toronto, ON
Division of Clinical Immunology and Allergy, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON
Maian Roifman [email protected]
Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON

Metrics & Citations

Metrics

Other Metrics

Citations

Cite As

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.

There are no citations for this item

View Options

View options

PDF

View PDF

Full Text

View Full Text

Get Access

Media

Media

Other

Tables

Share Options

Share

Share the article link

Share on social media