• Clinical science

Congenital immunodeficiency disorders

Summary

Congenital immunodeficiency disorders are characterized by a deficiency, absence, or defect in one or more of the main components of the immune system. These disorders are genetically determined and typically manifest during infancy and childhood as frequent, chronic, or opportunistic infections. Classification is based on the component of the immune system that is deficient, absent, or defective. The diagnosis is confirmed with tests such as differential WBC count, absolute lymphocyte count, quantitative immunoglobulin (Ig) measurements, and antibody titers. Treatment usually consists of prophylactic antibiotics to manage and prevent infections. The prognosis in congenital immunodeficiency disorders is variable and depends on the specific disorder.

Overview

Congenital B-cell immunodeficiencies

Immunodeficiency Etiology Clinical features Diagnostic findings
Bruton agammaglobulinemia
  • Onset: > 4 months after birth
  • Recurrent, severe pyogenic infections, especially by encapsulated organisms
  • Hypoplasia of lymphoid tissue
  • Absent or low B cells
  • Normal T-cell count
  • Low immunoglobulins of all classes
Selective IgA deficiency
  • Often asymptomatic
  • May manifest with respiratory infections, and/or chronic diarrhea/steatorrhea
  • Anaphylactic reaction to products containing IgA
  • Increased risk of gluten-sensitive enteropathy, inflammatory bowel disease, atopy
Common variable immunodeficiency
  • Onset later than other B-cell defects (usually 20–35 years of age)
  • Recurrent sinopulmonary infections
  • Increased risk of lymphoma, autoimmune disorders, and bronchiectasis

Congenital T-cell immunodeficiencies

Immunodeficiency Etiology Clinical features Diagnostic findings
DiGeorge syndrome
Autosomal dominant hyper-IgE syndrome (Job syndrome)
  • Remember the acronym FATED
    • Facies: coarse facial features
    • Abscesses: mainly staphylococcal
    • Teeth: retained primary teeth
    • Hyper-IgE (eosinophilia)
    • Dermatologic: severe eczema
IL-12 receptor deficiency
  • Onset varies but usually 1–3 years of age
  • Disseminated disease, especially tuberculosis
  • Fungal infections
Chronic mucocutaneous candidiasis
  • Several congenital defects (e.g., AIRE protein deficiency) → impaired T-cell function → imapired or absent immune response to Candida
  • Noninvasive Candida infections of the skin, nails, and mucous membranes
  • Associated with autoimmune disorders
IPEX syndrome

Congenital combined immunodeficiencies

Immunodeficiency Etiology Clinical features Diagnostic findings
Severe combined immunodeficiency
Wiskott-Aldrich syndrome (WAS)
Hyper-IgM syndrome
Ataxia telangiectasia
  • Onset: early childhood
  • Classic triad of 3 As
    • Progressive ataxia due to cerebellar atrophy
    • Spider angiomas
    • IgA deficiency
  • Susceptibility to infections (e.g., ear infections, sinusitis, pneumonia)
  • Increased risk of malignancy (e.g., lymphoma and leukemia)
  • Increased sensitivity to radiation

Congenital neutrophil and phagocyte disorders

Immunodeficiency Etiology Clinical features Diagnostic findings
Chronic granulomatous disease (CGD)
  • Recurrent, severe infections with catalase-positive organisms
  • Anemia and lymphadenopathy
  • Possible skin granulomas
  • Abnormal DHR test: absent or decreased green fluorescence
  • Negative nitroblue tetrazolium dye reduction test
  • Genotyping is confirmatory
Leukocyte adhesion deficiency type 1
Chédiak-Higashi syndrome
  • Peripheral smear: giant cytoplasmic granules in granulocytes and platelets
  • Mild coagulation abnormalities
  • Pancytopenia
Myeloperoxidase deficiency
  • Often asymptomatic
  • Recurrent Candida infections
  • Positive nitroblue tetrazolium test (intact NADPH oxidase)
  • Absent MPO on staining
  • Genetic analysis: MPO gene mutation
Severe congenital neutropenia
  • Absolute neutropenia, relative monocytosis
  • Bone marrow aspirate: normal or decreased cellularity; arrest of myeloid lineage

Complement disorders

Immunodeficiency Etiology Clinical features Diagnostic findings
C1 esterase inhibitor deficiency
  • Recurrent angioedemas provoked by triggers, e.g., trauma, surgery, infections, and drugs
  • Airway edemas can be life-threatening.
Terminal complement deficiency
C3 deficiency

Congenital B-cell immunodeficiencies

B-cell defects (humoral immunity deficiencies) account for 50–60% of all primary immunodeficiencies.

Bruton agammaglobulinemia (X-linked agammaglobulinemia)

  • Definition: X-linked recessive disease that causes a complete deficiency of mature B lymphocytes
  • Epidemiology: occurs mainly in boys
  • Etiology: defect of Bruton tyrosine kinase (BTK) expressed in B cells
  • Clinical features
  • Diagnosis
  • Treatment

Live vaccines (e.g., MMR) are contraindicated in patients with Bruton agammaglobulinemia.

Selective IgA deficiency (SIgAD)

  • Definition: most common primary immunodeficiency that is characterized by a near or total absence of serum and secretory IgA
  • Epidemiology: approx. 1:220 to 1:1000
  • Etiology: unknown
  • Clinical features
  • Diagnosis
    • Decreased serum IgA levels (< 7 mg/dL)
    • Normal IgG and IgM levels
    • Increased susceptibility to Giardia infection
  • Treatment

To prevent transfusion reactions, IgA-deficient patients must be given washed blood products without IgA or obtain blood from an IgA-deficient donor.

Common variable immunodeficiency (CVID)

References:[1][2][3][4][5][6][7]

Congenital T-cell immunodeficiencies

T-cell defects (cellular immunity deficiencies) are responsible for 5–10% of congenital immunodeficiencies.

DiGeorge syndrome (22q11.2 deletion syndrome)

CATCH-22 is the acronym for typical features of DiGeorge syndrome: Cardiac anomalies; Anomalous face; Thymic aplasia/hypoplasia; Cleft palate; Hypocalcemia; Chromosome 22.

Autosomal dominant hyperimmunoglobulin E syndrome (Job syndrome)

  • Definition: : defect in neutrophil chemotaxis
  • Etiology: autosomal dominant: STAT3 mutation → decreased Th17 cells → defect in neutrophil/macrophage recruitment
  • Clinical features
    • Course Facies
    • Abscesses, recurrent bacterial (staphylococcal) infections
    • Retained primary Teeth
    • Hyper-IgE (Eosinophilia)
    • Dermatologic (severe eczema)
    • Other features: Decreased bone density increases the risk of bone fractures following minor trauma. [8]
  • Diagnosis Treatment

FATED is the acronym for the typical features of Autosomal dominant hyper-IgE syndrome: Coarse Facies; Abscesses; Retained primary Teeth; Hyper-IgE; Dermatologic (severe eczema).

IL-12 receptor deficiency

  • Definition: impaired Th response due to IL-12 receptors
  • Etiology: autosomal recessive
  • Pathophysiology
  • Clinical features
    • The age of onset varies (depends on the age at exposure to causative pathogens): ∼ 1–3 years of age
    • Features of disseminated disease, especially tuberculosis (e.g., following administration of BCG vaccine)
    • Fungal infections
  • Diagnosis: IFN-γ
  • Treatment: antibiotics and IFN-γ therapy

Chronic mucocutaneous candidiasis

IPEX syndrome (immune dysregulation, polyendocrinopathy, enteropathy, X-linked)

References:[9][10][11][12][13][14][15][16][17]

Congenital mixed immunodeficiencies

Severe combined immunodeficiency (SCID, bubble boy disease, Glanzmann–Riniker syndrome, alymphocytosis)

Wiskott-Aldrich syndrome (WAS)

WIPE is the acronym for the classic triad seen in Wiskott-Aldrich syndrome: Wiskott-Aldrich, Infections, Purpura, Eczema.

Hyper-IgM syndrome

Ataxia telangiectasia

References:[20][21][18][22][23]

Congenital neutrophil and phagocyte disorders

Phagocytic defects are characterized by the impaired ability of phagocytic cells (e.g., monocytes, macrophages, granulocytes such as neutrophils and eosinophils) to kill pathogens. These types of defects account for 10–15% of primary immunodeficiencies.

Chronic granulomatous disease (CGD)

Leukocyte adhesion deficiency type 1 (LAD1)

  • Definition: : genetic condition characterized by a defect in the leukocytic chemotaxis that results in decreased phagocyte activity
  • Etiology
  • Clinical features
    • Recurrent nonsuppurative bacterial infections (e.g., skin and mucosal infections), impaired wound healing
    • Wounds with minimal inflammation and no pus
    • Omphalitis
    • Delayed separation of the umbilical cord (> 2 weeks postpartum)
  • Diagnosis
  • Treatment
    • Prevention of further infections (e.g., adequate dental hygiene)
    • Treatment of infections
    • Bone marrow transplant

Chédiak-Higashi syndrome

Myeloperoxidase deficiency

Severe congenital neutropenia

References:[20][25][13][24]

Congenital complement deficiencies

Complement deficiencies are rare (≤ 2%) deficiencies of comple