1. The Variability in Common Variable Immunodeficiency Mark Ballow, MD Division of Allergy & Immunology Morsani College of Medicine, USF All Children’s Hospital St Petersburg, FL

2. Mark Ballow: Disclosures I have a financial relationship or interest related to the content of this CME program with the following entities: – CSL Behring - advisory board, speaker, research grant – Baxter – advisory board, speaker – Grifols – speaker, advisory board  Kedrion - Data Safety Monitoring Board  Prometic - Data Safety Monitoring Board Off label products will be discussed

3. Learning Objectives At the conclusion of this session, the participant should be able to: Become aware of how therapeutic decisions will affect the management of patients with CVID over the course of their lifetime. Make more effective treatment decisions when managing complications in patients with CVID.

4. Molecular biology of PIDD Over 300 genetic abnormalities described for primary immune deficiencies

5. Relative Distribution of the Primary Immunodeficiencies Complement Deficiency Cellular Deficiency Combined Immunodeficiency Antibody Deficiencies Phagocytic

8. Common Variable Immunodeficiency (CVID) Recurrent sinopulmonary infections with encapsulated organisms Most common B-cell immune deficiency – 1:25,000 to 1:50,000 Variable onset of clinical findings – Often delayed diagnosis by 6-8 yrs Low serum IgG, IgA, IgM – At least 2 Ig isotypes (one of which is IgG) that are >2 SD below normal for age – Poor or absent specific antibody production – Diagnosis after age 4 to exclude transient delayed hypogammaglobulinemia of infancy (THI) Cunningham-Rundles C, Bodian C. Clin Immunol. 1999;92(1):34-48.

9. Diagnostic Criteria for CVID –ESID 2014 At least one of the following – Increased susceptibility to infection – Autoimmune disease – Granulomatous disease – Unexplained polyclonal lymphoproliferation – Affected family member with antibody deficiency AND marked decrease in serum IgG and decrease IgA with or without a low IgM AND at least one of the following – Poor antibody response to vaccines (and/or absent isohemagglutinins) – Low switched memory B-cells AND secondary causes of hypogammaglobulinemia have been excluded AND diagnosis after age 4 AND no evidence of profound T-cell deficiency

10. Clinical phenotypes and Prognosis

11. Risk of death 11 fold higher in patients with complications Increased mortality associated with: lymphoma hepatitis lung disease GI disease Resnick et al Blood, 2012

14. Medical Complications in Patients With CVID Chapel H, Cunningham-Rundles C. Br J Haematol. 2009;145(6):709-727. 37% 51%

15. Clinical Findings in CVID Recurrent sinopulmonary tract infections (73%) – Encapsulated organisms – Mycoplasma Recurrent GI symptoms, chronic GI infection – Campylobacter/Salmonella – 10% liver disease 1/3 develop lymphoproliferative disorder. – Intestinal nodular lymphoid hyperplasia, – Splenomegaly Autoimmunity (~25%): PA, celiac disease, ITP, AIHA, systemic rheumatic disease Subgroup of CVID have diminished T-cell function Increased incidence of lymphoma (NHL) and gastric cancer Giardia lamblia infection Celiac-like disease

16. CVID Clinical Phenotypes and Biomarkers Morbidity impacts mortality – 11 fold increase in mortality Predict disease course and complications, improve management – No other disease-related complications (infection only) – Cytopenias (neutropenia, ITP, hemolytic anemia) – Polyclonal lymphoproliferation Granuloma Lymphocytic interstitial pneumonia Lymphadenopathy Unexplained enteropathy – Effects on survival most marked for enteropathy, followed by lymphoproliferation, followed by cytopenias Chapel, H and Cunningham-Rundles,C Brit medical Journal 2009 Jolles, S JACI: In Practice, 2013

17. Chronic Diarrhea in a 32-year-old Woman

18. Gastrointestinal Issues Survey of 248 CVID patients – 21% had significant GI disease 1 – Often present with chronic diarrhea and malabsorption Focal nodular lymphoid hyperplasia – Liver disease in 12% Biliary cirrhosis Autoimmune hepatitis Nodular regenerative hyperplasia – portal hypertension and cholestasis – Overgrowth of small bowl with pathogens Giardia lamblia Yersinia, Campylobacter, C difficile, Salmonella Chronic viral enteritis – Enteroviruses – CMV – Norovirus – Autoimmune GI problems Celiac-like disease Inflammatory bowl disease Cunningham-Rundles C, Bodian C. Clin Immunol. 1999;92(1):34-48.

19. Gastrointestinal Management No lake swimming (Giardia lamblia) Stool studies – Reducing substances – lactose intolerance – Cultures – request special cultures for Yersinia/ Campylobacter O&P Liver function tests GI procedures – Imaging NLH – Endoscopy – Biopsies Celiac disease IBD Nutrition support – Diet – Vitamins – B12, vitamin E, vitamin A Cunningham-Rundles C. Blood. 2010;116(1):7-15.

21. Lung Disease in CVID Decline in lung function over time associated with: – lower Ig doses – IgG trough < 500 mg/dl – Low serum IgA – Low mannose binding lectin levels Reduced switched memory B-cells associated with higher frequency of bronchiectasis, reduced spirometry and chronic noninfectious diarrhea

22. Chen Y et al. J Allergy Clin Immunol. [Published online May 6, 2011]

24. Pulmonary Findings in CVID Diffuse parenchymal disease – Bronchitis/bronchiectasis – Asthma – Cryptogenic organizing pneumonia Serum IgG level at diagnosis does not predict subsequent pneumonias or bronchiectasis Granulomatous lung disease – 8%-12% of patients – May be diagnosed years before the hypogammaglobulinemia Well-formed, non-caseating granuloma with epitheloid giant cells Often misdiagnosed as sarcoid – Lung (54%); lymph nodes and spleen (43%); liver (32%) – Autoimmune disorders are commonly associated (54%) Autoimmune thrombocytopenia, hemolytic anemia most common Low number of switched memory B cells Ardeniz O, Cunningham-Rundles C. Clin Immunol. 2009;133(2):198-207. Chapel H et al. Blood. 2008;112(2):277-286. Mechanic LJ et al. Ann Intern Med. 1997;127(8 Pt 1):613-617.

25. Pulmonary Findings in CVID (cont’d) Lymphoid interstitial pneumonia (LIP) – Lymphoma Granulomatous lymphocytic interstitial lung disease (GLILD) – HHV8 – Poorer prognosis, T-cell deficiency, B-cell lymphoproliferative disease Median survival - 13.7 yrs vs. 28.8 yrs MALT Wheat WH et al. J Exp Med. 2005;202(4):479-484. Bates CA et al. J Allergy Clin Immunol. 2004;114(2):415-421.

26. GLILD in CVID Often confused with sarcoidosis Different histologic pattern in same biopsy – Granulomatous disease – Lymphocytic interstitial pneumonitis – Follicular bronchitis Frequently large areas of organizing pneumonia Granulomas in multiple organs Splenomegaly and diffuse adenopathy common Increased autoimmunity B-cell lymphomas Pulmonary component of a multi-systemic lymphoproliferative disease Clin Immunol 2010; Blood 2008; JACI 2004; J Clin Immunol 2013

27. Clinical Pathologic Correlates FeatureCVIDSarcoidosis Recurrent infections+++++/- Autoimmunity++++/- Hepatosplenomegaly++/++++/- Low serum IgG++++- Granuloma++++ LIP++++++ Follicular bronchitis++++++ Hilar adenopathy++++++ Seminars Resp Crit Care Med 35:330, 2014

28. Many immune deficiency disorders have granulomatous disease CVID, XLP2, CD40L def Hypomorphic RAG1/2, Artemis, JAK3 mutations CVID-like diseases – CTLA4, LRBA MHC Class I deficiency Ataxia telangiectasia GOF STAT3 mutations Best Practice & Research Clinical Rheumatology 28:191, 2014

29. Therapy for GLILD Retrospective analysis of 7 patients with CVID and GLILD @ – 4/7 patients had PFTs >80% of predicted 3/7 with normal chest x-rays Rituximab (375 mg/m2) weekly x 3-4 doses – Repeat in 6 months Azathioprine (1-2 mg/kg) titrated to WBC – MMF works well also Improvement in PFTs and scores of HRCT Splenomegaly improves in most patients No invasive infections from the immunosuppression @ J Routes J Clin Immunol 33:30,2013

30. Pulmonary Disease Management Baseline high-resolution chest CT – Chest x-rays – Spirometry If lung disease present: – Sputum cultures/sensitivities – Spirometry – DLCO – Pulmonary care – Biopsies Flow cytometry Clonality for MALT – May have oligoclonal lymphocyte populations that may not indicate a malignancy Chapel H and Cunningham-Rundles C, BJH, 2009 Gompels M et al, Clin Exp Immunol 2003

31. Pulmonary Disease Management (cont’d) Therapy – Bronchiectasis Adequate IVIG/SCIG replacement therapy Prophylactic antibiotics Pulmonary toilet Hatab AZ, Ballas ZK. J Allergy Clin Immunol. 2005;116(5):1161-1162. Lin JH et al. J Allergy Clin Immunol. 2006;117(4):878-882.

32. Clinical Findings in CVID: Autoimmune Disease Approximately 20%-30% have autoimmune disease – Diminished switched memory B cells – Most common hematologic (11%) Rx IVIG/steroids Rituximab Splenectomy – Rheumatologic – Endocrine – Pernicious anemia Secondary neurologic deficits – B12 deficiency Cunningham-Rundles C. Blood Rev. 2002;16(1):61-64. Wang J, Cunningham-Rundles C. J Autoimmun. 2005;25(1):57-62. Sève P et al. Medicine (Baltimore). 2008;87(3):177-184. Wong GK et al Clin Exp Immunol 2013

33. Lymphoid Tissues Lymphoid hyperplasia (20%) – Cervical, mediastinal, abdominal – Biopsies Reactive lymphoid hyperplasia Granulomatous disease Rule out lymphoma – Flow cytometry for tumor markers – Clonality by molecular analysis – EBV genome Hepatosplenomegaly – Secondary cytopenias – Evans syndrome – Liver disease Autoimmune hepatitis Nodular regenerative hyperplasia – Liver function testing Sander CA et al. Am J Surg Pathol. 1992;16(12):1170-1182. Gompels MM et al. Clin Exp Immunol. 2003;134(2):314-320. Cunninham-Rundles C et al. Am J Hematol. 2002;69(3):171-178. Gathmann B et al. Clin Exp Immunol. 2009;157(Suppl 1):3-11.

34. Cancer: Clinical Findings in CVID Malignancies – 2%-8% Non-Hodgkin lymphoma More common in the 4th-7th decade of life Female preponderance B-cell type, EBV negative Location in mucosal regions (marginal zone) – Almost always extra-nodal Associated with lymphoid hyperplasia, granulomatous disease, and elevated serum IgM – Gastric cancer May be associated with Helicobacter pylori Zullo A et al. Gut. 1999;45(1):77-81. Mellemkjaer L et al. Clin Exp Immunol. 2002;130(3):495-500. Cunningham-Rundles C et al. J Clin Immunol. 1987;7(4):294-299. Cunningham-Rundles C et al. Am J Hematol. 2002;69(3):171-178.

35. Immune Defects in CVID- a Heterogeneous Disorder T-cell defects – Decreased activation and proliferation – Reduced numbers of peripheral blood T-cell subsets – Impaired cytokine production – Reduced expression of CD40L – Increased immunoregulatory T-cells B-cell defects – Reduced number of circulating B-cells – Defective up-regulation of CD86 – Reduced somatic hypermutations – Lack of class-switched memory B-cells Innate immune defects – Invariant natural killer T-cells – Defective dendritic cell function – TLR9 activation defects – Deficient IL-12 function

36. Clinical Phenotypes and Biomarkers Clinical biomarkers – Poor T-cell function – Low B-cell numbers – Switched memory B cells – Reduced Treg – Very low CD21 + B cells – High serum levels of BAFF and April – Genetic markers Heterozygous mutations/polymorphisms in TNFRSF13B (TACI) – Develop autoimmunity and lymphoid hyperplasia Malphettes M et al. Clin Infect Dis. 2009;49(9):1329-1338. Ko J et al. Clin Immunol. 2005;116(1):37-41. Alachkar H et al. Clin Immunol. 2006;120(3):310-318. Knight AK et al. Clin Immunol. 2007;124(2):182-189. Salzer U et al. Blood. 2009;113(9):1967-1976.

37. Switched Memory B-cells in CVID Switched memory B-cells - – CD27+ IgM- IgD- – Group I 0.4% Patients with higher numbers (Group II) of switched memory B-cells had higher serum levels of immunoglobulins and better antibody responses to pneumococcal vaccine Patients in group I with low class switch memory B-cell had more autoimmmune disease – Poorer antibody production to polysaccharide antigens – More bacterial pneumonias and bronchiectasis Carsetti et al JACI 2005

38. Flow Cytometric Evaluation -CVID IgM IgD IgD Control Patient

39. Flow Cytometric Evaluation -CVID IgD CD27 Control Patient

40. TACI (TNFRSF13B) BCMA (TNFRSF16) (TNFRSF16) BAFF-R (TNFRSF13C) (TNFRSF13C) APRIL (TNFSF13) BAFF (TNFSF13B) CRD1 CRD2 TM Intracellular Domain stalk region B CELL

41. Fig 2 Journal of Allergy and Clinical Immunology 2013 131, 959-971DOI: (10.1016/j.jaci.2013.01.046) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions Terms and Conditions

42. Fig 3 Journal of Allergy and Clinical Immunology 2013 131, 959-971DOI: (10.1016/j.jaci.2013.01.046) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions Terms and Conditions

43. Gene Defects in Common Variable Immune Deficiency (CVID) Recent findings have identified specific B cell and T cell genetic defects associated with CVID – TACI (Transmembrane Activator and CAML Inducer) deficiency: ~10% CVID Disease-associated rather than disease causing – BAFF (B-cell Activating Factor) receptor deficiency: uncommon – CD19 deficiency: uncommon – CD20 deficiency: uncommon – CD21 deficiency: uncommon – CD81 deficiency: uncommon – ICOS (Inducible COstimulator of activated T cells) deficiency impaired T cell help (uncommon)

44. CVID-Like Immune Deficiency Diseases Protein deficiencyGene mutationInheritance CTLA 4 AD LPS-responsive beige-like anchor LRBAAR CARD 11 AR/GOF MALT1 AR NF-kB2NFKB2AD Protein kinase C  PRKCDAR Transcription factor E47TCF3AD PI3K  GOF P85  subunit PI3K PIK3R1AR/GOF Kabuki SyndromeKMT2DAR

46. Survival Curve for Patients With CVID 1973 to 1998 Cunningham-Rundles C, Bodian C. Clin Immunol. 1999;92(1):34-48.

47. Survival in Patients With CVID Chapel H, Cunningham-Rundles C. Br J Haematol. 2009;145(6):709-727.

48. “ …the greatest teachers of modern immunology: patients with immunodeficiency diseases. ” Robert A. Good, M.D., D.Sc., Ph.D.