Beruflich Dokumente
Kultur Dokumente
TABLE OF CONTENTS
I. Preface....................................................................................................................................................................................S1
II. Executive Summary...............................................................................................................................................................S2
III. Algorithms .............................................................................................................................................................................S7
IV. Summary Statements ...........................................................................................................................................................S14
V. General Considerations........................................................................................................................................................S20
VI. Humoral Immunodeficiencies .............................................................................................................................................S24
VII. Cellular Immunodeficiencies...............................................................................................................................................S30
VIII. Combined Immunodeficiencies ...........................................................................................................................................S33
IX. Phagocytic Cell Disorders ...................................................................................................................................................S40
X. Complement Deficiencies....................................................................................................................................................S43
XI. Acknowledgments................................................................................................................................................................S45
XII. References............................................................................................................................................................................S45
XIII. Appendix ..............................................................................................................................................................................S61
* Department of Medicine, Children’s Hospital Boston, and Department of 储储 National Jewish Medical Research Center, Associate Professor of Medi-
Pediatrics, Harvard Medical School, Boston, Massachusetts. cine and Immunology, University of Colorado Health Sciences Center,
† Department of Medicine and Environmental Health, University of Cincin- Denver, Colorado.
nati College of Medicine, Cincinnati, Ohio. *** Allergy and Immunology Service, Texas Children’s Hospital, Professor
‡ Department of Internal Medicine, University of Texas Southwestern Med- of Pediatrics and Immunology, Baylor College of Medicine, Houston, Texas.
ical Center, Dallas, Texas. ††† Department of Pediatrics, Louisiana State University Health Science
§ Division of Allergy/Immunology, Department of Internal Medicine, Uni- Center, New Orleans, Louisiana.
versity of Iowa and the Iowa City Veteran’s Administration Medical Center, The American Academy of Allergy, Asthma and Immunology (AAAAI) and the
Iowa City, Iowa. American College of Allergy, Asthma and Immunology (ACAAI) have jointly
¶ National Human Genome Research Institute, National Institutes of Health, accepted responsibility for establishing the Practice Parameter for the Diagnosis
Bethesda, Maryland. and Management of Primary Immunodeficiency. This is a complete and com-
储 Department of Pediatrics, Children’s Health Center, Duke University prehensive document at the current time. The medical environment is a changing
Medical Center, Durham, North Carolina. environment and not all recommendations will be appropriate for all patients.
** Department of Pediatrics, Emory University School of Medicine, Atlanta, Because this document incorporated the efforts of many participants, no single
Georgia. individual, including those who served on the Joint Task Force, is authorized to
†† Section of Allergy and Immunology, Department of Medicine and Neu- provide an official AAAAI or ACAAI interpretation of these practice parame-
rology, University of Pennsylvania School of Medicine, Philadelphia, Penn- ters. Any request for information about or an interpretation of these practice
sylvania. parameters by the AAAAI or ACAAI should be direct to the Executive Offices
‡‡ Division of Allergy and Immunology, Montreal Children’s Hospital, and of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and
Department of Pediatrics, McGill University, Montreal, Quebec. Immunology. These parameters are not designed for use by pharmaceutical
§§ Department of Medicine, Division of Hematology/Oncology Hematolog- companies in drug promotion. This parameter was edited by Dr Nicklas in his
ical Malignancy Program/Immunology, Indianapolis, Indiana. private capacity and not in his capacity as a medical officer with the Food and
¶¶ Children’s Hospital of Philadelphia, Division of Immunology, and De- Drug Administration. No official support or endorsement by the Food and Drug
partment of Pediatrics, University of Pennsylvania School of Medicine, Administration is intended or should be inferred.
Philadelphia, Pennsylvania. Received and accepted for publication January 11, 2005.
Algorithm 1. General approach for the diagnosis of primary immunodeficiency. SCID indicates severe combined immunodeficiency.
Phagocytic cell defects (Algorithm 4) may present with disposed to bacterial respiratory tract infections, but there
severe pyogenic bacterial and fungal infections of the respi- may be other host factors that interact to create such suscep-
ratory tract, skin, viscera, and gingivostomatitis. Laboratory tibility in an individual. There is no specific therapy for
evaluation shows neutropenia, normal numbers, or neutro- complement deficiency. Antibiotic prophylaxis may be con-
philia (in cellular adhesion defects). Functional studies show sidered for recurrent infections (Table 5).
most often a defect in oxidative metabolism, since chronic To improve consistency in evaluation and management and
granulomatous disease is the most common phagocyte defect. to have the best outcomes with respect to patient and family
In other disorders, there may be simply severe neutropenia or health, education, and planning, it is imperative that diagnosis
variable impairment of chemotaxis, phagocytosis, or intracel- and therapy are guided overall by individuals with direct
lular killing. Therapy is with antibacterial and antifungal experience with a broad range of immunodeficiencies.
prophylaxis and cytokines (IFN-␥) for chronic granulomatous
disease (CGD). BMT has also been applied for CGD. The
ALGORITHMS
care of patients with other forms of phagocyte defects is
primarily anti-infective and supportive. BMT has been ap- Annotations to Algorithm 1: General Approach for the
plied in some, but experience is limited (Table 5). Diagnosis of Primary Immunodeficiency
Complement deficiencies are the rarest of the primary 1-1. The patient exhibits symptoms and signs consistent with
immunodeficiencies, accounting for less than 1%. Most early primary immunodeficiency. It is assumed that immunosup-
classical and alternative pathway complement defects tend to pressive therapies and other medical conditions potentially
present with either systemic autoimmune disease that resem- resulting in secondary immunodeficiency and other anatomic
bles lupus erythematosus or recurrent respiratory tract bacte- or biochemical conditions potentially predisposing to infec-
rial infections similar to antibody deficiency (Table 7). De- tion either have been excluded or are not considered sufficient
ficiencies of terminal components may also be associated to explain the observed degree of infectious susceptibility.
with recurrent neisserial meningitis. Some patients with low 1-2. Antibody deficiency is most frequently encountered
serum levels of mannose-binding lectin (MBL) may be pre- and commonly presents with sinopulmonary bacterial infec-
tions. If these are the only types of infections under consid- 1-4. If the clinical presentation is consistent with SCID,
eration, screening for antibody deficiency is appropriate. then immediate referral for expedited evaluation and treat-
1-3. Other forms of primary immunodeficiency may ment (BMT) is indicated.
present with distinct infectious complications with or without 1-5. Successful outcomes depend on timely intervention.
sinopulmonary bacterial disease. Some of these forms of 1-6. Suspected antibody deficiency may be evaluated ac-
infection are more or less characteristic of specific categories cording to Algorithm 2. Complement deficiency, phagocyte
of immunodeficiency (Table 2). Neisserial infections charac- defects, and some combined deficiencies may have a clinical
terize terminal complement component deficiencies, ab- presentation similar to antibody deficiency and should be
scesses and fungal pathogens are seen in phagocyte defects, sought when there is not a definitive diagnosis of such.
and mycobacterial, disseminated, or opportunistic infections Depending on the clinical presentation, any of these could be
occur in cellular or combined deficiencies. an appropriate subsequent focus of investigation.
1-7. Suspected complement deficiency may be evaluated antibody production, even if serum immunoglobulin levels
according to Algorithm 5. are normal or near normal. This situation should also
1-8. Suspected phagocyte defects may be evaluated using prompt evaluation of lymphocyte subsets and cellular im-
Algorithm 4. munity (2-3).
1-9. Suspected cellular or combined immunodeficiencies 2-5. Cellular immunity is evaluated either because of severe
may be evaluated according to Algorithm 3. hypogammaglobulinemia or impaired specific antibody produc-
1-10. Depending on the specific characteristics of the in- tion (or both). If cellular immunity is abnormal, then the even-
fections and other medical problems that occur in a given tual diagnosis will be a form of CID. If cellular immunity is
patient, one or all of these immune effector mechanisms may normal, it is important to determine whether there appears to be
require evaluation. In some cases, no definitive immunologic a significant impairment of B-cell development (2-7).
defect is ascertained. These patients either have an undefined 2-6. There is no profound hypogammaglobulinemia or
form of compromised immunity or some other medical prob- demonstrable impairment of specific antibody production. Is
lem predisposing them to infection. there any abnormality of serum immunoglobulins or IgG
1-11. Whenever possible, the evaluation and/or manage- subclasses? Yes (2-8) or No (2-9).
ment of suspected primary immunodeficiency should be per- 2-7. Is B-cell count normal? Yes (2-10) or No (2-11).
formed by, or in close consultation with, a clinician with 2-8. All measurements are normal, and alternative expla-
experience in this area. At some time during evaluation or nations for recurrent infections should be sought.
after diagnosis is established, referral should be made for 2-9. Mild hypogammaglobulinemia in infants, low serum
further evaluation and/or guidance during therapy. IgA or IgG subclasses, or other poorly defined immunoglob-
Annotations to Algorithm 2: Diagnosis of Humoral ulin abnormalities may exist with normal levels of specific
Immunodeficiency antibodies as measured by standard assays. Potential diag-
noses include SIGAD, IGGSD, or THI.
2-1. The clinical presentation is primarily suggestive of an
2-10. Hypogammaglobulinemia and/or impaired specific an-
antibody defect or any evaluation of cellular function is so far
tibody formation are seen in CVID, SIGAD, IGGSD, SAD, and
normal, and the clinical presentation is at least consistent with a
some forms of HIM, such as activation-induced cytidine deami-
possible antibody deficiency. The initial laboratory examination
nase (AID) or uracil nucleoside glycosylase (UNG) deficiencies.
of humoral immunity consists of measuring the levels of various
2-11. Hypogammaglobulinemia or agammaglobulinemia
immunoglobulin isotypes (IgG, IgA, IgM) in serum, as well as
associated with low or absent B-cell counts is seen in X-
a measure of function, or specific antibody production.
linked agammaglobulinemia (XLA) or autosomal recessive
2-2. Profound hypogammaglobulinemia with serum IgG
agammaglobulinemia (ARA) and in CVID.
levels less than 100 mg/dL in an infant or less than 2 to 3 g/L
in an older child or adult should prompt additional evaluation Annotations to Algorithm 3: Diagnosis of Cellular and
of lymphocyte populations and cellular immune function Combined Immunodeficiencies
(2-3) to investigate CID and B-cell count. 3-1. In this situation, it is appropriate to perform a complete
2-4. Specific antibody responses may be impaired as a screening evaluation of specific immune function, including
result of a B-cell defect or failure of T-cell help for measurement of immunoglobulin levels, specific antibody pro-
duction, enumeration of lymphocyte subpopulations, evaluation 3-12. If there is selective depletion of CD8⫹ cells, consider
of NK cell cytotoxicity, and measurement of T-cell function. defects involving MHC class I expression or ZAP70 defi-
3-2. If the clinical and laboratory phenotype is consistent ciency (3-13).
with SCID, every effort must be made to expedite definitive 3-14. Omenn syndrome is associated with a variable host
therapy (BMT). It is desirable to know the actual molecular T-cell phenotype, although there is not usually extreme pre-
defect, but this should not delay therapy. ponderance of one cell type. One should also consider the
3-3 through 3-14. The particular form of SCID may often possibility of a less common (possibly undefined) form of
be suspected based on the lymphocyte phenotype (Table 5). If SCID or a severe phenotype of other CID, such as CD40
T cells are present, their origin (mother or patient) should be ligand (CD40L) deficiency.
determined. 3-15. If there is at least partial T-cell function, evaluation
3-4. If T cells are absent or only of maternal origin (3-6) of NK cell cytotoxicity may partly guide the subsequent
and B cells are also absent, then one of the alymphocytic evaluation. It has been recently recognized that a few CID
SCID syndromes should be considered (3-5). If B cells are syndromes may be associated with depressed NK cytotoxic-
present, along with NK cells (3-7), consider IL-7 receptor ␣ ity. These include (but are not limited to) XLP, NEMO
(IL7RA) mutation or complete DGS (3-8). deficiency and WAS. (3-16).
3-9. If B cells are present but NK cells absent, consider 3-17. Whether NK function is abnormal or not, there may
mutations that involve common ␥ chain, JAK3, or IL2RA. be characteristic clinical or laboratory features that may sug-
3-10. If host T cells are present and there is selective gest a particular molecular diagnosis (Table 3).
depletion of CD4⫹ cells, consider defects of major histocom- 3-18. The clinical presentation and laboratory evaluation
patibility complex (MHC) class II expression (3-11). so far is suggestive of 1 or more particular disorders. Ad-
Algorithm 5. Diagnosis of complement deficiency. AH50 indicates alternative pathway hemolytic activity; CH50, total hemolytic complement assay.
Algorithm 6. General considerations for therapy of primary immunodeficiency. BMT indicates bone marrow transplantation; CVID, common variable
immunodeficiency; IVIG, intravenous immunoglobulin; and SCIG, subcutaneous immunoglobulin.