Anti IFN-gamma autoantibody associated with adult-onset immunodeficiency Presented by Suda Punrin, MD.

1. Autoantibody to Interferon-gamma
Associated with
Adult-Onset Immunodeficiency
Suda Sibunruang, M.D.

2. Outline
• Reported cases
• Interferon  and interleukin-12 pathways
• Natural anti–INF-  antibodies
• Landmark study & present data
• Associated reactive dermatoses
• Autoantibodies to cytokines
• Mendelian susceptibility to mycobacterial infection
• Prognosis
• Treatment

3. ทีมแพทย์ รพ.ศรีนครินทร์ ม.ขอนแก่น
ค้นพบ“โรคภูมิคุ้มกันบกพร่องที่ไม่ใช่เอดส์”
เป็นครั้งแรกของโลก (พ.ศ.2543)
Access from www.kku.ac.th and www.rcpt.org
January 2, 2015
AIDS-like illness which occurs in
otherwise immunocompetent adults

4. Lamb RC. et al. International Journal of Dermatology 2014;53:1197–204
Non-tuberculous mycobacteria (NTM)

5. Lamb RC. et al. International Journal of Dermatology 2014;53:1197–204
Picture from www.drugline.org, Access January 8,2015
• NTM can be isolated from
soil, dust, water, vegetation,
animals, and hospital
environments
• Tap water is the main
reservoir for most
human NTM

6. Chetchotisakd P. et al. Clin Infect Dis 2000;30:29–34
Reported 16 cases of rapidly growing Mycobacterium
(RGM) from 1994 - 1998
• All had chronic bilateral cervical lymphadenopathy
• 12/16 had involvement of other organs
(sinuses, 6; lungs, 4; liver, 4; spleen, 3; skin, 3;
bone and joint, 2; and tonsils, 2)

7. Chetchotisakd P. et al. Clin Infect Dis 2000;30:29–34
• 11/16 had 14 episodes of reactive skin manifestations
(Sweet’s syndrome, 9; generalized pustulosis and
erythema nodosum, 2 each; and pustular psoriasis, 1)
• 8/16 had 11 episodes of other opportunistic
pathogens (salmonellosis, 4; penicilliosis, 3;
pulmonary tuberculosis, 2; and melioidosis and
cryptococcosis, 1 each)

8. Chetchotisakd P. et al. Clin Infect Dis 2000;30:29–34

9. Chetchotisakd P. et al. Clin Infect Dis 2007;45:421–6
From 1994-2006, there were 129 cases
• All patients but 1 were adults
• 99 cases due to RGM and 34 due to SGM

10. Chetchotisakd P. et al. Clin Infect Dis 2007;45:421–6

11. Chetchotisakd P. et al. Clin Infect Dis 2007;45:421–6
21/129 (16.3%) patients had positive
results of blood cultures
Infected with other
intracellular pathogens

12. Chetchotisakd P. et al. Clin Infect Dis 2007;45:421–6
The majority of patients had Sweet syndrome as their
first presentation along with cervical lymphadenopathy

13. Chetchotisakd P. et al. Clin Infect Dis 2007;45:421–6
Sweet syndrome NTM involved skin

14. Chetchotisakd P. et al. Clin Infect Dis 2007;45:421–6
Anti–IFN-  IgG autoantibodies were also present
in 5 anonymous serum samples obtained
from the patients tested

15. Hoflich C. et al. Blood. 2004;103:673-5
A 25-year-old Thai woman, Anti – HIV – negative
• Necrotizing lymphadenitis, tonsillitis, bilateral pneumonia,
splenic and intracerebral abscesses, and osteomyelitis from
Burkholderia cocovenenans (16S rDNA sequence)
• Fatal septic shock from Mycobacterium chelonae

16. Concanavalin A stimulation
• Whole blood stimulation revealed no
detectable IFN- production, whereas IL-4
production was unaffected
• Intracellular IFN- staining of whole blood
cells following stimulation was positive
• Stimulation of PBMCs showed normal levels
of IFN- secretion
• Inhibitory IFN- activity in the patient’s plasma
Hoflich C. et al. Blood. 2004;103:673-5

17. Hoflich C. et al. Blood. 2004;103:673-5
Add recombinant IFN- to the patient’s plasma and
measuring IFN- concentration by ELISA

18. Hoflich C. et al. Blood. 2004;103:673-5
PBMCs from a healthy volunteer were incubated with IFN-
in the presence of either patient’s plasma or control plasma
Absence of autologous plasma, the patient’s PBMCs responded
normally to exogenous and endogenous IFN-

19. Hoflich C. et al. Blood. 2004;103:673-5
High-affinity IFN-–binding activity is an
anti–IFN- IgG4 autoantibody
However, the pathogenesis of autoantibody
formation to IFN-  in this patient remains unclear

20. Doffinger R. et al. Clin Infect Dis 2004;38:e10-4
Autoantibodies to Interferon- in a Patient
with Selective Susceptibility to Mycobacterial
Infection and Organ-Specific Autoimmunity
A 47-year-old, previously fit, Filipino man
• Disseminated Mycobacterium tuberculosis
• Disseminated Mycobacterium chelonae

21. Doffinger R. et al. Clin Infect Dis 2004;38:e10-4
Autoantibodies to Interferon- in a Patient
with Selective Susceptibility to Mycobacterial
Infection and Organ-Specific Autoimmunity
Anti–IFN-  activity
Impaired IFN-  and IL-12 secretion
PBMC + 5% autologous serum

22. Doffinger R. et al. Clin Infect Dis 2004;38:e10-4
Autoantibodies to Interferon- in a Patient
with Selective Susceptibility to Mycobacterial
Infection and Organ-Specific Autoimmunity
Mendelian defects in IL-12–dependent INF-  pathway
were excluded by sequencing the IFNGR1, IFNGR2,
STAT1, IL12B, and IL-12RB1 genes

23. Doffinger R. et al. Clin Infect Dis 2004;38:e10-4
A year after the patient commenced IFN-  therapy
• recurrent candidiasis
The patient died of overwhelming mycobacterial infection
Similar to autoimmune polyendocrinopathy candidiasis-
ectodermal dystrophy

24. From 2004-2005
• 11 cases from 4 reports
• 8/11 were Asians
5 were Filipino
1 was Taiwanese
1 was Vietnamese
1 was Thai
Hoflich C. et al. Blood. 2004;103:673-5
Doffinger R. et al. Clin Infect Dis 2004;38:e10-4
Kampmann B. et al. J Clin Invest 2005;115:2480-8
Patel SY. et al. J Immunol 2005;175:4769-76

25. Interferon-  and interleukin-12
pathways

26. Dorman SE and Holland SM Cytokine & Growth Factor Reviews 2000;11;321-33
p35
p40

27. Dorman SE and Holland SM Cytokine & Growth Factor Reviews 2000;11;321-33
p35
p40

28. Dorman SE and Holland SM Cytokine & Growth Factor Reviews 2000;11;321-33
• Production of cytokines and chemokines
• Enhancement TNF- production
• Upregulation of MHC class II expression
• Enhancement antigen processing
• Production of reactive oxygen and
nitrogen intermediates (in mice)
Main regulatory pathway
of cell-mediated immunity

29. Dorman SE and Holland SM Cytokine & Growth Factor Reviews 2000;11;321-33
IFNGR1 gene is located on chromosome 6
IFNGR2 gene is located on chromosome 21

30. Dorman SE and Holland SM Cytokine & Growth Factor Reviews 2000;11;321-33
IFNR1/IFN complex
IFN-responsive genes
• Antiviral activity
• Apoptosis,
• Antigen processing
• MHC expression
• TH1 development
• Activates macrophages

31. Casanova JL. Swiss Med Wkly 2001;131:445-54

32. Doffinger R. et al. Curr Opin Rheumatol 2005;17:440—6
Bacterial ligands like
mycobacterial lipoarabinomannan

33. Natural anti–INF-  antibodies
Have been reported in patients with
• Tuberculosis
• Viral diseases
• Healthy subjects
• HIV-infected individuals
• Experimental African trypanosomiasis
Doffinger R. et al. Clin Infect Dis 2004;38:e10-4
But the potential pathogenic impact of these
antibodies has not been established

34. Madariaga L. et al. Int J Tuberc Lung Dis 1998;2:62-8
Anti–IFN-  antibodies
Autoantibody titres correlated with
serum interferon-  concentrations

35. Caruso A. et al. J Immunol 1990;144:685-90
180 Healthy individuals

36. Caruso A. et al. J Immunol 1990;144:685-90
Titer of anti-IFN-  antibodies
during a viral infection
Infectious mononucleosis
Varicella
Measles
Healthy persons

37. Natural anti–INF-  antibodies in healthy
patients were detected in low titers and
been biologically inactive without
antagonist activity against IFN-  signaling
Lee WI. et al. Immunobiology 2013;218:762–71

38. Browne SK et al. N Engl J Med 2012;367:725-34

39. Methods
Enrolled 203 persons from Thailand and Taiwan
• Group 1: 52 patients with disseminated, rapidly or
slowly growing, nontuberculous mycobacterial
(NTM) infection
• Group 2: 45 patients with another opportunistic
infection, with or without NTM infection
• Group 3: 9 patients with disseminated tuberculosis
• Group 4: 49 patients with pulmonary tuberculosis
• Group 5: 48 healthy controls
Browne SK et al. N Engl J Med 2012;367:725-34

40. Browne SK et al. N Engl J Med 2012;367:725-34 (supplementary appendix)
Group 1 - 4

41. Browne SK et al. N Engl J Med 2012;367:725-34
Normal range was defined “ 99th percentile
for the patients with pulmonary TB and
the healthy controls combined ”

42. Browne SK et al. N Engl J Med 2012;367:725-34
Anti–Interferon-  autoantibody concentrations according to study group
Group 1 & 2
99 percentile
These anti–interferon-  autoantibodies
did not block STAT1 phosphorylation

43. Browne SK et al. N Engl J Med 2012;367:725-34 (supplementary appendix)
Anti–IFN-  autoantibody levels
Although antibody levels may decrease
with disease quiescence, they can
persist for years

44. Browne SK et al. N Engl J Med 2012;367:725-34 (supplementary appendix)
Forty other anticytokine autoantibodies were assayed

45. Browne SK et al. N Engl J Med 2012;367:725-34 (supplementary appendix)

46. Browne SK et al. N Engl J Med 2012;367:725-34
STAT1 phosphorylation
However, permitting interferon-α–induced STAT1 phosphorylation

47. Browne SK et al. N Engl J Med 2012;367:725-34 (supplementary appendix)
• Absence of familial clustering
• Normal expression of interferon-  receptor 1
• Lymphocytes count (including CD4+ T cells) were normal

48. Remarks
• Trigger for production of these
autoantibodies remains elusive
• Nearly all patients identified have been
Asian-born Asians, implicates host
genetic factors, environmental
exposure, or both
Browne SK et al. N Engl J Med 2012;367:725-34

49. Chi CY. et al. Blood 2013;121:1357-66
HLA-DRB1*16:02 (odds ratio 8.68; 95%CI, 3.47-21.90)
HLA-DQB1*05:02 (odds ratio 7.16; 95%CI, 3.02-17.05)
were found in 82% (14 of 17) of our patients
Genetic risk factors ?

50. Genetic risk Factors ?
Even the largest cohort of patients
• No familial clustering
• Few reported in Asians born outside of Asia
Browne SK. et al. Annu Rev Immunol 2014;32:635–57
Suggesting
1. Genetics are likely complex
2. Environmental factors, possibly early in life,
may contribute to

51. Wongkulab P. et al. PloS One 2013;8:e76371

52. Wongkulab P. et al. PloS One 2013;8:e76371
Mean 2.460 ± 1.309 O.D. among cases
Mean 0.058 ± 0.004 O.D. among HIV
Mean 0.059 ± 0.005 O.D. among controls
n 20 20 20

53. Tang B. et al. CLINICAL AND VACCINE IMMUNOLOGY 2010;17:1132–8

54. Subgroup analysis:
• level of autoantibody in patients with active infections
was relatively higher than those without
(mean 3.279 ± 0.662 Vs 0.939 ± 0.630 O.D.)
• level of autoantibody may have a role in monitoring
disease activity or recurrence of the disease
Wongkulab P. et al. PloS One 2013;8:e76371

55. Wipasa J. et al. PloS One 2014;10:e110276
- No differences in %monocytes,
CD 68 and HLA-DR
- Normal inducible nitric oxide
synthase (iNOS) production
(not shown)
- Higher CD119, suggesting
the presence of activated
monocytes in the circulation

56. Wipasa J. et al. PloS One 2014;10:e110276
This adult-onset immunodeficiency may be associated
with one or more of the abnormal immune responses
Mitogen stimulation

57. Lee WI. et al. Immunobiology 2013;218:762–71
Normal genetic sequencing or/and candidate protein
expressions of IFN-R1, IFN-R2, IL-12p40, IL-12R-1,
STAT-1, NEMO, IKBA, CYBB and IRF8

58. Suggest including anti-IFN- autoantibodies
in the differential diagnosis of
• HIV-negative adult patients with unknown cell-mediated
immunodeficiency
• Severe, persistent or recurrent infections caused by NTM
or Salmonella
• Especially in Asian patients
• Reactive skin lesions or autoimmune endocrinopathy
Kampitak T. et al. Infection 2011;39:65–71

59. Chan J et al. Dermatology 2013;226:157–66

60. Chan J et al. Dermatology 2013;226:157–66
1. Progressive painful erythematous
papules over 2 weeks

61. Chan J et al. Dermatology 2013;226:157–66
2. Multiple painful non-ulcerated
infiltrated plaques

62. Chan J et al. Dermatology 2013;226:157–66
3. Progressively enlarging erythematous
scaly non-painful nodules

63. Chan J et al. Dermatology 2013;226:157–66
1. Suppurative inflammation
sparing the epidermis -> Sweet’s syndrome

64. Chan J et al. Dermatology 2013;226:157–662. Lobular panniculitis

65. Chan J et al. Dermatology 2013;226:157–663. Multiple epitheloid granulomas
-> skin infection by NTM

66. Different forms of dermatoses
Broadly classified into
• Reactive dermatoses
- Sweet’s syndrome
- Erythema nodosum
- Lobular panniculitis
- Generalized pustular eruptions (AGEP,
pustular psoriasis and subcorneal pustulosis)
• Direct invasion of the skin in disseminated infection
Chan J et al. Dermatology 2013;226:157–66
-> most common

67. Cohen PR. Orphanet Journal of Rare Diseases 2007;2:34
Sweet's syndrome
can present in several
clinical settings:
- Classical (or idiopathic)
- Malignancy associated
- Drug-induced

68. Cohen PR. Orphanet Journal of Rare Diseases 2007;2:34
Diagnostic criteria for classical Sweet's syndrome
Major
Minor
Both major criteria, and 2/4 of minor criteria

69. Cohen PR. Orphanet Journal of Rare Diseases 2007;2:34
Papillary dermal edema,
swollen endothelial cells
Diffuse infiltrate of neutrophils

70. Chan J et al. Dermatology 2013;226:157–66

71. Chiewchanvit S. et al. J Med Assoc Thai 2013;96:1609-16
Acitretin, a second-generation retinoid, have been
reported in the treatment of pustular diseases
including pustular psoriasis, subcorneal
pustular dermatosis, eosinophilic pustular
folliculitis, and AGEP

72. Chiewchanvit S. et al. J Med Assoc Thai 2013;96:1609-16

73. Chiewchanvit S. et al. J Med Assoc Thai 2013;96:1609-16

74. Chiewchanvit S. et al. J Med Assoc Thai 2013;96:1609-16

75. Chiewchanvit S. et al. J Med Assoc Thai 2013;96:1609-16

76. Chiewchanvit S. et al. J Med Assoc Thai 2013;96:1609-16

77. Autoantibodies to cytokines

78. Browne SK. Annu. Rev. Immunol. 2014;32:635–57

79. Browne SK. Annu. Rev. Immunol. 2014;32:635–57

80. Autoantibodies to cytokines
• Occur in many different conditions
• May also develop against
exogenously cytokines
• Have been identified in health and
disease, with their relationship
ranging from none to directly causal
Browne SK and Holland SM. Lancet Infect Dis 2010;10:875-85

81. Browne SK and Holland SM. Lancet Infect Dis 2010;10:875-85

82. Mendelian susceptibility to
mycobacterial infection (MSMD)

83. Mendelian susceptibility to
mycobacterial infection
• Selective susceptibility to weakly pathogenic
mycobacteria, such as BCG vaccine and
environmental NTM causing idiopathic,
disseminated infection, has long been
suspected to be a Mendelian disorder
Casanova JL. Swiss Med Wkly 2001;131:445-54

84. Muhsen SA and Casanova JL. J Allergy Clin Immunol 2008;122:1043-51
Geographical origin of kindreds with genetic defects of MSMD
Not confined to a particular ethnic group or geographic region

85. Vosse E. and Ottenhoff T. Microbes and Infection 2006;8:1167-73

86. Access January 8, 2015

87. Casanova JL. Swiss Med Wkly 2001;131:445-54
Muhsen SA and Casanova JL. J Allergy Clin Immunol 2008;122:1043-51
Six genes have been found to be mutated
IFNGR1 & IFNGR2
STAT 1
IL12 p40 IL12RB1
NEMO

88. Muhsen SA and Casanova JL. J Allergy Clin Immunol 2008;122:1043-51

89. Nine different inheritable disorders
• Two forms of complete recessive IFN R1 deficiency
• Complete IFN R2 deficiency
• Partial recessive IFN R1 deficiency
• Partial recessive IFN R2 deficiency
• Partial dominant IFN R1 deficiency
• Partial STAT-1 deficiency
• Complete IL-12 p40 deficiency
• Complete IL-12R1 deficiency
Casanova JL. Swiss Med Wkly 2001;131:445-54

90. Nine different inheritable disorders
• Two forms of complete recessive IFN R1 deficiency
• Complete IFN R2 deficiency
• Partial recessive IFN R1 deficiency
• Partial recessive IFN R2 deficiency
• Partial dominant IFN R1 deficiency
• Partial STAT-1 deficiency
• Complete IL-12 p40 deficiency
• Complete IL-12R1 deficiency
Casanova JL. Swiss Med Wkly 2001;131:445-54

91. Nine different inheritable disorders
• Two forms of complete recessive IFN R1 deficiency
• Complete IFN R2 deficiency
Casanova JL. Swiss Med Wkly 2001;131:445-54
• Early childhood ( < 3 yr)
• Overwhelming infections
• Lesions are multibacillary
• Impaired granuloma formation

92. Nine different inheritable disorders
• Two forms of complete recessive IFN R1 deficiency
• Complete IFN R2 deficiency
• Partial recessive IFN R1 deficiency
• Partial recessive IFN R2 deficiency
• Partial dominant IFN R1 deficiency
• Partial STAT-1 deficiency
• Complete IL-12 p40 deficiency
• Complete IL-12R1 deficiency
Casanova JL. Swiss Med Wkly 2001;131:445-54

93. Nine different inheritable disorders
• Partial recessive IFN R1 deficiency
• Partial recessive IFN R2 deficiency
• Partial dominant IFN R1 deficiency
• Partial STAT-1 deficiency
• Complete IL-12 p40 deficiency
• Complete IL-12R1 deficiency
Casanova JL. Swiss Med Wkly 2001;131:445-54
• Various ages
• Curable infections
• Lesions are paucibacillary
• Mature granulomas

94. Vosse E. et al. Lancet Infect Dis 2004;4:739–49

95. Muhsen SA and Casanova JL. J Allergy Clin Immunol 2008;122:1043-51

96. Vosse E. et al. Lancet Infect Dis 2004;4:739–49

97. Till…2013
25 reported cases from PubMed search
• Majority of cases were Asian (8 Chinese,
6 Filipino, 4 Thai, 4 Taiwanese, 2
Japanese, and 1 Vietnamese)
• Organs involved were the lymph nodes
(22), lungs (19), bones (12), soft tissue
(9), bone marrow (7), and skin (7)
Lee WI. et al. Immunobiology 2013;218:762–71

98. Till…2013
• Tissue cultures and pathology findings
rather than blood cultures provided
evidence of NTM
• Both slow- and rapidly growing NTM were
causative pathogens, with Mycobacterium
avium complex (14) and M. chelonae (7)
• 6 patients were infected with multiple
species of mycobacteria, including both
NTM and M. tuberculosis
Lee WI. et al. Immunobiology 2013;218:762–71

99. Till…2013
• Co-infections with P. marneffei and
Salmonella spp. simultaneously
developed in 11 and 7 patients
• Experience both dermatomal and
disseminated varicella zoster
reactivation at higher frequency
Lee WI. et al. Immunobiology 2013;218:762–71
Browne SK. et al. Annu Rev Immunol 2014;32:635–57

100. Till…2013
• Laboratory features often indicative of
chronic inflammation or infection,
including anemia, leukocytosis, elevated
ESR, CRP, and/or β2-microglobulin and
polyclonal hypergammaglobulinemia
Browne SK. et al. Annu Rev Immunol 2014;32:635–57

101. Till…2013
• grossly normal immunologic
parameters, including CD4+ T
lymphocytes, monocyte numbers, and
IFNγR1 expression
Browne SK. et al. Annu Rev Immunol 2014;32:635–57

102. Browne SK and Holland SM. Current Opinion in Allergy and Clinical Immunology 2010;10:534–41

103. Prognosis
• 32% mortality by a median of
25 months after diagnosis
Wongkulab P. et al. PloS One 2013;8:e76371

104. Treatment

105. Treatment
• Treating the disease consequences
• Targeting the autoantibody
Browne SK and Holland SM. Lancet Infect Dis 2010;10:875-85

106. Treatments
• Majority fail to show a sustained
response to IFN-  treatment
• IVIG for neutralizing and plasmapheresis
to remove antibody, are not consistently
effective
Lee WI. et al. Immunobiology 2013;218:762–71

107. Browne SK et al. Blood 2012;119:3933-9
Rituximab was used in 4 patients with high-titer
anti–IFN-  autoantibodies who had progressive refractory
NTM disease despite aggressive anti-infective treatment
• Treat according to a lymphoma regimen,
additional doses were given for persistence or relapse
• Aim of depleting B cells
• Other possible mechanisms; modulation cell surface
receptors, modulation B-cell, elimination plasmablasts

108. Browne SK et al. Blood 2012;119:3933-9
Rituximab was given at 375mg/m² weekly x 4 doses,
then at wider intervals
8 - 12 doses over the first year

109. Browne SK et al. Blood 2012;119:3933-9

110. Browne SK et al. Blood 2012;119:3933-9
Within 2-6 months after treatment, all patients had
marked clinical, radiologic, and laboratory improvement

111. Conclusion
• Not all cases of anti–IFN-  autoantibody-
mediated disseminated mycobacterial
disease require rituximab
• Recommend for those with persistent,
progressive, severe anti–IFN-  autoantibody–
associated infection
Browne SK et al. Blood 2012;119:3933-9

112. Czaja C. et al. Clin Infect Dis 2014;58:e115–8

113. Future well controlled
studies are needed to
evaluate the safety and
efficacy of this approach

114. Take home messages (1)
Suggest including anti-IFN- autoantibodies
in the differential diagnosis of
• HIV-negative patients
• Severe, persistent or recurrent infections
caused by NTM and other opportunistic
infections
• Reactive skin dermatoses
• Especially in Asian patients

115. Take home messages (2)
• Trigger for these autoantibodies
remains unknown
• Patients with genetic defects tend to
present early in life, and often show
familial clustering

116. Thank you for your attention