An unusual presentation of a human TLR pathway deficiency lessons

An unusual presentation of a human TLR pathway deficiency: lessons Helen Chapel Prague 2004 10/29/2008 CH IRAK-4 deficiency 1 Contents • • • • Case Clinical phenotypes TLRs and signalling pathways Defects 10/29/2008 CH IRAK-4 deficiency 2 Case report - infections Eldest of 3 siblings - non consanguinous • “septic pustules” at birth, IV antibiotics • 3 yrs - abscess over scapula • 3-6 years - more abscesses over shoulder, hip, knee, cheek • 6 yrs - septic arthritis • 7 yrs - four more abscesses 10/29/2008 CH IRAK-4 deficiency 3 Case: Pathogens Organisms • Pseudomonas aeruginosa • Staph. aureas • Strep. pyogenes All from separate sites at separate times • Septic arthritis - Strep. Pneumoniae • Meningitis/septicaemia - Shigella 10/29/2008 CH IRAK-4 deficiency 4 Case: Shigella sonnei meningitis/septicaemia • Outbreak in local water supply • Only individual to be systemically unwell • D & V for 5 days before becoming • Acutely unwell “ septic shock”; in ITU • Shigella sonnei cultured from stool, 10/29/2008 CSF, blood CH IRAK-4 deficiency 5 CH in ITU 10/29/2008 CH IRAK-4 deficiency 6 CH 10/29/2008 CH IRAK-4 deficiency 7 Contents • • • • Case Clinical phenotype TLRs and signalling pathways Defects 10/29/2008 CH IRAK-4 deficiency 8 Progress with time • 1974 Born • 1974 - 84 11 episodes of serious sepsis • 1984 Meningitis/ septicaemia • 1984 - 94 3 episodes of sepsis: cellulitis, abscess, osteomyelitis • 1994 - 00 2 abscesses, less severe 10/29/2008 CH IRAK-4 deficiency 9 • 2000 - 04 No infections Acute phase - poor • Neonatal abscess - Neutrophils 1.02 x 109/l • Septic arthritis - no fever, ESR 7, WBC 7.6 • Abscess -15 mls pus, ESR 5, Neutrophils 3.1 • Meningitis/septicaemia - ESR 10, WBC 7.2 • Osteomyelitis (14yr) - Neutrophils 5.1, ESR 35, CRP 6 mg/l • Cellulitis knee (16yr) -WBC 5.9, CRP 6, ESR 10/29/2008 CH IRAK-4 deficiency 10 3 Antibody tests Serum immunoglobulin concentrations: IgG ** IgA IgM IgE Antibodies to:  tetanus,  diphtheria,  pneumococcal ags 10/29/2008 16.7 1.1 1.9 400 6.0 – 13.0 g/l 0.8 – 3.0 g/l 0.4 – 2.5 g/l <125 KU/l 0.06 >0.01 IU/ml 0.18 0.1 IU/ml >100 > 50 U/ml 11 CH IRAK-4 deficiency Neutrophil tests Nitroblue tetrazolium dye test: Medium only Phorbol myristate acid (PMA) Lipopolysaccharide (LPS) Chemotaxis to: N-formalmethionyl peptides (FMLP) Casein 10/29/2008 2% 8.7 +/- 7.3% 99% 99.2 +/- 0.9% 7% >60% 12% 15.7 – 22.4% 7.0% 8.4 – 14.4% CH IRAK-4 deficiency 12 Tested for IL-6 production Casanova’s lab - Horst von Bernuth • Whole blood • Stimulation IL1 / SAC/ LPS / poly I:C stimulation • No pro-inflammatory cytokines [IL-6] • PMA - normal • TNF - normal IL-10 secretion 10/29/2008 CH IRAK-4 deficiency 13 patien t contro l Impaired production of IL-6 in response to all the TLRs. 10/29/2008 CH IRAK-4 deficiency 14 Impact of IRAK-4 deficiency from Puel et al 2003 10/29/2008 CH IRAK-4 deficiency 15 IRAK-4 deficiency • Homozygous IRAK4 mutation • Mutation 877 C to T leading to a premature stop Q 293 X in kinase domain • ? amorphic - IRAK4 mRNA /protein by Northern and Western blots - in progress • ? recessive, heterozygous members - being tested 10/29/2008 CH IRAK-4 deficiency 16 Thank you Oxford: • Patient • Physicians: Christopher Conlon Martin Moncrieff Siraj Misbah Richard Moxon Simon Kroll David Issacs Paris: • Jean-Laurent Casanova • Anne Puel • Horst von Bernuth Tatiana Lawrence Cheng-Lung Ku Estelle Chang • Oxford Immunology Laboratory 10/29/2008 CH IRAK-4 deficiency 17 Contents • • • • Case Clinical phenotypes TLRs and signalling pathways Defects 10/29/2008 CH IRAK-4 deficiency 18 TLR recognising viral proteins & related molecules 10/29/2008 CH IRAK-4 deficiency 19 From Vaidya & Cheng 2003 TLR signallin g in macrophages resulting in anti viral gene expression from Vaidya & Cheng 10/29/2008 2003 CH IRAK-4 deficiency 20 Recognition by mammalian (mice) TLR- pathways 10/29/2008 CH IRAK-4 deficiency From 21 Kopp & Medzhitov 2003 Contents • • • • Case Clinical phenotypes TLRs and signalling pathways Defects 10/29/2008 CH IRAK-4 deficiency 22 IFNA production (H24, PBMC) Clare 24h Ctl V 24h 2000 IFNA (pg/ml) 1600 1200 800 400 0 Medium PolyI:C 34 62 LPS 0 0 Flagellin 0 0 R848 0 931 3M-2 0 341 3M-6 0 0 3M-13 0 642 CpG capu 0 33 CpGAD19 0 2445 CpGC274 0 2679 HSV 333 6631 VSV 20 1782 Clare 24h Ctl V 24h 0 0 Impaired IFNa production in response to the ligands of TLR7/8 (R848, 3M), TLR9 (CpG) and two viruses (HSV, VSV), but a normal response to TLR3 (polyI:C) compared with control. 10/29/2008 CH IRAK-4 deficiency 23 IFNb production (PBMC, H24) Clare CV IFNb (IU/ml) 300 200 100 0 Medi um pol yI:C Cl ar e CV 0 0 0 8 LPS 0 0 Fl agel l i n 0 0 R848 0 7 3M-2 0 3,4 3M-6 0 0 3M-13 0 3,3 CpG capu 0 0,4 CpG D19 0 54 CpG C274 0 46 HS V 35 193 VS V 0 102 Impaired or diminished production of IFNb in response to all the TLRs and tested viruses. 10/29/2008 CH IRAK-4 deficiency 24 MX1 expression (PBMC, H6, dT, GUS) 100 80 Clare CV Fold induction 60 40 20 0 Clar e CV Med 1 1 poly I:C 49 54 LPS 21 36 Flagellin 1 1,6 R848 1 64 CpG C274 1 51 Med H24 1 1 HSV H24 59 14 VSV H24 30 58 Type I IFN induced MX1 gene expression: Normal to TLR3(polyI:C), TLR4(LPS) and HSV, but the response to TLR7/8 & TLR9 is abolished, the response to VZV is diminished. 10/29/2008 CH IRAK-4 deficiency 25 TNFa production (PBMC, H24) 4000 Clare Ctl V 3200 TNFa pg/ml 2400 1600 800 0 Mediu PolyI:C m Clare Ctl V 5 15 18 140 LPS 78 1244 Flagelli R848 n 17 66 0 3800 3M-2 11 8088 3M-6 3M-13 5 34 8 1016 CpG CpGA- CpGC capu D19 274 12 138 8 70 6 182 HSV 63 346 VSV 16 330 Impaired TNFa production in response to all the TLRs tested 10/29/2008 CH IRAK-4 deficiency 26 Relationship of surface receptors & NFkB from Puel et al 2003 10/29/2008 CH IRAK-4 deficiency 27 From Puel et al 2003 10/29/2008 CH IRAK-4 deficiency 28