A low %DHR value strongly predicts infection risk in X-linked CGD carriers, and the carrier state itself is associated with autoimmunity.

Ras-related C3 botulinum toxin substrate 2 (RAC2), through interactions with reduced NAD phosphate oxidase component p67phox, activates neutrophil superoxide production, whereas interactions with p21-activated kinase are necessary for fMLF-induced actin remodeling. We identified 3 patients with de novo RAC2[E62K] mutations resulting in severe T- and B-cell lymphopenia, myeloid dysfunction, and recurrent respiratory infections. Neutrophils from RAC2[E62K] patients exhibited excessive superoxide production, impaired fMLF-directed chemotaxis, and abnormal macropinocytosis. Cell lines transfected with RAC2[E62K] displayed characteristics of active guanosine triphosphate (GTP)–bound RAC2 including enhanced superoxide production and increased membrane ruffling. Biochemical studies demonstrated that RAC2[E62K] retains intrinsic GTP hydrolysis; however, GTPase-activating protein failed to accelerate hydrolysis resulting in prolonged active GTP-bound RAC2. Rac2+/E62K mice phenocopy the T- and B-cell lymphopenia, increased neutrophil F-actin, and excessive superoxide production seen in patients. This gain-of-function mutation highlights a specific, nonredundant role for RAC2 in hematopoietic cells that discriminates RAC2 from the related, ubiquitous RAC1.

Germline mutation in GATA2 can lead to GATA2 deficiency characterized by a complex multi-system disorder that can present with many manifestations including variable cytopenias, bone marrow failure, myelodysplastic syndrome/acute myeloid leukemia (MDS/AML), and severe immunodeficiency. Penetrance and expressivity within families is often variable. There is a spectrum of bone marrow disease in symptomatic cytopenic patients ranging from hypocellular marrows without overt dysplasia to those with definitive MDS, AML, or chronic myelomonocytic leukemia. Relatives of probands with the same mutations may demonstrate minimal disease manifestations and normal marrows. A comprehensive clinical, hematological and genetic assessment of 25 patients with germline GATA2 mutation was performed. MDS-associated mutations were identified in symptomatic GATA2 patients both with overt MDS and in those with hypocellular/aplastic bone marrows without definitive dysplasia. Healthy relatives of probands harboring the same germline GATA2 mutations had essentially normal marrows that were overall devoid of MDS-associated mutations. The findings suggest that abnormal clonal hematopoiesis is a common event in symptomatic germline mutated GATA2 patients with MDS and also in those with hypocellular marrows without overt morphologic evidence of dysplasia, possibly indicating a pre-MDS stage warranting close monitoring for disease progression.

Four patients with adult-onset, disseminated mycobacterial infection had 5' UTR mutations in IKBKG without clear physical stigmata of NEMO deficiency. These mutations caused decreased levels of NEMO protein and Toll-like receptor driven cytokine production. Three patients died from disseminated disease. These mutations may be missed by whole exome sequencing.

BACKGROUND Gastroesophageal reflux disease (GERD) and gastric acid hypersecretion respond well to suppression of gastric acid secretion. However, clinical management and research in diseases of acid secretion have been hindered by the lack of a non-invasive, accurate and reproducible tool to measure gastric acid output (GAO). Thus, symptoms or, in refractory cases, invasive testing may guide acid suppression therapy. AIM To present and validate a novel, non-invasive method of GAO analysis in healthy subjects using a wireless pH sensor, SmartPill® (SP) (SmartPill® Corporation, Buffalo, NY). METHODS Twenty healthy subjects underwent conventional GAO studies with a nasogastric tube. Variables impacting liquid meal-stimulated GAO analysis were assessed by modeling and in vitro verification. Buffering capacity of Ensure Plus® was empirically determined. SP GAO was calculated using the rate of acidification of the Ensure Plus® meal. Gastric emptying scintigraphy and GAO studies with radiolabeled Ensure Plus® and SP assessed emptying time, acidification rate and mixing. Twelve subjects had a second SP GAO study to assess reproducibility. RESULTS Meal stimulated SP GAO analysis was dependent on acid secretion rate and meal buffering capacity but not on gastric emptying time. On repeated studies, SP GAO strongly correlated with conventional BAO (r=0.51, P=0.02), MAO (r=0.72, P=0.0004) and PAO; (r=0.60, P=0.006). The SP sampled the stomach well during meal acidification. CONCLUSIONS SP GAO analysis is a non-invasive, accurate and reproducible method for the quantitative measurement of GAO in healthy subjects. SP GAO analysis could facilitate research and clinical management of GERD and other disorders of gastric acid secretion.

Summary In the absence of acquired or secondary immunosuppression, mutations causing failure to properly activate the IL-12/IFN-γ pathway, NF-κB, or STAT3 should be excluded in patients presenting with severe histoplasmosis.

Background Allogeneic hematopoietic stem cell transplant (HSCT) is curative for patients (pts) with severe aplastic anemia (SAA). For SAA pts who lack HLA-identical donors, we explored a HSCT approach that co-infuses PBSCs enriched for CD34+ cells from a haplo-identical relative combined with a single umbilical cord blood unit (UCB). Although most pts undergoing this approach had early haplo-myeloid engraftment that was eventually supplanted by the UCB unit, engraftment patterns were highly variable; in some pts full cord myeloid chimerism was delayed greater than one year, while others had loss of cord engraftment with sustained full haplo-donor myeloid chimerism. Here, we investigated the impact of various patient, UCB, and haplo-donor characteristics, as well as NK cell KIR ligand mismatches between graft sources, on engraftment kinetics following haplo-cord HSCT. Methods Pts with SAA or SAA evolved to MDS unresponsive to immunosuppressive therapy with severe neutropenia (ANC<500), who lacked an HLA-matched donor and had an available haploidentical family member, and had at least one ≥ 4/6 matched UCB unit with a minimum TNC dose ≥1.5x107 cells/kg were eligible for HSCT. Pts were conditioned with cyclophosphamide (120 mg/kg), fludarabine (125 mg/m2), equine-ATG (160 mg/kg) and 200 cGy of total body irradiation. On Day 0, pts received a CD34 selected (Miltenyi CliniMacs) G-CSF mobilized haplo-donor allograft combined with a single UCB. Tacrolimus and MMF were given for GVHD prophylaxis. Results 16 pts (median age: 18.9 yrs, range: 4.5-27.9) including 13 SAA and 3 with SAA evolved to MDS underwent haplo-cord transplant. Ten pts received a 4/6, and six pts received a 5/6 HLA-matched UCB unit. A median 3.6x107 TNC/kg (range: 1.96-6.93) from the UCB unit, and 3.3x106CD34+ cells/kg (range: 3.0-4.1) from the haplo-donor were transplanted. All 16 pts had sustained engraftment with 15/15 pts evaluable past day 100 having transfusion independence. At a median follow-up of 570 days (range: 55-1826), 14/16 pts survive for an overall survival rate of 81.8%. Two pts died at day 414 and 402 post-HSCT from viral related complications (CMV pneumonitis and limbic encephalopathy). Neutrophil and platelet recovery occurred at a median 10 (range: 9-22), and 21 (range: 10-213) days post-HSCT, respectively. By post-HSCT day 11, 15/16 pts had neutrophil recovery. Cord myeloid engraftment (cord ANC>500, calculated from chimerism data) occurred in 13/16 pts at a median 42 days. 3/16 did not achieve a cord ANC>500 but had sustained haplo-donor engraftment. The cumulative incidence of acute grade II-IV GvHD was 38.1%. Engraftment profiles were highly variable among pts; 12 achieved full cord chimerism in all cell lineages, 2 remained mixed haplo-cord chimeras, and 2 failed to have UCB engraftment but had sustained 100% haplo-donor myeloid chimerism. Higher degrees of HLA matching (out of 10 alleles) between recipient and UCB unit were associated with faster rates of full cord engraftment (p=0.006) and a higher probability of complete loss of haplo-donor chimerism (p=0.018). KIR ligand incompatibility in the haplo vs. cord direction (defined as the presence of a KIR ligand in the haplo-donor graft that is absent in the UCB unit at HLA epitopes Bw4, HLA-C Group 1 & 2, HLA-A3, and HLA-A11) negatively impacted cord myeloid engraftment. 5/5 (100%) pts who failed to achieve full cord myeloid chimerism by post-HSCT day 400 had haplo vs. cord KIR ligand incompatibility. Moreover, both pts who failed to have UCB engraftment and had sustained haplo-donor chimerism had haplo vs. cord KIR ligand incompatibility. In contrast, only 3/11 (27%) pts who achieved full cord myeloid chimerism post-HSCT by day 231 had haplo vs. cord KIR ligand incompatibility (p=0.026). KIR ligand incompatibility in the cord vs. haplo direction showed no significant effect on haplo-donor myeloid engraftment. Conclusion These results show that haplo-cord HSCT is an effective treatment option for pts with SAA who lack an HLA-matched donor. Further, these results suggest that NK cell alloreactivity, occurring as a consequence of KIR ligand mismatch between the two graft sources, may have a negative impact on cord engraftment when haplo vs. cord KIR ligand incompatibility is present. In summary, this study highlights a novel factor that should be considered during graft selection for haplo-cord transplantation. Disclosures: No relevant conflicts of interest to declare.

Interleukin-7 (IL7) is a multifunctional cytokine with critical and non-redundant roles in T-cell development, T-lymphopoiesis and peripheral T-cell homeostasis. We report preliminary results of the first phase I study of recombinant human IL7, “CYT 99-007” (rhIL7). Adults with incurable malignancy (11 men and 3 women), 20–71 years old (median 48) received escalating doses (3, 10, 30 or 60 μg/kg/dose) subcutaneously every other day for 2 weeks. IL7 was overall well tolerated with no Maximum Tolerated Dose yet reached. Dose-dependent and age independent biological effects consistent with murine and non-human primate pre-clinical models were observed in all patients receiving 10 μg/Kg/dose or more: enlargement of spleen and lymph nodes (but not thymus) by CT scan and marked proliferation and expansion of T-cells subsets. Increases in CD4+ and CD8+ T-cells were most prominent in naïve T-cells (CD27+CD45RA+), including Recent Thymic Emigrants (RTE) (CD4+/CD45RA+/CD31+) with a mean 6-fold expansion, and in memory T-cells (CD27+CD45RA−) but less so in effector T-cells (CD27−). Furthermore, IL7 therapy resulted in a decline in the relative frequency of T-regs (50–80% decline in FoxP3 mRNA copies normalized to Actin mRNA copies in sorted CD4+ T-cells). Although the magnitude of biological effects was variable, the kinetics were similar in all T-cell subsets and at all effective doses. After one week of therapy at 30μg/ Kg /dose, 30–70% of naïve CD4+ and CD8+ T-cells were in cycle (Ki-67+) and expressed elevated levels of Bcl-2. Bcl-2 up-regulation (maintained at week 2) and high proliferation rates resulted in T-cell expansion (mean of 6- and up to 14-fold in some individuals at the 30μg dose) persisting one to several weeks after treatment. Consistent with animal data, we observed IL7 receptor α-chain (IL7Rα) down-regulation: both IL7Rα mean fluorescent intensity by flow cytometry (CD127) and mRNA copy numbers declined more than 50% at one week. By the end of treatment, proliferation rates were halved and down to baseline by week 3, coincident with recovery of IL7Rα expression after cessation of treatment. The T-cell increase was primarily due to IL7 induced peripheral expansion. There was no dilution effect of T-Cell Receptor Excision Circles (TREC) numbers per 105 CD4+ sorted cells which suggests cell recruitment or expansion, consistent with preclinical data but does not exclude a thymic contribution. rhIL7 is safe at biologically active doses in humans and induces an expansion of naïve (including RTE) and memory T-cells. In contrast to IL2, IL7’s role in T-regs homeostasis appears to be minimal. rhIL7 may prove clinically valuable in adoptive immunotherapy as an immuno-restorative agent in conditions of disease (HIV) or chemotherapy induced T-cell depletion or as an adjunct to tumor vaccination for immune response modulation.