Primary immunodeficiency

From IDWiki

Clinical Manifestations

Red Flags for Immunodeficiency

Children Adults
New ear infections ≥4 in 1 year ≥2 in 1 year
Serious sinus infections ≥2 in 1 year ≥2 in 1 year, in the absence of allergy
Pneumonias ≥2 in 1 year ≥2 in 1 year
Deep skin or organ abscesses Recurrent Recurrent
Oral thrush or fungal skin infections Persistent Persistent
Family history of primary immunodeficiency Any Any
Other
  • ≥2 months on antibiotics with little effect
  • Failure to gain weight or grow normally
  • Need for IV antibiotics to treat infections
  • ≥2 deep-seated infections including bacteremia
  • Chronic diarrhea with weight loss
  • Recurrent need for IV antibiotics to treat infections
  • Recurrent viral infections, such as colds, herpes, warts, or condylomata
  • Infection with non-tuberculous mycobacteria

Differential Diagnosis

Children

Disease Defect Age at Diagnosis Notes
Humoural (65%)
X-linked agammaglobulinemia BTK mutation X-linked, very low antibody levels
Common variable immunodeficiency (CVID) multiple 20-40 years low IgG with poor antibody response
Transient hypogammaglobulinemia of infancy
Hyper-IgM syndrome multiple X-linked or autosomal recessive, high IgM with poor T-cell function
IgA deficiency decreased IgA low IgA, often associated with other immunodeficiencies
Cell-Mediated (5%)
DiGeorge syndrome thymus aplasia
Chronic mucocutaneous candidiasis
Combined (15%)
Severe combined immunodeficiency disease (SCID) near-absolute T cell deficiency lymphopenia with hypogammaglobulinemia
Wiskott-Aldrich syndrome WASP mutation X-linked, eczema, thrombocytopenia, low IgM with high IgA
Ataxia-telangiectasia ATM mutation autosomal recessive, with low IgA, CD3, and CD4, and malignancies
X-linked lymphoproliferative disease SAP mutation X-linked, low EBNA antibodies
CD40 ligand deficiency
Hyper-IgE syndrome (Job syndrome) STAT3 mutation eczema, pneumatoceles, mucocutaneous candidiasis, recurrent cutaneous and respiratory infections, and elevated IgE
Phagocytic (10%)
Chronic granulomatous disease (CGD) NADPH oxidase GI and GU granulomas, infections with Staphylococcus aureus, Burkholderia cepacia, Serratia marcescens, Nocardia, and Aspergillus
Leukocyte adhesion deficiency multiple types autosomal recessive
TLR3 deficiency recurrent HSV encephalitis
Complement (5%)
C2 deficiency and other classical complement deficiencies classical complement pathway low CH50, autoimmune disease in C1-C4, bacteremia and meningitis
Properdin deficiency alternative complement pathway more severe than classical complement deficiencies
Immune Dysregulation
Hemophagocytic lymphohistiocytosis
Autoimmune lymphoproliferative disorder (ALPS)
Immunodysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX)
Autoimmune polyendocrinopathy, candidiasis, and ectodermal dystrophy (APECED)

Adults

Disease Arm of Immune System Notes
Adult-Onset Common
IgA deficiency Humoural
Common variable immunodeficiency Humoural
IgG subclass deficiency Humoural
Complement deficiencies Complement
Good syndrome Combined humoural and cell-mediated Very rare. Associated with thymoma and autoimmune diseases
Delayed Presentation Possible
Adenosine deaminase deficiency Combined
Wiskott-Aldrich syndrome Combined
X-linked agammaglobulinemia Humoural
Chronic granulomatous disease Phagocytic
Childhood Onset with Survival to Adulthood
Common variable immunodeficiency Humoural
IgA deficiency Humoural
IgG subclass deficiency Humoural
Complement deficiencies Complement
X-linked agammaglobulinemia Humoural
X-linked hyper-IgM syndrome Humoural
Chronic granulomatous disease Phagocytic
Severe combined immunodeficiency Combined
Wiskott-Aldrich syndrome Combined
Ataxia-telangiectasia Combined
Leukocyte adhesion deficiency Phagocytic

Investigations

  • CBC and peripheral blood film, for lymphopenia, abnormal or unusual lymphocytes or phagocytes, and any other notable abnormalities
    • Lymphopenia may suggest T-cell immunodeficiency
  • Other general screening tests for immunodeficiency: immunoglobulin levels (IgG, IgM, IgA), lymphocyte subpopulations, vaccine titres, and complement assessment (e.g. CH50, AH50)
  • For suspected defect in humoural immunity
    • Serum immunoglobulin levels (IgG, IgM, IgA, and IgE)
    • Specific antibody titres
    • Pre- and post-vaccination IgG titres
    • Flow cytometry to count B cells
  • For suspected defect in cellular immunity
    • TREC newborn screen
    • Flow cytometry to count CD4 and CD8 T-cells and NK cells
      • Flow cytometry is almost always abnormal in SCID
    • Cutaneous delayed hypersensitivity
    • Spontaneous NK cytotoxicity
  • For suspected deficiencies in phagocytes
    • CBC and differential
    • Neutrophil staining for morphology on a peripheral blood film
    • Dihydrorhodamine 1,2,3 response (DHR) for neutrophil function
    • Flow cytometry for adhesion molecules
  • For suspected complement deficiencies
    • CH50 assay (for total complement activity)
    • AH50 assay (for alternative pathway activity)
    • Lectin pathway function
    • Level and/or function of specific complement factors

Further Reading

  • Primary immunodeficiency. Allergy Asthma Clin Immunol. 2018;14(Suppl 2):61. doi: 10.1186/s13223-018-0290-5
  • Attending to Warning Signs of Primary Immunodeficiency Diseases Across the Range of Clinical Practice. J Clin Immunol. 2014;34(1):10-22. doi: 10.1007/s10875-013-9954-6
  • Primary Immunodeficiency Diseases: an Update on the Classification from the International Union of Immunological Societies Expert Committee for Primary Immunodeficiency 2015. J Clin Immunol. 2015;35(8):696-726. doi: 10.1007/s10875-015-0201-1