A new CECR1 mutation associated with severe hematological involvement in ADA2 deficiency

doi:10.21203/rs.3.rs-2111441/v1

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A new CECR1 mutation associated with severe hematological involvement in ADA2 deficiency

https://doi.org/10.21203/rs.3.rs-2111441/v1

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Background: The deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessively inherited disease resulting from loss-of-function mutations in ADA2, formerly named CECR1 (cat eye syndrome chromosome region, candidate 1) gene. Disease manifestations could be separated into three major phenotypes: inflammatory/vascular, immune dysregulatory and hematologic, however, most patients presented with significant overlap between these three phenotype groups. Due to its large heterogeneity, DADA2 is often mistaken with other connective tissue diseases. Over 60 DADA2-associated mutations have been identified so far, still we describe a new mutation with possible relation to severe hematological involvement

Case presentation: We present a case of DADA2 deficiency with disease onset at 3 years old with fever, oligoarthritis, mouth sores and recurrent episodes of neutropenia misdiagnosed as Behcet disease, then systemic lupus erythematosus. At the age of 18 she developed gastrointestinal vasculitis complicated with multiple bowel resections, enterocutaneous fistulas and lower limb ischemia. Genetic testing reveals heterozygous mutations at positions 139 (exon 2) and 661_664 (exon 4) of the coding sequence of ADA2 (c.139G>A, c.661_664del), resulting respectively in amino acid substitution p.Gly47Arg and premature translational stop signal p.Ala221Glnfs*45 in ADA2. Thus, the patient was diagnosed with ADA2 deficiency. TNF blockers were started but the patient died due to septic complications related to severe, nonresponsive pancytopenia.

Conclusions: Our case highlights the valuable diagnostic benefit of early specific genetic testing for patients with complex unclear diseases in which vasculopathy/vasculitis, dysregulated immune function and/or hematologic abnormalities may predominate.

Adenosine deaminase 2 deficiency

DADA2

vasculitis

neutropenia

immunodeficiency

case report

The deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessively inherited disease that has undergone extensive phenotypic expansion since being first (1–3). Associated with biallelic mutations in ADA2 (previously CECR1), it was originally depicted in 2014, as a mimic of polyarteritis nodosum with early-onset stroke, systemic inflammation, vasculopathy, and mild immunodeficiency (3). Since then, accumulating reports of approximately 300 patients have broadened the phenotypic spectrum of this disease that ranges from mild skin involvement to major organ involvement to also include additional traits such as hematologic defects (1).

A 18-year-old female patient with recurrent severe neutropenia was transferred to our unit for diagnostic assessment. The patient started experiencing recurrent bouts of oral aphthae and fever since the age of 3. Around the age of 10, she associated recurrent episodes of acute onset oligoarthritis in small and large joints. Blood work depicted intermittent neutropenia and elevated C-reactive protein.

At the age of 16 she was diagnosed with Behcet’s syndrome, based on the presence of oral aphthae, one episode of genital aphthae and the presence of HLAB51 antigen. Corticotherapy and colchicine were commenced with a favorable outcome. Hematologic investigations (bone marrow aspiration, lymphocyte immunophenotyping) could not identify a plausible cause of leukopenia.

At the age of 17, she was admitted to the Pediatric Intensive Care Unit with spontaneous Clostridial myonecrosis (Fig. 1a). During hospitalization she develops severe abdominal pain and she is also diagnosed with perforated intestinal vasculitis. Prompt surgical intervention saved her life, but during the next months multiple complications arose, that led to left hip disarticulation, multiple bowel resections, enterocutaneous fistulas, skin grafts, ileocolostomy with repeated refistulisation (Fig. 1b). Low antinuclear antibodies and dsDNA led to the diagnosis of systemic lupus erythematosus so she received treatment with high corticosteroid doses, mycophenolate, hydroxycloquine and even Rituximab. During hospitalization blood work revealed repeated episodes of severe neutropenia.

Upon arrival in our Rheumatology Unit, blood work revealed mild anemia, mild hypogammaglobulinemia, negative autoimmune screening. Peripheral blood flow cytometry showed reversed CD4:CD8 ratios, NK-lymphopenia and decreased amount of peripheral B cells (0.28×109/L). During the prolonged hospitalization recurrent episodes of neutropenia associated with inflammatory syndrome were pointed out (up to 700/cmm leukocytes and 2 neutrophyles/cmm) requiring periodic administration of granulocyte-colony stimulating factor (G-CSF) and moderate to high doses of corticosteroids.

Thoracoabdominal computerized tomography (CT) revealed an entero-cutaneous fistula, important hepatosplenomegaly; no significant findings were noted on cerebral CT. Surgical excision of the entero-atmospheric fistula and of the ileo-cecal pouch was performed, followed by regular dressing and a vacuum system with slow good follow-up (Fig. 1c).

Next-generation sequencing revealed that the patient carried compound heterozygous mutations at positions 139 (exon 2) and 661_664 (exon 4) of the coding sequence of ADA2 (c.139G > A, c.661_664del), resulting respectively in amino acid substitution p.Gly47Arg and premature translational stop signal p.Ala221Glnfs*45 in ADA2. Thus, the patient was diagnosed with ADA2 deficiency. To the best of our knowledge, this second mutation was not described in the medical literature.

During her prolonged hospitalization she experienced multiple infectious episodes - recurrent Clostridium difficile colitis, colonization of surgical wounds with Klebsiella and Pseudomonas. The clinical picture was also complicated with acute interstitial edematous pancreatitis complicated by a pancreatic pseudocyst of 6 cm.

In conditions of relative quiescent disease, sustained favorable evolution of the surgical wounds, anti-tumor necrosis factor-alpha therapy with Etanercept 25mg was started. 48 hours after the first admnistration she developed progressive severe thrombocytopenia (up to 9.000/mm3), followed shortly by severe pancytopenia. Bone marrow biopsy revealed mild hypocellularity, elevated number of megakaryocytes with diminished thrombocyte formation, 3–5% blasts, and very frequent active macrophages. Serum folate and vitamin B12 were normal, feritine was slighty elevated. Thus, we excluded hemophagocytic lymphohistiocytosis or myelodysplastic syndrome as possible causes. Rising procalcitonin levels (> 10 ng/dl) made sepsis a more plausible cause. Despite supportive treatment, broad spectrum antibiotics and antifungal therapy, iv immunoglobulins, corticosteroids, erythrocytes and thrombocytes transfusions the patient’s overwhelming hyperinflammatory syndrome progressed over the next week. This was followed by respiratory deterioration requiring mechanical ventilation and multiorgan failure, which led to the patients demise the following day.

Initially, our patient was classified as having Bechet’s disease based on recurrent oral ulcers and positive HLA B51. Subsequently, the diagnosis became less due to the lack of response to colchicine and the persistence of neutropenia. Of note, clinical presentation of DADA2 as Behcet’s disease have been reported in two patients (2). In line with previous studies, which imply that DADA2 phenotypes likely represent continua rather than distinct categories, our patient presented isolated neutropenia for 6 years, only to develop signs of pancytopenia and possible intestinal vasculitis as part of her clinical course. Consistent with previous cases of DADA2 that showed signs of autoimmunity (1, 3–5) our patient also displayed laboratory features of systemic lupus erythematous (positive ANA, anti-dsDNA antibodies), HLAB51 antigen was present. Immunological phenotyping revealed inverted CD4/CD8 ratio with a phenotype of large granular lymphocytes and a decrease of LTh ( CD3 + CD4+/CD45+); mild decrease of B cells (CD19+) and NK cells (CD16+/CD56+). Immunoglobulin levels initially displayed elevated IgG (24,3 g/l) and IgA (8,7 g/l), later on, hypogammaglobulinemia.

It remains a challenge to define the patient’s gastrointestinal involvement. Aside from recurrent episodes of colicky abdominal pain for several years, she was diagnosed with intestinal perforation. It is difficult to discern whether it was intestinal vasculitis due to active disease, or neutropenic enterocolitis that led to the intestinal perforation. Furthermore, it is possible that the perforation in the intestinal wall led to spontaneous myonecrosis with Clostridium septicum, consistent with several cases reported in the literature (6). Other gastrointestinal manifestations in our case were hepatosplenomegaly, minor cholestasis, commonly associated with DADA2. However, pancreatic infarction has just recently expended the spectrum of DADA2 (7).

In the time frame before a definitive diagnosis was established, her therapeutic strategy included, along with corticotherapy, other lines of therapy, mycophenolate mofetil, azathioprine, hydroxychloroquine and rituximab, with suboptimal efficacy, as the neutropenic episodes did not subside. After several months having finally achieved a significant improvement of her surgical wounds, and because of persistent signs of systemic inflammation and severe disease manifestations, anti-TNF-alpha treatment was commenced. Unfortunatelly, 48 hours after administration she developed rapidly progressive trombocytopenia and 2 weeks later she succumbed to sepsis. In hindsight, it is difficult to discern whether the sepsis was associated with the initiation of anti-TNF therapy, or if it was the consequence of severe hematological manifestations related to active disease. Facts consistent with a more aggressive pattern of disease in the last month of life include new disease manifestations that arouse, such as an episode of acute pancreatitis, persistent lymphopenia (50–1300/uL, median 490/ul) and hypogammaglobulinemia. In addition, the patient was harboring the G47R mutation, known to be sometimes linked to a more unfavorable prognosis (8), present in most of the DADA2 patients that died (9).

Our case highlights the valuable diagnostic benefit of early specific genetic testing for patients with complex unclear diseases in which vasculopathy/vasculitis, dysregulated immune function and/or hematologic abnormalities may predominate.

DADA2 - The deficiency of adenosine deaminase 2

TNF – tumoral necrosis factor

HLA – human leukocyte antigen

CD – cluster differention

NK – natural killer

Cmm – cubic milimeters

CT – computerized tomography

Ethics approval and consent to participate

Local ethics comitee of Sfanta Maria Clinical Hospital approval was obtained reference number 4494/23.02.2022

All methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards.

Written informed consent was obtained from the patient’s parents. A copy of the written consent is available for review by the Editor-in-Chief.

Consent for publication

Written informed consent was obtained from the patient’s parents for publication of this case report and any accompanying images

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

None

Authors' contributions

DN, CN prepared the written manuscript. DN, CN, LG were responsible for literature research. RI, LG revised the manuscript. AS, AM, RC were the surgeons responsible for the case and had contribution in writing the manuscript. LG was the leading rheumatologist of the case. EP, LP, AG, RT were the intensive care specialists taking care of the case. MB carried out the molecular genetic studies, participated in the sequence alignment and drafted the manuscript.

All authors read and approved the final manuscript.

Acknowledgements

We acknowledge dr Alexandru Bardas from Fundeni Hematology Institute , Bucharest for hematologic evaluation of the patient and dr Alexis Cochino from Alfred Rusescu Mother and Child Institute for sharing advices.

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Editorial decision: Revise before peer review
04 Jul, 2023
Reviewers agreed at journal
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Reviewers invited by journal
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Editor assigned by journal
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First submitted to journal
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You are reading this latest preprint version

A new CECR1 mutation associated with severe hematological involvement in ADA2 deficiency

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Abstract

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Background

Case Presentation

Discussions And Conclusions

List Of Abbreviations

Declarations

References

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