Hindawi Publishing CorporationCase Reports in ImmunologyVolume 2013, Article ID 323614, 5 pageshttp://dx.doi.org/10.1155/2013/323614

Case ReportVariant of X-Linked Chronic GranulomatousDisease Revealed by a Severe Burkholderia cepacia InvasiveInfection in an Infant

Saul Oswaldo Lugo Reyes,1,2 Nizar Mahlaoui,3,4 Carolina Prando,5,6

Lizbeth Blancas Galicia,1,2 Marjorie Hubeau,2 Stéphane Blanche,4 Capucine Picard,2,3,4

Jean-Laurent Casanova,2,4,5 and Jacinta Bustamante2,3

1 Immunodeficiencies Research Unit, National Institute of Pediatrics, Coyoacan, 04530 Mexico City, DF, Mexico2 Laboratory of Human Genetics of Infectious Diseases, INSERM U980, University Paris Descartes, Paris Sorbonne Cite,75014 Paris, France

3 French Reference Center for Primary Immune Deficiencies (CEREDIH), Necker-Enfants Malades University Hospital,AP-HP, 75015 Paris, France

4 Pediatric Immunology-Hematology Unit, Necker-Enfants Malades University Hospital, AP-HP, 75015 Paris, France5 St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller University, New York, NY 10065, USA6Bioinformatics Laboratory, Pele Pequeno Principe Research Institute, 80250-060 Curitiba, PR, Brazil

Correspondence should be addressed to Jacinta Bustamante; jacinta.bustamante@inserm.fr

Received 13 May 2013; Accepted 19 June 2013

Academic Editors: V. Lougaris, N. Martinez-Quiles, Y. Nozaki, and A. Vojdani

Copyright © 2013 Saul Oswaldo Lugo Reyes et al. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Chronic granulomatous disease (CGD) is a primary immunodeficiency characterized by increased susceptibility to bacteria andfungi since early in life, caused bymutations in any of the five genes coding for protein subunits inNADPHoxidase. X-linked variantCGD can be missed during routine evaluation or present later in life due to hypomorphic mutations and a residual superoxideproduction. The case of a 10-month-old boy who died of pneumonia is reported. The isolation of Burkholderia cepacia from hislung, together with a marginally low nitroblue tetrazolium reduction assay (NBT), made us suspect and pursue the moleculardiagnosis of CGD. A postmortem genetic analysis finally demonstrated CGD caused by a hypomorphic missense mutation withnormal gp91phox expression. In a patient being investigated for unusually severe or recurrent infection, a high index of suspicion ofimmunodeficiency must be maintained.

1. Introduction

Chronic granulomatous disease (CGD) is a rare primaryimmunodeficiency that affects microbial killing by phago-cytes, resulting in bacterial, fungal, and/or mycobacterialinfections since early life [1, 2]. The superoxide productionby NADPH oxidase is markedly reduced or absent due tomutations in any of the five genes coding for protein subunitsof the enzymatic complex [3]. Mutations in CYBB, coding forgp91phox, result in the most common X-linked CGD (65%–70% of all cases) [4]. Hypomorphic mutations (Xgp91+ andXgp91−) may result in X-linked variant CGD [5, 6]. Patients

with variant CGD express the gp91phox protein and producedecreased but detectable superoxide, which allow the defectto manifest later in life with a milder history of infections.By far, themost commonmicro-organisms causing infectionsin CGD are Staphylococcus aureus and Aspergillus species;other agents include Pseudomonas, Serratia, Salmonella, andCandida species. Burkholderia cepacia infection is frequentlyassociated to CGD diagnosis (6–8). Here, we present thecase of a patient who died of Burkholderia cepacia lunginfection, in whom the diagnosis of X-CGD could only beattained postmortem due to residual superoxide productionand normal protein expression.

2 Case Reports in Immunology

2. Case Report

A 10-month-old boy, the first child of nonconsanguineousparents living in the Tahiti archipelago (French Polynesia),was referred for severe pneumonia.The father is from Europeand the mother is fromOceania; there was no relevant familyhistory. During the first months of life, the patient had expe-rienced some infections, mostly of the upper airways, as wellas bronchitis and diarrhea. He received all the immunizationsaccording to his age (including BCG) with no adverse events.He developed a failure to thrive at the age of 3 months.One month before admission he had a severe lung infectionwith fever, cough, dyspnea, and diarrhea, unresponsive toan empiric oral macrolide (josamycin). Upon admission tohis local hospital, he had fever (39.5∘C), mild respiratorydistress, and crackles on auscultation. Oxygen saturation was95% in room air. Complete blood count (CBC) reportedmarked leukocytosis (36,600/mL) with neutrophilia (29,000polymorphonuclear cells (PMN)/mL) and anemia (Hb = 7.6g/dL); serum immunoglobulin levels were as follows: IgG =1,900mg/dL (reference value for 7–12 months: 661 ± 219mg/dL), IgA = 166mg/dL (37 ± 18), IgM = 220mg/dL (54 ±23), and IgE 43 IU/mL (normal < 20 IU/mL). Chloride sweattest and tuberculin skin test were negative. Chest X-ray andcomputed tomography scan (CT) revealed bilateral pneumo-nia with multiple excavations in both lungs. Intravenous (IV)cefotaxime and fosfomycinwere started for suspected staphy-lococcal pneumonia. Bronchoscopy showed diffuse edemaof the trachea and bronchi. Bronchoalveolar lavage (BAL)and Gram stain reported 1,100 cells (97% PMN) and abun-dant Gram negative bacteria that grew Burkholderia cepacia(107 CFU, >25 white cells). Antibiotherapy was then switchedto IV rifamycin and trimethoprim/sulfamethoxazole.

After a transient improvement, the patient’s conditiondeteriorated, and he was referred to our hospital, wherehe was found to be small for his age and cachectic, withsevere respiratory distress and hepatosplenomegaly. LungCT scan revealed extensive destruction of the lungs withmultiple bullous lesions and opacification of the left lung;the right lung had multiple nodular lesions and opaci-fied upper lobe. Immunological workup confirmed markedleukocytosis with neutrophilia and anemia, elevated serumC-reactive protein (CRP = 165mg/L), and fibrinogen (6 g/L).BAL retrieved Burkholderia cepacia (106 CFU/mL, >25 whitecells/field). Lymphocyte subset counts, T lymphocytes prolif-eration, and specific antibody production assays were all nor-mal. Nitroblue tetrazolium reduction (NBT) test and luminolchemiluminescence to assess reactive oxygen species (ROS)production in PMNs repeatedly showed a baseline activitylevel at around 45% (low but detectable), and responseto stimulation was poor. Chemotaxis chamber assay wasnormal, as well as CD18 and CD11a,b,c expression on PMNs.When a peripheral blood smear reported vacuolized enlargedPMNs, dense granule disease was suspected and ruled out:normal secretory vesicles, secondary granules, azurophilegranules, and myeloperoxidase production; normal spe-cific staining of secondary granule proteases (neutrophilelastase, myeloperoxidase, Cathepsin G, and Lactoferrin).Despite intensive supportive care, including broad-spectrum

antibiotics and daily granulocyte transfusions, his lung infec-tion worsened, and he finally died of acute respiratorydistress andmultiorgan dysfunction in the intensive care unit.Permission to perform an autopsy was refused by his parents.

The clinical presentation and the impaired NBT reduc-tion assays of this boy were consistent with a primaryphagocyte defect. We assessed superoxide (O

2

−) productionin PMNs from the patient as measured by the cytochrome-creduction assay, compared to another patient with known X-linked CGD (−) and a healthy control (+), following stimula-tionwith phorbolmyristate acetate (PMA). ResidualNADPHoxidase activity was detected in the PMNs of the patient(Figure 1(a)). In addition, 123-dihydrorhodamine (DHR) oxi-dation assay by flow cytometry revealed a partial deficiencyof ROS production in the patient’s PMN, while his motherhad two granulocyte populations: one strongly rhodamine-positive (reactive) and the other rhodamine-low fluorescenceintensity (Figure 1(b)). These results again suggested that ourpatient had a partial defect in the respiratory burst. We nextinvestigated the H

2O2production upon milder activation,

involving priming with TNF-𝛼, IL-1𝛽, or cytochalasin b,followed by fMLF (formyl-methionyl-leucyl-phenylalanine)stimulation. PMNs from the patient produced detectable butlow H

2O2(Figure 1(c)).

Genomic sequencing of CYBB revealed a hemizygousA > G substitution in exon 9, generating the replacement ofa histidine by an arginine residue (H338R) in the FAD bind-ing domain (FADBR), a probably damaging substitutionaccording to the PolyPhen-2 prediction website (http://genetics.bwh.harvard.edu/pph2/). The patient’s mother washeterozygous, and his brother (born after the patient’s death)was hemizygous for the mutation. The mutation was con-firmed also in cDNA from the patient (c.1013A > G). Weinvestigated themolecular basis of the germlineH338Rmuta-tion through detection of flavocytochrome b

558expression by

flow cytometry, using the monoclonal antibody 7D5 (MBL,Nagasaki, Japan), which recognizes residues 160IKNP163 and226RIVRG230 on gp91phox in the presence of p22phox. Proteinexpression in Epstein-Barr virus transformed B cells (EBV-B cells) from the patient was similar to the healthy control(Figure 2).

3. Discussion

The isolation of Burkholderia cepacia from lung secretion orblood of a previously healthy patient is strongly suggestiveof CGD. Aside from it, lung infections caused by Burkhold-eria species can be seen in patients with existing bronchiecta-sis (lung epithelial damage is a prerequisite for Burkholderiainvasiveness), including notably patients with cystic fibrosis[7] and in some immunocompromised and hospitalisedpatients [8, 9]. In a child being investigated for recurrentinfections, isolation of Burkholderia should always raise thesuspicion of CGD [10–12]. For some patients with normalgp91phox expression and residual superoxide production asmeasured by conventional assays, a milder activation assaywith fMLF might be needed to demonstrate low ROS pro-duction.

Case Reports in Immunology 3

Non

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Figure 1: Continued.

4 Case Reports in Immunology

Nonstimulated fMLF Cytochalasin b

Side scatter (SSC)Side scatter (SSC)Side scatter (SSC)Side scatter (SSC)Side scatter (SSC)Side scatter (SSC)Side scatter (SSC)Side scatter (SSC)

100 101 102 103 104 100 101 102 103 104 100 101 102 103 104 100 101 102 103 104 100 101 102 103 104 100 101 102 103 104 100 101 102 103 104 100 101 102 103 104

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TNF-𝛼 IL-1𝛽 fMLF + TNF-𝛼 fMLF + cytochalasin bfMLF + IL-1𝛽

(c)

Figure 1: NADPH oxidase activity evaluation in PMNs. (a) Superoxide generation was measured by assaying superoxide dismutase-inhibitable cytochrome-c reduction in PNMs after adding three doses of PMA (4, 40, and 400 ng/mL), for healthy controls (C+), CGDpatient (C−), and our patient (P). (b) Histograms for the flow cytometric analysis of intracellular H

2O2production, using the fluorescent

123DHR probe in PMNs from a healthy control (C+), an X-linked CGD patient (C−), the proband (P), and the mother (H), before (NS) andafter stimulation with PMA (4, 40, and 400 ng/mL). (c) PMNs from C+, C−, and P were left untreated or treated with TNF-𝛼, IL-1𝛽, andcytochalasin b and then stimulated with fMLF. The results shown are representative of two independent experiments.

P

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l num

ber

Fluorescence

0

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7D5 AbCytochrome b expression

Isotype Ab

100 101 102 103 104 100 101 102 103 104 100 101 102 103 104

C+ C−

558

Figure 2: Expression of gp91phox in a patient with the H338R CYBB mutation. Immunostaining of cytochrome b558

in EBV-B cells from ahealthy control (C+), an X-linked CGD patient (C−), and the patient (P). Cell surface staining with mAb7D5 (an antibody specific for theextracellular epitope of gp91phox; solid lines); an isotype IgG1 (dotted lines) followed by staining with an Alexa Fluor 488 goat anti-mouse Igsecondary antibody. The results shown are representative of two independent experiments.

Missense mutations beyond aminoacid 309 of gp91phoxusually allow normal protein expression but result in nullsuperoxide production. The patient’s residual ROS genera-tion is thus different from the thorough survival analysisby Kuhns et al. [3]. Also, given this infant’s residual superox-ide production, a severe course with early demise is surpris-ing.

In conclusion, we identified postmortem a point muta-tion in a CGD causing gene from a 10-month-old boywho presented with a Burkholderia spp. overwhelming lunginfection. X-CGD diagnosis was delayed because of initialnormal results. A high index of suspicion for CGD must bemaintained in patients with Burkholderia isolates and closeto normal values of usual CGD diagnostic tests such as NBT.

Case Reports in Immunology 5

An early and accurate diagnosis can lead to genetic coun-selling, to family screening, and to a timely intervention.

Abbreviations

CGD: Chronic granulomatous diseasePID: Primary immune deficiencyNADPH: Nicotinamide adenine dinucleotide

phosphate hydrogenBCG: Bacillus Calmette-Guerin.

Conflict of Interests

The authors declare no conflict of interests.

Authors’ Contributions

Saul Oswaldo Lugo Reyes and Nizar Mahlaoui equally con-tributed to this work.

Acknowledgments

The authors thank the patient’s family members for theirwillingness to participate in this study. The authors thankMichelle N’Guyen, Martine Courat, and Tony Leclerc for sec-retarial and technical assistance. The Laboratory of HumanGenetics of Infectious Diseases is supported in part bygrants from BNP-Paribas and Schlumberger Foundations,the March of Dimes, the Dana Foundation, the St. GilesFoundation, and the Agence Nationale de la RechercheMedicale. The Immunodeficiencies Research Unit is sup-ported in part by FundacionMexicana paraNinas y ninos conInmunodeficiencias Primarias (FUMENI). Marjorie Hubeauis supported by a fellowship grant from the Societe Francaised’Hematologie.

References

[1] J. Bustamante, G. Aksu, G. Vogt et al., “BCG-osis and tubercu-losis in a child with chronic granulomatous disease,” Journal ofAllergy and Clinical Immunology, vol. 120, no. 1, pp. 32–38, 2007.

[2] J. Bustamante, A. A. Arias, G. Vogt et al., “Germline CYBBmutations that selectively affect macrophages in kindreds withX-linked predisposition to tuberculous mycobacterial disease,”Nature Immunology, vol. 12, no. 3, pp. 213–221, 2011.

[3] D. B. Kuhns, W. G. Alvord, T. Heller et al., “Residual NADPHoxidase and survival in chronic granulomatous disease dou-glas,”The New England Journal of Medicine, vol. 363, no. 27, pp.2600–2610, 2010.

[4] D. Roos, D. B. Kuhns, A. Maddalena et al., “Hematologicallyimportant mutations: X-linked chronic granulomatous disease(third update),” Blood Cells, Molecules, and Diseases, vol. 45, no.3, pp. 246–265, 2010.

[5] B. Boog, A. Quach, M. Costabile et al., “Identification andfunctional characterization of two novel mutations in the 𝛼-helical loop (residues 484–503) of CYBB/gp91𝑝ℎ𝑜𝑥 resultingin the rare X91+ variant of chronic granulomatous disease,”Human Mutation, vol. 33, no. 3, pp. 471–475, 2012.

[6] M. J. Stasia, B. Lardy, A. Maturana et al., “Molecular and func-tional characterization of a new X-linked chronic granulo-matous disease variant (X91+) case with a double missensemutation in the cytosolic gp91𝑝ℎ𝑜𝑥 C-terminal tail,” Biochimicaet Biophysica Acta, vol. 1586, no. 3, pp. 316–330, 2002.

[7] D. E. Greenberg, J. B. Goldberg, F. Stock, P. R. Murray, S. M.Holland, and J. J. Lipuma, “Recurrent Burkholderia infectionin patients with chronic granulomatous disease: 11-Year experi-ence at a large referral center,” Clinical Infectious Diseases, vol.48, no. 11, pp. 1577–1579, 2009.

[8] S. G. Avgeri, D. K. Matthaiou, G. Dimopoulos, A. P. Gramma-tikos, andM. E. Falagas, “Therapeutic options for Burkholderiacepacia infections beyond co-trimoxazole: a systematic reviewof the clinical evidence,” International Journal of AntimicrobialAgents, vol. 33, no. 5, pp. 394–404, 2009.

[9] V. Gautam, L. Singhal, and P. Ray, “Burkholderia cepacia com-plex: Beyond pseudomonas and acinetobacter,” Indian Journalof Medical Microbiology, vol. 29, no. 1, pp. 4–12, 2011.

[10] R. Lakshman, S. Bruce, D. A. Spencer et al., “Postmortem diag-nosis of chronic granulomatous disease: how worthwhile is it?”Journal of Clinical Pathology, vol. 58, no. 12, pp. 1339–1341, 2005.

[11] J. L. Madden, M. E. Schober, R. L. Meyers et al., “Successful useof extracorporeal membrane oxygenation for acute respiratoryfailure in a patient with chronic granulomatous disease,” Journalof Pediatric Surgery, vol. 47, pp. e21–e23, 2012.

[12] R. Renella, J. Perez, S. Chollet-Martin et al., “Burkholderiapseudomallei infection in chronic granulomatous disease,”European Journal of Pediatrics, vol. 165, no. 3, pp. 175–177, 2006.

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