Signs and symptoms of agammaglobulinemia (often referred as X-linked agammaglobulinemia, or XLA) start to appear several months after birth (between 7-9 months of age in most cases) when maternal immunoglobulins in the child slowly begin to disappear, and are completely absent at the end of the child's first year of life [1] [2]. Having in mind the complete or near-complete dysfunction of B-cells due to mutations in the Bruton tyrosine kinase (BTK) protein, situated on the X chromosome (resulting in almost exclusive appearance of the disease in males), infants are predisposed to numerous infections of bacterial, viral and fungal origin, and their recurrent appearance is usually the first and most important clinical presentation [3] [4]. In particular, patients are most susceptible to infections caused by encapsulated bacteria (such as streptococcus pneumoniae, haemophilus influenzae, and pseudomonas aeruginosa), mycoplasma spp., enteroviruses and giardia lamblia [4] [5]. Recurrent infections of the respiratory system (pneumonia and less commonly sinusitis), skin, the gastrointestinal tract (caused by rotavirus, salmonella spp., and campylobacter spp., in addition to giardiasis) are typical for agammaglobulinemia patients, and recurrent otitis media is described in the vast majority of cases [1] [4] [6]. Central nervous system (CNS) infections, both meningitis, and encephalitis, as well as sepsis and infections of the musculoskeletal system (osteomyelitis and arthritis), can develop in the absence of a timely diagnosis [1] [4] [6]. Hand-foot-and-mouth disease, hepatitis, opportunistic infections (pneumocystis jiroveci pneumonia - PCP) and polio vaccine-related poliomyelitis (as a result of depleted B-cells) are very rare manifestations of agammaglobulinemia but have been reported by certain authors [1] [4] [7].

• Pathologist

  This description may help the pathologist in considering a differential diagnosis when examining a diagnostic lymph node biopsy in these patients. [ncbi.nlm.nih.gov]

  PMID: 21039741 Assay Assay and technical information Invitae is a College of American Pathologists (CAP)-accredited and Clinical Laboratory Improvement Amendments (CLIA)-certified clinical diagnostic laboratory performing full-gene sequencing and deletion [invitae.com]

• Aspiration

  Bone marrow aspirates showed less than 0.01% CD19 B cells with normal percentages of TdT VpreB CD19- B cell precursors. [emedicine.com]

• Dystonia

  A progressive, fatal dystonia-Parkinsonism syndrome in a patient with primary immunodeficiency receiving chronic IBIG therapy. Mov Disord. 2007. 22:1664-6. [Medline]. Cunningham-Rundles C. [emedicine.com]

The diagnosis of agammaglobulinemia can be made only if physicians recognize the recurrent nature of infections in infancy and early childhood and order a thorough laboratory investigation. Despite evident clinical criteria for some form of immunodeficiency, however, up to 20% of children are not diagnosed by school age, indicating that clinical suspicion is probably the most important factor in detecting agammaglobulinemia [1] [3] [6]. A detailed patient history focused on the interview with the parents (as children are often too young to provide relevant information) can provide vital clues for the physician. A detailed family history is equally important and may be quite useful in determining whether close family members have or had the diagnosis or experience of similar symptoms, as a significant number of patients have a confirmed family member suffering from agammaglobulinemia [6]. Initial laboratory testing reveals neutropenia in about 15% of cases, whereas reductions in serum immunoglobulins (IgG, IgM and IgA) are readily encountered [1] [5] [6] [8]. A key diagnostic feature of agammaglobulinemia is a markedly lower number of CD19+ B cells (< 2%), while absent isohemagglutinins and/or poor vaccine responses are also important features that make the diagnosis of this primary immunodeficiency highly likely [1] [8]. Confirmation of agammaglobulinemia, however, is achieved by detecting BTK mutations through genetic studies in both the patient and in one of his maternal cousins [1].

• Mycoplasma Hominis

  In-vitro activities of tetracyclines, macrolides, fluoroquinolones and clindamycin against Mycoplasma hominis and Ureaplasma ssp. isolated in Germany over 20 years. Clin Microbiol Infect, 2010; 16(11):1649-55. [ PubMed ] [ CrossRef ]. [journal-imab-bg.org]

  Hypogammaglobulinemic patient with polyarthritis mimicking rheumatoid arthritis finally diagnosed as septic arthritis caused by Mycoplasma hominis. Intern Med. 2012. 51:425-9. [Medline]. Sukumaran S, Marzan K, Shaham B, Church JA. [emedicine.com]

Prolonged suboptimal treatment may cause bacterial resistance to β-lactam antibiotics in H. cinaedi. It is possible that this resistance may have contributed to the treatment failure. [ncbi.nlm.nih.gov]

Nevertheless, some frequent affections persist despite treatment, and lead to handicapping and further to morbid clinical complications for XLA individuals. [eurekaselect.com]

Management and treatment There is no curative treatment for XLA but good disease control can be achieved through consistent gammaglobulin therapy. [orpha.net]

Local antibiotic treatment (drops, lotions) are preferred over systemic treatment (pills) for long-term treatment, if possible. One of the future prospects of XLA treatment is gene therapy, which could potentially cure XLA. [en.wikipedia.org]

Prognosis The prognosis depends on the age at diagnosis, compliance with therapy and the development of complications. Most patients on treatment can lead a normal life. [orpha.net]

Prevention, and Complications Prognosis normal prognosis with regular IVIG therapy and early detection Prevention screening in newborns regular IVIG to prevent infections Complications small risk of malignancy Please rate topic. [step1.medbullets.com]

Diagnosis - X-Linked Agammaglobulinemia Prognosis - X-Linked Agammaglobulinemia Not supplied. Treatment - X-Linked Agammaglobulinemia Resources - X-Linked Agammaglobulinemia Not supplied. [checkorphan.org]

With early diagnosis and appropriate treatment, prognosis is good unless CNS viral infections develop. Drugs Mentioned In This Article Gammagard S/D [merckmanuals.com]

Etiology XLA is caused by mutations in the BTK gene (Xq21.33-q22) involved in B lymphocyte differentiation and maturation. [orpha.net]

Epidemiology and etiology of childhood pneumonia. Bulletin of the World Health Organization 2008; 86: 408-416 9 Stein RT, Marostica PJ. Community-acquired pneumonia: a review and recent advances. [thieme-connect.com]

Take home message • Early diagnosis and treatment - IVIG, ATB prophylaxis • Defining genetic etiology • Long-term follow-up : Infection 45. Thank you [slideshare.net]

(Etiology) The causative factors of Bruton’s Agammaglobulinemia include mutations in the BTK gene, located on the X chromosome. [dovemed.com]

Vach 3 Clinical Epidemiology, Institute of Medical Biometry and Medical Informatics, University Medical Centre, University of Freiburg, Germany, M. [thieme-connect.com]

[…] cytometry – if protein expression is absent or reduced, suggests X-linked agammaglobulinemia (XLA) in males Differential Diagnosis X-linked hyper IgM syndrome X-linked severe combined immunodeficienc y X-linked lymphoproliferative disease HIV Background Epidemiology [arupconsult.com]

Summary Epidemiology Estimated prevalence is 1/350,000 to 1/700,000. Annual incidence is not known. The disorder has been reported in various ethnic groups worldwide. Only males are affected and females are asymptomatic carriers. [orpha.net]

[…] immunodeficienc y X-linked lymphoproliferative disease HIV Background Epidemiology Incidence – estimated 1/250,000-700,000 male births Age 50% diagnosed by 2 years 80% diagnosed by 5 years Sex – 99% male Ethnicity – most commonly diagnosed in Caucasians Pathophysiology [arupconsult.com]

In addition to the genetic defects described above, other pathophysiology mechanisms may result in hypogammaglobulinemia or agammaglobulinemia, such as viral infections, malignancy, or drug effects. These are described in more detail in Causes. [emedicine.com]

Pathophysiology In the absence of BTK, B lymphocytes do not differentiate or mature. Without mature B lymphocytes, antibody-producing plasma cells are also absent. [emedicine.medscape.com]

Bruton Pathophysiology Thomas A.E. Plattes-Mills. Middleton's Allergy 8th Edition. 1144-74. Conley ME, et al. Immunological Reviews 2005. Vol. 203: 216–234. Vetrie D, et al. Nature1993;361:226–233. Tsukada S, et al. Cell 1993;72:279–290. 8. [slideshare.net]

Frequently called Bruton's Agammaglobulinemia, XLA is caused by a genetic mistake in a gene called Bruton's Tyrosine Kinase (BTK), which prevents B cells from developing normally. [aaaai.org]

These mutations prevent the development and regulation of B lymphocytes Pre-B-lymphocytes are unable to mature into B lymphocytes. [dovemed.com]

Prevention There is no known way to prevent XLA. However, if an individual believes a family member may have XLA, it is possible to get genetic counseling prior to pregnancy to determine if the individual is a carrier of the gene. [encyclopedia.com]

1. Machado P, Santos A, Faria E, Silva J, Malcata A, Chieira C. Arthritis and X-linked agammaglobulinemia. Acta Reumatol Port. 2008;33(4):464-467.
2. Ozturk C, Sutcuoglu S, Atabay B, Berdeli A. X-Linked Agammaglobulinemia Presenting with Secondary Hemophagocytic Syndrome: A Case Report. Case Reports in Medicine. 2013;2013:742795.
3. Sigmon JR, Kasasbeh E, Krishnaswamy G. X-linked agammaglobulinemia diagnosed late in life: case report and review of the literature. Clinical and molecular allergy : CMA. 2008;6:5.
4. Chen X-F, Wang W-F, Zhang Y-D, Zhao W, Wu J, Chen T-X. Clinical characteristics and genetic profiles of 174 patients with X-linked agammaglobulinemia: Report from Shanghai, China (2000–2015). Medicine (Baltimore). 2016;95(32):e4544.
5. Hernandez-Trujillo VP, Scalchunes C, Cunningham-Rundles C, et al. Autoimmunity and Inflammation in X-linked Agammaglobulinemia. J Clin Immunol. 2014;34(6):627-632.
6. Winkelstein JA, Marino MC, Lederman HM, et al. X-linked agammaglobulinemia: report on a United States registry of 201 patients. Medicine (Baltimore). 2006;85(4):193-202.
7. Jongco AM, Gough JD, Sarnataro K, et al. X-linked agammaglobulinemia presenting as polymicrobial pneumonia, including Pneumocystis jirovecii. Ann Allergy Asthma Immunol. 2014;112(1):10.1016/j.anai.2013.10.008.
8. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.