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Common Variable Immunodeficiency

CVID

Common variable immunodeficiency is an autoimmune condition featuring decreased immunoglobulin (Ig) levels in the serum and structurally normal B cells that are able to reproduce but lack the ability to mature into Ig-producing plasma cells. This results in the weakening of the patient's immune system, thus rendering an individual subject to multiple and severe infections and diseases. 


Presentation

Five clinical manifestations have been described for common variable immunodeficiency [6]:

Each and every patient that has a medical history of CVID runs the risk of developing three specific complications: periodic infections, autoimmune diseases and cancer. The recurrent infections usually affect the respiratory tracts (upper/lower); otitis media, diarrhea, pneumonia, and sinusitis are the most commonly occurring infections [11]. Infections caused by rarely encountered organisms, such as prototheca algae, may also be seen [12]. Giardia lamblia infections are common amongst CVID patients, causing diarrhea and malabsorption.

CVID patients are also subject to severe chronic diarrhea due to both infectious and autoimmune causes, rather than GI malignancies. Young children may especially experience hindered growth because of the recurrent infections or GI tract conditions. In cases where the bronchi are often affected, bronchiectasis may occur, with permanent damage being an expected complication. Patients are most frequently infected with h.influenzae, s.pneumoniae, m.catarrhalis and s.aureus.

Approximately 1/4 of the patients with CVID suffer complications of the autoimmune spectrum[13], including rheumatoid arthritis, vitiligo, hemolytic anemia, thrombocytopenia and neutropenia [14] [15]. As far as malignancy is concerned, patients also run the risk of B-cell lymphomas, which has been linked to the Epstein-Barr virus.

Recurrent Infection
  • Common variable immunodeficiency (CVID) is a heterogeneous disorder characterized by antibody deficiency, poor humoral response to antigens, and recurrent infections.[ncbi.nlm.nih.gov]
  • English common variable immunodeficiency immune disorder characterized by recurrent infections and low antibody levels, specifically in immunoglobulin CVID acquired agammaglobulinemia acquired hypogammaglobulinemia common variable agammaglobulinemia sporadic[wikidata.org]
  • Common variable immunodeficiency is the most common symptomatic primary immune deficiency characterized by hypogammaglobulinemia, recurrent infections, and increased risk of autoimmune disease and malignancy.[ncbi.nlm.nih.gov]
  • Common variable immunodeficiency is characterized by low levels of serum immunoglobulins and antibodies, recurrent infections, and a predisposition to malignancy.[ncbi.nlm.nih.gov]
  • Common variable immunodeficiency is a rare disorder of immunity associated with a myriad of clinical manifestations including recurrent infections, autoimmunity, and malignancy.[ncbi.nlm.nih.gov]
Anemia
  • METHODS: We describe four women (mean age 54 years) with CVID associated with idiopathic thrombocytopenic purpura (ITP) (n 3) and autoimmune hemolytic anemia (AIHA) (n 1).[ncbi.nlm.nih.gov]
  • We then performed several immunological evaluations including quantitative lymphocyte analysis and TRECs/sjKRECs analysis for 32 individuals with Fanconi anemia (FA).[ncbi.nlm.nih.gov]
  • Autoimmune diseases such as idiopathic thrombocytopenic purpura and autoimmune hemolytic anemia have a high reported prevalence in patients with common variable immunodeficiency (CVID).[ncbi.nlm.nih.gov]
  • ., thrombopenia or anemia (11/16). Ten patients were affected with lymphoproliferative diseases. Two patients were in the infection only group and the others belonged to one or several other CVID groups.[ncbi.nlm.nih.gov]
  • Univariate analysis revealed that splenomegaly (odds ratio [OR], 17.3; 95% confidence interval [CI], 3.9-74.5), history of immune thrombocytopenic purpura (ITP) or autoimmune hemolytic anemia (AIHA) (OR, 4.8; 95% CI, 1.1-20.2), low IgA level (OR, 3.6;[ncbi.nlm.nih.gov]
Fever
  • However, the NLRP12-associated periodic fever syndromes show a wide clinical spectrum, including patients without classical diagnostic symptoms.[ncbi.nlm.nih.gov]
  • Here we report the case of a 37 year-old man presenting to the emergency room with dyspnea, fever and cough; he developed respiratory failure requiring mechanical ventilation.[ncbi.nlm.nih.gov]
  • A 26-year-old Japanese man with history of common variable immune deficiency presented with diarrhea, abdominal pain, and fever. Venous administration of antibiotics did not improve his symptoms.[ncbi.nlm.nih.gov]
  • A 6-year-old boy presented with a 6-month history of weight loss and malaise and a 1-month history of fever and polyarticular arthritis. Parvovirus DNA was detected in plasma at 10 300 copies/mL.[pediatrics.aappublications.org]
  • If there are symptoms suggestive of lymphoid malignancy such as fevers or night sweats, consider computed tomography (CT) chest/abdomen/pelvis to screen for lymphoma. Otherwise, routine testing is for diagnosis with serum immunoglobulins.[clinicaladvisor.com]
Weakness
  • The researchers analyzed common variable immunodeficiency disorder (CVID), in which weak antibody responses lead to recurrent, often severe bacterial respiratory tract infections.[news-medical.net]
  • Patients generally suffer with weakness and severe fatigue . Anxiety and depression are commonly seen associated with symptoms specific to microbial infections.[xpertdox.com]
  • Others reported defective functions of DCs in patients with common variable immunodeficiency, inducing weak proliferation of allogeneic T cells and producing significantly low amounts of interleukin 12 upon CD40 signaling.[emedicine.com]
  • Additionally, chills, headache, dizziness and general weakness were observed. These symptoms characterize a reaction to the introduction of a large dose of protein, which is not an indication to stop administering the drug.[f1000research.com]
  • […] abnormal BAFF-R function predisposes to but does not suffice for CVID development. 22 TWEAK deficiency One CVID pedigree with autosomal dominant inheritance had a mutation in tumour necrosis factor superfamily member 12 ( TNFSF12 ), encoding TNF-like weak[jmg.bmj.com]
Recurrent Bronchitis
  • Infections are usually localized in the respiratory tract and a majority of patients have recurrent bronchitis, sinusitis, or otitis (which is more common in childhood-onset CVID), and have had one or more episodes of pneumonia. click for large version[the-rheumatologist.org]
Cough
  • A 42-year-old woman presented with cough and abnormal chest X-ray shadows. Laboratory tests showed remarkable hypogammaglobulinemia.[ncbi.nlm.nih.gov]
  • Case 2: A 38-year-old male patient with CVID, suffered from asthenia, anorexia, myalgia, lower limbs edemas, and dry cough. He had mediastinal and bilateral hilar adenopathies within which biopsy revealed non-necrotizing granulomatous infiltrate.[ncbi.nlm.nih.gov]
  • People may develop a chronic cough, cough up blood, or have difficulty breathing.[merckmanuals.com]
  • Here we report the case of a 37 year-old man presenting to the emergency room with dyspnea, fever and cough; he developed respiratory failure requiring mechanical ventilation.[ncbi.nlm.nih.gov]
  • If bronchiectasis has developed, a daily pulmonary toilet regimen (chest physiotherapy and postural drainage) may be needed to mobilize the secretions from the lungs and bronchi and make them easier to cough up.[primaryimmune.org]
Chronic Diarrhea
  • We present the case of a patient with common variable immunodeficiency suffering a chronic diarrhea episode and who was diagnosed with ileocaecal Crohn s-like disease after performing intestinal transit, CT abdomen and colonoscopy with biopsy.[ncbi.nlm.nih.gov]
  • The digestive clinic is common, in 10% of patients it is the only symptom, and 60 % present chronic diarrhea. Clinically it can be confused and related with other pathologies such as inflammatory bowel disease which is infrequent (2-13%).[ncbi.nlm.nih.gov]
  • Clinical features Chronic diarrhea, malabsorption, recurrent GI giardiasis Microscopic (histologic) description Mucosa may resemble celiac sprue or be normal but always has reduced plasma cells and no IgA plasma cells May have lymphoid hyperplasia or[pathologyoutlines.com]
  • Gastrointestinal problems including chronic diarrhea, weight loss, nausea, vomiting and abdominal pain can also be present. In some forms of CVID, patients develop granulomas in the lungs, lymph nodes, liver, skin or other organs.[aaaai.org]
  • In addition to respiratory infections, patients can suffer from chronic diarrhea caused by intestinal infection, where etiological agent is flagellate Giardia Lamblia.[wikilectures.eu]
Failure to Thrive
  • This case report describes a 10-year-old boy presenting with signs of common variable immunodeficiency (CVID), failure to thrive, impaired neurological development, and a history of recurrent mucocutaneous Candida infections.[ncbi.nlm.nih.gov]
  • Persistent diarrhoea and malabsorption (causing failure to thrive in children) from gastrointestinal infections.[patient.info]
  • Persistent diarrhea, chronic mucocutaneous candidiasis, and failure to thrive may occur in infancy. Blood transfusions can result in graft-versus-host disease and routine vaccinations in fatal infection.[medical-dictionary.thefreedictionary.com]
  • Possible poor growth or failure to thrive. T-Cell and Combined Immunodeficiency:. .. .. Presentation in early infancy.. .. .. Poor growth or failure to thrive.. .. .. Persistent oral thrush.. .. .. Opportunistic infection. Phagocytic Defects:. .. ..[hawaii.edu]
Recurrent Diarrhea
  • It is determined that Giardia lamblia is responsible for the recurrent diarrhea. The physician performs a serum analysis and finds normal levels of mature B lymphocytes.[medbullets.com]
  • diarrhea; 4) Bacterial infections of respiratory tract and/or recurrent diarrhea combined with severe generalized infections (septicemia, meningitis, osteomyelitis); 5) Any of the above criteria combined with autoimmune diseases, especially autoimmune[f1000research.com]
Dental Caries
  • All participants underwent examination for dental caries and periodontal disease. Blood and whole saliva samples were collected on the same day of the oral examination.[ncbi.nlm.nih.gov]
Arthralgia
  • Other findings less frequently reported included rash, arthralgias, myalgias, facial edema, and lymph node or liver test abnormalities, which can also occur in infectious meningitis, mainly of viral origin, with variable frequency.[doi.org]
Alopecia
  • Effect of IVIG on the hair regrowth in a common variable immune deficiency patient with alopecia universalis. Asian Pac J Allergy Immunol. 1999 Mar. 17(1):59-62. [Medline]. Kilic S, Ersoy F, Sanal O, Turkbay D, Tezcan I.[emedicine.com]
  • The most common cutaneous manifestations of common variable immunodeficiency are: Bacterial skin infections, such as impetigo, cellulitis and boils Autoimmune diseases, such as vitiligo, alopecia areata, psoriasis, systemic lupus erythematosus and vasculitis[dermnetnz.org]
Furunculosis
  • Gingivitis, abscesses, skin infection, including cellulitis and furunculosis. Complement Defects:. .. .. Early complement deficiency: Sinopulmonary infection, autoimmune disease.. .. ..[hawaii.edu]

Workup

Patients usually exhibit decreased plasma levels of immunoglobulin A and G and, at some points, equally diminished IgM levels, without any other known cause for this phenomenon. T and B lymphocytes in the serum can be evaluated with the aid of monoclonal antibodies for immunofluorescence staining, with the help of CD19 and CD20 (B cells), CD3 (T cells), CD4 (helper T cells), and CD8 (suppressor T cells). Natural killer cells (also known as NK cells) and T cells can also be enumerated with the use of monoclonal antibodies against CD16, CD56 and CD57.

A high-resolution thoracic computed tomography (CT) scan can prove useful for the diagnosis of pulmonary abnormalities; the information it provides for this specific type of disease is far more useful than that of an x-ray or a test to evaluate lung function. Biopsy samples can be harvested from enlarged lymph nodes in order to rule out malignancy. Bronchoscopy can also be used.

Endoscopy is reserved for patients suspected of suffering from gastrointestinal complications. Lesions and infectious processes can be observed, alongside villous atrophy, infection with cryptosporidium and lambliosis that can be evaluated histologically. Submucosal tissue and lymph nodes are also histologically tested. The former may be infiltrated by plasma cells and the latter may have been subject to the following changes: reactive follicular or atypical hyperplasia and granulomatous inflammation.

Antibody levels are not assessed in patients that have received IV immune globulin (IVIG) during the previous 6 months or earlier, because the antibodies that will be detected are essentially IVIG products. Flow cytometry is also used to determine B- and T-cell count, so as to eliminate the possibility of other conditions causing immunodeficiency, in order to identify CVID versus a multiplicity of other similar conditions: X-linked agammaglobulinemia, multiple myeloma and chronic lymphocytic leukemia. CVID patients usually have a decreased count of class switched memory B cells or CD21+ cells. Protein electrophoresis is used as a screening procedure to exclude monoclonal gammopathies (eg, myeloma), which may be also present with diminished levels of other immunoglobulins.

CVID patients should follow a yearly follow-up plan including spirometry, liver function tests, CBC and a metabolic check up. In cases of impaired lung function, a CT will help investigate the issue appropriately. Screening tests carried out to relatives of the patients are not a recommendation and they are reserved for patients with a given family history of the disease.  

In a nutshell, common variable immunodeficiency is diagnosed by observing considerably low levels of IgG and IgA and/or IgM, alongside a decreased antibody production or lack thereof [16]. CVID is fundamentally a condition that is diagnosed upon exclusion of other similar disorders.

X-Ray Abnormal
  • SCID is typically diagnosed by clinical features: absence of lymph nodes and tonsils, lymphopenia, absence of a thymic shadow on chest x-ray, abnormal T, B, NK cell enumeration with flow cytometric analysis, abnormal in vivo T cell function studies with[hawaii.edu]
Chest X-Ray Abnormal
  • SCID is typically diagnosed by clinical features: absence of lymph nodes and tonsils, lymphopenia, absence of a thymic shadow on chest x-ray, abnormal T, B, NK cell enumeration with flow cytometric analysis, abnormal in vivo T cell function studies with[hawaii.edu]
Bilateral Hilar Adenopathy
  • He had mediastinal and bilateral hilar adenopathies within which biopsy revealed non-necrotizing granulomatous infiltrate. A spontaneous resolution was detected after 9 months of evolution.[ncbi.nlm.nih.gov]
Immunoglobulin A Decreased
  • Diagnosis is based upon both serum immunoglobulin levels; decreased vaccine response; and exclusion of any other condition that could explain these inadequacies.[mastattack.org]
Lymphocytic Infiltrate
  • Immunohistochemical typing of the lymphocytic infiltrate showed that B-cells were almost absent, matching the immunological profile of CVID. The case described is the first case reported in the literature of DPB in a patient affected by CVID.[ncbi.nlm.nih.gov]
  • Abstract Common variable immunodeficiency (CVID) is a primary immunoglobulin deficiency characterized by recurrent infections and complications, including autoimmunity, enteropathy, polyclonal lymphocytic infiltration or lymphoid malignancy.[ncbi.nlm.nih.gov]
  • A novel hypothesis in CVID concurrent with aseptic, erosive polyarthritis is that excessive activation of residual B lymphocytes infiltrate into the synovium of the involved joints and lead to polyarthritis and joint destruction.[ncbi.nlm.nih.gov]
  • Lymphoid interstitial pneumonia (LIP) is a rare disease with lymphocytic infiltration of the alveolar interstitial and air spaces, sometimes classified as a clonal lymphoproliferative disease (LPD) with high prevalence in patients with immunodysregulation[ncbi.nlm.nih.gov]
  • Lymphoid malignancy is a complication feared mostly in cases of polyclonal lymphocytic infiltration.[symptoma.com]
Liver Biopsy
  • Haematemesis was attributed to portal hypertension due to liver cirrhosis, which was confirmed via liver biopsy. Coeliac disease can be a cause of diarrhoea in patients with immunodeficiency disorders and is often underdiagnosed.[ncbi.nlm.nih.gov]

Treatment

Ig replacement therapy (IV or SC) is the most successful and essential treatment plan for CVID. It hinders the recurrence of infections but does come at a certain financial cost.  
The levels that doctors wish to achieve in patients' blood are 400-500 mg/dL in adults; therefore, solutions of 3-12% IVIG can be used regularly. Common regimes stipulate that a dose of 400-600 mg/kg per month will achieve the expected result [6] [17]. Patients with permanent lung damage require greater amounts, 700-800 mg/dL. Doses are usually administered every 1-2 weeks (SC) or 3-4 weeks (IV).

Cyclosporin A has been administered to patients with lymphoid interstitial pneumonitis, which was caused by CVID; the outcome was extremely sucessful. Anti-CD20 monoclonal antibodies have been used against autoimmune thrombocytopenia and neutropenia. Sometimes surgery is bound to be a necessity: chronic sinusitis may be treated with endoscopic  surgery, autoimmune thrombocytopenia or hemolytic anemia can be treated with splenectomy.

Biopsy samples ensure that malignancy can be ruled out and an infection can be accurately diagnosed, should the lymph nodes be larger than expected. If an infection is diagnosed, antibiotics and IVIG are promptly administered. Furthermore, drugs like rituximab, TNF-α inhibitors (eg. infliximab), corticosteroids etc., can be used against autoimmune disorders, lymphoid interstitial pneumonia, and granuloma formation.

Prognosis

Male patients maintain a 20-year survival rate of 64% and female patients of 67%. The overall rate for male and female patients is 92% and 94%, respectively.

The prognosis depends on multiple factors: the existence of an acute autoimmune disease, periodic infections from which the patient sustains permanent lung damage and the emerge of cancer. Other factors that play a significant role in the estimation of the prognosis is the degree of organ damage and the extent to which a patient can successfully be protected against future infections. Lymphoid malignancy is a complication feared mostly in cases of polyclonal lymphocytic infiltration [6]. Increased serum IgM and diminished CD8 count may be indicative of polyclonal lymphocytic infiltration, as well as disorders of the autoimmune spectrum [6].

Etiology

Despite tremendous effort, 40 years of research have yet to discover the exact primary cause for common variable immunodeficiency. This is partly because of the great diversity of this condition. Approximately 20% of patients suffering from CVID have a parent, sibling or offspring who also exhibits a selective IgA deficiency, leading to the suggestion that the disease may be affected by genetic factors. In cases where multiple family members are affected with CVID, about 5% of the patients display a coexisting IgA deficiency; it has been proposed that the inheritance pattern involved in these cases is that of an autosomal recessive inheritance.

Antirheumatic or antiepileptic medication has also been incriminated for causing CVID. If it is proven later on that such a drug has indeed caused the disorder, genetic factors are perceived as having played the role of predisposition, as opposed to causality.

A common flaw of the B-cell differentiation process is bound to play an important role in the occurrence of the disease, but in the majority of the patients the molecular defect remains unknown. Mutations are also sporadic in more than 90% of the cases. There has only been a sub-category of patients whose molecular abnormalities were identified: most are extremely uncommon, except for mutations in TNFRSF13B, which encodes the transmembrane activator and calcium modulator and cyclophilin ligand (TACI). Mutations in TACI occur in ∼8–10% of patients with CVID [3] [4]. 

From a clinical point of view, CVID resembles X-linked agammaglobulinemia concerning the types of infections that arise, but the former characteristically presents between the ages of 20 and 40, namely at a later stage when compared to X-linked agammaglobulinemia. A definite genetic cause of CVID has been established in less than 10% of the patients. The most common type of the condition involves patients who report no prior medical history of CVID in their family; in these cases it is believed that the disease is caused by a synergy of environmental and genetic factors (aka multifactorial inheritance), with genes controlling the differentiation and function of plasma cells being deemed as the primary cause.

Epidemiology

Common variable immunodeficiency affects  approximately 1 person per 50,000 population throughout the world, without a definite tendency towards a specific race or gender.

It can occur in various ages, from infants to people  aged 40 years or older. Peaks of onset include children of 1-5 years and people of 16-20 years, with more than 2/3 of the patients having surpassed the 2nd decade of their lives when CVID is diagnosed [5]. It affects approximately 1 in 25,000–50,000 individuals [6] [7] [8], with report varying according to race. Given its relative prevalence and numbers of cases addressing a physician for medical help, CVID has an indubitable clinical significance [6] [9].

Sex distribution
Age distribution

Pathophysiology

Patients suffering from CVID exhibit multiple immune-system defects; usually the predominant flaw concerns an impaired antibody production. Humoral and cell-mediated lymphocytic reactions are irregular; the basic pathophysiologic mechanism in CVID is a  failure in the process of B lymphocyte maturation. However, studies have shown that this type of abnormality is not frequently observed in patients. One study used pokeweed mitogen to stimulate B cells in vitro and proved that they did not posess the capability to differentiate into plasma cells, something that strongly suggests that surface molecules are expressed in B-cells in an abnormal way.
Cellular irregularities such as these are believed to be caused by defects of the second messenger and translocation pathways of B cells: defective protein kinase C activation and tyrosine phosphorylation. Further studies suggested that the complete lack of IgG and IgA, an increased rate of spontaneous apoptosis, insufficient DNA repair and somatic mutations all impair the functionality of B-cells.

Various factors and cofactors trigger the production of Ig from B cells acquired from patients with CVID: B-cell mitogens, soluble T-cell factors, specific B-cell differentiation factors, the Epstein-Barr virus, IL-2, IL-4 and IL-10. Among patients suffering from the condition, 25-30% also present with augmented levels of CD8+ T cells and a diminished CD4/CD8 ratio (less than 1). It is believed that increased cyclic adenosine monophosphate levels and the activation of protein kinase A constitute the cause for this phenomenon. Moreover, 60% of patients with CVID display a flawed reaction to T-cell receptor stimulation and expression of receptors for IL-2, IL-4, interleukin 5 (IL-5), and interferon gamma. CVID carrying an autosomal dominant inheritance pattern has been associated with the chromosome 4q [10], with one study supporting the validity of a certain gene, thought to be responsible for the development of autosomal dominant CVID/IgA deficiency. This gene's location is believed to be on chromosome 4q. Other potential locations for dominant CVID genes include chromosomes 5p and 16q.

Prevention

There are not many preventive measures against CVID, since its causes still remain unknown. The only existing recommendation advises patients to receive a polysaccharide vaccine [18], because some of them are capable of producing sufficient antibodies, therefore rendering the immunization a success.

Summary

Common variable immunodeficiency is a condition otherwise known as acquired or adult-onset hypogammaglobulinemia. Its typical characteristic is insufficient immunoglobulin (Ig) levels in the plasma, accompanied by morphologically normal B cells that are able to multiply in number but exhibit an inability to turn into Ig-producing plasma cells, which is the last stage of their maturation process. Amongst the primary immunodeficiencies causing clinical manifestations, CVID is by far the most common and can include a broad range of symptoms and fluctuating degrees of severity. It is deemed as a group of conditions with no known cause, primarily due to the multiple immune system defects that have been found to cause this disorder. Low immunoglobulin levels result in a diminished ability to attack foreign substances (bacteria, viruses etc.) and protect the organism. Immunoglobulins are naturally produced by white blood B-type cells once they differentiate into plasma cells.

Common variable immunodeficiency features are decreased levels of most or all of the immunoglobulin classes (IgA, IgG, IgM, IgD, IgE). A diagnosis of CVID is based upon exclusion of other disorders causing immunodeficiency and is mainly established in cases of a B-cell dysfunction that cannot be traced to any other causes [1].

Lastly, CVID can present with a fluctuating clinical presentation and variable types of deficiency. Despite of decreased plasma concentration of immunoglobulin G (IgG) and immunoglobulin A (IgA) being typical of CVID, nearly 50% of patients with this disorder also exhibit low plasma levels of IgM and T-lymphocyte dysfunction. It has been estimated that about 20% of CVID patients will eventually be affected by an autoimmune disease [2].

Patient Information

People affected by common variable immunodeficiency have very low antibody levels and a normal number of B cells (lymphocytes). B cells follow a certain maturation pattern, and when they develop into the so-called plasma cells, they start producing antibodies. In cases of CVID, B cells fail to do so, resulting in less natural protection from microorganisms and other conditions.

Patients usually suffer from periodic infections, including pneumonia, sinusitis, diarrhea. Diarrhea in particular can also result from autoimmune causes; CVID patients are also at a greater risk of developing an autoimmune disease at a percentage of 25%. Antibiotics are administered in cases of infections and other types of treatment (corticosteroids, rituximab) are reserved for autoimmune phenomena.

Doctors suspect CVID by evaluating the symptomatology. Blood tests can measure antibody levels and observe how well the body responds to vaccines. Patients receive "supplementary antibodies" throughout their lives to compensate for those that cannot be naturally produced, namely sera containing antibodies of people with normally functioning immune systems. The majority of the patients have a normal life span, except for cases of a coexisting complication, such as a lymphoma which does not respond to treatment.

References

Article

  1. van de Ven AA, van de Corput L, van Tilburg CM, et al. Lymphocyte characteristics in children with common variable immunodeficiency. Clin Immunol. 2009 Dec 11.
  2. Cunningham-Rundles C. Autoimmune manifestations in common variable immunodeficiency. J Clin Immunol. 2008 May. 28 Suppl 1:S42-5
  3. Salzer U, Chapel HM, Webster AD, et al. Mutations in TNFRSF13B encoding TACI are associated with common variable immunodeficiency in humans. Nat Genet. 2005 Aug;37(8):820-8.
  4. Castigli E, Wilson SA, Garibyan L, et al. TACI is mutant in common variable immunodeficiency and IgA deficiency. Nat Genet. 2005 Aug;37(8):829-34.
  5. Resnick ES, Moshier EL, Godbold JH, Cunningham-Rundles C. Morbidity and mortality in common variable immune deficiency over 4 decades. Blood. 2012 Feb 16;119(7):1650-7.
  6. Chapel H, Lucas M, Lee M, et al. Common variable immunodeficiency disorders: division into distinct clinical phenotypes. Blood. 2008 Jul 15;112(2):277-86.
  7. Stray-Pedersen A, Abrahamsen TG, Frøland SS. Primary immunodeficiency diseases in Norway. J Clin Immunol. 2000 Nov;20(6):477-85.
  8. Fasth A. Primary immunodeficiency disorders in Sweden: cases among children, 1974-1979. J Clin Immunol. 1982 Apr;2(2):86-92.
  9. Cunningham-Rundles C. How I treat common variable immune deficiency. Blood. 2010 Jul 8;116(1):7-15.
  10. Finck A, Van der Meer JW, Schaffer AA, et al. Linkage of autosomal-dominant common variable immunodeficiency to chromosome 4q. Eur J Hum Genet. 2006 Jul. 14(7):867-75.
  11. Aghamohammadi A, Farhoudi A, Moin M, et al. Clinical and immunological features of 65 Iranian patients with common variable immunodeficiency. Clin Diagn Lab Immunol. 2005 Jul. 12(7):825-32.
  12. Kwong JC, Ward PB, Johnson PD. Cutaneous protothecosis in a patient with hypogammaglobulinemia. Med Mycol Case Rep. 2013 Jun 20. 2:132-3.
  13. Boileau J, Mouillot G, Gerard L, et al. Autoimmunity in common variable immunodeficiency: correlation with lymphocyte phenotype in the French DEFI study. J Autoimmun. 2011 Feb. 36(1):25-32.
  14. Bergler-Czop B, Brzezinska-Wcislo L. Pyoderma gangrenosum in a patient with common variable primary immunodeficiency. Postepy Dermatol Alergol. 2013 Jun. 30(3):188-91.
  15. Arunachalam M, Sanzo M, Lotti T, Colucci R, Berti S, Moretti S. Common variable immunodeficiency in vitiligo. G Ital Dermatol Venereol. 2010 Dec. 145(6):783-8.
  16. Geha RS, Notarangelo LD, Casanova JL, et al. International Union of Immunological Societies Primary Immunodeficiency Diseases Classification Committee. Primary immunodeficiency diseases: an update from the International Union of Immunological Societies Primary Immunodeficiency Diseases Classification Committee. J Allergy Clin Immunol. 2007 Oct;120(4):776-94.
  17. Orange JS, Hossny EM, Weiler CR, et al. Primary Immunodeficiency Committee of the American Academy of Allergy, Asthma and Immunology. Use of intravenous immunoglobulin in human disease: a review of evidence by members of the Primary Immunodeficiency Committee of the American Academy of Allergy, Asthma and Immunology. J Allergy Clin Immunol. 2006 Apr;117(4 Suppl):S525-53.
  18. Rezaei N, Siadat SD, Aghamohammadi A, et al. Serum Bactericidal Antibody Response One Year after Meningococcal Polysaccharide Vaccination in Patients with Common Variable Immunodeficiency. Clin Vaccine Immunol. 2010 Jan 27.

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Last updated: 2019-07-11 20:05