Dig Dis Sci DOI 10.1007/s10620-015-3638-4
ORIGINAL ARTICLE
Gastrointestinal Pathologic Abnormalities in Pediatricand Adult-Onset Common Variable Immunodeficiency Vassilios Lougaris1 • Alberto Ravelli1 • Vincenzo Villanacci2 • Marianna Salemme2 • Annarosa Soresina1 • Maurizio Fuoti1 • Francesco Lanzarotto3 • Alberto Lanzini3 • Alessandro Plebani1 • Gabrio Bassotti4
Received: 11 February 2015 / Accepted: 17 March 2015 Ó Springer Science+Business Media New York 2015
Abstract Background Common variable immunodeficiency is the most common form of primary symptomatic immunodeficiency. Gastrointestinal manifestations, such as gastritis, diarrhea, gastrointestinal infections, and malabsorption, may complicate the clinical history in almost 50 % of patients. Aim To evaluate gastrointestinal histopathological findings in pediatric- and in adult-onset common variable immunodeficiency patients. Methods Twenty-two patients with common variable immunodeficiency (13 children, nine adults) were retrospectively studied from a clinical and histopathological point of view. Results Increased T lymphocyte infiltrate and the absence of plasma cells in duodenal lamina propria and submucosa were the most frequent findings, independently from onset age, whereas follicular lymphoid hyperplasia and polymorphonuclear infiltrate, as well as parasitic and viral infections, were only present in the adult group. Common
& Gabrio Bassotti [email protected] Vincenzo Villanacci [email protected] 1
Pediatrics Clinic, Department of Clinical and Experimental Sciences, Spedali Civili, University of Brescia, Brescia, Italy
2
Institute of Pathology, Spedali Civili, University of Brescia, Piazza Spedali Civili, 1, 25100 Brescia, Italy
3
Gastroenterology Unit, Spedali Civili, University of Brescia, Brescia, Italy
4
Gastroenterology Section, Department of Medicine, School of Medicine, University of Perugia, Perugia, Italy
variable immunodeficiency patients with minor gastrointestinal symptoms also presented pathological findings, mainly the absence of plasma cells, T cell infiltrate, and infections, independently of age. Conclusions Gastrointestinal pathological abnormalities are common in both pediatric- and adult-onset common variable immunodeficiency patients. Histological alterations may vary depending upon the age of onset, possibly due to duration of disease. Minor gastrointestinal symptoms are also associated with pathological findings; therefore, these should be searched in all symptomatic patients. Keywords Adults Children Common variable immunodeficiency Histology Pathology
Introduction Common variable immunodeficiency (CVID) is the most common form of primary immunodeficiency, characterized by low immunoglobulin serum levels and an inability to mount a protective antibody response against antigens [1, 2]. The age of onset is variable, and patients may be diagnosed during childhood or adulthood, the latter being the most frequent. CVID patients have increased susceptibility to severe bacterial infections, mainly involving the upper and lower respiratory tract, the gastrointestinal tract, the central nervous system, and the skin. CVID patients are also at increased risk of developing autoimmune and lymphoproliferative diseases. Although the first description of CVID was made by Sanford et al. [3], only in recent years the underlying molecular and genetic mechanisms have been identified, namely mutations in TACI, ICOS, BAFF-R, CD19, CD81, CD20, CD21, in a small group of patients accounting for 10–15 % of all cases [4–11].
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Almost 50 % of CVID patients display a variety of gastrointestinal complaints ranging from dyspepsia to chronic diarrhea [12]; the latter may be severe and cause malabsorption. Infectious agents responsible for the gastrointestinal manifestations include Giardia intestinalis, Campylobacter jejuni, Salmonella spp., and others. Quite often, however, gastrointestinal symptoms and pathology are not related to a demonstrable infection and become part of the so-called CVID enteropathy that affects about 10 % of CVID patients [1, 2, 12–14], with clinical–pathological features similar to those found in celiac disease or in inflammatory bowel disease. Histopathological findings from gastrointestinal biopsies may thus pose significant interpretation problems, and especially in the past, this has led to diagnostic mistakes or inconsistencies. CVID enteropathy may be severe, causing chronic and massive immunoglobulin loss and severe malabsorption. Even when clinical and histopathological manifestations closely resemble those of celiac disease, gastrointestinal symptoms are not responsive to a gluten-free diet, but oral steroids such as budesonide are usually effective [15]. In some severe cases clinically and pathologically similar to inflammatory bowel disease, biological agents such as antiTNFa monoclonal antibodies can be also effective [16]. Since CVID is more frequently diagnosed in adulthood, its gastrointestinal pathological manifestations had been mainly studied in adult patients. However, in recent years, pediatric cases have become increasingly common and may also present gastrointestinal manifestations and complications. The purpose of the present study was to evaluate retrospectively the gastrointestinal symptoms and histopathological features in a group of Italian pediatric and adult patients with CVID, in order to see whether a correlation exists between the histopathological findings and the clinical manifestations.
Materials and Methods
for all patients (21/22 stomach and duodenum, eight adults and 13 children; 3/22 colon, one adult and two children). Three patients, two pediatric- and one adult-onset, were diagnosed with celiac disease and followed a gluten-free diet. The male/female ratio was 5:8 in the pediatric age-group and 6:3 in the adult age-group. The median (±SD) age of onset was 3 ± 5.31 years in pediatric patients and 23 ± 7 in the adult-onset group. Recurrent respiratory tract infections were the most common presenting manifestation in both patient groups. Patients included in this study presented variable gastrointestinal symptoms ranging from minor ones such as epigastric pain to more severe ones such as diarrhea (Table 1). Distribution of gastrointestinal symptoms was similar between pediatric- and adult-onset CVID patients. The study was approved by the Spedali Civili of Brescia Ethics Committee. Histopathological Analysis Upper endoscopy was carried out in 21/22 patients, and colonoscopy in 3/22 patients. Biopsies were taken from the esophagus (C4 biopsies from the distal and middle third), stomach (five biopsies according to the Sidney System protocol), and duodenum (C4 biopsies taken sequentially from the distal duodenum to the duodenal bulb). A minimum of two biopsies from terminal ileum, various colon segments (cecum, ascending, transverse, descending, sigmoid), and rectum were taken, oriented on acetate cellulose filters, fixed in formalin, and embedded in paraffin. Sections of 5 mm were cut and stained with hematoxylin/ eosin, PAS, PAS-diastase, and Giemsa. Immunostaining was carried out using the following antibodies: CD3 (clone SP7, Thermo Scientific, Fremont, CA, USA), CD20 (clone L26, Dako, Glostrup, Denmark), CD8 (clone C8/144B, Dako), and CD138 (clone M15, Dako), and in situ hybridization was also carried out using probes for kappa and lambda chain mRNA (A. Menarini diagnostics, Firenze, Italy).
Patients Retrospective data from 22 patients with CVID were retrieved and divided according to the age of onset in a pediatric-onset group (13 patients, age range 1 month– 16 years) and in an adult-onset group (nine patients, age range 18–40 years). The diagnosis of CVID was made according to the criteria established by the European Society of Primary Immune Deficiencies (ESID, www.esid. org). Patients included in this study are regularly followed at the Paediatrics Clinic of Spedali Civili, University of Brescia. Histopathological samples from the gastrointestinal tract, mainly stomach and duodenum, were available
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Results Histopathological findings are summarized in Table 3. Duodenal biopsies showed an increased intraepithelial T cell count ([25/100 epithelial cells as shown by immunostaining for CD3 and CD8) in 7/13 (54 %) of pediatric patients and 4/8 (50 %) of adult-onset patients (Fig. 1a). Plasma cells were absent in 10/13 (77 %) of pediatric patients and 5/8 (62.5 %) of adult-onset patients. Focal atrophy of the duodenal mucosa was present in 2/13 (15.4 %) of pediatric patients and in 2/8 (22.2 %) of adult-
Dig Dis Sci Table 1 Gastrointestinal symptoms among CVID patients
Total no. (%)
Pediatric-onset no. (%)
Adult-onset no. (%) 10/13 (77)
Epigastric pain/dyspepsia
18/22 (81.8)
8/9 (89)
Diarrhea
14/22 (63.6)
6/9 (67)
8/13 (61.5)
Abdominal pain
17/22 (77.2)
6/9 (67)
11/13 (84.6)
Constipation
4/22 (18)
1/9 (11)
3/13 (23)
Vomiting
9/22 (41)
3/9 (33)
6/13 (46)
Fig. 1 Histopathological findings in gastrointestinal biopsies from CVID patients. a CD3 immunostaining shows increased intraepithelial T cell infiltrate in the superficial epithelium of a duodenal biopsy of a pediatric-onset CVID patient ([25 T lymphocytes/100 epithelial cells) (original magnification 920). b Duodenal biopsy of an adultonset CVID patient showing atrophy and increase in T intraepithelial
lymphocytes on CD3 immunostaining (original magnification 910). c Giardia lamblia in the duodenal biopsy of an adult-onset CVID patient (hematoxylin and eosin, original magnification 9100). d Colonic biopsies of a pediatric-onset CVID case showing GVHDlike apoptotic bodies (arrows) (hematoxylin and eosin, original magnification 940)
onset patients (Fig. 1b). Polymorphonuclear infiltrate and follicular lymphoid hyperplasia, on the other hand, were present, respectively, in 1/8 (12.5 %) and 2/8 (25 %) of adult-onset CVID patients, but were not found in pediatric ones. Graft-versus-host-disease (GVHD)-like lesions characterized by the presence of apoptotic bodies, atrophy, and marked gland hyperplasia were never observed, irrespective of patients’ age of onset or gastrointestinal symptoms. Three of 13 pediatric (23 %) and two of eight adult-onset (22.2 %) patients had Helicobacter pylori; G. intestinalis was detected in two (22.2 %) adult-onset patients (Fig. 1c). Interestingly, one pediatric-onset CVID patient with minor symptoms (dyspepsia) resulted positive for H. pylori infection, while one adult patient with minor symptoms (epigastric pain/dyspepsia) was positive for G. intestinalis and H. pylori; both patients received
appropriate medical treatment with eradication of the infectious agents. Histological gastritis, quiescent or active, was observed in similar percentages in the pediatric- (8/13, 61.5 %) and adult-onset (5/8, 62.5 %) patients. CVID patients were further analyzed based on the type of gastrointestinal symptoms (Table 2). Mucosal atrophy was observed in both pediatric- and adult-onset CVID patients with similar frequency, independently of symptoms, except in constipated subjects. T cell infiltrate was observed in almost all symptomatic patients independently of age of onset and type of symptoms; absence of plasma cells was associated with all types of symptoms, although it was more frequent among pediatric-onset patients (Table 2). Colonic biopsies were available only for three CVID patients, two pediatric- and one adult-onset; the histological
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Dig Dis Sci Table 2 Histological findings in CVID patients based on age of onset and type of symptoms N
Mucosal atrophy
Absence of plasma cells
PMN infiltrate
GVHD-like lesions
T cell infiltrate
Follicular lymphoid hyperplasia
Total
21
4/21 (19 %)
15/21 (71.4 %)
1/21 (5 %)
0/21 (0 %)
11/21 (57 %)
2/21 (9.5 %)
Pediatric Adult
13 8
2/13 (15.4 %) 2/8 (25 %)
10/13 (77 %) 5/8 (62.5 %)
0/13 (0 %) 1/8 (12.5 %)
0/13 (0 %) 0/8 (0 %)
7/13 (54 %) 4/8 (50 %)
0/13 (0 %) 2/8 825 %)
Type of symptoms (results expressed in numbers)
Total (pediatric-/ adult-onset)
Total (pediatric-/ adult-onset)
Total (pediatric-/ adult-onset)
Total (pediatric-/ adult-onset)
Total (pediatric-/ adult-onset)
Total (pediatric-/ adult-onset)
Epigastric pain/dyspepsia
4/18 (2/2)
14/18 (9/5)
1/18 (0/1)
0/18 (0/0)
9/18 (5/4)
1/18 (1/0)
Diarrhea
4/14 (2/2)
9/14 (7/2)
1/14 (0/1)
0/14 (0/0)
6/14 (4/2)
1/14 (0/1)
Abdominal pain
2/17 (2/2)
11/17 (9/2)
1/17 (0/1)
0/17 (0/0)
7/17 (5/2)
1/17 (0/1)
Constipation
0/4 (0/0)
2/4 (2/0)
0/4 (0/0)
0/4 (0/0)
3/4 (0/3)
0/4 (0/0)
Vomit
3/9 (1/2)
5/9 (4/1)
0/9 (0/0)
0/9 (0/0)
6/9 (4/2)
0/9 (0/0)
CVID patients
abnormalities are summarized in Table 3. Overall, mucosal architecture was always preserved, while goblet cells were decreased only in the biopsies of pediatric patients; apoptotic bodies in the presence of CD138? plasma cells were noted only in one pediatric patient (Fig. 1d), and no patient had evidence of dysplasia. The two pediatric-onset CVID patients (Table 3) presented interesting clinical histories. The first one was diagnosed with ‘‘celiac disease’’ at the age of 12. At age 23, he underwent another upper endoscopy with biopsy because of persistent dyspeptic symptoms and vomiting while strictly adhering to a gluten-free diet; the gastric biopsies demonstrated H. pylori-positive MALT lymphoma. H. pylori was eradicated and therapy with anti-CD20 monoclonal antibodies started, resulting in complete clinical and histopathological remission. The second patient was diagnosed with CVID at age 7, and ‘‘celiac disease’’ was later diagnosed at age 24. Gluten-free diet did not induce any symptom improvement, with persistence of diarrhea and microcytic anemia; a repeated upper endoscopy with multiple biopsies showed persistent and refractory duodenal mucosal atrophy. CVID enteropathy was diagnosed, and steroid therapy with budesonide and a free diet prescribed, with resolution of gastrointestinal symptoms, anemia, and mucosal atrophy.
Discussion CVID is the most common primary symptomatic humoral immunodeficiency; however, CVID enteropathy, characterized—albeit not always—by an absence of mucosal plasma cells, a neutrophilic infiltrate, and GVHD-like lesions [12, 13], has been reported in only few studies from Italy [17, 18]. Most literature data refer to adult CVID patients and studies on gastrointestinal manifestations in pediatric CVID patients are scarce. In this retrospective study, we assessed clinical and histopathological findings in pediatric- and adult-onset of CVID patients with gastrointestinal manifestations. Duodenal mucosal atrophy is frequent in CVID patients with gastrointestinal manifestations, ranging from 32 to 51 % [12]. In our group, villous atrophy was observed in 15.4 % of pediatric patients and in 25 % of the adult ones. The most recent study included only adult-onset patients, 50 % of whom had duodenal mucosa atrophy [12], a percentage twofold higher than that we observed in our group. This fact might be due to the inclusion criteria, since we recruited patients also with minor gastrointestinal symptoms. Almost half of the reported adult-onset CVID patients present follicular lymphoid hyperplasia [12], whereas this was present in only 9.5 % of our adult patients
Table 3 Histological findings from colonic biopsies in CVID patients (two pediatric-onset and one adult-onset) Patients
P-onset 1
Colon Gland architecture
Goblet cells
Apoptotic Bodies
Plasma cells
Cryptic abscesses
Dysplasia
Preserved
Reduced
Present
Present
Absent
Absent
P-onset 2
Preserved
Reduced
Absent
Absent
Present
Absent
A-onset 1
Preserved
Normal
Absent
Absent
Absent
Absent
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Dig Dis Sci
(complaining of epigastric pain/dyspepsia, diarrhea, or abdominal pain). The lack of this feature among pediatric CVID patients may be expression of the different duration of the disease. Another recently identified feature of adult-onset CVID is the presence of GVHD-like lesions, reported in 12.2 % of patients [12]. However, despite the small number of cases, none of our CVID patients, independently from the type of symptoms, presented such lesions. Neutrophilic infiltration has been reported as a feature of CVID enteropathy in 44 % of a mixed pediatric- and adult-onset cohort [13]; this feature was not particularly frequent in our patients, since it was documented in only one adult patient, who complained of dyspepsia, diarrhea, and abdominal pain. This difference may be due to secondary events such as the presence of infections. Some histopathological findings were present in both patient groups, independently of age of onset. The absence of mucosal plasma cells remains a hallmark of CVID enteropathy [12, 13] in both pediatric- and adult-onset patients. Interestingly, in our group the absence of plasma cells was particularly frequent among CVID patients with minor symptoms such as epigastralgia/dyspepsia (14/18), independently of age. It is possible, as previously suggested [12–14], that the underlying humoral dysregulation represents an essential pathogenetic factor for the gastrointestinal manifestations in these patients, irrespective of the age of onset. Lymphocytic infiltrate has also been implicated in the pathogenesis of CVID enteropathy in adult-onset CVID; in our study, however, a lymphocytic infiltrate was found with a similar frequency also in pediatric patients, confirming the association between T cells and gastrointestinal mucosal pathology in this condition. Gastrointestinal manifestations in CVID may be related to infectious agents, namely H. pylori and G. intestinalis. Gastritis due to H. pylori infection has been reported in 13–41 % of patients with CVID [12, 13, 19]. Both pediatric- and adult-onset CVID patients included in our study had percentages of H. pylori infection (23 and 22.2 %, respectively), similar to that recently reported in an adult population [12]. The reported prevalence of G. intestinalis in CVID also varies, ranging from 12 % [12] to 21 % [14]. Interestingly, none of our pediatric-onset CVID patients had evidence of Giardia infestation, unlike the adult-onset CVID patients where Giardia was relatively common (22.2 %). The same infectious agents were identified in histological samples from CVID patients with minor symptoms (epigastric pain/dyspepsia). Finally, no gastrointestinal infection by CMV or cryptosporidium was found in our patients. Based on the results of this study, we suggest that the histopathological features of CVID gastrointestinal pathology vary depending on the type of symptoms and do
not appear related to the age of onset. Thus, CVID enteropathy should be suspected and researched even in paucisymptomatic patients. Certain prominent features such as the absence of plasma cells and the lymphocytic infiltrate are frequently observed, even in patients with minor symptoms (epigastric pain/dyspepsia), as well as mucosal atrophy (with the exception of constipated subjects), independently from age of onset. The presence of polymorphonuclear infiltrate and follicular lymphoid hyperplasia was observed in a very limited number of patients and did not allow any correlation. Further studies are thus warranted in order to better define the clinical approach for gastrointestinal evaluation and management of patients with CVID. Acknowledgments The research leading to these results has received funding from the European Community’s Seventh Framework Programme FP7/2007-2013 under Grant Agreement No. 201549. (EURO-PADnet HEALTH-F2-2008-201549). We would like to thank the patients, the patients’ families, and the nurses for all their efforts. Conflict of interest
None.
References 1. Park MA, Li JT, Hagan JB, Maddox DE, Abraham RS. Common variable immunodeficiency: a new look at an old disease. Lancet. 2008;372:489–502. 2. Yong PF, Tarzi M, Chua I, Grimbacher B, Chee R. Common variable immunodeficiency: an update on etiology and management. Immunol Allergy Clin N Am. 2008;28:367–386. 3. Sanford JP, Favour CB, Tribeman MS. Absence of serum gamma globulins in an adult. N Engl J Med. 1954;250:1027–1029. 4. Salzer U, Maul-Pavicic A, Cunningham-Rundles C, et al. ICOS deficiency in patients with common variable immunodeficiency. Clin Immunol. 2004;113:234–240. 5. Castigli E, Wilson SA, Garibyan L, et al. TACI is mutant in common variable immunodeficiency and IgA deficiency. Nat Genet. 2005;37:829–834. 6. Salzer U, Chapel HM, Webster AD, et al. Mutations in TNFRSF13B encoding TACI are associated with common variable immunodeficiency in humans. Nat Genet. 2005;37:820–828. 7. Warnatz K, Salzer U, Rizzi M, et al. B-cell activating factor receptor deficiency is associated with an adult-onset antibody deficiency syndrome in humans. Proc Natl Acad Sci USA. 2009;106:13945–13950. 8. van Zelm M, Reisli I, van der Burg M, et al. An antibody-deficiency syndrome due to mutations in the CD19 gene. N Engl J Med. 2006;354:1901–1912. 9. Kuijpers TW, Bende RJ, Baars PA, et al. CD20 deficiency in humans results in impaired T-cell dependent antibody responses. J Clin Invest. 2010;120:214–222. 10. van Zelm M, Smet J, Adams B, et al. CD81 gene defect in humans disrupts CD19 complex formation and leads to antibody deficiency. J Clin Invest. 2010;120:1265–1274. 11. Thiel J, Kimmig L, Salzer U, et al. Genetic CD21 deficiency is associated with hypogammaglobulinemia. J Allergy Clin Immunol. 2012;129:801–810. 12. Malamut G, Verkarre V, Suarez F, et al. The enteropathy associated with common variable immunodeficiency: the delineated
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Dig Dis Sci frontiers with celiac disease. Am J Gastroenterol. 2010;105: 2262–2275. 13. Daniels JA, Lederman HM, Maitra A, Montgomery EA. Gastrointestinal tract pathology in patients with common variable immunodeficiency: a clinicopathologic study and review. Am J Surg Pathol. 2007;31:1800–1812. 14. Khodadad A, Aghamohammadi A, Parvaneh N, et al. Gastrointestinal manifestations in patients with common variable immunodeficiency. Dig Dis Sci. 2007;52:2977–2983. 15. Elnachef N, McMorris M, Chey WD. Successful treatment of common variable immunodeficiency disorder-associated diarrhea with budesonide: a case report. Am J Gastroenterol. 2007;102: 1322–1325.
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16. Chua I, Standish R, Lear S, et al. Anti-tumour necrosis factoralpha therapy for severe enteropathy in patients with common variable immunodeficiency. Clin Exp Immunol. 2007;150: 306–311. 17. Luzi G, Zullo A, Iebba F, et al. Duodenal pathology and clinicalimmunological implications in common variable immunodeficiency patients. Am J Gastroenterol. 2003;98:118–121. 18. Biagi F, Bianchi PI, Zilli A, et al. The significance of duodenal mucosal atrophy in patients with common variable immunodeficiency: a clinical and histopathologic study. Am J Clin Pathol. 2012;138:185–189. 19. Zullo A, Romiti A, Rinaldi V, et al. Gastric pathology in patients with common variable immunodeficiency. Gut. 1999;45:77–81.
ORIGINAL ARTICLE
Gastrointestinal Pathologic Abnormalities in Pediatricand Adult-Onset Common Variable Immunodeficiency Vassilios Lougaris1 • Alberto Ravelli1 • Vincenzo Villanacci2 • Marianna Salemme2 • Annarosa Soresina1 • Maurizio Fuoti1 • Francesco Lanzarotto3 • Alberto Lanzini3 • Alessandro Plebani1 • Gabrio Bassotti4
Received: 11 February 2015 / Accepted: 17 March 2015 Ó Springer Science+Business Media New York 2015
Abstract Background Common variable immunodeficiency is the most common form of primary symptomatic immunodeficiency. Gastrointestinal manifestations, such as gastritis, diarrhea, gastrointestinal infections, and malabsorption, may complicate the clinical history in almost 50 % of patients. Aim To evaluate gastrointestinal histopathological findings in pediatric- and in adult-onset common variable immunodeficiency patients. Methods Twenty-two patients with common variable immunodeficiency (13 children, nine adults) were retrospectively studied from a clinical and histopathological point of view. Results Increased T lymphocyte infiltrate and the absence of plasma cells in duodenal lamina propria and submucosa were the most frequent findings, independently from onset age, whereas follicular lymphoid hyperplasia and polymorphonuclear infiltrate, as well as parasitic and viral infections, were only present in the adult group. Common
& Gabrio Bassotti [email protected] Vincenzo Villanacci [email protected] 1
Pediatrics Clinic, Department of Clinical and Experimental Sciences, Spedali Civili, University of Brescia, Brescia, Italy
2
Institute of Pathology, Spedali Civili, University of Brescia, Piazza Spedali Civili, 1, 25100 Brescia, Italy
3
Gastroenterology Unit, Spedali Civili, University of Brescia, Brescia, Italy
4
Gastroenterology Section, Department of Medicine, School of Medicine, University of Perugia, Perugia, Italy
variable immunodeficiency patients with minor gastrointestinal symptoms also presented pathological findings, mainly the absence of plasma cells, T cell infiltrate, and infections, independently of age. Conclusions Gastrointestinal pathological abnormalities are common in both pediatric- and adult-onset common variable immunodeficiency patients. Histological alterations may vary depending upon the age of onset, possibly due to duration of disease. Minor gastrointestinal symptoms are also associated with pathological findings; therefore, these should be searched in all symptomatic patients. Keywords Adults Children Common variable immunodeficiency Histology Pathology
Introduction Common variable immunodeficiency (CVID) is the most common form of primary immunodeficiency, characterized by low immunoglobulin serum levels and an inability to mount a protective antibody response against antigens [1, 2]. The age of onset is variable, and patients may be diagnosed during childhood or adulthood, the latter being the most frequent. CVID patients have increased susceptibility to severe bacterial infections, mainly involving the upper and lower respiratory tract, the gastrointestinal tract, the central nervous system, and the skin. CVID patients are also at increased risk of developing autoimmune and lymphoproliferative diseases. Although the first description of CVID was made by Sanford et al. [3], only in recent years the underlying molecular and genetic mechanisms have been identified, namely mutations in TACI, ICOS, BAFF-R, CD19, CD81, CD20, CD21, in a small group of patients accounting for 10–15 % of all cases [4–11].
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Dig Dis Sci
Almost 50 % of CVID patients display a variety of gastrointestinal complaints ranging from dyspepsia to chronic diarrhea [12]; the latter may be severe and cause malabsorption. Infectious agents responsible for the gastrointestinal manifestations include Giardia intestinalis, Campylobacter jejuni, Salmonella spp., and others. Quite often, however, gastrointestinal symptoms and pathology are not related to a demonstrable infection and become part of the so-called CVID enteropathy that affects about 10 % of CVID patients [1, 2, 12–14], with clinical–pathological features similar to those found in celiac disease or in inflammatory bowel disease. Histopathological findings from gastrointestinal biopsies may thus pose significant interpretation problems, and especially in the past, this has led to diagnostic mistakes or inconsistencies. CVID enteropathy may be severe, causing chronic and massive immunoglobulin loss and severe malabsorption. Even when clinical and histopathological manifestations closely resemble those of celiac disease, gastrointestinal symptoms are not responsive to a gluten-free diet, but oral steroids such as budesonide are usually effective [15]. In some severe cases clinically and pathologically similar to inflammatory bowel disease, biological agents such as antiTNFa monoclonal antibodies can be also effective [16]. Since CVID is more frequently diagnosed in adulthood, its gastrointestinal pathological manifestations had been mainly studied in adult patients. However, in recent years, pediatric cases have become increasingly common and may also present gastrointestinal manifestations and complications. The purpose of the present study was to evaluate retrospectively the gastrointestinal symptoms and histopathological features in a group of Italian pediatric and adult patients with CVID, in order to see whether a correlation exists between the histopathological findings and the clinical manifestations.
Materials and Methods
for all patients (21/22 stomach and duodenum, eight adults and 13 children; 3/22 colon, one adult and two children). Three patients, two pediatric- and one adult-onset, were diagnosed with celiac disease and followed a gluten-free diet. The male/female ratio was 5:8 in the pediatric age-group and 6:3 in the adult age-group. The median (±SD) age of onset was 3 ± 5.31 years in pediatric patients and 23 ± 7 in the adult-onset group. Recurrent respiratory tract infections were the most common presenting manifestation in both patient groups. Patients included in this study presented variable gastrointestinal symptoms ranging from minor ones such as epigastric pain to more severe ones such as diarrhea (Table 1). Distribution of gastrointestinal symptoms was similar between pediatric- and adult-onset CVID patients. The study was approved by the Spedali Civili of Brescia Ethics Committee. Histopathological Analysis Upper endoscopy was carried out in 21/22 patients, and colonoscopy in 3/22 patients. Biopsies were taken from the esophagus (C4 biopsies from the distal and middle third), stomach (five biopsies according to the Sidney System protocol), and duodenum (C4 biopsies taken sequentially from the distal duodenum to the duodenal bulb). A minimum of two biopsies from terminal ileum, various colon segments (cecum, ascending, transverse, descending, sigmoid), and rectum were taken, oriented on acetate cellulose filters, fixed in formalin, and embedded in paraffin. Sections of 5 mm were cut and stained with hematoxylin/ eosin, PAS, PAS-diastase, and Giemsa. Immunostaining was carried out using the following antibodies: CD3 (clone SP7, Thermo Scientific, Fremont, CA, USA), CD20 (clone L26, Dako, Glostrup, Denmark), CD8 (clone C8/144B, Dako), and CD138 (clone M15, Dako), and in situ hybridization was also carried out using probes for kappa and lambda chain mRNA (A. Menarini diagnostics, Firenze, Italy).
Patients Retrospective data from 22 patients with CVID were retrieved and divided according to the age of onset in a pediatric-onset group (13 patients, age range 1 month– 16 years) and in an adult-onset group (nine patients, age range 18–40 years). The diagnosis of CVID was made according to the criteria established by the European Society of Primary Immune Deficiencies (ESID, www.esid. org). Patients included in this study are regularly followed at the Paediatrics Clinic of Spedali Civili, University of Brescia. Histopathological samples from the gastrointestinal tract, mainly stomach and duodenum, were available
123
Results Histopathological findings are summarized in Table 3. Duodenal biopsies showed an increased intraepithelial T cell count ([25/100 epithelial cells as shown by immunostaining for CD3 and CD8) in 7/13 (54 %) of pediatric patients and 4/8 (50 %) of adult-onset patients (Fig. 1a). Plasma cells were absent in 10/13 (77 %) of pediatric patients and 5/8 (62.5 %) of adult-onset patients. Focal atrophy of the duodenal mucosa was present in 2/13 (15.4 %) of pediatric patients and in 2/8 (22.2 %) of adult-
Dig Dis Sci Table 1 Gastrointestinal symptoms among CVID patients
Total no. (%)
Pediatric-onset no. (%)
Adult-onset no. (%) 10/13 (77)
Epigastric pain/dyspepsia
18/22 (81.8)
8/9 (89)
Diarrhea
14/22 (63.6)
6/9 (67)
8/13 (61.5)
Abdominal pain
17/22 (77.2)
6/9 (67)
11/13 (84.6)
Constipation
4/22 (18)
1/9 (11)
3/13 (23)
Vomiting
9/22 (41)
3/9 (33)
6/13 (46)
Fig. 1 Histopathological findings in gastrointestinal biopsies from CVID patients. a CD3 immunostaining shows increased intraepithelial T cell infiltrate in the superficial epithelium of a duodenal biopsy of a pediatric-onset CVID patient ([25 T lymphocytes/100 epithelial cells) (original magnification 920). b Duodenal biopsy of an adultonset CVID patient showing atrophy and increase in T intraepithelial
lymphocytes on CD3 immunostaining (original magnification 910). c Giardia lamblia in the duodenal biopsy of an adult-onset CVID patient (hematoxylin and eosin, original magnification 9100). d Colonic biopsies of a pediatric-onset CVID case showing GVHDlike apoptotic bodies (arrows) (hematoxylin and eosin, original magnification 940)
onset patients (Fig. 1b). Polymorphonuclear infiltrate and follicular lymphoid hyperplasia, on the other hand, were present, respectively, in 1/8 (12.5 %) and 2/8 (25 %) of adult-onset CVID patients, but were not found in pediatric ones. Graft-versus-host-disease (GVHD)-like lesions characterized by the presence of apoptotic bodies, atrophy, and marked gland hyperplasia were never observed, irrespective of patients’ age of onset or gastrointestinal symptoms. Three of 13 pediatric (23 %) and two of eight adult-onset (22.2 %) patients had Helicobacter pylori; G. intestinalis was detected in two (22.2 %) adult-onset patients (Fig. 1c). Interestingly, one pediatric-onset CVID patient with minor symptoms (dyspepsia) resulted positive for H. pylori infection, while one adult patient with minor symptoms (epigastric pain/dyspepsia) was positive for G. intestinalis and H. pylori; both patients received
appropriate medical treatment with eradication of the infectious agents. Histological gastritis, quiescent or active, was observed in similar percentages in the pediatric- (8/13, 61.5 %) and adult-onset (5/8, 62.5 %) patients. CVID patients were further analyzed based on the type of gastrointestinal symptoms (Table 2). Mucosal atrophy was observed in both pediatric- and adult-onset CVID patients with similar frequency, independently of symptoms, except in constipated subjects. T cell infiltrate was observed in almost all symptomatic patients independently of age of onset and type of symptoms; absence of plasma cells was associated with all types of symptoms, although it was more frequent among pediatric-onset patients (Table 2). Colonic biopsies were available only for three CVID patients, two pediatric- and one adult-onset; the histological
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Dig Dis Sci Table 2 Histological findings in CVID patients based on age of onset and type of symptoms N
Mucosal atrophy
Absence of plasma cells
PMN infiltrate
GVHD-like lesions
T cell infiltrate
Follicular lymphoid hyperplasia
Total
21
4/21 (19 %)
15/21 (71.4 %)
1/21 (5 %)
0/21 (0 %)
11/21 (57 %)
2/21 (9.5 %)
Pediatric Adult
13 8
2/13 (15.4 %) 2/8 (25 %)
10/13 (77 %) 5/8 (62.5 %)
0/13 (0 %) 1/8 (12.5 %)
0/13 (0 %) 0/8 (0 %)
7/13 (54 %) 4/8 (50 %)
0/13 (0 %) 2/8 825 %)
Type of symptoms (results expressed in numbers)
Total (pediatric-/ adult-onset)
Total (pediatric-/ adult-onset)
Total (pediatric-/ adult-onset)
Total (pediatric-/ adult-onset)
Total (pediatric-/ adult-onset)
Total (pediatric-/ adult-onset)
Epigastric pain/dyspepsia
4/18 (2/2)
14/18 (9/5)
1/18 (0/1)
0/18 (0/0)
9/18 (5/4)
1/18 (1/0)
Diarrhea
4/14 (2/2)
9/14 (7/2)
1/14 (0/1)
0/14 (0/0)
6/14 (4/2)
1/14 (0/1)
Abdominal pain
2/17 (2/2)
11/17 (9/2)
1/17 (0/1)
0/17 (0/0)
7/17 (5/2)
1/17 (0/1)
Constipation
0/4 (0/0)
2/4 (2/0)
0/4 (0/0)
0/4 (0/0)
3/4 (0/3)
0/4 (0/0)
Vomit
3/9 (1/2)
5/9 (4/1)
0/9 (0/0)
0/9 (0/0)
6/9 (4/2)
0/9 (0/0)
CVID patients
abnormalities are summarized in Table 3. Overall, mucosal architecture was always preserved, while goblet cells were decreased only in the biopsies of pediatric patients; apoptotic bodies in the presence of CD138? plasma cells were noted only in one pediatric patient (Fig. 1d), and no patient had evidence of dysplasia. The two pediatric-onset CVID patients (Table 3) presented interesting clinical histories. The first one was diagnosed with ‘‘celiac disease’’ at the age of 12. At age 23, he underwent another upper endoscopy with biopsy because of persistent dyspeptic symptoms and vomiting while strictly adhering to a gluten-free diet; the gastric biopsies demonstrated H. pylori-positive MALT lymphoma. H. pylori was eradicated and therapy with anti-CD20 monoclonal antibodies started, resulting in complete clinical and histopathological remission. The second patient was diagnosed with CVID at age 7, and ‘‘celiac disease’’ was later diagnosed at age 24. Gluten-free diet did not induce any symptom improvement, with persistence of diarrhea and microcytic anemia; a repeated upper endoscopy with multiple biopsies showed persistent and refractory duodenal mucosal atrophy. CVID enteropathy was diagnosed, and steroid therapy with budesonide and a free diet prescribed, with resolution of gastrointestinal symptoms, anemia, and mucosal atrophy.
Discussion CVID is the most common primary symptomatic humoral immunodeficiency; however, CVID enteropathy, characterized—albeit not always—by an absence of mucosal plasma cells, a neutrophilic infiltrate, and GVHD-like lesions [12, 13], has been reported in only few studies from Italy [17, 18]. Most literature data refer to adult CVID patients and studies on gastrointestinal manifestations in pediatric CVID patients are scarce. In this retrospective study, we assessed clinical and histopathological findings in pediatric- and adult-onset of CVID patients with gastrointestinal manifestations. Duodenal mucosal atrophy is frequent in CVID patients with gastrointestinal manifestations, ranging from 32 to 51 % [12]. In our group, villous atrophy was observed in 15.4 % of pediatric patients and in 25 % of the adult ones. The most recent study included only adult-onset patients, 50 % of whom had duodenal mucosa atrophy [12], a percentage twofold higher than that we observed in our group. This fact might be due to the inclusion criteria, since we recruited patients also with minor gastrointestinal symptoms. Almost half of the reported adult-onset CVID patients present follicular lymphoid hyperplasia [12], whereas this was present in only 9.5 % of our adult patients
Table 3 Histological findings from colonic biopsies in CVID patients (two pediatric-onset and one adult-onset) Patients
P-onset 1
Colon Gland architecture
Goblet cells
Apoptotic Bodies
Plasma cells
Cryptic abscesses
Dysplasia
Preserved
Reduced
Present
Present
Absent
Absent
P-onset 2
Preserved
Reduced
Absent
Absent
Present
Absent
A-onset 1
Preserved
Normal
Absent
Absent
Absent
Absent
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Dig Dis Sci
(complaining of epigastric pain/dyspepsia, diarrhea, or abdominal pain). The lack of this feature among pediatric CVID patients may be expression of the different duration of the disease. Another recently identified feature of adult-onset CVID is the presence of GVHD-like lesions, reported in 12.2 % of patients [12]. However, despite the small number of cases, none of our CVID patients, independently from the type of symptoms, presented such lesions. Neutrophilic infiltration has been reported as a feature of CVID enteropathy in 44 % of a mixed pediatric- and adult-onset cohort [13]; this feature was not particularly frequent in our patients, since it was documented in only one adult patient, who complained of dyspepsia, diarrhea, and abdominal pain. This difference may be due to secondary events such as the presence of infections. Some histopathological findings were present in both patient groups, independently of age of onset. The absence of mucosal plasma cells remains a hallmark of CVID enteropathy [12, 13] in both pediatric- and adult-onset patients. Interestingly, in our group the absence of plasma cells was particularly frequent among CVID patients with minor symptoms such as epigastralgia/dyspepsia (14/18), independently of age. It is possible, as previously suggested [12–14], that the underlying humoral dysregulation represents an essential pathogenetic factor for the gastrointestinal manifestations in these patients, irrespective of the age of onset. Lymphocytic infiltrate has also been implicated in the pathogenesis of CVID enteropathy in adult-onset CVID; in our study, however, a lymphocytic infiltrate was found with a similar frequency also in pediatric patients, confirming the association between T cells and gastrointestinal mucosal pathology in this condition. Gastrointestinal manifestations in CVID may be related to infectious agents, namely H. pylori and G. intestinalis. Gastritis due to H. pylori infection has been reported in 13–41 % of patients with CVID [12, 13, 19]. Both pediatric- and adult-onset CVID patients included in our study had percentages of H. pylori infection (23 and 22.2 %, respectively), similar to that recently reported in an adult population [12]. The reported prevalence of G. intestinalis in CVID also varies, ranging from 12 % [12] to 21 % [14]. Interestingly, none of our pediatric-onset CVID patients had evidence of Giardia infestation, unlike the adult-onset CVID patients where Giardia was relatively common (22.2 %). The same infectious agents were identified in histological samples from CVID patients with minor symptoms (epigastric pain/dyspepsia). Finally, no gastrointestinal infection by CMV or cryptosporidium was found in our patients. Based on the results of this study, we suggest that the histopathological features of CVID gastrointestinal pathology vary depending on the type of symptoms and do
not appear related to the age of onset. Thus, CVID enteropathy should be suspected and researched even in paucisymptomatic patients. Certain prominent features such as the absence of plasma cells and the lymphocytic infiltrate are frequently observed, even in patients with minor symptoms (epigastric pain/dyspepsia), as well as mucosal atrophy (with the exception of constipated subjects), independently from age of onset. The presence of polymorphonuclear infiltrate and follicular lymphoid hyperplasia was observed in a very limited number of patients and did not allow any correlation. Further studies are thus warranted in order to better define the clinical approach for gastrointestinal evaluation and management of patients with CVID. Acknowledgments The research leading to these results has received funding from the European Community’s Seventh Framework Programme FP7/2007-2013 under Grant Agreement No. 201549. (EURO-PADnet HEALTH-F2-2008-201549). We would like to thank the patients, the patients’ families, and the nurses for all their efforts. Conflict of interest
None.
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