YBCMD-01837; No. of pages: 5; 4C: Blood Cells, Molecules and Diseases xxx (2014) xxx–xxx
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CD18 deficiency evolving to megakaryocytic (M7) acute myeloid leukemia: Case report Dewton de Moraes Vasconcelos a,b,⁎, Beatriz Beitler c, Gracia A. Martinez c, Juliana Pereira c, José Ulysses Amigo Filho c, Giselle Burlamaqui Klautau d, Yu Cheng Lian d, Marinella Della Negra d, Alberto José da Silva Duarte a a
Medical Investigation Laboratory Unit 56 (LIM/56), Faculdade de Medicina da Universidade de São Paulo, Brazil Primary Immunodeficiency Outpatient Unit (ADEE-3003), Faculdade de Medicina da Universidade de São Paulo, Brazil c Hematology Division, Faculdade de Medicina da Universidade de São Paulo, Brazil d Institute of Infectology Emílio Ribas, Brazil b
a r t i c l e
i n f o
Article history: Submitted 7 June 2014 Revised 8 July 2014 Accepted 8 July 2014 Available online xxxx Communicated by M. Narla Keywords: CD18 Beta-2 integrins Primary immunodeficiency diseases Leukocyte adhesion deficiency type 1 Megakaryocytic (M7) acute myeloid leukemia
a b s t r a c t Leukocyte adhesion deficiency type 1 (LAD 1 — CD18 deficiency) is a rare disease characterized by disturbance of phagocyte function associated with less severe cellular and humoral dysfunction. The main features are bacterial and fungal infections predominantly in the skin and mucosal surfaces, impaired wound healing and delayed umbilical cord separation. The infections are indolent, necrotic and recurrent. In contrast to the striking difficulties in defense against bacterial and fungal microorganisms, LAD 1 patients do not exhibit susceptibility to viral infections and neoplasias. The severity of clinical manifestations is directly related to the degree of CD18 deficiency. Here, a 20 year-old female presenting a partial CD18 deficiency that developed a megakaryocytic (M7) acute myeloid leukemia is described for the first time. The clinical features of the patient included relapsing oral thrush due to Candida, cutaneous infections and upper and lower respiratory tract infections, followed by a locally severe necrotic genital herpetic lesion. The patient's clinical features improved for a period of approximately two years, followed by severe bacterial infections. At that time, the investigation showed a megakaryocytic acute myeloid leukemia, treated with MEC without clinical improvement. The highly aggressive evolution of the leukemia in this patient suggests that adhesion molecules could be involved in the protection against the spread of neoplastic cells. © 2014 Published by Elsevier Inc.
Introduction Integrins are a superfamily of transmembrane glycoproteins found predominantly on the surface of leukocytes that mediate cell–cell and cell–substratum interactions [1]. Integrins have long been recognized as the dominant family of cell adhesion receptors that mediate attachment to the extracellular matrix (ECM) [2]. Only more recently, however, have integrins been credited as signaling receptors essential for proper growth and motility [3,4]. Integrin expression appears to be universal; at least one member of the integrin family has been found on every cell/tissue studied [5,6]. Integrin ligands include bacterial and viral proteins, coagulation and fibrinolytic factors, complement proteins and cellular counter-receptors [1]. Leukocyte integrins, also known as
⁎ Corresponding author at: Medical Investigation Laboratory Unit 56 (LIM/56), Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 500, Building 2, 3rd floor, CEP: 05403-000, São Paulo, SP, Brazil. E-mail address:
[email protected] (D. de Moraes Vasconcelos).
beta-2 integrins CD11a/CD18 (LFA-1), CD11b/CD18 (Mac-1/CR3) and CD11c/CD18 (gp150, 95/CR4) are important for phagocyte cell adhesion, migration across blood vessel walls and ingestion of bacteria opsonized with complement fragments [7]. When these integrins are defective, phagocytes cannot get to sites of infection to ingest and destroy pathogens [8]. Deficiencies have been identified in the leukocyte integrin common β2 subunit, CD18, which result in infections that are resistant to antibiotic treatment and persist despite an apparently effective cellular and humoral adaptive immune response [9,10]. This disease is designated leukocyte adhesion deficiency type 1 (LAD 1); a rare primary autosomal recessive immunodeficiency characterized by recurrent infections, principally bacterial and fungal [11]. The disease manifests in a severe form (b 1% CD18 expression) and also in a moderate form, with intermediate expression of CD18 (2.5–30% CD18 expression) [12]. Life-threatening infections, chronic neutrophilia and impaired wound healing characterize the severe form. Delayed separation of the umbilical cord, chronic gingivoperiodontitis and lack of pus complete the clinical picture. The moderate form presents less severe infectious processes. A hallmark of the adhesion molecule deficiencies is the
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Please cite this article as: D. de Moraes Vasconcelos, et al., Blood Cells Mol. Diseases (2014), http://dx.doi.org/10.1016/j.bcmd.2014.07.005
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D. de Moraes Vasconcelos et al. / Blood Cells, Molecules and Diseases xxx (2014) xxx–xxx
striking leukocytosis, mainly by neutrophils. Biopsies from infected lesions in these patients demonstrated inflammatory infiltrates totally devoid of neutrophils. This histopathological feature is particularly striking considering the marked peripheral neutrophilia. Although the defect in neutrophil adherence accounts for the major clinical manifestations, cellular and humoral immune functions are impaired in vitro [13]. Lymphoid tissue is also severely depleted of lymphocytes, indicating a role for LFA-1 in lymphocyte homing [14]. However, the in vivo significance of these abnormalities is still unclear, since susceptibility to viral infections and neoplasias is similar to that of normal subjects [15]. It is of paramount importance that until further progress occurs in the field of gene therapy, the only curative treatment for the severe form of leukocyte adhesion deficiency remains allogeneic hematopoietic stem cell transplantation (HSCT) [16,17]. Case report and results The case of a 20 year-old female patient born to a nonconsanguineous couple is described, presenting recurrent infections of the oropharynx and genital tract by Candida spp. since 8 years of age. At 18 years of age she presented acute genital herpetic lesions that evolved to necrosis of vulvar tissue, requiring long-lasting treatment with acyclovir and antibiotics, followed by surgical reconstruction. At that time, our service was contacted to evaluate the patient and observation revealed that she presented a striking leukocytosis with neutrophilia (between 30,000 and 70,000 neutrophils/mL), depending on her clinical status. The number of monocytes and lymphocyte subsets was normal and the proliferative responses to PHA and PWM were normal, but clearly depressed for Candida antigen (Table 1). A biopsy of the vulvar lesion showed leukocytoclastic vasculitis with a strikingly poor neutrophilic infiltrate in the tissue, but plenty of leukocytes inside the blood vessels (Fig. 1). Her myelogram was normal, excluding a diagnosis of leukemia. At that time, a diagnosis of a LAD was postulated and an investigation was initiated. Evaluation of CD11a, CD11b and CD18 expression on lymphocytes and monocytes revealed that these were far below normal levels (Table 2 and Fig. 2). Nevertheless, she return to her home town after being misdiagnosed and treated for Behçet's disease with prednisone and colchicine, which resulted in partial improvement of the ulcers [18]. A blood cell count obtained one year later in other service presented thrombocytosis (between 6 × 105 and 106 platelets/mL) as well as leukocytosis, suggesting the development of a myeloproliferative syndrome not evident at that time. Two years later, she returned to our service for further consultation in a septic state and severely pancytopenic, and was reevaluated and treated with resolution of the infectious event. The laboratorial exams showed several abnormalities. Her myelogram had a strikingly low cellularity without blasts, while peripheral blood lymphocyte phenotyping showed a depletion of all subsets of T cells and a severe B cell decrease. Table 1 Results of immunological tests before and during AML. Peripheral blood
Leukocytes Lymphocytes CD3+ CD4+ CD8+ CD2+ CD19+ CD4/CD8 ratio
a) Before AML
b) During AML
%
Absolute
%
Absolute
52,700 2635 2166 835 1130 2192 105 0.74
29.2 93.0 40.7 44.7 88.9 0.7
2200 642 597 261 287 571 4 0.91
5.0 82.2 31.7 42.9 83.2 4.0
Lymphoproliferation (S.I.)
Results
PHA PWM Candida
64.52 241.97 1.08
Fig. 1. Histopathological aspect of the vulvar lesion described in the text. Note the striking quantity of leukocytes inside the blood vessel compared to the paucity in the surrounding tissue.
After a few days, though remaining pancytopenic, a few blasts appeared in the peripheral blood. A bone marrow biopsy showed intense fibrosis and infiltration by megakaryoblasts, leading to a diagnosis of M7-type acute myeloid leukemia. Morphological analysis (Cytospin) showed 33% of peroxidase negative blasts and 33% of Sudan black positive blasts (Fig. 3), confirmed by flow cytometry immunophenotyping (BD FACScalibur). Precursor cells (CD34+) of myeloid (CD117+, CD13+, CD33+) and megakaryocytic lineages (CD41+, CD61+) were detected (Table 3 and Fig. 4). She was treated with MEC (Mitoxantrone, Etoposide and Ara-C) chemotherapy, but showed inadequate response to therapy and a poor bone marrow replacement, which impeded more aggressive chemotherapy, quickly evolving to death due to dissemination of the leukemia. Discussion During the development of a multicellular organism, embryonic cells must associate themselves with tissues. Integrins are the main cellular receptors involved in cellular interactions. Although integrins are constitutively expressed, they do not bind to their counter receptors unless the integrin is activated. The conformation of both the integrin and its ligands is central to integrin–ligand interactions. β2 integrins are expressed on most types of white blood cells where they play a role in leukocyte–leukocyte and leukocyte–endothelium interactions. This includes germinal center B cells in lymphoid follicles [19]; [20], homing of blood lymphocytes into lymphoid tissues, binding of B cells to follicular dendritic cells, adhesion of cytotoxic T cells to their target cells, mixed lymphocyte reactions, antigen-specific and CD3-induced T cell proliferation either in naïve or in memory/effector T helper cells [21] and the T cell-dependent antibody response [22–24]. Although integrins are involved in processes like inflammation, cellular growth, differentiation, junction formation and polarity, it is conceivable that the deficiency of accessory adhesion molecules could lead to enhancement of the spread of neoplastic cells [25–27]. Supporting this theory, an observation has shown that cells from intravascular malignant lymphomatosis (IML), a highly malignant form of lymphoma characterized Table 2 Immunophenotyping for beta-2 integrins in lymphocytes and monocytes. Staining
Normal values 1.92 0.97
N18.80 N8.42 N3.35
CD11a FITC CD18 FITC CD11b PE
Control
Patient (Before AML)
Lympho
Mono
Lympho
Mono
84.0 90.5 4.2
92.2 94.2 84.9
5.2 23.0 0.0
4.9 43.4 7.9
Please cite this article as: D. de Moraes Vasconcelos, et al., Blood Cells Mol. Diseases (2014), http://dx.doi.org/10.1016/j.bcmd.2014.07.005
D. de Moraes Vasconcelos et al. / Blood Cells, Molecules and Diseases xxx (2014) xxx–xxx
CONTROL
b)
PATIENT
LYMPHOCYTES
a)
3
d)
MONOCYTES
c)
Fig. 2. Expression of CD18 on lymphocytes and monocytes of the patient (b and d) and healthy control (a and c). In blue, isotypic control, and in red CD18 expression on lymphocytes (a and b) and monocytes (c and d). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
by multifocal proliferation of malignant lymphocytes within small blood vessels [28], and Burkitt's lymphoma cells are deficient in the expression of LFA-1 (CD11a/CD18), a pathophysiological feature that could be implicated in lymphoma metastasis [29,30]. Moreover, recently the deficiency of the expression of CD11a has been associated with acute promyelocytic leukemia [31] and specifically in acute megakaryoblastic leukemia [32]. On the other hand, beta-2 integrins have also been observed to be overexpressed in human small cell lung carcinoma [33] and in several inflammatory disorders associated with neutrophil activation [34];
e.g., in patients with burns, sepsis, hemodialysis, systemic lupus erythematosus [35], psoriasis [36] and particularly in diabetes [37] and coronary artery disease [38]. The information presented above shows the importance of the integrin family for the initiation, modulation and effectuation of the immune responses. Furthermore, despite all of these features supporting facilitation of the development and spread of neoplastic cells, to the best of our knowledge, this is the first case report of a CD18 deficiency evolving to leukemia. The long-lasting clinical and immunological features of the patient support the diagnosis of a partial CD18 deficiency. Given the Table 3 Bone marrow phenotyping (during AML). B cell antigens Cytoplasm
CD19 — Negative CD10 — Negative
CD22 — 4%
Myeloid antigens Membrane
Fig. 3. Sudan black staining of bone marrow showing negative cells with typical blebs (Megakaryocytic precursors — Arrows) and positive cells (Myeloid precursors — Arrow heads).
T cell antigens
Membrane
CD13 — 35% CD14 — 11% CD33 — 64% CD41 (gpIIb/IIIa) — 43% Glycophorin A — Negative CD117 — 63% CD61 — 33% CD61/CD33 — 17%
Cytoplasm MPO — 13%
Membrane
Cytoplasm CD3 — 10%
Precursor cells Membrane Cytoplasm CD34 — 74% TdT — 8%
CD45 — 85% CD56 — Negative CD38 — 61% CD95 — 14% CD38/CD56 — Negative Bcl 2 1:20 — 30% BAX 1:20 — 80%
Please cite this article as: D. de Moraes Vasconcelos, et al., Blood Cells Mol. Diseases (2014), http://dx.doi.org/10.1016/j.bcmd.2014.07.005
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D. de Moraes Vasconcelos et al. / Blood Cells, Molecules and Diseases xxx (2014) xxx–xxx
a)
b)
c)
d)
e)
f)
Fig. 4. Bone marrow phenotyping showing megakaryocytic markers (CD41 and CD61 on CD34+ blasts): a) gating on morphological characteristics; b) gating on CD34+ cells; c) isotypic control; d) CD117 X CD13; e) CD61 X CD33; and f) CD41 X alpha-glycophorin.
strong evidence of the modulation of integrin expression in neoplastic cells, it is important to stress that evaluation of the expression of β2integrins was performed at least one year before the development of thrombocytosis and prior to any evidence of bone marrow abnormality. Moreover, due to the appearance of thrombocytosis prior to megakaryoblasts, we postulate that either chronic myeloid leukemia or myeloproliferative syndrome developed prior to the acute myeloid leukemia. Unfortunately, the period of thrombocytosis occurred when the patient was in her home town, far from São Paulo, and we only had access to the results of these blood cell counts after her death, impeding the evaluation of possible chromosomal abnormalities, such as translocations like Philadelphia chromosome t(9;22)(q34;q11) or bcr/ abl molecular rearrangement. References [1] T.A. Haas, E.F. Plow, Integrin–ligand interactions: a year in review, Curr. Opin. Cell Biol. 6 (1994) 656–662. [2] R.O. Hynes, Integrins: versatility, modulation, and signaling in cell adhesion, Cell 69 (1992) 11–25. [3] F.G. Giancotti, E. Ruoslahti, Integrin signaling, Science 285 (1999) 1028–1032. [4] L.D. Notarangelo, R. Badolato, Leukocyte trafficking in primary immunodeficiencies, J. Leukoc. Biol. 85 (2009) 335–343. [5] S.M. Albelda, C.A. Buck, Integrins and other cell adhesion molecules, FASEB J. 4 (1990) 2868–2880. [6] C.W. Smith, Adhesion molecules and receptors, J. Allergy Clin. Immunol. 121 (2008) S375–S379. [7] E.S. Harris, T.M. McIntyre, S.M. Prescott, G.A. Zimmerman, The leukocyte integrins, J. Biol. Chem. 275 (2000) 23409–23412. [8] A. Etzioni, Leukocyte adhesion deficiencies: molecular basis, clinical findings, and therapeutic options, Adv. Exp. Med. Biol. 601 (2007) 51–60. [9] T.A. Springer, N.S. Thompson, L.J. Miller, F.C. Schmalsstieg, D.C. Anderson, Inherited deficiency of the MAC-1, LFA-1, p150, 95 glycoprotein family and its molecular basis, J. Exp. Med. 160 (1984) 1901–1918. [10] N. Hogg, M.P. Stewart, S.L. Scarth, R. Newton, J.M. Shaw, S.K. Law, N. Klein, A novel leukocyte adhesion deficiency caused by expressed but nonfunctional beta-2 integrins Mac-1 and LFA-1, J. Clin. Invest. 103 (1999) 97–106. [11] N. Hogg, P.A. Bates, Genetic analysis of integrin function in man: LAD-1 and other syndromes, Matrix Biol. 19 (2000) 211–222. [12] A. Fischer, B. Lisowska-Grospierre, D.C. Anderson, T.A. Springer, Leukocyte adhesion deficiency: molecular basis and functional consequences, Immunodefic. Rev. 1 (1988) 39–54.
[13] H.D. Ochs, S. Nonoyama, Q. Zhu, M. Farrington, R.J. Wedgwood, Regulation of antibody response: the role of complement and adhesion molecules, Clin. Immunol. Immunopathol. 67 (1993) s33–s39. [14] A. Smith, P. Stanley, K. Jones, L. Svensson, A. McDowall, N. Hogg, The role of the integrin LFA-1 in T-lymphocyte migration, Immunol. Rev. 218 (2007) 135–146. [15] A. Etzioni, J.M. Harlan, Cell adhesion and leukocyte adhesion defects, in: H.D. Ochs, C. I. Edvard-Smith, J.M. Puck (Eds.), Primary Immunodeficiency Diseases: A molecular and genetic approach, Oxford University Press, 1999. [16] W. Qasim, M. Cavazzana-Calvo, E.G. Davies, J. Davis, M. Duval, G. Eames, N. Farinha, A. Filipovich, A. Fischer, W. Friedrich, A. Gennery, C. Heilmann, P. Landais, M. Horwitz, F. Porta, P. Sedlacek, R. Seger, M. Slatter, L. Teague, M. Eapen, P. Veys, Allogeneic hematopoietic stem-cell transplantation for leukocyte adhesion deficiency, Pediatrics 123 (2009) 836–840. [17] R. Elhasid, J.M. Rowe, Hematopoietic stem cell transplantation in neutrophil disorders: severe congenital neutropenia, leukocyte adhesion deficiency and chronic granulomatous disease, Clin. Rev. Allergy Immunol. 38 (2010) 61–67. [18] A.J. Bedlow, E.G. Davies, A.L. Moss, N. Rebuck, A. Finn, R.A. Marsden, Pyoderma gangrenosum in a child with congenital partial deficiency of leukocyte adherence glycoproteins, Br. J. Dermatol. 139 (1998) 1064–1067. [19] M.A. Horton, D. Lewis, K. McNulty, Immunohistological characterization of myeloid and leukemia-associated monoclonal antibodies, in: E.L. Reinherz, et al., (Eds.), Leukocyte typing II, vol 3, Springer-Verlag, New York, 1986, pp. 255–260. [20] B. Ehlin-Henriksson, G. Klein, M. Patarroyo, Differential expression of integrins and other adhesion molecules on blood and tonsil CD19 + B lymphocytes, in: S.F. Schlossman, et al., (Eds.), Leukocyte typing V, Oxford University Press, Oxford, 1995, pp. 1604–1605. [21] G.A. van Seventer, R.T. Semnani, E.M. Palmer, B.L. McRae, J.M. van Seventer, Integrins and T helper cell activation, Transplant. Proc. 30 (1998) 4270–4274. [22] M. Patarroyo, M.W. Makgoba, Leukocyte adhesion to cells. Molecular basis, physiological relevance, and abnormalities, Scand. J. Immunol. 30 (1989) 129–164. [23] T.A. Springer, Adhesion receptors of the immune system, Nature 346 (1990) 425–434. [24] G. Koopman, H.K. Parmentier, H.J. Schuurman, W. Newman, C.J. Meijer, S.T. Pals, Adhesion of human B cells to follicular dendritic cells involves both the lymphocyte function-associated antigen 1/intercellular adhesion molecule 1 and very late antigen 4/vascular cell adhesion molecule 1 pathways, J. Exp. Med. 173 (1991) 1297–1304. [25] M. Patarroyo, Leukocyte adhesion in host defense and tissue injury, Clin. Immunol. Immunopathol. 60 (1991) 333–348. [26] M. Pignatelli, Integrins, cadherins and catenins: molecular cross talk in cancer cells, J. Pathol. 186 (1998) 1–2. [27] B. Wehrle-Haller, B.A. Imhof, Integrin-dependent pathologies, J. Pathol. 200 (2003) 481–487. [28] S. Jalkanen, R. Aho, M. Kallajoki, T. Ekfors, P. Nortamo, C. Gahmberg, A. Duijvestijn, H. Kalimo, Lymphocyte homing receptors and adhesion molecules in intravascular malignant lymphomatosis, Int. J. Cancer 44 (1989) 777–782.
Please cite this article as: D. de Moraes Vasconcelos, et al., Blood Cells Mol. Diseases (2014), http://dx.doi.org/10.1016/j.bcmd.2014.07.005
D. de Moraes Vasconcelos et al. / Blood Cells, Molecules and Diseases xxx (2014) xxx–xxx [29] G.R. Picchio, J.I. Cohen, E.R. Wyatt, D.E. Mosier, Enhanced tumorigenicity of an Epstein-Barr virus-transformed lymphoblastoid cell line is associated with a unique 1:18 chromosomal translocation and decreased expression of lymphocyte function associated antigen-1a (CD11a), Am. J. Pathol. 143 (1993) 342–349. [30] M. Neira, J. Rincón, H. Arias, S.K.A. Law, M. Patarroyo, Adhesion molecule CD11a/ CD18-deficient Burkitt's lymphoma cell lack the transcript for the β, but not the α, integrin subunit, Eur. J. Haematol. 58 (1997) 32–39. [31] Y. Zhou, J.L. Jorgensen, S.A. Wang, F. Ravandi, J. Cortes, H.M. Kantarjian, L.J. Medeiros, S. Konoplev, Usefulness of CD11a and CD18 in flow cytometric immunophenotypic analysis for diagnosis of acute promyelocytic leukemia, Am. J. Clin. Pathol. 138 (2012) 744–750. [32] H. Boztug, A. Schumich, U. Pötschger, N. Mühlegger, A. Kolenova, K. Reinhardt, M. Dworzak, Blast cell deficiency of CD11a as a marker of acute megakaryoblastic leukemia and transient myeloproliferative disease in children with and without Down syndrome, Cytometry B Clin. Cytom. 84 (2013) 370–378. [33] D.G. Tang, K.V. Honn, Adhesion molecules and tumor metastasis: an update, Invasion Metastasis 14 (1994–95) 109–122.
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[34] A. Mazzone, G. Ricevuti, Leukocyte CD11/CD18 integrins: biological and clinical relevance, Haematologica 80 (1995) 161–175. [35] Y. Molad, J. Buyon, D.C. Anderson, S.B. Abramson, B.N. Cronstein, Intravascular neutrophil activation in systemic lupus erythematosus (SLE): dissociation between increased expression of CD11b/CD18 and diminished expression of L-selectin on neutrophils from patients with active SLE, Clin. Immunol. Immunopathol. 71 (1994) 281–286. [36] T. Peters, A. Sindrilaru, H. Wang, T. Oreshkova, A.C. Renkl, D. Kess, K. ScharffetterKochanek, CD18 in monogenic and polygenic inflammatory processes of the skin, J. Investig. Dermatol. Symp. Proc. 11 (2006) 7–15. [37] H. Setiadi, J.L. Wautier, A. Courillon-Mallet, P. Passa, J. Caen, Increased adhesion to fibronectin and Mo-1 expression by diabetic monocytes, J. Immunol. 138 (1987) 3230–3234. [38] A. Mazzone, D. Pasotti, S. De Servi, G. Fossati, I. Hazzucchelli, P. Cavigliano, G. Ricevuti, Correlation between CD11b/CD18 and increase of aggregability of granulocytes in coronary artery disease, Inflammation 16 (1992) 315–323.
Please cite this article as: D. de Moraes Vasconcelos, et al., Blood Cells Mol. Diseases (2014), http://dx.doi.org/10.1016/j.bcmd.2014.07.005
