J ALLERGY CLIN IMMUNOL

VOLUME 125, NUMBER 4

LETTERS TO THE EDITOR 943

Disclosure of potential conflict of interest: The authors have declared that they have no

conflict of interest.

REFERENCES

1. Hjern A, Hedberg A, Haglund B, Rosen M. Does tobacco smoke prevent atopic

disorders? A study of two generations of Swedish residents. Clin Exp Allergy

2001;31:908-14.

2. Magnusson LL, Olesen AB, Wennborg H, Olsen J. Wheezing, asthma, hayfever,

and atopic eczema in childhood following exposure to tobacco smoke in fetal

life. Clin Exp Allergy 2005;35:1550-6.

3. Kramer U, Lemmen CH, Behrendt H, Link E, Schafer T, Gostomzyk J, et al. The

effect of environmental tobacco smoke on eczema and allergic sensitization in chil-

dren. Br J Dermatol 2004;150:111-8.

4. Bohme M, Lannero E, Wickman M, Nordvall SL, Wahlgren CF. Atopic dermatitis

and concomitant disease patterns in children up to two years of age. Acta Derm

Venereol 2002;82:98-103.

5. Wickman M, Kull I, Pershagen G, Nordvall SL. The BAMSE project: presentation

of a prospective longitudinal birth cohort study. Pediatr Allergy Immunol 2002;

13(suppl 15):11-3.

6. Gehring U, Leaderer BP, Heinrich J, Oldenwening M, Giovannangelo ME, Nor-

dling E, et al. Comparison of parental reports of smoking and residential air nico-

tine concentrations in children. Occup Environ Med 2006;63:766-72.

7. Murray CS, Woodcock A, Smillie FI, Cain G, Kissen P, Custovic A. Tobacco

smoke exposure, wheeze, and atopy. Pediatr Pulmonol 2004;37:492-8.

8. Magnusson CG. Maternal smoking influences cord serum IgE and IgD levels and

increases the risk for subsequent infant allergy. J Allergy Clin Immunol 1986;78:

898-904.

9. Devereux G, Barker RN, Seaton A. Antenatal determinants of neonatal immune

responses to allergens. Clin Exp Allergy 2002;32:43-50.

10. Noakes PS, Holt PG, Prescott SL. Maternal smoking in pregnancy alters neonatal

cytokine responses. Allergy 2003;58:1053-8.

11. Kulig M, Luck W, Lau S, Niggemann B, Bergmann R, Klettke U, et al. Effect of

pre- and postnatal tobacco smoke exposure on specific sensitization to food and in-

halant allergens during the first 3 years of life. Multicenter Allergy Study Group,

Germany. Allergy 1999;54:220-8.

Available online March 15, 2010.

doi:10.1016/j.jaci.2009.12.997

Therapeutic strategy in p47-phox deficientchronic granulomatous disease presenting asinflammatory bowel disease

To the Editor:Chronic granulomatous disease (CGD) is a rare inherited

disorder of the innate immune system (1 in 200,000 to 1 in250,000 live births per year; see also this article’s OnlineRepository at www.jacionline.org). A hallmark of the diseaseis uncontrolled inflammation often accompanied by granulomaformation both in the presence and absence of microorgan-isms. Such inflammation can affect various organ systems, in-cluding the gastrointestinal tract. Furthermore, patients withCGD are highly susceptible to distinct opportunistic bacteriaand fungi, but the disorder does not always manifest itselfthrough infections.1 Inflammatory bowel disease (IBD) is awell-known complication of CGD.1-4 However, in previouslarge cohort studies typical infections, such as pneumonia,and abscesses in lymph nodes or the liver facilitated the diag-nosis of this rare disorder.

CGD manifested as IBD in 7.8% of 154 cases (see thisarticle’s Online Repository). Here we report 8 patients withp47-phox deficient (A478) CGD who primarily presented withsymptoms typical for IBD, such as severe granulomatous colitis(5/8 patients), aphthous stomatitis (3/8 patients), bloody diar-rhea (4/8 patients), and perianal abscesses, eczema, fissures, orfistula formation (5/8 patients), as summarized in Table I. In 7patients the symptoms started very early in life, between 6

weeks and 5 years of age. Initially, Crohn disease was presumedin the majority of patients. However, ulcerative colitis and otherdiagnoses, such as juvenile idiopathic arthritis, Behcxet disease,and pyoderma gangrenosum, were also considered.

Histopathological evaluation of biopsy samples can provideclues for CGD in patients with IBD (eg, pigmented macrophages,as seen in patient 2), but the diagnosis has to be confirmedbiochemically.5 As typical for p47-phox deficiency, we found re-sidual nicotinamide adenine dinucleotide phosphate (NADPH) ox-idase activity (see this article’s Online Repository) in our patients,which likely prevented early infectious complications. In general,patients with CGD with such residual activity manifest symptomslater in life, experience longer symptom-free intervals, and have abetter overall prognosis than patients with complete lack ofNADPH oxidase activity. However, it is important to note thatpatients with residual NADPH oxidase activity can also acquirelife-threatening CGD-typical infections. Therefore it is importantto diagnose CGD as early as possible to provide CGD-specificcare, such as surveillance and prophylactic antimicrobialtreatment. It is possible that patients with Crohn-like disease andunrecognized CGD succumb to severe infections that are errone-ously attributed to the effects of immunosuppressive drugs.

In our patients p47-phox deficient CGD was diagnosed 2 to10 years after the first manifestation (median, 6 years; patients1–7 included; Table I), with c.75-76delGT in the neutrophil cy-tosolic factor 1 (NCF1) gene being the most common muta-tion.6 IBD was the prominent and first clinical CGDmanifestation, but 5 patients (nos. 1, 3, 5, 6, and 8) also hadother symptoms of dysregulated inflammation, such asgranulomatous lymphadenopathy, arthritis, encephalitis, andpyoderma-like skin lesions. Infections typical for CGD, suchas lymph node and organ abscesses or Aspergillus species–in-duced pneumonias, did not occur. Our patients with CGD eitherreceived prophylactic antibiotics (mostly co-trimoxazole) or thefull standard CGD prophylactic treatment comprising co-trimoxazole and itraconazole. Before and after CGD had beendetected, several therapeutic approaches were chosen to treatIBD, such as polymeric diet, mesalazine, steroids, thalidomide,azathioprine, methotrexate, anakinra, infliximab, and adalimu-mab. The improvements after such therapies varied consider-ably (see this article’s Online Repository). Steroids were mostfrequently applied in our and other studies and were helpfulin several patients. In some patients all treatments failed. Symp-toms in 2 patients (nos. 2 and 6; Table I) improved after a com-bination of polymeric diet, mesalazine, and azathioprine.

However, patient 6 acquired Candida albicans–induced enceph-alitis. Reduced-intensity conditioning hematopoietic stem celltransplantation (RIC-HSCT) was performed in this and 2 other pa-tients (nos. 4 and 8; Tables I and II) because of intractable orsteroid-dependent colitis, severe osteopenia, and failure to thrive.All patients are alive 8, 19 and 59 months after RIC-HSCT, respec-tively, with complete remission of intestinal and other CGD-related symptoms in the absence of graft-versus-host disease.HSCT should be considered in any patients with CGD with a his-tory of life-threatening infections or therapy-refractory inflamma-tory conditions that lead to organ dysfunction, chronic pain, orfailure to thrive.7 HSCT might also be indicated if necessary ther-apy is hampered by unacceptable side effects, such as steroid-associated osteoporosis, hypertension, or diabetes, or in cases ofcomplete intolerance or incompliance to standard and alternativeCGD prophylaxis. Yet the pros and cons of HSCT must be

TABLE I. Patient characteristics

Patient 1, male Patient 2, female Patient 3, female Patient 4, male

Age at onset of GI symptoms 6 wk 18 mo 2 y 3 y

Erroneously presumed

diagnosis

Behcxet or Crohn disease Indeterminate or ulcerative

colitis

Suspected Crohn disease Crohn disease

Age at CGD diagnosis 8 y 8 y 11 y 5 y

Disease-causing mutation Homozygous c.75_76delGT,

NCF1

c.75_76delGT;730G>A,

p.E244K, NCF1

Homozygous c.75_76delGT,

NCF1

Homozygous c.75_76delGT,

NCF1Residual NADPH oxidase

activity�0.9% 1% 2% 1.2%

Upper GI symptoms Aphthous stomatitis None Aphthous stomatitis None

Lower GI symptoms Perianal abscesses, fistulas,

diarrhea

Severe colitis Perianal eczema Severe colitis

Other symptoms and

findings

Nasal eczema Pigmented macrophages Recurrent laryngitis None

Family history Unremarkable Unremarkable Unremarkable Unremarkable

Therapy Prophylactic antibiotics,

thalidomide

Prophylactic antibiotics,

mesalazine, azathioprine,

polymeric diet, steroids

for flares

Prophylactic antibiotics Standard CGD prophylaxis,*

mesalazine, azathioprine,

steroids, anakinra,

infliximab methotrexate

Outcome IBD resolved One flare in the last 2 years Infrequent stomatitis IBD resolved after

successful RIC-HSCT

Patient 5, male Patient 6, female Patient 7, male Patient 8, female

Age at onset of GI symptoms 4 y 4 y 5 y 16 y

Erroneously presumed

diagnosis

None Crohn disease, sarcoidosis Crohn disease None

Age at CGD diagnosis 9 y 6 y 15 y 13 y

Disease-causing mutation c.75_76delGT;574G>A,

p.G192S, NCF1

Homozygous c.579G>A,

p.W193X, NCF1

WB negative for p47-phox,

NCF1

c.75_76delGT;574G->A,

p.G192S, NCF1Residual NADPH oxidase

activity

Trace in chemiluminescence

(CL, as in patient 8)

1.4% 1.1% §30% neutrophils weakly

NBT positive; trace in CL

Upper GI symptoms Aphthous stomatitis None None None

Lower GI symptoms Granulomatous proctitis Chronic anal fissures, severe

colitis

Perianal abscesses and

fistulas, severe colitis

Severe colitis

Other symptoms and

findings

Granulomatous

lymphadenopathy in the

past, arthritis

Granulomatous

Lymphadenopathy,

Candida species–induced

encephalitis

None Pyoderma-like and ecthyma-

like lesions, acne

pustulosa, arthritis

(oligoarticular)

Family history Brother of patient 8 Affected sister Unremarkable Unremarkable

Therapy Standard CGD prophylaxis,

mesalazine, steroids,

G-CSF, azathioprine,

etanercept, pimecrolimus

Standard CGD prophylaxis,

mesalazine, azathioprine,

steroids, polymeric diet

Standard CGD prophylaxis,

steroids, azathioprine,

methotrexate, thalidomide,

infliximab, adalimumab

Itraconazole prophylaxis,

mesalazine, steroids

Outcome Stable with azathioprine,

local steroid and

pimecrolimus ointments

No recurrence of IBD after

successful RIC-HSCT

IBD almost resistant to

therapy

IBD resolved after

successful RIC-HSCT

CL, Chemiluminescence; G-CSF, granulocyte colony-stimulating factor; GI, gastrointestinal tract; NBT, nitroblue tetrazolium; WB, western blot.

*Standard CGD prophylaxis: co-trimoxazole, trimethoprim, 4-5 mg/kg; itraconazole, 5-10 mg/kg; standard CGD antibiotic: co-trimoxazole alone.

�Percentage H2O2 compared with healthy donor; dihydrorhodamine 123 (DHR) assay if not stated otherwise.

§After stimulation with complement-opsonized zymosan.

J ALLERGY CLIN IMMUNOL

APRIL 2010

944 LETTERS TO THE EDITOR

weighed carefully because CGD colitis is rarely life-threatening,whereas HSCT in high-risk patients with CGD (defined as patientswith CGD with ongoing therapy-refractory infections and inflam-matory lesions at transplantation) might be associated with a con-siderable rate of complications, such as graft-versus-host diseaseand inflammatory flare-ups, leading to a mortality of up to36%.7 However, new low-toxicity regimens,8 including the oneused in the patients described here, might offer lower mortalityrates and a lower incidence of long-term toxicities, such as infer-tility (low busulfan/fludarabine/antithymocyte globulin or alemtu-zumab [Campath], n 5 11; disease-free survival, 91%; mortality,

9%; personal communication from T. G€ungor on behalf of the Eu-ropean Group for Bone Marrow Transplantation Pediatric Work-ing Party Inborn Errors).

Several conclusions can be made from these data:

d Clinicians and pathologists need to be alerted that CGD is adifferential diagnosis of IBD, especially, but not exclu-sively, when occurring early in life. Evaluation of cluesfor CGD (see this article’s Online Repository) in the med-ical history and physical findings is necessary.

TABLE II. Overview of RIC-HSCT and outcome

Status before

conditioning

Conditioning

(reduced

intensity) Donor/graft

Day of

neutrophils

reaching

0.5 g/L

GvHD and

rejection

prophylaxis Complications Chimerism

Outcome

(follow-up

after HSCT)

Patient 4 Active

inflammation

of terminal

ileum and

colon

Fludarabine,

30 mg/m2/d

for 6 d;

alemtuzumab,

23 0.2 mg/kg/d,

13 0.2 mg/kg/d;

Intravenous

busulfan, 2.4

mg/kg per

dose, 5 doses

12/12 HLA-

matched

unrelated

female/6 3 106

CD341 cells/kg,

T-replete

marrow

119 Mofetil

mycophenolate,

1200 mg/m2 for

4 mo;

cyclosporine for

6 mo (serum

level, 150–200

ng/mL)

Hemorrhagic

cystitis,

no GvHD,

no intestinal

flare-up

95% DHR assay,

RFLP-PCR same

range

Cured from CGD,

no intestinal

problems, well

and without

medication

(19 mo)

Patient 6 Active

inflammation

of colon,

steroid

dependent

Fludarabine,

30 mg/m2/d

for 6 d;

alemtuzumab,

23 0.2 mg/kg/d,

13

0.2 mg/kg/d;

intravenous

busulfan, 0.95

mg/kg per dose,

10 doses

9/10 HLA-matched

unrelated

female/2.3 3

106 CD341

cells/kg,

T-replete

marrow

119 Methotrexate, 10

mg/m2 on days

11, 13, 16;

cyclosporine

(serum level,

100–150 ng/mL

for 4.5 mo)

Vertebral fractures

caused by long-

term steroid

therapy,

no GvHD,

no intestinal

flare-up

100% DHR

assay, RFLP-

PCR same result

Cured from CGD,

no intestinal

problems, well

and without

medication

(8 mo)

Patient 8 Active

pancolitis

Fludarabine, 30

mg/m2/d for 6 d;

oral busulfan, 4

mg/kg/d for 2

days; rabbit

ATG, 10 mg/kg

for 4 days

Fully HLA-

matched sibling,

female/3.5 3

106 CD341

cells/kg, T-

replete marrow

117 Mofetil

mycophenolate,

2 3 1 g daily for

4 mo;

cyclosporine

(serum level,

150–200 ng/mL

for 6 mo)

Cholecystectomy

because of

cholecystitis,

no GvHD,

no intestinal

flare-up

98% DHR assay,

FISH: same

range

Cured from CGD,

no intestinal

problems, well

and without

medication

(59 mo)

ATG, Antithymocyte globulin; GvHD, graft-versus-host disease.

Patient 4: Drug monitoring was aimed at a cumulative area under the curve of busulfan between 45,000 and 65,000 ng/hxL (the cumulative area under the curve was 58,000 ng/

hxL). Fludarabine was administered on days 28 to 23, 0.5 mg/kg alemtuzumab was administered from days 28 to 26, and busulfan was administered from days 25 to 23.

GvHD prophylaxis with intravenous cyclosporine started on day 23. Mofetil mycophenolate (1200 mg/m2) was introduced on day 0 six hours after stem cell infusion. The drug

was continued and tapered later until day 1120.

Patient 6: Fludarabine was administered on days 28 to 23, intravenous busulfan was administered on days 25 to 23, and alemtuzumab was administered on days 28 to 26. The

patient was receiving 1 mg/d methylprednisolone at the time of transplantation. This was continued until day 1100 and then tapered and discontinued on day 1140.

Patient 8: Fludarabine was administered on days 27 to 22, oral busulfan was administered on days 23 and 22, and rabbit anti–T-cell globulin was administered on days 24 to

21. GvHD prophylaxis with intravenous cyclosporine started on day 23. Mofetil mycophenolate (1200 mg/m2) was introduced on day 0 six hours after stem cell infusion. The

drug was continued and tapered later until day 1120.

DHR, Dihydrorhodamine 123; FISH, fluorescent in situ hybridization.

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LETTERS TO THE EDITOR 945

d If CGD is confirmed biochemically, evaluation (see this ar-ticle’s Online Repository) for subclinical infections andprophylactic therapy of infections are necessary beforestarting IBD treatment. Careful surveillance is mandatory.

d Therapy for IBD in patients with CGD is not well established.Therefore further studies are needed to follow-up patientswith different therapies. Tentatively, individual therapieswith medication used in the treatment of Crohn diseaseshould be tailored (see this article’s Online Repository).

d CGD is not a contraindication against immunomodulatorsor immunosuppressive drugs that would be used in patientswith Crohn disease or autoimmune disorders. However,TNF-a blocking agents in combination with other immuno-suppressants, including high-dose steroids, might be dan-gerous and are not encouraged.

d RIC-HSCT, but not surgical resection, should be consideredfor patients with CGD and IBD if conventional therapyfails or if side effects cannot be tolerated and quality of

life is severely compromised, even if the underlying formof CGD is generally regarded as mild.

Folke Freudenberg, MDa

Uwe Wintergerst, MD, PhDd,h

Angela Roesen-Wolff, MD, PhDb

Michael H. Albert, MD, PhDi

Christine Prell, MDa

Brigitte Strahm, MDf

Sibylle Koletzko, MD, PhDa

Stephan Ehl, MD, PhDf

Dirk Roos, MD, PhDc

Alberto Tommasini, MDg

Alessandro Ventura, MD, PhDg

Bernd H. Belohradsky, MD, PhDh

Reinhard Seger, MDe

Joachim Roesler, MD, PhDb

Tayfun G€ungor, MDe

TABLE I. Description of patients with ALPS and control groups

included in the study

Classification Description

No. of

subjects

ALPS Ia Patients with ALPS and germline FAS

mutations

162

ALPS Ia-s Patients with ALPS and somatic FAS

mutations

9

Healthy mutation-

positive relatives

Healthy relatives of patients with ALPS

Ia who carry a FAS mutation

115

Mutation negative

relatives

Healthy relatives of patients with ALPS

Ia who do not carry a FAS mutation

179

ALPS III Patients who fulfill criteria for ALPS but

have no causative mutation identified

52

ALPS-phenotype Patients with autoimmune cytopenias, 40

J ALLERGY CLIN IMMUNOL

APRIL 2010

946 LETTERS TO THE EDITOR

From athe Division of Gastroenterology, Dr. v. Haunersches Kinderspital, Ludwig-Max-

imilians-Universitat, Munich, Germany; bthe Department of Pediatrics, University

Hospital Dresden, Dresden, Germany; cSanquin Research and Landsteiner Labora-

tory, Academic Medical Centre, University of Amsterdam, Amsterdam, The Nether-

lands; dHospital St Joseph, Braunau, Austria; ethe Division of Immunology/

Hematology/BMT, University Children’s Hospital, Z€urich, Switzerland; fthe Depart-

ment of Pediatric Hematology and Oncology, Center for Pediatrics and Adolescent

Medicine, University of Freiburg, Freiburg Germany; gthe Department of Pediatrics,

Institute of Child Health, Children’s Hospital IRCCS Burlo Garofolo, Trieste, Italy;hthe Division of Immunology, Dr. v. Haunersches Kinderspital, Ludwig-Maximili-

ans-Universitat, Munich, Germany (Wintergerst, Belohradsky); and ithe Division of

Hematoloty/Oncology/Stem Cell Transplantation, Dr. v. Haunersches Kinderspital,

Ludwig-Maximilians-Universitat, Munich, Germany. E-mail: roeslerj@rcs.urz.

tu-dresden.de.

Disclosure of potential conflcit of interest: U. Wintergerst has provided legal consulta-

tion/expert witness testimony for Landgericht Berlin and Feuersozietat M€unchen/

Berlin. M. H. Albert receives research support from Biotest AG. The rest of the authors

have declared that they have no conflict of interest.

lymphadenopathy/splenomegaly, and

ab-DNT cells >1%, without genetic

abnormalities or lymphocyte defective

apoptosis

REFERENCES

1. van den Berg JM, van KE, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al.

Chronic granulomatous disease: the European experience. PLoS One 2009;4: e5234.

2. Marciano BE, Rosenzweig SD, Kleiner DE, Anderson VL, Darnell DN, Anaya-

O’Brien S, et al. Gastrointestinal involvement in chronic granulomatous disease.

Pediatrics 2004;114:462-8.

3. Schappi MG, Smith VV, Goldblatt D, Lindley KJ, Milla PJ. Colitis in chronic gran-

ulomatous disease. Arch Dis Child 2001;84:147-51.

4. Schappi MG, Klein NJ, Lindley KJ, Rampling D, Smith VV, Goldblatt D, et al. The nature

of colitis in chronic granulomatous disease. J Pediatr Gastroenterol Nutr 2003;36:623-31.

5. Mauch L, Lun A, O’Gorman MR, Harris JS, Schulze I, Zychlinsky A, et al. Chronic

granulomatous disease (CGD) and complete myeloperoxidase deficiency both yield

strongly reduced dihydrorhodamine 123 test signals but can be easily discerned in

routine testing for CGD. Clin Chem 2007;53:890-6.

6. Roesler J,Curnutte JT, Rae J, BarrettD, Patino P, Chanock SJ, et al. Recombination events

between the p47-phox gene and its highly homologous pseudogenes are the main cause of

autosomal recessive chronic granulomatous disease. Blood 2000;95:2150-6.

7. Seger RA, Gungor T, Belohradsky BH, Blanche S, Bordigoni P, Di BP, et al. Treat-

ment of chronic granulomatous disease with myeloablative conditioning and an un-

modified hemopoietic allograft: a survey of the European experience, 1985-2000.

Blood 2002;100:4344-50.

8. Gungor T, Halter J, Klink A, Junge S, Stumpe KD, Seger R, et al. Successful low

toxicity hematopoietic stem cell transplantation for high-risk adult chronic granu-

lomatous disease patients. Transplantation 2005;79:1596-606.

Available online March 15, 2010.

doi:10.1016/j.jaci.2010.01.035

Using biomarkers to predict the presence ofFAS mutations in patients with features of theautoimmune lymphoproliferative syndrome

To the Editor:The autoimmune lymphoproliferative syndrome (ALPS) is

characterized by chronic lymphadenopathy, splenomegaly,autoimmune cytopenias, and expansion of T cell receptor(TCR) ab1 CD31CD4–CD8– (ab-double-negative [DNT]) cells(see this article’s Table E1 in the Online Repository at www.jacionline.org). Approximately two thirds of the patients withALPS symptoms are genetically characterized, and most havegermline (ALPS Ia) or somatic (ALPS Ia-s) TNFRSF6 (FAS)mutations. A small number of patients have defects in genesencoding Fas ligand (ALPS Ib), caspase-10 (ALPS II), or neuro-blatoma-RAS (NRAS) viral oncogene homolog (ALPS IV). Inaddition, a large group of patients with ALPS findings remaingenetically uncharacterized (ALPS III), and yet another has anundefined ALPS-like syndrome (ALPS-phenotype; Table I).1,2

Given the clinical similarities among all these groups, we sought

to develop a biomarkers-based algorithm to predict the presenceor absence of FAS mutations in this setting.

To this end, we investigated 26 parameters including immu-nophenotyping, eosinophil and monocyte counts, serum orplasma vitamin B12 (B12), soluble FAS ligand (sFASL), immu-noglobulins, and levels of 14 cytokines in 562 subjects classifiedinto 6 categories (Tables I and E1). The number of measurements,medians, and first and third quartiles are presented in this article’sTables E2 and E3 in the Online Repository at www.jacionline.org. A full description of the Methods can be foundin the Online Repository at www.jacionline.org.

Elevated ab-DNT cells are a hallmark of ALPS, but theirutility for predicting FAS mutations had not been previously eval-uated.3 Patients with ALPS Ia and Ia-s had a high percentage ofab-DNT cells, with median values 5.1% and 7.7%, respectively,compared with 0.5% for control mutation-negative relatives(MNRs; P < .0001; Fig 1, A; Table E2). The ab-DNT level waspredictive of FAS mutations, with values >4% found in 60%(90/152) of patients with type Ia and in the majority of patientswith type Ia-s (7/9), but in only 13% (11/85) of patients withALPS type III and ALPS-phenotype (Fig 1, A). This value was as-sociated with a positive likelihood ratio (LR) of 5.0 and a posttestprobability of 89.3% for harboring FAS mutations. Conversely,the presence of ab-DNT cells in the 1% to 2% range decreasedthe posttest probability to 25%, with a LR of 0.19 (Fig 2, B andC; see this article’s Table E4 in the Online Repository at www.jacionline.org).

In line with previous reports, patients with ALPS, regardless ofmutation status, had <16% of circulating B cells expressing thememory marker CD27 (Fig 1, B) 4. Finding memory B cells >16%made the diagnosis of ALPS very unlikely (LR 5 0.17). Otherdescribed abnormalities including increased CD31HLA-DR1

to CD31CD251 ratio and high number of B cells had noadditional diagnostic utility.4

We also evaluated serum B12 levels in patients with ALPSand found very elevated median levels in ALPS Ia and Ia-s(2259 ng/L; 1653 ng/L) compared with control MNRs (474 ng/L; P < .0001) and healthy mutation-positive relatives (570 ng/L;P < .0001). A modest but statistically significant increase wasalso noted in ALPS III and ALPS-phenotype, with medians of

CGD is characterized by severe infections caused by a distinctsusceptibility to certain opportunistic bacteria, such as Staphylo-coccus aureus, Burkholderia cepacia, and Serratia marcescens,and fungi, especially Aspergillus species. Lymph nodes, lungs,liver, bones, and skin are frequently involved in the infections,but any organ can be affected, and sepsis can also ensue. Recur-rent abscess formation in cervical or other lymph nodes, abscessesin the liver, and invasive Aspergillus (lung) infections are pathog-nomonic manifestations. However, CGD is also characterized byuncontrolled inflammation often accompanied by the formationof granulomas of any size, even in the absence of infection.Such manifestations frequently occur in the lungs, lymph nodes,urogenital tract, and gastrointestinal tract, but any organ can be af-fected. In addition, wound healing can be impaired.

The disease is caused by the failure of mainly neutrophils andmacrophages (but also other leukocytes) to produce reactiveoxygen metabolites (ROMs). The ROM superoxide (O22) is nor-mally generated by the multicomponent enzyme complex NADPHoxidase. All other ROMs are derived from O22. Defects in any of 4components of the NADPH oxidase (p47phox, p67phox, p22phox,or gp91phox encoded by NCF1, NCF2, CYBA, and CYBB, respec-tively; OMIM (Online Mendelian Inheritance in Man) *608512,*608515, *608508, *300481, #233700, #233710, #233690,#306400) lead to CGD. Autosomal recessive p47-phox deficiencyaccounts for approximately 25% of CGD cases (and X-chromo-somal gp91phox deficiency for 65%).E1 The residual amount ofNADPH oxidase activity in neutrophils lacking p47-phox is al-ways in the same range. The amount of H2O2 produced, as mea-sured by means of DHR or DCF (dichlorofluorescin), is stillremarkable, but O22 is generated in traces at best. This has beeninvestigated in some detail by Cross et alE2 in the early 1990s.Our results (Table I) were in accordance with these findings, butamounts of ROM were not quantified precisely.

For several reasons, the diagnosis of CGD is often missedinitially. It is a rare disease that can manifest as surprisinglydiverse clinical pictures, especially when uncontrolled inflam-mation is involved. Erroneous diagnoses comprise tuberculosis,sarcoidosis, hypersensitivity pneumonitis, tumors, rheumatoidarthritis, and IBD. About 25% to 50% (possibly up to 80%) ofpatients with CGD have upper intestinal manifestations, lowerintestinal manifestations, or both.E3-E5 Gingivitis, colitis, and per-ianal abscesses and fistulas are most common. However, othersymptoms, such as stomatitis; esophageal, pyloric, or intestinalobstruction; wall thickening; and terminal ileitis occur also. Thewhole picture resembles Crohn disease macroscopically and his-tologically. Therefore the term ‘‘Crohn-like disease in CGD’’ isoften used. Nevertheless, Crohn disease and IBD in CGD are his-topathologically and etiologically distinct disorders. Appropriatetesting for ROM production and NADPH compounds and geneticanalysis can verify CGD and reveal its subtype.

Our clinical centers are specialized in primary immunodefi-ciencies and have gathered information about the first manifes-tation of CGD in a total of 154 cases. In 12 (7.8%) patients withCGD, the disorder started with IBD. Of these, 8 had p47-phoxdeficiency, and 4 had gp91-phox deficiency. However, this highshare of p47-phox deficiency is probably biased (centers withoutsuch patients are not involved in this study). Nevertheless, theoverall percentage of 7.8% (12/154) demonstrates that a firstmanifestation of CGD with IBD is not extremely rare.

In contrast to common pediatric IBD, therapy of IBD in patientswith CGD is not well established and always demands special

precautions. In general, a considerable number of such patientsrespond to steroids.E6,E7 For some of them, mostly those with mildIBD, low-dose, every-other-day, intermittent, and/or local steroidsare sufficient. Other patients need high-dose steroids for a longtime, and some deteriorate as soon as steroids are reduced. An-other considerable subgroup does not improve with steroids at all.

Two of the patients (nos. 2 and 6) described in this study withsevere colitis went into intestinal remission during treatment witha combination of polymeric diet, mesalazine, and azathioprine.Polymeric diet is known to induce mucosal healing in patientswith pediatric Crohn disease and should always be considered inpatients with CGD colitis.

Specific precautions must be followed when using immuno-suppressants. Patients with CGD need special pre-evaluation forsubclinical infections before immunosuppressive drugs can beapplied safely. This assessment includes careful imaging (ultra-sound, computed tomographic scanning, and magnetic resonanceimaging). When applicable, invasive diagnostic techniques, suchas computed tomography–guided needle biopsies, should be usedwhen suspicion for infection is raised. However, if such infections(eg, aspergillosis) are excluded or treated appropriately, immu-nosuppressants can be fairly well tolerated in patients with CGD.

In a considerable number of cases, CGD colitis is completelyunresponsive to any conventional treatment or responds only todoses of drugs that cause intolerable side effects, as in patients 4and 8. Colectomy and other surgical resections are complicatedby compromised wound healing and the high risk of severeinfection and are therefore discouraged. Evidently, these inter-ventions do not cure CGD.

However, HSCT from a fully HLA-matched donor afterreduced-intensity conditioning might offer a long-term cure ofboth colitis and CGD.E8 Enrollment of patients with CGD under-going transplantation, such as the ones described in this report,into the European Group for Bone Marrow Transplantation data-base is important. Although these transplantations are performedas individual cases, they should eventually be assembled and com-pared as a series. This should contribute to future progress inHSCT for patients with CGD. Important resources for transplanta-tion guidelines, including for primary immunodeficiencies includehttp://www.ebmt.org/8TransplantGuidelines/tguide1.html and, forquestions, info@ebmt.org; communication.EBMT@EBMT.com.

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