Το σύνδρομο Hyper-IgE (HIES) είναι μια σπάνια πρωτοπαθής ανοσοανεπάρκεια η οποία χαρακτηρίζεται από υψηλά επίπεδα IgE στον ορό, υποτροπιάζουσες σταφυλοκοκκικές λοιμώξεις του δέρματος και επεισόδια πνευμονίας με σχηματισμό κύστεων. Επιπλέον, στο φαινότυπο του συνδρόμου περιλαμβάνονται και μη-ανοσολογικού τύπου ανωμαλίες όπως χαρακτηριστικό προσωπείο, υπερεκτασιμότητα των αρθρώσεων, σκολίωση, αυτόματα κατάγματα και διατήρηση των νεογιλών οδόντων. Προσφάτως, διαπιστώθηκε πως ετερόζυγες μεταλλάξεις στον μετγραφικό παράγοντα STAT3, ευθύνονται για την αυτοσωμική επικρατούσα μορφή του HIES. Στην παρούσα ερευνητική εργασία ταυτοποιήθηκε και χαρακτηρίστηκε μια νέα μετάλλαξη στην περιοχή δέσμευση του DNA (DNA-binding domain) του μεταγραφικού παράγοντα STAT3 σε έναν ασθενή με σύνδρομο Hyper IgE. Ανάλυση της αλληλουχίας του γονιδίου του STAT3 αποκάλυψε μια de novo ετερόζυγη αντικατάσταση βάσης από G (γουανίνη) σε A (αδενίνη), η οποία προκαλεί την αντικατάσταση στο επίπεδο της αμινοξικής αλληλουχίας του αμινοξέος γλυκίνη από το ασπαρτικό οξύ (G342D). Η ασθενής έχει φυσιολογικά επίπεδα της πρωτεΐνης STAT3, η οποία και εισέρχεται στον πυρήνα των κυττάρων κατόπιν ενεργοποίησης με ιντερλευκίνη-6 (IL-6). Παρoλ’ αυτά, μελέτη της ικανότητας της πρωτεΐνης STAT3 να δεσμεύεται στο DNA έδειξε πως η μετάλλαξη G342D επηρεάζει σημαντικά αυτή τη λειτουργία. Επιπλέον, ανάλυση με ποσοτική RT-PCR έδειξε πως η μετάλλαξη G342D αναστέλλει την STAT3-εξαρτώμενη επαγωγή του γονιδίου ROR γt, απαραίτητου γονιδίου για την διαφοροποίηση και ανάπτυξη των Th17 κυττάρων. Με βάση τα παραπάνω δεδομένα, φαίνετε πώς η νέα μετάλλαξη στο μεταγραφικό παράγοντα STAT3 επηρεάζει σημαντικά τη λειτουργικότητά του, και προκαλεί το σύνδρομο Hyper-IgE στην ασθενή. / The Hyper-IgE syndrome (HIES) is a rare primary immunodeficiency characterized by a highly elevated serum IgE, recurrent staphylococcal skin abscesses and cyst-forming pneumonia. Non-immunological abnormalities, including a distinctive facial appearance, hyperextensive joints, scoliosis, fracture following minor trauma, and the retention of primary teeth are also observed in many patients. Recently, it was shown that heterozygous mutations in signal transducer and activator of transcription 3 (STAT3), can cause autosomal-dominant HIES. Here we identify and characterize a novel mutation in the DNA binding domain of STAT3 in a patient with hyper-IgE syndrome. Sequence analysis revealed a de novo heterozygous transition of a G to A, causing a substitution of a glycine residue for an aspartic acid in the translated sequence (G342D). The patient has normal levels of STAT3, which is able to translocate to the nucleus upon IL-6 stimulation. However, enzyme-linked DNA–protein interaction analysis showed that the G342D mutation affects the binding ability of STAT3 to target DNA sequences. In addition, as shown by qRT-PCR, the mutation abrogates the STAT3 dependent transcription of the retinoid-related orphan receptor γt (ROR γt) gene, an indispensable transcription factor for the commitment of naive CD4+ T cells to the Th17 lineage. These data suggest that the novel G342D mutation affects the binding of STAT3 on DNA and the STAT3 dependent expression of ROR γt mRNA, leading to the HIES phenotype.

Agamaglobulinemia ligada ao X (XLA) é uma imunodeficiência primária caracterizada por ausência ou número reduzido de células B maduras em sangue periférico, de todos os isotipos de imunoglobulina e um aumento da susceptibilidade a infecções bacterianas e enterovirais graves. XLA é causada por mutações no gene Bruton\'s tirosino quinase, que codifica um membro da proteína da família das tirosino quinases citoplasmáticas que tem papel vital na modulação de muitos processos celulares. Neste estudo foram analisados trinta e três pacientes quanto à presença de mutações de BTK, por SSCP/HA e seqüenciamento. A análise da expressão foi realizada pela técnica por PCR em tempo real. Foram encontradas mutações do tipo stop codons, substituições de aminoácido, defeitos de splicing, pequenas deleções/inserções e frameshift nestes pacientes afetando os domínios PH, SH3, SH2 e o domínio da quinase da proteína. A análise da expressão mostrou níveis baixos nos pacientes com mutação do tipo stop codon, e nas outras mutações, os níveis de expressão foram de aproximadamente 15% e se correlacionaram com os tipos de mutação. / X-linked Agammaglobulinemia (XLA) is a primary immunodeficiency characterized by the absence or decreased numbers of mature B cells in peripheral blood, and by a lack of all immunoglobulin isotypes, leading to an increased susceptibility to severe bacterial and enteroviral infections. XLA is caused by mutations in the gene encoding for Bruton\'s tyrosine kinase (BTK), a protein member of the Tec family of cytoplasmic tyrosine kinases and plays a vital modulation role in many cellular processes. In this study thirty-three patients were analyzed for the presence of BTK mutations by SSCP/HA and sequencing. The expression analysis was carried out by the technique of Real-Time PCR. It was found mutations of the stop codons type, amino acid substitutions, splice defects, small deletions/insertions and frameshift in these patients affecting the PH, SH3, SH2 and tyrosine kinase domains of protein. The expression levels were very low in the patients with stop codon mutations, and in the other mutations, the expression levels were about 15% and were correlated with the mutation types.

IFNγ is an essential and pleiotropic activator of monocytes, but little is known about the effects IFNγ on cellular metabolism. Therefore, we sought to characterize and elucidate the mechanisms by which IFNγ reprograms monocyte metabolism to support its immunologic activities. First, we identified a critical role for IFNγ in the induction of immunoresponsive gene 1 (IRG1) and its product, itaconate. The immunometabolite, itaconate, has been reported to have antibacterial, anti-inflammatory and antioxidant activity. Irg1-/- mice, lacking itaconate, are highly susceptible and phenotypically similar to IFNγ knock out (GKO) mice upon infection with Mycobacterium tuberculosis. Therefore, we assessed the role of IRG1/itaconate in the context of non-tuberculous mycobacterial (NTM) infection, the most common type of infection in patients with immunodeficiencies caused by defects in IFNγ signaling. Our data suggest that impaired induction of itaconate in the context of mycobacterial infection may contribute to mycobacterial susceptibility and immune dysregulation in patients with defects in IFNγ signaling. Next, we evaluated the metabolic phenotype of IFNγ-stimulated human monocytes and found that IFNγ increased oxygen consumption rates (OCR), indicative of reactive oxygen species generation by both mitochondria and NADPH oxidase. Transcriptional profiling of human macrophages revealed that this oxidative phenotype was dependent on IFNγ-induced, nicotinamide phosphoribosyltransferase (NAMPT)-mediated NAD+ salvage to generate NADH and NADPH for oxidation by mitochondrial complex I and NADPH oxidase, respectively. These data identify an IFNγ-induced, NAMPT-dependent, NAD+ salvage pathway that is critical for complete induction of the respiratory burst in IFNγ stimulated human monocytes.

Bc. Klára Horáčková DIPLOMA THESIS Mechanisms of immune dysregulation leading to inflammatory bowel disease Abstract Inflammatory bowel disease (IBD) is a complex disorder characterized by chronic inflammation of the gastrointestinal tract. Classical IBD is a multifactorial disease with adulthood or later-childhood onset. However, children with very early onset IBD (VEO-IBD, before 6 years of age) are a specific cohort, whose pathology can be caused by severe genetic defects in genes connected to immune homeostasis in the gut. We aimed to identify the causal genetic variants in 20 pediatric patients diagnosed with IBD (age of onset from 3 to 154 months) using whole exome sequencing (WES). We evaluated several bioinformatical approaches for WES data analysis. This included a comparison of two methods of variant identification using VarScan2 or GATK4-based tools. Furthermore, we compared 4 gene lists ("virtual panels") for variant filtering, one of which was compiled purposefully for this thesis. We identified and validated via segregation analysis 5 causal variants in 4 genes (DUOX2 compound heterozygote, FOXP3, NLRP3 and NOD2) accounting for 20 % of the cohort. NOD2 (p.A755V) variant has already been reported in IBD cases, while DUOX2 (p.R1216W + p.A1131T), FOXP3 (p.H400L) and NLRP3 (p.V200M) were newly...

Primary immunodeficiencies represent a heterogeneous group of hereditary immune system malfunctions with very variable causes and symptoms. Multiparametric flow cytometry has become an important tool in primary immunodeficiency diagnostics and research because it provides detailed information on the phenotype of individual immune cells and their proportions in circulation. We have developed a complex monoclonal antibody panel composed of five eight-color tubes which is designed for immunophenotyping of basic lymphocyte subsets and further analysis of B and T cell subpopulations. We have optimized and standardized the panels so they will identify any changes originating from primary immunodeficiencies and provide comparable data on the level of cooperation between more laboratories. This was achieved by cooperation of six European research facilities which are all parts of the Euroflow consortium. The panels have been validated both on peripheral blood samples from healthy donors and patients with either gentically defined primary immunodeficiency or common variable immunodeficiency. Keywords: T lymphocyte, B lymphocyte, primary immunodeficiency, flow cytometry, immunophenotyping, Euroflow, optimization, standardization

A deficiência de CD40 Ligante (CD40L) ou síndrome de Hiper-IgM ligada ao X (X-HIGM) é considerada uma imunodeficiência primária combinada de células T e B. O CD40L é expresso na superfície de linfócitos T ativados e interage com o CD40 expresso na superfície de linfócitos B, macrófagos, células dendríticas, células endoteliais e neutrófilos. A interação CD40L-CD40 transmite sinais que induzem ativação, diferenciação e proliferação celular. Nosso objetivo foi analisar as alterações genético-moleculares da molécula CD40L que acometeram indivíduos de 5 famílias brasileiras, ocasionando X-HIGM. Genotipamos 25 indivíduos, sendo 6 pacientes com X-HIGM, 13 parentes relacionados heterozigotos e 6 homozigotos sadios. Dentre os pacientes com X-HIGM dois eram de origem caucasóide e 4 eram mestiços. A idade dos pacientes variou de 2 a 20 anos e o quadro clínico de infecções de repetição teve início em média nos primeiros 4 meses de vida. As principais infecções recorrentes manifestadas pelos pacientes foram pneumonia e otite. O paciente TB apresentou blastomicose, observação original nesta imunodeficiência. A análise genético-molecular foi heterogênea. No paciente TB foi detectado um defeito de splicing levando a deleção do exon 3 (r.345_402del do gene CD40L (CD40LG) no paciente FS uma nova substituição missense g.11856 G>C (c.476 G>C, pW140C), no paciente KC uma substituição nonsense g.11855 G>A (c.475G>A, p. W140X), e nos pacientes CH, FE e VIC uma deleção g. 3074_3077delTAGA, levando a alteração no processamento do RNA. A fenotipagem dos leucócitos demonstrou que a contagem de linfócitos T auxiliares (CD3+CD4+), linfócitos citotóxicos (CD3+CD8+), linfócitos B (CD19+CD40+) e linfócitos T ativados (CD3+CD69+) dos pacientes foram similares aos controles sadios. Contudo, foi observada uma redução significativa nos níveis de expressão de CD40L na superfície de linfócitos CD3+ e CD4+ dos pacientes. A análise dos linfócitos T por microscopia confocal revelou que as células dos homozigotos com expressão residual do CD40L em sua superfície também apresentam redução na densidade da expressão da molécula CD3, sugerindo a necessidade da integridade molecular do CD40L para a expressão normal do CD3. Concluímos que mutações no CD40L que levam à síndrome de X-HIGM são heterogêneas e a análise genético-molecular permitiu um diagnóstico preciso tornando possível o aconselhamento genético e a triagem dos recém-nascidos das famílias avaliadas. / CD40-Ligand (CD40L) deficiency or X linked Hyper-IgM syndrome (X-HIGM) is considered a T and B cell combined primary immunodeficiency. CD40L is expressed on the cell surface of activated T lymphocytes and interacts with CD40, expressed on the surface of B lymphocytes, macrophages, dendritic cells, endothelial cells, and neutrophils. The CD40L-CD40 interaction induces activation, differentiation, and cell proliferation. Our aim was to analyze the molecular-genetic alterations of CD40L molecule affecting individuals of 5 brazilian families, leading to X-HIGM. We genotyped 25 individuals, whom 6 were X-HIGM patients, 13 were heterozygote related patients, and 6 were healthy homozygotes. Within the patients with X-HIGM, two of them were of caucasoid origin and four were mestiços. The patients age ranged from 2 to 20 years and their recurrent infections started in average during their first 4 months of life. The main recurrent infections were pneumonia and otitis. The patient TB presented blastomycosis, a unique observation in this immunodeficiency. The molecular-genetic analysis revealed heterogeneity. TB patient presented a splicing defect causing a deletion of exon 3 (r.345_402del) of CD40L gene (CD40LG). Patient FS presented a new missense mutation g.11856 G>C (c.476 G>C, pW140C). Patient KC presented a nonsense substitution g.11855 G>A (c.475G>A, p. W140X). Patients CH, VIC, and FE presented a deletion g. 3074_3077delTAGA, causing an alteration on RNA processing. The leukocytes fenotyping demonstrated that T helper lymphocytes (CD3+CD4+), T cytotoxic lymphocytes (CD3+CD8+), B lymphocytes (CD19+CD40+), and T activated (CD3+CD69+) cell counts of patients were similar to healthy controls. However it was observed a significant reduction of CD40L expression on cell surface patients CD3+ and CD4+ lymphocytes. The T lymphocyte confocal microscopy analysis revealed that homozygotes with residual expression of CD40L in their surface also presented a reduction on the density of CD3 molecule expression, suggesting the need of molecular integrity of CD40L for normal CD3 expression. We conclude that mutations on CD40L leading to X-HIGM syndrome are heterogeneous and the molecular-genetic analysis allowed a precise diagnosis making possible the genetic counseling and newborn screening of the involved families.

Chaque individu est exposé quotidiennement à des agents infectieux comme les bactéries, les champignons, les virus et les parasites sans pour autant développer une maladie. Cependant, certains vont développer des infections graves et récurrentes, causées par des microbes dont certains ont un faible pouvoir pathogène pour l’homme. Ceci suggère, qu’il existe entre les individus sensibles et résistants une variabilité au niveau du système immunitaire. Deux types de déficits immunitaires primitifs (DIP) de transmission mendélienne ont été décrits. Les DIP dit « classiques » sont monogéniques et prédisposent majoritairement à une susceptibilité infectieuse à large spectre d’agents pathogènes (un gène, plusieurs infections). Les seconds DIP sont également monogéniques mais sont responsables d’une susceptibilité infectieuse réduite à un groupe de pathogènes (un gène, un seul type d’infection). Chez de nombreux, patients, le défaut génétique responsable de DIP n’est pas identifié. Dans ce contexte, l’objectif de recherche de mon doctorat a été de caractériser deux DIP responsables d’une susceptibilité aux infections bactériennes. J’ai tout d’abord mis en évidence un nouveau mécanisme physiopathologique de la protéine NEMO, régulateur de la voie NF-κB, responsable d’un DIP associé à une dysplasie ectodermale anhidrotique (EDA). Ce mécanisme pathologique est caractérisé par une expression et une structure protéique conservées mais confère sélectivement un défaut de liaison de NEMO à l’ubiquitine, interaction essentielle dans l’activation de la voie NF-κB. Ceci démontre qu’une expression et une structure protéique normales n'excluent en rien un rôle pathologique de mutations dans le gène NEMO, dans un EDA-DIP. Dans un deuxième temps, j’ai mis en évidence un nouveau DIP affectant la voie de l’explosion oxydative spécifiquement dans les polymorphonucléaires et qui confère une susceptibilité sélective aux infections bactériennes de type pyogènes. Le patient étudié est né de parents consanguins et a présenté des infections récurrentes des voies respiratoires supérieures ainsi qu’une cellulite à Staphylococcus epidermidis. Par une approche génétique associant analyse de liaison et séquençage de l'exome, une mutation homozygote rare a été identifiée dans le gène codant NRAMP1. Cette mutation co-ségrège avec la maladie selon un mode de transmission autosomique récessif et altère spécifiquement l’expression de la protéine dans les granulocytes. Ce premier déficit en NRAMP1 décrit chez l’homme, compromet à la fois la voie de l’explosion oxydative et le contrôle de l’infection in vitro par Staphylococcus aureus dans les granulocytes. Cette étude implique NRAMP1 dans l'immunité contre les bactéries pyogènes via son rôle dans la production des espèces réactives de l’oxygène dans les granulocytes. Ce travail ouvre la voie vers un meilleur diagnostique et conseil génétique pour les patients souffrant de PID. / Human populations are exposed to infectious agents such as bacteria, fungi, viruses and parasites on a daily basis without developing any disease. However, a minority of individuals will suffer from infections to some microbes that are usually non-pathogenic to man, or will undergo severe and/or recurrent diseases usually easily treatable for others. This means that there is variability among individuals regarding their immune system, underlined by genetics between susceptible and resistant individuals. Two types of primary immuno deficiencies with a Mendelian mode of inheritance have been described. The first known as the classical primary immunodeficiency and is monogenic and predisposes in general to infections with a broad spectrum of infectious agents (one gene, multiple infections). The second type is also monogenic but predisposes generally to infections limited to a particular group of pathogens (one gene, one type of infection). The aim of my doctoral research was to characterize two new immunodeficiencies. First I highlighted a new physiopathological mechanism of the NEMO protein, a regulator of NF-κB pathway. This defect is characterized by normal protein expression and folding, but a specific defect of NEMO’s ubiquitin binding, which is an essential mechanism for the activation and regulation of the NF-κB pathway. This demonstrates that normal expression and structure of the protein do not exclude a pathological role of NEMO mutations in EDA-ID. I also described a new immune deficiency affecting the respiratory burst pathway in granulocytes which specifically confers a selective susceptibility to pyogenic bacterial infections. We studied a patient who was born from consanguineous parents, and who suffered from recurrent infections of the upper respiratory tract and cellulitis to S. epidermidis. By a genetic approach involving linkage analysis and exome sequencing, I identified a rare homozygous mutation (V484M) in the gene encoding for the NRAMP1 protein that co segregates with the disease with an autosomal recessive transmission. Specifically, this mutation impairs NRAMP1 protein expression in granulocytes, while expression remains normal in other phagocytic cells. NRAMP1 deficiency impairs both the respiratory burst and control of in vitro infection by S. aureus in granulocytes. Therefore, we identified the first NRAMP1 human deficiency. The mutation selectively affects granulocytes and is clinically responsible for pyogenic infections. This study helps to delineate the role of NRAMP1 in immunity against pyogenic bacteria through its involvement in reactive oxygen species production in granulocytes.

A deficiência de CD40 Ligante (CD40L) ou síndrome de Hiper-IgM ligada ao X (X-HIGM) é considerada uma imunodeficiência primária combinada de células T e B. O CD40L é expresso na superfície de linfócitos T ativados e interage com o CD40 expresso na superfície de linfócitos B, macrófagos, células dendríticas, células endoteliais e neutrófilos. A interação CD40L-CD40 transmite sinais que induzem ativação, diferenciação e proliferação celular. Nosso objetivo foi analisar as alterações genético-moleculares da molécula CD40L que acometeram indivíduos de 5 famílias brasileiras, ocasionando X-HIGM. Genotipamos 25 indivíduos, sendo 6 pacientes com X-HIGM, 13 parentes relacionados heterozigotos e 6 homozigotos sadios. Dentre os pacientes com X-HIGM dois eram de origem caucasóide e 4 eram mestiços. A idade dos pacientes variou de 2 a 20 anos e o quadro clínico de infecções de repetição teve início em média nos primeiros 4 meses de vida. As principais infecções recorrentes manifestadas pelos pacientes foram pneumonia e otite. O paciente TB apresentou blastomicose, observação original nesta imunodeficiência. A análise genético-molecular foi heterogênea. No paciente TB foi detectado um defeito de splicing levando a deleção do exon 3 (r.345_402del do gene CD40L (CD40LG) no paciente FS uma nova substituição missense g.11856 G>C (c.476 G>C, pW140C), no paciente KC uma substituição nonsense g.11855 G>A (c.475G>A, p. W140X), e nos pacientes CH, FE e VIC uma deleção g. 3074_3077delTAGA, levando a alteração no processamento do RNA. A fenotipagem dos leucócitos demonstrou que a contagem de linfócitos T auxiliares (CD3+CD4+), linfócitos citotóxicos (CD3+CD8+), linfócitos B (CD19+CD40+) e linfócitos T ativados (CD3+CD69+) dos pacientes foram similares aos controles sadios. Contudo, foi observada uma redução significativa nos níveis de expressão de CD40L na superfície de linfócitos CD3+ e CD4+ dos pacientes. A análise dos linfócitos T por microscopia confocal revelou que as células dos homozigotos com expressão residual do CD40L em sua superfície também apresentam redução na densidade da expressão da molécula CD3, sugerindo a necessidade da integridade molecular do CD40L para a expressão normal do CD3. Concluímos que mutações no CD40L que levam à síndrome de X-HIGM são heterogêneas e a análise genético-molecular permitiu um diagnóstico preciso tornando possível o aconselhamento genético e a triagem dos recém-nascidos das famílias avaliadas. / CD40-Ligand (CD40L) deficiency or X linked Hyper-IgM syndrome (X-HIGM) is considered a T and B cell combined primary immunodeficiency. CD40L is expressed on the cell surface of activated T lymphocytes and interacts with CD40, expressed on the surface of B lymphocytes, macrophages, dendritic cells, endothelial cells, and neutrophils. The CD40L-CD40 interaction induces activation, differentiation, and cell proliferation. Our aim was to analyze the molecular-genetic alterations of CD40L molecule affecting individuals of 5 brazilian families, leading to X-HIGM. We genotyped 25 individuals, whom 6 were X-HIGM patients, 13 were heterozygote related patients, and 6 were healthy homozygotes. Within the patients with X-HIGM, two of them were of caucasoid origin and four were mestiços. The patients age ranged from 2 to 20 years and their recurrent infections started in average during their first 4 months of life. The main recurrent infections were pneumonia and otitis. The patient TB presented blastomycosis, a unique observation in this immunodeficiency. The molecular-genetic analysis revealed heterogeneity. TB patient presented a splicing defect causing a deletion of exon 3 (r.345_402del) of CD40L gene (CD40LG). Patient FS presented a new missense mutation g.11856 G>C (c.476 G>C, pW140C). Patient KC presented a nonsense substitution g.11855 G>A (c.475G>A, p. W140X). Patients CH, VIC, and FE presented a deletion g. 3074_3077delTAGA, causing an alteration on RNA processing. The leukocytes fenotyping demonstrated that T helper lymphocytes (CD3+CD4+), T cytotoxic lymphocytes (CD3+CD8+), B lymphocytes (CD19+CD40+), and T activated (CD3+CD69+) cell counts of patients were similar to healthy controls. However it was observed a significant reduction of CD40L expression on cell surface patients CD3+ and CD4+ lymphocytes. The T lymphocyte confocal microscopy analysis revealed that homozygotes with residual expression of CD40L in their surface also presented a reduction on the density of CD3 molecule expression, suggesting the need of molecular integrity of CD40L for normal CD3 expression. We conclude that mutations on CD40L leading to X-HIGM syndrome are heterogeneous and the molecular-genetic analysis allowed a precise diagnosis making possible the genetic counseling and newborn screening of the involved families.

Les infections fongiques invasives, sont des infections sévères grevées d’une lourde mortalité. Elles sont actuellement un problème majeur de santé publique et leur incidence augmente. Les candidémies représentent la quatrième cause d’infection hématogène nosocomiale aux Etats-Unis, les cryptococcoses sont responsables de 600 000 décès chaque année en Afrique et l’aspergillose invasive infecte 10% des patients transplantés de cellules souches. La mortalité de ces infections reste élevée avec des taux de mortalité de 50, 15 et 40% respectivement. L’augmentation de leur incidence est due à l’accroissement des populations immunodéprimées à risque de développer des infections fongiques en raison de l’augmentation des thérapeutiques immunosuppressives et de l’allongement de la durée de vie des patients immunodéprimés. Les infections fongiques invasives surviennent chez des patients immunodéprimés, majoritairement dans un contexte d’immunodépression acquise (neutropénie, chimiothérapie, greffe de cellules souches périphériques ou transplantation d’organe solide, diabète, infection par le virus de l’immunodéficience humaine), mais également secondairement à un déficit immunitaire héréditaire (granulomatose septique chronique, déficit immunitaire combiné, neutropénie congénitale, défaut de l’axe IFNγ-IL12). Cependant certains patients développent des infections fongiques invasives sans immunodépression ou facteurs de risques identifiés. Nous avons donc émis l’hypothèse que ces infections avaient possiblement une origine génétique non identifiée. Au cours de ma thèse, j’ai étudié une cohorte de patients présentant des infections fongiques invasives sans facteur favorisant identifié afin de rechercher une étiologie génétique à ces infections. Le premier groupe de patients que j’ai étudié présentait une dermatophytose invasive ou dermatophytose profonde sans immunodépression. Contrairement à la dermatophytose superficielle, en général bénigne et fréquente dans la population générale; la dermatophytose profonde est une infection rare, invasive et sévère, dans laquelle les dermatophytes (qui sont des champignons filamenteux) envahissent les tissus dermiques et hypodermiques, les ganglions et parfois les organes profonds. Les patients que j’ai étudié étaient tous originaires d’Afrique du Nord, pour la plupart issus de familles consanguines, dont certains avec des cas multiples. Ces observations suggéraient une origine génétique de la dermatophytose profonde avec une hérédité probablement récessive. Au cours de ma thèse, j’ai étudié les caractéristiques cliniques, immunologiques et génétiques de 18 patients atteints d’une dermatophytose profonde, issus de neuf familles Marocaines, Algériennes, Tunisiennes ou Egyptiennes. En parallèle, j’ai étudié des patients ayant présenté des infections fongiques avec localisations cérébrales. L’une de ces patients a présenté des abcès cérébraux suite à une infection disséminée à Exophiala dermatitidis et trois patients ont développé des infections du système nerveux central à Candida spp.. Les infections invasives à Exophiala dermatitidis sont des infections rares, avec de fréquentes atteintes du système nerveux central, survenant majoritairement chez des patients sans déficit immunitaire identifié suggérant l’existence d’une origine génétique probable méconnue chez ces patients. Les candidoses invasives surviennent habituellement chez des patients neutropéniques, ayant récemment subi une intervention chirurgicale ou étant porteurs d’un cathéter intraveineux. Parmi les candidoses invasives, les localisations au système nerveux central sont rares, et classiquement rapportées chez des nouveau-nés prématurés ou suite à une intervention neurochirurgicale. J’ai par ailleurs étudié une patiente ayant développé des infections invasives des tissus sous-cutanés et des adénopathies dues à un champignon filamenteux. (...) / Invasive fungal diseases are a major health problem as they are severe infections complicated with high mortality rates and with rising incidence. Invasive fungal diseases occur mainly in patients with acquired immunodeficiencies, but also with primary immunodeficiencies (chronic granulomatous disease, defect in IFN-ϒ/IL-12 axis, congenital neutropenia). However, few patients develop invasive fungal disease without known risk factor. We therefore hypothesized that these infections probably have an unidentified genetic etiology. I studied a cohort of patients who developed invasive fungal diseases without risk factors and searched for a genetic etiology to their infections. The first group of patients presented with deep dermatophytosis without known immunodeficiency. Deep dermatophytosis is a rare, invasive and severe infection where dermatophytes invade dermis, hypodermis, lymph nodes and sometimes deep organs. I could study clinical, immunological and genetic characteristics of 18 patients from nine families who presented deep dermatophytosis. I also studied patients who developed central nervous system (CNS) fungal infections; one patient with CNS Exophiala dermatitidis infection and three patients with CNS Candida spp. infection. Invasive E. dermatitidis infections are rare, with frequent CNS location, mainly reported in patients without known immunodeficiencies, suggesting a potential unknown genetic etiology in these patients. CNS candidiasis are also rare infections usually occuring in preterm neonates or following neurosurgery. Based on literature data previously reporting a large consanguineous Iranian family with CARD9 deficiency that developed chronic mucocutaneous and central nervous system candidiasis; according to candidate gene approach, I sequenced CARD9 in all patients. CARD9 is an adaptor protein expressed by myeloid cells that signals downstream Dectin-1 and Dectin2 that are the main Pattern Recognotion Receptor implicated in antifungal immunity. I identified in all studied patients homozygous CARD9 mutations. Among 18 patients with deep dermatophytosis, 16 had homozygous nonsense Q289X and two homozygous missense R101C mutation in CARD9. I identified R18W, R35Q and R70W homozygous missense mutations in the patients who developed E. dermatitidis and two patients who developed CNS candidiasis, respectively. Transmission was autosomal recessive for all patients, except for the one with E. dermatitidis infection who had an uniparental disomy. In contrast with controls, CARD9 expression is abolished in Q289X, reduced in R70W and normal in R18W patients’ myeloid cells. CARD9 deficient patients whole blood and dendritic cells display a selective response defect to Candida albicans and Saccharomyces cerevisiae ; with IL-6 and TNF-α production impairment after Candida albicans and Saccharomyces cerevisiae stimulation. This defect can explain elective fungal susceptibility of CARD9 deficient patients to invasive fungal infections. This work evidenced that CARD9 deficiency was the main genetic etiology of deep dermatophytosis. It also could evidence that CARD9 deficiency is associated with Exophiala dermatitidis and Candida spp. CNS infections. This susceptibility is associated with proinflammatory cytokines defect by dendritic cells and whole blood to fungal agents. Various fungal clinical phenotypes in CARD9 deficient patients assess CARD9 central role in skin and central nervous system antifungal immunity.

Background: There are over 300 Primary Immunodeficiency diseases (PID) that are a result of a genetic or idiopathic dysfunction of any aspect of the immune system. These conditions result in a higher frequency of infections, autoimmune conditions, or malignancies. Moderate intensity exercise is thought to help the immune system, while high intensity exercise may have a negative impact on immune function. The impact of exercise on individuals with an impaired immune system due to PID is not yet understood. Purpose: The purpose of this study was to investigate whether a low to moderate intensity exercise program would have an effect on stress, fatigue, and quality of life (QoL) for individuals diagnosed with PID. Methods: 34 participants were included in this eight-week, mixed-methods, randomized controlled trial, either as part of the control group, or as part of the exercise intervention group. Participants completed pre- and post-study outcome measures, reflective journaling, and a post-study interview. Results: There were no statistically significant differences between the groups for the outcome measures, infection incidence, or need for non-routine medical care. There was a clinically significant decline in the Physical Component Summary score of the SF-36v2 for the control group at the end of the study. The scores for the SF-36v2, for all participants, were below normative scores for all domains, at the beginning and end of the study. Four main themes emerged from the qualitative interviews: living with a ‘new normal’, the challenges of living with a chronic disease, facing the stigma of a chronic disease, and wanting to exercise, but were too exhausted to do so. Conclusions: Individuals with a diagnosis of PID have lower QoL scores as compared to population norms. They face high levels of stress, overwhelming fatigue, social isolation, and decreased emotional well-being. Exercise programs for this patient population did not result in increased infections or need for non-routine medical care but did result in emotional implications that need to be considered. Healthcare providers need to address emotional well-being and provide coping strategies. Exercise programs should be designed with a slow, methodical ramp-up to avoid increasing fatigue or stress, while exercise goals must be highly achievable and realistic. Physical therapists should collaborate with other healthcare professionals for a more holistic and interprofessional approach to working with patients with a diagnosis of PID.