Paradoxical CD4 Lymphopenia in Autoimmune Lymphoproliferative Syndrome (ALPS)
Authors: Andrea Lisco, Chun-Shu Wong, Susan Price, Peiying Ye, Julie Niemela, Megan Anderson, Elizabeth Richards, Maura Manion, Harry Mystakelis, Morgan Similuk, Bernice Lo, Jennifer Stoddard, Sergio Rosenzweig, Christophe Vanpouille, Adam Rupert, Irina Maric, Ainhoa Perez-Diez, David Parenti, Peter D Burbelo, V Koneti Rao, Irini Sereti
Journal: Front Immunol (2019)
Keywords: alps-fas, cd4 lymphopenia, apoptosis, autoimmune cytopenia, follicular t helper cells
MeSH terms: Autoantibodies / immunology, Autoimmune Lymphoproliferative Syndrome / complications, CD4-Positive T-Lymphocytes / immunology, Lymphopenia / etiology, Case Reports, Research Support, N.I.H., Intramural, Research Support, U.S. Gov't, P.H.S., Adolescent, Adult, Antibody Specificity, Antibody-Dependent Cell Cytotoxicity, Autoimmune Lymphoproliferative Syndrome / blood, Autoimmune Lymphoproliferative Syndrome / immunology, CD4 Lymphocyte Count, Case-Control Studies, Chickenpox Vaccine / adverse effects, Child, Disease Susceptibility, Female, Germ-Line Mutation, Humans, Immunocompromised Host, Lymphopenia / blood, Lymphopenia / immunology, Male, Pregnancy, Puerperal Disorders / etiology, Puerperal Disorders / immunology, Retrospective Studies, Vaccination, Varicella Zoster Virus Infection / etiology, Varicella Zoster Virus Infection / immunology, fas Receptor / deficiency, fas Receptor / genetics, Autoantibodies, Chickenpox Vaccine, FAS protein, human, fas Receptor

Autoimmune lymphoproliferative syndrome (ALPS) is caused by germline or somatic loss of function FAS mutations resulting in impaired apoptosis and consequent expansion of T-lymphocytes causing organomegaly and autoimmune anemia, neutropenia and thrombocytopenia. Herein, we report on a case of disseminated varicella zoster infection after post-partum vaccination in a patient found to have CD4 lymphopenia and eventually diagnosed with ALPS caused by a novel germline missense mutation in FAS death-domain. A subsequent retrospective analysis of 169 patients of the NIH ALPS-FAS cohort, revealed that CD4-T-cells lymphopenia (< 300 cells/μl) may occur in 5% of ALPS-FAS patients irrespectively of the underlying genetic defect, organomegaly or immunosuppressive treatment. Although immunophenotyping did not show depletion of specific CD4-T-cells subpopulations, CD4-lymphopenic ALPS-FAS subjects had an expansion of a subset of circulating T-follicular-helper (cTfh) cells, associated with autoantibody production (CCR7lowPD-1high). Furthermore, autoantibodies binding on CD4-T-cells were detected in 50% of the CD4-lymphopenic ALPS-FAS patients and caused cytotoxicity in a natural killer (NK)-mediated antibody-dependent-cellular cytotoxicity assay. Such autoantibodies can therefore be associated with CD4-T-cell death, impaired activation induced proliferation or impaired trafficking. The expansion of autoreactive T-cells in ALPS-FAS is known to be associated with autoimmune clinical manifestations, however our study reveals that ALPS-FAS can also be associated with a paradoxical depletion of CD4-T-cells due to the presence of autoantibodies on the surface of CD4-T-cells which can in turn result in increased susceptibility to opportunistic infections. These novel findings have implications for the diagnosis, clinical monitoring, and management of patients with ALPS-FAS.