Defining the Genetic Etiology of Suppurative Lung Disease in Children and Adults

Study Overview
=================
Brief Summary
-----------------
The investigators will utilize a systematic approach for the diagnostic evaluation of patients to identify characteristics which may distinguish between Primary Immunodeficiency (PID) disorders versus Primary Ciliary Dyskinesia (PCD).

Detailed Description
-----------------
This protocol utilizes a cross-sectional study design. Over a 5-year period, the investigators will enroll patients who have clinical and lab features characteristic of a PID disorder or PCD, but do not have a confirmed genetic diagnosis. Innovative, standardized methods (SOPs) will be utilized, including ciliary ultrastructural analyses by transmission electron microscopy (TEM), as pertinent. Measures of nasal nitric oxide (nNO) will be performed in all subjects to allow comparisons of nNO values in PID vs. PCD. Patients with high likelihood of a PID disorder or a high likelihood of PCD will initially undergo research genetic testing on a commercial approved panel for PID disorders or a panel of at least 37 PCD genes. All subjects who do not have a genetic diagnosis from the test panels will undergo whole exome sequencing (WES) to search for novel genetic etiologies for PID or PCD.

Official Title
-----------------
Defining the Genetic Etiology of Suppurative Lung Disease in Children and Adults

Conditions
-----------------
Primary Ciliary Dyskinesia, Primary Immune Deficiency, Kartagener Syndrome

Intervention / Treatment
-----------------
* Diagnostic Test: Genetic Testing for PCD or PID
* Other: Unaffected Family Member Genetic Testing


Participation Criteria
=================
Eligibility Criteria
-----------------
Pediatric subjects (aged 5-17 years): Inclusion criteria include the major criterion (bronchiectasis in > 1 lobe on current or chest CT in previous 24 months, if available for review), plus one minor criterion, or two minor criteria, if bronchiectasis is not present, (including at least 1 lung minor criteria). Adult subjects (aged 18-45 years): Inclusion criteria include the major criteria (bronchiectasis in > 1 lobe on current or chest CT in previous 36 months, if available for review), plus one minor criterion, or three minor criteria, if bronchiectasis is not present, (including at least 1 lung minor criteria). Inclusion Criteria: General Criteria Age 5-45 years Male and Female Subjects All races and ethnicities Major Clinical Criteria - Bronchiectasis in > 1 lobe Minor Clinical Criteria, Lung Neonatal respiratory distress (in term neonates with O2 requirement) Chronic wet cough (year-round for at least 12 months) Recurrent episodes of bacterial bronchitis Recurrent pneumonia (confirmed on chest x-ray) Respiratory non-tuberculous mycobacteria (NTM) (documented respiratory NTM culture) Minor Clinical Criteria, Other Chronic nasal congestion Recurrent/chronic paranasal sinusitis Ongoing middle-ear disease and/or tympanostomy tube placement at age ≥ 4 years Organ laterality defect Low nasal nitric oxide (< 77 nL/min) (by plateau measurement) Confirmed family history of PID or PCD Exclusion Criteria: Anyone who has a confirmed genetic diagnosis of PCD or PID Cystic Fibrosis Alpha-antitrypsin deficiency in adults (18 years and older) Congenital upper or lower airway anomalies Post-lung or heart transplant, or other conditions requiring immunosuppression therapy Other confounding features, such as lung disease due to prematurity (born < 28 weeks gestation) or HIV Neurological compromise and evidence of recurrent aspiration Conditions known to be commonly associated with bronchiectasis, such as prior mycobacterium tuberculosis Have not had standard clinical evaluation to address other potential causes of chronic oto-sino- pulmonary disease, particularly cystic fibrosis, aspiration or airway anatomic abnormalities.

Ages Eligible for Study
-----------------
Minimum Age: 5 Years
Maximum Age: 45 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Affected Participants<br>Subjects who have suppurative lung disease without a known genetic diagnosis | Diagnostic Test: Genetic Testing for PCD or PID<br>* Patients with high likelihood of a PID disorder or a high likelihood of PCD will initially undergo research genetic testing on a commercial approved panel for PID disorders or a panel of at least 37 PCD genes.<br>|
| Unaffected Family Members<br>Unaffected family members may be enrolled in the study for collection of DNA only | Other: Unaffected Family Member Genetic Testing<br>* Unaffected family members will undergo genetic testing if genetic findings are identified in their affected family member.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants with a Confirmed Diagnosis of PCD or PID | A commercial genetic panel will be used to test for disease causing mutation in PCD or PID. If the commercial panel does not yield positive results, WES research testing will be used to identify disease causing mutations in PCD and PID in order to confirm the diagnosis. | Up to approximately 4 years | 
| Prevalence of Neonatal Respiratory Distress Seen in PCD and PID | Medical records will be reviewed to denote presence or absence of neonatal respiratory distress (occurs at birth). | During a single 6-hour visit | 
| Prevalence of the Onset of Chronic Nasal Congestion Before Six Months of Age Seen in PCD and PID | Medical records will be reviewed to denote presence or absence of the onset of chronic nasal congestion before age 6 months. | During a single 6-hour visit | 
| Prevalence of the Onset of Daily Wet Cough Before Six Months of Age Seen in PCD and PID | Medical records will be reviewed to denote presence or absence of the onset of daily wet cough before age 6 months. | During a single 6-hour visit | 
| Prevalence of Laterality Defects Seen in PCD and PID | Medical records will be reviewed to denote presence or absence of laterality defects (situs inversus/heterotaxy). | During a single 6-hour visit | 
| Prevalence of Chronic/Recurrent Sinus Disease Seen in PCD and PID | Medical records will be reviewed to denote presence or absence of chronic/recurrent sinus disease. | During a single 6-hour visit | 
| Prevalence of Chronic/Recurrent Middle Ear Disease Seen in PCD and PID | Medical records will be reviewed to denote presence or absence of chronic/recurrent middle ear disease. | During a single 6-hour visit | 
| Prevalence of Recurrent Pneumonia/Sepsis Seen in PCD and PID | Medical records will be reviewed to denote to denote presence or absence of recurrent pneumonia/sepsis (that is not bronchiectasis). | During a single 6-hour visit | 
| Prevalence of Skin Infections/Abscesses Seen in PCD and PID | Medical records will be reviewed to denote to denote presence or absence of skin infections/abscesses. | During a single 6-hour visit | 
| Prevalence of Abnormal Nasal Nitric Oxide Values Seen in PCD and PID | Nasal nitric oxide will be measured to determine the number of subjects who have an abnormal value, utilizing a cut-off of 77 nl/min. | During a single 6-hour visit | 
| Prevalence of Abnormal Immunoglobulin G Values Seen in PCD and PID | Immunoglobulin G will be measured to determine the number of subjects who have an abnormal value, utilizing the local laboratory age-defined cut-off ranges (United States: mg/dL; Canada: g/L). | During a single 6-hour visit | 
| Prevalence of Abnormal Lymphocyte Markers Seen in PCD and PID (Laboratory Tests) | Lymphocyte Markers will be measured to determine the number of subjects who have an abnormal value, utilizing the local laboratory age-defined cut-off ranges (% of lymphocytes). | During a single 6-hour visit | 
| Mean FEV1 Percent Predicted Values in PCD and PID | Forced expired volume in 1 second (FEV1) will be assessed by percentage of the predicted value (0-100%). | During a single 6-hour visit |