Marta López-Nevado, Luis I. González-Granado, Raquel Ruiz-García, Daniel Pleguezuelo, Oscar Cabrera-Marante, Nerea Salmón, Pilar Blanco-Lobo, Nerea Domínguez-Pinilla, Rebeca Rodríguez-Pena, Elena Sebastián, Jaime Cruz-Rojo, Peter Olbrich, Jesús Ruiz-Contreras, Estela Paz-Artal, Olaf Neth, Luis M. Allende, Instituto de Salud Carlos III, European Commission, [López-Nevado,M, Pleguezuelo,D, Cabrera-Marante,O, Paz-Artal,E, Allende,LM] Immunology Department, University Hospital 12 de Octubre, Madrid, Spain. [López-Nevado,M, González-Granado,LI, Salmón,N, Domínguez-Pinilla,N, Ruiz-Contreras,J, Allende,LM] Research Institute Hospital 12 Octubre (imas12), Madrid, Spain. [González-Granado,LI, Ruiz-Contreras,J] Immunodeficiency Unit, Department of Pediatrics, University Hospital 12 de Octubre, Madrid, Spain. [Ruiz-García,R] Immunology Department, Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Spain. [Blanco-Lobo,P, Olbrich,P, Neth,O] Paediatric Infectious Diseases, Rheumatology and Immunology Unit, University Hospital Virgen del Rocío, Institute of Biomedicine, Biomedicine Institute (IBiS)/University of Seville/Superior Council of Scientific Investigations (CSIC), Seville, Spain. [Domínguez-Pinilla,N] Pediatric Hematology and Oncology Unit, Toledo Hospital Complex, Toledo, Spain and University Hospital 12 de Octubre, Madrid, Spain. [Rodríguez-Pena,R] Immunology Department, University Hospital La Paz, Madrid, Spain. [Sebastián,E] Hematology and Hemotherapy Unit, University Children’s Hospital Niño Jesús, Madrid, Spain. [Cruz-Rojo,J] Endocrine Unit, Department of Pediatrics, University Hospital 12 de Octubre, Madrid, Spain. [Ruiz-Contreras,J, Allende,LM] School of Medicine, Complutense University of Madrid, Madrid, Spain., and This work was supported by grants from Fondo de Investigación Sanitaria (FIS-PI16/2053) to LA and LG-G. The project has been co-financed with FEDER funds. ML-N was co-financed by Fondo Social Europeo, Programa Operativo de empleo juvenil (YEI).
Primary immune regulatory disorders (PIRD) are associated with autoimmunity, autoinflammation and/or dysregulation of lymphocyte homeostasis. Autoimmune lymphoproliferative syndrome (ALPS) is a PIRD due to an apoptotic defect in Fas-FasL pathway and characterized by benign and chronic lymphoproliferation, autoimmunity and increased risk of lymphoma. Clinical manifestations and typical laboratory biomarkers of ALPS have also been found in patients with a gene defect out of the Fas-FasL pathway (ALPS-like disorders). Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), we identified more than 600 patients suffering from 24 distinct genetic defects described in the literature with an autoimmune lymphoproliferative phenotype (ALPS-like syndromes) corresponding to phenocopies of primary immunodeficiency (PID) (NRAS, KRAS), susceptibility to EBV (MAGT1, PRKCD, XIAP, SH2D1A, RASGRP1, TNFRSF9), antibody deficiency (PIK3CD gain of function (GOF), PIK3R1 loss of function (LOF), CARD11 GOF), regulatory T-cells defects (CTLA4, LRBA, STAT3 GOF, IL2RA, IL2RB, DEF6), combined immunodeficiencies (ITK, STK4), defects in intrinsic and innate immunity and predisposition to infection (STAT1 GOF, IL12RB1) and autoimmunity/autoinflammation (ADA2, TNFAIP3,TPP2, TET2). CTLA4 and LRBA patients correspond around to 50% of total ALPS-like cases. However, only 100% of CTLA4, PRKCD, TET2 and NRAS/KRAS reported patients had an ALPS-like presentation, while the autoimmunity and lymphoproliferation combination resulted rare in other genetic defects. Recurrent infections, skin lesions, enteropathy and malignancy are the most common clinical manifestations. Some approaches available for the immunological study and identification of ALPS-like patients through flow cytometry and ALPS biomarkers are provided in this work. Protein expression assays for NKG2D, XIAP, SAP, CTLA4 and LRBA deficiencies and functional studies of AKT, STAT1 and STAT3 phosphorylation, are showed as useful tests. Patients suspected to suffer from one of these disorders require rapid and correct diagnosis allowing initiation of tailored specific therapeutic strategies and monitoring thereby improving the prognosis and their quality of life., his work was supported by grants from Fondo de Investigación Sanitaria (FIS-PI16/2053) to LA and LG-G. The project has been co-financed with FEDER funds. ML-N was co-financed by Fondo Social Europeo, Programa Operativo de empleo juvenil (YEI).