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Research Article, J Immunol Tech Infect Dis Vol: 6 Issue: 1
Progression of Common Variable Immunodeficiency in Romanian Patients
*Corresponding Author : Malina Oana Sava
Department of Otorhinolaryngology, County Clinical Emergency Hospital, Cluj-Napoca, Romania
E-mail: [email protected]
Received: June 05, 2017 Accepted: August 21, 2017 Published: August 26, 2017
Citation: Sava MO, Deleanu D (2017) Progression of Common Variable Immunodeficiency in Romanian Patients. J Immunol Tech Infect Dis 6:1. doi: 10.4172/2329-9541.1000156
Common variable immunodeficiency (CVID) is the most prevalent symptomatic primary immunodeficiency and belongs to the class of predominantly antibody deficiencies. For the positive diagnosis of CVID the following criteria must be fulfilled: a) serum levels of Ig G and at least one of the classes IgA and IgM at least 2 standard deviations below the average for age; b) patient age ≥ 4 years at diagnosis and c) any other defined causes of hypogammaglobulimenia (primary or secondary) have been excluded. Recent sets of diagnostic criteria additionally include clinical, serum immunology, immunophenotype, and histological characteristics that support the diagnosis of CVID (i.e. they increase the diagnostic probability).
Keywords: Common variable immunodeficiency; Immunoglobulin; Infectious disease; Autoimmune disease; Serum immunology; Immunophenotype
CVID: Common Variable Immunodeficiency; Ig: Immunoglobulin; OFGI: ‘Octavian Fodor’ Gastrenterology Institute (The Clinic Where This Research Was Conducted); ESID: European Society for Immunodeficiencies; PAGID: Pan American Group for Immune Deficiency; IVIG: Intravenous Immunoglobulins; AO: Age of the Patient at the Onset of CVID; AD: Age of the Patient When Being Diagnosed With CVID; DD: Diagnostic Delay-Time from Onset of CVID to Diagnosis; M-W: Mann-Whitney Test; K-S: Kolmogorov-Smirnov Test; RTI: Respiratory Tract Infections; UTI: Urinary Tract Infections; HSV: Herpes Simplex Virus; BLP: Benign Lymphoproliferation; LAP: Lymphadenopathy; NHL: Non-Hodgkin Lymphoma; LIP: Lymphoid Interstitial Pneumonia; ILD: Interstitial Lung Disease; GLILD: Granulomatous Lymphocytic Interstitial Lung Disease; COPD: Chronic Obstructive Pulmonary Disease
Common variable immunodeficiency (CVID) is the most prevalent symptomatic primary immunodeficiency and belongs to the class of predominantly antibody deficiencies. For the positive diagnosis of CVID the following criteria must be fulfilled: a) serum levels of Ig G and at least one of the classes IgA and IgM at least 2 standard deviations below the average for age; b) patient age ≥ 4 years at diagnosis and c) any other defined causes of hypogammaglobulimenia (primary or secondary) have been excluded. Recent sets of diagnostic criteria additionally include clinical, serum immunology, immunophenotype, and histological characteristics that support the diagnosis of CVID (i.e. they increase the diagnostic probability). Primary antibody deficiencies with a known causative genetic defect are no longer included in CVID [1-4].
CVID has infectious and noninfectious complications. Severe, recurrent and sometimes chronical bacterial infections are present in approximately 95% of CVID patients . Infection location is predominantly respiratory or digestive and their majority is caused by common pathogens . Noninfectious manifestations of CVID are present in approximately 70% of patients. These include: autoimmune diseases (esp. autoimmune cytopenias), enteropathy, hepatomegaly, chronic granulomatous disease, lymph proliferative diseases, cancer, splenomegaly and bronchiectasis. Of these, the autoimmune, inflammatory and lymphoproliferative diseases are considered intrinsically disease related complications (i.e. they are not possibly caused by other infectious or noninfectious disease manifestations or by their treatment) . For other disease complications, possibly causative associations have been found with other infectious or noninfectious disease manifestations or with the treatments for these (e.g.: bronchiectasis- severe infections, lymphoid neoplasia- polyclonal lymphocytic infiltration, and splenomegalyseveral CVID complications, cancer- immunosuppressive treatment). Numerous genetic and immunological defects have been identified so far in patients with CVID and their prevalence varies among the analyzed cohorts. A classification in subtypes of CVID based on the immunophenotype defects (EUROclass) has been proposed . For some immunophenotype and serum immunography defects correlation with certain clinical disease manifestations has been confirmed (low class-switched memory B-cells with splenomegaly, high serum IgM levels with polyclonal lymphocytic infiltration and lymphoma, etc)[7,8]. Reduced count of class-switched memory B-cells is the most constant immunophenotype defect (found in 80- 90% of CVID patients)  and is a diagnostic criteria for CVID in the ESID Registry- Working Definitions for Clinical Diagnosis of PID, 2016 (2016 Revised ESID criteria) .
It must be said that: only some associations between the various CVID manifestations (clinical-clinical or immunologic-clinical) have been statistically significant, as in some cohorts the number of cases of complications was low. Additionally, the associations found by some studies could not be confirmed by the subsequent studies. [5,7-9]
In Europe there are high differences in CVID prevalence in the general population between the states and in the prevalence of disease complications between the centers. Some of these differences are statistically significant . What is more, these prevalence parameters differ between the cohorts in Europe and those in the USA [10,11]. This indicates the low relevance of the statistic results obtained in a uni- or multicentric group of patients for other groups of patients.
Scientific medical literature presently includes no characterization of a group of Romanian CVID patients. Only 2 Romanian centers for diagnosis and treatment of CVID have reported their primary immunodeficiency patients to the former ESID registry (working from 2004 to 2014; the data of the new ESID registry are available to ESID members only): Timișoara- 7 patients and Târgu Mureș- 4 patients. Because of the low reporting rate, European studies carried out so far have not analyzed the features of Romanian patients separately by country or by center. Moreover, none of the Romanian centers has published the features of the CVID patients in its database. Knowledge of the progression of CVID in Romanian patients is necessary because, as previously shown, the features of the already studied cohorts differ significantly and have limited relevance for other groups of patients with this disease.
The main objective of this study is the demographic, immunological and clinical characterization of the CVID patients included in the Immunodeficiencies Registry of the “Octavian Fodor” Gastroenterology Institute (OFGI), Cluj-Napoca, Romania. Additional objectives are testing for the association of these features with the mode of disease progression and with survival and comparing the features of patients in this cohort with those of the reference cohorts studied previously [7,9,12].
Materials and Method
Regarding the study format, this study has two parts:
(1) Descriptive and (2) analytical: observational retrospective cohort type.
In the study were included patients treated for CVID at the OFGI at any time since the start of the National Program for Substitution Therapy in Humoral Immunodeficiencies in Adults- August 8, 2011 – until June 2016.
The criteria for inclusion in the study were: patient age over 18 at the time of inclusion in the study or at death (the condition was applied to patients deceased before inclusion in the study); confirmed diagnosis of CVID based on current diagnostic criteria: ESID/PAGID Criteria in 2011-2015, Revised ESID Criteria (the 2015 version was applied to these patients; for CVID this version is identical to the 2016 Revised ESID Criteria) [1,4].
The exclusion criteria were: primary immunodeficiency other than CVID in a patient included in the National Program for Substitution Therapy in Humoral Immunodeficiencies in Adults at the OFGI; reclassification according to the 2015 Revised ESID Criteria of a patient previously diagnosed with CVID; the identification of a secondary cause for the clinical and/or immunological (serum immunogram, immunophentype) phenotype of CVID; insufficient data for validating the CVID diagnosis according to the criteria in use at the time of data collection for the study; patient’s refusal to participate in the study.
Data required for the study were collected from October 2015 to July 2016. The data sources used were: the patient’s medical records (hospital discharge papers, medical letters, results of imaging/ laboratory investigations) found in the Immunodeficiencies Registry of OFGI or explicitly requested from patients; patient medical records from their admissions during the data collection period for this study; the electronic patient registry of the OFGI; patient medical history taken from the patients or their families.
For data collection we used a semi-structured questionnaire, which included: personal data; pedigree for confirmed immunodeficiencies, history of infections, non-infectious complications of CVID, neoplasia, allergies; AO, AD, mode of onset of disease; diagnostic criteria fulfilled; disease manifestations: infections (location, frequency, severity, other information), autoimmune diseases (disease, timing, other remarks), lymphocytic infiltration (disease, timing, other remarks), neoplasia (disease, timing, other remarks), enteropathy (disease, timing, other remarks), others diseases (disease, timing, other remarks); immunophentype; comorbidities (immunological, others); treatment (of CVID- initial and average maintenance dose of intravenous immunoglobulins (IVIG), body weight, side effects, treatment history; specific treatment for disease complications); disease progression: disease duration (from onset to present / to death), survival.
A database was created in a Microsoft Excel 2013 file, in which the data from the questionnaires were entered. Conversion into binary data and calculations of secondary parameters were made based on these primary data.
We anticipated the existence of missing data. We established that statistical parameters dependent on variables with missing data be calculated based only on the obtained data, regardless of whether the missing data will be random or non-random. The following categories had missing data: pedigree, AO, DD, mode of disease onset, infections (incomplete history of infections), comorbidities, immunophenotype, initial and maintenance doses of IVIG. The data of patients having missing data were reassessed completely. The missing data were considered random absent data, because no differences in disease progression or mortality were observed in these patients compared to the rest of the cohort. The exception from this convention was the immunophentype parameters. Immunophenotype sheets of different patients contained different parameters; each parameter was determined for 4-13 patients. Consequently, we set a 20% significance threshold for the prevalence of changes of an immunophenotype parameter and we did not test for correlations between clinical and immunophenotypical disease manifestations.
For classification and processing of data, the following were also established:
- in assessing the progression of infections under substitution therapy we considered the following improvement criteria: absence of severe infections that had occurred before treatment (2 points), a ≥ 50% decrease in the frequency/ the absence of an infection type present before treatment (1 point) and worsening criteria: occurrence/ increased frequency of severe infections (2 points), increased frequency of an infection type (1 point), appearance of a new type of infection (1 point)
- Patients with simultaneous lymphoma were not included in the ‘splenomegaly’ category because in this clinical context splenomegaly cannot be considered an intrinsic manifestation of CVID.
- The cases of intestinal lymphoproliferation were not included in the category of ‘benign lymphoproliferation’ (BLP), but in a separate category: ‘enteropathy’. A previous reference study proposed these two entities as distinct clinical phenotypes of disease because no association between them was found for the chosen statistical significance threshold (p<.001) .
Descriptive statistical processing was performed with the Microsoft Excel 2013 program and consisted of:
- distribution by gender, area of origin and mode of disease onset; frequency distributions for: age, AO, AD (age groups), DD (5-year intervals); median for age, AO, AD and DD (the median was used as a parameter for centrality because these data had non-normal distribution);
- prevalence for clinical manifestations, subtypes of clinical manifestations, relevant family history, relevant comorbidities, the belonging to one or more clinical phenotypes of CVID proposed by Chapel et al ;
- average serum immunoglobulin levels before initiation of IVIG treatment, prevalence of low serum levels for IgA, IgM, IgA and IgM, respectively; prevalence of immunophenotype changes;
- average maintenance dose of IVIG, specific treatments for non-infectious manifestations, prevalence and type of response to treatments, prevalence of and causes for interruption of treatment;
- survival rate at 5 and 10 years, median of survival, AO and DD in deceased patients, causes of death.
Analytical statistical processing was performed with the GraphPad Prism 7.01 program and it consisted of:
- verifying the normality of distribution of age values, AO, AD, DD and serum immunoglobulin levels at diagnosis with the D’Agostino&Pearson and Shapiro-Wilk tests;
- testing for difference between genders and between areas of origin for age, AO, AD, DD with the Mann-Whitney (Wilcoxon rank-sum) and Kolmogorov-Smirnov tests;
- Comparison to the gender distribution in the European cohort (binomial test) .
- Testing for correlations between clinical manifestations (Fisher’s exact test), between clinical manifestations and AO/ AD/ DD, between immunological and clinical manifestations (Fisher exact test), between immunological manifestations and AO/ AD/ DD (Spearman test for correlation), between clinical manifestations and family history / comorbidities (Fisher exact test). The tested correlations were chosen based on a possible pathophysiological causality and on the results obtained in larger cohorts in previous studies, in order to delineate distinct clinical phenotypes of CVID and to identify the risk factors for a particular phenotype.
In all statistical tests applied differences were considered significant if p <0.05 (marked ‘*’ in the Results section).
32 patients with CVID were included in the study. The prevalence of the disease was 1: 29,000 in Cluj County and 1: 22,000 in Cluj- Napoca. Table 1 shows the distribution by gender and by place of origin. The gender distribution in this cohort was significantly different from that at European level (p=.02*) .
|Place of origin||Urban||25||78|
Table 1: Distribution by gender and by place of origin.
Table 2 indicates the distribution of patient age, AO, AD, DD and time of disease evolution. All five parameters had a non-normal distribution to the Shapiro-Wilk and D’Agostino&Pearson tests. Between genders the difference was statistically insignificant for AO, DD and time of disease evolution and significant for AD (MW: p=.03*, K-S: p=.02*). Between places of origin the difference was statistically insignificant for the AO, AD, DD and time of disease evolution.
|Minimum||Maximum||Median (µ)||Gender||Place of origin||Patients %|
|µ male||µ female||µ urban||µ
|Age at onset||0.5||72||25||25||27||24.5||25|
|< 18 years||34%|
|Age at diagnosis||5||72||48||37||52||50||40|
|< 18 years||6%|
|< 5 years||50%|
|> 15 years||35%|
Table 2: Distribution parameters for age, AO, AD, DD and time of disease evolution- general/ by gender/ by place of origin.
The positive diagnosis was initially established based on the ESID/PAGID-1999 criteria in 30 patients (94%) and on the 2015 Revised ESID Criteria in 2 patients (6%). 2 patients did not fulfill the 2015 Revised ESID Criteria. A patient had at the time of diagnosis an inflammatory disease that is not considered specific to CVID (interstitial cystitis). During the treatment with IVIG she presented exclusively with cystitis, but only some of the episodes were bacteriologically differentiated from interstitial cystitis. In another patient the diagnosis was incidental and prior to diagnosis she had no history of infectious or non-infectious manifestations possibly due to CVID. During the treatment with IVIG she experienced lower urinary tract infections (2 episodes/ year) and an episode of cellulitis of the calf; the patient had type II diabetes mellitus concomitantly. Both patients discontinued the treatment for more than 6 months for reasons unrelated to the disease.
Parameters based on serum immunoglobulins levels at diagnosis are shown in Table 3 (serum immunoglobulin levels had a non-normal distribution). IgA and IgM levels were undetectable at diagnosis in 1 patient.
|very low (<150 mg/dl)||31 %|
|high (>500 mg/dl)||0|
|IgA & IgM||61%|
Table 3: Serum immunoglobulin levels at diagnosis.
Immunophenotyping of peripheral blood lymphocytes was performed in 12 patients (37%); the changes observed are shown in Table 4.
|Low levels||High levels||No. of patients assessed|
|T lymphocytes %||42%||12 (38%)|
|B lymphocytes %||67%||6 (19%)|
|NK cells %||50%||6|
|B lymphocytes||80%||5 (16%)|
|B lymphocytes <1%||20%||5|
Table 4: Immunophenotype changes in patients with CVID.
Table 5 shows the mode of clinical onset of CVID. One patient (3%) was asymptomatic before the time of diagnosis.
|Systemic HSV1 infection||1|
|lower RTI||5 (16%)|
|upper RTI||8 (25%)|
|upper and lower RTI||3 (9%)|
|non-Hodgkin lymphoma||4 (12%)|
|autoimmune disease||3 (9%)|
Table 5: Mode of onset of CVID (no. of patients).
The prevalence of CVID manifestations was determined, considering the period from disease onset to present or to death (Table 6).
|Category||No. of pts.||Prevalence|
|Lower respiratory tract||1||63%|
|Upper respiratory tract||13||41%|
|Lower urinary tract||14||44%|
|Chronic/ acute helicobacter pylori gastritis||3||9%|
|Bacterial skin/ soft tissue infections||1||16%|
|Specific viral infections||1||19%|
|Herpes simplex virus infections||4||12%|
|Viral hepatitis (B or A)||3||9%|
|Immune thrombocytopenic purpura||1|
Undifferentiated systemic vasculitis
|Polyclonal lymphocytic infiltration||5||16%|
Lymphoid interstitial pneumonitis, (Pulmonary granulomasf)
|Chronic digestive diseases||5||16%|
|Chronic pulmonary diseases||10||31%|
Fibrosing interstitial lung disease
|Recurrent aphthous ulcers
Recurrent interstitial cystitis
Pyoderma gangrenosum, Panniculitis
|Iron deficiency anemia||3||9%|
|No non-infectious complications||6||19%|
b enteropathy belongs to chronic digestive diseases,
c both manifestations were present in the same patient and belong to chronic pulmonary diseases,
d Crohn's disease belongs to autoimmune diseases,
e these manifestations were present in the same patient,
f histology did not confirm imaging findings,
g see Table X
Table 6: Non-infectious complications in patients with CVID.
100% of patients had infections, 66% of which had at least one severe infection. The severe infections found were: lung infections (41% of patients), sepsis (9%), severe acute diarrhea (9%), septic arthritis (6%), cellulitis (12%) and complicated Herpes zoster (6%). The severe lung infections were mainly pneumonia or bronchopneumonia which required hospitalization, intravenous antibiotic treatment and/or oxygen therapy. Additionally, there were two cases of secondary pulmonary tuberculosis, which responded to specific treatment. There was also a case of extensive superinfected bronchiectasis, with chronic lung abscesses and secondary pulmonary tuberculosis, for which the patient died due to the tuberculosis. In the last case the following microorganisms were identified in successive cultures from sputum or bronchial aspiration: Pseudomonas aeruginosa (most frequent result), Staphylococcus aureus, Streptococcus pneumoniae, Corynebacteria, Streptococcus viridans, Staphylococcus epidermidis and Candida albicans. Of the 3 cases of sepsis, 2 occurred before the beginning of the IVIG treatment and were caused by Pseudomonas aeruginosa and HSV type 1, respectively. These cases were cured by specific antimicrobial and supportive treatment. Pseudomonas aeruginosa caused 2 episodes of sepsis in the same patient, at an interval of approximately 2 years; the second episode associated septic myocarditis with subsequent dilative cardiomyopathy. The second patient had a chronic systemic infection with HSV type 1, worsened by repeated episodes of sepsis in infancy and an episode of herpetic encephalitis in adulthood; the sepsis episodes associated acute viral hepatitis and diffuse and severe bacterial super infection of the generalized cutaneous rash. The third case of sepsis occurred after the first 2 doses of substitution therapy and the etiology remained unknown. Concomitantly, the patient underwent chemotherapy for early recurrence of NHL; this patient deceased after about 2 months. All 3 patients with sepsis were female. Two of the cases of acute severe diarrhea were caused by Clostridium difficile; both patients were concomitantly undergoing chemotherapy for NHL and IVIG therapy; the third was caused by Salmonella species and Campylobacter jejuni before initiation of IVIG therapy. In the first case of septic arthritis the right elbow was affected, the result of bacterial examination of synovial fluid was not available to the investigators and surgical treatment was required. In the other case, the elbow and knee joints were successively affected and the microbiological examination of the synovial fluid was negative. Arthritis of the elbow responded to treatment with Teicoplanin; arthritis of the knee did not respond to treatment with Ciprofloxacin, Teicoplanin and Imipenem-Cilastatin, required surgical intervention and resulted in ankylosis. Both cases of arthritis occurred before initiation of IVIG therapy.
Table 7 shows the progression of satient infection status after initiation of IVIG treatment. In 30% of patients the risk of infection during IVIG treatment could not be assessed correctly because there was at least one confusion factor: chemotherapeutic or immunosuppressive treatment, type 2 diabetes mellitus or advanced cancer.
|Infections (%)||Total||Under IVIG treatment|
Table 7: Infection progression after initiation of IVIG substitution.
The prevalence of infections by location for all disease duration is shown in Table 6. Of the patients with tuberculosis, two had concomitant bronchiectasis and the third had concomitant NHL. All patients with oral candidiasis were under systemic or inhaler corticosteroid treatment.
For infections with prevalence >10% in this cohort, the following parameters were determined: prevalence before treatment, prevalence under treatment, prevalence difference, percentage of cases of improvement (out of all the existing cases before treatment), percentage of newly emerged cases during treatment (out of the total number of cases under treatment). After initiation of IVIG treatment in some patients were observed the absence or decreased frequency or severity of previous infections with a given location and the emergence of infections in a new location, respectively. Thus, the prevalence of pneumonia, bronchitis and acute diarrhea decreased, the prevalence of sinusitis increased and the prevalence of otitis media and lower UTI remained constant (Table 8).
|pretreatment cases (total)||remission/improvement||new location/worsening||cases under treatment (total)||Evolution under treatment|
|Acute bronchitis||9||6||3||6||↓ 33%|
|Acute diarrhea||8||6||3||5||↓ 37%|
Table 8: The progression of infections by location after initiation of IVIG treatment.
Microbiological examinations available for this study (59% of patients) indicated the following: lower RTI with Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus and Pseudomonas aeruginosa and, in one case, Moraxella catarrhalis and Klebsiella pneumoniae; enterocolitis with: Clostridium difficile, Campylobacter spp, Salmonella spp. and, in one case, Pseudomonas aeruginosa and Serratia marcescens; UTI with Escherichia coli; colonization of the lower respiratory tract in patients with bronchiectasis or chronic obstructive pulmonary disease with Haemophilus influenzae (50%), Candida albicans, Streptococcus pneumoniae and Pseudomonas aeruginosa; colonization of the lower respiratory tract in patients without bronchiectasis or chronic obstructive pulmonary disease with Staphylococcus aureus, Candida spp. (predominantly C. albicans) and, in one case: Haemophilus influenzae, Gram-negative bacilli (Escherichia coli, Acinetobacter baumannii, Citrobacter braakii, Enterobacter cloacae, Stenotrophomonas maltophila, Pseudomonas putida) or commensal oropharyngeal bacteria (Rothia mucilaginosa). In 2 of the 5 patients with documented opportunistic infections these were present only during chemotherapy for lymphoma; the other patients did not have lymphoma and were not undergoing chemotherapy or immunosuppressive therapy.
The available data on antibiotic treatments and prophylaxis received by patients in this cohort were insufficient for statistical processing.
28% of patients had autoimmune diseases (Table 6) systemic, solid organ or autoimmune cytopenias. 5 patients had each two autoimmune diseases. In 4 cases there was a coexistence of a systemic autoimmune disease with secondary antiphospholipid syndrome; one patient had Hashimoto’s thyroiditis and systemic vasculitis and another patient had autoimmune processes at more than three solid organs with no systemic autoimmune disease. No coexistence of autoimmune cytopenias with autoimmune diseases of solid organ or systemic was observed in any patient. The gender rate of patients with autoimmune diseases is 2: 7 (male: female). The association of autoimmune diseases with female gender was tested but was not statistically significant (p = 1). 2 cases (29%) of solid organ autoimmune disease completely resolved after specific treatment (with immunosuppressive and / or corticosteroid or non-steroidal anti-inflammatory medications): Graves’ disease and Crohn’s disease. It must be said that 5 patients had transient or persistent cytopenias, but the immunological diagnosis was only positive for the patient mentioned above.
16% of patients had BLP. In Table 9, the cases of BLP identified in this cohort are presented separately because of their heterogeneity. All of these patients had lymphadenopathy at multiple locations and each patient had additionally: only splenomegaly, only hepatomegaly, hepatosplenomegaly, intestinal lymphoid hyperplasia or LIP (this patient had concomitant hepatosplenomegaly and pulmonary granulomas were detected at high-resolution computed tomography; pulmonary biopsy confirmed the lymphoid infiltration of the lung histologically, but no granulomas were found). Biopsies were performed to 2 patients (40%): from lymph nodes and lymph nodes and lungs, respectively; the histological result was atypical lymphoid hyperplasia in both cases. The gender rate of patients with BLP is 2: 3 (male: female). None of the patients with BLP had been diagnosed with lymphoma by the end of the study. In the two histologically confirmed cases of atypical lymphocytic hyperplasia, corticosteroid treatment was indicated and partial remission was achieved. In the patient with celiac disease specific treatment for enteropathy was indicated; under treatment the infiltrative formations were stationary. No specific treatment was indicated to the other patients.
|1.||+||+||+||+||atypical lymphoid hyperplasia|
|3.||+||+||-||-||atypical lymphoid hyperplasia|
Table 9: Benign lymphoproliferation in patients with CVID.
34% of patients had tumors (Table 6). A patient had a benign tumor (neurinoma of cranial nerve VII) and a patient successively had Hodgkin’s lymphoma and colorectal carcinoma. The specific types of malignancies identified in this cohort are shown in Table 10. The gender rate of patients with malignant tumors was 3: 7 (male: female). Complete remission without recurrence by the end of the study was achieved in 66% (4 patients) of cases of NHL and healing was achieved in 3 of the solid tumors. There were two cases of relapse: large B-cell NHL and angioimmunoblastic T-cell lymphoma and two deaths caused by malignant tumors: metastatic colorectal carcinoma and angioimmunoblastic T-cell lymphoma with early relapse.
|Lymphoma||No. of pts.||Other cancers||No. of pts.|
|Hodgkin's lymphoma||1||Colorectal carcinoma||1|
|Non-Hodgkin's lymphoma||6||Basal cell carcinoma||1|
|Large B-cell||3||Thyroid papillary carcinoma||1|
|Burkitt type||2||Cervical carcinoma||1|
Table 10: Malignant tumors in patients with CVID.
16% of patients had non-infectious digestive diseases. In Table 11, the digestive diseases identified in this cohort are presented descriptively for each patient, because of concomitant presence of several types of digestive disorders in the same patient. There were 3 cases (60%) of coexistence with BLP in other organs and 1 case of coexistence with Helicobacter pylori- positive chronic gastritis; there were no cases of coexistence with other autoimmune diseases or lymphoma. All cases had a histological diagnosis. Specific treatment was indicated for celiac disease (immunosuppressant and corticosteroid) and Crohn’s disease (anti-inflammatory, corticosteroid and immunosuppressant) and partial remission was obtained in both cases.
|No. of pacient||Digestive diseases||Helicobacter pylori- positive gastritis||BLP in other organs|
|1||Atrophic gastritis||Unknown*||Lymph nodes, spleen|
|2||Celiac disease unresponsive to gluten, erythematous antral gastritis, esophagitis||Lymph nodes, liver, spleen|
|3||Nodular lymphoid hyperplasia of duodenum, esophagitis||Acute erosive, repetitive|
|4||Nodular lymphoid hyperplasia of terminal ileum||Lymph nodes, liver, spleen|
Table 11: Non-infectious digestive diseases in patients with CVID
25% of patients had bronchiectasis. 12% of patients had ILD. High resolution computed tomography was performed in all 4 cases of ILD. 3 of them were diagnosed as definite fibrosing ILD based on imaging findings only. In the remaining case imaging findings raised the suspicion of sarcoidosis and transbronchial lung biopsy was performed, which indicated lymphocytic interstitial pneumonitis (atypical lymphoid hyperplasia of the lung with no granulomas). Frequent coexistence of fibrosing ILD with systemic autoimmune diseases and bronchiectasis was observed.
12% of patients had splenomegaly. 2 patients had hypersplenism. In 2 patients splenectomy was indicated for immune thrombocytopenic purpura non-responsive to medication, and for an unknown indication, respectively. 9% of patients had hepatomegaly of unknown cause. Coexistence with lymphoid infiltration of other organs (in all hepatomegaly cases) and with enteropathy was observed. 9% of the patients were diagnosed with iron deficiency anemia, in association with the following manifestations: Crohn’s disease, Hunner ulcers and esophagitis, Helicobacter pylori- positive acute erosive gastritis, nodular lymphoid hyperplasia of the duodenum. In other patients with low hemoglobin levels, the differential diagnosis with anemia of chronic disease could not be made because serum iron and serum ferritin levels were not available.
9% of patients had specific inflammatory diseases. All affected patients were female. Two cases (aphthous ulcers and interstitial cystitis) were not associated with other non-infectious manifestations of CVID. The third case (pyoderma gangrenosum and paniculitis) occurred in a patient with concomitant colorectal cancer. No significant improvement was seen under IVIG treatment in any of the cases.
Apart from the classical manifestations described in CVID patients, the following were identified in patients in this cohort: idiopathic meningitis (2 patients), subcortical leukoencephalopathy (1 patient), ischemic optic neuropathy (1 patient), retinal necrosis (1 patient). For these diseases, etiology could not be established. Their appearance in these patients determined the immunological investigation and the diagnosis of CVID. Some appeared successively in the same patient: idiopathic meningitis and subcortical leukoencephalopathy, idiopathic meningitis and retinal necrosis, respectively.
Correlations between CVID manifestations-Clinical phenotypes
Table 12 presents the associations found between the noninfectious clinical manifestations of CVID.
|Infl/Ai diseases||LAP/BLP||Enteropathy||Spleno-megaly||Hepato-megaly||Bronchi-ectasis||ILD||Fibrosing ILD|
|Ai/ Infl diseases||1/5 (p>0.99)||0||0||0||3/8 †
|4/6 * (p=0.002)||3/4 *
|Spleno- megaly||3/4 *
|Hepato- megaly||2/8 †
Table 12: Correlations between non-infectious complications of CVID.
Severe infections (pneumonia/sepsis) did not correlate with bronchiectasis (p=0.08). Diagnostic delay did not correlate with low serum of IgG levels at diagnosis (p =0.83). Low serum IgG levels at diagnosis (IgG <150 mg/dL) correlated with severe infections (p=0.01*, OR=13). No correlation between IgG and IgM values at diagnosis was found. Correlations were weak between IgG and IgA (p<0.001*; r=0,62) and between IgA and IgM (p=0.004*; r=0,51) levels at diagnosis, respectively.
The number of clinical phenotypes of CVID was determined in every patient. Patient having only infections constituted a distinct phenotype. Based on the non-infectious complications, the following phenotypes were defined: autoimmune disease, BLP, tumors, enteropathy, inflammatory diseases, bronchiectasis, splenomegaly and ILD. The complications between which a correlation was found were considered to constitute a single disease phenotype (BLP/ lymphadenopathy - splenomegaly - hepatomegaly, bronchiectasis and splenomegaly, bronchiectasis and severe infections, bronchiectasis and ILD). The enteropathy and BLP of other organs present at the same patient were considered two distinct phenotypes. Thus, only one phenotype was present in 75% of patients, 2 phenotypes 16%, 3 phenotypes in 6% and 4 phenotypes in 3% (Figure 1).
The initial dose of IVIG in adult patients ranged from 400 to 600 mg/kg. The average maintenance dose of IVIG used in adult patients was 375 mg/kg. 21.8% of patients had adverse effects to IGIV treatment. The adverse effects identified were: edema at the site of administration, fever, chills, malaise, exanthema, vertigo, arthralgia, vomiting, hematochezia, hair loss, phlogistic reactions. 3 patients (9%) experienced phlogistic reactions. 3 patients (9%) discontinued the treatment because of the adverse effects. 5 patients discontinued the treatment for medical or non-medical reasons unrelated to treatment, and a patient interrupted treatment due to normalization of serum Ig levels.
The specific treatments for CVID manifestations were mentioned in the description of these diseases. 84% of patients were treated by physicians of specialties other than immunology for infectious or non-infectious complications of CVID. 9 patients (28%) required surgery for malignant (12%) or non-malignant (16%) complications of CVID (Table 13). The only ineffective operation was the repair of the oroantral communication of the maxillary sinus (maxillary sinusitis recurred after the repair). All patients were re-examined clinically, biochemically, by complete blood counts and levels of serum antibodies at each presentation for IVIG administration. For the newly discovered complications at a presentation specific investigations or examination by other specialties were indicated. 78% of the patients were monitored by doctors from other specialties for infectious or non-infectious complications of CVID. The disease manifestations found were monitored periodically, as indicated by the treating physician (hematologist, rheumatologist, etc.).
|Non-malignant||Bronchiectasis of right lung upper lobe||Upper right pulmonary lobectomy||1|
|Oroantral communication → Persistent acute maxillary sinusitis||Closure of oroantral communication||1|
|Immune thrombocytopenic purpura||Splenectomy||1|
|Septic arthritis||Surgical drainage||2|
|Malignant||Gastric B-cell NHL||Gastrectomy||1|
|Thyroid papillary carcinoma||Thyroidectomy||1|
|Right thoracic basal cell carcinoma||Excision of carcinoma||1|
|Cervical carcinoma||Hysterectomy + bilateral ovarectomy||1|
Table 13: Surgical treatments for complications of CVID.
Family history, comorbidities
A patient had 1st and 2nd degree relatives with confirmed antibody deficiencies: a brother with selective IgG deficiency and a nephew with CVID. In the other 1st and 2nd degree relatives of the patient antibody deficiencies were ruled out. The patient was diagnosed with selective IgA deficiency 21 years before establishing the diagnosis of CVID. Another patient had a daughter with selective IgG deficiency. 50% of patients had 1st and 2nd degree relatives with cancer, but presence of cancer at relatives did not correlate with presence at patients (p=0.67). 2 patients (6%) had 1st degree relatives with autoimmune disease and both had autoimmune disease; presence of autoimmune diseases at relatives did not correlate with presence at patients (p=0.06). 3 patients (10%) had relatives with increased susceptibility to infections, without being investigated for immunodeficiencies. Based on patient family history no cases of other possible CVID manifestations were found in 1st and 2nd degree relatives of patients in this cohort.
47% of patients had allergies. 22% of patients had type II diabetes mellitus. 6% of the patients had COPD. Of the patients in which the comorbidities are known, all of those who had phlogistic reactions to IGIV had allergies. Diabetes mellitus did not correlate with either severe infections (p=0.68) or lower UTI (p=1). One of the two COPD patients experienced severe and frequent lung infections.
At the time of completion of data collection 3 patients were deceased, which represents a mortality rate of 10%. The survival rate was 96% at 5 years from onset of disease and 90% at 10 years. The median of survival from onset of disease was 8 years. The median DD in deceased patients was 5 years. The median AO was 16 years. Immunophenotype was not performed in any of the deceased patients. All deceased patients were female. 2 of the deceased patients were from urban area and one patient was from rural area. The association of lower survival with female gender and urban area, respectively, was not significant (psex=0.53; parea=1). All deceased patients had noninfectious complications of CVID. Table 14 represents the cases of death. By the end of data collection, 3 patients were lost to followup; it is unknown whether they died, but based on previous clinical course of disease there is no suspicion of death because of a CVIDrelated cause.
|Cause of death||AO||Sv||Other relevant disease manifestations|
|1.||Secondary pulmonary tuberculosis||10||8||bronchiectsis, lung abscesses, splenomegaly|
|2.||Metastatic colorectal carcinoma||16||8||remitted Hodgkin's lymphoma|
|3.||Angioimmunoblastic T-cell lymphoma||57||2||-|
Table 14: Deceased patients.
The studies carried out previously on cohorts of CVID patients have shown variability of clinical and immunological features among patients and prevalence differences of these features between diagnostic centers/ countries. Correlations that were statistically significant in some studies could not be reproduced in other studies, and this fact questions the previously proposed causative associations [7,9]. Consequently, knowledge of the features of some cohorts of CVID patients is of limited use for the medical management of another group of patients. In turn, an ethnically new group of patients requires characterization. This may improve the knowledge about the possible manifestations of CVID and their determinism, which primarily benefits the patients from that ethnic group. This is the first study that characterizes and analyses a group of Romanian CVID patients.
In the first part of this study demographic, immunological and clinical features of the participant patients were determined. In the second part of the study we searched for correlations between these features.
The prevalence for Cluj county and Cluj Napoca, respectively, fitted into the European prevalence range (1:10000- 1:50000) . We decided to determine the prevalence for these territories because there are patients in our database that come from geographical regions that are officially attended by other centres of Immunoglobulin substitution treatment (București, Iași, Zalău, Baia Mare, Deva, Târgu Jiu). Prevalence was higher in Cluj Napoca compared to Cluj county, which is consistent with the higher number of diagnosed patients from urban compared to rural areas. In turn, DD did not differ between the urban and rural areas. In the main previous studies there are no data on the distribution by area of origin, thus no comparison with other cohorts could be made [7,9,12]. These determinations were performed to identify a possible lower rate of diagnosing in rural areas and small towns, given that this disease is little known. The differences found could be confirmed/ ruled out by a study at national level.
There were more female than male patients and the AD was higher in women than in men. The hypothesis of a milder course of disease in women was discordant with the AO and the DD being similar in the two genders. We subsequently checked for differences in disease progression between the genders.
The majority of participant patients (94%) had been diagnosed using the ESID/PAGID-1999 diagnostic criteria, which are considered less strict than the 2015 Revised ESID Criteria . In the two patients not fulfilling the present criteria the need to maintain this diagnosis and to continue treatment with IVIG is debatable. All available cohort studies were published until 2014 and thus contain no references to patients in this situation. Our patients in particular, who interrupted IVIG substitution, may be reassessed by the 2015 Revised ESID Criteria. In patients on IVIG substitution, the immune defect can only be proven if they have a low number of class-switched memory B-cells .
The major drawback at the OFGI in assessing patients suspected of CVID is the fact that specific antibody response (to vaccines and/ or isohaemagglutinins) is not being measured. This is a compulsory criterion in diagnosing an antibody deficiency . Omission of this standard at the OFGI is due to administrative reasons, yet this approach renders the diagnosis of CVID inaccurate. The diagnosis of CVID in these patients is maintained because they all have clinical criteria for antibody deficiency (frequent and severe infections with typical microorganisms, against which immune defense is mainly by antibody production); have low levels of at least 2 classes of immunoglobulins; and cellular immunodeficiency and secondary causes for antibody deficiency were not found. Testing for specific antibody responses needs to be included in the diagnostic algorithm used at the OFGI; in the new sets of diagnostic criteria [1,3] these tests are listed as alternative to counting class-switched memory B-cells (at least one of the two must have abnormal values within the same subset of criteria), so that for highest sensitivity of the diagnostic algorithm, both tests need to be performed.
One particular feature of the patients in this cohort is the absence of cases with high serum IgM at diagnosis. This fact delineates CVID from hyper-IgM syndromes and may represent a positive prognostic factor.[5,7]
Absence of immunophenotype determinations in the majority of participant patients raises two important problems: (1) immunophenotype exclusion of concomitant cellular immunodeficiency is lacking, this being established on clinical criteria only; (2) the class-switched memory B-cell status of the patients is unknown. These are both diagnostic criteria in the 2015 Revised ESID Criteria .
Patient history regarding infections was divided in: all disease duration, before treatment, under treatment. Both globally (the categories: ‘all infections’ and ‘severe infections’) and for each infection location the following patterns were observed: improvement/ stationary frequency and severity/ worsening. This fact suggests that only some infections respond favorably to immunoglobulin substitution. The present study indicates that IVIG treatment is effective for prevention of lower RTI and acute diarrhea. These are the most frequent type of infections in CVID patients [2,12], which is consistent with the global decrease of infection prevalence after treatment initiation. In turn, IVIG treatment was ineffective in decreasing the prevalence of otitis media, lower UTI (stationary prevalence) and sinusitis (increasing prevalence). A longitudinal cohort study  obtained both consistent (decrease in prevalence of all infections and pneumonia; increase in prevalence of sinusitis; stationary prevalence of UTI) and inconsistent (increase in prevalence of acute bronchitis and decrease in prevalence of otitis media) results with the present study. The prevalence of digestive infections is designated by the term ‘chronic diarrhea’ in the aforementioned study and by ‘acute diarrhea’ and ‘digestive parasitic infections’ in our study. Given that these terms are not overlapping, the two results were not compared. We believe that the two terms chosen for the present study ensure a better delineation between the cases of infectious and noninfectious diarrhea, respectively, which is necessary for the accuracy of a retrospective study. No risk factors have been identified that could explain the high and stationary prevalence of UTI under treatment in patients in this cohort. The number of patients with otitis media in this group was low (4 patients); this decreases the significance of this result. The aforementioned study explains its results by the fact that immunoglobulin preparations predominantly replace IgG and only to an insignificant degree IgA and IgM. IgG protect against acute and invasive infections (pneumonia, acute bronchitis, otitis media, acute diarrhea, septicemia, meningitis), whereas IgA and IgM- the major secretory immunoglobulins on the mucosae- protect against chronic mucosal infections (chronic rhinosinusitis, chronic bronchitis, chronic diarrhea). Based on these remarks it has been suggested that immunoglobulin substitution may be unjustified in patients having exclusively CVID manifestations of which it is known that they usually do not respond to this treatment (e.g. chronic rhinosinusitis, other noninfectious complications than autoimmune diseases). This way, for instance, for chronic rhinosinusitis it has been proposed that IVIG treatment only be initiated if antibiotic prophylaxis is ineffective. Nevertheless, it is currently recommended to adjust the IVIG doses so as to concomittantly:
1) Maintain through IgG levels at least near the middle of the normal range and
2) reduce the incidence of significant infections . Indeed, recent studies have shown that high doses of immunoglobulins provide a significantly better control of significant infections, including those with lower responsiveness to substitution therapy (e.g. chronic rhinosinusitis).[19,20]
Oligoarthritis with negative bacterial cultures corresponds to the description of oligoarthritis due to Mycoplasma spp, which is considered a typical infection in hypogammaglobulinemias. In the management of patients with CVID it is important to know that both bacterial culture and serological determinations are useless in diagnosing this infection (antibody response is usually inadequate and altered by the substitution immunoglobulins). The diagnostic method of choice is the multipathogen PCR analysis in synovial fluid . The high prevalence of infections with Mycobacteruim tuberculosis and Candida albicans compared to other cohorts  is explicable by the high prevalence of tuberculosis in Romania  and by the presence of many additional risk factors (immunosuppression caused by lymphoma/ glucocorticoid treatment, chronic pulmonary disease).
The bacteria causing infections in our cohort are predominantly those previously reported [2,5,10]. Sporadic opportunistic infections were found both in patients undergoing chemotherapy and in patients with no other identifiable risk factors. Bacterial and/ or fungal colonization of the lower respiratory tract was found in patient with and without chronic pulmonary disease. Previous studies did not investigate the rate and type or colonization of the lower respiratory tract, thus no comparison with the pattern of colonization in other CVID cohorts could be made and the cause of colonization in patients without chronic pulmonary disease remains unknown. As previously mentioned, IgA and IgM deficit decreases the microorganism neutralization capacity at mucosal level. The statistically significant association between severe infections and bronchiectasis found by Chapel et al.  could not be reproduced in either a larger cohort  or the present study. Colonization is possibly an inflammatory trigger even in the absence of acute infections and a precursory phenomenon, with causal role, in the appearance of bronchiectasis and other chronic pulmonary diseases found in CVID. A longitudinal study is needed for testing this hypothesis.
All the previously reported categories of noninfectious CVID complications [2,9,10] were found in the present group of patients. We found prevalence above 20% for: tumors of any type, lymphoma, autoimmune diseases, chronic pulmonary disease of any type and bronchiectasis; prevalence between 10-20% for: BLP, chronic digestive disease of any type, splenomegaly and hepatomegaly; and prevalence under 10% for: enteropathy, fibrosing ILD and LIP. These results are consistent with those obtained for the general European cohort with the exception of a higher prevalence of tumors (34% vs 8%) and a lower prevalence of granulomatous disease (3% vs 9%) in the present study . We found no correlation between the patient and family history of cancer that would explain the additional risk for neoplasia. We found no predominance of any of the noninfectious CVID complications in any of the genders.
A single case of autoimmune cytopenia was confirmed, although cytopenias are considered the most frequent autoimmune diseases within CVID [2,10]. We found frequent association of antiphospholipid syndrome with systemic autoimmune diseases (80% of cases) and concomitant family history of autoimmune disease in some patients with autoimmune diseases, but none of these was statistically significant. The category ‘inflammatory diseases’ had not been used in the reference studies about CVID. It is uncertain whether inflammatory diseases found in patients in this cohort make an homogenous and well-delineated group and whether their appearance is linked to CVID. They are being mentioned because there were 3 affected patients (approximately 10%) and because in 2 of these the inflammatory disease led to investigating the patient immune status and the diagnosing CVID. In the case where inflammatory diseases appeared concomitantly with colorectal cancer it is possible that these are paraneoplastic manifestations.
BLP was located in lymph nodes, spleen, liver, lungs and/or bowel. Intestinal lymphocytic infiltration was not included in this category for the statistic determinations. This choice is justified by the lack of a statistically significant association between the lymphocytic infiltration of other organs and that of the intestine in patients in this cohort. The histological diagnosis of atypical lymphoid hyperplasia in both patients in which a biopsy was performed is most likely a selection error, given that biopsy was only indicated to patients in which lymphoma was suspected. A succession from BLP to NHL was not found in any patient, but it must be said that in 4 (66%) of the patients with NHL this was the first diagnosed manifestation of CVID.
The most numerous group of malignant tumors was the B-cell NHL, in consistency with previous studies. Conversely, no case of gastric carcinoma was found, this being the second most frequent malignant tumor in CVID patients .
Interestingly, we found significant correlation of ILD, but not of the subgroup fibrosing ILD, with bronchiectasis. These associations have not been tested by previous studies [7,12] and the small size of this cohort makes the interpretation of this results difficult. Testing for these correlations on a larger cohort and prospectively would aid in explaining the progression of chronic lung disease in CVID patients. The radiological aspect of sarcoidosis in a patient with CVID is suggestive for granulomatous lymphocytic interstitial lung disease (the most common cause of ILD in CVID . Although in this patient this diagnosis was not confirmed by transbronchial lung biopsy , there are suggestions that open lung biopsy is the diagnostic method of choice [22,23]. All patients with hepatomegaly had infiltration of lymphoid organs (lymph nodes, spleen) on imaging studies and it was assumed hepatomegaly is caused by benign lymphoproliferation. While hepatomegaly did not progress in these patients, admittedly the follow-up period was short (up to 5.5 years) and in the absence of liver biopsy, concomitant presence of liver nodular regenerative hyperplasia (the main liver disease in CVID  could not be ruled out.
We tested for correlations between the clinical manifestations of CVID. Combinations of manifestations were selected based on frequent coexistence or on the known possibility of a pathogenic link between them. We found correlations between lymphadenopathies, splenomegaly and hepatomegaly, which supports their inclusion in the common clinical phenotype ‘BLP’, concordantly with previous proposal . Additionally, we found a correlation between bronchiectasis and splenomegaly, this result being discordant with that from the general European cohort . No pathogenic explanation was found for this association. Proving specific correlations between the clinical manifestations of CVID allow delineation of independent clinical phenotypes. The most important consequence of confirming these phenotypes is the possibility to identify the patients at risk of developing certain disease manifestations based on those already present. Consequently, these patients can be monitored for the appearance of the manifestations specific to their phenotype.
The average maintenance dose of IVIG used in these patients was in accordance with current recommendations [21,25]. 25% of patients interrupted treatment for medical or nonmedical reasons. This fact may negatively influence the prognosis of these patients, given that since introduction of substitution therapy in CVID patients the frequency of infections has decreased, quality of life has improved and patient survival has increased by almost 40 years . Especially in patients not undergoing substitution therapy prompt and correct antibiotic treatment is necessary in order to prevent the appearance of certain chronic diseases or their progression (esp. bronchiectasis) [6,21]. Worsening of infection status under substitution therapy in some patients is an indicator of insufficient immunoglobulin substitution. Increase of IVIG doses in spite of adequate IgG trough levels would benefit patients with persistent infections [18,19].
A case of progression of selective IgA deficit to CVID and two cases of familial aggregation of antibody deficiencies were identified in this cohort. For familial cases of antibody deficiency genetic diagnosis is recommended.
Almost 50% of patients had allergies. The high rate of diagnosing is probably partly due to the fact that physicians monitoring and treating CVID at our center are also allergologists. Local glucocorticoid treatment for allergies may decrease the defense capacity at mucosal level, thus increasing the risk for infections.
The low number of deceased patients is consistent with the short follow-up time since diagnosis. In turn, this did not allow for a statistical analysis of potential mortality risk factors and for a relevant comparison with the groups of deceased patients from other studies. The cases of death found confirm the fact that malignant tumors are a frequent cause of death in CVID patients  and stresses the high susceptibility for a severe infection uncharacteristic of CVID (tuberculosis) in a patient debilitated by the severe course in a typical CVID manifestation (bronchiectasis).
The main limits of this study are the low number of patients included, the retrospective format and the unavailability of specific antibody response measurements. The first issue could not be corrected, as in the study were included all patients form the IDR of the OFGI who fulfilled the inclusion criteria. The retrospective study format had several disadvantages. In some patients we could not reconstruct the time succession of the various disease manifestations/ of these in relation to possible confounding factors. Investigations relevant for the study (specific antibody response testings, immunophenotypings, biopsies, bacterial cultures, etc) had not been performed previously or their results could not be obtained. There are approximate data for: AO, number of infections, time of onset of a disease, adverse effects to IVIG treatment and there are missing data. Only adult patients were included in the study and this did not allow for an adequate description of the age distribution of disease manifestations. The low statistical significance threshold is justified by the small size of the patient group, but this could be the cause of some differences (distribution and AD in the two genders) and correlations (bronchiectasis- splenomegaly, bronchiectasis- ILD) that could not be explained subsequently.
The results obtained in this study allow conclusions to be drawn on the possible ways of clinical progression of CVID and demographic, clinical, immunological and therapeutic factors that may influence the progression of this disease.
• Gender distribution showed that most patients (72%) diagnosed with CVID were women. The age at diagnosis was higher in women than in men. No other differences in disease progression between the two genders were found.
• Distribution by place of origin showed that most patients (78%) diagnosed with CVID were from urban area. There were no differences in chronological parameters (age at onset of disease, age at diagnosis, diagnostic delay, the average time of the disease evolution, survival time) between the places of origin.
• The average age at onset of disease was 25 years. The average age at diagnosis was 48 years. The average diagnosis delay was 6 years. The diagnostic delay was < 5 years at 50% of the patients and > 15 years at 35% of the patients. The average time of the disease evolution was 10 years.
• At diagnosis 61% of patients had low levels of IgA and IgM, 21% only of IgA, 18% only of IgM. 31 of the patients had very low IgG levels (<150 mg/dL) at diagnosis. There were no patients with high IgM levels.
• The clinical onset of the disease was by: infections in 59% of patients, non-Hodgkin’s lymphoma in 13%, autoimmune disease in 9%, inflammatory disease in 6% and uncertain in 13%.
• All patients had infections. 66% of patients had severe infections. The most prevalent infections were: upper (41%) and lower (63%) respiratory tract infections, lower urinary tract infections (44%), digestive infections, sinusitis, otitis media, skin and soft tissue infections, specific viral infections.
• After initiation of IVIG treatment: prevalence of infections of any type (by 7%), severe infections (by 36%), upper respiratory tract infections and acute diarrhea decreased; prevalence of sinusitis increased; infection status improved in 43% of patients and worsened in 14%.
• 81% of patients had non-infectious manifestations of CVID. In the order of frequency, the non-infectious diseases were: neoplasia (predominantly non-Hodgkin’s lymphomas), autoimmune diseases (predominantly systemic and solid organs), bronchiectasis, splenomegaly, benign lymphoproliferation, chronic digestive diseases (predominantly enteropathy), hepatomegaly, interstitial lung disease, iron deficiency anemia, specific inflammatory diseases, lymphoid interstitial pneumonitis.
• Statistically significant correlations were found between the following disease manifestations: benign lymphoproliferation / lymphadenopathy - splenomegaly - hepatomegaly, bronchiectasis and splenomegaly, interstitial lung disease and bronchiectasis, low IgG levels at diagnosis and severe infections.
• 75% of patients had only one clinical phenotype of the disease.
• Besides IVIG treatment patient management consisted mainly of: monitoring, medication (mainly antibiotic, immunosuppressive and chemotherapeutic) and surgery.
• Disease manifestations did not correlate with family history and patient comorbidities, respectively.
• The cases of death had infectious and non-infectious causes. The average survival time since disease onset in deceased patients was 8 years. All deceased patients were female.
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text:
From Fathoms to Gather, meet the kings of Cape Coral's waterfront restaurants
With their new Gather, the Hoffmans and Voisins now own three unique waterfront restaurants in Cape Coral, a city they say is getting cooler everyday.
Correction: Gather is open 7 a.m.-10 p.m. Tuesday to Thursday and Sunday, and 7 a.m.-midnight Friday and Saturday. It's closed Monday. A previous version of this story misstated its hours.
Those watching the culinary ascent of Cape Coral, take note: The Cape has gotten even cooler.
In October, the people who brought Fathoms to Cape Harbour opened their sleek new eatery, Gather, in Tarpon Point Marina. Husband-and-wife couples and business partners, Meredith and Tim Hoffman along with Val Zanella-Voisin and Ben Voisin, have assembled their team of chefs and managers, plus designer friend Jonathan Unger, to transform the space that was formerly Melograno.
Now the restaurant is done in blue tones with bright pops of orange, and the menu — serving breakfast, lunch and dinner six days a week — features unexpected twists on international and American favorites.
The Hoffmans met the Voisins six years ago in Saint Kitts and Nevis, where the Hoffmans owned a boutique hotel. They hired Ben Voisin, who is French, to be the hotel’s executive chef.
“We still laugh about his interview,” Tim Hoffman says. “I couldn't understand a word he said, and I guess he couldn't understand a word I said either. So it was a good fit.”
The Hoffmans are American, and when they decided to move back to the United States to give their three school-age children better educations, they chose Cape Coral.
“I spent a lot of time in Florida,” Tim Hoffman says.
“I went to school in Miami, but we like the quietness of the west coast of Florida and the small town feeling of Cape Coral. It reminds me in many aspects of the islands. The way the community works together, it’s like island life.”
The Hoffmans searched for a small restaurant in Cape Coral to buy and discovered the space formerly known as The Joint in Cape Harbour. But it wasn’t the small restaurant they had in mind.
“It was a monster for two people to manage,” Val Voisin says. “So, they came back to the islands and asked us, ‘What about going in with the four of us?’ For Benjamin and I it was like another adventure, so we said yes.”
The Voisins visited Cape Coral and fell in love with the area, so they followed the Hoffmanns. In 2014 the two couples turned The Joint into Fathoms, and they started The French Press — a coffee, ice cream and sandwich shop — next door. In 2015 they founded a catering company, Black Salt, and they soon began talking about launching a new restaurant.
But none of the spaces they considered felt like the right fit.
“For us location is very, very important,” Val says. “Cape Coral is such a unique place with so much water, but unfortunately there aren't many spaces that are waterfront. We love to go to places that have a view, that can offer outdoor seating. We feel that people come to Florida to enjoy the outdoors.”
On Mother’s Day, the Hoffmans and the Voisins were having brunch at the Nauti Mermaid in Tarpon Point when they saw a sign taped to the door of the Italian restaurant Melograno saying that the space was scheduled to be vacated. They immediately called the property manager for Tarpon Point’s retail properties and asked to take a look. The space was perfect, they decided. The following week they signed a lease.
Gather opened at the beginning of October and serves breakfast, lunch and dinner stating at 7 a.m. every day except Monday, when it is closed. On Friday and Saturday nights, the kitchen is open late, and there is a D.J. on Fridays and a live musician on Saturdays.
Many of the restaurant’s patrons come from The Westin hotel next door or the condominiums in Tarpon Point, though many diners also make the drive from other parts of Cape Coral and Fort Myers. Though Tarpon Point is a gated community, visitors can pass through the gate freely on their way to the shops and restaurants.
“The Cape is a fantastic place in terms of growing and developing,” Tim Hoffman says.
“It’s definitely making a mark in terms of putting the Cape on the map for people looking for good food and drink. Three years ago people said, ‘You can’t do that in the Cape. The Cape’s not ready for that.’ Now we hardly get that any more.
"We put items on our menus that people swore up and down nobody would order. There’s a younger group of people coming and living here who want to go out and discover. It’s not the same Cape that it was even ten years ago.”
Though the partners could have launched Gather in Fort Myers, both couples wanted to keep their business in Cape Coral.
“We live on the Cape, and we love the cape,” Val Zanella-Voisin says.
“We feel that the Cape has so much room to grow. Even when we arrived here three and a half years ago, as a young couple, we were always looking for places to go out. Now we can’t decide where to go. There are so many places, so many cool spaces.
"You see Nice Guys, you see Point 57 — what an amazing restaurant — Shannon (Yates) and all his places. The Cape is growing, and there is still more room for adventure. We want people visiting from outside to go back home saying the Cape is cool.”
Artis Henderson is a freelance writer and author of ‘Unremarried Widow,’ a New York Times Editors’ Choice; find her at artishenderson.com and on Twitter.
If you go
Gather: 5971 Silver King Blvd., Cape Coral; 542-0123; facebook.com/gathercape
Fathoms: 5785 Cape Harbour Drive, Cape Coral; 542-0123; fathomsrestaurant.com
The French Press: 5789 Cape Harbour Drive, Cape Coral; 542-0212; thefrenchpressfl.com

domain: travel


Ireland cannot be bullied by the Conservative Party and its political allies
As the reckless and bullish behaviour of the British government continues, Labour leader Ivana Bacik said everything must be done to ensure no hard border on the island of Ireland. Bacik said the attempt to override the Northern Ireland protocol amounts to a breach of international law and will undermine the hard-won peace in Northern Ireland.
Deputy Bacik said:
“The reckless and dangerous approach of the British government to the sensitive issue of the Northern Ireland protocol must be condemned and challenged. Ireland cannot stand by and be bullied by a reckless British government and a Prime Minister who is acting as unpredictably as Donald Trump.
“At a time when compromise and trust are needed, the Tories have instead opted to ratchet up tensions by pursuing unilateral and unlawful actions, intending to ignore international obligations, choosing to risk the hard won peace on our island. We cannot stand by while it acts like a rogue state.
“The current path pursued by the British government will cause economic uncertainty; it will hinder the potential for growth in Northern Ireland; and it risks setting the peace-process back by years.
“As Tony Connelly of RTÉ put it, Prime Minister Boris Johnson has courted the hard-line European Research Group (ERG) to try to cling to his position following a worse-than-expected confidence motion result last week, while one of his key challengers, the Foreign Secretary Liz Truss, is doing precisely the same thing to take Johnson’s place should he be ousted during the summer. This is no way to do business.
“Despite this damaging and dangerous approach, it is not too late to find a political solution that protects peace on our island. It is not too late for a return to constructive talks with the EU. It can be successful, if solutions are sought on the basis of trust and honesty, as they should be.
“I am urging the government to remind Prime Minister Johnson and his colleagues of the importance to find solutions to the situation we now find ourselves in. We cannot stand idly by. The approach of the British government needs to be treated as the political dynamite that such an approach has the potential to be. To proceed with this reckless and dangerous legislation is unconscionable.
“The British government cannot seek a la carte legal advice as to the consequences of this unilateral move. We must not be bullied by the Conservative Party and its political allies. Our Government cannot allow any risk of a hard border on the island of Ireland.”


Horror Express (1972)
Peter Cushing and Christopher Lee made a remarkable 22 films together over the course of four decades – the first being one where they never even appeared in the same scene, as the pair actually appeared in Laurence Olivier’s Hamlet in 1948. More often than not they were antagonists, pitted against one another in a series of Dracula films from Hammer Studios and as Victor Frankenstein and his Monster. It’s a pleasure to come across a film where the two friends share the screen and are (mostly) friendly with one another.
Horror Express is not a Hammer film, but it certainly looks and sounds like one. The film features Lee as Sir Alexander Saxton, an archaeologist and scientist who discovers a “missing link” in a cave in Manchuria. Returning to England with the specimen via the Trans-Siberian Express, Saxton hopes to change the face of science with his mummified creature. They’re joined Saxton’s friendly rival Dr. Wells (Cushing), his assistant Miss Jones (Alice Reinhea), and a whole gang of suspicious characters that include a Polish Countess and her husband, a lovely stowaway, and a mad monk. Also on board is Inspector Mirov (Jose Pena), a police officer following Saxton around after the sudden and inexplicable death of a thief in close proximity to Saxton’s mummy. As soon as the train starts moving, people start dying. It rapidly becomes clear that the thing Saxton has in that case is not quite as dead as it appears, and is capable of murdering with one glance of its shimmering red eyes.
Horror Express is something like The Mummy meets Murder on the Orient Express with a healthy overtone of Italian giallo. The influence of the latter becomes obvious during the murder sequences, a bit more violent and disturbingly realistic than your usual horror fare of the time period. The violence is not overdone, however, and the film relies more cleanly on the slow realization of who, and what, is doing the killing. An abrupt shift halfway through the film makes for some excellent tension, while Saxton and Wells join forces to stop the creature and protect as many people as they can.
Cushing and Lee are enjoying themselves here, as perhaps the only English speakers in a Spanish/British horror film with a primarily Spanish cast. They begin initially as rivals and quickly become buddies, facing the monstrous horror with two very stiff upper lips. The pair are always fun to watch together; their chemistry tends to leap off the screen, even when the surrounding events might make lesser actors into hams. The rest of the cast is quite impressive on the whole, with no one standing out as a poor performer among the rest. You have to be willing to enter into the madhouse spirit of a film like this to get any enjoyment out of it, but at least the cast seem game, taking their parts seriously without overacting.
There’s really not much to complain about with Horror Express, so long as you accept the initial and rather silly premise. The denouement does feel rushed, however, and raises a number of questions of plotting that are never satisfactorily answered. The sudden introduction of Telly Savalas as a Cossack commander is jarring, not least because Savalas does not even attempt to sound like a Cossack. The final showdown comes off as perfunctory, especially after some strong tension building over the rest of the film.
I would not put Horror Express forward as the best film Cushing and Lee made together, but it is very far from the worst. It’s a solid, enjoyable hour and a half spent in the company of one nasty monster, and two of the finest horror actors to ever haunt the screen. As we mourn Lee’s passing, we can find a bright spot in the idea that he’s still stalking monsters with Cushing, on the screen and, perhaps, elsewhere as well.


We sat down with our CEO Chris Ruff to get his perspective on changes in the restaurant and food ordering industry. In speaking with the world’s largest restaurant and pizza brands across the country each day, he’s picked up some critical insight to help answer our number one question:
How can restaurants retain customers despite aggressive competition in the food delivery space?
“It’s really all about the empowered consumer,” says Chris, “And them being in charge of how and why they want to purchase things.”
According to Chris, giving customers the tools to engage with your restaurant digitally and making their orders available on-demand are how you do just that. Specifically, designing a smart in-store or curbside pickup process that makes ordering online and then collecting that takeout seamless is where restaurants need to focus.
In his recent Fortune article, John Kell reports, “The percentage of orders booked online or using a smartphone or tablet app—now 6.6% of the total—exceeded the quantity placed verbally over the telephone (5%).”
The impact, according to Kell, is that “digital transformation is bringing a host of challenges—and many are resolutely non-digital. They range from the need to rethink the design of some restaurants and kitchens to creating containers that will keep more types of food crisp and fresh while they’re being transported, since orders placed via app are often delivered to homes and offices.”
Restaurant Insider’s Mitchell Hall also comments on the in-store implications of the digital ordering trend. He writes, “With today’s consumers spending ever more time on their smartphones, online ordering makes take-out simpler and more convenient. Restaurants with online ordering are catering to a generation of consumers that are not used to waiting.“
That’s exactly the point that hits home for Glympse, and which Chris speaks to in our complete video interview with him. The growth of digital ordering is naturally going to prompt new expectations for carry out, and restaurants are going to need to think more like their impatient, on-the-go customer base and less like a traditional restaurant operation in order to stay relevant.
Watch the entire video interview with Glympse CEO Chris Ruff on Vimeo or below:
If you like the video, don’t forget to download our how-to guide, 4 Steps to Survive the Fast Casual Digital Ordering & Delivery Revolution.


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April 6, 2018
Walmart will be the official retail destination of Nickelodeon's upcoming movie, The SpongeBob Movie: Sponge Out Of Water, which opens in theaters Feb. 6.
The retailer will feature a host of SpongeBob movie products including toys, t-shirts, health products such as Band-Aids and even branded produce like pineapples.
From now through Feb. 28, Nickelodeon is also working with Walmart on an omni-channel marketing program for the film.
Nickelodeon will convert traffic across the store and drive product purchases with an interactive mobile experience, buoyed by marketing support across social media and digital channels.
Shoppers can use the "Blippar" app to scan key SpongeBob products and in-store signs to unlock an exclusive SpongeBob fan experience at Walmart stores. By filling their screens with images of SpongeBob movie products, fans can then access exclusive content and offers such as the movie trailer, pre-order the DVD set to get a free SpongeBob movie ticket and play SpongeBob-themed games.
As part of the mobile activation, shoppers can also scan products to generate special SpongeBob e-cards and to access a video game trailer and SpongeBob selfie photo booth app.
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Suburban homebuilder David Weekley Homes is joining the pack of developers working in the area around the soon-to-be-redeveloped Lone Star Brewery.
The Houston-based company plans to build 11 detached single-family homes on a 0.6-acre lot it purchased in late February at the corner of Clay and Probandt streets, a few hundred feet from the San Antonio River and a quarter-mile from the future site of the $300 million Lone Star mixed-use development, Gary Runner, the company’s division president in San Antonio, said in an email.
“We’ve been watching the Southtown market for some time and believe it’s one of the up-and-coming urban locations in San Antonio, offering proximity to the Blue Star Arts Complex, redevelopment of the Big Tex grain complex, potential Lone Star Brewery redevelopment and more,” Runner said.
The project is expected to break ground next month, with construction taking between a year and 18 months, he said.
Houston-based David Weekley has been building homes in San Antonio’s suburbs for more than 20 years, and it recently began to also develop homes in the urban core. It is currently building two projects in Tobin Hill and one in Mahncke Park.
Developers have been devoting more attention to the area around the southern stretch of the San Antonio River since the county completed the Mission Reach section of the River Walk a few years ago. The upcoming redevelopment of the Lone Star Brewery has also jump-started growth in the area.
Last year, the upscale Flats at Big Tex apartment complex opened just north of Lone Star, about a block from where David Weekley plans to build.
David Weekley bought the property from Bohls Bearings and Equipment, said Todd Ellis, the company’s vice president. It’s keeping the adjacent property, the site of its headquarters.
The purchase price was undisclosed, but a landholder used by David Weekley borrowed $885,000 to buy the land, records show.


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'Footloose': Remake stays in step with original
This new version of the 1984 film, "Footloose," directed by Craig Brewer this time around — and starring Kenny Wormald, Julianne Hough, Andie MacDowell and Dennis Quaid — is pretty much the same movie all over again, though Hough's dancing is a pleasure. The film is playing at several theaters in Seattle.
Seattle Times movie critic
'Footloose" with Kenny Wormald, Julianne Hough, Andie MacDowell, Dennis Quaid. Directed by Craig Brewer, from a screenplay by Brewer and Dean Pitchford. 113 minutes. Rated PG-13 for some teen drug and alcohol use, sexual content, violence and language. Several theaters.
If you liked the 1984 "Footloose," with a dewy Kevin Bacon as a dancing rebel and Lori Singer as a not-so-innocent minister's daughter, you'll probably like the 2011 "Footloose" — it's pretty much the same movie, minus some of the more egregious '80s fashions.
Directed this time around by Craig Brewer ("Hustle & Flow," "Black Snake Moan") and choreographed rather snappily by Jamal Sims, this remake meticulously follows the footsteps of its predecessor. Ren MacCormack (newcomer Kenny Wormald, a marvelous dancer but a bit long in the tooth to play a teen) arrives from Boston to the small town of Bomont, his leather jacket shiny, his collar precisely flipped and his gaze coolly distant. He soon catches the eye of Ariel (Julianne Hough, formerly of "Dancing with the Stars"), daughter of Reverend Shaw (Dennis Quaid) — who, in response to a terrible accident that killed his son and several other teens, has banned teenage parties, drinking and dancing in the town. Will Ren lure Ariel away from her nasty boyfriend Chuck (Patrick John Flueger), kick off his Sunday shoes and make Bomont safe for line-dancing once more? Oh, you already know he will.
Fans of Hough will enjoy her dancing here — she's perpetually skipping and wriggling, as if her spirited Ariel just can't hold herself still — both solo and paired with the talented Wormald, whose "angry dance" (alone in a warehouse, accessorized with chains, as all rebellious teen boys do) is wonderfully acrobatic. Miles Teller ("Rabbit Hole") steals scenes as Ren's new best friend Willard, who endearingly learns how to dance. But there's not much here that you won't find in the original, which also offers such pleasures as the very young Sarah Jessica Parker in a small role, and an exhaustive survey of early-'80s footwear over the opening credits.
Despite its frequent goofy charm, there's no compelling reason for the new "Footloose" to exist. Both homage and imitation, it's agreeable to watch but instantly forgotten.
Moira Macdonald: 206-464-2725 or email@example.com
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