Clinical, Immunological, and Molecular Findings in Five Patients with Major Histocompatibility Complex Class II Deficiency from India

Abstract

Major histocompatibility complex (MHC) class II deficiency is a rare autosomal recessive form of primary immunodeficiency disorder (PID) characterized by the deficiency of MHC class II molecules. This deficiency affects the cellular and humoral immune response by impairing the development of CD4⁺ T helper (Th) cells and Th cell-dependent antibody production by B cells. Affected children typically present with severe respiratory and gastrointestinal tract infections. Hematopoietic stem cell transplantation (HSCT) is the only curative therapy available for treating these patients. This is the first report from India wherein we describe the clinical, immunological, and molecular findings in five patients with MHC class II deficiency. Our patients presented with recurrent lower respiratory tract infection as the most common clinical presentation within their first year of life and had a complete absence of human leukocyte antigen-antigen D-related (HLA-DR) expression on B cells and monocytes. Molecular characterization revealed novel mutations in RFAXP, RFX5, and CIITA genes. Despite genetic heterogeneity, these patients were clinically indistinguishable. Two patients underwent HSCT but had a poor survival outcome. Detectable level of T cell receptor excision circles (TRECs) were measured in our patients, highlighting that this form of PID may be missed by TREC-based newborn screening program for severe combined immunodeficiency.

Keywords: T cell receptor excision circles; flow cytometry; hematopoietic stem cell transplantation; next-generation sequencing; primary immunodeficiency disorder.

Figure 1

Representative flow cytometric plots showing gating of (A) SSC/CD3⁺ T cells, (B) SSC/CD19⁺ B cells, and (C) SSC/CD14⁺ monocytes using FlowJo software. Dot plot analysis of human leukocyte antigen-antigen D related (HLA-DR) on immune cells showed normal HLA-DR expression for a healthy control on (D) T (CD3⁺) cells, (E) B (CD19⁺) cells, (F) monocytes (CD14⁺), and lack of HLA-DR expression was noted for patient P1on (G) T (CD3⁺) cells, (H) B (CD19⁺) cells, and (I) monocytes (CD14⁺).

Figure 2

T cell receptor (TCR) Vβ repertoire analysis: comparison of 24 different TCR Vβ families in patient P2 and Healthy control on (A) CD4⁺ Th cells and (B) CD8⁺ Tc cells.

Figure 3

DNA sequence chromatogram showing the c.1154delT mutation in RFX5 gene in the proband (P3) in a homozygous state and parents in a heterozygous state.