Activated phosphoinositide 3-kinase δ syndrome associated with nephromegaly, growth hormone deficiency, bronchiectasis: a case report

Abstract

Background: Activated phosphoinositide 3-kinase (PI3K) δ syndrome (APDS) is a rare form of primary immunodeficiency with 243 known cases reported in the literature. Known findings associated with the condition include recurrent sinusitis and bronchitis, bronchiectasis, immune cytopenias, mild developmental delay, splenomegaly, and lymphadenopathy. We report the case of a child with APDS accompanied by unique clinical features: nephromegaly and growth hormone deficiency with associated pituitary anatomic abnormality.

Case presentation: The patient is a nine-year-old boy with a heterozygous de novo variant in phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit δ (p.E1021K), previously reported in association with APDS. Our patient, who had no family history of immunodeficiency, exhibits classic findings of this syndrome but also has unique features that extend the phenotypic spectrum of this disorder. At 5 years of age, the patient showed marked growth deceleration and was demonstrated to have growth hormone (GH) deficiency with associated pituitary anatomic abnormality. He started GH therapy with an excellent response. He additionally has bilateral nephromegaly of unclear etiology, microscopic hematuria and proteinuria, asthma, and has developed left hip pain with arthrocentesis consistent with oligoarticular juvenile idiopathic arthritis. At age nine, the patient was referred to genetics and whole exome sequencing revealed APDS. Though there was initial concern that GH may increase risk for malignancy as GH signals through the PI3K pathway, he was allowed to continue treatment as the PI3K pathway was considered constitutively active at baseline.

Conclusions: Our patient's unique presentation adds to the clinical information regarding APDS, demonstrates the utility of genetic testing and illustrates the importance of a multidisciplinary collaborative approach in managing this complex syndrome.

Keywords: Asthma; Bronchiectasis; Growth hormone deficiency; Nephromegaly; Pituitary abnormality; Primary immunodeficiency.

Fig. 1

Pituitary magnetic resonance imaging. Sagittal T1 weighted images performed on a 1.5T magnet (GE Healthcare, Chicago, USA). a Pre-contrast T1 weighted images demonstrate nonvisualized/absent neurohypophysis (arrowhead) and abnormal thinning and hypoplasia of the mid to distal infundibular stalk (arrow). b Post-contrast T1 weighted images with fat suppression reveal no pituitary mass

Fig. 2

Length-for-age growth chart. Growth hormone therapy was initiated at 5 years 8 months of age (arrowhead)

Fig. 3

Pre- and post-bronchodilator flow-volume loop