National experience with adenosine deaminase deficiency related SCID in Polish children

Abstract

Introduction: Deficiency of adenosine deaminase (ADA) manifests as severe combined immunodeficiency (SCID), caused by accumulation of toxic purine degradation by-products. Untreated patients develop immune and non-immune symptoms with fatal clinical course. According to ESID and EBMT recommendations enzyme replacement therapy (ERT) should be implemented as soon as possible to stabilize the patient's general condition, normalize transaminases, treat pulmonary proteinosis, bone dysplasia, and protect from neurological damage. Hematopoietic stem cell transplantation (HSCT) from a matched related donor (MRD) is a treatment of choice. In absence of such donor, gene therapy (GT) should be considered. HSCT from a matched unrelated donor (MUD) and haploidentical hematopoietic stem cell transplantation (hHSCT) are associated with worse prognosis.

Material and methods: We retrospectively evaluated the clinical course and results of biochemical, immunological and genetic tests of 7 patients diagnosed in Poland with ADA deficiency since 2010 to 2022.

Results: All patients demonstrated lymphopenia affecting of T, B and NK cells. Diagnosis was made on the basis of ADA activity in red blood cells and/or genetic testing. Patients manifested with various non-immunological symptoms including: lung proteinosis, skeletal dysplasia, liver dysfunction, atypical hemolytic-uremic syndrome, and psychomotor development disorders. Five patients underwent successful HSCT: 3 patients from matched unrelated donor, 2 from matched sibling donor, and 1 haploidentical from a parental donor. In 4 patients HSCT was preceded by enzyme therapy (lasting from 2 to 5 months). One patient with multiple organ failure died shortly after admission, before the diagnosis was confirmed. None of the patients had undergone gene therapy.

Conclusions: It is important to diagnose ADA SCID as early as possible, before irreversible multi-organ failure occurs. In Poland HSCT are performed according to international immunological societies recommendations, while ERT and GT are less accessible. Implementation of Newborn Screening (NBS) for SCID in Poland could enable recognition of SCID, including ADA-SCID.

Keywords: ERT (enzyme replacement therapy); HSCT = hematopoietic stem cell transplant; SCID - severe combined immunodeficiency; adenosine deaminase (ADA) deficiency; lymphopenia.

Figure 1

ADA-SCID sypmtoms: (A) Chest X-ray: scapular spurring with flaring and cupping of rid ends in the patient 6. (B) atrophic changes in the CNS were found in the brain magnetic in the patient 3 (C) computed tomography of the chest as ground-glass opacities with interlobular and intralobular interstitial thickening in patient 5.

Figure 2

Local BCG disease in patient 5: (A) before enzyme replacement therapy (ERT) normal BCG vaccination scar (B) 4 weeks of ERT, at the site of the BCG injection small spot appeared and turned into a blister, treatment with two tuberculostatic drugs: isoniazid and rifampicin has started (C) & weeks of ERT, a crusty scrab formed, which healed into a small scar.

Figure 3

Enzyme replacement therapy (ERT): (A) Aminotransferases normalization in patient 5 after ERT, the arrow indicates the beginning of treatment, (B) Lymphocyte numbers in patient P2, P5, P6 and P7 after 1, 2 and 4 months ERT.