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Severe combined immunodeficiency, SCID, is a pediatric emergency that represents the most critical group of inborn errors of immunity (IEI). Affected infants present with early onset life-threatening infections due to absent or non-functional T cells. Without early diagnosis and curative treatment, most die in early infancy. As most affected infants appear healthy at birth, newborn screening (NBS) is essential to identify and treat patients before the onset of symptoms. Here, we report 47 Brazilian patients investigated between 2009 and 2020 for SCID due to either a positive family history and/or clinical impression and low TRECs. Based on clinical presentation, laboratory finding, and genetic information, 24 patients were diagnosed as typical SCID, 14 as leaky SCID, and 6 as Omenn syndrome; 2 patients had non-SCID IEI, and 1 remained undefined. Disease onset median age was 2 months, but at the time of diagnosis and treatment, median ages were 6.5 and 11.5 months, respectively, revealing considerable delay which affected negatively treatment success. While overall survival was 51.1%, only 66.7% (30/45) lived long enough to undergo hematopoietic stem-cell transplantation, which was successful in 70% of cases. Forty-three of 47 (91.5%) patients underwent genetic testing, with a 65.1% success rate. Even though our patients did not come from the NBS programs, the diagnosis of SCID improved in Brazil during the pilot programs, likely due to improved medical education. However, we estimate that at least 80% of SCID cases are still missed. NBS-SCID started to be universally implemented in the city of São Paulo in May 2021, and it is our hope that other cities will follow, leading to early diagnosis and higher survival of SCID patients in Brazil.

We would like to report our experience in the deployment of an Immunology outpatient clinic that over 14 years became a Reference Center for Inborn Errors of Immunity (IEI) in Brazil, which is located in the city of Taubaté, in the region of Vale do Paraíba, state of São Paulo, responsible for serving a region of approximately 2.5 million inhabitants. During this period, we participated in the pilot project to implement neonatal screening for severe combined immunodeficiency and initiated courses for physicians from basic health units, implementation of classes on clinical immunology in the undergraduate program of medicine, implementation of an outpatient clinic at the city's Faculty of Medicine, in addition to the assessment of patients hospitalized in emergency and intensive care units. Thus, the implementation of a Reference Center for IEI in Latin America proved to be viable and can serve as a model for other services to be initiated. Based on our experience, we suggest some itens for additional IEI centers to emerge.

Made available in DSpace on 2019-09-12T16:53:45Z (GMT). No. of bitstreams: 0 Previous issue date: 2019 American Lebanese Syrian Associated Charities California Institute of Regenerative Medicine [CLIN2-09504] National Heart, Lung, and Blood Institute [P01 HL053749] National Cancer Institute [CA21765] National Institute of Allergy and Infectious Diseases (NIAID) [Z01-AI-00988] NIAID [U54-AI082973] Assisi Foundation of Memphis Background Allogeneic hematopoietic stem-cell transplantation for X-linked severe combined immunodeficiency (SCID-X1) often fails to reconstitute immunity associated with T cells, B cells, and natural killer (NK) cells when matched sibling donors are unavailable unless high-dose chemotherapy is given. In previous studies, autologous gene therapy with gamma-retroviral vectors failed to reconstitute B-cell and NK-cell immunity and was complicated by vector-related leukemia. Methods We performed a dual-center, phase 1-2 safety and efficacy study of a lentiviral vector to transfer IL2RG complementary DNA to bone marrow stem cells after low-exposure, targeted busulfan conditioning in eight infants with newly diagnosed SCID-X1. Results Eight infants with SCID-X1 were followed for a median of 16.4 months. Bone marrow harvest, busulfan conditioning, and cell infusion had no unexpected side effects. In seven infants, the numbers of CD3+, CD4+, and naive CD4+ T cells and NK cells normalized by 3 to 4 months after infusion and were accompanied by vector marking in T cells, B cells, NK cells, myeloid cells, and bone marrow progenitors. The eighth infant had an insufficient T-cell count initially, but T cells developed in this infant after a boost of gene-corrected cells without busulfan conditioning. Previous infections cleared in all infants, and all continued to grow normally. IgM levels normalized in seven of the eight infants, of whom four discontinued intravenous immune globulin supplementation; three of these four infants had a response to vaccines. Vector insertion-site analysis was performed in seven infants and showed polyclonal patterns without clonal dominance in all seven. Conclusions Lentiviral vector gene therapy combined with low-exposure, targeted busulfan conditioning in infants with newly diagnosed SCID-X1 had low-grade acute toxic effects and resulted in multilineage engraftment of transduced cells, reconstitution of functional T cells and B cells, and normalization of NK-cell counts during a median follow-up of 16 months. (Funded by the American Lebanese Syrian Associated Charities and others; LVXSCID-ND ClinicalTrials.gov number, NCT01512888.) [Mamcarz, Ewelina; Triplett, Brandon; Janssen, William; Gottschalk, Stephen] St Jude Childrens Res Hosp, Dept Bone Marrow Transplantat & Cellular Therapy, 262 Danny Thomas Pl,Mail Stop 1130, Memphis, TN 38105 USA [Zhou, Sheng; Condori, Jose; Dowdy, Jola; Tang, Xing; Ryu, Byoung Y.; Weiss, Mitchell J.; Sorrentino, Brian P.] St Jude Childrens Res Hosp, Dept Hematol, 332 N Lauderdale St, Memphis, TN 38105 USA [Lockey, Timothy; Meagher, Michael M.] St Jude Childrens Res Hosp, Dept Therapeut Prod & Qual, 332 N Lauderdale St, Memphis, TN 38105 USA [Abdelsamed, Hossam; Youngblood, Benjamin] St Jude Childrens Res Hosp, Dept Immunol, 332 N Lauderdale St, Memphis, TN 38105 USA [Cross, Shane J.] St Jude Childrens Res Hosp, Dept Pharmaceut Sci, 332 N Lauderdale St, Memphis, TN 38105 USA [Kang, Guolian; Li, Chen] St Jude Childrens Res Hosp, Dept Biostat, 332 N Lauderdale St, Memphis, TN 38105 USA [Maron, Gabriela] St Jude Childrens Res Hosp, Dept Infect Dis, 332 N Lauderdale St, Memphis, TN 38105 USA [Aldave Becerra, Juan C.] Hosp Nacl Edgardo Rebagliati Martins, Allergy & Clin Immunol Div, Lima, Peru [Church, Joseph A.] Childrens Hosp Los Angeles, Dept Pediat, Div Allergy Immunol, Los Angeles, CA 90027 USA [Long-Boyle, Janel R.; Puck, Jennifer M.; Cowan, Morton J.] Univ Calif San Francisco, Dept Pediat, Benioff Childrens Hosp, Div Pediat Allergy Immunol Bone Marrow Transplant, San Francisco, CA USA [Dokmeci, Elif] Univ New Mexico, Dept Pediat Pediat Allergy & Immunol, Albuquerque, NM 87131 USA [Love, James T.] Univ Oklahoma, Hlth Sci Ctr, Tulsa, OK USA [da Matta Ain, Ana C.] Universidade de Taubaté (Unitau), Dept Pediat, Conselho Nacl Med, Sao Paulo, Brazil [van der Watt, Hedi] Copperfield Childcare, Claremont, South Africa [De Ravin, Suk See; Malech, Harry L.] NIAID, Genet Immunotherapy Sect, Lab Clin Immunol & Microbiol, NIH, 9000 Rockville Pike, Bethesda, MD 20892 USA

Early clinical studies of gene therapy for patients with X-linked Severe Combined Immunodeficiency (XSCID) only restored T cell immunity and carried a significant risk of iatrogenic leukemia. We developed a new gene therapy approach that utilizes a safety-modified lentiviral (LV) vector together with reduced exposure busulfan conditioning for newly diagnosed infants with XSCID (NCT01512888). Of the first enrolled 8 patients, 7 demonstrated robust reconstitution of T-, NK-, and B-cells with a median follow up of 16.4 months (range: 6.7 to 24.9 months; Mamcarz et al, N Engl J Med, 2019). Here we provide an update on our clinical study, which now includes 3 more patients (n=11 total), 8 months additional median follow-up (23.6 months; range: 1.5 to 33.9 months), more extensive analysis of T and B cell functional recovery, and detailed vector integration site studies. Overall, we successfully generated transduced autologous bone marrow (BM) CD34+ cells for all patients with a median vector copy number (VCN) of 0.45 VCN/cell (range: 0.16-1.13). Prior to the infusion of transduced CD34+ cells (median cell dose: 8.7 x106/kg; range: 4.5-19.0), patients received two daily doses of busulfan to target a cumulative area-under-the-curve (cAUC) of 22 mg*hr/L (achieved median: 22.3 mg*hr/L; range: 20.0-23.0). No severe adverse events, other than hematologic related to busulfan, were observed. All 11 patients had robust hematopoietic recovery within 3-4 weeks post cell infusion without blood product support. Nine patients, with a follow up of >3 months, achieved normal for age T-cell and NK-cell numbers within 3-4 months post gene therapy. T-cells matured appropriately as assessed by normal receptor excision circles (TREC) levels and TCRvb repertoire analysis. In addition, phytohemagglutinin (PHA) stimulation assays demonstrated normal T-cell function. So far, 5 patients are off IVIG of whom 3 responded to vaccines. As previously reported, patient #1 demonstrated poor immune reconstitution. He received a 2nd infusion of transduced CD34+ cells without conditioning one year after his initial infusion, which resulted in functional T-cell immune reconstitution. Clinically, all patients with a follow up >3 months recovered from pre-existing infections, are off protective isolation and prophylactic antimicrobials, and have normal growth in respect to height and weight. The median VCN at 12 months post gene therapy in seven patients, who have been followed for >12 months, was 2.25 VCN/cell (range: 1.24-3.03) in T cells, 0.34 VCN/cell (range: 0.23-1.25) in B cells, 1.55 VCN/cell (range 1.27-3.39) in NK cells, and 0.08 VCN/cell (range: 0.03-0.76) in myeloid cells in peripheral blood, and 0.10 (range: 0.05-0.66) in CD34+ bone marrow cells, respectively. Detailed integration sites analysis for the first 7 patients, who received a single infusion of transduced CD34+ cells, revealed that the majority of sites were located in introns and intergenic regions throughout the human genome. The integration site pattern was highly consistent across patients with integration site clusters that had been previously described by us and others after LV transduction. In conclusion, LV gene therapy for XSCID using low dose busulfan conditioning and a novel LV vector is well tolerated and results in the development of a functional normal immune system without evidence of malignant transformation with a median follow up of almost 2 years. Thus, our approach may present a promising alternative to current therapies, which rely in part on high dose chemotherapy followed by allogeneic hematopoietic cell transplantation. Disclosures Mamcarz: American Lebanese Syrian Associated Charities: Research Funding; UpToDate: Honoraria; NHLBI: Research Funding; ASSISI Foundation of Memphis: Research Funding; MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy; California Institute of Regenerative Medicine: Research Funding. Zhou:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Lockey:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Boi:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Koon-Kiu:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Cross:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy; NIH: Research Funding. Kang:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Ma:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Condori:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Dowdy:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Metais:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Langfitt:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Triplett:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Li:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Zhao:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Maron:Chimerix: Research Funding; MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy; Astellas: Research Funding. Janssen:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Weiss:GlaxoSmithKline: Consultancy; Cellarity INC: Consultancy; Esperian: Consultancy; Beam Therapeutics: Consultancy; Rubius INC: Consultancy. Youngblood:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Meagher:MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy. Puck:Pfeizer: Other: spouse serves on Rare Disease Advisory Board; NIAID: Research Funding; Invitae: Other: spouse employment. Cowan:NIH NIAD: Research Funding; Leadiant: Consultancy; Rocket Pharma: Consultancy; bluebird bio: Consultancy; California Institute Of Regenerative Medicine: Research Funding; Homology Medicine: Equity Ownership, Membership on an entity's Board of Directors or advisory committees; UpToDate: Honoraria. Gottschalk:Tidal: Membership on an entity's Board of Directors or advisory committees; Merck: Consultancy; TESSA Therapeutics: Other: Research Collaboration; Patents and patent applications in the fields of T-cell & Gene therapy for cancer: Patents & Royalties; EMD Serono: Honoraria; California Institute for Regenerative Medicine: Research Funding; Sanofi: Honoraria; NHLBI: Research Funding; Inmatics: Membership on an entity's Board of Directors or advisory committees; MBIO: Other: St. Jude Children's Research Hospital has an existing exclusive license and ongoing partnership with Mustang Bio for the further clinical development and commercialization of this XSCID gene therapy; America Lebanese Syrian Associated Charities: Research Funding; ViraCyte: Consultancy; ASSISI fundation of Memphis: Research Funding.

Background This paper aims at showing a severe case of a patient with Chronic Granulomatous Disease (CGD), an immunodeficiency which is not so uncommon, affecting 1/ 250000 born alive, and which is due to phagocytic dysfunction. It is characterized by inability of phagocytic cells to produce hydrogen peroxide and other oxidants needed to eliminate microorganisms, in addition there is excessive accumulation of immune cells into aggregates, known as granulomas, at sites of infection or inflammation. The patient may experience fungal or bacterial infections affecting the skin, lungs (Aspergillus pneumonias), lymph nodes, liver (liver abscesses 90% caused by Staphylococcus), bones (osteomyelitis), and granulomas which may lead to obstruction of gastrointestinal and urinary tracts.

Results In such period, 100 new patients were seen, mainly comprised of male (64%). Most patients (69%) were under 6 months old at the time of their first visit. In 41% of the patients, the first contact with cow’s milk protein occurred before 1 month old and only 21% had such contact after 6 months of age. One (1%) patient had symptoms with no direct exposure to cow’s milk (allergy linked to breast milk). Respiratory symptoms, whether alone or associated with other complaints, were the most frequent ones in 81% of the cases (rhinitis 32%), followed by dermatitis in 44% and vomiting in 20%. Patients assessed at first visit were on cow’s milk (LV) in 30%, soy milk 30%, breast milk (LM) 9%, partially hydrolyzed (PH) 11%, extensively hydrolyzed (EH) 9.5%, free amino acids (AA) 9.5% and 1 patient on calcium replacement. Following first evaluation, they were switched to: soy 35%, EH 30%, PH 22%, LV 6.5%, AA 6.5%, and LM 1%. At the time of first visit, 23.5% of patients on cow’s milk protein haven’t started treatment yet or were partially treated, thus requiring switch to another formula. Soy was properly indicated in 30% of patients, with no need for changing formula. In service experience, PH formula showed good results in patients whose relatives were atopic and/or oligosymptomatic. EH formulas were the most indicated ones (30%) at this first evaluation; therefore decreasing AA prescriptions (5.5%) which were below the numbers described in literature.