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Leptin, a pleiotropic hormone, has been suggested to be part of an acute-phase response during an inflammatory stimulus. Its correlation with other acute-phase reactants during minor infection in children has not been investigated.To study the correlation between levels of serum leptin and those of C-reactive protein, a well-documented acute-phase reactant, in a series of pediatric patients with acute minor infections.Leptin and CRP levels were measured in 62 blood samples of pediatric patients presenting with mild febrile illness who were admitted to Dana Children's Hospital in Israel. All children were finally diagnosed as having minor infection based on the negative blood/urine cultures and favorable outcome.Serum leptin level was positively correlated with CRP (r2 = 0.5), total white blood cells (r2 = 0.33) and absolute neutrophil count (r2 = 0.31). The regression coefficient was the highest between leptin and CRP.Circulating leptin concentrations are positively correlated with CRP levels during acute minor infection in children visiting the emergency room for febrile illnesses. Our observation suggests that leptin is indeed a part of acute-phase proteins. The wide scattering showed that it is not a better marker in minor infections than CRP, but it may contribute to weight loss and anorexia seen in a minority of patients during mild infections.

Extensive research in recent years has broadened the functions of nuclear envelope proteins beyond simply stabilizing the nucleus architecture. Particularly, integral nuclear membrane proteins, such as the alternative spliced isoforms of lamina-associated polypeptide 2 (LAP2), have been shown to be important for the initiation of replication and repression of transcription. The latter is regulated by epigenetic changes, induced by the binding of LAP2beta to histone deacetylase-3 (HDAC3), resulting in histone H4 deacetylation. Involvement of nuclear envelope proteins in pathological proliferative conditions, mainly those involving abnormal recruitment and activation of HDACs, is still unknown. In this paper, we show that various nuclear envelope proteins are highly expressed in normal and malignant activated lymphocytes. Specifically, rapidly replicating cells of various hematological malignancies highly express LAP2beta, while slowly proliferating malignant cells of chronic malignant hematological diseases do not. Taking together the elevated expression of LAP2beta in highly proliferative malignant cells with its known ability to modify histones through binding with HDAC3 raises the possibility of its role in hematological malignancies involving aberrant activity of HDAC3. Based on our presented results, we believe that the LAP2-HDAC regulatory pathway should be studied as a new target for rational therapy.

To study the correlation between genotype and phenotype in x-linked SCID, we have characterized the presentation of 2 unrelated patients. Both had infections suggestive of immunodeficiency, but their immune function and lymphoid tissues were normal. They were found to have an identical R222C mutation in the gammac gene.

The susceptibility and clinical manifestations of infectious diseases in human populations are influenced by a variety of factors, among them host genetics. Obvious examples for the effect of host genetics on predisposition to unique infections are the primary immunodeficiency diseases. Minor gene variants that influence the host immune system are much more common. The iceberg model can be used to illustrate the epidemiology of immunodeficiency states. Accordingly only a few individuals have known and severe recognized primary immunodeficiencies, whereas many more patients have mild immunodeficiencies that may remain undiagnosed and are predisposed to a unique infectious disease. We review some of the less common variants that influence the host defense and predispose to certain infectious agents or change their outcome.

The aim of this chapter is to increase the familiarity of physicians with conditions or complications associated with CD, a disease that is more common than had been thought in the past. The differentiation between atypical manifestations, associated disease, and complications of CD is not always clear. With careful adherence to the necessary dietary restrictions, patients with CD can remain relatively free of troublesome symptoms, their long-term prognosis is excellent, and most complications can be prevented. (24) Indeed, 5-year survival rates of patients with CD did not differ from those in the general population. (6) This review emphasizes the importance of a screening policy for silent CD, justified on the basis of later developing complications such as malignancy, development of low bone mineral density, risk of neurologic abnormalities, and associated diseases, which may be preventable by GFD.

Celiac disease (CD) is an inflammatory condition of the upper small intestine which is caused by gluten ingestion in genetically susceptible patients. Over the past few years, significant changes have occurred in our understanding of CD in terms of patterns of disease expression, pathological manifestations, associated diseases, definition of high-risk patients, screening policy and diagnosis, and epidemiological, genetic, immunological and pathogenetic aspects. We review new perspectives of CD in order to enhance the familiarity of physicians with a disease that is now considered to be more common than was thought in the past.

O-01 IL-10 receptor dependent signals regulate the generation and function of anti-inflammatory macrophages in mice and humans S.B. Snapper1 *, D. Shouval1, A. Biswas1, J.A. Goettel1, K. McCann1, J.C. Escher2, J.N. Samsom2, R.S. Somech3, B. Weiss3, R. Beier4, L. Conklin5, C.L. Ebens6, F.G.M. Santos7, M. Sherlock8, C. Klein9, A.M. Muise10, B.H. Horwitz11. 1Boston Children’s Hospital, Boston, United States of America, 2Erasmus Medical Center Sophia Children’s Hospital, Rotterdam, The Netherlands, 3Edmond and Lily Safra Children’s Hospital, Tel Hashomer, Israel, 4Hannover Medical School, Hannover, Germany, 5Children’s National Medical Center, Washington DC, United States of America, 6University of Michigan, Ann Arbor, United States of America, 7Hospital das Clinicas, Federal University of Minas Gerais, Minas Gerais, Brazil, 8McMaster Children’s Hospital, West Hamilton, Canada, 9Dr von Hauner Children’s Hospital, Munich, Germany, 10Hospital for Sick Children, Toronto, Canada, 11Harvard Medical School, Boston, United States of America

In order to raise the awareness of the potential side effects that can be induced by minocycline, we report three adolescent girls who experienced serious adverse reactions to this therapy, which was prescribed for acne vulgaris.

Patients with primary immunodeficiency present an excellent opportunity to understand the role of specific molecules in the human immune system. Recently we had the chance to investigate a young girl with a complete CARD11 deficiency due to a homozygous deletion of exon 21. Clinically the child presented with increased susceptibility to respiratory tract infections at 6 months, before she was diagnosed at 13 months with Pneumocystis jirovecii revealing her combined immunodeficiency. The immunological characterization showed severe hypogammaglobulinemia, but normal T-, B- and NK-cell numbers. While there were only subtle changes in the T cell compartment, B-cell differentiation was blocked at the transitional stage. In the absence of CARD11 protein expression activation of the canonical NF-κB pathway after antigen receptor or PMA stimulation was abrogated, while CD40 signaling in B cells was preserved. CARD11 deficient T cells were severely impaired in the up-regulation of ICOS, OX40, cytokine production and proliferation after TCR stimulation. On B cells BAFF receptor expression was reduced and after activation ICAM1 and CD25 were not induced while CD86 induction was comparable to control cells. Immunoglobulin production was intact after anti-IL-21/CD40L stimulation, demonstrating that plasma cell differentiation was not dependent on intact CARD11. Thus CARD11 plays a crucial, non-redundant role in the antigen specific immune response in humans.

Abstract 4478 Allogeneic stem cell transplantation (AlloSCT) is the treatment of choice in advanced chronic myelogenous leukemia (CML) and Ph+ acute lymphoblastic leukemia (ALL). However, post transplant relapse rate is high and outcome is often poor in this setting. Reduction of tumor mass pre-transplant and maintenance therapy post alloSCT, may improve response rate and reduce relapse rate. We speculated that the second-generation tyrosine-kinase inhibitor (TKI) Nilotinib (Tasigna, Novartis Pharmaceuticals) would be effective in achieving these goals. In the current study Nilotinib, was administered as maintenance therapy post alloSCT in patients (pts) with advanced CML and Ph+ ALL (study CAMN107AIL03T). However, TKIs have been demonstrated in previously published literature to affect T cells proliferation and signal transduction and to potentiate LGL and NK cell activity. Furthermore, in recent studies TKIs have also been demonstrated to ameliorate chronic GVHD. We therefore assessed immunological reconstitution and function including flow analysis of lymphocyte subsets, T-mitogenic response to αCD3 and PHA, thymic activity as determined by the quantification of the T cell receptor excision circles (TREC), TCR repertoire and NK cells cytotoxic activity against K562 cell line. In all, the study included 24 pts. Patients engrafted in a median day +15 (range, 10–38) with 100% donor chimerism. Acute GVHD grade 3/4 was reported in 3 pts (14%) and the rate of extensive chronic GVHD at last follow up was 50%. At 6 months after alloSCT, 11 of 15 pts with advanced CML had attained CCyR, 11 of 15 pts with advanced CML had attained a MMR or better, and 5 of 7 pts with Ph+ ALL attained a CR. The median OS was 16 months, with predicted 1- and 2- year rates of 55% (95% CI, 32% – 72%) and 50% (95% CI, 28% – 68%), respectively. The median PFS was 11 months, with predicted 1- and 2- year rates of 50% (95% CI, 28% – 68%) and 38% (95% CI, 17% – 59%), respectively. Immunological testing was performed pre- and post Nilotinib maintenance therapy in 12 pts (advanced CML-8, Ph+ ALL-4) who received Nilotinib for at least 90 days following alloSCT. The median age was 34.5 years (range, 21–57) and 75% were males. Six pts underwent alloSCT from an HLA-matched sibling donor, 4 from matched unrelated and 2 from an alternative donor (cord blood-1, haploidentical-1). All had myeloablative conditioning. GVHD prophylaxis included CSA and MMF. The relative percentage of T- lymphocyte subsets (assessed by FACS) and total lymphocytes number were stable during Nilotinib maintenance administration after alloSCT, while a 7.8±2.5 fold increase in B cells was noted. T cell mitogenic response with αCD3 and PHA (stimulation index ratio) was sustained (2.5±1.0, vs. 2.8±1.05 and 3.3±1.3 vs. 5.3±2.9 stimulation, pre- and post Nilotinib therapy, respectively). Mean thymic output determined by TREC quantification pre-, during and post Nilotinib administration was 81.8±108, 81.2±90.3 and 142.8±197.4 copies per 0.5ug DNA indicating continuous thymopoiesis. Similarly, no significant change of the TCR repertoire was observed during Nilotinib treatment. Specifically, normal expression of the TCR repertoire was detected in 15.1±5.5 and 15.3±5.6 of the examined TCRs, clonal expression was detected in 2.5±2.2 and 2.9±3 of the examined receptors, while reduced expression was detected only in 6.4±4.3 and 5.8±4.5 of the examined receptors pre-and post Nilotinib treatment, respectively. NK cytotoxic activity against K562 expressed as fold of change from baseline, also remained stable during Nilotinib treatment (2.8±1.1 and 2.3±0.8, respectively). In summary, Nilotinib maintenance therapy post alloSCT in pts with advanced CML and Ph+ALL did not interfere or jeopardized immune reconstitution and function including the number of immune cell subsets, T cell mitogenic response, TCR repertoire, thymic output and NK cytolytic activity post alloSCT. Based on this immunological data we would further recommend Nilotinib maintenance therapy post alloSCT in pts with advanced CML and Ph+ALL. Disclosures: Nagler: Novartis: Honoraria, Research Funding.

Abstract 2011 AlloSCT is the treatment of choice in advanced CML (>CP1) and in Ph+ ALL. However, the post transplant relapse rate is high and outcome is rather poor in this setting. Nilotinib (Tasigna, Novartis Pharmaceuticals) is a very effective, second generation, novel TKI. Reduction of tumor mass pre- and maintenance therapy post alloSCT, may improve response rate and reduce transplant related toxicities (TRT) and relapses. The aim of the current study (CAMN107AIL03T) was to investigate whether nilotinib administration pre-alloSCT (400mg BID) and at escalating doses of 200–400mg BID post-alloSCT will intensify remission, reduce relapse and improve outcome without increasing TRT in pts with advanced CML and Ph+ ALL. 24 pts (M-13, F-11) participated in the study. The median age was 36 years (range, 18–58). 17 pts were with advanced CML (BC-10, AP-7) and 7 with Ph+ ALL. Cytogenetic and molecular responses were assessed by FISH and RQ-PCR (Taqman, LeukemiaNet and Eutos criteria). 5 pts harbored ABL kinas domain mutations by Sequenom assay (Y253H-2, A397P-1, E255K-1, M351T-1). 9 pts received nilotinib (400mg BID) pre-alloSCT and 6 responded (2 are too early to evaluate) (BC- CHR–2, BC - CCR-2, AP - PCR-1, AP - CHR-1). 22/24 pts underwent alloSCT (2 are pending) from an HLA-matched sibling (n=11), matched unrelated (n=8) or alternative donor (CB-2, Haplo-1). All, but one, had myeloablative conditioning (Bu/Cy or Flu/Bu-14, TBI/Cy-7). Graft versus host disease (GVHD) prophylaxis included CSA and methotrexate or MMF. 21/22 pts engrafted in median day+13 (range, 9–38) with 100% donor chimerism. TRT included mucositis in all pts, encephalitis-2, pericarditis-1, VOD-1 and infection-3. 3 pts died very early post transplant from sepsis and multi organ failure. Acute GVHD ≥ Gr II was observed in 10 pts (III-IV in 5). Chronic GVHD was observed in 15 pts (extensive – 9). Sixteen of the 22 transplanted pts received nilotinib (200mg × 2/d – 10, 300mg × 2/d – 6) starting at median day +38 (range, 30–158) post alloSCT. 6 pts did not receive nilotinib post alloSCT due to early death -3, progressive disease -1, severe pancytopenia -1, refusal -1. No pt received the planned 400mg BID dose. In 9 pts nilotinib administration was delayed due to either liver abnormalities -3, severe thrombocytopenia -3 or infection -3. Nilotinib dose had to be reduced (n=4) or stopped (n=3) due to Gr III-IV non-hematological toxicities -5 pts, mainly abnormal liver function tests -4 in combination with pruritus -1, vomiting -1 and abdominal pain -1, or hematological toxicities -2 pts. In 1 pt we observed increased levels of amylase without clinical signs of pancreatitis. QTc (470 msec) prolongation was observed in 1 pt. All, but 2 pts achieved MMR post alloSCT and 6 of them (CML) converted to CMR following nilotinib therapy. Response was durable and maintained. Only in 1 pt with disease progression kinas mutation (G205E and F359V) were detected. With a median follow up of 14.5 months (range, 0.5–36) 12 pts are alive while 12 died (Infection -5, GVHD -3, TTP-1, disease progression -3). In 2 pts disease progressed but responded to further therapy. 5 of 6 pts that did not receive nilotinib died (early death post AllSCT -3, disease progression -1, GVHD Gr IV -1). Immunological evaluation pre- and post nilotinib administration disclosed no significant change in T, B and NK cell numbers and T cell mitogenic response to PHA and anti CD3. Thymic output (TREC) and receptor repertoire (Spectrotyping) analysis indicates continuous thymopoiesis in 8/13 evaluated pts. NK cytotoxic activity against K562 increased in 9/15 evaluated pts. In conclusion, post alloSCT nilotinib maintenance therapy in extremely high risk pts with advanced CML and Ph+ ALL may prevent relapse and disease progression as 1) pts achieved MMR and 6 converted to CMR with nilotinib therapy and 2) only 5/16 pts that received nilotinib post alloSCT progressed [in 4 of them nilotinib could not be administrated as per protocol because of side effects (n=2) or low compliance (n=2)]. Although a formal maximal tolerated dose (MTD) of nilotinib post alloSCT has not been reached, it seems that administration of nilotinib early post alloSCT may be associated with increased toxicity. nilotinib administration post alloSCT does not impair immunological reconstitution, while GVHD incidence seems not to be reduced. Based on these data we would recommend nilotinib maintenance therapy post alloSCT in pts with advanced CML and Ph+ ALL. Disclosures: Nagler: Novartis: Honoraria, Research Funding. Off Label Use: Nilotinib (Tasigna) for reduction of tumor mass pre- and maintenance therapy post alloSCT in patients with CML and Ph+ ALL (novel TKI).

Objective To define the neurologic characteristics and course of ataxia-telangiectasia (A-T). Study design Retrospective cross-sectional chart study of 57 children (ages 2 to 19 years) followed at an A-T clinic. Cerebellar and extracerebellar symptoms were graded according to degree of functional impairment. Head circumferences were plotted from the charts and z -scores were calculated and compared with that of family members. Results Ataxia was present in 87.7%, followed by dysarthria (82.1%), dysmetria (75.4%), bradykinesia (69.2%), hyperkinetic movements (58.9%), and dystonia (15.8%). All features aggravated with age. The most striking clinical observation in our patients was low head circumference ( z -score below 1), which was present in 60.9%; 17% had true microcephaly ( z -score below 2). Microcephaly appeared postnatally, was proportionate to height and weight, and did not correlate with severity of ataxia or genotype. Conclusions In addition to cerebellar ataxia, extrapyramidal symptoms, especially bradykinesia, were frequent and disabling. Microcephaly is an integral part of A-T; understanding its pathogenesis may shed light on the mechanism by which ATM mutation causes dysfunction in the nervous system.

Abstract 1176 Poster Board I-198 Therapeutic options in advanced CML (>CP1) and Ph+ALL are limited. AlloSCT is the treatment of choice for these indications, however post-transplant relapse rates are high and outcome is relatively poor. Nilotinib is a second generation, novel tyrosine kinase inhibitor (TKI) that is active in imatinib resistant and advanced CML, producing significant hematologic and cytogenetic responses in all phases of CML and Ph+ALL. Furthermore, nilotinib has activity against most BCR-ABL kinase domain (KD) mutations. We have previously demonstrated that nilotinib therapy pre transplantation allows alloSCT in a less advanced disease phase and with no increase in transplant related toxicity (TRT) in patients with advanced CML and Ph+ALL (Leukemia 23:190-194,2009). The aim of the current phase I/II study (CAMN107AIL03T) was to investigate whether nilotinib administered, at escalating doses starting at 200mg BID, in patients with advanced CML or Ph+ALL pre- and post- alloSCT can intensify remission, reduce relapse and improve outcome without increasing TRT. Nilotinib could also be used pre-transplant at standard doses to improve pre-transplant disease status. Eleven patients have been recruited to the study since July 2008. Seven advanced CML (BC-5, AP-2) and four with Ph+ALL, median age 39 years (range, 21-57), 7 men and 4 women. Previous therapies included chemotherapy for CML BC and Ph+ALL patients, and imatinib for all patients. Cytogenetic and molecular response were assessed by FISH and RQ-PCR (Taqman), respectively and defined as per LeukemiaNet criteria. Two out of eleven patients harbored the Y253H ABL KD mutation detected by the Sequenom assay (Leukemia 21:1318-21, 2007). Five out of eleven patients received nilotinib at the 400mg BID pre-alloSCT and 3 responded [BC „_ CP2 (n=2), AP „_ CP2 (n=1); CHR-1, PCyR-1, CCyR-1] (1 not evaluable). Nine of eleven patients underwent alloSCT (2 are pending) from an HLA-matched sibling (n=5) or alternative donor (n=4). All had myeloablative conditioning (Bu/Cy or Flu/Bu - 6, TBI/Cy-3). Graft versus host disease (GVHD) prophylaxis included CSA and MMF. All patients engrafted in a median of 11 days (range, 9-17) with 100% donor chimerisem. Acute GVHD ( >II) was observed in 5 patients (Gr III/IV - 3) and chronic GVHD in 5 (extensive - 3). No TRM was observed. No transplant-related organ toxicity was observed other than mild to moderate mucositis (n=9). Seven out of the nine transplanted patients received nilotinib at a dose of 200mg BID starting at day +38 (range,30-49) post alloSCT. Did not receive nilotinib: 1 due to severe cytopenia and 1 refused. In four patients nilotinib dose had to be reduced to 100mg BID due to hematological toxicity (2 patients) and non hematological toxicities (2 patients) including rash, pruritus, vomiting and diarrhea. In one patient we observed increased levels of amylase without clinical signs of pancreatitis. Cardiac toxicity or QTc prolongation was not observed. With a median follow up of 7.5 months (range, 4-12), seven out of nine patients are alive, while two died from GVHD and Fusarium fungemia (one each), both 9 months post alloSCT. The first patient was given nilotinib for a very short period and the second patient was never treated, both due to cytopenia. All patients achieved MMoLR (n=8) or CMoLR (n=1) post-alloSCT and the response was durable and maintained with nilotinib therapy without molecular or clinical relapse. No kinase domain mutations were detected post-alloSCT. In conclusion, post-alloSCT nilotinib therapy in patients with advanced CML and Ph+ALL may prevent relapse and disease progression. All patients achieved MMoLR or CMoLR and no patient died from the underlying malignancy. Although a formal maximal tolerated dose (MTD) of nilotinib post alloSCT has not been reached yet, it seems that administration of nilotinib early post alloSCT may be associated with increased toxicity which results in dose reduction in substantial number of patients. The study is ongoing, aiming to recruit 24 patients in 2 years. Disclosures: Nagler: Novartis: Consultancy, Honoraria, Research Funding.