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She had recurrent rhino pharyngitis and acute otitis media&#46; She had twice left inferior pneumonia&#46; She also had aphthae&#44; and persistent mouth candidiasis&#44; despite prolonged adequate treatment&#58; oral miconazole for 2 months&#44; followed by 3 weeks of amphotericin B&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">On clinical examination&#44; she was eupneic &#40;breath rate 27&#47;min&#41; with 100&#37; oxygen saturation&#46; She had no chest deformity&#44; pulmonary auscultation found crackles in the left lower lobe&#46; Fold candidiasis was visible&#46; Chest radiograph &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; showed left inferior opacity&#44; consistent with partial atelectasis&#44; associated with bilateral bronchial thickening&#46; CT scan &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; confirmed partial atelectasis of the lingula&#44; medial segment of the middle lobe&#44; anterobasal segment of the left lower lobe and small bronchiectasis of the anterior segment of the left upper lobe&#46; 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546&#47;&#956;l&#59; CD8&#43;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>258&#47;&#956;l&#59; CD19&#43; 576&#47;&#956;l&#59; CD 16<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>56<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>76&#47;&#956;l&#41;&#46;</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Because&#44; Mendelian predisposition to fungal infections was suspected&#44; DNA sequencing of STAT1 &#40;<a href="ncbi-n:NM_007315.3">NM&#95;007315&#46;3</a>&#41; gene exons was done&#58; it identified a heterozygous mutation C&#46;1154C&#62;T &#40;p&#46;T385M&#41; in exon 14 of STAT1 gene&#46; This mutation is listed among immunodeficiencies&#44; and is responsible for predisposition to fungal infections&#46; It is responsible of a STAT1 gain-of-function mutation&#46; This was a de novo mutation&#44; as it was not found in any of the two parents&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">On follow-up she presented monthly exacerbations&#44; with streptococcus pneumoniae and haemophilus influenzae on expectoration&#44; treated with oral amoxicillin 100<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d for 15 days&#46; She is currently under monthly intravenous immunoglobulin &#40;0&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#41; perfusions&#44; oral daily sulfamethoxazole&#8211;trimethoprim &#40;20<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41; and fluconazole &#40;6<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41; prophylaxis&#44; associated with chest physiotherapy twice weekly&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Heterozygous STAT1 gain-of-function mutation was first described in 2011&#46; Since then&#44; more than 50 mutations have been described&#46; It is responsible for more than 50&#37; of chronic mucocutaneous candidiasis &#40;CMC&#41;&#46; STAT1 &#40;signal transducer and activator of transcription 1&#41; is a protein of the JAK&#8211;STAT signaling pathway&#46; STAT1 GOF mutations lead to accumulation of phosphorylated STAT1 in the cytoplasm and nucleus&#44; increase the transcription of genes that promote Th1 pathway&#44; and dysregulates Th1&#47;Th17 balance&#46; Because IL17 is so important for antifungal immunity on epithelial surfaces&#44; CMC appears as a result&#46; Several case reports have been published<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#8211;4</span></a> but Toubiana et al&#46; published the largest case series &#40;274 patients&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Symptoms started around 12 months and were heterogenous&#46; 98&#37; of cases had chronic mucocutaneous candidiasis&#44; with 30&#37; of resistance to antifungal treatment&#44; that can evolve into dysphagia and esophageal cancer&#46; Infections are frequent whether bacterial &#40;in 74&#37; of cases skin and airways&#59; with mainly staphylococcus aureus and pseudomonas aeruginosa&#41;&#44; viral &#40;in 38&#37; of cases&#41; or mycobacterial &#40;in 6&#37; of cases&#41;&#46; They touch the respiratory tract in more than 50&#37; of cases with a possibility of fungal infection&#46; 47&#37; of patients had recurrent bacterial pneumonia&#44; and bronchiectasis was diagnosed in 20&#37; of cases&#46; Autoimmunity can be found in 40&#37; of cases&#46; Morbidity is severe&#44; and mortality is premature &#40;cancer&#44; cerebral aneurysm&#41;&#46; Treatment is symptomatic &#40;polyvalent immunoglobulins&#44; antibiotic and antifungal prophylaxis&#41;&#46; Indications of treatment with ruxolitinib &#40;a JAK inhibitor&#41; are not yet defined&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">GOF STAT1 gain-of-function mutation has already been described&#44; and pediatric immunologists are aware of it&#44; in cases of chronic mucocutaneous candidiasis&#46; It is not a well-known etiology of bronchiectasis or chronic suppurative lung disease among pediatric pulmonologist&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">This case highlights the fact that in front of idiopathic bronchiectasis with normal basic immunological tests&#44; in cases of associated candidiasis&#44; DNA sequencing of exons of the STAT1 gene should be performed and&#47;or the child referred to a pediatric immunologist&#46;</p></span>"
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Scientific Letter
Chronic Lung Suppurative Disease in a Child Related to a STAT1 Heterozygous Gain-of-Function Mutation
Enfermedad pulmonar supurativa crónica en un niño relacionada con una mutación en heterocigosis de ganancia de función del STAT1
Marie Catherine Renouxa,
Corresponding author
mc-renoux@chu-montpellier.fr

Corresponding author.
, Johan Moreaua, Marie Gabrielle Vigueb
a Pediatric Pulmonology Unit, Centre Hospitalier Universitaire, Montpellier, France
b Pediatric Immunology and Infectiology Unit, Centre Hospitalier Universitaire, Montpellier, France
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    "titulo" => "Chronic Lung Suppurative Disease in a Child Related to a STAT1 Heterozygous Gain-of-Function Mutation"
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        "titulo" => "Enfermedad pulmonar supurativa cr&#243;nica en un ni&#241;o relacionada con una mutaci&#243;n en heterocigosis de ganancia de funci&#243;n del STAT1"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of a 2-year-old female with chronic suppurative lung disease associated with esophageal candidiasis revealing a rare&#44; recently described genetic disease&#58; heterozygous STAT1 gain-of-function mutation&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">E&#46;&#44; a 2-year-old female&#44; was referred to a pediatric pulmonologist for persistent wet cough&#46; No past family records and no inbreeding are to be found&#46; In the first six months&#44; the infant was constantly crying and suffered from anorexia&#46; Esophagitis was suspected&#44; and she was treated &#8211; unsuccessfully &#8211; with esomeprazole 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#46; Then cow milk allergy was suspected&#44; and no cow milk protein milk was given for two months with no clinical benefits&#46; At 11 months failure to thrive was diagnosed&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Chronic wet cough began at 6 months&#46; She had recurrent rhino pharyngitis and acute otitis media&#46; She had twice left inferior pneumonia&#46; She also had aphthae&#44; and persistent mouth candidiasis&#44; despite prolonged adequate treatment&#58; oral miconazole for 2 months&#44; followed by 3 weeks of amphotericin B&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">On clinical examination&#44; she was eupneic &#40;breath rate 27&#47;min&#41; with 100&#37; oxygen saturation&#46; She had no chest deformity&#44; pulmonary auscultation found crackles in the left lower lobe&#46; Fold candidiasis was visible&#46; Chest radiograph &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; showed left inferior opacity&#44; consistent with partial atelectasis&#44; associated with bilateral bronchial thickening&#46; CT scan &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; confirmed partial atelectasis of the lingula&#44; medial segment of the middle lobe&#44; anterobasal segment of the left lower lobe and small bronchiectasis of the anterior segment of the left upper lobe&#46; Fiberoptic bronchoscopy showed thick&#44; diffuse secretions&#44; predominantly in the left bronchial tree &#40;lingula&#41;&#59; bronchoalveolar lavage was inflammatory &#40;79&#37; of neutrophils&#41; with 10<span class="elsevierStyleSup">8</span><span class="elsevierStyleHsp" style=""></span>UFC&#47;ml Haemophilus influenzae&#46; Gastro-esophageal endoscopy revealed erythematous esophagitis with white deposits&#44; consistent with candidiasis &#40;confirmed by biopsy&#41;&#46; The main etiologies of chronic lung suppurative disease were ruled out&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">sweat test &#40;sweat chloride<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mmol&#47;l <span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60&#41;&#44;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">immunological test&#58; complete blood count &#40;white cells 6280&#47;mm<span class="elsevierStyleSup">3</span>&#59; hemoglobin<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#59; platelet<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>458&#44;000&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#59; immunological quantitation&#58; IgG 15&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dl &#40;3&#46;35&#8211;8&#46;96&#41;&#59; IgM<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;15<span class="elsevierStyleHsp" style=""></span>g&#47;l &#40;0&#46;48&#8211;1&#46;53&#41;&#59; IgA<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;08<span class="elsevierStyleHsp" style=""></span>g&#47;l &#40;0&#46;27&#8211;1&#46;22&#41;&#59; immunoglobulin G1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#46;380<span class="elsevierStyleHsp" style=""></span>g&#47;l&#59; IgG2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;91<span class="elsevierStyleHsp" style=""></span>g&#47;l&#59; IgG3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;69<span class="elsevierStyleHsp" style=""></span>g&#47;l&#59; IgG4<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01<span class="elsevierStyleHsp" style=""></span>g&#47;l&#59; tetanus serology<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;37<span class="elsevierStyleHsp" style=""></span>UI&#47;ml &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;1&#41;&#44; pneumococcus serology<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>43&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;l&#59; total IgE &#60;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>Ku&#47;l&#44;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">barium swallow and pH readings were normal&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">She was initially treated with 7 days of intravenous ceftriaxone&#44; and fluconazole &#40;14 days&#41;&#44; chest physiotherapy&#44; and 3&#37; hypertonic saline nebulization&#46; Because of the association of bronchiectasis and persistent candidiasis&#44; she was referred to the pediatric immunologist&#44; who completed immunological tests&#58;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">lymphocytic phenotyping showed mild T CD4&#8722; CD8 and Natural Killer lymphopenia&#44; with normal count of B lymphocytes &#40;CD4&#43; 546&#47;&#956;l&#59; CD8&#43;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>258&#47;&#956;l&#59; CD19&#43; 576&#47;&#956;l&#59; CD 16<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>56<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>76&#47;&#956;l&#41;&#46;</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Because&#44; Mendelian predisposition to fungal infections was suspected&#44; DNA sequencing of STAT1 &#40;<a href="ncbi-n:NM_007315.3">NM&#95;007315&#46;3</a>&#41; gene exons was done&#58; it identified a heterozygous mutation C&#46;1154C&#62;T &#40;p&#46;T385M&#41; in exon 14 of STAT1 gene&#46; This mutation is listed among immunodeficiencies&#44; and is responsible for predisposition to fungal infections&#46; It is responsible of a STAT1 gain-of-function mutation&#46; This was a de novo mutation&#44; as it was not found in any of the two parents&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">On follow-up she presented monthly exacerbations&#44; with streptococcus pneumoniae and haemophilus influenzae on expectoration&#44; treated with oral amoxicillin 100<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d for 15 days&#46; She is currently under monthly intravenous immunoglobulin &#40;0&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#41; perfusions&#44; oral daily sulfamethoxazole&#8211;trimethoprim &#40;20<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41; and fluconazole &#40;6<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41; prophylaxis&#44; associated with chest physiotherapy twice weekly&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Heterozygous STAT1 gain-of-function mutation was first described in 2011&#46; Since then&#44; more than 50 mutations have been described&#46; It is responsible for more than 50&#37; of chronic mucocutaneous candidiasis &#40;CMC&#41;&#46; STAT1 &#40;signal transducer and activator of transcription 1&#41; is a protein of the JAK&#8211;STAT signaling pathway&#46; STAT1 GOF mutations lead to accumulation of phosphorylated STAT1 in the cytoplasm and nucleus&#44; increase the transcription of genes that promote Th1 pathway&#44; and dysregulates Th1&#47;Th17 balance&#46; Because IL17 is so important for antifungal immunity on epithelial surfaces&#44; CMC appears as a result&#46; Several case reports have been published<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#8211;4</span></a> but Toubiana et al&#46; published the largest case series &#40;274 patients&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Symptoms started around 12 months and were heterogenous&#46; 98&#37; of cases had chronic mucocutaneous candidiasis&#44; with 30&#37; of resistance to antifungal treatment&#44; that can evolve into dysphagia and esophageal cancer&#46; Infections are frequent whether bacterial &#40;in 74&#37; of cases skin and airways&#59; with mainly staphylococcus aureus and pseudomonas aeruginosa&#41;&#44; viral &#40;in 38&#37; of cases&#41; or mycobacterial &#40;in 6&#37; of cases&#41;&#46; They touch the respiratory tract in more than 50&#37; of cases with a possibility of fungal infection&#46; 47&#37; of patients had recurrent bacterial pneumonia&#44; and bronchiectasis was diagnosed in 20&#37; of cases&#46; Autoimmunity can be found in 40&#37; of cases&#46; Morbidity is severe&#44; and mortality is premature &#40;cancer&#44; cerebral aneurysm&#41;&#46; Treatment is symptomatic &#40;polyvalent immunoglobulins&#44; antibiotic and antifungal prophylaxis&#41;&#46; Indications of treatment with ruxolitinib &#40;a JAK inhibitor&#41; are not yet defined&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">GOF STAT1 gain-of-function mutation has already been described&#44; and pediatric immunologists are aware of it&#44; in cases of chronic mucocutaneous candidiasis&#46; It is not a well-known etiology of bronchiectasis or chronic suppurative lung disease among pediatric pulmonologist&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">This case highlights the fact that in front of idiopathic bronchiectasis with normal basic immunological tests&#44; in cases of associated candidiasis&#44; DNA sequencing of exons of the STAT1 gene should be performed and&#47;or the child referred to a pediatric immunologist&#46;</p></span>"
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Article information
ISSN: 03002896
Original language: English
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