Long-Term Observational Study of Chronic Granulomatous Disease About 41 Patients From Tunisia and Comparison to Other Long-Term Follow-Up Studies

Abstract

Chronic granulomatous disease (CGD) is an inherited autosomal recessive or X-Linked primitive immunodeficiency (PID), due to a defective nicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex impairing anti-infectious and anti-inflammatory role of peripheral blood mononuclear cells. It is characterized by severe bacterial and fungal infections and by excessive inflammation leading to granulomatous complications. This work was made over a period of 34 years on 41 Tunisian patients suffering from CGD. Cumulative follow-up of patients was 2768.5 months, median 31 months. Survival was studied by survival curves according to Kaplan-Meier method. Lymphatic nodes, pulmonary and cutaneous infections predominate as revealing manifestations and as infectious events during patients’ monitoring. At study end 12 patients died mainly of invasive pulmonary aspergillosis and septicemia. Median age of death was 30 months. CGD remains compatible with a decent quality of life. Early diagnosis, anti-infectious prophylaxis, and initiation of adequate management, as soon as complication is perceived, promote pretty good evolution.

Keywords

allergy/immunology genetics hematology/oncology infectious diseases

Introduction

Chronic granulomatous disease (CGD) is an inherited and genetically heterogenous immunodeficiency disorder resulting from defects of one of the subunits of the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase enzyme complex in phagocytic cells. Mutations in at least 5 different genes involved in the assembly and activation of the NADPH oxidase can lead to CGD.¹ NADPH oxidase has membrane-associated (eg, gp91-phox and p22-phox) and cytosolic components (eg, p47-phox and p67-phox). The gp91-phox defect is inherited in an X Linked (XL) manner, whereas the p22-phox, p47-phox, and p67-phox defects are inherited in an autosomal recessive (AR) manner. The X-Linked form usually more severe, presents earlier, and has a higher mortality.^2,3

CGD is characterized by gene defects that can affect one of the various genes: CYBB, CYBA, NCF1, NCF2, NCF3, encoding, respectively, for, gp91phox, p22phox, p47phox, p67phox, and p40phox. The mutation of the CYBB gene located on the X chromosome is responsible for the XL CGD, whereas mutations at the other genes are responsible for the AR forms of the disease. These gene mutations are usually responsible for the absence of the corresponding protein or the presence of a nonfunctional protein resulting in a defective NADPH oxidase complex.^4,5 In addition to its anti-infectious role, NADPH oxidase has a crucial role in regulating and controlling inflammation. Thus, peripheral blood mononuclear cells (PBMCs) from CGD patients had impaired activation of Nrf2, a redox-sensitive transcriptional factor that induces oxidant scavenging pathways and functions to limit cellular injury and inflammation.⁶

CGD is characterized by severe bacterial and fungal infections and excessive inflammation. In addition, this defect predisposes to granulomatous complications and autoimmune diseases.^5,7

Although most CGD patients are diagnosed as toddlers, it can present in infancy and even in adulthood. However, a growing number of patients are diagnosed in later childhood or adulthood.^2,8

The frequent sites of infection are lung mainly pneumonia, skin mainly abscesses, lymph nodes (lymphadenitis), osteomyelitis, and sepsis.⁹ Perianal abscesses and gingivitis are also common.^2,10 The microbiology of infections in CGD is remarkable for its relative specificity. The overwhelming majority of infections in CGD are due to only a limited number of organisms: Staphylococcus aureus, Burkholderia (Pseudomonas) cepacia complex, Klebsiella pnuemoniae, Salmonella species, Serratia marcescens, Nocardia species, and Aspergillus species.

In addition to recurrent infections, CGD is also characterized by abnormally exuberant inflammatory responses leading to granuloma formation, such as granulomatous enteritis resembling Crohn’s disease.¹¹ The urogenital tract is the second most commonly affected organ with genitourinary obstruction¹² followed by the lungs¹³ and eyes.¹⁴

Despite the significant progress made in antibiotic and antifungal therapy and prophylaxis, patients with CGD still develop serious infections. The US National Institutes of Health (NIH) has followed more than 250 patients with CGD over almost 40 years, the majority of whom were diagnosed following infections of skin, lymph node, lung or liver. The diagnosis was usually established early in the life (median age of diagnosis 5.4 years), although a small proportion were diagnosed as adults. Notably, the majority of these later diagnoses were due to AR forms of CGD.^1,15

Diagnosis of CGD is based on the demonstration of an absent respiratory burst.¹⁶ Diagnosis of CGD can be made by either by the Nitroblue Tetrazolium (NBT) dye reduction test¹⁷ or using flow cytometry based Dihydrorhodamine (DHR) assay, which is a more objective test.¹⁸ This test represents a very sensitive and specific assay that reliably detects all NADPH oxidase deficiencies in neutrophils.^17,19

We tried in this article to emphasize majors’ clinical and paraclinical aspects of CGD. Prediagnosis and postdiagnosis particularities are put in light, as well as monitoring, treatment (prophylactic and cure), and the evolution of this disease. Data of patients’ future, survival, and quality of life conclude this work. Twelve patients died during the work period, principaly by invasive pulmonary aspergillosis and septicemia.

Patients and Methods

Patients

This is a retrospective epidemiological study led over 34 years (from January 1983 to December 2017) of 41 patients with CGD at the Bone Marrow Transplant Center (Tunis, Tunisia).

Methods

Biological diagnosis

CGD diagnosis was established for earlier and later patients, respectively, by Nitroblue Tetrazolium test (NBT) (37 patients) and flow cytometry-based Dihydrorhodamine (DHR) 123 assay (4 patients).

Innate and adaptative immunity were analyzed, respectively, by immunoglobulin assay, B (CD 19, CD20) and T cells immunophenotyping (CD3, CD4, CD8). Lymphocytes functionality was checked by lymphocyte proliferation tests.

Aspergillus infections were defined either by galactomannan positive assays and/or by other clinical and paraclinical characters.

The inheritance mode of the disease was evaluated by a family tree study, since we not dispose of genetic study.

Follow-up

Clinical, biological, and follow-up informations were collected on a datasheet. The infectious episodes considered correspond to cases where an organism has been identified during clinical manifestations and / or in cases where systemic antibiotic therapy has been necessary. All inflammatory complications and also therapeutics administrated to patients were reported. All patients have had prophylactic antibiotic (Co-trimoxazole [25 mg/kg/day]) and anti-fungus (Itraconazole [10 mg/kg/day]) therapy at CGD diagnosis. These therapies are reevaluated every 3 months. All patients were submitted every 3 months and a battery of clinical and paraclinical exams. They have had a chest radiography every 3 months looking for pulmonary aspergillosis and an abdominal echography, which is now more commonly used for diagnosis of deep abssess, particularly liver absess.

Statistical analysis

SPSS software (Statistical Product and Services Solutions, version 16.0, SPSS Inc, Chicago, IL, USA) was used for statistical analyses. Survival data were studied by establishing survival curves according to Kaplan–Meier method. Survival forecasts factors search was made in univariate analysis by comparing the survival curves by the Log Rank test.

Results

Epidemiological Characteristics of Patients

Among the 41 studied patients, 28 (68%) were male and 13 (32%) female. All 41 patients belong to 33 families, and parental consanguinity was found in 68% of patients (Figure 1). Seven patients (17%) had family histories of GCD and 24 (58%) of the studied families have a history of 43 young deaths in a primary immunodeficiency context.

Figure 1.

Patients repartition according to the degree of consanguinity.

Clinical Study

Thirty six (88%) of patients developed the most frequent clinical symptoms commonly observed during this pathology. Lymphatic nodes proliferation, pulmonary, and cutaneous infections were the predominant types of symptoms present in our patients. In 75% of cases, those symptoms developed during the first year of life, 17% between 1 and 5 years, 5% between 5 and 10 years, and only 1 patient developed symptoms after the age of 10 years. Thirty one patients had BCG vaccine at birth and 17 among them developed BCG-itis, which was respectively, generalized 6 (35%), locoregional 6 (35%), and local 5 (30%).

CGD diagnosis was made at age 19 months in median (range: 1-683 months). For 16 patients (39%), CGD diagnosis was made before age 1 year, and then for 18 patients (44%), 3 (7%) and 4 (10%) patients, respectively, between ages 1 and 5 years, 5 and 10 years, and over 10 years. One of the patients with a liver abscess was 57 years old at CGD diagnosis. This patient had a Klebsiella pneumoniae septicemia, associated with 5 liver abscesses, a purulent casting of the right eye and severe hyalite of the left eye, responsible for a sequellar cecity.

Time limit between clinical symptoms onset and CGD diagnosis was 10 months in median (range: 0-135 months). For 2 patients born before 1985, CGD was made after 8 years and over 2 years for 9 patients (22%). This time limit was of 10 months for both patients born, respectively, after (range: 0-39) and before (range: 0-135) year 2000, no statistically significant difference was found between these 2 groups.

Eleven patients (27%) had a delayed height-weight development and only 6 (15%) a delayed weight development. Also 11 patients had hepatosplenomegaly, and 4 (10%) had an isolated hepatomegaly or splenomegaly.

Paraclinical Findings

Complete blood count

Anemia was found in 29 patients (70.7%), it was microcytic and normocytic, respectively, in 83% and 13% of cases. Twenty patients (49%) had hyperleucocytosis, and 20 patients (48.7%) had thrombocytosis.

NBT and DHR123 assays

All patients have had a semiquantitative NBT assay, for 30 of them (73%), NBT reduction was complete and weak for the 27 % remaining. DHR123 assay was performed for only 4 patients, and values were, respectively, 0%, 1%, 10%, and 10%.

Immunoglobulin assay

Respectively, 22 (53%) and 20 (49%) of patients had elevated IgG and IgA values.

Lymphocytes subpopulation count

Lymphocytes subpopulation count was performed for only 54% of patients. T CD8+ elevated count was found for 12 patients (34%), and T CD4+/ TCD8+ ratio was elevated for 5 patients (12%).

Lymphocyte proliferation tests

Lymphocyte proliferation tests were performed entirely for 37 patients (90%), results showed a normal proliferation ranging, respectively, from 24% for Candida, 32% Tetanos, 46 % anti-CD3, 49% PHA, and 51% Tetanus.

Genetic study

As we had no access to genetic studies, genetic inheritance mode study was based on family tree study, which had revealed that for 27 patients (66%), CGD inheritance mode was AR, and that it was X linked for 12 patients (29%). For 2 patients (5%), we could not determine the inheritance mode.

Treatment and Patient Monitoring

Cumulative follow-up of patients was 2768.5 months, median of 31 months (range: 0-336).

Prophylactic treatment

Twenty eight patients (68%) have had Co-trimoxazole and Itraconazole at CGD diagnosis, 3 patients (7%) were lost from view after CGD diagnosis, 2 patients (5%) received first ketoconazole treatment, and 3 died soon after CGD diagnosis. Those treatments were well tolerated by patients. Five patients (12%) received voriconazole as antifungal and 9 (22%) INF-γ following severe infections.

Infectious episodes

One hundred twenty-seven infectious episodes were identified over the monitoring period, what means 0.045 episode/patient month (Table 1). Among those infectious episodes, 40 severe infections (31.5%) requiring hospitalization and intravenous antibiotic therapy were identified, what means 0.014 severe infection/patient month.

Table 1.

Percentage of Different Infectious Episodes During Patient Monitoring.

	Pulmonary	Mucocutaneous	Lymph nodes	Gastrointestinal	Septicemia	Osteomyelitis	Liver abscess
Our results [41]	24.4	33.6	15	8	8	4	2.4
France & Swiss 1988 [48]²⁰	16.5	22.6	35.5	16.2	-	2.8	4.2
Japan 1999 [221]²¹	88.2	77.6	85.8	44.4	22.7	28.4	46
USA 2000 [368]²	79	42	53	15	0	25	27
Germany 2000 [39]²²	23	18	18.2	18.4	2.1	2.9	0
Iran 2006 [13]²³	#100	#56	#42	#15	0	#21	0
Italy 2007 [60]²⁴	14.2	14.5	6.6	9.4	4.1	1.6	3.8
Spain 2007 [13]²⁵	11.3	29.5	13.6	7.9	6.8	3.4	-
Israel 2008 [38]²⁶	84	42	61	29	29	29	63
England & Ireland 2008 [94]²⁷	29.2	69	29	37	10.8	7.4	22
Japan 2008 [23]¹⁰	39.9	3	15.3	14.2	1.5	6.9	3.9
Europe 2009 [438]²⁸	20.7	11.1	20.3	21	3.6	2.7	7.8
Turkey 2013 [89]²⁹	83.5	44.9	65.1	22.3	20.7	23.3	62.3
India 2014 [17]³⁰	29.2	20.4	23.3	7.3	4.4	3.6	4.4
USA 2015 [27]³¹	29.7	14.8	22.6	3.1	3.1	3.9	10.1
LASID 2015 [71]³²	#75	#40	#60	#35	#15	#15	-
Israel 2016 [84]³³	74	51	61	25	20	20	39
China 2018 [169]³⁴	95.9	45.38	58.5	43.1	28.5	7.7	4.6

[], number of patients; -, not mentioned; LASID, Latin American Society of Primary Immunodeficiencies; _, Percentage of patients; #: Approximate value.

Among infection episodes, cutaneous infections predominated with 43 episodes (33.6%), followed by pulmonary infections (24.4%) and lymphatic nodes infections (15%) (Figure 2).

Figure 2.

Infectious events during patient monitoring.

Microbiological profile

Microbiological study concerned 102 infectious episodes, representing 80.3% of all infections (Table 2). Microorganisms have been found only in 75.5% of explored episodes. Among those microorganisms, 18 types of organisms were identified in 86 samples. Bacteria was identified in 58 samples (67%), fungus in 18 (21%), parasites in 5 (6%) and viruses in 5 (6%) samples.

Table 2.

Percentage of Germs Commonly Found in Infectious Complications During CGD.

	Aspergillus	Staphylococcus	Salmonella	Klebsiella Pneumonia	Escherichia Coli	Corrynebacterium	Serratia
Our results [41]	18.8	18.8	10.4	8.1	5.8	5.8	4.6
France & Swiss 1988 [48]²⁰	16	31	14	2	7	0	7
USA 2000 [368]²	41	12	<1	0	0	0	5
Germany 2000 [39]²²	8	30	6	5	5	0	0.6
Italy 2007 [60]²⁴	32	20	2	2	2	0	10
Spain 2007 [13]²⁵	20.4	14.3	12.2	8.1	0	0	10.2
Israel 2008 [38]²⁶	39	45	21	3	26	0	16
England & Ireland 2008 [94]²⁷	5.2	13.9	2.2	0	0	0	0
Japan 2008 [23]¹⁰	45	—	—	—	—	—	—
Europe 2009 [438]²⁸	26	30	16	2	0	0	4
India 2014 [17]³⁰	36	2	0	0	0	0	0
USA 2015 [27]³¹	4	10.1	7.8	5.4	-	-	8.5
LASID 2015 [71]³²	13	20.3	7.2	10.1	4.3	0	8.7
Israel 2016 [84]³³	35	37	13	0	17	0	15
China 2018 [169]³⁴	5.3	32.14	7.1	10.71	7.1	0	0

Abbreviations: CGD, chronic granulomatous disease; [], number of patients; -, not mentioned; LASID, Latin American Society of Primary Immunodeficiencies; _, Percentage of patients.

Mainly isolated organisms were Staphylococcus and Aspergillus each in 16 infectious episodes. Galactomannan tests were positive, negative, and not made, respectively, in 31%, 50% and 19% of cases. For those positive the distribution was as follow, 13 pulmonary invasive infections, 1 osteomyelitis and 2 liver abscesses.

Management and evolution of infectious episodes

Forty-three mucocutaneous infections of different types and localizations were observed for 18 patients with an average of 2.4 infections/patient, and were distributed as follow, cutaneous abscess (26%), oral trush (21%), perianal abscess (16%), and miscellaneous infections (pustular dermatitis, boil, paronychia, etc) (37%). Thirty nine of these infections were explored, and organisms were found in 28 cases.

Thirty one pulmonary infection episodes were reported, which represented 24.4% of all identified infections, only 27 of them were explored. So we have identified 13 aspergillosis, 4 Haemophilus influenzae infections, 1 Staphylococcus infection and no organisms were identified for the 9 remaining infections. Ten patients have had pulmonary aspergillosis at a mean age of 67.5 months (range: 23-132). Note that for 2 patients, such infections were CGD revealing. Evolution after treatment (amphotericin B, voriconazole, flucytosine) was favorable for 9 patients, but unfortunally 1 patient had lost sight. Infection recurrence affected 3 patients, 1 of which died later of skin fistulization with costal involvement.

Nineteen lymph node infections were diagnosed, 14 infectious nontuberculous adenitis, 4 adeno phlegmons and 1 lymph node tuberculosis. Organisms commonly found were found in 17 pulmonary infections, respectively, 13 with Aspergillus and 4 with H influenzae; 16 Staphylococcus infections (10 mucocutaneous, 4 of lymph nodes and 1 pulmonary); 6 with K pneumoniae (3 mucocutaneous and 3 of lymph nodes), 5 Cytrobacterium infections (3 mucocutaneous and 2 of the lymph nodes). Other organisms were less fond, as Esherichia Coli, Enterobacter, Serratia, Proteus, Mycobacterium tuberculosis, Candida albicans, and so on.

Among the 10 gastroenteritis infectious episodes diagnosed in 7 patients, 8 were explored. Organisms implicated were, Entamoeba histolitica (4 cases), Salmonella (2 cases), and in 1 case, respectively, Giardia and Rotavirus. Evolution was favorable except for 1 patient who developed a Salmonella septicemia.

Ten episodes of septicemia occurred in 10 patients; respectively, 7 were due to Salmonella typhi, 1 to E coli, 1 to Staphylococcus, and 1 to K pneumonia. Four among these patients died of septicemia, respectively, 2 to Salmonella, 1 to E coli, and 1 to K pneumoniae. Five patients experienced each one an osteomyelitis episode, due, respectively, to Serratia (2 cases), C albicans (1 case), Aspergillus (1 case) and no organisms was identified in 1 case. Mean age onset of these infections was 72.2 months (range: 14-132). Osteomyelitis reached vertebra, hand and feet bones, frontal bone, long bones and mastoid bone. Evolution was favorable for 3 patients, 1 developed a chronic osteomyelitis and 1 had a C albicans cerebral abscess secondary to mastoid bone lesion which resolved gradually weeks later after surgical drainage, Amphotericin B and fluconazole medical treatment. Note that additionally to medical treatment, 3 patients had interferon-gamma therapy.

Other infectious episodes occurred for some patients, as liver abscess (3 patients), organisms implicated were Aspergillus, Proteus and Enterobacter; sinusitis (2 patients) due to H influenza, and peritonitis (1 patient), acute media otitis (1 patient) and Long-term fever (2 patients).

Inflammatory and granulomatous episodes

Ten patients had hepatomegaly and 12 splenomegaly and 1 patient had a scrotal granuloma . One patient had a Crohn-like colitis which became corticosteroid dependent, only TNFα has allowed a favorable evolution after months of cellcept and IFN-γ therapy. Six patients have had atopic eczema lesions.

Patients’ Future, Survival and Quality of Life

At December 31^th 2017, 22 patients (54%) were alive, 12 (29%) died and 7 (17%) were out of sight. Invasive pulmonary aspergillosis and septicemia were the most common death causes, (Table 3). Median age of death was 30 months (range: 7-253).

Table 3.

Major causes of Death by Number of Deceased Patients.

	Pneumonia, CLD& other lung disease		Sepsis		Nervous system disorders		Unknown & miscellaneous
	cause	Nb	Cause	Nb	cause	Nb
Our results [41]	Aspergillus	4	Salmonella	2			3
Our results [41]	unknown	1	E. coli	1			3
			Klebsiella	1
France & Swiss 1988 [48] “unknown” ²⁰	Aspergillus but no site had been reported
Japan 1999 [221] “36” ²¹	Aspergillus	10	Candida	2			6
Japan 1999 [221] “36” ²¹	unknown	4	Unknown	4			6
USA 2000 [368] “65” ²	Aspergillus	23	Burkholderia	9	Candida	2	18
USA 2000 [368] “65” ²	Burkholderia	5			Unknown	2	18
Germany 2000 [39] “8” ²²	Aspergillus	3	P. aeruginosa	1			1
Germany 2000 [39] “8” ²²	fibrosis	3	P. aeruginosa	1			1
Italy 2007 [60] “6” ²⁴	Aspergillus	2			Aspergillus	1	2
Italy 2007 [60] “6” ²⁴	Candida	1			Aspergillus	1	2
Spain 2007 [13] “4” ²⁵			GNB	1			3
Spain 2007 [13] “4” ²⁵							3
Jordan 2008 [15] “4” ³⁵	Aspergillus	1	Salmonella	1			1
Jordan 2008 [15] “4” ³⁵			Unknown	1			1
Israel 2008 [38] “7” ²⁶			Unknown	1
Israel 2008 [38] “7” ²⁶	CLD	5	Unknown	1
England & Ireland 2008 [94] “24” ²⁷	Pneumonia & septicemia: most common cause of death. Aspergillus species accounted for 50% of the causes of death where an organism was reported.
Japan 2008 [23] “3” ¹⁰	Aspergillus	2					1
Japan 2008 [23] “3” ¹⁰							1
Europe 2009 [438] “84” ²⁸	Aspergillus	12	Unknown	10	Aspergillus	3	44
	unknown	6	Burkholderia	3	unknown	1
	CLD	2	Salmonella	2
	CLD	2	Candida	1
Turkey 2013 [89] “9” ²⁹	Majority of death by sepsis caused by Aspergillus infections in the brain and lung.
India 2014 [17] “6” ³⁰	—	3	Unknown	3
India 2014 [17] “6” ³⁰
USA 2015 [27] “3” ³¹	unknown	1	Burkholderia	1	Measles	1
Israël (2016) [84] “16”³³	CLD + aspergillosis	3	Aspergillus	3
	CLD + pneumonia	2	P aeruginosa	1
	CLD	3	Staphylococcus	1
			Candida	2
China 2018 [169] ³⁴	unknown 2		S typhimurium	1214			29
			Aspergillus
			Unknown

Abbreviations [], number of patients; “ “, Total number of dead; CLD, chronic lung disease; GNB, gram negative bacillus; LASID, Latin American Society of Primary Immunodeficiencies, Nb: number.

In some cases, 1 patient may present many complications the same time, but we counted 1 mortal complication by patient.

Overall survival

The average survival rate and the average death rate were respectively, 53.6% and 29.2% (Table 4). The overall survival during the first year of disease was 74% and decreased to 71% after 5 years of evolution and persisted until 20 years of evolution. After 20 years and until 30 years of disease evolution, overall survival persisted constant at 47% (Figure 3).

Table 4.

Survival and Mortality Rates in CGD in Some International Studies.

	O.S rate at 10	O.S rate at 20	O.S rate at 25	O.S rate at 30	Average survival rate	Average mortality rate	Average age of death (years)
Our results [41]	67 %	56 %	56%	56 %	53.6 %	29.2%	4.5 (0.6-21)
France & Swiss 1988 [48] ²⁰	50 %	50%	—	—	—	—	—
Japan 1999 [221] ²¹	—	—	—	—	68.7%	23%	—
USA 2000 [368] ²	-	25.5 %	-	—	—	17.6 %	—
Germany 2000 [39] ²²	—	—	—	—	—	20 %	21(5-29)
Iran 2006 [13] ²³	—	—	—	—	84%	—	—
Italy 2007 [60] ²⁴	97 %	83 %	46 %	—	—	13 %	14
Spain 2007 [13] ²⁵	—	—	—	—	—	30 %	—
Jordan 2008 [15] ³⁵	—	—	—	—	86.6%	13.4%	2.9 (0.8-5)
Israel 2008 [38] ²⁶	—	—	—	—	68.4%	26%	—
England & Ireland 2008 [94] ²⁷	88 %	73 %	-	55 %	—	—	—
Japan 2008 [23] ¹⁰	—	87 %	—	—	—	13 %	—
Europe 2009 [438] ²⁸	—	—	—	—	—	—	—
Turkey 2013 [89] ²⁹	90 %	63 %	63 %		82 %	10 %	10.8 (3-24)
India 2014 [17] ³⁰	—	—	—	—	—	35 %	1.6 (0.6-14)
USA 2015 [27] ³¹	—	—	—	—	—	11.5%	—
China 2018 [169] ³⁴	—	—	—	—	—	36.6%	3.3

Abbreviations: CGD, chronic granulomatous disease; O.S., overall survival (years); [], number of patients; —: not mentioned.

Figure 3.

Overall survival curve according to monitoring years.

According to age, overall survival of patients without considering the date of diagnosis was 92% at 1 year of age and 72% at 2 years of age. Between ages 5 years to 20 years, overall survival was 67% and between ages 20 years to 30 years it decreased to 56% (Figure 4).

Figure 4.

Overall survival curve as a function of age.

According to the genetic likely inheritance mode, overall survival with respect to age in the AR forms of the disease seems to be higher than this in forms linked to X, but there was not a statistically significant difference (Figure 5 and Table 5).

Figure 5.

Global survival curve in relation to age according to the disease inheritance mode.

Table 5.

Survival and Mortality Rates in CGD in International Studies According to Its Genetic Transmission Modes.

	O.S rate at 10		O.S rate at 20		Average mortality rate		Average age of death (years)
	XLM	ARM	XLM	ARM	XLM	ARM	XLM	ARM
Our results (*) [41]	60 %	73%	0 %	73 %	41.6 %	22.2 %	—	—
France & Swiss 1988 [48] ²⁰	55 %	75 %	55 %	50%	25%	18 %	—	—
USA 2000 [368] ²	78.8 %	91.4 %	22 %	42 %	21.2 %	8.6 %	—	—
Germany 2000 [39] ²²	82 %	100 %	68 %	74 %	22.5 %	12.5 %	—	—
Jordan 2008 [15] ³⁵	—	—	—	—	14 %	0 %	—	—
Israel 2008 [38] ²⁶	75 %	95 %	50 %	90 %	27 %	25 %	—	—
Europe 2009 [438] ²⁸	87 %	95 %	76 %	90 %	23 %	15 %	—	—
Turkey 2013 [89] ²⁹	90 %	90 %	63 %	69 %	8.8 %	12 %	—	—
India 2014 [17] ³⁰	—	—	—	—	57 %	20 %	0.8	9
China 2018 [169] ³⁴

Abbreviations: CGD, chronic granulomatous disease; O.S, Overall survival (years); [], number of patients; XLM, X-linked mode; ARM, autosomal recessive mode; -, not mentioned; (*), probable mode of transmission.

Overall survival of patients treated with IFN-γ

The comparison of overall survival with a 10 years follow-up since CGD diagnosis, between the 9 patients that have received IFN-γ and those that do not, found no statistically significant difference between those 2 groups (Figure 6).

Figure 6.

Overall survival according to IFN-γ treatment.

Quality of life

Twenty two patients were alive at the time of the study, among them, 13 have had a Karnofsky score higher than 80%, 7 a score of 70%, and 2 a score of 50%. The 2 oldest patients were born in 1983, so they were 34 years old at the time of the study. No patient experienced malignancies or hemopathies during monitoring.

Discussion

Survival According to CGD Duration Time

Overall survival was 74% in the first year of follow-up, from 5 until 20 years it stabilized at 71% and then between 20 and 30 years it decreased to stabilize at 47% (Figure 3). The relative stability of the survival rate after 5 years of follow-up may be explained by a better knowledge of the disease and its complications by physicians and a better management once CGD diagnosis has been established. Regular and rapid patients’ follow-up and specialized management of any complication, anti-infectious prophylaxis established as soon as CGD diagnosis is made, count also in survival rate stabilization. Whereas the fall of this rate to 47% during the third decade can be explained by occurrence of severe infections despite adequate management, due to the development of drug resistance. Overall survivals at 10 and 20 years were higher than those found in the study of Mouy et al²⁰ carried out in 1988, which would probably be due to the absence of effective antifungal treatment at that time. Those rates were below those found in many European studies carried out beyond year 2000, at, respectively, 10 years,^24,27,29 20 years^10,24,27,29 and 25 years,^24,29 with the exception of the English serie²⁷ which shows at 30 years a slightly lower overall survival than ours.

Survival in Relation to Age

Since overall survival at 2 years of age was 72%, mortality in the first 2 years of life may be explained by the ignorance of primary immunodeficiencies (PID) by doctors who ensure the initial management of patients, the existence of children born before 1985 (where the disease was not well known and the care still not well codified), the epidemiological peculiarities of each country and also, existence of severe forms leading to rapid death (Figure 4). The plateau survival rate at 67% between 5 and 20 years can be explained by a lower susceptibility to infections at this age du to maturation of immune system. A lower rate of exposure to infections at these ages, as well as careful monitoring that contributes to better survival.

The average mortality rate in our study is close to that found in the Spanish series,²⁵ but it is higher than that found in many studies carried out in developed countries^{2,10,21,22,24,29,31,36} and some Middle East countries.^23,26,35 Only a recent Indian study³⁰ showed a mortality average rate higher than ours. Whereas, the average survival rates were higher than ours^{21,23,26,29,35} (Table 4). Concerning average age of death, our results were lower than those of some European countries^22,24,29 but higher than those of Jordan³⁵ and India.³⁰ The high rate of mortality in the first year of follow-up can be explained by: existence of severe forms of CGD leading to rapid death, difficulties in the management and medical resuscitation of these patients, erroneous diagnosis in cases where the clinical presentation has been modified by previous antibiotic therapy that was unjustified because abusive or not adapted to common CGD organisms.

Influence of CGD Inheritance Mode on Age Specific Survival and Disease Severity

The overall age-related survival was higher in likely AR forms that in probably XL forms (Figure 5). The absence of a statistically significant difference between the overall survivals of the 2 modes of inheritance of the disease is not very informative since there is no genetic study confirming the true mode of inheritance.

In our study, the overall 10-year survival rates for both XL and AR CGD were similar to those of the Mouy et al.²⁰ Whereas for survival at 20 years the differences between our results were clear, especially regarding the XL form. According to the different studies^{2,20,22,26,28-31,34,35} and even ours, survival rates at 10 and 20 years are higher for AR forms than for XL ones (Table 5). Köker et al³⁷ reported that the severity of the disease was related to the residual capacity of oxygen reactive forms and a residual activity of NADPH oxidase, which was thus associated with better survival.

Antecedents and Epidemiological Characteristics of CGD

In our study, CGD affects more boys than females, with a sex-ration of 2.15. In different studies^{2,10,20,26,28,30,31,34} there is also a male predominance. Parental consanguinity is found in 68% of the cases (Figure 1), which may explain the relative high frequency of AR forms. The European experience²⁸ noted a prevalence of these forms among immigrant groups from Arab countries and Turkey, which reflects the high frequency of consanguineous marriages in these communities. In our study, a history of confirmed CGD in the family was found in 17% of patients and allowed for earlier diagnosis of the disease as reported.³⁸ The recurrence of infant deaths also represent an indicator of PID.^39,40 In our series, notion of infant death is found in 58% of families, with an average of 2.3 deaths per family, suggesting the existence of CGD familial forms of particularly severe expression.

Clinical Characteristics of CGD

Fifty-five percent of our patients developed a BCG-itis, which represented the most frequent complication of vaccination, it was nonlocalized in 65% of the cases. The frequency of these complications varies from one study to another, while for Fattahi et al,³⁸ 60% of patients had BCG-itis, this frequency was 20% for Köker et al,³⁷ 30% for de Oliveira-Junior et al³² and dropped to 8% in the European experience.²⁸ Whereas, Zhou et al³⁴ reported, respectively, 46.2% and 13.1% of probable and definitive BCG infection. These differences may be explained by the fact that in Europe, except for France, BCG vaccination is not systematic. Some studies^41-43 suggest a particular vulnerability of patients with CGD to BCG vaccine, hence the need to evoke PID and in particular CGD in the case of nonlocalized or trailing BCG-itis. Nonvaccination with BCG as a preventive measure for patients with a familial history of CGD prevents this complication, which can become fatal in its generalized form. It was thus recommended to contraindicate the BCG vaccine in CGD.^31,41 Kawashima et al,⁴⁴ have suggested banning such vaccination before the age of 3 months. The production of tuberculosis vaccines from DNA fragments or ribosomal subunits could solve this problem.^45,46

For our patients, infections of Lymph nodes, lungs and skin predominated as manifestations revealing CGD. While the main revealing manifestations of CGD are the same, their percentages differ from one study to another.^2,13,21,34 While for some authors^29,34,38 it was pneumonia, for others^22,27 adenitis, cutaneous abscesses and pneumonia predominated. Recurrent pneumonia, pulmonary abscesses and adenitis constituted the bulk of CGD revelatory manifestations for some other studies^{2,24,26,30,32} For Bortoletto et al,³¹ lymphadenitis and skin abscess predominated.

Cutaneous granulomas is the clinical forms of cutaneous involvement most suggestive of CGD diagnosis, thus they may localisate in different sites according to the initial infectious focus. In our study a particular localization was found for 1 patient, it was a voluminous suppurative nasal granuloma, responsible for a loss of substance of nasal cartilage. Such types of granuloma are reported to be one of a particular complications revealing CGD; it’s generally secondary to a long lasting infection.^31,32,47

For our patients, three-quarters of the clinical manifestations related to CGD began in the first year of life, which is in agreement with other works. Thus, for Mouy et al²⁰ and Wolach et al,²⁶ these clinical manifestations began before 1 year of age, respectively, for 70.8 and 65.7% of their patients. Köker et al²⁹ reported that, 82.4% of XLCGD and 50% of AR CGD developed such clinical manifestations before age 1 year.

However, appearance of the clinical characteristics of the CGD, even if they are early, does not constitute a guarantee for a positive diagnosis of this disease. Thus, in our study, we reported the case of a patient for whom the diagnosis of CGD was made at age 57 years. Some authors have reported cases of late CGD diagnosis in adulthood.^36,48-52 Therefore there is a need to keep the possibility of a CGD diagnosis in mind even in an adult patient with recurrent purulent infection or granulomas.

Delay Between Onset of Clinical Manifestations and Positive Diagnosis

In our study, median age at diagnosis was 19 months (range:1-683). Positive diagnosis of CGD before 1 year was posed in 39% of cases, while the major percentage of positive diagnosis (44%) was posed between the age of 1 and 5 years. Only 1 case of extreme diagnosis was made a 57-year-old patient. Rawat et al³⁰ reported a median age at diagnosis of 36 months (range: 7-192), Martire et al²⁴ reported that the diagnosis of CGD was carried out in 20% of patients before the age of 1 year and that between 1 and 5 years, 10 and 20 years, respectively, 60% and 18 % of patients had been diagnosed, and an only 1 patient was diagnosed at 38 years of age. Winkelstein et al² reported that 76% of their patients were diagnosed before the age of 5 years, and 4% beyond the third decade of their life, the oldest patient diagnosed was 69 years old. Whereas van den Berg et al²⁸ reported that over half of their patients have had CGD diagnosis between 1 and 5 years of life, with 3 cases diagnosed after 40 years.

For our patients, time limit between clinical symptoms onset and CGD diagnosis was 10 months in median (range: 0-135). This time limit was of 10 months (range: 0-39), and also 10 months (range: 0-135) for patients born, respectively, after and before year 2000, no statistically significant difference was found between this 2 groups. A median delay in diagnosis of 2 years (range: 0-9), was reported by Rawat et al.³⁰ de Oliveira-Junior et al³² reported that there was a substantial interval between the manifestation of the first symptoms of CGD and the time of diagnosis. The mean age at the first occurrence of symptoms was 23.9 months (range: 0.13-156), and the mean age at diagnosis was 52.7 months (range: 1-199). Whereas, Magnani et al,⁵³ reported an age at disease onset of 0.3 years (range: 0-9.2), and an age at diagnosis of 1.4 years (range: 0-12.8). Bortoletto et al³¹ have observed a decrease in age at diagnosis in relation to more recent diagnostic dates, which would confirm better diagnostic tests and an accumulated awareness of CGD. These facts were confirmed by Zhou et al,³⁴ who reported a 5.5 months (range 1.2-16.5) delay, in their series, where 85.4% of patients were born after 2008, with an age of onset disease from 4 to 48 months.

The age at positive diagnosis was earlier in XL forms than in AR forms^{2,21,22,27,28,30,34,38} suggesting earlier and more severe expression of the XL forms. This fact probably reflects a milder phenotype of AR CGD, and hence more specific immunological testing at a early age than for X-linked forms, and not a bias in more early CGD diagnosis. Or it could be a more adequate screening of possibly affected boys in extended families with XLCGD, leading to very early diagnosis (eg, at birth) before any manifestations of disease signs.²⁸ As CGD is more commonly diagnosed in boys than in girls, we emphasize that girls with AR CGD may be missed as the index of suspicion is lower. This was certainly true for SCID, where x-linked disease was thought to be a higher percent of overall disease prior to newborn screening. In actuality girls were more likely to die undiagnosed because SCID was not considered, the same seems true for CGD.

In our study, 27% of patients had delayed weight development and hepatosplenomegaly at CGD diagnosis. What was reported by many authors^{22,26,27,30,31,34,36} and probably constituted a clinical consequence of recurrent infections and inflammations affecting the digestive tract. Hence the importance of thorough clinical examination and exploration of unexplained delayed height-weight development and unexplained hepatosplenomegaly.

Paraclinical Data

Anemia was found in 70% of our patients. This anemia was most often hypochromic microcytic probably related to a deficiency of supply or malabsorption, or secondary to inflammation. Wolach et al²⁶ reported that 74% of their patients were suffring from anemia. Kutluğ et al⁵⁴ found that anemia was one of the most common laboratory findings found in CGD. For Köker et al²⁹ the most common chronic manifestation in patients with CGD was anemia caused by chronic infection. According to Ross,¹⁹ iron-deficiency anemia can be in some cases, a presenting symptom of CGD, and it constitutes one among its inflammatory and structural complications.⁵⁵

Hyperleukocytosis and thrombocytosis were found in 49% of our patients. Carnide et al⁵⁶ reported that hyperleukocytosis may be frequent even in the absence of acute infection, probably because of the persistence of a chronic stimulus. As for thrombocytosis, it is related to the inflammatory state of the patients. Thrombocytopenia would be related to the autoimmune manifestations of the CGD.^57,58

Hypergammaglobulinemia account among the frequent inflammatory and structural complications of CGD and it’s considered among laboratory results frequently found in CGD patients.⁵⁵ IgG and IgA elevated values were found for, respectively, 53% and 49% of our patients, Rawat et al³⁰ reported such an elevation. Hypergammaglobulinemia would be related to the involvement of healthy effectors of acquired immunity in order to compensate for the failure of innate immunity. It’s also possible that a continuous inflammatory response causes chronic anemia and hypergammaglobulinemia in these patients.^55,59 This hypergammaglobulinemia has been reported since the first studies on CGD,⁶⁰ so it should represent an alert for CGD diagnosis, especially in the presence of an evocative clinical picture.⁵⁶

Only 34% of patients for whom lymphocytes count was made showed an elevated TCD8+ count (c). Whereas Rawat et al³⁰ found that lymphocyte subsets were within normal range in most of their patients. As the Th1 type cells secrete IFN-γ which activates macrophages and TCD8 + subpopulation; these last can in turn amplificate to compensate for the macrophages failure.

No lymphocyte proliferation disorder was described during CGD, however, a defect in the regulation of T lymphocyte activity may be one of the causes of the hyperinflammatory state observed in the CGD.¹⁹ Absent proliferation against specific antigens is likely to be the consequence of a lack or exceedance of the vaccination recall period. In all cases, a negative test should be confirmed after the vaccine recall.⁶¹

In our study determination of CGD inheritance mode was made thanks to the study of patients’ pedigree which showed a predominance of the AR inheritance mode. Other populations, Iranian,³⁸ Palestinian and Israelian,²⁶ Tunisian,⁶² Turkish²⁹ and migrant groups from North Africa and Arab countries in the European study,¹³ showed the same results. Whereas, the XLform was more frequently found in French,²⁰ English,²⁷ Japanese,¹⁰ American³¹ and Latin American³² studies.

Anti-Infectious Prophylaxis

The mainstay of clinical care in children with CGD is lifelong antibiotic and antifungal prophylaxis. Trimethoprim/ sulfamethoxazole (TMP-SX) (co-trimoxazole) is commonly employed for long-term prophylaxis.¹⁶ Prophylactic TMP-SX reduced the frequency of major infections from 1 episode every year to 1 every 3.5 years in a study by Margolis et al.⁶³ Itraconazole is the recommended prophylaxis for fungal infections, since it’s highly effective against Aspergillus species.¹⁶ Experiments have shown an improvement in phagocyte function following IFN-γ injections in-vitro, whereas, studies are still contradictory about the real benefit of using this therapy.^64,65 Eighty-six percent of our patients have received prophylactic treatment with co-trimoxazole and itraconazole and only 22% received INF-γ not as prophylactic therapy but following severe infections.

Infectious Complications During CGD Monitoring

Patients with CGD suffer from a variety of recurrent bacterial and fungal infections, which occur most commonly in organs in contact with the outside world/: lungs, gastrointestinal tract, skin and lymph nodes that drain these structures. Because of both contiguous and haematogenous spread of infection, a wide range of other organs can be affected, most notably the liver, bones, kidneys and brain. In approximately two-thirds of patients, the first symptoms of CGD appear during the first year of life in the form of infections, dermatitis (sometimes seen at birth), gastrointestinal complications (obstruction or intermittent bloody diarrhea due to colitis).^7,19

Microorganims Isolated From Patients

The infectious agents most frequently encountered during infectious complications are catalase positive, as Staphylococcus and Salmonella. Staphylococcus predominated in mucocutaneous and lymphatic infections. While Aspergillus, a fungus family member were mostly isolated in pneumonia.

In the revised definitions of diagnosis of invasive fungal disease (IFD), EORTC / MSG criteria⁶⁶ classifies these infections as: “proven,” “probable” and “possible.” These criteria include host, clinical, mycological and immunological conditions. The category of “possible” IFD was retained but was defined more strictly to include only those cases with the presence of appropriate host factors and with sufficient clinical evidence consistent with IFD. Whereas patients with CGD were included in such group even if their infection was without mycological support, which makes easier the diagnosis of possible “invasive fungal infection” in this patients.

In our study, Aspergillus antigenemia was only positive in 31% of cases, almost as reported by Beauté et al⁶⁷ The study of Aspergillus antigenemia by the galactomannan enzyme immunoassay is considered to be insensitive in CGD cases, because the antifungal prophylaxis and because the absence of fungal angio-invasion in this disease.⁶⁸ So, microbiological diagnosis of invasive aspergillosis remains difficult to establish in CGD.^7,34 As percentage of infections or as percentage of infected patients, pulmonary, mucocutaneous and lymphatic infections predominate in the majority of studies (Table 1). Aspergillus, Staphylococcus and Salmonella representing the organisms most frequently found in these infections (Table 2). For our patients, Salmonella was the most frequently isolated during septicemia. Moreover, other unusual organisms make increasingly their apparition in these patients, hence the importance of carrying out a microbiological diagnosis each time before any anti-infectious treatment.²⁴

Granulomatous and Inflammatory Complications

Not all encounters with microorganisms lead to overt pyogenic infections in CGD. In some cases, chronic inflammatory cell reactions consisting of lymphocytes and histiocytes develop. These inflammatory reactions can then organize to form granulomas, one of the hallmarks of CGD which can cause various clinical symptoms of obstruction. Recent research has concentrated on the origin of the hyperinflammatory state of CGD patients, and 2 different causes which are not necessarily mutually exclusive have been proposed. These are the involvement of autophagy in the microbial killing process and a mechanism of excessive T-cell activation prevention by phagocytes.¹⁹ On the other hand, efferocytosis (made by neutrophils) which is critical for quenching engoing inflammation and tissu necrosis, seems to be impaired in murine model of CGD.^69,70

For our patients, such complications were relatively rare and limited, and were mostly present as clinical manifestations revealing CGD. During disease evolution, hepatomegaly and splenomegaly was found, respectively, in one-quarter and one-third of our patients. A genital granuloma was also found in 1 patient, and 1 patient has had a Crohn-like colitis. No patient had autoimmune complications and 6 patients have had atopic eczema lesions. Some authors ^2,28,36,53 reported higher percentages of such complications, what is perhaps secondary to a more accurate clinical and paraclinical monitoring and/or a longer survival of patients.

Patients’ Evolution and Life Quality

Infections remain the major cause of death in CGD patients^{2,10,21,22,24-31,33,35,36,71,72} For our patients, the most frequent complications incriminated in deaths were pulmonary infections and septicemia. Aspergillus and Salmonella were the most implicated organisms. These results are consistent with those of other studies (Table 3). For Aspergillus, some species may be more virulent, as Aspergillus nidulans, who is more associated with invasive aspergillosis, because of its’ resistance against antifungal therapy.⁷³ Other organisms as Burkholderia cepacia formerly (Pseudomonas cepacia), are increasingly associated with morbidity and mortality in patients with CGD. This is due to the pathogenic mechanism of this bacterium, which induces significant necrosis levels of neutrophils, suggesting another severe pathological mechanism of the infection seen with Burkholderia in this patients.⁷⁴

Treatment with IFN-γ showed no improvement in our patients’ survival (Figure 6). Other studies have come to the same conclusions.^22,24-^26,28 Whereas most European physicians do not use IFN-γ prophylaxis routinely in CGD.¹⁶ American studies show a greater benefit for the survival in the treated patients,^2,31,64 although the American Academy of Allergy, Asthma & Immunology (AAAAI) guidelines recommended IFN-γ only for patients who have experienced severe infections.

A Karnofsky score greater than or equal to 80% was found in 59% of our surviving patients. Suggesting that CGD is a disease that can be associated with a satisfactory quality of life and that its adequate management makes it a chronic somewhat weakly disabling disease in some patients.

Most data from the literature agree that the association between GCD and malignant complications is unusual. None of our patients developed a tumor complication or hemopathy, despite the duration of the development of the CGD in some of them. However, rare cases of malignancies were reported. Wolach et al²⁶ found T-cell acute lymphoblastic leukemia (ALL) in a patient with XLCGD, which had a good evolution after treatment. The same authors⁷¹ found a cervix carcinoma of the uterus in a 25-year old woman with AR-CGD. Other tumor types have also been reported as, malignant melanoma,^6,28 cervical fibrosarcoma,⁶ retinoblastoma, rhabdomyosarcoma⁷⁵ and Hodgkin lymphoma.⁷⁶

Conclusion

Our study is in accordance with previous studies that have shown pulmonary infections to be the most frequent clinical presentation followed by skin infections and lymphadenopathy, these complications were also the most frequent as CGD revealing manifestations. As reported, overall survival with respect to age in the AR forms of the disease was significantly higher than this in forms linked to X. Despite its disabling character, CGD remains one among PIDs most associated with a decent quality of life. Early diagnosis, based on thorough interrogation and complementary explorations, the introduction of anti-infectious prophylaxis and the initiation of adequate management, as soon as a complication is perceived, promotes pretty good evolution for this disease.

Author Contributions

FM: contributed to conception and design; contributed to acquisition, analysis, and interpretation; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

HK: contributed to design; contributed to analysis and interpretation; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

ML: contributed to design; contributed to acquisition and analysis; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

MBK: contributed to design; contributed to acquisition; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

SR: contributed to design; contributed to acquisition; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

EBF: contributed to design; contributed to acquisition; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

MO: contributed to design; contributed to acquisition; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

MRB: contributed to conception; contributed to interpretation; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

MB: contributed to conception and design; contributed to analysis and interpretation; drafted manuscript; critically revised manuscript; gave final approval; agrees to be accountable for all aspects of work ensuring integrity and accuracy.

Footnotes

Acknowledgements

All data reported in this manuscript whether it be clinical, paraclinical and biological are part of the routine exams made for such patients. There is no conflict of interest of any other kind.

The authors would like to thank all the staff who have contributed to the monitoring and care of patients during these long years. We would also like to thank the patients and their families (especially parents), who were able over time to learn how to take care of their children.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Habib Ksouri

References

Segal

Leto

Gallin

Malech

Holland

. Genetic, biochemical, and clinical features of chronic granulomatous disease. Medicine (Baltimore). 2000;79(3):170-200.

Winkelstein

Marino

Johnston

Jr , et al. Chronic granulomatous disease: report on a national registry of 368 patients. Medicine (Baltimore). 2000;79(3):155-169.

Goldblatt

Thrasher

. Chronic granulomatous disease. Clin Exp Immunol. 2000;122(1):1-9.

Segal

Han

Bushey

, et al. NADPH oxidase limits innate immune responses in the lungs in mice. PLoS ONE. 2010;5:e9631.

Segal

DeCarlo

Kwon-Chung

Malech

Gallin

Holland

. Aspergillus nidulans infection in chronic granulomatous disease. Medicine (Baltimore). 1998;77:345-354

Finn

Hadzić

Morgan

, et al. Prognosis of chronic granulomatous disease. Arch Dis Child. 1990;65:942-945.

Rider

Jameson

Creech

. Chronic granulomatous disease: epidemiology, pathophysiology, and genetic basis of disease. J Pediatric Infect Dis Soc. 2018;7(suppl 1):S2-S5.

Kanariou

Spanou

Tantou

. Long-term observational studies of chronic granulomatous disease. Curr Opin Hematol. 2018;25(1):7-12.

Wintergerst

Kuijpers

Rosenzweig

, et al. Phagocytes defects. In: Rezaei

Aghamohammadi

Notarangelo

, eds. Primary Immunodeficiency Diseases: Definition, Diagnosis, and Management. 2nd ed. Berlin, Germany: Springer; 2017: 245-294.

10.

Kobayashi

Murayama

Takanashi

, et al. Clinical features and prognoses of 23 patients with chronic granulomatous disease followed for 21 years by a single hospital in Japan. Eur J Pediater. 2008;167:1389-1394.

11.

Marciano

Rosenzweig

Kleiner

, et al. Gastrointestinal involvement in chronic granulomatous disease. Pediatrics. 2004;114:462-468.

12.

Barese

Podesta

Litvak

Villa

Rivas

. Recurrent eosinophilic cystitis in a child with chronic granulomatous disease. J Pediatr Hematol Oncol. 2004;26(3):209-212.

13.

Mahdaviani

Mohajerani

Rezaei

Casanova

Mansouri

Velayati

. Pulmonary manifestations of chronic granulomatous disease. Expert Rev Clin Immunol. 2013;9:153-160.

14.

Goldblatt

Butcher

Thrasher

Russell-Eggitt

. Chorioretinal lesions in patients and carriers of chronic granulomatous disease. J Pediatr. 1999;134(6):780-783

15.

Hong

Dionis

, et al. Focus on FOCIS: the continuing diagnostic challenge of autosomal recessive chronic granulomatous disease. Clin Immunol. 2008;128(2):117-126.

16.

Rawat1

Bhattad1

Singh

. Chronic granulomatous disease. Indian J Pediatr (April. 2016;83(4):345-353.

17.

Baehner

Nathan

. Leukocyte oxidase: defective activity in chronic granulomatous disease. Science. 1967;155:835-836.

18.

Vowells

Sekhsaria

Malech

Shalit

Fleisher

. Flow cytometric analysis of the granulocyte respiratory burst: a comparison study of fluorescent probes. J Immunol Methods. 1995;178:89-97.

19.

Roos

. Chronic granulomatous disease. Br Med Bull. 2016;118(1):50-63.

20.

Mouy

Fischer

Vilmer

Seger

Griscelli

. Incidence, severity, and prevention of infections in chronic granulomatous disease. J Pediatr. 1989;114(4. Pt 1):555-560.

21.

Hasui

. Chronic granulomatous disease in Japan: incidence and natural history. Pediatr Int. 1999;41(5):589-593

22.

Liese

Kloos

Jendrossek

, et al. Long-term follow-up and outcome of 39 patients with chronic granulomatous disease. J Pediatr. 2000;137(5):687-693.

23.

Khalilzadeh

Bloorsaz

Mansouri

Baghaie

Hakimi

Velayati

. Clinical and radiological aspects of chronic granulomatous disease in children: a case series from Iran. Iran J Allergy Asthma Immunol. 2006;5(2):85-88

24.

Martire

Rondelli

Soresina

, et al. Clinical features, long-term follow-up and outcome of a large cohort of patients with Chronic Granulomatous Disease: an Italian multicenter study. Clin Immunol. 2008;126(2):155-164

25.

Soler-Palacín

Margareto

Llobet

, et al. Chronic granulomatous disease in pediatric patients: 25 years of experience. Allergol Immunopathol (Madr). 2007;35(3):83-89

26.

Wolach

Gavrieli

de Boer

, et al. Chronic granulomatous disease in Israel: clinical, functional and molecular studies of 38 patients. Clin Immunol. 2008;129(1):103-114

27.

Jones

McGrogan

Flood

, et al. Special article: chronic granulomatous disease in the United Kingdom and Ireland: a comprehensive national patient-based registry. Clin Exp Immunol. 2008;152(2):211-218

28.

van den Berg

van Koppen

Ahlin

, et al. Chronic granulomatous disease: the European experience. PLoS ONE. 2009;4(4):e5234

29.

Köker

Camcıoğlu

van Leeuwen

, et al. Clinical, functional, and genetic characterization of chronic granulomatous disease in 89 Turkish patients. J Allergy Clin Immunol. 2013;132(5):1156-1163.

30.

Rawat

Singh

Suri

, et al. Chronic granulomatous disease: two decades of experience from a tertiary care centre in North West India. J Clin Immunol. 2014;34(1):58-67.

31.

Bortoletto

Lyman

Camacho

Fricchione

Khanolkar

Katz

. Chronic granulomatous disease: a large, single-center US experience. Pediatr Infect Dis J. 2015;34(10):1110-1114.

32.

de Oliveira-Junior

Zurro

Prando

, et al. Clinical and genotypic spectrum of chronic granulomatous disease in 71 Latin American patients: first report from the LASID registry. Pediatr Blood Cancer. 2015;62(12):2101-2107.

33.

Wolach

Gavrieli

de Boer

van Leeuwen

Berger-Achituv

Stauber

, et al. Chronic granulomatous disease: Clinical, functional, molecular, and genetic studies. The Israeli experience with 84 patients. Am J Hematol. 2017 Jan; 92(1):28-36.

34.

Zhou

Hui

Ying

, et al. A Cohort of 169 chronic granulomatous disease patients exposed to BCG vaccination: a retrospective study from a single center in Shanghai, China (2004-2017). J Clin Immunol. 2018;38(3):260-272.

35.

Bakri

Martel

Khuri-Bulos

, et al. First report of clinical, functional, and molecular investigation of chronic granulomatous disease in nine Jordanian families. J Clin Immunol. 2009;29(2):215-230.

36.

Dunogué

Pilmis

Mahlaoui

, et al. Chronic granulomatous disease in patients reaching adulthood: a nationwide study in France. Clin Infect Dis. 2017;64(6):767-775.

37.

Köker

van Leeuwen

de Boer

, et al. Six different CYBA mutations including three novel mutations in ten families from Turkey, resulting in autosomal recessive chronic granulomatous disease. Eur J Clin Invest. 2009;39(4):311-319.

38.

Fattahi

Badalzadeh

Sedighipour

, et al. Inheritance pattern and clinical aspects of 93 Iranian patients with chronic granulomatous disease. J Clin Immunol. 2011;31(5):792-801.

39.

Barbouche

Sghiri

Mellouli

Boukhdir

Dellagi

Béjaoui

. Chronic septic granulomatous disease. 14 Cases. Presse Med. 1999;2728(37):2034-2036.

40.

Bejaoui

Barbouche

Sassi

, et al. Primary immunodeficiency in Tunisia: study of 152 cases. Arch Pediatr. 1997;4(9):827-831

41.

Bustamante

Aksu

Vogt

, et al. BCG-osis and tuberculosis in a child with chronic granulomatous disease. J Allergy Clin Immunol. 2007;120(1):32-38

42.

Movahedi

Norouzi

Mamishi

Rezaei

. BCGiosis as a presenting feature of a child with chronic granulomatous disease. Braz J Infect Dis. 2011;15(1):83-86

43.

Vieira

Vasconcelos

Fernandes

, et al. Lymphadenopathy after BCG vaccination in a child with chronic granulomatous disease. Pediatr Dermatol. 2004;21(6):646-651.

44.

Kawashima

Hasegawa

Nakamura

, et al. Hazards of early BCG vaccination: BCGitis in a patient with chronic granulomatous disease. Pediatr Int. 2007;49(3):418-419

45.

Andersen

. TB vaccines: progress and problems. Trends Immunol. 2001;22(3):160-168.

46.

Collins

Wilson

Campbell

, et al. Production of avirulent mutants of Mycobacterium bovis with vaccine properties by the use of illegitimate recombination and screening of stationary-phase cultures. Microbiology (Reading). 2002;148(Pt10):3019-3027.

47.

Benajiba

Amrani

Rkain

, et al. Serratia marcescens cutaneous gumma and chronic septic granulomatosis. Med Mal Infect. 2014;44(1):39-41.

48.

Asensi

Tricas

Meana

, et al. Visceral leishmaniasis and other severe infections in an adult patient with p47-phox-deficient chronic granulomatous disease. Infection. 2000;28(3):171-174

49.

Wolach

Scharf

Gavrieli

de Boer

Roos

. Unusual late presentation of X-linked chronic granulomatous disease in an adult female with a somatic mosaic for a novel mutation in CYBB. Blood. 2005;105(1):61-66.

50.

Sarwar

de Malmanche

Rassam

Grainge

Williams

Arnold

. Chronic granulomatous disease presenting as refractory pneumonia in late adulthood. Respirol Case Rep. 2015;3(2):54-56.

51.

Colin

Verdière

Noel

Lozano

, et al. Respiratory complications lead to the diagnosis of chronic granulomatous disease in two adult patients. J Clin Immunol. 2017;37(2):113-116.

52.

Liese

Jendrossek

Jansson

, et al. Chronic granulomatous disease in adults. Lancet. 1996;347(8996):220-223

53.

Magnani

Brosselin

Beauté

, et al. Inflammatory manifestations in a single-center cohort of patients with chronic granulomatous disease. J Allergy Clin Immunol. 2014;134(3):655-662.

54.

Kutluğ

Şensoy

Birinci

Saraymen

Yavuz Köker

Yıldıran

. Seven chronic granulomatous disease cases in a single-center experience and a review of the literature. Asian Pac J Allergy Immunol. 2018;36(1):35-41.

55.

Song

Jaishankar

Saleh

Jithpratuck

Sahni

Krishnaswamy

. Chronic granulomatous disease: a review of the infectious and inflammatory complications. Clin Mol Allergy. 2011; May 319(1):10.

56.

Carnide

Jacob

Castro

Pastorino

. Clinical and laboratory aspects of chronic granulomatous disease in description of eighteen patients. Pediatr Allergy Immunol. 2005;16(1):5-9

57.

De Ravin

Naumann

Cowen

, et al. Chronic granulomatous disease as a risk factor for autoimmune disease. J Allergy Clin Immunol. 2008;122(6):1097-1103

58.

Ben Abdallah Chabchoub

Turki

Mahfoudh

. Systemic lupus erythematosus in a boy with chronic granulomatous disease: case report and review of the literature. Arch Pediatr. 2014;21(12):1364-1366.

59.

O’Neill

Brault

Stasia

Knaus

. Genetic disorders coupled to ROS deficiency. Redox Biol. 2015;6:135-156

60.

Janeway

Craig

Davidson

, et al. Hypergammaglobulinemia associated with severe recurrent chronic non-specific infection. Am J Dis Child. 1954;88:388-392.

61.

Principi

Esposito

. Vaccine use in primary immunodeficiency disorders. Vaccine. 2014;32(30):3725-3731.

62.

El Kares

Barbouche

Elloumi-Zghal

, et al. Genetic and mutational heterogeneity of autosomal recessive chronic granulomatous disease in Tunisia. J Hum Genet. 2006;51(10):887-895.

63.

Margolis

Melnick

Alling

Gallin

. Trimethoprim-sulfamethoxazole prophylaxis in the management of chronic granulomatous disease. J Infect Dis. 1990;162(3):723-726

64.

The international chronic granulomatous disease cooperative study group. A controlled trial of interferon gamma to prevent infection in chronic granulomatous disease. N Engl J Med. 1991;324:509-516.

65.

Loffredo

Perri

Zicari

Del Ben

Angelico

Violi

. Chronic granulomatous disease as an SOS call for multicenter cooperative effort to prevent infections: a meta-analysis of the treatments. Ann Allergy Asthma Immunol. 2016;117(3):285-289

66.

De Pauw

Walsh

Donnelly

, et al. European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group; National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Revised Definitions of Invasive Fungal Disease from the European Organization for Research and Treatment of Cancer/invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clin Infect Dis. 2008;46(12):1813-1821.

67.

Beauté

Obenga

Le Mignot

, et al. Epidemiology and outcome of invasive fungal diseases in patients with chronic granulomatous disease: a multicenter study in France. Pediatr Infect Dis J. 2011;30(1):57-62

68.

Falcone

Holland

. Invasive fungal infection in chronic granulomatous disease: insights into pathogenesis and management. Curr Opin Infect Dis. 2012;25(6):658-669.

69.

Fernandez-Boyanapalli

McPhillips

Frasch

, et al. Impaired phagocytosis of apoptotic cells by macrophages in chronic granulomatous disease is reversed by IFN-γ in a nitric oxide-dependent manner. J Immunol. 2010;185:4030-4041.

70.

Fernandez-Boyanapalli

Frasch

Riches

, et al. PPARγ activation normalizes resolution of acute sterile inflammation in murine chronic granulomatous disease. Blood. 2010;116:4512-4522.

71.

Marciano

Spalding

Fitzgerald

, et al. Common severe infections in chronic granulomatous disease. Clin Infect Dis. 2015;60(8):1176-1183.

72.

Blumental

Mouy

Mahlaoui

, et al. Invasive mold infections in chronic granulomatous disease: a 25-year retrospective survey. Clin Infect Dis. 2011;53(12):e159-69

73.

Bylund

Campsall

Conway

Speert

. Burkholderia Cenocepacia induces neutrophil necrosis in chronic granulomatous disease. J. Immunol. 2005;174:3562-3569.

74.

Weel

Redekop

Weening

. Increased risk of malignancy for patients with chronic granulomatous disease and its possible link to the pathogenesis of cancer. Eur J Cancer. 1996;32A:734-735.

75.

Lugo Reyes

Suarez

Herbigneaux

, et al. Hodgkin lymphoma in 2 children with chronic granulomatous disease. J Allergy Clin Immunol. 2011;127(2):543-544

76.

Norouzi

Aghamohammadi

Mamishi

Rosenzweig

Rezaei

. Bacillus Calmette-Guérin (BCG) complications associated with primary immunodeficiency diseases. J Infect. 2012;64(6):543-554.