Combined immunodeficiency and atopy caused by a dominant negative mutation in caspase activation and recruitment domain family member 11 (CARD11) Harjit.

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Combined immunodeficiency in a patient with c-Rel deficiency

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Combined immunodeficiency and atopy caused by a dominant negative mutation in caspase activation and recruitment domain family member 11 (CARD11) Harjit Dadi, PhD, Tyler A. Jones, BS, Daniele Merico, PhD, Nigel Sharfe, PhD, Adi Ovadia, MD, Yael Schejter, MD, Brenda Reid, MN, Mark Sun, PhD, Linda Vong, PhD, Adelle Atkinson, MD, Sasson Lavi, MD, Joel L. Pomerantz, PhD, Chaim M. Roifman, MD Journal of Allergy and Clinical Immunology Volume 141, Issue 5, Pages 1818-1830.e2 (May 2018) DOI: 10.1016/j.jaci.2017.06.047 Copyright © 2017 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 1 Pedigree and structural analysis of the CARD11 R30W mutant. A, Pedigree of a multigenerational family with mutation in CARD11. The pedigree shows the heterozygous CARD11 R30W (c.88C>T) mutation in 4 genotyped cases. =, No variant detected. Circles represent female subjects, and squares denote male subjects. Half-solid symbols represent heterozygous subjects. The pedigree shows 3 generations of the family with 5 affected subjects. B, Structure of CARD11 protein with domains required for signaling activity. The R30W loss-of-function variant targeting the CARD domain is shown in green, whereas gain-of-function variants are shown in blue. The CARD sequence and secondary structure (helices α1-α6) are shown in the inset. C, Representation of the CARD11 CARD domain monomer structure. R30 is indicated in yellow. Residues at the CARD11:BCL10 interface are shown in violet, and residues required for ID interaction are shown in green. Journal of Allergy and Clinical Immunology 2018 141, 1818-1830.e2DOI: (10.1016/j.jaci.2017.06.047) Copyright © 2017 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 2 CARD11 R30W is a loss-of-function mutant with dominant negative activity. A, Indicated amounts in nanograms of expression vectors for wild-type (WT) or R30W mutant murine myc-CARD11 were expressed in 293T cells with the Igκ2-IFN-LUC reporter and the CSK-LacZ control, and levels of protein expression were assayed by means of Western blotting (WB) with anti-myc antibodies. B, Jurkat-KO T cells were transfected with Igκ2-IFN-LUC, CSK-LacZ, and expression vectors for wild-type or R30W CARD11, as indicated. To achieve a relative level of expression referred to as 1.0, 148 and 348 ng of expression vector were used, respectively, for the wild-type and R30W variants. To achieve 50% of that level of expression (referred to as 0.5), 107 and 200 ng of expression vector were used, respectively, for the wild-type and R30W variants. Forty hours after transfection, cells were stimulated for 5 hours with anti-CD3/anti-CD28 treatment and then harvested for luciferase and β-galactosidase assays. C, Jurkat-KO T cells were transfected with Igκ2-IFN-LUC, CSK-LacZ, and expression vectors for wild-type (WT) or R30W CARD11, as indicated. Forty hours after transfection, cells were stimulated for 5 hours with anti-CD3/anti-CD28 treatment and then harvested for luciferase and β-galactosidase assays. D, Equivalent amounts (107 ng) of expression vectors for wild-type or R30W mutant murine myc-CARD11 were expressed in 293T cells with the Igκ2-IFN-LUC reporter and the CSK-LacZ control, and levels of protein expression were assayed by means of Western blotting with anti-myc antibodies. E, Peripheral blood lymphocytes of patients 1 and 3 were stimulated with anti-CD3 plus anti-CD28 for the indicated period of time (in minutes). Protein samples were blotted with anti–phospho-p65 NF-κB, demonstrating a markedly diminished phosphorylation of p65 in patients compared with control subjects. F, Western blots show comparable expression of CARD11 in EBV-transformed B-cell lines obtained from patients and control subjects, as indicated. Journal of Allergy and Clinical Immunology 2018 141, 1818-1830.e2DOI: (10.1016/j.jaci.2017.06.047) Copyright © 2017 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 3 The R30W mutation affects binding to BCL10 and MALT1. HEK293T cells were transfected with expression vectors for wild-type and R30W variants of CARD11ΔID, FLAG-BCL10, FLAG-MALT1, and untagged BCL10, as indicated. Forty hours after transfection, anti-FLAG immunoprecipitations (IP) were performed, and the contents of the lysate input and immunoprecipitate were evaluated by Western blotting (WB) with the indicated antibodies. Journal of Allergy and Clinical Immunology 2018 141, 1818-1830.e2DOI: (10.1016/j.jaci.2017.06.047) Copyright © 2017 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 4 T-cell responses to antigens. Peripheral blood lymphocytes from patients and control subjects were incubated with antigens (Candida species, tetanus toxoid, zoster, and cytomegalovirus [CMV]) as indicated for 6 days, labelled with tritiated thymidine, harvested, and radioactivity counted. Three of 4 patients had no responses to cell antigens. Normal response is considered greater than 40 stimulation index. The figure displays a group of 44 control responses (mean ± SD). Journal of Allergy and Clinical Immunology 2018 141, 1818-1830.e2DOI: (10.1016/j.jaci.2017.06.047) Copyright © 2017 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 5 Clonal expansion in affected patients. The CD4+ and CD8+ T-cell repertoires of patients 1 (A), 2 (B), 3 (C), and 4 (D) were assessed by means of flow cytometry. All 4 patients had underrepresentation of 3 to 6 TCR Vβ families, and 4 to 7 overrepresented TCR Vβ families. The mean ± SD value was determined by assessing a large number of control subjects (>75 healthy subjects, mostly children). Journal of Allergy and Clinical Immunology 2018 141, 1818-1830.e2DOI: (10.1016/j.jaci.2017.06.047) Copyright © 2017 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 6 Cytokine secretion in response to PHA or anti-CD3 and anti-CD28. Peripheral blood lymphocytes (PBL) from patients (n = 2-3) or control subjects (n = 7-17) were stimulated with PHA or anti-CD3 and anti-CD28 for a period of 48 hours and subsequently assessed for IFN-γ (A), IL-2 (B), and IL-5 (C) secretion by means of ELISA. Control data are represented as means ± SDs. Comparisons were made with the unpaired t test. Journal of Allergy and Clinical Immunology 2018 141, 1818-1830.e2DOI: (10.1016/j.jaci.2017.06.047) Copyright © 2017 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 7 Defective T-cell activation in patients with CARD11 R30W mutations. A, T cells from control subjects and patients were stimulated with anti-CD3 and anti-CD28 or PMA, as indicated for 24 hours, and induction of CD25 was assessed by using flow cytometry. B, Comparison of CD25 and CD69 induction in T cells from control subjects and patients. Results are representative of 2 separate experiments with similar results. Journal of Allergy and Clinical Immunology 2018 141, 1818-1830.e2DOI: (10.1016/j.jaci.2017.06.047) Copyright © 2017 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig E1 Linear regression curves used to determine relative amounts of CARD11 wild-type (WT) and R30W expressed from a given DNA amount of expression vector. Band intensities over background from Fig 2, A, were quantitated by using ImageJ software and plotted. Best-fit linear regression equations and associated R2 values are shown. Journal of Allergy and Clinical Immunology 2018 141, 1818-1830.e2DOI: (10.1016/j.jaci.2017.06.047) Copyright © 2017 American Academy of Allergy, Asthma & Immunology Terms and Conditions