Journal of Allergy and Clinical Immunology

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Journal of Allergy and Clinical Immunology Defects in memory B-cell and plasma cell subsets expressing different immunoglobulin- subclasses in patients with CVID and immunoglobulin subclass deficiencies Elena Blanco, PhD, Martín Pérez-Andrés, PhD, Sonia Arriba-Méndez, MD, PhD, Cristina Serrano, MD, Ignacio Criado, PhD, Lucía Del Pino-Molina, PhD, Susana Silva, MD, PhD, Ignacio Madruga, MD, Marina Bakardjieva, MSc, Catarina Martins, PhD, Ana Serra-Caetano, MSc, Alfonso Romero, MD, Teresa Contreras-Sanfeliciano, MD, Carolien Bonroy, PhD, Francisco Sala, MD, Alejandro Martín, MD, PhD, José María Bastida, MD, PhD, Félix Lorente, MD, PhD, Carlos Prieto, PhD, Ignacio Dávila, MD, PhD, Miguel Marcos, MD, PhD, Tomas Kalina, MD, PhD, Marcela Vlkova, PhD, Zita Chovancova, MD, PhD, Ana Isabel Cordeiro, MD, Jan Philippé, MD, PhD, Filomeen Haerynck, MD, PhD, Eduardo López-Granados, MD, PhD, Ana E. Sousa, PhD, Mirjam van der Burg, PhD, Jacques J.M. van Dongen, MD, PhD, Alberto Orfao, MD, PhD Journal of Allergy and Clinical Immunology DOI: 10.1016/j.jaci.2019.02.017 Copyright © 2019 The Authors Terms and Conditions

Journal of Allergy and Clinical Immunology DOI: (10.1016/j.jaci.2019.02.017) Copyright © 2019 The Authors Terms and Conditions

Fig 1 Alterations in blood B-cell and PC subset counts useful for the diagnosis of PADs and for the differential diagnosis of IgAdef versus IgG/Adef versus CVID. A, Scheme illustrating the most useful peripheral blood B-cell subset alterations for the diagnosis of PADs (vs HDs; strongly reduced: absolute numbers lower than the minimum value in HDs) and the differential diagnosis of patients with IgAdef versus patients with IgG/Adef versus patients with CVID are shown. As displayed, these criteria showed a 100% and approximately 98% accuracy in the diagnosis of PADs and the discrimination between IgAdef and CVID, respectively, whereas approximately 10% of cases within both diagnostic subgroups overlapped with 10% and 10% of patients with IgG/Adef, respectively. B, Most useful peripheral blood B-cell subset criteria for the diagnosis of PAD versus HDs and the distinction between patients with IgAdef versus patients with CVID, patients with IgAdef versus patients with IgG/Adef, and patients with CVID versus patients with IgG/Adef are shown, together with the number of cases within the different diagnostic categories that fulfilled these criteria. Journal of Allergy and Clinical Immunology DOI: (10.1016/j.jaci.2019.02.017) Copyright © 2019 The Authors Terms and Conditions

Fig 2 Absolute counts of distinct maturation-associated subpopulations of blood B cells and PCs (A) and total switched, total IgA, and IgA subclass subsets of MBCs (B) and PCs (C) in patients with IgAdef (n = 68), patients with IgG/Adef (n = 10), and patients with CVID (n = 61) versus HDs (n = 223) grouped by age. Individual cases are represented as green dots (IgAdef), yellow dots (IgG/IgAdef), red dots (CVID), and gray dots (HDs). Dotted gray lines represent age-associated reference 5th and 95th values. Percentages of patients with reduced numbers compared with reference values per age group are depicted above each plot by using the same color code. Journal of Allergy and Clinical Immunology DOI: (10.1016/j.jaci.2019.02.017) Copyright © 2019 The Authors Terms and Conditions

Fig 3 Clustering analysis–based heat map representing all patients with PADs (A) and those with IgAdef (B) and CVID (C) grouped according to their (altered) blood MBC and PC subset immune profiles. Each heat map represents absolute counts of the different B-cell subsets normalized by the LLN in HDs for the corresponding age group (columns) versus individual cases (rows). Higher red color intensities represent a deeper degree of deficiency in a log10 scale compared with the corresponding age-matched LLN. Individual patients (rows) are identified by (1) their IUIS (clinical) diagnosis (Fig 3, A; light green for patients with IgAdef, intermediate green for patients with IgG/Adef, and dark green for patients with CVID); (2) their corresponding ESID IgAdef diagnosis (Fig 3, B), including IgAdef cases that fulfilled (black) or not (gray) the ESID criteria for IgAdef; and (3) CVID EUROclass classification subgroup (Fig 3, C), smB+CD21normal, smB+CD21lo, smB−CD21normal, smB−CD21lo, and B− cells from lighter to darker violet. The here-defined PAD-1 to PAD-5 (Fig 3, A), IgAdef-1 and IgAdef-2 (Fig 3, B), and CVID-1 to CVID-6 (Fig 3, C) clusters identified by using the K-means algorithm, as well as the main characteristics of these groups, are depicted at the right side of each heat map. Black arrows indicate those MBC and PC subsets that contributed most to the specific identification of each patient cluster. Journal of Allergy and Clinical Immunology DOI: (10.1016/j.jaci.2019.02.017) Copyright © 2019 The Authors Terms and Conditions

Fig 4 Illustrating dot plot examples of the numeric distribution of blood unswitched and switched MBC and PC subsets expressing different immunoglobulin isotypes and subclasses in a representative HD (A) and in representative patients with IgAdef (B) and CVID (C). Each plot corresponds to 3-dimensional Automated Population Separator (APS) views of principal component 1 (PC1) versus PC2 versus PC3 of the distinct subsets of MBCs and PCs defined by the immunoglobulin isotype and subclass expressed: IgM(D+) in green, IgG1 in light blue, IgG2 in intermediate blue, IgG3 in dark blue, IgG4 in black, IgA1 in orange, IgA2 in yellow, and IgD in violet. Additional cases from each group of patients with PADs are displayed in Figs E5 and E6. Journal of Allergy and Clinical Immunology DOI: (10.1016/j.jaci.2019.02.017) Copyright © 2019 The Authors Terms and Conditions

Fig 5 Frequency of distinct clinical manifestations of PADs and the existence (vs absence) of affected family members among the distinct clusters (ie, groups) of patients with IgAdef and those with CVID defined by their distinct patterns of altered blood B-cell and PC subset counts. Radar charts represent the percentage of patients with IgAdef (A) and patients with CVID (B) presenting with each type of clinical manifestation of the disease and the presence of family members affected by PADs. Colored lines indicate the distinct patient groups as defined by clustering analysis based on the B-cell and PC subset defects identified (see also Fig 3). #P ≤ .05 for patients with IgAdef-1 versus IgAdef-2. aP ≤ .05 for CVID-1 versus CVID-4. bP ≤ .05 for CVID-1 versus CVID-5. cP ≤ .05 for CVID-1 versus CVID-6. dP ≤ .05 for CVID-2 versus CVID-4. eP ≤ .05 for CVID-2 versus CVID-6. fP ≤ .05 for CVID-3 versus CVID-4. gP ≤ .05 for CVID-3 versus CVID-5. hP ≤ .05 for CVID-3 versus CVID-6. iP ≤ .05 for CVID-4 versus CVID-5. jP ≤ .05 for CVID-5 versus CVID-6. AI, Autoimmunity. Journal of Allergy and Clinical Immunology DOI: (10.1016/j.jaci.2019.02.017) Copyright © 2019 The Authors Terms and Conditions