Late Onset of Chronic Granulomatous Disease Revealed by Paecilomyces lilacinus Cutaneous Infection

Abstract

Chronic granulomatous disease (CGD) is an inherited immunodeficiency due to defective leukocyte NADPH responsible for recurrent infections and aberrant inflammation. Mutations in the CYBB gene are responsible for the X-linked CGD and account for approximately 70% of the cases. CGD is diagnosed during childhood in males. Female carriers may have biased X-inactivation and may present with clinical manifestations depending on the level of residual NADPH oxidase activity. We report the case of a previously asymptomatic female carrier who was diagnosed at age 67 with a skin infection with the rare fungus Paecilomyces lilacinus as the first manifestation of CGD. Dihydrorhodamine 123 (DHR) activity was below 10%. Next-generation sequencing (NGS) revealed mutations in DNMT3A, ASXL1, and STAG2 suggesting that clonal hematopoiesis could be responsible for a progressive loss of NADPH oxidase activity and the late onset of X-linked CGD in this patient. Long-term follow-up of asymptomatic carrier women seems to be essential after 50 years old.

Of Mycelium and Men: Inherent Human Susceptibility to Fungal Diseases

“…[ 369 ]. Additionally, CGD patients are at risk for infection with other moulds, albeit less frequently, including other hyalohyphomycetes (e.g., Paecilomyces [ 370 , 371 , 372 ] and the morphologically similar Rasamsonia [ 373 ] and Fusarium [ 374 ]) and basidiomycete mushrooms (e.g., Phellinus [ 375 , 376 , 377 ]). Thus, some patients may receive voriconazole or posaconazole prophylaxis.…”

Inborn errors of immunity in adulthood

“…X-linked carriers of null variants can also develop disease later in life [ 19 ]. Progressive skewing of X-chromosome inactivation in hematopoietic stem cells overtime can result in progressive reduction of normal protein production, eventually leading to symptomatology [ 21 ]. Another mechanistic cause of IEIs presenting in adulthood is the effect of genetic redundancy whereby other immune-related genes compensate for the defective protein until later in life [ 22 , 23 ].…”