To our knowledge, this is the first case in which this mutation is spontaneously reversed in vivo in an ADA-deficient Wnt inhibitors clinical trials patient. Interestingly, it has been demonstrated in vitro that this mutation results in almost no ADA activity and correlates well with the severity of the disease [5]. Our patient showed severe lymphopenia from the age of 1 month and developed a neonatal life-threatening severe infection, showing that this mutation had a causative effect in the phenotype observed initially. Moreover our patient continued
to suffer from recurrent and chronic infections that eventually led to failure to thrive as well as organ damage. However, he survived past 4 years only with antimicrobials and IVIG; therefore, the progressive retention of ADA activity in the revertant cells not only increased his T cell counts in time (although we did not observe lymphoproliferation to PHA), but also ameliorated his clinical condition. This is in contrast to other revertant patients in which their mutations have been associated with a milder phenotype from the initial diagnosis, making it difficult
to establish the actual contribution of the somatic reversion to the phenotypes [20,13]. Revertant somatic mosaicism leading to unusual phenotypes continues to be reported in the literature suggesting that these events might be more common than initially considered. In these patients, the reversions resulted from multiple mechanisms (reviewed in [21]), however back mutations like the one found in our patient, are most likely random and may reflect an increased mutation DAPT datasheet rate because of the accumulation of mutagenic metabolites [22]. As our patient was not eligible for HSCT or GT, we placed him on ERT with PEG-ADA at the age of 50 months. However, we believe that the impact of this therapy mafosfamide was marginal because although his clinical condition improved during the first months (gain of weight and less severe and frequent infections), he also developed sclerosing cholangitis just after
2 months of ERT, a complication linked to opportunistic infections with protozoa in patients with other PID [23]; however, we could not identify any microorganism in the biliary tract of our patient. Furthermore, we could not find any reports of this complication in patients with ADA deficiency, therefore we don’t know if this might have had an impact in the response to the ERT therapy. Known complications that contribute to mortality during treatment with PEG-ADA include refractory haemolytic anaemia, chronic pulmonary insufficiency, lymphoproliferative disorders and solid tumours in the liver [6, 24, 25]. However, these have been identified in patients under different circumstances, and their relationship to the ERT has not been established. Finally, our patient is the first to our knowledge in which a rare and aggressive germinal cell tumour has been identified.