Information on the following diseases can be found in the Related Disorders section of this report:

• Dermatitis, Atopic
• Granulomatous Disease, Chronic
• Wiskott-Aldrich Syndrome

The symptoms of AR-HIES vary from case to case. AR-HIES affects the immune system as well as the central nervous system. Symptoms may be apparent at birth (congenital) or during infancy or early childhood.

AR-HIES is considered a rare primary immunodeficiency disorder, one of a group of disorders characterized by irregularities in the cell development and/or cell maturation process of the immune system. The immune system is divided into several components, the combined actions of which are responsible for defending against different infectious agents (i.e., invading microscopic life-forms [microorganisms]). The T cell system (cell-mediated immune response) is responsible for fighting yeast and fungi, several viruses, and some bacteria. The B cell system (humoral immune response) fights infection caused by other viruses and particularly encapsulated bacteria. It does so by secreting immune factors called antibodies (also known as immunoglobulins) into the fluid portion of the blood (serum) and body secretions (e.g., saliva). There are four major classes of immunoglobulins (Ig) known as IgM, IgG, IgA, and IgE, , . Antibodies can directly kill microorganisms or coat them so they are more easily destroyed by white blood cells. (The white blood cells [leukocytes] are part of the body's system of defenses, playing an essential role in protecting against infection as well as fighting infection once it occurs.) In addition, antibodies are produced following vaccination, providing protection from infectious diseases like polio, measles, and tetanus.

Many individuals with AR-HIES have abnormally high levels of immunoglobulin IgE in the fluid portion of the blood (thus the term "hyper IgE"). Affected individuals also have abnormal clusters of white blood cells known as eosinophils throughout the body (eosinophilia). Because of problems within the immune system, individuals with AR-HIES are susceptible to recurrent episodes of certain bacterial infections that may affect the skin and lungs as well recurrent viral infections.

The first symptom of AR-HIES may be a dry, red flaky skin rash (eczema) that develops at birth or early during infancy. Itchiness (pruritis) may also occur. In addition, infants are particularly susceptible to bacterial infection, especially staphylococcal infections. Such infections may cause boils and pus-filled holes (abscesses) to form on the skin. These abscesses are referred to as “cold” abscesses because they lack the normal surrounding warmth and redness. Abscesses may also be found on the bone behind the ear (mastoid), joints, gums, air passages in the lungs (bronchi), and in the lungs themselves.

Individuals with AR-HIES also develop recurrent lung infections (pneumonia). Pneumonia is often associated with fluid accumulation around the lungs (pleural effusion) or pus in the area between the outer surface of the lung and the chest wall (empyema). Individuals with AR-HIES may develop repeated episodes of respiratory (bronchitis), sinus (sinusitis), and middle ear infections (otitis media).

Skin infections associated with AR-HIES are most often caused by Staphylococcus aureus. Pneumonia and respiratory infections associated with AR-HIES are most often caused by Staphylococcus aureus, Haemophilus influenzae, Proteus mirabilis, Pseudomonas aeruginosa, and Cryptococcus neoformans.

In addition to bacterial infections, individuals with AR-HIES are especially susceptible to viral infections as well. Affected individuals have developed infection with the herpes simplex virus, which causes inflammation of the cornea (keratitis) or the mouth (stomatitis). Some individuals with AR-HIES have developed a severe viral skin infection known as Molluscum contagiosum. This infection is characterized by raised bumps or growths (nodules) on the skin that often become red or inflamed. Nodules may be tender and itchy as well. One case reported in the medical literature developed repeated infection with the varicella zoster virus, the virus that causes chickenpox.

In addition to susceptibility to infection, individuals with AR-HIES may also have a variety of neurological symptoms. Such symptoms include partial facial paralysis, tissue degeneration due to lack of blood flow (ischemic infarction), inflammation of blood vessels (vasculitis) of the brain, and paralysis on one side of the body (hemiplegia). Neurological symptoms may progress to cause life-threatening complications including bleeding (hemorrhaging) in the brain or widening or bulging of the wall of a brain artery or vein (aneurysm).

Individuals with AR-HIES may also be prone to developing autoimmune disorders such as hemolytic anemia. The term "autoimmune" refers to conditions in which the body's natural defenses against invading microorganisms mistakenly attack healthy tissue. Hemolytic anemia is characterized by the premature destruction of red blood cells faster than they can be reproduced. Anemia may result in fatigue, paleness, a rapid heartbeat, shortness of breath, dark urine, and chills.

AR-HIES is inherited as an autosomal recessive trait. Genetic diseases are determined by the combination of genes for a particular trait that are on the chromosomes received from the father and the mother.

Recessive genetic disorders occur when an individual inherits the same abnormal gene for the same trait from each parent. If an individual receives one normal gene and one gene for the disease, the person will be a carrier for the disease, but usually will not show symptoms. The risk for two carrier parents to both pass the defective gene and, therefore, have an affected child is 25% with each pregnancy. The risk to have a child who is a carrier like the parents is 50% with each pregnancy. The chance for a child to receive normal genes from both parents and be genetically normal for that particular trait is 25%. The risk is the same for males and females.

All individuals carry 4-5 abnormal genes. Parents who are close relatives (consanguineous) have a higher chance than unrelated parents to both carry the same abnormal gene, which increases the risk to have children with a recessive genetic disorder. Several individuals with AR-HIES were from consanguineous parents.

The underlying immunological defects that result in AR-HIES are unknown. Researchers have speculated that abnormalities affecting T cells may be involved. Malfunction of the immune system can also lead to inflammation even without infection. This occurs when the immune system mistakenly acts against the healthy tissue of the body (autoimmunity).

AR-HIES affects males and females in equal numbers. More than 200 cases of hyper IgE syndrome (both the dominant and recessive forms) have been described in the medical literature. These disorders may often go unrecognized or misdiagnosed, making it difficult to determine their true frequency in the general population. Although AR-HIES is present during infancy, diagnosis may not be made until adolescence and, in some cases, adulthood.

The first case of hyper IgE syndrome was described in the medical literature in 1966. The physicians termed the disorder Job syndrome after the biblical character of Job who was covered in boils and sores over his entire body.

Symptoms of the following disorders can be similar to those of AR-HIES. Comparisons may be useful for a differential diagnosis.

Autosomal dominant hyper IgE syndrome (AD-HIES) is a rare primary immunodeficiency disorder. Like AR-HIES, it is associated with recurrent bacterial skin and lung infections. However, viral infections rarely occur. Individuals with AD-HIES also have characteristic facial features and various skeletal abnormalities including abnormal curvature of the spine (scoliosis) and repeated fractures of the long bones and ribs. Central nervous system abnormalities occur far less frequently in AD-HIES than AR-HIES and are less severe when they do. . The specific immunological defects associated with the two disorders also differ. Most cases of AD-HIES occur randomly as the result of a spontaneous genetic change (sporadically). (For more information on this disorder, choose "autosomal dominant hyper-IgE" as your search term in the Rare Disease Database.)

Atopic dermatitis is a chronic (long-lasting) disease that affects the skin. Dermatitis means inflammation of the skin and atopic refers to a group of diseases that are hereditary and often occur together. In atopic dermatitis, the skin becomes extremely itchy and inflamed causing redness, swelling, cracking, weeping, crusting, and scaling. Atopic dermatitis most often affects infants and young children, but it can continue into adulthood or first show up later in life. In most cases, there are periods of time when the disease is worse, called exacerbations or flares, followed by periods when the skin improves or clears up entirely, called remissions. Many children with atopic dermatitis will experience a permanent remission of the disease when they get older, although their skin often remains dry and easily irritated. Environmental factors can bring on symptoms of atopic dermatitis at any time in the lives of individuals who have inherited the atopic disease trait. Atopic dermatitis is often referred to as eczema, which is a general term for the many types of dermatitis. Atopic dermatitis is the most common of the many types of eczema. The cause of atopic dermatitis is unknown, although malfunction of the immune system plays a role. (For more information on this disorder, choose "atopic dermatitis" as your search term in the Rare Disease Database.)

Hypereosinophilic syndrome is a rare group of disorders characterized by abnormally high levels of certain white blood cells (eosinophils) are found in the body (eosinophilia) that occurs with no identifiable cause (idiopathic). Hypereosinophilic syndrome may not be associated with any symptoms (asymptomatic) or it can damage multiple organ systems of the body. General symptoms that may be associated with include fatigue, coughing, fever, muscle pain (myalgia), and breathlessness. Some affected individuals may develop a rash and itchiness (pruritis). Additional symptoms depend upon the specific organ systems involved. Hypereosinophilic syndrome occurs with greater frequency in men than women.

Diagnosis
A diagnosis of AR-HIES is made based upon a thorough clinical evaluation, a detailed patient history and identification of characteristic findings. Laboratory studies that may aid in a diagnosis include blood tests that demonstrate elevated levels of IgE in the blood and elevated levels of certain white blood cells known as eosinophils (eosinophilia).

X-ray studies such as computed tomography (CT scanning) may be used to detect lung infections. During a CT scan, a computer and x-rays are used to create a film showing cross-sectional images of certain tissue structures.


Treatment
The treatment of AR-HIES is directed toward the specific symptoms that are apparent in each individual. Treatment may require the coordinated efforts of a team of specialists. Pediatricians, dermatologists, pneumologists, immunologists, and other health care professionals may need to systematically and comprehensively plan an affect child’s treatment.

The mainstay for treatment of individuals with AR-HIES is preventative (prophylactic) antibiotic therapy against bacterial infection. Common antibiotic medications (e.g., anti-staphylococcal agents) used to treat individuals with AR-HIES include dicloxacillin, trimethoprim-sulfamethooxazole, cephalosporin, cotrimoxazole, and penicillin.
Surgical drainage of existing skin lesions, followed by a regimen of antibiotic therapy may be required in some cases. Topical steroids and moisturizing creams may also be used to treat skin lesions.

Genetic counseling may be of benefit for affected individuals and their families. Other treatment is symptomatic and supportive.

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.

For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:

Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: prpl@cc.nih.gov

A variety of treatments are under investigation for the treatment of individuals with AR-HIES including cyclosporine A, immunoglobulin supplementation, interferons, or bone marrow transplantation. Most of these treatments are used for individuals who are unresponsive to other forms of treatment. More research is necessary to determine the long-term safety and effectiveness of such potential therapies for individuals with AR-HIES.

Zerbe CS, Holland SM. Hyper IgE Syndrome. NORD Guide to Rare Disorders. Lippincott Williams & Wilkins. Philadelphia, PA. 2003:12-3.

Rimoin D, Connor JM, Pyeritz RP, Korf BR. Eds. Emory and Rimoin’s Principles and Practice of Medical Genetics. 4th ed. Churchill Livingstone. New York, NY; 2002:2085.

Frank MM, Austen KF, Claman HN, et al. Eds. Samter’s Immunological Diseases. 5th ed. Little Brown and Company, Boston, MA; 1995:541-5.

JOURNAL ARTICLES
Grimbacher B, Holland SM, Puck JM. Hyper-IgE syndromes. Immunol Rev. 2005;203:244-50.

DeWitt CA, Bishop AB, Buescher LS, Stone SP. Hyperimmunoglobulin E syndrome: two cases and a review of the literature. J Am Acad Dermatol. 2006;54:855-63.

Renner ED, Puck JM, Holland SM, et al., Autosomal recessive hyperimmunoglobulin E syndrome: a distinct disease entity. J Pediatr. 2004;144:93-99.

Grimbacher B, Holland SM, Gallin JI, et al., Hyper-IgE syndrome with recurrent infections – an autosomal dominant multisystem disorder. N Engl J Med. 1999;340:692-702.



Please cite the Immunity Tyk2 paper by Mineshegi et al, 2006; and our recent response correspondence in Immunity in 2007.

Please also cite the Textbook by Ochs et al., there is a chapter on HIES aswell by me, Holland and Puck.

ON THE INTERNET
Jyonouchi H. Hyperimmunoglobulinemia E (Job) Syndrome. Emedicine Journal, April 27, 2006. Available at: http://www.emedicine.com/ped/topic1074.htm Accessed on: October 20, 2006.

Schwartz RA. Job Syndrome. Emedicine Journal, July 11, 2006. Available at: http://www.emedicine.com/derm/topic845.htm Accessed on: October 20, 2006.

McKusick VA., ed. Online Mendelian Inheritance in Man (OMIM). Baltimore. MD: The Johns Hopkins University; Entry No:147060; Last Update:03/17/2004. Available at: http://www.ncbi.nlm.nih.gov/entrez/dispomim.cgi?id=147060 Accessed on: October 20, 2006.

McKusick VA., ed. Online Mendelian Inheritance in Man (OMIM). Baltimore. MD: The Johns Hopkins University; Entry No:243700; Last Update:05/07/1994. Available at: http://www.ncbi.nlm.nih.gov/entrez/dispomim.cgi?id=243700 Accessed on: October 20, 2006.