Chronic Granulomatous Disease - CGD

  • Diagnosis
  • Algorithms
  • Background
  • Lab Tests
  • References
  • Related Content

Indications for Testing

Laboratory Testing

  • Neutrophil oxidative burst assay (DHR) via flow cytometry
    • Preferred screening test
    • Disease is indicated by absence or significant alteration of activity
  • Other, less reliable tests
    • Measurement of superoxide production, ferricytochrome C reduction, nitroblue tetrazolium test
  • Nonspecific testing to rule out other disorders
    • Serum quantitative immunoglobulins – rule out hypogammaglobulinemia
    • Complement activity enzyme immunoassay – rule out complement deficiency
    • CBC with differential – rule out other causes of chronic infection (eg, neutropenic disorders)
    • Leukocyte adhesion deficiency panel – rule out leukocyte adhesion deficiency
  • Genetic testing
    •  X-linked chronic granulomatous disease (CGD) – CYBB gene
    • Autosomal recessive CGD – NCF1, NCF2, NCF4, CYBA genes

Differential Diagnosis

Immunodeficiency Evaluation for Chronic Infections in Adults and Older Children Testing Algorithm

Immunodeficiency Evaluation for Chronic Infections in Infants and Children Testing Algorithm

Chronic granulomatous disease (CGD) is an inherited primary immunodeficiency disorder characterized by severe, recurring infections with formation of granulomas. Phagocytic cells ingest but cannot digest bacteria or fungi due to a malfunction of the nicotinamide adenosine dinucleotide phosphate (NADPH) oxidase system.

Epidemiology

  • Incidence – 1/250,000 births
  • X-linked CGD
    • CYBB – 60-70% of cases
  • Autosomal recessive CGD
    • NCF1 – 25% of cases
    • CYBA – <5% of cases
    • NCF2 – <5% of cases
    • NCF4 – very rare
  • Age – dependent on type of CGD
    • Classic X-linked in males – typically <3 years
    • Carrier females of X-linked – usually >3 years
    • Females with skewed X-chromosome inactivation – similar to males
  • Sex – M>F by 85%

Inheritance

  • X-linked form – 60-70% of cases
    • Involves CYBB gene mutations in the 13 exons encoding the 91-kD heavy chain of cytochrome b558
      • Typically earlier onset and more severe disease than autosomal recessive CGD
  • Autosomal recessive forms
    • NCF1 – encodes p47-phox
      • GT deletion in exon 2 accounts for majority of mutations
    • CYBA – encodes p22-phox
    • NCF2 – encodes p67-phox
    • NCF4 – encodes p40-phox

Pathophysiology

  • Function of phagocytes (neutrophils and macrophages)
    • First line of defense against bacterial and fungal infections
    • Migrate to the site of infection – phagocytosis occurs, which generates microbicidal reactive oxygen products
    • Neutrophils and macrophages are ingested by the phagosome
    • Other nonoxidative factors are added that assist in killing pathogenic microorganisms
  • CGD – abnormalities of neutrophils and macrophages
    • Gene mutations cause defective microbicidal oxidant production secondary to a defect in the neutrophil respiratory burst
    • Results in decreased production of superoxide, hydrogen peroxide, hydroxyl radical, and hypochlorite ions within neutrophils and macrophages
      • Defective production causes susceptibility to infections from organisms that may be nonpathogenic in an immunocompetent individual
      • Most common infections – bacterial (eg, catalase-positive microorganisms) and fungal organisms

Clinical Presentation

  • Signs and symptoms usually appear very early in childhood
    • May not present until later in life, especially with mild cases or autosomal recessive/variant forms of X-linked CGD
  • Ophthalmic – chorioretinitis
  • Gastrointestinal – nausea, diarrhea, vomiting, colitis/enteritis with inflammatory bowel disease (IBD)-like manifestations (blood in stool, granulomas in gastrointestinal tract), splenomegaly
  • Genitourinary – urethral strictures, bladder granulomas
  • Pulmonary – pneumonia
  • Skin and musculoskeletal – lymphadenitis, skin and visceral abscesses, osteomyelitis
  • Infections
    • Chronic obstructive granulomas form at sites of infection
    • Characterized by bacterial and fungal infections, with most common agents including
      • Staphylococcus aureus
      • Burkholderia cepacia
      • Serratia marcescens
      • Nocardia spp
      • Aspergillus spp

Indications for Laboratory Testing

Tests generally appear in the order most useful for common clinical situations.
Click on number for test-specific information in the ARUP Laboratory Test Directory

Neutrophil Oxidative Burst Assay (DHR)  0096657
Method: Semi-Quantitative Flow Cytometry

Limitations

Results alone are not diagnostic

Specimen must remain ambient and be tested within 48 hours of collection

Follow Up

With abnormal result, consider genetic testing

Chronic Granulomatous Disease (CYBB Gene Scanning and NCF1 Exon 2 GT Deletion) with Reflex to CYBB Sequencing 2006356
Method: Polymerase Chain Reaction/High Resolution Melt Analysis

Limitations

Diagnostic errors can occur due to rare sequence variations

Deep intronic mutations in CYBB, mutations in NCF1 other than the GT deletion in exon 2, and mutations in additional genes associated with CGD are not evaluated

Large CYBB gene deletions/duplications will not be detected in females

Breakpoints of large CYBB deletions/duplications will not be determined in males

Lack of GT deletion in exon 2 does not rule out carrier status due to potential recombination between NCF1 and its pseudogenes

Chronic Granulomatous Disease (NCF1) Exon 2 GT Deletion 2006366
Method: Polymerase Chain Reaction/High Resolution Melt Analysis

Limitations

Diagnostic errors can occur due to rare sequence variations

Mutations in NCF1 other than the GT deletion in exon 2, and mutations in additional genes associated with CGD are not evaluated

Lack of GT deletion in exon 2 does not rule out carrier status due to potential recombination between NCF1 and its pseudogenes

Chronic Granulomatous Disease, X-Linked (CYBB) Gene Scanning with Reflex to Sequencing 2006361
Method: Polymerase Chain Reaction/High Resolution Melt Analysis

Limitations

Diagnostic errors can occur due to rare sequence variations

Deep intronic mutations in CYBB and mutations in additional genes associated with CGD are not evaluated

Large CYBB gene deletions/duplications will not be detected in females

Breakpoints of large CYBB deletions/duplications will not be determined in males

Additional Tests Available

Immunoglobulins (IgA, IgG, IgM), Quantitative 0050630
Method: Quantitative Nephelometry

Comments

Initial test in workup of immunoglobulin disorders

In adults and older children with suspected hypogammaglobulinemia, order in conjunction with serum protein electrophoresis and immunofixation

Panel includes IgA, IgG, IgM

Complement Activity Enzyme Immunoassay, Total 0050198
Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay

Comments

Rule out complement deficiency

CBC with Platelet Count and Automated Differential 0040003
Method: Automated Cell Count/Differential

Comments

Rule out other causes of chronic infection, including anemia

Leukocyte Adhesion Deficiency Panel 2004359
Method: Semi-Quantitative Flow Cytometry

Comments

Rule out leukocyte adhesion deficiency

Panel measures CD11b, CD15, and CD18 on neutrophils

Familial Mutation, Targeted Sequencing 2001961
Method: Polymerase Chain Reaction/Sequencing

Comments

Useful when a familial mutation identifiable by sequencing is known

Guidelines

Al-Herz W, Bousfiha A, Casanova J, Chatila T, Conley M, Cunningham-Rundles C, Etzioni A, Franco J, Gaspar B, Holland S, Klein C, Nonoyama S, Ochs H, Oksenhendler E, Picard C, Puck J, Sullivan K, Tang M. Primary immunodeficiency diseases: an update on the classification from the international union of immunological societies expert committee for primary immunodeficiency. Front Immunol. 2014; 5: 162. PubMed

General References

Hill H, Augustine N, Pryor R, Reed G, Bagnato J, Tebo A, Bender J, Pasi B, Chinen J, Hanson C, de Boer M, Roos D, Wittwer C. Rapid genetic analysis of x-linked chronic granulomatous disease by high-resolution melting. J Mol Diagn. 2010; 12(3): 368-76. PubMed

Immune Deficiency Foundation. Towson, MD [Accessed: Nov 2015]

Köker Y. Novel human pathological mutations. Gene symbol: NCF2. Disease: Chronic granulomatous disease. Hum Genet. 2010; 127(1): 113. PubMed

Locke B, Dasu T, Verbsky J. Laboratory diagnosis of primary immunodeficiencies. Clin Rev Allergy Immunol. 2014; 46(2): 154-68. PubMed

Roos D, Kuhns D, Maddalena A, Roesler J, Lopez J, Ariga T, Avcin T, de Boer M, Bustamante J, Condino-Neto A, Di Matteo G, He J, Hill H, Holland S, Kannengiesser C, Köker Y, Kondratenko I, van Leeuwen K, Malech H, Marodi L, Nunoi H, Stasia M, Ventura A, Witwer C, Wolach B, Gallin J. Hematologically important mutations: X-linked chronic granulomatous disease (third update). Blood Cells Mol Dis. 2010; 45(3): 246-65. PubMed

Song E, Jaishankar G, Saleh H, Jithpratuck W, Sahni R, Krishnaswamy G. Chronic granulomatous disease: a review of the infectious and inflammatory complications. Clin Mol Allergy. 2011; 9(1): 10. PubMed

Stasia M, Li X. Genetics and immunopathology of chronic granulomatous disease. Semin Immunopathol. 2008; 30(3): 209-35. PubMed

References from the ARUP Institute for Clinical and Experimental Pathology®

Bender J, Rand T, Ampofo K, Pavia A, Schober M, Tebo A, Pasi B, Augustine N, Pryor R, Wittwer C, Hill H. Family clusters of variant X-linked chronic granulomatous disease. Pediatr Infect Dis J. 2009; 28(6): 529-33. PubMed

Hill H, Augustine N, Pryor R, Reed G, Bagnato J, Tebo A, Bender J, Pasi B, Chinen J, Hanson C, de Boer M, Roos D, Wittwer C. Rapid genetic analysis of x-linked chronic granulomatous disease by high-resolution melting. J Mol Diagn. 2010; 12(3): 368-76. PubMed

Hill H. Hyperinflammatory pulmonary disease in chronic granulomatous disease. Pediatr Infect Dis J. 2011; 30(9): 808-10. PubMed

Madden J, Schober M, Meyers R, Bratton S, Holland S, Hill H, Rollins M. Successful use of extracorporeal membrane oxygenation for acute respiratory failure in a patient with chronic granulomatous disease. J Pediatr Surg. 2012; 47(5): E21-3. PubMed

Stasia M, van Leeuwen K, de Boer M, Martel C, Mollin M, Thuret I, Michel G, Hanson C, Augustine N, Coutton C, Satre V, Wittwer C, Hill H, Roos D. Rare duplication or deletion of exons 6, 7 and 8 in CYBB leading to X-linked chronic granulomatous disease in two patients from different families. J Clin Immunol. 2012; 32(4): 653-62. PubMed

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Last Update: January 2016