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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 45  |  Issue : 1  |  Page : 48-56

Assessment of B-lymphocyte and T-lymphocyte function in patients with myelodysplastic syndromes


Department of Internal Medicine, Hematology and BMT Unit, Ain Shams University, Cairo, Egypt

Date of Submission06-Jan-2020
Date of Acceptance20-Jan-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Walaa Elsalakawy
Faculty of Medicine, Ain Shams University, Abbassia, Cairo 11241, Egypt
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejh.ejh_2_20

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  Abstract 


Background An activated immune system has been observed in patients with myelodysplastic syndrome (MDS), but its exact contribution to disease development and control has not been fully clarified. The successful use of immunosuppressive therapies, the potentially curative role of allogeneic stem cell transplant, and the more recent data showing improved peripheral cytopenias and elimination of certain common cytogenetic abnormalities with immunomodulatory agents highlight the role immune dysregulation in the development of MDS.
Aim The aim of this study is to assess B-cell and T-cell function in patients with MDS and correlate them to the risk status of MDS.
Patients and methods The study included 30 adult Egyptian patients diagnosed with MDS based on blood picture, bone marrow (BM) examination, and cytogenetic studies. Patients were classified according to International Prognostic Scoring System risk scoring system. Immune system assessment was done by performing antinuclear antibodies, direct Coombs test, serum protein electrophoresis, and CD4/CD8 ratio in peripheral blood.
Results We have found an association between inverted CD4/CD8 ratio and higher risk strata, presence of neutropenia, and transfusion dependence. Regarding humoral immune system involvement, a positive Coombs test was related significantly to younger age and higher BM blasts count. Marked polyclonal gammopathy as well was found to be associated with higher BM blasts count and presence of cytogenetic abnormalities.
Conclusion Immune dysregulation, in the form of inverted CD4/CD8 ratio, positive antinuclear antibodies, positive Coombs test, and polyclonal gammopathy, is well documented in MDS. It is probably related to younger age, higher International Prognostic Scoring System risk, higher BM blasts count, and the presence of cytogenetic abnormalities.

Keywords: ANA, anemia, CD4, CD8 T cells, coomb’s test, direct antiglobin test, immunity, MDS, myelodysplatic syndroms, neutropenia, polyclonal gammopathy, protein electrophoresis


How to cite this article:
Moussa MM, Elsalakawy W. Assessment of B-lymphocyte and T-lymphocyte function in patients with myelodysplastic syndromes. Egypt J Haematol 2020;45:48-56

How to cite this URL:
Moussa MM, Elsalakawy W. Assessment of B-lymphocyte and T-lymphocyte function in patients with myelodysplastic syndromes. Egypt J Haematol [serial online] 2020 [cited 2020 Dec 3];45:48-56. Available from: http://www.ehj.eg.net/text.asp?2020/45/1/48/294779




  Introduction Top


Myelodysplastic syndrome (MDS) was probably first described in 1900 by Leube as ‘leukanamie’ referring to a macrocytic anemia progressing to acute leukemia, which at the time was thought to have an infectious etiology [1].

Many decades later, cohorts of patients who developed acute leukemia after having a macrocytic anemia were reported, and the common clinical features were described. Patients were given a diagnosis of ‘preleukemia’ until the 1970s, when it was realized that many such patients never developed acute leukemia but instead died of complications from the cytopenias. The ‘preleukemia’ terminology faded away, and the term MDS became widely accepted [1].

Recently, MDS are defined as a very heterogeneous group of clonal disorders of the bone marrow (BM) hematopoietic stem cells, characterized by ineffective hematopoiesis with peripheral blood cytopenias and a higher risk for developing acute myeloid leukemia (AML) [2],[3]. Several prognostic models such as the International Prognostic Scoring System (IPSS) allow stratification of patients into risk categories based on the degree and number of their cytopenias, observed cytogenetic abnormalities, and BM blast percentage [2]. Patients with high-risk MDS (IPSS high and intermediate) have a reduced life expectancy owing to higher risk of progression to AML [4].

Impaired cellular immunity in patients with MDS is a rapidly growing field of research. Evidence for autoimmune abnormalities in MDS comes from clinical and experimental sources [5],[6],[7],[8],[9].

Hamblin [10] first drew attention to an association between MDS and the autoimmune diseases. Furthermore, MDS is associated with aplastic anemia, a disease with an established autoimmune pedigree [11].

Based on the success of antithymocyte globulin to treat AA, many patients with MDS were treated by the same immunosuppressive treatment and achieved sustained red cell transfusion independence in up to 20% [12],[13].

Clinical manifestations of autoimmune phenomena in MDS may include an acute systemic vasculitic syndrome, skin vasculitis, fever, arthritis, pulmonary infiltrates, peripheral polyneuropathy, inflammatory bowel disease, glomerulonephritis, and even classical connective tissue disorders such as relapsing polychondritis [14].

On the contrary, asymptomatic immunological abnormalities, first recognized by Mufti et al. [15], have also been reported in these patients, such as polyclonal hypergammaglobulinemia, antinuclear antibodies (ANA), and inflammatory cytokines. It is suggested that these complex autoreactive immune responses may further induce cytopenias in patients with MDS [16].

The successful use of immunosuppressive therapies, the potentially curative role of allogeneic stem cell transplant, and the more recent data showing improved peripheral cytopenias and elimination of certain common cytogenetic abnormalities with immunomodulatory agents highlight the role immune dysregulation plays in the development of MDS.

However, only 30% of patients respond to classical immune-suppressive therapy, which in turn raises a lot of questions regarding the exact role of immune dysregulation in MDS [17].

Understanding the role of the immune system and identifying patients with immune dysregulation via simple clinical tools are crucial steps to identify and follow-up patients who will benefit from immune-suppressing therapies.

In this study, we aim to explore immunological abnormalities in patients with MDS via feasible, cheap clinical tools in relation to their risk stratification and clinical and laboratory characteristics.


  Patients and methods Top


A total of 30 adult patients with low/intermediate IPSS risk MDS were included in this study.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Patient selection

  1. Patients were diagnosed with MDS according to the diagnostic criteria proposed by the WHO in 2008 [18].
  2. Complete blood pictures were done serially for all patients and showed varying degrees of cytopenias.
  3. BM aspiration and biopsy were done to all patients:
    1. Dysplasia was judged to be present in a lineage if 10% or more of BM nucleated cells of the corresponding lineage were dysplastic.
    2. Mild megaloblastic changes without dyspoiesis in other cell lines were not considered sufficient for a diagnosis of MDS.
    3. Neither chemotherapy nor immunosuppression had been administered before the first BM collection.
    4. Iron stain was done in all patients to detect increased iron stores and sideroblastic anemia.
  4. Cytogenetic studies including conventional karyotyping by G-banding and fluorescence in situ hybridization for detection of 5q and 7q deletions were done to all patients.
  5. Treatment plans: all of the patients received treatment with erythropoietin and supportive medical treatment with or without transfusion.


Accordingly, patients were classified into transfusion dependent and transfusion independent.

Exclusion criteria

Patients with any of the following criteria have been excluded:
  1. High-risk MDS according to IPSS risk stratification.
  2. Hypoplastic MDS.
  3. MDS with excess blasts.
  4. Secondary AML.
  5. Associated autoimmune/collagen diseases.
  6. Patients receiving treatment with granulocyte colony-stimulating factor or hypomethylators (Azacitidine/Decitabine).


Methods

Peripheral blood samples were collected from all patients, for detection of the following:
  1. ANA: using indirect immunofluorescence method; a titer of more than 1/160 was considered positive.
  2. Coombs test (direct antiglobulin test).
  3. Serum protein electrophoresis (SPE) ([Figure 1]):
    1. All sera underwent electrophoresis in cellulose acetate gel by The Helena electrophoresis system (Helena Laboratories, Beaumont, Texas, USA). Titan III cellulose acetate plates were used at 350 V for 25 min in an alkaline buffer. The results were analyzed according to manufacturer’s guidelines.
    2. The patients were then classified according to the results into patients having either normal SPE, mild, moderate, or marked polyclonal gammopathy, with mild, moderate, and marked referring to gamma globulin fraction of 1.5–3 g/dl, 3–4 g/dl, and more than 4 g/dl, respectively.
    Figure 1 Showing sample result of serum protein electrophoresis done. It shows appearance of polycolonal gamopathy.

    Click here to view
  4. CD4/CD8 ratio in peripheral blood by flow cytometry ([Figure 2]):
    1. Peripheral blood lymphocytes were washed in phosphate buffered saline and stained for 30 min at room temperature in the dark.
    2. Total leukocytes (the panleucogate) and total lymphocytes are first gated using a CD3-antibodies (logarithmic scale) against side scatter (logarithmic scale) dot plot.
    3. CD4-positive and CD8-positive lymphocytes are then determined by gating the CD4 and CD8 bright populations using CD4 and CD8 antibodies (logarithmic scale) against side-scatter (logarithmic scale) dot plot of the total lymphocyte population. The analysis was done using EPICS XL flow cytometer (Beckman Coulter, Miami, Florida, USA).
    Figure 2 Showing a sample report of Flowcytometry performed in the study to assess CD4 to CD8 ratio on peripheral blood samples.

    Click here to view


Statistical analysis

Statistical presentation and analysis of the present study was conducted using mean, SE, the Student t test, the c2 test, and analysis of variance with SPSS (version 17; IBM Corporation, Armonk, New York, USA).

P value more than 0.05 was considered nonsignificant, P value 0.05 or less was considered significant, and P value 0.001 or less was considered highly significant.


  Results Top


Descriptive and initial laboratory data

This study was conducted on 30 patients diagnosed with low-risk/intermediate-risk IPSS MDS.

Our study included 12 (40%) males and 18 (60%) females, whose ages ranged between 20 and 63 years, with a mean of 43 years.

In our study, 20 (66.67%) patients had pancytopenia, five (16.67%) patients had bicytopenia, and another five (16.67%) patients had monocytopenia.

Among the 12 male patients, eight (66.67%) had pancytopenia, one (8.33%) had bicytopenia, and three (25%) had monocytopenia, whereas among the 18 female patients, 12 (67%) had pancytopenia, four (22.22%) had bicytopenia, and two (11.11%) had monocytopenia.

Patients with monocytopenia showed mean age of 42 years, whereas those with bicytopenia and pancytopenia showed mean ages of 46 and 45 years, respectively.

In our study, 20 (66.67%) patients had neutropenia, whereas 10 (33.33%) did not. Of 18 female patients, 12 (66.67%) had neutropenia, whereas of the 12 male patients, eight (66.67%) had neutropenia. However, this relation was statistically insignificant (P=0.6).

Neutropenic patients had a mean age of 42.1 years, whereas non-neutropenic patients had a mean age of 45.6 years. This relation was nonsignificant (P=0.438).

Only one (3.33%) patient had cytogenetic abnormality in the form of monosomy seven, and this patient was a 55-year-old female. All other included patients had normal conventional karyotyping and negative 5q and 7q by fluorescence in situ hybridization.

Immune assessment (antinuclear antibodies, Coombs test antiglobin test (coomb’s test), serum protein electrophoresis, and CD4/CD8 ratio)

Of the 30 patients, only two (6.67%) patients had positive ANA test. Five (16.67%) patients had positive direct Coombs test results. Of the 30 patients, 19 (63.33%) had normal SPE, whereas seven (23.33%) had mild, one (3.33%) had moderate, and three (10%) had marked polyclonal gammopathy. A total of 21 (70%) patients had normal CD4/CD8 ratio, whereas nine (30%) patients had inverted ratio.

Correlation of patients’ age with other immune parameters

  1. Patients with positive Coombs test result (direct antiglobulin test) had lower mean±SD age (34±8.9 years) compared with those with negative Coombs test result (45±11 years), with a statistically significant difference (P=0.045).
  2. Similarly, patients with positive ANA result had lower mean±SD age (33±5.6 years) compared with those with negative ANA result (44±11.4 years), with P value=0.193 (nonsignificant).
  3. Moreover, patients with inverted CD4/CD8 ratio had lower mean±SD age (37±12 years) compared with those with normal ratio (45.6±10 years), with P value=0.085 (nonsignificant).
  4. Patients having normal SPE pattern had a mean±SD age of 42±11.5 years, whereas those with polyclonal gammopathy had mean±SD age of 45±11 years, with P value=0.68 (nonsignificant).
  5. The low IPSS risk patients had a mean age of 45.2 years, whereas the intermediate IPSS risk patients had a mean age of 42.88 years, and this relation was not statistically significant (P=0.686).


Correlation of patients sex with immune parameters

  1. The only two patients with positive ANA test result were females; however, this was statistically insignificant (P=0.654).
  2. On the contrary, of the 18 female patients, 11 (61.11%) had normal SPE, and four (22.22%) and three (16.67%) patients had mild and marked polyclonal gammopathy, respectively.
  3. Of the 12 male patients, eight (66.67%) had normal SPE, and three (25%) and one (8.33%) patients had mild and moderate polyclonal gammopathy, respectively. However, these results were statistically insignificant.
  4. Of the nine patients having inverted CD4/CD8 ratio, four (44.44%) were females and five (55.55%) were males. On the contrary, 14 (66.67%) patients of 21 having normal ratio were females and seven (33.33%) were males. However, this was statistically insignificant (P=0.32).
  5. Of the five patients having positive Coombs test result, four (80%) were females and one (20%) was male, and this was statistically insignificant (P=0.299).


Correlation of bone marrow blast count to immune parameters

  1. Percentage of BM blasts ranged from 1 to 6 % with a mean of 1.78%.
  2. Low IPSS risk patients had lower BM blast count (1.2±0.447%) (mean±SD) compared with intermediate IPSS risk group (1.9±1.323%).
  3. Patients with positive Coombs test result had higher BM blast count (2.9±2%) (mean±SD) compared with those with negative Coombs test result (1.56±0.9%), which was a statistically significant relation (P=0.025).
  4. Patients with pancytopenia had higher BM blast count (1.63±0.89%) (mean±SD) compared with those with monocytopenia (1.2±0.45%), which was a statistically significant relation (P=0.039).
  5. Patients with marked polyclonal gammopathy had higher BM blasts count (3.17±2.57) (mean±SD) compared with those with normal SPE (1.39±0.76), which was a statistically significant relation (P=0.049).
  6. Patients with inverted CD4/CD8 ratio had higher BM blasts count (2±1.55) (mean±SD) compared with those with normal ratio (1.66±1.1), and this was not a statistically significant relation (P=0.442).
  7. Patients with negative ANA result had higher BM blast count (1.839±1.27) (mean±SD) compared with patients having positive ANA result (1±0), and this was not a statistically significant relation (P=0.366).


Correlation of neutropenia (defined as neutrophils count <500/ml) with other immune parameters

  1. In our study, one (5%) of the 20 patients with neutropenia had positive ANA result, and one (10%) patient as well out of the 10 without neutropenia had positive ANA result. However, this was statistically insignificant (P=0.795).
  2. On the contrary, 14 (70%) neutropenic patients had normal SPE, three (15%), one (5%), and two (10%) patients had mild, moderate, and marked polyclonal gammopathy, respectively (total of six neutropenic patients had polyclonal gammopathy). However, five (50%) non-neutropenic patients had normal SPE, and four (40%) and one (10%) patients had mild and marked polyclonal gammopathy, respectively.
  3. Moreover, the only patient with cytogenetic abnormality had neutropenia.
  4. Of the five patients having positive Coombs test, four (80%) were neutropenic, whereas 16 (64%) of the 25 patients with negative Coombs test result were neutropenic. However, this difference was statistically insignificant as well (P=0.862).
  5. Of those nine patients with inverted ratio, seven (77.78%) turned out to be neutropenic, whereas eight (38.1%) of those 21 with normal ratio had neutropenia, and this was statistically insignificant (P=0.672).


Risk stratification in relation to studied parameters

  1. The 30 patients being studied were stratified according to the IPSS risk score to five (16.67%) low-risk patients and 25 (83.33%) intermediate-risk patients.
  2. The low IPSS risk patients had a mean age of 45.2 years, whereas the intermediate IPSS risk patients had a mean age of 42.88 years. This relation was not statistically significant (P=0.686).
  3. Among the five low IPSS risk patients, two (40%) were females, whereas three (60%) were males. On the contrary, of the 25 intermediate-risk patients, 16 (64%) patients were females and nine (36%) were males (P=0.322).
  4. All of the five low-risk patients had monocytopenia, whereas of the 25 intermediate-risk patients, 20 (80%) had pancytopenia and five (20%) had bicytopenia. This difference was a statistically significant relationship (P<0.001).
  5. All of the low-risk patients had no neutropenia, whereas of the 25 intermediate-risk patients, 20 (80%) were neutropenic and five (20%) were not. This difference was statistically significant as well (P<0.001).
  6. Of the low-risk group, one (20%) patient had positive ANA result and also one (4%) patient of the intermediate-risk group had positive ANA result. However, this was statistically insignificant (P=0.255).
  7. All of the low-risk patients had negative Coombs test result, whereas only five (20%) intermediate-risk patients had positive Coombs test result; however, this was statistically insignificant (P=0.156).
  8. Of the five low-risk patients group, three (60%) had normal SPE, whereas two (40%) had mild polyclonal gammopathy. On the contrary, of the 25 intermediate-risk patient group, 16 (64%) patients showed normal SPE, five (20%) had mild, one (4%) had moderate, and three (12%) had marked polyclonal gammopathy. However, these results were statistically insignificant (P=0.555).
  9. A total of eight (88.89%) patients of those with inverted CD4/CD8 ratio fall in the intermediate-risk IPSS patient group, whereas 17 (80.95%) of those with normal ratio fall in the same group. However, this was statistically insignificant as well (P=1).
  10. All of the intermediate-risk patients were transfusion dependent, whereas only one (20%) low-risk patient was transfusion dependent. This was statistically significant (P<0.001).


Transfusion dependency in relation to other studied parameters

  1. Of the 30 patients, 26 (86.67%) were transfusion dependent and four (13.33%) were not. Transfusion-dependent patients showed a mean age of 43.5 years, whereas the transfusion-independent patients showed a mean age of 42 years. This relation was not statistically significant (P=0.816).
  2. Only one (25%) of the four transfusion-independent patients was a female, whereas of those 26 patients with transfusion dependence, 17 (65.38%) patients were females and nine (34.62%) were males. However, this relation was not statistically significant (P=0.126).
  3. The only patient with cytogenetic abnormality was transfusion dependent.
  4. All of the transfusion-independent patients had monocytopenia, whereas of those with transfusion dependence, 20 (76.9%) had pancytopenia, five (19.23%) had bicytopenia, and only one (3.85%) had monocytopenia. This was statistically significant (P<0.001).
  5. None of the transfusion-independent patients had neutropenia, whereas of the 26 transfusion-dependent patients, 20 (76.92%) had neutropenia and six (23.08%) did not. This was statistically significant as well (P<0.001).
  6. Of the four transfusion-independent patients, one (25%) had positive ANA result, and also one (3.85%) patient of the 26 patients with transfusion dependence had positive ANA result, and the other 25 (96.15%) patients had negative ANA result. However, this was statistically insignificant (P=0.19).
  7. All of the four transfusion-independent patients had negative Coombs test result, whereas only five (19.23%) of the 26 transfusion-dependent patients had positive Coombs test result; however, this was statistically insignificant (P=0.209).
  8. Of the four transfusion-independent patients, three (75%) had normal SPE and one (25%) had mild polyclonal gammopathy, whereas of the 26 transfusion-dependent patients, 16 (61.54%) had normal SPE, whereas six (23%), one (3.85%) and three (11.54%) patients had mild, moderate, and marked polyclonal gammopathy, respectively. However, this was statistically insignificant as well (P value=0.742).
  9. Of the nine patients with inverted CD4/CD8 ratio, eight (88.89%) patients were transfusion dependent, whereas 18 (85.71%) patients of the 21 with normal ratio was transfusion independent, but this finding was statistically insignificant (P=0.725).


Coombs test (direct antiglobulin test) in relation to other immune parameters

  1. All of the five Coombs test-positive patients had negative ANA result, whereas of the 25 Coombs test-negative patients, only two (8%) had positive ANA result. However, this was statistically insignificant (P=0.743).
  2. The only two ANA-positive patients had normal SPE pattern, whereas of the 28 ANA-negative patients, 17 (60.71%) had normal SPE, seven (25%) had mild, one (3.57%) had moderate, and three (10.71%) had marked polyclonal gammopathy. However, this was statistically insignificant as well.
  3. Of the nine patients with inverted CD4/CD8 ratio, three (33.33%) had positive Coombs test result, eight (88.89%) had normal SPE, and one (11.11%) had marked polyclonal gammopathy.
  4. On the contrary, of the 21 patients with normal CD4/CD8 ratio, two (9.52%) had positive ANA, five (16.67%) had positive Coombs test result and 10 (47.62%) had polyclonal gammopathy. However, these results were statistically insignificant.
  5. Of the five Coombs test-positive patients, one (20%) had mild and one (20%) had marked polyclonal gammopathy, whereas of the 25 Coombs test-negative patients, six (24%), one (4%), and two (8%) patients had mild, moderate, and marked polyclonal gammopathy, respectively. However, this was statistically insignificant as well (P=0.826).



  Discussion Top


MDS are defined as a very heterogeneous group of clonal disorders of the BM hematopoietic stem cells, characterized by ineffective hematopoiesis with peripheral blood cytopenias and a higher risk for developing AML.

MDS is associated with many autoimmune diseases like rheumatoid arthritis, vasculitis, and polymyalgia rheumatica [10].

Furthermore, the successful use of immunosuppressive therapies (like ATG or cyclosporine A) and the potentially curative role of allogeneic stem cell transplant highlight the role immune dysregulation plays in the development of MDS.

Many abnormal immune laboratory findings are noticed in patients with MDS, such as polyclonal hypergammaglobulinemia, ANA, and inflammatory cytokines [16], yet the clinical utility and significance of them is still unclear.

This study was designed in an attempt to use feasible, clinically applicable, and cheap tests to assess immune dysregulation in patients with MDS and to correlate them with risk stratification and clinical and laboratory findings in a way that helps treating physicians to determine the right treatment plan.

In our study, of the 30 patients with MDS, only two (6.67%) patients had positive ANA test result, five (16.67%) patients had positive direct anti globin test (DAT), and 11 (36.6%) had abnormal SPE [of them seven (23.33%) had mild, one (3.33%) had moderate, and three (10%) had marked polyclonal gammopathy].

Abnormal immune laboratory findings were previously documented in MDS. A similar study carried out by Novaretti et al. [19] on 29 patients with MDS revealed positive Coombs test result and polyclonal gammopathy in 34.4 and 54.4% of the patients, respectively.

In our study, patients with positive Coombs test direct anti globin test (direct coomb’s test) result were significantly younger in age (P=0.045). In parallel, positive ANA, polyclonal gammopathy, inverted CD4/CD8 ratio, monocytopenia, neutropenia, and transfusion independence was associated with young ages, but with nonsignificant P values.

This goes well with the study carried out by Zou et al. [20] in 2009, on 76 patients with MDS; they concluded that immunologic abnormalities associated with MDS are more prevalent in younger age groups [20].

Another study carried out by Molldrem et al. [21] on 61 patients with MDS concluded that younger age groups had higher incidence of responsiveness to immune-suppressive therapy [21].

This raises a question, do young patients with MDS have different behavior than older patients? In our study, all of the low-risk patients had negative Coombs test result. Overall, eight of nine patients who had inverted CD4/CD8 ratio and all with marked polycolonal gammopathy fall in intermediate-risk group.

Although these results were statistically nonsignificant, it was a striking finding that may point to a specific situation of young patients with MDS who may have obvious immune dysregulation that push them to higher risk groups despite their young age. This may occur via targeting the hematopoietic stem cells immunologically, leading to their permanent loss and aggravation of anemia. This hypothesis warrants further research involving only young MDS. A new category or a new classification may be needed for this distinct group of patients.

In our study, positivity of Coombs test and presence of marked polycolonal gammopathy were useful clinical tools to detect high BM blasts count and pancytopenia, that is, higher risk strata.

As we found that BM blast count was significantly higher in patients with pancytopenia versus monocytopenia (P=0.039) and in patients with positive DAT (P=0.025) and patients with marked polyclonal gammopathy (P=0.049).

Moreover, patients with high-risk strata (P=0.258) and inverted CD4/CD8 ratio (P=0.442) had higher BM blast count, with nonsignificant P values.

This finding may reflect that immune mechanisms play a crucial role in the pathogenesis of MDS and aggravate the cytopenias, worsening the clinical course and increasing the demands of transfusion, especially in case of positive Coombs test result. This is in agreement with the studies carried out by Kochenderfer et al. [9] and Molldrem et al. [21].

In contrary to our results, a study carried out by Kotsianidis et al. [22] studied autoimmunity in 88 patients with MDS and found an increased number of CD4+ interleukin-17 (IL-17)-producing cells in low-risk MDS compared to high-risk MDS, denoting increased autoimmunity in low-risk patients, probably because of a different flow cytometry technique, as they labeled the cells with anti-human IL-17 and IL-4 and anti-human interferon-c antibodies [22].

In a study conducted by Giannouli et al. [14], there was no correlation between IPSS grade and predisposition to development of immunologic abnormalities [14]. This does not match our results.

In our study, low-risk patients showed more monocytopenia (P<0.001) and transfusion independence (P<0.001) as expected by the IPSS, but they also showed a significantly higher incidence of neutropenia (P<0.001).

This means that patients with low-risk MDS are still at high risk of infections, so will this change our approach in their treatment plans?

In our study, upon measuring CD4/CD8 ratio in our patient groups, nine (30%) of 30 patients had inverted ratio.

Krupica et al. [23] concluded that reduction in CD4+ T cells may initiate a cytokine-dependent pathway known as ‘homeostatic proliferation’ in which cytokines such as IL-2, IL-7, IL-15, and/or IL-21 nonspecifically expand antigen-specific and self-reactive T cells leading to an increased risk for evasion of peripheral tolerance mechanisms leading to autoimmunity [23].

In our study, a larger percentage of the patients having inverted ratio fell in the intermediate IPSS risk group, suggesting a possible relation between higher risk and CD4/CD8 ratio inversion.

Moreover, a larger fraction of patients with inverted ratio had neutropenia, pancytopenia, and higher BM blast count. A slightly higher fraction of patients with inverted ratio as well were found to be transfusion dependent (which might be correlating to the severity of cytopenias), compared with patients with normal ratio, yet these results were statistically insignificant as well (P=0.672, 1, 0.442, and 0.725, respectively), possibly because of the small sample size used in our study.

This goes well with the study of Bennett and Komrokji [24] which demonstrated that diminished CD4/CD8 ratio correlates with higher risk and poor survival outcome in MDS.

However, the study by Zou et al. [20] revealed an inverted CD4/CD8 ratio in both low and intermediate IPSS risk groups, which is inconsistent with our results, probably because of different flow cytometric analysis, as they gated CD3+ lymphocytes after staining them with anti-Ki67+ antibodies to detect proliferating CD4+ and CD8+ lymphocytes. On the contrary, in our study, cells were gated only using CD3, CD4, and CD8 antibodies.

The immune dysregulation in MDS, is it a cause or a result? Among 111 patients diagnosed as having MDS, C3 hypocomplementemia was observed as high as 45.9%, and the C3 hypocomplementemic subgroup had more severe cytopenia of red cell and white cell lineages and was dominant in the low-risk IPSS patients [25].

These data indicate that a distinct subset of MDS, demonstrating complement activation, has more severe cytopenias, which suggest that complement activation contributes to the pathogenesis of autoimmune cytopenia in MDS [25].

Because of the high apoptotic load of the dysplastic and normal hematopoietic precursor cells, tumor-antigens and auto-antigens might be presented to the immune system and evoke an adaptive immune response.

Consequently, activated T cells and clonal T-cell expansions are found in most patients with MDS.

A report by Komrokji et al. [26] showed that patients with MDS with autoimmune diseases have better OS and less AML transformation.

Does this apply for those patients with primary MDS with immune dysregulation? Should they be treated by immunosuppression in early stages of the disease? And even monoclonal antibodies as in other autoimmune diseases? Do we need a new classification according to the immune default present? We think that there is still so much work to be done in this field of this heterogeneous group of diseases: the MDS.

These findings may open the way to further subclassification of patients with MDS according to presence or absence of the immunological abnormalities, thus help to determine the patients who will benefit most of immunosuppressive treatment and may help better understanding of the pathogenesis of this heterogeneous group of diseases via safe and effective clinically applicable methods.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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