Journal of Microbiology, Immunology and Infection (2015) 48, 113e118

Available online at www.sciencedirect.com

journal homepage: www.e-jmii.com

CASE REPORT

X-linked hyper-IgM syndrome with CD40LG

mutation: Two case reports and literature
review in Taiwanese patients
Hu-Yuan Tsai a, Hsin-Hui Yu a, Yin-Hsiu Chien a, Kuan-Hua Chu b,
Yu-Lung Lau c, Jyh-Hong Lee a, Li-Chieh Wang a, Bor-Luen Chiang a,
Yao-Hsu Yang a,*
a

Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan

Graduate Institute of Immunology, National Taiwan University, Taipei, Taiwan
c
Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, SAR, China
b

Received 28 November 2011; received in revised form 16 May 2012; accepted 9 July 2012
Available online 24 September 2012

KEYWORDS
CD40 ligand;
Hyper-IgM syndrome;
Immunodeficiency

Hyper-IgM syndrome (HIGM) is a rare primary immunodeficiency disorder characterized by

elevated or normal serum IgM and decreased IgG, IgA, and IgE due to defective immunoglobulin
class switching. X-linked HIGM (XHIGM, HIGM1) is the most frequent type, is caused by mutations in the CD40 ligand gene, and is regarded as a combined T and B immunodeficiency. We
report an 18-year-old male who was diagnosed initially with hypogammaglobulinemia in
infancy, but developed repeated pneumonia, sepsis, cellulitis, perianal abscess, pericarditis,
and bronchiectasis despite regular intravenous immunoglobulin replacement therapy. The
patient died at age 18 years due to pneumonia and tension pneumothorax. Mutation analysis
revealed CD40L gene mutation within Exon 5 at nucleotide position 476 (cDNA 476G > A). This
nonsense mutation predicted a tryptophan codon (TGG) change to a stop codon (TGA) at position 140 (W140X), preventing CD40L protein expression. Sequence analysis in the family
confirmed a de novo mutation. The second case of 6-month-old male infant presented as Pneumocystis jiroveci pneumonia and acute respiratory distress syndrome. Gene analysis of the
CD40L gene revealed G to C substitution in Intron 4 (c.409 5G > C) and mother was a carrier.
Hematopoietic stem cell transplantation, the only cure for XHIGM, was arranged in the second
case.
Copyright 2012, Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC. All rights
reserved.

* Corresponding author. Department of Pediatrics, National Taiwan University Hospital, 7, Chung-Shan South Road, Taipei 10002, Taiwan.
E-mail address: yan0126@ms15.hinet.net (Y.-H. Yang).
1684-1182/$36 Copyright 2012, Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.jmii.2012.07.004

114

Introduction
The hyper-IgM syndromes (HIGM), first described in 1960,
are a heterogeneous group of genetic disorders characterized by elevated or normal serum IgM and severely deficient
serum concentrations of IgG, IgA, and IgE, with normal
numbers of peripheral B cells.1 Defective immunoglobulin
class-switch recombination (CSR) and somatic hypermutation (SHM) in HIGM can be caused by molecular
defects in the CD40 ligand/CD40-signaling pathway or by
defects involving the enzymes required for CSR and SHM.2
Currently, HIGM can be classified into eight genetically
defined types. Defects in CD40 ligand (CD40L, CD154) result
in the most common hyper-IgM syndrome (HIGM1 or XHIGM),
which is inherited as an X-linked recessive trait, and
accounts for 65% to 70% of cases.3 CD40L is expressed
primarily on activated CD4 T cells, and interacts with CD40
expressed on B cells, monocytes, macrophages, and
dendritic cells. CD40L-CD40 interactions provide a costimulatory signal for T cells, and lead to T cell activation.4
The engagement of CD40 by CD40L on B cells leads to B cells
proliferation and CSR,5 The combined T and B immunological defect is clearly illustrated by the susceptibility of
patients with HIGM1 to recurrent pyogenic and opportunistic infections.6
Patients with HIGM are highly susceptible to recurrent
sinopulmonary infections, Pneumocystis jiroveci pneumonia (PJP), and chronic diarrhea due to Cryptosporidium
infection that may lead to sclerosing cholangitis. They are
also prone to intermittent or persistent neutropenia,
autoimmune diseases, and malignancies.6 Most patients
with XHIGM present in infancy. Here we report two male
XHIGM patients and further identified mutation in the
CD40L gene.

Case reports
Case 1
An 18-year-old male patient was diagnosed with hypogammaglobulinemia at age 3 years. The family history was
unremarkable (Fig. 1A). Starting at age 4 months, he suffered
from bronchopneumonia, recurrent upper respiratory tract
infections, occipital cellulitis (at age 7 months), recurrent

H.-Y. Tsai et al.

acute otitis media, cellulitis, and pneumococcal pneumonia
with pleural effusion (at age 3 years). Immunological evaluation showed normal blood cell counts, serum immunoglobulin levels: IgA <6.67 mg/dL, IgG <33.3 mg/dL, IgM
266 mg/dL, and IgE <10 IU/mL. Lymphocyte subsets showed
CD19 B cells 37%, CD3 T cells 63%, CD3CD8 T cells 15%,
CD3CD4 T cells 52%. With a diagnosis of hypogammaglobulinemia, he received regular intravenous immunoglobulin
(IVIG) replacement therapy every 3 weeks with trough serum
IgG levels of 500 to 800 mg/dL; however, at age 6 years, the
patient developed Pseudomonas aeruginosa sepsis, urinary
tract infection with Candida albicans, perianal abscess, and
pericarditis. Intermittent severe neutropenia (absolute
neutrophil count 200  106 cells/L) responsive to
granulocyte-colony stimulating factor was also noted during
infectious episodes.
Bruton agammaglobulinemia tyrosine kinase (BTK ) gene
mutation analysis showed wild type. By flow cytometry,
CD40 ligand expression on CD3CD8 T cells after stimulation with PMA (20 ng/ml) and inomycin (1 mg/ml) for 4
hours was 0.43%, compared with 85.2% in a healthy control
(Fig. 2).7 Subsequently, mutation analysis of the CD40L
gene revealed G to A substitution within Exon 5 cDNA at
nucleotide position 476 (cDNA 476G > A) (Fig. 3). This
nonsense mutation led to a tryptophan (W) codon (TGG)
change to a stop codon (TGA) at position 140 (W140X),
preventing CD40L protein expression (Fig. 2). DNA analysis
of his mother and two sisters showed normal sequence.
Therefore, the patient was thought to have a de novo
mutation of the CD40L gene. The diagnosis of X-linked HIGM
was confirmed.
From age 15 years, the patient had recurrent pneumonia typically presenting with hemoptysis and dyspnea,
and complicated by bronchiectasis. At age 16 years, he
developed pulmonary valve regurgitation with pulmonary
hypertension, and col pulmonale. Furosemide was started.
Pulmonary function testing revealed a moderate to severe
mixed ventilatory defect, predominantly obstructive type.
Bronchiectasis and recurrent pneumococcal pneumonia
precipitated his progressive lung dysfunction. He had
received bi-level positive airway pressure ventilation since
age 17 years. The patient died at age 18 years, due to
pneumonia with mixed infection of Pseudomonas aeruginosa and Candida albicans, complicated by tension pneumothorax, and ultimately by respiratory failure.

Figure 1. Pedigrees and clinical phenotypes of (A) Patient 1 and (B) Patient 2. Bar indicates mortality. The proband is indicated
by an arrow.

CD40LG mutations in X-linked hyper-IgM

115

Figure 2. (A) A CD3PE versus CD8APC dot plot showing the R2 gate set around the CD3/CD8 lymphocytes. Histograms from
R2 gates of (B) the patient and (C) control using unstimulated (shaded peaks) and stimulated cells (unshaded peaks) labeled with
CD3 PE/CD8 APC/CD154FITC antibodies. CD154 expression on stimulated CD3/CD8 lymphocytes was 0.43% in Patient 1 and 85.2% in
the control.

Case 2
A 6-month-old boy was admitted to our hospital for bronchopneumonia with cough, rhinorrhea and short of breath
for one week. Fever was noted after admission. Dyspnea
with diffuse wheezing and rales rapidly progressed under
empirical antibiotics. He was intubated 8 days after
admission due to progression to acute respiratory distress
syndrome (ARDS) (Fig. 4A). Sputum PJP PCR was positive.
Under the support of high frequency oscillator ventilation
and the treatment of co-trimethoxazole/sulfamethoxazole
(Sevatrim), ARDS improved and he was extubated 2 weeks
later. Immunological evaluation showed elevated white
blood cell counts 23.5  109/L, neutrophils 44.5%,
lymphocytes 45.8%, serum immunoglobulin levels: IgA
<22.6 mg/dL, IgG 13.5 mg/dL and IgM 68 mg/dL. Lymphocyte subsets showed CD19 B cells 52%, CD3 T cells 44%,
CD3CD8 T cells 8%, CD3CD4 T cells 35%, NK cell 1%.
Mitogen test for T cell function showed normal proliferation
response using phytohaemagglutinin and pokeweed
mitogen stimulation and decreased proliferation response
using CD3/CD28 stimulation. CD40 ligand expression on
stimulated CD3CD8 T cells of patient was 7.1%, compared
with that of normal control 67.8%. Gene analysis of the
CD40L gene revealed G to C substitution in Intron 4
(c.409 5G > C, IVS4 5G > C) (Fig. 4B). This splice site
mutation is predicted to destroy the donor site of Intron 4

and produce abnormal RNA and protein. DNA analysis of his

mother confirmed the mother as carrier. The diagnosis of Xlinked HIGM was confirmed. He was discharged smoothly
and received regular IVIG replacement therapy every 3
weeks with trimethoprim-sulfamethoxazole prophylaxis
during follow-up. Hematopoietic stem cells transplantation
was arranged.

Discussion
We report the case of a young man with XHIGM who
suffered from repeated infections of the respiratory tract,
lungs, and skin, complicated by early-onset bronchiectasis
despite regular IVIG replacement therapy. The male infant
with XHIGM was diagnosed soon after the recognition of PJP
pneumonia and ARDS as opportunistic infection. Either Xlinked agammaglobulinemia (BTK gene mutation) or XHIGM
(CD40LG gene mutation) could present with a hypogammaglobulinemia phenotype; however, susceptibility to opportunistic infection should raise the suspicion of abnormal
cellular immunity, as in XHIGM. CD40 ligand expression in
in vitro-activated lymphocytes should be assayed in
patients with low serum IgG, normal or elevated serum IgM,
and opportunistic infections or family history consistent
with X-linked inheritance. In addition, sound CD40L-CD40
signaling enhances the development of memory-B cell

116

H.-Y. Tsai et al.

Figure 3. Sequence analysis in genomic DNA of Patient 1, and his mother and two sisters. (A) A nonsense mutation in Exon 5
(c.476G > A) changes a tryptophan (W) codon (TGG) into a translation termination (X) codon (TGA) at amino acid position 140
(W140X). (B) The mother and (C,D) two sisters had wild type gene sequences.

from nave B cell. Absence of IgMIgDCD27 memory B cell

population in peripheral blood was also found in X-linked
hyper-IgM syndrome.8,9 The high IgM concentrations have
been assumed to reflect chronic antigenic stimulation, and
serum IgM levels may normalize after regular IVIG
treatment.
The CD40 ligand gene product, a 39-kDa type II
membrane glycoprotein, belongs to the family of TNF
receptor molecules. The CD40 ligand monomer consists of
four structural domains: a N-terminal intracellular tail
(amino acids 1e22), a transmembrane domain (amino acids
23e46), a portion that forms the extracellular unique

domain (amino acids 47e122), and the extracellular

C-terminal TNF homology (TNFH) domain (amino acids
123e261).10 Most CD40LG mutations are exonic single
nucleotide substitutions, mainly in the extracellular TNFH
domain, encoded by Exon 5 and part of Exon 4. According to
the mutation registry for HIGM1 (a former synonym for
CD40LG, now withdrawn), CD40Lbase (http://bioinf.uta.fi/
CD40Lbase),11 only one previous study has reported a point
mutation within Exon 5 at nucleotide position 476
(476G > T),12 leading to an amino acid change (W140C) in
the TNFH domain. The genetic mutation observed in our
two cases has not been reported previously. Moreover,

Figure 4. (A) Chest x-ray showed diffuse hazy density with clinically low arterial oxygen levels in patient 2. (B) Gene analysis of
the CD40L gene in patient 2 revealed G to C substitution in Intron 4 (c.409 5G > C).



7m
9









mo
y
m
m
5
2
4
4
5
6
7
8

ARDS Z acute respiratory distress syndrome; EC Z extracellular domain; FH Z family history; HIE Z hypoxic ischemic encephalopathy; PJP Z pneumocystis jiroveci pneumonia; Ref Z reference; TNF Z tumor
necrosis factor homology domain.
a
Post-IVIG IgG seral level.
b
CD40L surface expression on activated CD4 lymphocytes.

current
study

7.1
68
<22
13.5
d
IVS4 5G > C (I4)

22,23
24
25
current
study




0.5
6.8
<1
<1
128
216
140
266
4
<6.7
8.32
<6.7
18
184
51.3
<33
K96X (EC)
d
d
W140X (TNF)
307A > T (E2)
d
d
476G > A (E5)

29.6
<1
<1
<1
109
34
187
104
83
2
8
6
48
190
175a
12
T254M (TNF)
Y169N (TNF)
Y169N (TNF)
Y169N (TNF)
> C (E5)
> A (E5)
> A (E5)
> A (E5)
782T
526T
526T
526T

d
d
d
Sclerosing
cholangitis
d
Ileum perforation
HIE
Cellulitis,
perianal abscess,
pericarditis
PJP, ARDS




22 y
3 mo
3y
3y
1
2
3
4

IgM
IgA
IgG
Other
Septicemia
Chronic
diarrhea
Bronchiectasis
Sinupulmonary
infection






Ref
FH
CD40L
(%)b
Immunoglobulins
(mg/dL)

Predicted
effect on
protein
(domain)
CD40L gene
mutation
(exon/intron)
Clinical presentation

Clinical features, immunoglobulin levels, protein expression and gene analysis of 9 male HIGM patients in Taiwan

Onset age
No.

Table 1

Codon 140 is a hot spot for CD40LG gene mutation, with 11

mutations affecting Codon 140, including six missense
mutations (2 W140G, 2 W140C, 2a W140R), and five
nonsense mutations W140X recorded in CD40Lbase.11,12 The
nonsense mutations W140X cause truncation of the extracellular domain of CD40 ligand and are expected to result in
large deletions of the TNF homology region. The 12 patients
with XHIGM mutations in Codon 140 (including our case)
represented a variety of ethnicities. There were six Europeans, one Australian, one Korean, three Japanese, and
one Han-Chinese (our case). These patients experienced
Pneumocystis jiroveci pneumonia (one patient), bacterial
sepsis (three patients), diarrhea due to cryptosporidium
(three patients), neutropenia (seven patients), oral ulcers
(four patients), arthritis (one patient), hepatitis (three
patients), liver cirrhosis (one patient), and hepatocellular
carcinoma (one patient). Bronchiectasis was seen only in
our patient. None of them received a bone marrow transplant. The splice site mutation in Intron 4 (g.IVS4 1G > C)
of CD40L gene in two families had been reported by Seyama
et al.13 This mutation caused Exon 4 skip and inframe
deletion of 21 amino acids with frameshift.
HIGM with CD40L and CD40 mutations has been classified
into combined T and B immunodeficiency, not predominantly antibody deficiency. Only 20% of patients with XHIGM
survive beyond 25 years of age.1 The major causes of death
are PJP early and liver disease later in life. Winkelstein
et al6 reported that 59% of patients with pneumonia of
XHIGM had PJP compared with 27% having unknown pathogens. The use of trimethoprim-sulfamethoxazole for
prophylaxis of PJP may also be beneficial.14 Therapy for
HIGM is monthly infusions of IVIG that reduce the frequency
and severity of infections. However, IVIG did not prevent
the development of sclerosing cholangitis or bronchiectasis.15 In a previous report, 68% of XHIGM patients had
neutropenia and 45% were chronic. If neutropenia is severe,
it may respond to G-CSF. 16 Bone marrow transplantation
performed early in life may cure XHIGM.1,17 Hematopoietic
stem cell transplantation was curative in 58% of patients
with XHIGM and successful in 72% of patients without preexisting hepatic disease in a review of 38 patients in
Europe.17 In our first patient, lack of anti-PJP and anticandida prophylaxis might contribute to the development
of cor pulmonale because of T cell defects. When T cell
defects are found, stem cell transplantation should be
considered as early as possible. Among 13 published cases
with HIGM in Taiwan, only one received HLA-matched
sibling donor bone marrow transplantation successfully.18
Clinical features and genetic mutation of 9 Taiwanese
patients with HIGM in the literature are summarized in
Table 1.19e25 Sinopulmonary infection occurred in all
patients, while bronchiectasis, chronic diarrhea, and
septicemia were common presentations. Patient 1 with
missense mutation (Thr254Met) in the CD40L gene had
a less severe HIGM presentation, similar to common variable immunodeficiency phenotype. According to genomic
DNA sequencing, Patients 2, 3, and 4 from the same family
all had a missense mutation located at Tyr169Asn (526
T > A) in Exon 5 of the CD40L gene. Patient 2 developed
severe diarrhea and interstitial pneumonia caused by coxsackievirus B4 at age 3 months. Patient 3 presented with
recurrent pneumonia, sepsis, and recurrent herpetic

117

19
15,20
15
15,21

CD40LG mutations in X-linked hyper-IgM

118
gingivostomatitis since age 3 years, and he developed
bronchiectasis thereafter. Patient 4 presented with chronic
diarrhea, recurrent pneumonia, salmonellosis, and herpetic
gingivostomatitis since age 3 years. He developed sclerosing cholangitis at age 18 years despite regular IVIG
supplement. Patient 5 presented with pneumonia at age 5
months. CD40L gene analysis revealed a nonsense mutation
at nucleotide 307 A > T, resulting in a stop codon at Lys 96
position. He had painful recurrent oral ulcers and neutropenia. Patient 6 developed pneumonia and ileum
perforation followed by peritonitis at age 2 years. Pathologic findings showed massive intestinal lymphoproliferation. Patient 7 presented with pneumonia and hypoxic
ischemic encephalopathy at age 4 months. Patient 6 and 7
remained healthy during 1 year of follow-up.
In conclusion, we identified two patients with XHIGM,
with mutations of the CD40LG gene (Patient 1 de novo
mutation, Patient 2 X-linked transmission from carrier
mother). Recurrent infections despite regular IVIG supplement ultimately led death in the first case. Early diagnosis,
as in Patient 2, is essential for early hematopoietic stem
cell transplantation before the onset of significant organ
damage, which is the only cure for XHIGM.

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