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Congenital athymia is an ultra-rare immune condition primary immunodeficiency which is characterized by the lack of a functional thymus at birth. Estimated incidence in the United States is approximately 17 to 24 infants for every 4 million. Congenital athymia results in profound immunodeficiency and immune dysregulation1,3. The clinical manifestations are a direct result of the absence of the thymus and the inability to produce immunocompetent T-cells, leading to increased susceptibility to infection. These infections and autoimmune conditions can be fatal, and with only supportive care, children with congenital athymia typically do not survive beyond 2 to 3 years of age4.
The thymus is the only organ where thymocytes can mature, be selected, and ultimately survive to become naïve T-cells. Although T-cells originate in the bone marrow as progenitor cells, the bone marrow is not equipped with specialized tissue required for T-cell maturation1. T-cell progenitors emerging from the bone marrow migrate to the thymus for maturation, where they are selected to become naïve T-cells via positive and negative selection. Some progenitor cells begin to express CD4 or CD8 receptors. Subsequent downregulation of CD4 or CD8 results in development of naïve single positive cells that can exit the thymus and enter the peripheral bloodstream1.
Congenital athymia may be associated with other conditions such as: DiGeorge syndrome (22q11.2 deletion syndrome); mutations in the genes TBX1, CHD7, (CHARGE syndrome), and FOXN1 (FOXN1 deficiency); diabetic embryopathy1, 3, 6. These multi-faceted conditions and syndromes make the already complex diagnosis of congenital athymia even more challenging.
Congenital athymia is initially detected through T-cell receptor rearrangement excision cell circle (TREC) screening1. This test will identify infants who may have congenital athymia in addition to severe combined immunodeficiency (SCID) and is required in all 50 U.S. states for all newborns since 20181. TREC screening is critical as it provides the first indication of an immunologic issue in an infant’s T-cell development. Low TREC levels indicate the need for further testing6. Flow cytometry may show low levels of naive T-cells and may help strengthen the diagnosis of congenital athymia1.
Congenital athymia and SCID are both primary immunodeficiencies, but they are different1. Congenital athymia may be mistaken for SCID, as very low T-cell counts are present in both conditions.
Patients with congenital athymia lack T-cells but have normal numbers of B-cells and natural killer (NK) cells. They present with a T-B+NK+ phenotype. However, a complicating factor is that a subset of patients with SCID also present with a T-B+NK+ phenotype. Additional steps to confirm the diagnosis may be required if a genetic cause of athymia is not identified1. SCID is a group of disorders rooted in the dysfunction of hematopoietic stem cells of the bone marrow, not in dysfunction or absence of the thymus. Additionally, patients with SCID may lack B-cells or have impaired B-cell development1. In contrast, B-cell numbers are normal in patients with congenital athymia. Lack of B-cells is an important clue that the patient may have SCID. Below is a schematic of the diagnostic pathway including steps for how to differentiate athymia from SCID.
The sooner congenital athymia is identified, the sooner isolation and infection prevention measures can be initiated and the less likely a patient is to be treated with therapies that may not be effective in congenital athymia.
There are 2 phenotypes of congenital athymia: typical and atypical8. The typical phenotype is characterized by profound T-cell lymphopenia, absence of rash or lymphadenopathy, and lack of mitogen-stimulated T-cell proliferation3,8. The atypical phenotype frequently presents with signs and symptoms of autologous GVHD, such as rash, lymphadenopathy, high numbers of circulating T-cells (from oligoclonal T-cell expansion) and T-cell proliferation in response to mitogens (e.g., phytohemagglutinin)1.
Often, the expanded oligoclonal T-cells infiltrate the skin, gut, and other organs8. Biopsy of the inflammatory rash in patients with atypical congenital athymia shows T-cell infiltrates1. Some patients with typical congenital athymia will, over time, develop the atypical phenotype8.
As you discuss the care of your patient with their family or caregiver, you may find this additional reading material helpful.
Immune reconstitution sufficient to protect from infection is unlikely to develop prior to 6-12 months after treatment with RETHYMIC. Given the immunocompromised condition of athymic patients, follow infection control measures until the development of thymic function is established as measured through flow cytometry. Monitor patients closely for signs of infection including fever. If a fever develops, assess the patient by blood and other cultures and treat with antimicrobials as clinically indicated. Patients should be maintained on immunoglobulin replacement therapy until specified criteria are met, and two months after stopping, IgG trough level should be checked. Prior to and after treatment with RETHYMIC, patients should be maintained on Pneumocystis jiroveci pneumonia prophylaxis until specified criteria are met.
RETHYMIC may cause or exacerbate pre-existing graft versus host disease (GVHD). Monitor and treat patients at risk for the development of GVHD. Risk factors for GVHD include atypical complete DiGeorge anomaly phenotype, prior hematopoietic cell transplantation (HCT) and maternal engraftment. GVHD may manifest as fever, rash, lymphadenopathy, elevated bilirubin and liver enzymes, enteritis, and/or diarrhea.
Autoimmune-related adverse events occurred in patients treated with RETHYMIC. These events included: thrombocytopenia, neutropenia, proteinuria, hemolytic anemia, alopecia, hypothyroidism, autoimmune hepatitis, autoimmune arthritis, transverse myelitis, albinism, hyperthyroidism, and ovarian failure. Monitor for the development of autoimmune disorders, including complete blood counts with differential, liver enzymes, serum creatinine, urinalysis, and thyroid function.
Pre-existing renal impairment is a risk factor for death.
In the clinical studies of RETHYMIC, 3 out of 4 patients with pre-existing cytomegalovirus infection died. The benefits/risks of treatment should be considered prior to treating patients with pre-existing CMV infection.
Because of the underlying immune deficiency, patients who receive RETHYMIC may be at risk of developing post-treatment lymphoproliferative disorder. Patients should be monitored for the development of lymphoproliferative disorder.
Transmission of infectious disease may occur because RETHYMIC is derived from human tissue and because product manufacturing includes porcine- and bovine-derived reagents.
Immunizations should not be administered in patients who have received RETHYMIC until immune-function criteria have been met.
All patients should be screened for anti-HLA antibodies prior to receiving RETHYMIC. Patients testing positive for anti-HLA antibodies should receive RETHYMIC from a donor who does not express those HLA alleles. HLA matching is required in patients who have received a prior HCT or a solid organ transplant. Patients who have received a prior HCT are at increased risk of developing GVHD after RETHYMIC if the HCT donor did not fully match the recipient.
Of the 105 patients in clinical studies, 29 patients died, including 23 deaths in the first year (< 365 days) after implantation.
The most common (>10%) adverse events related to RETHYMIC included: hypertension, cytokine release syndrome, rash, hypomagnesemia, renal impairment/failure, thrombocytopenia, and graft versus host disease.
To report suspected adverse reactions, please contact the FDA at 1-800-FDA-1088 or www.fda.gov/safety/medwatch
RETHYMIC® (allogeneic processed thymus tissue–agdc) is indicated for immune reconstitution in pediatric patients with congenital athymia. RETHYMIC is not indicated for the treatment of patients with severe combined immunodeficiency (SCID).
1. Collins C, Sharpe E, Silber A, Kulke S, Hsieh EWY. Congenital athymia: genetic etiologies, clinical manifestations, diagnosis, and treatment. J Clin Immunol. 2021;41(5):881-895. doi.org/10.1007/s10875-021-01059-7
2. Data on file, Enzyvant.
3. Markert ML, Gupton SE, McCarthy EA. Experience with cultured thymus tissue in 105 children. J Allergy Clin Immunol. Published online August 3, 2021. doi:10.1016/j.jaci.2021.06.028
4. Hsieh EWY, Kim-Chang JJ, Kulke S, Silber A, O’Hara M, Collins C. Defining the clinical, emotional, social, and financial burden of congenital athymia. Adv Ther. 2021;38(8):4271-4288. doi.org/10.1007/s12325-021-01820-9
5. RETHYMIC [package insert]. Cambridge, MA: Enzyvant Therapeutics, Inc; 2021.
6. Markert ML. Defects in thymic development. In: Sullivan KE, Stiehm ER, eds. Stiehm’s Immune Deficiencies. 2nd ed. New York, NY: Elsevier; 2020:357-379.
7. Gupton SE, McCarthy EA, Markert ML. Care of children with DiGeorge before and after cultured thymus tissue implantation. J Clin Immunol. 2021;41(5):896-905. doi.org/10.1007/s10875-021-01044-0
8. Markert ML, Devlin BH, Alexieff MJ, et al. Review of 54 patients with complete DiGeorge anomaly enrolled in protocols for thymus transplantation: outcome of 44 consecutive transplants. Blood. 2007;109(10):4539-4547.
9. Markert ML, McCarthy EA, Gupton SE, Lim AP. Cultured thymus tissue transplantation. In: Sullivan KE, Stiehm ER, eds. Stiehm's Immune Deficiencies. 2nd ed.: Academic Press; 2020:1229-1239.