The Protean Manifestations of Gata2 Deficiency across The Lifespan

>> WE GET TO HONOR ONE OF OUR OWN - STEVE HOLLAND TODAY, IT'S A SPECIAL HONOR. BORN IN BUFFALO AND THINKS WEATHER OUT HERE IS SUMMER. HE GOT HIS UNDERGRADUATE DEGREE AT ST. JOHNS COLLEGE AND MD AT HOPKINS AND RESIDENCY AND INTERNSHIP AT HOPKINS WHERE HE WAS A FELLOW AND FACULTY. AND THEN CAME TO THE NIH WHERE HE WAS A RESEARCH ASSOCIATE IN MICROBIOLOGY. THEN JOINED THE TENURE-TRACK AND LABORATORY AND DEFENSES. FOR THE PAST 10 YEARS CHIEF OF THE LABORATORY OF INFECTIOUS DISEASES AND FOR THE PAST TWO DEPUTY DIRECTOR FOR INTRAMURAL CLINICAL RESEARCH. STEVE'S WORK IS FOCUSED ON DEFECTS THAT WE SUSCEPTIBILITY TOW INFECTION AND *** OOCYTES. THESE STUDIES COMBINED MACRO BIOLOGY, GENETICS, PHYSIOLOGY, MOLECULAR BIOLOGY, TO DEFINE A SET OF RARE DISEASES WHICH HAVE LED TO A MUCH DEEPER UNDERSTANDING OF HOW THE NORMAL BODY REJECTS INFECTIOUS ORGANISMS. YOU'LL HEAR ONE EXAMPLE TODAY OF A PARTICULAR INTERESTING DISEASE THAT DOES EFFECT SENSITIVITY AND INFECTIOUS DISEASE. HE IS THE ONLY PERSON I KNOW OF WHO HAS FOUR NIH DIRECTOR'S AWARDS FOR HIS SCIENTIFIC RESEARCH. IF YOU GO TO THE AWARDS CEREMONY, YOU NOTICE THAT MOST OF THE AWARDS ARE FOR ADMINISTRATIVE ACHIEVEMENTS AND NOT SCIENTIFIC ONES. AND READING THESE AWARDS GIVE YOU SOME FLAVOR OF THE BREATH OF STEVE'S WORK. HE CO-DISCOVERER OF OUR BACTER YUM, GRANULOPACTOR BETHESDA -- WHICH I CALL STEVE'S BACTERIA. HE HAS AN AWARD FOR IDEOLOGY OF JOB SYNDROME FOR HIS DESCRIPTION WITH OTHERS OF THE DOCK 8 DEFICIENCY AND ALSO DISCOVERY OF PLAID DEFICIENCY. HE IS AN INSPIRED AND INSPIRING SPEAKER AS YOU'LL HEAR AND FREQUENTLY INVITED TO GIVE GRAND ROUNDS AND SPECIAL LECTURES TO AUDIENCES AROUND THE WORST. ONE OF HIS JOBS AS DEPUTY DIRECTEDDOR OF CLINICAL RESEARCH IS TO BE AN AMBASSADOR FROM THE NIH TO CONVINCE PEOPLE THAT THERE IS FUN LIFE FOR THE NIH AND CLINICAL RESEARCH. HIS WORK HAS BEEN RECOGNIZED WITH MANY AWARDS INCLUDING THE ASM ABBOTT AWARD, ELECTION AS NIH DISTINGUISHED INVESTIGATOR, ELECTION TO THE AMERICAN ACADEMY OF PHYSICIANS AND MANY OTHER HONORS. SO PLEASE JOIN ME IN WELCOMING TODAY'S LECTURE, STEVE HOLLAND, ONE OF OUR OWN, WHO WILL TALK ABOUT THE PRETTYIAN -- I LOVE THAT WORD. [ APPLAUSE ] PROTEAN. >> THANK YOU, MICHAEL. THANK YOU, COLLEAGUES, FRIENDS, COLLABORATORS. THERE REALLY IS NOTHING MORE TERRIFYING THAN HAVING TO SPEAK HERE IN FRONT OF PEOPLE FOR WHOM I HAVE SUCH RESPECT AND WITH WHOM I WORK SO CLOSELY. NOT BECAUSE I HAVE ANY DISCOMFORT ABOUT THE TOPIC, BUT BECAUSE YOUR SKILL AND YOUR PARTICIPATION IS SO CRITICAL TO EVERYTHING THAT I DO. AND IT IS REALLY A VERY HUMBLING EXPERIENCE TO PRECEPT IN FRONT OF YOU. LET ME START OUT BY SAYING THAT I'M SURE THAT MANY OF YOU HAVE HEARD TOO MUCH FROM ME THIS YEAR. AND I HAVE BEEN AT SEVERAL OF THESE LECTURES AND IF GO OF THIS IS BORING OR REPETITIVE, I CAN ONLY SAY I THINK THE CHAIRS HERE ARE QUITE COMFORTABLE AND I HOPE YOU WILL ENJOY THEM. AND I'M GOING TO TRY TO HEP YOU -- TELL YOU A COMPREHENSIVE STORY ABOUT A DISEASE THAT WE HAVE WORKED ON FOR QUITE A WHILE. AND SO, DESPITE THE FACT THAT I WAS TOLD TODAY THAT I WAS INAPPROPRIATELY USING THE WORD, PROTEAN, BECAUSE HE HAS A PATENT ON IT, I'M GOING TO KEEP ON GOING ASSUMING THAT WE CAN BE OKAY. NOW, I NEED TO REMIND YOU THAT THE COMPLEXITY HERE IS, HOW DO WE RECOGNIZE PHENOTYPE AND HOW DO WE GO FROM PHENOTYPE TO GENOTYPE. AND SO, IT'S ALWAYS GOOD TO REMEMBER THE PHENOTYPE HAS LIKE SO MANY THINGS, A GREEK ROOT. THIS IS REALLY ABOUT SHOWING THE TYPE. SHOWING SOMETHING EXTERNAL AND THIS PARTICULARLY CLIMATE APPROPRIATE CARTOON SHOWS, THAT REALLY CAN BE CONFUSING. AND OF COURSE, IT IS VERY CONFUSE FIGURE YOU'RE ONE OF THESE GUYS AND IT MIGHT BE RATHER ATTRACTIVE IF YOU WERE THIS GUY. BUT IT'S VERY IMPORTANT TO KEEP IN MIND THAT WHAT LOOKS ONE WAY ON THE USE MIGHT NOT ALWAYS BE THAT WAY ON THE INSIDE. I WANT TO TAKE A LITTLE WALK TOGETHER, DOWN OUR PATH COMING TO THE RECOGNITION OF THIS DISEASE OVER THE LAST LITERALLY 20 YEARS. THIS STORY BEGINS TO THE BEST OF MY KNOWLEDGE, IN 1989, WITH THIS PAPER HERE FROM THE NEW ENGLAND JOURNAL BY CHRISTINE BYRON WHO IS ON OUR BOARD OF SCIENTIFIC COUNCILORS, REPORTING A VERY REMARKABLE YOUNG WOMAN WHO HAS SEVERE *** VIRUS INFECTIONS AND THEN DEVELOPED A FATAL MILD CONDITION WHO HAD NO NATURAL KILLER CELLS. AND THIS PAPER WAS FRUIT MY ATTENTION. I WAS A FELLOW AT THE TIME BY MY FATHER WHO WAS INTERESTED IN CANCERS AND THOUGHT THAT THIS DISEASE WITH NO NATURAL KILLER CELLS MUST BE VERY IMPORTANT IN UNDERSTANDING CANCER. AND WHAT WAS INTERESTING ABOUT THIS YOUNG GIRL WHO, THE PAPER I READ AT THE TIME, BUT I MUST SAY I FILED IT AWAY AND DIDN'T GO BACK FOR QUITE A WHILE. SHE HAD AN EPISODE OF LIFE-THREATENING CHICKEN POX AND CHICKEN POX AND PNEUMONIA, WHICH IS QUITE SEVERE AND CAN BE FATAL AND AFTER SHE RECOVERED FROM THAT, SHE HAD SEVERE LEUKOPENIA, VERY LOW WHITE COUNT, THAT DID NOT GET BETTER. AND OVER THE COURSE OF SEVERAL YEARS, SHE REMAINED ILL AND SUBSEQUENTLY DIED WHILE TRYING TO GET TO A BONE MARROW TRANSPLANT. AND THE CRITICAL ELEMENT IN THE PAPER REPORTING HER IN 1989 IS SHOWN HERE. THESE INVESTIGATORS WERE LOOKING AT THE ABILITY OF NATURAL KILLER CELLS TO LYSIS VIRALLY-INFECTED TARGETS. AND HERE YOU SEE THE CELLULAR TARGETS. HERE YOU SEE CONTROLS THAT ARE ABLE TO LYSIS TARGETS VERY EFFECTIVELY AND HERE ARE CELLS FROM THE PATIENT WHAT WERE NOT ABLE TO LYSIS THE TARGETS AT ALL. THEY CAME AWAY WITH THE MESSAGE THAT NK CELLS ARE IMPORTANT AND THEY ARE INVOLVED IN VIRAL PROTECTION. THE NEXT YEAR, A GROUP THAT ENGAGED SUE AT HARVARD, RECOGNIZED IN CHICKENS, THREE PROTEINS THAT WERE IN HEMATOPOIETIC AND OTHER CELLS THAT WERE ALL STRUCTURALLY SIMILAR. AND THESE CELLS, THEY POINTED OUT THESE THREE PROTEINS WERE DIFFERENT TRANSACTIVATING FACTORS BUT THEY ALL RECOGNIZED VIRTUALLY THE SAME TECHNIQUE OR THE SAME SEQUENCE IN CELLS. AND THEY SOMETIMES WERE WITHIN THE SAME CELL. AND SO THEY WERE PUZZLED BY THE FACT THAT THERE WERE THREE PROTEINS THAT WERE ALL RECOGNIZING THE SAME MOTIF. THE FOLLOWING YEAR, NOW, SO WE ARE STILL IN 1990. THEY FURTHER CHARACTERIZED THIS GENE AND THIS PROTEIN AND RECOGNIZED THAT IT BOUND A VERY SMALL SEQUENCE AND HERE IN GEL THAT IS NO ONE IN THE LAST 10 YEARS HAS EVER RUN, THEY RECOGNIZED THAT THE GENE SEQUENCE IT WAS TARGETING WAS THE SAME ONE THAT WE NOW REFER TO AS GATA, OR TATC, JUST TO KEEP US ON OUR TOES. AND THEY RECOGNIZED A PROTEIN, A SERIES OF PROTEINS THAT RECOGNIZED THE GATA OR THE GATTA SEQUENCE. AND THEN FINALLY, IN 1992, THEY RECOGNIZED THAT THIS SAME GENE THEY NOW REFERRED TO AS GATA2 WAS CRITICAL FOR ACTIVATING THE PRODUCTION OF PRE-PRO ENDOTHELIUM. THAT IS THIS GENE WAS CRITICAL FOR TURNING ON THE THE ABILITY TO MAKE ENDOTHELIAL CELLS ACTIVATE AND PROLIFERATE. SO, HERE WE HAVE TWO VERY DISPARATE THINGS, SEVERE VIRAL SUSCEPTIBILITY AND THEN ENDOTHELIAL FUNCTION ALL BEING REGULATED BY A PROTEIN AND OBVIOUSLY I'M TELLING YOU THIS STORY BECAUSE THESE ALL TURNED OUT TO BE ONE THING N1992, THE SAME YEAR THEY IDENTIFIED GATTA 2, I JOINED JOHN GALLON'S LABORATORY AND WE BEGAN TO LOOK AT PATIENT WITH MICROBACTERIAL DISEASE. AND WE IDENTIFIED A FEW PATIENTS. WE STARTED IN 92. YOU CAN SEE I WAS MUCH FASTER BACK THEN. WE GO THE THIS PUBLISHED IN 1994. AND WHAT WE RECOGNIZED WAS THAT WE COULD TREAT PATIENTS WITH DISSEMINATED MICROBACTERIAL DISEASE WITH INTERFERON AND IT CURED THEIR INFECTIONS. AND HERE WE HAVE A BOY WHEN HAD DISSEMINATED MICROBACTERIAL DISEASE AND WHEN WE GAVE HIM INTERFERON HE GREW AND CURED HIS INFECTION. AND HERE A MAN WHO HAD RECURRENT ABDOMINAL ACCUMULATION OF A FLUID THAT WAS INFECTED, WHEN WE GAVE HIM INTERFERON, IT DISAPPEARED. AND HE WAS CURED OF ACE INFECTION. SO WE STARTED ACCUMULATING PATIENTS HAD THESE INFECTIONS AND WE STARTED TRYING TO TREAT THEM WITH INTERFERON AND TO IDENTIFY THEIR UNDERLYING CAUSES. THE GOOD NEWS IS, WE IDENTIFIED ALL THE PATIENTS IN THAT FIRST REPORT AND ONE OF THEM, PATIENT NUMBER 5, IS SHOWN HERE. SO, OUT OF OUR SEQUENCE OF PATIENTS WITH SEVERE DISSEMINATED DISEASE, THE FIFTH ONE TO COME, CAME IN BECAUSE SHE HAD SEVERE DISSEMINATED MICROBACTER YUMAVE YUM AND A LARGE SKIN NODULE DRAINING *** FULL OF MILEAGE ROW BACTERIA AND SHE ALSO HAD A HEADACHE AND COMPLAINED OF HER LEFT EYE NOT WORKING PROPERLY. AND THAT IN FACT WAS A SMOOTH MUSCLE TUMOR THAT WAS INFECTED WITH EPSTEIN-BARR VIRUS. HER STORY IS WORTH NOTING BECAUSE SHE HAD BEEN WELL UNTIL SHE GOT INTO HER 30S WHEN SHE DEVELOPED PNEUMONIA TREATED. I'M NOT SAYING THAT'S THE INDICATE EVERY THERAPY FOR PNEUMONIA BUT THAT'S WHAT SHE WOUND UP WITH AT THE TIME. SUBSEQUENTLY SHE DEVELOPED DISSEMINATED REFRACTARY MICROBACTERIAL INFECTION DESPITE VERY AGGRESSIVE THERAPY. AND WHEN SHE GOT REFERRED HERE IN 1992, WE REALIZED THAT SHE HAD NO MONOCYTES, NO B-CELLS AND NO NK CELLS IN HER RIVER BLOOD DESPITE HAVING RELATIVELY NORMAL T-CELL NUMBERS. SHE ALSO HAD SEVERE PERENNIAL WARTS BUT WE TREATED HER DISEASE FOR MICROBACTERIAL DISEASE, WITH THE INTERFERON AND SHE CLEARED IT COMPLETELY. WENT BACK TO BEING A VERY HEALTHY HOMEMAKER. BUT AFTER SEVERAL YEARS, SHE DEVELOPED PROGRESSIVE ACCUMULATION, NOW OF THE MONOCYTES SHE HAD NONE. SHE NOW HAD SOME. AND SHE DEVELOPED CHRONIC MILE MONCYTIC LEUKEMIA. WE REALIZED THAT THIS WOMAN, PATIENT 5 AND ANOTHER, HAD VERY FEW MONOCYTES IN THEIR PERIPHERAL BLOOD AND VERY FEW B-CELLS DESPITE WHICH THEY HAD ADEQUATE NUMBERS OF HISTIOCYTIC, MACROPHAGE AND PLASMA CELL INFILTRATES AT INFLAMMATORY LESIONS. SO OUR PATIENT, WHO DEVELOPED THE CHRONIC MILE MONCYTIC LEUKEMIA, BECAUSE BACK IN THE 1990S, BONE MARROW TRANSPLANTATION WAS A FIELD IN INFANCY AND WE WERE NOT ABLE TO DO HER DISEASE HERE, WHICH I THINK WAS UNFORTUNATE FOR HER AND FOR US. SHE WAS TRANSPLANTED ELSEWHERE AND DIED SHORTLY AFTER TRANSPLANTATION FROM AN COMMUNITY-ACQUIRED RESPIRATORY VIRUS INFECTION. BUT SHE CAME BACK FOR AUTOPSY. WE WERE VERY GRATEFUL TO HER AND HER FAMILY FOR BEING COMMITTED TO OUR SCIENTIFIC ENTERPRISE. AND IT WAS CLEAR THAT DESPITE THE FACT THAT SHE HAD HAD VERY FEW MONOCYTES IN THE PERIPHERAL BLOOD, SHOOY HAD ABUNDANT MACROPHAGES IN THE TISSUE AND DESPITE THE FACT THAT SHE HAD NO B-CELLS IN THE PERIPHERAL BLOOD, SHE HAD ABUNDANT PLASMA CELLS IN THE PERIPHERAL TISSUES AS WELL AS NORMAL LEVELS OF IMMUNOGLOBULIN. SO, THE PATIENT DID NOT DO VERY WELL. BUT, IN THE PROCESS OF EVALUATING HER FOR TRANSPLANT, WE EXAMINED THE REST OF HER SIBLINGS AS POSSIBLE DONORS AND WE NOTICED HERE IS OUR PATIENT NUMBER 5, THAT THREE OF HER SISTERS WERE HEALTHY. ONE OF THEM WAS NOT. AND THIS WOMAN HAD HAD SEVERE WARTS FROM EARLY IN LIFE AND HAD NO B-CELLS, NO MONOCYTES AND NO NK CELLS IN HER PERIPHERAL BLOOD. IN THE PROCESS OF TAKING THE STORY FROM HER, WE ALSO REALIZED THAT HER MOTHER HAD HAD A VIRTUALLY IDENTICAL DISEASE BEGINNING IN HER 30s GET ILL AND THEN IN HER 40S AND 50S SHE DEVELOPED A SYNDROME THAT EVOLVED INTO MILE MONCYTIC LEUKEMIA WITH DISSEMINATED MACRO BACTERIAL DISEASE AND DIED FROM THAT. THE SISTER OF OUR PATIENT WAS SEEN HERE WHEN SHE DEVELOPED DISSEMINATED MICROBACTERIAL DISEASE. WE TREATED AND CURED HER. AND IN THE PROCESS OF EVALUATING HER, WE LOOKED AT HER CHEST CT AND YOU CAN SEE HERE THIS IS NOT A NORMAL LOOKING CHEST CT. ALTHOUGH THE LUNGS OF WELL INFLATED, THERE IS TOO MUCH MARCKING IN THE PERIPHERY. AND THERE ARE TOO MANY SMALL NODULES HERE THAT HAD US CONCERNED AND WE OFFERED HER A LUNG BIOPSY. AND SHE SAID, NO, I'M REALLY FINE. WHY WOULD I WANT TO DO THAT? I LIVE IN DENVER. I DON'T HAVE PROBLEMS BREATHING, I THINK I'LL PASSION YOUR GENEROUS OFFER. I'LL PASS. THAT WAS FINE. SHE DID WELL FOR SEVERAL YEARS AND CAME BACK IN 2007. AND AT THIS TIME, SHE DIDN'T LOOK AS GOOD. AND YOU CAN SEE HERE NOW HAS SEVERE LUNG DISEASE, ALTHOUGH WE THOUGHT FAVORITE THIS WAS INFILTRATED, IN FACT IT TURNED OUT NOT TO BE. WHAT THIS IS, PULMONARY AVEALIA PROTEINOSIS, ABNORMAL ACCUMULATION -- WITHIN ITS AIRWAVES REFLECTING MACROPHAGE, PULMONARY MACROPHAGE DYSFUNCTION AND INABILITY TO DIGEST AND DEGRADE PULMONARY ACCUMULATION. THE STANDARD TEAMS FOR THIS IS WHOLE LUNG LA ADVANTAGE PERFORMED IN HER AND IN SEVERAL PATIENTS LIKE HER AND WHAT YOU SEE IS THE STANDARD SORT OF APPEARANCE THAT IS THE FIRST LETTER IS VERY OPAQUE AND WHEN MUCH MATERIAL IS BEING RECOVERED, AND THEN OVER THE TIME OF THE 18 LITTERS A PROCESS THAT OUR PUMINOLOGYGIST REFORCE AS JUST AS IMPORTANT AS WATCHING PAINT DRY, BUT IS CRITICAL FOR CLEARING OUT PULMONARY SECRETIONS AND GETTING LUNGS BACK TO NORMAL. AND WHAT YOU SEE HERE IS THE MATERIAL IN THE FIRST 1, NOW BEING ALLUDED OUT AND CLEARED BY THE LAST ONE. SO DESPITE THE FACT THAT THIS WOMAN HAD NO MONOCYTES IN HER PERIPHERAL BLOOD, SHE HAD LOTS OF MACROPHAGES AND HER PULMONARY MACROPHAGES CHOCK FULL OF SER FACTANT AND OTHER RESPIRATORY DEBRIS. SO, WE RECOGNIZED THIS SYNDROME BEGINNING IN 1992. BUT WE DID NOT RECOGNIZE WHAT CAUSED IT. AND WE KNEW THAT SOME OF IT WAS FAMILIAL AND WE KNEW SOME OF IT WAS NOT. WE SUSPECTED IT OUGHT TO BE A SINGLE GENE. BUT WE WERE REALLY CONFUSED ABOUT WHAT WAS CAUSING IT. AND SO, WE WENT WITH A PHENOTYPIC DESCRIPTION AND REFERRED TO THIS AS MONOMACK, FOR MONMONOCYTOPENIA AND MICROBACTERIAL DISEASE. AND IT WAS CHARACTERIZED BY ABNORMALITIES IN THESE CELLS BOTH MYELOID AND LYMPHOID ABSENT FROM THE PERIPHERAL BLOOD OF THE THEY DISSEMINATED INFECTIONS WITH MACRO BACTERIA, HIST TOW PLASMA AND MANY VIRUSES AND THEY HAD PERIODS OF A PLASTIC ANEMIA BUT MANY OF THESE PATIENTS THEN RAPIDLY DEVELOPED MILD DYSPLASIA WITH EITHER ACUTE OR CHRONIC LEUKEMIA. SEVERAL WENT ON TO DEVELOP PULMONARY ALVEOLAR PROTEINOSIS AND PULMONARY HYPERTENSION. SOME OF THE APPEARANCES HERE JUST TO SORT OF GIVE YOU AN IDEA OF BOTH HOW SEVERE AND HOW SUBTLE SOME OF THIS COULD BE, HERE YOU SEE EXTENSIVE WARTS ON THE HAND OF A 24-YEAR-OLD WOMAN. HERE YOU SEE AN UNSUSPECTED HEPATIC TUMOR IN A 25-YEAR-OLD MAN, WHICH ON BIOPSY STAINS POSITIVE FOR EPSTEIN-BARR VIRUS, NOT IN B-CELLS WHERE WE EXPECTED TO BE. BUT IN FACT IN SMOOTH MUSCLE CELLS. INDICATING HE HAS A HAPPENED IN CONTROL OF EBV IN GENERAL AND IN CONTROL OF EBV IN THE PROPER TISSUES. HERE IS A MAN OR A SPECIMEN FROM A MAN WHO HAD AN ABSCESS IN A MUSCLE AND ON ASPIRATION YOU SEE HERE THIS MACROPHAGE CHOCK FULL OF HISTOPLASMA AND NUMEROUS ORGANISMS. AND THEN FINALLY, SOME OF THESE PATIENTS, ESPECIALLY BEFORE WE HAD GOTTEN OUR PROGRAM FULLY INTEGRATED WITH THAT AT THE CANCER INSTITUTE SO WE COULD MOVE TO BONE MARROW TRANSPLANTATION EARLY, SOME OF OUR PATIENTS DIED WHILE WE WERE TRYING TO GET THINGS READY. AND IN THIS PARTICULAR CASE, YOU SEE A MAN WHO DEVELOPED THE FIRST RECOGNIZED INFECTION WITH THE MOLD, NEOSARTORIA, IN THE FAMILY OF ASPERGILLUS. AND THEN, BECAUSE PHENOTYPE IS COMPLICATED, ONCE YOU GET INTO THE FAMILIES WHO NEED TO LOOK HARD WITHIN THOSE FAMILIES, HERE THIS IS IN THE MAN WHO HAD THE DISSEMINATED HISTOMRS. MOWSIS. HIS MOTHER WAS OTHERWISE ASYMPTOMATIC IN HER 60S EXCEPT FOR WHAT YOU SEE HERE, UNILATERAL LYMPHEDEMA AND SCATTERED WARTS ALONG HER LEG. AND THESE ARE THE FLAT FORMS OF HUMAN PAPILLOMA VIRUS WHICH ARE MORE CONSISTENT WITH IMMUNODEFICIENCY. SO, AFTER 18 YEARS OF STUDYING THIS DISEASE AND NOT SURE WHAT THE GENE WAS, WE DECIDED WE HAD BETTER TRY TO PUT OUT A PHENOTIP EMIC DESCRIPTION IN ORDER TO MAKE SURE WE CATALOG WHAT WE KNEW AND IN ORDER TO BEGIN RECRUITING MORE PATIENTS. AND SO, THE FIRST EASTERN PATIENTS ARE COLLECTED HERE AND YOU SEE SIMPLY A PHENOTYPIC COLLECTION OF WHAT WE UNDERSTOOD. WE COLLECTED PATIENTS BASED ON THEIR MICROBACTERIAL INFECTION, MANY HAD VIRAL INFECTIONS AND OTHER HEME LONGIC AND OTHER INFECTIOUS COMPLICATIONS. I ALSO BOAT THAT OVER THE PERIOD, WE STUDIED THEM. WE HAD MORE THAN A QUARTER OF PATIENTS DYING. SO THE HIGH MORTALITY, A HIGH RATE OF COMPLICATION WITH A VERY CONFUSING PHENOTYPE. NOW IN THE PROCESS OF PUTTING TOGETHER THEIR CLINICAL PHENOTYPE, WE WERE VERY FOCUSED ON THEIR LABORATORY ASPECTS AS WELL. AND ALTHOUGH I'M SURE THIS IS TOO SMALL TO READ FROM THE BACK, THE POINT TO TAKE HOME IS THAT ALL OF THESE PATIENTS HAD ABNORMALITIES IN MONOCYTES, B-CELLS, AND NK CELLS. THAT IS, OVER TWO DIFFERENT LINEAGES THAT IS LYMPHOID AND MYELOID, AND VERIABLE ABNORMALITIES IN THEIR T-CELLS. AND WHEN WE LOOKED AT THEIR BONE MARROWS, WHAT WE SAW WAS THAT THEY HAD A MIXED PICTURE OF HYPOCELLULAR BONE MARROWS, AS YOU SEE HERE, AS WELL AS VERY ATYPICAL CELLS, ESPECIALLY IN THE CAREIO SITES. AND THIS PICTURE COURTESY OF KATHY, SHOWS THE UNUSUAL APPEARANCE OF THESE MEGACAREIO SITES THAT ARE ABNORMAL BECAUSE THEIR NUCLEI ARE TOO FAR SPREAD APART. THEY ARE NOT DEVELOPING NORMALLY. THEY ARE NOT WORKING NORMALLY. AND WHEN KATHY DOES FLOW ON THESE BONE MARROWS, YOU SEE THEY HAVE HYPOCELLULARITY AND THE OTHER CELL LINES ARE ABNORMAL AS WELL. SO, THIS IS THE APPEARANCE OF THE GRANULOCYTES IN A NORMAL MARROW. AND YOU SEE THEY HAVE NORMAL SIDE SCATTER AND GRANULARITY, AND IN PATIENTS HAVE ADVANCED DEFECTS IN THIS DISEASE, MONOMACK, THEIR NEUTROPHILS DO NOT HAVE NORMAL GRANUALS SUGGESTING THIS IS A DEFECT THAT BEGINS VERY EARLY IN MYELOID ON KNOWLEDGE TONY AND IN ADDITION YOU SEE IN THE PERIPHERAL BLOOD, MONOCYTES ARE ABSENT IN THE BONE MARROW AND THE NUMBER OF LYMPHOCYTES IS DIMINISHED. WE CAN UNDERSTAND A LITTLE BIT FURTHER SOME OF WHAT HAPPENS HERE, HOW IT IS THAT PATIENTS CAN HAVE NO MAN OOCYTES IN THE MARROW BUT MACROPHAGES IN THE RIVER. THAT IS BECAUSE MACROPHAGES CAN REPLICATE OVER YEARS AND HOW CAN THEY HAVE NO B-CELLS IN THE PERIPHERAL BLOOD AND YET MAKE PLASMA CELLS AND HAVE IMMUNOGLOBULINS? WHAT YOU SEE HERE, IS THAT IN A NORMAL INDIVIDUAL, MATURE B-CELLS ARE EASILY DETECTED AS ARE IMMATURE B-CELLS AND YOU CAN SEE A PROGRESSION OF B-CELL MATURATION FROM CD10 POSITIVITY TO CD20 POSACTIVITY WINDING UP WITH A LARGE SIGNIFICANT POPULATION OF MATURE B-CELLS AND ALSO IMMATURE B-CELLS DEVELOPING. IN OUR PATIENTS THIS SYNDROME, THOUGH, THIS PROCESS IS DISORDER. AND WHAT YOU SEE IS THAT THE EARLY B-CELL PRECURSORS, ARE ABSENT AND THAT THE B-CELL MATURATION IS IMPAIRED BECAUSE NOW IMMATURE B-CELLS ARE GONE AND ALL THAT IS LEFT ARE A SMALL NUMBER OF THE MATURE B-CELLS. SO THESE ARE THE CELLS THAT PRESUMABLY ARE INVOLVED IN PLASMA CELL DEVELOPMENT AND IN THE ABILITY TO MAKE IMMUNOGLOBULIN AND THEY ARE NO LONGER BEING PRODUCED SO THEY ARE NOT GOING TO BE ANY EARLY B-CELLS AVAILABLE TO RESPOND TO NEW ANTIGENS. SO, WE HAVE GOT A VERY COMPLICATED DISEASE IT'S GOT LOTS OF MANIFESTATIONS AND HERE IN A DRAWING THAT TRIES TO CAPTURE EVERYTHING, THEREFORE IS VERY CONFUSING, WE HAVE LISTED ONLY HERE IN RED THE VERY FEW COMPLICATIONS THAT TODAY'S PATIENT NUMBER 5 HAD, VIRUSES AND LUNG DISEASE, DISSEMINATED MICROBACTERIAL INFECTIONS, SEVERE WARTS AND DEVELOPING MILO MONCYTIC LEUKEMIA. YOU CAN SEE THERE ARE MANY OTHER MANIFESTIZATIONS AND THEY ARE EXACTLY THE SAME DISEASE. SO, HOW CAN WE PUT TOGETHER THIS COMPLEX BACKGROUND, THAT IS WITH CELLULAR DEFECTS, INFECTION SUSCEPTIBILITY, BONE MARROW DYSFUNCTION, LYMPHATIC DYSFUNCTION, AS WELL AS LUNG DYSFUNCTION, ALL OF WHICH IS AN AUTO SOMAL DOMINANT PATTERN. THEREFORE IT HAS TO BE A MONOGENIC DISORDER. AND I CAN TELL BUT ALL THE WAYS WE MISSED THIS FOR ALL THOSE YEARS, 20 YEARS WORKING ON THIS DISEASE T IS THAT EXPRESSION NIH STANDS FOR NOT IN A HURRY. BUT IT WAS A OPPORTUNITY TO COLLECT THE INFORMATION AND THE PHENOTYPE. AND THEN AFTER GOING DOWN MANY OF THESE BLIND ALLEYS, THE LABORATORY SAID, HAY, WAIT A MINUTE, HOW CAN YOU POSSIBLY INVOLVE ALL THESE DIFFERENT CELL LINES, MEGO CAREIO SITES, MONOCYTES, DENDRITIC CELLS AND B-CELLS AND K CELLS? THE ONLY WAY TO ACHIEVE SOMETHING THAT GETS ALL OF THOSE CELLS IS TO HAVE SOMETHING THAT IS AFFECTING THE HEMATOPOIETIC STEM CELL. YOU MUST BE AT A MORE PRIMITIVE PRECURSOR AND IT OUGHT TO BE AT THE HEMATOPOIETIC STEM CELL LEVEL. THAT STARTED US DOWN THE TRACK OF LOOKING FOR TRANSCRIPTION FACTORS IN THE HEMATOPOIETIC STEM CELL AND AMY CAREFULLY SET OUT, WHAT ARE ALL THE POSSIBLE TARGETS AND THEN WENT ABOUT SEQUENCING THEM. AND TO CUT THROUGH FURTHER PROBLEMS, I CAN JUST TELL YOU THAT IT WAS ON MAY 3 OF 2011 THAT AMY CALLED ME EARLY IN THE MORNING, EXPLAINING 8 OUT OF 8, 8 OUT OF 8, THAT WE IDENTIFIED 8 OUT OF OUR TARGET PATIENTS WITH MUTATIONS IN THIS GENE NOW KNOWN AND KNOWN EARLIER TO OTHERS AS GATA2. AND WHY SHOULD GATA2 BE THE RIGHT TARGET FOR THIS? BECAUSE IT FITS ALL THE CRITERIA. LET ME POINT OUT THAT WHAT IT DOES, LIKE MANY TRANSCRIPTION FACTORS T CONTROLS OTHER TRANSCRIPTION FACTORS, GATA1 AND 3 AND OTHERS. IT CONTROLS HISTONE DEACETYLASES INVOLVED IN CHROMATIN WINDING AND UNWINDING. ENDOTHELIAL NITRIC OXIDE SYNTHASE AS WELL AS AMPLEIO PITTIC FACTORS CRITICALLY INVOLVED IN THE INVOLVEMENT OF ENDOTHELIUM AND LYMPHATICS. SO THIS GENE REALLY HAS IT ALL. WE IDENTIFIED THAT ON MAY 3. WE WERE VERY LUCKY TO FIND SYMPATHETIC EDITORS AT "BLOOD" TO GET THIS PAPER OUT FIVE WEEKS LATER. BECAUSE WE THOUGHTED IT WAS SO IMPORTANT AN OBSERVATION AND THEY AGREED, AND IT WAS A WONDERFUL EXAMPLE OF HOW WORKING WITH COLLEAGUES AT THE PUBLICATION LEVEL, A CRITICAL COMPONENT FOR ALL OF US, WHEN THEY UNDERSTAND WHAT IS IMPORTANT TO US, WE UNDERSTAND WHAT IS IMPORTANT TO THEM, EVERYONE SEEMS TO DO VERY WELL. AND AT THE SAME TIME, SIMULTANEOUSLY, AND SUBSEQUENTLY, THIS GENE WAS IDENTIFIED IN SEVERAL OTHER SYNDROMES AND SO, THE GROUP OF SCOTT AND HOROWITS HAD BEEN LOOKING AT FAMILIAL MYELOID PLASTIC SYNDROME AND ACUTE MYELOID LEUKEMIA. AND THEY ALSO IDENTIFIED THIS GENE IN SOME FOUR GENERATION FAMILIES AND THEY THOUGHT THAT THIS WAS A SYNDROME OF OUT OF THE BLUE LEUKEMIA. THAT IS ALL PEOPLE GOT WAS MILD DYSPLASIA LEUKEMIA WITH NO OTHER PROBLEMS. THE GROUP OF MATTHEW COLIN IN ENGLANDS WAS VERY INTERESTED IN DENDRITIC CELL DEFICIENCY SO THEY PLOWED THROUGH A SERIES OF SAMPLES AND RECOGNIZED PEOPLE WHO HAD NO PERIPHERAL BLOOD DENDRITIC CELLS WHO TURNED OUT TO HAVE THE SAME PROBLEM THAT THEY CALLED DCML, DENDRITIC CELL MONOCYTE B AND NK CELL LYMPHOID DEFIBER SEE. AND THEN ANOTHER GROUP IN ENGLAND NOTICED A SYNDROME THAT IS REFERRED TO AS EM BERGER SYNDROME, WHICH IS THE SYNDROME OF LYMPHEDEMA AND MILD DYSPLASIA OR ACUTE LEUKEMIA. AND YOU SEE HERE AN EXAMPLE OF THE LYMPHEDEMA ASSOCIATED WITH MILD DYSPLASIA. AND SUBSEQUENTLY, WE WERE ABLE TO WORK WITH THE GROUP OF HAIMER SCOTT AND MARSHAL HOROWITS AND OTHERS, TO IDENTIFY THE REASON THAT THE LYMPHATIC DYSFUNCTION IS THERE NOT ONLY THE ABNORMALITIES IN PREPRO ENDOTHELIUM EXPRESSION, BUT IT'S THE EXPRESSION OF GATTA TWO IN THE LYMPHATIC DUCTS THEMSELVES. AND HERE IS A LYMPHATIC INVOLVE. HERE IS THE EXPRESSION OF GATA2, WHICH IS CRITICAL FOR LYMPHATIC DEVELOPMENT. AND THEN OF COURSE FINALLY, WE WENT BACK WHEN WE RECOGNIZED THAT GATA2 WAS INVOLVED IN NK FUNCTION AND VIRAL SUSCEPTIBILITY AND COULD BE BOTH SPORADIC AND FAMILIAL. I CONTACTED CHRISTINE BYRON WHO SAID, I DON'T HAVE ANY CELLS. I CONTACTED JOHN SULLIVAN AT UMASS WHO HAD A VILE OF PERIPHERAL BLOOD MONONUCLEAR CELLS STORED FROM THIS GIRL FROM THE 1990s WE WERE ABLE TO GO BACK AND IDENTIFY THAT SHE TOO HAD A MUTATION IN GATA2 THAT LED TO A FRAMESHIFT. NOW, YOU MAY RECOGNIZE THE PROBLEM, ONE SET OF FOUNDATIONAL DOCUMENTS, MANY DIFFERENT INTERPRETATIONS OF THEM AND HOW DO WE GO FROM ONE TO MANY AND FROM MANY TO ONE. SO THERE ARE MANY WAYS TO CALL THIS DISEASE. WE STARTED OUT WITH MONOMACK AND OUR COLLEAGUES, BUT THE KEY POINT HERE IS THAT ALL OF IT IS DUE TO GATA2 DEFICIENCY. AS WE MOVE FORWARD, THE NAME WE SHOULD USE FOR THIS IS SIMPLY GATA2 DEFICIENCY AND NOT OUR OTHER MORE AUTONOMOUS NAMES. SO HOW DOES THIS WORK? LET ME REMIND YOU FOR A MINUTE BECAUSE WHEN WE IDENTIFIED GATA2 AS RESPONSIBLE GENE, I HAD NO CLUE WHY THIS WOULD BE IMPORTANT OR HOW IT WORKED. BUT THIS SUDDEN WIFE THOSE TWO DIGIT SCRUNCHING FINGER TRANSCRIPTION FACTORS THAT WINSTON CHURCHILL DESCRIBED AND YOU SEE THE WAY THEY IMPACT. YOU HAVE BOTH FICKERS THAT ARE STRADDLING DNA AND THEN THEY HAVE DOMAINS AT THE C AND N TERMINUS THAT RECRUIT OTHER TRANSCRIPTION FACTORS INTO THE COMPLEX TO TURN ON AND TURN OFF THE RESPECTED GENES. AND THEY BIND TO THE SEQUENCE HERE OF GATA OR TAPC, GIVING THEM A TARGET. THERE ARE SIX MAMMALIAN GATA FACTORS AND THEY SORT OF BREAK GENERALLY INTO THE HEMATOPOIETIC AND THE SOMATIC GROUP. THE HEMATOPOIETIC GROUP INCLUDE GATA1 ASSOCIATED WITH DOWN SYNDROME. AND GATA3 WHICH IS THE LYMPHOMANIACS THINK IS IMPORTANT IN TH2 CONTROL BUT IS CLINICALLY ASSOCIATED WITH THE DISEASE CALLED HDR, HYPOPARATHYROIDISM, DEAF INNOCENCE AND RENAL DISEASE AND NOT ASSOCIATED WITH ANY RECOGNIZED IMMUNODEFICIENCY. GADA FACTORS 4, 5 AND 6 INVOLVE OTHER TARGETS THAT LEAD TO ATRIAL AND VENTRICULAR DEFECTS AND HEART AND URINARY TRACT AND CORONARY DISEASE. WHAT YOU SEE IN RED ARE THE COMPLETELY CONSERVED ELEMENTS. SO WHAT YOU NOTICE IS THAT ALL OF THESE ARE ESSENTIALLY THE SAME IN THEIR ZINC FINGERS. AND ARE THEREFORE ABLE TO BIND TO EXACTLY THE SAME TARGETS. GIVING YOU SOME SENSE OF WHY THE PHENOTYPE MIGHT BE SO BROAD THAT IS, GATA2 IS GOING TO BE ABLE TO BIND TO GATA1 SITES AND VICE VERSA. AND IT STANDS TO REASON IT HAS NOT BEEN YET PROVEN THAT GATA2 CAN BIND TO GATA FOUR SITES AND VICE VERSA. WHICH MIGHT EXPLAIN WHY THERE IS OVERLAP IN SOME OF THESE STRUCTURAL ASPECTS OF THIS DISEASE ALONG WITH THE IMMUNOLOGIC ONES. NOW ONE THING THAT MAKES THIS GENE SO COMPLICATED IS THAT IT IS NOT ONLY INVOLVED IN THE REGULATION THAT I TALKED TO YOU ABOUT, BUT IT IS NOT INVOLVED SO MUCH IN BINDING TO PROMOTORS WHICH IS WHY I THINK MANY OF US STARTED OUT OUR MOLECULAR CAREERS THINKING THAT ACTIVITY WAS GOING TO TAKE PLACE. MOST OF THE WHAT THE GATA FACTORS BIND TO AND GATA2 IN PARTICULAR IS INTRONNIC AND ENHANCER REGIONS. THAT IS OUTSIDE OF THE STRUCTURAL ELEMENTS THAT ARE DIRECTLY ASSOCIATED WITH GENE REGULATION AS WE THINK ABOUT IT MOST COMMONLY. SO, NOW WE HAVE GOT A PROBLEM. WE HAVE GOT HETEROZYGOUS CHANGES IN GATA2 AND THEY ARE ASSOCIATED WITH THE DISEASE. WE KNOW THAT THEY ARE MONOGENIC BECAUSE WE CAN SEE THEM TRAVEL IN FAMILIES. AND SO NOW WE HAVE TO FIGURE OUT HOW TO DAY FUNCTION? WE HAVE THREE CHOICES HERE. THEY COULD BE DOMINANT NEGATIVE, DOMINANT GAIN OF FUNCTION OR HAPLOINSUFFICIENT. AND THIS HAS BEEN A SLIGHTLY CONTROVERSIAL POINT BUT I'M GOING TO USE THE CLINICAL EPIDEMIOLOGY TO TRY AND MAKE THE PERVASIVE POINT THAT THERE IS ONLY ONE MECHANISM THAT CAN POSSIBLY EXPLAIN IT. AND THE SIMPLE THING TO OBSERVED IS THAT WHEN WE HAVE GONE THROUGH NOW AND LOOKED AT ALL OF THE PATIENTS WITH THIS DISEASE, WE FIND THREE CLASSES OF EASILY IDENTIFIED MUTATION. MISSENSE MUTATIONS, TYPICALLY IN THE SECOND ZINC FINGER IN WHICH A PROTEIN ISITUDES. NONSENSE MUTATIONS WHICH ARE SPREAD MORE BROADLY IN WHICH NO PROSTEIN PRODUCED AND INTRONNIC MUTATIONS, NOTED HERE, WHICH ARE QUITE INTERESTING BECAUSE ALMOST A QUARTER OF OUR PATIENTS HAVE THESE INTRONNIC MUTATIONS AND THIS INTRON 5 IS WHERE GATA2 BINDS INSIDE ITS OWN GENE TO UP REGULATE TUESDAY. THE IMPORTANT POINT THAT ALMOST ALL OF THE FACTORS -- REGULATE TUESDAY. ALL THE PATIENTS WHO HAVE ANY MUTATIONS ARE VIRTUALLY INDISTINGUISHABLE. THAT IS THEIR CLINICAL PHENOTYPE IS ALMOST IDENTICAL ACROSS ALL THREE OF THOSE. MAKING IT EVEN MORE PERSUASIVE, THERE IS ANOTHER SMALL GROUP OF PATIENTS IN WHOM WE CAN'T FIND A MUTATION BUT WE SEE ONLY ONE MRNA PRODUCED. SO ONE ALLELE IS BEING EXPRESSED, ONE ALLELE IS NOT. AND AS FAR AS WE CAN TELL, THESE PATIENTS ARE ALL THE SAME. AND WE CAN SEE THIS CLINICALLY BECAUSE THE DISEASE THAT OCCURS HERE, I HAVE JUST TAKEN MILD DISPOLICE STATIONIA, NO MATTER WHAT KIND OF MUTATION THEY HAVE, THE RATE OF PROGRESSION AND DEVELOPMENT OF DISEASE IS THE SAME. THAT IS, NO MATTER WHETHER YOU'RE MAKING PROTEIN, NOT MAKING PROTEIN, EXPRESSING ALLELE OR ONLY EXPRESSING A LITTLE BIT OFA, LEGAL, THEY ARE ALL THE SAME PROBLEM. A -- ALLELE. SO THIS MUST THEN REFLECT THE UNDERLYING MECHANISM IS ONE OF HAPLOIN SUFFICIENCY. ONE ALLELE IS SIMPLY NOT ENOUGH. AND WE CAN PROVE THIS AT A MOLECULAR LEVEL BY LOOKING AT THE NUMBER OF GATA2 TRANSCRIPTS PRESENT IN CELL LINES AND HERE YOU SEE THAT NO MATTER WHAT THE UNDERLYING MECHANISM OF THE MUTATION, WHETHER IT IS INTRONNIC OR HETEROZYGOUS, MISSENSE OR NONSENSE, THEY ALL HAVE THE SAME CONSEQUENCE, WHICH IS LOW EXPRESSION OF GATA2 COMPARED TO THE NORMALS. AND COMPARED TO OTHER PATIENT POPULATIONS. SO HAPLOINSUFFICIENCY IS THE ORGANIZING THEME BEHIND THESE PROBLEMS. NOW, WHAT ARE SOME OF THE ASPECTS OF THIS DISEASE THAT I THINK WOULD BE USEFUL TO THINK ABOUT AS WE MOVE INTO THE LATER ASPECTS OF UNDERSTANDING IT? SO WE HAVE DOMINANT TRANSMISSION BECAUSE OF ALLELE LOSS, LEADING TO HAPLOINSUFFICIENCY. WHAT ARE THE CONSEQUENCES IF POPULAR MANY THINGS WE WILL LEARN OUT OF THIS ONE DISEASE. ONE OF THEM SO FAR HAS BEEN SOMETHING ABOUT NK CELL BIOLOGY. SO I STARTED OUT TELLING YOU ABOUT A GIRL WITH NK CELL DEFICIENCY WHO TURNED OUT TO BE GATA MUTATED. GATA2 IS REQUIRED FOR THE EXPRESSION EVER THE CD56 GRADE CELLS SO IMPORTANT IN NK FUNCTION AND BIOLOGY. AND THESE CELLS ARE ABSENT IN GATA2 DEFICIENT PATIENTS LEADING TO IMPAIRED ABILITY TO PERFORM SEVERAL CRITICAL FUNCTIONS FOR NK CELLS. PRESUMABLY, LEADING TO THEIR SUSCEPTIBILITY TOW VIRUSES AND CANCER. WE FOUND THIS UNDERLYING DEFECT IN SEVERAL OTHER HYPOPLASTIC MARROW DISORDERS. SO IN ABOUT 10% OF JUVENILE MILD DYSPLASIA, THOSE ARE DUE TO UNDERLYING GAT TWO MUTATIONS. IN 5-10% OF JUVENILE APLASTIC ANEMIA, THOSE ARE DUE TO UNDERLYING GATA2 MUTATIONS. IN THE FRENCH SERIES LOOKING AT PETE AT RICK NEUTROPENIA, 10% OF DUE TO GATA HAPLOINSUFFICIENCY. SO THERE ARE GOING TO BE MANY DIFFERENT MANIFESTATIONS. ONE OF THEM HERE IS ILLUSTRATED BY THIS CASE, A 12-YEAR-OLD BOY WITH SEVERE APLASTIC ANEMIA WHO CAME IN FOR EVALUATION AND TREATMENT. HE RECEIVED STANDARD THERAPY FOR HIS APLASTIC ANEMIA WHICH WAS SUCCESSFUL, EXCEPT TWO YEARS LATER AFTER HIS TREATMENT, HE CAME BACK WITH SEVERE MILD DYSPLASIA AND RAPIDLY EVOLVED INTO AN ACUTE MILE LODGEINS LEUKEMIA. ONLY AFTER HIS DEATH DID WE RECOGNIZE HIS UNDERLYING MUTATION WAS AN INTRON 5 MUTATION IN GATA2. SOME OF THE OTHER MANIFESTATIONS THAT ARE IMPORTANT AND WHAT MAKES THIS DISEASE SO DIFFICULT TO HAVE RECOGNIZED AT THE BEGINNING ARE VIRAL INFECTIONS. SO HERE WE ARE PLOTTING THE PERCENT WITHOUT A PARTICULAR MANIFESTATION. SO EARLY IN LIFE, UP UNTIL ABOUT AGE 10, CHILDREN ARE NORMAL. BUT FOLLOWING THAT, THEY DEVELOP VIRAL INFECTIONS TYPICALLY WITH HUMAN PAPILLOMA VIRUS, AND YOU CAN SEE THAT BY ADULTHOOD, ALL OF THEM HAVE SOME HPV MANIFESTATION. MICROBACTERIAL AND FUNGEL INFECTIONS OCCUR LATER AND PROGRESS OVER TIME SO IN OUR SERIES, WE RECRUIT FOR THESE INFECTIONS BUT IN OUR SERIES PATIENTS DEVELOP MORE MICROBACTERIAL DISEASE AND FUNGAL DISEASE OVER TIME. AND THEN MILD DYSPLASIA WHICH MONTHS AROUND THE SAME TIME AND FOLLOWING THE DEVELOPMENT OF THE SEVERE INFECTIONS, ALSO RUNS A PROGRESSIVE COURSE OVER THE COURSE OF GATA2 DEFICIENCY. FOLLOWING THESE THINGS, I THINK REFLECTING PROGRESSIVE SEVERE PULMONARY MACROPHAGE DYSFUNCTION, PULMONARY PROGNOSIS BECOMES EYE - PULMONARY ALVEOLAR BECOMES A PROGNOSIS. SO, CATALOGING DISEASE IS IMPORTANT FOR SCIENCE AND IT'S VERY IMPORTANT FOR US AS INVESTIGATORS. BUT, PATIENTS NEED SOMETHING MORE AND YOU CAN NOT SIMPLY SAY TO PATIENTS, BOY, THIS IS GREAT. WE NOW UNDERSTAND WHY YOU'RE GOING TO DIE. THAT'S JUST NOT AN ADDIAT ANSWER AND THAT IS NOT WHY WE HAVE A HOSPITAL. IF THAT'S WHAT WE WANTED, WE WOULD JUST BE A RESEARCH INSTITUTE. SO IT IS CRITICAL TO HAVE COLLABORATORS WHO ARE AS MOTIVATED AND AS AGGRESSIVE AND INTERESTED IN THE DISEASE AND ITS TREATMENT AS ALL OF US ARE IN DISEASE AND ETIOLOGY. SO IT'S BEEN MY GREAT GOOD FORTUNE TO COLLABORATE WITH JENNIFER RODRIGUEZ AND DENNIS, WHO RECOGNIZED IN THIS DISEASE A FANTASTIC OPPORTUNITY FOR IDENTIFY SOMETHING NOVEL AND TO TREAT IT AND TO COME UP WITH CRITICAL OBSERVATIONS BUT WOULD BE DIFFERENT FROM ALL OBSERVATIONS IN PREVIOUS EPISODES OF TRANSPLANETARY OF BONE MARROW. WHEN YOU GO INTO A NEW DISEASE, YOU HAVE NEW THINGS TO DO. SO I JUST TAKE ONE FIGURE FROM THEIR PAPER, WHICH ILLUSTRATES THAT AFTER TRANSPLANTATION, EXACTLY WHAT YOU EXPECT HAPPENS. IN. K CELLS COME BACK AS TO MONOCYTES. THAT IS, THIS MEANS THAT THE PROBLEM IS NOT IN THE STROMA OF THE MARROW. THE PROBLEM WAS IN THE HEMATOPOIETIC CELLS THEMSELVES. THAT CAN BE REPLACED AND THAT CAN BE REPAIRED. IN ADDITION TO THAT, NOT ONLY ARE THE HEMATOPOIETIC ELEMENTS REPAIRED BUT YOU CAN REPAIR AN ORGAN DAMAGE AS WELL. SO IN OUR FIRST PATIENT WHO UNDERWENT BONE MARROW TRANSPLANTATION, HIS LUNG DISEASE WAS SO SEVERE, HE WAS ON SIX LITERS OF OXYGEN AND HIGH DOSE FULL-TIME *** TO CONTROL PULMONARY HYPERTENSION. IT WAS A DICEY THINGS TO TAKE HIM TO TRANSPLANT BUT LUCKY FOR US, WE HAD AN AGGRESSIVE BUNCH OF TRANSPLANTERS WHO REALIZED THAT THEIR THERE WERE ONLY TWO CHOICES, PROGRESS OR DEATH AND THANK GOD THEY CHOSE PROGRESS. AND WITH TRANSPLANT, WHAT YOU SEE IS THAT OVER SIX MONTHS, HE WAS ABLE TO COME OFF OXYGEN AND COME OFF SILL BEN FILL AND RECOVER NORMAL LUNG FUNCTION FOR A TIME. HE HAD SUBSEQUENT PROBLEMS AND HAD TO UNDERGO LUNG TRANSPLANTATION BUT FROM THE HEMATOPOIETIC STANDPOINT, HE WAS ABLE TO MAKE IT THROUGH. NOW THE LAST THING I NEED TO TELL YOU ABOUT IS THAT WHAT WE RECOGNIZE IS DISEASE, AND THAT IS COMES WHAT COMES US AS CLINICIANS. ONCE WE RECOGNIZE A GENE, THEN WE HAVE TO GO BACK AND RECOGNIZE PEOPLE BEFORE THE DISEASE DEVELOPS. AND HOW WE UNDERSTAND THAT THEN LEADS US TO THE NEXT STEPS. SO, HERE I JUST PLOTTED -- THIS IS WORK THAT MICHAEL SPINNER AND LAUREN SANCHEZ DID PULLING TOGETHER ALL OUR DATA ON ALL OF OUR PATIENTS. AND LOOKING AT B, IN. K, MONOCYTE AND CD4 NUMBERS AND HERE IN THE NUMBERS BELOW ARE SIMPLY HOW MANY DISEASE MANIFESTATIONS PEOPLE HAVE. AND IT DOESN'T MATTER WHICH ONE IT IS, IF YOU HAVE NO DISEASE MANIFESTATIONS, THE KEY POINT IS, YOU GOT NORMAL NUMBERS OF B-CELLS AND NORMAL NUMBERS OF NK CELLS AND NORMAL NUMBERS OF MONOCYTES AND N T-CELLS. EVERYTHING THEN GOES TO HELL. AND SO THE QUESTION IS, WHY? ARE PEOPLE GETTING SICK BECAUSE THEY ARE CYTOPENIC OR ARE PEOPLE GETTING CYTOPENIC BECAUSE THEY ARE SICK? THIS IS A CRITICALLY IMPORTANT QUESTION BECAUSE IT DRIVES WHAT WE DECIDE TO DO IN TERMS OF PROPHYLAXIS, IN TERMS OF THERAPY, IN TERMS OF PREEMP TYPH TRANSPLANTATION. SO, ONE PIECE OF INFORMATION WAS PUBLISHED LAST WEEK AT UNIVERSITY OF WISCONSIN, A TREMENDOUS BIRCH OF COLLABORATORS FOR US IN WHICH THEY WERE ABLE TO MAKE HETEROZYGOUS MICE, WHICH THEY HAVE BEEN GOOD ENOUGH TO SHARE WITH US, AND WHAT YOU SEE HERE IS WHEN THEY TAKE EMBRYOS FROM THESE HETEROZYGOUS MICE AND LOOK AT THE NUMBER OF STEM CELLS THAT THEY CAN TRANSPLANT WHEN YOU DO SERIAL BONE MARROW TRANSPLANTS. YOU SEE THAT IN NORMAL MICE THE TRANSPLANTS ARE ABLE TO GROW SUCCESSFULLY AND EXPAND. WHEN YOU TAKE HETEROZYGOUS MICE, IS THERE A TROUBLE EXPANDING AND IN COMPETITIVE TRANSPLANTATION EXPERIMENTS, THEY DON'T COMPETE VERY WELL. AND IF YOU HAVE COMPLETE KNOCKOUT, THOSE DON'T MAKE STEM CELLS THAT ARE ABLE TO DO ANYTHING. AND THESE ANIMALS ARE ABLE TO UNDERGO THE WILDTYPE ANIMALS ABLE TO UNDERGO SECONDARY TRANSPLANTATION TO TRANSMIT AGAIN BUT THE HETEROZYGOUS KNOCKOUT ANIMALS DO NOT DO VERY WELL. INDICATING THAT THESE ANIMALS HAVE DIMINISHED NUMBER OF STEM CELLS AT THE BEGINNING AND AS TIME GOES ON, THEIR STEM CELLS REMAIN IMPAIRED. YOU CAN SEE THIS WHEN YOU TRY TO CULTURE STEM CELLS FROM THESE ANIMALS AND HERE THE WILDTYPE HAS THE NORMAL LEVEL OF CFUGM AND HERE IN THE HETEROZYGOUS KNOCKOUT ANIMALS, THE NUMBER OF CFUGM IS SIGNIFICANTLY ABOUT 50% REDUCED. WELL, HOW DOES THAT HELP US? SO NOW WE NEED TO GO BACK AND DO OUR BENCH TO BEDSIDE EXPERIMENTS RECRUITING WILLING VOLUNTEERS AS WE SO OFTEN DO. GET A CONSENSUS ADMINISTERED AND THANK GOD WE HAVE A VERY GOOD I ARE. B. OUR APPROACH IS TO TAKE OUR HETEROZYGOUS KNOCKOUT ANIMALS AND INFECT THEM INTRAVENOUSLY WITH THE COMPLEX AND TO ASK WHAT HAPPENS TO BONE MARROW? CAN WE REPRODUCE THE PROBLEMS IN THE KNOCKOUT ANIMALS THAT WE HAVE IN OUR HUMANS? AND SO WHAT IS IMPORTANT TO KNOW IS THAT AT THE BEGINNING WHEN THEY ARE NOT INFECTED, THE BONE MARROWS ARE COMPLETELY NORMAL IN THE KNOCKOUT AND WILDTYPE ANIMALS. AND SO, HERE WHEN WE ARE LOOKING AT OUR GATA2 UNINFECTED, WILDTYPE ANIMALS ON THE TOP AND MUTANT ANIMALS ON THE BOTTOM. WHEN THEY ARE UNINFECTED THIS PART OF THE SCREEN, WHEN THEY ARE UNINFECTED, THE NUMBER OF STEM CELLS IS DEDUCTIBLE AND JUST LIKE IT OUGHT TO BE. THESE ARE REDUCED COMPARED TO THESE BUT THEY ARE STILL PRESENT. BUT ONCE YOU INFECTED THE ANIMALS, YOU SEE THE WILDTYPE DO NOT LOSE SIGNIFICANT NUMBERS OF STEM CELLS WHEREAS AFTER INFECTION AND NOT BEFORE, THE GATA MUTANT ANIMALS BECOME STEM CELL DEPLETED. AND WE CAN SEE THIS HERE WHEN WE LOOK IN THE FLOW CYTOMETRIC STUDY. IF WE LOOK AT A STRINGENT MARKER FOR MURINE STEM CELLS, THE HETEROZYGOUS ANIMALS AFTER INFECTION ARE DEPLETED WHEREAS THE WILDTYPE ARE NOT. THEREFORE, SUGGESTING THAT IT IS THE INFECTION ITSELF THAT IS HELPING TO DRIVE THE CYTOPENIA AND NOT THE CYTOPENIA THAT IS MAKING THE INFECTION OCCUR. THIS I THINK IS IMPORTANT FOR INFORMING US IN WHAT WE SHOULD DO ABOUT PROPHYLAXIS AND IN TERMS OF WHAT ARE THE KINDS OF THINGS THAT ARE LIKELY LEADING TO THEIR PROBLEMS. OKAY. SO LASTLY NOW, THESE ARE, WE TALKED ABOUT GERMLINE PROBLEMS IN GATA2 WITH MUTATIONS THAT ARE PRESENT FROM BIRTH AND THAT MOVE ON. BUT GATA2 IS NOT ONLY INVOLVED IN THAT. AND SO, IN PEDIATRIC ACUTE LEUKEMIAS, THE DEVELOPMENT OF GATA MUTATION OCCURS IN THE SETTING OF PRE-EXISTING CDP ALPHA MUTATIONS AND IN THAT SETTING, GATA2 MUTATIONS SEEM TO BE AMELLATIVE AND TO HAVE SOMEWHAT BETTER SURVIVAL THAN IN PATIENTS WHO HAVE CEBPA MUTATIONS ALONE. BUT, IF THEIR GATA2 IS BEING OVEREXPRESSED IN THESE PATIENTS IS NORMALLY EXPRESSED. IF GATA2 IS OVER EXPRESSED IN LEUKEMIC CELLS, THAT LEADS TO WORSE PROGNOSIS. SO, THERE IS HAVING A NORMAL THING, A GOOD THING AND THEN THERE IS OF COURSE TOO MUCH OF A GOOD THING. SEE, IN CONCLUSION, HOW DOES GATA2 DO ALL THIS? IT HAS REGULATORY EFFECTS IN NUMEROUS TISSUES. ABNORMAL VESSELS AND LYMPHATICS AND OVERLAPPING TARGETS OF THE GATA FACTORS, A CRITICAL POINT IN HOW WE UNDERSTAND HOW DIFFUSE THE MECHANISMS ARE. EARLY POPULATION OF TISSUES WITH MACROPHAGES AND PLASMA CELLS WITHIN DEPLETION OF MONOCYTES AND B-CELLS LEAVING THOSE CELLS STRANDED OUT IN COLONIAL SITES WHERE THEY GET NO REPLENISHMENT AND NO NOURISHMENT. IMPAIRED DEFINITIVE HEMAPOISIS, INFECTION BONE MARRY DRIVEN EXHAUSTION AND SECONDARY MUTATION AND CYTOGENETIC DEFECTS. SO GATA2 DEFICIENCY TURNS OUT TO BE MUCH MORE COMMON THAN WE THOUGHT EARLY ON. IT IS INVOLVED IN MANY DIFFERENT DISEASES WITH MULTIPLE MANIFESTATION THAT IS CUT ACROSS DISCIPLINES AND IT PREDISPOSES TO A HOST OF INFECTIONS WHICH MAKES IT DIFFICULT TO ANTICIPATE T HAS A VARIABLE ONSET BUT THEN PROGRESSIVE CYTOPENIAS AND ITS MECHANISM IS HAPLOINSUFFICIENCY WITH REGULATORY MUTATIONS INDICATING THAT THE CONTROL OF THIS GENE IS EXTRAORDINARILY TIGHT. AND FINALLY IT IS ALREADY TAUGHT US A LOT ABOUT NK CELL DEFICIENCY AND DYSFUNCTION AND I THINK IT IS GOING TO TEACH US A LOT MORE ABOUT CANCER SUSCEPTIBILITY IN THE FUTURE. SO THIS IS ONE GENE THAT TIES TOGETHER INFECTION, HEMAPOISIS, IMMUNODEFICIENCY, LYMPHEDEMA, PAP AND CANCER. AND THERE AREN'T MANY OF THOSE. I TRIED TO TAKE YOU ON A TRIP, TRIED TO START YOU WITH THE FIRST RECOGNITION OF THIS DISEASE IN 1989, AND WALK YOU THROUGH THE 22 YEARS TO RECOGNITION OF THE GENETIC BASIS OF THIS DISEASE, AND THEN TELL YOU A LITTLE BIT ABOUT THE STILL EVOLVING AND COMPLEX MANIFESTATIONS OF THIS CONDITION THAT ARE STILL BEING WORKED OUT NOW. SO, I LIKE TO THINK OF THIS AS THE SYNDROME OF THE BLIND MEN WITH THE ELEPHANT AND GATA2 IS WHATEVER IT IS YOU WANT IT TO BE DEPENDING ON WHERE YOU'RE STANDING. I STARTED OUT HERE THINKING IT WAS MACRO BACTERIAL. IT'S HPV MANIFESTATIONS AND IT'S LYMPHEDEMA AND IT'S FUNGAL MANIFESTATIONS AND THE ACCUSED LEUKEMIC PROBLEMS AS WELL AS THE LUNG DISEASE. OF COURSE WHAT MAKES IT DIFFICULT AND DIFFICULT IN TERMS OF GENETIC COUNSELING AND UNDERSTANDING IN THE LONG RUN, IS THE FACT THAT AT SOME POINT IN EVERYBODY'S LIFE, THEY ARE NORMAL. AND HOW TO ANTICIPATE THAT, HOW TO WORK WITH IT, WHAT WHAT TO DO ABOUT IT IS WHAT THE NEXT PHASE OF OUR STUDY IS ABOUT. SO, PHENOTYPE CHANGES WITH TIME T CHANGES WITH EXPOSURE. IT CHANGES WITH ENVIRONMENT. WHETHER YOU GET SATISFACTION OR NOT, YOU REALLY STILL HAVE TO BE THINKING ABOUT WHAT IS IT THAT I EXPECT AT THIS TIME AND WHAT DO I EXPECT THIS DISEASE TO DO IN THIS PERSON? SO, WITH THAT I'D LIKE TO CONCLUDE BY ACKNOWLEDGING THE EXTRAORDINARY NUMBER OF PEOPLE THAT HAVE BEEN INVOLVED IN THIS PROJECT FROM ITS GET GO AND IN PARTICULAR, AMY SUE AND ELIZABETH HAVE BEEN CRITICALLY IMPORTANT IN THE LABORATORY. LAUREN SANCHEZ AND MICHAEL SPINNER PULLED TOGETHER ALL OF OUR CLINICAL DATA. KATHY AND DIANE AND MARC HAVE BEEN CRITICAL MOLECULAR AND HOMOLOGIC COLLABORATORS. STEPHANIA HELPED US WITH ALL OF OUR IMMUNOHISTOCHEMISTRY AND LI HAS BEEN DRIVING OUR MOUSE WORK AND KEEPING THAT AFLOAT. MANY OTHER COLLABORATORS HERE INTERNALLY, SOME OF WHO WHOM I HAVE MENTIONED AS WE HAVE GONE ALONG AND OUR COLLABORATORS IN THE NCI WITHOUT WHOM WE WOULD HAVE ONLY A PROGRAM THAT WOULD BE ABLE TO SAY, I'M SO INTERESTED IN YOUR PROBLEM AND I'M SO SORRY FOR YOUR LOSS. AND IF WE DO NOT MAINTAIN AN INSTITUTION THAT INSISTS ON MOVING BEYOND THE CATALOGING OF DISASTER, WE WILL NOT HAVE A FUTURE THAT IS EXCITING IN WHICH TO LIVE. THANK YOU VERY MUCH. [ APPLAUSE ] >> I'M SURE YOU WILL BE HAPPY TO TAKE QUESTIONS. WHILE YOU'RE GETTING TO THE MIC ROW PHONE, LET ME START. SINCE THIS IS SUCH A PROTEAN SYNDROME, HAVE YOU LOOKED AT OR HAS ANYONE LOOKED AT POLYMORPHISMS? DOES THAT OCCUR IN THE NORMAL POPULATION? DO ANY REPRESENT -- [ INDISCERNIBLE ] >> THAT'S A VERY IMPORTANT POINT. THE POLYMORPHISMS IS NOT -- THIS SET OF DISEASES. IN FACT, THERE IS A SNP ASSOCIATION IN TERMS OF VASCULAR DISEASE, WHICH I DON'T UNDERSTAND, AND THAT'S THE ONLY ONE I'M FAMILIAR WITH SO FAR. RIGHT NOW, THOUGH, A LOT OF PEOPLE ARE LOOKING LOOKING IN LOU CAMIA AND OTHER MYELOID PLASTIC SYNDROMES AND WE'LL COME UP WITH A BROADER SPECTRUM BOTH MUTATIONS AND PROBABLY SOME SNPS. AND I THINK AS THE WHOLE EXOME APPROACH IS MORE EXPLORED, WE WILL FIND OTHER ASSOCIATIONS AS WELL. >> STEVE, I WANTED TO KNOW HOW WELL THAT MOUSE MODEL RECAPITULATES THE HUMAN DISEASE? THERE IS A LOT OF CONCERN ABOUT MOUSE MODS ELSE AND HUMANS AND THE MOUSE THAT HAS BEEN AROUND FOR 25 YEARS AND RUNNING AROUND LABS AND NOBODY EVER SAW THE HUMANS AND THOUGHT, THERE IS A MOUSE JUST LIKE THAT. >> RIGHT. SO HOW GOOD IS MOUSE MODEL? WE HAD HOPED IT WOULD BE A LITTLE MORE BETTER. AND WE HAVE BEEN A LITTLE DISAPPOINTED THAT IT TOOK 22 WEEKS TO ACHIEVE A CELL, STEM CELL DEPLETION IN THE MOUSE MODEL WITH JUST MICROBACTERIAL INFECTIONS. I THINK ONE OF THE PROBLEMS IS KNOWING WHETHER WE ARE CHALLENGING THE MOUSE WITH THE RIGHT THING. I CHOSE MAC BECAUSE THAT'S WHAT GETS THE HUMANS. MICE DON'T GET MAC. MICE ARE HARTO -- HARD TO INFECT WITH MAC. NOW WE HAVE TO GO BACK AND THINK ABOUT WHAT IS THE RIGHT THING TO PUT IN THE MICE AND WHAT SHOULD WE DO ABOUT THAT AS WE GO ALONG? THE -- WHETHER THE MOUSE WILL BE A GOOD MARKER FOR HUMAN DISEASE, I THINK IS A TOUGH QUESTION. LISA MCREYNOLDS IS WORKING ON CROSSING IT TO OTHER KNOWN GENE DEFECTS SO WE CAN SEE IF WE CAN ACCELERATE THINGS LIKE IN MILD DYSPLASIA AND LEUKEMIA AND THOSE WOULD BE CRITICAL TARGETS TO KNOW WHETHER GATA2 IS INTERACTING WITH THOSE. WE LIKE IT TO BE A BETTER MODEL. >> YOU MENTIONED THAT GATA2 AND GATA1 OVERLAP IN TERMS OF BINDING CAPABILITIES AS WELL AS GATA2 AND 4. YET YOU HAD DISTINCT CLINICAL SYNDROMES ASSOCIATED. DO YOU THINK THERE MIGHT BE MORE OVERLAP BETWEEN SYNDROMES? HOW DO YOU EXPLAIN WHY THE SYNDROMES -- EVEN THOUGH GATA2 HAS SUCH PROTEAN MANIFESTATIONS, HOW THEY ARE STILL SORT OF DIFFERENT TYPES OF SYNDROMES? >> I THINK THAT IS A VERY IMPORTANT POINT AND I THINK THAT THERE ARE A LOT OF OVERLAPS IN THE SYNDROMES AND THE OVERLAPSE OCCUR AT THE LEVEL OF -- I THINK THE NUMBER OR WE ARE LIMITED BY WHAT WE HAVE STUDIED. NOT ONLY US BUT IN THE OTHER GATA FACTORS AND ALTHOUGH THEY ARE RECOGNIZED AS HAVING MANDELIAN ASSOCIATIONS, THEY ARE NOT NUMEROUS. THE CASE REPORTS. AND JUST AS MARSHAL HOROWITS HAD PUBLISHED HIS PATIENTS OUT OF THE BLUE LEUKEMIA, IN FACT NOW THAT WE HAVE GONE BACK AND MET HIS PATIENTS, IT WASN'T OUT OF THE BLUE AND IT WASN'T ONLY LEUKEMIA. WE ARE ALL SUBJECT TO THE QUESTIONS WE ASK. WE ALL GOT OUR ANSWERS BUT TURNS OUT THEY ARE ALL IN ONE HOLE. THE OVERLAP OF SYMPTOMS AT A 1 IS VERY IMPORTANT IN TERMS OF THE THROMOCYTE PENIA THESE PATIENTS GET WGATA THREE, SENSORIAL NEURAL HEARING LOSS IS A VERY COMMON MANIFESTATION TO GATA2 DEFICIENCY. NOW PROVEN THAT THE DEFECT OR THE OVERLAPPING SYNDROMES ARE BECAUSE OF OVERLAPPING BINDING SITES IS A LITTLE BIT DIFFICULT. WHAT WE CAN SHOW WITH SOME CONFIDENCE IS THAT TARGETS OVERLAP AND THAT THE BINDING CAN BE COINCIDENT. AND WHAT SORT OF EXCITING ABOUT THE INITIAL RECOGNITION OF THE CHICKEN WITH THOSE THREE GATA BINDING FABBORS IN THE SAME CELL, THEY KNEW THEY BOUND THE SAME TARGETS BUT THEY DIDN'T KNOW WHAT THE LEVEL OF COMPLEX REGULATION WAS. JUST LAST WEEK, ANOTHER PAPER IN "CELL STEM CELL," LOOKED AT THE FINE-TUNING OF GATA BINDING SITES AND ALTHOUGH GATA IS THE CONKEL SITES, THERE IS SUBTLE VARIATIONS WHEN YOU LOOK AT GATA1 AND 3 IN TERMS OF WHAT THEY DO AND IT VARIES TISSUE AND STIMULATION. AND I THINK THERE WILL BE A COMPLEX SET OF MANIFESTATIONS THAT WE LOOK FORWARD TO WORKING ON. >> AS THIS DISEASE EVOLVES INTO MILO DISPLASTIC AND THEN LEUKEMIA, DOES IT SHARE WITH RUN-OF-THE-MILL MILO DISPLASTIC AND POLY-SCI TEAMIA, AND JACK 2 MUTATION AT 267 THAT IS BEING TREATED WITH RUCKSEL ED NEB NOW? >> NOW THAT WE HAVE SEEN SO FAR. WE HAVE NOT LOOKED FOR JACK 2 MUTATIONS IN ALL OUR PATIENTS BUT IN THOSE IN WHOM WE HAVE LOOKED WE HAVE NOT SEEN IT. I THINK THE MECHANISMS ARE LIKELY TO BE DIFFERENT BUT I THINK ONE OF THE CRITICAL THINGS THAT WE NEED TO DO AND WE HAVE NOT YET DONE IS TO UNDERTAKE VERY AGGRESSIVE SEQUENCING AT MULTIPLE STAGES ALONG THE DEVELOPMENT. SO, ROB WEST'S LAB LOOKED AT THE ACCUMULATION OF ASXL1 MUTATIONS AND SHOWN THOSE ARE VERY IMPORTANT PRECURSOR TO THE DEVELOPMENT OF LEUKEMIA, ESPECIALLY CMML IN THESE PATIENTS. THE JACK 2 MUTATIONS I HAVE NOT SEEN YET. I DON'T KNOW ROB, IF YOU LOOKED AT ANY OF THOSE PATIENTS. IT'S AN IMPORTANT QUESTION AND WE DON'T HAVE ANY PROOF OF THAT YET BUT I THINK AS WE DO MORE WHOLE EXOME AND GENOME SEQUENCING DOWN THE ROAD, WE OUGHT TO BE ABLE TO SEE WHAT THE SPECTRUM OF MUTATIONAL DEVELOPMENT IS. WE LIKE TO BE ABLE TO UNDERSTAND WHAT IT IS THAT TRIGGERS THE TRISOME 8 MONOSOME 7, ARE VERY COMMON EVENTS HERE. WE'D LIKE TO UNDERSTAND THE GENETIC AND GENOMIC INSTABILITY THEY SEEM TO BE PART OF THIS. >> VERY FASCINATING TALK. WHAT ARE YOUR THOUGHTS ABOUT WHY IT TAKES SO LONG FOR THE MANIFESTATIONS OF GATA2 MUTATION TO BECOME MANIFEST? >> SO THIS IS A VERY PERPLEXING PROBLEM AND I GUESS I HAVE 2 1/2 ANSWERS. ONE IS, LIFE IS LIKE THAT. AND SOMETIMES WE SEE DISEASES IN WHICH THERE IS A LOT OF PHENOTYPIC VARIATION AND THAT MAY HAVE TO DO WITH A VARIETY OF ENVIRONMENTAL FACTORS. NUMBER 2, WHICH I THINK IS WHAT WE ARE TRYING TO FOCUS ON IS, HOW MUCH OF THIS IS INFECTION DRIVEN? THAT IS, IF WE CAN IDENTIFY INFECTIONS THAT ARE MAKING SOME PEOPLE GET SICK EARLIER, AND SOME PEOPLE GET SICK LATER, WE WOULD LIKE TO IDENTIFY THAT AND LIKE TO TRY AND PREVENT THOSE. AND THEN, OF COURSE, NUMBER 3 IS THAT THERE MIGHT BE LEVELS OF GENETIC VARIATION WITHIN FAMILIES AND SO, SOME OF THE FAMILY CLUSTERS IN WHICH WE HAVE HAD WILDLY SPREAD ONSETS OF DISEASE EVEN IN PEOPLE GROWING UP IN THE SAME HOUSE, SUGGEST WE NEED TO GO BACK AND LOOK AT REGULATORY FACTORS THAT MIGHT BE TURNING ON OR TURNING OFF GATA2. ALONG THAT LINE, THE FACT THAT REGULATION IS SO TIGHT, AND THAT HAVING ONLY 70% EXPRESSION OF THE GENE STILL GETS YOU SICK, THAT MEANS THAT THE CRITICAL 30% THAT GETS YOU DEPLETED, IS AN AREA IN WHICH THERE CAN BE A LOT OF INTERVENTION. SO THINKING ABOUT HOW WE CAN UPREGULATE GATA EXPRESSION MAYBE THERAPEUTICALLY, IS REALLY SOMETHING THAT WE WOULD LIKE TO BE ABLE TO FOCUS ON. SO MAYBE THERE ARE GENES THAT ARE GIVING SOME PEOPLE HIGHER LEVELS AND OTHER SLIGHTLY LOWER. >> SO, ALWAYS WHEN YOU HAVE GATA2 DEFICIENCIES DIRECTLY CORRELATED AND OBVIOUS THAT IT CAN DYSFUNCTION ALWAYS HAPPENS IN EVERY PATIENT? >> THE NK DYSFUNCTION HAS BEEN SEEN IN EVERY PATIENT AT EVERY TIME. NK DEFICIENCY, LOW NUMBER HAS NOT ALWAYS BEEN SEEN. SO THIS SUGGESTS THAT THERE IS A SEPARATION BETWEEN NK FUNCTION AND NK NUMBER. AND IN SOME OF THESE PATIENTS, ESPECIALLY THOSE THAT HAVE PERSIST WANT NK NUMBERS, WE CAN UPREGULATE THEIR FUNCTION WITH INTERFERON ALPHA AND WE HAVE USED THIS THERAPEUTICALLY IN SOME OF THE PATIENTS WHO HAVE VIRAL INFECTIONS QUITE SUCCESSFULLY. IN TERMS OF WHAT DRIVES THE DIFFERENT -- WHY IT IS THAT NK CELLS DISAPPEAR OVER TIME, THAT I DON'T KNOW. WHY THEY START OUT NORMAL AND THEN BECOME LOW WITH TIME, I JUST CAN'T TELL YOU THAT. >> AND ONE OTHER QUESTION. IS THERE ANY -- DEMOGRAPHIC IN SOME PARTS OF THE WORLD THAT HAVE GATA2 DEFICIENCY THAT IS NOT DISCOVERED YET? >> SO I THINK MANY SEVERE DISEASES THAT ARE OFTEN FATAL, THEY DON'TS LAST LONG IN POPULATIONS. AND SO, YES, WE FIND SOME FAMILIES IN WHICH WE HAVE 3-4 GENERATIONS BUT WE SEE NO, SO FAR, NO ETHNIC PREDISPOSITION AND NO REGIONAL PREDISPOSITION. NOW THIS DISEASE IS STILL IN VERY EARLY DAYS. AND THE FACT THAT WE SEE THE SAME MUTATIONS ARISING AT THE SOMATIC LEVEL IN LEUKEMIA AND THE GERMLINE LEVEL IN OUR PATIENTS TELLS YOU THESE ARE SPOTS THAT LIKE TO GET MUTATED T IS POSSIBLE IF THERE ARE SOME ETHNIC GROUPS MORE PRONE TO MUTATE THOSE REGIONS, BUT SO FAR, WE HAVEN'T SEEN ANY. >> SO I'LL ASK ABOUT AUTOIMMUNE DISORDERS ASSOCIATED. THE CD56 RIGHT NK CELLS HAS BEEN CALLED BY MANY IMMUNOREGULATORY IN. K CELLS MAKING IL10 AND CONTROLS. AND [ INDISCERNIBLE ] IN TREATMENT OF MULTIPLE SCLEROSIS FELT THAT MEALATION PROVIDED WAS AN INCREASE IN THIS SUBSET OF NK CELLS IN THEIR ABSENCE IS THERE ANY KIND OF ODDO -- AUTO IMMUNITIY? >> THERE IS A VERY BIG PROBLEM. THE AUTOIMMUNE FEATURES OF THIS DISEASE ARE DETECTABLE BUT NOT SOMATIC. SO, AND IT'S ALSO HARD TO KNOW IN THE SETTING OF COMPLEX MULTITISSUE GENE EXPRESSION DEFECTS WHAT IS AUTOIMMUNE WHAT IS INTRINSIC DYSFUNCTION? THAT BEING SAID, HYPOTHYROID SIMPLE RELATIVELY COMMON IN THIS DISEASE WITHOUT PREVIOUSLY RECOGNIZING ANTIBODIES. IT DOESN'T MEAN THERE ARE SOME INFILTRATES. WE HAVE NOT SEEN MUCH IN THE WAY OF LOCAL INFLAMMATORY INVOLVEMENT. SO HYPOTHYROIDISM. 10IC LIGHTIS IS VERY COMMON IN THIS DISEASE IN PEOPLE WHO HAVE THIS BACTERIAL INFECTION, EVEN WHEN WE CAN'T FIND THE ORGANISM. WHETHER THAT REAP CENTS A LOCAL INFLAMMATORY DYSREGULATION OR AN INFECTION WHICH WE CANNOT IDENTIFY, I DON'T KNOW. THERE HAVE BEEN OTHER EXAMPLES THAT WERE PRIMARY CIRRHOSIS IN THIS DISEASE, AND I UNDERSTAND AS MUCH ABOUT IT IN THIS CONTEXT AS I DO IN THE GENERAL CONTEXT. FINALLY, SOME OF THE INFLAMMATORY REACTIONS HAS BEEN QUITE DRAMATIC IN SEVERE WHICH MIGHT GET AT THE COUNTER REGULATORY INFLUENCES. AND IN PARTICULAR -- [ INDISCERNIBLE ] INFECTION HAS BEEN DRAMATICALLY SEVERE IN THIS DISEASE. WE HAD ONE PATIENT DIE AND ONE HAD A COLLECT ME AND ANOTHER ONE WOUND UP WITH ON A SEPTEMBER LATER BECAUSE OF THIS INFECTION. EVEN IN CHILDREN WHICH IS VIRTUALLY UNHEARD OF. THERE IS SOMETHING THAT PEOPLE GET INFECTED AND THEN HAVE A MORE DRAMATIC PROCESS EVEN WITH SOMETHING THAT IS IN THE LUMINAL REGION. AND THAT MIGHT BE SOMETHING THAT IS AT THE LEVEL OF A DYSREGULATED FUNCTION. WE DON'T HAVE THE KINDS OF TISSUE SAMPLES THAT WOULD LET US GO BACK AND LOOK AT NK INFILTRATION AND SAY WHETHER THAT IS UP OR DOWN. THANK YOU VERY MUCH. [ APPLAUSE ] >> THANK YOU FOR THAT TERRIFIC TALK. LET ME REMIND YOU THERE IS A RECEPTION SPONSPONSORED BY THE FAES IN THE LIBRARY. YOU'RE ALL WELCOME AND YOU CAN ASK MORE QUESTIONS THERE. THANK YOU.