Interpretation of Dihydrorhodamine-1,2,3 Flow Cytometry in Chronic Granulomatous Disease: an Atypical Exemplar

Agnes Donko, Douglas B. Kuhns, Margot A. Cousin, Matthew J. Smith, Keith A. Sacco, Eric W. Klee, Avni Y. Joshi, Ralitza H. Gavrilova, Steven M. Holland, Thomas L. Leto, Roshini S. Abraham

Research output: Contribution to journalArticlepeer-review


Purpose: This is a functional characterization of a novel CYBA variant associated with normal DHR flow cytometry. Chronic granulomatous disease (CGD) is an inborn error of immunity characterized by recurrent bacterial and fungal infections and dysregulated inflammatory responses due to defective phagocytic cell function leading to the formation of granulomas. CGD patients have pathogenic variants in any of the five components of the phagocytic NADPH oxidase, which transfers electrons through the phagosomal membrane and produces superoxide upon bacterial uptake. Here, we report a pediatric female patient with a novel homozygous missense variant (c.293C > T, p.(Ser98Leu)) in CYBA, encoding the p22phox protein, associated with autosomal recessive CGD. Methods and Results: The patient presented with severe recurrent pneumonia. Specific pathogens identified included Burkholderia and Serratia species suggesting neutrophil functional abnormalities; however, the dihydrorhodamine-1,2,3 (DHR) flow cytometric and cytochrome c reduction assays for neutrophil respiratory burst fell within the low side of the normal range. Western blot and flow cytometric analysis of individual NADPH oxidase components revealed reduced levels of p22phox and gp91phoxphox proteins. The pathological consequence of the p.Ser98Leu variant was further evaluated in heterologous expression systems, which confirmed reduced p22phox protein stability and oxidase activity. Conclusions: Although this patient did not exhibit all the classic features of CGD, such as granulomas and skin infections, she had recurrent pneumonias with oxidant-sensitive pathognomonic organisms, resulting in appropriate targeted CGD testing. This case emphasizes the need to contextually interpret laboratory data, especially using clinical findings to direct additional assessments including genetic analysis.

Original languageEnglish (US)
Pages (from-to)986-999
Number of pages14
JournalJournal of Clinical Immunology
Issue number5
StatePublished - Jul 2022


  • CGD
  • Chronic granulomatous disease
  • DHR
  • NADPH oxidase
  • Neutrophil respiratory burst
  • p22

ASJC Scopus subject areas

  • Immunology and Allergy
  • Immunology


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