Purine Nucleoside Phosphorylase Deficiency

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Purine nueoside phosphorylase (PNP) deficiency causes a form of severe combined immunodeficiency (SCID) characterized by profound T cell deficiency, failure to thrive (FTT), recurrent deep seeded infection, developmental delay, progressive neurological deterioration, and autoimmune complications.  Early diagnosis and early implementation of bone marrow transplantation (BMT) are crucial to minimize neurodevelopmental complications and ensure productive adult life in patients with PNP deficiency.  However, one of the expected difficulties is that PNP deficiency can be missed with current newborn SCID screening measures. [1]

Two genetic defects of the purine salvage pathway account for two immunodeficiencies that result in severe combined immunodeficiency (SCID). [2, 3] One disorder is adenosine deaminase (ADA) deficiency, which is Online Mendelian Inheritance in Man (OMIM) subject number 102700, and the other is purine nucleoside phosphorylase (PNP) deficiency, which is OMIM subject number 164050.

ADA and PNP deficiencies are autosomal recessive disorders. ADA and PNP are ubiquitous “housekeeping genes.” In both disorders, the enzyme deficiencies result in accumulation of toxic metabolites, especially in lymphocytes. In ADA deficiency, the toxic metabolites block T-cell, B-cell, and natural killer (NK)-cell development; whereas in PNP deficiency, the metabolites are especially toxic to T-lineage cells, resulting in profound T-cell deficiency and variable degree of B-cell dysfunction.

In addition, both ADA and PNP deficiencies cause developmental delays and progressive neurological deterioration if not treated. This is especially prevalent in PNP deficiency with neurologic symptoms, including mental retardation and muscle spasticity, reported in 67% of patients with PNP deficiency. In addition, PNP deficiency is associated with increased risk of autoimmune disorders, such as autoimmune hemolytic anemia, immune thrombocytopenia, neutropenia, thyroiditis, and lupus.

ADA deficiency results in absence of T, B, and NK cells, resulting in a SCID with marked lymphopenia. PNP deficiency causes profound T lymphopenia and variable numbers of B and NK cells. Serum immunoglobulin (Ig) levels are normal to near-normal, but specific antibody production is impaired.

PNP is an enzyme in the purine salvage pathway that metabolizes inosine and guanosine to hypoxanthine. [4, 5, 6, 7] In the preceding step of the pathway, ADA metabolizes adenosine to inosine. ADA deficiency causes a SCID that accounts for approximately 20% of all SCID cases. In both metabolic disorders, the enzyme deficiencies cause the accumulation of metabolites that are toxic to lymphoid lineage cells. See the image below.

In adenosine deaminase deficiency, adenosine and adenine accumulate in the plasma. [8, 9] ATP accumulates in erythrocytes, and ADP, guanosine triphosphate (GTP), and ATP accumulate in lymphocytes. Deoxy-ATP (dATP) can reach toxic levels that inhibit ribonucleotide reductase, an enzyme essential for synthesis of DNA precursors.

In purine nucleoside phosphorylase deficiency, similar changes occur, resulting in elevated deoxy-GTP (dGTP) levels. dATP and dGTP predominantly accumulates in lymphoid tissue. dGTP inhibits ribonucleotide reductase, which is needed for synthesis of deoxynucleotides. In both adenosine deaminase and purine nucleoside phosphorylase deficiencies, thymocytes are thought to be selectively destroyed because of elevated levels of dATP and dGTP.

In a further description of the mechanism of T-cell depletion in purine nucleoside phosphorylase deficiency, Arpaia et al reported increased in vivo apoptosis of T cells and increased in vitro sensitivity to gamma irradiation in a murine model. [4] The immune deficiency in purine nucleoside phosphorylase deficiency may be the result of inhibited mitochondrial DNA repair due to the accumulation of dGTP in the mitochondria. The end result is increased sensitivity of T cells and thymocytes to spontaneous mitochondrial damage, leading to T-cell depletion due to apoptosis.

With adenosine deaminase deficiency, destruction of resting T cells and B cells is increased. In comparison, purine nucleoside phosphorylase deficiency results in selective destruction of T cells, with little effect on B cells. Numerous mutations of the ADA gene (on chromosome 20) and PNP genes (on band 14q13) have been identified. [2] Purine nucleoside phosphorylase is a trimer with molecular weight of 84-94 kDa. Most identified mutations are missense mutations, but deletion is also described. All reported patients with homozygous mutations of PNP have been symptomatic. Because only small amounts of adenosine deaminase are necessary for competent immunity, some patients with ADA mutations may still have 8-42% adenosine deaminase activity and no profound immunodeficiency. [2, 3]

United States

PNP deficiency is rare; it has been reported in approximately 30 families. [7, 10, 11] PNP deficiency accounts for approximately 4% of all cases of SCID. [7]

ADA deficiency accounts for approximately 20% of all cases of SCID. [12, 13]


The prevalence of primary immunodeficiency ranges from approximately 1 case per 54,000 population in Switzerland to 1 case per 200,000 population in Japan. Combined immunodeficiency (CID) accounts for 11-13% of all primary immunodeficiency disorders. A recent study noted that the incidence of primary immunodeficiency disorders markedly increased from 1976-2006. [14]   In addition, recent introduction of newborn SCID screening in more than half of the states in the United States and other countries indicate that frequency of SCID is higher than initially thought, up to 1 case per 40,000 to 50,000.

Patients with PNP deficiency are at risk for life-threatening recurrent viral, bacterial, fungal, mycobacterial, and protozoal infections. In addition, failure to thrive eventually ensues. The risk of lymphoma is also increased in patients with PNP deficiency. Neurologic symptoms, including mental retardation and muscle spasticity, are major comorbid conditions that affect 67% of patients with PNP deficiency in one report and neurological deterioration is progressive with age if not treated.

Bone marrow transplantation may cure the immunodeficiency but does not reverse neurological damage that has already been caused by toxic metabolites. Patients are at risk for autoimmune diseases, including autoimmune hemolytic anemia, immune thrombocytopenia, thyroiditis, neutropenia, and lupus.

PNP and ADA deficiencies are autosomal recessive disorders with equal incidence in boys and girls.

Although symptoms typically appear in the first year of life in patients with PNP deficiency, gradual deterioration of the T-cell immune system may delay the onset of symptoms until the second year of life. As above, neurological deterioration is also pregressive with age.

Bone marrow transplantation BMT) can cure immunoderficinecy and prevent neurological deterioration.  Since neurodevelopmental impairment is progressive with age, early diagnosis and treatment (BMT) will be the key to minimize neurolodevelopmental damage and other complications.  However, PNP deficiency can be missed with current newborn SCID screening which assess naive T cell output from thymus by measureing TREC (TCR rearrangement excision circle), since progressive loss of T cells in PNP deficiency due to toxic metabolites may not be fully manifested at birth.  High index of suspicion is necessary for early diagnosis of PNP to have best clinical ouptcome.

Once diagnosis was made by measuring PNP activity, a patient and his/her family members need to be educated for treatment options (mainly BMT) and expected outcomes.  Especially it needs to be clarified that immunodeficiency is curable by BMT but neurodevelopmental impairment caused by toxic metabolites may not be reversible by BMT.

la Marca G, Giocaliere E, Malvagia S, Villanelli F, Funghini S, Ombrone D, et al. Development and validation of a 2nd tier test for identification of purine nucleoside phosphorylase deficiency patients during expanded newborn screening by liquid chromatography-tandem mass spectrometry. Clin Chem Lab Med. 2016 Apr. 54 (4):627-32. [Medline].

Hirshhorn R, Canotti F. Immunodeficiency due to defects of purine metabolism. Ochs HD, Smith CIE, Puck JM, eds. Primary Immunodeficiency Diseases: A Molecular and Genetic Approach. 2nd ed. New York, NY: Oxford University Press, Inc; 2007. 169-96.

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Arpaia E, Benveniste P, Di Cristofano A, et al. Mitochondrial basis for immune deficiency. Evidence from purine nucleoside phosphorylase-deficient mice. J Exp Med. 2000 Jun 19. 191(12):2197-208. [Medline].

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Markert ML, Finkel BD, McLaughlin TM, et al. Mutations in purine nucleoside phosphorylase deficiency. Hum Mutat. 1997. 9:118-121.

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Buckley RH, Schiff RI, Schiff SE, et al. Human severe combined immunodeficiency: genetic, phenotypic, and functional diversity in one hundred eight infants. J Pediatr. 1997 Mar. 130(3):378-87. [Medline].

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Aytekin C, Dogu F, Tanir G, et al. Purine nucleoside phosphorylase deficiency with fatal course in two sisters. Eur J Pediatr. 2010 Mar. 169(3):311-4. [Medline].

Parvaneh N, Ashrafi MR, Yeganeh M, Pouladi N, Sayarifar F, Parvaneh L. Progressive multifocal leukoencephalopathy in purine nucleoside phosphorylase deficiency. Brain Dev. 2007 Mar. 29(2):124-6. [Medline].

Bradford KL, Moretti FA, Carbonaro-Sarracino DA, Gaspar HB, Kohn DB. Adenosine Deaminase (ADA)-Deficient Severe Combined Immune Deficiency (SCID): Molecular Pathogenesis and Clinical Manifestations. J Clin Immunol. 2017 Oct. 37 (7):626-637. [Medline].

Manson D, Diamond L, Oudjhane K, Hussain FB, Roifman C, Grunebaum E. Characteristic scapular and rib changes on chest radiographs of children with ADA-deficiency SCIDS in the first year of life. Pediatr Radiol. 2013 Mar. 43(5):589-92. [Medline].

Grunebaum E, Cutz E, Roifman CM. Pulmonary alveolar proteinosis in patients with adenosine deaminase deficiency. J Allergy Clin Immunol. 2012 Jun. 129(6):1588-93. [Medline].

Hirschhorn R. In vivo reversion to normal of inherited mutations in humans. J Med Genet. 2003. 40:721-728.

Routes JM, Grossman WJ, Verbsky J, et al. Statewide newborn screening for severe T-cell lymphopenia. JAMA. 2009 Dec 9. 302(22):2465-70. [Medline].

[Guideline] Bonilla FA, Bernstein IL, Khan DA, et al. Practice parameter for the diagnosis and management of primary immunodeficiency. Ann Allergy Asthma Immunol. 2005 May. 94(5 Suppl 1):S1-63. [Medline].

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Broome CB, Graham ML, Saulsbury FT, et al. Correction of purine nucleoside phosphorylase deficiency by transplantation of allogeneic bone marrow from a sibling. J Pediatr. 1996 Mar. 128(3):373-6. [Medline].

Myers LA, Hershfield MS, Neale WT, et al. Purine nucleoside phosphorylase deficiency (PNP-def) presenting with lymphopenia and developmental delay: successful correction with umbilical cord blood transplantation. J Pediatr. 2004 Nov. 145(5):710-2. [Medline].

Classen CF, Schulz AS, Sigl-Kraetzig M, et al. Successful HLA-identical bone marrow transplantation in a patient with PNP deficiency using busulfan and fludarabine for conditioning. Bone Marrow Transplant. 2001 Jul. 28(1):93-6. [Medline].

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Infantile Onset

Late Onset

Adult Onset


Markedly decreased



CD3+ cells

Absent or trace

Markedly reduced

Markedly reduced

CD4/CD8 ratio

Too few to test

< 1

< 1

Phytohemagglutinin response




Antigen response




Mixed lymphocyte culture response


Ig response


Low to absent

Normal (low IgG2)





Antibody response


Absent to low

Low to polysaccharides antigens






Predominantly viral, fungal, opportunistic, bacterial

Bacterial sinopulmonary

Bacterial sinopulmonary, varicella-zoster, herpes simplex, candidal

Brand (Manufacturer)

Manufacturing Process



Parenteral Form and Final Concentration

IgA Content (mcg/mL)

Carimune NF (CSL Behring)

Kistler-Nitschmann fractionation; pH 4, nanofiltration


6% solution: 10% sucrose < 20 mg NaCl/g protein

Lyophilized powder 3%, 6%, 9%, 12%


Flebogamma (Grifols USA)

Cohn-Oncley fractionation, polyethyline glycol (PEG) precipitation, ion-exchange chromatography, pasteurization


Sucrose-free, contains 5% D-sorbitol

Liquid 5%

< 50

Gamunex (Talecris Biotherapeutics)

Cohn-Oncley fractionation, caprylate-chromatography purification, cloth and depth filtration, low pH incubation


Contains no sugar, contains glycine

Liquid 10%


Iveegam EN (Baxter Bioscience)

Cohn-Oncley fraction II/III; ultrafiltration; pasteurization


5% solution: 5% glucose, 0.3% NaCl

Lyophilized powder 5%

< 10

Gammagard S/D, Polygam S/D (Baxter Bioscience for the American Red Cross)

Cohn-Oncley cold ethanol fractionation, cation and anion exchange chromatography, solvent detergent treated, nanofiltration, low pH incubation


5% solution: 0.3% albumin, 2.25% glycine, 2% glucose

Lyophylized powder 5%, 10%

< 1.6 (5% solution)

Gammagard Liquid 10%

(Baxter Bioscience)

Cohn-Oncley cold ethanol fractionation, cation and anion exchange chromatography, solvent detergent treated, nanofiltration, low pH incubation


0.25M glycine

Ready-for-use Liquid 10%


Octagam (Octapharma USA)

Cohn-Oncley fraction II/III; ultrafiltration; low pH incubation; S/D treatment pasteurization


10% maltose

Liquid 5%


Panglobulin (Swiss Red Cross for the American Red Cross)

Kistler-Nitschmann fractionation; pH 4, trace pepsin, nanofiltration


Per gram of IgG: 1.67 g sucrose, < 20 mg NaCl

Lyophilized powder 3%, 6%, 9%, 12%


Privigen Liquid 10%

(CSL Behring)

Cold ethanol fractionation, octanoic acid fractionation, and anion exchange chromatography; pH 4 incubation and depth filtration


L-proline (~250 mmol/L) as stabilizer; trace sodium; does not contain carbohydrate stabilizers

Ready-for use liquid 10%

< 25

*IVIG products containing sucrose are more often associated with renal dysfunction, acute renal failure, and osmotic nephrosis, particularly with preexisting risk factors (eg, history of renal insufficiency, diabetes mellitus, age >65 y, dehydration, sepsis, paraproteinemia, nephrotoxic drugs).

Alan P Knutsen, MD Professor of Pediatrics, Director of Pediatric Allergy and Immunology, Director Jeffrey Modell Diagnostic & Research Center for Primary Immuodeficiences (CGCMC), Director of Pediatric Clinical Immunology Laboratory, Department of Pathology, St Louis University Health Sciences Center

Alan P Knutsen, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, Clinical Immunology Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

David J Valacer, MD 

David J Valacer, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association for the Advancement of Science, American Thoracic Society, New York Academy of Sciences

Disclosure: Nothing to disclose.

Harumi Jyonouchi, MD Faculty, Division of Allergy/Immunology and Infectious Diseases, Department of Pediatrics, Saint Peter’s University Hospital

Harumi Jyonouchi, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association of Immunologists, American Medical Association, Clinical Immunology Society, New York Academy of Sciences, Society for Experimental Biology and Medicine, Society for Pediatric Research, Society for Mucosal Immunology

Disclosure: Nothing to disclose.

Purine Nucleoside Phosphorylase Deficiency

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