Original Article

IRF8 Mutations and Human Dendritic-Cell

Immunodeficiency
Sophie Hambleton, M.D., Ph.D., Sandra Salem, B.Sc., Jacinta Bustamante, M.D., Ph.D., Venetia
Bigley, M.D., Ph.D., Stéphanie Boisson-Dupuis, Ph.D., Joana Azevedo, M.D., Anny Fortin,
Ph.D., Muzlifah Haniffa, M.D., Ph.D., Lourdes Ceron-Gutierrez, B.Sc., Chris M. Bacon, M.D.,
Ph.D., Geetha Menon, M.D., Céline Trouillet, B.Sc., David McDonald, Ph.D., Peter Carey,
M.D., Florent Ginhoux, Ph.D., Laia Alsina, M.D., Ph.D., Timothy J. Zumwalt, B.Sc., Xiao-Fei
Kong, M.D., Ph.D., Dinakantha Kumararatne, M.D., Ph.D., Karina Butler, M.B., B.Ch., Marjorie
Hubeau, M.Sc., Jacqueline Feinberg, Ph.D., Saleh Al-Muhsen, M.D., Andrew Cant, M.D.,
Laurent Abel, M.D., Ph.D., Damien Chaussabel, Ph.D., Rainer Doffinger, Ph.D., Eduardo
Talesnik, M.D., Anete Grumach, M.D., Ph.D., Alberto Duarte, M.D., Katia Abarca, M.D.,
Dewton Moraes-Vasconcelos, M.D., Ph.D., David Burk, Ph.D., Albert Berghuis, Ph.D., Frédéric
Geissmann, M.D., Ph.D., Matthew Collin, M.D., Ph.D., Jean-Laurent Casanova, M.D., Ph.D.,
and Philippe Gros, Ph.D.

N Engl J Med 2011; 365:127-138 July 14, 2011

The discovery of human primary immunodeficiencies that affect the development of

granulocytes, B cells, and T cells has been instrumental in defining the contribution of these cell
types to protective immunity.1,2 Monocytes, macrophages, and dendritic cells — all
mononuclear phagocytes — have essential functions in both innate and acquired immunity.
These cells initially recognize and engulf invading microbes, produce proinflammatory cytokines
(e.g., interleukin-12), and process antigens for presentation to naive T cells, which consequently
secrete various lymphokines (e.g., interferon-γ).3,4 On activation by cytokines secreted by T
cells, mononuclear phagocytes destroy ingested microorganisms. There are no known genetic
causes of primary immunodeficiencies affecting the development of the mononuclear phagocyte.

Bacille Calmette–Guérin (BCG) vaccines and environmental mycobacteria are efficiently

destroyed by T-cell–activated macrophages.5 However, disseminated mycobacterial disease after
BCG vaccination is a sign of immunodeficiency.6 It occurs in children with severe combined
immunodeficiency (i.e., an absence of T cells) or with chronic granulomatous disease. Although
such children are vulnerable to multiple infections, persons with mendelian susceptibility to
mycobacterial disease (MSMD)7 have a narrow vulnerability to poorly virulent mycobacteria,
including BCG. Some persons with MSMD harbor genetic defects in the circuit involving
interleukin-12 and interferon-γ, with mutations in IL12B, the gene encoding interleukin-12B
(also called interleukin-12p40), along with the interleukin-12 receptor β1 (IL12RB1), both
subunits of the receptor for interferon-γ and its signaling partner STAT1, the nuclear factor-κB
regulator IKBKG (NEMO), and the effector CYBB (GP91-PHOX).7
 We hypothesized that certain persons may be vulnerable to BCG because of mutations
impairing the development of mononuclear phagocytes. Among the genes encoding transcription
factors that are essential to the development of mononuclear phagocytes in mice, IRF8, encoding
interferon regulatory factor 8, stood out as a strong candidate.8 It is expressed at very high levels
in mononuclear phagocytes9 and regulates both the differentiation of granulocytes and
macrophages10,11 and the development of dendritic cells.12-15 Acting in heterodimeric
complexes with other transcription factors, IRF8 also controls the transcriptional response of
mature myeloid cells to interferons and toll-like receptor agonists, a response in which IRF8
binds and transactivates the promoters of IL12B and NOS2, which encodes inducible nitric oxide
synthase.8 Mice carrying the R294C hypomorphic variant (a mutation that partially compromises
protein function) in Irf8 have a specific dendritic-cell phenotype with loss of CD8α+ lymphoid
dendritic cells and CD103+ tissue myeloid dendritic cells, whereas Irf8 knockout mice (which
are devoid of Irf8) also lack plasmacytoid dendritic cells.13-15 Mice with mutant Irf8 are
susceptible to infection with intramacrophagic pathogens and are hypersusceptible to
Mycobacterium bovis BCG and M. tuberculosis infections.16,17

Methods

Study Subjects

A 10-week-old female infant (Subject 1) presenting with disseminated BCG infection

after vaccination, oral candidiasis, and cachexia was admitted to the hospital for evaluation of
suspected immunodeficiency. (Details about the case are provided in the Supplementary
Appendix, available with the full text of this article at NEJM.org.) The infant underwent multiple
rounds of aggressive antibiotic treatment that were only partially effective in improving her
health. She was successfully treated by means of transplantation with cord-blood stem cells. She
was the second-born child of healthy, unrelated parents of Irish ancestry (kindred A); the elder
sibling was well, and all four family members had received BCG vaccination.

Two additional persons in whom MSMD was diagnosed were also enrolled in the study.
The first of these persons (Subject 2 in kindred B) was a 40-year-old man born to
nonconsanguineous parents of Italian descent living in Brazil. He was vaccinated with BCG at
birth and had recurrent episodes of lymphadenopathies at the age of 15 months, 20 years, and 30
years. During two such episodes, analyses of lymph-node–biopsy samples revealed the presence
of acid-fast bacilli. All such episodes were successfully treated with antimycobacterial drug
regimens. His mother, father, and sister had been vaccinated with BCG and did not present with
clinical infectious disease suggesting immunodeficiency.

The second affected person with MSMD (Subject 3 in kindred C) was a 14-year-old girl
born to a nonconsanguineous family of Italian descent living in Chile. She was also vaccinated
with BCG at birth. At 1 year of age, lymphadenopathy with chronic granulomatous tuberculoid
lesions developed. At 2 years of age, she presented with multiple lymphadenopathies and fever,
requiring hospital admission. Histologic analysis of a lymph-node–biopsy sample and bacterial
culture identified pyrazinamide-resistant M. bovis, and the child was successfully treated with
adjusted antibiotic treatment administered for 12 months; no subsequent clinical episodes were
reported.

For all three subjects, we obtained written informed consent from the subjects or their
parents. The studies were approved by the institutional review board at each study center. The
Italian ancestry of the two subjects living in South America was determined in physicians'
interviews with either the subjects or their parents.

B. Genetic and Transcriptional Analyses

We sequenced the exons and selected noncoding sequences of IRF8 from the subjects'
genomic DNA after standard polymerase-chain-reaction amplification with sequence-specific
primers (Table S3 in the Supplementary Appendix). We assayed the transcriptional activity of
mutant and nonmutant IRF8 through activation of the IL12B and NOS2 promoters, using reporter
constructs that were transiently transfected into RAW 264.7 macrophages (a mouse macrophage
cell line), as described previously.16 Data regarding the methods that were used in biochemical
assays, molecular characterization, and statistical analysis are provided in the Supplementary
Appendix.

Results

A. Autosomal Recessive IRF8 Deficiency

In Subject 1, the 10-week-old infant, the blood count revealed a strikingly abnormal
myeloid compartment with an absence of monocytes and a very high neutrophil count. Depletion
of the Antigen-Presenting-Cell Compartment in an Infant with Autosomal Recessive IRF8
Deficiency., and Table S1 in the Supplementary Appendix). Analysis of peripheral-blood
mononuclear cells (PBMCs) by means of flow cytometry confirmed severe depletion of the
nonlymphoid (CD3−CD19−CD56−) HLA-DR+ compartment and in particular a total absence of
both CD14+ and CD16+ monocytes (Figure 1A, 1B, and 1C). Furthermore, we could not detect
any dendritic cells in the blood, including both CD11c+ myeloid cells (CD1c+ or CD141+) and
CD123+ plasmacytoid cells (Figure 1A through 1D). The only HLA-DR+ and lineage-negative
cells proved to be circulating CD34+ progenitor cells, which were present in elevated numbers
(Figure S1A in the Supplementary Appendix) and correlated with elevated serum levels of FMS-
like tyrosine kinase 3 ligand (Figure S1B in the Supplementary Appendix). In contrast, B cells
and natural killer cells were present in normal numbers, thus ruling out the recently described
syndrome of a deficiency in dendritic cells, monocytes, and B and natural killer cells18,19 (Table
S2 and Figure S2 in the Supplementary Appendix).

Assays of whole blood showed that the production of interleukin-12 in response to BCG,
phytohemagglutinin (PHA), and lipopolysaccharide was completely absent and interferon-γ
production was poor, with similarly poor production of tumor necrosis factor α, interleukin-10,
and interleukin-6 (Figure 1F, 1G, and 1H). Preincubation of the infant's cells with interleukin-12
partially restored interferon-γ production in response to the same stimuli (Figure 1G). Biopsy
samples of the infant's bone marrow and axillary lymph node showed striking myeloid
hyperplasia, as well as the presence of acid-fast bacilli within granulomata in the lymph node
(Figure S3 in the Supplementary Appendix). Despite the subject's profound peripheral
monocytopenia, the diseased node was positive for histiocytic markers CD68 and CD163, and
bone trabeculae showed evidence of normal osteoclast activity (Figure S4 in the Supplementary
Appendix). In dermal tissues, the density of CD1a+ and CD14+ dendritic cells was remarkably
low (Figure 1C and 1D). In contrast, we observed epidermal Langerhans' cells that were of
normal density (Figure 1E) and detected the occasional Langerin+CD1a+ dendritic cell in the
lymph node (Figure S4 in the Supplementary Appendix). We concluded that the infant had a
profound deficit of tissue dendritic cells and blood dendritic cells and monocytes, along with a
variable deficit of tissue macrophages and normal numbers of Langerhans' cells.

This combination of immunodeficiency,10,11 dendritic-cell deficiency,12-15 and

myeloproliferation20 is strikingly similar to the phenotype of mice with loss-of-function
mutations in Irf8. On sequencing of IRF8 in the infant, we observed a homozygous missense
variant predicted to cause the substitution of glutamic acid for lysine at position 108 (K108E)
(Figure 2AFigure 2Genetic Analysis of Autosomal Recessive and Autosomal Dominant IRF8
Deficiency.). Both parents were heterozygous for K108E, and an unaffected sibling lacked the
variant allele (Figure 2C). We sequenced IRF8 in 454 unrelated persons with clinical
susceptibility to mycobacterial infection and did not detect the variant or any other homozygous
variant.

Amino acid position 108 is within the DNA-binding domain of IRF8 (Figure 2A). The
lysine residue is invariant in IRF8 orthologues (Figure 2B) and is highly conserved among
human IRF family members (data not shown). We expressed the IRF8 variant in cultured mouse
macrophages. Immunoblotting studies showed similar expression levels of normal (K108) and
mutant (K108E) variants and a relatively slower electrophoretic mobility of the mutant variant,
suggesting that the mutation affects overall protein structure or folding (Figure 3EFigure
3Functional Characterization of the Mutant IRF8 Variants.). We tested the ability of normal and
mutant isoforms to activate transcription of IRF8 targets — the promoters of IL12B (Figure 3A)
and NOS2 (Figure 3B) — in mouse macrophages. Although the combination of normal IRF8 and
its coactivator, IRF1, induced a dose-dependent stimulation of IL12B and NOS2 promoters, the
K108E variant was almost inactive, suggesting that K108E abrogates the IRF1-dependent
transcriptional activity of IRF8. Moreover, the mutant IRF8 variant bound the IL12B promoter
much more weakly than did the normal variant (Figure 3D).

Molecular modeling with the use of the structure of DNA-bound IRF221 places K108 in
a short β strand that runs parallel to the major DNA-binding α helix, suggesting that it makes a
critical hydrogen bond with the DNA sugar backbone (length, 3.3 Å) that facilitates IRF8
docking onto DNA (Figure 2E, subpanel a). It is likely that the replacement of a positively
charged amino acid (lysine) by one that is negatively charged (glutamic acid) at position 108
would prevent the formation of a hydrogen bond (Figure 2E, subpanel b) and cause local
repulsion of the supporting IRF8 β strand away from DNA, allowing a water molecule to fill the
space. This model predicts loss of DNA binding and thus loss of transactivation.
These findings show that Subject 1 carried a loss-of-function mutation in IRF8. The
heterozygous parents were healthy, despite having received BCG as neonates, and had normal
numbers of PBMCs and dendritic cells, findings that are consistent with the autosomal recessive
inheritance of the IRF8 K108E allele.

Autosomal Dominant IRF8 Deficiency

In parallel with our analysis for Subject 1 with recessive disease, we sequenced IRF8 in
454 persons with MSMD in whom known MSMD-associated mutations had already been
excluded (for details, see the Supplementary Appendix). Two unrelated persons from Brazil
(Subject 2) and Chile (Subject 3) who had recurrent episodes of disseminated BCG disease were
each found to carry the same de novo heterozygous mutation that was predicted to cause a
threonine-to-alanine substitution at position 80 (T80A) of IRF8 (Figure 2A and 2D). We
genetically confirmed the reported biologic paternity of these two subjects. The finding that each
mutation was de novo suggests that the same T80A allele arose independently on two occasions.
We did not detect the T80A variant in 1064 healthy control subjects of diverse relevant ancestry
(for details, see the Supplementary Appendix). Amino acid position 80 of IRF8 is within the
DNA-binding domain (Figure 2A). The threonine residue is strictly conserved across IRF8
orthologues (Figure 2B) and human paralogous genes (data not shown).

The T80A mutation had no effect on the level or stability of IRF8 in immortalized B-cell
lines derived from the subjects (Figure 3E) or after expression in transfected macrophages (data
not shown). When the T80A mutant was tested for its ability to transactivate the promoters of
IL12B (Figure 3A) and NOS2 (Figure 3B) in mouse macrophages, it showed relatively low
activity, similar to that of the hypomorphic R294C Irf8 variant found in Irf8-deficient BXH2
mutant mice. The T80A mutant showed weak recruitment to the IL12B promoter (20% of the
amount of the nonmutant IRF8 protein), suggesting that the mutation interferes with DNA
binding (Figure 3D).

Homology modeling shows that T80 maps to the DNA-binding α helix of IRF8 that fits
into the major groove, with its side chain directed toward the DNA bases (Figure 2E, subpanel
c). Molecular-dynamics simulations indicate that T80A alters the hydrophobic interface between
the protein and DNA and possibly modulates the DNA-binding specificity of IRF8 (Figure 2E,
subpanel d). Alanine has a smaller side chain than does threonine, which may allow the entry of
a water molecule at the DNA–IRF8 interface. Although functional data suggest that T80A is
severely hypomorphic, we investigated whether the T80A variant is negatively dominant (i.e.,
whether it interferes with the function of the nonmutant IRF8 protein). We coexpressed the
mutant and nonmutant alleles in macrophages (Figure 3C) and observed decreasing activation of
the IL12B promoter (not shown) and the NOS2 promoter with increasing levels of mutant T80A
IRF8 added to fixed levels of nonvariant IRF8. The effect was T80A-specific; we did not observe
it to be associated with K108E (data not shown) or R294C mutant proteins. We conclude that the
T80A mutation has a dual effect on IRF8 function and causes autosomal dominant MSMD.

We observed subtle deficits in the PBMCs of Subjects 2 and 3. There were no

deficiencies of circulating lymphocytes and granulocytes (data not shown), monocyte subgroups,
or BDCA2+CD123+ plasmacytoid dendritic cells (Figure 4C and 4DFigure 4Selective Depletion
of Dendritic Cells in Autosomal Dominant IRF8 Deficiency.). However, within CD11c+ myeloid
dendritic cells, which are normally divided into minor CD141+ and major CD1c+ subgroups,
there was marked loss of CD1c+ dendritic cells (Figure 4A), whereas the CD141+ subgroup and
the total number of CD11c+ dendritic cells remained intact (Figure 4B). CD1c+ dendritic cells
from unaffected persons can produce large amounts of interleukin-12 when stimulated with the
toll-like receptor 7/8 ligand R848, as compared with PBMCs, whereas their depletion from
PMBCs was associated with relatively low levels of interleukin-12 production by the remaining
PBMCs (P<0.02 for all comparisons) (Figure 4E). PBMCs with the IRF8 T80A allele produced
one third the amount of interleukin-12 produced by control cells in response to R848 stimulation
(P<0.004 for all comparisons) (Figure 4E).

We suggest that depletion of interleukin-12–producing CD1c+ dendritic cells contributes

to the susceptibility to mycobacterial disease in these subjects. In vitro assays of whole blood
from the affected subjects showed no detectable effect on the production of interferon-γ (Figure
S6 in the Supplementary Appendix) or in the subjects' PBMCs in response to stimulation by
purified protein derivative (PPD), BCG, or PHA (Figure S7 in the Supplementary Appendix) or
by PHA-driven T-cell blasts stimulated with interleukin-12 (data not shown). The presence of
T80A does not seem to cause a generalized defect in interleukin-12 production, as shown by
normal levels of the cytokine in a whole-blood assay in response to BCG, in monocyte-derived
dendritic cells stimulated with CD40L, and by Epstein–Barr virus–transformed B cells
stimulated with phorbol dibutyrate (Figure S6, S8A, and S8B in the Supplementary Appendix).
Because the two healthy heterozygous parents of the infant with autosomal recessive IRF8
deficiency had normal levels of functional dendritic cells, the marked deficit of CD1c+CD11c+
dendritic cells was probably caused by the dominant-negative effect of the T80A mutant protein.

Discussion

We have described three subjects, an infant with autosomal recessive IRF8 deficiency and two
unrelated persons with an autosomal dominant form of the disease, whose conditions were
characterized by either a complete loss of mononuclear phagocyte subgroups (Subject 1) or a
selective loss of such subgroups (Subjects 2 and 3).

The IRF8 mutation underlying the autosomal recessive disorder (K108E) results in an
impairment of DNA binding and transactivation potential of IRF8. This defect caused a life-
threatening pediatric syndrome, characterized by the absence of blood monocytes and dendritic
cells, myeloproliferation of granulocyte precursors, and severe opportunistic infections, which
together required stem-cell transplantation in infancy. This finding suggests that any deficiency
of dendritic cells and monocytes will result in susceptibility to various infectious pathogens.

On the other hand, in the two subjects with autosomal dominant IRF8 deficiency, the disease was
associated with a heterozygous mutation resulting in a dominant-negative IRF8 allele (T80A)
that suppresses the transactivation potential of nonmutant IRF8 in vitro. The associated
syndrome was less severe than that in Subject 1 and was characterized by an abnormal
peripheral-blood myeloid phenotype with a marked loss of CD11c+CD1c+ dendritic cells.
Autosomal dominant IRF8 deficiency causes selective susceptibility to mycobacterial infections
and represents a novel, albeit rare, cause of MSMD. Together, these results establish a critical
role of IRF8 in the ontogeny of the human mononuclear phagocyte lineage and of circulating
monocytes and dendritic cells in particular.

After the cultivation of circulating stem cells from Subject 1 with growth factors that support the
formation of granulocyte and monocyte or macrophage colonies, we found that the newly formed
myeloid colonies were almost exclusively granulocytic (>98%), thus establishing that IRF8 is
critical in the differentiation of myeloid progenitors into monocytes. Irf8 deficiency in mice is
also associated with myeloproliferation of granulocyte precursors10,11,20 and very low levels of
circulating monocytes (Ginhoux F, Merad M: personal communication). The finding that tissue
macrophages and Langerhans' cells are well represented in autosomal recessive IRF8 deficiency
suggests heterogeneity within the mononuclear phagocyte compartment with respect to IRF8
independence or a potential for local self-renewal.22,23 Further work will be required to
establish the relative capacity of IRF8-deficient human CD34+ progenitors to produce fully
functional macrophages and dendritic cells in vitro.24 Studies in Irf8-deficient mice also show
normal numbers of F4/80+ tissue macrophages (unpublished data), although these cells are
abnormally susceptible to infection with intracellular pathogens in vitro.25,26 Finally, we
observed that although CD4+ T cells from Subject 1 had normal proliferation in response to
stimulation with CD3 and CD28 (Figure S5A and S5C in the Supplementary Appendix), they
had poor secretion of effector cytokines interferon-γ and interleukin-17 and, to a lesser extent,
interleukin-10 (Figure S5B in the Supplementary Appendix), with a similar pattern detected on
ex vivo stimulation with phorbol myristate acetate and ionomycin (data not shown). These
results strongly suggest a defect in the function of helper T cells that may be caused by abnormal
T-cell differentiation in an environment deficient in antigen-presenting cells.

The finding that autosomal dominant IRF8 deficiency is associated with a loss of interleukin-12–
producing CD1c+CD11c+ myeloid dendritic cells suggests that these cells are essential for
protective immunity to mycobacteria in humans. The marked reduction in CD1c+CD11c+
myeloid dendritic cells may be caused by altered ontogeny and maturation of this subgroup of
CD11c+cells, which is linked to target-specific or global transcriptional effects of the IRF8 T80A
variant.27 Despite the fact that mutant whole-blood cells produced normal amounts of
interleukin-12 on BCG stimulation in vitro, specific impairment of interleukin-12 secretion by
CD1c+ dendritic cells could contribute to mycobacterial susceptibility. Alternatively, the lack of
CD1c+CD11c+ myeloid dendritic cells may contribute to MSMD by other mechanisms, such as
impairment of cell migration between draining lymph nodes and infected tissues or of priming of
CD1c-restricted T cells for subsequent activation of infected macrophages. Indeed, CD1c-
restricted T cells that are specific for a mycobacterial phospholipid antigen have been
reported.28,29

In Subjects 2 and 3, we observed normal levels of CD141+ (BDCA3+) dendritic cells, a

subgroup that investigators have recently suggested may be the functional equivalent of mouse
CD8α+ dendritic cells that are absent in Irf8-deficient mice.30-33 Cells other than CD1c+
dendritic cells may also be involved in the pathogenesis of MSMD, and it is possible that IRF8
deficiency impairs the effector function of tissue macrophages.

These findings also suggest that mutations in heterodimerization partners of IRF8 (e.g., IRF1 and
PU.1) or specific transcriptional targets of such complexes27 may impair antimycobacterial
immunity. Finally, our study illustrates the value of performing genetic studies in mouse models
of infection to identity candidate genes for human primary immunodeficiencies.34

Supported by fellowships from the Medical Research Council (G0701897, to Dr. Hambleton, and
G0800358, to Dr. Bigley); by grants from the National Institutes of Health (AI035237, to Dr.
Gros) and the Canadian Institutes of Health Research (MOP106424, to Dr. Gros); by institutional
grants to Institut National de la Santé et de la Recherche Médicale (INSERM) U980 and
Rockefeller University; by grants from the Agence Nationale de la Recherche (ANR), the St.
Giles Foundation, the Jeffrey Modell Foundation, Talecris Biotherapeutics, the Rockefeller
University Center for Clinical and Translational Science (5UL1RR024143-03), the European
Union (HOMITB-CEE E08153KK) and (NEOTIM 018736), the March of Dimes (RO5050KK),
and the National Institutes of Health (AI089970, to Dr. Casanova); a Wellcome Trust fellowship
(WT088555MA, to Dr. Haniffa); a grant from the Leukaemia and Lymphoma Research Fund
(LRF060169, to Dr. Collin); an Arthritis Research UK Chair in Inflammation Biology (to Dr.
Geissmann); a program grant (G0900867) from the Medical Research Council, and a European
Research Council investigator award (ERC 2010-StG 261299, to Dr. Geissmann); and a grant
from the Gulbenkian Programme for Advanced Medical Education, sponsored by Fundação
Calouste Gulbenkian, Fundação Champalimaud, Ministério da Saúde e Fundação para a Ciência
e Tecnologia, Portugal (to Dr. Azevedo).

Disclosure forms provided by the authors are available with the full text of this article at
NEJM.org.

The following three groups of authors contributed equally to the article: Dr. Hambleton and Ms.
Salem; Drs. Bustamante, Bigley, Boisson-Dupuis, and Azevedo; and Drs. Geissmann, Collin,
Casanova, and Gros.

This article (10.1056/NEJMoa1100066) was published on April 27, 2011, at NEJM.org.

Source Information

The authors' affiliations are listed in the Appendix.

Address reprint requests to Dr. Collin at the Institute of Cellular Medicine, Newcastle University,
Framlington Place, Newcastle upon Tyne NE2 4HH, United Kingdom, or at
[email protected]; to Dr. Casanova at St. Giles Laboratory of Human Genetics of
Infectious Diseases, Rockefeller University, 1230 York Ave., New York, NY 10065, or at
[email protected]; or to Dr. Gros, Complex Traits Group and Department of
Biochemistry, McGill University, 3649 Sir William Osler, Montreal QC H3G-0B1, Canada, or at
[email protected].
Appendix

The authors' affiliations are as follows: the Institute of Cellular Medicine (S.H., V.B., M.H.,
D.M., A.C., M.C.) and the Northern Institute for Cancer Research (C.M.B.), Newcastle
University; and the Departments of Cellular Pathology (C.M.B., G.M.) and Haematology (P.C.),
Newcastle upon Tyne Hospitals NHS Foundation Trust — all in Newcastle upon Tyne; the
Centre for Molecular and Cellular Biology of Inflammation, Division of Immunology, Infection,
and Inflammatory Diseases, King's College London, London (J.A., C.T., F.G.); and the
Department of Clinical Immunology, Addenbrookes Hospital, Cambridge (L.C.-G., D.K., R.D.)
— all in the United Kingdom; the Department of Biochemistry, McGill University, Montreal
(S.S., A.F., D.B., A.B., P.G.); the Laboratory of Human Genetics of Infectious Diseases, Necker
Branch, INSERM U980 and University Paris Descartes, Necker Medical School, Paris (J.B.,
S.B.-D., M.H., J.F., L.A., J.-L.C.); St. Giles Laboratory of Human Genetics of Infectious
Diseases, Rockefeller Branch, Rockefeller University, New York (S.B.-D., X.-F.K., L.A., J.-
L.C.); Singapore Immunology Network, Agency for Science, Technology and Research,
Singapore (F.G.); Baylor Institute for Immunology Research and Baylor Research Institute,
Dallas (L.A., T.J.Z., D.C.); Allergy and Clinical Immunology Department, Hospital Sant Joan de
Déu, Barcelona University, Barcelona (L.A.); Institute of Biomedical Studies, Baylor University,
Waco, TX (T.J.Z.); Our Lady's Children's Hospital, Dublin (K.B.); Prince Naif Center for
Immunology Research, Department of Pediatrics, College of Medicine, King Saud University,
Riyadh, Saudi Arabia (S.A.-M., J.-L.C.); the Pontificia Universidad Católica de Chile, Santiago
(E.T., K.A.); and the Laboratory of Investigation in Dermatology and Immunodeficiencies,
Department of Dermatology, University of São Paulo Medical School, São Paulo (A.G., A.D.,
D.M.-V.).