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Germline hypomorphic CARD11 mutations in severe atopic disease

A Corrigendum to this article was published on 27 October 2017

This article has been updated


Few monogenic causes for severe manifestations of common allergic diseases have been identified. Through next-generation sequencing on a cohort of patients with severe atopic dermatitis with and without comorbid infections, we found eight individuals, from four families, with novel heterozygous mutations in CARD11, which encodes a scaffolding protein involved in lymphocyte receptor signaling. Disease improved over time in most patients. Transfection of mutant CARD11 expression constructs into T cell lines demonstrated both loss-of-function and dominant-interfering activity upon antigen receptor–induced activation of nuclear factor-κB and mammalian target of rapamycin complex 1 (mTORC1). Patient T cells had similar defects, as well as low production of the cytokine interferon-γ (IFN-γ). The mTORC1 and IFN-γ production defects were partially rescued by supplementation with glutamine, which requires CARD11 for import into T cells. Our findings indicate that a single hypomorphic mutation in CARD11 can cause potentially correctable cellular defects that lead to atopic dermatitis.

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Figure 1: Novel heterozygous CARD11 mutations in families with a history of severe atopic dermatitis.
Figure 2: Atopy-associated CARD11 mutations are hypomorphic and dominantly interfere with wild-type (WT) CARD11 signaling to NF-κB and mTORC1.
Figure 3: Impaired CBM complex formation leads to defective signaling in CARD11-mutant patient T cells.
Figure 4: Decreased surface expression of activation markers and defective proliferation after TCR stimulation in patients with CARD11 mutations.
Figure 5: Impaired IFN-γ, augmented TH2 cytokine production and Treg phenotype in patients with CARD11 mutations.
Figure 6: Effect of glutamine supplementation and cytokines on TCR-induced proliferation and IFN-γ defects in a patient with CARD11 mutation.

Change history

  • 14 July 2017

    In the version of this article initially published online, the name of author Neil Romberg appeared incorrectly as Neil D Romberg, and the affiliation of author Nina Jones was incorrect and should have appeared as Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc., NCI Campus at Frederick, Frederick, Maryland, USA. In addition, the following sentences were omitted from the Acknowledgments: "This project has been funded in whole or in part with federal funds from the National Cancer Institute, National Institutes of Health, under contract HHSN261200800001E. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products or organizations imply endorsement by the US government." These errors have been corrected in the print, PDF and HTML versions of this article.


  1. 1

    Mogensen, T.H. Primary immunodeficiencies with elevated IgE. Int. Rev. Immunol. 35, 39–56 (2016).

    CAS  PubMed  Google Scholar 

  2. 2

    Freeman, A.F. & Olivier, K.N. Hyper-IgE syndromes and the lung. Clin. Chest Med. 37, 557–567 (2016).

    Article  Google Scholar 

  3. 3

    Chan, S.K. & Gelfand, E.W. Primary immunodeficiency masquerading as allergic disease. Immunol. Allergy Clin. North Am. 35, 767–778 (2015).

    Article  Google Scholar 

  4. 4

    Bønnelykke, K., Sparks, R., Waage, J. & Milner, J.D. Genetics of allergy and allergic sensitization: common variants, rare mutations. Curr. Opin. Immunol. 36, 115–126 (2015).

    Article  Google Scholar 

  5. 5

    Hershey, G.K., Friedrich, M.F., Esswein, L.A., Thomas, M.L. & Chatila, T.A. The association of atopy with a gain-of-function mutation in the α subunit of the interleukin-4 receptor. N. Engl. J. Med. 337, 1720–1725 (1997).

    CAS  Article  Google Scholar 

  6. 6

    Chatila, T.A. Interleukin-4 receptor signaling pathways in asthma pathogenesis. Trends Mol. Med. 10, 493–499 (2004).

    CAS  Article  Google Scholar 

  7. 7

    Gao, L. et al. Targeted deep sequencing identifies rare loss-of-function variants in IFNGR1 for risk of atopic dermatitis complicated by eczema herpeticum. J. Allergy Clin. Immunol. 136, 1591–1600 (2015).

    CAS  Article  Google Scholar 

  8. 8

    Bernasconi, A. et al. Characterization of immunodeficiency in a patient with growth hormone insensitivity secondary to a novel STAT5b gene mutation. Pediatrics 118, e1584–e1592 (2006).

    Article  Google Scholar 

  9. 9

    Datta, S. & Milner, J.D. Altered T-cell receptor signaling in the pathogenesis of allergic disease. J. Allergy Clin. Immunol. 127, 351–354 (2011).

    CAS  Article  Google Scholar 

  10. 10

    McKinnon, M.L. et al. Combined immunodeficiency associated with homozygous MALT1 mutations. J. Allergy Clin. Immunol. 133, 1458–1462, 1462.e1–1462.e7 (2014).

    CAS  Article  Google Scholar 

  11. 11

    Siggs, O.M. et al. Opposing functions of the T cell receptor kinase ZAP-70 in immunity and tolerance differentially titrate in response to nucleotide substitutions. Immunity 27, 912–926 (2007).

    CAS  Article  Google Scholar 

  12. 12

    Jun, J.E. et al. Identifying the MAGUK protein Carma-1 as a central regulator of humoral immune responses and atopy by genome-wide mouse mutagenesis. Immunity 18, 751–762 (2003).

    CAS  Article  Google Scholar 

  13. 13

    Thome, M., Charton, J.E., Pelzer, C. & Hailfinger, S. Antigen receptor signaling to NF-κB via CARMA1, BCL10, and MALT1. Cold Spring Harb. Perspect. Biol. 2, a003004 (2010).

    Article  Google Scholar 

  14. 14

    Greil, J. et al. Whole-exome sequencing links caspase recruitment domain 11 (CARD11) inactivation to severe combined immunodeficiency. J. Allergy Clin. Immunol. 131, 1376–83.e3 (2013).

    CAS  Article  Google Scholar 

  15. 15

    Stepensky, P. et al. Deficiency of caspase recruitment domain family, member 11 (CARD11), causes profound combined immunodeficiency in human subjects. J. Allergy Clin. Immunol. 131, 477–85.e1 (2013).

    CAS  Article  Google Scholar 

  16. 16

    Fuchs, S. et al. Omenn syndrome associated with a functional reversion due to a somatic second-site mutation in CARD11 deficiency. Blood 126, 1658–1669 (2015).

    CAS  Article  Google Scholar 

  17. 17

    Hara, H. et al. The MAGUK family protein CARD11 is essential for lymphocyte activation. Immunity 18, 763–775 (2003).

    CAS  Article  Google Scholar 

  18. 18

    Turvey, S.E. et al. The CARD11–BCL10–MALT1 (CBM) signalosome complex: stepping into the limelight of human primary immunodeficiency. J. Allergy Clin. Immunol. 134, 276–284 (2014).

    CAS  Article  Google Scholar 

  19. 19

    Snow, A.L. et al. Congenital B cell lymphocytosis explained by novel germline CARD11 mutations. J. Exp. Med. 209, 2247–2261 (2012).

    CAS  Article  Google Scholar 

  20. 20

    Hirota, T. et al. Genome-wide association study identifies eight new susceptibility loci for atopic dermatitis in the Japanese population. Nat. Genet. 44, 1222–1226 (2012).

    CAS  Article  Google Scholar 

  21. 21

    Gaide, O. et al. CARMA1 is a critical lipid raft–associated regulator of TCR-induced NF-κB activation. Nat. Immunol. 3, 836–843 (2002).

    CAS  Article  Google Scholar 

  22. 22

    Lin, C.Y., Graca, L., Cobbold, S.P. & Waldmann, H. Dominant transplantation tolerance impairs CD8+ T cell function but not expansion. Nat. Immunol. 3, 1208–1213 (2002).

    CAS  Article  Google Scholar 

  23. 23

    Pomerantz, J.L., Denny, E.M. & Baltimore, D. CARD11 mediates factor-specific activation of NF-κB by the T cell receptor complex. EMBO J. 21, 5184–5194 (2002).

    CAS  Article  Google Scholar 

  24. 24

    Nakaya, M. et al. Inflammatory T cell responses rely on amino acid transporter ASCT2 facilitation of glutamine uptake and mTORC1 kinase activation. Immunity 40, 692–705 (2014).

    CAS  Article  Google Scholar 

  25. 25

    Hamilton, K.S. et al. T cell receptor–dependent activation of mTOR signaling in T cells is mediated by Carma1 and MALT1, but not Bcl10. Sci. Signal. 7, ra55 (2014).

    Article  Google Scholar 

  26. 26

    Staal, J. et al. T-cell receptor–induced JNK activation requires proteolytic inactivation of CYLD by MALT1. EMBO J. 30, 1742–1752 (2011).

    CAS  Article  Google Scholar 

  27. 27

    Delgoffe, G.M. et al. The kinase mTOR regulates the differentiation of helper T cells through the selective activation of signaling by mTORC1 and mTORC2. Nat. Immunol. 12, 295–303 (2011).

    CAS  Article  Google Scholar 

  28. 28

    Kurebayashi, Y. et al. PI3K–Akt–mTORC1–S6K1/2 axis controls Th17 differentiation by regulating Gfi1 expression and nuclear translocation of RORγ. Cell Rep. 1, 360–373 (2012).

    CAS  Article  Google Scholar 

  29. 29

    Lee, K. et al. Mammalian target of rapamycin protein complex 2 regulates differentiation of Th1 and Th2 cell subsets via distinct signaling pathways. Immunity 32, 743–753 (2010).

    CAS  Article  Google Scholar 

  30. 30

    Zeng, H. et al. mTORC1 and mTORC2 kinase signaling and glucose metabolism drive follicular helper T cell differentiation. Immunity 45, 540–554 (2016).

    CAS  Article  Google Scholar 

  31. 31

    Altin, J.A. et al. Decreased T-cell receptor signaling through CARD11 differentially compromises forkhead box protein 3–positive regulatory versus TH2 effector cells to cause allergy. J. Allergy Clin. Immunol. 127, 1277–85.e5 (2011).

    CAS  Article  Google Scholar 

  32. 32

    Noval Rivas, M. et al. Regulatory T cell reprogramming toward a Th2-cell-like lineage impairs oral tolerance and promotes food allergy. Immunity 42, 512–523 (2015).

    CAS  Article  Google Scholar 

  33. 33

    Lexmond, W.S. et al. FOXP3+ Tregs require WASP to restrain Th2-mediated food allergy. J. Clin. Invest. 126, 4030–4044 (2016).

    Article  Google Scholar 

  34. 34

    McCully, R.R. & Pomerantz, J.L. The protein kinase C–responsive inhibitory domain of CARD11 functions in NF-κB activation to regulate the association of multiple signaling cofactors that differentially depend on Bcl10 and MALT1 for association. Mol. Cell. Biol. 28, 5668–5686 (2008).

    CAS  Article  Google Scholar 

  35. 35

    Sommer, K. et al. Phosphorylation of the CARMA1 linker controls NF-κB activation. Immunity 23, 561–574 (2005).

    CAS  Article  Google Scholar 

  36. 36

    Matsumoto, R. et al. Phosphorylation of CARMA1 plays a critical role in T cell receptor–mediated NF-κB activation. Immunity 23, 575–585 (2005).

    CAS  Article  Google Scholar 

  37. 37

    Jattani, R.P., Tritapoe, J.M. & Pomerantz, J.L. Intramolecular interactions and regulation of cofactor binding by the four repressive elements in the caspase recruitment domain–containing protein 11 (CARD11) inhibitory domain. J. Biol. Chem. 291, 8338–8348 (2016).

    CAS  Article  Google Scholar 

  38. 38

    Hara, H. et al. Clustering of CARMA1 through SH3–GUK domain interactions is required for its activation of NF-κB signalling. Nat. Commun. 6, 5555 (2015).

    CAS  Article  Google Scholar 

  39. 39

    Round, J.L. et al. Scaffold protein Dlgh1 coordinates alternative p38 kinase activation, directing T cell receptor signals toward NFAT but not NF-κB transcription factors. Nat. Immunol. 8, 154–161 (2007).

    CAS  Article  Google Scholar 

  40. 40

    Yamane, H. & Paul, W.E. Early signaling events that underlie fate decisions of naive CD4+ T cells toward distinct T-helper cell subsets. Immunol. Rev. 252, 12–23 (2013).

    Article  Google Scholar 

  41. 41

    Pollizzi, K.N. & Powell, J.D. Integrating canonical and metabolic signalling programmes in the regulation of T cell responses. Nat. Rev. Immunol. 14, 435–446 (2014).

    CAS  Article  Google Scholar 

  42. 42

    Aronica, M.A. et al. Preferential role for NF-κB/Rel signaling in the type 1 but not type 2 T cell–dependent immune response in vivo. J. Immunol. 163, 5116–5124 (1999).

    CAS  PubMed  Google Scholar 

  43. 43

    Ong, P.Y. & Leung, D.Y. Bacterial and viral infections in atopic dermatitis: a comprehensive review. Clin. Rev. Allergy Immunol. 51, 329–337 (2016).

    CAS  Article  Google Scholar 

  44. 44

    Molinero, L.L., Cubre, A., Mora-Solano, C., Wang, Y. & Alegre, M.L. T cell receptor/CARMA1/NF-κB signaling controls T-helper (Th) 17 differentiation. Proc. Natl. Acad. Sci. USA 109, 18529–18534 (2012).

    CAS  Article  Google Scholar 

  45. 45

    Medoff, B.D. et al. CARMA1 is critical for the development of allergic airway inflammation in a murine model of asthma. J. Immunol. 176, 7272–7277 (2006).

    CAS  Article  Google Scholar 

  46. 46

    Blonska, M., Joo, D., Zweidler-McKay, P.A., Zhao, Q. & Lin, X. CARMA1 controls Th2 cell–specific cytokine expression through regulating JunB and GATA3 transcription factors. J. Immunol. 188, 3160–3168 (2012).

    CAS  Article  Google Scholar 

  47. 47

    Arjunaraja, S. & Snow, A.L. Gain-of-function mutations and immunodeficiency: at a loss for proper tuning of lymphocyte signaling. Curr. Opin. Allergy Clin. Immunol. 15, 533–538 (2015).

    CAS  Article  Google Scholar 

  48. 48

    Haniuda, K., Fukao, S., Kodama, T., Hasegawa, H. & Kitamura, D. Autonomous membrane IgE signaling prevents IgE-memory formation. Nat. Immunol. 17, 1109–1117 (2016).

    CAS  Article  Google Scholar 

  49. 49

    van Zwol, A., Moll, H.A., Fetter, W.P. & van Elburg, R.M. Glutamine-enriched enteral nutrition in very low birthweight infants and allergic and infectious diseases at 6 years of age. Paediatr. Perinat. Epidemiol. 25, 60–66 (2011).

    Article  Google Scholar 

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We thank W. Tsai, M. Gadina and C. Malinverni for technical assistance. We thank the patients and their families for participating in this research. The patients were enrolled on an IRB-approved protocol and provided informed consent. CARD11-deficient Jurkat cells (JPM50.6) were originally provided by X. Lin (MD Anderson Cancer Center). This work was supported by the Intramural Research Program of the National Institute of Allergy and Infectious Diseases, National Institutes of Health, the NIAID Clinical Genomics Program and grants from the National Institutes of Health (1R21AI109187 to A.L.S. and AI061093 to E.M.), the Henry M. Jackson Foundation (Val Hemming Fellowship to J.R.S.), Telethon (GGP13254 to E.R.), and the Joanne Siegel Fund (to E.W.G.). This project has been funded in whole or in part with federal funds from the National Cancer Institute, National Institutes of Health, under contract HHSN261200800001E. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products or organizations imply endorsement by the US government.

Author information




C.A.M., Yuan Zhang, M.A.W. and S.G. performed experiments with primary patient cells. J.R.S. and B.D. produced all CARD11 mutant constructs. J.R.S., E.R., S.A., K.V. and B.D. conducted cell transfection experiments. J.J.L., C.G.N., T.D., K.D.S., H.F.M. and J.D.M. were involved in clinical workup of patient A.-I. J.S., J.N. and S.D.R. performed sequence analysis on patient A.-I. J.K.A., P.J.H., P.R.R. and E.W.G. were involved in clinical care and sequence analysis of family B. Yu Zhang, B.K., M.A.C., N.R., S.G. and E.M. were involved in clinical workup of family C. A.P., M.O., E.P., A.R.B., G.D. and S.D. were involved in clinical care and workup of family D. J.Z. and M.A.M. performed sequence analysis of family D. N.Y. performed regulatory T cell experiments. J.J.M. provided sequencing resources and data. N.J. provided patient care and information. C.A.M., M.A.W., J.R.S., A.L.S. and J.D.M. co-wrote the manuscript. E.W.G., A.L.S. and J.D.M. supervised the project. All authors discussed the results and contributed to the manuscript.

Corresponding author

Correspondence to Joshua D Milner.

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Competing interests

The authors declare no competing financial interests.

Integrated supplementary information

Supplementary Figure 1 Atopy-associated CARD11 mutants reduce the percentage of transfected cells signaling to NF-κB and mTORC1, and the Q945X mutant is functionally “null” and does not interfere with wild-type CARD11 signaling.

(a,b) Quantification of %κB-GFP+ JPM50.6 cells transfected in Figure 2a-d. Data are mean ± s.d. for 8 (a) and 5 (b) separate experiments. Asterisks denote statistically significant differences (Student’s t-test) for each LOF mutant versus wild-type (WT) with (black) or without (gray) stimulation, P < 0.05. (c) Flow cytometric histograms measuring NF-κB-driven GFP reporter expression in JPM50.6 cells transfected with empty vector (EV), WT, or Q945X CARD11 constructs, ± 24 h anti-CD3/CD28 stimulation. (d) Quantification of NF-κB-driven GFP reporter expression (MFI) in transfected JPM50.6 cells. Data are mean ± s.e.m. for three separate experiments. (e) Cropped immunoblot for CARD11-FLAG expression in transfected JPM50.6 lysates (c). Data representative of three independent experiments. (f) Flow cytometric histograms for JPM50.6 cells transfected with WT CARD11 plus EV, WT or mutant constructs and stimulated as in c. (g) GFP MFI quantification for JPM50.6 cells transfected in g. Data are mean ± s.e.m. (right) for five separate experiments; asterisks denote significance versus stimulated WT+WT (E57D P = 1.4 x 10−3; L194P P = 2.4 x 10−3; Q945X P = 0.113). (h) Cropped immunoblot for CARD11 expression in transfected JPM50.6 lysates described in h. Data representative of three independent experiments. (i) NF-κB-driven luciferase activity in WT Jurkat cells transfected with CARD11 (EV, WT, R975W, Q945X) plus luciferase reporter plasmids. Data represent mean ± s.d. fold change in κB-driven luciferase activity ± 24 h stimulation, normalized to Renilla luciferase activity for three separate experiments. (J) Quantification of % phospho-S6+ Jurkat cells transfected in Figure 2i,j. Data are mean ± s.d. for four separate experiments. Asterisks denote significance for each LOF mutant versus WT with stimulation (E57D P = 4.9 x 10−3; L194P P = 5.2 x 10−3; R975W P = 2.9 x 10−3; dup183_196 P = 0.013). (k) Percent inhibition of pS6 signal calculated for each mutant versus EV (gray) or WT (black) transfected cells in b, based on the change in % pS6+ cells ± stimulation. (l) Flow cytometric histograms measuring phospho-S6 in Jurkat cells transfected with EV, WT, L194P or Q945X CARD11 constructs, ± anti-CD3/CD28 stimulation for 20 min. Data are representative of three independent experiments.

Supplementary Figure 2 Increased incubation time of PMA diminishes the p-S6 activation defect in patient A-I compared to the healthy control.

PBMCs were rested and treated with 1 ng/mL PMA and stained with phospho-S6 antibody and gated on CD4+ cells as described in the Online Methods. Data are representative of two independent experiments (HC, healthy control; NS, no stimulation).

Supplementary Figure 3 CARD11 mutated patients show mildly impaired B cell signaling and efficient B cell development.

(a) PBMCs were stimulated with PMA and the signaling constituents were analyzed by intracellular flow cytometry (NS, no stimulation). (b) Representative analysis of CD19+CD27+ conventional memory B cells in a related healthy control (HC) subject and CARD11 mutated patients (left); summary of frequencies is depicted on the right. (c) Representative dot plots of CD21 and CD10 staining on CD19+CD27 naïve B cells in a related healthy control and CARD11 mutated patients (upper panels). Lower panels indicate frequencies of CD19+CD27CD21loCD10hi transitional type 1 B cells, CD19+CD27CD21+CD10+ transitional type 2 B cells, CD19+CD27CD21+CD10 mature naïve B cells and CD19+CD27CD21−/loCD10 B cells of CARD11 mutant patients compared with healthy control subjects. Each symbol represents a subject; solid lines display means, dashed lines show HC mean.

Supplementary Figure 4 Defective naive CD4 T cell proliferation in patient A-I, ELISA analysis of A-I and family B patients, and glutamine/cytokines rescue of IFN-γ in the family D patients.

(a) Blastogenesis and proliferation of isolated naïve CD4+ cells from representative healthy control (HC) vs. CARD11 patients after anti-CD3/CD28 activation for 5 days. CellTrace Violet (Violet) staining was used for tracking the number of the cell divisions. (b) Culture media from the PMA/ionomycin-treated patients’ PBMCs for 6 h were collected, and the IFNγ, IL-4, IL-13 and IL-5 secretions were measured by ProcartaPlex ELISA (eBioscience) (mean ± s.e.m.). (c) Intracellular flow cytometry identifying IFNγ/IL-4-producing cell ratio from CD3+CD8 CD45RO+ T cells within PBMC from CARD11 patients of family D and travel control (TC). PBMCs were cultured with anti-CD3/CD28 activation for 5 days, with or without cytokines (Th0) and plus 3 mM glutamine.

Supplementary Figure 5 CARD11 mutated patients show normal Treg cell frequencies, and CARD11 mutated patient Treg cells display normal suppressive function.

(a) Representative analysis of gated CD25+CD127lo (upper panels) and CD25+FOXP3+ (lower panels) on CD3+CD4+ T cells of a healthy (HC) control subject and CARD11 mutated patients (A-I, Family C) vs. control (C-II.2). (b) Quantitation of FOXP3+CD25+ Tregs among CD45RO+ CD127low CD4 T cells for family B members vs. healthy controls (HC). (c) Representative histograms of Treg-mediated suppression of autologous and heterologous CFSE labeled responder T cells (Tresp) from two CARD11 mutated patients compared to a healthy donor. Dashed line display non-stimulated Tresp cells. (d,e) Autologous and heterologous suppressive capacity of Treg cells of HC and CARD11 mutated patients. (f) Suppression of healthy control and CARD11 mutated patient Tresp cells by Tregs from healthy control. Full lines display the means and the dashed lines show the mean of the HC.

Supplementary Figure 6 Glutamine rescues of cell proliferation and IFN-γ production of the family D patients.

Blastogenesis and IFNγ+ cell ratio of PBMC from travel control vs. Family D patients after anti-CD3/CD28 activation for 5 days. Cytokines and glutamine were added as indicated.

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Ma, C., Stinson, J., Zhang, Y. et al. Germline hypomorphic CARD11 mutations in severe atopic disease. Nat Genet 49, 1192–1201 (2017).

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