Monique E. De Paepe

In utero gene editing (IUGE) is a potential treatment for inherited diseases that cause pathology before or soon after birth. Preexisting immunity to adeno-associated virus (AAV) vectors and Cas9 endonuclease may limit postnatal gene editing. The tolerogenic fetal immune system minimizes a fetal immune barrier to IUGE. However, the ability of maternal immunity to limit fetal gene editing remains a question. We investigated whether preexisting maternal immunity to AAV or Cas9 impairs IUGE. Using a combination of fluorescent reporter mice and a murine model of a metabolic liver disease, we demonstrated that maternal anti-AAV IgG antibodies were efficiently transferred from dam to fetus and impaired IUGE in a maternal titer–dependent fashion. By contrast, maternal cellular immunity was inefficiently transferred to the fetus, and neither maternal cellular nor humoral immunity to Cas9 impaired IUGE. Using human umbilical cord and maternal blood samples collected from mid- to late-gestation pregnancies, we demonstrated that maternal-fetal transmission of anti-AAV IgG was inefficient in midgestation compared with term, suggesting that the maternal immune barrier to clinical IUGE would be less relevant at midgestation. These findings support immunologic advantages for IUGE and inform maternal preprocedural testing protocols and exclusion criteria for future clinical trials.

Dysmorphic pulmonary vascular growth and abnormal endothelial cell (EC) proliferation are paradoxically observed in premature infants with bronchopulmonary dysplasia (BPD), despite vascular pruning. The pentose phosphate pathway (PPP), a metabolic pathway parallel to glycolysis, generates NADPH as a reducing equivalent and ribose 5-phosphate for nucleotide synthesis. It is unknown whether hyperoxia, a known mediator of BPD in rodent models, alters glycolysis and the PPP in lung ECs. We hypothesized that hyperoxia increases glycolysis and the PPP, resulting in abnormal EC proliferation and dysmorphic angiogenesis in neonatal mice. To test this hypothesis, lung ECs and newborn mice were exposed to hyperoxia and allowed to recover in air. Hyperoxia increased glycolysis and the PPP. Increased PPP, but not glycolysis, caused hyperoxia-induced abnormal EC proliferation. Blocking the PPP reduced hyperoxia-induced glucose–derived deoxynucleotide synthesis in cultured ECs. In neonatal mice, hyperoxia-induced abnormal EC proliferation, dysmorphic angiogenesis, and alveolar simplification were augmented by nanoparticle-mediated endothelial overexpression of phosphogluconate dehydrogenase, the second enzyme in the PPP. These effects were attenuated by inhibitors of the PPP. Neonatal hyperoxia augments the PPP, causing abnormal lung EC proliferation, dysmorphic vascular development, and alveolar simplification. These observations provide mechanisms and potential metabolic targets to prevent BPD-associated vascular dysgenesis.

Background: The axis formed by CXC chemokine receptor 4 (CXCR4), expressed on mesenchymal stromal cells (MSCs), and stromal cell-derived factor-1 (SDF-1), expressed in recipient organs, is a critical mediator of MSC migration in non-pulmonary injury models. The role and regulation of SDF-1 expression in preterm lungs, of potential relevance for MSC-based cell therapy for bronchopulmonary dysplasia (BPD), is unknown. The aim of this study was to determine the spatiotemporal pattern of CXCR4/SDF-1 expression in lungs of extremely preterm infants at risk for BPD. Methods: Postmortem lung samples were collected from ventilated extremely preterm infants who died between 23 and 29 wks (“short-term ventilated”) or between 36 and 39 wks (“long-term ventilated”) corrected postmenstrual age. Results were compared with age-matched infants who had lived <12 h or stillborn infants (“early” and “late” controls). CXCR4 and SDF-1 expression was studied by immunohistochemistry, immunofluorescence/confocal microscopy, and qRT-PCR analysis. Results: Compared with age-matched controls without antenatal infection, lungs of early control infants with evidence of intrauterine infection/inflammation showed significant upregulation of SDF-1 expression, localized to the respiratory epithelium, and of CXCR4 expression, localized to stromal cells. Similarly, pulmonary SDF-1 mRNA levels were significantly higher in long-term ventilated ex-premature infants with established BPD than in age-matched controls. The pulmonary vasculature was devoid of SDF-1 expression at all time points. Endogenous CXCR4-positive stromal cells were preferentially localized along the basal aspect of SDF-1-positive bronchial and respiratory epithelial cells, suggestive of functionality of the CXCR4/SDF-1 axis. Conclusions: Incipient and established neonatal lung injury is associated with upregulation of SDF-1 expression, restricted to the respiratory epithelium. Knowledge of the clinical associations, time-course and localization of pulmonary SDF-1 expression may guide decisions about the optimal timing and delivery route of MSC-based cell therapy for BPD.

Non-albicans Candida species such as Candida parapsilosis and Candida glabrata have emerged as prevalent pathogens in premature infants. The aim of this study was to systematically delineate the histopathologic findings in neonatal non-albicans candidiasis. We performed a retrospective clinicopathologic analysis of extremely premature (23–28 weeks’ gestation) infants diagnosed with invasive candidiasis. Archival autopsy tissues were subjected to periodic acid-Schiff, methenamine-silver and anti-Candida (immuno)histochemical stains, as well as dual anti-Candida and anti-cytokeratin or anti-CD31 immunofluorescence assays. In addition, we studied the prevalence of intestinal Candida colonization in a consecutive autopsy series of extremely premature infants. Based on positive postmortem blood and/or lung cultures, invasive candidiasis (3 non-albicans and 11 Candida albicans) was diagnosed in 14 of the 187 extremely premature infants examined between 1995 and 2017. In contrast to the well-known inflammatory and tissue-destructive phenotype of congenital C. albicans infection, invasive non-albicans candidiasis/candidemia caused by C. parapsilosis and C. glabrata was inconspicuous by routine hematoxylin-eosin-based histopathologic analysis despite a heavy fungal presence detected in intestines, lungs, and blood by targeted (immuno)histochemical assays. Intestinal colonization by Candida species was identified in 16 of the 26 (61%) extremely premature neonates who had lived for at least 1 week, as assessed by anti-Candida immunostaining. Invasive neonatal non-albicans candidiasis/candidemia appears to have no distinct histopathologic signature. Based on the notoriously low sensitivity of fungal blood cultures and the observed high frequency of Candida intestinal colonization (>50%), it is likely that non-albicans candidiasis/candidemia may be underdiagnosed in (deceased) preterm infants. Routine inclusion of targeted (immuno)histochemical fungal detection strategies in the perinatal autopsy may lead to deeper insight into the prevalence and clinical relevance of neonatal non-albicans candidiasis.

Simpson–Golabi–Behmel syndrome type I (SGBS, OMIM312870), caused by defects of the GPC3 and GPC4 genes on chromosome Xq26, is an X-linked recessive macrosomia/multiple congenital anomaly disorder characterized by somatic overgrowth, coarse facial features, variable congenital anomalies, increased tumor risk, and mild-to-moderate neurodevelopmental anomalies. We report the postmortem findings in 3 second-trimester male siblings with SGBS who displayed ambiguous genitalia (in all 3) and gonadal dysgenesis (ovotestis) (in 1), thus expanding the SGBS spectrum to include these disorders of sex development.