We performed a single-center retrospective analysis of chronic granulomatous disease (CGD) autopsy reports to better understand causes of death, end-organ damage, and disease pathophysiology. Forty-four autopsies of CGD patients, including one X-linked female carrier, were performed from February 1990 to June 2025. These cases represent approximately 60% of the CGD deaths over 35 years. There was an increase in age at death over this time, despite a heavy burden of infections. The immediate cause of death was infection n = 30 (68%); Aspergillus species (33%) was the most frequent pathogen. One death was associated with SARS-CoV-2. An aggressive new Aspergillus species, Aspergillus tanneri, and an unidentified Burkholderia species were identified in this cohort.Noninfectious causes of death in 14 patients were associated to accident (1), respiratory failure (2), renal failure (2), surgical complications (1), post-transplant complications (2), cardiovascular complications (2), cerebral infarction (1), Transfusion-Related Acute Lung Injury (TRALI), a serious complication of blood transfusions where the recipient experiences acute lung injury in one case, and one death attributed to metastatic pancreatic ductal adenocarcinoma.A substantial portion had characteristic pigmented-laden macrophages in multiple organs, with a high concentration in the brain parenchyma. Atherosclerotic manifestations were present in a third of the cases. One patient, p22phox, had minimal atherosclerosis manifestations early in life (19 yrs). Lungs and hearts were significantly heavier when compared to norms. Livers were not significantly larger, although there was evidence of underlying inflammatory disease. Periportal inflammation was noted in 19 patients (46%), and nodular regenerative hyperplasia (NRH) was found in 7 (16%). Kidneys were small overall (atrophic), which may be related to drug exposure, specifically amphotericin B. Glomerulosclerosis or chronic renal compromise was found in 17 patients (41%), two of whom were children. Among those with glomerulosclerosis, one had never received amphotericin B. This pathology review shows pigment-laden macrophages across multiple organs not previously recognized, including the brain parenchyma. This is the largest autopsy series known in this population, underscoring the increased survival over time. With fungal infections being the most common cause of death, this emphasizes the importance of antifungal development and definitive cure in this disease.

Metastatic progression requires cancer cells to adapt to the unique constraints of distant organ microenvironments, yet the mechanisms that drive organ-specific adaptations remain poorly understood. Here, we show that the liver actively rewrites metastatic cancer cell identity, driving tumor cells toward a hepatobiliary progenitor-like state. Through integrated transcriptomic, proteomic, metabolomic, and epigenomic analyses of patient-derived rapid-autopsy samples and experimental models, we identify this state as selectively enriched in liver metastases. It is characterized by co-activation of hepatic and biliary/progenitor regulators HNF4A and SOX9 and is observed across multiple epithelial cancers, indicating a conserved response to the hepatic niche. Mechanistically, hepatocyte-derived TGF-β and hypoxia converge to activate a HIF-1α-ACLY axis, increasing nuclear acetyl-coenzyme A availability and histone acetylation at hepatic lineage regulatory elements to drive hepatobiliary reprogramming. This coordinated niche-response program can be captured transcriptionally and is associated with inferior overall survival. Disruption of this pathway suppresses hepatic reprogramming and impairs liver metastatic fitness. These findings identify the liver as an active determinant of metastatic cell fate, linking microenvironmental signaling to metabolic and chromatin remodeling programs that enable lineage plasticity. More broadly, they reveal organ-specific reprogramming as a fundamental principle of metastasis and a therapeutic vulnerability in liver metastases.

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED/APS-1) is a monogenic autoimmune disorder of impaired central tolerance classically diagnosed by the presence of 2 out of 3 classic triad manifestations: chronic mucocutaneous candidiasis, hypoparathyroidism, and adrenal insufficiency. However, many patients develop non-triad manifestations years earlier, delaying recognition and care. In 2016, we proposed expanded diagnostic criteria incorporating 3 early clinical manifestations — APECED rash, autoimmune enteritis, and enamel hypoplasia — based on observations in 35 North American patients. Here, we provide further support for the clinical utility of these expanded diagnostic criteria in independent cohorts of 57 American and 12 European patients enrolled in a prospective natural history study at the NIH. Across all cohorts, the expanded diagnostic criteria decreased the time to diagnosis by half relative to the classic diagnostic criteria. Patients exhibited an enrichment of early non-endocrine autoimmune manifestations, underscoring disease heterogeneity and the potential for developing organ-specific autoimmunity before endocrine failure. These findings demonstrate the clinical utility of the expanded APECED diagnostic criteria and support the notion that their adoption might enable earlier disease recognition and timely immunomodulatory therapy to improve long-term outcomes.

ecDNA heterogeneity in SCLC, related to Figure 4

BACKGROUND Cardiopulmonary changes in noncirrhotic portal hypertension (NCPH) are poorly understood. AIM To investigate cardiopulmonary changes using transthoracic echocardiography (TTE) in NCPH and their correlation with clinical features. METHODS Prospective cohort including 10 preclinical NCPH [without portal hypertension (PH)] and 32 NCPH subjects who underwent TTE with agitated saline injection and comprehensive clinical evaluation were assessed. PH was defined by presence of either varices, ascites or portosystemic shunting. Intrapulmonary vascular dilatation (IPVD) is defined as appearance of microbubbles in the left atrium after three heartbeats. Right ventricular systolic pressure (RVSP) > 38 mmHg was used to identify possible porto-pulmonary hypertension. Cardiomyopathy is defined using cirrhotic cardiomyopathy consortium criteria. RESULTS Among 42 subjects, 17 (40%) had IPVD, 4 (9.5%) had RVSP > 38 mmHg, and 6 (14%) had cardiomyopathy. Aspartate aminotransferase to alanine aminotransferase (AST/ALT) (1.3 vs 1, P = 0.04) and liver stiffness measurement (LSM) (12.4 kPa vs 7.1 kPa, P = 0.03) were higher in those with IPVD. Presence of either LSM > 10 or AST/ALT > 1.2 aided in identifying subjects with IPVD-sensitivity, specificity, and accuracy of 76%. RVSP correlated with oxygen saturation (r = -0.33), and free right hepatic vein pressure (r = 0.43). Those with PH had higher left atrial volume (LAV) (62 mL vs 48 mL, P < 0.01), and LAV index (LAVI) (35 m2 vs 23 m2, P < 0.01) compared to those without PH. Total bile acids, especially primary bile acids positively correlated with LAV (r = 0.36), and LAVI (r = 0.41). CONCLUSION Similar to cirrhotic patients, cardiopulmonary changes are prevalent in NCPH, especially among those with PH. In NCPH, cardiopulmonary changes occur despite preserved synthetic function, suggesting the NCPH model's value in understanding cardiopulmonary dysfunction in liver disease.

Few studies have assessed hypomorphic variants in ZAP70, leading to profound, late-onset combined immunodeficiency. A previously healthy 21-year-old man presented with primary EBV B cell lymphoproliferative disease (LPD). He developed hemophagocytic lymphohistiocytosis treated with rituximab, although EBV LPD rapidly relapsed. He subsequently underwent matched, unrelated donor hematopoietic cell transplantation complicated by fatal hepatic sinusoidal obstructive syndrome. The family history included profound immune dysregulation in his younger sister, characterized by juvenile systemic lupus erythematosus/juvenile idiopathic arthritis overlap diagnosed at 7 years of age, HPV+ warts, and EBV viremia. She failed therapy with methotrexate, leflunomide, sulfasalazine, hydroxychloroquine, rituximab, tofacitinib, abatacept, tocilizumab, and adalimumab. After NIH evaluation, she was confirmed to be HLA:B27-positive and had a marked clinical response to ustekinumab without loss of viral control. Maternal history included epidermodysplasia verruciformis, recurrent infectious rectovaginal fistulas, and lymphocytic colitis. Whole-exome sequencing (WES) revealed novel homozygous, splice-site variants in ZAP70 (c.1623+5G>A) in all 3 affected family members. WES homology was consistent with founder effect without consanguinity, although the mother and father were fourth cousins. cDNA analysis of patient cells confirmed aberrant splicing between exons 12 and 13 (Figure 1). Figure 1. cDNA generated from RNA of the proband, his affected sister, and his affected mother confirmed aberrant splicing at Exon 12 and Exon 13 of ZAP70, consistent with the homozygous, splice-site variant found on whole-exome sequencing. All affected family members had CD4 lymphopenia, although CD8 central and effector memory T cells were relatively preserved. Naïve CD4+ and CD8+ T cells were nearly absent in the proband and his sister. Assays in cells from all affected individuals showed reduced ZAP70-dependent T cell receptor stimulation (Figure 2) and decreased T cell proliferation to mitogens. Maternal lymphocyte phenotyping showed increased NK cells with strong cytolytic function, which may have contributed to her relatively mild phenotype. Markedly increased phospho-S6 and PD-1 expression in CD8 cells as well as increased CD4+ and CD8+ TIGIT and PD-1 double-positive cells were consistent with immune dysregulation and T cell exhaustion. Figure 2. T cells from the proband, his affected sister, and his affected mother showed decreased total ZAP70 protein as well as decreased ZAP70 signaling (phospho-ZAP70, phospho-LAT, and phospho-ERK). Here we present a 3-member kindred with variable expressivity of a novel homozygous, hypomorphic, splice-site variant in ZAP70. While all family members suffered from severe viral infections, they also presented with multiple features not typically associated with ZAP70 deficiency, including late-onset CID, profound immune dysregulation, and relative preservation of total and memory CD8+ T cell populations.

BACKGROUND & AIMS:Fibrosis stage is a key determinant of outcomes in metabolic dysfunction-associated steatohepatitis (MASH). Assessment of fibrosis change is a critical component of the assessment of therapeutic efficacy of interventions. Conventional assessment of fibrosis stage is limited by sampling and inter- and intra-observer variability. Second harmonic generation/2-photon excitation fluorescence (SHG/TPEF) imaging provides an alternate way to assess fibrosis from unstained histologic sections. The aim of this study is to establish repeatability and reproducibility of SHG/TPEF imaging in metabolic dysfunction-associated steatohepatitis histologic samples. METHODS:The SHG/TPEF images were acquired by 3 Genesis machines for the included samples. Each sample was scanned 3 times by each machine at different time points. qFibrosis stage (qFS) and qFibrosis continuous value (qFC) were calculated by an artificial intelligence-based algorithm that was previously correlated with the Nonalcoholic Steatohepatitis Clinical Research Network fibrosis staging system. RESULTS:The overall intra-/inter-system weighted kappas of qFS were 0.880 (95% confidence interval [CI], 0.844-0.915) and 0.850 (95% CI, 0.811-0.889), respectively. Using the pairwise agreement method, the intra-/inter-system agreements of qFS were 89.16% (95% CI, 0.856-0.921) and 86.46% (95% CI, 0.829-0.890), respectively. For qFC, the intra-/inter-system agreements were 87.53% (95% CI, 0.837-0.911) and 78.05% (95% CI, 0.737-0.824), respectively. Furthermore, the Bland-Altman method was used to evaluate the intra-/inter-system agreements of qFC, with 93.77% (95% CI, 0.911-0.960) and 93.50% (95% CI, 0.908-0.959), respectively. CONCLUSIONS:The qFibrosis system has good repeatability and reproducibility for fibrosis staging. It can provide an accurate reference for pathologists to stage liver fibrosis more objectively.

One of the major complications following hematopoietic cell transplantation (HCT) is the occurrence of graft-versus-host disease (GVHD). The liver is a target organ in both acute and chronic GVHD. Histologically, there are two distinct forms of hepatic involvement by GVHD, namely cholestatic (classical) and hepatic. Autoimmune-like hepatitis has been reported as a late complication of HCT with some considering it to be a variant of hepatic GVHD. However, there are no reports of hepatic form of GVHD and autoimmune-like hepatitis in the same patient post-HCT. Herein, we report a patient who initially developed hepatic GVHD followed by autoimmune-like hepatitis.

Anti-vascular endothelial growth factor (VEGF) treatment has shown clinical activity together with immune checkpoint blockade (ICB), but the exact mechanism is not known. We show that VEGF blockade in combination with anti-cytotoxic T-lymphocyte associated protein 4 (CTLA4) + anti-programmed death-ligand 1 (PD-L1) in cholangiocarcinoma (CCA) potentiated a multimodal mechanism dependent on B cell activating factor (BAFF), leading to a proinflammatory B cell response. It led to a BAFF- and interleukin (IL)-12-dependent expansion and rewiring of T regulatory cells (Tregs) toward an anti-tumor T helper-1 (Th-1)-like fragile state. We translated this approach to the clinic and observed immunological changes characterized by Treg cell expansion and rewiring toward fragile and unstable states. We explored the effect of VEGF receptor 2 (VEGFR2) signaling on Treg cell transcriptional programming and established a mouse model ablating VEGFR2 expression on Treg cells. This study reveals the immunological interplay resulting from targeting VEGF together with CTLA-4 and PD-L1 blockade.

ecDNA in SCLC, related to Figure 1

INTRODUCTION:Fluoroquinolones (FQ) have a favorable safety profile, but the risk of drug-induced liver injury (DILI) is well described. The aim of this study was to identify clinical features and HLA genetic variants associated with FQ-DILI in a large national registry. METHODS:Analysis of FQ-DILI cases enrolled in DILI Network between 2004 and 2022. HLA class I and II alleles were sequenced by the Illumina MiSeq platform. RESULTS:Sixty-one cases (32 ciprofloxacin, 22 levofloxacin, 7 moxifloxacin) were included. Clinical features between the 3 drugs were similar. The median duration of therapy was 7 (range 2-54) days, median age 53 (range 22-80) years, and 67% were female. Median latency to onset was 12 (range 2-1,370) days with 44% hepatocellular, 30% mixed, and 26% cholestatic pattern of liver injury. Median time to recovery was 65 days, but 13% had persistent injury at 6 months, 15% died (11% because of liver failure). Two HLA alleles were associated with an increased risk of liver injury: HLA-DQA1*03:01 (carriage frequency 38% in cases vs 19% in controls) and HLA B*57:01 (15% vs 6%). There was a significant difference between the combined carriage frequency of the 2 alleles of 48% in cases vs 24% controls ( P = 0.0001). No clinical characteristics or outcomes were associated with carriers compared with noncarriers. DISCUSSION:FQ DILI is a class effect that presents with a short latency, variable pattern of liver injury, and carries a significant risk of chronicity and mortality. There is a significant association with HLA-DQA1*03:01 and HLA B*57:01 .