Complement Deficiencies Clinical Presentation

Infants may have Leiner disease, which manifests as recurrent diarrhea, wasting, and generalized seborrheic dermatitis. The defect in persons with Leiner disease is usually attributed to a defect of the fifth component of complement (C5). However, a child was described by Sonea and associates who had Leiner disease associated with diminished C3, and another was described by Goodyear and Harper with a low level of the fourth component of complement and reduced neutrophil mobility. ^{[11, 12]} Thus, the C5 defect may not be the sole cause of Leiner disease, as has been suggested; diminished C3 or C4, or C5 dysfunction or deficiency with hypogammaglobulinemia or other lymphoid deficiency, is also required for its expression.

One family from the Arabian Gulf region with multiple members affected by meningococcemia and abscent serum complement 5 (C5) was found to have a homozygous nonsense mutation in exon 1, with the change of cytosine to thymine at position 55 (55C > T) leading to change of the glutamine amino acid at position 19 to a stop codon (Q19X), and serologically absence of C5 in the serum. ^[13]

The 3 major sequelae of complement deficiencies, based on the pathophysiology of each defect, are (1) defects that result in inadequate opsonization, (2) defects in cell lysis, and (3) the association of complement deficiencies with immune complex diseases.

Defects that result in inadequate opsonization

Opsonization is the process of coating a pathogenic organism so that it is more easily ingested by the macrophage system. The complement protein C3b, along with its cleavage product C3bi, is a potent agent of opsonization in the complement cascade. Any defect that causes decreased production of C3b results in inadequate opsonization ability. Such opsonization defects can be caused by deficiencies in components of the classic, alternative, or MBL pathways, or defects may be caused by deficiencies of the C3b component itself.

The clinical history of patients with classic pathway deficiencies varies slightly from other complement-deficient patients. In the small number of patients studied, patients with classic pathway deficiencies (ie, deficiency of C1qrs, C2, or C4) are similar in presentation to patients with primary immunoglobulin deficiencies. For example, patients tend to have frequent sinopulmonary infections with organisms such as Streptococcus pneumoniae. More commonly, these patients develop autoimmune syndromes.

In order to generate an antibody response, an antigen must bind to the complement receptor (CR2) on B cells and the complement protein C3d. A deficiency of C1-C4 proteins leads to an inadequate humoral response in these patients. Patients also have a decrease in classic pathway production of the opsonin C3b, but the alternative and MBL pathways seem to compensate for this defect because opsonin is not completely absent.

Opsonization defects can also be caused by alternative pathway deficiencies. In the alternative pathway, a deficiency of factor B, factor D, or properdin can result in a decreased amount of C3b. Deficiencies in properdin have been described in some detail. Properdin is a protein encoded on the X chromosome. Properdin stabilizes the C3 convertase (C3bBb) of the alternative pathway. Stabilization of C3 convertase increases the half-life of the complex from 5 minutes to 30 minutes, exponentially increasing the amount of C3b that can be deposited on a microbial surface. The role of C3b as an opsonin is essential in defense against neisserial infection, and the risk of overwhelming neisserial infection increases in the absence of properdin.

The third pathway whose deficiencies can result in opsonization defects is the MBL pathway. MBL is one of the collectin proteins. These proteins share specific structural characteristics, namely the presence of a collagenlike region and a Ca²⁺ -dependent lectin domain. Of all the lectin proteins, only MBL has been shown to have the ability to activate the complement system. The MBL protein can activate the C4 and C2 components of complement by forming a complex with serine proteases known as MASP1 and MASP2. MASP1 and MASP2 activation results in the protein products C3 and C3b. The MBL protein is versatile because it can bind to a variety of substrates, prompting some to describe the MBL as a kind of universal antibody. Clinically, MBL deficiencies increase risk of infection with the yeast Saccharomyces cerevisiae and encapsulated bacteria such as Neisseria meningitides and S pneumoniae. ^[14]

Finally, absolute deficiencies of C3 itself also result in defective opsonization. The C3 component occupies an important place at the junction of both the classic and alternative pathways. As such, C3 deficiency results in severe opsonization dysfunction. C3 deficiency also causes deficient leukocyte chemotaxis because of decreased C3a concentrations and decreased bactericidal killing secondary to decreased formation of MAC. Clinically, patients present at an early age with overwhelming infections from encapsulated bacteria. In addition to opsonization problems, C3 deficiency also impairs adequate clearance of circulating immune complexes, and 79% of patients with C3 deficiency develop some form of collagen vascular disease.

Deficiencies of the inhibitory proteins of the classic and alternative pathways can also result in a functional C3 deficiency through uncontrolled consumption of C3. Factors H and I are proteins that inhibit C3 formation in the alternative and classic pathways, respectively. Deficiencies in either of these C3 inhibitors can result in an overactivation of C3 and subsequent C3 depletion. Clinically, these patients are similar to patients with absolute C3 deficiency.

While deficiencies in complement proteins can predispose patients to infections such as the clinical conditions described above, a deficiency in regulation of complement can also lead to disease. Deficiencies or defective regulation of the alternative complement pathway can occur because of genetic mutations or deficiencies in the regulatory protein Factor H. This defective regulation of the alternative pathway can be associated with diseases such as an atypical form of hemolytic uremic syndrome, membranoproliferative glomerulonephritis (type I and II), and age-related macular degeneration.

Defects in cell lysis

Complement deficiencies of the terminal cascade proteins also predispose patients to infection, but the clinical history of these patients is different. The terminal complement proteins are the proteins in the cascade that form the MAC, ie, complement proteins C5-C9. These proteins are responsible for bactericidal killing of organisms such as N meningitidis. The frequency rate of meningococcal infection in patients with terminal complement deficiency is as high as 66%. In addition to this high rate of first-time infection, the frequency rate of recurrence with the same organism is also as high as 50%. The serogroups of N meningitidis responsible for infections in this group tend to be the more rare serogroups Y and W135, rather than the more common serogroups B, A, and C.

Clinically, patients with terminal deficiency tend to present with infection at an older age compared with patients with other complement deficiencies. These individuals also have less morbidity and mortality associated with infection. Unlike patients with a classic pathway deficiency, humoral immunity is intact but lysis of pathogenic organisms is impaired.

Both the opsonization and lytic function of complement protect against a variety of other nonbacterial pathogens, such fungi, viruses, and mycobacteria. The role of complement in defense against viral infection is sufficiently important that pathogenic viruses have had to develop strategies to evade complement activation. For example, human immunodeficiency virus type 1 has recently been described as escaping complement-mediated lysis through the incorporation of regulatory proteins, such as DAF, into the viral envelope. Similarly, other viruses have also evolved complement-specific means of escape.

Complement deficiencies and associated immune complex diseases

Patients with complement deficiencies of the classic pathway are predisposed to develop immune complex diseases.

Patients with deficiencies of the classic pathway components C1qrs, C2, or C4 have been shown to have an increased likelihood of developing SLE. C1q deficiency is less commonly linked with neuropsychiatric SLE, which may be first evident with seizures. ^[15]  Homozygous deficiency of C1q has the highest association with SLE, with a recently quoted prevalence rate of 93%. Subsequent components of the classic pathway have respective prevalence rates of 57% for C1rs deficiency, 75% association with homozygous C4 deficiencies, and 10% prevalence in patients with C2 deficiencies.

The reason complement deficiency increases the risk of developing SLE is that complement helps in the prevention of immune complex disease by decreasing the number of circulating immune complexes; the greater the concentration of these precipitating immune complexes, the higher the likelihood that they will deposit in nearby tissues and cause an inflammatory response.

Complement aids in neutralization and clearance of antigen-antibody complexes in several ways. The classic pathway acts to inhibit immune complex precipitation by physically interfering with immune complex aggregation. Secondly, complement enhances the clearance of circulating immune complexes by binding to complement receptors (CR1) on cells such as erythrocytes, B lymphocytes, T lymphocytes, and macrophages. When complement (specifically C3b) binds to CR1 on erythrocytes, the immune complex can be transported through the circulation to be presented to the macrophage systems in the spleen and liver.

Components of the classical pathway also play an important role in the recognition and clearance of apoptotic cells. Normally, intracellular proteins are displayed on the surface of cells undergoing apoptosis. If these apoptotic cells are not cleared efficiently by the complement system, these cell surface proteins have the potential to act as autoantigens, acting as potential triggers for autoimmune diseases such as systemic lupus.

In addition to its role in the development of diseases such as SLE, complement activation also likely plays a role in the pathogenesis of the antiphospholipid antibody syndrome (APS), a thrombophilic inflammatory disorder that can be associated with SLE or can occur independently. In a mouse model of antiphospholipid-antibody associated fetal death, mice who were deficient in C3 and mice who were treated with a regulatory protein that inhibits C3 cleavage were protected from fetal loss. Recent studies in human subjects have also found a positive association between the presence of C4d deposition on activated platelets and the presence of arterial thrombosis. Further studies in human subjects are ongoing. ^[16]

Complement component C8, when entirely absent, results in increased susceptibility to gram-negative bacteria such as Neisseria species. ^[10] Two functionally distinct C8 deficiency states have been described: C8 alpha-gamma deficiency and C8beta deficiency. A duplication mutation in C8-beta deficiency was recently documented, extending the molecular heterogeneity of this disorder. Complement screening would detect this rare primary immunodeficiency and allow prophylaxis to prevent recurrent Neisseria infections with this potentially severe outcome. ^[17]

A relatively small sampling of Finnish non-tuberculous mycobacteria patients had significantly more often C4 deficiencies than the healthy control subjects, suggesting that both a deficiency of complement C4 and bronchiectasis in healthy females as risk factors for pulmonary NTM infections. ^[18]

No specific physical findings are pathognomonic for complement deficiencies. Rather, clinical manifestations are representative of the infections and immune complex diseases to which patients are predisposed. The complement system helps to clear bacteria, protecting the host against infections, including S. pneumoniae and N. meningitidis. ^[19]

Because N meningitides is the overwhelmingly prevalent bacterial pathogen in these patients, knowledge of the physical characteristics of disseminated meningococcal disease is important. ^[20] The characteristic maculopapular rash that occurs in up to 75% of individuals with meningococcemia occurs soon after disease onset. The rash consists of pink lesions on the trunk and extremities; lesions are approximately 2-10 mm in diameter. The rash can quickly progress to hemorrhagic lesions. Petechiae are also a prominent finding and can occur on the skin of the trunk and extremities or on mucous membranes, such as the palate and conjunctivae.

Noninfectious diseases, such as SLE, that are associated with complement deficiencies can also have a characteristic physical presentation. Complement deficiencies associated with the deposition of immune complexes in various tissues can result in many of the sequelae of SLE, such as glomerulonephritis, arthralgia, uveitis, and vasculitic rash.

Most complement deficiencies are caused by a genetic defect in one of the genes that code for the various complement proteins.

No clear environmental or drug-related causes have been identified.