Inhibition of lysosomal degradation increases expression of mutant ADA2 in DADA2 monocytes.

Background: Deficiency of adenosine deaminase 2 (DADA2) is an inborn error of immunity causing vasculitis and bone marrow failure. Bone marrow failure is mostly unresponsive to TNF-α inhibitors. The limited understanding of the pathomechanisms driving the disease impedes the development of new treatment options. Unlike cellular model systems expressing pathogenic ADA2 variants, primary monocytes from patients with DADA2 lack ADA2 protein expression.

Objectives: This study aimed to analyze the role of protein degradation in the pathogenesis of DADA2 and the therapeutic potential of the lysosomotropic drug hydroxychloroquine in the treatment of patients with DADA2.

Methods: ADA2 protein expression in CD14 monocytes from healthy controls (n = 8) and patients with DADA2 (n = 11) was determined by Western blot after inhibition of lysosomal and proteasomal degradation, as well as after hydroxychloroquine treatment in vivo in 1 patient with DADA2. Lipidation of microtubule associated protein 1 light chain 3 beta (LC3B) was analyzed as a measure of autophagic activity. Clinical and laboratory data were recorded in cytopenic patients with DADA2 treated with hydroxychloroquine, 200 mg per day.

Results: We demonstrated that inhibition of lysosomal degradation restores ADA2 protein expression in DADA2 monocytes in vitro. DADA2 monocytes exhibited increased autophagic activity. We observed clinical improvement in 2 cytopenic patients with DADA2 who were treated with hydroxychloroquine, and we showed a concomitant increase in ADA2 protein levels in monocytes from one of these patients in vivo.

Conclusion: We identified lysosomal protein degradation of ADA2 as a pathomechanism of DADA2 and introduced hydroxychloroquine as a potential treatment option in patients with DADA2 with refractory cytopenia.