Research Articles

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Inborn errors of human IL-17A/F or IFN-γ immunity are each associated with a specific set of infections. Inborn errors of IL-17A/F underlie chronic mucocutaneous candidiasis (CMC), which is characterized by infections of the skin, nails, oral and genital mucosae with Candida

albicans, typically in the absence of other infections. Five genetic etiologies of CMC have been reported, with mutations in five genes (1, 2). Inborn errors of IFN-γ underlie Mendelian susceptibility to mycobacterial disease (MSMD), which is characterized by selective sus-ceptibility to weakly pathogenic mycobacteria, such as Mycobacterium bovis Bacille Calmette-Guérin vaccines (BCG) and environmental myco-bacteria. Eighteen genetic etiologies of MSMD have been reported, involving mutations of nine genes (3, 4). Only a few patients display both candidiasis and mycobacteriosis, including some patients with IL-12p40 and IL-12Rβ1 deficiencies, which impair IFN-γ immunity in all patients and IL-17A/F immunity in some patients (4). We studied seven patients from three unrelated consanguineous families with this unusual combination of infectious diseases but with no known genetic disorder. A Palestinian child (Fig. 1A, Kindred A, patient P1, and supplementary materials (SM) case reports] died at the age of six years from disseminated BCG disease. Two other children (P2 and P3) in Kindred A had similar clinical presentations but survived and are now 7 and 4 years old, respectively. A 6-year-old Chilean child (Kindred B, P4, SM case reports) had disseminated BCG infection at age 16 months. Finally, three siblings from Saudi Arabia (Kindred C, P5, P6 and P7, SM case reports), aged 9, 6 and 3 years, had mycobacterial diseases, caused by BCG in two children and by M. tuberculosis

in the third. Six of the seven patients also had mucocutaneous candidiasis, of various severities (table S1).

Bi-allelic RORC mutations We combined whole-exome sequencing (WES) and genome-

Impairment of immunity to Candida and Mycobacterium in humans with bi-allelic RORC mutations Satoshi Okada,1,2*# Janet G. Markle,1*# Elissa K. Deenick,3† Federico Mele,4† Dina Averbuch,5† Macarena Lagos,6† Mohammed Alzahrani,7† Saleh Al-Muhsen,7,8,9† Rabih Halwani,8 Cindy S. Ma,3 Natalie Wong,3 Claire Soudais,10 Lauren A. Henderson,11 Hiyam Marzouqa,12 Jamal Shamma,12 Marcela Gonzalez,6 Rubén Martinez-Barricarte,1 Chizuru Okada,1 Danielle T. Avery,3 Daniela Latorre,4 Caroline Deswarte,13,14 Fabienne Jabot-Hanin,13,14 Egidio Torrado,15‡ Jeffrey Fountain,15§ Aziz Belkadi,13,14 Yuval Itan,1 Bertrand Boisson,1 Mélanie Migaud,13,14 Cecilia S. Lindestam Arlehamn,16 Alessandro Sette,16 Sylvain Breton,17 James McCluskey,18 Jamie Rossjohn,19,20, 21 Jean-Pierre de Villartay,22 Despina Moshous,22,23 Sophie Hambleton,24 Sylvain Latour,25 Peter D. Arkwright,26 Capucine Picard,1,13,14,27,28 Olivier Lantz,10 Dan Engelhard,5 Masao Kobayashi,2 Laurent Abel,1,13,14 Andrea M. Cooper,15‖ Luigi D. Notarangelo,11,29‖ Stéphanie Boisson-Dupuis,1,13,14‖ Anne Puel,1,13,14‖ Federica Sallusto,4,30¶ Jacinta Bustamante,1,13,14,28¶ Stuart G. Tangye,3¶ Jean-Laurent Casanova1,13,14,27,31# 1St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY, USA. 2Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan. [continued next page]

#Corresponding author. E-mail: jmarkle@rockefeller.edu (J.G.M.); jean-laurent.casanova@rockefeller.edu (J.-L.C.)

Human inborn errors of immunity mediated by the cytokines interleukin-17A/F (IL-17A/F) underlie mucocutaneous candidiasis, whereas inborn errors of interferon-γ (IFN-γ) immunity underlie mycobacterial disease. We report the discovery of bi-allelic RORC loss-of-function mutations in seven individuals from three kindreds of different ethnic origins with both candidiasis and mycobacteriosis. The lack of functional RORγ and RORγT isoforms resulted in the absence of IL-17A/F-producing T cells in these individuals, probably accounting for their chronic candidiasis. Unexpectedly, leukocytes from RORγ- and RORγT-deficient individuals also displayed an impaired IFN-γ response to Mycobacterium. This principally reflected profoundly defective IFN-γ production by circulating γδ T cells and CD4+CCR6+CXCR3+ αβ T cells. In humans, both mucocutaneous immunity to Candida and systemic immunity to Mycobacterium require RORγ, or RORγT, or both.

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wide linkage (GWL) analysis to search for homozygous ge-netic lesions in the three probands (P1, P4, and P6) (fig. S1). We identified a homozygous C/T mutation in the RORC gene in P1, P2, and P3, resulting in a missense S38L substi-tution in the retinoic acid-related orphan receptors γ (RORγ) isoform, or a S17L substitution in the RORγT iso-form (Fig. 1, A and B, and fig. S2). In P4, we identified a homozygous RORC C/T mutation converting the Q329 resi-due of RORγ (or Q308 in RORγT) into a stop codon (Fig. 1, A and B, and fig. S2). In P5, P6 and P7, we identified a homo-zygous C/T mutation converting the Q441 residue of RORγ (or Q420 in RORγT) into a stop codon (Fig. 1, A and B, and fig. S2). In each kindred, all unaffected family members were either heterozygous or homozygous for the WT allele (Fig. 1A and fig. S2). The familial segregation of these mu-tant RORC alleles was therefore consistent with an autoso-mal recessive (AR) pattern of inheritance. There were no other genes mutated in the three kindreds among the 173 genes on the 6.87 Mb interval linked with disease (maxi-mum LOD score 6.35). The S17L mutation affects a strictly conserved residue of the DNA binding domain (DBD) of RORγT (Fig. 1B) and is predicted to be damaging by multi-ple software algorithms (5). The Q308X and Q420X

nonsense mutations are predicted to result in truncated proteins lack-ing part of the ligand-binding domain (LBD, Fig. 1B). The Q308X and Q420X alleles were not found in the NCBI, En-sembl, ExAC, and dbSNP databases, our own in-house database of over 3,000 exomes, or in 1,052 controls from 52 ethnic groups in the CEPH-HGD panel, indi-cating that they were very rare variants, possi-bly private to these three kindreds. There were no nonsense or frameshift mutations affecting iso-form 2 (RORγT) in these databases. The S17L al-lele was found in one heterozygous individual of the ExAC database, indicating that its fre-quency is less than 10−5. We therefore hypothe-sized that the bi-allelic RORC mutations found in these three kindreds

were disease-causing.

Complete RORγ and RORγT deficiency In mice and humans, the RORγ and RORγT isoforms are generated by transcription from different start sites (6–10) (Fig. 1B). Both molecules are transcription factors, but they have different expression patterns in inbred mice: RORγ is ubiquitous, whereas RORγT is restricted to leukocytes (10). RORγT plays an important role in T-cell development and function in mice (11, 12). Animals lacking only RORγT ap-parently have the same immunological phenotype as those lacking both isoforms (10). We first assessed the impact of RORC mutations by transiently expressing wild-type (WT) and mutant RORγT and RORγ in HEK293T cells in the presence and absence of stimulation with phorbol 12-myristate 13-acetate (PMA) and ionomycin. We detected both the WT and S17L RORγT proteins at the expected mo-lecular mass of 56 kD (Fig. 1C). The Q308X and Q420X RORγT mutant proteins had MW consistent with truncation at residues 308 and 420, respectively (Fig. 1C). Similar re-sults were obtained upon expression of RORγ (fig. S3). We then performed EMSA to assess the ability of the mutant RORγT and RORγ isoforms to respectively bind to RORE-2

3Immunology Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia, and St Vincent’s Clinical School University of New South Wales, Sydney, Australia. 4Institute for Research in Biomedicine, Università della Svizzera Italiana, Bellinzona, Switzerland. 5Department of Pediatrics, Hadassah University Hospital, Jerusalem, Israel. 6Department of Immunology, School of Medicine, Universidad de Valparaíso, and Department of Pediatrics, Padre Hurtado Hospital and Clinica Alemana, Santiago, Chile. 7Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. 8Department of Pediatrics, Prince Naif Center for Immunology Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia. 9Bronchial Asthma Research Chair, Prince Naif Center for Immunology Research, Riyadh, Saudi Arabia. 10Institut Curie, INSERM U932, Paris, France. 11Division of Immunology, Boston Children's Hospital, Boston, MA, USA. 12Caritas Baby Hospital, Post Office Box 11535, Jerusalem, Israel. 13Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM UMR 1163, Imagine Institute, Paris, France, EU. 14Paris Descartes University, Imagine Institute, Paris, France, EU. 15Trudeau Institute, Inc., Saranac Lake, NY, USA. 16La Jolla Institute for Allergy and Immunology, La Jolla, CA, USA. 17Department of Radiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Necker Hospital for Sick Children, Paris, France, EU. 18Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, Victoria, Australia. 19Department of Biochemistry and Molecular Biology, School of Biomedical Sciences, Monash University, Clayton, Victoria, Australia. 20Australian Research Council Centre of Excellence for Advanced Molecular Imaging, Monash University, Clayton, Victoria, Australia. 21Institute of Infection and Immunity, Cardiff University, School of Medicine, Heath Park, Cardiff CF14 4XN, UK. 22INSERM UMR 1163, Laboratoire Dynamique du Génome et Système Immunitaire Université Paris Descartes-Sorbonne Paris Cité, Imagine Institute, Paris, France, EU. 23Pediatric Hematology-Immunology Unit, Assistance Publique-Hôpitaux de Paris (AP-HP), Necker Hospital for Sick Children, Paris, France, EU. 24Institute of Cellular Medicine, Newcastle University and Great North Children’s Hospital, Newcastle upon Tyne, NE4 6BE, UK. 25Laboratory of Lymphocyte Activation and Susceptibility to EBV Infection, INSERM UMR 1163, University Paris Descartes Sorbonne Paris Cité, Imagine Institute, Paris, France, EU. 26University of Manchester, Department of Paediatric Allergy Immunology, Royal Manchester Children's Hospital, Manchester, UK. 27Pediatric Hematology-Immunology Unit, Necker Hospital for Sick Children, Paris, France, EU. 28Center for the Study of Primary Immunodeficiencies, Paris AP-HP, Necker Hospital for Sick Children, Paris, France, EU. 29Manton Center for Orphan Disease Research, Children’s Hospital Boston, MA, USA. 30Center of Medical Immunology, Institute for Research in Biomedicine, University of Italian Switzerland, Switzerland. 31Howard Hughes Medical Institute, New York, USA.

‡Present address: Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.

§Present address: National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Office of Infectious Diseases, Centers for Disease Control and Prevention (CDC/OID/NCHHSTP), Atlanta, GA, USA.

*These authors contributed equally to this work.

†These authors contributed equally to this work.

‖These authors contributed equally to this work.

¶These authors contributed equally to this work.

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and RORE-1, the consensus binding sites in the promoter of IL17A (fig. S3). The three mutations abolished DNA binding of RORγT to RORE-2 (Fig. 1C) and of RORγ to RORE-1 (fig. S3), but not by disrupting the nuclear localization of the protein (fig. S3). Each mutation resulted in the loss of IL17A promoter activation by RORγT (Fig. 1D) or RORγ (fig. S4). Thus, each mutant allele was associated with a complete loss of function of the two encoded protein isoforms, identi-fying these patients as cases of human AR complete RORγ/RORγT deficiency (hereafter referred to as RORγT deficiency).

Broad immunological phenotype Mouse RORγT is expressed in lymphoid tissue inducer (LTi) cells, innate lymphoid cells type 3 (ILC3), type 1 natural kill-er T cells (NKT, also designated iNKT), some γδ T cells, im-mature CD4+CD8+ αβ thymocytes, and IL-17A/F-producing CD4+ αβ T cells [T helper (Th)17 cells] (7, 11, 13–16). LTi, ILC3, type 1 NKT and Th17 cells fail to develop in Rorc–/– mice, and CD4+CD8+ αβ thymocytes have a reduced life span (11, 14, 17). RORC–/– patients displayed clinical signs consistent with LTi deficiency, including absence of palpa-ble axillary and cervical lymph nodes (despite visible ton-sils), and had reduced thymus size (Fig. 2A). Like in Rorc–/– mice, ILC3 were barely detectable in the patients’ blood (fig. S5). In Rorc–/– mice, the short lifespan of CD4+CD8+ αβ thy-mocytes results in an inability to use the most 5′ segments of the T cell receptor Vα array (12), including those encod-ing the Vα chains of mucosal associated invariant T (MAIT) (12) and type I NKT cells (18). High throughput sequencing of the TRA/TRD and TRG loci revealed that 5′ Vα gene segment use was decreased, while Vδ and Vγ usage was normal in RORC–/– T cell clonotypes (fig. S6). Further, these patients lacked TRA clonotypes utilizing 5′ Vα and distal 3′ Jα pairings (fig. S6). In total RORC–/– T cell clonotypes, us-age of Vγ9 was elevated (fig. S6), consistent with antigen-driven peripheral expansion of this subset, perhaps driven by mycobacteria (19). Abolished use of the Vα segments TRAV10 (encoding Vα24) and TRAV1.2 (encoding Vα7.2) was confirmed by qPCR (fig. S7) and resulted in a lack of both CD161+Vα7.2+ MAIT cells and Vα24+Vβ11+ type I NKT cells (Fig. 2, B and C, and fig. S7). Some Vα7.2+ cells other than MAIT cells have been recently shown to recognize Mycobac-terium-derived mycolyl lipids (20); they were also missing in RORC–/– patients. Nevertheless, RORC–/– patients dis-played only mild CD4+ and CD8+ αβ T-cell lymphopenia, with normal B- and NK-cell counts (Fig. 2D and table S2). These patients did not, therefore, have T-cell, or “combined” immunodeficiency (CID), consistent with their lack of broad infectious and autoimmune phenotypes (21). Finally, the frequencies of circulating γδ T cells were normal (Table S2). Overall, these RORC–/– patients displayed the general im-munological features characteristic of Rorc–/– mice (11, 12, 14, 22, 23). These studies also revealed that the development of MAIT and other Vα7.2+ T cells is critically dependent on

RORγT, which had been predicted but not shown in mice. No infectious phenotype can be unambiguously assigned to any of these individual immunological anomalies.

Abolished production of IL-17A/F Given the critical role of murine RORγT in generating IL-17A/F- and IL-22-producing lymphocytes, including ILC3, γδ T cells, and Th17 cells (11, 13, 24), and the finding that pa-tients with compromised IL-17A/F immunity are susceptible to mucocutaneous candidiasis (1) we assessed the develop-ment and function of IL-17A/F-producing lymphocytes in the patients. Circulating ILC3 cells were too few to assess their production of IL-17. CD3+ T cells from RORC–/– pa-tients displayed a severe impairment in the production of IL-17A, IL-17F, and IL-22 both at the mRNA (fig. S8) and at the protein level (Fig. 3A) after polyclonal stimulation. CD4+ αβ T cells are a major source of IL-17A/F (9). Memory (CD45RA–) CD4+ T cells from RORC–/– patients produced much less IL-17A, IL-17F, and IL-22 than WT and heterozy-gous controls (Fig. 3B). In contrast, the memory CD4+ T cells from these patients produced large amounts of IL-4, IL-5, and IL-13 (fig. S8). In separate experiments, naïve (CD45A+CCR7+) CD4+ T cells from RORC–/– patients cultured under Th17-polarizing conditions secreted less IL-17A and IL-17F than cells from healthy donors or heterozygous rela-tives (Fig. 3C). We next assessed the proliferation and cyto-kine secretion of highly purified WT, heterozygous, and RORC–/– CCR6+CD4+ memory αβ T cells (fig. S9), a popula-tion enriched in IL-17A/F-secreting cells (Th17, which ex-press CCR4), as well as cells secreting IL-17A/F and IFN-γ (herein designated as Th1*, which express CXCR3) (25), fol-lowing stimulation with C. albicans lysate. By monitoring the incorporation of a radioactive label, we found that CD4+CCR6+ T cells from RORC–/– patients had normal fre-quencies of antigen-specific cells recognizing C. albicans (Fig. 3D). However, these cells (including both Th17 and Th1*, whose proportions were normal, fig. S9) secreted much less IL-17A and IL-22 than control cells (Fig. 3E). IFN-γ was also reduced, but large amounts of IL-4 were secreted, serving as control (Fig. 3E). Finally, Herpesvirus saimiri-transformed CD4+ αβ T cells from RORC–/– patients showed abolished induction of RORC (Fig. 4A) and IL17A (Fig. 4B), but not IFNG serving as a control (fig. S10). The defect in IL17A induction could be rescued by retroviral transduction with WT RORC (Fig. 4B). Collectively, these data demon-strate a profound diminution of IL-17A/F and IL-22 produc-tion by all leukocytes tested in RORC–/– patients. As CMC-causing germline mutations have previously been identified in IL17F, IL17RA, IL17RC, and ACT1 (1, 2, 26), we conclude that impaired IL-17A/F immunity in RORC–/– patients ac-counts for their development of CMC. Human IL-17A/F-producing ILC3, γδ T cells, and αβ T cells, or any of their subsets, may individually or collectively confer protection against Candida.

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Selective defect in IFN-γ production We then investigated the cellular mechanism underlying the patients’ surprising susceptibility to mycobacteria. The pa-tients did not display chronic granulomatous disease or se-vere combined immunodeficiency, which can underlie BCG disease (4). The CD3+ T cells (including both γδ and αβ T cells) from RORC–/– patients produced IFN-γ normally, fol-lowing the stimulation of whole blood or PBMCs with PMA and ionomycin (fig. S10). Likewise, total CD4+ αβ T cells, memory (CD45RA–) CD4+ T cells, naïve CD4+ T cultured un-der Th1-polarizing conditions, and Herpesvirus saimiri-transformed T cells from the patients, produced IFN-γ nor-mally (fig. S10). Overall, and in contrast to the IL-17A/F de-fect, RORγT deficiency does not impair IFN-γ secretion in conditions of polyclonal stimulation. We next assessed My-cobacterium-specific IFN-γ responses from whole blood (Fig. 5A) or PBMCs (Fig. 5B) of RORC–/– patients, heterozygous family members, and healthy controls. The patients’ cells produced very little IFN-γ in response to BCG plus IL-12 treatment (Fig. 5, A and B). This defect was as profound as that seen in patients with IL-12Rβ1 deficiency (27). The pro-duction of IL-12p40 by RORC–/– cells was normal (fig. S11). Impaired IFN-γ production may account for mycobacterial diseases in RORC–/– patients. This IFN-γ defect was not sec-ondary to excessive IL-4, IL-5, or IL-13 production (fig. S11) or to the IL-17A/F defect (fig. S12). Many single-gene immu-nodeficiencies do not predispose to BCG disease despite im-paired or abolished development or function of various αβ T cell subsets, including CD4+ T cells (28), CD8+ T cells (29), type 1 NKT cells (30, 31), and MAIT cells (31). Even rare pa-tients deficient in total αβ T cell function [ZAP70–/– (32), TRAC–/– (33)] have not been reported to develop BCG dis-ease. Whole blood or PBMCs from such patients responded to BCG plus IL-12 normally, except for patients lacking all functional αβ T cells (fig. S12). As MAIT cells were shown to respond to mycobacteria (34), we purified these cells from WT donor PBMCs and added them to PBMCs from RORC–/– patients before BCG stimulation. The lack of MAIT cells in RORC–/– patients did not account for their impaired IFN-γ production (fig. S13). Overall, the absence of type 1 NKT and MAIT cells, the mild T-cell lymphopenia, and the poor de-velopment of IL-17A/F T cells may contribute marginally to mycobacterial susceptibility, but do not account for the low level of IFN-γ production by RORC–/– leukocytes stimulated with BCG and IL-12, and probably not for the patients’ my-cobacterial disease.

Impaired IFN-γ production by γδ T cells We thus systematically characterized the consequences of leukocyte population depletions on BCG-dependent IFN-γ production by PBMCs in healthy controls. We found no overt IFN-γ defect as a consequence of depleting NK cells, CD14+ cells, CD4+ or CD8+ T cells. Depletion of αβ T cells, γδ T cells, or both resulted in diminished IFN-γ production (fig. S14). To probe the kinetics of this phenotype, a similar ex-

periment was repeated and supernatant was assessed at 6, 12, 18, 24 and 48h post-stimulation (fig. S14). The effect of γδ T cell depletion was most apparent at 24h (fig. S14). We observed high expression of RORC isoform 2 mRNA in both αβ and γδ T cells of healthy donors (fig. S15), prompting further analyses of γδ T cell function. Flow cytometry anal-yses revealed that the TCRhigh γδ T cells from RORC–/– pa-tients could not secrete IFN-γ in response to PMA-ionomycin, unlike TCRlow γδ T cells (fig. S15). TCR Vδ2+ cells have been reported as the predominant cells responding to human BCG vaccination (19). RORC–/– patients had normal frequencies of TCR Vδ2+ cells, but these cells were unable to secrete IFN-γ when stimulated with PMA and ionomycin (fig. S15), suggesting a possible contribution of this γδ T cell subset defect to mycobacterial susceptibility in RORC–/– pa-tients. Overall, RORγT deficiency diminishes the IFN-γ-producing capacity of γδ T cells, which normally produce this cytokine in response to Mycobacterium stimulation.

The patients’ CCR6+CD4+ αβ T cells produce little IFN-γ in re-sponse to BCG Previous studies have demonstrated that the T-bet- and RORγT-expressing, IFN-γ and IL-17A/F-producing CCR6+CXCR3+ Th1* subset is strongly enriched for Mycobac-terium-responsive CD4+ αβ T cells, unlike the CCR6+CCR4+ Th17 cells that only express RORγT and produce IL-17A/F and are enriched for Candida-responsive T cells (25). We therefore purified memory (CD45RA–) αβ T cell subsets (fig. S9), and assessed their proliferation and cytokine produc-tion in response to a pool of BCG peptides. CCR6+CD4+ αβ T cells from RORC–/– patients had a normal or high frequency of antigen-specific cells recognizing BCG peptides, as demonstrated by the induction of proliferation (Fig. 5C and fig. S16). However, although CCR6+CD4+ T cells from RORC–/– patients responded to mycobacterial antigens, they secreted much less IFN-γ than CCR6+CD4+ αβ T cells from normal donors (Fig. 5D). The normal proliferation and cyto-kine production of other CD4+ memory T cell subsets in re-sponse to Candida and Mycobacterium (fig. S17) and to irrelevant viral stimuli (fig. S18) indicate a selective RORγT-dependent functional defect in Mycobacterium-specific CCR6+CD4+ αβ T cells. Although we did not purify and test Th1* cells, they were present in normal proportions in the patients (fig. S9), implying that they are functionally defec-tive for IFN-γ production upon Mycobacterium stimulation. Collectively, these data suggest that mycobacterial diseases in RORC–/– patients may result from the poor production of IFN-γ by γδ T cells, CCR6+CXCR3+CD4+ αβ Th1* cells, or both, in response to mycobacteria. IFN-γ treatment may therefore be beneficial for RORC–/– patients. This combined defect probably also accounts for mycobacterial disease in SCID patients, as patients with various forms of CID are normally resistant to BCG (27, 33). Finally, the lack of MAIT and type 1 NKT cells, reduction in ILC3, and possibly of oth-er lymphocytes not analyzed using blood samples (e.g., LTi),

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may aggravate the mycobacterial phenotype of RORC–/– pa-tients.

Conclusion Collectively, these data demonstrate that human RORC play a surprising dual role in host defense. These findings are clinically, immunologically, and genetically robust, as they were consistent in seven patients, from three ethnic groups, homozygous for three different RORC mutations that are loss-of-function for both isoforms. Interestingly, although the two infectious phenotypes are purely recessive, some immunological phenotypes showed co-dominant or domi-nant inheritance. The mild T-cell lymphopenia, small thy-mus, lack of palpable axillary and cervical lymph nodes, and absence of MAIT and type 1 NKT cells in RORC–/– patients were consistent with the phenotype of Rorc–/– mice (table S3). Likewise, impaired IL-17A/F immunity was predicted to account for impaired protection against Candida albicans (35), as Rorc is the master gene controlling Th17 differentia-tion in inbred mice (11) and mutations affecting human IL-17A/F immunity underlie isolated CMC (1, 26, 36). The IL-17A/F defect therefore underlies CMC in RORγT-deficient patients, probably but not necessarily because of T cells as other cells can normally produce these cytokines. We ex-pected these patients to be susceptible to candidiasis, but their susceptibility to mycobacterial disease, and its severity, were unanticipated. This phenotype does not seem to be human-specific, as we also found that mice deficient for Rorc (14) are susceptible to mycobacterial infection (fig. S19). Our data conclusively demonstrate that human RORC plays an indispensable role in the induction of IFN-γ-dependent anti-mycobacterial systemic immunity. The mechanism underlying disease in these patients probably involves an impairment of the induction of IFN-γ produc-tion by γδ T cells, or CCR6+CXCR3+CD4+ αβ Th1* cells, or both, in response to mycobacteria. Other mechanisms may also be at work. Human RORC is essential not only for the development of IL-17A/F-producing lymphocytes protecting the mucocutaneous barriers against Candida, but also for the activation of IFN-γ-producing T cells, and for systemic protection against Mycobacterium.

REFERENCES AND NOTES 1. A. Puel, S. Cypowyj, J. Bustamante, J. F. Wright, L. Liu, H. K. Lim, M. Migaud, L.

Israel, M. Chrabieh, M. Audry, M. Gumbleton, A. Toulon, C. Bodemer, J. El-Baghdadi, M. Whitters, T. Paradis, J. Brooks, M. Collins, N. M. Wolfman, S. Al-Muhsen, M. Galicchio, L. Abel, C. Picard, J.-L. Casanova, Chronic mucocutaneous candidiasis in humans with inborn errors of interleukin-17 immunity. Science 332, 65–68 (2011). Medline doi:10.1126/science.1200439

2. Y. Ling, S. Cypowyj, C. Aytekin, M. Galicchio, Y. Camcioglu, S. Nepesov, A. Ikinciogullari, F. Dogu, A. Belkadi, R. Levy, M. Migaud, B. Boisson, A. Bolze, Y. Itan, N. Goudin, J. Cottineau, C. Picard, L. Abel, J. Bustamante, J.-L. Casanova, A. Puel, Inherited IL-17RC deficiency in patients with chronic mucocutaneous candidiasis. J. Exp. Med. 212, 619–631 (2015). Medline doi:10.1084/jem.20141065

3. D. Bogunovic, M. Byun, L. A. Durfee, A. Abhyankar, O. Sanal, D. Mansouri, S. Salem, I. Radovanovic, A. V. Grant, P. Adimi, N. Mansouri, S. Okada, V. L. Bryant, X. F. Kong, A. Kreins, M. M. Velez, B. Boisson, S. Khalilzadeh, U. Ozcelik, I. A. Darazam, J. W. Schoggins, C. M. Rice, S. Al-Muhsen, M. Behr, G. Vogt, A. Puel, J.

Bustamante, P. Gros, J. M. Huibregtse, L. Abel, S. Boisson-Dupuis, J.-L. Casanova, Mycobacterial disease and impaired IFN-γ immunity in humans with inherited ISG15 deficiency. Science 337, 1684–1688 (2012). Medline doi:10.1126/science.1224026

4. J. Bustamante, S. Boisson-Dupuis, L. Abel, J.-L. Casanova, Mendelian susceptibility to mycobacterial disease: Genetic, immunological, and clinical features of inborn errors of IFN-γ immunity. Semin. Immunol. 26, 454–470 (2014). Medline doi:10.1016/j.smim.2014.09.008

5. M. Kircher, D. M. Witten, P. Jain, B. J. O’Roak, G. M. Cooper, J. Shendure, A general framework for estimating the relative pathogenicity of human genetic variants. Nat. Genet. 46, 310–315 (2014). Medline doi:10.1038/ng.2892

6. A. Medvedev, A. Chistokhina, T. Hirose, A. M. Jetten, Genomic structure and chromosomal mapping of the nuclear orphan receptor ROR gamma (RORC) gene. Genomics 46, 93–102 (1997). Medline doi:10.1006/geno.1997.4980

7. I. Villey, R. de Chasseval, J. P. de Villartay, RORgammaT, a thymus-specific isoform of the orphan nuclear receptor RORgamma / TOR, is up-regulated by signaling through the pre-T cell receptor and binds to the TEA promoter. Eur. J. Immunol. 29, 4072–4080 (1999). Medline doi:10.1002/(SICI)1521-4141(199912)29:12<4072::AID-IMMU4072>3.0.CO;2-E

8. Y. W. He, M. L. Deftos, E. W. Ojala, M. J. Bevan, RORgamma t, a novel isoform of an orphan receptor, negatively regulates Fas ligand expression and IL-2 production in T cells. Immunity 9, 797–806 (1998). Medline doi:10.1016/S1074-7613(00)80645-7

9. Q. Ruan, V. Kameswaran, Y. Zhang, S. Zheng, J. Sun, J. Wang, J. DeVirgiliis, H. C. Liou, A. A. Beg, Y. H. Chen, The Th17 immune response is controlled by the Rel-RORγ-RORγ T transcriptional axis. J. Exp. Med. 208, 2321–2333 (2011). Medline

10. G. Eberl, D. R. Littman, The role of the nuclear hormone receptor RORγt in the development of lymph nodes and Peyer’s patches. Immunol. Rev. 195, 81–90 (2003). Medline doi:10.1034/j.1600-065X.2003.00074.x

11. I. I. Ivanov, B. S. McKenzie, L. Zhou, C. E. Tadokoro, A. Lepelley, J. J. Lafaille, D. J. Cua, D. R. Littman, The orphan nuclear receptor RORgammat directs the differentiation program of proinflammatory IL-17+ T helper cells. Cell 126, 1121–1133 (2006). Medline

12. J. Guo, A. Hawwari, H. Li, Z. Sun, S. K. Mahanta, D. R. Littman, M. S. Krangel, Y. W. He, Regulation of the TCRalpha repertoire by the survival window of CD4(+)CD8(+) thymocytes. Nat. Immunol. 3, 469–476 (2002). Medline doi:10.1038/ni791

13. X. O. Yang, B. P. Pappu, R. Nurieva, A. Akimzhanov, H. S. Kang, Y. Chung, L. Ma, B. Shah, A. D. Panopoulos, K. S. Schluns, S. S. Watowich, Q. Tian, A. M. Jetten, C. Dong, T helper 17 lineage differentiation is programmed by orphan nuclear receptors ROR alpha and ROR gamma. Immunity 28, 29–39 (2008). Medline doi:10.1016/j.immuni.2007.11.016

14. G. Eberl, S. Marmon, M. J. Sunshine, P. D. Rennert, Y. Choi, D. R. Littman, An essential function for the nuclear receptor RORgamma(t) in the generation of fetal lymphoid tissue inducer cells. Nat. Immunol. 5, 64–73 (2004). Medline doi:10.1038/ni1022

15. C. E. Sutton, S. J. Lalor, C. M. Sweeney, C. F. Brereton, E. C. Lavelle, K. H. Mills, Interleukin-1 and IL-23 induce innate IL-17 production from gammadelta T cells, amplifying Th17 responses and autoimmunity. Immunity 31, 331–341 (2009). Medline doi:10.1016/j.immuni.2009.08.001

16. M. L. Robinette, A. Fuchs, V. S. Cortez, J. S. Lee, Y. Wang, S. K. Durum, S. Gilfillan, M. Colonna, L. Shaw, B. Yu, A. Goldrath, S. Mostafavi, A. Regev, E. Y. Kim, D. F. Dwyer, M. B. Brenner, K. F. Austen, A. Rhoads, D. Moodley, H. Yoshida, D. Mathis, C. Benoist, T. Nabekura, V. Lam, L. L. Lanier, B. Brown, M. Merad, V. Cremasco, S. Turley, P. Monach, M. L. Dustin, Y. Li, S. A. Shinton, R. R. Hardy, T. Shay, Y. Qi, K. Sylvia, J. Kang, K. Fairfax, G. J. Randolph, M. L. Robinette, A. Fuchs, M. Colonna; Immunological Genome Consortium, Transcriptional programs define molecular characteristics of innate lymphoid cell classes and subsets. Nat. Immunol. 16, 306–317 (2015). Medline doi:10.1038/ni.3094

17. M. L. Michel, D. Mendes-da-Cruz, A. C. Keller, M. Lochner, E. Schneider, M. Dy, G. Eberl, M. C. Leite-de-Moraes, Critical role of ROR-γt in a new thymic pathway leading to IL-17-producing invariant NKT cell differentiation. Proc. Natl. Acad. Sci. U.S.A. 105, 19845–19850 (2008). Medline doi:10.1073/pnas.0806472105

18. T. Egawa, G. Eberl, I. Taniuchi, K. Benlagha, F. Geissmann, L. Hennighausen, A. Bendelac, D. R. Littman, Genetic evidence supporting selection of the Valpha14i NKT cell lineage from double-positive thymocyte precursors. Immunity 22, 705–716 (2005). Medline doi:10.1016/j.immuni.2005.03.011

19. D. F. Hoft, R. M. Brown, S. T. Roodman, Bacille Calmette-Guérin vaccination

on January 28, 2021

http://science.sciencemag.org/

Dow

nloaded from

/ sciencemag.org/content/early/recent / 9 July 2015 / Page 6 / 10.1126/ science.aaa4282

enhances human gamma delta T cell responsiveness to mycobacteria suggestive of a memory-like phenotype. J. Immunol. 161, 1045–1054 (1998). Medline

20. I. Van Rhijn, A. Kasmar, A. de Jong, S. Gras, M. Bhati, M. E. Doorenspleet, N. de Vries, D. I. Godfrey, J. D. Altman, W. de Jager, J. Rossjohn, D. B. Moody, A conserved human T cell population targets mycobacterial antigens presented by CD1b. Nat. Immunol. 14, 706–713 (2013). Medline doi:10.1038/ni.2630

21. L. D. Notarangelo, Functional T cell immunodeficiencies (with T cells present). Annu. Rev. Immunol. 31, 195–225 (2013). Medline doi:10.1146/annurev-immunol-032712-095927

22. Z. Sun, D. Unutmaz, Y. R. Zou, M. J. Sunshine, A. Pierani, S. Brenner-Morton, R. E. Mebius, D. R. Littman, Requirement for RORgamma in thymocyte survival and lymphoid organ development. Science 288, 2369–2373 (2000). Medline doi:10.1126/science.288.5475.2369

23. G. Eberl, D. R. Littman, Thymic origin of intestinal alphabeta T cells revealed by fate mapping of RORgammat+ cells. Science 305, 248–251 (2004). Medline doi:10.1126/science.1096472

24. H. Takatori, Y. Kanno, W. T. Watford, C. M. Tato, G. Weiss, I. I. Ivanov, D. R. Littman, J. J. O’Shea, Lymphoid tissue inducer-like cells are an innate source of IL-17 and IL-22. J. Exp. Med. 206, 35–41 (2009). Medline doi:10.1084/jem.20072713

25. E. V. Acosta-Rodriguez, L. Rivino, J. Geginat, D. Jarrossay, M. Gattorno, A. Lanzavecchia, F. Sallusto, G. Napolitani, Surface phenotype and antigenic specificity of human interleukin 17-producing T helper memory cells. Nat. Immunol. 8, 639–646 (2007). Medline doi:10.1038/ni1467

26. B. Boisson, C. Wang, V. Pedergnana, L. Wu, S. Cypowyj, M. Rybojad, A. Belkadi, C. Picard, L. Abel, C. Fieschi, A. Puel, X. Li, J.-L. Casanova, An ACT1 mutation selectively abolishes interleukin-17 responses in humans with chronic mucocutaneous candidiasis. Immunity 39, 676–686 (2013). Medline doi:10.1016/j.immuni.2013.09.002

27. J. Feinberg, C. Fieschi, R. Doffinger, M. Feinberg, T. Leclerc, S. Boisson-Dupuis, C. Picard, J. Bustamante, A. Chapgier, O. Filipe-Santos, C.-L. Ku, L. de Beaucoudrey, J. Reichenbach, G. Antoni, R. Baldé, A. Alcaïs, J.-L. Casanova, Bacillus Calmette Guérin triggers the IL-12/IFN-gamma axis by an IRAK-4- and NEMO-dependent, non-cognate interaction between monocytes, NK, and T lymphocytes. Eur. J. Immunol. 34, 3276–3284 (2004). Medline doi:10.1002/eji.200425221

28. M. Ouederni, Q. B. Vincent, P. Frange, F. Touzot, S. Scerra, M. Bejaoui, A. Bousfiha, Y. Levy, B. Lisowska-Grospierre, D. Canioni, J. Bruneau, M. Debré, S. Blanche, L. Abel, J.-L. Casanova, A. Fischer, C. Picard, Major histocompatibility complex class II expression deficiency caused by a RFXANK founder mutation: A survey of 35 patients. Blood 118, 5108–5118 (2011). Medline doi:10.1182/blood-2011-05-352716

29. O. de la Calle-Martin, M. Hernandez, J. Ordi, N. Casamitjana, J. I. Arostegui, I. Caragol, M. Ferrando, M. Labrador, J. L. Rodriguez-Sanchez, T. Espanol, Familial CD8 deficiency due to a mutation in the CD8 alpha gene. J. Clin. Invest. 108, 117–123 (2001). Medline doi:10.1172/JCI10993

30. B. Pasquier, L. Yin, M. C. Fondanèche, F. Relouzat, C. Bloch-Queyrat, N. Lambert, A. Fischer, G. de Saint-Basile, S. Latour, Defective NKT cell development in mice and humans lacking the adapter SAP, the X-linked lymphoproliferative syndrome gene product. J. Exp. Med. 201, 695–701 (2005). Medline doi:10.1084/jem.20042432

31. E. Martin, N. Palmic, S. Sanquer, C. Lenoir, F. Hauck, C. Mongellaz, S. Fabrega, P. Nitschké, M. D. Esposti, J. Schwartzentruber, N. Taylor, J. Majewski, N. Jabado, R. F. Wynn, C. Picard, A. Fischer, P. D. Arkwright, S. Latour, CTP synthase 1 deficiency in humans reveals its central role in lymphocyte proliferation. Nature 510, 288–292 (2014). Medline doi:10.1038/nature13386

32. A. C. Chan, T. A. Kadlecek, M. E. Elder, A. H. Filipovich, W. L. Kuo, M. Iwashima, T. G. Parslow, A. Weiss, ZAP-70 deficiency in an autosomal recessive form of severe combined immunodeficiency. Science 264, 1599–1601 (1994). Medline doi:10.1126/science.8202713

33. N. V. Morgan, S. Goddard, T. S. Cardno, D. McDonald, F. Rahman, D. Barge, A. Ciupek, A. Straatman-Iwanowska, S. Pasha, M. Guckian, G. Anderson, A. Huissoon, A. Cant, W. P. Tate, S. Hambleton, E. R. Maher, Mutation in the TCRα subunit constant gene (TRAC) leads to a human immunodeficiency disorder characterized by a lack of TCRαβ+ T cells. J. Clin. Invest. 121, 695–702 (2011). Medline doi:10.1172/JCI41931

34. L. Le Bourhis, E. Martin, I. Péguillet, A. Guihot, N. Froux, M. Coré, E. Lévy, M. Dusseaux, V. Meyssonnier, V. Premel, C. Ngo, B. Riteau, L. Duban, D. Robert, S.

Huang, M. Rottman, C. Soudais, O. Lantz, Antimicrobial activity of mucosal-associated invariant T cells. Nat. Immunol. 11, 701–708 (2010). Medline doi:10.1038/ni.1890

35. H. R. Conti, F. Shen, N. Nayyar, E. Stocum, J. N. Sun, M. J. Lindemann, A. W. Ho, J. H. Hai, J. J. Yu, J. W. Jung, S. G. Filler, P. Masso-Welch, M. Edgerton, S. L. Gaffen, Th17 cells and IL-17 receptor signaling are essential for mucosal host defense against oral candidiasis. J. Exp. Med. 206, 299–311 (2009). Medline doi:10.1084/jem.20081463

36. L. Liu, S. Okada, X.-F. Kong, A. Y. Kreins, S. Cypowyj, A. Abhyankar, J. Toubiana, Y. Itan, M. Audry, P. Nitschke, C. Masson, B. Toth, J. Flatot, M. Migaud, M. Chrabieh, T. Kochetkov, A. Bolze, A. Borghesi, A. Toulon, J. Hiller, S. Eyerich, K. Eyerich, V. Gulácsy, L. Chernyshova, V. Chernyshov, A. Bondarenko, R. M. Cortés Grimaldo, L. Blancas-Galicia, I. M. Madrigal Beas, J. Roesler, K. Magdorf, D. Engelhard, C. Thumerelle, P.-R. Burgel, M. Hoernes, B. Drexel, R. Seger, T. Kusuma, A. F. Jansson, J. Sawalle-Belohradsky, B. Belohradsky, E. Jouanguy, J. Bustamante, M. Bué, N. Karin, G. Wildbaum, C. Bodemer, O. Lortholary, A. Fischer, S. Blanche, S. Al-Muhsen, J. Reichenbach, M. Kobayashi, F. E. Rosales, C. T. Lozano, S. S. Kilic, M. Oleastro, A. Etzioni, C. Traidl-Hoffmann, E. D. Renner, L. Abel, C. Picard, L. Maródi, S. Boisson-Dupuis, A. Puel, J.-L. Casanova, Gain-of-function human STAT1 mutations impair IL-17 immunity and underlie chronic mucocutaneous candidiasis. J. Exp. Med. 208, 1635–1648 (2011). Medline doi:10.1084/jem.20110958

37. Materials and methods are available as supplementary materials on Science Online.

38. A. V. Grant, S. Boisson-Dupuis, E. Herquelot, L. de Beaucoudrey, O. Filipe-Santos, D. K. Nolan, J. Feinberg, A. Boland, S. Al-Muhsen, O. Sanal, Y. Camcioglu, A. Palanduz, S. S. Kilic, J. Bustamante, J.-L. Casanova, L. Abel, Accounting for genetic heterogeneity in homozygosity mapping: Application to Mendelian susceptibility to mycobacterial disease. J. Med. Genet. 48, 567–571 (2011). Medline doi:10.1136/jmg.2011.089128

39. S. Purcell, B. Neale, K. Todd-Brown, L. Thomas, M. A. Ferreira, D. Bender, J. Maller, P. Sklar, P. I. de Bakker, M. J. Daly, P. C. Sham, PLINK: A tool set for whole-genome association and population-based linkage analyses. Am. J. Hum. Genet. 81, 559–575 (2007). Medline doi:10.1086/519795

40. G. R. Abecasis, S. S. Cherny, W. O. Cookson, L. R. Cardon, Merlin—rapid analysis of dense genetic maps using sparse gene flow trees. Nat. Genet. 30, 97–101 (2002). Medline doi:10.1038/ng786

41. M. Byun, A. Abhyankar, V. Lelarge, S. Plancoulaine, A. Palanduz, L. Telhan, B. Boisson, C. Picard, S. Dewell, C. Zhao, E. Jouanguy, S. Feske, L. Abel, J.-L. Casanova, Whole-exome sequencing-based discovery of STIM1 deficiency in a child with fatal classic Kaposi sarcoma. J. Exp. Med. 207, 2307–2312 (2010). Medline doi:10.1084/jem.20101597

42. H. Li, R. Durbin, Fast and accurate short read alignment with Burrows-Wheeler transform. Bioinformatics 25, 1754–1760 (2009). Medline doi:10.1093/bioinformatics/btp324

43. A. McKenna, M. Hanna, E. Banks, A. Sivachenko, K. Cibulskis, A. Kernytsky, K. Garimella, D. Altshuler, S. Gabriel, M. Daly, M. A. DePristo, The Genome Analysis Toolkit: A MapReduce framework for analyzing next-generation DNA sequencing data. Genome Res. 20, 1297–1303 (2010). Medline doi:10.1101/gr.107524.110

44. H. Li, B. Handsaker, A. Wysoker, T. Fennell, J. Ruan, N. Homer, G. Marth, G. Abecasis, R. Durbin; 1000 Genome Project Data Processing Subgroup, The Sequence Alignment/Map format and SAMtools. Bioinformatics 25, 2078–2079 (2009). Medline doi:10.1093/bioinformatics/btp352

45. K. Wang, M. Li, H. Hakonarson, ANNOVAR: Functional annotation of genetic variants from high-throughput sequencing data. Nucleic Acids Res. 38, e164 (2010). Medline doi:10.1093/nar/gkq603

46. S. Dupuis, E. Jouanguy, S. Al-Hajjar, C. Fieschi, I. Z. Al-Mohsen, S. Al-Jumaah, K. Yang, A. Chapgier, C. Eidenschenk, P. Eid, A. Al Ghonaium, H. Tufenkeji, H. Frayha, S. Al-Gazlan, H. Al-Rayes, R. D. Schreiber, I. Gresser, J.-L. Casanova, Impaired response to interferon-alpha/beta and lethal viral disease in human STAT1 deficiency. Nat. Genet. 33, 388–391 (2003). Medline doi:10.1038/ng1097

47. M. Tsumura, S. Okada, H. Sakai, S. Yasunaga, M. Ohtsubo, T. Murata, H. Obata, T. Yasumi, X. F. Kong, A. Abhyankar, T. Heike, T. Nakahata, R. Nishikomori, S. Al-Muhsen, S. Boisson-Dupuis, J.-L. Casanova, M. Alzahrani, M. A. Shehri, G. Elghazali, Y. Takihara, M. Kobayashi, Dominant-negative STAT1 SH2 domain mutations in unrelated patients with Mendelian susceptibility to mycobacterial disease. Hum. Mutat. 33, 1377–1387 (2012). Medline doi:10.1002/humu.22113

48. K. Ichiyama, H. Yoshida, Y. Wakabayashi, T. Chinen, K. Saeki, M. Nakaya, G.

on January 28, 2021

http://science.sciencemag.org/

Dow

nloaded from

/ sciencemag.org/content/early/recent / 9 July 2015 / Page 7 / 10.1126/ science.aaa4282

Takaesu, S. Hori, A. Yoshimura, T. Kobayashi, Foxp3 inhibits RORgammat-mediated IL-17A mRNA transcription through direct interaction with RORgammat. J. Biol. Chem. 283, 17003–17008 (2008). Medline doi:10.1074/jbc.M801286200

49. T. Rauen, Y. T. Juang, C. M. Hedrich, K. Kis-Toth, G. C. Tsokos, A novel isoform of the orphan receptor RORγt suppresses IL-17 production in human T cells. Genes Immun. 13, 346–350 (2012). Medline doi:10.1038/gene.2011.85

50. H. S. Robins, P. V. Campregher, S. K. Srivastava, A. Wacher, C. J. Turtle, O. Kahsai, S. R. Riddell, E. H. Warren, C. S. Carlson, Comprehensive assessment of T-cell receptor beta-chain diversity in alphabeta T cells. Blood 114, 4099–4107 (2009). Medline doi:10.1182/blood-2009-04-217604

51. A. M. Sherwood, C. Desmarais, R. J. Livingston, J. Andriesen, M. Haussler, C. S. Carlson, H. Robins, Deep sequencing of the human TCRγ and TCRβ repertoires suggests that TCRβ rearranges after αβ and γδ T cell commitment. Sci. Transl. Med. 3, 90ra61 (2011). Medline doi:10.1126/scitranslmed.3002536

52. H. Robins, C. Desmarais, J. Matthis, R. Livingston, J. Andriesen, H. Reijonen, C. Carlson, G. Nepom, C. Yee, K. Cerosaletti, Ultra-sensitive detection of rare T cell clones. J. Immunol. Methods 375, 14–19 (2012). Medline doi:10.1016/j.jim.2011.09.001

53. C. S. Carlson, R. O. Emerson, A. M. Sherwood, C. Desmarais, M. W. Chung, J. M. Parsons, M. S. Steen, M. A. LaMadrid-Herrmannsfeldt, D. W. Williamson, R. J. Livingston, D. Wu, B. L. Wood, M. J. Rieder, H. Robins, Using synthetic templates to design an unbiased multiplex PCR assay. Nat. Commun. 4, 2680 (2013). Medline doi:10.1038/ncomms3680

54. C. S. Ma, D. T. Avery, A. Chan, M. Batten, J. Bustamante, S. Boisson-Dupuis, P. D. Arkwright, A. Y. Kreins, D. Averbuch, D. Engelhard, K. Magdorf, S. S. Kilic, Y. Minegishi, S. Nonoyama, M. A. French, S. Choo, J. M. Smart, J. Peake, M. Wong, P. Gray, M. C. Cook, D. A. Fulcher, J.-L. Casanova, E. K. Deenick, S. G. Tangye, Functional STAT3 deficiency compromises the generation of human T follicular helper cells. Blood 119, 3997–4008 (2012). Medline doi:10.1182/blood-2011-11-392985

55. B. Biesinger, I. Müller-Fleckenstein, B. Simmer, G. Lang, S. Wittmann, E. Platzer, R. C. Desrosiers, B. Fleckenstein, Stable growth transformation of human T lymphocytes by herpesvirus saimiri. Proc. Natl. Acad. Sci. U.S.A. 89, 3116–3119 (1992). Medline doi:10.1073/pnas.89.7.3116

56. L. Ruggieri, A. Aiuti, M. Salomoni, E. Zappone, G. Ferrari, C. Bordignon, Cell-surface marking of CD(34+)-restricted phenotypes of human hematopoietic progenitor cells by retrovirus-mediated gene transfer. Hum. Gene Ther. 8, 1611–1623 (1997). Medline doi:10.1089/hum.1997.8.13-1611

57. E. van de Vosse, E. M. Verhard, R. A. de Paus, G. J. Platenburg, J. C. van Deutekom, A. Aartsma-Rus, J. T. van Dissel, Antisense-mediated exon skipping to correct IL-12Rbeta1 deficiency in T cells. Blood 113, 4548–4555 (2009). Medline doi:10.1182/blood-2008-12-196220

58. R. Geiger, T. Duhen, A. Lanzavecchia, F. Sallusto, Human naive and memory CD4+ T cell repertoires specific for naturally processed antigens analyzed using libraries of amplified T cells. J. Exp. Med. 206, 1525–1534 (2009). Medline doi:10.1084/jem.20090504

59. A. Roberts, A. Cooper, J. Belisle, J. Turner, M. Gonzalez-Juarerro, I. Orme, Methods in Microbiology, D. K. S. Kaufmann, Ed. (Academic Press, London, 2002).

60. L. Kjer-Nielsen, O. Patel, A. J. Corbett, J. Le Nours, B. Meehan, L. Liu, M. Bhati, Z. Chen, L. Kostenko, R. Reantragoon, N. A. Williamson, A. W. Purcell, N. L. Dudek, M. J. McConville, R. A. O’Hair, G. N. Khairallah, D. I. Godfrey, D. P. Fairlie, J. Rossjohn, J. McCluskey, MR1 presents microbial vitamin B metabolites to MAIT cells. Nature 491, 717–723 (2012). Medline

61. A. J. Corbett, S. B. Eckle, R. W. Birkinshaw, L. Liu, O. Patel, J. Mahony, Z. Chen, R. Reantragoon, B. Meehan, H. Cao, N. A. Williamson, R. A. Strugnell, D. Van Sinderen, J. Y. Mak, D. P. Fairlie, L. Kjer-Nielsen, J. Rossjohn, J. McCluskey, T-cell activation by transitory neo-antigens derived from distinct microbial pathways. Nature 509, 361–365 (2014). Medline doi:10.1038/nature13160

62. R. Reantragoon, A. J. Corbett, I. G. Sakala, N. A. Gherardin, J. B. Furness, Z. Chen, S. B. Eckle, A. P. Uldrich, R. W. Birkinshaw, O. Patel, L. Kostenko, B. Meehan, K. Kedzierska, L. Liu, D. P. Fairlie, T. H. Hansen, D. I. Godfrey, J. Rossjohn, J. McCluskey, L. Kjer-Nielsen, Antigen-loaded MR1 tetramers define T cell receptor heterogeneity in mucosal-associated invariant T cells. J. Exp. Med. 210, 2305–2320 (2013). Medline doi:10.1084/jem.20130958

63. M. O. Chandesris, I. Melki, A. Natividad, A. Puel, C. Fieschi, L. Yun, C. Thumerelle, E. Oksenhendler, D. Boutboul, C. Thomas, C. Hoarau, Y. Lebranchu, J. L.

Stephan, C. Cazorla, N. Aladjidi, M. Micheau, F. Tron, A. Baruchel, V. Barlogis, G. Palenzuela, C. Mathey, S. Dominique, G. Body, M. Munzer, F. Fouyssac, R. Jaussaud, B. Bader-Meunier, N. Mahlaoui, S. Blanche, M. Debré, M. Le Bourgeois, V. Gandemer, N. Lambert, V. Grandin, S. Ndaga, C. Jacques, C. Harre, M. Forveille, M. A. Alyanakian, A. Durandy, C. Bodemer, F. Suarez, O. Hermine, O. Lortholary, J.-L. Casanova, A. Fischer, C. Picard, Autosomal dominant STAT3 deficiency and hyper-IgE syndrome: Molecular, cellular, and clinical features from a French national survey. Medicine (Baltimore) 91, e1–e19 (2012). Medline doi:10.1097/MD.0b013e31825f95b9

64. S. Rigaud, M. C. Fondanèche, N. Lambert, B. Pasquier, V. Mateo, P. Soulas, L. Galicier, F. Le Deist, F. Rieux-Laucat, P. Revy, A. Fischer, G. de Saint Basile, S. Latour, XIAP deficiency in humans causes an X-linked lymphoproliferative syndrome. Nature 444, 110–114 (2006). Medline doi:10.1038/nature05257

65. A. J. Coffey, R. A. Brooksbank, O. Brandau, T. Oohashi, G. R. Howell, J. M. Bye, A. P. Cahn, J. Durham, P. Heath, P. Wray, R. Pavitt, J. Wilkinson, M. Leversha, E. Huckle, C. J. Shaw-Smith, A. Dunham, S. Rhodes, V. Schuster, G. Porta, L. Yin, P. Serafini, B. Sylla, M. Zollo, B. Franco, A. Bolino, M. Seri, A. Lanyi, J. R. Davis, D. Webster, A. Harris, G. Lenoir, G. de St Basile, A. Jones, B. H. Behloradsky, H. Achatz, J. Murken, R. Fassler, J. Sumegi, G. Romeo, M. Vaudin, M. T. Ross, A. Meindl, D. R. Bentley, Host response to EBV infection in X-linked lymphoproliferative disease results from mutations in an SH2-domain encoding gene. Nat. Genet. 20, 129–135 (1998). Medline doi:10.1038/2424

66. F. Sallusto, D. Lenig, C. R. Mackay, A. Lanzavecchia, Flexible programs of chemokine receptor expression on human polarized T helper 1 and 2 lymphocytes. J. Exp. Med. 187, 875–883 (1998). Medline doi:10.1084/jem.187.6.875

67. S. Kurebayashi, E. Ueda, M. Sakaue, D. D. Patel, A. Medvedev, F. Zhang, A. M. Jetten, Retinoid-related orphan receptor gamma (RORgamma) is essential for lymphoid organogenesis and controls apoptosis during thymopoiesis. Proc. Natl. Acad. Sci. U.S.A. 97, 10132–10137 (2000). Medline doi:10.1073/pnas.97.18.10132

ACKNOWLEDGMENTS

We would like to thank the patients and their families for their collaboration, and both branches of the Laboratory of Human Genetics of Infectious Diseases for helpful discussions and support. We thank G. C. Tsokos for providing the IL17A reporter luciferase plasmid, E. Van de Vosse for providing the pLZRS-IRES-ΔNGFR vector, and D. Littman for helpful discussions. We thank B. Fleckenstein and M. Schmidt for the generation of patient-derived T cell lines. We also thank Y. Nemirovskaya, L. Amar, E. Anderson, M. Courat, and T. Nivare for administrative support. The data presented in the manuscript are tabulated in the main paper and in the supplementary materials. The sequence data are available at Sequence Read Archive (SRA) website (http://www.ncbi.nlm.nih.gov/sra) with following accession numbers (SRS964935, SRS965039, SRS965040, and SRS965042). J.M. and The University of Melbourne filed Australian Provisional Patent Application nos. 2014901185 and 2014901 that relate to ligands that bind MR1 and stimulate MAIT cells. The Laboratory of Human Genetics of Infectious Diseases is supported by grants from the National Center for Research Resources and the National Center for Advancing Sciences (NCATS), NIH; (8UL1TR000043), the French National Research Agency (ANR) under the “Investments for the future” program (grant ANR-10-IAHU-01); grant IFNGPHOX (13-ISV3-0001-01 to J.B.), and grant GENCMCD (11-BSV3-005-01 to A.P), Laboratoire d’Excellence Integrative Biology of Emerging Infectious Diseases (ANR-10-LABX-62-IBEID), the National Health and Medical Research Council (NHMRC) (to E.K.D., C.S.M., S.G.T, and J.M.), the Rockefeller University, INSERM, Paris Descartes University, the St. Giles Foundation, the National Institute of Allergy and Infectious Diseases (R37AI095983 to J.L.C.), and the NIH (Contract HHSN272200900044C to A.S.). S.O. was supported by Grants in Aid for Scientific Research from the Japan Society for the Promotion of Science (25713039 and 25670477), J.M. by the Canadian Institutes of Health Research (CIHR), R.M.B. by the European Molecular Biology Organization (EMBO), and Y.I. by the AXA Research Fund, and L.A.H. by the Rheumatology Research Foundation's Scientist Development Award. Research by F.S. is supported by grants from the ERC (ERC-2012-ADG-2012314 to F.S.) and the Swiss National Science Foundation (149475). The Institute for Research in Biomedicine and the Center of Medical Immunology are supported by the Helmut Horten Foundation.

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SUPPLEMENTARY MATERIALS www.sciencemag.org/cgi/content/full/science.aaa4282/DC1 Materials and Methods Supplementary Text Figs. S1 to S19 Tables S1 to S3 References (38–67) 7 December 2014; accepted 29 June 2015 Published online 9 July 2015 10.1126/science.aaa4282

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Fig. 1. Identification of homozygous loss-of-function mutations affecting the human RORγT protein. (A) Sanger sequencing results and familial segregation of previously unidentified homozygous RORC mutations in three unrelated consanguineous families, indicating an autosomal recessive pattern of inheritance, with complete clinical penetrance. (B) Graphical representation of the RORγ and RORγT proteins, encoded by RORC isoforms 1 and 2, respectively. AF2, activation function 2 domain. Red arrows indicate the location of the sites affected by the RORC mutations found in the families. (C) HEK293T cells were either mock-transfected or transfected with the indicated plasmids. After 24 hours, cells were either left untreated or were stimulated with PMA and ionomycin. Whole-cell lysates were obtained and subjected to Western blotting (lower panel), and nuclear lysates were subjected to EMSA with a 32P-labeled RORE-2 probe derived from the IL17A promoter sequence (upper panel). (D) IL17A reporter plasmids, the pRL-SV40 vector and WT or mutant RORC plasmid were used to transfect HEK293T cells. After 24 hours, cells were stimulated with PMA and ionomycin as in (C), then subjected to luciferase assays. Experiments were performed in triplicate, and IL17A promoter activity is expressed as fold-induction relative to mock-transfected cells.*P < 0.05 versus WT controls, in two-tailed Mann-Whitney tests.

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Fig. 2. RORC–/– patients display abnormal thymus size and TCRα rearrangement, in line with their mild T-cell lymphopenia with a complete absence of MAIT and type 1 NKT cells. (A) Chest CT scan of P4 at the age of 16 months, revealing right lung infiltrate and thymic hypoplasia. (B and C) PBMCs from WT, heterozygous family members or from RORC–/– patients were analyzed for MAIT (B) and type 1 NKT (C) cell frequencies by flow cytometry. Each plot is representative of n = 3 experiments. (D) Cell counts were performed on fresh blood samples from heterozygous family members (n = 4) and RORC–/– patients (n = 3). Dotted lines indicate the normal ranges for each lymphocyte population per μL of blood, based on the results for healthy individuals tested at the Necker Hospital for Sick Children, Paris, France.

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Fig. 3. Cellular mechanisms of compromised IL-17 immunity and CMC in RORC–/– patients. (A) Whole blood from healthy WT donors, heterozygous family members, or RORC–/– patients was activated by PMA and ionomycin in the presence of brefeldin A, then assessed by intracellular flow cytometry for the production of IL-17A and IL-22. (B) Naïve and memory CD4+ T cells from WT controls (n = 7), heterozygous family members (n = 2) and RORC–/– patients (n = 3) were cultured with T-cell activation and expansion (TAE) beads, and the culture supernatants were then assessed for secretion of the cytokine indicated (37). (C) Cytokine production by in vitro-differentiated CD4+ T cells from control donors and RORC–/– patients. Naïve (CD45RA+CCR7+) CD4+ T cells were purified from the PBMCs of WT controls (n = 6) or RORC–/– patients (n = 3), then cultured in the presence of TAE beads alone or TAE beads together with polarizing stimuli to induce the differentiation of Th1- or Th17-type cells (37). After 5 days, culture supernatants were assessed for the secretion of the cytokine indicated. (D) Sorted CCR6+ memory CD4+ T cells from WT controls, heterozygous family members and RORC–/– patients were initially polyclonally stimulated to generate T-cell libraries, then cultured with autologous irradiated B cells, with or without a 3-hour pulse with C. albicans lysate (CA, 5 μg/mL) (37). Proliferation was assessed by evaluating radiolabel incorporation on day 4, and is expressed as Δcpm values (37). Dotted lines represent the cutoff values. The frequencies of specific T cells using the Poisson distribution were 315/106, 631/106, 874/106 in WT, heterozygous family and RORC–/– patient, respectively. (E) Concentration of the indicated cytokines were measured in the supernatants from positive cultures (Δcpm values above the cut-off value) from experiments performed as in (D) with cells from WT controls, heterozygous family members, and RORC–/– patients (n = 2 each) The number of wells included was n = 45-64 for WT controls n = 4-10 for heterozygous family members and n = 14-23 for RORC–/– patients *P < 0 05

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Fig. 4. T cell lines from RORC–/– patients fail to induce IL17A after mitogen stimulation. (A) Herpesvirus saimiri-transformed T cells from healthy donors (C1, C2, C3) or RORC–/– patients (P2, P4) were cultured in the presence (+) or absence (–) of PMA and ionomycin and then total RNA was extracted and used for qRT-PCR for total RORC. T cell lines from RORC–/– patients were transduced with retrovirus encoding either a tag only (empty vector), or tagged WT RORC isoform 2. (B) IL17A expression was assessed in the same RNA samples presented in (A). n = 3, error bars represent SEM.

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Fig. 5 Cellular mechanisms of impaired IFN-γ immunity to Mycobacterium in RORC–/– patients. (A) Whole-blood samples from healthy controls (n = 23), heterozygous family members (n = 4), or RORC–/– patients (n = 4) were incubated for 48 hours under three different sets of activation conditions: medium alone, live Mycobacterium bovis-BCG (BCG) at a MOI of 20 BCG cells/leukocyte, and with BCG plus 20 ng/ml IL-12. The IFN-γ levels of culture supernatants were determined by ELISA. (B) Equal numbers of live PBMCs from healthy controls, WT family members, heterozygous family members, or RORC–/– patients were cultured in the presence of live BCG, BCG and IL-12, or PMA/ionomycin for 48 hours. IFN-γ concentration in the culture supernatant was assessed by ELISA. (C) Sorted CCR6+ memory CD4+ T cells were polyclonally stimulated with PHA in the presence of irradiated allogeneic feeder cells and IL-2, to generate T-cell libraries, as in Fig. 3D. Library screening was performed 14-21 days after initial stimulation, by culturing thoroughly washed T cells with autologous irradiated B cells, with or without a three-hour pulse with Mycobacterium bovis-BCG peptide pools. Proliferation was measured by radiolabel incorporation on day 4, and is expressed as Δcpm values. Each symbol illustrates one culture. Dotted lines represent the cutoff value. The frequencies of specific T cells calculated using the Poisson distribution were 467/106, 749/106, 875/106 in WT, Het. family and RORC–/– patient, respectively. (D) The cytokines indicated were determined in the culture supernatants from (C), for wells with Δcpm values above the cutoff value. The number of wells included was n = 45-64 for WT controls, n = 4-10 for heterozygous family members, and n = 14-23 for RORC–/– patients. *P < 0.05 versus WT controls, in two-tailed Mann-Whitney tests.

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mutationsRORC in humans with bi-allelic Mycobacterium and CandidaImpairment of immunity to

Stuart G. Tangye and Jean-Laurent CasanovaAbel, Andrea M. Cooper, Luigi D. Notarangelo, Stéphanie Boisson-Dupuis, Anne Puel, Federica Sallusto, Jacinta Bustamante,Sophie Hambleton, Sylvain Latour, Peter D. Arkwright, Capucine Picard, Olivier Lantz, Dan Engelhard, Masao Kobayashi, Laurent Arlehamn, Alessandro Sette, Sylvain Breton, James McCluskey, Jamie Rossjohn, Jean-Pierre de Villartay, Despina Moshous,Jabot-Hanin, Egidio Torrado, Jeffrey Fountain, Aziz Belkadi, Yuval Itan, Bertrand Boisson, Mélanie Migaud, Cecilia S. Lindestam Marcela Gonzalez, Rubén Martinez-Barricarte, Chizuru Okada, Danielle T. Avery, Daniela Latorre, Caroline Deswarte, FabienneAl-Muhsen, Rabih Halwani, Cindy S. Ma, Natalie Wong, Claire Soudais, Lauren A. Henderson, Hiyam Marzouqa, Jamal Shamma, Satoshi Okada, Janet G. Markle, Elissa K. Deenick, Federico Mele, Dina Averbuch, Macarena Lagos, Mohammed Alzahrani, Saleh

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