case_images: PMC9043559_01
case_images: PMC9043559_02
case_images: Clinical data. (A) Levels of leukocytes and neutrophils of the patient since birth. "a" and "d": normal stage; "b", "c" and "e": stage of infection or immune reaction. (B) A bone marrow (BM) smear stained with Wright-Giemsa (x1000) shows a hypercellular BM with mild granulocytic hyperplasia (myeloid: erythroid, 3.19:1) and plentiful granulocytic cells with right-shifted maturation, which is not consistent with peripheral neutropenia. Some neutrophils have coarse granules ( ), cytoplasmic vacuoles ( ), and multi-lobed nuclei ( ). (C) Pedigree of the family. (D) Diagnosis of incomplete KD. Patient clinical features or laboratory tests highlighted in red showed the process of our clinical decision making. Due to WHIM syndrome, laboratory tests highlighted in green are controversial issues in the diagnosis of KD. (
  *
  ) In the absence of a "gold standard" for diagnosis, this algorithm cannot be evidence based but rather represents the informed opinion of the expert committee. Consultation with an expert should be sought any time assistance is needed. (
  **
  ) Patients who lack full clinical features of classic KD are often evaluated for incomplete KD. If coronary artery abnormalities are detected, the diagnosis of KD is considered confirmed in most cases.
case_images: fimmu-13-857527-g002.jpg
case_images: PMC9043559_03_fimmu-13-857527-g002.jpg
case_images: f2
case_images: Surprisingly, his white blood cell and neutrophil levels could return to normal when he developed infection or inflammation ( Figure 2A ). Using the same method, we failed to find this variation in the other family members ( Figure 2C ).
case_images: PMC9043559_03
case_images: Clinical data. (A) Levels of leukocytes and neutrophils of the patient since birth. "a" and "d": normal stage; "b", "c" and "e": stage of infection or immune reaction. (B) A bone marrow (BM) smear stained with Wright-Giemsa (x1000) shows a hypercellular BM with mild granulocytic hyperplasia (myeloid: erythroid, 3.19:1) and plentiful granulocytic cells with right-shifted maturation, which is not consistent with peripheral neutropenia. Some neutrophils have coarse granules ( ), cytoplasmic vacuoles ( ), and multi-lobed nuclei ( ). (C) Pedigree of the family. (D) Diagnosis of incomplete KD. Patient clinical features or laboratory tests highlighted in red showed the process of our clinical decision making. Due to WHIM syndrome, laboratory tests highlighted in green are controversial issues in the diagnosis of KD. (
  *
  ) In the absence of a "gold standard" for diagnosis, this algorithm cannot be evidence based but rather represents the informed opinion of the expert committee. Consultation with an expert should be sought any time assistance is needed. (
  **
  ) Patients who lack full clinical features of classic KD are often evaluated for incomplete KD. If coronary artery abnormalities are detected, the diagnosis of KD is considered confirmed in most cases.
case_images: fimmu-13-857527-g002.jpg
case_images: PMC9043559_03_fimmu-13-857527-g002.jpg
case_images: f2
case_images: Surprisingly, his white blood cell and neutrophil levels could return to normal when he developed infection or inflammation ( Figure 2A ). Using the same method, we failed to find this variation in the other family members ( Figure 2C ).
case_images: Genetic analysis and illustration of the heterozygous c.1032_1033delTG mutation of CXCR4 gene. (A) Sanger sequencing of CXCR4 cDNA from the patient and his family, showing TG deletion from exon2(c.1032_1033del)in the proband and his father. The red arrow indicates the variant site of exon2. (B) Base deletion (exon2; NM_003467; c.1032_1033delTG) results in original stop-codon loss, frameshift, and prolonged protein.
case_images: fimmu-13-857527-g003.jpg
case_images: PMC9043559_03_fimmu-13-857527-g003.jpg
case_images: f3
case_images: E345Vfs*12), which may make the function of CXCR4 protein changed (PVS1_PM4,  Figure 3B ). PCR and Sanger sequencing confirmed the heterozygous variation at this site in the patient's father, but not in his mother, suggesting that the variation is a novel autosomal dominant mutation ( Figure 3A  and  Supplementary Table 4 ).
case_images: Potentially pathogenic variants may affect the function of CXCR4 protein. 3D modeling of the p. E345V.fs*12 variant reveals disruption of the spatial structure of the N- and C- terminal region and alterations to the position and numbers of ligand binding site residues and active sites, when compared with WT CXCR4. There is no active site in three-dimensional modeling of WT CXCR4 predicted by COFACTOR and COACH. Light green balls represent ligand. Ligand binding site residues are shown by blueline and marked with red number. The active sites are represented by white and gray hockey stick model.
case_images: fimmu-13-857527-g004.jpg
case_images: PMC9043559_03_fimmu-13-857527-g004.jpg
case_images: f4
case_images: PCR and Sanger sequencing confirmed the heterozygous variation at this site in the patient's father, but not in his mother, suggesting that the variation is a novel autosomal dominant mutation ( Figure 3A  and  Supplementary Table 4 ). E345Vfs*12 variant significantly disrupted spatial structure of the N- and C- terminal region, when compared with WT CXCR4 ( Figure 4 ). E345Vfs*12 variant was further predicted, showing that the ligand binding sites and active site residues of CXCR4 receptors were changed, and the number of them were increased, which may lead to conformational rearrangement ( Figure 4 ).
case_images: PMC9043559_04