- Lee, Yu Nee;
- Frugoni, Francesco;
- Dobbs, Kerry;
- Tirosh, Irit;
- Du, Likun;
- Ververs, Francesca A;
- Ru, Heng;
- Ott de Bruin, Lisa;
- Adeli, Mehdi;
- Bleesing, Jacob H;
- Buchbinder, David;
- Butte, Manish J;
- Cancrini, Caterina;
- Chen, Karin;
- Choo, Sharon;
- Elfeky, Reem A;
- Finocchi, Andrea;
- Fuleihan, Ramsay L;
- Gennery, Andrew R;
- El-Ghoneimy, Dalia H;
- Henderson, Lauren A;
- Al-Herz, Waleed;
- Hossny, Elham;
- Nelson, Robert P;
- Pai, Sung-Yun;
- Patel, Niraj C;
- Reda, Shereen M;
- Soler-Palacin, Pere;
- Somech, Raz;
- Palma, Paolo;
- Wu, Hao;
- Giliani, Silvia;
- Walter, Jolan E;
- Notarangelo, Luigi D
Recombination-activating genes 1 and 2 (RAG1 and RAG2) play a critical role in T and B cell development by initiating the recombination process that controls the expression of T cell receptor (TCR) and immunoglobulin genes. Mutations in the RAG1 and RAG2 genes in humans cause a broad spectrum of phenotypes, including severe combined immunodeficiency (SCID) with lack of T and B cells, Omenn syndrome, leaky SCID, and combined immunodeficiency with granulomas or autoimmunity (CID-G/AI). Using next-generation sequencing, we analyzed the TCR and B cell receptor (BCR) repertoire in 12 patients with RAG mutations presenting with Omenn syndrome (n = 5), leaky SCID (n = 3), or CID-G/AI (n = 4). Restriction of repertoire diversity skewed usage of variable (V), diversity (D), and joining (J) segment genes, and abnormalities of CDR3 length distribution were progressively more prominent in patients with a more severe phenotype. Skewed usage of V, D, and J segment genes was present also within unique sequences, indicating a primary restriction of repertoire. Patients with Omenn syndrome had a high proportion of class-switched immunoglobulin heavy chain transcripts and increased somatic hypermutation rate, suggesting in vivo activation of these B cells. These data provide a framework to better understand the phenotypic heterogeneity of RAG deficiency.