Clinical, immunological, treatment characteristics, and outcomes in 22 patients with major histocompatibility complex class II deficiency

Background: Major histocompatibility complex (MHC) class II deficiency is a rare, life-threatening primary immunodeficiency that presents in early infancy with a SCID phenotype. However, emerging data indicate substantial clinical and immunological heterogeneity, including atypical presentations and neurological involvement. Methods: We retrospectively evaluated the clinical, immunological, genetic, and treatment-related characteristics and outcomes of 22 patients from 19 unrelated families diagnosed with MHC class II deficiency at a single referral center (2000-2019). Ten patients underwent HSCT at our center; transplant-related outcomes were evaluated, and long-term follow-up data were available for the six surviving patients through 2025. Results: T cell recovery was higher after MAC than RTC, while T-cell chimerism remained mixed in both groups. Conclusion: MHC class II deficiency is a SCID-like pediatric immunological emergency that is fatal without HSCT in most patients. Early diagnosis is critical, as initial infections may be rapidly progressive. HSCT provides durable engraftment and sustained clinical stability in long-term survivors. Incorporating HLA-DR expression analysis into first-line immunological screening, even in the absence of profound lymphopenia, may facilitate earlier diagnosis, prompt HSCT referral, and improve survival.