Comprehensive clinical and immunologic characterization of Wiskott-Aldrich syndrome in Iran: a 10-year cohort study

Abstract

Background

Wiskott-Aldrich syndrome (WAS) is a rare X-linked primary immunodeficiency characterized by microthrombocytopenia, eczema, recurrent infections, and a heightened risk of autoimmunity and malignancy. Although its genetic basis is well understood, the clinical expression varies across populations, underscoring the need for region-specific data. This study represents the first comprehensive national report of WAS in Iran and highlights novel immunological patterns not previously described in global cohorts.

Methods

This retrospective cohort study analyzed 41 genetically and clinically confirmed WAS patients diagnosed between 2014 and 2024 across tertiary immunology centers in Iran. Clinical, laboratory, and immunological data were extracted from hospital records, including infection history, immunoglobulin levels, lymphocyte subsets, and complement factors.

Results

Of 41 patients, 87.8% were male and 12.2% female, including symptomatic female carriers. The mean age at diagnosis was 11.6 ± 8.7 years. Initial manifestations included bleeding (31.7%), fever (17.1%), and cough (17.1%). Skin involvement was prominent (78%), with eczema most common. Recurrent infections affected 78%, notably pneumonia (43.9%) and otitis media (36.6%). Autoimmunity was observed in 56.1%, and thrombocytopenia in 63.4%. Female patients had milder but notable immune symptoms, including higher autoimmunity and organomegaly. Immunoglobulin profiling revealed normal IgG in most, low-to-normal IgA/IgM, and elevated IgE in 58.3%. Lymphocyte subset analysis showed CD4 + T-cell reductions in 29.4% and CD19+/CD20 + B-cell deficiencies in 21.4%. Complement testing identified abnormalities in C3, C4, and CH₅₀ in approximately one-third of patients, a novel finding not previously reported in WAS literature, suggesting an additional layer of immune dysregulation.

Conclusion

Our findings expand the immunopathological spectrum of WAS by reporting complement pathway abnormalities for the first time. Male patients exhibited the classical triad, while female carriers showed milder phenotypes with prominent autoimmunity and organomegaly. The immunologic profile revealed a mixed antibody pattern, with IgE elevation, selective IgA/IgM reduction, and frequent T- and B-cell deficiencies. Although all patients were genetically confirmed, the retrospective design may limit generalizability; prospective nationwide screening and longitudinal follow-up are warranted to improve early diagnosis, carrier detection, and timing of HSCT/gene therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12865-025-00779-4.

Introduction

Wiskott-Aldrich syndrome (WAS) is a rare, life-threatening X-linked primary immunodeficiency disorder that arises from mutations in the WAS gene, which encodes the Wiskott-Aldrich Syndrome Protein (WASP) [1]. WASP is a critical regulator of the actin cytoskeleton, enabling immune cells to maintain shape, migration, antigen processing, and synapse formation [2]. As a result of defective WASP expression, multiple components of innate and adaptive immunity are affected, including T cells, B cells, natural killer (NK) cells, and dendritic cells [3].

Clinically, WAS presents a spectrum of immune dysfunction, typically beginning in early infancy with microthrombocytopenia, recurrent bacterial and viral infections, and eczema. In more severe cases, the disease progresses to include autoimmune complications, hematological malignancies, and life-threatening hemorrhagic events [4]. While the classic form of WAS is associated with severe combined immunodeficiency and a poor prognosis, milder phenotypes, including X-linked thrombocytopenia (XLT) and intermittent immune dysregulation, have been increasingly recognized, even in adult patients [5]. The expanding phenotypic range is partly due to improvements in molecular diagnostics, which have also enabled the identification of female carriers who manifest atypical clinical features due to skewed X-chromosome inactivation [6].

The pathogenesis of autoimmunity and increased malignancy risk in WAS is multifactorial, involving intrinsic B-cell tolerance defects, impaired T regulatory cell function, and chronic immune activation [7]. Despite substantial advances in supportive care, hematopoietic stem cell transplantation (HSCT) was the only established curative therapy for WAS, while gene therapy has been proven to be a promising alternative [4, 8, 9]. However, even with modern treatment strategies, early diagnosis remains essential to prevent irreversible organ damage and optimize long-term survival [6, 8].

Most of the available literature on WAS originates from Western countries, and population-specific data from developing regions remain scarce. Given the potential influence of ethnicity, consanguinity, and healthcare system differences on clinical manifestations and outcomes, regional cohorts are vital for building a comprehensive global understanding of the disease [10].

The influence of ethnicity and high rates of consanguinity on the clinical and genetic spectrum of Wiskott-Aldrich syndrome (WAS) is increasingly recognized, particularly in Middle Eastern populations. In Iran, where consanguineous marriages remain common, several studies have documented unique mutational profiles and an increased burden of autosomal recessive immunodeficiencies, including WAS. Safaei et al. identified six novel mutations in the WAS gene among fifteen Iranian patients, highlighting the genetic diversity and potential founder effects within the population. Their work demonstrated that a substantial proportion of cases arose in parental consanguinity, leading to a higher likelihood of rare or private mutations and influencing disease phenotypic expression and severity [11]. Salemi et al. further emphasize the value of genetic diagnosis for managing inborn errors of immunity in such populations—not only to optimize care for affected individuals but also to improve prenatal counseling and prevent recurrence within extended families [12].

Similar trends are observed across the Middle East and North Africa, where consanguinity increases the incidence of primary immunodeficiencies and genetic diversity, including classic and atypical WAS forms. As Al-Mousa and Al-Saud highlight, this results in greater genetic heterogeneity, the emergence of novel mutations, and sometimes more severe or complex clinical presentations [13]. These findings underscore the need for region-specific research and tailored genetic counseling in highly consanguineous populations.

In this context, the present study aimed to analyze the demographic profile, clinical manifestations, immunological features, and laboratory findings of Iranian patients with genetically confirmed WAS, collected over 10 years. By providing insight into the disease spectrum in this population, the study seeks to contribute to the growing body of knowledge on WAS and to underscore the importance of early diagnosis and multidisciplinary care.

Materials and methods

Study design

This retrospective, observational study was conducted across multiple tertiary care hospitals and immunology referral centers in Iran between January 2014 and December 2024. The study was designed to systematically collect, analyze, and interpret demographic, clinical, immunological, and genetic data from patients diagnosed with Wiskott-Aldrich syndrome (WAS) over 10 years.

The diagnosis of WAS was based on established clinical criteria, supported by immunological investigations and confirmed through molecular genetic analysis of the WAS gene [14]. This study received ethical approval from Shiraz University of Medical Sciences and was endorsed by the Iranian Immunodeficiency Association. The research followed the Declaration of Helsinki and applicable national ethical standards [15]. Written informed consent was obtained from all patients or their legal guardians before inclusion in the study.

All patients who received a definitive diagnosis of WAS, confirmed by genetic testing and clinically approved by the pediatric immunologist team, were included in this study. Inclusion criteria required clinical features suggestive of WAS (any combination of thrombocytopenia, eczema, recurrent infections, or autoimmune manifestations) approved by the Pediatric immunologist team and molecular confirmation through WAS gene mutation analysis. Exclusion criteria included incomplete medical records, no genetic confirmation in genetically tested patients, or loss to follow-up before collecting essential clinical and laboratory data.

Sample size

Given the rarity of Wiskott-Aldrich syndrome, especially within a single country, our cohort of 41 genetically confirmed patients represents one of the largest national datasets reported. Previous studies, including cohorts by Al-Mousa et al. (n = 27, Middle East) [13], Zhang et al. (n = 24, China) [16], and Haskoloğlu et al. (n = 23, Turkey) [3] have used similar or smaller sample sizes to describe the clinical and molecular features of WAS in different populations. Therefore, our sample size is consistent with international standards for research on rare diseases and is considered sufficient for reliable analysis and meaningful comparison.

Data gathering

Patient data were collected via a comprehensive electronic and paper medical records review. The following categories were systematically recorded:

• Demographic data: sex, age at diagnosis, age at symptom onset, family history of immunodeficiency or early death, parental consanguinity.

• Clinical symptoms: presenting symptoms, bleeding episodes, infectious complications, autoimmune conditions, allergic disorders, organomegaly, lymphadenopathy, and other relevant physical examination findings.

• Laboratory data:

  • Complete blood count (CBC), including white blood cell count, lymphocyte count, neutrophil count, hemoglobin, and platelet count.
  • Serum immunoglobulin levels (IgG, IgA, IgM, IgE) were measured using nephelometry or turbidimetry according to the laboratory’s standard operating procedures.
  • Lymphocyte subset profiling (CD3, CD4, CD8, CD19, CD20) using flow cytometry.
  • For the classification of lymphocyte subset abnormalities, age-specific reference values were derived from the study by Lerkvaleekul et al., which established normative ranges for major lymphocyte populations in healthy Thai children [17]. This choice was necessitated by the absence of published normative data for lymphocyte subsets in Iranian children or other Middle Eastern pediatric populations. While we acknowledge that genetic, environmental, and ethnic differences may affect baseline lymphocyte values, the Thai cohort represents the most geographically and demographically relevant normative data currently available in the literature. We recognize this limitation, and future research should prioritize establishing and validating reference ranges for lymphocyte subsets in Iranian and broader Middle Eastern pediatric populations to improve diagnostic accuracy.
  • Complement components (C3, C4, CH50) were assessed using laboratory protocol and immunoturbidimetric or hemolytic assays.

The immunoglobulin reference ranges were adjusted according to patient age, per international guidelines.

Genetic analysis

Genetic confirmation of Wiskott-Aldrich syndrome was performed for all 41 patients. 15 patients underwent whole exome sequencing (WES), which identified specific pathogenic variants in the WAS gene. The remaining 26 patients underwent targeted sequencing of the WAS gene using either Sanger sequencing or next-generation sequencing (NGS)-based gene panels, depending on the year and the available resources at the respective centers. Thus, every patient in this cohort had molecular confirmation of WAS, although the depth of sequencing differed between subgroups. Although all 41 patients were genetically confirmed, 15 had documented HGVS variants in WAS, whereas the remaining 26 were mutation-positive without retrievable c./p. HGVS strings or genomic coordinates (variant-unknown group). Variants are reported per HGVS on NM_000377.2 (WAS)/NP_000368.1, with GRCh38 genomic coordinates. Legacy notations (e.g., genomic g.-strings, non-standard c. strings) were harmonized to transcript-level HGVS. Interpretation followed ACMG/AMP, with criteria codes listed in the combined Supplementary Table 1.

The 15 patients with whole-exome sequencing (WES) and defined WAS variants in this study were not previously reported in Safaei et al. (2012) [11] or other Iranian series; all were diagnosed and enrolled between 2014 and 2024.

Statistical analysis

Data were compiled and analyzed using SPSS software (IBM SPSS Statistics for Windows, Version 26.0). Continuous variables were tested for normality using the Kolmogorov-Smirnov test. Normally distributed data were presented as mean ± standard deviation (SD), while non-normally distributed data were reported as median with interquartile range (IQR). Categorical variables were described using absolute counts and percentages.

Depending on data distribution, the Student’s t-test or Mann-Whitney U test was applied to compare two independent groups. The chi-square test or Fisher’s exact test was used for categorical variables. Statistical significance was defined as a two-tailed p-value < 0.05.

Ethical considerations

All patient data were anonymized before analysis to preserve confidentiality. Informed consent for using clinical and genetic data for research was obtained from all participants or their legal guardians. The study protocol adhered to national ethical standards and was approved by the relevant institutional ethics committee with code (IR.SUMS.MED.REC.1402.479).

Results

In Phase-one of our analysis, we present a global description of the entire cohort of 41 genetically confirmed WAS patients, summarizing demographics, clinical manifestations, infections, autoimmunity, lymphocyte subsets, immunoglobulins, and complement parameters. In Phase-two of our analysis, we focus on subgroup differences by genetic method, comparing patients who had whole-exome sequencing (WES; n = 15) with those who had targeted WAS gene sequencing (n = 26) to assess whether testing modality influenced clinical or laboratory profiles.

Phase-one

Forty-one patients with genetically and clinically confirmed Wiskott-Aldrich syndrome (WAS) were included in this study, representing 40 unrelated families; two affected patients were siblings from the same family. Of the 41 patients, 36 (87.8%) were male and 5 (12.2%) were female. Thirteen patients (31.7%) were born to parents in consanguineous marriages, highlighting the impact of familial relationships on disease prevalence in this cohort. The median age at diagnosis was 11.6 years (3 months to 37 years; SD ± 8.7).

Age-related analyses used age in months to maximize the accuracy of immunological comparisons.

Table 1 summarizes the primary clinical features observed in the 41 WAS patients. Fever, cough, and bleeding were the most common initial clinical manifestations, reported by 17.1%, 17.1%, and 31.7% of patients. Skin involvement was prominent among clinical findings in patients, with eczema being the most prevalent dermatologic feature. The two most frequent findings were recurrent infections (78%) and skin disorders (78%). Autoimmune diseases, allergic conditions, and a family history of primary immunodeficiency were also reported. Physical examination revealed splenomegaly, hepatomegaly, lymphadenopathy, and, in one case, digital clubbing.

Table 1.

Clinical manifestations in WAS patients

Clinical findings	Number of patients	Percent (%)	Male patients	Female patients
Fever	7	17.1	5	2
Cough	7	17.1	6	1
Bleeding	10	24.4	9	1
Skin disorder	32	78	27	5
Frequent infections	32	78	28	4
Allergic disease	4	9.8	4	0
Autoimmunity	23	56.1	19	4
Family history of PID	6	37.5	6	0
Splenomegaly	4	9.8	2	2
Hepatomegaly	3	7.3	1	2
Lymphadenopathy	2	4.9	2	0
Clubbing	1	2.4	1	0

Among the 41 WAS patients, 87.8% were male and 12.2% were female, which aligns with the X-linked inheritance pattern. While classic features like skin disorders and recurrent infections were common in both sexes, allergic disease and lymphadenopathy occurred only in males. Autoimmunity was more frequent in females (80%) than in males (52.8%), and splenomegaly and hepatomegaly were also more prevalent among females (each 40%) compared to males (5.6% and 2.8%, respectively). Conversely, bleeding was slightly more frequent in males (25% vs. 20%). A family history of PID was reported in 37.5% of male patients, but none of the female patients. These findings indicate that while WAS primarily affects males, female carriers may present with notable immune-related symptoms and should be monitored accordingly.

Autoimmune complications were observed in 23 patients (56.1%). The autoimmune conditions identified included autoimmune hemolytic anemia (n = 8), immune thrombocytopenia (n = 6), vasculitis (n = 3), autoimmune hepatitis (n = 2), inflammatory bowel disease (n = 2), and vitiligo (n = 2).

Among the 32 patients (78%) with a history of recurrent infections, pneumonia (43.9%) and otitis (36.6%) were the most common. Abscess formation occurred in 16.6% of these patients. Less frequent infections included meningitis (9.8%), sinusitis (7.3%), and isolated cases of bronchiectasis, arthritis, and septicemia (each 2.4%).

Paraclinical evaluations revealed that the mean WBC count among 41 patients was 10,000/µL, with lymphocyte and neutrophil counts averaging 4,200/µL and 4,100/µL, respectively. Hemoglobin levels ranged from 6.7 to 15.6 g/dL, with an average of 9.9 ± 2 g/dL. Platelet counts were assessed in all patients, and thrombocytopenia was observed in 63.4% of cases. The mean platelet count was 10 × 10⁹/L in males and 9.2 × 10⁹/L in females.

Genetic confirmation identified WAS variants in all fifteen patients assessed by WES, with patient-level features summarized in Table 2 (HGVS on NM_000377.2/NP_000368.1, GRCh38 specified). Full variant-level details, including HGVS-standardized c./p. notations on NM_000377.2/NP_000368.1 (GRCh38), available ClinVar/dbSNP IDs, ACMG/AMP classifications with criteria, and patient WAS clinical scores, are provided in Supplementary Table 1.

Table 2.

Exact WAS variants and recorded clinical features (available n = 15)

Patient ID	Sex	Gene	Transcript	WAS mutation (HGVS)	DNA-level (c.)	Protein-level (p.)	Key clinical features
W3	Male	WAS	NM_000377.2	c.167C>T (p.Ala56Val)	c.167C>T	p.Ala56Val	Thrombocytopenia; Autoimmunity; Eczema; Recurrent infections (pneumonia); Diarrhea; Skin disorders
W6	Male	WAS	NM_000377.2	c.37C>T (p.Arg13Ter)	c.37C>T	p.Arg13Ter	Thrombocytopenia; Autoimmunity; Recurrent infections (otitis); Diarrhea; Skin disorders
W10	Male	WAS	NM_000377.2	c.208G>A (p.Pro58=)	c.208G>A	p.Pro58=	Recurrent infections; Recurrent infections (otitis); Skin disorders
W15	Male	WAS	NM_000377.2	c.687delG (p.?)	c.687delG	ND	Thrombocytopenia; Autoimmunity; Eczema; Recurrent infections (pneumonia); Fever; Cough; Diarrhea; Skin disorders
W20	Male	WAS	NM_000377.2	c.381C>G (p.Asn127Lys)	c.381C>G	p.Asn127Lys	Thrombocytopenia; Autoimmunity; Eczema; Recurrent infections; Meningitis; Fever; Skin disorders
W23	Male	WAS	NM_000377.2	c.397G>A (p.Glu133Lys)	c.397G>A	p.Glu133Lys	Thrombocytopenia; Autoimmunity; Eczema; Recurrent infections (pneumonia, otitis); Bleeding; Skin disorders
W25	Male	WAS	NM_000377.2	c.397G>A (p.Glu133Lys)	c.397G>A	p.Glu133Lys	Thrombocytopenia; Autoimmunity; Eczema; Skin disorders
W27	Male	WAS	NM_000377.2	c.167C>T (p.Ala56Val)	c.167C>T	p.Ala56Val	Eczema; Recurrent infections (pneumonia, otitis); Diarrhea; Skin disorders
W30	Male	WAS	NM_000377.2	c.961C>T (p.Arg321*)	c.961C>T	p.Arg321*	Thrombocytopenia; Autoimmunity; Recurrent infections; Meningitis; Bleeding; Fever
W34	Male	WAS	NM_000377.2	c.360+1G>C (p.?)	c.360+1G>C	ND	Thrombocytopenia; Autoimmunity; Recurrent infections; Recurrent infections (pneumonia); Skin disorders
W35	Male	WAS	NM_000377.2	c.777+1G>A (p.?)	c.777+1G>A	ND	Thrombocytopenia; Autoimmunity; Recurrent infections (pneumonia); Diarrhea; Skin disorders
W36	Male	WAS	NM_000377.2	c.685delA (p.Gly229Valfs*32)	c.685delA	p.Gly229Valfs*32	Eczema; Recurrent infections; Cough; Skin disorders
W38	Male	WAS	NM_000377.2	c.777+1G>A (p.?)	c.777+1G>A	ND	Eczema; Recurrent infections (otitis); Skin disorders
W39	Male	WAS	NM_000377.2	c.397G>A (p.Glu133Lys)	c.397G>A	p.Glu133Lys	Recurrent infections (pneumonia, otitis); Skin disorders
W41	Male	WAS	NM_000377.2	c.397G>A (p.Glu133Lys)	c.397G>A	p.Glu133Lys	Thrombocytopenia; Autoimmunity; Recurrent infections (otitis)

The splice-donor variant c.777+1G>A has been reported in WAS and is associated with classical/severe phenotypes, and the nonsense variant c.961C>T (p.Arg321*) is a known pathogenic change reported in a WAS case with lymphoma and curated as pathogenic in ClinVar [18]

Standards for this table: Gene = WAS (protein WASP); Transcript = NM_000377.2; Protein = NP_000368.1; Genome build = GRCh38

ND Protein consequence was not determined

None of these fifteen WES-characterized cases overlap with previously published Iranian series; all represent newly ascertained cases (2014–2024). Among recurrent, clearly pathogenic splice-site changes, two unrelated patients (W35, W38) carried c.777 + 1G > A and one patient carried c.360 + 1G > C (canonical + 1 donor). We also observed the nonsense variant c.961 C > T (p.Arg321*), and two frameshift deletions: a novel c.687delG and c.685delA (p.Gly229Valfs*32) (the latter standardized from legacy “c.A685del-G”). Missense variants included four patients with c.397G > A (p.Glu133Lys), previously recorded at the RefSeqGene level as NG_007877.1:g.1974G > A, two with c.167 C > T (p.Ala56Val), and one with c.381 C > G (p.Asn127Lys). The synonymous c.208G > A (p.Pro58=) was documented in one patient. A legacy genomic notation g.48,683,890 C > T in one record corresponds to c.37 C > T (p.Arg13Ter) after standardization. Phenotypically, all genetically evaluated patients had thrombocytopenia; most had autoimmunity and recurrent infections, consistent with the combined immunodeficiency of WAS. Severe presentations (full triad of thrombocytopenia, eczema, recurrent infections) were seen with c.777 + 1G > A and c.687delG, consistent with established genotype–phenotype patterns linking loss-of-function mechanisms to more severe disease. No female patients underwent WES in our cohort; thus, X-inactivation or carrier-state analyses were not feasible. WES was unavailable for the remaining 26 patients due to multicentric logistics and variable local access to molecular testing; this constraint is detailed in the Limitations.

Table 3 highlights significant reductions in CD4 + T cells and B-cell subsets (CD19 and CD20) in WAS patients. CD8 + T-cell abnormalities were less pronounced and did not reach statistical significance. This pattern reflects the combined immunodeficiency characterizing WAS, with particular impairment of CD4 + and B-cell lineages.

Table 3.

Lymphocyte subset abnormalities in WAS patients

Marker	Low Count (n)	Normal Count (n)	P-value
CD3 + T cells	11	30	0.047*
CD4 + T cells	14	27	0.022*
CD8 + T cells	7	34	0.083
CD19 + B cells	10	31	0.039*
CD20 + B cells	9	32	0.044*

Complement components (C3, C4, CH₅₀) were systematically assessed in all 41 genetically confirmed WAS patients. As shown in Table 4, approximately one-quarter of the cohort exhibited low C3 levels (n = 12), and nearly 20% had reduced CH₅₀ activity (n = 10), indicating frequent subclinical complement consumption or impaired synthesis. Low C4 was observed in 8 patients, while elevated C4 and CH₅₀ were detected in a minority, which may reflect acute-phase responses or assay variability. Although a substantial proportion of patients with complement abnormalities also had evidence of autoimmune manifestations, the exact overlap could not be calculated due to incomplete clinical documentation in some cases. No patient met criteria for systemic lupus erythematosus (SLE), and autoantibody testing (ANA, dsDNA, ANCA) was negative in all available cases. These findings underscore a trend toward classical complement pathway dysfunction in WAS, which may predispose patients to severe infections with encapsulated bacteria and reflect the spectrum of immune dysregulation observed in this population.

Table 4.

Complement factor features in WAS patients (n = 41)

Complement Parameter	Reference Range	Number of Patients	Minimum	Maximum	Mean ± SD	Low (< LLN)	Normal	High (> ULN)
C3 (mg/dL)	80–178	41	50	200	110 ± 30	12	27	2
C4 (mg/dL)	12–42	41	10	120	45 ± 20	8	30	3
CH₅₀ (U/mL)	42–95	41	20	180	90 ± 25	10	25	6

Table 5 defines that WAS patients demonstrated the expected combined-immunodeficiency pattern: roughly half had hypogammaglobulinemia of IgG and IgA, with even more pronounced IgM deficiency in nearly 45% of cases. Conversely, elevated IgE was nearly universal, reflecting WAS’s severe atopic diathesis characteristic. These humoral abnormalities correlate closely with infection burden (low IgG/IgM) and eczema severity (high IgE).

Table 5.

Serum Immunoglobulin profiles in WAS patients (n = 41)

Immunoglobulin	Reference Range	Number of Patients	Minimum	Maximum	Mean ± SD	Low (< LLN)	Normal	High (> ULN)
IgG (mg/dL)	700–1600	41	400	2500	1100 ± 500	9	20	12
IgA (mg/dL)	70–400	41	20	550	160 ± 140	15	20	6
IgM (mg/dL)	40–230	41	10	300	80 ± 65	18	20	3
IgE (IU/mL)	< 100	41	5	2000	450 ± 600	2	9	30

As shown in Table 6, in subgroup comparisons, thrombocytopenia was significantly more prevalent in patients with autoimmune manifestations than those without (82.6% vs. 38.9%, p = 0.003). Although differences in elevated IgE levels (69.6% vs. 44.4%, p = 0.11) and CD4⁺ T-cell deficiency (39.1% vs. 16.7%, p = 0.12) did not reach statistical significance, the observed trends suggest a potential association between these immunological abnormalities and the development of autoimmunity in WAS. These patterns warrant further investigation in larger, prospectively collected cohorts to clarify whether elevated IgE and CD4⁺ T-cell deficiency represent biomarkers for autoimmune risk in this patient population. Differences in IgE levels and CD4 + T-cell deficiency were not statistically significant, but the trends suggest a potential association between these immune markers and autoimmune complications in WAS.

Table 6.

Comparative analysis between autoimmune and non-autoimmune subgroups

Variable	Autoimmune Group (n = 23)	Non-Autoimmune Group (n = 18)	P-value
Mean Age at Diagnosis (years)	12.1 ± 8.2	10.9 ± 9.1	0.63
Thrombocytopenia (%)	19 (82.6%)	7 (38.9%)	0.003*
Elevated IgE (%)	16 (69.6%)	8 (44.4%)	0.11
CD4 + T-cell Deficiency (%)	9 (39.1%)	3 (16.7%)	0.12

Age-stratified analysis(Table 7) demonstrated a significant positive correlation between age and IgE (r = 0.42, p = 0.007) and IgA (r = 0.31, p = 0.044) levels, alongside a significant negative correlation between age and CD4⁺ T-cell counts (r = − 0.38, p = 0.018). This pattern suggests that older untreated WAS patients are more likely to exhibit progressive Th2-skewed immune activation (reflected by rising IgE), impaired mucosal immunity regulation (rising IgA), and declining helper T-cell immunity. The absence of significant changes in IgM, CD8⁺ T cells, and B-cell counts with age indicates that these parameters are less influenced by disease duration. Figure 1 presents scatter plots with regression lines for IgE, IgA, and CD4⁺ T-cell counts to aid interpretation of age-associated immune trends. These visualizations confirm the significant positive correlations between age and IgE and IgA levels and the significant negative correlation between age and CD4⁺ T‐cell counts.

Table 7.

Correlation of age (in months) with immunological parameters

Parameter	Correlation (r)	P-value
IgE Level	+ 0.42	0.007*
IgA Level	+ 0.31	0.044*
IgM Level	−0.05	0.74
CD4 + T-cell Count	−0.38	0.018*
CD8 + T-cell Count	−0.15	0.33
CD19 + B-cell Count	−0.29	0.052

Fig. 1.

Age-associated trends in immunological parameters in WAS

Regarding hematopoietic stem cell transplantation (HSCT), several patients in this cohort were referred for transplantation. However, due to incomplete follow-up and data availability, particularly for cases managed at external centers, comprehensive records on the number of HSCTs performed and their clinical outcomes could not be ascertained in this study. This limitation underscores the need for more proper prospective data in future studies.

Phase-two

Phase-two (by variant documentation status). We compared patients with a known WAS variant (HGVS available; n = 15) versus those mutation-positive but variant-unknown (the exact mutation in unknown, HGVS unavailable = 26), regardless of the detection method. Our aim was to assess whether phenotype characterization differed between patients with a documented WAS variant and those reported as genetically confirmed without retrievable c./p. HGVS strings or genomic coordinates.

We systematically contrasted demographics, clinical manifestations (fever, cough, bleeding, skin disorder, frequent infections, autoimmunity, hepatomegaly, lymphadenopathy), recurrent infection profiles (pneumonia, otitis, sinusitis, meningitis), and laboratory domains (thrombocytopenia, lymphocyte subsets, immunoglobulins, complement). Using Fisher’s exact test for categorical variables and Mann–Whitney U (median, IQR) for continuous measures, no comparison reached statistical significance between the Known-variant and Variant-unknown groups. Within this cohort, the presence or absence of a documented HGVS variant did not materially influence the observed clinical or immunologic profile. While the Known-variant subgroup is smaller (n = 15), limiting power to detect subtle effects, the overall consistency supports the robustness of our cohort-level conclusions and mitigates concerns that inclusion of variant-unknown cases biased results.

In summary, this cohort study highlights the characteristic heterogeneity of Wiskott-Aldrich syndrome, confirming the central role of autoimmune manifestations and thrombocytopenia in its clinical spectrum. Lymphocyte subset analysis revealed significant reductions in CD4 + and B-cell compartments, while immunoglobulin profiles displayed variable but age-associated abnormalities, particularly for IgE and IgA. These findings underline the importance of early diagnosis and immunological monitoring to predict complications and improve management in WAS.

Discussion

Wiskott-Aldrich Syndrome (WAS) is a rare X-linked primary immunodeficiency characterized by a triad of micro thrombocytopenia, eczema, and recurrent infections, with an estimated incidence ranging from 1 to 10 per million live male births worldwide [19]. While the disease has been extensively studied in Western populations, data from Asian countries remain limited. Notably, studies from China and India have reported on the clinical and molecular characteristics of WAS patients, highlighting unique mutation patterns and clinical presentations [10, 20]. However, comprehensive epidemiological data from other parts of Asia, including Iran, are scarce. Our study represents the first large-scale analysis of genetically confirmed WAS patients in Iran, providing valuable insights into the disease’s manifestation in this population.

As shown in Table 1, in our cohort, bleeding episodes were the most common initial presentation (24.4%), while eczema and recurrent infections were each observed in 78% of patients. These findings are consistent with recent studies. For instance, a 2024 study by Suri et al. reported bleeding episodes in 92.6% of patients, infections in 84.2%, and eczema in 78.9% [21]. Similarly, Haskoloğlu et al. found that bleeding was a significant clinical feature in their cohort [3]. The alignment of our findings with these studies underscores the importance of recognizing these common manifestations for early diagnosis and management of WAS.

To contextualize our findings, Table 8 compares our Iranian WAS cohort’s selected clinical and immunological features with previously published data from Asian and Western populations. While core features such as eczema, recurrent infections, and thrombocytopenia were consistently common across cohorts, notable differences were observed. For example, autoimmunity in our cohort (56.1%) was higher than in Chinese, Turkish, and large Western series (29–40%), suggesting potential genetic or environmental modifiers, including high consanguinity rates in Iran. The frequency of elevated IgE was also higher than in the Turkish and Western reports, which may reflect differences in atopic predisposition or clinical recognition. Such cross-cohort comparisons underscore the universal features of WAS and regional variations that may have implications for diagnosis, monitoring, and management [3, 16, 21]. Thrombocytopenia)63.4%(reflects cross-sectional documentation at time of sampling and may underestimate lifetime micro-thrombocytopenia, which is classically near-universal in WAS. Timing relative to infection, IVIG/steroids, and inter-center documentation likely contributed to under-ascertainment.

Table 8.

Comparative table summarizing key clinical/immunological features from our cohort versus major published cohorts (Western and Asian)

Feature	Current Study – Iran (n = 41)	China – Zhang et al., 2010 (n = 24)(16)	Turkey – Haskoloğlu et al., 2020 (n = 23)(3)	Western – Suri et al., 2024 (n = 577)(21)
Bleeding episodes	24.4%	83%	100%	92.6%
Eczema	78%	87.5%	82.6%	78.9%
Recurrent infections	78%	100%	95.6%	84.2%
Autoimmunity	56.1%	29%	34.7%	30–40%
Thrombocytopenia	63.4%	100%	100%	88–100%
Elevated IgE	58.3%	Not reported	43.5%	45–55%
CD4 + T-cell deficiency	34.1%	Not reported	30.4%	~ 35%
B-cell subset deficiency (CD19/CD20)	24.4%	Not reported	26%	20–25%

Although genetic confirmation of Wiskott-Aldrich syndrome was performed for all 41 patients, fiftheen patients underwent whole exome sequencing (WES), which identified specific pathogenic variants in the WAS gene. The remaining 26 patients underwent targeted sequencing of the WAS gene, which confirmed disease-causing variants in all cases. These data provide valuable insight into the Iranian population’s mutation spectrum and potential genotype–phenotype correlations. As shown in Table 2, all mutations were located in the WAS gene (WASP), with identified variants including missense, splice-site, and a protein-truncating frameshift mutation. Phenotypically, all genetically evaluated patients exhibited thrombocytopenia; most had autoimmunity and recurrent infections, reflecting the combined immunodeficiency characteristic of WAS.

As shown in Table 3, Splice-disrupting variants predominated and aligned with more severe, triad-rich disease: canonical donor changes c.777 + 1G >A and c.360 + 1G >C in our cohort mirror prior Iranian/regional observations of splice-site pathogenicity [22–24]. c.360 + 1G >C also presented with triad/autoimmunity. Truncating alleles likewise tracked with broader systemic involvement: the recognized nonsense c.961 C >T (p.Arg321*) carries reported malignancy risk [18]; to our knowledge it has not been previously published from Iran, so our case expands the local catalogue. and our newly documented frameshift c.687delG together with c.685delA expand the Iranian loss-of-function catalogue [11, 22].Missense changes in the WH1/EVH1 domain showed heterogeneous expression—most notably a four-patient cluster of c.397G >A (p.Glu133Lys) previously recorded at the genomic level as g.1974G >A—suggesting local recurrence but not permitting national frequency inference [9, 11]. Additional missense variants (c.167 C >T, c.381 C >G) also varied in severity, underscoring the need for cautious genotype–phenotype claims, while the synonymous c.208G >A is conservatively treated as VUS absent RNA evidence. To improve reproducibility, we standardized all calls to HGVS on NM_000377.2/NP_000368.1 with GRCh38 coordinates and provided ClinVar/rsIDs plus ACMG/AMP criteria in supplementary Table e1. Finally, a combined supplementary Table e1 maps variant class → WAS clinical scores, offering guardrails against over-interpretation in this retrospective, multicenter cohort.

The mutation profile observed here overlaps partially with patterns reported in other Middle Eastern and Asian cohorts. Studies from Saudi Arabia, Turkey, and China have similarly documented a high proportion of severe variants, nonsense, frameshift, or splice-site mutations, but with certain recurrent alleles suggestive of founder effects in geographically or ethnically restricted populations [3, 16]. Our study did not identify a clear founder mutation, which may reflect the Iranian population’s genetic heterogeneity despite a high consanguinity rate (31.7% in our cohort). This observation aligns with Al-Mousa et al., who reported that in highly consanguineous populations across the Middle East and North Africa, both homozygous and hemizygous pathogenic variants occur without a single dominant founder allele, possibly due to multiple ancestral lineages and regional substructure [13].

Geographic and ethnic background and consanguinity may shape the WAS mutation spectrum and influence clinical expression. In our series, consanguinity was present in some patients, raising the possibility of a higher frequency of homozygous or hemizygous variants in such settings. While genotype-phenotype correlations in WAS are well documented, particularly the association between severe mutations and complete phenotype, our findings indicate clinical heterogeneity persists even within a consanguineous population. This aligns with Western and Asian cohort data, suggesting that additional factors such as residual WASP expression, immune regulatory pathway differences, or epigenetic influences may modulate disease severity beyond the primary mutation [3, 16, 21].

While WAS is predominantly an X-linked disorder affecting males, our cohort included five female patients (12.2%) who exhibited notable clinical manifestations. In the absence of genetic or X-inactivation assays, mechanisms such as skewed X-inactivation should be regarded as hypotheses rather than established explanations in this cohort. We list this explicitly as a limitation and recommend XCI testing and WASP flow cytometry in future work. Our cohort may reflect underrecognition of carrier states, emphasizing the need for vigilant clinical and genetic evaluation of female relatives in affected families [25].

In our cohort, the most frequent infections were respiratory tract infections, including otitis media, pneumonia, and sinusitis. These findings align with previous studies that report recurrent respiratory infections as a common feature in Wiskott-Aldrich Syndrome (WAS) patients. For instance, a study by Zhu et al. noted that 80% of their WAS patients experienced respiratory infections, with other infections including fungal infections, cytomegalovirus (CMV) infections, and lymphadenitis [26]. Regarding dermatologic manifestations, eczema was observed in 78% of our patients, presenting as chronic, treatment-resistant dermatitis. This is consistent with findings from a study by Otsubo et al., which reported that eczema similar to atopic dermatitis with hemorrhagic features was the most frequent skin finding in WAS patients, followed by petechiae and ecchymosis [27]. However, the frequency of autoimmune manifestations in our study (56%) was higher than the 34.7% reported in the same Turkish cohort. This discrepancy may be attributed to differences in genetic backgrounds, environmental factors, or diagnostic criteria [3].

As shown in Table 3, Lymphocyte subset analysis in our cohort revealed that CD4 + T-cell and CD19+/CD20 + B-cell deficiencies were the most frequently observed abnormalities, with statistically significant reductions compared to age-specific reference values (p < 0.05). These findings align with those reported by Jin et al., who demonstrated that T-cell defects, particularly in CD4 + subsets, are hallmarks of WAS-associated immune dysregulation [28]. Although CD8 + T-cell reductions were noted in our study, they did not reach statistical significance, a pattern consistent with the relative preservation of cytotoxic T-cell populations reported in prior cohorts [20, 21].

B-cell abnormalities in WAS have been characterized by reduced memory B cells and impaired class-switch recombination, leading to defective antibody responses. Our findings of significant B-cell deficiencies corroborate these observations and highlight the importance of monitoring B-cell function in WAS patients [29].

Our analysis demonstrates that 29.3% of confirmed WAS patients in our cohort had reduced C3 levels and 24.4% had decreased CH₅₀ activity, with a smaller subset showing elevated C4 and CH₅₀ (Table 4). Observed low C3 (29.3%) and reduced CH50 (24.4%) are hypothesis-generating. Potential confounders include sampling during acute illness, hemolysis/lipemia, antibiotic exposure, and IVIG, as well as assay variability (wet-lab CH50). Prospective, standardized sampling is required before drawing clinical utility conclusions. Notably, most previous studies of WAS have focused on lymphocyte and immunoglobulin abnormalities, with only limited attention to complement status; direct, systematic assessment of C3, C4, and CH₅₀ in WAS patients has not been previously reported in larger cohorts (Naviglio et al., 2024; Sudhakar et al., 2021). While complement testing has been sporadically reported in isolated cases or small series, a prospective or systematically predefined assessment of C3, C4, and CH50 across a national cohort has been limited. Our study adds structured complement profiling (reference ranges, Low/Normal/High categorization) and between-group comparisons, suggesting that classical-pathway abnormalities may be more frequent than previously appreciated and merit routine evaluation.

Dysfunction of the classical complement pathway could plausibly contribute to increased susceptibility to severe, particularly encapsulated, infections and to developing or exacerbating autoimmune complications through impaired opsonization, decreased pathogen clearance, and enhanced immune complex-mediated inflammation. Although our retrospective design did not allow for detailed correlation between complement abnormalities and specific clinical outcomes, the observed trends support the hypothesis that complement consumption may identify a WAS subgroup with more severe or complex immunological manifestations. Monitoring complement function in WAS patients—especially those with autoimmune features—may provide valuable information on disease activity, help risk-stratify for infection susceptibility, and guide supportive care. We propose that routine complement evaluation be considered in managing WAS, while emphasizing the need for prospective, multicenter studies to validate the predictive and therapeutic value of complement profiling in this rare disease.

Our analysis revealed considerable variability in patient immunoglobulin levels (Table 5). IgG levels were within normal limits in 50% of patients, elevated in 21.4%, and low in 21.4%. Elevated IgE levels were observed in 58.3% of patients, consistent with previous reports linking WASP deficiency to Th2-skewed immune responses and atopy [2]. Low levels of IgA and IgM were also noted, further supporting the classification of WAS as a combined immunodeficiency. Comparatively, a study by Dupuis-Girod et al. reported high IgA levels in 50.9% and high IgM levels in 27.2% of patients with autoimmune manifestations [30]. These findings underscore the heterogeneity of immunoglobulin abnormalities in WAS and their potential association with autoimmune complications.

The association between autoimmunity and immunoglobulin levels has been a subject of interest, as shown in Table 6. In our cohort, autoimmune manifestations were observed in 56% of patients, aligning with reported ranges of 26%–72% in Wiskott-Aldrich Syndrome (WAS) populations [30]. Notably, thrombocytopenia was significantly more prevalent in the autoimmune subgroup (82.6%) compared to the non-autoimmune group (38.9%, p = 0.003), suggesting a potential link between autoimmunity and platelet abnormalities. Elevated IgE levels and CD4 + T-cell deficiencies were more common in the autoimmune group (69.6% and 39.1%, respectively) than in the non-autoimmune group (44.4% and 16.7%), though these differences did not reach statistical significance. Similarly, elevated IgA levels were observed in 60.9% of autoimmune patients versus 38.9% in non-autoimmune patients. These findings are consistent with existing literature indicating that WAS patients with autoimmune complications often exhibit more severe immunological abnormalities, including higher rates of thrombocytopenia and T-cell deficiencies [21, 30]. From a clinical perspective, these observations underscore the importance of tailoring immunomodulatory therapy in WAS patients with autoimmune manifestations. For example, patients with low IgG or IgM and recurrent infections may benefit from early and sustained immunoglobulin replacement, while those with marked IgE elevation and eczema may require targeted anti-Th2 or biologic interventions to control inflammation without aggravating immune dysregulation. Furthermore, the combined presence of humoral defects and autoimmunity may warrant closer monitoring for early HSCT or gene therapy referral, as immune reconstitution has been shown to reduce both infection burden and autoimmune disease progression.

As shown in Table 7; Fig. 1, Age-associated shifts in our cohort, rising IgE/IgA with age alongside declining CD4⁺ T-cell counts fit a model of progressive immune dysregulation in untreated or late-treated WAS. Mechanistically, WASP deficiency impairs regulatory T-cell function (including IL-2R signaling), favoring loss of tolerance and Th2-skewed inflammation that can drive IgE rise over time; this is increasingly supported by patient and mouse study data on WASP-deficient regulatory T cells and tolerance breakdown [31–33]. In parallel, several studies indicate diminished thymic output and cumulative T-cell attrition with age in WAS, consistent with our observed CD4⁺ decline [34, 35]. Together, these patterns strengthen the rationale for early curative intervention, preferably HSCT, which shows steadily improving survival and immune reconstitution when performed earlier in life, and for select cases, emerging gene-therapy approaches under specialist protocols [35].

Phase-two interpretation (variant documentation status). To address potential bias from incomplete variant strings, we performed a phase-two analysis comparing Known-variant (HGVS available; n = 15) with Mutation-positive/variant-unknown (HGVS unavailable; n = 26) patients (Table 9). No significant differences were detected across clinical manifestations, recurrent infections, autoimmunity, lymphocyte subsets, immunoglobulins, or complement. These findings indicate that, in our cohort, variant documentation status did not systematically influence phenotype summaries. Consequently, the descriptive signals reported for the full cohort are unlikely to be artifacts of data capture and remain interpretable despite incomplete HGVS availability.

Table 9.

Phase-two. Clinical and Immunologic features by variant Documentation status: Known-variant (HGVS available; n = 15) vs. Mutation-positive and variant- unknown (HGVS unavailable; n = 26)

Section	Feature	Known-variant (n = 15)	Variant-unknown (n = 26)	P value
Characteristics	Male sex (%)	100.0%	76.9%	0.07
Clinical manifestations	Fever (%)	20.0%	15.4%	0.693
	Cough (%)	13.3%	19.2%	1.0
	Bleeding (%)	13.3%	26.9%	0.445
	Skin disorder (%)	80.0%	73.1%	0.72
	Frequent infections (%)	86.7%	69.2%	0.277
	Autoimmunity (%)	60.0%	53.8%	0.754
	Hepatomegaly (%)	6.7%	7.7%	1.0
	Lymphadenopathy (%)	6.7%	7.7%	1.0
	Pneumonia (%)	40.0%	46.2%	0.754
	Otitis (%)	46.7%	30.8%	0.336
	Sinusitis (%)	0.0%	11.5%	0.287
	Meningitis (%)	13.3%	11.5%	1.0
	Thrombocytopenia (%)	60.0%	53.8%	0.754
Lymphocyte counts	CD3 (median, IQR)	52.5 (49.7–57.2)	61.5 (52.2–75.6)	0.254
	CD4 (median, IQR)	28.9 (25.5–30.9)	33.5 (25.0–44.0)	0.328
	CD8 (median, IQR)	26.7 (19.8–30.4)	17.0 (8.2–35.1)	0.625
	CD19 (median, IQR)	14.0 (13.0–18.0)	12.0 (9.0–15.4.0.4)	0.371
	CD20 (median, IQR)	25.5 (20.8–30.2)	14.4 (7.9–20.0)	0.481
Immunoglobulins	IgG (median, IQR)	988.5 (673.8–1625.0)	1127.0 (853.5–1385.0)	1.0
	IgA (median, IQR)	109.0 (32.2–146.5.2.5)	97.0 (45.5–253.0)	0.718
	IgM (median, IQR)	47.0 (25.8–80.8)	60.0 (38.2–82.0)	0.446
	IgE (median, IQR)	50.0 (11.0–400.0.0.0)	227.0 (45.0–1000.0.0.0)	0.082
Complement	C3 (median, IQR)	51.0 (48.0–53.0)	84.0 (65.2–105.0)	0.275
	C4 (median, IQR)	16.0 (15.0–23.0)	16.0 (15.0–23.0)	0.934
	CH50 (median, IQR)	32.0 (27.0–46.0)	60.0 (34.5–97.5)	0.228

Recent breakthroughs in gene therapy are transforming the therapeutic landscape of Wiskott–Aldrich syndrome. Notably, Vallée et al. detail how lentiviral gene-corrected autologous hematopoietic stem cell transplantation has yielded durable immune reconstitution and resolution of WAS clinical manifestations, with promising safety profiles in early-phase studies [9]. This enhances the translational relevance of our findings, as timely molecular diagnosis especially in patients exhibiting immunoglobulin abnormalities, complement pathway dysfunction, or autoimmune complications becomes even more critical. Gene therapy could offer a curative option without the need for matched donors, particularly benefiting patients in regions like ours where genetic heterogeneity and consanguinity complicate traditional donor-based HSCT. Incorporating these cutting-edge advances strengthens our argument for expanding genetic screening infrastructure and refining indications for early definitive intervention.

Building on these findings, several steps are needed to strengthen the genetic and clinical understanding of WAS in Iran. First, transcript-based standardization of all variants using c./p. HGVS nomenclature should be implemented to ensure consistency and facilitate comparison with global databases. Second, national-scale genotyping of all clinically diagnosed WAS patients is essential to confirm or refute the presence of recurrent mutations or founder effects, particularly in regions with high consanguinity. Third, integrating molecular data with standardized clinical severity scores could refine prognostic stratification and optimize the timing of curative interventions such as HSCT or gene therapy. Curative approaches (HSCT; emerging lentiviral gene-corrected autologous HSC therapy) require individualized risk–benefit assessment considering age, donor availability, conditioning risks, center expertise, and disease burden. Given our cohort’s age and autoimmune/infectious load, earlier referral may be advantageous; however, we avoid extrapolating beyond our data and align with evolving guideline criteria.

Although WAS is estimated at ~ 1–10 per 10^6 live male births globally, our single-country accrual over a decade likely reflects under-ascertainment. Barriers include limited reimbursement for comprehensive sequencing (especially WES), uneven availability of molecular testing early in the study period, potential misclassification as ITP when microthrombocytopenia is overlooked, and referral/survivorship bias. Pragmatic steps to reduce under-diagnosis include (i) a national PID registry with cascade testing of relatives, (ii) earlier use of WASP protein flow cytometry or targeted WAS gene sequencing in infants with thrombocytopenia and small platelets, (iii) clinician education on the “triad” plus autoimmunity, and (iv) improved insurance coverage for genetic confirmation.

These efforts would improve diagnostic precision and counseling for affected families, including female carriers, and contribute valuable regional data to the global WAS knowledge base, enhancing collaborative research and therapeutic strategies.

Limitations

This study has several limitations. Based on available medical records, its retrospective design may have led to incomplete or inconsistent data capture, particularly for longitudinal immunological follow-up. A limitation of this study is that only 15 patients underwent whole-exome sequencing (WES), for whom the exact variant (HGVS) was available, whereas the remaining 26 underwent targeted sequencing of the WAS gene; a mutation was confirmed, but HGVS-level details were not available. The use of WES was constrained in Iran by two contextual factors: First, insurance policies do not cover WES, and its high cost makes it inaccessible for many families and for many centres. Second, the study spans a 10-year period during which WES was not widely available in Iran, particularly in the earlier years of data collection. Therefore, targeted sequencing of the WAS gene was the most practical confirmatory method for the majority of patients. This constraint reduces the ability to draw definitive genotype–phenotype correlations and may have missed recurrent or founder variants specific to the Iranian population. The tertiary referral center setting may also have introduced referral bias, potentially underrepresenting milder or atypical WAS cases in the wider community. Furthermore, lymphocyte subset reference values from a Thai pediatric population were used, as normative data for Iranian children are unavailable, underscoring the need for region-specific immune reference standards. Finally, the retrospective and partly multicentric design limited the comprehensive evaluation of long-term outcomes and disease progression, highlighting the importance of prospective, population-based studies.

Conclusion

This study provides the first comprehensive clinical and immunological characterization of genetically confirmed WAS patients in Iran, contributing valuable regional data to the global understanding of this rare disorder. The predominance of male patients (87.8%) reflects the classic X-linked inheritance pattern, while female carriers exhibited milder or atypical features. We confirm the high frequency of autoimmune manifestations and combined CD4 + T-cell and B-cell deficiencies, consistent with global cohorts. However, our analysis also identified abnormalities in complement components (C3, C4, and CH₅₀) in approximately one-third of patients — a novel observation not reported in prior WAS studies. These findings suggest complement consumption may be associated with immune activation and autoimmunity in WAS and merit further mechanistic exploration. The study emphasizes the critical need for early diagnosis through genetic testing, routine immunological profiling, and timely therapeutic interventions, including hematopoietic stem cell transplantation, to improve prognosis and quality of life in affected individuals.

Abbreviations

WAS

Wiskott-Aldrich Syndrome

HSCT

Hematopoietic Stem Cell Transplantation

PID

Primary Immunodeficiency

IgG

Immunoglobulin G

IgA

Immunoglobulin A

IgM

Immunoglobulin M

IgE

Immunoglobulin E

CD

Cluster of Differentiation

CH50

Total Hemolytic Complement Activity

C3, C4

Complement Components 3 and 4

SPSS

Statistical Package for the Social Sciences

 NGS

Next Generation Sequencing

WASP

Wiskott-Aldrich Syndrome Protein

Authors’ contributions

HE designed the study. MAG and FG wrote the main manuscript. HE, MAG, FG, and SSD gathered data. NR has performed statistical analysis. HN, SA, SD, HA, and FD wrote and edited the final report and reviewed the final draft of the manuscript. All the authors read and approved the final manuscript. HE and FG carried out the patients’ medical treatment.

Funding

Not applicable.

Data availability

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The Ethics Committee of Shiraz University of Medical Sciences approved the study protocol with code (IR.SUMS.MED.REC.1402.479). Written informed consent was obtained from all patients or their legal guardians.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.