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Pagon RA, Adam MP, Ardinger HH, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2014.

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WAS-Related Disorders

, MD, , MS, and , MD, MBA.

Author Information
, MD
Professor of Pediatric Hematology/Oncology, Division of Hematology/Oncology
Immunodeficiency and Histiocytosis Program
Cincinnati Children's Hospital Medical Center
University of Cincinnati College of Medicine
Cincinnati, Ohio
, MS
Genetic Counselor, Division of Human Genetics
Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio
Associate Professor of Pediatrics, Division of Human Genetics
Cincinnati Children's Hospital Medical Center
University of Cincinnati College of Medicine
Cincinnati, Ohio

Initial Posting: ; Last Update: March 20, 2014.


Disease characteristics. The WAS-related disorders, which include Wiskott-Aldrich syndrome, X-linked thrombocytopenia (XLT), and X-linked congenital neutropenia (XLN), are a spectrum of disorders of hematopoietic cells, with predominant defects of platelets and lymphocytes caused by pathogenic variants in WAS. WAS-related disorders usually present in infancy. Affected males have thrombocytopenia with intermittent mucosal bleeding, bloody diarrhea, and intermittent or chronic petechiae and purpura; eczema; and recurrent bacterial and viral infections, particularly recurrent ear infections. At least 40% of those who survive the early complications develop one or more autoimmune conditions including hemolytic anemia, immune thrombocytopenic purpura (ITP), immune-mediated neutropenia, arthritis, vasculitis of small and large vessels, and immune-mediated damage to the kidneys and liver. Individuals with a WAS-related disorder, particularly those who have been exposed to Epstein-Barr virus (EBV), have an increased risk of developing lymphomas, which often occur in unusual, extranodal locations such as the brain, lung, or gastrointestinal tract. Males with XLT have thrombocytopenia with small platelets; other complications of Wiskott-Aldrich syndrome, including eczema and immune dysfunction, are mild or absent.

Diagnosis/testing. The diagnosis of a WAS-related disorder is suspected in males with characteristic hematologic findings and confirmed in the presence of a pathogenic variant in WAS.

Management. Treatment of manifestations: Treatment options depend on an individual's predicted disease burden; hematopoietic cell transplantation (HCT) is the only known curative treatment. Topical steroids for eczema; antibiotics for infected eczema; judicious use of immunosuppressants for autoimmune disease; granulocyte colony stimulating factor (G-CSF) and appropriate antibiotics for neutropenia.

Prevention of primary manifestations: Antibiotic prophylaxis, intravenous immunoglobulin (IVIgG) replacement therapy every three to four weeks by age six months, routine childhood immunizations to prevent infections; judicious use of platelet transfusions for significant bleeding and surgical procedures.

Prevention of secondary complications: Pneumocystis jiroveci (formerly known as Pneumocystis carinii, or PCP) prophylaxis with Bactrim® (trimethoprim-sulfamethoxazole) or pentamidine.

Surveillance: Routine monitoring of blood counts and adequacy of IVIgG replacement therapy.

Agents/circumstances to avoid: Circumcision of at-risk newborn males who have thrombocytopenia; use of medications that interfere with platelet function.

Evaluation of relatives at risk: Evaluation of at-risk newborn males so that morbidity and mortality can be reduced by early diagnosis and treatment.

Genetic counseling. WAS-related disorders are inherited in an X-linked manner. If the mother is a carrier of a WAS pathogenic variant, the chance of transmitting the pathogenic variant in each pregnancy is 50%: males who inherit the pathogenic variant will be affected; females who inherit the pathogenic variant will be carriers. Males will pass the pathogenic variant to all of their daughters and none of their sons. Female carriers of a WAS pathogenic variant are asymptomatic and have no immunologic or biochemical markers of the disorder. Carrier testing for at-risk relatives and prenatal testing for pregnancies at increased risk are possible if the pathogenic variant has been identified in the family.

GeneReview Scope

WAS-Related Disorders: Included Disorders 1
  • Wiskott-Aldrich syndrome
  • X-linked thrombocytopenia (XLT)
  • X-linked severe congenital neutropenia

1. Forms of disorders associated with genes other than WAS are not addressed in this GeneReview.


Clinical Diagnosis

WAS-related disorders comprise a phenotypic spectrum of disordered hematopoietic cells ranging from severe to mild. Before the availability of molecular genetic testing, these phenotypes were thought to be distinct entities rather than a continuum. The phenotypes and their diagnostic criteria, modified from the recommendations of the European Society of Immunodeficiencies (ESID), are the following:

Wiskott-Aldrich syndrome. The diagnosis of Wiskott-Aldrich syndrome should be considered in a male with profound thrombocytopenia (<70,000 platelets/mm2) and small platelet size. Additional diagnostic criteria include the following:

  • Recurrent bacterial or viral infection or opportunistic infection in infancy or early childhood
  • Eczema
  • Lymphoma
  • Autoimmune disorder
  • Family history of one or more maternally related males with a WAS-related phenotype or disorder
  • Absent or decreased Wiskott-Aldrich syndrome protein (WASP) as determined by flow cytometry or western blotting

X-linked thrombocytopenia (XLT). The diagnosis of XLT should be considered in a male with congenital thrombocytopenia and small platelet size in the absence of other clinical findings of Wiskott-Aldrich syndrome. Additional diagnostic criteria include the following:

  • Family history of one or more maternally related males with a WAS-related phenotype or disorder
  • Decreased or absent Wiskott-Aldrich syndrome protein (WASP) as determined by flow cytometry or western blotting
    Note: Some affected individuals have near-normal amounts of WASP.

X-linked congenital neutropenia (XLN). The diagnosis of XLN should be considered in a male with recurrent bacterial infections, persistent neutropenia, and arrested development of the bone marrow in the absence of other clinical findings of Wiskott-Aldrich syndrome. WASP expression is normal in individuals with XLN.


Test results as follows suggest the diagnosis of WAS-related disorders.


  • Small platelet size (mean platelet volume >2 SD below the mean for the laboratory)
  • Proportion and absolute numbers of reticulated platelets (>2 SD below the mean for the laboratory)


  • Decreased T-cell subsets, especially proportion and absolute number of CD8+T cells
  • Decreased NK cell function. Lymphocyte subsets, mitogen responses, and other tests of cell-mediated immunity can vary among individuals, and over time in the same individual.
    Note: (1) Some individuals, particularly children, have normal lymphocyte numbers and normal function. (2) Although the proportion of CD8+ cells is often decreased, it is occasionally increased.
  • Abnormal immunoglobulin levels: decreased IgM, low IgG2; increased IgA, increased IgE
    Note: Quantitative immunoglobulin levels may be normal in some individuals, especially early in life, and can vary over time in the same individual.
  • Absent isohemagglutinins
    Note: Interpretation of the significance of isohemagglutinin titers is unreliable in children younger than age 18 years.
  • Absent or greatly decreased antibody production in response to pneumococcal vaccine (Pneumovax®)

WASP expression

  • Absent or decreased intracellular WASP detection in hematopoietic cells as determined by flow cytometry or western blotting.

Molecular Genetic Testing

Gene. WAS is the only gene in which pathogenic variants are known to cause the WAS-related disorders of Wiskott-Aldrich syndrome, X-linked thrombocytopenia (XLT), and X-linked congenital neutropenia (XLN).

Clinical testing

Table 1. Summary of Molecular Genetic Testing Used in WAS-Related Disorders

Gene 1Test MethodProportion of Probands with a Pathogenic Variant Detectable by This Method
Affected MalesCarrier Females
WASSequence analysis 2 >~95% 3, 4~95% 4, 5
Deletion/duplication analysis 6~5% 7~5% 7

1. See Table A. Genes and Databases for chromosome locus and protein name. See Molecular Genetics for information on allelic variants.

2. Sequence analysis detects variants that are benign, likely benign, of unknown significance, likely pathogenic, or pathogenic. Pathogenic variants may include small intragenic deletions/insertions and missense, nonsense, and splice site variants; typically, exonic or whole-gene deletions/duplications are not detected. For issues to consider in interpretation of sequence analysis results, click here.

3. Lack of amplification by PCR prior to sequence analysis can suggest a putative (multi)exon or whole-gene deletion on the X chromosome in affected males; confirmation may require additional testing by deletion/duplication analysis.

4. Sequencing of the entire coding region and intron/exon boundaries of WAS is estimated to detect approximately 95% of pathogenic variants [Lutskiy et al 2005; Proust et al 2007; Author, personel observation].

5. Sequence analysis of genomic DNA cannot detect deletions of one or more exons or the entire X-linked gene in a heterozygous female.

6. Testing that identifies exonic or whole-gene deletions/duplications not detectable by sequence analysis of the coding and flanking intronic regions of genomic DNA. Included in the variety of methods that may be used are: quantitative PCR, long-range PCR, multiplex ligation-dependent probe amplification (MLPA), and chromosomal microarray (CMA) that includes this gene/chromosome segment.

7. Lutskiy et al [2005]; Proust et al [2007]; Author, personal observation.

X-chromosome inactivation studies. Although hematopoietic cells from obligate female carriers, particularly T cells and platelets, tend to demonstrate a non-random pattern of X-chromosome inactivation, X-chromosome inactivation studies are not adequate to determine carrier status in Wiskott-Aldrich syndrome.

Testing Strategy

To establish the diagnosis in a male proband


Confirm the presence of thrombocytopenia and small platelet size.


Assay for decreased T-cell subsets, decreased NK function, abnormal immunoglobulin levels, absent isohemagglutinin titers, and abnormal antibody production in response to vaccines.


Assay for absent or decreased intracellular WAS protein expression.

Molecular genetic testing may be used to confirm the diagnosis.


Sequence analysis of WAS should be performed first.


Deletion/duplication analysis of WAS may confirm the presence of a large deletion suspected on sequence analysis.

Clinical Description

Natural History

Wiskott-Aldrich syndrome, X-linked thrombocytopenia (XLT), and X-linked neutropenia (XLN) are a spectrum of disorders caused by WAS pathogenic variants that result in deficiency of the Wiskott-Aldrich syndrome protein (WASP), leading to low platelet counts (with small platelet size) and significant risk of serious bleeding, and, in some individuals, abnormal lymphocyte function with susceptibility to serious bacterial, viral, and fungal infections. Autoimmune disorders and lymphomas are frequently encountered in individuals with pathogenic variants in WAS.

Attempts have been made to classify affected individuals as having either XLT or Wiskott-Aldrich syndrome based on (1) presence or absence of autoimmune or inflammatory complications, (2) presence or absence of WAS protein, (3) overall clinical scoring system, or (4) type of WAS mutation; however, it has not been possible to eliminate the considerable overlap between XLT and Wiskott-Aldrich syndrome, an observation that emphasizes the notion that the phenotypes comprising the WAS-related disorders comprise a spectrum, not discrete entities.

WAS-related disorders usually present in infancy; however, because the clinical phenotype may worsen with age, it is particularly difficult to predict eventual disease severity in an infant. The range of clinical complications experienced by affected males can vary widely, even in the same kindred. Long-term prognosis varies based on the predicted disease burden in a particular individual. In some families, adult males in their 60s have mild manifestations such as chronic thrombocytopenia, whereas other affected male relatives succumb from complications of severe manifestations in infancy and childhood [Beel & Vandenberghe 2009, Albert et al 2010b, Buchbinder et al 2011].

The prognosis for individuals with WAS-related disorders has improved in the last 20 years as a result of improved treatment (see Management).

Wiskott-Aldrich Syndrome

Wiskott-Aldrich syndrome usually presents in infancy. Although a triad of (1) bloody diarrhea, mucosal bleeding and/or petechiae; (2) eczema; and (3) recurrent middle-ear infections and purulent drainage from the ears was originally described [Aldrich et al 1954], this triad is identified in only 27% of children with Wiskott-Aldrich syndrome [Sullivan et al 1994].

Common manifestations of Wiskott-Aldrich syndrome include the following:

Thrombocytopenia. Thrombocytopenia is usually present at birth; however, near-normal platelet counts in the newborn period, followed by chronic thrombocytopenia, have been reported. Intracranial bleeding is a potential early life-threatening complication. Intermittent mucosal bleeding and bloody diarrhea are commonly observed, as are intermittent or chronic petechiae and purpura. Life-threatening bleeding occurs in 30% of males prior to diagnosis and accounts for 23% of all non-bone marrow transplantation (BMT)-related deaths [Sullivan et al 1994]. Platelet counts do not adequately represent the risk of bleeding in an individual with Wiskott-Aldrich syndrome [Albert et al 2010a].

Thrombocytopenia may be reversed by splenectomy; however, recurrent thrombocytopenia associated with the development of immune thrombocytopenia purpura (ITP) is observed in some splenectomized individuals.

Eczema. Eczema occurs in about 80% of males with Wiskott-Aldrich syndrome [Sullivan et al 1994]. The severity varies from mild to severe, and tends to be worse in males with a family history of allergies and asthma.

Other skin disorders including impetigo, cellulitis, and abscesses are common.

Infection. Boys with Wiskott-Aldrich syndrome are susceptible to recurrent bacterial and viral infections, particularly recurrent ear infections. They have an increased risk of mortality secondary to bacterial sepsis from encapsulated organisms including Streptococcus pneumonia and Hemophilus influenza B.

Infections by opportunistic agents including cytomegalovirus (CMV), herpes simplex virus (HSV), Epstein-Barr virus (EBV), and adenovirus are common. Pneumocystis carinii pneumonia (PCP) is a possible early life-threatening complication.

Splenectomy, commonly performed in the past to increase platelet counts and reduce risk of fatal hemorrhage, increases the risk of overwhelming bacterial infection.

Autoimmune disorders. At least 40% of males who survive the early complications of Wiskott-Aldrich syndrome develop one or more autoimmune conditions including hemolytic anemia (destruction of red blood cells), immune thrombocytopenic purpura, immune-mediated neutropenia, rheumatoid arthritis, vasculitis of small and large vessels, and immune-mediated damage to the kidneys and liver [Sullivan et al 1994]. High serum IgM concentration in young children prior to splenectomy may be a risk factor for the development of autoimmune hemolytic anemia [Dupuis-Girod et al 2003]; however, the predictive value of this finding awaits confirmation by other investigators.

For a comprehensive review of the autoimmune complications of Wiskott-Aldrich syndrome, see Schurman & Candotti [2003].

The risk of developing an autoimmune disorder increases with age.

The presence of an autoimmune disorder significantly increases the risk of developing lymphoma [Sullivan et al 1994, Schurman & Candotti 2003].

Allogeneic bone marrow transplantation (BMT) corrects autoimmunity in individuals with Wiskott-Aldrich syndrome [Pai et al 2006].

Lymphoma. Individuals with Wiskott-Aldrich syndrome, particularly those who have been exposed to Epstein-Barr virus (EBV), have a high risk of developing lymphomas, which often occur in unusual, extranodal locations such as the brain, lung, or gastrointestinal tract. Although B-cell lymphomas predominate, EBV-associated T-cell lymphomas and Hodgkin lymphomas have also been reported.

Approximately 13% of individuals with Wiskott-Aldrich syndrome develop lymphoma, at an average age of 9.5 years. The risk of developing lymphoma increases with age and in the presence of autoimmune disease [Schurman & Candotti 2003].

The prognosis of individuals with Wiskott-Aldrich syndrome following conventional chemotherapy is poorer than that of age-matched normal controls. Individuals with Wiskott-Aldrich syndrome have a significant risk of relapse or development of a second de novo lymphoma. Individuals with Wiskott-Aldrich syndrome and lymphoma should undergo allogeneic BMT to increase their chances of relapse-free survival.

Life span. The reported median survival of children with Wiskott-Aldrich syndrome who do not undergo successful allogeneic BMT is between eight and 14.5 years [Dupuis-Girod et al 2003]. The causes of non-BMT-related deaths include infection (44% of individuals), malignancy (26%), and bleeding (23%). Survival into adulthood occurs, particularly given the improvement in medical treatment of this disorder over the last 20 years. BMT provides a potential cure for Wiskott-Aldrich syndrome [Friedrich et al 2009].

X-Linked Neutropenia (XLN)

Males with XLN typically present with congenital neutropenia associated with myelodysplasia, increased myeloid cell apoptosis, and lymphoid cell abnormalities. Beel & Vandenberghe [2009] described two males with XLN who developed myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). Boztug & Klein [2011] estimate that 20%-30% of males with XLN are at risk for MDS or AML.

X-Linked Thrombocytopenia (XLT)

Males with XLT have small platelet volume and thrombocytopenia that may be intermittent. Albert et al [2010a] found that life expectancy is not significantly affected in males with XLT as a group; however, severe disease-related events including life-threatening infections, bleeding, autoimmune diseases, and malignancies were common.

Female Carriers for WAS-Related Disorders

Female carriers of a WAS pathogenic variant rarely have significant clinical symptoms and generally have no immunologic or biochemical markers of the disorder; however, mild thrombocytopenia is noted in a small proportion [Parolini et al 1998, Inoue et al 2002, Lutskiy et al 2002, Andreu et al 2003].

Genotype-Phenotype Correlations

Individuals with Wiskott-Aldrich syndrome show remarkable variable expressivity of clinical findings.

While several earlier reports described missense mutations in association with XLT or mild disease and nonsense, frameshift, or splice site mutations in severe disease [Zhu et al 1997, Notarangelo & Ochs 2003, Imai et al 2004], other studies failed to find consistent correlation between a particular mutation and clinical outcome [Greer et al 1996, Schindelhauer et al 1996, Lemahieu et al 1999, Fillat et al 2001].

XLT is typically associated with missense WAS mutations and most males with XLT are able to produce WASP. Specific mutations are not universally associated with XLT and disease severity varies considerably within families [Albert et al 2010b].

X-linked congenital neutropenia (XLN) is caused by rare pathogenic variants in WAS, generally described in the GTPase binding domain, which cause constitutive activation of WASP and lead to increased formation of actin polymers and abnormal cell division. WASP expression in individuals with XLN is comparable to that of normal controls [Devriendt et al 2001]. Disease severity varies considerably within families [Beel & Vandenberghe 2009].

While predictions can sometimes be made based on groups of affected individuals or types of mutations, considerable caution must be exercised in assigning a phenotype to a young, newly diagnosed male based on genotype alone for the following reasons:

Some studies have focused on WAS protein expression as a better predictor of clinical severity of a WAS-related disorder than mutation alone.

  • In one study, 74.2% of individuals who produced WASP had the XLT phenotype, while 86.5% of individuals who produced no WASP had the Wiskott-Aldrich syndrome phenotype [Imai et al 2003].
  • As a group, individuals who expressed a normal-sized mutated WAS protein were significantly less likely to develop autoimmune disease and/or malignancy than individuals who did not express WASP or who expressed only a truncated protein [Jin et al 2004].
  • Lutskiy et al [2005] proposed that clinical phenotype was dependent on the presence or absence of WASP, the level of protein expression, and the molecular structure of the protein; they documented good clinical correlation for five of the most common pathogenic variants in WAS.


Penetrance is complete in males with a WAS pathogenic variant.


Anticipation has not been documented in WAS-related disorders.


The estimated prevalence of WAS-related disorders is between 1:1,000,000 and 1:100,000 males [Ochs & Thrasher 2006].

The disorder occurs worldwide with no racial or ethnic predilection.

Differential Diagnosis

Wiskott-Aldrich Syndrome

Idiopathic thrombocytopenic purpura (ITP) should be considered in the differential diagnosis of males presenting early in life with thrombocytopenia. In contrast to Wiskott-Aldrich syndrome, ITP is associated with increased platelet size and increased reticulated platelet count. ITP is usually transient and self limited.

Wiskott-Aldrich syndrome-2 (WAS-2, WIP deficiency) is a rare immunodeficiency characterized by recurrent infections, eczema, and thrombocytopenia. Like individuals with WAS, individuals with WIP deficiency show low numbers of B and T cells, defective T cell proliferation and chemotaxis, low NK cell function, and abnormal WASP. Unlike individuals with WAS, individuals with WAS-2 have normal platelet volumes. WAS-2 is caused by biallelic pathogenic variants in WIPF1 (WIP) [Lanzi et al 2012]. Molecular testing for WIPF1 pathogenic variants should be considered in symptomatic males, especially those with normal platelet volumes or in whom sequence analysis of WAS did not identify a pathogenic variant, and in symptomatic females.

In males who initially present with Pneumocystis carinii pneumonia, the following conditions should be considered; however, persistent thrombocytopenia is rarely, if ever, seen in these conditions.

  • X-linked severe combined immunodeficiency (X-SCID) typically presents within a few months after birth with persistent viral, bacterial, and fungal infections, lymphocytopenia, growth failure, and thymic hypoplasia. Affected individuals have a low number of T cells, variable number of B cells, low immunoglobulins, and no specific antibodies. X-SCID is caused by a pathogenic variant in the common gamma chain gene (IL2RG).
  • X-linked hyper IgM syndrome typically presents as recurrent bacterial infections (e.g., otitis media, sinusitis, pneumonias) by age one year. Males with this condition often develop autoimmune hematologic disorders including neutropenia, thrombocytopenia, and hemolytic anemia. Other medical complications may include lymphomas and other malignancies, serious gastrointestinal complications, and neurologic deterioration. Elevated IgM in the absence of other immunoglobulins is diagnostic of this condition. X-linked hyper IgM syndrome is caused by pathogenic variants in CD40LG (CD40 ligand).
  • Autosomal recessive severe combined immunodeficiencies, a group of conditions that present with T- and B-cell dysfunction, result in recurrent infections in addition to other variable clinical features, but rarely result in persistent thrombocytopenia. These disorders are caused by pathogenic variants in a number of different genes.
  • Human immunodeficiency virus (HIV) infection results in gradual destruction of the immune system. Individuals infected with HIV are at risk for illness and death from opportunistic infections and neoplasms.

Note to clinicians: For a patient-specific ‘simultaneous consult’ related to Wiskott-Aldrich syndrome, go to Image SimulConsult.jpg, an interactive diagnostic decision support software tool that provides differential diagnoses based on patient findings (registration or institutional access required).

X-Linked Neutropenia (XLN)

The differential diagnosis for XLN is broad and includes autoimmune neutropenia and benign ethnic neutropenia in addition to several novel genetic causes of severe congenital neutropenia. An algorithm for the diagnostic evaluation of patients with neutropenia has been published [Boztug & Klein 2011].

Note to clinicians: For a patient-specific ‘simultaneous consult’ related to X-linked severe congenital neutropenia, see Image SimulConsult.jpg (registration or institutional access required).

X-Linked Thrombocytopenia (XLT)

The differential diagnosis for XLT includes GATA1-related cytopenia, characterized by: thrombocytopenia and/or anemia ranging from mild to severe; and one or more of the following: platelet dysfunction, mild β-thalassemia, neutropenia, and congenital erythropoietic porphyria (CEP) in males. Thrombocytopenia typically presents in infancy as a bleeding disorder with easy bruising and mucosal bleeding, such as epistaxis. Anemia ranges from minimal (mild dyserythropoiesis) to severe (hydrops fetalis requiring in utero transfusion). At the extreme end of the clinical spectrum, severe hemorrhage and/or erythrocyte transfusion dependence are life long; at the milder end, anemia and the risk for bleeding decrease spontaneously with age.

Note to clinicians: For a patient-specific ‘simultaneous consult’ related to X-linked thrombocytopenia, see Image SimulConsult.jpg (registration or institutional access required).


Evaluations Following Initial Diagnosis

At initial diagnosis of Wiskott-Aldrich syndrome an inventory should be made regarding the following:

  • Platelet count and size
  • T-cell subsets
  • Immunoglobulin levels

Medical genetics consultation may also be considered.

Treatment of Manifestations

Treatment options vary based on the predicted disease burden in a particular individual.

Hematopoietic cell transplantation (HCT). The only curative treatment clinically available for Wiskott-Aldrich syndrome is allogeneic HCT. The first successful bone marrow transplant (BMT) for Wiskott-Aldrich syndrome was performed in 1968. Currently, affected boys who receive HCT from a matched healthy sibling or closely matched unrelated donor before their second birthday have a greater than 90% probability of being cured of the disorder [Moratto et al 2011, Shin et al 2012].

Currently, individuals with a WAS pathogenic variant who meet the clinical diagnostic criteria for WAS (WAS score 3-5), have markedly decreased WASP expression and have a suitably matched donor are candidates for HCT. Myeloablative conditioning prior to transplantation is the most widely used approach, as reduced intensity conditioning increases the risk of partial engraftment, which may not be curative [Moratto et al 2011]. Some symptoms (e.g., autoimmune disease) may take months to resolve following complete engraftment.

Since the phenotype of WAS may evolve over time, optimal timing of transplantation is challenging. Current evidence suggests that individuals with absent intracellular WASP detection in hematopoietic cells are likely to evolve to the full WAS phenotype over time, although a minority will exhibit the milder X-linked thrombocytopenia (XLT) phenotype throughout their life span. HCT before development of autoimmunity and malignancy is highly desirable, and younger age at transplant is associated with improved long-term outcome following HCT; however, the use of multiple chemotherapeutic agents necessary to achieve myeloablation is a risk in young infants.

Individuals with WAS who do not have a suitably matched donor but who experience life-threatening complications are candidates for gene therapy (see Therapies Under Investigation).

Eczema. Topical steroids are the mainstay of therapy. When chronic infections of the skin worsen eczema, antibiotics may be useful.

Autoimmune disease. Treatment usually consists of judicious use of immunosuppressants tailored to the individual's diagnosis.

Therapy for individuals with XLT. The primary management of individuals with XLT (WAS score 1-2) remains controversial. The preponderance of evidence suggests that those with XLT be conservatively treated, and that treatment be geared towards management of presenting symptoms. Splenectomy in individuals with XLT has been shown to improve platelet counts. However, lifelong anti-infective prophylaxis is required to avoid potentially fatal bacteremia.

Neutropenia. Treatment of XLN is with granulocyte colony-stimulating factor (G-CSF) and appropriate antibiotics.

Prevention of Primary Manifestations

See Treatment of Manifestations for discussion of hematopoietic cell transplantation (HCT).


  • Antibiotic prophylaxis. Prophylaxis against PCP and antimicrobial therapy for infections
  • Intravenous immune globulin. Replacement therapy with intravenous immunoglobulin every three to four weeks (because of the individual's inability to generate the full array of normal protective antibodies)
  • Routine childhood immunizations


  • Splenectomy. Splenectomy is palliative, and while it may be life-saving in an individual with severe bleeding, it does not prevent any of the other possible complications of the disorder [Mullen et al 1993]. In a survey of clinical immunologists performed by the European and Pan American Groups on Immunodeficiencies, respondents from centers treating the highest numbers of individuals with Wiskott-Aldrich syndrome did not recommend splenectomy [Conley et al 2003]. Because splenectomy significantly increases the risk of life-threatening infections in males with XLT [Albert et al 2010b] as well as in males with Wiskott-Aldrich syndrome who subsequently undergo hematopoietic cell transplantation (HCT) [Ozsahin et al 2008], it should be used with caution.

    Males who have had splenectomy must take antibiotics routinely for the rest of their lives because of the increased risk for overwhelming infection.
  • Platelet transfusions. Platelet transfusions should be administered judiciously, e.g., for significant bleeding and surgical procedures.

Prevention of Secondary Complications

Prophylaxis for pneumonia secondary to Pneumocystis jiroveci, formerly known as Pneumocystis carinii (PCP), is indicated for infants with Wiskott-Aldrich syndrome as they are at risk of developing PCP. Typical prophylaxis is Bactrim® (trimethoprim-sulfamethoxazole) orally or pentamidine by intravenous or inhalation therapy.

IVIgG replacement should be considered by the time the child is six months old, as individuals with Wiskott-Aldrich syndrome cannot generate antibodies to encapsulated bacteria naturally and are at risk for overwhelming infection from these organisms. IVIgG is a highly purified blood derivative (a combination of many specific antimicrobial antibodies) that is typically given every three to four weeks or can be administered subcutaneously, usually on a weekly basis.

Additional antibiotic prophylaxis should be considered on a case-by-case basis.


Regular follow-up is indicated to monitor blood counts, adequacy of the IVIgG replacement therapy, and other potential complications.

Agents/Circumstances to Avoid

Circumcision of an at-risk newborn male should not be undertaken in the presence of thrombocytopenia.

The use of over-the-counter medications should be discussed with a physician as some medications can interfere with platelet function.

When possible, elective surgical procedures should be deferred until after bone marrow transplantation.

Evaluation of Relatives at Risk

Evaluation of newborn at-risk males is recommended before any elective procedure such as circumcision.

It is appropriate to test at-risk males so that morbidity and mortality can be reduced by early diagnosis and treatment. Rapid screening of at-risk males may be accomplished by WASP staining using flow cytometry; definitive testing is possible by molecular genetic testing if the pathogenic variant in the family is known.

See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.

Pregnancy Management

There is no evidence that C-section reduces the risk of morbidity and mortality in males with Wiskott-Aldrich syndrome.

Therapies Under Investigation

Gene therapy shows promise in the treatment of WAS, especially in severely affected males without an HLA-matched donor [Klein et al 2003, Qasim et al 2009, Boztug et al 2010]. However, initial attempts at gene therapy using a retroviral vector resulted in leukemic proliferation in several affected individuals. More recent attempts using a lentiviral vector are promising. Platelet counts in those with WAS after lentiviral gene therapy improve to a point where bleeding and brusing are reversed. Thus far, no evidence of leukemic transformation has been reported with the use of the lentivirus vector [Aiuti et al 2013].

Search ClinicalTrials.gov for access to information on clinical studies for a wide range of diseases and conditions.

Genetic Counseling

Genetic counseling is the process of providing individuals and families with information on the nature, inheritance, and implications of genetic disorders to help them make informed medical and personal decisions. The following section deals with genetic risk assessment and the use of family history and genetic testing to clarify genetic status for family members. This section is not meant to address all personal, cultural, or ethical issues that individuals may face or to substitute for consultation with a genetics professional. —ED.

Mode of Inheritance

WAS-related disorders are inherited in an X-linked manner.

Risk to Family Members

Parents of a proband

  • The father of an affected male will not have a WAS-related disorder nor will he be a carrier of a WAS pathogenic variant.
  • In a family with more than one affected individual, the mother of an affected male is an obligate carrier. Female carriers of a WAS pathogenic variant are asymptomatic and have no immunologic or biochemical markers of the disorder.
  • If pedigree analysis reveals that the proband is the only affected family member, the mother may be a carrier or the affected male may have de novo mutation, in which case the mother is not a carrier.

Sibs of a proband

  • The risk to sibs depends on the carrier status of the mother.
  • If the mother is a carrier of a WAS pathogenic variant, the chance of transmitting the pathogenic variant in each pregnancy is 50%. Males who inherit the pathogenic variant will be affected; females who inherit the pathogenic variant will be carriers and may occasionally have mild thrombocytopenia [Parolini et al 1998, Inoue et al 2002, Lutskiy et al 2002, Andreu et al 2003].
  • Germline mosaicism has been demonstrated in this condition. Thus, even if the pathogenic variant found in the proband has not been identified in DNA extracted from the mother's leukocytes, the sibs remain at increased risk [Areveiler et al 1990].

Offspring of a proband

Other family members of a proband. The proband's maternal aunts or other maternal relatives and their offspring may be at risk of being carriers of a WAS pathogenic variant, if female, or of being affected with a WAS-related disorder, if male; the precise risk to the proband's maternal relatives depends on the family relationships.

Carrier Detection

Carrier testing of at-risk female relatives is possible if the pathogenic variant has been identified in an affected male relative.

If an affected male is not available for testing, molecular genetic testing of at-risk female relatives is done first by sequence analysis, and then, if no pathogenic variant is identified, by deletion/duplication analysis.

Related Genetic Counseling Issues

See Management, Evaluation of Relatives at Risk for information on evaluating at-risk relatives for the purpose of early diagnosis and treatment.

Family planning

  • The optimal time for determination of genetic risk, clarification of carrier status, and discussion of the availability of prenatal testing is before pregnancy.
  • It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected, are carriers, or are at risk of being carriers.

DNA banking is the storage of DNA (typically extracted from white blood cells) for possible future use. Because it is likely that testing methodology and our understanding of genes, allelic variants, and diseases will improve in the future, consideration should be given to banking DNA of affected individuals.

Prenatal Testing

If the pathogenic variant has been identified in an affected family member, prenatal testing for pregnancies at increased risk may be available from a clinical laboratory that offers either testing for this disease/gene or custom prenatal testing.

Preimplantation genetic diagnosis (PGD) may be an option for some families in which the pathogenic variant has been identified.


GeneReviews staff has selected the following disease-specific and/or umbrella support organizations and/or registries for the benefit of individuals with this disorder and their families. GeneReviews is not responsible for the information provided by other organizations. For information on selection criteria, click here.

  • Canadian Immunodeficiencies Patient Organization (CIPO)
    362 Concession Road 12
    RR #2
    Hastings Ontario K0L 1Y0
    Phone: 877-262-2476 (toll-free)
    Fax: 866-942-7651 (toll-free)
    Email: info@cipo.ca
  • Immune Deficiency Foundation (IDF)
    40 West Chesapeake Avenue
    Suite 308
    Towson MD 21204
    Phone: 800-296-4433 (toll-free)
    Email: idf@primaryimmune.org
  • Jeffrey Modell Foundation/National Primary Immunodeficiency Resource Center
    747 Third Avenue
    New York NY 10017
    Phone: 866-463-6474 (toll-free); 212-819-0200
    Fax: 212-764-4180
    Email: info@jmfworld.org
  • European Society for Immunodeficiencies (ESID) Registry
    Dr. Gerhard Kindle
    University Medical Center Freiburg Centre of Chronic Immunodeficiency
    UFK, Hugstetter Strasse 55
    79106 Freiburg
    Phone: 49-761-270-34450
    Email: registry@esid.org
  • NCI Inherited Bone Marrow Failure Syndromes (IBMFS) Cohort Registry
    National Cancer Institute
    Phone: 800-518-8474
    Email: lisaleathwood@westat.com
  • Primary Immunodeficiency Diseases Registry at USIDNET
    40 West Chesapeake Avenue
    Suite 308
    Towson MD 21204-4803
    Phone: 866-939-7568
    Fax: 410-321-0293
    Email: contact@usidnet.org

Molecular Genetics

Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.

Table A. WAS-Related Disorders: Genes and Databases

Data are compiled from the following standard references: gene symbol from HGNC; chromosomal locus, locus name, critical region, complementation group from OMIM; protein name from UniProt. For a description of databases (Locus Specific, HGMD) to which links are provided, click here.

Table B. OMIM Entries for WAS-Related Disorders (View All in OMIM)


Gene structure. WAS comprises 12 exons that span more than 9 kb of genomic DNA. For a detailed summary of gene and protein information, see Table A, Gene Symbol.

Benign allelic variants. One normal allelic variant of WAS (p.Val332Ala) has been reported. Several intronic sequence variants have been reported, but these are highly unlikely to have any pathogenic effect on WASP [NCBI SNP Cluster ID: rs482472].

Pathogenic allelic variants. Approximately 240 pathogenic WAS variants have been published. Pathogenic variants have been found in all 12 exons. About half of these pathogenic variants are missense mutations that interfere with protein function or nonsense mutations that lead to protein truncation. The remaining mutations are small deletions/insertions, splicing mutations, and gross deletions/insertions. See Table A.

Normal gene product. The 1.8 kb of mRNA transcript encodes an intracellular 53-kd proline-rich protein of 502 amino acids termed WASP (Wiskott-Aldrich syndrome protein). WASP is expressed mainly in hematopoietic cells and has a role in signal transduction [Cory et al 1996, Snapper & Rosen 1999] and actin cytoskeleton organization in response to external stimuli [Kolluri et al 1996, Bompard & Caron 2004, Stradal et al 2004].

WASP activity is regulated by interaction with activated guanosine triphosphate (GTP)-loaded Cdc42 [Hemsath et al 2005] and post-translational modification (e.g., phosphorylation) [Badour et al 2004]. In normal NK cells, WASP is expressed and localized to the activating immunologic synapse with filamentous actin (F-actin), which presumably plays an important role in NK cell cytolytic function [Orange et al 2002].

Abnormal gene product. WAS pathogenic variants lead to changes in the amino acid sequence, truncation, or absence of WASP.

Because the actin cytoskeleton plays an important role in cell adhesion and migration, T and B lymphocytes, neutrophils, macrophages, and dendritic cells of males with WAS-related disorders exhibit defects in migration, anchoring, and localization [Kolluri et al 1996, de Noronha et al 2005, Snapper et al 2005, Gallego et al 2006].


Published Guidelines/Consensus Statements

  1. American Society of Human Genetics and American College of Medical Genetics. Points to consider: ethical, legal, and psychosocial implications of genetic testing in children and adolescents. Available online. 1995. Accessed 7-15-14. [PMC free article: PMC1801355] [PubMed: 7485175]
  2. American Society of Human Genetics Social Issues Subcommittee on Familial Disclosure. ASHG statement. Professional disclosure of familial genetic information. Available online. Registration or institutional access required. 1998. Accessed 7-15-14. [PMC free article: PMC1376910] [PubMed: 9537923]
  3. European Society for Immunodeficiencies (ESID). Diagnostic criteria for primary immunodeficiencies: Wiskott-Aldrich syndrome. Available online. 2006. Accessed 7-15-14.

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Suggested Reading

  1. Bosticardo M, Marangoni F, Aiuti A, Villa A, Roncarolo MG. Recent advances in understanding the pathophysiology of Wiskott-Aldrich syndrome. Blood. 2009;113:6288–95. [PubMed: 19351959]
  2. French DL, Newman PJ, Poncz M. Inherited disorders of platelets. In: Scriver CR, Beaudet AL, Sly WS, Valle D, Vogelstein B, eds. The Online Metabolic and Molecular Bases of Inherited Disease (OMMBID). Chap 177. New York, NY: McGraw-Hill. Available online. Accessed 3-17-14.
  3. Griffith LM, Cowan MJ, Notarangelo LD, Kohn DB, Puck JM, Pai SY, Ballard B, Bauer SC, Bleesing JJ, Boyle M, Brower A, Buckley RH, van der Burg M, Burroughs LM, Candotti F, Cant AJ, Chatila T, Cunningham-Rundles C, Dinauer MC, Dvorak CC, Filipovich AH, Fleisher TA, Bobby Gaspar H, Gungor T, Haddad E, Hovermale E, Huang F, Hurley A, Hurley M, Iyengar S, Kang EM, Logan BR, Long-Boyle JR, Malech HL, McGhee SA, Modell F, Modell V, Ochs HD, O'Reilly RJ, Parkman R, Rawlings DJ, Routes JM, Shearer WT, Small TN, Smith H, Sullivan KE, Szabolcs P, Thrasher A, Torgerson TR, Veys P, Weinberg K, Zuniga-Pflucker JC. on behalf of the workshop participants. Primary Immune Deficiency Treatment Consortium (PIDTC) report. J Allergy Clin Immunol. 2014;133:335–47. [PMC free article: PMC3960312] [PubMed: 24139498]
  4. Gulacsy V, Freiberger T, Shcherbina A, Pac M, Chernyshova L, Avcin T, Kondratenko I, Kostyuchenko L, Prokofjeva T, Pasic S, Bernatowska E, Kutukculer N, Rascon J, Iagaru N, Mazza C, Toth B, Erdos M, van der Burg M. Marodi L Genetic characteristics of eighty-seven patients with the Wiskott-Aldrich syndrome. Mol Immunol. 48:788–92. [PubMed: 21185603]
  5. Kamani NR, Kumar S, Hassebroek A, Eapen M, LeRademacher J, Casper J, Cowan M, Sánchez de Toledo J, Ferster A, Szabolcs P, Wingard JR, Horwitz E, Filipovich AH. Malignancies after hematopoietic cell transplantation for primary immune deficiencies: a report from the Center for International Blood and Marrow Transplant Research. Biol Blood Marrow Transplant. 2011;17:1783–9. [PMC free article: PMC3370408] [PubMed: 21658461]
  6. Massaad MJ, Ramesh N, Geha RS. Wiskott-Aldrich syndrome: a comprehensive review. Ann N Y Acad Sci. 2013;1285:26–43. [PubMed: 23527602]
  7. Ochs HD, Filipovich AH, Veys P, Cowan MJ, Kapoor N. Wiskott-Aldrich syndrome: diagnosis, clinical and laboratory manifestations, and treatment. Biol Blood Marrow Transplant. 2009;15:84–90. [PubMed: 19147084]
  8. Pai SY, Notarangelo LD. Hematopoietic cell transplantation for Wiskott-Aldrich syndrome: advances in biology and future directions for treatment. Immunol Allergy Clin North Am. 2010;30:179–94. [PMC free article: PMC2930258] [PubMed: 20493395]

Chapter Notes

Revision History

  • 20 March 2014 (me) Comprehensive update posted live
  • 28 July 2011 (me) Comprehensive update posted live
  • 27 April 2007 (me) Comprehensive update posted to live Web site
  • 30 September 2004 (me) Review posted to live Web site
  • 1 October 2003 (jj) Original submission
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