Adenosine Deaminase Deficiency

[ADA Deficiency. Includes: Adenosine Deaminase-Deficient Severe Combined Immunodeficiency Disease (SCID), Delayed-/Late-Onset Adenosine Deaminase Deficiency, Partial Adenosine Deaminase Deficiency]

Clinical Diagnosis

Diagnostic criteria for adenosine deaminase (ADA) deficiency:

• Evidence of combined immunodeficiency

• Less than 1% of normal ADA catalytic activity in hemolysates (in un-transfused patients) or in extracts of other cells (e.g., blood mononuclear cells, fibroblasts)

Testing

Immune function

• Lymphopenia, the laboratory hallmark of ADA-deficient severe combined immunodeficiency disease (SCID), is present at birth. The total blood lymphocyte count is usually lower than 500/µL (normal for neonates: 2,000 to >5,000).

• All lymphoid lineages (T-, B-, and NK-cells) are depleted as demonstrated by flow cytometry.

• In vitro lymphocyte function, as measured by proliferative response to mitogens and antigens, is low or absent.

• Serum immunoglobulins are low and no specific antibody response to infections and immunizations is observed.

Adenosine deaminase (ADA) catalytic activity

• Affected individuals who have not been transfused have less than 1% of normal ADA catalytic activity in erythrocyte hemolysates.

• Affected individuals who have been recently transfused may require testing of another cell type, such as fibroblasts or leukocytes.

Note: (1) Both spectrophotometric and radiochemical methods have been used to assay ADA catalytic activity [Hershfield & Mitchell 2001]. (2) Analysis of plasma is not useful for diagnosis because ADA catalytic activity is much lower in plasma than in cells, even in controls, and because plasma contains a nonspecific "ADA-like" activity not derived from ADA.

For laboratories offering biochemical testing, see .

Biochemical markers of ADA deficiency. The inability to deaminate 2'-deoxyadenosine (dAdo) results in specific metabolic abnormalities in erythrocytes and urine of affected individuals. These markers may help to confirm the diagnosis and to monitor therapies intended to restore ADA function:

• Elevated erythrocyte dAdo nucleotides (dAXP). Normal red cells lack dAXP, usually determined by high-pressure liquid chromatography (HPLC). ADA deficiency permits excessive dAdo phosphorylation, leading to a pathognomonic marked increase in total dAXP (mainly dATP) levels in red cells. If the affected individual has not been transfused, the level of dAXP correlates with clinical phenotype (ADA-deficient SCID > "delayed/late" onset > "partial ADA deficiency") and can be used in monitoring the biochemical effectiveness of therapy.

• Reduced erythrocyte S-adenosylhomocysteine hydrolase (AdoHcyase, SAHase) activity. Owing to inactivation by dAdo, AdoHcyase (SAHase) activity is less than 5% of normal.

• Urinary dAdo. Excretion of dAdo, usually measured by HPLC, is markedly elevated in individuals with ADA-deficient SCID.

Molecular Genetic Testing

GeneReviews designates a molecular genetic test as clinically available only if the test is listed in the GeneTests Laboratory Directory by either a US CLIA-licensed laboratory or a non-US clinical laboratory. GeneTests does not verify laboratory-submitted information or warrant any aspect of a laboratory's licensure or performance. Clinicians must communicate directly with the laboratories to verify information.—ED.

Gene. ADA is the only gene associated with ADA deficiency.

Clinical testing

• Sequence analysis. Sequence analysis of ADA (exons and intron/exon boundaries) can identify most known mutations, except for large deletions.

Table 1 summarizes molecular genetic testing for this disorder.

Table 1. Molecular Genetic Testing Used in Adenosine Deaminase Deficiency

Gene Symbol	Test Method	Mutations Detected	Mutation Detection Frequency by Test Method	Test Availability
ADA	Sequence analysis	Sequence variants	>90% 1	Clinical
	Duplication/deletion testing	Large deletions, rearrangements	Unknown	Research only

1. In individuals with biochemically documented ADA deficiency

Interpretation of test results. If novel single nucleotide changes are within the coding region, the effect on ADA enzymatic activity should be assessed (e.g., by expressing an ADA cDNA with the novel change in E. coli).

For issues to consider in interpretation of sequence analysis results, click here.

Testing Strategy

Confirming the diagnosis in a proband. Expeditious testing for ADA deficiency in individuals suspected of having SCID is critical both because such individuals are often seriously ill and in need of specific therapy by the time this diagnosis is considered and because the therapeutic options for ADA deficiency are different from those for SCID caused by other molecular defects.

• Biochemical testing for the absence of ADA enzymatic activity in red cells is usually the most rapid means of diagnosis: results are often obtained within 24-48 hours. Finding elevated dAXP in red cells confirms the diagnosis of ADA deficiency and is often informative in individuals with SCID who have been transfused.

• Molecular genetic testing for ADA deficiency usually cannot be performed as rapidly as biochemical testing.

Carrier testing for at-risk relatives requires prior identification of the disease-causing mutations in the family.

Note: Carriers are heterozygotes for this autosomal recessive disorder and are not at risk of developing the disorder.

Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for at-risk pregnancies require prior identification of the disease-causing mutations in the family.

Genetically Related (Allelic) Disorders

No other phenotypes are associated with mutations in ADA.

Natural History

Adenosine deaminase (ADA) deficiency is a systemic purine metabolic disorder that primarily affects lymphocyte development and function [Hirschhorn 1999, Hershfield & Mitchell 2001, Hershfield 2004]. The phenotype ranges from SCID in infants, to less severe "delayed/late" onset in older children and adults, to benign "partial ADA deficiency."

Severe combined immunodeficiency disease (SCID). Infants with ADA-deficient SCID have failure to thrive and opportunistic infections associated with marked lymphocytopenia and the absence of both humoral and cellular immune function. The diagnosis of SCID is generally made within the first six months of life.

The initial hospitalization is often for pneumonitis, which may result from viral infection or Pneumocystis jiroveci infection; however, a causative agent may not be identified. Persistent diarrhea, extensive dermatitis, and other life-threatening illnesses caused by opportunistic infections occur frequently.

Physical findings include growth failure, the absence of lymphoid tissues (tonsils, lymph nodes), and effects of specific infections. Thymus shadow is absent on x-ray. Although similar clinically to other forms of SCID, ADA-deficient SCID may be accompanied by characteristic rib abnormalities (cupping and flaring of costochondral junctions) and a higher incidence of hepatic and various neurologic abnormalities.

The manifestations of combined immune deficiency dominate the clinical presentation of ADA deficiency. In some cases, abnormal liver function tests or various neurologic abnormalities (including sensorineural deafness) also occur and may be clinically significant [Bollinger et al 1996, Tanaka et al 1996, Albuquerque & Gaspar 2004]. It is often unclear whether these hepatic and neurologic abnormalities are caused by the metabolic effects of ADA deficiency itself or are secondary to the immunodeficiency (i.e., to infections or to their treatment, e.g. with aminoglycoside antibiotics). However, in some individuals, hepatic and neurologic abnormalities have improved or resolved with institution of enzyme replacement therapy (ERT).

If immune function is not restored, individuals with ADA-deficient SCID rarely survive beyond age one to two years.

Delayed-/late-onset ADA deficiency. Approximately 15%-20% of children with ADA deficiency have a "delayed" onset of clinical symptoms after age six months or during the first few years of life. Rarely, individuals are diagnosed in the second to fourth decades ("late/adult" onset). Infections in delayed- and late-onset types may initially be less severe than those in individuals with ADA-deficient SCID and growth may be less severely affected. Recurrent otitis, sinusitis, and upper-respiratory infections are common. By the time of diagnosis, these individuals often have chronic pulmonary insufficiency and possibly autoimmune phenomena, including cytopenias and anti-thyroid antibodies. Allergies and elevated serum concentration of IgE are common.

Individuals with a delayed- or late-onset phenotype may survive undiagnosed into the first decade of life or beyond. However, the longer the disorder goes unrecognized, the more immune function deteriorates and the more likely are chronic sequelae of recurrent respiratory and other types of infection.

Partial ADA deficiency. Screening of populations and families of probands with ADA-deficient SCID has identified some healthy individuals with very low or absent ADA activity in erythrocytes, but greater levels of ADA activity (2%-50% of normal) in nucleated cells. This benign condition has been called "partial ADA deficiency."

Genotype-Phenotype Correlations

Most known ADA mutations have been discovered through research into the relationship of genotype to phenotype [Hirschhorn et al 1990, Santisteban et al 1993, Arredondo-Vega et al 1994, Ozsahin et al 1997].

• A good correlation has been established between the effect of mutations on ADA activity and both clinical and metabolic phenotype [Arredondo-Vega et al 1998].

• In several individuals the relationship of genotype to phenotype was modulated by mosaicism in lymphoid cells for reversion of deleterious mutations [Hirschhorn et al 1994, Hirschhorn et al 1996, Ariga et al 2001a, Arredondo-Vega et al 2002, Liu et al 2008].

Systematic expression in E. coli of more than 30 cDNAs with single missense mutations identified in ADA-deficient individuals has shown that the total ADA activity expressed by both of an individual's mutant alleles correlates with age at diagnosis and the level of erythrocyte dAXP measured prior to treatment [Arredondo-Vega et al 1998]. A system for ranking the severity of genotypes has been proposed based on these data and the potential of other alleles to provide ADA activity. For this purpose, individual mutant ADA alleles are clustered in groups, as follows:

• Group 0: "null" alleles (deletion, frameshifting, or nonsense mutations)

• Groups I-IV: missense mutations ranked in order of increasing activity expressed in the E. coli system

• Splice-site mutations: a separate group, as a low level of normal splicing may result in variable levels of ADA activity

Phenotype correlation with mutation type was assessed for 52 clinically diverse individuals with 43 genotypes composed of 42 different mutant alleles [Arredondo-Vega et al 1998]:

• ADA-deficiency SCID: Both alleles scored as 0 or I.

• Delayed-/late-onset ADA deficiency: At least one allele in group II or III was detected.

• Partial ADA deficiency: At least one group IV allele was detected.

Discordance in phenotype among first-degree ADA-deficient relatives in several families has been attributed to the following:

• Individual differences in "leakiness" of a splice-site mutation [Arredondo-Vega et al 1994]

• Mosaicism for reversion of a mutant allele in lymphoid cells [Arredondo-Vega et al 2002]

• The segregation of both severe and mild mutant alleles in a family [Santisteban et al 1995, Ozsahin et al 1997, Ariga et al 2001b]

Prevalence

ADA deficiency has been estimated to occur in from 1:200,000 to 1:1,000,000 births.

All racial and ethnic groups are affected. Prevalence is higher in some geographic areas where a high degree of consanguinity exists in certain population groups.

Evaluations Following Initial Diagnosis

To establish the extent of disease in an individual diagnosed with adenosine deaminase (ADA) deficiency, the following evaluations are recommended:

• Identification of specific disease-causing viral, fungal, or bacterial organisms (both normal pathogens and opportunistic agents)

• Complete blood count (CBC)

• Flow cytometry to quantify lymphocyte subsets (T-, B-, NK-cells)

• Assessment of humoral immune function by measuring serum immunoglobulins and the titer of specific antibodies related to infections and immunizations

• Evaluation of cellular immune function by in vitro response of blood mononuclear cells to mitogens and antigens

• Measurement of erythrocyte dAXP concentration to evaluate metabolic severity

• Liver function testing to assess for metabolic hepatitis

• Auditory testing

• Other testing as indicated by clinical manifestations

Treatment of Manifestations

The following are appropriate:

• Treatment of infections with specific antibiotic, antifungal, and antiviral agents

• Prophylaxis for Pneumocystis jiroveci

• Intravenous immunoglobulin (IVIg)

Prevention of Primary Manifestations

Restoring a functional immune system is essential and can be achieved in several ways. The choice of therapy is complex and depends on a number of factors, including the patient's age and clinical status, the expectations and desires of the parents, and the specific experience and expertise of physicians in treating ADA-deficient SCID. The experience with treatment of individuals with ADA deficiency was the subject of a workshop in 2006 [Booth et al 2007]. A second workshop aimed at producing consensus guidelines for therapy was conducted in September 2008; publication of a report in 2009 is anticipated.

For more than 20 years the method of choice for treating all forms of SCID has been bone marrow/stem cell transplantation (BMT/SCT) from an HLA-identical healthy sibling [Buckley et al 1999]. This can be performed without cytoreductive conditioning of the patient, and without depletion of donor T-cells. Results vary among transplant centers, but the procedure is curative in approximately 70% or more of affected individuals. The main risks are graft-versus-host disease and delayed or incomplete recovery of humoral immune function, requiring continued treatment with IVIg.

For the majority of individuals with ADA-deficient SCID who lack an HLA-identical related donor, two other forms of treatment, which have been available for more than 15 years, can be considered:

• BMT/SCT from a "non-ideal" donor (HLA-matched, unrelated; HLA-haploidentical parent; umbilical cord blood)

• Enzyme replacement therapy (ERT) with polyethylene glycol-modified bovine adenosine deaminase (PEG-ADA, Adagen^®)

• The status of gene therapy is discussed in Therapies Under Investigation.

BMT/SCT from a "non-ideal" donor. Donor-derived T-cells are depleted to minimize the risk of graft-versus-host disease. Pre-transplant cytoreductive "conditioning" of the recipient (patient with SCID) is often performed to prevent graft loss, which occurs with relative frequency in SCID patients with ADA deficiency who are not conditioned. Some transplant centers do not perform conditioning of the recipient prior to a haploidentical transplant because of the risk of peri-transplant morbidity [Buckley et al 1999]. However, this latter approach has frequently been associated with a failure to achieve stable engraftment [Booth et al 2007].

Following a T-cell-depleted transplant, return of functional T-cells requires three to four months. B-cell reconstitution is delayed longer, or may not be adequately achieved, requiring long-term therapy with IVIg.

Universal agreement regarding the best methods for performing partially mismatched BMT/SCT does not exist. When considering therapeutic options, it is therefore important for parents to obtain specific information about prior experience and long-term results of transplants for ADA-deficient SCID at the center where their child will be treated.

In addition to differences in methodology, evaluation of results with partially mismatched BMT/SCT is difficult because ADA deficiency accounts for only approximately 15% of SCID. Nevertheless, available data indicate greater morbidity and mortality after pre-transplant conditioning among patients with ADA deficiency than among those with other forms of SCID [Haddad et al 1998, Antoine et al 2003, Grunebaum et al 2006]. Survival beyond two to three years post-transplant has ranged from below 50% to approximately 65%. Individuals with ADA-deficient SCID may also be more likely to develop various neurologic abnormalities as a late complication after BMT/SCT, regardless of the HLA compatibility of the donor and recipient [Rogers et al 2001, Grunebaum et al 2006, Honig et al 2007]. This is an area of ongoing interest.

Enzyme replacement therapy (ERT). PEG-ADA is composed of purified bovine ADA covalently linked to multiple strands of PEG (average mass: 5 kd) in order to prolong circulating life and reduce immunogenicity. It is administered by intramuscular injection once or twice a week (~15-60 U/kg per week). By maintaining a high level of ADA activity in plasma, PEG-ADA eliminates extracellular Ado and dAdo, preventing the toxic metabolic effects that interfere with lymphocyte viability and function and that may injure other organs (liver, lung, brain) [Hershfield et al 1987, Hershfield & Mitchell 2001, Hershfield 2004].

ERT is not curative; PEG-ADA must be given regularly and at a sufficient dose to maintain a non-toxic metabolic environment.

PEG-ADA has been used as a primary therapy in individuals who lack an HLA-identical marrow/stem cell donor when the risks associated with a partially mismatched transplant are deemed too great or when the risk of graft failure is high, as in older individuals with a delayed- or late-onset phenotype. PEG-ADA has also been used as a secondary therapy in patients who have failed to engraft following an unconditioned BMT/SCT, or in whom an acceptable recovery of immune function has not been achieved following experimental gene therapy.

Most individuals treated with PEG-ADA recover partial immune function that is sufficient to prevent opportunistic infections and other clinical manifestations of SCID. As with T cell-depleted BMT/SCT, a lag of approximately two to four months occurs before T-cell function appears, but B-cells often increase earlier than after BMT/SCT. Lymphocyte counts and in vitro lymphocyte function usually increase during the first year of ERT, but beyond the first year or two most PEG-ADA-treated individuals remain lymphopenic and in vitro lymphocyte function fluctuates over a wide range. Most individuals remain clinically well, but over time lymphocytes gradually decline in number and display various functional abnormalities [Chan et al 2005, Malacarne et al 2005]. Approximately half of those maintained on ERT continue to receive IVIg.

PEG-ADA received FDA approval in 1990. As of April 2006, more than 150 individuals have been treated worldwide, and approximately 90 individuals are currently under treatment [Booth et al 2007]. The outcome of PEG-ADA therapy through 2004 has been reviewed [Hershfield 2004]. Survival of PEG-ADA-treated individuals beyond five years and through approximately ten years has been 75%-80%, comparable or superior to that achieved with BMT/SCT. Most deaths have occurred during the first six months of treatment, with the majority in the first month due to life-threatening infections present at diagnosis. Most late deaths (beyond two years of treatment) have been caused by progression of chronic pulmonary insufficiency that was present at the time ERT was begun.

Lymphoproliferative disorders have developed in four individuals who were treated with PEG-ADA for eight to 15 years [Hershfield 2004, Chan et al 2005, Kaufman et al 2005, Husain et al 2007]. Several other patients have developed persistent hemolytic anemia, which in some cases began in association with a viral infection or with central catheter sepsis [Hershfield 2004, Lainka et al 2005].

The limitations of PEG-ADA therapy include primary failure to recover protective immune function, the development of neutralizing antibodies that reduce or eliminate efficacy, immune dysregulation (particularly in the first few months of therapy), and a risk that immune function will eventually (i.e., beyond 10-15 years) decline to an inadequate level. Approximately 20% of patients have discontinued ERT in order to undergo BMT/SCT. In most of these cases, the transplant had been intended at the time of diagnosis but not performed because a suitable donor was not available or the patient had been too ill to undergo the procedure. In a minority of individuals, the transplant was performed because of declining immune function while receiving PEG-ADA. Overall, approximately half of these secondary transplants have been successful [Hershfield 2004].

Most individuals treated with PEG-ADA for longer than a year develop antibodies that bind specifically to bovine ADA and are detectable by an enzyme-linked immunosorbent assay (ELISA); these are of no clinical significance. Neutralizing antibodies that inhibit catalytic activity and enhance clearance of PEG-ADA (and which do compromise efficacy) have developed in fewer than 10% of treated individuals [Chaffee et al 1992, Hershfield 1997]. No allergic or hypersensitivity reactions to PEG-ADA have occurred, and the treatment has generally been well tolerated.

Prevention of Secondary Complications

As noted under Treatment of Manifestations, patients receive antibiotic prophylaxis for Pneumocystis, and also IVIG, prior to immune reconstitution. The use of such prophylaxis following transplantation and while receiving ERT varies and depends on the level of immune reconstitution achieved.

Surveillance

Annual (or more frequent) evaluation of lymphocyte counts and in vitro tests of cellular and humoral immune function (i.e., as listed above for the evaluation of patients suspected of having SCID) should be performed following BMT/SCT and during ERT.

Individuals on ERT also require periodic monitoring as follows:

• Plasma levels of PEG-ADA activity

• Erythrocyte dAXP concentration

• Development of neutralizing antibodies, particularly if plasma ADA activity or clinical or immunologic status declines unexpectedly

Agents/Circumstances to Avoid

The use of adenine arabinoside (a substrate for ADA) as an antiviral agent or for chemotherapy of malignancies, should be avoided.

Pentostatin, a potent ADA inhibitor used to treat some lymphoid malignancies, would be ineffective in patients who lack ADA, and would interfere with PEG-ADA.

Testing of Relatives at Risk

In the newborn sibs of a proband, it is appropriate to either assay ADA catalytic activity or perform molecular genetic testing (if the family-specific disease-causing mutations are known) so that morbidity and mortality can be reduced by early diagnosis and treatment.

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

Therapies Under Investigation

Experimental gene therapy for ADA-deficient SCID employing retroviral vectors has been under clinical investigation for more than 15 years [Engel et al 2003, Cavazzana-Calvo et al 2005]. Clinical trials since about 2000 have employed an approach first reported for two patients treated in Milan, Italy [Aiuti et al 2002]. This involves discontinuing PEG-ADA (in patients receiving ERT) and administering non-myeloablative conditioning prior to the infusion of ADA vector-transduced autologous CD34+ stem cells. In addition to Milan, variations on this protocol are currently under investigation in the UK, US, and Japan. The total number of patients treated at these centers to date is approximately 25, although results have been reported for only a few cases [Aiuti et al 2002, Gaspar et al 2006, Engel et al 2007]. In most, but not all, patients treated in Milan, stable ADA expression in lymphoid cells has been achieved, along with correction of metabolic abnormalities in erythrocytes, which has resulted in maintenance of good health without the need for ERT. In contrast to the experience with gene therapy for X-linked SCID, no patients with ADA deficiency have thus far developed leukemia due to vector-associated insertional mutagenesis following gene therapy [Aiuti et al 2007].

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

Other

Genetics clinics are a source of information for individuals and families regarding the natural history, treatment, mode of inheritance, and genetic risks to other family members as well as information about available consumer-oriented resources. See the GeneTests Clinic Directory.

Support groups have been established for individuals and families to provide information, support, and contact with other affected individuals. The Resources section may include disease-specific and/or umbrella support organizations.

Mode of Inheritance

Adenosine deaminase (ADA) deficiency is inherited in an autosomal recessive manner.

Risk to Family Members

Parents of a proband

• The parents of an affected child are obligate heterozygotes and therefore carry one mutant allele.

• Heterozygotes (carriers) are asymptomatic.

Sibs of a proband

• At conception, each sib of an affected individual has a 25% chance of being affected, a 50% chance of being an asymptomatic carrier, and a 25% chance of being unaffected and not a carrier.

• Once an at-risk sib is known to be unaffected (i.e., immunocompetent), the risk of his/her being a carrier is 2/3.

• Heterozygotes (carriers) are asymptomatic.

Offspring of a proband. The offspring of an individual with ADA deficiency are expected to be obligate heterozygotes (carriers) for a disease-causing mutation in ADA.

Other family members of a proband. Each sib of the proband's parents is at a 50% risk of being a carrier.

Carrier Detection

Molecular genetic testing. Carrier testing for at-risk family members is possible once the mutations have been identified in the family.

Biochemical testing. Measurement of ADA activity in erythrocytes has been used to identify heterozygotes. However, as there is some overlap between the erythrocyte ADA activity in heterozygotes and the lower end of the normal range, the results of biochemical testing should be interpreted with caution.

Related Genetic Counseling Issues

See Management, Testing of Relatives at Risk for information on testing 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, carriers, or at risk of being carriers.

DNA banking. 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, mutations, and diseases will improve in the future, consideration should be given to banking DNA of affected individuals. DNA banking is particularly relevant when the sensitivity of currently available testing is less than 100%. See for a list of laboratories offering DNA banking.

Prenatal Testing

Biochemical testing. Prenatal diagnosis for pregnancies at increased risk is possible by analysis of ADA activity in cultured amniotic fibroblasts or cultured chorionic villi cells grown from fetal cells obtained by amniocentesis, usually performed at approximately 15-18 weeks' gestation, or chorionic villus sampling (CVS) at approximately ten to 12 weeks' gestation.

Note: Gestational age is expressed as menstrual weeks calculated either from the first day of the last normal menstrual period or by ultrasound measurements.

Molecular genetic testing. No laboratories offering molecular genetic testing for prenatal diagnosis of ADA deficiency are listed in the GeneTests Laboratory Directory. However, prenatal testing may be available for families in which the disease-causing mutations have been identified in an affected family member. For laboratories offering custom prenatal testing, see .

Preimplantation genetic diagnosis (PGD) may be available for families in which the disease-causing mutations have been identified. For laboratories offering PGD, see .

Literature Cited

Published Statements and Policies Regarding Genetic Testing

No specific guidelines regarding genetic testing for this disorder have been developed.

Suggested Reading

Revision History

• 28 April 2009 (et) Comprehensive update posted live

• 3 October 2006 (me) Review posted to live Web site

• 24 April 2006 (mh) Original submission