Autoimmune Lymphoproliferative Syndrome Database (ALPSbase)

Database Submission Form

Data may be submitted to ALPSbase by completing the form below. Information submitted will be reviewed before being added to the database.

Patient ID Number:

Mutation Type:

Domain:

Exon/Intron Number:

Exon Intron Flag Exon Intron

cDNA Mutation (using transcription start site=1, e.g. "266C->G" or "140delG"):

Amino acid containing mutation, or first amino acid disrupted by mutation (first methionine residue counts as position 1):

Result of Mutation:

mRNA Detected?:

Cell Surface Expression of FAS:

Clinical Data

Autoantibodies:
Age Dx:
Family History?:	YES NO
Ethnic Origin:
Affected Relatives And Relationship:

Significant infections at or before presentation:
Lymphadenopathy:	YES NO
Splenomegaly:	YES NO
Splenectomy:	YES NO
Autoimmune Thrombocytopenia:	YES NO
Autoimmune Hemolytic Anemia:	YES NO
Autoimmune Neutropenia:	YES NO

Other Autoimmune Diseases (list):

Coombs' Positive:	YES NO
Other Autoantibodies (list):

T cell:
number/mm³:

CD4^-/CD8^- T cells with any TCR:
number/mm³:		percentage:

CD4^-/CD8^- T cells with Alpha Beta TCR:
number/mm³:		percentage:

B cell:
number/mm³:		percentage:

Submitter Data

Referring Investigator:
Referring Laboratory:
Reference (if published):
Comments:

Comments, suggestions and problems to bioinformatics@nhgri.nih.gov

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