Treatment of severe Epstein-Barr virus-induced polyclonal B-lymphocyte proliferation by anti-B-cell monoclonal antibodies. Two cases after HLA-mismatched bone marrow transplantation

We treated two children who developed Epstein-Barr virus-induced polyclonal B-cell proliferation after HLA-mismatched bone marrow transplantation for congenital immunodeficiency with two monoclonal anti-B-cell antibodies. Lymphoproliferative syndrome occurred between 50 and 60 days after bone marrow infusion, and was diagnosed by the presence of spontaneously growing B cells containing Epstein-Barr-nuclear antigen in the blood and bone marrow. The mouse monoclonal anti-B-cell antibodies used were a CD21-specific antibody recognizing the CR2 receptor on B cells (BL13, IgG1) and a CD24-specific antibody binding B cells at all steps of differentiation (ALB9 IgG1). Both antibodies were given intravenously (0.2 mg/kg/body weight.d for 10 days). All clinical and biological manifestations resolved within 3 weeks of treatment. Recurrence was not seen at 18- and 15-month follow-ups. T-cell function developed normally; B-cell function remained partially deficient in one patient 21 months after bone marrow transplantation. These results suggest that monoclonal anti-B-cell antibodies could be useful in controlling severe polyclonal lymphoproliferative syndrome in profoundly immunodeficient patients after bone marrow transplantation.

Value of bronchoalveolar lavage in the management of severe acute pneumonia and interstitial pneumonitis in the immunocompromised child

The diagnostic value of 73 bronchoalveolar lavages was assessed in 67 immunocompromised children (aged 3 months to 16 years) with pulmonary infiltrates. Thirty one children had primary and 19 secondary immune deficiency, 14 acquired immunodeficiency syndrome (AIDS), and three AIDS related complex. Bronchoalveolar lavage was performed during fibreoptic bronchoscopy, under local anaesthesia in all but two. One or more infective agents was found in eight of 11 patients with severe acute pneumonia and in 26 of 62 patients with interstitial pneumonitis. In interstitial pneumonitis, the most frequently encountered agents were Pneumocystis carinii (12), cytomegalovirus (8), and Aspergillus fumigatus (3). The yield was related to the severity of interstitial pneumonitis. The mean cellular count and cytological profile in lavage returns from patients with varying infective agents or underlying pathological conditions showed no significant difference, except in those children with AIDS and AIDS related complex who had appreciable lymphocytosis (mean percentage of lymphocytes 28 (SD 17]. In children with AIDS and chronic interstitial pneumonitis lymphocytosis without pneumocystis infection was observed in eight of nine bronchoalveolar lavage returns and was suggestive of pulmonary lymphoid hyperplasia. Finally, bronchoalveolar lavage produced a specific diagnosis from the microbiological or cytological findings in 44 instances (60%). Transient exacerbation of tachypnoea was observed in the most severely ill children but there was no case of respiratory decompensation attributable to the bronchoscopy. Bronchoalveolar lavage is a safe and rapid examination for the investigation of pulmonary infiltrates in immunocompromised children. It should be performed as a first line investigation and should reduce the use of open lung biopsy techniques.

[Nervous system involvement in HIV1 infections in infants]

A prospective survey of 38 HIV1-infected infants has been performed. Thirty-four percent of the patients expressed neurological abnormalities. Three main clinical entities of various intensity have been defined: 8 patients had severe intellectual and motor dysfunctions associated with a bucco-lingual dyspraxia; in 4 patients, the intellectual and motor alterations were less intense but were associated with a severe bucco-lingual dyspraxia; finally one patient had no clinical symptomatology but a chronic lymphocytic meningitis. No opportunistic infection of the CNS was observed. The neurological alterations were correlated in intensity with the immunological dysfunction. CT scans were normal or showed cerebral atrophy in most cases. CSF were normal in 12 cases and a pleiocytosis was observed in one case. However, in 4 of the 6 tested cases, anti-HIV antibodies were detected in CSF.

Longitudinal study of 18 children with perinatal LAV/HTLV III infection: attempt at prognostic evaluation

We performed a longitudinal study (mean follow-up 19.5 months, range 3 to 42 months) in 18 consecutive children with clinical symptoms of LAV/HTLV III infection. Twelve patients were born to mothers infected with LAV/HTLV III, and six were infected by blood products administered during the first weeks of life. Immunologic studies included lymphocyte markers, in vitro responses to mitogens and antigens with corresponding skin tests, and antibody response with isoagglutinins, post-vaccination antibodies, and Candida. A serologic profile of antibody to GP110, P18, and P25 LAV/HTLV III antigens by radioimmunoprecipitation assay was also performed. The antigen-induced proliferative responses were normal in 10 patients who had a stable course, but were profoundly impaired in eight others who died or had poor condition with opportunistic infections. These in vitro measurements were well correlated with antigen skin tests. An abnormal antibody response to antigens, a low level of isoagglutinins, and a peculiar profile of LAV/HTLV III antibodies were also frequently observed in these eight patients. These measurements appear to be of prognostic value because they were noticed soon after onset of clinical symptoms.

Prevention of graft failure by an anti-HLFA-1 monoclonal antibody in HLA-mismatched bone-marrow transplantation

Seven patients with immunodeficiencies (Wiskott-Aldrich syndrome, combined immunodeficiency, and osteopetrosis) were given a mouse monoclonal antibody against the alpha subunit of human leucocyte functional antigen (HLFA-1; CD18) to facilitate the engraftment of mismatched haploidentical related-donor bone marrow. Other conditioning included busulphan, cyclophosphamide, and antilymphocyte globulin. To prevent graft-versus-host disease the bone-marrow T cells were depleted with sheep erythrocyte rosetting and cyclosporin therapy was given. HLFA-1 antibody injections were well tolerated without side-effects except slight, transient fever (38-40 degrees) after the first injection. Engraftment was rapid in all seven patients. The regenerating leucocytes were of donor origin in all cases, and two patients have a mixed chimera. Two patients died from infections. The others are alive and well 60-395 days after transplantation. In a historical control group given the same treatment without anti-HLFA-1 infusion, only one of seven transplants partially engrafted; only two patients remain alive with autologous reconstitution but with uncorrected immunodeficiency.

[LAV infections and the acquired immunodeficiency syndrome in infants]

The clinical and immunologic abnormalities of 7 infants with Lymphadenopathy Associated Virus (LAV) infection are reported. Indicative immune changes, positive anti-LAV serologic test and/or virus isolation led to the diagnosis. In a case with a particularly severe form of the disease, whose mother died from AIDS, serologic tests and virus isolation were negative. Beside a case associated with blood transfusion, the familial and ethnic context helped the diagnosis. Clinical and biochemical features were close to those in adult AIDS, including hepatosplenomegaly, polyadenopathy, a decreased absolute number of OKT4(+) lymphocytes and hypergammaglobulinemia. The importance of cellular and sometimes also humoral immune deficiency was highly variable. For 4 patients, the severity of the immune deficiency allowed the diagnosis of AIDS. Occurrence of such an infection in the first months of life suggests a fetomaternal viral transmission; however, a postnatal contamination cannot be ruled out. Long-term prognosis is difficult to assess. It depends, among other factors, on the importance of the immune deficiency.

[Value of lymph node biopsy in lymphadenopathies occurring in patients at risk for AIDS]

On the basis of four cases of patients with persistent lymphadenopathy and at risk for acquired immune deficiency syndrome (AIDS), (3 Haitians, one haemophiliac), histopathologic features of lymph node biopsy in AIDS are recalled. Two main types of alterations of lymph node architecture--follicular hyperplasia or lymphoid depletion--can be associated with interfollicular lesions: vascular proliferation, numerous plasma cells, epithelioid reaction that may reflect an infectious process. Alterations of T-cell subsets distribution were also analyzed using immunocytochemical labelling of frozen sections from lymph nodes. In all four cases, T4 (helper)--lymphocytes were markedly depleted, whereas they normally represent the majority of lymph node T cells. They were replaced by prominent T8 (cytotoxic, suppressor)-cells, particularly inside the follicle. T8 lymphocytes are usually rare in this latter area. The fine analysis of these abnormalities is useful in prodromal or mild forms of AIDS.