Chronic granulomatous disease

Chronic granulomatous disease of childhood: clinical, pathological, biochemical, molecular, and genetic aspects of the disease

The pathobiology of chronic granulomatous disease (CGD) of childhood, a heterogeneous phenotypic disorder characterized by chronic and recurrent infection, has become more completely understood over the past three decades. Blood neutrophils, monocytes, and eosinophils lack a respiratory burst required for effective killing of catalase positive bacteria by reduced by-products of oxygen. The disease is transmitted in at least two genetic forms: X-linked and autosomal recessive. In the X-linked form, a gene coding for a beta subunit protein required for cytochrome b presence on the plasma membrane of phagocytic cells is not expressed. The protein appears to be a constituent of the cytochrome b complex that requires an additional alpha subunit for complete expression. Cytochrome b is likely a component of leukocyte oxidase, which catalyzes the respiratory burst. The autosomal recessive form of the disorder appears to be controlled by a set of genes coding for soluble cofactors essential for oxidase expression. One or more of these cofactors have recently been shown to be deficient in several patients with autosomal recessive CGD. Optional therapy for CGD patients is presently not available. Long-term use of antibiotics may be helpful. The cloned product interferon gamma has been reported to improve superoxide generation, bactericidal activity, and immunoreactive cytochrome b in some CGD neutrophils and monocytes, both in vitro and in vivo. Currently a prospective clinical evaluation of the efficacy of interferon gamma is in progress. Molecular studies of expression and function of the X-CGD gene in phagocytic cells are in progress as well.

Enhancement of normal neutrophil chemiluminescence by chronic granulomatous disease neutrophils

Neutrophils and other phagocytic cells from patients with chronic granulomatous disease (CGD) lack the ability to generate reactive oxygen intermediates (ROI), although other phagocytic functions appear to be intact. The effects of CGD neutrophils on the ability of normal neutrophils to produce ROI as measured by luminol-enhanced chemiluminescence (CL) were examined. Normal neutrophils (2 x 10(5)) had a peak CL response to phorbol myristate acetate (PMA; 20 ng/ml) of 6.5 +/- 0.9 mV, while the CL response to CGD neutrophils was completely absent. However, the addition of CGD neutrophils (8 x 10(5)) to normal neutrophils (2 x 10(5)) markedly increased the peak CL response to PMA to 11.0 +/- 1.1 mV (P less than 0.001). The peak response of normal neutrophils (2 x 10(5)) alone to the peptide N-formyl-methionyl-leucyl-phenylalanine (FMLP; 10(-6) M) was 9.0 +/- 1.1 mV, and this increased to 22.2 +/- 3.5 mV (P less than 0.001) when 8 x 10(5) CGD neutrophils were added and to 18.9 +/- 3.6 mV (P less than 0.005) when 4 x 10(5) CGD neutrophils were added. Thus, CGD neutrophils increase the release of ROI from normal cells, suggesting nonoxidative regulatory factors in ROI production.

Chronic granulomatous disease--a case showing long-term survival

The diagnosis of chronic granulomatous disease of childhood was made in a 10-year-old boy following episodes of recurrent cervical abscesses and ulcerative stomatitis since the age of 4 years. Nineteen years on, on antibiotic prophylaxis, he is now married and remains active although he has been hospitalized with serious complications on many occasions.

Chronic granulomatous disease of childhood: gastric manifestation and response to salazosulfapyridine therapy

The case history of a 10-year-old boy with chronic granulomatous disease (CGD) and gastric obstruction is presented. First abdominal symptoms occurred at 4 years of age when antral narrowing was detected. Due to unresponsiveness to antibiotic and steroid treatment, salazosulfapyridine therapy was initiated. Objective remission was observed within 3 months and salazosulfapyridine was withdrawn after a further 6 months of therapy. At 6 years of age clinical and radiological recurrence of gastric obstruction was observed. Salazosulfapyridine was reinstated and continued as maintenance therapy. The child has been well for more than 4 years. Salazosulfapyridine therapy can be recommended as safe conservative treatment of gastric obstruction in CGD.

Aspergillosis

Aspergillus spores are ubiquitous in the environment and may become concentrated in hospital ventilation systems. Colonization in normal hosts can lead to allergic diseases ranging from asthma to allergic bronchopulmonary aspergillosis. Normal hosts rarely develop invasive disease, which is primarily an infection of severely immunocompromised patients. The major predisposing factors for infection include prolonged neutropenia, chronic administration of adrenal corticosteroids, the insertion of prosthetic devices, and tissue damage due to prior infection or trauma. Since Aspergillus spp. are respiratory pathogens, the most common form of infection is pneumonia followed by sinusitis. Patients with preexistant cavitary disease may develop noninvasive aspergillomas. Most infections are caused by Aspergillus fumigatus. The organism is capable of invading across all natural barriers, including cartilage and bone. It has a propensity for invading blood vessels causing thrombosis and infarction. The diagnosis of pulmonary infection is usually difficult to establish because the organism is seldom cultured from sputum and can represent contamination in some cases. Therapy is immunocompromised hosts is less than satisfactory and amphotericin B is the only agent with significant activity. There is anecdotal evidence to suggest that the addition of 5-fluorocytosine to amphotericin B may be beneficial.

Incidence, severity, and prevention of infections in chronic granulomatous disease

We retrospectively analyzed the frequency and nature of infections occurring in 48 patients with chronic granulomatous disease. The long-term use of trimethoprim-sulfamethoxazole and ketoconazole as a preventive therapy for infections has also been evaluated. Lymphadenitis, lung infections, dermatitis, enteral infections, and hepatic abscesses were the most frequent infections. Staphylococcus aureus, Salmonella, and Aspergillus were the main microorganisms encountered. Twelve patients died: five from lung aspergillosis, three from hepatic abscesses, two from pneumonopathy of unknown origin, one from salmonellosis, and one from another probable infection that could not be proved. The actuarial survival rate was 50% at 10 years of age, with a prolonged plateau thereafter. There was no difference in survival rates between patients with X-linked and those with autosomal recessive chronic granulomatous disease. The 8-year actuarial survival rate was significantly higher for patients born in 1978 or afterward than for patients born before 1978 (92.9% vs 70.5%). A retrospective analysis of the occurrence of bacterial and fungal infections in patients who received trimethoprim-sulfamethoxazole and ketoconazole as infection prophylaxis indicated that the former was effective against bacterial infections but that ketoconazole provided no protection against Aspergillus infections.

Pigmented, lipid-laden histiocytes in the central nervous system in chronic granulomatous disease of childhood

In addition to granulomas, infiltrates of pigmented, lipid-laden histiocytes are a consistent morphologic finding in visceral organs of the reticuloendothelial system in patients with chronic granulomatous disease. We report a case with widespread meningeal and focal brain stem infiltrates of these distinctive histiocytes. The noninfectious involvement of the central nervous system in chronic granulomatous disease may be greater than previously recognized and related to the role of the CNS in the reticuloendothelial system.

Primary tuberculous osteomyelitis of skull: report of two cases

Two cases of primary tuberculous osteomyelitis of skull confirmed by appropriate laboratory investigations are described here. Primary tuberculous osteomyelitis of skull is rare. Only two cases of chronic granulomatous osteomyelitis have been described so far in the literature.

Fatal aspergillosis associated with smoking contaminated marijuana, in a marrow transplant recipient

A 34-year-old man presented with pulmonary aspergillosis on the 75th day after marrow transplant for chronic myelogenous leukemia. The patient had smoked marijuana heavily for several weeks prior to admission. Cultures of the marijuana revealed Aspergillus fumigatus with morphology and growth characteristics identical to the organism grown from open lung biopsy specimen. Despite aggressive antifungal therapy, the patient died with disseminated disease. Physicians should be aware of this potentially lethal complication of marijuana use in compromised hosts.

Immunodeficiency due to defects of polymorphonuclear leukocyte function

Functional defects of polymorphonuclear leukocytes can lead to clinical immunodeficiency. Understanding these conditions requires a knowledge of normal polymorph physiology and the means to analyse various aspects of polymorph function. Primary diseases of polymorph function are rare, whereas disorders secondary to other diseases are more common. Prompt diagnosis of these conditions leads to better patient management.

Superoxide dependent iron release from ferritin in inflammatory diseases

Convincing evidence is presented that oxygen free radicals are involved in the pathogenesis of rheumatoid arthritis (RA). Superoxide is produced by polymorphonuclear leucocytes (PMN) in synovial fluid and by macrophages in the synovial membrane. Tissue damage typical for free radical attack is detected in RA. No absolute deficiency of protective factors is found in RA compared to controls, but the available protection is insufficient to cope with all radicals formed. The toxicity of superoxide is increased by iron. It is doubtful whether a low molecular weight iron pool is present. Superoxide is able to release iron from ferritin, providing a suitable source of iron, for the formation of hydroxyl radicals. This new pathogenetic mechanism stimulates to the application of iron chelators in the treatment of RA. Preliminary results with desferrioxamine were disappointing because of serious side-effects. Hopefully in the future intra-articular injection of iron chelators with better pharmacodynamics will be possible. The interaction of free radicals and ferritin is probably also involved in the pathogenesis of other inflammatory diseases such as systemic lupus erythematosus, hepatitis, and haemochromatosus.

Neutrophil function disorders

The polymorphonuclear leukocyte (neutrophil) is the most important phagocytic cell that defends the host against acute bacterial infection. Disorders of neutrophil function are suggested by recurrent cutaneous, periodontal, respiratory, or soft tissue infections. Staphylococcus aureus, gram-negative bacilli, and less commonly, Candida albicans, are the causative organisms. Treatment is supportive involving surgical drainage and antibiotics. Bone marrow transplantation offers hope to some patients. The biochemical and molecular defects have been identified for some of these disorders. Identification of these defects and their physiologic consequences have improved our understanding of how the activated neutrophil is attracted and adheres to inflammatory sites, and produces toxic products that destroy bacteria. However, the activated neutrophil may also damage normal tissue and participate in diseases such as rheumatoid arthritis and the adult respiratory distress syndrome (ARDS).

Evaluation of immunity

Immunodeficiency disease is rapidly increasing in frequency. The AIDS epidemic, the increasing use of transplantation with immunosuppression, the aggressive immunotherapy, the persistent deficiencies after bone marrow transplantation--all contribute to the astronomically increasing numbers of patients with host defense failure. This review has presented my viewpoint as to the approaches which can be utilized by practitioners with varying focal points to provide diagnosis and maximize the potential for a cure today or at least to provide the beginnings of understanding from which will come the cures of tomorrow.

Chronic granulomatous disease with cranial fungal osteomyelitis and epidural abscess. Case report

A patient is described with osteomyelitis of the cranium and epidural abscess due to Aspergillus fumigatus as the presenting manifestations of chronic granulomatous disease. The diagnosis was suggested by the unusual nature of the organism isolated and confirmed by appropriate laboratory studies. The details of diagnostic assessment and therapeutic management are discussed, and the central nervous system manifestations of chronic granulomatous disease are reviewed.

Decreased numbers of chemotactic factor receptors in chronic neutropenia with defective chemotaxis: spontaneous recovery from the neutrophil abnormalities during early childhood

Childhood chronic neutropenia with decreased numbers of chemotactic factor receptors as well as defective chemotaxis was first demonstrated in an 8-month-old girl. Chemotactic factor receptors on neutrophils were assayed using tritiated N-formyl-methionyl-leucyl-phenylalanine (3H-FMLP). The patient's neutrophils had decreased numbers of the receptors: numbers of the receptors were 20,000 (less than 3 SD) as compared with those of control cells of 52,000 +/- 6,000 (mean +/- SD) (n = 10). The neutropenia disappeared spontaneously by 28 months of age parallel with the improvement of chemotaxis and increase in numbers of chemotactic factor receptors. These results demonstrate a transient decrease of neutrophil chemotactic factor receptors as one of the pathophysiological bases of a transient defect of neutrophil chemotaxis in this disorder.

Identity between human interferon-gamma and "macrophage-activating factor" produced by human T lymphocytes

Human peripheral blood monocytes purified by counterflow elutriation were activated in vitro by human natural or recombinant interferon-gamma (IFN-gamma) as shown by enhanced killing of Listeria monocytogenes and increased production of H2O2 in response to phorbol myristate acetate. Half-maximal stimulation for macrophage activation (MAF) was observed with 10-20 antiviral U/ml of purified recombinant IFN-gamma. These MAF activities were found to correlate with the antiviral activity dependent on IFN-gamma under several experimental conditions. Both activities were recovered together from supernatants of concanavalin A-stimulated peripheral blood mononuclear cells and in the media of a large number of T cell clones of different specificities. The parallelism between the two activities was also observed upon fractionation of culture media from producing cells and upon treatment of such preparations with low pH and high temperature. Finally, three antibodies with different specificities were found to abrogate the MAF and antiviral activities from lymphocyte culture supernatant. These results indicate that MAF released by stimulated lymphocytes is identical to IFN-gamma.

Cytochrome b and FAD content in polymorphonuclear leucocytes in a family with X-linked chronic granulomatous disease

Chronic granulomatous disease (CGD), an immunodeficiency syndrome characterized by extreme susceptibility to bacterial infections, is due to a defect of the respiratory burst in human phagocytes. NADPH oxidase, the enzyme that catalyzes the reduction of oxygen and the release of oxidative radicals, was studied in polymorphonuclear leucocytes (PMNs) in a family affected by an x-linked inheritance form at high penetrance of the disease. The contents of cytochrome b, suggested as the terminal component of the oxidase electron transport chain, and FAD, the hypothetical proximal component of the chain, were determined in patients and in carriers. Cytochrome b showed the typical behaviour of x-linked CGD: total absence in patients, intermediate values in carriers. FAD content evaluated on plasma membranes was less decreased than cytochrome b. Carriers also showed a decrease of this flavoprotein. Cytochrome b and FAD contents were compared to NBT test and superoxide production: a clear correlation was observed for the cytochrome b, but FAD plasma membrane evaluation could also be an interesting tool for the metabolic characterization of the disease in patients and in carriers.

Primary Candida meningitis and chronic granulomatous disease

The occurrence of two rare entities in a single patient can be fortuitous or may signify some deeper relationship. A young boy was recently treated for primary Candida meningitis. Autopsy findings suggested to an experienced pathologist the presence of chronic granulomatous disease (CGD), unrecognized during his life. The patient's identical twin brother was tested and found to have the typical laboratory features of CGD. The literature on Candida meningitis was reviewed and 15 cases were discovered that apparently arose in the absence of recognized predisposing causes. All but one of these cases occurred in males, and most occurred during the first three decades of life. The case reports and literature review presented herein suggest that CGD should be suspected when a case of "primary" Candida meningitis is encountered.

Discoid lupus erythematosus-like lesions in an autosomal form of chronic granulomatous disease

Chronic granulomatous disease (CGD) is characterized by a bactericidal defect involving the oxidative metabolism of polymorphonuclear leukocytes (PML) and is most often transmitted as an X-linked trait. The cutaneous features of this disorder include infections and lupus-like rashes. These have been described in female carriers as well as in males with the disease. Two cases of siblings presenting an autosomal form of CGD syndrome, with lupus-like cutaneous manifestations, are reported here.

Surgery of the immunodeficient child

A great deal has been learned about the surgery of immunodeficient patients. If one assesses the problem and follows the surgical principles described, in most instances one can solve the problem and be a great help to the oncologist and immunotherapist. A team approach is most important.

The pathology of disseminated Aspergillus terreus infection in dogs

Disseminated Aspergillus terreus infection was diagnosed in ten previously healthy adult dogs--nine German shepherds and one dalmatian. The disease was characterized by the presence of multiple granulomas and infarcts in a wide range of organs. The kidney, spleen, and skeletal system were most commonly and severely affected. Fungal hyphae were demonstrated in large numbers within granulomas and thrombi, and A. terreus was readily isolated by culture. This disseminated mycosis appears unique; in this series of cases there was no apparent predisposing factor, portal of entry, or primary focus for dissemination of the infection.

Phagocytic cells in periodontal defense. Periodontal status of patients with chronic granulomatous disease of childhood

Both qualitative and quantitative neutrophil abnormalities have been associated with severe forms of periodontitis. Defects in chemotaxis, phagocytosis and bacterial killing have been reported among both peripheral blood and gingival neutrophils harvested from patients with juvenile and rapidly progressive periodontitis. Chronic granulomatous disease of childhood (CGD) is a rare, inherited disorder associated with the occurrence of severe, life-threatening, suppurative infections of skin, liver, lymph nodes and other organs. Neutrophils and monocytes from individuals with CGD lack enzymes necessary for the production of oxygen reduction/products such as H2O2 and superoxide anion, and therefore are unable to kill many species of bacteria and fungi. However, no detailed study of the periodontium of these patients has been undertaken. Accordingly, five patients whose ages ranged from 17 to 32 years were included in this study. An additional (sixth) patient was included based on complete dental records. Neutrophils from all patients demonstrated defective O2 metabolism, and all patients had histories of chronic recurrent abscesses consistent with CGD. All patients were receiving antibiotic prophylaxis. Several patients had ulcerative lesions of the oral cavity of unknown etiology. Examination of the periodontium revealed that three patients had gingivitis, one had localized early periodontitis, and one had generalized early-to-moderate periodontitis. The severity of periodontal disease was consistent with patient age and local etiologic factors. No patients had evidence of juvenile, severe or rapidly-progressing disease in spite of their leukocyte defects. These findings suggest the following possibilities.(ABSTRACT TRUNCATED AT 250 WORDS)

Embolotherapy of a mycotic pseudoaneurysm of the internal mammary artery in chronic granulomatous disease

We report a case demonstrating an unusual and previously unpublished complication of chronic granulomatous disease (CGD), that is massive hemorrhage from a mycotic pseudoaneurysm of the left internal mammary due to invasive Aspergillus fumigatus of the anterior chest wall. This brief report further illustrates the angiographic diagnosis and embolotherapeutic control of a mycotic pseudoaneurysm of the internal mammary artery.

Recurrent severe infections in a girl with apparently variable expression of mosaicism for chronic granulomatous disease

A carrier of chronic granulomatous disease (CGD) has had recurrent severe purulent infections like those characteristic of CGD. The carrier state was demonstrated by the presence of both normal and CGD granulocytes in her blood; the percentage of normal granulocytes varied from 4% to 44% over 4 years. In addition, her granulocytes were partially defective in killing Escherichia coli and staphylococci and in the release of superoxide anion during stimulation. Extensive evaluation of her immune system and phagocyte function failed to reveal a second abnormality. The course in this child indicates that the carrier state for X-linked CGD cannot be considered a benign condition and might be more properly conceptualized as a continuum in expression of the full disease. Screening assays for CGD should possess the capacity to diagnose carriers of the X-linked form of the disease.

Presumed BCG infection in a boy with chronic granulomatous disease. A report of a case and a review of the literature

A male child with chronic granulomatous disease (CGD) developed protracted axillary lymphadenopathy with liquefaction following a bacille Calmettle-Guérin (BCG) immunization. Except for phagocytic dysfunctions characteristic of the underlying disease, immunological examinations were normal. The literature dealing with CGD cases with disseminated BCG infection was reviewed. It is concluded that the possibility of CGD should be considered in those who developed such adverse reactions to BCG immunization.

Chronic granulomatous disease in two sisters

Two sisters with chronic granulomatous disease (CGD) have been studied. The diagnosis was suggested by the histopathological findings from the spleen and lymph nodes of the proband and confirmed by the low values obtained in the following tests performed on polymorphonuclear leukocytes (PMN): chemiluminescence, nitroblue tetrazolium (NBT) reduction, killing of Staphylococcus aureus, and O2- production. NADPH oxidase activity was not detected in the homogenates of the patients' PMN but cytochrome b was normally present. In addition, PMN depolarization induced by phorbol-myristate acetate was absent, thus suggesting a defect of the activation mechanism of the respiratory enzyme. The normal depolarization induced by ouabain indicated that the membrane polarity regulated by the Na/K pump in the patients' cells was not affected. The low, but not completely absent, respiratory activity of the patients' PMN could suggest an X-linked mode of inheritance with incomplete Lyonization. From a clinical point of view, one sister had mild symptoms whereas the other was almost symptomless, thus confirming once more the heterogeneity of CGD syndrome.

Prenatal diagnosis of chronic granulomatous disease

A luminol enhanced chemiluminescence micromethod has been adapted for use in prenatal diagnosis of chronic granulomatous disease (CGD). After validation of the assay in normal adults, newborns, fetuses, CGD carriers, and CGD patients, the fetuses of two pregnant CGD carriers were tested after fetoscopic aspiration of fetal blood. Normal neutrophil chemiluminescence and nitroblue tetrazolium slide tests were followed by delivery of two healthy infants whose normality was confirmed. Amniocytes proved useless for the prenatal diagnosis of CGD. They were found to have negligible nitroblue tetrazolium reduction, oxygen metabolism, and oxygen dependence.

Human polymorphonuclear leukocyte interaction with cyclosporine A

The effects of cyclosporin A (cyA) on human polymorphonuclear leukocyte function, including phagocytosis, its associated metabolic burst, bacterial killing, and chemotaxis, were evaluated. Both Pseudomonas aeruginosa and Staphylococcus aureus were used as test particles. Polymorphonuclear leukocytes incubated in 10 and 50 micrograms of cyA per ml behaved normally with respect to phagocytosis and hexose monophosphate shunt activity at both high (10:1) and low (2:1) S. aureus/leukocyte ratios. With a small bacterial inoculum, killing of S. aureus was slightly impaired at early times only in the presence of 50 micrograms of cyA per ml. Phagocytosis and killing of P. aeruginosa with both large and small bacterial inocula were unaffected by cyA. Chemotaxis was within normal limits under all conditions. In addition, polymorphonuclear leukocytes from four renal transplant recipients receiving both cyA and prednisone demonstrated normal metabolic bursts and bacterial killing with both small and large inocula of S. aureus.

Defective bactericidal activity and absence of specific granules in neutrophils from a patient with recurrent bacterial infections

Recent studies have suggested that specific granules and/or their contents may have a role in neutrophil adherence, oxidative metabolism, and other aspects of cell function. In the current report, we studied neutrophil function in a 13-year-old female with recurrent pyogenic infections and absent specific granules previously documented by electron microscopy. Levels of cobalamin (vitamin B12)-binding protein and lactoferrin were markedly decreased in this patient's neutrophils. Bactericidal activity against Escherichia coli was decreased at 60 and 120 min (percentage organisms killed: patient neutrophils, 48 and 33%; control neutrophils, 90 and 99%, respectively). Defective killing of Staphylococcus aureus was also documented. Degranulation and adherence were normal. Levels of lactoferrin and cobalamin-binding protein were decreased in plasma but normal in saliva, indicating that the defect was specific for hematopoietic tissue. Superoxide anion production was normal in the patient, while hydroxyl radical generation was decreased in response to opsonized zymosan. The data support the concept that specific granules and their contents are important for oxidative metabolism and other neutrophil functions.

Chronic granulomatous disease of childhood. Probable diffuse gastric involvement

Diffuse gastric infiltration in a child with CGD is described as a cause for gastric outlet obstruction.

Chronic granulomatous disease: value of the newer imaging modalities

The contribution of computed tomography (CT), ultrasound (US), and nuclear medicine studies in the evaluation and management of seven patients with chronic granulomatous disease was retrospectively reviewed. These modalities proved valuable in detecting sites of infection, particularly in the abdomen. Three patients had liver abscesses, two had suppurative retroperitoneal lymphadenopathy, one had empyema, and one had a scrotal abscess. Furthermore, CT or US-guided percutaneous aspiration and/or drainage of infected material was successfully performed on three separate occasions in a single patient, obviating the need for surgery. The newer imaging modalities are useful in the prompt diagnosis and in some instances non-operative therapy of complications of chronic granulomatous disease.

Defective phagocyte Aspergillus killing associated with recurrent pulmonary Aspergillus infections

An apparently healthy boy was suffering from recurrent Aspergillus infections. No classical conditions of immunodeficiency were found. Studies on the patient's phagocytic system revealed neutrophils and monocytes to function normally except in Aspergillus killing (microbicidal activity for bacteria and Candida was normal). Aspergillus killing mechanisms may be complex and peculiarly selective, possibly involving both oxygen-dependent and independent mechanisms.

Gastrointestinal complications of congenital immunodeficiency states. The surgeon's role

Ninety-one congenitally immunodeficient patients treated from 1972 to 1981 were reviewed to assess the incidence and nature of gastrointestinal complications. Thirty-three of these patients (36%) developed 59 complications. Patients with immunodeficiencies characterized by neutrophil dysfunction--chronic granulomatous disease (20 patients) and cyclic neutropenia (eight patients)--developed 22 surgical infections, 22 of which required operation. In patients with neutrophil defects, postoperative morbidity was frequent and severe. Gastrointestinal symptoms were common in patients with isolated defects of B or T lymphocytes. Ten of forty-one patients with congenital hypogammaglobulinemia developed gastrointestinal complications, as did one of four patients with DiGeorge Syndrome, and the single patient with secretory IgA deficiency. However, operation was not required for these patients with isolated disorders of lymphocyte function. Patients with combined B and T cell disorders developed gastrointestinal disease, requiring operative therapy at intermediate rates. Gastrointestinal symptoms developed in four of nine patients with severe combined immunodeficiency and three of eight with Wiskott-Aldrich syndrome. Operative therapy was required in two of these seven symptomatic patients.

Abnormal regulation of inflammatory skin responses in male patients with chronic granulomatous disease

A common characteristic of the response to infection seen in patients with chronic granulomatous disease (CGD) is an exaggerated and prolonged inflammatory response with frequent development of draining lymph nodes and granuloma formation. Recent reports of several CGD patients with minor but significant in vitro abnormalities of cellular and humoral components of neutrophil chemotactic responses would predict lessened responses to inflammatory stimuli. The following studies were, therefore, performed to assess in vivo inflammatory responses in patients with CGD. Twenty-four-hour Rebuck skin-window procedures were performed on eight patients (five male and three female) with CGD and on ten volunteers. The windows were changed 1, 3, 5, 8, 12, and 24 h after the abrasion. Quantitation of the skin windows was performed with the assistance of a microscope-image analyzer computer facility. Neutrophil accumulation into skin windows was normal in CGD patients throughout the first 5 h. However, during the 8- to 24-h period, when neutrophils characteristically disappear from normal inflammatory responses and are replaced by monocytes, there was abnormal persistence of PMN at the inflammatory foci in male but not in female CGD patients (P less than 0.05 for the comparison of the rates of decline of PMN, from hour 8 to hour 24, in five male CGDs and in 10 normals). Monocyte recruitment was normal. In one CGD male, the abnormal skin-window response was normalized while he was receiving white cell transfusions. The data indicate that there is an abnormal "turn off" of the acute inflammatory response in male CGD patients and support a modulatory role for products of oxidative metabolism on the inflammatory response.(ABSTRACT TRUNCATED AT 250 WORDS)

Bactericidal activity of a granule extract from human polymorphonuclear leukocytes against Bacteroides species

The microbicidal activity of an acetate extract of human polymorphonuclear leukocyte granules was tested against Bacteroides fragilis, Bacteroides vulgatus, Bacteroides distasonis and Bacteroides thetaiotaomicron. All strains tested were killed by the extract, and there were no significant differences between the different Bacteroides species.

Chronic granulomatous disease of childhood: a changing pattern?

We have followed nine male patients with Chronic Granulomatous Disease at The Hospital for Sick Children, Toronto, since 1972. The diagnosis was established in each case by the failure of neutrophils to reduce nitroblue tetrazolium dye and to kill Staphylococcus aureus normally in vitro. Bacterial infections began between 6 months and 14 years of age. In five of the nine patients, infections began after 4 years of age. The first significant infection in five patients was a liver abscess(es), and one patient each had lymphadenitis, pulmonary aspergillosis, a parapharyngeal abscess, and a draining inguinal incision following surgery. Following diagnosis, all patients were started on Trimethoprim-Sulfamethoxazole at a dose of 2 mg/kg/day of Trimethoprim. The patients have been followed for 50 patient-years. Five of nine patients have been free of infection during 16 years of observation. For the remaining four patients, there have been six infections during 34 years of observation. A possible infection-related death occurred in one patient. The patients reported here appear to differ from those in previous reports. They present later in life, often with a liver abscess. They have a low incidence of subsequent bacterial infections which may, in part, be due to Trimethoprim-Sulfamethoxazole prophylaxis. The patients with chronic granulomatous disease reported here appear to have a better prognosis than previously thought.

Continuous therapy with sulfamethoxazole-trimethoprim in patients with chronic granulomatous disease

In a retrospective study, the effect of long-term treatment with sulfamethoxazole-trimethoprim was evaluated in nine male patients with chronic granulomatous disease. During this treatment, a marked reduction was observed in the number of infectious episodes, the number of causative agents, and the number of surgical interventions. Furthermore, a significant reduction in days of hospitalization per year was found. The mean observation period was six years before and four years during treatment. Transient alopecia was observed in one patient during therapy. We conclude that prophylactic treatment with sulfamethoxazole-trimethoprim is beneficial in patients with chronic granulomatous disease.

The kinetic measurement of phagocyte function in whole blood

A technique has been developed for the kinetic measurement on the same blood sample of a variety of functions of phagocytic cells. Adherence to glass, the clearance of a mixture of microorganisms and their subsequent solubilisation, and the secretion of granule contents from the cells were determined. The numbers of residual viable intracellular staphylococci were measured at the completion of the study. These methods were used to investigate phagocyte function in 33 normal subjects and 6 patients with chronic granulomatous disease.

Chronic granulomatous disease involving the central nervous system

Two male sibling infants died following a short course of lethargy and obtundation after a lifelong history of persistent, unrelenting diarrhea. Postmortem examination revealed extensive necrosis and early granuloma formation in the liver, spleen, lungs, and lymph nodes as well as in the central nervous system. To our knowledge, this fulminant clinical course, with documentation of granulomatous CNS lesions, has not been reported in patients with chronic granulomatous disease of childhood.