Congenital aplasia of the thymus gland (DiGeorge's syndrome)

The spectrum of the DiGeorge syndrome

Clinical and autopsy data on 25 patients with DiGeorge syndrome and its variants are presented. Congenital heart disease was the most common presenting complaint; 15 patients came to medical attention in the first 48 hours of life because of cyanosis, cardiac murmurs, or tachycardia and tachypnea. Two unusual anomalies, interrupted aortic arch or truncus arteriosus, were seen in 17 patients. Clinically documented hypocalcemia associated with seizures was seen in ten patients, with a median age at onset of eight days. Fifteen of our 25 patients died at less than one month of age. Most of the patients surviving the first month of life developed purulent rhinitis, maculopapular rashes, failure to thrive, and developmental delay. Sixteen patients had major congenital anomalies not localized to the anterior neck and thorax; these anomalies included arhinencephaly, cleft lip, palate, or uvula, diaphragmatic abnormalities, hydronephrosis, malrotation of the gut and imperforate anus. The 24 autopsied cases constitute 0.7% of the 3,469 sequential postmortem studies done in the period 1950--1975 at The Children's Orthopedic Hospital and Medical Center.

The use of bacteria for the functional characterization of human lymphocyte subpopulations in various lymphoid organs

In a haemolytic plaque assay staphylococcal strain Cowan 1 was shown to induce polyclonal antibody secretion in human blood lymphocytes, whereas Haemophilus influenzae and Escherichia coli gave low responses. Diplococcus pneumoniae and haemolytic streptococci generally did not activate blood cells. All five bacteria could activate spleen, tonsil and adenoid cells both to polyclonal Ig secretion and increased DNA synthesis. Thus blood cell reactivity does not necessarily reflect the response pattern in other lymphatic organs. The adenoid was shown to contain lymphocytes more responsive to bacteria normally residing in nasopharynx than cells residing in other lymphatic organs. On the other hand, spleen and mesenteric lymph node contain a subpopulation of cells highly responsive to bacteria such as Escherichia coli normally residing in the bowel. Therefore, we conclude that there exists a functional compartmentalization of lymphocytes in distinct secondary lymphoid organs.

Circulating thymic-hormone activity in congenital immunodeficiency

Circulating thymic-hormone activity was assayed by measuring Thy 1-2 antigen induction on null lymphocytes from athymic mice incubated with human plasma or serum. Plasma from 19 normal children aged under 10 had inductive activity equivalent to 10-6-16-2 ng thymopoitin/ml. Plasma from 15 infants were severe combined immuno-deficiency, 2 of whom had appreciable immunoglobulin synthesis, and from 2 infants with DiGeorge syndrome had little or no inductive activity. Successful reconstitution with thymus or bone-marrow grafts and with red-cell infusions (if adenosine-deaminase deficiency is present) was followed by a rise in circulating thymic-hormone activity.

Demonstration of the production of human thyroid-stimulating immunoglobulins (HTSI) by Graves' lymphocytes cultured in vitro with phytohaemagglutinin (PHA)

The lymphocytes from patients with Graves' disease or from healthy subjects have been cultured in vitro either alone or with phytohemagglutinin (PHA). After six days the culture supernatants have been assayed for their human thyroid-stimulating activity by measuring increases in adenosine 3',5' monophosphate (cyclic AMP) in human thyroid slices with which the supernatants have been incubated. Significant levels of human thyroid stimulator activity were found in the culture in which Graves' lymphocytes were cultured with PHA. This activity has been abolished by precipitation of the IgG from the culture supernatant with goat antihuman IgG serum. In contrast, when Graves' lymphocytes were cultured alone, or when control lymphocytes were cultured either alone or with PHA, there was no overall significant production of human thyroid-stimulating immunoglobulin (HTSI). It is concluded that Graves' lymphocytes can be stimulated by PHA to produce HTSI in vitro. Since PHA is known to stimulate only the T lymphocytes, which do not themselves elaborate immunoglobulins as the B lymphocytes do, the above observations indicate a cooperation between T and B lymphocytes in the production of HTSI, at least in this system.

Paracortical alteration in lymphadenopathic and tumor-draining lymph nodes: histologic study

Histologic studies of 142 enlarged lymph nodes from 124 patients, diagnosed histologically as nonspecific chronic lymphadenitis or reactive hyperplasia, revealed a characteristic nodular alteration in the paracortical area of nodes from the axillary, cervical, and inguinal regions, and rarely in abdominal, mediastinal, and retroperitoneal groups. In 1389 lymph nodes from 100 radical mastectomy specimens similar changes were noted more frequently in the lower than in higher levels of the tumor-draining axillary nodes. The nodule was composed of small lymphocytes associated with postcapillary venules and histiocytes-macrophages. The latter varied in distribution from a scattered pattern resembling a starry-sky appearance in the initial phase of paracortical alteration to the replacement of small lymphocytes in advanced stages. Plasma cells and lymphatic sinuses were characteristically absent from this nodular alteration. An impressive example of such changes was seen in four cases of dermatopathic lymphadenitis. Studies of the paracortical area may provide new insight into the pathogenesis of some lymphadenopathies.

Mesocolic lymph node histology is an important prognostic indicator for patients with carcinoma of the sigmoid colon: an immunomorphologic study

Histologic parameters which are thought to reflect either cell-mediated (T cell) or humoral (B cell) immune responses in lymph nodes have been studied in regional lymph nodes draining carcinoma of the sigmoid colon. Patients whose lymph nodes show morphological evidence of cell-mediated immunity, manifested either by an increased number of paracortical immunoblasts or sinus histiocytosis, survive significantly longer than those whose lymph nodes show no such changes. Patients whose lymph nodes show simultaneous paracortical activity and sinus histiocytosis have the best survival of all. Of this latter group, 11/13 (83 percent) are living without signs of recurrent tumor 5 or more years after surgery. Histologic parameters which suggest an antibody-mediated immune response (germinal center activity) were not an important prognostic indicator. The occurrence of favorable lymph node histology does not appear to significantly correlate with the modified Duke's classification. Rather, the favorable changes allow selection of a large proportion of those patients within the various Duke's categories who are destined to become long-term survivors.

Congenital cardiovascular disease and anomalies of the third and fourth pharyngeal pouch

Patients with the third and fourth pharyngeal pouch syndrome, thymic and parathyroid aplasia or hypoplasia, have a very high incidence of aortic arch anomalies and congenital heart disease. These patients present with a unique syndrome characterized by profound hypocalcemia, defective thymic-mediated cellular immune function, and cardiovascular anomalies. The cardiac abnormalities most frequently are conotruncal malformations of the tetralogy of Fallot or truncus arteriosus types and are often the cause of death. Patients with profound neonatal hypocalcemia should be screened for evidence of normal thymic function and congenital heart disease.

The diagnosis of immune deficiency diseases

The functions of the immune system, divided into three types, are conceived as the basis for classification of immune deficiency disorders, and useful laboratory procedures are reviewed.

Wiskott-Aldrich syndrome, a genetically determined cellular immunologic deficiency: clinical and laboratory responses to therapy with transfer factor

Patients with diseases associated with defects in cellular immunity, such as the Wiskott-Aldrich syndrome, characteristically have severe recurrent infections and usually succumb to overwhelming infection at an early age. This communication describes a patient with this syndrome, defective delayed hypersensitivity by skin tests and by in vitro lymphocyte response, who was treated with dialysate of peripheral blood leukocytes (transfer factor). After treatment, the clinical status of the patient improved dramatically, concomitant with the development of delayed hypersensitivity to antigens to which the donor was sensitive. In vitro tests after transfer indicated that the patient's lymphocytes, when stimulated by specific antigen, produced migration inhibitory factor without concomitant DNA synthesis. These observations dissociate skin test sensitivity and activity of migration inhibitory factor from in vitro blastogenesis. Further, the response to phytohemagglutinin remained diminished before and after therapy. While these findings represent only an individual case, the climical results suggest that investigation of the use of transfer factor appears warranted in the therapy of Wiskott-Aldrich syndrome and other genetically-determined diseases associated with impaired cellular immunity.

Cells involved in the immune response. XVI. The response of immune rabbit cells to phytohemagglutinin, antigen, and goat anti-rabbit immunoglobulin antiserum

There exists in the rabbit a population of lymphocytes carrying immunoglobulin-like receptors on their surface. These receptors interact with antigen and with anti-immunoglobulin antibodies and appear to mediate the recognition process leading to the humoral immune response. There exists in the rabbit a second population of lymphocytes capable of reacting with phytohemagglutinin. This population of lymphocytes is different from the one capable of reacting with soluble protein antigens or anti-immunoglobulin antiserum and is probably involved in the mediation of cellular immunity.