The syndrome of cellular immunodeficiency with immunoglobulins

Disseminated measles infection after vaccination in a child with a congenital immunodeficiency

An infant boy with a congenital immunodeficiency had fatal disseminated measles after administration of a live attenuated measles vaccine. This rare complication was confirmed with molecular virologic techniques. Although efforts to expand availability of vaccinations are critically important, caution is warranted in children with potentially severe immunologic dysfunction.

Growth hormone deficiency and combined immunodeficiency

The first description of an association of isolated growth hormone deficiency (IGHD) and combined immunodeficiency is presented. The findings suggest that IGHD should be considered as a cause of short stature in children with combined immunodeficiency before attributing growth retardation to infection.

Recurrent orf in an immunocompromised host

A 30-year-old farmer with Nezelof's syndrome developed a giant orf on his hand. Recurrence followed surgical excision. Three excisions and split skin grafts were required before its eradication. He re-presented 8 years later with a further orf on the finger of his opposite hand. This lesion had not grown to the exuberant proportion of the previous lesion, but it defied repeated excisions, and various medical therapies including idoxuridine, interferon and transfer factor. Excision with hypochlorite dressings perioperatively and delayed split skin grafting led to eventual eradication.

Effect of eosinophil-degranulating estrogens on spleen eosinophils and white pulp/red pulp ratio

A role for eosinophils in the immune reaction has not been yet established. Considering that these leukocytes accumulate in lymphoid organs under glucocorticoid stimulation, we explored the possibility that they participate in the depression of immune reactions induced by these hormones and that they degranulate to exert this action. In this context, we investigated the dose effect of three estrogens on the number and degranulation of spleen red pulp eosinophils and on the percentage of spleen cross sectional area comprising white pulp. Estradiol-17 beta or 4 (OH) estradiol-17 beta increased red pulp eosinophils at low doses: 2 (OH) estradiol-17 beta increased them at a very high dose. The three estrogens degranulated the spleen eosinophils and decreased the lymphocyte containing spleen white pulp. We propose that the decrease in white pulp is a response mediated by agents released from degranulating eosinophils under the action of estrogen. Consequently, both estrogen-induced eosinophil degranulation and estrogen-induced increase in red pulp eosinophil numbers are conditions contributing to a decrease in white pulp volume. All above evidence supports the hypothesis that eosinophils are involved in immunoregulation by diminishing the number of lymphocytes contained in lymphoid organs.

Novel primary thymic defect with T lymphocytes expressing gamma delta T cell receptor

Flow cytometric analysis of the peripheral blood mononuclear cells in a six year old girl with a primary cellular immune deficiency showed a normal fraction of CD3 positive T cells. Most (70%) of the CD3 positive cells, however, expressed the gamma delta and not the alpha beta T cell receptor. Immunoprecipitation and sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) showed that most of the gamma delta T cell receptors existed as disulphide-linked heterodimers. Proliferative responses to mitogens were severely reduced, but specific antibody responses after vaccination could be detected. A thymic biopsy specimen showed severe abnormalities of both the thymic lymphoid and epithelial component with abortive medullary differentiation and almost an entire lack of Hassall's corpuscles. This patient represents a case of primary immune deficiency syndrome not previously described. Thymic deficiency associated with a high proportion of T cells expressing the gamma delta T cell receptor has been described in nude mice, and it is suggested that the immune deficiency of this patient may represent a human analogue.

Cellular and genetic analyses of IL-2 production and IL-2 receptor expression in a patient with familial T-cell-dominant immunodeficiency

Cellular and genetic analyses of interleukin-2 (IL-2) production and IL-2 receptor (IL-2R) expression were examined in a immunodeficient patient and his family members. Mononuclear cells (MNC) of the patient showed no proliferative response (stimulation index, less than 2) to T-cell mitogens (PHA and Con A) and were defective in IL-2 production and IL-2R expression (less than 1%), whereas productions of other lymphokines (B-cell differentiation factor and IFN-gamma) were not impaired significantly. His brother died of the same disease and his father also lacked in proliferative response and IL-2 production by PHA stimulation. In Southern blot analyses using DNA probes of IL-2 and IL-2R, patterns of the patient were the same as those of healthy volunteers, whereas the transcription of DNA coding for IL-2R to mRNA was lacking in the patient. These results suggest that inheritant defects of IL-2 production and IL-2R expression reside in this family and the defects are not linked to DNAs coding for IL-2 and IL-2R but to a transcriptional deficiency.

Human eosinophil cationic proteins (ECP and EPX) and their suppressive effects on lymphocyte proliferation

ECP (eosinophil cationic protein) and EPX (eosinophil protein X) are two highly basic proteins contained in the granules of human eosinophils. In this study, the effect of ECP and EPX upon lymphocyte proliferation in vitro has been investigated. Peripheral blood mononuclear cells from normal donors were cultured in medium containing ECP or EPX at concentrations from 10(-10) to 10(-7) M. 3H-Thymidine incorporation in PHA-blasts or MLR-blasts was dose-dependently inhibited by both ECP and EPX. The effect was irreversible and was not due to cytotoxic damage. The suppressive effect of EPX may involve suppressor cells. The effect of ECP and EPX on lymphocyte proliferation at relevant in vivo concentrations suggests a regulatory role for the eosinophil in immunological reactions.

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.

Acquired immune deficiency syndrome in childhood

The acquired immunodeficiency syndrome has been observed with increasing frequency in children with associated hemophilia, high-risk environmental backgrounds, and blood transfusions. AIDS should be considered in the differential diagnosis of childhood immunodeficiency, and it must be distinguished from congenital disorders. We emphasize the importance of epidemiologic, clinical, and laboratory data in diagnosis and aggressive management of infectious complications. The relationship between human retrovirus infection and AIDS remains to be precisely defined, especially with regard to cofactors that may play a role in the development of severe immunodeficiency following exposure to the agent.

Pathology of suspected acquired immune deficiency syndrome in children: a study of eight cases

Biopsy and/or autopsy material from lymphoreticular and other organs was studied in 8 children with suspected acquired immune deficiency syndrome (AIDS). One or both parents of each of these children had one or more of the recognized risk factors for AIDS, such as intravenous drug abuse, prostitution, Haitian origin. The following histologic patterns were noted in the lymph nodes: (1) follicular hyperplasia with normocellular paracortex, (2) follicular hyperplasia with depletion of paracortex, and (3) atrophy of follicles with depletion of paracortex. Lymphoid interstitial pneumonitis (LIP), a previously unreported lesion in AIDS, was present in 4 cases. It is suggested that the pulmonary lymphoid lesion may be part of a more generalized lymphoid hyperplasia involving B cells. The gross and microscopic features of the thymus, available in 2 of the 8 cases, indicated that the immunologic defect in these children was not of congenital type. Pathologic findings can be helpful in the diagnosis of the syndrome when correlated with clinical and immunologic features of suspected cases and of the pulmonary lesion. The latter is of importance in deciding the type of therapy to be given for the pulmonary disease process.

Transfusion-associated acquired immune deficiency syndrome in infants

Two preterm infant boys not known to be at risk developed clinical, laboratory, and pathologic features of acquired immune deficiency syndrome (AIDS) after receiving multiple blood transfusions in the neonatal period. Their clinical courses were characterized by failure to thrive, recurrent otitis media, hepatomegaly, and fatal interstitial pneumonia. Laboratory evaluation revealed progressive lymphopenia, reversed T helper/suppressor ratios, increased percentages of B-lymphocytes, decreased lymphoproliferative responses to mitogens, hyperimmunoglobulinemia, and high levels of circulating immune complexes. At postmortem examination thymic involution, lymphocyte depletion in spleen and lymph nodes, and micronodular mineralization in the central nervous system were seen. The findings were not specific for other known congenital immune deficiencies and were most indicative of AIDS. The lack of other risk factors suggests transmission of AIDS via blood transfusions in the neonatal period.

Acquired immunodeficiency syndrome in infants

Fourteen infants with clinical and laboratory features of an acquired immunodeficiency syndrome were identified in a single metropolitan area from November 1980 to July 1983. Patients were predominantly of Haitian parentage, although two cases occurred in offspring of non-Haitian intravenous drug abusers. Only one patient had received a blood transfusion before the development of clinical findings. The predominant clinical findings included failure to thrive, persistent infection of the oral mucosa by Candida albicans, chronic pulmonary infiltrates, hepatosplenomegaly, lymphadenopathy, and diarrhea. Immunologic studies showed most of the infants to have inverted ratios of T-cell subsets, greatly increased immunoglobulin levels, and circulating immune complexes. Lymphopenia was not common, as it is in adult patients. Infectious agents responsible for opportunistic infections in this series included Pneumocystis carinii, herpesviruses, particularly cytomegalovirus, and C. albicans. Bacterial infections were common, and gram-negative sepsis was the major cause of death in the seven infants who have died. At autopsy, two infants had disseminated lymphadenopathic Kaposi's sarcoma. These observations suggest the likelihood of transplacental, perinatal, or postnatal transmission of an as yet unidentified infectious agent that causes this disease.

The human thymic microenvironment

Several major points should be emphasized that provide directions for future research. First, using monoclonal reagents we have been able to phenotypically identify four major regions of the human thymus microenvironment: the thymic capsule, interlobular septae and stroma (TE-7+), the subcapsular cortex (TE-4+, Thy-1+, A2B5+, anti-p19+, BB TECS+, TE-3+), the cortex (TE-3+), and the medulla (TE-4+, A2B5+, anti-p19+, BB TECS+). TE-4+ and TE-3+ thymic epithelium constitute HLA+, Ia+ subsets of thymic epithelium that are candidates for cell types of the human thymic microenvironment that might participate in conferring MHC restriction to maturing T lymphocytes. TE-7+ stroma most likely represents the mesodermal-derived thymic component that early in development induces thymic epithelial differentiation. Second, whereas TE-4, anti-p19, and BB TECS antibodies may be thymic epithelial lineage markers, they all react with the basal layer of squamous epithelium of various organs. In particular, in the tonsil, A2B5+, TE-4+ epithelium splays out in the base of tonsillar crypts and morphologically appears similar to thymic medullary epithelial cells. Therefore, these markers of endocrine thymic epithelium may also identify extrathymic areas of T cell differentiation. Third, the concept that thymic epithelium is constantly differentiating in the developed thymus is suggested by the coexpression of TE-4, TE-8, TE-16, and TE-15 antigen by layers of squamous epithelial keratinocytes and by thymic epithelium. That there is a TE-4/TE-8/TE-15 keratinocyte maturation pathway in skin gives credence to the notion that a similar pathway exists from TE-4+, TE-8-, TE-15- endocrine medullary epithelial cells to TE-4-, TE-8+, TE-15+ Hassall's bodies. Fourth, from the literature and the work presented in this review, three phases of thymic microenvironment development can be defined. The first phase is during early fetal development (4 to 8 weeks in humans) when mesodermal-derived fibrous tissue induces endodermal and ectodermal-derived thymic epithelium to proliferate and mature. TE-7+ mesenchymal stroma invaginates TE-4+ thymic epithelium and effects thymic lobulation. The second phase occurs between 9 and 15 weeks fetal development when the thymic primordia is colonized by blood-borne thymocyte precursors. Presumably during this stage, thymic epithelium promotes bone marrow cell colonization of thymus by producing chemoattractant molecules.(ABSTRACT TRUNCATED AT 400 WORDS)

T system immunodeficiencies in infancy and childhood

Some problems concerning the diseases due to deficiencies of the T immune system in infancy and childhood are reviewed. The relationships between SCID and Nezelof syndrome and the pathogenesis of this group of diseases are particularly discussed.

Bronchiectasis complicating chronic lymphatic leukaemia with hypogammaglobulinaemia

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Abnormal lymphocyte capping in a patient with severe combined immunodeficiency disease

Despite the presence of normal numbers and distribution of T and B lymphocutes and normal levels of serum immunoglobulins, a five-month-old infant failed to show any evidence of T-cell or B-cell immunity. In trying to identify a specific membrane abnormality as a potential cause of the immunologic dysfunction, we examined the lateral mobility of the cell-surface receptor for concanavalin A. In contrast to normal cells, in which the receptor is distributed uniformly over the cell surface, the patient's lymphocytes showed an unusually high accumulation of concanavalin A receptors in surface caps. This capping abnormality appeared in both T and B lymphocytes and was exaggerated by colchicine, an inhibitor of microtubule assembly. These findings support the theory that plasma-membrane-cytoskeleton interactions have a role in the expression of specific immunity; the findings also identify new areas that should be considered in trying to understand the primary immunodeficiency diseases.

Extraneous HLA antigens in severe combined immunodeficiency disease (scid). Survey of the literature and report of one new case

In a female infant with severe combined immunodeficiency disease extraneous HLA specificities were found which could neither have been inherited from the father nor the mother. The case is reported in detail and a survey of the literature with similar observations is given. The different explanations of this phenomenon are discussed.

Fetal thymus transplantations in severe combined immunodeficiency

Two brothers with severe combined immunodeficiency were treated with repeated transplantations of fetal thymus tissue. The first patient was not treated until he was critically ill, and the intramuscular transplants had no effect. He died at 11 months of age of overwhelming pneumonia. At postmortem examination a transplanted thymus seemed viable. In the second patient an intramuscular transplant had no effect, but three subsequent intraperitoneal transplants led to transient increase in circulating T lymphocytes with a concomitant fall in B lymphocytes. The results suggested an additive effect of each transplant. However, delayed hypersensitivity skin tests and in vitro mitogen responses were not influenced. Initially, transfer factor was given, and fetal liver was administered intraperitoneally together with the last thymic transplant. Neither of these measures had any observed effect, and this patient, similarly, died of pneumonia at nearly 12 months of age.

Combined immunodeficiency with hyper-gamma-globulinaemia

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Small intestinal disease in T cell deficiency

Biopsies of the proximal small bowel were obtained in four children with impairment of cell-mediated immunity, chronic diarrhia, and malabsorption; one child had an isolated T cell defect and three had significant B and T cell defects. All of them had malabsorption and, in addition to alterations of the small bowel epithelium, large vacuolated macrophages were seen in the lamina propria in all biopsies. Electron microscopy demonstrated lipid and patches of small pleomorphic inclusions within the macrophages. Since large vacuolated macrophages have also been described in Whipple's disease and chronic granulomatous disease, we suggest the possibility of a common thread of defective host defense and gastrointestinal malfunction in these three conditions.