Antenatal diagnosis of severe combined immunodeficiency from fetal cord blood

[Development of specific immunity in prenatal life]

The various defense mechanisms of specific immunity, which involves the T and B lymphocytes and the antigen presenting cells, are gradually developed during intra-uterine life. The first hematopoietic organ is the yolk sac which appears at the 4th week of development. Thereafter, the hematopoiesis takes place in the fetal liver (from the 6th week) followed by the bone-marrow during the 3rd trimester. The differentiation of the T lymphocytes begins around the 10th week. The thymic epithelial rudiments appear during the 7th week and the thymus migrates to its definitive place at ten weeks. It is then colonized by the T cell precursors, which there undergo their maturation process. From the 12th week of development, mature T cells are readily detectable in lymphoid organs and fetal blood. The maturation of B cells, which occurs firstly in fetal lever, and thereafter in bone marrow begins also early in fetal life (12th week). The antigen presenting cells, the precursors of which are detected in the yolk sac as soon as 4-6 weeks, are normally present and functional in secondary lymphoid organs as soon as 12 weeks. Thus, the specific immune response appears possible by the end of the 1st trimester. However, the naive nature of T and B lymphocytes is responsible for a delayed, slow and relatively ineffective primary response. This observation explains the particular susceptibility of neonates, especially premature neonates to bacterial and viral infections. The various antigenic stimulations and T/B cell cooperations allow a complete maturation of the immune system during the first years of life.

Prenatal diagnosis of syndromes associating albinism and immune deficiencies (Chediak-Higashi syndrome and variant)

We have successfully undertaken the prenatal diagnosis of two hereditary syndromes associating albinism and immune defects. Because the genes responsible for these diseases have not yet been mapped and the immune abnormalities are too subtle to be diagnosed in utero, the prenatal diagnosis was made using a morphological approach. In the case of Chediak-Higashi syndrome, it was based on light microscopic examination of the hair shaft and on light and electron microscopic study of polymorphonuclear cells. In the syndrome associating immune deficiency and partial albinism, the Griscelli syndrome, only examination of the hair was feasible. The diagnosis was negative in 12 fetuses at risk and positive in four.

Lymphocyte subpopulations in primary immunodeficiency disorders

Venous blood mononuclear cells from 42 children with primary immunodeficiency disorders and from controls matched for age were studied for lymphocyte subpopulations by E rosetting, surface immunoglobulin, and a panel of anti T cell monoclonal antibodies (OKT series). In 3 cases of severe combined immunodeficiency (SCID) due to adenosine deaminase deficiency, very few circulating T or B cells were found. The other 7 cases of SCID all had normal or, in 3 cases, very high numbers of circulating B cells, but in 6 of these very few cells showed T cell markers. One child had very high numbers of B cells and T cells with an immature pattern of reactivity similar to that found on common thymocytes. In T cell deficient children no consistent pattern was found, but in those with cartilage hair hypoplasia with immunodeficiency there was a low helper (OKT4) to suppressor (OKT8) ratio and high numbers of circulating OKT10 positive cells. In cases of X-linked agammaglobulinaemia circulating B cells were not found but the pattern of T cell markers was normal. In cases of common variable hypogammaglobulinaemia there was a wide scatter of helper (OKT4) to suppressor (OKT8) cell ratios. Five children were studied before and after treatment with the synthetic thymic hormone preparation TP5. There were appreciable alterations in the pattern of staining with anti T cell monoclonal antibodies in 4 of these cases, but in 1 case only was this accompanied by improvements in clinical and immune function.

Prenatal exclusion of severe combined immunodeficiency

By analysing leucocyte subpopulations with monoclonal antisera, we have shown that the diagnosis of severe combined immunodeficiency can be made soon after birth. The technique of staining has been adapted for small blood samples, and normal ranges of leucocyte subpopulations have been established for fetal blood taken from mid-trimester pregnancies. Using this information, we gave prenatal advice to an at risk family and predicted that the pregnancy would be normal; this was confirmed after birth. This technique should allow prenatal diagnosis for severe combined immunodeficiency, especially if the phenotype of a previously affected child is known.