Serum immunoglobulins in kwashiorkor

Hypogammaglobulinemia Associated With Oxcarbazepine Use in a Teen

BACKGROUND

There are no prior cases in the literature that report immunoglobulins dropping secondary to oxcarbazepine use in an adolescent patient.

CASE

This patient was an adolescent female taking buspirone, mirtazapine, and oxcarbazepine for mood stabilization. She was admitted to an inpatient disordered eating program for malnutrition. During her malnutrition evaluation, the patient was found to have low serum IgA, low IgM, and low-normal IgG. A slow wean of oxcarbazepine was initiated, and all immunoglobulins showed an increasing trend after stopping oxcarbazepine.

DISCUSSION

Gabapentin was an added medication during hospitalization but is not known to affect immunoglobulins. Malnutrition is the only other significant factor that changed during the patient's hospital stay. With malnutrition alone, immunoglobulins are normal and IgA could be increased; this essentially rules out malnutrition and disordered eating as the cause of this patient's hypogammaglobulinemia, implicating oxcarbazepine as the cause.

CONCLUSION

Chronic oxcarbazepine use was the most likely cause of the hypogammaglobulinemia seen in this patient; this is not currently a reported side effect of oxcarbazepine. This case highlights the importance of judicious use of all medications given the risk of even rare potential side effects.

The immune system in children with malnutrition--a systematic review

Background

Malnourished children have increased risk of dying, with most deaths caused by infectious diseases. One mechanism behind this may be impaired immune function. However, this immune deficiency of malnutrition has not previously been systematically reviewed.

Objectives

To review the scientific literature about immune function in children with malnutrition.

Methods

A systematic literature search was done in PubMed, and additional articles identified in reference lists and by correspondence with experts in the field. The inclusion criteria were studies investigating immune parameters in children aged 1–60 months, in relation to malnutrition, defined as wasting, underweight, stunting, or oedematous malnutrition.

Results

The literature search yielded 3402 articles, of which 245 met the inclusion criteria. Most were published between 1970 and 1990, and only 33 after 2003. Malnutrition is associated with impaired gut-barrier function, reduced exocrine secretion of protective substances, and low levels of plasma complement. Lymphatic tissue, particularly the thymus, undergoes atrophy, and delayed-type hypersensitivity responses are reduced. Levels of antibodies produced after vaccination are reduced in severely malnourished children, but intact in moderate malnutrition. Cytokine patterns are skewed towards a Th2-response. Other immune parameters seem intact or elevated: leukocyte and lymphocyte counts are unaffected, and levels of immunoglobulins, particularly immunoglobulin A, are high. The acute phase response appears intact, and sometimes present in the absence of clinical infection. Limitations to the studies include their observational and often cross-sectional design and frequent confounding by infections in the children studied.

Conclusion

The immunological alterations associated with malnutrition in children may contribute to increased mortality. However, the underlying mechanisms are still inadequately understood, as well as why different types of malnutrition are associated with different immunological alterations. Better designed prospective studies are needed, based on current understanding of immunology and with state-of-the-art methods.

Expansion of the humoral effector cell compartment of both systemic and mucosal immune systems in a weanling murine model which duplicates critical features of human protein-energy malnutrition

A direct comparison of systemic (spleen) and mucosal (intestine) antibody-producing systems was made in weanling male C57BL/6J mice subjected to wasting protein-energy malnutrition (PEM) by means of a low-protein protocol known to duplicate immunological and physiological features of human malnutrition. ELISA revealed low concentrations of biliary and gut lumen immunoglobulin (Ig) A in malnourished mice concomitantly with a high concentration of blood IgA. The low-protein model, therefore, exhibited fidelity to human protein-energy malnutrition in its influence on the concentrations of the mucosal Ig, IgA, in critical biological fluids. The number of IgA-, IgM- and IgG-containing cells was estimated morphometrically on a per organ basis. The low-protein protocol supported expansion in numbers of mucosal IgA-containing cells (18 x relative to a zero-time control group) and of splenic IgG-containing cells (135x), albeit an attenuated expansion in comparison with that of well-nourished control animals (132x and 571x respectively relative to zero-time controls). Up to terminal differentiation of Ig-containing cells, systemic and mucosal antibody-producing systems exhibited similarly remarkable resistance to wasting malnutrition. Epithelial transport of IgA may be an aspect of the mucosal antibody response which is particularly sensitive to PEM.

Serum immunoglobulin (G, A and M) classes and IgG subclasses in sickle cell anaemia

Serum concentrations of immunoglobulins G, A, M and IgG subclasses were determined by single radial immunodiffusion assay in a population of sickle cell anaemia patients resident in the tropics. Fifty apparently healthy subjects of haemoglobin genotype AA, of comparable age, sex and socioeconomic status (SES), and in the same environment as the patients, were included as controls. Three indices of morbidity in SCA, namely frequency of crisis, degree of anaemia and the number of organ complications, were used to derive a severity score for each patient; and thus categorize the subjects into severity groups. Immunoglobulin levels were then correlated with the indices of morbidity as well as the derived severity score. IgG, IgA, IgM, IgG1 and IgG3 levels were significantly raised in the SCA subjects when they were compared as a group with the controls. When separated into disease severity groups, the mildly affected patients were found to have virtually normal levels of immunoglobulins. Total IgG concentration and level of the IgG3 subclass showed significant positive correlation with frequency of crisis and derived severity score. Markedly raised levels of IgG and IgG3 may be predictive of severity in sickle cell anaemia.

IgE responses of malnourished mice: immunogenic and tolerogenic effects of low-grade antigenic stimulation

Mice maintained on protein-restricted diets after weaning manifested normal IgE (and IgG) responses following intraperitoneal immunization under conditions of maximal antigenic stimulation, i.e., antigen adsorbed to adjuvant. However, antigenic challenge at levels closer to the stimulation threshold, employing soluble antigen alone, revealed marked differences between the immune competence of normal and malnourished animals. Diminished IgE responsiveness to soluble antigen in the malnourished mice was accompanied by enhanced susceptibility to the induction of antigen-specific tolerance associated with the appearance of suppressor T cells in the spleen. It is argued that enhanced susceptibility to suppressor T-cell induction under conditions of minimal antigenic stimulation may underlie the diminished IgE responsiveness of the malnourished animals.

Response to live attenuated measles vaccine in children with severe kwashiorkor

An impaired response to vaccination with live attenuated measles vaccine was found in severely malnourished children, when compared with well nourished controls. It is suggested that humoral immune response may fail in children with severe protein energy malnutrition due to diversion of available amino acids to other uses. The possibility of a delayed antibody response to measles vaccine in malnourished children was not excluded.

Immunoglobulin-containing cells in jejunal mucosa of children with protein-energy malnutrition and gastroenteritis

Jejunal biopsies from 20 well nourished children (average age 12.8 months) with gastroenteritis, and 20 children (average age 20 months) with protein-energy malnutrition were examined by immunofluorescent technique for immunoglobulins A, G, M, E, and D, and for epithelial glycoprotein secretory component. Compared with previous studies on normal infants, the children with gastroenteritis showed a moderate increase in IgA-containing cells, a large increase in IgM-containing cells, and no change in IgG-containing cells. These findings are similar to previously recorded findings on adults with gastroenteritis. In contrast there was a pronounced and highly significant decrease in IgA-containing cells in the jejunal mucosa of the children with protein-energy malnutrition. No significant differences were noted between the populations of IgG-, IgM-, IgE-, and IgD-containing cells in the two groups. It is suggested that this selective deficiency in mucosal IgA results from a delay in maturation of the secretory IgA system, and the mechanisms of such a deficiency are discussed.

The effects of malnutrition on secretory and cellular immune processes

About 15 million children under 5 years of age die each year due to suppressed immunity and the resulting increased infection. In severely malnourished children and animals some immune systems such as T-cell function, secretory IgA and complement are significantly suppressed. Other systems, such as the serum IgG or IgA, are normal or even elevated. Some of these changes are apparently caused by nutritional stress while others may be due to stimulation by increased incidence of infection and antigen load. On the other hand, marginal malnutrition stimulates increased phagocytosis and T-cell function with increased immunity to cancer but decreased resistance to certain microbial agents. The mechanisms of immune suppression by malnutrition, persistence of these effects after renutrition, and the effect of maternal malnutrition on newborn immunity are critically reviewed. Possible non-nutritional means of rapid immunological restoration of malnourished children are described.

The effects of kwashiorkor serum on lymphocyte transformation in vitro

The serum from twelve children with kwashiorkor was deficient in its ability to support lymphocyte transformation in vitro, whereas lymphocytes from these children responded to phytohaemagglutinin and al-ogeneic lymphocytes in a relatively normal manner when cultured in normal serum. This serum abnormality improved with therapy and could not be clearly correlated with the degree of malnutrition, the presence or absence of infection or other laboratory manifestations of kwashiorkor. These observations indicate that defective cellular immune reactions in kwashiorkor may be symptomatic of a lack of some humoral factor and do not necessarily reflect an intrinsic cellular defect.

The effects of total parenteral nutrition on immunodepression due to malnutrition

An experimental study was performed in 16 dogs to investigate the effects of sub-acute malnutrition on humoral and cellular immunity and phagocytic functions and, subsequently, to investigate the ability of total parenteral nutrition (TPN) to restore abnormal immunological variables. Deficiencies of IgG, C3, primary immune response to sheep red blood cells (SRBC),lymphocyte counts, lymphocyte response to phytohemagglutinin (PHA), and neutrophi chemotaxis were found to be caused by malnutrition. Nutritional repletion by means of TPN resulted in a return to normal or supranormal serum concentrations of IgG, IgM, and C3, and the primary immune response to SRVC was prompter and higher. Moreover, TPN resulted in restoration of normal neutrophil chemotactic responses. TPN did not improve lymphocyte response to PHA in these experiments. The study demonstrates that subacute malnutrition results in broad based deficiencies of the immunological response of the type that predispose to infection and that the proper use of TPN can correct most of these abnormalities.

Interaction of nutrition and infection in clinical practice

Resistance to infection is determined by a great many interralted factors, but one of the most significant variables is nutritional status of the host. The interaction between nutrition and infection has been described as synergistic, with malnutrition reducing resistance to infection, and infection, in turn, negatively affecting nutritional status. There are qualitative if not quantitative similarities between the evidence that has been gathered from studies of children living in vast areas of the developing countries, in which high rates of both severe malnutrition and infectious diseases are linked with high mortality rates, and evidence from studies of disadvantages children living in the United States in economically depressed migrant camps, Indian reservations, or rural and urban poverty, or children compromised by debilitating chronic diseases. Maternal nutritional status during pregnancy must receive more attention as a factor in the newborn's resistance to infection. Intrauterine malnutrition may cause impaired cellular immune function in the small-for-date infant which persists throughout the first year of life. Further research is needed to clarify this relationship. The optimal management of infections includes management or maintenance of nutritional status, and, in turn, management of nutritional deficiencies include prevention and treatment of infections.

Secretory IgA in protein-calorie malnutrition

The secretory IgA system was investigated in children with protein-calorie malnutrition (PCM). The results of the study indicated that in children suffering from kwashiorkor and marasmus the concentration of IgA in duodenal fluid, saliva, nasal secretions, and tears was significantly reduced on admission and returned to normal 4 weeks after treatment. However, the concentration of secretory IgA in children with mild to moderate PCM was similar to that of normal children. Secretory IgA deficiency may be an important factor in promoting bacterial growth and this may account for the increased incidence and severity of mucosal infections in children with severe PCM.

Growth and immune function in Aboriginal children during recovery from malnutrition and infection

The clinical, nutritional progress and immunological changes of 30 Aboriginal children admitted to the Alice Springs Hospital with malnutrition and infection, and 11 adequately nourished children admitted with acute infection were studied. The initial toxic phase of infection lasted from six to 21 days during which the mean weight velocity of malnourished children averaged 8-8 g/kg/day. The subsequent period of nutritional rehabilitation was accompanied by a slower weight velocity of 3-7 g/kg/day up to a body weight at discharge of approximately 80% standard weight for age. The principal clinical form of malnutrition was moderate protein calorie malnutrition of marasmic type. All children showed laboratory evidence of persistent immunological stimulation with leukocytosis, elevated numbers of T and B lymphoid cells, raised erythrocyte sedimentation rates and hyperimmunoglobulinaemia. These findings were not significantly changed by short-term antibiotic therapy and nutritional rehabilitation and may indicate an underlying defect resulting in the high rate of reinfection and readmission of these children.

Immune modulation and disease patterns in population groups

A hypothesis which explains disease prevalence among different socio-economic groups following early infantile modulation of cell-mediated immunity by infection and nutrition related stress is presented. Wealthy populations living under highly hygienic circumstances can develop their cell-mediated immunity to genetic expectation while their humoral systems remains unstimulated. Primitive populations protect the infant's immune development by breast feeding and suffer from temporary cell-mediated immune deficiencies due to intercurrent infectious disease and famine later on. Intermediary populations harbour a small percentage of people, whose cell-mediated immune system has been permanently damaged by infection in early childhood, leading to a high incidence of diseases linked to cell-mediated immune deficiency. The possible cocarcinogenesis of the cell-mediated immune deficiency following repeated gastroenteritis and persistent stimulation of B cells, leading to alpha heavy chain disease and primary intestinal lymphoma, or due to falciparum malaria in newborns and its impact on the EB virus genome in development of Burkitt's lymphoma, are discussed.

Studies on the immunity of sheep to Oesophagostomum columbianum: effects of low-protein diet on resistance to infection and cellular reactions in the gut

Adult Oesophagostomum columbianum populations were larger in sheep fed low-protein diets than in adequately fed animals. Diet did not influence the numbers of larva which became established in sheep. Sheep fed high-protein diets eliminated more worms and were more immunologically competent than poorly fed animals. More encapsulated larvae, showing arrested development, were found in adequately fed sheep than in those fed low-protein diets. Adult O. columbianum produced eggs at an earlier time after infection in poorly fed sheep than worms in well fed sheep. More eggs/female worm were produced in sheep on a low-protein diet compared with the number of eggs produced in well fed hosts over the last week of the infection. The effects of immunity on the behaviour of the worm in both host diet groups is discussed.

There was a greater cellular proliferation in the intestines of infected adequately fed sheep than in infected animals on low-protein diets. These changes were most pronounced in the large intestine where the adult parasites were found. The macrophage-lymphocyte series of cells underwent hyperplasia in well fed animals but these changes were reduced, particularly among the plasma cells, in sheep fed low-protein diets. Increased mucin and mast cell counts were observed in sheep on high-protein, but not in hosts on low-protein diets: the intestinal populations of eosinophil and globule leucocytes were also reduced in poorly fed sheep.

The relationship of these various cellular reactions and their effect on the protective immunity of sheep to O. columbianum is discussed. It was concluded that the increased susceptibility of protein deprived sheep to O. columbianum infections was associated with malfunctions of the innate immunity of the gut, involving decreased peristalsis and failure of the mucin cell response, and with reduction of the adaptive immune response which was reflected by impoverished lymphocyte and plasma cell reactions, and possibly with poor cooperation between sensitized lymphocytes, antibodies and the mast cell-granulocyte effector mechanisms in protective immunity.

Lymphocyte transformation in malnourished children

In vitro lymphocyte stimulation with phytohaemagglutinin gave subnormal transformation values in children with protein-calorie malnutrition. It is suggested that impaired cell-mediated immunity may be one important mechanism for the susceptibility of malnourished children to infections. Lymphocyte transformation was also subnormal in children with measles and gastroenteritis but tended to be increased in pneumonia.

A survey of nutritional-immunological interactions

There is some evidence to show that the immune response is suppressed in malnutrition but the mechanism is not entirely clear. A more complete understanding of nutritional-immunological relationships is important, especially for child health in developing countries. This memorandum discusses a general approach to the problem and proposes specific methods for investigating the effects of malnutrition on the immune response. Several field studies incorporating these proposals are now in progress.

Impaired cellular immunity in kwashiorkor with improvement after therapy

Children with kwashiorkor showed a high incidence of deranged cellular immunity as evidenced by impairment of delayed cutaneous hypersensitivity reactions to candida and diphtheria toxoid antigens and of lymphocyte transformation after phytohaemagglutinin stimulation. This may contribute to their susceptibility to infection. A correlation was shown between the degree of impairment of tests of cellular immunity and the severity of the kwashiorkor. Once recovery was initiated the skin tests gave the expected positive results and the lymphocyte transformation index improved. Protein deprivation may result in impaired deoxyribonucleic acid (DNA) synthesis and in atrophy of both the thymus and the lymphoid tissue.

The colon in kwashiorkor

The colon in kwashiorkor was investigated by means of rectal biopsy and sigmoidoscopy in 20 children, followed by barium enema in 10 of the children. The colon during the acute phase of the disease showed a surface epithelial atrophy, with infiltration of plasma cells and congestion of small vessels. Viewed under the dissecting microscope, a disorganized vascular pattern was seen in all cases. On recovery from kwashiorkor after 3 to 4 weeks, the abnormal vascular pattern and epithelial atrophy of the colon had returned to normal in most children.

Serum immunoglobulins in edematous protein--calorie malnourished children. Studies in Guatemalan children at INCAP

Serum levels of IgG, IgA and IgM were found to be either normal or elevated in PCM patients, with no relation to the degree of protein-calorie depletion, the percentage of white cells and plasmocytoid lymphocytes in peripheral blood, or the prognosis. The IgG rose in a child developing mumps even though his diet was only sufficient for nitrogen equilibrium. These results still do not elucidate the discrepancy that exists between elevated immunoglobulin fractions and the high mortality rate asso ciated with the presence of infection in protein-calorie malnutrition.