Partial myeloperoxidase deficiency in preleukemia

Infections in patients with leukemia and lymphoma

Infectious complications remain a significant issue in the care of patients with hematologic malignancies. Inherent immune defects related to the primary disease process are present in patients with disorders such as chronic lymphocytic leukemia, multiple myeloma, hairy cell leukemia, and Hodgkin lymphoma. Therapy-related immunosuppression is also commonplace in these patients. This includes not only treatment-related neutropenia, but also defects in cell-mediated immunity, such as those that occur with purine analog therapy. In this chapter, we will review the pathogenesis of infection in these disorders, as well as the spectrum of infectious complications seen and suggested strategies for the prevention of infection.

Myeloperoxidase: a front-line defender against phagocytosed microorganisms

Successful immune defense requires integration of multiple effector systems to match the diverse virulence properties that members of the microbial world might express as they initiate and promote infection. Human neutrophils--the first cellular responders to invading microbes--exert most of their antimicrobial activity in phagosomes, specialized membrane-bound intracellular compartments formed by ingestion of microorganisms. The toxins generated de novo by the phagocyte NADPH oxidase and delivered by fusion of neutrophil granules with nascent phagosomes create conditions that kill and degrade ingested microbes. Antimicrobial activity reflects multiple and complex synergies among the phagosomal contents, and optimal action relies on oxidants generated in the presence of MPO. The absence of life-threatening infectious complications in individuals with MPO deficiency is frequently offered as evidence that the MPO oxidant system is ancillary rather than essential for neutrophil-mediated antimicrobial activity. However, that argument fails to consider observations from humans and KO mice that demonstrate that microbial killing by MPO-deficient cells is less efficient than that of normal neutrophils. We present evidence in support of MPO as a major arm of oxidative killing by neutrophils and propose that the essential contribution of MPO to normal innate host defense is manifest only when exposure to pathogens overwhelms the capacity of other host defense mechanisms.

Immune alterations in untreated and treated myelodysplastic syndrome

INTRODUCTION

Current literature suggests a variety of immune abnormalities are present in myelodysplastic syndrome (MDS) patients. However, they have not been comprehensively characterized or systematized to date. As a result, their clinical implications remain largely unknown. In addition, an increased incidence of various autoimmune conditions has been documented in MDS patients.

AREAS COVERED

The authors offer a comprehensive review of the existing literature on immune mechanisms involved in the pathogenesis of MDS, various immune abnormalities documented in its course, their link with the clonal evolution of MDS as well as immune alterations induced by the existing MDS therapies.

EXPERT OPINION

The course of MDS is accompanied by complex immune alterations, including T-cell and NK-cell defects, decreased functional abilities of neutrophils and antigen-presenting cells, altered antibody and cytokine production. While contemporary MDS therapies are shown to possess some immunomodulatory properties, authentic autoimmune conditions have also been documented with lenalidomide and recombinant erythropoietin. Caution should be exerted with the use of these agents in MDS patients with evidence of autoimmune disorders, as exacerbation of autoimmune phenomena can be anticipated. While the heterogeneity of MDS represents an inherent limitation, integration of emerging information from molecular biology, genetics, immunology research and clinical practice could translate into improved outcomes of this disease spectrum.

Myelodysplastic syndromes. Pathogenesis, diagnosis and treatment

Our understanding of the biology of leukemia and myelodysplasia is still only partial. The diagnosis of myelodysplasia is often based on quantitative and qualitative findings in the peripheral blood and bone marrow. These findings are often shared by other disorders. There is a need for sensitive and inexpensive laboratory tests to determine clonality and karyotypic abnormalities in this disorder. Future classifications of these syndromes will need to be based on morphologic and biologic markers that are closely linked to disease progression, response to treatment, and survival. Our limited understanding of the pathogenesis of MDS decreases the specificity and effectiveness of our therapeutic interventions. Agents that are minimally toxic such as CRA, danazol, 1,25-dihydroxyvitamin D3, androgens, and pyridoxine are seldom useful. Antileukemic therapy and allogeneic bone marrow transplantation have a major role to play in patients younger than 45 years of age; in older patients these treatment modalities remain controversial because of their toxicity. Hematopoietic growth factors, used alone or in combination, may improve the quality of life and improve survival of patients with MDS. Growth factors may also decrease treatment-related mortality associated with chemotherapy and bone marrow transplantation and render these treatment modalities available for a higher percentage of patients. The development of more specific differentiating agents may permit hematopoietic differentiation while minimizing side effects.

Superoxide anion production and expression of cytochrome b 558 by neutrophils are impaired in some patients with myelodysplastic syndrome

Superoxide anion (O2-) production and expression of cytochrome b 558 by neutrophils were determined in 20 patients with myelodysplastic syndrome (MDS). The reduction of O2- production was noted in eight of the 20 patients and an increase was noted in four patients when neutrophils were stimulated by n-formyl-methionyl-leucyl-phenylalanine (FMLP), while a low level of O2- production was found in 11 and an increase in six MDS patients when they were stimulated by phorbol myristate acetate (PMA). Among them, seven patients showed a decrease and four an increase in O2- production on stimulation with either FMLP or PMA. Expression of cytochrome b 558 was found to be at low levels in patients who had neutrophils showing decreased O2- production when stimulated with FMLP, indicating that decreased expression of cytochrome b 558 might contribute to the impairment of O2- production in some MDS patients. In this study, no significant differences in O2- production were noted among subtypes of MDS; however, the patients who had received prednisolone showed lower levels of O2- production than those who had not received prednisolone. Patients manifesting episodes of infection had reduced levels of O2- production compared with those without infection. Furthermore, the fact that one patient who exhibited a marked reduction in neutrophil counts together with reduced O2- production died of fatal infection, suggests that the determination of O2- production, in combination with hematological features, may be of some help in predicting severe infection.

Biosynthesis and processing of myeloperoxidase--a marker for myeloid cell differentiation

Myeloperoxidase (MPO), a heme protein, is a major component of azurophilic granules of neutrophils. Optimal oxygen-dependent microbicidal activity depends on MPO as the critical enzyme for the generation of hypochlorous acid and other toxic oxygen products. MPO is synthesized during the promyelocytic stage of myeloid differentiation, the stage at which azurophilic granules are formed. Like other lysosomal enzymes, MPO is synthesized as a larger precursor which is subsequently processed and transported intracellularly to the lysosomes. The primary translation product is a single 80-kDa protein which undergoes cotranslational N-linked glycosylation to produce a 92-kDa glycoprotein. Glucosidases in the endoplasmic reticulum or early cis Golgi convert the proMPO to a 90-kDa form which is sorted into a prelysosomal compartment that undergoes final proteolytic maturation to native MPO, a pair of heavy-light protomers with subunits of 60 kDa and a 12 kDa. These events contrast with similar processes seen with other lysosomal enzymes in two ways. First, alkalinization of lysosomes with NH4+ does not alter processing or transport, in contrast to the pH dependence of these processes for other lysosomal enzymes. However, some studies indicate retardation of processing in the presence of the proton ionophore monensin. Second, intracellular transport of MPO is not apparently mediated by the mannose-6-phosphate receptor system. The gene for MPO is on the long arm of chromosome 17 (17q22, 23) near the breakpoint of the 15, 17 translocation of acute promyelocytic leukemia. The gene spans approximately 14 kb and contains 11 irons and 12 exons. The cloned full-length cDNA is approximately 2.2 kb and both normal bone marrow and cultured promyelocytic leukemia cells express two species of mRNA. Inherited MPO deficiency, a relatively common disorder, is associated with the absence of mature MPO but the presence of proMPO, consistent with a post-translational defect. Studies at the molecular level aimed at identifying the underlying genetic defect are thus far consistent with that hypothesis. In addition, the basis for the observed association between acquired MPO deficiency and some myeloid leukemias can now be studied at the molecular level using these probes.

Biology of myelodysplastic syndromes

Myelodysplastic syndromes (MDS) represent a diverse spectrum of disorders ranging from refractory anemia to a preleukemic state. Peripheral cytopenias, cellular marrow, dysplasias and dysfunctions of myeloid and lymphoid cells constitute hematological hallmarks, and are caused by ineffective hemopoiesis. Investigations of cell cultures and cellular functions indicate that the disease originates in a stem cell pluripotent to all myeloid cells and possibly lymphoid cells as well. The disease commonly runs a chronic indolent course, often terminating in acute leukemia or nonleukemic death, notably infections and/or hemorrhage due to cytopenias and cellular dysfunctions. Clonal expansion or clonal evolution appears to be related to the disease progression with a greater degree of malignancy. However, the initial sequence of events causing damage to stem cells is still undefined.