[Humoral immunodeficiency : awareness for better support]

Les déficits immunitaires humoraux (DIH) sont des maladies hétérogènes allant des formes asymptomatiques rencontrés lors des déficits sélectifs en immunoglobulines A (IgA) et en sous-classes d'IgG aux formes graves des agammaglobulinémies congénitales. Les patients atteints de DIH présentent souvent des infections ORL ou des voies respiratoires récidivantes ou sévères. Ces patients peuvent présenter un certain nombre de complications non infectieuses, telles que des manifestations auto-immunes et des entéropathies, qui pourraient être le seul symptôme clinique révélateur. Les formes sévères des DIH sont facilement diagnostiquées grâce au dosage des IgG totaux, des IgA et des IgM. La thérapie substitutive par les immunoglobulines reste le traitement de choix chez ces patients.

Safety, efficacy and pharmacokinetics of a new 10% liquid intravenous immunoglobulin (IVIG) in patients with primary immunodeficiency

Introduction

An investigational 10% liquid intravenous immunoglobulin (IVIG) was studied in 63 patients with primary immunodeficiency (PID) at 15 study sites.

Methods

Patients were treated every 3 or 4 weeks with 254–1029 mg/kg/infusion of IVIG.

Results

Overall, Biotest-IVIG infusions were well tolerated. The proportion of infusions that were associated with adverse events during infusion, and up to 72 h after infusion, including those unrelated to study product, was 27.7% with an upper 95% confidence limit ≤30.6%. Two serious bacterial infections (SBIs) were observed resulting in a serious bacterial infection rate of 0.035 per person per year and an upper one-sided 99% confidence limit of ≤0.136 SBI/patient/year. The number of days of work or school missed due to infection were relatively low at 2.28 days/patient/year. Two patients were hospitalized for infection producing a rate of 0.21 hospitalization days/patient/year. The IgG half-life was approximately 30 days with variation among individuals.

Conclusions

Pharmacokinetic parameters of specific antibody activities were essentially the same as those of total IgG. Biotest-IVIG is safe and effective in the treatment of PID.

Clinical and laboratory evaluation of periodically monitored Turkish children with IgG subclass deficiencies

IgG subclass deficiencies are common immune system disorders during childhood. The aim of this retrospective study was to review clinical findings and laboratory results of patients with IgG subclass deficiencies in order to determine the changes in serum IgG subclass levels during follow-up, the percentage and time span until normalization of the IgG subclass levels to age-corresponding normal levels, the type of infections incurred and the benefits of prophylaxis. Among the 59 pediatric patients reviewed, the most frequent defect was an IgG3 subclass deficiency (77%). Nine percent of the patients had an isolated IgG2 deficiency and 14% had an IgG2+G3 deficiency. The most common clinical presentations were recurrent upper respiratory tract infections, followed by pneumonia, acute gastroenteritis and urinary tract infections. Atopy was present in 15% of the patients. Ninety percent of the patients were given a prophylactic treatment (benzathine penicillin, oral antibiotics, oral bacterial lysate or intravenous immunoglobulin). The frequency of recurrent infections decreased from 13.4 +/- 7.4 per year to 5.7 +/- 3.9 in patients receiving a prophylactic regimen. Serum IgG subclass levels reached normal ranges in 30% of the patients in the IgG3 deficiency group and in 35.7% of the patients in the IgG2+G3 deficiency group. Patients with an isolated IgG2 deficiency did not reach age-related normal levels during the study period. Our study shows that IgG subclass levels may normalize in 30 to 40% of patients at about 6 years of age. We emphasize the need of monitoring IgG levels together with the clinical symptomatology in affected individuals and initiate preventive measures when appropriate.

Recurrent infections and joint pain

A seven-year-old white male presented with recurrent bouts of paranasal sinusitis, streptococcal pharyngotonsillitis, lower respiratory tract infections, continuous low-grade fever, and conjunctivitis, which required frequent use of antibiotics over a period of two years. A careful review of systems also revealed a six-month history of arthralgia affecting his knees, elbows, and hands, which limited his daily activities. Prominent in the history were recurrent bouts of a generalized salmon-red, nonpruritic rash, which was most pronounced on the face and trunk and which was exacerbated by fever. His past medical history revealed severe bouts of gastroesophageal reflux disease, chronic intermittent bloody mucous diarrhea, and atopic dermatitis. A detailed review of the patient's family pedigree over five generations revealed a strong genetic predisposition for autoimmune diseases of several types. His physical examination revealed a thin, pale, chronically ill-appearing male, bilateral conjunctivitis, and pale nasal mucosae with no lymphadenopathy, organomegaly, arthritis, or rash. All laboratory results were unremarkable except for a positive rheumatoid factor and a suboptimal antibody response to immunization with pneumococcal vaccine. A diagnosis of juvenile rheumatoid arthritis of the systemic onset type was established, and, based upon his humoral immune deficiency, treatment with intravenous immunoglobulin was initiated with remarkable improvement in his symptomatology.

The response to intravenous immunoglobulin replacement therapy in patients with asthma with specific antibody deficiency

In a retrospective analysis of our patient population, 20 difficult-to-treat patients with asthma were found to have clinical and laboratory evidence of specific antibody deficiency, and several had mild hypogammaglobulinemia. Intravenous immunoglobulin replacement therapy at 400-600 mg/kg every 3-4 weeks gave remarkable clinical benefits, with reduction in morbidity, number of hospitalizations, steroid therapy, and number of respiratory infections. We believe that, in this group of patients, the use of intravenous immunoglobulin perhaps allows the achievement of asthma prevention rather than an amelioration of inflammation.

Adverse reactions of prophylactic intravenous immunoglobulin infusions in Iranian patients with primary immunodeficiency

BACKGROUND

Although long-term intravenous immunoglobulin infusion is an effective treatment for children with antibody deficiencies, it can be complicated by systemic adverse reactions.

OBJECTIVE

To evaluate the adverse reactions of intravenous immunoglobulin therapy in patients with primary immunodeficiency.

METHODS

Seventy-one immunodeficient patients receiving intravenous immunoglobulin were evaluated during a 7-year period (1995-2002) at Children's Medical Center in Tehran, Iran. Immunological diagnoses were as follows: common variable immunodeficiency (31 patients), X-linked agammaglobulinemia (25 patients), IgG subclass deficiency (5 patients), hyper-IgM syndrome (2 patients), and ataxia-telangiectasia (8 patients).

RESULTS

One hundred fifty-two cases (12.35%) of adverse reactions occurred following 1,231 infusions in 35 patients. The most frequent immediate adverse reactions were mild reactions (131 infusions), including chills, fever, flushing, muscle pains, nausea, headache, and anxiety. Moderate reactions, such as vomiting, chest pain, and wheezing, occurred in 19 infusions. Two patients experienced severe adverse reactions. The highest proportion (23.06%) of reaction to injection was in patients with common variable immunodeficiency.

CONCLUSIONS

Intravenous immunoglobulin is a well tolerated medical agent for patients with antibody deficiency. However, to prevent occurrence of immediate adverse reactions during infusion in these patients, physicians should perform a detailed history and proper physical examination and check the titer of anti-IgA.

[Subclasses of immunoglobulin G in children with atopic bronchial asthma]

We examined immunoglobulin G (IgG) and its subclasses IgG1-IgG4 in the group of asthmatic children aged from 6 to 16 (n = 50) before of specific (mite) immunotherapy and in control group (n = 150) The results showed isolated decrease of IgG2 (22%) and connected with deficiency of other subclasses (16%). After immunotherapy during 3 years we showed deficiency of IgG subclasses in 60% children with asthma. In our opinion IgG should be examined before decision about immunotherapy because its deficiency in spite of good results of immunotherapy may be conductive for recurrent respiratory tract infections. In these cases immunocorrection methods should be considered.

Immune deficiency: office evaluation and treatment

Congenital deficiencies of the immune system occur in children or adults and can cause severe or recurrent infections. The overall incidence of these immunodeficiency diseases is estimated at approximately 1 in 10,000, excluding selective immunoglobulin A deficiency, but this estimation is based on population studies, not hospital or clinic populations. The majority of immune defects involve antibody production; these immune deficiencies are found more often in adults than infants and children. In an allergy practice, recurrent infections are common, and determining if an immune defect is likely to be present can be problematic. Some guidelines concerning the clinical presentation and laboratory evaluation and treatment options can aid the practicing clinician.

Chronic active EB virus infection complicated with IgG3 subclass deficiency: an adult case treated with intravenous immunoglobulin and IFN-alpha

A 60-year-old man presented with recurrent genital and oral ulcers, necrotic papules on his face and scalp, spiking fever and indurated skin erythema on the trunk. A diagnosis of chronic active Epstein-Barr virus infection and IgG3 subclass deficiency was made, and he was supplemented by intravenous gammaglobulin injection. The spiking fever was resistant to treatment, but the addition of systemic interferon-alpha therapy was partially effective in treating his clinical symptoms, although the patient eventually died from pulmonary effusions and cardiac insufficiency.

Transverse sinus thrombosis and IVIg treatment: a case report and discussion of risk-benefit assessment for immunoglobulin treatment

A 54 year old woman presented with symptoms resulting from a thrombosis of the lateral transverse and sagittal sinuses the day after an infusion of intravenous immunoglobulin (IVIg) replacement treatment. She had previously suffered a milder episode after IVIg. Following recurrent bacterial chest infections and sinusitis for more than 40 years, a diagnosis of IgG1 deficiency had been made two years earlier, after exclusion of other causes. She made a good recovery from the thrombosis but high platelet counts were investigated and primary thrombocythaemia was diagnosed. Investigation of humoral immunity revealed protective amounts of IgG antibodies to pathogens, and because the previous IgG1 deficiency had resolved IVIg infusions were not restarted. She made a good response to treatment with hydroxyurea, with improvement of the headaches and lowering of the platelet counts. Prophylactic antibiotics reduced the number of bacterial chest infections and nasal corticosteroids improved the chronic sinusitis. This case is presented to highlight the need to look for other contributing factors for severe recurrent headaches after IVIg treatment, and to consider the risk of thrombosis even when replacement doses of IVIg are used. It is also important to emphasise the need to ensure that an isolated IgG subclass deficiency is not transient; that failure to produce specific IgG antibodies to immunisation and/or exposure antigens is confirmed, thus meeting the criteria for the diagnosis of primary antibody deficiency. A thorough risk-benefit assessment is essential before blood product treatment is started.

Use of OM-85 BV in children suffering from recurrent respiratory tract infections and subnormal IgG subclass levels

BACKGROUND

Recurrent acute respiratory tract infections (RARTIs) in children are related to IgG subclass deficiencies. The aim of the trial was to evaluate the effect of OM-85 BV in the number of RARTIs as well as in the IgG subclass levels.

METHODS

This was a randomized, double-blind, placebo-controlled clinical trial. Patients of ages three to six years, having three or more documented ARTIs during the last six months with subnormal IgG subclass levels were included. Patients took either one capsule of OM-85 BV (3.5 mg) or placebo orally every day for ten consecutive days per month during three consecutive months. Patients were followed three further months without drug intake. IgG subclass levels were determined before and after treatment.

RESULTS

IgG4 levels diminished after the OM-85 BV treatment (-3 [-8.0, -1.0] median difference [95 % CI] p < 0.05 by Wilcoxon test). No other significant changes in IgG subclasses were observed. After six months the patients in the OM-85 BV group (n = 20) experienced 2.8 1.4 (mean SD) ARTIs, while the patients in the placebo group (n = 20) suffered 5.2 1.5 ARTIs (-2.4 [3.3, -1.5] mean difference [95 % CI] p < 0.001 by Student's t test). Three patients with OM-85 BV had gastrointestinal events related to drug administration, as well as three placebo patients.

CONCLUSION

This study demonstrated the clinical benefit of OM-85 BV in patients suffering from RARTIs and subnormal levels of IgG subclasses. This trial opens new perspectives in the research of the mechanism of action of OM-85 BV.

Effect of intravenous immunoglobulins on in vitro immunoglobulin formation in patients with antibody immunodeficiency

Seventeen patients with antibody immunodeficiency (9 subclass IgG immunodeficiencies, 8 common variable immunodeficiencies) and clinically unambiguous immunodeficiency symptomatology participated in the study with 14 healthy donors. The patients were given regular intravenous immunoglobulin (IVIG) infusions with Endobulin. Blood was collected before and 7 days after infusion of the usual IVIG dose. Mononuclear cells were isolated from peripheral blood (PBMC) of the patients by Ficoll-Paque gradient centrifugation. In order to monitor the ability to inhibit or activate polyclonal production of immunoglobulins in vitro, we stimulated PBMC with pokeweed mitogen (PWM) and with a mixture of pokeweed mitogen + concanavalin A (PWM+ConA). We found that an immunomodulatory effect of IVIG persists in vitro even one week after infusion. Polyclonally stimulated IgA and IgM production was suppressed by IVIG infusion mainly in patients with IgG subclass deficiency. The positive stimulatory effect of IVIG infusion on IgG production was confirmed. The IgG production increased in vitro after infusion in both groups of patients and was significantly higher than in healthy donors. Co-stimulation of PWM-stimulated cells with ConA caused an inhibition of immunoglobulin release in normal healthy donors. The infusion supported the capability of ConA to inhibit IgG production in vitro in patients with IgG subclass deficiency, whereas an increase in IgG production with PWM+ConA stimulation after infusion was found in CVID patients. We assume that lymphocytes activated by ConA produce suppressive factors, which can be affected by the IVIG infusion and which can have both an immunostimulatory and an immunosuppressive effect.

[Intravenous immunoglobulin (GB-0998) for prophylaxis of recurrent acute otitis media and lower respiratory tract infection in infancy with IgG 2 deficiency]

The prophylactic effect of intravenous immunoglobulin (GB-0998) on the recurrent acute otitis media, bronchitis and bronchopneumonia in IgG 2 deficient infants was investigated in a multicenter trial. GB-0998 was administered 6 times every 4 weeks. The doses were 300 mg/kg wt. during the first treatment, followed by 5 doses of 200 mg/kg wt. The results indicated that GB-0998 was effective in the prophylaxis of the recurrent infection of acute otitis media, bronchitis and bronchopneumonia in infancy with IgG 2 deficiency and/or IgG 2 antibody deficiency specific for Streptococcus pneumoniae.

Lupus vulgaris in a patient with systemic lupus erythematosus and persistent IgG deficiency

We present the case of a patient with juvenile onset systemic lupus erythematosus (SLE) who developed a persistent, acquired hypogammaglobulinaemia with IgG deficiency. The hypogammaglobulinaemia was probably a complication of high dose corticosteroid treatment. The serum IgG level remained subnormal despite intravenous immunoglobulin therapy. Lupus vulgaris, which developed on the nasal cartilage in this patient with SLE, is not an expected finding. This patient is probably the first reported case of SLE associated with lupus vulgaris.

[Mechanisms of action of intravenous immunoglobulins]

Intravenous immunoglobulins (IVIG) are now used to treat various diseases, including autoimmune diseases, systemic inflammatory diseases, allografts and for replacement therapy in the case of IgG deficiency. Only in some of the indications has the efficacy of this treatment been confirmed in large-scale studies. Also, in many cases the modes of action remain unclear. Principally, the following therapeutic strategies can be differentiated: Replacement treatment, blocking of the effector molecules, influencing of the cellular and humoral limbs of the immune defence system and interaction with cytokines. In certain CNS diseases, displacement of pathological immunoglobulins may be involved. It would be desirable to acquire more detailed knowledge about modes of action with the aim of using IVIG with greater specificity in the future.

HCV infection in a patient with hyper IgM syndrome

The association between an acquired form of hyper-IgM syndrome and a chronic hepatitis C virus (HCV) infection in a 71-year-old female patient is described. Both diseases were diagnosed at the age of 58 years. She was started on intramuscular and then intravenous immunoglobulin replacement therapy. HCV RNA was detected in 1992. The patient remained in well-balanced clinical condition until 1994, when total and specific anti-HCV IgM levels increased and the patient developed an IgM kappa monoclonal gammopathy. Adherent cells and B cells were HCV RNA positive, while T cells were HCV RNA negative. Anti-IgM reactivity was specifically directed to the core antigen of the HCV. The patient we describe showed a picture of a late-onset form of hypogammaglobulinemia with a progressive increase in IgM antibodies, possibly due to the concomitant HCV infection. It is possible that the immunodeficiency might also result from the HCV infection, with formation of specific antibodies belonging to the IgM class, and that the worsening of the clinical condition may be directly related to the persistent viral infection.

Successful bone marrow transplantation in a child with combined IgG subclass deficiency and neutropenia

An 8-year-old boy with combined IgG1 deficiency and neutropenia underwent allogeneic BMT from his HLA-identical, MLC-negative sister, because immunoglobulin (Ig) infusions and prophylactic antibiotics failed to prevent life-threatening infections. Conditioning was with busulfan and cyclophosphamide, MTX and CYA were given for the prophylaxis of GVHD. For 16 months after BMT no serious infections have occurred and serum IgG1 levels have returned to the normal range without Ig replacement. BMT may be appropriate treatment for patients with IgG subclass deficiency who rarely respond to conservative therapy.

Antibody response in patients with osteomyelitis of the mandible

Patients with mandibular osteomyelitis had quantification of 10 antibodies against certain bacterial proteins and polysaccharides. Sera from 31 patients with acute or chronic osteomyelitis of the mandible and from 17 healthy controls were analyzed. Some patients showed low levels of investigated antibodies in general and a lack of specific antiteichoic acid antibodies, as well as of different antipneumococcal antibodies particularly. Two patients with therapy-resistant osteomyelitis showed IgG2 and IgG3 subclass deficiency. They had replacement therapy with intravenous 10 or 15 gm immunoglobulin every 3 weeks for 6 months. Both patients showed considerable improvement in their clinical symptoms after treatment with immunoglobulin. This study indicates that impaired humoral immune response may be of importance in subgroups of patients with osteomyelitis of the mandible.

Immunologic Defects in Patients with Chronic Recurrent Sinusitis: Diagnosis and Management

Twenty patients with chronic refractory sinusitis or rhinitis were identified to have immune defects on the basis of total immunoglobulin level, immunoglobulin G subclass, and vaccine response. Eight patients were immunoglobulin A deficient, five had low immunoglobulin levels with vaccine hyporesponse, and four had low immunoglobulin levels with normal vaccine responses. Three subjects showed isolated immunoglobulin G1 deficiency. Demographic variables such as age, sex, infection pattern, and any other related disorders were studied retrospectively, which may have contributed to the diagnosis. An immunologic screen was essential for the diagnosis of immunodeficiency in these patients. Treatment options included prophylactic antibiotics, management of associated allergies, functional endoscopic sinus surgery, and replacement therapy with immunoglobulin in selected patients.

Symptomatic IgG3 deficiency successfully treated with intravenous immunoglobulin therapy

We report the case of a 35 year old female who presented with an 8 year history of repeated upper respiratory tract infection, lymphadenopathy and sinusitis associated with IgG3 deficiency. Courses of monthly intravenous immunoglobulin therapy (0.4 g/kg) resulted in a dramatic clinical improvement on three different occasions. We suggest that investigation of adults with features of immunosuppression, despite normal levels of total IgG, should include IgG3 subclass analysis and that symptomatic patients should be given a trial of immunoglobulin replacement therapy.

Chronic sinusitis, steroid-dependent asthma, and IgG subclass and selective antibody deficiencies

In the past 20 years considerable progress has been made in understanding the ways in which subtle immunologic defects can adversely affect health. Immunoglobulin G subclass deficiencies have been identified and are related to an increased susceptibility to respiratory tract infections in certain patients. To assess the immunocompetence of such patients, the quantity and quality of their antibody response must be evaluated. Immunologic evaluation is best performed by measuring selective antibodies before and after a specific challenge. Patients with mild immunodeficiency may benefit from prophylactic antibiotic therapy; those with profound immunodeficiency require antibody replacement therapy.

IgG subclasses: importance in pediatric practice

Although many clinical studies provide evidence of a relation between IgG subclass deficiency and increased susceptibility to infection, a direct cause-and-effect relationship clearly does not exist. Each patient must be managed in the full context of clinical symptomatology, reliable measurement of IgG subclasses, and evaluation of specific antibody production. Future studies may clarify the factors that stimulate and regulate the production of IgG subclasses and improve our understanding of their role in the health of children.

Long-term use of IgA-depleted intravenous immunoglobulin in immunodeficient subjects with anti-IgA antibodies

The use of intravenous immunoglobulin is standard practice for antibody replacement in the humoral immunodeficiency diseases. Most infusions proceed uneventfully, but a proportion of infusions (5-8%) produces some degree of an infusion reaction. While the cause of most of these infusion reactions is unknown, an established, but rare cause of reactions is IgA antibodies in the serum of the patient, which apparently forms an immune complex with the traces of IgA in the infused immunoglobulin. This article describes our studies of five immunodeficient patients who had high-titered anti-IgA antibodies and a history of severe infusion reactions to intravenous immunoglobulin products not depleted of IgA (IgA content, 270-720 micrograms/ml). Over a 6-year period we gave these patients IgA-depleted intravenous immunoglobulin for a total of 170 infusions. These infusions were generally well tolerated; however, mild to moderate infusion reactions did occur in 9 of the 170 infusions (5.3%). These reactions were not related to the IgA content of the immunoglobulin solutions used--ascertained to vary between 0.4 and 2.9 micrograms/ml of IgA. Levels of plasma C3a and C4a increased after immunoglobulin infusions but the appearance of these components was not accompanied by any infusion reaction. We conclude that the long-term infusions of IgA-depleted intravenous immunoglobulin, within the range of IgA concentrations investigated, into patients with even very high-titered antibodies to IgA, is a safe practice.

IgG subclass deficiency

IgG subclasses have been recognized since the early 1960s. Four such subclasses, designated IgG1, IgG2, IgG3, and IgG4, are known to exist. Approximately 65 to 70% of the total circulating IgG in normal persons is of the IgG1 subclass. IgG2 constitutes 20 to 25% of circulating IgG, and IgG3 and IgG4 each represent less than 10%. Deficiencies in the various IgG subclasses have been detected in adults and children with common variable hypogammaglobulinemia as well as in those with relatively normal total IgG levels. An important issue facing clinicians today is to determine what, if any, therapeutic implications are associated with demonstration of an IgG subclass deficiency.

Phenytoin-induced IgG2 and IgG4 deficiencies in a patient with epilepsy

A five-year-old girl with epilepsy and recurrent respiratory infections was investigated for serum IgG subclass concentrations. She was diagnosed as having a combined deficiency of IgG2 and IgG4 with a decreased serum concentration of IgA and IgG3 and was given replacement therapy with i.v. immunoglobulins. Since then, she has been free from respiratory infections. After phenytoin therapy was stopped, IgG subclass deficiency improved. This case describes the further action of phenytoin on the immune system, adding IgG subclass deficiency to the list.