Immune complex disease associated with Epstein-Barr virus infectious mononucleosis

We describe a patient with immune complex-mediated glomerulonephritis and leukocytoclastic vasculitis associated with Epstein-Barr virus (EBV) infectious mononucleosis. The patient required hemodialysis and has residual hypertension. This case implicates acute EBV infection as a cause of immune complex-mediated glomerulonephritis.

Inherited complement C3 deficiency: reduced C3 mRNA and protein levels in a Laotian kindred

To determine the molecular basis of complement C3 deficiency in a Laotian kindred, the homozygous C3-deficient male propositus was studied. By ELISA, this individual's serum was determined to contain approximately 4 microg/ml C3 (0.3% of normal). In accord with this result, anti-C3 immunoprecipitation of [35S]-methionine-labeled fibroblasts from this C3D individual revealed pro-C3 of normal size (180,000 Mr), but in significantly reduced amounts (approximately 1% of normal fibroblasts), that was processed and secreted with normal-size alpha- and beta-chains. In addition, C3-specific mRNA of normal size (5.2 kb) but in reduced quantity (approximately 1% of normal) was detected in this individual's fibroblasts by Northern analysis. The nucleotide sequence of the transcriptional initiation site, the promoter, and the IL-1beta/IL-6 cis-regulatory elements of the C3-deficient gene are normal in this C3-deficient individual, indicating that the low C3 mRNA and protein levels are not caused by reduced C3 transcription that is the result of a cis-mutation. Moreover, cDNA sequencing studies revealed no defect in the C3-deficient mRNA, including the areas mutated in four previously characterized C3-deficient patients. These data indicate that (1) C3 protein deficiency in this Laotian patient results from reduced levels of C3-specific mRNA, (2) the small amount of expressed C3 protein is processed and secreted normally from the deficient cells, and (3) the molecular genetic defect(s), although not yet delineated, is different from those described in other C3-deficient individuals, thereby providing additional evidence for numerous mutations that cause inherited C3 deficiency in humans.

Aortic regurgitation at diagnosis of HLA-B27 associated spondyloarthropathy

A 14-year-old boy with a 9 month history of rheumatic symptoms was found to have hemodynamically significant aortic regurgitation in association with an HLA-B27 associated spondyloarthropathy (SpA). Valvular incompetence due to aortitis can occur early in the clinical course of pediatric patients with SpA, and careful cardiac monitoring is warranted.

Defective production of granulocyte-macrophage colony-stimulating factor and interleukin-1 by mononuclear cells from children treated for acute lymphoblastic leukemia

The production of colony-stimulating activity (CSA) by phytohemagglutinin (PHA)-stimulated peripheral blood mononuclear cells (PBMC) from patients receiving maintenance chemotherapy for acute lymphoblastic leukemia (ALL) was examined. Supernatants from only 14 of 22 patient PBMC cultures (64%), but all supernatants from normal PBMC cultures, supported myeloid colony growth. When present, colony-stimulating activity always included granulocyte-macrophage colony-stimulating factor (GM-CSF). In addition, in nine of ten patient studies and in all control studies, stimulated PBMC produced interleukin-1 (IL-1). These results show that the chemotherapy administered to children with ALL can damage the cytokine production mechanisms in PBMC; the diminished ability to produce GM-CSF and IL-1 may contribute to the increased risk of overwhelming infection in these patients.

Indomethacin-sensitive monocyte killing defect in a child with disseminated atypical mycobacterial disease

A child with disseminated disease due to Mycobacterium avium had progressive disease in spite of 4.5 years of therapy with multiple antimicrobial agents selected on the basis of in vitro sensitivity testing of her organism. A defect in monocyte bactericidal activity was detected which was corrected in vitro by exposure of the patient's monocytes to indomethacin and normal serum. Indomethacin therapy resulted in normalization of monocyte bactericidal activity and striking, albeit temporary, clinical improvement.

Elevated interleukin-2 production by cord blood mononuclear cells from premature newborns

This study was undertaken to delineate the elements of the interleukin-2 (IL-2) system in premature newborns by quantitating IL-2 production and IL-2 receptor (IL-2R) expression and density in cord blood mononuclear cells (CBMC) from 19 premature (estimated gestational age = 27-36 weeks, mean = 33.7), but otherwise healthy, infants and 25 term newborns. Phytohemagglutinin (PHA)-induced IL-2 production by premature CBMC was significantly greater (p less than 0.05) than that produced by term newborn CBMC with a mean value of 52.0 mu/ml for prematures versus 18.2 mu/ml for terms. The mean percentage of CBMC expressing PHA-induced cell-surface IL-2R was 23.4 and 23.0% while the IL-2R density per cell was 4.72 x 10(4) and 6.93 x 10(4) for premature and term newborns, respectively. PHA-induced proliferation was similar in both groups. These results show a significantly increased PHA-induced IL-2 production, but similar IL-2R expression, in CBMC from premature as compared to term newborns, demonstrating that the preterm newborn possesses a competent IL-2 system at birth.

Successful bone marrow transplantation with split lymphoid chimerism in DiGeorge syndrome

A female infant with DiGeorge syndrome associated with severe T-cell immunodeficiency underwent a successful bone marrow transplantation from her HLA-identical, mixed leukocyte culture-nonreactive brother at 5 months of age. Mature circulating T cells and mitogen-induced proliferative responses were detectable at 10 days posttransplant, and by 8 months post-transplant functional T- and B-cell reconstitution was documented by normal responses to mitogens and normal levels of serum immunoglobulins as well as in vitro and in vivo T-cell reactivity to specific antigens and production of specific antibody to T cell-dependent antigens in vivo. Phytohemagglutinin-induced interleukin-2 production and cell surface interleukin-2 receptor expression improved posttransplant, with normal production values observed by 8 months posttransplant. Histologic examination of appendix and thoracic lymph node obtained 9 and 17 months posttransplant, respectively, revealed near-normal lymphoid architecture, with germinal center formation providing morphologic confirmation of reconstitution. Stable split lymphoid chimerism with T cells of donor origin and B cells remaining recipient in origin was documented by sex chromosome analysis. Two years posttransplant the subject remains free of serious infections. In conclusion, this case indicates that bone marrow transplantation can produce peripheral immunoreconstitution without need for significant thymic influence, most likely by providing a source of postthymic T cells, and that bone marrow transplantation should be considered a therapeutic option in patients with DiGeorge syndrome associated with severe T-cell deficiency.

Prolonged defects of interleukin-2 production, responsiveness, and receptor expression in patients with acute lymphoblastic leukemia

The proliferative responsiveness to, production of, and the expression of cell-surface receptors for interleukin-2 (IL-2) were examined in 14 children with acute lymphoblastic leukemia (ALL) in remission and receiving maintenance chemotherapy for 6 to 35 months; in 19 children with ALL in remission and off all therapy for 2 to 138 months; and 15 control subjects. Short-term concanavalin A (Con A)-activated, purified T lymphocytes from patients on, as well as patients off, therapy had a significantly decreased proliferative responsiveness to a saturating amount of exogenous, recombinant IL-2 as compared to control subjects (P less than 0.005 and less than 0.05, respectively). Phytohemagglutinin (PHA)-stimulated IL-2 production by peripheral blood mononuclear cells (PBMC) was also substantially decreased in both patient groups with the median values of IL-2 produced being 2.2, 2.1, and 8.1 U/mL in the on therapy, off therapy, and control groups, respectively. In addition, PHA-induced expression of cell-surface receptors for IL-2 on PBMC was significantly decreased in both patient groups as compared to control subjects (P less than 0.01). Lymphocyte proliferation to mitogens (PHA, Con A, and pokeweed mitogen) was similar in all three groups studied. These results demonstrate that substantial quantitative and qualitative abnormalities of the IL-2-T lymphocyte system are present in the majority of treated patients with ALL, not only during maintenance therapy, but also for a prolonged period after the cessation of all chemotherapy. These long-lasting defects of the IL-2 system are most likely a late effect of chemotherapy and may result in increased complications in some long-term survivors of ALL.

Elevated production of interleukin-2 by lymphocytes from children with acute leukemia

Abnormalities of the production of interleukin-2 (IL-2) may play an important role in the immunologic dysfunction observed in pediatric leukemia patients. For an evaluation of the ability of lymphocytes from leukemic children to produce this cytokine, the production of IL-2 by mitogen-stimulated peripheral blood mononuclear cells was determined in children with acute leukemia at the time of diagnosis, during clinical remission, and at the time of relapse. Of 16 patients, 11 (69%) with either acute lymphoblastic leukemia or acute nonlymphoblastic leukemia at the time of diagnosis had IL-2 production levels above the highest level observed in control subjects, and all but one had values above the control mean. Three of five treated patients had elevated IL-2 production at the time of bone marrow relapse. In addition, of 37 patients examined during clinical remission (both during chemotherapy and after the completion of maintenance chemotherapy), five had IL-2 production values above the control range and four of these five patients subsequently had relapses, compared with only one relapse in the remaining 32 patients with normal or below-normal levels of IL-2 production. These results demonstrate an increased ability to produce IL-2 by many patients with acute leukemia, both at the time of diagnosis and at relapse. Elevated IL-2 production may represent an immunologic response to leukemic cells and in some patients may provide a marker for persistent leukemia.

Granulocyte macrophage colony-stimulating activity production by cultured human thymic nonlymphoid cells is regulated by endogenous interleukin-1

Supernatants of cultured human thymic nonlymphoid cells were assayed for granulopoietic factors using cultures of low density bone marrow mononuclear cells (LD-BMMC). Thymic nonlymphoid cell-conditioned medium (TNLC-CM) supported vigorous myeloid colony growth of LD-BMMC, and of LD-BMMC depleted of T lymphocytes and/or monocytes. Colony stimulating activity (CSA) in TNLC-CM was abrogated by a highly specific neutralizing antiserum against recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF). TNLC-CM also enhanced colony growth in LD-BMMC stimulated by colony stimulating activity from a giant cell tumor culture (GCT). The enhancing activity of TNLC-CM, unlike its CSA activity, required the presence of adherent cells in the marrow cell culture. The addition of anti-interleukin-1 (anti-IL-1) antibody to TNLC-CM inhibited the GCT-enhancing activity, but not the CSA. When the anti-IL-1 immunoglobulin was added directly to cultures of thymic nonlymphoid cells, GM-CSF production was completely inhibited, and the GCT enhancing activity was neutralized. We conclude that an intercellular regulatory network exists in cultured thymic explants in which GM-CSF expression is induced by IL-1. In this system, the granulopoietic effect of IL-1 derives not from a direct effect on myeloid progenitors, but from its ability to recruit CSA production by other cells.

Interleukin 2 production, proliferative response, and receptor expression by cord blood mononuclear cells

To analyze the elements of the interleukin 2 (IL-2) system in newborns, the proliferative responsiveness to, production of, and expression of cell surface receptors for IL-2 were quantitated in cord blood mononuclear cells (CBMC) from 25 normal, full-term newborns and were compared to results in peripheral blood mononuclear cells (PBMC) from 15 juveniles and 28 adults in order to examine the IL-2 system as a function of age. Proliferative responsiveness of purified cord blood T lymphocytes to a saturating amount of human, recombinant IL-2 was significantly greater (p less than 0.05) than that of T lymphocytes from juveniles or adults at all three cell concentrations used. Similarly, phytohemagglutinin (PHA)--induced IL-2 production by CBMC was significantly greater (p less than 0.05) than that produced by PBMC from juveniles or adults with a mean value of 20.3U/ml compared to 11.1U/ml and 11.2U/ml for juveniles and adults, respectively. However, the proportion of CBMC and PBMC from juveniles expressing cell-surface IL-2 receptors (IL-2R) following PHA stimulation was equivalent. These results indicate a significantly enhanced proliferative responsiveness to, and production of, IL-2, but equivalent IL-2R expression, by cord blood T lymphocytes as compared to normal children and adults demonstrating that full-term newborns possess a fully competent IL-2 system at birth.

Inherited C3 deficiency with recurrent infections and glomerulonephritis

A 10-year-old Laotian boy had homozygous deficiency of the third component of complement and recurrent bacterial infections beginning at age 5 months. Cellular and humoral immunity were normal, as were polymorphonuclear leukocyte chemotaxis and bactericidal activities. Serum complement-mediated hemolytic, chemotactic, and opsonic activities were deficient. In vitro addition of purified C3 to patient serum restored hemolytic complement to normal levels, and plasma infusion during each of four episodes of pneumonia significantly enhanced serum opsonic activity for as long as 36 hours. A renal biopsy specimen revealed mesangiopathic glomerulonephritis, although significant levels of circulating IgG immune complexes were not detected. These findings further support the association of C3 deficiency with immune-complex disease and suggest that plasma infusion may be an adjunct to antibiotic therapy in the management of severe pyogenic infections in patients with C3 deficiency.

Interleukin 2 production and responsiveness in individuals with acquired immunodeficiency syndrome and the generalized lymphadenopathy syndrome

Proliferative responsiveness to, and production of, interleukin 2 (IL-2) was determined in 9 homosexually active men with the acquired immunodeficiency syndrome (AIDS) and in 28 homosexually active men with the persistent generalized lymphadenopathy syndrome (PGL). All were seropositive for antibody to human T-lymphotrophic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV). Purified T lymphocytes from individuals with AIDS and PGL had a significantly decreased (P less than 0.01) proliferative response to a saturating amount of exogenous, purified IL-2 as compared to seronegative male controls. Similarly, T4+-enriched T lymphocytes also had a significantly decreased proliferative responsiveness to IL-2 (AIDS, P less than 0.05; PGL, P less than 0.005). T8+-enriched T lymphocytes from individuals with AIDS or PGL did not suppress the IL-2-induced proliferation of autologous T4+ T lymphocytes. In addition, production of IL-2 was significantly decreased in the AIDS group (P less than 0.01) and the PGL group (P less than 0.005) with median values of IL-2 produced being 0.1 and 1.0 U/ml, respectively, compared to 9.9 U/ml for control. These findings demonstrate that substantial quantitative and qualitative abnormalities of the IL-2-T-lymphocyte system exist in patients with AIDS as well as in relatively healthy individuals with PGL. These defects are likely important contributing factors to the depressed T-lymphocyte functions commonly observed in HTLV-III/LAV-associated diseases.

The effects of thymic epithelial monolayer-conditioned medium on suppressor cell function following chemotherapy in pediatric patients

Human thymic epithelial monolayer-conditioned medium (TEM-CM) enhanced concanavalin A (ConA)-induced suppressor T-lymphocyte activity in 15 of 17 studies of fractionated light-density bone marrow mononuclear cells (LD-BMMC) obtained from pediatric cancer patients within 7 days of chemotherapy (P less than 0.001). However, TEM-CM depressed ConA-induced suppressor T-lymphocyte activity in 14 of 18 studies of LD-BMMC obtained from patients who had received their chemotherapy 14-21 days previously (P less than 0.05). In studies of LD-BMMC from normal subjects, TEM-CM did not show any significant effect on suppressor cell activity, nor did TEM-CM significantly affect spontaneous suppressor cell activity in patients or normals. The effect of direct culture on thymic epithelial monolayers was equivalent to the effect of TEM-CM in both ConA-induced and spontaneous suppressor cell assays. These data demonstrate thymic factor-mediated changes in suppressor T-cell activity of pediatric cancer patients and suggest a postchemotherapy alteration in the bone marrow population of inducible prethymic T cells.

Mixed-pattern immune deposit glomerulonephritis in a child with inherited deficiency of the third component of complement

The renal histopathology of a 7-year-old Laotian male with inherited deficiency of the third component of complement, recurrent infections, and persistent hematuria and proteinuria is described. The histologic changes are predominantly those of mesangiopathic disease with isolated changes resembling type I membranoproliferative glomerulonephritis and transmembranous glomerulonephritis. IgG, IgA, IgM, C4, and fibrinogen, but not C3, were detected by immunofluorescence in mesangial zones and in segments of capillary walls. A normal distribution of C3b receptors was present along all capillary walls. This report provides additional support for the association of congenital C3 deficiency and immune deposit glomerulonephritis.

Bone marrow transplantation for severe combined immune deficiency in an infant with chimerism due to intrauterine-derived maternal lymphocytes: donor engraftment documented by chromosomal marker studies

Chromosomal heteromorphisms defined by the quinacrine banding technique were used to identify the maternal origin of 46,XX lymphocytes present in the blood of a male infant with severe combined immune deficiency disease. These chromosomal markers were also used to document the engraftment by donor lymphocytes from the sister and the concurrent disappearance of maternal lymphocytes after a successful bone marrow transplantation. Donor lymphocytes were detected by this technique 6 days after transplantation, earlier than is usually possible with other marker systems and before definite evidence of immunoreconstitution. Maternal lymphocytes persisted in the patient's peripheral blood for a prolonged period of time, being detectable 172 days after transplantation. Analysis of T-lymphocyte- and B-lymphocyte-enriched populations after transplantation documented lymphoid chimerism with T-lymphocytes of donor origin and B-lymphocytes of both patient and donor origin, demonstrating prolonged persistence of patient B-lymphocytes and suggesting that the patient's immune defect is primarily at the T-lymphocyte level.

Recurrent sepsis with deficiencies of C2 and galactokinase

A 4-year-old girl with recurrent, severe bacterial infections and absence of both the second component of complement and galactokinase was investigated for immunodeficiency. The C2 deficiency (C2D) was diagnosed after four major pyogenic infections. Results of studies of cellular and humoral immunity were normal, as were polymorphonuclear leukocyte chemotaxis and bactericidal activities and alternative-pathway hemolytic activity. Serum chemotactic and opsonic activities were deficient in this patient and in an older, asymptomatic sibling with C2D. Fresh-frozen plasma, administered during an episode of Streptococcus pneumoniae meningitis, enhanced serum opsonic activity at 12 hours after infusion. To our knowledge, this is the first description of C2D in a patient with a documented second, unusual genetic defect.

Fatal lymphoma after transplantation of cultured thymus in children with combined immunodeficiency disease

A fatal, widespread, polyclonal, B-cell immunoblastic lymphoproliferative disorder developed in three children with combined immunodeficiency shortly after intra-abdominal transplantation of cultured thymus epithelium for immunoreconstitution. All three had surface immunoglobulin-bearing cells (15 to 20 per cent) in the peripheral blood before transplantation and polyclonally elevated immunoglobulins afterward. Abnormal immunoregulation was demonstrated by a lack of concanavalin A-induced suppressor-cell activity in mixed leukocyte culture in all three patients before transplantation and in two afterward. We suggest that the transplant acted as a promoter through immunostimulation or production of promoter factors, and that excessive polyclonal B-cell proliferation resulted because of inadequate immunoregulatory mechanisms. Although this complication occurred in only three of 30 patients with various forms of immunodeficiency treated with cultured thymus, these cases illustrate a potential problem in immunoreconstitution of combined immunodeficiency disorders.

Functional relationship of macrophages and basophils to the thymus gland

Human thymus epithelium, depleted of thymocytes and macrophages by means of organ culture, was used in chemotaxis experiments with peripheral blood cells. Such cultured thymus epithelium can attract specifically macrophages and basophils. T-lymphocytes were attracted only by short-term (8 day) cultured thymus tissue which still retains some of the original macrophage population. Thymic macrophages formed rosette structures with thymocytes. In other experiments 'activated' rabbit macrophages had the capability to destroy thymocytes, whether autochthonous or allogeneic. The possible role of macrophages and basophils in thymus function is discussed.

Fever in the first eight weeks of life

Sixty-one febrile infants in the first eight weeks of life were evaluated for serious, treatable illness. Infants with bacteremia could not be distinguished from non-bacteremic infants by height of fever, white blood cell count, absolute number of juvenile or mature polymorphonuclear leukocytes, or the presence of a focus of infection (meningitis excluded). The examiners' overall assessment ("clinical judgment") correctly identified eight of the nine infants with bacteremia as not being "well"; one 2-week-old with group B streptococcal bacteremia was "missed" clinically, This points up the limitation of clinical judgment in assessing febrile infants in the age group studied and supports an aggressive approach in the management of very young febrile infants.