Progressive varicella in three patients with Wiskott-Aldrich syndrome: treatment with adenine arabinoside

Patients with Wiskott-Aldrich Syndrome have an increased incidence of serious infections, often with microorganisms that usually produce mild disease in immunologically normal subjects. Three patients with Wiskott-Aldrich syndrome complicated by progressive varicella are reported. There have been no previous reports of similar cases. Two of the patients were treated with adenine arabinoside and had rapid recovery.

Malignant lymphoma in patients with the Wiskott-Aldrich syndrome

The type and incidence of malignant lymphoma developing in patients with the Wiskott-Aldrich syndrome being followed at the National Cancer Institute (NCI) between the years 1966 and 1982 was evaluated. Histologic material from lymphoid tissue was available for review on 24 of the 50 Wiskott-Aldrich patients followed by the Metabolism Branch of the NCI. In 17 patients, specimens were obtained by biopsy performed for diagnosis of lymphoid mass lesions, and in 16 patients autopsy specimens were reviewed. In 9 of the 24 patients a diagnosis of malignant lymphoma was made. A distinct preponderance of non-Hodgkin's lymphoma (NHL) over Hodgkin's disease (HD) with a ratio 8:1 was observed, and the overall incidence of malignant lymphoma in all 50 patients was 18%. The most common histologic subtype of NHL was large cell immunoblastic. In all but one patient the diagnosis of lymphoma was made antemortem, most often presenting in extranodal sites or the brain. Involvement of peripheral lymph nodes was conspicuous by its absence. Immunoperoxidase staining for kappa and lambda chain immunoglobulin and lysozyme was negative in the four cases studied, failing to provide supportive evidence for a B-cell or true histiocytic origin for the tumor cells. Histologic subtypes of lymphoma commonly observed in childhood, such as Burkitt's lymphoma and lymphoblastic lymphoma, were not observed. Despite treatment with combination chemotherapy in some patients, there were no long-term remissions and median survival was less than one year following the diagnosis of lymphoma.

Immunodeficiency syndromes and the gut

The gastrointestinal tract in immunodeficiency disorders is involved with diseases similar to those seen in the immune competent. However, in some immune deficient states the incidence of gastrointestinal disease is high whereas in others it is no different than in the general population. This review clarifies the unique and specific abnormalities seen in immune deficient states and stresses the newest recognised abnormalities. It highlights the fact that the most frequent and severe abnormalities occur in patients with combined immune deficient states.

Acute immune complex mediated glomerulonephritis in a Chinese girl with Wiskott-Aldrich syndrome variant

This study presents a 12-year-old girl with Wiskott-Aldrich syndrome variant, who developed acute glomerulonephritis without history of transfer factor therapy and the efficacy of splenectomy for the control of the patient's thrombocytopenia. The patient presented with eczema, severe thrombocytopenia and immunodeficiency. The impaired immunity was featured by impaired delayed hypersensitivity and lymphoproliferative response to nonspecific mitogen, low serum IgM, low isohaemagglutinins, recurrent infections and high IgE. She developed hematuria about one month prior to admission. For her severe thrombocytopenia splenectomy was performed and proved to be effective. At the time of splenectomy, renal biopsy was done and showed proliferative glomerulonephritis with coarse granular deposition of immunoglobulins (IgA and IgM) and C3. Electron microscopy demonstrated granular electron-dense deposits in the glomerulus, indicating an immune complex glomerulonephritis.

Overwhelming sepsis in the adult variant of Wiskott-Aldrich syndrome

Two brothers with a variant form of Wiskott-Aldrich syndrome suffered episodes of severe bacterial infection commencing in their fourth decade of life. One man died of overwhelming pneumococcal infection. This study emphasizes (1) the importance of recognizing the variant form of Wiskott-Aldrich syndrome in male adults with thrombocytopenia and (2) the treatment of these patients with prophylactic antibiotics.

Gastrointestinal complications of congenital immunodeficiency states. The surgeon's role

Ninety-one congenitally immunodeficient patients treated from 1972 to 1981 were reviewed to assess the incidence and nature of gastrointestinal complications. Thirty-three of these patients (36%) developed 59 complications. Patients with immunodeficiencies characterized by neutrophil dysfunction--chronic granulomatous disease (20 patients) and cyclic neutropenia (eight patients)--developed 22 surgical infections, 22 of which required operation. In patients with neutrophil defects, postoperative morbidity was frequent and severe. Gastrointestinal symptoms were common in patients with isolated defects of B or T lymphocytes. Ten of forty-one patients with congenital hypogammaglobulinemia developed gastrointestinal complications, as did one of four patients with DiGeorge Syndrome, and the single patient with secretory IgA deficiency. However, operation was not required for these patients with isolated disorders of lymphocyte function. Patients with combined B and T cell disorders developed gastrointestinal disease, requiring operative therapy at intermediate rates. Gastrointestinal symptoms developed in four of nine patients with severe combined immunodeficiency and three of eight with Wiskott-Aldrich syndrome. Operative therapy was required in two of these seven symptomatic patients.

Mepartricin: a new antifungal agent for the treatment of disseminated Candida infections in the immunocompromised host

Mepartricin, a new semisynthetic heptene, was given for systemic Candida infections to 11 immunocompromised patients. All patients were undergoing bone marrow transplantation or treatment with antilymphocytic globulin: 6 had acute leukemia, 4 aplastic anemia and 1 had Wiskott-Aldrich syndrome. In all patients systemic Candida infection was diagnosed on the basis of fungemia or positive cultures from at least three different sites, two of which were outside the gut. Mepartricin was given intravenously as a slow drip, at the dose of 100-700 U/kg/day for a total of 198 patient-days (range 9-36, mean +/- SD 18 +/- 8). Patients had to be premedicated with steroids and antihistamines to avoid reactions such as chills and fever. The treatment was well tolerated in all patients, and renal function tests were unchanged during therapy. There was a complete resolution of the fungal infection in 10 of the 11 patients.

Immunodeficiency diseases: head and neck manifestations

Infections of the upper respiratory tract are common to both the immunodeficient and the normal child during their development. The most common head and neck manifestations of immunodeficiency disease are recurrent suppurative otitis media, tonsillitis, sinusitis, rhinitis, and nasopharyngitis. Often the head and neck specialist is confronted with a child with one or more of these problems and must institute the appropriate therapy or decide on an avenue for further investigation. This paper outlines the major immunodeficiency state, discusses the immune defects thought to be responsible for the spectrum of clinical findings, and suggests a systematic approach to the evaluation of these difficult diseases. The recognition of immunodeficient individuals is an important step in their treatment so that adjunctive immunological therapy can be provided.

Primary immunodeficiency disorders in Sweden: cases among children, 1974-1979

A nationwide survey of symptomatic primary immunodeficiency disorders in children in Sweden during the 6-year period 1974-1979 resulted in 201 reported cases. The reported data for 174 children were analyzed. Antibody deficiencies were the most frequent (45.0%), followed by phagocytic disorders (22.0%) and combined T- and B-cell disorders (20.8%). Thirty-two children (18.4%) died, with the highest mortality for combined T- and B-cell defects. The sex ratio for all disorders was 2:1 for boys:girls. Neutropenia was significantly more common in the northern part of Sweden.

Wiskott-Aldrich syndrome: histopathologic findings in the lymph nodes and spleens of 15 patients

Seventeen lymph nodes and 13 spleens from 15 patients with the Wiskott-Aldrich syndrome were examined histologically. The material included both biopsy and autopsy specimens. Consistent findings included depletion of small lymphocytes from T cell areas (all cases), prominence of the reticulum cell stroma (all cases), the presence of atypical plasma cells with and without plasmacytosis (16 lymph nodes and 11 spleens), and extramedullary hematopoiesis (13 lymph nodes and 9 spleens). Less frequent features noted were tissue eosinophilia, hemophagocytosis, focal fibrosis, and progressive depletion of germinal centers. One case with a unique abundance of transformed lymphocytes is described.

Primary immunodeficiency syndrome in Japan. I. Overview of a nationwide survey on primary immunodeficiency syndrome

The results of a nationwide survey on primary immunodeficiency syndrome (PIS) in Japan are presented. By the repeated questionnaire method, 497 PIS cases were collected prior to February 1979 with clinical information. Numbers of each type of PIS, age at the time of diagnosis, patient's status at the time of registration, familial incidence of PIS, and development of malignancy, autoimmune diseases, and allergic diseases among all reported patients are presented and discussed.

Nephropathy in the Wiskott-Aldrich syndrome

Nephropathy was detected in five of 32 patients with the Wiskott-Aldrich syndrome who were participating in a study of transfer factor (TF) therapy. In two patients, nephropathy was present before TF and did not appear changed by TF therapy. One of these patients subsequently developed progressive renal failure requiring dialysis beginning 5 1/2 years after TF therapy. In two patients, decreased renal function appeared very soon after the administration of TF. One patient showed gradually decreasing renal function beginning after two years of TF therapy. An additional patient was identified who died with renal failure without having received TF. The results suggest that renal failure occurs in the Wiskott-Aldrich syndrome more frequently than generally recognized and that administration of TF may precipitate or accelerate the renal disease in patients with this syndrome.

Lymphoreticular disorders in primary immunodeficiencies: new findings based on an up-to-date histologic classification of 35 cases

A histologic review was undertaken of 35 lymphoreticular disorders that developed in primary immuno-deficiency patients from the Immunodeficiency Cancer Registry. Twenty-one (60%) of the lesions were non-Hodgkin's lymphomas: these included eight B-immunoblastic sarcomas. Eight (23%) of the lesions were Hodgkin's disease, with a high frequency of lymphocytic depletion type in an unusually young age group. Three lesions (8.5%) represented abnormal proliferative processes, which could not be definitely categorized as either benign or malignant. There were only two acute lymphoblastic leukemias (6%). Differences were found between lymphomas arising in Wiskott-Aldrich syndrome and those occurring in ataxia-telangiectasia; this suggests that different pathogenetic mechanisms might operate in their development. The lymphomas in Wiskott-Aldrich syndrome were all of non-Hodgkin's type, predominantly B-immunoblastic sarcomas, and presented as localized extranodal infiltrates. The lymphomas in ataxia-telangiectasia were either Hodgkin's disease, mostly of lymphocytic depletion type, or non-Hodgkin's lymphomas of the histologic subtypes associated with 14q translocations.

The Wiskott-Aldrich syndrome in the United States and Canada (1892-1979)

Information was collected on 301 cases of the Wiskott-Aldrich syndrome in the United States and Canada Examination of available medical records, death certificates and published case reports on these patients showed that they came from a wide geographic area and many diverse ethnic and racial groups. No significant difference was found in the incidence of cases born between 1947 and 1976; the overall rate was 4.0 per million live male births in the United States. Median survival has increased with time from eight months for patients born before 1935 to 6.5 years for those born after 1964. Seventy-six of the 301 patients (25%) were still alive at last follow-up and ranged in age from 1 to 36 years with a median of 10 years. Causes of death were primarily limited to infections or bleeding, but malignancy represented a significant problem. Twelve percent of the group (36 of 301) developed malignancy, the predominant types being lymphorecticular tumors (23 of 36) and leukemia (7 of 36). The overall relative risk for malignancy was found to be greater than 100 times that of the general population and was found to increase with increasing age.

Wiskott-Aldrich syndrome: review of literature and report of case

Wiskott-Aldrich syndrome has been described. Other reports and studies of the syndrome have been compiled. Discussion of the incompletely understood pathogenesis and current treatment modalities are included with a differential diagnosis of related conditions. Although this syndrome is uncommon, it is not rare. The patient's susceptibility to infection and propensity to bleed makes early recognition and vigorous treatment an important and challenging task. It is hoped that this report will foster awareness of such patients and the complications involved in treatment.

Hodgkin's disease occurring in a patient with the Wiskott-Aldrich syndrome

Hodgkin's disease, nodular sclerosing, developed in a 16-year-old man with the Wiskott-Aldrich syndrome. Two brothers and two nephews had documented Wiskott-Aldrich syndrome and had died of infectious complications in childhood. While the patient reported here had lifelong thrombocytopenia and recurrent upper respiratory infections, he had no severe infection prior to the development of Hodgkin's disease. Skin test sensitization with dinitrochlorobenzene was unsuccessful. No antibodies were found after immunization with pneumococcal polysaccharides. Platelet aggregation studies were abnormal in the patient, his mother, and one of his nephews. A complete response of short duration occurred after treatment with nitrogen mustard, vincristine, procarbazine, and prednisone. On recurrence, he proved unresponsive to further chemotherapy or radiation therapy. Infection with four different fungi was found at autopsy. This patient is the third recorded case of Hodgkin's disease associated with the Wiskott-Aldrich syndrome.

Immune deficiency, thrombocytopenia and osteomyelitis in pediatric patients

Surgical decompression of osteomyelitis in pediatric patients should be an essential part of therapy in most cases. The initial deferral of prompt decompression in two patients because of underlying chronic, hemorrhagic (thrombocytopenic) disorders-one with Wiskott-Aldrich syndrome and one with Gaucher's disease-resulted in more serious and prolonged courses of the infectious processes. The complications might have been ameliorated by earlier drainage in each case. Based upon the experience gained from these two patients, we recommend early drainage, with appropriate treatment of the hemorrhagic disorder, to prevent more widespread dissemination or prolongation of osseous infection in similarly affected children.

Primary reticulum cell sarcoma of the brain in Wiskott-Aldrich syndrome. Report of a case

We report a case of Wiskott-Aldrich syndrome in a 3 1/2-year-old boy. The patient developed reticulum cell sarcoma primarily in the brain; a biopsy specimen was obtained, and treatment with irradiation and chemotherapy was begun. Computerized tomography performed after three months of therapy showed remarkable regression of tumor. When the patient died five months postoperatively, no viable tumor was present; death was the result of pneumonia and sepsis. Only two previous cases of lymphoreticular neoplasm confined to the brain and associated with this syndrome have been described. We discuss the relationship between immunodeficiency and the occurrence of neoplasia in this syndrome.

Hepatitis B virus infection in the Wiskott-Aldrich syndrome

Testing of paired serum samples of 12 children with the Wiskott-Aldrich syndrome for the presence of hepatitis B surface antigen (HBsAg) antibody to HB, Ag, and antibody to the hepatitis B core antigen revealed evidence of hepatitis B virus infection in three. None of the three, however, developed overt clinical hepatitis or the chronic HBsAg carrier state. These data suggest that the immunologic defects seen in the Wiskott-Aldrich syndrome permit adequate immune responses to the hepatitis B virus and do not predispose to the chronic HBsAg carrier state.

Malignant lymphoma of the jejunum in a patient with Wiskott-Aldrich syndrome. Surgical treatment

An 8-year-old boy with Wiskott-Aldrich syndrome underwent laparotomy and resection of a stage 1E malignant lymphoma of the jejunum. Although preoperative platelet counts were less than 10,000/cu mm, intraoperative bleeding was minimal, and postoperative bleeding from the wound was easily controlled with platelet infusions and local application of epinephrine. Six weeks later, he underwent reoperation for small intestinal obstruction and no residual tumor could be identified. The patient died 4 1/2 months following the initial surgery from an intracerebral hemorrhage. Postmortem examiniation did not reveal residual lymphoma.

Wiskott-Aldrich syndrome associated with idiopathic infantile cortical hyperostosis (Caffey's disease)

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