Results in two infants with the DiGeorge syndrome--effects of long-term TP5

We treated two patients affected by DiGeorge syndrome with long-term administration of the synthetic thymic hormone thymopoietin (TP5). In both cases we obtained durable immunological reconstitution, starting as early as 2 weeks after beginning of TP5 treatment. High levels of circulating immature thymocytes and precursor T cells (defined by monoclonal antibodies OKT6, OKT9, and OKT10) were present prior to therapy, and they steadily decreased during the first few weeks of study. During the same time, phenotypically mature T lymphocytes (OKT3+ and OKT4+/OKT8+) markedly increased, thereafter remaining at near normal levels. OKT10+ cells appeared to rise again after 3 months of TP5 treatment. In vitro function of T cells, assessed by PHA stimulation, and in vivo cell-mediated immunity (skin tests with Candida) were normal at 3 and at 2 months, respectively, after initiation of therapy. No severe infection episodes were recorded and normal development was achieved. No side effect or adverse reaction occurred. In these two patients the other features of the DiGeorge syndrome were successfully treated by early cardiac surgery and vitamin D therapy. The immunological reconstitution, in absence of functioning thymus observed in these two cases, provides further evidence of the effectiveness of long-term treatment with thymic hormones--with maintenance of the improvement of cell-mediated immunity.

Chronic diarrhea due to cow's milk allergy. A 4- to 10-year follow-up study

There is general agreement that chronic diarrhea due to cow's milk allergy (CMA) resolves with a cow's milk-free diet, and that tolerance to cow's milk is achieved by 2 years of life. We have followed for 4 to 10 years, 41 infants with chronic diarrhea due to CMA, who had at onset of diarrhea RAST and/or skin tests positive to cow's milk. After the diarrhea subsided, the diet was continued for 6 months and, subsequently, cow's milk reintroduction was attempted at 6-month intervals. In contrast to 25/37 children (four cases were lost to follow-up) in whom CMA subsided at a median age of 2 years, 12/37 (32.5%) children did not tolerate cow's milk at a median age of 6 years. In addition, a large proportion of children (27/37 = 73%) suffered during the follow-up period from other atopic manifestations, due either to CMA or to inhalant allergy. Our data suggest that in infants with chronic diarrhea due to CMA, RAST and/or skin tests positive to cow's milk may indicate either the tendency of CMA to persist throughout childhood, or the risk of developing other atopic diseases.

The Omenn's syndrome: histological, immunohistochemical and ultrastructural evidence for a partial T cell deficiency evolving in an abnormal proliferation of T lymphocytes and S-100 +/T-6 + Langerhans-like cells

A 7 month old female infant was affected by a rapidly fatal familial disease highly reminiscent of Omenn's syndrome. She presented with widespread eczematous lesions, hepatosplenomegaly, superficial lymphadenopathy, peripheral blood lymphocytosis, eosinophilia and hyper-IgE. An axillary lymph node was involved by a marked proliferation of T-3 +/T-10-- lymphocytes admixed with S-100+/T-6+/Leu-3a+/Ia + reticular cells which lacked typical LC granules; cell suspension study revealed that 90%-96% of the lymph node cells were T-11+/T-3+ lymphocytes characterized by low expression of Leu-3a and T-8 antigens and by high expression of Ia antigens (52%). Peripheral blood T lymphocytes exhibited a similar distribution of surface phenotypes. The patient died of interstitial pneumonia and an autopsy was performed. The thymus was markedly atrophic and completely devoid of lymphocytes. The peri-arteriolar lymphoid sheets of the spleen were poorly developed and were mainly composed of T-8+ lymphocytes. The mediastinal nodes were rudimentary and were populated by T-3+/T-10+ lymphocytes with low expression of Leu-3a and T-8 antigens. Our results raise the possibility that Omenn's syndrome is a peculiar primary immunodeficiency in which, despite early thymic involution, some abnormal T lymphocytes still develop in the peripheral lymphoid organs. Antigenic triggering of these cells might result in prominent proliferations of T lymphocytes and Langerhans-like cells which lead to the clinical manifestation of the disease.

Epidemiology, incidence and clinical aspects of food allergy

Clinical manifestations of food allergy (FA) include a large variety of symptoms, most of which are gastrointestinal. Among the various clinical conditions, cow's milk protein allergy (CMPA) usually appears during early infancy; therefore, it is predominantly a problem of childhood. As with any type of FA, the diagnosis of CMPA rests mostly on clinical observation rather than on laboratory tests. Our studies confirm that both skin tests and RAST are valuable tools in the diagnosis. In particular, our follow-up study of a group of infants with CMPA demonstrates that the majority of RAST-positive subjects do not tolerate cow's milk after many years, whereas all RAST-negative infants tolerate cow's milk in their second year of life. Accordingly, RAST may be useful either in the diagnosis or in the prognosis of CMPA. It is generally agreed that treatment of FA should center on avoidance diets. This may not be easy in children with multiple allergies. Prophylactic drugs may be very useful. Disodium cromoglycate, for instance, seems to be effective in the prevention of IgE-mediated FA. They may also be needed when symptoms persist, mostly because of lack of compliance with the antigen avoidance diet. Early prophylaxis against FA appears to be best achieved by breast-feeding. Exclusive breast-feeding should be encouraged for as long as possible when there is a family history of allergy.

Current concepts on the relationship between immunodeficiency and allergy

The relationship between immunodeficiency and atopy represent one of the most significant yet at the same time one of the least understood phenomena in medicine today. This paper will therefore attempt to review the present state of knowledge. Current data focusing on the role of histamine as a negative feed-back regulator of the immune system will also be summarized. It has recently become evident that although several lines of evidence have documented abnormal suppressor T cell functions or numbers in the atopic state, the exact mechanism, however, is not clear yet. It would be important to assess whether the disturbed T cell activity is primary or secondary to the other findings in the atopic diathesis.

Collaborative clinical assay of the biological potency of allergen skin-test extracts

A multicentre collaborative clinical trial has been made at one centre in each of six countries to decide if the potency of allergen extracts can be determined satisfactorily by skin-prick tests in man. Although there was considerable variation in potency of antigen when determined in different patients, if a sufficiently large group (n = 54) of persons were tested, it was shown to be feasible to compare potencies of sequential batches of the same specificity, and also of antigens of different specificities. It was shown that batches of mite extract were weaker than that of a grass pollen, but it proved to be a simple matter to adjust the concentration to give the same biological potency.

Bone marrow transplantation and thymopoietin pentapeptide treatment in two infants with immunodeficiency with predominant T-cell defects

Two infants with immunodeficiency with predominant T-cell defects received transplants of HLA-identical bone marrow cells along with thymopoietin pentapeptide (TP-5) treatment and no prior immunosuppressive therapy. Both patients achieved durable engraftment with early reconstitution of cell-mediated immunity. The study of cell surface antigens with monoclonal antibodies (MoAb) revealed that the early appearance of T-cell subsets defined by OKT4 and OKT8 MoAb occurred. Neither of the patients showed any signs or symptoms of graft versus host disease over a 1-year period. This experience suggests that patients with T-cell deficiency who do not benefit from thymic hormones alone can be successfully treated by bone marrow transplantation. The association of TP-5 with bone marrow transplantation seems to induce an early and stable reconstitution and to protect against fatal post-transplant infection.

A three year controlled study in children with pollinosis treated with immunotherapy

The clinical course of 87 children with pollen induced rhinitis or both rhinitis and asthma was followed in a prospective controlled study over a three year period. All children were treated with specific IT. The long term results have shown that IT was successful in 94% of children with asthma and rhinitis and 90% with rhinitis given more than 80,000 PNU. By contrast, the outcome of 78 selected controls also followed during the same period who did not receive IT was almost exactly the opposite. In addition to demonstrating the clinical effectiveness of IT, the authors stress the relationship among successful results, highest tolerated doses, and larger cumulative dosage which is irrespective of the duration of the therapy. The authors also discuss whether the children in the control group should be injected with placebo solutions or treated with all available medication.

Systemic mastocytosis in a 5-year-old child: successful treatment with disodium cromoglycate

Most clinical signs and symptoms of systemic mastocytosis (SM) are attributed to histamine release. We report here a 5-year-old male child with SM, who suffered from the age of 4 months from disseminated skin lesions, vomiting, diarrhoea, abdominal pain, flushing, tachycardia, hypotension, somnolence, and transient blindness, triggered by heat and egg ingestion. Oral disodium cromoglycate (DSCG) or placebo were started in a single blind trial at a dose of 100 mg/kg/day in four divided doses. The child was studied for 21 months during the administration of three courses of DSCG, each of 6 months' duration, interspersed with three 1-month courses of placebo. During treatment with DSCG all the systemic manifestations improved, and the histaminaemia decreased. During the placebo periods the symptoms, signs, and histaminaemia recurred.

Predictive value of cord blood IgE levels in 'at-risk' newborn babies and influence of type of feeding

Cord serum IgE levels were examined in 101 newborn infants of atopic parents, and reviewed at the ages of 3, 6, 9, 12, 15, 18, 21 and 24 months, in order to determine any relation with signs and symptoms of allergic rhinitis, bronchial asthma, atopic dermatitis, urticaria and food allergy. Cord blood IgE levels were 1.06 +/- 1.02 U/ml in the group of infants who developed atopic disease, and 0.34 +/- 0.79 U/ml in the group of infants who did not develop atopy (P less than 0.001). In the breast-fed group 37.5% of the infants with cord blood IgE more than 0.8 U/ml and 11.5% with IgE below 0.8 U/ml had atopic disease. In the soy-fed group 33.3% of the infants with cord blood IgE more than 0.8 U/ml and 15.8% with cord blood IgE less than 0.8 U/ml developed atopy. Ninety percent of the cow's milk-fed infants with cord blood IgE above 0.8 U/ml and 16% with cord blood IgE below 0.8 U/ml showed atopy during the follow-up period. No correlation was found between the IgE levels in maternal and respective cord blood.

Primary immunodeficiency syndromes in Italy: a report of the national register in children and adults

The Italian Register for Immune Deficiencies was organized in 1977. Seven hundred ninety-seven cases of primary immunodeficiencies, diagnosed according to the World Health Organization criteria, have been registered up to April 1982. In this paper we report the percentages of the different forms of primary immunodeficiencies and the incidence of neoplastic and autoimmune diseases. A prevalence of humoral defects and selective IgA deficiency was found, followed by T-cell disorders. Two and thirty-eight hundredths percent of the patients developed cancer, and 5.89% developed autoimmune diseases. A comparison among the Italian, Swedish, and Japanese Registers showed a higher incidence of IgA defects in the Italian Register while nonspecific phagocyte defects were more frequent in the Swedish Register. The incidence of cancer and autoimmune disorders is similar to that observed in other registers.

Severe combined immunodeficiencies, primary T-cell defects and DiGeorge syndrome in humans: characterization by monoclonal antibodies and natural killer cell activity

Peripheral blood mononuclear cells from three patients with severe combined immunodeficiency (SCID), three with SCID whether B cell positive or with pure T-cell defect, and two with DiGeorge syndrome were analyzed with a panel of monoclonal antibodies against immature and mature T-cell subsets. Natural killer (NK) cells were enumerated by the use of the HNK-1 monoclonal antibody. NK activity against the K562 and MOLT 4 cell lines was also investigated. According to the monoclonal antibodies profile and the NK activity, patients could be divided into three groups. Patients with classical SCID had no detectable circulating T cells as well as NK cells and activity, probably due to an early block in stem cell differentiation. Patients affected by SCID with B cells or pure T cell defect showed a decrease in lymphocytes with mature phenotypes but prothymocytes or immature thymocytes circulated in peripheral blood. Children with DiGeorge syndrome had a decrease in mature thymocytes and, in this study, NK cells were normal. These data help to clarify both the preeminent immunologic features of SCID and related syndromes and the character of NK cells.

Prevention of atopic disease in "at-risk newborns" by prolonged breast-feeding

The protective effect of breast feeding against atopic disease (AD) has been confirmed in several prospective studies, while some retrospective studies have yielded controversial results. We have evaluated the prophylactic effect of prolonged breast feeding on the development of AD in 101 newborns at hereditary risk for allergic disease. The study design also included a strict dietary avoidance regimen of the nursing mothers. Our data demonstrate that breast feeding or breast feeding supplemented with soy milk exert a prophylactic effect on the development of AD in these at-risk infants. Mechanisms by which breast feeding protects from atopy are discussed.

On the reliability of RAST in childhood food allergy

144 children, showing adverse reactions to cow's milk and/or egg, were studied retrospectively. The case finding criteria used was positive elimination and challenge tests with the offending food (s). Specific IgE against the offending food(s) were found in 70% of cases, the majority of whom exhibited early-onset symptoms. RAST seems to be a useful laboratory test in food allergy characterized by early-onset symptoms. Likewise, RAST may be a valuable tool when severe reactions following the ingestion of food are suspected, and dangerous challenge tests are to be avoided.

Evaluation of nasal and blood eosinophilia in children suffering from perennial allergic rhinitis treated with beclomethasone dipropionate

In 16 children suffering from allergic rhinitis, and treated with intranasal Beclomethasone Dipropionate (BDP) for 3 months, therapy significantly diminished the number of nasal eosinophils, while it did not cause any change in blood eosinophilia. This may confirm the local effect of this drug, given at 300 microgram/die. The reduction of nasal eosinophilia during BDP therapy can be explained by the attenuation of the tissue damage characterized by allergic inflammation. The release of mediators, particularly histamine, increases epithelial permeability and promotes penetration of the high molecular weight allergens which thereby gain access to submucosal mast cells. Further release of mediators makes the mucosa more and more permeable to allergen entry. BDP decreases mucous permeability and allergen absorption, so reducing inflammation and consequently the migration of eosinophils to the sites of the allergic reaction.

Effectiveness of oral sodium cromoglycate (SCG) in preventing food allergy in children

The efficacy of oral SCG in preventing food allergy symptoms in children was investigated. Ten children with cow's milk and/or egg IgE-mediated allergy were selected for this study. The subjects were challenged with the offending food before and after a seven-day pre-treatment period with oral SCG (30 mg/kg b.w. per day). Full protection was achieved in six out of eight children with cow's milk allergy and in four of the five children with egg allergy. The mode of action of SCG in the prevention of clinical manifestations of food allergy is discussed.

T-cell subsets in atopic dermatitis

The T-cell subpopulations as defined by monoclonal antibodies OKT4 and OKT8 have been evaluated in 17 children with severe atopic dermatitis and high IgE levels. Normal percentage and absolute number of total T-cells and helper and suppressor/cytotoxic subsets were found. No relationship could be established between the distribution of T-cell subsets, serum IgE levels or the severity of the eczema.

IgE levels and PMN chemotaxis in atopic dermatitis

In the recent years immunological abnormalities, including defective polymorphonuclear neutrophils (PMN) chemotaxis and both quantitative and functional defects in T-lymphocytes, have been reported in atopic dermatitis (AD). To date there is still a controversy regarding the causes of PMN chemotaxis defect and the possible mechanism underlying this abnormality in patients with AD. The aim of this study was to investigate the PMN chemotactic function in 18 children affected with AD and high levels of serum IgE, and in 4 children with Hyper IgE Syndrome (HIES). Our results showed a marked PMN chemotaxis defect (p less than 0.01) in the patients with HIES, while in the subjects with AD PMN cellular chemotaxis was normal and there was no correlation between the results of chemotaxis and serum IgE levels.

Heterogeneity of immunological abnormalities in ataxia-telangiectasia

Peripheral blood mononuclear cells from five patients with ataxia-telangiectasia were evaluated for their reactivity with a panel of monoclonal antibodies directed against T-cell subsets and for their in vitro functions in a pokeweed mitogen-induced immunoglobulin biosynthesis assay. All the patients had significantly reduced proportions of cells identified by monoclonal antibodies to subpopulations of T lymphocytes with helper activity (OKT4 and 5/9) and produced low amounts or no IgA and IgG in vitro. Immunoglobulin biosynthesis was increased by the addition of normal x-irradiated peripheral blood mononuclear cells in one of three patients, suggesting a helper T-cell deficiency in this patient and intrinsic B-cell defects in the other two. Two patients had increased proportions of cells identified by a monoclonal antibody to a subpopulation of T lymphocytes which includes suppressor T cells (OKT8), and their cells were able to suppress immunoglobulin biosynthesis by peripheral blood mononuclear cells from normal donors. These findings indicate heterogeneous disturbances of immunoregulatory mechanisms in ataxia-telangiectasia.

Thymopoietin pentapeptide treatment of primary immunodeficiencies

26 patients with primary immunodeficiencies (3 infants with severe combined immunodeficiency [SCID] 3 with DiGeorge syndrome, 6 with T-cell defect or SCID with B cells, 4 with common variable hypogammaglobulinaemia and associated T-cell defect, 5 with ataxia-telangiectasia, and 5 with hyper-IgE syndrome) were treated with thymopoietin pentapeptide (TP-5) at a dose of 0 . 5 mg/kg daily for 2 weeks and then 3 times a week at 0 . 5 mg/kg for 10 weeks, 3 patients with DiGeorge syndrome and 3 with primary T-cell defect demonstrated pronounced clinical and immunological improvement during treatment. None of the patients with SCID and 3 of 6 patients with SCID with B cells or primary T-cell defect showed any clinical or immunological changes during therapy. In 5 patients with ataxia-telangiectasia clinical manifestations and immunological tests were unchanged by TP-5. Abnormality of T cells in cases of hyper-IgE syndrome was not corrected by TP-5 treatment.