Does immunodeficiency in uremic patients promote dialysis-related amyloidosis?

The present study was undertaken to evaluate the immune function of 5 hemodialysis patients with dialysis-related amyloidosis as compared to 6 without, both groups having a dialytic age from 7 to 21 years, and 5 healthy controls. We investigated serum levels of immunoglobulins (IgG, IgA, IgM), made skin tests and measured peripheral lymphocyte subsets using monoclonal antibodies. 1) The absolute numbers of T3, T4 and T8 cells were significantly lower in hemodialysis patients than controls and T3, T4 cells were lower in patients with amyloidosis than in those without: T3 (m +/- SD/microliter), 387 +/- 253 vs 744 +/- 207 (p = 0.03); T4, 262 +/- 115 vs 589 +/- 297 (p = 0.04). 2) Serum levels of IgG and IgM were significantly lower in patients with amyloidosis than in the others: IgG (m +/- SD, g/l), 10.2 +/- 1.4 vs 15.4 +/- 3.2 (p less than 0.001); IgM, 0.65 +/- 0.28 vs 1.65 +/- 0.37 (p less than 0.001). 3) Delayed hypersensitivity studied by skin tests showed less than 3 positive antigens in 4/5 patients with amyloidosis against 1/6 patients without. These data suggest there is a marked defect of T-cell help in uremic patients with dialysis-related amyloidosis.

Inadequacy of mucosal IgM antibodies in selective IgA deficiency: excretion of attenuated polio viruses is prolonged

A nationwide vaccination campaign with oral poliovirus vaccine was organized in Finland in 1985 in order to cease an outbreak of poliomyelitis. We followed eight IgA-deficient individuals and nine controls for poliovirus excretion in feces and for antibody responses in serum and saliva. Five weeks after oral poliovirus vaccination all eight IgA-deficient individuals were still excreting polioviruses, in contrast to one of nine controls. The concentration of polioviruses, as estimated by a semi-quantitative immunofluorescent assay, was generally higher and the test was significantly more often positive in the samples from the IgA-deficient individuals. Although serum levels of antibodies to poliovirus type 3 were lower in IgA-deficient individuals before vaccination, both measurements showed that the two groups had similar antibody levels 4 weeks after vaccination. IgA-deficient individuals lacked salivary IgA antibodies to poliovirus types 1 and 3 but had increased levels of IgM antipolio antibodies, which were shown to carry secretory component. We conclude that the mucosal IgM antibodies of IgA-deficient individuals eliminate polioviruses less efficiently than do the IgA antibodies of normal individuals.

[IgG subclass deficiency in childhood. Changes in the antigen specific immune response and significance of low IgG4 level]

The definition of IgG subclass deficiency and the correlations between low IgG subclass serum concentrations and high incidence of infections in certain patients are still obscure. Therefore 260 children from 6 months to 18 years with severe recurrent infections or a known immunodeficiency were screened for IgG subclass deficiency. Nine patients with severe IgG2 deficiency (Ig2 less than 0.3 g/l) and 35 patients with non-detectable IgG4 in immunoprecipitation were detected. One of these patients had a concomitant IgA deficiency, eight revealed an additional IgA and IgG2 deficiency, two an IgA, IgG2, and IgG3 deficiency, eighteen an IgG2 deficiency and one patient an IgG2 and IgG3 deficiency. The proportion of patients with non-detectable IgG4 in immunoprecipitation was 13.5% and thus in the same order of magnitude as described in the literature for healthy people. Our data show that there is no relation between low IgG4 serum levels and the increased occurrence of severe infections. In all patients investigated with non-detectable IgG4 in immunoprecipitation the gene for the heavy chain gene constant domain C gamma 4 could be detected by Southern blotting. Using a sensitive ELISA method IgG4 could be directly demonstrated in all patients at a serum level of 0.5-29 micrograms/ml. Specific IgG4 antibodies against protein antigens could not be detected in IgG4-deficient patients. Nevertheless total IgG antibodies against diphtheria and tetanus toxoid reached protecting titers. Patients with IgG2 deficiency showed an impaired immune response against polysaccharides from pneumococci and haemophilus influenzae type b.

Serum IgG subclass levels in paediatric clinic patients with variable degrees of IgA deficiency

We measured IgG subclass levels by radial immunodiffusion with polyclonal antisera in 60 patients with IgA deficiency. The low IgA levels were measured by a sensitive and specific enzymoimmunometric method. None of the patients had complete deficiency of IgG2, but 4 patients had serum levels of IgG2 and 4 of IgG3 below the range for controls. Elevated levels of IgG1 were found in patients with juvenile rheumatoid arthritis and coeliac disease. None of the patients with coeliac disease or juvenile rheumatoid arthritis had low IgG2 or IgG3 levels. The levels of IgG4 were highly variable but patients with coeliac disease had particularly high values. The severity of IgA deficiency did not correlate with the level of serum IgG2.

Subclass restriction pattern of antigen-specific antibodies in donors with defective expression of IgG or IgA subclass heavy chain constant region genes

We have developed a method for the measurement of the IgG and IgA subclass distribution of antigen-specific human antibodies. The controls for the specificity of the assay include the use of a number of monoclonal human antibodies and sera from individuals with deletions of particular immunoglobulin heavy chain constant region genes. The system was used to determine the shift in immunoglobulin subclass patterns of specific antibodies against a variety of protein and polysaccharide antigens in individuals with a regulatory deficiency of a given IgG or IgA subclass. Normally, the pattern is quite distinct and antibodies against protein antigens are mainly of the IgG1 subclass, whereas antibodies against polysaccharide antigens are mainly of the IgG2 subclass. The results on serum from an IgG1 deficient donor suggested that IgG3 and IgG4 appear to compensate for a lack of IgG1, whereas isolated deficiencies of IgG3, IgG4, or IgA2 do not markedly influence the expected distribution of specific antibodies. In IgG2-deficient individuals a more complex pattern was observed where antibodies against protein antigens were retained, whereas levels of antibodies against polysaccharide antigens could vary markedly between donors, which appeared to be dependent on whether the IgG2 deficiency was an isolated defect or combined with IgG4/IgA deficiency. However, all the IgG2-deficient donors had a skewed pattern of anti-polysaccharide antibodies with a shift to IgG1 to IgG3.

[Clinical relevance of immunoglobulin subclasses in children with chronic pulmonary diseases]

In 52 children (age 4-19.5 years; 17 female, 35 male) with chronic chest symptoms IgG-Subclass levels were measured by radial immunodiffusion techniques. Thirteen children had proven bronchiectasis, 22 chronic bronchitis and 17 steroid dependent asthma bronchiale. Cystic fibrosis, alpha-1-antitrypsin deficiency, tuberculosis and chronic foreign bodies were excluded in each patient; all of them showed normal levels of total IgG. Four children (3 with bronchiectasis, one with steroid dependent asthma bronchiale) had a complete lack if IgG4. In two children with chronic bronchitis one showed fluctuating levels of IgG2 and IgG4 and another deficiency of IgG3. All patients with an isolated IgG4 deficiency were treated with immunoglobulins. Of 3 patients with bronchiectasis one improved, two remained unchanged as shown by positive sputum cultures and of chronic chest symptoms. One patient with steroid dependent asthma bronchiale markedly improved during immunoglobulin therapy. It is concluded, that early screening of IgG subclass deficiency is indicated in all children with chronic chest symptoms.

Selective immunodeficiency affecting staphylococcal response

Eight patients with recurrent staphylococcal infections, necessitating up to 213 hospital admissions in one patient, gave normal results with the usual immunological investigations, including measurement of serum IgG and IgG2. In the staphylococcal inhibition test all showed persistently subnormal results, corrected by the addition of compatible normal plasma or normal IgG therapy for 6 months to 21 years, and one died from staphylococcal septicaemia 6 months after withdrawal of treatment. The impairment in anti-staphylococcal response, with failure to produce adequate antibodies, was probably acquired in utero in four patients and inherited in two. In these six patients symptoms started soon after 4 months. In the remaining two the syndrome was acquired later in life.

Humoral immunity in bronchiectasis

Bronchiectasis occurs in patients with immunodeficiency and fungal hypersensitivity disorders. To assess the prevalence of abnormal humoral immune parameters in bronchiectasis, a retrospective study was carried out on sera from 30 patients. Studies included immunoglobulin quantitation and specific antibody to fungal species. Eleven patients were found to have immunodeficiency (nine with panhypoglobulinemia and two with selective IgM deficiency). Six patients had elevations of serum IgA and four patients had elevations of serum IgE. Six patients had elevated total antibody to Aspergillus or Candida species and six had precipitin bands to one or more fungal antigens. This study indicates that immunodeficiency is prevalent and plays a causative role in some patients with bronchiectasis. Hypersensitivity reactions to Aspergillus, Candida, and other ubiquitous environmental fungi may also play an etiopathogenic role in this disease (bronchiectasis, humoral immunity, immunodeficiency).

Immunoglobulin-producing cells in secretory immune system in patients with selective IgA deficiency

This study evaluated the class distribution and J chain-positivity of immunoglobulin-producing cells (Ig-PCs) in gastrointestinal mucosa and salivary glands of Japanese patients with selective IgA deficiency. The proportional patterns of gland-associated Ig-PCs showed an increase in not only IgM cells but also IgG cells, most of which were J chain-positive. This may represent a maturation arrest at B cell differentiation, rather than a compensatory phenomenon. No patients showed an increase of IgD cells in salivary glands. This behavior of IgD cells in Japanese patients may reflect associated diseases or ethnic difference in B cell differentiation.

Serum IgG subclasses in patients with an increased susceptibility to respiratory tract infections

Serum IgG subclass concentrations were assayed in 45 patients with chronic respiratory tract infections and 16 patients with recurrent acute respiratory tract infections. Eleven of these 61 patients, all but one with recurrent acute infections, were IgA-deficient but the remainder had normal or high serum immunoglobulin concentrations. Only 4% of patients with chronic infections were IgG2-deficient. The prevalence of IgG2 deficiency amongst patients with recurrent acute infections was greater (31%), but in most cases this appeared to be due to an association with IgA deficiency. Owing to the limits of assay sensitivity it was not possible to determine whether any patient was IgG4-deficient, but the number of sera with undetectable IgG4 was greater in patients with recurrent acute infections than in controls (37.5% vs 10%, p less than 0.01), although such patients were mainly those with IgA and IgG2 deficiency. None of the patients had IgG1 or IgG3 deficiency; in fact IgG3 concentrations were higher than those of controls in both groups of patients (p less than 0.001) and IgG1 concentrations were higher than those of controls in patients with recurrent infections (p less than 0.01). Thus, unequivocal IgG subclass deficiency is uncommon in non-IgA-deficient patients, but those with IgG2 deficiency may have an immune defect requiring further investigation.

Jejunal plasma cells and in vitro immunoglobulin production in adult coeliac disease

IgA, IgE, IgG and IgM plasma cells in small bowel mucosal biopsies from 15 controls, 16 untreated and 14 treated coeliac patients and five patients with selective serum IgA deficiency (four of whom also had coeliac disease) were quantified using an indirect immunoperoxidase technique. The IgA, IgG and IgM plasma cell counts were significantly increased in the untreated coeliac patients. The cell counts were intermediate in the treated coeliac group. These changes were in parallel to production in vitro of IgA and sIgA, IgG, and IgM by cultured mucosal biopsies from the same patients. The IgA deficient patients had very few mucosal IgA cells but elevated IgG and IgM plasma cell numbers; again these changes were reflected in the production in vitro of immunoglobulins. IgE plasma cell counts were very low in all patients and there were no differences between patient groups. The changes in cell counts and mucosal immunoglobulin production were not reflected in serum IgA, IgM and IgG concentrations but serum secretory IgA was significantly elevated in the untreated coeliac patients compared with controls, with the treated coeliac patients being intermediate. The raised mucosal plasma cell counts reflect the local mucosal production of immunoglobulin but not the immunoglobulin concentrations of serum, emphasising the importance of studying the immune function of the gut itself in coeliac disease rather than immunological abnormalities in serum.

Naturally occurring antibodies to phosphocholine as a potential index of antibody responsiveness to polysaccharides

Naturally occurring antibodies reactive with the phosphocholine (PC) determinant of pneumococcal teichoic acids may be useful for evaluating the potential of patients to make antibodies to polysaccharides. Antibodies to PC are present in most adults under the age of 60 years, are absent in very young children, and are present at low levels in Wiscott-Aldrich patients and in IgG2-deficient adults. These last three groups respond very poorly to polysaccharide antigens. Antibodies to PC are also found at low levels in the elderly, a group that has previously been shown to have low levels of antibody to blood groups A and B carbohydrates. The levels of antibody to PC over time were constant in most individuals and, in adults, seemed to show slightly less variation than did titers of antibody to blood group B. Our findings suggest that titers of antibody to PC may be superior to titers of antibody to blood group A or B for monitoring responsiveness to carbohydrate antigens.

Selective IgM deficiency in adults: phenotypically and functionally altered profiles of peripheral blood lymphocytes

Peripheral blood lymphocytes from four patients with selective IgM deficiency were examined phenotypically and functionally. Although B cell subpopulations determined by surface immunoglobulins were within normal or nearly normal range, T8+ cells were significantly increased and T4/T8 ratios were inverted in three patients. IgM specific hyporesponsiveness in the PWM-driven immunoglobulin production system was observed in all four patients. Ia-like antigen positive T cells were increased in two patients; both had increased Leu2a+ Leu15+ suppressor-effector cells. In addition, Leu3a+ Leu8+ suppressor-inducer cells were increased in one of these two patients. Excessive (either IgM-specific or isotype non-specific) suppressor activity of T cells and IgM specific hyporesponsiveness of non-T cells were observed in these two patients in the recombination plaque assay. Although these results showed the complexity of the pathogenesis of this syndrome, they suggested that suppressor-associated T cells may play a role in some patients with selective IgM deficiency.

IgA antibody-producing cells in peripheral blood after antigen ingestion: evidence for a common mucosal immune system in humans

The finding that ingestion of antigens results in the selection induction of IgA antibodies in external secretions suggests that antigen sensitizes Peyer's patch lymphoid cells, which migrate to mucosal sites and generate local secretory IgA (S-IgA) antibody responses. Evidence for a common mucosal immune system in humans has been scanty because of the difficulty in demonstrating migratory behavior of Peyer's patch cells. In the present study, peripheral blood mononuclear cells (PBMC) from human volunteers who had ingested capsules containing killed Streptococcus mutans were assayed for spontaneous antibody-producing cells. Four of five volunteers exhibited circulating IgA-producing cells within 7 days and reached maximum responses by days 10-12. One IgA-deficient subject exhibited IgM responses with identical kinetics. Pokeweed-mitogen-stimulated PBMC produced anti-S. mutans antibodies predominantly of the IgA isotype. Significant S-IgA anti-S. mutans antibodies were detected in saliva and tears by day 14, and the antibodies reached maximum titers by 3 weeks. No changes in serum anti-S. mutans antibodies were noted. The IgA-deficient subject produced salivary secretory IgM antibodies. These results suggest that, after antigen ingestion, peripheral blood contains antigen-specific precursors of IgA plasma cells and that their presence precedes the appearance of S-IgA antibodies in external secretions. Therefore, these experiments provide further support for the existence of a common mucosal immune system in humans.

The clinical condition of IgA-deficient patients is related to the proportion of IgD- and IgM-producing cells in their nasal mucosa

Nasal biopsy specimens from 15 adult patients with selective IgA deficiency but normal IgG-subclass levels were examined by immunohistochemistry for the presence of immunocytes producing various Ig isotypes. The mucosal samples were completely IgA-deficient except in two cases where 0.9% and 8.4% IgA cells were found, respectively (normal, 69.8%). Numerous IgG- (mainly IgG1-) producing cells were present in 10 samples; in five of these there were additional IgM- but virtually no IgD-producing cells, whereas in the other five a marked dominance of the IgD over the IgM isotype was seen. The latter category of patients had more upper airways infections (recurrent acute rhinosinusitis, otitis media, and tonsillitis) than the former, who had no recurrent upper respiratory tract infections except one patient with recurrent acute rhinosinusitis. The five remaining samples, which contained very few Ig-producing cells, were derived from patients with even more frequent infections than those showing IgD predominance. Our results indicate that IgM acts as a compensatory secretory Ig in the upper respiratory tract of some IgA-deficient subjects. However, immunoregulatory events favouring local IgD responses apparently do not support mucosal defence satisfactorily, either because local production of IgM is hampered or because IgD (which is not a secretory Ig) blocks complement-dependent reactions mediated by IgG and IgM antibodies within the mucosa.

Attempts to localize the defect in dysgammaglobulinemia of UM-B19 chickens by studying the effect of immunomodulating substances on immunoglobulin and antibody production

The extreme decreased levels of IgG in dysgammaglobulinemic UM-B19 chickens are linked with decreased antibody activity. Antibody activity to T-dependent (although diminished) and T-independent antigens is present but is restricted to IgM and IgA antibodies. Complete Freund's adjuvant enhances the existing isotype pattern of serum immunoglobulins and antibodies. The antibody response to a "T-independent" antigen (B. abortus) is greatly increased by CFA in dysgammaglobulinemic chickens. Beside the appearance of high levels of IgG in dysgammaglobulinemic chickens during the first weeks of life and in transitory dysgammaglobulinemia, remarkable IgG synthesis can be temporarily induced by the mitogenic activity of LPS and even more by the regulatory function of Levamisole. Furthermore, LPS and Levamisole induce IgG antibody synthesis to concomitantly administered antigen, the IgG antibodies appearing within the normal time. Contrary to a missing feedback inhibition from total IgG to IgM serum immunoglobulins, a feedback inhibition from IgG to IgM antibodies is found. No correlation can be found between Levamisole-induced IgG immunoglobulin concentrations, and IgG antibodies. Germfree rearing for one week or longer prevents the dysgammaglobulinemic defect. The following conclusions are drawn: Early antigenic stimulation seems to be the inducing factor for dysgammaglobulinemia in UM-B19 chickens. A BG cell pool is still present in adult dysgammaglobulinemic chickens. This BG cell pool is probably diminished to a varying extent. T cell helper functions seem to be present (albeit they may be disturbed) and can be stimulated. IgG specific T cell suppression is probable. From these conclusions the etiology of the dysgammaglobulinemia in UM-B19 chickens is hypothesized to be primarily due to delayed bursal development: Immature BG cells are eliminated by environmental antigens during the neonatal period in a process similar to tolerance induction. This event, in turn, induces suppressor mechanism(s) or disturbance in helper mechanism(s).

IgG subclasses--a review

Recognition that IgG consists actually of four subclasses has opened up a vast amount of knowledge regarding the biology of each subclass. Of particular interest has been the recognition that various antibodies are restricted to some subclasses. The possible role of IgG4 in immunization, desensitization, and allergy is being determined. IgG subclass deficiencies are being increasingly recognized, especially in association with infection. These patients can now be effectively treated.

Nephelometry of the kappa/lambda light-chain ratio in serum of normal and diseased children

We determined, immunonephelometrically, the ratio between the two types of light chains of immunoglobulins, kappa and lambda, in serum of 94 children, ages 0.4 to 14 years, with no manifest immunological disorders. Children with an abnormal protein pattern by immunoelectrophoresis show other values for this ratio than do children in this reference group. We also determined the ratios for children with IgA deficiency (I), juvenile rheumatic arthritis (II), and acute lymphoblastic leukemia (III). Children with I show the same kappa/lambda ratios as for the children in the reference group. Children with II also show the same mean kappa/lambda ratios, but a significantly wider range of ratios. In children with III, the ratio during chemotherapy is slightly depressed, significantly lower than after cessation of therapy. All groups--healthy children and patients--show an increase in kappa-chain-bearing immunoglobulins with age, but the concentration of lambda-chain-bearing immunoglobulins remains relatively constant.

An investigation into the effect of the IgG antibody system on the susceptibility of IgA-deficient patients to respiratory tract infections

Serum IgG subclass concentrations and IgG-tetanus toxoid antibody (IgG-TTab) responses were measured in IgA-deficient patients with severe respiratory tract infections (n = 11), mild respiratory tract infections (n = 5) or no increased susceptibility to respiratory tract infections (n = 15). The severe infection group had lower IgG2 concentrations than the patients without infections (P less than 0.02) and was the only group with IgG2-deficient patients (36%). The number of sera in which IgG4 was not detected was higher in patients with severe infections than in both normal controls (45% vs 10%, P less than 0.01) and the other IgA-deficient patients (45% vs 20%), in part explained by a strong association with IgG2 deficiency. Subnormal IgG-TTab responses were demonstrated in 45% of patients with severe infections but in only one patient from each of the other two groups. Five patients with IgG2 deficiency and/or subnormal IgG-TTab responses were treated with gammaglobulin and apparently improved. There was a high serum concentration of IgG1 in 35% and IgG3 in 19% of the 31 patients, predominantly in those without severe infections. Thus a proportion of IgA-deficient patients have additional defects of IgG; IgG1 and IgG3 antibody responses may compensate for the IgA deficiency in asymptomatic patients.

Transient phenytoin induced IgA deficiency and permanent IgE increase

This is a report of a 9-year-old epileptic boy, who was studied over a period of 7 years. The seizures started when he was 2 months old. He was treated with phenytoin from the age of 2 years and 7 months. Serum and salivary IgA were absent with high IgE serum total. The routine immunologic studies were normal. The IgA was normalized after phenytoin withdrawal, but IgE determination increased progressively without any atopic symptoms. The T4 (helper)/T8 (suppressor) ratio decreased (1.0 and 1.2) on two different days, although above the normal limit. The phenytoin only modified the IgA levels. These data suggest that a primary immunoregulatory abnormality may be present in drug induced IgA deficiency.

Secretory piece and IgA deficiency in a patient with Waldenstrom's macroglobulinemia

A case of a patient suffering from Waldenstrom's macroglobulinemia who developed diarrhea and mild steatorrhea is described. Laboratory studies revealed low serum IgA, intestinal secretory IgA deficiency, and small intestine bacterial overgrowth as demonstrated by the C14-cholylglycine breath test. These findings suggest that selective IgA deficiency and secretory component deficiency may be contributing factors in the development of diarrhea in Waldenstrom's macroglobulinemia.

IgG subclass deficiency in children with IgA deficiency presenting with recurrent or severe respiratory infections

A group of 22 children presenting with recurrent or severe respiratory tract infections who had low IgA levels (more than 2 SD below the mean for age) were examined for IgG subclass deficiency. Patients were screened for possible defects in neutrophil chemotaxis, bactericidal, fungicidal, and quantitative iodination activity, as well as for complement function. The majority of the patients showed IgG subclass levels below the mean for age. Nine of the children showed definite IgG subclass deficiency and at least two showed definite deficiency of more than one IgG subclass. The predominant subclass deficiency was found to be IgG1. While nine children showed IgG4 levels below the level detectable by the technique used, it is not possible to assess whether these patients are deficient in this isotype since some healthy subjects also give values below the level of detection. Most of the patients who had very low (1-6 mg/dl) or undetectable (less than 1 mg/dl) levels of serum IgA did not show IgG subclass deficiencies, while IgG subclass deficiencies were common among those with borderline low IgA levels (slightly more than 2 SD below the mean for age). Nine children showed total IgG levels close to 2 SD below mean for age, and at least six of these showed IgG subclass deficiency. The result suggests that patients with recurrent and/or severe respiratory infections who have borderline IgA and IgG levels may have IgG subclass deficiencies and if they do could benefit from immunoglobulin therapy.

Analysis of IgG subclass production in cell cultures from IgA deficient patients and in normal controls as a function of age

IgA deficient individuals may also have low serum levels of IgG subclasses, especially IgG2. In the present study we examined the development of plasma cells producing IgM, IgA or IgG, and the IgG1 and IgG2 subclasses, following lipopolysaccharide (LPS) and pokeweed mitogen (PWM) stimulation of mononuclear cells (MNC) from normal and IgA deficient individuals as a function of age. Studies of blood MNC from 38 normal donors (age range 2-44 years) revealed an age-related distribution pattern of mu, gamma, alpha, gamma 1 and gamma 2 plasma cells produced in mitogen-stimulated and control cultures. Decreased IgA responses to both LPS and PWM were consistently observed in cultures of MNC from all of the nine children with IgA deficiency. When compared with age-matched controls the IgG response was also diminished in PWM stimulated cultures, whereas the IgM responses were normal. The IgG deficit was due to reduced responses for the gamma 1 and gamma 2 subclasses, and was most pronounced for IgG2; IgG2 plasma cell differentiation was particularly depressed in LPS cultures. In contrast to normal adult cells, blood MNC from the nine children with IgA deficiency and age-matched controls (2-17 years) yielded more IgG1 than IgG2 plasma cells in both control and LPS cultures, while the pattern of response to PWM was similar in all groups (gamma 1 greater than gamma 2). A good concordance was found between the level of secreted Ig in the culture supernatants and the relative number of IgM or, IgG and IgA plasma cells identified by immunofluorescence staining of cytoplasmic immunoglobulins.

Manifestations of milk allergy in infancy: clinical and immunologic findings

In a study of the manifestations of cow milk allergy in 100 young children (mean age 16 months), 30 items of historical data and information relating to the effects of a standardized milk challenge were entered into a computer data base. Three clusters of patients were derived using a K-means algorithm. In group 1 were 27 patients with predominantly urticarial and angioedematous eruptions, which developed within 45 minutes of ingesting cow milk. They had positive skin test reactions to milk and elevated total and milk specific IgE serum antibody levels. In group 2, 53 patients had pallor, vomiting, or diarrhea between 45 minutes and 20 hours after milk ingestion. These children were relatively IgA deficient. The 20 patients in group 3 had eczematous or bronchitic or diarrheal symptoms; in 17 symptoms developed more than 20 hours after commencing milk ingestion. Of the patients in group 3, only those with eczema had a positive skin test reaction and elevated IgE antibodies to milk. The patients in group 3 were the most difficult to identify clinically; they had a history of chronic ill health, and symptoms developed many hours or days after commencing milk ingestion in the challenge situation. In view of the heterogeneous clinical and immunologic findings in our patients, it is unlikely that a single laboratory test will identify cow milk allergy in all susceptible patients.

Humoral immunodeficiency

Humoral (or antibody) immunodeficiency syndromes may occur as apparent congenital or acquired abnormalities, with deficiencies in all or in only some classes of immunoglobulins. Most patients are recognized because of recurrent infections with high-grade extracellular encapsulated bacterial pathogens, but some with selective IgA deficiency or with transient hypogammaglobulinemia of infancy may have few or no infections. Although general population statistics are not available, most defects are thought to be rare; humoral immunodeficiency is more prevalent than cellular immunodeficiency, possibly due to early death from the latter defects. Disorders affecting B-cell function may be inherited as X-linked recessive or as autosomal traits. Although considerable information exists about such defects at a functional and cellular level, the primary biologic errors are as yet unknown for all of them. Apparent abnormalities of B-cell maturation and/or intrinsic B-cell malfunction are seen in a majority of these defects. The heterogeneity of B-cell morphology and function in large pedigrees of patients with X-linked agammaglobulinemia makes it unlikely that the defect is due to a distinct gene rearrangement abnormality at a specific stage of B-cell maturation. Early recognition of B-cell deficiency and institution of adequate immunoglobulin replacement therapy can prevent extensive damage to the lungs and other life-threatening problems from infection and allow a relatively normal childhood and adult life.

Secretory antibodies in IgA-deficient and immunosuppressed individuals

Total levels of IgM and secretory IgM as well as specific antibodies to poliovirus type I antigen, Escherichia coli O antigens, and beta-lactoglobulin were measured in unstimulated and stimulated saliva as well as nasal secretion using an enzyme-linked immunosorbent assay (ELISA). The levels of these antibodies in IgA-deficient adults with and without frequent respiratory infections and children under immunosuppressive therapy for malignant disease were compared to those in normal adults and infants 1-7 months of age. The IgA-deficient adults had significantly higher IgM levels (P less than 0.002) than the normal adults as well as higher levels of IgM antibodies to poliovirus type I (P less than 0.05) and E. coli O antigen (P less than 0.002). There was a less pronounced IgM anti-beta-lactoglobulin compensation. Secretory component (SC)-carrying antibodies against all three antigens were lower than in normal adults. The infants studied had levels of IgM in secretions close to those of the normal adults and significantly lower than those of the IgA-deficient adults (P less than 0.001) but with a higher proportion of SC-carrying IgM. The increase in total IgM and specific bacterial and viral IgM antibodies in saliva above that of the normal adults was significant (P less than 0.001-0.005) for those IgA-deficient individuals without, but not for those with, frequent infections. There was, however, no significant difference between the levels in the two groups of IgA-deficient adults.(ABSTRACT TRUNCATED AT 250 WORDS)

[Defects of IgG subclasses as a cause of severe, recurrent respiratory tract infection]

IgG Immunoglobulins can be differentiated into four subclasses with different structures and functions. Partial or complete defects of one or two subclasses can be related to an impaired immune defence. We describe four children with severe recurrent bacterial airway infections. Two children had developed bronchiectasia following recurrent bronchopulmonary inflammation. Prior to diagnosis of IgG subclass deficiency other common causes of recurrent airway infections were excluded. Defects of IgG 2 or IgG 4 antibodies as well as of both classes were found with compensatory elevation of IgG 1 and IgG 3. In repeated sputum cultures haemophilus influenzae and staphylococcus aureus were isolated. This might be due to an impaired antibody production against special antigens as alpha-toxin of staphylococcus or capsular polysaccharide of haemophilus influenzae. The four cases demonstrate that in children with severe recurrent airway infections including bronchiectasia and otitis media defects of IgG subclasses have to be considered. Diagnosis should be proved by repeated determinations of blood levels after exclusion of other common causes for infections. Diminution of IgG subclasses without clinical symptoms of airway infections is also possible. If diagnosis seems to be certain intravenous substitution with 7 s gammaglobulin beside symptomatic antibiotic therapy is recommended.

The human IgA system: a reassessment

In healthy adults the total daily production of secretory and serum IgA exceeds that of other immunoglobulin classes. Secretory and serum IgA display features of mutual independence: they are represented by molecules with different physiochemical and immunochemical properties and antibody activities and are produced by cells with different organ distributions. Secretory and serum IgA also exhibit different effector functions: interaction of secretory IgA with environmental antigens results in prevention of the penetration of such antigens by a variety of mechanisms. Although the function of polymeric serum IgA antibodies in certain animal species involves elimination of antigenic substances by noninflammatory means, the primary function of serum IgA remains unknown. It is proposed that in humans monomeric serum IgA (which prevents activation of the complement systems, inhibits phagocytosis and antibody-dependent cellular cytotoxicity) may protect endogenous antigens expressed on various cells and tissues by preventing their interaction with humoral and cellular immune mechanisms that may lead to tissue damage.

Immunological investigations in individuals with selective IgA deficiency

Concentrations of IgG2, IgG4 and IgE were low in 16, 24 and 20% of 25 persons with selective IgA deficiency. Fifty-two per cent had IgD concentrations below 5 iu/ml. Trends for association between any of these parameters and the presence of clinical symptoms were not significant. All patients, except one, had normal amounts of Ig-bearing lymphocytes in the blood. IgG1 antibodies against casein were increased in titre and frequency, whereas IgG4 antibodies were normal. Similar results were found in other sera from persons with selective IgA deficiency.

Spectrum of IgG2 subclass deficiency in children with recurrent infections: prospective study

Serum immunoglobulins and IgG subclasses were measured in 30 children with recurrent infections. Seven patients had low IgG2 concentrations (less than 3SD below the geometric mean for age). Four of these seven patients had normal concentrations of IgG, IgA and IgM, and thus would have been considered immunologically normal by routine criteria. The seven children with IgG2 deficiency had more severe infections than the 23 children with normal IgG2. Five children had recurrent pneumonia or sinusitis, one had recurrent invasive Haemophilus influenzae type b infections, and one had severe pneumococcal meningitis. Their immunologic abnormalities were heterogeneous. Two children had isolated IgG2 deficiency, two had IgG2-IgG4 deficiency, one had IgG2-IgG4-IgA deficiency, one had IgG2-IgA deficiency, and one had severe IgG1-IgG2 deficiency with abnormal T cell function and thrombocytopenia. Thus IgG2 deficiency occurs frequently among children with recurrent infections, and is associated with a variety of clinical and immunologic abnormalities.

Clinical heterogeneity and reversibility of selective immunoglobulin A deficiency in 80 children

80 children with selective immunoglobulin A (IgA) deficiency--40 with severe deficiency (serum IgA less than 5 mg/dl) and 40 with partial deficiency (serum IgA greater than 5 mg/dl but less than minus 2 SD of the age-normal mean)--were followed up for 1.5 to 9 years; during which their serum and salivary IgA levels were measured periodically and the number and type of infections they had were recorded. In the partial deficiency group serum IgA rose to normal levels in half the group at a median age of 14 years and at a median time of 4 years after diagnosis, but they did not reach the normal range in the severe deficiency group. Pneumonia occurred more frequently in the severe than in the partial deficiency group. In addition, 11 of the 12 severely IgA deficient patients who had pneumonia had levels of both serum and salivary IgA of less than 0.5 mg/dl, and only 1 had detectable serum IgA levels. These data indicate that in childhood severe IgA deficiency is persistent and predisposed to pneumonia, whereas partial IgA deficiency is often transient and only occasionally associated with pneumonia.

Selective immunoglobulin M deficiency associated with disseminated molluscum contagiosum

A 16-year-old girl with disseminated molluscum contagiosum (MC) was found to have a very low level of serum IgM, elevated levels of IgG and IgA, and a high level of IgE. She had normal numbers of peripheral blood IgM+, IgG+ and IgA+ B-lymphocytes but their terminal differentiation into plasma cells could not be induced by pokeweed mitogen (PWM) in vitro. On the other hand, the patient's T-cells showed normal helper functions in the PWM system and normal interferon (IFN) production in vitro. However, the IgM+ B-cells can be induced to differentiate into IgM secreting cells by Epstein-Barr virus (EBV), suggesting that the genetic mechanism for synthesis of the component immunoglobulin proteins is present. T-cell functions were impaired, as shown by delayed type cutaneous hypersensitivity (DTH) and mitogen response. The data suggest that the selective IgM deficiency of the patient is due mainly to defects in B-cells at the terminal differentiation stage, but immunological abnormalities are present in both B and T-cell systems. Neutrophil functions examined were normal. MC was treated by intravenous injection of IFN without any side effects; however, no clinical improvement was achieved.

The association of hyperlipoproteinemia with dysimmunoglobulinemia

In a study of the immunoglobulin concentrations in an urban population and in patients with hyperlipoproteinemia we observed significant positive correlations between serum triglycerides and IgA independent of sex, age and body weight. In men serum triglycerides also correlated with IgG and IgM, and serum cholesterol with IgA. The prevalence of hyper- and hypoimmunoglobulinemia was significantly higher in hyperlipidemic than in normolipemic subjects. We propose that the occurrence of hyperlipoproteinemia with hypoimmunoglobulinemia may be caused by different pathobiological mechanisms than the occurrence with hyperimmunoglobulinemia.

Selective partial IgM deficiency: functional assessment of T and B lymphocytes in vitro

Seven patients with selective IgM deficiency (SIgMD) were studied for cell surface immunoglobulin (SmIg), T-cell subpopulations, and immunoglobulin (Ig) synthesis in vitro by peripheral blood lymphocytes (PBL). Serum IgM levels were less than 25 mg/dl, while IgA, IgG, and IgD were within normal levels. The patients had respiratory or urinary tract infections and two were diagnosed as having systemic lupus erythematosus (SLE). T/B-cell ratios in PBL were within normal ranges. Percentage ratios of B cells bearing SmIg were normal in five patients and decreased in two; however, normal values were seen after 7 days of culture in the presence of PWM. OKT4/OKT8 ratios decreased in five of seven patients, in whom two were due to a decrease in OKT4 and two to an increase in OKT8 cells. One showed a decrease in OKT4 and an increase in OKT8. Analysis of lymphocyte function for Ig synthesis in vitro, using a coculture of counterpart T and B cells from healthy individuals and patients with SIgMD, revealed that the increased function of IgM isospecific suppressor T cells (Ts) was responsible for the IgM deficiency in all seven patients.

Evidence for a defect in "switch" T cells in patients with immunodeficiency and hyperimmunoglobulinemia M

Immunodeficiency with hyperimmunoglobulinemia M is a syndrome characterized by normal to elevated serum levels of IgM and low levels or absence of IgG and IgA. The defect in this syndrome is thought to reside within the B lymphocyte, which may be unable to undergo a "switch" in immunoglobulin class from IgM to IgG or IgA. To address this question more directly, we cultured B cells from nine patients with this syndrome with pokeweed mitogen and either "switch" T cells or normal control T cells. In cultures with normal T cells, only IgM was secreted, whereas in cultures with switch T cells, IgG as well as IgM, or IgM, IgG, and IgA were secreted. Furthermore, analysis of the immunoglobulin heavy-chain genes in these B cells by means of genetic probes of constant and switch regions revealed normal gene patterns. These data suggest that B cells from patients with hyperimmunoglobulinemia M may not be abnormal, as previously proposed, and that, at least in some patients with this syndrome, a defect in switch T cells may be pathogenic.

Molecular analysis of a case of IgA2 deficiency

A family with two members with selective IgA2 deficiency was analysed by direct gene analysis with different probes for the IgCH region. No gross gene deletions or rearrangements were detected. Genetic analysis based on serological and molecular markers did not rule out linkage with the IgCH region. However, a defect of other genes not linked to the Ig heavy chain region and controlling the expression of IgA may be possible as well.

Selective immunoglobulin A deficiency associated with primary biliary cirrhosis in a family with liver disease

A family is described in which multiple members are afflicted with liver disease and primary biliary cirrhosis (PBC). In the third generation, one member died of PBC, and a second individual has both symptomatic PBC and selective immunoglobulin A (IgA) deficiency, an association not previously reported. By culturing this patient's lymphocytes in vitro it was shown that the IgA deficiency was due to a failure of B cells to secrete IgA. Two other siblings of this patient have multiple serum biochemical and serologic abnormalities that are sometimes associated with PBC, but they do not have histopathologically overt PBC or IgA deficiency. All three surviving family members have a diminished autologous mixed lymphocyte reaction, an immunologic abnormality that has previously been found in patients with PBC, selective IgA deficiency, and several autoimmune diseases. As there is an association between selective IgA deficiency and certain autoimmune diseases, it is possible that this immunodeficiency contributed to the development of PBC in the patient in whom the two diseases coexisted. Furthermore, the occurrence of PBC in a patient with selective IgA deficiency indicates that the pathogenesis of PBC does not require IgA-dependent immune mechanisms.