Angioimmunoblastic lymphadenopathy: a T-cell deficiency

Hodgkin's Disease Developing in A Patient with Angioimmunoblastic Lymphadenopathy with Dysproteinemia - A Case Report

The case of a woman presenting the clinical and pathologic phenomena of angioimmunoblastic lymphadenopathy (AILD) with dysproteinemia is reported. The patient developed lesions in the lymph nodes, skin, lungs, liver and spleen, and her response to steroid and cyclophosphamide therapy was poor. At autopsy, microscopic findings in the mediastinal and abdominal lymph nodes were consistent with the diagnosis of Hodgkin's disease. Whereas the development of immunoblastic lymphoma is frequent in AILD, Hodgkin's disease is far less common. It is argued that malignant lymphoma in AILD may be the consequence of chronically depressed lymphocyte functions.

Effects of phenytoin administration on murine immune function

The results obtained in these series of experiments indicate that oral administration of phenytoin (100, 50, or 25 mg/kg) to mice significantly depressed both humoral and cellular immune responses, evaluated by the techniques of enumeration of direct and indirect spleen plaque-forming cells (PFC) and the delayed-type hypersensitivity reaction (DTH) against sheep red blood cells (SR BC), when compared with those observed in normal control animals. Furthermore, spleen cells, purified splenic T lymphocytes or Ly 2 + T cells obtained from 100 mg/kg phenytoin-treated donor mice were capable of diminishing both PFC and DTH responses of normal cells transferred into lethally irradiated mice. The immunodepressor effect of phenytoin was observed despite the fact that administration of this drug induced a rise in spleen cellularity.

Effects of carbamazepine on murine humoral and cellular immune responses

Oral administration of carbamazepine (CBZ) (15, 10, or 5 mg/kg) to mice significantly decreased both humoral and cellular immune responses evaluated by enumeration of direct and indirect plaque-forming spleen cells (PFC) and delayed-type hypersensitivity reaction (DTH) against sheep red blood cells (SRBC) as compared with those observed in normal control animals. Moreover, spleen T cells obtained from CBZ-treated donor mice were capable of decreasing both PFC and DTH responses of normal spleen cells transferred into lethally irradiated recipient animals. The immunodepressor effect of CBZ was observed even though administration of CBZ induced augmentation of spleen cellularity.

Pulmonary lymphoproliferative disorders

Pulmonary lymphoproliferative disorders are a diverse group of conditions that primarily or secondarily involve the lungs. Modern diagnostic modalities, including immunologic and molecular genetics techniques, have contributed substantially to the continuously evolving understanding of these complex lesions. In this review, we classified pulmonary lymphoproliferative disorders into benign, intermediate or indeterminate, and malignant categories and described the clinical, radiographic, and pathologic features for the entire spectrum. Our emphasis is on the clinical findings and the role of tissue biopsy as well as ancillary techniques in diagnosis. Various treatments and expected responses are also discussed.

Angioimmunoblastic lymphadenopathy with dysproteinemia: report of a case in infancy with review of literature

A case of angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) in infancy is reported. The disease had a mild onset with generalized lymphadenopathy, hepatosplenomegaly, thrombocytopenia, polyclonal hypergammaglobulinemia, and T-cell deficiency. The AILD course lasted more than 100 months, alternating clinical remission to recurrent relapses. Hepatitis B viral infection suddenly evolving to hepatic failure was the cause of death. From a rapid survey of the present knowledge, the nosology, immunological features, and therapy of AILD are discussed and a possible presumptive pathogenetic pathway is proposed.

Immunologic abnormalities in angioimmunoblastic lymphadenopathy

In this study we describe the results of phenotypic, serologic, and functional analyses performed in nine patients with angioimmunoblastic lymphadenopathy (AILD). The study investigates the nature of the T-cell defects which seem to represent a consistent feature in this disease. The study, based on the analysis of T-cell subsets with monoclonal antibodies and on functional in vitro tests, showed the following main abnormalities: reduction of the absolute number of circulating T-cells; inversion of the CD4/CD8 ratio, both in the peripheral blood and in the involved lymph nodes; high percentages of activated T-cells (CD8+/HLA-DR+); defective T-cell response in vitro to the PHA mitogen; and minimal helper and enhanced in vitro suppressor functions. Some of these immunologic dysfunctions are also observed in acquired immune deficiency syndrome (AIDS) which has in common with AILD several clinical features. However, no evidence of HTLV-III infection could be demonstrated in our patients with AILD.

Polyarthritis and angioimmunoblastic lymphadenopathy

Angioimmunoblastic lymphadenopathy (AILD) is a lymphoproliferative disorder with well established clinical and histological features, one of the clinical manifestations being a peripheral polyarthritis. A case of AILD with a symmetrical non-erosive peripheral polyarthritis is described, including the findings in the synovial fluid and histology of the synovium. There was a marked reduction in the number of peripheral blood T lymphocytes bearing the CDT8 phenotype in both the peripheral blood and synovial fluid. The arthritis was difficult to control, requiring large doses of corticosteroids, which produced significant side effects. Levamisole 150 mg, one day each week, was effective in controlling the arthritis and returning the numbers of CDT8 lymphocytes to normal. The aetiology of AILD is unknown, though a defect in T cell regulation, in particular T cell suppression, with a secondary B cell proliferation has been postulated. The demonstration of reduced numbers of lymphocytes bearing the CDT8 phenotype in this patient supports that theory.

Autoimmunity in 28 patients after allogeneic bone marrow transplantation: comparison with Sjögren syndrome and scleroderma

The occurrence of autoantibodies in 28 long-term survivors of allogeneic bone marrow transplantation (BMT) (21 with chronic graft-versus-host disease) was compared with 48 cases of idiopathic Sjögren syndrome and 82 cases of scleroderma. Antinuclear, anti-smooth muscle, and anti-mitochondria antibodies occurred respectively in 80%, 82% and 14% of the post BMT cases. Anti-native DNA, anti-soluble nuclear antigen and anticentromere antibodies were not found. Antiepidermal antibodies were present in 14% of the cases but their pathological role is unclear. Although the clinical manifestations of chronic graft-versus-host disease are similar to Sjögren syndrome and scleroderma the autoantibody profile is significantly different.

Angioimmunoblastic lymphadenopathy with malignant transformation during long-term remission of ocular melanoma

A 52-year-old woman presented with angioimmunoblastic lymphadenopathy five years after undergoing enucleation for ocular melanoma. She was first treated by corticotherapy and azathioprine and had two successive remissions over an 18-month period. Lymph node biopsy performed when lymphadenopathy relapsed for the second time showed focal malignant transformation of angioimmunoblastic lymphadenopathy. Intensive polychemotherapy induced a complete remission. Three months after completion of chemotherapy, the patient presented with hepatic metastases from her melanoma and died shortly thereafter. This is believed to be the first documented association between angioimmunoblastic lymphadenopathy and melanoma. Issues regarding the relationship between angioimmunoblastic lymphadenopathy and nonlymphoid malignancies are raised.

Angioimmunoblastic lymphadenopathy (AIBL): a case report from Saudi Arabia

Angio immunoblastic lymphadenopathy (AIBL) is a recently described disease. It occurs most commonly in elderly patients with an average age of about 60 years. In children, few cases have been reported so far in the English literature (three occurred after thymic transplant and one case after infectious mononucleosis). AIBL has characteristics manifested by clinical, pathological and laboratory findings. Steroids, alone or with chemotherapy, are used for treatment with variable results. Herein, we report one child with AIBL who was treated with prednisone initially and then relapsed. Chemotherapy (cyclophosphamide, vincristine and prednisone) was added and she has been in remission for more than 3 years. The purpose of this report is to add AIBL to the differential diagnosis of acute generalized lymphadenopathy in children.

Infectious antecedent of immunoblastic lymphoma. Progressive immunosuppression in a patient with lymphogranuloma venereum

Angioimmunoblastic lymphadenopathy is a nonmalignant disease of unknown etiology often progressing to immunoblastic lymphoma. Immunologic deficiency is evident in these patients as well as in those with various infections found in association with the acquired immune deficiency syndrome (AIDS). This report describes a previously healthy young woman in whom angioimmunoblastic lymphadenopathy developed in association with lymphogranuloma venereum, with progressive loss of immunologic competence. This deterioration paralleled the evolution of angioimmunoblastic lymphadenopathy into a rapidly fatal immunoblastic lymphoma.

Histological, immunohistological and autopsy findings in lymphogranulomatosis X (including angio-immunoblastic lymphadenopathy)

172 cases of lymphogranulomatosis X (LgX) were studied by light microscopy. In 53 cases immunohistological techniques for detecting intracytoplasmic immunoglobulins were applied. In the lymph nodes of all cases the nodal architecture was found to be effaced. Active germinal centres were absent, and there was a generalized, markedly increased proliferation of epithelioid venules. A polymorphic infiltrate was present in all cases. It was dominated by immunoblasts in 14%, by plasma cells in 16%, by epithelioid cells in 23% and by lymphocytes in 6% of the cases. In the remaining 41% of the cases no special type of cell predominated (mixed cell type of LgX). The clusters of clear cells present in some cases with immunoblastic predominance did not stain for intracytoplasmic immunoglobulins; in contrast, the basophilic immunoblasts exhibited a polyclonal Ig pattern. In some of the cases with lymphocytic predominance most of the lymphocytes showed abundant cytoplasm with azurophil granules. Transformation into malignant lymphoma was proven at autopsy in 5 of 38 cases (13.2%). Malignant transformation (biopsy and autopsy material) was confirmed in a total of 11 of 172 cases (6.4%) and suspected in an additional 7%. Among the malignant lymphomas were one immunologically proven B-immunoblastic lymphoma, one peripheral T cell lymphoma and 5 cases of Hodgkin's disease. An association between LgX and carcinoma was histologically verified in 7 cases. 26 cases with active germinal centres and 11 cases with only locally pronounced vascularization but with histological and cytological changes that were otherwise similar to LgX were designated as hyperimmune reactions (HR). These cases had a significantly better prognosis. Two cases that presented as HR with active germinal centres later developed into LgX. It is suggested that the disappearance of active germinal centres is important in the pathogenesis of LgX. The possibility that this may correspond morphologically to an alteration of different components of the T-cell system is discussed.

[Immunoblastic lymphadenopathy occurring during treatment with carbamazepine. 2 cases]

Dysimmune lymphadenopathies during carbamazepine treatment. A report of two cases. We report on two cases of dysimmune lymphadenopathies with histological aspect of angio immunoblastic lymphadenopathy (AIL) developing after administration of carbamazepine. Clinical manifestations consisted of fever, erythroderma, generalized pruritus, facial edema, lymphadenopathy, liver enlargement. The two patients had anemia, hypogammaglobulinemia, impaired liver function and a negative Coomb's test. Lymphocyte stimulation test with carbamazepine in vitro was positive in both cases. Lymph node biopsy disclosed the angioimmunoblastic proliferation characteristic of AIL. After discontinuing carbamazepine, a complete remission was obtained.

Blood findings in lymphogranulomatosis X

A quantitative analysis of leukocytes in the peripheral blood of 16 patients with lymphogranulomatosis X revealed the following findings: The number of total leukocytes, monocytes, neutrophils, and eosinophils varied considerably and showed no clear common tendency. Blood basophils were found to be clearly increased with a mean value of 0.17 +/- 0.18 X 10(9)/1 as compared to 55 normal donors (0.04 +/- 0.01 X 10(9)/1). Lymphocyte counts were within the normal range. Lymphopenia was seen in 2 patients. Lymphocytes with azure granules which encompass T-suppressors were found to exceed normal values by a factor of 15. In 14 cases a variable number of hyperbasophil cells were present. Lymphogranulomatosis X seems to present with a characteristic blood picture which might be of diagnostic aid.

Angioimmunoblastic lymphadenopathy. Long-term follow-up study

The clinical course of 41 previously reported patients with angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) on whom follow-up information has been obtained for five or more years is described. Of the 41 patients, 27 achieved a complete remission (CR). The durations of the CR ranged from two to 214 months, with a median of 48 months. Nine of these 27 complete responders are still alive and well without evidence of disease, whereas the remaining 18 patients have died of pneumonia, septicemia, immunoblastic lymphoma, or unrelated causes. These 27 patients had a significantly longer median survival (51 mos) than did the 14 patients who had partial or no response (9 mos) (P = 0.0006). Only two of these 14 patients who did not initially achieve a CR are alive (survivals, 66 months and 70 months). There was a trend suggesting that patients who received combination chemotherapy which included prednisone had a slightly longer survival than did the remaining patients (P = 0.087). Lymphocytopenia was evident in a higher proportion of dead patients than in those who remained alive (P = 0.089).

Angioimmunoblastic lymphadenopathy with hypogammaglobulinemia. Possible role of monocyte suppression

A patient wit angioimmunoblastic lymphadenopathy had low serum immunoglobulin values and no antibodies to injected immunogens. This occurred despite the proliferation of polyclonal B cells. T cells were deficient in number and in lymphoproliferative responses, but their helper and suppressor functions were maintained. Ia-antigen bearing leukocytes from the patient stimulated poorly in mixed leukocyte culture. In vitro immunoglobulin synthesis by mononuclear leukocytes form the patient was severely impaired. These leukocytes actively suppressed immunoglobulin synthesis by normal cells from healthy subjects in co-culture. The responsible cell had characteristics of a monocyte. The suppression was selective for humoral immunity and was manifest despite normal numbers of monocytes. It appears that heterogeneous immunoregulatory abnormalities can underlie the syndrome of angioimmunoblastic lymphadenopathy. Furthermore, monocyte suppressor abnormalities may be implicated in clinical disease phenomena.

The lung in immunoblastic lymphadenopathy

Immunoblastic lymphadenopathy presents with fever, malaise, cough, dyspnea, lymphadenopathy, hepatosplenomegaly, hypergammaglobulinemia, interstitial pulmonary infiltrates, mediastinal adenopathy, and effusions. The diagnosis is made on the basis of lymph node biopsy. Based on the course in our patients and the cases presented in previous reports, a suggested program of treatment for immunoblastic lymphadenopathy includes administration of moderate doses of steroids initially, with a subsequent increase to a higher dosage if desired improvement does not occur. Chemotherapy with three drugs, cyclophosphamide, vincristine, and prednisone, is indicated if remission using steroids fails. The diagnostic dilemma of whether pulmonary infiltrates are due to the disease itself or to pulmonary infection or to cytotoxic changes from chemotherapy always exists and often requires specimens from either transbronchoscopic or open-lung biopsy for definitive diagnosis and treatment.

Angioimmunoblastic lymphadenopathy after infectious mononucleosis

Angioimmunoblastic lymphadenopathy occurred in a 46-year-old man 16 months after an episode of infectious mononucleosis induced by Epstein-Barr (EB) virus. The features of infectious mononucleosis included fever, pharyngitis, lymph gland enlargement, hepatosplenomegaly, hyperbasophilic mononuclear cells, and IgM antibodies to EB virus, although heterophile antibodies were not detected. The illness was severe and prolonged and included an asymptomatic measles virus infection. Over a year later massive enlargement of the lymph nodes led to a biopsy, which showed a diffuse infiltration with lymphoid cells and a proliferation of arborising small vessels typical of angioimmunoblastic lymphadenopathy. In spite of corticosteroids, levamisole, chlorambucil, and radiotherapy, no remission occurred, and serious infections led to death 18 months after the onset. Viral infections with EB virus and measles virus associated with pre-existing or subsequent immunological changes probably resulted in the appearance of angioimmunoblastic lymphadenopathy.

Immunoblastic lymphoma: an immunologic study

An immunologic study of a 59-year-old man with immunoblastic lymphoma is presented. Shortly after his hospital admission, an uncompensated hemolytic process developed, caused by cold agglutinins. These antibodies had anti-i specificity, were of low titer at cold temperature, but demonstrated a high thermal amplitude. An apparent paraprotein was found by further immunochemical analysis to be polyclonal. The majority of cells in the peripheral blood (over 2000/cu nm), lymph node, and bone marrow that contained cytoplasmic IgG or IgM were plasma cells, although a small number of cells resembled lymphoblasts. Their staining with anti-lambda and anti-kappa chain reagents confirmed the polyclonality of the immunoglobins. Some plasma cells displayed the concomitant presence of both IgM and IgG immunoglobulins. Free immunoglobin was also demonstrated intercellularly in the lymph node section. The patient's acute hemolysis was controlled by plasmapheresis and eventually by combination chemotherapy. After chemotherapy, the clinical improvement was rapid, immunoglobulin levels returned to normal, and the patient remains asymptomatic 40 months after completing six courses of combination chemotherapy. This report provides evidence for polyclonal proliferation of B-lymphocytes in immunoblastic lymphoma.

Immunoblastic lymphadenopathy and asbestosis

Immunoblastic lymphadenopathy was diagnosed in a 71-year-old white man who had weakness, with weight loss, fever, cough, and generalized lymphadenopathy. The patient had a long occupational history of shipyard work. Diagnosis of asbestosis was made clinically by chest x-ray, and ferruginous bodies were found in the lung at autopsy. Recent reports have suggested a possible association between asbestos exposure and lymphoproliferative neoplasms. Chronic antigenic stimulation by asbestos could predispose one to the immunoproliferative disorder seen in this patient or be responsible for it. The possible significance of this relationship, previously unreported, is discussed for future consideration.

Angioimmunoblastic lymphadenopathy in a patient with allergy to insulin: a case report

A patient with allergy to insulin experienced reactive lymphadenopathy and, later, angioimmunoblastic lymphadenopathy; all occurred within 18 months. It is suggested that insulin may be added to the list of drugs associated with the appearance of angioimmunoblastic lymphadenopathy.

Skin lesions in angioimmunoblastic lymphadenopathy: histological and immunological studies

Angioimmunoblastic lymphadenopathy with drysproteinaemia is reported (AILD) in four patients with different skin pictures. As the disease progresses two main forms predominate; papulonodular and erythroderma. In all cases the histological picture of the skin mirrors that of the lymph-node. Our results point to an increase in the peripheral blood, lymph-nodes and skin of T and subsequently of B lymphocytes suggesting that a proliferation of helper T cells and hence activation of the B-cell subpopulation may be involved in the pathogenesis of some cases of AILD.

The relationship between disease activity, treatment response, and immunologic reactivity in immunoblastic lymphadenopathy: a longitudinal study of treatment with levamisole and cytostatics

In a longitudinal study, several immunologic in vitro tests were performed on peripheral lymphocytes in four patients with immunoblastic lymphadenopathy during sequential therapy with Levamisole and polychemotherapy. The percentage of T cells tended to fall with increasing disease activity, while the percentage of B cells remained almost constant. Blast transformation tests showed that both the T-cell and B-cell responses are defective and that improvement in disease status is correlated closely with an improvement of the blast transformation response. Levamisole treatment improved the blast transformation response but did not produce clinical remission in contrast to polychemotherapy, which produced clinical remission as well as improvement of the blast transformation response. No conclusions about the pathogenesis of this disease could be made in the present study. No proof was found of a primary defective T-cell function (including T-suppressor activity) although the available methods did not preclude this possibility completely.

Atypical lymphadenopathies of the head and neck

Atypical lymphadenopathies fail to achieve the morphologic criteria of a malignant neoplasm, but exceed the usual concepts of follicular, lymphoid, or sinus histiocytic hyperplasias. Rich cellular proliferations usually composed of prominent histiocytes, or immunoblasts, or both with or without a vascular scaffolding obscure the nodal architecture. Toxoplasmosis, infectious mononucleosis, zoster, and vaccination-induced lymphadenopathies are caused by infectious agents, dermatopathic lymphadenitis is associated with cutaneous disease, anticonvulsant pseudolymphoma occurs in individuals hypersensitive to anticonvulsants (usually phenytoin), and Chediak-Higashi syndrome is an inherited abnormality of lysosomal microtubule function; the causes of sinus histiocytosis with massive lymphadenopathy, giant lymph node hyperplasia, angioimmunoblastic lymphadenopathy, mucocutaneous lymph node syndrome, and this histiocytoses remain unknown. The clinical course of these abnormalities varies from self-limited acute diseases (viral lymphadenopathies, toxoplasmosis, dermatopathic lymphadenitis, and usually anticonvulsive lymphadenopathy) to protracted, but benign abnormalities (sinus histiocytes with massive lymphadenopathy, giant lymph node hyperplasia, and multifocal eosinophilic granuloma). The diagnosis of angioimmunoblastic lymphadenopathy, Chediak-Higashi syndrome, and mucocutaneous lymph node syndrome necessitates a guarded prognosis, for death or the advent of a malignant lymphoma may interrupt their clinical course. Acute disseminated histiocytosis, even though the proliferated cell lacks the cytologic criteria of malignancy, should be regarded and treated as a malignant neoplasm.

Immune dysfunction in non-Hodgkin's lymphoma

Immune dysfunction seems to be more common in lymphoproliferative disorders wherein the malignant cells originate from the immune system itself. The reaction of Dinitrochlorobenzene (DNCB) and six recall antigens were found to be diminished in patients with non-Hodgkin's lymphomas as compared to control subjects (P less than 0.005). The skin reactivity was lost in increasing order in well differentiated, poorly differentiated, and histiocytic types. The depression in delayed hypersensitivity was greater with generalized as compared to localized disease. In angioimmunoblastic lymphadenopathy (AIL), skin tests also showed negative response in 7 of 8 patients. This T-cell dysfunction in a preneoplastic condition (AIL) suggests early appearance of immunodeficiency and probably a prerequisite for the development of a lymphoma. The serum immunoglobulin levels failed to show any relation with respect to histology or extent of disease. Presumably, the alteration of IgG is secondary to a malignancy.

Screening tests for cell-mediated immunodeficiency diseases

As our knowledge of immunology has become more sophisticated we have had to alter our ideas of the etiology of many immune deficiency diseases. Indeed, current concepts now prevalent have led to reclassification of a number of disease entities. In order to keep our diagnostic efforts abreast of the information being generated by the extensive immunology research programs now in progress, the clinical laboratory has been required to offer a new array of sophisticated tests on a relatively routine basis. This article is intended to serve as a brief review of immunobiology and immunodeficiency diseases with an indepth coverage of specialized tests generally available at the large centers. With an understanding of the principles, procedures, and pitfalls of the tests carried out the laboratory scientist is in a better position to assist the clinician in reaching the correct diagnosis. The detailed review is concerned with methods available to separate, classify, and subclassify lymphocytes and thereby allow a categorization of immune deficiency diseases. Toward that end there is a discussion of surface markers, rosetting, mitogenic and antigenic responsiveness as well as lymphokine production. With a view to present day research tests that might eventually find their way into the armamentarium of the clinical laboratory in the future, there is brief discussion of the methods presently used to classify T-cells as helper, suppressor, or effector cells, assays of some of the lymphokines, and measurement of antibody synthesis in cell culture.

Cutaneous manifestations of angioimmunoblastic lymphadenopathy

Angioimmunoblastic lymphadenopathy (AIL) is an uncommon immunoproliferative disorder with a presentation similar to malignant lymphoma but with a benign histopathologic picture. We report a case of a 49-year-old woman with AIL who manifested a pruritic maculopapular eruption as her presenting complaint and whose disease pursued an aggressive clinical course. Forty-four percent of patients with AIL experience a nonspecific dermatitis that in general is maculopapular and precedes other clinical symptoms by at least several weeks. AIL should be included in the differential diagnosis of any maculopapular eruption of unknown etiology accompanied by lymphadenopathy.

Angioimmunoblastic lymphadenopathy with dysproteinemia. A pathogenetic link between lymphoid proliferation and malignant lymphoma

Two patients with angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) were studied. Both patients had marked increases in all three major immunoglobulin classes, and both lacked suppressor cell activity in vitro. These findings are consistent with the theory that AILD is a defectively regulated immune response to an unidentified antigen(s) and could provide clues to the pathogenesis of other lymphoproliferative disorders as well.