Immunologic studies of three family members with the immunodeficiency with hyper-IgM syndrome

CD40:CD40L interactions in X-linked and non-X-linked hyper-IgM syndromes

Hyper-IgM (HIM) syndrome is a rare immunodeficiency characterized by low or absent IgG, IgA, and IgE with normal or elevated levels of IgM. This disorder can be acquired or familial with either X-linked or autosomal patterns of inheritance. The X-linked form of the disease is a consequence of mutations in the CD40 ligand (CD40L) gene that encodes a protein expressed primarily on activated CD4+ T cells. The cognate interaction between CD40L on T cells and CD40 on antigen-stimulated B cells, macrophage, and dendritic cells is critical for the development of a comprehensive immune response. The non-X-linked form of HIM syndrome is heterogeneous and appears in some cases to be a consequence of mutations in the AlD gene which encodes a B cell specific protein required for class switch recombination, somatic mutation, and germinal center formation. However, mutations in other unidentified genes are clearly the basis of the disease in a subset of patients. In this article, we review the essential features of the X-linked and non-X-linked forms of HIM syndrome and discuss the critical role the CD40:CD40L receptor-ligand pair plays in the pathogenesis of these immune deficiencies.

Mutations in activation-induced cytidine deaminase in patients with hyper IgM syndrome

Recent studies have shown that mutations in a newly described RNA editing enzyme, activation-induced cytidine deaminase (AID), can cause an autosomal recessive form of hyper IgM syndrome. To determine the relative frequency of mutations in AID, we evaluated a group of 27 patients with hyper IgM syndrome who did not have defects in CD40 ligand and 23 patients with common variable immunodeficiency. Three different mutations in AID were identified in 18 patients with hyper IgM syndrome, including 14 French Canadians, 2 Lumbee Indians, and a brother and sister from Okinawa. No mutations were found in the remaining 32 patients. In the group of patients with hyper IgM syndrome, the patients with mutations in AID were older at the age of diagnosis, were more likely to have positive isohemagglutinins, and were less likely to have anemia, neutropenia, or thrombocytopenia. Lymphoid hyperplasia was seen in patients with hyper IgM syndrome and normal AID as well as the patients with hyper IgM syndrome and defects in AID.

Cutaneous histoplasmosis in a child with hyper-IgM

Immunodeficiency with hyperimmunoglobulinemia M is a rare disease characterized by very low levels of IgG and IgA and normal or high levels of serum IgM and IgD. Recurrent and severe systemic infections with pathogenic bacteria are frequent if immunoglobulin replacement therapy is not given. Histoplasmosis is a systemic granulomatous mycosis due to Histoplasma capsulatum and characterized by a particular affinity for the reticuloendothelial system. Glabrous skin involvement in histoplasmosis is highly unusual except in patients with advanced human immunodeficiency viral disease. Cutaneous histoplasmosis and granulomatous reaction were diagnosed in a 5-year-old boy with hyper-IgM disease. The lesion improved after oral ketoconazole therapy. To our knowledge, this is the first case of cutaneous histoplasmosis associated with hyper-IgM to be reported.

Hyper IgM syndrome associated with defective CD40-mediated B cell activation

Recent studies show that most patients with X-linked hyper IgM syndrome have defects in the gene for CD40 ligand. We evaluated 17 unrelated males suspected of having X-linked hyper IgM syndrome. Activated T cells from 13 of the 17 patients failed to bind a soluble CD40 construct. In these patients, the sequence of CD40 ligand demonstrated mutations. By contrast, T cells from the remaining four patients exhibited normal binding to the CD40 construct. Sequencing of the cDNA for CD40 ligand from these patients did not show mutations. The possibility that hyper IgM syndrome in these four patients was due to abnormalities in the B cell response to CD40-mediated signals was examined. Peripheral blood lymphocytes were stimulated with anti-CD40 alone, IL4 alone or anti-CD40 plus IL4. In comparison with B cells from controls or patients with hyper IgM syndrome and mutant CD40 ligand, B cells from the patients with hyper IgM syndrome and normal CD40 ligand were defective in their ability to secrete IgE (P < 0.02) or express activation markers, CD25 and CD23 (P < 0.02) in response to stimulation with anti-CD40. The failure of these B cells to respond to CD40-mediated activation could not be attributed to a generalized deficiency in B cell activation because IL4 induced normal up-regulation of CD23 and CD25 expression. These findings indicate that hyper IgM syndrome may result from defects in expression of CD40 ligand by activated T cells or defects in CD40-mediated signal transduction in B cells.

Hypogammaglobulinaemia associated with normal or increased IgM (the hyper IgM syndrome): a case series review

The clinical and immunological aspects of 16 children with the syndrome of hypogammaglobulinaemia associated with normal or increased IgM (the hyper IgM syndrome) and their responses to treatment are reviewed. Increased concentrations of IgM, neutropenia, and recurrent infections could usually be controlled by antimicrobial and intravenous immunoglobulin treatment. Together with the bacterial infections characteristic of hypogammaglobulinaemia, these patients often developed opportunistic infections, including Pneumocystis carinii pneumonia, often presenting in the first year of life. The occurrence of sclerosing cholangitis, neurological complications, and neutropenia may be a result of an underlying cell mediated immune deficiency, autoimmunity, or infection. Despite a high incidence of opportunistic infections, immunological investigations did not show any abnormality of T cell function. These findings are discussed in the light of the recent demonstration that the lack of expression of a T lymphocyte activation antigen is the molecular basis of the X linked form of the disorder.

CD40 ligand and its role in X-linked hyper-IgM syndrome

CD40 ligand (CD40L) on activated T cells binding to CD40 on B cells is of critical importance for Ig heavy-chain switching and rescue of B cells from apoptosis after somatic mutation in the germinal centre. Mutations in the CD40L gene are now known to cause X-linked hyper-IgM syndrome (HIGM1), an immunodeficiency characterized by the absence of serum IgG, IgA and IgE. In this review, we discuss how basic and clinical immunology have combined to provide major insights into the function of CD40 in T-B cell collaboration.

Immunodeficiency with increased immunoglobulin M associated with growth hormone insufficiency

Growth hormone deficiency associated with hypogammaglobulinemia has been reported only in a few publications. Our patient was a male with recurrent episodes of infections. Serum immunoglobulin (Ig) G was extremely low although IgM concentration was much greater than the normal limit. Growth hormone responses to insulin, 1-Dopa and growth hormone-releasing hormone were low. The mean growth hormone concentration during sleep was less than the normal limit. These results are consistent with hyper-IgM immunodeficiency associated with growth hormone deficiency. The mode of transmission appears to be autosomal dominant. This combination has not been reported previously.

CD40 ligand gene defects responsible for X-linked hyper-IgM syndrome

The ligand for CD40 (CD40L) is a membrane glycoprotein on activated T cells that induces B cell proliferation and immunoglobulin secretion. Abnormalities in the CD40L gene were associated with an X-linked immunodeficiency in humans [hyper-IgM (immunoglobulin M) syndrome]. This disease is characterized by elevated concentrations of serum IgM and decreased amounts of all other isotypes. CD40L complementary DNAs from three of four patients with this syndrome contained distinct point mutations. Recombinant expression of two of the mutant CD40L complementary DNAs resulted in proteins incapable of binding to CD40 and unable to induce proliferation or IgE secretion from normal B cells. Activated T cells from the four affected patients failed to express wild-type CD40L, although their B cells responded normally to wild-type CD40L. Thus, these CD40L defects lead to a T cell abnormality that results in the failure of patient B cells to undergo immunoglobulin class switching.

Expansion of a suppressor T-cell population associated with the hyper-IgM syndrome and generalized lymphadenopathy

Immunoglobulin deficiency with increased IgM (hyper-IgM recurrent infection syndrome) is thought to be due to a defect of IgM/IgG isotype switching in B cells. Considerable genetic heterogeneity (X-linked, autosomal dominant or autosomal recessive inheritance, acquired forms) exists. We describe a case of hyper-IgM syndrome associated with massive lymphadenopathy in a 10-year-old girl with normal B-cell function. Absolute and relative increases of T-suppressor cells (CD8+) and a decrease of circulating CD4+ ("helper") cells were observed. The CD4+ cells present were all of the CD45R+ subtype, representing relatively immature ("naive") helper cells. In contrast, the number of CD4+ cells within the lymph nodes was increased. When tested fractionally, the patient's CD8+ cells selectively inhibited synthesis of IgG and IgA by normal B cells, but spared IgM. Normal allogenic T cells could induce IgG and IgA production by the patient's B cells. These findings suggest (a) a state of selective suppression of IgG and IgA synthesis with exclusive production of IgM, and (b) an abnormal recirculation of immature T-helper cells. This case represents a variant of this heterogeneous syndrome resembling the findings in neonatal lymphocytes and can be distinguished from the "adult" form of hyper-IgM syndrome which may be due to defective switch T cells.

Evidence that in X-linked immunodeficiency with hyperimmunoglobulinemia M the intrinsic immunoglobulin heavy chain class switch mechanism is intact

X-linked immunodeficiency with hyperimmunoglobulinemia M (XHM) reflects an impairment of the immunoglobulin (Ig) heavy (H) chain class switch of B lymphocytes from IgM to IgG and IgA. XHM is recessive; female carriers manifest normal IgG and IgA production. Due to random X chromosome inactivation in all somatic cells of females, about half of the lymphocytes of XHM carriers are not able to express an intact XHM gene. An intrinsic defect of the Ig H chain class switch mechanism in XHM B lymphocytes would thus lead to a skewed X chromosome inactivation pattern in the IgG- and IgA-expressing B lymphocytes of female carriers. IgM-, IgG- and IgA-expressing B lymphoblastoid cells (BLC) were established by Epstein-Barr virus transformation of peripheral blood mononuclear cells of two female XHM carriers. In an analysis of differential methylation of the polymorphic DXS255 loci, random X chromosome inactivation patterns were found in populations of T lymphocytes, in IgM-expressing B lymphocytes and in IgG- or IgA-expressing B lymphocytes. The heterogeneity of Ig H chain rearrangements and the Ig light chain usage in the IgA- or IgG-expressing BLC clones that had inactivated the X chromosome which carries the intact XHM gene and in BLC clones with the homologous X chromosome inactivated were similar. The results indicated that the intrinsic Ig H chain class switch mechanism in XHM B lymphocytes is fully intact. We conclude that the XHM gene encodes a class switch inducer that is transferred to B lymphocytes.

Immunoglobulin deficiency with increased immunoglobulin M in three siblings: effect of long-term immunoglobulin therapy

Diagnosis of immunoglobulin deficiency with increased IgM (hyper-IgM syndrome) was made in three siblings (two girls and a boy) on the basis of history, physical findings, and laboratory data. The prominent clinical findings were recurrent viral and bacterial infections of the respiratory tract. The most severe infections affected the male patient, who died at the age of 8 years. Family history and the lack of clinical signs in the parents and relatives indicated no immunodeficiency which, together with the occurrence of the disease in both sexes, indicated an autosomal recessive inheritance. The two female patients (18 years old and 3 years old) have been treated with intravenous acid-treated immunoglobulin for 2 years, resulting in significant clinical improvement with respect to the frequency and severity of infections.

The effect of acute exercise on natural killer-cell activity of trained and sedentary human subjects

The effect of acute exercise on natural killer (NK) activity and on the distribution of phenotypic characteristics of peripheral blood lymphocytes was examined. Trained and sedentary individuals underwent a standard progressive exercise test on a cycle ergometer using an incremental work load of 15 W (90 kpm), increased every minute. Each subject was encouraged to exercise to exhaustion, and total ventilation and mixed expired O2 and CO2 were measured every 30 sec. All subjects reached the "anaerobic" threshold as judged by the deflection of ventilation at a work load near VO2max. NK activity against K562 reached maximum levels immediately after exercise, dropped to a low point 120 min later, then slowly came back to preexercise levels within 20 hr. No significant differences were observed between the trained and the sedentary groups. Furthermore, immediately after exercise the proportion of OKT-3+ and OKT-4+ cells was reduced by 29.8 +/- 3.6 and 33.6 +/- 5.4%, respectively; the percentage Leu-7+ and Leu-11a+ cells was increased by 53.9 +/- 1.7 and 57.3 +/- 2.9%, respectively. The percentage OKT-8+ cells was not significantly altered. When the percentage binding of effector to target cells was examined, it was highest at 0 min post-exercise (19 +/- 6.2%) and lowest at 120 min postexercise (7 +/- 3.9%), but the absolute number of NK cells remained unchanged. The source of serum used in the lytic assay had no effect on the NK activity, as fetal calf serum and autologous sera drawn at different time intervals during exercise gave similar results.(ABSTRACT TRUNCATED AT 250 WORDS)

Monoclonal antibody against K562 cell line accelerates killing of the target cells by large granular lymphocytes

A monoclonal antibody (MoAb 11-4) was raised against K562, a human erythroleukemia cell line sensitive to natural killer cell-mediated cytotoxicity (NK-CMC). Immunological analysis revealed MoAb to be IgG2b. Alone, the MoAb was not cytotoxic for K562 and did not bind to the effector cells, but the addition of this antibody to macrophage-depleted human peripheral blood lymphocytes increased killing of K562 in a 4-hr NK-CMC assay. The maximum increase in NK-CMC was observed when MoAb 11-4 was added to target cells prior to the formation of effector/target cell conjugates. This effect was dose dependent, was specific for K562, and, contrary to conventional antisera, occurred at very low concentrations of MoAb. When MoAb was added either to Percoll-purified large granular lymphocytes (LGL) or to LGL-depleted lymphocytes, only the latter demonstrated a significant increase in the killing of K562 in a 4-hr chromium release assay. Kinetics studies revealed that although the overall LGL-mediated lysis was only slightly increased at 4 hr, the maximum lytic activity was reached within 2 hr. These studies suggest that (1) human LGL and LGL-depleted cell populations bear Fc receptors for mouse IgG2b and (2) although the cytotoxic activities of both cell populations are increased by treatment with MoAb 11-4, the kinetics of this increase are different.

Changes in immunoregulatory lymphocyte populations in patients with histoplasmosis

Circulating T-lymphocyte subpopulations were enumerated in 65 patients with histoplasmosis and correlated with the different clinical manifestations of the disease. Acute pulmonary histoplasmosis, rheumatologic, disseminated, and chronic inflammatory manifestations of histoplasmosis were all associated with a significant elevation above normal of OKT8+ (suppressor-cytotoxic) lymphocytes and a significantly lower than normal OKT4+ (helper-inducer)-lymphocyte to OKT8+-lymphocyte ratio. In contrast, cavitary disease was associated with an increase in OKT4+ lymphocytes, a decrease in OKT8+ lymphocytes, and a higher than normal OKT4/OKT8 ratio. Clinical recovery was associated with normalization of these values. Functional activity determined by coculture techniques correlated closely with T-lymphocyte subset measurements. These distinct subset abnormalities may help monitor immunological aspects of disease activity.

Surface markers and biological functions of PMNC fractionated by countercurrent centrifugal elutriation

Peripheral blood mononuclear cells (PMNC) were separated by countercurrent centrifugal elutriation (CCE) in PBS-EDTA medium into 13 fractions. Properties associated with B cells were restricted mainly to the first fractions (F2 and F4) while those associated with T cells were confined to fractions F4, F6 and F8. The final fraction (FF) contained more than 90% monocytes while fraction F10 contained 40% monocytes and 60% null cells, and F12 contained 50% monocytes and 50% null cells. Natural killer (NK) cell activity against K-562, a human erythroleukaemia cell line, and against an adherent undifferentiated sarcoma target, was distributed between fractions F6 and F8. Using electron and scanning microscopy and a new single cell liquid cytotoxic assay, we studied membrane interaction and binding of the CCE fractionated cells with the 2 targets. Effector/target cell conjugates revealed interdigitations in the area of cell contact but no membrane fusion, although certain effector cells had a distinct large granulocytic lymphocyte morphology. Furthermore, different cell types from different fractions were able to bind to the targets although the killing was associated with certain fractions only. When purified monocytes from fraction FF were added to F6 and F8, NK activity against both targets was depressed. This inhibition was not reversed by indomethacin, and binding of the targets to the effector cells was unaffected. CCE is a powerful technique which allows the fractionation of PMNC without altering their biological functions, contrary to what is seen with nylon wool or dextran fractionation. In this report, the activity associated with CCE fractions is studied and discussed.