Monoclonal gammopathies in children

Maternal T and B cell engraftment in two cases of X-linked severe combined immunodeficiency with IgG1 gammopathy

X-linked severe combined immunodeficiency (X-SCID), caused by defects in the common gamma chain, is typically characterized by T and NK cell defects with the presence of B cells. T cell dysfunction and impaired class-switch recombination of B cells mean that patients typically have defects in class-switched immunoglobulins (IgG, IgA, and IgE) with detectable IgM. Here, we describe two patients with X-SCID with IgG1 gammopathy, in whom we identified maternal T and B cell engraftment. Exclusively, maternal B cells were found among the IgD^-CD27⁺ class-switched memory B cells, whereas the patients' B cells remained naïve. In vitro stimulation with CD40L+IL-21 revealed that peripheral blood cells from both patients produced only IgG1. Class-switched maternal B cells had restricted receptor repertoires with various constant regions and few somatic hypermutations. In conclusion, engrafted maternal B cells underwent class-switch recombination and produced immunoglobulin, causing hypergammaglobulinemia in patients with X-SCID.

A Rare Case of Acquired Fanconi's Syndrome With Monoclonal Gammopathy in an Infant

BACKGROUND

Monoclonal gammopathies associated with acquired Fanconi's syndrome (AFS) have been reported in the adult population. AFS is characterized by renal dysfunction resulting in proteinuria, aminoaciduria, hypophosphatemia, glucosuria, and hyperchloremic metabolic acidosis. In this case report, we document the clinical and laboratory findings of a preterm infant with features of both AFS and monoclonal gammopathy in the urine.

METHODS

Clinical suspicion of AFS prompted the following laboratory studies to be performed: urine protein electrophoresis (UPEP), urine immunofixation, and urine amino acid analysis with high performance liquid chromatography (HPLC).

RESULTS

Urine amino acid analysis revealed aminoaciduria. On UPEP, nonselective glomerular proteinuria was seen with a faint band in the gamma region. Urine immunofixation confirmed the presence of a monoclonal IgG lambda component with free monoclonal lambda light chains.

CONCLUSION

To the best of our knowledge, this is the first case of pediatric AFS reported with a monoclonal gammopathy and monoclonal free light chains.

Evaluation of monoclonal and oligoclonal gammopathies in a pediatric population in a major urban center

OBJECTIVES

A growing body of literature has documented monoclonal proteins in children. Little is known about their associated diagnoses.

METHODS

We retrospectively evaluated all patients (aged 0-21 years) with abnormal findings on serum immunofixation electrophoresis (SIFE) from 2005 to 2011. We also documented the monoclonal immunoglobulin classes and light chain types involved and then correlated these data with the clinical diagnoses.

RESULTS

A total of 695 SIFE tests were performed on this patient population. Of these, 95 SIFE tests (14%) identified a gammopathy (from 83 different patients), and of these, 74 (11%) demonstrated only a monoclonal gammopathy (from 63 different patients). The most common associated diagnosis in the study interval was ataxia-telangiectasia (22%). No patient in the study population was diagnosed with multiple myeloma or Waldenström macroglobulinemia.

CONCLUSIONS

The significance and presence of a monoclonal or oligoclonal gammopathy in pediatric and young adult populations is distinct from that seen in adults.

The role of the physician in laboratory medicine: a European perspective

Advances in medical laboratory technology have driven major changes in the practice of laboratory medicine over the past two decades by the development of automated, cross-disciplinary single platform analysers. This has led to the blurring of boundaries between traditional disciplines and the emergence of core automated or blood science laboratories. This paper was commissioned by the Union of European Medical Specialists to examine the changing role of laboratory-based physicians in the light of these advances by focusing on the added value of expert interpretation of test results and resultant improvements in clinical outcomes. The paper also considers the broad range of responsibilities of laboratory-based physicians and the difficulties in precisely measuring how this translates into improved clinical outcomes. Given its provenance, the paper concentrates predominantly on the role of laboratory-based physicians while acknowledging the essential and vital role of scientists in running diagnostic laboratory services.

An unusual concurrence of graft versus host disease caused by engraftment of maternal lymphocytes with DiGeorge anomaly

We describe a girl with DiGeorge anomaly and normal cytogenetic and molecular studies, whose clinical course was complicated by graft versus host disease caused by intrauterine materno-fetal transfusion, and several immunohematological alterations including a monoclonal gammapathy of undetermined significance (first IgG, which subsequently changed to IgM). The main clinical features and pathological findings are discussed.

Acute renal failure in a neonate caused by the transplacental transfer of a nephrotoxic paraprotein: successful resolution by exchange transfusion

Acute renal failure was diagnosed within 6 days of birth in a full-term neonate. The mother was known to have a monoclonal gammopathy, immunoglobulin G (IgG) lambda, discovered a year before pregnancy on being investigated for hematuria and proteinuria. Her renal function was intact. Maternal renal biopsy performed at the time showed a focal proliferative glomerulonephritis with nonfibrillary homogeneous mesangial and intramembranous electron-dense deposits. Immunoperoxidase staining was positive for IgG and lambda and kappa light chains along the glomerular and tubular basement membranes. Pregnancy was uneventful. Protein electrophoresis and immunofixation of the infant girl's serum and urine samples showed the presence of a paraprotein electrophoretically identical to that found in the mother. Exchange transfusion resulted in a rapid improvement of renal function in parallel to the disappearance of the monoclonal component.

Oligo-/monoclonal gammopathy and hypergammaglobulinemia in ataxia-telangiectasia. A study of 90 patients

We investigated the presence of hypergammaglobulinemia and oligo-/monoclonal gammopathy in 90 patients (from 80 families) with ataxia-telangiectasia ranging in age from 2 to 29 years. Of the 90 patients, 38.8% displayed hypergammaglobulinemia. An isolated increase in IgM was the most common finding (23.3%) followed by a simultaneous increase in IgM and IgG (8.8%), an isolated increase in IgA (3.3%), an elevated level of IgG (2.2%) and a concomitant increase in IgM and IgA (1.1%), respectively. Seven of the patients (8.1%) had oligo-/monoclonal gammopathy. The gammopathies included all major immunoglobulin isotypes. Chemotherapeutic intervention in 2 cases precipitated the emergence of new clones within a matter of weeks. Further investigation of oligo-/monoclonal gammopathies in these patients may lead to a clearer understanding of the clinical course and provide further insight into the underlying mechanisms of B-cell abnormalities in ataxia-telangiectasia.

Monoclonal gammopathy of the immunoglobulin A class in a two-year-old girl with ataxia telangiectasia

Ataxia telangiectasia is an autosomal recessive neurologic disorder which is frequently associated with a deficiency of IgA immunoglobulin. We report an unusual case of monoclonal gammopathy of the IgA kappa type in a 2-year-old female patient newly diagnosed with ataxia telangiectasia. Quantitative analysis of the patient's immunoglobulins revealed a marked elevation in the IgA fraction with a value of 672 mg/dL (normal 14-123 mg/dL). The IgG and IgM fractions were normal. Serum protein electrophoresis showed a band of restricted mobility present in the gamma region, which was identified as a monoclonal IgA kappa immunoglobulin on immunofixation electrophoresis. This is the first case report of a patient with ataxia telangiectasia associated with an IgA monoclonal gammopathy.

Serum kappa and lambda light immunoglobulin chains in cynomolgus macaques (Macaca fascicularis) during the first twenty months of age

Growth is coupled to physiological modifications of the immune system which reaches the functional capabilities according to age-related milestones. Few data are available on the circulating immunoglobulin levels and no data exist on total immunoglobulin light chains in infant macaques. Therefore we studied by a nephelometric assay, the age-dependent variations of kappa and lambda serum light chains in the experimental animal model Macaca fascicularis during the first 20 months of age. Both kappa and lambda showed a marked increase in their concentrations during the first 7-8 months of life. Infants' light chain levels were anyhow significantly lower than those of the nursing dams and of the control group, never attaining, even at the 20th month, the same concentration as the adult, although the value of the kappa/lambda ratio was apparently the same.

Ten years after acquiring an HIV-1 infection: a study in a cohort of eleven neonates infected by aliquots from a single plasma donation

We present data from a 10-year follow-up study of 11 children who had been infected in the neonatal period by small aliquots of plasma from a single donation. Three of the children died within the first 2.5 years of life, 5 other children died between 6.2 and 11 years after infection and 3 are alive at present. The latter children are classified as P1B (asymptomatic), P2A (non-specific findings) and P2B (neurological changes). All infected children showed progressive decline of cellular immunity. Immunoglobulin levels in serum were increased in the majority of children for prolonged periods and homogeneous immunoglobulin components were present. The severity of the disease was related neither to the clinical condition of the infants in the neonatal period nor to the volume of transfused plasma, the interval between freezing and thawing of the plasma, gestational age at birth and age at transfusion. Coinciding infections with other viruses had no impact on disease progression during the follow-up period of 10 years.

Serum immunoglobulin class and IgG subclass levels and the occurrence of homogeneous immunoglobulins during the course of ageing in humans

Serum levels of IgM and IgA classes and of IgG subclasses were determined and related to the presence of homogeneous immunoglobulin components (H-Ig) in volunteers equally distributed in age groups from 25 to 98 years, who all met the Senieur admission criteria for immunogerontological studies. In addition, sera of non-Senieur volunteers aged 75 years and older were included. Furthermore, the amount of IgD was determined in sera of Senieur individuals equally distributed in age groups from 15 to 98 years. In the Senieur persons, the contribution of the IgG subclasses and the IgM and IgA classes to the pool of serum immunoglobulins remained relatively unchanged during the course of ageing. In comparison with Senieur individuals aged 25-34 years, a slight increase in IgM and IgA levels was observed from the age 35 to 44 onwards and in IgG1 from the age 55 to 64 onwards. The variability of the immunoglobulin concentrations increased during ageing. The most prominent observation was the continuous decline of serum IgD starting in young adults. The non-Senieur persons differed from their Senieur age-matched counterparts mainly by the elevated IgG2 and IgA levels. During the course of ageing, H-Ig mainly of low concentration were detected at an increasing frequency in the Senieur persons and even more frequently in the elderly non-Senieur volunteers. Although in some individuals the elevation of immunoglobulin levels correlated with the appearance of H-Ig within the corresponding isotype, this relationship was not conclusive for all sera investigated. These results suggest that the rise of serum levels of individual immunoglobulin isotypes associated with ageing is usually the consequence of a polyclonal B cell activation. The occurrence of H-Ig and the decline of serum IgD in aged Senieur persons indicate that these are, at least partly, true phenomena of ageing and not always the consequence of disease.

Current concepts on monoclonal gammopathies

This is a review of the monoclonal gammopathies, including a discussion of cause. The role of T lymphocytes and B lymphocytes is presented. The recognition of a monoclonal protein in the serum and urine is presented in detail. The frequency of benign and malignant monoclonal gammopathies is provided. A long-term follow-up of 241 patients with apparently benign monoclonal gammopathy is examined closely. In this series, multiple myeloma, macroglobulinaemia, amyloidosis, or related disorders developed in 22% of the 241 patients with long-term disease. The median duration from the recognition of the monoclonal protein until the development of serious disease was approximately eight to ten years. The differentiation of benign from malignant monoclonal gammopathies is examined in detail. The point is made that patients must be followed indefinitely because malignancy may develop more than 20 years later. The association of monoclonal gammopathies with other apparently unrelated diseases is discussed.

Immunoblotting techniques for the detection of low level homogeneous immunoglobulin components in serum

Because of the increasing demand for simple and reliable techniques for the detection of low concentrations of paraproteins against a highly heterogeneous serum background, two techniques were investigated for their sensitivity: isoelectric focusing (IEF) and Wieme high resolution electrophoresis, each with subsequent blotting by diffusion. The techniques were compared using isolated mouse monoclonal antibodies (mAb) of known concentration and specificity. Wieme electrophoresis in combination with immunoblotting (IBL) or antigen-specific immunoblotting (ABL) has a detection limit of 100 ng/ml and 10 ng/ml, respectively. For IEF in combination with IBL or ABL these limits were 1000 and 30 ng/ml, respectively. For ABL, polyvinylidene difluoride (PVDF) and nylon-supported nitrocellulose (NSNC) membranes gave similar detection limits, although for IBL, PVDF is preferred to NSNC. While IEF is essential for investigating the spectrum of the antibody repertoire. Wieme electrophoresis is the most powerful technique for the detection of homogeneous immunoglobulin components (H-Ig). After separation of the proteins. IBL is fast, simple and sensitive enough for routine detection and characterization of H-Ig. However, when the antibody specificity is known, ABL should be chosen for its superior sensitivity.

Age-related monoclonal gammapathies: clinical lessons from the aging C57BL mouse

In this article the long-held notion that benign monoclonal gammapathy (BMG) is a premalignant stage in the development of multiple myeloma (MM) is attacked. Jiri Radl argues that clinical and experimental observations indicate that they are separate entities which may be distinguished in the laboratory and which should be managed in radically different ways.

Monoclonal gammopathies in human aging: increased occurrence with age and correlation with health status

To determine the incidence of monoclonal gammopathies (MG) in relation to the aging process as such, and to evaluate the influence of disease on the occurrence of MG, we studied 439 elderly subjects aged 75-84 years. These individuals were categorized into 4 groups on the basis of their health status. There was a group of "optimally healthy" elderly, a group of "apparently healthy" residents of homes for the aged, a group of geriatric outpatients and a group of randomly chosen inpatients from a general hospital. Whereas no MG were detected in a control group of healthy young subjects aged 25-34 years, the frequency of MG in the aged groups ranged from 11% in the "optimally healthy" aged group to 38% in the inpatients group. In a tentative classification according to possible cause, most of the MG belonged to the pathogenetic category of immunodeficiency. There was a clear association of the occurrence of monoclonal gammopathies of this category with the health status.

Development of multiple monoclonal serum immunoglobulins (multiclonal gammopathy) following both HLA-identical unfractionated and T cell-depleted haploidentical bone marrow transplantation in severe combined immunodeficiency

We have identified five patients with severe combined immunodeficiency (SCID) who developed multiple monoclonal serum immunoglobulin components (multiclonal gammopathy) following bone marrow transplantation. Four patients received haploidentical bone marrow stem cells depleted of T cells and other mature marrow cells by soy lectin agglutination and/or sheep erythrocyte rosetting. One patient received unfractionated HLA-identical bone marrow. Twenty-one distinct paraproteins were detected: 14 IgG, 5 IgM, and 2 IgA, all containing either kappa or lambda light chains. In the haploidentical stem-cell recipients, these monoclonal immunoglobulins appeared immediately prior to, or concomitant with, a rise in T-cell numbers and function. Resolution or diminution of this multiclonal gammopathy occurred as T-cell function was established. Posttransplant karyotypic analyses revealed PHA-stimulated T cells to be of donor origin in all patients. Karyotyping of B-cell lines posttransplantation revealed them to be 100% donor in the patient receiving unfractionated HLA-identical marrow and 100% host (1/4), 100% donor (1/4), mixed (1/4), or not tested (1/4) in the patients receiving haploidentical marrow stem cells. There was no evidence of Epstein-Barr virus (EBV) infection in any of the patients. All patients are currently alive and well. Immunoglobulin synthesis is normal in the patient who received the HLA-identical marrow but remains below normal in the four patients who received T cell-depleted haploidentical stem cells. The posttransplantation development of monoclonal immunoglobulins in the absence of EBV infection did not adversely affect the outcome of either HLA-identical marrow or haploidentical stem-cell grafting.(ABSTRACT TRUNCATED AT 250 WORDS)