AGAMMAGLOBULINEMIA, MALABSORPTION AND RHEUMATOID-LIKE ARTHRITIS

Studies on the enteropathy associated with primary hypogammaglobulinaemia

Twelve patients with primary hypogammaglobulinaemia with diarrhoea not associated with known microbial pathogens were investigated. Histological evidence of inflammation was common in the stomach and jejunum. Moreover, eight of 10 patients undergoing colonoscopy had low grade 'microscopic colitis' with raised intraepithelial lymphocytes and an intact crypt architecture. Five of 12 patients had small intestinal inflammation on 111indium leucocyte scintigrams and all had increased faecal excretion (normal < 1%) of 111indium (over four days), which varied in intensity from mild (faecal excretion of 111indium = 1-3%) to that comparable with moderately active (7-14.5%) Crohn's disease. Three patients had small intestinal strictures superficially resembling Crohn's disease. Histologically, however, these lacked characteristic diagnostic features of Crohn's disease in two and the third patient had non-steroidal anti-inflammatory drug induced diaphragm like strictures. Six of seven who were most severely symptomatic were successfully treated with an elemental diet with rapid improvement of symptoms. The faecal excretion of 111indium was repeated in five and all improved but histologically the colitis remained unchanged. These studies show that some patients with primary hypogammaglobulinaemia have intestinal inflammation unlike that found in classic inflammatory bowel disease. Elemental diet is a useful temporary measure in the treatment of these patients.

An unusual inflammatory lesion of the jejunum in a patient with late onset immunoglobulin deficiency

A 40-year-old male patient is reported in whom a grossly inflamed thickened 70-cm segment of jejunum complicated a 'late onset' immunoglobulin deficiency state. The pathogenesis is unknown, but extensive occlusion of the vascular supply to the lesion may have contributed to its development.

Intestinal lesions in immune deficiency

The descriptive studies of intestinal lesions in immune deficiency and the research that has been done in order to explain their pathogenesis are reviewed. Current knowledge in this field is inadequate, and some of the intriguing phenomena described defy reasonable explanation, including the special role of Giardia lamblia and the rarity of gastrointestinal lesions in isolated IgA deficiency. Several hypotheses have been proposed regarding these phenomena.

Intestinal bacterial flora and bile salt studies in hypogammaglobulinaemia

Five patients with adult acquired hypogammaglobulinaemia, four of whom were achlorhydric, were studied. Jejunal bacterial counts were much higher than those in a control group of acid secretors, but were similar to those in a control group of patients with pernicious anaemia; Giardia lamblia were isolated from the jejunal content of all patients with hypogammaglobulinaemia. The concentration of conjugated bile acids in the fasting state was lower in hypogammaglobulinaemia than in pernicious anaemia, but in the two hypogammaglobulinaemic patients with steatorrhoea there was a normal bile salt response to a fatty meal.