Clinical and immunologic features of dysgammaglobulinemia type I. Report of a case diagnosed in the first year of life

Membranous glomerulonephritis associated with hepatitis C virus infection in an adolescent

The clinical, laboratory and pathological findings are reported in an adolescent patient with hyper-IgM immunodeficiency syndrome (dysgammaglobulinemia) which was complicated by primary sclerosing cholangitis and membranous glomerulonephritis. Hepatitis C virus (HCV) RNA was detected in serum by the polymerase chain reaction. A possible etiological relationship between hepatitis C virus infection and membranous nephropathy is discussed.

Orofacial manifestations in the primary immunodeficiency disorders

Primary immunodeficiencies are increasingly recognized yet there is little data concerning the oral manifestations of such disorders. This article reviews the current literature and details the oral aspects of well-characterized primary immunodeficiencies.

Defective expression of CD40 ligand on T cells causes "X-linked immunodeficiency with hyper-IgM (HIGM1)"

X-linked immunodeficiency with hyper-IgM (HIGM1) is a rare disorder, characterized by recurrent infections associated with very low or absent IgG and IgA, and normal to increased IgM serum levels. The disease has been earlier mapped to the q26-27 region of the X-chromosome. We have identified a novel molecule expressed on the surface of activated T cells, which was designated TRAP (Tumor necrosis factor Related Activation Protein), and could demonstrate that TRAP is a ligand for the CD40 receptor expressed on B cells. Our mapping of the TRAP gene to the Xq26.3-27.1 region suggested a causal relationship to HIGM1. Further work revealed that various mutations of the TRAP/CD40 ligand (CD40L) gene may lead to a defective expression of the TRAP/CD40L molecule on the T-cell surface in HIGM1 patients. A combination of structural and functional analyses finally demonstrated that the failure of TRAP/CD40L on T cells to interact with CD40 on B cells is responsible for the inefficient T-cell help for B cells observed in HIGM1. The observations made in HIGM1 allowed us to conclude that TRAP/CD40L is not required for IgM synthesis. In contrast, functional expression of TRAP is a prerequisite for effective immunoglobulin isotype switching and subsequent production of IgG, IgA and IgE by B cells in vivo. The interaction of TRAP/CD40L with CD40 thus provides a very critical link between the cellular and the humoral part of the immune system. The knowledge of TRAP/CD40L cDNA sequence, the availability of various reagents for the testing of expression and function of TRAP/CD40L, and our recent elucidation of the exon-intron structure of the TRAP/CD40L gene now provide all necessary tools for early diagnosis of affected patients and the detection of female carriers of HIGM1. The available information will also provide a basis for future attempts at gene therapy in this disease.

Orofacial manifestations in primary immunodeficiencies: common variable immunodeficiencies

The orofacial manifestations of 15 patients with Common Variable Immunodeficiencies (CVID) are reported. Aphthous-like ulceration, pseudomembranous candidosis and/or enamel hypoplasia were observed in 11 patients. Four patients had no orofacial lesions.

Hyper-IgM immunodeficiency syndrome: influence of lymphokines on in vitro maturation of peripheral B cells

Peripheral B cells from six patients affected with the hyper-IgM immunodeficiency syndrome, characterized by an absence of IgG and IgA in serum with a concomitant elevated level of IgM, were analyzed for phenotypic and functional characteristics. We report that although the membrane antigenic pattern expression was characteristic of mature B cells, B cells from most patients exhibited an impairment in their in vitro response to several lymphokines, such as recombinant interleukin 2 (rIL-2) and low molecular weight B-cell growth factor (BCGF), that induce proliferation of anti-mu-activated B cells. This impairment was also found in response to a lymphokine mixture from a CD2-activated T-cell clone. The decrease in lymphokine-induced B-cell proliferation was accompanied by a low B-cell differentiation, whether patients' B cells were stimulated by the T-cell clone supernatant or rIL-2 and rIL6, lymphokines able to support differentiation of Staphylococcus aureus Cowan I (SAC)-activated B cells. In addition, none of the lymphokines tested were able to induce patients' B cells to switch from IgM-secreting cells to IgG- and IgA-secreting cells. We conclude that this syndrome is associated with a defect in lymphokine-dependent maturation of B lymphocytes, although the T- or the B-cell origin of the defect still cannot be determined.

Carrier detection of the X-linked primary immunodeficiency diseases using X-chromosome inactivation analysis

Carrier detection of three of the X-linked primary immunodeficiency diseases (X-linked agammaglobulinemia, X-linked severe combined immunodeficiency disease, and the Wiskott-Aldrich syndrome) is possible by analyzing patterns of X-chromosome inactivation in those cells affected by the disorder. Normal women have balanced patterns of X-chromosome inactivation; that is, in a given population of cells, approximately half of their active X chromosomes are of paternal origin and half of their active X chromosomes are of maternal origin. In contrast, female carriers of these X-linked immunodeficiency disorders have an unbalanced pattern of X-chromosome inactivation in those cell lineages that are affected by the disorder; that is, all the active X chromosomes in affected cell lineages are the X chromosomes that carry the normal allele. Two techniques are available for X-chromosome inactivation analysis. One technique depends on methylation differences between the active and inactive X chromosome, and the other technique uses somatic cell hybrids that selectively retain the active X chromosome. In either case, carrier detection can be performed in individuals from families in which only one member of the family has been affected, since neither of these methods depends on linkage analysis.

Presence of immunoglobulin (Ig) M and IgG double isotype-bearing cells and defect of switch recombination in hyper IgM immunodeficiency

We established a transformed B cell line expressing both IgM and IgG on the cell surface from a patient with hyper IgM immunodeficiency using Epstein-Barr viruses. DNA and RNA of the cells were analyzed. DNA rearrangements of Ig JH gene loci were observed on both chromosomes. Cloning and DNA sequence analyses showed that one has a VHDHJH structure while the other has a DHJH structure. Southern hybridization with 5'-S mu and S gamma region-containing probes indicated germline configuration in the switch regions of mu and gamma genes on both chromosomes. To test expression of mu and gamma chains in the transformed cells at the mRNA-level, we used the polymerase chain reaction with three kinds of synthetic oligonucleotides as primers, one of which was part of the VH gene, while the other two were complementary to parts of C mu and C gamma genes. Sequence analysis of the amplified products showed that the same VHDHJH sequence is directly connected with either the C mu or the C gamma sequence in the mRNAs. This is direct evidence showing that in double isotype-bearing cells one VHDHJH exon in the transcript is alternatively spliced to C mu or C gamma without DNA rearrangement. The defect in this disease could be at the S-S recombination stage.

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.

Rapid transient reversal of anemia and long-term effects of maintenance intravenous immunoglobulin for autoimmune hemolytic anemia in patients with lymphoproliferative disorders

Seven patients with autoimmune hemolytic anemia (AIHA) associated with an underlying lymphoproliferative disorder were treated with intravenous immunoglobulin. Five patients with chronic lymphocytic leukemia, a patient with Hodgkin's lymphoma with severe AIHA associated with a "warm" IgG antibody, and a patient with non-Hodgkin's lymphoma with an IgM "cold" antibody were treated with intravenous immunoglobulin G (0.4 g/kg) daily for five doses followed by maintenance therapy every 21 to 28 days if evidence of recurrence was noted. Two additional patients with refractory chronic lymphocytic leukemia and hypogammaglobulinemia were given maintenance therapy with intravenous immunoglobulin G every 21 days for previously recurrent AIHA and infections. Hematocrit levels of patients with AIHA stabilized followed by a gradual improvement at 21 days after intravenous immunoglobulin G infusion without steroids. Treatment with steroids and intravenous immunoglobulin G resulted in faster and higher increments in hematocrit levels in these patients. Other patients who had partial responses to steroids showed further improvement in their hematocrit levels by the addition of intravenous immunoglobulin G. Another patient with a cold agglutinin disease was refractory to intravenous immunoglobulin G therapy. Five patients with chronic lymphocytic leukemia and acute AIHA and two patients with previous recurrences of AIHA required maintenance intravenous immunoglobulin G every 21 days. All seven patients except one did not have any episodes of AIHA from six months to as long as four years while receiving the three-week intravenous immunoglobulin G therapy. These observations indicate a role for intravenous immunoglobulin G in the management of IgG-mediated but not IgM-associated autoimmune hemolysis in immunocompromised patients with lymphoproliferative diseases.

Serum lactate dehydrogenase levels in adults and children with acquired immune deficiency syndrome (AIDS) and AIDS-related complex: possible indicator of B cell lymphoproliferation and disease activity. Effect of intravenous gammaglobulin on enzyme levels

Twenty-seven of 33 patients with the acquired immune deficiency syndrome (AIDS) or AIDS-related complex (16 adults and 17 children) demonstrated significant elevation of serum lactate dehydrogenase activity, occurring in the isomorphic distribution. Serum lactate dehydrogenase activity was the highest in all nine patients with acute Pneumocystis carinii pneumonitis, in seven of whom extensive interstitial pulmonary infiltrates with lymphocytes and plasma cells were documented. Lactate dehydrogenase activity was also significantly elevated on a long-term basis in all 17 pediatric patients with non-Pneumocystis lymphoid interstitial pneumonitis. Clinical resolution of Pneumocystis carinii pneumonitis was associated with a decline in lactate dehydrogenase activity. Periodic intravenous gammaglobulin was more effective than conventional therapy (trimethoprim/sulfamethoxazole and pentamidine) in achieving clinical and immunologic improvement and reduction of serum lactate dehydrogenase activity in patients with Pneumocystis carinii pneumonitis. Intravenous gammaglobulin was also more effective in patients with AIDS and non-Pneumocystis carinii pneumonitis and lymphoid interstitial pneumonitis. Lactate dehydrogenase activity declined to normal, at least temporarily, in nine of 12 intravenous gammaglobulin-treated patients as compared with only two of 12 untreated patients. Six adult patients with AIDS or AIDS-related complex and no interstitial pneumonitis exhibited normal lactate dehydrogenase levels. These findings suggest that serum lactate dehydrogenase activity in patients with AIDS or AIDS-related complex may be a useful indicator of pulmonary interstitial inflammation. As such, it may be utilized to predict disease course and monitor response to intravenous gammaglobulin treatment.

Genetic regulation of immunoglobulin synthesis: selection of two rats' lines with respectively a high or low IgM serum level

Two directional selections of rats for a high or a low IgM serum levels have been carried out. The criterium of selection was the individual merit of each rat in having a high or a low IgM level when they were 3 months old. All animals were kept together, in order to avoid external influence on the IgM synthesis. The founding population was a mixed nucleus of rats, obtained by breeding of 13 different strains of inbred or outbred rats for two generations. Two lines, one with a high IgM serum level and another with a low IgM serum level, have been separated. At generation 10, they differed from each other by a coefficient of approximately four. These IgM serum levels were not due to differences in IgM catabolism of the two lines since both lines had similar IgM half-lives. Analyses of the data obtained show that, for IgM synthesis, the coefficient of heritability varies between 0.30 to 0.40, and the number of 'independent loci' controlling IgM synthesis ranges from 11 to 14.

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

We report the results of immunologic studies in a family in which the father (III-5) and his two daughters (IV-7 and IV-8) had the hyper-IgM syndrome (IHIS). Repeated immunoglobulin levels done on III-5 showed a typical IHIS pattern: low IgG, traces of IgA, and high IgM. IV-7, who also had stage IIA Hodgkin's disease, had a similar pattern except after irradiation therapy to sites of disease, when IgM dropped to normal range while IgG and IgA remained low. IV-8, on the other hand, had normal IgG and IgA and moderately elevated IgM until age 18 months, when she gradually developed the IHIS pattern. All three patients had normal numbers of B cells (sIg) and of T cells, although IV-7 had increased suppression. Finally, all three patients shared the A3,B7 haplotype and none was blood type O. IHIS is not necessarily X linked, is not associated with blood type O, and appears to be heterogeneous even within the same family. Inheritance in this family is apparently autosomal dominant and the father may represent a new mutation.

Autoimmune blood dyscrasias in five patients with hypogammaglobulinemia: response of neutropenia to vincristine

Five patients with autoimmune blood dyscrasias and primary hypogammaglobulinemia are described. The autoimmune neutropenia in two patients rapidly responded to vincristine but was resistant to steroids. The three patients with autoimmune hemolytic anemia responded to steroids. Vincristine is therefore the drug of choice in patients with autoimmune neutropenia and hypogammaglobulinemia and is preferable to a trial of steroids in severely ill patients. Two of the patients had increased numbers of circulating T suppressor cells for in vitro immunoglobulin production. It is therefore unlikely that the autoimmunity in these patients is based on a lack of such suppressor cells.

Kinetics of delayed-type hypersensitivity (DTH) reactions and Ig levels in FCA-induced dysgammaglobulinemic B 12 chickens

Kinetic studies on delayed-type hypersensitivity (DTH) to Freund's complete adjuvant (FCA) have been done in spontaneous dysgammaglobulinemic chickens, which have drastically reduced serum IgG levels and highly elevated IgM and IgA levels - in comparison to chickens with normal immunoglobulin (Ig) levels. For a period of five weeks, serum Ig levels, leukocyte migration inhibition (LMIT), and wattle reaction were examined once a week. In normal chickens, FCA treatment resulted in stimulation of IgG, but did not affect IgM synthesis, whereas in spontaneous dysgammaglobulinemic chickens, FCA stimulated only IgM synthesis. Spontaneous dysgammaglobulinemic chickens could produce LMIT and wattle reactions as well as normal birds. Whereas in normal birds, both types of DTH reactions declined continuously about the third or fourth week, in immunodeficient chickens, further increments of LMIT and wattle reactions up to the fifth week persisted as evidenced by LMIT and wattle reactions even 15 weeks after sensitization. In contrast, only minimal signs of reactivity were seen in normal birds. Spontaneous dysgammaglobulinemic chickens, nearly unable to synthesize IgG even after FCA stimulation in vivo, lack suppressive mechanisms regulating the course of DTH reaction to FCA. The possible B-cell nature of the regulatory cell population is discussed.

Immunologic function of patients with chronic benign lymphadenopathy

Three children with chronic lymphoid hyperplasia and hypergamma-globulinemia are presented. They had normal numbers of circulating T-cells and normal in vitro lymphocyte responses to phytohemagglutinin and specific mitogens. The number of cells staining for surface immunoglobulins was decreased in two patients but increased in one patient with chronic lymphocytosis which is still present 5 years after his initial hospitalization. Lymphocytes without detectable markers ("Null cells") were increased in all three patients. Levels of antibody titers to common antigens were normal. Lymph node biopsies showed nonspecific hyperplasia of the B-cell areas. The combination of normal immune responses with lymphoid hyperplasia and with a chronic lymphocytosis in one of the children suggests that this syndrome may be due to a defect in the regulation rather than the initiation of immune responses.

Influence of exchange transfusion on the development of serum immunoglobulins

Thirteen neonates with severe jaundice of various etiologies were followed after exchange transfusion for a period of one year. Blood levels of IgG, IgA, and IgM were measured before and after exchange transfusion, four and ten days later, and at 1, 3, 6, 9, and 12 months of age. Normal and jaundiced but not exchange-transfused infants, matched for age, were used as control subjects. It was concluded that exchange transfusion suppresses the production of autologous IgG and IgA, whereas it provokes IgM synthesis.

Vitiligo and dysgammaglobulinemia. A case report and family study

This report concerns an 8 year old female with vitiligo and dysgammaglobulinemia characterized by absent IgA, very low IgG, and normal IgM. The t-cell immune system was intact but other family members had low levels or absence of IgA. The possible relationship of dysgammaglobulinemia and vitiligo is discussed along with the classification and inheritance of the immune cell defects.

Thymic alymphoplasia, monoclonal gammopathy, and Pneumocystis carinii pneumonia in an infant

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