Severe combined immunodeficiency with natural killer-cell predominance: abrogation of graft-versus-host disease and immunologic reconstitution with HLA-identical bone marrow cells

Transplantation immunology: solid organ and bone marrow

Development of the field of organ and tissue transplantation has accelerated remarkably since the human MHC was discovered in 1967. Matching of donor and recipient for MHC antigens has been shown to have a significant positive effect on graft acceptance. The roles of the different components of the immune system involved in the tolerance or rejection of grafts and in graft-versus-host disease have been clarified. These components include antibodies, antigen-presenting cells, helper and cytotoxic T-cell subsets, immune cell-surface molecules, signaling mechanisms, and cytokines. The development of pharmacologic and biological agents that interfere with the alloimmune response has had a crucial role in the success of organ transplantation. Combinations of these agents work synergistically, leading to lower doses of immunosuppressive drugs and reduced toxicity. Reports of significant numbers of successful solid-organ transplantations include those of the kidneys, liver, heart, and lung. The use of bone marrow transplantation for hematologic diseases, particularly hematologic malignancies and primary immunodeficiencies, has become the treatment of choice in many of these conditions. Other sources of hematopoietic stem cells are also being used, and diverse immunosuppressive drug regimens of reduced intensity are being proposed to circumvent the mortality associated with the toxicity of these drugs. Gene therapy to correct inherited diseases by means of infusion of gene-modified autologous hematopoietic stem cells has shown efficacy in 2 forms of severe combined immunodeficiency, providing an alternative to allogeneic tissue transplantation.

A non-peptide substance P antagonist (CP-96,345) inhibits morphine-induced NF-kappa B promoter activation in human NT2-N neurons

Opioids and the neuropeptide substance P (SP) modulate the expression of inflammatory cytokines and chemokines, which are under the control of nuclear factor kappaB (NF-kappaB). We investigated whether the neurokinin-1 receptor (SP receptor) pathway is biologically involved in morphine-mediated modulation of NF-kappaB promoter activation in a human neuronal cell line (NT2-N) that expresses both the mu-opioid receptor (MOR) and the SP receptor. Morphine significantly enhanced NF-kappaB promoter-directed luciferase activity in NT2-N neurons. DAMGO, a selective mu-opioid receptor agonist, also induced NF-kappaB promoter activation. The induced activation of NF-kappaB promoter by morphine or DAMGO was abolished not only by naltrexone (a opioid receptor antagonist) and CTAP (a selective, competitive mu-opioid receptor antagonist), but also by CP-96,345, a non-peptide SP receptor antagonist. Investigation of the mechanism responsible for morphine-induced activation of NF-kappaB promoter in NT2-N neurons demonstrated that morphine activates the SP promoter and induces SP expression in these cells. We also observed that SP activated NF-kappaB promoter and that CP-96,345 downregulated the expression of endogenous SP. Furthermore, dual immunofluorescent labeling revealed that there is co-expression of NK-1R and MOR in the processes of NT-2N neurons. These results suggest that morphine, by activating MOR, engages a positive feedback loop between NK-1R and SP. Activation of NK-1R could then impact NF-kappaB expression and therefore may be an important participant in the effect of morphine on immune responses in the central nervous system.

27. Transplantation immunology: organ and bone marrow

The discovery of the human MHC in 1967 launched the field of organ and tissue transplantation. More than 800,000 such transplants have been performed during this time. Although matching of donor and recipient for MHC antigens was shown to be of great importance and continues to be so, the development of pharmacologic agents and antilymphocyte antibodies that interfere with the process of graft rejection has had a crucial role in the success of organ transplantation during the past 2 decades. Enormous progress has been made in understanding the immunologic mechanisms of graft rejection and of graft-versus-host disease. The roles of antibodies, antigen-presenting cells, helper and cytotoxic T cells, immune cell surface molecules, and signaling mechanisms and the cytokines they release have been clarified. This understanding is leading to the development of newer immunosuppressive agents targeting various components of the rejection process. Combinations of these agents work synergistically, leading to lower doses and reduced toxicity. Similarly, the development of effective T-cell depletion techniques has been of great importance for bone marrow transplantation when an HLA-identical sibling is not available. The major obstacle to the performance of solid organ transplantation currently is the shortage of donor organs.

Human severe combined immunodeficiency: genetic, phenotypic, and functional diversity in one hundred eight infants

OBJECTIVE

To determine the relative frequencies of the different genetic forms of severe combined immunodeficiency (SCID) and whether there are distinctive characteristics of the particular genotypes.

STUDY DESIGN

The demographic, genetic, and immunologic features of 108 infants with SCID who were treated consecutively at Duke University Medical Center were analyzed.

RESULTS

Eighty-nine subjects were boys and 19 were girls; there were 84 white infants, 16 black infants, and 8 Hispanic infants. Forty-nine had X-linked SCID with mutations of common cytokine receptor gamma chain (gamma c), 16 had adenosine deaminase (ADA) deficiency, 8 had Janus kinase 3 (Jak3) deficiency, 21 had unknown autosomal recessive mutations, 1 had reticular dysgenesis, 1 had cartilage hair hypoplasia, and 12 (all boys) had SCID of undetermined type. Deficiency of ADA caused the most profound lymphopenia; gamma c or Jak3 deficiency resulted in the most B cells and fewest natural killer (NK) cells; NK cells and function were highest in autosomal recessive and unknown types of SCID.

CONCLUSIONS

Different SCID genotypes are associated with distinctive lymphocyte characteristics. The presence of NK function in ADA-deficient, autosomal recessive, and unknown type SCIDs, and low NK function in a majority of gamma c and Jak3 SCIDs indicates that some molecular lesions affect T, B, and NK cells (gamma c and Jak3), others primarily T cells (ADA deficiency), and others just T and B cells.

Food allergy in human immunodeficiency virus (HIV) infection

BACKGROUND

Gastrointestinal complaints and pruritic skin conditions are common in patients infected with human immunodeficiency virus (HIV). Because atopic disorders such as drug allergy, asthma, and allergic rhinitis are apparently increased, we hypothesized that food allergy may also be more common in patients with HIV.

OBJECTIVE

The purpose of this study was to estimate the prevalence of food allergy in patients infected with HIV.

METHODS

Consecutive patients visiting our outpatient adult HIV clinic were screened for possible food allergy by use of a questionnaire. One hundred seventy-six patients responded. Sixty-two of these patients reported symptoms compatible with a possible food allergy. Followup of the 62 subjects was possible in 40. Thirty-one patients were skin tested for foods thought to produce reactions.

RESULTS

Three patients (1.7%) described previous anaphylactic responses to specific foods and were therefore not skin tested or challenged orally. Six patients (3.4%) described very strong histories of food allergy but either refused or were too ill for testing. Twenty-nine of the 31 patients had negative skin tests. One of the two patients with a positive skin test to a suspected food also had a positive double-blind, placebo-controlled food challenge (DBPCFC). There was no correlation between CD4 cell count and likelihood of food allergy. Based on a strong history alone, the maximal estimated prevalence of food allergy in this group was 5.7% (10 of 176). By using the more strict criterion of positive DBPCFC, the prevalence of food allergy in this patient population was 0.57% (1 of 176).

CONCLUSION

These results suggest that food allergy is an uncommon disease in patients with HIV infection with an estimated prevalence similar to that found in the general adult population. Our data do not suggest an obvious direct correlation between HIV infection and food allergy.

Breakthroughs in the understanding and therapy of primary immunodeficiency

In the 40 years since Ogden Bruton discovered agammaglobulinemia, more than 50 additional immunodeficiency syndromes have been described. Until recently, there was little insight into the fundamental problems underlying a majority of these conditions. Recently, however, the molecular bases of three X-linked immunodeficiency disorders have been reported. These include X-linked immunodeficiency with hyper IgM, X-linked agammaglobulinemia, and X-linked severe combined immunodeficiency. These remarkable accomplishments have been made possible through a combination of new knowledge of molecular signaling mechanisms between and within cells of the immune system and greatly improved approaches to disease loci mapping within the human genome. Improvements in the therapy of immunodeficiency diseases have been impressive, and the development of generally safe and effective intravenous immunoglobulin preparations and T cell depletion techniques that permit the use of non-HLA-identical bone marrow donors have been the most important advances over the past 14 years. The identification and cloning of the genes for several of the primary immunodeficiency diseases have obvious implications for potential future somatic cell gene therapy for these patients. The rapidity of these advances suggests that soon there will be many more to come.

Donor type natural killer cells after haploidentical T cell-depleted bone marrow stem cell transplantation in a patient with adenosine deaminase-deficient severe combined immunodeficiency

T cell-depleted haploidentical (parental) bone marrow stem cell transplants are given to most infants with the syndrome of severe combined immunodeficiency (SCID) because they have no available HLA-identical sibling potential donors. Since they usually do not undergo cytoreduction prior to transplantation, these children later demonstrate mixed hematopoietic chimerism. Most often, T cells (but usually not B lymphocytes, macrophages, or other hematopoietic cells) can be shown to be of donor type. The origin of natural killer (NK) cells in such chimeras has not been reported. Two lymphocyte lines derived from the CD16+ fraction of an adenosine deaminase (ADA)-deficient male SCID's blood mononuclear cells (MNC) 13 months following maternal marrow stem cell transplantation demonstrated typical phenotypic and functional characteristics of NK cells after expansion. Karyotyping showed both lines to be XX. Thus, NK cell engraftment can occur in SCID infants who have not been conditioned, even when significant NK cell function is present before transplantation.

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)

Lymphokine-activated killer cells in primary immunodeficiencies and acquired immunodeficiency syndrome

Cytotoxic mechanisms (e.g., natural killer (NK) lysis, antibody-dependent cellular cytotoxicity, and cytotoxic T lymphocyte lysis) play an important role in host defense against various infections and neoplasms. Lymphokine-activated killer (LAK) cytotoxicity, induced in vitro by incubating mononuclear cells with interleukin 2 (IL-2) for 2-5 days, may also represent an important component of the body's cytotoxic repertoire. In 10 patients with congenital cellular immunodeficiencies, including 5 with severe combined immunodeficiency, the mean LAK activity in a 3-hr chromium release assay against Raji target cells was 44 +/- 8.1%, which is equivalent to that observed in normal adults and neonates. In only one case, a patient with reticular dysgenesis, was there absent LAK cell generation. Haploidentical T cell-depleted bone marrow transplantation (BMT) restored LAK activity in this patient. LAK activity was first observed in this patient and two others 3-6 weeks following BMT, prior to other evidence of immunologic engraftment such as lymphocyte proliferation to mitogens, NK activity, or interferon-gamma production. One patient with adenosine deaminase deficiency showed normal levels of LAK activity despite absent NK activity. Three patients with chronic granulomatous disease also had normal LAK activity (57 +/- 14% specific lysis). In 9 patients with acquired immunodeficiency syndrome (AIDS), IL-2 activation resulted in a mean cytotoxic activity of 56 +/- 8.7% toward Raji targets. In addition, 9 patients with pre-AIDS complex also showed normal levels of cytotoxicity (37 +/- 3.3% toward Raji targets), equivalent to that of 8 normal controls, including two healthy homosexual males (mean lysis 38 +/- 3.9%). These results indicate that LAK cells appear early in immunologic ontogeny. Further, the mechanism of lysis is not oxygen dependent since LAK activity was present in the 3 patients with chronic granulomatous disease. The ability to generate LAK in a wide spectrum of immunodeficiencies may indicate that IL-2 could be used in therapy of such disorders.

Severe T lymphocyte immunodeficiency associated with hypogammaglobulinemia: defective lymphokine secretion but enhanced autologous mixed lymphocyte reaction

The multiparameter immunologic study of T cells of a patient with acquired hypogammaglobulinemia was investigated, since he had a normal B-cell number and function. His peripheral blood lymphocytes were found to contain predominant CD4+ CD45R+ T cells with a clear deficiency of CD4+ CDw29+ as well as CD8+ T cells. His T cells proliferated in response to phytohemagglutinin (PHA) and pokeweed mitogen (PWM), but no immunoglobulin was secreted in PWM-induced patient's T-cell and normal B-cell differentiations. His T cells were also found to possess concanavalin A (Con A)-induced suppressor function when cocultured with normal T cells, as well as IgG-, IgA-, and IgM-specific suppressor function on PWM-induced normal T- and B-cell differentiations. The patient's T cells were found to secrete elevated amounts of interleukin-2 but failed to secrete two important B-cell stimulating factors, B-cell growth factor and B-cell differentiation factor, in response to PHA. An investigation of immunoregulatory T-cell function in the autologous mixed lymphocyte reaction (AMLR) and allogeneic mixed lymphocyte reaction (MLR) indicated that the patient's T cells produced an enhanced AMLR but were deficient in MLR. These results suggest that the abnormalities we have identified in this patient with hypogammaglobulinemia reflect an intrinsic defect of T cells in the humoral immune response to produce three major immunoglobulins.

Biology of natural killer cells

Studies of cytotoxicity by human lymphocytes revealed not only that both allogeneic and syngeneic tumor cells were lysed in a non-MHC-restricted fashion, but also that lymphocytes from normal donors were often cytotoxic. Lymphocytes from any healthy donor, as well as peripheral blood and spleen lymphocytes from several experimental animals, in the absence of known or deliberate sensitization, were found to be spontaneously cytotoxic in vitro for some normal fresh cells, most cultured cell lines, immature hematopoietic cells, and tumor cells. This type of nonadaptive, non-MHC-restricted cellmediated cytotoxicity was defined as “natural” cytotoxicity, and the effector cells mediating natural cytotoxicity were functionally defined as natural killer (NK) cells. The existence of NK cells has prompted a reinterpretation of both the studies of specific cytotoxicity against spontaneous human tumors and the theory of immune surveillance, at least in its most restrictive interpretation. Unlike cytotoxic T cells, NK cells cannot be demonstrated to have clonally distributed specificity, restriction for MHC products at the target cell surface, or immunological memory. NK cells cannot yet be formally assigned to a single lineage based on the definitive identification of a stem cell, a distinct anatomical location of maturation, or unique genotypic rearrangements.

Natural killer (NK)-cell activity in sorted subsets of peripheral blood mononuclear cells from patients with severe combined immunodeficiency

Natural killer-cell activity for K562 target cells was measured in 13 patients with severe combined immunodeficiency before bone marrow transplantation. Both unseparated peripheral blood mononuclear cells and sorted cell subsets (B73.1 positive, B73.1 negative, OKT3 positive, OKT3 negative) were tested. Heterogeneity of natural killer-cell activity was observed, the level of which did not correlate with the usual subdivision of severe combined immunodeficiency, as defined by a scientific group on immunodeficiency for the WHO. In those patients in whom natural killer-cell activity was observed in unseparated cells, testing of this function in sorted cell subsets revealed some unexpected findings. In three of four patients, B73.1-negative cells showed remarkable natural killer-cell activity. In addition, in one of these patients, no activity was observed in the B73.1-positive cells.

Appearance of multiple benign paraproteins during early engraftment of soy lectin T cell-depleted haploidentical bone marrow cells in severe combined immunodeficiency

Recent advances in the prevention of graft-versus-host disease through postthymic T-cell depletion have allowed the use of haploidentical bone marrow cells for immunologic reconstitution of severe combined immunodeficiency disease. We report a male infant with severe combined immunodeficiency (with normal adenosine deaminase) who developed two IgG kappa and one IgA lambda paraproteins 7 weeks following the administration of 1.4 X 10(9) maternal bone marrow cells depleted of postthymic T cells by soy lectin agglutination and sheep erythrocyte rosetting. Serum IgG rose from 128 to 820 mg/dl, and IgA from 0 to 2400 mg/dl, peaking at 10 weeks postgrafting. By 14 weeks posttransplantation T-cell numbers and function had risen to normal (all dividing T cells had the donor karyotype) and paraprotein concentrations began to decline. These observations strongly suggest that the later-appearing T cells regulated the B-cell clones from which the paraproteins were derived. Failure of such function to appear could account for the increased incidence of B-cell lymphomas in severe combined immunodeficiency.