Primary acquired agammaglobulinemia, with a family history of collagen disease and hematologic disorders

Primary B cell immunodeficiencies: comparisons and contrasts

Sophisticated genetic tools have made possible the identification of the genes responsible for most well-described immunodeficiencies in the past 15 years. Mutations in Btk, components of the pre-B cell and B cell receptor (lambda5, Igalpha, Igbeta), or the scaffold protein BLNK account for approximately 90% of patients with defects in early B cell development. Hyper-IgM syndromes result from mutations in CD40 ligand, CD40, AID, or UNG in 70-80% of affected patients. Rare defects in ICOS or CD19 can result in a clinical picture that is consistent with common variable immunodeficiency, and as many as 10% of patients with this disorder have heterozygous amino acid substitutions in TACI. For all these disorders, there is considerable clinical heterogeneity in patients with the same mutation. Identifying the genetic and environmental factors that influence the clinical phenotype may enhance patient care and our understanding of normal B cell development.

Acquired immunodeficiency, malabsorption and lymphoma

A 66 year old female with a long history of recurrent pulmonary infection presented with a full-blown malabsorption syndrome. She was found to be suffering from acquired immunodeficiency. She later developed non-Hodgkin's lymphoma of the cervical lymph nodes. The possible relationships between immunodeficiency, malabsorption and lymphoma are discussed.

Childhood common variable immunodeficiency with autoimmune disease

Clinical and laboratory findings in eight patients with childhood common variable immunodeficiency and autoimmune disease are described. Six of the eight patients had initial signs of the disease, persistent secretory diarrhea, recurrent upper respiratory tract infections, or both, in the first year of life. Autoimmune manifestations included idiopathic thrombocytopenia (4/8), hemolytic anemia (3/8), secretory diarrhea (4/8), arthritis (2/8), chronic active hepatitis (2/8), parotitis (2/8), and Guillain-Barré syndrome (2/8). In addition to the expected sinusitis, otitis, and pneumonia caused by encapsulated bacteria, these patients also had severe infections with viruses of the herpes group. Most of these patients had lymphadenopathy, splenomegaly, growth failure, and failure to develop secondary sexual characteristics. Laboratory studies demonstrated a significant increase in the ratio of T cells expressing the T helper phenotype (OKT4) to T cells expressing the T suppressor-cytotoxic phenotype (OKT8) (T4/T8). This increase could be attributed to a decrease in the absolute number of T8 cells. Additional findings included fluctuating levels of serum immunoglobulins and markedly diminished in vitro antibody production by B cells. The clinical course was relapsing and remitting, and dominated by the autoimmune manifestations of the disease. This group of patients constitutes a distinct subset of children with hypogammaglobulinemia, a subset with a complex, multisystemic disorder associated with significant morbidity and mortality.

Cancer and autoimmune disease in families with common variable immune deficiency

Twenty-five families including 34 individuals with common variable immune deficiency (CVID), with at least one affected female in each family, were studied. The distribution of cases within families was compatible with autosomal recessive inheritance, making it plausible to test hypotheses about the disease risk of heterozygote carriers of putative CVID genes by comparing the frequency of autoimmune disorders and cancer in 1033 adult blood relatives to that in 566 spouse controls. For cancer, observed numbers of cases or deaths were also compared to expected numbers derived from population rates. No single family had an unusual clustering of autoimmune conditions, and, overall, autoimmune disease was not found more frequently in blood relatives than in spouse controls. Blood relatives did have a modest, although not significant, excess of rheumatic heart disease. For cancer analyses, comparisons with general population rates indicated no heterozygote predisposition, while direct comparisons of blood relatives to spouse controls revealed a significantly elevated cancer rate in females (rate ratio = 2.3, P less than 0.003). The estimated relative risk of cancer for female CVID heterozygotes was most elevated in the 45-69-year-old age group. It is arguable whether comparisons with population or spouse controls are the most appropriate for evaluating the cancer risk of CVID heterozygotes. The hypothesis that the CVID gene predisposes heterozygous female carriers to cancer may be evaluated more easily in the future when the genetic basis for CVID is better understood.

Hypogammaglobulinaemia during pregnancy in identical twin sisters

The clinical histories and reaction to pregnancy is described in identical twin sisters with acquired hypogammaglobulinemia. Additional evidence for the genetic basis of this disorder is advanced. A possible association with myasthenia gravis is noted and the occurrence of fetal growth retardation is described. Replacement therapy should be given when the diagnosis is made, and high doses might be useful during pregnancy especially if fetal growth retardation seems to be present.

Immunoblastic lymphoma: an immunologic study

An immunologic study of a 59-year-old man with immunoblastic lymphoma is presented. Shortly after his hospital admission, an uncompensated hemolytic process developed, caused by cold agglutinins. These antibodies had anti-i specificity, were of low titer at cold temperature, but demonstrated a high thermal amplitude. An apparent paraprotein was found by further immunochemical analysis to be polyclonal. The majority of cells in the peripheral blood (over 2000/cu nm), lymph node, and bone marrow that contained cytoplasmic IgG or IgM were plasma cells, although a small number of cells resembled lymphoblasts. Their staining with anti-lambda and anti-kappa chain reagents confirmed the polyclonality of the immunoglobins. Some plasma cells displayed the concomitant presence of both IgM and IgG immunoglobulins. Free immunoglobin was also demonstrated intercellularly in the lymph node section. The patient's acute hemolysis was controlled by plasmapheresis and eventually by combination chemotherapy. After chemotherapy, the clinical improvement was rapid, immunoglobulin levels returned to normal, and the patient remains asymptomatic 40 months after completing six courses of combination chemotherapy. This report provides evidence for polyclonal proliferation of B-lymphocytes in immunoblastic lymphoma.

Agammaglobulinemia: The Fundamental Defect

Addition of phytohemagglutinin and of streptolysin S to in vitro cultures of leukocytes of normal and agammaglobulinemic subjects resulted in mitosis of lymphocytes and their differentiation to plasma cells. In contrast, specific antigens induced mitosis and differentiation of lymphocytes of normal but not of agammaglobulinemic donors. The data suggest that the absence of plasma cells in agammaglobulinemia is not in itself responsible for failure of antibody production, but is rather the morphologic concomitant of the primary defect (failure of antibody production on exposure to antigenic stimulus).