PNEUMOCYSTIS CARINII PNEUMONIA AND CONGENITAL HYPOGAMMAGLOBULINAEMIA

Cellular and molecular characterisation of the hyper immunoglobulin M syndrome associated with congenital rubella infection

INTRODUCTION

The hyper-immunoglobulin M syndrome (HIM) is a rare group of immune deficiency disorders characterised by normal or increased serum IgM with normal or reduced IgG, IgA and IgE.

MATERIALS AND METHODS

We have undertaken detailed cellular and molecular studies in a 53-year-old man with HIM as a result of congenital rubella.

RESULTS

No mutations were detected in the CD40 ligand, activation-induced cytidine deaminase and uracil DNA glycosylase. His T-cell responses to lectins and antigens were normal. Flow cytometry confirmed the presence of CD40 ligand on activated T cells. Most CD40-dependent functions that were tested, including B-cell proliferation, isotype switching and production of memory B cells, were normal. CD40/IL4 dependent rescue from anti-IgM-induced apoptosis was impaired.

CONCLUSION

The detection of cell-surface IgG but lack of serum IgG indicated that he may have an antibody secretion defect.

Cutaneous sarcoid-like granulomas in a patient with X-linked hyper-IgM syndrome

We describe a 5-year-old boy with red-pink, firm, nodular lesions, with central resolution and prominent borders, localized to the face, backs of the hands, extensor surfaces of the arms and legs, and the buttocks. He also had recurrent bacterial respiratory infections. Quantitative immunoglobulin levels revealed hypogammaglobulinemia and increased IgM levels. Histopathologic examination of a nodular lesion revealed perivascular and periadnexal granulomas composed of epithelioid cells surrounded by a mantle of lymphocytes; three cultures for fungi and acid-fast bacilli were negative. Clinical, histopathologic, and immunologic studies supported a diagnosis of hyper-IgM (HIM) syndrome. The boy was treated with pulsed-dose antibiotics and intravenous gamma globulin every 3 weeks, with improvement of clinical symptoms. Skin lesions were treated with topical corticosteroids, with immediate recurrence upon cessation of therapy. To the best of our knowledge, this is the first description of cutaneous granulomas in HIM syndrome.

Mucocutaneous manifestations of the hyper-IgM immunodeficiency syndrome

BACKGROUND

The recurrent pyogenic infections of patients with hyper-IgM syndrome are controlled by intravenous gamma globulin administration, but patients may suffer from early-onset oral ulcerations and warts.

OBJECTIVE

We have characterized the mucocutaneous manifestations associated with this condition to allow physicians to more readily identify it.

METHODS

Three male patients with the mucocutaneous manifestations of the hyper-IgM syndrome are described. In one, histopathologic examination of the oral mucosal lesion was performed.

RESULTS

Recurrent large, painful oral ulcerations can occur that are not necessarily associated with neutropenia nor do they respond to granulocyte colony-stimulating factor administration. Histopathologic examination of an ulcer showed a heavy infiltrate of mixed inflammatory cells. Warts tend to be widespread and resistant to traditional therapy.

CONCLUSION

Physicians should consider this uncommon condition when examining a male patient with severe oral ulcers or recalcitrant widespread warts.

Hypogammaglobulinaemia associated with normal or increased IgM (the hyper IgM syndrome): a case series review

The clinical and immunological aspects of 16 children with the syndrome of hypogammaglobulinaemia associated with normal or increased IgM (the hyper IgM syndrome) and their responses to treatment are reviewed. Increased concentrations of IgM, neutropenia, and recurrent infections could usually be controlled by antimicrobial and intravenous immunoglobulin treatment. Together with the bacterial infections characteristic of hypogammaglobulinaemia, these patients often developed opportunistic infections, including Pneumocystis carinii pneumonia, often presenting in the first year of life. The occurrence of sclerosing cholangitis, neurological complications, and neutropenia may be a result of an underlying cell mediated immune deficiency, autoimmunity, or infection. Despite a high incidence of opportunistic infections, immunological investigations did not show any abnormality of T cell function. These findings are discussed in the light of the recent demonstration that the lack of expression of a T lymphocyte activation antigen is the molecular basis of the X linked form of the disorder.

Pentamidine isethionate. A review of its antiprotozoal activity, pharmacokinetic properties and therapeutic use in Pneumocystis carinii pneumonia

Pentamidine isethionate, an aromatic diamidine, is an antiprotozoal agent proven to decrease mortality from Pneumocystis carinii pneumonia in debilitated infants and immunodeficient adults and children. Like the combination antimicrobial agent co-trimoxazole, pentamidine has been shown in retrospective studies to resolve episodes of pneumonia in approximately 41 to 87% of patients, including those with the acquired immunodeficiency syndrome (AIDS), when used alone or as sequential therapy. Although about 45% of all patients given pentamidine experience side effects--which may include nephrotoxicity, hypotension, hypoglycaemia or local reactions--in patients with AIDS the incidence of side effects is less with pentamidine than with co-trimoxazole. Thus, despite its profile of potentially severe side effects, pentamidine isethionate is a proven antimicrobial agent with a distinct place in the treatment of Pneumocystis carinii pneumonia in the growing population of AIDS patients.

Treatment of pneumocystis carinii pneumonia in children

Eighteen children with pneumocystis carinii pneumonia diagnosed over a period of 16 years at a children's hospital are reviewed. All had an underlying disease, either congenital immunodeficiency or a malignancy. 15 patients were treated, 10 with pentamidine isethionate alone, 2 with both pentamidine and co-trimoxazole, and 3 with co-trimoxazole alone. 12 of the treated group recovered and the 3 untreated patients died. The 3 deaths after treatment occurred in children receiving pentamidine alone, and in whom secondary factors contributed. The side effects of treatment with pentamidine were high, and included local reactions, hypoglycaemia, and uraemia. However, our results confirm that pentamidine is an effective treatment for pneumocystis carinii pneumonia in childhood. Co-trimoxazole may be an effective and relatively nontoxic alternative treatment.

Pneumocystis carinii pneumonia. Diagnosis by lung biopsy

Pneumocystis carinii pneumonia was suspected in 52 patients who underwent lung biopsy for diagnosis of diffuse pulmonary infiltrates. All but five of the procedures were limited thoracotomies. There were no instances of significant postoperative hemorrage or of pneumothorax compromising ventilation. The diagnosis of P. carinii pneumonia was made rapidly from imprints of the lung stained by the Gram-Weigert method in the 18 patients who had P. carinii pneumonia. Over-all, the rate of recovery from Pneumocystis pneumonia after treatment with pentamidine isethionate was 41 percent. However, among patients with no other pulmonary lesion (group A), the survival rate was 58 per cent; none of the patients with coexisting pulmonary disease (group B) recovered. The pulmonary infiltrates in the other 32 patients represented a variety of processes, of which 5 were fungal infections and 5 were due to lymphoma. Fifteen patients had an organizing interstitial and intraalveolar pneumonia of undertermined origin.

Chronic primary pneumocystis carinii pneumonia

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Immunoglobulin levels in infantile pneumocystosis

Two hundred and twelve determinations of IgA, IgG, and IgM were performed in 50 infants during an epidemic of interstitial plasma cell pneumonia. Criteria for diagnosis are discussed. The immunoglobulin levels in pneumocystic, non-pneumocystic, and normal American infants are compared. An analysis of the findings in individual cases reveals a time-related immunoglobulin response, which helps to elucidate the pathogenicity of the disease.

Pneumocystis carinii pneumonia and reticuloses

Three cases of Pneumocystis carinii pneumonia occurring in the course of diseases of the lymphoreticular system are described. One case was diagnosed in life and unsuccessfully treated with pentamidine isethionate. Incidence of the pneumonia is associated with a depressed immune response and may be more frequent than is usually realized in patients with reticuloses who are receiving corticosteroid and cytotoxic drugs.

The parasitic diseases of childhood with emphasis on the newer diagnostic methods

The ubiquitousness of certain protozoan and helminth parasites and the increasing geographic mobility of individuals point up the need for an awareness of the role of parasitic infections in pediatric prac tice.

This paper (a) surveys the advances in diagnosis and clinical understanding of those parasitic diseases of children which are the most common in Northern tem perate climates—amebiasis, giardiasis, pin worm infestation, visceral larva migrans, toxoplasmosis, pneumocystosis—and (b) surveys the usefulness, specificity, and limitations of the newer serologic tests in the diagnosis and management of these diseases. Therapy is not stressed.

Because of the recent recognition of the significance of Pneumocystis carinii infection, this is considered in somewhat greater detail than its rarity might other wise warrant.

Inverse effect on the serum levels of gamma-G- and gamma-M-globulins after prednisone treatment of lupoid hepatitis

Immunoglobulin levels were determined in two cases of liver disease with hypergammaglobulinaemia. Prednisone treatment resulted in dramatic reduction of γG-levels, whereas the γM-levels increased significantly. Possible explanations of these findings are discussed.

Pneumocystis carinii pneumonia: an unsuccessfully treated case

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