Dysgammaglobulinemia Associated With Glu349del, a Hypomorphic XIAP Mutation

BACKGROUND

X-linked lymphoproliferative syndrome type 2 is a rare hereditary immunodeficiency caused by mutations in the XIAP gene. This immunodeficiency frequently results in hemophagocytic lymphohistiocytosis, although hypogammaglobulinemia and dysgammaglobulinemia are also common.

OBJECTIVE

We identified 17 patients from 12 Japanese families with mutations in XIAP. The Glu349del mutation was observed in 3 patients, each from a different family. Interestingly, these patients exhibited dysgammaglobulinemia but not hemophagocytic lymphohistiocytosis. We conducted an immunological study of patients carrying Glu349del and other mutations to elucidate the pathogenic mechanisms of dysgammaglobulinemia in patients with mutations in the XIAP gene.

PATIENTS AND METHODS

We performed an immunological study of 2 patients carrying the Glu349del mutation and 8 patients with other mutations.

RESULTS

Flow cytometry showed that the percentage of memory B cells in patients with a mutation in XIAP was lower than that observed in the healthy controls. The patients with the Glu349del mutation had a lower percentage of memory B cells than those with other mutations. Ig production was reduced in patients with the Glu349del mutation. Increased susceptibility to apoptosis was observed in the patients with other mutations. Susceptibility to apoptosis was normal in patients with Glu349del. Microarray analysis indicated that expression of Ig-related genes was reduced in patients with the Glu349del mutation and that the pattern was different from that observed in the healthy controls or patients with other mutations in XIAP.

CONCLUSIONS

Patients carrying the Glu349del mutation in the XIAP gene may have a clinically and immunologically distinct phenotype from patients with other XIAP mutations. The Glu349del mutation may be associated with dysgammaglobulinemia.

Selective antibody deficiency and its relation to the IgG2 and IgG3 subclass titers in recurrent respiratory infections

BACKGROUND

Selective antibody deficiency with normal immunoglobulins (SADNI) may be identified as part of distinct primary or secondary immunodeficiency disorders. The clinical manifestations include recurrent, often severe or prolonged, upper or lower respiratory tract infections.

OBJECTIVES

To evaluate SADNI in patients with recurrent sinopulmonary infections and its relation to IgG subclass deficiencies.

METHODS

In a case-control study, anti-pneumococcal antibody titer and IgG2, IgG3 levels before injection of pneumococcal vaccine and anti-pneumococcal antibody titer at least 4 weeks after vaccination were measured in 46 patients and 54 controls. The results were compared using student's t-test.

RESULTS

There was a significant correlation between age and anti-pneumococcal antibody titers before and after vaccination in patients. No significant relation was found between pre and post vaccination pneumococcal antibody titer and IgG2 and IgG3 in cases and controls (p>0.05). The mean of anti-pneumococcal antibody before and after vaccination were significantly different in cases and controls and were higher in control group (p=0.01, p=0.001, respectively). Anti-pneumococcal antibody titers in 97.8% of cases and 100% of controls group were normal (>3.4 µg/ml). 34.8% of cases and 9.1% of controls had low titers of anti-pneumococcal antibody (<20 µg/ml) while 18.7% of cases and no controls failed to respond to vaccine.

CONCLUSION

Evaluation of anti-pneumococcal antibody titer in patients with recurrent, chronic and severe respiratory infections with normal immunoglobulin levels seems to be necessary as early diagnosis. Treatment of such cases could prevent later sequelae such as mastoiditis and bronchiecstasia.

[Primary selective IgM deficiency--forgotten primary immunodeficiency?]

Immunoglobulin M is a pentamer found in the intravascular compartment and on the surface of B lymphocytes. It is the antibody isotype produced initially in the immune response, and the first immunoglobulin class to be synthesized by a fetus or newborn. IgM antibodies do not cross the placenta. Decreased levels of IgM have been associated with autoimmune disease, several primary immunodeficiency but exist also as selected primary immunodeficiency.

Benign monoclonal gammapathy

The natural history of benign monoclonal gammapathy (BMG) has been followed by repeated studies of patients with M components through periods up to two decades. The disappearance of an M component is quite exceptional--in this material only once. Populations with increase in IgG, IgA and IgM have been studied separately. Slow, but steady, increase through many years may be found without development of myeloma (MM). Rapid transition from a steady state of the M component to progression is rare and usually, but not always, indicates the development of clearcut myeloma. Intermediate patterns are not uncommon and make it very difficult in rare individual cases to draw a sharp line between myeloma that should be treated and the benign state that should only be observed. The cause of pain may be difficult to judge. Osteolytic foci in the skull are usually diagnostic for MM, but vertebral fracture may also occur in osteopenia. It is evident that a period of at least three years of close observation without treatment should be the routine. "Prophylactic" treatment of BMG with cytostatic drugs should never be attempted.

Subcutaneous immunoglobulin replacement therapy for primary antibody deficiency: advancements into the 21st century

OBJECTIVES

To provide a review of the world literature and discuss the clinical role of subcutaneous immunoglobulin (SCIG) therapy for primary antibody deficiency.

DATA SOURCES

English-language publications on SCIG therapy were identified through MEDLINE and through the reference list of the initially identified publications.

STUDY SELECTION

Articles pertaining to SCIG for the treatment of immunodeficiency, particularly primary antibody deficiency, were selected.

RESULTS

SCIG therapy has been shown to be effective and safe for the treatment of primary immunodeficiency. The risk of systemic reactions during infusion is generally reported to be less than 1%. Many patients prefer SCIG over conventional intravenous immunoglobulin therapy because of increased convenience and independence associated with SCIG therapy. Publications show SCIG therapy to be advantageous in selected patient populations, such as children, pregnant women, and patients with poor intravenous access.

CONCLUSION

SCIG therapy has been widely used in some European countries for a number of years, but a Food and Drug Administration-approved product was only recently introduced into the United States in 2006. SCIG therapy offers unique advantages that are applicable to many patients receiving immunoglobulin therapy for primary immunodeficiency.

Virus antibody levels in IgA deficiency

IgA-deficient blood donors and their age- and sex-matched controls were compared for the occurrence of complement-fixing antibodies in serum against several viruses. The level in the IgA-deficient persons was slightly higher against several respiratory pathogens (adenoviruses, type B influenza virus, parainfluenza virus, and respiratory syncytial virus) that give rise to localized infections, and against coxsackie B group of viruses. No corresponding difference was observed in mumps, varicella, and cytomegalovirus infections, where viraemia is a characteristic feature, or in Mycoplasma pneumoniae infection.

Selective immunoglobulin M deficiency in an adult with Streptococcus pneumoniae sepsis and invasive aspergillosis

Primary selective immunoglobulin (Ig) M deficiency usually presents early in life with recurrent or severe infections caused by encapsulated and gram-negative organisms. Primary selective IgM deficiency in adults is rare and is usually associated with autoimmune diseases or malignant neoplasm. We performed an extensive immunological analysis of innate and adaptive immunity in an adult patient with possible primary selective IgM deficiency who presented with life-threatening Streptococcus pneumoniae septic shock and invasive Aspergillus fumigatus infection. The patient had no evidence of autoimmune disease or malignant neoplasm. Serum IgG, IgA, and IgE were normal; however, serum IgM levels and specific antibody titers against all 14 pneumococcal polysaccharide serotypes were consistently low. Complement CH50, C3, C4, and neutrophil phagocytosis and oxidative burst were normal. Toll-like receptor expression on monocytes was also normal. Therefore, adult patients with serious life-threatening and unusual infections should be investigated for possible selective primary IgM deficiency.

Fatal neonatal-onset mitochondrial respiratory chain disease with T cell immunodeficiency

We present the clinical and laboratory features of a boy with a new syndrome of mitochondrial depletion syndrome and T cell immunodeficiency. The child suffered from severe recurrent infectious diseases, anemia, and thrombocytopenia. Clinically, he presented with severe psychomotor retardation, axial hypotonia, and a disturbed pain perception leading to debilitating biting of the thumb, lower lip, and tongue. Brain imaging showed hypoplasia of corpus callosum and an impaired myelinization of the temporo-occipital region with consecutive supratentorial hydrocephalus. Histologic examination of a skeletal muscle biopsy was normal. Biochemical investigation showed combined deficiency of respiratory chain complexes II+III and IV. MtDNA depletion was found by real-time PCR. No pathogenic mutations were identified in the TK2, SUCLA2, DGUOK, and ECGF1 genes. A heterozygous missense mutation was found in POLG1. The pathogenic relevance of this mutation is unclear. Interestingly, a lack of CD8(+) T lymphocytes as well as NK cells was also observed. The percentage of CD45RO-expressing cells was decreased in activated CD8(+) T lymphocytes. Activation of T lymphocytes via IL-2 was diminished. The occurrence of the immunologic deficiency in our patient with mtDNA depletion is a rare finding, implying that cells of the immune system might also be affected by mitochondrial disease.

Defective B cell responses in the absence of SH2D1A

More than half of patients with X-linked lympho-proliferative disease, which is caused by a defect in the intracellular adapter protein SH2D1A, suffer from an extreme susceptibility to Epstein-Barr virus. One-third of these patients, however, develop dysgammaglobulenemia without an episode of severe mononucleosis. Here we show that in SH2D1A(-/-) mice, both primary and secondary responses of all Ig subclasses are severely impaired in response to specific antigens. Because germinal centers were absent in SH2D1A(-/-) mice upon primary immunization, and because SH2D1A was detectable in wt germinal center B cells, we examined whether SH2D1A(-/-) B cell functions were impaired. Using the adoptive cotransfer of B lymphocytes from hapten-primed SH2D1A(-/-) mice with CD4(+) T cells from primed wt mice into irradiated wt mice provided evidence that signal transduction events controlled by SH2D1A are essential for B cell activities resulting in antigen specific IgG production. Defects in naive SH2D1A(-/-) B cells became evident upon cotransfer with non-primed wt CD4(+) cells into Rag2(-/-) recipients. Thus, both defective T and B cells exist in the absence of SH2D1A, which may explain the progressive dysgammaglobulinemia in a subset of X-linked lympho-proliferative disease patients without involvement of Epstein-Barr virus.

[Gammaglobulin preparations used for treatment of primary humoral immunodeficiencies]

In the review safety and efficacy of substitution therapy in patients with predominant antibodies immunodeficiencies were presented. Differences between intravenous gammaglobulin preparation has been performed.

Immunoglobulin deficiencies and susceptibility to infection among homozygotes and heterozygotes for C2 deficiency

About 25% of C2-deficient homozygotes have increased susceptibility to severe bacterial infections. C2-deficient homozygotes had significantly lower serum levels of IgG2, IgG4, IgD, and Factor B, significantly higher levels of IgA and IgG3 and levels of IgG1 and IgM similar to controls. Type 1 (28 bp deletion in C2 exon 6 on the [HLA-B18, S042, DR2] haplotype or its fragments) and type II (non-type I) C2-deficient patients with increased susceptibility to bacterial infection had significantly lower mean levels of IgG4 (p < 0.04) and IgA (p < 0.01) than those without infections (who had a higher than normal mean IgA level) but similar mean levels of other immunoglobulins and Factor B. Of 13 C2-deficient homozygotes with infections, 85% had IgG4 deficiency, compared with 64% of 25 without infections. IgD deficiency was equally extraordinarily common among infection-prone (50%) and noninfection-prone (70%) homozygous type I C2-deficient patients. IgD deficiency was also common (35%) among 31 type I C2-deficient heterozygotes (with normal or type II haplotypes), but was not found in 5 type II C2-deficient heterozygotes or 1 homozygote. Thus, C2 deficiency itself is associated with many abnormalities in serum immunoglobulin levels, some of which, such as in IgG4 and IgA, may contribute to increased susceptibility to infection. In contrast, IgD deficiency appears not to contribute to increased infections and appears to be a dominant trait determined by a gene or genes on the extended major histocompatibility complex (MHC) haplotype [HLA-B 18, S042, DR2] (but probably not on type II C2-deficient haplotypes) similar to those previously identified on [HLA-B8, SC01, DR3] and [HLA-B18, F1C30, DR3].

[Immunological confirmation of allergy in children with hypoimmunoglobulinemia]

The recognition of allergy in children with hypoimmunoglobulinemia is very difficult because they have very low level or even lack of specific IgE antibodies. Our research hypothesis was the possibility of detecting the specific sensitization of lymphocytes T to food allergens in children with hypoimmunoglobulinemia and with clinical symptoms of allergy.

MATERIAL

32 children actually treated in our Immunology Outpatients Department due to immunodeficiency connected with hypoimmunoglobulinemia and with clinical suspicion of allergy.

METHODS

IgE concentration in serum and IgE specific antibodies to food and pollens were examined by FEIA CAP-SYSTEM. Lymphocyte specific response to allergens (cow's milk, gluten) was examined by classical blast transformation test. Immunological profile of children was also evaluated.

RESULTS

In the group of 32 children we recognised: 20 children with predominantly antibody deficiencies (2 - agammaglobulinemia; 8 - CVID; 5 - selective immunoglobulins deficiency; 5 - hypoimmunoglobulinemia of infants) and 12 children who had combined immunodeficiency with hypoimmunoglobulinemia ( 3 - AT; 8 - Nijmegen S; 1 - Di George). The children had atopic dermatitis and clinical symptoms of allergy in respiratory and digestive tracts. Concentration of IgE in serum of children was very low, even < 2KU/L, Pediatric Phadiatop was negative, f2 and f79 were absent. Using lymphocytes transformation test (culture stimulated with cow's milk and gluten antigens) we detected sensitivity to cow's milk in 24 children and additionally in 4 of them sensitivity to gluten.

CONCLUSIONS

1) Laboratory difficulties in allergy diagnosis in children with hypoimmunoglobulinemia by evaluation of specific IgE concentration in serum may by caused by defect in biosynthesis of mentioned antibodies. 2) In children with hypoimmunoglobulinemia the lymphocyte blastic transformation test with specific allergens in cultures has a diagnostic value indicating lymphocytes specific response to allergens.

Enhanced differentiation of splenic plasma cells but diminished long-lived high-affinity bone marrow plasma cells in aged mice

In the present work, we have dissected the mechanisms responsible for the impaired humoral responses in aging. We found that there was a substantially higher level of Ab-forming cells in the spleens of aged mice than that of young controls. However, the number of high-affinity, class-switched Ab-forming cells was severely decreased in the spleen of aged mice. The accumulation of low-affinity IgM Ab-forming cells in the spleens of aged animals was not due to a deficiency in isotype switching because the number of total IgG1 splenic plasma cells was not significantly reduced. Remarkably, plasma cells of both low and high affinity were significantly diminished in the bone marrow of aged mice compared with that of young mice. The results from reconstitution experiments showed that aged bone marrow was less supportive for plasma cells derived from young splenic B cells. These findings suggest that humoral immune deficiency in aging results from at least two mechanisms: the inability to generate sufficient numbers of high-affinity Ab-forming cells, which is a result of diminished germinal center reaction, and the defective bone marrow environment that has diminished ability to support the selection and survival of long-term Ab-forming cells.

Long term maintenance of IgE-mediated memory in mast cells in the absence of detectable serum IgE

Mast cells and basophils involved in allergic responses do not have clonotypic Ag receptors. However, they can acquire Ag specificity through binding of Ag-specific IgE to FcepsilonRI expressed on their surface. Previous studies demonstrated that IgE binding induced the stabilization and accumulation of FcepsilonRI on the cell surface and resulted in up-regulation of FcepsilonRI. In this study we have further analyzed the maintenance of IgE-mediated memory in mast cells and basophils in vivo by comparing kinetics of serum IgE levels, FcepsilonRI expression, and ability to induce systemic anaphylaxis. A single i.v. injection of trinitrophenyl-specific IgE induced 8-fold up-regulation of FcepsilonRI expression on peritoneal mast cells in B cell-deficient (micro m(-/-)) mice. Serum IgE levels became undetectable by day 6, but the treatment of mice with anti-IgE mAb induced a significant drop in body temperature on days 14, 28, and 42. The administration of trinitrophenyl -BSA, but not BSA, in place of anti-IgE mAb gave similar results, indicating the Ag specificity of the allergic response. This long term maintenance of Ag-specific reactivity in the allergic response was also observed in normal mice passively sensitized with IgE even though the duration was shorter than that in B cell-deficient mice. The appearance of IgE with a different specificity did not interfere with the maintenance of IgE-mediated memory of mast cells and basophils. These results suggest that IgE-mediated stabilization and up-regulation of FcepsilonRI enables mast cells and basophils not only to acquire Ag specificity, but also to maintain memory in vivo for lengthy periods of time.

Late pregnancy suppresses relapses in experimental autoimmune encephalomyelitis: evidence for a suppressive pregnancy-related serum factor

Women with multiple sclerosis have significantly diminished disease activity during pregnancy. The purpose of our study was to identify the underlying mechanism for the diminished disease activity. We found that during the period of late pregnancy there is protection against paralysis, during both the induction and effector phases of relapsing experimental autoimmune encephalomyelitis, a mouse model of multiple sclerosis. We did not find any changes in the cytokine secretion profiles or the proliferative activity of autoreactive T cells from mice induced during late pregnancy compared with virgin controls. In mice mated after disease onset, the inflammatory histologic lesions did not clear, despite marked clinical improvement during pregnancy. We found evidence for a serum factor present in late pregnancy that suppresses T cell activation. In the presence of sera taken from mice late in pregnancy, the proliferative response and IL-2 production of proteolipid protein p139-151-specific T cells were significantly diminished as compared with stimulation in the presence of normal mouse sera. In conclusion, serum from late pregnancy has the capacity to down-regulate T cell responses and might be associated with the amelioration of disease activity in experimental autoimmune encephalomyelitis.

Lethal pneumococcal infection in an 18-month-old girl with splenic hypoplasia and dysgammaglobulinemia

We report the case of an 18-month-old girl who died of overwhelming pneumococcal sepsis. Autopsy revealed a small spleen with unusual architecture. There was a marked rarefaction of the white pulp with only very few but florid germinal centers. Immunohistochemical staining showed a low number of T and B lymphocytes in the spleen, whereas normal numbers and distribution of lymphocytes were found in all other primary and secondary lymphatic organs. Whereas levels of IgM were normal, IgA and IgG levels were significantly lower than in age-matched controls. Consistent with serological data, B cells mainly expressed IgM and IgD, whereas IgG expression was lower than expected. Additionally, intestinal immunoglobulin distribution in B-cell areas of lymphofollicular hyperplasia showed normal expression of IgM, but almost no expression of IgA. A review of the literature failed to disclose a similar case of dysgammaglobulinemia associated with isolated structural spleen anomalies. We propose that the patient suffered from a defect of the B-cell differentiation pathway.

Common variable immunodeficiency (CVID) in a family: an autosomal dominant mode of inheritance

BACKGROUND

Common variable immunodeficiency (CVID) is characterised by a late onset deficiency of immunoglobulins resulting in recurrent infectious and non-infectious ailments. Most cases are sporadic but occasional familial clustering has been described. We present an extensively affected family with CVID in three consecutive generations.

METHODS

We conducted a study in this family to establish clinical phenotype, to clarify the mode of inheritance and to attempt to characterise the immune disturbance by determining immunoglobulin concentrations and B- and T-cell analysis.

RESULTS

We describe six patients with CVID in three consecutive generations. In addition, we encountered 10 family members with dysimmunoglobulinemia. B-cell counts were normal, but T-cell analysis showed slightly abnormal results.

CONCLUSIONS

The six cases of overt late onset hypogammaglobulinemia are compatible with an autosomal dominant mode of inheritance. The family members with dysimmunoglobulinemia may be at risk to develop overt CVID in the future, in view of the gradual course of progression of the disease in the clinically affected family members. B- and T-cell analysis are inconclusive though may support a possible defect in T-cell function to be involved. To further study this remarkable family and attempt to clarify pathogenesis, we are planning DNA linkage analysis in the near future.

Immunologic reconstitution following bone marrow transplantation for X-linked hyper IgM syndrome

X-linked hyper IgM syndrome (XHIM), caused by mutations of the CD40 ligand (CD40L) gene, is characterized by recurrent bacterial and opportunistic infections, an increased incidence of autoimmunity and malignancies, and immunodeficiency due to abnormal T/B cell interaction. Because of poor long-term prognosis, bone marrow transplantation (BMT) has been proposed as an alternative treatment. An 8-month-old boy with XHIM and a splice site mutation of CD40L underwent BMT using a fully matched sibling donor. Markers of engraftment and immunologic reconstitution were measured serially. After BMT, activated T cells expressed functional CD40L, and genomic DNA obtained from circulating white cells contained predominantly wild-type CD40L sequences. Serum immunoglobulin levels including IgE and antibody responses to recall antigens normalized, and immunization with the T-cell-dependent neoantigen, bacteriophage &phi;X174, demonstrated amplification of the response and isotope switching. BMT provides a permanent cure for XHIM if a fully matched sibling donor is available and the procedure is performed before complications have occurred.

Improved dysgammaglobulinaemia in congenital rubella syndrome after immunoglobulin therapy: correlation with CD154 expression

A boy with congenital rubella syndrome developed dysgammaglobulinaemia with elevated serum levels of IgM. CD154 was not induced on his peripheral blood mononuclear cells when rubella virus RNA was detected in his throat swabs and peripheral blood by reverse transcriptase polymerase chain reaction. Following intravenous immunoglobulin therapy, improvement of immunoglobulin abnormalities, disappearance of rubella virus and normalisation of CD154 expression were demonstrated.

CONCLUSION

These findings implicate the efficacy of intravenous immunoglobulin therapy for dysgammaglobulinaemia in congenital rubella syndrome and a role of CD154 for a prolonged virus infection.

X-linked hyper IgM syndrome: a report of the first case in Thailand with a confirmed mutation of CD40 ligand gene

X-linked hyper IgM (XHIM) syndrome is a rare congenital immunodeficiency disease caused by failure of B cell to isotype switch from IgM to other classes of immunoglobulins in response to infections. Recently, a molecular cloning of the gene responsible for the syndrome, the CD40L gene has been accomplished and the gene was successfully mapped to the long arm of X chromosome at the position Xq26. We, herein, report the first case of molecular proven XHIM in a Thai boy with a classic presentation and with a confirmed mutation of the CD40L gene.

CASE REPORT

A.S. was a 1 year 7 month old boy referred from Buriram Provincial Hospital for a work up and treatment for his recurrent infections consisted of chronic respiratory tract infections with otitis media (since 6 months of age), chronic diarrhea (since 9 months of age) and malnutrition (marasmus) secondary to his longstanding illnesses. He was a product of a consanguineous marriage but without history of similar illness observed in his pedigree. Abnormal laboratory works up included IgG of 300 mg/dl, IgA 10 mg/dl, IgM 1,635 mg/dl, positive stool examinations for Cryptosporidium, chronic colitis on radiographic gastrointestinal follow through study, a positive acid fast bacillus (AFB) stain of gastric aspirate and multiple positive bacterial cultures from various body sources. His anti-HIV serology was negative. His hospital course was significant for several bouts of infections of gastrointestinal, respiratory, and genitourinary systems. His treatment consisted of multiple courses of antibiotics, antituberculous drugs and IVIG administrations. His hospital course was complicated with feeding problem from an esophageal stricture requiring several esophageal dilatations. The analysis of CD40L gene revealed a point mutation of exon 5 (A619T) of the CD40L gene resulting in a stop codon confirming that indeed he had XHIM. He died with Pseudomonas septicemia during the waiting period for a bone marrow transplantation from a cord-blood stem cell.

Periodontal implications of immunodeficient states: manifestations and management

The importance of the immune system in modulating the host response to plaque is well recognised, and in this context the immune system is clearly a risk/modifying factor for human periodontal disease. This review examines the periodontal manifestations of subjects with immunodeficiencies and considers potential preventive protocols for the periodontal management of these patients.

Chronic inflammatory demyelinating polyneuropathy associated with dysglobulinemia: a peripheral nerve biopsy study in 18 cases

The possible occurrence of chronic inflammatory demyelinating polyneuropathy (CIDP) in association with an identified dysglobulinemic status is recognized and a causal relationship between the two has been suggested. We had the opportunity to study 18 patients presenting with CIDP and dysglobulinemia. This was an IgG monoclonal gammopathy (IgG MG) in 8 cases, an IgM monoclonal gammopathy (IgM MG) in 8, an IgG-IgM biclonal gammopathy in 1 case and an IgM monoclonal cryoglobulinemia in another. A peripheral nerve biopsy specimen was available for all patients and the morphological findings in these specimens in the cases of CIDP with IgG MG or cryoglobulin did not differ from those without, whereas characteristic features were observed in the cases of CIDP with IgM MG and anti-myelin associated glycoprotein activity.

Decreased vaginal disease in J-chain-deficient mice following herpes simplex type 2 genital infection

J-chain-deficient (Jch(-/-)) mice were used to study the role of polymeric IgA (pIgA) in primary disease and protective immunity following genital herpes simplex type 2 (HSV-2) infection. Vaginal IgA in the Jch(-/-) mice was composed primarily of monomeric IgA and was not associated with secretory component (SC). In contrast, vaginal IgA in wild-type (WT) mice was predominantly polymeric and bound to SC. Following HSV-2 genital infection, the Jch(-/-) mice consistently exhibited fewer vaginal symptoms (P = 0.010) and mortality (P = 0.075) than did the WT mice. The variation in disease expression could not be explained by differences in local viral replication, since titers in vaginal wash fluid were comparable. To assess the effect of J chain deficiency on protective immunity, WT and Jch(-/-) mice were immunized intravaginally with attenuated HSV-2, challenged intravaginally with wild-type virus 5 weeks later, and evaluated for vaginal infection and neurological disease. Although the Jch(-/-) mice had reduced vaginal HSV-specific IgA and IgG levels following immunization, both WT and Jch(-/-) mice were protected from symptoms following wild-type virus challenge. We conclude that pIgA is not required for protective immunity against genital HSV-2 disease and that J chain deficiency offers some protection against symptoms following primary HSV-2 genital infection.

The [HLA-B18, F1C30, DR3] conserved extended haplotype carries a susceptibility gene for IgD deficiency

We showed previously that the conserved extended MHC haplotype [HLA-B8, SCO1, DR3] carries recessive susceptibility genes for IgA and IgG4 deficiency and dominant genes for IgD and IgG3 deficiency. [HLA-B18, F1C30, DR3] has similar class II and III regions to [HLA-B8, SC01, DR3] and is common in the Basques. We therefore studied serum immunoglobulin concentrations in Basque homozygotes, heterozygotes, and noncarriers of (FIC30, DRB1*0301, DRB3*02, DQA1*0501. DQB1*0201) (F1C30, DR3). As shown by others, no subjects were deficient in IgA, IgM, or IgG subclasses. In contrast, 29% of homozygotes and three of seven double heterozygotes with (SC01, DRB1*0301, DRB3*0101, DQA1*0501, DQB1*0201) (presumed homozygotes for IgD deficiency susceptibility genes) were IgD deficient. Thus, 32% of presumed homozygotes were IgD deficient compared with 1.6% of noncarriers. Of haplotype heterozygotes, 25% were IgD deficient. The high frequency of IgD deficiency in both homozygotes and heterozygotes for (F1C30, DR3) suggests a partially penetrant dominant susceptibility gene for IgD deficiency on [HLA-B18, F1C30, DR3].

Light chain deposition disease detected by antisera to a variable region of the kappa1 light chain subgroup

A 59-year-old male started maintenance hemodialysis, and 80 months later died of congestive heart failure. Just before death he had no urine, and no monoclonal immunoglobulin could be demonstrated in the serum on immunoelectrophoresis. An autopsy showed deposition of periodic acid-Schiff-positive and Congo red-negative material in the interstitium and vessel walls of almost all organs and tissues. In the glomeruli there was a multifocal nodular accumulation of the material. Electron microscopy showed finely granular, not fibrillar deposits. In spite of these impressive lesions on light microscopy, the material was not stained with commercially available antisera to light chains. However, the material was positive for antisera to the variable region of the kappa1 light chain subgroup. This is the first case with light chain deposition disease that showed positive staining only with antisera to the variable region of the light chain.

Schistosoma mansoni infection in IgE-producing and IgE-deficient mice

The immunoglobulin E (IgE) response, a hallmark of helminthic infection, is generally considered a major host defense against schistosomiasis mansoni. In support, it was reported that mice with a null mutation of the Ce gene, which are thus incapable of making IgE, developed Schistosoma mansoni worm burdens 2-fold greater than wild-type mice. However, in another study, reduction of the IgE response in mice to a primary S. mansoni infection by anti-IgE treatment resulted in decreased worm burden and fecundity, suggesting that IgE plays a detrimental, rather than beneficial, role for the host in schistosomiasis. In a third study, S. mansoni worm burden and egg production in normal and in IL-4-deficient mice that produce negligible IgE levels did not differ significantly, and it appeared that IgE did not affect parasite survival or fecundity. In an attempt to resolve these controversies, we examined hepatic worm load and egg production in the liver and small intestine of IgE-deficient (SJA/9) and control IgE-producing (SJL/J) mice, 8 wk after S. mansoni infection. No differences were observed in worm burden, total egg production, and number of eggs produced per female worm in the 2 mouse strains, confirming the data that imply that IgE does not play an essential role in primary S. mansoni infection.

Immunoglobulin deficiencies and impaired immune response to polysaccharide antigens in adult patients with recurrent community-acquired pneumonia

The frequency of humoral immunodeficiencies was analysed in 39 patients with a history of recurrent (> or = 3) episodes of community-acquired pneumonia. Total immunoglobulin levels and/or IgG subclass levels were low in 14 patients (36%), including eight patients with IgG or IgG2 deficiency. The specific antibody activity to pneumococcal capsular polysaccharides (serotypes 3, 6A, 19F, and 23F) and to phosphorylcholine was low in the IgG/IgG2-deficient patients compared to 36 healthy controls, and they also responded poorly to vaccination with a 23-valent pneumococcal capsular polysaccharide vaccine. The remaining 25 patients, with normal immunoglobulin and IgG subclass levels, had specific anti-pneumococcal antibody levels comparable to the healthy controls, and all but 3 responded to vaccination. We conclude that immunoglobulin deficiencies and the inability to respond to polysaccharide antigens are common risk factors for recurrent pneumonia in adult patients. Immunoglobulin levels (including IgG subclasses) and antibody response to polysaccharide antigens should be investigated in these patients.

Acquired B lymphocyte deficiency and chronic enterocolitis in a 3-year-old quarter horse

This case report describes a 3-year-old American Quarter Horse with acquired immunodeficiency. Clinical signs included chronic diarrhea due to Salmonella typhimurium and bacterial pneumonia. Characterization of the immunodeficiency involved in vivo phytohemagglutinin (PHA) intradermal testing, in vitro lymphocyte proliferation in response to concanavalin A, immunofluorescence flow cytometry data on blood lymphocytes, serum protein electrophoresis and immunoglobulin (Ig) quantification. A diagnosis of B lymphocyte deficiency with resulting deficiencies in serum IgG, IgA and IgM and a concurrent decrease in T cell function was made based on these tests. Postmortem examination revealed no evidence of lymphosarcoma. This case represents a variation of young adult-onset B cell deficiency not previously described in the literature.

Non-infective colitis in infancy: evidence in favour of minor immunodeficiency in its pathogenesis

Forty two infants below the age of 2 years presenting with chronic non-infective diarrhoea and shown to have histologically proved colitis were investigated over a five year period. Allergic colitis was the most common cause of colitis, accounting for 62% of the cases. Other colitides diagnosed included: non-specific colitis, autoimmune enterocolitis, and ulcerative colitis accounting for 10% each; severe combined immunodeficiency 7%, and Crohn's disease 3%. A positive family history and a personal history of atopy were obtained in 48% and 29% of the cases respectively. Serum immunoglobulin A, IgG2, and IgG4 were very low in over 50% of the entire cohort of infants with colitis; 66% of those with severe combined immunodeficiency, autoimmune enterocolitis, and ulcerative colitis (n = 11) had low CD3 and CD4 T lymphocytes with an accompanying increase in CD8 in two thirds of those with severe combined immunodeficiency. T lymphocytes were normal in those with allergic colitis. Thus infants with proved non-infective colitis as a group show a high prevalence of IgA, IgG2, and IgG4 deficiency. It is likely that this minor deficiency of mucosa associated immunoglobulin production has a role in the pathogenesis of the colitic process.

Antibody independent crescentic glomerulonephritis in mu chain deficient mice

The hypothesis that crescent formation in glomerulonephritis (GN) is a delayed type hypersensitivity (DTH)-like lesion, not dependent on a humoral immune response, was addressed using mice with deletion of the mu immunoglobulin heavy chain gene (mu chain deficient mice). Homozygous mu chain deficient mice do not develop mature B cells or produce immunoglobulin, but have intact cell mediated immunity. GN was induced in sensitized mice by a subnephritogenic dose of sheep anti-mouse GBM globulin. Heterozygous mice (mu chain +/-) demonstrated normal antibody and DTH responses to sheep globulin and developed a proliferative GN with proteinuria (6.4 +/- 1.4 mg/24 hr), renal impairment (serum creatinine 32.6 +/- 3.3 mumol/liter) and crescents in 33 +/- 24% of glomeruli, when this antigen was planted in their glomeruli. This lesion was demonstrated to be T cell dependent by in vivo T cell depletion. Homozygous mu chain deficient mice (-/-) also developed proliferative GN, histologically indistinguishable from +/- mice. Proteinuria (3.8 +/- 1.0 mg/24 hr), renal impairment (serum creatinine 24.5 +/- 3.4 mumol/liter) and crescent formation (29 +/- 2% of glomeruli) were no different from =/- mice. Mouse immunoglobulin was absent in their serum and glomeruli, however, cutaneous DTH to sheep globulin was identical to heterozygous mice. These results demonstrate that glomerular crescent formation and injury can occur independent of a humoral immune response to planted glomerular antigen and without glomerular deposition of autologous antibody. This strongly supports the hypothesis that crescent formation is a manifestation of DTH.

IL-10-driven immunoglobulin production by B lymphocytes from IgA-deficient individuals correlates to infection proneness

In search for a possible explanation of the phenotypic heterogeneity in IgA deficiency, we studied the function of B cells from IgA-deficient (IgAd) individuals. Two groups of IgAd individuals, one frequently infected and one clinically apparently healthy, as well as normal controls, were studied. Peripheral blood mononuclear cells (PBMC) and B cells from IgAd individuals and controls were cultured with Staphylococcus aureus Cowan I strain and with anti-CD40 MoAb presented on the CD32-transfected fibroblast cell line in the presence of IL-10. In this experimental system PBMC and B cells from the infection-prone IgAd individuals produced only minute amounts of IgA. In contrast, PBMC and B cells from healthy IgAd subjects secreted significantly more IgA1 and IgA2 in comparison with infection-prone IgAd patients (P < 0.05). These data suggest that the abnormalities of B cell differentiation in IgAd could be of heterogeneous origin. Thus, whereas in healthy IgAd subjects IgA production may be efficiently up-regulated in vitro by addition of IL-10 to CD40-activated B cell culture, the corresponding B cell differentiation does not occur in infection-prone IgAd patients. These observations provide a conceptual framework for phenotypic heterogeneity in IgAd subjects.

Pneumocystis carinii infection in transgenic B cell-deficient mice

Pneumocystis carinii is an important cause of pneumonia in immunocompromised hosts. Both cellular and humoral immunity seem important in resistance to this pathogen, but the specific role of each component is poorly understood. An outbreak of P. carinii pneumonia in transgenic B cell-deficient mice (muMT) was studied. Over 4 months, >50% of 41 muMT/muMT mice maintained in a sterile environment died of pneumonia. Some mice had concurrent infection with Pasteurella pneumotropica. Homozygous muMT/muMT mice had no detectable serum immunoglobulins, while their heterozygous muMT/+ counterparts had normal levels of IgM, IgG, and IgA and did not develop pneumonia. The infection was controlled by treating the mice with trimethoprim-sulfamethoxazole, and the pathogen was eliminated by cesarean rederivation. These observations suggest an important role for B cells in the host defense against P. carinii.

Stressed rats fail to expand the CD45RC+CD4+ (Th1-like) T cell subset in response to KLH: possible involvement of IFN-gamma

Exposure to stressors effects various aspects of immune function, including the in vivo antibody response. We have previously reported that rats exposed to an acute session of inescapable tail shock (IS) show long-term reductions in anti-KLH (keyhole limpet hemocyanin) IgM and IgG. The mechanisms responsible for this suppression are currently unknown. Previous work has suggested changes in CD4+ T cells could be important. We report here that exposure to IS results in a reduction in Con A-stimulated IFN-gamma levels in mesenteric lymphocytes and splenocytes taken immediately after IS termination. In addition, IS exposure prevents the KLH-induced increase in the number of CD45RC+CD4+ T cells (Th1-like) in both the mesenteric lymph nodes and the spleen 4 days after immunization. The failure of KLH to expand the CD45RC+CD4+ subset could be due to the stress-induced reduction in IFN-gamma levels reported in cells taken at the time of immunization. Implications of these findings as a mechanism for the decrease in the in vivo antibody response previously reported is discussed.

Antibody response elicited by T-dependent and T-independent antigens in gene targeted kappa-deficient mice

Animal models substantially contribute to the understanding of the pathogenesis of various human diseases, including those associated with genetic defects. Our study investigated the characteristics of antibody responses elicited by T-dependent and T-independent antigens in mice rendered kappa-deficient by targeted deletion of the J kappa C kappa gene segments. It is known that in normal murine species the kappa repertoire dominates the antibody repertoire (kappa/lambda ratio = 95:5). Our results indicate that the kappa gene deletion causes the alternative usage of lambda 1 (93%) and lambda 2 (7%) light chains, confirming previous studies demonstrating that in kappa-deficient mice all B cells express Ig lambda receptors. The anti-trinitrophenylbenzene (TNP) response in K-/- mice was compensated for by lambda 1 and lambda 2 bearing Igs. However, isoelectric focusing analysis of anti-TNP antibodies showed a considerably more restricted pattern of lambda anti-TNP antibodies in K-/- as compared with kappa antibodies in normal mice. No major differences were observed in the affinity for the hapten of kappa or lambda 1 or lambda 2 mAbs obtained from 129/Sv and K-/- mice. Furthermore, lambda 1 and lambda 2 chains can reconstitute the expression of an idiotype (460Id) borne on kappa anti-TNP antibodies. The 460Id was detected both in polyclonal and monoclonal anti-TNP antibodies obtained from K-/- mice. Our results clearly showed that the kappa anti-TNP repertoire is compensated by the lambda repertoire even though the latter is clonally restricted in K-/- mice.

[Neuropathy associated with dysglobulinemia and monoclonal gammopathy]

Monoclonal gammopathy, especially monoclonal gammopathy of undetermined significance (MGUS) with IgM M-components, are associated with demyelinating neuropathy. In approximately 50% of these patients, the IgM M-component reacts with myelin associated glycoprotein (MAG) or other subcomponents of myelin such as glycolipids or gangliosides and a pathogenetic role of the M component has been proposed. Polyneuropathies associated with monoclonal gammopathies are of interest because of the potential relationship between the monoclonal protein and immune-mediated nerve damage. Many patients have been described in whom polyneuropathy is associated with IgM or IgG monoclonal gammopathy. While some such patients have MGUS, others have a variety of malignant plasma cell dyscrasia. The associated polyneuropathies clinically, electrodiagnostically, and histologically heterogeneous, but some exhibit primarily demyelination features, while others show axonal features. I have reviewed clinical, and immunological data in patients with MGUS and polyneuropathy in our clinic. The mechanism of neuropathy in patients with monoclonal gammopathy in the field of immunological studies is also reviewed. In summary, antibody activity in patients with monoclonal gammopathies associated with peripheral neuropathies almost exclusively found in monoclonal proteins of the IgM class. The most prevalent antibody is directed against MAG. IgG and IgA monoclonal proteins did not react components of peripheral nerve myelin. IgM-MGUS neuropathy should be separated conceptionally from monoclonal IgG neuropathies from my data.

PKU-related dysgammaglobulinaemia: the effect of diet therapy on IgE and allergic sensitization

The effect of diet on the development of immunoallergic signs and symptoms in children with phenylketonuria (PKU) was evaluated. Immunological indices of 58 children with PKU treated with diets were compared to the immunological indices of 58 healthy (non-PKU) children. In the PKU group, 39 children had been placed on diet therapy within the first month of life; 19 children had been placed on diet therapy after 6 months of age. Total circulating lymphocytes; CD3+, CD4+, CD8+ circulating lymphocytes; and serum IgA, IgM, IgG and total IgE levels were measured for each child. Skin prick tests were performed for common inhalant and food allergens. Every 3 months over the 2-year period of this study, the signs and symptoms of eczema, allergic rhinitis and asthma were recorded. The PKU group had lower IgG levels (p = 0.004) and higher total IgE levels (p = 0.0001) than the control group. Significantly lower IgE levels were found in children started on diet therapy within the first month of life compared with those started on diet therapy after 6 months of age (p = 0.0001). Allergic sensitization was significantly more frequent in the PKU group (24/58 vs 13/58, z = 2.00, p < 0.05), but no significant difference in the incidence of eczema and allergic rhinitis was found. Asthma was less frequent in the PKU group than in the control group (5/58 vs 14/58, z = 2.09, p < 0.05). Thus, diet appeared to prevent the development of immunoallergic signs and symptoms.

[Nonspecific anaphylactoid reaction in low IgE patients]

We reported two cases of anaphylactoid reaction caused by ranitidine and alprostadil. We suggest that these anaphylactoid reactions are nonspecific reactions which are observed in low IgE patients, because plasma IgE was still low 6 weeks after allergic reaction and these drugs have not been given to them before and eosinophilic and basophilic cells showed no change at all. We have to consider that there is a high risk of allergic reaction during general anesthesia, because many drugs are injected intravenously during general anesthesia.

A sensitive enzyme immunoassay for the measurement of low concentrations of IgA

A microtitre plate enzyme immunoassay (EIA) for determining low concentrations of IgA is described and validated for serum and plasma products. The measuring range of the assay was 3.3-150 micrograms/l. The predilution requirement of samples was matrix dependent, ranging from 1/16 for serum to 1/2 for 4% albumin. Dilute protein solutions required no predilution. The limits of detection were 50 micrograms/l for serum, 25 micrograms/l for intravenous immunoglobulin, 13 micrograms/l for 20% albumin, 7 micrograms/l for 4% albumin and 3 micrograms/l for washing solutions of blood cell components. Interassay coefficients of variation over the range of 3.4 mg to 1.5 g IgA/l ranged from 3.8 to 5.7%. Respective values for two low-level sera, containing 309 and 512 micrograms IgA/l, were 15.5% and 11.1%. Comparison of the EIA with a commercial radial immunodiffusion (RID) method showed that the results of the two assays correlated well ([EIA] = 0.877 x [RID] + 0.401 mg/l, r = 0.996, n = 20). This assay is also suitable for the large-scale screening of blood donors.

Role of x-linked immunodeficiency (xid) and NK activity in rejection of human tumor xenotransplants in nude mice

In order to elucidate the factors influencing the takes of human tumor xenografts in nude mice, we compared the transplantability of human tumors in nude mice with additional genetic defects in the immune system. The nude mice strains tested were classified as follows by expression of the beige gene and the x-linked immunodeficiency (xid) gene: 1) high NK nude (C57BL/6N, nu/nu), 2) low NK nude (C57BL/6 bg/bg nu/nu), 3) high NK nude with B-cell defect (CBA/N nu/nu), and 4) low NK nude with B-cell defect (NIH(S)III). Takes of human tumor xenografts including gastric carcinoma, T-cell lymphoma and B-cell lymphoma were better in nude mice with xid (CBA/N and NIH(S) III nude mice) than in nude mice without xid (B6 and beige nude mice). In addition, among the nude mice with xid expression, the takes were slightly better in nude mice with a CBA/N background than in those with a NIH(S) background. Moreover, the xenotransplantation rate in (CBA/N x C57BL/6N)F1 male nude mice with xid expression was higher than in (C57BL/6N x CBA/N)F1 males without xid expression, but did not react the same level as that in CBA/N nude. On the other hand, introduction of the beige gene into nude mice minimally improved the takes of human tumor xenografts under limited experimental conditions (inoculation of 100 x 10(5) T-cell lymphoma and 1 x 10(5) gastric carcinoma cells) despite the reduction of NK activity. In xenotransplantation of human tumors directly from patients, the take rates of the tumors were also better in CBA/N nude mice than in BALB/cA nude mice. The results in the present report confirmed the effect of xid and CBA/N genetic background on human tumor xenografts in nude mice, suggesting the existence of serum factors, possibly present in serum IgM, mediating rejection of the xenografts.

Selective IgM deficiency in a patient with Hashimoto's disease

A 70-year-old man with Hashimoto's disease had selective IgM deficiency, while other immunoglobulin levels were normal. In vitro mixing experiments were carried out in which B cells and T cells from the patient and from a healthy control donor were co-cultured in the presence of pokeweed mitogen, in order to investigate the etiology of IgM hypoproduction. The results indicated that the patient had B-cell dysfunction, involving the impairment of B-cell differentiation. In addition, both IgG of the healthy control donor and thyroid hormone may play important roles in the pathogenesis of this case.

Acquired resistance to Schistosoma japonicum in IgE-deficient SJA/9 mice immunized with irradiated cercariae

Participation of IgE in protective immunity against Schistosoma japonicum was examined by comparing congenital IgE-deficient SJA/9 and IgE-producing SJL/J mice. Mice immunized with 100 irradiated cercariae 7 weeks previously were infected with 50 live cercariae. In SJL/J mice at 40 days after infection, a 3-to 4-fold increase of total IgE levels and anti-S, japonicum egg IgE antibody production were observed with no significant difference between immunized and nonimmunized mice. IgE was not detected in SJA/9 mice throughout the experiments. Protective immunity evaluated by recovery of adult worms was found in SJA/9 mice and was comparable to that of SJL/J mice. These results suggest that acquired immunity in mice with irradiated cercariae of S. japonicum was not dependent on IgE in these strains of mice.