V(D)J recombination defects in lymphocytes due to RAG mutations: severe immunodeficiency with a spectrum of clinical presentations

Severe combined immunodeficiency (SCID) comprises a heterogeneous group of primary immunodeficiencies, a proportion of which are due to mutations in either of the 2 recombination activating genes (RAG)-1 and -2, which mediate the process of V(D)J recombination leading to the assembly of antigen receptor genes. It is reported here that the clinical and immunologic phenotypes of patients bearing mutations in RAGs are more diverse than previously thought and that this variability is related, in part, to the specific type of RAG mutation. By analyzing 44 such patients from 41 families, the following conclusions were reached: (1) null mutations on both alleles lead to the T-B-SCID phenotype; (2) patients manifesting classic Omenn syndrome (OS) have missense mutations on at least one allele and maintain partial V(D)J recombination activity, which accounts for the generation of residual, oligoclonal T-lymphocytes; (3) in a third group of patients, findings were only partially compatible with OS, and these patients, who also carried at least one missense mutation, may be considered to have atypical SCID/OS; (4) patients with engraftment of maternal T cells as a complication of a transplacental transfusion represented a fourth group, and these patients, who often presented with a clinical phenotype mimicking OS, may be observed regardless of the type of RAG gene mutation. Analysis of the RAG genes by direct sequencing is an effective way to provide accurate diagnosis of RAG-deficient as opposed to RAG-independent V(D)J recombination defects, a distinction that cannot be made based on clinical and immunologic phenotype alone.

Factorial structure of traits delineating personality disorders in clinical and general population samples

Categorical and dimensional models for classifying personality disorders were evaluated by comparing the structure of personality pathology in a clinical sample (n = 158) with the structure in a general population sample (n = 274). Subjects completed 100 personality scales. Separate factor analyses revealed similar structures in the 2 samples. An underlying structure in a combined sample showed limited agreement with the concepts of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987). Fifteen factors were retained: Generalized Distress, Rejection, Restricted Expression, Compulsivity, Stimulus Seeking, Insecure Attachment, Diffidence, Intimacy Problems, Oppositionality, Interpersonal Disesteem, Conduct Problems, Cognitive Dysfunction, Affective Reactivity, Narcissism, and Social Apprehensiveness. The results are consistent with a dimensional representation of personality disorder.

Categorical distinctions in the study of personality disorder: implications for classification

This article discusses the historical underpinnings of psychiatric classification and examines empirical evidence relevant to (a) whether personality disorders are distinct from each other and from normal personality and (b) whether personality disorders should be classified separately from other mental disorders. At the phenotypic level, research evidence strongly supports the use of a dimensional model to delineate personality disorders; evidence about their genotypic representation is less conclusive though still supportive. Neither empirical nor rational arguments indicate strong justification for separating personality disorders from other mental disorders, as has been done in both the third and fourth editions of the Diagnostic and Statistical Manual of Mental Disorders. Distinctions between abnormal and disordered personality are considered, and suggestions are made for more satisfactory diagnostic classificatory schemes.

Shortening of bleeding time by 1-deamino-8-D-arginine vasopressin in various bleeding disorders

To evaluate the effect of 1-deamino-8-D-arginine vasopressin (DDAVP) in various bleeding disorders, 10 micrograms/m2 DDAVP was administered to subjects with von Willebrand disease (13), platelet function defects (12), von Willebrand disease and platelet defects together (8), or isolated prolongation of the bleeding time (5). DDAVP shortened the bleeding time similarly in all patient groups. Shortening of the bleeding time was also observed in 2 patients with aspirin-induced platelet defects and in 2 normal subjects. DDAVP administration was associated with falls in the platelet count, mean platelet volume, and partial thromboplastin time, and rises in platelet adhesion, factor VIII coagulant activity, factor VIII related antigen, and von Willebrand factor activity. The basal bleeding time was the only predictor of the magnitude of the bleeding-time correction. Normal haemostatis was achieved with DDAVP plus epsilon-aminocaproic acid and no blood product support during operations in 18 patients with bleeding disorders.

Psoriatic arthritis in children

A proposed definition of juvenile psoriatic arthritis (JPsA) was used to identify definite or probable JPsA in 35 children. Definite JPsA (24 patients) was defined as arthritis associated, but not necessarily coincident, with a typical psoriatic rash, or arthritis plus at least 3 of 4 minor criteria: dactylitis, nail pitting, psoriasis-like rash, or family history of psoriasis. Probable JPsA (11 patients) was defined as arthritis plus 2 of the minor criteria. In 33 of 35 patients, the onset of arthritis was pauciarticular, but the disease followed a polyarticular course in 23 of 35. Chronic anterior uveitis (6 of 35), antinuclear antibodies (22 of 35), anticollagen antibodies (10 of 35), HLA-DR4 (2 of 28), and HLA-DR8 (5 of 28) occurred with frequencies similar to those seen in patients with juvenile rheumatoid arthritis. JPsA may have more in common with juvenile rheumatoid arthritis than with the seronegative spondylarthropathies with which it is traditionally associated.

Adult-onset familial adrenal 21-hydroxylase deficiency

Two sisters (28 and 30 years) were investigated for primary infertility and milk hirsutism. Both had normal puberty, were having regular menses and had normal female sexual characteristics. Studies revealed elevated urinary 17-ketosteroid levels (15.8, 18.8 mg/24 hours) and increased serum levels of 17-OH-progesterone (2,756, 1,121 ng/dl), 21-desoxycortisol (1,882, 1,090 ng/dl), progesterone (300, 346 ng/dl), dehydroepiandrosterone (DHA) (1,600, 1,700 ng/dl), and androstenedione (402, 366 ng/dl) and testosterone (100, 104 ng/dl), together with a slight increase in serum 11-desoxycortisol (1,180, 1,560 ng/dl). Blood pressure, serum sodium/potassium plasma renin and serum aldosterone, corticosterone, 11-desoxycorticosterone and cortisol levels were normal. The administration of ACTH caused a further increase in 21-hydroxylase precursors; the administration of dexamethasone normalized hormone levels and produced ovulatory cycles. Similar studies in two siblings were normal. The affected sisters were HLA identical and did not share any HLA antigens with their healthy siblings. The data suggest that these patients have a mild form of 21-hydroxylase deficiency which was insufficient to cause prenatal virilization. The gene for this disorder may be allelic with that for typical congenital adrenal hyperplasia.

Immunoglobulin A deficiency: genetic studies

Immunoglobulin A (IgA) deficiency (less than 0.01 mg/ml) was demonstrated in 155 of 72,296 blood donors. Studies of families of 60 donors revealed IgA deficiency in other members of 12 families. No consistent pattern of inheritance of IgA deficiency was found. HLA typing of 62 unrelated IgA deficient blood donors showed a significant increase in the prevalence of HLA-B8 (p less than 0.005).

Dimensional assessment of personality pathology in patients with eating disorders

This study examined patients with eating disorders on personality pathology using a dimensional method. Female subjects who met DSM-IV diagnostic criteria for eating disorder (n = 136) were evaluated and compared to an age-controlled general population sample (n = 68). We assessed 18 features of personality disorder with the Dimensional Assessment of Personality Pathology - Basic Questionnaire (DAPP-BQ). Factor analysis and cluster analysis were used to derive three clusters of patients. A five-factor solution was obtained with limited intercorrelation between factors. Cluster analysis produced three clusters with the following characteristics: Cluster 1 members (constituting 49.3% of the sample and labelled 'rigid') had higher mean scores on factors denoting compulsivity and interpersonal difficulties; Cluster 2 (18.4% of the sample) showed highest scores in factors denoting psychopathy, neuroticism and impulsive features, and appeared to constitute a borderline psychopathology group; Cluster 3 (32.4% of the sample) was characterized by few differences in personality pathology in comparison to the normal population sample. Cluster membership was associated with DSM-IV diagnosis -- a large proportion of patients with anorexia nervosa were members of Cluster 1. An empirical classification of eating-disordered patients derived from dimensional assessment of personality pathology identified three groups with clinical relevance.

Homocystinuria and megaloblastic anemia responsive to vitamin B12 therapy. An inborn error of metabolism due to a defect in cobalamin metabolism

We describe an inborn error of vitamin B12 metabolism in an infant who had severe developmental delay, megaloblastic anemia, and homocystinuria. There was no evidence of methylmalonic aciduria or deficiency of folate or vitamin B12. Treatment with hydroxocobalamin, but not with cyanocobalamin and folic acid, resulted in rapid clinical and biochemical improvement. Cultured fibroblasts showed an absolute growth requirement for methionine, defective incorporation of radioactivity from [14C]5-methyltetrahydrofolate into protein, and normal incorporation of radioactivity from [14C]propionate, thus assigning the intracellular defect to methionine synthesis. The proportion of intracellular methylcobalamin in the fibroblasts was decreased, but that of 5'-deoxyadenosylcobalamin was normal. Methionine synthetase activity in cell extracts was normal, as was cobalamin incorporation into cultured cells. This defect differs from those described previously in being limited to methylcobalamin accumulation and defective use of 5-methyltetrahydrofolate by intact cells with normal activity of methylmalonyl CoA mutase.

Rheumatic diseases in an Inuit population

Prevalence and incidence rates for rheumatic diseases were found to be minimal among the Inuit people in the Keewatin District of the Northwest Territories, Canada. Patient identification was achieved by a review of medical records. All identified patients were interviewed and examined by a participating rheumatologist. Among women, the prevalence of rheumatoid arthritis, adjusted for age of the Manitoba population, was 1,822 per 100,000 and was comparable with that observed in other populations; no cases of rheumatoid arthritis in men were confirmed. The age-adjusted prevalence of osteoarthritis, 1,219 per 100,000 in men and 2,144 per 100,000 in women, was apparently low. A moderately high incidence of Reiter's syndrome, 24.9 per 100,000, was found. The findings in children suggested a high frequency of seronegative spondylarthropathies (yearly incidence 60.1 per 100,000), although the adjusted yearly incidence for juvenile rheumatoid arthritis also appeared to be high, 23.6 per 100,000. The frequencies of HLA antigens in patient groups were compared with those found in 19 patients with musculoskeletal complaints but no rheumatic disease. Both HLA-B27 and HLA-DR4 appeared to be common in these controls, 36.8% and 63.2%, respectively. Nevertheless, there was a higher frequency of HLA-B27 in patients with seronegative spondylarthropathies (87%) than in controls (P = 0.001). Because of the small numbers of patients who had rheumatoid arthritis, no associations with HLA were made for this condition. Although the findings suggest differences in the distribution of rheumatic diseases compared with those found in other populations, more complete studies are required to confirm these observations.

Three new adenosine deaminase mutations that define a splicing enhancer and cause severe and partial phenotypes: implications for evolution of a CpG hotspot and expression of a transduced ADA cDNA

We report three novel adenosine deaminase (ADA) mutations with interesting implications. A Somali child with severe combined immunodeficiency disease (SCID) had reduced ADA mRNA in T cells and was homozygous for the nonsense mutation Q3X. Unexpectedly, her healthy father was a compound ADA heterozygote whose second allele carried a 'partial' mutation, R142Q, due to a G-->A transition of a CpG dinucleotide. A C-->T transition of the same CpG produced a nonsense mutation, R142X, in two homozygous Canadian Mennonite infants with SCID. The severe and healthy phenotypes associated with R142X and R142Q, the high frequency of 'partial' ADA mutations arising from CpGs in healthy individuals of African descent and the presence of CAA (glutamine) at codon 142 in murine ADA, suggest selection for replacement of this CpG hotspot by CpA during ADA evolution. R142X, located within a purine-rich segment at nt 62/116 of exon 5, caused skipping of the exon, possibly by disrupting a splicing enhancer. Absence of exon 5 in T cell ADA mRNA and low ADA activity in T cells and erythrocytes obtained at age 18-22 months from one of the Mennonite children, indicate limited expression of a normal ADA cDNA from retrovirally transduced CD34+ umbilical cord leukocytes infused shortly after birth in an attempt at stem cell gene therapy.

Inherited platelet-storage pool deficiency associated with a high incidence of acute myeloid leukaemia

A family with an inherited bleeding disorder extending over four generations, and multiple cases of myeloblastic and myelomonoblastic leukaemia was studied. Ten members of the family had, by history, a haemorrhagic diathesis. There were three documented cases of myeloblastic leukaemia, two documented cases of myelomonoblastic leukaemia and two more cases of leukaemia by history. In four of the cases the bleeding diathesis clearly antedated the leukaemia, in two by many years. The bleeding disorder is characterized by a long bleeding time, abnormal platelet aggregation, low platelet ADP and decreased numbers of platelet dense bodies consistent with a dense granule storage pool deficiency. The number of dense granules was decreased by immunofluorescence employing quinacrine or using an antibody to the dense granule membrane protein, granulophysin, confirming an absolute decrease in dense granule numbers rather than the presence of empty granule sacs. This congenital storage pool deficiency is associated with a high incidence of acute myeloid leukaemia in this family.

Dimensions of personality disorder. The DSM-III-R cluster A diagnoses

The authors adopt a construct validity approach to examine the structural validity of diagnoses of paranoid, schizoid, and schizotypal personality disorders. Systematic descriptions of these diagnoses were developed based on features identified from the literature that were organized using the clinicians' ratings. Each diagnosis was described in terms of a series of behavioral dimensions. Sets of behavioral exemplars were developed to assess each dimension. Dimensions and diagnoses were found to exhibit satisfactory levels of internal consistency that were cross-validated in a general population sample of 274 subjects and a clinical sample of 133 patients with a diagnosis of personality disorder. Some dimensions did not correlate highly with the total diagnosis score. Diagnoses could probably be refined by eliminating these dimensions. The structural relationships between dimensions delineating each diagnosis were explored using factor analysis. Diagnoses were not unifactorial. Instead, each diagnosis was found to be composed of two factors. The factorial structure of each diagnosis was found to be similar in the general population and clinical sample. It is suggested that the results support a dimensional representation of these diagnoses using three dimensions: paranoid behaviors, social avoidance, and perceptual cognitive distortion.

Factorial structure of traits delineating personality disorders in clinical and general population samples

Categorical and dimensional models for classifying personality disorders were evaluated by comparing the structure of personality pathology in a clinical sample (n = 158) with the structure in a general population sample (n = 274). Subjects completed 100 personality scales. Separate factor analyses revealed similar structures in the 2 samples. An underlying structure in a combined sample showed limited agreement with the concepts of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987). Fifteen factors were retained: Generalized Distress, Rejection, Restricted Expression, Compulsivity, Stimulus Seeking, Insecure Attachment, Diffidence, Intimacy Problems, Oppositionality, Interpersonal Disesteem, Conduct Problems, Cognitive Dysfunction, Affective Reactivity, Narcissism, and Social Apprehensiveness. The results are consistent with a dimensional representation of personality disorder.

Canine platelet alloimmunization: the role of donor selection

Five different platelet transfusion programmes were evaluated in a canine model to determine the most effective method of providing long-term platelet support. When a weekly transfusion from a single unrelated donor was used, alloimmune platelet refractoriness developed in 95% of recipients after an average of 3.1 +/- 0.7 transfusions, and donor platelets circulated for a total of 8.2 +/- 2.3 d. When multiple unrelated donors were used, the percentage of refractory recipients was similar (60% versus 77%) whether platelets came from six single donors given sequentially or from a pool of the same six donors given repeatedly. There was, however, a significant difference in the number of transfusions given prior to immunization (14 +/- 5 transfusions lasting 32 +/- 12 d for sequential single donors as compared to 5.5 +/- 1.0 transfusions lasting 13 +/- 2 d for the pooled donors). When littermates were used as platelet donors, the frequency of refractory recipients, the number of transfusions required to immunize, and the circulation time of donor platelets before refractoriness was not better than when multiple unrelated single donors were used. Furthermore, there was no significant difference in effectiveness between DLA-identical and DLA-nonidentical littermate platelet donors. In recipients previously immunized by a pool of six unrelated donors, the same percentage of recipients was refractory to DLA-identical littermate donors as had been observed following only DLA-identical platelet transfusions. This suggests that non-DLA immunizing platelet antigens, not shared between approximately 30% of DLA-identical littermates, are well represented in a random canine population. However, prior random transfusions did not compromise long-term platelet support from 'truly' platelet compatible DLA-identical littermate donors. These studies indicate that single donor transfusions either from littermates or sequential unrelated donors are the most effective method of providing long-term platelet support. However, the use of pooled unrelated donor transfusions, followed by DLA-identical donors in immunized recipients is an equally acceptable alternative.

Severe hereditary haemolytic anaemica in dogs treated by marrow trasplantation

Severe hereditary haemolytic anaemia related to pyruvate kinase deficiency occurs in Basenji dogs homozygous for this autosomal recessive defect. In the current study, three anaemic dogs were treated by total body irradiation and marrow transplantation from non-anaemic histocompatible littermates with resultant complete correction of their haemolytic anaemia. The possible use of marrow transplantation for life-threatening haemolytic anaemias in man is discussed.

Immunity to soluble retinal antigen in patients with uveitis accompanying juvenile rheumatoid arthritis

Studies of immunity to bovine soluble retinal antigen (antigen S) were carried out using serum and peripheral blood lymphocytes from children with juvenile rheumatoid arthritis and chronic anterior uveitis (JRA-uveitis), children with JRA alone, children with nonrheumatic diseases, and controls who had no ocular or rheumatic disease. Enzyme-linked immunosorbent assay and the lymphocyte transformation assay were used to determine immunity. Antibody to antigen S was present significantly more frequently in children with JRA-uveitis than in children with JRA alone, children with nonrheumatic disorders, or controls. These latter groups did not differ in positivity for this antibody. Lymphocyte transformation occurred more frequently in children with JRA-uveitis than in children with JRA alone or controls. Children with JRA alone and controls had similar frequencies of lymphocyte transformation positivity. Enzyme-linked immunosorbent assay positivity and lymphocyte transformation positivity tended to occur in different children. Children with JRA-uveitis who had HLA-B35 had the highest frequency of antibody to antigen S. Immunity to antigen S may be the result of ocular damage by mechanisms other than a pathogenic mechanism per se.

Dimensions of personality pathology

The reliability of DSM-III-R diagnoses of personality disorders is poor and their validity has yet to be established. There is little evidence that the features of personality pathology cluster into these diagnostic entities. For these reasons, it is important to explore alternative ways of classifying personality disorders. In this preliminary study, reliable scales were developed to assess 100 personality dimensions which were systematically developed. The factorial structure underlying the dimensions was evaluated in a heterogeneous sample of 110 subjects from the general population. Sixteen components, accounting for 81.4% of the variance, were retained for rotation to oblique structure. The components were labelled social avoidance, narcissism, insecure attachment, compulsive behaviours, interpersonal disesteem, mobility, anxiousness, conduct problems, stimulus seeking, identity disturbance, self-harm, rejection, diffidence, and hypersensitivity. Two components were not interpreted because they only had one or two salient loadings.

Autoantibodies in chronic arthritis of childhood: relations with each other and with histocompatibility antigens

BACKGROUND

Studies have shown the presence of either antibodies to histone or anticardiolipin antibodies in some forms of childhood chronic arthritis. The relation between these autoantibodies has not been previously reported, however, and the immunogenetics of their association with childhood arthritis has not been studied.

METHODS

The interrelation of fluorescent antinuclear antibodies, antibodies to histone, and anticardiolipin antibodies and their associations with histocompatibility antigens (HLA) were studied in 114 children with chronic arthritis (45 children with pauciarticular onset juvenile chronic arthritis (JCA), 22 with polyarticular onset JCA, 13 with systemic onset JCA, and 34 with juvenile psoriatic arthritis (JPsA). Antibodies to histone and anticardiolipin antibodies were determined in 108 children. HLA antigens (A, B, C, and DR) were studied in the 83 white children.

RESULTS

Antibodies to histone occurred in 0% (systemic onset JCA) to 42% (uveitis negative, pauciarticular onset JCA), and anticardiolipin antibodies in 26% (JPsA) to 55% (polyarticular onset JCA) of patients. Only 12 patients (11%) had both antibodies to histone and anticardiolipin antibodies. Neither antibodies to histone nor anticardiolipin antibodies associated with the type of arthritis. Neither of these antibodies alone associated with uveitis. Antibodies to histone were associated with HLA-A2, probably reflecting the known association of HLA-A2 with pauciarticular onset JCA. There was no other HLA association. Fluorescent antinuclear antibodies occurred most often in patients with uveitis; however, the occurrence of fluorescent antinuclear antibodies in patients with pauciarticular onset JCA (the group most at risk for uveitis) was not significantly greater in children with uveitis than in those without uveitis (100 and 88% respectively).

CONCLUSIONS

Although antibodies to histone and anticardiolipin antibodies often occur in serum samples from patients with JCA and JPsA, they rarely occur together. Their presence does not associate with uveitis. This study did not show any strong evidence that production of either antibodies to histone or anticardiolipin antibodies in patients with JCA or JPsA is under the control of the histocompatibility locus.

Actinic prurigo: Clinical features and HLA associations in a Canadian Inuit population

BACKGROUND

Actinic prurigo (AP) is an idiopathic familial photodermatitis. AP of the Inuit is rarely reported and poorly characterized.

OBJECTIVE

Our purpose was to examine the clinical features and HLA associations of AP in an Inuit population.

METHODS

Thirty-seven Inuit subjects with AP were administered a questionnaire and underwent a cutaneous examination. Other causes of photosensitivity were excluded. HLA class I typing was performed by polymerase chain reaction and sequence-specific primers and class II typing by polymerase chain reaction and sequence-specific oligonucleotide probes.

RESULTS

Subjects were 81.1% female, 67.6% had a family history of photosensitivity, and all experienced seasonal variation. The average age at onset of photosensitivity was 29 years, and only 27% had a trend toward improvement in photosensitivity. Involvement of eyes and nonexposed skin was reported in 62.2% and 18.9% of subjects, respectively. Physical examination revealed involvement of the face (64.9%), lip (32.4%), ear (13.5%), and dorsal aspect of the hand (24.3%). HLA-DRB1*14 was present in 51.2% of subjects and 26.2% of controls (P =.022, odds ratio = 2.975). This is a previously unreported HLA association.

CONCLUSION

AP in the Inuit is a seasonal, pruritic photodermatitis, often commencing in adulthood and worsening over time. A novel association with HLA-DRB1*14 has been discovered. Overall, this novel HLA association, the absence of HLA associations previously reported in non-Inuit populations, and clinical distinguishing features support the concept that AP in the Inuit may have a distinct immunopathogenic basis that translates into a different phenotype. It also raises the question of whether AP in the Inuit is a distinct photosensitivity disorder specific to this group that has been genetically isolated because of geographic and cultural seclusion.

Categorical distinctions in the study of personality disorder: implications for classification

This article discusses the historical underpinnings of psychiatric classification and examines empirical evidence relevant to (a) whether personality disorders are distinct from each other and from normal personality and (b) whether personality disorders should be classified separately from other mental disorders. At the phenotypic level, research evidence strongly supports the use of a dimensional model to delineate personality disorders; evidence about their genotypic representation is less conclusive though still supportive. Neither empirical nor rational arguments indicate strong justification for separating personality disorders from other mental disorders, as has been done in both the third and fourth editions of the Diagnostic and Statistical Manual of Mental Disorders. Distinctions between abnormal and disordered personality are considered, and suggestions are made for more satisfactory diagnostic classificatory schemes.