Depression of neutrophil function followed by severe infection in a child with Marasmic Kwashiorkor

Malnutrition in childhood continues to be one of the most important risk factor for secondary immunodeficiency in the world; therefore one should think of existence of malnutrition in a child suffering of frequent infections, not only in developing country, rarely but still possible in developed country also. Undernourishment in the early childhood is a trigger for starting a vicious cycle of impaired immunity, recurrent infections, and worsening malnutrition. Taking out from that cycle is an urgent and complex process, in which in parallel the infection should be controlled and the nutritional status solved out, and then, slowly follows the restoration of the immune system. We present a patient at the age of 13 months, with marasmic kwashiorkor accompanied by severe infection manifested with sepsis. The laboratory investigations revealed severe anaemia, hypoproteinemia and impaired immunological response, first of all neutrophil dysfunction with decreased oxidative metabolic response during the phagocytosis, paralyzed first line of defense of the organism and open possibility for bacterial or fungal invasion, multiorgan failure and high risk for fatal outcome. Because malnutrition and infections had many causes, only multiple and synergistic interventions embedded in true multisectoral programs, fortunately, were effective and got positive outcome.

Prostaglandin E2 is raised in kwashiorkor

OBJECTIVE

Infection is a common occurrence in children with kwashiorkor. It has been suggested that infection in kwashiorkor results from immune depression, and that the immune depression of kwashiorkor is caused by a diet-associated elevation of prostaglandin E2 (PGE2). The purpose of this study was to determine whether levels of PGE2 are abnormal in children with kwashiorkor.

SETTING AND SUBJECTS

Plasma PGE2 and plasma proteins were measured in children admitted with oedematous kwashiorkor, and compared with PGE2 in children with cerebral palsy.

RESULTS

Plasma PGE2 was higher in children with kwashiorkor than in control children (7.25 +/- 3.5 v. 3.51 +/- 1.59, P < 0.01). Within the kwashiorkor study group there was a significant negative correlation between log-transformed serum PGE2 and total plasma protein (r = -0.59, P < 0.001), plasma albumin (r = -0.63, P < 0.001), weight-for-age (r = -0.37, P < 0.05), and height-for-age (r = -0.37, P < 0.05). The difference in mean values of PGE2 in children with kwashiorkor who recovered from the illness and those who died was not significant (7.1 +/- 2.6 v. 9.1 +/- 4.8, P = 0.36).

CONCLUSION

Significantly higher PGE2 levels in children with kwashiorkor provide adequate reason for the depression of immune function known to occur in these children. Elevated PGE2 levels may also be implicated in other components of the illness.

Leucocyte migration inhibition factor (L-MIF) in malnourished Nigerian children

Leucocyte Migration Inhibition Factor (L-MIF) was measured in 41 children with marasmus, 19 with kwashiorkor, 5 with marasmic-kwashiorkor and 35 well-fed healthy children serving as controls. For L-MIF assay, two different antigens (live attenuated measles virus vaccine and diptheria pertussis tetanus (DPT) vaccine were used. Percentage migration indices obtained with the two antigens were significantly higher in the malnourished than in the well-fed healthy sex and age-matched controls (P < 0.01). The total serum protein and albumin concentrations were significantly reduced in the malnourished children compared with the controls (P < 0.01). Mean total leucocyte numbers were not significantly different in marasmic and marasmic-kwashiorkor children compared with the controls (P > 0.21).

Dietary linoleic acid, immune inhibition and disease

Review of the evidence available in published literature supports a radical change in viewpoint with respect to disease in countries where maize is the predominant dietary component. In these countries, the pattern of disease is largely determined by a change in immune profile caused by metabolites of dietary linoleic acid. High intake of linoleic acid in a diet deficient in other polyunsaturated fatty acids and in riboflavin results in high tissue production of prostaglandin E2, which in turn causes inhibition of the proliferation and cytokine production of Th1 cells, mediators of cellular immunity. Tuberculosis, measles, hepatoma, secondary infection in HIV and kwashiorkor are all favoured by this reduction in cellular immunity. Diet-associated inhibition of the Th1 subset is a major contributor to the high prevalence of these diseases found in areas of sub-Saharan Africa where maize is the staple.

Comparison of milk and maize based diets in kwashiorkor

The dual sugar test of intestinal permeability is a reliable non-invasive way of assessing the response of the small intestinal mucosa to nutritional rehabilitation.

AIM

To compare a local mix of maize-soya-egg to the standard milk diet in the treatment of kwashiorkor.

DESIGN

The diets were alternated three monthly in the sequence milk-maize-milk. There were a total of 533 kwashiorkor admissions of at least five days during the study who received either milk or maize. Intestinal permeability was assessed at weekly intervals by the lactulose-rhamnose test in 100 kwashiorkor cases, including 55 on milk and 45 on the maize diet.

RESULTS

Permeability ratios (95% confidence interval) on the milk diet improved by a mean of 6.4 (1.7 to 11.1) compared with -6.8 (-16.8 to 5.0) in the maize group. The improved permeability on milk occurred despite more diarrhoea, which constituted 34.8% of hospital days (29.8 to 39.8) compared with 24.3% (17.8 to 30.8) in the maize group. Case fatality rates for all 533 kwashiorkor admissions were 13.6% v 20.9%, respectively, giving a relative risk of death in the maize group of 1.54 (1.04 to 2.28). The maize group also had more clinical sepsis (60% v 31%) and less weight gain (2.9 v 4.4 g/kg/day) than the milk group.

IMPLICATIONS

Milk is superior to a local maize based diet in the treatment of kwashiorkor in terms of mortality, weight gain, clinical sepsis, and improvement in intestinal permeability.

In vitro lymphocyte-differentiating effects of thymulin (Zn-FTS) on lymphocyte subpopulations of severely malnourished children

This work investigates how thymic dysfunction contributes to the depression of cell-mediated immunity in protein-energy malnutrition (PEM). In Bolivian children hospitalized for severe PEM, the size of the thymus was measured by echography, and the lymphocyte subpopulations were detected by using monoclonal antibodies. These data were compared with those obtained from healthy control subjects. Regardless of the clinical form of PEM, our results show a high degree of T lymphocyte immaturity in severely malnourished children, which correlates with a severe involution of the thymus. Before in vitro incubation with thymulin, this significant increase in the percentage of circulating immature T lymphocytes was concomitant with a decrease in mature T lymphocytes and a slight increase in cytotoxic T subpopulations. After in vitro incubation with thymulin, immature T lymphocytes decreased and mature T lymphocytes increased.

Interleukin-1 in malnutrition

The effect of malnutrition on the in vitro production of interleukin-1 by lipopolysaccharide stimulated circulating monocytes has been investigated in children suffering from kwashiorkor and marasmus. The interleukin-1 activity was significantly lower in children with severe malnutrition. Furthermore, macrophages from children with kwashiorkor produced factors that suppressed mouse thymocyte proliferation. These observations show a significant impairment of macrophage function and provide a mechanism for the suppression of cellular immunity in malnutrition.

Monocyte factors modulate in vitro T-lymphocyte mitogenesis in protein malnutrition

This study investigated changes in T-lymphocyte mitogenesis and immunoregulatory cytokines during protein malnutrition. In vitro T cell response to concanavalin A was compared among protein deprived (PD), energy restricted pair fed control (PF), and ad libitum control (C) rabbits. Cell cultures were supplemented with crude monocyte supernatants (CMS) from PD, PF or C animals at either 1% or 8% final concentration in culture. Prostaglandin E2 (PGE2) concentration of unstimulated or stimulated lymphocyte culture supernatants and CMS was determined. Lymphocyte cultures from PD, PF and C animals had enhanced 3H-thymidine incorporation when supplemented with C and/or PF derived CMS. Addition of 8% CMS from PD rabbits inhibited proliferation below levels observed in mitogen-only stimulated groups in all cultures. At the 1% concentration, inhibition was seen in PD and C derived cells cultures and modest enhancement was seen in PF cultures. PGE2 concentration in supernatants from stimulated and unstimulated lymphocyte cultures from PD rabbits were higher than in C and PF cell cultures. These results suggest (a) that under appropriate culture conditions lymphocytes from PD donors are capable of enhanced proliferation and (b) that depressed T cell mitogenesis observed in protein malnutrition may reflect alterations in immunoregulatory signals. The role of interleukin 1 (IL-1) and PGE2 in the modulation of this response is discussed.

Depressed natural killer cell activity in children with protein--calorie malnutrition. II. Correction of the impaired activity after nutritional recovery

Natural killer (NK) cell activity and responsiveness to interferon (IFN) were measured in the peripheral blood of infants having kwashiorkor or marasmus and of nutritionally recovered malnourished children. Depression of NK activity in the peripheral blood lymphocytes (PBLs) of the malnourished children was noted, while normal levels of activity were observed in the nutritionally recovered infants. Addition of exogeneous interferon in vitro potentiated the NK levels of PBLs from well-nourished and nutritionally recovered infants, but had either a nonsignificant impact on cells from the marasmic infants or a suppressive effect on the cells from infants with kwashiorkor. The success of exogenous interferon to potentiate the NK levels of PBLs from nutritionally recovered infants suggests that nutritional repletion corrects the impaired cellular responsiveness in these patients.

Secretory IgA synthesis in Kwashiorkor

The synthesis of intestinal secretory IgA was studied in in vitro cultures of duodenal mucosal biopsies from children with Kwashiorkor. Production of secretory IgA was measured by the incorporation of radioactive label and visualized following PAGE and autoradiography. Results obtained before and after nutritional rehabilitation demonstrate an enhanced synthesis of sIgA in children with acute Kwashiorkor. Histological examination of plasma cells in the biopsy tissue confirms a twofold increase in IgA staining plasma cells in acute Kwashiorkor. Peripheral blood B lymphocytes in acute Kwashiorkor however, showed a reduction in IgA synthesis in the acute stage. These results suggest an effective mucosal sIgA response to the increased intestinal antigen load in Kwashiorkor.

Impaired polymorphonuclear leukocyte motility in malnourished infants: relationship to functional abnormalities of cell adherence

The humoral and cellular contributions to PMN motility in vitro were studied in 37 malnourished (PCM) pediatric patients. Early-phase directed migration to BCF and to ZANS was diminished significantly (p less than 0.001) in severe PCM patients as compared to healthy adult or age-matched controls or respective nutritionally restored patients. Abnormalities were reversible after nutritional restoration and unrelated to occurrence of clinical infection. To determine the pathogenic mechanism of impaired PMN mobility in PCM, studies of cell morphology and adhesive function were performed. Abnormalities observed in severe PCM suspensions included significantly (p less than 0.001) increased baseline (unstimulated) adherence values and impaired CF modulation of adhesive function. Diminished enhancement of PMN adherence or decreased (relative to baseline) adherence values were observed in response to BCF (mean % delta = +5) or f-Met-Leu-Phe (mean % delta = -6) as compared to adult PMN values of +28% delta and +31% delta, respectively. That these abnormalities may result from in vivo CF prestimulation was suggested by findings of "activated" PMN morphology in suspensions prior to in vitro stimulation, and abnormalities of the distribution of PMN surface adhesion sites under conditions of chemotactic stimulation. Further investigations will be required to determine the underlying pathogenic mechanism(s) accounting for our observations.

Measles vaccination in severely malnourished Sudanese children

The clinical and serological responses to attenuated measles virus vaccine were compared in 35 severely malnourished and 35 well-nourished children. A third group of severely malnourished children, who received an injection of vitamin B12, served as controls. The children were observed for three weeks following vaccination. Paired sera were collected from each child before and after administration of the vaccine or vitamin B12 and measles antibody titres were estimated using HAI technique. The malnourished children who received measles vaccine developed higher fever of longer duration and had more lower respiratory tract disease than the other two groups but had fewer skin rashes than the well-nourished group. Sero-conversion rates were 96% had 92.6% in the malnourished and well-nourished vaccinated children, respectively. Antibody titres were lower in children who had marasmic/kwashiorkor than in the marasmic children.

Response to live attenuated measles vaccine in children with severe kwashiorkor

An impaired response to vaccination with live attenuated measles vaccine was found in severely malnourished children, when compared with well nourished controls. It is suggested that humoral immune response may fail in children with severe protein energy malnutrition due to diversion of available amino acids to other uses. The possibility of a delayed antibody response to measles vaccine in malnourished children was not excluded.

Secretory IgA in nasal secretions of children with acute gastroenteritis and kwashiorkor

Secretory immunoglobulin A (IgA) was quantitated using the Mancini technique in the nasal washings of children with acute gastroenteritis and in children with kwashiorkor but without gut symptoms. The total immunoglobulin was expressed as a percentage of total protein in nasal secretion measured by biuret method. The IgA level was slightly lower in the kwashiorkor group than in the control group, and there was no statistical difference between IgA level in the acute gastroenteritis and the control group. An explanation for these observations is offered.

[General practice of nutrition diagnosis]

Important condition for a parenteral, enteral or parenteral-enteral nutrition, especially in patients before extended operations of during conservative therapy, is an exact nutritional assessment before beginning of this therapy. By means of biochemical examinations (visceral proteins), anthropometric measurements (body mass, triceps skinfold, arm muscle circumference, creatinine index) and immunological methods (total lymphocyte count in the blood, skin testing with test antigens) it is possible to classify nutritional conditions in severity and kind of malnutrition. By evaluating the digestive and resorptive capacity it is possible to determine the way of application.

Lymphocyte proliferation kinetics in malnourished children measured by differential chromatid staining

1. Utilizing the bromodeoxyuridine differential-chromatid labelling technique the in vitro proliferation of lymphocytes from children with kwashiorkor was followed in phytohaemagglutinin-stimulated cultures and compared with controls. 2. Analyses of first, second and third or subsequent division cells as a function of culture time between 40 and 96 h showed that cell-cycle duration was prolonged in kwashiorkor cultures. The extent of this increase was approximately 4.5 h for the first-division cells and 1.5 h for third-division cells. 3. The peak for second-division cells was depressed in kwashiorkor cultures. 4. A decreased number of third or subsequent-division cells was observed in kwashiorkor cultures at all time points studied. 5. These findings suggest that the loss in lymphocyte activity to PHA in malnourished children in general could be due to an increase in cell-cycle duration of responding lymphocytes.

The occurrence and properties of E rosette inhibitory substance in the sera of malnourished children

In vitro sheep erythrocyte (E) rosette inhibitory activity was observed in the sera of nine out of 22 (41%) children with kwashiorkor, three of 15 (20%) marasmic children, neither of the two children with marasmic-kwashiorkor and in one of 42 (2%) well nourished control children. Sera of children with kwashiorkor containing the E rosette inhibitory substance did not inhibit in vitro rosette formations by autologous lymphocytes whereas rosette formations by homologous lymphocytes were inhibited. Inhibition of E rosette formation occurred when lymphocytes were pretreated with serum having the inhibitory substance before incubation with sheep red cells, but there was no such inhibition when sheep red cells were pretreated with the same serum before incubation with lymphocytes. The inhibitory substance was observed to be stable at 4 degrees C up to about 1 week and migrated electrophoretically with the alpha-2 globulins. It was digested by papain. It is probable that the E rosette inhibitory substance demonstrated in the present study is attached to markers on T lymphocyte surfaces in some malnourished children thereby making the lymphocytes unreactive in vitro and presumably in vivo as well.

Effect of renutrition on humoral and cell-mediated immunity in severely malnourished children

Forty-three Colombian children suffering from either kwashiorkor (21), combined protein-calorie malnutrition (11), or maramus (11) were hospitalized and provided a high protein, high calorie diet for 4 to 5 wk. Improvement in clinical and nutritional status was accompanied by significant increases in levels of serum immunoglobulins G and M and C3 complement and by significant decreases in serum immunoglobulin A concentrations, especially in infants with kwashiorkor. Skin test reactions to purified protein derivative and candidin improved during renutrition. Lymphocyte blastogenesis after stimulation in vitro with phytohemagglutinin and pokeweed mitogen increased rapidly during hospitalization. After 1 yr posttreatment, cell-mediated immune responses, both in vivo and in vitro, had diminished. These results indicate that some aspects of the immune response are affected to a different degree in kwashiorkor, maramus, and combined malnutrition. Short-term nutritional rehabilitation has a differential effect on the long-term restoration of various aspects of immunity.

Influence of nutrition on postvaccinial tuberculin sensitivity

Response to BCG vaccination was studied in 261 apparently normal preschool children in a community. They were classified into different nutritional groups based on deficit in weight for age. In addition, nine children who had kwashiorkor and were admitted to the hospital were investigated. They were given 0.1 ml of BCG vaccine, and 6 months later, tuberculin sensitivity was assessed using 5 U of PPD. Blood samples were collected from 84 subjects and leukocyte migration inhibition was determined using the same antigen. After BCG vaccination, over 80% of children in the community showed positive tuberculin test, irrespective of the extent of growth retardation. There were no significant differences in the size of induration or the percentage of reactors between the various groups, indicating that the immune response to BCG vaccination is not affected by milder grades of malnutrition. However, the skin test was negative in most of the children who had had kwashiorkor. Leukocyte migration inhibition was similar in all the groups of children including those with kwashiorkor indicating that sensitisation of lymphocytes was not influenced by the nutritional status. In children with kwashiorkor, the leukocyte migration inhibition test was positive though the skin test was negative, suggesting that the former may be a better measure of assessing the response to BCG vaccination.

Immunity to measles in malnourished children

This work tests the hypothesis that the increased severity of measles in malnourished children is related to the immune response of the host to the virus. Peripheral blood mononuclear cells (PBM) from well-nourished and malnourished children who had not had measles were infected in vitro with measles virus. The yield of virus from the cells of malnourished children was significantly greater than the yield from well nourished children. This was not due to lack of interferon as both types of cells produced similar amounts on challenge with measles virus. Antibody-independent and antibody-dependent cellular cytotoxicity to Hela cells persistently infected with measles virus was measured on average 1 week after the onset of the measles rash. Mononuclear cells from malnourished children killed infected Hela cells as well as cells from well-nourished children in both types of assay. There was also no significant difference in the ability of serum from the two groups of children to lyse PMB which were infected with measles virus. However, plasma from malnourished children was found to depress proliferation of lymphocytes in the presence of PHA or Candida antigen to a greater degree than plasma from well-nourished children. We conclude that the severity of measles in the malnourished may well be related to the immune response for if their cells are abnormally susceptible to infection and if this infection is followed by a normal cellular and humoral immune response severe and extensive allergic damage would result. The reaction in turn may generate immunosuppressive factors in the patient's plasma thus making the child susceptible to secondary infections.

Infantile jejunal mucosa in infection and malnutrition

Sixteen children with refractory diarrhea and three malnourished children who had frequent episodes of acute gastroenteritis but little diarrhea at the time of hospital admission, were studied by peroral upper small intestinal biopsy. Six children were adequately nourished; five children weighed 62 to 79% of expected weight and eight weighed less than 60% of expected weight. Two of the malnourished children had giardiasis. Pathogenic bacteria were found in only one case. Varying degrees of mucosal atrophy with reduction of mean villous height were seen in 18 cases. The concentration of mononuclear inflammatory cells and plasma cells was about half that seen in well-nourished children with severe nongastrointestinal infections. The concentration of mononuclear cells in the lamina propria was about twice that seen in normal adults. The proportions of IgA-producing cells and cells that stained for secretory component were significantly reduced, as compared with normal adult control values. This reduction was most striking in children with malnutrition complicated by giardiasis. Enzyme histochemical studies were performed for leucine aminopeptidase, alkaline phosphatase and acid phosphatase. There was a tendency for considerably reduced acid phosphatase activity in all clinical groups (kwashiorkor, marasmic kwashiorkor and marasmus) of growth-retarded infants.

Some observations on the properties of precipitating antibody to Staphylococcus aureus in children with kwashiorkor

Using three relatively sensitive immunochemical assay procedures, we were unable to detect either precipitating or hemagglutinating antibodies to food antigens in sera from normal and kwashiorkor Nigerian children. However, antibody to Staphylococcus aureus, a common pathogenic bacteria in the tropics, could be detected in the sera of 28 of 30 control children but in only 7 of 30 kwashiorkor cases, suggesting that there is an impairment to specific antibody production in children with malnutrition. Comparative biologic and physicochemical studies carried out on precipitating antibodies to S. aureus isolated from normal and kwashiorkor subjects showed that the antibody from malnourished individuals fixed complement less readily and was deficient in some essential amino acids. These defects might in part explain why children with protein-energy malnutrition are more susceptible to infection in spite of the fact that they have normal serum immunoglobulin concentrations.

Deficiency in kwashiorkor serum of factors required for optimal lymphocyte transformation in vitro

Blastogenic responses of normal human peripheral blood lymphocytes cultured in media supplemented with serum from children with kwashiorkor were, on average, 47.7% of those observed when the same cells were cultured in the presence of normal AB serum. Incorporation of radioactive uridine was also diminished in the presence of normal AB serum. Incorporation of radioactive uridine was also diminished in the presence of kwashiorkor serum indicating that lectin-induced RNA synthesis was also affected. The kwashiorkor serum effect was not due to a cytotoxic action nor could it be attributed to the presence of saccharides or other inhibitors of the inducing lectins. Mixing experiments showed that kwashiorkor serum was not inhibitory, but that it lacked factors present in normal serum that are required for optimal lymphocyte blastogenesis. The deficiency of these factors could largely be rectified by supplementing kwashiorkor serum with an ultrafiltrate of normal serum containing components with molecular weights of less than 500 Daltons. We conclude that nutritional deprivation of severity sufficient to cause kwashiorkor leads to a deficiency of low molecular weight lymphocyte growth factors. This lack may contribute to the immunodeficiency associated with the disease.

Plasma levels of complement components and complement haemolytic activity in protein-energy malnutrition

The plasma levels of complement haemolytic activity (CH50) of some complement components and of C3d, a C3 breakdown product, were measured in fifty-nine African children with various types of protein-energy malnutrition (PEM) including kwashiorkor, before and during recovery. A significant decrease of CH50, C3, C9 and factor B was observed in PEM without a concomitant decrease of C4 and C5. Increased plasma levels of C3d were also found in PEM patients. Two mechanisms seem to be involved in the impairment of the complement system in PEM: (1) a decreased synthesis of at least C3 and C9 as suggested by a significant correlation between C3 or C9, levels and those of albumin and cholinesterase; (2) an increased catabolism of C3 possibly due to an activation of the alternative complement pathway, as suggested by the increased level of C3d and the decreased level of factor B which are significantly correlated with C3 levels but not with albumin levels. These data support the possible role of a relative complement deficiency upon the decreased resistance to infections observed in malnourished children.

The effects of kwashiorkor serum on lymphocyte transformation in vitro

The serum from twelve children with kwashiorkor was deficient in its ability to support lymphocyte transformation in vitro, whereas lymphocytes from these children responded to phytohaemagglutinin and al-ogeneic lymphocytes in a relatively normal manner when cultured in normal serum. This serum abnormality improved with therapy and could not be clearly correlated with the degree of malnutrition, the presence or absence of infection or other laboratory manifestations of kwashiorkor. These observations indicate that defective cellular immune reactions in kwashiorkor may be symptomatic of a lack of some humoral factor and do not necessarily reflect an intrinsic cellular defect.

Effects of autologous plasma on lymphocyte transformation in malaria and in acute protein-energy malnutrition. Comparison of purified lymphocyte and whole blood cultures

Phytohaemagglutinin (PHA) induced lymphocyte transformation in whole blood and in purified lymphocyte cultures was investigated in Gambian children with acute Plasmodium falciparum malaria or with acute protein-energy malnutrition (PEM). Responses of purified lymphocytes cultured in the absence of autologous plasma were normal, with one exception. Autologous plasma depressed the response of purified lymphocytes to a low dose of PHA in several malaria and PEM patients. In whole blood cultures of 1 day and of 3 day duration, responses of several children with malaria or PEM were less than those of control children. Responses were not related to absolute lymphocyte counts. In 3 day, but not 1 day, cultures from control and malarious children, responses were inversely proportional to neutrophil counts. Cultures of whole blood and of purified lymphocytes in autologous plasma gave comparable results in 58 of 70 patients.

[Protein-calorie deficiency and the immune processes]

The paper deals with issues that concern the influence of alimentary factors, of protein-caloric deficiency in particular, on the function of the immune system. Subject to a consecutive study was the pathogenesis of disorders in endocytosis of antigens, in humoral and cellular immunity and in reactions of hypersensitivity with proteinic deficiency. An inference is drawn to the effect that immunogenesis and a number of immune reactions are extrmely sensitive to alimentary effects and, above all, to the proteinic deficiency. Mention is also made of the fact that under certain conditions alimentary factors can direct favourably the course of a given immune process.

Defective local leukocyte mobilization in children with kwashiorkor

The Rebuck window technique was used to determine the functional integrity of the inflammatory response in nine children with kwashiorkor. The total numbers of leukocytes mobilized into skin abrasions were similar between kwashiorkor and control patients. However, children with kwashiorkor showed significantly delayed and decreased macrophage migration and increased polymorphonuclear leukocyte migration. These defects of leukocyte mobilization were corrected with nutritional repair.

[T and B lymphocytes in the peripheral blood of the in-utero malnourished new born infant]

The per centum distribution of T and B lymphocytes was determined in 30 full term newborns showing adequate development for their gestational age and in 42 full term newborns showing in utero malnutrition. A significant decrease (p less than 0.001) of both lymphocytic subpopulations was found in the in utero malnutrition group. The possibility of a decreased efficiency of the immune response in this group of patients is discussed.

[Rosette-forming peripheral lymphocytes, in children with measles]

During measles infection in human beings, depression of cellular immunity appears. The authors studied several groups of children with measles complaining of various degrees of malnutrition in terms of rosette forming lymphocytes in peripheral blood; marked reduction of T lymphocytes were seen in all of the groups during the acute stage of the disease, that persisted up to two weeks after the exanthematous stage. When comparison was established of eutrophic and 1st degree malnourished children with those affected with 3rd degree malnutrition, differences were found in the recovery of the number of rosett-E forming cells.

Antibody production and complement system in protein energy malnutrition

Antibody production in kwashiorkor and marasmic infants was studied by dividing them into three groups and giving the first group a single dose of trivalent live attenuated polio virus, the second group live attenuated measles virus and the third group diphtheriatoxoid. The production of antibodies was found to be deficient in PEM as compared to normals and diminished more in kwashiorkor than in marasmus cases. The individuals of the complement system were significantly lower in kwashiorkor than in normal controls. However, C3 was the only fraction which is significantly diminished in marasmic infants. The results are discussed and as a conclusion it is suggested that deficient production of antibodies and diminution in the complement system in PEM may explain the susceptibility of such infants to repeated attacks of infection.

[Cellular immunity in protein-caloric malnutrition]

In order to have a clearer idea on the relationship between infectious diseases and malnutrition, cellular immunity is studied in 3 to 18 months old malnourished and healthy infants. Nutritional status is evaluated by the food intake the anthropologic measurements and some biological parameters like transferrin. Cellular immunity is investigated by skin tests to tuberculin, monilia, P.H.A. and DNCB. Absolute number of peripheral lymphocytes and percentage of T cells are studied too. The results show that there is a cellular immunity deficiency: frequent non-response to antigens, weak sensitization to DNCB. Some patients have a low percentage of spontaneous rosettes. The transferrin titering is useful to appreciate the nutritional status and the iron therapy opportunity, the prognostic and the immunitary possibilities.

Complement components in children with protein-calorie malnutrition

Complement components of C1-C9 were estimated in children with protein-calorie malnutrition. The diagnosis of kwashiorkor and marasmus were based on clinical examination, anthropometric measurements and on biochemical estimations. The children were examined clinically and bacteriologically for any evidence of infection. All the complement components except C4 and C5 were significantly lower in children with protein-calorie malnutrition: of all the complement components C3 and C9 were the most severely depressed. C5 was the only complement component that was significantly higher in malnourished children than in normal children. Malnourished children with C-reactive protein in their serum had significantly lower values of C3 and C9 and higher values of C5 than malnourished children without C-reactive protein in their serum. During refeeding C3 was the first complement to show a significant rise. This was followed by C9. There was a fall in C5 concentration while there was no change in C4 concentration. The roles of infection, malnutrition and C-reactive protein on complement depletion are discussed.

Secretory IgA in protein-calorie malnutrition

The secretory IgA system was investigated in children with protein-calorie malnutrition (PCM). The results of the study indicated that in children suffering from kwashiorkor and marasmus the concentration of IgA in duodenal fluid, saliva, nasal secretions, and tears was significantly reduced on admission and returned to normal 4 weeks after treatment. However, the concentration of secretory IgA in children with mild to moderate PCM was similar to that of normal children. Secretory IgA deficiency may be an important factor in promoting bacterial growth and this may account for the increased incidence and severity of mucosal infections in children with severe PCM.

Defective leucocyte inhibitory factor (LIF) production by lymphocytes in children with kwashiorkor

Production of the lymphokine leucocyte inhibitory factor (LIF) by phytohaemagglutinin (PHA)-stimulated lymphocytes was assessed in 25 children with kwashiorkor. Although the lymphocytes of 12 of these patients produced adequate amounts of LIF, the rest of the group failed to produce lymphokine after PHA activation. There was no correlation between the ability to produce LIF and the age, severity of malnutrition or any other clinical parameters assessed in these patients. This finding confirms the presence of defective cell-mediated immunity observed in a substantial proportion of kwashiorkor children.