Case Report / Kasuistik F. T. Sacchi, F. A. Ferrari, A. Fortunato, G. Maggiore, M. Marconi, A. Pagani, A. G. Siccardi
A Defect in Neutrophil Motility in Two Siblings with Recurrent Infections and a Remarkable Family History Summary: Two siblings with recurrent infections were found to have impaired neutrophil motility. The same association of infections (otitis media, bronchitis, chronic diarrhoea) has caused seven fatalities in the paternal side of the family, suggesting genetic implications. Zusammenfassung: Defekt in der NeutrophiIen-Motilitiit bei zwei Geschwistern mit rezividierenden Infektionen und einer auflergew6hnlichen Familienanamnese. Bei zwei Geschwistern mit wiederholten Infektionen ist ein wahrscheinlich genetischer Schaden der Granulocyten-Chemotaxis gefunden worden. Durch H~iufung yon Infekten (Mittelohrentziindung, Bronchitis, chronischer Durchfall) sind sieben Geschwister in der v~terlichen Familie in jungem Alter gestorben.
Introduction The identification of functional abnormalities of the cellular and humoral components of leukocyte migration has contributed to the understanding of the mechanisms of impaired host defences in a variety of clinical settings (for a review see 1 and 2). Most of the described defects, which are not due to abnormalities of serum components but to the polymorphonuclear leukocytes (PMN) themselves, have been shown to be associated with elevated levels of immunoglobulin E (1--5). This paper describes two siblings with a cell-associated defect in leukocyte migration, normal levels of IgE, and a peculiar association of recurrent infections (otitis media, bronchitis and chronic diarrhoea). Seven fatalities are reported in the paternal side of the family as being due to the same association of infections. Isolated defects in neutrophil chemotaxis in patients suffering from repeated episodes of otitis media and diarrhoea have been described by Hill et al. (6) who have suggested an important role for the phagocyte in the protection of the mucosal surfaces of the respiratory and gastrointestinal tracts.
for weight and height. Since a few days after birth G. M. has suffered from frequent episodes of diarrhoea, purulent otitis media, upper respiratory tract infections and bronchitis (sometimes asthmatic). She has also had severe bronchopneumonia. At admission to our clinic, G. M. was suffering from acute pharyngitis, conjunctivitis and otitis media. Laboratory findings (Table 1) were unremarkable with the exception of a moderate hypergammaglobulinemia; all cultures were negative and the chest X-ray was unremarkable.
°< Figure 1: Family-tree of the patients (GM and GS). Seven fatalities ('~) in early infancy are reported as being due to an association of persistent diarrhoea, respiratory infections and otitis media (0). G. S. is a 13 month old male, born in the eighth month of pregnancy following a Caesarean section (birth weight , ~ a ,~. since the first days of life he has suffered fr,~m severe and recurrent diarrhoea (frequently with hyperpyrexia) and failure to thrive; in addition, middle ear and upper respiratory tract infections have often occurred. On admission to our clinic he was small (below the third percentile for weight and the tenth percentile for height) and had otitis media, upper respiratory tract infection, and persistent diarrhoea. Laboratory findings (Table 1) showed neutropenia and lymphocytosis with a low relative count of T lymphocytes. Chest X-ray was normal; sweat test, 24 hour faecal fat excretion, barium meal and xylose absorption were normal.
Case Reports
Materials and Methods
G. M. and G. S. are the only two children of unrelated parents coming from Central Italy. The family history is unremarkable on the maternal side, while seven fatalities in early infancy are reported on the paternal side with histories of recurrent respiratory infections and persistent diarrhoea (Figure 1). G. M. is a 7 year old female, born in the sixth month of pregnancy (birth weight 1,200 g), who showed reduced development until the age of four, later becoming normal
Platelet-free leukocytes were purified from heparinized venous blood by dextran (10/o)-erythroprecipitation and lowspeed spinwashings in phosphate-buffered saline (PBS). Received: 24 April 1978 Dr. F. T. Sacchi, Dr. F. A. Ferrari, Dr. G. Maggiore, Dr. M. Marconi, Dr. A. Pagani, Clinica Pediatrica dell'Universit~t, Ospedale S. Matteo, 1-27100 Pavia, Italy; Dr. A. Fortunato, Dr. A. G. Siccardi, Istituto di Genetica, Via S. Epifanio 14, 1-27100 Pavia, Italy.
Infection 7 (1979) Nr. 1
45
F. T. Sacchi et al.: Defective Leukocyte Motility and Recurrent Infections Table 1: Laboratory findings. G.M.
G.S.
RBC (xl06x/z1-1) Hb (gxl00 m1-1) Fe (~gxl00 ml -~)
4.8 I3.3 52
4.0 11.4 45
WBC (xl0°x/z1-1) Neutrophils (0/0) Lymphocytes (0/0) Eosinophils (°/0) ESR (Katz Index) Plasma Total Protein (gxl00 m1-1) Albumin (°/0) Globulin (°/0)
6.1 46 50 2 12.5
8.0 18 78 1 6.5
7.0 41.4 58.6
6.1 54.8 45.2
IgG (mgxl00 m1-1) IgA (mgxl00 m1-1) IgM (mgxl00 m1-1) IgE (I. U. xml -~) ~T lymphocytes (°/0) 2B lymphocytes (°/0) 0DTH-Skin Tests 4CH 50 (%) ~A. P. C. (Rabbit) (%) 5A. P. C. (Yeast) (0/0)
G.M.
G.S.
1122 145 178 95 62.5 15.5 N
624 35 142 22 42 NT N
98 103 97
102 100 89
1. Peripheral lymphocytes forming E-rosettes; 2. Peripheral lymphocytes Ig-positive with fluorescent anti-Ig antiserum, NT = not tested; 3. Delayed-type hypersensitivity skin tests (PPD, Candidin, Trichophyton, Streptokinase-Streptodornase), N == normal reactivity; 4. Complement level, assayed with the hemolytic assay on antibody-sensitized sheep erythrocytes; 5. Alternative pathway of complement activation, assayed with the hemolytic assay on unsensibilized rabbit erythrocytes (7) and with the yeast opsonization test (8). The results of the complement tests are expressed as percentages relative to a reference standard, a pool of sera from normal controls.
Candida albicans (from a hospital source) was maintained on Sabourad's agar slants and grown in Sabourad's broth to log phase (all yeast forms) before use in candidacidal tests. Staphylococcus aureus (ATCC 6538) was grown in Antibiotic Medium N. 3 (Difco) to mid-log phase and washed in fresh medium before use in bactericidal tests. CandidacidaI activity was assayed by the method of Lehrer and Cline (9) with a Candida: P M N ratio of 1 : 1. The data are expressed as the fraction (CK) of Candida cells killed in two hours. Bactericidal activity (S. aureus) was determined by a modification of the method described in (10) using a bacteria: P M N ratio of 1 : 10 to ensure total phagocytosis. The data are given as the fraction (BK) of bacterial cells killed in 90 rain. Phagocytosis and NBT reduction tests were performed by a modification of the method of Preisig and Hitzig (11); a leukocyte suspension containing 106 P M N was dispended into plastic tissue culture dishes (Nunclon, 4 cm) with 1.5 ml of PBS at 37 °C. After 30 rain the dishes were rinsed in PBS and additioned of 2 ml of NBT medium (NBT 0.1°/0, w/v, in PBS pH 6.8) and of 107 serum-treated, boiled Candida cells; after 30 rain the dishes were rinsed again, fixed and stained with safranin. 150 P M N were inspected (100 X objective, oil immersion) and classed on the basis of the number of intracellular yeasts (0-7) and the presence of formazan deposits ( + / - - ) . Three indexes were then calculated; PhF = phagocytosis frequency (the fraction of phagocyting PMN over total PMN inspected), Phi = phagocytic index (the average number of intracellular yeasts/PMN) and N R F = NBT reduction frequency (the fraction of phagocyting P M N with formazan deposits over total phagocyting PMN). An estimate of leukocyte adherence (mean number of leukocytes/high-power field) was also obtained. The phagocytosis-dependent metabolic activation of P M N leukocytes (12) was measured as the KCN-resistant production of 14CO2 from ~4Ct-glucose (0.1 #Ci/assay; 1.44 ~Ci/ #mole) in the presence and in the absence of latex phagocytosis. The results are expressed as P/R (cpm phagocyting/ cpm resting) ratios. Leukocyte motility tests were performed as in (13) with modified Boyden chambers and Millipore filters (pore size 3 #m). Bacterial LPS (Difco, 10#g/ml) plus normal serum (5°/0) were used as the chemotactic stimulus where appro-
46
Infection 7 (1979) Nr. 1
priate. Both random filter- and chemotactic filter-migrations (RM and CT) were evaluated (at 60 min) by the "leading front" method described by (14) as the average distance (in /zm) travelled by the two fastest cells in each of highpower fields.
Results and Discussion T h e leukocyte f u n c t i o n tests p e r f o r m e d on the two patients and on their parents (Tables 2 and 3) show that both patients have an isolated defect in leukocyte motility. T h e defect is persistent at clinical remission and confined mainly to the r a n d o m migration process. A l t h o u g h chemotactic migration is highly reduced for b o t h patients in absolute values, the chemotactic index (i. e. the ratio of c h e m o t a c t i c / r a n d o m migrations)attains n o r m a l values (2.0--2.92; range of controls: 1.6--2.2) indicating that the patients' cells are responsive to the chemotactic stimuIus. T h e defect did not appear to be the result of a serum inhibitor of leukocyte motility, as the t r e a t m e n t of n o r m a l leukocytes with the serum of the patients did not impair their motility; m o r e o v e r , washing the patients' cells with serum f r o m a pool of controls did not restore chemotactic responsiveness. The defect encountered in the two siblings thus seems to be an intrinsic cellular defect in motility; in view of the functional classification scheme p r o p o s e d by Gatlin and Wolff (15) it is interesting to note that P M N adherence to plastic seems to be n o r m a l in both patients (Table 2). T h e n o r m a l levels of IgE, the abn o r m a l r a n d o m motility, and the lack of restoration of n o r m a l motility by incubation in n o r m a l sera clearly differentiate these patients f r o m those described by Hill and Quie (3), van Scoy et aI. (4), and by Gahr et al (5). A very detailed description of an association between otitis media, chronic diarrhoea and defective chemotaxis has been published by Hill et al. (6); in their case, the
F. T. Sacchi et al.: Defective Leukocyte Motility and Recurrent Infections Table 2: Leukocyte/unction tests* (except motility). Tests
G.M.
G.S.
Mothers
Range of controls**
Adherence (PMN/hpf)
11.26
12.02
11.32
10.21-12.60
0.92 3.81
0.91 3.41
0.78 2.63
0.71- 0.95 2.10- 4.10
Phagocytosis PhF Phi Metabolic activation P/R NRF
6.81 0.97
4.03 0.97
5.43 0.97
3.90- 7.20 0.87- 0.99
S. aureus killing BK
0.78
0.85
0.90
0.75- 0.90
C. albicans killing CK
0.63
0.84
0.65
0.60- 0.75
* See Methods for description; the mean values of two independent experiments are given. ** 8 healthy adult individuals. defects are t r a n s i e n t (or i n t e r m i t t e n t ) a n d d i s a p p e a r at clinical r e m i s s i o n ; n o i n d i c a t i o n is g i v e n of the possible i n v o l v e m e n t of genetic factors. C o n v e r s e l y , o u r p a t i e n t s s u f f e r f r o m a very similar assoc i a t i o n o f s y m p t o m s , b u t t h e m o t i l i t y defects h a v e persisted at clinical r e m i s s i o n a n d t h e v e r y r e m a r k a b l e f a m i l y h i s t o r y suggests a f a m i l i a l p r e v a l e n c e of t h e condition. T h e m o d e of genetic t r a n s m i s s i o n , h o w e v e r , is n o t obvious; were t h e c o n d i t i o n i n d e e d genetic it m i g h t b e due to a d o m i n a n t gene w i t h i n c o m p l e t e p e n e t r a n c e (see f a m i l y - t r e e in Fig. 1).
Acknowledgements The authors wish to thank Prof. G. R. Burgio for his constant interest and support, Prof. S. Jayakar for reading the manuscript and Mrs. F. Gallo-Balma for secretarial help. Literature 1. Quie, P. G., Cates, K. L.: Clinical manifestations of disorders of neutrophil chemotaxis. In: Gallin, J. L, Quie, P. G. (eds.): Leukocyte chemotaxis. Raven Press, New York, 1978, p. 307-324.
2. Clark, R. A.: Disorders of granulocyte chemotaxis. In: Gallin, J. I., Quie, P. G. (eds.): Leukocyte chemotaxis. Raven Press, New York, 1978, p. 329-356. 3. Hill, H. R., Quie, P. G.: Raised serum IgE levels and defective neutrophil chemotaxis in three children with eczema and recurrent bacterial infections. Lancet 1 (1974) 183-187. 4. van Scoy, R. E., Hill, H. R., Ritts, R. E., Quie, P. G.: Familial neutrophil chemotaxis defect, recurrent bacterial infections, mucocutaneous candidiasis and hyperimmunoglobulinemia E. Ann. Int. Med. 82 (1975) 766-771. 5. Gahr, M., Ranti, J., SchrSter, W.: A new defect of neutrophil chemotaxis and r a n d o m motility in a child with recurrent infections and hypergammaglobutinemia E. Eur. J. Pediatr. 127 (1.978) 173-179. 6. Hill, H. R., Book, L. S., Hemming, V. G., Herbst, J. J.: Defective neutrophil chemotactic responses in patients with recurrent episodes of otitis media and chronic diarrhoea. Am. J. Dis. Child. 131 (1977) 433-436. 7. Platt-Mills, T. A. E., Ishizaka, K.: Activation of the alternative pathway of h u m a n complement by rabbit cells. J. Immunol. 113 (1974) 348-361. 8. Soothill, J. F., Harvey, B. A. M.: Defective opsonization. A c o m m o n immunity deficiency. Arch. Dis. Child. 51 (1976) 91-99. 9. Lehrer, R. I., Cline, M. J.: Interaction of Candida albicans with h u m a n Ieukocytes and serum. J. Bacteriol. 98 (1969) 996-1004. 10. Keusch, G. T., Douglas, S. D.: Intracellular bactericidal activity of leukocytes in whole blood for the diagnosis of chronic granulomatous disease of childhood. J. Infect. Dis. 131 (1975) 584-588. 11. Preisig, E., Hitzig, W. H.: Nitro-blue tetrazolium test for the detection of chronic granulomatous disease: technical modification. Eur. J. Clin. Invest. 1 (1971) 409-412. 12. Keusch, G. T., Douglas, S. D., Mildvan, D., Hirschman, S. Z.: 14C-glucose oxidation in whole blood: a clinical assay for phagocyte dysfunction. Infect. Immun. 5 (1972) 414-415. 13. Wilkinson, P. C.: Neutrophil leukocyte function tests. In: Thompson, R. A. (ed.): Techniques in clinical immunology. Blackwell Scientific Publications, Oxford, 1977, p. 201-218. 14. Zigmond, S. H., Hirsch, J. G.: Leukocyte locomotion and chemotaxis: New methods for evaluation and demonstration of cell derived chemotictic factors. J. Exp. Med. 137 (1973) 387--410. 15. Gallin, J. I., Wolff, S. M.: Leukocyte chemotaxis: Physiological considerations and abnormalities. Clin. Haematol. 4 (1975) 567-607.
Table 3: Leukocyte motility tests*. Tests
H**
R a n d o m filter migration RM
Chemotactic filter migration CT
G.M.
G.S.
D
36 + 2.65 (3)
12 _+1.15 (3)
R
35 + 4.24 (2)
20 + 5.66 (2)
D
74 + 6.24 (3)
35 _+6.24 (3)
R
70 + 7.07 (2)
40 _+4.24 (2)
Mother
Father
Range of controls***
68 + 8.49 (2)
62 + 7.07 (2)
5 5 - 70
115 -t- 4.24 (2)
118 -/- 2.83 (2)
105-120
* See Methods for description; the mean values + S. D. are given.; the n u m b e r of independent experiments is reported in parentheses. ** H = state of health; D = during the disease; R = at remission. *** Ten healthy adult individuals.
Infection 7 (1979) Nr. 1
47
A Defect in Neutrophil Motility in Two Siblings with Recurrent Infections and a Remarkable Family History Summary: Two siblings with recurrent infections were found to have impaired neutrophil motility. The same association of infections (otitis media, bronchitis, chronic diarrhoea) has caused seven fatalities in the paternal side of the family, suggesting genetic implications. Zusammenfassung: Defekt in der NeutrophiIen-Motilitiit bei zwei Geschwistern mit rezividierenden Infektionen und einer auflergew6hnlichen Familienanamnese. Bei zwei Geschwistern mit wiederholten Infektionen ist ein wahrscheinlich genetischer Schaden der Granulocyten-Chemotaxis gefunden worden. Durch H~iufung yon Infekten (Mittelohrentziindung, Bronchitis, chronischer Durchfall) sind sieben Geschwister in der v~terlichen Familie in jungem Alter gestorben.
Introduction The identification of functional abnormalities of the cellular and humoral components of leukocyte migration has contributed to the understanding of the mechanisms of impaired host defences in a variety of clinical settings (for a review see 1 and 2). Most of the described defects, which are not due to abnormalities of serum components but to the polymorphonuclear leukocytes (PMN) themselves, have been shown to be associated with elevated levels of immunoglobulin E (1--5). This paper describes two siblings with a cell-associated defect in leukocyte migration, normal levels of IgE, and a peculiar association of recurrent infections (otitis media, bronchitis and chronic diarrhoea). Seven fatalities are reported in the paternal side of the family as being due to the same association of infections. Isolated defects in neutrophil chemotaxis in patients suffering from repeated episodes of otitis media and diarrhoea have been described by Hill et al. (6) who have suggested an important role for the phagocyte in the protection of the mucosal surfaces of the respiratory and gastrointestinal tracts.
for weight and height. Since a few days after birth G. M. has suffered from frequent episodes of diarrhoea, purulent otitis media, upper respiratory tract infections and bronchitis (sometimes asthmatic). She has also had severe bronchopneumonia. At admission to our clinic, G. M. was suffering from acute pharyngitis, conjunctivitis and otitis media. Laboratory findings (Table 1) were unremarkable with the exception of a moderate hypergammaglobulinemia; all cultures were negative and the chest X-ray was unremarkable.
°< Figure 1: Family-tree of the patients (GM and GS). Seven fatalities ('~) in early infancy are reported as being due to an association of persistent diarrhoea, respiratory infections and otitis media (0). G. S. is a 13 month old male, born in the eighth month of pregnancy following a Caesarean section (birth weight , ~ a ,~. since the first days of life he has suffered fr,~m severe and recurrent diarrhoea (frequently with hyperpyrexia) and failure to thrive; in addition, middle ear and upper respiratory tract infections have often occurred. On admission to our clinic he was small (below the third percentile for weight and the tenth percentile for height) and had otitis media, upper respiratory tract infection, and persistent diarrhoea. Laboratory findings (Table 1) showed neutropenia and lymphocytosis with a low relative count of T lymphocytes. Chest X-ray was normal; sweat test, 24 hour faecal fat excretion, barium meal and xylose absorption were normal.
Case Reports
Materials and Methods
G. M. and G. S. are the only two children of unrelated parents coming from Central Italy. The family history is unremarkable on the maternal side, while seven fatalities in early infancy are reported on the paternal side with histories of recurrent respiratory infections and persistent diarrhoea (Figure 1). G. M. is a 7 year old female, born in the sixth month of pregnancy (birth weight 1,200 g), who showed reduced development until the age of four, later becoming normal
Platelet-free leukocytes were purified from heparinized venous blood by dextran (10/o)-erythroprecipitation and lowspeed spinwashings in phosphate-buffered saline (PBS). Received: 24 April 1978 Dr. F. T. Sacchi, Dr. F. A. Ferrari, Dr. G. Maggiore, Dr. M. Marconi, Dr. A. Pagani, Clinica Pediatrica dell'Universit~t, Ospedale S. Matteo, 1-27100 Pavia, Italy; Dr. A. Fortunato, Dr. A. G. Siccardi, Istituto di Genetica, Via S. Epifanio 14, 1-27100 Pavia, Italy.
Infection 7 (1979) Nr. 1
45
F. T. Sacchi et al.: Defective Leukocyte Motility and Recurrent Infections Table 1: Laboratory findings. G.M.
G.S.
RBC (xl06x/z1-1) Hb (gxl00 m1-1) Fe (~gxl00 ml -~)
4.8 I3.3 52
4.0 11.4 45
WBC (xl0°x/z1-1) Neutrophils (0/0) Lymphocytes (0/0) Eosinophils (°/0) ESR (Katz Index) Plasma Total Protein (gxl00 m1-1) Albumin (°/0) Globulin (°/0)
6.1 46 50 2 12.5
8.0 18 78 1 6.5
7.0 41.4 58.6
6.1 54.8 45.2
IgG (mgxl00 m1-1) IgA (mgxl00 m1-1) IgM (mgxl00 m1-1) IgE (I. U. xml -~) ~T lymphocytes (°/0) 2B lymphocytes (°/0) 0DTH-Skin Tests 4CH 50 (%) ~A. P. C. (Rabbit) (%) 5A. P. C. (Yeast) (0/0)
G.M.
G.S.
1122 145 178 95 62.5 15.5 N
624 35 142 22 42 NT N
98 103 97
102 100 89
1. Peripheral lymphocytes forming E-rosettes; 2. Peripheral lymphocytes Ig-positive with fluorescent anti-Ig antiserum, NT = not tested; 3. Delayed-type hypersensitivity skin tests (PPD, Candidin, Trichophyton, Streptokinase-Streptodornase), N == normal reactivity; 4. Complement level, assayed with the hemolytic assay on antibody-sensitized sheep erythrocytes; 5. Alternative pathway of complement activation, assayed with the hemolytic assay on unsensibilized rabbit erythrocytes (7) and with the yeast opsonization test (8). The results of the complement tests are expressed as percentages relative to a reference standard, a pool of sera from normal controls.
Candida albicans (from a hospital source) was maintained on Sabourad's agar slants and grown in Sabourad's broth to log phase (all yeast forms) before use in candidacidal tests. Staphylococcus aureus (ATCC 6538) was grown in Antibiotic Medium N. 3 (Difco) to mid-log phase and washed in fresh medium before use in bactericidal tests. CandidacidaI activity was assayed by the method of Lehrer and Cline (9) with a Candida: P M N ratio of 1 : 1. The data are expressed as the fraction (CK) of Candida cells killed in two hours. Bactericidal activity (S. aureus) was determined by a modification of the method described in (10) using a bacteria: P M N ratio of 1 : 10 to ensure total phagocytosis. The data are given as the fraction (BK) of bacterial cells killed in 90 rain. Phagocytosis and NBT reduction tests were performed by a modification of the method of Preisig and Hitzig (11); a leukocyte suspension containing 106 P M N was dispended into plastic tissue culture dishes (Nunclon, 4 cm) with 1.5 ml of PBS at 37 °C. After 30 rain the dishes were rinsed in PBS and additioned of 2 ml of NBT medium (NBT 0.1°/0, w/v, in PBS pH 6.8) and of 107 serum-treated, boiled Candida cells; after 30 rain the dishes were rinsed again, fixed and stained with safranin. 150 P M N were inspected (100 X objective, oil immersion) and classed on the basis of the number of intracellular yeasts (0-7) and the presence of formazan deposits ( + / - - ) . Three indexes were then calculated; PhF = phagocytosis frequency (the fraction of phagocyting PMN over total PMN inspected), Phi = phagocytic index (the average number of intracellular yeasts/PMN) and N R F = NBT reduction frequency (the fraction of phagocyting P M N with formazan deposits over total phagocyting PMN). An estimate of leukocyte adherence (mean number of leukocytes/high-power field) was also obtained. The phagocytosis-dependent metabolic activation of P M N leukocytes (12) was measured as the KCN-resistant production of 14CO2 from ~4Ct-glucose (0.1 #Ci/assay; 1.44 ~Ci/ #mole) in the presence and in the absence of latex phagocytosis. The results are expressed as P/R (cpm phagocyting/ cpm resting) ratios. Leukocyte motility tests were performed as in (13) with modified Boyden chambers and Millipore filters (pore size 3 #m). Bacterial LPS (Difco, 10#g/ml) plus normal serum (5°/0) were used as the chemotactic stimulus where appro-
46
Infection 7 (1979) Nr. 1
priate. Both random filter- and chemotactic filter-migrations (RM and CT) were evaluated (at 60 min) by the "leading front" method described by (14) as the average distance (in /zm) travelled by the two fastest cells in each of highpower fields.
Results and Discussion T h e leukocyte f u n c t i o n tests p e r f o r m e d on the two patients and on their parents (Tables 2 and 3) show that both patients have an isolated defect in leukocyte motility. T h e defect is persistent at clinical remission and confined mainly to the r a n d o m migration process. A l t h o u g h chemotactic migration is highly reduced for b o t h patients in absolute values, the chemotactic index (i. e. the ratio of c h e m o t a c t i c / r a n d o m migrations)attains n o r m a l values (2.0--2.92; range of controls: 1.6--2.2) indicating that the patients' cells are responsive to the chemotactic stimuIus. T h e defect did not appear to be the result of a serum inhibitor of leukocyte motility, as the t r e a t m e n t of n o r m a l leukocytes with the serum of the patients did not impair their motility; m o r e o v e r , washing the patients' cells with serum f r o m a pool of controls did not restore chemotactic responsiveness. The defect encountered in the two siblings thus seems to be an intrinsic cellular defect in motility; in view of the functional classification scheme p r o p o s e d by Gatlin and Wolff (15) it is interesting to note that P M N adherence to plastic seems to be n o r m a l in both patients (Table 2). T h e n o r m a l levels of IgE, the abn o r m a l r a n d o m motility, and the lack of restoration of n o r m a l motility by incubation in n o r m a l sera clearly differentiate these patients f r o m those described by Hill and Quie (3), van Scoy et aI. (4), and by Gahr et al (5). A very detailed description of an association between otitis media, chronic diarrhoea and defective chemotaxis has been published by Hill et al. (6); in their case, the
F. T. Sacchi et al.: Defective Leukocyte Motility and Recurrent Infections Table 2: Leukocyte/unction tests* (except motility). Tests
G.M.
G.S.
Mothers
Range of controls**
Adherence (PMN/hpf)
11.26
12.02
11.32
10.21-12.60
0.92 3.81
0.91 3.41
0.78 2.63
0.71- 0.95 2.10- 4.10
Phagocytosis PhF Phi Metabolic activation P/R NRF
6.81 0.97
4.03 0.97
5.43 0.97
3.90- 7.20 0.87- 0.99
S. aureus killing BK
0.78
0.85
0.90
0.75- 0.90
C. albicans killing CK
0.63
0.84
0.65
0.60- 0.75
* See Methods for description; the mean values of two independent experiments are given. ** 8 healthy adult individuals. defects are t r a n s i e n t (or i n t e r m i t t e n t ) a n d d i s a p p e a r at clinical r e m i s s i o n ; n o i n d i c a t i o n is g i v e n of the possible i n v o l v e m e n t of genetic factors. C o n v e r s e l y , o u r p a t i e n t s s u f f e r f r o m a very similar assoc i a t i o n o f s y m p t o m s , b u t t h e m o t i l i t y defects h a v e persisted at clinical r e m i s s i o n a n d t h e v e r y r e m a r k a b l e f a m i l y h i s t o r y suggests a f a m i l i a l p r e v a l e n c e of t h e condition. T h e m o d e of genetic t r a n s m i s s i o n , h o w e v e r , is n o t obvious; were t h e c o n d i t i o n i n d e e d genetic it m i g h t b e due to a d o m i n a n t gene w i t h i n c o m p l e t e p e n e t r a n c e (see f a m i l y - t r e e in Fig. 1).
Acknowledgements The authors wish to thank Prof. G. R. Burgio for his constant interest and support, Prof. S. Jayakar for reading the manuscript and Mrs. F. Gallo-Balma for secretarial help. Literature 1. Quie, P. G., Cates, K. L.: Clinical manifestations of disorders of neutrophil chemotaxis. In: Gallin, J. L, Quie, P. G. (eds.): Leukocyte chemotaxis. Raven Press, New York, 1978, p. 307-324.
2. Clark, R. A.: Disorders of granulocyte chemotaxis. In: Gallin, J. I., Quie, P. G. (eds.): Leukocyte chemotaxis. Raven Press, New York, 1978, p. 329-356. 3. Hill, H. R., Quie, P. G.: Raised serum IgE levels and defective neutrophil chemotaxis in three children with eczema and recurrent bacterial infections. Lancet 1 (1974) 183-187. 4. van Scoy, R. E., Hill, H. R., Ritts, R. E., Quie, P. G.: Familial neutrophil chemotaxis defect, recurrent bacterial infections, mucocutaneous candidiasis and hyperimmunoglobulinemia E. Ann. Int. Med. 82 (1975) 766-771. 5. Gahr, M., Ranti, J., SchrSter, W.: A new defect of neutrophil chemotaxis and r a n d o m motility in a child with recurrent infections and hypergammaglobutinemia E. Eur. J. Pediatr. 127 (1.978) 173-179. 6. Hill, H. R., Book, L. S., Hemming, V. G., Herbst, J. J.: Defective neutrophil chemotactic responses in patients with recurrent episodes of otitis media and chronic diarrhoea. Am. J. Dis. Child. 131 (1977) 433-436. 7. Platt-Mills, T. A. E., Ishizaka, K.: Activation of the alternative pathway of h u m a n complement by rabbit cells. J. Immunol. 113 (1974) 348-361. 8. Soothill, J. F., Harvey, B. A. M.: Defective opsonization. A c o m m o n immunity deficiency. Arch. Dis. Child. 51 (1976) 91-99. 9. Lehrer, R. I., Cline, M. J.: Interaction of Candida albicans with h u m a n Ieukocytes and serum. J. Bacteriol. 98 (1969) 996-1004. 10. Keusch, G. T., Douglas, S. D.: Intracellular bactericidal activity of leukocytes in whole blood for the diagnosis of chronic granulomatous disease of childhood. J. Infect. Dis. 131 (1975) 584-588. 11. Preisig, E., Hitzig, W. H.: Nitro-blue tetrazolium test for the detection of chronic granulomatous disease: technical modification. Eur. J. Clin. Invest. 1 (1971) 409-412. 12. Keusch, G. T., Douglas, S. D., Mildvan, D., Hirschman, S. Z.: 14C-glucose oxidation in whole blood: a clinical assay for phagocyte dysfunction. Infect. Immun. 5 (1972) 414-415. 13. Wilkinson, P. C.: Neutrophil leukocyte function tests. In: Thompson, R. A. (ed.): Techniques in clinical immunology. Blackwell Scientific Publications, Oxford, 1977, p. 201-218. 14. Zigmond, S. H., Hirsch, J. G.: Leukocyte locomotion and chemotaxis: New methods for evaluation and demonstration of cell derived chemotictic factors. J. Exp. Med. 137 (1973) 387--410. 15. Gallin, J. I., Wolff, S. M.: Leukocyte chemotaxis: Physiological considerations and abnormalities. Clin. Haematol. 4 (1975) 567-607.
Table 3: Leukocyte motility tests*. Tests
H**
R a n d o m filter migration RM
Chemotactic filter migration CT
G.M.
G.S.
D
36 + 2.65 (3)
12 _+1.15 (3)
R
35 + 4.24 (2)
20 + 5.66 (2)
D
74 + 6.24 (3)
35 _+6.24 (3)
R
70 + 7.07 (2)
40 _+4.24 (2)
Mother
Father
Range of controls***
68 + 8.49 (2)
62 + 7.07 (2)
5 5 - 70
115 -t- 4.24 (2)
118 -/- 2.83 (2)
105-120
* See Methods for description; the mean values + S. D. are given.; the n u m b e r of independent experiments is reported in parentheses. ** H = state of health; D = during the disease; R = at remission. *** Ten healthy adult individuals.
Infection 7 (1979) Nr. 1
47
