Pediatric Pulmonology 13:259-265 (1992)
Aplasia of Respiratory Tract Cilia K. DeBoeck, MD, pm,' M. Jorissen, MD, pm,* K. Wouters, MD,' B. Van der S~hueren,~ M. Eyssen, MD,' M. Casteels-VanDaele, MD,' and L. Corbeel, MD' Summary. We report on ciliary aplasia of the respiratorytract, a rare disorder of the rnucociliary apparatus, that is insufficiently recognized as a distinct entity. A culture method for ciliogenesis was developed by our laboratory and offers the advantage of studying cilia free of secondary changes associated with infection. Three cases of primary ciliary aplasia were documented histologically in direct biopsy specimens and also in biopsy specimens cultured specifically for ciliogenesis. Primary ciliary aplasia should be differentiated from secondary ciliary aplasia in which basal bodies are present and ciliogenesis takes place in specific culture. Only hereditary ciliary abnormalities are expressed in cell cultures. We critically review the cases of ciliary aplasia reported to date. Pediatr Pulmonol. 1992; 13:259-265 Q 1992Wiley-Liss. Inc. Key words: Primary ciliary dyskinesia; immotile cilia syndrome; chronic respiratory disease.
INTRODUCTION
Primary ciliary dyskinesia is a rare but well-known cause of chronic upper and lower respiratory tract disease.' We report on ciliary aplasia, a rare congenital disorder of the mucociliary apparatus that is insufficiently recognized as a specific entity. This condition is documented in direct biopsy specimens as well as in biopsies cultured specifically for ciliogenesis, from a set of twins and an unrelated girl. Primary ciliary aplasia is contrasted with a case report of secondary ciliary aplasia, associated with acute infection, in which basal bodies are present and ciliogenesis does take place in vitro. CASEREPORTS Case A.C. A.C. was born at term as one member of monozygous twins of Italian descent. Her birthweight was 3,100 g. The baby remained in the hospital for 40 days because of ill-defined respiratory problems. As a toddler she suffered from frequent upper and lower respiratory tract infections. Tonsillectomy and adenoidectomy did not bring about any improvement. Rhinitis, cough, sputum production, intermittent wheezing, and fever continued to be a problem. At the age of 11 years scoliosis required the prescription of a brace. One year later, the girl came to our attention. The family tree showed that the maternal grandmother had married her own uncle. The twin sister, K.C., had a similar history of nasal discharge, chronic cough and sputum production. A 25-year-old female cousin living in Italy suffered from respiratory tract infections and infertility. 0 1992 Wiley-Liss, Inc.
Physical examination revealed a short and thin earlypubertal girl (weight, 20 kg (P3 = 28 kg); height, 129 cm (P3 = 138 cm); Tanner score, A1 M2 P2). She had a marked scoliosis and mild clubbing. Fine rales and wheezes were audible over both lung bases. The tympanic membranes were retractile and mildly scarred. A purulent nasal discharge was present. Hemophilus injluenzae 3+ was isolated from the sputum culture. Viral cultures remained negative. Chest x-ray film showed a left lower lobe consolidation and increased perihilar bronchial markings. In addition, computerized tomography revealed bronchiectatic changes in the left lower and right middle lobe. The head and neck of the I I th rib had an increased size and were speckled with calcifications. This suggested a benign rib tumor, most likely an enchondroma. The sweat test was normal. Serum immunoglobulins were within the normal range for age (IgG, 1,386 mg/dL; IgA, 216 mg/dL; IgM, 285 mg/dL; IgE < 20 U/mL). IgG subclasses were normal. Secretory IgA was present. Percentages of B and T lymphocytes and T lymphocyte subsets were normal. Gastroesophageal reflux was excluded by barium swallow, reflux scintigraphy, and 24hour pH monitoring. Normal serum alpha I antitrypsine
From the Departments of Pediatrics,' Otorhinolaryngology,' and Genetics,3 University of Leuven, Leuven, Belgium. Received October 1, 1991; (revision) accepted for publication February 25, 1992. Address correspondence and reprint requests to Dr. K. De Boeck. Department of Pediatrics, University Hospital Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium.
260
DeBoeck et al.
Fig. 1. Electron microscopy of bronchial epithelial cells shows absence of cilia and basal bodies (magnification: bar = 1 Fm). Only microvilliare present at the apical cell side.
and negative tuberculin skin test excluded other causes of chronic pulmonary disease. Mucociliary transport assessed by technetium scintigraphy was absent. Direct microscopic examination and electron microscopy studies of epithelial cells in scrapings from the inferior nasal turbinate did not reveal ciliated cells. Direct microscopic examination of bronchial brushings taken from the trachea and the main stem bronchi also did not reveal ciliated cells. Ciliary movement was never seen. Two nasal biopsies and two bronchial biopsies from each main stem bronchus were taken. One biopsy from each site was used for electron microscopy studies of the epithelial cells. In the nasal biopsy and in one bronchial biopsy, only two cells having less than 7 cilia were found (a normal cell has about 200 cilia). These cilia originated in a basal body, but since they were cut longitudinally, the transverse ultrastructure could not be assessed. Basal bodies, other than the few associated
with the cilia were not found. Electron microscopy of the other epithelial cells in the nasal and bronchial biopsies showed no cilia or basal bodies. The epithelial cells had only numerous apical villi without microtubular structures (Fig. 1). Striated roots, mitochondria, and Golgi apparatus were all present at the apical cell side. The other nasal biopsy and the bronchial biopsy from each stem bronchus were cultured specifically for ciliogenes ~ s After . ~ in vitro cell culture no cilia formation took place. No basal bodies were present (Fig. 2). Another nasal biopsy was studied 4 months later. Again no cilia were seen by direct microscopic examination or after cell culture for ciliogenesis. Hypocaloric intake was the reason for the dystrophy, which improved on adequate nutrition. Treatment with antibiotics and physiotherapy resulted in a marked reduction of cough and sputum production. Maximal expiratory flows improved forced vital capacity (FVC) to 75%
Aplasia of Respiratory Tract Cilia
261
Case K.C. K.C., the twin sister of A.C., had a similar history of repeated upper and lower respiratory tract infections since birth. She presented with rhinitis, chronic cough, sputum production, and intermittent wheezing. She was 131 cm tall and weighed 26 kg, both values slightly below P3. Clubbing was present as were rales and wheezes over the chest. There was no scoliosis. Purulent nasal discharge indicated chronic rhinitis; otitis media with effusion was present. Hemophilus injluenzae was isolated from sputum culture. Chest radiograph showed hyperinflation and marked increase in bronchial markings. Serum immunoglobulins were within normal limits: IgG, 1,477 mg/dL; IgA, 210 mg/dL; IgM, 280 mg/dL, IgE, C 20 U/mL. IgG subclasses were normal. IgA was present in the sputum. Cellular immunity assessed by percentage of T and B lymphocytes and T lymphocyte subsets was normal. Sweat test was normal. Gastroesophageal reflux was excluded. Technetium scintigraphy revealed the absence of ciliary transport. In addition to nasal and bronchial scrapings, three nasal and four bronchial biopsies were also studied in this girl. The epithelial cells had no cilia. Only microvilli without microtubular content were present at the apical cell side. The different ciliary studies were performed over a 6-month period and at every occasion in the interval between bouts of respiratory tract infection. Case D.N. D.N. was born at term as the first child of healthy unrelated Belgian parents. The pregnancy was uneventful. Respiratory problems became evident at birth with chest retractions, cyanosis on exertion, and rales by auscultation. Her chest radiograph revealed streaky pulmonary infiltrates. Generalized seizures occurred on day 9. Routine biochemistry, lumbar puncture, electroencephalography, fundoscopic examination, and metabolic screening all gave normal results. Computerized tomography of the brain revealed moderate supratentorial hydrocephalus. The head circumference was not increased. Coughing and wheezing persisted despite treatment with antibiotics and chest physiotherapy. The baby remained Fig. 2. Electron microscopy of nasal epithelial cells cultured specifically for ciliogenesis shows absence of normal cilia and hospitalized for 4 weeks and was readmitted three times basal bodies (magnlfication: bar = 1 pm). At the apical cell side in the first year of life because of pulmonary infiltrates. numerous vllll without microtubular structures are visible; stri- Sweat test, gastroesophageal reflux studies, and humoral ated roots, the normal accessory structures of basal bodies are and cellular immunity were normal. Nasal brushings present. were studied on three occasions. By direct microscopy, cilia and ciliary movement were never seen. Bronchial of normal, forced expiratory volume in 1 second (FEV,) biopsies, two from each main stem bronchus, were studto 66% of normal with no change after bron~hodilator.~ied twice at 2 years’ interval. All biopsies revealed total Total lung capacity (TLC) remained at 101% of normal. absence of cilia and basal bodies in the respiratory tract Thoracic gas volume (TGV) was 149% of normal. The epithelium. The epithelial cells only had a microvillar head of the eleventh rib was resected and the presence of border with absent to very scanty filaments or microtubuli. At the apical cell surface, numerous dense mitoan enchondroma was proved on histology.
262
DeBoeck et al.
Fig. 3. Electron microscopyof bronchial epithelial cells reveals nearly complete absence of cilia but the presence of a normal amount of basal bodies and an ample amount of microtubuli (magnification:bar = 1 pn).
chondria were noticed as well as striated roots and a well-established Golgi apparatus. The same abnormalities were documented in epithelial cells obtained by nasal biopsy and cultured specifically for ciliogenesis. At present the girl is 9 years old. Chronic rhinitis and chronic middle ear effusion continue to be a problem as are chronic cough and sputum production. She had three more episodes of generalized seizures associated with a febrile illness. Her height and weight are at P3 to P25 and head circumference is at P90. She has mild clubbing. Ronchi, wheezes, and rales are heard over both lung fields. Chest radiograph reveals hyperinflation and streaky pulmonary infiltrates. Pulmonary function tests revealed FVC of 65% of normal, FEV, of 56% of normal, and TGV of 171% of normal. The absence of respiratory tract cilia has been documented a total of 6 times
over a 7-year period on material obtained by brushings, biopsies, and cell culture in both nasal and bronchial sites. Case S.P.
S.P. was born at term from healthy, non-consanguineous parents. At the age of 3 years, she had four episodes of febrile convulsions associated with upper respiratory tract infections. She presented at the age of 9 years with a 3-month history of cough without fever. Physical examination revealed a child in good general health. Height and weight were both at P25. On chest auscultation localized rales were heard over the left lower lobe. A left lower lobe infiltrate was present on chest radiograph. Sedimentation rate was 19 mm after 1 hour; white blood cell count was 11,2001p.L with 63% neutrophils. Viral serologies 6
Aplasia of Respiratory Tract Cilia TABLE 1-Case
263
Reports of Ciliary Aplasia Classified According to the Methods Used for Documentationa
Author Nasal acilia only Dudley‘ “Total ciliary aplasia” by light microscopy only Jahrsdoerfer Evander E9 Buchdahl’” ‘Total ciliary aplasia” by light and electron microscopy in nasal biopsy Fonzi’
Chronic upper resp. tract infection
Chronic lower resp. tract infection
Normal
+
-
Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal
Abnormal Not done Not done Abnormal Not done Not done
+ + + + + +
+ + + + + +
F F M
Abnormal Abnormal Abnormal
Not done Not done Not done
+ + +
+ +
Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal
Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal
+ + + + + + +
+ + + + +
Abnormal Abnormal Abnormal
Abnormal Abnormal Abnormal
+ + +
Year
Age at report (years)
Sex
Nasal biopsy
1982
3 months
M
Abnormal
1979 1983 1983 1988
8 29 33 mean age 8.4
M M F F F F
1982
11 14
Matwijiw” Total ciliary aplasia by light and electron microscopy in nasal and bronchial biopsy Gotz’*
1987
23
GordonI3 ~e santi14 De Santi15 Total ciliary aplasia by light and electron microscopy in nasal and bronchial culture Present study
1984 1988 I990
13 11 8
F F F F M M F
1992
12 12 9
F F F
I983
3 months to 9 years
Bronchial biopsy
Situs inversus
Other
+ +
+
+
+ +
‘Superscript numbers by authors are references.
weeks apart showed a seroconversion from negative to 1/32 for respiratory syncitial virus. Sweat test was normal. Immunoglobulins were within normal limits for age. T and B lymphocytes and T subsets as well as lymphocyte transformation tests with mitogens and antigens were normal. Neutrophil chemotaxis, phagocytosis, and killing were normal. Foreign body inhalation was excluded by bronchoscopy . Bronchography revealed tubular bronchiectasis of the left lower lobe bronchi. Gastroesophageal reflux was absent on barium swallow. FVC was 72% of normal, FEV, was 67% of normal, and Tiffenau index was 75. This airway obstruction was unresponsive to inhaled bronchodilators. Nasal brushings were studied on two occasions. They revealed only a few ciliated cells with decreased motility. Bronchial biopsies
were studied on one occasion, after 2 months’ treatment with antibiotics. The epithelial cells had almost no cilia, but a normal amount of basal bodies and ample microtubuli were present (Fig. 3). Golgi apparatus and mitochondria were also present. The few cilia that were present showed an abnormal amount of peripheral pairs and absent or supernumerous central microtubuli. The central microtubuli of neighboring cells were oriented differently, a feature compatible with secondary ciliary dyskinesia. A nasal ciliary biopsy was studied on one occasion and was cultured specifically for ciliogenesis. After 6 weeks of culture, a normal number of cilia were present. Fifty cross sections were studied: ciliary ultrastructure was normal. Ciliary beating was assessed in a qualitative way and was found to be normal. The girl eventually
264
DeBoeck et at.
became asymptomatic under antibiotics (R/erythromycin S.P. in the present report) have been noted. This also and amoxicillin) and chest physiotherapy. Ciliary studies points to a congenital and widespread absence of ciliary function. Consanguinity and the occurence of several were not repeated. cases within one family indicate a hereditary disorder. In the reported cases, the pattern of inheritance is compatiDISCUSSION ble with an autosomal recessive disorder. I n conclusion, ciliary aplasia is a rare congenital and Textbooks on pediatric respiratory medicine do not hereditary disorder of the rnucociliary apparatus. The discuss ciliary aplasia.’ Ciliary aplasia is a rare congeniclinical picture and the associated abnormalities are the tal disorder of the mucociliary apparatus defined by total in primary ciliary dyskinesia. Few cases have same as absence of respiratory epithelial cilia on cells that manifully documented. Absence of basal bodies differenbeen fest all other ultrastructural features of normal ciliated tiates primary ciliary aplasia from ciliary aplasia secondcells. Chronic infection of the upper and lower respiraary to acute infection. Microscopic examination of bioptory tract comprises the clinical picture. The disorder sies cultured specifically for ciliogenesis aids in cannot be distinguished from primary ciliary dyskinesia differentiating primary and secondary ciliary asplasia; on clinical grounds. The first report of nasal acilia syndrome6 coincided with the report on total acilia of the ciliary outgrowth does not take place in biospies with respiratory tract by F ~ n z i We . ~ traced a total of 1 1 pa- absent basal bodies. pers”I6 (Table l ) of which only 4 provide sufficient detail to allow a confident diagnosis of ciliary aplasia. REFERENCES Reference 15 describes previously reported patients. I 4 * l 5 I . Afzelius BA. A human syndrome caused by immotile cilia. SciThis adds up to a total of seven adequately documented ence. 1976; 193:317-319. patients. It is difficult to prove the absence of something. 2. van der Baan S, Veerman AJP, Wcltevreden E, Feenstra L. Kartagener’s syndrome: Clinical features and laboratory studies. Eur J However, in the twins described, the ciliary aplasia was Respir Dis. 1983; 64(Suppl 127):91-95. documented three times over a 6-month period after re3. Jorisscn M. Van der Schueren B, Van den Berghe H, Cassiman covery from acute infection. In the third patient, it was JJ. The preservation and regeneration of cilia o n human nasal documented six times over a 7-year period between epiepithelial cells cultured in vitro. Arch Otorhinolaryngol. 1989: sodes of acute infection. These abnormalities therefore 246:308-3 14. 4. Zapletal A, Motoyama EK. Van de Woestijne KP, Hunt VR, do not represent transient ciliary changes induced by pulBouhuys A. Maximum expiratory flow-volume curves and airway monary infection as described by Corbeel.” Indeed, priconductance in children and adolesccnts. J Appl Physiol. 1969: mary ciliary abnormalities must always be distinguished 1491343-371, from secondary ones caused by infection and injury.I8 5 . Sturgess JM, Turner JAP. The immotile cilia syndrome. In: CherThe fourth case illustrates such a condition. Stockinger” nick V, ed. Kendig’s Disorders of the Rcspiratory Tract in Children. Philadelphia: WB Saunders, l990:675482. classified the primary ciliary deficiencies according to the 6. Dudley JP, Welch MJ, Stiehm ER, Carney JM, Soderbergarrest in ciliary development at the level of formation of Warner M. Scanning and transmission electron microscopic asprocentrioles, formation of kinetosomes, and outgrowth pects of the nasal acilia syndromc. Laryngoscope. 1982; 92:297of the ciliary shaft. Disorders at the first level lead to 299. partial or total aplasia of respiratory tract cilia. According 7. Fonzi L, Lungarella G, Palatresi R. Lack of kinocilia in the nasal mucosa in the immotile cilia syndromc. Eur J Respir Dis. 1982: to Stockinger, alterations at this level are exclusively due 63:558-563. to hereditary factors. The absence of basal bodies in our 8. Jahrsdoerfer R. Feldman PS, Rubel EW, GUerGdnt JL, Egglcston three patients clearly classifies them into this group. AbPA, Selden RF. Otitis media and the immotile cilia syndrome. sence of basal bodies in electron microscopic studies was Laryngoscope. 1979; 89:769-777. also considered crucial by other authors. 9. Evander E, Arborelius M, Jonnon B, Simonsson BG, Svensson G. Lung function and bronchial reactivity in six patients with immoAn aid to differentiate primary (i.e., congenital) or tile cilia syndrome. Eur J Respir Dis. 1983: 64(Suppl 127):137hereditary absence of cilia formation from ciliary aplasia 143. secondary to infection is to culture biopsy material spe- 10. Buchdahl RM, Reiser J. lngram D, Rutman A. Cole PJ. Warner cifically for ciliogenesis.’ This offers the advantage of JO. Ciliary abnormalities in respiratory disease. Arch Dis Child. studying cilia free from secondary changes associated 1988; 631238-243. with infection. The culture from the patient whose cells 11, Matwijiw I, Thilveris JA, Faiman C. Aplasia of nasal cilia with situs inversus, azoospermia and normal sperm flagella: A unique contained basal bodies produced normal cilia formation. variant of the immotile cilia syndrome. J Urol. 1987; 137522On the other hand, hereditary ciliary abnormalities are 524. expressed in vitro.*’ Similarly to primary ciliary dyskine- 12. Gotz M , Stockinger L. Aplasia of respiratory tract cilia. Lancet. sia,in ciliary aplasia associated abnormalities such as 1983: 1:1283. dextrocardia. azoosoermia. and hvdroceohalus (mtient 13. Gordon RE. Kattan M. Absence of cilia and basal bodies with
Aplasia of Respiratory Tract Cilia predominance of brush cells in the respiratory mucosa from a patient with immotile cilia syndrome. Ultrastruct Pathol. 1984; 6:4549. 14. De Santi MM, Gardi C, Barlocco EG, Canciani M, Mastella G, Lungarella G. Cilia-lacking respiratory cells in ciliary aplasia. Biol Cell. 1988; 64:67-70. 15. De Santi MM, Magni A, Valletta EA, Gardi C, Lungarella G. Hydrocephalus, bronchiectasis and ciliary asplasia. Arch Dis Child. 1990;65:543-544. 16. Barlocco EG, Valletta EA, Cancianoi M, Lungarella G, Gardi C, De Santi M, Mastella G. Ultrastructural ciliary defects in children with recurrent infections of the lower respiratory tract. Pediatr Pulmonol. 1991; 1O:Il-17.
265
17. Corbeel L, Comillie F, Lauweryns J , Boel M, Van den Berghe G. Ultrastructural abnormalities of bronchial cilia in children with recurrent airway infections and bronchiectasis. Arch Dis Child. 1981; 56:929-933. 18. Afzelius BA. lmmotile cilia syndrome and ciliary abnormalities induced by infection and injury. Am Rev Respir Dis. 1981; I 24: 107- 109. 19. Stockinger L, Sellner W, Ellinger A, Hofler H. Pathophysiology of the ciliated epithelium of the respiratory mucosa in humans. Exp Lung Res. 1989; 15:925-941. 20. Jorissen M, Vanderschueren B, De Boeck K, Cassiman JJ. Expression of hereditary abnormalities in cultured nasal epithelial cells. Eur Respir J. 1991; 4(Suppl 14):522S.
Aplasia of Respiratory Tract Cilia K. DeBoeck, MD, pm,' M. Jorissen, MD, pm,* K. Wouters, MD,' B. Van der S~hueren,~ M. Eyssen, MD,' M. Casteels-VanDaele, MD,' and L. Corbeel, MD' Summary. We report on ciliary aplasia of the respiratorytract, a rare disorder of the rnucociliary apparatus, that is insufficiently recognized as a distinct entity. A culture method for ciliogenesis was developed by our laboratory and offers the advantage of studying cilia free of secondary changes associated with infection. Three cases of primary ciliary aplasia were documented histologically in direct biopsy specimens and also in biopsy specimens cultured specifically for ciliogenesis. Primary ciliary aplasia should be differentiated from secondary ciliary aplasia in which basal bodies are present and ciliogenesis takes place in specific culture. Only hereditary ciliary abnormalities are expressed in cell cultures. We critically review the cases of ciliary aplasia reported to date. Pediatr Pulmonol. 1992; 13:259-265 Q 1992Wiley-Liss. Inc. Key words: Primary ciliary dyskinesia; immotile cilia syndrome; chronic respiratory disease.
INTRODUCTION
Primary ciliary dyskinesia is a rare but well-known cause of chronic upper and lower respiratory tract disease.' We report on ciliary aplasia, a rare congenital disorder of the mucociliary apparatus that is insufficiently recognized as a specific entity. This condition is documented in direct biopsy specimens as well as in biopsies cultured specifically for ciliogenesis, from a set of twins and an unrelated girl. Primary ciliary aplasia is contrasted with a case report of secondary ciliary aplasia, associated with acute infection, in which basal bodies are present and ciliogenesis does take place in vitro. CASEREPORTS Case A.C. A.C. was born at term as one member of monozygous twins of Italian descent. Her birthweight was 3,100 g. The baby remained in the hospital for 40 days because of ill-defined respiratory problems. As a toddler she suffered from frequent upper and lower respiratory tract infections. Tonsillectomy and adenoidectomy did not bring about any improvement. Rhinitis, cough, sputum production, intermittent wheezing, and fever continued to be a problem. At the age of 11 years scoliosis required the prescription of a brace. One year later, the girl came to our attention. The family tree showed that the maternal grandmother had married her own uncle. The twin sister, K.C., had a similar history of nasal discharge, chronic cough and sputum production. A 25-year-old female cousin living in Italy suffered from respiratory tract infections and infertility. 0 1992 Wiley-Liss, Inc.
Physical examination revealed a short and thin earlypubertal girl (weight, 20 kg (P3 = 28 kg); height, 129 cm (P3 = 138 cm); Tanner score, A1 M2 P2). She had a marked scoliosis and mild clubbing. Fine rales and wheezes were audible over both lung bases. The tympanic membranes were retractile and mildly scarred. A purulent nasal discharge was present. Hemophilus injluenzae 3+ was isolated from the sputum culture. Viral cultures remained negative. Chest x-ray film showed a left lower lobe consolidation and increased perihilar bronchial markings. In addition, computerized tomography revealed bronchiectatic changes in the left lower and right middle lobe. The head and neck of the I I th rib had an increased size and were speckled with calcifications. This suggested a benign rib tumor, most likely an enchondroma. The sweat test was normal. Serum immunoglobulins were within the normal range for age (IgG, 1,386 mg/dL; IgA, 216 mg/dL; IgM, 285 mg/dL; IgE < 20 U/mL). IgG subclasses were normal. Secretory IgA was present. Percentages of B and T lymphocytes and T lymphocyte subsets were normal. Gastroesophageal reflux was excluded by barium swallow, reflux scintigraphy, and 24hour pH monitoring. Normal serum alpha I antitrypsine
From the Departments of Pediatrics,' Otorhinolaryngology,' and Genetics,3 University of Leuven, Leuven, Belgium. Received October 1, 1991; (revision) accepted for publication February 25, 1992. Address correspondence and reprint requests to Dr. K. De Boeck. Department of Pediatrics, University Hospital Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium.
260
DeBoeck et al.
Fig. 1. Electron microscopy of bronchial epithelial cells shows absence of cilia and basal bodies (magnification: bar = 1 Fm). Only microvilliare present at the apical cell side.
and negative tuberculin skin test excluded other causes of chronic pulmonary disease. Mucociliary transport assessed by technetium scintigraphy was absent. Direct microscopic examination and electron microscopy studies of epithelial cells in scrapings from the inferior nasal turbinate did not reveal ciliated cells. Direct microscopic examination of bronchial brushings taken from the trachea and the main stem bronchi also did not reveal ciliated cells. Ciliary movement was never seen. Two nasal biopsies and two bronchial biopsies from each main stem bronchus were taken. One biopsy from each site was used for electron microscopy studies of the epithelial cells. In the nasal biopsy and in one bronchial biopsy, only two cells having less than 7 cilia were found (a normal cell has about 200 cilia). These cilia originated in a basal body, but since they were cut longitudinally, the transverse ultrastructure could not be assessed. Basal bodies, other than the few associated
with the cilia were not found. Electron microscopy of the other epithelial cells in the nasal and bronchial biopsies showed no cilia or basal bodies. The epithelial cells had only numerous apical villi without microtubular structures (Fig. 1). Striated roots, mitochondria, and Golgi apparatus were all present at the apical cell side. The other nasal biopsy and the bronchial biopsy from each stem bronchus were cultured specifically for ciliogenes ~ s After . ~ in vitro cell culture no cilia formation took place. No basal bodies were present (Fig. 2). Another nasal biopsy was studied 4 months later. Again no cilia were seen by direct microscopic examination or after cell culture for ciliogenesis. Hypocaloric intake was the reason for the dystrophy, which improved on adequate nutrition. Treatment with antibiotics and physiotherapy resulted in a marked reduction of cough and sputum production. Maximal expiratory flows improved forced vital capacity (FVC) to 75%
Aplasia of Respiratory Tract Cilia
261
Case K.C. K.C., the twin sister of A.C., had a similar history of repeated upper and lower respiratory tract infections since birth. She presented with rhinitis, chronic cough, sputum production, and intermittent wheezing. She was 131 cm tall and weighed 26 kg, both values slightly below P3. Clubbing was present as were rales and wheezes over the chest. There was no scoliosis. Purulent nasal discharge indicated chronic rhinitis; otitis media with effusion was present. Hemophilus injluenzae was isolated from sputum culture. Chest radiograph showed hyperinflation and marked increase in bronchial markings. Serum immunoglobulins were within normal limits: IgG, 1,477 mg/dL; IgA, 210 mg/dL; IgM, 280 mg/dL, IgE, C 20 U/mL. IgG subclasses were normal. IgA was present in the sputum. Cellular immunity assessed by percentage of T and B lymphocytes and T lymphocyte subsets was normal. Sweat test was normal. Gastroesophageal reflux was excluded. Technetium scintigraphy revealed the absence of ciliary transport. In addition to nasal and bronchial scrapings, three nasal and four bronchial biopsies were also studied in this girl. The epithelial cells had no cilia. Only microvilli without microtubular content were present at the apical cell side. The different ciliary studies were performed over a 6-month period and at every occasion in the interval between bouts of respiratory tract infection. Case D.N. D.N. was born at term as the first child of healthy unrelated Belgian parents. The pregnancy was uneventful. Respiratory problems became evident at birth with chest retractions, cyanosis on exertion, and rales by auscultation. Her chest radiograph revealed streaky pulmonary infiltrates. Generalized seizures occurred on day 9. Routine biochemistry, lumbar puncture, electroencephalography, fundoscopic examination, and metabolic screening all gave normal results. Computerized tomography of the brain revealed moderate supratentorial hydrocephalus. The head circumference was not increased. Coughing and wheezing persisted despite treatment with antibiotics and chest physiotherapy. The baby remained Fig. 2. Electron microscopy of nasal epithelial cells cultured specifically for ciliogenesis shows absence of normal cilia and hospitalized for 4 weeks and was readmitted three times basal bodies (magnlfication: bar = 1 pm). At the apical cell side in the first year of life because of pulmonary infiltrates. numerous vllll without microtubular structures are visible; stri- Sweat test, gastroesophageal reflux studies, and humoral ated roots, the normal accessory structures of basal bodies are and cellular immunity were normal. Nasal brushings present. were studied on three occasions. By direct microscopy, cilia and ciliary movement were never seen. Bronchial of normal, forced expiratory volume in 1 second (FEV,) biopsies, two from each main stem bronchus, were studto 66% of normal with no change after bron~hodilator.~ied twice at 2 years’ interval. All biopsies revealed total Total lung capacity (TLC) remained at 101% of normal. absence of cilia and basal bodies in the respiratory tract Thoracic gas volume (TGV) was 149% of normal. The epithelium. The epithelial cells only had a microvillar head of the eleventh rib was resected and the presence of border with absent to very scanty filaments or microtubuli. At the apical cell surface, numerous dense mitoan enchondroma was proved on histology.
262
DeBoeck et al.
Fig. 3. Electron microscopyof bronchial epithelial cells reveals nearly complete absence of cilia but the presence of a normal amount of basal bodies and an ample amount of microtubuli (magnification:bar = 1 pn).
chondria were noticed as well as striated roots and a well-established Golgi apparatus. The same abnormalities were documented in epithelial cells obtained by nasal biopsy and cultured specifically for ciliogenesis. At present the girl is 9 years old. Chronic rhinitis and chronic middle ear effusion continue to be a problem as are chronic cough and sputum production. She had three more episodes of generalized seizures associated with a febrile illness. Her height and weight are at P3 to P25 and head circumference is at P90. She has mild clubbing. Ronchi, wheezes, and rales are heard over both lung fields. Chest radiograph reveals hyperinflation and streaky pulmonary infiltrates. Pulmonary function tests revealed FVC of 65% of normal, FEV, of 56% of normal, and TGV of 171% of normal. The absence of respiratory tract cilia has been documented a total of 6 times
over a 7-year period on material obtained by brushings, biopsies, and cell culture in both nasal and bronchial sites. Case S.P.
S.P. was born at term from healthy, non-consanguineous parents. At the age of 3 years, she had four episodes of febrile convulsions associated with upper respiratory tract infections. She presented at the age of 9 years with a 3-month history of cough without fever. Physical examination revealed a child in good general health. Height and weight were both at P25. On chest auscultation localized rales were heard over the left lower lobe. A left lower lobe infiltrate was present on chest radiograph. Sedimentation rate was 19 mm after 1 hour; white blood cell count was 11,2001p.L with 63% neutrophils. Viral serologies 6
Aplasia of Respiratory Tract Cilia TABLE 1-Case
263
Reports of Ciliary Aplasia Classified According to the Methods Used for Documentationa
Author Nasal acilia only Dudley‘ “Total ciliary aplasia” by light microscopy only Jahrsdoerfer Evander E9 Buchdahl’” ‘Total ciliary aplasia” by light and electron microscopy in nasal biopsy Fonzi’
Chronic upper resp. tract infection
Chronic lower resp. tract infection
Normal
+
-
Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal
Abnormal Not done Not done Abnormal Not done Not done
+ + + + + +
+ + + + + +
F F M
Abnormal Abnormal Abnormal
Not done Not done Not done
+ + +
+ +
Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal
Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal
+ + + + + + +
+ + + + +
Abnormal Abnormal Abnormal
Abnormal Abnormal Abnormal
+ + +
Year
Age at report (years)
Sex
Nasal biopsy
1982
3 months
M
Abnormal
1979 1983 1983 1988
8 29 33 mean age 8.4
M M F F F F
1982
11 14
Matwijiw” Total ciliary aplasia by light and electron microscopy in nasal and bronchial biopsy Gotz’*
1987
23
GordonI3 ~e santi14 De Santi15 Total ciliary aplasia by light and electron microscopy in nasal and bronchial culture Present study
1984 1988 I990
13 11 8
F F F F M M F
1992
12 12 9
F F F
I983
3 months to 9 years
Bronchial biopsy
Situs inversus
Other
+ +
+
+
+ +
‘Superscript numbers by authors are references.
weeks apart showed a seroconversion from negative to 1/32 for respiratory syncitial virus. Sweat test was normal. Immunoglobulins were within normal limits for age. T and B lymphocytes and T subsets as well as lymphocyte transformation tests with mitogens and antigens were normal. Neutrophil chemotaxis, phagocytosis, and killing were normal. Foreign body inhalation was excluded by bronchoscopy . Bronchography revealed tubular bronchiectasis of the left lower lobe bronchi. Gastroesophageal reflux was absent on barium swallow. FVC was 72% of normal, FEV, was 67% of normal, and Tiffenau index was 75. This airway obstruction was unresponsive to inhaled bronchodilators. Nasal brushings were studied on two occasions. They revealed only a few ciliated cells with decreased motility. Bronchial biopsies
were studied on one occasion, after 2 months’ treatment with antibiotics. The epithelial cells had almost no cilia, but a normal amount of basal bodies and ample microtubuli were present (Fig. 3). Golgi apparatus and mitochondria were also present. The few cilia that were present showed an abnormal amount of peripheral pairs and absent or supernumerous central microtubuli. The central microtubuli of neighboring cells were oriented differently, a feature compatible with secondary ciliary dyskinesia. A nasal ciliary biopsy was studied on one occasion and was cultured specifically for ciliogenesis. After 6 weeks of culture, a normal number of cilia were present. Fifty cross sections were studied: ciliary ultrastructure was normal. Ciliary beating was assessed in a qualitative way and was found to be normal. The girl eventually
264
DeBoeck et at.
became asymptomatic under antibiotics (R/erythromycin S.P. in the present report) have been noted. This also and amoxicillin) and chest physiotherapy. Ciliary studies points to a congenital and widespread absence of ciliary function. Consanguinity and the occurence of several were not repeated. cases within one family indicate a hereditary disorder. In the reported cases, the pattern of inheritance is compatiDISCUSSION ble with an autosomal recessive disorder. I n conclusion, ciliary aplasia is a rare congenital and Textbooks on pediatric respiratory medicine do not hereditary disorder of the rnucociliary apparatus. The discuss ciliary aplasia.’ Ciliary aplasia is a rare congeniclinical picture and the associated abnormalities are the tal disorder of the mucociliary apparatus defined by total in primary ciliary dyskinesia. Few cases have same as absence of respiratory epithelial cilia on cells that manifully documented. Absence of basal bodies differenbeen fest all other ultrastructural features of normal ciliated tiates primary ciliary aplasia from ciliary aplasia secondcells. Chronic infection of the upper and lower respiraary to acute infection. Microscopic examination of bioptory tract comprises the clinical picture. The disorder sies cultured specifically for ciliogenesis aids in cannot be distinguished from primary ciliary dyskinesia differentiating primary and secondary ciliary asplasia; on clinical grounds. The first report of nasal acilia syndrome6 coincided with the report on total acilia of the ciliary outgrowth does not take place in biospies with respiratory tract by F ~ n z i We . ~ traced a total of 1 1 pa- absent basal bodies. pers”I6 (Table l ) of which only 4 provide sufficient detail to allow a confident diagnosis of ciliary aplasia. REFERENCES Reference 15 describes previously reported patients. I 4 * l 5 I . Afzelius BA. A human syndrome caused by immotile cilia. SciThis adds up to a total of seven adequately documented ence. 1976; 193:317-319. patients. It is difficult to prove the absence of something. 2. van der Baan S, Veerman AJP, Wcltevreden E, Feenstra L. Kartagener’s syndrome: Clinical features and laboratory studies. Eur J However, in the twins described, the ciliary aplasia was Respir Dis. 1983; 64(Suppl 127):91-95. documented three times over a 6-month period after re3. Jorisscn M. Van der Schueren B, Van den Berghe H, Cassiman covery from acute infection. In the third patient, it was JJ. The preservation and regeneration of cilia o n human nasal documented six times over a 7-year period between epiepithelial cells cultured in vitro. Arch Otorhinolaryngol. 1989: sodes of acute infection. These abnormalities therefore 246:308-3 14. 4. Zapletal A, Motoyama EK. Van de Woestijne KP, Hunt VR, do not represent transient ciliary changes induced by pulBouhuys A. Maximum expiratory flow-volume curves and airway monary infection as described by Corbeel.” Indeed, priconductance in children and adolesccnts. J Appl Physiol. 1969: mary ciliary abnormalities must always be distinguished 1491343-371, from secondary ones caused by infection and injury.I8 5 . Sturgess JM, Turner JAP. The immotile cilia syndrome. In: CherThe fourth case illustrates such a condition. Stockinger” nick V, ed. Kendig’s Disorders of the Rcspiratory Tract in Children. Philadelphia: WB Saunders, l990:675482. classified the primary ciliary deficiencies according to the 6. Dudley JP, Welch MJ, Stiehm ER, Carney JM, Soderbergarrest in ciliary development at the level of formation of Warner M. Scanning and transmission electron microscopic asprocentrioles, formation of kinetosomes, and outgrowth pects of the nasal acilia syndromc. Laryngoscope. 1982; 92:297of the ciliary shaft. Disorders at the first level lead to 299. partial or total aplasia of respiratory tract cilia. According 7. Fonzi L, Lungarella G, Palatresi R. Lack of kinocilia in the nasal mucosa in the immotile cilia syndromc. Eur J Respir Dis. 1982: to Stockinger, alterations at this level are exclusively due 63:558-563. to hereditary factors. The absence of basal bodies in our 8. Jahrsdoerfer R. Feldman PS, Rubel EW, GUerGdnt JL, Egglcston three patients clearly classifies them into this group. AbPA, Selden RF. Otitis media and the immotile cilia syndrome. sence of basal bodies in electron microscopic studies was Laryngoscope. 1979; 89:769-777. also considered crucial by other authors. 9. Evander E, Arborelius M, Jonnon B, Simonsson BG, Svensson G. Lung function and bronchial reactivity in six patients with immoAn aid to differentiate primary (i.e., congenital) or tile cilia syndrome. Eur J Respir Dis. 1983: 64(Suppl 127):137hereditary absence of cilia formation from ciliary aplasia 143. secondary to infection is to culture biopsy material spe- 10. Buchdahl RM, Reiser J. lngram D, Rutman A. Cole PJ. Warner cifically for ciliogenesis.’ This offers the advantage of JO. Ciliary abnormalities in respiratory disease. Arch Dis Child. studying cilia free from secondary changes associated 1988; 631238-243. with infection. The culture from the patient whose cells 11, Matwijiw I, Thilveris JA, Faiman C. Aplasia of nasal cilia with situs inversus, azoospermia and normal sperm flagella: A unique contained basal bodies produced normal cilia formation. variant of the immotile cilia syndrome. J Urol. 1987; 137522On the other hand, hereditary ciliary abnormalities are 524. expressed in vitro.*’ Similarly to primary ciliary dyskine- 12. Gotz M , Stockinger L. Aplasia of respiratory tract cilia. Lancet. sia,in ciliary aplasia associated abnormalities such as 1983: 1:1283. dextrocardia. azoosoermia. and hvdroceohalus (mtient 13. Gordon RE. Kattan M. Absence of cilia and basal bodies with
Aplasia of Respiratory Tract Cilia predominance of brush cells in the respiratory mucosa from a patient with immotile cilia syndrome. Ultrastruct Pathol. 1984; 6:4549. 14. De Santi MM, Gardi C, Barlocco EG, Canciani M, Mastella G, Lungarella G. Cilia-lacking respiratory cells in ciliary aplasia. Biol Cell. 1988; 64:67-70. 15. De Santi MM, Magni A, Valletta EA, Gardi C, Lungarella G. Hydrocephalus, bronchiectasis and ciliary asplasia. Arch Dis Child. 1990;65:543-544. 16. Barlocco EG, Valletta EA, Cancianoi M, Lungarella G, Gardi C, De Santi M, Mastella G. Ultrastructural ciliary defects in children with recurrent infections of the lower respiratory tract. Pediatr Pulmonol. 1991; 1O:Il-17.
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17. Corbeel L, Comillie F, Lauweryns J , Boel M, Van den Berghe G. Ultrastructural abnormalities of bronchial cilia in children with recurrent airway infections and bronchiectasis. Arch Dis Child. 1981; 56:929-933. 18. Afzelius BA. lmmotile cilia syndrome and ciliary abnormalities induced by infection and injury. Am Rev Respir Dis. 1981; I 24: 107- 109. 19. Stockinger L, Sellner W, Ellinger A, Hofler H. Pathophysiology of the ciliated epithelium of the respiratory mucosa in humans. Exp Lung Res. 1989; 15:925-941. 20. Jorissen M, Vanderschueren B, De Boeck K, Cassiman JJ. Expression of hereditary abnormalities in cultured nasal epithelial cells. Eur Respir J. 1991; 4(Suppl 14):522S.
