THE JOURNAL OF INFECTIOUS DISEASES • VOL. 133, NO.1· © 1976 by the University of Chicago. All rights reserved.
JANUARY 1976
Recurrent Bacterial Infections in Four Siblings with Neutropenia, Eosinophilia, Hyperimmunoglobulinemia A, and Defective Neutrophil Chemotaxis From the Department of Pediatrics, University Hospital of Umed, Umed, Sweden
B. Bjorksten and K. M. Lundmark
Impaired chemotaxis of leukocytes has recently been described in children with recurrent bacterial infections. Reported abnormalities include deficiencies of serum factors and inhibition of chemotaxis, as well as intrinsic neutrophil defects [1, 2]. We report here a family in which four of five siblings have recurrent infections, neutropenia, eosinophilia, and abnormalities in chemotaxis, serum immunoglobulins, and cellular immunity. All of the children have exhibited normal growth and development, and none have red hair [3]. The parents are healthy and apparently not consanguineous. They have normal numbers of the different types of blood leukocyte and do not have depressed neutrophil chemotaxis.
to eight years suffered from recurrent skin abscesses, otitis media, and persistent eczema. In October 1973 she developed severe varicella. One month later an intermittent fever and generalized rubelliform rash appeared. No infectious etiology could be demonstrated. In January 1974, H.D. developed moderate polyarticular arthralgia and arthritis of the metacarpophalangeal joints. The erythrocyte sedimentation rate was elevated (117-138 mm/hr), and normochromic anemia (hemoglobin concentration, 6 g/ 100 m1) developed. These signs were suggestive of rheumatoid arthritis. In February, treatment with prednisolone (2 mg/kg per day) was started, and the patient became afebrile within 24 hr. The sedimentation rate decreased to 38 mm/hr, and the hemoglobin concentration rose to 10.8 g/100 ml within a week. During die following months, the dose of prednisolone was gradually reduced. One year after the onset of symptoms, corticosteroids were withdrawn. In 1974 the patient suffered pneumonia on two occasions, and, although a specific bacterial diagnosis was never made, there was a prompt response to antibiotic treatment. Case no. 2. This boy (N.D.) was born on January 19, 1966, and at the age of 18 months became seriously ill with gastroenteritis, _pneumonia, and gluteal abscess. Staphylococcus aureus and Candida albicans were isolated from stool, pus, and throat swabs, but not from the blood. After this episode, the boy suffered from recurrent skin infections, otitis media, and eczema.
Case Reports
Case no. 1. This girl (H.D.) was born on August 18, 1964, and from the age of four months
Received for publication July 10, 1975, and in revised form September 17, 1975. This work was supported by a grant from the Medical Faculty of the University of Umea, We are indebted to Dr. Arne Tarnvik who performed the in vitro stimulations of lymphocyte cultures: The technical assistance of Mr. Hakan Persson is gratefully acknowledged. Please address requests for reprints to Dr. Bengt Biorksten, Department of Pediatrics, University of Minnesota, Box 483, Mayo Memorial Building, Minneapolis, Minnesota 55455.
63
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Four siblings with recurrent bacterial infections, neutrophil chemotactic defect, neutropenia, and eosinophilia were studied. During periods of infection the peripheral neutrophil count increased to normal, while the eosinophilia disappeared. In addition, these children had high levels of serum IgA and poor antibody responses to tetanus and polio vaccinations. A defect in cell-mediated immunity was demonstrated by an absent or weak reactivity to various skin test antigens and by abnormal lymph node histology. Thus these siblings had an unusual combination of defective inflammatory response and immunologic abnormalities.
64
Materials and Methods
Leukocyte function tests. Nitroblue tetrazoHum (NBT) tests and endotoxin-stimulated NBT assays were done as described previously [4]. For study of the size of the marginal neutrophil pool in the blood vessels of the children, 0.4 mg of adrenalin was injected sc and the number of neutrophils per mm" of blood was counted before and 15, 30, 60, and 120 min after the injections. An increase of ~ 50 % in the number of blood neutrophils after injection was considered to be normal Phagocytosis and bactericidal capacity were studied in vitro by the method of Alexander et al. [5] with use of S. aureus, Oxford strain, as the test organism. In addition, the phagocytosis of heat-killed yeast particles was studied as described by Brandt [6]. The cellular inflammatory response was studied
by skin window tests according to the method of Rebuck and Crowley [7]. The skin on the volar side of the forearm was abraded down to the corium; care was taken to avoid bleeding. The abraded area was covered with sterile coverslips which were changed after 3, 6, 8, and 19 hr. The number of cells and the proportions of different types of white blood cell were evaluated. Skin window tests performed simultaneously on healthy persons served as controls. Leukocyte chemotaxis was studied by use of the leading front technique of Wilkinson [8]. Venous blood was drawn into a sterile plastic tube containing heparin to a final concentration of 10-20 international units of heparin/rnl of blood. Leukocyte-rich plasma was collected as described by Boyum [9] and was centrifuged at 500 g for 5 min. The cell button was washed twice and re.. suspended in Gey's solution (pH 7.3) [8] to a final leukocyte concentration of 1-5 X 106 cells/rnl. Concentrations of polymorphonuclear leukocytes were similar in patients and controls. Tuberculin syringes were used as chemotactic chambers as described by Wilkinson [8]. The cell suspension (0.4 ml) was placed in the upper part of the chemotactic chamber, and 4 ml of Gey's solution and serum in equal parts was placed in the lower part as attractant. The chamber was incubated at 37 C for 70 min, after which Millipore filters were fixed and stained. Filters were inspected at a magnification of X 400, and the distance travelled by leading front leukocytes was measured as the mean of five different fields. Determinations of complement. The levels of total hemolytic complement were determined by the method of Lange [10], and the complement factors C3 and C4 were measured by radial immunodiffusion. Tests of humoral immunity. The concentration of the immunoglobulins IgG, IgA, and IgM were determined by single radial immunodiffusion on agar gel [11]. The 19B concentration was measured by radioimmunoabsorbance with use of a Phadebas IgE test kit (Pharmacia Laboratories, Uppsala, Sweden). The determinations of neutralizing antibodies to poliovirus, HA antibodies to Clostridium tetani, CF antibodies to varicella-zoster virus, and titers of isohemagglutinins were made by customary laboratory methods.
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In October 1973, N.D. became critically ill with varicella complicated by encephalitis and disseminated pneumonia. H~ was treated with cytosine arabinoside (1.5 rug/kg of body weight) sc for seven days. He eventually recovered but has since suffered from pneumonia on three occasions. Although no specific etiology was determined in these infections, there was appropriate response to antibiotic therapy. Case no. 3. Patient E.D., a girl born on July 11, 1967, was healthy up to the age of six months, at which time she developed a thoracic skin abscess from which S. aureus was isolated. Later in infancy, E.D. was well except for moderate perianal dermatitis. In the following years she suffered from pneumonia on three occasions, pseudocroup once, and severe varicella in 1973. Aside from these episodes, the girl has not had infections as serious and frequent as those of her elder siblings. Case no. 4. This girl (A.D.) was born on July 29, 1972. A routine examination on the fourth day of life revealed neutropenia (400 neutrophils/rnm" of blood), but the child remained healthy during infancy except for a slight persistent eczema in the perianal region and behind the ears. At the age of 13 months, she developed severe varicella, and at the age of two years she developed pneumonia.
Bjorksten and Lundmark
Leukocyte Abnormalities in Four Siblings
65
Results
When well, each child usually had a slight leukopenia of < 4,000 white blood cells associated with a neutropenia of < 1,SOO neutrophils and an eosinophilia of 700-2,000 eosinophils/rnm" of blood (figures 1 and 2). On single occasions, completely normal numbers and proportions of leukocytes were recorded. There was no cyclic variation in the neutrophil counts. However, with febrile infections, all of the children demonstrated increased numbers of peripheral leukocytes, including increased numbers of neutrophils. Simultaneously, the eosinophilia disappeared, not to return until the children were recovering. This
• (4700)
4000 o Neutrophils • Eosinophils
3500 3000
Figure 1. Neutrophil and eosinophil counts of patient N.D. recorded on different occasions. Arrows indicate months when the patient had pneumonia.
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L.....----,---r----,r---.,..---r-----,--.---r-----r--.---r---...
Jan
Feb Mar Apr May Jun Jul
1974
Aug Sep Oct Nov Dec
Month
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pattern is illustrated in figures 1 and 2, in which the results of blood neutrophil counts performed in N.D. and A.D. on different occasions are plotted. When N.D. was admitted to the hospital in September 1974 (figure 1) for eczema, we had a good opportunity to study the changes in blood leukocyte counts during an infection. On admission he had a generalized itching eczema but no signs of infection. A peripheral eosinophil count at this time was 900/mm3 . Three days later, he developed a fever and chest X ray revealed pneumonia. The blood eosinophil count at this time was only 200/mm3 • The child responded well to oral erythromycin, and the eosinophil count four days later was 1,100/mm3 • The eosinophilia persisted for a few days, but then the fever recurred and the eosinophil count fell to 300/mm3 . The boy responded to treatment with cephalothin but had a persistent cough. On a follow-up examination one month later, the patient was well and had a normal erythrocyte sedimentation rate and an eosinophil count of BOO/mm3 • In patient A.D. a similar response to pneumonia occurred (figure 2). This child was admitted in September 1974 with bronchopneumonia. At this time she had neutrophilia and a normal number of eosinophils in the blood. One month later the patient was well and had a normal erythrocyte sedimentation rate, and the number of eosinophils was BOO/mm3 of blood. In November, A.D .
Tests of cellular immunity. The skin reactivity to tuberculin was tested using two, five, and 10 units of tuberculin injected intracutaneously. The reactivity to dinitrochlorobenzene was tested after prior sensitization. The skin reactivity was also assessed against two different candida antigens (Vitrum AB, Stockholm, Sweden and Bencard, Bentford, England) and mixtures of bacterial suspensions (staphylococcal mix and streptococcal mix, Hollister-Stier Laboratories, Spokane, Wash.). The histology of a lymph node of one child was evaluated after biopsy. The lymphocyte response to phytohemagglutinin (PHA) and concanavalin A was studied in vitro [12, 13].
66
Bjorksten and Lundmark
(4200)
(11400
(4600)
o
Figure 2. Neutrophil and eosinophil counts of patient A.D. recorded on different occasions. Arrows indicate months when the patient had pneumonia.
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1972
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Aug Sep Oct Nov
Dec Month
1974
again developed bronchopneumonia and was admitted to the hospital. She had neutrophilia and a low number of eosinophils during the first three days of antibacterial treatment. Two days after becoming afebrile, she developed neutropenia and eosinophilia. Bone marrow aspirates, drawn when the children were well, revealed normal cellularity and low proportions of segmented neutrophils, but elevated proportions of promyelocytes and eosinophils in all the children. The cellular morphology appeared to be normal. The response to adrenalin after sc injections was tested twice in H.D. and once in N.D. After the injection, there was an increase of > 50% in the number of neutrophils in peripheral blood, a finding that indicated a normal proportion of neutrophils in the marginal pool as compared with the number of circulating neutrophils [14]. NBT tests performed on blood samples from the children on several occasions revealed elevated proportions of NBT-positive neutrophils during bacterial infections and after incubation with endotoxin (table 1). The phagocytic and bactericidal capacities of neutrophils were normal in the three elder children; however, the neutrophils were not tested in A.D. The levels of total hemolytic complement and of C3 and C4 were normal in all of the children. The skin window test performed on three of the children revealed a delayed inflammatory response and neutropenia in the exudates from N.D.
and E.D. but not from H.D. (figure 3). This girl, H.D., usually had a lower level of eosinophilia in the blood than did her siblings. For comparison, the inflammatory response seen in a healthy control is included in figure 3. The cellularity and the types of cell found in the exudates at different intervals are typical for a normal response [7]. In all of the children there was a depressed neutrophil chemotaxis, and this defect was not restored to normal by resuspension of the leukocytes in fresh serum from a healthy person. Fresh serum from the children did not significantly inhibit the chemotactic activity of leukocytes from controls (table 2). As shown in table 3, concentrations of IgA were elevated persistently, those of IgM were Table 1. Results of nitroblue tetrazolium (NBT) tests and endotoxin-stimulated NBT tests to determine granulocyte function in four siblings.
Patient H.D. N.D. B.D. A.D. Normal values
NBT test*
Endotoxinstimulated NBTtest*
Bacteria killed (%) t
6-42 2 14 0-3
40-82 24 21 18-38
95 95 99 NTt
0-12
>20
* Percentage of NBT-positive neutrophils.
t Bacteria were incubated for 60 min. tNT
= not tested.
~90
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•
67
Leukocyte Abnormalities in Four Siblings
Monocyt.. - PMutrophila - ' - '_'. Eoainophila '" -. - .•..
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80 60 40
20
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60 40
------
20
19 Hours Cellularity
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+++
Cellularity
Figure 3. Results of skin window tests in three of the siblings and in a control. The cellularity of the slides is expressed on a graded scale ranging from (-), indicating no cells, to (+++), indicating a dense monolayer of cells. The proportions of the different types of cell are expressed as the percentage of the total number of cells on each slide.
slightly less than normal, and those of IgG and IgE were normal except on two occasions. The antibody response to tetanus and polio vaccinations was normal in the eldest girl, H.D., whereas there was no response to polio and an abnormally weak response to tetanus vaccinations in N.D. and in E.D. The latter two children belonged to blood group A, and they both had very low titers of antibody to the B determinant ( 1: 1 and 1: 2, Table 2. Chemotactic activity of patients' granulocytes in their own plasma and in control plasma, and of control granulocytes in patients' plasma. Source of plasma Source of granulocytes H.D. N.D. B.D. A.D. Controls
Patients' own plasma 19 (6-27) 11 16 13
78 (40-128)
Control plasma
Patients' plasma
24 (9-40) 17 28 39 73 (46-105) * 66t
NOTE. Results are expressed as -!-tID travelled by the leading front granulocytes in 70 min. The data for control granulocytes are means (ranges) of 10 experiments. All other data represent means (ranges) of three experiments. * Granulocytes tested in plasma of patient H.D. t Granulocytes tested in plasma of patient N.D.
respectively). In H.D. and A.D., the titers of antibody to the B determinant were normal (1: 16 and 1: 32, respectively). All of the children had been vaccinated with bacille Calmette-Guerin vaccine within the first few days of life, and they repeatedly showed no skin reactivity to tuberculin. Dinitrochlorobenzene sensitization was successful in the two youngest siblings, but was repeatedly negative in the two eldest. The skin tests with different candida, staphylococcal, and streptococcal antigens were negative in all of the children. Lymphocyte cultures from the three elder children showed normal response to stimulation with PHA ·and concanavalin A in vitro. All of the children showed only a minor enlargement of lymphoid tissue in response to infections. Biopsy of a superficial lymph node of N.D. when he was suffering from a bacterial skin infection showed a partial depletion of small lymphocytes in cortical and paracortical areas. The number of germinal centers was reduced. The medullary part of the lymph node appeared to be normal. Discussion
We describe the clinical features of four siblings with recurrent infections. The children had neu-
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100
++ ++
68
Biorksten and Lundmark
Table 3.
Immunoglobulin levels in the serum of four siblings at different ages. Age of patient
Patient, immunoglobulin
3-9 months
9 months to 2 years
H.D. IgG
960 240 30
19A IgM IgE N.D. IgG
19A IgM IgE A.D. IgG
19A IgM IgE Normal values IgG IgA IgM IgE
920-1,410 320-470 10-50 179-650
648 156 30
1,060 580-660 24-30 35-40
545 55 42
510-880 50-190 20-50
1,220 288 45 85
850 50 40
1,060 70-110 31 13-80
IgM IgE B.D. IgG
5-10 years
220-846 3-47 18-104 4-60
321-1,125 7-66 20-97 6-53
530-1,406 29-163 34-166 21-198
637-1,692 36-202 35-170 18-451
Levels of IgG, IgA, and IgM are expressed as mg/100 ml, and levels of IgE as units/ml.
tropenia and eosinophilia in the blood and neutropenia, eosinophilia, and elevated proportions of promyelocytes in the bone marrow. This latter finding possibly indicates a disturbed neutrophil maturation. Leukocytes from the children had a profound defect in chemotactic activity as shown by in vitro tests and by abnormal results in skin window tests. The number of neutrophils in the blood was partly restored to normal when the children were infected. The release of neutrophils from the marginal neutrophil pool and bone marrow in response to sc injections of adrenalin was normal, and this result could possibly explain the increased number of neutrophils recorded during infections. There was an inverse relation between the numbers of blood neutrophils and eosinophils; the latter rapidly fell during infections while the former rose to normal values. It is not known why acute infections are ac-
companied by a reduction in the number of circulating eosinophils. The usual assumption is that the eosinopenia is a manifestation of adrenal stimulation, but Bass [15] recently proved that this is not the case. Thus, other explanations must be sought. The reasons for the eosinophilia sometimes found in immune deficiency syndromes are not known, but Beeson and his associates in 1970 and 1971 [16-18] presented good evidence that eosinophilia is an immunologic phenomenon. In a series of experiments on rats with use of trichinella larvae as antigens, they showed that an eosinophil response was evoked when the antigen was deposited in the lung or a muscle. When the same antigen was homogenized before inoculation and, thus, was presumably delivered rapidly to the reticuloendothelial tissue, the rats failed to develop eosinophilia; however, the antibody response was brisk under these conditions. Although it is not yet possible to prove our hy-
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513-743 83-200 21-25
19A
NOTE.
2-5 years
Leukocyte Abnormalities in Four Siblings
69
Table 4.
Summary of laboratory findings in the present study of four siblings with neutropenia and immune deficiency and laboratory findings from three previous reports of patients with intrinsic defect of chemotaxis and increased susceptibility to infection. Source of data Laboratory finding Phagocytes Leukopenia Neutropenia Eosinophilia Bone marrow
Plasma cells Serum IgG Serum 19A Serum IgM Serum IgE Antibody response to vaccination Isohemagglutinins Lymphocytes Lymphocyte count Lymphoid tissue
Response to skin tests Phytohemagglutinin stimulation
Hill et aI.
Hill and Quie
[21]
[3]
[22]
Present study Yes Yes Yes Eosinophilia; maturation arrest
Yes Yes No Normal
Variable Variable Variable ?
No No Variable ?
Normal
No
?
?
Normal Normal Normal Normal Abnormal Abnormal
? Normal Normal ? Abnormal Abnormal
? Normal Normal Normal ? Abnormal
Normal Normal Normal Normal ? Abnormal
No
No
No
No
Normal High Normal or low Normal
Normal Normal Normal ?
Normal Normal or high Normal or high High
Normal Normal Normal High
Weak or normal Weak or normal
? ?
? ?
Normal ?
Normal Poor condition; depletion of small lymphocytes Deficient
? ?
Normal ?
Normal ?
?
?
?
Normal
Normal
Normal
Normal
pothesis, we are tempted to suggest that the eosinophilia found in our patients and in other immune deficiency syndromes is an expression of delayed or inefficient antigen elimination. Similarly, a defect in phagocyte function interfering with their processing of normal antigen could prevent or delay the close contact between the processed antigen and the reticuloendothelial system that is necessary to evoke a normal immune response. Eosinophilia has been reported previously at least twice in patients with defective leukocyte chemotaxis [19] and those with neutropenia [20].
The children in this family may have a defect in the cellular immunity, as indicated by the weak or absent skin test responses to different antigens and also by the lymph node histology. However, cultures of lymphocytes from the children responded to stimulation in vitro with PHA and concanavalin A. The abnormal responses to antigen stimulation in vivo and the normal results of the in vitro tests could possibly be explained by a low number of circulating T-lymphocytes in the blood. As shown in table 2, neutrophils from controls displayed a normal chemotactic activity in serum
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Response to adrenaline stimulation Stimulated nitroblue tetrazolium test Phagocytosis Bactericidal capacity Complement levels Skin window test Chemotaxis Serum inhibitors of chemotaxis
Miller et aI.
70
References 1. Miller, M. E. Leukocyte movement-in vitro and in vivo correlates. J. Pediatr. 83: 1104-1106, 1973. Lancet 1:438-440, 1974.
2. Leading article (unsigned). Disorders of neutrophil function. Lancet 1: 438-440, 1974. 3. Hill, H. R., Ochs, H. D., Quie, P. G., Clark, R. A., Pabst, H. F., Klebanoff, S. J., Wedgwood, R. J. Defect in neutrophil granulocyte chemotaxis in Job's syndrome of .recurrent "cold" staphylococcal abscesses. Lancet 2:617-619, 1974. 4. Bjorksten, B. The influence of technical factors on the NBT test. Scand. J. Haematol. 12:46-50, 1974. 5. Alexander, J. W., Windhorst, D. B., Good, R. A. Improved tests for the evaluation of neutrophil function in human disease. J. Lab. Clin. Med. 72: 136-148, 1968. 6. Brandt, L. Studies on the phagocytic activity of neutrophilic leukocytes. With special reference to chronic myeloproliferative conditions and megaloblastic anemia. Scand. J. Haematol. (Suppl. 2): 16-19, 1967. 7. Rebuck, J. W., Crowley, J. H. A method of studying leukocytic functions in vivo. Ann. N.Y. Acad. Sci. 59:757-805, 1955. 8. Wilkinson, J. C. Chemotaxis and inflammation. Churchill Livingstone, Edinburgh, 1974, p. 168172. 9. Boyum, A. Separation of leukocytes from blood and bone marrow. Scand. J. Clin. Lab. Invest. 21 (Suppl. 97) :7, 1968. 10. Lange, K. Uber den immunologischen Mechanismus der akuten und chronischen Glomerulonephritis. In E. Wollheim [ed.]. Internationales Nierensymposium, Wtirzburg, 1960. Glomerulare und TubuHire Nierenerkrankungen, Georg Thieme Verlag, Stuttgart, 1962, p. 232-245. 11. Johansson, S. G. 0., Berg, T. Immunoglobulin levels in healthy children. Acta Paediatr. Scand., 56:572-579, 1967. 12. Parker, J. W., Lukes, R. J. A microculture method for lymphocyte transformation studies in the clinical laboratory. Am. J. Clin. Pathol. 56: 174180, 1971. 13. Hartzman, R. J., Bach, M. L., Bach, F. R., Thurman, G. B., Sell, K. W. Precipitation of radioactively labeled samples: a semi-automatic multiple sample processor. Cell. Immunol. 4: 182-186, 1972. 14. Athens, J. W., Raab, O. P., Raab, S. E., Mauer, A. M., Ashenbrucker, H., Cartwright, G. E., Wintrobe, M. M. Leukokinetic studies. IV. The total blood, circulating and marginal granulocyte pools and the granulocyte turnover rate in normal subjects. J. Clin. Invest. 40:989-995, 1961. 15. Bass, D. A. Behavior of eosinophil leukocytes in acute inflammation. I. Lack of dependence of adrenal function. J. Clin. Invest. 55: 1229-1236, 1975. 16. Boyer, M. H., Basten, A., Beeson, P. B. Mechanism of eosinophilia. III. Suppression of eosinophilia by agents known to modify immune responses. Blood 36:458-469, 1970.
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from the patients, whereas neutrophils from the patients showed a decreased activity even in the presence of fresh serum from controls. Thus, there was apparently an intrinsic neutrophil defect in the patients. Such intrinsic defects of neutrophil chemotaxis have been reported previously [3, 21, 22]. The laboratory findings reported in these papers are compared with the findings in our patients in table 4. None of the other patients with neutropenia had eosinophilia, and the very high serum 19B levels presented in two of the reports [3, 22] were not found in our patients. There were, however, other quantitative and qualitative abnormalities in humoral immunity in our patients, as shown by the high levels of IgA in the serum and by weak antibody response to different vaccinations, as well as by low titers of isohemagglutinins in two of the children. In a recent paper [23], two more patients with an abnormal neutrophil chemotaxis were reported. They had very high levels of serum IgE, decreased lymphocyte responses to Candida, and decreased delayed skin test results, but they did not have neutropenia. In contrast to patients with Job's syndrome [3], the children in this family showed an inflammatory response to skin infections that was normal, except· for the presence of neutropenia. One of the children (H.D.) developed rheumatoid arthritis, but her symptoms responded very well to corticosteroids. Collagen diseases, as well as allergic diseases, are common in patients with immune deficiency syndromes, and it has been suggested that the tendency to these diseases results from a defect in antigen elimination [24]. This family with recurrent severe infections represents an unusual combination of abnormalities of host defense. Neutropenia and depressed chemotaxis are evidence of ? defect in the inflammatory response. Consistently elevated levels of IgA and poor antibody response to vaccinations are signs of abnormality of the immunoglobulin system, and a defect in delayed hypersensitivity response to skin test antigens suggests defective cell-mediated immunity.
Bjorksten and Lundmark
Leukocyte Abnormalities in Four Siblings
leukocyte syndrome: a new disorder of neutrophil function. Lancet 1: 665-669, 1971. 22. Hill, H. R., Quie, P. G. Raised serum 19B levels and defective neutrophil chemotaxis in three children with eczema and recurrent bacterial infections. Lancet 1: 183-187, 1974. 23. Van Scoy, R. E., Hill, H. R, Ritts, R E., Jr., Quie, P. G. Familial neutrophil chemotaxis defect, recurrent bacterial infections, mucocutaneous candidiasis, and hyperimmunoglobulinemia E. Ann. Intern. Med. 82:766-771, 1975. 24. Fudenberg, H. H. Are autoimmune diseases immunologic deficiency states? In R A. Good and D. W. Fisher [ed.]. Immunobiology. Sinauer Associates, Stamford, Connecticut, 1971, p. 175-183.
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17. Basten, A., Boyer, M. H., Beeson, P. B. Mechanism of eosinophilia. I. Factors affecting the eosinophil response of rats to Trichinella spiralis. J. Exp. Med. 131: 127l-1287, 1970. 18. Basten, A., Beeson, P. B. Mechanism of eosinophilia. II. Role of the lymphocyte. J. Exp. Med. 131: 1288-1305, 1970. 19. Smith, C. W., Hollers, J. C., Dupree, E., Goldman, A. S., Lord, R. A. A serum inhibitor of leukotaxis in a child with recurrent infections. J. Lab. Clin. Med. 79:878-885, 1972. 20. Andrews, J. P., McClellan, J. T., Scott, C. H. Lethal congenital neutropenia with eosinophilia occurring in two siblings. Am. J. Med. 29:358-362, 1960. 21. Miller, M. E., Oski, F. A., Harris, M. B. Lazy
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JANUARY 1976
Recurrent Bacterial Infections in Four Siblings with Neutropenia, Eosinophilia, Hyperimmunoglobulinemia A, and Defective Neutrophil Chemotaxis From the Department of Pediatrics, University Hospital of Umed, Umed, Sweden
B. Bjorksten and K. M. Lundmark
Impaired chemotaxis of leukocytes has recently been described in children with recurrent bacterial infections. Reported abnormalities include deficiencies of serum factors and inhibition of chemotaxis, as well as intrinsic neutrophil defects [1, 2]. We report here a family in which four of five siblings have recurrent infections, neutropenia, eosinophilia, and abnormalities in chemotaxis, serum immunoglobulins, and cellular immunity. All of the children have exhibited normal growth and development, and none have red hair [3]. The parents are healthy and apparently not consanguineous. They have normal numbers of the different types of blood leukocyte and do not have depressed neutrophil chemotaxis.
to eight years suffered from recurrent skin abscesses, otitis media, and persistent eczema. In October 1973 she developed severe varicella. One month later an intermittent fever and generalized rubelliform rash appeared. No infectious etiology could be demonstrated. In January 1974, H.D. developed moderate polyarticular arthralgia and arthritis of the metacarpophalangeal joints. The erythrocyte sedimentation rate was elevated (117-138 mm/hr), and normochromic anemia (hemoglobin concentration, 6 g/ 100 m1) developed. These signs were suggestive of rheumatoid arthritis. In February, treatment with prednisolone (2 mg/kg per day) was started, and the patient became afebrile within 24 hr. The sedimentation rate decreased to 38 mm/hr, and the hemoglobin concentration rose to 10.8 g/100 ml within a week. During die following months, the dose of prednisolone was gradually reduced. One year after the onset of symptoms, corticosteroids were withdrawn. In 1974 the patient suffered pneumonia on two occasions, and, although a specific bacterial diagnosis was never made, there was a prompt response to antibiotic treatment. Case no. 2. This boy (N.D.) was born on January 19, 1966, and at the age of 18 months became seriously ill with gastroenteritis, _pneumonia, and gluteal abscess. Staphylococcus aureus and Candida albicans were isolated from stool, pus, and throat swabs, but not from the blood. After this episode, the boy suffered from recurrent skin infections, otitis media, and eczema.
Case Reports
Case no. 1. This girl (H.D.) was born on August 18, 1964, and from the age of four months
Received for publication July 10, 1975, and in revised form September 17, 1975. This work was supported by a grant from the Medical Faculty of the University of Umea, We are indebted to Dr. Arne Tarnvik who performed the in vitro stimulations of lymphocyte cultures: The technical assistance of Mr. Hakan Persson is gratefully acknowledged. Please address requests for reprints to Dr. Bengt Biorksten, Department of Pediatrics, University of Minnesota, Box 483, Mayo Memorial Building, Minneapolis, Minnesota 55455.
63
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Four siblings with recurrent bacterial infections, neutrophil chemotactic defect, neutropenia, and eosinophilia were studied. During periods of infection the peripheral neutrophil count increased to normal, while the eosinophilia disappeared. In addition, these children had high levels of serum IgA and poor antibody responses to tetanus and polio vaccinations. A defect in cell-mediated immunity was demonstrated by an absent or weak reactivity to various skin test antigens and by abnormal lymph node histology. Thus these siblings had an unusual combination of defective inflammatory response and immunologic abnormalities.
64
Materials and Methods
Leukocyte function tests. Nitroblue tetrazoHum (NBT) tests and endotoxin-stimulated NBT assays were done as described previously [4]. For study of the size of the marginal neutrophil pool in the blood vessels of the children, 0.4 mg of adrenalin was injected sc and the number of neutrophils per mm" of blood was counted before and 15, 30, 60, and 120 min after the injections. An increase of ~ 50 % in the number of blood neutrophils after injection was considered to be normal Phagocytosis and bactericidal capacity were studied in vitro by the method of Alexander et al. [5] with use of S. aureus, Oxford strain, as the test organism. In addition, the phagocytosis of heat-killed yeast particles was studied as described by Brandt [6]. The cellular inflammatory response was studied
by skin window tests according to the method of Rebuck and Crowley [7]. The skin on the volar side of the forearm was abraded down to the corium; care was taken to avoid bleeding. The abraded area was covered with sterile coverslips which were changed after 3, 6, 8, and 19 hr. The number of cells and the proportions of different types of white blood cell were evaluated. Skin window tests performed simultaneously on healthy persons served as controls. Leukocyte chemotaxis was studied by use of the leading front technique of Wilkinson [8]. Venous blood was drawn into a sterile plastic tube containing heparin to a final concentration of 10-20 international units of heparin/rnl of blood. Leukocyte-rich plasma was collected as described by Boyum [9] and was centrifuged at 500 g for 5 min. The cell button was washed twice and re.. suspended in Gey's solution (pH 7.3) [8] to a final leukocyte concentration of 1-5 X 106 cells/rnl. Concentrations of polymorphonuclear leukocytes were similar in patients and controls. Tuberculin syringes were used as chemotactic chambers as described by Wilkinson [8]. The cell suspension (0.4 ml) was placed in the upper part of the chemotactic chamber, and 4 ml of Gey's solution and serum in equal parts was placed in the lower part as attractant. The chamber was incubated at 37 C for 70 min, after which Millipore filters were fixed and stained. Filters were inspected at a magnification of X 400, and the distance travelled by leading front leukocytes was measured as the mean of five different fields. Determinations of complement. The levels of total hemolytic complement were determined by the method of Lange [10], and the complement factors C3 and C4 were measured by radial immunodiffusion. Tests of humoral immunity. The concentration of the immunoglobulins IgG, IgA, and IgM were determined by single radial immunodiffusion on agar gel [11]. The 19B concentration was measured by radioimmunoabsorbance with use of a Phadebas IgE test kit (Pharmacia Laboratories, Uppsala, Sweden). The determinations of neutralizing antibodies to poliovirus, HA antibodies to Clostridium tetani, CF antibodies to varicella-zoster virus, and titers of isohemagglutinins were made by customary laboratory methods.
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In October 1973, N.D. became critically ill with varicella complicated by encephalitis and disseminated pneumonia. H~ was treated with cytosine arabinoside (1.5 rug/kg of body weight) sc for seven days. He eventually recovered but has since suffered from pneumonia on three occasions. Although no specific etiology was determined in these infections, there was appropriate response to antibiotic therapy. Case no. 3. Patient E.D., a girl born on July 11, 1967, was healthy up to the age of six months, at which time she developed a thoracic skin abscess from which S. aureus was isolated. Later in infancy, E.D. was well except for moderate perianal dermatitis. In the following years she suffered from pneumonia on three occasions, pseudocroup once, and severe varicella in 1973. Aside from these episodes, the girl has not had infections as serious and frequent as those of her elder siblings. Case no. 4. This girl (A.D.) was born on July 29, 1972. A routine examination on the fourth day of life revealed neutropenia (400 neutrophils/rnm" of blood), but the child remained healthy during infancy except for a slight persistent eczema in the perianal region and behind the ears. At the age of 13 months, she developed severe varicella, and at the age of two years she developed pneumonia.
Bjorksten and Lundmark
Leukocyte Abnormalities in Four Siblings
65
Results
When well, each child usually had a slight leukopenia of < 4,000 white blood cells associated with a neutropenia of < 1,SOO neutrophils and an eosinophilia of 700-2,000 eosinophils/rnm" of blood (figures 1 and 2). On single occasions, completely normal numbers and proportions of leukocytes were recorded. There was no cyclic variation in the neutrophil counts. However, with febrile infections, all of the children demonstrated increased numbers of peripheral leukocytes, including increased numbers of neutrophils. Simultaneously, the eosinophilia disappeared, not to return until the children were recovering. This
• (4700)
4000 o Neutrophils • Eosinophils
3500 3000
Figure 1. Neutrophil and eosinophil counts of patient N.D. recorded on different occasions. Arrows indicate months when the patient had pneumonia.
o
'0
g
2500
o
:0
ME 2000
o
E Gi 1500 a. ~
>. g
~
~
..J
• o
1000 500
o
•
•
.
o
• o
•
•
o
•
L.....----,---r----,r---.,..---r-----,--.---r-----r--.---r---...
Jan
Feb Mar Apr May Jun Jul
1974
Aug Sep Oct Nov Dec
Month
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pattern is illustrated in figures 1 and 2, in which the results of blood neutrophil counts performed in N.D. and A.D. on different occasions are plotted. When N.D. was admitted to the hospital in September 1974 (figure 1) for eczema, we had a good opportunity to study the changes in blood leukocyte counts during an infection. On admission he had a generalized itching eczema but no signs of infection. A peripheral eosinophil count at this time was 900/mm3 . Three days later, he developed a fever and chest X ray revealed pneumonia. The blood eosinophil count at this time was only 200/mm3 • The child responded well to oral erythromycin, and the eosinophil count four days later was 1,100/mm3 • The eosinophilia persisted for a few days, but then the fever recurred and the eosinophil count fell to 300/mm3 . The boy responded to treatment with cephalothin but had a persistent cough. On a follow-up examination one month later, the patient was well and had a normal erythrocyte sedimentation rate and an eosinophil count of BOO/mm3 • In patient A.D. a similar response to pneumonia occurred (figure 2). This child was admitted in September 1974 with bronchopneumonia. At this time she had neutrophilia and a normal number of eosinophils in the blood. One month later the patient was well and had a normal erythrocyte sedimentation rate, and the number of eosinophils was BOO/mm3 of blood. In November, A.D .
Tests of cellular immunity. The skin reactivity to tuberculin was tested using two, five, and 10 units of tuberculin injected intracutaneously. The reactivity to dinitrochlorobenzene was tested after prior sensitization. The skin reactivity was also assessed against two different candida antigens (Vitrum AB, Stockholm, Sweden and Bencard, Bentford, England) and mixtures of bacterial suspensions (staphylococcal mix and streptococcal mix, Hollister-Stier Laboratories, Spokane, Wash.). The histology of a lymph node of one child was evaluated after biopsy. The lymphocyte response to phytohemagglutinin (PHA) and concanavalin A was studied in vitro [12, 13].
66
Bjorksten and Lundmark
(4200)
(11400
(4600)
o
Figure 2. Neutrophil and eosinophil counts of patient A.D. recorded on different occasions. Arrows indicate months when the patient had pneumonia.
o
•
%
2%
3/,0 3cy,
1972
2%
2Y3
'r4
2% 0/7
1973
2% Date
Jul
•
Aug Sep Oct Nov
Dec Month
1974
again developed bronchopneumonia and was admitted to the hospital. She had neutrophilia and a low number of eosinophils during the first three days of antibacterial treatment. Two days after becoming afebrile, she developed neutropenia and eosinophilia. Bone marrow aspirates, drawn when the children were well, revealed normal cellularity and low proportions of segmented neutrophils, but elevated proportions of promyelocytes and eosinophils in all the children. The cellular morphology appeared to be normal. The response to adrenalin after sc injections was tested twice in H.D. and once in N.D. After the injection, there was an increase of > 50% in the number of neutrophils in peripheral blood, a finding that indicated a normal proportion of neutrophils in the marginal pool as compared with the number of circulating neutrophils [14]. NBT tests performed on blood samples from the children on several occasions revealed elevated proportions of NBT-positive neutrophils during bacterial infections and after incubation with endotoxin (table 1). The phagocytic and bactericidal capacities of neutrophils were normal in the three elder children; however, the neutrophils were not tested in A.D. The levels of total hemolytic complement and of C3 and C4 were normal in all of the children. The skin window test performed on three of the children revealed a delayed inflammatory response and neutropenia in the exudates from N.D.
and E.D. but not from H.D. (figure 3). This girl, H.D., usually had a lower level of eosinophilia in the blood than did her siblings. For comparison, the inflammatory response seen in a healthy control is included in figure 3. The cellularity and the types of cell found in the exudates at different intervals are typical for a normal response [7]. In all of the children there was a depressed neutrophil chemotaxis, and this defect was not restored to normal by resuspension of the leukocytes in fresh serum from a healthy person. Fresh serum from the children did not significantly inhibit the chemotactic activity of leukocytes from controls (table 2). As shown in table 3, concentrations of IgA were elevated persistently, those of IgM were Table 1. Results of nitroblue tetrazolium (NBT) tests and endotoxin-stimulated NBT tests to determine granulocyte function in four siblings.
Patient H.D. N.D. B.D. A.D. Normal values
NBT test*
Endotoxinstimulated NBTtest*
Bacteria killed (%) t
6-42 2 14 0-3
40-82 24 21 18-38
95 95 99 NTt
0-12
>20
* Percentage of NBT-positive neutrophils.
t Bacteria were incubated for 60 min. tNT
= not tested.
~90
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•
67
Leukocyte Abnormalities in Four Siblings
Monocyt.. - PMutrophila - ' - '_'. Eoainophila '" -. - .•..
HD
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------
% 100
80 60 40
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20 6 Cellularity
-
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+++
+ ED
CONTROL
% 80
80 60 40
20
.> ~-
60 40
------
20
19 Hours Cellularity
+++ ++++++
+++
Cellularity
Figure 3. Results of skin window tests in three of the siblings and in a control. The cellularity of the slides is expressed on a graded scale ranging from (-), indicating no cells, to (+++), indicating a dense monolayer of cells. The proportions of the different types of cell are expressed as the percentage of the total number of cells on each slide.
slightly less than normal, and those of IgG and IgE were normal except on two occasions. The antibody response to tetanus and polio vaccinations was normal in the eldest girl, H.D., whereas there was no response to polio and an abnormally weak response to tetanus vaccinations in N.D. and in E.D. The latter two children belonged to blood group A, and they both had very low titers of antibody to the B determinant ( 1: 1 and 1: 2, Table 2. Chemotactic activity of patients' granulocytes in their own plasma and in control plasma, and of control granulocytes in patients' plasma. Source of plasma Source of granulocytes H.D. N.D. B.D. A.D. Controls
Patients' own plasma 19 (6-27) 11 16 13
78 (40-128)
Control plasma
Patients' plasma
24 (9-40) 17 28 39 73 (46-105) * 66t
NOTE. Results are expressed as -!-tID travelled by the leading front granulocytes in 70 min. The data for control granulocytes are means (ranges) of 10 experiments. All other data represent means (ranges) of three experiments. * Granulocytes tested in plasma of patient H.D. t Granulocytes tested in plasma of patient N.D.
respectively). In H.D. and A.D., the titers of antibody to the B determinant were normal (1: 16 and 1: 32, respectively). All of the children had been vaccinated with bacille Calmette-Guerin vaccine within the first few days of life, and they repeatedly showed no skin reactivity to tuberculin. Dinitrochlorobenzene sensitization was successful in the two youngest siblings, but was repeatedly negative in the two eldest. The skin tests with different candida, staphylococcal, and streptococcal antigens were negative in all of the children. Lymphocyte cultures from the three elder children showed normal response to stimulation with PHA ·and concanavalin A in vitro. All of the children showed only a minor enlargement of lymphoid tissue in response to infections. Biopsy of a superficial lymph node of N.D. when he was suffering from a bacterial skin infection showed a partial depletion of small lymphocytes in cortical and paracortical areas. The number of germinal centers was reduced. The medullary part of the lymph node appeared to be normal. Discussion
We describe the clinical features of four siblings with recurrent infections. The children had neu-
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100
++ ++
68
Biorksten and Lundmark
Table 3.
Immunoglobulin levels in the serum of four siblings at different ages. Age of patient
Patient, immunoglobulin
3-9 months
9 months to 2 years
H.D. IgG
960 240 30
19A IgM IgE N.D. IgG
19A IgM IgE A.D. IgG
19A IgM IgE Normal values IgG IgA IgM IgE
920-1,410 320-470 10-50 179-650
648 156 30
1,060 580-660 24-30 35-40
545 55 42
510-880 50-190 20-50
1,220 288 45 85
850 50 40
1,060 70-110 31 13-80
IgM IgE B.D. IgG
5-10 years
220-846 3-47 18-104 4-60
321-1,125 7-66 20-97 6-53
530-1,406 29-163 34-166 21-198
637-1,692 36-202 35-170 18-451
Levels of IgG, IgA, and IgM are expressed as mg/100 ml, and levels of IgE as units/ml.
tropenia and eosinophilia in the blood and neutropenia, eosinophilia, and elevated proportions of promyelocytes in the bone marrow. This latter finding possibly indicates a disturbed neutrophil maturation. Leukocytes from the children had a profound defect in chemotactic activity as shown by in vitro tests and by abnormal results in skin window tests. The number of neutrophils in the blood was partly restored to normal when the children were infected. The release of neutrophils from the marginal neutrophil pool and bone marrow in response to sc injections of adrenalin was normal, and this result could possibly explain the increased number of neutrophils recorded during infections. There was an inverse relation between the numbers of blood neutrophils and eosinophils; the latter rapidly fell during infections while the former rose to normal values. It is not known why acute infections are ac-
companied by a reduction in the number of circulating eosinophils. The usual assumption is that the eosinopenia is a manifestation of adrenal stimulation, but Bass [15] recently proved that this is not the case. Thus, other explanations must be sought. The reasons for the eosinophilia sometimes found in immune deficiency syndromes are not known, but Beeson and his associates in 1970 and 1971 [16-18] presented good evidence that eosinophilia is an immunologic phenomenon. In a series of experiments on rats with use of trichinella larvae as antigens, they showed that an eosinophil response was evoked when the antigen was deposited in the lung or a muscle. When the same antigen was homogenized before inoculation and, thus, was presumably delivered rapidly to the reticuloendothelial tissue, the rats failed to develop eosinophilia; however, the antibody response was brisk under these conditions. Although it is not yet possible to prove our hy-
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513-743 83-200 21-25
19A
NOTE.
2-5 years
Leukocyte Abnormalities in Four Siblings
69
Table 4.
Summary of laboratory findings in the present study of four siblings with neutropenia and immune deficiency and laboratory findings from three previous reports of patients with intrinsic defect of chemotaxis and increased susceptibility to infection. Source of data Laboratory finding Phagocytes Leukopenia Neutropenia Eosinophilia Bone marrow
Plasma cells Serum IgG Serum 19A Serum IgM Serum IgE Antibody response to vaccination Isohemagglutinins Lymphocytes Lymphocyte count Lymphoid tissue
Response to skin tests Phytohemagglutinin stimulation
Hill et aI.
Hill and Quie
[21]
[3]
[22]
Present study Yes Yes Yes Eosinophilia; maturation arrest
Yes Yes No Normal
Variable Variable Variable ?
No No Variable ?
Normal
No
?
?
Normal Normal Normal Normal Abnormal Abnormal
? Normal Normal ? Abnormal Abnormal
? Normal Normal Normal ? Abnormal
Normal Normal Normal Normal ? Abnormal
No
No
No
No
Normal High Normal or low Normal
Normal Normal Normal ?
Normal Normal or high Normal or high High
Normal Normal Normal High
Weak or normal Weak or normal
? ?
? ?
Normal ?
Normal Poor condition; depletion of small lymphocytes Deficient
? ?
Normal ?
Normal ?
?
?
?
Normal
Normal
Normal
Normal
pothesis, we are tempted to suggest that the eosinophilia found in our patients and in other immune deficiency syndromes is an expression of delayed or inefficient antigen elimination. Similarly, a defect in phagocyte function interfering with their processing of normal antigen could prevent or delay the close contact between the processed antigen and the reticuloendothelial system that is necessary to evoke a normal immune response. Eosinophilia has been reported previously at least twice in patients with defective leukocyte chemotaxis [19] and those with neutropenia [20].
The children in this family may have a defect in the cellular immunity, as indicated by the weak or absent skin test responses to different antigens and also by the lymph node histology. However, cultures of lymphocytes from the children responded to stimulation in vitro with PHA and concanavalin A. The abnormal responses to antigen stimulation in vivo and the normal results of the in vitro tests could possibly be explained by a low number of circulating T-lymphocytes in the blood. As shown in table 2, neutrophils from controls displayed a normal chemotactic activity in serum
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Response to adrenaline stimulation Stimulated nitroblue tetrazolium test Phagocytosis Bactericidal capacity Complement levels Skin window test Chemotaxis Serum inhibitors of chemotaxis
Miller et aI.
70
References 1. Miller, M. E. Leukocyte movement-in vitro and in vivo correlates. J. Pediatr. 83: 1104-1106, 1973. Lancet 1:438-440, 1974.
2. Leading article (unsigned). Disorders of neutrophil function. Lancet 1: 438-440, 1974. 3. Hill, H. R., Ochs, H. D., Quie, P. G., Clark, R. A., Pabst, H. F., Klebanoff, S. J., Wedgwood, R. J. Defect in neutrophil granulocyte chemotaxis in Job's syndrome of .recurrent "cold" staphylococcal abscesses. Lancet 2:617-619, 1974. 4. Bjorksten, B. The influence of technical factors on the NBT test. Scand. J. Haematol. 12:46-50, 1974. 5. Alexander, J. W., Windhorst, D. B., Good, R. A. Improved tests for the evaluation of neutrophil function in human disease. J. Lab. Clin. Med. 72: 136-148, 1968. 6. Brandt, L. Studies on the phagocytic activity of neutrophilic leukocytes. With special reference to chronic myeloproliferative conditions and megaloblastic anemia. Scand. J. Haematol. (Suppl. 2): 16-19, 1967. 7. Rebuck, J. W., Crowley, J. H. A method of studying leukocytic functions in vivo. Ann. N.Y. Acad. Sci. 59:757-805, 1955. 8. Wilkinson, J. C. Chemotaxis and inflammation. Churchill Livingstone, Edinburgh, 1974, p. 168172. 9. Boyum, A. Separation of leukocytes from blood and bone marrow. Scand. J. Clin. Lab. Invest. 21 (Suppl. 97) :7, 1968. 10. Lange, K. Uber den immunologischen Mechanismus der akuten und chronischen Glomerulonephritis. In E. Wollheim [ed.]. Internationales Nierensymposium, Wtirzburg, 1960. Glomerulare und TubuHire Nierenerkrankungen, Georg Thieme Verlag, Stuttgart, 1962, p. 232-245. 11. Johansson, S. G. 0., Berg, T. Immunoglobulin levels in healthy children. Acta Paediatr. Scand., 56:572-579, 1967. 12. Parker, J. W., Lukes, R. J. A microculture method for lymphocyte transformation studies in the clinical laboratory. Am. J. Clin. Pathol. 56: 174180, 1971. 13. Hartzman, R. J., Bach, M. L., Bach, F. R., Thurman, G. B., Sell, K. W. Precipitation of radioactively labeled samples: a semi-automatic multiple sample processor. Cell. Immunol. 4: 182-186, 1972. 14. Athens, J. W., Raab, O. P., Raab, S. E., Mauer, A. M., Ashenbrucker, H., Cartwright, G. E., Wintrobe, M. M. Leukokinetic studies. IV. The total blood, circulating and marginal granulocyte pools and the granulocyte turnover rate in normal subjects. J. Clin. Invest. 40:989-995, 1961. 15. Bass, D. A. Behavior of eosinophil leukocytes in acute inflammation. I. Lack of dependence of adrenal function. J. Clin. Invest. 55: 1229-1236, 1975. 16. Boyer, M. H., Basten, A., Beeson, P. B. Mechanism of eosinophilia. III. Suppression of eosinophilia by agents known to modify immune responses. Blood 36:458-469, 1970.
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from the patients, whereas neutrophils from the patients showed a decreased activity even in the presence of fresh serum from controls. Thus, there was apparently an intrinsic neutrophil defect in the patients. Such intrinsic defects of neutrophil chemotaxis have been reported previously [3, 21, 22]. The laboratory findings reported in these papers are compared with the findings in our patients in table 4. None of the other patients with neutropenia had eosinophilia, and the very high serum 19B levels presented in two of the reports [3, 22] were not found in our patients. There were, however, other quantitative and qualitative abnormalities in humoral immunity in our patients, as shown by the high levels of IgA in the serum and by weak antibody response to different vaccinations, as well as by low titers of isohemagglutinins in two of the children. In a recent paper [23], two more patients with an abnormal neutrophil chemotaxis were reported. They had very high levels of serum IgE, decreased lymphocyte responses to Candida, and decreased delayed skin test results, but they did not have neutropenia. In contrast to patients with Job's syndrome [3], the children in this family showed an inflammatory response to skin infections that was normal, except· for the presence of neutropenia. One of the children (H.D.) developed rheumatoid arthritis, but her symptoms responded very well to corticosteroids. Collagen diseases, as well as allergic diseases, are common in patients with immune deficiency syndromes, and it has been suggested that the tendency to these diseases results from a defect in antigen elimination [24]. This family with recurrent severe infections represents an unusual combination of abnormalities of host defense. Neutropenia and depressed chemotaxis are evidence of ? defect in the inflammatory response. Consistently elevated levels of IgA and poor antibody response to vaccinations are signs of abnormality of the immunoglobulin system, and a defect in delayed hypersensitivity response to skin test antigens suggests defective cell-mediated immunity.
Bjorksten and Lundmark
Leukocyte Abnormalities in Four Siblings
leukocyte syndrome: a new disorder of neutrophil function. Lancet 1: 665-669, 1971. 22. Hill, H. R., Quie, P. G. Raised serum 19B levels and defective neutrophil chemotaxis in three children with eczema and recurrent bacterial infections. Lancet 1: 183-187, 1974. 23. Van Scoy, R. E., Hill, H. R, Ritts, R E., Jr., Quie, P. G. Familial neutrophil chemotaxis defect, recurrent bacterial infections, mucocutaneous candidiasis, and hyperimmunoglobulinemia E. Ann. Intern. Med. 82:766-771, 1975. 24. Fudenberg, H. H. Are autoimmune diseases immunologic deficiency states? In R A. Good and D. W. Fisher [ed.]. Immunobiology. Sinauer Associates, Stamford, Connecticut, 1971, p. 175-183.
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17. Basten, A., Boyer, M. H., Beeson, P. B. Mechanism of eosinophilia. I. Factors affecting the eosinophil response of rats to Trichinella spiralis. J. Exp. Med. 131: 127l-1287, 1970. 18. Basten, A., Beeson, P. B. Mechanism of eosinophilia. II. Role of the lymphocyte. J. Exp. Med. 131: 1288-1305, 1970. 19. Smith, C. W., Hollers, J. C., Dupree, E., Goldman, A. S., Lord, R. A. A serum inhibitor of leukotaxis in a child with recurrent infections. J. Lab. Clin. Med. 79:878-885, 1972. 20. Andrews, J. P., McClellan, J. T., Scott, C. H. Lethal congenital neutropenia with eosinophilia occurring in two siblings. Am. J. Med. 29:358-362, 1960. 21. Miller, M. E., Oski, F. A., Harris, M. B. Lazy
71
