Repeat treatment of acute hereditary angioedema attacks with open-label icatibant in the FAST-1 trial.

Hereditary angioedema (HAE) is characterized by potentially life-threatening recurrent episodes of oedema. The open-label extension (OLE) phase of the For Angioedema Subcutaneous Treatment (FAST)-1 trial (NCT00097695) evaluated the efficacy and safety of repeated icatibant exposure in adults with multiple HAE attacks. Following completion of the randomized, controlled phase, patients could receive open-label icatibant (30 mg subcutaneously) for subsequent attacks. The primary end-point was time to onset of primary symptom relief, as assessed by visual analogue scale (VAS). Descriptive statistics were reported for cutaneous/abdominal attacks 1-10 treated in the OLE phase and individual laryngeal attacks. Post-hoc analyses were conducted in patients with ≥ 5 attacks across the controlled and OLE phases. Safety was evaluated throughout. During the OLE phase, 72 patients received icatibant for 340 attacks. For cutaneous/abdominal attacks 1-10, the median time to onset of primary symptom relief was 1·0-2·0 h. For laryngeal attacks 1-12, patient-assessed median time to initial symptom improvement was 0·3-1·2 h. Post-hoc analyses showed the time to onset of symptom relief based on composite VAS was consistent across repeated treatments with icatibant. One injection of icatibant was sufficient to treat 88·2% of attacks; rescue medication was required in 5·3% of attacks. No icatibant-related serious adverse events were reported. Icatibant provided consistent efficacy and was well tolerated for repeated treatment of HAE attacks.

Effects of levamisole on normal and abnormal leukocyte locomotion.

The anti-helminthic drug levamisole hydrochloride has been reported to stimulate immune responses in humans and experimental animals. We have investigated levamisole effects on human leukocyte locomotion in vitro in studies of neutrophils and mononuclear cells from normal adults, from patients with Chediak-Higashi disease and from patients with the syndrome of hyperimmunoglobulin E, recurrent pyogenic infections, and defective leukocyte chemotaxis. Directed migration (chemotaxis) of neutrophils and mononuclear cells from normal adults and from the hyperimmunoglobulin E syndrome patients, but not from Chediak-Higashi patients, were stimulated by levamisole at concentrations of 0.01-1.0 micronM, with stimulation observed most consistently at 0.1 micronM. These concentrations of drug also increased cyclic GMP levels in mononuclear cells and enhanced hexose monophosphate shunt activity in neutrophils, but did not alter chemotactic factor-induced changes in the surface charge of neutrophils. Other concentrations of levamisole did not affect leukocyte locomotion except for a high concentration (5.0 mM) which stimulated both random and directed leukocyte migration. When patients with the hyperimmunoglobulin E syndrome took levamisole by mouth, the abnormal chemotactic responses of their neutrophils were significantly improved towards normal. These studies are the first to show pharmacologic improvement of in vitro leukocyte locomotion in patients in whom recurrent infections have been attributed to a defect of this leukocyte function.

Effect of transfer factor on lymphocyte function in anergic patients.

Dialyzable transfer factor, obtained from frozen-thawed peripheral blood leukocytes from a single donor, was given to five anergic patients with chronic mucocutaneous candidiasis. Studies of immunological responses including delayed cutaneous hypersensitivity, in vitro antigen-induced thymidine incorporation, and production of macrophage migration inhibition factor (MIF) were conducted both before and after injection of transfer factor. Before transfer factor, none of the patients had delayed skin responses to any of the natural antigens studied. Their lymphocytes did not produce MIF after exposure to antigens in vitro and only one patient showed increased thymidine incorporation when his lymphocytes were cultured with candida and streptokinase-streptodornase (SK-SD). After injection of transfer factor, four patients developed delayed skin responses to antigens to which the donor was sensitive; no recipient reacted to an antigen to which the donor was nonreactive. Lymphocytes from recipients produced MIF when cultured with antigens that evoked positive delayed skin tests. Only one patient developed antigen-induced lymphocyte transformation and this response occurred only intermittently. Attempts to sensitize three of the patients with the contact allergen, chlorodinitrobenzene, both before and after transfer factor, were unsuccessful. The fifth patient, a 9-yr old boy with an immunologic profile similar to the Nezelof syndrome, did not become skin test-reactive or develop positive responses to the in vitro tests. These findings suggest that transfer factor acts on the immunocompetent cells that respond to antigens with lymphokine production, but has little, if any, effect on cells that respond to antigens by blastogenesis. The failure to sensitize the subjects with chlorodinitrobenzene illustrates the specificity of the immunologic effects of transfer factor, and implies that it does not function through nonspecific, adjuvant-like mechanisms. Failure of transfer factor to produce positive skin tests or MIF production in a patient with Nezelof's syndrome may be evidence that lymphokine-producing cells are thymus derived.

Stimulation of monocyte cGMP by leukocyte dialysates. An antigen-independent property of dialyzable transfer factor.

We studied the effects of dialysates from leukocyte lysates containing dialyzable transfer factor activity and other leukocyte dialysates devoid of transfer factor activity on accumulation of cyclic nucleotides in human leukocytes. Dialysates from normal leukocytes produced 4- to 11-fold increases in leukocyte cGMP, and experiments with purified cell populations revealed that the increases were predominantly, if not entirely, in blood monocytes. Substances that increased monocyte cGMP could be obtained from several cell populations including mononuclear cells from Hypaque-Ficoll gradients, plastic-adherent monocytes, nonadherent lymphocytes, and neutrophils, but were not present in dialysates of leukemic lymphocytes from patients with the Sezary syndrome. Moreover, dialysates that increased leukocyte cGMP had essentially no effect on intracellular cAMP. Dialysates of lysed mononuclear cells contained serotonin, ascorbate, and an unidentified cholinergic activity, agents known to increase leukocyte cGMP. After passage of dialyzable transfer factor from mononuclear cells through a gel-filtration column, four fractions were obtained that increased leukocyte cGMP. Two of these fractions contained ascorbate; two other active fractions, including one that also caused conversion of delayed skin tests, did not contain detectable ascorbate or serotonin. The dialysate of lysed neutrophils also increased cGMP, but this activity was limited to the column fractions which contained ascorbic acid. These observations raise the possibility that alterations in monocyte cGMP content could modulate either the specific antigen-dependent, or, more likely, the antigen-independent activities in preparations of transfer factor.

Age-related and thymus-dependent rejection of adenovirus 2-transformed cell tumors in the Syrian hamster.

Adenovirus type 2-transformed hamster cell-induced newborn tumor lines were usually rejected when transplanted s.c. into 21-day-old syngeneic, weanling hamsters. The tumor-inducing capacity of two of these lines (Ad2HTL3 and Ad2HTL6) was tested in intact and neonatally thymectomized hosts. After s.c. injection of suspensions prepared from these lines, none of the weaning hamsters developed tumors while 100% of the newborns and 35.2% of neonatally thymectomized, weanling hamsters developed progressively enlarging neoplasms. The susceptibility of neonatally thymectomized hamsters to tumor challenge was directly related to the degree of immunosuppression observed following thymectomy as indicated by the amplitude of the in vitro response of blood leukocytes to concanavalin A. Pretreatment of thymectomized weanlings with syngeneic adult lymphoid cells (i.p.) resulted in a significant reduction in tumor susceptibility (p = 0.03). These findings suggest that acquisition of resistance to adenovirus type 2-transformed cells during the first 21 days of life may be a thymus-dependent cellular immune process.

Rejection of adenovirus 2-transformed cell tumors and immune responsiveness in Syrian hamsters.

Transplantation of adenovirus type 2-transformed cell-induced newborn tumor lines to different aged hamsters revealed that the cell-mediated host defenses responsible for tumor graft rejection matured early in the second week of life. When light microscopic examinations were performed during the course of tumor development, the primary histopathological difference between progressing tumors removed from newborn or thymectomized weanling hamsters and regressing lesions from normal weanlings was the lack of an early, mononuclear cell infiltrate in neoplasms from newborn and thymectomized hosts. These results suggest that the maturation of cellular immunity determines resistance to tumor transplantation in this system. This conclusion was supported by the in vitro detection of concanavalin A-responsive lymphocytes in spleens from tumor-resistant suckling but not tumor-susceptible neonatal hamsters. Although the incomplete seeding of thymus-dependent lymphocytes to the peripheral lymphoid tissues of newborn hamsters may partially explain the deficient concanavalin A responses of neonatal spleen cells, there appears to be an additional requirement for a radioresistant, adherent accessory cell population. These findings suggest that the development of a cell-mediated immune response is necessary for the rejection of adenovirus type 2-transformed cells and transformed cell-induced tumors and that this response requires the interaction of T-cells and accessory cell populations.

Altered excretion of modified nucleosides and beta-aminoisobutyric acid in subjects with acquired immunodeficiency syndrome or at risk for acquired immunodeficiency syndrome.

Urinary excretion of modified nucleosides and beta-aminoisobutyric acid, subsequently referred to as markers, was determined in populations of patients with acquired immunodeficiency syndrome (AIDS) or at risk for development of AIDS. Our results show that asymptomatic adult male homosexuals excreted elevated amounts of markers as compared to male heterosexuals. This aberrant excretion was more pronounced in asymptomatic adult male homosexuals with antibodies to HTLV-III. Significantly greater excretion of 1-methylinosine, N4-acetylcytidine, and N2-methylguanosine was observed in asymptomatic adult male homosexuals with antibodies to HTLV-III than in asymptomatic male homosexuals without antibodies to HTLV-III. Increased amounts of markers were also excreted by subjects with the generalized or chronic lymphadenopathy syndrome, AIDS related complex (ARC), or AIDS. In these subjects, the most pronounced differences between groups were between subjects with chronic lymphadenopathy syndrome and those with ARC; subjects with ARC excreted greater amounts of seven of the ten urinary markers. There were few differences between subjects with ARC and those with AIDS, Kaposi's sarcoma, or AIDS with opportunistic infections. This observation may be useful for identifying subjects who are at risk of developing AIDS. A prospective study to test this hypothesis is under way.

Digoxin Immune Fab therapy in the management of digitalis intoxication: safety and efficacy results of an observational surveillance study.

An observational surveillance study was conducted to monitor the safety and effectiveness of treatment with Digoxin Immune Fab (Ovine) (Digibind) in patients with digitalis intoxication. Before April 1986, a relatively limited number of patients received treatment with digoxin-specific Fab fragments through a multicenter clinical trial. Beginning with commercial availability in July 1986, this study sought additional, voluntarily reported clinical data pertaining to treatment through a 3 week follow-up. The study included 717 adults who received Digoxin Immune Fab (Ovine). Most patients were greater than or equal to 70 years old and developed toxicity during maintenance dosing with digoxin. Fifty percent of patients were reported to have a complete response to treatment, 24% a partial response and 12% no response. The response for 14% of patients was not reported or reported as uncertain. Six patients (0.8%, 95% confidence interval 0.3% to 1.8%) had an allergic reaction to digoxin-specific antibody fragments. Three of the six had a history of allergy to antibiotic drugs. Twenty patients (2.8%, 95% confidence interval 1.7% to 4.3%) developed recrudescent toxicity. Risk of recrudescent toxicity increased sixfold when less than 50% of the estimated dose of antibody was administered. A total of 215 patients experienced posttreatment adverse events. The events for 163 patients (76%) were judged to result from manifestations of underlying disease and thus considered unrelated to Fab treatment. Digoxin-specific antibody fragments were generally well tolerated and clinically effective in patients judged by treating physicians to have potentially life-threatening digitalis intoxication.

Lymphokines and platelets promote human monocyte adherence to fibrinogen and fibronectin in vitro.

Monocytes must accumulate in areas of tissue injury and inflammation to effect phagocytosis, antigen presentation, and monokine production. Fibrinogen/fibronectin matrices have been demonstrated in healing wounds and in delayed-type hypersensitivity skin reactions. We have developed an in vitro system for investigation of the ability of fibrinogen and fibronectin matrices to serve as substrata for human peripheral blood monocyte adherence. Monocyte adherence was greatest on matrices of both fibrinogen and fibronectin, less to fibrinogen alone, and least to fibronectin alone. Lymphokines increased adherence of monocytes to all three surfaces but not to albumin-coated surfaces. Addition of platelets also caused a dose-dependent increase in monocyte adherence to all three surfaces. This increased adherence was not a simple function of arachidonic acid metabolites, stable platelet products, nor monocyte binding sites on the platelet membrane. The effect of platelets was not additive to the effect of lymphokines. We conclude that fibrinogen and fibronectin provide a framework for monocyte adherence and that factors present in areas of inflammation and wound healing, such as lymphokines and platelets, can augment this adherence. Such adherence facilitates the transformation of monocytes into macrophages in vitro and may also foster such transformation in vivo.

Purification of transfer factors.

Transfer factor activities have been studied in both clinical and basic science settings for several decades. Until now, highly purified transfer factors that are suitable for molecular analysis have not been available. This has impeded progress towards understanding the molecular and cellular basis of the activities of these important inducers of cell-mediated immune responses. Murine transfer factors with specificities for chicken egg albumin or horse spleen ferritin were purified to virtual homogeneity using a combination of affinity chromatography and reversed-phase and polytypic high performance liquid chromatography (hplc). Transfer factors prepared by this methodology were recovered in high yield and in biologically-active, antigen-specific forms. The purified materials were further analyzed using sodium dodecyl sulfate polyacrylamide gel electrophoresis, chromatographic methods and an in vivo assay for immunological activity. For the first time definitions for unit transfer factor activity and specific activity are introduced. The results of these experiments indicate that transfer factors are a family of highly polar, hydrophilic molecules of low molecular weight (approximately 5,000) which are produced in small quantities by lymphoid cells and which have potent biological activity. The availability of purified transfer factors should facilitate definitive studies into the nature and mechanisms of production and action of these molecules.

A microtiter assay for human monocyte activation by lymphokines.

This report describes a microtiter assay of human lymphokine activity based on lymphokine-induced increases in monocyte adherence to plastic surfaces. Supernatants were generated by stimulation of peripheral blood mononuclear cells with streptokinase/streptodornase or purified protein derivative. Monocyte adherence was measured by a 51chromium radioassay. The increased adherence was shown to be due to a soluble factor that was produced by antigen-stimulated mononuclear cells from donors who were responsive to the antigen but not by mononuclear cells from donors who were unresponsive. The factor was not dialyzable. The assay requires only 20 ml of peripheral blood and is easily automated and quantifiable, making it suitable for clinical laboratory use.

Host factors in defense against fungal infections.

The immune system contains multiple components that provide protection against specific groups of microorganisms. The degree of specialization of function is clearly illustrated in patients with immunodeficiency syndromes in whom the nature of the defect determines the sites of the infections and the susceptibility to certain organisms. Chronic mucocutaneous candidiasis is an especially dramatic illustration of the role of the T-lymphocyte system in defense against opportunistic fungal infections, especially of the skin and mucous membranes. There is considerable heterogeneity of the immune abnormalities in patients with chronic mucocutaneous candidiasis. The most consistent defects involve subnormal production of lymphokines by T-cells in response to Candida antigens. However, some patients have more global defects and are unresponsive to all antigens and may have reduced responsiveness to mitogens as well. Successful therapy of this infection requires a combination of treatments, including such antifungal drugs as clotrimazole, ketoconazole, or amphotericin B and correction of the underlying immune defect with such agents as transfer factor.

Long-term therapy of chronic mucocutaneous candidiasis with ketoconazole: experience with twenty-one patients.

Our experience in the treatment of chronic mucocutaneous candidiasis with ketoconazole is reviewed. Of 21 patients, 15 have evidence of deficient cellular immunity and eight have endocrine abnormalities. Six patients had concurrent dermatophytosis or chromomycosis. All patients responded to treatment. Mucosal lesions improved in 6.7 +/- 0.5 days and cutaneous lesions responded to 22.7 +/- 5.1 days. The responses by infected nails were more variable (mean response time 92.4 +/- 14.4 days). Concurrent dermatophytoses did not prolong response times. Adverse effects were infrequent: one patient had drug-induced hepatitis and two patients became hypertensive. The relationship of hypertension to ketoconazole treatment is unclear. One patient was able to remain in remission after treatment was discontinued. Two patients had relapses while on treatment. Candida albicans isolated from these patients was highly resistant to ketoconazole in vitro. We conclude that ketoconazole is an effective and well-tolerated drug for the treatment of the infectious component of chronic mucocutaneous candidiasis.

Mucocutaneous candidiasis and thymoma.

The clinical, pathologic and immunologic features of 27 patients with chronic mucocutaneous candidiasis and thymic tumors are reviewed. This form of chronic candidiasis is unique in that the infections do not occur until after the third decade and, in contrast to patients in whom candidiasis develops during infancy or childhood, it is not accompanied by failure of endocrine organs. Instead, the patients have the disorders that often accompany thymoma, such as myasthenia gravis, hypogammaglobulinemia, and abnormalities of the bone marrow and circulating blood elements. Evidence of impaired cell-mediated immunity was found in 16 of the 21 patients in whom studies were made. The pathogenesis of the immunodeficiency in these patients is unknown. Immunosuppressive activities in the plasma of four patients were found, but none of the five patients in whom the appropriate studies were made was found to have suppressor cells. The features of this disorder are unique enough that it should be considered a syndrome, and patients in whom candidiasis develops during their adult years should be studied for the presence of thymoma.

Selective hypogammaglobulinemia with persistence of IgE, malabsorption and a nutritionally dependent, reversible defect in cell-mediated immunity.

A 46 year old man presented with selective hypogammaglobulinemia, malabsorption and long-standing secondary malnutrition. Although the patient had essentially unmeasurable levels of immunoglobulins G (IgG), M (IgA), he had normal levels of immunoglobulin E (IgE). He was found to be anergic when tested for the delayed cutaneous hypersensitivity reaction. Evaluation of his cell-mediated immunity in vivo and in vitro suggested one discrete lesion, a defective production of the lymphocyte mediator macrophage migration inhibitory factor. With improved nutrition the patient "repaired" this defect in the "efferent" limb of cellular immunity and was no longer anergic.

Immunosuppressive activity of cord blood leukocytes.

The in vitro effects of cord blood cells from term and preterm infants on cell-mediated immune responses by adult lymphocytes were studied. The experiments showed that cord blood cells were potent suppressors of antigen- and mitogen-induced proliferation of adult T cells. In contrast to the previously reported observations with adult suppressor cells, the cord blood cells did not require mitogenic activation to exert their suppressive activity. It was also found that a similar, if not identical, suppressive activity was released into the fluid phase when cord blood cells were placed in tissue culture for three to five days. Studies with subpopulations of cord blood cells showed that the suppressive factor was released from rosette-forming T lymphocytes, but not from cell populations that were depleted of T cells. In addition, the production of and the action of the soluble suppressive factor was inhibited by indomethacin.

Correlation of absent inner dynein arms and mucociliary clearance in a patient with Kartagener's syndrome.

Recent experimental studies have demonstrated extensive biochemical differences between the outer and inner dynein arms of cilia. The inner dynein arms are now emerging as the "prime movers" for ciliary clearance. We studied ciliary motility as evidenced by radioisotope mucociliary clearance, and the ultrastructure of respiratory cilia in a patient with Kartagener's syndrome. Cilia exhibited complete absence of only the inner dynein arms, while retaining outer arms, and mucociliary clearance was totally absent. We also studied neutrophil chemotaxis and other immunologic functions in our patient and found them to be normal. Our findings demonstrate an association between the structural abnormality of absent inner dynein arms alone and ciliary immotility in Kartagener's syndrome. The neutrophil migration abnormalities may have a different mechanism which needs further study.

Radiologic findings of adult primary immunodeficiency disorders. Contribution of CT.

STUDY OBJECTIVE: We wished to review the chest radiographic and computed tomographic (CT) findings in adults with primary immunodeficiency disorders, and to evaluate the influence of CT on the treatment of these patients. DESIGN: Retrospective blinded review of radiographs, CT scans, and clinical data. SETTING: National referral center for immunodeficiency disorders. PATIENTS: Forty-six chest radiographs and 22 CT examinations of subjects with primary immunodeficiency disorders were independently scored. Nineteen of the subjects who had CT scans had B-cell deficiency, while 3 had T-cell deficiency. RESULTS: CT-detected bronchiectasis in 15 of 19 subjects with B-cell deficiency, compared with 7 cases detected on chest radiograph. Unsuspected upper lobe bronchiectasis was found on CT in 15 cases. Other CT findings in this group included small nodules in seven subjects, interstitial lines in four, air trapping in seven, ground glass or parenchymal consolidation in nine, evidence of small airways disease in nine, and mucus plugs in four. Two of the three subjects with T-cell disorders showed cavitation and two had unsuspected reactive mediastinal adenopathy. Clinical management appeared to be altered in five subjects with B-cell deficiency by CT findings of severe focal or diffuse bronchiectasis or small airways disease. Additionally, CT localized the bleeding site in three subjects with hemoptysis. CONCLUSIONS: CT is valuable for detection of bronchiectasis in subjects with B-cell immunodeficiency and may alter treatment of these patients.

Chronic mucocutaneous candidiasis.

Chronic mucocutaneous candidiasis should be viewed as a spectrum of disorders in which the patients have persistent and/or recurrent candidiasis of the skin, nails and mucous membranes. Some of the conditions have genetic predispositions. A common immunologic abnormality is failure of the patient's T lymphocytes to produce cytokines that are essential for expression of cell-mediated immunity to Candida. Antifungal drugs are effective in clearing the infections, and treatments that restore cellular immunity have produced long term remissions.

Structural nature and functions of transfer factors.

Transfer factors are molecules that "educate" recipients to express cell-mediated immunity. This effect is antigen-specific. The most consistent effects of transfer factors on the immune system are expression of delayed-type hypersensitivity and production of lymphokines such as macrophage migration inhibitory factor (MIF), which is probably identical to gamma-interferon in response to exposure to antigen. Transfer factors bind to antigens in an immunologically specific manner. This discovery has enabled us to isolate individual transfer factors from mixtures that contain several transfer factors. This reactivity probably explains the specificity of individual transfer factors, and it has provided a method for purification of individual transfer factors to apparent homogeneity. The purified materials are immunologically active and antigen-specific. They have molecular weights of approximately 5,000 Da and appear to be composed entirely of amino acids. Transfer factors appear to offer a novel means of molecular immunotherapy for certain patients with defective cell-mediated immunity.