Clinical and laboratory correlates of lung disease and cancer in adults with idiopathic hypogammaglobulinaemia.

Idiopathic hypogammaglobulinaemia, including common variable immune deficiency (CVID), has a heterogeneous clinical phenotype. This study used data from the national UK Primary Immune Deficiency (UKPID) registry to examine factors associated with adverse outcomes, particularly lung damage and malignancy. A total of 801 adults labelled with idiopathic hypogammaglobulinaemia and CVID aged 18-96 years from 10 UK cities were recruited using the UKPID registry database. Clinical and laboratory data (leucocyte numbers and serum immunoglobulin concentrations) were collated and analysed using uni- and multivariate statistics. Low serum immunoglobulin (Ig)G pre-immunoglobulin replacement therapy was the key factor associated with lower respiratory tract infections (LRTI) and history of LRTI was the main factor associated with bronchiectasis. History of overt LRTI was also associated with a significantly shorter delay in diagnosis and commencing immunoglobulin replacement therapy [5 (range 1-13 years) versus 9 (range 2-24) years]. Patients with bronchiectasis started immunoglobulin replacement therapy significantly later than those without this complication [7 (range 2-22) years versus 5 (range 1-13) years]. Patients with a history of LRTI had higher serum IgG concentrations on therapy and were twice as likely to be on prophylactic antibiotics. Ensuring prompt commencement of immunoglobulin therapy in patients with idiopathic hypogammaglobulinaemia is likely to help prevent LRTI and subsequent bronchiectasis. Cancer was the only factor associated with mortality. Overt cancer, both haematological and non-haematological, was associated with significantly lower absolute CD8(+) T cell but not natural killer (NK) cell numbers, raising the question as to what extent immune senescence, particularly of CD8(+) T cells, might contribute to the increased risk of cancers as individuals age.

Granulocyte macrophage-colony stimulating factor protects against substantia nigra dopaminergic cell loss in an environmental toxin model of Parkinson's disease.

Parkinson's disease (PD) has been linked to exposure to a variety of chemical (e.g., pesticides) and inflammatory agents, which may act cumulatively over time. Finding novel means of limiting pathology associated with toxin exposure would have tremendous clinical importance. To this end, we assessed whether the hematopoietic trophic cytokine, granulocyte macrophage colony stimulating factor (GM-CSF), would inhibit the neurodegenerative effects of the pesticide, paraquat, administered either alone or following priming with the bacterial endotoxin, lipopolysaccharide (LPS). As previously observed, paraquat provoked a modest but significant neurodegenerative effect that was markedly augmented with LPS priming. Central infusion of GM-CSF into the substantia nigra pars compacta (SNc) prevented the loss of SNc dopamine neurons to a degree comparable to that of glial derived neurotrophic factor. Importantly, systemic administration of GM-CSF also had neuroprotective consequences, suggesting that the trophic cytokine can cross the blood brain barrier to promote neuronal survival. Indeed, GM-CSF acted to inhibit the LPS and paraquat induced microglial response, while augmenting astrocyte immunoreactivity within the SNc. Moreover, GM-CSF blunted the paraquat induced reduction of brain derived neurotrophic factor within the hippocampus, as well as in cultured mesencephalic neurons. Although paraquat reduced mesencephalic levels of the anti-apoptotic protein, Bcl-2, GM-CSF had no effect in this regard. Hence, GM-CSF appears to affect inflammatory and/or neuroplastic factors within the SNc that may be linked to neurodegeneration, as well as in other brain regions (hippocampus), which could be important for co-morbid non-motor symptoms in PD. These data suggest that peripheral GM-CSF administration might hold promise as a treatment of PD.

Scedosporium apiospermum in chronic granulomatous disease treated with an HLA matched bone marrow transplant.

A patient with chronic granulomatous disease who was being treated with steroids was diagnosed with a soft tissue Scedosporium apiospermum infection. Despite extensive treatment with antifungals progression to involve solid tissue (bone) occurred. Treatment required an HLA matched bone marrow transplant, which led to complete clearance of the fungal infection, although the patient subsequently died.

Lipid association improves the therapeutic index of lomustine [1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea] to suppress 36B-10 tumor growth in rats.

The therapeutic efficacy and tumor accumulation of a liposome formulation of 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU), an effective agent used in the treatment of malignant brain tumors, was examined in an animal tumor model. Pharmacokinetic studies in normal and tumor-bearing rats indicated that a 2-fold greater plasma exposure was achieved with liposome-formulated CCNU compared with the free drug. In Fisher rats bearing s.c. tumors 36B-10, tumor growth was delayed substantially when liposomal CCNU was delivered compared with free-drug treatment. In single-dose treatments of 20, 35, and 50 mg/kg, tumor progression after each dose was reduced approximately 2-fold with liposomal compared with free CCNU (four animals in each treatment group). Multiple-dose treatments (given as three weekly doses with eight animals in each treatment group) with cumulative doses of 80 and 100 mg/kg of free and liposomal CCNU also resulted in a 2-fold reduction in tumor progression when compared with free-drug treatment. When drug levels in tumors relative to plasma were examined, it was observed that tumor drug concentrations did not exceed those found in plasma after administration of free CCNU; after administration of liposomal CCNU, however, tumor concentrations exceeded those in plasma by nearly 10-fold. These results suggest that the increased efficacy of liposome-formulated CCNU may be attributable to enhanced drug accumulation in tumor tissues.

Treatment of EBV driven lymphoproliferation with erythrophagocytosis: 12 year follow up.

This is a report of a case of Epstein-Barr virus (EBV) associated haemophagocytic syndrome in a 17 year old woman with antibody deficiency. For two years before this presentation, serology showed abnormally high titres to EBV early antigen, suggestive of persistent infection with EBV. She became acutely unwell with clinical features consistent with virus associated haemophagocytic syndrome (VAHS). Histology showed lymphoproliferation with erythrophagocytosis and evidence of EBV encoded RNAs in liver, spleen, and lymph node. VAHS is often fatal, particularly when it occurs in patients with underlying immunodeficiencies. In this case, treatment with intravenous immunoglobulin, aciclovir, and alpha interferon was followed by a dramatic recovery. Twelve years later the patient remains relatively well on regular intravenous immunoglobulin.

Common variable immunodeficiency: an update on therapeutic approaches.

Common variable immunodeficiency (CVID) is not a homogeneous disease, as has become clear from recent scientific studies. This makes the interpretation of studies of clinical therapeutics difficult to assess and raises questions about historical case reports. The evidence for the optimum use of replacement immunoglobulin in CVID is reviewed. This therapy represents the current gold standard, despite attempts to use other immunostimulatory compounds. Questions of product properties, product selection, adverse events and infectious risks are addressed. Products are not interchangeable and have different physicochemical characteristics. Despite intravenous immunoglobulin being in use for 20 years, there are still unanswered questions over dose and target trough IgG levels, particularly with respect to patients with established lung disease. The management of organ-based complications of CVID is discussed. This includes the treatment of unusual infections such as mycoplasmas and enteroviruses, which are specific to antibody deficiency. The diagnosis and treatment of the granulomatous disease of CVID is discussed. The role of surgery, including lung transplantation, in the management of CVID complications is reviewed. There are few available data on optimum strategies for antibiotic usage for bacterial infective complications and it is clear that present regimens, at least in severe recurrent sinus disease, are not consistently effective. Better clinical trials are required to identify appropriate regimens and validate or disprove widely held assumptions about therapy in CVID. Despite advances in diagnosis and management, there is abundant evidence in the UK that patients do not yet receive rapid diagnosis and optimum therapy, even within the limited published data currently available. This leads to considerable avoidable morbidity and mortality.

Lipid association increases the potency against primary medulloblastoma cells and systemic exposure of 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU) in rats.

PURPOSE: To reduce the systemic toxicity and prolong the systemic presence of 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU), a lipid-based drug carrier was designed and characterized. METHODS: The degree of CCNU association with lipid vesicles composed of 1, 2-dimyristoyl-sn-glycero-3-phosphocholine (DMPC) and 1,2-dimyristoyl-sn-glycero-3-phosphoglycerol (DMPG) (1:1, m/m) was characterized and the drug decomposition rates of lipid-drug complexes were monitored. Effects of lipid association on drug potency against medulloblastoma cells and total systemic drug exposure in rats were determined. RESULTS: At a CCNU:lipid molar ratio greater than 1:5, more than 90% of the drug was associated with the lipid vesicles. In aqueous suspensions, lipid association significantly reduced the first-order drug decomposition rate. In addition, lipid-associated CCNU exhibited a 4-fold increase in drug sensitivity with medulloblastoma cells. IC50 values for CCNU admixed and encapsulated with lipid vesicles were 18+/-4.9 and 14.0+/-2.2 microM, respectively, compared to 83+/-11.0 microM for free CCNU. When administered to rats, lipid-associated CCNU increased the AUC (area under the concentration-time curve) of CCNU by approximately 2-fold (20.46+/-2.15 compared to 39.59+/-1.87 microg x min/ml), and the terminal half-life (t1/2beta) by almost 9-fold (17+/-9 compared to 147+/-48 min) over free CCNU. Despite the increase in total systemic drug exposure, rats treated with lipid-associated CCNU exhibited a significantly lower frequency of acute neurotoxicity. CONCLUSIONS: These data indicate that CCNU associated with lipid vesicles may increase drug stability, potency, and systemic exposure in rats.

Apolipoprotein E is associated with islet amyloid and other amyloidoses: implications for Alzheimer's disease.

Apolipoprotein E (ApoE) has recently been proposed as an aetiological factor of Alzheimer's disease (AD): ApoE is co-localized to amyloid plaques and neurofibrillary tangles in the brain and binds to A beta-protein in vitro. An association of ApoE epsilon 4 allele with the development of AD has been reported. Islet amyloid is formed from islet amyloid polypeptide (IAPP) in pancreatic islets of 90 per cent of patients with non-insulin-dependent diabetes mellitus (NIDDM) which, like AD, is an age-dependent pathology. The relationship of ApoE to islet amyloid and other amyloidoses is largely unknown. In this study, ApoE was localized by immunocytochemistry on pancreatic specimens from non-diabetic man, monkey, and mouse, and on amyloid-containing human tissues from pancreas, heart, brain, and intestine. All types of amyloid deposits, irrespective of the constituent peptide, site of deposition, or species, showed immunoreactivity for ApoE (ApoE-IR). Quantitative morphometry showed that similar proportions of islet amyloid were labelled for IAPP and ApoE in monkey islets. ApoE-IR was observed in pancreatic islet cells of non-diabetics. These results suggest that the association of ApoE with amyloid is non-specific for AD or to the component peptide of amyloid fibrils. If ApoE promotes amyloid formation, its synthesis in pancreatic islets could be important for the initiation or the development of pancreatic amyloid in NIDDM.