Immunophenotyping large B-cell lymphomas. Flow cytometric pitfalls and pathologic correlation.

Large cell lymphomas often challenge the diagnostic flow cytometrist. The purposes of this study were to improve our protocols for diagnosing large cell lymphomas and to correlate flow cytometric (FC) data with demographic and histologic features. We identified 63 cases of large B-cell lymphoma between January 1, 1995, and July 30, 1999, and reviewed the diagnostic slides and FC light scatter and staining patterns. The 51 lymphomas with adequate material for systemic review fell into 2 light scatter patterns: "clear cut," with large abnormal cells (high forward scatter relative to normal lymphocytes), 17 cases (33%); and "complex," 34 cases (67%). Clear-cut cases were more mitotically active (average of 42 vs 25 per 10 high-power fields), with higher cellularity. Apoptosis, geographic necrosis, and sclerosis were present histologically in many cases, regardless of FC findings. We conclude that morphologic features of large cell lymphomas do not predict which cases will be difficult to diagnose by FC. Gating strategies can be critical to improve the diagnostic yield.

A reappraisal of amniotic fluid alpha-fetoprotein measurement at the time of genetic amniocentesis and midtrimester ultrasonography.

OBJECTIVE: To evaluate the contemporary utility of amniotic fluid alpha-fetoprotein measurement as a complementary test for fetal abnormalities at the time of invasive genetic testing. METHODS: A review of amniotic fluid alpha-fetoprotein test results was conducted to determine the frequency with which elevated alpha-fetoprotein values added independent diagnostic information and altered clinical management. Amniotic fluid specimens processed for alpha-fetoprotein between 1995 and 1998 were included. Elevated alpha-fetoprotein cases were classified as either incidental to the fetal abnormality diagnosed or central to the identification of a fetal anomaly on the basis of whether an ultrasonographic examination had already identified the anomaly before amniocentesis. The costs associated with alpha-fetoprotein testing were used to estimate the expenditure per pregnancy in which elevated alpha-fetoprotein values would add discriminatory diagnostic value. A hypothetical national cost model was constructed to explore the utility of selective rather than routine amniotic fluid alpha-fetoprotein measurement. RESULTS: Eighty-two (3%) of 2769 amniotic fluid alpha-fetoprotein values were elevated. In only 1 instance was the elevated result found to be partially discriminatory (e.g., an established diagnosis of microcephaly with an associated small encephalocele identified after the elevated amniotic fluid alpha-fetoprotein value prompted repeated ultrasonographic assessment). Sixty-one other neural tube defects were detected by ultrasonography alone (myelomeningocele, n = 28; anencephaly, n = 24; and encephalocele, n = 9). Thus, an elevated alpha-fetoprotein result added diagnostic precision in only 1 (0.036%) of 2769 cases. Cost estimates suggested that routine amniotic fluid alpha-fetoprotein assessment resulted in a $219,000 expenditure per informative case. CONCLUSIONS: Routine measurement of amniotic fluid alpha-fetoprotein during amniocentesis may not be warranted in centers with expertise in targeted ultrasonographic imaging.

Breakthrough varicella infection in a healthcare worker despite immunity after varicella vaccination.

Although varicella vaccination is recommended for varicella-susceptible healthcare workers (HCWs), breakthrough infection after vaccination is not unusual, especially following household exposures. We report breakthrough varicella in a vaccinated HCW and review the data on breakthrough infection and concerns for the healthcare setting.

Serum dioxin and immunologic response in veterans of Operation Ranch Hand.

The authors studied immune response and exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (dioxin) among veterans of Operation Ranch Hand, the US Air Force unit responsible for the aerial spraying of herbicides in Vietnam from 1962 to 1971. A comparison group of Air Force veterans who served in Southeast Asia but were not involved in spraying herbicides was included. The authors studied delayed-type hypersensitivity skin test responses to Candida albicans, mumps, Trichophyton, and a bacterial antigen made from lysed Staphylococcus aureus. Lymphocyte measurements included total lymphocyte counts; T-cell (CD3, CD4, CD5, and CD8), B-cell (CD20), and NK-cell (CD16 and CD56) subsets; and expression of the activation antigen CD25 on CD3 T cells. The authors quantitated the serum concentrations of immunoglobulin (Ig)A, IgG, and IgM; examined sera for the presence of monoclonal immunoglobulins (M proteins); and looked for a broad range of autoantibodies (rheumatoid factor, antinuclear antibody, smooth muscle autoantibody, mitochondrial autoantibody, parietal cell autoantibody, and thyroid microsomal autoantibodies). They measured the level of dioxin in 1987 or 1992, extrapolated the result to the time of service in Vietnam, and assigned each veteran to one of four exposure categories: Comparison and three Ranch Hand groups (Background, Low, or High). Overall, the authors found no evidence of a consistent relation between dioxin exposure category and immune system alteration.

Plasma-soluble CD30 in childhood tuberculosis: effects of disease severity, nutritional status, and vitamin A therapy.

Plasma-soluble CD30 (sCD30) is the result of proteolytic splicing from the membrane-bound form of CD30, a putative marker of type 2 cytokine-producing cells. We measured sCD30 levels in children with tuberculosis, a disease characterized by prominent type 1 lymphocyte cytokine responses. We postulated that disease severity and nutritional status would alter cytokine responses and therefore sCD30 levels. Samples from South African children enrolled prospectively at the time of diagnosis of tuberculosis were analyzed. (Patients were originally enrolled in a randomized, double-blind placebo-controlled study of the effects of oral vitamin A supplementation on prognosis of tuberculosis.) Plasma samples collected at the time of diagnosis and 6 and 12 weeks later (during antituberculosis therapy) were analyzed. sCD30 levels were measured by enzyme immunoassay. The 91 children included in the study demonstrated high levels of sCD30 at diagnosis (median, 98 U/liter; range, 11 to 1,569 U/liter). Although there was a trend toward higher sCD30 levels in more severe disease (e.g., culture-positive disease or miliary disease), this was not statistically significant. Significantly higher sCD30 levels were demonstrated in the presence of nutritional compromise: the sCD30 level was higher in patients with a weight below the third percentile for age, in those with clinical signs of kwashiorkor, and in those with a low hemoglobin content. There was minimal change in the sCD30 level after 12 weeks of therapy, even though patients improved clinically. However, changes in sCD30 after 12 weeks differed significantly when 46 patients (51%) who received vitamin A were compared with those who had received a placebo. Vitamin A-supplemented children demonstrated a mean (+/- standard error of the mean) decrease in sCD30 by a factor of 0.99 +/- 0.02 over 12 weeks, whereas a factor increase of 1.05 +/- 0.02 was demonstrated in the placebo group (P = 0.02). We conclude that children with tuberculosis had high sCD30 levels, which may reflect the presence of a type 2 cytokine response. Nutritional compromise was associated with higher sCD30 levels. Vitamin A therapy resulted in modulation of sCD30 levels over time.

A comparison of commercially available adjuvants for use in research.

We evaluated an adjuvant, TiterMax, as an alternative to complete Freund's adjuvant (CFA) for producing antisera in animals. TiterMax, consists of a microparticulate stabilized water-in-oil emulsion of a metabolizable oil, squalene, with the adjuvant block copolymer CRL89-41. This paper reports two evaluations of TiterMax versus CFA and other commercially available adjuvants. In the first study, mice were immunized with a hapten, trinitrophenol, conjugated to hen egg albumin (TNP-HEA) in one of several adjuvants: TiterMax, CFA, Adjuvax, Ribi adjuvant system (RAS), Alhydrogel or Lipovant. TiterMax induced higher longer lasting titers with fewer injections than any of the other adjuvants. The magnitude of the response to TNP varied with species and route of immunization. In the second study, CFA, TiterMax, Adjuvax and RAS were compared in rabbits, mice and goats. Animals were immunized with luteinizing hormone-releasing hormone (LHRH) conjugated to BSA in each adjuvant using comparable protocols. TiterMax induced titers against the peptide equivalent to CFA in all three species. The inflammatory responses induced by TiterMax were mild and transient compared with those induced by CFA. These data suggest that TiterMax is an effective alternative to CFA in many situations.

Immunomodulatory ionophore copolymers, T150R1 and T130R2, induce corticotropin from anterior pituitary cells.

T150R1 is a synthetic copolymer with Na+ ionophore activity. We demonstrated previously that T150R1, when injected into mice, produces rapid thymic involution with depletion of cortical thymocytes. Elevated serum ACTH and corticosterone levels, as well as abrogation of the effects of T150R1 on the thymus by adrenalectomy and hypophysectomy, suggested a pituitary-mediated mechanism. In this work, we investigated the ability of T150R1, and of the related ionophore copolymer T130R2, to stimulate ACTH in vitro from the mouse anterior pituitary cell line AtT-20. Copolymer-induced ACTH release was dose-, time-, and temperature-dependent. Hormone induction peaked at 30 degrees C for T150R1 and 37 degrees C for T130R2. The temperature dependence of ACTH release paralleled that of ionophore activity measured in red blood cells, providing evidence that the ability to induce ACTH is related to the ionophore property of the copolymers. Peak ionophore activity and hormonal release occurred at the temperatures when the copolymers form partially soluble complexes which interact optimally with cell membranes. Cotreatment with exogenous phospholipase C inhibited the effects of T150R1, which suggests that the enzyme either blocks the insertion of T150R1 into the cell membrane or that the phospholipase C-induced increase in intracellular calcium inhibits the ionophore activity of T150R1. These data support an ionophore mechanism for copolymer-induced ACTH release in which changes in the physicochemical structure of the copolymers may affect their interaction with cell membranes. The data also suggest that direct stimulation of pituitary ACTH accounts for at least some of the in vivo immunomodulatory effects of T150R1.

Immunohistochemical progesterone receptor assay. Measurement by image analysis.

To determine the efficiency of image analysis in immunohistochemical progesterone receptor (PgR) measurement, 94 primary breast carcinoma tissue samples were evaluated for PgR by biochemical dextran-coated charcoal assay (DCC) and an immunohistochemical method. Frozen sections immunostained for PgR with a monoclonal antibody (Abbott PgR-ICA, Chicago, IL) and the peroxidase-antiperoxidase technique were scored semiquantitatively histologic score by microscopy and quantitatively (percentage nuclear area immunopositivity [PNA] using the CAS 200 image analyzer (Cell Analysis Systems, Elmhurst, IL). There was a positive correlation between dextran-coated charcoal assay and both histologic score (r = 0.82) and PNA (r = 0.69). Selected cutoff points of 60 histologic score and 6.5% PNA based on sensitivity/specificity calculations yielded a predictive value of a negative test of 73% and 80%, respectively, and a positive predictive value of 100% for both; ranges of fmol/mg protein PgR correspond to ranges of histologic score and PNA. The use of an image analyzer to measure PNA in PgR-immunostained sections is a viable alternative to dextran-coated charcoal assay, especially when insufficient fresh tissue is available.

Immunogenicity of Streptococcus pneumoniae type 14 capsular polysaccharide: influence of carriers and adjuvants on isotype distribution.

This project investigated the effects of novel carriers and adjuvants on the isotype of murine immunoglobulin G (IgG) antibody to pneumococcal capsular polysaccharide type 14 (S14PS). S14PS conjugated to bovine serum albumin induced a weak antibody response which was 100% IgG1 following injection without adjuvant. The same polysaccharide conjugated to flagella of Salmonella typhi induced an antibody response which was 88% IgG3. S14PS-bovine serum albumin was injected with block copolymer L121 or Quil A in squalane-in-water emulsions. The copolymer L121 was at least as effective as Quil A or complete Freund adjuvant in inducing IgG antibodies. IgG1 was the dominant subclass for all. Addition of monophosphoryl lipid A, but not the threonyl derivative of muramyl dipeptide or nontoxic Rhodopseudomonas sphaeroides lipopolysaccharide, to copolymer L121 increased production of the IgG2a, IgG2b, and IgG3 subclasses. S14PS-flagella with copolymer L121 induced higher titers with a markedly altered isotype distribution: 13% IgG1, 52% IgG2a, 6% IgG2b, and 29% IgG3. Monophosphoryl lipid A added to L121 reduced IgG1 antibody to 5%, but increased IgG2a antibody to 14%, IgG2b antibody to 3%, and IgG3 antibody to 78%. These studies demonstrate that both the carrier and the adjuvant can influence the titer and isotype distribution of antipolysaccharide antibody responses.

Murine IgG isotype responses to the Plasmodium cynomolgi circumsporozoite peptide (NAGG)5. I. Effects of carrier, copolymer adjuvants, and lipopolysaccharide on isotype selection.

The tandem repeat peptide of the circumsporozoite protein of Plasmodium cynomolgi, (NAGG)5, conjugated to BSA or Salmonella flagella, was injected into mice with block copolymer and other adjuvants. The flagella carrier preferentially stimulated IgG2a antibodies to (NAGG)5 that constituted as much as 85% of the total IgG antibody whereas the BSA carrier stimulated as much as 98% IgG1. The distribution of isotypes of antibody to (NAGG)5 was also modified by using the copolymer adjuvants L121 or L141, either alone, or especially in combination with a nontoxic LPS. L121 or L141 increased the proportion of IgG2a and IgG2b antibodies to (NAGG)5 after immunization with (NAGG)5-BSA whereas LPS stimulated further increases in IgG2 antibodies (up to 69% of the total IgG). The hapten density, physical form of emulsion, and route of immunization further affected the isotypes produced in this study.

Immunoendocrine modulation and stimulation of hematopoiesis with the ionophore copolymer T150R1.

T150R1, an 8000-dalton copolymer with sodium ionophore activity, has been shown to modulate cellular responses in multiple systems. In this article, we studied its effects on lymphoid and hematopoietic organs in the context of the adrenal-pituitary axis. When injected in mice as an oil in water emulsion, T150R1 caused a rapid, profound, and dose-dependent thymic involution accompanied by splenic hyperplasia. Time course experiments with a 2.5-mg dose revealed that the thymus size was minimal at Day 2, rose to normal by Day 14, then enlarged and gradually returned to normal by Week 6 postinjection. Thymic involution was due to cellular depletion of the cortical area, whereas thymic enlargement was due to cortical hyperplasia. Splenomegaly was seen as early as Day 4, peaked by Day 14, and gradually returned to normal by Week 6. The splenic enlargement was due to hyperplasia of the red pulp, with evidence of proliferating erythropoietic, myelopoietic, and megakaryopoietic precursors. In addition, the bone marrow was stimulated and extramedullary hematopoiesis was present in the liver. The effects of T150R1 on the thymus appeared to be mediated by corticosteroids while the effects on hematopoiesis were not. Corticosterone and ACTH levels were increased in treated animals. Adrenalectomy diminished the T150R1-induced thymic involution but enhanced the splenic hyperplasia. Hypophysectomy did not prevent thymic involution, suggesting that T150R1 has endocrine stimulatory effects. These data suggest that T150R1 represents a new class of ionophores which may act on excitable cells within the endocrine, immune, and hematopoietic systems.

Induction of macrophage Ia expression in vivo by a synthetic block copolymer, L81.

Certain synthetic, nonionic, block copolymers of polyoxypropylene and polyoxyethylene are potent immunoadjuvants. While investigating their mechanisms of action, we found that one of these copolymers, L81, induced the expression of macrophage Ia in vivo. L81 is a 2750-Da, linear copolymer with a 43-unit core of hydrophobic polyoxypropylene flanked on each side by 3 U of hydrophilic polyoxyethylene. It induced threefold to sevenfold increases in the proportion of peritoneal macrophages expressing I-A from 5 to 7 days after an i.p. injection of 5 mg. As little as 1 mg caused a twofold increase. I-A density increased with time after injection of L81. Macrophages induced by L81 actively synthesized I-A, showing an 18-fold increase in biosynthetic capacity. Ia induction did not require the presence of mature T lymphocytes, because similar increases in I-A expression were seen in athymic and euthymic mice. L81-induced macrophages were 10-fold more effective than normal macrophages in presenting Ag to a T cell hybridoma. Other functional studies showed that they were primed for the secretion of superoxide ion and could be stimulated in vitro by IFN-gamma and LPS to lyse tumor target cells. These results suggest that the induction of macrophage Ia expression by L81 may play a role in its activity as an immunoadjuvant.

Increased whole blood viscosity during coronary artery bypass surgery. Studies to evaluate the effects of soluble fibrin and poloxamer 188.

This study was designed to test the hypothesis that soluble fibrin complexes resulting from the trauma of surgery could produce elevated blood viscosity, to characterize the soluble fibrin polymers, and to evaluate in vitro the effect of a new hemorheologic agent, poloxamer 188, on viscosity in these abnormal situations. Ten patients undergoing aortocoronary bypass surgery were studied before and at various times after surgery. By 6 h after surgery, the mean hematocrit decreased by 23%, fibrinogen decreased 48%, and erythrocyte sedimentation rate decreased 33%, whole blood viscosity at a low shear rate rose on average of 69% and soluble fibrin rose 118%. Over the 6-day observation period, the concentrations of soluble fibrin paralleled the changes in viscosity, whereas the concentrations of fibrinogen varied nearly inversely with viscosity. The effects of various forms of fibrinogen and fibrin were tested by additions to normal blood. Soluble fibrin polymers, but not fibrin monomers, increased blood viscosity two to three fold. Poloxamer 188 reduced the viscosity of all patient samples to the normal range. These data support the hypothesis that increased whole blood viscosity at low shear rates is caused by hydrophobic adhesion of fibrin polymers to red cells and that poloxamer 188 normalizes viscosity by effectively disrupting the weak hydrophobic bonds.

Modification of acute focal ischemia in rabbits by poloxamer 188.

We studied the effect of a synthetic copolymer surfactant, poloxamer 188, on cerebral blood flow in a rabbit model of focal cerebral ischemia. Following retro-orbital craniectomy, the parietal branch of the middle cerebral artery was occluded with bipolar current. Cerebral blood flow was measured by the hydrogen clearance technique using platinum-iridium electrodes placed within the parietal cortex. Ten rabbits were infused with 50 mg/kg poloxamer 188 in saline beginning 30 minutes after occlusion; 12 control rabbits received an equal volume of saline. Poloxamer 188 increased blood flow significantly in areas of severe or moderate ischemia but had little effect in areas with mild or no ischemia. The improvement in blood flow could not be accounted for by hemodilution, and the copolymer did not affect blood viscosity at any shear rate from 1 to 100 sec-1. We hypothesize that poloxamer 188 increases circulation in ischemic tissue by inhibiting adhesive interactions among proteins (fibrin and fibrinogen) and cells in the microcirculation.

An improved method for determining the microbial inhibitory activity of serum and its application to the study of patients with leukemia.

Numerous investigators have demonstrated that derangements in serum transferrin and iron can contribute to susceptibility to infection, but the complexity and imprecision of assays have impeded both research and development of clinical testing in this area. This article describes an automated assay for measuring the microbial inhibitory activity of transferrin in serum and its use in patients with acute myelogenous leukemia (AML) and in normal controls. The assay measured the ability of heat-inactivated serum to inhibit the growth of an antibiotic-resistant strain of Pseudomonas aeruginosa. The serum dilutions were prepared in a special low iron chemically defined broth. An inhibition index, the reciprocal of the serum dilution producing 50% inhibition of bacterial growth when compared with the growth in broth alone, was determined. The results showed the serum from the patients with leukemia had a significantly lower inhibition index than that of controls (16 +/- 11 vs. 35 +/- 13, P less than 0.01). In addition, they had higher serum iron levels (162 +/- 65 vs. 75 +/- 27, P less than 0.01), lower serum transferrin levels (231 +/- 65 vs. 309 +/- 71, P less than 0.01), and higher percentage saturation of transferrin with iron (59 +/- 21 vs. 20 +/- 8, P less than 0.01) than did controls. Because the assay uses equipment available in many clinical laboratories, it could be developed for routine use as an index of susceptibility to infection in selected patients.

IgG subclasses in children with nephrotic syndrome.

To determine whether the hypogammaglobulinemia of childhood nephrotic syndrome is characterized by symmetric depression of the IgG subclasses, the authors compared the IgG subclass concentrations in nephrotic patients in relapse versus remission. The authors used a highly sensitive monoclonal antibody-based enzyme immunoassay that allows quantitation with comparable precision of all four subclasses. They analyzed 28 sera obtained from 22 nephrotic patients during relapse (n = 16) and/or remission (n = 12). The mean ages of the two groups were similar. IgG1 and IgG2 were significantly decreased during relapse compared with remission, whereas IgG3 and IgG4 were not significantly different. This pattern of asymmetric depression of IgG subclasses supports a cause other than urinary losses in the pathogenesis of this abnormality.

Hypocomplementemic proliferative glomerulonephritis with C3 nephritic-factor-like activity in multiple myeloma.

Advanced renal failure, nephrotic-range proteinuria due to proliferative glomerulonephritis and multiple myeloma with circulating IgG2 lambda and free lambda light-chain paraproteins occurred in a 31-year-old male. Commonly established causes of renal failure in multiple myeloma were excluded. Immunofluorescence revealed heavy granular glomerular deposition of C3. Serum C3 was decreased, and C3c was increased. C3 nephritic-factor (C3 NeF)-like activity was demonstrated in the serum. Plasmapheresis and chemotherapy resulted in a decrease in paraprotein concentration up to 90%, a decrease in C3 NeF-like activity to negligible, normal serum complement levels and a marked improvement in both renal function and proteinuria. With reference to the literature, the possibility of a syndrome of paraproteinemia, C3 NeF-like activity and glomerulonephritis is forwarded.

Human immunoglobulin G and immunoglobulin G subclasses: biochemical, genetic, and clinical aspects.

Human IgG consists of two identical heavy (H) chains and two identical light (L) chains joined by interchain disulfide bridges. Heterogeneity in the amino acid sequences of the H and L polypeptides results in at least three types of IgG variants at the structural and genetic levels. The four isotypic forms are IgG1, IgG2, IgG3, and IgG4, which share extensive homologies in the primary structure of their H chains. As a result, the subclasses cross-react antigenically, but they can be differentiated on the basis of subtle architectural dissimilarities. The biological and effector properties of the IgG isotypes have been associated, in part, with their structural differences. Genes determining the synthesis of human IgG heavy chains are located on chromosome 14. In several clinical situations the isotypes appear to be regulated or expressed in patterns reflecting the gene arrangement. The numeric designations of the subclasses correspond to the order of their proportional amounts in healthy adult serum: IgG1 greater than IgG2 greater than IgG3 greater than IgG4. Awareness of the importance of the roles of the four IgG isotypes in human health has steadily increased since they were first described in the 1960s. The recognition that deficits or increases in selected IgG subclasses may have clinical consequences has prompted considerable interest in quantifying the four isotypes in clinical specimens. In particular, deficiencies of IgG2, IgG3, and IgG4, singly or combined, are associated with chronic infections which may not be readily recognized in otherwise healthy people with normal serum total IgG concentrations. Different assay methods using polyclonal or monoclonal antisera with various calibrants have been applied; however, no standardized method exists at the present. IgG deficits are associated with gene defects and are acquired in secondary immunodeficiencies in conjunction with other disorders. IgG isotype selectivity has been recognized in autoimmune diseases and in response to carbohydrate and protein antigens derived from pathogenic microorganisms and common allergens.

IgG subclass distribution in patients with multiple myeloma or with monoclonal gammopathy of undetermined significance.

Multiple myeloma provides a unique model for studying factors affecting IgG isotype distribution in humans. Evaluations were made as to whether monoclonal immunoglobulins (M-proteins) of different IgG isotypes are associated with different extents of hypogammaglobulinemia and whether all residual subclasses are decreased comparably. The isotype patterns were analyzed in the context of the gene order of the constant regions of gamma (gamma) heavy chains on chromosome 14. Using monoclonal antibody-based immunoenzymometric assays, IgG subclasses were quantitated in the sera of 50 patients having IgG M-proteins, 38 with multiple myeloma and 12 with monoclonal gammopathy of undetermined significance. Thirty-three (66 percent) patients had IgG1, nine (18 percent) had IgG2, four (8 percent) had IgG3, and four had IgG4 M-proteins, paralleling the normal IgG subclass distribution. The concentration of residual IgG (sum of the evaluatable polyclonal IgG subclasses) was significantly decreased in patient sera (p less than 0.05). However, in only seven (14 percent) of the patients were all three subclasses below the reference range, suggesting some selectivity of immunosuppression. Patients with M-proteins of different IgG subclasses had markedly different patterns of suppression. Patients with IgG2 M-proteins (78 percent) were more likely to have depressed residual IgG than patients with IgG3 (50 percent), IgG1 (27 percent) or IgG4 (0 percent) M-proteins. Some patients had deficits of only one or two IgG subclasses. When considering all sera together, residual IgG1 was disproportionately reduced, followed by residual IgG2, IgG3, and IgG4. Next it was determined whether or not patterns of suppression were predicted by the gamma heavy-chain gene order (5' to 3'): gamma 3, gamma 1, gamma 2, gamma 4, as seen in some other immunologic disorders. Interestingly, the normal isotypes encoded by genes in juxtaposition to that of the M-protein were most often decreased (p less than 0.05). Thus, the patterns of hypogammaglobulinemia in multiple myeloma are heterogeneous. They may be influenced by the M-protein itself, possibly through interactions with regulatory cells. In addition, factors at the gene rearrangement level may contribute.