Loss of B Cells in Patients with Heterozygous Mutations in IKAROS.

BACKGROUND: Common variable immunodeficiency (CVID) is characterized by late-onset hypogammaglobulinemia in the absence of predisposing factors. The genetic cause is unknown in the majority of cases, and less than 10% of patients have a family history of the disease. Most patients have normal numbers of B cells but lack plasma cells. METHODS: We used whole-exome sequencing and array-based comparative genomic hybridization to evaluate a subset of patients with CVID and low B-cell numbers. Mutant proteins were analyzed for DNA binding with the use of an electrophoretic mobility-shift assay (EMSA) and confocal microscopy. Flow cytometry was used to analyze peripheral-blood lymphocytes and bone marrow aspirates. RESULTS: Six different heterozygous mutations in IKZF1, the gene encoding the transcription factor IKAROS, were identified in 29 persons from six families. In two families, the mutation was a de novo event in the proband. All the mutations, four amino acid substitutions, an intragenic deletion, and a 4.7-Mb multigene deletion involved the DNA-binding domain of IKAROS. The proteins bearing missense mutations failed to bind target DNA sequences on EMSA and confocal microscopy; however, they did not inhibit the binding of wild-type IKAROS. Studies in family members showed progressive loss of B cells and serum immunoglobulins. Bone marrow aspirates in two patients had markedly decreased early B-cell precursors, but plasma cells were present. Acute lymphoblastic leukemia developed in 2 of the 29 patients. CONCLUSIONS: Heterozygous mutations in the transcription factor IKAROS caused an autosomal dominant form of CVID that is associated with a striking decrease in B-cell numbers. (Funded by the National Institutes of Health and others.).

Evasion of human innate and acquired immunity by a bacterial homolog of CD11b that inhibits opsonophagocytosis.

Microbial pathogens must evade the human immune system to survive, disseminate and cause disease. By proteome analysis of the bacterium Group A Streptococcus (GAS), we identified a secreted protein with homology to the alpha-subunit of Mac-1, a leukocyte beta2 integrin required for innate immunity to invading microbes. The GAS Mac-1-like protein (Mac) was secreted by most pathogenic strains, produced in log-phase and controlled by the covR-covS two-component gene regulatory system, which also regulates transcription of other GAS virulence factors. Patients with GAS infection had titers of antibody specific to Mac that correlated with the course of disease, demonstrating that Mac was produced in vivo. Mac bound to CD16 (FcgammaRIIIB) on the surface of human polymorphonuclear leukocytes and inhibited opsonophagocytosis and production of reactive oxygen species, which resulted in significantly decreased pathogen killing. Thus, by mimicking a host-cell receptor required for an innate immune response, the GAS Mac protein inhibits professional phagocyte function by a novel strategy that enhances pathogen survival, establishment of infection and dissemination.

Defective membrane potential changes in neutrophils from human neonates.

In an attempt to determine the mechanism of the profound defect in chemotaxis observed in the polymorphonuclear leukocytes (PMN) of human neonates, we have examined membrane potential changes and alterations in free intracellular calcium following chemotactic factor stimulation. Following exposure to formyl-methionyl-leucyl-phenylalanine (FMLP), PMN from adult donors (11) showed a marked change in membrane potential (31%) as determined by fluorescence emission using the cyanine dye, 3-3-dipentyloxacarbocyanine [DiOC5(3)]. In marked contrast, FMLP-stimulated PMN from 10 human neonates failed to show any significant change in membrane potential (1-2%). Using the calcium-sensitive probe Quin 2/AM, FMLP induced an increase in fluorescence of up to 51% in adult PMN (10). In contrast, the change in intracellular free calcium induced in neonatal PMN was much less (32%; P less than 0.01). These results suggest that the profound defect in chemotactic responsiveness of PMN from human neonates may result from an inability of these cells to undergo changes in membrane potential following inflammatory mediator stimulation.

Human recombinant interferon gamma enhances neonatal polymorphonuclear leukocyte activation and movement, and increases free intracellular calcium.

In previous studies, we have reported that after chemotactic factor stimulation, PMNs from neonates fail to undergo certain critical activation steps. Furthermore, the concentration of free intracellular calcium reached is significantly below that of PMNs from adults. Interferon-gamma (IFN-gamma) is a lymphokine that has been shown to activate phagocytic cells, and IFN-gamma messenger RNA production by neonatal mononuclear leukocytes has been reported to be depressed. In the present studies, we found that recombinant human IFN-gamma markedly enhanced the chemotactic responses of PMNs from neonates to levels that were not different from that of PMNs from adults. Furthermore, preincubation of the neonatal cells with this recombinant human lymphokine also corrected the abnormality in intracellular calcium metabolism. These results suggest that this developmental defect in phagocytic cell movement may be the result of an intrinsic defect in IFN-gamma production resulting in deficiency of this critical phagocyte-activating lymphokine.

Fibronectin enhances the opsonic and protective activity of monoclonal and polyclonal antibody against group B streptococci.

We have investigated the opsonic and protective effects of fibronectin (FN) against type III group B streptococci. When used by itself, the FN failed to promote actual internalization of group B organisms. The addition of FN to group B streptococci that had been preopsonized in an immunoglobulin preparation modified for intravenous use ( IgIV ) or a type-specific, murine monoclonal antibody of IgG isotype markedly enhanced interaction with human polymorphonuclear leukocytes (PMN). A similar enhanced effect was observed when the FN was combined with type-specific monoclonal antibody preparations of IgM and, surprisingly, IgA isotype. Preincubation experiments indicated that the major effect was upon the PMN rather than directly on the bacteria, but we could not demonstrate an effect of FN on cell surface receptors for the Fc fragment of Ig or C3b using rosetting techniques. In addition to enhancing the in vitro opsonic activity of Ig, the FN significantly increased the protective effect of the polyclonal and monoclonal Ig preparations in an animal model of neonatal group B streptococcal disease. Thus, FN appears to have a critical role in the host defense mechanisms against group B streptococci.

Clinical relevance of multiple antibody specificity testing in anti-phospholipid syndrome and recurrent pregnancy loss.

We wanted to evaluate whether testing for anti-phosholipid antibodies other than anti-cardiolipin (aCL) and anti-beta-2 glycoprotein I (abeta2GPI) immunoglobulin (Ig)G and IgM identifies patients with recurrent pregnancy loss (RPL) who may be positive for anti-phospholipid syndrome (APS). In a cross-sectional study comprising 62 patients with APS, 66 women with RPL, 50 healthy blood donors and 24 women with a history of successful pregnancies, we tested IgM and IgG antibodies to phosphatidic acid, phosphatidyl choline, phosphatidyl ethanolamine, phosphatidyl glycerol, phosphatidyl inositol and phosphatidyl serine with and without beta-2 glycoprotein I (beta2GPI) from a single manufacturer as well as aCL and abeta2GPI antibodies. Diagnostic accuracies of individual and combined anti-phospholipid (aPL) assays were assessed by computing sensitivities, specificities, positive predictive values and negative predictive values together with their 95% confidence intervals. There was a general trend for increased sensitivities in the presence of beta2GPI co-factor with significant effect for certain specificities. The overall combined sensitivity of the non-recommended aPL assays was not significantly higher than that of the aCL and aB2GPI tests. Multiple aPL specificities in RPL group is not significantly different from controls and therefore of no clinical significance.

Elevation of IgA anti-epidermal transglutaminase antibodies in dermatitis herpetiformis.

BACKGROUND: Dermatitis herpetiformis (DH) is a papulovesicular eruption caused by ingestion of gluten. It is characterized by the deposition of IgA in the dermal papillae. IgA antibodies directed at tissue transglutaminase (TG2) are elevated in gluten-sensitive diseases including DH and coeliac disease (CD). More recently, antibodies directed at epidermal transglutaminase (TG3) were identified in patients with DH, and this may be the dominant autoantigen in this disease. OBJECTIVES: To measure IgA antibodies to TG3 and TG2 in patients with DH and CD, and control populations. METHODS: Serum IgA antibodies against TG2 and TG3 were measured from adults with DH, adults and children with CD, patients with psoriasis, adult Red Cross blood donors, and paediatric controls. RESULTS: Patients with DH and CD had elevated levels of IgA anti-TG2 antibodies compared with control populations. The levels in the patients with DH and adults with CD were similar. IgA anti-TG2 antibodies were higher in the children with CD compared with adults with DH and CD, and with control populations. Patients with DH and adults with CD had elevated levels of IgA anti-TG3 antibodies compared with children with CD and control populations. There was a trend towards higher levels in the patients with DH compared with adults with CD. CONCLUSIONS: IgA antibodies to TG3 are elevated in patients with DH and adults with CD. The progressive expansion of the epitope-binding profile of IgA antitransglutaminase antibodies in patients with CD may explain the development of DH in patients with undiagnosed CD during their adult life.

Hyperactivity of neutrophil leukotactic responses during active bacterial infection.

To determine if changes in neutrophil leukocyte function occur during active bacterial infection, the neutrophils of 25 patients with active bacterial infection and 25 age-matched controls were compared for leukotactic activity, random mobility, and nitroblue tetrazolium reduction. The neutrophil leukocytes of patients with bacterial infection were hyperactive in unidirectional movement toward a chemotactic stimulus as measured in the leukotactic assay and usually had increased nitroblue tetrazolium reduction. The mean leukotactic index was 165+/-56 in patients with bacterial infection and 70+/-11 in controls (P < 0.001). After 7-10 days of appropriate therapy with clinical and bacteriological response, leukotactic activity returned to normal values. A hyperactive leukotactic response continued, however, in patients with persisting bacterial infection. The hyperactive leukotactic response of circulating neutrophils appears to be an early and sensitive event in the inflammatory cycle stimulated by bacterial infection and may aid in the localization of invading bacteria.

Assessment of group B streptococcal opsonins in human and rabbit serum by neutrophil chemiluminescence.

The factors important in host defense against group B streptococci are not well understood. The role of antibody and complement in the prevention of serious infection by these organisms is not known because, to date, a reliable measure of functional opsonic activity has not been developed. Recently, it has been shown that neutrophils produce a chemiluminescence after ingestion of particulate matter, and that this event can be detected and quantitated in a liquid scintillation system. We have adapted the chemiluminescence procedure to examine rabbit hyperimmune and human serum for the presence of group B streptococcal opsonins. Group B streptococci of types Ia, II, and III that were opsonized in homologous but not heterologous type serum produced a peak in chemiluminescence when added to normal human neutrophils. Such activity was correlated, in each instance, with ingestion of bacteria by neutrophils and deposition of immunoglobulin and C3 on the bacterial surface as detected by indirect immunofluorescence. With this assay, we have examined sera from colonized and diseased patients for the presence of opsonins to types Ia, II, and III group B streptococci. Maternal sera often contained type-specific opsonins which resided in the IgG fraction and which crossed the placenta to appear in paired cord specimens. 63% of patients colonized with group B streptococci had serum opsonins to their colonizing type of organism. In contrast, none of the 15 patients with sepsis or meningitis had opsonins directed against their infecting strain. These data suggest that the lack of type-specific opsonins to group B streptococci may be one of the important factors in determining host susceptibility to systemic infection with strains of this group.

Luminol-induced neutrophil chemiluminescence.

Out studies suggest that luminol directly enhances the chemiluminescence of human neutrophils. We show that a significant peak in chemiluminescence production in a particle-free system occurs between 5 and 15 min following exposure of cells to micromolar concentrations of luminol. The response is directly related to dose over a wide rane of luminol concentrations and can be inhibited by superoxide dismutase (90%), catalase (100%) and sodium azide (40%). Evidence is presented which suggests that the effect of luminol eliciting a peak in neutrophil chemiluminescence is mediated within intact cells rather than at the cell membrane. Luminol may produce a peak in chemiluminescence by stimulating very low levels of hexose monophosphate shunt activity and superoxide generation or it may simply amplify light production generated by the production of excited oxygen radicals resulting from surface interactions.

Purification of the proteinase from group B streptococci that inactivates human C5a.

We previously reported that group B streptococci (GBS) possess a cell-associated activity that inactivates the chemotactic activity generated in zymosan-activated serum by cleaving a specific site within the carboxy termini of C5a and C5adesarg. This inactivates the major chemoattractants for neutrophils that are generated when serum complement is activated. We now report the isolation of the enzyme responsible for the proteolytic cleavage of C5a. Treatment of GBS with mutanolysin, an endo-N-acetyl muramidase, released activity from GBS which destroyed the functional activity of C5a. The soluble activity was purified to homogeneity by hydroxyapatite, ion-exchange and gel-filtration chromatography. Analysis by SDS-PAGE showed that the enzyme (GBS C5a-ase) has an Mr of approx. 120,000. The GBS C5a-ase appears to be a serine esterase on the basis of its sensitivity to di-isopropyl fluorophosphate. This enzyme is distinct from the C5a-cleaving enzyme produced by group A streptococci, since the two bacterial products migrate differently on SDS-PAGE, and lack antigenic cross reactivity. This enzyme may play a role in the pathogenesis of group B streptococcal disease through its ability to rapidly inactivate the potent neutrophil agonist, C5a, at sites of infection.

Analysis of phage MS2 coat protein mutants expressed from a reconstituted phagemid reveals that proline 78 is essential for viral infectivity.

A full-length cDNA copy of the RNA genome of bacteriophage MS2 was assembled by the in-frame ligation of the central portion of the genome into a plasmid containing the 5' and 3' ends. Upon transformation of the ligation reaction into Escherichia coli, infectious phage particles were released into the medium. The plaquing ability of the phage produced from the cDNA construct was assessed against various bacterial strains confirming that the bacteriophage produced were male-specific. Sensitivity to RNase in agar overlay was used to confirm that the phage contained RNA. In addition, the phage were unable to infect piliated cells overexpressing MS2 coat protein, a resistance conferred by the binding of recombinant coat protein to the infecting strand of RNA at the replicase initiation region, thus preventing translation of the replicase gene. The phage capsids were visualised after negative staining by transmission electron microscopy, and appeared as spherical particles of approximately 25 nm diameter. The capsid proteins were examined by Western blotting, confirming the presence of a single protein of approximately 14 kDa, which bound anti-MS2 coat protein antibodies. The genomic RNA from single plaques was analysed by reverse transcription-PCR and the presence of the MS2 coat protein gene confirmed by DNA sequencing. The production of replicative MS2 phage from cDNA fragments was used to assess the viability of MS2 coat protein mutants, which had previously been shown to assemble into T = 3 capsid-like particles when expressed in vivo from a bacterial vector. The E76D mutation did not appear to affect phage viability, whilst replacement of the completely conserved P78 residue with asparagine abolished the production of infectious particles, suggesting that P78 may be involved in interactions with the phage maturation protein.

Induction of cyclooxygenase-2 by human monocytes exposed to group B streptococci.

Group B streptococcal (GBS) infections are associated with high morbidity and mortality. The molecular pathways mediating the pathophysiological events in GBS infection are not fully delineated. Cyclooxygenases (COX) are the enzymes that convert arachidonate to active eicosanoids. To identify the effects of GBS on eicosanoid metabolism and regulatory mechanisms, we exposed human monocytes to GBS and found that they secreted prostaglandin E2, prostacyclin, and thromboxane A2. Exposure to GBS caused monocytes to express COX-2 mRNA and protein in both a time- and concentration-dependent manner that correlated with eicosanoid production. COX-1 protein was unchanged. Addition of the anti-inflammatory cytokines interleukin (IL)-4 or IL-10 markedly attenuated GBS-induced COX-2 protein accumulation after GBS exposure, as did inhibition of p38 MAPK. Our experiments are the first to show that exposure of monocytes to a gram-positive bacterium (GBS) results in induction of functional COX-2, suggesting that eicosanoids may play important roles in the pathogenesis of GBS infections.

Inflammatory and immune cell function in psoriasis--a subtle disorder I. In vivo and in vitro survey.

Intradermal skin testing of normal and psoriatic subjects with common antigens, SKSD, Derm-O and PPD, reveals psoriatic subjects to have a decrease in both the amount (not incidence) of erythema (p less than 0.005) and in-duration (p less 0.005) to SKSD. Among all subjects having more than 10 mm erythema to Derm-O and SKSD, 49% of psoriatic and 77% of normal subjects have more than 10 mm induration (p less than 0.001). After sensitization, the response to 30 microgram challenge dose of dinitrochlorobenzene is positive in 50% of psoriatic and 88% of normal subjects (p less than 0.02). Uptake of (3)H thymidine by mitogen stimulated lymphocytes from psoriatic subjects is suppressed at each point of the linear component of a dose response curve. The mitogen dose to produce peak responses in psoriatics was 125% greater than that for normal subjects. In one-way mixed lymphocyte responses to pooled allogeneic stimulator lymphocytes, peripheral blood mononuclear cells from psoriatic subjects show suppression, the mean stimulation index was 55% of that of normal (p less than 0.01). Finally, in vitro polymorphonuclear leukocyte functions (chemotaxis, phagocytosis, and NBT reduction) appear to be within normal limits. When the foregoing parameters were compared with disease activity, there was no correlation.

A simplified procedure for cyclic nucleotide radioimmunoassay and its application to human blood leukocytes.

Rapid treatment of leukocyte suspensions was found to be an effective alternative to acid treatment in the preparation of these cells for radioimmunoassay of cyclic GMP and cyclic AMP. A 2-sec heating to boiling temperature, followed by sonication and micropore filtration, was employed. This procedure adequately inactivated or removed enzymes and binding proteins that can alter cyclic nucleotide concentrations or otherwise interfere with the radioimmunoassay. Moreover, heating in this manner did not appear to affect the stability of cyclic nucleotides or cause significant formation of cyclic GMP from endogenous GTP. Recovery of cyclic nucleotides after heating and filtration was high (89-96%), making possible the measurement of both cyclic GMP and cyclic AMP in small cellular samples. Variation in cyclic nucleotide recovery was small (+/- 2-4% SD), therefore individual recovery determinations were unnecessary.

Comparative opsonic activity of intravenous gamma globulin preparations for common bacterial pathogens.

Immune globulin intravenous is a reduced and alkylated preparation of gamma globulin that is stabilized in 10 percent maltose and 0.1 M glycine at pH 6.8. Recently, a modified immune globulin intravenous preparation was developed that is identical to the standard preparation except that it does not contain glycine and the pH has been lowered to 5.25. The effect of these modifications has resulted in a higher IgG monomer content in the preparation. In the present studies the opsonic activity against several common bacterial pathogens was assessed in the standard (pH 6.8) versus the more acidic immune globulin intravenous (pH 5.25). Opsonic activity was detected in each preparation for Staphylococcus aureus, group B streptococci, Pseudomonas aeruginosa, Escherichia coli, and Serratia marcescens. With all of the organisms except S. marcescens, an intact complement system was required for optimal uptake and killing with each preparation. In general, the opsonic activity of the pH 5.25 immune globulin intravenous was equivalent to the standard pH 6.8 preparation. With several organisms, however, the more acidic preparation had greater activity than the standard one. An immune globulin intravenous preparation with increased antibody titers to P. aeruginosa was also prepared from selected donors and tested for opsonic activity against six of the seven Pseudomonas immunotypes. This preparation was found to have strikingly increased opsonic titers for most of the Pseudomonas immunotypes when compared with the standard immune globulin intravenous. These studies indicate that changes in donor selection or minor modifications in production techniques may markedly affect the biologic activity of intravenous gamma globulin.

Neonatal cellular and humoral immunity to group B streptococci.

The mechanisms of host resistance to group B streptococci have not been defined precisely. In the studies reported here we have assessed the contributions of both humoral and cellular factors in protection against strains of this group. With assays of specific opsonic activity based upon the production of polymorphonuclear leukocyte chemiluminescence and radiolabeled bacterial uptake, we have demonstrated that specific heat-stable antibody and the classic complement pathway are major factors in opsonization of these organisms. In the absence of specific antibody, fresh serum resulted in markedly reduced bacterial uptake indicating, at best, a minor role for the alternative complement pathway. Additional studies have indicated that strain-specific antiphagocytic factors as well as type-specific ones may play a role in the virulence of these organisms. Neonates who developed group B streptococcal sepsis usually lacked opsonic activity in their infecting strain. In addition, polymorphonuclear leukocytes from normal term and stressed neonates showed impaired metabolic activation as measured in the chemiluminescence assay following exposure to opsonized group B streptococci. These results suggest that neonates who develop group B streptococcal disease may have defects in both the humoral and cellular aspects of their acute inflammatory response which may contribute to the high mortality observed in this most fulminant of bacterial infections.

Growth failure, intracranial calcifications, acquired pancytopenia, and unusual humoral immunodeficiency: a genetic syndrome?

We report on two children who may represent a novel syndrome consisting of a deficiency of immunoglobulin-bearing B lymphocytes and serum antibody, deficient intrauterine and/or postnatal growth, intracranial calcifications, and acquired pancytopenia. Poor growth, intracranial calcifications, developmental delay, and hematological abnormalities are common manifestations of congenital infection. However, humoral immunodeficiency is not characteristic in these infections, and no infection was found on extensive evaluation. Rare genetic syndromes may mimic intrauterine infections and may also include immunodeficiency. However the children reported here lack important characteristics or share distinctive manifestations not described in these disorders. Infants presenting with apparent congenital infections in whom a specific infectious cause cannot be identified should be followed carefully with immunological evaluations since this disorder may be progressive and considerable morbidity is attributable to hematological and immunological manifestations.

Immunologic and clinical correlations in rheumatic fever and rheumatic heart disease.

The intimate relationship of Streptococcus pyogenes and rheumatic fever is well-established, but the precise pathogenesis of rheumatic fever and rheumatic heart disease continues to elude intense investigative efforts by students of the disease worldwide. Technologic advances in molecular biology, not thought possible two decades ago, have given additional insight into the immunologic aspects of the disease. On the clinical side echocardiography has proved to be a marvelous, non-invasive technique to evaluate cardiac anatomy and function. We are now able to gain a closer correlation of the clinical presentation and the autoimmune response. The increased understanding acquired both from the "bench" and the "bedside" are making this perplexing disease somewhat less mysterious. We seem tantalizingly close to grasping a complete understanding of the pathogenesis of rheumatic fever and rheumatic heart disease.

Granulocyte function disorders: aspects of development, genetics and management.

The field of phagocytic disorders has attained major biologic and clinical significance in the past 40 years. The development of exciting new techniques in molecular biology and the cellular physiology of signal transduction have made it possible to identify the genetic defects involved in many of these disorders. Moreover through immunopharmacologic intervention, bone marrow or peripheral or cord blood stem cell transplantation along with the prospect of gene therapy, we have begun attempts to at least partially correct genetic defects in cell development and activation pathways in the entire spectrum of phagocyte disorders. Carrier detection and prenatal diagnosis employing with chain reaction techniques or direct nucleotide sequencing in fetal blood have made these diseases potentially preventable or treatable in utero or shortly after birth.