Latent and Overt Polyautoimmunity in Children and Adolescents With Immune Thrombocytopenia.

Autoantibodies are biomarkers for autoimmune disease diagnosis, monitoring, and prediction. Therefore, this study established the frequency of latent and overt polyautoimmunity in children and adolescents with >6 months of diagnosis of immune thrombocytopenia (ITP). Forty-seven patients with chronic or persistent disease had non-organ-specific and organ-specific autoantibodies assessed. Frequency of latent polyautoimmunity was 36.2%, and, of overt polyautoimmunity, it was 4.3%. Of ITP patients with latent polyautoimmunity, 52.9% were positive for antinuclear antibody (ANA), 47.1% for autoantibodies other than ANA, and 64.7% for multiple autoantibodies. In addition, patients with latent polyautoimmunity and those positive for ANA were significantly older at disease onset. Both ITP patients positive and negative for autoantibodies reported family members with autoimmune diseases. The autoantibodies observed were as follows: ANA, anti-dsDNA, anti-SSA/Ro, IgM aCL, anti-GAD, anti-IA2, anti-IAA, anti-TG, anti-TPO, anti-LKM1, and SMA. Of ITP patients with overt polyautoimmunity, 1 was diagnosed with type 1 diabetes mellitus and the other with thyroiditis. In conclusion, children and adolescents with ITP present high frequency of latent and overt polyautoimmunity even for autoantibodies other than ANA. Therefore, ANA and other non-organ-specific and organ-specific autoantibodies should be considered for assessment during ITP patients' follow-up.

Transfer of antibodies across the placenta and in breast milk from mothers on intravenous immunoglobulin.

We studied the levels of immunoglobulins in colostrum, milk and sera from two common variable immunodeficiency (CVID) mothers (M1 and M2), and in sera from their newborn infants. During pregnancy they continued intravenous immunoglobulin therapy (IVIG). Antibody levels from maternal and cord blood collected at delivery and colostrum and milk, collected on the 3rd and 7th post-partum days, respectively, were analyzed. Although cord/maternal blood ratios of total immunoglobulins and subclasses, as well as specific antibodies differed between M1 and M2, both showed good placental transfer of anti-protein and anti-polysaccharide antibodies, despite lower cord/maternal blood ratios in M2. Anti-Streptococcus pneumoniae antibody avidity indexes were similar between paired maternal and cord serum. Both mothers' colostrum and milk samples showed only traces of IgA, and IgM and IgG levels in colostrum were within normal range in M1, whereas M2 presented elevated IgG and low IgM levels, when compared with healthy mothers. The study of colostrum and milk activity showed that they strongly inhibited enteropathogenic Escherichia coli adhesion in vitro. CVID patients must be informed about the relevance of regular IVIG administration during pregnancy, not only for their own health but also for their immune immature offspring. Breast-feeding should be encouraged as colostra from these CVID patients strongly inhibited E. coli adhesion to human epithelial cells thus providing immunological protection plus nutritional and psychological benefits for the infant.

Neutropenia in antibody-deficient patients under IVIG replacement therapy.

Patients with antibody deficiencies are more prone to develop acute neutropenic episodes even during immunoglobulin replacement. The aims of this study were to evaluate the presence of acute neutropenia in 42 patients with primary antibody immunodeficiencies, currently receiving intravenous immunoglobulin (IVIG), and to describe the clinical and laboratory findings during neutropenic episodes. Of all patients, 10 (23.8%) presented acute neutropenia (absolute neutrophil count <1500 cells/mm3) during follow up (mean of 6.4 yr). The absolute neutrophil count ranged from 71 to 1488 cells/mm3. Neutropenia was not clearly associated with antibiotic prophylactic therapy or immunoglobulin levels, while infections were associated with neutropenia in the majority of episodes. Most acute neutropenia episodes were mild or moderate, except in CVID patients who present more severe neutropenia. Although IVIG may have contributed to reducing the severity of neutropenia, it does not prevent its occurrence in all patients. In conclusion, primary immunodeficient patients, even submitted to IVIG replacement therapy, must be regularly evaluated for neutropenia in order to minimize the risk of infections and its appropriate approach.

TNF receptor-associated periodic syndrome (TRAPS): description of a novel TNFRSF1A mutation and response to etanercept.

TRAPS is the most common of the autosomal dominant periodic fever syndromes. It is caused by mutations in the TNFRSF1A gene, which encodes for the type 1 TNF-receptor (TNFR1). We describe here a Brazilian patient with TRAPS associated to a novel TNFRSF1A de novo mutation and the response to anti-TNF therapy. The patient is a 9-year-old girl with recurrent fevers since the age of 3 years, usually lasting 3 to 7 days, and recurring every other week. These episodes are associated with mild abdominal pain, nausea, vomiting and generalized myalgia. Recurrent conjunctivitis and erysipela-like skin lesions in the lower limbs also occur. Laboratory studies show persistent normocytic normochromic anemia, thrombocytosis, elevated erythrocyte sedimentation rate and C-reactive protein. IgD levels are normal. Mutational screening of TNFRSF1A revealed the association of a novel C30F mutation with the common R92Q low-penetrance mutation. The R92Q mutation is seen in 5% of the general population and is associated with an atypical inflammatory phenotype. The patient had a very good response to etanercept, with cessation of fever and normalization of inflammatory markers. Our report expands the spectrum of TNFRSF1A mutations associated with TRAPS, adding further evidence for possible additive effects of a low-penetration R92Q and cysteine residue mutations, and confirms etanercept as an efficacious treatment alternative.

Pineal melatonin and the innate immune response: the TNF-alpha increase after cesarean section suppresses nocturnal melatonin production.

The nocturnal surge of melatonin is the endocrine expression of the circadian system and is essential for organizing the timing of various endogenous processes. Previous works suggest that, in the beginning of a defense response, the increase in circulating tumor necrosis factor-alpha (TNF-alpha) leads to a transient block of nocturnal melatonin production and promotes a disruption of internal time organization. In the present paper, the concentration of melatonin and cytokines [TNF-alpha, interferon-gamma (IFN-gamma), interleukin (IL)-2, IL-4, IL-5, IL-10, IL-12] in the colostrum (postdelivery day 3) and in the milk (postdelivery days 10, 15, 20 and 30) obtained at midday and midnight from mothers who gave birth by vaginal or cesarean section were compared. The nocturnal melatonin surge observed 3 days after vaginal delivery was absent after cesarean section. IL-12 presented no daily variation in either case, while daily variations in IFN-gamma, IL-10, IL-4 and IL-5 were observed after vaginal delivery and cesarean section. On the other hand, the increase in TNF-alpha after cesarean section resulted in suppression of the nocturnal melatonin surge. Daily variation of IL-2 was only observed after recovery of the nocturnal melatonin surge, 30 days after cesarean section. The present paper supports the hypothesis of a cross-talk between the pineal gland and the immune system, which could represent a putative immune-pineal axis.

Injury switches melatonin production source from endocrine (pineal) to paracrine (phagocytes) - melatonin in human colostrum and colostrum phagocytes.

A large number of data show that melatonin has immunomodulatory properties and is produced by immunocompetent cells; also, some evidence suggests a 'feedback' of the activated immune system on the pineal gland. In this paper, we studied immune-pineal interactions in colostrum obtained from healthy puerperae and mothers with mastitis taking into account that, (a) melatonin levels in milk reflects pineal activity and (b) colostrum quiescent mononuclear and polymorphonuclear phagocytes from healthy mothers in culture are adequate for evaluating the ability of immunocompetent cells to produce melatonin. Here we compared the diurnal and nocturnal melatonin levels in colostrum from healthy puerperae and mothers with mastitis; this is a unique noninvasive model for determining pineal activity in the proinflammatory phase of a defense response. In addition, we determined the 'in vitro' production of melatonin by colostrum immunocompetent cells stimulated by enteropathogenic Escherichia coli or zymosan. Suppression of nocturnal melatonin rise in mothers with mastitis was highly correlated with increased tumor necrosis factor-alpha (TNF-alpha) secretion. This result, interpreted taking into account the presence of the transcription factor nuclear factor kappa B in pineal gland, suggest that the proinflammatory cytokine can inhibit nocturnal pineal melatonin production. On the other hand, stimulated, but not quiescent, immunocompetent cells secreted in the colostrum produced melatonin in vitro. In addition, this production ceases after bacteria killing. These results suggest that during the response to an injury the production of melatonin can be transiently shifted from an endocrine (pineal) to a paracrine (immunocompetent cells) source.

Response to polysaccharide antigens in patients with ataxia-telangiectasia.

OBJECTIVE: To analyze the production of antibodies to polysaccharide antigens in patients with ataxia-telangiectasia. PATIENTS AND METHODS: We used the ELISA technique to measure the levels of IgG antibodies to serotypes 1, 3, 5, 6B, 9V and 14 of Streptococcus pneumoniae in 14 patients with ataxia-telangiectasia before and after immunization with 23-valent polysaccharide vaccine. Adequate response to individual polysaccharide can be defined as a postimmunization antibody titer equal to or greater than 1.3 microg/ml or as a minimum fourfold increase over the baseline (preimmunization) value. RESULTS: Six (43%) patients showed an absent response to all serotypes analyzed. Four patients showed adequate response to only one serotype, one patient to two serotypes, two patients to three serotypes and only one patient to four out of six serotypes analyzed. No patient had adequate response to all serotypes tested. Postimmunization pneumococcus IgG levels were higher than preimmunization levels to all serotypes analyzed, except for serotype 3. In spite of this, the mean postimmunization levels were lower than 1.3 microg/ml in all serotypes, except for serotype 14. Mean increment was less than four in all serotypes analyzed. CONCLUSIONS: Our results suggest that patients with ataxia-telangiectasia are at a high risk of having an impaired response to pneumococcus, which may be one of the causes of recurrent sinopulmonary infections in these patients.

Response to polysaccharide antigens in patients with ataxia-telangiectasia

OBJECTIVE: To analyze the production of antibodies to polysaccharide antigens in patients with ataxia-telangiectasia.PATIENTS AND METHODS: We used the ELISA technique to measure the levels of IgG antibodies to serotypes 1, 3, 5, 6B, 9V and 14 of Streptococcus pneumoniae in 14 patients with ataxia-telangiectasia before and after immunization with 23-valent polysaccharide vaccine. Adequate response to individual polysaccharide can be defined as a postimmunization antibody titer equal to or greater than 1.3 µg/ml or as a minimum fourfold increase over the baseline (preimmunization) value. RESULTS: Six (43%) patients showed an absent response to all serotypes analyzed. Four patients showed adequate response to only one serotype, one patient to two serotypes, two patients to three serotypes and only one patient to four out of six serotypes analyzed. No patient had adequate response to all serotypes tested. Postimmunization pneumococcus IgG levels were higher than preimmunization levels to all serotypes analyzed, except for serotype 3. In spite of this, the mean postimmunization levels were lower than 1.3 µg/ml in all serotypes, except for serotype 14. Mean increment was less than four in all serotypes analyzed. CONCLUSION: Our results suggest that patients with ataxia-telangiectasia are at a high risk of having an impaired response to pneumococcus, which may be one of the causes of recurrent sinopulmonary infections in these patients.

Secretory immunoglobulin A obtained from pooled human colostrum and milk for oral passive immunization.

Passive immunization is useful in cases of immunodeficiencies or infectious diseases, but usually seric gammaglobulin or hyperimmune sera are administered parenterally, providing good systemic immunization, though with low protection of the mucosal surfaces. The oral administration of secretory antibodies, especially surface immunoglobulin (SIg)A, which is perfectly adapted to the mucosal environment, would therefore, be preferable. The aim of the present study was to obtain a SIgA preparation from pooled human colostrum and milk, which should maintain the essential properties of the antibodies suitable for clinical oral administration. IgA preparations were obtained from colostrum and milk pools by salt precipitation. The final products were evaluated in terms of yield and purity, as well as antibody activity to bacterial antigens and toxins and inhibitory activity of bacterial adhesion to epithelial cells. The best yield and purity were achieved when the colostrum pool was used as a source of IgA; the final product showed very few bands of protein contamination. The IgA preparations preserved the antibody reactivity against various microbial antigens, well comparable with the reactivity exhibited by the original milk and colostrum pools. SIgA preparations were able to inhibit greatly the adhesion of enteropathogenic Escherichia coli to Hep-2 cells and the invasion of enteroinvasive E. coli. These promising results show the feasibility of obtaining SIgA suitable for oral use, which may in future be administered to immunodeficient patients with gastrointestinal manifestations, from human colostrum and milk.

Immunological evaluation of allergic respiratory children with recurrent sinusitis.

The objective of this study was to evaluate humoral immunity of allergic respiratory children with chronic/recurrent sinusitis. Twenty-seven allergic respiratory (persistent mild/moderate asthma and persistent allergic rhinitis) children (7-15-year old) with chronic or recurrent sinusitis were evaluated. Patients had symptoms and abnormal computer tomography scan even after two adequate treatments (long-lasting antibiotics, decongestants, and short-term oral corticosteroids). clinical examination, sweat test, total blood cell count, measurement of serum levels of: total and specific IgE, immunoglobulins (G, M, A), IgG subclasses, antibodies to Haemophilus influenza type b (IgG anti-Ps Hib) and pneumococcal serotypes (IgG anti-Ps 1, 3, 5, 6B, 9V, and 14) before and after active immunization (Act-Hib and Pneumo23, Aventis Pasteur SA, Lyon, France), Rubella neutralizing antibody titers and human immunodeficiency virus antibodies. Specific IgE to inhalant allergens higher than class III were observed in 24/27 patients. One patient had IgA plus IgG2 deficiency and other an IgG3 deficiency. Eight and 12 of 27 patients had IgG2 and IgG3 serum levels below 2.5th percentile, respectively. Immunological responses to protein and polysaccharide antigens were normal in all patients. Although our patients have been appropriately treated of their allergic diseases, they persisted with chronic/recurrent sinusitis and 60% of them had a documented osteomeatal complex blockade. In spite of the diagnosis of IgA plus IgG2 deficiency and an isolated IgG3 deficiency, in all patients an adequate response to Ps antigens was observed. Primary and/or secondary humoral immunodeficiency seems not to be the main cause of chronic/recurrent sinusitis in patients with respiratory allergic disease.

A síndrome de deficiência de anticorpos com imunoglobulinas normais não está relacionada ao aumento de número de células B cd19+cd5+ / Specific antibody deficiency with normal immunoglobulins is not related to an increase numbers of B cells CD19+CD5+

Objetivos: Caracterizar a Síndrome de Deficiência de Anticorpos anti Polissacarídeos com Níveis Séricos Normais de Imunoglobulinas (SAD) pelo estudo da resposta imunológica sob os seguintes aspectos: estudo das sub-populações. de linfócitos B e células T duplo negativas no sangue periférico e a capacidade linfoproliferativa frente a antígeno (toxóide tetânico) e mitógeno (PHA) em pacientes com SAD Casuística fi Métodos: Foram avaliados 13 pacientes maiores de quatro anos de idade que tiveram os seguintes critérios: a) níveis séricos normais de imunoglobulinas e subclasses de IgG para a idade b) níveis normais pós-vacinais de antic9rpos específicos para antígenosprotéicos c) níveis de anticorpos anti-pneumococo inferiores aos da normalidade para a idade e para cada sorotipo em estudo Foram incluídos como controles adultos saudáveis (n= 18) e um grupo de pacientes com Imunodeficiência Comum Variável (ICY). Resultados: Exceto em um paciente, os ensaios linfoproliferativos foram normais quando comparados aos controles. Os linfócitos B CD 19+ foram semelhantes ao grupo controle com exceção de um paciente. A porcentagem de células CD 19+CDS+ foi normal de acordo aos' valores obtidos do grupo controle. A porcentagem de linfócitos CD 19+CD21 +, exceto em uma paciente de seis anos de idade, foi semelhante ao grupo controle

Leishmaniose visceral: aspectos clínicos e laboratoriais / Visceral leishmaniasis: clinical and laboratorial aspects

Objetivo: comparar os dados clínicos e laboratoriais no pré e pós-tratamento de pacientes portadores de leishmaniose visceral (LV), admitidos em hospital pediátrico localizado em área näo-endêmica, destacando a importância do reconhecimento da LV na faixa etária pediátrica. Métodos: avaliaçäo dos dados clínicos, laboratoriais e de tratamento de pacientes portadores de LV no período compreendido entre 1981 e 1992, comparando-se os valores médios de hemoglobina, leucócitos, neutrófilos, plaquetas, albumina, gamaglobulina, classes e subclasses de imunoglobulinas, tamanho do fígado e baço antes e após o tratamento, utilizando-se o teste "t" para amostras pareadas. Resultados: foram incluídos 78 pacientes, com idade variando entre 8 meses e 13,5 anos, sendo 44 casos do sexo masculino e 61 provenientes da Bahia. Febre e esplenomegalia estavam presentes em 96,1 por cento e 100 por cento dos casos, respectivamente. O diagnóstico parasitológico foi obtido em 74/78 pacientes, com positividade pelo mielograma e/ou mielocultura em 67 casos (85,7 por cento), 5 pela biópsia hepática e 2 pela punçäo esplênica. Os valores hematológicos e a albumina sérica apresentaram melhora significante ao término do tratamento (p<0,001), o mesmo näo ocorrendo com a gamaglobulina sérica (p=0,087). Houve predomínio da subclasse IgG1, com dois pacientes apresentando níveis reduzidos de IgG2. O tratamento inicial utilizou antimonial em 67 casos e Anfotericina B em 5. Onze pacientes (15,7 por cento) necessitaram segundo esquema de tratamento, com resoluçäo em todos os casos. Houve melhora significativa do tamanho do fígado e baço ao término do tratamento (p <0,001). Um paciente apresentou resoluçäo espontânea, e cinco faleceram por sangramento. Conclusöes: os autores alertam para a inclusäo da LV na suspeita diagnóstica de pacientes pediátricos apresentando febre e visceromegalia, provenientes de áreas endêmicas, para a adequada abordagem diagnóstica e tratamento, especialmente em serviços de saúde de regiöes de baixa incidência desta endemia

[Visceral leishmaniasis: clinical and laboratorial aspects]. / Leishmaniose visceral: aspectos clínicos e laboratoriais.

OBJECTIVE: To compare the clinical and laboratorial data before and after the treatment of patients with visceral leishmaniasis admitted to a pediatric hospital in a nonendemic area, highlighting the importance of recognizing visceral leishmaniasis in pediatric patients. METHODS: Clinical, laboratorial and treatment data of 78 patients with visceral leishmaniasis were evaluated from 1981 to 1992. We analyzed the average level of hemoglobin, leukocyte, neutrophil, platelet, albumin, gammaglobulin, class and subclass of immunoglobulin, size of the liver and spleen during the pre- and post-treatment using the paired t test. RESULTS: We included 78 patients with visceral leishmaniasis, 44 males, with age ranging from 8 months to 13.5 years. Sixty-one patients were from Bahia. Fever and splenomegaly were present in 96.1% and 100% of the cases, respectively. The parasitological diagnosis was obtained in 74/78 patients: 67 patients through smear and/or culture of bone marrow (85.7%), five through liver biopsy and two through spleen puncture. The hematological findings and serum albumin presented significant improvement at the end of treatment (P<0.001), differently from serum gammaglobulin levels (P=0.087). There was predominance of IgG1 subclass, with two patients presenting low levels of IgG2. Initial treatment used antimoniate in 67 cases and amphotericin B in five. Eleven patients (15.7%) needed a second treatment, and were considered cured after it. There was significant improvement in the liver and spleen size at the end of the treatment (P<0.001). One patient presented spontaneous remission and five died due to bleeding. CONCLUSIONS: In order to obtain accurate diagnosis and treatment, especially regarding health services of areas with low-incidence of visceral leishmaniasis, the diagnosis of patients with fever and visceromegaly, who come from endemic areas, should include visceral leishmaniasis.

Deficiência da glicose-6-fosfato desidrogenase com infeções de repetição: relato de caso / Glucose-6-phosphate dehydrogenase deficiency with recurrent infections: case report

Objetivo: relatar a ocorrência de uma deficiência funcional de neutrófilos rara, com quadro clínico e laboratorial semelhante ao da doença granulomatosa crônica. Métodos: relato de caso de paciente com deficiência acentuada da glicose-6-fosfato desidrogenase e infecções de repetição. Realizada pesquisa bibliográfica utilizando as bases de dados Medline e Lilacs abrangendo o período de 1972 a 2000. Resultados: paciente com nível da glicose-6-fosfato desidrogenase extremamente reduzido e quadro de infecções graves com melhora clínica após uso de cotrimoxazol contínuo. Os leucócitos do paciente apresentam defeito no metabolismo oxidativo, similar ao da doença granulomatosa crônica. Conclusões: o diagnóstico da deficiência da glicose-6-fosfato desidrogenase em neutrófilos deve ser considerado em qualquer paciente com anemia hemolítica não esferocítica congênita no qual o nível da glicose-6-fosfato desidrogenase esteja anormalmente baixo ou apresente infecções de repetição. É diagnóstico diferencial da doença granulomatosa crônica

Delayed phagocytosis and bacterial killing in Chediak-Higashi syndrome neutrophils detected by a fluorochrome assay: ultrastructural aspects

The few studies already published about phagocyte functions in Chediak-Higashi syndrome (CHS) has stated that neutrophils present slow rate of bacterial killing but normally ingest microorganisms. In the present study, both phagocytosis and killing of Staphylococcus aureus were verified to be in neutrophils from two patients with CHS when these functions were simultaneously evaluated by a fluorochrome phagocytosis assay. Electron microscopic examination showed morphologic differences among neutophils from CHS patients and normal neutrophils regarding the cytoplasmic structures and the aspects of the phagolysosomes. It was noteworthy the presence of giant phagolysosomes enclosing bacteria in active proliferation commonly observed in CHS neutrophils after 45 min of phagocytosis, wich corresponded with the impaired bactericidal activity of these leukocytes. The present results suggest that phagocytosis may also be defective in CHS, and point out to the sensitivity of the fluorochrome phagocytosis assay and its application in clinical laboratories