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The association of platelets with leukocytes was investigated, using gel-filtered platelets stimulated with thrombin and then fixed with formaldehyde. Evidence is presented that stimulation of gel-filtered platelets with low concentrations of thrombin (0.01 to 0.1 U/mL) induces the expression of surface determinants interacting strongly with monocytes and polymorphonuclear leukocytes (PMNs) but only weakly with lymphocytes. Both monocyte-platelet binding and PMN-platelet binding occurred at 37 degrees C and more intensively at 0 degrees C; it was Ca2+-dependent and was unaffected by the addition of sodium azide. The binding also occurred with the monocytoid cell lines HL 60 and U 937 in exponential growth and was much less two days after induction of terminal differentiation by phorbol myristate acetate (PMA). No other tested cell lines (B cells, T cells, and myeloid cells) bound thrombin-stimulated platelets. Monocyte-derived macrophages kept in culture for one week also exhibited reduced binding of thrombin- stimulated platelets. IgG and fibronectin could be ruled out as ligands that mediate binding.

Zusammenfassung Im Rahmen einer kontrollierten prospektiven multizentrischen Studie wurde an 13 verschiedenen Kliniken bei 212 Patienten im Alter von einem Tag bis 83 Jahre ein neues intravenös applizierbares Immunglobulinpräparat auf seine Verträglichkeit untersucht. Der Einsatz erfolgte bei Patienten mit primärem und sekundärem Antikörpermangelsyndrom, wie auch bei solchen mit normalen Immunglobulinkonzentrationen im Serum. Insgesamt wurden bei 811 Behandlungen 7128 g Immunglobulin mit einer maximalen Dosierung von 30 g pro Tag infundiert. Außer einer spontan reversiblen flüchtigen Temperaturerhöhung, die bei einer Patientin mit Antikörpermangelsyndrom im Rahmen einer Dauersubstitution wiederholt auftrat, wurden weder klinisch noch laborchemisch wesentliche Nebenwirkungen registriert. Bei einem Teil der Patienten wurden Immunglobulinkonzentrationsmessungen vor und nach Infusion durchgeführt. Dadurch konnte ein signifikanter Anstieg der Konzentration um 112,5 mg/100 ml und übertragene Einheit Immunglobulin von je 3 g beobachtet werden. Bei einer geschätzten Halbwertszeit von 23 Tagen ergibt sich mit dem vorliegenden Präparat eine gute Möglichkeit zur Dauersubstitution immundefizienter Patienten.

The association of platelets with leukocytes was investigated, using gel-filtered platelets stimulated with thrombin and then fixed with formaldehyde. Evidence is presented that stimulation of gel-filtered platelets with low concentrations of thrombin (0.01 to 0.1 U/mL) induces the expression of surface determinants interacting strongly with monocytes and polymorphonuclear leukocytes (PMNs) but only weakly with lymphocytes. Both monocyte-platelet binding and PMN-platelet binding occurred at 37 °C and more intensively at 0 °C; it was Ca2+-dependent and was unaffected by the addition of sodium azide. The binding also occurred with the monocytoid cell lines HL 60 and U 937 in exponential growth and was much less two days after induction of terminal differentiation by phorbol myristate acetate (PMA). No other tested cell lines (B cells, T cells, and myeloid cells) bound thrombin-stimulated platelets. Monocyte-derived macrophages kept in culture for one week also exhibited reduced binding of thrombin-stimulated platelets. IgG and fibronectin could be ruled out as ligands that mediate binding.

A marked imbalance of the two light chain types of immunoglobulins was observed in two young male adults suffering from primary hypogammaglobulinemia and intrinsic factor-deficient pernicious anemia. In one patient, the kappa/lambda light chain ratio of serum immunoglobulins was 0.01; in the other, it was approximately 6 (normal value, 1.8 +/- 0.3). This light chain imbalance was found within each of the three main immunoglobulin classes. The number of mature immunoglobulin-producing cells in the bone marrow and in the mucosa of the gastrointestinal tract was reduced. The relative frequency of kappa- and lambda-producing cells in these tissues corresponded to the kappa/lambda ratio of serum immunoglobulins. However, the number of peripheral lymphocytes with membrane-associated immunoglobulins as well as the percentage distribution of blood lymphocytes with kappa- or lambda-type immunoglobulins on the membrane were within normal limits in both cases. The results suggested a hitherto unknown defect in the maturation of B-cells leading to an abnormal ratio of kappa- and lambda- type immunoglobulin-secreting cells.

High-dose intravenous gammaglobulin (IVIgG) was given to 12 children and adults with chronic idiopathic thrombocytopenic purpura (ITP) to avoid splenectomy or because they either failed to respond to or required maintenance with high doses of steroids and/or immunosuppressives. The average platelet count increase to initial therapy was 239,500/microliters (range 23,000–790,000). A concomitant IgG Fc receptor blockade, measured by IgG-sensitized 51Cr-labeled autologous erythrocytes, was seen in 11 of 11 patients tested, both splenectomized and not splenectomized, lasting 3–4 wk. Six or more months after treatment, 2 children are in remission, 2 children and 2 adults are stable requiring no therapy with platelet counts of approximately 50,000 and 30,000, respectively, 3 children require maintenance IVIgG therapy at 2–10-wk intervals, and 1 child and 2 adults have become refractory to further IVIgG. Splenectomy was not performed in 4 children. Two adults were able to discontinue daily prednisone. The 3 patients who became unresponsive to Swiss Red Cross gamma-globulin (IgSRK) therapy did so in conjunction with a markedly elevated platelet-associated IgG and IgM. Serum IgM increased an average of 103 mg/dl after the IVIgG infusions. No significant side effects were seen.

Experiences gathered while exploring the usefulness of intravenous immunoglobulin for children with idiopathic (immune) thrombocytopenic purpura (ITP) are reviewed in view of further investigations characterizing the effects of IgG i.v. in other immune diseases without detectable antibody deficiency. The most pertinent factors to be considered are i) the heterogeneity of an immune disease investigated; ii) the criteria used to evaluate the effects of the IgG therapy; iii) the IgG preparations used and i.v. dose-fractionation. Controlled, prospective clinical trials will be required to further explore the practical usefulness of IgG i.v.

The efficacy of IgG infusion therapy in ITP is now established even in cases resistant to other forms of therapy. However, the mechanism of action is still speculative. We assume that a correction of the elevated thrombocyte clearance is brought about at several levels. First, antibodies specific for an inciting antigen (and for which the patient is deficient) may remove free antigen and/or immune complexes which adhere to platelet surfaces, thereby rendering platelets less susceptible to clearance. Second, IgG may act nonspecifically by protecting the platelet surface from becoming covered with immune complexes. Third, monomeric IgG may display a nonspecific inhibitory effect at the level of the interaction of immunologically altered platelets with Fc receptors of mononuclear phagocytes. For the latter effect, good in vivo evidence exists. However, it must be born in mind that interaction of antibodies with Fc receptors is but one mechanisms for triggering adherence and endocytosis. A variety of other receptors and binding sites exists which may interact with immunologically altered thrombocytes. These may either trigger phagocytes on their own or facilitate the interaction of antibodies and Fc receptors. How IgG infusion influences such interactions remains to be determinded.

The capacity of immunoglobulin for intravenous application (IgG-IV) to interact with Fc receptors of human monocytes and macrophages was tested by quantifying the inhibition of phagocytosis of IgG-sensitized erythrocytes. To this end a spectrometric phagocytosis test has been used. When compared with IgG for i.m. use (IgG-IM), all IgG-IV had reduced activity. This reduction was related, in part, to the reduced amount of IgG dimers and polymers in IgG-IV. On a weight basis dimeric IgG and polymeric IgG exerted 6-fold and 14-fold higher activity, respectively, than monomeric IgG. When this difference was corrected for, chemically modified IgG-IV still had significantly reduced inhibitory activity; DEAE-Sephadex-treated IgG and acid-treated IgG had an activity similar to IgG-IM, and PEG-treated IgG showed a slightly reduced activity. Pepsin-treated IgG was >100-fold less active than IgG-IM. The reactivity of IgG-IV with monocyte and macrophage Fc receptors was closely correlated. The most conspicuous differences found were related to the concentration at which IgG was used. Thus, ß-propiolactone-treated IgG and plasmin-treated IgG were found to have significantly reduced activity at concentrations >20 µg/ml, but almost normal activity when used at lower concentrations.

Seven children with chronic or intermittent and six with acute idiopathic thrombocytopenic purpura (ITP) were treated with large intravenous doses of polyvalent, intact immunoglobulin (Ig). In all patients the platelet count rose sharply within 5 days, but the initial response and the subsequent course varied from patient to patient. Among children with chronic ITP the initial response was more marked in splenectomised than in non-splenectomised patients. Among those with acute ITP the two who remained Ig dependent had a smaller initial response than the four patients who required no maintenance treatment. During the 90 - 110 days of observation five of six patients with chronic ITP could be maintained with Ig alone. No untoward effects of Ig therapy were observed.

In a randomised, multicentre study intravenous IgG was compared with oral corticosteroids in 108 children with untreated acute immune thrombocytopenic purpura. IgG was an efficient treatment with no severe untoward reactions. The effects of corticosteroids and IgG were identical for rapid responders, who accounted for 62% of all patients. In contrast, patients requiring more than initial treatment responded better if randomised to IgG. The serum IgG level increased two-fold after IgG. A significant rise in IgM levels was observed after both IgG and corticosteroids. The platelet-associated IgG index was high in 75% of all patients. No significant differences between the two treatment groups were found, but rapid responders had a smaller mean initial platelet-associated IgG index which returned more rapidly and more permanently to normal than that of slow responders.

Zusammenfassung Plasmazytoide Zellen im Knochenmark von drei Patienten mit Myelom und Plasmazellen im Knochenmark eines sechsjährigen Knaben mit Infekt wurden zuerst nach Giemsafärbung und anschließend nach Feulgenfärbung zytophotometrisch gemessen. An Hand der Anzahl Meßpunkte konnte die Zellfläche und die Kernfläche und daraus die Kern-Plasma-Relation bestimmt werden. Die mittlere Kern-Plasma-Relation und der mittlere DNS-Verteilungsfehler im Kern variieren von Myelompatient zu Myelompatient und erlaubten nicht, Plasmazellen von Myelomzellen zu unterscheiden. Eine Differenzierung dieser Zelltypen war auch auf Grund des Produktes aus mittlerer Kern-Plasma-Relation und mittlerem DNS-Verteilungsfehler nicht möglich. Zwischen Zellfläche und Zytoplasmafläche bestand eine signifikante Korrelation sowohl bei den Myelomzellen als auch bei den Plasmazellen.

Intravenous γ-globulin (IVGG) effectively elevates the platelet count of most patients with chronic idiopathic thrombocytopenic purpura (ITP). This study examined whether this effect was related to changes inin vitro immunoglobulin secretion and suppression in coculture. Before treatment, patientin vitro immunoglobulin secretion was less than 50% of the concurrent control in all eight cases and the patients suppressed antibody synthesis in coculture an average of 39%. After treatment, increases inin vitro immunoglobulin secretion and decreases in suppression were closely related to a good response to IVGG therapy as measured both by acute increases in the platelet count (P<0.05) and by the long-term outcome from therapy (P<0.05). Decreases in platelet-associated IgG correlated with increases inin vitro immunoglobulin secretion (P<0.05). Data consistent with the lack of inhibition ofin vitro immunoglobulin secretion following IVGG included long-term increases in both serum IgM and IgG (independent of transfused IgG) and maintenance of the percentage of total IgG that was IgG3. T-cell numbers and subsets and lymphocyte proliferation were unaffected by IVGG. IVGG tends to normalizein vitro immunoglobulin secretion and its suppression in those ITP patients with good clinical responses in conjunction with decreased levels of autoantibody. This evidence suggests that good responders to IVGG may have inhibition of antiplatelet antibody production. IVGG does not appear to interfere with normal antibody production.

An improved method for the isolation of normal immunoglobulin E is described. The method is based on the use of an immunoadsorbent formed by the mechanical entrapment of antibodies against a myeloma immunoglobulin E into a lattice of a highly cross-linked macroporous polyacrylamide gel. Normal immunoglobulin E was isolated from an immunoglobulin E-rich serum pool as well as from an individual healthy donor. The isolated immunoglobulin E was contaminated with about 20% of immunoglobulin G. An antiserum against normal immunoglobulin E was prepared by immunizing rabbits with the isolated immunoglobulin E.

Zusammenfassung Es wird über Ausscheidungsstudien mit PVP-I131 an 22 Patienten mit „nephrotischem Syndrom“ berichtet. Nach den vorliegenden Untersuchungsergebnissen ist die Durchlässigkeit der Darm wand für Makromoleküle bei unbehandelten und anbehandelten Patienten im Sinne einer Proteindiarrhoe erhöht. Bei länger behandelten Fällen liegen die Darmausscheidungswerte im Bereiche der Norm. Es wird gezeigt, daß Proteinurie und Proteindiarrhoe unabhängig voneinander vorliegen können. Die Bedeutung dieser Befunde für die Pathogenese der nephrotischen Hypoproteinämie wird erörtert.

Intravenous gammaglobulin (IVIgG) was used to treat autoimmune neutropenia of infancy in two males with repeated infections. The neutrophil count increased significantly in both patients with the initial IVIgG therapy; 1 patient went into remission. The neutrophil count in the other remained above baseline for 3 wk, and a subsequent booster infusion also caused the neutrophil count to increase. The patients have remained clinically well since their treatment began. Serial studies of antineutrophil antibody and serum lysozyme, performed to elucidate the mechanism of action, suggested decreased neutrophil destruction, perhaps by Fc receptor blockade, as well as decreased synthesis of antineutrophil antibody. Neutrophil function was not impaired after the neutrophil count increased. Many patients with immune neutropenia have a benign course, but those who have significant infections could be treated, acutely or prophylactically, with intravenous gammaglobulin.

Intravenous gammaglobulin (IVIgG) was used to treat autoimmune neutropenia of infancy in two males with repeated infections. The neutrophil count increased significantly in both patients with the initial IVIgG therapy; 1 patient went into remission. The neutrophil count in the other remained above baseline for 3 wk, and a subsequent booster infusion also caused the neutrophil count to increase. The patients have remained clinically well since their treatment began. Serial studies of antineutrophil antibody and serum lysozyme, performed to elucidate the mechanism of action, suggested decreased neutrophil destruction, perhaps by Fc receptor blockade, as well as decreased synthesis of antineutrophil antibody. Neutrophil function was not impaired after the neutrophil count increased. Many patients with immune neutropenia have a benign course, but those who have significant infections could be treated, acutely or prophylactically, with intravenous gammaglobulin.

A HIGHLY cross-linked polyacrylamide gel containing a trapped protein antigen has been prepared. It can be used as an immunosorbent. The principle of the method is based on those of Bernfeld and Wan1and Hicks and Ubdike2for dissolving enzymes for chemical analysis. Their protein-polyacrylamide gel is, however, of no practical use as an immunosorbent, for its permeability is too low to enable antibodies in solution to enter the gel and react with the trapped antigens. Fawcett and Morris3have shown that by changing the total monomer concentration a marked increase in gel permeability can be achieved.