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Summary: We describe the case of a 24-year-old male with hyper-IgE syndrome (HIES) which was diagnosed at 4 years of age and died from a very rare cardiac complication. He had typical clinical and laboratory manifestations of HIES, including total serum IgE as high as > 100,000 IU/mL. Stem cell transplantation was not available. During the 20-year follow-up, he suffered numerous various infections of the skin and deep organs, partial lung resection, as well as multiple bone fractures. At age 24, he developed acute decompensated heart failure associated with elevated serum troponin I and brain natriuretic protein. Two-dimensional echocardiogram revealed global hypokinesis of the left ventricle with estimated ejection fraction 20-25%, and catheterization revealed ectasia of multiple coronary arteries. Endomyocardial biopsy showed lymphocytic myocarditis, focal necrosis, mild fibrosis, and myxoid degeneration, but cultures were negative. The patient improved on corticosteroid therapy and was discharged on heart failure therapy and external defibrillator. Six weeks later, he developed supraventricular tachycardia and persistent global hypokinesis and was treated with amiodarone. A trial of intravenous immunoglobulin was initiated and was repeated as outpatient every four weeks for four times. However, his cardiac function did not improve and he developed severe hypotension and pulseless electrical activity arrest. Resuscitation was unsuccessful. To the best of our knowledge, this is the first reported case of HIES complicated with lymphocytic myocarditis. Both immunologists and cardiologists need to be aware of such a complication and practice caution in using immunosuppressants when the patient's immune status is markedly compromised.

Background: Schnitzler syndrome (SS) is a rare clinical entity characterized by chronic recurrent urticarial rash, monoclonal IgM gammopathy, intermittent fever and other symptoms. In this report, we present the cases of two patients with SS: a male and a female aged 50 and 49 years, respectively. Both patients had hyperimmunoglobulinemia E and showed good response to elimination diet., Methods: The patients had chronic urticaria, IgM gammopathy and an elevation of the serum levels of inflammation markers. Total IgE levels were found to be high (2000 U/ml and 540 U/ml, respectively). No underlying causes for hyperimmunoglobulinemia E (allergy, parasites, etc.) were revealed. The first patient did not respond to the treatment with antihistamines, while the second one responded only to high doses. The response to prednisolone in the second patient was incomplete., Results: Following a strict elimination diet resulted in marked improvement in skin lesions in both patients. In one of our patients we observed a decrease in IgE and IgM levels after a 3 week diet. The systemic symptoms persisted and improved only after adding pefloxacin, followed by a 3-day empirical course of intravenous prednisone in the first patient and a course of plasmapheresis in the second one., Conclusion: The high serum levels of total IgE may be associated with chronic urticaria activity, severe disease course and a poor response to treatment with antihistamines, and may be considered a possible marker of a subset of patients with SS showing a good response to the restriction diet. In general, we can assume that elimination diet can have an influence on the skin lesions and other symptoms of SS as well as on total IgE and IgM levels, but such association, the underlying mechanisms and the reasons for excessive IgE synthesis should be investigated in further studies.

Atopic dermatitis (AD) is related to immunoglobulin E (IgE) production, and a type-1 and type-2 helper T cell (Th1/Th2) imbalance has been hypothesized as the aetiology. While itching and scratching are important factors in the development of dermatitis, the mechanisms underlying these phenomena are poorly understood. We investigated the relationship between scratching, transepidermal water loss (TEWL), signs of dermatitis and serum Ig levels in NC/Nga mice, a model of AD. We also sensitized specific pathogen-free (SPF)-NC/Nga mice and BALB/c mice to mite antigen to determine the effects of IgE overproduction on scratching and investigated the involvement of mast cells and T/B cells in the induction of scratching using WBB6F1-W/W(v) mice and C.B.17/Icr-scid mice. Under conventional conditions, the scratch counts increased, followed by increases in TEWL and the inflammation score in NC/Nga mice that were not kept under SPF conditions. However, no change was observed in scratching, TEWL, or signs of dermatitis in mite antigen-sensitized SPF-NC/Nga and BALB/c mice, although the serum total IgE, IgG(1) and IgG(2a) levels increased. The scratch count increased significantly in both the WBB6F1-W/W(v) mice and C.B.17/Icr-scid mice when they were co-housed with skin-lesioned NC/Nga mice, raised under conventional conditions. These results show that IgE overproduction results from itch-associated scratching-induced dermatitis in NC/Nga mice., (© 2011 John Wiley & Sons A/S.)

Increases in total serum IgE levels can be observed in many diverse conditions, from infection to atopy to primary immunodeficiency. The differentiation of atopy from immunodeficiency most often is made on a clinical basis, after taking findings from history, physical examination, and laboratory studies into consideration. However, total IgE level is neither a sensitive nor a specific diagnostic marker for any particular disease and, therefore, should not be relied on to establish a diagnosis of either atopy or primary immunodeficiency.

Aim: Hyperimmunoglobulin-E syndrome (HIES) is a primary immunodeficiency characterized by eczema, recurrent skin and lung infections with pneumatocoele formation, and extremely elevated serum immunoglobulin-E. The precise immunologic defect and genetic etiology remain unknown. Non-immunologic findings include characteristic facial features (prominent forehead, fleshy nasal tip, and increased interalar distance); skeletal involvement (pathological fractures, scoliosis, and craniosynostosis); and retention of primary teeth. This study aims to characterize intraoral soft tissue findings in HIES patients., Methods: Sixty HIES patients (4-54 years, 27 males, 33 females) received intraoral and radiographic evaluations. Chronological dental development was also assessed., Results: Lesions of the hard palate and dorsal tongue were found in 55% and 60% of patients, respectively. Palatal lesions ranged from a generalized surface keratosis to a midline sagittal fibrotic bridge. Tongue lesions consisted of multiple fissures and a midline cleft. On the lip and buccal mucosa, keratotic plaques and/or surface fissures were found in 8% and 23% of patients, respectively. Manifested in 76.7% of patients, the intraoral lesions were significantly more prevalent than the characteristic facial traits (P=0.0013)., Conclusions: Alterations in oral mucosa and gingiva were present in the majority of HIES patients. These novel intraoral findings may facilitate the diagnosis of HIES.

Background: Hyperimmunoglobulinemia E syndrome is a primary immunodeficiency disorder characterized by elevated IgE levels, recurrent infections, pruritic rash, and skeletal and dental abnormalities. Autosomal dominant, autosomal recessive, and sporadic forms have been described. Coronary artery aneurysms and analysis of central (TCMs) and effector (TEMs) memory T cells have not been previously reported with this syndrome., Objective: To describe a 30-year-old woman with hyperimmunoglobulinemia E syndrome who was found to have coronary artery aneurysms, deficiency in CD4+ TCMs, and expansion of CD4+ TEMs expressing CD45RA antigen (TEMRAs)., Methods: The patient presented to the clinic after hospitalization for chest pain. Coronary angiogram performed during the hospitalization revealed aneurysms in multiple coronary arteries with thrombus formation. In addition, she had a history of recurrent pneumonia, staphylococcal skin abscesses, and a pruritic facial rash. An extensive immunologic evaluation was performed., Results: Immunologic studies revealed increased serum IgE levels (13,434 IU/dL), decreased proliferative responses to the soluble recall antigens tetanus toxoid and Candida albicans, and normal responses to mitogens. Analysis of lymphocyte subsets showed a deficiency of CD4+ TEMs and an increase in CD4+ TEMRAs. In addition, a decreased proportion and number of memory B cells and a deficiency in antibody response to pneumococcal antigens were observed., Conclusion: Hyperimmunoglobulinemia E syndrome may be associated with coronary artery aneurysms and with deficiency in CD4+ TEMs and expansion of CD4+ TEMRAs. Comprehensive immunologic evaluation should be performed in patients with this syndrome.

Hyper IgE recurrent infection syndrome (HIES, or Job's syndrome) is a primary immunodeficiency characterized by recurrent skin and lung infections, eczema, elevated serum immunoglobulin E (IgE) levels, and various connective tissue and skeletal system abnormalities including characteristic facies, scoliosis, joint hyperextensibility, retained primary dentition, craniosynostosis, osteopenia, and pathologic fractures. We have identified two patients with aneurysmal coronary artery disease. One was a forty-three-year-old man with HIES and coronary artery aneurysms and ectasia identified on cardiac catheterization following myocardial infarction. The other was a 48-year-old man with coronary artery ectasia-aneurysm identified after cardiac catheterization for evaluation of chest pain. Although connective tissue abnormalities are common in HIES, this is the first report of coronary artery aneurysms in HIES. Further studies are necessary to determine the incidence, pathogenesis, and optimal therapy of these arterial abnormalities in HIES.

A 22-year-old man was admitted to the department of pediatrics of our institute in February 2005, because of pulmonary aspergillosis. He had been diagnosed as hyper immunoglobulin-E syndrome in infancy, and repeated pulmonary infectious desease, such as pulmonary aspergillosis. He received art of right upper lobectomy by pulmonary aspergillosis at the age of 17. In February 2005, he had hemosputum and the chest X-ray showed a giant cavity with niveau in the right lung. In spite of medical treatment by antibiotics and antimycotics, the lesion rapidly increased in size. Therefore, right completion pneumonectomy and omentopexy around the bronchial stump was done. His postoperative course was uneventful.

Background: Hyper-immunoglobulin E (IgE) syndrome is a complex immune deficiency characterized by chronic eczematous dermatitis, recurrent staphylococcal infections, pneumatoceles, reduced neutrophil chemotaxis, and variably impaired T cell function. Although decreased interferon-gamma (IFN-gamma) production in patients with hyper-IgE syndrome is pointed out and known as a cause of reduced neutrophil chemotaxis, precise mechanism of their inadequate production of IFN-gamma remains unknown. To elucidate the pathogenesis of the defective production of IFN-gamma in patients with hyper-IgE syndrome, we assessed the in vitro production and secretion of IFN-gamma by peripheral blood mononuclear cells (PBMCs) from patients with hyper-IgE syndrome., Methods: Chemotaxis of neutrophils, mRNA levels of several cytokines, intracellular production and extracellular secretion of IFN-gamma, interleukin-2 (IL-2), and IL-4 by PBMCs from three patients with hyper-IgE syndrome were determined., Results: The transcription of IFN-gamma mRNA and the production of its protein molecules progressed normally. However, selective insufficiency in the secretion of IFN-gamma molecules was found in patients with hyper-IgE syndrome. Confocal laser scanning microscopy clearly demonstrated the accumulation of IFN-gamma in patients with hyper-IgE syndrome., Conclusion: We demonstrated that there was a selective insufficiency in the secretion of IFN-gamma in patients with hyper-IgE syndrome. We hope that this fact would offer a new paradigm for understanding this disease.

Objective: To study subclinical involvement of the peripheral nerves in myelitis with hyperIgEaemia and mite antigen-specific IgE (atopic myelitis: AM)., Material and Methods: We carried out a nerve conduction study of the median, ulnar, tibial, and sural nerves in 21 patients with AM and in 28 patients with clinically definite or laboratory-supported definite multiple sclerosis (MS)., Results: The patients with AM showed a significantly higher frequency of abnormal records than the MS patients in the sensory nerve conduction study (52.4% vs. 14.3%, p = 0.0106). The frequency of abnormal records in the motor nerve conduction study in AM patients was twice as high as in MS patients (38.1% vs. 17.9%), but the difference was not statistically significant. Abnormality in the F-wave-evoked frequency in the median nerve was also significantly more common in AM patients than in MS patients (57.9% vs. 10.7%, p = 0.0016)., Conclusions: These findings suggest that subclinical peripheral neuropathy is frequent in patients with AM.

IgE hyperproduction frequently observed in patients with atopic dermatitis (AD) may greatly contribute to the pathogenesis of AD, but its mechanisms are still unclear. NC/Nga mice raised in nonsterile circumstances spontaneously suffered from AD-like skin lesions with elevation of plasma IgE levels. We investigated mechanisms of the IgE hyperproduction in NC/Nga mice. Splenic T cells from SPF NC/Nga mice had a level of CD40 ligand (CD40L) expression comparable to that of BALB/c mice. Although there was no difference in the expression of CD40 on B cells between NC/Nga and BALB/c mice, B cells of NC/Nga mice produced much more IgE in the presence of soluble CD40L and IL-4. The stimulation with CD40L and/or IL-4 resulted in tyrosine phosphorylation of Janus kinase 3 (JAK3) in B cells, which was more strongly inducible in NC/Nga mice than in BALB/c mice. In B cells isolated from PBMC of AD patients with high serum IgE levels, JAK3 was constitutively phosphorylated at the tyrosine residue, and its phosphorylation was enhanced by the treatment with CD40L and/or IL-4 as was that in splenic B cells of NC/Nga mice with dermatitis and high IgE levels. Thus, it is suggested that constitutive and enhanced JAK3 phosphorylation in B cells highly sensitive to CD40L and IL-4 may be attributable to IgE hyperproduction in NC/Nga mice and patients with AD.

An occurrence of acute localised myelitis was recently seen in four adult patients with atopic dermatitis who had hyperIgEaemia and mite antigen specific IgE. The total and mite antigen specific IgE was therefore studied in serum samples from 19 consecutive patients with acute localised myelitis of unknown aetiology, 56 patients with clinically definite multiple sclerosis, and 40 healthy controls. The total IgE concentration was significantly higher in acute localised myelitis (median=360 U/ml) than in multiple sclerosis (median=52 U/ml, p<0.0001) and the controls (median=85 U/ml, p=0.0002). The specific IgE to Dermatophagoides pteronyssinus was found more often in patients with acute localised myelitis (95%) than in patients with multiple sclerosis (34%, p<0.0001) and the controls (35%, p<0.0001) and the specific IgE to Dermatophagoides farinae was similar (acute localised myelitis 79%, multiple sclerosis 29% (p<0.0001), controls 30%, (p=0.0003). Atopic dermatitis coexisted more commonly in patients with acute localised myelitis (37%) than in patients with multiple sclerosis (0%, p<0.0001) and the controls (7.5%, p=0.0089). Therefore, acute localised myelitis with hyperIgEaemia, in which atopy to mite antigens seems to exist, may be a distinct subtype of allergic myelitis-that is, atopic myelitis.

Background: The hyperimmunoglobulinemia E syndrome is a serious disorder of an unknown etiology without effective treatment. Cyclosporin A has immunosuppressive properties. Its effect in a patient with hyperimmunoglobulinemia E syndrome was evaluated., Methods: We report a 3-year-old boy with severe hyperimmunoglobulinemia E syndrome in whom various therapeutic modalities were ineffective. He was started on cyclosporin A 3 mg/kg/d for 6 months. We examined several humoral and cellular immune functions during the treatment period and monitored his clinical condition., Results: Marked improvement in his clinical condition was observed during therapy with cyclosporin A. There was a significant decrease in serum IgE and significant increase in neutrophil chemotactic function. No change in CD40 ligand expression was observed. Cyclosporin A blood level did not exceed 150 ng/mL during the study., Conclusions: A small dose of cyclosporin A (3 to 5 mg/kg/d) is beneficial in patients with hyperimmunoglobulinemia E syndrome. It should be considered in severe cases where other therapeutic modalities have failed.

Atopic dermatitis (AD) usually develops in patients with an individual or family history of allergic diseases, and is characterized by chronic relapsing inflammation seen especially in childhood, association with IgE hyperproduction and precipitation by environmental factors. However, the exact etiology of AD has been unclear. To further explore the pathogenesis and treatment of AD, a suitable animal model is required. We found that skin lesions, which were clinically and histologically very similar to human AD, spontaneously appeared on the face, neck, ears and dorsal skin of inbred NC/Nga mice when they were raised in non-sterile (conventional) circumstances, but not under specific pathogen-free conditions. Plasma levels of total IgE in conventional NC/Nga mice were markedly elevated from 8 weeks of age, correlating with clinical skin severity of dermatitis. Immunohistochemical examination of the skin lesion showed increased numbers of mast cells and CD4+ T cells containing IL-4 necessary for IgE synthesis. Thus, NC/Nga mice suffered from dermatitis very similar to human AD with IgE hyperproduction, which may be triggered by some environmental factor(s).

Background: Elevation of immunoglobulin E (IgE) is rarely detected in patients with underlying malignancy. There has been only one report of such a finding in a patient with a T cell lymphoma and none to our knowledge in association with a B-cell lymphoma., Objective: To report a patient with elevation of IgE associated with a B-cell lineage lymphoma., Material and Methods: Case report and review of literature., Results: A 73-year-old woman was found to have elevated IgE (11,766 IU/mL) in a routine evaluation for rhinitis. No underlying allergic diathesis or disease associated with IgE elevation was noted. Because of an abnormal lymphocyte profile, an extensive malignancy evaluation was performed which revealed a B-cell lymphoma., Conclusion: B-cell lineage lymphoma can be associated with elevated of IgE and should be included in the differential diagnosis in a patient presenting with this finding.

Nonactivated, fixed peripheral blood T cells (PBT) from healthy donors or patients with X-linked-hyper-IgM (HIGM) syndrome, or cloned T cells provided effective help for tonsillar B lymphocytes for induction of IgE or other immunoglobulin (Ig) isotypes. Helper activity was mediated by staphylococcal superantigens adsorbed to the T cells prior to fixation and required presence of IL-4 in the cultures. We demonstrated that the T cells neither expressed detectable CD40 ligand at the beginning of the superantigen treatment nor 24 h later. Phorbol ester (PMA) plus Ca-ionophore treatment efficiently induced CD40L. Such T cells did not, however, provide any help for B-cell activation in some experiments or stimulated only low responses in others. Antibodies against CD2, CD3 and ICAM-1 adsorbed to fixed T cells prior to coculturing inhibited helper activity. A soluble CTLA4 construct was also inhibitory. Our results suggest a pathway of B-cell activation independent of CD40L expressed on T cells.

At least two cell-derived signals have been shown to be necessary for the induction of immunoglobulin isotype switching in B-cells. The first signal is given by either of the soluble lymphokines, interleukin (IL)-4 or IL-13, which induce germline epsilon transcript expression, but this alone is insufficient to trigger secretion of immunoglobulin E (IgE). The second signal is provided by a physical interaction between B-cells and activated T-cells, basophils and mast cells, and it has been shown that the CD40/CD40 ligand (CD40L) pairing is crucial for mediating IgE synthesis. In hyper-immunoglobulin M1 (HIGM1) syndrome, which is characterized by greatly decreased levels of immunoglobulin G, A and E (IgG, IgA and IgE), there are mutations in the CD40L resulting in a completely non-functional extracellular domain. The CD40L is, therefore, playing a central role in immunoglobulin isotype switching. Amongst the numerous pairs of surface adhesion molecules, the CD23-CD21 pair seems to play a key role in the generation of IgE. The CD23 molecule is positively and negatively regulated by factors which increase or decrease IgE production, respectively. Antibodies to CD23 have been shown to inhibit IL-4-induced human IgE production in vitro and to inhibit antigen-specific IgE responses in a rat model, in an isotype selective manner. CD23 interacts with CD21 on B-cells, preferentially driving IgE production. CD23 recognizes two main epitopes on the CD21 molecule. One region consists of short consensus repeat (SCR) sequences 1-2 and the other of SCR 5-8. In the latter region, Asn 370 and 295 are critical in the interaction with the lectin CD23. Therefore, a restricted number of cytokines and surface molecules seems to selectively regulate human immunoglobulin E synthesis.

Four related male infants presented with neonatal diabetes mellitus, immune dysregulation with extremely high concentrations of immunoglobulin E, and intractable diarrhoea. They were all from one family, and all of them died. As far as is known this X-linked recessive disorder has not been described before. It is suggested that this is a new immunodeficiency in which type 2 T helper responses predominate.

A 13-year-old boy with hyperimmunoglobulin E (hyper-IgE) syndrome presented with headache, blurred vision, photophobia and bilateral papilledema due to cryptococcal meningitis. Treatment with amphotericin B, and S-fluorocytosine for several weeks and repeated lumbar punctures did not reduce the intracranial pressure, and a myeloperitoneal shunt was performed. The child was maintained on fluconazole for an additional six months. Patients with hyper-IgE syndrome are at increased risk of opportunistic fungal infections such as cryptococcal meningitis.

Background: Dysregulation of IgE synthesis has been noted in the past in several immunodeficiency states. More recently, analysis of IgE synthesis and atopy in patients who are infected with the human immunodeficiency virus (HIV) has been conflicting., Objective: To determine whether IgE dysregulation occurs in HIV-infected patients and if so, whether this dysregulation is antigen-specific and accompanied by any significant changes in T and B cell markers., Methods: Thirty-six HIV-infected patients were enrolled in the study. Twenty-nine patients completed the study. All patients completed an allergy questionnaire and physical examination. Interval visits occurred every 3 months. Blood was obtained at baseline and every 3 months for total IgE, antigen-specific IgE to eight environmental allergens and lymphocyte markers. Study was not blinded., Results: Analysis of results at baseline and 1 year revealed a subset of patients who had marked elevations in serum IgE protein. This increase was not accompanied by any detectable antigen-specific IgE to the measured allergens nor was any significant change noted in lymphocyte markers. Student's paired t tests were used for data analysis., Conclusion: In a subset of patients with HIV infection, acquired dysregulation of IgE synthesis occurs that results in increased circulatory levels of IgE protein not attributable to atopic allergens or associated with detectable changes in lymphocyte markers.

Epstein-Barr virus (EBV) and recombinant interleukin-4 (rIL-4) induce IgE production by normal B-cells. We demonstrate here the difference in IgE synthesis in patients with elevated IgE levels and normal control subjects. EBV and rIL-4 induced the synthesis of IgE by surface IgE-negative B-cell precursors isolated by cell sorting. IgE synthesis in normal subjects became apparent in the second week with increasing rIL-4 concentrations, whereas in patients with elevated IgE levels, there was a marked elevation in IgE synthesis without rIL-4 stimulation. We did not observe the presence of DNA rearrangement occurring between IgM and IgE switch regions (S mu and S epsilon, respectively) during switching to IgE isotype in patients with elevated IgE levels. We found that with the limited sensitivity of Southern blotting, this method may not be useful for the study of B-cell populations in which only a small percentage of cells have undergone switching.

The induction of immunoglobulin E (IgE) switching in B cells requires at least two signals. The first is given by either of the soluble lymphokines interleukin 4 (IL-4) or IL-13, whereas the second is contact dependent. It has been widely reported that a second signal can be provided by the CD40 ligand (CD40L) expressed on the surface of T cells, mast cells, and basophils. A defect in the CD40L has been shown recently to be responsible for the lack of IgE, IgA, and IgG, characteristic of the childhood X-linked immunodeficiency, hyper IgM syndrome (HIGM1). IgE can however be detected in the serum of some HIGM1 patients. In this study, we isolated T cell clones and lines using phytohemagglutinin (PHA) and allergen, respectively, from the peripheral blood of one such patient who expressed a truncated form of CD40L, and investigated their ability to induce IgE switching in highly purified, normal tonsillar B cells in vitro. Unexpectedly, 4 of 12 PHA clones tested induced contact-dependent IgE synthesis in the presence of exogenous IL-4. These clones were also shown to strongly upregulated IL-4-induced germline epsilon RNA and formed dense aggregates with B cells. Of the four helper clones, three were CD8+, of which two were characteristic of the T helper cell 2 (Th2) subtype. Two allergen-specific HIGM1 T cell lines, both of the Th0 subtype, could also drive IgE synthesis when prestimulated using specific allergen. All clones and lines were negative for surface expression of CD40L, and the mutated form of CD40L was confirmed for a representative clone by RNase protection assay and sequencing. The IgE helper activity could not be attributed to membrane tumor necrosis factor alpha (TNF-alpha) although it was strongly expressed on activated clones, and the addition of neutralizing anti-TNF-alpha antibody did not abrogate IgE synthesis. These results therefore suggest the involvement of T cell surface molecules other than CD40L in the induction of IgE synthesis, and that these molecules may also be implicated in other aspects of T-B cell interactions.

In the current study, we investigated whether Staphylococcus aureus grown from affected skin of atopic dermatitis (AD) patients secreted identifiable toxins that could act as allergens to induce IgE-mediated basophil histamine release. The secreted toxins of S. aureus grown from AD patients were identified by ELISA using antibodies specific for staphylococcal enterotoxin (SE) exfoliative toxin (ET), or toxic shock syndrome toxin (TSST-1). S. aureus isolates from 24 of 42 AD patients secreted identifiable toxins with SEA, SEB, and TSST accounting for 92% of the isolates. 32 of 56 AD sera (57%) tested contained significant levels of IgE primarily to SEA, SEB, and/or TSST. In contrast, although SEA, SEB, or TSST secreting S. aureus could be recovered from the skin of psoriasis patients, their sera did not contain IgE antitoxins. Freshly isolated basophils from 10 AD patients released 5-59% of total histamine in response to SEA, SEB, or TSST-1 but only with toxins to which patients had specific IgE. Basophils from eight other AD patients and six normal controls who had no IgE antitoxin failed to demonstrate toxin-induced basophil histamine release. Stripped basophils sensitized with three AD sera containing IgE to toxin released 15-41% of total basophil histamine only when exposed to the relevant toxin, but not to other toxins. Sensitization of basophils with AD sera lacking IgE antitoxin did not result in release of histamine to any of the toxins tested. These data indicate that a subset of patients with AD mount an IgE response to SEs that can be grown from their skin. These toxins may exacerbate AD by activating mast cells, basophils, and/or other Fc epsilon-receptor bearing cells armed with the relevant IgE antitoxin.

The hyper-IgE (HIE) syndrome is characterized by high IgE serum levels, chronic dermatitis and recurrent infections. To determine whether an impairment of the antibody response to Staphylococcus aureus contributes to infections in this syndrome we measured total serum IgG subclass, specific IgG1 and IgG2 levels against peptidoglycan (PG), the immunodominant cell wall component of S. aureus and serum opsonic activity to PG. Of the 14 patients with HIE syndrome, nine had increased level of serum IgG1 and six had IgG2 subclass deficiency. In regard to specific response of IgG1 and IgG2 antibodies to PG, patients were divided into five groups related to ages and compared with 10 control subjects for each age cohort. Patients with HIE syndrome had significant high levels of serum-specific IgG1 to PG and significant decreased levels of serum-specific IgG2 to PG in all five groups. Additionally, serum opsonic activity in patients was significantly higher than that in normal control subjects. It is concluded that IgG2 deficiency or poor IgG2 antibody response to S. aureus is not the explanation of the abnormal susceptibility to S. aureus infections of HIE patients.

To investigate whether an underlying defect in antibody (Ab)-forming capacity could contribute to the infection susceptibility of patients with hyper-IgE syndrome, we evaluated 11 such patients for their responses to bacteriophage phi X174 (phi X174), diphtheria and tetanus toxoids, and pneumococcal (Pneumovax) and Hemophilus influenzae vaccines. Three of nine patients immunized with phi X174 had normal primary and secondary Ab responses, five had accelerated declines in their titers after initially normal primary Ab responses and lower than normal secondary Ab responses, and two of the latter patients failed to switch normally from IgM to IgG Ab production. Only one of 10 patients tested had normal Ab responses to diphtheria toxoid, and postimmunization antitetanus titers were abnormally low in five of the 10 patients tested. Serum Abs to H. influenzae polyribose phosphate were protective in seven of the eight immunized patients. Five of the nine patients administered Pneumovax had poor Ab responses to at least one of the pneumococcal serotypes 7, 9, or 14. Abnormal antipolysaccharide responses did not correlate with IgG2 deficiency. All patients responded with protective Ab levels to type 3. Thus, patients with hyper-IgE syndrome are heterogeneous with respect to their Ab-forming capacities. Ab deficiency may contribute to infection susceptibility in some of these patients.

We measured the in vitro production of interferon-gamma (IFN-gamma) in five cases of hyper-IgE syndrome (HIgE), induced by mitogens, calcium ionophores and phorbol ester. The biosynthesis of IFN-gamma was severely reduced or undetectable in HIgE, while it was near normal in most atopic patients. The in vitro spontaneous production of IgE was increased overall in HIgE patients, although no correlation was found with serum IgE levels. Recombinant interleukin-4 (IL-4) induced a further increase in IgE synthesis, and its effect was totally antagonized by recombinant IFN-gamma; the same pattern of response was also observed in atopic subjects with high production of IgE. IFN-alpha synergized with IL-4 on IgE synthesis, whereas recombinant IL-6 gave opposite changes in individual cases tested. We propose that IFN-gamma deficiency may be responsible for some of the features of HIgE patients, including IgE levels and infections.

The Hyperimmunoglobulinemia-E-Syndrome (HIE) is characterized by high levels of serum-IgE, diminished counts of T-suppressor-cells, eosinophilia, and disturbed chemotactic functions of neutrophil granulocytes. An 8 years old female, suffering from hyperimmunoglobulinemia E (HIE), showed marginal corneal ulcera since five years. Positive conjunctival smears included several bacterias and chlamydia, but never local herpes virus. Inspite of treatment by antibiotics, virostatica, and therapeutical contact lens, a spontaneous corneal perforation occurred. A penetrating keratoplasty was successful for a short time, but soon ulceration rose again. At last a second penetrating keratoplasty was necessary. The early status showed tidy results, but some weeks later marginal ulceration occurred again. There was no clinical proof for herpetical genesis of the course, but evidence is conceivable for pathomechanisms similar to conjunctivitis vernalis.

In order to investigate the imbalance of IgG subclasses and its relationship to IgE level, 14 patients with hyper IgE syndrome (HIE syndrome) were examined for serum IgG subclasses and IgE levels and five of these patients were studied for in vitro IgE and IgG subclass production by peripheral blood lymphocytes (PBL) in response to interleukin-4 (IL-4)/interferon-gamma (IFN-gamma). Serum IgE levels were highly correlative with serum IgG4 levels (r = 0.75, P less than 0.005), but not with IgG1, IgG2 or IgG3 levels (r = 0.21, 0.43 and 0.41, respectively). In an in vitro study, recombinant IL-4 enhanced not only spontaneous IgE synthesis but also IgG4 synthesis in cultures of PBL from patients with HIE syndrome as well as in healthy donors (P less than 0.01), and the effect of recombinant IL-4 on both IgE and IgG4 synthesis was inhibited by low concentrations of recombinant IFN-gamma (P less than 0.01). The disturbed regulation of IgE and IgG4 seen in patients with hyper IgE syndrome may be caused mainly by the disturbed regulation of both cytokines.

The hyper-IgE (HIE) syndrome is characterized by high IgE serum levels, chronic dermatitis, and recurrent infections. The mechanisms responsible for hyperproduction of IgE in HIE patients are presently unknown. We investigated whether spontaneous in vitro IgE synthesis by PBMC from seven HIE patients was sensitive to signals (cell adhesion, T/B cell cognate interaction and lymphokines: IL-4, IL-6, and IFN-gamma) known to regulate IgE induction in normals. Our results show that, unlike IL-4 dependent IgE synthesis induced in normals, spontaneous IgE production by PBMC from HIE patients was not blocked by monoclonal antibodies to CD2, CD4, CD3, and MHC class II antigens. Furthermore, antibodies to IL-4 and IL-6 did not significantly suppress IgE production. IFN-gamma had no significant effects on spontaneous in vitro IgE synthesis. To test whether an imbalance in lymphokine production might underlie hyperproduction of IgE in HIE patients, mitogen-induced secretion of IL-4 and IFN-gamma by PBMC was assessed. No significant difference was detected between HIE patients and normal controls. Thus, ongoing IgE synthesis in the HIE syndrome is largely independent of cell-cell interactions and endogenous lymphokines, and is due to a terminally differentiated B cell population, no longer sensitive to regulatory signals.

Hyper-IgE syndrome is a rare immunodeficient disorder characterized by recurrent severe staphylococcal infections of the skin and sinopulmonary tract, chronic eczematoid rashes, coarse facial features, mild eosinophilia, and markedly elevated serum IgE levels. Hyperimmunoglobulinemia D, depressed DTH, and varying degrees of pathogenesis of this syndrome is unknown. The clinical manifestations and the recent research findings indicated the followings: 1) increased production of IL-4: hyperimmunoglobulinemia E, increased number of Fc epsilon R(+)-cells in peripheral blood, 2) defective production of IFN-gamma: abnormal local inflammatory responses (formation of cold abscesses), chemotactic defect in the circulating neutrophils (abnormalities in IFN-gamma/IL-8 pathway), depressed DTH, 3) T-cell immunodeficiency?-chronic dermatitis? 4) genetic factors (frequent familial occurrence, characteristic facial appearance with broad nasal bridge). These observations led us to postulate that both the increased production of IL-4 and the defective production of IFN-gamma may be the immunopathological bases of this syndrome. Recently, these cytokines were demonstrated to be secreted by different subsets of helper T-cells, designated TH1 and TH2, in murine system, suggesting that the regulatory imbalances between IL-4 and IFN-gamma in this syndrome might be due to the differential activation or inactivation of these helper T-cell subsets.

Of 32 unrelated children with serum IgE greater than 1,000 U/ml, 17 were found to have infection proneness according to standard clinical criteria, and 15 were not infection prone. There were no statistical differences between these 2 groups of children with regard to age, sex, serum IgE levels or prevalence of asthma. However, the prevalence of eczema was significantly lower in the infection-prone group (p = 0.035). Of greater interest was the finding that 7 children in the infection-prone group had IgG subclass and/or IgA deficiency compared with none in the non-infection-prone group (p = 0.006). These results suggest that IgG subclass studies may be warranted in children with markedly elevated levels of serum IgE and proneness to infection.

The hyper IgE syndrome develops in childhood and leads to repeated infectious episodes, usually of staphylococcus aureus origin and affecting mainly the skin and pulmonary parenchyma. It may be associated with a predominantly facial atypical dermatitis and more rarely with allergic manifestations. Biological tests show mainly an eosinophilia and a hypergammaglobulinemia E alone without modifications in other immunoglobulin types. Disorders of neutrophil and monocyte chemotaxis are inconstant findings. The initial mechanism of the affection appears related to a deficit in suppressive T function selectively acting on the IgE isotype.

The studies presented herein provide details of an in vitro system in which IgE biosynthesis by human peripheral mononuclear cells can be stimulated by exposure to pokeweed mitogen (PWM). Mononuclear cells of normal donors or patients with hyperimmunoglobulinemia E were cultured in 2 stages, the first stage consisting of exposure of cells to stimulating mitogen; after this first stage incubation, cells were washed and replated in cultures devoid of any additional mitogen for a further 6 days. Under such conditions, human mononuclear cells were shown to synthesize significant quantities of IgE. Both T cells and surface IgE-bearing cells were shown to be necessary in order to obtain an IgE response in this system. Supernatants from 2-way human mixed lymphocyte cultures were shown to contain an IgE class-specific suppressive factor capable of selectively inhibiting in vitro IgE (and not IgG) biosynthesis. This model can be used to compare the regulation of IgE synthesis in normal and atopic donors, and further experiments examining the production and action of this class-specific suppressive factor may have prognostic and therapeutic implications.

We have developed an immunoradiometric assay for IgE antibodies to Staphylococcus aureus (Staph IgE-Ab) which uses purified cell walls (PCW) from the Wood 46 strain of S. aureus as an immunosorbent. We compared Wood 46 PCW and whole organisms (WO) as immunosorbents for Staph IgE-Ab by performing tests on sera from patients with atopic dermatitis (AD) or the hyperimmunoglobulin E syndrome (hyper IgE syndrome). Sera with Staph IgE-Ab demonstrated dose-dependent binding to PCW and WO, but the ratio of specific to non-specific binding was much greater with PCW. Mean non-specific binding to WO was greater than to PCW, 5% versus 2%; and non-specific binding to WO varied directly with the serum concentration of IgE. Results of tests on patients' sera indicated that PCW are required in screening assays for Staph IgE-Ab to avoid false positive results caused by high levels of non-specific binding to WO.

Mucocutaneous lymph node syndrome (MCLS) is a newly recognized disease characterized by fever persisting for more than 5 days, an erythematous skin eruption, conjunctival congestion, dry red fissured lips, reddened tongue, palms, and soles, nonpurulent lymphadenopathy, and sometines diarrhea, arthralgia, and aseptic meningitis. Additional features may include carditis, pericarditis, aneurysmal dilation and thrombosis of coronary arteries, and sudden death. There is a striking similarity of fatal cases to infantile polyarteritis nodosa, a disease recently reported to be associated with elevated levels of serium IgE. Indeed, it is likely that MCLS represents a disease which can progress to polyarteritis nodosa in infants and young children. The paired acute and convalescent serum IgE levels of 20 subjects with acute nonfatal MCLS were studied along with 20 near-age unaffected controls from the same communities in Japan. The results indicate that most if not all subjects with MCLS in the study had an elevation of total serum IgE during the acute phase of the disease (geometric mean 157 IU/ml compared with the control value of 38 IU/ml, P = 0.005). The level appeared to reach a peak 1-2 weeks after onset and declined over the ensuing 1-2 months.

An 8-year old girl suffering from chronic relapsing staphylococcal skin infection since the first days of life was found to have extremely high (up to 26,500 units/ml) serum IgE levels and impaired polymorphonuclear chemotaxis. The other immunological tests appeared to be normal. There seemed to be a correlation between impaired chemotaxis and rise in IgE, the latter perhaps being related to a deficiency in some thymus-dependent lymphocyte functions.

This report is of seven-year-old girl with a lifelong history of severe eczema, intestinal features of food allergy, recurrent respiratory tract infections, chronic bilateral keratitis and mucocutaneous candidiasis. Immunological tests showed high serum IgE levels, with specific IgE antibodies to cow's milk and egg white, defective PMN chemotaxis and a marked defect in both the function and number of T-lymphocytes. On a cow's milk-free and egg-free diet the eczema subsided and the respiratory infections improved. A partial correction of the immunodeficiency was also observed. The relationships between the immune system and atopy are discussed.

Salivary immonoglobulins of patients with multiple myeloma, lymphoid leukaemia, agammaglobulinaemia and of normal healthy adults were examined. Higher IgG level was identified in 4 cases IgG monoclonal gammopathy. In these cases extremely large quantities of IgG monoclonal protein were transmitted from serum into salivary secretions. On the basis of the results it appears that monoclonal IgA is transferred to external secretions in patients with IgA monoclonal gammopathy. High IgM level was found in both serum and saliva of agammaglobulinaemic patients. "IgM secretory component" complex could be identified in saliva. In lymphoid leukaemic patients the salivary immunoglobulins presented normal values except of a patient whose tigA lacked in serum and also in saliva.

We fractionated, by gel chromatography, sera with high IgE content from atopic subjects and five cases with the hyper-IgE syndrome, and measured the presence of IgE in high molecular weight (HMW) fractions. Two out of four asthmatics and four out of five hyper-IgE had HMW IgE. The same serum fractions gave positive results for conglutinin binding IgG (all six) and IgA (three cases) as well as C1q binding complexes (five cases). IgG auto-antibodies to IgE were also detected together with IgE in HMW fractions. Anti-F(ab)'2 activity was present in five cases (one of them negative for IgG anti-IgE). Our data indicate that complexes made of IgE and IgG anti-IgE are present mainly in patients with chronic allergic symptoms and most frequent in cases of hyper-IgE syndrome.