Search

A patient with respiratory syncytial virus (RSV) infection and severe combined immunodeficiency was studied during a 3-month period of bone marrow transplantation and palivizumab infusion. No RSV isolates with palivizumab escape mutations were identified. Donor lymphocytes, including CD8 cells, appeared to markedly reduce the RSV load but increased the pulmonary symptoms. Immunosuppressive therapy ameliorated lung disease but allowed the RSV load to rebound.

Ocular manifestations have been attributed to the Epstein-Barr virus (EBV), largely on the basis of seroepidemiologic data. Two patients who developed conjunctival disease as the presenting feature of EBV infection are reported, each confirmed by in situ hybridization of EBV genome in affected tissue biopsy specimens. Recognition of EBV-induced ocular disease as an initial presentation of clinical EBV infection is important to the practitioner because of the ubiquitous nature of this herpesvirus.

The primary immunodeficiencies are a heterogeneous group of disorders that affect either the development or the function of the immune system. In the last ten years, the genes responsible for many of the most common and best studied immunodeficiencies have been identified. As might be expected, the expression of most of these genes is limited to the hematopoietic system. Although most are members of gene families, their association with disease indicates that they do not perform redundant functions. Some immunodeficiencies involve the effector functions of the immune system, for example the NADPH oxidase system or perforin; however, a striking number of the disorders involve signal transduction pathways. These include defects in ligands, transmembrane receptors, kinases, adaptor proteins and transcription factors. Mutations for each disorder tend to be highly variable and the specific mutation in a gene is only one of the factors that influence the clinical phenotype. Polymorphic variations in susceptibility genes may also contribute to the disease phenotype. Not all genes responsible for immunodeficiency have been identified. As many as 20 to 30% of patients with clinical and laboratory evidence of single gene defects of the immune system do not fit any well described clinical disorder.

Patients with genetic defects in B-cell development provide an unusual opportunity to dissect the requirements for normal B-cell maturation. It is striking that all of the known genetic defects that result in a failure of B-cell development involve signaling through the pre-B-cell receptor (pre-BCR). Approximately 85% of affected patients are males with mutations in the X chromosome-encoded cytoplasmic tyrosine kinase Btk. Preliminary experiments using stem cell transplants and retroviral-mediated gene therapy in Btk-deficient mice suggest that it may be relatively easy to correct serum immunoglobulins but harder to correct antibody production to T-cell-independent antigens in this disorder. About 3-6% of patients with defects in B-cell development have deletions or critical base pair substitutions in the mu constant region gene. Patients with defects in Igalpha, lambda5 and B-cell linker protein (BLNK) have also been described. All of these patients have a block at the pro-B to pre-B-cell transition. Defects in Btk, lambda5 and BLNK result in a more severe phenotype in the human compared to the mouse. These findings suggest that requirements for signaling through the pre-BCR are more stringent in the human compared to the mouse. Possible explanations for this observation are discussed.

Gene therapy for inherited disorders is more likely to succeed if gene-corrected cells have a proliferative or survival advantage compared with mutant cells. We used a competitive reconstitution model to evaluate the strength of the selective advantage that Btk normal cells have in Btk-deficient xid mice. Whereas 2,500 normal bone marrow cells when mixed with 497,500 xid cells restored serum IgM and IgG3 levels to near normal concentrations in 3 of 5 lethally irradiated mice, 25,000 normal cells mixed with 475,000 xid cells reliably restored serum IgM and IgG3 concentrations and the thymus-independent antibody response in all transplanted mice. Reconstitution was not dependent on lethal irradiation, because sublethally irradiated mice all had elevated serum IgM and IgG3 by 30 weeks postreconstitution when receiving 25,000 normal cells. Furthermore, the xid defect was corrected with as few as 10% of the splenic B cells expressing a normal Btk. When normal donor cells were sorted into B220(+)/CD19(+) committed B cells and B220(-)/CD19(-) cell populations, only the B220(-)/CD19(-) cells provided long-term B-cell reconstitution in sublethally irradiated mice. These findings suggest that even inefficient gene therapy may provide clinical benefit for patients with XLA.

X-linked agammaglobulinemia (XLA) is an immunodeficiency caused by mutations in the gene coding for Bruton agammaglobulinemia tyrosine kinase (BTK). A database (BTKbase) of BTK mutations lists 544 mutation entries from 471 unrelated families showing 341 unique molecular events. In addition to mutations, a number of variants or polymorphisms have been found. Mutations in all the five domains of BTK cause the disease, the single most common event being missense mutations. Most mutations lead to truncation of the enzyme. The mutations appear almost uniformly throughout the molecule. About one-third of point mutations affect CpG sites, which usually code for arginine residues. The putative structural implications of all the missense mutations are provided in the database. BTKbase is available at http://www.uta.fi/imt/bioinfo.

The degree of immunodeficiency associated with deficiency of adenosine deaminase (ADA) is variable. Most patients are infants with severe combined immunodeficiency (SCID), but in about 20 percent immune dysfunction becomes manifest later in childhood ("delayed-onset"); several patients with "late" or "adult" onset of immune dysfunction have been diagnosed at 15-39 years. Over 40 ADA gene mutations have thus far been identified. To better define the genotype-phenotype relationship, we report 7 novel ADA mutations, including 5 missense mutations (G74C, V129M, G140E, R149W, Q199P) and two short deletions (462delG, E337del). These were identified among 7 patients (3 with SCID and 4 with delayed-onset). A homozygote for 462delG had SCID, whereas patients homozygous or heterozyous for V129M had delayed-onset. Two other delayed-onset patients, one heterozygous for G74C and the other for Q199P, each had a second allele carrying the previously reported "severe" mutation G216R. These findings are consistent with previous observations suggesting that, in general, SCID occurs when both alleles eliminate ADA function, and a milder phenotype when at least one allele can supply a low level of function.

Defects in the gene for Bruton's tyrosine kinase (Btk) result in the disorder X-linked agammaglobulinemia (XLA). Whereas XLA is characterized by a profound defect in B-cell development, Btk is expressed in both the B lymphocyte and myeloid cell lineages. We evaluated a patient with XLA who had reduced amounts of Btk transcript but no abnormalities in his coding sequence. A single base-pair substitution in the first intron of Btk was identified in this patient, suggesting that this region may contain regulatory elements. Using reporter constructs we identified two transcriptional control elements in the first 500 bp of intron 1. A strong positive regulator, active in both pre-B cells and B cells, was identified within the first 43 bp of the intron. Gel-shift assays identified two Sp1 binding sites within this element. The patient's mutation results in an altered binding specificity of the proximal Sp1 binding site. A negative regulator, active in pre-B cells only, was located between base pairs 281 and 491 of the intron. These findings indicate that regulation of Btk transcription is complex and may involve several transcriptional regulatory factors at the different stages of B-cell differentiation.

Severe combined immunodeficiency (SCID) is a syndrome of profoundly impaired cellular and humoral immunity. In humans, SCID is most commonly caused by mutations in the X-linked gene IL2RG, which encodes the common gamma chain, gamma c, of the leukocyte receptors for interleukin-2 and multiple other cytokines. To investigate the frequency and variety of IL2RG mutations that cause SCID, we analyzed DNA, RNA, and B-cell lines from a total of 103 unrelated SCID-affected males and their relatives using a combination of molecular and immunologic techniques. Sixty-two different mutations spanning all eight IL2RG exons were found in 87 cases, making possible correlations between mutation type and functional consequences. Although skewed maternal X chromosome inactivation, single-strand conformation polymorphism, mRNA expression, and cell surface staining with anti-gamma c antibodies were all helpful in establishing IL2RG defects as the cause of SCID, only dideoxy fingerprinting and DNA sequence determination each detected 100% of the IL2RG mutations in our series. Abnormal gamma c chains may be expressed in the lymphocytes of as many as two thirds of patients with X-linked SCID. Specific mutation diagnosis thus remains technically challenging, but it is important for genetic counseling and perhaps for helping to select appropriate subjects for retroviral gene therapy trials, This is a US government work. There are no restrictions on its use.

Seven male patients in the David T Purtilo International X-linked Lymphoproliferative Disease (XLP) Registry have undergone allogeneic hematopoietic stem cell transplantation (HSCT). All patients received HSCT from HLA-identical donors: sibling BM, five; unrelated BM, one; and sibling umbilical cord blood, one. Ages at time of HSCT ranged from 5 to 30 years. Pre-HSCT clinical course varied, but four boys had a significant history of chronic and/or serious infections. Conditioning regimens varied: TBI containing regimens, four, chemotherapy only, three. All patients engrafted. Six developed grade I-II acute GVHD but no chronic GVHD. Four are alive and well with normal immune function greater than 3 years following HSCT. Three died within 100 days: disseminated adenovirus, one; polymicrobial sepsis, one; and multiple organ system failure and bleeding diathesis, one. No EBV-associated post-transplant complications were observed, even though all donors except the umbilical cord blood were EBV-seropositive. Unsuccessful HSCT was associated with age at HSCT (15 years), TBI-containing regimen and significant history for pre-HSCT infections. These results provide evidence that HSCT performed during childhood with HLA-identical sibling donors, regardless of EBV serostatus, offers the only curative therapy for XLP.

Ligation of CD38 inhibits proliferation and induces apoptosis of human immature B cells, but the molecular mechanisms underlying this function are unknown. We found that CD38 dimerization with the specific mAbs T16 and IB4 induces rapid and transient tyrosine phosphorylation of several intracellular proteins in the immature B cell lines RS4;11, REH, 380, Nalm6, and OP-1. This effect could be markedly reduced by incubating cells with the tyrosine kinase inhibitors genistein, staurosporine, and herbimycin A. CD38 dimerization induced tyrosine phosphorylation of the protein kinase syk and increased syk kinase activity. CD38 dimerization also induced tyrosine phosphorylation of phospholipase C-gamma and of the p85 subunit of phosphatidylinositol 3-kinase (PI 3-K). The latter was accompanied by a distinct increase in PI 3-kinase activity in the immunoprecipitates obtained with an anti-phosphotyrosine Ab. In contrast to the signaling triggered by surface Ig engagement in B lymphocytes, CD38 ligation did not appear to induce tyrosine phosphorylation of the src-like protein tyrosine kinases lyn, fyn, and btk, or of vav- and ras-GTPase-activating protein, nor did it induce detectable changes in cytosolic CA2+ concentrations. CD38 signaling also differed from cytokine-induced signaling in that it did not cause tyrosine phosphorylation of Jak1 and Jak2. Finally, CD38 ligation did not inhibit IL-3-induced tyrosine phosphorylation of Jak2. These results identify CD38 as a cell surface receptor with signal transduction properties activated by dimerization. Induction of signal transduction by CD38 ligation implies the existence of a yet unidentified natural ligand of CD38.

A young boy with hyper-immunoglobulin M (IgM) syndrome had recurrent severe infections, failure to thrive, and chronic neutropenia for 2 years despite treatment with i.v. gammaglobulin (IVIG).With the addition of granulocyte colony-stimulating factor (G-CSF; Filgrastim, Amgen, Inc., Thousand Oaks, CA), increased doses of IVIG, and prophylactic trimethoprim-sulfamethoxazole, his absolute neutrophil count increased from 0.64 x 10(9)/L to 3.36 x 10(9)/L, and he has been free of significant infection for the past 22 months.The use of G-CSF merits consideration in patients with hyper-IgM syndrome and severe neutropenia.

Congenital thrombocytopenia may occur in isolation or accompanied by eczema and immunodeficiency, as part of the X-linked hereditary Wiskott-Aldrich syndrome (WAS). Because the clinical and immunologic picture of WAS is variable, particularly early in life, definite diagnosis cannot always be made in cases with a negative family history. Two unrelated males with sporadic congenital thrombocytopenia had only questionable immunologic abnormalities as infants, making them clinically indistinguishable from cases of isolated thrombocytopenia, although one developed episodic neutropenia and the other began to manifest a multisystem autoimmune disease at 2 years of age. Evaluation of X chromosome inactivation in the T cells of both patients' mothers showed each of these women to have the same highly skewed X chromosome inactivation pattern seen in carriers of typical familial WAS. A T-cell defect was subsequently directly demonstrated in the second patient, whose lymphocytes failed to proliferate to periodate and anti-CD43. Taken together, these data suggest the presence of T cell immunodeficiency consistent with WAS in these patients. Furthermore, their mothers were found to have a very high likelihood of being carriers, lending support to the diagnosis of a hereditary disease in these boys and making possible genetic prediction in other family members and subsequent pregnancies.

Monoclonal hybridoma antibodies to the human IgA subclasses were produced by immunizing mice with purified myeloma proteins. These antibodies were shown to be specific for the appropriate IgA subclass by enzyme-linked immunoabsorbant assay (ELISA) and by immunofluorescent staining of myeloma plasma cells and B cells from normal individuals. These antibodies were used to demonstrate age-related shifts in the proportions of IgA1- and IgA2-bearing B cells that could be correlated with 3 distinct staining patterns. In the newborn equal numbers of IgA1 and IgA2, B cells were found. These cells had only small amounts of surface IgA in a patchy distribution. They also expressed surface IgM. In the infant, large lymphoblastoid cells were observed that bore more IgA in a homogeneous pattern but did not express IgM. Of these cells, 98% were positive for IgA1. In the adult, 80% of the IgA B cells were positive for surface IgA1, and 20% were positive for IgA2. These were small lymphocytes brightly stained for IgA and negative for IgM. In culture, the adult B cells responding to pokeweed gave rise to roughly equal numbers of IgA1 and IgA2 plasma cells. These results suggest that there are equal numbers of precursor cells for IgA1 and IgA2 whose expansion, further differentiation, and migration are selectively affected by immunoregulatory controls.

Ig protein and mRNA expression was examined in a collection of 18 monoclonal EBV-transformed B cell lines derived from five patients with X-linked agammaglobulinemia (XLA). A diversity of H and L chain isotypes were synthesized by these lines: the majority (12 lines) expressed mu kappa chains, while mu lambda (two lines), gamma kappa (one), gamma lambda (one), delta lambda (one), and alpha kappa (one) isotype expression was also observed. For all the mu kappa-producing XLA B cell lines, the mu and kappa mRNA transcripts were of native size, and sequence analysis across the regions of VHDJH and V kappa J kappa gene joining showed that Ig gene rearrangements occurred in a typical manner. A variety of VHDJH and V kappa J kappa gene rearrangements were observed, not only within the set of mu kappa+ XLA B cells as a whole, but also among the cell lines derived from single patients. Southern blot analysis for genomic Ig H chain gene rearrangements was done to fully assess the extent of clonal heterogeneity among multiple mu kappa+ XLA B cell lines derived from two patients; all the B cell lines possessed distinct gene rearrangement patterns demonstrating their clonal unrelatedness. Our findings indicate that the B cell repertoire in individual XLA patients is clonally diverse and that it is unlikely that the defect in B cell differentiation in XLA is the result of inefficient or ineffective rearrangement of Ig H or L chain genes. Rather, this study provides support for the idea that the XLA defect relates to a more generalized cellular function, such as regulating the proliferation and/or clonal expansion of cells of the B lymphoid lineage.

In vitro regulation of IgA subclass synthesis was investigated in pokeweed mitogen (PWM)-stimulated cultures of peripheral blood lymphocytes. In past experiments we have demonstrated that 50% of the IgA plasma cells derived from PWM-stimulated cultures are positive for IgA1 and 50% are positive for IgA2. This observation is surprising because approximately 80% of the IgA B cells in the peripheral circulation bear IgA1 and 20% bear IgA2. To determine if the shift toward IgA2 predominance in PWM-stimulated cultures might be due to an enriched source for IgA2 plasma cells from a precursor pool of immature B cells, we used panning techniques to separate immature precursors that express surface IgM (sIgM+) from mature precursors that no longer express IgM (sIgM-). These separated B cells were cultured with equal numbers of T cells and PWM for 7 days. In all 10 experiments there was an enrichment for IgA2 in the sIgM+ cultures; 55 +/- 9.6% of the total IgA plasma cells were positive for IgA2 in the sIgM+ cultures vs 38 +/- 6.3% in the sIgM- cultures (p less than 0.001). These results indicate that both sIgM+ and sIgM- cells can give rise to IgA plasma cells in PWM-stimulated cultures and that there is an enrichment for IgA2 precursors in the sIgM+ population. Other possible regulatory mechanisms were also investigated. To determine if there was isotype switching from IgA1 to IgA2, monoclonal anti-IgA1 antibodies were added to PWM cultures. These antibodies resulted in a mean suppression of IgA1 plasma cell production of 82% with a concomitant 45% suppression of total IgA but only 4.6% suppression of IgA2. These results make it unlikely that IgA2 plasma cells in PWM-stimulated cultures are derived from cells that initially produced IgA1. To investigate the possibility that one IgA subclass might be more T cell dependent than the other, T and B cells were separated and B cells were reconstituted with T cells in ratios that varied from 1:10 to 10:1 or with irradiated T cells. These procedures did not alter the proportion of IgA plasma cells positive for IgA1 or IgA2, indicating that the two subclasses do not differ in their response to T cell signals in PWM-stimulated cultures.

In past experiments, using limited dilution analysis, we have demonstrated that a high percentage of immunoglobulin-secreting clones derived from Epstein-Barr virus- (EBV) stimulated lymphocytes secrete IgA. To further characterize the IgA produced by these clones, the IgA subclass of supernatants from clones stimulated 4 to 6 wk previously with EBV was determined by radioimmunoassay. All of 17 IgA-producing clones secreted IgA1; none secreted IgA2. Because we have shown that surface IgM+ (sIgM+) B cells are an enriched source of IgA2 plasma cell precursors, panning techniques were used to purify sIgM+ B cells from tonsils. Of 103 clones derived from these sIgM+ B cells, 102 secreted IgA1 and only one secreted IgA2. The relative absence of IgA2-producing clones could not be attributed to an absence of EBV receptors on IgA2 cells. A mean of 84 +/- 4% of freshly isolated IgA2 B cells and 78 +/- 6% of IgA1 B cells could be stained with a monoclonal antibody binding the EBV receptor; and there was no failure of EBV to infect IgA2 plasma cells precursors. Of IgA2 plasma cells derived from peripheral blood lymphocytes stimulated 7 days previously with EBV, 54 +/- 7% were positive for the EBV nuclear antigen, compared with 54 +/- 18% of IgA1 plasma cells from the same cultures. Seven days after EBV stimulation, a mean of 25% of the total IgA plasma cells were positive for cytoplasmic IgA2, whereas by 21 days after stimulation only 7% were positive for IgA2. This shift in the proportions of IgA1 and IgA2 plasma cells could be attributed to a failure of the IgA2 plasma cell number to increase after 10 days in culture. There was no evidence for selective suppression of IgA2 production by T cells or selective lysis of IgA2 plasma cells by infectious EBV particles. These results demonstrate that although precursors for both IgA1- and IgA2-producing cells can be stimulated to differentiate in response to EBV, there is preferential transformation of IgA1-producing cells.

X-linked agammaglobulinemia (XLA) has been described as a disorder in which pre-B cells fail to differentiate into B cells. However, a small number of B cells have been seen occasionally in patients with this disorder. Because the phenotype of these cells might be helpful in defining the site of the defect in XLA, immunofluorescent staining techniques were used to characterize the B cells that can be found in patients with XLA. Surface IgM-positive B cells could be detected in the peripheral circulation of all seven patients studied. These B cells constituted a very small percentage of the total lymphocytes (0.01 to 0.3% compared with 3.2 to 13.7% in controls) and differed in phenotype from control B cells. They were much more brightly stained for surface IgM (p less than 0.001) and less brightly stained for Ia (p less than 0.01). This phenotype is similar to that described for immature B cells in the mouse. Over 80% of the patients' B cells expressed surface IgD, and all expressed the B cell marker B1, but only 35% expressed the B cell marker B2. This B cell marker, which is the C3d receptor and the Epstein-Barr virus receptor, is expressed later in ontogeny than B1 and can be detected on over 80% of control B cells. All B cells expressed either kappa or lambda light chain. These findings indicate that the defect in differentiation of pre-B cells into B cells is not absolute in patients with XLA. The immature phenotype of the B cells additionally suggests that there may be a block in the maturation of B cells at more than one stage of differentiation in this disorder.

Immunologists have long been intrigued by the striking number of immunodeficiencies inherited on the X chromosome. In man, there are five well described X-linked disorders of lymphocyte proliferation or differentiation: X- linked agammaglobulinemia (XLA), X-linked severe combined immunodeficiency (XSCID), Wiskott-Aldrich syndrome (WAS), X-linked lymphoproliferative syndrome (XLP) and X-linked hyper-IgM syndrome. For each of these disorders, atypical families have been described, leaving open the possibility that there are in fact additional X-linked immunodeficiencies that have not yet been well characterized. Although there are at least preliminary mapping data for each of these disorders (Table 1) the absent or abnormal gene product has not yet been identified for any one of them.

Monoclonal hybridoma antibodies to the human IgA subclasses were produced by immunizing mice with purified myeloma proteins. These antibodies were shown to be specific for the appropriate IgA subclass by enzyme-linked immunoabsorbant assay (ELISA) and by immunofluorescent staining of myeloma plasma cells and B cells from normal individuals. These antibodies were used to demonstrate age-related shifts in the proportions of IgA1- and IgA2-bearing B cells that could be correlated with 3 distinct staining patterns. In the newborn equal numbers of IgA1 and IgA2, B cells were found. These cells had only small amounts of surface IgA in a patchy distribution. They also expressed surface IgM. In the infant, large lymphoblastoid cells were observed that bore more IgA in a homogeneous pattern but did not express IgM. Of these cells, 98% were positive for IgA1. In the adult, 80% of the IgA B cells were positive for surface IgA1, and 20% were positive for IgA2. These were small lymphocytes brightly stained for IgA and negative for IgM. In culture, the adult B cells responding to pokeweed gave rise to roughly equal numbers of IgA1 and IgA2 plasma cells. These results suggest that there are equal numbers of precursor cells for IgA1 and IgA2 whose expansion, further differentiation, and migration are selectively affected by immunoregulatory controls.

X-linked severe combined immunodeficiency (SCID) (McKusick 30040; IMD4) is a disease of unknown pathogenesis characterized by severe and persistent infections from early in life that are due to absence of both cellular and humoral immune function. Although the disease has been provisionally mapped to proximal Xq, high lethality and lack of a carrier test have limited the number of scorable meioses. We performed linkage analysis in six new kindreds with X-linked SCID, using a random pattern of T-cell X inactivation to rule out the carrier state in at-risk women. Our linkage results, combined with analysis of Xq interstitial deletions, confirmed the regional assignment of X-linked SCID, narrowed the boundaries within which this locus lies to Xq13.1-q21.1, and established the locus order DXS159-(PGK1, SCID)-DXS72-DXS3, defining flanking markers for prenatal diagnosis and carrier testing.

The magnitude and the kinetics of the serum-specific polymeric (p-) and monomeric (m-) IgA antibody responses were analysed following parenteral stimulation with tetanus toxoid (TT) vaccine in 10 volunteers, 5-20 years after a previous boost. A rapid marked serum IgA antibody response involving both the monomeric and polymeric components of IgA was observed: m-IgA and p-IgA antibodies reached a peak of serum activity at about 11 days, around 6 days before the peak of IgG antibody activity. At the peak of the IgA response, p-IgA accounted for approximately half of the anti-TT activity (median 54%, 25-79%). However, p-IgA antibodies rapidly disappeared from serum over a few weeks, whereas the serum m-IgA antibody response was maintained over a prolonged period of time. For one subject out of five, anti-TT IgA were also detected in saliva with a peak of activity earlier than in serum. Calculation of the albumin relative coefficient of excretion for anti-TT IgA in this saliva suggested a local synthesis of these antibodies. The present study indicates that a polymeric IgA antibody response in serum can be produced by parenteral immunization in primed individuals, and it raises the question of the mechanisms that control polymeric versus monomeric IgA production.

In past experiments, using limited dilution analysis, we have demonstrated that a high percentage of immunoglobulin-secreting clones derived from Epstein-Barr virus- (EBV) stimulated lymphocytes secrete IgA. To further characterize the IgA produced by these clones, the IgA subclass of supernatants from clones stimulated 4 to 6 wk previously with EBV was determined by radioimmunoassay. All of 17 IgA-producing clones secreted IgA1; none secreted IgA2. Because we have shown that surface IgM+ (sIgM+) B cells are an enriched source of IgA2 plasma cell precursors, panning techniques were used to purify sIgM+ B cells from tonsils. Of 103 clones derived from these sIgM+ B cells, 102 secreted IgA1 and only one secreted IgA2. The relative absence of IgA2-producing clones could not be attributed to an absence of EBV receptors on IgA2 cells. A mean of 84 +/- 4% of freshly isolated IgA2 B cells and 78 +/- 6% of IgA1 B cells could be stained with a monoclonal antibody binding the EBV receptor; and there was no failure of EBV to infect IgA2 plasma cells precursors. Of IgA2 plasma cells derived from peripheral blood lymphocytes stimulated 7 days previously with EBV, 54 +/- 7% were positive for the EBV nuclear antigen, compared with 54 +/- 18% of IgA1 plasma cells from the same cultures. Seven days after EBV stimulation, a mean of 25% of the total IgA plasma cells were positive for cytoplasmic IgA2, whereas by 21 days after stimulation only 7% were positive for IgA2. This shift in the proportions of IgA1 and IgA2 plasma cells could be attributed to a failure of the IgA2 plasma cell number to increase after 10 days in culture. There was no evidence for selective suppression of IgA2 production by T cells or selective lysis of IgA2 plasma cells by infectious EBV particles. These results demonstrate that although precursors for both IgA1- and IgA2-producing cells can be stimulated to differentiate in response to EBV, there is preferential transformation of IgA1-producing cells.

X-linked agammaglobulinemia (XLA) has been described as a disorder in which pre-B cells fail to differentiate into B cells. However, a small number of B cells have been seen occasionally in patients with this disorder. Because the phenotype of these cells might be helpful in defining the site of the defect in XLA, immunofluorescent staining techniques were used to characterize the B cells that can be found in patients with XLA. Surface IgM-positive B cells could be detected in the peripheral circulation of all seven patients studied. These B cells constituted a very small percentage of the total lymphocytes (0.01 to 0.3% compared with 3.2 to 13.7% in controls) and differed in phenotype from control B cells. They were much more brightly stained for surface IgM (p less than 0.001) and less brightly stained for Ia (p less than 0.01). This phenotype is similar to that described for immature B cells in the mouse. Over 80% of the patients' B cells expressed surface IgD, and all expressed the B cell marker B1, but only 35% expressed the B cell marker B2. This B cell marker, which is the C3d receptor and the Epstein-Barr virus receptor, is expressed later in ontogeny than B1 and can be detected on over 80% of control B cells. All B cells expressed either kappa or lambda light chain. These findings indicate that the defect in differentiation of pre-B cells into B cells is not absolute in patients with XLA. The immature phenotype of the B cells additionally suggests that there may be a block in the maturation of B cells at more than one stage of differentiation in this disorder.

Two infants with AIDS who presented with interstitial pneumonitis, failure to thrive, lymphadenopathy, and hypergammaglobulinemia have been studied. Antibody to human T-lymphotropic retrovirus (HTLV-III) was identified by ELISA and Western blot analysis in serum samples from both patients. The T4/T8 ratios of peripheral blood T-lymphocytes in both patients were mildly decreased, with normal absolute numbers of lymphocytes and positive T4 cells. Lung biopsies from both patients demonstrated similar histopathologic features with features of lymphocytic interstitial infiltrates and accumulation of macrophages in the air spaces. Immunoperoxidase studies of the lung biopsy from 1 patient revealed that the lymphocytic infiltrate was composed predominantly of T cells of the T8 subset. Each patient was treated with prednisone, with improvement or resolution of pulmonary symptoms, hepatosplenomegaly, lymphadenopathy, and growth failure. Neither patient has had any opportunistic infections. One patient has been followed for more than 4 years and the other for 8 months.

CVI in childhood is not a well described entity. We have followed 6 children (2 males and 4 females) with this disease who have also had multiple severe, autoimmune disorders that have overshadowed infections as clinical problems. These children have all had onset of disease before 5 years of age and all have had severe growth failure. The autoimmune disorders have included ITP with autoimmune hemolytic anemia (3/6), diarrhea, malabsorption or gastritis (5/6), JRA (2/6), parotitis (2/6), chronic active hepatitis (2/6) and Guillian Barre Syndrome (2/6). All have had hypogammaglobulinemia. T and B cells have been present in the peripheral circulation, although in some cases in reduced numbers. Delayed hypersensitivity skin tests and proliferative responses to mitogens have been normal. T cell subsets, done in 4 of the patients, demonstrated an increased ratio of T helpers to T suppressors (T4/T8); 3.2 ± 0.6 vs. 1.8 ± 0.4. In vitro assays demonstrated normal or increased T cell help. When patient T cells were added to control B cells in pokeweed mitogen stimulated cultures, the number of plasma cells produced was equal to or greater than that produced when control T cells were added. In contrast, patient B cells did not differentiate into plasma cells even when supplemented with normal T cells. CVI in childhood with autoimmune disease may represent a unique syndrome which may provide new insights into understanding of B cell differentiation.

XLA is characterized by hypogammaglobulinemia and absent B cells, but normal numbers of pre-B cells. Atypical cases of XLA have been reported in which immunoglobulin concentrations are higher than expected or pre-B cells are absent. We have recently demonstrated that B cells from obligate carriers of typical XLA selectively use the X chromosome that does not carry the gene defect as the active X. To extend this observation, we developed a technique that combines the production of somatic cell hybrids that retain the active X, with the use of X-linked RFLPs that permit the distinction of the two X chromosomes. This technique, which allows the identification of the active X in cells from any woman, was used to study an obligate carrier and 4 women at risk in families with typical XLA. We also studied the mother of a boy with atypical XLA who has low numbers of B cells, absent IgA and IgM but normal IgG and no family history. All 10 B cell hybrids from the known carrier used the same X as the active X; 3 of the 4 women at risk also demonstrated nonrandom X chromosome inactivation in B cells; 7 of the hybrids from the last woman used one X chromosome and 8 used the other, indicating that this woman is not a carrier. All 19 B cell hybrids from the mother of the sporadic case also used the same X, indicating that this woman is a carrier for an X-linked form of disease. These results show that this technique can be used for carrier detection in both sporadic cases of XLA and in XLA pedigrees. Further, by increasing the number of individuals who are informative for mapping in atypical XLA families, we will be able to examine heterogeneity of XLA.

We have demonstrated by limiting dilution analysis that a high percentage of clones derived from Epstein-Barr Virus (EBV) stimulated peripheral blood lymphocytes (PBL) secrete IgA. To further characterize the IgA produced by these clones the IgA subclass of supernatants from clones stimulated 6–8 weeks earlier with EBV was determined by RIA. 17/17 clones were positive for IgA1; none were positive for lgA2. Because we have shown an enrichment for lgA2 precursors in surface lgM+ B cells, panning techniques were used to separate slgM+ B cells from tonsils. 32/32 clones from these slgM+ B cells secreted IgA1, none secreted lgA2. Past experiments have demonstrated a discordance between plasma cell production and immunoglobulin secretion. Therefore cytoplasmic staining for lgA2 was done on EBV stimulated PBL harvested 7, 10, 14 and 21 days after culture. In all 5 experiments, the percentage of IgA plasma cells positive for IgA2 decreased with increasing duration of culture. A mean of 25.5% of the IgA plasma cells were positive for lgA2 at Day 7 and 7.2% at Day 21. These results are unlikely to be due to isotype switching from lgA2 to IgA1 as the gene for α2 is more distal to the υ gene than the gene for α1. Instead, there may be a difference between limited proliferation and differentiation induced by EBV, and immortalization. Although lgA2 plasma cell precursors may undergo some proliferation and differentiation after EBV stimulation they are not immortalized. There is selective immortalization of lgA1 producing cells.