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We report the clinical and immunologic features and outcome in 56 patients with X-linked hyper-IgM syndrome, a disorder caused by mutations in the CD40 ligand gene. Upper and lower respiratory tract infections (the latter frequently caused by Pneumocystis carinii), chronic diarrhea, and liver involvement (both often associated with Cryptosporidium infection) were common. Many patients had chronic neutropenia associated with oral and rectal ulcers. The marked prevalence of infections caused by intracellular pathogens suggests some degree of impairment of cell-mediated immunity. Although lymphocyte counts and in vitro proliferation to mitogens were normal, a defective in vitro proliferative response to antigens was observed in some patients, and additional defects of cell-mediated immunity may be presumed on the basis of current knowledge of CD40-ligand function. All patients received regular infusions of immunoglobulins. Four patients underwent liver transplantation because of sclerosing cholangitis, which relapsed in there. Three patients underwent bone marrow transplantation. Thirteen patients (23%) died of infection and/or liver disease. X-linked hyper-IgM syndrome, once considered a clinical variant of hypogammaglobulinemia, is a severe immunodeficiency with significant cellular involvement and a high mortality rate.

Accumulating evidence indicates that peripheral lymphocyte variants with altered antigen receptor expression may be capable of expressing recombination-activating genes (RAG). We and others recently observed functional RAG gene products in mature T cells with defective TCR expression (MacMahan and Fink, Immunity 1998. 9: 637 - 647; Lantelme et al., J. Immunol., 2000. 164: 3455 - 3459). Here, the association between TCR expression and RAG activity was assessed further in lymphocytes from patients with defective responses to DNA damage. We show that T cells with altered TCR surface expression are present in increased numbers in these patients and that they express RAG genes. The finding of RAG gene expression by TCR variants suggests the possibility that secondary V(D)J rearrangements could be induced in these cells to rescue their defective phenotype and cellular function. Moreover, as V(D)J recombination has been implicated in chromosome translocations involving antigen receptor genes, we discuss a possible relationship between altered TCR expression, RAG activity and the frequent lymphoma-specific translocations observed in these patients.

The recombinase-activating genes, RAG-1 and RAG-2, can be expressed by a subset of B cells within germinal centers, where they mediate secondary V(D)J rearrangements. This receptor revision mechanism could serve either receptor diversification or tolerance-induced functions. Alternatively, it might rescue those cells the receptors of which have been damaged by somatic mutation. Less is known about the occurrence of similar mechanisms in T cells. Here we show that mature T cells with defective TCR surface expression can express RAG genes and are capable of initiating secondary V(D)J rearrangements. The possibility that a cell rescue mechanism based on the generation of a novel Ag receptor might be active in peripheral T cells is envisaged.

SUMMARYIn the present study we evaluated in vitro immunoglobulin production from IgAD individuals and healthy controls. Peripheral blood mononuclear cells (PBMC) from IgAD and controls were cultured with anti-CD40 MoAb presented on a CDw32-transfected fibroblast cell line (CD40 system) in the presence of IL-10, IL-2, IL-4, transforming growth factor-beta (TGF-β) alone as well as of IL-10 in combination with each of the other three cytokines. Only IL-10 added alone induced significant changes in baseline immunoglobulin production; marked increases in median supernatant levels of all three isotypes were observed in both groups. The most striking finding of this study was the synergizing effect of IL-4 on IgA production in the IgAD group when added with IL-10; median IgA supernatant level increased to a value superimposable on that found in the normal controls which remained about the same as when stimulated with IL-10 alone. The synergic effect of IL-4 and IL-10 was specific to the IgA isotype.

To date, corticospinal tract functional integrity in ataxia-telangiectasia has not been studied. Thorough evaluation of central motor pathways is also lacking in neuropathologic and clinical studies. Using electromagnetic stimulation, we assessed the integrity of the corticospinal tracts in eight patients with ataxia-telangiectasia. Cortical and peripheral compound motor action potentials were recorded from the abductor pollicis brevis muscle. Recordings of the shortest F-wave latency and of the compound motor action potential distal latency were made from the abductor pollicis brevis muscle after electrical stimulation of the median nerve at the wrist. A significant increase in central motor conduction time was observed in four patients, two of whom had clinical findings compatible with a pyramidal lesion. This study demonstrates involvement of the central motor pathways in ataxia-telangiectasia, which appears to be more frequent late in the course of the disease. (J Child Neurol 1997;12:327-331).

A history of poor growth in early childhood associated with persistent diarrhea and iron deficiency anemia led to a diagnosis of celiac disease in a 9-yr-old boy hospitalized for acute rhabdomyolysis. Elevated serum creatine kinase levels had been documented over the previous years, and Becker's muscular dystrophy was diagnosed by immunostaining of dystrophin and DNA analysis.

Activation of polymorphonuclear cells (PMNs), neutrophils and eosinophils, occurs in response to infections. Myeloperoxidase (MPO) is an enzyme contained in neutrophils with toxic activity for many microorganisms including bacteria. Fosinophil cationic protein (ECP) and eosinophil X protein (EPX) are released by activated eosinophils in response to different inflammatory stimuli. Determination of serum levels of MPO, ECP and EPX permits assessment of the state of activation of these cells. The purpose of this study was to evaluate the state of activation of neutrophils and eosinophils present in tonsillar tissue and peripheral blood from 30 children (18 boys and 12 girls) undergoing tonsillectomy for chronic tonsillitis. For determination of serum levels of MPO, ECP and EPX, peripheral blood samples were obtained at the time of surgery: PMNs were separated by erythrosedimentation from peripheral blood and from tonsillar tissue after surgery and cultured for 7 days. The cells were plated (10(5) well) and the plates were incubated in 5% CO(2), 7% O(2), 80% N(2). After 2, 24, 48, 72, 96, 120, 144 h, supernatants were removed from the cultures of both tonsillar tissue and peripheral blood PMNs for determination of in vitro release of MPO, ECP and EPX. The assays were carried out using a radioimmunotechnique (RIA, Pharmacia) and the concentrations of the three proteins (mean/6 wells) for each time were expressed in mu g/l. The data suggest activation of PMNs in children with chronic tonsillitis.

The results obtained using a new in vitro screening test for atopy Phadiatop-paediatric (Phad-P) and RAST for multiple food and inhalant allergens in 132 children (82 with atopic dermatitis and 50 with a negative history of atopic symptoms are compared. 64% of the subjects were RAST-positive for food allergens (55/82) in those with dermatitis and only 5/50 in those without atopic symptoms. The only difference between the new test and the RAST is that a mixture of food and inhalant allergens, rather than a single allergen, is conjugated to the paper disk and the results are expressed as positive or negative so as to identify atopic subjects for further allergologic evaluation. The sensibility and specificity of Phad-P as compared to RAST were respectively 87% and 85% with an efficiency of 86%. On the basis of these data, assuming a 20% prevalence of atopy, in the general population the predictive value of negative results of the new test would be 97% and of positive results 59% with an expected efficiency of 86% values similar to those observed in other studies and at the moment considered satisfactory for a screening test fo atopy.

We describe here an immunocompetent boy with fever, regional adenopathy, multifocal hepatosplenic granulomas, and high and increasing serum antibody titers for Bartonella henselae in whom diffuse bilateral reticulonodular pulmonary infiltrates developed in the absence of respiratory symptoms.

We describe a mentally retarded 12-year-old girl with ataxia in whom diagnostic evaluation for short stature revealed isolated growth hormone (GH) deficiency and multiple central nervous system (CNS) lesions. Assessment of immunologic status, performed because of the persistence of recurrent respiratory tract infections, showed associated deficiencies of IgG2-IgG4 and specific antibody response; in addition, in vitro lymphocyte response to mitogens was low, in vitro production of interleukin-2 and of IgM was absent, and natural killer activity was decreased. The possibility that association of the CNS lesions, GH deficiency and immune defects could be due to alterations of the neuro-immuno-endocrine network secondary to a disturbance of neurotransmitters induced by precocious CNS damage of a viral or ischemic nature is discussed.

In 104 children with atopic dermatitis (AD) and RAST tests for 2 inhalant and 9 food allergen mixtures, RAST results, severity of skin involvement and presence of respiratory symptoms by history were analyzed in addition to total serum IgE values available in 66 children. Overall frequency of sensibilization was high (74%) with more positive RAST results for foods than inhalants, although of the latter the only two tested were among the more frequently positive. When the subjects positive for inhalants were considered alone, the frequency of respiratory symptoms was significantly higher in those sensitized to both inhalant mixtures tested (dermatophagoides and graminaceae) and the presence of more severe skin lesions was more common among those sensitized to graminaceae.

In the present study salivary IgA, anti-Escherichia coli, anti-beta-lactoglobulin and anti-poliovirus type 1 IgA and IgM in serum and saliva were evaluated longitudinally in 13 breast-fed and 14 formula-fed infants over the first six months of life. Salivary IgA was quantified by electroimmunodiffusion; specific IgA and IgM antibodies were determined in serum and saliva by ELISA. Salivary IgA was significantly lower at age one month in breast-fed compared with formula-fed infants but in breast-fed infants salivary IgA increased with age and was significantly higher at six months than at one month. In both groups of infants, at the age of six months, salivary IgA levels were significantly lower than in adult controls. No significant differences in secretory anti-E. coli were observed between the two groups of infants. Salivary anti-poliovirus IgA and IgM antibodies increased transiently only to disappear in most babies at age six months, while anti-beta lactoglobulin IgA and IgM, present in saliva at all ages, showed a wide scatter. No important differences in specific serum IgA or IgM antibodies were observed either between the groups or at different times within the groups.

The Multitest skin test allows the simultaneous intradermal application of seven standardized recall antigens in a reproducible manner. Response reading is based on a scoring system that distinguishes between normal and diminished delayed hypersensitivity (DH). To determine incidence and size of DH responses for each antigen in relation to age and sex in healthy Italian children, a multicentric study was performed on a representative paediatric population of 491 subjects (285 males and 296 females) aged from 4 months to 16 years. In both sexes DH reactivity as measured by score and number of positive responses increased significantly with age. The incidence of anergy was 8.8% for the whole population and decreased significantly with age in both sexes. Incidence of positive responses was highest for tetanus and diphteria toxoids, intermediate for Candida, Proteus and Streptococcus, and lowest for tuberculin and Trichophyton antigens. There was no significant difference between sexes in the incidence of positive response to each antigen.

Fifty children with IgA deficiency were folllowed for 1 to 4 years from 1975 to 1978. Thirty-five had complete deficiency of serum IgA (less than 2.5 IU/ml) and 15 partial deficiency (serum IgA below the 10th centile for age). Patients with another associated immunodeficiency, such as ataxia-telangiectasia, were not included. Most children with complete deficiency of IgA had recurrent respiratory and/or gastrointestinal infections, about half with onset in the first year of life, while partial deficiency of IgA has probably little if any importance for anti-infectious immunity but is important in the pathogenesis of atopy. Atopic diseases were frequent in both groups. Chromosomal abnormalities were found in 2 patients: trisomy 21 in one and in the other a ring chromosome 18. No important defects in cellular immunity were detected but some isolated, borderline abnormalities were often present.

Summary Secretory-IgA (SIgA) concentrations were determined in whole saliva, unstimulated or stimulated by lemon juice, of thirty-eight children with atopic dermatitis, which comprised three adolescents, sixteen with IgE detected by RAST to one or more common allergen and twenty-two without specific IgE by RAST. There were thirty healthy controls matched for age and sex. The mean amount of total IgE was significantly greater in the RAST-positive than in the RAST-negative group. The mean SIgA concentration in unstimulated saliva of the RAST-positive atopic dermatitis group was less than that of the RAST-negative atopic dermatitis group and control groups, though the mean concentrations of SIgA of stimulated saliva were not significantly different in the three groups. It is suggested that the pathogenesis of atopic dermatitis may differ in children with or without specific-IgE antibodies; in those who were RAST-positive deficient exclusion of allergen by the intestinal barrier contributed to the pathogenesis, but not in those who were RAST-negative.

IgG subclass levels were determined in 448 normal children from 6 months to 18 years of age and in 141 healthy adults by radial immunodiffusion using monoclonal antibodies. Age-normal percentile values were calculated for each year of age up to 18 years for IgG1, IgG2, IgG3 and in adults for all four subclasses. The broad spread of IgG4 values in children did not permit calculation of reference values.

Detection of specific IgE by the radioallergosorbent test (RAST) which uses labelled antibody can be hampered by the presence of antibodies other than IgE but with the same specificity and may limit usefulness of the RAST for diagnosis of IgE-mediated milk allergy in infancy when high titres of cow's milk protein-specific IgG antibodies are known to be present. This can be avoided by using a system employing labelled antigen, such as the enzyme-linked immunosorbent assay (ELISA) described here, where IgE in the test serum is immunoadsorbed to anti-human IgE coated to microtitre plates. Biotinylated antigen, in this case cow's milk proteins, binds to specific IgE and the reaction is revealed colorimetrically by adding horseradish peroxidase (HRP)-avidin conjugate.

The Paul-Bunnell test, now 50 years old, is still of fundamental importance in the diagnosis of infectious mononucleosis, even though various immunologic methods have been developed in clinical practice to identify constituents of the Epstein-Barr virus (EBV). The demonstration of sheep red cell agglutinins in infectious mononucleosis (Paul-Bunnell) was in fact the first observation of the presence of heterophil antibodies in this viral disease which was later shown to evoke a polyclonal antibody response to a wide spectrum of autoantigens as well. The selective tropism of EBV for B lymphocytes and the reactivity of T lymphocytes to these infected B lymphocytes are the pathophysiological elements characteristic of infectious mononucleosis, and are the reason for this massive antibody response.

Two cases of visceral leishmaniasis in children are described. In both "in vitro" lymphocyte response to mitogens and allogeneic cells was initially markedly depressed, but returned to normal within a few days after six days of treatment with N-methylglucamine antimonate; in one the candidin skin test reverted from negative to positive after treatment and in the other a circulating serum factor was found which strongly inhibited phytohemagglutinin--and mixed--responsiveness of normal lymphocytes, but disappeared after therapy.

A case of hypertrophic osteoarthropathy is described in an 8-year-old child with late-onset agammaglobulinemia, bronchiectasis and clubbing of the fingers and toes. The child presented with pain of recent onset in the legs, ankles, and knees and a diagnosis of hypertrophic osteoarthropathy was made on the basis of the radiologic findings. Therefore the differential diagnosis of bone and joint pain in agammaglobulinemic subjects must take into account hypertrophic osteoarthropathy.

An 11 year old girl with retarded growth, recurrent infections, bronchiectasis, and normal serum immunoglobulin concentrations had a combined deficit of the IgG2 subclass and IgG and IgM specific antibodies. Immunoglobulin replacement was followed by clinical improvement. The importance of determining both IgG subclasses and antibody activity in patients with recurrent infections and normal serum immunoglobulin values is emphasised.

A new solid-phase immunoassay based on the biotin/avidin system (BAS) for measuring serum Lolium perenne (LP)-specific IgE antibody is described. LP-specific IgE was assayed by the BAS assay and RAST for comparison in the sera of thirty-two normal asymptomatic subjects RAST-negative for LP and of twenty-six subjects with hay fever and RAST-positive for LP. The specificity of the BAS assay for LP-specific IgE was demonstrated by absorption experiments. An overall agreement of 91% (53/58) was observed between the BAS and RAST and a high correlation (r = 0.87, P less than 0.001) was found between the LP-specific IgE determined by the two methods. The advantages of the BAS assay as compared to both the RAST and classical ELISA are discussed.

The various "in vitro" tests for evaluating polymorphonuclear leucocyte function in children with recurrent infections are described and the different clinical conditions caused or accompanied by defects in polymorphonuclear function are summarized briefly. The necessity of correct interpretation of the results of the laboratory tests used in the diagnostic evaluation of patients with suspected immunodeficiency is stressed.

Twelve children with intractable childhood epilepsy (ICE) were treated with high-dose intravenous immunoglobulins every 21 days for 6 months after immunologic and neurologic evaluations had been carried out. 50% (6/12) were found to have a deficiency of serum IgG2 and all but 1 of these responded to treatment with marked reduction in the daily number of seizures assessed both clinically and electroencephalographically. The response to treatment was, in fact, significantly higher in the children with IgG2 deficiency than in the others. IgG4 deficiency, observed in 5 children, did not affect treatment response. It is suggested that IgG2 deficiency may predispose to some form of viral encephalitis which may trigger an immune mechanism leading to the ICE.

Seven girls with precocious puberty, idiopathic in 6 and associated with the McCune Albright syndrome in 1, were treated with 70 mg/M2/die of cyproterone acetate (CPA) for 11 to 36 months. Before and during treatment clinical parameters (weight, height, bone age, height velocity, prediction of adult height and pubertal development) were evaluated and plasma hormone assays in basal conditions (LH, FSH, 17 beta-estradiol, progesterone, testosterone, PRL, ACTH and cortisol) and after stimulation (LH, FSH, cortisol, GH) were carried out to assess the efficacy and eventual side effects of CPA. The regression observed in the clinical signs of puberty was considered satisfactory and the increase observed in the developmental quotient indicated an improved prognosis for adult height. No symptoms of adrenal insufficiency were observed but an adrenal suppressive effect of CPA was evident from the response to insulin hypoglycemia observed in 4 patients.

The purpose of these experiments was to study the influence of β-adrenergic receptor blockade on lymphocyte (PBL) responsiveness to PHA and IgE production in atopic subjects. PBL from 26 asymptomatic patients from 3 to 12 years of age with mild atopic dermatitis (AD), taking no drugs, and 17 age- and sex-matched controls (C) were stimulated in vitro with PHA. The degree of inhibition of proliferation induced by various concentrations of isoproterenol (I) in the two groups was compared.

Anti-streptolysin O (ASO) antibodies are an expression of the frequent encounters even during the first years of life with beta hemolytic Streptococci, they are easily measured by quantitative laboratory tests and so possess the characteristics of a screening test for impaired antibody production. We have assessed ASO titers in 1955 healthy subjects of different ages (range: 1 month to 97 years). The behaviour of ASO titer is extensively described in the text. The percentage of people with less than 10 TU titers is under 5% after the age of 5 years up to 15 years; from 15 to 60 years there are no subjects with undetectable ASO titer and after this age the percentage is still under 5%. It seems therefore advisable not to define a "normal" treshold when titrating these antibodies to avoid the risk of missing low antibody producers.

Serum IgG and serum and secretory IgM, IgA and IgD levels were determined in 14 children with selective IgA deficiency and in 12 age and sex matched healthy controls. IgD was determined using a highly sensitive ELISA technique. In the healthy controls serum IgG, IgA and IgM were all in the age normal range, and serum IgA was significantly higher than secretory IgA with IgA in nasal secretions being significantly higher than in saliva. In the IgA deficient children serum IgG and IgM and secretory IgM were present in higher concentrations than in the controls but the difference was statistically significant only for serum IgG and salivary IgM. IgD was detectable in the serum and secretions of all patients and all but one control subject. Like IgM, serum IgD levels were significantly higher than secretory IgD levels and IgD was present in greater concentrations in nasal secretions than in saliva both in the patients and the controls, with no difference between the two groups. Thus, the data of this study show that while serum and secretory IgM levels are elevated in children with selective IgA deficiency, serum and secretory IgD are present in normal concentrations, supporting the hypothesis of a compensatory increase in IgM but not in IgD in such patients.

Similar frequencies of atopic diseases and of elevated total serum IgE levels were observed in 40 children with serum IgA levels below 5 mg/dl and absence of salivary IgA (severe selective IgA deficiency, SIgAD) and in 40 children with serum IgA levels above 5 mg/dl but below -2 SD of age-normal mean values and presence of salivary IgA (partial SIgAD). These findings suggest that the absence of secretory IgA, which has been postulated to play a protective role by excluding allergens at the mucosal level, does not appear to play a crucial role in the pathogenesis of atopic diseases.

Detection of specific IgE by the radioallergosorbent test (RAST) which uses labelled antibody can be hampered by the presence of antibodies other than IgE but with the same specificity and may limit usefulness of the RAST for diagnosis of IgE-mediated milk allergy in infancy when high titres of cow's milk protein-specific IgG antibodies are known to be present. This can be avoided by using a system employing labelled antigen, such as the enzyme-linked immunosorbent assay (ELISA) described here, where IgE in the test serum is immunoadsorbed to anti-human IgE coated to microtitre plates. Biotinylated antigen, in this case cow's milk proteins, binds to specific IgE and the reaction is revealed colorimetrically by adding horseradish peroxidase (HRP)-avidin conjugate.

An 11-year old girl who presented non-pitting edema of the face and neck, shoulder pain and a gallop rhythm about 10 days after a febrile episode with sore throat is described. The mask-like facial appearance and limited movement of the neck led to suspect scleredema which may be accompanied by carditis. Skin and muscle biopsy findings confirmed the diagnosis. Cardiac involvement included a gallop rhythm persisting for 6 months, ECG changes consisting in transitory T-wave inversion in leads II and V2 - V4, a transitory pericardial function rub and hepatomegaly due to right-sided failure which responded to digitalization. In this case the presence of a gallop rhythm and elevated ASLO titer led to an initial diagnosis of acute rheumatic fever; dermatomysitis and sclerodermia are also to be considered in the differential diagnosis of scleredema of Buschke. In our patient the edema resolved completely within 12 months, the gallop rhythm within 6 months and the ECG became normal after 8 months.

HLA supratypes as well as serum IgG, IgA and IgM levels were determined in 44 children and adolescents with severe IgA deficiency (serum IgA less than 5 mg/dl) and in first degree relatives. Frequencies of the HLA alleles B14, DR1, DQW1, C4A2 and C4B2 were significantly higher in the IgA-deficient patients than in the controls. The most recurrent haplotype among patients was B14, DR1 (p less than 10(-4) preferentially associated with A33, A28 or A blank. The supratype B14, Bfs, C4A2, C4B2, DR1, DQW1 was present in a 14-fold higher frequency than in the controls, and strongly suggests the presence of a gene in the HLA region involved in the deficiency of IgA. The fact that this supratype was not always associated with IgA deficiency in the parents and that not all IgA-deficient subjects had this supratype is discussed. Severe IgA deficiency was found in four mothers (two of the four mother-child pairs shared the B14, DR1 haplotype); three other relatives (one father and two brothers) had partial IgA deficiency and did not have the B14, DR1, DQW1 haplotype.

The relationship between the presence of hepatitis B surface antigen (HBsAg) and antibodies to human thyroglobulin (HTgAb) has been studied in 110 subjects with Down's syndrome (DS) from 4 months to 50 years of age and in 122 controls carefully matched for sex, age and socio-environmental conditions. The overall percentage of HBsAg carriers was 22.7 in DS and 6.6 in controls and that of HTgAb-positive subjects was 41.8 in DS and 19.7 in controls. In DS the frequency of HTgAb-positive subjects was very high, even in the youngest age groups in which the percentage of HBsAg carriers was relatively low; the latter thereafter showed a marked increase with age. A positive association between the presence of HBsAg and HTgAb was found only in the oldest age group of DS subjects. It is thus concluded that in DS the high frequency of HTgAb cannot be attributed to chronic hepatitis B virus infection. On the contrary, the presence of HTgAb might well represent an early "marker" of immunodeficiency and increased susceptibility to infection with hepatitis B virus.

A double blind vs placebo study was carried out to study the effect of letosteine on the symptoms and clinical course of paediatric patients suffering from acute febrile bronchitis. Forty children were recruited for the research: 20 were treated with letosteine in a dose of 25 mg x 3 g/die and 20 with placebo; treatment lasted 10 days. The following parameters were assessed during the trial: body temperature, cough, thoracic objectivity, respiratory function indices. The results of the study show that in the letosteine treated group there is a statistically significant decrease in fever, a favourable evolution of thoracic objectivity and an improvement in certain respiratory function parameters (MEF 75, PEF). It is concluded that treatment with letosteine leads to a significant increase in the rate of regression of thoracic symptomatology and a faster, more substantial reduction in fever in children suffering from acute bronchitis. This is probably the result of drug action on mucus viscosity, restoring optimal mucociliary clearance, and through action fostering the penetration of antibacterial substances into the mucus.

In 113 children with atopic dermatitis RAST results for 9 food mixtures were analyzed. Sixty-eight children (60%) were RAST positive (greater than or equal to ++) for one or more mixture and 87% of those RAST positive had specific IgE for egg and/or cereals and/or legumes. Sensitization to egg, cow milk and meat was more frequent in the first years of life. RAST for the mixture of cereals and each single cereal, performed in 37 children, gave concordant results in 76%; agreement for the positive results was 88%, but only 54% for the negative ones. Breast versus cow milk feeding in the first months of life was not found to affect intensity of the skin manifestations or frequency of RAST positivity for the food mixtures or the respiratory symptoms.