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Impaired antibody response to polysaccharides in association with functional asplenia
CLINICAL AND LABORATORY OBSERVATIONS
Impaired antibody response to polysaccharides in association with functional asplenia A l a n D. G a i n e s , MD, a n d R e b e c c a
H. B u c k l e y , MD
From the Division of Allergy and immunology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
Impaired antibody responses to polysaccharide antigens despite normal or nearly normal levels of immunoglobulins (including IgG subclasses) have been noted uniformly in patients with Wiskott-Aldrich syndrome and recently in patients without that condition, some of whom also had normal antibody responses to certain protein antigens. 1,2 We present here a boy with similar immunologic findings in whom we found an associated unexplained functional asplenia. CASE REPORT A 21A-year-01dblack male child was referred to Duke University Medical Center for immunologic evaluation because of a history of recurrent serious infections. He was the 3180 gm product of a pregnancy complicated only by some maternal weight loss in the third trimester. His neonatal course was notable for the congenital absence or malformation of several fingers on both hands, consistent with the amniotic band syndrome. The patient was first hospitalized at 2 months of age for pneumonia, followed by hospitalizations at 4 months for Haemophilus influenzae meningitis and at 5, 6, and 9 months for episodes of pneumococcal sepsis. Immunoglobulin and isohemagglutinin levels were reportedly normal, and empiric prophylactic amoxicillin therapy was begun. The patient then did fairly well until 29 months of age, when he developed severe disseminated varicella with lung and liver involvement,as well as disseminated intravascular coagulation. He eventually recovered after intravenous acyclovir therapy. METHODS ImmunoglobulinsG, A, and M were measured by radial immunodiffusion, and specific antibodies to diphtheria and tetanus were measured by tanned cell hemagglutination in our laboratory2 Analysis of lymphocyte proliferation in
Supported in part by a grant from the General Clinical Research Centers, Division of Research Resources, National Institutes of Health (MO 1-RR30), and from National Institute of Allergy and Infectious Diseases grant AI 18613. Submitted for publication May 24, 1988; accepted July 26, 1988. Reprint requests: Rebecca H. Buckley, MD, Chief, Division of Pediatric Allergy and Immunology, Box 2898, Duke University Medical Center, Durham, NC 27710.
Table I. Studies of cellular immunity 1/29/87 Patient
Normal
Lymphocyte phenotype (% cells positive) Surface IgM+ 33.6 11.5 CD3+ 31.1 68.4 CD4+ 11.9 38.6 CD8+ 21.1 34.2 CD4/CD8 ratio 0.56 1.13 Proliferative response (cpm • 10-3.) to: PHA 47 109 ConA 30 119 PWM 23 78 Candida 18 36 Tetanus 10 I0
3/17/87 Patient
Normal
36.3 14.1 22.3 0.63
69.0 43.4 20.8 2.09
115 117 69 79 69
115 167 90 67 48
PHA, Phytohemagglutinin;ConA, concanavalinA; PWM, pokeweed mitogen. *3H-Thymidineincorporationinto DNA. response to phytohemagglutinin, concanavalin A, pokeweed mitogen, and tetanus, Candida, and varicella antigens was performed on Ficoll-Hypaque purified cells in our laboratory by methods previously described, as was lymphocyte subset analysis with monoclonal antibodies2 The IgG subclasses were measured by immunoradiometric assay, and antibodies to 11. influenzae capsular polysaccharide and tO pneumococcal serotypes 3, 7, 9, and 14 were measured by enzyme immunoassay (Specialty Laboratories, Los Angeles, Calif.). Antibodies to bacteriophage cI,X-174 were measured by phage neutralization by Dr. Hans Ochs, of the University of Washington, Seattle. RESULTS Lymphocyte proliferation to mitogens and antigens was initially low immediately after acute varicella, but normal responsiveness returned within 2 months of clinical recovery (Table I). However, analysis of lymphocyte subsets consistently showed a decreased percentage of CD4positive cells with a reversed CD4/CD8 ratio and increased percentage of IgM-bearing B cells (Table I). Assays for antibodies to human immunodeficiency virus 89
90
Clinical and laboratory observations
The Journal of Pediatrics January 1989
T a b l e II. Antibody responses to immunization
Antigen
Before
After
Diphtheria Tetanus H. influenzae type b Pneumococcal Type 3 Type 7 Type 9 Type 14
1 : 2187 1:2187 33
1 : 19683 1 : 19683 55
75 77 63 I90
75 84 56 220
Units
Mean for age"
HA titer HA titer ng/ml
>1 : 10000 >1 : 10000 >10-fold increase
ng Ab N/ml ng Ab N/ml rig Ab N/ml ng Ab N/ml
>6-fold increase >5-foid increase >6-fold increase Minimal increase
HA, Hemagglutinin;Ab, antibody;N, nitrogen. *Hemagglutinintiters of >1 : 10,000are normalresponsesin our laboratoryafter diphtheriaand tetanusboosters.Meanresponsesfor 24 to 35-month-oldchildren after pneumoCoccalvaccineare from SullivanJL, Ochs HD, SchiffmanG, et al. (Lancet 1978;1:178-81)and after H. influenzaetype b vaccinefrom Warrier I and RavindranathY (J PED~ATR1986;109:305-7) with 68 of 68 childrenachievinglevels>150 ng/mL
were negative on two separate occasions in both the patient and his mother, and the patient's serum was also negative for the human immunodeficiency virus antigen p24. The CHs0 value was' 39 U / m l (normal >30). Results of immunoglobulin measurements On several occasions ranged as follows: IgG 580 to 770 mg/dl (normal range 503 to 1279), IgA 48 to 140 mg/dl (normal range 35 to 222), IgM 21 to 36 m g / d l (normal range 32 to 131), and IgE 120 tO 210 U / m l (normal range 5 to 621). IgG subclasses showed IgG1 480 mg/dl (normal range 300 to 850), IgG2 59 mg/dl (normal range 50 to 300), IgG3 27 mg/dl (normal range 12 to 70), and IgG4 12 mg/dl (normal range 3 to 80). Despite normal isohemagglutinin titers for age of 1 : 8 for both anti-A and anti-B, and despite normal antibody responses to diphtheria and tetanus boosters, there was no significant response to immunization at 35 months of age with either H. influenzae capsular p01ysaccharide vaccine or polyvalent pneumococcal vaccine (Table II). Primary response to intravenously administered bacteriophage ~X-174 was also relatively low, with a peak of 0.04 kV (normal >8). Because of the clinical history and some possible Howell-Jolly bodies on one blood smear, splenic function was investigated. An ultrasound study revealed an anatomically normal spleen. Four months later, the blood smear was negative for Howell-Jolly bodies. However, a technetium 99 sulfur colloid liver-spleen scan showed no splenic uptake, indicating functional asplenia. Hemoglobin electrophoresis revealed normal hemoglobin A2 levels with slightly elevated fetal hemoglobin levels at 1.4% (normal <1%). This was shown on a-globin gene mapping to be due to a single gene deletion a-thalassemia trait. DISCUSSION The cause and duration of this child's functional asplenia are unclear. Most cases in children have been associated with sickle hemoglobinopathies, but functional asplenia has also been associated with vascular insults, anoxia, malignancy, and chemotherapy plus irradiation?
One case has been reported of functional asplenia in a leukemic Child after disseminated varicella; however, there was no documentation by scan of a functional spleen before the illness, and the diagnosis was not based on a scan specific for splenic dysfunction? ,s In our patient, the history is strongly suggestive of splenic dysfunction even in early infancy, before anti-polysaccharide antibodies play a significant protective role. Theoretically, the impaired ability of asplenic individuals to respond to intravenous antigens 6 (reflected in this patient's poor response to bacteriophage immunization) could lead to prolonged viremia and could explain the dissemination of varicella. Although very young infants usually do not mount significant antibody responses to polysaccharide antigens, the vast majority of infants show significant increases in titer to many such antigens by 24 to 35 months, with some pneumococcal serotypes (including type 3) being highly immunogenic at as young as 6 months of age. 7'8 Thus our patient's failure to make anti-pneumococcal and anti-H. influenzae antibodies at age 35 months is distinctly abnormal. Our patient did respond, as do even normal young infants, to the carbohydrate blood group antigens, as measured by isohemaggl~tinins. Whether the fact that isohemagglutinins are primarily IgM, whereas antibodies to bacterial polysaccharide antigens are primarily IgG2, accounts for this difference is unknown, but a differential response has been described in other patients with similar impaired ability to respond to bacterial polysaccharide antigens, z It has been postulated that splenic dysfunction could result in impaired antibody response to polysaccharide antigens; this ability in mice is unique to a lymphocyte subset (Lyb5 § that resides primarily in the spleen. 9 Other studies demonstrating impaired antibody responses of Splenectomized mice to pneumococcal polysaccharide type 3 immunization given 7 to 10 days after splenectomy have implicated a loss of amplifier T cells in the impairment. L~ Moreover, a decreased number of plaque-forming cells is
Volume 114 Number 1
induced by pokeweed mitogen in splenectomized human patients in comparison with control subjects. II The significance of these factors in humans is unclear; many studies show a nearly normal ability to make antibodies against bacterial polysaccharide antigens in patients who have had a splenect0my or who have acquired functional asplenia because of hemoglobinopathy.6,~2 However, the ability to mount an antibody response may depend on the timing of the initial exposure to an antigen relative to the loss of splenic function.13 A lack of splenic function starting very early in life (possibly during the neonatal period or even earlier) may thus prevent maturation of the ability to respond to certain types of antigens, on the basis of either abnormal T cell regulation or a lack of the necessary lymphocyte subset. In summary, our patient, who had recurrent infections (caused by encapsulated organisms) and disseminated varicella, proved to have very abnormal specific antibody responses despite normal total immunoglobulin and subclass values. He also had unexplained functional asplenia, presumably since at least early infancy, which could be related to his humoral immunodeficiency. Because of the complexity of the immunodeficiency associated with the asplenic state in addition to antibody deficiency, this patient was maintained prophylactically on long-term antibiotic therapy. In patients with an isolated deficiency of anti-polysaccharide antibodies, there may be a greater role for immunoglobulin replacement therapy, although the severity of their illnesses and the possibility of suppressing their previously normal antibody responses to protein antigens would need to be taken into account.
Clinical and laboratory observations
91
2. Ambrosino DM, Siber GR, Chilmonczyk BA, et al. An immunodeficiency characterized by impaired antibody response to polysaccharides. N Engl J Med 1987;316:790-7. 3. Sindel LJ, Buckley RH, Schiff SE, et al. Severe combined immunodeficiencywith natural killer predominance. J Allergy Clin Immunol 1984;73:829-36. 4. Spencer RP. Spleen imaging. In: Alavari A, Arger PH, eds. Multiple imaging procedures; vol 3: Abdomen. New York: Grune & Stratton, 1980:73-85. 5. Warrier I, Ravindranath Y. Splenic infarction and total functional asplenia in disseminated varicella. J PEDIATR 1986;109:305-7. 6. Sullivan JL, Ochs HD, Schiffman G, et al. Immune response after splenectomy. Lancet 1978;1:178-81. 7. Makela PH, Peltola H, Kayhty H, et al. Polysaccharide vaccines of group A Neisseria meningitidis and Haemophilus influenzae type b: a field trial in Finland. J Infect Dis 1977;136:$43-$50. 8. Douglas RM, Paton JC, Duncan SJ, Hansman DJ. Antibody response to pneumococcal vaccination in children younger than five years of age. J Infect Dis 1983;148:131-7. 9. Timens W, Poppema S. Impaired immune response to polysaccharides [Letter]. N Engl J Med 1987;317:837. 10. Amsbaugh DF, Prescott B, Baker PJ. Effect of splenectomy on the expression of regulatory T cell activity. J Imlnunol 1978;121:1483-5. 11. Nielsen JL, Tauris P, Johnsen HE, Ellegard J. The cellular immune response after splenectomy in humans: impaired immunoglobulin synthesis in vitro. Scand J Haematol 1983;31:85-95. 12. Giebink GS, Foker JE, Kim Y, Schiffman G. Serum antibody and opsonic responses to vaccination with pneumococcal capsular polysaccharide in normal and splenectomized children. J Infect Dis 1980;141:404-12. 13. Amlot PL, Hayes AE. Impaired human antibody response to the thymus independent antigen DNP-Ficoll after splenectomy: Implications for post-splenectomy infections. Lancet 1985;1:1008-11.
REFERENCES
1. Nahm MH, Blaese RM, Crain MJ, Briles DE. Patients with Wiskott-Aldrich syndrome have normal IgG2 levels. J Immunol 1986;137:3484-7.
Bacterial contamination rates in voided urine collections in girls J a c o b A. Lohr, MD, Leigh G. Donowitz, MD, a n d Sharon MI D u d l e y From the Department of Pediatrics, Children's Medical Center of the University of Vi(ginia, Charlottesville
Standard practice for collecting a voided urine specimen from girls for bacterial culture includes cleansing of the urethral meatus and midstream collection.1,2 Our study
was performed to determine the effect of meatal cleansing and midstream collection on bacterial contamination rates in voided specimens collected from girls. METHODS
Submitted for publication June 7, 1988; accepted July 28, 1988. Reprint requests: Jacob A. Lohr, MD, Department of Pediatrics, Box 386, Children's Medical Center of the University of Virginia, Charlottesville, VA 22908.
One hundred two healthy, prepubescent girls, aged 2 to 10 years, were studied. All the girls were toilet trained, had no history of renal disease, including urinary tract infec-
Impaired antibody response to polysaccharides in association with functional asplenia A l a n D. G a i n e s , MD, a n d R e b e c c a
H. B u c k l e y , MD
From the Division of Allergy and immunology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
Impaired antibody responses to polysaccharide antigens despite normal or nearly normal levels of immunoglobulins (including IgG subclasses) have been noted uniformly in patients with Wiskott-Aldrich syndrome and recently in patients without that condition, some of whom also had normal antibody responses to certain protein antigens. 1,2 We present here a boy with similar immunologic findings in whom we found an associated unexplained functional asplenia. CASE REPORT A 21A-year-01dblack male child was referred to Duke University Medical Center for immunologic evaluation because of a history of recurrent serious infections. He was the 3180 gm product of a pregnancy complicated only by some maternal weight loss in the third trimester. His neonatal course was notable for the congenital absence or malformation of several fingers on both hands, consistent with the amniotic band syndrome. The patient was first hospitalized at 2 months of age for pneumonia, followed by hospitalizations at 4 months for Haemophilus influenzae meningitis and at 5, 6, and 9 months for episodes of pneumococcal sepsis. Immunoglobulin and isohemagglutinin levels were reportedly normal, and empiric prophylactic amoxicillin therapy was begun. The patient then did fairly well until 29 months of age, when he developed severe disseminated varicella with lung and liver involvement,as well as disseminated intravascular coagulation. He eventually recovered after intravenous acyclovir therapy. METHODS ImmunoglobulinsG, A, and M were measured by radial immunodiffusion, and specific antibodies to diphtheria and tetanus were measured by tanned cell hemagglutination in our laboratory2 Analysis of lymphocyte proliferation in
Supported in part by a grant from the General Clinical Research Centers, Division of Research Resources, National Institutes of Health (MO 1-RR30), and from National Institute of Allergy and Infectious Diseases grant AI 18613. Submitted for publication May 24, 1988; accepted July 26, 1988. Reprint requests: Rebecca H. Buckley, MD, Chief, Division of Pediatric Allergy and Immunology, Box 2898, Duke University Medical Center, Durham, NC 27710.
Table I. Studies of cellular immunity 1/29/87 Patient
Normal
Lymphocyte phenotype (% cells positive) Surface IgM+ 33.6 11.5 CD3+ 31.1 68.4 CD4+ 11.9 38.6 CD8+ 21.1 34.2 CD4/CD8 ratio 0.56 1.13 Proliferative response (cpm • 10-3.) to: PHA 47 109 ConA 30 119 PWM 23 78 Candida 18 36 Tetanus 10 I0
3/17/87 Patient
Normal
36.3 14.1 22.3 0.63
69.0 43.4 20.8 2.09
115 117 69 79 69
115 167 90 67 48
PHA, Phytohemagglutinin;ConA, concanavalinA; PWM, pokeweed mitogen. *3H-Thymidineincorporationinto DNA. response to phytohemagglutinin, concanavalin A, pokeweed mitogen, and tetanus, Candida, and varicella antigens was performed on Ficoll-Hypaque purified cells in our laboratory by methods previously described, as was lymphocyte subset analysis with monoclonal antibodies2 The IgG subclasses were measured by immunoradiometric assay, and antibodies to 11. influenzae capsular polysaccharide and tO pneumococcal serotypes 3, 7, 9, and 14 were measured by enzyme immunoassay (Specialty Laboratories, Los Angeles, Calif.). Antibodies to bacteriophage cI,X-174 were measured by phage neutralization by Dr. Hans Ochs, of the University of Washington, Seattle. RESULTS Lymphocyte proliferation to mitogens and antigens was initially low immediately after acute varicella, but normal responsiveness returned within 2 months of clinical recovery (Table I). However, analysis of lymphocyte subsets consistently showed a decreased percentage of CD4positive cells with a reversed CD4/CD8 ratio and increased percentage of IgM-bearing B cells (Table I). Assays for antibodies to human immunodeficiency virus 89
90
Clinical and laboratory observations
The Journal of Pediatrics January 1989
T a b l e II. Antibody responses to immunization
Antigen
Before
After
Diphtheria Tetanus H. influenzae type b Pneumococcal Type 3 Type 7 Type 9 Type 14
1 : 2187 1:2187 33
1 : 19683 1 : 19683 55
75 77 63 I90
75 84 56 220
Units
Mean for age"
HA titer HA titer ng/ml
>1 : 10000 >1 : 10000 >10-fold increase
ng Ab N/ml ng Ab N/ml rig Ab N/ml ng Ab N/ml
>6-fold increase >5-foid increase >6-fold increase Minimal increase
HA, Hemagglutinin;Ab, antibody;N, nitrogen. *Hemagglutinintiters of >1 : 10,000are normalresponsesin our laboratoryafter diphtheriaand tetanusboosters.Meanresponsesfor 24 to 35-month-oldchildren after pneumoCoccalvaccineare from SullivanJL, Ochs HD, SchiffmanG, et al. (Lancet 1978;1:178-81)and after H. influenzaetype b vaccinefrom Warrier I and RavindranathY (J PED~ATR1986;109:305-7) with 68 of 68 childrenachievinglevels>150 ng/mL
were negative on two separate occasions in both the patient and his mother, and the patient's serum was also negative for the human immunodeficiency virus antigen p24. The CHs0 value was' 39 U / m l (normal >30). Results of immunoglobulin measurements On several occasions ranged as follows: IgG 580 to 770 mg/dl (normal range 503 to 1279), IgA 48 to 140 mg/dl (normal range 35 to 222), IgM 21 to 36 m g / d l (normal range 32 to 131), and IgE 120 tO 210 U / m l (normal range 5 to 621). IgG subclasses showed IgG1 480 mg/dl (normal range 300 to 850), IgG2 59 mg/dl (normal range 50 to 300), IgG3 27 mg/dl (normal range 12 to 70), and IgG4 12 mg/dl (normal range 3 to 80). Despite normal isohemagglutinin titers for age of 1 : 8 for both anti-A and anti-B, and despite normal antibody responses to diphtheria and tetanus boosters, there was no significant response to immunization at 35 months of age with either H. influenzae capsular p01ysaccharide vaccine or polyvalent pneumococcal vaccine (Table II). Primary response to intravenously administered bacteriophage ~X-174 was also relatively low, with a peak of 0.04 kV (normal >8). Because of the clinical history and some possible Howell-Jolly bodies on one blood smear, splenic function was investigated. An ultrasound study revealed an anatomically normal spleen. Four months later, the blood smear was negative for Howell-Jolly bodies. However, a technetium 99 sulfur colloid liver-spleen scan showed no splenic uptake, indicating functional asplenia. Hemoglobin electrophoresis revealed normal hemoglobin A2 levels with slightly elevated fetal hemoglobin levels at 1.4% (normal <1%). This was shown on a-globin gene mapping to be due to a single gene deletion a-thalassemia trait. DISCUSSION The cause and duration of this child's functional asplenia are unclear. Most cases in children have been associated with sickle hemoglobinopathies, but functional asplenia has also been associated with vascular insults, anoxia, malignancy, and chemotherapy plus irradiation?
One case has been reported of functional asplenia in a leukemic Child after disseminated varicella; however, there was no documentation by scan of a functional spleen before the illness, and the diagnosis was not based on a scan specific for splenic dysfunction? ,s In our patient, the history is strongly suggestive of splenic dysfunction even in early infancy, before anti-polysaccharide antibodies play a significant protective role. Theoretically, the impaired ability of asplenic individuals to respond to intravenous antigens 6 (reflected in this patient's poor response to bacteriophage immunization) could lead to prolonged viremia and could explain the dissemination of varicella. Although very young infants usually do not mount significant antibody responses to polysaccharide antigens, the vast majority of infants show significant increases in titer to many such antigens by 24 to 35 months, with some pneumococcal serotypes (including type 3) being highly immunogenic at as young as 6 months of age. 7'8 Thus our patient's failure to make anti-pneumococcal and anti-H. influenzae antibodies at age 35 months is distinctly abnormal. Our patient did respond, as do even normal young infants, to the carbohydrate blood group antigens, as measured by isohemaggl~tinins. Whether the fact that isohemagglutinins are primarily IgM, whereas antibodies to bacterial polysaccharide antigens are primarily IgG2, accounts for this difference is unknown, but a differential response has been described in other patients with similar impaired ability to respond to bacterial polysaccharide antigens, z It has been postulated that splenic dysfunction could result in impaired antibody response to polysaccharide antigens; this ability in mice is unique to a lymphocyte subset (Lyb5 § that resides primarily in the spleen. 9 Other studies demonstrating impaired antibody responses of Splenectomized mice to pneumococcal polysaccharide type 3 immunization given 7 to 10 days after splenectomy have implicated a loss of amplifier T cells in the impairment. L~ Moreover, a decreased number of plaque-forming cells is
Volume 114 Number 1
induced by pokeweed mitogen in splenectomized human patients in comparison with control subjects. II The significance of these factors in humans is unclear; many studies show a nearly normal ability to make antibodies against bacterial polysaccharide antigens in patients who have had a splenect0my or who have acquired functional asplenia because of hemoglobinopathy.6,~2 However, the ability to mount an antibody response may depend on the timing of the initial exposure to an antigen relative to the loss of splenic function.13 A lack of splenic function starting very early in life (possibly during the neonatal period or even earlier) may thus prevent maturation of the ability to respond to certain types of antigens, on the basis of either abnormal T cell regulation or a lack of the necessary lymphocyte subset. In summary, our patient, who had recurrent infections (caused by encapsulated organisms) and disseminated varicella, proved to have very abnormal specific antibody responses despite normal total immunoglobulin and subclass values. He also had unexplained functional asplenia, presumably since at least early infancy, which could be related to his humoral immunodeficiency. Because of the complexity of the immunodeficiency associated with the asplenic state in addition to antibody deficiency, this patient was maintained prophylactically on long-term antibiotic therapy. In patients with an isolated deficiency of anti-polysaccharide antibodies, there may be a greater role for immunoglobulin replacement therapy, although the severity of their illnesses and the possibility of suppressing their previously normal antibody responses to protein antigens would need to be taken into account.
Clinical and laboratory observations
91
2. Ambrosino DM, Siber GR, Chilmonczyk BA, et al. An immunodeficiency characterized by impaired antibody response to polysaccharides. N Engl J Med 1987;316:790-7. 3. Sindel LJ, Buckley RH, Schiff SE, et al. Severe combined immunodeficiencywith natural killer predominance. J Allergy Clin Immunol 1984;73:829-36. 4. Spencer RP. Spleen imaging. In: Alavari A, Arger PH, eds. Multiple imaging procedures; vol 3: Abdomen. New York: Grune & Stratton, 1980:73-85. 5. Warrier I, Ravindranath Y. Splenic infarction and total functional asplenia in disseminated varicella. J PEDIATR 1986;109:305-7. 6. Sullivan JL, Ochs HD, Schiffman G, et al. Immune response after splenectomy. Lancet 1978;1:178-81. 7. Makela PH, Peltola H, Kayhty H, et al. Polysaccharide vaccines of group A Neisseria meningitidis and Haemophilus influenzae type b: a field trial in Finland. J Infect Dis 1977;136:$43-$50. 8. Douglas RM, Paton JC, Duncan SJ, Hansman DJ. Antibody response to pneumococcal vaccination in children younger than five years of age. J Infect Dis 1983;148:131-7. 9. Timens W, Poppema S. Impaired immune response to polysaccharides [Letter]. N Engl J Med 1987;317:837. 10. Amsbaugh DF, Prescott B, Baker PJ. Effect of splenectomy on the expression of regulatory T cell activity. J Imlnunol 1978;121:1483-5. 11. Nielsen JL, Tauris P, Johnsen HE, Ellegard J. The cellular immune response after splenectomy in humans: impaired immunoglobulin synthesis in vitro. Scand J Haematol 1983;31:85-95. 12. Giebink GS, Foker JE, Kim Y, Schiffman G. Serum antibody and opsonic responses to vaccination with pneumococcal capsular polysaccharide in normal and splenectomized children. J Infect Dis 1980;141:404-12. 13. Amlot PL, Hayes AE. Impaired human antibody response to the thymus independent antigen DNP-Ficoll after splenectomy: Implications for post-splenectomy infections. Lancet 1985;1:1008-11.
REFERENCES
1. Nahm MH, Blaese RM, Crain MJ, Briles DE. Patients with Wiskott-Aldrich syndrome have normal IgG2 levels. J Immunol 1986;137:3484-7.
Bacterial contamination rates in voided urine collections in girls J a c o b A. Lohr, MD, Leigh G. Donowitz, MD, a n d Sharon MI D u d l e y From the Department of Pediatrics, Children's Medical Center of the University of Vi(ginia, Charlottesville
Standard practice for collecting a voided urine specimen from girls for bacterial culture includes cleansing of the urethral meatus and midstream collection.1,2 Our study
was performed to determine the effect of meatal cleansing and midstream collection on bacterial contamination rates in voided specimens collected from girls. METHODS
Submitted for publication June 7, 1988; accepted July 28, 1988. Reprint requests: Jacob A. Lohr, MD, Department of Pediatrics, Box 386, Children's Medical Center of the University of Virginia, Charlottesville, VA 22908.
One hundred two healthy, prepubescent girls, aged 2 to 10 years, were studied. All the girls were toilet trained, had no history of renal disease, including urinary tract infec-