Chorioretinitis with a combined defect in T and B lymphocytes and granulocytes

Chorioretinitis with a Combined Defect in T and B Lymphocytes and Granulocytes A New Syndrome Successfully Treated with Dialyzahle Leukocyte Extracts (Transfer Factor)

CATHERINE U. KYONG, M.D. GREGORY B. WILSON, Ph.D H HUGH FUDENBERG, M.D. JEAN M. GOUST, M.D., Ph.D. PETER RICHARDSON, M.D. JOHN ECKERD, M.D.* Charleston, South Carolina

From the Departments of Pediatrics, Basic and Clinical Immunology and Microbiology, and Ophthalmology, Medical University of South Carolina, Charleston, South Carolina. Publication no. 332. This research was supported in part by U.S. Public Health Service Grants HD-09938 and CA25746. Requests for reprints should be addressed to Dr. G. B. Wilson, Department of Basic and Clinical Immunology and Microbiology, Medical University of South Carolina, 171 Ashley Avenue, Charleston, South Carolina 29403. Manuscript accepted August 6,1979. * Present address: Greer Pediatric Clinic, 314 Memorial Drive, Greer. South Carolina 29651.

A patient with immune deficiency, recurrent pyogenic infections and active chorioretinitis is described; in addition to agammaglobulinemia, both quantitative and qualitative T&l deficiencies were documented. Furthermore, the patient’s granulocytes (polymorphonuclear leukocytes), although normal in their bactericidal capacity for Staphylococcus, responded poorly to both leukocyte migration inhibition factor and neutrophil immobilizing factor obtained from normal cells. The immunologic features of this patient appear to comprise a new syndrome. Remarkable diminution of the ocular lesions and increased visual acuity occuned within two months after the initiation of therapy with dialyzable leukocyte extracts (transfer factor). Concurrent testing of the patient’s cell-mediated immunity showed increased numbers of circulating T lymphocytes and improved T-cell function following dialyzable leukocyte extract (IKE) therapy. The dramatic clinical results indicate that similar therapy may prove to be beneficial in other patients with chorioretinitis and T-cell deficiency. The organisms responsible for infectious chorioretinitis in immunologically compromised hosts are opportunistic pathogens. Suppression of immunity, especially cell-mediated immunity, appears to be linked closely to cytomegalovirus (CMV), histoplasmosis and Candida albicans chorioretinitis [l]. The prognosis of infectious chorioretinitis in immunologically compromised hosts is extremely poor, and therapy with corticosteroids is dangerous. In such patients the role of therapy with DLE has not been adequately evaluated. In this report we describe the clinical and immunologic features of one patient with infectious chorioretinitis and the response of this patient to DLE therapy. In addition, we describe a granulocyte defect in the patient: to our knowledge, this is the first report of such a defect in a case of combined immunodeficiency. CASE REPORT The patient, a Caucasian girl, was first seen at the Medical University of South Carolina Hospital in ]une 1975, at 11 years of age, for evaluation of recurrent infections of two years’ duration. She had a normal birth history, with normal growth and development. She had no unusual illness until the age of nine years, when she began to have recurrent otitis media, pneumonia, skin infections and oral thrush. Our initial laboratory results included a hemoglobin level of 11.3

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Figure 1. A, right eye three mdnths before DLE therapy and 6, two days before DLE therapy, showing active lesions. C, left eye two days before DLE therapy remains quiescent. D, right eye two months after DLE therapy, showing remission of the active lesions. E, right eye ten months after DLE therapy remains inactive. F, left eye ten months after DLE therapy remains inactive.

g/100 ml. a hematocrit value of 32.8 per cent, a normal platelet count and a white blood cell count of 3,9OO/mm”. with 51 per cent polymorphonuclear cells. 9 per cent band forms, 4 per cent monocytcs and 30 per cent lymphocytes. The serum immunoglobulin levels were immunoglobulin G (IgG) 110 mg/lOO ml. immunoglobulin A [IgAl 0 mg/lOO ml and immunoglobulin M (IBM) 18 mg/lOO ml. Secretory IgA was also undetectable in parotid saliva collected with a Curby capsule. An inguinal lymph node biopsy specimen showed complete absence of germinal centers and plasma cells. In February 1976. when the patient was 12 years old, therapy with biweekly Cohn fraction 11 (therapeutic gammaglobulin) injections (0.3 ml/kg] wasstarted. However, following this therapy the patient continued to have documented recurrent pyogenic infections (pneumonia, otitis media. dental abscesses]. In January 1977. at age 13 vcars. her local physician noted progressively decreasing iision of the right eye. A diagnosis of bilateral chorioretinitis active in the right cyc was made. In February 1978, at age 14, she was reevaluated at the Medical University Hospital. General assessment at that time showed a well developed and well nourished girl with no abnormal physical findings except for the fundi. Areas of exudate, hemorrhage and inflammation were seen in the right retina. There was a hyperemic disk in the left eye (Figure 1 A, B and C). Visual acuity was 20/100 in the right eye and 20/20 in the left. Laboratory results in February 1978 included a hemoglobin level of 13.7 g/100 ml, a hcmatocrit value of 39 per cent; a white blood cell count of 4.000/mm3. with 61 per cent polymorphonuclear leukocytes, 3 per cent monocytes and 20 per cent lymphocytes; blood group 0. Rh positive. with no detectable anti-A or anti-B isohemagglutinins. and antistreptolysin 0 (ASO) titer 12 Todd units: no detectable antibodies to IgA or IgC; negative skin tests to purified protein derivative. Candida.

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strcptokinase-streptodornase (SKSD). Trichophyton, mumps and histoplasmin; low numbers of both active and total T cells (as measured by rosette formation]: an extremely low percentage of B lymphocytes in peripheral blood (2 per cent): low in vitro DNA synthesis response to phytohemagglutinin (PHA). a normal response to concanavalin A (ConA) and no response to pokcweed mitogen: and intact polymorphonuclear cell staphylococcal bactericidal capacity but poor polymorphonuclear cell response tp leukocyte migration inhibitory factor and neutrophil immobilizing factor obtained from normal cells. Repeated tear and urine cultures for fungus and virus were negativk. In the end of February 1978. the patient was initially given 2 U of DLE in divided doses prepared from leukocytes obtained from her father. followed by 1 U every two weeks. Because of the poor clinical response to Cohn fraction II therapy, that treatment was replaced by a monthly infusion of 1 U of fresh plasma donated by her parents. The patient’s ocular lesions subsided [Figure 1 D, E and F) and visual acuity improved remarkably two months after initiation of DLE therapy. Concurrent cellular immunity studies showed conversion of skin tests to SKSD and mumps, increased active and total T cells, and a low but statistically significant response to pokeweed mitogen. In addition to the DLE therapy, Cohn fraction II injections were replaced by monthly infusions of plasma donated by her parents. During the first four months of plasma therapy. the patient showed reasonably high levels of serum IgG (1200 mg/lOO ml]. Clinically, she had substantial weight gain and fewer pyogenic infections. Subsequently, recurrent pneumonia of the left lung again developed with roentgenologic evidence of bronchiectasis. Her serum IgG levels declined, despite the fact that the same volume and schedule of plasma infusions obtained from the same donors were given. On fol-

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low-up, her ocular lesions were inactive and remained through the last examination (January 1979).

IN T AND

so

METHODS Delayed cutaneous hypersensitivity responses to C. albicans (1:100 dilution, Hollister-Stier Laboratories), intermediate strength purified protein derivative, SKSD (40110 U/ml., Lederlc Laboratories], mumps (Lilly). and Trichophyton (1:30, Hollistcr-Stier Laboratories] were determined by intradermal injection of 0.1 ml of the test solutions. The cutaneous responses were assessed at 24.48 and 72 hours. Induration of 5 mm or more was scored as positive. Serum immunoglobulins were determined by radial diffusion using commercial plates. The percentage of B lymphocytes in peripheral blood was determined by immunofluorescence, using a fluoresceinated sheep Fab’z anti-human immunoglobulin serum 121. Active and total T cells were measur.ed by the sheep red cell rosette techniques described previously [3]. Peripheral blood lymphocytes from the patient were obtamed by Ficoll-Hypaque gradient centrifugation. PHA-, ConA- and pokeweed mitogen-induced lymphocyte DNA synthesis responses were expressed as the stimulation index [counts per minute in stimulated cultures divided by counts per minute in unstimulated cultures]. The bactericidal capacity of the polymorphonuclear leukoeytes was measured by the method of Hirsch and Strauss [4]. using Staph. aureus (strain 502 A). DLE was prepared by a modification of the method of Lawrence and Al-Askari (51. The leukocytes were donated by the patient’s father, who had positive skin tests to SKSD, Candida and mumps: normal percentages of active and total T cells: normal lymphocyte DNA synthesis in response to PHA, ConA and pokeweed mitogcn; and normal leukocyte migration inhibitory factor production. One unit of DLE wasdefined as the amount of dialyzable material (molecular weight (MW) <20,000) obtained from 5 X lOa leukocytes. Leukocyte Migration Inhibition. The direct (or one-step) and indirect [or two-step) agarose leukocyte migration inhibition techniques were used as described previously 16.71. In the direct leukocyte migration inhibition assay, the effects of Candida or PHA (Burroughs-Wellcome), referred to collectively as test substances, were tested briefly as follows: peripheral blood lymphocytes (2.0 x 108 cells/ml) were incubated with medium only or test substance at 37“C in a humidifier incubator gassed with 5 per cent carbon dioxide in air, for 90 minutes when Candida was employed and for 60 minutes when PHA was used. PHA was used at either 5 pg/ml or 1 @g/ml, and Candida (Hollister-Stier Laboratories, Spokane, Washington) at a dilution of 1 to 10 to 1 to 40. The optimal concentrations of Candida and PHA were determined previously. Stock solutions of Candida were dialyzed for 18 hours against 100 volumes of serum-free TCl99 medium using Spectrapor-3 (MW cut-off 3,500. Spectrum Medical Industries, Los Angeles, California) dialysis tubing to remove preservatives. All test substances were mixed with complete TCl99 medium (containing 10 per cent heat-inactivated horse serum] prior to use. Stock solutions in serum-free TCl99 were kept at -70°C until used. The incubation times, migration times and methods used to record the migration were as described previously [6,7]. For the indirect or two-step agarose leukocyte migration

B LYMPHOCYTES

AND GRANULOCYTES-KYONG

ET AL.

inhibition technique using PHA, enriched mononuclear leukocyte and polymorphonuclear cell populations (>98 per cent mononuclear leukocytes or polymorphonuclear leukocytes) were obtained by separation from peripheral blood lymphocytes using Ficoll-Isopaque gradient centrifugation as described by Boyurn [8]. The polymorphonuclear leukocytes were used at a concentration of 1.43 X lo* cells/ml and incubated with cell-free supernatants.obtained from mononuclear leukocytes stimulated with PHA for 90 minutes at 37’C prior to spotting in agarose plates. Mononuclear leukocytes were cultured at 2 x 106 cells/ml in RPM1 1640 medium containing 10 per cent AB serum and antibiotics plus test substance, with or without 2 rg/ml PHA, for 72 hours prior to harvesting. All cultures were set up as three 1 ml replicates. The medium was filtered through a 0.45 pm filter (Millipore Corp., Bedford, Massachusetts) prior to incubation with polymorphonuclear leukocytes. To investigate whether the patient’s mononuclear leukocytes or polymorphonuclear leukocytes or both were responsible for the anergy observed in vivo and in vitro, the following experiment was performed. Enriched populations of mononuclear leukocytes and polymorphonuclear leukocytes were obtained from the patient and her mother as described. The cell populations were then mixed asshown in Table I, in each case at an optimal ratio of mononuclear leukocytes to polymorphonuclear leukocytes of 1:2. The results were compared with the effects of PHA on unseparated peripheral blood lymphocytes from the patient and from her mother and on reconstituted mononuclear leukocytes and polymorphonuclear leukocytes from the same donor. In addition, migration inhibition values were determined for polymorphonuclear leukocytes from normal donors incubated with cell-free supernatants of PHA-stimulated mononuclear leukocytes from cither the patient or her mother. The results are expressed as migration inhibition, calculated as a migration index (MI]. For determining the reactivity of donor peripheral blood lymphocytes to Candida or PHA in the direct assay: MI = mean migration area in presence

of antigen or mitogen only

mean migration area in medium only For the indirect assay, the migration index value was calculated by comparison with the migration of polymorphonuclear leukocytes cultured in cell-free supernatants obtained from mononuclear leukocytes cultured in the presence of medium only and then supplemented with PHA. at the end of the culture period, to their migration when incubated with medium obtained from mononuclear leukocytes stimulated with PHA for 72 hours. Positive migration inhibition was indicated by migration index values> <0.80 for PHA and <0.90 for Candida. Production of Neutrophil Immobilizing Factor (NIF]. Three procedures shown previously to generate substances from human polymorphonuclear leukocytes that function as inhibitors of both chemotaxis and random migration of polymorphonuclear leukocytes [9,10] were used. In keeping with the nomenclature proposed by Goetzl and Austen [ll], the neutrophil immobilizing factor released by incubation of polymorphonuclear leukocytes at acidic pH is referred to as

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TABLE I

ET /\I..

Responsiveness of Patlent’s Lymphocytes to Phytohemagglutlnln (PHA) In Vitro as Shown by Direct Leukocyte Mlgratlon lnhlbltlon (LMI) Assay With Unseparated or Reconstituted Cell Populatlons and by IndIrect Leukocyte Mtgratlon Inhibition Assay M&ration h&xi

Cell Populatkd Unseparated Patient’s PBL Mother’s PBl Reconstituted Mother’s PMN + mother’s MNL Patient’s PMN ipatient’s MNL Mother’s PMN + Patient’s MNl Patient’s PMN + mother’s MNL

Dhct LMI Assay 5 Ccs/mlPHA 1j@hlPHA

0.94 0.56

0.97 0.75

0.69

0.93

0.97

0.95

0.70

0.98

0.82

1.03

9upematantundilutsd

0.74 0.68

lndlfect LMl Assay: 8upsrnatael DlMed 1:2

0.89 0.83

supemetanl Diluted I:4

0.99 0.93

NOTE: PBL = peripheral blood lympho+s; PMN = polymorphonuclear leukocytes; MNL = mononuclear leukocytes. ulseparated cell populations contatned 2 X 108 P@Uml. Reconstttuted populations contained equivalent nun&s of PBL in the combinations indicated. at an MNL to PMN ratio of 1:2. t See “Materials and Methods.” Values are means of three replicate experiments. Migration index >0.80 indicates no response to PHA. t Two-step LMl assay. The patient’s cw mother’s cells (2 X 106 Wml) were fttst stimulated with PHA (2 pg/ml). The cell-free culture medium (supernatant) was then added to indicator cells (1.43 X lo* PMN/ml) from a normal donor at the dilutions indicated. l

A-NIF

and the neutrophil immobilizing factor released by polymorphonuclear leukocytes during phagocytosis as Ph-NIF. In addition, two preparati&s of dialyzable products (MW <20,ooO) obtained from extracts of human white blood cells were used [lo]. These dialyzable extracts of human blood cells have been shown previously to contain two types of neutrophil immobilizing factors [lo) which differ only in their molecular weight; they appear to be identical to the two neutrophil immobilizing factors produced by phagocytosing polymorphonuclear leukocytes as described by Goetzl and Austen [ll]. Purified polymorphonuclear leukocytes were used to prepare all neutrophil immobilizing factor-containing material tested, except for DLE, which were prepared from unseparated peripheral blood lymphocytes. Erythrocytes were routinely removed from all cell preparations by hypoosmotic lysis. The methods of Goetzl and Austen [ll] were used as described previously [lo], taking advantage of previous assessments of the optimal conditions for maximal production of each type of neutrophil immobilizing factor while maintaining a sufficient percentage of viable polymorphonuclear leukocytes. Stock solutions of each preparation were made by dialyzing lx concentrated material [from 10’ cells/ml) against pyrogen-free distilled water to equilibrium using Spectrapor-3 dialysis tubing (MW cut-off 3,500. Spectrum Medical Industries, Inc., Los Angeles, California] and then lyophilizing the material retained in the bag. We previously showed that this procedure removes transfer factor and other low-MW components contained in cell extracts [12] while retaining the low-molecular weight neutrophil immobilizing factor [lo]. Each preparation was reconstituted in serum-free TC199 medium so that the product from 2 X 108 cells was contained in 1.0 ml. Appropriate medium-only controls were prepared following identical procedures. Viability of polymorphonuclear leukocytes was >80 per cent as judged by Trypan blue

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exclusion after completion of the protocols for preparing either A-NIF or Ph-NIF.

Agarose Leukocyte Migration Inhibition Assay for Effect of Neutmphil Immobilizing Factor on Random Migration. The effects of the various neutrophil immobilizing factor (or neutrophil immobilizing factor-containing) preparations on the random migration of purified polymorphonuclear leukocytes were determined using the direct agarose leukocyte migration inhibition assay. Purified polymorphonuclear leukocytes were used at 1.43 X 108 cells/ml. Polymorphonuclear leukocytes were mixed with test substances for 90 minutes at 3?C in a humidified tissue culture incubator gassed with 5 per cent carbon dioxide in air prior to placing triplicate 7 ~1 aliquots into wells prepunched in the agarose. All preparations were tested on at least three separate occasions using polymorphonuclear leukocytes from several donors. The polymorphonuclear leukocytes were allowed to migrate for 18 hours. The results were expressed as: MI = mean migration area in medium plus neutrophil

immobilizing

factor

mean migration area in medium alone In cases in which a special medium was used or in which it was necessary to use a control for the effects of a particular procedure, the denominator would be the control. Significant inhibition of migration was determined by comparison of the means and standard deviations for control and treated samples, using a one-way analysis of variance. RESULTS R-cell Immunity. Serum IgG and IgM levels were depressed before and after DLE therapy (Table II). The

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ET AL.

Patient’s Serum lmmunoglobulinLevels and Lymphocyte Counts

Measurement

Before DLE'

Alter ME+

NormalRange

143 3.6 3.2

760-l ,600 36-228 66-444

lmmunoglobulins (mg/lOO ml) 179 lgG 10 lgM 5 lgA Lymphocytes (absolute no./mm3) 4,000 Total white cells 800 Lymphocytes 637(69)+ Total T cells 254(27.5) Active T cells

3,600 1,008 836(83) 493(49)

7,800 f 3,000 >1,500 (68 f 8) (25 f 6)

Note: DLE = dialyzable leukocyte extract (transfer factor). Three weeks after Cohn fraction II injection. + Four months after DLE, three days after plasma infusion. + Figures in parentheses are per cents. l

percentage of B lymphocytes in peripheral blood was extremely low. Serum and salivary IgA were nndetectable. T-cell Immunity Before DLE Therapy. Delayed skin reactivity to C. albicans, purified protein derivative, SKSD, mumps and Trichophyton was negative. The percentages of active and total T cells in peripheral blood were in the normal range, but because of lymphopenia the absolute numbers were low. Lymphocytes cultured with mitogens showed no DNA synthesis in response to pokeweed mitogen, a low response to PHA and a normal response to ConA. No polymorphonuclear leukocyte migration inhibition was observed by the TABLE III

agarose leukocyte migration inhbition assay in the presence of C. albicans or PHA (Table III]. T-cell Immunity After DLE Therapy. After DLE therapy, previously negative skin reactivity to mumps and SKSD antigens changed to positive. The Candida skin test remained nonreactive. The absolute numbers of both active and total T cells as measured by rosette formation increased significantly. A low but significant lymphocyte DNA synthesis response to pokeweed mitogen was observed. The responses to PHA and ConA also increased. The results of the agarose leukocyte migration inhibition assay in the presence of Candida or PHA showed no migration inhibition of the patient’s

Patient’s Cell-Mediated Immune Status

Meawemenl

Before ME’

Skln tests PPD Negative SKSD Negative Mumps Negative Trichophyton Negative Candida Negative Lymphocyte stlmulatlon (Sl)f PHA 75.6 ConA 53.2 PWM 0 Leukocyte mlgratlon lnhlbltlon (Ml)* Candide 1:lO 0.94 1:20 1.04 1:40 1.03 PHA 0.2 pg/ml 1.15 1.O pug/ml 1.02 5.0 I.cg/ml 0.94

After ME*

Normalraltgs

Negative Positive Positive Negative Negative 192.6 156 47.9

0.91 0.96 0.99 Not tested 0.97 0.94

150-500 50-100 50-150

0.59-0.786

0.89-1.055 0.70-0.815 0.48-0.75s

NOTE: DLE= dialyzable leukocyte extract; PPD = purified protein derivative; SKSD = streptokinase-streptodornase: PHA = phytohemagglutinin; Con A = concanavalin A; PWM = pokeweed mitogen. As in Table II. + Stimulation index (see “Materials and Methods”). + Migration index (see “Materials and Methods”). 5 Results for 20 normal controls. l

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TABLE IV

ET AL.

Effect of Neutrophll immobilizing Factor on Random Migration of Patient’s Polymorphonuclear Leukocytes

Test Substance* Dialyzable PMN extract High-MW NIF from human DLE Ph-NIF A-NIF

Migration Index7 30 lLt*

Subiscis

No.

40 lcli

Controls Patient Controls Patient Controls Patient Controls Patient

5

0.77 f 0.06 0.81 0.59 f 0.05 0.82 0.48 f 0.05 0.62 NT NT

40. 5 5

NT NT 0.64 f 0.02 0.97 0.62 f 0.05 0.80 0.59 f 0.06 0.83

0.89 0.92 0.70 0.95 0.79 0.95 0.75 0.99

20 ul* f 0.04 f 0.03 f 0.04 f 0.03

10 UP 0.95 f 0.02 0.95 NT NT 0.93 f 0.07 1.00 0.91 f 0.04 1.03

NOTE: NIF = neutrophil immobilizingf&tor; PMN = polymorphonuclear leukocytes; DLE = dialyzable leukocyte extract; NT = not tested. For each test substance, 1 ml contained the material derived from 2 X lOa polymorphonuclear leukocytes. Abbreviations as defined in “Materials and Methods.” + Mean values f standard error of the mean for controls. * Amount of test substance added. l

polymorphonuclear

leukocytes

(migration

index

>O.QO).

Polymorphonuclear Leukocyte Function (After DLE Therapy). The bactericidal capacity of .the patient’s polymorphonuclear leukocytes for Staph. aureus (strain 502 A) was normal, both before and after DLE therapy. However, when the patient’s polymorphonuclear leukocytes were incubated with leukocyte migration inhibitory factor-containing supernatants from her mother the migration was not significantly inhibited (migration index 0.82, Table I). The patient’s mononuclear leukocytes were found to be capable of making leukocyte migration inhibitory factor and inhibiting the migration of the mother’s polymorphonuclear leukocytes or polymorphonuclear leukocytes from an unrelated normal control donor (Table I). These da@ suggested that the poor response to PHA shown by direct leukocyte migration inhibition could be attributed, at least in part, to a defect in the ability of the patient’s polymorphonuclear leukocytes to respond to leukocyte migration inhibitory factor. When the response of the patient’s polymorphonuclear leukocytes to another mediator, namely neutrophil immobilizing factor, was compared with that of normal polymorphonuclear leukocytes (Table IV), the patient’s polymorphonuclear leukocytes were also found to be refractory to neutrophil immobilizing factor-induced inhibition. Thus, the patient’s polymorphonuclear leukocytes were consistently almost completely unresponsive to two distinct mediators. COMMENTS Immunologically compromised hosts, especially those with diminished cell-mediated immunity, are specific targets of opportunistic organisms, e.g., CMV, histoplasmosis, herfies simplex, toxoplasmosis and Candida species. A definitive diagnosis of chorioretinitis in otherwise normal patients is based on the isolation of infectious organisms, and a presumptive diagnosis is made on the basis of increased antibody titers; however, in

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patients with hypogammaglobulinemia the latter is extremely difficult, since no detectable antibodies are formed. Although there has been one report of the successful use of DLE therapy in renal transplant recipients with CMV retinitis whose immune responses were iatrogenically suppressed [l3], to our knowledge this is the first reported instance of its successful use for the treatment of chorioretinitis in any other condition. Such therapy is not without risk, since increased inflammation in the target organ after the use of DLE has been reported [13]. Thus, we elected to start the treatment of our patient with small divided doses of DLE, followed by gradual increments and accompanied by close observation of her ophthalmologic status. The remarkable diminution of the ocular lesions observed in our patient, together with conversion of skin test results to SKSD and mumps, increased in vitro response to pokeweed mitogen, and increased T cells, indicates the efficacy of the DLE therapy, suggesting that this may be a promising area for further clinical studies. In our patient, there was a decrease rather than an increase of serum IgG levels following DLE therapy, thus arguing against the suggestion made by other investigators that DLE increases immunoglobulin synthesis [14]. One possible cause of the decrease in IgG levels after DLE therapy is that the patient’s suppressor T cells may have outnumbered her helper T cells, and that DLE therapy stimulated the suppressor T-cell activity to inhibit IgG synthesis. Indeed, it has been reported previously that DLE may suppress IgM synthesis in vivo and in vitro, depending on the dosage used [15]. Other possible interpretations are rapid catabolism [which can result from persistent infection [IS]] and/or a possible dilution effect. Of particular interest is the documented polymorphonuclear leukocyte defect, since a defect in polymorphonuclear leukocyte function has not been described previously in any case of combined or common variable immunodeficiency, and since this

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type of granulocyte defect apparently has not been reported previously in any patient. Thus, either this parameter has not hitherto been examined in combined immunodeficiency or the present case represents a previously undescribed syndrome. Presumably, the combined polymorphonuclear leukocyte, T-cell and

B LYMPHOCYTES

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GRANULOCYTES-KYONG

ET AL.

B-cell defects in our patient contributed jointly to the increased susceptibility to pyogenic infections. ACKNOWLEDGMENT We thank Charles L. Smith for excellent editorial assistance.

REFERENCES O’Connor GR: Current concepts in ophthalmology. N Engl ] Med 1978; 299: 130. 2. Fu SM. Hoffman T. Kunkel HG: IgG on lymphocyte surfaces: technical problems and the significance of a third population. J Immunol1975; 114: 1210. 3. Wybran J. Carr MC, Fudenberg HH: The human rosette forming cell as a marker of a population of thymus-derived cells. J Clin Invest 1972; 51: 2537. 4. Hirsch IG. Strauss 8: Studies on heat labile oosonin in rabbit serum. J Immunol1964: 92: 145. 5. Lawrence HS, AI-Askari S: The oreoaration and ourification . . of transfer factor. In: Bloom BR, Glade PR. eds. In vitro methods of group treatment. New York: Academic Press, 1971: 531. 6. Wilson GB, Fudenberg HH. Bahm VJ: Distinct components in dialyzable leukocyte extracts have specific and nonspecific effects on cellular immunity as shown by leukocyte migration inhibition. Trans Assoc Am Physicians 1978: 91:

identification of an antigen-independent leukocyte migration inhibitory activity in human dialyzable leukocyte extracts as neutrophil immobilizing factor. In: Khan A, Kirkpatrick CH. Hill NO, eds. Immune regulators in transfer factor. New York: Academic Press, 1979: 191. 10. Wilson GB. Smith CL, Fudenberg HH: Effects of dialyzable leukocyte extracts (DLE) with transfer factor activity on leukocyte migration in vitro. III. Characterization of the antigen-independent migration inhibition factor in DLE as a neutrophil immobilizing factor. I Allernv I_ Clin Immunol

1.

294.

7.

Wilson GB, Fudenberg HH. Horsmanheimo M: Effects of dialyzable leukocyte extracts (DLE) with transfer factor activity on leukocyte migration in vitro. I. Antigen-dependent inhibition and antigen-independent inhibition and enhancement of migration. J Lab Clin Med 1979: 93:

1979; 64: 56.

11.

Go&l EJ. Austen KF: A neutrophil-immobilizing factor derived from human leukocytes. J Exp Med 1972: 136: 564. 12. Wilson GB. Welch TM, Fudenberg HH: TX: a comoonent in human dialyzable transfer facior that induces delayed hypersensitivity in guinea pigs. Clin lmmunol Immuno_ path01 1977; 7: i89. 13. Rytel MW. Aabery TM, Dee TH: Therapy of cytomegalovirus rotinitis with transfer factor. Cell Immunoll975; 19: 8. 14. Ealdivar NM, Parageorgiou PS, Kafee S: The use of transfer factor in a patient with agammaglobulinemia. Pediatrics 1975: 9: 541. 15.

800. 8.

9.

Boyum A: Isolation of mononuclear cells and granulocytes from human blood. Stand J Clin Lab Invest 1968; 97 J~~poll: 77. W&on GB. Johnson L. Smith CL, Fudenberg HH: Possible

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Ballow M: Modulation of immunoglobulin synthesis in vitro by dialyzable transfer factor. In: Khan A. Kirkpatrick CH. Hill NO, eds. Immune regulators in transfer factor. New York: Academic Press, 1979: 461. Stiehm ER. Vaerman JP. Fudcnberg HH: Plasma infusion in immunologic deficiency states: metabolic and therapeutic studies. Blood 1966; 28: 918.

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