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Defective antibody response to bacteriophage ØX 174 in Down syndrome
February 1975 The Journat o f P E D I A T R I C S
207
Defective antibody response to bacteriophage OX 174 in Down syndrome Antibody responses to bacteriophage OX 174 were studied in 17 institutionalizedpatients with trisomy 21 and in six mentally retarded eontrol patients with normal karyotype. Primary antibody response was significantly impaired in 11 o f the 17patients. Secondary immune response was normal in one, moderately impaired in seven, and very low in nine patients. Tertiary immunization further differentiated the two groups: those with moderately impaired secondary immune responses developed normal serum titers of predominantly IgG antibody; patients with low secondary immune responses had extremely impaired tertiary immune responses consisting mainly o f serum IgM antibody.
Vicente Lopez, M.D., Hans D. Ochs, M.D.,* Horace C. Thuline, M.D., Starkey D. Davis, M.D., and Ralph J. Wedgwood, M.D., Seattle, Wash.
E V ID E N C E that immunodeficiency may be a feature of Down syndrome includes unusual susceptibility to bacterial infections, 1-3increased risk of leukemia and malignancies,a, 5 high incidence for the chronic carrier state of hepatitis B antigen, 6, 7 and the frequent presence of autoantibodies in the serum of these individuals. 8 A n u m b e r of observations concerning the humoral i m m u n e s y s t e m in "Down s y n d r o m e have b e e n reported. Serum IgG levels in affected newborn infants are significantly lower than maternal levels at the time of delivery, and lower than in normal infants. 9 Affected older children, adolescents, and adults generally have higher serum IgG levels than normal controls; serum IgM and IgA levels have b e e n variable. 1~ Specific antibody responses, however, have received little attention and conflicting results have been published. 1417 From the Department of Pediatrics, University of Washington, and Rainier School Supported in part by U.S. Public Health Service grant AI07073, a grant from the Washington Association for Retarded Children Trust Fund, and a grant RSS-28 from the National Foundation. *Investigator of the Howard Hughes Medical Institute. Reprint address:Division of Immunology, Departmentof Pediatrics, Universityof Washington,R D-20, Seattle, Wash. 98195.
B a c t e r i o p h a g e 0 X 174, a p o t e n t p r o t e i n antigen, allows precise definition of the humoral i m m u n e response with determination of antigen clearance, primary and secondary antibody responses, and the class of antibody produced. 182~In the study presented here, 17 c h i l d r e n with D o w n s y n d r o m e and six control children of comparable age and sex residing at the same institution were immunized with bacteriophage and the kinetics of their antibody response determined. In addition, serum concentrations of immunoglobulins were assessed. PATIENTS Seventeen individuals with trisomy 21 (12-18 years of age; eight male and nine female) and six control subjects (12-18 years of age; three male and three female) with unclassified mental retardation and normal karyotype were studied. All are residents of Rainier School. Approval from the Washington State D e p a r t m e n t of Institutions and informed parental consent were obtained for each subject. Six of the 17 c h i l d r e n with Down s y n d r o m e are chronic carriers of HB antigen; three were hospitalized on several occasions for bacterial pneumonia; one has chronic purulent rhinitis and persistent skin infections; and one has an atrial septal defect.
Vol. 86, No. 2, pp. 207-211
208
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The Journal of Pediatrics February 1975
rather than normal Gaussian frequency distribution. F o r this reason the log10 of the K v was used to calculate means and variance, and the geometric rather than the arithmetic mean was used to compare results in the two groups. Statistical analysis was carried out with Student's t test.
2~
RESULTS q~
0
I
2 5 Weeks
4
Fig. 1. Primary antibody response to bacteriophage ~X 174:2 X 109 plaque-forming units/kg body weight was given intravenously and antibody titers were determined at different time intervals. The range of antibody titers of the controls is indicated by the stippled area. Geometric means of the Kv are indicated for controls (9 9 and patients ( e ~ e ) . Individual patient Kv's are represented by ( 9 ). MATERIALS
AND METHODS
Concentrations Of s e r u m IgG, IgA, and IgM were d e t e r m i n e d by single radial i m m u n o d i f f u s i o n } 1 Bact e r i o p h a g e ~ X 174 was p r e p a r e d as p r e v i o u s l y reported. 18Phage was given intravenously in a dose of 2 x 10 9 p l a q u e - f o r m i n g u n i t s per k i l o g r a m b o d y weight. Blood was collected 15 minutes later to determine the circulating phage titer and thereafter at weekly intervals for one month. A Second dose was given 5 to 6 weeks after the initial dose and four samples were obtained at weekly intervals. Three control and six Study patients received a tertiary immunization 6 months after the second dose was given. No adverse reactions which could be related to the procedure were observed at any time. A n t i b o d y activity was d e t e r m i n e d by p h a g e neutralization and was expressed as the rate of phage inactivation ( K v ) , d e r i v e d f r o m a s t a n d a r d e q u a t i o n } 8 S e r u m p r o t e i n s w e r e s e p a r a t e d by c o l u m n c h r o m a t o g r a p h y using S e p h a d e x G - 2 0 0 } 9 A n t i b o d y suSceptibility to reducing agents was determined by the method of G r u b b and Swahn} 2using 2-mercaptoethanol. The a n t i b o d y titers (Kv) c o n f o r m to l o g - n o r m a l
The s e r u m IgG concentration was greater (but not s t a t i s t i c a l l y significantly different) in p a t i e n t s with Down syndrome (1,486 +__346 mg/dl*) than in the controis (1,183 +__ 301 mg/dl*). Serum IgA levels were not different (235 -+ 93 mg/dl versus 262 + 91 mg/dl*). Serum concentrations of IgM were significantly lower (p < 0.02) in Study patients (55 +_ 21 mg/dl*) than in controls (102 _--_34 mg/dl*). The antibody responses i n the Down syndrome patients a n d c o n t r o l s after p r i m a r y i m m u n i z a t i o n are represented in Fig. 1. Antigen clearance in patients and c o n t r o l s was c o m p l e t e at one week ( w i t h i n n o r m a l limits). Controls reached peak serum antibody titers 2 w e e k s after i m m u n i z a t i o n ; a n t i b o d y activity t h e n declined slowly. In contrast, serum antibody titers of the study patients peaked earlier and declined at a more rapid rate; the antibody titers were significantly lower at three (p (0.02) and four (p < 0.01) weeks following primary immunization. Antibody responses to a second phage injection are represented in Fig. 2. Controls reached maximal antib o d y activity two weeks after i m m u n i z a t i o n . A diminished antibody response was seen in all b u t one individual with Down syndrome. The patients could be divided into two distinct groups on the basis of their response to the second immunization. At 2 weeks after immunization, seven patients had a moderately diminished antibody response with a Kv > i 0 (referred to as "moderate" responders) and nine had low antibody titers with Kv < 10 (referred to as "low" responders). Six of these patients, three " m o d e r a t e " responders and three "low" responders, and three controls r e c e i v e d a third i m m u n i z a t i o n with phage 6 months following the second dose. The three "low" responders again had a poor antibody response (Kv ~< 10). In contrast, the three " m o d e r a t e " responders attained antibody titers comparable to normal controls (Fig. 3). Sera from 12 patients With Down syndrome and six controls were studied by column chromatography to assess t h e i m m u n o g l o b u l i n class ( I g G , IgM) of the neutralizing antibody. TM19 Antibody Of both control and study patients was predominantly IgM after secondary *Mean • 1 SD.
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Defective antibody response in Down syndrome
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Fig. 2. Secondary antibody response to bacyeriophage ~X 174. Range of antibody titers of controls is illustrated by the stippled area. Geometric means of the Kv are shown for controls ((3 (3) and patients ( e - - e). Individual patient Kv's are represented by (e).
Fig. 3. Tertiary antibody response to bacteriophage ~X 174. A third intravenous phage injection resulted in a high antibody titer in controls ((3 - - ( 3 ) and in patients with a moderate secondary antibody response ( A - - A ) . A low tertiary antibody titer was seen in the patients who had a low secondary response ( 9 m 9
immunization. After tertiary immunization, the controls and the three " m o d e r a t e " responders made predominantly IgG antibody; the "low" responder group continued to make IgM antibody. T h e r e was no a p p a r e n t r e l a t i o n s h i p b e t w e e n the ability to produce specific antibody and susceptibility to infection, the presence or absence of HB antigen, age,
b o d y r e s p o n s e s to i n t r a v e n o u s i n j e c t i o n o f b a c teriophage 0 X 174. Although they developed a normal initial (one week) antibody response tO primary immunization, they were unable to sustain their serum antibody titer, an abnormality of kinetics which might be missed if only one antibody determination was performed. The impairment of immune response was even more striking after secondary immunization with ba~cteriophage. All b u t o n e p a t i e n t had d i m i n i s h e d responses. On the basis of their s e c o n d a r y a n t i b o d y r e s p o n s e s , the p a t i e n t s c o u l d be d i v i d e d into two groups: " m o d e r a t e " (seven patients) and " l o w " (nine patients) responders. Three "low" responders were immunized a third time and the antibody response was again clearly impaired. Three " m o d e r a t e " responders, although abnormal during secondary immunization, responded with a normal antibody rise following tertiary immunization. A d m i n i s t r a t i o n of b a c t e r i o p h a g e r 174 to previouslY i m m u n i z e d n o r m a l controls, c h i l d r e n , and adults, has been reported to give a rapid serum antibody response consisting mainly of I g G ) 82~ 23, 24 During this study both controls and patients failed to produce IgG antibody after secondary immunization with phage. We have no explanation for this difference. The controls
or sex.
DISCUSSION The association of frequent bacterial infections, increased risk of leukemia, and persistence of HB antigen in patients with Down syndrome has resulted in a number of studies of humoral and cellular immunity. Norm~l levels o f " n a t u r a l " antibodies to Escherichia coli and i s o h e m a g g l u t i n i n s have b e e n recorded, f3 A n t i b o d y responses following immunization with tetanus toxoid and typhoid vaccine were found low and of short duration in one study, 14 b u t n o r m a l antibody responses to the same antigens were reported b y others./s, 16Dimini s h e d r e s p o n s e s to influenza vaccine, p a r t i c u l a r l y noticeable with new antigenic variants and in older patients, have been documented. 17 Our study shows that institutionalized 12- to 18-yearo l d patients with Down syndrome have abnormal anti-
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Lopez et al.
participating in this study had no known chromosomal aberrations and are residents of the same institution. Neither controls nor the study patients had viral infections or were receiving drugs reported to interfere with the i m m u n e response. After a third phage injection all controls studied and half of the patients p r o d u c e d high s e r u m a n t i b o d y levels, c o n s i s t i n g p r e d o m i n a n t l y of IgG, T h e three " l o w , responders, however, were unable to produce a significant " b o o s t e r " effect and the s e r u m a n t i b o d y consisted mainly of IgM. The variability of the humoral i m m u n e deficiency in Down syndrome and the inability to switch from IgM to IgG a n t i b o d y after multiple phage immunization has been found in a n u m b e r of other immunodeficiency syndromes. 18-2~ Trisomy 21 was confirmed by chromosomal analysis in all our patientsl How the additional chromosome relates to the multiple biologic alterations of Down syndrome is not clear. Premature aging of individuals with Down syndrome has been suggested 2s, 26and a diminution of cellular and humoral i m m u n e response has been observed with aging (immunosenescence) in experimental animals27, 28 and in humans. 29, 30 Variability in t h e expression of the immunodeficiency and a quantitative rather than absolute defect, as found in our patients, would be expected under these circumstances. The fact that half of our patients were able to develop a reasonably normal antibody response on repeated immunization is of interest. The ability to develop a normal a n t i b o d y response after repeated antigenic exposure might explain in part the age-related morbidity and mortality rates from infections in patients with Down syndrome. 31 The observation also raises questions as to the optimal i m m u n i z a t i o n schedule for children with this syndrome.
REFERENCES
1. Penrose LS, and Smith GF: Down's anomaly, London, 1966, J. & A. Churchill, Ltd. 2. Donner M: A study of the immunology and biology of mongolism, Ann Med Exp Biol Fenn 32(suppl. 9): 1954. 3. SiegelM: Susceptibility of mongoloids to infection. I, Incidence of pneumonia, influenza A and shigella dysenteriae (Sonne), Am J Hyg 48:53, 1948. 4. Stewart A, Webb J, and Hewitt D: A survey of childhood malignancies, Br Med J 1:1495, 1958. 5. Schuler D, Dobos M, Fekete G, Machay T, and Nemeskeri A: Down's syndrome and malignancy, Acta Paediatr Acad Sci Hung 13:245, 1971. 6. Sutnick AI, London WT, Gerstley BJS, Cronlund MM, and Blumberg BS: Anicteric hepatitis associated with Australia antigen. Occurrence in patients with Down's syndrome, JAMA 205:670, 1968. 7. Esber HJ, Barbarich M, Menninger FF Jr, Meshorer E,
The Journal of Pediatrics February 1975
8. 9.
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Monedjikova V, and Rosenkrantz H: Hepatitis-associated antigen and immunoglobulin composition in patients with Down's anomaly, Am J Clin Pathol 59:872, 1973. Fialkow PJ: Thyroid autoimmunity and Down's syndrome, Ann NY Acad Sci 171:500, 1970. Miller ME, Mellman WJ, Cohen MM, Kohn G, and Dietz WH Jr: Depressed immunoglobulin G in newborn infants with Down's syndrome, J PEDIATR75:996, 1969. Stiehm ER, and Fudenberg HH: Serum levels of immune globulins in health and disease. A survey, Pediatrics 37:715, 1966. Van Rootselaar FJ, and Westendorp Boerma F: Serum levels of immunoglobulinsin mongolism, in epilepsy, and in unclassified mental deficiency, Psychiatr Neurol Neurocbir 71:501, 1968. Sumick AI, London WT, and Blumberg BS: Effects of host and environment on immunoglobulins in Down's syndrome, Arch Intern Med 124:722, 1969. Adinolfi M, Gardner B, and Martin W: Observations on the levels of yG, yA, and yM globulins, Anti-A and AntiB agglutinins and antibodies to Escherichia coli in Down's anomaly, J Clin Pathol 20:860, 1967. SiegelM: Susceptibility of mongoloids to infection. II. Antibody response to tetanuS toxoid and typhoid vaccine, Am J Hyg 48:63, 1948. Leibowitz A, and Yannet H: The production of humoral antibodies by the monogolian~Am J Ment Defic 46:304, 1942. Griffiths AW, and Sylvester PE: Mongols and nonmongols compared in their response to active tetanus immunization, J Ment Defic Res 11:263, 1967. Gordon MC, Sinha SK, and Carlson SD: Antibody responses t0 influenza vaccine in patients with Down's syndrome, Am J Ment Defic 75:391, 1971. Ching Y-C, Davis SD, and Wedgwood RJ: Antibody studies in hypogammaglobulinemia, J Clin Invest 45:1593, 1966. Ochs HD, Davis SD, and Wedgwood RJ: Immunologic responses to bacteriophage ~X 174 in immunodeficiency diseases, J Clin Invest 50:2559, 1971. Wedgwood RJ, Ochs HD, and Davis SD: The recognition and classification of immunodeficiency diseases with bacteriophage OX 174, Birth Defects (in press). Lopez V, and Golder S: A new immunodiffusion method for quantitative determination of proteins in biological fluids based on a separate application of antibody and antigen to small agar discs, Clin Claim Acta 21:517, 1968. Grubb R, and Swahn B: Destruction of some agglutinins but not of others by two sulfhydryl compounds, Acta Patbol Microbiol Scand 43:305, 1958. Peacock D B, Jones JV, and Gough M: The immune response'to O'X 174 in man. 1. Primary and secondarY antibody production in normal adults, Clin Exp Immunol 13:497, 1973. Uhr JW, Dancis J, Franklin EC, Finkelstein MS, and Lewis EW: The antibody response to bacteriophage ~iX 174 in newborn premature infants, J Clin Invest 41:1509, 1962. Haberland C: Alzheimer's disease in Down syndrome: Clinical-neuro-pathological observations, Acta Neurol Belg 69:369, 1969. Schneider EL, and Epstein CJ: Replication rate and
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lifespan of cultured fibroblasts in Down's sytldrome, Proc Soc Exp Biol Med 141:1092, 1972. Rodey GE, Good'RA, and Yunis EJ: Progressive loss in vitro of cellular immunity with ageing in strains of mice susceptible to autoimmune disease, Clin Exp Immunol 9:305, 1971. Makinodan T, and Peterson WJ: Secondary antibodyforming potential of mice in relation to age--its significance in senescence, Dev Biol 14:96, 1966.
Defective antibody response in Down syndrome
29.
• 11
Pisciotta AV, Westring DW, DePrey C, and Walsh B: Mitogenic effect of phytohaemagglutinin at different ages, Nature 215:193, 1967. 30. Heine K-M, Stobbe H, Klatt R, Sahi J, Herrmann H, and Kupke J: Funktionsstoerungen der Lymphocyten im Alter, Z Altersforsch 24:23, 1971. 31. Collmann RD, and Stoller A: A life table for mongols in Victoria, Australia, J Merit Defic Res 7:53, 1963.
207
Defective antibody response to bacteriophage OX 174 in Down syndrome Antibody responses to bacteriophage OX 174 were studied in 17 institutionalizedpatients with trisomy 21 and in six mentally retarded eontrol patients with normal karyotype. Primary antibody response was significantly impaired in 11 o f the 17patients. Secondary immune response was normal in one, moderately impaired in seven, and very low in nine patients. Tertiary immunization further differentiated the two groups: those with moderately impaired secondary immune responses developed normal serum titers of predominantly IgG antibody; patients with low secondary immune responses had extremely impaired tertiary immune responses consisting mainly o f serum IgM antibody.
Vicente Lopez, M.D., Hans D. Ochs, M.D.,* Horace C. Thuline, M.D., Starkey D. Davis, M.D., and Ralph J. Wedgwood, M.D., Seattle, Wash.
E V ID E N C E that immunodeficiency may be a feature of Down syndrome includes unusual susceptibility to bacterial infections, 1-3increased risk of leukemia and malignancies,a, 5 high incidence for the chronic carrier state of hepatitis B antigen, 6, 7 and the frequent presence of autoantibodies in the serum of these individuals. 8 A n u m b e r of observations concerning the humoral i m m u n e s y s t e m in "Down s y n d r o m e have b e e n reported. Serum IgG levels in affected newborn infants are significantly lower than maternal levels at the time of delivery, and lower than in normal infants. 9 Affected older children, adolescents, and adults generally have higher serum IgG levels than normal controls; serum IgM and IgA levels have b e e n variable. 1~ Specific antibody responses, however, have received little attention and conflicting results have been published. 1417 From the Department of Pediatrics, University of Washington, and Rainier School Supported in part by U.S. Public Health Service grant AI07073, a grant from the Washington Association for Retarded Children Trust Fund, and a grant RSS-28 from the National Foundation. *Investigator of the Howard Hughes Medical Institute. Reprint address:Division of Immunology, Departmentof Pediatrics, Universityof Washington,R D-20, Seattle, Wash. 98195.
B a c t e r i o p h a g e 0 X 174, a p o t e n t p r o t e i n antigen, allows precise definition of the humoral i m m u n e response with determination of antigen clearance, primary and secondary antibody responses, and the class of antibody produced. 182~In the study presented here, 17 c h i l d r e n with D o w n s y n d r o m e and six control children of comparable age and sex residing at the same institution were immunized with bacteriophage and the kinetics of their antibody response determined. In addition, serum concentrations of immunoglobulins were assessed. PATIENTS Seventeen individuals with trisomy 21 (12-18 years of age; eight male and nine female) and six control subjects (12-18 years of age; three male and three female) with unclassified mental retardation and normal karyotype were studied. All are residents of Rainier School. Approval from the Washington State D e p a r t m e n t of Institutions and informed parental consent were obtained for each subject. Six of the 17 c h i l d r e n with Down s y n d r o m e are chronic carriers of HB antigen; three were hospitalized on several occasions for bacterial pneumonia; one has chronic purulent rhinitis and persistent skin infections; and one has an atrial septal defect.
Vol. 86, No. 2, pp. 207-211
208
Lopez et al.
The Journal of Pediatrics February 1975
rather than normal Gaussian frequency distribution. F o r this reason the log10 of the K v was used to calculate means and variance, and the geometric rather than the arithmetic mean was used to compare results in the two groups. Statistical analysis was carried out with Student's t test.
2~
RESULTS q~
0
I
2 5 Weeks
4
Fig. 1. Primary antibody response to bacteriophage ~X 174:2 X 109 plaque-forming units/kg body weight was given intravenously and antibody titers were determined at different time intervals. The range of antibody titers of the controls is indicated by the stippled area. Geometric means of the Kv are indicated for controls (9 9 and patients ( e ~ e ) . Individual patient Kv's are represented by ( 9 ). MATERIALS
AND METHODS
Concentrations Of s e r u m IgG, IgA, and IgM were d e t e r m i n e d by single radial i m m u n o d i f f u s i o n } 1 Bact e r i o p h a g e ~ X 174 was p r e p a r e d as p r e v i o u s l y reported. 18Phage was given intravenously in a dose of 2 x 10 9 p l a q u e - f o r m i n g u n i t s per k i l o g r a m b o d y weight. Blood was collected 15 minutes later to determine the circulating phage titer and thereafter at weekly intervals for one month. A Second dose was given 5 to 6 weeks after the initial dose and four samples were obtained at weekly intervals. Three control and six Study patients received a tertiary immunization 6 months after the second dose was given. No adverse reactions which could be related to the procedure were observed at any time. A n t i b o d y activity was d e t e r m i n e d by p h a g e neutralization and was expressed as the rate of phage inactivation ( K v ) , d e r i v e d f r o m a s t a n d a r d e q u a t i o n } 8 S e r u m p r o t e i n s w e r e s e p a r a t e d by c o l u m n c h r o m a t o g r a p h y using S e p h a d e x G - 2 0 0 } 9 A n t i b o d y suSceptibility to reducing agents was determined by the method of G r u b b and Swahn} 2using 2-mercaptoethanol. The a n t i b o d y titers (Kv) c o n f o r m to l o g - n o r m a l
The s e r u m IgG concentration was greater (but not s t a t i s t i c a l l y significantly different) in p a t i e n t s with Down syndrome (1,486 +__346 mg/dl*) than in the controis (1,183 +__ 301 mg/dl*). Serum IgA levels were not different (235 -+ 93 mg/dl versus 262 + 91 mg/dl*). Serum concentrations of IgM were significantly lower (p < 0.02) in Study patients (55 +_ 21 mg/dl*) than in controls (102 _--_34 mg/dl*). The antibody responses i n the Down syndrome patients a n d c o n t r o l s after p r i m a r y i m m u n i z a t i o n are represented in Fig. 1. Antigen clearance in patients and c o n t r o l s was c o m p l e t e at one week ( w i t h i n n o r m a l limits). Controls reached peak serum antibody titers 2 w e e k s after i m m u n i z a t i o n ; a n t i b o d y activity t h e n declined slowly. In contrast, serum antibody titers of the study patients peaked earlier and declined at a more rapid rate; the antibody titers were significantly lower at three (p (0.02) and four (p < 0.01) weeks following primary immunization. Antibody responses to a second phage injection are represented in Fig. 2. Controls reached maximal antib o d y activity two weeks after i m m u n i z a t i o n . A diminished antibody response was seen in all b u t one individual with Down syndrome. The patients could be divided into two distinct groups on the basis of their response to the second immunization. At 2 weeks after immunization, seven patients had a moderately diminished antibody response with a Kv > i 0 (referred to as "moderate" responders) and nine had low antibody titers with Kv < 10 (referred to as "low" responders). Six of these patients, three " m o d e r a t e " responders and three "low" responders, and three controls r e c e i v e d a third i m m u n i z a t i o n with phage 6 months following the second dose. The three "low" responders again had a poor antibody response (Kv ~< 10). In contrast, the three " m o d e r a t e " responders attained antibody titers comparable to normal controls (Fig. 3). Sera from 12 patients With Down syndrome and six controls were studied by column chromatography to assess t h e i m m u n o g l o b u l i n class ( I g G , IgM) of the neutralizing antibody. TM19 Antibody Of both control and study patients was predominantly IgM after secondary *Mean • 1 SD.
Volume 86 Number 2
Defective antibody response in Down syndrome
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Fig. 2. Secondary antibody response to bacyeriophage ~X 174. Range of antibody titers of controls is illustrated by the stippled area. Geometric means of the Kv are shown for controls ((3 (3) and patients ( e - - e). Individual patient Kv's are represented by (e).
Fig. 3. Tertiary antibody response to bacteriophage ~X 174. A third intravenous phage injection resulted in a high antibody titer in controls ((3 - - ( 3 ) and in patients with a moderate secondary antibody response ( A - - A ) . A low tertiary antibody titer was seen in the patients who had a low secondary response ( 9 m 9
immunization. After tertiary immunization, the controls and the three " m o d e r a t e " responders made predominantly IgG antibody; the "low" responder group continued to make IgM antibody. T h e r e was no a p p a r e n t r e l a t i o n s h i p b e t w e e n the ability to produce specific antibody and susceptibility to infection, the presence or absence of HB antigen, age,
b o d y r e s p o n s e s to i n t r a v e n o u s i n j e c t i o n o f b a c teriophage 0 X 174. Although they developed a normal initial (one week) antibody response tO primary immunization, they were unable to sustain their serum antibody titer, an abnormality of kinetics which might be missed if only one antibody determination was performed. The impairment of immune response was even more striking after secondary immunization with ba~cteriophage. All b u t o n e p a t i e n t had d i m i n i s h e d responses. On the basis of their s e c o n d a r y a n t i b o d y r e s p o n s e s , the p a t i e n t s c o u l d be d i v i d e d into two groups: " m o d e r a t e " (seven patients) and " l o w " (nine patients) responders. Three "low" responders were immunized a third time and the antibody response was again clearly impaired. Three " m o d e r a t e " responders, although abnormal during secondary immunization, responded with a normal antibody rise following tertiary immunization. A d m i n i s t r a t i o n of b a c t e r i o p h a g e r 174 to previouslY i m m u n i z e d n o r m a l controls, c h i l d r e n , and adults, has been reported to give a rapid serum antibody response consisting mainly of I g G ) 82~ 23, 24 During this study both controls and patients failed to produce IgG antibody after secondary immunization with phage. We have no explanation for this difference. The controls
or sex.
DISCUSSION The association of frequent bacterial infections, increased risk of leukemia, and persistence of HB antigen in patients with Down syndrome has resulted in a number of studies of humoral and cellular immunity. Norm~l levels o f " n a t u r a l " antibodies to Escherichia coli and i s o h e m a g g l u t i n i n s have b e e n recorded, f3 A n t i b o d y responses following immunization with tetanus toxoid and typhoid vaccine were found low and of short duration in one study, 14 b u t n o r m a l antibody responses to the same antigens were reported b y others./s, 16Dimini s h e d r e s p o n s e s to influenza vaccine, p a r t i c u l a r l y noticeable with new antigenic variants and in older patients, have been documented. 17 Our study shows that institutionalized 12- to 18-yearo l d patients with Down syndrome have abnormal anti-
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participating in this study had no known chromosomal aberrations and are residents of the same institution. Neither controls nor the study patients had viral infections or were receiving drugs reported to interfere with the i m m u n e response. After a third phage injection all controls studied and half of the patients p r o d u c e d high s e r u m a n t i b o d y levels, c o n s i s t i n g p r e d o m i n a n t l y of IgG, T h e three " l o w , responders, however, were unable to produce a significant " b o o s t e r " effect and the s e r u m a n t i b o d y consisted mainly of IgM. The variability of the humoral i m m u n e deficiency in Down syndrome and the inability to switch from IgM to IgG a n t i b o d y after multiple phage immunization has been found in a n u m b e r of other immunodeficiency syndromes. 18-2~ Trisomy 21 was confirmed by chromosomal analysis in all our patientsl How the additional chromosome relates to the multiple biologic alterations of Down syndrome is not clear. Premature aging of individuals with Down syndrome has been suggested 2s, 26and a diminution of cellular and humoral i m m u n e response has been observed with aging (immunosenescence) in experimental animals27, 28 and in humans. 29, 30 Variability in t h e expression of the immunodeficiency and a quantitative rather than absolute defect, as found in our patients, would be expected under these circumstances. The fact that half of our patients were able to develop a reasonably normal antibody response on repeated immunization is of interest. The ability to develop a normal a n t i b o d y response after repeated antigenic exposure might explain in part the age-related morbidity and mortality rates from infections in patients with Down syndrome. 31 The observation also raises questions as to the optimal i m m u n i z a t i o n schedule for children with this syndrome.
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