- Email: [email protected]
Humoral immunity in burns
172
Burns,8,172-175
PrintedinGreatBritain
Humoral immunity S. R. Sengupta,A.
Y. Sukhtankar,T.
in burns N. Dhole and K. P. Dubey
Department of Microbiology, VM Medical College, Solapur, India
Summary
Evaluation of serum immunoglobulin levels for IgG, IgA and IgM in burned patients was performed by Johanson’s modification of Mancini’s techniaue. Influence of serum immunoglobulin levels upon the bactericidal capacities was also measured. Levels ofall three immunoglobulins were found to be affected in burned individuals compared with healthy control group. For bums below 25 per cent, immunoglobulin G showed two troughs on the third and seventh days post bum, signifying mechanical depletion and possibly loss in opsonic activities respectively; immunoglobulin A was found persistently below normal limits signifying possibly major loss in opsonic activities; immunoglobulin M showed only an occasional fall signifying minimal loss. The role of immunoglobulins in enhancing the bactericidal index was also made very clear in the present study. INTRODUCTION
ALEXANDER AND MANCRIEF (1966) made the first observations on the impairment of the ability to produce specific antibodies in severely burned patients. Levels of immunoglobulins in serum were found to be depressed in proportion to the extent of burns. There was correlation between the period of sample collection and depression of immunoglobulin level (Artuson et al., 1969; Khon and Cort, 1969; Ritzman et al., 1969; Munster et al., 1970; Albin and Hodder, 1974; Georges and Schlotterer, 1978). The role of specific antibodies raised by polyvalent antibacterial vaccines in enhancing bactericidal capacities was suggested by various workers (Alexander et al., 1969; Sachs, 1970; Jones, 1979). Later on Bjomson et al. (1979) questioned the role of immunoglobulins in opsonization. As observations made by various workers regarding serum levels of immunoglobulins (IgG, IgA and IgM) according to the
extent of bums and period of the sample collection were not unequivocal, the present study was undertaken. Moreover it was aimed at finding out the effect of depression in immunoglobulin levels upon bactericidal capacities.
PATIENTS
AND
METHODS
Twenty-five patients, admitted to the General Hospital, Solapur with bum injuries ranging from 6 to 72 per cent were examined and included in the study. Twenty-five, age-matched healthy adults were also examined and included in the study. Blood samples were collected in heparinized and plain bulbs. Sera were preserved in the deep freeze after sodium azide (1 in 105) was added. All sera were processed on one day by radial immunodiffusion (Johanson et al., 1968). The bactericidal index was worked out by the method described by Grogan et al. (1976).
RESULTS
The levels of immunoglobulins (IgG, IgA, IgM) and the bactericidal index were found to be depressed significantly during burns (Table Z). Immunoglobulin levels tend to decrease with the increasing extent of burns. Levels of IgA are persistently below normal limits whereas levels of IgM have little tendency to fall below normal limits. The lowest value for all immunoglobulin levels was observed in patients with 65 per cent burns (Table II). Immunoglobulin G fell initially on the second day, it reached a normal value on the fifth day, it fell to a second trough on the seventh day and recovered by the tweltth day (Table ZZZ).
Sengupta et al.: Humoral immunity in Burns Table 1. lmmunoglobulin
173
levels and bactericidal index showing statistical significance
Serum
Serum lgG lsA levels levels (m&l 00 ml) (mg/l OOml) 1. Mean for patient 2. Mean for control 3. Difference between 1 and 2 4. Twice the standard error of difference 5. Significant if 3 is greater than 4
Serum lgM levels (mg/l OOml)
Bactericidal index (%)
719 1144
71 186
64 143
54 90
425
115
79
36 6
146
16.4
28
Yes
Yes
Yes
Table Il. Mean serum immunoglobulin of burns
Yes
levels according to extent
Mean serum IgM level
Extent of burns (%I
Mean serum IgG level (mg/lOO ml)
Mean serum IgA level (mg/lOO ml)
6 10 12 16 17 18 20 22 24
980 550 980 550 600 750 900 470 550 720 600 880 550 700 375’ 550 600
68 110 80 80 50 28 55 82 80 80 110 80 21 110 15’ 110 40
Lower normal limit
765
115
55
Upper normal limit
1995
350
350
:: 49 58 62 65 68 72
‘Indicates
(mg/lOO
ml)
22 115 E 45 45 55 115 115 ;: 72 32 198
.
:Fl 70
lowest value.
Immunoglobulin A fell initially on the third day and subsequently tended towards recovery; the level was approaching the normal limit on the eleventh day (Table III). Immunoglobulin M showed a very irregular pattern, however, with a tendency to remain at
normal limits with a peak on the eleventh day being the remarkable features (Table IfI). A correlation was observed in levels of and bactericidal index. immunoglobulins Improving levels of immunoglobulins appear to improve the bactericidal index (Table IV.
174
Burns Vol. 8/No. 3 Tab/e /I. Mean serum immunoglobulin levels according to time sequence after smaller burns (below 25 per cent BSA) Time sequence after burn (d)
Mean serum IgG level (mg/lOO ml)
Mean serum IgA level (mg/lOO ml)
: :
360’ 820 460 630
54 58 45”
106 44 36 64
: 7 8 9 10 11 12
1200’ 900 550’ 610 660 720 560 880’
zz 67 80 80 80 80
84 60 34 46 56 68 195’ 36
765
115
55
1995
350
350
Lower normal limit Upper normal limit
Mean serum IgM level (mg/lOO ml)
‘Indicates respective falls and rises. TableIV. Serum immunoglobulin levels v. mean burns index
Immunoglobin
W
IgA
IgM
Serum immunoglobulin level (mg/lOO ml) 300-600 600-900 900-l 200 1200-l 500 1 O-30 30-50 50-70 70-90 90-l 10 O-70 70-l 40 140-210
DISCUSSION
This present study clearly brings out the fact that levels of IgG, IgA and IgM are depressed in burns. The fall in the level of immunoglobulins was related to the extent of burns, the period after bums and also the type of immunoglobulin. Artuson et al. (1969) and Kohn et al. (1969) made similar observations.
Mean bactericidal index 46 49 85 69 33 41 :: 52 53
In burns of a smaller size (below 25 per cent), IgG was found to be depressed to nadir on the third day. This probably signifies mechanical depletion. This is followed by a peak on the fifth day probably signifying the reabsorption process. Kohn et al. (1969) made a similar record. The present study makes one additional event more clear-the fall in IgG levels on the
Sengupta et al.: Humoral Immunity an Burns
seventh day signifies a loss in opsonic activity and the subsequent recovery on the twelfth day illustrates the body’s compensatory mechanism. Immunoglobulin A was found to be depressed and persistently below normal limits irrespective of the extent of burns and the period of sample collection. Probably its loss signifies a major contribution to opsonic activities. Immunoglobulin M underwent an insignihcant depression and had little relation to the extent of bums or the period of sample collection. Its minimal depression may signify a loss in intravascular opsonic activity. Munster (1970) had correlated a fall in levels of immunoglobulin M to invasion by fungi. lmmunoglobulins IgG and IgA both made a major contribution to the use of bactericidal capacities whereas the levels of immunoglobulin M, which were little affected, did not show significant correlation with bactericidal capacity. Our findings contradict the observation made by Bjornson (1979) who denied the influence of immunoglobulins upon bactericidal capacities. The present study suggests there is a place for supplementing the immunoglobulins to enhance bactericidal capacities. Kohn et al. (1969) has, however, observed that levels of immunoglobulins recover to normal or supernormal values after burning in a short period and these obviate the need for supplementation of immunoglobulins. REFERENCES R. J. and Holder I. A. (I 974) lmmunoglobulin G and complement fixing pseudo-intercellular antibodies after thermal injury. Arch. Dermafol. 109, 881.
175
Alexander J. W. and Mancrief J. A. (1966) Alteration of the immune response following severe thermal injury. Arch. Surg. 93,75. Alexander J. W., Fisher M. W., MacMillan B. G. et al. (I 969) Prevention of invasive Pseudomonas infection in bums with a new vaccine. Arch. Surg. 99,249. Artuson G., Hogman C. F., Johanson S. G. 0. et al. (1969) Changes in immunoglobulin levels in severely burned patients. Lancef 1,546. Bjornson A. B., Altemeier W. A. and Bjomson H. S. (1979) The septic burned patient, a model for studying the role of complement and immunoglobulins in opsonization of opportunist micro-organisms. Ann. Surg. 189,5 15. Georges S. and Schlotterer M. (1978) lmmunoglobulin G level, mortality index during the hydroelectric phase ofbum injury. BurnsS, 192. Grogan J. B. (1976) Altered phagocytic function in bum patients. J. Trauma 16,985. Johanson S. G. O., Hogman C. F. and Killander J. (I 968) Quantitative immunoglobulin determination. Comparison of two methods. Estimation of normal levels and levels in persons lacking IgA and IgD. Acta Path. Microbial. &and. 74,5 19. Jones R. J. (1979) Antibody responses of burned patients immunized with a polyvalent pseudomonas vaccine. J. Hyg. (Camb.) 82,543. Kohn J. and Cort D. F. (1969) lmmunoglobulins in burned patients. Lancer 1,836. Munster A. M., Hoagland H. C. and Pruitt B. A. (1970) Effect of thermal injury on serum immunoglobulins. Ann Surg. 172,956. Ritzman S. E.. Larson D. L., Maclung C. et al. (1969) Immunoglobulin levels in burned patients. Lancet 1, 1152. Sachs A. (1970) Active immunoprophylaxis in bums with a new multivalent vaccine. Lancet 2,959.
Albin
Paper accepted 24 November 1980.
Requests /ix reprmts should he addressed IO: Professor S. R. Sengupta, Department of Mwobiology, Solapur 4 I3 003. Maharashtra. India.
V M Medical College,
Burns,8,172-175
PrintedinGreatBritain
Humoral immunity S. R. Sengupta,A.
Y. Sukhtankar,T.
in burns N. Dhole and K. P. Dubey
Department of Microbiology, VM Medical College, Solapur, India
Summary
Evaluation of serum immunoglobulin levels for IgG, IgA and IgM in burned patients was performed by Johanson’s modification of Mancini’s techniaue. Influence of serum immunoglobulin levels upon the bactericidal capacities was also measured. Levels ofall three immunoglobulins were found to be affected in burned individuals compared with healthy control group. For bums below 25 per cent, immunoglobulin G showed two troughs on the third and seventh days post bum, signifying mechanical depletion and possibly loss in opsonic activities respectively; immunoglobulin A was found persistently below normal limits signifying possibly major loss in opsonic activities; immunoglobulin M showed only an occasional fall signifying minimal loss. The role of immunoglobulins in enhancing the bactericidal index was also made very clear in the present study. INTRODUCTION
ALEXANDER AND MANCRIEF (1966) made the first observations on the impairment of the ability to produce specific antibodies in severely burned patients. Levels of immunoglobulins in serum were found to be depressed in proportion to the extent of burns. There was correlation between the period of sample collection and depression of immunoglobulin level (Artuson et al., 1969; Khon and Cort, 1969; Ritzman et al., 1969; Munster et al., 1970; Albin and Hodder, 1974; Georges and Schlotterer, 1978). The role of specific antibodies raised by polyvalent antibacterial vaccines in enhancing bactericidal capacities was suggested by various workers (Alexander et al., 1969; Sachs, 1970; Jones, 1979). Later on Bjomson et al. (1979) questioned the role of immunoglobulins in opsonization. As observations made by various workers regarding serum levels of immunoglobulins (IgG, IgA and IgM) according to the
extent of bums and period of the sample collection were not unequivocal, the present study was undertaken. Moreover it was aimed at finding out the effect of depression in immunoglobulin levels upon bactericidal capacities.
PATIENTS
AND
METHODS
Twenty-five patients, admitted to the General Hospital, Solapur with bum injuries ranging from 6 to 72 per cent were examined and included in the study. Twenty-five, age-matched healthy adults were also examined and included in the study. Blood samples were collected in heparinized and plain bulbs. Sera were preserved in the deep freeze after sodium azide (1 in 105) was added. All sera were processed on one day by radial immunodiffusion (Johanson et al., 1968). The bactericidal index was worked out by the method described by Grogan et al. (1976).
RESULTS
The levels of immunoglobulins (IgG, IgA, IgM) and the bactericidal index were found to be depressed significantly during burns (Table Z). Immunoglobulin levels tend to decrease with the increasing extent of burns. Levels of IgA are persistently below normal limits whereas levels of IgM have little tendency to fall below normal limits. The lowest value for all immunoglobulin levels was observed in patients with 65 per cent burns (Table II). Immunoglobulin G fell initially on the second day, it reached a normal value on the fifth day, it fell to a second trough on the seventh day and recovered by the tweltth day (Table ZZZ).
Sengupta et al.: Humoral immunity in Burns Table 1. lmmunoglobulin
173
levels and bactericidal index showing statistical significance
Serum
Serum lgG lsA levels levels (m&l 00 ml) (mg/l OOml) 1. Mean for patient 2. Mean for control 3. Difference between 1 and 2 4. Twice the standard error of difference 5. Significant if 3 is greater than 4
Serum lgM levels (mg/l OOml)
Bactericidal index (%)
719 1144
71 186
64 143
54 90
425
115
79
36 6
146
16.4
28
Yes
Yes
Yes
Table Il. Mean serum immunoglobulin of burns
Yes
levels according to extent
Mean serum IgM level
Extent of burns (%I
Mean serum IgG level (mg/lOO ml)
Mean serum IgA level (mg/lOO ml)
6 10 12 16 17 18 20 22 24
980 550 980 550 600 750 900 470 550 720 600 880 550 700 375’ 550 600
68 110 80 80 50 28 55 82 80 80 110 80 21 110 15’ 110 40
Lower normal limit
765
115
55
Upper normal limit
1995
350
350
:: 49 58 62 65 68 72
‘Indicates
(mg/lOO
ml)
22 115 E 45 45 55 115 115 ;: 72 32 198
.
:Fl 70
lowest value.
Immunoglobulin A fell initially on the third day and subsequently tended towards recovery; the level was approaching the normal limit on the eleventh day (Table III). Immunoglobulin M showed a very irregular pattern, however, with a tendency to remain at
normal limits with a peak on the eleventh day being the remarkable features (Table IfI). A correlation was observed in levels of and bactericidal index. immunoglobulins Improving levels of immunoglobulins appear to improve the bactericidal index (Table IV.
174
Burns Vol. 8/No. 3 Tab/e /I. Mean serum immunoglobulin levels according to time sequence after smaller burns (below 25 per cent BSA) Time sequence after burn (d)
Mean serum IgG level (mg/lOO ml)
Mean serum IgA level (mg/lOO ml)
: :
360’ 820 460 630
54 58 45”
106 44 36 64
: 7 8 9 10 11 12
1200’ 900 550’ 610 660 720 560 880’
zz 67 80 80 80 80
84 60 34 46 56 68 195’ 36
765
115
55
1995
350
350
Lower normal limit Upper normal limit
Mean serum IgM level (mg/lOO ml)
‘Indicates respective falls and rises. TableIV. Serum immunoglobulin levels v. mean burns index
Immunoglobin
W
IgA
IgM
Serum immunoglobulin level (mg/lOO ml) 300-600 600-900 900-l 200 1200-l 500 1 O-30 30-50 50-70 70-90 90-l 10 O-70 70-l 40 140-210
DISCUSSION
This present study clearly brings out the fact that levels of IgG, IgA and IgM are depressed in burns. The fall in the level of immunoglobulins was related to the extent of burns, the period after bums and also the type of immunoglobulin. Artuson et al. (1969) and Kohn et al. (1969) made similar observations.
Mean bactericidal index 46 49 85 69 33 41 :: 52 53
In burns of a smaller size (below 25 per cent), IgG was found to be depressed to nadir on the third day. This probably signifies mechanical depletion. This is followed by a peak on the fifth day probably signifying the reabsorption process. Kohn et al. (1969) made a similar record. The present study makes one additional event more clear-the fall in IgG levels on the
Sengupta et al.: Humoral Immunity an Burns
seventh day signifies a loss in opsonic activity and the subsequent recovery on the twelfth day illustrates the body’s compensatory mechanism. Immunoglobulin A was found to be depressed and persistently below normal limits irrespective of the extent of burns and the period of sample collection. Probably its loss signifies a major contribution to opsonic activities. Immunoglobulin M underwent an insignihcant depression and had little relation to the extent of bums or the period of sample collection. Its minimal depression may signify a loss in intravascular opsonic activity. Munster (1970) had correlated a fall in levels of immunoglobulin M to invasion by fungi. lmmunoglobulins IgG and IgA both made a major contribution to the use of bactericidal capacities whereas the levels of immunoglobulin M, which were little affected, did not show significant correlation with bactericidal capacity. Our findings contradict the observation made by Bjornson (1979) who denied the influence of immunoglobulins upon bactericidal capacities. The present study suggests there is a place for supplementing the immunoglobulins to enhance bactericidal capacities. Kohn et al. (1969) has, however, observed that levels of immunoglobulins recover to normal or supernormal values after burning in a short period and these obviate the need for supplementation of immunoglobulins. REFERENCES R. J. and Holder I. A. (I 974) lmmunoglobulin G and complement fixing pseudo-intercellular antibodies after thermal injury. Arch. Dermafol. 109, 881.
175
Alexander J. W. and Mancrief J. A. (1966) Alteration of the immune response following severe thermal injury. Arch. Surg. 93,75. Alexander J. W., Fisher M. W., MacMillan B. G. et al. (I 969) Prevention of invasive Pseudomonas infection in bums with a new vaccine. Arch. Surg. 99,249. Artuson G., Hogman C. F., Johanson S. G. 0. et al. (1969) Changes in immunoglobulin levels in severely burned patients. Lancef 1,546. Bjornson A. B., Altemeier W. A. and Bjomson H. S. (1979) The septic burned patient, a model for studying the role of complement and immunoglobulins in opsonization of opportunist micro-organisms. Ann. Surg. 189,5 15. Georges S. and Schlotterer M. (1978) lmmunoglobulin G level, mortality index during the hydroelectric phase ofbum injury. BurnsS, 192. Grogan J. B. (1976) Altered phagocytic function in bum patients. J. Trauma 16,985. Johanson S. G. O., Hogman C. F. and Killander J. (I 968) Quantitative immunoglobulin determination. Comparison of two methods. Estimation of normal levels and levels in persons lacking IgA and IgD. Acta Path. Microbial. &and. 74,5 19. Jones R. J. (1979) Antibody responses of burned patients immunized with a polyvalent pseudomonas vaccine. J. Hyg. (Camb.) 82,543. Kohn J. and Cort D. F. (1969) lmmunoglobulins in burned patients. Lancer 1,836. Munster A. M., Hoagland H. C. and Pruitt B. A. (1970) Effect of thermal injury on serum immunoglobulins. Ann Surg. 172,956. Ritzman S. E.. Larson D. L., Maclung C. et al. (1969) Immunoglobulin levels in burned patients. Lancet 1, 1152. Sachs A. (1970) Active immunoprophylaxis in bums with a new multivalent vaccine. Lancet 2,959.
Albin
Paper accepted 24 November 1980.
Requests /ix reprmts should he addressed IO: Professor S. R. Sengupta, Department of Mwobiology, Solapur 4 I3 003. Maharashtra. India.
V M Medical College,