Sustained depression of monocyte cytotoxicity in a boy with disseminated nontuberculous mycobacteriosis

264

Brief clinical and laboratory observations

confirmed by recent studies performed in other SCID patients." Cell surface characteristics together with analysis of cell functions show that the SCID syndrome may occur in the presence of a normal n u m b e r of circulating E rosette-forming cells. The demonstration of an abnormal accumulation in the blood of immature T cells unable to differentiate into functional T lymphOcytes illustrated the considerable interest of using monoclonal antibodies to T-cell differentiation antigens in immunodeficiencies. ADDENDUM Several months after a fetal thymus and liver transplantation a normal distribution of T cell subpopulations defined by immunofluorescence study with monoclonal antibodies was observed, whereas T cell functions were not modified. This was observed despite any evidence of prolonged take of fetal cells. Thus, the persistent T cell dysfunction cannot be anymore.correlated with an abnormal distribution of T cell subset markers. We thank M. Wyss, M.D., and M. Jeannet, M.D. (Geneva), who investigated the sister of our patient. REFERENCES 1. Fudenberg HH, Good RA, Goodman HC, Hitzig W, Kunkel H, Roitt IM, Rosen FS, Rowe DS, Seligman M, and Soothill JR: Primary immunodeficiencies, Bull WHO 45:125, 1971. 2. Griscelli C, Durandy A, Virelizier JL, Ballet J J, and Daguillard F: Selective defect of precursor T cells associated with apparently normal B lymphocytes in severe combined

The Journal q[ Pediatrics June 1981 immunodeficiency disease, J PEDIATR93:404, 1978. 3. Touraine JL, Betuel H, Souillet G, and Jeune M: Combined immunodeficiency disease associated with absence of ceil surface HLA-A and B antigens, J PEDIATR93:47, 1978. 4. Gehrz RC, McAulffe J, Linner KM, and Kersey JH: Defective membrane function in a patient with severe combined immunodeficiency disease, Clin Exp Immunol 39:344, I980. 5. Goldstein AL, Guha A, Zatz MA, and White A: Purification and biological activity of thymosin, hormone of the thymus gland, Proc Nail Acad Sci USA 69:1800, 1972. 6. Bach JF, Dardenne M, Pleau JM, and Roja J: Biochemical characterisation of a serum thymic factor, Cell Immunoi 266:55, 1977. 7. Reinherz EL, Kurg PC, Goldstein G, Levey RH, and Schlossman SF: Discrete stages of human intrathymic differentiation: analysis of normal thymocytes and leukemic iymphoblasts of T lineage, Proc Nail Acad Sci USA 77:1588, 1980. 8. Breard JM, Reinherz EL, Kung PC, Goldstein G, and Sehlossman SF: A monoclonal antibody reactive with human peripheral blood monocyte, J Immunol (in press). 9. Reinherz EL, Kung PC, Goldstein G, and Schlossman SF: A monoclonal antibody with selective reactivity with functionally mature human thymocytes and cell peripheral human T ceils, J Immnnol 123:1312, 1979. 10. Pike KW, Dosch HM, Ipp MM, and Gelfand EW: Demonstration of an intrathymic defect in a case of severe combined immunodeficiency disease, N Engl J Med 28:421, 1975. 11. Reinherz EL, Schlossman SF, and Rosen FS: Human immunodeficiency states resulting from disorders of T cell maturation and regulation, in Primary Immunoddficiencies INSERM Symposium No. 16, 1980, p 109.

Sustained depression of monocyte cytotoxicity in a boy with disseminated nontuberculous mycobacteriosis Troels Herlin,* Thomas Thelle, Knud Kragballe, Niels Borregaard, and Kristian Thestrup-Pedersen, Aarhus, Denmark

IN CHILDREN, infections with nontuberculous mycobacteria are usually localized, resulting in swelling of superficial lymph nodes? Disseminated infections caused by Mycobacterium intracellulare and the closely related Mycobacteriurn avium are very rare?, ~ M. intracellulare

occurs ubiquitously and is of low virulence. A widespread infection is, therefore, presumed to take place only in an immunodeficient host. This report describes a sustained

See related article, p. 268.

From the Department of Pediatrics, Aarhus Kommunehospital, and Departments of Dermatology and Medicine, Marselisborg Hospital, University of Aarhus. Supported by The Danish Medical Research Council (Grant No. 512-20089). *Reprint address: Departmentof Dermatology, Marselisborg Hospital, DK-8000Aarhus C, Denmark.

Abbreviations used PPD: purified protein derivative PHA: phytohemagglutinin ADCC: antibody-dependent cell-mediated cytotoxicity HMPS: hexose monophosphate shunt PMA: phorbol myristate acetate

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Brief clinical and laboratory observations

26 5

Table I. In vitro reactivity o f l y m p h o c y t e s f r o m a p a t i e n t with d i s s e m i n a t e d n o n t u b e r c u l o u s mycobacteriosis

Date June 18, 1979 Sept. 10, 1979 March 10, 1980 Normal range

Unstimulated 5-day culture (cym)

PPD-S, 10 t~g/ml 5-day culture (SI)

Unstimulated 3-day culture (cpm)

PHA, 10 tLg/ml 3-day culture (SI)

3,400 1,500 4,500 1,000-3,500

0.76 9.67 6.49 3.0-9.3

2,300 3,500 1,000 1,000-2,500

10.13 8.73 32.40 7.8-45.3

DNA synthesis was measured as aH-thymidine incorporation in lymphocytes incubated with PPD-S and PHA. St is the stimulation index and is the ratio between stimulated and unstimulaied cell cultures (mean of triplicate determinations). Therapy was initiated August 3, 1979.

depression of antibody-dependent

monocyte-mediated

cytotoxicity a n d i n c r e a s e d s e r u m JgE levels in a 10year-old

boy

with

disseminated

osteolytic

processes

caused b y i n f e c t i o n with M. intracellulare e v e n after regression o f t h e active disease a n d n o r m a l i z a t i o n o f o t h e r l a b o r a t o r y investigations.

CASE REPORT This boy was the only child in the family. In his first four years of life he had recurrent asthmatic bronchitis, several times treated systemically with 2 to 4 mg triamcinolone daily for periods of one week. When 31/2 years of age he had a positive P P D - S skin reaction without having been BCG vaccinated. Concurrently, a round infiltrate developed in the right lung hilus, which totally cleared without treatment after three months. When 4 years of age he had an encephalitic-like reaction with symptomatic epilepsy, causing admission to hospital for seven months. Spinal fluid was normal, and neurologic and neuroradiologic examinations revealed no cause of the disease. An indolent preauricular lymph node enlargement and blood eosinophilia w e r e noted concomitantly. The symptoms gradually subsided during the following year. He was thereafter healthy and did not have increased susceptibility to pyogenic or viral infections. He was readmitted at 10 years of age for localized pain and tender swellings of the ribs and left leg. There was no enlargement of superficial lymph nodes, liver, or spleen. Laboratory investigations. Erythrocyte sedimentation rate 109 mm/hr, Hgb 102 gm/L, WBC 12.1 x 109/ml with 68% neutrophils, 26% lymphocytes, 4% monocytes, and 2% eosinophils. Radiographs showed disseminated osteolytic lesions in the theca cranii, ribs, pelvis, long bones, and left foot, together with an enlargement of the nodes in the right tracheobronchial angle. Histologic examinations of bone lesions and of a hilar gland revealed an inflammatory process with neutrophils, lymphocytes, and plasma cells, but most prominently a massive histiocytic infiltration without formation of granuloma or giant cells. Many of the histiocytes were atypical, with aberrant nuclei, polynucleated forms, and pronounced erythrophagocytosis, not unlike the findings in malignant histiocytosis. No bacteria, fungi, or acid-fast organisms were seen. Outside the lesions the bone marrow was normal. M. intracellulare serotypc 14 was cultured subsequently from the bone lesions and bronchial aspirate.

Immunologic investigations. Serum contained markedly elevated concentrations of IgG (20.0 gm/L) and IgA (6.2 gin/L), but IgM was normal (0.97 gm/L). Serum IgE concentration was high initially (1,075 U/ml) and increased to 8,186 U / m l one year after the start of therapy. At this time RAST to M. intracellulare antigen showed a 3 + reaction graded on a scale 0 to 4. RAST to common allergens showed 2 + to horse and dog epithelium and was negative to others. Skin tests for PPD-S, 2 TU, produced 4 mm, PPD-B 14 mm, and PPD-A 11 mm of induration. Normal total count and percentage of T and B lymphocytes were obtained. Lymphocyte function in vitro was measured as the increase in DNA synthesis after antigen and mitogen stimulation. Reactivity to PPD-S antigen was completely abolished prior to therapy (Table I) but thereafter the PPD-S responsiveness was normal or even supranormal. PHA induced normal lymphocyte transformation both before and after therapy. To investigate monocyte and neutrophil function, an antibody-dependent cell-mediated cytotoxicity assay was employed referring to the lysis of B-erythrocytes sensitized with anti-B antiserum? ADCC involves generation of reduced oxygen radicals and lysosomaI enzyme release? Monocyte ADCC was depressed throughout the observation period (Table II) and was 46 to 68% of that of normal subjects investigated on the same day. Activation of the hexose monophosphate shunt during monocyte ADCC was 55% of normal, but normal lysozyme liberation was obtained (Table II). During neutrophil ADCC cytolysis, activation of HPMS and lysozyme liberation were normal (Table II). Monocytes and neutrophils from the parents revealed normal ADCC. Superoxide anion liberation after stimulation with phorbol myristate acetate ~ was normal in both monocytes and neutrophils, indicating a normal response in postphagocytic metabolism. The NBT slide test and results of tests for neutrophil glucose-6-phosphate dehydrogenase, 6-phosphogluconate dehydrogenase, glutathione reductase, glutathione peroxidase, and myeloperoxidase were all normal. Antituberculous chemotherapy with rifampicin, isoniazide, ethambutol, and Isoprodiane was established with excellent clinical effect within a few weeks and without significant side effects. After 2V2 months, we found complete normalization of laboratory tests other than monocyte ADCC and serum IgE concentration. During the first year of observation steady regression of osteolytic processes was seen; most of them have disappeared.

266

Brief clinical and laboratory observations

The Journal o[ Pediatrics June 1981

Table II. Cytotoxic function of monocytes and neutrophils in a patient with disseminated nontuberculous mycobacteriosis

ADCC Date Monocytes Aug. 16, 1979 Nov. 12, 1979 April 8, 1980 June 2, 1980 Normals (n = 6) Neutrophils June 2, 1980 Normals (n = 6)

Erythrocytes lysed per phagocyte

I

wm of "CO2 from (1-1~C)-glucose

Lysozymereleased (%)

0 aliberation (fmol/cell/min)

1.47 • 0.08

ND ND ND 1,740 3,160 • 270

ND ND ND 11.8 11.2 • 2.4

ND ND ND 2.3 2.5 + 0.16

1.010 0.98 _+ 0.08

4,850 5,100 _+ 430

13.4 15.1 _+ 2.1

12.8 13.0 • 0.08

0.993 1.091 0.901

0.850

[

During monocyteand neutrophilADCC cytolysisof sensitized erythrocytes, activationof HMPS and lysozymerelease was determined.Liberationof '4CO~ from (1-~4C)-glucosereflectsactivationof the HMPS. Erythrocyte to monocyteratio 8:1, incubationtime 18hr. Erythrocyte to neutrophilratio 4:1, incubation time 30 minutes. O~liberationfrom the phagocyteswas measured after stimulationwith 5 /~g/mlPMA.4 Therapy was initiated Aug. 3, 1979. DISCUSSION In two-thirds of the patients with disseminated M. intracellulare-avium infections reviewed by Wolinsky, ~ no underlying illness was documented, In the others, the patients most often had malignant hematologic diseases or underwent immunosuppressive treatment, including the use of steroids. However, in only a few of these patients were immunologic examinations performed. In our patient, we suggest a primary p u l m o n a r y infection with 34. intracellulare when 3Vz years of age, with dissemination of the infection seven years later. It cannot be ruled out that intermittent steroid therapy may have played a role in maintaining the infection, ~ but during the last five years before the infection spread he had received no steroids. We observed a sustained suppression of monocyte ADCC that has now lasted for nine months after clinical remission and normalization of other laboratory tests except for serum IgE. A primary defect in monocyte function may therefore be suggested, but we cannot definitely exclude the possibility that disease activity in the few remaining osteolytic processes may interfere with monocyte cytotoxicity. However, the normalization of lymphocyte function argues against this possibility. Our findings are consistent with another case report describing a defect of monocyte candidacidal activity but normal lymphocyte function in progressive dissemination of M. avium infection," but the defect has not been described in clinical remission. Depressed monocyte A D C C but normal neutrophil function has also been described during clinical remission of histiocytosis X/Interestingly, the histologic findings in our patient showed a proliferation of histiocytes resem-

bling a primary histiocytic disorder. This is often seen in disseminated nontuberculous diseases, 1 and in our patient it may be due to a failing i m m u n e response to the mycobacteriu m. We tried to elucidate the mechanisms behind the defective monocyte A D C C reaction. Although the activation of HMPS during monocyte A D C C was halved, the oxygen generating apparatus in monocytes was not defective as it is in chronic granulomatous disease/ since superoxide generation upon PMA stimulation was n o r m a l We have found both depressed monocyte and neutrophil ADCC, increased serum IgE values, but a normal oxygen generating apparatus in severe atopic dermatitis, s in which a defect in the initiation of monocyte ADCC is suspected? Our patient never had atopic dermatitis, however, and in patients with atopies other than atopic dermatitis we have found normal monocyte cytotoxicity, i~ Whether the monocyte defect is related to the impaired regulation of IgE cannot be deduced from this study, since we found no close correlation between depressed monocyte A D C C and increased serum IgE values in patients with atopic dermatitis. 10 Unlike the patients with hyper IgE syndrome described by Buckley et al, 1' our patient had normal neutrophil function, no pyogenic or mycotic infections, and no dermatitis. Monocytes and macrophages play a prominent role in the efferent arm of the i m m u n e response to infections with mycobacteria? The sustained depression of monocyte cytotoxicity even after clinical remission strongly indicates a causal relationship between the monocyte defect and the disseminated nontuberculous mycobacteriosis. The same specific monocyte defect is seen in histiocytosis X, 7 and it is conceivable that patients with

Volume 99 Number 2

Brief clinical and laboratory observations

this type of i m m u n e defect will react with histiocytic proliferation resembling reticuloendotheliosis in response to infections with M. intracellulare avium.

5. 6.

Dr. H.C. Engbaek, State Serum Institute, Copenhagen, is thanked for culturing the mycobacteria. Dr. G. Pallesen and Dr. J. Hastrup, Dep. of Pathology, Arhus Kommunehospital, are thanked for examining the histological preparations. We also wish to thank Mrs. Winnie Heidemann for expert technical assistance.

7.

8.

REFERENCES 1. Lincoln EM, and Gilbert LA: Disease in children due to Mycobacteria other than mycobacterium tuberculosis, Am Rev Respir Dis 105:683, 1972. 2. Wolinsky E: Nontuberculous mycobacteria and associated diseases, Am Rev Respir Dis 119:107, 1979. 3. Kragballe K, Ellegaard J, and Herlin T: Antibody-dependent monocyte-mediated cytotoxicity. The effects of adherence and removal of mononuclear phagocytic cells, and of in vitro incubation, Scand J Haematol 24:405, 1980. 4. Borregaard N, and Kragballe K: Role of oxygen in anti-

9.

10.

11.

267

body-dependent cytotoxicity mediated by monocytes and neutrophils, J Clin Invest 66:676, 1980. Dannenberg AM: Macrophages in inflammation and infection, N Engl J Med 293:489, 1975. Duriseti L, Galant S, Morozumi P, Green G, Lehrer R, and Shimizu I: Monocyte killing defect in disseminated atypical mycobacteriosis, Clin Res 26"184 A, 1978. Kragballe K, Zachariae H, Herlin T, and Jensen JR: Histiocytosis X an immunedeficiency? A study with antibody-dependent monocyte-mediated cytotoxicity, Br J Dermatol (in press). Kragballe K, and Borregaard N: Mechanism of decreased antibody-dependent cytotoxicity mediated by monocytes and neutrophils in atopic dermatitis, Acta Dermatovenerol 61:11, 1981. Kragballe K, and Herlin T: Antibody-dependent monocyte-mediated cytotoxicity in atopic dermatitis. Relation to clinical state and cAMP response, Allergy 36:27, 1981. Kragballe K, Herlin T, and Jensen JR: Impaired monocytemediated cytotoxicity in atopic dermatitis, Arch Derm Res 269:21, 1980. Buckley RH, Wray BB, and Belmaker EZ: Extreme hyperimmunoglobulinemia E and undue susceptibility to infection, Pediatrics 49:59, 1972.

Cupping lesions simulating child abuse Russell S. Asnes, M.D.,* and David H. Wisotsky, M.D., New York, N. Y.

P H Y S I C I A N S have b e c o m e increasingly knowledgeable a b o u t child abuse, and alert in considering this diagnosis. False accusations of child abuse m a y arise w h e n physicians fail to include certain cultural practices, such as Cao gio (coin r u b b i n g ) or cupping, in the differential diagnosis of traumatic skin lesions? The following case report describes a child who was found to have skin lesions suspicious of abuse. However, further evaluation revealed that the patient h a d d e r m a l manifestations of an infrequently e n c o u n t e r e d but previously accepted form of medical therapy. CASE REPORT An 8-year-old boy presented to our office with a five-day history of cough, coryza, and low-grade temperature elevation. The child and his family had recently immigrated to the United States from the U.S.S.R. During the initial nursing assessment the patient was found to have traumatic-appearing lesions on his

From the Department of Pediatrics, College of Physicians and Surgeons of Columbia University, and Englewood Hospital *Reprint address: 111 Dean Drive, Tenafly, NJ 07670.

0022-3476/81/080267 + 02500.20/0 9 1981 The C. V. Mosby Co.

back, and the physicians were alerted to the possibility of battering. Upon physical examination the child was found to be alert, happy, and responsive. The vital signs were normal and the height and weight were appropriate for age. There was evidence of a mild upper respiratory infection. Eight symmetrical, circular, ecchymotic lesions measuring 4 cm in diameter were on the child's back (Figure). There was no other evidence of trauma. The mother appeared embarrassed when the lesions were discovered. She related that they had resulted from cupping, a procedure she employed whenever her son was i11. The method had been taught to her by her own mother and was used by most of her relatives and friends in the U.S.S.R. The technique involved the heating of an eye cup or "shot glass" with a lighted cotton ball which had been soaked in alcohol. The cotton was discarded and the cup was applied firmly to the skin for several minutes. DISCUSSION T h e use of c u p p i n g as a therapeutic modality dates back to the fourth century BC. T h o m a s M a p l e r s o n ' s 1813 treatise on cupping gives credit to the Egyptians for the discovery of this technique. ~ Two forms of c u p p i n g