Bożena Mikołuć

Disseminated bacillus Calmette-Guérin infection and immunodeficiency.

To the Editor: Disseminated bacillus Calmette-Guerin (BCG) infection has been noted in patients with primary immunodeficiency. Incidence rates have ranged from 0.06 to 1.56 cases per million vaccinated, and mortality rates have remained at ≈60% (1–7). Of 946 patients with primary immunodeficiency, including 29 with severe combined immunodeficiencies, diagnosed from 1980 through 2006 at the Children’s Memorial Health Institute in Warsaw, adverse events after BCG vaccination were observed in 16 (8,9). All 16 were children who had been vaccinated at birth with BCG, Brazilian strain (BioMed, Lublin, Poland). Four patients with severe combined immunodeficiency showed adverse reactions to BCG. Patient M.K. had mild inflammation at the site of the BCG injection and was successfully treated with rifampin. The patient subsequently received a bone marrow transplant, and 2 months later poor appetite, failure to thrive, and subfebrile condition were noted. Disseminated skin changes (with pus formation in the subcutaneous layer), osteomyelitis, and multiple lesions in the liver were found. A skin biopsy showed tuberculoma formations, which were PCR-positive for Mycobacterium tuberculosis complex (Amplified Mycobacterium Tuberculosis Direct [MTD] Test, Gen-Probe, Inc., San Diego, CA, USA) but had negative culture results. Complete recovery, including full immunologic reconstitution, was reached after 12 months of treatment with triple antituberculosis (TB) therapy (rifampin, isoniazid, and ciprofloxacin). Patient M.C., a 6-month-old boy, was admitted to an intensive care unit because of respiratory insufficiency. An unhealed BCG vaccination site was noted. Bronchopulmonary lavage samples were tested for M. bovis; positive PCR and culture results led to the diagnosis of disseminated BCG infection. Despite intensive anti-TB therapy, the child died of multiple organ failure. Autopsy showed typical granuloma formations and a hypoplastic thymus, typical for severe combined immunodeficiency. Male patients S.D. and C.G. were admitted to intensive care units at 6 and 8 months of age, respectively, with lymphadenopathy and multiple organ insufficiency. Each boy died of multiple organ failure; postmortem examination found granuloma formation and a hypoplastic thymus in each (8). Eight patients with severe combined immunodeficiency had local adverse events after vaccination with BCG. Inflammation <1 cm in diameter at the vaccination site was observed for all 8. For all except 1, dual anti-TB therapy (rifampin, isoniazid) or monotherapy was successful. For 1 of these patients, anti-TB treatment was stopped 3 months after bone marrow transplant, but increasing inflammation and lymphadenitis appeared 1 month later, with positive PCR and negative culture results for Mycobacterium spp. After 12 months of triple anti-TB therapy, this patient fully recovered. In 2-month-old female patient, W.M., who had interferon-γ–receptor deficiency, axillary lymphadenopathy with normal healing of the vaccination site was noted 7 weeks after BCG vaccination. Tuberculous lymphadenitis was diagnosed by histopathologic methods. Despite dual anti-TB therapy and streptomycin administration, the girl died. At autopsy, multiple tuberculous granulomas were found (5). In 4-month-old female patient M.K., who had interleukin-2–receptor deficiency, axillary lymphadenopathy with positive results from Mycobacterium typing was noted. Dual anti-TB therapy for 12 months produced good results. In 7-month-old female patient B.B., axillary lymphadenopathy was noted. Mycobacteria PCR-positive for the M. tuberculosis complex were found in the purulent secretion. Despite dual anti-TB therapy, the patient experienced 2 episodes of relapse. After another 2 years of anti-TB therapy, disseminated BCG infection, with pulmonary consequences, developed. In patient R.C., a 6-month-old boy, osteomyelitis was diagnosed, and delayed healing of the BCG vaccination scar was noted. Investigation of his immunologic status showed no abnormalities. However, because granulomatous inflammation was present in a bone biopsy sample and staining for BCG produced a positive result, triple anti-TB therapy was provided for 12 months, with good results. The literature describes >200 cases of disseminated BCG infection in patients with primary immunodeficiency (1–7). The diagnostic difficulties described for 8 of our patients with primary immunodeficiency have been noted by others (1–6,8–10). In only 2 cases was the Mycobacterium species successfully isolated and identified as M. tuberculosis complex, and in 1 case it was the M. bovis BCG strain. We propose novel criteria for the diagnosis of disseminated BCG infection in persons with primary immunodeficiency (Table). These criteria have recently been submitted to the European Society for Immunodeficiencies. Table Suggested diagnostic criteria for disseminated bacillus Calmette-Guerin (BCG) infection in persons with primary immunodeficiency* We believe that patients with severe combined immunodeficiency and any form of mild local changes at the BCG injection site should be given anti-TB therapy, which should be continued until complete immunologic reconstitution occurs after bone marrow transplant. Disseminated BCG infection with regional lymph node involvement needs at least triple anti-TB therapy followed by long-term prophylaxis. Disseminated BCG infection needs anti-TB therapy, including ≥4 anti-TB drugs, until the patient fully recovers.

Application of derivative spectrophotometry for determination of coenzyme Q10 in pharmaceuticals and plasma

The use of derivative spectrophotometry is proposed in this work for determination of coenzyme Q10 in formulations and in human plasma. The spectrophotometric procedure is simpler and less expensive than chromatographic techniques commonly used for the analysis of coenzyme. The active compound can be determined in the range 0.25-10 ppm for standard solutions and pharmaceuticals and 0.05-1.5 ppm in plasma. The proposed method was applied for coenzyme determination in real samples. The results agree well with declared value and with these obtained by HPLC.

Oxidative stress, mitochondrial abnormalities and antioxidant defense in Ataxia-telangiectasia, Bloom syndrome and Nijmegen breakage syndrome.

Rare pleiotropic genetic disorders, Ataxia-telangiectasia (A-T), Bloom syndrome (BS) and Nijmegen breakage syndrome (NBS) are characterised by immunodeficiency, extreme radiosensitivity, higher cancer susceptibility, premature aging, neurodegeneration and insulin resistance. Some of these functional abnormalities can be explained by aberrant DNA damage response and chromosomal instability. It has been suggested that one possible common denominator of these conditions could be chronic oxidative stress caused by endogenous ROS overproduction and impairment of mitochondrial homeostasis. Recent studies indicate new, alternative sources of oxidative stress in A-T, BS and NBS cells, including NADPH oxidase 4 (NOX4), oxidised low-density lipoprotein (ox-LDL) or Poly (ADP-ribose) polymerases (PARP). Mitochondrial abnormalities such as changes in the ultrastructure and function of mitochondria, excess mROS production as well as mitochondrial damage have also been reported in A-T, BS and NBS cells. A-T, BS and NBS cells are inextricably linked to high levels of reactive oxygen species (ROS), and thereby, chronic oxidative stress may be a major phenotypic hallmark in these diseases. Due to the presence of mitochondrial disturbances, A-T, BS and NBS may be considered mitochondrial diseases. Excess activity of antioxidant enzymes and an insufficient amount of low molecular weight antioxidants indicate new pharmacological strategies for patients suffering from the aforementioned diseases. However, at the current stage of research we are unable to ascertain if antioxidants and free radical scavengers can improve the condition or prolong the survival time of A-T, BS and NBS patients. Therefore, it is necessary to conduct experimental studies in a human model.

Treosulfan-based conditioning regimen in a second matched unrelated peripheral blood stem cell transplantation for a pediatric patient with CGD and invasive aspergillosis, who experienced initial graft failure after RIC.

Chronic granulomatous disease (CGD) is a rare primary immunodeficiency caused by a defect of phagocyte NADPH-oxidase and characterized by severe, recurrent bacterial and fungal infections. Invasive aspergillosis (IA) is the leading cause of mortality in patients with CGD. We report the case of a 3-year-old boy with CGD, who developed IA despite antifungal prophylaxis. His treatment consisted of a 10-month-long multi-drug antifungal therapy, together with surgery, but these did not cause any substantial clinical improvement. BMT in high-risk patients with CGD remains a challenge due to both, higher risk of graft rejection and inflammatory flare in the course of immune recovery. Our patient rejected the first matched unrelated donor (MUD) allograft after RIC regimen recommended by the EBMT Inborn Errors Working Party for high-risk patients. After treosulfan-based conditioning and second MUD peripheral blood stem cell transplantation both, full reconstitution of the granulocytic series and complete recovery from IA, were achieved.

Comparison of Selected Parameters of Redox Homeostasis in Patients with Ataxia-Telangiectasia and Nijmegen Breakage Syndrome

This study compared the antioxidant status and major lipophilic antioxidants in patients with ataxia-telangiectasia (AT) and Nijmegen breakage syndrome (NBS). Total antioxidant status (TAS), total oxidant status (TOS), oxidative stress index (OSI), and concentrations of coenzyme Q10 (CoQ10) and vitamins A and E were estimated in the plasma of 22 patients with AT, 12 children with NBS, and the healthy controls. In AT patients, TAS (median 261.7 μmol/L) was statistically lower but TOS (496.8 μmol/L) was significantly elevated in comparison with the healthy group (312.7 μmol/L and 311.2 μmol/L, resp.). Tocopherol (0.8 μg/mL) and CoQ10 (0.1 μg/mL) were reduced in AT patients versus control (1.4 μg/mL and 0.3 μg/mL, resp.). NBS patients also displayed statistically lower TAS levels (290.3 μmol/L), while TOS (404.8 μmol/L) was comparable to the controls. We found that in NBS patients retinol concentration (0.1 μg/mL) was highly elevated and CoQ10 (0.1 μg/mL) was significantly lower in comparison with those in the healthy group. Our study confirms disturbances in redox homeostasis in AT and NBS patients and indicates a need for diagnosing oxidative stress in those cases as a potential disease biomarker. Decreased CoQ10 concentration found in NBS and AT indicates a need for possible supplementation.

Whey Protein Concentrate WPC-80 Improves Antioxidant Defense Systems in the Salivary Glands of 14-Month Wistar Rats

Whey protein concentrate (WPC) is characterized by powerful antioxidant properties, but its effect on redox homeostasis of salivary glands of aging organisms is still unknown. In this study, we are the first to evaluate the antioxidant barrier of salivary glands of 14-month Wistar rats fed WPC-80. Total antioxidant status (TAS), total oxidant status (TOS), oxidative stress index (OSI), activities of glutathione peroxidase (GPx), superoxide dismutase (SOD), catalase (CAT) as well as concentrations of reduced glutathione (GSH) are estimated in the submandibular and parotid glands of rats administered WPC-80 intragastrically for a period of 7 and 14 days. We demonstrate a significant increase in GSH, GPx and SOD in the salivary glands of rats fed WPC-80 for 14 days and a significant increase in TAS, GPx and SOD in the parotid glands of rats fed WPC-80 for 7 days compared to control rats. The beneficial effects of WPC-80 on salivary glands are also demonstrated by lower TOS and OSI in the parotid glands of rats fed WPC-80 compared to the submandibular glands. In summary, we demonstrate that WPC-80 improves redox homeostasis in salivary glands, particularly in the parotid glands of old rats.

Neutrophil Phenotypic Characteristics in Children with Congenital Asplenia and Splenectomized for Hereditary Spherocytosis

The spleen plays an important role in the granulocyte homeostasis due to such mechanisms as pooling, elimination of senescent cells and regulatory effects on granulocyte renewal in the bone marrow. The expression profile of granulocyte receptors was tested in children with congenital asplenia, and splenectomized for spherocytosis. Receptors tested included those appearing with maturation (CD16, CD11b, CD11c, TREM-1), disappearing (CD54, CD49d, CD64) and maintained during maturation (CD11a, CD45). In general, we found that the circulating granulocyte pool in the asplenic patients had phenotypical features of highly matured but not apoptotic neutrophils with a significantly elevated expression of CD16 (CD16high), tendency to a lower expression of CD45 (CD45low) and an unchanged expression of CD64 (and other markers indicating systemic inflammatory reactions). The high fluorescence intensity of CD11b,c, and TREM-1 in the congenital asplenia may indicate a potentially elevated pro-inflammatory status of granulocytes, possibly due to the low activity of vagus nerve and spleen-dependent cholinergic anti-inflammatory pathway.

Ocena realizacji zaleceń żywieniowych oraz profilu lipidowego w surowicy krwi dzieci chorych na fenyloketonurię

Streszczenie Cel badania Ocena realizacji zalecen dotyczących spozycia bialka, weglowodanow, tluszczow i energii w diecie dzieci chorych na fenyloketonurie oraz profilu lipidowego surowicy tych dzieci w odniesieniu do grupy kontrolnej. Material i metody Do grupy badanej wlączono 107 dzieci (46 dziewcząt i 61 chlopcow) w wieku średnio 8,8 lat (SD 2,06) chorych na fenyloketonurie rozpoznaną w okresie noworodkowym na podstawie skryningu populacyjnego. U wszystkich dzieci przeprowadzono analize wywiadu zywieniowego, ocene stezenia cholesterolu, cholesterolu lipoprotein HDL i trojglicerydow, w surowicy krwi. Grupe kontrolną stanowilo 62 zdrowych dzieci (31 dziewcząt i 31 chlopcow) w wieku średnio 8,6 lat (SD 1,1) ktore nigdy nie wymagaly leczenia dietetycznego. Wyniki Przeprowadzone badania wykazaly, ze dieta badanych dzieci chorych na fenyloketonurie prawidlowo zbilansowana w zakresie podazy bialka i Phe moze wiązac sie z nieprawidlową realizacją zapotrzebowania na tluszcze i energie. Profil lipidowy dzieci z PKU odniesiony do norm dla dzieci zdrowych, poza podwyzszonym stezeniem trojglicerydow, jest korzystniejszy z punktu widzenia prewencji procesu miazdzycowego. Wniosek Dieta dziecka chorego na fenyloketonurie poza odpowiednią podazą bialka i Phe wymaga takze prawidlowego zbilansowana pod wzgledem ilości spozywanych kalorii i tluszczow.

Vitamin D deficiency in children with recurrent respiratory infections, with or without immunoglobulin deficiency

PURPOSE The objective of this study was to evaluate thevitamin D concentration in patients with recurrent respiratory infections with or without immunoglobulin G, A or M (IgG, IgA, IgM) deficiency, and to find a correlation between the vitamin D concentration and the response to hepatitis B vaccination. MATERIALS AND METHOD The study involved 730 patients with recurrent respiratory infections. The concentration of 25-hydroxyvitamin D (25(OH)D), immunoglobulins G, A and M, anti-HBs was determined. RESULTS The tests showed that 11% of patients presented IgG levels below the age related reference values. Children with reduced IgG concentration were also found to have significantly lower vitamin D concentrations in comparison to children with normal IgG. Vitamin D deficiency was observed in schoolchildren between 7 and 18 years of age. No correlation was found between 25(OH)D concentration and Hbs antibody levels. CONCLUSIONS An investigation of a large group of patients who have recurrent infection found patients with IgG deficiency to whom special proceeding have to be performed: 1. Significantly lower vitamin D concentration observed in the group of children with IgG deficiency implicated in long-lasting monitoring of vitamin D level require adding to the practice guidelines for Central Europe 2013. 2. Intervention treatment with suitable doses of vitamin D to clarified metabolism of vitamin D has to be plan for children with IgG deficiency and significant lower vitamin D concentration.

Gastrointestinal disorders next to respiratory infections as leading symptoms of X-linked agammaglobulinemia in children – 34-year experience of a single center

Introduction Respiratory tract infections constitute the most frequent manifestation of X-linked agammaglobulinemia (XLA). There are not many papers elucidating gastrointestinal (GI) disorders, including inflammatory bowel disease (IBD), in such patients. The aim of the study was to evaluate the occurrence of gastrointestinal disorders and IBD compared to respiratory tract infections in XLA individuals. Material and methods Of 1563 patients with primary immunodeficiencies diagnosed in the Department of Immunology, the Children’s Memorial Health Institute (CMHI), 66 boys had a provisional diagnosis of agammaglobulinemia. Forty-four subjects fulfilled definitive ESID (European Society for Immunodeficiencies) diagnostic criteria of XLA. A retrospective analysis of medical history of XLA patients was undertaken. Results Recurrent respiratory tract infections, particularly bronchitis (73%) and pneumonia (59%), were the most common symptoms of XLA. The GI disorders constituted the next main manifestation (63.6%), followed by upper respiratory tract infections. Twenty-six of 28 XLA patients with GI disorders complained of diarrhea, which was resolved generally after immunoglobulin therapy introduction. Single but prolonged episodes of Campylobacter jejuni diarrhea were reported in two individuals. Inflammatory bowel disease of mild to moderate activity was diagnosed in 1 patient, and local enteritis of mild activity in another one. Conclusions Gastrointestinal disorders were one of the main manifestations of XLA, reported almost as often as lower respiratory tract infections. The most common GI symptom was diarrhea, which usually resolved after immunoglobulin therapy was started. Infections caused by Giardia lamblia were reported occasionally. Inflammatory bowel disease was diagnosed quite exceptionally, which presumably may be connected with normal T cell immunity.