Postgrad. med. J. (February 1969) 45, 116-128. Postgrad Med J: first published as 10.1136/pgmj.45.520.116 on 1 February 1969. Downloaded from

The gamma system, pathology and therapeutics

RICARDO HORACIO DE LELLIS M.D. Docente auturizado de Pediatriz de la facultad de Medicinz de Buenos Aires, Medico de los Hospitale del Hospital de Pediatria Pedro de Elizalde, Buenos Aires

Hypothesis for the integration of childhood immunity Ford & Micklem, 1963; Harris & Ford, 1964). Thus Advances in the immunobiology of the , bone-marrow cells may replace the thymus after immunological competence and radiation induced of the thymus. These cells have made it necessary to attempt a provisional may acquire 'distinguishing' properties in the scheme to describe the interplay of 'germ and soil'. thymus (Metcalfe, 1964; Auerbach, 1966) and lose Good & Papermaster (1964) have emphasized the the property of repopulating the significance of adaptive immunity which is charac- (Dustin & Gregorie, 1931; Ford, 1966). terized by an immunological memory, the second phase of the homograft reaction and the secondary immunological response. Recently the thymus has Lymphopoiesis in the thymus been ascribed a fundamental place in the phylo- In the initial stages of ontogenesis, thymic genetic and ontogenetic development ofthe lymphoid lymphopoiesis appears to be autonomous. InProtected by copyright. system of the higher vertebrates. The inheritance of succeeding stages it may derive from circulating genetic information for the development of this precursors which settle in the thymus and differen- potential is transmitted through the lymphoid tiate (Trinin & Law, 1963; Sainte Marie & Leblond, system of mammals (Fig. 1). The thymus may be 1964); Ford, 1966. Fragments of thymus in tissue involved in the differentiation and maintenance of culture becomes differentiated by the seventh day. the potential for synthesis, but the mainten- The spleen and bone-marrow do not form lymphoid ance of the synthesis of takes place in tissue, whereas the thymus forms lymphoid tissue mature, immunocompetent cells (Talmage & independently (Auerbach, 1966). Thymic lympho- Claman, 1964). cytes are of entodermal origin in contrast to peri- Both lymphopoiesis and immunogenesis have pheral which are of mesenchymal different aspects depending upon whether they are origin (Sainte Marie & Leblond, 1964). considered in the context of the thymus or the The thymus differs from the remainder of the peripheral lymphoid system. It can be assumed that lymphoid system in the following respects: (1) the there exists a central (thymic) and peripheral mitotic index is ten times greater in the thymus http://pmj.bmj.com/ lymphopoiesis in the same way that there is thymic than in peripheral lymphoid organs; (2) it becomes and peripheral immunogenesis. The first is charac- involuted with age; (3) the mitotic indices are un- terized, at any rate in the early periods of life, by affected by antigenic stimulation; (4) the weight is increased proliferation of lymphoid cells, the extent uninfluenced by peripheral lymphoid tissue; (5) of which appears to be genetically determined and implants of thymic tissue grow in the same way in to decline with age (Metcalf, 1956). Peripheral thymectomized subjects as in controls; and (6) its would thus be and is not reduced lymphopoiesis thymus-dependent proliferative activity by extraneous on September 29, 2021 by guest. increasingly -dependent with the progress of , and is comparable in intensity to that of maturation. many tumour cells. Central immunogenesis would be characterized by The proliferative stimulus would not operate the production of competent (uncommitted or 'x') diffusely since the thymus is constituted by indepen- cells (Ford, Gowans & McCullagh, 1966; Sterzl, dent subunits, each with its own source of prolifera- 1966) or by the differentiation of lymphocytes, tive stimulation. It may originate in the epithelial which, once they had reached a certain degree of cells of the medulla or indirectly via the reticular differentiation, would be liberated into the - cells of the cortex, possibly mediated by a humoral stream (Miller, 1961). Secondly the provision of a factor (Metcalf, 1966). milieu of immunological tolerance for lymphoid cells Clark (1966) confirmed the existence of secretory would allow the differentiation of immunologically material in the epithelial cells of mouse thymus competent cells (Miller, Marshall & White, 1962; medulla, and defined three stages of maturation in The gamma system, pathology and therapeutics 117 Postgrad Med J: first published as 10.1136/pgmj.45.520.116 on 1 February 1969. Downloaded from

Differentotion ond mointenance / \ of the potential

I Central lymphopoiesis c / T 0 CP / h 4 of the immunologicolly / Epithliol J competent cell call m Entoerm T o I e ra nc e

Blood-thymus barrier 111111111111111111111111111111111111111111111 1llllllllllllplnllllllllllll 111l 11111111111111 I n t I e ra n c e Small Iymphocy e FLS Change to periphery L Division and expression Y of the potential S M M , Peripheral lymphopoiesis Protected by copyright. Immunologicol competence H ______L P T r N Immune response e r 0 e v y n D Macrophoge-Smoll lymphocyta e e s

S ------Immunoblost P1Tmo cell -.-Lymphocytes - r r I rr I - --- - _____-I Secondary |

Hypooctive< \ Form I e s Subclinicol response Normolly active E< y-Globul ii Form2 http://pmj.bmj.com/

Hyperactive < ^ Form3 ^*'N^_ ____,____|_ Srcondary|/ hyperactivity

FIG. 1. Hypothesis for immunological integration in children. Inherited genetic information. on September 29, 2021 by guest.

relation to secretory content of a mucopolu- epithelial cell, large, medium and small lymphocytes saccharide acid sulphate: (1) densely basophilic (Dustin & Gregoire, 1931). The last of these are the granules before birth, (2) clusters of vacuoles after most differentiated () and are the product birth, and (3) PAS-sensitive amorphous inclusion of successive reduction mitoses (Sainte Marie & material 15 days after birth. Leblond, 1964). In summary, thymic lymphoiesis would appear to be autonomous in the initial stages of ontogenesis, Fate of the thymocytes it is stimulated by the epithelial cells of the medulla The thymus produces in its cortex more lympho- acting as subunits of stimulation and developing cytes than it needs for local development. The high according to an irreversible sequence: entoderm, mitotic activity in relation to the stability of the 118 Ricardo Horacio de Lellis Postgrad Med J: first published as 10.1136/pgmj.45.520.116 on 1 February 1969. Downloaded from organ raises two possibilities, that either the small Claman & Talmage, 1963; Nossal & Mitchell, 1966). degenerates and is destroyed in the A series of experimental investigations have thymus or that it migrates. The first alternative is demonstrated that thymic lymphoid cells can pro- most likely since the ratio of the number of mitotic duce antibodies (Miller et al., 1962), can become cells to the number of pyknotic cells is related to the immunologically competent and can re-establish the weight of the organ and falls with involution. The immunological activity of thymectomized animals second alternative is suggested by the effects of (Yunis et al., 1964). The thymocytes of mice and rats thymectomy and of thymic extract on peripheral immunized with tetanus toxin are capable ofactivat- lymphopoiesis. A direct or humoral stimulus might ing an immune response when transferred to regulate the production and maturation of the isologous, irradiated recipients (Stoner & Bond, peripheral lymphoid system. 1963). Thymic tissue transplanted to the anterior Some authors believe that the never chamber of the eye of an irradiated mouse, produces leaves the thymus, but that nucleoproteins accumu- a specific antibody response, and isolated thymic lated in pyknotic cells are discharged and utilised in cells are also capable of producing a reaction rapid cell division elsewhere (Ford, 1966). The between graft and host in newly born mice (Miller, thymus would thus be a reservoir for DNA which 1964). could be utilized at any time (Bryant, 1962). Despite this the potential immune response of the Transplantation of thymocytes and lymphocytes lymphoid thymic cells in the intact animal is im- labelled with 32p gives rise in the to both paired by the existence of a blood-thymus barrier so homologous and heterologous thymocytes (Fich- that the antigen cannot be fixed by the thymus. In telius & Bryant, 1964). Labelled chromosome contrast to other lymphoid tissue in the normal studies have demonstrated that lymphoid cells join animal neither secondary follicles nor plasma cells the peripheral after a period of are developed (Miller et al., 1962).

residence in the thymus (Ford & Micklem, 1963). The blood-thymus barrier has, however, anProtected by copyright. The difficulty in establishing the migration of the evolving character and is not complete for all thymocyte beyond doubt resides in the difficulty of antigens. In adult rats there is a partial barrier but labelling thymic cells without simultaneously label- in the newborn it is ineffective for both soluble anti- ling lymphoid cells. Nossal injected thymidine gens (bovine serum albumin) and specific (S. directly into the thymus of the guinea-pig with adelaide) antigens. It can be shown that the barrier minimal involvement of the other organs and found begins to develop in the rat after the 3rd week of life a ratio of one labelled thymic cell per 50,000 in the and is linked in the 6th week to restricted perme- lymph nodes. While confirming the migration of ability similar to that of the adult (Nossal, thymocytes to the periphery, this low incidence 1966). indicated that this occurs to a limited extent (Nossal, 1964; Metcalf, 1964). Immunological competence The spread to the periphery of the lymphoid The thymic barrier and immunological tolerance system (Archer et al., 1962) forms a process of

When the thymocyte leaves the thymus, it aban- maturation with phylo- and ontogenetic specificities http://pmj.bmj.com/ dons an environment of immunological tolerance. and serves to integrate the individual into distinct Immunotolerance is a state of non-reactivity to levels of potential immune response according to agents which are antigenic in other circumstances, two main logical and functional thymus-dependent and is associated with the differentiation between differentiation, secondly, the progressive develop- self and non-self established during embryonic life ment at the periphery of the antigen-dependent (Burnet, 1961; Mackay & Burnet, 1963). It is specific immunological response. for antigens to which the immature animal is Peripheral lymphopoiesis differs from thymic exposed and its persistence often depends upon their lymphopoiesis by the differing sensitivites of the on September 29, 2021 by guest. continued existence within the recipient tissues. The two systems to corticosteroids, sex hormones, antigen may thus direct the lymphoid cell towards irradiation and inanition, all of which have a smaller either immunity or tolerance. The dose and age are effect upon the peripheral system (Dougherty, 1952). factors which influence this although the cellular Two mechanisms are utilized, the exposure of the mechanism is not understood. Tolerance can be lymphoid cells of these organs to external antigens, induced by low and persistent concentration of the the other is not fully understood because of the antigen but can continue without it in a tolerant difficulty in measuring the liberation of cells pre- cell population. Tolerance, which is permanent, may formed in the thymus. It is not known whether the be attained by thymectomy or by the maintenance thymic precursors in the peripheral lymphoid system of the antigen in diffuse form until lymphogenesis are stimulated by a factor for lymphopoietic stimula- has been exhausted (Brent & Gowland, 1963; tion (FLS) or whether the stimulus is a direct one The gamma system, pathology and therapeutics 119 Postgrad Med J: first published as 10.1136/pgmj.45.520.116 on 1 February 1969. Downloaded from to the committed cells. With both precompetence or lymphocytosis in newborn and thymectomized competence, FLS might stimulate the maturation adult mice (Metcalf, 1964). Extracts of thymus in- of the non-competent cell (Metcalf, 1964). Peri- jected into adult rats rendered lymphopenic by pheral thymus-dependent lymphopoiesis is affected irradiation, restore the number of circulating by thymectomy and thymic extracts as in the case lymphocytes to normal values (Camblin & Bridges, of defective peripheral lymphoid development with 1964). Extracts of rabbit thymus irradiated with normal thymic lymphopoiesis in 'germ free' develop- doses sufficient to destroy the lymphoid cells ment, where antigenic stimulation has been reduced injected into adult rats produce a lymphoid hyper- to a minimum (Gordon, 1959). Immunological plasia (Gregoire & Duchateau, 1956), cell free competence is manifest beyond the thymic barrier extracts of thymus also stimulate lymphopoiesis under the influence of antigenic stimulation even (Kunii, Firth & Berwick, 1966). Finally, extracts of though much of this may be thymus-dependent. It thymus from rats, mice and calves, cause an increase appears essential even in adult life to maintain a pool in the uptake of radioactive precursors of DNA of immunologically competent cells. and ganglion proteins by mouse lymph nodes, but The effect of thymectomy in mice upon the extracts of other lymphoid organs and external development of immune capacity by peripheral proteins give negative results (Klein, Goldstein & lymphoid tissue diminishes progressively with age. White, 1965). Even if this procedure does not provoke in the adult The stimulation of lymphoid development in the mouse the same immediate impairment as in the germ-free animal produces appreciable mitotic newborn, this decline appears 6-9 months later. activity in the cells of lymphoid tissues, which pre- The delay may be due to the existence of a reservoir cedes antibody production (Leduc, Coons & of immunologically competent cells produced Connoly, 1955). This stimulation thus seems to before the thymectomy (Miller, 1964). The same accelerate thymus-induced production in these considerations apply to the 'germ free' mouse in peripheral organs (Gluberson & Auerbach, 1964; Protected by copyright. which the immunological capacity of the cells of the Leuchars, Davis & Koller, 1966). spleen increases progressively until 8 months of age, The repeated exposure to infection would seem to but then declines (Makinodan & Petersen, 1967). initiate the conditions of regional immunity which The colonization by the thymocyte of the peri- free these centres from dependence on the thymus. pheral lymphoid system (Fichtelius & Diderholm, The increase in the concentration of antibodies in 1959; Everett, Rieke & Caffrey, 1964) demonstrates the blood leads to a progressive decline in thymus- that normal thymic cells and some cells of other dependent lymphopoiesis and immunogenesis origin which have resided in the thymus, have a (Albright, Capalbo & Makinodan, 1964). particular capacity to establish and grow in the (Ford, 1966). During the first stages of onto- The immune response genesis the thymus produces lymphocytes in the There is no agreement as to whether the lymphoid epithelial cells of the medulla, they migrate and cell becomes competent within the thymus (Sterzl, settle in the spleen and in the lymphatic nodes 1966) as thymus cells derived from the ectoderm in (Levey, Trinin & Lay, 1963; Feldman & Mekori, early life (Metcalf, 1966) or outside the thymus http://pmj.bmj.com/ 1966). Thus cells of the spleen in the 15-day-old through the action of FLS (Taylor, 1963; Defendi, chick are of thymic origin (Aspinall et al., 1963) Roosa & Koprowski, 1966). and small lymphocytes in the thoracic duct of the rat The first response converts the competent cell into labelled with tritiated thymidine 'home' to the spleen, a committed one and this then produces the secon- lymph nodes and Peyer's patches (Gowans, 1964). dary response by means of the small lymphocyte The FLS theory was originally proposed by which is the carrier of the immune memory (Fichte- Metcalf (1956). Thermolabile extract from adult lius & Diderholm, 1959). Two classes of small mice injected into newborn rats and the thymecto- lymphocyte seem to exist: one potentially capable on September 29, 2021 by guest. mized adult caused an increase in circulating of initiating a response (competent or uncommitted) lymphocytes which was attributed to lymphopoietic and the other with the capacity only for a specific stimulation (Metcalf, 1956). Intraperitoneal capsules response (committed). Sterzl has named those cells containing newborn thymic tissue implanted into which acquire their immunological competence thymectomized mice, are able to make good deficient before migrating to the peripheral tissues 'x' cells, FLS (Osoba & Miller, 1964). 'y' cells those which are produced in response to FLS is produced by the reticulo-endothelial cells activation by them, and 'z' cells those which differen- of the medulla, is filtrable, thermolabile, non-dialys- tiate from the 'y' cell in the secondary response able. It is present in normal blood, and increased (Ford et al., 1966; Sterzl, 1966). concentrations occur in leukaemia. Extract of the The 'immunocytic complex' (Dameshek, 1966) in- thymus of adult mice and of human subjects produce cludes cellular forms which participate in prolifera- 120 Ricardo Horacio de Lellis Postgrad Med J: first published as 10.1136/pgmj.45.520.116 on 1 February 1969. Downloaded from tive activity induced by the antigen. It includes three migrates rapidly have demonstrated a recently stages: (1) during which the antigen is acquired immune role in contrast to yM and yG broken up by the (histiocytes); (2) in their complexes (de Lellis & Winckler, 1966). information in which an aggregation of lymphocytes Sahiar & Schwartz (1964) suggested a possible with foot appendages obtain specific information feed-back sequence in the immune response starting from the macrophages; and (3) immunological with the production of yM. This would be produced activity: some of these lymphocytes differentiate by the immunoblast and by 6-mercaptopurine, and into large pironinophilic cells (immunoblasts) which would block the production of yG. yA is a vehicle for become dedifferentiated into two cellular forms antibodies and secretions, but its origin has not yet according to the type of stimulating antigen, been determined. lymphocytes, and plasma cells (Dameshek, 1966). The passage of information from to lymphocyte has been suggested (McFarland & Primary and secondary dysgammaglobulinaemias Heilmann, 1965) and antigen has been shown to Our experience ofchanges in the system in states of form a complex with macrophage RNA, which is susceptibility to infection, particularly in the 1st year capable of stimulating antibody formation by of life, has enabled us to define by clinical, haemato- lymph node cells (Fischman & Alder, 1963; Nossal, logical, therapeutic criteria, three levels of response. Ada & Austin, 1964; Askonas & Rhodes, 1965; Both types of autonomous lymphopoiesis, differen- Friedman, Stavitsky & Solomon, 1965. It is not tiate the immunologically competent cell, thymus- enough to find antigen in the lymphocyte; it is also dependent in the embryonic state, and in more necessary to determine the exact origin ofthe plasma advanced stages, from extrathymic precursors. The cell whose division is preceded by that of the progressive development of immunological com- large basophilic blast cells (Schodley, 1961; Congdom petence is determined in close relation to antigen & Duda, 1961; Nossal & Makela, 1962; Dutton, induced peripheral lymphopoiesis, initiated by dis-Protected by copyright. Eady & Belman, 1963). Two lines of lymphoid cells semination of the thymocyte and influenced either develop into cells which contain antibodies, plasma directly or indirectly through FLS. The system is cells and lymphokinecytes. The latter are medium subject to the participation of the immunocytic and small lymphocytes which contain specific complex in the immune response and the production antibody and incorporate labelled DNA from pre- of the immunological memory. cursors resembling blast cells. Adult plasma cells The whole of the process of peripheral develop- do not divide and can be considered terminal cells. ment possesses quantitative and qualitative aspects Some small lymphocytes have an endoplasmic which are closely linked to the levels of integration reticular network and contain or produce antibody. which we are proposing. The child in early infancy In conclusion it would seem likely that plasma cells has at least three modes of clinical response: which are derived from lymphocytes. can clinically be identified by: (a) occurrence during the 2nd month of life; (b) cyclical infections; Immunoglobulins (c) ineffectiveness of antibiotics and chemotherapy The immunoglobulins are the final product of the in preventing reinfections; and (d) response to http://pmj.bmj.com/ immunocytic complex, the product of the immuno- therapy with y-globulin. logically competent cell. The synthesis of yA, yM, Form 1: Fever and lymphoid hypertrophy; form yG, the most studied immunoglobulins of 'Gamma 2, catarrhal, with progressive lymphoid develop- system' (Heremans, 1960), appear to have a sequence ment and form 3, spasmodic bronchitis with whose stages have hardly been elucidated. yM is lymphoid hypertrophy. The y system has a differen- produced as the first humoral response to antigenic tial pattern for each clinical form especially regard- stimulation; yG results from the secretion of plasma ing the development and rapid The former ofyA yG. on September 29, 2021 by guest. cells in the second stage of the mechanism set into is absent in the febrile form, normal in the catarrhal, motion by the action of the antigen. The early and frequently raised in form 3. Rapid yG is absent mobilization of yM with the production of poorly in the more immature form, decreased in form 2 specific antibodies would seem to represent a and normal in form 3 (de Lellis & Winckler, 1967, rudimentary onto- and phylogenetic mechanism 1968). initiated by various natural antigens, usually related Apart from situations in which the 'soil' plays a to viruses, Gram-negative bacteria, hydrocarbon decisive part in the infection (primary dysgamma- antigens and iso- and autoantibodies (Schultze, globulinaemias) the remaining conditions are more 1959; Schwick, 1966). yG is the vehicle for highly diffuse and bacterial or viral antigens are of com- specific and delayed antibodies; so that infections paratively greater significance. In these the course increased the potential of yG in childhood. Our may be either secondary hyperimmunoglobulin- studies on the electrophoretic fraction of yG which aemia, in which the overproduction of immuno- The gamma system, pathology and therapeutics 121 Postgrad Med J: first published as 10.1136/pgmj.45.520.116 on 1 February 1969. Downloaded from globulins is related to the duration of contact be- had previous experience of similar antigens. We tween the antigen and the immune systems, or put forward five clinical criteria of normality: secondary hypoimmunoglobulinaemia in which History. The absence of the smallest clinical deficient synthesis, accelerated catabolism or in- episode of an infectious nature with generalized creased secretory loss from the immunologically symptoms and partial clinical expression. The levels competent cell occur. of immunity in the experimental animal related to From the therapeutic view point the primary the existence of bacteraemia, local lesions and latent dysgammaglobulinaemias are specifically influenced infections may be the mold for this clinical picture by therapeutic y-globulin while, unlike the secondary (Boyd, 1943). dysgammaglobulinaemias, they are insensitive to Examination. The development of the proposed the antibiotics and chemotherapeutic agents. The immunological scheme (Fig. 1) ascribes to it a narrow therapeutic effect of the y-globulin and the pre- connection with the immunological development of dominant symptomatology of the primary dys- the child, however imprecise. gammaglobulinaemias suggest certain features of Humoral. This utilizes the technique of protein their pathophysiology. Form 1 can be explained fractionation for the evaluation of the immune in the terms of a stimulant (or deficiency of a globulins and their relation to the normal protein depressant) which enters allosteric combination with picture. the repressing substance (aporepressant) of the regu- Biological. Measurement of the capacity for anti- lating gene, and initiates the mechanism of the body production of delayed sensitivity and graft operant gene (Jacob & Monod, 1961). This would rejection. explain the therapeutic effectiveness of small doses Histological. This can be obtained by biopsy of of y-globulin. In the children studied effects were the lymphatic organs. similar with doses of 150, 300, 600 and 900 mg. Our normal subjects were selected using 1-3 and

At the cellular level another explanation for the the physiological variations of immunoglobulin Protected by copyright. failure of differentiation of precursors into plasma levels were evaluated by comparing the levels of cells may be due to an inability to circumscribe the intensity of gel precipitation lines with the quanti- antigen (Nossal & Mitchell, 1966). The passage of tative values of adults (Table 1). the antigen into solution may disseminate the anti- without in sector and gen blockage any lymphoid TABLE 1. y-Globulin levels in children aged 0-2 years thus determine the clinical picture in prolonged (gel precipitation) febrile illness. There may also exist low doses of or failure in the y-Globulin antigen processing of this by the Age (months)y-Glo macrophages. This could be considered to be a state A M Gr GI of clinical tolerance to the antigen with a permeable thymic barrier. 0-2 (-) (±) (++) (+++) In 2-4 () (+) (+) (+ ++) dysgammaglobulinaemia 2 a change in these 4-8 (+) (+)(++) (+++) circumstances and the degree of maturation would 7-24 (++) (+-+) (+++) (++±+) allow a rapid increase in the immune response in http://pmj.bmj.com/ response to the succession of infectious experiences. Form 3 can be explained in accord with Azar (1964) These values are subject to physiological varia- by the production of a crude y-globulin which, tions, especially in the young infant. The newborn despite normal blood levels, is not completely has values similar to those of the adult and even effective resulting in defect in the small lymphocyte higher than those of the mother. The blood concen- with the genetic information of the thymus. A single tration follows a downward course from the 6th clone would be produced in potential for responding week and reaches its lowest point between the 2nd to other antigenic stimuli. and 4th month, thereafter it rises, and reaches adult on September 29, 2021 by guest. levels after 1 year. We postulate that the high con- centration of yG of the newborn occurs at the Pathophysiology of the gamma system expense of the rapid yG, which would appear to be of Immunologically normal child: physiological placental origin (de Lellis and Winckler, 1964b). It variations disappears progressively to a state of physiological There cannot be an absolute criterion of normality hypoglobulinaemia between the 2nd and 4th month. for the immunological state of a child just as it is This physiological deficit seems to occur at the not possible to measure the primary immune expense of rapid yG. response to the first antigenic stimulus. Where The subsequent rise occurs as a consequence of there is a powerful antibody response to a supposedly clinical or subclinical infections. We believe that primary stimulus it is probable that the child has rapid yG constitutes a molecular complex related to 122 Ricardo Ho racio de Lellis Postgrad Med J: first published as 10.1136/pgmj.45.520.116 on 1 February 1969. Downloaded from recent immunological stimuli (de Lellis & Winckler, In the first we have eight categories: (1) deficit of 1966). A, M and G; (2) deficit of A and M; (3) deficit of M; yM and yA do not cross the . The former (4) deficit of A; (5) deficit of G; (6) increase in A; increases rapidly in the 1st months of life and (7) increase in M; and (8) increase in A and M. reaches adult levels at about the 9th month. The Grades 1 and 2 both denote great variability of concentration of yA follows a more regular curve the immunoglobulins which is related to the clinical and in contrast to yM does not have the same initial picture. On the other hand malnourished patients in rise, but is apparently absent during the 1st month grade 3 are characterized by reduced mobility of the and reaches adult levels after 2 years. y system with either: (1) generally increased im- munoglobulins, or (2) increased A and G with absent M. In contrast with the first group, the sympto- Primary dysgammaglobulinaemias matology has a uniform aspect, similar from one This term refers to the changes in the system in child to the next, with predominance of focal infec- which immaturity, or maladjustment of the immuno- tion and an absence of an acute septicaemic picture, logical integration of the child is responsible for occasional fever and a tendency to lymphocytosis. infective symptomatology to a greater extent than The results reveal that the grade of the malnutri- the actual aetiological agent. The cyclical or recur- tion determines the differential pattern of the y rent nature of the episodes constitute a clear expres- system. We suggest that the inadequate y system sion of the host pathology. Otherwise it must be (grades 1 and 2) or adequate (grade 3) primarily or supposed that the child is infected regularly, but secondarily affected (dysgammaglobulinaemia of the fortuitously by the same or different organisms, at primary and secondary type) is responsible for the intervals of 20-30 days, which would be unlikely. grade of malnutrition. In summary, malnutrition Using the five listed criteria, three clinical forms grades 1 and 2 tend to be associated with hypo- can be differentiated. immunoglobulinaemia and malnutrition grade 3 Protected by copyright. Symptomatology. Form 1 is febrile, Form 2 tends towards hyperimmunoglobulinaemia. catarrhal (adenoiditis, angina, otitis, catarrhal The possible courses ofthe malnutrition ofthe first bronchitis, pneumonias), Form 3 is one of spasmodic and second grade are: (1) recovery; (2) higher bronchitis. mortality; (3) higher mortality before passage into Lymphoid tissue development. The tonsils, sub- the third grade; and (4) passage to the third grade. maxillary nodes and the spleen are small in Form 1, In their turn the severe malnutritions may follow a variable in Form 2 and hypertrophic in Form 3, in number of different courses, recovery, failure pro- which a hypertrophic thymus can also be seen on portionally less than grades 1 and 2, failure at a X-ray. later stage, i.e. after a further attack, passage to the Immunoelectrophoresis. Together with immuno- stage of atrophy. Children in the third grade who diffusion serotyping will differentiate qualitatively have gone through grades 1 and 2 of the malnutrition and quantitatively the patterns characteristic of each have increased immunoglobulin levels as they pass clinical form, Form 1 yA, yM and yG diminished; into the third grade. Form 3: normal or absent or raised It could not yA raised, yM be shown that: (1) those patients in http://pmj.bmj.com/ and yG normal. the first and second grades of malnutrition who Electrophoresis. Very reduced y-globulin in Form recover do so by virtue of the hypoimmunoglobulin- 1, reduced in Form 2, and normal in Form 3. Changes aemia; (2) those in the third grade had increased in the ol- and ac2-globulins in Forms 1 and 2 only. immunoglobulins in the second and third grades of Therapeutic. The action of y-globulin with varia- their malnutrition: or (3) that there was a possibility tions in response according to the clinical form of predicting the grade of involvement of the y (q.v.). system by the particular characteristics of the anti- gen. If alternatives (1) and (2) could be demon- on September 29, 2021 by guest. strated and the third set we could establish malnutrition aside, Infantile that the primary level of aptitude of the y system We will consider three grades of malnutrition up determines the grade of malnutrition. to the age of 2 years in relation to the percentage Present information supports the hypothesis of weight loss: up to 15, 15-30 and over 30%. The the immune aptitude of the grade 3 malnourished different patterns of the y system make it possible to subject, and is based on following evidence: (1) differentiate two immunological modalities which increased yA is a sign of a high level of immunity; appear to be related to the dominant clinical (2) the complete and constant development of rapid symptomatology-that shown by malnourished yG may represent an immature immunological patients in the first two grades (mild and moderate) immunoelectrophoretic zone in the infant; and (3) and those in the third grade (severe). the variability of the pattern in grades 1 and 2 The gamma system, pathology and therapeutics 123 signify inconstancy of response in contrast to the The atrophy which occurs after severe malnutri- Postgrad Med J: first published as 10.1136/pgmj.45.520.116 on 1 February 1969. Downloaded from uniformity of grade 3. From the point of view of tion has some features in common with the wasting immune-integration these subjects suffer from an syndrome which occurs in thymectomized mice and accelerated peripheralization, with a highly experi- guinea-pigs (Parrot & East, 1962; Miller, 1964). enced (de Lellis & Winckler, Since allogenic lymphoid cells accelerate the wasting 1966b, 1968b). disease a collapse of immunity with atrophy of the

IgA NO.of (mg/l00ml) Diagnosis cases 255075100 200 300 400 500 600 700 Newborn 32 1 Premature 0I Agammaglobulinaemia 2 Dysgammaglobulinaemia I 12 Dysgammaglobulinaemia I 84 i Dysgammaglobulinaemia m 47 Normal children 6 Normal adults 20 i Multifocal pneumonia 22 Unifocal pneumonia 28 Pneumonitis 13 Malnutrition grades I and I 25 i Malnutrition grade m 17 Sepsis 16 Tuberculosis 5 Asthma 38 - I * Catarrhal bronchitis 8 l Collagenosis 12 HAVA 7 1

Nephropathies 18 Protected by copyright. Haemolytic-uraemic syndrome 17 Hypertrophic thymus 7 * I Total 456 li. FIG. 2. Concentrations of IgA in children (Plate method).

IgM (mg/100 ml) Nacof Diagnosis cases 25 50 75 100 2 0 300 400 50 6000 __ Newborn 32 Premature 10 Agammaglobulinaemia 2 Dysgammaglobulinaemia I 2 1 Dysgammaglobulinaemia II 84 _

Dysgammaglobulinaemia 47 * l http://pmj.bmj.com/ Normal children 16 . Normal adults 20 ' Multifocal pneumonia 22 I Unifocal pneumonia 28 Pneumonitis 13 Catarrhal bronchitis 8 - Asthma 38 _ Malnutrition grades I and II 25

Malnutrition grade I 177 on September 29, 2021 by guest. Sepsis 16 Tuberculosis 5 * _ HAVA 7 I Collagenosis 12 i Nephropathies 18 Haemolytic-uraemic syndrome 17 - Hypertrophic thymus 7 * Total 456

Fig. 3. Concentrations of gM in children (Plate method). 124 Ricardo Horacio de Lellis Postgrad Med J: first published as 10.1136/pgmj.45.520.116 on 1 February 1969. Downloaded from

k1n ,% IgG (mg/lOOml) ILU.. I l ------, 600 Diaanosis-- cases 200--- 40 $0000 1000 200 400 600 800 2000 200 400 800 3000 200 400 600 000 40001 - p T I I Newborn 32 I I i Premature 10 Agammaglobulinoemia 2 I Dysgammaglobulinaemia I 12 Dysgammaglobulinaemia U 84 I - Dysgammaglobulinaemia m 47 I I Normal children 16 I Normal adults 20 I C -1 Multifocal pneumonia 22 .. I I Unifocal pneumonia 28 II Pneumonitis 13 I.M Catarrhal bronchitis 8 Asthma 38 Malnutrition grades I and I 25 9 Malnutrition grade m 17 -7 Sepsis 16 wo I W.. Tuberculosis 5 I H AVA 7 I I Collagenosis 12 II .M Nephrosis 5 II Nephritis 13 II 17 I Haemolytic-uraemic syndrome I Hypertrophic thymus 7 I Total 456 II_ I. L--" I!!I Protected by copyright. FIG. 4. Concentrations of IgG in children (Plate method). thymus and over-peripheralization of an auto- therapeutic aims. The dose was varied for each immune mechanism is suggested (Miller, 1962). aetiological agent in relation to the objective and Quantitative determinations of the immune globu- for this there are established doses, both preventive lins in normal and pathological states are given in and curative for measles, hepatitis, whooping-cough Figs. 2, 3 and 4, and together with observations and mumps. This effect is most pronounced with from the literature are summarized in Fig. 5. hyperimmune y-globulin (Cedrato & Albores, 1964; Barandum, 1964). Treatment with y-globulin The supplementary action is seen when it supple- Our experience is based upon the use of three types ments a defective immune system: (a) agamma- and both and of y-globulins: (1) standard y-globulin, obtained hypogammaglobulinaemia, congenital http://pmj.bmj.com/ form Cohn's Fraction II from a pool of 10,000 acquired; (b) transitory hypogammaglobulinaemias donors in which the concentration and type of of infancy or secondary; and (c) dysgamma- antibody depended upon previous immunizations globulinaemias. The supplementary action per- and infections; (2) hyperimmune y-globulin, ob- haps differs according to the nature of the infection. tained from donors specifically immunized against In the agammaglobulinaemias the productive given infective diseases; and (3) intravenous y- system has not been able to develop (Smith, 1960). globulin (Gamma Venina Behringwerke), obtained It has been established empirically that these patients by enzymatic treatment of yG with pepsin, with can remain free from infection with serum levels of on September 29, 2021 by guest. preservation of the subfractions I and II, which 150 mg/100 ml. This can be achieved with doses of contain antibodies and extraction of Fraction III 0-3-0-4 ml per pound body weight, administered with antigenic and anticomplementary properties every 30 days (Uhr, Finkelstein & Baumann, 1962). (Porter, 1959). During the first months of treatment it is advisable The therapeutic action of these y-globulins can be to determine the blood level before each injection in attributed to four actions, specific, supplementary, order that the dose can be adjusted to a size adequate additive and selective. The specific action against the to maintain a serum level of 150 mg/100 ml. microbe is based upon the provision of specific The mechanisms postulated for the dysgamma- antibodies-antibacterial, antitoxins and antiviral. In globulinaemias suggest the need for a qualitative these circumstances there develops a type of passive rather than a quantitative therapeutic effect, and the immunity which can be useful for preventive and dose frequency and duration of treatment are The gamma system, pathology and therapeutics 125 Postgrad Med J: first published as 10.1136/pgmj.45.520.116 on 1 February 1969. Downloaded from

Antigenic stimulus,systemic and recurrent The significance of the selective action is not yet Chronic sepsis, autoimmunity,collagenosis, but will await certain fully understood with increased hepatic diseases, neoplasms understanding of the pathology of the y system. Acute and subacute sepsis,tuberculosis, acute rheumatism,nephrits, Hodgkins, The provision of yA, yM and other subfractions of neoplasms, Systemic Lupus erythematosis standard y-globulin would assist the elucidation of Primary antibody response this process. Primitive macroglobulinaemias (Waldenstr8m), We will summarize our experience, secondary syphilis,cryoagglutinaemias, excluding tropical infections, typhoid conditions in which y-globulin was used with the Allergenic stimulus hope of a effect. Atopic eczema and other allergies, leprosy, specific chronic brucellosis,myeloma,dysgammaglobulin- aemia type3 Dysgammaglobulinaemia 1 and 2: rapid initial Pneumonitis (infantile), certain recurrent types of bronchitis effect. The cycles are arrested with a single dose of about 300 mg. An equal effect can be obtained with Malnutrition, asthma higher doses. However, this must be repeated over a period of several months for Form 1 and every 2-3 months for Form 2. Nephrosis,certain chronic nephritides, atypical rheumatism,Aldrich's syndrome, allergic thrombocytopaenia Dysgammaglobulinaemia 3: The results are less spectacular than for the preceding forms. The Primry and secondLry maintenance of the medication every 20-30 days in doses of 320 mg serves to prevent recurrences, Primary and secondary SCA there is much individual variation as Physiological at school age though regards Myeloma yG, asymptomatic agammaglobuliri- the speed of this effect. It is possible that this aemia A is constituted a hetero- Protected by copyright. Primary or secondary SCA (virus,Gram-negative dysgammaglobulinaemia by Dysgammaglobulinaemia type 4 (Gitlin) geneous group of patients and other dysgammaglo- bulinaemias from this group might yet be isolated. Partial hypoimmunoglobulinoemia, physiotogicol in first 2 In some cases it should be in relation to the months. Newly born (virol and Grom-negative) graded Congenital ogammaglobulinoemia (AlM) aetiopathogenic mechanism of this group which Oysgommoglobulinaemio,type 2 (Gitlin) differs from that of forms 1 and 2. Dysgammoglobulinaemia, type 2 (catarrhal) Secondary hypogammaglobulinaemia: y-Globulin Primitive: hypogommoglobulinoemia of the newborn (tran- has no significant action against the causes of this: sient). Secondory: removal by the antigen, severe sepsis Myeloma: monoclonal gommapathies. Franklin' disease, (a) in the invasion of lymphoreticular tissue or dysgammaglobulinaemia type3 (Gitlin) the destruction or sequestration of the immuno- Global hypoimmunoglobulinaemia Agamma- and hypogammaglobulinaemia,cong- logically competent cell as in leukaemia, enital and acquired and myeloma; (b) protein loss as in nephrosis, burns Dysgammaglobulinaemia, type (febrile) and the protein-losing enteropathies; and (c)

FIG. 5. immunosuppression after irradiation and immuno- http://pmj.bmj.com/ Principal immunoglobulin responses. suppressant drugs. With the exception of nephrosis in which the y-globulin would have no immuno- logical role, the indication for their use lies in their characteristic of each clinical form to such an important symptomatic function before the collapse extent that the therapeutic effect may have diag- of the y system. High doses are essential when it nostic significance. can be inferred that the hypoimmunoglobulinaemia An additive action occurs where there is re- is secondary to serious sepsis which initiates the inforcement of the response of the gamma system to mechanism of synthesis in a variable manner. The on September 29, 2021 by guest. infection. This treatment is indicated: (a) in bacterial difficulty in accurately gauging the deficit caused us or viral infections of whatever nature, at an early to use a weekly dose. stage when the infection is extracellular; (b) in chronic and recurrent infections; and (c) in addition Thymic hyperplasia with hypogammaglobulinaemia: to treatment with corticosteroids. The action of re- The direct relationship between the thymus and the inforcement or of addition may be opsonizing immunoglobulins in experimental medicine is con- (Hassiz 1962). y-Globulin permits the process of troversial, however our cases of hyperplasia with degradation of bacteria phagocytosed by the leuco- hypogammaglobulinaemia in the neonate have all cyte as shown, and has been shown to form a com- been helped with this medication. The frequency plex with both the antibody and constituent of the and the size of the doses are similar to those recom- bacteria (Geltzer & Suter, 1959). mended for the dysgammaglobulinaemias. 126 Ricardo Horacio de Lellis Postgrad Med J: first published as 10.1136/pgmj.45.520.116 on 1 February 1969. Downloaded from Asthma: Episodes are shortened and lasting CAMBLIN, J.G. & BRIDGES, J.B. (1964) Effects of cell-free asthma is prevented. Three forms of response may extracts of thymus in leucopoenic rats. Transplantation, be listed: those with those without 2, 785. recovery, change CEDRATO, A.E. & ALBORES, J.M. (1964) Uso e indicaciones de in the symptomatology, and least frequently those las gammaglobulinas. Fichero Medico Terapeutico Puris- where symptoms are aggravated. simus. Edicion especial XXVI. CLARK S.L. Jr. (1966) The Penetration ofProteins ofColloidal Materials into the Thymus from the Blood Stream. Ciba Haemolytic-uraemic syndrome: We have treated Foundation Symposium (Ed. by G. E. W. Wolstenholme), the hypoimmunoglobulinaemia which occurs initi- p. 3. Churchill, London. ally with y-globulin without untoward conse- CLAMAN, H.N., & TALMAGE, D.W. (1963) Thymectomy, As our are prolongation of immunological tolerance in the adult quences. yet findings equivocal. mouse. Science, 141, 1193. CONGDOM, C.C. & DUDA, D.B. (1961) Precention of bone Pneumonias: In the various forms of multifocal marrow heterografting. Arch. Path. 71, 311. DAMESHEK, W. (1966) The Thymus: Experimental and Clinical pneumonia, unifocal pneumonia pneumonitis and Studies: Ciba Foundation Symposium (Ed. by G. E. W. bronchitis, the use of y-globulin has given excellent Wolstenholme), p. 399. Churchill, London. results. In extremely severe cases intravenous y- DEFFENDI, V., ROOSA, R.A. & KOPROWSKI, A. (1964) The globulin (y-venin) acted with spectacular effects. In Thymus in Immunobiology (Ed. by R. A. Good and the best results were obtained in those A. E. Gabrielsen), p. 504. Hoeber, New York. pneumonias DE LELLIS, R.H., LEVERATTO, I., DIMARI, N., MASCARDI, N. & that supervened upon a previous dysgammaglo- LANGLEY, R. (1964a) Anabolicos en distroficos graves. Il bulinaemia. Jornades Argentinas de Puericultura. Cordoba. DE LELLIS, R.H. & WINCKLER, J.A. (1966a) Estudio de la fraccion rapida de la gamma G globulina por immuno- Malnutrition: It would seem to be indicated in the electroforesis, su significacion en el desarrollo de la maduracion del lactante. Arch. malnutritions of the first and second grades. In the inmunologica Arg. Pediat. Protected by copyright. third medication succeed in 65, 7; 100. grade might lessening DE LELLIS R.H. & WINCKLER, J.A. (1966b) El sistema gamma the process of accelerated peripheral distribution, en el nino distrofico. Arch. Arg. Pediat. 65, 7; 108. and combined with anabolic agents this has pro- DE LELLIS, R.H. & WINCKLER, J.A. (1968a) Drei formen duced an excellent clinical response (de Lellis et al., dysgammaglobulinamie des saugling. Die Gelben Hefte, 1964a). 14, 635. DE LELLIS, R.H. & WINCKLER, J.A. (1968b) Estudios pre- liminares papa un diagnostico immunologico de las en- fermedades respiratorias bajas de las infancia. Soc. Arg. References Pediat. (In press). ALBRIGHT, J.F., CAPALBO, E.E., & MAKINODAM, T. (1964) DE LELLIS, R.H. & WINCKLER, J.A. (1967) Fisiopathologia del Some quantitative properties of antibody-producing cells. sistema gamma en pediatria. Gaceta Sanitaria, 4, 131. Proceedings IX Congress of the International Society of DE LELLIS, R.H. WINCKLER, J.A. & YANEZ, M. (1964b) Haematology. Immonoelectroforesis de las proteinas sericas del recien ARCHER, O.K., PIERCE, J.C., PAPERMASTER, B.W. & GOOD, nacido normal. Pediat. panamer. 90, 102. R.A. (1962) Reduced antibody responses in thymectom- R.F. Effect of hormones on ized rabbits. Nature 191. 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YI-CHUAN CHING, DAVIS, S.D. & WEDGEWOOD, A. (1966) YUNIS, E.J., HILGARD, H., SJODIN, K., MARTINEZ, G. & Antibody studies in hypogammaglobulinaemia. J. clin. GOOD, R.A. (1964) Immunological reconstitution of Invest. 10, 1593. thymectomized mice by injections of isolated thymocytes. Nature (Lond.), 201, 784. Protected by copyright. http://pmj.bmj.com/ on September 29, 2021 by guest.