Archives ofDisease in Childhood 1993; 69: 463-466 463

CURRENT TOPIC Arch Dis Child: first published as 10.1136/adc.69.4.463 on 1 October 1993. Downloaded from

Leucocyte adhesion deficiency

Magdi H El Habbal, Stephan Strobel

Rare experiments of nature often lead to a interactions are dependent on cytokines for better understanding of fundamental principles their regulation,4 others require firm leuco- of human biology. The clinical description of a cyte-cell or leucocyte-matrix contact, called severe congenital immunodeficiency presenting adhesion.5 Adhesion events are often tran- with persistence of a 'fleshy' often infected sient, follow cell activation and are an umbilical cord ('delayed cord separation') and early step, for example in transendothelial overwhelming septicaemias' has led to a rapid migration of leucocytes, which is of a great progress in our appreciation of the importance biological relevance in host defence and tissue of leucocyte-leucocyte and leucocyte-endo- injury.6 thelial interaction in health and disease. Leucocyte adhesion deficiency (LAD), as the disease is now called, is a rare immunodefi- Classification of adhesion molecules ciency characterised by severe recurrent and Three families of adhesion receptors (tables 1 often fatal bacterial infections with a failure of and 2) are so far known,7 and we will focus pus formation and delayed wound healing.2 A here on those related to LAD. deficiency in leucocyte 32 integrins was recog- nised to be the cause of this syndrome in the early 1980s.3 THE LEUCOCYTE INTEGRINS The essential function of the integrins is the integration of the cytoskeleton with the extra- Cardiothoracic Unit Background cellular environment and are and Host Defence they found on Unit, Institute of Child The cellular elements of human immune most cell types (tables 1 and 2). The 132

Health and Hospitals system (polymorphonuclear leucocytes, integrin (CD 1/CD 18), a glycoprotein com- http://adc.bmj.com/ for Sick Children, monocytes/macrophages, T and B cells, and plex, is required for adhesion dependent func- London Magdi H El Habbal other types of leucocytes) are constantly com- tions such as aggregation, spreading on Stephan Strobel municating with each another. This network artificial substrates, chemotaxis, phagocyto- includes endothelial surfaces as well as extra- cell mediated Correspondence to: sis, killing, and adherence to Professor Stephan Strobel, cellular matrices and leads to modulation of endothelium.8 The various functions of this Host Defence Unit, Institute immune and and to in of Child Health, 30 Guilford inflammatory responses molecule have common the need of the cell

Street, London WC 1N 1EH. control of cell traffic (homing). Some of these to adhere to a target in a reversible manner on September 29, 2021 by guest. Protected copyright. and are temperature dependent and coupled Table 1 Families ofadhesion molecules: the integrins to the presence of divalent cations.9 Each Receptor Tissue distnibution Ligand integrin consists of a distinct heavy (150-180 kDa) ct polypeptide chain non-covalently 1 integrins VLA-1 (CD49a/CD29) Activated lymphocytes, fibroblasts Laminin, collagen linked to a (95 kDa) 1B polypeptide chain VLA-2 (CD49b/CD29, Activated T cells, platelets, Laminin, collagen (CD 18) common to all three subunits: LPAM-2) fibroblasts, endothelium, epithelium CD 1 a (lymphocyte function-associated anti- VLA-3 (CD49c/CD29) Fibroblasts, epithelium Fibronectin, laminin, gen-I (LFA- 1) present on the surface ofvirtu- collagen VLA-4 (CD49d/CD29, Lymphocytes, monocyte, fibroblast, Fibronectin, VCAM- ally all circulating leucocytes), CD1 lb (CR3, LPAM-1) neural crest derived cells Mac-i, Mol, is limited to neutrophils, mono- VLA-5 (CD49e/CD29) T cells, thymocytes, platelets, Fibronectin fibroblasts, endothelium, cytes and natural killer cells) and CD 11 c epithelium (CR4, gp 150,95 has a similar distribution to VLA-6 (CD49f/CD29) Fibroblasts Laminin CD1 lb). 12 integrins CDlla/CD18 (LFA-1) Leucocytes ICAM-1, ICAM-2 Neutrophils from patients with the defici- CD 1 lb/CD 18 (CR3, Granulocytes, monocytes, ICAM-1, C3bi, fibrinogen Mac-1, MO-1) , large lymphocytes, ency demonstrate in vitro defects in adhesion CD5 +ve B cells dependent functions that can be reproduced in CDIlc/CD18 (p150,95; Granulocytes, monocytes, C3bi CR4) macrophages, activated normal neutrophils by addition of monoclonal lymphocytes antibodies directed to function related epitopes P3 integrins CD4 1/CD6 1 (GPIIb-IIIa) Platelets, megakaryocytes Fibrinogen, vWf, of the glycoprotein complex.10 Monoclonal fibronectin, antibodies to CD 1 lb and/or CD 18 have been thrombospondin CD51/CD61 (C3) Platelets, megakaryocytes Vitronectin, vWf, shown in vitro to prevent neutrophil aggrega- thrombospondin, tion and adherence to endothelial mono- fibrinogen 04 integrins Epithelial cells CD21, TAPA-1, Leu-13 layers.1' Unstimulated neutrophils express 15 integrins Epithelial cells Fibronectin, vWF CD 1 b on the cell surface and even in greater 16 integrins (LPAM-1) Lymphocytes Unknown P7 integrins T lymphocytes CD28 quantities within the secondary and/or tertiary granules.'2 Upon stimulation, the contents of 464 El Habbal, Strobel

Table 2 Families ofadhesion molecules: the immunoglobulin and superfamilies cord in neonates and formation of dysplastic

scars18 due to secondary wound healing Arch Dis Child: first published as 10.1136/adc.69.4.463 on 1 October 1993. Downloaded from Receptor Tissue distnibution Ligand processes in older children are common mani- Immunoglobulin superfamily: festations. Intradermal skin testing is unaffected ICAM-1 (CD54) Activated lymphocytes, monocytes, CD11/CD18 (LFA-1, histiocytes, fibroblasts, endo- Mac-1) as is delayed hypersensitivity (Mantoux test). thelium, epithelium Increased susceptibility to viral infections, ICAM-2 Endothelium, lymphocytes, CD11a/CD18 (LFA-1) monocytes although theoretically possible, is not part ofthe CD2 (LFA-2) Lymphocytes CD58 clinical spectrum. CD58 (LFA-3) Macrophages, T and B lymphocytes, CD2 endothelium The clinical severity of the disease is often VCAM-1 Endothelium VLA-4 proportional to the degree of the deficiency. CD3/TcR T lymphocytes, -y/B T cells MHCI, II CD4 differentiation (thymus) MHCII, gpl20 Patients with the complete deficiency state CD8 T cells MHCI (type I) often die at an early age with over- MHC class II T lymphocyte CD4 MHC class I Natural killer cells, viral protein CD8 whelming sepsis whereas those with the partial CD28 (Tp44) T cell, plasma cells B7 form (type II) of the disease may have a milder CD21 (CR2) B lymphocytes C3d/EBV CD35 (CR1) Erythrocyte, neutrophil, monocytes, C3b, C4b course and can survive into adulthood lymphocytes, macrophates provided infections are treated early or Selectin superfamily: L-selectin (mel-14, LAM-1, Leucocytes E-, P- reduced by continuous antibiotic prophy- LECAM-1) laxis.19 Heterozygous individuals (parents) are E-selectin (ELAMI) Endothelium SSEA-1, L-selectin P-selectin (CD62, Platelets, endothelium sLewis-X, L-selectin asymptomatic. The recognition of a new case PADGEM, GMP-140 of LAD depends on the awareness of the phys- ician of the possibility of a LAD in a patient Previously used or alternative names in brackets. with recurrent and serious infection in the presence of often persistently high leucocyte Table 3 Clinicalfeatures ofLAD counts. The exact diagnosis is confirmed by examining the neutrophils for surface expres- Often persistent leucocytosis (12-160x 109/1) Skin/subcutaneous infections sion of CD 11/CD18 molecules by immunoflu- Indolent subcutaneous abscess or cellulitis orescence techniques and by flow cytometry. Cellulitis or abscess associated with wound or trauma Gingivitis/periodontitis Otitis media Ulcerative stomatitis/pharyngitis Systemic infection Pathogenesis of LAD Peritonitis Clinical manifestations of the LAD syndrome Perianal abscess Pneumonia are related to the deficient function of Aseptic meningitis CD 1 1/CD 18 molecules. The molecular defect Necrotising pharyngitis/tracheitis Delayed umbilical cord severance/infection is heterogeneous and ranges from defective Impaired wound healing and/or infection of surgical wounds gene expression with undetectable mRNA,20 to aberrant gene splicing with production of an 3 to in abnormal chain, point mutations the http://adc.bmj.com/ these granules are translated to the cell surface, highly conserved region of the ,B subunit that resulting in a threefold to 10-fold increase in results in a precursor that is unable to associate surface associated CD 1l b.13 It has been sug- with the cx units.21 gested that this increase in surface expression CD11/CD18 molecules are essential for possibly after conformational changes may phagocytic cell function (macrophages and play a part in the mechanism of enhanced monocytes) but the relative contribution of neutrophil adhesiveness.14 this heterodimer varies with the cell type. In neutrophils, binding with iC3b coated on September 29, 2021 by guest. Protected copyright. particles, spreading, aggregation, chemotaxis, Clinical manifestations and diagnosis neutrophil dependent adherence to the endo- LAD syndrome is characterised by delayed thelium, and phagocytosis are largely mediated umbilical cord separation, recurrent severe by CD1 1/CD18.22 In monocytes, CD11/ bacterial infection, periodontitis, delayed CD 18 also facilitates iC3b binding and phago- wound healing, and often persistent leuco- cytosis but not spontaneous or stimulus cytosis with absent pus formation. The clinical induced monocyte aggregation which is manifestation are summarised in table 3. CD1 la/CD 18 dependent.23 The monocyte Patients with LAD present with recurrent and neutrophil CD 1 1 c/CD 18 may contribute and often life threatening infections. to monocyte binding to iC3b. Antibody depen- Staphylococcus aureus, group ax/3 haemolytic dent cytotoxicity and natural killer activities as streptococci, Proteus mirabilis, Pseudomonas well as endothelium dependent adhesion of aeruginosa, and Escherichia coli are common phagocytes is mediated by all heterodimers. pathogens.15 Recurrent otitis media, severe In B and T lymphocytes, all CD1 1/CD18 gingivitis, pharyngitis, stomatitis,16 and perirec- dependent functions are mediated by tal abscesses are also common. Deep seated CD1 la/CD18.24 Anti-CD1 la/CD18 mono- infections of the lungs, gastrointestinal tract, or clonal antibodies inhibit homotypic and nervous system may progress to overwhelming heterotypic interactions of B and T lympho- sepsis despite aggressive treatment.'7 Increased cytes to endothelium and to other targets.25 T susceptibility to infections is directly related to cell proliferation in response to stimuli which inability of deficient phagocytes (both granulo- require cell-cell contact is also inhibited.26 cytes and monocytes) to migrate to sites of These data account for impaired cell mediated tissue infection and to clear the offending organ- cytotoxicity, lymphoproliferative responses, isms (through phagocytosis and cell mediated and antibody production in response to T cell cytotoxicity). Delayed separation of umbilical dependent antigens seen in vitro. Leucocyte adhesion deficiency 465

The gene encoding the I subunit has been degranulation in response to soluble stimuli are

mapped to chromosome 21 at 2 1q22, which is normal. Arch Dis Child: first published as 10.1136/adc.69.4.463 on 1 October 1993. Downloaded from a breakpoint in chromosomal translocations associated with blast crisis in chronic myeloid leukaemia.27 An increase of leucocyte Lymphocytes in LAD adhesiveness due to over expression of Abnormalities in functions of affected lympho- CD 11 a/CD 18 has been reported in patients cytes have been found in vitro. Defects with trisomy 21 (Down's syndrome); its clini- in antigen-mitogen or alloantigen-induced cal relevance remains to be established.28 All lymphoproliferation, cell mediated killing by three ot subunits have been localised to T and natural killer cells, homotypic and p ll-pl3.1 on chromosome 16. Inversions in heterotypic adhesion of B and T cells inter- translocations involving this region have been actions, and T and B cell adhesion to endo- reported in patients with acute myelomono- thelium are reported. Many ofthese defects are cytic leukaemia.27 most apparent at low rather than high concen- The causes for delayed and defective wound trations of a stimulus. At higher concentrations healing are not well understood. Acute inflam- of the stimulus or during secondary stimula- mation and polymorphonuclear infiltration of tion, many of these functions become normal wound is the initial step of healing. Inability of especially in patients with the partial defici- macrophages to emigrate to wound site render ency. The above mentioned effects on T cell the inflammatory reaction incomplete and/or functions have been clinically exploited by inadequate, which may explain the delay in incorporating the infusion of CD 1 la (LFA- 1) healing and formation of hypertrophic scars. antibodies into bone marrow transplantation Absence of inflammation, however, cannot be protocols before and after transplantation. the only explanation for impaired wound This policy has increased engraftment of healing as scarless healing of wounds due to haploidentical bone marrow grafts in patients surgery in utero (fetus), where neutrophil with severe combined immunodeficiencies.32 functions are down regulated,29 is reported. Prevention of T cell allorecognition via The role of amniotic growth factors in this infusion of anti-CD 11 a monoclonal antibodies process needs to be established. can also be used alone or in combination with other antibodies (for example CD3, CD4, CD8, CD25) in the treatment of graft versus NEONATAL NEUTROPHILS host disease. Human neonates are at high risk of infection, which is thought to be due to immaturity of their non-adaptive immune system. Studies in Conservative treatment neonates have demonstrated diminished or Early identification of the affected individuals delayed emigration of the neutrophil into of high risk families is most important for extravascular inflammatory sites. Significant formulation of rational treatment strategies. http://adc.bmj.com/ differences of neutrophil (chemotactic) func- tions compared with adults have been reported and marked reduction in the level of ANTIBIOTICS CD1 lb/CD 18 on the surface of the neonatal The mainstay of conservative treatment is anti- neutrophil may be the cause for these func- biotics given during infections and as a tional abnormalities.30 These abnormalities are prophylaxis. A broad spectrum antibiotic transient in a healthy newborn and disappear (intravenous) should be commenced as soon as on September 29, 2021 by guest. Protected copyright. with maturation. the necessary cultures (including fungal cultures) are taken. Adjustment of the anti- biotic regimen can be made at a later time. In Laboratory findings severe systemic infections not responding to Complete (0-2%, type I) or partial antibiotic treatment, antifungal treatments (>10-20%, type II) absence of the leucocyte need to be considered early as patients with adhesion molecule CD11/CD18 on the cell LAD are functionally neutropenic. To avoid surface is diagnostic and also allows prenatal infections, strict dental hygiene is important diagnosis for severe forms of LAD by cordo- and all surgical procedures should be centesis in families with history of the performed under cover of appropriate broad disease.3' Another characteristic finding is the spectrum antibiotics. persistent neutrophilia that is invariably seen Patients with LAD should receive all vacci- even in infection-free periods. Deficient nations according to the current recommenda- phagocytes are unable to ingest serum tions and injections should be given under opsonised particles due, in part, to their strict antiseptic precautions. inability to bind to complement iC3b, the major serum opsonic C3 fragment. The res- piratory burst and degranulation responses Leucocyte transfusion and bone marrow associated with the process of phagocytosis are transplantation secondarily impaired. Stimulated random and Granulocyte transfusion may be useful in directed migration, homotypic and heterotypic selected cases of (localised) infections that can- cell interactions are also impaired resulting in a not be controlled otherwise. Their use is paucity ofphagocytes (but not lymphocytes) at limited because of difficulties in supply (daily infected sites in vivo. Adhesion independent donors) and of potential development of functions such as superoxide generation and alloantibodies. At present, the only corrective 466 El Habbal, Strobel

that can be offered is a bone marrow 12 Todd IIIR, Arnaout M, Rosin R, Crowley C, Peters W, treatment Babior B. Subcellular localisation of the large subunit of

transplantation, which allows generation of Mol (Mola; formerly gp 110) a surface glycoprotein Arch Dis Child: first published as 10.1136/adc.69.4.463 on 1 October 1993. Downloaded from and other associated with neutrophil adhesion. J Clin Invest 1984; healthy neutrophils leucocytes.33 74: 1280-90. Patients with complete (type I) LAD constitute 13 Farrell C, Rest R. Up-regulation of human neutrophil a lower risk because of a receptors for Neisseria gonorrhoea expressing PII outer transplantation membrane proteins. Infect Immun 1990; 58: 2777-84. reduced rejection rate. 14 Vedder N, Harlan J. Increased surface expression of CD llb/CD18 (Mac-1) is not required for stimulated neutrophil adherence to cultured endothelium. J Clin Invest 1988; 81: 676-82. Gene therapy 15 Etzioni A, Frydman M, Pollack S, et al. Brief report: recurrent severe infections caused by a novel leuko- A more selective and curative approach cyte adhesion deficiency. N Engl J Med 1992; 327: involves somatic intro- 1789-92. gene therapy through 16 Waldrop T, Anderson D, Hallmon W, Schmalstieg F, duction into haematopoietic stem cells of the Jacobs R. Periodontal manifestations of the heritable normal CD18 subunit viral vectors34 as Mac-1, LFA-1, deficiency syndrome. Clinical, histo- using pathologic and molecular characteristics. JfPeriodontol currently being used for somatic gene therapy 1987; 58: 400-16. for adenosine deaminase A trans- 17 Hawkins H, Heffelfinger S, Anderson D. Leukocyte deficiency.35 adhesion deficiency: clinical and postmortem observa- fection rate of over 10% may be sufficient to tions. PediatrPathol 1992; 12: 119-30. I to a less severe or even 18 Abramson J, Mills E, Sawyer M, Regelmann W, Nelson J, convert type type (II) Quie P. Recurrent infections and delayed separation of to a heterozygote state. the umbilical cord in an infant with abnormal phagocytic cell locomotion and oxidative during partial phagocytosis. JfPediatr 1981; 99: 887-94. 19 Anderson D, Schmalstieg F, Finegold M, et al. The severe and moderate phenotypes of heritable Mac-1, LFA-1 Counselling deficiency: their quantitative definition and relation to LAD is transmitted in an autosomal recessive leukocyte dysfunction and clinical features. JfInfect Dis manner and affects of different ethnic 1985; 152: 668-89. patients 20 Dimanche-Boitrel M, Guyot A, De Saint-Basil G. carriers are in the molecular defect to the background. Heterozygous asymp- Heterogeneity J leading of an affected leukocyte adhesion deficiency. Eur Immunol 1988; 18: tomatic. The likelihood having 1575-9. child is one in four and increases in consan- 21 Matsuura S, Kishi F, Tsukahara M, et al. Leukocyte guineous marriages. Gene mutation in a carrier adhesion deficiency: identification of novel mutations in two Japanese patients with a severe form. Biochem Biophys mother has been reported and the child had Res Commun 1992; 184: 1460-7. severe form of the disease. 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