Leukocytic function in hypogammaglobulinemia Ira D. Mickenberg, … , Richard K. Root, Sheldon M. Wolff J Clin Invest. 1970;49(8):1528-1538. https://doi.org/10.1172/JCI106370. Research Article The phagocytic, bactericidal, and metabolic capabilities of circulating blood leukocytes from three adults (two males, one female) with hypogammaglobulinemia and recurrent pneumonia, chronic sinusitis, and intestinal giardiasis were studied. These functions were found to be normal when leukocytes from the patients were incubated in media containing normal human serum. Phagocytosis of Staphylococcus albus and polystyrene balls by both patient and normal leukocytes was diminished when the cells were incubated in hypogammaglobulinemic plasma. A similar defect in opsonization by patient plasma was also noted for pneumococci, Escherichia coli and variably with Staphylococcus aureus. Both patient and normal sera had equivalent levels of heat-labile S. albus opsonins; normal serum, however, contained heat-stable S. albus-specific absorbable opsonins in significantly greater quantities to account for its superior opsonic capacity. The addition of commercial gamma globulin or purified IgG to hypogammaglobulinemic sera restored full S. albus opsonic activity. The relevancy of these observations to the impaired host defenses in these patients will be discussed. Find the latest version: https://jci.me/106370/pdf Leukocytic Function in Hypogammaglobulinemia IRA D. MIcKENBERG, RICHARD K. ROOT, and SmELON M. WOLFF From the National Institutes of Health, National Institute of Allergy and Infectious Diseases, Laboratory of Clinical Investigation, Bethesda, Maryland 20014 A B S T R A C T The phagocytic, bactericidal, and meta- gations, three adult patients with acquired hypogamma- bolic capabilities of circulating blood leukocytes from globulinemia were studied to determine the phagocytic, three adults (two males, one female) with hypogam- bactericidal, and metabolic properties of their peripheral maglobulinemia and recurrent pneumonia, chronic sinus- leukocytes, with particular attention to the influence of itis, and intestinal giardiasis were studied. These func- homologous or normal serum upon these functions. The tions were found to be normal when leukocytes from the results indicate that phagocytic function is impaired in patients were incubated in media containing normal hu- the hypogammaglobulinemic state, and that the defect man serum. Phagocytosis of Staphylococcus albus and lies, not in the cells themselves, but rather in a lack of polystyrene balls by both patient and normal leukocytes heat-stable serum opsonins in affected patients. was diminished when the cells were incubated in hy- pogammaglobulinemic plasma. A similar defect in op- METHODS sonization by patient plasma was also noted for pneumo- Patients. All patients were hospitalized at the National cocci, Escherichia coli and variably with Staphylococcus Institutes of Health during the period of study. Pertinent aureus. Both patient and normal sera had equivalent clinical data concerning the patients are presented in Table I. Leukocytes. Leukocytes were obtained by sedimenting levels of heat-labile S. albus opsonins; normal serum, heparinized' peripheral blood with 3% dextran (mol wt 124,- however, contained heat-stable S. albus-specific ab- 000). The leukocyte-rich supernatant plasma was aspirated sorbable opsonins in significantly greater quantities to and centrifuged at 900 rpm for 6 min at 4VC. The leuko- account for its superior opsonic capacity. The addition cytes were then washed twice in modified Hanks' solution of commercial gamma globulin or purified IgG to hy- (MHS) ,2 and cells were counted in an electronic particle counter.' Differential counts of Wright's stained smears pogammaglobulinemic sera restored full S. albus opsonic were performed and the percentage of phagocytic cells activity. The relevancy of these observations to the (granulocytes and monocytes) enumerated. Occasionally, impaired host defenses in these patients will be discussed. patients were plasmaphoresed and the blood was centrifuged at 2500 rpm for 3 min. The buffy coat and homologous plasma were then aspirated, mixed, and the erythrocytes allowed INTRODUCTION to sediment at 37'C for 1 hr. The resulting leukocyte-rich plasma supernatant was centrifuged. The cells were washed Repeated pyogenic infections, most frequently involving twice in MHS and counted as described above. Normal the respiratory tract, characterize the clinical course of leukocytes were obtained in a similar manner from blood patients with acquired hypogammaglobulinemia. Al- anticoagulated with acid-citrate-dextrose (ACD). Serum and plasma. Fresh serum was obtained from nor- though this predilection to infection might be presumed mal donors by centrifugation of whole clotted blood. The to be on the basis of impaired antibody formation (1), serum was stored at -70'C until used. Plasma was obtained it has been established that during the initial exposure from anticoagulated blood (10 U/ml heparin) from both pa- to an organism, phagocytosis of the invading bacteria tients and normal volunteers. It was stored at - 70'C and host defense mechanism (2). Phagocytosis before use was thawed and centrifuged at 3000 rpm for 20 is the major min at 4VC to remove fibrin. Heat inactivation of serum is facilitated by both heat-labile (3) and heat-stable and plasma was carried out at 560C for 30 min. serum opsonins (4). It has been reported that patients Serum and heparinized plasma gave identical results and with Swiss type agammaglobulinemia have decreased were used interchangeably. Citrated plasma was not used phagocytic function (5, 6), but some of these patients because the citrate ion which is known to inhibit several other glycolytic enzymes (11) depressed hexose monophosphate are also complement deficient (7, 8). On the hand, shunt activities. For heat inactivation studies, only normal there have been no reports of systematic studies of phago- serum was used since heat-inactivated normal plasma in- cytic function in other types of hypogammaglobulinemia beyond several case reports in which leukocyte function 110 ,u/ml Pan Heparin, Abbott Laboratories, Baltimore, to be normal (9, 10). In the present investi- Md. appeared 2K2HPO4, 1.568 g/liter; NaCl, 8.12 g/liter; glucose, Received for publication 12 January 1970 and in revised 2000 mg/liter. form 13 April 1970. I Coulter Electronics, Industrial Div., HIialeah, Fla. 1528 The Journal of Clinical Investigation Volume 49 1970 TABLE I Clinical Data of Patients Clinical re- sponse to Age at gamma onset of Immunoglobulin* globulin symp- Family Positive Isohem- Serum adminis- Patient Age Sex toms Patient characteristics history IgG IgA IgM skin tests agglutinin titer complement tration R.S. 23 M 18 Intestinal giardiasis; No 0.7 0 0 Mumps and Anti-A neg Normal Good frequent otitis DNCB Anti-B neg media, pneumonia 1.01 0 0 and sinusitis; mal- adsorption syn- drome and nodular lymphoid hyper- plasia of bowelt G. W. 42 F 28 Intestinal giardiasis; Yes 0.4 0 0 DNCBII Anti-A 1:1 Normal Question- bronchiectasis re- (nephew) Anti-B 1:1 able quiring prophy- 0.4§ 0 0 lactic antibiotics and previous lobectomy; chronic sinusitis H. R. 36 M 20 Intestinal giardiasis; No 1.2§ 0 0 Tuberculin Anti-A neg Not done Good frequent otitis and Anti-B neg media and pneu- histo- monias plasmin * Normal levels for the laboratory are: IgG 8.5 mg/ml (4.3-13.9), IgA 1.8 (0.8-4.7), IgM 1.3 (0.5-4.0). 1; Radiological findings reported elsewhere (12). 1 wk following gamma globulin intramuscularly. II Denotes ability of patient to develop delayed hypersensitivity to dinitrochlorobenzene after sensitization. The method of sensitization has been de- scribed elsewhere (13). creased hexose monophosphate shunt levels. On the other MHS or HBSS to bring the total volume to 2 ml. In these hand, phagocytic mixtures with heat-inactivated hypogam- studies, the final concentration of serum or plasma was 10%o. maglobulinemic plasma and sera gave identical hexose After 1 hr incubation at 37°C in a shaker incubator, the mix- monophosphate shunt activities. tures were spun at 750 rpm for 5 min. The cells were re- Phagocytic particles. Cultures of Staphylococcus albus, suspended in serum and slides made and stained with Staphylococcus aureus, and Escherichia coli isolated from pa- Wright's stain. 100-200 cells were counted and the per cent tients were maintained in semisolid media. A strain of pneu- of cells containing bacteria determined. Vacuolation and de- mococcus Type 25 was obtained from the Department of granulation were also noted. Preventative Medicine, Seattle, Wash., and stored in defi- Opsonic titers. Whole serum opsonic titers were deter- brinated rabbit blood under petrolatum jelly at -20°C until mined for S. albus, S. aureus, and pneumococcus Type 25 by used. Before use, a loopful of bacteria was inoculated into twofold dilutions of patient and normal sera in HBSS. 5 X trypticase soy broth (TSB) and cultured for 16 hr. Pneu- 10' PWBC and 5 X 100 bacteria (ratio PWBC: bacteria = mococci were cultured in Todd-Hewitt broth for 16 hr and 1: 100) were suspended in 1 ml of the serum-HBSS mix- then subcultured for 4 hr. The bacteria were centrifuged at tures and tumbled at 37°C for 30 min (pneumococci) or 60 2000 rpm for 10 min and washed once with MHS. When dead min (S. albus and S. aureus). The opsonic titer was defined S. albus were required, the washed organisms were boiled for as the greatest dilution of serum which permitted ingestion 45 min. The bacterial concentration was estimated turbido- of one or more organisms by 90%o or more of the cells. metrically at 650 mA in a spectrophotometer (Coleman Leukocyte bactericidal assay. To assess bacterial killing Junior) by comparison to a standard curve previously pre- by leukocytes as well as phagocytosis, a modification of the pared by plating out serial dilutions of bacterial suspensions. bactericidal assay described by Cohn and Morse (14) was When indicated, S. albus were preopsonized by incubating employed. For each determination, four suspensions consisting 2 X 10' bacteria with 1 ml of serum at 37°C for 1 hr with of 10% serum, 10 X 106 PWBC, approximately 10 X 106 agitation.