Arch Dis Child: first published as 10.1136/adc.53.7.580 on 1 July 1978. Downloaded from Archives of Disease in Childhood, 1978, 53, 580-584 Successful restoration of immunity in the DiGeorge syndrome with fetal thymic epithelial transplant Y. H. THONG, EVELYN F. ROBERTSON, HENRY G. RISCHBIETH, GREGORY J. SMITH, GREGORY F. BINNS, KEVIN CHENEY, AND A. C. POLLARD From the Department ofPaediatrics, University ofAdelaide, and Departments ofPaediatric Medicine, Chemical Pathology, Histopathology and Haematology, Adelaide Children's Hospital, North Adelaide, South Australia SUMMARY A 13-month-old girl presented with right upper lobe pneumonia and hypocalcaemic seizures: investigations showed hypoparathyroidism and impaired cell-mediated immune responses. Other features of the DiGeorge syndrome included hypertelorism, short philtrum of the lip, right- sided aortic arch, and aberrant origin of the left subclavian artery. Successful restoration of the immunodeficiency was achieved by transplantation of fetal thymic epithelium. The DiGeorge syndrome is a congenital immuno- the mother 23 years. The only sibling died 6 days after deficiency disorder characterised by absence or birth from respiratory distress: birthweight 1 kg and hypoplasia of the thymus and parathyroid glands gestation 28 weeks. (DiGeorge, 1965, 1968). Soon after the description Our patient presented first at the age of 13 months of the syndrome successful restoration of cell- with a right upper lobe pneumonia, with mild fever mediated immunity was reported in 2 patients and respiratory distress. She weighed 8 * 3 kg, height transplanted with fetal thymuses (August et al., 1968; was 74 cm, and head circumference 45 cm. The Cleveland et al., 1968). features were unremarkable, except for a short In order to reduce the risk of graft-versus-host philtrum of the lip and mild hypertelorism (Fig. 1). disease in immune-deficient subjects (Ammann et al., Hb was 13 0 g/dl, red cell count 5 01 x 1012/1, 1973; Pyke et al., 1975), some workers have used WBC count 6-2 x 109/1 with 46% neutrophils, 6% http://adc.bmj.com/ thymuses enclosed in millipore diffusion chambers eosinophils, 1% basophils, 29% lymphocytes, 17% to prevent the egress of donor lymphocytes (Steele et al., 1972; Frenkel et al., 1974). Others have used lymphocyte-depleted thymic epithelium instead, and reported successful reconstitution of immunity in patients with severe combined immune deficiency (Hong et al., 1976; Jones et al., 1977). We describe a case of the DiGeorge syndrome successfully treated on October 2, 2021 by guest. Protected copyright. with thymic epithelium. Case report The patient was a product of a 37-week pregnancy and normal delivery; birthweight 2-4 kg. Except for a few 'colds', there were no serious infections during infancy. Immunisations with diphtheria-pertussis- tetanus and live polio vaccine were well tolerated. Her milestones were slightly delayed: she sat without support only at 10 months, and stood with support at 13 months. She was described as a 'jittery' and 'difficult' baby. The parents were healthy and non- consanguineous; the father was aged 25 years and Fig. 1 Facial appearance ofpatient with the DiGeorge Received 2 December 1977 syndrome, showing hypertelorism and short philtrum. 580 Arch Dis Child: first published as 10.1136/adc.53.7.580 on 1 July 1978. Downloaded from Successful restoration of immunity in the DiGeorge syndrome with fetal thymic epithelial transplant 581 monocytes, and 1 % plasma cells. Barium swallow pieces and pressed gently against a 250 ptm-size showed a persistent filling defect at T3-T4 level and stainless steel mesh, washed thoroughly, and put a right-sided aortic arch; this was confirmed by into plastic tissue culture flasks containing RPMI bronchoscopy. She was treated with antibiotics and 1640 medium with 10% fetal calf serum, 100 U/ml physiotherapy and discharged after 2 weeks, penicillin, and 100 Vg/ml streptomycin. After 8 clinically and radiologically well. days at 37°C in a 5% C02-air atmosphere, the She was readmitted 2 days later with a generalised epithelium was removed and washed several times seizure lasting 3-4 minutes; another convulsion to get rid of any contaminating lymphocytes. It was occurred the following day. Plasma Ca 1 20 mmol/l minced into tiny pieces with sterile scissors. A half- (4*8 mg/100 ml) (normal 2 25-2*65 mmol/l; thymus equivalent of this lymphocyte-depleted 9-10 6 mg/100 ml), Mg 0 60 mmol/l (1 46 mg/100 epithelium was divided into two portions; one was ml) (normal 0 70-1 *05 mmol/l; 1 *7-2 - 5 mg/100 ml). injected into the peritoneal cavity and the other into Plasma concentrations of sodium, potassium the right gluteal region with a 16-gauge needle. chloride, glucose, urea, and serum albumin, globulin, and thyroxine were normal. A repeat estimation Results showed plasma Ca 1-30 mmol/l (5-2 mg/100 ml), Mg 0-60 mmol/l (1-46 mg/100 ml), and P 2-70 Serum immunoglobulin levels on first admission: mmol/l (8 * 4 mg/100 ml) (normal 1 * 35-1 - 95 mmol/l; IgG 9 *4 g/l, IgA 0 * 5 g/l, IgM 2 v25 g/l, and IgE 10 * 8 4 18-6@04 mg/100 ml). These values were consistent U/ml. T cells were 28% (normal 50-65 Y.), B cells with a diagnosis of hypoparathyroidism. 40% (normal 15-25%), and 3H-thymidine uptake Correction of the hypocalcaemia was achieved after stimulation of lymphocytes by phytohaemag- by the use of AT 10 (vitamin D2) 1 ml daily, reducing glutinin (PHA) was 1742 cpm as compared with 611 to 0 * 5 ml daily, and calcium in the form of Sandocal cpm in unstimulated cultures. Skin testing showed 500 mg twice daily reducing to 500 mg daily. Plasma negative delayed hypersensitivity response to candida Ca and P gradually returned to normal. Liver antigen. function tests, cerebrospinal fluid, and microscopy Histology of the inguinal node showed normal of urine were normal. Electrocardiogram normal. architecture but marked hypocellularity. Several Initial electroencephalogram (EEG) one week after small poorly formed follicles were present in the her convulsions was reported as markedly abnormal: cortex, with inactive germinal centres containing no 'rhythmic high voltage 2-3 cycles per second delta identifiable mitotic figures or macrophages and only waves predominated bilaterally posteriorly, while a few large lymphoid cells. The postcapillary rhythms in the 5-6 cycle per second range were venules of the paracortex were prominent, but the http://adc.bmj.com/ prominent in the central region'. These findings may adjacent tissue contained few small lymphocytes, merely have been postictal. A repeat EEG 2 months large lymphoid cells, or mitotic figures. Plasma cells, after her thymus transplant was considered normal. eosinophils, and neutrophils were present, and Developmental assessment suggested a delay of histiocytes and reticulin cells prominent. No small about 3 months behind chronological age. lymphocytes were seen in the lumen of a post- capillary venule or passing through the wall of such Materials and methods a vessel. There was no clear demarcation between the hypocellular paracortex and medulla, and similar on October 2, 2021 by guest. Protected copyright. Immunological investigations were carried out by cells were seen in both areas. The sinuses contained standard techniques: serum concentrations of predominantly histiocytes with some eosinophils and immunoglobulin (A,G,M) by commercially available neutrophils. The presence of these cells is evidence radial immunoassay plates (Behringwerke, West of the recent antigenic stimulation. The presence of Germany); IgE by radioimmunoassay (Pharmacia, follicles in the cortex and numerous plasma cells Sweden); lymphocyte transformation to mitogens throughout the node is indicative of normal B cell and allogeneic cells by a microculture method (Thong function. There were occasional large lymphoid cells et al., 1973); T cells by E-rosette formation (Schein- and mitotic figures in the paracortex, suggesting berg et al., 1976); B cells by surface immuno- some T cell functional capacity, but the appearance globulins detected with polyvalent fluorescin- of the paracortex was indicative of a severe T cell labelled antiserum (Cooper et al., 1971). Biopsy of defect (Fig. 2). the left inguinal lymph node was performed 5 days After transplantation of thymic epithelium, her after subcutaneous injection of 0 * 5 ml TAB vaccine. lymphocytes showed marked response to PHA For transplantation, a thymus was obtained from stimulation when tested one week later (Fig. 3). a 20-week-old fetus delivered by hysterotomy as a There was an increase, though transient, in E-rosette therapeutic procedure. It was cut into 1 cm size percentage in the second week, E-rosettes remaining Arch Dis Child: first published as 10.1136/adc.53.7.580 on 1 July 1978. Downloaded from 582 Thong, Robertson, Rischbieth, Smith, Binns, Cheney, and Pollard low throughout the period of follow-up. PHA A lymph node taken from the superior media- responsiveness was maintained throughout and the stinum at operation showed normal architecture and response was excellent to mixed lymphocyte culture cellularity. In the cortex were many follicles with of 3471 cpm 3H-thymidine uptake to heterologous large active germinal centres having macrophages, cells compared to 400 cpm to autologous cells. large lymphoid cells, and mitotic figures. The para- Thoracotomy performed at age 18 months (3 cortex showed much more cellularity than in the months after thymus transplantation) showed that initial biopsy, with small lymphocytes predominating. an aberrant left subclavian artery arising from a Large lymphoid cells and mitotic figures were seen right-sided aortic arch was responsible for the filling in the vicinity of most postcapillary venules, plasma defect of the oesophagus on radiography. Thymic cells in the paracortex and medulla, but eosinophils tissue could not be found in the mediastinum. and neutrophils were sparse. Few histiocytes were identifiable in the sinusoids and these structures were much less conspicuous than in the initial biopsy.