ALLERGOL. ET IMMUNOPATHOL., 1998;26(5):241-249
ORIGINAL ARTICLES
Chronic granulomatous disease: six new cases
M. A. Martín Mateos, M. Álvaro, M. T. Giner, A. M. Plaza, J. I. Sierra and F. Muñoz-López
Immunoallergy Section. Pediatrics Unit. Hospital Clínico-Hospital San Juan de Dios. University of Barcelona.
SUMMARY
We report six new cases of chronic granulomatous disease (CGD) diagnosed at our service. The cases represent 1.1% of all primary immunodeficiencies diagnosed.
Four of the children were boys and two were girls. The hereditaty mechanism was X-linked in three cases and autosomal recessive in the other three.
Clinical manifestations appeared before the age of 2 years in all cases; the illness appeared earlier in males, and was more severe, consisting of bacterial infections such as abscesses in the liver, lungs or skin, suppurating lymphadenitis and mastoiditis. None of the patients had osteomyelitis. The germs isolated were bacteria (Staphylococcus, Salmonella, Serratia, Pseudomonas, Enterococcus) and fungi (Candida, Aspergillus, Trichopyton). Orientative complementary evidence was intense leukocytosis, high levels of acute phase reactants (PCR and VSG), polyclonal hypergammaglobulinemia and high LB ant LT4 levels. Definitive diagnosis was provided by the NBT test and chemiluminescence in all cases.
Key words: Chronic granulomatous disease. Non-specific immunodeficiency.
Allergol et Immunopathol 1998;26:241-9.
INTRODUCTION
Chronic granulomatous disease (CGD) is an inherited non-specific cellular immunodeficiency characterized by defects in the oxidative metabolism of neutrophils, which are unable to generate the oxidative toxic products required for microbicidal activity. The pattern of inheritance is either X-linked (65% of all cases) or autosomal recessive (35%) (1). All cases studied to date have presented a deficit in one or more of the four proteins that make up an enzyme complex which transfers electrons from NADPH to O2, generating microbicidal oxidants. Each of these four proteins is coded by a different gene and represents a specific inheritance pattern (2, 3, 5, 6).
This primary immunodeficiency has an approximate incidence of 1/1,000,000 and occurs mainly in males (ratio 4:1) (4).
Symptomatology usually emerges during the first two years of life. The most frequent clinical manifestations are acute or chronic pyogenic infections, including (in descending order of frequency) pneumonia, dermatitis, lymphadenitis, liver abscesses, osteomyelitis, persistent diarrhea, sepsis, meningitis, conjunctivitis, perianal abscesses and stomatitis.
The illness is characterized by the formation of granulomata, which can affect any organ. The most frequently isolated organisms in these patients are catalase positive bacteria (Staphylococcus aureus in 40% of cases, Escherichia coli, Klebsiella, Enterobacter, Serratia, Salmonella and various species ofPseudomona) and fungi (Aspergillus in 30% of all cases). Relatively often, though, no germs are found in cultures of patients with a suggestion of active clinical infection and fever (7).
Diagnosis is based on the nitroblue tetrazolium test (NBT) (8) and the study of the oxidative metabolism of the granulocytes using chemiluminescence and flow cytometry (9-10). Genetic study provides the inheritance pattern found in each patient. Today, prenatal diagnosis is possible in samples of chorionic villi and fetal blood; genetic study provides accurate information in 70-80% of cases (11).
Long-term infections should be treated energetically (12-13). Anti-staphylococcus antibiotics (14) and interferon-gamma (15) are used as prophylaxis. The definitive treatment is correction of the genetic defect, or alternatively cord blood cells transplantation (16).
Prognosis of the disease is variable. Some children with prophylaxis and appropriate control suffer few infections, develop normally, and reach adulthood, and some women have even had children. The disease has also been diagnosed in some adults. Most patients have repeated infections of varying severity, which are difficult to monitor and which require hospitalization, antibiotic treatment and surgery.
Here we describe six cases diagnosed at our center in recent years.
Table I | ||
| Inheritance | Genetic locus | Deficient protein |
| X-linked (65%) | Xp 21.1 | gp 91 phox |
| Autosomal recessive (5%) | 16 q 24 | p 22 phox |
| Autosomal recessive (25%) | 7 q 11.23 | p 47 phox |
| Autosomal recessive (5%) | 1 q 25 | p 67 phox |
PATIENTS AND METHODS
Case 1
Clinical assessment
Seven-year-old boy, diagnosed in 1972 on presenting with pneumonia of unrecorded chronic evolution. Brother died at the age of 12 years of an unrecorded pulmonary infection. Physical examination revealed a dome-shaped abdomen, general discomfort and hepatomegalya of 7 cm. The chest x-ray showed round granulomatous images measuring 2 x 2 cm in both pulmonary hila.
Additional examinations
Leukocytosis 35,000/mm3 with polynuclear cells 75%, ESR 110 1st hour, absence of eosinophils. NBT test 0% and liver biopsy with characteristics granulomatous images (Fig. 1). The course of the illness was progressive, and no germ was identified. The boy died at the age of 10 years.
Figure 1.--Liver biopsy with characteristics granulomatous images.
Case 2
Clinical assessment
Sixteen-year-old adolescent with no family history of pathology. From the age of 2 years, presented lesions in the form of erythematous plaques on face, neck and scalp (Fig. 2). At the age of 3 years, tinea capitis that evolved favorably after antifungal treatment. Between the ages of 6 and 10, frequent skin infections: an abscess on the scalp with a positive culture for negative plasmocoagulase Staphylococcus. At the age of 8, herpes zoster. Persistent scaly lesions in nostrils with several positive culture for Staphylococcus aureus. The biopsy of these lesions showed a pattern compatible with discoid lupus. At the age of 11, "butterfly-wing" facial erythema; pathological examination revealed discoid lupus with positive immunofluorescence. Since the age of 12, purplish erythematous lesions on fingers (Fig. 3). and eyelids, which occasionally developed into pustules. In the last 2 years she has presented frequent abscesses with positive cultures for Staphylococcus aureus in abdomen, groin, pubis and buttocks. Anal abscess with fistulization, requiring debridement.
Figure 2.--Lesions in the form of erythematous plaques on the.
Figure 3.--Purplish erythematous lesions on the fingers.
Normal development of psychomotor faculties, height and weight. Normal bone and sexual maturation.
Additional examinations
Hemogram normal. ESR 25-40 mm/1st hour. Plasma zinc 64 µg/dl (N = 80-120). Positive cultures for Candida, Staphylococucs aureus (abscesses) and plasmocoagulase negative Staphylococcus (nasopharyngeal). Negative ANA, ATA , antimicrosomal and anti-DNA antibodies and rheumatoid factor.
Immunological studies
IgG 1,490 mg/dl, subclasses: IgG1 764 mg/dl, IgG2 621 mg/dl, IgG3 714 mg/dl, IgG4 65 mg/dl; IgA 425 mg/dl; IgM 172 mg/dl (values in the upper limits of normality). Detection of total IgE below 2 kU/L. Lymphoid populations: B 27% (high); T3 67%, T4 45%, T8 27% (normal). Lymphocyte/blast transformation test (LTT) positive for PHA, concanavalin and PWM. Study of delayed cellular immunity positive for tetanus and diphtheria, negative for tuberculin, candidina and trichophyton. Detection of complement: C3 176 mg/dl, C4 34.5 mg/dl (both normal). Nitroblue tetrazolium test (NBT) score was zero; the mother''s score, used as a control, was 20% (normal, using Park''s technique). Oxidation test by flow cytometry: very low oxidative capacity both basally and after stimulus with opsonized zymosan and PMA.
The patient is receiving cotrimoxazol prophylaxis with a good clinical course, although two relapses have been recorded: a perianal abscess and cellulitis on the neck, both of which responded well to treatment.
Case 3
Clinical assessment
Newborn male with no family history of interest admitted to hospital on the 10th day of life with fever and purulent exudate in the navel. Discharged after 2 months with a diagnosis of omphalitis, thromboflebitis of the umbilical vein, clinical and analytical sepsis, meningitis, hepatic abscesses (Fig. 4), peritonitis, plaquetopenia, anemia, acute bilateral otitis media and skin candidiasis. All cultures were negative for bacteria.
Figure 4.--Abdominal echography showing hepatic abscesses.
After 3 months of life, and 5 days after the first dose of diphtheria-tetanus-pertussis vaccinations, an abscess appeared on the buttock (Fig. 5), which drained spontaneoulsy. The boy was admitted to hospital, and antibiotic treatment initiated. Cultures were negative. Sluggish course, with necrosis of the wound. Abscess in the perfusion area of the left foot, with a positive culture forSalmonella enteritidis.
Figure 5.--Abscess od buttock.
Additional examinations
In the acute infection phases, increase in leukocytes (54,000 cells with BN16-N71-E0-L8-M5) with C-reactive protein (CRP) 207 mg/L. Normal liver and kidney biochemistry.
Study of humoral immunity: IgG-843 mg/dl, IgM-39 mg/dl, IgA-143 mg/dl.
Study of cellular immunity: LT-78%, LB-12%, LT4-64%, LT8-35%.
Complement normal (C3, C4, CH50).
Presence of receptor CR3; leukocyte adhesion deficiency syndrome thus ruled out.
NBT score of 0%. Negative chemiluminescence, with a lack of production of oxidative metabolism of the granulocytes either at baseline or after stimulation with opsonized zymosan and phorbol myristate acetate.
Prophylaxis with cotrimoxazol, withdrawal from kindergarten and discontinuation of intramuscular injections. The patients has occasional bronchitis that responds well to symptomatic treatment. Again hospitalized for a pulmonary abscess, suppurating otitis and mastoiditis. Staphylococcus epidermidis isolated.
Case 4
Clinical assessment
Six-year-old girl with pathological history of repeated skin lesions since the first year of life. At 2 years of age, pulmonary Aspergillosis was diagnosed (chest x-ray and lung CT shown in Fig. 6).
Figure 6.--Pulmonary aspergillosis. Chest x-ray and lung computerized tomography.
Additional examinations
Hemogram: 19,700 leukocytes with BN4-N66-E0-B0-L24-M6, CRP 205 mg/L. Humoral immunity study: IgG 1,430 mg/dl, IgA 778 mg/dl, IgM 154 mg/dl. Cellular immunity: lymphocytes B: 29%, LT: 65%, LT4: 58%, LT8: 20%. Complement normal.
NBT score of 0%. Chemiluminescence test revealed a lack of production of oxidative metabolism of the granulocytes either at baseline or after stimulation with PMA (Fig. 7), opsonized zymosan (Fig. 8) and phorbol myristate acetate. Erytrocyte phenotype: K-, K+, Kpa-, Kpb+. Cytochrome b-245 spectrum: compatible with the presence of the cytochrome b-245 in the neutrophil membrane. Autosomal recessive pattern of inheritance.
Figure 7.--Stimulation with PMA. Multiuse 2.01, 1251 luminometer control program © BioOrbit Oy A/fago47.dat. Mon, Jun 17 1996, 11: 22: 32.
Figure 8.--Stimulation with 50 µg/ml opsonized. Zimosán®. Multiuse 2.01, 1251 luminometer control program © BioOrbit Oy.
The patient is now receiving preventive treatment with cotrimoxazol; her evolution is good.
Case 5
Clinica Assessment
Five-year-old boy, brother of case 4. At the age of 3 years, repeated submaxillary and laterocervical adenitis began with fever and sluggish evolution. At the age of 5 years, admitted for abdominal pain and tumoration in the epigastrium (Fig. 9).
Figure 9.--Tumoration in the epigastrium.
Additional examinations
Hemogram: 18,400 leuk with BN8-N64-E0-B0-L18-M10, ESR 122. Negative viral serologies. Atypical negative PPD and Mantoux test for mycobacterias. Humoral immunity study: IgG 1,970 mg/dl. IgA 671 mg/dl, IgM 136 mg/dl. Cellular immunity: lymphocytesubrets: B 20%, T 71%, T4 36% and T8 33%. Complement, normal.
On two occasions, ganglion biopsy and drainage were performed, demonstrating granulomatous lymphadenitis with caseous necrosis and star-shaped abscesses. Culture of the ganglion exudate was positive for Serratia marcenscens.
Abdominal echography: hypodense images in the liver, suggesting hepatic abscesses. Abdominal CT (Fig. 10): multiple hypodense images. Puncture of epigastric tumor: negative culture; histology: non-specific granulomatous lymphadenitis. Fistulization of the mass with subsequent debridement.
Figure 10.--Abdominal echography. Hypodense images of hepatic abscesses.
NBT score was 0%. Study of the oxidative metabolism by chemiluminescence: no production of hydrogen peroxide or superoxide after stimulation. Cytochrome b-245 spectrum: presence of cytochrome b-245 in the neutrophil membrane. Autosomal recessive pattern of inheritance.
The patient is receiving preventive treatment with cotrimoxazol and his clinical course to date has been good.
Case 6
Clinical assessment
Five-month-old male admitted for fever of 6 days evolution. Physical examination normal. A maternal uncle died at the age of 3 years of repeatd infections; no analytical data available.
On day three after admission, painful laterocervical adenopathies and purulent tonsillar exudate; fever persisted.
Additional examinations
44,100 leuk with BN3-N47-E0-B0-L43-M8; CRP 34.8 mg/l. Red cells and platelets normal. Chest x-ray normal. Urine sediment normal. Negative pharyngeal smear culture. Negative hemoculture. GOT 1,578 UI/L, GPT 1,631 UI/L.
Viral serologies (HAV, HBV, TORCH, VIH, EBV) negative. Negative PPD for M. tuberculosis and M. scrofulaceum. Abdominal echography normal. Cervical echography: solid laterocervical adenopathies. IgG 1,215 mg/dl, IgA 161 mg/dl, IgM 217 mg/dl, IgE 22 KU/L. Lymphocyte populations: LT-44%, LB-44%, LT4-44%, LT8-18%.
Ganglion biopsy: fibroconnective, adipose tissue with abscess and granulation tissue. Exudate culture positive for Serratia liquefaciens. Right otitis media with a positive culture for Pseudomonas aeruginosa and right mastoiditis.
NBT score was 0%. Chemiluminescence study of phagocytes oxidative metabolism in peripheral blood was negative both basally and after stimulation with opsonized zymosan and phorbol myristate acetate. Study of family members: phagocytes of mother and maternal grandmother presented reduced production of oxygen radicals, compatible with CGD carriers.
After 10 days os intravenous antibiotic treatment the patient was discharged without fever and with normal physical examination and hemogram. Re-admitted 1 month later for fistulization of submaxillary adenopathies; surgical exeresis performed. In the exudate Serratia liquefaciens was isolated.
Table II summarizes the characteristics of the six patients described above.
| Table II | ||||||
| Case n.º/Age/Sex | Inheri- tance | Clinical assessment | NBT/ Oxid | Immunol mg/dl | Cell IMM | Germs isolated |
| 1/7-year old/boy | Pulmonary and | 0%/? | ||||
| X | hepatic granulomata | ? | ? | ? | ||
| 2/14-year-old/girl | Tinea capitiss
Cutaneous abscess Perianal abscess | G-1490 ** | LT-67% | Candida albicans | ||
| AR | 0%/ decreased | M-172 * | LB-27% * | Staphy- lococcus PC+ | ||
| A-425 ** | LT4-45% | Staphy- lococcus PC- | ||||
| LT8-27% | Tricho- phyton | |||||
| 3/1-month-old/boy | Omphalitis (RN) | |||||
| X | Trombo- phlebitis | G-843 * | LT-80% | Staphy- lococcus PC- | ||
| Sepsis | 0%/ negative | M-39 | LB-12% | Salmonella enteritidis | ||
| Hepatic abscess | A-143 ** | LT4-64% * | Entero- coccus fecalis | |||
| LT8-35% | Candida albicans | |||||
| Abscess on | ||||||
| buttock, pulmonary | ||||||
| abscess | ||||||
| Mastoiditis | ||||||
| 4/6-year-old/girl | AR | Chronic cutanoeus impetigo | 0%/ negative | G-1430 * | LT-65% | |
| cytochrome | Abscessed | M-154 * | LB-29% * | Aspergillus | ||
| b-245 + | pneumonia | A-778 ** | LT4-58% * | |||
| LT8-20% | ||||||
| 5/5-year-old/boy | AR | Submaxillary | LT-71% | |||
| cytochrome | adenitis Latero- | 0%/ negative | G-1920 ** | LB-20% * | Serratia marcensens | |
| b-245 + | cervical adenitis | M-136 * | LT4-36% | |||
| Hepatic abscess | A-671 ** | LT8-33% | ||||
| 6/5-month-old/boy | Submaxillary | |||||
| X | adenitis Latero- | 0%/ negative | G-1215 ** | LT-44% | Serratia liquefaciens | |
| cervical adenitis | M-161 * | LB-44% * | Pseu- domonas aeruginosa | |||
| c | Mastoiditis | A-217 ** | LT4-50% | |||
| Otitis | LT8- 18% | |||||
DISCUSSION
Among the most interesting findings in this study the incidence of the disease, amounting to 1.1% of the primary immunodeficient illnesses diagnosed at our service a figure higher than in other reports (1). Of the six cases diagnosed, four were males and two females, as is habitual ratio. As regards the hereditary mechanism, however, 50% were linked to the X chromosome and 50% were autosomal recessive. In cases 4 and 5, a brother and sister, the pattern was autosomal recessive, indicating high penetrance of the gene in this hereditary mechanism.
In all cases the clinical symptoms were first manifested in the first 2 years of life. In males, onset was earlier, and the condition was more severe and aggressive regardless of the hereditary mechanism. In case 3 onset was particularly severe, with omphalitis, hepatic abscesses and abscess on the buttock after vaccination (DTP) with extensive tissue necrosis which left scars; the patient now presents pulmonary abscesses, otitis and mastoiditis.
In girls, the evaluation was slower and less typical. Clinical manifestations consisted of cutaneous lesions of recrudescent impetigo and purplish erythematous cutaneous plaques on the face and fingers, similar to lupus lesions; biopsy ruled out the latter infection. Clinical evaluation in girls was less severe, although evolution was slow and required debridement of abscesses, exeresis of pulmonary abscess and intensive antibiotic treatment. As a whole, the clinical symptomatology of our patients with early onset included omphalitis, hepatic, cutaneous or pulmonary abscesses, submaxillary adenitis, cold suppurating laterocervical adenitis and mastoiditis. Girls in whom symptoms emerged later presented persistent cutaneous infections. The diagnosis was late in most cases, probably due to unfamiliarity with the symptomatology, and because analysis suggested an immune hyperresponse to infection.
Common laboratory findings that were used for diagnostic orientation were: leukocytosis between 18,000 and 45,000/mm3 with absence of eosinophils, polynucleosis, leftward shift and extremely high acute phase reactants (ESR between 90 and 120 mm 1st hour, and PCR > 300) in the acute phases of the infection.
Immunological study revealed high humoral and cellular immune responses, with polyclonal hypergammaglobulinemia and large increase in IgG which in one case reached 1,920 mg/dl (case 5), and IgA which reached 778 mg/dl (case 4). These levels remained high even in periods of non-infection. The lymphocyte populations were also increased, especially B and T4, showing persistent immune stimulus caused by active uncontrolled infection. Specific cellular and humoral immunity function adequately but cannon control the infection due to failure of non-specific cellular immunity to destroy intercellular bacteria.
The germs isolated were bacteria (Staphylococcus aureus, Staphylococcus epidermidis, Salmonella enteritidis, Serratia liquefaciens, Pseudomonas aeruginosa) and fungi (Aspergillus fumigatus, Candida albicans, Trichopyton). On occasion patients presented clinical manifestations of acute infection localized in the lung, ear or skin after cultures or ear suppuration, skin abscesses or serial hemocultures on fever elevations, but the germ has not been identified.
Definitive diagnosis was made in all cases with the nitroblue tetrazolium test, which has also been used to identify maternal carriers in cases of X-linked inheritance and in both parents in cases of autosomal recessive inheritance. Chemiluminescence study of the oxidative metabolism of the granulocytes showed a lack of production of oxygen radicals in all cases, either basally or after stimulation with opsonized zymosan and phorbol myristate acetate.
In cases in which biopsies of adenopathies were performed, pathologial study revealed classic granulomatous lesions consisting of polymorphonuclear leukocytes containing bacteria, surrounded by cells attracted to the focus of infection such as T lymphocytes, B lymphocytes and giant cells, which attempt to isolate the bacteria but which do not kill them (Fig. 1).
The treatment in the active infection phase comprised intense use of antibiotics selected according to the antibiogram when the germ was identified, and directed against catalase-positive bacteria and fungi when it was not. The response to treatment was slow and poor; the infection was reactivated on several occasions, especially in the patient with suppurating adenopathies and hepatic abscesses, which required surgical removal and cleaning in all cases; this combined treatment (antibiotics + surgery) was effective. The postoperative period was satisfactory in all cases. The scars after surgical removal of adenopathies were more visible than in healthy children.
In two cases steroids were used with simultaneous antibiotic treatment, due to compressive respiratory complications caused by granulomata; the response to treatment was favorable, symptoms improving within 48 hours.
In cases of fever with no signs of localization, treatment with antistaphylococcals and aminoglucosides was used.
Prophylaxis in all cases consisted of trimetropin-sulfametoxazol for 3 days in consecutive weeks, with excellent tolerance and good protection except in cases 1 and 3. Antistaphyloccocal prophylaxis was not used in spite of the results of other authors (16), as we considered that the possible resistance would reduce the effectiveness of antibiotics in the case of active infection. The administration of interferon-gamma requires injections 3 days a week, with the risk of facilitating infections in these children, and with no guarantee of achieving 100% effective prophylaxis.
Cord blood transplantion and gene therapy (17-19) especially the latter may be possible in the near future.
CONCLUSIONS
1) The incidence of CGD in our setting accounts for 1.1% of all primary immunodeficiencies.
2) The hereditary mechanism is 50% AR and 50% X-linked.
3) CGD is found mainly in males: our sample comprised four boys and two girls.
4) Clinical manifestations appear before the age of 2 years in the form of serious bacterial infections: abscesses in the liver, lungs or skin, suppurating lymphadenitis and mastoiditis. None of the patients had osteomyelitis.
5) The germs isolated were bacteria (Staphylococcus, Salmonella, Serratia, Pseudomonas, Enterococcus) and fungi (Candida, Aspergillus, Trichopyton).
6) Orientative complementary evidence was: intense leukocytosis, high CRP, hypergammaglobulinemia and high LB and LT4 levels.
7) Diagnosis was confirmed with the NBT test and chemiluminescence in all cases.
RESUMEN
Se describen seis nuevos casos de enfermedad granulomatosa crónica (EGC) diagnosticados en nuestro servicio, lo que supone el 1,1% de todas las inmunodeficiencias primarias, diagnosticadas.
De los seis niños, cuatro son varones y dos niñas. El mecanismo hereditario fue ligado al X en tres niños y autosómico recesivo en los otros tres.
La clínica se inició antes de los dos años en todos los casos siendo más precoz y grave en los varones y consistió en infecciones bacterianas: abscesos hepáticos, pulmonares, cutáneos, linfadenitis supurada y mastoiditis. Los gérmenes aislados son bacterias (Estafilococo aureus y epidermidis, Salmonella, Serratia, Psedumona, Enterococo) y hongos (Cándida, Aspergillus, Trycophiton).
Las pruebas complementarias orientativas para el diagnóstico fueron: leucocitosis intensa, gran elevación de reactantes de fase aguda (PCR y VSG), hipergammaglobulinemia policlonal y aumento de linfocitos B y T4.
El diagnóstico de confirmación se realizó con el test de nitroazul de tetrazolio (NAT) y quimioluminiscencia en todos los casos.
Palabras clave: Enfermedad granulomatosa crónica. Inmunodeficiencia inespecífica.
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Correspondence:
M. A. Martín Mateos
Hospital San Juan de Dios
Pg. Sant Joan de Deu, 2
08950 Esplugues de Llobregat
Barcelona
