angioimmunoblastic lymphadenopathy with hypogammaglobulinemia: possible role of monocyte suppression

Angioimmunoblastic Lymphadenopathy with

Hypogammaglobulinemia

Possible Role of Monocyte Suppression

LAWRENCE RICE, M.D. STUART L. ABRAMSON, Ph.D. ARLINE H. LAUGHTER, MS. THOMAS M. WHEELER, M.D. JEREMIAH J. TWOMEY, M.B.

Houston, Texas

From the Department of Medicine, Baylor College of Medicine, Sections of Hematology and Clinical Immunology, lmmunohematotogy Research Lab- oratory, Veterans Administration Medical Center, and Department of Pathology, Baylor College of Medicine and Methodist Hospital, Houston, Texas. Dr. Wheeler is a 1980-81 Fellow of the American Cancer Society. This study was supported in part by grants 5-ROl-Al15394 from the United States Public Health Service, and 5RO l-CA1 5333 and l-ROl-NS16325 from the National Institutes of Health. Presented in part at the International So- ciety of Hematology meetlng, Montreal, Canada, in August 1980. Requests for reprints should be addressed to Dr. Lawrence Rice, Methodist Hos- pital, 0565 Fannin, station 902, Houston, Texas 77030. Manuscript accepted November 2, 1981.

A patient wlth angloimmunoblastlc lymphadenopathy had low serum immunoglobulln values and no antibodies to Injected lmmunogens. This occurred desptte the proliferation of polyclonal B cells. T cells were deflclent In number and In lymphoproliferatlve responses, but their helper and suppressor functions were maintained. la-antigen bearing leukocytes from the patlent stimulated poorly in mixed leukocyte culture.

In vitro lmmunoglobulln synthesis by mononuclear leukocytes from the paflent was severely Impaired. These leukocytes actively suppressed immunoglobulin synthesis by normal cells from healthy subjects In co-culture. The responslble cell had characteristics of a monocyte. The suppression was selective for humoral immunity and was manifest despite normal numbers of monocytes. It appears that heterogeneous immunoregulatory abnormalities can underlie the syndrome of angiolmmunoblastlc lymphadenopathy. Further- more, monocyte suppressor abnormalities may be implicated in clinical disease phenomena.

Angioimmunoblastic lymphadenopathy with dysproteinemia (immunoblastic lymphadenopathy; AILD) has emerged as a distinct clin- icopathologic entity [l-3] that is characterized by hyperactivity of the immune system. Noting the frequency of hypergammaglobulinemia and autoantibodies, as well as histologic overlap with graft-versus-host disease, even the first investigators of this syndrome postulated an underlying disturbance of immune regulation. A defect in suppressor T-cell function has been demonstrated in two affected patients [4].

The experience reported herein suggests that immune dysregulation may not always deviate toward suppressor deficiency. Although our patient displayed classic symptoms, signs, and histology for AILD, his case was unusual in that serum immunoglobulin values were low. Careful study of in vitro immunologic responses revealed a pattern of dysregulation not previously seen with AILD. The observations support the concept that monocyte suppression observed in culture can be relevant to events in vivo.

CASE REPORT

A 69 year old white man presented with fever, weight loss, marked fatigue, diffuse maculopapular skin rash, angioedema and sensorimotor neuropathic symptoms of his lower legs. Desensitization injections for hay fever had been

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AILD WITH MONOCYTE SUPPRESSOR CELLS-RICE ET AL.

given for the preceding 13 years. Examination revealed lymph nodes reaching 3 cm in cervical, supraclavicular, axillary, epitrochlear, inguinal, and femoral areas. There was moderate hepatospfenornegaly and peripheral neuropathies were found. Hematocrit value was 31 percent, reticulocytes 7 percent, platelets 148,000/mm3, and leukocytes 3,500/mm3, with 44 percent neutrophils, 8 percent band forms, 1 percent eosinophils, 7 percent monocytes, and 42 percent lymphocytes (two-thirds of which had the morphology of immunoblasts). Chemical survey, including liver enzymes, was en- tirely normal. Chest x-ray showed a 5 mm nodule in the upper lobe and Coombs’ test gave negative results. Also negative were serologic tests for antinuclear antibodies, rheumatoid factors, cold agglutinins, heterophile antibodies, hepatitis B surface antigen, cytomegalovirus, Toxoplasma, herpes simplex, fungi, and syphilis. Protein electrophoresis showed hypogammaglobulinemia, and repeated immunodiffusion tests showed serum IgG from 464 rng/dl to 620 mg/dl (normal 659 to 1,650 mg/dl), IgA from 76 to 82 mg/dl (normal 100 to 350 mg/dl), IgM from 27 to 41 mg/dl (normal 50 to 150 mg/dl) and IgE less than 5 IU/ml. Ouchterlony diffusions did not demonstrate antibody titers to the repeatedly injected immunogens (extracts of ragweed, pollens, molds, grasses, and trees).

Excisional biopsy specimens of the lymph nodes from both axillas (the first time carried out at the Mayo Clinic) were di- ‘agnostic of AILD. Specifically, the architecture was diffusely replaced by small lymphocytes, plasma cells, histiocytes, and immunoblasts; there was prominent angiogenesis and moderate acidophilic interstitial material. lmmunoperoxidase staining with antiserums specific for IgG, IgA, IgM, and K and X light chains showed the B-cell proliferation to be polyclonal (i.e., there was significant staining with each). When gluco- cotticoid therapy was administered, there was improvement and eventually, after 15 months, complete remission. The patient was successfully treated for an episode of bacterial pneumonia. Eighteen months after presentation, the patient had a relapse of the disease and was successfully treated ,with the reinstitution of glucocorticoids.

MATERIALS AND METHODS

Heparinized blood was studied on four occasions, with the bulk of the work performed on the first collection before the patient was treated (cell markers, lymphoproliferation, immunoglobulin synthesis, and suppressor assays). Prednisone therapy was withheld for four to six days prior to subsequent studies that were performed two, three, and 13 months later. These subsequent studies clarified specific points, such as characteristics of the suppressor cell. Disease activity was evident throughout the study period, during which there was no diminution of suppressor activity or increase in serum immunoglobulins. During each experiment, one or two control subjects were simultaneously tested; the results always fell within our normal range. Control subjects were healthy vol- unteers in the third and fourth age decades; normal ranges were first determined from a series of such control subjects.

Mononuclear leukocytes were separated from blood by isopyknic flotation on Ficoll-Hypaque gradients [5]. T cells were enumerated as rosettes with e-amino ethylisothiouro-

nium bromide (AETFtreated sheep erythrocytes [6]. Surface immunoglobulins on B cells were detected after overnight incubation in globulin-free medium with fluorescein-conjugated polyvalent antihuman immunoglobulin serum by direct immunofluorescent microscopy. Antiserums specific for K, x or individual heavy chains were also conjugated with fluorescein or with peroxidase (Behring Diagnostics, Dallas, Texas) [7,8]. A monocyte subset reported to have helper activity was identified by indirect immunofluorescence with monoclonal antibody Mac-120 (gift of J. Stobo, San Fran- cisco, California) [ 91. la antigen was similarly detected using mOnOClOnal antibodies L203 and L227 (gifts of R. Levy, Stanford, Connecticut) [lo]. Binding with Drthoclone monoclonal antibodies OKT3,OKT4 and 0KT8 was also determined by indirect immunofluorescence [ 111. Nonadherent cell POPUlatiOnS were mononuclear leukocytes eluted from plastic petri dishes or Sephadex GlO beads (reducing esterase-positive cells to less than 1 percent) [ 121. Nonad- herent cells were rosetted twice with AET-treated sheep erythrocytes, and then centrifuged through Ficoll-Hypaque to prepare T-cell and B-cell (plus null cell) populations. Irra- diation was 2,500 rads from a cesium source Gammator B. Steroid treatment was hydrocortisone 100 pg/ml for 16 hours.

Lymphoproliferation was tested to optimal concentrations of mitogens (three-day culture) and antigens (sevenday culture) in microtiter plates [ 12,131. The mixed leukocyte reaction employed lo5 irradiated mononuclear leukocytes per ml stimulating 1 O5 responder cells per ml [ 12,131. Sup- pressor assays were performed as previously described [ 12-141. Basically, adherent cell suppression is determined by adding increasing numbers of irradiated mononuclear leukocytes to a mixed leukocyte reaction. Prostaglandin suppression compares lymphoproliferation to phytohem- agglutininP (PHA) with and without the addition of 1 pg/ml indomethacin. In the spontaneous T-cell suppression assay, autologous T cells are added to responding cells in the mixed leukocyte reaction. Results are determined from 3H-thymidine uptake of responder cells, with 3H-leucine measure in some experiments [ 12- 141.

For immunoglobulin synthesis, mononuclear leukocytes were washed in fetal calf serum, cultured at 106/ml (or B cells at 0.25 X 106/ml) and stimulated in duplicate flat-bottomed glass vials with pokeweed mitogen (PWM) or Epstein-Barr virus ([EBV] 895-8, gift of M. Blaese, Bethesda, Maryland) [ 14- 161. Supernatant immunoglobulin was assayed after 14 days with immunofluor kits (Bio-Rad, Richmond:, California). In one experiment, cultures were grown in plastic diffusion chambers (Adaps, Dedham, Massachusetts) with cell populations separated by a 0.2 p membrane [ 171. Co-cultures contained cells from each of two donors (0.5 X 106/ml). Predicted co-culture immunoglobulin value was the sum of the measured immunoglobulin by lo6 cells per ml from each donor, divided by two; percent suppression in co-cultures was

l- measured immunoglobulin

predicted immunoglobulin x 100.

Suppression is reported for IgG (IgA and IgM gave similar results). All statistical analyses were performed using the Student t test.

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TABLE I Surface Markers and Lymphoproiiferation

Patient Normal Subject’

Surface Markers T Cells (E-rosettes) 39 % l 0KT4 positive 61% 0KT6 positive 32% B Cells (surface immunoglobulin) 45% l

K to h ratio 1.9 Monocytes (esterase) 20% Mac-120 positive 8% la on nonrosettes 82% l

Results of Lymphoprollferatlon PWM response 25.9 PHA response 44.0’ Candida response 0.0 Mixed leukocyte reactions

Response by mononuclear cells 21.5 Response by monocytedepleted 21.7

cells Stimulaticn by mononuclear cells 6.0”

76% (1) 68% (2) 33% (2) 15% (1)

1.95” 20% (2) 7% (1)

70% (3)

26.2 (5.1) 144.0 (8.9)

5.0‘.

33.3 (2.6) 43.0 (8.5)

33.3 (2.6)

Results of lymphoproliferation are expressed as counts per minute X 10m3 of 3H-thymidine incorporation. l Significant difference from normal (p <0.05). l + Based on two controls, rather than a control series. t Figures in parentheses are standard errors of the mean.

RESULTS

Cell Surface Markers (Table I). Cell surface markers were studied on three occasions with identical findings each time. Among peripheral blood mononuclear cells, there were 39 percent which formed E-rosettes, and a similar degree of T-cell depletion was uncovered with 0KT3 (41 percent). The percentages of E-rosetting cells staining with 0KT4 and OKT8 were normal. (OKT3 is present on all normal peripheral T cells, OKT4 on helper cells, and OKT8 on cytotoxic/suppressor cells [ 1 l] .) Mononuclear leukocytes bearing surface immunoglobulins were increased to 45 to 53 percent. The polyclonal nature of the B-cell proliferation was evident from the normal staining ratio with selective antiserums to K and x light chains. Monocyte percentages in mononuclear cell preparations (and absolute numbers ,in peripheral blood) were normal. The Mac-120 monocyte antigen, expressed by a helper monocyte subpopulation, was expressed equally by patient and control mononuclear cells. Lymphoproiiferation to Mitegens and Antigens (Table I). The patient’s mononuclear cells were tested on two occasions with the predominantly B-cell mitogen, PWM; there was normal response. Responses by mononuclear leukocytes to T-cell mitogens and antigens were impaired, demonstrated most clearly by the statistically impaired response to PHA.

Stimulation of Mixed Leukocyte Reaction (Table I). Tested with leukocytes from two normal responders who were allogeneic, irradiated leukocytes from the patient demonstrated poor stimulation in the mixed leukocyte reaction. As shown in suppressor cell assays (to follow), the poor stimulation did not result from suppression of the responding cells by cells among the irradiated stimulator cells from the patient. Because of the importance of membrane la antigen in stimulating the mixed leukocyte reaction, this was determined on patient mononuclear leukocytes using indirect immunofluorescence and monoclonai antibodies against la determinants. Mononuclear leukocytes were 25 percent positive with L203 and 23 percent positive with L227 (normal 20 percent for each). With L203, nonrosetting mononuclear cells were 82 percent positive (normal 70 percent), consistent with the increased percentage of B cells. Regulation of T-Ceil Proliferation. To elucidate the cause of the impaired T-cell responses to mitogens and antigens, distinct suppressor cell systems that regulate lymphoproliferation were studied [ 13,141. Spontaneous suppression of T cells, studied by adding irradiated autologous T cells to responder cells in mixed leukocyte cultures, was normal at 0 percent (normal -4 percent f 2.8 standard error of the mean [SEMI). Prostaglan- din-related suppression, mediated by monocytes and studied by adding indomethacin to PHA-stimulated cultures, was normal at 25 percent (normal 22 percent f 3 SEM). Finally, adherent cell suppression distinct from prostaglandin-related suppression was studied. When increasing numbers of irradiated mononuclear leukocytes were added to mixed leukocyte cultures, a normal suppression curve was uncovered: 2 X lo5 irradiated mononuclear cells per ml enhanced tritiated thymidine uptake by 53 percent over cultures containing 1 X lo5 irradiated mononuclear cells per ml (2 X lo5 cells per ml suppress responders in disease states characterized by excessive suppression [ 12,181). There was 66 percent suppression by 6 X 1 O5 irradiated patient cells per ml (mean normal 74 percent). Strengthening this point, monocyte-mediated suppression was not found to be excessive in depletion experiments. The poor response by patient mononuclear cells in the mixed leukocyte reaction was not improved when monocyte-depleted T cells from the patient were substituted as responders (Table I). immunoglobulin Synthesis and Regulation. Mono- nuclear leukocytes were cultured with polyclonal B-cell mitogens EBV or PWM, the former acting directly and the latter dependent on helper T cells [ 151. Supernatant immunoglobulin was measured after 14 days. Immu- noglobulin synthesis was grossly impaired to both mitogens (Figure 1). Furthermore, stimulated co-cultures

1000 June 1992 The American Journal of Medicine Volume 72


q IgA

12-

3 e lo-

I

i 8-

c’

g 8- 0

$4 :: ! . . . . . .

, Lll CD2 :: . .

P . .

0 ::

Figure 1. lmmunoglobulin synthesis. 1 Last whnn is a co-culture (see text,). EBV = Epstein-Barr virus; lg = immunoglob- din; MNL = mononuclear leukocytes; P WM = poke weed mitogen.

NORMAL PATIENT NORMAL PATIENT NORMAL + MNL MNL MNL MNL PATIENT

+ E8V l EBV + PWM + PWM MNL + PWM

of mononuclear leukocytes from both the patient and the normal subject produced virtually no immunoglobulin, indicating active suppression of the normal subject’s immunoglobulin synthesis by cells from the patient.

The capability of helper T cells from the patient was found to be normal in several experiments. Most directly, the addition of 0.5 X lo6 patient T cells per ml to 0.5 X lo6 normal T-depleted cells per ml in PWM- stimulated cultures resulted in 133 percent augmentation of immunoglobulin synthesis, intermediate between the augmentation effected by 0.5 X lo6 T cells per ml from two normal donors. Confirming that helper T-cell deficiency was not a problem, the addition of normal T cells to stimulated patient nonrosetting cells did not augment the minimal immunoglobulin produced.

T-cell suppressor activity over immunoglobulin synthesis was also found to be normal. Depleting T cells from EBV-stimulated mononuclear leukocytes did not improve immunoglobulin synthesis. In other experiments, patient T cells were added in increasing numbers to normal T-depleted cells in PWM-stimulated cultures. Enhancement of immunoglobulin production was seen with 0.5 X lo6 patient T cells (as previously described). The addition of 1 X lo6 T cells per ml effected suppression, and 2 X lo6 T cells per ml effected 57 percent suppression: this level of suppression was intermediate between the percentages of suppression caused by T cells from each of the two control subjects. Characterization of Suppressor Cells (Table II). Co-culturing of mononuclear leukocytes from the pa-

tient with normal mononuclear leukocytes resulted in 93 to 98 percent suppression, based on predicted ad- ditive immunoglobulin synthesis by co-cultured cells in the absence of active suppression. To characterize suppressor cells, patient mononuclear bukocytes that had been irradiated or preincubated with hydrocortisone were added to normal mononuclear leukocytes in PWM-stimulated cultures. The suppressor cells proved resistant to radiation and corticosteroids. When patient cells were rosetted with sheep erythrocytes, suppressor cells were among the nonrosetting fraction. When these nonrosettes were depleted of monocytes by adherence (B-cell enrichment), they were no longer suppressive,

TABLE II Characteristics of Suppressar Cells

Patient Cell Population Percent Added to Normal MNL Suppression

MNL MNL preincubated with steroids MNL separated by membrane in

93 95

diffusion chamber 92 Nonrosetting cells (0.125 X 106/ml) 83

MNL, irradiated (2,500 rads) 62

Sephadex, nonadherent +64

B Cells (0.25 X 10s/ml) +73

T Cells +64

T Cells (0.25 X 106/ml) i-143

These co-cultures of PWM-stimulated immunoglobulin synthesis contained 0.5 X lo6 normal mononuclear leukocytes (MNL) per ml, and except where indicated, 0.5 X lo6 patient cells per ml were added. Suppression was calculated as described under Methods. + = enhancement, rather than suppression, of response.

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but instead enhanced immunoglobulin production by normal mononuclear cells. Fresh mononuclear leukocytes from the patient depleted of adherent cells on Sephadex G10 beads, had no ability to suppress immunoglobulin synthesis in co-cultures. Further implicating adherent cells in the patient’s immunoglobulin synthesis problem, nonrosettes were partially depleted of these cells (B-cell enriched), and EBV-stimulated immunoglobulin values rose significantly (1,100 pg/ml by B-enriched cells compared to 0 pg/ml by unfrac- tionated mononuclear leukocytes).

The mechanism and level of suppression were studied. PWMstimulated immunoglobulin cultures were performed in diffusion chambers, in which normal mononuclear cells were separated from patient mononuclear cells by a 0.2 p filter that prevented cell- to-cell contact [ 171. Patient cells were suppressed across the membrane, implicating soluble mediators in suppression. Next, we addressed the paradox that the patient had multiple enlarged lymph nodes, each containing substantial numbers of plasma cells staining for polyclonal immunoglobulin, yet serum samples showed hypogammaglobulinemia. As previously indicated, patient mononuclear leukocytes adequately incorpo- rated 3H-thymidine when stimulated by B-cell mitogens. Patient mononuclear leukocytes were stimulated by PWM, and 3H-leucine uptake was measured. This result was normal, indicating normal induction of protein synthesis. These data suggested a hypothesis that the suppressor block was at the level of immunoglobulin release. Cells from 14day immunoglobulin synthesis cultures were smeared on coded glass slides and stained for cytoplasmic immunoglobulin with fluorescein-tagged antiserums. Stimulated normal mononuclear cells were scored as 4+ staining. Stimulated patient mononuclear cells alone, stimulated cocultures containing normal mononuclear cells with patient mononuclear cells, and stimulated co-cultures of normal cells with patient nonrosetting cells, all showed clearly reduced staining (0 to 2+). This experiment thus im- plicates a block prior to the formation of cytoplasmic immunoglobulin.

COMMENTS

From the first descriptions, AILD was thought to rep- resent an exuberant polyclonal activation and expansion of the B-cell series, with hyperimmune and autoimmune features [l-3]. Parallels were drawn to diseases such as systemic lupus erythematosus and graft-versus-host disease, both associated with deficits of suppressor T-cell function [ 19,201. In the only published study directly on the subject of T-cell control of immunoglobulin synthesis in AILD, Bluming [4] demonstrated T-cell suppressor deficiency in two patients. Rather than being a primary problem, this regulatory T-cell deficit may be

but one manifestation of overall T-cell function im- pairment, evidenced by many studies showing de- creased percentages of T cells in blood, impaired lymphoproliferation to T-cell mitogens and cutaneous anergy with AILD [ 8,2 l-231. The two patients studied by Bluming [4] were unusual in that their hypergammaglobulinemia was extreme, making it difficult to generalize that a T-cell suppressor defect is present in all patients with the syndrome. Another study, using very indirect methods, could not find any evidence of an important suppressor T-cell deficiency in four patients

P41. Our patient exhibited already classic features of AILD,

but his case was most intriguing because of his quan- titative immunoglobulin deficiency. In about 80 percent of patients with AILD, polyclonal hypergammaglobulinemia is observed, but also observed have been a variety of paraproteinemias [ 231. IgA deficiency has been documented [25], and there has been one reported case with hypogammaglobulinemia, although quanti- tative immunoglobulin data were not given [26]. In our patient, we discovered many immunologic abnormalities previously described in AILD: polyclonal proliferation of B cells in blood and tissue, peripheral T-cell lymphopenia, and impaired T-cell proliferative responses. Surface marker studies showed that OKT4- bearing cells (which includes helper T cells) and OKT&bearing cells (including suppressor T cells) were equally depleted. Total monocytes and a helper monocyte subpopulation were normal in number. In tests of distinct regulatory systems governing lymphoproliferation, it was found that suppression by T cells, by adherent cells, and by prostaglandins was not excessive; thus, the observed T-cell proliferation deficit appears due to intrinsic effector T-cell hypofunction. An additional finding in these studies was the poor ability of irradiated leukocytes from the patient to stimulate lymphoproliferation by allogeneic responder cells, despite la-antigen expression. This phenomenon has previously been noted only in cases of chronic lymphocytic leukemia and probably reflects a cell membrane abnormality [27].

Directly correlating with the patient’s hypogammaglobulinemia and the inability to produce antibodies against immunogens, in vitro immunoglobulin synthesis by the patient’s leukocytes was profoundly impaired. Co-culture experiments as well as cell depletion experiments implicated active suppression in the im- pairment of immunoglobulin synthesis. T cells were not the excessively active suppressor cells, as indicated by many experiments, including cell depletion and a cell addition protocol identical to Bluming’s [4]. In fact, suppression by T cells was neither excessive nor de- ficient, and T-cell helper activity was similarly shown to be normal. Rather, the abnormally suppressive cells


had the characteristics of monocytes. It has become clear that monocytes normally exert important positive and negative regulatory influences on both T- and S-cell effector functions, both in animal and human systems. Studies from our own and other laboratories have shown monocyte suppressor cells to be adherent, radio- resistant, steroid-resistant, and nonrosetting [ 13,28-291. Monocyte suppression frequently involves soluble mediators, some of which have been identified and others that appear labile, which explains their ability to suppress across cell impermeable membranes [ 17,30-321. Monocyte suppression may sometimes require interaction of the monocyte with other immu- nocompetent cells [33]. It is possible that the suppression observed in our patient required interactions with nonmonocytes, although suppression was observed in T-cell depleted cultures.

An excess of monocyte suppressor activity has been implicated in the immune deficiencies accompanying Hodgkin’s disease [ 14,18,34], multiple myeloma [ 351, sarcoidosis [ 361, solid tumors [ 371, and membranous glomerulonephropathy [38]. However, the relevance of the excessive suppression in vitro to clinical phe-

nomena is not conclusively established, partly because of the difficulties always inherent in such extrapolations. Often, the excessive monocyte suppression can be partly or totally explained by elevated monocyte percentages in the blood and mononuclear cell preparations studied [ 14,16,34,36]. In addition, the studies of Hodgkin’s disease and multiple myeloma conducted in our laboratory have found that both immunoglobulin synthesis and T-cell proliferation are proportionately suppressed in any given subject [ 14,161. We can, for example, consistently find excessive monocyte suppression of in vitro immunoglobulin synthesis in un-

AILD WITH MONOCYTE SUPPRESSOR CELLS-RICE ET AL,

treated patients with Hodgkin’s disease in whom humoral immune function is clinically intact.

In contrast, our patient had a clinically apparent humoral immune deficit which correlated with in vitro observations of monocyte suppression of immunoglobulin synthesis. The number of monocytes in peripheral blood and mononuclear cell preparations were normal. Lymphoproliferation was not affected by the suppression, This certainly strengthens the premise that in vitro observations are relevant to the clinical problem and lends credence to the general premise that monocyte regulatory dysfunction can contribute to disease in humans. The finding that suppression affected only immunoglobulin synthesis establishes the fact that monocyte suppressor cells are capable of such se- lectivity. Our laboratory is now exploring whether distinct monocyte subpopulations regulate humoral as opposed to cellular immunity, as has already been established for regulatory T cells [39].

The careful dissection of a variety of immunologic responses and control mechanisms uncovered a previously unreported pattern of perturbed reactivity in our patient. Clearly then, heterogeneous immunoregulatory abnormalities may be associated with AILD. Beyond implications for the pathogenesis of this immunologic disease, the findings have relevance to more basic issues concerning the importance of monocytes in immune regulation.

ACKNOWLEDGMENT

We are especially indebted to Dr. Robert Rich for his assistance, and also to Dr. C. Mattioli, Dr. M. V. Gresik and Dr. R. Hausner who were kind enough to review the pathologic slides.

REFERENCES

1. Frizzera G, Rappaport H, Moran EM: Angio-immunoblastic lymphadenopathy with dysproteinemia. Lancet 1974; 1: 7. 1070-1073.

2. Lukes RJ, Tindle BH: lmmunoblastic lymphadenopathy: a hyperimmune entity resembling Hodgkin’s disease. N Engl J Med 1975; 292: 1-12.

3. Frizzera G, Moran EM, Rappaport H: Angio-immunoblastic lymphadenopathy: diagnosis and clinical copse. Am J Med 1975; 59: 803-818.

8.

4. Burning AZ, Cohen HG, Saxon A: Angioimmunoblastic lymphadenopathy with dysproteinemia: a pathogenetic link between physiologic lymphokl proliferation and malignant lymphoma. Am J Med 1979; 67: 421-428.

5. Boyum A: Isolation of mononuclear cells and granulocytes from human blood. Stand J Clin Lab 1968; Pl(suppl 97): 77-89.

6. Pellegrino MA, Ferrone S, Dierich MP, Reisfeld RA: En- hancement of sheep red blood cell human lymphocyte rosette formation by sulfhydryl compound P-amino ethyl- isothiouronium bromide. Clin lmmunol lmmunopathol 1975;

9.

10.

11.

3: 324-333. Taylor CR, Mason DY: The immunohistological detection of

intracellular immunoglobulin in formalin-paraffin sections from multiple myeloma and related conditions using the immunoperoxidase technique. Clin Exp lmmunol 1974; 18: 417-429.

Neiman RS, Dervan P, Haudenschild C, Jaffe R: Angioimmu- noblastic lymphadenopathy: an ultrastructural and immunologic study with review of the literature. Cancer 1978; 41: 507-518.

Raff HV, Picker LJ, Stobo JD: Macrophage heterogeneity in man. A subpopulation of HLA-DR-bearing macrophages required for antigen-induced T cell activation also contains stimulator for autologous-reactive T cells. J Exp Med 1980; 152: 581-593.

Rich RR, Abramson SL, Seldin MF, Puck JM, Levy R: The role of la+ cells in induction of secondary human immune responses to hapten in vitro. J Exp Med 1980; 152: 218S- 2348.

Reinherz EL, Schlossman SF: Regulation of the immune re-

June 1992 The American Journal of Mediclne Volume 72 1003


12.

13.

14.

15.

16.

17.

16.

19.

20.

21.

22.

23.

24.

25.

26.

sponse-inducer and suppressor T lymphocyte subsets in human beings. N Engl J bled 1980; 303: 370-373.

Laughter AH, Twomey JJ: Suppression of lymphoproliferation by high concentrations of normal human mononuclear leukocytes. J lmmunol 1977; 119: 173-179.

Rice L, Laughter AH, Twomey JJ: Three suppressor systems in human blood that modulate lymphoproliferation. J Im- munol 1979; 122: 991-996.

Twomey JJ, Laughter AH, Rice L, Ford R: The spectrum of immunodeficiencies with Hodgkin’s disease. J Clin Invest 1960; 66: 629-637.

Laughter AH, Lidsky MD, Twomey JJ: Suppression of immunoglobulin synthesis by monocytes in health and in patients with systemic lupus erythematosus. Clin lmmunol Immu- nopathol 1979; 14: 435-440.

Twomey JJ, Laughter AH, Rice L, Ford RJ: Regulation of lymphocyte responses with untreated and treated multiple myeloma. Blood (in press)

Laughter AH, Rice L, Twomey JJ: Suppression of lymphocyte responses by monocytoid cells does not require cell-cell contact. Cell Immunol, 1960; 60: 440-452.

Twomey JJ, Laughter AH, Farrow S, Douglass CC: Hodgkin’s disease: an immunodepleting and immunosuppressive disorder. J Clin Invest 1975; 56: 467-475.

Twomey JJ, Laughter AH, Steinberg AD: A serum inhibitor of immune regulation in patients with systemic lupus erythematosus (SLE). J Clin Invest 1976; 62: 713-715.

Reinherz EL, Parkman R, Rappaport J, Rosen FS, Schlossman SF: Aberrations of suppressor T cells in human graft-versus-host disease. N Engl J Med 1979; 300: 1061-1066.

Ellegaard J, Boesen AM: Restoration of defective cellular immunity by levamisole in a patient with immunoblastic lymphadenopathy. Stand J Haematol 1976; 17: 36-43.

Kosmidis PA, Axelrod AR, Palagas C, Stahl M: Angioimmu- noblastic lymphadenopathy. A T cell deficiency. Cancer 1976; 42: 447-452.

Cullen MH, Stansfeld AG, Oliver RTD, Lister TA, Malpas JS: Angidmmunoblastic lymphadenopathy: report of ten cases and review of literature. Q J Med 1979; 46: 151-177.

Brincker H, Birkeland SA: The relationship between disease activity, treatment response, and immunologic reactivity in immunoblastic lymphadenopathy: a longitudinal study of treatment with levamisole and cytostatics. Cancer 1981; 47: 266-271.

Budman DR, Koziner B, Rundles C, Filippa D, Good RA: IgA deficiency associated with angioimmunoblastic lymphadenopathy. N Engl J f&d 1976; 296: 1204.

Nathwani BN, Rappaport H, Moran EM, Pangalis GA, Kim H:

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

Malignant lymphoma arising in angioimmunoblastic lymphadenopathy. Cancer 1976; 41: 576-606.

Halper JP, Fu SH, Gottlieb AB, Winchester RS, Kunkel HG: Poor mixed lymphocyte reaction stimulatory capacity of leukemia B cells of chronic lymphocytic leukemia patients despite the presence of ia antigens. J Clin Invest 1979; 64: 1141-1148.

Kirchner H, Fernbach BR, Herberman RB: Macrophages suppressing T and B cell mitogen responses and the mixed leukocyte reaction. In: Dppenheim JJ, Rosentreich DL, eds. Mitogens in immunobiology. New York: Academic Press, 1975; 495-507.

Knapp W, Baumgartner G: Monocyte-mediated suppression of human B lymphocyte differentiation in vitro. J lmmunol 1978; 121: 1177-1183.

Waldman SR, Gottlieb AA: Macrophage regulation of DNA synthesis in lymphoid cells: effects of a soluble factor from macrophages. Cell lmmunol 1973; 9: 142.

Nelson DS: Nonspecific immunoregulation by macrophages and their products. In: Nelson DS, ed. lmmunobiology of the macrophage. New York: Academic Press, 1976; 235-257.

Page RC, Davies P, Allison AC: The macrophage as a se- cretory cell. Int Rev Cytol 1976; 52: 119.

Stobo JD: lmmunosuppression in man: suppression by macrophages can be mediated by interactions with regulatory T cells. J lmmunol 1977; 119: 916-924.

Schechter GP, Soehnlen F: Monocyte-mediated inhibition of lymphocyte blastogenesis in Hodgkin’s disease. Blood 1976; 52: 261-271.

Broder S, Humphrey R, Durm M, et al.: Impaired synthesis of polyclonal (non-protein) immunoglobulins by circulating lymphocytes from patients with multiple myeloma: role of suppressor cells. N Engl J Med 1975; 293: 667-692.

Goodwin JS, DeHoratius R, lsreal H, Peake GT, Messner RP: Suppressor cell function is sarcoidosis. Ann Intern Med 1979; 90: 169-173.

Zembala M, Bozena M, Popiela T, Asherson GL: Depressed in vitro peripheral blood lymphocyte response to mitogens in cancer patients: the role of suppressor cells. Int J Cancer 1977; 19: 605-613.

Ooi BS, Ooi YM, Hsu A, Hurtubise PE: Diminished synthesis of immunoglobulin by peripheral lymphocytes of patients with idiopathic membranous glomerulonephropathy. J Clin Invest 1980; 65: 789-797.

Whisler RL, Stobo JD: Suppression of humoral and delayed hypersensitivity responses by distinct T cell subpopulations. J lmmunol 1978; 121: 539-542.


angioimmunoblastic lymphadenopathy with hypogammaglobulinemia: possible role of monocyte suppression

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