Clinical-Epidemiological Pattern of Primary Immunodeficiencies in Malaysia 1987-2006: A 20 year experience in Four Malaysian Hospitals.

AIM OF STUDY: To determine the clinical and epidemiological characteristics of patients seen with primary immunodeficiencies referred at four Malaysian Hospitals between 1987 to 2007. METHODS: Patient data were retrospectively obtained from patient records and supplemented by information from a standardized questionnaires taken at the time of diagnosis from 4 participating hospitals. The completed data were transferred to document records kept by the first author. The diagnoses made were based on criteria set by WHO Scientific Committee 1986. RESULTS: Fifty one (51) patients with completed records satisfied the criteria of primary immunodeficiencies based on WHO Scientific Committee 1986. Predominant Antibody deficiency (40.4%) is the commonest of the class of primary immunodeficiency (based on modified IUIS classification) followed by phagocytic defect (17.3%), combined immunodeficiencies (15.4%) and other cellular immunodeficiencies (11.5%). The commonest clinical presentation is pneumonia (54%) . A positive Family history with a close family relative afflicted was a strong pointer to diagnosis for PID (52.6%) Primary immnodeficiencies are seen in all the major ethnic groups of Malaysia, predominantly among Malays. As observed in other patient registries, diagnostic delay remains the major cause of morbidity and mortality. CONCLUSION: Primary immunodeficiencies is relative rare but is an emerging disease in Malaysia. Creating awareness of the disease, may reveal more cases within the community. It is sufficient to be a health issue in Malaysia as in other developing countries in the future.

Mixed-genotypes infections with hepatitis C virus in hemodialysis subjects.

Mixed-genotypes hepatitis C virus (HCV) infections are normally ignored in chronic hemodialysis patients. The aim of this study is to investigate the prevalence of mixed-genotypes infections among hemodialysis patients in Pahang province, Malaysia. Reverse-transcription and polymerase chain reaction methods were performed using two different sets of primers, targeting the 5' untranslated region and nonstructural 5B region. Target region base sequences were obtained by direct sequencing. Discrepancy in outcomes from phylogenetic analysis of both regions suggests double infections. Of 40 subjects in eight hemodialysis centres, evidence of mixed-genotypes infections was found in 5 subjects (12.5%) from three different centres. Four patients were infected with mixed genotypes 3 and 1 and one with genotypes 3 and 4. Cases of mixed HCV genotypes infection were considered high among hemodialysis patients in Pahang. However, further investigation is needed to confirm whether they are true mixed infections or perhaps infection with recombinant virus and also to assess the clinicopathologic characteristics of the infection.

Mixed-genotypes Infections with Hepatitis C Virus in Hemodialysis Subjects

Mixed-genotypes hepatitis C virus (HCV) infections are normally ignored in chronic hemodialysis patients. The aim of this study is to investigate the prevalence of mixedgenotypes infections among hemodialysis patients in Pahang province, Malaysia. Reverse-transcription and polymerase chain reaction methods were performed using two different sets of primers, targeting the 5’ untranslated region and nonstructural 5B region. Target region base sequences were obtained by direct sequencing. Discrepancy in outcomes from phylogenetic analysis of both regions suggests double infections. Of 40 subjects in eight hemodialysis centres, evidence of mixed-genotypes infections was found in 5 subjects (12.5%) from three different centres. Four patients were infected with mixed genotypes 3 and 1 and one with genotypes 3 and 4. Cases of mixed HCV genotypes infection were considered high among hemodialysis patients in Pahang. However, further investigation is needed to confirm whether they are true mixed infections or perhaps infection with recombinant virus and also to assess the clinicopathologic characteristics of the infection.

Prevalence of latex hypersensitivity among health care workers in Malaysia.

Health care workers have been reported to constitute one of the few high-risk groups related to IgE-mediated hypersensitivity associated with the use of latex products. This paper describes the first ever study of prevalence carried out in Malaysia among these workers. One hundred and thirty health care personnel from Hospital Kuala Lumpur were skin tested. Extracts used were prepared from seven different brands of natural rubber latex gloves with varying levels of extractable protein (EPRRIM). Out of the 130 volunteers, 4 (3.1%) had positive skin test to latex with extracts with high levels of EPRRIM (> 0.7 mg/g). The prevalence among the Malaysian health care workers can be considered to be low in comparison to that of some consumer countries as the USA which reported a prevalence of as high as 16.9%.

Anticardiolipin antibody isotype profile in lupus nephritis--a cross sectional survey.

Thirty-six patients with lupus nephritis (LN) attending the Nephrology Clinic, Hospital Kuala Lumpur were studied for the prevalence of anticardiolipin antibody (ACA) isotypes (IgG and IgM) and other associated antibodies, antinuclear antibody (ANA) and anti-ds DNA antibody and to determine the possible association between serological and clinical parameters. The study population consisted of 20 (55.6%) Malays, 15 (41.7%) Chinese and 1 (2.8%) Indian with a mean age of 31.4 +/- 11.3 years, range 14 to 60 years. The female to male ratio was 11:1. The average time between diagnosis and blood sampling was 4.4 years (range 0.25 to 15 years). Increased ACA levels were found in 20 (55.6%) patients where raised IgG ACA and IgM ACA were observed in 20 (55.6%) and 2 (5.6%) cases respectively. ANA and anti-ds DNA antibodies were detected in 22 (61.1%) and 4 (11.1%) individuals respectively, with the majority (82%) showing a speckled pattern of nuclear staining. However, neither the IgM ACA nor IgG ACA showed any significant association with thrombosis or any other clinical parametres. Our preliminary study indicates that ACA is a frequent finding in lupus nephritis and that the IgG isotype is more prevalent.

The occurrence of autoantibodies in sera of healthy pregnant women.

Autoantibodies have been known to be detected during pregnancy. The occurrence of autoantibodies during pregnancy was studied in a group of 146 healthy pregnant women from Jan-March 1995. Serum samples were tested for antinuclear (ANA), anti-ds DNA, anti-mitochondrial, anti-smooth muscle and anti-parietal cell antibodies employing the technique of indirect immunofluorescence. Sera from 66 non-pregnant women were used as controls. Among the pregnant group, 2 (1.4%) were found to have ANA positivity in comparison to none in the control group. This difference was found to be not statistically significant. Only 1 (0.7%) was positive for anti-mitochondrial antibody in the pregnant group compared to one in the control group (p > 0.05). However, anti-ds DNA, anti-smooth muscle and anti-parietal cell antibodies were not detected in both groups. All those positive for autoantibodies were in their 2nd trimester. When these cases were followed-up at the end of their pregnancy, none had complicated pregnancies nor infant abnormalities. Our findings suggest that (a) the occurrence of autoantibodies in pregnant women was not significantly different from non-pregnant controls and that (b) maternal autoantibodies did not appear to cause complications during pregnancy or infant morbidity.

Severe combined immunodeficiency in a Malaysian child.

A 3-month-old Malay male infant presented with multiple infections (candidiasis, Pseudomonas aeruginosa, Cytomegalovirus), persistent pneumonia, intractable diarrhoea and failure to thrive. There was lymphopaenia affecting both T and B subsets. He developed Graft versus Host disease weeks following transfusion with non irradiated blood. In spite of aggressive microbicidal and supportive therapy including regular immunoglobulin infusions, the child succumbed to infection before a bone marrow transplant could be instituted.

Comparison between dual and tri-colour reagents for the analysis of lymphocyte subsets.

The aim of this project was to compare dual and tri-colour reagents for lymphocyte immunophenotyping. A total of 37 patient and normal specimens were immunophenotyped concurrently with the following mean values (% dual vs tri-colour): CD3 (69.4 vs 68.3) CD4 (24.0 vs 24.2) and CD19 (13.9 vs 12.6). A comparison of the results obtained using the paired t test showed that there were no significant differences for cells expressing CD3, CD4 and CD19. However, there was a significant difference in the NK (18.3 vs 16.3) cell component. A major advantage in using 3 colour immunophenotyping is the ability to analyse specimens that cannot be analysed using dual colour reagents due to debris or contamination of the gate with non-lymphocytic cells.

Anti-nuclear, anti-mitochondrial, anti-smooth muscle and anti-parietal cell antibodies in the healthy Malaysian population.

A study of 101 sera from 69 Malay, 14 Chinese and 18 Indian healthy adult Malaysians was undertaken to determine the frequency of antinuclear antibodies (ANA), antimitochondrial antibodies (AMA), antismooth muscle antibodies (SMA) and antiparietal cell antibodies (APCA). There were 67 females and 34 males with a mean age of 31.7 years (+/-8.6). ANA was assayed by immunofluorescence (IF) using both mouse liver and HEp-2 cell substrates. AMA, SMA and APCA were also tested by IF using composite sections from mouse liver, kidney and stomach substrates. Analysis showed 6.9% were positive for ANA at a titre of 1:40 with HEp-2 while only 1.9% were detected using mouse liver. 9.9% had detectable AMA from titres 1:10 to 1:90. None of them had detectable SMA and only 1 (0.09%) had APCA at a titre of 1:80. This study suggests that a diagnosis of an autoimmune disorder has to be cautiously made taking into consideration that autoantibodies are present in low titres in the healthy population.

Significantly increased activated T cells are associated with declining CD4 cells in human immunodeficiency virus positive patients.

A cross-sectional study on the expression of 6 lymphocyte markers was carried out on 481 patients with human immunodeficiency virus (HIV) and 79 normals after stratification based on absolute CD4 counts. The data were stratified according to the following groups: (I) 1201 to 1600, (II) 801 to 1200, (III) 401 to 800 and (IV) 0 to 400 (x 10(6) CD4 cells per mm3). The mean percentages of the subsets before stratification showed that HIV patients had increased percentages of CD3+ (75.7 against 66.9), CD3+CD8+ (52.2 against 32.3) and CD3+HLA-DR+ (36.1 against 14.4) cells and lower percentages of CD19 (10.3 against 13.3) and natural killer cells (13.7 against 20.4) when compared to controls in the same group. A definite trend, however, was only seen in CD3+CD8+ (47.4, 50.0, 54.0, 57.5 for groups I, II, III and IV respectively) and CD3+HLA-DR+ (29.1, 32.9, 38.4, 43.9 for groups I, II, III and IV respectively).

Reference ranges for lymphocyte subsets in a defined Malaysian population.

The aim of this study was to establish the lymphocyte subset reference ranges in a defined Malaysian population as well as to determine inter-racial differences for these values. Normal blood obtained from 152 subjects (55.9% Malay, 26.3% Chinese and 17.7% Indian) was immunophenotyped. Results obtained (expressed as mean +/- SD %), absolute count (x 10(6) cells/mm3) were as follows: CD3:66.5 +/- 8.6%, 2,066; CD4:33.2 +/- 8.5%, 1,028; CD831.6 +/- 8.9%, 982; CD19:12.0 +/- 0%, 5,374, and CD56+CD16:20.9 +/- 9%, 1,638. There were no significant differences between the percent lymphocyte subsets of the three racial groups. However, the absolute number of CD4 cells and CD19 cells in Chinese was significantly lower (p < 0.05) compared to the Indian and the Indian and Malay groups respectively. Comparison of our results with other reports showed that the percentage of Natural Killer cells in this population is higher than that reported for Caucasian population.

Application of protein-A indirect ELISA (PAI-ELISA) for the detection of anti-Smith antibodies in systemic lupus erythematosus patients.

An indirect form of protein-A ELISA (PAI-ELISA) was optimized and, when used to detect anti-Smith antibodies in sera of 31 systemic lupus erythematosus (SLE) patients, gave results comparable with those using a commercial immunodiffusion kit. The number of sera found to be positive for anti-Smith antibodies by ELISA was seven, four of which were also found positive by immunodiffusion.

Chronic granulomatous disease--a report in two Malay families.

Chronic granulomatous disease (CGD) is a very rare disease whose defect lies in an abnormal intracellular killing resulting in recurrent abscesses, lymphadenitis and granuloma formation. We describe 2 Malay male infants with CGD whom we believe to be the first report of this disorder in Malays. Both children presented with recurrent abscesses, pneumoniae and hepatosplenomegaly; lymphadenopathy was also present in one of the patients. The organisms isolated were catalase positive bacteria. Both neutrophil chemiluminescence (against fungal and bacterial antigens, phorbol myristate acetate) and intracellular killing assays were severely depressed. Recognition of CGD is important as great strides have been made in the treatment of this disease which include gamma interferon therapy besides the conventional prophylactic antibacterial therapy.