[Controlled immunoglobulin therapy in immune hemolytic anemia by positive pool immunoglobulin fluorescence test]. / Gezielte Immunglobulintherapie einer immunhämolytischen Anämie bei positivem Pool-Immunglobulin-Fluoreszenz-Test.

An Italian boy with homozygous beta-thalassemia showed a shortening of transfusion intervals at the age of three years. He had a positive direct antiglobulin test (DAT) because of C3d-loaded red blood cells without any detectable erythrocytic antibody. Serologic investigations indicated a recent EBV infection. Pool immunoglobulin fluorescence test (PIT) revealed a loading of red blood cell membranes with antigens. Oral prednisone therapy did not show any effect. After a single infusion of 400 mg immunoglobulin per kg body weight decrease of hemoglobin concentration slowed down to the rate before crisis. DAT and PIT became negative. The immune hemolytic crisis was possibly due to erythrocyte loading with EBV antigen that caused activation of the alternate complement pathway. Detection of antigen loaded red blood cells by PIT suggested a immunoglobulin therapy in order to coat the structures promoting hemolysis. Thus, a positive PIT seems to be a criterion for successful application of immunoglobulins in immune hemolytic anemia.

Comparison of the clinical efficacy and safety of an intramuscular and an intravenous immunoglobulin preparation for replacement therapy in idiopathic adult onset panhypogammaglobulinaemia.

A prospective, randomized, cross-over study was performed to evaluate the safety and clinical efficacy of an immunoglobulin preparation for intravenous use (Intraglobin F) in comparison with the standard intra-muscular preparation. Twelve patients with idiopathic adult-onset panhypogammaglobulinaemia received intravenous Intraglobin F infusions of 300 mg/kg body weight every 4 weeks, or standard intramuscular injections of 25 mg/kg body weight every week (following a 4-week loading phase of 50 mg/kg/week) in random order for 24 weeks each with a 'washout' period between. At the end of this comparative trial eight of the patients received a further 24 weeks treatment with Intraglobin F at 300 mg/kg body weight every 3 weeks. Patients were assessed by diary cards, interview, laboratory screening (including assessment of serum opsonic capacity), chest and sinus radiographs, and full lung function tests. There were statistically significant, favourable changes in clinical parameters and trough serum IgG levels using the intravenous preparation but no other significant differences with respect to the two preparations. The eight patients who subsequently received the 3-weekly intravenous regimen improved further in these parameters, including serum IgG levels and serum opsonic capacity. Thirty per cent of infusions were associated with mild adverse reactions related to the rate of administration but one patient was withdrawn due to anaphylactoid reaction to her fifth infusion. Ten of the eleven remaining patients elected to continue intravenous therapy at the end of the trial. We conclude that Intraglobin F is preferable to the standard intramuscular preparations for control of idiopathic adult-onset panhypogammaglobulinaemia but that infusion intervals should be tailored to the individual's clinical response and results of appropriate functional in vitro assays, eg. opsonization.

Immunomodulating therapy of rheumatoid arthritis by high-dose intravenous immunoglobulin.

11 patients with rheumatoid arthritis were treated with intravenous immunoglobulin (IVGG). In 6 patients clinical results were impressive, although lasting responses could be achieved in 3 patients only. This treatment was immunomodulating, since the immunoregulatory T-cell ratio (CD4/CD8) decreased following therapy by reducing CD4-positive cells in-vivo. By use of anti-mu-antibodies as a B-cell specific mitogen, IVGG-treatment was seen to suppress early processes of B cell activation. In parallel to these cellular effects, IVGG led to a reduction in the levels of polyethyleneglycol-precipitated circulating immune complexes as measured by lasernephelometry.

[Successful therapeutic use of intraglobin-F in idiopathic immuno-thrombopenia, refractory to corticosteroid and immunosuppressive therapy as well as to splenectomy]. / Corticosteroid, immunsuppressiv kezelésre és splenectomiára refrakter idiopathiás immunthrombopenia eredményes kezelése intraglobin-F-fel.

The authors present the case of a 21-year old woman patient who was admitted to hospital because of typical symptoms of chronic idiopathic thrombopenic purpura. Prednisolone therapy alone and subsequently combined with Immuran as well as later applied large dose of Methylprednisolone failed to be effective. Owing to the ineffective therapies and increasing hemorrhagic diathesis splenectomy was performed under perioperative Venagamma protection without success. Intraglobin-F therapy brought perfect recovery. The authors review the expectable results of immunoglobulin therapy, the strategy of ITP therapy changed as a consequence of the new therapeutic possibility as well as the indications of immunoglobulin treatment.

[Anaphylactic shock reaction following intravenous administration of 7S immunoglobulin in patients with hypogammaglobulinemia, especially in children with acute lymphoblastic leukemia (ALL)]. / Anaphylaktische Schockreaktion nach intravenöser Gabe von 7S-Immunglobulin bei Patienten mit Hypogammaglobulinämie, insbesondere bei Kindern mit akuter lymphoblastischer Leukämie (ALL).

Severe anaphylactic reactions were observed in 2 children, aged 2 and 14 years, with acute lymphocytic leukemia and a 12 month old infant with a functional T-cell defect after intravenous administration of a polyethyleneglycol (PEG)-treated immunoglobulin preparation. All 3 children suffered additionally from hypogammaglobulinemia. Intravenous infusions of 7S-immunoglobulin preparations with a modification of the Fc portion, however, had been well tolerated by the same patients. Investigations of the immunoglobulin preparations revealed IgG aggregates (approximately 35%) in one batch of the PEG-treated immunoglobulin preparation. Prekallikrein activator and kallikrein were not increased in the immunoglobulin preparations tested. These results in addition to our clinical experiences suggest that only 7S-immunoglobulin preparations with a modification of the Fc portion should be used in patients with hypo- or a-gammaglobulinemia, in order to avoid complement activation released by the intact 7S-preparations.

Intravenous immunoglobulin for prevention of sepsis in preterm and low birth weight infants.

The effect of an intravenous polyvalent immunoglobulin preparation given prophylactically to prevent neonatal sepsis was tested in preterm and low birth weight infants. Infants matched for gestational age, sex and birth weight (+/- 250 g) were randomly allocated into 3 groups of 50 each, one group (Group C) being used as control. Group A received Intraglobulin (Biotest Pharma, West Germany), 120 mg/kg intravenously, within 2 to 4 hours of delivery; Group B received the same on days 1 and 8. The control group received no immunoglobulin. The frequency of infection and serum immunoglobulin concentrations were determined in each group. Infection rate in the control group was 16% (8 of 50) while in each of the treated groups it was 4% (2 of 50) (P less than 0.005). The immunoglobulin concentrations achieved in the treated group were significantly higher than the control group. No adverse effect of the therapy was noted during the study and at a 6-month follow-up. It is suggested that in nurseries where the infection rate is high, prophylactic intravenous polyvalent immunoglobulin therapy for the preterm and low birth weight infants may provide protection from infection.

Antibody against the human immunodeficiency virus in commercial intravenous gammaglobulin preparations.

In a 6-month study, antibody levels against the human immunodeficiency virus (HIV) were determined in intravenous gammaglobulin preparations and 45 serum samples from 20 patients on gammaglobulin therapy. All 10 lots of a reduced and alkylated preparation and 4 of 8 lots of a pH4/pepsin-treated preparation were seropositive by enzyme-linked immunosorbent assay (ELISA). By Western blot analysis, 8 of 10 lots of the reduced and alkylated preparation and 3 of 8 lots of the pH4/pepsin-treated preparation were positive. Before gammaglobulin infusion, 2 of 45 preinfusion samples were seropositive by ELISA but seronegative by Western blot. After infusion, 15 of 45 samples were seropositive by ELISA, and 8 had antibody against p24 by Western blot. Seropositivity persisted for less than 1 month. Cultures of HIV-positive intravenous gammaglobulin lots were negative for reverse transcriptase activity or viral antigen expression. These results suggest that current methods of preparation either exclude or inactivate HIV.

Active and passive immunization strategies for Pseudomonas aeruginosa pneumonia.

The unusually high mortality associated with Pseudomonas aeruginosa pneumonia has provided an incentive for the development of immunologic strategies for preventing or treating this infection. A guinea pig model of experimental P. aeruginosa pneumonia was employed to determine prophylactic efficacy of active immunization with a detoxified lipopolysaccharide vaccine; efficacy of passive immune therapy utilizing a new hyperimmune immunoglobulin G preparation enriched for antibodies to P. aeruginosa immunotypes 1, 2, 4, and 6; and efficacy of active and passive immunization against the mucoid exopolysaccharide antigen associated with mucoid strains of P. aeruginosa. Each of these immunologic methods provided an element of protection against P. aeruginosa pneumonia.

IgG subclass composition of intravenous immunoglobulin preparations: clinical relevance.

Each immunoglobulin G (IgG) subclass has unique physicochemical properties and, probably, unique functions. Each heavy chain is coded by a separate gene on chromosome 14. Deficient synthesis of a subclass may be associated with recurrent or chronic infections, the deficiency not being detected by measurements of levels of total serum IgG. Measurement of levels of IgG subclasses should be part of the work-up of patients who have frequent infections but have normal levels of major immunoglobulin classes. Deficiencies of IgA or IgE frequently coexist with deficiencies of IgG2 or IgG4. Patients with a subclass deficiency often benefit from replacement therapy with intramuscular or intravenous IgG or plasma from a donor free of hepatitis and HTLV-III viruses. It may be critical to provide IgG or plasma that is a good source of the missing immunoglobulin class or subclass. Sometimes it is necessary to administer a product with antibodies to the virus or bacteria responsible for a particular infection.

Three generations of immunoglobulin G preparations for clinical use.

The first purified human immunoglobulin G (IgG) preparation used clinically was immune serum globulin (ISG), which was prepared in the 1940s by E. J. Cohn's group. It was originally formulated in water with 0.3 M glycine at pH 6.8 and was 70%-80% monomeric. ISG was safe when given intramuscularly and efficacious for measles and hepatitis prophylaxis. The next generation of purified IgG began in the 1960s with chemically modified preparations suitable for intravenous administration. The first such IgG intravenous preparation (IGIV) in the United States was IGIV pH 6.8 (Gamimune, Cutter Biological), in which the anticomplement activity found in ISG was removed by reduction and alkylation of disulfide bridges. This product was originally formulated as a 5% IgG solution in water (pH 6.8) with 0.2 M glycine in 10% maltose for stabilization. It remained stable for at least 2.5 years at 5 degrees C, was 80%-90% monomeric, had virtually no anticomplement activity, was safe given intravenously, and was efficacious for prophylaxis in agammaglobulinemic patients. A third generation of purified IgG has since been developed; IGIV pH 4.25, (Gamimune N, Cutter Biological), which was isolated by the Cohn method from human plasma and is safe for intravenous use, is a 5% solution of IgG in water (pH 4.25) with 10% maltose. The product is greater than 99% IgG, greater than 95% monomeric, and has greater than 90% less anticomplement activity than ISG.

Protective and opsonic activities of a native, pH 4.25 intravenous immunoglobulin G preparation against common bacterial pathogens.

The in vitro opsonic activity of a native, pH 4.25 immunoglobulin G preparation modified for intravenous use (IGIV pH 4.25) was compared with the activities of a standard reduced and alkylated, pH 6.8 preparation (IGIV-R/A pH 6.8) and a reduced and alkylated, pH 5.25 preparation (IGIV-R/A pH 5.25) against a variety of common bacterial pathogens. In most instances the opsonic titers of IGIV pH 4.25 equaled or exceeded that of IGIV-R/A pH 6.8; IGIV-R/A pH 5.25 usually had an intermediate level of activity. The protective activity of IGIV pH 4.25 against Escherichia coli in a neonatal rat model was also greater than that of IGIV-R/A pH 6.8. Thus, the functional activity of the new IGIV pH 4.25 apparently equals or exceeds that of standard reduced and alkylated preparations.

Use of a new, low-pH immunoglobulin G preparation during episodes of bacteremia in the rat.

A rapidly expanding role for immunoglobulin G preparations in conditions other than the classical immunodeficiency syndromes is evident. This relatively new concept of treatment with polyclonal antibody has been tested in the rat with severe Salmonella typhimurium bacteremia with use of a newly developed, native immunoglobulin G preparation for intravenous use (IGIV pH 4.25). IGIV pH 4.25 increased survival time and decreased absolute mortality, prevented hypotension and acidosis, and ameliorated or prevented changes in variables indicative of organ damage during S. typhimurium bacteremia in the rat. Intravenous infusion of IGIV pH 4.25 at high rates did not cause further deterioration in the arterial blood pH in the acid-base-compromised rat and hence should not cause clinically significant decreases in pH in patients with compromised acid-base regulating systems.

Immunoglobulin G: potentiation of tobramycin and azlocillin in the treatment of Pseudomonas aeruginosa sepsis in neutropenic mice and neutralization of exotoxin A in vivo.

Mice with cyclophosphamide-induced neutropenia were challenged with four immunotypes of Pseudomonas aeruginosa by contamination of a small dorsal surface wound. The infections were lethal; 100% of control animals (n = 80) treated only with albumin died. Administration of an immunoglobulin G intravenous preparation (IGIV) and/or therapy with tobramycin or azlocillin was begun 16 hr after challenge. Mortality among mice (n = 120) treated only with an antibiotic was 75.0%, while that among mice (n = 80) treated only with IGIV was 78.8%. Combination therapy with IGIV and an antibiotic (n = 120) resulted in mortality of 38.3%. The protection afforded by IGIV may have resulted in part from neutralization of exotoxin A, as mice treated with IGIV before challenge with exotoxin A were subject to lower mortality and had lower levels of serum aspartate and alanine aminotransferases than controls.

Half-life and clearance of pH 6.8 and pH 4.25 immunoglobulin G intravenous preparations in patients with primary disorders of humoral immunity.

The half-life (t1/2) and clearance of IgG and three antibodies--to tetanus, pneumococcus type 3, and pneumococcus type 7--were evaluated in 38 patients who participated in a multicenter, double-blind, crossover study comparing two immunoglobulin G intravenous preparations, IGIV pH 6.8 and the new IGIV pH 4.25. IgG metabolism was evaluated after the sixth infusion by measuring the decline in concentration of IgG and specific antibody. The t1/2 values of IgG varied greatly, but the mean values of 32 and 37 days are comparable to those determined in previous studies with use of radiolabeled IgG and are longer than those reported in normal volunteers. The t1/2 values for specific antibodies, especially those to tetanus, tended to be shorter than those for IgG. The clearance of IgG and antibodies also varied widely, but even though there was some relationship between the clearance and t1/2 in individual patients, the poor correlation (R2 less than .5) suggested that other factors, such as redistribution or loss of damaged molecules, are as important as the catabolic rate. Thus, clearance may be a more reliable parameter than t1/2 in evaluating the metabolism of IgG.

Comparative studies of impurities in intravenous immunoglobulin preparations.

In a comparative study, seven commercially available immunoglobulin preparations and one experimental preparation, processed by various manufacturers in the United States and Europe, were investigated for non-IgG proteins and impurities. The basic fractionation methodology affects the purity of subsequently processed intravenous preparations. Five of the seven products manufactured in Europe contained varying amounts of plasma proteins other than IgG. A residual heterologous protein was detected and quantitated in one product whose processing includes porcine pepsin treatment. Only one of the eight products was low in aggregates (as judged by both anticomplement activity and nephelometric turbidity), while three products contained anticomplement activity at levels high enough to be a potential cause of reactions in patients. In general, the level of prekallikrein activator activity was proportional to that of amidolytic activity; four products had only trace levels of amidolytic activity as well as prekallikrein activator. Only one product contained significant isoagglutinin levels, while six products had detectable IgA levels.

Effect of intravenous immunoglobulin G on neutrophil kinetics during experimental group B streptococcal infection in neonatal rats.

A modified form of serum immunoglobulin G (pH 4.25) was tested for its effect on neutrophil kinetics and survival rates in neonatal rats with type III, group B streptococcal pneumonia and sepsis. Each of 30 animals received a transthoracic inoculation of 10(5) organisms/g of body weight; all died within 48 hr. When 100, 1,000, or 2,000 mg of immunoglobulin G/kg was administered intraperitoneally at the time of bacterial inoculation, survival rates rose to 20%, 90%, and 100%, respectively. Even when the immunoglobulin preparation was administered intraperitoneally 2 hr after transthoracic inoculation of bacteria, all 19 animals survived. Only seven of 15 animals survived when immunoglobulin administration was delayed for 22 hr. Immunoglobulin facilitated the neutrophil inflammatory response: when immunoglobulin (rather than an albumin control) was administered, neutrophils were released more rapidly from the storage pool and accumulated more quickly at the site of bacterial inoculation. Unlike infected control animals, immunoglobulin recipients did not develop neutropenia or depletion of the neutrophil storage pool.

Safety and toxicity of a new serum immunoglobulin G intravenous preparation, IGIV pH 4.25.

A new preparation of serum immunoglobulin G for intravenous use (IGIV) was investigated. The reagent, IGIV pH 4.25, is a liquid preparation of native, unmodified human serum IgG without preservatives but stabilized in 10% maltose. Its physical characteristics have multiple advantages over those of other available IGIV preparations. In a multicenter, randomized, double-blind, crossover study, this product was compared with a commercially available standard preparation, IGIV pH 6.8. Thirty-nine patients with various forms of primary immunodeficiency disease received infusions consisting of 400 mg/kg every four weeks; an overall total of 232 infusions were administered. Extensive clinical and laboratory observations were made. Adverse effects from infusion therapy were transient and minimal. No clinically significant abnormalities in vital signs and laboratory values occurred. There were no statistically significant differences between the results for IGIV pH 6.8 and those for the new IGIV pH 4.25 preparation. It was possible to infuse the new IGIV pH 4.25 reagent rapidly (0.1 ml/kg per hr) without inducing vasomotor adverse effects.

Passive immunotherapy for encephalitis caused by herpes simplex virus.

Passive administration of antiviral antibody has been assessed in animal models as a potential form of treatment for infections due to herpes simplex virus (HSV). Previous investigative work has demonstrated the beneficial effect of immune serum administered either before or after HSV infection of mice. In some studies the protective effect of antibody was abrogated in the absence of T lymphocytes, an observation suggesting that cellular effector mechanisms may be necessary for antibody efficacy. In the present study of a mouse model of encephalitis caused by HSV type 2, a 0.5-ml dose of human immunoglobulin (1,250 mg of immunoglobulin G/kg of body weight) prepared at pH 4.25 for intravenous administration reduced mortality and prolonged survival when administered by intraperitoneal injection 24 hr before or up to 8 hr after intranasal viral challenge. The serum titer of HSV-neutralizing antibody and the response to therapy were dose dependent. Clinical trials of passive immunotherapy for severe HSV infections may be warranted.