XYLOSE TEST

 The xylose absorption test may be ordered to help determine whether a person is absorbing
carbohydrates normally and to distinguish between malabsorption disorders caused by
insufficient pancreatic enzymes or bile and those due to dysfunction of the intestines.
 With the xylose absorption testing procedure, high blood and urine levels of xylose are normal.
They indicate good xylose absorption by the intestines. This suggests that the tested person's
symptoms are likely due to another cause, such as pancreatic insufficiency or bile insufficiency.

 High blood levels but low urine levels may be seen in someone with kidney dysfunction. In this
case, it is the blood levels that will be used to evaluate the individual for malabsorption.

 Low levels of blood and urine xylose indicate poor absorption. A variety of conditions that
affect digestion and absorption may cause decreased xylose levels. These may include bacterial
overgrowth in the intestines, parasitic infections, a shortened bowel (such as from surgery) and
celiac disease.
Hydrogen breath test

 In these tests, hydrogen exhaled in the breath is estimated using a gas

chromatograph. Bacteria, especially anaerobic, colonizing the large bowel in
health and small bowel in diseased conditions produce hydrogen by
fermentation of unabsorbed carbohydrates. Though small amount of hydrogen
is produced from limited amounts of unabsorbed carbohydrate reaching the
colon, large amounts of hydrogen may be produced if there is malaborption of
carbohydrate in the small intestine allowing larger amount to reach the colon
or if there is excess of bacteria in the small bowel. The hydrogen produced by
the bacteria is absorbed through the wall of the small or large intestine or
both. The hydrogen-containing blood travels to the lungs where the hydrogen
is released and exhaled in the breath where it can be measured.
Fecal elastase

 Fecal elastase is a test that measures how well the pancreas is functioning.

 The fecal elastase test measures the concentration of the elastase-3B enzyme
found in fecal matter with an enzyme-linked immunosorbent assay (ELISA).
Results of this test can give a good indication of exocrine pancreatic status,
and the test is less invasive and expensive than the current "gold standard",
secretin-cholecystokinin test. Levels of fecal elastase lower than 200 μg / g of
stool indicate an exocrine insufficiency.
Alpha one antitrypsin clearance test

 Alpha-1-antitrypsin (A1A) is resistant to degradation by digestive enzymes and

is, therefore, used as an endogenous marker for the presence of blood proteins
in the intestinal tract. A1A clearance is reliable for measuring protein loss
distal to the pylorus.
Interpretation
 Elevated alpha-1-antitrypsin (A1A) clearance suggests excessive
gastrointestinal protein loss. (The positive predictive value of the test has
been found to be 97.7% and the negative predictive value is 75%.)
 Patients with protein-losing enteropathies generally have A1A clearance values
greater than 50 mL/24 hours and A1A stool concentrations above 100 mg/mL.
 Approach to
Immunodeficiency in
Pediatrics
Dr. Salma Burayzat
Assistant Professeur/ Al-Hashemite University
Faculty of Medicine/ Department of Pediatrics
Primary immunodeficiency

 PID involves an infectious predisposition associated with a deficiency of certain

immune components.
 There are more than 250 characterized PIDs affecting an estimated 1 in 1200
live births. 
 The infectious predisposition (ex viral, bacterial or fungal) differs, depending on
which gene or genes are involved, with more severe deficiencies presenting
early in infancy.
 Suspicion of Immunodeficiency
R/O Common causes of R/O Secondary
infection Immunodeficiency

Consider Primary Immunodeficiency

Note types locations of infections, age of child, and other
associated factors

Categories and screen

Predominantly Predominantly Granulocyte Complement
B cell defect T cell defect defect defect
 Evaluation of suspected immunodeficiency

 Primary care physicians must have a high index of

suspicion if defects of the immune system are to be
diagnosed early enough that appropriate treatment can be
instituted before irreversible damage develops.

 Evaluation of immune function should be initiated in:

 Evaluation of suspected immunodeficiency

1. Infants or children who do have clinical manifestations of a specific immune

disorder.
2. In all who have a positive family history of early infant death or a known
immunodeficiency disorder.
3. Unusual, chronic, or recurrent infections such as
A. 1 or more systemic bacterial infections (sepsis, meningitis)
B. 2 or more serious respiratory or documented bacterial infections (cellulitis,
abscesses, draining otitis media, pneumonia, lymphadenitis) within 1 yr
C. Serious infections occurring at unusual sites (liver, brain abscess)
D. Infections with unusual pathogens (Pneumocystis jiroveci, Aspergillus, Serratia
marcescens, Nocardia, Burkholderia cepacia)
E. Infections with common childhood pathogens but of unusual severity.
 Evaluation of suspected immunodeficiency

 Additional clues to immunodeficiency include

 failure to thrive with or without chronic diarrhea
 persistent infections after receiving live vaccines
 chronic oral or cutaneous moniliasis
 Characteristic clinical pattern in some primary
immunodeficiency

In newborn and child (0-6 months) Diagnosis

Hypocalcaemia, heart disease, unusual faces DiGeorge anomaly

Delayed umbilical cord detachment, Leukocyte adhesion defect

leukocytosis, recurrent infections

Diarrhea, pneumonia, thrush, failure to thrive Severe combined immunodeficiency

Maculopapular rash, alopecia, Severe combined immunodeficiency with

lymphadenopathy graft-versus-host disease

Bloody stools, draining ears, eczema Wiskott-Aldrich syndrome

Mouth ulcers, neutropenia, recurrent XL-Hyper IgM syndrome

infections
 Characteristic clinical pattern in some primary
immunodeficiency
Infancy and young children (6 m-5 y) Diagnosis

Severe progressive infectious mononucleosis X-linked lymph proliferative syndrome

Recurrent cutaneous and/or systemic Hyper-IgE syndrome

staphylococcal abscesses, coarse facial
features
Persistent thrush, nail dystrophy, Chronic mucocutaneous candidiasis
endocrinopathies

Short stature, fine hair, severe varicella Cartilage hair hypoplasia with short-limbed
dwarfism

Oculocutaneous albinism, recurrent infection Chédiak-Higashi syndrome

Lymphadenopathy, dermatitis, pneumonia, Chronic granulomatous disease

osteomyelitis
 Characteristic clinical pattern in some primary
immunodeficiency

In older children (>5 years) and adults Diagnosis

Progressive dermatomyositis with chronic X-linked agammaglobulinemia

enterovirus encephalitis

Sinopulmonary infections, neurologic Ataxia-telangiectasia

deterioration, telangiectasia

Recurrent neisserial meningitis C6, C7, or C8 deficiency

Sinopulmonary infections, malabsorption, Common variable immunodeficiency

splenomegaly, autoimmunity

Candidiasis with raw egg ingestion Biotin-dependent cocarboxylase deficiency

Initial Screening Immunologic Testing of
the Child with Recurrent Infections

 The initial evaluation of immunocompetence

includes………………………..
Initial Screening Immunologic Testing of the Child with Recurrent
Infections
 Complete Blood count with
differentiation and ESR
 Absolute lymphocyte count; normal
result rules against T-cell defect
 Absolute neutrophil count; normal
result rules against congenital or
acquired neutropenia and [usually] both
forms of leukocyte adhesion deficiency,
in which elevated counts are present
even between infections
 Platelet count; normal result excludes
Wiskott-Aldrich syndrome
 Howell-Jolly bodies; absence rules
against asplenia
 Erythrocyte sedimentation rate; normal
result indicates chronic bacterial or
fungal infection unlikely
 Screening tests for B cell defects
 Immunoglobulin (Ig) A measurement; if
abnormal, IgG and IgM measurement
 Isohemagglutinins
 Antibody titers to blood group substances,
tetanus, diphtheria, Haemophilus influenzae,
and pneumococcus
 Screening tests for T cell defects
 Absolute lymphocyte count; normal result
indicates T-cell defect unlikely
 Flow cytometry to examine for the presence
of naïve T cells (CD3+CD45RA+ cells)
 Screening tests for phagocytic cell defects
 Absolute neutrophil count
 Respiratory burst assay
 Screening tests for complement deficiency
 CH50
 Primary Defects of
Antibody Production
Primary Defects of Antibody Production

 Of all of the primary immunodeficiency diseases, those

affecting antibody production are most frequent.
 Selective absence of serum and secretory immunoglobulin
(Ig)A is the most common defect.
 Recurrent infections with encapsulated bacteria.
Primary Defects of Antibody Production

 Antibody production by B cells is easily evaluated by

measuring serum immunoglobulin levels and determining
antibody titers to protein and polysaccharide antigens.
 A simple screening test for B-cell defects is the
measurement of serum immunoglobulin (Ig) A
 If immunoglobulins are low, it is crucial before starting
intravenous immunoglobulin therapy that antibody titers
to specific antigens are measured
Primary Defects of Antibody Production

 Polysaccharide antigens, anti-pneumococcal antibodies

can be measured before and 3 wk after immunization with
23 valent unconjugated pneumococcal polysaccharide
vaccine in patients 2-3 yr old or older.
 Patients found to be agammaglobulinemic should have
their blood B cells enumerated by flow cytometry
Primary Defects of Antibody Production

1. X-linked agammaglobulinemia 
2. Common variable immunodeficiency (CVID) 
3. Selective IgA deficiency
4. Selective IgG subclass deficiencies 
5. Hyper-IgM syndrome
X-linked agammaglobulinemia

 Patients with X-linked agammaglobulinemia (XLA), or

Bruton agammaglobulinemia, have a profound defect in B-
lymphocyte development
 The primary defect in XLA is the failure of pre-B cells to
differentiate into mature B lymphocytes
 10% of boys with presumed XLA do not have the mutation
in Btk
 10% of patients are girls.
X-linked agammaglobulinemia

Clinical Manifestations

 Most boys with XLA remain well during the 1st 6-9 mo
of life.
 They acquire infections with extracellular pyogenic
organisms
 Infections include sinusitis, otitis media…...
X-linked agammaglobulinemia

Diagnosis
 Lymphoid hypoplasia is found on physical examination
 serum concentrations of IgG, IgA, IgM, and IgE are far below the
95% confidence limits
 Levels of natural antibodies to type A and B red blood cell
polysaccharide antigens (isohemagglutinins) and antibodies to
antigens given during routine immunizations are abnormally low in
this disorder
 Flow cytometry demonstrates the absence of circulating B cells.
Common variable immunodeficiency

 Common variable immunodeficiency (CVID) is a syndrome

characterized by hypogammaglobulinemia with
phenotypically normal B cells.
 Most of the patients usually do not become symptomatic
until 15-35 years of age.
 CVID patients have an increased risk of developing
autoimmune diseases, lymphatic and gastrointestinal
malignancies, malabsorption and granulomatous
inflammation.
Common variable immunodeficiency

 The diagnosis of CVID is based on :

 low IgG levels
 IgM and IgA levels may present in significant amounts or
absent
 Poor specific antibody responses to immunizations
T cell and B cell enumeration are usually normal
 Some patients may have abnormal T cell function
Selective IgA deficiency

 An isolated absence or near absence (<10 mg/dL) of serum

and secretory IgA is the most common well-defined
immunodeficiency disorder.
 Infections occur predominantly in the respiratory,
gastrointestinal, and urogenital tracts.
 Intestinal giardiasis is common.
 Serum concentrations of other immunoglobulins are
usually normal
 IgA deficiency is associated with a celiac-like syndrome.
Selective IgA deficiency

 The incidence of autoantibodies, autoimmune diseases,

and malignancy is increased.
 Only 5-times washed (in 200-mL volumes) normal donor
erythrocytes (frozen blood would have this done
routinely), or blood products from other IgA-deficient
individuals, should be administered to patients with IgA
deficiency.
 Many intravenous immunoglobulin (IVIG) preparations
contain sufficient IgA to cause anaphylactic reactions.
Hyper-IgM syndrome

 The hyper-IgM syndrome is characterized by normal or elevated serum

IgM levels associated with low or absent IgG, IgA, and IgE serum
levels, indicating a defect in the class-switch recombination (CSR)
process.
 X-linked hyper-IgM syndrome is the commonest type which has a
defect of the CD40 ligand (CD40L or CD154) gene of T cells.
 HIM presents with recurrent sinopulmonary infections and
Pneumocystis carinii pneumonia (PCP).
 The unique susceptibility to opportunistic infections and neutropenia
with high IgM levels distinguishes HIM from XLA or other
hypogammaglobulinemias.
Hyper-IgM syndrome

 Treatment of HIM is based on regular administration of

IVIG and use of trimethoprim-sulfamethoxazole to prevent
PCP.
 Recently stem cell transplantation has been performed
successfully.
 The long term prognosis of HIM appears to be worse than
in other forms of congenital hypogammaglobulinemia.
X-Linked lymphoproliferative disease

 XLP disease, also referred to as Duncan disease is an X-

linked recessive trait characterized by an inadequate
immune response to infection with Epstein-Barr virus
(EBV).
 The mean age of presentation is <5 yr.
 XLP has an unfavorable prognosis; 70% of affected boys die
by age 10 years
 Individuals are asymptomatic initially.
Treatment of B-Cell Defects

 Judicious use of antibiotics to treat documented infections and

regular administration of IVIG are the only effective treatments for
primary B-cell disorders.
 The most common forms of replacement therapy are either
intravenous or subcutaneous immunoglobulin (IVIG or SCIG).
 IVIG or SCIG at a dose of 400 mg/ kg per month achieves trough IgG
levels close to the normal range.
 Anaphylactic reactions caused by a patient’s IgE antibodies to IgA in
the IVIG or SCIG preparation may occur in patients with CVID or IgA
deficiency.
Primary Defects of
Cellular Immunity
Primary Defects of Cellular Immunity
 In general, patients with defects in T-cell function have infections or
other clinical problems that are more severe than in patients with
antibody deficiency disorders
 These individuals rarely survive beyond infancy or childhood.
 T cells and T-cell subpopulations can be enumerated by flow
cytometry
 This is a particularly important test to perform on any infant who is
lymphopenic
 The flow cytometry for infants suspected of having SCID should also
include monoclonal antibodies to naïve (CD45RA) and memory
(CD45RO) T cells.
Thymic Hypoplasia; DiGeorge syndrome

 Thymic hypoplasia results from dysmorphogenesis of the 3rd and 4th

pharyngeal pouches during early embryogenesis, leading to hypoplasia
or aplasia of the thymus and parathyroid glands.
 The diagnosis is often first suggested by hypocalcemic seizures during
the neonatal period
 The CATCH 22 syndrome (cardiac, abnormal facies, thymic
hypoplasia, cleft palate, hypocalcemia) includes the broad clinical
spectrum of conditions with 22q11.2 deletions.
 Partial DiGeorge syndrome
Thymic Hypoplasia; DiGeorge syndrome

 Approximately one-third of infants with complete DiGeorge

syndrome have CHARGE association
 Concentrations of serum immunoglobulins in DiGeorge syndrome
are usually normal
 Absolute lymphocyte counts are usually only moderately low for
age
 Thymic tissue, when found, contains Hassall corpuscles, a normal
density of thymocytes, and corticomedullary distinction
 Lymphoid follicles are usually present
Thymic Hypoplasia; DiGeorge syndrome

Clinical Manifestations

 Children with partial thymic hypoplasia may have little trouble with infections and grow
normally
 Patients with complete DiGeorge syndrome resemble patients with severe combined
immunodeficiency
 Complete DiGeorge is fatal without treatment
 A T-cell count should be obtained on all infants born with primary hypoparathyroidism,
CHARGE syndrome, truncus arteriosus, and interrupted aortic arch
 The immune deficiency in the complete DiGeorge syndrome is correctable by
cultured unrelated thymic tissue transplants.
 Primary Combined
Antibody and Cellular
Immunodeficiencies
Severe Combined Immunodeficiency

 SCID results from mutations in any 1 of at least 13 known genes that

encode components of the immune system crucial for lymphoid cell
development.
 All patients with SCID have very small thymuses
 Both the follicular and paracortical areas of the spleen are depleted
of lymphocytes.
 Lymph nodes, tonsils, adenoids, and Peyer patches are absent or
extremely underdeveloped
Severe Combined Immunodeficiency

 Clinical manifestation
 Affected infants present within the 1st few mo of life
 recurrent or persistent diarrhea, pneumonia, otitis media,
sepsis, and cutaneous infections.
 Growth may appear normal initially.
 Persistent infections with opportunistic lead to death.
 Affected infants also lack the ability to reject foreign tissue
and are therefore at risk for severe or fatal graft-versus host
disease (GVHD)
Severe Combined Immunodeficiency

 All molecular types of SCID lack T cells

 Serum immunoglobulin concentrations are low or absent
 Analyses of lymphocyte populations and subpopulations
demonstrate distinctive phenotypes for the various
genetic forms of SCID.
Severe Combined Immunodeficiency

 SCID is a true pediatric emergency.

 >92% of cases can be treated successfully with
hematopoietic stem cell transplantation.
Wiskott-Aldrich syndrome

 Wiskott-Aldrich syndrome is characterized by:

 Atopic dermatitis
 Thrombocytopenic purpura with normal-appearing
megakaryocytes but small defective platelets
 Undue susceptibility to infection.
Wiskott-Aldrich syndrome

 Patients often have prolonged bleeding

 Atopic dermatitis and recurrent infections usually develop during the 1st yr of
life
 Survival beyond the teens is rare
 Patients with this defect uniformly have an impaired humoral immune
response to polysaccharide antigens
 The predominant immunoglobulin pattern is a low serum level of IgM,
elevated IgA and IgE, and a normal or slightly low IgG concentration
Wiskott-Aldrich syndrome

 Good supportive care

 Aggressive management of eczema
 platelet transfusion for serious bleeding episodes
 splenectomy if.................
 Bone marrow or cord blood transplantation is the
treatment of choice
Ataxia-telangiectasia

 Ataxia-telangiectasia is a complex syndrome with immunologic,

neurologic, endocrinologic, hepatic, and cutaneous abnormalities

 The most prominent clinical features are

 progressive cerebellar ataxia
 oculocutaneous telangiectasias
 chronic sinopulmonary disease
 high incidence of malignancy
 variable humoral and cellular immunodeficiency.
Treatment of Cellular or Combined
Immunodeficiency
 Good supportive care is critical while patients await more definitive therapy.
 Transplantation of MHC-compatible sibling or rigorously T-cell– depleted
haploidentical (half-matched) parental hematopoietic stem cells is the
treatment of choice for patients with fatal T-cell or combined T- and B-cell
defects.
 Of patients with SCID, 92% have survived after T-cell–depleted parental
marrow is given soon after birth when the infant is healthy.
 Currently, bone marrow transplantation remains the most important and
effective therapy for SCID.
 Disorders of
Phagocyte Function
Disorders of Phagocyte Function

 Neutrophils are the first-line of defense against microbial

invasion.
 Children with phagocytic defects present with deep tissue
infection, pneumonia, adenitis, or osteomyelitis.
 Chemotaxi and motility defects present with significant
skin and mucosal infections.
Leukocyte adhesion deficiency

 Leukocyte adhesion deficiency 1 (LAD-1), 2 (LAD-2), and 3 (LAD-3) are rare

autosomal recessive disorders of leukocyte function.
 LAD-1 affects about 1 per 10 million individuals and is characterized by
recurrent bacterial and fungal infections and depressed inflammatory
responses despite striking blood neutrophilia.
 The neutrophils have significant defects in adhesion, motility, and ability to
phagocytose bacteria
Leukocyte adhesion deficiency

 LAD-1 results from mutations of the gene on chromosome 21 encoding CD18

β2-leukocyte transmembrane integrin subunit.
 This group of leukocyte integrins is responsible for the tight adhesion of
neutrophils to the endothelial cell surface, egress from the circulation, and
adhesion to iC3b-coated microorganisms
 Neutrophils cannot transmigrate through the vessel wall and move to the site
infection.
 Neutrophils that do arrive at inflammatory sites fail to recognize
microorganisms opsonized with complement fragment iC3b
 Monocyte function is also impaired
Leukocyte adhesion deficiency

 Children with LAD-2 share the clinical features of LAD-1 but have
normal CD11/CD18 integrins.
 Features unique to LAD-2 include: neurological defcts, cranial facial
dysmorphism, and absence of the erythrocyte ABO blood group
antigen.
 Infections in LAD-2 are milder than that in LAD-1.
 LAD-3 is characterized by a Glanzmann thrombasthenia-like bleeding
disorder.
Leukocyte adhesion deficiency

 Children with severe forms of LAD present in infancy with

recurrent, indolent bacterial infections.
 Significant neutrophilic leukocytosis, often
>25,0000/mm3, is a prominent feature.
 They may have a history of delayed separation of the
umbilical cord, usually with associated infection of the
cord stump.
 Infected areas characteristically have very little
neutrophilic infiltration.
Leukocyte adhesion deficiency

 The pathogens infecting patients with LAD-1 are similar to

those affecting patients with severe neutropenia and
include Staphylococcus aureus and enteric Gram-negative
organisms such as Escherichia coli.
 Typical signs of inflammation may be absent. Pus does not
form, and few neutrophils are identified microscopically
in biopsy specimens of infected tissues.
 The circulating neutrophil count during infection typically
exceeds 30,000/μL and can surpass 100,000/μL
Leukocyte adhesion deficiency

 The diagnosis of LAD-1 is established most readily by flow

cytometric measurements of surface CD11b/CD18 in
stimulated and unstimulated neutrophils.
 Delayed-type hypersensitivity reactions are normal, and
most individuals have normal specific antibody synthesis.
 The diagnosis of LAD-2 is established by flow cytometric
measurement of sialyl Lewis X (CD15) on neutrophils.
Leukocyte adhesion deficiency

 Early allogeneic hematopoietic stem cell transplantation

(HSCT) is the treatment of choice for severe LAD-1 and
LAD-3.
 Other treatment is largely supportive.
 Some LAD-2 patients have responded to fucose
supplementation.
 The severity of infectious complications correlates with
the degree of β2-integrin deficiency.
Chédiak-Higashi syndrome

 Chédiak-Higashi syndrome (CHS) is a rare autosomal recessive

disorder characterized by increased susceptibility to infection caused
by
 defective degranulation of neutrophils
 mild bleeding diathesis
 partial oculocutaneous albinism
 progressive peripheral neuropathy
 and a tendency to develop a life-threatening form of
hemophagocytic lymphohistiocytosis
Chédiak-Higashi syndrome

 The diagnosis of CHS is established by finding large

inclusions in all nucleated blood cells.
 The patients have progressive neutropenia and abnormal
platelet, neutrophil, and NK function.
 High-dose ascorbic may improve the clinical status of
some children in the stable phase.
 The only curative therapy to prevent the accelerated
phase is HSCT.
Chronic Granulomatous Disease

 CGD is characterized by neutrophils and monocytes

capable of normal chemotaxis, ingestion, and
degranulation, but unable to kill catalase positive
microorganisms because of a defect in the generation of
microbicidal oxygen metabolites.
 CGD is a rare disease with an incidence of 4-5 per 1
million individuals; it is caused by 4 genes, 1 X-linked and
3 autosomal recessive in inheritance.
Chronic Granulomatous Disease

 They present with recurrent pneumonia, lymphadenitis,

hepatic or subcutaneous or other abscesses, osteomyelitis
at multiple sites, a family history of recurrent infections,
or any infection with an unusual catalase-positive
organism.
 The onset of clinical signs and symptoms usually occurs in
early infancy
 The most common pathogen is S. aureus
Chronic Granulomatous Disease

 Perirectal abscesses and recurrent skin infections.

 Granuloma formation and inflammatory processes are a
hallmark of CGD
 More than 80% of CGD patients have positive serology for
Crohn disease.
 Persistent fever especially with splenomegaly and
cytopenia warrants an evaluation for secondary
macrophage activation syndrome.
Chronic Granulomatous Disease

 The diagnosis is most often made by performing flow cytometry using

dihydrorhodamine 123 (DHR).
 The nitroblue tetrazolium dye test is frequently cited in the literature
but is now only rarely used clinically.
 HSCT is the only known cure for CGD.
Disorders of the complement system

 A defect of complement function should be considered in any patient with

recurrent angioedema, autoimmune disease, chronic nephritis, hemolytic
uremic syndrome, or partial lipodystrophy, or with recurrent pyogenic
infections, disseminated meningococcal or gonococcal infection.
 Testing for total hemolytic complement activity (CH50) effectively screens
for most of the common diseases of the complement system.
 No specific therapy is available at present for genetic deficiencies of the
components of the classical, alternative, and lectin complement pathways.
Thank you