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Blussé van Oud Alblas, D.

Furth, R. van

Leijh, P.

Meer, J.W.M. van der

Weemaes, C.

NARCIS 

Normal microbicidal function of moncytes in a girl with chronic granulomatous disease

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Ada Ptediatr Scarni 70:421—425, 198§
CASK R E P O R T
N O R M A L  M IC R O B IC ID A L  FU N CT ION  O F  M O N O C YT ES  IN A G IR L
W ITH  C H R O N IC  G R A N U L O M A T O U S  D ISEA SE
C. W E E M A E S . '  P. L E I JH . : D. B LU SSÉ  VAN O U D  A L B L A S , :
J. V AN  D ER  M E E R : and R. V AN  F U R T H :
From the 'Department of Paediatrics, University Hospital. Nijmegen 
and the ^Department of Infections Diseases. University Hospital.
Leiden, Tlie Netherlands
ABSTRACT. Weemaes, C ., (Department of Paediatrics, University Hospital, Nijmegen, The 
Netherlands), Leijh, P., B lusse van Oud Alblas, I)., van der Meer, J .  and van Furth, R. 
(Department of Infectious Diseases, University Hospital, Leiden, The Netherlands). Normal 
microbicidal function of monocytes in a girl with chronic granulomatous disease. Acta 
Paediatr Scand, 70:421, 1981.— The history of a 13-year-old girl with a syndrome resembling 
Chronic Granulomatous Disease (C .G .D .) is described. Metabolic studies in granulocytes and 
monocytes classified the patient as having C .G .D . The granulocytes failed to kill Staphylococ­
cus aureus and Candida Albicans; however, the killing of these microorganisms by the 
patient's monocytes was nearly normal. Family studies revealed no abnormalities in the 
phagocytic cells of the parents and the siblings.
KEY W ORDS: Chronic Granulomatous Disease
Chronic granulomatous disease (C .G .D .) is a 
disorder in which the inability of phagocytic 
cells to kill certain ingested bacteria or fungi 
leads to recurrent severe bacterial and fungal 
infections (1, 2). Staphylococcus aureus and 
other catalase-positive microorganisms are the 
organisms that cannot be killed normally by 
the granulocytes of children with C .G .D . and 
are the usual source of infection (3). In affect­
ed patients the granulocytes fail to show the 
normal stimulation of respiratory activity, in­
creased 0 2 consumption, oxidation of glucose 
through hexosemonophosphate shunt and gen­
eration of hydrogen-peroxide (H 20 2), events 
associated with bactericidal action (4, 5). The 
monocytes of patients with C .G .D ., have a 
microbicidal defect similar to that of granulo­
cytes: intracellular killing of both Staphylo­
coccus aureus (6, 7) and Candida albicans (8, 
9) is impaired.
C .G .D . has been originally described in
males as a syndrome with an X-linked mode of 
transmission (10). A similar syndrome has 
been described in females (11, 12) and the 
functional and metabolic defects of granulo­
cytes from these patients are indistinguishable 
from those of male patients. To our knowl­
edge, no studies on monocyte function in fe­
male C .G .D . patients have been reported. 
This case report concerns a girl with a mild
C.G.D.-syndrome and abnormal killing by 
granulocytes, in whom the monocyte func­
tions were practically unaffected. An X-linked 
mode of transmission could not be demon­
strated.
C A SE  REPORT
A 13-year-old girl had an uneventful medical history until 
the age of nine, when she developed scaling inflammatory 
lesions of the upper lip and nose and intermittent fever. 
Further physical examination was normal, but roentgeno­
grams showed bilateral pulmonary infiltrates. The only 
abnormal laboratory findings were leucocytosis and an
Ac fa Paeiliutr Sea ml 70
422 C. Weemaes et eil.
Table 1. Leucocyte function
Origin of serum 
or cells
Phagocytosis of S. aureus
Opsonic activity for 
S. aureusGranulocytes Monocytes
60 min
(%)
120 min 
(%)
60 min
(7c)
120 min
(7c)
60 min 
(7c)
120 min
(7c)
Patient 97.0 97.8 90.0 96.8 94.0 99.1
Father 99.8 99.8 98.0 99.6 97.0 99.5
Mother 99.7 99.8 98.3 99.1 97.0 99.6
Sister 1 N .D . 99.8 99.8 99.8 93.2 98.0
Sister 2 99.8 99.8 99.3 99.7 99.1 99.8
Normal-controls 96.3±2.8 99.0± 1.1 94.8±6.7 98.2±4.2 96.3 ±2.8 99.0± 1.1
C.G.D.-controls 96.8±4.3 98.1 ±2.1 91.3 ± 7.8 N.D . •
elevated erythrocyte sedimentation rate. The causative
w *
agent of the pulmonary infiltrates could not he cultured 
and antimicrobial therapy was unsuccessful. On gluco- 
corticosteroid treatment the patient recovered, however, 
rapidly. A recurrence of the pulmonary infiltrates after 
some months was treated successfully again with
or
glucocorticosteroids. At the age of 10 years she was ad­
mitted to the pediatric ward of the University Hospital 
Nijmegen for an evaluation of her host defence mecha­
nisms. At that time, she was a thin, but healthy appearing 
girl with scaling inflammatory lesions of the upper lip and 
nose. She had a conjunctivitis and keratitis. The remain­
der of the physical examination was normal. Her height 
was according to age. X-rays of the chest revealed no 
abnormalities. The serum immunoglobulins were normal: 
lgG 13 g/l, IgA 2 g/l. IgM 2 g/I. IgE was slightly increased 
(885 U/ml). The patient’s lymphocytes responded normal­
ly in vitro to phytohaemagglutinin and poke-weed mitogen 
and positive delayed hypersensitivity skin reactions were 
obtained with mumps, trichophyton and Candida albicans
granulocytes monocytes
100
o 2 0  -
0 60 120 0 60 120
minutes
Fig. /. Rate of intracellular killing of Staphylococcus 
aureus.
as antigens. At the age of I I years she developed Rayn­
aud's phenomenon. Tests for rheumatoid factor and antin- 
uclear antibody were negative. No antibodies to thyroid, 
stomach, muscle or mitochondria were detected. The last 
two years she had some episodes of recurrent ulcerative 
stomatitis and skin lesions o f the upper lip and nose. Her 
parents and two sisters are healthy.
MATERIALS AND METHODS
Phagocytosis and intracellular killing of Staphylococcus 
aureus and of Candida albicans by granulocytes and 
monocvtes were measured as described elsewhere (9. 13).*
In patient’s serum the opsonic activity for staphylococci 
was determined with the same assay as for the phagocyto­
sis (13). however, instead of donor serum patient’s serum 
was used. The metabolic burst during phagocytosis was 
measured as 0 2 consumption (14) and H :0 2 production
(15) by Dr D. Roos of the Central Laboratory of the 
Netherlands, Red Cross Blood Transfusion Service. A m ­
sterdam, and as nitroblue tétrazolium (NBT) reduction
(16). Chemiluminescence was tested in the presence of 
Luminol (17) by Dr E. Mills at the Laboratory of Micro-
gronulocytes m onocytes
m inutes
Fig. 2. Rate of intracellular killing of Candida albicans
Acta Paediatr Scarni 70
Table 2. Metabolic activity
M icrob ic ida l-m onocy te  fu n c t io n  in C .G .D .  423
Chemiluminescence
()2 consumption H 20 2 production (mean peak response to Zymosan
(nmol O-./ (nmol/ particles (5 mg), luminol
I06 cell s/mi n) I06 cells/min) augmented cpnx 10')
Granulocytes
Normal controls 4.2-9.6 3.0-5.0 426
Patient 0.6 0.0 6
Mother 6.5 4.5 402
Father 5.6 3.0 564
Sistei'i 7.6 3.9
Sister2 4.7 3.1
Monocytes
Normal controls 8±3 1 140
Patient 0 7
biology. University of Utrecht. The following enzymes 
were tested: glulathion reductase (18). glutathion peroxi­
dase (19) and myeloperoxidase (20). As controls granulo­
cytes and monocytes of normal subjects and of two boys 
with classical X-linked inherited C .G .D . (9) were used. 
Random migration and chemotaxis of granulocytes and 
monocvtes was measured by a modified Bovden chamber 9 * * 
assay (21). using casein ( I mg/ml) and endotoxin-activated 
plasma.
R E S U L T S
The total and differential white blood cell 
counts o f the patient were normal at the time 
when the leucocyte functions were studied. 
The phagocytosis o f Staphylococcus aureus 
(Table 1) and Candida albicans by granulo­
cytes and monocytes was norm al. The op ­
sonic activity o f patient's serum was normal 
(Table 1 ).
The intracellular killing o f Staphylococcus 
aureus and Candida albicans by granulocytes 
was impaired equally as found for other pa­
tients with C .G .D . (Fig. 1-2). The intracellular 
killing by monocytes, however, was almost 
normal (tested at three occasions over a peri­
od o f eighteen months) (Fig. 1-2), whereas for 
the C .G .D . controls an im pairm ent o f the bac­
tericidal activity o f monocytes was found (Fig. 
1-2 ).
N o reduction o f N B T  was found in the gran­
ulocytes o f the patient. The metabolic burst 
was not stimulated in granulocytes and m ono­
cytes o f the patient (Table 2), where both pa-
Table 3. Chemotaxis assay
Distance travelled towards attractant"
Cells
Random
migration
Endotoxin activated plasma
Casein* Patient Control
Granulocytes
Patient
Control
Monocytes
Patient
Control
26.6±2.6
26.9±3.0
41.7±4.1 
45.6±3.4
66.3 ±8.6 
66.7±7.5
55.8±6.8
57.0±6.9
7 1.7±4.8 
75.0 ±5.5
65.4 ±5.4 
65.7 ± 5.5
54.4±3.6 
60.5±7.1
62.3 ±6.7 
65.9 ±7.2
" Distance in// ±1 S.D. travelled into a filter with 3// poresize for granulocytes and 8 u poresize for monocytes. 
h Gey's solution on both sides of the filter.
‘ Casein I mg/ml in G ey ’s solution.
1‘ 10% solution in G ey ’s of fresh heparinised plasma, incubated for 30' with /:. coli endotoxin (l5//g/ml) at 37°C.
Acta Paediatr Sea ml 70
424 C. Weemcies et cd.
tient’s parents and the two sibs showed a nor­
mal metabolic activity. Chemiluminescence
Raynauds phenomenon, pulmonary infiltrates 
responding to corticosteroids— resembles the
studies revealed an abnormal response in the illness described in carriers of C .G .D . (25), the 
patient’s granulocytes and monocytes (Table results of the chemiluminescence and the
metabolic studies, performed on leucocytes of 
the mother and the sisters do not show an X-
2). The granulocytes of the parents showed a 
normal chemiluminescence pattern (Table 2).
The glutathion reductase, glutathion peroxi- linked mode of transmission. The genetic de- 
dase and myeloperoxidase were normal in the feet can still be autosomal recessive. A spon- 
patient's granulocytes. Random migration and taneous mutation, even on the X-chromo- 
chemotaxis of granulocytes and monocytes some, can not be excluded, either. However,
this does not explain the different microbicidal 
capacity of the patient's granulocytes and 
monocytes.
A need for the study of monocyte function 
The granulocytes of the patient described in in other female C .G .D . patients is clear. This
were within normal limits (Table 3).
D ISCU SS IO N
this paper show abnormal microbicidal func­
tion and abnormal oxidative metabolism mani-
might contribute to further insight into the 
microbicidal mechanisms of granulocytes and
A C K N O W L E D G E M E N T
The authors wish to express their gratitude to Dr D. Roos 
and Dr Elaine Mills for performing the metabolic studies. 
The technical help of Miss Langenhuysen. Marina van 
den Barselaar and Ans Matze van der Lans is greatly 
acknowledged.
tested by deficient 0 2 consumption, H 20 2 monocytes and the wide clinical spectrum of 
production, NBT reduction and chemilumi- the C .G .D . syndrome, 
nescence. These findings with the clinical syn­
drome (though rather mild) classify her as hav­
ing C .G .D . The similarly disturbed oxidative 
metabolism of the monocytes fits the C.G.D.- 
picture, but the nearly normal microbicidal 
function of the monocytes is an unexpected 
finding. Thus the microbicidal function of mo­
nocytes is not solely dependent on hydrogen 
peroxide production. In this respect a parallel 
may be drawn with the microbicidal capacities 
of murine peritoneal macrophages, which pro­
duce very little H 20 2 (22), but are neverthe­
less capable to kill ingested micro-organisms 
(13).
In female patients with C .G .D . it has been 
suggested that there is an autosomal mode of 
transmission (23). However, chemilumines­
cence studies performed on granulocytes of 
female C .G .D . patients and their relatives pro­
vide evidence for an X-linked mode of inher­
itance (23).
This observation is in accordance with the 5.
Lyon hypothesis (24) and the female C .G .D . 
patients are supposed to be carriers with a 
large proportion of functionally defective leu- 6. 
cocytes as a consequence of random X-inacti- 
vation. Although a number of signs in our 
patient— episodes of ulcerative stomatitis, 7.
4.
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leukocytes: diminished activity in chronic granuloma­
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Submitted July 10, 1980
Accepted Sept. 22, 1980
(C. W.) Department of Paediatrics
University of Nijmegen
St. Radboud Hospital
Geert Grooteplein Z. 20
6500 HG Nijmegen
The Netherlands
28-812873 A eta Paediatr Sea ml 70


Normal microbicidal function of moncytes in a girl with chronic granulomatous disease

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