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Neutrophil disorders and their management

Article in Journal of Clinical Pathology · February 2001

DOI: 10.1136/jcp.54.1.7 · Source: PubMed

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J Clin Pathol 2001;54:7–19 7

Neutrophil disorders and their management

R Lakshman, A Finn

Abstract degranulation and respiratory burst activity

Neutrophil disorders are an uncommon and this leads to killing of the target as well as
yet important cause of morbidity and inflammatory changes in the tissues. The
mortality in infants and children. This respiratory burst is an important pathway for
article is an overview of these conditions, microbial killing and involves the generation of
with emphasis on clinical recognition, superoxide, hydrogen peroxide, hydroxyl radi-
rational investigation, and treatment. A cal, and subsequently hypochlorous acid and
comprehensive list of references is pro- chloramines. Degranulation involves release of
vided for further reading. the contents of the cell granules and contrib-
(J Clin Pathol 2001;54:7–19) utes to “oxygen independent bactericidal
activity”. If granulocyte activation persists,
Keywords: neutrophil disorders; chronic granulomatous
disease; neutrophil chemotaxis; phagocytosis neutrophils release substances such as
monocytic chemotactic protein that attract
monocytes to the area. These in turn release
Neutrophils are phagocytic granulocytes that monokines that enhance lymphocytic infiltra-
constitute an important component of the tion and also present antigens to T cells to pro-
rapid “non-specific” immune defences. They, duce cell mediated immune responses and
like other leucocytes, are derived from pluripo- promote T dependent humoral (B cell) re-
tent stem cell progenitors in the bone marrow. sponses.
Upon stimulation by colony stimulating fac- Neutrophils have a short circulating life span
tors, including stem cell factor, granulocyte– (about eight hours) after leaving the bone mar-
monocyte colony stimulating factor (GM- row and then undergo apoptosis.4 Anti-
CSF), and granulocyte colony stimulating apoptotic signals generated by growth factors
factor (G-CSF), phagocyte precursors prolifer- and cytokines can aVect neutrophil survival
ate and develop in the bone marrow to form and increase neutrophil numbers.5
mature segmented neutrophils. The first three Neutrophil disorders can result from a
stages of neutrophil maturation—myeloblast, reduced number of cells or defective function.
promyelocyte, and myelocyte—involve young Neutropenias are a result of one or more
actively dividing cells. After the myelocyte defects in the diVerentiation or proliferation in
stage, the cells lose their ability to divide and the bone marrow, or increased peripheral
form metamyelocytes, band cells, and finally destruction. Functional disorders include dis-
segmented polymorphonuclear neutrophils. In orders of chemotaxis, adhesion, phagocytosis,
times of stress, corticosteroids, complement and the respiratory burst. The extent to which
fragments, and catecholamines accelerate the such disorders are recognised and diagnosed,
release of mature neutrophils, as well as meta- understood at the cellular and molecular level,
myelocytes and band cells, into the circulation. and amenable to corrective or compensatory
Chemotactic substances such as C5a, inter- medical treatment is very variable. In consider-
leukin 8 (IL-8), monocyte chemotactic factor, ing disorders of neutrophils, it is worth bearing
leukotrienes, and bacterial peptides induce the in mind that humans can survive quite
migration of circulating neutrophils to sites of prolonged periods without medical interven-
infection and inflammation. This extravasation tion with profound deficiency of specific (lym-
involves selectin mediated rolling along the phocytic) immunity, but all would perish of
vascular endothelium, integrin mediated firm infection within days of onset of absolute neu-
adhesion to the endothelium, and transend- tropenia.
othelial migration through intercellular junc-
tions to extravascular sites. Migrating neu-
trophils have a profoundly diVerent shape and Disorders of neutrophil number:
form from those seen in the circulation; neutropenia
progress through the tissues is thought to be Neutropenia is an absolute reduction in the
SheYeld Institute for mediated principally by the integrin CD11b/ number of circulating neutrophils. Interpret-
Vaccine Studies,
Division of Child CD18 on the cell surface,1 and might be regu- ation of peripheral blood neutrophil counts is
Health, University of lated by soluble gradients (chemotaxis) or fixed rendered more diYcult by the fact that these
SheYeld Children’s gradients (haptotaxis)2 of chemoattractants.3 can change rapidly within an individual in
Hospital, SheYeld Neutrophils have an array of surface recep- response to non-specific changes such as exer-
S10 2TH, UK tors that enable them to bind to and ingest for- cise and heart rate. Reference ranges6 vary
R Lakshman eign particles and microbes by a process known with age and race; infants have lower neutro-
A Finn
as phagocytosis. This mechanism is greatly phil counts than older individuals, as do Afri-
Correspondence to: facilitated if microbes are coated with opsonic cans compared with whites.7 Neutrophil
Dr Lakshman proteins such as immunoglobulins, comple- counts obtained by analysis of blood many
[email protected] ment fragment C3b, and mannan binding lec- hours after collection may show falsely low
Accepted for publication tin, for which the neutrophil expresses multiple values. After infancy, absolute neutrophil
20 July 2000 specific receptors. Phagocytosis is followed by counts (ANC) < 1.5 × 109/litre are considered

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8 Lakshman, Finn

Table 1 Causes of neutropenia reduced bone marrow reserve of neutrophils

and neutrophil precursors (such as Kost-
Transient
Chronic
mann’s syndrome) pose a greater risk for severe
(1) Congenital neutropenias infections compared with those associated with
Failure of production (bone marrow) normal reserve and increased peripheral de-
Severe chronic neutropenia
Cyclic neutropenia
struction (such as autoimmune neutropenia of
Reticular dysgenesis infancy). Although there is good correlation
(2) Associated with syndromes between the severity of neutropenia and occur-
Primary immunodefeciencies: XLA, hyper-IgM
Glycogen storage disease (1b) rence of infections, there is considerable varia-
Shwachman diamond syndrome tion in infective symptoms for any given
Cardioskeletal myopathy neutrophil range, within a patient population
Onychotrichodysplasia
Antibody mediated neutropenias and also in a single individual, owing presum-
Autoimmune neutropenia of infancy ably to other compensatory immunological
Alloimmune neonatal neutropenia factors and to chance.
Neonatal neutropenia owing to autoimmune disease in mother
Autoimmune neutropenia seen in association with primary specific immunodeficiencies In our experience, children with neutropenia
Idiopathic commonly present with malaise and lethargy
Chronic benign neutropenia (parents often describe their children as totally
XLA, X linked agammaglobulinaemia. unwilling to get up and walk around), skin
infections (cellulitis and subcutaneous ab-
to be abnormally low and severe infections scesses), mucosal and respiratory infections
occur at values below 0.5 × 109/litre. (gingivitis, stomatitis, apthous ulcers, peri-
Transient states of neutropenia, often only odontitis, perirectal abscess, pneumonia, and
noted on a single measurement, and not lasting otitis media), and septicaemia. In one series, six
for more than two weeks, are common in chil- of 23 girls with chronic neutropenia had a his-
dren and not usually associated with clinical tory of abscess or cellulitis aVecting the labia
problems. They are usually associated with majora.9 The paucity of neutrophils may
viral infections and may therefore be the result dampen the inflammatory response, reducing
of transient dysregulation of myelopoeisis or the ability to localise the infection and permit-
accelerated consumption. By contrast, neutro- ting rapid dissemination. Classic radiological
penia in neonates might be caused by exhaus- features of pneumonia may be absent and there
tion of bone marrow reserves and can be an might be little or no abdominal tenderness
important sign of severe generalised infection, even in the presence of ruptured viscus.
such as septicaemia. Other causes of transient The most common causes of infections in
neutropenia include drugs such as cytotoxic individuals with chronic neutropenia are
agents and nonsteroidal anti-inflammatory mainly endogenous flora: Staphylococcus spp,
agents. Neutropenia can also occur in babies Serratia marcescens, Klebsiella spp, other Gram
born to mothers with pregnancy induced negative organisms and Aspergillus spp. They
hypertension. The term chronic neutropenia is are not noted to have an increased susceptibil-
usually reserved for abnormally low absolute ity to viral or parasitic infections.
neutrophil counts lasting more than six
months.8 Children with severe chronic neutro- SEVERE CONGENITAL NEUTROPENIA (SCN)
penia (SCN) can be registered with the Severe Children with SCN are characterised by the
Chronic Neutropenia International Registry.* early onset of life threatening infections, severe
Chronic states of neutropenia (table 1) may in persistent neutropenia, and maturation arrest
some cases have definable underlying genetic at the myelocyte/promyelocyte stage.
causes and are discussed at greater length here. Most of the initial cases were reported from
They consist of three major groups, those with Sweden10 and showed an autosomal recessive
congenital causes (which can result from the pattern of inheritance. However, subsequently,
failure of production and/or maturation of autosomal dominant11 and sporadic forms have
neutrophil precursors or can be associated with been recognised. In two of a series of 13
various syndromes), those caused by antibody patients with SCN, Dong and colleagues12
mediated destruction of neutrophil or neutro- found mutations in the G-CSF receptor
phil precursors (immune), and those where the (GCSFR) gene that aVected the maturation
neutropenia is the sole abnormal finding and signalling function of the GCSFR. Previously,
the pathogenesis unclear—so called chronic he and colleagues had described similar muta-
benign neutropenia. Increasingly, clinical and tions in three children with SCN, two of whom
laboratory evidence supports the view that later developed acute myeloid leukaemia.13 It is
most children with chronic benign neutropenia possible that such mutations render the recep-
have immune mediated neutropenia, although tor defective and hyporesponsive to G-CSF in
the demonstration of autoantibodies may be physiological doses.14 However, in most chil-
diYcult in some cases. dren with SCN, mutations of this gene are not
The risk of infection in chronic neutropenia found and they might have a defect in other
is inversely proportional to the absolute specific molecules in the G-CSF signal trans-
neutrophil count (including immature forms) duction pathway.12 Ward et al have reported a
and to the reserve of neutrophils present in the novel point mutation in the extracellular
bone marrow. Conditions associated with domain of the G-CSF receptor in a patient
with SCN who was hyporesponsive to recom-
binant human G-CSF (rhG-CSF).15 An associ-
* The Severe Chronic Neutopenia International Regis-
try (SCNIR) can be contacted by email at ation with human major histocompatibility
[email protected] complex (HLA) B12 has also been described.16

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Neutrophil disorders and their management 9

Clinical features CYCLICAL NEUTROPENIA

The condition usually presents in the first few This is a rare blood disease characterised by
months of life with life threatening infections regularly recurring symptoms of fever, malaise,
such as omphalitis, cellulitis, lymphadenitis, mucosal ulcers, and occasionally life threaten-
stomatitis, septicaemia, meningitis, respiratory ing infections related to regular cyclical fluc-
infections, and peritonitis. These infections are tuations in numbers of blood neutrophils.
commonly caused by Staphylococcus aureus, A pattern of autosomal dominant inherit-
Escherichia coli, and pseudomonas species. ance with variable expression is seen in up to
Before the use of rhG-CSF, three quarters of 25% of cases.26 It has been reported in identical
patients with SCN died before 3 years of age twins.27 The condition is caused by cyclical
and at a mean age of 2 years.17 Since the use of oscillations in the bone marrow production and
G-CSF, life expectancy has increased signifi- release of mature neutrophils,28–30 which might
cantly. However, some patients have gone on to be associated with cyclical fluctuations in
develop acute myelogenous leukaemia (AML) numbers of other blood cells such as mono-
or myelodysplasias (MDS). A recent paper has cytes, eosinophils, lymphocytes, platelets, and
suggested a risk of just under 9% for the devel- reticulocytes.31 Bone marrow myeloid progeni-
opment of AML/MDS for patients with SCN tors are present in high concentrations and the
who are on G-CSF.18 This might be associated defect is thought to be caused by the inability of
with mutations in the GCSFR gene13 19; eight of these precursors to respond to physiological
16 patients with SCN and the mutation devel- concentrations of G-CSF.32 In humans, trans-
oped AML or MDS.20 However, Bernard et al plantation of the defective bone marrow has
have suggested that such mutations might not resulted in transfer of the cyclic haematopoesis
be involved in the transformation into AML.21 to the recipient.33 Recently, Horwitz et al have
In addition, the predisposition of individuals demonstrated mutations in the gene encoding
with SCN to develop AML was noted before neutrophil elastase (a 240 amino acid mature
rhG-CSF became available.22 23 Therefore, it protein found in neutrophil granules) in a
appears that this kind of progression towards series of patients with cyclical neutropenia, and
malignant transformation might be intrinsic to postulated that the condition is caused by per-
the natural history of some SCN cases and has turbed interaction between neutrophil elastase
become “exposed” by the prolonged survival of and serpins or other substrates, which aVects
these patients on rhG-CSF treatment, rather the timing of the biological clock governing
than being a direct side eVect of the treatment. haematopoeisis.34

Investigations and diagnosis Clinical features

Investigations reveal absolute neutropenia, Children with cyclic neutropenia nearly always
which may be present from the 1st day of present before 10 years of age; their clinical
life, with neutrophil counts persistently below features may be characteristic with regular
0.2 × 109/ litre of blood.10 There may be associ- episodes of fever, malaise, mood swings, and
ated monocytosis, eosinophilia, anaemia, and oral ulcers lasting for three to six days and
thrombocytosis. On bone marrow examina- occurring at intervals of about three weeks.
tion, there is myeloid hyperplasia with matura- However, in our experience, the periodic
tion arrest at the level of the promyelocyte/ nature of symptoms is often not obvious even
myelocyte stage. Bone marrow culture shows on direct questioning of the patient. This is
that the precursor stem cell in the bone marrow important because it means it is worthwhile
is capable of proliferating, with colonies of nor- looking for cyclical neutropenia in cases where
mal size and number, but these do not usually the periodicity is not obvious and cyclical neu-
form mature neutrophils without exogenous tropenia is not initially demonstrated. Because
G-CSF.24 these children are often repeatedly ill, it is not
uncommon to find that full blood counts have
RETICULAR DYSGENESIS been done repeatedly in the past and neutro-
This is a rare condition characterised by penia often demonstrated but ignored because
congenital agranulocytosis, lymphopenia, and it is not persistent. The disorder does not
lymphoid and thymic hypoplasia, leading to appear to predispose to leukaemia or aplastic
severe combined immunodeficiency.25 It ap- anaemia and, as these children get older, the
pears to be the result of a sporadically condition tends to improve, although it can
occurring defect in the development of hae- persist in adults. Although considered rela-
matopoietic stem cells. AVected children tively benign, it always carries the risk of
present with overwhelming infections in the 1st potentially life threatening infection; death
few days or weeks after birth. The full blood occurs from overwhelming infection in as
count shows neutropenia and lymphopenia. many as 10% of aVected patients as a result of
Lymphocyte subset analysis shows severe defi- infections such as pneumonia, cellulitis, gan-
ciency of all types of lymphocytes. The haemo- grene, or peritonitis.35–37
globin and platelet counts are normal. The
bone marrow examination shows pronounced Investigations and diagnosis
hypoplasia with absent myeloid and lymphoid The diagnosis is made by monitoring full blood
elements. The diVerential diagnosis of reticular counts twice a week for six weeks and identify-
dysgenesis is severe combined immuno- ing the characteristic cyclical changes in the
deficiency with maternal engraftment causing neutrophil counts. In 70% of patients, there is
neutropenia through a graft versus host disease a 21 day cycle, with severe neutropenia persist-
eVect. ing for three to 10 days before recovering. In

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10 Lakshman, Finn

others, the period can be as short as 15 days or best antibody screening procedure is a combi-
as long as 35 days, but tends to stay fixed for nation of granulocyte immunofluorescence
each individual.38 Patients also have character- and agglutination techniques,45 which in com-
istic values at which they cycle, with some bination detect antineutrophil antibodies in
cycling at very low values so that they only almost all such patients. Antibody titres may be
“reach” normality briefly every month. The low and screening for granulocyte specific
bone marrow shows hypoplasia or maturation antibodies in patient’s serum may have to be
arrest during neutropenic episodes and hyper- repeated several times.41 A positive test for
plasia during recovery. granulocyte antibody can be crucial in the
diagnosis of AIN and can render bone marrow
ANTIBODY MEDIATED NEUTROPENIAS biopsy unnecessary. Bone marrow examination
These consist of two main groups, autoim- reveals a normocellular or hypercellular mar-
mune neutropenia of infancy (AIN) and the row with myeloid hyperplasia.
antibody mediated neutropenias that occur in SCN often presents with infections in the
the neonatal period. Chronic benign neutrope- first month of life, while AIN usually presents
nia in childhood (CBN) is a label usually used later. The incidence and severity of bacterial
for children whose symptoms clinically resem- infections is usually much less in AIN than in
ble those of AIN and most probably have anti- SCN. AIN may be mistaken for cyclic neutro-
body mediated neutropenia, but in whom penia because it shows day to day fluctuations
antineutrophil antibodies cannot be of neutrophil counts. The main feature diVer-
demonstrated.9 39–41 Such children may also entiating AIN from both SCN and cyclic neu-
have AIN but are probably reaching the end of tropenia is the presence of granulocyte anti-
their neutropenic period, when the antibodies bodies. Such antibodies can also be found in
disappear and neutropenia resolves. Autoim- alloimmune neonatal neutropenia (see below),
mune neutropenias and other cytopenias are but in those cases, the antibodies do not last
also seen in association with some primary beyond 6 months of age and similar antibodies
specific immunodeficiencies. are detectable in the maternal serum.

Autoimmune neutropenia of infancy (AIN) Immune neutropenia in the neonate

This is the most common cause of chronic Neutropenia in the neonate may be caused by
neutropenia in childhood and is characterised antineutrophil antibodies that are transplacen-
by the presence of antineutrophil antibodies. tally transferred. Maternal antineutrophil anti-
The autoantibodies can mediate peripheral bodies may be present in association with
destruction of the neutrophils and/or inhibit autoimmune disease, such as systemic lupus
myelopoesis in the bone marrow. It has been erythematosus or rheumatoid arthritis (neona-
suggested that antibodies directed against neu- tal maternal autoimmune neutropenia), or
trophil precursors may produce a more severe might be the result of prenatal maternal sensi-
neutropenia and clinical course than antibod- tisation by fetal neutrophils (alloimmune (iso-
ies against mature neutrophils.42 43 Boxer et al immune) neonatal neutropenia; ANN).46 47 In
documented the presence of antineutrophil ANN, the antibodies are most commonly
antibodies that disappeared with subsequent directed against paternal NA1 or NA2 (neutro-
remission in patients with chronic neutrope- phil antigen 1 or 2), which are inherited by the
nia.44 The reason why such antibodies are pro- fetus; such antibodies can remain detectable in
duced is not known and, in most patients, it is the infant for up to six months. Most infants
not associated with other autoimmune ill- with alloimmune neonatal neutropenia are
nesses, although in some it may be associated asymptomatic; some present with omphalitis,
with autoimmune haemolytic anaemia and/or delayed separation of the cord, mild skin infec-
thrombocytopenia. The disappearance of au- tions, fever, or pneumonia in the 1st weeks of
toantibodies precedes the spontaneous nor- life. The diagnosis of alloimmune neutropenia
malisation of the neutropenia and remission of is confirmed by the demonstration of antineu-
the condition.41 trophil antibodies both in the baby and in the
Bux et al reported the diagnosis and clinical mother.
course of 240 cases of autoimmune neutrope-
nia of infancy.41 They found that the average Chronic congenital neutropenia in association
age at diagnosis was 8 months. Eighty percent with syndromes and metabolic conditions
of patients only suVered from mild infections Congenital neutropenia is seen in several
such as pyoderma, otitis media, and infections syndromes and metabolic conditions and may
of the upper respiratory tract. In 8% of cases, cause considerable additional morbidity in
AIN was detected by chance, and 12% suVered these children. The diagnosis and management
severe infections such as pneumonia, meningi- of the neutropenia might improve the quality of
tis, and sepsis. In most patients, the neutrope- life of these children.
nia lasted seven to 24 months and then sponta- Glycogen storage disease type 1b (GSD 1b)—
neously resolved. Clinically, this condition is identical to the
The full blood count shows absolute neutro- classic von Gierke glycogen storage disease
penia, although there is often non-cyclical ran- (GSD 1a), but in addition almost all these chil-
dom fluctuation in neutrophil numbers from dren suVer from neutropenia and recurrent
zero to near normal. There may be associated infections, including oral lesions and perianal
monocytosis, eosinophilia, anaemia, and abscesses.48 49
thrombocytosis. The diagnostic feature is the Shwachman-Diamond syndrome—This is an
presence of antigranulocyte antibodies. The autosomal recessive condition characterised by

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Neutrophil disorders and their management 11

pancreatic insuYciency and neutropenia.50 (5) Lymphocyte subsets should be measured to

The absolute neutrophil count is generally exclude reticular dysgenesis in infants.
between 0.2 and 0.4 × 109/litre. Other features (6) An autoantibody screen is necessary to rule
include metaphyseal dysostosis and chronic out systemic lupus erythematosus and other
eczema. autoimmune conditions.
Cardioskeletal myopathy51–53—This X linked (7) Specific tests should be carried out if a syn-
recessive condition is a relatively common dromic or metabolic disorder is suspected.
cause of dilated cardiomyopathy and neutrope-
nia in boys during infancy and early childhood. MANAGEMENT OF CHRONIC NEUTROPENIA
It can present as isolated neutropenia without Management depends on the severity of
clinical evidence of cardiac disease. Examina- neutropenia, clinical course in the individual,
tion also reveals weakness in skeletal muscles. and the aetiology of the chronic neutropenia.
Onychotrichodysplasia—This is an autosomal
recessive condition characterised by sparse General measures
hair, hypoplastic nails, and persistent neutrope- EVective management to prevent and treat
nia.54 infections is essential in all cases of chronic
neutropenia. It is thought that good mouth
APPROACH TO DIAGNOSIS IN CHRONIC care, dental hygiene, and skin care can reduce
NEUTROPENIA recurrent infections. Vigilance for the emer-
The urgency of investigations is dictated by gence of serious infection and, when it is
age, clinical presentation, past history, and suspected, early and vigorous parenteral treat-
examination findings. Asymptomatic patients ment with broad spectrum antibiotics after
with isolated neutropenia can be observed obtaining blood and other appropriate cultures
clinically for several weeks, whereas those in is essential in all cases.
whom the history and examination findings
suggest the possibility of a serious underlying Prophylactic antibiotics
problem need to be evaluated urgently and Regular prophylactic cotrimoxazole can be a
completely. History should include any family simple but eVective intervention in children
history of immunodeficiency including indirect with chronic neutropenias.41 58 As in other
evidence such as unexplained deaths, repeated forms of immunodeficiency, the decision to
infections or known neutropenia, past history intervene in this way is influenced by both the
of infections, and history of drug ingestion. clinical picture and pathology results, including
Examination should include the evaluation of the severity of neutropenia.
growth and development, careful examination
of skin and mucous membranes, upper and rhG-CSF
lower respiratory tract, and palpation for Komiyama et al were the first to explore using
lymphadenopathy and hepatosplenomegaly. colony stimulating factor purified from urine to
The following tests should be considered. treat patients with chronic neutropenia.59 Bon-
(1) Repeated full blood counts will help diVer- illa et al administered rhG-CSF to five patients
entiate transient, cyclical, and chronic neutro- with SCN.60 All five patients showed a response
penias. This will also diVerentiate isolated neu- and maintained neutrophil counts of
tropenia from that associated with anaemia > 1.0 × 109/litre for more than nine months
and/or thrombocytopenia and may point to with subcutaneous maintenance treatment.
associated immunological or oncological dis- Several subsequent studies have confirmed the
ease. eVect of this treatment on the neutrophil count
(2) Neutrophil antibody assays are usually per- in children with SCN and have also shown that
formed in specialist laboratories and require it results in the resolution of pre-existing infec-
separate analysis of neutrophils and serum tions, reduced numbers of new infections, and
from the patient. They are positive in cases significant improvement in survival and quality
with AIN and ANN. of life.61–64 Bonilla et al65 published data on the
(3) Bone marrow aspiration is useful to rule out long term safety of rhG-CSF in patients with
aplastic anaemia, leukaemia, and infiltration by chronic neutropenia. Their study comprised 54
another malignancy, such as neuroblastoma. patients, who were followed up while being
Although the bone marrow picture is usually treated with regular rhG-CSF for four to six
characteristic in SCN and reticular dysgenesis, years. The dose required to maintain ANC
some authorities maintain that it is diYcult to over 1.0 × 109/litre ranged from 0.8–60 µg/kg/
distinguish reliably between the absence of day. Only in three patients was there any
mature forms resulting from maturation arrest evidence of refractoriness to treatment; one of
in SCN and autoimmune destruction in AIN. these stopped treatment, whereas in the other
(4) Serum immunoglobulin estimations are an two, a response was seen with further increases
essential part of the investigation of patients in dose. The higher doses needed in SCN may
with neutropenia. Persistent or cyclic neutro- be useful to diVerentiate it from chronic benign
penia is a well recognised association of hyper- neutropenia.66 The decision on whether to start
IgM syndrome (CD40 ligand or gp39 defi- continuous rhG-CSF in children with cyclical
ciency).55 56 Up to one third of boys with X neutropenia can be diYcult and in some cases
linked agammaglobulinaemia (XLA) may also intermittent use to cover the troughs may be
have neutropenia.57 In other patients with neu- feasible.64 67–73 Such treatment reduces the
tropenia, polyclonal raised immunoglobulin duration of the cycles and increases the mean
values may reflect the chronic infections they neutrophil nadir,74 and is associated with a
experience. pronounced improvement in the symptoms

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12 Lakshman, Finn

and frequency of infections. Although daily matched bone marrow transplant, all children
administration of rhG-CSF increases neutro- with reticular dysgenesis would succumb to
phil counts to normal within two weeks75–77 in overwhelming infection.84
children with CBN/AIN, in association with
clinical improvement and a reduction in the Disorders of neutrophil function
frequency of new infections,8 most authorities CHRONIC GRANULOMATOUS DISEASE (CGD)
will be influenced considerably by the clinical CGD is a rare disorder characterised by absent
picture in deciding which children to treat. or reduced function of the respiratory burst,
rhG-CSF has also been used in neonatal which produces oxygen free radicals important
neutropenia of various aetiologies47 78 and in for intracellular killing.
treating the neutropenia associated with GSD CGD is caused by congenital defects in the
1b and Shwachman-Diamond syndrome. Side five components of the enzyme NADPH
eVects thought to be the result of treatment oxidase (fig 1), which catalyses the respiratory
included osteoporosis/osteopenia, bone pains, burst. The mutations underlying such defects
hepatomegaly, haematuria, thrombocytopenia, are heterogenous. In about two thirds of cases,
and splenomegaly (observed radiologically but CGD occurs as an X linked recessive disease
not clinically). caused by a mutation in the glycoprotein 91
phagocyte oxidase gene (gp91 phox gene),
Intravenous immunoglobulin treatment (IVIG) which encodes a membrane bound subunit of
In those diagnosed to have antibody mediated the enzyme; the remaining one third of cases
neutropenia and suVering recurrent or serious are inherited in an autosomal recessive manner
infections, treatment measures available in- and are caused by defects in the cytosol
clude ã-globulin infusions. Although IVIG can components p47phox (25%), p67phox (5%),
be used to correct neutrophil counts, the eVect or the smaller membrane bound subunit,
is short lived and this approach is only used p22phox (5%). In general, patients with
occasionally—for example, as an adjunctive p22phox and p67phox deficiency CGD have a
approach in severe and life threatening similar clinical phenotype to those with X
infections,79–82 unless the child has an associ- linked 91phox deficiency, but patients with 47
ated disorder of antibody production. phox deficiency follow a milder course.85–88
Patients with X linked CGD can, on the basis
Granulocyte transfusions of genotypic analysis, be divided into the X910
Granulocyte or buVy coat transfusions have (complete deficiency), X91− (partial defi-
been used as an adjuvant management strategy ciency), or X91+ (stable but inactive gp91
in individuals with chronic neutropenia and phox) subgroups.89
focal bacterial or fungal infections not respon-
sive to usual treatment. Transfusion of paternal Clinical features
neutrophils that lack the sensitising antigen Most children with CGD present in the 1st
have been described in the treatment of year of life with recurrent bacterial and fungal
neonates with alloimmune neutropenia with infections.90 The most frequently encountered
sepsis. However, the safety and eVectiveness of pathogens are S aureus, Aspergillus spp, enteric
this treatment modality are unknown. Gram negative bacteria (including S marcescens
and various salmonella species), and Burkhol-
deria cepacia. Catalase negative organisms
Bone marrow transplantation (BMT)
(such as Streptococcus pneumoniae and Haemo-
In patients with SCN who do not respond to
philus influenzae) are less frequent pathogens in
rhG-CSF, bone marrow transplantation re-
83 children with CGD; the hydrogen peroxide
mains an option. Without an early HLA
they produce may be converted to hypo-
X linked chorous acid by neutrophil myeloperoxidase
Autosomal recessive 2/3 of cases and used to kill the bacteria. Infections include
Chromosome 16q24 (males affected, female pneumonia, cutaneous infections (including
Rare carriers usually healthy) perirectal abscesses), lymphadenitis, liver ab-
scess, osteomyelitis, septicaemia, and otitis
media. One of the hallmarks of the condition is
the presence of granulomas caused by the
chronic inflammatory response to the patho-
p22phox gp91phox Plasma membrane gen. These can mimic Crohn’s disease or can
present with obstructive gastrointestinal or uri-
nary symptoms. Features commonly found on
Cytoplasm clinical examination include failure to thrive,
P47phox p67phox
hepatosplenomegaly, lymphadenopathy, and
anaemia.
p40phox Finn et al reviewed 31 patients followed up
Autosomal recessive
Autosomal recessive Rare
between 1964 and 1989; the actuarial analysis
1/4 of cases Chromosome 1q25 showed 50% survival to the 3rd decade of life.91
Chromosome 7q11.23 With newer treatment approaches, the progno-
sis may be better, particularly for those with
CGD caused by 47 phox deficiency.89
No cases described Carriers of autosomal recessive forms of
Figure 1 Components of NADPH oxidase and subgroups of chronic granulomatous CGD are asymptomatic. Approximately half
disease. of X linked carriers suVer from recurrent

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Neutrophil disorders and their management 13

stomatitis and/or gingivitis and about 25% If all four subunits are detectable on western
develop discoid lupus erythematosus on sun blot in an individual with respiratory burst
exposure. A very small proportion of X linked dysfunction, the diagnosis may be a so called
CGD carriers may suVer from increased, “+variant” of CGD. These are conditions
although mild, infections. where the synthesis of the protein is normal but
the enzyme activity is lost. In such cases, cell
Investigations free oxidase assays are used to diVerentiate
The diagnosis of CGD can be made at diVerent defects in the cytosolic components from those
levels. The bacterial killing test is a comprehen- aVecting the membrane components. Some
sive screening test for defects in opsonisation, individuals have partial loss of 91 phox and
phagocytosis, or intracellular killing. It looks at proportional loss of NADPH oxidase activity;
the ability of phagocytes to kill catalase positive they are referred to as “−variants”.
bacteria, such as S aureus, in vitro. However, it Further tests can be done to identify the
is technically diYcult and time consuming to defect at the DNA level by mutation analysis;
perform. The phorbol myristate acetate (PMA) for autosomal recessive forms, this is the best
nitroblue tetrazolium (NBT) slide test is an way to identify carrier status. Mutations may
extremely easy and reliable screening test for involve deletions, insertions, splice site muta-
disorders of oxidative metabolism. It detects all tions, missense mutations, or nonsense muta-
but the most mild X linked CGD carriers and tions. Prenatal diagnosis of CGD can be made
variants.92 Neutrophils are exposed to a stimu- by the analysis of DNA from chorionic villous
lus, such as PMA, incubated with NBT, and sampling or amniotic fluid cells if the specific
staining assessed by counting 100 neutrophils mutation in the family has previously been
on a smear. After stimulation, more than 95% identified.94
of neutrophils from healthy individuals stain
positive, with a blue black precipitate of forma-
zan granules, whereas < 5% of neutrophils are Management
stained in individuals with CGD. Carriers of X Management involves measures to reduce the
linked CGD usually show 30–70% positive frequency of infections and to ensure their
cells. However, the test may give falsely prompt recognition and treatment. Avoidance
positive/normal results in certain mild forms of of BCG vaccination is advocated; children
CGD. More sensitive quantitative tests to must receive all other routine immunisations
measure respiratory burst activity in stimulated and a yearly influenza vaccine. Oral and
neutrophils using flow cytometric analysis are perianal hygiene are important and regular
now available.93 Neutrophils are stimulated in dental care, including antibacterial mouth
vitro using reagents such as PMA and the washes, can help prevent gingivitis and peri-
superoxide or hydrogen peroxide generated is odontitis. Injuries must be washed well and
measured. In one assay, hydrogen peroxide rinsed with antiseptic solutions. Regular
generated by stimulated neutrophils converts prophylaxis with cotrimoxazole can reduce
dihydrorhodamine to rhodamine and this is bacterial infections.58 The evidence is less clear
detected using a fluorescent detector. Other about antifungal prophylaxis,95 96 but itracona-
methods, generally used in research rather than zole is often used in severe cases or where inva-
clinical diagnosis, involve the measurement of sive fungal infection has occurred previously.
oxygen consumption using an oxygen elec- Gallin et al showed that prophylactic treatment
trode, or estimating superoxide generation by with ã interferon (IFN-ã) can reduce infection
the reduction of ferricytochrome c, or by rates in patients with CGD.85 97 98 However, the
hydrogen peroxide production by oxidation of infection rates in the placebo control group in
homovanillic acid. Chemiluminescence with that study were higher than those generally
luminol can also be used as a sensitive test of seen in the UK where daily antimicrobial (cot-
NADPH oxidase activity. rimoxazole) prophylaxis is routine. Accord-
The diagnosis of suboptimal respiratory ingly, in most UK centres IFN-ã prophylaxis is
burst dysfunction leads to further investiga- oVered only in selected cases. IFN-ã does not
tions to identify the subgroup of CGD. correct the defective metabolism in CGD but
Western blot analysis using antibodies against
may work by augmenting nitric oxide produc-
each of the four NADPH oxidase components
tion in neutrophils.99 Once infection occurs,
can show whether one of the components is
this must be treated with appropriate
missing. The absence of 47 phox protein and
67 phox protein is indicative of a gene parenteral antibiotics in suYcient dosage and
mutation; however, for the membrane bound duration to eradicate the organism; often
components, if one (either the 91 kDa or the abscess formation will need surgical measures.
22 kDa phox protein) is missing the other will Although corticosteroids should be generally
be absent too because all the subunits are avoided in CGD, they are useful in low doses in
needed for stabilisation and full expression. In the management of symptomatic complica-
such cases, it is useful to confirm or refute car- tions of granuloma formation at diVerent
rier status in the mother using the NBT slide sites.100 101 Results of bone marrow transplanta-
test or dihydrorhodamine flow cytometry assay. tion have been much better in the past decade
However, failure to find that the mother is an X (using matched siblings as donors), although
linked carrier does not completely rule out X numbers are still limited, and there are reports
linked CGD; such defects can occur as new of successful outcomes even in the most
mutations. severely infected patients.102

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14 Lakshman, Finn

OTHER DISORDERS OF INTRACELLULAR KILLING receptors. An example is the carbohydrate

Myeloperoxidase (MPO) deficiency blood group antigen, sialyated Lewis X
This is a minor phagocyte intracellular killing (SLeX).
defect caused by deficiency of the MPO The term leucocyte adhesion deficiency
enzyme. It is common, with an incidence of (LAD) was first proposed by Anderson and
between 1/2000–4000 in the general popula- Springer in 1987104 for a condition caused by a
tion.103 It is caused by a mutation in the MPO defect of the â2 integrins, heterodimers of á
gene on chromosome 17. Granulocytes with and â subunits called CD11 and CD18,
MPO deficiency have defective generation of respectively. Three diVerent á subunits
hypochlorite ion, but have normal superoxide CD11a, CD11b, and CD11c combine with a
ion production and hence intracellular killing common â subunit CD18. The molecular
of phagocytosed microbes is only minimally defect results from absent or diminished â2
aVected. In some individuals, in vitro assays subunit (CD18) caused by mutations that can
show slightly reduced killing of S aureus and, be mapped to chromosome 21q21.3.104 This
more importantly, impaired killing of Candida leads to a lack of functional CD11/CD18
albicans. Most individuals with MPO defi- glycoproteins in all leucocytes. The neutrophils
ciency are completely asymptomatic; those in this condition were able to roll along
who suVer from recurrent or severe candidiasis endothelial cells but were unable to adhere
may also have diabetes mellitus or other firmly to them or emigrate to the tissues. Thus,
compromises in immune function. The diag- neutrophils do not accumulate at extravascular
nosis is usually made by appropriate histo- inflammatory sites, despite pronounced pe-
chemical staining of the neutrophils: some ripheral blood leucocytosis. Subsequently, an-
modern haematology automated cell counters other similar condition, LAD 2 was described,
can be set to detect low MPO values. where the defect is one of addition of fucosyl
groups. A variant form of LAD 1, in which â2
Glutathione synthetase deficiency integrins are expressed but not functional, has
This is a very rare condition aVecting the pro- also been described.105 106
duction of glutathione, which is a potent
antioxidant found in most cells, including LAD 1
granulocytes. AVected children have subnor- Inheritance is autosomal recessive. More than
mal respiratory burst function and intracellular 600 cases have been described and present
killing. Children present with haemolytic anae- with recurrent bacterial infections from birth.
mia and recurrent otitis. The diagnosis is con- Infections mainly aVect the skin and mucous
firmed by demonstrating absent or low glutath- membranes; omphalitis and delayed separation
ione synthetase values in red blood cells. of the cord (often beyond 21 days107) is a com-
mon presentation. Infected sites often undergo
Severe glucose-6-phosphate dehydrogenase necrosis but characteristically there is no pus,
(G6PD) deficiency even though there is pronounced peripheral
White individuals with severe (< 1%) G6PD blood neutrophilia. Chronic skin ulcers with-
activity can present with clinical features simi- out pus can form and there is delayed wound
lar to CGD. This is not seen in Asians or black healing. Recurrent subcutaneous and mucosal
individuals with similar severe enzyme defi- infections (perirectal abscesses, pyoderma gan-
ciency. G6PD is important for ensuring the grenosum,108 otitis media, pharyngitis, ulcera-
adequate availability of NADPH for the respi- tive stomatitis, gingivitis, and periodontitis) are
ratory burst. AVected children present with seen. Life threatening infections such as septi-
recurrent infections similar to CGD. In addi- caemia, bronchopneumonia, and aseptic men-
tion, they are prone to haemolysis and may ingitis can occur; more than 75% of these chil-
suVer recurrent episodes of severe anaemia and dren die before the age of 5 years if they do not
jaundice. Investigations show a raised reticulo- receive a bone marrow transplant. The most
cyte count and absent NBT dye reduction in frequent bacteria involved are S aureus and
almost all neutrophils. The diagnosis is con- Gram negative enteric organisms. Patients also
firmed by demonstrating undetectable red suVer from fungal infections but do not have
blood cell and leucocyte G6PD. increased susceptibility to viral infections. The
severity of infections and complications is
LEUKOCYTE ADHESION DEFICIENCY related to the severity of CD18 deficiency;
The process of neutrophil migration from the cases with < 1% expression are clinically
blood stream through the endothelium is severe, whereas those with 2.5–10% expression
mediated by various families of adhesion mol- are moderate to mild. LAD 1 carriers have 50%
ecules and their ligands. Integrins are trans- expression of CD18 and are clinically asympto-
membrane cell surface proteins present in all matic.
leucocytes and are essential for firm adhesion The diagnosis is to be suspected in any infant
of the leucocyte to the endothelium and subse- with serious infections accompanied by strik-
quent transendothelial migration. Each in- ing neutrophilia in the peripheral blood.
tegrin molecule is a heterodimer consisting of Absence of neutrophilia in a newborn infant
an á and a â chain. Selectins are another family who has delayed cord separation but is
of adhesion molecules that mediate the initial otherwise well generally rules out the diagno-
transient “rolling” interaction between leuco- sis.109 The white blood cell count ranges
cytes and endothelium. Characteristically, their between 15 and 160 × 109/litre and 50–90% of
counterligands are glycosylation moieties these are neutrophils. The diagnosis can be
(hence the name lectin) that decorate counter- confirmed by flow cytometric analysis of

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Neutrophil disorders and their management 15

peripheral blood neutrophils using monoclonal Other disorders of chemotaxis

antibodies for CD11 or CD18.110 111 In our Normal chemotaxis is essential for the migra-
laboratory, we routinely measure the expres- tion of neutrophils from the circulation to the
sion of CD11a and CD11b á chains and CD18 site of infection. It requires the generation of
â chains and also assess modulation of expres- chemotactic substances and normal neu-
sion after stimulation with N-formyl-L- trophilic responsiveness to them. Disordered
methionyl-L-leucil-L-phenylalanine (fMLP). neutrophil chemotaxis is seen in a wide variety
In vitro functional studies, if performed, show of conditions (table 2); however, in many of
reduced chemotaxis, reduced adherence to these conditions this does not greatly contrib-
endothelial monolayers, and abnormal granu- ute to a decrease in resistance to bacterial
locyte aggregation. infections. When considering disorders of
Leucocytes express CD18 at 20 weeks gesta- chemotaxis, it must be remembered that labo-
tion and at this time blood can be obtained by
ratory investigations for these are diYcult to
cordocentesis for prenatal diagnosis. Muta-
standardise and subject to artifacts.
tional analysis on chorionic villous biopsy or
Hyper-IgE syndrome 115 116—This condition
cells obtained by amniocentesis may be possi-
ble when the precise familial mutation is usually presents in infancy with serious recur-
known. rent staphylococcal infections of the skin and
All patients with severe LAD 1 need bone the lungs, which sometimes develop into cystic
marrow transplantation.112 Patients with mild pneumonias. The children may have coarse
to moderate deficiency may be managed with facies and chronic eczematoid dermatitis. The
prophylactic antimicrobial treatment to pre- condition can occur sporadically or as an auto-
vent infections and measures to ensure their somal dominant condition with variable pen-
prompt recognition and treatment. etrance.115 The cause of infections is poorly
understood but might be related to the
presence of high concentrations of antistaphy-
LAD II lococcal IgE, low concentrations of antistaphy-
LAD II has been described in only three unre-
lococcal IgG, a neutrophil chemotactic defect,
lated boys. A recent paper113 describes the third
or some combination thereof. Recently, Borges
patient, who was investigated extensively, and
found to have severe hypofucosylation of et al have found that lymphocytes of patients
glycoconjugates bearing fucose in diVerent gly- with hyper-IgE syndrome have an impaired
cosidic linkages in all types of cells. The response to IL-12, resulting in decreased
authors suggest that this is not only a disorder IFN-ã production, and have suggested that a
of leucocytes but a generalised metabolic defective IL-12–IFN-ã pathway might be of
disease aVecting the metabolism of fucose. It is key importance in the pathogenesis of immune
associated with severe mental retardation and abnormalities of the hyper-IgE syndrome.116 In
short stature and presents with frequent infec- the absence of a clear understanding of the
tions similar to the moderate to mild pheno- underlying pathophysiology or of a diagnostic
type of LAD I. These children too had reduced test it is very diYcult to know how to draw a
signs of inflammation with infections and no diagnostic line between individuals with this
pus formation in spite of pronounced periph- syndrome and those with severe atopic eczema
eral blood neutrophilia. These children also and associated staphylococcal superinfection.
have the Bombay blood group (absence of the Blood and sputum eosinophilia may be dem-
H antigen) and this is a useful clue; confirma- onstrated and raised serum IgE, often more
tion of diagnosis needs cell sorter analysis for than 5000 IU/litre, is found. Concentrations of
SLeX (CD15) expression on leucocytes. There IgD are also high, whereas those of IgG, IgA,
was a normal density of CD11/CD18 on their and IgM are typically normal. Lymphocyte
leucocytes and this could be increased by acti- counts are normal, but poor antibody and cell
vation, unlike the children with LAD 1. Their
mediated responses to antigens are sometimes
neutrophils performed poorly in assays for
seen. Variable defects in neutrophil chemotaxis
chemotaxis.114 These children had less frequent
and less severe infections as they grew older are present in some patients. Prophylactic anti-
and were managed conservatively. biotics are the mainstay of the management of
this disorder. Although many authorities rec-
Table 2 Conditions associated with subnormal neutrophil chemotaxis ommend long term penicillinase resistant
penicillins, we and others prefer to use
Defects in the neutrophil
Neonatal neutrophils cotrimoxazole for its better tissue penetration,
Neutrophil actin dysfunction reserving antistaphylococcal agents for use
Syndromes: Schwachman, glycogenosis type 1b, Chediak Higashi, and hyper-Ig E
Acrodermatitis enteropathica (zinc deficiency) against symptomatic infections as indicated.
Specific granule deficiency Surgical drainage may also be indicated on
Chromosome 7 abnormalities occasion. Intravenous immunoglobulin is used
Direct inhibition of neutrophil chemotaxis in patients with hyper-IgE who are deficient in
Juvenile periodontitis
Immune complex diseases immunoglobulins or IgG subclasses, or have a
Wiskott Aldrich syndrome known defect in antibody responses to polysac-
Bone marrow transplant
Drugs such as corticosteroids, amphotericin B, antithymocyte globulin charide. The administration of IFN-ã results in
Granulomatous diseases such as sarcoidosis pronounced improvement in neutrophil
Malignancies chemotaxis117; however, it is as yet unclear
Defective generation of chemotactic factors whether such treatment is of any clinical
Familial complement deficiencies of alternative or classical pathway
benefit.

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16 Lakshman, Finn

DISORDERS OF OPSONISATION AND INGESTION picture.126 Individuals who survive to become

Neutrophil phagocytosis is enhanced by op- adults may suVer from neurological disabilities.
sonisation of the organism by antibody, com- The peripheral smear shows large cytoplas-
plement, and mannan binding lectin (MBL). mic granules in neutrophils and lymphocytes.
Defects in any of these will impair phagocyto- Tests for neutrophil function show defective
sis.118 119 Measurement of mannan binding lec- chemotaxis and intracellular killing. Lym-
tin, in addition to complement and immu- pocyte function and platelet aggregation are
noglobulins, is now undertaken when also abnormal. In the accelerated phase of the
screening for immunodeficiency. Similarly de- illness, there are high and persistent concentra-
fects in the neutrophil binding sites for immu- tions of antibodies to Epstein-Barr virus
noglobulin might predispose to a higher risk of antigens. In the stable phase, management is
infections by encapsulated organisms. Indi- centred around the prompt recognition and
viduals who are homozygous for both the treatment of infections. Ascorbic acid appears
FcãRIIA allele, with arginine in position 131, to correct some of the microbicidal defects in
and the FcãaRIIIB*NA2 allele appear to be at vitro, but has not been eVective in reducing
higher risk for meningococcal septicaemic infections in patients.127 The management of
shock120 and recurrent upper respiratory infec- the accelerated phase is diYcult and has
tions by encapsulated bacteria,121 owing to included the use of corticosteroids and chemo-
defects in IgG2 mediated neutrophil phagocy- therapeutic agents. Bone marrow transplanta-
tosis.122 DNA analysis on blood or saliva can be tion with HLA matched marrow before the full
performed to look for these mutations.123 124 blown accelerated phase has been successful.128

Specific granule deficiency

DISORDERS OF DEGRANULATION
This is an extremely rare, autosomal recessively
The neutrophil granules contain toxic proteins
inherited condition characterised by recurrent
that are released into the phagocytic vacuole to
bacterial infections starting in infancy associ-
aid microbial killing. The two main conditions
ated with absent granules in peripheral blood
associated with defects in degranulation are
neutrophils. Management consists of prophy-
Chediak Higashi syndrome (CHS) and specific
lactic antibiotics and aggressive management
granule deficiency.
of infections; individuals have survived into
adulthood.
Chediak Higasi syndrome
CHS is a rare autosomal recessive disorder of APPROACH TO CHILDREN SUSPECTED TO HAVE
granule bearing cells. It is caused by mutations DISORDERS OF PHAGOCYTE FUNCTION
in the lysosomal traYcking regulator gene, Patients with chronic or recurrent pyogenic or
LYST, present on the long arm of chromosome fungal infections and a slow response to antibi-
1 (1q42.1–q42.2).125 This leads to defective otics must be evaluated systematically for
membrane targeting of the proteins present in phagocyte function using some or all of the fol-
secretory lysosomes. There is uncontrolled lowing tests.
granule fusion leading to large but defective (1) A full blood count and peripheral smear
granules in all granule bearing cells including examination can provide useful clues to the
Schwann cells, melanosomes, and neutrophils. diagnosis of phagocyte dysfunction. The pres-
These large granules are seen in both periph- ence of pronounced polymorphonuclear leuco-
eral blood granulocytes and in their progenitor cytosis might suggest the diagnosis of LAD.
cells in the bone marrow, and are associated Neutropenia can be seen in conditions also
with delayed and incomplete degranulation. In associated with phagocyte dysfunction such as
addition, these children also have neutropenia CHS. The peripheral smear must be examined
(because of the death of many myeloid precur- carefully for features of disorders of degranula-
sors in the bone marrow) and defective chemo- tion. Specific granule deficiency is character-
taxis (because intrinsic defects in the neutro- ised by bilobed nuclei in more than 80% of the
phil impair their mobility). Lymphocytes neutrophils and there is a striking decrease in
contain large giant cytoplasmic granules and cytoplasmic granularity. Giant granules are
function poorly in antibody dependent cell seen in individuals with CHS. MPO deficiency
mediated cytolysis of tumour cells. Natural can be diagnosed by the use of appropriate his-
killer cell function is compromised and this tochemical stains or certain automated cell
may be responsible for the later development of counters.
malignancies. A deficiency of granules contain- (2) The NBT test and/or quantitative tests to
ing serotonin and adenosine phosphate in measure respiratory burst activity in stimulated
platelets leads to defective platelet aggregation neutrophils using flow cytometric analysis
and prolonged bleeding time. should be performed in children in whom
Children with CHS present in childhood CGD is suspected.
with partial albinism (hypopigmentation of (3) The measurement of G6PD and glutath-
hair and eyes compared with other family ione synthetase. Severe deficiency of G6PD or
members) and recurrent infections of skin, glutathione sythetase can lead to intracellular
mouth, and respiratory tract. Death often killing defects similar to CGD and subnormal
occurs before 7 years of age because of serious NBT. In patients presenting with features simi-
infection or an accelerated phase of the condi- lar to CGD, these enzymes should be measured
tion, which may be related to infection with if CGD has been ruled out.
Epstein-Barr virus or other lymphotropic (4) The estimation of CD11/CD18 expression
viruses, and presents with a lymphoma-like in peripheral blood neutrophils is performed in

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Neutrophil disorders and their management 17

infants suspected of having LAD 1. Leucocyte Conclusions

activation before flow cytometry can greatly Neutrophil disorders are an uncommon, yet
enhance the expression of these glycoproteins important, cause of morbidity and mortality in
and magnify the diVerences between healthy infants and children and should be considered
subjects and patients.129 Flow cytometric analy- when investigating children for immuno-
sis for SLeX (CD15) expression on leucocytes deficiency. They are especially likely when the
using an anti-SLeX monoclonal antibody clinical presentation includes features such as
should be performed to rule out LAD 2. oral ulcers and gingivitis, delayed separation of
(5) The estimation of serum immunoglobulin the umbilical cord, uncommon infections such
isotypes, mannan binding lectin, and total as hepatic or brain abscesses, uncommon
organisms such as S marcescens or Pseudomonas
complement haemolytic activity, and DNA
spp, or when the individual has features of syn-
studies for Fcã receptor polymorphisms. De-
dromic conditions associated with neutropenia
fects in opsonisation caused by deficiencies in or neutrophil dysfunction. All patients with
these factors are more common causes of recurrent oral infections, skin abscesses, peri-
disorders of phagocytic function than intrinsic anal and perirectal abscesses, poor wound
defects in the neutrophil. healing, sinopulmonary infections, or deep vis-
(6) Neutrophil chemotaxis can be determined ceral abscesses should be evaluated for defects
by the use of a modified Boyden chamber.130 A in phagocyte function. Appropriate investiga-
siliconised or non-siliconised glass tube is used tions can lead to specific diagnoses, and general
as the upper compartment of the chamber in and specific management measures can reduce
which neutrophils are placed and fMLP, a both mortality and morbidity and permit
potent synthetic chemoattractive peptide, is genetic counselling and antenatal diagnosis in
placed into the lower compartment. The some cases.
chamber is incubated and the number of cells
reaching the bottom surface of the filter is 1 Hughes BJ, Hollers JC, Crockett-Torabi E, et al. Recruit-
expressed as the average number of cells/field ment of CD11b/CD18 to the neutrophil surface and
adherence-dependent cell locomotion. J Clin Invest
after counting five fields for each filter. Another 1992;90:1687–96.
classic test for the in vivo study of adhesion and 2 Middleton J, Neil S, Wintle J, et al. Transcytosis and surface
presentation of IL-8 by venular endothelial cells. Cell 1997;
chemotaxis is the Rebuck skin window.130 91:385–95.
However, these tests are diYcult and not often 3 Baggiolini M, Dewald B, Moser B. Human chemokines: an
update. Annu Rev Immunol 1997;15:675–705.
performed outside a research setting. In this 4 Faustino M, Niels B, Laurence AB. Novel trends in neutro-
regard, it is useful to remember that although phil structure, function and development. Immunol Today
1999;20:535–7.
subnormal chemotaxis has been described in a 5 Keel M, Ungethum U, Steckholzer U, et al. Interleukin-10
variety of conditions, there are no known counterregulates proinflammatory cytokine-induced inhi-
bition of neutrophil apoptosis during severe sepsis. Blood
disorders that can be diagnosed specifically 1997;90:3356–63.
using only functional chemotaxis assays. 6 HinchliVe RF. Reference values. In: Lilleyman J, ed. Pediat-
ric hematology. London: Churchill Livingstone, 1999:2–3.
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mary disorders of phagocytosis are rare. As negroes: a normal phenomenon. New York State Journal of
Medicine 1972;72:1815–17.
already mentioned, most conditions with 8 Bernini JC. Diagnosis and management of chronic neutro-
penia during childhood. Pediatr Clin North Am 1996;43:
subnormal phagocytosis are caused by defi- 773–92.
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intrinsic and extrinsic phagocytic defects, both J Dis Child 1991;145:232–5.
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cytometeric techniques.130 granulocyte colony-stimulating factor receptor gene in
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18 Lakshman, Finn

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