Use of oral mucosal neutrophil counts to detect the onset and resolution of profound neutropenia following high-dose myelosuppressive chemotherapy

Severe neutropenia following cytotoxic, anti-cancer chemotherapy is well-known to be associated with an increased risk of infections that may be life-threatening, particularly if not treated immediately. Consequently, serial measurements of neutrophil counts in peripheral blood are done routinely following the administration of high-dose myelosuppressive chemotherapy in order to monitor the onset, severity, and duration of iatrogenic neutropenia. We have studied a non-invasive method of quantifying neutrophils recoverable from the oral mucosa, a normal tissue site of neutrophil turnover, as an alternative approach for monitoring severe, chemotherapy-induced neutropenia. This method is based on the quantification of fluorochrome-stained neutrophils present in timed mouthwash specimens. Blood neutrophil (ANC) and mucosal neutrophil counts (MNC) were measured repeatedly in 23 patients who had been treated with dose-intensive chemotherapy for a variety of indications. All 23 patients developed profound neutropenia (ANC < 100/mm3), and 19 developed neutropenic fever (>101 degrees F) during the 2 weeks following treatment. Nadirs of neutropenia defined by MNC were significantly less prolonged than those defined by the ANC. Furthermore, the onset and resolution of neutropenic fever coincided more precisely with nadirs of neutropenia defined by the MNC than with those defined by the ANC. Our findings indicate that oral mucosal neutrophil counts predict the timing of clinical events associated with neutropenia (e.g., the onset and resolution of fever) with significantly greater accuracy than blood neutrophil counts.     

Plasma Lysozyme in Drug-induced and Spontaneous Cyclic Neutropenia

S ummary . In order to evaluate how well the plasma lysozyme concentration reflects changes in the neutrophil status in a non-steady state system, six patients, treated with bone-marrow depressing agents, were followed with neutrophil counts and plasma lysozyme determinations. In all patients, plasma lysozyme rather accurately mirrored changes in the neutrophil counts. The minimum change in neutrophil counts detectable by sequential studies of plasma lysozyme concentration was about 1000 neutrophils per μl blood, corresponding to a change in the granulocyte turnover rate of 30 × 10⁷ neutrophils per kg per day. No time lag was found between changes in the neutrophil counts and plasma lysozyme concentrations, which suggests that the life span of the neutrophilic granulocytes in the tissues is less than 24 hr. In the neutrophil nadir phases the plasma lysozyme concentration was consistently higher than expected from the neutrophil counts. This was probably to a large extent due to 'background' lysozyme from non-neutrophilic sources, but might in addition suggest a reduced life span in the neutropenic phases.
Similar investigations were carried out in two patients with spontaneous cyclic neutropenia. Whereas in these patients little variation of plasma lysozyme with the neutrophil phases could be demonstrated, plasma lysozyme was constantly higher than the concentrations found in the patients with drug-induced neutropenia at similar neutrophil levels. This suggests a reduced neutrophil life span in the patients with cyclic neutropenia, especially in the nadir phases. Kinetic studies of blood neutrophils with DF³²P labelling in one of the patients with cyclic neutropenia showed a slightly reduced blood half-disappearance time in the zenith phase and a greatly reduced half-disappearance time in the nadir phase.     

Neutrophil life span in paroxysmal nocturnal hemoglobinuria

We have studied neutrophil intravascular life span in six patients with paroxysmal nocturnal hemoglobinuria (PNH); four had normal neutrophil counts when studied and two were neutropenic. Five patients had enough circulating neutrophils to isolate for tests in vitro. Lysis of labeled neutrophils was greatly increased, compared to that of normal volunteers, when these neutrophils were incubated with acidified fresh serum as a source of active complement plus serum containing antineutrophil antibodies (from three different sources). Despite the in vitro lesion, however, each of these patients had a normal neutrophil intravascular life span as measured by the 32P- diisopropylfluorophosphate technique. One neutropenic patient, who had a normal neutrophil life span, had a shift of cells from the circulating to marginated pool of sufficient degree to cause the neutropenia. A second (severely) neutropenic patient was found to have developed extreme marrow hypoplasia, also explaining the neutropenia. Thus, in contrast to the shortened red cell life span, we have been unable to find a shortened neutrophil life span in PNH.     

Assessment of neutrophil apoptosis ex vivo in hepatosplenic patients with neutropenia pre and post splenectomy

The pathophysiology of neutropenia seen in patients with schistosomiasis or hepatitis C infection that complicates the course of liver disease is poorly understood. We evaluated the neutrophil apoptosis before and after splenectomy to clarify the role of apoptosis and splenomegaly in the occurrence of neutropenia. Neutrophils were isolated from 23 hepato-splenic patients with neutropenia, 8 hepatosplenic patients with normal neutrophil counts, 7 patients who were post splenectomy, and a further ten normal control subjects. These were cultured for 24 h and the time course of neutrophil apoptosis was assessed by determination of Annexin V and propidium iodide binding by flow cytometry. Fas and Bcl2 expression were determined on fresh neutrophils using flow cytometry. Levels of tumor necrosis factor alpha, interleukin 3, and gamma interferon were evaluated using an immunosorbent assay. Neutrophil apoptosis was minimal in the fresh neutrophils, however, cultured neutrophils exhibited significantly greater apoptosis in neutropenic patients when compared to non-neutropenic patients (P=0.01 at 4 h and P<0.05 at 24 h) and control group (P<0.01 at 4 h and 24 h). After splenectomy, the percentage of neutrophil apoptosis declined to the normal control levels (P>0.05). Fas and Bcl2 expression on neutrophil were significantly higher in the neutropenic group as compared to normal controls (P<0.05, P=0.01 respectively). Serum TNF alpha, IL-3, and IFN gamma levels were not significantly different in all studied groups. In conclusion: Neutrophils from neutropenic hepatosplenic patients exhibit markedly accelerated apoptosis, which is normalized after splenectomy. Thus increased neutrophil apoptosis may in part be responsible for the occurrence of neutropenia.     

Bone marrow granulocyte reserve in chronic benign idiopathic neutropenia

Fifteen patients with chronic benign idiopathic neutropenia (CBIN) with neutrophil counts less than 1.0 X 10(9)/1 have been studied. The mean age was 33 years (range 23-50) comprising 11 females and 4 males. Bone marrow cellularity was normal except in two patients who showed slight reduction and one who had a slight increase. Bone marrow differential counts were normal apart from a small increase in the percentage of promyelocytes and reduction in the myeloid/erythroid ratio in some patients. Peripheral blood counts showed no 'compensatory' monocytosis. Epinephrine stimulation tests showed no evidence of excess neutrophil margination. After endotoxin administration there was a one- to two-fold increase in neutrophil counts in three patients, a three-fold increase in three patients and a greater than four-fold increase in the remaining nine patients. The findings suggest that the benign course of CBIN is not due to excess neutrophil margination nor to compensatory monocytosis, but that at least one mechanism includes a functionally adequate release of neutrophils to the peripheral blood under conditions of stress with subnormal delivery of neutrophils under basal conditions. The variability in responses to endotoxin suggests that CBIN is not entirely homogeneous with respect to mechanism. The findings of relatively normal bone marrow cellularity and differential counts and a normal or substantial neutrophil response to endotoxin appear characteristic. They may help predict a benign clinical course in neutropenic patients and assist diagnosis of the CBIN variant of idiopathic neutropenia.     

Cell Production and Cell Function in Human Cyclic Neutropenia

In vitro studies have been done on haematopoietic cells from a patient with cyclic neutropenia characterized by severe depression of blood neutrophil levels every 21 days. Serial blood counts reveal periodic fluctuations in neutrophils, monocytes and reticulocytes. Agar culture of marrow cells shows normal concentration of colony forming cells. The percentage of colony forming cells in S phase is highly increased during profound neutropenia and normal during the recovery phase relating the granulocyte production to the peripheral neutrophil level. Studies of ingestion rate, bactericidal activity, lactate production and glucose oxidation during phagocytosis in isolated granulocytes show normal results. Also the ingestion rate in isolated monocytes is normal. Serial karyotype analyses of marrow cells during the neutrophil cycle display a normal pattern. Serum myeloperoxidase levels vary inversely with the peripheral neutrophil count indicating increased granulopoietic activity during profound neutropenia, which might be associated with non effective granulopoiesis during profound neutropenia, leading to a lack of granulocyte reserves in the marrow.     

Cell production and cell function in human cyclic neutropenia.

In vitro studies have been done on haematopoietic cells from a patient with cyclic neutropenia characterized by severe depression of blood neutrophil levels every 21 days. Serial blood counts reveal periodic fluctuations in neutrophils, monocytes and reticulocytes. Agar culture of marrow cells shows normal concentration of colony forming cells. The percentage of colony forming cells in S phase is highly increased during profound neutropenia and normal during the recovery phase relating the granulocyte production to the peripheral neutrophil level. Studies of ingestion rate, bactericidal activity, lactate production and glucose oxidation during phagocytosis in isolated granulocytes show normal results. Also the ingestion rate in isolated monocytes is normal. Serial karyotype analyses of marrow cells during the neutrophil cycle display a normal pattern. Serum myeloperoxidase levels vary inversely with the peripheral neutrophil count indicating increased granulopoietic activity during profound neutropenia, which might be associated with non effective granulopoiesis during profound neutropenia, leading to a lack of granulocyte reserves in the marrow.     

Assessment of Neutrophil Apoptosis Ex Vivo in Hepatosplenic Patients with Neutropenia Pre and Post Splenectomy

The pathophysiology of neutropenia seen in patients with schistosomiasis or hepatitis C infection that complicates the course of liver disease is poorly understood. We evaluated the neutrophil apoptosis before and after splenectomy to clarify the role of apoptosis and splenomegaly in the occurrence of neutropenia. Neutrophils were isolated from 23 hepato-splenic patients with neutropenia, 8 hepatosplenic patients with normal neutrophil counts, 7 patients who were post splenectomy, and a further ten normal control subjects. These were cultured for 24 h and the time course of neutrophil apoptosis was assessed by determination of Annexin V and propidium iodide binding by flow cytometry. Fas and Bcl2 expression were determined on fresh neutrophils using flow cytometry. Levels of tumor necrosis factor alpha, interleukin 3, and gamma interferon were evaluated using an immunosorbent assay.

Neutrophil apoptosis was minimal in the fresh neutrophils, however, cultured neutrophils exhibited significantly greater apoptosis in neutropenic patients when compared to non-neutropenic patients (P=0.01 at 4 h and P<0.05 at 24 h) and control group (P<0.01 at 4 h and 24 h). After splenectomy, the percentage of neutrophil apoptosis declined to the normal control levels (P>0.05). Fas and Bcl2 expression on neutrophil were significantly higher in the neutropenic group as compared to normal controls (P<0.05, P=0.01 respectively). Serum TNF alpha, IL-3, and IFN gamma levels were not significantly different in all studied groups.

In conclusion: Neutrophils from neutropenic hepatosplenic patients exhibit markedly accelerated apoptosis, which is normalized after splenectomy. Thus increased neutrophil apoptosis may in part be responsible for the occurrence of neutropenia.     

Serum myeloperoxidase and lactoferrin in neutropenia.

Radioimmunosorbent assays for determination of serum content of the neutrophil proteins myeloperoxidase and lactoferrin are described. Serial studies were performed in patients with neutropenia. In 2 cases of cyclic neutropenia the myeloperoxidase level showed slight variations within the normal range during the cycle while lactoferrin displayed a clear correlation with neutrophil counts. In 1 case with persistent agranulocytosis myeloperoxidase was normal but lactoferrin was extremely low. During the regeneration phase of drug-induced neutropenia neutrophil counts and serum lactoferrin increased in a parallel fashion. Since serum myeloperoxidase was normal during profounded neutropenia it is suggested to derive primarily from myeloperoxidase-rich granulopoietic precursor cells of the marrow. Serum lactoferrin on the other hand seems to derive from leakage of more granulopoietic cells of blood and marrow. Studies of neutrophil proteins of serum may aid in evaluation of neutropenic patients.     

Serum Myeloperoxidase and Lactoferrin in Neutropenia

Radioimmunosorbent assays for determination of serum content of the neutrophil proteins myeloperoxidase and lactoferrin are described. Serial studies were performed in patients with neutropenia. In 2 cases of cyclic neutropenia the myeloperoxidase level showed slight variations within the normal range during the cycle while lactoferrin displayed a clear correlation with neutrophil counts. In 1 case with persistent agranulocytosis myeloperoxidase was normal but lactoferrin was extremely low. During the regeneration phase of drug-induced neutropenia neutrophil counts and serum lactoferrin increased in a parallel fashion. Since serum myeloperoxidase was normal during profounded neutropenia it is suggested to derive primarily from myeloperoxidase-rich granulopoietic precursor cells of the marrow. Serum lactoferrin on the other hand seems to derive from leakage of more mature granulopoietic cells of blood and marrow. Studies of neutrophil proteins of serum may aid in evaluation of neutropenic patients.     

Enhanced neutrophil apoptosis in neutropenic patients with hepatosplenic schistosomiasis: evidence of serum Fas ligand

Enhanced neutrophil apoptosis has been reported in neutropenic hepatosplenic schistosomiasis. The shortening of neutrophil survival via apoptosis may explain the neutropenia that occur in these patients. However, the regulation of neutrophil apoptosis in hepatosplenic schistosomiasis has not been clearly defined. Neutrophils harvested from neutropenic patients with hepatosplenic (HS) schistosomiasis, (n=25), non-neutropenic patients with hepatointestinal (HI) schistosomiasis (n=10), and age-/gender-matched healthy control subjects (n=10) were incubated with autologous serum. Neutrophils apoptosis was quantified by flow cytometry through determination of propidium iodide nuclear staining and confirmed by DNA gel electrophoresis at 0 (i.e. fresh neutrophils), 4 and 24 h culture. Neutrophils from healthy subjects were also incubated with either 10% heterologous normal or neutropenic serum, with and without anti-Fas ligand antibody. Fas expression was assessed in fresh neutrophils using flow cytometry. Compared with normal healthy neutrophils, and HI neutrophils, neutropenic neutrophils demonstrated greater apoptosis in the presence of autologous serum (P<0.01, 0.05, respectively). Furthermore, compared with normal neutrophils exposed to heterologous normal serum, those exposed to heterologous neutropenic serum exhibited higher apoptosis rates ( P<0.01). Moreover, anti-Fas L antibody attenuated the neutropenic serum-induced neutrophil apoptosis in normal neutrophils. Fas expression was significantly higher in the neutropenic group when compared to both HI and normal healthy controls (P<0.05). In addition, Fas expression by neutrophils was paralleled by high neutrophil apoptosis. On the other hand, neutrophil apoptosis was not correlated to the size of spleen in neutropenic group. In conclusion, the rate of neutrophil apoptosis is accelerated in patients with neutropenic hepatosplenic schistosomiasisis. These findings suggest that the enhanced neutrophil apoptosis that occurs in neutropenic HS patients is triggered by a serum factor, which is mostly a Fas ligand.     

Low Fcgamma receptor III and high granulocyte colony-stimulating factor serum levels correlate with the risk of infection in neutropenia due to Felty's syndrome or systemic lupus erythematosus

PURPOSE: To determine whether serum levels of soluble Fcgamma receptor III and granulocyte colony-stimulating factor (G-CSF) are associated with the risk of infection in patients with neutropenia due to Felty's syndrome or systemic lupus erythematosus. SUBJECTS AND METHODS: Serum levels of G-CSF and soluble Fcgamma receptor III were measured by enzyme-linked immunosorbent assays in 13 patients with neutropenia due to Felty's syndrome, 10 patients with neutropenia due to systemic lupus erythematosus, and 41 controls with normal leukocyte counts (25 with systemic lupus erythematosus, 16 with rheumatoid arthritis). We calculated the area under the receiver operating characteristic (ROC) curves for the absolute neutrophil count, soluble Fcgamma receptor III levels, and G-CSF levels. RESULTS: Nine of the neutropenic patients (7 with Felty's syndrome, 2 with lupus) had one or more infections within 3 months before and after blood samples were obtained. Absolute neutrophil counts were similar in neutropenic patients who did or did not have infections. However, the median level of soluble Fcgamma receptor III (63 vs. 126 arbitrary units, P = 0.005) was significantly lower among patients who developed infections, whereas the median level of G-CSF (90.9 vs. 53.3 pg/mL, P = 0.04) was significantly higher compared with patients without infections. The area under the ROC curve was 0.58 (P = 0.49) for the absolute neutrophil count, 0.84 (P = 0.007) for soluble Fcgamma receptor III levels, and 0.73 (P = 0.03) for G-CSF levels. CONCLUSION: In patients with chronic neutropenia due to rheumatic diseases, low soluble Fcgamma receptor III levels and elevated G-CSF levels are better indicators of the risk of infection than is the neutrophil count.     

Enhanced Neutrophil Apoptosis in Neutropenic Patients with Hepatosplenic Schistosomiasis: Evidence of Serum Fas Ligand

Enhanced neutrophil apoptosis has been reported in neutropenic hepatosplenic schistosomiasis. The shortening of neutrophil survival via apoptosis may explain the neutropenia that occur in these patients. However, the regulation of neutrophil apoptosis in hepatosplenic schistosomiasis has not been clearly defined. Neutrophils harvested from neutropenic patients with hepatosplenic (HS) schistosomiasis, (n=25), non-neutropenic patients with hepatointestinal (HI) schistosomiasis (n=10), and age-/gender-matched healthy control subjects (n=10) were incubated with autologous serum. Neutrophils apoptosis was quantified by flow cytometry through determination of propidium iodide nuclear staining and confirmed by DNA gel electrophoresis at 0 (i.e. fresh neutrophils), 4 and 24 h culture. Neutrophils from healthy subjects were also incubated with either 10% heterologous normal or neutropenic serum, with and without anti-Fas ligand antibody. Fas expression was assessed in fresh neutrophils using flow cytometry. Compared with normal healthy neutrophils, and HI neutrophils, neutropenic neutrophils demonstrated greater apoptosis in the presence of autologous serum (P<0.01, 0.05, respectively). Furthermore, compared with normal neutrophils exposed to heterologous normal serum, those exposed to heterologous neutropenic serum exhibited higher apoptosis rates ( P<0.01). Moreover, anti-Fas L antibody attenuated the neutropenic serum-induced neutrophil apoptosis in normal neutrophils. Fas expression was significantly higher in the neutropenic group when compared to both HI and normal healthy controls (P<0.05). In addition, Fas expression by neutrophils was paralleled by high neutrophil apoptosis. On the other hand, neutrophil apoptosis was not correlated to the size of spleen in neutropenic group.

In conclusion, the rate of neutrophil apoptosis is accelerated in patients with neutropenic hepatosplenic schistosomiasisis. These findings suggest that the enhanced neutrophil apoptosis that occurs in neutropenic HS patients is triggered by a serum factor, which is mostly a Fas ligand.     

A noninvasive oral rinse assay to monitor engraftment, neutrophil tissue delivery and susceptibility to infection following HSCT in pediatric patients

The time interval between neutrophil tissue delivery and blood confirmed engraftment following hematopoietic stem cell transplantation (HSCT) may serve as an indicator of patient susceptibility to infection. Using an oral rinse protocol, we studied neutrophil tissue delivery kinetics and its relationship to clinical parameters post-HSCT in 29 pediatric patients. Oral neutrophil counts were compared to circulating neutrophil levels, oral mucositis scores and infection-related febrile episodes after engraftment. Blood engraftment (BE) is currently defined by a blood neutrophil count of > or =0.5 x 10(9)/l. We defined oral engraftment (OE) as the day neutrophils returned in the mouth post-HSCT (> or =0.25 x 10(4)/ml oral neutrophils in the rinse sample). We found that neutrophils reappeared 6.3+/-3.9 s.d. days earlier in the mouth than in the circulation enabling us to identify successful engraftment almost 1 week sooner than using blood count values alone. Furthermore, the time-span between OE and BE was inversely related to the number of infection-related febrile episodes post-BE. We conclude that monitoring the timing of neutrophil tissue delivery through a rapid oral rinse may yield important insights into the biology of neutrophil recovery during and after engraftment and the factors associated with neutrophil tissue recruitment.     

Skin Window Studies of the Acute Inflammatory Responses of Neutropenic Patients

The acute inflammatory responses ofthree cyclic neutropenic and 15 chronicneutropenic patients were studied withthe Rebuck skin window technique.The neutrophil responses at 3 and 5 hrafter initiation of the inflammation wereroughly proportional to the blood neutrophil counts. Cyclic neutropenics intheir neutropenic phase and severechronic neutropenics both showed normal mononuclear cell responses. Theseobservations indicate that neutrophilaccumulation at an inflammatory site isnot necessary to initiate the mononuclearcell response as previously postulated.It is further suggested that in these patients with decreased neutrophils butnormal monocyte counts the monocytesplay a vital role in preventing seriousinfections.

Submitted on March 22, 1971 Accepted on April 5, 1971     

Neutrophil marrow cellularity in neutropenia

In order to identify individuals in whom marrow abnormalities might be contributing to or responsible for neutropenia, we quantitatively examined the number and distribution of cells comprising neutrophil marrow in patients with blood neutrophils less than 2,000/μl. Neutrophil marrow cellularity was determined from ferrokinetic estimation of normoblast numbers and neutrophil-normoblast ratios obtained from marrow biopsy sections. Only two of 30 patients exhibited the change in cellularity expected of a normal marrow responding to removal of circulating neutrophils: reduced numbers of segmented cells, an expanded mitotic pool, and a normal ratio of metamyelocytes and band forms to promyelocytes and myelocytes. Twenty-three patients had basal mitotic pool size or increased numbers of segmented marrow cells despite neutropenia, a hypoplastic mitotic pool, or a reduction in the number of metas and bands relative to promyelocytes and myelocytes. The results in individual patients were consistent with hypoplasia, subnormal proliferative or release responses, loss of cells during ontogeny, or combinations thereof. In five cases the results could not be so classified. Clinical observations seldom predicted marrow cellularity. Diverse disorders of marrow function appear to be common among neutropenic patients. Neutropenia constitutes a rich field for study of neutrophil marrow physiology.     

Colony-stimulating factor in patients with chronic neutropenia.

Urinary and serum colony-stimulating factor (CSF) levels were measured in 11 patients with chronic idiopathic neutropenia without infections and in 10 normal individuals. Urinary CSF output was determined using mouse marrow target cells, and serum CSF activity was assayed with human marrow target cells by the double agar layer technique. Using these methods, there was no significant difference between CSF levels of neutropenic and normal subjects. These data indicate that CSF levels are not inversely related to the blood neutrophil count in chronic idiopathic neutropenia and suggest that CSF is not a hormone regulating the blood neutrophil count in a manner analogous to the erythropoietin regulation of circulating erythrocyte levels.     

Lithium therapy of children with chronic neutropenia

We treated five children with chronic neutropenia using lithium carbonate and studied the effect in vivo on granulopoiesis. Granulocyte precursors (CFU-C) from blood and marrow, and colonystimulating activity (CSA) from peripheral blood leukocytes, were assayed in a methylcellulose tissue culture system. Three patterns of response to lithium were seen. In patients with aplastic anemia (one acquired and two Fanconi's aplastic anemia) despite increased colony-stimulating activity, CFU-C numbers remained very low and the neutropenia persisted. In a patient with Kostmann neutropenia colony-stimulating activity, and blood and marrow CFU-C numbers increased, but the agranulocytosis was unchanged. An impressive therapeutic effect was seen in one patient with idiopathic neutropenia with low colony-stimulating activity who responded to lithium with an increase in colony-stimulating activity and CFU-C resulting in persisting normal neutrophil counts. Lithium appears useful in treating a select group of neutropenic patients in whom colonystimulating activity production is responsive to lithium, and the granulocytic progenitor compartment is capable of producing mature neutrophils.     

Differential cell count and lymphocyte subsets in bronchoalveolar lavage during pneumonia with and without peripheral neutropenia

One hundred immunocompromised HIV negative patients with microbiologically positive pneumonia underwent bronchoalveolar lavage (BAL) studies. Thirty cases showed peripheral neutropenia (<1000 neutrophils/L), 70 did not. The total cell number in BAL, the differential cell counts, and the lymphocyte subsets (CD4, CD8, CD19, CD57) were measured. Patients with pneumonia and normal or elevated peripheral neutrophils had a significantly increased total number of cells in BAL compared to patients with peripheral neutropenia (3,2 ± 2 vs 1,3 ± 0,6 × 105 cells/ml lavage fluid, p < 0.01). Ninety percent of the BAL differential cell counts obtained in patients exceeding 1000 neutrophils/L showed a lymphocytic and/or neutrophilic alveolitis, whereas only 54% of patients with peripheral neutropenia displayed abnormal counts (p < 0.01). Yet the typical pattern of neutrophilic alveolitis was found more often for peripheral neutrophil counts over 1000/L with high significance (p < 0.0001). Abnormal BAL cell patterns for neutropenic patients uniformly showed a lymphocytic alveolitis, only 10% additionally conformed with the pattern of neutrophilic alveolitis. Patients with pneumonia with and without peripheral neutropenia had similar findings in BAL lymphocyte subsets and exhibited a reduced CD4/CD8 ratio compared to controls (p < 0.05). The high susceptibility of severe neutropenic patients to pulmonary, especially fungal infections may be explained by the local lack of neutrophils.

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Contrasting effects of recombinant human granulocyte-macrophage colony- stimulating factor (CSF) and granulocyte CSF treatment on the cycling of blood elements in childhood-onset cyclic neutropenia

Recombinant human granulocyte colony-stimulating factor (G-CSF) treatment has been shown to increase average neutrophil counts substantially in patients with childhood-onset cyclic neutropenia (or "cyclic hematopoiesis"), but not to eliminate the cyclic oscillations of neutrophil counts or those of other blood elements (monocytes, platelets, eosinophils, and reticulocytes) that are characteristic of this hematopoietic disorder. Indeed, oscillations of neutrophil counts are amplified during G-CSF treatment. We have compared the effects of recombinant granulocyte-macrophage-CSF (GM-CSF) with those of G-CSF in three patients with this disease (2 men and 1 woman, 17, 30, and 32 years of age). These patients were treated with GM-CSF (2.1 micrograms/kg/day, subcutaneously) for 6 weeks, preceded and followed by 6 to 13 weeks of detailed observation to document changes in the cyclic oscillations of blood neutrophils and other blood elements; two of the patients were subsequently treated with G-CSF (5.0 micrograms/kg/d, subcutaneously) and observed for comparable periods of time. Unlike G-CSF treatment, which increased average neutrophil counts more than 20-fold, GM-CSF increased neutrophil counts only modestly, from 1.6- to 3.9-fold, although eosinophilia of varying prominence was induced in each patient. However, at the same time, GM-CSF treatment dampened or eliminated the multilineage oscillations of circulating blood elements (neutrophils, monocytes, platelets, and/or reticulocytes) in each of the patients. In contrast, G-CSF treatment of the same patients markedly amplified the oscillations of neutrophil counts and caused the cycling of other blood elements (monocytes in particular) to become more distinct. These findings support the conclusion that the distinctive cycling of blood cell production in childhood-onset cyclic neutropenia results from abnormalities in the coordinate regulation of both GM-CSF-responsive, multipotential progenitor cells and G-CSF-responsive, lineage-restricted, neutrophil progenitors.