VOXSang. 36: 9-12 (1979)
Chronic Autoimmune Neutropenia Due to Anti-NA1 Antibody M . Valbonesi, A . Campelli, M . G.Maram., F. Cottafava and C . Jannuzzi Blood Transfusion Center; II Clinica Malattie Infettive dell’Universit8, and I Clinica Pediatrica dell’Universid, Istituto G. Gaslini, Genova
Abstract. A 12-month-old child neutropenic since the age of 8 months, was referred to our institute for a sepsis from Candida albicans.On exploring the cause of neutropenia, an anti-NA, antibody could be detected in the patient’s serum. This antibody seemed to be responsible for the neutropenia because the child’s PMN type was NA,+. The reactivity of the autoantibody with the patient’s own granulocytes was confirmed by direct and indirect immunofluorescence studies performed on blood and marrow cells. A reduced number of T lymphocytes with poor PHA responsivity has been interpreted as the possible cause of the autoimmune disease. Steroid therapy did not cure the neutropenia but the child’s generalconditionimproved. In earlier studies, chronic autoimmune neutropenia had been suggested to be a separate clinical entity, but since simple, sensitive and reliable techniques for detecting the presence of granulocytic autoantibodies were lacking, autoimmune neutropenia could not be proven. Lalezari et al. [5] and Boxer et al. [l] appear to have been the first to report well-documented examples of isolated chronic autoimmune neutropenia. Since 1974, however, further cases have been observed and documented [2,3,7,11,151, so that the disease seems to be more common than it was generally thought. In this paper, we report a new case of chronic autoimmune neutropenia due to anti-NA, autoantibodies, observed in a child With hepatosplenomegaly,
lymphadenopathy, hypergammaglobulinemia and reduced number of T lymphocytes.
Case History C. M.,a 1-year-old girl was well until she was 7 months old: at that age she became chronically
ill with intermittent fever, otitis, bronchopneumonia and pyoderma. She was found to be neutropenic (absolute neutrophil count: 24O/mmS) and was thus referred to our Department of Infectious Diseases. On admission, physical examination showed a girl too small for her age with pyoderma of the face and vulva, anemia, hepatosplenomegaly and mild generalized lymphadenopathy. The laboratory data were: red blood cells (RBC) 4.5 1061 cmb; hemoglobin (Hb) 8 g/lOOml; white blood cells
-
10
Valbonesi/Campelli/Marazzi/Cottafava/Jannuzzi
(WBC) 1.2 . 10Vl with a differential count: segmented neutrophilis (N) 1%, eosinophils (E) 2%, basophils (B) 1%, lymphocytes Q 89%, monocytes (M) 7%. Platelet and reticulocyte count, blood urea nitrogen, transaminases, fibrinogen, Hb electrophoresis, leukocyte alcaline phosphatase were in the normal range (NR). A test for antinuclear antibodies and a lupus erytematodes cell test were negative as was the Waaler-Rose test. Chromosomal examination was normal. Serum immunoglobulins were: IgG 2,655 mg%; IgA 184 mg%; IgM 366mg%; at the last control, the values were: IgG 2,166mg%; IgA 108mg%; IgM 261 mg% (normal values, NV, for immunoglobulins, for the age of the patient, are: IgG 661 +219 mg%; IgA 3 7 f 1 8 m g % ; IgM 54+23 mg%). On admission, lactate dehydrogenase was: 601 mU/ml (NV: 102-306mU/ml); at the last control: 268 mU/ml. The serum complement levels were: C3 88 mg%; C4 41 mg%. Subsequent values were: C3 84mg%; C4 16mg%. Present values are: C3 124mg%; C 4 = 7 4 mg % (NV in all cases were: C3 105-148 mg%; C4 39-65 mg%). Evaluation of T lymphocytes in peripheral blood, performed by E rosette test, resulted in decreased values: 33.75% (NV in the same agegroup: 68 f 12%). Evaluation of B lymphocytes, by the surface immunofluorescence (IF) technique with anti-Ig was: Ig total 35%; IgD 10%; IgM 17%; IgG 14% (NV = Ig total 22f7.5%). The lymphocyte blastogenesis following stimulation with phytohemagglutinin (PHA) 0.01 ml/ml 0.5 x 106 L gave the result of 47.583 cpm; the NR, established testing a population of normal controls of the same age as the examinated patient, was: 200,000 50,000 cpm. The bone marrow showed a maturation arrest of the granulocyte compartment at the myelocyte level. The differential count was: myeloblasts 0.4%; promyelocytes 5%; myelocytes: N 24.2%, E 0.4%, B 0%; metamyelocytes 10.8%; granulocytes (PMN): N 1.6%, E 0.2%, B 0%; lymphocytes 36.2% ; monocytes 0.3% ; reticulocytes 0.2%; megakariocytes 0.2%; erytroid series 19.9%, and plasrnocytes 0.5 % . The patient’s blood group was A Rh (D) + ; direct and indirect Coombs tests were negative. Preliminary studies showed that in the patient’s serum antigranulocytic antibodies were present, as revealed by the anti-IgG consumption test
.
+
[13; the consumption was 5 times that of the normal controls] and by the agglutination test [4,16], as confirmed by Lalezari [8]. The titer of leukoagglutinins was ‘14; but 2 months later, during prednisone therapy, leukoagglutinins became undetectable while no variation in the antiglobulin consumption test could be observed. At that moment, the presence of IgG antigranulocytic antibodies in the patient’s serum, on granulocytes and on bone marrow granulocytic line could be demonstrated by a newly developed fluorescence technique [14]. By the direct IF test, the staining of the cells of the granulocytic line, from myelocytes to granulocytes, was evident in the patient while bone marrow cells from 5 patients not affected by autoimmune neutropenia were not reactive. By the indirect IF test, bone marrow cells from 4 NA,+ individuals gave the same positive result using the patients serum: in the same experiment NA,- bone marrow cells were not reactive. Furthermore, all controls confirmed the specificity of the reaction. The girl’s serum was tested by Dr. Verheugt on normal granulocytes: by the indirect IF test, granulocytespecific IgG antibodies could be detected only on granulocytes of 14/14 NA,+ donors while the serum was not reactive on 9 NA,-samples; so it could be concluded that the serum contained anti-NA, antibodies. Patient’s granulocyte typing was performed by leukoagglutination and confirmed by the indirect IF test. The results were: NA,+, NA,+, NB,+, NC,+, 9a-. Moreover, the reaction between the patient’s granulocytes and serum was positive as well as direct fluorescence on the patient’s cells. The leukoagglutinin found on admission in the patient’s serum was anti-NA,-specific: it agglutinated 616 NA,+ donors, sera and it did not react with 616 NA,- samples. NA,+ and NA,- samples were obtained using a monospecific anti-NA, serum we got from Dr. Verheugt. Prednisone therapy (during 60 days at a dose of 2mg/kg/day, then for 45 days at a dose of 1 mg/kg/day, finally on alternate days) failed to produce a significant rise in the PMN count. (fig. 1). Nevertheless, prednisone therapy caused general improvement, hepatosplenomegaly reduction, the normalization of erythrocyte count and the disappearance of leukoagglutinins.
Autoimmune Neutropcnia Due to Anti-Na,
During hospitalization, the child presented the following infections: on admission, a sepsis from which she recovered with clotrimazole therapy (C. albicans was isolated from blood), a gastroenteritis (Salmonella Wien) and two episodes of bronchitis. All the infections were not very serious from the clinical point of view. Since then the child was well but PMN count remained low (medium values: 800-1,000/mms). Prednisone therapy was gradually discontinued and the patient was discharged 9 months after hospitalization. In the following 2 months, the patient suffered from a mild Escherichia coli 078-K 80 enteritis; at last, an important pharingitis led to the latest hospitalization. On admission, the laboratory data were: WBC 6,000/mma with N 6%, E 2%, B 0%, L 91%, M 1%; IgG 1,45Omg%; IgM 295mg%; IgA 120mg%; IgD undetectable. The data concerning the immune state were: B cells 18% (NV: 22.5 +7.1%). E-rosette-forming cells 50% (NV: 65 f 10%).The PHA- and Con-A-induced lymphocyte blastogenesis gave, respectively, the results of 24.996 and 47.719cpm; the normal values of lymphocyte blastogenesis following stimulation with PHA and Con A were, respectively, 200,000+ 50,OOO and 165,000+35,000cpm. These ranges were obtained testing a population of normal controls of the same age as the patient. A MLC gave normal result: patient + normal-myt. 12,500 cpm; patient-myt. + normal 15,000 cpm. Antinuclear and antiperinuclear factors were undetectable. Pharyngitis has been successfully treated with gentamycin (40mg/day) and the patient was discharged still neutropenic. 4 months later, WBC. count spontaneously rose to values of 800 with 18-20% of PMN. Since then, the patient is free from illness and PMN values are unmodified.
11
Discussion Presently, there is evidence for an immunological mechanism in neonatal alloimmune neutropenia and in posttransfusion reactions due to specific alloimmunization. Although an autoimmune mechanism concerning PMN pathology has been suspected for many years, laboratory data supplied documentary evidence only in few cases. In our 2-year-old NA,+ patient, the demonstration of anti-NA, antibodies reactive with her own bone marrow and peripheral cells of the granulocytic line, in the presence of a maturation arrest at myelocyte level, seems to recognize only an autoimmunemechanism. The presence of hepatosplenomegaly, lymphadenopathy and hypergammaglobulinemia with a decreased number of T lymphocytes supports this hypothesis. The therapy of chronic autoimmune neutropenia is usually based on steroids, splenectomy and immunosuppressive agents. In view of the patient’s young age, splenectomy has not been considered and immunosuppressive agents have been excluded to avoid a possible enhancement of the suspected unbalanced B-T lymphocyte relation. According to Lulezuri’s experience, we tried steroid therapy which is known to induce a decreased synthesis of marrow IgG and of macrophagic IgG recep-
Valbonesi/Campelli/Marazzi/Cottafava/Jannuzzi
12
tors [lo, 121. In our case, steroids had no effect on neutropenia but improved the child’s general condition. PMN transfusions have not been necessary; antibiotics permitted to overwhelm infections.
Acknowledgements We are indebted to Prof. P . Lalezari for confirming the presence of leukoagglutinins in the patient’s serum, to Dr. F. Verheugt for performing PMN typing and confirming the presence of autoantibodies anti-PMN, to Prof. L. Massimo and Prof. G . Sansone for B and T lymphocyte evaluations.
References Boxer, L. A.; Stossel, T. P.; Grenberg, M. S., and Moses, J. L.: Idiopathic autoimmune neutropenia. Blood 44: 941 (1974). Boxer, L. A.; Greenberg, M.S.; Boxer, G. J., and Stossel, T. P.: Autoimmune neutropenia. New Engl. J. Med. 293: 748 (1975). Kay, W. M.; White, A. G.; Barclay, G. R.; Darg, C.; Raeburn, J. A.; Uttley, J. S.;McCrae, W. M., and Innes, I.M.: Leucocyte function in a case of chronic benign neutropenia of infancy associated with circulating leucoagglutinins. Br. J. Haemat. 32: 451 (1976). Lalezari, P., and Bernard, G.: Improved leukocyte antibody detection with prolonged incubation. Vox Sang. 9: 664 (1974). Lalezari, P.; Jiang, A. P.; Yegen, L., and Santorineou, M.:Chronic autoimmune neutropenia associated with anti-NA, antibody. Blood 44: 940 (1974). Lalezari, P. and Radel, E.: Neutrophil-specific antigens: immunology and clinical significance. Semin. Hematol. 11: 281 (1974).
7 Lalezari, P.; Jiang, A.; Yegen, L., and Santorineou, M.: Chronic autoimmune neutropenia due to anti-NA, antibody. New Engl. I. Med. 293: 744 (1975). 8 Lalezari, P.:Personal communication (1976). 9 Editorial: Immune neutropenia. Lancet ii: 24 (1976). 10 McMillan, R.; Longmire, R. L., and Yelenosky, R. J.: The effect of corticosteroids on human IgG synthesis. Blood 44: 941 (1974). 11 Nepo, A.; Gunay, U.;Boxer, L. A., and Honig G. R.: Autoimmune neutropenia in an infant. J. Pediat. 87: 251 (1975). 12 Schreiber, A.D. and Cooper, R.A.: Effect of corticosteroids on the human monocyte IgG receptors. Blood 44: 941 (1974). 13 Stefen, C.:in Methods of immunohaematologic research. Biblthca haemat., no. 14, p. 83 (Karger, Base1 1963). 14 Verheugt, F.W.A.; Borne, A.E.G. Kr. von dem; Decary, F., and Engelfriet, C.P.: Detection of granulocyte allo-antibodies by an indirect immunofluorescence test. Br. J. Haemat. 36: 533 (1977). 15 Verheugt, F. W. A.; Borne, A. E. G. Kr. von dem; Noord-Bokhorst, J. C. van, and Engelfriet, C. P.: Auto-immune granulocytopenia: the detection of granulocyte auto-antibodies with the immunofluorescence test (submitted for publication). 16 Zmijewski, C.M.; Pierre, R.L. St.; Fletcher, J. L.; Wilson, S. F.; Cannady, W., and Zmijewski, H. E.: A comparison of two leukoagglutination tests. Histocompatibility testing 1967, p. 389 (Munksgaard, Copenhagen 1967).
Received: January 20, 1978 Accepted: May 12,1978 Dr. M. Valbonesi, Primario del Servizio di ImmunoBmatologia e Trasfusionale dell’ospedale di Saronno, 1-21047Saronno-Varese (Italy)
Chronic Autoimmune Neutropenia Due to Anti-NA1 Antibody M . Valbonesi, A . Campelli, M . G.Maram., F. Cottafava and C . Jannuzzi Blood Transfusion Center; II Clinica Malattie Infettive dell’Universit8, and I Clinica Pediatrica dell’Universid, Istituto G. Gaslini, Genova
Abstract. A 12-month-old child neutropenic since the age of 8 months, was referred to our institute for a sepsis from Candida albicans.On exploring the cause of neutropenia, an anti-NA, antibody could be detected in the patient’s serum. This antibody seemed to be responsible for the neutropenia because the child’s PMN type was NA,+. The reactivity of the autoantibody with the patient’s own granulocytes was confirmed by direct and indirect immunofluorescence studies performed on blood and marrow cells. A reduced number of T lymphocytes with poor PHA responsivity has been interpreted as the possible cause of the autoimmune disease. Steroid therapy did not cure the neutropenia but the child’s generalconditionimproved. In earlier studies, chronic autoimmune neutropenia had been suggested to be a separate clinical entity, but since simple, sensitive and reliable techniques for detecting the presence of granulocytic autoantibodies were lacking, autoimmune neutropenia could not be proven. Lalezari et al. [5] and Boxer et al. [l] appear to have been the first to report well-documented examples of isolated chronic autoimmune neutropenia. Since 1974, however, further cases have been observed and documented [2,3,7,11,151, so that the disease seems to be more common than it was generally thought. In this paper, we report a new case of chronic autoimmune neutropenia due to anti-NA, autoantibodies, observed in a child With hepatosplenomegaly,
lymphadenopathy, hypergammaglobulinemia and reduced number of T lymphocytes.
Case History C. M.,a 1-year-old girl was well until she was 7 months old: at that age she became chronically
ill with intermittent fever, otitis, bronchopneumonia and pyoderma. She was found to be neutropenic (absolute neutrophil count: 24O/mmS) and was thus referred to our Department of Infectious Diseases. On admission, physical examination showed a girl too small for her age with pyoderma of the face and vulva, anemia, hepatosplenomegaly and mild generalized lymphadenopathy. The laboratory data were: red blood cells (RBC) 4.5 1061 cmb; hemoglobin (Hb) 8 g/lOOml; white blood cells
-
10
Valbonesi/Campelli/Marazzi/Cottafava/Jannuzzi
(WBC) 1.2 . 10Vl with a differential count: segmented neutrophilis (N) 1%, eosinophils (E) 2%, basophils (B) 1%, lymphocytes Q 89%, monocytes (M) 7%. Platelet and reticulocyte count, blood urea nitrogen, transaminases, fibrinogen, Hb electrophoresis, leukocyte alcaline phosphatase were in the normal range (NR). A test for antinuclear antibodies and a lupus erytematodes cell test were negative as was the Waaler-Rose test. Chromosomal examination was normal. Serum immunoglobulins were: IgG 2,655 mg%; IgA 184 mg%; IgM 366mg%; at the last control, the values were: IgG 2,166mg%; IgA 108mg%; IgM 261 mg% (normal values, NV, for immunoglobulins, for the age of the patient, are: IgG 661 +219 mg%; IgA 3 7 f 1 8 m g % ; IgM 54+23 mg%). On admission, lactate dehydrogenase was: 601 mU/ml (NV: 102-306mU/ml); at the last control: 268 mU/ml. The serum complement levels were: C3 88 mg%; C4 41 mg%. Subsequent values were: C3 84mg%; C4 16mg%. Present values are: C3 124mg%; C 4 = 7 4 mg % (NV in all cases were: C3 105-148 mg%; C4 39-65 mg%). Evaluation of T lymphocytes in peripheral blood, performed by E rosette test, resulted in decreased values: 33.75% (NV in the same agegroup: 68 f 12%). Evaluation of B lymphocytes, by the surface immunofluorescence (IF) technique with anti-Ig was: Ig total 35%; IgD 10%; IgM 17%; IgG 14% (NV = Ig total 22f7.5%). The lymphocyte blastogenesis following stimulation with phytohemagglutinin (PHA) 0.01 ml/ml 0.5 x 106 L gave the result of 47.583 cpm; the NR, established testing a population of normal controls of the same age as the examinated patient, was: 200,000 50,000 cpm. The bone marrow showed a maturation arrest of the granulocyte compartment at the myelocyte level. The differential count was: myeloblasts 0.4%; promyelocytes 5%; myelocytes: N 24.2%, E 0.4%, B 0%; metamyelocytes 10.8%; granulocytes (PMN): N 1.6%, E 0.2%, B 0%; lymphocytes 36.2% ; monocytes 0.3% ; reticulocytes 0.2%; megakariocytes 0.2%; erytroid series 19.9%, and plasrnocytes 0.5 % . The patient’s blood group was A Rh (D) + ; direct and indirect Coombs tests were negative. Preliminary studies showed that in the patient’s serum antigranulocytic antibodies were present, as revealed by the anti-IgG consumption test
.
+
[13; the consumption was 5 times that of the normal controls] and by the agglutination test [4,16], as confirmed by Lalezari [8]. The titer of leukoagglutinins was ‘14; but 2 months later, during prednisone therapy, leukoagglutinins became undetectable while no variation in the antiglobulin consumption test could be observed. At that moment, the presence of IgG antigranulocytic antibodies in the patient’s serum, on granulocytes and on bone marrow granulocytic line could be demonstrated by a newly developed fluorescence technique [14]. By the direct IF test, the staining of the cells of the granulocytic line, from myelocytes to granulocytes, was evident in the patient while bone marrow cells from 5 patients not affected by autoimmune neutropenia were not reactive. By the indirect IF test, bone marrow cells from 4 NA,+ individuals gave the same positive result using the patients serum: in the same experiment NA,- bone marrow cells were not reactive. Furthermore, all controls confirmed the specificity of the reaction. The girl’s serum was tested by Dr. Verheugt on normal granulocytes: by the indirect IF test, granulocytespecific IgG antibodies could be detected only on granulocytes of 14/14 NA,+ donors while the serum was not reactive on 9 NA,-samples; so it could be concluded that the serum contained anti-NA, antibodies. Patient’s granulocyte typing was performed by leukoagglutination and confirmed by the indirect IF test. The results were: NA,+, NA,+, NB,+, NC,+, 9a-. Moreover, the reaction between the patient’s granulocytes and serum was positive as well as direct fluorescence on the patient’s cells. The leukoagglutinin found on admission in the patient’s serum was anti-NA,-specific: it agglutinated 616 NA,+ donors, sera and it did not react with 616 NA,- samples. NA,+ and NA,- samples were obtained using a monospecific anti-NA, serum we got from Dr. Verheugt. Prednisone therapy (during 60 days at a dose of 2mg/kg/day, then for 45 days at a dose of 1 mg/kg/day, finally on alternate days) failed to produce a significant rise in the PMN count. (fig. 1). Nevertheless, prednisone therapy caused general improvement, hepatosplenomegaly reduction, the normalization of erythrocyte count and the disappearance of leukoagglutinins.
Autoimmune Neutropcnia Due to Anti-Na,
During hospitalization, the child presented the following infections: on admission, a sepsis from which she recovered with clotrimazole therapy (C. albicans was isolated from blood), a gastroenteritis (Salmonella Wien) and two episodes of bronchitis. All the infections were not very serious from the clinical point of view. Since then the child was well but PMN count remained low (medium values: 800-1,000/mms). Prednisone therapy was gradually discontinued and the patient was discharged 9 months after hospitalization. In the following 2 months, the patient suffered from a mild Escherichia coli 078-K 80 enteritis; at last, an important pharingitis led to the latest hospitalization. On admission, the laboratory data were: WBC 6,000/mma with N 6%, E 2%, B 0%, L 91%, M 1%; IgG 1,45Omg%; IgM 295mg%; IgA 120mg%; IgD undetectable. The data concerning the immune state were: B cells 18% (NV: 22.5 +7.1%). E-rosette-forming cells 50% (NV: 65 f 10%).The PHA- and Con-A-induced lymphocyte blastogenesis gave, respectively, the results of 24.996 and 47.719cpm; the normal values of lymphocyte blastogenesis following stimulation with PHA and Con A were, respectively, 200,000+ 50,OOO and 165,000+35,000cpm. These ranges were obtained testing a population of normal controls of the same age as the patient. A MLC gave normal result: patient + normal-myt. 12,500 cpm; patient-myt. + normal 15,000 cpm. Antinuclear and antiperinuclear factors were undetectable. Pharyngitis has been successfully treated with gentamycin (40mg/day) and the patient was discharged still neutropenic. 4 months later, WBC. count spontaneously rose to values of 800 with 18-20% of PMN. Since then, the patient is free from illness and PMN values are unmodified.
11
Discussion Presently, there is evidence for an immunological mechanism in neonatal alloimmune neutropenia and in posttransfusion reactions due to specific alloimmunization. Although an autoimmune mechanism concerning PMN pathology has been suspected for many years, laboratory data supplied documentary evidence only in few cases. In our 2-year-old NA,+ patient, the demonstration of anti-NA, antibodies reactive with her own bone marrow and peripheral cells of the granulocytic line, in the presence of a maturation arrest at myelocyte level, seems to recognize only an autoimmunemechanism. The presence of hepatosplenomegaly, lymphadenopathy and hypergammaglobulinemia with a decreased number of T lymphocytes supports this hypothesis. The therapy of chronic autoimmune neutropenia is usually based on steroids, splenectomy and immunosuppressive agents. In view of the patient’s young age, splenectomy has not been considered and immunosuppressive agents have been excluded to avoid a possible enhancement of the suspected unbalanced B-T lymphocyte relation. According to Lulezuri’s experience, we tried steroid therapy which is known to induce a decreased synthesis of marrow IgG and of macrophagic IgG recep-
Valbonesi/Campelli/Marazzi/Cottafava/Jannuzzi
12
tors [lo, 121. In our case, steroids had no effect on neutropenia but improved the child’s general condition. PMN transfusions have not been necessary; antibiotics permitted to overwhelm infections.
Acknowledgements We are indebted to Prof. P . Lalezari for confirming the presence of leukoagglutinins in the patient’s serum, to Dr. F. Verheugt for performing PMN typing and confirming the presence of autoantibodies anti-PMN, to Prof. L. Massimo and Prof. G . Sansone for B and T lymphocyte evaluations.
References Boxer, L. A.; Stossel, T. P.; Grenberg, M. S., and Moses, J. L.: Idiopathic autoimmune neutropenia. Blood 44: 941 (1974). Boxer, L. A.; Greenberg, M.S.; Boxer, G. J., and Stossel, T. P.: Autoimmune neutropenia. New Engl. J. Med. 293: 748 (1975). Kay, W. M.; White, A. G.; Barclay, G. R.; Darg, C.; Raeburn, J. A.; Uttley, J. S.;McCrae, W. M., and Innes, I.M.: Leucocyte function in a case of chronic benign neutropenia of infancy associated with circulating leucoagglutinins. Br. J. Haemat. 32: 451 (1976). Lalezari, P., and Bernard, G.: Improved leukocyte antibody detection with prolonged incubation. Vox Sang. 9: 664 (1974). Lalezari, P.; Jiang, A. P.; Yegen, L., and Santorineou, M.:Chronic autoimmune neutropenia associated with anti-NA, antibody. Blood 44: 940 (1974). Lalezari, P. and Radel, E.: Neutrophil-specific antigens: immunology and clinical significance. Semin. Hematol. 11: 281 (1974).
7 Lalezari, P.; Jiang, A.; Yegen, L., and Santorineou, M.: Chronic autoimmune neutropenia due to anti-NA, antibody. New Engl. I. Med. 293: 744 (1975). 8 Lalezari, P.:Personal communication (1976). 9 Editorial: Immune neutropenia. Lancet ii: 24 (1976). 10 McMillan, R.; Longmire, R. L., and Yelenosky, R. J.: The effect of corticosteroids on human IgG synthesis. Blood 44: 941 (1974). 11 Nepo, A.; Gunay, U.;Boxer, L. A., and Honig G. R.: Autoimmune neutropenia in an infant. J. Pediat. 87: 251 (1975). 12 Schreiber, A.D. and Cooper, R.A.: Effect of corticosteroids on the human monocyte IgG receptors. Blood 44: 941 (1974). 13 Stefen, C.:in Methods of immunohaematologic research. Biblthca haemat., no. 14, p. 83 (Karger, Base1 1963). 14 Verheugt, F.W.A.; Borne, A.E.G. Kr. von dem; Decary, F., and Engelfriet, C.P.: Detection of granulocyte allo-antibodies by an indirect immunofluorescence test. Br. J. Haemat. 36: 533 (1977). 15 Verheugt, F. W. A.; Borne, A. E. G. Kr. von dem; Noord-Bokhorst, J. C. van, and Engelfriet, C. P.: Auto-immune granulocytopenia: the detection of granulocyte auto-antibodies with the immunofluorescence test (submitted for publication). 16 Zmijewski, C.M.; Pierre, R.L. St.; Fletcher, J. L.; Wilson, S. F.; Cannady, W., and Zmijewski, H. E.: A comparison of two leukoagglutination tests. Histocompatibility testing 1967, p. 389 (Munksgaard, Copenhagen 1967).
Received: January 20, 1978 Accepted: May 12,1978 Dr. M. Valbonesi, Primario del Servizio di ImmunoBmatologia e Trasfusionale dell’ospedale di Saronno, 1-21047Saronno-Varese (Italy)
