5. Neutrophil
• Circulate as spherical cells about 12-15 μm in
diameter
• Nucleus of a neutrophil is segmented
Abbas AK, Lichtman AH, Pillai Shiv. Cellular and molecular immunology. 8th ed.Philadelphia, W.B. Saunders
Company.2015.
6. Neutrophil
• Granule ( large lysosome):
1. Azurophilic granule (1°)
:Defensins (>50% of contents)
:Cathelicidins
:MPO (myelopeoxidase)
2. Specific granule (2°)- only in neutrophil:
:Lactoferrin
:Lysozyme
MPO – green color in pus
Abbas AK, Lichtman AH, Pillai Shiv. Cellular and molecular immunology. 8th ed.Philadelphia, W.B. Saunders
Company.2015.
7. Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
8. Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
9. Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
10. Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
11. Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
12. Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
13. Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
14. Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
16. Janeway & colleagues
1st reported 5 children
with serum gamma
globulin levels with
recurrent infections
1954
Assari T. Chronic Granulomatous Disease; fundamental stages in our understanding of CGD. Med Immunol 2006;5:4.
17. Janeway & colleagues
1st reported 5 children
with serum gamma
globulin levels with
recurrent infections
1954 1957
Bridges et al. described 4 boys
with hypergammaglobulinemia,
suffering recurrent infections of
the lungs, lymph nodes, and skin,
with granulomatous lesions
" fatal granulomatous disease of
childhood" was first described
Assari T. Chronic Granulomatous Disease; fundamental stages in our understanding of CGD. Med Immunol 2006;5:4.
18. Janeway & colleagues
1st reported 5 children
with serum gamma
globulin levels with
recurrent infections
1954 1957
Bridges et al. described 4 boys
with hypergammaglobulinemia,
suffering recurrent infections of
the lungs, lymph nodes, and skin,
with granulomatous lesions
" fatal granulomatous disease of
childhood" was first described
1960
Studies on patient blood
confirmed CGD to be a disease of
impaired phagocytes
Assari T. Chronic Granulomatous Disease; fundamental stages in our understanding of CGD. Med Immunol 2006;5:4.
19. Janeway & colleagues
1st reported 5 children
with serum gamma
globulin levels with
recurrent infections
1954 1957
Bridges et al. described 4 boys
with hypergammaglobulinemia,
suffering recurrent infections of
the lungs, lymph nodes, and skin,
with granulomatous lesions
" fatal granulomatous disease of
childhood" was first described
1960
Studies on patient blood
confirmed CGD to be a disease of
impaired phagocytes
1967
Tx using erythromycin &
novobiocin antibiotics&
regular sx drainage,
survival rate 4yrs to 12yrs
Chronic granulomatous disease
20. Speculation that a b-type
cytochrome may also be
involved in this O2-.
generating activity
1979
Assari T. Chronic Granulomatous Disease; fundamental stages in our understanding of CGD. Med Immunol 2006;5:4.
21. Speculation that a b-type
cytochrome may also be
involved in this O2-.
generating activity
1979 1980
Saw the formation of a disease-
gene relationship.
Assari T. Chronic Granulomatous Disease; fundamental stages in our understanding of CGD. Med Immunol 2006;5:4.
22. Speculation that a b-type
cytochrome may also be
involved in this O2-.
generating activity
1979 1980
Saw the formation of a disease-
gene relationship.
1986
The gp91phox subunit was first
cloned , encoded from the CYBB
gene
Assari T. Chronic Granulomatous Disease; fundamental stages in our understanding of CGD. Med Immunol 2006;5:4.
24. Epidemiology
• Based on 2 large retrospective studies in the
United States and Europe
-> incidence= 1:200,000
Winkelstein JA, Marino MC, Johnston RB, Jr., Boyle J, Curnutte J, Gallin JI, et al. Chronic granulomatous disease. Report on a
national registry of 368 patients. Medicine (Baltimore) 2000;79:155-69.
van den Berg JM, van Koppen E, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al. Chronic granulomatous disease:
the European experience. PLoS One 2009;4:e5234.
25. Epidemiology
• Sweden -> 1 :450,000
• Japan -> 1 :300,000
• Israeli Arabs -> 1 :111,000
Ahlin A, De Boer M, Roos D, Leusen J, Smith CI, Sundin U, et al. Prevalence, genetics and clinical presentation of chronic
granulomatous disease in Sweden. Acta Paediatr 1995;84:1386-94.
Hasui M, Japa SGPD. Chronic granulomatous disease in Japan: Incidence and natural history. Pediatrics International
1999;41:589-93.
Wolach B, Gavrieli R, de Boer M, Gottesman G, Ben-Ari J, Rottem M, et al. Chronic granulomatous disease in Israel: clinical,
functional and molecular studies of 38 patients. Clin Immunol 2008;129:103-14.
26. H
Winkelstein JA, Marino MC, Johnston RB, Jr., Boyle J, Curnutte J, Gallin JI, et al. Chronic granulomatous disease. Report on a
national registry of 368 patients. Medicine (Baltimore) 2000;79:155-69.
27. Winkelstein JA, Marino MC, Johnston RB, Jr., Boyle J, Curnutte J, Gallin JI, et al. Chronic granulomatous disease. Report on a
national registry of 368 patients. Medicine (Baltimore) 2000;79:155-69.
28. Winkelstein JA, Marino MC, Johnston RB, Jr., Boyle J, Curnutte J, Gallin JI, et al. Chronic granulomatous disease. Report on a
national registry of 368 patients. Medicine (Baltimore) 2000;79:155-69.
29. Winkelstein JA, Marino MC, Johnston RB, Jr., Boyle J, Curnutte J, Gallin JI, et al. Chronic granulomatous disease. Report on a
national registry of 368 patients. Medicine (Baltimore) 2000;79:155-69.
30. Winkelstein JA, Marino MC, Johnston RB, Jr., Boyle J, Curnutte J, Gallin JI, et al. Chronic granulomatous disease. Report on a
national registry of 368 patients. Medicine (Baltimore) 2000;79:155-69.
31. Winkelstein JA, Marino MC, Johnston RB, Jr., Boyle J, Curnutte J, Gallin JI, et al. Chronic granulomatous disease. Report on a
national registry of 368 patients. Medicine (Baltimore) 2000;79:155-69.
32. van den Berg JM, van Koppen E, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al. Chronic granulomatous disease:
the European experience. PLoS One 2009;4:e5234.
33. van den Berg JM, van Koppen E, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al. Chronic granulomatous disease:
the European experience. PLoS One 2009;4:e5234.
34. van den Berg JM, van Koppen E, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al. Chronic granulomatous disease:
the European experience. PLoS One 2009;4:e5234.
35. van den Berg JM, van Koppen E, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al. Chronic granulomatous disease:
the European experience. PLoS One 2009;4:e5234.
37. Abbas AK, Lichtman AH, Pillai Shiv. Cellular and molecular immunology. 8th ed.Philadelphia, W.B. Saunders
Company.2015.
38. Abbas AK, Lichtman AH, Pillai Shiv. Cellular and molecular immunology. 8th ed.Philadelphia, W.B. Saunders
Company.2015.
39. Abbas AK, Lichtman AH, Pillai Shiv. Cellular and molecular immunology. 8th ed.Philadelphia, W.B. Saunders
Company.2015.
40. Abbas AK, Lichtman AH, Pillai Shiv. Cellular and molecular immunology. 8th ed.Philadelphia, W.B. Saunders
Company.2015.
41. NADPH Oxygen complex
Harris JB, Michelow IC, Westra SJ, Kradin RL. Case records of the Massachusetts General Hospital. Case 21-2008. An 11-
month-old boy with fever and pulmonary infiltrates. N Engl J Med 2008;359:178-87.
48. NADPH Oxygen derive reductant
Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM. Genetic, biochemical, and clinical features of chronic
granulomatous disease. Medicine (Baltimore) 2000;79:170-200.
49. NADPH Oxygen derive reductant
Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM. Genetic, biochemical, and clinical features of chronic
granulomatous disease. Medicine (Baltimore) 2000;79:170-200.
50. NADPH Oxygen derive reductant
Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM. Genetic, biochemical, and clinical features of chronic
granulomatous disease. Medicine (Baltimore) 2000;79:170-200.
51. NADPH Oxygen derive reductant
Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM. Genetic, biochemical, and clinical features of chronic
granulomatous disease. Medicine (Baltimore) 2000;79:170-200.
52. NADPH Oxygen derive reductant
Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM. Genetic, biochemical, and clinical features of chronic
granulomatous disease. Medicine (Baltimore) 2000;79:170-200.
53. NADPH Oxygen derive reductant
Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM. Genetic, biochemical, and clinical features of chronic
granulomatous disease. Medicine (Baltimore) 2000;79:170-200.
54. NADPH Oxygen derive reductant
Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM. Genetic, biochemical, and clinical features of chronic
granulomatous disease. Medicine (Baltimore) 2000;79:170-200.
55. NADPH Oxygen derive reductant
Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM. Genetic, biochemical, and clinical features of chronic
granulomatous disease. Medicine (Baltimore) 2000;79:170-200.
60. Song E, Jaishankar GB, Saleh H, Jithpratuck W, Sahni R, Krishnaswamy G. Chronic granulomatous disease: a review of the
infectious and inflammatory complications. Clin Mol Allergy 2011;9:10.
61. Song E, Jaishankar GB, Saleh H, Jithpratuck W, Sahni R, Krishnaswamy G. Chronic granulomatous disease: a review of the
infectious and inflammatory complications. Clin Mol Allergy 2011;9:10.
62. Song E, Jaishankar GB, Saleh H, Jithpratuck W, Sahni R, Krishnaswamy G. Chronic granulomatous disease: a review of the
infectious and inflammatory complications. Clin Mol Allergy 2011;9:10.
63. Song E, Jaishankar GB, Saleh H, Jithpratuck W, Sahni R, Krishnaswamy G. Chronic granulomatous disease: a review of the
infectious and inflammatory complications. Clin Mol Allergy 2011;9:10.
64. Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM. Genetic, biochemical, and clinical features of chronic
granulomatous disease. Medicine (Baltimore) 2000;79:170-200.
65. Relation among the Components of NADPH Oxidase That Are Affected
in Patients with Chronic Granulomatous Disease.
Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
66. X-linked CGD
Song E, Jaishankar GB, Saleh H, Jithpratuck W, Sahni R, Krishnaswamy G. Chronic granulomatous disease: a
review of the infectious and inflammatory complications. Clin Mol Allergy 2011;9:10.
72. X-linked CGD
In affected women, lyonization (ie, the inactivation of one or the other X
chromosome in every cell) leads to two populations of phagocytes: one with
normal respiratory burst function and the other with impaired respiratory burst
activity .
Repine JE, Clawson CC, White JG, Holmes B. Spectrum of function of neutrophils from carriers of sex-linked chronic
granulomatous disease. J Pediatr 1975;87:901-7.
73. X-linked CGD
Carriers with less than 20 percent of normal oxidase activity due to
skewed X-chromosome lyonization may present with the
phenotype of mild to severe CGD.
Anderson-Cohen M, Holland SM, Kuhns DB, Fleisher TA, Ding L, Brenner S, et al. Severe phenotype of chronic
granulomatous disease presenting in a female with a de novo mutation in gp91-phox and a non familial, extremely skewed
X chromosome inactivation. Clin Immunol 2003;109:308-17.
74. AR-CGD
Song E, Jaishankar GB, Saleh H, Jithpratuck W, Sahni R, Krishnaswamy G. Chronic granulomatous disease: a
review of the infectious and inflammatory complications. Clin Mol Allergy 2011;9:10.
78. Inflammation
• Persistent inflammation can occur
independently of infection
• Inflammatory sites are frequently sterile.
• One possible explanation for failure to resolve
inflammation
->Inability of CGD phagocytes to degrade
chemotactic factors
Seger RA. Modern management of chronic granulomatous disease. Br J Haematol 2008;140:255-66.
79. Autoimmune disease
• CYBB &other CGD-related genes could be
lupus-susceptibility genes
• Abnormal apoptosis coupled to abnormal
clearance of apoptotic cells
• Complement deficiencies
Carneiro-Sampaio M, Liphaus BL, Jesus AA, Silva CA, Oliveira JB, Kiss MH. Understanding systemic lupus
erythematosus physiopathology in the light of primary immunodeficiencies. J Clin Immunol 2008;28 Suppl
1:S34-41.
80. Battersby AC, Cale AM, Goldblatt D, Gennery AR. Clinical manifestations of disease in X-linked carriers of chronic granulomatous disease. J Clin
Immunol 2013;33:1276-84.
82. H
Winkelstein JA, Marino MC, Johnston RB, Jr., Boyle J, Curnutte J, Gallin JI, et al. Chronic granulomatous disease. Report on a
national registry of 368 patients. Medicine (Baltimore) 2000;79:155-69.
83. H
Winkelstein JA, Marino MC, Johnston RB, Jr., Boyle J, Curnutte J, Gallin JI, et al. Chronic granulomatous disease. Report on a
national registry of 368 patients. Medicine (Baltimore) 2000;79:155-69.
84. Harris JB, Michelow IC, Westra SJ, Kradin RL. Case records of the Massachusetts General Hospital. Case 21-2008. An 11-
month-old boy with fever and pulmonary infiltrates. N Engl J Med 2008;359:178-87.
85. Harris JB, Michelow IC, Westra SJ, Kradin RL. Case records of the Massachusetts General Hospital. Case 21-2008. An 11-
month-old boy with fever and pulmonary infiltrates. N Engl J Med 2008;359:178-87.
86. Harris JB, Michelow IC, Westra SJ, Kradin RL. Case records of the Massachusetts General Hospital. Case 21-2008. An 11-
month-old boy with fever and pulmonary infiltrates. N Engl J Med 2008;359:178-87.
87. Harris JB, Michelow IC, Westra SJ, Kradin RL. Case records of the Massachusetts General Hospital. Case 21-2008. An 11-
month-old boy with fever and pulmonary infiltrates. N Engl J Med 2008;359:178-87.
88. Harris JB, Michelow IC, Westra SJ, Kradin RL. Case records of the Massachusetts General Hospital. Case 21-2008. An 11-
month-old boy with fever and pulmonary infiltrates. N Engl J Med 2008;359:178-87.
89. van den Berg JM, van Koppen E, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al. Chronic granulomatous disease:
the European experience. PLoS One 2009;4:e5234.
90. van den Berg JM, van Koppen E, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al. Chronic granulomatous disease:
the European experience. PLoS One 2009;4:e5234.
91. van den Berg JM, van Koppen E, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al. Chronic granulomatous disease:
the European experience. PLoS One 2009;4:e5234.
92. van den Berg JM, van Koppen E, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al. Chronic granulomatous disease:
the European experience. PLoS One 2009;4:e5234.
93. van den Berg JM, van Koppen E, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al. Chronic granulomatous disease:
the European experience. PLoS One 2009;4:e5234.
94. van den Berg JM, van Koppen E, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al. Chronic granulomatous disease:
the European experience. PLoS One 2009;4:e5234.
95. van den Berg JM, van Koppen E, Ahlin A, Belohradsky BH, Bernatowska E, Corbeel L, et al. Chronic granulomatous disease:
the European experience. PLoS One 2009;4:e5234.
96. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
97. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
2.6 cases per
100 patient-years
98. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
1.06 cases per
100 patient-years
99. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
0.98 cases per
100 patient-years
100. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
0.81 cases per
100 patient-years
101. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
1.44 cases per
100 patient-years
102. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
Total
268
103. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
Total
268
104. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
105. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
106. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
107. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
108. Marciano BE, Spalding C, Fitzgerald A, Mann D, Brown T, Osgood S, et al. Common severe infections in
chronic granulomatous disease. Clin Infect Dis 2015;60:1176-83.
109. Panel A shows painful inflammation of the nares.
Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
110. Fig. 1 Left fundus demonstrating typical punched out chorioretinal lesion with retinal vessel bowing in the base and pigmented
margins.
David Goldblatt , Jeremy Butcher , Adrian J. Thrasher , Isabelle Russell-Eggitt
Chorioretinal lesions in patients and carriers of chronic granulomatous disease
The Journal of Pediatrics, Volume 134, Issue 6, 1999, 780 - 783
http://dx.doi.org/10.1016/S0022-3476(99)70299-4
111. Panel B shows a large granuloma in the neck (arrow)
Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
112. Panel C shows severe gingivitis (arrow).
Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
113. Massive lymphadenopathy in the cervical, axillary, and preauricular
areas
Esfandbod M, Kabootari M. Images in clinical medicine. Chronic granulomatous disease. N Engl J Med
2012;367:753.
114. Massive lymphadenopathy in the inguinal areas
Esfandbod M, Kabootari M. Images in clinical medicine. Chronic granulomatous disease. N Engl J Med
2012;367:753.
115. Chest radiographr evealed multiple bilateral abscesses in both lungs
Esfandbod M, Kabootari M. Images in clinical medicine. Chronic granulomatous disease. N Engl J Med
2012;367:753.
116. Lublin M, Bartlett DL, Danforth DN, et al. Hepatic abscess in patients with chronic granulomatous disease.
Ann Surg 2002;235:383-91.
117. Marciano BE, Rosenzweig SD, Kleiner DE, Anderson VL, Darnell DN, Anaya-O'Brien S, et al. Gastrointestinal involvement in
118. Panel D, a barium swallow shows an esophageal stricture (arrow) caused
by a granuloma.
Lekstrom-Himes JA, Gallin JI. Immunodeficiency diseases caused by defects in phagocytes. N Engl J Med
2000;343:1703-14.
119. Lublin M, Bartlett DL, Danforth DN, et al. Hepatic abscess in patients with chronic granulomatous disease.
Ann Surg 2002;235:383-91.
120. Lublin M, Bartlett DL, Danforth DN, et al. Hepatic abscess in patients with chronic granulomatous disease.
Ann Surg 2002;235:383-91.
122. Song E, Jaishankar GB, Saleh H, Jithpratuck W, Sahni R, Krishnaswamy G. Chronic granulomatous disease: a review of the
infectious and inflammatory complications. Clin Mol Allergy 2011;9:10.
123. Song E, Jaishankar GB, Saleh H, Jithpratuck W, Sahni R, Krishnaswamy G. Chronic granulomatous disease: a review of the
infectious and inflammatory complications. Clin Mol Allergy 2011;9:10.
124. Diagnostic method of CGD
• Nitroblue tetrazolium (NBT) dye test
• Ferricytochrome C reduction
• Chemiluminescence
• Dihydrorhodamine and other fluorescene
assay
• H2O2 reduction(scopoletin oxidation)
Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM. Genetic, biochemical, and clinical features of chronic
granulomatous disease. Medicine (Baltimore) 2000;79:170-200.
125. Diagnostic method of CGD
• Nitroblue tetrazolium (NBT) dye test
• Ferricytochrome C reduction
• Chemiluminescence
• Dihydrorhodamine and other fluorescene
assay
• H2O2 reduction(scopoletin oxidation)
Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM. Genetic, biochemical, and clinical features of chronic
granulomatous disease. Medicine (Baltimore) 2000;79:170-200.
126. Diagnostic method of CGD
• Nitroblue tetrazolium (NBT) dye test
• Ferricytochrome C reduction
• Chemiluminescence
• Dihydrorhodamine and other fluorescene
assay
• H2O2 reduction(scopoletin oxidation)
Segal BH, Leto TL, Gallin JI, Malech HL, Holland SM. Genetic, biochemical, and clinical features of chronic
granulomatous disease. Medicine (Baltimore) 2000;79:170-200.
127. Nitroblue tetrazolium (NBT) dye test
• Measures the ability of phagocytic cells to
ingest
• Reduce a soluble yellow dye to an intracellular
blue crystal
• Screening to rule out CGD
Boxer LA .Neutrophil abnormalities Pediatr Rev. 2003 Feb;24(2):52-62.
129. Dihydrorhodamine reduction test
• DHR :Uncharged & nonfluorescent reactive
oxygen species
• Activation of granulocyte loaded with DHR
->generates reactive oxygen intermediate that
react with DHR
• Results in increase green fluorescence
Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for
evaluation of male patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin
Immunol 2003;111:374-9.
130. Dihydrorhodamine reduction test
Leukocytes were loaded with DHR
At 37°C for 5 minutes in the presence of catalase
Cells were stimulated with phorbol myristate acetate
(PMA) for 14 minutes
Immediately analyzed by flow cytometry
Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for
evaluation of male patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin
Immunol 2003;111:374-9.
131. Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for
evaluation of male patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin
Immunol 2003;111:374-9.
Number of
cell react
with DHR
Fluorescence
intensity
132. Harris JB, Michelow IC, Westra SJ, Kradin RL. Case records of the Massachusetts General Hospital. Case 21-2008. An 11-
month-old boy with fever and pulmonary infiltrates. N Engl J Med 2008;359:178-87.
Figure 3. Dihydrorhodamine-123 Fluorescence Assay of Peripheral-
Blood Neutrophils Unrelated Healthy Control.
133. Harris JB, Michelow IC, Westra SJ, Kradin RL. Case records of the Massachusetts General Hospital. Case 21-2008. An 11-
month-old boy with fever and pulmonary infiltrates. N Engl J Med 2008;359:178-87.
Figure 3. Dihydrorhodamine-123 Fluorescence Assay of Peripheral-
Blood Neutrophils Unrelated Healthy Control.
134. Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for evaluation of male
patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin Immunol 2003;111:374-9.
135. Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for evaluation of male
patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin Immunol 2003;111:374-9.
136. Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for evaluation of male
patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin Immunol 2003;111:374-9.
137. Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for evaluation of male
patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin Immunol 2003;111:374-9.
138. Dihydrorhodamine reduction test
Stimulation index=
mean channel fluorescence of
stimulated neutrophils
mean channel fluorescence of
unstimulated neutrophils
Vowells SJ, Fleisher TA, Sekhsaria S, Alling DW, Maguire TE, Malech HL. Genotype-dependent variability in
flow cytometric evaluation of reduced nicotinamide adenine dinucleotide phosphate oxidase function in
patients with chronic granulomatous disease. J Pediatr 1996;128:104-7.
139. Dihydrorhodamine reduction test
Subjects Stimulation index
Normal subjects 127.9 (85.2-264.6)
gp91-phox-deficient 1.32 (0.9 -2.2)
p47-phox-deficient 13.2 (3.5-52.1)
Vowells SJ, Fleisher TA, Sekhsaria S, Alling DW, Maguire TE, Malech HL. Genotype-dependent variability in
flow cytometric evaluation of reduced nicotinamide adenine dinucleotide phosphate oxidase function in
patients with chronic granulomatous disease. J Pediatr 1996;128:104-7.
140. Dihydrorhodamine reduction test
CV
of each fluorescent histogram =
Standard deviation
Mean
Vowells SJ, Fleisher TA, Sekhsaria S, Alling DW, Maguire TE, Malech HL. Genotype-dependent variability in
flow cytometric evaluation of reduced nicotinamide adenine dinucleotide phosphate oxidase function in
patients with chronic granulomatous disease. J Pediatr 1996;128:104-7.
x 100
141. Dihydrorhodamine reduction test
Subjects Coefficient of variation of
histogram
Normal subjects 18.9 (11.4- 41.1)
gp91-phox-deficient 24.6 (18.1-48.8)
p47-phox-deficient 75.5 (49.3 - 100)
Vowells SJ, Fleisher TA, Sekhsaria S, Alling DW, Maguire TE, Malech HL. Genotype-dependent variability in
flow cytometric evaluation of reduced nicotinamide adenine dinucleotide phosphate oxidase function in
patients with chronic granulomatous disease. J Pediatr 1996;128:104-7.
142. Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for evaluation of male
patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin Immunol 2003;111:374-9.
143. Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for evaluation of male
patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin Immunol 2003;111:374-9.
144. Western immunoblot analysis
Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for evaluation of male
patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin Immunol 2003;111:374-9.
145. CYBB mutation analysis
Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for evaluation of male
patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin Immunol 2003;111:374-9.
146. CYBB mutation analysis
Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for evaluation of male
patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin Immunol 2003;111:374-9.
147. CYBB mutation analysis
Jirapongsananuruk O, Malech HL, Kuhns DB, Niemela JE, Brown MR, Anderson-Cohen M, et al. Diagnostic paradigm for evaluation of male
patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin Immunol 2003;111:374-9.
154. General health care
• CGD pts should receive all routine
immunizations(avoidance of BCG vaccination)
• Dental hygiene is very important
• Avoiding sources of Aspergillus spores
• Risk of perirectal abscesses can be diminished by
avoiding constipation
Seger RA. Modern management of chronic granulomatous disease. Br J Haematol 2008;140:255-66.
155. Seger RA. Modern management of chronic granulomatous disease. Br J Haematol 2008;140:255-66.
Antibiotic prophylaxis
161. A controlled trial of interferon gamma to prevent infection in chronic granulomatous disease. The
International Chronic Granulomatous Disease Cooperative Study Group. N Engl J Med 1991;324:509-16.
162. A controlled trial of interferon gamma to prevent infection in chronic granulomatous disease. The
International Chronic Granulomatous Disease Cooperative Study Group. N Engl J Med 1991;324:509-16.
163. A controlled trial of interferon gamma to prevent infection in chronic granulomatous disease. The
International Chronic Granulomatous Disease Cooperative Study Group. N Engl J Med 1991;324:509-16.
164. Treatment of acute infection
• Antibiotic therapy
• Antifungal therapy
• Surgical intervention
• White cell transfusion
Seger RA. Modern management of chronic granulomatous disease. Br J Haematol 2008;140:255-66.
165. Antibiotic therapy
Seger RA. Modern management of chronic granulomatous disease. Br J Haematol 2008;140:255-66.
Burkholderia spp., S. aureus and Nocardia spp
166. Antifungal therapy
Seger RA. Modern management of chronic granulomatous disease. Br J Haematol 2008;140:255-66.
167. Surgical intervention
• Drainage of abscesses
• Relief of obstruction
• Excision of consolidated suppurative &
granulomatous lesions
Seger RA. Modern management of chronic granulomatous disease. Br J Haematol 2008;140:255-66.
168. White cell transfusion
• Complication
1. Leucoagglutinin
2. Rapid decrease of neutrophil
3. Leukastasis
4.Alloimmunization to HLA Ag
Seger RA. Modern management of chronic granulomatous disease. Br J Haematol 2008;140:255-66.
175. Myeloablative bone marrow conditioning with
busulfan based regimen
Human leukocyte antigen (HLA)–identical sibling
donors bone marrow transplantation
N = 27 >
Survival rate 85% , Cure rate 81%
Seger RA, Gungor T, Belohradsky BH, Blanche S, Bordigoni P, Di Bartolomeo P, et al. Treatment of chronic granulomatous
disease with myeloablative conditioning and an unmodified hemopoietic allograft: a survey of the European experience,
1985-2000. Blood 2002;100:4344-50.
176. Seger RA, Gungor T, Belohradsky BH, Blanche S, Bordigoni P, Di Bartolomeo P, et al. Treatment of chronic granulomatous
disease with myeloablative conditioning and an unmodified hemopoietic allograft: a survey of the European experience,
1985-2000. Blood 2002;100:4344-50.
177. Seger RA, Gungor T, Belohradsky BH, Blanche S, Bordigoni P, Di Bartolomeo P, et al. Treatment of chronic granulomatous disease with
myeloablative conditioning and an unmodified hemopoietic allograft: a survey of the European experience, 1985-2000. Blood 2002;100:4344-50.
178. Seger RA, Gungor T, Belohradsky BH, Blanche S, Bordigoni P, Di Bartolomeo P, et al. Treatment of chronic granulomatous
disease with myeloablative conditioning and an unmodified hemopoietic allograft: a survey of the European experience,
1985-2000. Blood 2002;100:4344-50.
180. Ott MG, Schmidt M, Schwarzwaelder K, Stein S, Siler U, Koehl U, et al. Correction of X-linked chronic granulomatous disease
by gene therapy, augmented by insertional activation of MDS1-EVI1, PRDM16 or SETBP1. Nat Med 2006;12:401-9.
181. Ott MG, Schmidt M, Schwarzwaelder K, Stein S, Siler U, Koehl U, et al. Correction of X-linked chronic granulomatous disease
by gene therapy, augmented by insertional activation of MDS1-EVI1, PRDM16 or SETBP1. Nat Med 2006;12:401-9.
182. Ott MG, Schmidt M, Schwarzwaelder K, Stein S, Siler U, Koehl U, et al. Correction of X-linked chronic granulomatous disease
by gene therapy, augmented by insertional activation of MDS1-EVI1, PRDM16 or SETBP1. Nat Med 2006;12:401-9.
183. Ott MG, Schmidt M, Schwarzwaelder K, Stein S, Siler U, Koehl U, et al. Correction of X-linked chronic granulomatous disease
by gene therapy, augmented by insertional activation of MDS1-EVI1, PRDM16 or SETBP1. Nat Med 2006;12:401-9.
184. Ott MG, Schmidt M, Schwarzwaelder K, Stein S, Siler U, Koehl U, et al. Correction of X-linked chronic granulomatous disease
by gene therapy, augmented by insertional activation of MDS1-EVI1, PRDM16 or SETBP1. Nat Med 2006;12:401-9.
185. Ott MG, Schmidt M, Schwarzwaelder K, Stein S, Siler U, Koehl U, et al. Correction of X-linked chronic granulomatous disease
by gene therapy, augmented by insertional activation of MDS1-EVI1, PRDM16 or SETBP1. Nat Med 2006;12:401-9.
186. Take Home Message
• CGD is a genetically heterogeneous condition
characterized by
:Recurrent life-threatening bacterial & fungal
infections
:Granuloma formation
• Most patients are diagnosed before the age of
five years
187. Take Home Message
• CGD is caused by defects in phagocyte NADPH
oxidase.
:Respiratory burst
• Mutations in all four genes
(gp91phox,p47phox, p22phox & p67phox)
:Most common mutations are X linked
gp91phox
188. Take Home Message
• A neutrophil function test is the initial
diagnostic test performed.
:NBT
:DHR
• Current prophylaxis with :trimethoprim-
sulfamethoxazole, itraconazole & in selected
cases additional interferon gamma is efficient