Pediatric Chronic Granulomatous Disease Workup
- Author: Lawrence C Wolfe, MD; Chief Editor: Robert J Arceci, MD, PhD more...
The following tests are indicated in chronic granulomatous disease (CGD):
- Nitroblue tetrazolium (NBT) test
- The standard assay for phagocytic oxidase activity is the NBT test. The colorless compound NBT is reduced to blue formazan by the activity of the phox enzyme system. Several versions of the test exist; each has advantages and disadvantages.
- The most efficient and informative version is the NBT slide test, in which a drop of whole blood is placed on a microscope slide coated with an activating agent, such as lipopolysaccharide or phorbol ester. Phagocytes adhering to the slide are activated and develop blue inclusions on incubation with NBT. The number of NBT-positive cells is scored under a microscope. This test is often preferred because of the small amount of blood required and the lack of a need for specialized equipment. Although the result is nonquantitative, an experienced technologist can differentiate normal phagocytes reliably from low-level phox activity observed in some cases of p47 deficiency.
- The NBT test can be useful in identifying X-linked carrier female individuals when peripheral phagocytes consist of 2 cell populations: one that reduces NBT to formazan and one that does not.
- The NBT is limited by its subjectivity, need for experienced technician, and false-negative results that cause the diagnosis of chronic granulomatous disease to be missed. False-negative findings occur when formazan accumulates in cells with low levels of active adenine dinucleotide phosphate (NADPH) oxidase. These patients clinically have the disease, but their NBT test results are negative.
- In an alternative technique, leukocytes are isolated from blood and incubated with NBT in a test tube. Formazan is solubilized by addition of an organic solvent, and the blue color intensity is read by a spectrophotometer.
- Dihydrorhodamine (DHR) test
- This flow cytometric test is now widely and commercially available and should be considered the preferred screening and diagnostic test for chronic granulomatous disease. This test should be considered the most accurate diagnostic test for chronic granulomatous disease.
- Phagocytic cells reduce DHR to the strongly fluorescent compound rhodamine. Individual fluorescent cells can then be counted, and the amount of fluorescence per cell is quantified with flow cytometry.
- This test combines the best features of the slide and tube NBT tests, although a specialized instrument is required.
- Deficiencies of gp91 (no activity, no DHR conversion) and p47 (low activity, minimal DHR conversion) can be distinguished with this method. X-linked carriers of chronic granulomatous disease can also be identified with the DHR test.
- Genetic testing
- Specific gene mutation is useful to establish the genetic inheritance pattern and aid in family counseling. Although the family history is sometimes informative in cases of X-linked chronic granulomatous disease (X-CGD), the high incidence of new mutations and the appearance of male subjects with autosomal recessive mutations make some type of laboratory confirmation important.
- The low incidence of chronic granulomatous disease and the large number of unique mutations preclude standardized genetic testing. Therefore, individual genetic analysis remains the domain of specialized research laboratories.
- Mutations can currently be identified in nearly all patients and in about 90% of mothers of affected children.
- Identification of the precise molecular defect in individual patients takes on added importance with the recent initiation of gene-therapy trials in chronic granulomatous disease.
- Other tests
- When screening results are inconclusive or when additional confirmation is required, other assays of phagocyte oxidative metabolism can be performed in research laboratories capable of studying phagocytes.
- On Western blot analysis, failure to detect the p22, p47, or p67 products can be taken as evidence of autosomal recessive mutation in the corresponding gene.
- Prenatal diagnosis
- Prenatal diagnosis for siblings of affected patients can be achieved in one of two ways. When a mutation is precisely identified in the affected child, chorionic villus biopsy can be performed to obtain enough DNA to identify affected fetuses. As an alternative, dinucleotide repeat polymorphisms linked to the CYBB gene may be useful in the prenatal diagnosis of X-CGD.
- When these DNA detection methods are not available, fetal blood can be sampled and an NBT slide test performed.
- Chorionic villus sampling is technically preferred because of its applicability early in gestation and the reduced risk of fetal loss.
- If parents are not considering termination of a pregnancy, newborns can be tested by using the slide NBT or flow cytometric DHR tests because affected fetuses do not appear to be at increased risk of infection in utero.
- Other laboratory findings
- Other than the specific tests of phagocyte oxidative metabolism that help in establishing the diagnosis, no consistent or characteristic laboratory findings define this disease.
- Most patients have WBC counts that are within the reference range or elevated, with further increases during infectious episodes.
- Phagocyte morphology, phagocytic cell-surface adhesion proteins, chemotaxis, and phagocytosis are normal.
- Patients may have anemia of chronic disease.
- The erythrocyte sedimentation rate can be elevated even between infections.
- Hypergammaglobulinemia is a common feature of the illness and is believed to represent a host response to recurrent or persistent infection.
Imaging studies such as chest radiography and CT imaging are valuable in the diagnosis and management of pulmonary and hepatosplenic infections.
The two most frequent findings on histologic examination of the lesions observed in chronic granulomatous disease are infection and postinfectious granulomas.
Frequent sites of infection are the skin, lymph nodes, lungs, liver, spleen, bones, and joints; the GI and genitourinary (GU) tracts are less commonly involved.
Histologic findings consist of suppurative lesions with collections of phagocytic cells, predominantly neutrophils, with the causative bacteria or fungi and abscess formation.
Granulomatous involvement of the GI and GU tracts is not uncommon. Biopsy of these lesions shows necrotic granulomas with pigmented histiocytes and macrophages. These are most often sterile.
Similar granulomatous infiltrations of the skin and lungs are described.
von Rosenvinge EC, O'Donnell TG, Holland SM, Heller T. Chronic granulomatous disease. Inflamm Bowel Dis. 2009 Mar 25. [Medline].
Ko SH, Rhim JW, Shin KS, Hahn YS, Lee SY, Kim JG. Genetic analysis of CYBB gene in 26 korean families with X-linked chronic granulomatous disease. Immunol Invest. 2014. 43(6):585-94. [Medline].
Ben-Ari J, Wolach O, Gavrieli R, Wolach B. Infections associated with chronic granulomatous disease: linking genetics to phenotypic expression. Expert Rev Anti Infect Ther. 2012 Aug. 10(8):881-94. [Medline].
Vining M, Sharma N, Guill M. Atypical presentation of chronic granulomatous disease with Burkholderia cepacia. BMJ Case Rep. 2014 Aug 6. 2014:[Medline].
Roos D, Kuhns DB, Maddalena A, et al. Hematologically important mutations: the autosomal recessive forms of chronic granulomatous disease (second update). Blood Cells Mol Dis. 2010 Apr 15. 44(4):291-9. [Medline].
Marciano BE, Rosenzweig SD, Kleiner DE, et al. Gastrointestinal involvement in chronic granulomatous disease. Pediatrics. 2004 Aug. 114(2):462-8. [Medline].
Xu H, Tian W, Li SJ, Zhang LY, Liu W, Zhao Y, et al. Clinical and molecular features of 38 children with chronic granulomatous disease in mainland china. J Clin Immunol. 2014 Aug. 34(6):633-41. [Medline].
Jones LB, McGrogan P, Flood TJ, Gennery AR, Morton L, Thrasher A. Special article: chronic granulomatous disease in the United Kingdom and Ireland: a comprehensive national patient-based registry. Clin Exp Immunol. 2008 May. 152(2):211-8. [Medline].
Cole T, McKendrick F, Titman P, Cant AJ, Pearce MS, Cale CM, et al. Health Related Quality of Life and Emotional Health in Children with Chronic Granulomatous Disease: A Comparison of Those Managed Conservatively with Those That Have Undergone Haematopoietic Stem Cell Transplant. J Clin Immunol. 2012 Aug 12. [Medline].
Ahlin A, Fasth A. Chronic granulomatous disease - conventional treatment vs. hematopoietic stem cell transplantation: an update. Curr Opin Hematol. 2014 Nov 12. [Medline].
Shigemura T, Nakazawa Y, Hirabayashi K, Kobayashi N, Sakashita K, Agematsu K, et al. Dramatic Improvement in the Multifocal Positron Emission Tomography Findings of a Young Adult with Chronic Granulomatous Disease Following Allogeneic Hematopoietic Stem Cell Transplantation. J Clin Immunol. 2014 Nov 4. [Medline].
Mouy R, Veber F, Blanche S, et al. Long-term itraconazole prophylaxis against Aspergillus infections in thirty-two patients with chronic granulomatous disease. J Pediatr. 1994 Dec. 125(6 Pt 1):998-1003. [Medline].
Walsh TJ, Anaissie EJ, Denning DW, et al. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2008 Feb 1. 46(3):327-60. [Medline].
Sfaihi L, Maaloul I, Fourati H, Stasia MJ, Mnif Z, Hachicha M. Resistant Invasive Aspergillosis in an Autosomal Recessive Chronic Granulomatous Disease. Fetal Pediatr Pathol. 2012 Sep 24. [Medline].
Gallin JI, Alling DW, Malech HL, et al. Itraconazole to prevent fungal infections in chronic granulomatous disease. N Engl J Med. 2003 Jun 12. 348(24):2416-22. [Medline].
International Chronic Granulomatous Disease Cooperative Study Group. 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 Feb 21. 324(8):509-16. [Medline].
Marciano BE, Wesley R, De Carlo ES, et al. Long-term interferon-gamma therapy for patients with chronic granulomatous disease. Clin Infect Dis. 2004 Sep 1. 39(5):692-9. [Medline].
Miki M, Ono A, Awaya A, et al. Successful bone marrow transplantation in chronic granulomatous disease. Pediatr Int. 2009 Dec. 51(6):838-41. [Medline].
Seger RA. Modern management of chronic granulomatous disease. Br J Haematol. 2008 Feb. 140(3):255-66. [Medline].
Liese JG, Jendrossek V, Jansson A, et al. Chronic granulomatous disease in adults. Lancet. 1996 Jan 27. 347(8996):220-3. [Medline].
Barton LL, Moussa SL, Villar RG, Hulett RL. Gastrointestinal complications of chronic granulomatous disease: case report and literature review. Clin Pediatr (Phila). 1998 Apr. 37(4):231-6. [Medline].
Berendes H, Bridges RA, Good RA. A fatal granulomatosus of childhood: the clinical study of a new syndrome. Minn Med. 1957 May. 40(5):309-12. [Medline].
Bjorgvinsdottir H, Ding C, Pech N, et al. Retroviral-mediated gene transfer of gp91phox into bone marrow cells rescues defect in host defense against Aspergillus fumigatus in murine X-linked chronic granulomatous disease. Blood. 1997 Jan 1. 89(1):41-8. [Medline].
Carson MJ, Chadwick DL, Brubaker CA, et al. Thirteen boys with progressive septic granulomatosis. Pediatrics. 1965 Mar. 35:405-12. [Medline].
Danziger RN, Goren AT, Becker J, et al. Outpatient management with oral corticosteroid therapy for obstructive conditions in chronic granulomatous disease. J Pediatr. 1993 Feb. 122(2):303-5. [Medline].
Del Giudice I, Iori AP, Mengarelli A, et al. Allogeneic stem cell transplant from HLA-identical sibling for chronic granulomatous disease and review of the literature. Ann Hematol. 2003 Mar. 82(3):189-92. [Medline].
Dohil M, Prendiville JS, Crawford RI, Speert DP. Cutaneous manifestations of chronic granulomatous disease. A report of four cases and review of the literature. J Am Acad Dermatol. 1997 Jun. 36(6 Pt 1):899-907. [Medline].
Gallin JI, Malech HL. Update on chronic granulomatous diseases of childhood. Immunotherapy and potential for gene therapy [clinical conference]. JAMA. 1990 Mar 16. 263(11):1533-7. [Medline].
Goebel WS, Mark LA, Billings SD, et al. Gene correction reduces cutaneous inflammation and granuloma formation in murine X-linked chronic granulomatous disease. J Invest Dermatol. 2005 Oct. 125(4):705-10. [Medline].
Gorlach A, Lee PL, Roesler J, et al. A p47-phox pseudogene carries the most common mutation causing p47-phox-deficient chronic granulomatous disease. J Clin Invest. 1997 Oct 15. 100(8):1907-18. [Medline].
Heyworth PG, Cross AR, Curnutte JT. Chronic granulomatous disease. Curr Opin Immunol. 2003 Oct. 15(5):578-84. [Medline].
Ishibashi F, Nunoi H, Endo F, et al. Statistical and mutational analysis of chronic granulomatous disease in Japan with special reference to gp91-phox and p22-phox deficiency. Hum Genet. 2000 May. 106(5):473-81. [Medline].
Jirapongsananuruk O, Malech HL, Kuhns DB, et al. Diagnostic paradigm for evaluation of male patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin Immunol. 2003 Feb. 111(2):374-9. [Medline].
Johnston RB. Clinical aspects of chronic granulomatous disease. Curr Opin Hematol. 2001 Jan. 8(1):17-22. [Medline].
Kamani N, August CS, Campbell DE, et al. Marrow transplantation in chronic granulomatous disease: an update, with 6-year follow-up. J Pediatr. 1988 Oct. 113(4):697-700. [Medline].
Kume A, Dinauer MC. Gene therapy for chronic granulomatous disease. J Lab Clin Med. 2000 Feb. 135(2):122-8. [Medline].
Landing BH, Shirkey HS. A syndrome of recurrent infection and infiltration of viscera by pigmented lipid histiocytes. Pediatrics. 1957 Sep. 20(3):431-8. [Medline].
Leung T, Chik K, Li C, Yuen P. Bone marrow transplantation for chronic granulomatous disease: long- term follow-up and review of literature. Bone Marrow Transplant. 1999 Sep. 24(5):567-70. [Medline].
Malech HL. Progress in gene therapy for chronic granulomatous disease. J Infect Dis. 1999 Mar. 179 Suppl 2:S318-25. [Medline].
Malech HL, Nauseef WM. Primary inherited defects in neutrophil function: etiology and treatment. Semin Hematol. 1997 Oct. 34(4):279-90. [Medline].
Margolis DM, Melnick DA, Alling DW, Gallin JI. Trimethoprim-sulfamethoxazole prophylaxis in the management of chronic granulomatous disease. J Infect Dis. 1990 Sep. 162(3):723-6. [Medline].
Meischl C, Roos D. The molecular basis of chronic granulomatous disease. Springer Semin Immunopathol. 1998. 19(4):417-34. [Medline].
Mouy R, Fischer A, Vilmer E, et al. Incidence, severity, and prevention of infections in chronic granulomatous disease. J Pediatr. 1989 Apr. 114(4 Pt 1):555-60. [Medline].
Nakhleh RE, Glock M, Snover DC. Hepatic pathology of chronic granulomatous disease of childhood. Arch Pathol Lab Med. 1992 Jan. 116(1):71-5. [Medline].
Ochs HD, Igo RP. The NBT slide test: a simple screening method for detecting chronic granulomatous disease and female carriers. J Pediatr. 1973 Jul. 83(1):77-82. [Medline].
Rae J, Newburger PE, Dinauer MC, et al. X-Linked chronic granulomatous disease: mutations in the CYBB gene encoding the gp91-phox component of respiratory-burst oxidase. Am J Hum Genet. 1998 Jun. 62(6):1320-31. [Medline].
Rosen GM, Pou S, Ramos CL, et al. Free radicals and phagocytic cells. FASEB J. 1995 Feb. 9(2):200-9. [Medline].
Schapiro BL, Newburger PE, Klempner MS, Dinauer MC. Chronic granulomatous disease presenting in a 69-year-old man. N Engl J Med. 1991 Dec 19. 325(25):1786-90. [Medline].
Segal BH, DeCarlo ES, Kwon-Chung KJ, et al. Aspergillus nidulans infection in chronic granulomatous disease. Medicine (Baltimore). 1998 Sep. 77(5):345-54. [Medline].
Segal BH, Leto TL, Gallin JI, et al. Genetic, biochemical, and clinical features of chronic granulomatous disease. Medicine (Baltimore). 2000 May. 79(3):170-200. [Medline].
Thrasher AJ, Keep NH, Wientjes F, Segal AW. Chronic granulomatous disease. Biochim Biophys Acta. 1994 Oct 21. 1227(1-2):1-24. [Medline].
Vowells SJ, Fleisher TA, Sekhsaria S, et al. Genotype-dependent variability in flow cytometric evaluation of reduced nicotinamide adenine dinucleotide phosphate oxidase function in patients with chronic granulomatous disease. J Pediatr. 1996 Jan. 128(1):104-7. [Medline].
Weening RS, Kabel P, Pijman P, Roos D. Continuous therapy with sulfamethoxazole-trimethoprim in patients with chronic granulomatous disease. J Pediatr. 1983 Jul. 103(1):127-30. [Medline].
Weening RS, Leitz GJ, Seger RA. Recombinant human interferon-gamma in patients with chronic granulomatous disease--European follow up study. Eur J Pediatr. 1995 Apr. 154(4):295-8. [Medline].
Winkelstein JA, Marino MC, Johnston RB Jr, et al. Chronic granulomatous disease. Report on a national registry of 368 patients. Medicine (Baltimore). 2000 May. 79(3):155-69. [Medline].
Yang KD, Hill HR. Neutrophil function disorders: pathophysiology, prevention, and therapy. J Pediatr. 1991 Sep. 119(3):343-54. [Medline].