Phase 1 Study of the E-Selectin Inhibitor GMI 1070 in Patients with Sickle Cell Anemia

Background

Sickle cell anemia is an inherited disorder of hemoglobin that leads to a variety of acute and chronic complications. Abnormal cellular adhesion, mediated in part by selectins, has been implicated in the pathophysiology of the vaso-occlusion seen in sickle cell anemia, and selectin inhibition was able to restore blood flow in a mouse model of sickle cell disease.

Methods

We performed a Phase 1 study of the selectin inhibitor GMI 1070 in patients with sickle cell anemia. Fifteen patients who were clinically stable received GMI 1070 in two infusions.

Results

The drug was well tolerated without significant adverse events. There was a modest increase in total peripheral white blood cell count without clinical symptoms. Plasma concentrations were well-described by a two-compartment model with an elimination T_1/2 of 7.7 hours and CLr of 19.6 mL/hour/kg. Computer-assisted intravital microscopy showed transient increases in red blood cell velocity in 3 of the 4 patients studied.

Conclusions

GMI 1070 was safe in stable patients with sickle cell anemia, and there was suggestion of increased blood flow in a subset of patients. At some time points between 4 and 48 hours after treatment with GMI 1070, there were significant decreases in biomarkers of endothelial activation (sE-selectin, sP-selectin, sICAM), leukocyte activation (MAC-1, LFA-1, PM aggregates) and the coagulation cascade (tissue factor, thrombin-antithrombin complexes). Development of GMI 1070 for the treatment of acute vaso-occlusive crisis is ongoing.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00911495","term_id":"NCT00911495"}}NCT00911495     

The Physical Foundation of Vasoocclusion in Sickle Cell Disease

The pathology of sickle cell disease arises from the occlusion of small blood vessels because of polymerization of the sickle hemoglobin within the red cells. We present measurements using a microfluidic method we have developed to determine the pressure required to eject individual red cells from a capillary-sized channel after the cell has sickled. We find that the maximum pressure is only ∼100 Pa, much smaller than typically found in the microcirculation. This explains why experiments using animal models have not observed occlusion beginning in capillaries. The magnitude of the pressure and its dependence on intracellular concentration are both well described as consequences of sickle hemoglobin polymerization acting as a Brownian ratchet. Given the recently determined stiffness of sickle hemoglobin gels, the observed obstruction seen in sickle cell disease as mediated by adherent cells can now be rationalized, and surprisingly suggests a window of maximum vulnerability during circulation of sickle cells.Human capillaries are narrower than the erythrocytes they convey. In sickle cell disease, red cells can become rigid in those capillaries, because the hemoglobin inside the red cell will aggregate into stiff polymers. This happens once the molecules deliver their oxygen, and led to the long-held view that capillary occlusion was central to the pathophysiology of the disease (1,2). This was challenged when microscopic study of animal model tissues perfused with sickle blood revealed blockages that began further downstream, in the somewhat larger venules (3–5), at the site of adherent red or white cells which diminished the vessel lumen without fully obstructing the flow. Yet no rationale has been presented for the failure of the prior assumption of capillary blockage. Microfluidic methods (6) are ideally suited to discover why cells don’t get stuck in the capillaries, yet occlude subsequent vessels, and we have constructed a system to address this question. Our measurements show that the pressure differences across capillaries in vivo can easily dislodge a cell sickled within a capillary, giving an experimental answer to the question of why sickled cells don’t stick in capillaries. It turns out that the pressure a cell can withstand is quantitatively explained by the Brownian ratchet behavior of sickle hemoglobin polymerization.We constructed single-cell channels in transparent polydimethylsiloxane, with a cross section (1.5 μm × 4 μm) that is smaller than the resting diameter of red cells (Fig. 1). These channels are much narrower than those that have been employed in other recent studies of the sickling process (7,8), and they resemble human capillaries in permitting only one cell at a time to pass through them. We used a laser photolysis method to create ligand free (deoxygenated) cells, and this requires that the hemoglobin bind CO, which can then be readily removed by strong illumination, in contrast to bound O₂ which is released with far lower efficiency than CO. The microfluidic chips were enclosed in a gas-tight chamber flushed with CO to avoid introduction of oxygen and keep the cells fully ligated before photolysis. The profiles of the channels were confirmed by microscopic observation. To confirm that liquid did not pass around the cells when they were trapped in the channels, fluorescent beads were introduced into some cell solutions. The beads did not pass the cells, nor did they approach the cell when it was occluded, verifying that no significant flow occurred around the cell when it was stuck.Open in a separate windowFigure 1An erythrocyte enters a channel (moving left to right) and is positioned in the center, where it will be photolyzed. The channel cross section is 1.5 μm × 4 μm, smaller than a resting red cell diameter.Optical measurements were carried out on a microspectrophotometer constructed on an optical table. The system employed ×32 LWD objectives (Leitz, Wetzlar, Germany), which were autofocused during collection of absorption spectra to minimize aberrations. Spectra were obtained using a series 300 camera (Photometrics, Tucson, AZ); video imaging was done with a high-speed camera (Photron, San Diego, CA). Photolysis was provided by a 2020 Argon Ion laser (Spectra Physics, Houston, TX). Sickle cells were obtained from patients at the Marian Anderson Sickle Cell Center at St. Christopher''s Hospital for Children, Philadelphia, PA by phlebotomy into EDTA-containing tubes. The blood was centrifuged at 5°C at 1200g for 4 min, and then the pellet was washed 4× with 15 volumes of buffer (120 mM NaCl, 2 mM KCl, 10 mM dibasic Na Phosphate, 7 mM monobasic Na Phosphate, 3.4 mM Na Bicarbonate, and 6 mM Dextrose) by repeated suspension and centrifugation at 30g for 4 min. This minimizes fibrinogen and platelets in the final suspension, to insure that these studies are controlled by the mechanical properties of the cells themselves.Our experiment began by parking a cell in the center of a channel (Fig. 1). The cell, its hemoglobin, and the microchannel environment all were saturated with CO. Because the thickness of the channel is known, we were able to determine the hemoglobin concentration inside the cell from its absorption spectrum (Fig. 2 A). Steady-state laser illumination then removed the CO, allowing the hemoglobin to polymerize, in which condition it remained while the laser was kept on. Removal of CO was confirmed by observing the spectral difference between COHb and deoxyHb. Photolysis of COHb generates negligible heating (9–11). During illumination, hydrostatic pressure was applied until the cell broke free.Open in a separate windowFigure 2(A) Absorption of the cell (points), fit to a standard spectrum (9). (B) Pressure to dislodge a cell sickled in the microchannel, as a function of intracellular concentration. Note that typical intracellular concentrations are ∼32 g/dL. (Line) Brownian-ratchet theory described in the text. The coefficient of friction (0.036) is within the observed range, and is the only parameter varied.The magnitude of the dislodging pressure, measured by simple height difference between input and output cell reservoirs, is shown in Fig. 2 B. The pressure needed to dislodge the cell increased with increasing intracellular Hb concentration, implying that an increased mass of polymerized hemoglobin is more difficult to dislodge. A clear concentration threshold for capture is apparent. While there is a well-known solubility below which polymers cannot form (18.5 g/dL for the 22°C of this experiment (12)), the threshold here is significantly higher.Central to explaining these observations is a Brownian ratchet mechanism (13) which derives from the metastable nature of this polymerization process. Unless disrupted, as by centrifugation, polymerization in sickle hemoglobin terminates before the thermodynamic limit of monomer solubility is reached (14,15). This arises from the fact that polymers only grow at their ends, which are easily occluded in the dense mass of polymers that form. This end obstruction leaves the system in a metastable state and fluctuations accordingly provide polymers with space into which they can incrementally grow. This Brownian ratchet has been shown to lead to dramatic fiber buckling when individual fibers are isolated in sickle cells (16). The force can be simply expressed as f = (kT/δ) ln S(c), where k is Boltzmann’s constant, T the absolute temperature, δ the net spatial elongation from addition of a single monomer, and S is the supersaturation of the solution when the metastable limit is reached, at monomer concentration c. In this calculation, c is taken as the terminal concentration, computed from our empirical finding (15) that in this metastable system the amount of polymerized hemoglobin Δ is Δ(∞) = 2/3 (c_o-c_s), rather than the expected thermodynamic limit c_o-c_s, where c_o is the initial concentration and c_s is the solubility.For determining the net force, the total number of fibers must be known, and can be calculated based on the double nucleation mechanism (17) which has been quantitatively successful in describing polymerization. The concentration of polymers [p(t)] initially grows exponentially, described by[p(t)]=(AB2J)exp(Bt),where A and B are parameters related to nucleation, and J is the polymer elongation rate, as described in Ferrone et al. (17). Because A and B are both extremely concentration-dependent (9), they will drop dramatically once monomers begin to add to polymers in any significant numbers, and thereby diminish the remaining monomer pool. Thanks to the extreme concentration dependence of the reaction, this rapidly shuts off further polymerization. This happens at approximately the 10th time (the time when the reaction has reached 1/10 of its maximum). Thus, the [p(t_1/10)] ≈ [p(∞)]. Moreover, at one-tenth of the reaction,Δ(t1/10)=12Aexp(Bt1/10)=Δ(∞)10,and thus[p(∞)]=(BJ)(Δ(∞)10)=(BJ)((co−cs)15).For computing the number of fibers, the volume of the cell was taken as 90 μm³. This calculation shows, as expected, that the number of polymers in the cell is highly concentration-dependent, and very few fibers are produced at concentrations just above solubility, but the number grows sharply as concentration rises. This is the main contribution to the threshold in holding force shown by the data.With the force per fiber, and the total number of fibers, the net force against the wall is known. With a coefficient of friction, this reveals the force that a trapped cell can withstand. If the force is divided by the cross-sectional area across which the force is applied, we get a prediction of the dislodging pressure, which can be compared to the data. For a quantitative comparison with the results, two further corrections, of order unity, were applied. Because only normal force will contribute to friction, the calculated force was determined by integrating cos θ. This integration is not over all angles (π) because of the possibility that large incidence angles of the fibers against the wall will lead to fiber runaway (18). Therefore, the integration described is taken to the runaway threshold, here ∼1 rad. Finally, it is necessary to assign a coefficient of friction. Known values span the range of 0.03–0.06 (19). We therefore selected a value within the range, 0.036, as the best match for the data. The predicted pressures match the measurements well, as the line in Fig. 2 B shows.Because the flow resistance is comparable for red cells traversing glass channels and endothelial-lined capillaries (20), we conclude that in vivo the pressures a sickled cell inside a capillary can withstand are no more than hundreds of Pa. This is significantly smaller than typical arteriovenous pressure differentials that have been measured, which range from 0.7 kPa (in hamster skin (21)) to 7.9 kPa (in rat mesentery (22)).Our measurements coupled with recent determination of the stiffness of sickle hemoglobin gels (23) provide the missing physical basis for the processes of vasoocclusion seen in ex vivo tissue and animal models of sickle cell disease, arguing that these observations indeed represent fundamental behavior of sickle cell disease. We now understand this behavior in terms of three possible outcomes, all intimately connected with kinetics:

• 1.Certain escape: A cell that does not polymerize until after passing the obstruction can reach the lungs where it reoxygenates and resets its polymerization clock.
• 2.Possible escape: A cell that polymerizes within the capillary will assume an elongated sausage shape. The forces that it can exert against the wall cannot hold it there, and it will emerge into the postcapillary venule. There it has some chance of passing a subsequent obstruction, though it might also obstruct flow were it to rotate before reaching the adherent cell, so as to present its long dimension to the reduced space it must traverse.
• 3.Certain occlusion: A cell that does not polymerize in the capillary reassumes a larger diameter as soon as it escapes. If the cell then polymerizes before it encounters a cell attached to the venule wall, this rigidified cell will not be able to squeeze past the adherent cell, because that kind of deformation takes MPa (23). This would precipitate the type of blockage that is observed. This suggests that there is a window of greatest vulnerability, toward which therapies might be addressed.

     

Urinary Bladder Dysfunction in Transgenic Sickle Cell Disease Mice

Background

Urological complications associated with sickle cell disease (SCD), include nocturia, enuresis, urinary infections and urinary incontinence. However, scientific evidence to ascertain the underlying cause of the lower urinary tract symptoms in SCD is lacking.

Objective

Thus, the aim of this study was to evaluate urinary function, in vivo and ex vivo, in the Berkeley SCD murine model (SS).

Methods

Urine output was measured in metabolic cage for both wild type and SS mice (25-30 g). Bladder strips and urethra rings were dissected free and mounted in organ baths. In isolated detrusor smooth muscle (DSM), relaxant response to mirabegron and isoproterenol (1nM-10μM) and contractile response to (carbachol (CCh; 1 nM-100μM), KCl (1 mM-300mM), CaCl₂ (1μM-100mM), α,β-methylene ATP (1, 3 and 10 μM) and electrical field stimulation (EFS; 1-32 Hz) were measured. Phenylephrine (Phe; 10nM-100μM) was used to evaluate the contraction mechanism in the urethra rings. Cystometry and histomorphometry were also performed in the urinary bladder.

Results

SS mice present a reduced urine output and incapacity to produce typical bladder contractions and bladder emptying (ex vivo), compared to control animals. In DSM, relaxation in response to a selective β3-adrenergic agonist (mirabegron) and to a non-selective β-adrenergic (isoproterenol) agonist were lower in SS mice. Additionally, carbachol, α, β-methylene ATP, KCl, extracellular Ca²⁺ and electrical-field stimulation promoted smaller bladder contractions in SS group. Urethra contraction induced by phenylephrine was markedly reduced in SS mice. Histological analyses of SS mice bladder revealed severe structural abnormalities, such as reductions in detrusor thickness and bladder volume, and cell infiltration.

Conclusions

Taken together, our data demonstrate, for the first time, that SS mice display features of urinary bladder dysfunction, leading to impairment in urinary continence, which may have an important role in the pathogenesis of the enuresis and infections observed the SCD patients.     

Evaluation of a Density-Based Rapid Diagnostic Test for Sickle Cell Disease in a Clinical Setting in Zambia

Although simple and low-cost interventions for sickle cell disease (SCD) exist in many developing countries, child mortality associated with SCD remains high, in part, because of the lack of access to diagnostic tests for SCD. A density-based test using aqueous multiphase systems (SCD-AMPS) is a candidate for a low-cost, point-of-care diagnostic for SCD. In this paper, the field evaluation of SCD-AMPS in a large (n = 505) case-control study in Zambia is described. Of the two variations of the SCD-AMPS used, the best system (SCD-AMPS-2) demonstrated a sensitivity of 86% (82–90%) and a specificity of 60% (53–67%). Subsequent analysis identified potential sources of false positives that include clotting, variation between batches of SCD-AMPS, and shipping conditions. Importantly, SCD-AMPS-2 was 84% (62–94%) sensitive in detecting SCD in children between 6 months and 1 year old. In addition to an evaluation of performance, an assessment of end-user operability was done with health workers in rural clinics in Zambia. These health workers rated the SCD-AMPS tests to be as simple to use as lateral flow tests for malaria and HIV.     

Inflammation in Sickle Cell Disease: Differential and Down-Expressed Plasma Levels of Annexin A1 Protein

Sickle cell disease (SCD) is an inherited hemolytic anemia whose pathophysiology is driven by polymerization of the hemoglobin S (Hb S), leading to hemolysis and vaso-occlusive events. Inflammation is a fundamental component in these processes and a continuous inflammatory stimulus can lead to tissue damages. Thus, pro-resolving pathways emerge in order to restore the homeostasis. For example there is the annexin A1 (ANXA1), an endogenous anti-inflammatory protein involved in reducing neutrophil-endothelial interactions, accelerating neutrophil apoptosis and stimulating macrophage efferocytosis. We investigated the expression of ANXA1 in plasma of SCD patients and its relation with anemic, hemolytic and inflammatory parameters of the disease. Three SCD genotypes were considered: the homozygous inheritance for Hb S (Hb SS) and the association between Hb S and the hemoglobin variants D-Punjab (Hb SD) and C (Hb SC). ANXA1 and proinflammatory cytokines were quantified by ELISA in plasma of SCD patients and control individuals without hemoglobinopathies. Hematological and biochemical parameters were analyzed by flow cytometry and spectrophotometer. The plasma levels of ANXA1 were about three-fold lesser in SCD patients compared to the control group, and within the SCD genotypes the most elevated levels were found in Hb SS individuals (approximately three-fold higher). Proinflammatory cytokines were higher in SCD groups than in the control individuals. Anemic and hemolytic markers were higher in Hb SS and Hb SD genotypes compared to Hb SC patients. White blood cells and platelets count were higher in Hb SS genotype and were positively correlated to ANXA1 levels. We found that ANXA1 is down-regulated and differentially expressed within the SCD genotypes. Its expression seems to depend on the inflammatory, hemolytic and vaso-occlusive characteristics of the diseased. These data may lead to new biological targets for therapeutic intervention in SCD.     

Pichia anomala (Candida pelliculosa) Fungemia in a Patient with Sickle Cell Disease

This case report discusses a patient with sickle cell disease who presented with fungemia from Pichia anomala (teleomorph: Candida pelliculosa). The organism was identified as P. anomala by MALDI-TOF VITEK mass spectrometry and VITEK 2 yeast identification card. Pichia anomala should be considered in sickle cell patients with recurrent fungemia.     

An Experimental-Computational Approach to Quantify Blood Rheology in Sickle Cell Disease

In sickle cell disease, aberrant blood flow due to oxygen-dependent changes in red cell biomechanics is a key driver of pathology. Most studies to date have focused on the potential role of altered red cell deformability and blood rheology in precipitating vaso-occlusive crises. Numerous studies, however, have shown that sickle blood flow is affected even at high oxygen tensions, suggesting a potentially systemic role for altered blood flow in driving pathologies, including endothelial dysfunction, ischemia, and stroke. In this study, we applied a combined experimental-computation approach that leveraged an experimental platform that quantifies sickle blood velocity fields under a range of oxygen tensions and shear rates. We computationally fitted a continuum model to our experimental data to generate physics-based parameters that capture patient-specific rheological alterations. Our results suggest that sickle blood flow is altered systemically, from the arterial to the venous circulation. We also demonstrated the application of this approach as a tool to design patient-specific transfusion regimens. Finally, we demonstrated that patient-specific rheological parameters can be combined with patient-derived vascular models to identify patients who are at higher risk for cerebrovascular complications such as aneurysm and stroke. Overall, this study highlights that sickle blood flow is altered systemically, which can drive numerous pathologies, and this study demonstrates the potential utility of an experimentally parameterized continuum model as a predictive tool for patient-specific care.     

Validation of a Low-Cost Paper-Based Screening Test for Sickle Cell Anemia

Background

The high childhood mortality and life-long complications associated with sickle cell anemia (SCA) in developing countries could be significantly reduced with effective prophylaxis and education if SCA is diagnosed early in life. However, conventional laboratory methods used for diagnosing SCA remain prohibitively expensive and impractical in this setting. This study describes the clinical validation of a low-cost paper-based test for SCA that can accurately identify sickle trait carriers (HbAS) and individuals with SCA (HbSS) among adults and children over 1 year of age.

Methods and Findings

In a population of healthy volunteers and SCA patients in the United States (n = 55) the test identified individuals whose blood contained any HbS (HbAS and HbSS) with 100% sensitivity and 100% specificity for both visual evaluation and automated analysis, and detected SCA (HbSS) with 93% sensitivity and 94% specificity for visual evaluation and 100% sensitivity and 97% specificity for automated analysis. In a population of post-partum women (with a previously unknown SCA status) at a primary obstetric hospital in Cabinda, Angola (n = 226) the test identified sickle cell trait carriers with 94% sensitivity and 97% specificity using visual evaluation (none of the women had SCA). Notably, our test permits instrument- and electricity-free visual diagnostics, requires minimal training to be performed, can be completed within 30 minutes, and costs about $0.07 in test-specific consumable materials.

Conclusions

Our results validate the paper-based SCA test as a useful low-cost tool for screening adults and children for sickle trait and disease and demonstrate its practicality in resource-limited clinical settings.     

Incidence of Sickle Cell Disease and Other Hemoglobin Variants in 10,095 Lebanese Neonates

Hemoglobinopathies are highly prevalent diseases and impose a public health burden. Early diagnosis and treatment can ameliorate the course of these diseases and improve survival. Despite purported high incidence of hemoglobinopathies in Lebanon, there are no nationwide screening programs. In this study, newborn screening utilizing high pressure liquid chromatography was executed in all public hospitals across Lebanon between 2010 and 2013. All newborns with an abnormal hemoglobin (Hb) were offered genetic counseling and all those with disease were enrolled in comprehensive hemoglobinopathy clinics. Among newborns, 2.1% were found to have an abnormal Hb variant with sickle Hb being the most common while 0.1% were found to have sickle cell disease (SCD). The majority of those with SCD had non-Lebanese origins. The most common causes of hospitalizations in infants with SCD were acute splenic sequestration and pain crises. No bacteremia or other life threatening infections were noted. At a median follow up 14 months (follow up range 7 to 34 months), all children with disease are alive and compliant with treatment. Systematic screening for SCD and other Hb variants was shown to be feasible, cost effective, and of accurate predictive value. This program was also clinically effective because it led to the identification of babies with disease and to providing them with free early multidisciplinary care. Conclusively, a newborn screening program should be implemented across Lebanon to detect hemoglobinopathies and initiate early therapeutic and preventive strategies and genetic counseling.     

Prevalence of Vitamin D Deficiency in Sickle Cell Disease: A Systematic Review

Vitamin D deficiency has emerged as a public health focus in recent years and patients with sickle cell disease (SCD) reportedly have a high prevalence of the condition. Our objectives were to summarize definitions of vitamin D deficiency and insufficiency used in the literature, and to determine the prevalence and magnitude of each in patients with SCD through a systematic review conducted according to PRISMA guidelines. From a PubMed search, 34 potential articles were identified and 15 met eligibility criteria for inclusion. Definitions of deficiency and insufficiency varied greatly across studies making direct comparisons difficult. This review provides evidence to suggest that suboptimal vitamin D levels are highly prevalent among those with SCD, far more so than in comparable non-SCD patients or matched control populations. Defining deficiency as vitamin D <20ng/mL, prevalence estimates in SCD populations range from 56.4% to 96.4%. When compared with results from the population-based National Health and Nutrition Examination Survey, however, the general African American population appeared to have a similarly high prevalence of vitamin D deficiency. African American patients with and without SCD were both substantially higher than that of Caucasians. What remains to be determined is whether there are adverse health effects for patients with SCD because of concurrent vitamin D deficiency.     

Sickle Cell Disease in Pregnancy: Trend and Pregnancy Outcomes at a Tertiary Hospital in Tanzania

SCD in pregnancy is associated with increased adverse fetal and maternal outcomes. In Tanzania where the frequency of sickle cell trait is 13% there has been scanty data on SCD in pregnancy. With progressive improvement in childhood survival the burden of SCD in pregnancy will increase. We analyzed all deliveries at Muhimbili National Hospital (MNH) from 1999 to 2011. Fetal and maternal outcomes of SCD deliveries were compared with non-SCD. Data were analyzed using IBM SPSS statistics version 19. Chi square and Fisher Exact tests were used to compare proportions and the independent t-test for continuous data. To predict risks of adverse effects, odds ratios were determined using multivariate logistic regression. A p-value<0.05 was considered significant. In total, 157,473 deliveries occurred at MNH during the study period, of which 149 were SCD (incidence of 95 SCD per 100,000 deliveries). The incidence of SCD had increased from 76 per 100,000 deliveries in the 1999–2002 period to over 100 per 100, 000 deliveries in recent years. The mean maternal age at delivery was lower in SCD (24.0±5.5 years) than in non-SCD deliveries (26.2±6.0 years), p<0.001. Compared with non-SCD (2.9±0.7 Kg), SCD deliveries had less mean birth-weight (2.6±0.6 Kg), p<0.001. SCD were more likely than non-SCD to deliver low APGAR score at 5 minutes (34.5% Vs 15.0%, OR = 3.0, 95%CI: 2.1–4.2), stillbirths (25.7% Vs 7.5%, OR = 4.0, 95%CI: 2.8–5.8). There was excessive risk of maternal deaths in SCD compared to non-SCD (11.4% Vs 0.4%, OR = 29, 95%CI: 17.3–48.1). The leading cause of deaths in SCD was infections in wholly 82% in contrast to only 32% in non-SCD. In conclusion SCD in pregnancy is an emerging problem at MNH with increased adverse fetal outcomes and excessive maternal mortality mainly due to infections.     

A Family Study of IgG Subclasses in Sickle Cell Anemia

Three siblings with sickle cell anemia were studied immunologically and hematologically. Their patterns of Protein A-Sepharose chromatography distribution showed considerable heterogeneity, particularly with respect to the IgG2 and IgG3 subclasses, even though their hematological make up was similar. An attempt was made to correlate their IgG2: IgG1 subclass ratios with their clinical history of recurrent bacterial infections, as well as a possible compensatory IgG3 heterogeneity.