1210

There is little to choose between the 4% and 2%solutions, but the latter has the advantage that it is readilyavailable. The large volume (10 ml.) is offset by the factthat injection is quite painless. In our experience, con-centrated (4%) lignocaine was no more toxic, and thisconfirms previous work (Braid and Scott 1966). Theabsence of correlation between the plasma-level and body-weight in adults has also been previously reported (Braidand Scott 1966), and brings into question the practice ofestimating dosage in mg. per kg.

In patients with serious arrhythmias in whom animmediate effect is desired, a bolus intravenous injectionof 50-75 mg. could be given at the same time as theintramuscular dose.We thank Astra A.B., Sweden, especially Dr. B. Ortengren, for the

lignocaine estimations and Dr. P. Frisch for the statistical analysis.Requests for reprints should be addressed to D. G. J.

REFERENCES

Braid, D. P., Scott, D. B. (1966) Br. J. Anœsth. 38, 596.Foldes, F. F., Molloy, R., McNall, P. G., Koukal, L. R. (1960) J. Am. med.

Ass. 172, 1493.Jewitt, D. E., Kishon, Y., Thomas, M. (1968) Lancet, i, 266.Killip, T. (1968) in Acute Myocardial Infarction (edited by D. G. Julian

and M. F. Oliver); p. 106. Edinburgh.Lawrie, D. M., Higgins, M. R., Godman, M. J., Oliver, M. F., Julian, D. G.,

Donald, K. W. (1968) Lancet, ii, 523.Lown, B., Fakhro, A. M., Hood, W. B., Thorn, G. W. (1967) J. Am. med.

Ass. 199, 156.

Preliminary Communications

IMPLANTATION OF A FŒTAL THYMUS,RESTORING IMMUNOLOGICAL COMPETENCE

IN A PATIENT WITH THYMIC APLASIA

(DiGEORGE’S SYNDROME)

Summary A 21-month-old male with congenitalaplasia of the thymus (DiGeorge’s syn-

drome) underwent implantation of thymus fragments froma 16-week-old female foetus. Abnormalities of lymphocytefunction as manifested by failure to reject a skin allograft,to develop delayed hypersensitivity to Monilia and

dinitrofluorobenzene, or to respond to phytohæmag-glutinin were promptly rectified. There was no evidenceof a graft-versus-host reaction.

INTRODUCTION

CONGENITAL absence of the thymus and parathyroidglands (DiGeorge’s syndrome) has been attributed to afailure of embryonic differentiation of structures derivedfrom the third and fourth pharyngeal pouch endodermand branchial-cleft ectoderm.1 2 The immunologicaldeficiency which results is similar to that produced byneonatal thymectomy in animals.2-4 In affected individualsboth humoral antibody synthesis and serum-immuno-globulins are normal. Cellular immunity, however, isabnormal. Affected children cannot reject skin allograftsnormally and do not manifest delayed hypersensitivityreactions to common antigens, such as Monilia or strepto-kinase and streptodornase; no skin contact reactivity,which develops in over 95% of normal individuals afterapplication of dinitrofluorobenzene (D.N.F.B.), is induced;and, in vitro, the patients’ lymphocytes do not undergo1. DiGeorge, A. M. J. Pediat. 1965, 67, 907.2. DiGeorge, A. M. in Immunologic Deficiency Diseases in Man (edited

by D. Bergsma); p. 116. New York, 1968.3. Cleveland, W. W., Fogel, B. J., Kay, H. E. J. clin. Invest. 1968, 47, 20a.4. Kretschmer, R., Say, B., Brown, D., Rosen, F. S. New Engl. J. Med.

(in the press).

blast transformation and mitosis when exposed to phyto-heemagglutinin (P.H.A.) or other antigenic stimuli.5

It has been suggested that patients with congenitalaplasia of the thymus are ideal candidates for immuno-logical reconstitution.2-6 Indeed, Cleveland et awl. havereported the successful implantation of foetal thymus tissuein just such an infant. We report here the successfulreconstitution of another infant with congenital absence ofthe thymus.

CASE-REPORT

The patient was a 21-month-old male diagnosed as a case ofcongenital aplasia of the thymus and parathyroid glands at age9 months. During the neonatal period he had hypocalcaemictetany. Subsequently he had oral moniliasis and recurrentupper and lower respiratory-tract infections. The details of hisclinical course and immunological investigation are given else-where (patient E. M. in the series described by Kretschmeret al.4).When immunological reconstitution was attempted, the child

was not acutely infected and had an allograft of skin from anunrelated donor which apparently had been accepted for9 months. Except for the skin-graft, the patient had neverreceived any foreign cells. Three attempts to induce contactsensitivity with 5% D.N.F.B. were unsuccessful. Physicalexamination revealed that he was below the third percentile forheight and weight; he had facies which are characteristic of thesyndrome and chronic otitis media. His absolute lymphocyte-count was 2100 per c.mm. A variety of skin tests were appliedand were read 48 hours later. The responses to Monilia

antigen, streptokinase-streptodornase, and diphtheria toxinwere negative. D.N.F.B. diluted 1/1000 elicited only rednesswithout vesiculation; D.N.F.B. diluted 1/100 produced a vesicantburn surrounded by redness. The response of his peripheralblood lymphocytes to phytohaemagglutinin was negligible(see table).Thymus fragments from a normal female foetus (crown to

rump 11.5 cm., probably 16 weeks gestation) were implanted in

P.H.A.-STIMULATED UPTAKE OF TRITIATED-THYMIDINE BY PERIPHERAL

BLOOD LEUCOCYTES AFTER FCETAL THYMUS GRAFTING

a pocket surgically created in the patient’s rectus abdominusmuscle. Nothing else was given. 4 days later the lymphocyte-count was 3000 per c.mm. (within normal limits) and theresponse of his peripheral leucocytes to p.H.A. was completelynormal when evaluated quantitatively by the uptake of tritiatedthymidine and autoradiographic enumeration of labelled cells.

2 weeks after the implantation, the child responded normallyto skin testing with Monilia and D.N.F.B. at 1/10,000 and 1/1000dilutions. Chromosomal analysis of bone-marrow cells yielded40 mitotic figures of only male karyotypes.

9 days after skin-grafting from an unrelated donor, a rejectionreaction began. Biopsy of the graft 15 days after the implanta-tion revealed necrosis with a mononuclear cell infiltrate in thedermis of the graft and at the graft margin in the recipient. Onthe 17th day, the graft was completely rejected.5. Lischner, H. W., Punnett, H. H., DiGeorge, A. M. Nature, Lond.

1967, 214, 580.6. Kay, H. E. M. in Immunologic Deficiency Diseases in Man (edited by

D. Bergsma); p. 168. New York, 1968.7. Rosen, F. S. New Engl. J. Med. 1968, 279, 643.

1211

In-vitro leucocyte responses to P.H.A. were repeated 8, 13,19, and 25 days after implanting the foetal thymus and werenormal on each occasion (see table). Chromosomes of the cellsundergoing mitosis were found to be male in every instance(see table).

DISCUSSION

The fact that, after implantation of thymus tissue, ourpatient gained immunological competence without havingto be primarily sensitised suggests that the immunologicaldefect in this syndrome lies in the " effector " portion ofthe immune response. In this, our experience confirmsthe observations of Cleveland et awl. It seems that theseathymic patients " recognise " and " process " antigenssatisfactorily but that the cells required to effect animmune response are either absent or

" uninstructed ".After thymic implantation, the cells that divided in

response to P.H.A. were observed to be male (i.e., thepatient’s). This suggests that the transplanted thymus insome way conferred upon the patient’s lymphocytes thecapacity to respond, rather than serving as the source ofthe dividing cells.The change observed in the responses of the patient’s

peripheral leucocytes in vitro after the foetal thymus graftindicates that a normal P.H.A. response requires an intactthymus. The fact that exogenous influences, for example,virus infections, can depress P.H.A. responsiveness8 9

suggests that, although the thymus may be necessary, it isnot sufficient for normal P.H.A. reactivity. Clearly furtherclinical and experimental studies are needed to clarify thispoint.The fact that patients with congenital aplasia of the

thymus do not reject allografts means that attempts atimmunological reconstitution might produce graft-versus-host reactions. Such reactions, as proven by the existenceof XX/XY chimærism between donor and recipient, havebeen observed clinically in patients with hereditary thymicdysplasia who have received infusions of maternal bone-marrow,!o whole blood,!1 and lymphoid cells presumablyin utero.12 2 The risks of graft-versus-host reactions incongenital aplasia of the thymus are not known, but ourown experience and that of Cleveland et awl. suggest thatin this syndrome immunological reconstitution withfoetal thymus is not only possible but also probablysafe.

Supported by grants AI-05877 and FR-00128 of the U.S. PublicHealth Service. The foetal tissue bank of the Royal Marsden Hospitalis supported by a grant from the Medical Research Council.

C. S. AUGUSTM.D. Harvard

F. S. ROSENM.D. Western Reserve

R. M. FILLERM.D. Washington

C. A. JANEWAYM.D. Johns HopkinsB. MARKOWSKI

M.D. Warsaw

H. E. M. KAYM.D. Lond., M.R.C.P., F.C.PATH.

Departments of Medicine and Surgery,Children’s Hospital Medical Center,

and Harvard Medical School,Boston, Massachusetts 02115

Royal Marsden Hospital,London S.W.3

8. Robbins, J. H. Science, N.Y. 1964, 146, 1648.9. Montgomery, J. R., South, M. A., Rawls, W. E., Melnick, J. L.,

Olson, G. B., Dent, P. B., Good, R. A. ibid. 1967, 157 1068.10. Rosen, F. S., Gotoff, S. P., Craig, J. M., Ritchie, J., Janeway, C. A.

New Engl. J. Med. 1966, 274, 18.11. Hong, R., Kay, H. E. M., Cooper, M. D., Meuwissen, H., Allan,

M. J. G., Good, R. A. Lancet, 1968, i, 503.12. Kadowaki, J., Thompson, R., Zuelzer, W. W., Wooley, P. V., Jr.,

Brough, A. J., Gruber, D. ibid, 1965, ii, 1152.

FŒTAL THYMIC TRANSPLANT IN A CASE OF

DiGEORGE’S SYNDROME

Summary An infant with the third and fourth

pharyngeal pouch syndrome is described.Radiographic evidence of absence of the thymus wasstrongly supported by tests of immunological function.At 7 months of age thymic tissue acquired from a 13-weekfoetus was implanted in the rectus abdominis muscle.

Immunological data after transplant, as well as the infant’sability to resist infection, suggests that immunologicalfunction has been reconstituted by transplant of fœtal

thymic tissue.INTRODUCTION

ABSENCE of the parathyroids and thymus constitutes theDiGeorge or third and fourth pharyngeal pouch syndrome:an anomaly of the aortic arch (which forms at the sametime as these glands) is also a common feature.! Severalcases have been described at necropsy

2-5 but significantclinical data are available in only three reports.3-5 In oneof DiGeorge’s cases 4 immunological function was studiedextensively. In this syndrome the immunological dis-turbance is less severe than that encountered in thecommoner " Swiss " type of lymphopenic agamma-

globulinxmia in which the whole of the lymphoreticularsystem is hypoplastic. It also differs from thymic dysplasiawith selective deficiency of immunoglobulins and fromconditions where cellular immunity is impaired but

immunoglobulins are normal.CASE-REPORT

A Caucasian male born after an uncomplicated 34-weekpregnancy weighed 4 lb. 12 oz. (2-2 kg.) at birth. Bilateralcataracts were observed during the initial physical examination.At 9 days of age, the infant had a clonic-tonic seizure, becamecyanotic, and required mouth-to-mouth resuscitation. He wasadmitted to another hospital where aspiration pneumonia,cataracts, right inguinal hernia, and convulsive disorder

1. DiGeorge, A. M. J. Pediat. 1965, 67, 907.2. Lobdell, D. H. Archs Path. 1959, 67, 412.3. Taitz, L. S., Concedcion, Z., Schwartz, E. Pediatrics, Springfield, 1966,

38, 412.4. DiGeorge, A. M. in Immunologic Deficiency Diseases in Man (edited

by D. Bergsma); p. 116. New York, 1968.5. Huber, J., Cholnoky, P., Zoethout, H. E. Archs Dis. Childh. 1967, 42,

190.6. Bergsma, D. (editor) Immunologic Deficiency Diseases in Man.

New York, 1968.

Fig. 1-Calcium and phosphorus levels in serum before and afterparathyroid transplant.