Boxwood (Buxus spp.) are commercially important evergreen ornamental plants with an annual market value of over $103 million in the United States. The recent U.S. incursion of boxwood blight disease caused by the fungus Calonectria pseudonaviculata (syn. Cylindrocladium pseudonaviculatum, Cy. buxicola) threatens the health and productivity of boxwood in both landscape plantings and nurseries. The first confirmed U.S. reports of the disease were made from Connecticut and North Carolina in November 2011 (2,4), followed by diagnoses in 10 additional states during 2012 and 2013. By August 2013, symptoms consistent with boxwood blight had been observed from B. sempervirens in Delaware, Maryland, New Jersey, and southeastern New York. Affected plants showed rapid onset of disease symptoms: dark brown to black spots or diffuse dark areas on leaves, followed by defoliation. Narrow, elongate black cankers also formed on current season shoots. Symptomatic stems and leaves were placed in petri dishes with moistened filter paper at 22°C for 3 days under continuous light. Conidiophores were excised, then placed on potato dextrose agar amended with streptomycin and neomycin (0.3 g/l). Resultant colonies showed dark brown pigmentation at the colony center surrounded by tan to reddish brown rings with white mycelia at the advancing edge. Conidia (n = 30 per isolate) were hyaline, cylindrical, rounded at both ends, with a single septum (45 to 76 × 4 to 6 μm; avg. 63 × 5 μm). Conidiophores (n = 20 per isolate) comprised a stipe, a hyaline septate stipe extension (length 119 to 192 μm; avg. 150 μm) and a terminal ellipsoidal vesicle (diameter 4 to 10 μm; avg. 7 μm). Based on morphological characteristics, the causal agent was identified as C. pseudonaviculata (1,4). Voucher specimens were deposited in the U.S. National Fungus Collections (BPI 892698 to 701). To verify morphological diagnosis, genomic DNA was extracted from fungal biomass grown in liquid cultures of yeast extract peptone dextrose media. A portion of the β-tubulin gene (TUB2) was PCR amplified and sequenced bi-directionally using primers Bta/Bt2b (3). BLASTn searches of NCBI GenBank databases using the TUB2 sequences (Accession Nos. KF785808 to 11) demonstrated 96 to 100% sequence identity with other C. pseudonaviculata isolates. To confirm pathogenicity, 5-month-old B. sempervirens and B. microphylla seedlings were spray-inoculated with a spore suspension of 1 × 104 conidia/ml. One isolate from each state was independently tested with four replicates each. Non-inoculated water-sprayed plants served as negative controls. Plants were maintained in growth chambers at 22°C under constant light. Blight symptoms developed 4 to 5 days post inoculation. C. pseudonaviculata was re-isolated from inoculated plants; no symptoms or signs were observed from control plants. To our knowledge, this is the first report of C. pseudonaviculata in the states of Delaware, Maryland, New Jersey, and New York. This report demonstrates that C. pseudonaviculata is now widespread across the United States eastern seaboard, and represents a substantial threat to boxwood plants in North American landscapes and nurseries. References: (1) P. Crous et al. Sydowia 54:23, 2002. (2) D. F. Farr and A. Y. Rossman. Fungal Databases, USDA-ARS. Retrieved from http://nt.ars-grin.gov/fungaldatabases , 30 August 2013. (3) N. L. Glass and G. C. Donaldson. Appl. Environ. Microbiol. 61:1323, 1995. (4) K. L. Ivors et al. Plant Dis. 96:1070, 2012.

Intravenous (IV) insulin is currently the standard of care but requires frequent monitoring and can cause excess hypoglycemia. This article presents results from a pilot study to determine the feasibility, efficacy, and safety of IV exenatide in hyperglycemic cardiac intensive care unit patients [Intravenous Exenatide in Coronary Intensive Care Unit Patients; NCT00736229].

Emergence of CD45RA+ and CD62L+ Blood T Cells in Infants with Severe Combined Immunodeficiency (SCID) Given HLA-Identical or Haploidentical T Cell-Depleted Bone Marrow Stem Cells

Background Most patients with congenital hypogammaglobulinemia and absent B cells are males with X-linked agammaglobulinemia, which is caused by mutations in the gene for Bruton's tyrosine kinase (Btk); however, there are females with a similar disorder who do not have mutations in this gene. We studied two families with autosomal recessive defects in B-cell development and patients with presumed X-linked agammaglobulinemia who did not have mutations in Btk.Methods A series of candidate genes that encode proteins involved in B-cell signal-transduction pathways were analyzed by linkage studies and mutation screening.Results Four different mutations were identified in the mu heavy-chain gene on chromosome 14. In one family, there was a homozygous 75-to-100-kb deletion that included D-region genes, J-region genes, and the mu constant-region gene. In a second family, there was a homozygous base-pair substitution in the alternative splice site of the mu heavy-chain gene. This mutation would inhibit production of the membrane form of the mu chain and produce an amino acid substitution in the secreted form. In additions, a patient previously thought to have X-linked agammaglobulinemia was found to have an amino acid substitution on one chromosome at an invariant cysteine that is required for the intrachain disulfide bond and, on the other chromosome, a large deletion that included the immunoglobulin locus.Conclusions Defects in the mu heavy-chain gene are a cause of agammaglobulinemia in humans. This implies that an intact membrane-bound mu chain is essential for B-cell development. (C) 1996, Massachusetts Medical Society.

Background: Gastrointestinal and respiratory symptoms and failure to thrive not associated with infections or medications were noted in patients with severe combined immunodeficiency. Objective: The aim of our study was to determine the frequency of gastroesophageal reflux in patients with severe combined immunodeficiency.Methods: We studied the case histories of 73 pediatric patients who had been treated at Duke University Medical Center for severe combined immunodeficiency between 1982 and 1995. Charts were reviewed for documentation of gastroesophageal reflux on the basis of clinical course and results of barium swallow esophageal pH probe monitoring, or endoscopy. To compare the incidence of gastroesophageal reflux in patients with severe combined immunodeficiency to known high-risk populations, we additionally tabulated the underlying diagnoses in an age-matched group of patients who underwent Nissen fundoplication from 1990 to 1995. Results: We found clinically significant gastroesophageal reflux in 15 of the 73 patients (20.5%), much higher than has been reported in the normal population (0.1% to 0.3%, p < 0.001). Of patients treated between 1990 and the present, 10 of 36 (27.7%) had significant gastroesophageal reflux compared with five of 37 patients (13.5%) in the previous years. Thus with greater recognition and improved methods for diagnosis, the observed incidence of gastroesophageal reflux has increased greatly. The clinical presentations were not different from those of patients with other well-documented underlying diagnoses. Seven of the 15 patients (46.6%) did not respond to medical treatment with antacids, H-2-blockers, and prokinetic agents and underwent surgical treatment. Indications for surgery included persistent esophagitis, vomiting, pneumonia, and growth failure. Conclusions: The reason for the high incidence of gastroesophageal reflux in patients with severe T-cell disorders remains unclear. Considering the frequency of this association, early recognition and treatment is important to enable adequate nutrition and prevent damage to the esophagus and lungs.

Recent studies show that most patients with X-linked hyper IgM syndrome have defects in the gene for CD40 ligand. We evaluated 17 unrelated males suspected of having X-linked hyper IgM syndrome. Activated T cells from 13 of the 17 patients failed to bind a soluble CD40 construct. In these patients, the sequence of CD40 ligand demonstrated mutations. By contrast, T cells from the remaining four patients exhibited normal binding to the CD40 construct. Sequencing of the cDNA for CD40 ligand from these patients did not show mutations. The possibility that hyper IgM syndrome in these four patients was due to abnormalities in the B cell response to CD40-mediated signals was examined. Peripheral blood lymphocytes were stimulated with anti-CD40 alone, IL4 alone or anti-CD40 plus IL4. In comparison with B cells from controls or patients with hyper IgM syndrome and mutant CD40 ligand, B cells from the patients with hyper IgM syndrome and normal CD40 ligand were defective in their ability to secrete IgE (P < 0.02) or express activation markers, CD25 and CD23 (P < 0.02) in response to stimulation with anti-CD40. The failure of these B cells to respond to CD40-mediated activation could not be attributed to a generalized deficiency in B cell activation because IL4 induced normal up-regulation of CD23 and CD25 expression. These findings indicate that hyper IgM syndrome may result from defects in expression of CD40 ligand by activated T cells or defects in CD40-mediated signal transduction in B cells.

A patient with common variable immunodeficiency and autoimmune hemolytic anemia was given high-dose (450 mg/kg) intravenous gamma globulin (Sandoglobulin) for five days, followed by single doses of 100 to 200 mg/kg at four-week intervals or whenever the hemoglobin level and hematocrit fell or the reticulocyte count increased. This treatment was accompanied by a stabilization of hematopoietic parameters and reversal of Coombs' positivity, which have been sustained for 34 months. The use of high-dose gamma globulin for autoimmune hemolytic anemia can eliminate the need for other therapeutic modalities that may be detrimental to an immunocompromised host.

Serums from 23 patients with isolated IgA deficiency contained precipitating antibodies to ruminant IgM proteins. Purified IgM proteins from bovine serum as well as similar proteins in other ruminant (goat, sheep, deer and elk) serum and in cow's milk reacted with the patient serum. IgA-deficient serum did not precipitate serum proteins from humans, nonhuman primates or numerous other animals. Patients with diseases reported to be associated with milk precipitins (e.g., Down's and Heiner's syndromes) may or may not have this factor in addition to antibodies directed toward other bovine milk and serum proteins. Because of the increased prevalence of rheumatoid arthritis in IgA-deficient persons this "reversed rheumatoid factor" (an IgG antibody to IgM proteins) in many IgA-deficient serums is noteworthy. This factor, however, will be missed in IgA-deficient serum if radial immunodiffusion tests with goat anti-IgA serum are used for the quantitation of IgA. The test will be misinterpreted and thought to show low IgA concentrations.

Fatal graft-versus-host (G-V-H) disease has been an invariable accompaniment of incompatible bone marrow transplantation in infants with lymphopenic defects. This report describes an approach which permitted circumvention of this complication. Histocompatibility studies demonstrated no HL-A compatible donors for a female infant with lymphopenic agammaglobulinemia (very low IgG, absent IgA, IgM, and IgE). Serum from her mother (para 16) contained antibodies (1:64 titer) to paternal HL-A antigens inherited by the patient. Maternal lymphocytes were not stimulated by paternal or infant's leukocytes in mixed leukocyte culture in media containing maternal plasma. Immunologic enhancement was attempted at age 5 months by pretreating the infant with cell-free maternal plasma I.V. 24 hours before the I.V. infusion of 5 × 106 immature albumin-gradient-separated maternal marrow cells. Appetite and growth increased dramatically during the first 3 months, thrush and pneumonia cleared, and no overt signs of G-V-H were noted. Delayed cutaneous responsiveness to C. albicans was seen by the 13th day and persists. Lymph node biopsy at 90 days contained plasma cells which stained with fluoroscein-conjugated anti-IgG, IgA, IgM or IgE. A second maternal marrow transplant was given at age 11 months, again without overt G-V-H. This 19-month-old infant has gained 4 kg and grown 20 cm since the first transplant 14 months ago. A normal serum IgA concentration and somewhat low but constant levels of IgG and IgM are present now 5 months after the last plasma infusion. These findings suggest possible usefulness of immunologic enhancement in future attempts when compatible donors are unavailable.

Serologic tests helpful in confirming rheumatoid arthritis in adults are most often negative in juvenile rheumatoid arthritis (JRA). Since rheumatoid factors (RF) have been shown to have iso- as well as hetero-antigenic specificities, this study was designed to determine whether a test employing human gamma globulin with a number of isoantigenic determinants would permit more frequent detection of RF. Human O, Rh + RBC were sensitized with an incomplete anti-D antibody (Ri) known to be positive for a number of Gm isoantigens. Dilutions of sera (heated at 56°C for 30 min) were made in V-bottomed microtiter plates, 0.1% (Ri) cells added, the plates centrifuged and tilted 35° from the verticle for 20–30 min before reading. Sera from children with no disease, acute rheumatic fever (ARF) and JRA were tested with sensitized sheep cells (SSC), the Hyland latex slide test, and (Ri) cells. A titer of 1 : 32 was considered positive for the SSC and (Ri) tests. The finding confirm those of others showing a low but definite incidence of RF in normal children. The (Ri) rest detected RF more frequently in JRA than the SSC and latex tests. The data suggest: (1) the (Ri) test may be helpful in the differential diagnosis between ARF and JRA, and (2) with the significantly (p < 0.005) higher percentage of (Ri) positive reactors in the JRA group that this test may be a more sensitive laboratory aid than those presently available for confirming JRA.