Four patients (2 with X-linked, one with common variable hypogammaglobulinaemia, and 1 with ulcerative colitis) developed non-A, non-B hepatitis (NANBH) following administration of a specific batch of intravenous immunoglobulin (IV IgG) manufactured by the Scottish National Blood Transfusion Service using the pH4/mild pepsin method. Each patient had normal serum ALT levels over a preceding period of 12-67 months, with raised values developing within 4-18 weeks of first administration of the implicated batch. Two patients had very mild symptoms of hepatitis, the other 2 being asymptomatic. Over a follow-up period of 8-12 months, ALT levels returned to normal in 3 patients, but biopsy-proven chronic NANBH developed in the fourth. The level of NANBH virus in the starting plasma used to manufacture this batch may have exceeded the capacity of the process to inactivate the virus. The transmission of NANBH by one of approximately 110 batches administered demonstrates the importance of continued close surveillance of recipients of IV IgG, even if asymptomatic, by regular monitoring of liver function tests and recording of all batches received.

Patients with the acquired immunodeficiency syndrome (AIDS) suffer from a deficiency of cellular immunity. However, some HIV-infected children and adults suffer from recurrent upper respiratory tract infections suggestive of a failure to synthesise specific antibodies, despite the hypergammaglobulinaemia that is present. Intravenous immunoglobulin (IV IgG) appears to benefit HIV-infected children with recurrent infections, in doses similar to those used for treating patients with primary hypogammaglobulinaemia. In some HIV-infected adults, IV IgG also appears to reduce bacterial respiratory infections but the treatment schedules remain to be defined. In patients with life-threatening bleeding due to immune thrombocytopenic purpura associated with HIV infection, high dose IV IgG treatment (1-2 g/kg) also increases platelet counts but unlike other therapies for ITP, is not immunosuppressive and has no other serious adverse effects. It is likely that over the next few years, specific anti-HIV preparations will be evaluated. Neutralising antibody has been demonstrated in HIV-infected patients and a specific antibody preparation against HIV might either prevent HIV infection after initial exposure to the virus or slow the progression of HIV-related disease. However, the development of a specific, effective, neutralising anti-HIV immunoglobulin preparation (whether polyclonal or monoclonal) will require information about which HIV antigens elicit protective immunity and the role played by neutralising antibody in HIV-related disease.

No abstract