The defects in lymphocyte apoptosis that underlie the autoimmune lymphoproliferative syndrome (ALPS) are usually attributable to inherited mutations of the CD95 (Fas) gene. In this report , we present the histopathological and immunophenotypic features seen in the lymph nodes (n ؍ 16) , peripheral blood (n ؍ 10) , bone marrow (n ؍ 2) , spleen (n ؍ 3) , and liver (n ؍ 2) from 10 patients with ALPS. Lymph nodes showed marked paracortical hyperplasia. Interfollicular areas were expanded and populated by T cell receptor-␣ CD3 ؉ CD4 ؊ CD8 ؊ (double-negative, DN) T cells that were negative for CD45RO. CD45RA؉ T cells were increased in all cases studied. The paracortical infiltrate was a result of both reduced apoptosis and increased proliferation , as measured by in situ detection of DNA fragmentation and staining with MIB-1 , respectively. The paracortical proliferation may be extensive enough to suggest a diagnosis of malignant lymphoma. Many of the paracortical lymphocytes expressed markers associated with cytotoxicity , such as perforin , TIA-1 , and CD57. CD25 was negative. In addition , most lymph nodes exhibited florid follicular hyperplasia , often with focal progressive transformation of germinal centers; in some cases , follicular involution was seen. A polyclonal plasmacytosis also was present. The spleens were markedly enlarged , more than 10 times normal size. There was expansion of both white pulp and red pulp , with increased DN T cells. DN T cells also were observed in liver biopsies exhibiting portal triaditis. In the peripheral blood , the T cells showed increased expression of HLA-DR and CD57 but not CD25.
CD45RA؉ T cells were increased in the four cases
CD8Ϫ , doublenegative (DN) T cells in the circulation and lymphoid tissues. Sneller et al 1 first reported a detailed clinical and immunological study of two patients, recognizing similarities to the MRL and C3H/Hej strains of mice possessing the lpr and gld mutations, respectively. Genetic elucidation of the lpr and gld loci as representing recessive mutations in the genes encoding CD95 (Fas/Apo-1) and CD95L (FasL), respectively, 2-4 led to the discovery of functional CD95 mutations in ALPS patients. [5][6][7][8] With the ability to diagnose specific CD95 mutations in ALPS cases, it was appreciated that patients affected with this disorder had been included in published series by a number of investigators of undefined chronic lymphoproliferation or splenomegaly with associated autoimmune phenomena. 9,10