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X-Linked Agammaglobulinemia

(Bruton Disease)

By James Fernandez, MD, PhD, Clinical Assistant Professor of Medicine; Director, Allergy and Clinical Immunology; Cleveland Clinic, Staff, Department of Allergy and Clinical Immunology, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University; Louis Stokes VA Medical Center, Wade Park;

X-linked agammaglobulinemia is a hereditary immunodeficiency disorder due to a mutation in a gene on the X (sex) chromosome. The disorder results in no B cells (lymphocytes) and very low levels of or no antibodies (immunoglobulins).

  • Infants with X-linked agammaglobulinemia start having recurring coughs and/or infections of the nose, ears, skin, sinuses, and lungs at about age 6 months.

  • Doctors diagnose the disorder by measuring immunoglobulin levels and the number of B cells.

  • Immune globulin is given throughout life, and antibiotics may be given continuously.

X-linked agammaglobulinemia results from a mutation in a gene on the X (sex) chromosome (called an X-linked disorder). X-linked disorders usually affects boys.


For about the first 6 months after birth, immunoglobulins from the mother protect against infection. At about age 6 months, levels of these immunoglobulins start to decrease, and affected infants start having recurring cough, nasal infections (rhinitis), and/or infections of the ears, skin, sinuses, and lungs. The infections are usually due to bacteria such as pneumococci, streptococci, and Haemophilus bacteria. Some unusual viral infections of the brain may develop. The tonsils are very small, and lymph nodes do not develop.

X-linked agammaglobulinemia increases the risk of developing infections in the joints (infectious arthritis), irreversible widening due to chronic inflammation of the airways (bronchiectasis), and certain cancers.

With early diagnosis and treatment, life span is often unaffected, unless brain infections develop.


  • Blood tests

  • Sometimes genetic testing

Blood tests are done to measure immunoglobulin levels and the number of B cells.

Genetic testing may be done to confirm the diagnosis of X-linked agammaglobulinemia but is not usually needed. Testing is recommended for close relatives.


  • Immune globulin

  • Antibiotics

Immune globulin (antibodies obtained from the blood of people with a normal immune system) is given throughout life to provide the missing antibodies and thus help prevent infections. Immune globulin may be injected into a vein (intravenously) or under the skin (subcutaneously).

Antibiotics are promptly given to treat bacterial infections and may be given continuously.

People with X-linked agammaglobulinemia are not given vaccines that contain live but weakened organisms (viruses or bacteria). These vaccines include rotavirus vaccines, measles-mumps-rubella vaccine, chickenpox (varicella) vaccine, varicella-zoster (shingles) vaccine, bacille Calmette-Guérin (BCG) vaccine, and influenza vaccine given as a nasal spray.

Despite these measures, chronic sinus and lung infections often develop.