Historically, the nitroblue tetrazolium (NBT) test has been the recognized diagnostic test for chronic granulomatous disease (CGD). Relying on light microscopy, the NBT test provides only a qualitative determination of phagocyte nicotinamide adenine dinucleotide phosphate (NADPH) oxidase activity.

The dihydrorhodamine (DHR) test produces fewer false-negative results than the NBT test and is known for its1,2:

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Relative ease of use

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Ability to distinguish between X-linked (gp91phox) and autosomal
recessive forms of CGD

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Ability to detect carrier status

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High sensitivity that can detect low levels of NADPH activity

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Ability to quantitatively assess residual superoxide production

If you suspect CGD,
get a DHR Collection Kit at no cost to
confirm a diagnosis

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Examples of pre- and
postactivation DHR histograms

What to look for when reading DHR histograms

INDIVIDUAL WITHOUT CGD

The histograms below show the difference in neutrophil NADPH oxidase activity in both an unstimulated sample and a sample that has been stimulated with PMA. There is a strong shift on the x-axis after PMA stimulation, indicating normal, robust neutrophil NADPH oxidase activity.

Histogram showing differences in NADPH oxidase activity between an unstimulated sample and a sample stimulated with PMA
Blue square icon

Unstimulated sample

Orange square icon

After PMA stimulation*

PATIENT WITH X-LINKED CGD

The histogram for the stimulated sample shows almost no shift along the x-axis, indicating an absence of neutrophil oxidative burst due to defective NADPH oxidase function.

Histogram showing absence of neutrophil oxidative burst due to defective NADPH oxidase function in PMA stimulated and unstimulated samples in patient with x-linked CGD
Blue square icon

Unstimulated sample

Orange square icon

After PMA stimulation*

X-LINKED FEMALE CGD CARRIER†

The stimulated sample shows 2 populations of cells. In one population, there is minimal shift along the x-axis because of the absence of NADPH oxidase activity. The other population does have NADPH oxidase activity, as indicated by the shift along the x-axis to the right.

Histogram showing NADPH oxidase activity in X-linked female CGD carrier for unstimulated sample and sample with PMA stimulation
Blue square icon

Unstimulated sample

Orange square icon

After PMA stimulation*

PATIENT WITH AUTOSOMAL RECESSIVE CGD

The stimulated sample shows a low degree of neutrophil NADPH oxidase activity, as demonstrated by a shift to the right along the x-axis that is much less dramatic than in histograms of patients with X-linked CGD. Both males and females can present with autosomal recessive CGD.

Histogram showing NADPH oxidase activity in patient with autosomal recessive CGD for unstimulated sample and sample with PMA stimulation
Blue square icon

Unstimulated sample

Orange square icon

After PMA stimulation*

These values are representations of possible DHR outcomes. Because of heterogeneity in disease severity and genotype, outcomes will vary. Lab results typically include percentage (%) of residual oxidative burst values.

Abbreviations: MFI, mean fluorescence intensity; PMA, phorbol myristate acetate.

*PMA is an activator used to stimulate neutrophil NADPH oxidase activity.

†Usually a female with a healthy and a mutated allele for gp91phox.

Adapted from Leiding JW, et al (2013)3 and Jirapongsananuruk O, et al (2003).4

Importance of family testing

Because CGD is an inherited disorder, families of patients with CGD may benefit from DHR testing. Testing can help distinguish CGD subtype and identify carrier status.

An X-linked carrier mother has a 50% chance of having a carrier daughter or an affected son.2 With autosomal recessive CGD, both parents are carriers. Each child has a 75% chance of being affected or a carrier.2

Graphic showing X-Linked CGD inheritance patterns, with a 50% chance of females being unaffected or being a carrier, and a 50% chance of males being unaffected or having CGD

Graphic showing X-Linked CGD inheritance patterns, with a 50% chance of females being unaffected or being a carrier, and a 50% chance of males being unaffected or having CGD

Graphic showing Autosomal Recessive CGD inheritance patterns, with a 25% chance of each child being unaffected, a 50% chance of each child being a carrier, and a 25% chance of each child being affected

Graphic showing Autosomal Recessive CGD inheritance patterns, with a 25% chance of each child being unaffected, a 50% chance of each child being a carrier, and a 25% chance of each child being affected

Carriers may benefit from genetic counseling prior to starting a family. While CGD carriers themselves are usually not affected, they can exhibit CGD-like symptoms such as5-7:

  • Dermatitis
  • Stomatitis
  • Discoid lupus-like disease
  • Photosensitive rashes

See how to use the DHR
Collection Kit

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If you suspect CGD,
the DHR Collection Kit is being
offered at no cost

Request a Kit

1. Kuhns DB, Alvord WG, Heller T, et al. Residual NADPH oxidase and survival in chronic granulomatous disease. N Engl J Med. 2010;363(27):2600-2610. doi:10.1056/NEJMoa1007097 2. Leiding JW, Holland SM. Chronic granulomatous disease. In: Pagon RA, Adam MP, Ardinger HH, et al, eds. GeneReviews®. Seattle, WA: University of Washington, Seattle; 1993-2016. 3. Leiding JW, Malech HL, Holland SM. Clinical Focus on Primary Immunodeficiencies: Chronic Granulomatous Disease. Immune Deficiency Foundation; 2013. 4. Jirapongsananuruk O, Malech HL, Kuhns DB, et al. Diagnostic paradigm for evaluation of male patients with chronic granulomatous disease, based on the dihydrorhodamine 123 assay. J Allergy Clin Immunol. 2003;111(2):374-379. doi:10.1067/mai.2003.58 5. Holland SM. Chronic granulomatous disease. Hematol Oncol Clin North Am. 2013;27(1):89-99. doi:10.1016/j.hoc.2012.11.002 6. Magnani A, Brosselin P, Beauté J, et al. Inflammatory manifestations in a single-center cohort of patients with chronic granulomatous disease. J Allergy Clin Immunol. 2014;134(3):655-662. doi:10.1016/j.jaci.2014.04.014 7. Song E, Jaishankar GB, Saleh H, Jithpratuck W, Sahni R, Krishnaswamy G. Chronic granulomatous disease: a review of the infectious and inflammatory complications. Clin Mol Allergy. 2011;9(1):10. doi:10.1186/1476-7961-9-10