[PAGID] Patient with lymphopenia

[Oner Ozdemir]

Dear Dr. Raasch;

There are some patients who had warts and lymphopenia reported in the
literature:

 1- Multiple flat warts associated with idiopathic CD4-positive T
-lymphocytopenia. J Am Acad Dermatol. 2008 Feb; 58(2 Suppl): S37-38.

2- Idiopathic CD4+ T-cell lymphocytopaenia associated with recalcitrant
viral warts and squamous malignancy. Acta Derm Venereol. 2007; 87(1): 76-77.

You could check these literature which may help.

Öner Özdemir, MD
Assoc. Prof. Pediatrics
Sema Teaching and Training Hospital (Private)
Dragos, Maltepe-Kartal, İSTANBUL -TÜRKİYE





 On 4/21/08, Jason Raasch, MD <raas0027 at umn.edu> wrote:


> Mel,

>

>

> No.  A technical question I wanted input on is whether that degree of

> lymphopenia would result in falsely low results with a standard sample.

> Would I need to draw a [relatively] large volume of blood and

> 'concentrate'

> her lymphocytes prior to the stim tests?

>

>

>

> --jason

>

>

>

> Jason P. Raasch, MD

>

> Midwest Immunology Clinic

>

>

>

> West Health

>

> 2805 Campus Dr, #215

>

> Plymouth, MN 55441

>

>

>

> Telephone: 763.577.0008

>

> FAX: 763.577.0192

>

> e-mail: raas0027 at umn.edu

>

> _____

>

> From: pagid-bounces at list.clinimmsoc.org

> [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Berger, Melvin

> Sent: Sunday, April 20, 2008 8:53 PM

> To: pagid at list.clinimmsoc.org

> Subject: Re: [PAGID] Patient with lymphopenia

>

>

>

> Have mitogen/antigen stim tests been done ?

>

>

>

> Melvin Berger, M.D., Ph.D.

>

> Professor of Pediatrics and Pathology

>

> Case Western Reserve University

>

> phone 216 844 3237

>

>

>

> Director, Jeffrey Modell Center for Primary Immune Deficiencies

>

> Division of Allergy-Immunology

>

> Rainbow, Babies and Children's Hospital

>

> University Hospitals of Cleveland

>

> RB&C Rm 504, MS 6008B

>

> 11100 Euclid Ave.

>

> Cleveland, OH 44106

>

>

>

> _____

>

> From: pagid-bounces at list.clinimmsoc.org on behalf of Jason Raasch, MD

> Sent: Sun 4/20/2008 9:42 PM

> To: pagid at list.clinimmsoc.org

> Subject: [PAGID] Patient with lymphopenia

>

> Please offer your insight into this 53 year old woman with persistent

> verruca plantaris (plantar warts) and severe lymphopenia.  Consider the

> following questions as you review the case:

>

>

>

> First note flow cytometry (presented in absolute numbers, gated on CD45):

>

>

>

> Total CD3 lymphocytes: 53 per mm3 (reference 1064-1672)

>

> CD3+CD4+: 10 (627-1102)

>

> CD3+CD8+: 38 (247-741)

>

> CD4:CD8 = 0.27

>

> CD19:  93 (95-418)

>

> CD56+16+: 93 (95-494)

>

>

>

> At first glance, whether primary or acquired, this is striking.  Now

> consider her clinical history:  She was well from birth through

> adolescence.

> Varicella at age five; shingles at age 19.  Seizures at age 23; on

> Phenobarbital for 10 years this was then discontinued and she has had no

> further neurologic events.

>

>

>

> By her late 20's she began having persistent verruca vulgaris on hands,

> knees, pre-tibial area and feet.  Over the last 30 years has failed OTC

> therapies as well as excision, laser ablation, cryotherapy, topical and

> oral

> retinoids and localized bleomycin.

>

>

>

> Variably positive ANA (up to 1:320, but often undetectable) starting in

> her

> 30s.  Other than intermittent arthralgias, no other symptoms.

> Hypothyroidism diagnosed at age 51 (thyroglobulin and thyroperoxidase

> antibodies undetectable).

>

>

>

> Lymphopenia brought to her attention at age 52 (WBC 4,000/mm3; ANC=3,200;

> ALC=240).  Medical record review actually demonstrates same findings as

> far

> back as 1970's and persistently each decade thereafter, suggesting a

> long-standing finding.

>

>

>

> Review of systems completely unremarkable except for the above, as well as

> mild depression and hypothyroidism.  No GI symptoms.  No history of

> recurrent infection.  No history of heart disease or abnormal facies.

> Patient reports unremarkable family history.

>

>

>

> Over the last 18 months the following have been UNREMARKABLE:

> electrolytes,

> ALT/AST, serum albumin and protein, B12, folate and iron levels, serum

> electrophoresis/immunofixation, quantitative immunoglobulins,

> tetanus/diphtheria, pneumococcal and varicella titers, isohemagglutinins,

> rheumatoid factor, dsDNA, CCP antibody, CRP, ESR, C3, C4, CH50, TSH and

> T4.

> Stool alpha-1 antitrypsin normal.  HIV ELISA X 2 negative.  FANA 1:40 with

> homogeneous pattern.

>

>

>

> INTERESTINGLY, this patient reports that her HEALTHY adolescent daughter

> was

> incidentally found to have just as severe a lymphopenia AND neutropenia.

>

>

>

> In summary this is a fairly health woman with a striking lymphopenia (that

> most likely has been present over the last 30+ years), persistent verruca

> vulgaris and intermittently positive ANA.  A HEALTHY daughter has

> lymphopenia and neutropenia and has not had evaluation.

>

>

>

> So the questions:

>

> 1.      Who has seen cases like this?

>

> 2.      Why has she had such a benign course despite such a lymphopenia?

>

> 3.      To what extent should a diagnosis be pursued?  In her daughter?

>

>

>

> I am interested in any comments.

>

>

>

> Have a great week.

>

>

>

> --jason

>

>

>

> Jason P. Raasch, MD

>

> Children's Hospitals and Clinics of Minnesota

>

>

>

> Midwest Immunology Clinic

>

> 2805 Campus Dr, #215

>

> Plymouth, MN 55441

>

>

>

> Telephone: 763.577.0008

>

> FAX: 763.577.0192

>

> e-mail: raas0027 at umn.edu

>

>

>

> Visit us at www.UHhospitals.org <http://www.uhhospitals.org/>.

>

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>

>

>

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