[PAGID] Candidiasis and cellular dysfunction in a previouslyhealthy adult

[Paris, Kenneth]

Hi,
 
I cared for a similar patient (60 yo female) recently who presented with only esophageal candidiasis.  Her immunologic workup showed a similar pattern to your patient, however a CT scan revealed a malignant thymoma which was successfully resected.  I've followed her over the last 1 1/2 years, and her antibody immunity remains normal with normal immunoglobulins and no significant infections (the candidiasis has resolved as well).   After the resection, we did find very high anti-ACH receptor antibodies which was likely the cause of fatigue.
 
Ken
 
Kenneth Paris MD, MPH
Assistant Professor of Pediatrics
Division of Allergy and Immunology
LSU Health Sciences Center
Children's Hospital of New Orleans
 
Mail: 
200 Henry Clay Avenue
Children's Hospital 
Research Institute for Children 4th Floor
New Orleans, LA 70118
Phone:  504-896-9589
Fax:  504-896-9311
Email:  kparis at lsuhsc.edu <mailto:kparis at lsuhsc.edu> 
 
The information contained in this e-mail is privileged and confidential and is intended only for the use of the addressee(s) indicated above. Use or disclosure of information e-mailed in error is respectfully prohibited. If you have received this e-mail in error, please contact the sender and immediately delete the original message or you may call 504-896-9589. Thank you.

________________________________

From: pagid-bounces at list.clinimmsoc.org on behalf of Richard L. Wasserman
Sent: Tue 12/2/2008 10:28 PM
To: PAGID
Subject: [PAGID] Candidiasis and cellular dysfunction in a previouslyhealthy adult



I'd very much appreciate comments and suggestions for further work up of
this patient.
Richard Wasserman
Dallas

The case:
I saw a 32 yo woman with candida esophagitis. She had been completely
well until several months after the birth of her second child when she
developed malaise, fatigue and non-specific GI symptoms of bloating,
abdominal pain and intermittent diarrhea. She has lost more than 10% of
her body weight and is significantly below her pre-pregnant weight. She
has been on a high calorie diet and continues to loose weight. She has
had an extensive GI evaluation including EGD, colonoscopy and capsule
study; all normal. There have been no other infections (no significant
infection history ever), no signs nor symptoms of collagen vascular
disease. Her studies of cellular immunity are:


Abs.CD19+ Lymphs          245 /uL                    12-645
Absolute CD 3            1433 /uL                    622-2402
Absolute CD 4 Helper      1053 /uL                    359-1519
Abs. CD 8 Suppressor      326 /uL                    109-897
% CD19+ Lymphs            13.6 %                      3.3-25.4
% CD 3 Pos. Lymph.        79.6 %                      57.5-86.2 
% CD 4 Pos. Lymph.        58.5 %                      30.8-58.5
% CD 8 Pos. Lymph.        18.1 %                      12.0-35.5
CD4/CD8 Ratio            3.23                        0.92-3.72 
WBC                      5.4 x10E3/uL                4.0-10.5
 Hemoglobin                13.0 g/dL                  11.5-15.0
 Neutrophils              56 %                        40-74          
 Lymphs                    34 %                        14-46 
 Monocytes                8 %                        4-13 
 Eos                      1 %                        0-7 
 Basos                    1 %                        0-3           
Tests: (3) Lymphocyte Activation (826963)
Unstimulated CD4          12 ng/mL
PHA - CD4 Activation [L]  119 ng/mL           >225             Normal
activation of CD4 cells is indicated if the
patient's responses reach the threshold or
reference value shown.  The cellular immune
response to PHA stimulation can be categorized as
follows:
ng/mL of ATP        Interpretation
<226                  Low Immune Cell Response
226-524            Moderate Immune Cell Response
 >524                 Strong or High Level of Immune Cell Response

Tests: (4) Tetanus toxoid-CD4 Activation (827140)
Tetanus toxoid-CD4 Act.*
                     [L]  10 ng/mL                    >23 
This test was developed and its performance

characteristics determined by IBT Reference Lab.
It has not been cleared or approved by the FDA.
**Effective October 29, 2008 this panel will be**
 non orderable. For replacement number, please
 contact your local LabCorp Representative.
 placement number, please contact
 your local LabCorp Representative.

Tests: (5) Concanavalin A(CON A)-CD4 Act. (827144)
Concanaval A (Con-A)-CD4 Act.*
                           189 ng/mL                  >136
This test was developed and its performance
characteristics determined by IBT Reference Lab.
It has not been cleared or approved by the FDA.

Tests: (6) Varicella-Zoster-CD4 Act. (827138)
Varicella-Zoster-CD4 Act.*
                     [L]  14 ng/mL                    >22
This test was developed and its performance
characteristics determined by IBT Reference Lab.
It has not been cleared or approved by the FDA.

Tests: (7) Candida albicans-CD4 Act. (827134)
Candida albicans-CD4 Act.*
                     [L]  13 ng/mL                    >25 
This test was developed and its performance
characteristics determined by IBT Reference Lab.
It has not been cleared or approved by the FDA.

Tests: (8) ANA w/Reflex if Positive (164863)
! Antinuclear Antibodies Direct
                           38 AU/mL                    0-99            
                               Negative        <100
                               Equivocal  100 - 120
                               Positive        >120



Tests: (9) Sedimentation Rate-Westergren (005215)
Sedimentation Rate-Westergren    5 mm/hr       0-20         
Tests: (10) C-Reactive Protein, Quant (006627)
C-Reactive Protein, Quant    2.7 mg/L           0.0-4.9     


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