[PAGID] oral Ig

[YaeJean Kim]

Hi, all 

 

I have another question about a patients with WAS who got transplanted and
has had chronic diarrhea due to virus called “calicivirus”.

 

This is a pt with WAS who was transplanted about a year ago. He developed
severe severe GVH including skin and gut. He got better
then he developed
severe diarrhea which was suspected for GVH back then and H-O guy put him on
a significant immunosuppresion
later calicivirus was reported. He has had
calicivirus dected for the past 7 months
still has diarrhea upto 8-10 times
a day. Multiple endoscopies
the most recent one showed no evidence of GVH
but more likely viral enteritis
no CMV or EBV were seen on staining. 

 

I requested for EM
because I was expecting to see virus particle if there is
any invasion
 this is pending and takes long time
I am not sure whether we
can identify calici by EM
anyway I though that was worth of try. 

 

For tx options
there is nothing to give but the child is still suffering a
lot. And finally, I have thought of oral IVIG 
.giving Ig by mouth to
control the viral infection in the gut mucosa
.there is no guarantee that Ig
will be destroyed by gastric juice 
but I can still think and if that is the
concern, I can persuade GI guy,  do the endoscopy and let him spary Ig on
the surface of the gut
. Or Ig enema even!!

 

Do you also try things like this with IVIG?  If I give Ig, how much (the
dose, and frequencies) should I give per mouth? 

Thanks for any comments. 

 

YaeJean Kim, MD

 

Assistant Professor 

50 Ilwon-dong Gangnam-gu

Division of Infectious Diseases

Department of Pediatrics

Samsung Medical Center

Sungkyunkwan University

Seoul, 135-710

South Korea

tel) 82-2-3410-3539, 0987

fax) 82-2-3410-0043

yaejeankim at skku.edu

  _____  

From: pagid-bounces at list.clinimmsoc.org
[mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Torgerson, Troy
Sent: Friday, June 26, 2009 8:21 AM
To: pagid at list.clinimmsoc.org
Subject: Re: [PAGID] two questions on enteritis

 

YaeJean,

 

IPEX is certainly a good initial thought given his symptoms but I would
include a couple of other disorders:

First, for IPEX:  Has he had eczema or other rash?   Has he had other
autoimmunity as well (hemolytic anemia, thrombocytopenia, liver disease,
etc.)?  Most of the pts with FOXP3 mutations have other autoimmune
manifestations in addition to the enteropathy, eczema, and endocrinopathy.
Have you been able to get flow cytometry done to see if he has FOXP3+ cells
in his CD4+ population, would also look at CD25 expression by flow to make
sure it is there (see James’ comment)?  When they sequenced FOXP3, do you
know what they sequenced and how much of the gene they looked at?  About 5%
of the mutations we have identified are in non-coding regions of the gene
(polyadenylation site or upstream non-coding region).  If they sequenced
genomic DNA did they look at all of the exon/intron junctions to rule out a
splicing mutation or did they sequence cDNA?  

 

Second, Leaky SCID:  Some Leaky SCID/Omenn or maternally engrafted SCID
patients can look a lot like IPEX.  Pts with IPEX can get infections for
sure but pneumonias are not all that common and “frequent” infections are
not all that common.  What are the T/B/NK numbers?  Are they his T/B/NK
cells or his mom’s?  Do his T cells proliferate to mitogens/antigens?  Do
you know whether his T cells are mostly CD45RA+ (naïve) or CD45RO+ (mature)?
– leaky SCID’s & maternally engrafted SCID’s are usually very skewed to
CD45RO+.  Are his parents consanguineous? 

 

Third, CGD:  Incidence of IBD/IBD-like symptoms is very high in CGD and we
recently saw an infant here in Seattle with initial presentation of early
onset “Crohn’s” disease with granulomatous lesions on biopsy that has X-CGD.
Pneumonia also common in CGD.  Would check neutrophil oxidative burst as
this would dramatically alter the therapeutic approach.

 

Best,

 

TT

 

Troy R. Torgerson, MD PhD

 

Assistant Professor, Pediatric Immunology/Rheumatology

University of Washington, Department of Pediatrics

 

Co-Director, Immunology Diagnostic Laboratory

Center for Immunity and Immunotherapies

Seattle Children’s Research Institute

1900 9th Ave., C9S-7

Seattle, WA  98101-1305

 

Tel:  (206) 987-7450

Fax:  (206) 987-7310

 

Email:  Troy.Torgerson at seattlechildrens.org

 

  _____  

From: pagid-bounces at list.clinimmsoc.org
[mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of YaeJean Kim
Sent: Thursday, June 25, 2009 2:46 PM
To: pagid at list.clinimmsoc.org
Subject: [PAGID] two questions on enteritis

 

Dear all,

 

I am YaeJean Kim who attended the 2007 PID summer school while I was a
fellow in Seattle and now am relocated to Seoul, Korea. 

 

I see a patient in my institute and have questions as below. 

 

This is a now 18 month boy who is suspected for IPEX or IPEX like syndrome.
He has had intractable diarrhea, recurrent infections including pneumonia
and anal infection, fistula, hypothyroidism (only endocrinopathy
manifestiation he has) since age of 1 month. His brother died too with
similar features. 

 

He was initially presented with failure to thrive. Intestinal biopsy (at the
age of 7 mo) was suspected for IPEX but FOXP3 mutation was not observed.
Because of severe anal fistula, he received cecostomy. He is now on
azathioprine by our GI guy who is the main doctor for him. He still seems to
have frequent infection with fevers and get hospitalized for antibiotics. Do
you have any suggestions? Or should we repeat the test? All the tests were
done about 10 months ago. 

 

I would appreciate any feedback. Thanks a lot.  

 

 

Jean

 

--------------------------------------------

 

YaeJean Kim, MD

 

Assistant Professor 

50 Ilwon-dong Gangnam-gu

Division of Infectious Diseases

Department of Pediatrics

Samsung Medical Center

Sunggyungwan University

Seoul, 135-710

South Korea

tel) 82-2-3410-3539, 0987

fax) 82-2-3410-0043

yaejeankim at skku.edu

 

Children's Hospital and Regional Medical Center is now Seattle Children's.
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