[PAGID] oral Ig
YaeJean Kim
yaejeankim at skku.edu
Sun Jun 28 05:39:07 EDT 2009
Thanks for your response.
Yes, I was also concerned about the possibility that the Ig would get all
destroyed while passing through GI tract. Anyway, I am also considering
intravenous IgG as well.
YaeJean
_____
From: pagid-bounces at list.clinimmsoc.org
[mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Daniel Conway
Sent: Saturday, June 27, 2009 8:03 PM
To: pagid at list.clinimmsoc.org
Subject: Re: [PAGID] oral Ig
If one is a "believer" in enteric Ig (and I am not), consider placement of
nasojejunal tube and pass this as far as one would need to bypass gastric
contents. Not that protein digestion fails to occur in the small intestine,
however.
Have you considered a trial of Ivig (considering higher doses)?
Sincerely,
Daniel H. Conway, MD
Asst. Professor of Pediatrics
St. Christopher's Hospital for Children
Drexel University College of Medicine
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The information in this communication is confidential and is directed only
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From: yaejeankim at skku.edu
To: pagid at list.clinimmsoc.org
Date: Sat, 27 Jun 2009 19:45:56 +0900
Subject: [PAGID] oral Ig
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 moms? Do his T cells proliferate to mitogens/antigens? Do
you know whether his T cells are mostly CD45RA+ (naïve) or CD45RO+ (mature)?
leaky SCIDs & maternally engrafted SCIDs 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 Crohns 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 Childrens 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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