[PAGID] Eosinophilic abscesses in a CGD patient. .

[Sabiha Anis]

I agree with Dr Ashish on the reliability of Quantiferon Gold test in this case.  If the patient is giving a strong positive result with PPD then this test will not resolve the issue if there is already a hyerreactive immune system. 

 

Regards

Sabiha Anis
Clinical Immunologist

Sindh Institute of Urology and Transplantation

Karachi, Pakistan
 

> Date: Wed, 2 Jun 2010 13:48:54 -0400

> From: Ashish.Kumar at cchmc.org

> To: pagid at list.clinimmsoc.org

> Subject: Re: [PAGID] Eosinophilic abscesses in a CGD patient. .

> 

> Is Quantiferon useful/reliable in patients with CGD or 1L-12/IFN-g

> pathway defects? Specifically, is the negative predictive value good

> enough?

> Ashish 

> 

> Ashish Kumar, MD, PhD

> Assistant Professor

> Cincinnati Children's Hospital Medical Center

> Cincinnati, OH

> 

> 

> 

> >>> Howard Lederman <hlederm1 at jhmi.edu> 6/2/2010 1:36 PM >>>

> Mary Ellen,

> 

> Quantiferon gold is a commercial in vitro test. Whole blood is mixed

> with TB Ags. Read-out is interferon-gamma production. Here's a link to

> a page at the CDC website.

> http://www.cdc.gov/tb/publications/factsheets/testing/QFT.htm 

> 

> Howard

> Howard M. Lederman, M.D., Ph.D. 

> Professor of Pediatrics, Medicine and Pathology 

> Division of Pediatric Allergy and Immunology 

> Johns Hopkins Hospital - CMSC 1102 

> 600 N. Wolfe Street 

> Baltimore, MD 21287-3923 

> Phone: 410-955-5883 

> Fax: 410-955-0229 

> Email: Hlederm1 at jhmi.edu 

> 

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> Information sent by e-mail may not remain confidential. 

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> 

> -----Original Message-----

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

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

> Ellen

> Sent: Wednesday, June 02, 2010 1:15 PM

> To: 'pagid at list.clinimmsoc.org'

> Subject: Re: [PAGID] Eosinophilic abscesses in a CGD patient. .

> 

> Hi Steve,

> Can you explain to some of us ignorant (but interested) folks what a

> quantiferon gold is?

> Mary Ellen

> 

> 

> Mary Ellen Conley, MD

> Department of Immunology/ Mail Stop 351

> St. Jude Children's Research Hospital

> 262 Danny Thomas Place

> Memphis, TN 38105-3678

> FAX 901-595-3977

> TEL 901-595-2576

> 

> 

> -----Original Message-----

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

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

> Steven (NIH/NIAID) [E]

> Sent: Wednesday, June 02, 2010 11:41 AM

> To: Howard Lederman; pagid at list.clinimmsoc.org 

> Subject: Re: [PAGID] Eosinophilic abscesses in a CGD patient. .

> 

> Was the material cultured for Granulibacter and similar organisms? I

> doubt Churg Straus but stopping mesalamine in the short run seems

> harmless enough. Necrotizing granulomatous abscesses in CGD should be

> due to a bacterial or fungal infection. I would treat him empirically

> with ceftriaxone and vori, adding meropenem if he were acutely ill. If

> he is from Maryland then M. marinum or another NTM could do this,

> although 15 mm is pretty big. I would send a quantiferon gold.

> 

> Steve

> 

> 

> On 6/2/10 12:29 PM, "Howard Lederman" <hlederm1 at jhmi.edu> wrote:

> 

> Colleagues,

> 

> I have a 4 ½ year old male patient who was diagnosed with chronic

> granulomatous disease at 5 weeks of age after presentation with

> bilateral neck masses (cervical lymphadenitis caused by

> methicillin-sensitive S. aureus). He has had multiple episodes of

> cervical lymphadenitis, requiring parenteral antibiotics. He is

> maintained on interferon gamma (3x/week) and Ciprofloxacin (TMP/SMZ

> caused leukopenia and thrombocytopenia). Other medications are iron and

> multivitamin daily.

> 

> He has a history of bloody stools in early infancy thought to be due to

> cow's milk enterocolitis. Symptoms resolved when he was switched to an

> elemental formula, and a colonoscopy while on Elecare was normal. He

> has introduced to cow's milk at 12 months of age without problems.

> 

> When he was 3 ½ yrs old, he had bloody stools and poor weight gain.

> Cultures, and stool test for ova and parasites were normal. RASTs to

> food allergens were negative. Milk elimination did not help. In Jan

> 2010, EGD showed chronic duodenitis, and colonoscopy showed many areas

> with crypt distortion, prominent lamina propria eosinophils and rare

> intraepithelial eosinophils. Granulomas were not seen. He was started

> on Apriso (mesalamine) in early April to treat inflammatory bowel

> disease.

> 

> At the end of April, he developed fevers to 103 F with no obvious

> source. Over a two week period, his WBC increased to WBC 30,000 with

> 44% polys, 43% lymphs and 6% eos. CRP 16 mg/dL. He then developed

> abdominal distension and a new hydrocele over a short period of time,

> due to bulky lymphadenopathy involving the mesentery and

> retroperitoneum. A PPD was placed and was positive with 15 mm

> induration.

> 

> He underwent an excisional biopsy of several mesenteric nodes so that

> we could identify the mycobacterium that we were confident was the cause

> of his acute symptoms. No acid fast organisms were seen in the lymph

> nodes. Cultures are still negative but it has been only 2 weeks so

> far. However, the lymph node histology was a complete surprise to us. 

> There were granulomas, but the center of many of them were filled with

> abscesses of eosinophils! [The CIS has posted a photomicrograph of

> the lymph node biopsy at

> http://www.clinimmsoc.org/UserFiles/file/pagid_lederman.pdf] 

> 

> Our pathologists favor a diagnosis of Churg-Strauss based only upon the

> histology. The Infectious Diseases group thinks that this represents

> a drug hypersensitivity reaction and wants us to stop Apriso. Neither

> diagnosis explains the positive PPD.

> 

> Does anyone have a differential diagnosis for this?

> 

> Howard

> Howard M. Lederman, M.D., Ph.D.

> Professor of Pediatrics, Medicine and Pathology Division of Pediatric

> Allergy and Immunology Johns Hopkins Hospital - CMSC 1102 600 N. Wolfe

> Street Baltimore, MD 21287-3923

> Phone: 410-955-5883

> Fax: 410-955-0229

> Email: Hlederm1 at jhmi.edu <mailto:Hlederm1 at jhem.jhmi.edu>

> 

> WARNING: E-mail sent over the Internet is not secure.

> Information sent by e-mail may not remain confidential.

> 

> DISCLAIMER: This e-mail is intended only for the individual to whom it

> is addressed. It may be used only in accordance with applicable laws. If

> you received this e-mail by mistake, please notify the sender and

> destroy the e-mail.

> 

> 

> 

> Chief, Laboratory of Clinical Infectious Diseases CRC B3-4141 MSC 1684

> Bethesda, MD 20892-1684

> 301-402-7684 (v)

> 301-480-4508 (fax)

> smh at nih.gov 

> Assistant: Adrienne Woodworth

> 301-451-9019 (v)

> 301-480-4506 (fax)

> awoodworth at niaid.nih.gov 

> 

> 

> 

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