[PAGID] 70 year old nurse with low serum immunoglobulins, arthralgia, diminished specific antibody titer 1 year post immunization and decreased switched memory B cells

[michael clayton]

Hello everyone:  I have a patient that I would like to get feedback on.  A colleagues' 70 year old nurse was referred for consultation after her rheumatologist found slightly low serum immunoglobulins ( IgG 564, IgM 62, IgA 54).  She was sent to the rheumatologist because of achy joints, recurrent fevers to 101 every 21 days and recurrent aphthous stomatitis.  The only known significant infection was pneumonia within the previous 6 months.  ANA, RF and ANCA all wnl.  Parvovirus, Lyme and T pallidum titers all negative.  Serum albumin normal, and normal urinalysis.  No neutropenia noted during febrile episodes.  Protein electrophoresis was normal.  I ordered specific antibody titers and tetanus was 0.0 IU/ml, pneumococcal titers showed only 6/14 serotypes in protective range.  She was immunized with both, showing excellent response: tetanus 0.46 IU/ml, and now all pneumococcal serotypes showing fourfold increase in titer, or an increase to > 1.0 ug/ml.

I did not see her again until last month, when I was disappointed to find that she has continued to have the symptoms.  The rheumatologist tried colchicine empirically for Famiial Mediteranean Fever without any consistent improvement.  I repeated her labs, and the pneumococcal serotypes showed similar levels of antibody, but her tetanus titer had dropped to 0.05 IU/ml in 10 months.  Immune panel:  CD3 75%, CD4 49%, CD8 25%, CD 19%, CD 16/56 15%, CD/CD8 2  (all wnl).  CBC= WBC 4.3, 64% neutrophils, 27% lymphs, 8% monos, 1% eos, 182K plts.  Immunoglobulins now IgG 591, IgA 48, IgM 50.  I ordered a B cell panel from National Jewish wondering if she was evolving into CVID and she had a decreased number of switched memory B cells:  IgD-/CD27+   4.1%  of  CD20+ cells (nl 8-42).  The ICOS and BAFF receptor assays were normal. 

The questions I have about her are as follows:  What am I to make of the decrease in switched memory B cells in light of the fact that her tetanus titer appears to have dropped precipitously over 10 months?  Her IgG level is not impressively low, but she has had pneumonia which was well documented,  recurrent fevers of undetermined etiology and mouth ulcers that never heal.  I would appreciate any of your thoughts.................


Michael H. Clayton, MD, MPH
Assistant Professor, UNM Dept. of Pediatrics, ID/Immunology Division
2211 Lomas Blvd. N.E.
Albuquerque, N.M.   87131
505-296-5426 (office)
505-228-7958 (cell)
mhclayton at msn.com