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

[Charlotte cunningham-rundles]

Hi Michael,

I am thinking that the clinical concerns seem more weighty than the lab
data.  -- the pneumococcal response is not particularly unusual according to
my reading, and it stayed put over time.  I am myself wondering if the
second tetanus test was accurate -- pretty hard to loose this antibody in 10
months. 

PS, my opinion, I don't think the B cell panel adds anything much to an
antibody workup, except for real CVID and she does not seem to be in that
category.   I also think a lab offering ICOS or BAFFr for money is pretty
indefensible (for research maybe, not otherwise.)

I assume with Andy that there is something else brewing.

Charlotte


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