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

[Riedl, Marc]

Michael,

We're seeing a sizeable population of these patients as our internists and other specialists are more frequently sending screening QUIGs in "ill" patients.  I agree with others that one needs to be very concerned about lymphoma or monoclonal gammopathy in this age group.  I also agree that it's unusual to lose protective tetanus titers that rapidly, so would recheck, though we not infrequently see this phenomenon with pneumococcal titers.

Ultimately, in my experience, this comes down to clinical judgment as to whether Ig replacement is going to benefit the patient.  We typically obtain full PFTs with DLCO +/- hi-res Chest CT to definitively r/o bronchiectasis or other smoldering chronic lung disease that may be overlooked.  In the absence of this or other significant sinopulmonary infection, it's tough to expect benefits from IVIG, though clearly that's a decision to be made on a case-by-case basis.

Best,

Marc

Marc Riedl, M.D., M.S.
Assistant Professor of Medicine
Section Head, Clinical Immunology and Allergy
UCLA - David Geffen School of Medicine
10833 Le Conte Ave, 37-131 CHS
Los Angeles, CA  90095-1680
Tel 310.206.4345  Fax 310.267.0090



-----Original Message-----
From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Charlotte cunningham-rundles
Sent: Saturday, July 31, 2010 3:37 PM
To: PAGID
Subject: Re: [PAGID] 70 year old nurse with low serum immunoglobulins, arthralgia, diminished specific antibody titer 1 year post immunization and decreased switched memory B cells

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



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