[PAGID] REcurrent Campylobacter jejuni in a XLA patient

[Lengkeek, Marguerite S. LCDR]

If you change him from IVIG to subcutaneous Ig, you may be able to decrease
the protein loss in his stool and achieve higher steady state IgG levels.

One of my x-linked SCID patients had protein losing enteropathy due to a
celiac-like process.  He also had a history of chronic GI infections
(Giardia and C. diff) prior to the diagnosis.  He was initially requiring 2
grams/kg/month of IVIG, but when we changed him to SCIG, we were able to
decrease his requirement to an equivalent of 1.2 grams/kg/month.  He had to
have the SCIG infused twice weekly in 3 sites, but he had higher IgG levels.

Sincerely,

Marguerite S. Lengkeek, MD
LCDR, MC, USN
Division Head, Allergy and Immunology
Naval Medical Center San Diego
Naval Training Center
2051 Cushing Rd.
San Diego, CA  92106
(619) 524-1519 




-----Original Message-----
From: pagid-bounces at list.clinimmsoc.org
[mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Junker, Anne
Sent: Tuesday, September 14, 2010 12:53 PM
To: 'pagid at list.clinimmsoc.org'
Subject: Re: [PAGID] REcurrent Campylobacter jejuni in a XLA patient

If you do find chronic GI infection, you might consider oral Ig therapy
which has been used in several anecdotal reports of normo-immune and immune
compromised children with persistent rotovirus, polio, cryptosporidia or
clostridium difficile GI infections. We have successfully used IVIg product
at a dose of 150mg/kg, giving one dose on alternate days for 2 weeks, in
treatment of several of our immunocompromised patients, including post-BMT
with, respectively, rotovirus, polio, and salmonella B.  We reconsituted
lyophilized preparations of Ig for intravenous use as a 5% solution and
administered by NG tube.  We based this dose and scheduling on a single
report on the kinetics of orally administered IVIg, which showed that
rotovirus antigen would clear, and remain Ig-complexed, in stools of
rotovirus-infected patients for up to 3 days after the single dose of
150mg/kg.  If you have the lab support, you could consider testing the
opsonic capability of your available Ig preparation - one report I came
across showed that maternal serum was more effective than commercial Ig
product as a campylobacter opsonin for PMN-killing in an infected XLA
patient (Clin Inf Dis 1996; 12:526  Autenrieth et al).
 
anne
  
Anne K. Junker, MD
Associate Professor, Division of Infectious & Immunological Diseases,
Department of Pediatrics 
Director, Clinical and Population Health Studies, Child & Family Research
Institute
BC Children's and University of British Columbia
Director, Mother Infant Child Youth Research Network -Reseau de Recherche en
Sante des Enfants et des Meres au Canada
 
Room K4-223
4480 Oak Street
Vancouver, BC, CANADA  V6H 3V4
Ph: 604-875-3591  Fx: 604-875-2414
ajunker at cw.bc.ca


________________________________

	From: pagid-bounces at list.clinimmsoc.org
[mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Richard Wasserman
	Sent: Tuesday, September 14, 2010 6:40 AM
	To: pagid at list.clinimmsoc.org
	Subject: Re: [PAGID] REcurrent Campylobacter jejuni in a XLA patient
	
	
	I share Kate's concern about a focus of infection. In similar
circumstances cholecystectomy has solved the problem.
	Richard Wasserman
	Dallas
	
	
	On Tue, Sep 14, 2010 at 5:17 AM, Kate Sullivan
<sullivak at mail.med.upenn.edu> wrote:
	

		I think the speciation of these species is quite
problematic.  I defer to the ID folks to explain why.  My guess is that this
is either the type of Campylobacter that used to be called Flexispira or you
have a focus that you haven't cleared.  It is relevant because in both cases
you will need very prolonged multicoverage therapy.  TO look for a focus,
PET scans can be quite helpful.  To get a more precise read on the actual
bacteria, you might reach out to your national laboratories to see if they
can culture it and do DNA analysis or you might try the US NIH labs. 


		Kate 

		On Sep 14, 2010, at 4:58 AM, Pere Soler Palacin wrote:


			
			Dear colleagues, we would be pleased if you could
consider evaluating the following case we have just been referred:

			 

			10-year-old boy with diagnosis of XLA, malnutrition
and malabsorption (fecal alpha-1-antitrypsin was 1,68 mg/gr in 2009 and 2.1
mg/ gr in 2010) leading to failure to thrive and the need of increasing
doses of IVIG to reach normal plasma levels. The patient has presented
several respiratory tract infections and CT scan (2009) showed
bronchiectasis in lower left lobe.
			The patient has presented recurrent bacteremia due
to Campylobacter jejuni since 2009. Due to resistance pattern, the patient
has received both gentamycin and imipenem subsequently. Despite of
antibiotic treatment, stool cultures repeatedly yielded macrolide resistant
Campylobacter jejuni.
			In his last episode of bacteremia (July 2010) the
patient has been treated with cefotaxime and gentamycin for 2 weeks but was
then switched to meropenem (for 10 days) with good clinical response. Blood
cultures became negative but stool cultures remain positive. He is now
receiving oral cephalosporin.
			Abdominal ultrasound study and bone scintigraphy
were normal and echocardiogram showed mild pericardial effusion but no signs
of IE.
			Oral kanamycin is not available in Spain, and the
isolated strain showed was resistant to neomycin, therefore aminoglycosides
do not seem to be an option for oral treatment. Would you consider oral
doxycicline?
			In our opinion, this patient’s will be at risk of
recurrent bacteremia until stool cultures become negative. Do you agree with
it? What would be the next step in this patient?
			Thanks again,

			 

			Pere Soler-Palacín
			Pediatric Infectious Diseases and Immunodeficiencies
Unit.
			Vall d'Hebron University Hospital.
			Barcelona, Spain.

			----- Mensaje original -----
			De: pagid-request at list.clinimmsoc.org
			Para: psoler at vhebron.net
			Enviados: Miércoles, 15 de Julio 2009 21:27:58
			Asunto: Welcome to the "PAGID" mailing list
			
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		Kathleen Sullivan MD PhD
		Professor of Pediatrics
		Chief, Division of Allergy Immunology
		The Children's Hospital of Philadelphia
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	-- 
	Richard L. Wasserman, MD, PhD
	DallasAllergyImmunology
	7777 Forest Lane, Suite B-332
	Dallas, Texas 75230
	Office (972) 566-7788
	Fax (972) 566-8837
	Cell (214) 697-7211
	

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