[CIS-PAGID] Asymptomatic hypogammaglobulinemia

[Lengkeek, Marguerite S. LCDR]

Have you checked for any secondary loss of protein/immunoglobulin?  Does he
have any GI symptoms that might cause a protein losing enteropathy?  Have
you considered ordering stool alpha 1 anti-trypsin and urine protein or
UPEP?  

The other cases with the almost absent Ig run the risk of their first
infections being severe ones.  I follow 2 CVID patients that were
misdiagnosed until their 60s. One was picked up after H. flu meningitis with
gross pus from his spinal tap and a week in the ICU comatose on a vent.  The
other was picked up after S. pneumoniae sepsis.  They did have infections
(sinusitis and PNA) previously, so they may be different.

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 
Marguerite.lengkeek at med.navy.mil


-----Original Message-----
From: pagid-bounces at list.clinimmsoc.org
[mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Charlotte
cunningham-rundles
Sent: Thursday, December 30, 2010 11:55 AM
To: PAGID
Subject: Re: [CIS-PAGID] Asymptomatic hypogammaglobulinemia

Hi Joe,


There are a lot of these around. We did a survey of our referrals for a 2
year block and came up with over 100 --- referred with just this question.
On paper, with pretty good antibodies, not CVID exactly. For insuracne, you
can use that term I guess, but as for treatment, as others noted, maybe Ig
is not currently needed.   If he came to me, I’d do a bunch more antibodies
to firm up the current info, and follow yearly or more often if infections
became an issue.

PS: with regard to other exchanges:  Some CVID subjects, with virtually no
immune globulin, just do not have any infections. It is a real mystery, but
it is a real fact.  I have one like the one Andy mentioned, an engineer of
at least 60 now, with IgG of about 150, no IgA or M, with NO antibody and NO
infections. Sure, he is a CVID, but he refuses Ig, and has done for 15 or 20
years.  

PSS: have a wonderful New Year!


Charlotte

Church, Joseph



	Colleagues:
	 
	I am seeing a 42yo man with no significant infection history.  A low
globulin fraction on a chem. panel lead to his primary MD to obtain QUIGs:
IgG 309, IgA <7, IgM 30.  He has protective tetanus and Hib antibody, but
responded to only 3 of 23 serotypes following Pneumovaxtm.
	 
	Review of past chem. panels suggest these finding have been present
for 10 years.  
	 
	Glaum and Levinson reported similar patients (Ann Allergy Asthma
Immunol 2008;100:396-7), but I could not get a sense of what they did about
their findings.
	 
	Should patients like this be placed on immunoglobulin replacement?
	 
	Joe Church
	Children’s Hospital Los Angeles
	
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