[CIS-PAGID] gut protein leak - severe lymphopenia

[Pedro Avila]

Dear PAGID members,

Your suggestions on treatment and work up to locate a possible gut 
protein leak are welcome.

This is a 46yo W male who had lymphoma in 1984 (S/P splenectomy, XRT, 
chemo, appendectomy ->remission), and in 2001 had 3xCABG for CAD. 
Also tumor in vocal cord in 1984 -> XRT -> hypothyroidism.

In a check up in 2009, labs showed low albumin, further work up 
revealed low IgG (392mg/dL) and IgM, and lymphopenia (CD4=47, normal 
B cell count).

Infections: Only once he had bilateral pneumonia treated with Biaxin 
x 2 wks as outpatient in 2007. No sinus problems, no frequent URIs, 
nor bronchitis.

Work up (attached): No proteinuria, HIV, or constrictive pericarditis.

He has persistently low IgG (390s), IgM, and severe T lymphopenia ( 
CD4=40s, labs attached). Pneumovax response was minimal. IgA is 
normal. His fecal alpha1-anti-trypsin was 145 (nl < 55mg/dL).

He has been very healthy all along despite low IgG, IgM and severe 
CD4 lymphopenia (~40/mm3). He has 2 elementary school kids who attend 
day care, so he is exposed to respiratory microbes often.

Because he has been so healthy, he is reluctant to start Bactrim (PCP 
prophylaxis due to CD4 lymphopenia).

Is the increase in fecal alpha1-anti-trypsin disproportional to the 
marked CD4 lymphopenia?

Any suggestions for further therapy and to locate the protein leak in 
his GI tract?

I thank in advance for your help,

Pedro



Pedro Avila, MD
Associate Professor of Medicine
Division of Allergy-Immunology
Northwestern University Feinberg School of Medicine
Chicago, IL
Tel: 312-695-4000
Fax: 312-695-4141

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