[CIS-PAGID] gut protein leak - severe lymphopenia

[Routes, John]

Pedro
Assuming he has been scoped from above and below, suggest capsule endoscopy to find the source of the protein leak. We have had very good luck finding small bowel problems with this technique.
good luck
Jack

John M. Routes, MD
Chief, Section of Allergy and Clinical Immunology
Professor of Pediatrics, Medicine, Microbiology and Molecular Genetics
Department of Pediatrics
Children's Hospital of Wisconsin
Medical College of Wisconsin
9000 W. Wisconsin Ave.
Milwaukee, WI  53226-4874

Phone: 414-456-4802; 414-266-6997
Fax: 414-456-6487 (Clinical)
Fax: 414-456-6323 (Laboratory)
Email: jroutes at mcw.edu




________________________________
From: Pedro Avila <pa at northwestern.edu>
Reply-To: "pagid at list.clinimmsoc.org" <pagid at list.clinimmsoc.org>
Date: Tue, 21 Jun 2011 12:05:56 -0500
To: "pagid at list.clinimmsoc.org" <pagid at list.clinimmsoc.org>
Subject: [CIS-PAGID]  gut protein leak - severe lymphopenia

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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