[CIS-PAGID] gut protein leak - severe lymphopenia

[Pedro Avila]

Thank you, Dr. Fleisher and others for your input.
I wonder whether an abdominal lymphatic leak would be another possibility (S/P
apendectomy). He did not have overt ascites though.
I'll check with the radiologists here in Chicago to see what they have available to
wowrk up such cases.

Pedro



> Could any of his chest surgeries nicked the lymphatic duct, his combination of low

> albumen, Igs and T cells fits well with a lymphatic leak and as Dewton noted

> intestinal lymphangiectasia is one possibility and since you have ruled out

> constrictive pericarditis which would be a secondary cause, a lymphatic duct leak is

> a possibility (although not terribly likely without some accumulation of lymph in

> the chest). I do not think that radiolabeled albumen studies are available here in

> the US, the Waldmann/Strober labs in the 1960-70s studied IL with chromium 51

> labeled albumen and I cc'd Warren for his possible thoughts on this intriguing

> patient. Interestingly most IL patients do relatively well despite their rather

> strikingly abnormal lab findings.

>

> Thomas A. Fleisher, M.D.

> Chief, Department of Laboratory Medicine

> NIH Clinical Center

> 301 496-5668 (T)

> 301 402-1612 (F)

> ________________________________

> From: Pedro Avila [mailto:pa at northwestern.edu]

> Sent: Tuesday, June 21, 2011 1:06 PM

> To: '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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-- 
Pedro Avila, MD
Northwestern University Feinberg School of Medicine
Division of Allergy-Immunology
Chicago, IL 60611
Email: pa at northwestern.edu