[CIS-PAGID] Problem Patient

[Ochs, Hans]

I like Dewton's suggestion of Giardia.
If your patient reports weight loss, malabsorption (fat, B12) in addition to abdominal cramping, a set of multiple small bowel biopsies to check for Giardia by an expert is indicated - or a "therapeutic trial"with metronidazole
hans

Hans D. Ochs, MD, Dr. med
Professor of Pediatrics | Jeffrey Modell Chair of Pediatric Immunology Research
Center for Immunity and Immunotherapies
Seattle Children's Research Institute | University of Washington

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allgau at u.washington.edu<mailto:allgau at u.washington.edu>, hans.ochs at seattlechildrens.org<mailto:hans.ochs at seattlechildrens.org>

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From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Church, Joseph
Sent: Saturday, September 24, 2011 1:40 PM
To: pagid at list.clinimmsoc.org
Subject: [CIS-PAGID] Problem Patient

Colleagues

I follow a 50yo man with decades of the following:
     - "sinus" symptoms
     -  fatigue/fibromyalgia
     - "non-specific" colitis (pathology reports not available) with intermittent severe crampy pain and diarrhea
     - vitiligo
     - multiple food and drug intolerances (GI sx).

He recently developed dysuria with persistent burning despite normal UA and UC.

Laboratory studies have revealed the followijng:
     - IgG repeatedly normal (>1100)
     - IgA repeatedly undetectable
     - IgM repeatedly low (<30)
     - Normal T and B cell subsets
     - Normal antibody to tetanus toxoid
     - Absent responses to Pneumovax antigens
     - No lab evidence of autoimmune processes (negative ANA, ADNA, RF)
     - Normal thyroid function.

A 6-month trial of IVIG resulted in no benefit and was discontinued.

He is followed by a rheumatologist, gastroenterologist and urologist.

Could we be missing a chronic viral infection?

Any other suggestions?

Joe Church
Children's Hospital Los Angeles





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