[CIS-PAGID] Challenging case: hypogammaglobulinemia and hypocomplementemia

[Zachary D. Jacobs, MD]

Hello,


 I am a (relatively) young immunologist just out of training and am hoping
that I could garner some helpful suggestions from this incredibly adept and
intelligent community for what I feel is a challenging case.


I recently saw a 68 year-old woman referred by rheumatology for a low IgG
level found incidentally.  She was seen initially by the rheumatologist for
evaluation of neck pain and intermittent fatigue along with painful hands.
Her cervical spine showed degenerative changes on X-ray.  Her diagnosis was
osteoarthritis of the cervical spine and hands.  In the course of her
work-up for rheumatologic conditions, her IgG was found to be 351 mg/dl and
she was sent to me for evaluation.


As far as her infectious history, it is for all intents and purposes
nonexistent.  She has not had pneumonia since childhood.  She does not have
issues with recurrent or chronic sinusitis and does not have a history of
sinus surgery.  She does not have a history of invasive infections,
admission for infections, recurrent soft tissue infections, or urinary
tract infections.  She does relate that she takes a little longer to get
over “colds.”  She does not have chronic diarrhea or foamy urine.  Her exam
to me was unremarkable.


Meds:  Naprosyn prn, omeprazole, multi-vitamin, vitD


 No chronic medical illness or hospitalizations, family history is negative
for autoimmunity and immune deficiency.


The following is her laboratory evaluation with some labs performed twice:
Boldfaced type equals abnormal findings.

·        CBC: Hgb 12.7, Hct 37, Plt 208 – normal

·        WBC: 7700 (PMN 78.5%, L 16.1%, Eos 1%) – normal

·        Liver transaminases, LDH, uric acid, serum chemistries and renal
function normal

·        Urinalysis: Normal, no blood or protein, microscopy normal

·        Anti-CCP antibody: 2 (0-30)

·        *IgG: Two occasions, 351 and 214 mg/dl (614-1286)*

·        IgA: 72 and 106 mg/dl (87-474)

·        IgM 134 and 291 mg/dl (52-330)

·        *Serum electrophoresis: Minimal monoclonal IgM lamda at approx.
0.2 g/dl, thought to be of no significance*

·        Tetanus Ab: 0.51 (nl > 0.1)

·        *Pneumococcal serotypes: All 12 tested were under <1.3 u/ml
(highest was 0.9, most of them undetectable at < 0.3).  Repeated 6 weeks
post-Pneumovax and no change in any of the serotypes.*

·        *CRP: 23, mildly elevated (0-10 normal)*

·        ESR: 1

·        *CH50: < 3 (repeated twice, normal 30-75)*

·        *C3: 62 (83-172)*

·        *C4: 6 (18-51)*

·        Flow cytometry: Normal

o   ALC: 1300

o   CD4: 53% (absolute 689)

o   CD8: 27% (absolute 351)

o   CD4:CD8: 2.0

o   CD16/56: 20% (absolute 260)

o   CD19: 5% (absolute 65)


Even without a pattern of recurrent infections, my thinking is that she
warrants IgG replacement therapy given the low IgG and completely absent
specific antibody response to Pneumovax.  I have failed to find anything in
the literature to this point concerning the concurrence of
hypocomplementemia and hypogammaglobulinemia.  My feeling is that they
should represent the same etiology as opposed to having two separate and
rare etiologies.  Any thoughts on further work-up, therapy, and possible
diagnoses would be greatly appreciated.  I have given thought towards
sending complement degradation products to determine production vs.
consumption but have never ordered this lab before.



Thank you so much for any help provided with this case.


Zach

--
Zachary D. Jacobs, M.D.

The Center for Allergy & Immunology

St. Luke’s Physician Partners
Medical Plaza II
4330 Wornall, Suite 40
Kansas City, MO 64111

Ph: 816.531.0930
Fax: 816.753.2671

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