[CIS-PAGID] IVIG reaction

[Elie Haddad]

Hi Niraj
I would try subQ. We've had (or we've heard of) many patients compltely intolerant to IVIG with the same symptoms you describe who tolerate perfectly SubQ.
It could be done in a monitored setting for the first injection.
All the best
Elie

Le 2012-02-15 à 15:22, Patel, Niraj C a écrit :


> Dear Colleagues,

>  

> I saw this patient for the first time this week, and she has extreme difficulty tolerating IVIG infusions.

> 45 yo female with lupus since 1994, history of pericarditis, antiphospholipid syndrome, oral ulcers and peripheral neuropathy. She received epratuzumab (antiCD22) for lupus in June 2008 (IgG level prior was 610).  She was started on IVIG in March 2009 for low IgG 530 (normal IgA, IgM) and chronic sinusitis despite. No antibody to vaccines was done.  She initially tolerated IVIG (400mg/kg) for several months (IgG levels in 700-800), until she began developing headaches, vomiting, fever.  No laryngeal swelling, wheezing, or hives.  Despite premedication with 50mg Benadryl, changing IVIG formulations, 20mg demamethasone the night prior and 20mg the morning of infusion, decadron (unknown dose) prior to infusion, and rate slowed to 70cc/hr (15 hour-long infusion), her symptoms worsened. She had aseptic meningitis in May 2011 and Nov 30 2011 thought due to IVIG, although the latter episode occurred 6 days after infusion and no lumbar puncture done either time. Symptoms included fever, neck pain, vomiting, photophobia and was hospitalized for 1 week each time and treated with high-dose steroids.

>  

> During the almost 2 years on IVIG, she noted remarkable improvement in sinus symptoms and had just 1 sinusitis during this time period (compared to chronic nasal symptoms and antibiotics at least once monthly prior to IVIG).  She stopped her IVIG after Nov 30 2011 due to adverse reaction and her chronic nasal symptoms returned after 4-6 weeks.  CT of sinus this week was negative except scant sphenoid fluid and endoscopy of nasal passages was normal (she was on levoquin at that time).  Most recent labs on 1/26/12:

>  

> IgG 563 (791-1643)

> IgA 89 (66-436)

> IgM 75 (43-279)

> WBC 9,100

> ALC 1,065

> CD19B 53 (90-660)

> CD3T 809 (690-2,540)

> CD4T 405 (410-1,590)

> CD8T 362 (195-1,140)

> CD56/16 181 (90-590)

>  

> 1) Would you restart Ig replacement? Try subQ in a monitored setting?

> 2) Hold on Ig replacement therapy until more definitive evidence of a chronic infectious process?

> 3) Could an autoantibody to Ig be present in this setting?  If so, offer rituximab?

>  

> Thank you in advance for your help.

>  

> Niraj

>  

> Niraj Patel, MD MS

>  

> Department of Pediatrics

> Infectious Diseases and Immunology

>  Levine Children's Hospital

> Carolinas Medical Center

> PO Box 32861

> Charlotte, NC 28232-2861

>  

> Tel:   (704) 381-6803

> Fax:  (704) 381-6841

> Appt: (704) 381-8840

>  

> Email: niraj.patel at carolinashealthcare.org

>  

> 

> 

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