[CIS-PAGID] IVIG reaction

[Cunningham-Rundles, Charlotte]

I agree with Jack.  In my experience, the ones that have the most trouble
with bad reactions over time, are the most likely to not need it....

I have not collected data on this very rigorously but sure have seen this a
lot --aseptic meningitis,  admissions to ER etc/....  You may have to
persuade her to have a better workup first.


Charlotte
  
Charlotte Cunningham-Rundles, MD, PhD
Departments of Medicine and Pediatrics
The Immunology Institute
Mount Sinai School of Medicine
1425 Madison Avenue
New York, NY 10029
Phone: 212 659 9268
Fax: 212 987 5593
Email: Charlotte.Cunningham-Rundles at mssm.edu





> From: Jack R <jroutes at mcw.edu>

> Reply-To: PAGID <pagid at list.clinimmsoc.org>

> Date: Wed, 15 Feb 2012 14:48:44 -0600

> To: PAGID <pagid at list.clinimmsoc.org>

> Subject: Re: [CIS-PAGID] IVIG reaction

> 

> HI Niraj

> I am not convinced that she needs Ab replacement. Was there documented sinus

> disease prior to the initiation of IVIG or just symptoms compatable with

> sinusitis? Did she have an abnormal specific Ab response to pneumovax? Was she

> tried on more conservative measures (nasal washes, intranasal steroids) prior

> to IVIG?

> 

> I frequently see patients with symptoms suggestive of recurrent/chronic

> sinusitis, but no or little abnormalities when I obtain a CT scan.

> Furthermore, most patients will have a reduction in URIs with IVIG, regardless

> of whether they have an immune deficiency.

> 

> If you are convinced she has specific Ab deficiency and needs replacement

> therapy, I agree with Elie and would use subcut.

> 

> 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

> 

> ________________________________

> From: pagid-bounces at list.clinimmsoc.org [pagid-bounces at list.clinimmsoc.org] On

> Behalf Of Patel, Niraj C [Niraj.Patel at carolinashealthcare.org]

> Sent: Wednesday, February 15, 2012 2:22 PM

> To: 'pagid at list.clinimmsoc.org'

> Subject: [CIS-PAGID] IVIG reaction

> 

> 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<mailto:niraj.patel at carolinashealthcare.org>

>

> 

> 

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