[CIS-PAGID] IVIG reaction

[Nelson, Robert P Jr]

Agree with Jack and Charlotte, multiple anecdotes.  Bob

Robert P. Nelson Jr., MD
Professor of Medicine and Pediatrics
Divisions of Hematology/Oncology
535 Barnhill Dr. Ste 473
Indianapolis, IN  46202
Telephone: 317-948-1186
E-mail: ronelson at iupui.edu
pager:  317-312-1773


-----Original Message-----
From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Cunningham-Rundles, Charlotte
Sent: Wednesday, February 15, 2012 3:58 PM
To: PAGID
Subject: Re: [CIS-PAGID] IVIG reaction

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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