[CIS-PAGID] IVIG reaction

[Hare, Nathaniel D]

And yes, both episodes of aseptic meningitis were documented by lumbar puncture.

Nathaniel D. Hare MD
Allergy & Immunology
CMC - Dartmouth Hitchcock Keene
Keene, NH  03431
 
ph  (603) 354-5496
fax (603) 354-5498
-----Original Message-----
From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Hare, Nathaniel D
Sent: Wednesday, February 15, 2012 6:21 PM
To: pagid at list.clinimmsoc.org
Subject: Re: [CIS-PAGID] IVIG reaction

As a follow up question though - I have 1 patient with recurrent pneumonia (documented), specific antibody deficiency, IgG in the 500's, otherwise normal immune evaluation, who has had aseptic meningitis with both IVIG and subQ IgG treatment.

Assuming you have a patient with an appropriate diagnosis of immune deficiency that is antibody based, who has severe documented infections, who needs IgG replacement therapy, what do you do if they have aseptic meningitis with both IV and SubQ IgG replacement?

I realize you may argue with me about my specific patient's need for IgG therapy, but if you could address the question about what to do with aseptic meningitis with both product formulations, that would be great.

Thanks,

Nathan Hare



Nathaniel D. Hare MD
Allergy & Immunology
CMC - Dartmouth Hitchcock Keene
Keene, NH  03431
 
ph  (603) 354-5496
fax (603) 354-5498
-----Original Message-----
From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Nelson, Robert P Jr
Sent: Wednesday, February 15, 2012 4:31 PM
To: 'pagid at list.clinimmsoc.org'
Subject: Re: [CIS-PAGID] IVIG reaction

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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