[CIS-PAGID] IVIG reaction

[Jason Raasch, MD]

All,

A few observations:

I have found that quite predictably patients who have a history of migraine headaches  (before ever having IVIG) have difficulty with post-infusions headaches, often severe.  In these instances no amount/type of pre-medications, fluids, etc has been particularly helpful.  Are these episodes migraine or are they asceptic meningitis?  Are migraines a predictive factor for asceptic meningitis?

I have also had these same patients experience headache, "flu-like" symptoms (fatigue, nausea, myalgia) after Hizentra.  None of them ever has had an LP to see if consistent with asceptic meningitis.  No hospitalizations from ScIg.

 I have found that a fair number of patients who do not tolerate Privigen  (migraine history or not)  cannot tolerate Hizentra.  Proline intolerance?

When I started using Hizentra, I was quite dubious when patients would report adverse effects (as noted above) as most tolerated Vivaglobin without incident.  On 3 occasions with Hizentra, I switched patients back to Viva (when it was still available), had their symtpoms resolve, switched them BACK to Hizentra and their symptoms recurred.  These three have successfully transitioned to subcutaneous Gammagard Liquid and tolerating it without difficulty.

In patients who have not tolerated Hizentra (and again I find this more frequently than when we were using Vivaglobin) we have transitioned patients to subcutaneous GGL, Gamunex-C and even a few on subcu Flebogamma.

So Niraj, if this patient does benefit from IgG replacement (and for the sake of argument presuming it is indicated) I think consideration/discussion of product is important and in the case of ScIg (as Hans' points out) consideration of product, dose, frequency and method (pump versus push) of ScIg may be important.

It is interesting that we as a community typically oppose third-party mandates of what IVIG/ScIg product to use (freedom of choice) but in our academic discussions (particularly at meetings) we rarely discuss product-specific experiences. 

-J


Jason Raasch, MD

Midwest Immunology Clinic
15700 37th Ave N
Ste 110
Plymouth, MN 55446

Phone: (763) 577-0008
FAX:     (763) 577-0192



On Feb 15, 2012, at 14:22 PM, Patel, Niraj C wrote:


> 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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> 


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