[CIS-PAGID] IVIG reaction

[Hare, Nathaniel D]

Jason,

 

That is interesting.  I have discussed this with our neurologist.  The
only reference I could find about this issue was:

 

http://www.ncbi.nlm.nih.gov/pubmed/8037406,

 

which concludes that aseptic meningitis is more likely to develop in
patients with a history of migraine.  Not sure if that is true, but
interesting to think about none the less.  My patient too has a history
of migraines, and her migraines worsened after her first episode of
aseptic meningitis.

 

Thank you for your comments.

 

Nathan

 

 

Nathaniel D. Hare MD

Allergy & Immunology

CMC - Dartmouth Hitchcock Keene

Keene, NH  03431

 

ph  (603) 354-5496

fax (603) 354-5498

________________________________

From: pagid-bounces at list.clinimmsoc.org
[mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Jason Raasch, MD
Sent: Thursday, February 16, 2012 8:51 AM
To: pagid at list.clinimmsoc.org
Subject: Re: [CIS-PAGID] IVIG reaction

 

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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