[CIS-PAGID] Patient with Selective Antibody deficiency andautoimmune disorder

[Richard Wasserman]

Although I have no personal experience, there was some discussion at last
year's CIS and Modell meetings that rituximab was, on balance, a better
biologic response modifier for patients on IgG therapy because the IgG
covers its effect while the anti-TNF drugs impair another segment of the
host defense system.
Richard Wasserman

On Wed, Mar 7, 2012 at 5:23 PM, Paris, Kenneth <kparis at lsuhsc.edu> wrote:


> I would agree that immunoglobulin will cover the antibody defect, and that

> if her diagnosis is truly limited to SAD, then there isn't too much risk

> over what we would anticipate in the usual patient.  But, I may keep a

> closer eye on her.  I wouldn't follow efficacy of IVIG using "trough"

> levels however, since pts with SAD have normal IgG at onset of therapy.

> I'm a little concerned about the "undefined inflammatory process"

> diagnosis, however.   ESR is elevated while on immunoglobulin replacement,

> and therefore CRP is a better test, but isn't specific at all.  I don't

> think an elevation in either is justification for use of immunomodulators,

> especially if there isn't a well defined diagnosis or a constellation of

> symptoms that points to to a specific disease.  We've used immunomodulators

> (very few) in some ab deficient patients, usually for inflammatory bowel

> disease or similar organ specific inflammation.  Tese patients have been

> mostly classic CVID patients, not SAD patients.

>

> Ken

>

> Kenneth Paris MD, MPH

> Assistant Professor of Pediatrics

> A/I Fellowship Training Program Director

> Division of Allergy and Immunology

> LSU Health Sciences Center

> Children's Hospital of New Orleans

>

> Mail:

> 200 Henry Clay Avenue

> Children's Hospital

> Research Institute for Children 4th Floor

> New Orleans, LA 70118

> Phone:  504-896-9589

> Fax:  504-896-9311

> Email:  kparis at lsuhsc.edu <mailto:kparis at lsuhsc.edu>

>

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>

> ________________________________

>

> From: pagid-bounces at list.clinimmsoc.org on behalf of Church, Joseph

> Sent: Wed 3/7/2012 5:00 PM

> To: pagid at list.clinimmsoc.org

> Subject: [CIS-PAGID] Patient with Selective Antibody deficiency

> andautoimmune disorder

>

>

>

> Colleagues:

>

>

>

> I have followed a 40yo woman with selective antibody deficiency for

> several months.  Despite excellent IgG levels on Hizentra (>2000mg/dL) she

> continues to have recurrent, but non-serious URIs.

>

>

>

> Her rheumatologist sees her for an undefined inflammatory process, perhaps

> RA or evolving SLE.  He wishes to treat the patient with a TNF blocker or

> Imuran, but is concerned about the potential for increased risk for serious

> infections because of the patient's antibody deficiency.

>

>

>

> My sense is that the patient's antibody deficiency is well covered by the

> Hizentra and that the risk for infection is perhaps marginally increased

> over the usual risks with these agents.

>

>

>

> I would very much appreciate your thoughts on this issue.

>

>

>

> Joe Church

>

> Children's Hospital Los Angeles

>

>

>

>

>

>

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-- 
Richard L. Wasserman, MD, PhD
DallasAllergyImmunology
7777 Forest Lane, Suite B-332
Dallas, Texas 75230
Office (972) 566-7788
Fax (972) 566-8837
Cell (214) 697-7211
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