[CIS-PAGID] Infant with severe enteropathy and T cell defect

[Dr. Esther de Vries]

Dear Jane, have you considered 'phenotypic diarrhea' = Trichohepatoenteric Syndrome? 
Your story resembles very much a patient I have been taking care of for years now. I described him in: "De Vries E, Visser DM, van Dongen JJ, Jacobs CJ, Hoekstra JH, van Tol MJ. Oligoclonal gammopathy in phenotypic diarrhea. J Pediatr Gastroenterol Nutr. 2000 Mar;30(3):349-50". There is a picture of his face and hairs in that paper from his toddler years. The gene defect has recently been found (Hartley JL, Zachos NC, Dawood B, Donowitz M, Forman J, Pollitt RJ, Morgan NV, Tee L, Gissen P, Kahr WHA, Knisely AS, Watson S, Chitayat D, Booth IW, Protheroe S, Murphy S, de Vries E, Kelly DA, Maher ER. Mutations in TTC37 Cause Trichohepatoenteric Syndrome (Phenotypic Diarrhoea of Infancy). Gastroenterology. 2010 Jun;138(7):2388-98). 
There are many similarities in the story, and the 'baby hair' you describe was a very distinctive feature in my patient when he was very young. Necker hospital in Paris can analyze the hairs, this might help in deciding whether you want to go for the genetic analysis. 
Best regards, Esther de Vries, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands.

Op 4 apr 2012, om 10:16 heeft Jane Peake het volgende geschreven:


> Hi 

> I was wondering if anyone would have any ideas regarding further investigations, diagnosis or management of this infant. 

> 

> 13/12 old male

> Born 30/40 Prem, 1/52 neonatal ICU requiring CPAP. NICU stay complicated by a staph infection and very slow to gain weight. Discharged home at term from SCN at 1.9kg.  Failure to thrive since then. Multiple admissions to provincial hospital in first couple of months for diarrhoea and poor weight gain. Otherwise reasonably well, with no further infections and was attending day care 2-3 times per week for 2 months. Couple of mild episodes of oral thrush responded to topical therapy.

> At 9 months had rhinovirus bronchiolitis then LRTI with moraxella and Haemophilus Influenzae on NPS.  Continued poor weight gain on amino acid formula and started on TPN at 9months of age. (Weight 4.3kg <<3rd centile).  Gained weight on TPN with improvement in diarrhoea.  Weight plateaued when TPN weaned and diarrhoea returned when NG feed rate increased beyond >15ml/hour. Has remained TPN dependent.

> At 10/12 had CVL infection with enterococcus faecalis and profoundly neutropaenic requiring GCSF.  BMA was consistent with early marrow regeneration following a myelotoxic insult(eg infection). Neutropenia recovered after one month and has not recurred.

> At 11/12 had a pseudomonas CVL infection - requiring PICU admission.  Recovered quickly. WCC rose, however did not make a CRP response to these infections.

> 

> Investigations:

> IgG 1.6g/l (3-13) IgA	0.07g/l (0.3-0.9) IgM	0.5 (0.5-1.6)

> No specific antibody responses of any kind even following repeat booster immunisation

> 

> CD3 6170 (72%) CD4 5410 (63%) CD8 860 (10%) CD19 1860 (22%)	CD56/16 470	(6%)

> CD4+CD27+CD45RA+ 91%

> Normal numbers of CD19+ B cells with normal proportion of immature B cells.  Reduced proportion of memory B cells and markedly reduced proportion of isotype switched memory B Cells.

> T cell proliferation: PHA - normal x 3, No antigen response to candida (x3), nor tetanus following immunisation		

> CD40L expression normal

> Foxp3 expression normal

> Chromosomes - 46XY.		

> Gut biopsy - Evidence of apoptosis, villous blunting, no intra-epithelial lymphocytosis, acute inflammation or granulomata seen and very few plasma cells.  No features of a specific enteropathy identified. 

> 

> Mother had a brother and an uncle who were both born very premature and died in first few days thought to be as a result of extreme prematurity. One well sister. He has 8 normal teeth and thin "baby" hair. Skin completely normal

> 

> I am wondering about possible NEMO and seeing if I can get this done locally but  would appreciate any other thoughts

> Thanks kindly

> Jane

> 

> Dr Jane Peake

> Paediatric Immunologist and Allergist

> Senior Lecturer

> University of Queensland

> level 3 Foundation Building

> Royal Children's Hospital

> Herston Rd, Herston QLD 4029

> Tel (61 7) 33655333 or 36365059

> Fax (61 7) 33655455

> 

> 

> 


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