[CIS-PAGID] CVID? Diagnosed Incidentally in Healthy Patient, What Do I Do?

[Berger, Melvin]

What are her lymphocyte and subset counts, and can she mount a DTH skin test response ?
 
Melvin Berger, M.D., Ph.D.
Adjunct Professor of Pediatrics and Pathology
Case Western Reserve University
Cleveland, OH 44106

________________________________

From: pagid-bounces at list.clinimmsoc.org on behalf of Alan Redding
Sent: Thu 5/3/2012 12:44 PM
To: pagid at list.clinimmsoc.org
Subject: [CIS-PAGID] CVID? Diagnosed Incidentally in Healthy Patient,What Do I Do?


       Recently, an internist referred a 54 yo F to me because her total protein (TP) level was low (5.8 g/dL) and her gamma globulin fraction was low (0.2 g/dL).  Bloodwork was done as part of a routine physical.  In her twenties, while pregnant, she says that she was hospitalized for pneumonia (patient doesn't know details of this infection).  Since then, she says that she has been treated for pneumonia twice as an outpatient, but she cannot recall having a CXR on either occasion.  This is her only infectious history.  Other than hypercholesterolemia, she is healthy.  She feels perfectly fine.  No history of recurrent sinusitis, bronchitis, cough, etc.  She even asked me "Why am I here?"       
       On further workup, total Ig A was undectectable (<4 mg/dL), IgM was low at 23 mg/dL, and IgG was low at 240 mg/dL.  She had protective levels to tetanus (0.45 IU/mL) and diptheria (0.07 IU/mL), which increased after Tdap vaccination to 1.85 mg/dL and 0.20 mg/dL, respectively.  She also had protective antibody levels to Varicella Zoster virus.  She did not respond to the first dose of hepatitis A virus vaccine, but did show "reactive" antibody levels after receiving the second dose of hepatitis A virus vaccine.  However, she showed zero response to Pneumovax vaccine, the H. flu vaccine, or the meningoccal polysaccharide vaccine.    
     In summation, it appears that she can mount an immune response to protein antigens, both new and old.   However, since she did not respond to the H. flu conjugate vaccine, and, she did not respond to the hepatitis A vaccine until after the second dose, the response may be sluggish.   And, she cannot respond to new polysaccharide vaccines.
          I have never seen a patient like this, before.  Could it be that I have just caught CVID, and she is just lucky that she has not had a serious infection?  Or, might one say, "Well, she does have low antibody levels.  But, something must be working right, because she is 54, and hasn't had frequent or severe infections.   It may be difficult to talk her into starting immunoglobulin replacement when she feels normal, and has hardly been sick.   However, I want to recommend the safest course of action, both for her sake, and, for mine.  I would appreciate any recommendations, especially, if anyone has ever had personal experience with patients such as this.  
 
Sincerely,
Alan Redding, M.D.
Redding Allergy and Asthma Center
3193 Howell Mill Rd. NW, Ste 102
Atlanta, GA 30327
direct line (404) 941-1183
cell (404) 593-33338
fax (404) 355-0079
 
 
     
   




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