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

[Alan Redding]

Lymphocyte subsets are all completely normal.  CD4/CD8 ratio is 1.54.

On Thu, May 3, 2012 at 12:51 PM, Berger, Melvin <
Melvin.Berger at uhhospitals.org> wrote:


> 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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