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

[Alan Redding]

I have never done DTH skin testing on any patient.  We did not learn this
at University of Tennessee, where I finished fellowship four years ago.

On Thu, May 3, 2012 at 1:52 PM, Alan Redding <aredding99 at gmail.com> wrote:


> 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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>>

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>>

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>>

>

>

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