[CIS PIDD] some help from Chile

[patricia roessler vergara]

Dear all:

I would appreciate some help about this case:

The patient is a woman 32 years old

She carries the diagnosis of multiple sclerosis (MS), onset at the age of
15. She was treated with avonex, IV methylprednisolone and IGIV. The first
years of treatment she did well but finally she continued with flare ups,
so she recevied Rituxan in 2007 with good response. She recevied another
round of Rituxan in 2009.

Since rituxan she did not have flares of MS until december 2011 (the one
that was treated with methylprednisolone) and she did not receive another
treatments

She also has a history of other autoimmune diseases: Hashimoto´s tiroiditis
at age 15, seronegative Sjögren disease, positive Scl-70 and ulcerative
colitis.

Her mother has a history of antiphospholipid syndrome, psoriatic arthritis
and Hashimoto´s tiroiditis

She has a neurogenic bladder which has resulted in recurrent urinary tract
infections. In the last 18 months she has had 10 sepsis, some of urinary
origin and other from an intestinal perforation secondary to *Clostridium
difficile* enterocolitis.

She also has 3 sinusitis per year since the last 3 years.

I saw her last week for the first time and this are the immunologic labs
until now:

Oct 2011: IgG  445 (nr: 639-1349), with normal IgM and IgA

May 2012: IgG 633, with normal IgM and IgA

I order other labs:

-       specific anti pneumococcal antibodies: pending

-       CD3, CD4, CD8, CD19 and CD56 all within normal range in number and
percentage

-       Naive B lymphocytes CD19+IgD+CD27- :     82 (nr: 39-84)

-       Memory B lymphocytes without isotypic switch CD19+IgD+CD27+ : 1
(3-20)

-       Memory B lymphocytes with isotypic switch CD19+IgD-CD27+:  3 (6-35)



Abdomen scan: innumerable subcentimeter pulmonary nodules at the lung
bases. Torax scan: pending



Questions:

-       Can this immunologic findings, specifically those concerning CD27,
be secondary to Rituxan? Or we are talking about a common variable
immunodeficiency that has result in all of her autoinmune diseases (I
incline for this )

-       They are planning to give her Rituxan again because she is
recurring in her neurologic symptoms. What do you think about that?

- Would you give her IGIV even though we still haven´t got the specific
anti pneumococcal antibodies



Thanks,



Patricia Roessler

Immunologist

Chile
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