[CIS PIDD] Warts and T-cell lymphopenia

[Jason Raasch, MD]

Charles,

Agreed that these lymphopenias are tough (diagnostically and management-wise) and I look forward to the commentary.

I briefly saw a similar patient several years ago, a caucasian woman in her early 50s.  Fairly benign course overall, history of hypothyroidism and verucca of hands and feet.  Sent to me because of persistent lymphopenia (incidentally identified many years prior), similar to data you reported.

T-cell proliferation to mitogens was low also but could not rule out low cell numbers as confounding factor (this was before flow-based proliferation commercially available).  

I have seen a fair number of 'low' tetanus proliferation in adults that normalized after administering a tetanus booster.  I was not able to perform this in my patient.

This woman went on to develop a Burkitt-type non-Hodkin lymphoma within a year of our first visit.  She was treated and apparently has been in remission.  No further details as she receives her care elsewhere.

Of interest, she had a 20 year-old daughter with a more modest lymphopenia (CD3 in 700 range) and also ANC in 500-900 range.  This was incidentally noted during a wellness visit in preparation for college.  No history of malignancy, autoimmunity, infection or verucca.  She is out of state now, I am not sure of her clinical history over the last few years.

I do not have experience with cidofovir in patients like this.

Was the mitogen proliferation by flow (although I am not certain if this matters as the candida proliferation was normal)?

Would anyone place this patient on PCP prophylaxis?  The "party line" would be to do so as the CD4 count is <200, however one could argue that this recommendation is based on the HIV literature/clinical experience, not idiopathic lymphopenia.  Anyone care to dissent?


Regards,

Jason


Jason Raasch, MD

Midwest Immunology Clinic
15700 37th Ave N
Ste 110
Plymouth, MN 55446

Phone: (763) 577-0008
FAX:     (763) 577-0192



On Aug 7, 2012, at 09:35 AM, Kirkpatrick, Charles wrote:


> I am evaluating a 48 y/o Caucasian male who developed extensive warts on his hands and feet  about 1998 but spreading widely over feet and hands since 2003.  He was well until then, but he had a cutaneous VZV infection shortly before the onset of warts.  There have been no genital lesions. Failed treatments include liquid nitrogen, Aldara, topical sensitization and application of 2% and 4% CDNB, intralesional injections of Candida skin test antigen, V-Beam laser treatments, duct tape and many herbal and OTC medications.

>  

> Labs:  HIV – negative X2, CBC normal, IgG, IgA, IgM all normal, absolute CD3 – 260/ul; CD4 190/ul; CD8 – 60/ul; CD45/CD4 RA 2.3% of total T-cells (control 57.7%); CD45/CD4/RO -96.8% of total T-cells (control 40.8%).

> T-cell proliferations to PHA, ConA and PWM all low; proliferation response to tetanus – low; to Candida normal.  DTH to Candida 28 mm induration.

>  

> Any comments about diagnosis?  Does anyone have experience with topical or intravenous Cidifovir in patients such as this?

>  

> All comments appreciated.

>  

> Charles Kirkpatrick, M.D.

> Allergy and Immunology

> University of Colorado Health Sciences Center


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