[CIS PIDD] Warts and T-cell lymphopenia

[Bleesing, Jacob]

Perhaps, but who knows how this works in a transplanted patient with the infection in one anatomical location and the vaccine given in another. One can measure the immune response and learn more (that can benefit all of us).

JB

From: Boyce, Thomas G., M.D. [mailto:Boyce.Thomas at mayo.edu]
Sent: Thursday, August 09, 2012 12:19 PM
To: pagid at list.clinimmsoc.org <pagid at list.clinimmsoc.org>
Subject: Re: [CIS PIDD] Warts and T-cell lymphopenia

HPV vaccine, while low risk and thus reasonable, is unlikely to be helpful. it protects against acquisition of new strains but has no effect on the patient who is already infected with that strain.


Thomas G. Boyce, MD, MPH
Pediatric Infectious Diseases and Immunology
Mayo Clinic
Rochester, MN 55905
phone: 507-255-8464
fax: 507-255-7767

________________________________
From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Jason W. Caldwell
Sent: Thursday, August 09, 2012 11:01 AM
To: pagid at list.clinimmsoc.org
Subject: Re: [CIS PIDD] Warts and T-cell lymphopenia

I will offer him the HPV vaccine, but was looking into the future if the vaccine did not provide much protection secondary to his immune suppression.  (I have not seen him in clinic and don’t have any studies for immune status.  He is follow at Duke for his transplantations)

In further review of his record, he did have an OLT liver transplant.  This was secondary to cirrhosis per the notes.  While he was being evaluated for the liver transplant, he acquired a pneumonia and during this treatment developed acute renal failure.  Then within a short time he developed pancreatitis.  With this his CR again began to rise and then eventually was in renal failure they are calling acute tubular necrosis.  Ultimately, Duke called him hepto-renal syndrome and he ended up receiving a liver and cadaveric kidney transplant in 2008.



Jason W Caldwell, DO
Assistant Professor Internal Medicine & Pediatrics
[Wake Forest School of Medicine]
Section Pulmonary, Critical Care, Allergic and Immunological Diseases
Medical Center Boulevard  \  Winston-Salem, NC 27157
p 336.716.5166  \  f 336.716.7277  \  pager 336.806.8330
jcaldwel at wakehealth.edu  \  WakeHealth.edu



From: pagid-bounces at list.clinimmsoc.org [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Bleesing, Jacob
Sent: Thursday, August 09, 2012 11:40 AM
To: pagid at list.clinimmsoc.org
Subject: Re: [CIS PIDD] Warts and T-cell lymphopenia

Jason:

Just wondering; why not give an HPV vaccine?

Both available vaccines cover type 16, while there may cross-protection for type 45 (and perhaps new vaccines in the pipe-line).

Out of curiosity (ignorance): where did the donor liver come from (or asking in another way; CF was not reason to be denied for OLT)?

Jack

________________________________
From: pagid-bounces at list.clinimmsoc.org<mailto:pagid-bounces at list.clinimmsoc.org> [pagid-bounces at list.clinimmsoc.org] on behalf of Jason W. Caldwell [jcaldwel at wakehealth.edu]
Sent: Thursday, August 09, 2012 9:53 AM
To: pagid at list.clinimmsoc.org<mailto:pagid at list.clinimmsoc.org>
Subject: Re: [CIS PIDD] Warts and T-cell lymphopenia
I have also taken some interest in the discussion about the problematic warts described in these patients.
The pediatric ENT called me Monday with a question about HPV.  She is caring for a patient that has CF.  His CF course has been complicated by liver failure secondary to medications and has undergone liver transplant.  He is on chronic immunosuppresion with mycophenolate and tacrolimus.  ENT is involved because of nasal polyposis that has been debulked on several occasions. The ENT noticed on the last couple of procedures that the polyps had a papilloma type of appearance.  She requested PCR for HPV and the polyps were positive for HPV 16 and 45.
I would also be very interested in the protocol used with alpha interferon or the one meds used in intralesional injection.
Thanks in advance,
Jason
Jason W Caldwell, DO
Assistant Professor Internal Medicine & Pediatrics
[Wake Forest School of Medicine]
Section Pulmonary, Critical Care, Allergic and Immunological Diseases
Medical Center Boulevard  \  Winston-Salem, NC 27157
p 336.716.5166  \  f 336.716.7277  \  pager 336.806.8330
jcaldwel at wakehealth.edu<mailto:jcaldwel at wakehealth.edu>  \  WakeHealth.edu



From: pagid-bounces at list.clinimmsoc.org<mailto:pagid-bounces at list.clinimmsoc.org> [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Kumar, Ashish
Sent: Wednesday, August 08, 2012 4:57 PM
To: pagid at list.clinimmsoc.org<mailto:pagid at list.clinimmsoc.org>
Subject: Re: [CIS PIDD] Warts and T-cell lymphopenia

Stan,
This is unlikely an immune deficiency. Laryngeal papillomas are known to recur after resection. Intralesional Cidofovir, HPV-vaccination are some of the adjuvant therapies that are described as successful in some patients. I have seen one patient respond to Gefitinib (EGFR inhibitor).

Ashish

From: pagid-bounces at list.clinimmsoc.org<mailto:pagid-bounces at list.clinimmsoc.org> [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Stan Ress
Sent: Wednesday, August 08, 2012 2:49 PM
To: <pagid at list.clinimmsoc.org<mailto:pagid at list.clinimmsoc.org>>
Subject: Re: [CIS PIDD] Warts and T-cell lymphopenia

I've just seen a 18-year old girl who was referred for evaluation of possible underlying immune deficiency. She was found to have a large papillima below her vocal cords causing hoarseness, that was repeatedly ressected by ENT surgeon over several months, and also injected with Zidovudine several times but with no response. On flow she had reduced NK cell numbers , absolute values 69 cells/ul & 80 cells/ul on 2 occasions. Normal B-cells & T-cells & CD4/8 ratio. Functional NK activity has not been done.

I was very interested to read about Terry Harville's approach of nebulized alpha-IFN for vocal cord warts, & wonder if he would be willing to share details of the protocol.

Thanks & Regards,

Stan Ress




--
Stanley Ress
Associate Professor of Medicine
Head: Division of Clinical Immunology
Department of Medicine
H47 Old Main Building-room 26
Groote Schuur Hospital and UCT
Observatory 7925
Cape Town
South Africa
TEL:INTERN. + 2721-4066201 or 4066197
FAX:   "    + 2721-4486815
Cell: 0833115482
email: stan.ress at uct.ac.za<mailto:stan.ress at uct.ac.za>

>>> "Harville, Terry O" <HarvilleTerryO at uams.edu<mailto:HarvilleTerryO at uams.edu>> 2012/08/07 11:27 PM >>>

Chuck,

We have been able to get rid of warts in immunodeficient patients by local injections of alpha-interferon.  We has used alpha-interferon topically with success for optical varicella, and nebulize for vocal cord warts.
Terry Harville MD PhD
-Medical Director, Special Immunology Laboratory
-Medical Director, Histocompatibility Laboratory
-Medical Director, Immunogenetics and Transplantation Laboratory
-Specialist in Pediatric Immunology and Rheumatology
Departments of Pathology and Laboratory Services and Pediatrics
University of Arkansas for Medical Sciences
4301 West Markham
Mail Slot #502
Little Rock, AR  72205-7199

Work Phone 1..........................................................501.686.7257
Work Phone 2..........................................................501.526.7511
Work Phone 3..........................................................501.686.7556
Work Phone 4..........................................................501.364.1885
Work Fax 1..............................................................501.686.7443
Work Fax 2..............................................................501.526.4621

Email.....................................................harvilleterryo at uams.edu

Special Immunology Laboratory..............................501.364.1804
Histocompatibility Laboratory..................................501.686.7257
Immunogenetics and Transplantation Laboratory...501.686.7374

On Aug 7, 2012, at 9:36 AM, "Kirkpatrick, Charles" <Charles.Kirkpatrick at ucdenver.edu<mailto:Charles.Kirkpatrick at ucdenver.edu>> 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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