[CIS PIDD] [cis-pidd] Lymphopenia after thoracic duct ligation

[Richard Wasserman]

Colleagues,

Two month old male with abnormal newborn TREC screen. Newborn screen on day
of life 2 was normal. On day of life 4, presented with an interrupted
aortic arch, AP window and ASD. Initial CBC showed a white count of 16,700,
ALC  4800. IAA repair on day 8. Post-op chylothorax required chemical
pleurodesis on DOL 30 but chylous drainage persisted and thoracic duct
ligation was performed on DOL 41. From DOL 9 - 41 ALC ranged from 574 to
1782.

Repeat newborn screen showed very low TREC on DOL 16. On discharge at DOL
51, the patient’s ALC was 3332. Follow up CBC on DOL 58 showed an ALC of
8692/mm3. Additionally, chromosomal microarray and FISH for DiGeorge
Syndrome were normal.

There have been no significant infections There is no family history
suggestive of immunodeficiency.

The abnormal TREC was felt to be related to the lymphocytopenia stemming
from his chylothorax. We saw him at 63 days of life and appeared in good
heath. The third newborn screen is pending. Studies are shown. Mitogen
stimulation is pending.

*T&B Lymphocyte/Nat Killer (T cell subsets)*

Abs.CD19+ Lymphs                H 3845 (/uL)                600-1900

% CD19+ Lymphs                   H 69.9 (%)                   4.0-26.0

Absolute CD 3                         L 787 (/uL)                  2300-7000


% CD 3 Pos. Lymph.               L 14.3 (%)                   60.0-85.0

Absolute CD 4 Helper              L 561 (/uL)                  1700-5300

% CD 4 Pos. Lymph.               L 10.2 (%)                   41.0-68.0

Abs. CD 8 Suppressor             L 226 (/uL)                  400-1700

% CD 8 Pos. Lymph.               L 4.1 (%)                     9.0-23.0

CD4/CD8 Ratio                       2.49
0.92-3.72

Ab NK (CD56/16)                  726 (/uL)                      200-1400

% NK (CD56/16)                    13.2 (%)                      3.0-23.0



WBC                                       10.9 (x10E3/uL)
5.0-12.4

RBC                                        3.75 (x10E6/uL)
2.72-4.84

Hemoglobin                              10.3 (g/dL)
8.8-14.3

Hematocrit                               31.0 (%)
26.6-41.0

MCV                                       83 (fL)
81-97

MCH                                       27.5 (pg)
27.1-34.0

MCHC                                    33.2 (g/dL)
31.9-36.0

RDW                                       16.0 (%)
12.2-16.4

Platelets                                    519 (x10E3/uL)
150-579

Neutrophils                               23 (%)
            10-42

Lymphs                                    51 (%)
            3-11

Eos                                          H 7 (%)                        0-5


Basos                                       0 (%)
0-2

Neutrophils (Absolute)              2.5 (x10E3/uL)             0.6-4.4

Lymphs (Absolute)                   5.5 (x10E3/uL)             1.4-8.6

Monocytes(Absolute)               H 2.1 (x10E3/uL)         0.2-1.1

Eos (Absolute)                         H 0.8 (x10E3/uL)         0.0-0.4

*Immunoglobulin M, Qn, Serum*     24 (mg/dL)       0-145
Do you think we can account for the T cell lymphopenia and B cell
lymphocytosis by the duct ligation alone?

Thanks,
-- 
Richard L. Wasserman, MD, PhD
DallasAllergyImmunology
7777 Forest Lane, Suite B-332
Dallas, Texas 75230
Office (972) 566-7788
Fax (972) 566-8837
Cell (214) 697-7211

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