[CIS PIDD] [cis-pidd] Chronic norovirus enteritis in CVID

[Isabelle Meyts]

Dear Panida,

I have had a troublesome course with 1 CVID patient and with 1 XCGD patient (post-HSCT) who both suffered from prolonged norovirus related diarrhea. Oral Igs didn't change the frequency and volumes of diarrhea at all. We had a go with sirolimus (there a few reports on decreased shedding and finally disappearance of norovirus after changing from antimetabolite immunosuppression to mTOR inhibition) which proved effective. It's however a delicate balance: we ran low levels because of side effect of cytopenia.
Moreover, there are some notes on nitazoxanide having a beneficial effect.
Surely a trial is needed but maybe in the short run, you could try a low dosage of sirolimus / everolimus in addition to high serum levels of IgG?

Best wishes
isabelle

Kindest regards,

Isabelle Meyts, MD, PhD
Department of Pediatrics,
Primary Immunodeficiency,
University Hospitals Leuven,
Leuven, Belgium

isabelle.meyts at uzleuven.be<mailto:isabelle.meyts at uzleuven.be>
+32 16 34 38 41
+32 16 34 38 42
UZ Leuven | campus Gasthuisberg | Herestraat 49 | B - 3000 Leuven | www.uzleuven.be<http://www.uzleuven.be/>


Van: Sriaroon, Panida [mailto:psriaroo at health.usf.edu]
Verzonden: donderdag 17 juli 2014 4:40
Aan: CIS-PIDD
Onderwerp: [cis-pidd] Chronic norovirus enteritis in CVID

Dear colleagues,

We have a 15yo boy with CVID who presents with chronic norovirus enteritis for over 3 months now. He is on SCIG weekly with IgG level around 800s. Past history includes biopsy-proven GLILD treated with rituximab and Imuran a few years ago. He also has lymphopenia and low mitogen responses.

Aside from enteritis, he is doing fine infection-wise. We check his stool every few weeks and he is still shedding the virus. We plan on increasing his SCIG dose to raise the IgG level. In the meantime, his diarrhea is still ongoing (5x or more/d) and he is now losing weight.

I understand that the infection can persist for a prolonged period of time and was wondering if anyone has suggestion for the treatment for norovirus enteritis in CVID. There are several reports of oral Ig therapy given in divided doses for 1-2 days (extrapolated from treatment for rotavirus enteritis) with variable success, but most cases are s/p transplant or on immunosuppression.

We plan on building a case and requesting an authorization for oral Ig use from his insurance--which might not be easy since it is not a proven therapy.

Does anyone have any suggestions for the management of chronic norovirus infection in CVID?

Best,
Panida

Panida Sriaroon, MD
Assistant Professor
Associate Director, Fellowship Program
Associate Director, USF/All Children's Hospital Allergy/Immunology clinic
Beeper 727.825.4379
Office 727.553.3521
E-mail:psriaroo at health.usf.edu

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