[CIS PIDD] [cis-pidd] 74yo F with Lymphopenia

[Church, Joseph]

Jack:  I agree this is not CVID.  The patient was never treated with systemic steroids.  JC

-----Original Message-----
From: Routes, John [mailto:jroutes at mcw.edu] 
Sent: Monday, October 06, 2014 8:05 AM
To: CIS-PIDD
Subject: Re: [cis-pidd] 74yo F with Lymphopenia

Joe
This patient does not CVID and I wonder if the relatively minor reduction in IgG due to drug effect-steroids being the most common in a case like this Was the patient on steroids when the flow cytometry was drawn?
Is the patient on chronic steroids or does she get intermittent bursts of steroids for her COPD?

One could also consider thymoma (other abnormalities on the CBC?) if it is not drug effect

Jack




John M. Routes, MD
Chief, Section of Allergy and Clinical Immunology Professor of Pediatrics, Medicine, Microbiology and Molecular Genetics Department of Pediatrics Children's Hospital of Wisconsin Medical College of Wisconsin
9000 W. Wisconsin Ave.
Milwaukee, WI  53226-4874
Phone: Office 414-266-6840
Fax: 414-955-6487 (Clinical)
Fax: 414-955-6323 (Laboratory)
Email: jroutes at mcw.edu<mailto:jroutes at mcw.edu>

From: <Church>, Joseph <JChurch at chla.usc.edu<mailto:JChurch at chla.usc.edu>>
Reply-To: CLINICAL IMMUNOLOGY LISTSERV <cis-pidd at lists.clinimmsoc.org<mailto:cis-pidd at lists.clinimmsoc.org>>
Date: Monday, October 6, 2014 at 9:49 AM
To: CLINICAL IMMUNOLOGY LISTSERV <cis-pidd at lists.clinimmsoc.org<mailto:cis-pidd at lists.clinimmsoc.org>>
Subject: [cis-pidd] 74yo F with Lymphopenia

Colleagues:

I was referred a 74yo F who over the last 5 years has developed lymphopenia.

She was diagnosed with "CVID" in 2007.  She had recurrent pneumonias and was started on IVIg although her total IgG level was 853.  She did well on IVIg with no further significant infections.  At 'routine follow up' by her PMD  T-cells were shown to be 61% (343) and 5 months later 48% (381).

However, review of her labs demonstrated the low T-cells to be a reflection of a low absolute lymphocyte count, and absolute B-cells were also low.

Most recently:
Absolute Lymphocyte count 600
CD3 45% (273)
CD3,4+ 20% (119)
CD3,8+ 24% (142)
CD19+ 15% (88)
NK  38% (230)

Lymphoproliferation to PHA and PWM were normal.

She has had multiple other medical problems:  COPD (many pack years of smoking), s/p cardiac arrest during surgery, s/p small stroke, s/p major auto accident - all 2011-2013.  Despite these factors on examination she was alert and neurologically intact with good general motor function.

I would very appreciate any suggestions as to the need for and choice of further investigations.  Also, would anyone place on prophylactic antibiotics (PJP, fungus)?

Joe Church
Children's Hospital Los Angeles



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