[CIS PIDD] [cis-pidd] Sub-protective pneumococcal titers in a CVID patient on therapeutic doses of IgSQ and recurrent bronchitis
Fahrenholz, John Michael
john.m.fahrenholz at Vanderbilt.Edu
Thu Jan 22 18:05:39 EST 2015
I would consider infection with Chlamydophila (or Chlamydia) pneumoniae which can wax and wane with apparent frequent "recurrent" bronchitis. Prolonged treatment with macrolide or perhaps better doxycycline - 3 to 6 weeks can be required.
Best,
John
John Fahrenholz, M.D.
Assistant Professor of Medicine
Section of Allergy and Immunology
Vanderbilt University School of Medicine
Nashville, Tennessee
phone 615-479-3877
email john.m.fahrenholz at vanderbilt.edu
________________________________
From: Soheil Chegini [schegini at yahoo.com]
Sent: Thursday, January 22, 2015 3:20 PM
To: CIS-PIDD
Subject: Re: [cis-pidd] Sub-protective pneumococcal titers in a CVID patient on therapeutic doses of IgSQ and recurrent bronchitis
No smoking history or current 2nd hand tobacco smoke exposure. He has had prior to starting SQIg, but was OK during the summer while on treatment. He has had 2 episodes of bronchitis in 10 weeks. I hope that I can intervene and prevent recurrence because extrapolation from this frequency will get him past what is an acceptable number of episodes in a year.
________________________________
From: "Ravishankar.Sargur at sth.nhs.uk" <Ravishankar.Sargur at sth.nhs.uk>
To: CIS-PIDD <cis-pidd at lists.clinimmsoc.org>
Sent: Thursday, January 22, 2015 2:34 PM
Subject: RE: [cis-pidd] Sub-protective pneumococcal titers in a CVID patient on therapeutic doses of IgSQ and recurrent bronchitis
Dear Soheil,
Two episodes in year is not much. I would not consider increasing Ig dosage in the first instance.
We had at least 3 CVIDs with recurrent bronchitis ( 6 – 8 times / year) . No bronchiectasis. 2 of them had colonisation with non-typable HI. Cleared with prolonged course of antibiotics and bronchitis improved.
In the other one prophylactic Azithromycin resulted in significant improvement.
Is he a smoker ? , Does he have Chronic bronchitis ?
Best regards
Ravi
Dr Ravishankar Sargur
MD, FRCPath, FRCP
Consultant Clinical Immunologist & Clinical Lead
Protein Reference Unit, Immunology, NGH
Sheffield Teaching Hospitals Foundation NHS Trust.
Training Programme Director
Immunology
East Midlands Deanery and Yorkshire & Humber Deanery
Email : Ravishankar.sargur at sth.nhs.uk<mailto:Ravishankar.sargur at sth.nhs.uk>
Phone : 0114 2715704
Hayley Rowan ( Secrretary) : 0114 2269020
Fax : 0114 2269244
________________________________
From: Nacho Gonzalez [mailto:nachgonzalez at gmail.com]
Sent: 22 January 2015 19:20
To: CIS-PIDD
Subject: Re: [cis-pidd] Sub-protective pneumococcal titers in a CVID patient on therapeutic doses of IgSQ and recurrent bronchitis
Dear Soheil,
Nearly absent IgA and IgM increases the risk of upper respiratory tract infections in your patient. 2 episodes per year is not that much and you maintain the patient quite stable with decent trough IgG levels and minor infections. I would be hesitant to increase SQ dosage. But any answer to this precise question may be controversial.
Best regards,
Luis Ignacio Gonzalez-Granado
Immunodeficiencies Unit
Pediatric Hematology & Oncology Unit.
Pediatrics
Hospital 12 octubre.
Madrid . Spain
2015-01-22 20:06 GMT+01:00 Keller, Michael <MKeller at childrensnational.org<mailto:MKeller at childrensnational.org>>:
Hi Soheil,
Increasing his hizentra dose sounds like a very good move as we often (albeit in pediatric patients) see much higher levels achieved with subQ.
You mention no bronchiectasis - has he had a recent chest CT or MRI to ensure that there is no developing interstitial disease?
Best regards,
Mike
-------------------------
Michael D. Keller MD
Assistant Professor, Division of Allergy / Immunology
Center for Cancer and Immunology Research
Children's National Health System
111 Michigan Ave NW, Room 1W-314B
Washington, DC 20010
Clinic: 202.476.3016
Office: 202.476.5843
Fax: 202.476.2280
www.childrensnational.org<http://www.childrensnational.org/>
________________________________
From: Soheil Chegini [schegini at yahoo.com<mailto:schegini at yahoo.com>]
Sent: Thursday, January 22, 2015 2:00 PM
To: CIS-PIDD
Subject: [cis-pidd] Sub-protective pneumococcal titers in a CVID patient on therapeutic doses of IgSQ and recurrent bronchitis
Dear all,
I am wondering what others would suggest to reduce the frequency of bronchitis in a 54 y.o. man with CVID who is on Hizentra 10 g SQ weekly and has an excellent IgG level (814 in 6/14 and 916 1/15). He has responded well to oral antibiotics (Ceftin and Augmentin x 10 each) for 2 episodes of bronchitis that he has had this fall with resolution of his symptoms. He is also treated for asthma with Symbicort 160/4.5 and his spirometry is stable at his baseline with some irreversible airflow obstruction. No bronchiectasis.
Here are his 14-serotype pneumococcal titers:
Type 1 0.9
Type 3 0.9
Type 4 <0.3
Type 5 1.4
Type 8 1.0
Type 9 0.7
Type 12 0.4
Type 14 3.3
Type 19 1.4
Type 23 0.9
Type 26 1.1
Type 51 1.3
Type 56 1.2
Type 68 0.7
These titers suggest adequate protection only against 4 of the 14 tested serotypes, but I am not inclined to increase his dose of Hizentra given his excellent total IgG. He does not produce any Ig (IgA,7 and IgM 11), and his pre-Treatment IgG was 151. He is tolerating the infusions well and I have no other excuse to change the Ig preparation.
I would very much appreciate your help and advice. Thank you very much in advance.
Best regards,
sc
Soheil Chegini, M.D.
Exton Allergy & Asthma Associates
656 West Lincoln Hwy.
Exton , PA 19341
Phone: (610) 269-3066
Fax: (610) 269-8615
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