[CIS PIDD] [cis-pidd] Sub-protective pneumococcal titers in a CVID patient on therapeutic doses of IgSQ and recurrent bronchitis

Thu Jan 22 19:36:50 EST 2015

I wish to thank all who shared their pearls of wisdom with me. To check or not to check pneumococcal titers in CVID patients?, and if we do how to pool the information that we collect to hopefully one day be able to make sense of what we observe ...
Hearing this fact from Charlotte, who is certainly a key opinion leader in CVID makes me feel better, but only a little, because my ignorance suddenly seems a bit less personal. However, this also acutely demonstrates how much we collectively need to learn and hopefully will discover as we collect and share data as we move forward.
This also brings up yet another more fundamental question: if titers that are considered protective in immunocompetent individuals cannot be extrapolated in patients receiving IgSQ or IVIg, is there a justification to even to check pneumococcal titers in patients receiving them? On the other hand, isn't this how we have learned much of what we now know?
Thanks again.

Soheil Chegini, M.D.
Exton Allergy & Asthma Associates
656 West Lincoln Hwy.
Exton, PA 19341
Phone: (610) 269-3066
Fax: (610) 269-8615

      From: "Cunningham-Rundles, Charlotte" <charlotte.cunningham-rundles at mssm.edu>
 To: CIS-PIDD <cis-pidd at lists.clinimmsoc.org> 
 Sent: Thursday, January 22, 2015 6:32 PM
 Subject: Re: [cis-pidd] Sub-protective pneumococcal titers in a CVID patient on therapeutic doses of IgSQ and recurrent bronchitis

 I have seen not great titers to pneumovax in other supposedly well treated CVID subjects.  Have not known what to make of this. 

Charlotte Cunningham-Rundles, MD, PhDDepartments of Medicine and PediatricsThe David S Gottesman ProfessorThe Immunology InstituteMount Sinai School of Medicine1425 Madison AvenueNew York, NY 10029Phone: 212 659 9268Fax: 212 987 5593Email: Charlotte.Cunningham-Rundles at mssm.edu

From: Soheil Chegini <schegini at yahoo.com>
Reply-To: "cis-pidd at lists.clinimmsoc.org" <cis-pidd at lists.clinimmsoc.org>
Date: Thursday, January 22, 2015 at 4:10 PM
To: "cis-pidd at lists.clinimmsoc.org" <cis-pidd at lists.clinimmsoc.org>
Subject: Re: [cis-pidd] Sub-protective pneumococcal titers in a CVID patient on therapeutic doses of IgSQ and recurrent bronchitis

His pre-Treatment IgG was 151.
From: "Church, Joseph" <JChurch at chla.usc.edu>
To: CIS-PIDD <cis-pidd at lists.clinimmsoc.org>
Sent: Thursday, January 22, 2015 3:24 PM
Subject: RE: [cis-pidd] Sub-protective pneumococcal titers in a CVID patient on therapeutic doses of IgSQ and recurrent bronchitis

What was the patient’s baseline IgG?  If it was>400mg/dL he probably needs more Ig as the change from baseline to steady-state on SCIG would only be ~400mg/dL.  From: Soheil Chegini [mailto:schegini at yahoo.com]
Sent: Thursday, January 22, 2015 11:00 AM
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                   0.9Type 3                   0.9Type 4                   <0.3Type 5                   1.4Type 8                   1.0Type 9                   0.7Type 12                 0.4Type 14                 3.3Type 19                 1.4Type 23                 0.9Type 26                 1.1Type 51                 1.3Type 56                 1.2Type 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
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