[CIS PIDD] Chronic EBV ?

[Elias Akl MD]

CH50 was normal, No ANA or tryptase done.
No other viral loads.
We are also working her up for immune def/dysfunction.

Thank you, your input is very helpful.



On Fri, Mar 13, 2015 at 11:13 AM, Elias Akl MD <eliasgakl at gmail.com> wrote:

> Dear all,
>
> Any insights on this patient would be greatly appreciated.
>
> Our patient is a 6 year old Caucasian female with a history of asthma on
> Budesonide 80 mcg 2 puffs BID and montelukast 4 mg, history of allergic
> rhinitis on Azelastin nasal spray and cetirizine 5 mg daily presenting for
> persistent EBV infection. In March of 2013 she was diagnosed with an acute
> EBV infection for which she received supporting treatment at home. At the
> time she complained of generalized fatigue, malaise and myalgia along with
> mild grade fever, headache and occasional abdominal pain. Her symptoms
> resolved in around a week time and she went back to her normal daily
> activities.
>
> 3 months ago, the patient started again complaining of the same symptoms
> she had with her EBV infection consisting mainly of daily low grade fevers
> of 99-100.8 F at around 4 pm, daily frontal headaches that would get worse
> throughout the day and are relieved by acetaminophen. Her HA were not
> associated with an aura, were localized and had no accompanying symptoms of
> nausea or vomiting. She was not sensitive to light or noise and had no
> seizure like activity. Other symptoms included an almost once a week severe
> periumbilical pain, stabbing in nature, lasting around 1 hour with no
> associated symptoms of nausea or vomiting. Patient had an US of the abdomen
> done with no abnormalities noted. She did also admit to petechial-like
> spots that would show up once a week on random body parts mainly on her
> neck, upper back, arms and stomach, last around couple days and then
> resolve. These lesions show up on average once a week.  Over the last 3
> weeks, she had been also complaining of increased itching and had an
> episode of hives that lasted around 3 days. Other symptoms include general
> malaise and fatigue although she slept for 11 or 12 hours a day.
>
> On ROS pt had a dry cough that was worse at night, relieved by albuterol
> with NO SOB. No joint pain, no muscle pain, no joint swelling or decreased
> range of motion, no lower extremity swelling and no weight loss. Appetite
> was at baseline and no other household members had the same symptoms.
>
>
>
> Patient also describes recurrent infections:
>
> PNA once or twice a year. Last episode was 2 weeks prior to her symptoms.
>
> Bronchitis once or twice a year.
>
> Several sinus infections. Last one almost 2 months ago.
>
> Has been on antibiotics and prednisone on several occasions.
>
>  Patient was up to date on her vaccinations and her physical exam was
> benign with a 2/6 nonradiating systolic murmur on the pulmonary area of
> auscultation. She also had petechiae on her neck.
>
>  Labs:
>
> *3/2013:*
>
> EBV Ab VCA IgM POSITIVE
>
> EBV Early Ag Ab, IgG: NEGATIVE
>
> EBV Ab VCA IgG : NEGATIVE
>
> EBV Ab VCA : NEGATIVE
>
> EBV Nuclear Ag Ab IgG: NEGATIVE
>
> *10/2014:*
>
> EBV Ab VCA IgM 87.5 U/mL
>
> EBV Early Ag Ab, IgG < 9 U/mL
>
> EBV Ab VCA IgG 94.4 U/mL
>
> EBV Nuclear Ag Ab IgG 412 U/mL
>
> EBV DNA Quant (serum): UNDETECTABLE
>
> EBV DNA Quant (whole blood): POSTIVE.
>
>  *11/2014:*
>
> IgA 80mg/dL
>
> IgE 79 IU/mL
>
> IgG 648 mg/dL
>
> IgM 75 mg/dL
>
> CRP and ESR Normal
>
> EhrlichChaf IgG/IgM NEGATVE
>
> HGE IgG/IgM NEGATIVE
>
> Toxo and H Influenza NEGATIVE.
>
> LEP within normal limit
>
> CBC with diff WNL
>
> Pneumo titers were positive to only 4/14 and repeat 6 weeks after prevnar
> was positive for 13/14
>
> Tetanus IgG Ab < 0.10 IU/mL with repeat 1.80 after vaccination.
>
> *Questions:*
> 1. Are her symptoms consistent with chronic EBV infection ?
> 2. What treatment (if any) has worked for this condition?
> 3. Use of rituximab was thought of as a treatment but she doesn't have
> severe enough symptoms to justify use of this medication, with its
> associated long term immune suppression ?
>
> --
> Best Regards,
>
> *Elias Akl MD*
>
> *Allergy and Immunology FellowVirginia Commonwealth University Health
> Center*
> *Work email: eakl at mcvh-edu.lb <eakl at mcvh-edu.lb>*
> *Office: 804-828-8681 <804-828-8681>*
> *Cell: 716-904-3649 <716-904-3649>*
>



-- 
Best Regards,

*Elias Akl MD*

*Allergy and Immunology FellowVirginia Commonwealth University Health
Center*
*Work email: eakl at mcvh-edu.lb <eakl at mcvh-edu.lb>*
*Office: 804-828-8681*
*Cell: 716-904-3649*

---
You are currently subscribed to cis-pidd as: pagid at list.clinimmsoc.org.
To unsubscribe click here: http://lm.clinimmsoc.org/u?id=96171615.db94721c3ca76e22c7616a473dde85b4&n=T&l=cis-pidd&o=2540050
or send a blank email to leave-2540050-96171615.db94721c3ca76e22c7616a473dde85b4 at lists.clinimmsoc.org
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <https://pairlist7.pair.net/pipermail/pagid/attachments/20150313/8a195e71/attachment-0001.html>