[CIS PIDD] [cis-pidd] 17 mo M with autoimmune cytopenias, hypotonia, 3rd nerve palsy

Fri Jun 19 15:19:47 EDT 2015

Are B cell counts normal, or are these by any chance high normal or elevated? 

Mikko Seppänen
HUH, Finland

________________________________________
Lähettäjä: Jonathan Tam [kiditamae at gmail.com]
Lähetetty: 19. kesäkuuta 2015 21:48
Vastaanottaja: CIS-PIDD
Aihe: [cis-pidd] 17 mo M with autoimmune cytopenias, hypotonia, 3rd nerve palsy

We here at CHLA have a case of a 17 month old M with autoimmune cytopenias
(thrombocytopenia, hemolytic anemia and neutropenia), hypotonia and new 3rd
nerve palsy with no focal findings on MRI.

He was increase in double negative T cells (CD3+ CD4-CD8-, TCR a/b 5.1%),
but no palpable lymphadenopathy (only LAD on CT) and normal looking nodes
on biopsy.

Any input would be appreciated.

Thoughts on Rituxan for for this patient?
Further diagnositic studies?

*Patient Summary*:

Patient is a now 13-month-old boy with a history of developmental
delay, hypotonia and febrile seizure who was first seen 12/2014 with
thrombocytopenia that was responsive to IVIG.   He was then hospitalized
4/26-4/28/15 for fever, hypoxemia found to be +metapneumovirus.  He
represented on 4/29 to an outside hospital due to persistent fever,
possible febrile seizure, and respiratory distress.  At the OSH he was
treated for PNA diagnosed on CXR with vancomycin and ceftriaxone x14 days.
He was noted to have thrombocytopenia and received 6 g IVIG on 5/21/15.
Developed new dysconjugate gaze with L lid half closed, evaluated by peds
neuro with *MRI brain and orbits reported negative *except for right
sphenoid and ethmoid sinus disease.  He was subsequently transferred back
to our care.

Repeat MRI/MRA/MRV did not detect any focal lesions in the brain.  CT of
the chest abdomen and pelvis did note hilar, mediastinum, retroperitoneum,
and groin adenopathy.  Additionally in the chest there was patchy
“bilateral lung opacities both upper and lower lungs that may be
infectious/inflammatory, but areas of atelectasis/scarring not excluded”.

LN biopsy on a node from the groin did not show any significant
abnormalities (no cancer, not consistent with ALPS).  Bone marrow was
similarly underwhelming.

Ophtho and neurology calling the new ptosis Miller-Fisher variant
Guillain-Barre syndrome.  Neuronal ab screen (Hu) was positive, but western
blot was negative.

 FH:

--No consanguinty.  No history of recurrent infections.

--The patient's mother is of Filipino and Mexican descent. The patient's
father is of Mexican descent.

--Maternal uncle, paternal uncle, and grandmother with asthma.  Mom with
atopic dermatitis.  Paternal uncle with allergic rhinitis.  No family
history of thrombocytopenia

SH: Recently moved to LA from New Mexico.  2 dogs at home.  No smokers at
home.  Lives with mom, dad, paternal uncle, and paternal grandparents.

Birth history: Born full term via NSVD.  No complications. Birth weight 5
lbs 6 oz.  No NICU stay. Born in New Mexico (no newborn screen)

Developmental history:  Crawls (started at age 12 months), Cruises (started
at 15 months), Says mama and dada (started at 10 months), Reaches for
objects

*Labs/Imaging*:

*CD3+                                 17.5 %*

*Abs CD3+                        296 Cells/uL*

*CD3+CD4+                       9.0 %*

*Abs CD4+                        152 Cells/uL*

*CD3+CD8+                       6.3 %*

*Abs CD8+                         106 Cells/uL*

*CD3+ CD4-CD8-, TCR a/b    5.1%*

*CD3/4+ CD45RA+           2%*

*CD31+CD45RA+            <1%*

TREC sent to Viracor >950 (normal >801)

*CD25+CD127dim+         4%*

CD3-CD16+CD56+         20.0 %

Abd NK                             338 Cells/uL

CD3+HLA DR+                 5 %

CD19+                                60.3 %

Abs CD19+                       1,021 Cells/uL

IgD-CD27+CD19+           10%

NK function normal

IgG 1,760 mg/dL  (one week after IVIg for thrombocytopenia)

IgM 387 mg/dL
IgA 128 mg/dL

C3            88 mg/dL
C4            22 mg/dL
CH50       238 Unit

12/23/14

12/27/14

3/11/15

4/24/15

5/28/15

WBC

6.22 K/uL

7.19 K/uL

 3.43 K/uL

5.45 K/uL

*3.60 K/uL*

ANC

2150

2000

1960

600

*0*

ALC

2740

3390

1280

3160

1690

RBC

3.52 M/uL

4.10 M/uL

3.20 M/uL

3.53 M/uL

2.64 M/uL

HGB

9.0 g/dL

10.9 g/dL

8.3 g/dL

9.6 g/dL

*7.8 g/dL*

HCT

27.4 %

32.3 %

26.6 %

29.3 %

24.7 %

MCV

77.8 fL

78.8 fL

83.1 fL

83.0 fL

93.6 fL

MCH

25.6 pg

26.6 pg

25.9 pg

27.2 pg

29.5 pg

MCHC

32.8 %

33.7 %

31.2 %

32.8 %

31.6 %

PLT

*13 K/uL*

218 K/uL

*41 K/uL*

107 K/uL

*9 K/uL*

RDW

14.8 %

14.9 %

H 15.6 %

H 16.7 %

H 18.2 %

O+, *DAT+ and warm antibody positive.*

Neuronal (Hu) ab screen positive, but western blot *negative*

HIV, EBV, CMV HSV PCR negative

Free T4     0.72 ng/dL
TSH            1.81 uIU/mL
Thyroid Stim Immunoglobulin    * <89 % baseline
Thyroglobulin ab    * <244 I.U./mL (Negative)
TPO    * <33.4 I.U./mL (Negative)

LKM ab <20
Smooth muscle ab 29 (normal <20)

LN biopsy - Both H\T\E stained sections demonstrate benign lymph nodes
with mild follicular hyperplasia and mild paracortical expansion.
Germinal centers are well formed with a crisp mantle zone. The
paracortex is composed of a heterogeneous population of small
lymphocytes, immunoblasts, plasma cells and with mild vascular
proliferation. There is focal sinus histiocytosis (A2)

Abd US:  Nonspecific coarsened echotexture within the liver, which can be
seen in infiltrative processes such as steatosis. No discrete liver lesion
or evidence of biliary duct dilatation.

MRI/MRA/MRV Brain/Orbits:

--No evidence of acute infarct, hemorrhage, hydrocephalus, or mass.

--No signal abnormality or abnormal enhancement within the orbits.

--Normal course and caliber the visualized portions of the circle of Willis.

--No evidence of occlusion or high-grade stenosis of the major dural venous
sinuses.

CT Chest/Abd/Pelvis:

1. Patchy bilateral lung opacities both upper and lower lungs that maybe
infectious/inflammatory, but areas of atelectasis/scarring not excluded.
Greatest area is at right base where it seems more consolidated.

2. Right hilar, mediastinum, retroperitoneum, groin adenopathy of which
some are partially calcified at the right groin along with

hepatosplenomegaly. Would wonder about granulomatous disease whether TB or
cocci since calcified nodes are less typical for histiocytosis

or cat scratch. Otherwise could relate to other
rheumatologic/infectious/inflammatory process. Further down the
differential would be leukemia/lymphoma (not typical for neuroblastoma).

 Swallow study normal.

---------------------------------------------------

Jonathan Tam, MD

Assistant Professor of Pediatrics

Division of Clinical Immunology & Allergy

Children’s Hospital Los Angeles

4650 Sunset Blvd, MS#75

Los Angeles, CA 90027

jstam at chla.usc.edu

Phone: 323.361.2501

Fax: 323.361.1191

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