[CIS PIDD] [cis-pidd] Skin Candida with partial MBL deficiency & Low CD8 effector memory

[Stan Ress]

Dear colleagues,

I’d appreciate your opinion on an interesting 38 year-old lady referred to me by her dermatologist for immune evaluation. She has a background history of life long irritable bowel syndrome and frequent gastroenteritis but is generally otherwise well.
Upper endoscopy in 2010 reported erosions ? H. Pylori (but no treatment details). In September 2014 she developed a significant skin rash and Candida was isolated, in March it also involved her face, and her dermatologist treated these with  oral itraconazole and Terbinafine HCL and a facial cream, to which she has responded. Aside from symptoms of bloating and heartburn, there was no history of any other infections or antibiotic use that could precipitate the Candida. Blood tests showed normal FBC, ESR –5, random glucose & HBA1c 5.5, normal full liver functions, and negative HIV. Normal serum Ig A,G,M levels, C3 & C4 & CH50, but partial deficiency of MBL 759 ng/ml (>1000). Coeliac serology negative. IGRA TB T-spot test negative (positive PHA control). Lymphoproliferation to candida was normal, reduced to Varicella Zoster, and absent to Tetanus. Baseline vaccination status indicated sufficient protective IgG to S. Pneumonia, Tetanus Toxoid, C. diphtheriae, and very high levels against B. Pertussis but insufficient titre against H. Influenza. Flow cytometry indicated normal CD3/CD4 but reduced CD8  of 360 /ul (500-900) and NK 191/ul (200-400) with CD4/8 ratio of 2.55:1. B-cell % was 13.5% with total memory B-cells of 20.7%, Naïve B-cells of 73%, and class-switched memory B-cells of 9.48%. CD4/CD45 Naïve & memory T-cells were normal range, as were recent thymic emigrants, central memory helper cells, effector memory helper cells, total naïve cytotoxic cells, and central memory cytotoxic cells. However, effector memory cytotoxic T-cells were low at 2/ul (0-36).

Are the findings of partial reduction in MBL, low CD8+ T-cells and lowish effector memory cytotoxic T-cells enough to explain her susceptibility to Candida with significant skin involvement?

I’d greatly value thoughts about this and any suggestion for further investigations and treatment (Prophylactic itraconazole long term?)

Thanks,

Stan
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Stanley Ress
Specialist Physician & Clinical Immunologist
Emeritus Associate Professor of Medicine, UCT
UCT Private Academic hospital,
Anzio Road, Observatory,
Cape Town, 7925
South Africa
TEL:INTERN. + 2721-4421966 or 4421816
FAX:   "    + 2721-(0)865173095
Cell: 0833115482
email: stan.ress at uct.ac.za<mailto:stan.ress at uct.ac.za>
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