[CIS PIDD] [cis-pidd] Patient with low IgM

[CIS-PIDD]

Hello, I was hoping you could provide some insight for a patient that I am
seeing. Thank you in advance for your help.


The patient is a 41 year old male who was referred to me after he developed
left arm cellulitis after a pneumovax and flu vaccination in September
2015. He required 1-2 days of IV antibiotics and completed an oral
antibiotic regiment.  He also developed pneumonia and sepsis in June 2015
after testing positive for the flu vaccine. He required intubation at that
time and was hospitalized for a few weeks.


He has no other history of recurrent infections including sinusitis or
pneumonia. He was hospitalized in 2012 for alcohol withdrawal. He has a
history of moderate etoh intake and he was told that he had to be treated
for alcohol withdrawal during the June 2015 hospitalization as well.

He states he no longer drinks alcohol.


He does not have any other significant medical history. He does not have a
history of asthma or eczema. He was born in the US.  He does not take any
medications but did receive vivitrol IM injections for 8 months in 2012 for
etoh abuse.  He is of Irish and Sicilian descent; he is married with three
young healthy children. His mother passed away from uterine cancer and his
father had HTN and passed away from heart disease.  He has two sisters, one
who is in her 40s and has a “positive ANA.” He has a maternal great aunt
with lupus.  He is self-employed in real estate.


His labs are notable for a low IgM.


WBC 14.8 (range 4-10), normal Hg, Hct and Platelets, normal differential

BMP/LFTs normal


IgG: 494 (range 700-1600 mg/dL) à repeat  605 mg/dL (range 700-1600 mg/dL)

IgM: 18 (range 40-230 mg/dL) à *repeat 19* (range 40-230 mg/dL)

IgA: 74 (range 91-414 mg/dL) à repeat 92 (range 91-414 mg/dL)

IgG subclass: IgG1: 333 mg/dL (range 422-1292 mg/dL), IgG2: 230 mg/dL
(117-747 mg/dL), IgG3: 41mg/dL (41-129 mg/dL), IgG4 16 mg/dL (1-291 mg/dL)

IgE 14 IU/mL (range 0-100)



HIV negative

He is blood group A; he has a positive Isohemagglutinin B titer 1:8.

C3 normal, C4 40 mg/dL (9-36 mg/dL)


He has protective titers for diphtheria, tetanus, varicella, rubella and H.
Influenzae type B.

He does not have protective titers for n. meningitides, mumps, rubeola and
only has 8/23 protective titers for pneumococcus (2 weeks after pneumovax).



He has negative titers for HbsAg, HepBs IgM/IgG, HepB core IgM, HepA IgM,
HCV IgG.


A lymphocyte panel including absolute values for CD3: 1452 (range
622-2402); CD4: 796 (range 359-1519); CD8 557 (109-897), CD19 348 (12-645)
is normal.


He is ANA negative.

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