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

[CIS-PIDD]

Were Pneumovax and influenza vaccine administered in opposite sides or in the same arm? If the former were the case, you could isolate the culprit by laterality, and focus your attention on the culprit.
I have seen a few Arthus-type reactions in patients who have had a high titers of preexisting antibodies to one of the vaccine components prior to vaccination. They display swelling, redness warmth and tenderness, and are often misdiagnosed with infectious cellulitis and subjected to unnecessary antibiotics. Severe infection caused by influenza virus, and pneumonia in an apparently immunocompetent host shortly prior to vaccination would be consistent with this assumption.
I am not certain, if a definitive pathologic value can be assigned to isolated low IgM. I have stumbled into patients with low IgM and in them I could not find a single condition that could explain the low levels of IgM, which could be generalized to different individuals who displayed it. I am not sure, if this is of any help. I hope others will be able to share their insight, so that we can utilize collective knowledge and experience in managing similar cases.
Soheil Chegini, M.D. 

Exton Allergy & Asthma Associates 

656 West Lincoln Hwy.

Exton, PA 19341 

Phone: (610) 269-3066 

Fax: (610) 269-8615



      From: CIS-PIDD <cis-pidd at lists.clinimmsoc.org>
 To: CIS-PIDD <cis-pidd at lyris.dundee.net> 
 Sent: Monday, October 19, 2015 10:14 AM
 Subject: [cis-pidd] Patient with low IgM
   
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 developedleft 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 inJune 2015 after testing positive for the flu vaccine. He required intubation atthat time and was hospitalized for a few weeks.
He has no other history of recurrent infections including sinusitisor pneumonia. He was hospitalized in 2012 for alcohol withdrawal. He has ahistory of moderate etoh intake and he was told that he had to be treated foralcohol withdrawal during the June 2015 hospitalization as well. He states he nolonger drinks alcohol.
He does not have any other significant medical history. Hedoes not have a history of asthma or eczema. He was born in the US.  He does not take any medications but didreceive vivitrol IM injections for 8 months in 2012 for etoh abuse.  He is of Irish and Sicilian descent; he ismarried with three young healthy children. His mother passed away from uterinecancer and his father had HTN and passed away from heart disease.  He has two sisters, one who is in her 40s andhas 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, normaldifferentialBMP/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) àrepeat 19 (range 40-230 mg/dL)IgA: 74 (range 91-414 mg/dL) àrepeat 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 (1-291mg/dL)IgE 14 IU/mL (range 0-100)

HIV negativeHe 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 weeksafter pneumovax). 

He has negative titers for HbsAg, HepBs IgM/IgG, HepB coreIgM, HepA IgM, HCV IgG. 
A lymphocyte panel including absolute values for CD3: 1452 (range622-2402); CD4: 796 (range 359-1519); CD8 557 (109-897), CD19 348 (12-645) isnormal. 
He is ANA negative.   ---  You are currently subscribed to cis-pidd as: schegini at yahoo.com.  To unsubscribe click here: http://cts.dundee.net/u?id=96396879.1c4ba390e5cba8b441ad14c59c207858&n=T&l=cis-pidd&o=3219923  (It may be necessary to cut and paste the above URL if the line is broken)  or send a blank email to leave-3219923-96396879.1c4ba390e5cba8b441ad14c59c207858 at lyris.dundee.net

  
---
You are currently subscribed to cis-pidd as: pagid at list.clinimmsoc.org.
To unsubscribe click here: http://cts.dundee.net/u?id=96396833.5a9591ccd1e327fe6bc4d1543298c482&n=T&l=cis-pidd&o=3221161
or send a blank email to leave-3221161-96396833.5a9591ccd1e327fe6bc4d1543298c482 at lyris.dundee.net
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <https://pairlist7.pair.net/pipermail/pagid/attachments/20151019/c6c29c8d/attachment-0001.html>