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

Tue Oct 20 08:56:03 EDT 2015

Thank you very much for your review. Please see my comments below.

On Tue, Oct 20, 2015 at 2:03 AM, CIS-PIDD <cis-pidd at lists.clinimmsoc.org>
wrote:

> Hi!
>
> The person posting this gave us no clue who he/she is? Could you please
> always sign? *I am an allergist/immunologist in practice in New York. I
> will make sure to sign in the future and have signed below.  *
>
> According to the levels given, this patient has low IgG, low IgM and
> borderline low IgA, thus the title of this case is somewhat misleading? He
> sounds like a CVID candidate/in the making, but there are quite a few
> secondary causes potentially possible.
>
> What is his nutritional (protein nutrition) status?
> What are the Ig levels when measured at least 3 months after the previous
> invasive infection?
> Calprotectin levels in stools?
> Diarrhea due to exocrine pancreatic insufficiency?
> Urine albumin/protein loss?
> Fecal antitrypsin levels?
> Has monoclonal gammopathy been excluded?
>

 *His total protein and albumin levels are normal. He weighs 103 kg and his
Vitamin B12 and D levels are normal. He does not have Ig levels measured
prior to the invasive infection. He does not have any systemic complaints
of diarrhea. An serum protein electrophoresis was performed and did not
show a monoclonal gammopathy. Stool studies have not been performed on the
patient.  *

>
> In alcohol hepatopathy, one would expect to see high Ig levels (esp IgA
> and IgG).
>
> What was the logic behind measuring anti-PnP as early as in 2 weeks-  I
> did not quite get that? *This patient has seen a few physicians prior to
> me and the labs available reflect what has been performed thus far. I hope
> to repeat his pneumococcal titers 4 weeks post vaccination to have an
> accurate assessment of his response. *
>

> Was the vaccine given very early after a septic episode? *The vaccine was
> given 3 months after he was treated for sepsis. *
>
> All the cases of presumed cellulitis after Pneumovax I have seen (n about
> 6-7) were all sterile- though looked a lot like bacterial, and though IV
> antibiotics were given, skin was almost back to normal in just 3-4 d, which
> in bacterial cellulitis just does not happen. And all these patients had
> very robust anti-PnP levels 4 weeks after vaccine, they were thus rather
> hyperresponsive (which one can be even with panhypogamma).
>
> I would want to see the anti-PnP titers and Ig levels  now...?
>
> A single or even recurrent bacterial pneumonia due to alcohol  abuse is
> not rare.
>
> Thus ....this case left me with more questions than answers...
>
> Isolated low IgM- tend to agree with Soheil, far too common, most of the
> patients too healthy...
>
> Sorry for maybe just confusing you more?
>
> Mikko
>
>
> Oyl Mikko Seppänen
> Harvinaissairauksien yksikkö (HAKE)
>
> Chief, Rare Disease Center,
> Helsinki University Hospital (HUH)
> FINLAND
>
> phone +358 947180201
> GSM +358 50 4279606
> fax +358 9 47174703
>
>

*Jennifer Camacho, M.D.*
*Allergist/Immunologist*
*Scarsdale Medical Group*

> CIS-PIDD <cis-pidd at lists.clinimmsoc.org> kirjoitti 20.10.2015 kello 0.26:
>
> 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
> 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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