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

Wed Jan 20 02:16:56 EST 2016

Dear all,
I agree, I would do B cell subsets as an additional piece of the mosaic.
I would also exclude lymphoma and carcinoma (as we sometimes see hypo-IgM as a first marker, not sure why though).
Elevated lymphocytes may indicate nicotin consumption?
I would offer to see him again if any new infection occurs, or in 12 mos to re-check on his Ig’s..
Best, Bodo

****************************************
Univ.-Prof. Dr. med. B. Grimbacher

Scientific-Director
CCI-Center for Chronic Immunodeficiency
UNIVERSITÄTSKLINIKUM FREIBURG
Tel.: 0761 270-77731  Fax: -77744
Engesserstraße 4, 79108 Freiburg
bodo.grimbacher at uniklinik-freiburg.de<mailto:bodo.grimbacher at uniklinik-freiburg.de>
www.uniklinik-freiburg.de/cci

and

Consultant Immunologist
Institute of Immunity & Transplantation
Dept of Immunology
Royal Free Hospital
UNIVERSITY COLLEGE LONDON
Pond Street
London NW3 2QG
b.grimbacher at ucl.ac.uk<mailto:b.grimbacher at ucl.ac.uk>
www.centreforimmunodeficiency.com

Von: CIS-PIDD <cis-pidd at lists.clinimmsoc.org<mailto:cis-pidd at lists.clinimmsoc.org>>
Antworten an: CIS-PIDD <cis-pidd at lyris.dundee.net<mailto:cis-pidd at lyris.dundee.net>>
Datum: Tuesday 20 October 2015 08:46
An: CIS-PIDD <cis-pidd at lyris.dundee.net<mailto:cis-pidd at lyris.dundee.net>>
Betreff: Re: [cis-pidd] Patient with low IgM

Like Mikko I also wondered about a CVID-like condition, rather than selective IgM deficiency. Would you consider molecular studies in this regard, and do you have data on memory B-cell subsets (especially any reduction in class-switched memory B-cell value?).

It's an interesting case, please give us a follow up in due course.

Regards,

Stan Ress
Emeritus Associate Professor of Medicine, UCT
UCT Private Academic hospital
Observatory, Cape Town
Tel: 021-4421966<tel:021-4421966>/1816
Cell: 0833115482<tel:0833115482>
Fax: 0865173095<tel:0865173095>
Email: Stan.ress at uct.ac.za<mailto:Stan.ress at uct.ac.za>

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On 19 Oct 2015, at 4:18 PM, CIS-PIDD <cis-pidd at lists.clinimmsoc.org<mailto:cis-pidd at lists.clinimmsoc.org>> wrote:

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) --> repeat  605 mg/dL (range 700-1600 mg/dL)
IgM: 18 (range 40-230 mg/dL) --> repeat 19 (range 40-230 mg/dL)
IgA: 74 (range 91-414 mg/dL) --> 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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