[CIS PIDD] [cis-pidd] a 3 mo boy with cytopenia, hepatosplenomegaly, recurrent skin rash and fever since birth

[CIS-PIDD]

Dr. Kim --

I would like to suggest evaluation for histiocytosis X / Langerhans cell histiocytosis, as well as re-evaluation of the bone marrow biopsy for signs of hemophagocytosis.  

Also, given the cat history and hepatosplenic involvement, please evaluate for bartonellosis, if you haven't yet.  If peliosis is seen in the liver biopsy, then this goes to the top of the differential diagnosis.

Is the patient's placenta available for pathologic examination?

Good luck with this case.

   - K

Karl O. A. Yu, M.D., Ph.D., F.A.A.P.
Instructor of Pediatrics (Pediatric Infectious Diseases)
University of Chicago - Comer Children's Hospital
5841 S Maryland Ave, MC 6054, Chicago IL 60637
Pager:  773-702-6800   x1744
Fax:  773-702-1196
Lab phone (Bubeck Wardenburg laboratory): 773-834-6976


________________________________________
From: CIS-PIDD [cis-pidd at lists.clinimmsoc.org]
Sent: Tuesday, March 08, 2016 10:43 AM
To: CIS-PIDD
Subject: Re: [cis-pidd] a 3 mo boy with cytopenia, hepatosplenomegaly, recurrent skin rash and fever since birth

What about the mother's Igs levels?
Mother's autoabs?

Direct Coombs is persistently positive?
And Complement factors (C3,C4,CH50) are persistently low?
Ferritin?
Other autoantibodies?

Family history of autoimmune diseases?
Which genes were investigated for ALPS?
Absolute counts of lymphocytes subsets were all low by 2 months. Is this persistent?

Low C3,C4 and CH50 and positive Coombs favors autoimmunity and not autoinflammatory diseases, isn't it?

Hypergamma and lymphoproliferation suggests immune dysregulation.
Since: not ALPS, not LHL, no autoimmune endocrinopathy (yet?), no enteropathy, no colitis, no encephalopathy, no partial albinism (yet?)...what about CD25 def ?!?!

BR,


2016-03-08 12:20 GMT-03:00 CIS-PIDD <cis-pidd at lists.clinimmsoc.org<mailto:cis-pidd at lists.clinimmsoc.org>>:
Maybe mevalonic aciduria? Like hyperIgD syndrome? Did you check for inborn metabolic disorders?

Ayça Aslan Kıykım, MD
Marmara University
Pediatric Allergy and Immunology
Istanbul TURKEY


8 Mar 2016 tarihinde 16:44 saatinde, "CIS-PIDD" <cis-pidd at lists.clinimmsoc.org<mailto:cis-pidd at lists.clinimmsoc.org>> şunları yazdı:

Dear All,

I have a question about a 3 mo old  twin boy with pancytopenia, hepatosplenomegaly, recurrent skin rash and fever since birth

-1st baby of twin (the other twin girl is health)
born at 33+6/7 weeks at 1,560 g, by emergency C-sec d/t maternal HELLP syndrome

- Maternal hx: significant for preeclampsia (HELLP syndrome) and oligohydroamnios, RH- AB blood type, received RhoGAM twice d/t positive indirect Coombs test -> became negative before delivery. Also received steroid

- At birth CBC was 5.8-14.7-83K and hepatosplenomegaly was noticed.
He developed rash on post natal age 7 day with elevation of CRP. Since then, he has recurrent rash, fever, and CRP elevation (not periodically but almost every somewhere 1-2 week)
- He continued to have hepatosplenomegaly and cytopenia (mainly thrombocytopenia around 20K, WBC counts are up and down from 2 to 5x10^3) .
- His CBC continue to show many immature cells, increased eosinophils, atypical lymphocytes, but no blast forms.
- It seems like the WBC and CRP counts rise when there is fever and rash. The rash is all over the body, involving extremities, face and trunk.Rashes are macular patch like ill defined rash but no pustules or they are not thrombocytopenia related petechiae.

- Extensive work-up for congenital infections for TORCH, syphilis, HIV, etc etc in two different hospitals multiple times: negative
Mom has cat ownership during pregnancy but toxo tests in mom and the baby are repeatedly negative.
- Additional work-up for any infection (bacterial, virus, fungus including PCP, mycobacterium) every time for rash/high CRP and fever: negative, except recent rhinovirus infection that he got from his mother who returned from visiting home. So far no invasive infection or confirmed pathogen from culture, PCR, BM, skin bx staining.

-  immune work-up lab done around  2 months old in Feb
  IgG 1377, IgA 118, IgM 123 mg/dL
  IgE 181 -> 465 IU/mL
  C3 64 ->97, C4 4->7.3 mg/dL, CH50 10-> 29 U/mL
- He did not receive IVIG at all so far.

- lymphocyte subset at 2 month old
CD3 1207 (80%), CD4 935 (62%), CD8 272 (18%), CD19 166 (11%), CD16+56+3- 106 (7%)
- DNT cells to check for ALPS, 0%
- neutorphil burst test, normal
- direct coombs test, positive
- anti-RNP/Anti-Sm, negative
- anti neutrophil Ab, anti platelet antibody: negative

- BM exam done twice, non diagnostic, no malignancy,  trilineage hematopoiesis observed
- Commercial NGS was sent out and genes were analyzed for SCID, WAS, hyper IgE, bone marrow failure, glycogen storage diseases, ALPS, congenital HLH, IPEX, DIRA etc: non-diagnostic
- brain normal, no calcification, no seizure
- eyes normal

- The baby grew relatively well now doubled the body weight and now 3.2 kg. Development appears normal.
- We started steroid at a dose of 2 mg/kg about 10 days ago becuase at that time the baby had fever, rash and liver enzyme up to 700 and he appeared responding to steroid. He is now tapered to 0.5mg/kg but now the fever and rash come back. Not sure but it appears that it is just a time for the fever and rash come back.
- We plan to perform a liver bx next week. Ultrasound exam showed no significant findings ( no nodules or no micro abscess like lesions) except persistent hepatosplenomegaly.

At this point, the baby is dependent to platelet and RBC transfusion. Congenital infection appears less likely after those extensive work-up and in a setting of the other twin is perfectly healthy.

I hope to get some more information from liver biopsy. So, here are some of my questions and I hope to get some other feedback also for diagnosis and management. Would this be something auto-inflammatory or autoimmune condition that I pursue further? Does anybody have suggestions on high IgE? Why the skin rash and fever come and go once in a a while? What should I do with steroid?  Will splenectomy help the baby out of this situation?

I apologize for this long description above. I would appreciate your feedback or suggestion. Thank you.

Best wishes,

YaeJean

Yae-Jean Kim, MD, PhD

Associate Professor
Division of Infectious Diseases and Immunodeficiency
Department of Pediatrics,
Samsung Medical Center,
Sungkyunkwan University School of Medicine,
81 Irwon-ro, Gangnam-gu, Seoul, South Korea

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