[CIS PIDD] [cis-pidd] MAI pulmonary infection with hypogam

Wed Jun 15 13:33:59 EDT 2016

Hello all,

       I recently saw a 67-year-old male with severe COPD with multiple bullous lesions on his CT scan of the chest on Advair 500/50, Spiriva for an immune evaluation because of his persistent pulmonary MAI infection .  He has been suffering from pulmonary MAI infection for the last 3 years.  He was originally diagnosed with MAI infection in July 2013 with  BAL fluid culture.  Since then he has been treated with thrice weekly azithromycin, ethambutol and rifampin.  He has been getting sputum cultures every 3 months and so far only 2 negative cultures occurred.  He was asymptomatic without major infections until 5-6 yrs. ago, later on started to have issues with sinusitis and it is also possible that he received 4-5 prednisone tapers/yr until 2 yrs. ago but he is not on any steroids  in last 2 yrs. He recently switched his care to our institution when we repeated the sputum culture he had Nocardia. Please see below for the details of the cultures and the susceptibilities. He is not on any inhaled aminoglycosides. 

Sputum, 6/16/2015: Nocardia cyriacigeorgica, confirmed by DNA sequencing analysis. AFB smear negative, and mycobacterial culture negative.

Sputum, 2/14/2015: Mycobacterium avium complex by gene probe after negative stain.

Sputum on 1/18/2016 is positive for Mycobacterium fortuitum.

BAL wash, 6/12/2013: Mycobacterium avium complex on culture, no AFB seen on concentrated smear.

Amikacin MIC: 16 µg/mL

Ciprofloxacin MIC: 8 µg/mL

Clarithromycin MIC: 0.25 µg/mL, susceptible

Linezolid MIC: 4 µg/mL, susceptible

Moxifloxacin MIC: 0.5 µg/mL, susceptible

Moraxella catarrhalis and Haemophilus influenzae, both beta lactamase positive also isolated.

On his immune evaluation: IgG-464, IgA-138, IgM-31, IgE-39 IgG1-250, IgG2- 205, IgG3-34, IgG4-32.  Patient has normal CBC with a differential including monocyte count of 410 cells per microliter with absolute lymphocyte count of 1960/ul. Pneumococcal titers are 7/14 titers are protective with pneumonia vaccine given >1 yr ago. Tetanus titer-5.3 IU/ml.

Component    Latest Ref Rng

5/16/2016

T Cells    60.0-86.0 %

66.9

CD4 % Helper T Cell   33.0-59.0 %

52.5

CD4 T Cell Abs    >=550 cells/uL

1021

CD8 Suppressors 11.0-40.0 %

13.6

CD19    5.0-25.0 %

14.9

NK Cells   6.0-29.0 %

17.6

H/S Ratio  1.0-2.9

3.9 (H)

Abs T Cells >=850 cells/uL

1301

CD8 T Cell Abs   >=300 cells/uL

264 (L)

Abs CD19    >=150 cells/uL

290

Abs. NK Cells   >=150 cells/uL

342

Lymph Recovery  95.0-100.0 %

99.4

Do you consider these MAI positive cultures now a colonization or a symptom of some underlying immune issue or something else. I am not able to explain hypogam in this patient.  

Given the hypogam I am planning on starting him on IVIG but I wanted to ask your advice on next steps  on both diagnostic and therapeutic .

Thanks for your help.

Anil

Anilkumar Katta, M.D.

Clinical Asst. Professor of Medicine, Tufts University School of Medicine,

Department of Allergy and Immunology, Lahey Hospital and Medical Center,

31 Mall Rd., Burlington, MA - 01805.

Phone: 781-744-8442.

Fax: 781-744-3442.

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