[CIS PIDD] [cis-pidd] CVID with chronic GI campylobacter

Wed Apr 5 19:55:08 EDT 2017

Hi,

Interesting case.  My IBD colleague,  who is a microbiome expert. and I discussed this case.  We both think the campylobsctor  is not what causing the diarrhea in this patient.  Assuming you already looked for norovirus, giardia, crypto, c. Diff.  I suggest putting this patient on enteragam which is an oral iGG medical food supplant and helps improve chemical gut barrier function and treating his active gut inflammation.  I think this is PID/CVID related.  Your email suggests he just has a colitis so I would start him on budesonide MMX 9 mg daily in the short term.  In the longer term, I would consider starting him on vedolizumab or sirolimus. I personally prefer vedo but sirolimus does have advantages.  Would also thoroughly evaluate his small bowel with a CT or MRI enterography and make sure he gets duodenal and ileal biopsies.  Have your pathologist check colon biopsies for CMV and do CD8 IHC.  I have seen a fair amount of pancreatic exocrine insufficiency in these folks so would check a fecal elastase as well.  If low, would start pancreatic enzyme supplementation.

SG

Sarah C. Glover, DO, AGAF
Director, Inflammatory Bowel and Celiac Disease Program
Associate Professor of Medicine
University of Florida
PO Box 103643 <x-apple-data-detectors://1>
Gainesville, FL 32610<x-apple-data-detectors://1>
http://gastroliver.medicine.ufl.edu/ibd/
Phone (UF Health patient access center): 352-273-9400<tel:352-273-9400>
Phone (IBD research): 352-265-8971<tel:352-265-8971>
Phone (Cell): 312-933-8039<tel:312-933-8039>
Fax 352-265-8979<tel:352-265-8979>?

Sent from my iPhone

On Apr 5, 2017, at 4:05 PM, CIS-PIDD <cis-pidd at lists.clinimmsoc.org<mailto:cis-pidd at lists.clinimmsoc.org>> wrote:

I just took over care for a 66 y/o male with CVID, inclusion body myositis (previously thought to be polymositis but 2nd opinion leaning inclusion), pancytopenia (WBC 3-4,000, Hgb~10, platelets 40-70 and ALC 300-800 over last few years).  On diagnosis in 2012 his labs were IgG<40, IgA<5, and IgM<5, last IgG trough was 798.  No genetics have been done.

His biggest active issue is chronic diarrhea from chronic GI campylobacter.  He has had treatment with amoxicillin, levofloxacin, ciprofloxacin, azithromycin, and doxycycline.  Based on stool PCR testing, none of these have cleared the infection.  Multiple endoscopies hae shown active colitis, granulation tissue, crypt apoptosis, always thought to be secondary to campylobacter

As recent as last year his IgG had been closer to 1200 and he had no sinopulmonary infections (he has had 2 pneumonias this year with lower levels, we will be working on getting IgG trough back up), but did have continued diarrhea and campylobacter.

Most recent stool culture and multiplex PCR in February was positive for campylobacter.  He has had significant weight loss and loss of IgG from this diarrhea.  ID is planning to repeat culture with sensitivities next week.  But I wanted to reach out to see if anyone else has experience with chronic campylobacter in patients with CVID.  Any ideas for next step in treatment?

Thank you for your help
Nick
--

Nicholas Hartog, MD

Allergy and Clinical Immunology

Assistant Professor - Michigan State University College of Human Medicine

Nicholas.hartog at spectrumhealth.org<mailto:Nicholas.hartog at spectrumhealth.org>

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