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

Wed Apr 5 22:54:32 EDT 2017

Thank you for the additional info.  I would favor CVID enteropathy based on those biopsy findings.  Agree this is not Crohns.  I still think the campylobactor is not the cause.  It should have responded to the abx you gave him.  We see colonization with c. Diff which can be as high as 30 percent at our institution.  Fecal transplsnt has been shown to be of clear benefit with c. Diff infection but I would use caution in using it in a PID patient with chronic active colitis and ileitis.  You may inadvertently introduce bacteria that may make his gut inflammation worse.  Still think it's worth looking at total CD8 on bx.

You may want to consider trying budesonide MMX. Works much better in the colon.  Regular budesonide only impacts TI and right colon.  Would also consider the vedolizumab,  We have used it safely in a number of CVID enteropathy folks. Very gut specific but you need to give it a good 14 weeks to kick in.  Would repeat colonoscopy no earlier than 14 weeks but probably 20 weeks to check for mucosal healing.    I have used tacrolimus in these patients as well.  Well absorbed through inflamed gut, T cell specific, quick onset of action and if you get in trouble it's gone In 72 hours.  For classic UC,  the trough levels need to address active inflammation around 10. But, I would start low at 1 mg BID if you go this route and titrate to effect.  As I mentioned earlier, sirolimus also an option.

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 10:27 PM, CIS-PIDD <cis-pidd at lists.clinimmsoc.org<mailto:cis-pidd at lists.clinimmsoc.org>> wrote:

Thanks for the response.

To give you a little more information, stool PCR for C diff toxin, P shigelloides, Salmonella, vibrio, V coolera, Y enterocolitis, EAEC, EPEC, ETEC, STEC, EIEC, crypto, E histolytica, giardia, adenovirus, astrovirus, norovirus, rotavirus, and sapovirus was negative at least twice (only campylobacter positive).

2016 biopsies (included ileum biopsy)
showed active enterocolitis with ulcr/inflammed granulation tissue, no granulata.  chronic inflammatory cells was devoid of plasma cells.  Pathologist felt unlikely secondary to IBD, infection not excluded, possibly consisted with CVID-related enterocolitis

2014 biopsies (Right and left colon and ileum)
R colon-chronic active colitis, decreased plasma cells, apoptosis of crypt epithelium
L colon-chronic active colitis, decreased plasma cells, apoptosis of crypt epithelium
Ileum-predominently acutely inflamed granulation tissue and fibrinopurulent exudate, consistent with ulceration

2014 biopsies
small intestine—paucity of plasma cells and increased eosinophils
stomach—chronic active colitis, decreased plasma cells, negative H pylori
eosophagus-candida esophagitis (no problem with this since or before)
R colon—chronic active colitis, moderate activity with acutely inflamed granulation tissue, decreased plasma cells, apoptosis of crypt epithelium
L colon-focal active colitis with prominent lymphoid follicles

At the beginning of the course he was treated with methotrexate and azathioprine and budesonide without improvement.

I am by no means an IBD expert, but isn’t it possible to see some of the biopsy changes secondary to campylobacter?

I am glad you brough up enteragram as oral IgG was one thought of mine.  If this does prove secondary to campylobacter would fecal transplant be a reasonable option?

Nick

On Apr 5, 2017, at 7:55 PM, CIS-PIDD <cis-pidd at lists.clinimmsoc.org<mailto:cis-pidd at lists.clinimmsoc.org>> wrote:

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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