[CIS PIDD] [cis-pidd] Fw: HLH in SCid with CMV?

Thu Nov 2 15:09:02 EDT 2017

Hi Dr. Yu -

Thank you so much. The CMV is confirmed in the blood (viral load >1.6 million copies/mcl) and is in the urine as well.

NPA was negative for 16 viruses, viral PCR was negative for HSV1/2/VZV in blood (EBV and HHV6 still pending, as is adenovirus PCR). Bone marrow was sent for cultures (including mycobacterial, fungal, bacterial), as was the bronchoscopy BAL fluid - results pending. Galactomannan in blood was negative. Blood/CSF/urine negative for bacteria/HSV/VZV (CSF pending for CMV). His mother spent her childhood/teenage years in Paraguay, so we also are evaluating for congenital Chagas and strongyloides. At this point we have not added Amphotericin coverage, but I am going to strongly consider it empirically.

Despite the child already having CMV, we have suggested stopping breastfeeding because of risk for periodic shedding in breastmilk. I was wondering what others' practice is when the infection is already established.

Thank you again,
Tamar

________________________________
From: cis-pidd at lyris.dundee.net <cis-pidd at lyris.dundee.net> on behalf of CIS-PIDD <cis-pidd at lists.clinimmsoc.org>
Sent: Thursday, November 2, 2017 1:18:58 PM
To: CIS-PIDD
Subject: RE: [cis-pidd] Fw: HLH in SCid with CMV?

Dr. Rubin:

It certainly sounds like S/CID, with an HLH-like presentation.  While CMV is certainly a good idea, the list does not stop there.  With the infant’s young age, I suggest an evaluation for the respiratory viruses (adenovirus would be my top D/Dx), tuberculosis, HSV, aspergillus / endemic fungi, and C. trachomatis -- if it hasn’t been done yet – and especially if the CMV PCR is negative.  Depending on the patient’s risk factors, I may start empiric coverage even before results are available (e.g., lived in a house with a moldy basement buys amphotericin; recently-traveled grandma with a hacking cough buys anti-TB therapy, etc.).  Make sure the proper diagnostics are sent, otherwise, it’ll be difficult to decide when to stop coverage.

As much as it would complicate the social situation, I would withhold breastfeeding until CMV is ruled out (in both mom and baby).  I would advise the mother to continue pumping and freezing milk for now, until the workup is complete.  (I am sure other clinicians would disagree with me).

    - K

Karl O. A. Yu, M.D., Ph.D., F.A.A.P.

Scientist and Assistant Director, Center for Infectious Diseases and Immunology

RGH Research Institute | Rochester General Hospital | Rochester Regional Health

1425 Portland Ave., Room R-403, Rochester, NY   14621

Tel  585-922-3709  |  Fax  585-922-2415

From: cis-pidd at lyris.dundee.net [mailto:cis-pidd at lyris.dundee.net] On Behalf Of CIS-PIDD
Sent: Thursday, November 02, 2017 2:00 PM
To: CIS-PIDD
Subject: Re: [cis-pidd] Fw: HLH in SCid with CMV?

Dear Tamar,

Partial or full-blown presentations of (2') HLH can occur in (S)CID patients, typically infection associated.

In addition to CMV directed therapy high dose (2g) IVIG may help you to dampen the immune activation. I would also not hesitate to use steroids. If things threaten to get out of control, conditioning for haplo rather than etoposide would be my last resort.

Do not wait for genetics for your clinical decisions!

Best wishes, Stephan

Von meinem iPhone gesendet

_____________________
Am 02.11.2017 um 17:35 schrieb CIS-PIDD <cis-pidd at lists.clinimmsoc.org<mailto:cis-pidd at lists.clinimmsoc.org>>:

Hello all - my apologies if this is being sent a second time, but I am not sure if the first email went through.

I would greatly appreciate your expert management advice on a 3 month old boy with suspected SCID and disseminated CMV infection, with some HLH-like features.

My main question is regarding treatment for immune activation versus simply trying to treat infection (and of course any other suggestions for managing the severe infection). On a secondary note- what is the role of holding breastfeeding  in the context of established CMV infection?

Here is the story:

3 month old boy with some HLH features but not meeting criteria: Ferritin >3500, pancytopenia with hemoglobin 70 g/L, platelets 20 x 10^9/L, WBC 2-5 x 10^9/L, hypofibrinogenemia, hypertriglyceridemia, massive hepatomegaly, normocellular bone marrow in keeping with inflammatory/reactive process without hemophagocytosis; no fever and no splenomegaly at any point, normal soluble IL2R levels). Not enough T cells or NK for Cd107a, Perforin/granzyme expression. He has prominent neurologic symptoms (seizures, irritability) with increased protein and cell count in CSF (evenly lymphocytes, neutrophils and monos/macro), but no infections identified there (CMV PCR pending). He has rising liver enzymes (AST, GGT both in hundreds). MRI/CT brain normal. Worsening bilateral infiltrates and ground glass opacities on CXR and CT chest, small effusion. He is on low flow oxygen.

His immune workup showed almost no T or NK cells (36 cells/mcl T cells) on two occasions, but normal B cells in peripheral blood (similar distribution in the marrow). He has low IgG 1.5 g/L, absent IgA, and normal IgM (0.27 g/L). No thymus seen on CT/CXR (acknowledging he is sick/stressed), no secondary lymphoid tissue on exam. Diarrhea since receiving rotavirus 1 month ago (however no rotavirus in stool- repeat pending).

Pending investigations: SAP, XIAP, CD132 by flow; mitogen proliferations, TRECs (retrospectively since we don’t screen in this province yet), CD45Ra/Ro/recent thymic emigrants, bronchoscopy infectious results, Genetic panel for SCID.

Current management includes:

-IVIG replacement recently given

-Septra PJP treatment dose

-Gancyclovir

-Ceftriaxone

Thank you so much!

Sincerely,

Tamar Rubin

Tamar Rubin, MD, FRCPC

Pediatric Clinical Immunology and Allergy

University of Manitoba

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