COMMON VARIABLE IMMUNODEFICIENCY. INTERNAL MEDICINE RESIDENT’S GRAND ROUNDS MARCH 9, 1995 JAMES W. SCHNELL, MD. INTRODUCTION. First case of hypogammaglobulinemia was reported by Bruton in 1952. First case reports of common variable immunodeficiency in 1954.
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INTERNAL MEDICINE RESIDENT’S GRAND ROUNDS
MARCH 9, 1995
JAMES W. SCHNELL, MD
1. Increased CD8+ T cells.
2. Depressed levels of T cell cytokines(IL2).
- 7/220 pts with stomach CA.
- 3/220 pts. with lymphoma.
- 47 fold increase in stomach CA. - 30 fold increase in lymphoma.
- 7/98 pts with lymphoma (all females).
- 1/98 pts with stomach CA.
- 438 fold increase in lymphomas in
1. Reactive lymphoid hyperplasia.
2. Atypical lymphoid hyperplasia.
-Most patients have panhypoglobulinemia.
-IgG is consistently low.
-IgA and IgM may sometimes be normal.
HPI: W.C was a previously healthy 48yowm who presented to NCBH with a 6 mo c/o of weakness, fatigue, anorexia, diarrhea, and a 40lbs weight loss. Sx’s began after drinking contaminated water in FL. Intermittent nausea, vomiting and diarrhea. No hematochezia, hemetemesis but possibly melena. Also reported a 3 wk c/o productive cough, fevers and chills.
PMH: None. Recently involved in a MVA in mount Airy, NC. Was started on Lodine, Trazadone, and cyclobenzaprine.
SH: Recently moved to NC from New Mexico. No ETOH, Tobacco or homosexual activity. Divorced but living with girlfriend.
FH: Mother died age 59 stomach CA, father died age 60 with liver CA.
PE: T 102.4 P 104 BP 110/60 RR 20
GEN: Cachectic, pale WM in NAD
HEENT: Pale MM’s
NECK: Supple, no adenopathy
LUNGS: Decreased BS and rales right base
CVS: RRR with II/VI SEM
ABD: Soft, NT, +BS. no masses.
RECTAL: Heme- , no masses.
LABS: WBC: 1,800 (50% s, 40%L)
Hb: 4.8 MCV 107
Na: 131 K: 3.2 LDH: 742
Prot: 4.0 Alb: 2.9 Chol: 80
CXR: RLL infiltrate
IMPRESSION: Pneumonia and pancytopenia due to malignancy vs. B12 deficiency vs. myelopthisic process.
IgA 3 L (70-350)
IgG 408 L (700-1700)
IgM 14 L (70-210)
1. Common variable immunodeficiency
4. Atrophic gastritis + pernicious anemia
5. Nodular lymphoid hyperplasia
FOLLOW UP: The patient was referred for immunologic evaluation and the diagnosis of CVID was confirmed by documenting inappropriately low post immunization antibody titers to tetanus toxoid and pneumococcus vaccine. The patient was started on IVIG 400mg/kg/month and IM B12. He has not had any further pulmonary or gastrointestinal infections and his anemia has resolved.