Phenytoin-induced IgG2 and IgG4 deficiencies in a patient with epilepsy

Epilepsy and chronic obstructive pulmonary disease among U.S. adults: National Health Interview Survey 2013, 2015, and 2017

BACKGROUND

Among U.S. adults, over 4 million report a history of epilepsy, and more than 15 million report a history of chronic obstructive pulmonary disease (COPD); Chronic obstructive pulmonary disease, which includes chronic bronchitis and emphysema, is a common somatic comorbidity of epilepsy. This study assessed the relationship between self-reported physician-diagnosed epilepsy and COPD in a large representative sample of the U.S. adult population and explored possible mechanisms.

METHODS

Cross-sectional National Health Interview Surveys for 2013, 2015, and 2017 were aggregated to compare the prevalence of COPD between U.S. respondents aged ≥18 years with a history of physician-diagnosed epilepsy (n = 1783) and without epilepsy (n = 93,126). We calculated prevalence of COPD by age-standardized adjustment and prevalence ratios of COPD overall adjusted for sociodemographic and risk factors, by using multivariable logistic regression analyses. A Z-test was conducted to compare the prevalence between people with and without epilepsy at the statistical significance level of 0.05. Prevalence ratios whose 95% confidence intervals did not overlap 1.00 were considered statistically significant.

RESULTS

The overall age-standardized prevalence was 5.7% for COPD and 1.8% for epilepsy. Age-standardized prevalence of COPD among respondents with epilepsy (15.4%) exceeded that among those without epilepsy (5.5%). The association remained significantly different among all sociodemographic and risk factor subgroups (p < .05). In the adjusted analyses, epilepsy was also significantly associated with COPD, overall (adjusted prevalence ratio = 1.8, 95% confidence interval = 1.6-2.1) and in nearly all subgroups defined by selected characteristics.

CONCLUSIONS

Epilepsy is associated with a higher prevalence of COPD in U.S. adults. Public health interventions targeting modifiable behavioral and socioeconomic risk factors among people with epilepsy may help prevent COPD and related premature death.

Clinical and Immunological Features of 78 Adult Patients with Primary Selective IgG Subclass Deficiencies

The purpose of this study is to describe both clinical and immunological features in large cohort of adult patients with IgG subclass deficiency, and response to immunoglobulin therapy. This is a retrospective study of data obtained from electronic medical records and paper charts of 78 patients with IgG subclass deficiency seen and followed at our immunology clinics from 2010 to 2016. Both isolated selective IgG subclass deficiency as well as combined (two) subclass deficiencies were observed. IgG3 subclass deficiency, isolated and in combination with other IgG subclass deficiency, is the most frequent of IgG subclass deficiency. A majority of patients presented with upper and lower respiratory tract infections, especially chronic sinusitis. Both allergic and autoimmune manifestations are common; however, there is no subclass preference. The proportions and absolute numbers of CD3⁺ T cells, CD4⁺ T and CD8⁺ T cells, CD19⁺ B cells, and CD3^-CD16⁺CD56⁺ NK cells were normal in the majority of patients in all IgG subclass deficiencies. Total serum IgG levels did not correlate with IgG subclass levels across all IgG subclass deficiencies. Anti-pneumococcal polysaccharide antibody responses were impaired in 56% of patients. IgG3 subclass deficiency is the most common IgG subclass deficiency, and anti-polysaccharide antibody responses are distributed among IgG subclasses with modest preference in IgG2 subclass. The majority of patients treated with immunoglobulin responded by reduction in frequency of infections and requirement of antibiotics.

Diagnostic strategy for patients with hypogammaglobulinemia in rheumatology

The discovery of hypogammaglobulinemia, which is defined as a plasmatic level of immunoglobulin (Ig) under 5 g/L is rare in clinical practice. However, the management of immunodepressed patients in rheumatology, sometimes due to the use of immunosuppressive treatments such as anti-CD20 in chronic inflammatory rheumatisms, increases the risk of being confronted to this situation. The discovery of hypogammaglobulinemia in clinical practice, sometimes by chance, must never be neglected and requires a rigorous diagnosis approach. First of all, in adults, secondary causes, in particular lymphoid hemopathies or drug-related causes (immunosuppressors, antiepileptics) must be eliminated. A renal (nephrotic syndrome) or digestive (protein-losing enteropathy) leakage of Ig is also possible. More rarely, it is due to an authentic primary immunodeficiency (PID) discovered in adulthood: common variable immunodeficiency (CVID) which is the most frequent form of PID, affects young adults between 20 and 30 years and can sometimes trigger joint symptoms similar to those in rheumatoid arthritis; or Good syndrome, which associates hypogammaglobulinemia, thymoma and recurrent infections around the age of 40 years. In most cases, after confirming hypogammaglobulinemia on a second test, biological examinations and thoracic-abdominal-pelvic CT scan will guide the diagnosis, after which the opinion of a specialist can be sought depending on the findings of the above examinations. At the end of this review, we provide a decision tree to guide the clinician confronted to an adult-onset hypogammaglobulinemia.

Reversible panhypogammaglobulinemia associated with phenytoin treatment

We report the case of a 24-y-old woman who presented with repeated episodes of otitis due to panhypogammaglobulinemia and low levels of mature CD19 + B cells (84 cells/microl) associated with phenytoin treatment. Lymphocyte subpopulations and immunoglobulin levels need to be monitored if symptoms indicating immunodeficiency occur after the initiation of this treatment.

Secondary hypogammaglobilinemia after use of carbamazepine: case report and review

Immunologic disorders related to anticonvulsant therapy have been described in the last three decades, including cellular and humoral alterations that result in recurrent infections; however, the physiopathologic mechanisms are not completely understood. This report describes a patient with complex partial epilepsy and hypogammaglobulinemia while in treatment with carbamazepine, with significant improvement in clinical signs and laboratory tests after substitution to sodium valproate. The authors stress the importance of clinical and laboratory evaluation of patients in continuous anticonvulsant therapy, including immunoglobulins levels and peripheral blood evaluations.

Phenytoin promotes Th2 type immune response in mice

The effects of chronic administration of phenytoin, a common anticonvulsive drug, on immune responses were studied in mice. Anti-keyhole limpet haemocyanin (KLH) IgE antibody response after KLH-immunization was enhanced in phenytoin-treated mice. Proliferative responses of spleen cells induced with KLH, concanavalin A (ConA), lipopolysaccharide and anti-CD3 antibody were reduced in phenytoin-treated mice. Accessory function of spleen adherent cells on ConA-induced T cell proliferative response was reduced in phenytoin-treated mice. KLH-induced IL-4 production of spleen cells was enhanced, while IFN-gamma production was reduced in phenytoin-treated mice. In addition, production of IL-1 alpha, but not IL-6 and IL-12 by spleen adherent cells from phenytoin-treated mice was reduced. Natural killer cell activity was reduced in phenytoin-treated mice. These results suggest that phenytoin treatment preferentially induces a Th2 type response. We also observed that plasma ACTH and corticosterone levels were increased in phenytoin-treated mice, and speculated that phenytoin might act directly and indirectly, through HPA axis activation, on the immune system to modulate Th1/Th2 balance.

Immunodeficiency due to a unique protracted developmental delay in the B-cell lineage

A unique immune deficiency in a 24-month-old male characterized by a transient but protracted developmental delay in the B-cell lineage is reported. Significant deficiencies in the number of B cells in the blood, the concentrations of immunoglobulins in the serum, and the titers of antibodies to T-dependent and T-independent antigens resolved spontaneously by the age of 39 months in a sequence that duplicated the normal development of the B-cell lineage: blood B cells followed by immunoglobulin M (IgM), IgG, IgA, and specific IgG antibodies to T-independent antigens (pneumococcal polysaccharides). Because of the sequence of recovery, the disorder could have been confused with other defects in humoral immunity, depending on when in the course of disease immunologic studies were conducted. Investigations of X-chromosome polymorphisms suggested that the disorder was not X linked in that the mother appeared to have identical X chromosomes. An autosomal recessive disorder involving a gene that controls B-cell development and maturation seems more likely. In summary, this case appears to be a novel protracted delay in the development of the B-cell lineage, possibly due to an autosomal recessive genetic defect.

IgA and IgG2 deficiency associated with zonisamide therapy: a case report

PURPOSE

To report a previously undescribed adverse effect, IgA/IgG subclass deficiency associated with zonisamide (ZNS) therapy.

METHODS

Serum IgA and IgG subclass levels were determined by the turbidimetric immunoassay and enzyme-linked immunosorbent assay, respectively, in a 2-year-old boy with postmeningitis sequelae who was treated by ZNS.

RESULTS

Four months after initiation of ZNS, combined deficiency of IgA and IgG2 was noted. After cessation of ZNS, serum IgA level was promptly increased. IgG2 level was gradually increased, but remained subnormal after 7 months.

CONCLUSIONS

This case documents, for the first time, the action of ZNS on IgG immune system as well as IgA system. If patients with ZNS therapy showed IgA deficiency and recurrent infections, it is preferable to check serum IgG subclass concentrations as well.

Salivary protein composition in epileptic patients on different medications

Several salivary proteins were assayed in saliva from epileptic patients who were using different anti-epileptic drugs, viz, phenytoin, valproate and carbamazepine, and were compared with levels in unmedicated healthy control subjects. Flow rate and pH of the patient groups were not different from the controls. In all patient groups the specific amylase activity was increased up to twofold. In the phenytoin group only, the salivary IgA concentration was strongly reduced. Levels of salivary cystatin C were similar among all patient groups studied, and were not different from those of the control group. In contrast, the absolute and relative concentrations of cystatin S were diminished, particularly in patients using either valproate or phenytoin. These data suggest that use of anti-epileptic drugs over long periods may result in decreased levels of several salivary proteins such as sIgA and cystatins, which are involved in the protection of the oral cavity against microbial infections.