Non-Infectious Complications in B-Lymphopenic Common Variable Immunodeficiency

BACKGROUND AND OBJECTIVE

Common variable immunodeficiency (CVID) is considered the most symptomatic type of inborn errors of immunity in humans. Along with infectious complications, which have numerous consequences, non-infectious complications are also a major challenge among CVID patients.

METHODS

All registered CVID patients in the national database were included in this retrospective cohort study. Patients were divided into two groups based on the presence of B-cell lymphopenia. Demographic characteristics, laboratory findings, non-infectious organ involvements, autoimmunity, and lymphoproliferative diseases were evaluated.

RESULTS

Among 387 enrolled patients, 66.4% were diagnosed with non-infectious complications; however, 33.6% had only infectious presentations. Enteropathy, autoimmunity, and lymphoproliferative disorders were reported in 35.1%, 24.3%, and 21.4% of patients, respectively. Some complications, including autoimmunity and hepatosplenomegaly, were reported to be significantly higher among patients with B-cell lymphopenia. Among organ involvement, dermatologic, endocrine and musculoskeletal systems were predominantly affected in CVID patients with B-cell lymphopenia. Among autoimmune manifestations, the frequency of rheumatologic, hematologic, and gastrointestinal autoimmunity was reported to be higher compared to other types of autoimmunity independent from the B cell-lymphopenia. Furthermore, hematological cancers, particularly lymphoma, were slightly introduced as the most common type of malignancy. Meanwhile, the mortality rate was 24.5%, and respiratory failure and malignancies were reported as the most common cause of death in our patients without significant differences between the two groups.

CONCLUSION

Considering that some of the non-infectious complications might be associated with B-cell lymphopenia, therefore, regular patient monitoring and follow-up along with proper medications (besides immunoglobulins replacement therapy) are highly recommended to prevent further sequels and increase the patients' quality of life.

Anaphylaxis reaction to Samsum ant (Pachycondyla sennaarensis): a case series study

Summary

Background. Anaphylaxis is a life-threatening hypersensitivity reaction. The present study aimed to investigate the cases of anaphylaxis to ant stings in Iran to determine the characteristics of patients, geographical distribution and the type of ants that cause anaphylaxis. Methods. Patients with a history of anaphylaxis to ant sting underwent skin allergy test with extracted substance from Solenopsis invicta. Samples of ants were collected from the sites where each patient was bitten and their species were identified by a medical entomologist. Results. Nineteen patients (mean age: 26.2 years; range: 4-48 years) were included in the study. Most patients (89.5 percent) were female. The lower limb was the most common site of the sting and most stings had occurred in the morning (31.6 %) and evening (31.6%). Skin manifestations were the most common clinical symptoms (94.7%). Most cases of stings were observed in the Hormozgan province (89.5%) located in southern Iran. Sixteen patients had positive skin prick test for ant venom. All collected ants that caused anaphylaxis belonged to the Pachycondyla sennaarensis species. Conclusions. Ant sting anaphylaxis is not uncommon in Iran, especially in its southern regions. All cases of anaphylaxis in this study were due to samsum ant sting (Pachycondyla sennaarensis), which is a species similar to the fire ant (Solenopsis invicta). Allergy skin testing with fire ant extract was positive and helpful in identifying samsum ant allergy in all cases.

Sustained unresponsiveness development in wheat oral immunotherapy: predictive factors and flexible regimen in the maintenance phase

Summary

Background and aim. Immunotherapy may induce sustained unresponsiveness (SU) in which the patient can tolerate the allergen without any severe symptoms after discontinuing immunotherapy. The present study evaluated serum and cutaneous markers for predicting SU in patients with wheat anaphylaxis who underwent oral immunotherapy. Moreover, we investigated the effectiveness of a flexible regimen of 5 to 10 g wheat protein (WP) in the maintenance phase of oral immunotherapy (OIT). Methods. This study was conducted on 19 patients with wheat anaphylaxis who underwent OIT. The result of the skin prick test (SPT), besides specific serum IgE (sIgE) and IgG4 (sIgG4) to WP, were evaluated before the desensitization. The maintenance dose started from the preferred dose of 5 to 10 g WP after the build-up phase, if the patient could tolerate it. All patients were recruited 7 to 9 months after undergoing this flexible regimen, and the results of SPT and sIgE, and sIgG4 levels were obtained once more. The patients underwent oral food challenge (OFC) after a 3-4-week avoidance to evaluate SU. Results. There was an association between mean IgE reduction and SU (p less than 0.0006), while no association was observed between the mean increase in specific IgG4 (p = 0.1) and the mean wheal diameter decrease (p = 0.29). In the present study, a 50% reduction in sIgE was associated with SU. Thirteen patients were considered to have a SU. Moreover, there was no association between the flexible regimen and the desensitization rate. Conclusions. The results revealed that the reduction of 50% sIgE is a predictive factor for SU in patients with IgE-mediated wheat allergy.

Assessment of IgE- and cell-mediated immunity in pediatric patients with eosinophilic esophagitis

Summary

Eosinophilic esophagitis (EoE) is a chronic allergen/immune-mediated disease leading to esophageal dysfunction. Food allergens play critical roles in the pathogenesis and treatment of EoE via different mechanisms. This study aimed to present the characteristics and evaluate the ability of skin prick test (SPT), skin prick to prick test (SPP) (IgE-mediated), and atopic patch test (APT) (cell-mediated) individually or simultaneously to diagnose food allergy in patients suffering from EoE. This prospective study was conducted on 58 patients with EoE. Seven patients (12.1%) were positive to only one, 3 (5.2%) were simultaneously positive to two, and 32 (55.2%) were simultaneously positive to three tests. Single and double sensitizations were totally 10.4% in IgE-mediated reactions, while 36.5% in cell-mediated reactions. In contrast, poly sensitization (> 2 allergens) was 51.7% in IgE-mediated tests and 20.7% in the cell-mediated test. Multiple sensitization findings showed egg white, milk, yolk, and soy were the most frequent allergens. Our findings indicate that EoE is early onset and associated with multiple food sensitizations, particularly via IgE-mediated mechanisms. These immune-mediated responses encompass both IgE-mediated (SPT and SPP) and cell-mediated (APT) reactions simultaneously not individually. Therefore, employing multiple assays may strengthen the diagnosis of food sensitization.

Can concurrent lower gastrointestinal manifestations help the timely diagnosis of small intestinal bacterial overgrowth in CVID patients?

Summary

Introduction and objective. Gastrointestinal complications are considered as one of the most common manifestations in patients with Common Variable Immunodeficiency (CVID). These complications can result from Small Intestinal Bacterial Overgrowth (SIBO). Hydrogen breath test is extensively used to diagnose SIBO. The objective of this study was to evaluate the prevalence of SIBO using the Hydrogen Breath Test (HBT) in patients with CVID. Materials and methods. Twenty-seven patients with CVID entered this cross-sectional study. Demographic and lower gastrointestinal symptoms were recorded in a check list. Hemoglobin level was measured in all patients. The concentration of IgA and IgG was assessed using nephelometry. Moreover, SIBO was detected by means of Glucose hydrogen breath test. Results. The mean (plus-minus SD) age of the patients was 35.25 (plus-minus 11.69) years. Twenty patients (74.1%) manifested at least one lower gastrointestinal symptom. The most frequent lower gastrointestinal manifestations were bloating (66.7%) and chronic diarrhea (40.7%), respectively. IgA level less than 10 mg/dl and IgG level less than 600 mg/dl were determined in 77.8% and 25.9% of patients, respectively. Positive HBT was detected in 40.7% (n = 11) of the patients. In the positive HBT group, bloating, chronic diarrhea and abdominal pain were the most common lower GI manifestations. There was no significant difference in terms of age, BMI, IgA level, and duration of CVID between the positive and negative HBT groups. The significant association of co-occurrence of anemia and abdominal pain with positive HBT (positive predictive value: 100%) might be considered as a clue to SIBO diagnosis. Conclusions. Regarding the high prevalence and non-specific manifestation of SIBO, it is suggested to consider concurrent symptoms in patients with CVID to manage the timely and precise diagnosis of SIBO.

Combination of bolus dose vitamin D with routine vaccination in infants: a randomised trial

INTRODUCTION

The present study was designed to compare two methods of vitamin D supplementation in infants: every two months as a routine vaccination versus a daily dose.

METHODS

A randomised clinical trial was performed on 120 healthy breastfed infants between January and September 2007 in Yazd, Iran. The infants were randomly divided into three groups with different doses of vitamin D3 supplementation: 200 IU daily, 400 IU daily and a bolus of 50,000 IU every two months. A blood sample was taken and evaluated for 25-hydroxy vitamin D and calcium levels when the infants were six months old. The data was reported as the mean and standard deviation.

RESULTS

No significant differences were observed between the serum level of 25-hydroxy vitamin D in the groups administered with 200 IU and 400 IU vitamin D daily. However, the serum level of 25-hydroxy vitamin D reached significance in the third group (p is less than 0.001). All the blood calcium measured was below 11 mg/dl in the bolus group. A few complications such as diarrhoea and agitation, all of which were self-limited, were seen in the bolus group. No other significant side effects were reported in the other groups.

CONCLUSION

This study demonstrates that a bolus of 50,000 IU of vitamin D every two months with a routine child vaccination program provides the ideal serum level of vitamin D. This method produces no serious side effects and offers a highly convenient way to supply vitamin D, especially among non-compliant parents.

Pulmonary complications in primary hypogammaglobulinemia: a survey by high resolution CT scan

BACKGROUND

Primary hypogammaglobulinemia disorders are a group of heterogeneous immunodeficiency syndromes with an increased susceptibility to pulmonary complications.

METHODS

The aim of this study was to evaluate the extent of lung abnormalities in primary hypogammaglobulinaemic patients by high resolution computed tomography (HRCT) scan and pulmonary function test (PFT). HRCT and PFT were performed in 22 Iranian patients with primary hypogammaglobulinemia.

RESULTS

Pathological bronchial findings were observed in thirteen patients: three patients showed only peribronchial thickening and the remaining ten patients suffered from both bronchiectasis and peribronchial wall thickening. Mild type of bronchiectasis and peribronchial wall thickening were the most common type, predominantly observed in the right middle and both right and left lower lobe segments of lungs. Although bullae were not found, emphysema, air-trapping, and collapse/consolidation were observed in two patients. Bronchial involvement was mostly limited to 1 up to 5 bronchopulmonary segments; only one HRCT indicated bronchial involvement in more than nine bronchopulmonary segments. Pathological bronchial findings mostly observed in the proximal bronchi; meanwhile the involvement of the distal bronchi was less common. Decreasing FEVI and FVC were observed in 65% and 55% of patients, respectively. There was a significant correlation between the HRCT score and the predicted values by PFT. The delay of diagnosis in patients with bronchiectasis was significantly higher than those without bronchiectasis.

CONCLUSIONS

It seems that the majority of hypogammaglobulinaemic patients suffer from the mild type of bronchiectasis, which is mostly observed in the proximal bronchi of the lower lobe segments. The delay of diagnosis plays an important role in the occurrence of this complication in these patients.