Age: 36.0
Sex: F
Vaccine: PPV, TD
Symptoms: Antinuclear antibody positive, Immune system disorder, Laboratory test abnormal
Clinical narrative: It was reported in a published article that a 36 year old female developed common variable immunodeficiency and negative antibodies after being vaccinated with pneumococcal vaccine 23 polyvalent. The literature article is as followed: A 36 year old woman presented with a 6 year history of recurrent sinopulmonary infections and conjunctivitis. The patient  was also know to have a long history of allergic rhinitis. The family history revealed that the patient's mother had breast cancer and her father had recurrent sinusitis. Physical examination was unremarkable. Initial quantitative Igs showed a low IgA level (less than 8 mg/dL) with normal IgG and IgM. Two years after the initial evaluation (at the age of 38 years), repeat quantitative Igs showed hypogammaglobulinemia with IgG 261 mg/dL (694 to 1618), IgM < 14 mg/dL (48 to 271), and IgA < 13 mg/dL (81 to 463). The patient had no response to pneumococcal vaccine but showed an excellent response to Td vaccine (pre-vaccine titers are 0.38 and 0.007 IU/mL, and the post-vaccine titers are 3.25 and 0.375 IU/mL to tetanus and diphtheria, respectively, with protective titers to tetanus being 0.1 IU/mL and to diphtheria 0.01 IU/mL) with increase of titers by eight- and 50-fold for tetanus and diphtheria, respectively. Anti-IgA (IgG) antibodies evaluated by EIA were present. The patient had a normal CBC, chest radiograph, pulmonary function test, and lymphocyte subsets by flow cytometry, and she had a normal DTH response to tetanus and Candida antigens. Because of the number of infections, the hypogammaglobulinemia and the poor response to Pneumovax, the patient was started on IVIG at a dose of 400 mg/kg every 4 weeks since she was 38 years old, manifesting in good trough serum IgG levels (>500 mg/dL) with no complications and significant improvement in the number of infections. The authors' discussion is as followed: It is known that there is a sequential acquisition of antibody synthesizing capacity in humans. Antibody responses to complex protein (T cell-dependent) antigens such as tetanus and diphtheria toxoid are observed soon after birth, whereas responses to carbohydrate antigens such as the polysaccharides of pneumococci (which do not require cognate T cell help) are not acquired until several years of age. Patients with CVID appear to have a loss of normal antibody synthesis that coincides with declining levels of Igs, particularly IgG and IgA. In our patients, the antibody response to polysaccharide antigens is lost first, and the loss of ability to synthesize antibody against protein antigen comes later, if at all. The response to polysaccharide antigens was either absent when these patients were initially seen or was lost subsequently. Absence of antibody response to polysaccharide antigens may be a universal finding in CVID patients, whereas preservation of T cell-dependent protein antibody response may been seen. It can be seen from the findings above that vigorous response to T cell-dependent protein antigens may be preserved even in the face of profound hypogammaglobulinemia (patient 1). However, even this response may be ultimately lost in some CVID patients (patient 3). The Ig loss was progressive in the three patient's who were followed prospectively; they were either normal or moderately hypogammaglobulinemic at the time of presentation, then progressed to severe hypogammaglobulinemia with an average loss of serum IgG of 120 mg/dL each year. IgG subclasses are not routinely performed on our immunodeficiency patients because the decision to start IVIG depends on the antibody response rather than on the IgG subclasses level. IVIG infusions may be associated with adverse reactions of variable severity. These reactions are usually mild and characterized by back pain, headache, flushing, chills, and myalgia. Severe anaphylactic reactions are rare and sometimes caused by anti-IgA antibodies. These antibodies are usually of the IgG class, although IgM and IgE anti-IgA antibodies have also been reported. Upon internal review, common variable disease was determined to be an other important medical event (OMIC). The article also discussed the experience of three other patients after being vaccinated with pneumococcal vaccine 23 polyvalent (WAES 0302USA02696, 0302USA02835, 0302USA02836).