Age: 0.35
Sex: M
Vaccine: DTAP, HIBV, PNC, RV5
Symptoms: Blood product transfusion, Diarrhoea, Immunodeficiency, Oedema peripheral, Protein-losing gastroenteropathy
Clinical narrative: 2-3 d after 2nd rotavirus vaccine, baby began with vomiting & diarrhea. Prolonged diarrhea. Presented to office with diarrhea & profound peripheral edema.  Admitted to hospital, protein losing enteropathy.  Transferred to another hospital out of state, protein losing enteropathy, immunodeficiency.  Now on IVIG q wk.  02/25/2008 MR received for DOS 12/10/2007-1/2/2008 with Transfer DX:  protein enteropathy with either primary or secondary immune deficiency.  Infant presented with increasing diarrhea (5-10x/day), swelling of extremities and face.  Pt was noted to be hypoalbuminemic and was admitted. Pt had persistant low albumin level with evidence of enteropathy.  Pt was subsequently noted to have significant T-cell deficiency. PE (+) for swelling in all 4 extremities. Transfered to higher level of care on 1/2/2008. 03/03/08 Transfer summary for above received. Transfer Dx:  Protein enteropathy with primary 2' to T-cell immune deficiency with abnormal total CD4, CD8 count along with abnormal myeloproliferation studies. 4/14/2008 MR received for DOS 1/02-24/2008 with D/C DX: Protein losing enteropathy.  2' Immunodeficiency with lymphopenia. Hypogammaglobulinemia.  Hypoalbuminemia.  Neutropenia. Low serum Zinc level. PE on admission WNL except a hypopigmented macule above the umbilicus. Pt gained wt during admission and d/c 1/24/08 Follow-up: To Whom It May Concern: Pt was born at term, vaginally with low forcep to a 27 year old primagravida in good health. Apgars were 8 and 9. Mother's blood type A negative. Pt is A positive. Hepatitis B vaccine was given on day 1. All newborn screenign labs were normal. Birth weight was 8 pounds 8 ouces. Pt was breastfed and gained weigt appropriately. He was seen on 08-23-2007 for second Hepatitis B vaccine. On 09-24-2007 pt was 13lbs 3.2 ouces and was breast feeding well. Immunizations were given DTaP, HIB, PREVNAR, IPV, and Rotavirus with no adverse sequellae. On November 6, 2007 pt weighed 16.8 pounds. He was breast feeding with supplemental Isomil formula. PREVACID was begun for GERD symptoms and Enfamil Gentlease was recommended. At pt four month check up on November 28, 2007, he was formula fed with persistent reflux symptoms. DTaP, HIB, PREVNAR and Rotavirus were administered. Pt had mild upper airway congestion at this time. Pt's next visit was December 3, 2007 for diarrhea. Weight was 18.6 pounds. Rice cereal had been introduced. Pt was placed on pedialyte followed by diluted formula. On December 5, 2007 he returned for a follow up. He continued to have watery stools but was happy and alert. His weight was 18.4 pounds. Pt returned to the office on December 10, 2007. He was happy and alert; diarrhea had continued. Extremities were mottled and extremely edematous. Weight was 19.4 pounds. Pt was transferred to hospital where evaluation revealed severe hypoproteinemia with protein losing enteropathy and hypogammaglobulinemia of unknown etiology. On January 2, 2008 pt was transferred to hospital where he began receiving IVIG infusions. He was discharged January 24, 2008 and he continued to receive IVIG infusions on a weekly basis. He has now discontinued the IVIG infusions and is being monitored by Dr. Serum IgG levels are in the 200 range. My questios are these: Pt was breast fed when he received his first Rotavirus vaccine. At four months of age he was formula fed when he received his second Rotavirus vaccine. His protracted diarrhea began 5 days after the Rotavirus vaccine. Admission to hospital was December 10, 2007, 12 days after receiving ROTATEQ. At this point all studies were negative. Without protective IgA from breast milk, at four months of age pt had also lost his maternal IgG from birth. If he has a congenital hypogammaglobulinemia a live vaccine such as ROTATEQ could have lead to this prolonged illness. We saw similar problems with live oral polio vaccine in the 1970's and 1980's. (I have been practicing pediatrics for 31 years.) Would it not be more prudent to administer a live oral vaccine such as ROTATEQ in the second year of life after congenital immunodeficiency would be evident. I am now hesitant to recommend this live viral vaccine to young infants without knowledge of their immune status.