Age: 8.0
Sex: M
Vaccine: PPV, TD
Symptoms: Hypercapnia, Hypertension, Lung disorder
Clinical narrative: It was reported in a published article, that an 8 y.o. male developed common variable immunodeficiency and negative antibodies after being vax'd with pneumococcal vax 23 polyvalent. The literature article is as followed: "An 8 y.o. boy presented with recurrent sinopulmonary infections. The PT had a history of recurrent otitis media requiring pressure-equalizing tube placement and adenotonsillectomy. He also had reversible obstructive lung disease that was documented by spirometry. The family history revealed that the mother had allergic rhinitis. The physical exam was unremarkable. Initial lab investigations showed IgG 430 mg/dL (774 to 1,641), IgM 106 mg/dL (48 to 292), and IgA 68 (52 to 256) w/good response to both pneumococcal and Td vax's. Because of poor follow-up, the lab investigations were not repeated until 5 yrs after the initial evaluation (at the age 13 yrs) and showed IgG 220 mg/dL (612 to 1,295), IgM 104 mg/dL (53 to 334), and IgA 51 mg/dL (70 to 309). Repeat evaluation of the immune response after receiving a booster Td vax showed a good response (prevax titers 0.1 IU/mL and 0/01 IU/mL, and postvax titers 3.0 IU/mL and 0.1 IU/mL to tetanus and diphtheria, respectively, w/protective titers to tetanus being 0.5 IU/mL and to diphtheria 0.01 IU/mL) w/increase of titers by 30- and 10-fold to tetanus and diphtheria, respectively. The PT had poor response to pneumococcal vax by responding to only 1 of 12 antigens evaluated w/the remaining antibodies below protective levels (antibody titers to serotype 14 was 5.5 g/mL w/protective levels >4.5 g/mL). Anti IgA (IgG or IgM) antibodies evaluated by EIA were not detected. The PT had a normal CBC and lymphocyte subsets by flow cytometry, and he had a normal DTH response to Candida and mumps antigens. IVIG therapy was not instituted at the time of writing this report because of significant safety concerns of the parents." The author's 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 yrs of age. PT's w/CVID appear to have a loss of normal antibody synthesis that coincides w/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 be seen. It can bee seen from the findings above that vigorous response to T cell-dependent protein antigens may be preserved even in the face of profound hypogammaglobulinemia (PT 1). However, even this response may be ultimately lost in some CVID patients (PT 3). The Ig loss was progressive in the 3 patients who were followed prospectively; they were either normal or moderately hypogammaglobulinemic at the time of presentation, then progressed to severe hypogammaglobulinemia w/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 w/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 immunodeficiency was determined to be an other important medical event. (OMIC) The article also discussed the experience of 3 other PT's who were vax'd with pneumococcal vax 23 polyvalent.