I am taking care of a 6 month old boy in my clinic that has had several illnesses in his short life. Briefly, he was a full term infant with no complications. He was breastfed until about 4 months of age, then transitioned to formula. He was in daycare until 4 months of age, his 2 yo sister remains in daycare.
He has been hospitalized 3 times with respiratory illnesses, at age 2 months, 4 months and now 6 months. The first illness was a presumed viral illness. The second was again a presumed viral illness, though he was also treated with antibiotics for a potential right sided pneumonia. The third illness he was documented to have both RSV and Pertussis.
Otherwise, he has had no other significant infections (no ear, skin, urine infections, etc). He is growing and developing well. There is no family history of immunodeficiencies.
I am hoping that his difficult course has been due to "bad luck," however I think I need to screen him for immunodeficiencies at this point. I have my thoughts, but what tests would you send?
Hi Stacey
ReplyDeleteI have few questions first:
1. What about the vaccination history of this boy? The fact that his infections were at 2, 4, 6 months seem to me to implicate they followed vaccinations?? If yes, how long after the vaccination did each illness develop? If No, are there other household contacts receiving vaccination around that time (other than his 2 year old sister, it seems he is no longer in daycare too)?
2. Did any of these infections require hospitalization? And what were the viral infections at age 2 and 4: are you referring to respiratory infections or diarrhea or what?
3. Also, are we sure of the diagnosis of pertussis…how was this diagnosis made..clinically or proved by culture/PCR?
4. Is there any other person in the house who is coughing (according to the CDC, this is commonest source of infection to infants in USA)
So, it seems from the story that he is an infant with recurrent viral infections (probably respiratory) and Pertussis but with normal growth and development…I checked out immunity to RSV and, though this is a viral infection, immunity to it is mainly through formation of antibodies surface proteins (mucosal and serum Ab response). Therefore, given his growth and development, possibilities are:
• possible transient hypogammaglobulinemia of infancy or selective IgA deficiency (after all this is the commonest of primary immune deficiencies). We need more information about the other “viral infections” ( generally viral infections would tend to point to deficiency of T cells but he doesn’t seem like a person with T cell deficiency since it seems that infections were not long-lasting and his growth is fine??)
• Maybe he is not immune deficient at all, if all the infections are in the respiratory system (no diarrhea, no sinus infections), isn’t it likely that he might have a congenital anomaly in the lungs or reflux increasing his risk of local infections there
So in view of the limited information given, I would
• do serum IgG, IgM and IgA level for him,
• do chest Xray to see the thymic shadow as well as the appearance of the lung fields
• only with more information would I check his antibody levels to prior vaccinations
Thanks for this post and keep us updated
Regarding your questions,
ReplyDelete1. I know that this boy has been immunized, however I am honestly not sure if the illnesses occurred just following immunizations, that's an interesting question.
2. All of his illnesses have required hospitalization and supplemental oxygen. The illnesses are all respiratory in nature.
3. The pertussis was diagnosed by PCR.
4. His sister and several other kids at his sister's daycare are coughing and have been diagnosed with PCR+ Pertussis, so you are right, this was the presumed route of transmission/contact.
Overall, I am also thinking that he either has an underlying pulmonary problem making him predisposed to recurrent illnesses (ex. inflammation due to chronic aspiration/reflux) or an immunodeficiency of his Tcells or ability to make appropriate antibodies.
At his next visit, I will be planning on arranging a chest CT with bronchoscopy and drawing screening immuno labs (CBC, T and B cells subsets, immunoglobulins, titers to his vaccines).
Thanks for your input.
That sounds like the right thing to do. In the notes we say "start simple and cheap" but with this history, the bronchoscopy seems warranted. Maybe add a simple screen for complement levels?
ReplyDeleteCan you update us on the results?
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