Q:

Pt with common variable immune deficiency who has been on replacement gammaglobulin IV, and subq (Vivaglobin, Hyzentra). Over last 6 years has increased herpes infections (diagnoses by gyn) on buttocks, vagina, face. The use of Famvir or Valaciclovir does help control but pt has increased migraines. Has been evaluated by university immunologist also. Currently trying Hyzentra q2 weeks since quality of life has worsened (due to herpes). Any suggestions?

A:

Thank you for your recent inquiry.

From my perspective, you are probably doing all that you can. As you know, common variable immunodeficiency is really a heterogenous entity and in many patients defects in cellular immunity occur as well. Sometimes they are the harbinger that the patient may be developing a lymphoreticular neoplasm.

Since I do not have any further practical suggestions for you, I am going to ask Dr. Charlotte Cunningham-Rundles, an internationally known expert in common variable immunodeficiency, to see if she has further suggestions. As soon as I receive her response, I will forward it to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

 

We have received the response from Dr. Charlotte Cunningham-Rundles, which is copied below. Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

 

Response from Dr. Charlotte Cunningham-Rundles:
The question is a mixed one. The first is about the herpes, and I assume actually cultures have proven that the virus is the cause. There is little or no increase in the incidence of herpes infections in CVID in my experience, however. The second question is about migraines. I can’t comment about anti-virals and migraines, as I am not familiar with that or if it occurs.

As for Ig therapy migraines can occur with IVIg of course and tend to be more troublesome in those with such a prior history. By the SQ route, that is not common but I suppose could occur too. I would check the dose of SQ Ig. We use 400 to 500 mg/kg per month divided into 4 doses. The package insert for these suggests a higher dose than we actually use or patients need. For reactors, one can divide that differently too, to reduce the amount per time even more. Hope this helps!

Charlotte Cunningham-Rundles MD PhD
Departments of Medicine, Pediatrics
The Immunology Institute
Mount Sinai School of Medicine

AAAAI - American Academy of Allergy Asthma & Immunology