Q:

10/30/2012
57-year-old female with history of recurrent pneumonia. She has had 2 episodes in the last 2-years both confirmed by CXR. Her immune work-up included a normal IgG (698), IgA, protective tetanus titers, and diptheria titers but her pneumococcal titers was nonprotective 3 months after Pneumovax (only 2 serotypes > 2mcg and 3 serotypes between 1.1 & 1.6). Would the next step be to revaccinate and repeat titers in 4-6 weeks?

A:

Thank you for your inquiry.

Before proceeding to answer your question, I want to call your attention to an excellent reference which deals in detail with the use of vaccination to determine the presence of immunodeficiency. You will find this very helpful as you continue to treat this and other patients. It is:

Orange JS, et al. Use and interpretation of diagnostic vaccination in primary immunodeficiency: a working group report of the Basic and Clinical Immunology Interest Section of the American Academy of Allergy, Asthma, and Immunology. J Allergy Clin Immunol 2012 (September); 130(3 supplement):S1-S24.

For your convenience, I have copied below a portion of Summary Statement 28 which deals with the question you posed. As you can see from this statement, a repeat booster dose of pneumococcal vaccine is not indicated at this time.

“Summary Statement 28: Immediate repeat booster doses of PPV are ineffective (and not recommended and might promote hyporesponsiveness). (Ib B)

It is unnecessary to immediately administer repeat courses of PPV23 because a significant boost in antibody titer is unlikely to occur. In the context of repeated pneumococcal vaccination, development of hyporesponsiveness has been documented, specifically in adults who have received an initial vaccination with PPVs followed by a booster with the PPV or a booster with PCVs.87”

This document contains sections dealing with a patient as you described who has evidence of decreased resistance to encapsulated bacteria, relatively normal or low normal immunoglobulins, and a poor response to pneumococcal vaccine. The clinical decision of whether or not to start immunoglobulin replacement therapy in such patients is discussed in detail. The section is a little too long to copy here, but you should have ready access to this article to help you proceed from this point.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.



AAAAI - American Academy of Allergy Asthma & Immunology