Q:

10/1/2012
I have patients with recurrent sinusitis which I typically workup with testing for immunodeficiencesy by serology for diphtheria, haemophilus, and pneumococcal antibody titers, quantitative immunoglobulins, CBC and if the titers are not protective then get vaccinations and check titers after a month. If abnormalities, then also would check T cells quantitative +/- function.

Questions are:
1. In adults with non protective titers for all 3 mentioned above, would you vaccinate to all and repeat titers a month later?
2. Is vaccination intended to not only check responsiveness, but also to protect against the pneumococcal and haemophilus bacteria to make the patient less susceptible to recurrences of infections by these bacteria?
3. One particular male adult patient of mine is unsure if he received his childhood vaccinations as he grew up overseas. He has asthma; he has non-protective hemophilus titers; should I vaccinate with any of the conjugated H flu vaccines?
4. In the presence of normal immunoglobulins or decreased IgM or IgA (decrease in 1 out of 3), would postvaccination titers be helpful since lack of responsiveness to vaccination alone is not an indication for supplemental IgG?

A:

Thank you for your inquiry.

First of all, there is an excellent reference which I have copied for you below which will help you approach patients in who you suspect antibody deficiencies. Please note that one of the authors of this document was Dr. Rohit Katial. Therefore I am going to ask Dr. Katial to respond to your inquiry.

When we receive Dr. Katial’s response, we will forward it to you.

Thank you again for your inquiry.

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 & Immunology
Jordan S. Orange, Mark Ballow, E. Richard Stiehm, Zuhair K. Ballas, Javier Chinen, Maite De La Morena, Dinakantha Kumararatne, Terry O. Harville, Paul Hesterberg, Majed Koleilat, Sean McGhee, Elena E. Perez, Jason Raasch, Rebecca Scherzer, Harry Schroeder, Christine Seroogy, Aarnoud Huissoon, Ricardo U. Sorensen, Rohit Katial et al.
September 2012
Journal of Allergy and Clinical Immunology Vol. 130, Issue 3, Supplement, Pages S1-S24.

Sincerely,
Phil Lieberman, M.D.

We received a response from Dr. Rohit Katial. Thank you again for your inquiry and we hope this response is helpful to you.
 
Sincerely,
Phil Lieberman, M.D.
 
1. In adults with non protective titers for all 3 mentioned above, would you vaccinate to all and repeat titers a month later?

Response from Dr. Rohit Katial:
If the quantitative Igs are all low and no antibody response is noted after vaccination then this is consistent with CVID. If the question is asking about pre titers, then one can check protein response with tetanus and HIB and polysaccharide response with the pneumococcal vaccine.

2. Is vaccination intended to not only check responsiveness, but also to protect against the pneumococcal and haemophilus bacteria to make the patient less susceptible to recurrences of infections by these bacteria?

Response from Dr. Rohit Katial:
In the case of strep pneumo yes. Invasive haemophilus is unusual in immunocompetent adults and therefore standard vaccination schedules don't routinely suggest HIB unless there is a special circumstance such as upcoming splenectomy which puts the subject at risk of infection with encapsulated organisms. However, yes the vaccine does end up conferring protection even though the primary intention was for diagnostic purposes.

3. One particular male adult patient of mine is unsure if he received his childhood vaccinations as he grew up overseas. He has asthma; he has non -protective hemophilus titers; should I vaccinate with any of the conjugated H flu vaccines?

Response from Dr. Rohit Katial:
Yes if immigrated here I would vaccinate to all the standard vaccines, checking titers would be helpful.

4. In the presence of normal immunoglobulins or decreased IgM or IgA (decrease in 1 out of 3), would postvaccination titers be helpful since lack of responsiveness to vaccination alone is not an indication for supplemental IgG?

Response from Dr. Rohit Katial:
Supplemental IgG is for IgG deficiency where the IgG is not functional. Many people may have a slightly low IgG from heavy systemic CS use, however, these patients maintain there vaccine response. In this case IgG replacement is usually not indicated. Decreased IgM or IgA cannot be replaced since there are very small amount in IgG preparations so post vaccine titers are not helpful unless IgG low, since ultimately replacement is for IgG.

AAAAI - American Academy of Allergy Asthma & Immunology