Q:

11/16/2011
A 49 year old female received chemotherapy for non-hodgkin's lymphoma now with a total IGG of 485, IGA 33, and IGM 31 with a poor response to polysaccharide bacterial. I attempted to boost her with a pneuomococcal vaccine and her oncologist adamently stated she would not respond and did not see the point. She is healthy and rarely sick. Is there any chance she would respond and is there any harm in trying? At what level would you supplement her with IVIG if she remains healthy? Lastly, can you use subcutaneous since it is assumed it is secondary to the chemotherapy? Thank you for your help.

A:

Thank you for your recent inquiry.

In answer to your questions:

Is there any chance she would respond and is there any harm in trying? You stated that she had a "poor response to polysaccharide bacterial". I assume that you meant to "pneumococcal vaccine." If she did have a poor response, it would be unlikely that she would respond to another injection. However, there would be no harm in administering the injection.

At what level would you supplement her with IVIG if she remains healthy? Normally, if she remains healthy, I would not consider supplementation at this time. There is no definitive level at which supplementation is given. This issue has been discussed in several entries to our website. These are a little too long to copy for you here, but should you wish further detail in this regard, the following entries would be of help to you in understanding when immunoglobulin replacement therapy might be indicated.

Previous Postings to Website:
(1). Criterion to establish the need for the administration of immunoglobulin therapy to patients with hypogammaglobulinemia. Posted 8/18/2010.

(2). Intravenous IVIG immunoglobulin replacement in a patient with chronic lymphocytic leukemia. Posted 5/20/2010.

(3). Hypogammaglobulinemia M in an asymptomatic patient. Posted 12/12/2009.

(4). Indications for immunoglobulin replacement therapy in disorders with hypogammaglobulinemia. Posted 7/10/2009.

In addition, should you decide to give her Pneumovax and reassess her response, the following entry would help you make a judgment as to what an adequate response would be.

Previous Posting to website:
(1). What criterion are used to establish an adequate response to immunization in the workup of a patient with immunodeficiency. Posted 8/3/2010.

In brief, you will see from all of the above entries, that the issue as to when to initiate immunoglobulin replacement therapy and what is an adequate response to pneumococcal vaccination cannot be answered dogmatically, but perhaps the most important criteria is whether or not the patient is experiencing clinically significant bacterial infections.

Lastly, can you use subcutaneous since it is assumed it is secondary to the chemotherapy?
Yes, should you choose to initiate immunoglobulin replacement therapy, subcutaneous therapy could be administered.

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