Q:

7/15/2013
I recently saw a 4 year-old girl with asthma, allergic rhinitis and conjunctivitis, and multiple infections. She had multiple ear infections before tonsillectomy, adenoidectomy and ear tubes in the past. More recently, she had a few sinus infections, and 3 episodes of chest x-ray documented pneumonia in the past 6-7 months, requiring hospitalization for pneumonia and asthma exacerbation. She is currently taking Budesonide 0.5mg twice daily, Singulair, cetirizine, and albuterol as needed. Her immunoglobulins were IgA 160 (61-345), IgG 874 (528-2190), and IgM 157 (41-190). She had decreased pneumococcal antibody titers at baseline. She did receive age appropriate prevnar doses. She then received vaccination with pneumovax. Repeat titers 6 weeks later showed excellent response to vaccination; however, she persists to have infections and was recently diagnosed with another sinus infection and treated for asthma exacerbation. Please advise on further care for this patient. Thank you.

A:

Thank you for your inquiry.

Unfortunately such recalcitrant cases are not uncommon in the practice of Allergy-Immunology, and the good news is that quite often, with time, things improve regardless of the course of action we take. In the child that you described, all that you have done seems appropriate, and I think that you have done due diligence in evaluating this child.

Obviously, there is no definable antibody deficiency and therefore no good reason to initiate immunoglobulin replacement therapy. However, you could consider prophylactic antibiotics, especially during the winter months. Except for this, I can think of nothing to add to your program.

However, I am going to ask Dr. Michael Blaiss, my partner, who has far greater experience in dealing with this age child than I, to respond to your inquiry. As soon as I receive his response, I will forward it to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

We received a response from Dr. Michael Blaiss. Thank you again for your inquiry, and we hope this response is helpful to you.
 
Sincerely,
Phil Lieberman, M.D.

Response from Dr. Michael Blaiss:
It is very frustrating for the child, parents, and physician when trying to control their allergies and asthma, the child continues to have recurrent infections. From your studies, there is no evidence of a true humeral antibody deficiency or a functional humeral immune defect. Here are my suggestions for further evaluation of possible causes for the increased infections:

1. I would suggest a CT scan of the sinuses to see if the child has chronic rhinosinusitis as the etiology or a factor in her condition. She may never be clearing chronic sinus disease.

2. Primary ciliary dyskinesia (Immotile cilia syndrome) is another rare possibility-Measuring the amount of exhaled nasal nitric oxide (nNO), which is very low or absent in patients with PCD, is a useful screening test for patients with a clinical suspicion of PCD.

3. Cystic fibrosis could present at this age with her symptoms-Elevated sweat chloride ¡Ý60 mmol/L (on two occasions)

It is still possible this is a normal variant especially if she has recently stated day care or preschool. Children this age can have 10-12 infections a year. Also, as you know, atopic children have a higher rate of recurrent and persistent upper respiratory infections, such as sinusitis, rhinitis, and otitis media. I hope this helps.

1. Daly KA, Hoffman HJ, Kvaerner KJ, et al. Epidemiology, natural history, and risk factors: panel report from the Ninth International Research Conference on Otitis Media. Int J Pediatr Otorhinolaryngol 2010; 74:231.

2. James KM, Peebles RS Jr, Hartert TV. Response to infections in patients with asthma and atopic disease: an epiphenomenon or reflection of host susceptibility? J Allergy Clin Immunol 2012; 130:343.

3. Ballow M. Approach to the patient with recurrent infections. Clin Rev Allergy Immunol 2008; 34:129.

4. Slatter MA, Gennery AR. Clinical immunology review series: an approach to the patient with recurrent infections in childhood. Clin Exp Immunol 2008; 152:389.

Sincerely,
Michael S. Blaiss, MD

AAAAI - American Academy of Allergy Asthma & Immunology