Q:

10/11/2013  
I recently saw a 59 year-old woman who tells me that she has problems with infections. She had gastric bypass in 1998 and had persistent green drainage coming from the wound. She did not have a fever and was told that it's not infected. This problem lasted for months. She finally had corrective surgery. Since then she has noted that she has difficulty after surgery with healing. Apparently she had tremendous long-term postoperative pain, and healed poorly. Since then she's had persistent problems with healing when the occasional surgery occurs.

Naturally, over the years, she's had a number of blood tests, especially CBCs. What's of interest is that she runs a fairly low white blood cell count. She will often be in the 3000-4000 range, even when sick. Her absolute neutrophil counts have always been above 1000, although they seem relatively low for someone who has an infection. So she's not "officially neutropenic". And I don't believe she was sick as a child with these kinds of infections.

I was just wondering if this rang a bell to anyone or if this is just perhaps the low end of normal.

A:

Thank you for your inquiry.

No, I am afraid that the patient you described does not “ring any diagnostic bell.” She does not appear to have any of the classical “primary immunodeficiency disorders” as described in a very comprehensive review of primary immunodeficiency (Bonilla FA. Practice Parameter for the Diagnosis and Management of Primary Immunodeficiency. Annals of Allergy, Asthma, and Immunology 2005; 94(5) Supplement 1:S1-S63.

A defect such as you described would be most likely explained by an abnormality in neutrophil function or adhesion, but again, the symptoms do not suggest any of those of which I am aware that are commonly considered primary leukocyte-related immunodeficiency disorders.

However, there are other causes of poor wound healing. Here is an excellent review of this issue. It is of note that obesity itself is a cause, and there are other systemic causes discussed in this review as well.

In summary, I do not believe any further immunologic workup would be helpful in regards to this patient, but you might be able to assist her with nutrition or find other factors (such as smoking, for example) that are mentioned in the article which can be obtained by going to the above mentioned link.

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