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Why so many infections in otherwise healthy man?

John, 52, had more infections than anyone else I had ever seen in the 30 years I've been practicing allergy and clinical immunology.

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John, 52, had more infections than anyone else I had ever seen in the 30 years I've been practicing allergy and clinical immunology.

At 5-foot-8 and 170 pounds, he didn't look sickly. He dressed in casual clothes and looked relaxed. He had an engaging smile and a firm handshake, and he seemed fit. He looked like he could run a 5K race easily.

But after speaking with him for five minutes, I knew something was terribly wrong.

At his first visit, John mentioned that he suffered from three to four episodes of sinusitis each year. I see many patients with spring and fall seasonal allergies who have multiple sinus infections each year, but John was different. He also reported that he experienced three to four ear infections each year and had pneumonia four times in the last eight years. Ear infections can tag along with sinus infections, but when John told me about the episodes of pneumonia, my antennae rose even higher.

I asked him about other types of infections, and, yes, he had even had meningitis, a potentially life-threatening infection that involved the lining of his brain and spinal cord. In addition, he had had kidney stones and occasionally required antibiotics for urinary tract infections.

John was allergic only to sulfa antibiotics, so his previous doctors were easily able to treat him with common antibiotics. I am often asked to see patients who have allergies to a variety of antibiotics and who are very difficult to treat because they cannot tolerate usual antibiotics like Amoxicillin, Ceftin or Zithromax. John tolerated all of these.

Despite all the infections, John needed no routine medicines for conditions common to men his age, such as high blood pressure, cholesterol, or elevated blood-sugar levels.

In summary, John had more infections in the last 10 years than my last 100 patients, but he was taking fewer medicines (none) than my average patient. How could such a healthy person be so unwell so often?

Solution

John was not HIV positive, so I knew his infections could not be explained by a diagnosis of AIDS. When his blood tests came back, I saw that his white blood cell count was normal. He didn't have leukemia.

But my suspicions were confirmed - he did have an immunodeficiency. His immunoglobulin levels were dangerously low. He had hypogammaglobulinemia, also called common variable immunodeficiency (CVID). It was like he was trying to fight infections with both hands tied behind his back.

Immunoglobulins, also called antibodies, are immune proteins. They are the frontline troops of the immune system that fight infections. There are different classes of immunoglobulins: IgA, IgE, IgG, and IgM. Immunoglobulin E is an immune protein involved in allergic diseases. Having a high level of IgE is not necessarily a good thing, but having sufficient levels of the other immunoglobulins is crucial. John had severe deficiencies of IgA, IgG, and IgM. His antibody levels to strep, a common bacteria, were also extremely low. He needed to receive replacement therapy - either intravenous or subcutaneous infusions of immunoglobulins.

Until recently, the choices for John would have included monthly intravenous infusions into a vein in the arm or weekly subcutaneous infusions that could go into the soft tissue under the skin of the abdomen - the same place where patients with diabetes give themselves their injections. Each infusion takes four to six hours.

Now, however, patients can get monthly subcutaneous infusions at home.

Although the therapy contains IgG and IgM, it cannot increase IgA levels. As a result, John will still be susceptible to respiratory infections like sinusitis and will still need antibiotics more frequently than my typical patient. But his immunoglobulin G and M levels will rise to normal, and he will be able to fight off many infections he previously couldn't handle.

Thomas Klein is chief of allergy/immunology at Delaware County Memorial Hospital.