Treatment Plan in Patient With Shingles and Inactive TB
Treatment Plan in Patient With Shingles and Inactive TB
A 22-year-old woman presented with an outbreak of shingles. She had received medication for 6 months for "inactive tuberculosis" and has had 5 different episodes of pneumonia since she was a child. She had her tonsils removed last year due to an apparent "abscess." No work-up for immunodeficiency had been done by her previous physician. I did a complete blood count (CBC), blood chemistry, and HIV test; all test results were normal and negative for the HIV test. Besides a chest x-ray, what other tests should be done, ie, immunoglobulins (Igs)?
Michael A. Kaliner, MD, Professor of Medicine, George Washington University School of Medicine, Washington, DC; Section Chief, Allergy, Washington Hospital Center, Washington, DC
It sounds like this patient needs an immune evaluation. We routinely measure IgG, IgA, and IgM levels. This patient should receive a pneumococcal vaccination to help prevent her from getting strep infections, and I would then measure her postimmunization titers 2 months later. You could measure her antitetanus toxoid titers as well. We repeat the pneumococcal vaccination every 7 years.
If a patient who has had pneumonia and who has received the pneumococcal vaccination does not develop adequate titers, I would immunize with other antigens to see whether she has "specific antibody deficiency," a disease of which patients cannot raise antibodies to antigens to which they are exposed or immunized.
We do not measure IgG subclasses because their relevance is uncertain. I always get a CBC and sedimentation rate, just as a routine screen. The idea of a chest x-ray is also appropriate. I do not routinely get lymphocyte function studies or do delayed skin testing in such patients because the potential primary immunologic problem is likely humoral.
Question
A 22-year-old woman presented with an outbreak of shingles. She had received medication for 6 months for "inactive tuberculosis" and has had 5 different episodes of pneumonia since she was a child. She had her tonsils removed last year due to an apparent "abscess." No work-up for immunodeficiency had been done by her previous physician. I did a complete blood count (CBC), blood chemistry, and HIV test; all test results were normal and negative for the HIV test. Besides a chest x-ray, what other tests should be done, ie, immunoglobulins (Igs)?
Response from the Expert
Michael A. Kaliner, MD, Professor of Medicine, George Washington University School of Medicine, Washington, DC; Section Chief, Allergy, Washington Hospital Center, Washington, DC
It sounds like this patient needs an immune evaluation. We routinely measure IgG, IgA, and IgM levels. This patient should receive a pneumococcal vaccination to help prevent her from getting strep infections, and I would then measure her postimmunization titers 2 months later. You could measure her antitetanus toxoid titers as well. We repeat the pneumococcal vaccination every 7 years.
If a patient who has had pneumonia and who has received the pneumococcal vaccination does not develop adequate titers, I would immunize with other antigens to see whether she has "specific antibody deficiency," a disease of which patients cannot raise antibodies to antigens to which they are exposed or immunized.
We do not measure IgG subclasses because their relevance is uncertain. I always get a CBC and sedimentation rate, just as a routine screen. The idea of a chest x-ray is also appropriate. I do not routinely get lymphocyte function studies or do delayed skin testing in such patients because the potential primary immunologic problem is likely humoral.
Source...