Common variable immunodeficiency (CVID) - a Twitter summary from the 2011 ACAAI meeting

This summary was compiled from the tweets posted by some of the allergists who attended the 2011 ACAAI meeting. The tweets were labeled #ACAAI. The text was edited and modified by me.

Higher doses for IVIG replacement

There is increasing evidence that higher levels of Ig replacement provide better outcomes. However, average number of reported infections has not changed in those on IIVIG since the 1990s, despite rising average IgG trough levels. IVIG infusions raise IgG levels in the saliva and nasal secretions but sinopulmonary infections are still common in antibody deficient patients. Do we need to replace IgM or IgA too? The current formulations provide only IgG replacement.

The dose now aimed for with IVIG seems to be 570 mg/kg/month - a significant increase since 1980's (400 mg/kg/month). However, overall infections have not improved tremendously during that period. This phenomenon could be due to viral infections and sinusitis however which do less well with IVIG replacement. Inflammatory cytokines are increased in nasal secretions in CVID patients and mimic infectious changes. Many CVID patients are also IgA-deficient.

Individual CVID patients may have different optimal IgG trough levels that prevent infections. Don't let insurance companies dictate which levels are "normal." Beware 3rd party payer (insurance companies) limitations when optimizing IgG treatment and dose for patients with humoral immune deficiency.

Is there any actual utility to measuring IgG trough levels in subcutaneous IgG (SCIG) therapy? The PIDD expert Dr. Jordan Orange is not sure.

CVID and GI symptoms

If a patient with CVID has GI complaints, rule out infections, and think about hypertrophied Peyer's patches. For example, it’s not a good idea for a CVID patients to swim in a lake (according to PIDD expert Mark Ballow)..

CVID and respiratory symptoms

If a patient with CVID has respiratory complaints, consider bronchiectasis and granulomatous lung disease. Bronchiectasis outcomes are improving with earlier detection via CT of the chest, but worry about granulomatous disease that may occur in 8-12% of CVID patients.

CXR and high-resolutiom chest CT scan are recommended at baseline in CVID patients. They need yearly spirometry and perhaps a repeat chest CT scan every 5 years.

CVID and maligancy

The malignancies in CVID are predominantly Non-Hodgkin Lymphoma that may occur in 2-8% of patients, and rarely gastric cancer.

Outcome of allogeneic stem cell transplantation (ASCT) in adults with common variable immunodeficiency (CVID) (JACI, 2011).

This summary was compiled from some of the tweets posted by Dr. David Fischer @IgECPD4, Robert Silge, MD, @DrSilge, Danny Ramirez, MD @allergysa, and a few others. The tweets were labeled #ACAAI and they reached more than 10,000 people. I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Disclaimer: The text was edited, modified, and added to by me.

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