HIV - Immune deficiency

Question 1

Common causes of secondary immune deficiencies

Answer 1

Malnutrition - commonest cause worldwide
Measles
Mycobacterium tuberculosis - inflammatory immune re-constitution syndrome
HIV
SARS-CoV-2
Drugs

Question 2

Which drugs are an important cause of immune deficiency?

Answer 2

Small molecules

Small molecules: Glucocorticoids and mineralocorticoids

Cytotoxic agents - methotrexate, mycophenolate cyclophosphamide, azathioprine

Calcineurin inhibitors - cyclosporine and tacrolimus

Antileptic drugs - phenytoin

DMARDs - sulphasalazine, leflunomide

JAK inhibitors -

Biologics

Cellular therapy e.

Question 3

Give an example of an anti-CD20 agents that gives rise to immune deficiency

Answer 3

Rituximab

rhinovirus

Question 4

Rituximab can give rise to which infection due to immune deficiency? What prophylaxis do you give?

Answer 4

Pneumocytis jirovecci
PCP prophylaxis

Question 5

B cell malignancy
ANCA related vasculitis

Question 6

What infection can anti-TNF give rise to due to deficiency?

Answer 6

TB - therefore give anti-TB drugs

Question 7

What is Goods’ syndrome?

Answer 7

Thymoma and antibody deficiency

Question 8

What can Goods syndrome give rise to?

Answer 8

Increased risk of

CMV
Pneumocystis jero…
Combined T and B cell deficiency?

Question 9

How would you evaluate secondary immune deficiency?

Answer 9

Check the clinical history of infection
Check the history of other illnesses
FH of infection, autoimmune disease, cancer
Drugs history
Vaccine history

Question 10

Investigations for immune deficiency

Answer 10

Full blood count - HB<10g/L, neutrophil count, lymphocyte count, platelet
Immunoglobulins
Serum complement - c3, c4
HIV test

Haematological malignancies - renal and liver profile, calcium and bone profile, total protein and albumin, urine protein/creatinine ratio, serum protein electrophoresis, serum free light chain

Question 11

Isolated reduction in IgG - cause

Answer 11

Protein losing enteropathy
Prednisolone over 10mg

Question 12

Reduction in IgG and IgM

Answer 12

Monitor for B cell neoplasm

Question 13

Reduction in IgG and IgA

Answer 13

Primary antibody deficiency

Question 14

Monoclonal protein

Answer 14

WMG
NHL
MGUS
Multiple myeloma???

Question 15

Second line tests to investigate immune deficiencies

Answer 15

Tetanus toxoid - protein antigen - this tells us how well B cells and T cells talk to each other

Pneumovax vaccine - carbohydrate antigen - T cell independent

Question 16

What else can you do?

Answer 16

Flow cytometry to check T cells, CD counts etc

Question 17

Third line investigations

Answer 17

Analysis of naive and memory T and B cell subsets
Assessment of IgG
Anti
Male predominance??

Question 18

Management of secondary immune deficiency

Answer 18

Vaccinations
Education to treat infections promptly with higher and longer

Question 19

What can we used to treat

Answer 19

IgG replacement - but there is a protocol for this

Question 20

Guy with low IgG taking predisnolone 5mg and rituximab. What’s the cause?

Answer 20

Rituximab

For pred to cause it it has to be 10mg