Correspondence

Hypogammaglobulinemia in HIV-Infected Infants

N Engl J Med 1995; 333:321-322August 3, 1995

Article

To the Editor:

We wish to address a statement made by Dr. Wong in his discussion of the differential diagnosis of panhypogammaglobulinemia in the Case Records (March 9 issue).1 Dr. Wong states that “adults with HIV [human immunodeficiency virus]-associated diseases typically present with elevated or normal immunoglobulin levels, whereas diminished levels are observed in children with HIV infection.” In our experience, the vast majority of children with symptomatic or asymptomatic HIV infection have hypergammaglobulinemia. By six months of age, almost all HIV-infected children have serum immunoglobulin concentrations at least 2 SD higher than the age-adjusted mean,2 and hypergammaglobulinemia may be the earliest manifestation of HIV infection in vertically exposed infants.3 Furthermore, the degree of hypergammaglobulinemia in HIV-infected children is usually greater than that found in their adult counterparts.4 Although there have been reports of children with hypogammaglobulinemia and HIV infection,5 this association is uncommon.

James T. Love, Jr., M.D., Ph.D.
William T. Shearer, M.D., Ph.D.
Baylor College of Medicine, Houston, TX 77030-3498

5 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 7-1995). N Engl J Med 1995;332:663-671
   Full Text | Web of Science | Medline

2. 2

   Kline MW, Hollinger FB, Rosenblatt HM, Bohannon B, Kozinetz CA, Shearer WT. Sensitivity, specificity and predictive value of physical examination, culture and other laboratory studies in the diagnosis during early infancy of vertically acquired human immunodeficiency virus infection. Pediatr Infect Dis J 1993;12:33-36
   CrossRef | Web of Science | Medline

3. 3

   European Collaborative Study. Children born to women with HIV-1 infection: natural history and risk of transmission. Lancet 1991;337:253-260
   CrossRef | Web of Science | Medline

4. 4

   Lewis DE, Hanson CG, Shearer WT. Immunopathogenesis of pediatric HIV infection. Semin Pediatr Infect Dis 1990;1:21-26
   

5. 5

   Simpson BJ, Andiman WA. Difficulties in assigning human immunodeficiency virus-1 infection and seroreversion status in a cohort of HIV-exposed children using serologic criteria established by the Centers for Disease Control and Prevention. Pediatrics 1994;93:840-842
   Web of Science | Medline

Author/Editor Response

Dr. Wong replies:

To the Editor: A subgroup of children infected with HIV-1, predominantly premature infants, have panhypogammaglobulinemia that can persist beyond the first six months of age.1,2 These often severely ill babies have a higher incidence of bacterial infections, consistent with their hypogammaglobulinemia. These patients often lack HIV-specific antibodies; HIV infection has been demonstrated by viral isolation or detection of HIV antigen. Thus, the diagnosis may be missed and the patient misclassified as having a primary immunodeficiency. The great majority of HIV-infected children have hypergammaglobulinemia,3 as correctly pointed out by Drs. Love and Shearer. But even in these patients, specific antibody responses are often subnormal. They may, like patients with hypogammaglobulinemia, have an increased susceptibility to bacterial infections and benefit from intravenous immunoglobulin.4

Johnson T. Wong, M.D.
Massachusetts General Hospital, Boston, MA 02114

4 References

1. 1

   Saulsbury FT, Wykoff RF, Boyle RJ. Transfusion-acquired human immunodeficiency virus infection in twelve neonates: epidemiologic, clinical and immunologic features. Pediatr Infect Dis J 1987;6:544-549
   CrossRef | Web of Science | Medline

2. 2

   Pahwa R, Good RA, Pahwa S. Prematurity, hypogammaglobulinemia, and neuropathology with human immunodeficiency virus (HIV) infection. Proc Natl Acad Sci U S A 1987;84:3826-3830
   CrossRef | Web of Science | Medline

3. 3

   Schuval SJ, Bonagura VR, Ilowite NT. Rheumatologic manifestations of pediatric human immunodeficiency virus infection. J Rheumatol 1993;20:1578-1582
   Web of Science | Medline

4. 4

   Pahwa S. Immune defects in pediatric AIDS, their pathogenesis, and role of immunotherapy. Crit Care Med 1990;18:Suppl:S138-S143
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Lenora Mendoza Noroski. (1997) Human Immunodeficiency Virus Infection in a Patient with Primary Immunodeficiency. Annals of Allergy, Asthma & Immunology 79:4, 281-282
   CrossRef