Correspondence
Case 22-2005: Intravenous Immune Globulin in Chronic Lymphocytic Leukemia
N Engl J Med 2005; 353:1862-1863October 27, 2005
- Article
To the Editor:
Case 22-2005 (July 21 issue)1 describes an 81-year-old man with a six-year history of chronic lymphocytic leukemia (CLL) who was admitted to the hospital with cough, purulent sputum production, altered mental status, and fever (39.6°C). The serum IgG level was 310 mg per deciliter three years before admission. Instead of providing immediate immune globulin replacement on admission, his clinicians remeasured the serum IgG five days later (130 mg per deciliter), and immune globulin replacement was given seven days after admission. The patient died on the 12th hospital day.
There is an extensive body of literature supporting the value of intravenous immune globulin replacement for patients with CLL with hypogammaglobulinemia and infection.2-4 The cause of death in this case was determined to be West Nile encephalitis, and case reports suggest that intravenous immune globulin may be therapeutic in such patients without hypogammaglobulinemia.5 The managing clinicians did not explain the delay in providing replacement, and the discussant did not address the likelihood that immediate immune globulin replacement might have prevented the fatal outcome in this case. Because this was a teaching case, their informed opinions could be valuable.
5 ReferencesSamuel R. Newcom, M.D.
Emory University, Atlanta, GA 30322
snewcom@msn.com 1
Case Records of the Massachusetts General Hospital (Case 22-2005). N Engl J Med 2005;353:287-295
Full Text | Web of Science | Medline2
Besa EC . Use of intravenous immunoglobulin in chronic lymphocytic leukemia. Am J Med 1984;76:209-218
CrossRef | Web of Science | Medline3
Cooperative Group for the Study of Immunoglobulin in Chronic Lymphocytic Leukemia
Full Text | Web of Science | Medline4
NIH Consensus Conference: intravenous immunoglobulin: prevention and treatment of disease. JAMA 1990;264:3189-3193
CrossRef | Web of Science5
Haley M ,Retter AS ,Fowler D ,Gea-Banacloche J ,O'Grady NP . The role of intravenous immunoglobulin in the treatment of West Nile virus encephalitis. Clin Infect Dis 2003;37:e88-e90
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Newcom suggests that early treatment with intravenous immune globulin might have prevented the fatal outcome of West Nile virus encephalitis in this patient. The patient had received intravenous immune globulin many times over the years because of hypogammaglobulinemia and recurrent bacterial infections, and we agree that it would have been appropriate to give it promptly during the hospitalization in 2003, when infection of some kind was suspected. However, since West Nile virus is a relatively new and uncommon pathogen in the United States, it is unlikely that pooled immune globulin available during 2003 would have had high titers of West Nile virus antibodies. No evidence of West Nile virus infection was detected on a polymerase-chain-reaction assay of the cerebrospinal fluid, so that a search for a preparation with high titers of antibody to West Nile virus would not have been indicated. Although anecdotal reports suggest that treatment with intravenous immune globulin may be of benefit in human West Nile virus infection, no data from controlled trials are available to confirm this. The National Institute of Allergy and Infectious Diseases is currently conducting a placebo-controlled trial in humans infected with West Nile virus of an intravenous immune globulin preparation with high titers of West Nile virus antibodies (ClinicalTrials.gov number, NCT00068055).
Leonard Ellman, M.D.
Martin Hirsch, M.D.
Massachusetts General Hospital, Boston, MA 02114Harry Hollander, M.D.
University of California at San Francisco, San Francisco, CA 94143
