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Prolonged severe immunodeficiency following thymectomy and radiation: a case report.

Wickemeyer JL, Sekhsaria S - J Med Case Rep (2014)

Bottom Line: Although his immunoglobulin levels were unremarkable, he failed to respond to 11 of 12 serotypes of the pneumococcal vaccine.As a result, he was placed on Bactrim® (trimethoprim-sulfamethoxazole) prophylaxis to prevent opportunistic infections, and his CD4+ and CD8+ counts were monitored over the course of 8 years.This case report informs the practices of allergists, oncologists, and neurologists in the continuing care of patients with thymoma.

View Article: PubMed Central - PubMed

Affiliation: Medstar Union Memorial Hospital, 3333 N Calvert St, Suite 520, Baltimore, MD 21218, USA. asthma4@yahoo.com.

ABSTRACT

Introduction: Immunodeficiency can occur both in patients undergoing radiation therapy, as well as in patients who have had thymectomies. However, few studies have examined the immune recovery of a patient following both procedures. We aim to emphasize the need for assessment and consistent monitoring of patients with thymoma prior to and after combined treatment of thymectomy and radiation, both of which are likely to result in an increased risk for immunodeficiency.

Case presentation: We describe the longitudinal progress of a 59-year-old Asian male who underwent thymectomy followed by radiation therapy and subsequently presented with generalized urticaria. Revelation of a low absolute lymphocyte count (615 cells/mcL) on initial evaluation prompted further analysis of his immunoglobulin levels and antigen response to a polysaccharide pneumococcal vaccine (PneumoVax-23). Although his immunoglobulin levels were unremarkable, he failed to respond to 11 of 12 serotypes of the pneumococcal vaccine. As a result, he was placed on Bactrim® (trimethoprim-sulfamethoxazole) prophylaxis to prevent opportunistic infections, and his CD4+ and CD8+ counts were monitored over the course of 8 years. His lymphocyte counts 87 months after thymectomy and 85 months after radiation therapy were as follows: absolute lymphocyte count 956 cells/mcL, absolute CD3+/CD4+ 164/mm3 (16%) and absolute CD3+/CD8+ 257/mm3 (25%). The patient was able to discontinue Bactrim® (trimethoprim-sulfamethoxazole) prophylaxis after 9 years of treatment.

Conclusions: The lymphocytopenia, low CD4+ count, and failed response to pneumococcal vaccination that presented in our patient are consistent with immunodeficiency. After radiation alone, a recovery of T-lymphocytes is usually observed after approximately 3 weeks. Over the course of 8 years, he has still not made a full recovery according to laboratory markers, which seem to have stabilized at chronically low levels. To prevent serious complications, we suggest that patients who have undergone both thymectomy and radiation therapy be monitored for immunodeficiency. This case report informs the practices of allergists, oncologists, and neurologists in the continuing care of patients with thymoma.

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CD3+/CD4+ and CD3+/CD8+ absolute counts over 7-year period. The patient’s absolute T-cell counts of CD3+/CD4+ and CD3+/CD8+ measured in cells/mm3 are shown based on the amount of time in months post-thymectomy. The red data points represent CD3+/CD8+ absolute cell counts; the blue data points represent CD3+/CD4+ absolute cell counts. Age-appropriate T-cell counts are represented by the vertical brackets, with values provided in the adjacent boxes. The red bracket corresponds to normal CD3+/CD8+ absolute cell counts, and the blue bracket corresponds to normal CD3+/CD4+ absolute cell counts.
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Fig2: CD3+/CD4+ and CD3+/CD8+ absolute counts over 7-year period. The patient’s absolute T-cell counts of CD3+/CD4+ and CD3+/CD8+ measured in cells/mm3 are shown based on the amount of time in months post-thymectomy. The red data points represent CD3+/CD8+ absolute cell counts; the blue data points represent CD3+/CD4+ absolute cell counts. Age-appropriate T-cell counts are represented by the vertical brackets, with values provided in the adjacent boxes. The red bracket corresponds to normal CD3+/CD8+ absolute cell counts, and the blue bracket corresponds to normal CD3+/CD4+ absolute cell counts.

Mentions: In the following 3 years since the lung resection, we monitored him with a physical examination every 2 to 3 months and a laboratory work-up every 4 to 7 months. He continued to complain of hives consistent with CIU. During this time, he maintained his drug plan of doxepin 50mg every evening at bedtime, fexofenadine 180mg once daily before noon, and Bactrim® (trimethoprim-sulfamethoxazole) double strength once daily prophylaxis. As in the months before, he experienced CD4+ lymphocytopenia, wavering between approximately 130/mm3 and 160/mm3. During the 3 years preceding his last visit, he experienced no recurrent sinopulmonary or opportunistic infections for 3 years while maintaining Bactrim® (trimethoprim-sulfamethoxazole) prophylaxis. This allowed for discontinuation of the prophylaxis treatment, contingent on close monitoring of his health and resumption of Bactrim® (trimethoprim-sulfamethoxazole) if symptoms occurred. His last laboratory work-up at our office, approximately 85 months after his thymectomy, revealed an absolute lymphocyte count of 956 cells/mcL, absolute CD3+/CD4+ of 164/mm3 (16%), and absolute CD3+/CD8+ of 257/mm3 (25%): nml 850 to 3900 cells/mcL; 490 to 1740/mm3, 30 to 61%; 180 to 1170/mm3, 12 to 42%, respectively (See Figures 1 and 2).Figure 1


Prolonged severe immunodeficiency following thymectomy and radiation: a case report.

Wickemeyer JL, Sekhsaria S - J Med Case Rep (2014)

CD3+/CD4+ and CD3+/CD8+ absolute counts over 7-year period. The patient’s absolute T-cell counts of CD3+/CD4+ and CD3+/CD8+ measured in cells/mm3 are shown based on the amount of time in months post-thymectomy. The red data points represent CD3+/CD8+ absolute cell counts; the blue data points represent CD3+/CD4+ absolute cell counts. Age-appropriate T-cell counts are represented by the vertical brackets, with values provided in the adjacent boxes. The red bracket corresponds to normal CD3+/CD8+ absolute cell counts, and the blue bracket corresponds to normal CD3+/CD4+ absolute cell counts.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4307222&req=5

Fig2: CD3+/CD4+ and CD3+/CD8+ absolute counts over 7-year period. The patient’s absolute T-cell counts of CD3+/CD4+ and CD3+/CD8+ measured in cells/mm3 are shown based on the amount of time in months post-thymectomy. The red data points represent CD3+/CD8+ absolute cell counts; the blue data points represent CD3+/CD4+ absolute cell counts. Age-appropriate T-cell counts are represented by the vertical brackets, with values provided in the adjacent boxes. The red bracket corresponds to normal CD3+/CD8+ absolute cell counts, and the blue bracket corresponds to normal CD3+/CD4+ absolute cell counts.
Mentions: In the following 3 years since the lung resection, we monitored him with a physical examination every 2 to 3 months and a laboratory work-up every 4 to 7 months. He continued to complain of hives consistent with CIU. During this time, he maintained his drug plan of doxepin 50mg every evening at bedtime, fexofenadine 180mg once daily before noon, and Bactrim® (trimethoprim-sulfamethoxazole) double strength once daily prophylaxis. As in the months before, he experienced CD4+ lymphocytopenia, wavering between approximately 130/mm3 and 160/mm3. During the 3 years preceding his last visit, he experienced no recurrent sinopulmonary or opportunistic infections for 3 years while maintaining Bactrim® (trimethoprim-sulfamethoxazole) prophylaxis. This allowed for discontinuation of the prophylaxis treatment, contingent on close monitoring of his health and resumption of Bactrim® (trimethoprim-sulfamethoxazole) if symptoms occurred. His last laboratory work-up at our office, approximately 85 months after his thymectomy, revealed an absolute lymphocyte count of 956 cells/mcL, absolute CD3+/CD4+ of 164/mm3 (16%), and absolute CD3+/CD8+ of 257/mm3 (25%): nml 850 to 3900 cells/mcL; 490 to 1740/mm3, 30 to 61%; 180 to 1170/mm3, 12 to 42%, respectively (See Figures 1 and 2).Figure 1

Bottom Line: Although his immunoglobulin levels were unremarkable, he failed to respond to 11 of 12 serotypes of the pneumococcal vaccine.As a result, he was placed on Bactrim® (trimethoprim-sulfamethoxazole) prophylaxis to prevent opportunistic infections, and his CD4+ and CD8+ counts were monitored over the course of 8 years.This case report informs the practices of allergists, oncologists, and neurologists in the continuing care of patients with thymoma.

View Article: PubMed Central - PubMed

Affiliation: Medstar Union Memorial Hospital, 3333 N Calvert St, Suite 520, Baltimore, MD 21218, USA. asthma4@yahoo.com.

ABSTRACT

Introduction: Immunodeficiency can occur both in patients undergoing radiation therapy, as well as in patients who have had thymectomies. However, few studies have examined the immune recovery of a patient following both procedures. We aim to emphasize the need for assessment and consistent monitoring of patients with thymoma prior to and after combined treatment of thymectomy and radiation, both of which are likely to result in an increased risk for immunodeficiency.

Case presentation: We describe the longitudinal progress of a 59-year-old Asian male who underwent thymectomy followed by radiation therapy and subsequently presented with generalized urticaria. Revelation of a low absolute lymphocyte count (615 cells/mcL) on initial evaluation prompted further analysis of his immunoglobulin levels and antigen response to a polysaccharide pneumococcal vaccine (PneumoVax-23). Although his immunoglobulin levels were unremarkable, he failed to respond to 11 of 12 serotypes of the pneumococcal vaccine. As a result, he was placed on Bactrim® (trimethoprim-sulfamethoxazole) prophylaxis to prevent opportunistic infections, and his CD4+ and CD8+ counts were monitored over the course of 8 years. His lymphocyte counts 87 months after thymectomy and 85 months after radiation therapy were as follows: absolute lymphocyte count 956 cells/mcL, absolute CD3+/CD4+ 164/mm3 (16%) and absolute CD3+/CD8+ 257/mm3 (25%). The patient was able to discontinue Bactrim® (trimethoprim-sulfamethoxazole) prophylaxis after 9 years of treatment.

Conclusions: The lymphocytopenia, low CD4+ count, and failed response to pneumococcal vaccination that presented in our patient are consistent with immunodeficiency. After radiation alone, a recovery of T-lymphocytes is usually observed after approximately 3 weeks. Over the course of 8 years, he has still not made a full recovery according to laboratory markers, which seem to have stabilized at chronically low levels. To prevent serious complications, we suggest that patients who have undergone both thymectomy and radiation therapy be monitored for immunodeficiency. This case report informs the practices of allergists, oncologists, and neurologists in the continuing care of patients with thymoma.

Show MeSH
Related in: MedlinePlus