Dear Ana

Your patient's clinical features may suggest underlying T cell/NK cell deficiency. You may want to carry out a detailed investigations into her T cell/NK cell dysfunction (numerical and functional). This is one for Immunologists. I would be interested to know what you find.

Best wishes

i think you should continuous in treatment of local lesion with stop the therapeutic after doing the level of lymphocytes and WBC count

What other investigations should I order next?

Dear Ana,

I’m quite sure that your patient has an EBV reactivation; to be sure you have to request a serology made by IFT and Not as usually by Elisa

the relationship between EBV and HHVs are very closed and only a neutralisation of the first will allow to regulate the second

You have two issues here that deserve your attention. First, why those white cell numbers are low? Is this some thing to do with bone marrow? Or, there is an on- going chronic infection that depletes white cells and its function. Second, her white cell functions are also down. That allows for the recurrent infections here and there. The first step is to arrange for assay of lymphocyte stimulation tests, and phagocytic assay. Checking EBV infection is a good idea. If none of them is abnormal, I would think of lymphocyte subset deficiency, both in quantity and quality of function.

Shih-Wen Huang

The laboratory results (particularly the Lymphopenia with relevant CD4/CD8 deficiency), as well as the present and anamnestic clinical data appear conclusive for a cellular immunodeficiency. However, it is difficult to place these data between the various forms of primary cellular immunodeficiency. Although none of the reported drugs has been described as causing lymphopenia, the possibility that the unusual mixture of this patient should be considered as an etiological factor of secondary immunodeficiency. Even considering the state of "supportive therapy" of the drugs taken, it might be useful to evaluate the "ex adiuvantibus" effect of suspending all drugs for an adequate period

The patient has been surprisingly responding well to topical imiquimod, with reduction of the frequency and severity of herpes flares!

What is the lymphocytic sub populations status currently?

Hi Antonio,

lymphocytes 816

CD4+ 542

CD8+ 166.

My previous question was: the good response to the imiquimod, was accompained by an increase of lymphocytes?

Not ordered yet. These numbers are from 30 days ago. I’m going to order now EBV serology, a new lymphocytes count and vitamin B12.

I'm curious, so I'll wait for this

Thanks

I think that you have to add Valaciclovir 1000 mg 3 times daily for 7 days and next virussuppressive dose of 500 mg within 42 days. Water supply must be ample

Apart from the herpetic lesions and the efficacy of therapy, we must consider that the herpetic infection as well as that mycotic are only the symptoms of a not yet defined immunodeficiency: that is the the disease

Indeed, Dr La Gioia. I've already ordered further investigations. Interestingly, she is well with no new herpetic lesions, following imiquimod application 3 times a week. Antonio La Gioia I aim to publish this case report in the future.

Herpetic infections can be not only symptoms, but the reason of immunodeficiency, especially mixed (HSV+EBV+CMV etc.)

It may be even multidermatomal H Zoster..Anyway valciclovir as mentioned or Acyclovir for 7days may beneficial..

LDH levels?

Retroviral status?

I am concerned about the ovules of boric acid. It is a very toxic semimetal, has been banned from medicine since the middle of XX century, but still nowadays it has been sent in 'homeopatic' or 'natural' drugstores. I strongly suggest to stop using the ovules of boric acid; it is quickly absorbed by skin and mucosa and takes a few days to be excreted in urine. At this point, it would be a nice idea to prescribe complex B vitamins, as a good level riboflavin can protect in part from boric acid damages.

Moreover, of course with such amount of chronic medications, her lymphopenia may be related to this aspect. Really a very complex case you have in your hands.

I am surprised no one suggested CD19 to compare with CD4/ CD8.

Regarding the suggested immunodeficiency above- albeit 2 years ago I would like to suggest the flllowing.

Any dip in CD19 would suggest the possibility of EBV or.. Aplastic Anemia. . Reference ranges are usually missing but the closer you get CD19 at or below 2% (in the USA)-the more acceptable immunotherapy becomes. Since you are up to speed on reoccurring herpes infections kindly keep ParvoB19 in mind for the rash. Especially if this is a subclinical hemolytic disorder disguised. I suggest evaluation of Myathenia gravis symptoms and following the diagnostic algorithms available.

After reading this thread, I had the opportunity to prescribe topic imiquimode for some adult patients presenting either recurrent oral or sacral herpes. Indeed, the patients told the crisis became less frequently and less intense, but a total suppression was not achieved.

There has been rising literature that spironolactone inhibits herpesvirus in general, including epstein-barr virus, who knows?

https://www.askdrray.com/spironolactone-helps-against-herpes-infections/