Dear Niklas Thilo, 

My apologies on using abbreviations without clarifying.

LFT is Liver function tests, and includes serum bilirubin and enzymes. RFT is Renal function tests including blood urea and creatinine.

There were no other abnormalities. My suspicion was the same too and I have decided to repeat the tests from another lab after a gap of 2-3 weeks.

Thanks for the inputs.

Regards

Interesting senario...

First at all, may I know why the Ig levels were offered to her? Do you worried of Autoimmune hepatitis? Does she has any other immunocompromised illness, such as HIV and Epstein-Barr virus? Haemophilic status?

Pathophysiology of hypogammaglobulinemia:

(a)Conditions that cause an abnormal loss or increased catabolism of Ig:

Nephrotic syndrome and other severe renal diseases

Severe burns

Sepsis

Protein-losing enteropathy

Intestinal lymphangiectasia

(b)Conditions/factors affecting Ig production

Nutritional due to malnutrition or alcoholism

Drugs e.g. phenytoin, carbamazepine, immunosuppressive drugs

Malignancies, especially haemato malignancies

Rheumatological disease, e.g. rheumatoid arthritis or SLE

Viruses including HIV, Epstein-Barr virus, rubella, cytomegalovirus

HCV with low Ig levels - we should think of:

-HCV Related Cryoglobulinemia

-HCV Related Lymphoproliferation

-Drug induced, e.g. rituximab

Few articles did mentioned about the relationship between low Ig levels with Hepatitis C:

IgA deficiency is a risk factor for HCV infection in some patients - IgA deficiency associated with chronic hepatitis C virus infection. A cause or an effect?

by Ilan Y et al. Arch Intern Med. 1993 Jul 12;153(13):1588-92.

Dear Chieng jin yu ,

The patient came to me as they wanted to know the "why" of hypogammaglobulinemia. She was under follow up of another Physician elsewhere in the city and I really don't know why this test was ordered in the first place. 

She does not have any of the reasons that you have suggested. There was no M band too. Cryoglobulinemia and hypogammaglobulinemia is an uncommon association and in case the repeat test comes abnormal, I shall look into it.

Thanks and regards

I would state that in absence of any lymphocyte abnormality (a transient lymphocytopenia) the hypogammaglobulinemia you found was due to a lab problem.

Dear Dr Michele Barone,

I am not too sure about that. The lymphocytopenia need not exist at all. After all the lymphocyte subpopulation is made of both T and B lymphocytes. One can well have a fall in B cell counts that are not apparent at all.

Flow cytometry is not routinely done in evaluation of hypogammaglobulinemia. Even if done, the common markers are CD3, CD4, CD8 for T cells and CD19/20 for B cells and CD16/56 for NK cells. 

Take a condition like Common Variable Immunodeficiency (CVID), one of the commonest primary immunodeficiency diseases seen in adults. Most patients with CVID have normal numbers of circulating T and B lymphocytes. However, most can be shown to have somewhat reduced levels of circulating memory B cells (CD27+ B cells) and especially low levels of isotype switched memory B cells (CD27+ IgD- IgM-).

If we see lymphopenia, we are indeed lucky. But it is much more likely that one subtype was reduced (that we do not pick up at all in routine lab evaluation) and the lymphocyte counts were normal.

regards