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Immunodeficiency in the Older Population

by Don McNeil, M.D., F.A.A.A.A.I Allergists are also immunologists if board certified by the American Board of Allergy and Immunology. This certification enables an immunologist to recognize and treat patients who have a compromised immune system. The human body has multiple means of protecting itself from harm. The following is a description of the mechanism […]

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by Don McNeil, M.D., F.A.A.A.A.I

Allergists are also immunologists if board certified by the American Board of Allergy and Immunology. This certification enables an immunologist to recognize and treat patients who have a compromised immune system.
The human body has multiple means of protecting itself from harm. The following is a description of the mechanism of protection that fails in the immune system in a variety of circumstances. These may occur at any age but this topic deals with the immune disorders encountered as adults, particularly the elderly.
Primary immunodeficiencies (PI) occur more frequently in the newborn and younger population, approximately one in every 1,200 people. Secondary immunodeficiencies are even more common. These are frequently due to age, illness, injury or medication. PI may occur in patients over age 60 and may be new-onset but could also be pre-existing and overlooked. It is important to recognize these no matter the age because it may certainly prolong life and provide a better quality of life.
Diseases which are associated with an immune disorder or secondary to another illness include cancer, HIV, malnutrition, diabetes, Down’s syndrome and patients after the spleen has been removed (splenectomy). There is also an infallible loss of immune function after age 60 termed immunesenescence. Some examples of a loss of immune function will help to make this clearer.

Case 1.
A 69 year old female who has been healthy all her life, develops painful shingles on her chest and arm following a respiratory infection and asthma symptoms. Treatment included steroids. She had been given the shingles vaccine nine years previously.
An extensive work up to identify an underlying cause such as cancer or another infection such as HIV was unremarkable but an evaluation of her immune system revealed an abnormality in the number of T lymphocytes. The white cell population in the circulation is comprised of several cell types; the two which are important for immune protection are T and B cells. The patient’s immune status to varicella (the cause of shingles) was very low. This was due to the abnormal T cell in the circulation, specifically a T cell subpopulation CD3 and CD4 helper T cells. The patient was restored to normal health with treatment for varicella (Valacyclovir). This disorder is termed Idiopathic CD4 lymphocytopenia. This disorder has also occurred in relation to other viral diseases.

Case 2.
A 75 year old male had also been healthy all his life. In the last year, he complained of headaches, recurrent sore throat, chronic sinus infections and nasal discharge. A CT scan of the sinuses revealed sinusitis and he recovered after 2 weeks of antibiotics. However, symptoms recurred soon after finishing the antibiotic. Laboratory studies showed normal blood counts and normal levels of immunoglobulins. The polysaccharide pneumococcal vaccine Pneumovax was administered and a poor antibody response after 4 weeks demonstrated a selective antibody deficiency (SAD). The patient then received a protein pneumococcal vaccine Prevnar which resulted in protective levels of all serotypes of pneumococcal vaccine. Occasionally a patient like this will require replacement therapy with immune globulin.

Secondary immune deficiency is common and actually expected with many treatments, particularly chemotherapy treatment for cancer, which is known to impair the immune system. Rarely, the drug phenytoin (Dilantin) used for epilepsy causes an immunodeficiency.

Irradiation and chemotherapy used in cancer treatment are frequently associated with immunodeficiency. Examples of these are rituximab, nitrogen mustard, cyclophosphamide, chlorambucil and melphalan but there are many other agents which have a similar effect.

Don’t be afraid to ask your allergist in Columbus Ohio if you have concerns about your immune system. The two are related!

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