An 8 year old with recurrent otitis media and past history of leukemia

Dr  Ira Shah

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An 8 year old with recurrent otitis media and past history of leukemia

Dr Ira Shah.

Medical Sciences Department, Pediatric Oncall, Mumbai, India.

ADDRESS FOR CORRESPONDENCE
Dr Ira Shah, Medical Sciences Department, Pediatric Oncall, 1, B Saguna, 271, B St. Francis Road, Vile Parle {W}, Mumbai 400056.

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Clinical Problem
An eight years old female child presented with bilateral recurrent otorrhea since 2 years and cough since 15 days. On examination, she had right infrascapular crepts and X-Ray chest showed right lower zone haziness suggestive of right lower lobe pneumonitis. She was treated with oral Amoxicillin/Clavulanic acid for 10 days to which she responded.

At the age of 4 years, she had fever with joint pains, hepatosplenomegaly, generalized lymphadenopathy and ecchymosis. She had anemia (Hb = 4.6 gm%) and thrombocytopenia (platelet count = 35,000 cells/cum) with peripheral smear showing 98% blasts, suggestive of acute lymphoblastic leukemia. Her immunophenotyping of the bone marrow was that of B-cell leukemia (CD2 = 12%, CD3 = 10%, CD10 = absent, CD19 = 70%, CD13 = 9%, CD13 = 9%, CD33 = 6%). She received chemotherapy for 2 years during which she had 10 episodes of febrile neutropenia.

What is the cause of her recurrent otitis media?

Discussion
The immune system consists of skin and mucosal barriers, non-specific immunity (phagocytic cells, NK cells, complement system) and specific immunity consisting of T and B lymphocytes. Recurrent infections are the primary clinical manifestations of antibody deficiency syndrome typically after 6 months of age after disappearance of maternal antibodies. Repeated respiratory tract infections especially with staphylococci, streptococci, pneumococci and encapsulated bacteria such as Hemophilus & meningococci are seen. Other common infections are mastoiditis, chronic otorrhea, brain abscess and empyema. Hypogammaglobulinemia is also seen secondary due to:
Drugs - Antimalarials
Captopril
Carbamazepine
Glucocorticoids
Fenclofenac
Gold salts
Penicillamine
Phenytoin
Sulfasalazine
Infections - HIV
Congenital rubella
Congenital CMV
Congenital toxoplasmosis
Epstein-Barr virus

Malignancy - Chronic lymphocytic leukemia
Thymoma
Non-Hodgkin’s lymphoma
B-cell malignancy
Systemic disorders - Nephrotic syndrome
Burns
Diarrhea
Lymphangiectasia

In view of bilateral otorrhea since 2 years, an immunodeficiency was suspected. Her HIV ELISA was negative. Her serum immunoglobulins were done which showed IgG <200 mg/dl (Normal for age = 1093 to 1680 mg/dl), IgA = 70 mg/dl (Normal for age = 110 to 190 mg/dl) and IgM was 175 mg/dl (Normal for age = 45 to 188 mg/dl) suggestive of IgG with IgA deficiency.Thus, she was diagnosed as hypogammaglobulinemia secondary to B-cell leukemia. Treatment consists of IVIG therapy.

Compliance with ethical standards

Funding: None

Conflict of Interest: None

Cite this article as:
Shah I. An 8 year old with recurrent otitis media and past history of leukemia. Pediatr Oncall J. 2004;1.