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Myeloperoxidase deficiency


50% have complete loss / no chlorine formation in azurophilic (primary) granules / usually asymptomatic except in diabetics who have increased risk of disseminated candidiasis
Chediak-Higashi

Autosomal recessive mutation in LYST (microtubule and lysosomal defects)

Recurrent staph and strep, partial albinism, mental retardation, platelet dysfunction, severe periodontal disease, and in those patients surviving into 20s, striking peripheral nerve defects (nystagmus, neuropathy)

Labs: mild neutropenia and normal IG levels

Course: 85% have fatal infiltration of CD8+ and macrophages with eventual pancytopenia

Neutrophil-Specific Granule Deficiency


S. aureus, S. epidermidis, enteric bacteria (skin/lungs) / abnormal migration and atypical nuclear morphology / lack of primary granule defensins, lack of eosinophil-specific granules
Felty’s Syndrome (see rheumatology)

neutropenia, splenomegaly, from long standing RA


Complement deficiencies [labs]
most are recessive, all occur at similar rates (except C2 may be more common, 1% prevalence) / C3 (severe disease) / C5-8  GC meningitis, arthritis
Biology of Complement [activation cascade]
Functions: lysis, opsonization, anaphylatoxins (degranulation), chemotaxis
Classical: Ag:Ab complex, C1, C4, C2

attachment, activation, amplification, attack


Alternative: microbe + P, D, B, C3b
Lectin (new): MBP opsonizes foreign carbohydrates

C3a, C5a also anaphylatoxins

C5a is also a chemotactic factor
Deficiency syndromes


Clq, C1r, C1s, C4, C2

SLE, some get infections

C3

Repeated infections, partial lipodystrophy, SLE / C3 or C4 nephritic factor stabilizes convertase of alternate or classical pathway


C5-C8

Neisseria infections, arthritis


D and properdin (XLR)

Recurrent meningococcal meningitis


C1 inhibitor (AD)



Hereditary angioedema / may occur in SLE, lymphoproliferative disorders, paraproteinemias


MBP (3rd pathway)

Infections in SLE


DAF and CD59

Paroxysmal nocturnal hemoglobinuria

Factors H and I

Pyogenic infections, urticaria, glomerulonephritis, secondary C3 deficiency



Complement Studies





Normal C3 / Normal C4


Normal C3 / Decreased ↓C4

Alterations in vitro (improper specimen handling)

Coagulation-associated complement consumption

Inborn errors (other than C4 or C3)


Immune complex disease

Hypergammaglobulinemic states



Cryoglobulinemia

Hereditary angioedema

Inborn C4 deficiency


Decreased ↓C3 / Normal C4

Decreased ↓C3 / Decreased ↓C4


Acute glomerulonephritis

MPGN

Immune complex disease



Active SLE

Inborn C3 deficiency



Active SLE

Serum sickness

Chronic active hepatitis

Subacute bacterial endocarditis

Immune complex disease




C1 inhibitor (acquired or AD)

hereditary angioedema / may occur in SLE, lymphoproliferative disorders, paraproteinemias

recurrent GI attacks of colic are common / no pruritis or urticarial lesions

Allergy
Anaphylaxis

Most common  B-lactams / ⅓ of cases are idiopathic

5-60 minutes following exposure, but delayed reaction is possible



Angioedema with or without urticaria (not true anaphylaxis without life threatening hypotension or laryngeal edema)

Presentation: pruritis, flushing, urticaria, angioedema, diaphoresis, sneezing, rhinorrhea, congestion, hoarseness, stridor, laryngeal edema, dyspnea, tachypnea, wheezing, bronchorrhea, cyanosis, tachycardia, bradycardia, hypotension, cardiac arrest, arrhythmias, nausea, vomiting, diarrhea, abdominal cramping, dizziness, weakness, syncope, sense of impending doom, seizures

Treatment:

  • Epinephrine(EpiPen, Adrenaline)

  • IM (anterolateral thigh is fastest absorbed)

  • Benadryl 50 mg PO or IV every 4 hrs

  • H2 blockers (Zantac, Pepcid, etc.)

  • Methylprednisolone (Solu-Medrol, Depo-Medrol)

  • Recumbent position, elevate legs, oxygen (Beta2-adrenergic Agonists: Terbutaline)

  • Volume replacement, pressors as needed


Longer Term Treatments

  • Anabolic steroids: Stanozolol (Winstrol) / increases C1 esterase inhibitor and C4

  • Antigonadotropic agents: Danazol (Danocrine) / increases C4 levels

  • Serine Proteinase Inhibitors (serpins) / C1 inhibitor, human (Cinryze) / IV infusion repeated every few days

Ddx: EM minor (urticarial or bullous lesions), SJS, TEN [these syndromes cause fever, headache, malaise, arthralgia, corneal ulcerations, arrhythmia, pericarditis, electrolyte abnormalities, seizures, coma, sepsis]
Dilantin hypersensitivity: very common, ranges from minor to life-threatening, mechanism unclear
Iodine allergy: not true allergic reaction; hyperosmolar dye causes degranulation of mast cells/basophils
Pretreatment protocol: 40 mg prednisone 24 hrs before then 12 hrs, etc… / H2 blockers (ranitidine), benadryl / avoid contrast dye with renal insufficiency and sickle cell disease / normal maximum dye load would be 2 CT scans within a 24 hour period (assuming normal renal function)


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