Humoral immunity in nasal mucosa of patients with common variable immunodeficiency

Immunoglobulins and inflammatory cytokines in nasal secretions in humoral immunodeficiencies

OBJECTIVE

Chronic respiratory tract infections are a common problem in patients with severe humoral immunodeficiency despite intravenous immunoglobulin therapy (IVIG), often presenting as rhinosinusitis.

METHODS

Because it is unclear whether IVIG is a good substitute at the mucosal surface, we analyzed immunoglobulin levels and inflammatory cytokines (ECP, IL-8, and TNF-alpha) in nasal secretions of 13 patients with common variable immunodeficiency (CVID) and in 10 patients with IgA deficiency.

RESULTS

In patients with CVID, median IgG and IgM levels did not differ significantly from controls, whereas inflammatory cytokines were markedly elevated, reflecting persistent inflammation at the mucosal site. In contrast, patients with IgA deficiency showed significantly raised IgG and IgM levels, whereas ECP and TNF-alpha were only slightly increased.

CONCLUSION

Low levels of SIgA might be compensated locally at the mucosal site by high levels of IgM and IgG. Our findings implicate that adequate IVIG is not sufficient to prevent chronic inflammation of the sinuses in patients with severe humoral immunodeficiency.

Pathophysiological classification of chronic rhinosinusitis

Background

Recent consensus statements demonstrate the breadth of the chronic rhinosinusitis (CRS) differential diagnosis. However, the classification and mechanisms of different CRS phenotypes remains problematic.

Method

Statistical patterns of subjective and objective findings were assessed by retrospective chart review.

Results

CRS patients were readily divided into those with (50/99) and without (49/99) polyposis. Aspirin sensitivity was limited to 17/50 polyp subjects. They had peripheral blood eosinophilia and small airways obstruction. Allergy skin tests were positive in 71% of the remaining polyp subjects. IgE was<10 IU/ml in 8/38 polyp and 20/45 nonpolyp subjects (p = 0.015, Fisher's Exact test). CT scans of the CRS without polyp group showed sinus mucosal thickening (probable glandular hypertrophy) in 28/49, and nasal osteomeatal disease in 21/49. Immunoglobulin isotype deficiencies were more prevalent in nonpolyp than polyp subjects (p < 0.05).

Conclusion

CRS subjects were retrospectively classified in to 4 categories using the algorithm of (1) polyp vs. nonpolyp disease, (2) aspirin sensitivity in polyposis, and (3) sinus mucosal thickening vs. nasal osteomeatal disease (CT scan extent of disease) for nonpolypoid subjects. We propose that the pathogenic mechanisms responsible for polyposis, aspirin sensitivity, humoral immunodeficiency, glandular hypertrophy, eosinophilia and atopy are primary mechanisms underlying these CRS phenotypes. The influence of microbial disease and other factors remain to be examined in this framework. We predict that future clinical studies and treatment decisions will be more logical when these interactive disease mechanisms are used to stratify CRS patients.

Recurrent sinusitis: examining medical treatment options

Recurrent sinusitis is an increasingly important disease in its own right and is an often overlooked underlying trigger for chronic asthma and/or bronchitis. The complications of unresolved recurrent sinusitis may include intracranial conditions with significant clinical implications. Patients failing conventional therapy require more aggressive therapy to avoid the necessity for invasive measures, and extensive patient education may help increase compliance with the regimen. Invasive measures (surgery) for the treatment of recurrent sinusitis carry a serious complication rate of 0.5% in 200,000 cases/ year. For this reason, aggressive medical management of these patients is an essential effort. This article explores recurrent sinusitis and its pathophysiology, and suggests a medical treatment regimen using nasally inhaled corticosteroids together with antimicrobial and supportive therapy.