eMedicine Specialties > Allergy and Immunology > Immunodeficiencies

Wiskott-Aldrich Syndrome: Treatment & Medication

Author: Donald A Dibbern Jr, MD, Consulting Staff (Allergist), Providence St Vincent Medical Center
Coauthor(s): John M Routes, MD, Professor of Pediatrics, Medical College of Wisconsin; Chief, Section of Allergy and Clinical Immunology, Department of Pediatrics, Children's Hospital of Wisconsin
Contributor Information and Disclosures

Updated: Jun 5, 2009

Treatment

Medical Care

Patients require vigilant general medical or pediatric care. Promptly and aggressively treat infections and bleeding.

  • Eczema may be severe. Manage the eczema in the usual fashion, with careful attention to skin care, moisturization, and appropriate (eg, route and potency) steroid therapy.29
  • Patients with thrombocytopenia may require intravenous immunoglobulin and/or corticosteroids. Patients with bleeding may require platelet and/or red blood cell transfusions.
  • Surveillance for malignancy is an important aspect of care.
  • Bone marrow transplantation may be curative if an appropriate histocompatible donor is available. However, this intervention carries substantial risks and mortality.2
    • Donor histocompatibility is a very important determinant of survival after bone marrow transplant for WAS. A survival rate of 80% was observed in patients who received HLA-identical transplants, but a survival rate of only 23% was observed in patients who received mismatched (haploidentical) transplants.35 A later study of outcome of bone marrow transplant in patients with WAS examined 170 patients and found a 70% 5-year survival rate for all patients who received transplants. This included a 5-year survival rate of 87% with HLA-identical sibling donors, 52% with other related donors, and 71% with unrelated donors.36 More recent studies have shown continued improvement in graft success and survival rates, with rates now generally near 70-80% in case series from 1990-2005 in Italy27 and 1985-2004 in Japan.26 When a matched sibling donor is unavailable, umbilical cord blood stem cell transplantation has been used.37
    • Increased attention has been given to pretransplant reduced-intensity conditioning regimens, in comparison to myeloablative conditioning, with regard to posttransplant mixed chimerism and the possibility of increased autoimmunity.38
    • If bone marrow transplantation is successful, hematologic and immunologic defects are corrected and eczema resolves.25,39
  • Gene therapy trials (phase I/II studies to start in Europe) to reconstitute WASp expression in autologous hematopoietic stem cells have been planned.40,41 Mouse models for this process to date have used a modified lentiviral (HIV-1 derived) vector.41,42,43

Surgical Care

Patients may require splenectomy to help control thrombocytopenia44 , although this intervention may increase the already elevated risk of infection from encapsulated organisms (eg, pneumococcal sepsis). Studies demonstrate that most patients who had a splenectomy achieve normal platelet counts, and their rates of serious bleeding decrease 5- to 6-fold.2,25,45

Consultations

  • Refer patients to an allergist/clinical immunologist and/or pediatric hematologist to exclude other comorbid immune defects and to ensure accurate diagnosis.
  • Patients with associated thrombocytopenia, bleeding, and malignancies may require consultation with a hematologist or oncologist to assist with management.
  • Patients with refractory infections may require consultation with an infectious diseases specialist.

Diet

Patients do not require dietary restrictions.

Activity

Patients with thrombocytopenia must take precautions to prevent bleeding (eg, fall precautions, protective headgear, no contact sports).

Medication

WAS is treated with a variety of therapeutic agents from several different categories, including antibiotics, antivirals, antifungals, chemotherapeutic agents, immunoglobulins, and corticosteroids. Agents are selected based on the patient's clinical presentation and response. When treating infections, if possible, identify the suspected pathogen before selecting antibiotic, antiviral, and/or antifungal agents. Antibiotics are indicated to treat bacterial infections and for prophylaxis in patients who have had a splenectomy. Antiviral and antifungal agents are indicated to treat viral and fungal infections, respectively. Chemotherapeutic agents are indicated to treat lymphoreticular and/or hematologic malignancies, but are also used as ablative agents, with or without total-body irradiation, prior to bone marrow transplantation. Immunoglobulins and systemic corticosteroids are indicated to treat thrombocytopenia. Use topical steroids to treat eczema.

Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.


Prednisone (Sterapred)

Immunosuppressant for treating autoimmune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Used to treat thrombocytopenia. Many different steroid treatment regimens are used to treat thrombocytopenia. Consider using other corticosteroids at equivalent doses (eg, prednisolone, methylprednisolone).

Adult

1-2 mg/kg/day PO qday or divided bid/qid; taper over 2-3 wk as symptoms resolve

Pediatric

Administer as in adults

Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tuberculous skin infections; GI disease

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abruptly discontinuing glucocorticoids may cause adrenal crisis if they have been administered qd for >14 d; hyperglycemia, edema, osteonecrosis, myopathy, upper GI bleeding, small intestine perforation, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use


Methylprednisolone (Medrol, Solu-Medrol)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Used to treat thrombocytopenia. Many different steroid treatment regimens are used to treat thrombocytopenia. Consider using other corticosteroids at equivalent doses (eg, dexamethasone, prednisolone).

Adult

Pulse of high-dose IV at 15-30 mg/kg/day IV for 2-3 days sometimes used or if PO therapy fails

Pediatric

Administer as in adults

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease levels (adjust dose); monitor for hypokalemia with concurrent diuretics

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use


Fluocinolone (Synalar)

High-potency topical corticosteroid that inhibits cell proliferation. Immunosuppressive, antiproliferative, and anti-inflammatory. Used to treat eczema. Use lowest effective potency and dose. Consider using equivalent doses of other topical corticosteroid preparations (eg, hydrocortisone, mometasone). Topical steroids are preferred, but for rapid control of severe disease, consider a brief burst of moderate-dose PO steroids.

Adult

Apply qday/bid as severity warrants

Pediatric

Administer as in adults

Documented hypersensitivity; herpes simplex infection; fungal, viral, or tubercular skin lesions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause adverse systemic effects if used over large areas, denuded areas, on occlusive dressings, or during prolonged treatment periods; may cause adverse local effects (eg, atrophy, depigmentation), particularly in areas such as the face, groin, and axillae

Immunoglobulins

Provide functional immunoglobulins in patients whose ability to respond to bacterial antigens is abnormal and may inhibit platelet sequestration by the reticuloendothelial system.


Immune globulin (Gammagard, Gamunex, Iveegam EN, Octagam, Privigen)

Used to treat thrombocytopenia; also may be indicated if serum IgG level is low or patient cannot produce functional antibody responses (eg, to polysaccharide antigens). See Hypogammaglobulinemia for dosing.

Adult

400 mg/kg/day IV for 2-5 days or 1 g/kg/day for 1-2 days; may need to be repeated q10-21d

Pediatric

Administer as in adults

May impair response to vaccines

Documented hypersensitivity; do not use IgA-containing preparations on IgA-deficient patients; little data support routine use for immune defects in WAS in the absence of low serum IgG

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Administer slowly to decrease infusion-related reactions (eg, chills, headache, rash); pretreatment with acetaminophen and antihistamines, and occasionally corticosteroids, may be necessary in certain cases; aseptic meningitis is reported infrequently, particularly with high-dose (>2 g/kg) therapy; hepatitis C is rarely transmitted, although all current preparations now include virucidal processes
Possible risk of reversible and/or irreversible renal failure, particularly with sucrose-containing preparations in patients with renal insufficiency and with higher doses
Do not use IgA-containing preparations in IgA-deficient patients because 17-40% have circulating anti-IgA antibodies and have risk of anaphylaxis
Little data are available regarding pregnancy precautions, although 1 report described 2 patients with common variable immunodeficiency who were given IV immunoglobulin during the last trimester of pregnancy and delivered healthy newborns; IVIG may increase serum viscosity and thromboembolic events

More on Wiskott-Aldrich Syndrome

Overview: Wiskott-Aldrich Syndrome
Differential Diagnoses & Workup: Wiskott-Aldrich Syndrome
Treatment & Medication: Wiskott-Aldrich Syndrome
Follow-up: Wiskott-Aldrich Syndrome
Multimedia: Wiskott-Aldrich Syndrome
References
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Further Reading

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Keywords

hypoimmunoglobulinemia M, hypogammaglobulinemia M, dysgammaglobulinemia M, dysimmunoglobulinemia M, dysgammaglobulinemia type V, gamma-M deficiency, selective IgM deficiency, selective immunoglobulin M deficiency, WAS, thrombocytopenia, eczema, autoimmune disease, hematologic malignancy

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Contributor Information and Disclosures

Author

Donald A Dibbern Jr, MD, Consulting Staff (Allergist), Providence St Vincent Medical Center
Donald A Dibbern Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Allergy Asthma and Immunology, and Oregon Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

John M Routes, MD, Professor of Pediatrics, Medical College of Wisconsin; Chief, Section of Allergy and Clinical Immunology, Department of Pediatrics, Children's Hospital of Wisconsin
John M Routes, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Microbiology, American Society for Virology, Clinical Immunology Society, and Federation of American Societies for Experimental Biology
Disclosure: Nothing to disclose.

Medical Editor

Charles H Kirkpatrick, MD, Professor of Medicine and Immunology, University of Colorado School of Medicine; Director of Adult Immune Deficiency Program, Department of Medicine, University of Colorado Health Sciences Center; Consulting Staff, Department of Medicine, National Jewish Medical and Research Center
Charles H Kirkpatrick, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Physicians, American Federation for Clinical Research, American Society for Clinical Investigation, and Clinical Immunology Society
Disclosure: Lev Pharmaceuticals Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael R Simon, MD, MA, Clinical Professor Emeritus, Departments of Internal Medicine and Pediatrics, Wayne State University School of Medicine; Adjunct Staff, Division of Allergy and Immunology, Department of Internal Medicine, William Beaumont Hospital
Michael R Simon, MD, MA is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, American Federation for Medical Research, Michigan Allergy and Asthma Society, Michigan State Medical Society, Royal College of Physicians and Surgeons of Canada, and Society for Experimental Biology and Medicine
Disclosure: Secretory IgA, Inc. Ownership interest Board membership

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
Disclosure: Abbott Consulting fee Consulting; Alcon Consulting fee Consulting; Glaxo Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering Consulting fee Consulting; Teva  Consulting; Meda Honoraria Speaking and teaching

 
 
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