eMedicine Specialties > Allergy and Immunology > Immunodeficiencies

Immunoglobulin M Deficiency

Iftikhar Hussain, MD, Director of Allergy, Asthma, and Immunology Center, PC
Srividya Sridhara, MD, Resident Physician, Department of Internal Medicine, University of Oklahoma; Bilal Ahmed, MD, MBBS, Clinical Research Assistant, Allergy, Asthma and Immunology Center, PC

Updated: Jul 21, 2009

Introduction

Background

Selective immunoglobulin M (SIgM) deficiency is a rare form of dysgammaglobulinemia characterized by an isolated low level of serum immunoglobulin M (IgM). Reported IgM concentrations in SIgM deficiency vary from 40 mg/dL (though some sources say 20 mg/dL) to undetectable levels (reference range 45-150 mg/dL in adults).¹ Recent series report IgM levels of 29.7±8.7 mg/dL (mean±SD) for adults and 16.5±13.8 (mean±SD) in children.^2,3 In this context, remember that 2.1% of "normal" individuals have values <2 SD below the mean and that values in children must be compared with reference range values for age.⁴ The levels of other immunoglobulin classes are within reference ranges.

SIgM deficiency may occur as a primary or secondary condition. Secondary SIgM deficiency is much more common than primary SIgM deficiency and may be seen in association with malignancy, autoimmune disease, gastrointestinal disease, and immunosuppressive treatment.

Some patients are asymptomatic, whereas others (often infants and small children) develop serious infections. Patients may develop prolonged or life-threatening infections caused by both encapsulated bacteria and viruses, especially in infancy. In older children and adults, SIgM deficiency is usually discovered during the investigation of other conditions, such as autoimmune disease or malignancy.

Serum immunoglobulin levels are controlled by intricate immunological regulatory mechanisms, and heterogeneity is believed to exist in the pathogenesis of SIgM deficiency. Little is known about the pathological features of SIgM deficiency at a cellular level, given that the condition is so uncommon. Processes that control the survival of IgM in the circulation and may otherwise regulate its concentration in serum have not been well described; alterations in clearance mechanisms, in addition to altered production of IgM by lymphocytes, may contribute to selective deficiency of this immunoglobulin isotype.

Pathophysiology

The cause of SIgM deficiency is unknown. Increased regulatory T-cell activity specific for IgM has been described.⁵ The absence of IgM in the presence of normal levels of immunoglobulin G (IgG) and immunoglobulin A (IgA) has yet to be explained, as this appears to contradict the theory of sequential immunoglobulin gene rearrangement. Normal mature B cells are expected to have IgM and immunoglobulin D (IgD) on their surfaces, and, with proper stimulation, rearrange their immunoglobulin genes to switch from expressing IgM to IgG, IgA, or immunoglobulin E (IgE).

Having normal levels of IgG and IgA in the face of low IgM is thus counterintuitive. One could speculate that failure to regenerate B-cell precursors could lead first to depletion of IgM, with gradual loss of IgG and other isotypes occurring later as class-switched memory B-cells and plasma cells fail to be replaced. This hypothesis has not been tested, and few studies are available to determine whether only the serum IgM level is low or whether the number of B cells with surface IgM is also decreased in patients with selective IgM deficiency. Gradually, current state-of-the-art laboratory technology is being applied in studying patients with SIgM deficiency, though much remains to be learned.

The currently available literature suggests a heterogeneous population of patients of SIgM deficiency. Some patients are capable of normal antibody responses of other immunoglobulin classes following specific immunization, whereas others respond poorly. Certain patients with decreased helper T-cell activity have been described.⁶ Cell-mediated immunity appears to be intact, but an insufficient number of detailed studies are available to confirm this. Suggested etiologies include rapid isotype switching of B cells from production of IgM to production of other isotypes and hypercatabolism of IgM.

Frequency

United States

In a retrospective study of a large allergy practice (20,000 patients) database, Goldstein et al reported prevalences of SIgM deficiency of 0.26% among adults and 0.03% among children.^2,3

International

SIgM deficiency is rare, with an incidence of less than 0.03% in the general population and 1% in hospitalized patients.⁷

Mortality/Morbidity

Since IgM may have a different range of specificities than placentally-transferred maternal IgG, infants can succumb to overwhelming infections such as meningitis, pneumonia, and gram-negative sepsis.

Patients with SIgM deficiency are susceptible to recurrent sepsis and overwhelming infection with encapsulated bacteria (eg, Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae).^8,9,10 They may also have autoimmune disease including glomerulonephritis and osteomyelitis from which organisms are not recoverable,^11,12 as well as malignancies, chronic dermatitis, diarrhea, and upper respiratory infections.

Race

The incidence of SIgM deficiency in various races has not been reported, given the low overall incidence.

Sex

The disorder occurs in both males and females, with no known discrepancies between the sexes.

Age

Infants can present with severe and overwhelming infections. Older children may present with recurrent sinopulmonary infections secondary to encapsulated organisms and an increased incidence of gram-negative septicemia.

Clinical

History

Patients may be asymptomatic, with a decreased IgM level noted during the investigation of other diseases, such as malignancies or autoimmune diseases.
Prolonged or life-threatening infections also occur, especially in infancy. Recurrent infections (eg, sinusitis and pneumonia) are often caused by encapsulated bacteria, and pneumococcal sepsis has been reported.⁸ Infections with gram negative bacteria are also more common than in normal individuals, especially with Pseudomonas aeruginosa.
Associated disorders or symptoms may include atopic or chronic dermatitis, allergic rhinitis, wheezing, and diarrhea. Patients may have a history of splenectomy.

Physical

Failure to thrive may be present, due at least in part to frequent infections. Other associated signs may include features of dermatitis, allergic rhinitis, wheezing, and splenomegaly, as well as those of other primary conditions associated with secondary SIgM deficiency, such as malignant or autoimmune disorders.

Causes

The cause of SIgM deficiency is unknown, and no clear pattern of inheritance has been suggested. The stability of the finding of selective deficiency of IgM, vs progression to deficiency of other immunoglobulin isotypes, has not been well characterized.

Patients with malignant neoplasms (eg, clear cell sarcoma, Bloom syndrome, promyelocytic leukemia), autoimmune diseases (eg, rheumatoid arthritis, Hashimoto thyroiditis, systemic lupus erythematosus, autoimmune hemolytic anemia), infections (eg, Brucella), or those given immunosuppressive agents may develop secondary SIgM deficiency.^13,14
Two case reports of epidermodysplasia verruciformis (caused by human papillomavirus) associated with SIgM deficiency are reported. One of these patients developed squamous cell carcinoma.^15,16
As cited by Zaka-ur-Rab, associations exist between SIgM deficiency and gastrointestinal conditions, including Crohn disease, chronic diarrhea, lymphoid nodular hyperplasia, Whipple disease, and splenomegaly.¹⁷
Infants with permanent congenital hypothyroidism were shown to have undetectable or lower concentrations of IgA and lower concentrations of IgM than normal controls.¹⁸
A report of 13 multiple myeloma patients in a phase 2 study showed that the 7 patients who received rituximab following autologous stem cell transplantation developed severely depressed levels of IgM that were persistent with continued rituximab therapy. When compared to the 6 myeloma patients who had received autologous stem cell transplantation without rituximab, not only were IgM levels significantly decreased, but those in the rituximab group experienced far more infections, including 21 cases of pneumonia, 2 cases of sepsis, and one death during the first 12 months.¹⁹
Three cases of 22q11.2 deletion syndrome associated with SIgM deficiency have been reported. The diagnoses were made at ages 9, 10, and 14 years. All 3 patients presented with recurrent otitis media, velopharyngeal insufficiency, speech delay, and learning disability, and 1 patient also had atrial septal defect/ventricular septal defect.^20,21

Differential Diagnoses

DiGeorge Syndrome
Hypocomplementemia
Hypogammaglobulinemia
Immunoglobulin A Deficiency
Immunoglobulin G Deficiency
Wiskott-Aldrich Syndrome

Workup

Laboratory Studies

Quantitative levels of IgM, IgG, IgA, and IgE, along with IgG subclasses, are measured. This is done to exclude more common immunodeficiency disorders, such as common variable immunodeficiency and IgA deficiency. Particularly in adults, serum immunoelectrophoresis should be done to rule out the possibility of a concomitant clonal B-cell disorder such as multiple myeloma or chronic lymphocytic leukemia.
The biological significance of a seemingly isolated low IgM level may be assessed by immunizing the patient with protein (eg, tetanus) and polysaccharide (eg, unconjugated Streptococcus pneumoniae) vaccines and assessing whether antigen-specific IgG responses are normal.

Imaging Studies

Imaging studies are not required routinely for SIgM deficiency. However, if patients report a history of recurrent sinopulmonary infection, CT scans of the sinuses and chest may be helpful for diagnosing chronic sinusitis and bronchiectasis, respectively.

Other Tests

Flow cytometry for B cells with surface IgM may be helpful.
Other tests are not required routinely for SIgM deficiency. However, other tests may be needed for further evaluation of associated diseases.

Procedures

Diagnostic procedures are not routinely required for SIgM deficiency. They may be needed for diagnosis of infections, complications, or associated diseases.

Treatment

Medical Care

Replacement of IgM is not an option, as IgM is not a significant component of therapeutic preparations of intravenous immunoglobulin. However, defective antigen-specific IgG responses have been demonstrated in some patients. For such patients, intravenous immunoglobulin (IVIG) replacement may be an option.
Prophylactic and/or rigorous therapeutic antibiotic treatments may be beneficial.
Fresh frozen plasma may be considered for severe infections.¹⁷
In a patient who is asymptomatic and in whom a decreased IgM level has been noted incidentally, prophylactic antibiotics are not needed. However, the IgM level should be determined and specific antibody studies should be performed if recurrent infections develop.

Consultations

Patients with SIgM deficiency should be under the care of a clinical immunologist, as a workup to exclude other immunodeficiencies is essential.
Consultation with an infectious disease specialist may also be helpful in a patient with recurrent infections.

Medication

Infections should be treated promptly with appropriate antibiotics, depending on the suspected pathogen. Empiric broad-spectrum therapy may be necessary before specific organisms are isolated. Some patients with selective IgM deficiency may also have increased susceptibility to fungal infections, so excessive use of broad spectrum antibiotics should be avoided, and anti-fungals should be added when appropriate.

Intravenous immunoglobulin is a therapeutic consideration for patients with SIgM deficiency who have demonstrated findings of defective antigen-specific IgG responses, particularly if they lack IgG against encapsulated bacteria and have chronic or recurrent sinopulmonary infection.

Follow-up

Further Outpatient Care

Determination of quantitative immunoglobulins (IgM, IgG, IgA, IgE) and IgG subclasses should be performed at periodic intervals (ie, every 1-2 y).

Complications

Prompt treatment of infections helps to decrease morbidity and mortality.

Prognosis

Patients with severe life-threatening infections clearly have poor prognoses. Other patients who are asymptomatic may have excellent prognoses.

Patient Education

Educate patients to promptly report any symptoms of infection.

Miscellaneous

Medicolegal Pitfalls

Patients should be promptly referred to a clinical immunologist. Quantitative measurements of other immunoglobulin isotypes (in order to exclude other humoral immunodeficiencies) upon discovering low IgM levels must also be done, and the possibility of clonal B-cell disorders should be ruled out.

References

Sorensen RU, Moore C. Primary immune deficiencies: presentation, diagnosis, and management. Pediatr Clin North Am. 2000;47:1240.
Goldstein MF, Goldstein AL, Dunsky EH, Dvorin DJ, Belecanech GA, Shamir K. Selective IgM immunodeficiency: retrospective analysis of 36 adult patients with review of the literature. Ann Allergy Asthma Immunol. Dec 2006;97(6):717-30. [Medline].
Goldstein MF, Goldstein AL, Dunsky EH, Dvorin DJ, Belecanech GA, Shamir K. Pediatric selective IgM immunodeficiency. Clin Dev Immunol. 2008;2008:624850. [Medline].
Ballow M. Primary immunodeficiency disorders: antibody deficiency. J Allergy Clin Immunol. 2002;109:581-91.
Ohno T, Inaba M, Kuribayashi K. Selective IgM deficiency in adults: phenotypically and functionally altered profiles of peripheral blood lymphocytes. Clin Exp Immunol. Jun 1987;68(3):630-7. [Medline].
De la Concha EG, Garcia-Rodriguez MC, Zabay JM. Functional assessment of T and B lymphocytes in patients with selective IgM deficiency. Clin Exp Immunol. Sep 1982;49(3):670-6. [Medline].
Inoue T, Okumara Y, Shirahama M, et al. Selective partial IgM deficiency: Functional assessment of T and B lymphocytes in vitro. J Clin Immunol. 1986;6(2):130-5.
Hong R, Gupta S. Selective immunoglobulin M deficiency in an adult with Streptococcus pneumoniae sepsis and invasive aspergillosis. J Investig Allergol Clin Immunol. 2008;18(3):214-8. [Medline].
Ideura G, Agematsu K, Komatsu Y, Hatayama O, Yasuo M, Tsushima K, et al. Selective IgM Deficiency Accompanied with IgG4 Deficiency, Dermal Complications and a Bronchial Polyp. Allergol Int. Mar 2008;57(1):99-105. [Medline].
Belgemen T, Suskan E, Dogu F, Ikinciogullari A. Selective Immunoglobulin M Deficiency Presenting with Recurrent Impetigo: A Case Report and Review of the Literature. Int Arch Allergy Immunol. Feb 12 2009;149(3):283-288. [Medline].
Antar M, Lamarche J, Peguero A, Reiss A, Cole S. A case of selective immunoglobulin M deficiency and autoimmune glomerulonephritis. Clin Exp Nephrol. Aug 2008;12(4):300-4. [Medline].
Makay B, Unsal E, Anal O, Gunes D, Men S, Cakmakci H, et al. Chronic recurrent multifocal osteomyelitis in a patient with selective immunoglobulin M deficiency. Rheumatol Int. May 2009;29(7):811-815. [Medline].
Yamasaki T. Selective IgM deficiency: functional assessment of peripheral blood lymphocytes in vitro. Intern Med. Jul 1992;31(7):866-70. [Medline].
Herrod, HG. Common variable hypogammaglobulinemia and other humoral immune deficiencies. [Full Text].
Iraji F, Faghihi G. Epidermodysplasia verruciformis: association with isolated IgM deficiency and response to treatment with acitretin. Clin Exp Dermatol. Jan 2000;25(1):41-3. [Medline].
Gul U, Soylu S, Yavuzer R. Epidermodysplasia verruciformis associated with isolated IgM deficiency. Indian J Dermatol Venereol Leprol. Nov-Dec 2007;73(6):420-2. [Medline].
Zaka-ur-Rab Z, Gupta P. Pseudomonas septicemia in selective IgM deficiency. Indian Pediatrics. 2005;42:961-2.
Stagi S, Azzari C, Bindi G, et al. Undetectable serum IgA and low IgM concentration in children with congenital hypothyroidism. Clin Immunol. 2005;116:94-8.
Lim SH, Zhang Y, Wang Z, et al. Rituximab administration following autologous stem cell transplantation for multiple myeloma is associated with severe IgM deficiency. Blood. 2004;103:1971-2.
Al-Herz W, McGeady SJ, Gripp KW. 22q11.2 deletion syndrome and selective IgM deficiency: an association of a common chromosomal abnormality with a rare immunodeficiency. Am J Med Genet. 2004;127A:99-100.
Kung SJ, Gripp KW, Stephan MJ, Fairchok MP, McGeady SJ. Selective IgM deficiency and 22q11.2 deletion syndrome. Ann Allergy Asthma Immunol. Jul 2007;99(1):87-92. [Medline].
Fallon KE. Inability to train, recurrent infection, and selective IgM deficiency. Clin J Sport Med. 2004;14:357-9.
Faulk WP, Kiyasu WS, Cooper MD. Deficiency of IgM. Pediatrics. Feb 1971;47(2):399-404. [Medline].
Guill MF, Brown DA, Ochs HD. IgM deficiency: clinical spectrum and immunologic assessment. Ann Allergy. Jun 1989;62(6):547-52. [Medline].
Ideura G, Agematsu K, Komatsu Y, et al. Selective IgM deficiency accompanied with IgG4 deficiency, dermal complications and a bronchial polyp. Allergol Int. Mar 2008;57(1):99-105. [Medline].
Nies KM, Stevens RH, Louie JS. Impaired immunoglobulin M synthesis by peripheral blood lymphocytes in systemic lupus erythematosus: a primary B-cell defect. Clin Immunol Immunopathol. Apr 1981;19(1):118-30. [Medline].

Keywords

immunoglobulin M deficiency, IgM deficient, selective IgM deficiency, SIgMD, hypogammaglobulinemia, IgM, IgM deficiency, DiGeorge syndrome, hypocomplementemia, hypogammaglobulinemia, IgA deficiency, IgG deficiency, Wiskott-Aldich syndrome, IgG reference range, Ig reference ranges, common variable immunodeficiency

Contributor Information and Disclosures

Author

Iftikhar Hussain, MD, Director of Allergy, Asthma, and Immunology Center, PC
Iftikhar Hussain, MD 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 Thoracic Society, and Association of Clinical Research Professionals
Disclosure: Nothing to disclose.

Coauthor(s)

Srividya Sridhara, MD, Resident Physician, Department of Internal Medicine, University of Oklahoma
Disclosure: Nothing to disclose.

Bilal Ahmed, MD, MBBS, Clinical Research Assistant, Allergy, Asthma and Immunology Center, PC
Disclosure: Nothing to disclose.

Medical Editor

Melvin Berger, MD, PhD, Adjunct Professor of Pediatrics and Pathology, Case Western Reserve University; Senior Medical Director, Clinical Research and Development, CSL Behring, LLC
Melvin Berger, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Clinical Investigation, and Clinical Immunology Society
Disclosure: CSL Behring Salary Employment

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

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

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Christina O'Relley Barnes, MD, to the development and writing of this article.

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