Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Agammaglobulinemia Clinical Presentation

  • Author: Terry W Chin, MD, PhD; Chief Editor: Harumi Jyonouchi, MD  more...
 
Updated: May 06, 2014
 

History

History in patients with agammaglobulinemia, or hypogammaglobulinemia, is similar to that for Bruton agammaglobulinemia because the patient is unable to produce functional humoral immunity. Patients may have problems with recurrent upper and/or lower respiratory tract infections or with chronic diarrhea. However, patients with mutations in the μ heavy chain and non-Btk mutations tend to develop symptoms earlier and are more likely to have severe symptoms.

Encapsulated bacteria with Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, and pseudomonal species (in that order) cause most infections. Other bacteria, such as Salmonella and Giardia species, may also cause problems. Chronic bacteremia and skin infections by Helicobacter and related species such as Flexispira and Campylobacter in patients with X-linked agammaglobulinemia (XLA) are now appreciated.[19]

Almost three fourths of patients with agammaglobulinemia have infections occurring in the upper respiratory tract with otitis and sinusitis. Lower respiratory tract infections (eg, pneumonia, bronchiolitis), GI tract infections (eg, gastroenteritis), or both occur in more than two thirds of patients. Some have suggested obtaining immunoglobulin levels in all children with community-acquired pneumonia who require hospitalization may be cost effective.[20]

Other bacterial infections, such as pyoderma, sepsis, meningitis, osteomyelitis, and septic arthritis occur less frequently. Lower-grade pathogens, such as Pneumocystis carinii pneumonia, have also been reported. Additionally, sites of infection may be unusual with the encapsulated pyogenic bacteria, such as H influenzae lymphadenopathy or pneumococcal meningitis.

Although patients with agammaglobulinemia are usually able to handle viral infections, they are susceptible to certain viruses that replicate in the GI tract and then spread to the CNS. This indicates the importance of antibody production in limiting the spread of infections by enteroviruses such as poliovirus, echovirus, and coxsackievirus.

Patients may present with vaccine-related poliomyelitis after immunization with the live poliovirus vaccine.[21, 22] Although prolonged secretions of a virus have been described (up to 637 days after vaccination), poliovirus carriers among people with primary immune deficiency appears to be rare, based on 3 separate studies, and may not manifest with disease.

Alternately, echovirus infection of the CNS may cause chronic encephalomyelitis or meningoencephalitis. In 13 patients with primary hypogammaglobulinemia, Rudge et al (1996) described 3 clinical pictures: (1) progressive myelopathy in 1 patient, (2) myelopathy progressing to an encephalopathy in 4 patients, and (3) pure encephalopathy in 8 patients.[23] Enteroviral infection was found in 7 patients by either culture or polymerase chain reaction (PCR) in the cerebrospinal fluid (CSF). However, Katamura et al (2002) described a nonprogressive viral myelitis in a patient and suggested that the prognosis of CNS infections in agammaglobulinemia is not determined by the immunoglobulin (Ig) level alone and that they are not always progressive or fatal.[24]

The use and potential efficacy of interventricular infusion of Ig have been well-documented in these patients. The use of an antiviral agent Pleconaril with intravenous immunoglobulin (IVIG) in these patients has been described.[25]

In addition, rare CNS disorders such as progressive multifocal leukoencephalopathy may present in patients with hypogammaglobulinemia.[26]

GI disorders such as chronic or acute diarrhea, malabsorption, abdominal pain, and inflammatory bowel diseases can all indicate immune deficiency.[27, 28]

Virus-induced autoimmune diseases such as a dermatomyositislike syndromes and chronic arthritis may also occur. These diseases suggest an element of dysregulated antibody production in their pathogenesis. In some cases, enteroviruses have been isolated from skin or joints. Therefore, any joint symptom should be suspected to be caused by various infectious agents in patients with humoral immunodeficiencies. Conversely, noninfectious arthritis may indicate an underlying autoimmune disorders such as lupus or rheumatoid arthritis.[29]

Mycoplasma or Ureaplasma organisms may play a role in other cases of chronic arthritis. In a survey of 358 patients with primary antibody deficiency, mycoplasmal infection was the most common cause of severe chronic erosive arthritis. Patients with mild cases rapidly respond to antimicrobial therapy, such as tetracycline. In more severe cases, arthritis improved following treatment with intravenous Ig. Overall, 7-22% of patients with agammaglobulinemia develop joint manifestations. Reactive arthritis with Campylobacter coli infections is also common. Various types of arthritis such as psoriatic, enthesitis-related, septic, and relapsing polychondritis have all been described.[30, 31]

Always consider that infections may mimic autoimmune arthritis in patients with hypogammaglobulinemia (eg, Mycoplasma).[32]

Enthesitis-related arthritis has also been described in a boy with XLA.[33]

The constellation of symptoms in a family of brothers with leukoencephalopathy, arthritis, colitis, and hypogammaglobulinemia prompted some to label this the LACH syndrome.[34]

Other associated autoimmune disorders most commonly include hematological manifestations (eg, thrombocytopenia, hemolytic anemia, neutropenia), alopecia totalis, glomerulonephritis, protein-losing enteropathy, malabsorption with disaccharidase deficiency, and amyloidosis.

Hypogammaglobulinemia has also been described in the immediate period following transplantation of intestines, kidneys, liver, and lungs.[35, 36, 37] Most likely it is secondary to the immunosuppressive therapy required for transplantation, and restoration of humoral immunity with IVIG decreases the number of infectious complications[38]

Other patients in whom measurements of Ig may be helpful include those with renal dialysis and patients in pediatric ICUs. In the former, IgG and IgG subclass deficiency were found in 8 out of 12 children undergoing continuous ambulatory peritoneal dialysis.[39] Similarly, total IgG levels were below the reference range for age in 14 of 20 patients admitted to a pediatric ICU.[40] However, these studies included a small number of subjects.

A new syndrome has been described warts, hypogammaglobulinemia, infections, and myelokathexis (WHIM) syndrome. These patients also have neutropenia and a tendency to develop B-cell lymphoma.

Next

Physical

Patients with agammaglobulinemia appear to be healthy between bouts of infections. Patients usually do not fail to thrive, although chronic diarrhea, if present, could cause some dehydration and malabsorption. Any abnormal physical findings indicate presence of various infections for which patients have increased susceptibility. Concomitant short stature in a male suggests X-linked hypogammaglobulinemia with growth hormone deficiency syndrome.

Most patients with agammaglobulinemia were recognized to have immunodeficiency during or shortly after their first hospitalization for infection. Most of the patients had a history of recurrent otitis or upper respiratory tract infection at the time of diagnosis, which when combined with the physical finding of markedly small or absent tonsils and cervical lymph nodes, should alert physicians to the diagnosis of agammaglobulinemia.

Some patients have cutaneous manifestations representing several unique syndromes. One of these is known as WHIM syndrome, consisting of warts, hypogammaglobulinemia, infections, and myelokathexis. The gene responsible for this syndrome has been identified as a chemokine receptor CXCR4.[41]

The concomitant occurrence of hypogammaglobulinemia and thymoma is known as Good syndrome.[42] These patients appear to have more severe cellular deficiency with the possibility of opportunistic infections.

Previous
Next

Causes

Genetic factors have included mutations of Btk only (accounting for 85-90% of patients with early onset agammaglobulinemia and absence of B cells). The remaining cases in males and females are clinically similar to XLA and represent mutations affecting the IGHM, CD79AA, and IGLL1 genes involved in the composition of the pre-BCR or the BLNK gene involved in pre-BCR signal transduction. Patients who do not have XLA may have other defects that result in an arrest of B-cell differentiation at a pro–B-cell level (before the onset of Ig gene rearrangements) or defects in an adjacent gene to the Btk gene responsible for growth hormone production (XLA with growth hormone deficiency).

Other genetic factors do not involve the Btk gene (which would be Bruton’s X-linked agammaglobulinemia) but involve other genes for the µ heavy chin, Igα, Igβ, λ, B-cell linger (BLNK), leucine-rich repeat-containing 8 (LRRC8), CD79a, transcription factor E47 or the p85α subunit of phosphoinositide 3-kinase (PL13K).

A female has been described with a translocation involving a new gene in chromosome 9 (LRRC8) that resulted in a block in B-cell differentiation at pro–B-cell to pre–B-cell transition.[43] She had minor facial anomalies and congenital agammaglobulinemia and absent B cells in peripheral blood.

Patients with mutations in the μ heavy chain usually present initially around 4 months of age with pneumonia, otitis, gastroenteritis, chronic enterovirus encephalitis, and septic shock with Pseudomonas aeruginosa infection. One 15-month-old child presented with fever, weakness, rash, and neutropenia 2 weeks after an oral poliovirus vaccine.

One newborn girl with mutation in the Ig-α gene developed recurrent diarrhea and failure to thrive in the first month of life. By age 1 year, she had chronic bronchitis.

One infant boy with mutation in the λ light chain had recurrent otitis media at age 2 months. At age 3 years, he had H influenzae meningitis with arthritis.

Three cases of Igβ deficiency have been reported, the most recent presenting with neutropenia, ecthyma, and mild respiratory infections.[44]

One boy with a BLNK defect presented with overwhelming sepsis during childhood. With intravenous immunoglobulin (IVIG) treatment, he survived to adulthood without any growth or developmental delay.

Five cases of autosomal recessive agammaglobulinemia involving a mutation in CD79a have been described, one presenting with an invasive CNS infection.[45]

Four patients with decreased number of peripheral B cells and mutation in the transcription factor E47 and possible autosomal dominant form of agammaglobulinemia have been described.[46]

Other patients have been described with reduced pro-B cells but no identifiable molecular defect. One was a 4-month-old infant girl with failure to thrive, recurrent otitis, candidiasis, H influenzae arthritis, and herpes simplex stomatitis. Another girl had microcephaly, persistent diarrhea, failure to thrive, and recurrent respiratory and gastrointestinal infections. This patient eventually developed pancytopenia with progressive bone marrow failure.

Finally, hypogammaglobulinemia (with almost absent B cells) has been described in several patients with specific dysmorphic features, and limb anomalies and labeled as Hoffman syndrome.[47]

In a detailed study performed in China of 21 children with congenital agammaglobulinemia, mutations of in Btk was identified in 18 patients.[48] A compound heterozygote mutation in the IGHM gene was found in one patient. No molecular etiology was found in the other two.

Also, certain infections and drugs may result in low or absent Ig levels. In a survey of laboratory values indicating hypogammaglobulinemia, patients with IgG levels less than half of the lower limit for age revealed 33% with a primary immune deficiency.[49] Secondary hypogammaglobulinemia was found most often due to chemotherapy or from complex cardiac anomalies, malignancy, or autoimmune disorders.

Certain viral infectious have been shown to cause transient or permanent immune deficiency.

Congenital rubella infection can cause hypogammaglobulinemia. Although infection with human immunodeficiency virus (HIV) usually causes hypergammaglobulinemia, hypogammaglobulinemia has been reported in some pediatric cases.

Patients with X-linked lymphoproliferative syndrome (ie, Duncan disease, Purtilo syndrome) may develop overwhelming disease with infection by Epstein-Barr virus with subsequent agammaglobulinemia and a decrease in B cells. Therefore, any male with persistent hypogammaglobulinemia following mononucleosis should be closely monitored for X-linked lymphoproliferative disease.

Drug-induced hypogammaglobulinemia has been described with immunosuppressive agents (eg, corticosteroids, rituximab[50, 51] ), epilepsy medications (eg, phenytoin, carbamazepine[52] ), and antipsychotic medications (eg, chlorpromazine). Recurrent infections and reduced serum Ig levels resolved when the medication was stopped. However, this may take some time and require IVIG in the interim.[53]

IgG levels should be determined in patients with drug rash with eosinophilia and systemic symptoms (DRESS).[54]

Oral prednisone at a dose of at least 12.5 mg/d for patients with asthma has been shown to be able to cause hypogammaglobulinemia.[55] Hypogammaglobulinemia is also frequently seen in steroid-sensitive nephrotic syndrome. Therefore, in patients with autoimmune diseases such as systemic lupus erythematosus who are being treated with prednisone and other immunosuppressive medications, the hypogammaglobulinemia could be due to either medication use or could reflect the underlying autoimmune process.

Some have speculated on the association between anticonvulsant hypersensitivity syndrome (a life-threatening, drug-induced, multiorgan system reaction) with herpesvirus reactivation and hypogammaglobulinemia.

Speculation that phenytoin-induced suppressor T-cell activity and subsequent antibody deficiency has found some support with in vitro experiments.

Malignancies such as leukemias, multiple myeloma, and neuroblastoma may also manifest hypogammaglobulinemia.

The association of hypogammaglobulinemia associated with thymoma is known as Good syndrome.[56] The most common autoimmune disorder associated with hypogammaglobulinemia is systemic lupus erythematosus.[57, 58] As noted above, antibody deficiency must be distinguished from an underlying condition versus drug-induced or renal losses.

Body losses of protein may result in hypogammaglobulinemia. A case was reported of agammaglobulinemia due to protein losses through the skin in a patient with exfoliative dermatitis.[59] Excessive protein loss from the GI tract may result in hypogammaglobulinemia; however, primary antibody deficiency may also cause chronic diarrhea. Therefore, any protein-losing enteropathy should be considered in patients presenting with hypogammaglobulinemia. In these situations, specific antibody responses are intact, and circulating B cells are normal. About 4% of patients with malabsorption syndrome have been found to have hypogammaglobulinemia.[60] Concomitant infections such as with Giardia have been described and need to be treated.[61]

On the other hand, GI protein loss may also occur from lymphatic obstruction in diseases such as intestinal lymphangiectasia. Concomitant loss of lymphocytes into the intestinal tract may result in lymphopenia.

Similarly, patients with chylothorax also have hypogammaglobulinemia (IgG = 179 ± 35 mg/dL) and lymphopenia (985 ± 636 cells/μL).[62]

Cow's milk allergy may also result in hypogammaglobulinemia, possibly due to immunoglobulin leakage through inflamed GI mucosa.[63] Avoidance of the allergen resulted in normalization of immunoglobulin levels.

Hypogammaglobulinemia has also been described in the immediate period following transplantation of intestines, kidneys, liver, and lungs.[35, 36, 37] Most likely it is secondary to the immunosuppressive therapy required for transplantation and restoration of humoral immunity with IVIG decreases the number of infectious complications in these patients.[38]

Previous
 
 
Contributor Information and Disclosures
Author

Terry W Chin, MD, PhD Associate Clinical Professor, Department of Pediatrics, University of California, Irvine, School of Medicine; Associate Director, Cystic Fibrosis Center, Attending Staff Physician, Department of Pediatric Pulmonology, Allergy, and Immunology, Memorial Miller Children's Hospital

Terry W Chin, MD, PhD 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 College of Chest Physicians, American Federation for Clinical Research, American Thoracic Society, California Society of Allergy, Asthma and Immunology, California Thoracic Society, Clinical Immunology Society, Los Angeles Pediatric Society, Western Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Harumi Jyonouchi, MD Faculty, Division of Allergy/Immunology and Infectious Diseases, Department of Pediatrics, Saint Peter's University Hospital

Harumi Jyonouchi, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association of Immunologists, American Medical Association, Clinical Immunology Society, New York Academy of Sciences, Society for Experimental Biology and Medicine, Society for Pediatric Research, Society for Mucosal Immunology

Disclosure: Nothing to disclose.

Acknowledgements

John Wilson Georgitis, MD Consulting Staff, Lafayette Allergy Services

John Wilson Georgitis, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association for the Advancement of Science, American College of Chest Physicians, American Lung Association, American Medical Writers Association, and American Thoracic Society

Disclosure: Nothing to disclose.

References
  1. York NR, de la Morena MT. 50 years ago in the journal of pediatrics: a decade with agammaglobulinemia. J Pediatr. 2012 May. 160(5):756.

  2. Khan WN. Colonel Bruton's kinase defined the molecular basis of X-linked agammaglobulinemia, the first primary immunodeficiency. J Immunol. 2012 Apr 1. 188(7):2933-5. [Medline].

  3. Samson M, Audia S, Lakomy D, et al. Diagnostic strategy for patients with hypogammaglobulinemia in rheumatology. Joint Bone Spine. 2011 May. 78(3):241-5. [Medline].

  4. Nelson KS, Lewis DB. Adult-onset presentations of genetic immunodeficiencies: genes can throw slow curves. Curr Opin Infect Dis. 2010 Aug. 23(4):359-64. [Medline].

  5. Conley ME, Famer DM, Dobbs AK, et al. A minimally hypomorphic mutation in Btk resulting in reduced B cell numbers but no clinical disease. Clin Exp Immunol. 2008. 152:39-44.

  6. Conley ME, Dobbs AK, Quintana AM, et al. Agammaglobulinemia and absent B lineage cells in a patient lacking the p85a subunit of PI3K. J Exp Med. 2012 Mar 12. 209(3):463-70. [Medline]. [Full Text].

  7. Litzman J, Brysova V, Gaillyova R, et al. Agammaglobulinaemia in a girl with a mosaic of ring 18 chromosome. J Paediatr Child Health. 1998 Feb. 34(1):92-4. [Medline].

  8. Ohga S, Nakao F, Narazaki O, et al. Hypogammaglobulinaemia in a patient with ring chromosome 21. Arch Dis Child. 1997 Sep. 77(3):252-4. [Medline].

  9. Revy P, Busslinger M, Tashiro K, et al. A syndrome involving intrauterine growth retardation, microcephaly, cerebellar hypoplasia, B lymphocyte deficiency, and progressive pancytopenia. Pediatrics. 2000 Mar. 105(3):E39. [Medline].

  10. Roifman CM. Antibody deficiency, growth retardation, spondyloepiphyseal dysplasia and retinal dystrophy: a novel syndrome. Clin Genet. 1999 Feb. 55(2):103-9. [Medline].

  11. Stewart DM, Tian LL, Notaranelo LD, Nelson DL. X-linked hypogammaglobulinemia and isolated growth hormone deficiency: an update. Immunol Rev. 2008. 40:262-70. [Medline].

  12. al-Attas RA, Rahi AH. Primary antibody deficiency in Arabs: first report from eastern Saudi Arabia. J Clin Immunol. 1998 Sep. 18(5):368-71. [Medline].

  13. Bousfiha AA, Jeddane L, El Hafidi N, Benajiba N, Rada N, El Bakkouri J, et al. First Report on the Moroccan Registry of Primary Immunodeficiencies: 15 Years of Experience (1998-2012). J Clin Immunol. Mar 2914. E PUB. [Medline].

  14. Leal RC, Bertelli EC, Soler ZA. Recurrent pneumonia caused by genetic immunodeficiency: a prophylactic and rehabililtative approach. Braz J Infect Dis. 2007. 11:307-10. [Medline].

  15. Lam DS, Lee TL, Chan KW, et al. Primary immunodeficiency in Hong Kong and the use of genetic analysis for diagnosis. Hong Kong Med J. 2005 Apr. 11(2):90-6. [Medline].

  16. Wang LL, Jin YY, Hao YQ, et al. Distribution and clinical features of primary immunodeficiency diseases in Chinese children (2004-2009). J Clin Immunol. 2011 Jun. 31(3):297-308. [Medline].

  17. de Silva NR, Gunawardena S, Rathnayake D, Wickramasingha GD. Spectrum of primary immunodeficiency disorders in Sri Lanka. Allergy Asthma Clin Immunol. Dec 2013. 9:50. [Medline].

  18. Schatorjé EJ, Gathmann B, van Hout RW, de Vries E; PedPAD consortium. The PedPAD study: Boys predominate in the hypogammaglobulinemia registry of the ESID Online Database. Clin Exp Immunol. Feb 2014. Epub. [Medline].

  19. van den Bruele T, Mourad-Baars PE, Claas EC, et al. Campylobacter jejuni bacteremia and Helicobacter pylori in a patient with X-linked agammaglobulinemia. Eur J Clin Microbiol Infect Dis. 2010 Nov. 29(11):1315-9. [Medline]. [Full Text].

  20. Vancikova Z, Freiberger T, Vach W, Trojanek M, Rizzi M, Janda A. X-linked agammaglobulinemia in community-acquired pneumonia cases revealed by immunoglobulin level screening at hospital admission. Klin Padiatr. Nov 2013. 225:339-42. [Medline].

  21. Mamishi S, Shahmahmoudi S, Tabatabaie H, et al. Novel BTK mutation presenting with vaccine-associated paralytic poliomyelitis. Eur J Pediatr. 2008 Nov. 167(11):1335-8. [Medline]. [Full Text].

  22. Shaghaghi M, Parvaneh N, Ostad-Rahimi P, Fathi SM, Shahmahmoodi S, Abolhassani H, et al. Combined immunodeficiency presenting with vaccine-associated paralytic poliomyelitis: a case report and narrative review of literature. Immunol Invest. 2014. 43:292-8. [Medline].

  23. Rudge P, Webster AD, Revesz T, et al. Encephalomyelitis in primary hypogammaglobulinaemia. Brain. 1996 Feb. 119 ( Pt 1):1-15. [Medline].

  24. Katamura K, Hattori H, Kunishima T, et al. Non-progressive viral myelitis in X-linked agammaglobulinemia. Brain Dev. 2002 Mar. 24(2):109-11. [Medline].

  25. Wildenbeest JG, van den Broek PJ, Benschop KS, et al. Pleconaril revisited: clinical course of chronic enteroviral meningoencephalitis after treatment correlates with in vitro susceptibility. Antivir Ther. 2012. 17(3):459-66. [Medline].

  26. Sveinsson O, Matell H, Herrman L. Progressive multifocal leukoencephalopathy in a patient with Good's syndrome. BMJ Case Rep. Jul 2013. 284(1-2):2013. [Medline].

  27. Mancuso A, Gentiluomo M, Vangeli M, Torre MD, Belli LS. Diarrhea as sole presentation of Good's syndrome mimicking Crohn's disease. Clin Immunol. Apr 2013. 147:9-10. [Medline].

  28. Agarwal S1, Mayer L. Diagnosis and treatment of gastrointestinal disorders in patients with primary immunodeficiency. Clin Gastroenterol Hepatol. Sep 2013. 11:1050-63. [Medline].

  29. Bloom KA, Chung D, Cunningham-Rundles C. Osteoarticular infectious complications in patients with primary immunodeficiencies. Curr Opin Rheumatol. 2008 Jul. 20(4):480-5. [Medline]. [Full Text].

  30. Gavrilova T, Capitle E. A case of relapsing polychondritis and hypogammaglobulinemia. Ann Allergy Asthma Immunol. Aug 2013. 111:147-8.

  31. Wynes J, Harris W 4th, Hadfield RA, Malay DS. Subtalar joint septic arthritis in a patient with hypogammaglobulinemia. J Foot Ankle Surg. Mar-Apr 2013. 52:242-8. [Medline].

  32. Sato H, Iino N, Ohashi R, Saeki T, Ito T, Saito M, et al. Hypogammaglobulinemic patient with polyarthritis mimicking rheumatoid arthritis finally diagnosed as septic arthritis caused by Mycoplasma hominis. Intern Med. 2012. 51:425-9. [Medline].

  33. Sukumaran S, Marzan K, Shaham B, Church JA. A child with x-linked agammaglobulinemia and enthesitis-related arthritis. Int J Rheumatol. 2011. 2011:175973. [Medline]. [Full Text].

  34. Bonkowsky JL, Bohnsack JF, Pennington MJ, et al. Leukoencephalopathy, arthritis, colitis, and hypogammaglobulinemia (LACH) in two brothers: a novel syndrome?. Am J Med Genet A. 2004. 128:52-6. [Medline].

  35. Farmer DG, Kattan OM, Wozniak LJ, Marcus E, Ponthieux S, Hwang V, et al. Incidence, timing, and significance of early hypogammaglobulinemia after intestinal transplantation. Transplantation. May 2013. 95:1154-9. [Medline].

  36. Mozer-Glassberg Y, Shamir R, Steinberg R, Kadmon G, Har-Lev E, Mor E, et al. Hypogammaglobulinemia in the early period after liver transplantation in children. Clin Transplant. May-Jun 2013. 27:E289-94. [Medline].

  37. Chambers DC, Davies B, Mathews A, Yerkovich ST, Hopkins PM. Bronchiolitis obliterans syndrome, hypogammaglobulinemia, and infectious complications of lung transplantation. J Heart Lung Transplant. Jan 2013. 32:36-43. [Medline].

  38. Carbone J, Sarmiento E, Del Pozo N, Rodriguez-Molina JJ, Navarro J, Fernandez-Yañez J, et al. Restoration of humoral immunity after intravenous immunoglobulin replacement therapy in heart recipients with post-transplant antibody deficiency and severe infections. Clin Transplant. May-Jun 2013. 26:e277-83. [Medline].

  39. Akman S, Guven AG, Ince S, et al. IgG and IgG subclasses deficiency in children undergoing continuous ambulatory peritoneal dialysis and its provocative factors. Pediatr Int. 2002 Jun. 44(3):273-6. [Medline].

  40. Rehman S, Bytnar D, Berkenbosch JW, et al. Hypogammaglobulinemia in pediatric ICU patients. J Intensive Care Med. 2003 Sep-Oct. 18(5):261-4. [Medline].

  41. Dotta L, Tassone L, Badolato R. Clinical and genetic features of Warts, Hypogammaglobulinemia, Infections and Myelokathexis (WHIM) syndrome. Curr Mol Med. 2011 Jun. 11(4):317-25. [Medline].

  42. Agarwal S, Cunningham-Rundles C. Thymoma and immunodeficiency (Good syndrome): a report of 2 unusual cases and review of the literature. Ann Allergy Asthma Immunol. 2007. 98:185-90. [Medline].

  43. Sawada A, Takihara Y, Kim JY, et al. A congenital mutation of the novel gene LRRC8 causes agammaglobulinemia in humans. J Clin Invest. 2003 Dec. 112(11):1707-13. [Medline].

  44. Lougaris V, Vitali M, Baronio M, Moratto D, Tampella G, Biasini A, et al. Autosomal Recessive Agammaglobulinemia: The Third Case of Igβ Deficiency Due to a Novel Non-sense Mutation. J Clin Immunol. Apr 2014. epub. [Medline].

  45. Khalili A1, Plebani A, Vitali M, Abolhassani H, Lougaris V, Mirminachi B, et al. Autosomal Recessive Agammaglobulinemia: A Novel Non-sense Mutation in CD79a. J Clin Immunol. Feb 2014. 34:138-41. [Medline].

  46. Boisson B, Wang YD, Bosompem A, Ma CS, Lim A, Kochetkov T, et al. A recurrent dominant negative E47 mutation causes agammaglobulinemia and BCR(-) B cells. J Clin Invest. Nov 2013. 123:4781-5. [Medline].

  47. Hugle B, Hoffman H, Bird LM, et al. Hoffman syndrome: New patients, new insights. Am J Med Genet A. 2011 Jan. 155A(1):149-53. [Medline].

  48. Zhang ZY, Zhao XD, Jiang LP, et al. Clinical characteristics and molecular analysis of 21 Chinese children with congenital agammaglobulinemia. Scand J Immunol. 2010 Nov. 72(5):454-9. [Medline].

  49. Onigbanjo MT, Orange JS, Perez EE, Sullivan KE. Hypogammaglobulinemia in a pediatric tertiary care setting. Clin Immunol. 2007. 125:52-9. [Medline].

  50. Casulo C, Maragulia J, Zelenetz AD. Incidence of hypogammaglobulinemia in patients receiving rituximab and the use of intravenous immunoglobulin for recurrent infections. Clin Lymphoma Myeloma Leuk. Apr 2013. 13:106-11. [Medline].

  51. Besada E, Bader L, Nossent H. Sustained hypogammaglobulinemia under rituximab maintenance therapy could increase the risk for serious infections: a report of two cases. Rheumatol Int. Jun 2013. 33:1643-4. [Medline].

  52. Ozaras N, Goksugur N, Eroglu S, Tabak O, Canbakan B, Ozaras R. Carbamazepine-induced hypogammaglobulinemia. Seizure. Apr 2012. 21:229-31. [Medline].

  53. Okumura A, Tsuge I, Kamachi Y et al. Transient hypogammaglobulinemia after antileptic drug hypersensitivity. Pediatr Neurol. 2007. 36:342-4. [Medline].

  54. Boccara O, Valevrie-Allanore L, Crickx B et al. Association of hypogammaglobulinemia with DRESS (Drug Rash with Eosinophilia and Systemic Symptoms). Eur J Dermatol. 2006. 16:666-8. [Medline]. [Full Text].

  55. Kawano T, Matsuse H, Obase Y, et al. Hypogammaglobulinemia in steroid-dependent asthmatics correlates with the daily dose of oral prednisolone. Int Arch Allergy Immunol. 2002 Jul. 128(3):240-3. [Medline].

  56. Kitamura A, Takiguchi Y, Tochigi N, et al. Durable hypogammaglobulinemia associated with thymoma (Good syndrome). Intern Med. 2009. 48(19):1749-52. [Medline].

  57. Yong PF, Aslam L, Karim MY, Khamashta MA. Management of hypogammaglobulinaemia occurring in patients with systemic lupus erythematosus. Rheumatology (Oxford). 2008 Sep. 47(9):1400-5. [Medline].

  58. Carneiro-Sampaio M, Liphaus BL, Jesus AA, Silva CA, Oliveira JB, Kiss MH. Understanding systemic lupus erythematosus physiopathology in the light of primary immunodeficiencies. J Clin Immunol. 2008 May. 28 Suppl 1:S34-41. [Medline].

  59. Lankisch P, Laws HJ, Weiss M, Borkhardt A. Agammaglobulinemia and lack of immunization protection in exudative atopic dermatitis. Eur J Pediatr. Jan 2014. 173:117-9. [Medline].

  60. Ghoshal UC, Goel A, Ghoshal U, et al. Chronic diarrhea and malabsorption due to hypogammaglobulinemia: a report on twelve patients. Indian J Gastroenterol. 2011 Jul. 30(4):170-4. [Medline].

  61. Furtado AK, Cabral VL, Santos TN, Mansour E, Nagasako CK, Lorena SL, et al. Giardia infection: protein-losing enteropathy in an adult with immunodeficiency. World J Gastroenterol. May 2012. 18:2430-3. [Medline].

  62. Orange JS, Geha RS, Bonilla FA. Acute chylothorax in children: selective retention of memory T cells and natural killer cells. J Pediatr. 2003. 143:243-9. [Medline].

  63. Bezrodnik L, Raccio AC, Canil LM, Rey MA, Carabajal PC, FOssati CA, et al. Hypogammaglobulinemia secondary to cow-milk allergy in children under 2 years of age. Immunology. 2007. 122:140-6. [Medline].

  64. Ricci G, Piccinno V, Giannetti A, et al. Evolution of hypogammaglobulinemia in premature and full-term infants. Int J Immunopathol Pharmacol. 2011 Jul-Sep. 24(3):721-6. [Medline].

  65. Ozen A, Baris S, Karakoc-Aydiner E, et al. Outcome of hypogammaglobulinemia in children: immunoglobulin levels as predictors. Clin Immunol. 2010 Dec. 137(3):374-83. [Medline].

  66. Kainulainen L, Vuorinen T, Rantakokko-Jalava K, Osterback R, Ruuskanen O. Recurrent and persistent respiratory tract viral infections in patients with primary hypogammaglobulinemia. J Allergy Clin Immunol. 2010 Jul. 126(1):120-6. [Medline].

  67. Bondioni MP, Duse M, Plebani A et al. Pulmonary and sinusal changes in 45 patients with primary immunodeficiencies: computed tompgraphy evaluation. J Comput Assist Tompgr. 2007. 31:620-8. [Medline].

  68. Gharagozlou M, Ebrahimi FA, Farhoudi A, et al. Pulmonary complications in primary hypogammaglobulinemia: a survey by high resolution CT scan. Monaldi Arch Chest Dis. Jun 2006. 65:69-74.

  69. Tavakol M, Kouhi A, Abolhassani H, Ghajar A, Afarideh M, Shahinpour S, et al. Otological findings in pediatric patients with hypogammaglobulinemia. Iran J Allergy Asthma Immunol. Jun 2014. 13:166-73. [Medline].

  70. Chinen J, Shearer WT. Subcutaneous immunoglobulins: alternative for the hypogammaglobulinemic patient?. J Allergy Clin Immunol. 2004. 114:934-5. [Medline].

  71. Ochs, HD, Gupta S, Kiseeling P et al. Safety and efficacy of self-administered subcutaneous immunoglobulin in patients with primary immunodeficiency diseases. J Clin Immunol. 2006. 26:265-73. [Medline].

  72. Gustafson R, Gardulf A, Hansen S et al. Rapid subcutaneous immunoglobulin administration every second week results in high and stable serum immunoglobulin G levels in patients with primary antibody deficiencies. Clin Exp Immunol. 2008. 152:274-9. [Medline].

  73. Orange JS, Grossman WJ, Navickis RJ, Wilkes MM. Impact of trough IgG on pneumonia incidence in primary immunodeficiency: A meta-analysis of clinical studies. Clin Immunol. 2010 Oct. 137(1):21-30. [Medline].

  74. Berger M. Incidence of infection is inversely related to steady-state (trough) serum IgG level in studies of subcutaneous IgG in PIDD. J Clin Immunol. 2011 Oct. 31(5):924-6. [Medline].

  75. Lacy CF, Armstrong LL, Goldman MP, Lance LL, eds. Drug Information Handbook 2008-2009. 16th edition. Cleveland, OH: Lexi-Comp Inc; 2008.

  76. Hooper JA. Intravenous immunoglobulins: evolution of commercial IVIG preparations. Immunol Allergy Clin North Am. 2008 Nov. 28(4):765-78, viii. [Medline].

  77. Shah S. Pharmacy considerations for the use of IGIV therapy. Am J Health Syst Pharm. 2005 Aug 15. 62(16 Suppl 3):S5-11. [Medline].

  78. Siegel J. The Product: All intravenous immunoglobulins are not equivalent. Pharmacother. 2005. 25(11 Pt 2):78S-84S.

  79. Shaghaghi M, Parvaneh N, Ostad-Rahimi P, Fathi SM, Shahmahmoodi S, Abolhassani H, et al. Combined immunodeficiency presenting with vaccine-associated paralytic poliomyelitis: a case report and narrative review of literature. Immunol Invest. Mar 2014. 43:292-8. [Medline].

  80. Gonzalo-Garijo MA, Sánchez-Vega S, Pérez-Calderón R, Pérez-Rangel I, Corrales-Vargas S, Fernández de Mera JJ, et al. Renal amyloidosis in a patient with X-linked agammaglobulinemia (Bruton's disease) and bronchiectasis. J Clin Immunol. Jan 2014. 34:119-22. [Medline].

  81. Howard V, Myers LA, Williams DA, et al. Stem cell transplants for patients with X-linked agammaglobulinemia. Clin Immunol. 2003 May. 107(2):98-102. [Medline].

  82. Quinti I, Pierdominici M, Marziali M, et al. European surveillance of immunoglobulin safety--results of initial survey of 1243 patients with primary immunodeficiencies in 16 countries. Clin Immunol. 2002 Sep. 104(3):231-6. [Medline].

  83. Buckley RH. Pulmonary complications of primary immunodeficiencies. Paediatr Respir Rev. 2004. 5 (Suppl A):S225-33. [Medline].

  84. Chen Y, Stirling RG, Paul E, et al. Longitudinal decline in lung function in patients with primary immunoglobulin deficiencies. J Allergy Clin Immunol. 2011 Jun. 127(6):1414-7. [Medline].

  85. Ozcan C, Metin A, Erkoçoğlu M, Kocabas CN. Bronchial hyperreactivity in children with antibody deficiencies. Allergol Immunopathol (Madr). Jan 2014. Epub. [Medline].

  86. Quinti I, Soresina A, Guerra A, et al. Effectiveness of immunoglobulin replacement therapy on clinical outcome in patients with primary antibody deficiencies: results from a multicenter prospective cohort study. J Clin Immunol. 2011 Jun. 31(3):315-22. [Medline].

  87. Patiroglu T, Akyildiz B, Patiroglu TE, Gulmez IY. Recurrent pulmonary alveolar proteinosis secondary to agammaglobulinemia. Pediatr Pulmonol. 2008 Jul. 43(7):710-3. [Medline].

  88. Berlucchi M, Soresina A, Redaelli De Zinis LO, et al. Sensorineural hearing loss in primary antibody deficiency disorders. J Pediatr. 2008 Aug. 153(2):293-6. [Medline].

  89. Tavakol M, Kouhi A, Abolhassani H, Ghajar A, Afarideh M, Shahinpour S, et al. Otological findings in pediatric patients with hypogammaglobulinemia. Iran J Allergy Asthma Immunol. Jun 2014. 13:166-73. [Medline].

  90. Ishimura M, Takada H, Doi T, et al. Nationwide survey of patients with primary immunodeficiency diseases in Japan. J Clin Immunol. 2011 Dec. 31(6):968-76. [Medline].

  91. Brosens LA, Tytgat KM, Morsink FH et al. Multiple colorectal neoplasms in X-linked agammaglobulinemia. Clin Gastroenterol Hepatol. 2008. 6:115-9. [Medline].

  92. Slotta JE, Heine S, Kauffels A, et al. Gastrectomy with isoperistaltic jejunal parallel pouch in a 15-year-old adolescent boy with gastric adenocarcinoma and autosomal recessive agammaglobulinemia. J Pediatr Surg. 2011 Sep. 46(9):e21-4. [Medline].

  93. Ziegner UH,, Kobayashi RH, Cunningham-Rundles C, et al. Progressive neurodegeneration in patients with primary immunodeficiency disease on IVIG treatment. Clin Immunol. 2002. 102:19-24. [Medline].

  94. Papapetropoulos S, Friedman J, Blackstone C et al. A progressive, fatal dystonia-Parkinsonism syndrome in a patient with primary immunodeficiency receiving chronic IBIG therapy. Mov Disord. 2007. 22:1664-6. [Medline].

  95. Cunningham-Rundles C. Autoimmunity in primary immune deficiency: taking lessons from our patients. Clin Exp Immunol. 2011 Jun. 164 Suppl 2:6-11. [Medline]. [Full Text].

  96. Dalal I, Reid B, Nisbet-Brown E, Roifman CM. The outcome of patients with hypogammaglobulinemia in infancy and early childhood. J Pediatr. 1998 Jul. 133(1):144-6. [Medline].

  97. Kidon MI, Handzel ZT, Schwartz R, et al. Symptomatic hypogammaglobulinemia in infancy and childhood - clinical outcome and in vitro immune responses. BMC Fam Pract. 2004 Oct 21. 5:23. [Medline].

  98. Desar IM, Weemaes CM, van Deuren M et al. Reversible hypogammaglubulinaemia. Neth J Med. 2007. 65:381-5. [Medline].

  99. Aghamohammadi A, Moin M, Farhoudi A, et al. Efficacy of intravenous immunoglobulin on the prevention of pneumonia in patients with agammaglobulinemia. FEMS Immunol Med Microbiol. 2004 Mar 8. 40(2):113-8. [Medline].

  100. Baumgart KW, Britton WJ, Kemp A, et al. The spectrum of primary immunodeficiency disorders in Australia. J Allergy Clin Immunol. 1997 Sep. 100(3):415-23. [Medline].

  101. Black C, Zavod MB, Gosselin BJ. Haemophilus influenzae lymphadenopathy in a patient with agammaglobulinemia: clinical-histologic-microbiologic correlation and review of the literature. Arch PatholLab Med. 2005. 129:100-3. [Medline].

  102. Buehring I, Friedrich B, Schaaf J, et al. Chronic sinusitis refractory to standard management in patients with humoral immunodeficiencies. Clin Exp Immunol. 1997 Sep. 109(3):468-72. [Medline].

  103. Conley ME. Early defects in B cell development. Curr Opin Allergy Clin Immunol. 2002. 2:517-22. [Medline].

  104. Conley ME, Broides A, Hernandez-Trujillo V, et al. Genetic analysis of patients with defects in early B-cell development. Immunol Rev. 2005. 203:216-34. [Medline].

  105. Conley ME, Dobbs AK, Farmer DM, et al. Primary B cell immunodeficiencies: comparisons and contrasts. Annu Rev Immunol. 2009. 27:199-227. [Medline].

  106. Dittrich AM, Schulze I, Magdorf K, et al. X-linked agammaglobulinaemia and Pneumocystis carinii pneumonia--an unusual coincidence?. Eur J Pediatr. 2003 Jun. 162(6):432-3. [Medline].

  107. Eijkhout HW, van Der Meer JW, Kallenberg CG, et al. The effect of two different dosages of intravenous immunoglobulin on the incidence of recurrent infections in patients with primary hypogammaglobulinemia. A randomized, double-blind, multicenter crossover trial. Ann Intern Med. 2001 Aug 7. 135(3):165-74. [Medline].

  108. Eley BS, Hughes J, Cooper M, Pienaar S, Beatty DW. Primary immunodeficiency diseases at Red Cross War Memorial Children's Hospital. S Afr Med J. 1997 Dec. 87(12):1684-8. [Medline].

  109. Ferrari S, Lougaris V, Caraffi S, et al. Mutations of the Igbeta gene cause agammaglobulinemia in man. J Exp Med. 2007 Sep 3. 204(9):2047-51. [Medline].

  110. Feydy A, Sibilia J, De Kerviler E, et al. Chest high resolution CT in adults with primary humoral immunodeficiency. Br J Radiol. 1996 Dec. 69(828):1108-16. [Medline].

  111. Fijolek J, Wiatr E, Demkow U, Orlowsk TM. Immunological disturbances in Good's syndrome. Clin Invest Med. 2009 Aug 1. 32(4):E301-6. [Medline].

  112. Halsey NA, Pinto J, Espinosa-Rosales F et al. Search for poliovirus carriers among people with primary immune deficiency diseases in the United States, Mexico, Brazil and the United Kingdom. Bull World Heatlh Organ. 2004. 82:3-8. [Medline].

  113. Kainulainen L, Nikoskelainen J, Vuorinen T, et al. Viruses and bacteria in bronchial samples from patients with primary hypogammaglobulinemia. Am J Respir Crit Care Med. 1999 Apr. 159(4 Pt 1):1199-204. [Medline].

  114. Kano Y, Inaoka M, Shiohara T. Association between anticonvulsant hypersensitivity syndrome and human herpes 6 reactivation and hypogammaglobulinemia. Arch Dermatol. 2004. 140:183-8. [Medline].

  115. Kawai T, Malech HL. WHIM syndrome: congenital immune deficiency disease. Curr Opin Hematol. 2009 Jan. 16(1):20-6. [Medline]. [Full Text].

  116. Kutukculer N, Gulez N. The outcome of patients with unclassified hypogammaglobulinemia in early childhood. Pediatr Allergy Immunol. 2009 Nov. 20(7):693-8. [Medline].

  117. Liu Y, Wu Y, Lam KT, Lee PP, Tu W, Lau YL. Dendritic and T Cell Response to Influenza is Normal in the Patients with X-Linked Agammaglobulinemia. J Clin Immunol. 2012 Feb 1. [Medline]. [Full Text].

  118. Mila J, Matamoros N, Pons de Ves J, et al. [The Spanish Registry of Primary Immunodeficiencies. REDIP-1998]. Sangre (Barc). 1999 Apr. 44(2):163-7. [Medline].

  119. Morales P, Hernandez D, Vicente R, et al. Lung transplantation in patients with x-linked agammaglobulinemia. Transplant Proc. 2003 Aug. 35(5):1942-3. [Medline].

  120. Mueller BU, Pizzo PA. Cancer in children with primary or secondary immunodeficiencies. J Pediatr. 1995 Jan. 126(1):1-10. [Medline].

  121. Ozdoba C, Ramelli G, Schroth G. MRI in a patient with congenital agammaglobulinaemia. Neuroradiology. 1998 Aug. 40(8):516-8. [Medline].

  122. Plebani A, Soresina A, Rondelli R, et al. Clinical, immunological, and molecular analysis in a large cohort of patients with X-linked agammaglobulinemia: an Italian multicenter study. Clin Immunol. 2002 Sep. 104(3):221-30. [Medline].

  123. Quartier P, Debre M, De Blic J, et al. Early and prolonged intravenous immunoglobulin replacement therapy in childhood agammaglobulinemia: a retrospective survey of 31 patients. J Pediatr. 1999 May. 134(5):589-96. [Medline].

  124. Raynaud M, Ronce N, Ayrault AD, et al. X-linked mental retardation with isolated growth hormone deficiency is mapped to Xq22-Xq27.2 in one family. Am J Med Genet. 1998 Mar 19. 76(3):255-61. [Medline].

  125. Skull S, Kemp A. Treatment of hypogammaglobulinaemia with intravenous immunoglobulin, 1973-93. Arch Dis Child. 1996 Jun. 74(6):527-30. [Medline].

  126. Teramoto T, Kaneko H, Funato M, et al. Progressive multifocal leukoencephalopathy in a patient with X-linked agammaglobulinemia. Scand J Infect Dis. 2003. 35(11-12):909-10. [Medline].

  127. Tokuda K, Nishi J, Miyanohara H, et al. Relapsing cellulitis associated with Campylobacter coli bacteremia in an agammaglobulinemic patient. Pediatr Infect Dis J. 2004 Jun. 23(6):577-9. [Medline].

  128. Wang LJ, Yang YH, Lin YT, Chiang BL. Immunological and clinical features of pediatric patients with primary hypogammaglobulinemia in Taiwan. Asian Pac J Allergy Immunol. 2004. 22:25-31. [Medline].

 
Previous
Next
 
Early stages of B-cell differentiation can be identified by the status of the immunoglobulin genes and by the cell surface markers CD34, CD19, and surface immunoglobulin (sIg). From: Conley ME. Genes required for B cell development. J Clin Invest. 2003;112: 1636-8. Reproduced with permission of American Society for Clinical Investigation via Copyright Clearance Center.
Table 1. Immune Globulin, Intravenous [75, 76, 77, 78]
Brand(Manufacturer) Manufacturing Process pH Additives (IVIG products containing sucrose are more often associated with renal dysfunction, acute renal failure, and osmotic nephrosis, particularly with preexisting risk factors [eg, history of renal insufficiency, diabetes mellitus, age >65 y, dehydration, sepsis, paraproteinemia, nephrotoxic drugs].) Parenteral Form and Final Concentrations IgA Content (mcg/mL)
Carimune NF



(ZLB Behring)



Kistler-Nitschmann fractionation; pH 4 incubation, nanofiltration 6.4-6.8 6% solution: 10% sucrose, < 20 mg NaCl/g protein Lyophilized powder 3%, 6%, 9%, 12% Trace
Flebogamma



(Grifols USA)



Cohn-Oncley fractionation, PEG precipitation, ion-exchange chromatography, pasteurization 5.1-6 Sucrose free, contains 5% D-sorbitol Liquid 5% < 50
Gammagard Liquid 10%



(Baxter Bioscience)



Cohn-Oncley cold ethanol fractionation, cation and anion exchange chromatography, solvent detergent treated, nanofiltration, low pH incubation 4.6-5.1 0.25M glycine Ready-for-use liquid 10% 37
Gammar-P IV



(ZLB Behring)



Cohn-Oncley fraction II/III; ultrafiltration; pasteurization 6.4-7.2 5% solution: 5% sucrose, 3% albumin, 0.5% NaCl Lyophilized powder 5% < 20
Gamunex



(Talecris Biotherapeutics)



Cohn-Oncley fractionation, caprylate-chromatography purification, cloth and depth filtration, low pH incubation 4-4.5 Contains no sugar, contains glycine Liquid 10% 46
Gammaplex



(Bio Products)



Solvent/detergent treatment targeted to enveloped viruses; virus filtration using Pall Ultipor to remove small viruses including nonenveloped viruses; low pH incubation 4.8-5.1 Contains sorbitol (40 mg/mL); do not administer if fructose intolerant Ready-for-use solution 5% < 10
Iveegam EN



(Baxter Bioscience)



Cohn-Oncley fraction II/III; ultrafiltration; pasteurization 6.4-7.2 5% solution: 5% glucose, 0.3% NaCl Lyophilized powder 5% < 10
Polygam S/D



Gammagard S/D



(Baxter Bioscience for the American Red Cross)



Cohn-Oncley cold ethanol fractionation, followed by ultracentrafiltration and ion exchange chromatography; solvent detergent treated 6.4-7.2 5% solution: 0.3% albumin, 2.25% glycine, 2% glucose Lyophilized powder 5%, 10% < 1.6 (5% solution)
Octagam



(Octapharma USA)



9/24/10: Withdrawn from market because of unexplained reports of thromboembolic events



Cohn-Oncley fraction II/III; ultrafiltration; low pH incubation; S/D treatment pasteurization 5.1-6 10% maltose Liquid 5% 200
Panglobulin



(Swiss Red Cross for the American Red Cross)



Kistler-Nitschmann fractionation; pH 4 incubation, trace pepsin, nanofiltration 6.6 Per gram of IgG: 1.67 g sucrose, < 20 mg NaCl Lyophilized powder 3%, 6%, 9%, 12% 720
Privigen



(CSL Behring)



pH 4 incubation; octanoic acid fractionation, depth filtration, and virus filtration 4.6-5 10% solution; Preservative-free, sucrose-free, and maltose-free Ready-to-use solution 10% < 25
Table 2. Immune Globulin, Subcutaneous
Brand(Manufacturer) Manufacturing Process pH Additives Parenteral Form and Final Concentrations IgA Content mcg/mL
Vivaglobin



(ZLB Behring)



Cold ethanol fractionation, pasteurization 6.4-7.2 2.25% glycine, 0.3% NaCl Liquid 16% (160 mg/mL) < 50 mcg/mL
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.