eMedicine Specialties > Pediatrics: General Medicine > Allergy & Immunology

Agammaglobulinemia: Follow-up

Author: Terry Chin, MD, PhD, Associate Professor of Pediatrics, Pediatric Allergy/Immunology/Pulmonology, Department of Pediatrics, University of California Irvine School of Medicine; Associate Director, Miller Children's Hospital at Long Beach Memorial Medical Center
Contributor Information and Disclosures

Updated: Nov 11, 2008

Follow-up

Further Outpatient Care

  • Avoid live viral vaccines for patients with agammaglobulinemia and any siblings or other children in the household because the attenuated virus is excreted and poses a threat to immunodeficient patients. If the patient has been exposed to a live viral vaccine, or if the live poliovirus has been given, obtain a stool culture to determine if the patient has the attenuated virus. Although most laboratories can determine the presence of an enterovirus, poliovirus identification requires sending the viral specimen to a state referral laboratory. Administer intravenous immunoglobulin (IVIG) and maintain serum immunoglobulin (Ig)G levels higher than 500 mg/dL.
  • Frequent monitoring of the patient's pulmonary status is important because the main long-term complication continues to be chronic lung disease. Regular measurements of pulmonary lung function should be obtained and high-resolution CT scanning of the lungs should be performed. If end-stage lung disease develops, lung transplantation has been performed in patients with agammaglobulinemia using intensive IVIG administration (every 48 h during the first 10 d after transplant).
  • Extensive diagnostic tests including cerebrospinal fluid (CSF) analyses with polymerase chain reaction (PCR) for viral genomes, neuroimaging, and electrophysiologic studies need to be pursued to evaluate for infectious or autoimmune complications.
  • Successful cure has been reported using stem cells from either cord blood or bone marrow from human leukocyte antigen (HLA)-matched siblings.36

Inpatient & Outpatient Medications

  • Administer IVIG to every patient with agammaglobulinemia. In rare circumstances (eg, temporary lack of venous access), intramuscular IgG can be given. Subcutaneous administration of IVIG is an option depending on individual preferences. A survey revealed that 90% of 1243 (1119) patients with primary immunodeficiencies in 16 countries receive IVIG in an inpatient setting, whereas 7% (87) are treated with subcutaneous Ig (SCIG), mainly at home.37 However, this survey was performed before the SCIG preparation was available.
  • Because these patients risk developing unusual infections, attempt to identify any pathogens in either the respiratory or gastrointestinal tracts. More modern techniques using PCR helped diagnose Mycoplasma pneumoniae osteomyelitis in a patient with hypogammaglobulinemia with repeatedly sterile pus cultures.
    • For patients to have refractory Campylobacter jejuni infection longer than 2 years is not unusual, despite therapy with various antibiotics and IVIG preparations.
    • In patients with respiratory symptoms, analyzing bronchial samples obtained during bronchoscopy using traditional culture as well as PCR may help determine the various viruses and bacteria present.

Complications

  • Maintain IVIG and aggressively treat pneumonias with antibiotics to avoid chronic lung disease. Recurrent infections may eventually cause either obstructive disease alone or combined obstructive and restrictive lung disease. Aerosol treatments with bronchodilators and chest physiotherapy, such as postural drainage, may prevent further damage in these patients.
    • Although most children with agammaglobulinemia or early onset hypogammaglobulinemia develop recurrent bacterial respiratory tract infections during infancy, 20% of cases are diagnosed in children aged 3-5 years, reflecting the widespread use of antibiotics. Unfortunately, permanent damage to the lungs with bronchiectasis may have already occurred.38
    • No good studies have examined the effectiveness of aerosol treatments in these patients, although one may speculate that mobilization of secretions should help. Similarly, no good studies have examined the usefulness of prophylactic antibiotics, either systemically or topically (ie, aerosolized).
  • Chronic sinusitis may also result from repeated infections and subsequent structural changes. Chronic ear infections may result in hearing loss; watch for mastoiditis, also.
  • Patients with low or absent Ig levels have increased risk of malignancy, especially in the lymphoreticular and GI organs, which may be the result of altered immune surveillance, especially at the GI level, where multiple neoplasms have been described in X-linked agammaglobulinemia (XLA).39
    • The risk for malignancy in certain patients with immunodeficiency is estimated to be 100-300 times higher than in the general population. Most are diagnosed when the patient is younger than 10 years, except for those whose immunodeficiencies developed later in life (eg, common variable immunodeficiency disease [CVID]).
    • The association of hypogammaglobulinemia with thymoma is well recognized and is known as Good syndrome.
  • Reports of progressive neurodegeneration in patients with primary immunodeficiency on IVIG treatment are concerning.40,41 Extensive diagnostic tests including CSF analyses with PCR for viral genomes, neuroimaging, and electrophysiologic studies need to be pursued to evaluate for infectious or autoimmune complications.
  • Autoimmune diseases (eg, inflammatory bowel disease, atrophic gastritis, pernicious anemia) are also observed in patients with agammaglobulinemia or hypogammaglobulinemia. Their occurrence suggests that the altered immune system, with its low resistance to infectious pathogens, may cause an inappropriate hyperfunction toward self-antigens that cause autoimmune disorders.

Prognosis

  • Overall prognosis is good when patients comply with their IVIG or SCIG therapy and attend to the possible complications of chronic infections in the upper and lower respiratory tracts.
  • In a 10-year prospective study of children younger than 4 years with hypogammaglobulinemia, Dalal et al (1998) identified 3 groups: (1) those who developed normal Ig levels with specific antibody production, (2) those who developed normal IgG levels but only transient antibody production, and (3) those with persistently low IgG levels.42  In a similar study with 8-year follow-up, Kidon et al (2004) found that 75% of children with hypogammaglobulinemia normalized their serum Ig levels (and were therefore diagnosed with transient hypogammaglobulinemia of infancy).43 Cases of so-called "reversible hypogammaglobulinemia} have been reported in which adults patients on IVIG therapy resume immunoglobulin production.44
  • In studies of patients before IVIG treatment was developed, 75% of patients older than 20 years had developed chronic lung disease, and 5-10% had cor pulmonale.

Patient Education

  • Patients can be expected to attend school and hold jobs.
  • Two organizations offering scholarships to patients with immune disorders are the Immune Deficiency Foundation and the Jeffrey Modell Foundation. They are also excellent resources for the parents of a child with an immune deficiency disorder.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider the possibility of immunodeficiency such as agammaglobulinemia when administering attenuated or live virus vaccines is a pitfall. Live polio vaccine should not be given to the patient or to any person living in the same household.
  • Failure to explore coexisting T-cell deficiency could be disastrous because T-cell deficiency warrants more aggressive therapy.
  • Another pitfall is failure to refer a patient to an immunology specialist if the attending physician is uncomfortable interpreting the results of various immune function tests.

Special Concerns

 


More on Agammaglobulinemia

Overview: Agammaglobulinemia
Differential Diagnoses & Workup: Agammaglobulinemia
Treatment & Medication: Agammaglobulinemia
Follow-up: Agammaglobulinemia
Multimedia: Agammaglobulinemia
References
[ CLOSE WINDOW ]

References

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

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

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

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

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

  6. 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].

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

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

  9. 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].

  10. 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. Dec 1997;87(12):1684-8. [Medline].

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

  12. 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. Apr 2005;11(2):90-6. [Medline].

  13. Freeman AF, Holland SM. Persistent bacterial infections and primary immune disorders. Curr Opin Microbiol. 2007;10:70-5. [Medline].

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

  15. Hidalgo S, Garcia Erro M, Cisierna D, Freire MC. Paralytic poliomyelitis caused by a vaccine-derived polio virus in an antibody-deficient Argentinean child. Pediatr Infect Dis J. 2003;22:570-2. [Medline].

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

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

  18. 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].

  19. 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. Jun 2002;44(3):273-6. [Medline].

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

  21. Gulino AV. WHIM syndrome: a genetic disorder of leukocyte trafficking. Curr Opin Allergy Clin Immunol. 2003;3:443-50. [Medline].

  22. Lynn J, Knight AK, Kamoun M, Levinson AI. A 55-year-old man with hypogammaglobulinemia, lymphopenia, and unrelenting cutaneous warts. J Allergy Clin Immunol. Aug 2004;114(2):409-14. [Medline].

  23. 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].

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

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

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

  27. 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. [Full Text].

  28. 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. Jul 2002;128(3):240-3. [Medline].

  29. 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].

  30. 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].

  31. 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].

  32. Rusconi F, Panisi C, Dellepiane RM, et al. Pulmonary and sinus diseases in primary humoral immunodeficiencies with chronic productive cough. Arch Dis Child. Dec 2003;88(12):1101-5. [Medline].

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

  34. 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].

  35. 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].

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

  37. 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. Sep 2002;104(3):231-6. [Medline].

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

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

  40. 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].

  41. 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].

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

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

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

  45. Abe S, Suzuki T, Hori T, Baba A, Shiraishi H. Hypogammaglobulinemia during antipsychotic therapy. Psychiatry Clin Neurosci. Feb 1998;52(1):115-7. [Medline].

  46. 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. Mar 8 2004;40(2):113-8. [Medline].

  47. Asmar BI, Andresen J, Brown WJ. Ureaplasma urealyticum arthritis and bacteremia in agammaglobulinemia. Pediatr Infect Dis J. Jan 1998;17(1):73-6. [Medline].

  48. 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].

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

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

  51. 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].

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

  53. 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. Aug 7 2001;135(3):165-74. [Medline].

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

  55. 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].

  56. 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. Apr 1999;159(4 Pt 1):1199-204. [Medline].

  57. 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].

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

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

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

  61. 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. Sep 2002;104(3):221-30. [Medline].

  62. 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. May 1999;134(5):589-96. [Medline].

  63. 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. Mar 19 1998;76(3):255-61. [Medline].

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

  65. 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].

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

  67. 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].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

agammaglobulinemia, hypogammaglobulinemia, X-linked agammaglobulinemia, XLA, X-linked hypogammaglobulinemia, early-onset agammaglobulinemia, late-onset agammaglobulinemia, B-cell development, B-cell maturation, Bruton tyrosine kinase, Btk, Bruton agammaglobulinemia, immunodeficiency, Ig levels, B-cell linker protein, BLNK, common variable immunodeficiency, CVID, hyper-IgM syndrome, intrauterine growth retardation, X-linked immunodeficiency with hyper IgM

transient hypogammaglobulinemia of infancy, B-cell disorders, spondyloepiphyseal dysplasia, retinal dystrophy, growth hormone deficiency, pneumonia, bacteremia, sinusitis, bronchiectasis, Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, gastroenteritis, bronchiolitis, arthritis, osteomyelitis, poliovirus, echovirus, coxsackievirus, encephalomyelitis, meningoencephalitis, LACH syndrome, colitis, WHIM syndrome, Good syndrome, human immunodeficiency virus infection, HIV, Duncan disease, Purtilo syndrome, Epstein-Barr virus, mononucleosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Terry Chin, MD, PhD, Associate Professor of Pediatrics, Pediatric Allergy/Immunology/Pulmonology, Department of Pediatrics, University of California Irvine School of Medicine; Associate Director, Miller Children's Hospital at Long Beach Memorial Medical Center
Terry 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 Thoracic Society, California Thoracic Society, Clinical Immunology Society, and Western Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Ann O'Neill Shigeoka, MD †, Former Clinical Associate Professor, Department of Pediatrics, Division of Immunology-Rheumatology, University of Utah School of Medicine
Ann O'Neill Shigeoka, MD † is a member of the following medical societies: American Federation for Medical Research, Clinical Immunology Society, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

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.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Harumi Jyonouchi, MD, Associate Professor, Division of Pulmonary Allergy/Immunology and Infectious Diseases, Department of Pediatrics, UMDNJ-New Jersey Medical School
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 Mucosal Immunology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.