Evaluation for isolated low IgA level

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU

A 27-year-old male is in the allergy clinic for evaluation of suspected IgA deficiency. He has no history of asthma, allergic rhinitis, food allergy, or atopic dermatitis.

He has a history of nonspecific abdominal pain, the screening test for celiac disease (TTGA IgA) showed IgA level below 15 mg/dL, and he is here for evaluation. Biopsies from EGD/colonoscopy were negative for abnormalities. He follows a gluten free diet. IBS was considered but the symptoms worsened with IBS therapy.

He has no history of recurrent or severe infections, but he does feel that when the get a cold it lasts longer. No pneumonia or skin infections.

Physical examination is normal apart from pale boggy turbinates and postnasal drip.

Current Medications: None.

Labs reviewed: ImmunoCAP for common food allergens all negative, below 0.35.

What is the most likely diagnosis?

- allergic rhinitis
- isolated, asymptomatic selective partial IgA deficiency

What diagnostic test would you suggest?

He had a percutaneous skin testing with indoor and outdoor allergens that was positive for Dust mite, Trees, and Ragweed.

What happened next?

This patient may have partial IgA deficiency, asymptomatic.

The majority of patients with IgA deficiency are asymptomatic. These patients require only education about the condition.s seems to fall in this category.

The majority of patients with IgA deficiency are asymptomatic. These patients require only education about the condition.s seems to fall in this category.

Only a minority of IgA deficient individuals are symptomatic. These patients may develop recurrent sinopulmonary infections, autoimmune antibodies and/or disorders, gastrointestinal disorders, and rare anaphylactic reactions to blood products. Evaluation begins with measurement of serum levels of IgA, IgG, and IgM (ordered today). Serum levels of IgG and IgM levels must be normal to consider the diagnosis of selective IgA deficiency. Two severities of IgA deficiency are distinguished: A serum IgA level lower than 7 mg/dL is considered severe deficiency. Partial deficiency refers to a level above 7 mg/dL but below the lower limit of age-adjusted normal.

Patients with recurrent sinopulmonary symptoms should be thoroughly evaluated and treated for other conditions predisposing to upper respiratory tract infections (eg, allergic rhinitis/asthma, chronic rhinosinusitis). In patients who continue to have sinopulmonary infections despite aggressive management of predisposing conditions (eg, allergic rhinitis/asthma, chronic rhinosinusitis), a trial of prophylactic antibiotics can be considered.

He also has allergic rhinitis and conjunctivitis with sensitization to Dust mite, Trees, Ragweed.

What management would you suggest?

Regarding suspected IgA deficiency, screening for immunodeficiency with IgG, A, M, titers for diphtheria, tetanus, 23 pneumococcus serotypes was recommended.

Regarding his allergic rhinitis and conjunctivitis, avoidance of relevant allergens was recommended and detailed instructions provided. He can take Zyrtec (cetirizine) 10 mg po qpm as needed. If not better, intranasal steroid could be added. Immunotherapy can be discussed in the future.

A follow up in 1-3 months was suggested to monitor the effect of therapy and to discuss the results of the laboratory tests.


UpToDate, 2013

Published: 02/12/2013
Updated: 05/22/2013

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