IMMUNOLOGY TEXTBOOK - Mercury Podillia 2013

ACQUIRED IMMUNODEFICIENCY STATES

Immunodeficiency with Recurrent Viral Infections

Immunocorrective therapy regimen:

- groprinosin (isoprinosine) orally at 50 mg/kg divided into 6 doses, course duration of 7 days;

- interferon-gamma 3 thousand IU/kg per injection for a course of up to 7 days (or leukinferon).

- Applications of 15% dimexide (from 8 to 20 ml per Procedure) for 8-10 days. The application site for dimexide depends on the clinical local symptoms, which may include the chest, Liver area, anterior abdominal wall, PROJECTION OF THE submandibular and other Lymph Nodes, and the like;

- in case of exacerbation - acyclovir in age-appropriate doses (or heviran).

4. Phagocytic immunodeficiencies

Antibacterial (antifungal drugs).

Broad-spectrum immunostimulants:

- polyoxidonium at a dose of 6 to 12 mg;

- lycopid at a dose of 1 mg-10 mg, for 10 days.

Granulocyte-macrophage colony-stimulating factor preparations:

- molgramostim (leucomax) 150 mcg; 300 mcg; 400 mcg;

- filgrastim (neupogen) 300 mcg, 480 mcg 1-5 mcg/kg/day subcutaneously every other day, 8-10 injections.

- granocyte (lenograstim) 105, 265, and 365 mcg.

- Trace Elements in the following order: zinc, copper, selenium;

- Vitamins A, E, B;

- ribomunyl in two courses of 4 weeks with a one-month interval.

Replacement therapy:

- leukocyte mass 3 ml/kg of body weight, course of 1-2-3 injections (as needed);

- cytokines - roncoleukin administered at 0.25-1 mg (25 thousand - 1 million IU) in 200 - 400 ml of 0.9% sodium chloride solution intravenous infusion.

Adjunctive therapy

Extracorporeal immunocorrection Methods:

- extracorporeal immunopharmacotherapy (ECIPT);

- plasmapheresis;

- Immunosorption.

II. Stage of anti-relapse immunorehabilitation (during remission):

- adaptogens (ginseng, eleutherococcus, etc.);

- plant-derived immunostimulants (immunofan, etc.);

- spa and sanatorium Treatment;

- physiotherapy;

- broad-spectrum immunostimulating Vaccines (ribomunyl, respibron).

The type of immunotherapy (general and local) and its specific method (physical, chemical, biological) are determined by The Nature of the deficiency and its belonging to a particular type of immune system disorder.

The combination of local and general immunocorrective therapy achieves the greatest clinical effect. Combined immunocorrection may include a combination of 3-4 agents and methods with different Mechanisms of action, primarily affecting different Components of the immune system.

The duration of outpatient or inpatient treatment depends on The Nature and severity of the disease and ranges from 3 weeks to 2 months.

Therapy of infectious complications. Various Isolation Methods are used to reduce the patient's contact with microorganisms. Simple methods of preventive isolation include: placing the patient in a separate room with sanitary facilities (a single-patient room); The Use of changing gowns, masks, gloves, and thorough hand washing by the staff; prohibiting patients from eating raw fruits, vegetables, and dairy products, which are potential sources of Gram-negative Bacteria. More complex technologies are aimed at purifying the air around the patient.

Elimination of the etiological factor is possible when the cause of the secondary immunodeficiency is known—such as immunosuppressive effects, occupational agents, etc., which must be removed.

Since secondary immunodeficiencies manifest as infectious complications, antimicrobial therapy plays a key role in their treatment. The choice of drugs depends on the type of microflora and the Specific features of the secondary immunodeficiency. However, combination therapy is often necessary due to the presence of mixed microbial associations. Antiviral drugs that inhibit viral Replication release their Nucleic Acids to induce interferons, and capsid Proteins to activate antibodyogenesis.

Antibacterial therapy. In secondary immunodeficiencies, bacterial infections frequently recur. Treatment includes an initial course and maintenance therapy. The Principles of Rational antibacterial therapy are applied. The duration of antibiotic therapy is 2-3 times longer than the treatment period for ordinary patients. High doses of broad-spectrum Antibiotics, their combinations, and prolonged courses of each drug (up to 10-14 days if effective) are used. Treatment of bacterial infection flares is typically achieved by sequentially administering

2-3 or more courses of antibiotic therapy, with a total duration of at least 4-5 weeks. The duration of treatment with a single drug ranges from 10 to 21 days.

For active nonspecific and semispecific therapy, opportunistic microorganisms are used in the form of heterovaccines consisting of

microbes that colonize the respiratory tract (ribomunyl, IRS-19, respibron), or immunostimulants are used (likopid, polyoxidonium).

An effect similar to vaccines is produced by nucleic acid preparations, in particular, sodium nucleinate derived from Yeast. It reduces T- and B-Cell and IgM deficiencies, increases resistance to many bacterial infections, and has proven effective in chronic parotitis, Chronic Bronchitis, PEPTIC ULCER DISEASE, and in treating the complications of radio- and Chemotherapy.

Among immunomodulatory agents, preparations derived from immune Organs (tactivin, thymalin, myelopid, etc.) are indicated. The choice of agents is determined by the type of immunodeficiency and the impairment of specific immune pathways.

Antifungal therapy. Antifungal drugs are used for therapeutic and prophylactic purposes in patients with secondary immunodeficiencies. Patients with Various Forms of immunodeficiencies have varying susceptibility to fungal infections. In patients with humoral and many combined defects, fungal infections are infrequent; therefore, antifungal drugs (fluconazole, ketoconazole, clotrimazole, itraconazole) are used in prophylactic doses during repeated courses of antibiotics.

Antifungal therapy becomes of paramount importance in the treatment of generalized forms of fungal infection. Such patients may experience Skin and mucosal lesions caused by Candida and Aspergillus species, but severe infections are also possible—especially in AIDS and Cancer—caused by highly pathogenic Histoplasma capsulatum, Coccidioides immitis; phaeohyphomycosis (Curvularia spp., Alternaria spp., etc.), zygomycosis (Rhizopus spp., Mucor spp.), and hyalohyphomycosis (Fusarium spp., etc.) occur rarely in connection with endogenous colonization. In these patients, even non-pathogenic Yeasts can cause fatal infections.

Life-threatening superficial Candida infections, in particular relapsing mucocutaneous candidiasis, are effectively eliminated by imidazole derivatives. Fluconazole or itraconazole (5-10 mg/kg/day) is used to prevent Pneumocystis Pneumonia. Pentamidine (via aerosols and intravenously) is used for the Prevention and treatment of Pneumocystis pneumonia in HIV infection, and dapsone is used in case of intolerance.

Antiviral Therapy is indicated for T-cell and interferon-mediated secondary immunodeficiencies. Prevention of certain viral infections is achieved through vaccination provided that the patient retains The ability to synthesize Antibodies. Their deficiency is accompanied by viral encephalitis and meningitis, and ECHO virus infections.

When treating viral respiratory infections in patients with secondary immunodeficiencies, all standard therapies are employed alongside additional therapeutic or preventive measures to avert complications, tailored to the specific immune defect (such as antibiotics, emergency plasma transfusion, or gamma globulin administration).

An effective therapeutic approach for acute herpetic infections (including genital herpes, proctitis, and pneumonia) is acyclovir (Zovirax) administered at 400 mg orally every 8 hours, with a suppressive dose of 200–400 mg every 12 hours. Its MECHANISM OF ACTION relies on blocking specific viral Enzymes. For herpes simplex and cytomegalovirus (CMV) infections, foscarnet (60 mg/kg IV every 8 hours) and ganciclovir (5 mg/kg IV every 12 hours) are also used, followed by famciclovir (250 mg orally every 8 hours). For severe herpes zoster infections, acyclovir is prescribed at 10 mg/kg IV every 8 hours for 7–14 days; for mild cases, 800 mg orally every 4 hours, famciclovir at 500 mg orally every 8 hours, or valacyclovir at 1 g orally every 8 hours.

Interferon preparations are prescribed as indicated, with dosages varying According to the specific type of immune defect. Interferon exhibits antiviral, immunomodulatory, antiproliferative, and radioprotective properties. METABOLISM/2.html">THE CONCEPT OF the "interferon status" has been established, the assessment of which is based on determining serum interferon levels as well as the production capacity for α-interferon and γ-interferon.

In this context, the interrelation of these components is far more significant than their isolated values (under physiological conditions, serum interferon levels do not exceed 4 IU and consist of a mixture of various interferon types). γ-Interferon can exert both stimulatory and suppressive effects on the inflammatory process, whereas α-interferon is successfully used in Sepsis treatment by actively stimulating T Cells and neutrophils. Human recombinant α2-interferon combined with antioxidants (Viferon) is recommended for treating viral and bacterial infections in newborns and young children (an immunodeficiency risk group); it helps reduce the administration of Blood products and shortens the duration of antibiotic therapy in severe neonatal infections. Interferon Inducers such as cycloferon, amiksin, and neovir are prescribed at a daily dose of 5–8 mg/kg in repeated courses over 5–10 days for protracted infections, including hepatitis, herpes, chlamydia, and campylobacteriosis.

Isoprinosine also exhibits antiviral activity.

Lincomycin inhibits numerous Viruses (such as herpes simplex type 1, encephalomyelitis, etc.).

Antiparasitic therapy. Standard medications and dosages are used in the treatment of parasitic infections in immunocompromised patients.

Toxoplasmosis is most frequently observed in HIV infection. Because Toxoplasma gondii is an intracellular parasite, treatment involves pyrimethamine (100 mg orally on the first day, followed by 75 mg), sulfadiazine (25 mg/kg every 6 hours), or clindamycin (600 mg orally every 6 hours).

Treatment and prevention with IMMUNOGLOBULINS. For antibody deficiencies and secondary hypogammaglobulinemias, the administration of Blood Plasma products and intravenous immunoglobulins serves as the primary method of treatment and infection prevention.

In cases of immunoglobulin (Ig) deficiency (agammaglobulinemia), Igs are administered intravenously in a loading regimen of 400–800 mg/kg of body weight. Octagam is given at 400–800 mg/kg as a bolus; the course consists of a single dose (200 mg/kg) repeated at 3–4 week intervals. Pentaglobin is administered to adults at rates ranging from 0.4 ml/kg/h up to 15 ml/kg/h for 3 days. Native fresh-frozen plasma is used at 10–40 ml/kg, with a course of 1000–2400 ml twice a week. To prevent infection in secondary immunodeficiencies, Ig levels should be maintained at no less than 4–6 g/l (200–800 mg/kg/month of Octagam). Native plasma is administered for the same purpose once a month at 15–20 ml/kg.

Prophylactic immunization. According to the WHO memorandum (1995), live vaccines must not be administered in severe cases of immune deficiency:

- in secondary hypogammaglobulinemia;

- in acquired immunodeficiencies associated with lymphomas, lymphogranulomatosis, leukemia, and other malignancies of The Immune System;

- during immunosuppressive and Radiation therapy.

The efficacy of vaccination in children with secondary immunodeficiencies is low due to quantitative antibody deficiency resulting from immunoglobulin insufficiency, though immunization with toxoids remains safe.