IMMUNOLOGY TEXTBOOK - Mercury Podillia 2013

ACQUIRED IMMUNODEFICIENCY STATES

Secondary Immunodeficiencies in Chronic Recurrent Furunculosis

Chronic recurrent furunculosis (CRF) is characterized by a persistently relapsing clinical course and poor response to antibacterial and symptomatic therapy.

A furuncle develops As a result of acute purulent-necrotic inflammation of the Hair follicle and surrounding Tissues, representing a complication of staphylococcal osteofolliculitis. Furuncles may occur singly or in multiples (furunculosis). When furuncles recur frequently, the condition is diagnosed as chronic recurrent furunculosis.

Immunological mechanisms. In CRF, impairments are detected across virtually all links of The Immune System. In 50–70% of CRF patients, defects occur in the phagocytic branch of Immunity, manifested by decreased intracellular bactericidal activity of neutrophils and impaired Generation of reactive oxygen species. Defects that disrupt granulocyte migration can lead to chronic bacterial infections. Impaired pathogen disposal within phagocytes—such as NADPH oxidase deficiency—results in incomplete phagocytosis and a severe Clinical presentation.

Low serum iron levels may contribute to a reduced efficacy of oxidative killing of pathogenic microorganisms by neutrophils. Patients with CRF exhibit a decreased total count of peripheral Blood T-lymphocytes. In 20–50% of CRF patients, CD4+ lymphocyte counts are lowered, whereas in 10–60%, CD8+ lymphocyte counts are elevated.

In 30–40% of CRF patients, B-lymphocyte counts are decreased. Evaluation of humoral immunity components in patients with furunculosis reveals various dysimmunoglobulinemias. The most common findings are reduced IgG and IgM levels, alongside a decrease in immunoglobulin avidity.

It follows from the above that alterations in the immune status of CRF patients are diverse: 30–50% exhibit changes in lymphocyte subpopulation composition, 50–70% in the phagocytic branch, and 30–60% in the humoral branch of the immune system. Depending on the severity of these immune status alterations, patients with CRF can be stratified into three groups: mild, moderate, and severe, which correlates with the clinical course of the disease. In mild furunculosis, the majority of patients (70%) have immune parameters within the normal range. In moderate and severe cases, alterations predominantly involve the phagocytic and humoral Branches of the immune system.

Regimen and types of immunotherapy. During an acute flare-up of CRF, local therapy is required, involving the Treatment of furuncles with antiseptic solutions, antibacterial ointments, and hypertonic saline; if furuncles are localized in the HEAD and Neck region or present in multiple numbers, antibacterial therapy should be administered taking into account pathogen susceptibility. At any stage of the disease, correction of identified underlying pathology is essential (sanation of chronic infection foci, treatment of gastrointestinal and endocrine disorders, etc.).

If latent sensitization is detected in CRF patients or if clinical manifestations of allergy are present, antihistamines must be added to the treatment regimen, a hypoallergenic diet prescribed, and surgical interventions performed with premedication using hormonal and antihistamine drugs.

During the acute phase of CRF, The Use of the following immunomodulators is recommended:

✵ in the presence of phagocytic immunity alterations, polyoxidonium is indicated at 6–12 mg intramuscularly for 6–12 days;

✵ for decreased immunoglobulin avidity—galavit 100 mg every other day intramuscularly, 15 injections;

✵ for decreased B-lymphocyte levels or altered CD4/CD8 ratio shifting toward a lower immunoregulatory index (IRI), myelopid is indicated at 3 mg intramuscularly daily or every other day for 5–7 days;

✵ for decreased IgG levels against the Background of a severe CRF flare-up with clinical inefficacy of galavit, intravenous immunoglobulin preparations (octagam, gabriglobin, intraglobin) are employed.

Immunorehabilitation. During the remission period, the following immunomodulators may be prescribed:

✵ polyoxidonium 6–12 mg intramuscularly for 6–12 days in the presence of phagocytic immunity alterations;

✵ licopid 10 mg orally daily for 10 days, then every other day for 2–3 weeks, in the presence of defects in reactive oxygen species generation;

✵ galavit 100 mg, 15 intramuscular injections, for decreased immunoglobulin avidity or protracted, persistently recurring furunculosis;

✵ intravenous immunoglobulin preparations (octagam, gabriglobin, intraglobin) for persistent relapses of CRF against the background of humoral immunity alterations;

✵ combined Immunomodulatory therapy: a) during furunculosis flare-ups, polyoxidonium may be prescribed, followed by The addition of galavit if immunoglobulin avidity defects are detected; b) during furunculosis relapses—tactivin, myelopid (1 ml each) for 7 days; then tactivin every 3 days for 2–3 weeks;

✵ topically to affected areas—Applications of 33% dimexide with 0.1% iodine or 0.05% chlorhexidine. Medical immunocorrection is beneficially combined with non-pharmacological Methods that provide beneficial immunomodulation: ultraviolet and laser blood irradiation, plasmapheresis, and UHF therapy.

As an example of a phagocytic-type immunodeficiency, we present the case history of patient R., 28 years old, who underwent treatment in the surgical department with a Diagnosis of chronic recurrent (streptococcal) furunculosis.

Patient R., 28 years old (Table 72), complains of pustules on her torso and limbs. These pustules first appeared 3 years ago; flare-ups occur 3–4 times a year, with the last flare-up lasting 2 weeks. The patient received doxycycline 100 mg/day for 10 days, with a poor response of the Skin lesions. The patient was diagnosed with chronic recurrent furunculosis, phagocytic-type immunodeficiency (D84.9).

Bacteriological examination OF the furuncle content revealed hemolytic streptococcus.

Class="center">Table 72. Immunogram of patient R., 28 years old

Immunogram Conclusion. The immunogram reveals signs of dysregulation in the T-Cell link with a relative decrease in the T-helper population; IRI is 0.94. B-lymphocyte function and immunoglobulin production are unimpaired. NK cells are within normal limits. A decrease in granulocyte activity is observed. There is a significant reduction in the engulfing capacity of neutrophils (phagocytic index, phagocytic number), spontaneous bactericidal activity (NBT test sp. < 10), the functional reserve of the oxidation-reduction potential of phagocytes (NBT test res. < 16), alongside an elevated complement level (CH-50). Signs of intoxication are present (ESR).

Conclusion: phagocytic immunodeficiency state - deficiency in the engulfing function and digestive activity of neutrophils. Signs of a chronic inflammatory process accompanied by intoxication and reduced reactivity of the immune system.

Final diagnosis: chronic recurrent (streptococcal) furunculosis. Phagocytic-type immunodeficiency (D 84.9)

Immunotropic therapy:

1) specific antibacterial therapy (immunotherapy with normal human immunoglobulin 4.5 mL i.m. every other day for 10 days);

2) etiotropic antibacterial therapy - spiramycin 500 mg twice daily;

3) topical - Triderm applied to the affected areas twice daily for 2 weeks;

4) polyoxidonium 6 mg i.m. twice a week for 20 days, or galavit 100 mg every other day i.m. for 20 days;

5) probiotic Linex 2 caps. 3 times daily for 20 days.

Immunorehabilitation:

6) Viferon 150 thousand IU, rectally every other day, 10 administrations;

7) sodium nucleinate 0.1 g 3 times daily for 30 days.