Monday, 14 July 2014

Common Variable Immune Deficiency

Common Variable Immune Deficiency

Common Variable Immune Deficiency (CVID) is a frequently diagnosed immunodeficiency, especially in adults, characterized by low levels of serum immunoglobulins and antibodies, which causes an increased susceptibility to infection. While CVID is thought to be due to genetic defects, the exact cause of the disorder is unknown in the large majority of cases.

Overview of Common Variable Immune Deficiency

Compared to other human immune defects, CVID is a relatively frequent form of primary immunodeficiency, found in about 1 in 25,000 persons; this is the reason it is called “common.” Thedegree and type of deficiency of serum immunoglobulins, and the clinical course, varies from patient to patient, hence, the word “variable.” In some patients, there is a decrease in both IgG and IgA; in others, all three major types of immunoglobulins (IgG, IgA and IgM) are decreased. In still others there are defects of the T-cells, and this may also contribute to increased susceptibility to infections as well as autoimmunity, granulomata and tumors.
To be sure that CVID is the correct diagnosis, there must be evidence of a lack of functional antibodies and other possible causes of these immunologic abnormalities must be excluded. Frequent and/or unusual infections may first occur during 
early childhood
, adolescence or adult life. Patients with CVID also have an increased incidence of autoimmune or inflammatory manifestations, granulomata and an increased susceptibility to cancer when compared to the general population. Sometimes it is the presence of one of these other conditions that prompts an evaluation for CVID.
The medical terms for absent or low blood immunoglobulins are agammaglobulinemia and hypogammaglobulinemia, respectively. Due to the late onset of symptoms and diagnosis, other names that have been used in the past include “acquired” agammaglobulinemia, “adult onset” agammaglobulinemia, or “late onset” hypogammaglobulinemia. The term “acquired immunodeficiency” refers to a syndrome caused by the AIDS virus (HIV) and should not be used for individuals with CVID, as these disorders are very different.

Clinical Features of Common Variable Immune Deficiency


Both males and females may have CVID. In the majority, the diagnosis is not made until the third or fourth decade of life. However, about 20% of patients have symptoms of the disease or are found to be immunodeficient in childhood. Because the immune system is slow to mature, the diagnosis of CVID is generally not made until after the age of 4.
The usual presenting features of CVID are recurrent infections involving the ears, nasal sinuses, bronchi (breathing tubes) and lungs (respiratory tract). When the lung infections are severe and occur repeatedly, permanent damage with widening and scarring of the bronchial tree, a condition termed bronchiectasis, may develop.
The organisms commonly found in these sinopulmonary infections are bacteria that are widespread in the population and that often cause pneumonia(Hemophilus influenzae, pneumococci, and staphylococci) even in people who do not have CVID. The purpose of treatment of lung infections is to prevent their recurrence and the accompanying chronic and progressive damage to lung tissue. A regular cough in the morning and the production of yellow or green sputum may suggest the presence of chronic bronchitis or bronchiectasis.

Patients with CVID may also develop enlarged lymph nodes in the neck, the chest or abdomen. The specific cause is unknown, but enlarged lymph nodes may be caused by infection, an abnormal immune response or both. Similarly, enlargement of the spleen is relatively common, as is enlargement of Peyer’s patches which are collections of lymphocytes in the walls of the intestine.

In some cases, other collections of inflammatory cells, called granulomas, can be found in lungs, lymph nodes, liver, skin or other organs. These are largely composed of cells called monocytes and macrophages. They may be a response to an infection, but the cause is not really known.
Although patients with CVID have depressed antibody responses and low levels of immunoglobulins in their blood, some of the antibodies that are produced by these patients may attack their own tissues (autoantibodies). These autoantibodies may attack and destroy blood cells, like red cells, white cells or platelets. Although, most individuals with CVID present first with recurrent bacterial infections, in about 20% of cases the first manifestation of the immune defect is a finding of very low platelets in the blood or severe anemia due to destruction of red cells. Autoantibodies may also cause other diseases such as arthritis or endocrine disorders, like thyroid disease.
Gastrointestinal complaints such as abdominal pain, bloating, nausea, vomiting, diarrhea and weight loss are not uncommon in CVID. Careful evaluation of the digestive organs may reveal malabsorption of fat and certain sugars or inflammatory bowel disease. If a small sample (biopsy) of the bowel mucosa is obtained, characteristic changes may be seen. These changes are helpful in diagnosing the problem and treating it. In some patients with digestive problems, a small parasite called Giardia lamblia has been identified in the biopsies and in the stool samples. Eradication of these parasites by medication may eliminate the gastrointestinal symptoms.

Some patients with CVID who may not be receiving optimal immunoglobulin replacement therapy may also develop a painful inflammation of one or more joints. This condition is called polyarthritis. In the majority of these cases, the joint fluid does not contain bacteria. To be certain that the arthritis is not caused by a treatable infection; the joint fluid may be removed by needle aspiration and studied for the presence of bacteria. In some instances, a bacterium called Mycoplasma may be the cause and can be difficult to diagnose. The typical arthritis associated with CVID may involve the larger joints such as knees, ankles, elbows and wrists. The smaller joints, like the finger joints, are rarely affected. Symptoms of joint inflammation usually disappear with adequateimmunoglobulin therapy and appropriate antibiotics. In some patients, however, arthritis may occur even when the patient is receiving adequate immunoglobulin replacement.
Finally, patients with CVID may have an increased risk of cancer, especially cancer of the lymphoid system or gastrointestinal tract.

Diagnosis of Common Variable Immune Deficiency

CVID should be suspected in children or adults who have a history of recurrent bacterial infections involving ears, sinuses, bronchi and lungs. The characteristic laboratory features include low levels of serum immunoglobulins, including IgG, often IgA and sometimes IgM. Another part of the diagnosis of CVID is to determine if there is a lack of functional antibody. This is done by measuring serum levels of antibody, against vaccine antigens such as tetanus or diphtheria, measles, mumps, or rubella, hemophilus or pneumococcal polysaccharide. Patients with CVID have very low or absent antibody levels to most of these vaccines.
Immunization with killed vaccines is used to measure antibody function, and this functional testing is crucial prior to beginning treatment. These tests also help the physician decide if the patient will benefit from immunoglobulin replacement therapy and can be key in obtaining insurance authorization for this therapy. The number of B- and T-lymphocytes may also be determined and their function tested in tissue cultures.

Genetics and Inheritance of Common Variable Immune Deficiency

Patients with CVID usually have normal numbers of the cells that produce antibody (B-lymphocytes), but these cells fail to undergo normal maturation into plasma cells, the cells capable of making the different types of immunoglobulins and antibodies for the blood stream and secretions.
The genetic causes of CVID are largely unknown, although recent studies have shown the involvement of a small group of genes in a few patients. These include inducible co-stimulatory (ICOS) and a few other proteins on B-cells. These appear to be causes of autosomal recessive CVID. Mutations in a cell receptor (TACI) needed for normal growth and regulation of B-cells have also been found in about 8% of patients with CVID. However, a causative role of TACI mutations in this immune defect is not yet clear, since some of these mutations can be found in people with normal immunoglobulins. As these are very rare gene defects for the most part, genetic testing is not yet required or indicated for the diagnosis of CVID.

Treatment of Common Variable Immune Deficiency

The treatment of CVID is similar to that of other disorders with low levels of serum immunoglobulins. In the absence of a significant T-lymphocyte defect or organ damage, immunoglobulin replacement therapy almost always brings improvement of symptoms. Immunoglobulin is extracted from a large pool of human plasma; it consists mostly of IgG and contains all the important antibodies present in the normal population. (See chapter titled “Immunoglobulin Therapy and Other Medical Therapies for Antibody Deficiencies.”)
Patients with chronic sinusitis or chronic lung disease may also require long-term treatment with broad-spectrum antibiotics. If mycoplasma or other chronic infections are suspected, antibiotics specific for those organisms may be indicated. If bronchiectasis has developed, a daily pulmonary toilet regimen (chest physiotherapy and postural drainage) may be needed to mobilize the secretions from the lungs and bronchi and make them easier to cough up.
Patients with gastrointestinal symptoms and malabsorption should be evaluated for the presence of Giardia lamblia, rotavirus and a variety of other gastrointestinal infections. In some cases inflammatory bowel disease is found, and this is treated by the medications normally prescribed for patients who are non-immunodeficient. Maintaining a balance between the immunosuppression used to control the autoimmune process while avoiding compounding the defects of the underlying primary immunodeficiency requires close cooperation between the patient and the various specialists involved in their care. (See chapter titled “Autoimmunity in Primary Immunodeficiency.”)
If autoimmune or inflammatory disease, granulomas, or tumors develop, the treatment is usually the same as would be given to a person with a normal immune system. However when patients with CVID have these complications, there is a tendency for them to be less responsive to therapy. Regular checkups including lung function are recommended.

Expectations for Patients with Common Variable Immune Deficiency

Immunoglobulin replacement therapy combined with antibiotic therapy has greatly improved the outlook of patients with CVID. The aim of the treatment is to keep the patient free of infections and to prevent the development of chronic inflammatory changes in tissues. The outlook for patients with CVID depends on how much damage has occurred to their lungs or other organs before the diagnosis is made and treatment with immunoglobulin replacement therapy started, as well as how successfully infections can be prevented in the future by using these therapies. The development of autoimmune disease, inflammatory problems, granulomata or malignancy can have a significant impact on the quality of life and response to treatment.


Top 5 Signs of Iron Deficiency

Top 5 Signs of Iron Deficiency


Iron is a highly important component in the human body that helps it function properly. Iron deficiency can sometimes be fatal. The following are some of the signs of iron deficiency anemia:
 
1. Fatigue: Fatigue is one of the most common and easily identifiable signs of iron deficiency anemia. Hemoglobin carries oxygen to the tissues. However, lack of hemoglobin, which is rich in iron, means that the body's ability to carry oxygen to the tissues is reduced, resulting in a state of extreme tiredness and fatigue. Signs of iron deficiency in children are lack of endurance during physical activity and a state of tiredness.


2. Shortness of breath or palpitation: If the process of transfer of oxygen to the tissues does not function properly, the heart has to work harder, resulting in shortness of breath and fatigue. The patient looks weak and experiences quick changes in heart rate or palpitation. Lack of endurance during exercise and increased palpitation are common signs of an iron deficiency.


3. Paleness: Paleness is one of the easily recognizable signs of iron deficiency anemia. A person who lacks the required number of red blood cells which carry oxygen to different parts of the body looks pale. More than normal blood loss during menstruation can lead to iron deficiency in women.


4. Pica or Pagophagia: Is a state in which the patient experiences extreme craving for the consumption of unusual products such as non-food items. Patients might develop a craving for ice, paint, cement, sand, or starch. Patients often experience a state of compulsive ice consumption -- one of the leading signs and symptoms of iron deficiency. A patient afflicted with Pagophagia craves iced drinks or ice.


5. Alopecia or hair loss: Alopecia is one of the most noticeable signs and symptoms of iron deficiency. Though other factors also contribute to alopecia, it is commonly associated with an iron and zinc deficiencyExcessive hair loss or baldness can indicate iron deficiency anemia. Adequate doses of iron will help control hair loss considerably.

Is iron deficiency anemia fatal?

There are many conditions in Western industrialised societies today that were unheard of, or at least very rare, just a century ago. The same conditions are still unheard of in primitive peoples who do not have the 'benefits' of our knowledge. There is a very good reason for this: They eat what Nature intended; we don't. The diseases caused by our incorrect and unnatural diets are those featured on these pages.

Introduction

If there is a large intake of 'anti-nutrients' such as phytate, dietary fibre and tannins, which impair the absorption of iron,[i] and a low intake of flesh foods (another result of the 'healthy' diet-heart recommendations), there is a real risk of iron deficiency anaemia. Twenty years ago sub-optimal iron intakes were already being found in Britain, USA, Canada and South Africa.[ii]

Iron deficiency anemia is the most common type of anemia. It is a condition in which blood lacks adequate healthy red blood cells, which carry oxygen to tissues. As the name implies, iron deficiency anemia is due to insufficient iron. Your body needs the element iron to make hemoglobin, a substance in red blood cells that enables them to carry oxygen.

Iron deficiency anaemia is common, especially in women. One in five women and half of all pregnant women are iron deficient. Lack of iron in your diet is the most common cause of iron deficiency anaemia, but there are other causes as well.

Complications

Mild iron deficiency anemia usually doesn't cause complications; however, if it isn't corrected, iron deficiency anemia can lead to serious health problems, such as:
  • Heart problems. Your heart has work harder pumping more blood to compensate for the lack of oxygen in the blood when you're anemic. In people with coronary artery disease in which the arteries that feed the heart are narrowed anemia can lead to the chest pain called angina. Angina is caused by insufficient oxygen reaching the heart muscle. Iron deficiency anemia may lead to a rapid or irregular heartbeat.
  • Problems during pregnancy. If you are pregnant, severe iron deficiency anemia can cause premature births and low birth weight babies.
  • Growth problems in infants. As well as anemia, delayed growth is common in infants and childrenwith severe iron deficiency. If it not corrected, iron deficiency anemia can cause physical and mental delays in infants and children. Iron deficiency anemia is associated with an increased susceptibility to infectious diseases.

Signs and symptoms

The symptoms of any form of anemia are:
  • fatigue, which may often be quite extreme,
  • overall weakness,
  • shortness of breath,
  • frequent and lasting headaches,
  • light-headedness,
  • pale skin and cold hands and feet.
Occasionally, people with iron deficiency anemia experience restless legs syndrome. Additional symptoms found in iron deficiency are:
  • inflammation or soreness of your tongue
  • Brittle nails
  • Unusual cravings for non-nutritive substances, such as pure starch or soil
  • Poor appetite, especially in infants and children.
Initially, iron deficiency anemia can be so mild that it goes unnoticed. But as the body becomes more deficient in iron and anemia worsens, the signs and symptoms intensify. If you or your child develops signs and symptoms that suggest iron deficiency anemia, your diet may be at fault.

Dietary causes of iron deficiency anemia

Your body needs a supply of oxygenated blood to function. Oxygenated blood helps give your body its energy and your skin a healthy glow. It is the red blood cells called erythrocytes that carry oxygen from your lungs, by way of your bloodstream, to your brain and the other organs and tissues.

Red blood cells contain an iron-rich substance called haemoglobin. Just as rust is red, so it is the iron the haemoglobin in red blood cells that give blood its colour. Rust is oxidized iron. The iron in hemoglobin carries oxygen from your lungs to all parts of your body. Iron deficiency leads to inadequate amounts of hemoglobin. Without enough hemoglobin, red blood cells are smaller and paler than normal and they can't carry as much oxygen to your tissues.

Your body gets the iron it needs from the foods you eat. Examples of iron-rich foods include liver, red meat, egg yolks, dairy products or iron-fortified foods. For proper growth and development, infants and children need iron from their diet, too. There are also plants which contain iron, but many of these foods that are apparently rich in iron are not good providers. Many such foods contain antinutrients which bind with the iron so that you cannot absorb it from your food. The worst offenders are the cereals, particularly wholemeal and soy, which contain phytic acid. It is the bran in cereals that contains the phytic acid.

Other dietary causes of anemia

The other major cause of anemia is a lack of vitamin B12. In this case it is called Pernicious Anemia and is often fatal. Vitamin B12 is also needed for the body to manufacture hemoglobin. Not surprisingly, extreme vegetarianism, if practised without sufficient knowledge is another major cause of anemia. Vitamin B12 works in conjunction with another B vitamin: folic acid. The two are needed together. If folic acid is taken when the body is deficient in vitamin B12, this can be very dangerous as the folic acid can mask the vitamin B12 deficiency until it becomes too late to prevent death.
Non-dietary causes of iron deficiency anemia include:
  • Menstruation. Women with heavy periods are at risk of iron deficiency anemia because they lose a lot of blood during menstruation and, of course the iron in that blood, which has to be replaced.
  • Ulcers and tumors. Long-term blood loss from any cause within the body — peptic ulcer, a kidney orbladder tumor, a colon polyp, ulcerative colitis, colorectal cancer, or uterine fibroids — can cause iron deficiency anemia. Blood lost from within the body may show up in your urine or stools, producing black or bloody stools. Inform your doctor if you notice blood in your urine or stools.
  • An inability to absorb iron. Intestinal disorders such as Crohn's disease or celiac disease, reduce the intestine's ability to absorb nutrients from digested food, can lead to iron deficiency anemia. If part of your small intestine has been bypassed or removed surgically, that may affect your ability to absorb iron and other nutrients.
  • Prescription drugs. The regular use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can cause gastrointestinal bleeding. These should always be taken with a meal, to prevent this happening. Stomach acid blockers called proton pump inhibitors can also lead to iron deficiency anemia, although this is unusual. Your body needs stomach acid, which these products suppress, to convert dietary iron into a form that can readily be absorbed by the small intestine.
  • Pregnancy. Iron deficiency anemia occurs in many pregnant women because they are eating for two — not only is their own blood volume increased it is a source of hemoglobin for the growing fetus. A fetus needs iron to develop red blood cells, blood vessels and muscle.
  • Infancy and childhood. Children need extra iron during growth spurts, because iron is also important for muscle development. If your child isn't eating a diet rich in animal products such as red meat and liver, he or she may be at risk of anemia.

Treatment

Once you become deficient in iron to the point you develop anemia, increased intake of iron-rich foods is usually all that is needed. Doctors may recommend a daily multivitamin containing iron or iron tablets such as prescription ferrous sulphate. These oral iron supplements are usually best absorbed in an empty stomach; however there are risks: iron can irritate your stomach, and it is also possible to overdose on iron taken in this way. iron supplements can also cause constipation. Iron almost always turns stools black. While this is a harmless side effect, it does mimic the effects of a bleeding colon which could be caused by a tumor. If you have very dark or black stools, you should see your doctor.

Prevention

You can help prevent iron deficiency anemia by eating foods from animal sources which are rich in iron. Eating iron-containing foods is particularly important for people who have higher iron requirements, such as children and menstruating or pregnant women.

Foods rich in iron include liver, red meat, seafood, poultry and eggs. Meat sources of iron are easily absorbed by your body.

Some plant-based foods also contain iron, although they're less easily absorbed. Among the best are iron-fortified cereals, breads and pastas, but they must not be wholemeal or be eaten with bran. Beans and peas, dark green leafy vegetables such as spinach and raisins, nuts, and seeds also contain iron, but again the iron is not well absorbed into the body.

Iron deficiency (sideropenia or hypoferremia) is one of the most common of the nutritional deficiencies.[1][2] Iron is present in allcells in the human body, and has several vital functions. Examples include as a carrier of oxygen to the tissues from the lungs as it's a key component of the hemoglobin protein acting as a transport medium for electrons within the cells in the form of cytochromes, and as an integral part of enzyme reactions in various tissues. Too little iron can interfere with these vital functions and lead to morbidityand death.
The eventual consequence of iron deficiency is iron deficiency anemia where the body's stores of iron have been depleted and the body is unable to maintain levels of haemoglobin in the blood. Children and pre-menopausal women are the groups most prone to the disease.
Total body iron averages approximately 3.8 g in men and 2.3 g in women. In blood plasma, iron is carried tightly bound to the proteintransferrin. There are several mechanisms that control human iron metabolism and safeguard against iron deficiency. The main regulatory mechanism is situated in the gastrointestinal tract. When loss of iron is not sufficiently compensated by adequate intake of iron from the diet, a state of iron deficiency develops over time. When this state is uncorrected, it leads to iron deficiency anemia. Before it occurs anemia, the medical condition of Iron Deficiency without anemia is called Latent Iron Deficiency (LID) or Iron-deficient erythropoiesis (IDE).

Signs and symptoms[edit]

Symptoms of iron deficiency can occur even before the condition has progressed to iron deficiency anemia.
Symptoms of iron deficiency are not unique to iron deficiency (i.e. not pathognomonic). Iron is needed for many enzymes to function normally, so a wide range of symptoms may eventually emerge, either as the secondary result of the anemia, or as other primary results of iron deficiency. Symptoms of iron deficiency include:
Continued iron deficiency may progress to anaemia and worsening fatigue. Thrombocytosis, or an elevated platelet count, can also result. A lack of sufficient iron levels in the blood is a reason that some people cannot donate blood.

Can Low Iron Levels Kill You?

Can Low Iron Levels Kill You?
Clams are an iron-rich food that can help you avoid low iron levels. PhotoCredit Digital Vision./Photodisc/Getty Images
Iron is a mineral that plays various important roles in the body, most notably the production of hemoglobin -- the molecule in your blood that delivers oxygen. Iron deficiency is a common occurrence that can result in a condition known as anemia. According to the World HealthOrganization, the true toll of iron deficiency anemia is hidden in the overall death rates in developing countries.

A Silent Killer

The WHO notes that iron deficiency is in fact an epidemic that affects more people than any other health condition. Because the symptoms of iron deficiency can be more subtle than some other other nutritional deficiencies, it is not often credited as a direct cause of death. However, worldwide it is a major cause of ill health, premature death and lost earnings.Poor and developing countries are most affected by iron deficiency.

Iron Deficiency Symptoms

While low levels of iron can negatively affect the body, most physical symptoms do not show up until more severe iron deficiency anemia occurs. Symptoms of iron deficiency anemia include weakness and tiredness, decreased cognitive performance, compromised immune function, brittle nails and hair, headaches, rapid heartbeat, shortness of breath, feeling cold, pale or yellow skin, and pounding in the ears.

Vitamin Deficiencies in Poultry