A member presented a medical case:
Urinary tract and respiratory tract infections in a 21 year-old who may have an immune disorder.
21 year-old man who has had 8 months of upper respiratory and urinary tract symptoms, felt caused by infections, and may have an immune system disorder on test results, looking for a clear diagnosis.
Close details
Patient demographics
Gender
Age
21
Ethnicity
East Asian
Occupation
Translator-teacher
Chief complaint or problem to solve
March 19. 2015. Flu-like symptoms post sexual exposure. Night sweats 1 day after expoaure. Subfebrile temperature. Dysuria, Itchy urination, a mild genital ulcer, angular cheilitis. Started mild consistent hematuria and with occasional protenuria followed by upper respiratory tract infection. Recurrent upper respiratory tract infections with strep a. Immune dysregulation: elevated cd8 and decreased cd4 and cd3. Elevated IgM and IgA, decreased IgG. Tests: HIV ELISA - negative 6 week, 3 and 5 month post possible exposure. HIV rapid test 3 and 5 month post exposure - negative HIV pcr rna plasma: 2 month post possible exposure - negative
Case history
March 19. 2015. Flu-like symptoms post sexual exposure. Night sweats 1 day after expoaure. Subfebrile temperature. Dysuria, Itchy urination, a mild genital ulcer, angular cheilitis. Started mild consistent hematuria and with occasional protenuria followed by upper respiratory tract infection. Recurrent upper respiratory tract infections with strep a. Immune dysregulation: elevated cd8 and decreased cd4 and cd3. Elevated IgM and IgA, decreased IgG. Tests: HIV ELISA - negative 6 week, 3 and 5 month post possible exposure. HIV rapid test 3 and 5 month post exposure - negative HIV pcr rna plasma: 2 month post possible exposure - negative
PMH: no diagnosis
Meds: none
Allergies:none
Other tests: March 19. 2015. Flu-like symptoms post sexual exposure. Night sweats 1 day after expoaure. Subfebrile temperature. Dysuria, Itchy urination, a mild genital ulcer, angular cheilitis. Started mild consistent hematuria and with occasional protenuria followed by upper respiratory tract infection. Recurrent upper respiratory tract infections with strep a. Immune dysregulation: elevated cd8 and decreased cd4 and cd3. Elevated IgM and IgA, decreased IgG. Tests: HIV ELISA - negative 6 week, 3 and 5 month post possible exposure. HIV rapid test 3 and 5 month post exposure - negative HIV pcr rna plasma: 2 month post possible exposure - negative
Xrays: Chest x-ray: negative for TB
Procedures: No
Purpose of case discussion
Diagnostic dilemma: "What's the diagnosis?"
Supplemental Materials

Dr. Michael Sanders
Internal Medicine - Pulmonology
4 doctors agree

In brief: Possible vasculitis

I would have an ANCA panel checked, especially with you saying you're having hematuria and proteinuria.
There are a few conditions we refer to as pulmonary renal syndromes and they are all a type of vasculitis. Some of the names are Wegener's and Goodpasture's.

In brief: Possible vasculitis

I would have an ANCA panel checked, especially with you saying you're having hematuria and proteinuria.
There are a few conditions we refer to as pulmonary renal syndromes and they are all a type of vasculitis. Some of the names are Wegener's and Goodpasture's.
Dr. Michael Sanders
Dr. Michael Sanders
Thank
Dr. Saptarshi Bandyopadhyay
Internal Medicine - Hospital-based practice
3 doctors agree

In brief: Idiopathic CD4+ lymphocytopenia?

There is a very rare condition called Idiopathic CD4+ Lymphocytopenia (ICL) which mimics the CD8/CD4 inversion seen in HIV positive disease but without PCR-detectable HIV.
Depending on his absolute CD4 count & T-cell percentage, he may meet the diagnostic criteria for this disease. The cause is "idiopathic" - ie, unknown. ICL seems to be more indolent than HIV (slower drop in CD4 counts) but susceptible to the same opportunistic infections. Interestingly, lymphomas & autoimmune diseases are more common in ICL, which may explain the hematoproteinuria (or it could be explained by infection & gamma globulinuria). I'd be curious to know if immunodeficiency runs in his family, though ICL does NOT seem to have a genetic predisposition. Nutritional & metabolic deficiencies, I presume, have been ruled out in this case (angular cheilitis - severe B12 or purine deficiency?). I also presume that his platelet count & Hgb are within the reference range, excluding myelodysplastic diseases like MM.

In brief: Idiopathic CD4+ lymphocytopenia?

There is a very rare condition called Idiopathic CD4+ Lymphocytopenia (ICL) which mimics the CD8/CD4 inversion seen in HIV positive disease but without PCR-detectable HIV.
Depending on his absolute CD4 count & T-cell percentage, he may meet the diagnostic criteria for this disease. The cause is "idiopathic" - ie, unknown. ICL seems to be more indolent than HIV (slower drop in CD4 counts) but susceptible to the same opportunistic infections. Interestingly, lymphomas & autoimmune diseases are more common in ICL, which may explain the hematoproteinuria (or it could be explained by infection & gamma globulinuria). I'd be curious to know if immunodeficiency runs in his family, though ICL does NOT seem to have a genetic predisposition. Nutritional & metabolic deficiencies, I presume, have been ruled out in this case (angular cheilitis - severe B12 or purine deficiency?). I also presume that his platelet count & Hgb are within the reference range, excluding myelodysplastic diseases like MM.
Dr. Saptarshi Bandyopadhyay
Dr. Saptarshi Bandyopadhyay
Thank
Dr. John Chiu
Internal Medicine - Allergy & Immunology
3 doctors agree

In brief: Immune deficiency

Would like to know how low the IgG is .
In this case I would consider a functional immune evaluation by studying his pre and post Pneumococcal 23, and Td immune response if the IgG is only borderline low. If it is very low, then IVIG is likely indicated (I have yet had a patient who can tolerate SCIG). I would also like to find out what the urinary culture results are. If they have not been revealing , then a PCR bacterial analysis would be indicated. The mucosal ulcerations is suggestive of an autoimmune disorder and I would include Reiter's syndrome in my diagnosis.

In brief: Immune deficiency

Would like to know how low the IgG is .
In this case I would consider a functional immune evaluation by studying his pre and post Pneumococcal 23, and Td immune response if the IgG is only borderline low. If it is very low, then IVIG is likely indicated (I have yet had a patient who can tolerate SCIG). I would also like to find out what the urinary culture results are. If they have not been revealing , then a PCR bacterial analysis would be indicated. The mucosal ulcerations is suggestive of an autoimmune disorder and I would include Reiter's syndrome in my diagnosis.
Dr. John Chiu
Dr. John Chiu
Thank
2 doctors agree

In brief: See below

It may me not only one, but combination of causes, so consider to test for other STD's: Chamidia, gonorrhea, syphilis, Herpes.
Also check for EBV and Candida. Genital Ulcer in combination with URT d-se described in some cases of Salmonella typhi. Rule out aphthosis, such as in Behcet’s disease or Crohn’s disease. Best!

In brief: See below

It may me not only one, but combination of causes, so consider to test for other STD's: Chamidia, gonorrhea, syphilis, Herpes.
Also check for EBV and Candida. Genital Ulcer in combination with URT d-se described in some cases of Salmonella typhi. Rule out aphthosis, such as in Behcet’s disease or Crohn’s disease. Best!
Dr. Ecaterina Sartina
Dr. Ecaterina Sartina
Thank
2 comments
Dr. Michael Kleerekoper
I am not sure I agree. You list a long stream of possible issues but I don't see how the doctor will focus on every one of the concerns. Michael Kleerekoper
Dr. Ayaz Samadani
I would check for infections related with immune disorder
Dr. James Lin
Urology
1 doctor agrees

In brief: Here are some...

The urinary & respiratory symptoms may not be related.
However, to sort all the potentially related things out correctly for good/right care can not be that hard by following suggestion/instruction in articles listed in http://formefirst.com/onDealSickness.html. Key points are judicious symptomatic care + differential diagnosis as suggested + realistic understanding & acceptance of life.

In brief: Here are some...

The urinary & respiratory symptoms may not be related.
However, to sort all the potentially related things out correctly for good/right care can not be that hard by following suggestion/instruction in articles listed in http://formefirst.com/onDealSickness.html. Key points are judicious symptomatic care + differential diagnosis as suggested + realistic understanding & acceptance of life.
Dr. James Lin
Dr. James Lin
Thank
1 doctor agrees

In brief: Have you been tested for syphilis?

You have a difficult diagnostic situation.
Syphilis is a condition that can present with a complex set of signs and symptoms. I suggest that you get tested for this if you haven't already.

In brief: Have you been tested for syphilis?

You have a difficult diagnostic situation.
Syphilis is a condition that can present with a complex set of signs and symptoms. I suggest that you get tested for this if you haven't already.
Dr. Spencer Long
Dr. Spencer Long
Thank
Dr. Amrita Dosanjh
Pediatrics - Pulmonology
1 doctor agrees

In brief: UA

I would suggest a UA and microscopic examination, IgE levels and a review of atopic history.
Additional testing can include antibody levels following vaccination.

In brief: UA

I would suggest a UA and microscopic examination, IgE levels and a review of atopic history.
Additional testing can include antibody levels following vaccination.
Dr. Amrita Dosanjh
Dr. Amrita Dosanjh
Thank
1 comment
Dr. George Klauber
Immune disorders usually present well before age 20 - 21 & thus would advise thorough work-up by a pulmonologist. Hopefully has had urinalysis to rule out urinary infection. Need to describe urinary symptoms. Could they be related to medication given for respiratory symptoms or respiratory symptoms can be caused by nitrofurantoin given for UTIs.
Dr. Tom Klein
Aesthetic Medicine

In brief: Answer

Yes

In brief: Answer

Yes
Dr. Tom Klein
Dr. Tom Klein
Thank
Dr. Julan Crane
Pediatrics

In brief: Immunity

Need more information

In brief: Immunity

Need more information
Dr. Julan Crane
Dr. Julan Crane
Thank
Dr. Michael Kleerekoper
Internal Medicine - Endocrinology

In brief: Diagnosis

Having read your important information it is necessary to first see your Primary doctor who will take your medical history, examine you, and order laboratory and imaging studies.
It is very likely that the doctor will refer you to specialists related to the issues your primary doctor found. Please let me know how things go and we can discuss it further if needed.

In brief: Diagnosis

Having read your important information it is necessary to first see your Primary doctor who will take your medical history, examine you, and order laboratory and imaging studies.
It is very likely that the doctor will refer you to specialists related to the issues your primary doctor found. Please let me know how things go and we can discuss it further if needed.
Dr. Michael Kleerekoper
Dr. Michael Kleerekoper
Thank
Get help from a real doctor now
Dr. Christopher Crosby
Board Certified, Dermatology
13 years in practice
93K people helped
Continue
111,000 doctors available
Read more answers from doctors