Recurrent fever, bulging fontanelle and elevated white blood cell

Abstract

This patient presented with fever, seizure and bulging fontanelle when he was 6-month-old.According to the investigations, white blood cell (WBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) increased significantly, and Streptococcus Pneumonia grew in both blood and cerebrospinal fluid (CSF). He responded to standard antibiotic treatment poorly even it lasted long enough.At the same time, the inflammation seemed to be over-activated, the WBC level was still elevated, high fever continued.Thus they thought of primary immunodeficiency and sent blood sample for gene panel testing (Sanger sequencing) but got negative result.At last, they added steroid together with anti-tuberculosis drug therapy, his temperature as well as the intracranial pressure became better ever since.At the age of 1 year and 1 month, he got another Streptococcus Pneumonia meningitis, while he was still on anti-tuberculosis drug therapy and tapering off steroid.At this time, he presented with coarse hair, hypohidrosis and delayed eruption of teeth, which strongly indicated Anhidrotic Ectodermal Dysplasia with Immunodeficiency (EDA-ID). NEMO is the most common gene responsible for EDA-ID and locates on X chromosome.It has a pseudogene named IKBKGP which locates downstream of NEMO. IKBKGP and NEMO share 3-10 exons with the homology of 99.8%, which makes it difficult to find out most real mutations within NEMO with Sanger sequencing.Then they performed PCR with the primer starting upstream of the shared exons.Finally, they found out the pathogenic mutation [c.505G>C(p.A169P)] of NEMO, which has been reported.This finding led us to make the right diagnosis as well as the proper treatment and the prognosis for this patient. Key words: Recurrent infection; Streptococcus Pneumonia meningitis; Primary immunodeficiency; Anhidrotic ectodermal dysplasia with immunodeficiency