RECURRENT SINUSITIS AND IMMUNODEFICIENCY

Abstract

Recurrent sinusitis may be due to an underlying primary immunodeficiency disorder. The immune system evaluation entails analysis of the lymphocytic (antibody and cellular), phagocytic, and complement components of the immune system. This workup needs to be coupled with a detailed history and physical examination. With appropriate screening of the patient with recurrent sinusitis, the diagnosis of an underlying primary immunodeficiency can be established. The immune workup may include evaluations of serum immunoglobulins; isohemagglutinins; complete blood count; IgG subclasses; delayed hypersensitivity skin testing with Candida , tetanus, and PPD; humoral immune assessment-baseline and postimmunization blood specimens to assess for functional humoral immunity; chest and sinus roentgenograms; and serum C3, C4, and CH 50 determinations. If indicated, special white blood cell studies, such as nitroblue tetrazolium testing, myeloperoxidase staining, chemotaxis, and chemiluminescence assessments, and surface glycoprotein measurements can be performed. If a patient has received gamma globulin injections or infusions, the true extent of functional humoral immunity may be difficult to ascertain objectively. In this setting, bacteriophage ФX-174 can be used. Because ФX-174 is a potent T cell–dependent antigen found only in bacteria, primary and secondary responses can be determined as a function of antigen clearance. In this way, functional humoral immunity can be assessed. When the clinician establishes primary immunodeficiency as part of the diagnosis in the patient who presents with recurrent sinusitis, treatment regimens can be instituted in a more efficacious manner. The immunodeficiency diseases most commonly associated with chronic sinusitis are antibody deficiency states, such as Bruton’s (X linked) congenital agammaglobulinemia, common variable immunodeficiency, IgG subclass deficiency, and selective IgA deficiency. Patients with cellular immune defects that permit survival also suffer from chronic sinusitis, e.g., ataxia telangiectasia. Treatment of antibody-deficient patients with intravenous immunoglobulin replacement therapy is rewarded by at least partial relief of symptoms when administered in conjunction with appropriate antimicrobial treatment. Identifying the patient with primary immunodeficiency disorder is the first step to successful treatment of underlying sinusitis. Understanding that recurrent sinopulmonary infection may be secondary to underlying immunodeficiency should guide therapeutic options and comprehensive management.