University of Oulu

Laajala, A., Kuismin, O., Tastula, M. et al. Tonsillar granuloma associated with hypogammaglobulinemia. Allergy Asthma Clin Immunol 16, 43 (2020).

Tonsillar granuloma associated with hypogammaglobulinemia

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Author: Laajala, Aleksi1,2; Kuismin, Outi3; Tastula, Mikko1;
Organizations: 1Department of Otorhinolaryngology and Head and Neck Surgery, Oulu University Hospital, Oulu, Finland
2PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland
3Department of Clinical Genetics, PEDEGO Research Unit, Medical Research Center, Oulu University Hospital and University of Oulu, Oulu, Finland
4Respiratory Medicine, Research Unit of Internal Medicine, University of Oulu and Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
5Department of Pathology, Cancer Research and Translational Medicine Research Unit, University of Oulu and Oulu University Hospital, Oulu, Finland
6Department of Radiology, Oulu University Hospital, Oulu, Finland
7Research Unit of Biomedicine, University of Oulu, Oulu, Finland
8Rare Disease Center and Pediatric Research Center, Children and Adolescents, Adult Immunodeficiency Unit, Inflammation Center, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
9Department of Internal Medicine, Oulu University Hospital, Oulu, Finland
Format: article
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 1.4 MB)
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Language: English
Published: Springer Nature, 2020
Publish Date: 2020-07-06


Background: Rare tonsillar granulomas may be caused for example by infections, malignancies or sarcoidosis. Granulomas also occur in inborn errors of immunity (IEI) such as common variable immunodeficiency (CVID) with B cell maturation defects and hypogammaglobulinemia. CVID shares various features with sarcoidosis and drug-induced secondary hypogammaglobulinemia; careful consideration of differential diagnosis between these conditions is warranted.

Case presentation: A 29-year-old female with epilepsy developed dysphagia, dyspnea and impaired exercise tolerance. Obstruction caused by swollen lingual tonsil and edema in the epiglottis and arytenoid mucosa were found. Lingual tonsil and epiglottis biopsies displayed non-necrotizing granulomas. There was no evidence of viral, bacterial, mycobacterial or fungal infections. Chest X-ray, computerized tomography of chest and ultrasound of neck and abdomen remained unremarkable. Positron emission tomography/computed tomography (PET/CT) showed laryngeal enhancement. Empiric antimicrobials combined with prednisolone were insufficient to control her disease. In immunological evaluation, the patient had normal counts of B and T cells. Proportions of CD27+ memory B cells (30.3%) and IgDIgMCD27+ switched memory B cells (7.2%; normal range 6.5–29.2%) were normal. Percentage of activated CD21low B cells was high (6.6%; normal range 0.6–3.5%). IgG (3.5 g/L; normal range 6.77–15.0 g/l) and all IgG subclass concentrations were low. Anti-polysaccharide responses were impaired, with 3/10 serotypes reaching a level of 0.35 µg/ml after immunization with Pneumovax®. The findings were consistent with hypogammaglobulinemia resembling CVID, possibly secondary to antiepileptic medication. Her dyspnea and dysphagia responded favorably to subcutaneous IgG and rituximab.

Conclusions: Tonsillar granulomas can be the presenting and only clinical feature of B cell deficiency, highlighting the diversity of symptoms and findings in primary or secondary immunodeficiencies.

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Series: Allergy, asthma & clinical immunology
ISSN: 1710-1484
ISSN-E: 1710-1484
ISSN-L: 1710-1484
Volume: 16
Issue: 1
Article number: 43
DOI: 10.1186/s13223-020-00441-1
Type of Publication: A1 Journal article – refereed
Field of Science: 3125 Otorhinolaryngology, ophthalmology
Funding: The study was partly supported by Oulu University Hospital VTR.
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