Patients with T lymphocyte defects should not be given live vaccines or blood products that are not irradiated

Author: Anjali Subbaswamy, MD

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Live attenuated virus vaccines (measles, mumps, rubella, varicella, bacille Calmette-Gu´ erin) could be lethal in individuals with T cell defects and should not be administered. The replication of vaccine viruses can be enhanced in persons with immune deficiencies, such as leukemia, lymphoma, generalized malignancy, or patients under therapy with alkylating agents, antimetabolites, radiation, large doses of corticosteroids. Case reports have linked measles vaccine and measles infection to subsequent death in severely immunocompromised children.

The immune system is classically divided into two responses, the innate and the adaptive responses. The innate immune system is comprised of neutrophils, macrophages, natural killer cells, and complement proteins, which respond rapidly to infections in a manner that is relatively nonspecific to any particular infection. The adaptive immune system is composed primarily of T and B cells, and typically responds to infections more slowly than the innate immune system. The adaptive immune system is much more specific to particular infections than the innate immune system due to a mechanism known as memory.

The adaptive immune system has been defined further into the humoral and cellular immune arms. The humoral immune system primarily involves B cells and their production of immunoglobulins, whereas the cellular immune system classically involves T cells and their ability to produce various cytokines. The humoral and cellular immune systems are functionally dependent on each other in mounting effective immune responses. Blood administration also carries particular risks for the immunocompromised patient. Patients with pure B cell immunodeficiency have few transfusion-related problems. Those with T cell defects are susceptible to transfusion-associated graft-versus-host disease (TaGvHD). Three factors create this situation: (a) immunocompetent donor T cells, (b) histoincompatibility between donor and recipient, and (c) the inability of the recipient to reject donor T cells. There are risks with red blood cells, platelets, granulocytes and fresh liquid plasma. Previously, frozen products suchasfreshfrozenplasmadidnotcarrythesamerisk.Lymphocyteviability declines with age, so older red blood cells carry reduced risk. TaGvHD can presentfrom4daysto1monthposttransfusion.Thesymptomsincluderash, diarrhea, hepatitis, fever, lymphadenopathy, and bone marrow suppression, leading to thrombocytopenia and anemia. Diagnosis requires demonstration ofhumanleukocyteantigenchimerismandthetreatmentincludeshigh-dose corticosteroids and supportive therapies. Irradiation of blood products can prevent TaGvGHD.

Suggested Readings

Badami KG. The immunocompromised patient and transfusion. Postgrad Med J. 2001;77:230– 234.
Recommendations of the Advisory Committee on Immunization Practices (ACIP): use of vac cines and immune globulins in persons with altered immunocompetence. MMWR Recomm Rep. 1993;42(RR-4):1–18.
Verbsky JW, Grossman WJ. Cellular and genetic basis of primary immune deficiencies. Pediatr Clin North Am. 2006;53(4):649–684.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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