Immunodeficiency

Young children all have a relative physiologic immunodeficiency because of a slow continual rise in plasma immunoglobulins (IgG, IgM, IgA) until 6 to 10 years of age, when adult levels are finally reached.29 Thus, children are theoretically more susceptible to infection during this period. Immunologic assessment is typically not warranted in all children with chronic rhinosinusi-tis; however, the clinician must have a low threshold of suspicion for primary or secondary immune deficiency in patients with recalcitrant disease. Chronic rhinosinusitis is reportedly the most common clinical presentation of common variable immune deficiency (CVID),56 a disorder characterized by reduced levels of at least two serum immunoglobulin classes, usually IgG and IgA. IgG subclass deficiency also may manifest as chronic rhinosinusitis.56 Less common childhood immunodeficiencies are X-linked agammaglobulinemia, C4 deficiency, ataxia-telangiectasia, and hyper-IgM immunodeficiency.56 Evaluation for immunodeficiency should include serum imm-nunoglobulin levels, IgG subclasses, and assessment of response to immunization with protein antigens (i.e., diphtheria and tetanus toxoid) and polysaccharide antigens (i.e., pneumococcal vaccine).44,57 Recommendations for this workup in children with chronic rhinosinutis are the following:57

1. History of infections at other sites

2. Inadequate response to appropriate antimicrobial therapy

3. Sinus cultures exhibiting unusual pathogens

4. Persistent rhinosinusitis despite surgical intervention and restoration of sinus ventilation and mucociliary transport

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