Recurrent periorbital cellulitis and otitis media in an asthmatic child with chronic diarrhea and short stature

HISTORY OF PRESENT ILLNESS A 28-month-old male presented in September 1999 to our allergy/immunology clinic for followup of asthma and recurrent infections. Swelling and redness of the left suborbital area was noted that morning. However, the patient was still afebrile and playful. A review of his available medical records revealed that the patient was seen once at our clinic at the age of 10 months. He had been referred for recurrent otitis media (six episodes) and a periorbital cellulitis requiring hospitalization at 8 months of age. The infant’s poor growth had heightened the pediatrician’s suspicion of an immune deficiency. The patient was born at term with a birth weight of 2.93 kg. At 9 months of age, his weight plotted at the 5th percentile and his length was slightly below the 5th percentile. He had a history of five emergency room visits for wheezing and was started on nebulized cromolyn sodium. He had just been evaluated by an otorhinolaryngologist for persistent nasal congestion, snoring, and recurrent otitis media. A tympanostomy had been scheduled and the patient was started on mometasone furoate nasal spray and cefpodoxime proxetil for otitis media prophylaxis. The initial work-up obtained by the pediatrician showed the following: immunoglobulin (Ig)G 5.63 g/L (normal range is 5.76 to 14.03), IgA 260 mg/L (normal 140 to 1,590), IgM 690 mg/L (normal 470 to 2,280), and IgE 17 kIU/L (normal 0.8 to 15). White blood cell count was 5.8 109/L with 17% neutrophils, 49% lymphocytes, and 29% atypical reactive lymphocytes. Hemoglobin 1.78 mmol/L (normal 1.78 to 2.40), mean corpuscular volume 88 fL (normal 82 to 96), mean corpuscular hemoglobin 0.44 fmol (normal 0.37 to 0.47), mean corpuscular hemoglobin concentration 5.17 mmol/L (normal 4.96 to 5.58), platelets 237 109/L. A sweat chloride test was within normal range. Skin prick tests to common indoor allergens done in our clinic at 10 months of age were negative. The evaluation, at that time, was asthma, moderate in severity, and rhinitis. Discontinuation of cefpodoxime proxetil after 3 weeks was suggested. A followup appointment in 2 months was scheduled, but the patient returned 18 months later, because his asthma was poorly controlled.