P3B104: Mimicry of Primary Immunodeficiency in a New Immigrant Child with Malnutrition

Introduction: Children worldwide are being forced to move from their homes due to poverty, conflict, climate change, natural disasters, and rising global inequities. Displaced persons flee from their homes, undertaking journeys in which they face new threats to their lives, including starvation and illnesses. Insufficient understanding exists regarding the impact of immunosuppression due to malnutrition in infants, children, and adolescents on the move.

Case Description: A 16-month-old child and his teenage mother were forcibly displaced from El Salvador and traveled by land to the United States. Their journey involved traversing Guatemala and Mexico before crossing the border into Arizona. The child was malnourished upon arrival and brought to medical attention. Due to the child’s complex medical needs, he was admitted to a quaternary pediatric hospital for care.

On presentation, the patient was 8.29 kg ( < 0.01%, Z = -3.95) in weight and 71 cm ( < 0.01%, Z = -4.55) in height with a prealbumin of 7 mg/dL. He was found to have GI Salmonella, norovirus, and disseminated Histoplasma capsulatum with associated systemic granulomatous disease. Initial immunologic work-up revealed an absolute lymphocyte count of 996, CD3+ T-cell count of 687 (69%), and CD19+ B-cell count of 74 (7.4%). While being treated for his infections and receiving nutritional rehabilitation, the patient acutely developed septic and hypovolemic shock and respiratory failure secondary to viral sepsis requiring intensive care for five days. Infectious work-up revealed adenovirus, cytomegalovirus, Epstein-Barr virus, and BK virus. The patient required intubation, transfusions of multiple blood products, and antibiotic, antiviral, and antifungal therapies.

Given the patient’s severe lymphopenia and multiple opportunistic infections, an extensive immunogenetic evaluation was completed but non-diagnostic for primary immune disorders. Following a three-month hospitalization and ten-month stay in a residential rehabilitation facility, he was discharged home. The patient’s nutritional status and lymphocyte counts normalized over the course of eight months after inpatient hospital discharge, and he continues to be followed by an outpatient multidisciplinary team.

Discussion: The journey that children and families undergo to seek safe haven in the United States is often fraught with challenges, including lack of basic needs such as food, shelter, and access to timely and appropriate medical attention. Inadequate caloric intake can lead to malnutrition-associated immunodeficiency, increasing risk for infection and disease, which then worsens malnutrition. Further research is needed to determine the extent to which this occurs in forcibly displaced children arriving in the United States.

Conclusion: Asylum seekers and refugees are a vulnerable population that face unique health challenges due to their status as displaced individuals. This case illustrates that immunosuppression secondary to malnutrition can mimic the clinical and laboratory presentation of a primary immunodeficiency, however the abnormalities may be reversible with proper nutritional support and infectious disease treatment.