case_images: PMC6886192_01
case_images: Lymph nodes from the patient (a, b) and normal control (c). Plasma cells staining with CD138 are shown in brown. a The patient has normal lymph node architecture. b Showing reduced numbers of plasma cells in the germinal centre in the patient. c The plasma cells are in the interfollicular areas in the control. CVID is typically associated with the absence of plasma cells and poorly formed germinal centres. The patient was not on immunosuppression at the time of the lymph node excision
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case_images: PMC6886192_01_13223_2019_383_Fig1_HTML.jpg
case_images: Fig1
case_images: Excision biopsy of a left inguinal lymph node showed the presence of discrete non-caseating granulomas, reactive follicles and overall normal lymph node architecture (Fig. 1a). Plasma cells were present although slightly reduced compared to a normal control (Fig. 1b, c).
case_images: MRI of the cauda equina. Enhancing lesions of the nerve roots are seen consistent with granulomatous inflammation. A biopsy was not possible, given the location
case_images: 13223_2019_383_Fig2_HTML.jpg
case_images: PMC6886192_01_13223_2019_383_Fig2_HTML.jpg
case_images: Fig2
case_images: A repeat MRI scan of brain and spine revealed enhancing lesions in the cauda equina roots suggestive of granulomatous inflammation (Fig. 2).
case_images: IgG levels during immunosuppression. In mid-2018 the IgG normalised briefly between resolution of the cauda equine syndrome and treatment of renal disease. Cauda Cauda equine syndrome, Evans Evans syndrome, ITP immune thrombocytopenia, IVIG intravenous immunoglobulin, IS immunosuppression, Renal renal impairment
case_images: 13223_2019_383_Fig3_HTML.jpg
case_images: PMC6886192_01_13223_2019_383_Fig3_HTML.jpg
case_images: Fig3
case_images: In mid-2018 when the immunosuppression was lifted, his IgG increased from 3.0 g/l to 8.8 g/l (Fig. 3) and the previously decreased IgA and IgM also normalised.