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Kim DH, Hong J, Shin DY, Kim I, Yoon SS, Bang SM, Lee JO, Lee JY, Kim SA, Byun JM, Koh Y. Phase II trial of posaconazole prophylaxis during anti-thymocyte globulin treatment for aplastic anaemia and hypoplastic myelodysplastic syndrome. Br J Haematol 2024. [PMID: 38699798 DOI: 10.1111/bjh.19500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/20/2024] [Indexed: 05/05/2024]
Affiliation(s)
- Dong Hyun Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
- Center for Medical Innovation, Seoul National University Hospital, Seoul, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
- Center for Medical Innovation, Seoul National University Hospital, Seoul, Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
- Center for Medical Innovation, Seoul National University Hospital, Seoul, Korea
| | - Soo Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Jeong-Ok Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Ji Yun Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Sang-A Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
- Center for Medical Innovation, Seoul National University Hospital, Seoul, Korea
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Vallejo C, Rosell A, Xicoy B, García C, Albo C, Polo M, Jarque I, Esteban B, Codesido ML. A multicentre ambispective observational study into the incidence and clinical management of aplastic anaemia in Spain (IMAS study). Ann Hematol 2024; 103:705-713. [PMID: 38175253 DOI: 10.1007/s00277-023-05602-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024]
Abstract
Aplastic anemia (AA) is a rare, life-threatening hematological disease, with a poorly defined incidence. As the data available on AA varies substantially worldwide, a multicenter, ambispective, observational study was carried out between 2010 and 2019 to assess the incidence, clinical management and survival of AA at seven Spanish hospitals. The incidence of AA was 2.83 per million inhabitants per year, consistent with that reported previously in Europe, with a median age at diagnosis of 61 years-old (range 12-86), and a similar number of males and females. The initial diagnosis was severe or very severe AA in 55.8% of cases and 93.7% required transfusion. The most frequent first line therapy was anti-thymocyte globulin (ATG) plus cyclosporin A (CsA, 44.2%), followed by other CsA-based regimes (46.3%), with hematopoietic stem cell transplantation an infrequent 1st line therapy. The 6-month response rate was 68.2%, which then increased over a median follow-up of 3.9 years. The 5-year overall survival (5OS) was 73.6%, similar in severe (78.6%) and very severe AA patients (74.6%) but lower in moderate AA (MAA) patients (68.4%). The 5OS was 100% in 0-25 year-old patients but dropping to 58.3% in patients ≥ 60 years-old. At the last contact, 75.8% of the patients were alive. In conclusion, the incidence, characteristics and management of AA in our study are consistent with that reported previously. In terms of survival, although the global long-term OS rate was good, there is room for improvement, particularly in older patients. Finally, what appears to be a worse long-term survival of MAA patients, as reported previously, reinforces the importance of not underestimating this condition when diagnosed as MAA.
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Affiliation(s)
- Carlos Vallejo
- Complejo Asistencial Universitario de Salamanca, Salamanca, Spain.
- Hospital Universitario Donostia, San Sebastián, Spain.
- PETHEMA Cooperative Group, Madrid, Spain.
- Instituto de Investigación Sanitaria Biodonostia, Donostia-San Sebastián, Spain.
| | - Ana Rosell
- Hospital Universitario Virgen de La Victoria, Málaga, Spain
| | - Blanca Xicoy
- Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Carmen García
- Hospital General Universitario de Alicante, Alicante, Spain
| | - Carmen Albo
- Hospital Universitario Álvaro Cunqueiro, Vigo, Spain
| | - Marta Polo
- Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | - Brígida Esteban
- Instituto de Investigación Sanitaria Biodonostia, Donostia-San Sebastián, Spain
| | - M Lorena Codesido
- Instituto de Investigación Sanitaria Biodonostia, Donostia-San Sebastián, Spain
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Lionel SA, Selvarajan S, Korula A, Kulkarni U, Devasia A, Abubacker FN, Abraham A, Mathews V, Lakshmi KM, George B. Profile and Predictors of Infection Following Anti-thymocyte Globulin or Anti-lymphocyte Globulin with Cyclosporine in Aplastic Anemia. Indian J Hematol Blood Transfus 2023; 39:419-428. [PMID: 37304482 PMCID: PMC10247602 DOI: 10.1007/s12288-022-01597-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/12/2022] [Indexed: 12/23/2022] Open
Abstract
Immunosuppressive therapy (IST) with anti-thymocyte globulin (ATG) and Cyclosporine (CSA) in aplastic anaemia (AA) results in improvement of blood counts between 3 and 6 months for the majority of patients. Infection is the most lethal complication in aplastic anemia and may arise due to several factors. We performed this study to determine the prevalence and predictors of specific infection types before and after IST. Six hundred and seventy-seven (546 adults; 434 males) transplant ineligible patients received ATG and CSA between 1995 and 2017. All patients who were transplant ineligible and received IST in this period were included. Infections before IST was seen in 209 (30.9%) and in 430 (63.5%) patients post IST. There were 700 infective episodes in the six months post-IST, including 216 bacterial, 78 fungal, 33 viral, and 373 culture-negative febrile episodes. Infections were highest (98, 77.8%) in very severe aplastic anaemia as compared to Severe AA (SAA) and Non-Severe AA (NSAA) (p < 0.001). Infections were also significantly higher in those who did not respond to ATG (71.1% vs. 56.8%, p = 0.003). At six months post-IST were 545 (80.5%) alive, and there were 54 (7.9%) deaths due to infection. Significant predictors of mortality were paediatric AA, very severe aplastic anaemia, pre or post ATG infections, and lack of response to ATG. Mortality was highest in those with combined bacterial and fungal infections post IST (p < 0.001). We conclude that infections are a common complication (63.5%) of IST. Mortality was highest when both bacterial and fungal infections were present. Routine use of growth factors and prophylactic antifungal and antibacterial agents was not part of our protocol, despite which 80.5% of the cohort was alive at the end of six months.
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Affiliation(s)
| | - Sushil Selvarajan
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu India
| | - Anu Korula
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu India
| | - Uday Kulkarni
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu India
| | - Anup Devasia
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu India
| | - Fouzia N. Abubacker
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu India
| | - Aby Abraham
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu India
| | - Vikram Mathews
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu India
| | - Kavitha M. Lakshmi
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu India
| | - Biju George
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu India
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Aplastic Anemia and Chagas Disease: T. cruzi Parasitemia Monitoring by Quantitative PCR and Preemptive Antiparasitic Therapy. Trop Med Infect Dis 2022; 7:tropicalmed7100268. [PMID: 36288009 PMCID: PMC9609300 DOI: 10.3390/tropicalmed7100268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Aplastic anemia is a rare and life-threatening condition, seldomly witnessed concomitantly with Chagas disease. We aim to discuss the management of these patients under risk of chronic Chagas disease reactivation (CDR), a severe condition with a high morbimortality that occurs in chronic Chagas disease patients under immunosuppression. Case reports: Trypanosoma cruzi (T. cruzi) parasitemia was monitored in three patients for 4−58 months by conventional PCR (cPCR), quantitative PCR (qPCR), microhematocrit/buffy coat, blood culture, and/or xenodiagnosis. One patient received antiparasitic treatment (benznidazole) and the other received allopurinol. Although parasitemia was controlled during and after benznidazole treatment at 300 mg/d for 51 days, in one patient, hematologic parameters worsened continuously before, during, and after treatment. Allopurinol led only to the temporary suppression of T. cruzi parasitemia in the second patient, but after danazol and hematological improvement, parasitemia became undetectable until the end of monitoring. Discussion and Conclusion: Unexpected undetectable or low parasitemia by cPCR/qPCR was reported. We show that the monitoring of parasitemia by qPCR and the use of preemptive therapy when the parasitemia was positive proved to be beneficial to our patients. As a result of the toxicity of more effective antiparasitics, shorter regimens of benznidazole or less toxic drugs in preemptive therapy are options that deserve future studies.
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Zhang Y, Chen X, Yang D, Pang A, Zhang R, Ma Q, Zhai W, He Y, Wei J, Jiang E, Han M, Feng S. The prognostic impact of previously infectious complications on allogeneic hematopoietic stem cell transplantation for patients with severe aplastic anemia: A single-center, retrospective study. Front Immunol 2022; 13:1004787. [PMID: 36172387 PMCID: PMC9510614 DOI: 10.3389/fimmu.2022.1004787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 08/22/2022] [Indexed: 12/03/2022] Open
Abstract
Whether infections before transplantation impair the survival of patients with severe aplastic anemia (SAA) remains unclear. The aim of this retrospective cohort analysis was to compare survival between patients with SAA who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) with infection (n=66) and patients without infection (n=189) from one medical center. There were no differences in baseline characteristics, except that more patients in the infection group were diagnosed with VSAA (59.09% vs. 30.69%, P<0.001), and their grafts were more peripheral blood stem cells (89.39% vs. 76.72%, P=0.042). In addition, the percentage of patients with multidrug-resistant organism colonization or infection in the infection group was larger (16.7% vs. 0.5%, P<0.001). The median days of engraftment were similar between the two groups; however, the 28-day engraftment rates of neutrophils and platelets were lower in the infection group. No differences were observed in terms of grades II–IV acute graft-versus-host disease (aGVHD) (P=0.418), grades III–IV aGVHD (P=0.075), mild to severe chronic GVHD (cGVHD) (P=0.899), and moderate to severe cGVHD (P=0.342). Patients in the infection group had more bloodstream infections before engraftment (28.8% vs. 15.3%, P=0.016), and the primary cause of death was infection instead of aGVHD in contrast to patients without infection (16.7% vs. 4.2%, P=0.002). Finally, the estimated overall survival (OS), failure-free survival (FFS), and GVHD-free FFS at 5 years were 63% (95% CI, 51–78), 60% (95% CI, 47–74), and 55% (95% CI, 43–70) in patients with infection before transplantation versus 86% (95% CI, 81–92) (P<0.001), 82% (95% CI, 76–88) (P<0.001), and 75% (95% CI, 69–82) (P=0.003) in patients without infection before transplantation, respectively. Multivariate analysis identified haploidentical HSCT and pre-HSCT anti-infection response, defined as partial remission (PR) or stable disease (SD), as adverse factors of OS and FFS. In conclusion, our study demonstrated that SAA patients with infection defined as PR or SD but not complete remission before allo-HSCT showed inferior survival compared with patients without infection. Therefore, more attention should be paid to prophylaxis and complete control of infectious complications before transplantation among SAA patients.
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Affiliation(s)
- Yuanfeng Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Department of Hematology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Xin Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Donglin Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Aiming Pang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Rongli Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Qiaoling Ma
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Weihua Zhai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yi He
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Jialin Wei
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Mingzhe Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- *Correspondence: Sizhou Feng, ;
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Murakami D, Matsuda K, Honda A, Masamoto Y, Kurokawa M. Severe infections and renal dysfunction during immunosuppressive therapy with cyclosporine A for aplastic anemia. Int J Hematol 2022; 116:482-488. [PMID: 35750997 DOI: 10.1007/s12185-022-03399-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 05/30/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Abstract
Although immunosuppressive therapy (IST) with cyclosporine A (CyA) has been widely used in patients with aplastic anemia (AA), little attention has been given to its safety. This study aimed to clarify the adverse events of IST in patients with AA. We retrospectively identified 42 patients with AA treated with IST. Seventeen of the 42 patients (40%) experienced severe infection at a median of 142 days from the start of IST, and 18 (49%) experienced renal dysfunction at a median of 73 days. A large proportion of infected patients had severe AA (90 vs. 14%, p = 0.056). Notably, all patients with severe infection showed poor response to IST at the time of infection onset. Analysis regarding risk factors for renal dysfunction showed that median age at the initiation of IST was significantly higher in patients with renal dysfunction than those without renal dysfunction (65 years vs. 44 years, p = 0.020). Only 2 of 18 patients showed improvement in serum creatinine levels despite reduction or discontinuation of CyA. Our results suggest that poor responders to IST and elderly patients are at higher risk of severe infection and renal dysfunction, respectively.
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Affiliation(s)
- Daisuke Murakami
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Kensuke Matsuda
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Akira Honda
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yosuke Masamoto
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Mineo Kurokawa
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan. .,Department of Cell Therapy and Transplantation Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
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Li H, Li X, Chen X, Li N. Successful treatment with HLA-matched peripheral hematopoietic stem cell transplantation for very severe hepatitis-associated aplastic anemia complicated with multidrug-resistant bacterial and fungal infections: A case report. Front Pediatr 2022; 10:828918. [PMID: 36389369 PMCID: PMC9659588 DOI: 10.3389/fped.2022.828918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 09/27/2022] [Indexed: 11/13/2022] Open
Abstract
Hepatitis-associated aplastic anemia (HAAA) is a life-threatening hematologic disorder characterized by bone marrow failure. Allogeneic hematopoietic stem cell transplantation (HSCT) is the first-line treatment for HAAA. Severe infection and complications in patients with very severe aplastic anemia are the challenges to the efficacy of HSCT. We report a rare case of successful transplantation with HLA-matched peripheral hematopoietic stem cells for a 15-year-old girl suffering from HAAA with multidrug-resistant bacterial and fungal infections. Through effectively controlling infection and optimal timing of transplantation by adjusting the conditioning regimen, the allo-HSCT was successfully performed for the patient. Updated data of following-up 26 months after transplantation showed that the patient was still in complete remission with a good quality of life. This case provided a reference for treating severely infected patients with HAAA before HSCT.
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Affiliation(s)
- Hua Li
- Hemopoietic Stem Cell Transplantation Center, Fujian Provincial Key Laboratory on Hematology, Clinical Research Center for Hematological Malignancies of Fujian Province, Fujian Institute of Hematology, Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, China.,Department of Hematology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Xiaofan Li
- Hemopoietic Stem Cell Transplantation Center, Fujian Provincial Key Laboratory on Hematology, Clinical Research Center for Hematological Malignancies of Fujian Province, Fujian Institute of Hematology, Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xianling Chen
- Hemopoietic Stem Cell Transplantation Center, Fujian Provincial Key Laboratory on Hematology, Clinical Research Center for Hematological Malignancies of Fujian Province, Fujian Institute of Hematology, Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Nainong Li
- Hemopoietic Stem Cell Transplantation Center, Fujian Provincial Key Laboratory on Hematology, Clinical Research Center for Hematological Malignancies of Fujian Province, Fujian Institute of Hematology, Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
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Necrotizing Bacterial Myositis as the Initial Presentation of Severe Aplastic Anaemia. Case Rep Hematol 2022; 2021:8276937. [PMID: 34970463 PMCID: PMC8714340 DOI: 10.1155/2021/8276937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 11/17/2021] [Accepted: 12/14/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Necrotizing soft tissue infections are rapidly progressing infections associated with severe inflammation and cytokine release. Early recognition and surgical intervention are key factors to secure survival. The current case presents a patient with multifocal necrotizing soft tissue infection as the initial presentation of severe aplastic anaemia. Case Presentation. A man in his fifties was admitted with septic shock with multiorgan failure and severe pancytopenia, after two days of malaise with high fever and right flank pain. The diagnosis streptococcal necrotizing myositis was significantly delayed due to atypical clinical findings. After initial surgical exploration, the decision was made to defer from surgical debridement due to extensive involvement of several muscle groups, grave pancytopenia, and suspected dismal prognosis. Surprisingly, the patient stabilized after antibiotics and intensive care treatment. Based on severe pancytopenia and hypocellular bone marrow, with no evidence of other bone marrow disorders, the patient was diagnosed with aplastic anaemia. Treatment for aplastic anaemia with antithymocyte globulin, cyclosporine, and eltrombopaq was started, and 2 months later, a partial haematological recovery was observed. The patient could be discharged from hospital without antibiotic treatment. Conclusions This case illustrates the crucial role of a multidisciplinary approach on admission and further during the clinical course. Clinical improvement despite severe neutropenia and stabilization during immunosuppressive therapy suggest that immunological factors modulate clinical course in necrotizing soft tissue infections.
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Staphylococcus aureus Infections in the Paediatric Intensive Care Unit: Illustrated Cases. Case Rep Pediatr 2021; 2021:6661932. [PMID: 34150343 PMCID: PMC8195667 DOI: 10.1155/2021/6661932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/18/2021] [Accepted: 05/16/2021] [Indexed: 11/17/2022] Open
Abstract
Staphylococcus aureus is known to be one of the most common gram-positive microorganisms and an important pathogen associated with sepsis and toxic shock. We present four anonymized consecutive cases in a paediatric intensive care unit (PICU) to illustrate the different clinical manifestations of staphylococcal infections, including local infection versus systemic infection, toxic shock versus septic shock, and osteomyelitis. Eczema, short gut syndrome, and scald injury may be associated. Haematologic and coagulopathic abnormalities may be present. Prompt diagnosis and use of appropriate antimicrobial treatments is essential to reducing mortality and morbidity associated with staphylococcal infections.
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Di Pasquale MF, Sotgiu G, Gramegna A, Radovanovic D, Terraneo S, Reyes LF, Rupp J, González Del Castillo J, Blasi F, Aliberti S, Restrepo MI. Prevalence and Etiology of Community-acquired Pneumonia in Immunocompromised Patients. Clin Infect Dis 2020; 68:1482-1493. [PMID: 31222287 PMCID: PMC6481991 DOI: 10.1093/cid/ciy723] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/20/2018] [Indexed: 12/12/2022] Open
Abstract
Background The correct management of immunocompromised patients with pneumonia is debated. We evaluated the prevalence, risk factors, and characteristics of immunocompromised patients coming from the community with pneumonia. Methods We conducted a secondary analysis of an international, multicenter study enrolling adult patients coming from the community with pneumonia and hospitalized in 222 hospitals in 54 countries worldwide. Risk factors for immunocompromise included AIDS, aplastic anemia, asplenia, hematological cancer, chemotherapy, neutropenia, biological drug use, lung transplantation, chronic steroid use, and solid tumor. Results At least 1 risk factor for immunocompromise was recorded in 18% of the 3702 patients enrolled. The prevalences of risk factors significantly differed across continents and countries, with chronic steroid use (45%), hematological cancer (25%), and chemotherapy (22%) the most common. Among immunocompromised patients, community-acquired pneumonia (CAP) pathogens were the most frequently identified, and prevalences did not differ from those in immunocompetent patients. Risk factors for immunocompromise were independently associated with neither Pseudomonas aeruginosa nor non–community-acquired bacteria. Specific risk factors were independently associated with fungal infections (odds ratio for AIDS and hematological cancer, 15.10 and 4.65, respectively; both P = .001), mycobacterial infections (AIDS; P = .006), and viral infections other than influenza (hematological cancer, 5.49; P < .001). Conclusions Our findings could be considered by clinicians in prescribing empiric antibiotic therapy for CAP in immunocompromised patients. Patients with AIDS and hematological cancer admitted with CAP may have higher prevalences of fungi, mycobacteria, and noninfluenza viruses.
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Affiliation(s)
- Marta Francesca Di Pasquale
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, University of Milan
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, University of Milan
| | - Dejan Radovanovic
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Pulmonary Unit, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco
| | - Silvia Terraneo
- Respiratory Unit, San Paolo Hospital, Department of Medical Sciences, University of Milan, Italy
| | - Luis F Reyes
- Microbiology Department, Universidad de La Sabana, Chia, Colombia
| | - Jan Rupp
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein/Campus Lübeck, Germany
| | - Juan González Del Castillo
- Emergency Department, Hospital Clínico San Carlos, Universidad Complutense.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, University of Milan
| | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, University of Milan
| | - Marcos I Restrepo
- Division of Pulmonary Diseases and Critical Care Medicine, The University of Texas Health Science Center at San Antonio
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Samanta A, Chandra J, Kaur R, Anand R, Shukla S, Mandal P. Clinical Profile and Microbiologic Spectrum of Febrile Neutropenic Episodes in Children With Severe Aplastic Anemia. J Pediatr Hematol Oncol 2020; 42:193-197. [PMID: 32209945 DOI: 10.1097/mph.0000000000001631] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Febrile neutropenia (FN) is a common life-threatening complication in patients with severe aplastic anemia (SAA). However, few studies have examined the spectrum of infections in FN in patients with SAA, especially in children. Therefore, the current study was planned to study the clinicomicrobiologic profile of FN episodes in these children. MATERIALS AND METHODS Data of 38 episodes of FN that occurred in 31 children with SAA from November 2015 to April 2017 were collected prospectively and analyzed. RESULTS FN episodes occurred more frequently (54.8%) in patients on immunosuppressive therapy. Clinically documented infections accounted for 21 (55.26%) episodes, microbiologically documented infections for 15 (39.47%), bacteremia for 13 (34.21%), and invasive fungal diseases for 6 (15.78%) episodes. Among clinically documented infections, the lower respiratory tract was the commonest site in 23.68% episodes, followed by skin and soft tissue infections. No focus of infection could be identified in 12 (31.57%) episodes. Gram-negative bacteria (71.42%) were the predominant isolates (commonest Klebsiella pneumoniae) over Gram-positive bacteria (commonest coagulase-negative Staphylococcus). High prevalence of aminoglycoside, piperacillin-tazobactam, and carbapenem resistance was noted among Gram-negative organisms. Gram-positive organisms showed excellent sensitivity to vancomycin, linezolid, and clindamycin. The overall mortality rate was 42%. CONCLUSIONS Empirical antimicrobial therapy should include adequate coverage for Gram-negative pathogens. The antimicrobial regimen should be modified according to the results of the culture and sensitivity testing.
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Affiliation(s)
| | | | | | | | - Shailaja Shukla
- Pathology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, New Delhi, India
| | - Piali Mandal
- Departments of Pediatrics, Division of Hemato-oncology
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12
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Clucas DB, Fox LC, Wood EM, Hong FS, Gibson J, Bajel A, Szer J, Blombery P, McQuilten ZK, Hiwase D, Firkin F, Cole-Sinclair MF. Revisiting acquired aplastic anaemia: current concepts in diagnosis and management. Intern Med J 2019; 49:152-159. [PMID: 30324755 DOI: 10.1111/imj.14140] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 07/26/2018] [Accepted: 09/30/2018] [Indexed: 12/24/2022]
Abstract
Acquired aplastic anaemia is a rare, serious, immunologically mediated bone marrow failure syndrome, characterised by marrow hypoplasia of varying severity and significant pancytopenia. Careful attention and investigation, including molecular testing, is required to confirm the diagnosis and exclude other mimicking conditions, such as inherited bone marrow failure syndromes. In a proportion of patients, the disease evolves to myelodysplasia or acute myeloid leukaemia and in some there is an association with paroxysmal nocturnal haemoglobinuria. The disease has a major impact on patient quality of life. Haemopoietic stem/progenitor cell transplantation for eligible patients with an available donor is the only current curative therapy. Other patients may receive immunosuppression, most commonly with anti-thymocyte globulin and cyclosporin. An initial response to immunosuppression is often encouraging, but relapse is common. Supportive care, including management of transfusion requirements and infections, is central to management. Promising new diagnostic tools and emerging therapies will likely transform approaches to this important, chronic and life-threatening condition.
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Affiliation(s)
- Danielle B Clucas
- Department of Clinical Haematology, Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Lucy C Fox
- Department of Clinical Haematology, Epworth Hospital, Monash University, Melbourne, Victoria, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Frank S Hong
- Department of Clinical Haematology, The Northern Hospital, Melbourne, Victoria, Australia.,Clinical Services and Research, Australian Red Cross Blood Service, Melbourne, Victoria, Australia
| | - John Gibson
- Institute of Haematology, Royal Prince Alfred Hospital, Adelaide, South Australia, Australia.,The University of Sydney, Sydney, South Australia, Australia
| | - Ashish Bajel
- Integrated Haematology Service, Victorian Comprehensive Cancer Centre (The Royal Melbourne Hospital/Peter MacCallum Cancer Centre), Melbourne, Victoria, Australia
| | - Jeff Szer
- Integrated Haematology Service, Victorian Comprehensive Cancer Centre (The Royal Melbourne Hospital/Peter MacCallum Cancer Centre), Melbourne, Victoria, Australia
| | - Piers Blombery
- Molecular Haematology Laboratory, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Zoe K McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Medical Centre, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Devendra Hiwase
- Department of Clinical Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,The University of Adelaide, Adelaide, South Australia, Australia
| | - Frank Firkin
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
| | - Merrole F Cole-Sinclair
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
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13
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Frietsch JJ, Winkelmann N, Hunstig F, Schnetzke U, Hammersen FJ, Dönicke T, Lenz M, Gras F, Scholl S, Hochhaus A, Hilgendorf I. A Mosquito Bite with Devastating Complications in an Immunocompromised Patient. Case Rep Oncol 2019; 12:22-28. [PMID: 30792641 PMCID: PMC6381905 DOI: 10.1159/000495878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 11/27/2018] [Indexed: 11/23/2022] Open
Abstract
Infectious complications such as invasive aspergillosis or infection with Stenotrophomonas maltophilia (SM) in immunocompromised patients are associated with a high mortality rate. Our report concerns a 40-year-old male newly diagnosed very severe aplastic anemia (vSAA) who in consequence of a mosquito bite was suffering from skin lesion and consecutive soft tissue phlegmon subsequent to the administration of antithymocyte globulin; a full-thickness autologous meshed skin graft successfully performed to cover skin ulcera after allogeneic stem cell transplantation (SCT). This unusual case illustrates the importance of appropriate diagnosis, anti-infective therapy and close interdisciplinary diagnostic algorithms to minimalize side effects and the selection of resistant strains and to improve patients' outcome.
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Affiliation(s)
- Jochen J Frietsch
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Nils Winkelmann
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Friederike Hunstig
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Ulf Schnetzke
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Friedrich J Hammersen
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Torsten Dönicke
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena, Jena, Germany
| | - Mark Lenz
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena, Jena, Germany
| | - Florian Gras
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena, Jena, Germany
| | - Sebastian Scholl
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Andreas Hochhaus
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Inken Hilgendorf
- Klinik für Innere Medizin II, Hämatologie und internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
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14
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Lertpongpiroon R, Rattarittamrong E, Rattanathammethee T, Chai-Adisaksopha C, Tantiworawit A, Salee P, Norasetthada L. Infections in patients with aplastic Anemia in Chiang Mai University. BMC HEMATOLOGY 2018; 18:35. [PMID: 30534380 PMCID: PMC6280474 DOI: 10.1186/s12878-018-0129-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/28/2018] [Indexed: 12/16/2022]
Abstract
Background Infection is a major complication in aplastic anemia (AA) patients. Primary objectives of this study were to determine the prevalence of infections and to determine types of pathogens associated with infections in patients with AA. Secondary objectives were to evaluate overall survival after infections as well as risk factors of infections in patients with AA. Methods The authors retrospectively evaluated the infectious episodes (IEs), type of infections, associated pathogens, and outcomes of infections in patients with AA who were diagnosed and treated at Chiang Mai University between January 2010 and December 2015. Results Sixty-seven patients with a median age of 51 years (range, 15–87 years) were enrolled. Forty two patients (62.6%) were severe AA. Median absolute neutrophil count (ANC) was 984 /mm3 (range, 120–5500/mm3). Twenty five patients (37.3%) received antithymocyte globulin plus cyclosporine A, 41 patients (61.1%) received anabolic hormone, and 2 patients (2.9%) underwent allogeneic hematopoietic stem cell transplantation. Overall, 31 IEs were documented in 22 patients (32.8%). The most common microbiologically documented site of infection was bloodstream infection (23.4%) followed by pulmonary infection (14.9%). Culture-negative febrile neutropenia occurred in 12.7%. Common pathogens identified were bacteria (73.9%), mainly gram-negative (52.9%) including Acinetobacter baumannii (23.5%) and Pseudomonas aeruginosa (17.6%). Fungal infections were diagnosed in 21.7% and all were Aspergillus spp. Six patients (9%) died during the study period. All of them died from infection which gram-negative bacteria were most common pathogens (66.7%). Patients with infections had 5-year overall survival of 72% that is significantly less than patients without infection (100%) (p = 0.0002). Only risk factor that correlates with high probability of infection was ANC < 500/mm3. (HR 2.29, 95%CI 1.03–7.72, p = 0.043). Conclusions Prevalence of infections in AA patients in Chiang Mai University was 32.8% Bacterial infections especially gram-negative bacteria were the major pathogens. Patients with ANC < 500/mm3 had higher risk of infections. Infection was the most important cause of death in AA.
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Affiliation(s)
- Rapee Lertpongpiroon
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
| | - Ekarat Rattarittamrong
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
| | - Thanawat Rattanathammethee
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
| | - Chatree Chai-Adisaksopha
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
| | - Adisak Tantiworawit
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
| | - Parichat Salee
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
| | - Lalita Norasetthada
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
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15
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Allogeneic Hematopoietic Stem Cell Transplantation for the Treatment of Severe Aplastic Anemia Patients with Infection: A Single-Center Retrospective Study. Biol Blood Marrow Transplant 2018; 24:2532-2539. [DOI: 10.1016/j.bbmt.2018.07.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/11/2018] [Indexed: 11/20/2022]
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16
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Pickard AS, Huynh L, Ivanova JI, Totev T, Graham S, Mühlbacher AC, Roy A, Duh MS. Value of transfusion independence in severe aplastic anemia from patients' perspectives - a discrete choice experiment. J Patient Rep Outcomes 2018; 2:13. [PMID: 29757294 PMCID: PMC5934914 DOI: 10.1186/s41687-018-0032-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 02/01/2018] [Indexed: 01/15/2023] Open
Abstract
Background Aplastic anemia is a rare, serious blood disorder due to bone marrow failure to produce blood cells. Transfusions are used to reduce risk of bleeding, infection and relieve anemia symptoms. In severe patients, transfusions may be required more than once/week. It is unclear from the patient perspective the impact that transfusions have on quality of life. This study aimed to elicit patient preferences for attributes associated with severe aplastic anemia (SAA) treatment, including transfusion independence. Methods An online discrete choice experiment (DCE) was conducted among patients with SAA who experienced insufficient response to immunosuppressive therapy and transfusion dependence for ≥3 months in the past 2 years. Recruitment occurred through the Aplastic Anemia and Myelodysplastic Syndromes International Foundation and referrals from clinical sites in the US and France. Respondents chose between hypothetical treatment pairs characterized by a common set of attributes: transfusions frequency, fatigue, risk of infection, and risk of serious bleeding. Conditional logit model with effects coding was used to estimate part-worth utilities for different attribute levels and the relative importance of each attribute. Predicted utility scores for transfusion frequency levels were reported. Results Thirty patients completed the survey. Most were age ≥ 40 years (73.3%), female (70.0%), and from the US (86.7%). 33.3% underwent bone marrow transplant; 36.7% received iron chelation therapy. Patients largely agreed that transfusion independence would result in less burden on time and costs, greater control and quality of life, less fatigue (86.7% noted each) and less scheduling around medical appointments (83.3%). The DCE found highest relative importance for risk of bleeding (0.30), followed by risk of infection (0.28), fatigue (0.23), and frequency of transfusions (0.20). More frequent transfusions resulted in lower utility, particularly when increasing monthly transfusions frequency from 4 (0.57) to 8 (0.35). Conclusions Our study showed that higher utility was associated with fewer transfusions in SAA patients with insufficient response to immunosuppressive therapy. While risk of bleeding, risk of infection, and fatigue were more important for patient treatment preferences, frequency of transfusions was also important.
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Affiliation(s)
| | - Lynn Huynh
- 2Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA 02199 USA
| | | | - Todor Totev
- 2Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA 02199 USA
| | | | - Axel C Mühlbacher
- 5IGM Institute Health Economics and Health Care Management at Hochschule Neubrandenburg, Neubrandenburg, Germany
| | - Anuja Roy
- 6Novartis Pharmaceuticals Corporation, East Hanover, NJ USA
| | - Mei Sheng Duh
- 2Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA 02199 USA
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17
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Pergam SA. Fungal Pneumonia in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation. Clin Chest Med 2017; 38:279-294. [PMID: 28477639 DOI: 10.1016/j.ccm.2016.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Invasive fungal infections, which occur primarily as a consequence of prolonged neutropenia and immunosuppression, are a life-threatening complication seen among patients with hematologic malignancies. The routine use of triazole antifungal prophylaxis, enhanced diagnostics, and newer antifungal agents have led to improvements in the care of fungal pneumonias, but invasive fungal infections remain a major cause of morbidity and mortality. This article covers risk factors for major fungal infections, diagnostic approaches, and treatment options for specific fungal pathogens, including Aspergillus and Mucorales species, and discusses current approved strategies for prevention of common and uncommon fungal pneumonias.
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Affiliation(s)
- Steven A Pergam
- Vaccine & Infectious Disease Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, E4-100, Seattle, WA 98109, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, E4-100, Seattle, WA 98109, USA; Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; Infection Prevention, Seattle Cancer Care Alliance, 825 Eastlake Avenue East, Seattle, WA 98109, USA.
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18
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Lengline E, Drenou B, Peterlin P, Tournilhac O, Abraham J, Berceanu A, Dupriez B, Guillerm G, Raffoux E, de Fontbrune FS, Ades L, Balsat M, Chaoui D, Coppo P, Corm S, Leblanc T, Maillard N, Terriou L, Socié G, de Latour RP. Nationwide survey on the use of eltrombopag in patients with severe aplastic anemia: a report on behalf of the French Reference Center for Aplastic Anemia. Haematologica 2017; 103:212-220. [PMID: 29170252 PMCID: PMC5792265 DOI: 10.3324/haematol.2017.176339] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/15/2017] [Indexed: 11/24/2022] Open
Abstract
Few therapeutic options are available for patients with aplastic anemia who are ineligible for transplantation or refractory to immunosuppressive therapy. Eltrombopag was recently shown to produce trilineage responses in refractory patients. However, the effects of real-life use of this drug remain unknown. This retrospective study (2012–2016) was conducted by the French Reference Center for Aplastic Anemia on patients with relapsed/refractory aplastic anemia, and patients ineligible for antithymocyte globulin or transplantation, who received eltrombopag for at least 2 months. Forty-six patients with aplastic anemia were given eltrombopag without prior antithymocyte globulin treatment (n=11) or after antithymocyte globulin administration (n=35) in a relapsed/refractory setting. Eltrombopag (median daily dose 150 mg) was introduced 17 months (range, 8–50) after the diagnosis of aplastic anemia. At last followup, 49% were still receiving treatment, 9% had stopped due to a robust response, 2% due to toxicity and 40% due to eltrombopag failure. Before eltrombopag treatment, all patients received regular transfusions. The overall rates of red blood cell and platelet transfusion independence were 7%, 33%, 46% and 46% at 1, 3, 6 months and last follow-up. Responses were slower to develop in antithymocyte treatment-naïve patients. In patients achieving transfusion independence, hemoglobin concentration and platelet counts improved by 3 g/dL (interquartile range, 1.4–4.5) and 42×109/L (interquartile range, 11–100), respectively. Response in at least one lineage (according to National Institutes of Health criteria) was observed in 64% of antithymocyte treatment-naïve and 74% of relapsed/refractory patients, while trilineage improvement was observed in 27% and 34%, respectively. We found high rates of hematologic improvement and transfusion independence in refractory aplastic anemia patients but also in patients ineligible for antithymocyte globulin receiving first-line treatment. In conclusion, elderly patients unfit for antithymocyte globulin therapy may benefit from eltrombopag.
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Affiliation(s)
- Etienne Lengline
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France
| | - Bernard Drenou
- Department of Hematology, Hôpital Emile Muller - CH de Mulhouse, France
| | - Pierre Peterlin
- Department of Hematology, Nantes University Hospital, France
| | - Olivier Tournilhac
- Service d'Hematologie Clinique et de Therapie Cellulaire, CHU, Universite d'Auvergne, Clermont-Ferrand, France
| | - Julie Abraham
- Service d'Hématologie Clinique et Thérapie Cellulaire, CHU de Limoges, France
| | - Ana Berceanu
- Department of Hematology, Besançon University Hospital, France
| | | | - Gaelle Guillerm
- Department of Hematology and Oncology, CH Augustin Morvan, Brest, France
| | - Emmanuel Raffoux
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France
| | - Flore Sicre de Fontbrune
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France
| | - Lionel Ades
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France
| | - Marie Balsat
- Department of Hematology 1G, Centre Hospitalier Lyon Sud, Pierre Benite, France
| | - Driss Chaoui
- Department of Hematology, CH Victor Dupouy, Argenteuil, France
| | - Paul Coppo
- Department of Hematology, French Reference Center for Thrombotic Microangiopathies, Saint Antoine University Hospital, Paris, France
| | - Selim Corm
- Department of Hematology, Hôpital Privé Médipole de Savoie, Challes les Eaux, France
| | - Thierry Leblanc
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France.,Department of Pediatric Hematology, Robert-Debré University Hospital, Paris, France
| | - Natacha Maillard
- Bone Marrow Transplant Unit Clinical Hematology, Hopital La Miletrie, Poitiers University Hospital, France
| | - Louis Terriou
- Department of Internal Medicine, Clinical Immunology, Hôpital Huriez Lille University Hospital, France
| | - Gerard Socié
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France.,University Paris Denis Diderot & INSERM UMR 1160, France
| | - Regis Peffault de Latour
- Department of Hematology, CRNMR Aplasie Médullaire, Saint-Louis University Hospital - AP-HP, Paris, France
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19
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Walter SR, Day RO, Gallego B, Westbrook JI. The impact of serious adverse drug reactions: a population-based study of a decade of hospital admissions in New South Wales, Australia. Br J Clin Pharmacol 2017; 83:416-426. [PMID: 27614089 PMCID: PMC5237693 DOI: 10.1111/bcp.13124] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 08/22/2016] [Accepted: 09/05/2016] [Indexed: 11/29/2022] Open
Abstract
AIMS Adverse drug reactions (ADRs) have major impacts on patients and the hospital system. Methods identifying ADRs from selected International Classification of Diseases-10th revision (ICD-10) diagnosis and external cause codes can be applied to population-level hospital admissions data, enabling the study of rare, yet serious ADRs. The present study aimed to use ICD10-based methods to identify four types of serious idiosyncratic ADRs in Australia, and to assess changes in incidence and their impact on length of stay (LOS), readmission and in-hospital mortality. METHODS The study used a census of hospital admission data from New South Wales between July 2000 and June 2012. Changes in incidence rates over time relative to a control group were estimated using log-linear regression. To assess impacts on LOS, readmission and mortality, each ADR case was matched with five controls, and cases were compared with controls via generalized linear models appropriate to each outcome. RESULTS The incidence of three ADR types showed a significant increase over time relative to controls, while the fourth type showed no evidence of change. All ADR types were significantly associated with an increase in LOS of between 22% and 328%. Significant increases in risk of readmission or death were only observed for some ADR types. CONCLUSIONS Reducing the incidence of idiosyncratic ADRs is challenging. ICD10-based methods support population-level analyses that can provide important insights into the effects and changes in ADRs over time. This, combined with strategies related to both patient care and drug monitoring pre- and post-commercial release, provides ways forward.
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Affiliation(s)
- Scott R. Walter
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health SciencesMacquarie UniversitySydneyNSWAustralia
| | - Richard O. Day
- St Vincent's Clinical SchoolUniversity of New South Wales, St Vincent's HospitalSydneyNSWAustralia
| | - Blanca Gallego
- Centre for Health Informatics, Australian Institute of Health Innovation, Faculty of Medicine and Health SciencesMacquarie UniversitySydneyAustralia
| | - Johanna I. Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health SciencesMacquarie UniversitySydneyNSWAustralia
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20
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Fu R, Chen T, Song J, Wang G, Li L, Ruan E, Liu H, Wang Y, Wang H, Xing L, Wu Y, Liu H, Qu W, Shao Z. De-escalation empirical antibiotic therapy improved survival for patients with severe aplastic anemia treated with antithymocyte globulin. Medicine (Baltimore) 2017; 96:e5905. [PMID: 28178130 PMCID: PMC5312987 DOI: 10.1097/md.0000000000005905] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 12/13/2016] [Accepted: 12/27/2016] [Indexed: 01/05/2023] Open
Abstract
We aimed to investigate the efficacy and safety of de-escalation empirical therapy for controlling infection in patients with severe aplastic anaemia (SAA) treated with antithymocyte globulin (ATG). Eighty-seven ATG-treated SAA patients who had microbiological culture-confirmed infections from 2006 to 2015 in our center were retrospectively analyzed. The efficacy of de-escalation and non-de-escalation therapy was compared. Among all 87 patients, 63 patients were treated with de-escalation therapy and 24 patients with non-de-escalation therapy. More patients showed response to anti-infection treatment in de-escalation group than in non-de-escalation group both on day 7 (60.32% vs. 25.00%, P = 0.003) and on day 30 (79.37% vs. 58.33%, P = 0.047) since the initial antimicrobial therapy. On day 30, more patients had increased absolute neutrophil count in de-escalation group compared with non-de-escalation group (76.19% vs. 45.83%, P = 0.007), and de-escalation group had lower morality rate (17.46% vs. 37.50%, P = 0.047) and better survival outcome (P = 0.023) on day 90. Twenty-three patients in de-escalation group and 5 patients in non-escalation group received granulocyte transfusions. Granulocyte transfusions helped to control infections in both de-escalation group (P = 0.027) and non-de-escalation group (P = 0.042) on day 7, but did not improve survival on day 90. We concluded that de-escalation antibiotics improved survival in SAA patients after ATG treatment. Early administration of broad-spectrum antibiotics pending microbiological cultures combined with a commitment to change to narrow-spectrum antibiotics should be recommended for controlling infections in SAA patients treated with ATG. Granulocyte transfusions might be an adjunctive therapy in controlling infections.
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21
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Abstract
OBJECTIVE Use of high-dose cyclophosphamide without hematopoietic stem cell transplant to treat severe aplastic anemia (SAA) has been controversial due to concern for increased infectious toxicity as compared with antithymocyte globulin and cyclosporine A. As children often tolerate dose-intensive therapy better than adults, we sought to perform a detailed retrospective analysis of both treatment response and toxicity in 28 patients younger than 22 years of age treated with 29 courses of high-dose cyclophosphamide as the sole form of immunosuppression. STUDY DESIGN Children and adolescents with SAA who lacked an human leukocyte antigen-matched sibling donor were treated with cyclophosphamide 50 mg/kg/d for 4 consecutive days then received daily granulocyte colony stimulating factor until neutrophil recovery, transfusion support, and antimicrobial prophylaxis. RESULTS Overall survival was 85%, with hematologic response of 79% and complete response of 66%. Cumulative incidences of bacterial infection (86%) and fungal infection (62%) were high but deaths due to infection were rare, as were clonal evolution (1/28), clinically relevant paroxysmal nocturnal (1/28), and relapse (2/28). CONCLUSIONS Response rates and survival following high-dose cyclophosphamide in pediatric patients with SAA exceed those seen in adults and compare favorably to antithymocyte globulin/cyclosporine A with manageable infectious toxicity.
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Ye L, Jing L, Yang W, Zhou K, Peng G, Li Y, Li Y, Li J, Song L, Wu Z, Zhang F, Zhang L. [Effects of peri-immunosupressive therapy period infection on hematologic response and survival of severe aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2015; 36:670-5. [PMID: 26462637 PMCID: PMC7348267 DOI: 10.3760/cma.j.issn.0253-2727.2015.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To explore the effects of peri-immunosuppressive treatment(IST)infection on outcomes of severe and very severe aplastic anemia(SAA/VSAA)patients. METHODS Medical record and follow-up data of 105 SAA/VSAA who underwent first-line IST were retrospectively analyzed to find out the characters of infections(1 month before to 3 months after IST), and its effects on hematologic response and survival. RESULTS Of 105 patients, a total of 270 febrile episodes were recorded in 97 patients(92.4%)during their peri- IST periods, with the median infections of 2(1-7)episodes in each patient with the median febrile duration of 7(1-47)days. Respiratory system(35.1%)was the primary anatomic site of infection. Bacteria(88.2%)were common causes of total 169 pathogenic bacteria in 96 clear pathogenic bacteria episodes. And patients who got infection 1 month before IST had much lower 6- month hematologic response rate than their counterpart ones(50.8% vs 80.0%, P=0.004). Multiple febrile episodes ( ≥3 times) and the total febrile duration ≥4 days showed the best sensitivity and specificity according to the ROC curve analysis. The 5-year overall survival of the 105 patients was 76%. The 5- year OS of patients with multiple febrile episodes ( ≥3 times) were much lower than their counterpart ones[(59.6±7.2)% vs(89.5±4.0)%](P<0.01). The 5-year OS of the total febrile duration ≥4 days was much lower than their counterpart ones[(63.4±5.8)% vs 100.0%](P<0.01). CONCLUSION Infections 1 month before IST were associated with hematologic response. Multiple febrile episodes(≥3 times) and infections with the febrile duration ≥4 days presented inferior hematologic response and survival.
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Affiliation(s)
- Lei Ye
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Liping Jing
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Wenrui Yang
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Kang Zhou
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Guangxin Peng
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Yang Li
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Yuan Li
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Jianping Li
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Lin Song
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Zhijie Wu
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Fengkui Zhang
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Li Zhang
- Anemia Therapeutic Centre, Institute of Hematology and Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
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Wang H, Wu Y, Fu R, Qu W, Ruan E, Wang G, Liu H, Song J, Xing L, Guan J, Li L, Liu C, Shao Z. Granulocyte transfusion combined with granulocyte colony stimulating factor in severe infection patients with severe aplastic anemia: a single center experience from China. PLoS One 2014; 9:e88148. [PMID: 24505406 PMCID: PMC3914902 DOI: 10.1371/journal.pone.0088148] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 01/06/2014] [Indexed: 12/14/2022] Open
Abstract
Objective To investigate the efficacy and safety of granulocyte transfusion combined with granulocyte colony stimulating factor (G-CSF) in severe infection patients with severe aplastic anemia (SAA). Methods Fifty-six patients in severe infections with SAA who had received granulocyte transfusions combined with G-CSF from 2006 to 2012 in our department were analyzed. A retrospective analysis was undertaken to investigate the survival rates (at 30 days, 90 days and 180 days), the responses to treatment (at 7 days and 30 days, including microbiological, radiographic and clinical responses), the neutrophil count and adverse events after transfusion. Results All SAA patients with severe infections were treated with granulocyte transfusions combined with G-CSF. Forty-seven patients had received antithymocyte globulin/antilymphocyte globulin and cyclosporine A as immunosuppressive therapy. The median number of granulocyte components transfused was 18 (range, 3–75). The survival at 30 days, 90 days and 180 days were 50(89%), 39(70%) and 37(66%) respectively. Among 31 patients who had invasive fungal infections, the survival at 30 days, 90 days and 180 days were 27(87%), 18(58%) and 16(52%) respectively. Among the 25 patients who had refractory severe bacterial infections, the survival at 30 days, 90 days and 180 days were 23(92%), 21(84%) and 21(84%) respectively. Survival rate was correlated with hematopoietic recovery. Responses of patients at 7 and 30 days were correlated with survival rate. Common adverse effects of granulocyte transfusion included mild to moderate fever, chills, allergy and dyspnea. Conclusion Granulocyte transfusions combined with G-CSF could be an adjunctive therapy for treating severe infections of patients with SAA.
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Affiliation(s)
- Huaquan Wang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Yuhong Wu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Rong Fu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Wen Qu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Erbao Ruan
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Guojin Wang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Hong Liu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Jia Song
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Limin Xing
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Jing Guan
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Lijuan Li
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Chunyan Liu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Zonghong Shao
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
- * E-mail:
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Respiratory and Systemic Infections in Children with Severe Aplastic Anemia on Immunosuppressive Therapy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 788:417-25. [DOI: 10.1007/978-94-007-6627-3_57] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Dvorak CC, Fisher BT, Sung L, Steinbach WJ, Nieder M, Alexander S, Zaoutis TE. Antifungal prophylaxis in pediatric hematology/oncology: new choices & new data. Pediatr Blood Cancer 2012; 59:21-6. [PMID: 22102607 PMCID: PMC4008331 DOI: 10.1002/pbc.23415] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 10/11/2011] [Indexed: 12/22/2022]
Abstract
A severe complication of the treatment of pediatric cancers is the development of an invasive fungal infection (IFI). The data to support antifungal prophylaxis in pediatric oncology patients derive primarily from adult patients, and thus the optimal agent to utilize is not clear. Fluconazole has been a standard option, but agents with antimold activity are now available, each with limitations. Pediatric dosing for voriconazole and posaconazole is uncertain and multiple drug interactions exist. The echinocandins are well-tolerated, but only available in intravenous form. Ultimately, studies demonstrating biologic risk factors for the development of IFI may lead to personalized prophylactic strategies.
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Affiliation(s)
- Christopher C Dvorak
- Division of Pediatric Blood & Marrow Transplant, Department of Pediatrics, University of California San Francisco, San Francisco, California 94143-1278, USA.
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Quarello P, Saracco P, Giacchino M, Caselli D, Caviglia I, Longoni D, Varotto S, Rana I, Amendola A, Misuraca A, Licciardello M, Paolucci P, Ladogana S, Rivetti E, Dufour C, Castagnola E. Epidemiology of infections in children with acquired aplastic anaemia: a retrospective multicenter study in Italy. Eur J Haematol 2012; 88:526-34. [DOI: 10.1111/j.1600-0609.2012.01770.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zwitserloot AM, Mavinkurve-Groothuis AMC, Galama JM, Verweij PE, Hoogerbrugge PM, Warris A. Importance of neutropenia for development of invasive infections at various phases of treatment for hemato-oncological diseases in children. ACTA ACUST UNITED AC 2012; 44:355-62. [DOI: 10.3109/00365548.2011.641505] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Wang TF, Wu YF, Ho YH, Huang SC, Chu SC, Kao RH. Successful allogeneic peripheral blood stem cell transplantation with reduced intensity conditioning in a patient with severe aplastic anemia and active infection. Tzu Chi Med J 2011. [DOI: 10.1016/j.tcmj.2011.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Abstract
Acquired aplastic anemia is a potentially fatal bone marrow failure disorder that is characterized by pancytopenia and a hypocellular bone marrow. Hematopoietic stem-cell transplantation or bone marrow transplantation (BMT) is the treatment of choice for young patients who have a matched sibling donor. Immunosuppression with either anti-thymocyte globulin and cyclosporine or high-dose cyclophosphamide is an effective therapy for patients who are not suitable BMT candidates owing to age or lack of a suitable donor. Results of BMT from unrelated and mismatched donors are improving, but presently this treatment option is best reserved for those patients who do not respond, relapse or develop secondary clonal disorders following immunosuppressive therapy. Efforts are currently underway to both improve immunosuppressive regimens and to expand the application of BMT.
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Affiliation(s)
- Amy E Dezern
- Division of Medical Oncology, Department of Medicine, The Johns Hopkins School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205, USA
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Kako S, Nakasone H, Endo H, Sakamoto K, Ashizawa M, Sato M, Terasako K, Kikuchi M, Kimura SI, Okuda S, Yamazaki R, Oshima K, Tanihara A, Nishida J, Usuki K, Kanda Y. Clinical course of patients with aplastic anemia or myelodysplastic syndrome associated with persistent neutropenia. Hematol Oncol 2011; 30:82-8. [PMID: 21692099 DOI: 10.1002/hon.1001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 05/02/2011] [Accepted: 05/04/2011] [Indexed: 12/20/2022]
Abstract
Patients with aplastic anemia (AA) or myelodysplastic syndrome (MDS) often have persistent severe neutropenia and are susceptible to infectious complications. We retrospectively reviewed the clinical course of patients with AA or MDS who had neutropenia (neutrophil count < 500/µl) for more than 25 days. A total of 46 patients, 11 with AA and 35 with MDS, were included. Twenty-three patients had infectious events (IE), and the cumulative incidence of IE was 30% at 6 months and 51% at 1 year. The cumulative incidence of IE was 67% at 1 year in 30 patients who experienced very severe neutropenia of less than 200/µl. Overall survival in all patients was 76% at 6 months and 65% at 1 year. In a multivariate analysis, male sex, underlying diseases, and a neutrophil count of less than 200/µl as a time-dependent covariate significantly affected IE. In analyses that excluded patients with AA, male sex was the only factor. In conclusion, severe neutropenia was significantly associated with IE in patients with AA or MDS, and IE might be lethal. When we only considered patients with MDS, the neutrophil count alone could not be used to predict the prognosis.
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Affiliation(s)
- Shinichi Kako
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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A series of complications after third molar osteotomy in a pancytopenia patient and spontaneous healing after bone marrow transplantation. J Oral Maxillofac Surg 2011; 69:2508-12. [PMID: 21571420 DOI: 10.1016/j.joms.2011.02.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Revised: 01/04/2011] [Accepted: 02/06/2011] [Indexed: 11/24/2022]
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Abstract
Invasive mould infections represent important complications of different pediatric conditions. Epidemiology and clinical features vary according to the type of underlying conditions that determine the risk of invasive mycosis. No pediatric study has specifically evaluated the efficacy of prophylaxis or therapy invasive moulds infections, while pediatric dosages for the treatment of invasive aspergillosis are available for drugs that produced positive results in clinical trials undertaken in adults.
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Konishi H, Fukushima K, Sudo M, Sumi M, Minouchi T, Iga I, Shibata N, Yamaji A. Effect of blood decrease on micafungin disposition in rats. Eur J Drug Metab Pharmacokinet 2011; 36:35-9. [PMID: 21350921 DOI: 10.1007/s13318-011-0023-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 02/01/2011] [Indexed: 10/18/2022]
Abstract
Micafungin (MCFG) is a novel echinocandin-class antifungal agent that extensively undergoes metabolic removal in the liver. In the present study, the influence of decreased blood volume on pharmacokinetic disposition of MCFG was examined using a rat model prepared by phlebotomy. In phlebotomized rats, hematocrit level and plasma albumin concentration were decreased by 50 and 15%, respectively. Regarding the pharmacokinetic parameters of MCFG, there were no significant differences in the total body clearance (CL(tot)) and elimination rate constant (k (e)) between control and phlebotomized rat groups. A slight increase was observed in the apparent volume of distribution at steady-state (Vd(ss)), but the degree of change was minimal. These findings demonstrate that the elimination capacity for MCFG is only slightly affected by severe anemia and moderate hypoalbuminemia, and provide experimental evidence for the preceding clinical studies suggesting that neither hematocrit level nor serum albumin concentration is a contributory factor for the metabolic clearance of MCFG.
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Affiliation(s)
- Hiroki Konishi
- Laboratory of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Osaka Ohtani University, 3-11-1 Nishikiori-kita, Tondabayashi, 548-8540, Japan.
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[Requirements for hygiene in the medical care of immunocompromised patients. Recommendations from the Committee for Hospital Hygiene and Infection Prevention at the Robert Koch Institute (RKI)]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2010; 53:357-88. [PMID: 20300719 PMCID: PMC7095954 DOI: 10.1007/s00103-010-1028-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Quillen K, Wong E, Scheinberg P, Young NS, Walsh TJ, Wu CO, Leitman SF. Granulocyte transfusions in severe aplastic anemia: an eleven-year experience. Haematologica 2010; 94:1661-8. [PMID: 19996117 DOI: 10.3324/haematol.2009.010231] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Infections, particularly those caused by invasive fungi, are a major cause of death in patients with severe aplastic anemia. The purpose of this study was to analyze our experience with granulocyte transfusions in such patients. DESIGN AND METHODS A retrospective analysis was performed on all patients with severe aplastic anemia who had received granulocyte transfusions between 1997 and 2007 in our institute. Survival to hospital discharge was the primary outcome. Secondary outcomes included microbiological, radiographic and clinical responses of the infection at 7 and 30 days after initiating granulocyte therapy, and post-transfusion absolute neutrophil count, stratified by HLA alloimmunization status. RESULTS Thirty-two patients with severe aplastic anemia underwent granulocyte transfusions; the majority had received horse antithymocyte globulin and cyclosporine A. One quarter of patients had demonstrable HLA alloimmunization prior to the initiation of granulocyte therapy. Infections were evenly divided between invasive bacterial and fungal infections unresponsive to maximal antibiotic and/or antifungal therapy. The median number of granulocyte components transfused was nine (range, 2-43). The overall survival to hospital discharge was 58%. Survival was strongly correlated with hematopoietic recovery. Among the 18 patients who had invasive fungal infections, 44% survived to hospital discharge. Response at 7 and 30 days correlated with survival. The mean post-transfusion absolute neutrophil count did not differ significantly between response groups (i.e. patients grouped according to whether they had complete or partial resolution of infection, stable disease or progressive infection). There was also no difference in mean post-transfusion absolute neutrophil count between the patients divided according to HLA alloimmunization status. CONCLUSIONS Granulocyte transfusions may have an adjunctive role in severe infections in patients with severe aplastic anemia. HLA alloimmunization is not an absolute contraindication to granulocyte therapy.
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Affiliation(s)
- Karen Quillen
- Department of Transfusion Medicine, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, USA.
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Aplastic anaemia in childhood. Description of two cases and review of the literature. Open Med (Wars) 2009. [DOI: 10.2478/s11536-009-0024-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractChildhood aplastic anaemia (AA) is an uncommon but potentially fatal haematological disorder. Patients with AA receive supportive care based on transfusions and timely treatment of opportunistic infections, along with specific therapies, which may be bone marrow transplantation and immunosuppressive therapy. Early diagnosis and supportive therapy are required to prevent fatal complications like overwhelming sepsis or life threatening haemorrhages. We report two cases of aplastic anaemia having a different aetiology. The diagnostic work-up and the therapeutic management for each case are described below.
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Walsh TJ. Advances and challenges in infectious diseases supportive care of patients with hematologic malignancies, hematopoietic stem cell transplantation, and severe aplastic anemia. Semin Hematol 2009; 46:191-7. [PMID: 19549573 DOI: 10.1053/j.seminhematol.2009.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Infectious diseases are important causes of morbidity and mortality in immunocompromised patients with hematological malignancies, severe aplastic anemia (SAA), and myelodysplasia. Major advances in infectious diseases supportive care have been critical to improving the outcome of patients suffering from these life-threatening diseases. Advances in diagnosis, treatment, and prevention of life-threatening infections have reduced morbidity and mortality, improved quality of life, and enabled the use of potentially curative chemotherapy, radiation, hematopoietic stem cell transplantation (HSCT), and immunosuppressive therapy to patients battling these devastating diseases. Despite these advances, the continued development of antimicrobial resistance, emergence of new pathogens, and the evolution of host factors present evolving challenges to the successful management of infectious complications in this expanding patient population.
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Affiliation(s)
- Thomas J Walsh
- Immunocompromised Host Section, Pediatric Oncology Branch, National Cancer Institute, Bethesda, MD 20892, USA
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George B, Mathews V, Viswabandya A, Srivastava A, Chandy M. Fludarabine-based reduced intensity conditioning regimens for allogeneic hematopoietic stem cell transplantation in patients with aplastic anemia and fungal infections. Clin Transplant 2009; 23:228-32. [DOI: 10.1111/j.1399-0012.2008.00909.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Potenza L, Barozzi P, Codeluppi M, Morselli M, Forghieri F, Volzone F, Riva G, Pietrosemoli P, Pecorari M, Leonardi G, Torelli G, Luppi M. Epstein-Barr virus associated pneumonia in an adult patient with severe aplastic anaemia: resolution after the transient withdrawal of cyclosporine. Am J Hematol 2007; 82:944-6. [PMID: 17617784 DOI: 10.1002/ajh.20950] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Cortez KJ, Lyman CA, Kottilil S, Kim HS, Roilides E, Yang J, Fullmer B, Lempicki R, Walsh TJ. Functional genomics of innate host defense molecules in normal human monocytes in response to Aspergillus fumigatus. Infect Immun 2006; 74:2353-65. [PMID: 16552065 PMCID: PMC1418921 DOI: 10.1128/iai.74.4.2353-2365.2006] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Aspergillus fumigatus induces the release of innate immune-related molecules from phagocytic cells early in the course of infection. Little is known, however, about the complex expression profiles of the multiple genes involved in this response. We therefore investigated the kinetics of early gene expression in human monocytes (HMCs) infected with conidia of A. fumigatus using DNA microarray analysis. Total RNA from HMCs at 0, 2, 4, and 6 h was extracted, linearly amplified, hybridized onto Affymetrix HG133 Plus 2.0 gene chips, and analyzed with an Affymetrix scanner. Changes in gene expression were calculated as a ratio of those expressed by infected versus control HMCs. Aspergillus fumigatus induced differential regulation of expression in 1,827 genes (P < 0.05). Genes encoding cytokines and chemokines involved in host defense against A. fumigatus, including interleukin-1beta (IL-1beta), IL-8, CXCL2, CCL4, CCL3, and CCL20, as well as the opsonin long pentraxin 3, were up-regulated during the first 2 to 6 h, coinciding with an increase in phagocytosis. Simultaneously, genes encoding CD14, ficolin1, and MARCO were down-regulated, and genes encoding IL-10 and matrix metalloproteinase 1 were up-regulated. Up-regulation of the genes encoding heat shock proteins 40 and 110 and connexins 26 and 30 may point to novel molecules whose role in the pathogenesis of aspergillosis has not been previously reported. Verification of the transcriptional profiling was obtained for selected genes by reverse transcription-PCR and enzyme immunoassay. Thus, A. fumigatus conidia induced a coordinated expression of genes important in host defense and immunomodulation.
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Affiliation(s)
- Karoll J Cortez
- Immunocompromised Host Section, Pediatric Oncology Branch, National Cancer Institute, NIH, 10 Center Drive, CRC Rm. 1-5250, Bethesda, MD 20892-1882, USA
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Abstract
BACKGROUND Few studies concerning oral manifestations of aplastic anemia (AA) in children have been reported. The purpose of the authors' study was to describe oral lesions in children with AA. METHODS The authors conducted a retrospective review using medical records of children diagnosed with AA who were treated at the Pediatric Service of the Regional Hospital of Concepción, Chile, between March 1996 and May 2001. They recorded episodes of oral mucosal lesions and assessed platelet and neutrophil counts at the time the oral lesions appeared. RESULTS Twelve children (nine boys and three girls) were diagnosed with AA. Their age range was 3 to 12 years (median age, 7 years). Nine subjects were receiving immunosuppressive therapy, and three received only supportive care. The most common oral manifestation of the disease was hemorrhage, which developed most often in patients with platelet counts less than 25 x 10(9) cells/liter. The second and third most common oral manifestations were candidiasis and viral infection, respectively. CONCLUSIONS Children with AA frequently exhibit oral manifestations of the condition. Prevention, early diagnosis and proper treatment of oral complications are essential to diminish morbidity and avoid a possible fatal outcome. CLINICAL IMPLICATIONS Oral lesions can be the first manifestation of AA; consequently, dentists should be aware of these manifestations so that an early diagnosis of the disease can be made.
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Affiliation(s)
- Ester Sepúlveda
- Department of Diagnosis and Oral Pathology, University of Concepción, Concepción, Chile
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Jeng MR, Naidu PE, Rieman MD, Rodriguez-Galindo C, Nottage KA, Thornton DT, Li CS, Wiang WC. Granulocyte-macrophage colony stimulating factor and immunosuppression in the treatment of pediatric acquired severe aplastic anemia. Pediatr Blood Cancer 2005; 45:170-5. [PMID: 15593082 DOI: 10.1002/pbc.20278] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Immunosuppressive therapy (IS) is effective in the treatment of patients with acquired severe aplastic anemia (SAA). An enhanced myeloid response and decreased infection risk may be possible with the addition of a hematopoietic cytokine. Published data on the combination of cytokines and IS in patients with SAA are limited. The addition of G-CSF to IS shortens the time to neutrophil count recovery, but may not improve overall survival. Because GM-CSF acts differently than G-CSF, its use in combination with IS may be different. PROCEDURE A retrospective chart review was performed on patients diagnosed with SAA and treated with IS and GM-CSF at St. Jude Children's Research Hospital. Hematologic recovery, prognostic factors, and infection data were collected. RESULTS Eighteen patients were included in this study. The median age at diagnosis was 7.2 years (range 1.8-17.0). Ten patients (56%) had a complete response, four (22%) a partial response, and four (22%) no response. Median time to erythrocyte and platelet transfusion independence were 90 (18,243) and 64 days (18-243), and to discontinuation of treatment 287 days (90-730). Median time to partial (ANC > 500) and full (ANC > 1,500) neutrophil recovery were 41 and 51 days, respectively. Seventeen documented discrete infections occurred in six patients over 36 patient years. CONCLUSIONS GM-CSF, in addition to IS, may shorten time to neutrophil count recovery, may be beneficial in decreasing infection rates, and may improve platelet response in patients with SAA. However, consistent with studies utilizing G-CSF, GM-CSF probably does not affect overall response rate. To fully answer whether or not cytokine therapy is of added value to IS in pediatric patients, a multi-institutional randomized trial is needed.
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Affiliation(s)
- Michael R Jeng
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California 94305, USA.
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