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Eglenen Polat B, Safi D, Hafez M, Kamran A. Pembrolizumab-Induced Myasthenia Gravis: A Case Report and Review of the Literature. Cureus 2023; 15:e41087. [PMID: 37519591 PMCID: PMC10378713 DOI: 10.7759/cureus.41087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 08/01/2023] Open
Abstract
Myasthenia gravis (MG) is one of the most common neuromuscular adverse effects of immune checkpoint inhibitors (ICIs) and can result in significant morbidity and mortality when it affects the bulbar and respiratory muscles. Diagnosing immune-related MG (irMG) is challenging due to its nonspecific presentation and high negativity rate for MG antibody markers. Patients, primary care providers, and emergency care providers should be educated about MG as a potential adverse effect of ICIs for timely diagnosis and intervention.
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Affiliation(s)
- Buse Eglenen Polat
- Internal Medicine, West Virginia University (WVU) Medicine Camden Clark Medical Center, Parkersburg, USA
| | - Danish Safi
- Hematology and Medical Oncology, West Virginia University School of Medicine, Morgantown, USA
| | - Maria Hafez
- Hematology and Medical Oncology, West Virginia University School of Medicine, Morgantown, USA
| | - Amir Kamran
- Hematology and Medical Oncology, Charleston Area Medical Center, Charleston, USA
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Martens A, Schauwvlieghe PP, Madoe A, Casteels I, Aspeslagh S. Ocular adverse events associated with immune checkpoint inhibitors, a scoping review. J Ophthalmic Inflamm Infect 2023; 13:5. [PMID: 36811715 PMCID: PMC9947214 DOI: 10.1186/s12348-022-00321-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/11/2022] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICIs) have become an important part of the treatment of multiple cancers, especially for advanced melanoma and non-small cell lung cancer. Some tumors are capable of escaping immunosurveillance by stimulating checkpoints on T-cells. ICIs prevent activation of these checkpoints and thereby stimulate the immune system and indirectly the anti-tumor response. However, the use of ICIs is associated with various adverse events. Ocular side effects are rare but may have a major impact on the quality of life of the patient. METHODS A comprehensive literature search of the medical databases Web of Science, Embase and PubMed was performed. Articles that provided a comprehensive description of a case report containing 1) cancer patient(s) treated with (a combination of) immune checkpoint inhibitors, and 2) assessed occurrence of ocular adverse events, were included. A total of 290 case reports were included. RESULTS Melanoma (n = 179; 61.7%) and lung cancer (n = 56; 19.3%) were the most frequent reported malignancies. The primary used ICIs were nivolumab (n = 123; 42.5%) and ipilimumab (n = 116; 40.0%). Uveitis was most the common adverse event (n = 134; 46.2%) and mainly related to melanoma. Neuro-ophthalmic disorders, including myasthenia gravis and cranial nerve disorders, were the second most common adverse events (n = 71; 24.5%), mainly related to lung cancer. Adverse events affecting the orbit and the cornea were reported in 33 (11.4%) and 30 cases (10.3%) respectively. Adverse events concerning the retina were reported in 26 cases (9.0%). CONCLUSION The aim of this paper is to provide an overview of all reported ocular adverse events related to the use of ICIs. The insights retrieved from this review might contribute to a better understanding of the underlying mechanisms of these ocular adverse events. Particularly, the difference between actual immune-related adverse events and paraneoplastic syndromes might be relevant. These findings might be of great value in establishing guidelines on how to manage ocular adverse events related to ICIs.
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Affiliation(s)
- A. Martens
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - P. P. Schauwvlieghe
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - A. Madoe
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - I. Casteels
- grid.410569.f0000 0004 0626 3338Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - S. Aspeslagh
- grid.411326.30000 0004 0626 3362Department of Medical Oncology, University Hospital Brussels, Brussels, Belgium
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Seligman C, Chang YM, Luo J, Garden OA. Exploring the role of immune checkpoint inhibitors in the etiology of myasthenia gravis and Lambert-Eaton myasthenic syndrome: A systematic review. Front Neurol 2023; 13:1004810. [PMID: 36698907 PMCID: PMC9868566 DOI: 10.3389/fneur.2022.1004810] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
Background While immune checkpoint inhibitors (ICIs) have been revolutionary in the treatment of cancer, their administration has been associated with a variety of immune-related adverse events (irAEs), including myasthenia gravis (MG), and Lambert-Eaton myasthenic syndrome (LEMS). Objective To provide a comprehensive synthesis of the evidence supporting an etiological role for ICIs in MG and LEMS in patients with no prior history of autoimmune disease. Hypothesis ICIs may trigger MG and LEMS in patients with no prior susceptibility to autoimmune disease. Methods Relevant primary research on Medline was interrogated using a series of search algorithms. Search terms were constructed based on the PICOS tool endorsed by the Cochrane Collaboration, which describes population, intervention, comparison, outcomes, and study design. Papers were screened according to inclusion and exclusion criteria. Additional papers were retrieved from the reference lists of screened papers. Each paper included in the qualitative synthesis was assigned an integrated metric of evidence (IME) value, ranging from 0 to 7, based on study design, quality of data, likelihood of a causal link between the immune checkpoint inhibitor(s) and MG/LEMS, confidence of MG/LEMS diagnosis, and the number of patients treated with an ICI prior to MG/LEMS diagnosis. Results Ninety-four papers describing at least one patient treated with ICI(s) prior to the onset of MG and/or LEMS were documented. Overall evidence for a causal link between ICI administration and MG/LEMS was low, with a median IME value of 2.88 (range 2.05-6.61). Conclusions There is a paucity of evidence in support of an etiological relationship between ICIs and MG/LEMS, due largely to the lack of mechanistic studies and/or prospective clinical trials with relevant study endpoints. The current literature is dominated by case reports and retrospective cohort studies, which inherently yield only low-level evidence, supporting the need for further work in this area. A role of ICIs in the etiology of MG/LEMS remains plausible, arguing for continued vigilance for irAEs in patients treated with these drugs. We argue that there is a need for future mechanistic, high quality, large-scale studies specifically investigating the possible etiological role of ICIs in MG/LEMS.
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Affiliation(s)
- Carly Seligman
- Garden & Luo Immune Regulation Laboratory, Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Yu-Mei Chang
- Department of Comparative Biomedical Sciences, Royal Veterinary College, University of London, London, United Kingdom
| | - Jie Luo
- Garden & Luo Immune Regulation Laboratory, Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Oliver A. Garden
- Garden & Luo Immune Regulation Laboratory, Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States,Dean's Office, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, United States,*Correspondence: Oliver A. Garden ✉
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Zhou L, Wei X. Ocular Immune-Related Adverse Events Associated With Immune Checkpoint Inhibitors in Lung Cancer. Front Immunol 2021; 12:701951. [PMID: 34504488 PMCID: PMC8421677 DOI: 10.3389/fimmu.2021.701951] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/05/2021] [Indexed: 02/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are novel immunotherapy-based drugs that have become increasingly popular in the treatment of lung cancer. Researchers have recognized ocular immune-related adverse events (irAEs) secondary to ICIs because of their vision-threatening characteristics. However, they are incompletely characterized and no studies have reported the ICI-related ocular irAEs in lung cancer. Therefore, we aimed to comprehensively illustrate the clinical characteristics, contributory factors, diagnosis, and management of ICI-related ocular irAEs in lung cancer, based on previously reported 79 patients. Ophthalmoplegia (40.51%), uveitis (20.25%), and dry eye (17.72%) were the most common ICI-related ocular irAEs in lung cancer. Ptosis was the most common (36.71%) and the highest mortality (23.33%) of ophthalmoplegia. Patients in Asia and patients who underwent combination therapy with programmed cell death-1 and cytotoxic T-lymphocyte-associated antigen 4 inhibitors demonstrated significantly higher frequency of ophthalmoplegia than other ocular irAEs. Most ICI-related ophthalmoplegia and uveitis in lung cancer were observed in the first 10 weeks following the initiation of ICIs. Furthermore, the onset time of dry eye and other ocular irAEs was much longer. In addition, 92.31% of the patients with ocular irAEs other than ophthalmoplegia could be remised. In conclusion, ocular irAEs secondary to ICIs in lung cancer are non-negligible, particularly ophthalmoplegia. Ethnicity and the type of ICIs play important roles in the distribution of ocular irAEs. ICI-related ophthalmoplegia in lung cancer presented with early onset and worse prognosis features, thus necessitating further attention.
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Affiliation(s)
- Lin Zhou
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Wei
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China
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Trontzas IP, Rapti VE, Syrigos NK, Kounadis G, Perlepe N, Kotteas EA, Bamias G. Enteric plexus neuropathy associated with PD-L1 blockade in a patient with small-cell lung cancer. Immunotherapy 2021; 13:1085-1092. [PMID: 34247513 DOI: 10.2217/imt-2020-0350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Immune checkpoint inhibitors have revolutionized the management of patients with cancer. The increasing use of these agents has brought up a new set of adverse events which are widely heterogenous and potentially life-threatening. Rare immune-related adverse events associated with nervous system have not been described thoroughly, but their early recognition and management may be crucial. Immune-related autonomic neuropathy may be presented with a constellation of symptoms ranging from gastrointestinal and urinary complaints, to sweating and hypotension. Intestinal pseudo-obstruction as consequence of immune-related myenteric autonomic neuropathy is an under-recognized, not-well described and potentially fatal adverse event. We herein, present a unique case of enteric plexus neuropathy induced by PD-L1 blockade in a patient with small-cell lung cancer.
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Affiliation(s)
- Ioannis P Trontzas
- 3rd Department of Internal Medicine, Oncology Unit, Sotiria General Hospital, Athens School of Medicine, 11527, Greece
| | - Vasiliki E Rapti
- 3rd Department of Internal Medicine, Oncology Unit, Sotiria General Hospital, Athens School of Medicine, 11527, Greece
| | - Nikolaos K Syrigos
- 3rd Department of Internal Medicine, Oncology Unit, Sotiria General Hospital, Athens School of Medicine, 11527, Greece
| | - George Kounadis
- 3rd Department of Internal Medicine, Gastroenterology Unit, Sotiria General Hospital, Athens School of Medicine, 11527, Greece
| | - Nikoleta Perlepe
- 3rd Department of Internal Medicine, Gastroenterology Unit, Sotiria General Hospital, Athens School of Medicine, 11527, Greece
| | - Elias A Kotteas
- 3rd Department of Internal Medicine, Oncology Unit, Sotiria General Hospital, Athens School of Medicine, 11527, Greece
| | - Giorgos Bamias
- 3rd Department of Internal Medicine, Gastroenterology Unit, Sotiria General Hospital, Athens School of Medicine, 11527, Greece
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Yu CW, Yau M, Mezey N, Joarder I, Micieli JA. Neuro-ophthalmic Complications of Immune Checkpoint Inhibitors: A Systematic Review. Eye Brain 2020; 12:139-167. [PMID: 33173368 PMCID: PMC7648547 DOI: 10.2147/eb.s277760] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/24/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICIs) are novel cancer therapies that may be associated with immune-related adverse events (IRAEs) and come to the attention of neuro-ophthalmologists. This systematic review aims to synthesize the reported ICI-associated IRAEs relevant to neuro-ophthalmologists to help in the diagnosis and management of these conditions. METHODS A systematic review of the literature indexed by MEDLINE, Embase, CENTRAL, and Web of Science databases was searched from inception to May 2020. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Primary studies on ICIs and neuro-ophthalmic complications were included. Outcomes included number of cases and incidence of neuro-ophthalmic IRAEs. RESULTS Neuro-ophthalmic complications of ICIs occurred in 0.46% of patients undergoing ICI and may affect the afferent and efferent visual systems. Afferent complications include optic neuritis (12.8%), neuroretinitis (0.9%), and giant cell arteritis (3.7%). Efferent complications include myasthenia gravis (MG) (45.0%), thyroid-like eye disease (11.9%), orbital myositis (13.8%), general myositis with ptosis (7.3%), internuclear ophthalmoplegia (0.9%), opsoclonus-myoclonus-ataxia syndrome (0.9%), and oculomotor nerve palsy (0.9%). Pembrolizumab was the most common causative agent for neuro-ophthalmic complications (32.1%). Mortality was highest for MG (19.8%). Most patients (79.8%) experienced improvement or complete resolution of neuro-ophthalmic symptoms due to cessation of ICI and immunosuppression with systemic corticosteroids. CONCLUSION While incidence of neuro-ophthalmic IRAEs is low, clinicians involved in the care of cancer patients must be aware of their presentation to facilitate prompt recognition and management. Collaboration between oncology and neuro-ophthalmology teams is required to effectively manage patients and reduce morbidity and mortality.
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Affiliation(s)
- Caberry W Yu
- Faculty of Medicine, Queen’s University, Kingston, Canada
| | - Matthew Yau
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Natalie Mezey
- Faculty of Medicine, Queen’s University, Kingston, Canada
| | - Ishraq Joarder
- Faculty of Science, University of Toronto, Scarborough, Ontario, Canada
| | - Jonathan A Micieli
- Department of Ophthalmology and Vision Sciences and Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
- Kensington Vision and Research Centre, Toronto, Canada
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Su C, Wang H, Liu Y, Guo Q, Zhang L, Li J, Zhou W, Yan Y, Zhou X, Zhang J. Adverse Effects of Anti-PD-1/PD-L1 Therapy in Non-small Cell Lung Cancer. Front Oncol 2020; 10:554313. [PMID: 33072580 PMCID: PMC7531287 DOI: 10.3389/fonc.2020.554313] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/14/2020] [Indexed: 12/19/2022] Open
Abstract
Currently, immunotherapy has shown great efficacy in clinical trials, and monoclonal antibodies directed against immune checkpoint PD-1/PD-L1 have shown encouraging results in first-line or second-line treatment of non-small cell lung cancer patients. Meanwhile, anti-PD-1/PD-L1 immune checkpoint drugs combined with other treatments, such as chemotherapy, targeted therapy as well as anti-CTLA-4 checkpoint therapy, are considered an attractive treatment with higher efficacy. However, toxicity associated with PD-1/PD-L1 blockade is worth attention. Understanding the adverse effects caused by anti-PD-1/PD-L1 immunosuppressive agents is vital to guide the clinical rational use of drug. In this review, we summarized the adverse effects that occurred during the clinical use of anti-PD-1/PD-L1 inhibitors in the treatment of non-small cell lung cancer and discussed how to effectively manage and respond to these adverse reactions.
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Affiliation(s)
- Chaoyue Su
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China.,School of Public Health, Hainan Medical University, Haikou, China
| | - Hui Wang
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China.,Guangzhou Institute of Pediatrics/Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yunru Liu
- School of Public Health, Hainan Medical University, Haikou, China
| | - Qiaoru Guo
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Lingling Zhang
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Jiajun Li
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Wenmin Zhou
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Yanyan Yan
- Institute of Immunology and School of Medicine, Shanxi Datong University, Datong, China
| | - Xinke Zhou
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Jianye Zhang
- The Fifth Affiliated Hospital, Key Laboratory of Molecular Target and Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, China.,School of Public Health, Hainan Medical University, Haikou, China
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Comont T, Belliere J, Sibaud V, Alric L, Meyer N, Mazières J, Caron P, Acket B, Michot JM, Beyne-Rauzy O, Lambotte O. [Immune-related adverse events after immune checkpoints inhibitors in 2019: An update]. Rev Med Interne 2019; 41:37-45. [PMID: 31668882 DOI: 10.1016/j.revmed.2019.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/23/2019] [Accepted: 09/26/2019] [Indexed: 12/11/2022]
Abstract
Use of checkpoint inhibitors to treat cancer was one of the most important revolution these last years and an increasing number of new types of tumors is currently under investigation with these new treatments. However, immune-related adverse events associated with these agents frequently affect various organs, mimicking auto-immune or inflammatory diseases. Some of these effects can be severe, often requiring hospitalization and specialized treatment (immunosuppression). Most known agents are ipilimumab (anti-CTLA-4 antibody) nivolumab and pembrolizumab (anti-PD-1 antibodies). New molecules are now approved or in development as anti-PD-L1 antibodies, anti-LAG-3 or anti-TIM-3 antibodies, increasing the probability and new description of immune-related adverse events. With his experience in auto-immune diseases, the immunologist/internal medicine specialist has an important role in the management of these toxicities. The goal of this review is to focus on the incidence, diagnostic assessment and recommended management of the most relevant immune-related adverse events.
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Affiliation(s)
- T Comont
- Service de médecine interne et immunopathologie, centre hospitalier universitaire de Toulouse, institut universitaire du cancer de Toulouse Oncopôle, 31100 Toulouse, France; UFR Purpan, université Toulouse III Paul-Sabatier, 31100, Toulouse, France; UMR1037-Inserm, ERL5294 CNRS, centre de recherche en cancérologie de Toulouse, 31100 Toulouse, France.
| | - J Belliere
- Département de néphrologie et transplantation d'organe, hôpital Rangueil, centre hospitalier universitaire de Toulouse, 31400 Toulouse, France
| | - V Sibaud
- Service d'oncodermatologie, institut universitaire du cancer de Toulouse oncopôle, centre hospitalier universitaire de Toulouse, 31100 Toulouse, France
| | - L Alric
- Service de médecine interne et immunologie clinique, hôpital Rangueil, centre hospitalier universitaire de Toulouse, 31400 Toulouse, France
| | - N Meyer
- UMR1037-Inserm, ERL5294 CNRS, centre de recherche en cancérologie de Toulouse, 31100 Toulouse, France; Service d'oncodermatologie, institut universitaire du cancer de Toulouse oncopôle, centre hospitalier universitaire de Toulouse, 31100 Toulouse, France
| | - J Mazières
- Service de pneumologie hôpital Larey, centre hospitalier universitaire de Toulouse, 31400 Toulouse, France
| | - P Caron
- Service d'endocrinologie et maladies métaboliques, hôpital Larrey, centre hospitalier universitaire de Toulouse, 31400 Toulouse, France
| | - B Acket
- Service de neurologie, hôpital Pierre-Paul-Riquet, centre hospitalier universitaire de Toulouse, 31400 Toulouse, France
| | - J-M Michot
- Département des innovations thérapeutiques et essais Précoces, Gustave-Roussy, université Paris-Saclay, 94800 Villejuif, France
| | - O Beyne-Rauzy
- Service de médecine interne et immunopathologie, centre hospitalier universitaire de Toulouse, institut universitaire du cancer de Toulouse Oncopôle, 31100 Toulouse, France; UFR Purpan, université Toulouse III Paul-Sabatier, 31100, Toulouse, France; UMR1037-Inserm, ERL5294 CNRS, centre de recherche en cancérologie de Toulouse, 31100 Toulouse, France
| | - O Lambotte
- Service de médecine interne et immunologie clinique, hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, 94270 Le Kremlin-Bicêtre, France; UMR1184 université Paris-Sud, INSERM, CEA, immunologie des infections virales et des maladies autoimmunes, 94276 Le Kremlin-Bicêtre, France
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