Invasive Central Nervous System Aspergillosis in a Patient Receiving Long-term Acalabrutinib Therapy

Fungal infection in patients treated with Bruton tyrosine kinase inhibitor-from epidemiology to clinical outcome: a systematic review

BACKGROUND

The Bruton tyrosine kinase inhibitor (BTKi) has emerged as a key treatment for B-cell lymphomas. Despite its efficacy in the treatment of malignancies, numerous cases of invasive fungal infections (IFI) have been reported in patients receiving ibrutinib, a first-generation BTKi. Cases of invasive aspergillosis have also been reported with acalabrutinib and zanubrutinib.

OBJECTIVES

The objective of this study was to provide an overview of the pathogens involved, the time of onset of infections and factors influencing survival.

METHODS

Data sources: PubMed, Embase and Web of Science databases were used, and the results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

STUDY ELIGIBILITY CRITERIA

Case reports, case series, clinical trials and cohort studies were included.

PARTICIPANTS

All reported cases of IFI in patients treated with BTKi were analysed. For case reports/case series, demographic, microbiological and outcome data were retrieved. Assessment of risk of bias: Given the significant heterogeneity in clinical trials/cohort studies, only epidemiological analysis was performed, without formal incidence analysis. Methods of data synthesis: Epidemiologic data were presented as descriptive statistics.

RESULTS

In total, 25 215 patients from 92 retrospective and prospective clinical trials/cohort studies and 211 patients from 115 case reports/case series were included. Among clinical trials/cohorts, 736 IFI were reported, including 234 candidiasis (31.8%), 227 aspergillosis (30.8%) and 124 Pneumocystis jirovecii pneumonia (PJP) (16.8%). Among the case reports/case series, 155 (73.5%) had chronic lymphocytic leukaemia, and 56 (26.5%) had other malignancies. The main IFI were aspergillosis (n = 107, 50.7%), cryptococcosis (n = 33, 15.6%), PJP (n = 26, 12.3%) and mucormycosis (n = 23, 10.9%). The median delay between the initiation of BTKi and IFI was 2.3, 4.0, 3.0 and 3.0 for aspergillosis, cryptococcosis, PJP and mucormycosis, respectively. The survival rate improved when BTKi was discontinued during infection.

CONCLUSIONS

Targeted therapies in lymphocytic malignancies raised new issues concerning infectious complications. Monitoring IFI in patients receiving second- and third-generation BTKi is crucial for improving the management of these manifestations.

Strongyloides stercoralis infection in a DLBCL patient treated with rituximab and BTK inhibitor: A case report and literature review

RATIONALE

Diffuse large B-cell lymphoma (DLBCL) is a common subtype of non-Hodgkin's lymphoma characterized by high malignancy, rapid onset and aggressive clinical behavior. The disease exhibits considerable heterogeneity, which influences clinical and immunophenotypic characteristics, which in turn affect treatment outcomes and prognosis. Recently, targeted therapies have been introduced, offering improved therapeutic efficacy but with risks such as immunosuppression and opportunistic infections.

PATIENT CONCERNS

We report a case of a patient diagnosed with DLBCL who experienced immunosuppression as a result of treatment with rituximab and a Bruton's tyrosine kinase inhibitor, which subsequently led to Strongyloides stercoralis infection.

DIAGNOSES

The patient was diagnosed with S. stercoralis infection, confirmed by appropriate diagnostic tests after the onset of clinical symptoms suggestive of parasitic infection.

INTERVENTIONS

The patient was treated with a combination of rituximab and a Bruton's tyrosine kinase inhibitor as part of her DLBCL therapy. Antiparasitic treatment was started after diagnosis of S. stercoralis infection.

OUTCOMES

The patient's infection was successfully managed with antiparasitic therapy, although the case highlights the need for vigilant monitoring of immunosuppressive therapy in patients with DLBCL due to the risk of opportunistic infections.

LESSONS

This case highlights the potential complications of targeted therapies in DLBCL, particularly the risk of opportunistic infections such as S. stercoralis. It highlights the importance of careful patient monitoring and prompt intervention to effectively manage such infections.

Evaluation of infectious morbidity due to BTK inhibitors in indolent B-cell lymphomas: latest research findings and systematic analysis

INTRODUCTION

Randomized clinical trials (RCTs) have suggested that BTK inhibitors (BTKis) might increase infectious disease (ID) risk. Systematic analysis of this topic as derived from RCTs and clinical practice is needed.

AREAS COVERED

An extensive Medline, Embase, and Cochrane search of peer-reviewed sources reporting on ID morbidity in patients on BTKis was performed (1 January 2014 - 31 December 2023). Contribution of intrinsic immune defects in indolent B-cell lymphomas to this morbidity was carefully considered.

EXPERT OPINION

Patients with indolent B-cell lymphomas display a wide range of innate and adaptive immune defects. In addition, BTKi use is linked with an increased signal of upper respiratory tract infections (URTIs) and pneumonias, mainly grade 1-2. These agents also increase the risk of rare invasive fungal infections (IFIs), mainly due to Cryptococcus and Aspergillus spp. with a peak within several months after the start of therapy. More than half of these IFIs are fatal. Research suggests a similar ID risk across 1st, 2nd and 3rd generations of BTKis, all causing B-cell dysfunction due to BTK inhibition, along with off-target functional neutrophil/macrophage alterations. Expanding the knowledge base on ID morbidity in patients on BTKis would facilitate timely diagnosis and treatment, and improve clinical outcomes.

Invasive Aspergillosis with impaired neutrophil responses against Aspergillus fumigatus in patients treated with Acalabrutinib-findings from three cases

OBJECTIVES

Ibrutinib, a first-generation covalent Bruton's tyrosine kinase inhibitor (BTKi) was found to be a risk factor for the occurrence of invasive fungal complications. Acalabrutinib is a second-generation covalent BTKi used to treat B-cell malignancies. Healthy donor neutrophils incubated ex vivo with acalabrutinib lose ability to control Aspergillus conidia germination. In patients receiving acalabrutinib, the potential effect on neutrophil antifungal activity is unknown. Furthermore, only two cases of invasive aspergillosis have been reported during treatment with acalabrutinib, outside of a few cases in a clinical trial.

METHODS

We describe three new cases of invasive aspergillosis occurring within the first months of acalabrutinib therapy in patients with chronic lymphocytic leukemia. We used videomicroscopy and flow cytometry approaches to investigate the basic functional responses against Aspergillus of neutrophils from acalabrutinib-treated patients.

RESULTS

We showed an alteration in the anti-Aspergillus response after 1 month of acalabrutinb therapy: neutrophils lost their capacities of killing Aspergillus fumigatus germinating conidia and decreased their reactive oxygen species production when stimulated by Aspergillus.

CONCLUSIONS

It is important to follow-up patients treated with acalabrutinib for the risk of aspergillosis as well as those treated with ibrutinib.