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Honkila M, Niinimäki R, Taskinen M, Kuismin O, Kettunen K, Saarela J, Turunen S, Renko M, Tapiainen T. A nearly fatal primary Epstein-Barr virus infection associated with low NK-cell counts in a patient receiving azathioprine: a case report and review of literature. BMC Infect Dis 2019; 19:404. [PMID: 31077135 PMCID: PMC6509764 DOI: 10.1186/s12879-019-4022-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 04/25/2019] [Indexed: 12/14/2022] Open
Abstract
Background Symptomatic primary Epstein-Barr virus infection is a usually self-limiting illness in adolescents. We present a case of an adolescent who had been receiving azathioprine for inflammatory bowel disease for four years and developed a life-threatening primary Epstein-Barr virus infection successfully treated with rituximab. Case presentation An 11-year-old girl presented with chronic, bloody diarrhea. Endoscopic biopsies confirmed a diagnosis of chronic ulcerative colitis with features of Crohn’s disease. Azathioprine was initiated after one year due to active colitis. She responded well and remission was achieved. At the age of 16 years she developed a life-threatening Epstein-Barr virus infection including severe multiple organ failure and was critically ill for 4 weeks in the intensive care unit. Natural killer cells were virtually absent in the lymphocyte subset analysis. Azathioprine was stopped on admission. She was initially treated with corticosteroids, acyclovir and intravenous immunoglobulin. Approximately 30 days after admission, she developed signs of severe hepatitis and pneumonitis and received weekly rituximab infusions for 8 weeks. Primary immunodeficiency was excluded by whole exome sequencing in two independent laboratories. Persistent viremia stopped when the natural killer cell count started to rise, approximately 90 days after the cessation of azathioprine. Conclusions We found 17 comparable cases in the literature. None of the previous cases reported in the literature, who had been treated with azathioprine and developed either a severe or a fatal Epstein-Barr virus infection, underwent full genetic and prospective immunological workup to rule out known primary immunodeficiencies. Recently, azathioprine has been shown to cause rather specific immunosuppression, resulting in natural killer cell depletion. Our case demonstrates that slow recovery from azathioprine-induced natural killer cell depletion, 3 months after the stopping of azathioprine, coincided with the clearance of viremia and clinical recovery. Finally, our choice of treating the patient with rituximab, as previously used for patients with a severe immunosuppression and Epstein-Barr virus viremia, appeared to be successful in this case. We suggest testing for Epstein-Barr virus serology before starting azathioprine and measuring natural killer cell counts during the treatment to identify patients at risk of developing an unusually severe primary Epstein-Barr virus infection.
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Affiliation(s)
- Minna Honkila
- Department of Children and Adolescents, Oulu University Hospital, P.O. Box 23, FIN-90029 OYS, Oulu, Finland. .,PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland.
| | - Riitta Niinimäki
- Department of Children and Adolescents, Oulu University Hospital, P.O. Box 23, FIN-90029 OYS, Oulu, Finland.,PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Mervi Taskinen
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Helsinki University Hospital, Helsinki, Finland
| | - Outi Kuismin
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland.,Department of Clinical Genetics, Oulu University Hospital, Oulu, Finland
| | - Kaisa Kettunen
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Janna Saarela
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
| | - Sami Turunen
- Department of Children and Adolescents, Oulu University Hospital, P.O. Box 23, FIN-90029 OYS, Oulu, Finland
| | - Marjo Renko
- Department of Children and Adolescents, Oulu University Hospital, P.O. Box 23, FIN-90029 OYS, Oulu, Finland.,PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Terhi Tapiainen
- Department of Children and Adolescents, Oulu University Hospital, P.O. Box 23, FIN-90029 OYS, Oulu, Finland.,PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
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Andrisani G, Armuzzi A, Marzo M, Felice C, Pugliese D, Papa A, Guidi L. What is the best way to manage screening for infections and vaccination of inflammatory bowel disease patients? World J Gastrointest Pharmacol Ther 2016; 7:387-396. [PMID: 27602239 PMCID: PMC4986392 DOI: 10.4292/wjgpt.v7.i3.387] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 06/16/2016] [Indexed: 02/07/2023] Open
Abstract
The use of biological agents and immunomodulators for inflammatory bowel disease (IBD) is associated with an increased risk of opportunistic infections, in particular of viral or bacterial etiology. Despite the existence of international guidelines, many gastroenterologists have not adopted routine screening and vaccination in those patients with IBD, which are candidate for biologic therapy. Available strategies to screen, diagnose and prevent bacterial and viral infections in patients with IBD prior to start biological therapy are discussed in this review.
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Kessler RA, Mealy MA, Levy M. Treatment of Neuromyelitis Optica Spectrum Disorder: Acute, Preventive, and Symptomatic. Curr Treat Options Neurol 2015; 18:2. [PMID: 26705758 DOI: 10.1007/s11940-015-0387-9] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OPINION STATEMENT Neuromyelitis optica spectrum disorder (NMOSD) is a rare, autoimmune disease of the central nervous system that primarily attacks the optic nerves and spinal cord leading to blindness and paralysis. The spectrum of the disease has expanded based on the specificity of the autoimmune response to the aquaporin-4 water channel on astrocytes. With wider recognition of NMOSD, a standard of care for treatment of this condition has condition based on a growing series of retrospective and prospective studies. This review covers the present state of the field in the treatment of acute relapses, preventive approaches, and therapies for symptoms of NMOSD.
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Affiliation(s)
- Remi A Kessler
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, 21287, USA
| | - Maureen A Mealy
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, 21287, USA
| | - Michael Levy
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, 21287, USA.
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Lam GY, Halloran BP, Peters AC, Fedorak RN. Lymphoproliferative disorders in inflammatory bowel disease patients on immunosuppression: Lessons from other inflammatory disorders. World J Gastrointest Pathophysiol 2015; 6:181-192. [PMID: 26600976 PMCID: PMC4644882 DOI: 10.4291/wjgp.v6.i4.181] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 09/28/2015] [Indexed: 02/06/2023] Open
Abstract
Immunosuppressive agents, such as thiopurines, methotrexate, and biologics, have revolutionized the treatment of inflammatory bowel disease (IBD). However, a number of case reports, case control studies and retrospective studies over the last decade have identified a concerning link between immunosuppression and lymphoproliferative disorders (LPDs), the oncological phenomenon whereby lymphocytes divide uncontrollably. These LPDs have been associated with Epstein-Barr virus (EBV) infection in which the virus provides the impetus for malignant transformation while immunosuppression hampers the immune system’s ability to detect and clear these malignant cells. As such, the use of immunosuppressive agents may come at the cost of increased risk of developing LPD. While little is known about the LPD risk in IBD, more is known about immunosuppression in the post-transplantation setting and the development of EBV associated post-transplantation lymphoproliferative disorders (PTLD). In review of the PTLD literature, evidence is available to demonstrate that certain immune suppressants such as cyclosporine and T-lymphocyte modulators in particular are associated with an increased risk of PTLD development. As well, high doses of immunosuppressive agents and multiple immunosuppressive agent use are also linked to increased PTLD development. Here, we discuss these findings in context of IBD and what future studies can be taken to understand and reduce the risk of EBV-associated LPD development from immunosuppression use in IBD.
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Annese V, Beaugerie L, Egan L, Biancone L, Bolling C, Brandts C, Dierickx D, Dummer R, Fiorino G, Gornet JM, Higgins P, Katsanos KH, Nissen L, Pellino G, Rogler G, Scaldaferri F, Szymanska E, Eliakim R. European Evidence-based Consensus: Inflammatory Bowel Disease and Malignancies. J Crohns Colitis 2015; 9:945-65. [PMID: 26294789 DOI: 10.1093/ecco-jcc/jjv141] [Citation(s) in RCA: 288] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 08/10/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Vito Annese
- University Hospital Careggi, Department of Gastroenterology, Florence, Italy
| | - Laurent Beaugerie
- Department of Gastroenterology, AP-HP Hôpital Saint-Antoine, and UPMC Univ Paris 06, Paris, France
| | - Laurence Egan
- Pharmacology and Therapeutics, School of Medicine, National University of Ireland, Galway, Ireland
| | - Livia Biancone
- University Tor Vergata of Rome, GI Unit, Department of Systems Medicine, Rome, Italy
| | - Claus Bolling
- Agaplesion Markus Krankenhaus, Medizinische Klinik I, Frankfurt am Main, Germany
| | - Christian Brandts
- Department of Medicine, Hematology/Oncology, Goethe University, Frankfurt am Main, Germany
| | - Daan Dierickx
- Department of Haematology, University Hospital Leuven, Leuven, Belgium
| | - Reinhard Dummer
- Department of Dermatology, University Zürich, Zürich, Switzerland
| | - Gionata Fiorino
- Gastroenterology Department, Humanitas Research Hospital, Rozzano, Italy
| | - Jean Marc Gornet
- Service d'hépatogastroentérologie, Hopital Saint-Louis, Paris, France
| | - Peter Higgins
- University of Michigan, Department of Internal Medicine, Ann Arbor, USA
| | | | - Loes Nissen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gianluca Pellino
- Second University of Naples, Unit of Colorectal Surgery, Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, Naples, Italy
| | - Gerhard Rogler
- Klinik für Gastroenterologie und Hepatologie, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Franco Scaldaferri
- Università Cattolica del Sacro Cuore, Department of Internal Medicine, Gastroenterology Division, Roma, Italy
| | - Edyta Szymanska
- Department of Pediatrics, Nutrition and Metabolic Disorders, Children's Memorial Health Institute, Warsaw, Poland
| | - Rami Eliakim
- Department of Gastroenterology and Hepatology, Sheba Medical Center & Sackler School of Medicine, Israel
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Nissen LHC, Nagtegaal ID, de Jong DJ, Kievit W, Derikx LAAP, Groenen PJTA, van Krieken JHJM, Hoentjen F. Epstein-Barr virus in inflammatory bowel disease: the spectrum of intestinal lymphoproliferative disorders. J Crohns Colitis 2015; 9:398-403. [PMID: 25740811 DOI: 10.1093/ecco-jcc/jjv040] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) patients on thiopurine therapy are at increased risk of Epstein-Barr virus (EBV)-associated lymphomas. This virus is frequently detected in the intestinal mucosa of IBD patients and may cause a wide spectrum of lymphoproliferations similar to post-transplantation lymphoproliferative disorders (PTLDs). We aimed to assess whether histological aberrations aid in predicting EBV presence and to correlate histological assessment and EBV load with disease outcome in IBD. METHODS We included all IBD patients from our centre who underwent EBV testing of intestinal biopsies between January 2004 and October 2013. All biopsies were classified according to the WHO PTLD classification and the EBV load was scored per high-power field (HPF). Clinical data were collected from patient charts. Reported clinical outcomes included colectomy, need for chemotherapy and mortality. RESULTS Our cohort included 58 patients: 28 were EBV-positive and 30 EBV-negative. An atypical infiltrate was seen more frequently in EBV-positive than in EBV-negative patients (57.1 versus 3.3%; p < 0.001). A high EBV load occurred more frequently in EBV-positive patients undergoing colectomy than in EBV-positive patients without colectomy (50.0 versus 10.0%; p = 0.048). Monomorphic lymphoproliferative disorders, including two overt lymphomas, were present in 10 patients. Reduction of immunosuppression resulted in histological normalization and loss of EBV expression in seven of eight non-lymphoma patients. CONCLUSION The presence of atypical infiltrate in the intestinal mucosa of IBD patients warrants EBV testing. Reduction of immunosuppression is an effective strategy to achieve morphological normalization and loss of EBV. Lymphoproliferation related to IBD appears to have less aggressive clinical behaviour than PTLDs.
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Affiliation(s)
- Loes H C Nissen
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dirk J de Jong
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wietske Kievit
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lauranne A A P Derikx
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - J Han J M van Krieken
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank Hoentjen
- Inflammatory Bowel Disease Center, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
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Risk and clinical characteristics of lymphoma in Korean patients with inflammatory bowel diseases: a multicenter study. J Clin Gastroenterol 2015; 49:e11-6. [PMID: 24705089 DOI: 10.1097/mcg.0000000000000129] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Studies of lymphoma risk in Western inflammatory bowel disease (IBD) patients show conflicting results; however, none have examined the lymphoma risk and clinical characteristics of Asian IBD patients. METHODS Patients with lymphoma were identified in an IBD database from 3 tertiary referral centers in Seoul, Korea. The standardized incidence ratio (SIR) of lymphoma was estimated using data from the Korea Central Cancer Registry of the National Cancer Center. The risk of lymphoma in relation to specific medications was also explored. RESULTS Seven cases of lymphoma (0.1%) were identified in 6585 IBD patients. The median age at lymphoma diagnosis was 43 years (range, 33 to 70 y) and the median duration of IBD at lymphoma diagnosis was 96.1 months (range, 15.1 to 171.6 mo). Three patients had underlying ulcerative colitis and 4 had Crohn's disease (CD). Non-Hodgkin lymphoma was diagnosed in 5 patients (71.4%) and Hodgkin disease (HD) in 2 patients (28.6%). The SIR of lymphoma was 2.03 [95% confidence interval (CI), 0.81-4.18] in the entire IBD patients. Both the SIR of lymphoma in CD patients (9.31; 95% CI, 1.13-33.62) and the SIR of HD (13.16; 95% CI, 1.59-47.53) in IBD patients were increased. The SIR of lymphoma in patients who were exposed to thiopurines was 5.93 (95% CI, 1.61-15.18). CONCLUSIONS The risk of lymphoma in CD patients and the risk of HD in IBD patients seem to be increased in Korea. Thiopurine may be related with the risk of lymphoma in Korean IBD patients.
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Abstract
The use of biological agents and immunomodulators for inflammatory bowel disease (IBD) has remarkably improved disease management in the current era but at the same time has increased the risk of infectious complications. Patients with IBD on corticosteroids, immunomodulators, and biological agents are considered immunocompromised and are at risk for opportunistic infections. These are infections caused by organisms that take advantage of a weakened immune system, and cause disease, when they ordinarily would cause mild illness or no disease in an immunocompetent host. Risk factors for opportunistic infections include malnutrition, older age, congenital immunodeficiency, HIV infection, chronic diseases, and use of corticosteroids, immunomodulators, and anti-tumor necrosis factor alpha therapy. Apart from immunosuppressive medications and older age, there is only indirect evidence for above risk factors contributing directly to opportunistic infection risk in patients with IBD. Opportunistic infections in patients with IBD include viral infections (herpes viruses, human papillomavirus, influenza virus, and JC virus), bacterial infections (tuberculosis, nocardiosis, Clostridium difficile infection, pneumococcal infection, legionellosis, and listeriosis), fungal infections (histoplasmosis, cryptococcosis, Pneumocystis jirovecii infection, aspergillosis, and candidiasis), and parasite infections (Strongyloides stercoralis). Although these infections lead to high morbidity and mortality, only a minority of patients with IBD develop opportunistic infections. Currently, we lack a test to accurately predict patients at risk of opportunistic infection, and future research needs to focus on biomarkers or predictive models for risk stratification. Until such a test is developed, we need to screen, prevent, diagnose, and treat opportunistic infections in all patients with IBD in a timely manner.
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Magro F, Peyrin-Biroulet L, Sokol H, Aldeger X, Costa A, Higgins PD, Joyce JC, Katsanos KH, Lopez A, de Xaxars TM, Toader E, Beaugerie L. Extra-intestinal malignancies in inflammatory bowel disease: results of the 3rd ECCO Pathogenesis Scientific Workshop (III). J Crohns Colitis 2014; 8:31-44. [PMID: 23721759 DOI: 10.1016/j.crohns.2013.04.006] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 04/05/2013] [Indexed: 12/28/2022]
Abstract
The incidence of lymphoproliferative disorders (LD) is increasing in developed countries. Patients with inflammatory bowel disease (IBD) exposed to thiopurines are at additional risk of three specific forms of LD: Epstein-Barr-Virus-related post-transplant like LD, hepato-splenic T-cell lymphoma and post-mononucleosis lymphoproliferation. The risk of the two latter forms of LD can be reduced when considering specific immunosuppressive strategies in young males. It is still unclear whether the risk of uterine cervix abnormalities is increased in IBD women, irrespective of the use of immunosuppressants. Given the excess risk demonstrated in various other contexts of immunosuppression, it is currently recommended that all women with IBD, particularly those receiving immunosuppressants, strictly adhere to a screening program of cervical surveillance and undergo vaccination against HPV, when appropriate. Patients with IBD receiving immunosuppressants are at increased risk of skin cancers. The risk of non-melanoma skin cancer is notably increased in patients receiving thiopurines. Recent data suggest that the risk of melanoma is mildly increased in patients exposed to anti-TNF therapy. All IBD patients should adhere to a program of sun protection and dermatological surveillance, whose details should take into account the other non-IBD-related risk factors.
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Affiliation(s)
- Fernando Magro
- Gastroenterology Department, Centro Hospitalar S. João, Institute of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal; Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal
| | - Laurent Peyrin-Biroulet
- Inserm U954 and Department of Hepato-Gastroenterology, University Hospital of Nancy, and Université Henri Poincaré 1,Vandoeuvre-lès-Nancy, France
| | - Harry Sokol
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine F-75012 and ERL 1057 INSERM/UMRS 7203, UPMC Univ Paris 06F-75005, Paris, France
| | - Xavier Aldeger
- Department of Gastroenterology of University Hospital Doctor Josep Trueta de Girona, Spain
| | - Antonia Costa
- Department of Gynecology and Obstetrics Department, Centro Hospitalar S. João, Portugal, and Faculty of Medicine, Porto University, Porto, Portugal
| | - Peter D Higgins
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Joel C Joyce
- Department of Dermatology, Medical College of Wisconsin, WI, USA
| | - Konstantinos H Katsanos
- Department of Internal Medicine & Hepato-Gastroenterology Unit, Medical School University of Ioannina, Ioannina, Greece
| | - Anthony Lopez
- Inserm U954 and Department of Hepato-Gastroenterology, University Hospital of Nancy, and Université Henri Poincaré 1,Vandoeuvre-lès-Nancy, France
| | | | - Elena Toader
- Gastroenterology and Hepatology Center, University Hospital Sf. Spiridon, and University of Medicine and Pharmacy Gr. T. Popa, Iasi, Romania
| | - Laurent Beaugerie
- Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine F-75012 and ERL 1057 INSERM/UMRS 7203, UPMC Univ Paris 06F-75005, Paris, France.
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Bernheim O, Colombel JF, Ullman TA, Laharie D, Beaugerie L, Itzkowitz SH. The management of immunosuppression in patients with inflammatory bowel disease and cancer. Gut 2013; 62:1523-8. [PMID: 23903238 DOI: 10.1136/gutjnl-2013-305300] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Oren Bernheim
- The Dr Henry D Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, , New York, New York, USA
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Khan N, Abbas AM, Lichtenstein GR, Loftus EV, Bazzano LA. Risk of lymphoma in patients with ulcerative colitis treated with thiopurines: a nationwide retrospective cohort study. Gastroenterology 2013; 145:1007-1015.e3. [PMID: 23891975 DOI: 10.1053/j.gastro.2013.07.035] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 06/10/2013] [Accepted: 07/17/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS There is controversy over whether the treatment of patients with ulcerative colitis (UC) with thiopurines increases their risk of lymphoma. We evaluated the risk of lymphoma (ongoing, residual, and per year of therapy) among thiopurine-treated patients with UC. METHODS We obtained nationwide data from the Veterans Affairs (VA) health care system from 2001 to 2011. We performed a retrospective cohort study, analyzing data on 36,891 patients from their date of diagnosis of UC in the VA health care system to a diagnosis of lymphoma or October 1, 2011 (subjects followed up for a median of 6.7 years). Thiopurine exposure was assessed using the VA pharmacy database. Patients who developed lymphoma were identified based on ICD-9 codes and confirmed by manual chart review. RESULTS In total, 4734 patients with UC (13%) were treated with thiopurines for a median of 1 year. Lymphoma developed in 119 patients who had not been treated with thiopurines, 18 who were treated with thiopurines, and 5 who had discontinued treatment with thiopurines. The incidence rates of lymphoma were 0.60 per 1000 person-years among patients who had not been treated with thiopurines, 2.31 among patients who were treated with thiopurines, and 0.28 among patients who had discontinued treatment with thiopurines. The incidence rates of lymphoma during the first year, second year, third year, fourth year, and >4 years of thiopurine therapy were 0.9, 1.6, 1.6, 5, and 8.9 per 1000 person-years, respectively. The age-, sex-, and race-adjusted hazard ratios of developing lymphoma were 4.2 (95% confidence interval, 2.5-6.8; P < .0001) while being treated with thiopurines and 0.5 (95% confidence interval, 0.2-1.3; P = .17) after discontinuing treatment with thiopurines compared with patients who had not been treated with thiopurines. CONCLUSIONS Based on a retrospective, nationwide cohort study, patients with UC have a 4-fold increase in risk of lymphoma while being treated with thiopurines compared with patients who have not been treated with thiopurines. The risk increases gradually for successive years of therapy. Discontinuing thiopurine therapy reduces the risk of lymphoma.
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Affiliation(s)
- Nabeel Khan
- Section of Gastroenterology, Department of Internal Medicine, Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana; Section of Gastroenterology and Hepatology, Department of Internal Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana.
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Gómez-García M, Cabello-Tapia MJ, Sánchez-Capilla AD, Teresa-Galván JD, Redondo-Cerezo E. Thiopurines related malignancies in inflammatory bowel disease: Local experience in Granada, Spain. World J Gastroenterol 2013; 19:4877-86. [PMID: 23946592 PMCID: PMC3740417 DOI: 10.3748/wjg.v19.i30.4877] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 08/25/2012] [Accepted: 09/12/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the incidence of neoplasms in inflammatory bowel disease (IBD) patients and the potential causative role of thiopurines.
METHODS: We performed an observational descriptive study comparing the incidence of malignancies in IBD patients treated with thiopurines and patients not treated with these drugs. We included 812 patients which were divided in two groups depending on whether they have received thiopurines or not. We have studied basal characteristics of both groups (age when the disease was diagnosed, sex, type of IBD, etc.) and treatments received (Azathioprine, mercaptopurine, infliximab, adalimumab or other immunomodulators), as well as neoplasms incidence. Univariate analysis was performed with the student t test, χ2 test or Wilcoxon exact test as appropriate. A logistic regression analysis was performed as multivariate analysis. Statistical significance was establish at P values of less than 0.05, and 95%CI were used for the odds ratios.
RESULTS: Among 812 patients included, 429 (52.83%) have received thiopurines: 79.5% azathioprine, 14% mercaptopurine and 6.5% both drugs. 44.76% of patients treated with thiopurines and 46, 48% of patients who did not receive this treatment were women (P > 0.05). The proportion of ulcerative colitis patients treated with thiopurines was 30.3% compare to 66. 67% of patients not treated (P < 0.001). Mean azathioprine dose was 123.79 ± 36.5 mg/d (range: 50-250 mg/d), mean usage time was 72.16 ± 55.7 mo (range: 1-300 mo) and the accumulated dose along this time was 274.32 ± 233.5 g (1.5-1350 g). With respect to mercaptopurine, mean dose was 74.7 ± 23.9 mg/d (range: 25-150 mg/d), mean usage time of 23.37 ± 27.6 mo (range: 1-118 mo), and the accumulated dose along this time was 52.2 ± 63.5 g (range: 1.5-243 g). Thiopurine S-methyltransferase activity was tested in 66% of patients treated with thiopurines, among which 98.2% had an intermediate or high activity. Among the patients treated with thiopurines, 27.27% (112 patients) and 11.66% (50 patients) received treatment with Infliximab and Adalimumab respectively, but only 1.83% (7 patients) and 0.78% (3 patients) received these drugs in the group of patients who did not received thiopurines (P < 0.001 and P < 0.001 respectively). Finally, 6.8% (29 patients) among those treated with thiopurines have received other immunesupresants (Methotrexate, Tacrolimus, Cyclosporin), compare to 1% (4 patients) of patients not treated with thiopurines (P < 0.001). Among patients treated with thiopurines, 3.97% developed a malignancy, and among those not treated neoplasms presented in 8.1% (P = 0.013). The most frequent neoplasms were colorectal ones (12 cases in patients not treated with thiopurines but none in treated, P < 0.001) followed by non-melanoma skin cancer (8 patients in treated with thiopurines and 6 in not treated, P > 0.05).
CONCLUSION: In our experience, thiopurine therapy did not increase malignancies development in IBD patients, and was an efective and safe treatment for these diseases.
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Luo FY, Bai AP. Risk of lymphoma after treatment of inflammatory bowel disease with azathioprine. Shijie Huaren Xiaohua Zazhi 2013; 21:2121-2127. [DOI: 10.11569/wcjd.v21.i22.2121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic, non-specific inflammatory disease of the intestine, characterized by excessive activation of the immune system. Immunosuppressive therapy has been widely and effectively used in IBD patients. However, the occurrence of lymphoma after immunosuppressive therapy for IBD, especially azathioprine, has been recently reported. This article reviews the clinical application of azathioprine in IBD, the possible mechanisms responsible for lymphoma induction by azathioprine, and the assessment of benefit and risk of immunosuppressive therapy for IBD.
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Selvaraj SA, Chairez E, Wilson LM, Lazarev M, Bass EB, Hutfless S. Use of case reports and the Adverse Event Reporting System in systematic reviews: overcoming barriers to assess the link between Crohn's disease medications and hepatosplenic T-cell lymphoma. Syst Rev 2013; 2:53. [PMID: 23826928 PMCID: PMC3710465 DOI: 10.1186/2046-4053-2-53] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 06/24/2013] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND To identify demographic and clinical characteristics associated with cases of hepatosplenic T-cell lymphoma (HSTCL) in patients with Crohn's disease, and to assess strength of evidence for a causal relationship between medications and HSTCL in Crohn's disease. METHODS We identified cases of HSTCL in Crohn's disease in studies included in a comparative effectiveness review of Crohn's disease medications, through a separate search of PubMed and Embase for published case reports, and from the Food and Drug Administration (FDA) Adverse Event Reporting System (AERS). We used three causality assessment tools to evaluate the relationship between medication exposure and HSTCL. RESULTS We found 37 unique cases of HSTCL in patients with Crohn's disease. Six cases were unique to the published literature and nine were unique to AERS. Cases were typically young (<40 years of age) and male (86%). The most commonly reported medications were anti-metabolites (97%) and anti-tumor necrosis factor alpha (anti-TNFa) medications (76%). Dose and duration of therapy were not consistently reported. Use of aminosalicylates and corticosteroids were rarely reported, despite the high prevalence of these medications in routine treatment. Using the causality assessment tools, it could only be determined that anti-metabolite and anti-TNFa therapies were possible causes of HSTCL in Crohn's disease based on the data contained in the case reports. CONCLUSION Systematic reviews that incorporate case reports of rare lethal events should search both published literature and AERS, but consideration should be given to the limitations of case reports. In this study, establishing a causative effect other than 'possible' between anti-metabolite or anti-TNFa therapies and HSTCL was not feasible because case reports lacked data required by the causality assessments, and because of the limited applicability of causality assessment tools for rare irreversible events. We recommend minimum reporting requirements for case reports to improve causality assessment and routine reporting of rare life-threatening events, including their absence, in clinical trials to help clinicians determine whether rare adverse events are causally related to a medication.
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Affiliation(s)
- Saranya A Selvaraj
- Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205-2196, USA.
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Abstract
BACKGROUND Subgroups of patients with inflammatory bowel disease (IBD) may have an increased risk of developing lymphoma. We sought to identify factors that were associated with lymphoma in patients with IBD. METHODS Cases and controls were identified through a centralized diagnostic index. We identified 80 adult patients with IBD who developed lymphoma between 1980 and 2009. For each case, 2 controls were matched for subtype of IBD, geographic location, and length of follow-up. Conditional logistical regression was used to assess associations between risk factors and the development of lymphoma. RESULTS Sixty patients were males (75%) versus 77 controls (48%). Median age at index date was 59 years for cases and 42 years for controls. Twenty patients (25%) and 23 controls (14%) were receiving immunosuppressive medications at the index date. Four patients (5%) and 6 controls (4%) were receiving anti-tumor necrosis factor α agents at the index date. In multiple variable analysis, age per decade (odds ratio, 1.83; 95% confidence interval, 1.37-2.43), male gender (odds ratio, 4.05; 95% confidence interval, 1.82-9.02) and immunosuppressive exposure at the index date (odds ratio, 4.20; 95% confidence interval, 1.35-13.11) were significantly associated with increased odds of developing lymphoma. Disease severity and use of anti-tumor necrosis factor α agents were not independently associated with developing lymphoma. When testing was performed on patients exposed to immunosuppressive or anti-tumor necrosis factor α medications, Epstein-Barr virus was identified 75% of the time. CONCLUSIONS In this case-control study, increasing age, male gender, and use of immunosuppressive medications were associated with an increased risk of lymphoma in patients with IBD.
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Fitzgerald MP, Armstrong L, Hague R, Russell RK. A case of EBV driven haemophagocytic lymphohistiocytosis complicating a teenage Crohn's disease patient on azathioprine, successfully treated with rituximab. J Crohns Colitis 2013; 7:314-7. [PMID: 22640698 DOI: 10.1016/j.crohns.2012.05.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 05/01/2012] [Accepted: 05/01/2012] [Indexed: 02/08/2023]
Abstract
We report a case of Epstein-Barr virus infection with the subsequent development of haemophagocytic lymphohistiocytosis in a teenage Crohn's disease patient treated with azathioprine. We found that the early introduction of the anti-B cell monoclonal antibody rituximab precipitated a rapid fall in circulating B-cells and EBV viral load, resulting in a prompt and sustained recovery from what is a potentially fatal complication of azathioprine therapy in Crohn's disease patients.
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O'Connor A, Qasim A, O'Moráin CA. The long-term risk of continuous immunosuppression using thioguanides in inflammatory bowel disease. Ther Adv Chronic Dis 2012; 1:7-16. [PMID: 23251725 DOI: 10.1177/2040622310368736] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The efficacy of thiopurine treatment in the induction, and especially maintenance, of remission in inflammatory bowel disease is well proven; however, it is associated with side effects in both medium and long-term use. The potential harmful effects may be anticipated and minimised by due diligence prior to commencing these drugs followed by close monitoring of haematological and biochemical parameters once started. Careful clinical examination and history taking are also essential. Affected patients are expected to lead lives that include travel, employment and pregnancy - the implications of continued thiopurine therapy in such patients are discussed.
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Affiliation(s)
- Anthony O'Connor
- Dr Asghar Qasim Prof. Colm A. O'Moráin Department of Gastroenterology, Adelaide and Meath Hospital incorporating the National Children's Hospital/Trinity College Dublin, Belgard Road, Tallaght, Dublin 24, Ireland
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Affiliation(s)
- Gareth Walker
- Department of Gastroenterology, Bristol Royal Infirmary, University Hospitals Bristol Trust, Bristol, UK.
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McGinness JL, Spicknall KE, Mutasim DF. Azathioprine-induced EBV-positive mucocutaneous ulcer. J Cutan Pathol 2012; 39:377-81. [PMID: 22236092 DOI: 10.1111/j.1600-0560.2011.01829.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Epstein-Barr virus (EBV)-positive mucocutaneous ulcer was recently described as a clinicopathologic entity occurring secondary to iatrogenic or age-related immune suppression. The histopathology of EBV-positive mucocutaneous ulcer reveals a polymorphous infiltrate including atypical large B-cells and Reed-Sternberg-like cells which are CD20-positive, CD30-positive and EBV-positive. The disorder follows an indolent and self-limited course. We report a case of EBV-positive mucocutaneous ulcer secondary to prolonged use of azathioprine for the treatment of pemphigoid and highlight the need for recognition of this disorder by dermatopathologists and dermatologists.
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Affiliation(s)
- Jamie L McGinness
- Department of Dermatology, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0592, USA
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Rojas-Feria M, Eslam M, Castro-Fernández M, Guerrero P, Larraona-Moreno JL, Romero-Gómez M. Cutaneous lymphoma in a patient with ulcerative colitis after immunosuppressive therapy. J Crohns Colitis 2011; 5:608-11. [PMID: 22115382 DOI: 10.1016/j.crohns.2011.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Revised: 04/12/2011] [Accepted: 04/20/2011] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Biologics are generally safe and well tolerated. However, the risk of haematopoietic cancer in patients with inflammatory bowel disease receiving infliximab has been a growing concern. CASE PRESENTATION We report the first case of cutaneous lymphoma after short use of infliximab in 75-year old Caucasian man with a 7-year history of ulcerative colitis. CONCLUSION Our current knowledge is not sufficient to rule out an increased risk of lymphoma associated with biologics, or allow definitive conclusions to be drawn about the association of infliximab and lymphoma. However, this case and others direct the attention to that both higher index of suspicion and closer follow up are required if patients are maintained on long-term infliximab together with other immunosuppressive therapy.
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Affiliation(s)
- Maria Rojas-Feria
- Unit for The Clinical Management of Digestive Diseases and CIBERehd, Hospital Universitario de Valme, Ctra de Cadiz s/n, Sevilla 41014, Spain.
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Ye BD. [Inflammatory bowel disease and lymphoproliferative disorders]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2011; 58:171-7. [PMID: 22042416 DOI: 10.4166/kjg.2011.58.4.171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The risk of lymphoproliferative disorders (LPDs) has been reported to be increased in autoimmune diseases and chronic inflammatory diseases. Similar with other chronic inflammatory diseases such as rheumatoid arthritis, there is a concern about the risk of LPDs in patients with inflammatory bowel disease (IBD). Generally, in IBD patients, the risk of LPDs appears to be similar with or very slightly higher, compared to the general population. The association of therapeutic agents with the risk of LPDs is difficult to evaluate due to multiple other potentially involved factors and co-treatment with other agents. To date, data show that thiopurine is associated with a moderately increased risk of LPDs in patients with IBD. Evidence regarding the risk of LPDs in IBD patients using methotrexate is not sufficient, but the risk of LPDs seems low. The responsibility of anti-TNF-a agents on the risk of LPDs is difficult to determine, because most of IBD patients receiving anti-TNF-a agents are co-treated with thiopurines. Attention should be given to the high risk of hepatosplenic T-cell lymphoma in young male patients treated with anti-TNF-a agents together with thiopurines. The risk and benefit of immunosuppressive therapy for IBD should be carefully evaluated and individualized considering the risk of LPDs.
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Affiliation(s)
- Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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Owen CE, Callen JP, Bahrami S. Cutaneous lymphoproliferative disorder complicating infectious mononucleosis in an immunosuppressed patient. Pediatr Dermatol 2011; 28:149-55. [PMID: 20497356 DOI: 10.1111/j.1525-1470.2010.01087.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Infectious mononucleosis is the syndrome produced by primary infection with Epstein-Barr virus during adolescence or early adulthood. In immunosuppressed individuals, depressed T-cell function allows the Epstein-Barr virus-driven B-cell proliferation to continue unabated, potentially leading to a lymphoproliferative disorder. A 15-year-old girl with a history of ulcerative colitis treated with 6-mercaptopurine and mesalamine presented with the acute onset of a rapidly enlarging, ulcerative nodule on her left lower eyelid 4 weeks following recovery from infectious mononucleosis. The biopsy revealed an Epstein-Barr virus-positive lymphoproliferative disorder. Systemic disease was absent. Following discontinuation of 6-mercaptopurine, the patient was treated with two courses of intravenous cyclophosphamide. The lesion resolved completely and she remains disease free at 14 months following diagnosis. We report a solitary cutaneous lesion of an immunosuppression-related lymphoproliferative disorder (IR-LPD) occurring as a complication of infectious mononucleosis, and review the pathogenesis and reported cases of Epstein-Barr virus-related immunosuppression-related lymphoproliferative disorder arising in the setting of inflammatory bowel disease. It is important for dermatologists and dermatopathologists to be aware of the occurrence of IR-LPD in patients being treated for inflammatory conditions, including inflammatory bowel disease. Given the role of primary infection with Epstein-Barr virus in the development of IR-LPD, consideration may be given to assessing Epstein-Barr virus status prior to initiating immunosuppressive therapy in young patients.
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Affiliation(s)
- Cindy England Owen
- Division of Dermatology, Department of Medicine, University of Louisville, Louisville, Kentucky 40202, USA.
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Furst DE, Markalanda E, Clements PJ. Immunosuppressives (chlorambucil, cyclosporine, cyclophosphamide [Cytoxan], azathioprine [Imuran], mofetil, tacrolimus). Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00055-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Lymphoma with central nervous system involvement in a young patient with Crohn disease treated with azathioprine. J Pediatr Gastroenterol Nutr 2010; 51:790-2. [PMID: 20948446 DOI: 10.1097/mpg.0b013e3181edf33f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Epstein-Barr virus-associated lymphoproliferative disorder in Crohn disease treated with azathioprine. J Pediatr Gastroenterol Nutr 2010; 51:229-31. [PMID: 20512052 DOI: 10.1097/mpg.0b013e3181d893c6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Smith MA, Irving PM, Marinaki AM, Sanderson JD. Review article: malignancy on thiopurine treatment with special reference to inflammatory bowel disease. Aliment Pharmacol Ther 2010; 32:119-30. [PMID: 20412066 DOI: 10.1111/j.1365-2036.2010.04330.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immunosuppression is a risk factor for carcinogenesis. Thiopurines specifically contribute to this. As thiopurines are used more aggressively in the treatment of IBD, it is likely that we will see more thiopurine-related malignancy. AIM To review the literature, exploring how immunosuppression, thiopurines specifically, might cause cancer and which malignancies occur in practice, placing specific emphasis on IBD cohorts. METHODS Search terms included 'malignancy' 'cancer' 'azathioprine' 'mercaptopurine' 'tioguanine (thioguanine)' 'thiopurine' and 'inflammatory bowel disease' 'Crohn's disease' 'ulcerative colitis'. We also searched for specific cancers (lymphoma, colorectal cancer, skin cancer, cervical cancer) and reviewed the reference lists of the articles detected. RESULTS Immunosuppression is associated with an increased risk of cancer. Thiopurines are associated with specific additional risks. In IBD cohorts, very few thiopurine-related malignancies have been reported. However, studies suggest a relative risk of 4-5 for lymphoma. This still translates into a low actual risk, (one extra lymphoma in every 300-1400 years of thiopurine treatment). CONCLUSIONS Whilst we must be aware of this risk and counsel our patients appropriately, thiopurines remain a mainstay of IBD therapy. We present practical advice aimed at minimizing our patients' risk of developing malignancy, whilst optimizing the benefits that thiopurines can provide.
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Affiliation(s)
- M A Smith
- Department of Gastroenterology Guy's & St. Thomas' NHS Foundation Trust, London, UK
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Guidelines for the management of inflammatory bowel disease in children in the United Kingdom. J Pediatr Gastroenterol Nutr 2010; 50 Suppl 1:S1-13. [PMID: 20081543 DOI: 10.1097/mpg.0b013e3181c92c53] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Van Domselaar M, López San Román A, Bastos Oreiro M, Garrido Gómez E. [Lymphoproliferative disorders in an inflammatory bowel disease unit]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 33:12-6. [PMID: 19889478 DOI: 10.1016/j.gastrohep.2009.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 08/18/2009] [Accepted: 09/04/2009] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The relationship between inflammatory bowel disease (IBD) and lymphoproliferative disorders (LD) has been previously reported. AIMS To establish the local incidence of LD in an IBD unit, and to describe the clinical characteristics of observed cases. MATERIAL AND METHODS All the clinical records of patients with ulcerative colitis (UC) or Crohn's disease (CD) followed-up in a tertiary center were reviewed. In all cases, IBD had been diagnosed according to standard criteria. RESULTS Of 911 patients with IBD, we identified seven with lymphoma. Five of the patients were men, four had been diagnosed with UC and three with Crohn's disease. The mean time from IBD to lymphoma diagnosis was 4.82 years (r: 0-20). The mean age at lymphoma diagnosis was 53 years (r: 33-76). Four were colorectal lymphomas. There was only one case of Hodgkin's disease. Five patients had been treated with thiopurines, and four of these had also been treated with biological agents. Three cases were associated with Epstein-Barr (EBV) virus infection. The estimated incidence of LD in these IBD patients was 81.74/100,000/year. After a mean follow-up of 32.3 months (r: 5-57) following the last treatment for LD, all patients except one are in remission. DISCUSSION The incidence rate of LD was much higher than the expected rate for the general population (81.74 vs. 22). Chronic inflammation, immune-modifying drugs and Epstein Barr virus infection may be implicated in the pathogenesis of this disease.
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Serrate C, Silva-Moreno M, Dartigues P, Poujol-Robert A, Sokol H, Gorin NC, Coppo P. Epstein-Barr virus-associated lymphoproliferation awareness in hemophagocytic syndrome complicating thiopurine treatment for Crohn's disease. Inflamm Bowel Dis 2009; 15:1449-51. [PMID: 19177429 DOI: 10.1002/ibd.20823] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Sousa H, Portela F, Cipriano MA. Posttransplant lymphoproliferative disorders in patients with IBD on immunosuppressive treatment. Inflamm Bowel Dis 2009; 15:481-3. [PMID: 18668677 DOI: 10.1002/ibd.20634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Fatal Epstein-Barr virus primo infection in a 25-year-old man treated with azathioprine for Crohn's disease. J Clin Microbiol 2009; 47:1252-4. [PMID: 19193838 DOI: 10.1128/jcm.02052-08] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
We report a case of Epstein-Barr virus (EBV) primo infection with the development of successive infectious mononucleosis, hemophagocytic lymphohistiocytosis, and B-cell lymphoproliferative disorder in a patient treated with azathioprine for Crohn's disease. This case report suggests that specific EBV-related clinical and virological management should be considered when treating a patient with inflammatory bowel disease with azathioprine.
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Molina TJ, Le Tourneau A, Damotte D, Diebold J, Audouin J. [Hematologic pathology and immunodepression outside of HIV infection: modification of the histopathologic semiology]. Ann Pathol 2008; 28 Spec No 1:S120-1. [PMID: 18984287 DOI: 10.1016/j.annpat.2008.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Thierry J Molina
- Laboratoire de pathologie, Hôtel-Dieu, place du Parvis-Notre-Dame, 75000 Paris, France.
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Sawadogo A, Boursier J, Calès P, Oberti F, Schmidt A. [Non hodgkin's lymphoma associated with chronic auto-immune hepatitis treated with azathioprine]. ACTA ACUST UNITED AC 2008; 32:143-5. [PMID: 18494156 DOI: 10.1016/j.gcb.2007.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rizzi R, Curci P, Delia M, Rinaldi E, Chiefa A, Specchia G, Liso V. Spontaneous remission of “methotrexate-associated lymphoproliferative disorders” after discontinuation of immunosuppressive treatment for autoimmune disease. Review of the literature. Med Oncol 2008; 26:1-9. [DOI: 10.1007/s12032-008-9069-8] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Accepted: 04/17/2008] [Indexed: 12/17/2022]
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Bargalló A, Carrión S, Domènech E, Antonio Arévalo J, Mañosa M, Cabré E, Luis Cabriada J, Àngel Gassull M. Mononucleosis infecciosa en pacientes con enfermedad inflamatoria intestinal en tratamiento con azatioprina. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:289-92. [DOI: 10.1157/13119881] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Sandborn WJ, Feagan BG, Lichtenstein GR. Medical management of mild to moderate Crohn's disease: evidence-based treatment algorithms for induction and maintenance of remission. Aliment Pharmacol Ther 2007; 26:987-1003. [PMID: 17877506 DOI: 10.1111/j.1365-2036.2007.03455.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with Crohn's disease alternate between periods of active, symptomatic disease and periods of remission. The treatment goal for Crohn's disease is to induce and then maintain remission of symptoms. AIM To review evidence from randomized, controlled, clinical trials on medical therapies for inducing and maintaining remission in patients with mild-to-moderate Crohn's disease, and to suggest the best evidence-based approaches for induction and maintenance therapies. METHODS PubMed search using the following terms: sulfasalazine or salicylazosulfapyridine or aminosalicylate or aminosalicylic acid or mesalamine or mesalazine or corticosteroid or prednisone or prednisolone or methylprednisolone or budesonide or antibiotic or metronidazole or ciprofloxacin or immunosuppressive or azathioprine or mercaptopurine or thiopurine or methotrexate and Crohn's disease. RESULTS Randomized, controlled trials demonstrated that sulfasalazine, budesonide, and conventional corticosteroids are effective for inducing remission of mild-to-moderate Crohn's disease when administered for a period of 8-16 weeks. An ideal maintenance therapy does not currently exist. CONCLUSIONS Selection of maintenance therapy is based on a combination of evidence from controlled trials and patient features including disease severity and location, co-morbidities, previous response to treatment, and previous surgical resection. The options for maintenance therapy include therapy cessation and patient observation following successful induction, budesonide, or immunosuppressive therapy.
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Affiliation(s)
- W J Sandborn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
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Jones JL, Loftus EV. Lymphoma risk in inflammatory bowel disease: is it the disease or its treatment? Inflamm Bowel Dis 2007; 13:1299-307. [PMID: 17600819 DOI: 10.1002/ibd.20211] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
With the increasingly widespread use of immunosuppressive and biologic agents for the treatment of Crohn's disease and ulcerative colitis come concerns about potential long-term consequences of such therapies. Disentangling the potential confounding effects of the underlying disease, its extent, severity, duration, and behavior, and concomitant medical therapy has proven to be exceedingly difficult. Unlike the case in rheumatoid arthritis, the overwhelming preponderance of population-based evidence suggests that a diagnosis of inflammatory bowel disease (IBD) is not associated with an increased relative risk of lymphoma. However, well-designed studies that evaluate the potential modifying effect of IBD severity have yet to be performed. Although the results from hospital- and population-based studies have conflicted, the results of a recent meta-analysis suggest that patients receiving purine analogs for the treatment of IBD have a lymphoma risk approximately 4-fold higher than expected. Analyses of lymphoma risk in patients receiving biologic agents directed against tumor necrosis factor-alpha are confounded by concomitant use of immunosuppressive agents in most of these patients. Nevertheless, there may be a small but real risk of lymphoma associated with these therapies. Although the relative risk of lymphoma may be elevated in association with some of the medical therapies used in the treatment of IBD, this absolute risk is low. Weighing the potential risk of lymphoma associated with select medical therapies against the risk of undertreating IBD will help physicians and patients to make more informed decisions pertaining to the medical management of IBD.
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Affiliation(s)
- Jennifer L Jones
- Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada.
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Reynolds GJ, Annis KA, de Villiers WJS. Review article: multiple myeloma and inflammatory bowel disease. Dig Dis Sci 2007; 52:2022-8. [PMID: 17420948 DOI: 10.1007/s10620-006-9165-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2005] [Accepted: 11/27/2005] [Indexed: 01/30/2023]
Abstract
Since 1964 only nine cases of multiple myeloma occurring in the setting of inflammatory bowel disease have been reported. Although this occurrence may be a mere unfortunate coincidence, there are sound pathophysiological reasons for such an event. The possibility that chronic inflammatory conditions, immunomodulator therapy, and infliximab can predispose to multiple myeloma and lymphoma is reviewed. We discuss in detail the only reported case of multiple myeloma arising in the setting of infliximab treatment for Crohn's disease. It is highly probable that infliximab therapy had a causal role in our patient developing multiple myeloma. The pathogenesis of multiple myeloma arising in the setting of infliximab therapy may be related to decreased apoptosis of plasma cell populations. Since it is possible that a causal association exists between infliximab therapy and multiple myeloma, additional screening measures may be required in patients with Crohn's disease on infliximab.
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von Roon AC, Reese G, Teare J, Constantinides V, Darzi AW, Tekkis PP. The risk of cancer in patients with Crohn's disease. Dis Colon Rectum 2007; 50:839-55. [PMID: 17308939 DOI: 10.1007/s10350-006-0848-z] [Citation(s) in RCA: 193] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE The risk of cancer in patients with Crohn's disease is not well defined. Using meta-analytical techniques, the present study was designed to quantify the risk of intestinal, extraintestinal, and hemopoietic malignancies in such patients. METHODS A literature search identified 34 studies of 60,122 patients with Crohn's disease. The incidence and relative risk of cancer were calculated for patients with Crohn's disease and compared with the baseline population of patients without Crohn's disease. Overall pooled estimates, with 95 percent confidence intervals, were obtained, using a random-effects model. RESULTS The relative risk of small bowel, colorectal, extraintestinal cancer, and lymphoma compared with the baseline population was 28.4 (95 percent confidence interval, 14.46-55.66), 2.4 (95 percent confidence interval, 1.56-4.36), 1.27 (95 percent confidence interval, 1.1-1.47), and 1.42 (95 percent confidence interval, 1.16-1.73), respectively. On subgroup analysis, patients with Crohn's disease had an increased risk of colon cancer (relative risk, 2.59; 95 percent confidence interval, 1.54-4.36) but not of rectal cancer (relative risk, 1.46; 95 percent confidence interval, 0.8-2.55). There was significant association between the anatomic location of the diseased bowel and the risk of cancer in that segment. The risk of small bowel cancer and colorectal cancer was found to be higher in North America and the United Kingdom than in Scandinavian countries with no evidence of temporal changes in the cancer incidence. CONCLUSIONS The present meta-analysis demonstrated an increased risk of small bowel, colon, extraintestinal cancers, and lymphoma in patients with Crohn's disease. Patients with extensive colonic disease that has been present from a young age should be candidates for endoscopic surveillance; however, further data are required to evaluate the risk of neoplasia over time.
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Affiliation(s)
- Alexander C von Roon
- Department of Biosurgery and Surgical Technology, Imperial College, St. Mary's Hospital, London, W2 1NY, UK
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Daniel F, Damotte D, Moindrot H, Molina T, Berger A, Cellier C. A steroid-refractory ulcerative colitis revealing Epstein-Barr virus/cytomegalovirus-positive colonic lymphoma. Int J Colorectal Dis 2006; 21:288-90. [PMID: 15747126 DOI: 10.1007/s00384-004-0719-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2004] [Indexed: 02/04/2023]
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Kwon JH, Farrell RJ. The risk of lymphoma in the treatment of inflammatory bowel disease with immunosuppressive agents. Crit Rev Oncol Hematol 2005; 56:169-78. [PMID: 15979323 DOI: 10.1016/j.critrevonc.2005.02.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2004] [Revised: 01/30/2005] [Accepted: 02/10/2005] [Indexed: 01/12/2023] Open
Abstract
Immunosuppressive agents have become an established part of the therapeutic armamentarium for inflammatory bowel disease (IBD). However, when used in transplant recipients or for other indications, agents that suppress or modulate the immune system (immunomodulators) have been associated with an increased risk of lymphoma. Fortunately, in part because of the lower doses used in IBD patients, the risk of lymphoma in IBD patients appears to be significantly less than that associated with renal and hepatic transplant-related immunosuppression. Whether the risk of azathioprine or 6-mercaptopurine associated lymphoma in IBD is real or relates to the underlying disease remains unclear. The results of several recent large well designed population-based studies suggest that the lymphoma risk associated with azathioprine and 6-mercaptopurine therapy is likely to be of minimal clinical significance compared to the established and more frequent risks of myelosuppression and infection, and is far outweighed by the clinical benefit of immunomodulator therapy in IBD. While the issue of lymphoma risk is likely to become more relevant with the growing number of biologic and immunomodulators being tested in clinical trials for IBD, early post-marketing surveillance data on infliximab suggests that the lymphoma risk may not be any greater than that associated with azathioprine and 6-mercaptopurine.
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Affiliation(s)
- John H Kwon
- Center for Inflammatory Bowel Disease, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Dana 501, Boston, MA 02215, USA
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Lémann M, Mary JY, Colombel JF, Duclos B, Soule JC, Lerebours E, Modigliani R, Bouhnik Y. A randomized, double-blind, controlled withdrawal trial in Crohn's disease patients in long-term remission on azathioprine. Gastroenterology 2005; 128:1812-8. [PMID: 15940616 DOI: 10.1053/j.gastro.2005.03.031] [Citation(s) in RCA: 272] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS An open study reported that patients with Crohn's disease in remission who have taken azathioprine for longer than 3.5 years are at low risk of relapse when azathioprine is discontinued. To confirm this observation, we performed a multicenter, double-blind, noninferiority withdrawal study. METHODS Patients who were in clinical remission on azathioprine for > or = 42 months were randomized to continue azathioprine or to receive an equivalent placebo for 18 months. The primary end point was clinical relapse at 18 months. RESULTS Forty patients were randomly assigned to receive azathioprine and 43 to receive placebo. Characteristics of patients at entry were similar in the 2 study groups. At 18 months, 3 patients had a relapse in the azathioprine group, and 9 had a relapse in the placebo group. Kaplan-Meier estimates of the relapse rate at 18 months were 8% +/- 4% and 21% +/- 6%, respectively. The hypothesis that placebo was inferior to azathioprine was not rejected (P = .195). Among the baseline variables, C-reactive protein level > 20 mg/L, time without steroids < 50 months, and hemoglobin level < 12 g/dL were found to be predictive of relapse in the multivariate analysis. CONCLUSIONS This study shows that azathioprine withdrawal is not equivalent to continued therapy with azathioprine for maintenance of remission in patients with Crohn's disease who have been in remission on azathioprine for > or = 3.5 years. Thus, azathioprine maintenance therapy should be continued beyond 3.5 years.
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Affiliation(s)
- Marc Lémann
- Hôpital Saint-Louis, Centre Hospitalier Universitaire Lariboisière-Saint-Louis, Paris, France.
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Abstract
6-Mercaptopurine and azathioprine have become important therapeutic options for patients with inflammatory bowel disease (IBD). Although accumulating data in the literature have supported the use of these immunomodulators in the management of IBD, marked variation exists in the pattern of clinical practice regarding azathioprine or 6-mercaptopurine therapy in patients with IBD. This article provides a critical review of the data on the clinical efficacy and toxicities of 6-mercaptopurine and azathioprine in the management of IBD. Emerging literature on the potential application of pharmacogenetic testing and metabolite monitoring are also discussed.
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Losco A, Gianelli U, Cassani B, Baldini L, Conte D, Basilisco G. Epstein-Barr virus-associated lymphoma in Crohn's disease. Inflamm Bowel Dis 2004; 10:425-9. [PMID: 15475752 DOI: 10.1097/00054725-200407000-00015] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Although no increased risk of developing lymphoproliferative disorders has been observed in population-based studies of patients with Crohn's disease, the possibility has been suggested in the subset of patients previously treated with thiopurine metabolites and suffering from concomitant Epstein-Barr virus infection. A few cases of lymphomas have occurred in patients with Crohn's disease treated with infliximab, only one of whom showed the presence of the Epstein-Barr virus genome. We here describe the case of a patient with steroid-dependent ileal Crohn's disease treated with azathioprine and a single infusion of infliximab, who developed a diffuse large B cell ileal lymphoma. Epstein-Barr virus genome was detected in the neoplastic cells by means of polymerase chain reaction. Epstein-Barr virus may be detected in the neoplastic tissues of lymphomas of patients with Crohn's disease treated with immunosuppressants and infliximab. The identification of such cases may help to define the frequency of this association and how to manage the lymphoproliferative disorder.
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Affiliation(s)
- Alessandra Losco
- Postgraduate School of Gastroenterology, University of Milan, IRCCS - Ospedale Maggiore and Ospedale S Paolo, Milan, Italy
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Su C, Lichtenstein GR. Treatment of inflammatory bowel disease with azathioprine and 6-mercaptopurine. Gastroenterol Clin North Am 2004; 33:209-34, viii. [PMID: 15177535 DOI: 10.1016/j.gtc.2004.02.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
6-Mercaptopurine and azathioprine have become important therapeutic options for patients with inflammatory bowel disease (IBD). Although accumulating data in the literature have supported the use of these immunomodulators in the management of IBD, marked variation exists in the pattern of clinical practice regarding azathioprine or 6-mercaptopurine therapy in patients with IBD. This article provides a critical review of the data on the clinical efficacy and toxicities of 6-mercaptopurine and azathioprine in the management of IBD. Emerging literature on the potential application of pharmacogenetic testing and metabolite monitoring are also discussed.
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Affiliation(s)
- Chinyu Su
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania School of Medicine, 3rd Floor Ravdin Building, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA
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Tchuenbou J, de Muret A, Dumont P, Bacq Y. Maladie de Hodgkin au cours d’un traitement par azathioprine (Imurel®) pour hépatite chronique auto-immune. ACTA ACUST UNITED AC 2004; 28:316-8. [PMID: 15094689 DOI: 10.1016/s0399-8320(04)94930-5] [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: 01/01/2023]
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Reijasse D, Le Pendeven C, Cosnes J, Dehee A, Gendre JP, Nicolas JC, Beaugerie L. Epstein-Barr virus viral load in Crohn's disease: effect of immunosuppressive therapy. Inflamm Bowel Dis 2004; 10:85-90. [PMID: 15168806 DOI: 10.1097/00054725-200403000-00004] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND More than 80% of non-Hodgkin lymphomas (NHLs) occurring in transplant recipients on immunosuppressive therapy are associated with Epstein-Barr virus (EBV) infection. EBV viral load (EBV-VL) is predictive of NHL occurrence in this setting. The aim of this work was to determine EBV-VL in patients with Crohn's disease (CD), both according to disease activity and use of immunosuppressive therapy, including infliximab. METHODS Between December 1999 and July 2001, EBV-VL was determined 212 times by quantitative polymerase chain reaction (PCR) assay in 138 patients with CD and in 24 EBV-seropositive controls free of CD. RESULTS EBV-VL did not differ significantly between the controls and the patients with CD and was not influenced by CD activity or by immunosuppressive therapy, including recent infliximab infusion. High EBV-VL values were observed in two patients with severe uncontrolled CD, but returned to normal once the flare-up had been controlled (by immunosuppressive drugs in one case and by surgery in the other case). CONCLUSIONS EBV viral load is on the whole similar in patients with Crohn's disease and in EBV-seropositive controls. Infliximab infusion does not seem to increase significantly EBV-VL in the short-term. However, some patients with Crohn's disease have transient, very high EBV-VL values that are compatible with an increased risk of NHL in the transplant setting. The long-term clinical outcome of these patients must be determined.
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Affiliation(s)
- Didier Reijasse
- Department of Gastroenterology, Saint-Antoine University, Paris, France
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