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D'hont A, De Wachter M, Driesen Y, Sabato V, Joos R, Ceulemans B. Successful Rituximab Therapy for Pediatric Antiphospholipid-Related Chorea: A Case Report and Review of the Literature. Neuropediatrics 2022; 53:366-369. [PMID: 35388438 DOI: 10.1055/a-1819-1883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chorea is considered a nonthrombotic manifestation of the antiphospholipid syndrome, often preceding thrombotic events in children. It can be present in up to 5% of pediatric patients with antiphospholipid syndrome. Immunomodulatory treatment regimens seem to be successful in these patients, emphasizing the underlying immunological etiology. Corticosteroids are considered first-line treatment, but chorea tends to be therapy-resistant and guidelines about second-line therapy in children are solely based on small case studies. We present a case of a therapy-resistant chorea, successfully treated with rituximab. Furthermore, we give an overview of the existing literature concerning rituximab for the treatment of chorea in children. Our findings indicate that rituximab can be considered a safe option to treat antiphospholipid syndrome-related chorea in children.
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Affiliation(s)
- Alexia D'hont
- Department of Pediatrics, ZNA Jan Palfijn, University of Antwerp, Antwerp, Belgium
| | - Matthias De Wachter
- Department of Pediatric Neurology, Pediatrics, Antwerp University Hospital, Antwerp University, Edegem, Belgium
| | - Yentl Driesen
- Department of Pediatrics, ZNA Jan Palfijn, Merksem, Belgium
| | - Vito Sabato
- Department of Immunology, Allergology and Rheumatology, Antwerp University Hospital, Antwerp University, Edegem, Belgium
| | - Rik Joos
- Department of Rheumatology, ZNA Jan Palfijn, Merksem, Belgium
| | - Berten Ceulemans
- Department of Pediatric Neurology, Pediatrics, Antwerp University Hospital, Antwerp University, Edegem, Belgium
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Yang S, Yang L, Liao H, Chen M, Feng M, Liu S, Tan L. Clinical Characteristics and Prognostic Factors of Children With Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Front Pediatr 2021; 9:605042. [PMID: 33968840 PMCID: PMC8100243 DOI: 10.3389/fped.2021.605042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 03/23/2021] [Indexed: 12/24/2022] Open
Abstract
Objective: Anti-N-methyl-D-aspartate (anti-NMDA) receptor encephalitis is the most common autoimmune encephalitis in pediatric patients. The study aimed to investigate the clinical characteristics and prognostic factors of anti-NMDA receptor encephalitis in children in South China. Methods: This was a retrospective study of children diagnosed with anti-NMDA receptor encephalitis between 01/2014 and 12/2017 at Hunan Children's Hospital. Laboratory, brain magnetic resonance imaging (MRI), and electroencephalography data were collected. The short-term (6-month) outcomes were assessed using the Liverpool score by the same pediatric neurologist. The children were divided into good (scores 4-5) and poor (score <3) clinical outcomes. Results: Among the 51 patients, 21 (41.2%) were male. The most common clinical symptoms were dyskinesia (88.2%), personality change (84.3%), seizure (82.4%), and cognitive disorder (31.4%). Two were transferred to another hospital, 45 (91.8%) received intravenous immunoglobulins, 41 (83.7%) received methylprednisolone, and 8 (16.3%) received plasma exchange. Eight (16.3%) received rituximab for second-line treatment, six after intravenous immunoglobulin and methylprednisolone treatment, and two after plasma exchange therapy failed. Seven were lost to follow-up. The short-term outcome was good in 23 patients. Cognitive disorder [odds ratio (OR): 23.97, 95% confidence interval (CI): 1.12-513.30, P = 0.042) and abnormal brain MRI (OR: 14.29, 95% CI: 1.36-150.10, P = 0.027] were independently associated with a poor short-term outcome after adjustment for age, GCS, and rituximab use. Conclusions: MRI abnormalities and cognitive disorders are independently associated with poor short-term outcomes in children with anti-NMDA receptor encephalitis. The use of rituximab is not associated with the 6-month outcomes.
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Affiliation(s)
- Sai Yang
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Liming Yang
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Hongmei Liao
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Mei Chen
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Mei Feng
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Shulei Liu
- Department of Neurology, Hunan Children's Hospital, Changsha, China
| | - Lihong Tan
- Department of Neurology, Hunan Children's Hospital, Changsha, China
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Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología. ACTA ACUST UNITED AC 2019; 15:3-20. [DOI: 10.1016/j.reuma.2018.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 12/31/2022]
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Duan BC, Weng WC, Lin KL, Wong LC, Li ST, Hsu MH, Lin JJ, Fan PC, Lin MI, Chiu NC, Lin YC, Wang HS, Hung KL, Lee WT. Variations of movement disorders in anti-N-methyl-D-aspartate receptor encephalitis: A nationwide study in Taiwan. Medicine (Baltimore) 2016; 95:e4365. [PMID: 27631202 PMCID: PMC5402545 DOI: 10.1097/md.0000000000004365] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 06/09/2016] [Accepted: 07/01/2016] [Indexed: 12/19/2022] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is one of the most common autoimmune encephalitis that presents with a wide variety of movement disorders. The purpose of our study is to review the manifestations and duration of movement disorders in different ages with NMDAR encephalitis.A retrospective cohort of 28 patients (20 females and 8 males) with positive cerebrospinal fluid (CSF) anti-NMDAR antibody in a 5-year period from major hospitals in Taiwan was enrolled. They were categorized into 3 age groups: 7 patients were ≤10 years, 14 patients were 10 to 18 years, and 7 patients were >18 years.Total 28 patients (20 females and 8 males) with age ranging from 8 months to 38 years were enrolled. Nearly all patients (n = 27/28, 96%) presented with at least 2 types of disorders, including orofacial-lingual dyskinesia (OFLD; n = 20), catatonia (n = 19), tremor (n = 11), bradykinesia (n = 11), dystonia (n = 11), choreoathethosis (n = 9), and ballism (n = 3). Only 1 patient below 10 years presented with isolated periodic choreoathethosis without other movement disorders. OFLD was common in all age groups. Choreoathetosis was most common in patients aged ≤10 years, while catatonia was most common in patients aged >10 years (P = 0.001 and 0.020, respectively). Bradykinesia was also more common in patients aged >10 years (P = 0.020). The clinical presentations of movement disorders were not significantly different in the age of 10 to 18 years and those >18 years. Neither patient ≤10 years old nor male patients had associated tumors. All patients' movement disorders were improved after treatment, while female patients with tumors had worse short-term outcome (P = 0.014). Compared with other disorders, choreoathetosis persisted significantly longer in patients ≤10 years (P = 0.038), while OFLD and catatonia last longer in patients >10 years (P = 0.047 and 0.002, respectively).Our study shows that hyperkinetic movements such as choreoathetosis are more common and last longer in younger age groups, whereas hypokinetic movements such as catatonia and bradykinesia are more common and last longer in older age groups. Female patients with ovarian tumors had worse short-term outcome.
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Affiliation(s)
- Bi-Chun Duan
- Department of Pediatric Neurology, National Taiwan University Children's Hospital, Taipei
| | - Wen-Chin Weng
- Department of Pediatric Neurology, National Taiwan University Children's Hospital, Taipei
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Lee Chin Wong
- Department of Pediatric Neurology, National Taiwan University Children's Hospital, Taipei
| | - Sung-Tse Li
- Department of Pediatrics, Hsinchu Mackay Memorial Hospital, Hsinchu
| | - Mei-Hsin Hsu
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung
| | - Jainn-Jim Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Pi-Chaun Fan
- Department of Pediatric Neurology, National Taiwan University Children's Hospital, Taipei
| | - Ming-I. Lin
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Nan-Chang Chiu
- Department of Pediatrics, Mackay Memorial Hospital, Taipei
| | - Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Kun-Long Hung
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan
| | - Wang-Tso Lee
- Department of Pediatric Neurology, National Taiwan University Children's Hospital, Taipei
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Zekeridou A, Karantoni E, Viaccoz A, Ducray F, Gitiaux C, Villega F, Deiva K, Rogemond V, Mathias E, Picard G, Tardieu M, Antoine JC, Delattre JY, Honnorat J. Treatment and outcome of children and adolescents with N-methyl-d-aspartate receptor encephalitis. J Neurol 2015; 262:1859-66. [DOI: 10.1007/s00415-015-7781-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 05/06/2015] [Accepted: 05/08/2015] [Indexed: 01/03/2023]
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B-Cell Targeted Therapies in Autoimmune Cytopenias and Thrombosis. MILESTONES IN DRUG THERAPY 2014. [PMCID: PMC7123699 DOI: 10.1007/978-3-0348-0706-7_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ever since the advent of Rituximab and subsequently the emergence of other compounds targeting B cells, a cornucopia of medical applications have been found for this family of compounds. After their establishment as standard of care in many conditions such as rituximab in lymphoma and rheumatoid arthritis, they have been progressively found to aid in the treatment of many other conditions. This area constituted a fertile area of research in the past 12 years. Physicians have investigated the B-cell depleting agents use in cases of autoimmune hematologic cytopenias such as immune thrombocytopenia, Evans syndrome, cold and warm autoimmune hemolytic anemia, and other thrombophilic disorders such as the antiphospholipid syndrome and thrombocytopenic purpura. This chapter presents a historical perspective reviewing the various studies that have been published in this field. In addition, it offers a current assessment of the evidence regarding the use of B-cell depleting agents in the aforementioned conditions.
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Khattri S, Zandman-Goddard G, Peeva E. B-cell directed therapies in antiphospholipid antibody syndrome — New directions based on murine and human data. Autoimmun Rev 2012; 11:717-22. [DOI: 10.1016/j.autrev.2011.12.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 12/22/2011] [Indexed: 12/31/2022]
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Dierickx D, Beke E, Devos T, Delannoy A. The use of monoclonal antibodies in immune-mediated hematologic disorders. Med Clin North Am 2012; 96:583-619, xi. [PMID: 22703857 DOI: 10.1016/j.mcna.2012.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In this article, the evidence on the clinical use of monoclonal antibodies in the treatment of immune-mediated hematologic disorders is described. Insights into pathogenic mechanisms have revealed a major role of both B and T cells. Controlled trials have shown conflicting results, necessitating further research regarding pathogenesis, mechanism of action, and resistance. Although the use of more potent and specific monoclonal antibody therapy, mainly targeting costimulation signals, may improve response rates and long-term outcome, its use should be carefully balanced against potential side effects.
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MESH Headings
- Alemtuzumab
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Murine-Derived/pharmacology
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Antigens, CD20/immunology
- Basiliximab
- Daclizumab
- Graft vs Host Disease/drug therapy
- Hematologic Diseases/immunology
- Hematologic Diseases/therapy
- Hematopoietic Stem Cell Transplantation/adverse effects
- Humans
- Immunoglobulin G/pharmacology
- Immunoglobulin G/therapeutic use
- Immunosuppressive Agents/pharmacology
- Immunosuppressive Agents/therapeutic use
- Infliximab
- Recombinant Fusion Proteins/pharmacology
- Recombinant Fusion Proteins/therapeutic use
- Rituximab
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Affiliation(s)
- Daan Dierickx
- Department of Hematology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Mahmood NA, Silver K, Onel K, Ko M, Javed A. Efficacy and safety of rituximab in pediatric neuromyelitis optica. J Child Neurol 2011; 26:244-7. [PMID: 21183724 DOI: 10.1177/0883073810381445] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Neuromyelitis optica is a central nervous system disease characterized by optic neuritis and transverse myelitis. It is a devastating illness, and early treatment may prevent future relapses and severe disability. However, there is much variability in protocols used for treatment. In limited studies, rituximab has shown efficacy in adult neuromyelitis optica patients. There is a paucity of literature on the efficacy and tolerability of rituximab in the pediatric population. The authors report the use of rituximab in 2 pediatric patients with neuromyelitis optica, demonstrating its efficacy, dosing, and tolerability. This report may be a useful guide for administering rituximab safely in pediatric neuromyelitis optica patients.
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Affiliation(s)
- Naznin A Mahmood
- Section of Pediatric Neurology, University of Chicago Medical Center, Chicago, IL, USA
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Lerario A, Cogiamanian F, Marchesi C, Belicchi M, Bresolin N, Porretti L, Torrente Y. Effects of rituximab in two patients with dysferlin-deficient muscular dystrophy. BMC Musculoskelet Disord 2010; 11:157. [PMID: 20618995 PMCID: PMC2912795 DOI: 10.1186/1471-2474-11-157] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Accepted: 07/11/2010] [Indexed: 12/20/2022] Open
Abstract
Background The administration of rituximab (RTX) in vivo results in B-cell depletion, but evidence for multiple mechanisms of action have been reported. Surprisingly, B cell depletion produced a response in patients with polymyositis, which is characterized as a T cell-mediated autoimmune disorder with biopsy findings similar to Miyoshi myopathy (MM). Indeed, in dysferlinopathies, there is evidence of immune system involvement including the presence of muscle inflammation and a down regulation of the complement inhibitory factor, CD55. Methods Two patients were treated with four weekly infusions of RTX 375 mg/m2. To measure the improvement in muscle strength after treatment, the isometric hand grip maximal voluntary contraction (MVC) was measured by load cell four times during treatment, and again after one year. In order to assess the reproducibility of our grip assessment, we determined the hand MVC analysis in 16 healthy subjects. Moreover, we measured the number of B cells present in patients by flow cytometric analysis during the course of treatment. Results The analysis of B cell number during the course of treatment showed that CD20- and CD19-positive cells were depleted to 0-0.01%. The decrease in B cells was followed by an improvement in the mobility of the pelvic and shoulder girdles as shown by the MRC%. The MVC values of both patients began at values lower than normal whereas during treatment patients had improved percentage of muscle strength. The strength peak in both patients coincided with the minimum B cell values. There were no severe adverse events associated with an infusion of RTX. Conclusion We consider the increase in muscle strength observed in both treated patients to be a consequence of their treatment with RTX. To our knowledge, these are the first cases of increased muscle strength in patients with MM. Furthermore, the results of this study indicate that B cell depletion with RTX may be useful in the treatment of patients affected by MM, suggesting a possible role for B cells in the pathophysiology of this muscle disorder.
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Affiliation(s)
- Alberto Lerario
- Department of Neurological Sciences, Fondazione IRCCS Ospedale Maggiore Policlinico, Centro Dino Ferrari, University of Milan, via F, Sforza 35, Milan, Italy
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Rituximab therapy produced rapid and sustained clinical improvement in a patient with systemic onset juvenile idiopathic arthritis refractory to TNF alpha antagonists. J Clin Rheumatol 2010; 15:363-5. [PMID: 20009975 DOI: 10.1097/rhu.0b013e3181ba3c6f] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We describe a patient with systemic onset juvenile idiopathic arthritis refractory to disease-modifying antirheumatic drugs, intravenous gamma globulin, and TNF inhibitors (etanercept and infliximab), in whom treatment with rituximab resulted in remission of systemic symptoms (rash and fever), a fall in erythrocyte sedimentation rate, C-reactive protein, and ferritin serum levels, with recovery in disability index and improvement of arthritis. A total of 4 cycles of rituximab were given over 18 months because of relapses. Since her last course, she remains stable and asymptomatic. To our knowledge, this is the first case reported on a long-lasting beneficial effect of rituximab in a patient with soJIA.
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Dogan M, Oner AF, Acikgoz M, Uner A. Treatment of chronic immune thrombocytopenic purpura with rituximab in children. Indian J Pediatr 2009; 76:1141-4. [PMID: 20092026 DOI: 10.1007/s12098-009-0230-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the rituximab treatment in children with chronic immune thrombocytopenic purpura METHODS This study included ten children with chronic immune thrombocytopenic purpura, which were nonresponsive to Steroid (S), IVIG and anti-D treatments. Rituximab was given with a dosage of 375 mg/m2 weekly for 4-6 weeks. Initial platelet count was less than 30x109/L and responses were assessed in follow-up. The patients' groups were categorized as complete remission (CR);a platelet count > or = 150x109/L, partial remission (PR);a platelet count ranging from 50x109/L to 150x109/L, minimal remission (MR); a platelet count ranging from 30x109/L to 50x109/L and no response (NR); a platelet count less than 30x109/L. RESULTS Of our patients, four female and six male, their ages ranged from 39 mth to 13 yr and the mean age was 83.4 +/- 44.58 mth. None of the patients was splenectomized. The follow-up period after rituximab treatment ranged between 12 to 42 mth and the mean follow-up period was 25.10 +/- 13.03 months. While on this treatment, we had a CR in two patients, a PR in one, a MR in three, but no response in four. The patients in CR/PR are still being followed as in remission and they have 40 mth of mean follow-up period. The three patients in MR had a decrease in values of platelets earliest in one mth and the latest in four mth. Adverse effects of rituximab, such as itching and scraps that were not clinically significant were observed in three patients during rituximab infusion. There were no increase in infections after rituximab in any patient. CONCLUSION CR was found in 20% of our patients, PR in 10% and MR in 30% with rituximab. On this treatment, while some series had good outcomes with this treatment (72%-100%, remission ratios), but many series, such as ours, had a poor response rate contrast to many reported case series in the literature. This condition may be associated with the age of our most patients who were young at the time of commenced rituximab. However, we believe that more studies are required to elucidate the reasons for different results in different case series reported in literature.
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Affiliation(s)
- Murat Dogan
- Department of Pediatrics, Yuzuncu Yil University, Van, Turkey.
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Tzaribachev N, Koetter I, Kuemmerle-Deschner JB, Schedel J. Rituximab for the treatment of refractory pediatric autoimmune diseases: a case series. CASES JOURNAL 2009; 2:6609. [PMID: 20184679 DOI: 10.1186/1757-1626-0002-0000006609] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 03/05/2009] [Indexed: 01/19/2023]
Abstract
INTRODUCTION To report on efficacy, tolerability and safety of rituximab in children with refractory autoimmune diseases. CASE PRESENTATION Five patients (juvenile dermatomyositis, Wegener's granulomatosis, systemic lupus erythematosus, myasthenia gravis and multiple sclerosis with systemic lupus erythematosus) were treated with rituximab and followed for a median time of 2.5 years. Two patients achieved remission (systemic lupus erythematosus, Wegener's granulomatosis). Three patients had a refractory disease course and underwent autologous stem cell transplantation. Of those, two achieved remission (juvenile dermatomyositis, myasthenia gravis), one died of complications after transplantation (multiple sclerosis/systemic lupus erythematosus). No severe adverse events occurred. CONCLUSION Efficacy of rituximab was variable ranging from complete remission to inefficacy. Treatment was safe.
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Affiliation(s)
- Nikolay Tzaribachev
- University Children's Hospital, Hoppe-Seyler Str. 1, 72076, Tuebingen, Germany.
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Abstract
INTRODUCTION To report on efficacy, tolerability and safety of rituximab in children with refractory autoimmune diseases. CASE PRESENTATION Five patients (juvenile dermatomyositis, Wegener's granulomatosis, systemic lupus erythematosus, myasthenia gravis and multiple sclerosis with systemic lupus erythematosus) were treated with rituximab and followed for a median time of 2.5 years. Two patients achieved remission (systemic lupus erythematosus, Wegener's granulomatosis). Three patients had a refractory disease course and underwent autologous stem cell transplantation. Of those, two achieved remission (juvenile dermatomyositis, myasthenia gravis), one died of complications after transplantation (multiple sclerosis/systemic lupus erythematosus). No severe adverse events occurred. CONCLUSION Efficacy of rituximab was variable ranging from complete remission to inefficacy. Treatment was safe.
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Kelly C, Saravanan V. Treatment strategies for a rheumatoid arthritis patient with interstitial lung disease. Expert Opin Pharmacother 2009; 9:3221-30. [PMID: 19040342 DOI: 10.1517/14656560802591430] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This review article describes our present understanding of interstitial lung disease (ILD) complicating rheumatoid arthritis (RA). It discusses its high prevalence and clinical relevance, our recent improvement in understanding both its pathology and physiology, and our expectations of ongoing research into the immunology and genetics of the disease. An important section relates to the effects of drugs routinely used in the treatment of the articular manifestations of RA on the lung, especially in the presence of ILD. The major focus of the article is on therapeutic intervention, and here we discuss traditional and often unsuccessful approaches to treatment, leading on to discuss newly introduced therapeutic options such as anticoagulation and oral N-acetylcysteine. In the later sections, we focus our attention on several promising new therapeutic agents, including mycophenolate and new monoclonal antibody therapies, reviewing the limited literature available to support the use of these agents, concluding with a number of other aspects of treatment that are worthy of consideration.
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Affiliation(s)
- Clive Kelly
- Queen Elizabeth Hospital Foundation Trust, Department of Rheumatological Medicine, Sheriff Hill, Gateshead NE9 6SX, UK.
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Tieng AT, Peeva E. B-cell-directed therapies in systemic lupus erythematosus. Semin Arthritis Rheum 2008; 38:218-27. [PMID: 18206214 DOI: 10.1016/j.semarthrit.2007.11.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Revised: 10/30/2007] [Accepted: 11/28/2007] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Owing to their ability to promote the onset and flares of systemic lupus erythematosus (SLE), B-cells are now established as key players in the pathogenesis of the disease, and, therefore, have become a major therapeutic focus in SLE. In this article, we review the literature on B-cell-directed therapies for SLE focusing on B-cell depletion, B-cell tolerance, costimulatory signals, and cytokines that affect B-cell survival and activation. METHODS The clinical trials reviewed in this article were accessed from the PubMed database (www.pubmed.gov) and Clinical Trials database (www.clinicaltrials.gov) through an English language search of the literature published between January 2002 and March 2007. Keywords included the following terms: B-cells, SLE, and therapy. RESULTS Seventeen completed clinical trials enrolling 973 patients and 5 ongoing studies with anticipated enrollment of 785 patients were reviewed. Novel SLE therapies that target B-cells directly or indirectly were included. B-cell-depleting therapies with the monoclonal antibodies rituximab and epratuzumab have shown good therapeutic results. On the contrary, the well-studied B-cell tolerogen LJP 394 has not demonstrated much clinical benefit. Studies targeting costimulatory pathways have shown variable results; clinical trials with anti-CD40L antibody were terminated because of thromboembolic events, whereas studies targeting the B7-CD28 pathway seem promising. Anticytokine agents against B-lymphocyte stimulator (BLyS), interleukin (IL)-10, IL-6, and interferon alpha (IFN-alpha) are the newcomers that need further evaluation in the treatment of SLE. CONCLUSIONS Progress in technology has led to the variety of B-cell-directed therapies. In contrast to general immunosuppressants, novel treatments that interfere with specific aspects of B-cell functions create the possibility of developing targeted therapeutic approaches for specific subpopulations of lupus patients.
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Affiliation(s)
- Arlene T Tieng
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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Bell J, Moran C, Blatt J. Response to rituximab in a child with neuroblastoma and opsoclonus-myoclonus. Pediatr Blood Cancer 2008; 50:370-1. [PMID: 16652344 DOI: 10.1002/pbc.20899] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Opsoclonus-myoclonus (OM) is a paraneoplastic syndrome of probable autoimmune origin. Despite current therapies aimed at decreasing autoantibody formation, OM is difficult to control and may impact long-term neurologic outcome. We present a case of a 19-month-old patient who initially presented with OM, neuroblastoma and a constitutional cytogenetic abnormality t(5;12)(q11.2;q15). The patient's OM was recalcitrant to conventional therapies, but showed significant improvement following treatment with rituximab.
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Affiliation(s)
- Jessica Bell
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Bussel JB, Giulino L, Lee S, Patel VL, Sandborg C, Stiehm ER. Update on therapeutic monoclonal antibodies. Curr Probl Pediatr Adolesc Health Care 2007; 37:118-35. [PMID: 17434008 DOI: 10.1016/j.cppeds.2007.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Monoclonal antibodies are among the most important class of drugs introduced into the therapeutic armamentarium since the introduction of antimicrobials in the 1930s. The first therapeutic monoclonal antibody, the anti T-cell monoclonal antibody OKT4, was licensed in 1986. Since then, 18 additional antibodies have been licensed in the US, with many more in the pipeline. Before 1986, many monoclonal antibodies were available for laboratory studies, notably to identify specific cells in the blood and tissues. This is best illustrated by the cluster designation (CD) system for antigens present on hematopoietic cells, now numbering over 200.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, Cornell University School of Medicine, New York, NY, USA
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El-Hallak M, Binstadt BA, Leichtner AM, Bennett CM, Neufeld EJ, Fuhlbrigge RC, Zurakowski D, Sundel RP. Clinical effects and safety of rituximab for treatment of refractory pediatric autoimmune diseases. J Pediatr 2007; 150:376-82. [PMID: 17382113 DOI: 10.1016/j.jpeds.2006.10.067] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Revised: 08/19/2006] [Accepted: 10/19/2006] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the safety, tolerability, and clinical effects of rituximab, an anti-CD20 monoclonal antibody, in the treatment of severe pediatric autoimmune diseases. STUDY DESIGN We reviewed the records of 10 patients treated with rituximab for severe, refractory autoimmune diseases at a single tertiary care children's hospital. Adverse events as well as treatment effects were recorded. RESULTS All patients received 4 weekly doses of rituximab at 375 mg/m2 per dose. One patient died as the result of complications of her underlying systemic lupus erythematosus 7 weeks after rituximab therapy. Three patients had serious infections, all of which resolved with standard therapy. Rituximab led to transient or sustained improvement in clinical and laboratory parameters in nine subjects. At a median follow-up of 9 months, the median prednisone dose was reduced in the responders by 0.75 mg/kg per day (mean decrease of 63%), and four patients were able to discontinue corticosteroids entirely. With longer follow-up (median, 22 months), we found that 5 of 9 patients remained clinically stable after rituximab therapy, whereas 4 patients had recurrent or new features of their underlying autoimmune disorders requiring additional corticosteroids or other immunosuppressive medications. CONCLUSIONS Rituximab had an acceptable toxicity profile in this group of patients with severe, refractory autoimmune diseases, although there were three serious infections and one patient death. Rituximab appears to be beneficial for patients with refractory autoimmune diseases and may reduce corticosteroid exposure. Although rituximab therapy provided a durable clinical benefit for some patients in this population, other patients had reemergence of their underlying autoimmune disease.
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Affiliation(s)
- Moussa El-Hallak
- Department of Medicine, Children's Hospital Boston, Boston, Massachusetts 02115, USA
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21
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Dunkley S, Kershaw G, Young G, Warburton P, Lindeman R, Matthews S, Rennisson F. Rituximab treatment of mild haemophilia A with inhibitors: a proposed treatment protocol. Haemophilia 2006; 12:663-7. [PMID: 17083518 DOI: 10.1111/j.1365-2516.2006.01351.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Inhibitors are an uncommon complication of mild haemophilia A but represent a severe disease, typically with high titre inhibitors and an associated high rate of bleeding. We present data from three patients with MHAI who were successfully treated with Rituximab alone and unequivocally prove that such inhibitors respond to this agent. A treatment protocol is suggested.
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Affiliation(s)
- S Dunkley
- Haemophilia and Thrombosis Unit, Royal Prince Alfred Hospital, Sydney, Australia.
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22
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Kerkar N, Cohen S, Dugan C, Morotti RA, Phelps RG, Herold B, Shneider B, Emre S. Bullous pemphigoid after liver transplantation for liver failure. Liver Transpl 2006; 12:1705-10. [PMID: 17058253 DOI: 10.1002/lt.20930] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Coomb's positive autoimmune hemolytic anemia with giant cell hepatitis (GCH) is a rare cause of liver failure and is usually associated with poor prognosis. A child with liver kidney microsomal (LKM) antibody positivity underwent successful liver transplantation for liver failure secondary to GCH with Coomb's positive hemolytic anemia. Autoimmune neutropenia developed ten months after transplant. Four months later, pemphigoid skin lesions developed. The diagnosis of bullous pemphigoid (BP) was made on the basis of skin biopsy, direct and indirect immunofluorescence test results. Treatment was with immunosuppressants - prednisone and azathioprine/rapamycin, with addition of dapsone when lesions persisted. This child is unique in that his liver function and hemolytic anemia appeared to normalize after liver transplant, but neutropenia and BP both thought to be autoimmune in etiology, developed more than a year post-transplant.
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Affiliation(s)
- Nanda Kerkar
- Division of Pediatric Hepatology, Department of Pediatrics, Mount Sinai School of Medicine, New York, NY, USA.
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23
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Abstract
Neutralizing alloantibodies (inhibitors) to factor VIII or factor IX develop in approximately 25% of patients with haemophilia A and <3% of patients with haemophilia B treated with factor concentrate. Patients with high titre inhibitors, in whom immune tolerance therapy fails, have few treatment options. Targeted anti-B-cell therapy with rituximab (chimeric anti-CD20) has been useful in several antibody-mediated autoimmune states. Case reports of rituximab treatment in small numbers of haemophilia patients with inhibitors have been inconclusive. We describe three adolescent patients with severe haemophilia and inhibitors treated with four weekly doses of rituximab, 375 mg m(-2). Treatment with rituximab was effective in reducing the inhibitor titre in two of three patients. Rituximab may be beneficial for patients with severe haemophilia and inhibitors in whom standard therapies have failed, but larger prospective studies are required to determine safety, efficacy and predictors of success.
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Affiliation(s)
- R A Fox
- Department of Medicine, Children's Hospital, Boston, MA, USA
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24
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Looney RJ, Anolik J, Sanz I. New therapies for systemic lupus erythematosus: cellular targets. Rheum Dis Clin North Am 2006; 32:201-15, xi. [PMID: 16504831 DOI: 10.1016/j.rdc.2005.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Antilymphocyte antibodies have been widely used in oncology and transplantation and are now being tested in autoimmune diseases. For systemic lupus erythematosus, anti-B-cell antibodies are furthest along in development. This article discusses the B-cell abnormalities found in systemic lupus erythematosus and the clinical and immunologic effects of anti-B-cell therapies.
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Affiliation(s)
- R John Looney
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY14420, USA.
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25
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Willems M, Haddad E, Niaudet P, Koné-Paut I, Bensman A, Cochat P, Deschênes G, Fakhouri F, Leblanc T, Llanas B, Loirat C, Pillet P, Ranchin B, Salomon R, Ulinski T, Bader-Meunier B. Rituximab therapy for childhood-onset systemic lupus erythematosus. J Pediatr 2006; 148:623-627. [PMID: 16737873 DOI: 10.1016/j.jpeds.2006.01.041] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Revised: 12/12/2005] [Accepted: 01/20/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the safety and efficacy of rituximab in the treatment of childhood-onset systemic lupus erythematosus (SLE). STUDY DESIGN We conducted a French multicenter retrospective study of childhood-onset SLE treated with rituximab. RESULTS Eleven girls with severe SLE, including 8 girls with class IV or V lupus nephritis, 2 girls with severe autoimmune cytopenia, and 1 girl with antiprothrombin antibody with severe hemorrhage, were treated with rituximab. The mean age at onset of rituximab treatment was 13.9 years. Patients received 2 to 12 intravenous infusions of rituximab (350-450 mg/m2/infusion), with corticosteroids. Six patients also received different standard immunosuppressive agents, including Cyclophosphamide (2 patients). Remission was achieved in 6 of 8 patients with lupus nephritis and in the 2 patients with autoimmune cytopenia. Steroid therapy was tapered in 5 patients who responded to treatment, and low-dose prednisone treatment was maintained in 1 patient. The mean follow-up period was 13.2 months (range, 6-26 months), and remission lasted in all who patients who responded to treatment, except 1 patient who was successfully retreated with a second course of rituximab. Anti-double-stranded DNA antibody levels decreased in 6 of 11 patients, and anticardiolipin antibody levels decreased in 3 of 4 patients. Severe adverse events developed in 5 patients. Effective depletion of peripheral blood B cells was observed in 7 of 8 patients who were examined, and this paralleled the remission. CONCLUSION Rituximab may be an effective co-therapy; however, further investigations are required because severe adverse events occurred in 45% of the patients in this study.
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Affiliation(s)
- M Willems
- Department of Pediatrics, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
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26
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Arabshahi B, Thompson ED, Smergel EM, Goldsmith DP. Long-term treatment of antiphospholipid syndrome-associated cerebral arterial thromboses with intravenous immunoglobulin: a case report. Clin Rheumatol 2005; 26:251-3. [PMID: 16328092 DOI: 10.1007/s10067-005-0127-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2005] [Revised: 08/11/2005] [Accepted: 08/12/2005] [Indexed: 11/29/2022]
Abstract
We report a now 13-year-old male with trisomy 21, hypothyroidism, and insulin-dependent diabetes who developed acute hemiplegia due to the antiphospholipid antibody syndrome (APS) at age four. The risks of long-term anticoagulation were initially considered to be high; hence, he was treated with monthly infusions of intravenous immunoglobulin (IVIG) at 2 g/kg for 2 years and then every other month for 7 years. Antiphospholipid antibodies were no longer detectable within 6 months and have continued to be negative. There was no clinical deterioration or further changes on magnetic resonance arteriography over 7 years. IVIG may be an alternative therapeutic choice for children with APS who are not candidates for conventional anticoagulation.
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Affiliation(s)
- B Arabshahi
- Section of Rheumatology, St. Christopher's Hospital for Children/Drexel University College of Medicine, Philadelphia, PA, USA.
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27
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Abstract
Although the pathogenesis of SLE remains poorly understood, there is consensus that it involves a combination of genetic, hormonal, and environmental factors. New technologies applied to genomic and gene expression studies have revealed novel gene mutations and cytokine alterations in this disease. Recently, advances in monoclonal antibodies and recombinant DNA technology have resulted in the development of new drugs to arrest disease progression and restore physiologic immune responses without major side effects. Clinical trials to test several of these novel therapies are currently underway.
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28
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Kong HH, Prose NS, Ware RE, Hall RP. Successful treatment of refractory childhood pemphgus vulgaris with anti-CD20 monoclonal antibody (rituximab). Pediatr Dermatol 2005; 22:461-4. [PMID: 16191003 DOI: 10.1111/j.1525-1470.2005.00118.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Pemphigus vulgaris is an uncommon autoimmune blistering skin disorder that is particularly rare in children. Immunosuppressive treatment can be challenging. Rituximab (anti-CD20 monoclonal antibody) has been used to treat autoimmune disorders by depletion of CD20 B cells. Successful rituximab therapy has been reported in adults with refractory pemphigus vulgaris. We present a girl with childhood pemphigus vulgaris unresponsive to treatment with azathioprine, mycophenolate mofetil, plasmapheresis, and intravenous immunoglobulin with systemic prednisone who responded to treatment with rituximab. She had a corresponding decline in circulating antibodies against desmoglein 1 and 3 and a decline in diphtheria and tetanus-specific antibody titers.
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Affiliation(s)
- Heidi H Kong
- Division of Dermatology, Duke University Medical Center, Durham, North Carolina 27710, USA
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29
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Sibilia J, Sordet C. [Rituximab: a original biotherapy in auto-immune disorders]. Rev Med Interne 2005; 26:485-500. [PMID: 15936477 DOI: 10.1016/j.revmed.2004.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2004] [Accepted: 12/27/2004] [Indexed: 01/13/2023]
Abstract
SUBJECT After several decades of hegemony of the T lymphocyte, recent work has suggested the importance of the B lymphocyte in auto-immune diseases. As a consequence, there has emerged over the last few years the idea of using anti-B lymphocyte therapy, in particular rituximab (a chimeric anti-CD20 monoclonal antibody). CURRENT TOPICS AND IMPORTANT RESULTS This review addresses various current topics: a) the role of B lymphocytes in auto-immune diseases, notably their capacity to be antigen presenting cells and to be activated by original systems like Blys/Baff; b) the mechanism of action of rituximab (apoptosis, complement-dependent cytotoxicity and antibody-dependent cell cytotoxicity) and the phenomena explaining failures and cases escaping treatment, in particular among lymphoproliferations; c) The results include efficacy and tolerance data for the principal auto-immune affections. Among these, the most promising indications would seem to be for rheumatoid polyarthritis and systemic lupus erythematosis, although some preliminary open studies point to an effect in Goujerot-Sjögren's syndrome, neuropathies, auto-immune cytopenia, idiopathic thrombocytopenic purpura, cryoagglutinins, blistering cutaneous affections... PERSPECTIVES AND PROJECTS Controlled studies will be required to determine the true efficacy and tolerance of this molecule, as it is imperative to validate these new immunotherapeutic strategies, above all when they concern innovative and expensive therapy. Nevertheless, these different observations arouse great hopes and at the same time exciting questions, notably as to the role of B lymphocytes in auto-immune diseases.
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Affiliation(s)
- J Sibilia
- Service de rhumatologie, Hôpitaux universitaires de Strasbourg, université Louis-Pasteur, 1, avenue Molière, 67098 Strasbourg cedex, France
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30
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Chitlur M, Abella E, Singh TP, Savaşan S. Severe neutropenia and thrombocytopenia following cardiac transplantation in a child. Pediatr Transplant 2005; 9:94-6. [PMID: 15667619 DOI: 10.1111/j.1399-3046.2004.00233.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hematological complications have been occasionally described after cardiac transplantation. We are reporting a 5-yr-old child who developed sequential severe neutropenia and thrombocytopenia following cardiac transplantation while on tacrolimus-based immune suppression therapy. There was no improvement in blood counts following a change in immune suppression to cyclosporine A. The neutropenia was associated with a maturation arrest in the bone marrow. The occurrence of thrombocytopenia coincided with rising anti-herpes virus 6 IgG titers suggesting a possible contributory role. Neutropenia resolved following treatment with rituximab, and the thrombocytopenia responded to Dapsone therapy eventually. This case points out the potential multifactorial pathogenesis of cytopenias following cardiac transplantation with differing response to various immune suppressive therapies.
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Affiliation(s)
- Meera Chitlur
- Division of Hematology/Oncology, Children's Hospital of Michigan, Detroit, MI 48201, USA
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31
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an update on the clinical manifestations of SLE in children. Emerging clues on the pathogenesis of the disease based on recent human studies conducted both in children and adults, will also be summarized. RECENT FINDINGS Pediatric Rheumatologists caring for children with SLE face many challenges. As the life expectancy of these patients improves, new recognized complications such as accelerated atherosclerosis and hypertension emerge as major causes of morbidity. However, few longitudinal studies describing the long term outcome of these children, including the impact of disease and treatment on their physical and psychological development are available. Few prospective interventional studies have been carried out to assess the efficacy of established and novel treatments in the pediatric population. Recently, basic studies aimed at understanding the immune alterations underlying this disease have been performed in children. These studies indicate an important role for interferon-alpha (IFN-alpha) in the pathogenesis of this disease and reveal an overall striking homogeneity of leukocyte gene expression profiles in children and adults with SLE. The contribution of novel gene polymorphisms to disease susceptibility and the sequential breakdown of tolerance to nuclear antigens that precedes clinical manifestations in patients with SLE are among the recent studies that are helping us understand the complex SLE puzzle. SUMMARY SLE continues to cause significant morbidity in the pediatric age group. A better recognition of the age-specific manifestations and long-term complications of this disease is required to improve its outcome. Understanding its unique pathogenesis will hopefully lead to the development of better, more targeted and less toxic therapies.
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Affiliation(s)
- Dorothee Stichweh
- Baylor Institute for Immunology Research, Dallas, Texas, and the UT Southwestern Medical Center, Dallas, Texas, USA
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32
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Abstract
PURPOSE OF REVIEW Children with rheumatic diseases frequently require therapy with disease-modifying antirheumatic drugs and/or biologic agents. Therapies that have been prospectively tested in adults are often used in children before full evaluation of their safety and efficacy. Published experience that may report "off-label" usage can be helpful in decision making, although such reports do not reduce the need for prospective clinical trials in children. The purpose of this review is to summarize the recent published evidence regarding efficacy (and safety, when available) of standard and novel agents used in pediatric rheumatic disease. RECENT FINDINGS Etanercept, one of three currently available tumor necrosis factor-alpha inhibitors has a juvenile idiopathic arthritis indication. Novel "off-label" uses in children for interleukin-1 receptor agonist (Anakinra), antiinterleukin-6 receptor antibody (MRA), and rituximab (anti-CD20 monoclonal antibody) are discussed. SUMMARY This review summarizes the published evidence that supports the use of selected disease-modifying antirheumatic drugs and novel biologic agents in children with rheumatic diseases.
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Affiliation(s)
- Nora G Singer
- Department of Pediatrics and Internal Medicine, CASE School of Medicine and Rainbow Babies and Children's Hospital/University Hospitals, Cleveland, Ohio 44106, USA.
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Abstract
PURPOSE OF REVIEW Trials treating human rheumatic diseases with biologic agents and drugs that selectively affect B cells will be reviewed. Rituximab, an anti-CD20 monoclonal mouse/human antibody, will be the primary focus of the review because it has been widely used in several autoimmune and rheumatic conditions, but the limited studies on other reagents such as anti-BlyS, anti-CD154, and B cell tolerogens will also be covered. RECENT FINDINGS The single most important recent development was the completion of a randomized, double-blind, placebo-controlled trial of rituximab in methotrexate-resistant rheumatoid arthritis. In this trial, B cell depletion with rituximab led to a sustained clinical response with an impressive improvement in America College of Rheumatology 50% response (ACR 50) at both 24 and 48 weeks. Additional open studies of rituximab showing clinical benefit in systemic lupus erythematosus, cryoglobulinemia, antineutrophil cytoplasmic antibodies+ vasculitis, and dermatomyositis are noteworthy but must be interpreted with caution until randomized control trials are available. Two well-designed studies of anti-CD154 antibodies in systemic lupus erythematosus were reported. Unfortunately, one was halted because of unexpected vascular complications, and the other failed to show any beneficial clinical effect. A phase I study using anti-BlyS in SLE demonstrated a selective effect on B cells and no overt toxicity, but in this very short-term study no effect on serology or clinical activity was seen. Two B cell tolerogens have been used in human trials. The first tolerogen, directed at anti-dsDNA responses in SLE, did significantly decrease titers of high-affinity anti-dsDNA antibodies but had no clinically beneficial effect overall. A phase I trial of a tolerogen directed at anti-beta2-glycoprotein I antibodies demonstrated a decrease in antibody titers after a single injection. SUMMARY Several therapeutic agents targeting B cells have now been tested or are being tested in human trials. The success of rituximab in a well-controlled trial confirms previous preliminary reports indicating that B cell depletion can treat established autoimmune disease.
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Affiliation(s)
- R John Looney
- Department of Medicine, University of Rochester, Box 695, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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