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Jo EA, Min S, Jo AJ, Han A, Ha J, Song EY, Lee H, Kim YC. The time-dependent changes in serum immunoglobulin after kidney transplantation and its association with infection. Front Immunol 2024; 15:1374535. [PMID: 38707898 PMCID: PMC11066164 DOI: 10.3389/fimmu.2024.1374535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/02/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction Kidney transplant recipients often experience significant alterations in their immune system, which can lead to increased susceptibility to infections. This study aimed to analyze time-dependent changes in serum immunoglobulin and complement levels and determine the risk factors associated with infection. Methods A retrospective analysis of serum samples from 192 kidney transplant recipients who received transplantations between August 2016 and December 2019 was conducted. The serum samples were obtained at preoperative baseline (T0), postoperative 2 weeks (T1), 3 months (T2), and 1 year (T3). The levels of serum C3, C4, IgG, IgA, and IgM were measured to evaluate immune status over time. Results The analysis revealed significant decreases in IgG and IgA levels at T1. This period was associated with the highest occurrence of hypogammaglobulinemia (HGG) and hypocomplementemia (HCC), as well as an increased incidence of severe infection requiring hospitalization and graft-related viral infections. Using a time-dependent Cox proportional hazards model adjusted for time-varying confounders, HGG was significantly associated with an increased risk of infection requiring hospitalization (HR, 1.895; 95% CI: 1.871-1.920, P-value<0.001) and graft-related viral infection (HR, 1.152; 95% CI: 1.144-1.160, P-value<0.001). Discussion The findings suggest that monitoring serum immunoglobulin levels post-transplant provides valuable insights into the degree of immunosuppression. Hypogammaglobulinemia during the early post-transplant period emerges as a critical risk factor for infection, indicating that serum immunoglobulins could serve as feasible biomarkers for assessing infection risk in kidney transplant recipients.
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Affiliation(s)
- Eun-Ah Jo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Sangil Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ae jung Jo
- Department of Information Statistics, Andong National University, Andong, Republic of Korea
| | - Ahram Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Young Song
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hajeong Lee
- Department of Nephrology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong Chul Kim
- Department of Nephrology, Seoul National University College of Medicine, Seoul, Republic of Korea
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2
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de Toledo Piza CFS, Aranda CS, Solé D, Jolles S, Condino-Neto A. Screening for Antibody Deficiencies in Adults by Serum Electrophoresis and Calculated Globin. J Clin Immunol 2023; 43:1873-1880. [PMID: 37505322 DOI: 10.1007/s10875-023-01536-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/09/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE This study aimed to investigate the correlation between calculated globulin (CG, total protein level minus albumin level) and the gamma globulin fraction (Gamma), obtained from serum protein electrophoresis with serum IgG levels in adults (≥ 18 years). METHODS Using linear regression models, analyses of CG and Gamma levels correlation with IgG levels in adults were performed. Receiver-operator curves were created to determine cutoff values and the respective sensitivity and specificity measures. RESULTS A total of 886 samples were analyzed. CG and Gamma were positively and statistically correlated with IgG levels (r2 = 0.4628 for CG, and = 0.7941 for Gamma, p < 0.0001 for both analyses). For the detection of hypogammaglobulinemia, i.e., IgG level below the reference value (6 g/L), a CG cutoff value of 24 g/L showed a sensitivity of 86.2% (95% CI 69.4-94.5) and a specificity of 92% (90.0-93.6). A Gamma cutoff value of 7.15 g/L yielded a sensitivity of 100% (88.3-100) and a specificity of 96.8 (95.3-97.8). CONCLUSION Both CG and Gamma levels determined by protein electrophoresis analysis may be used to screen for antibody deficiencies in adults, enabling earlier diagnosis of antibody deficiencies in a routine clinical setting.
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Affiliation(s)
| | - Carolina Sanchez Aranda
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Dirceu Solé
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, Wales, UK
| | - Antonio Condino-Neto
- Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, SP, Brazil.
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3
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Boqué C, Sánchez-Ramón S, Córdoba R, Moreno C, Cabezudo E. Current Approach in the Management of Secondary Immunodeficiency in Patients with Hematological Malignancies: Spanish Expert Consensus Recommendations. J Clin Med 2023; 12:6356. [PMID: 37835000 PMCID: PMC10573502 DOI: 10.3390/jcm12196356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/22/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
A Delphi-based survey was designed to assess the opinions of clinical hematologists (n = 17) and clinical immunologists (n = 18) from across Spain on secondary immunodeficiencies (SID) in the management of oncohematological patients. There was 100% agreement on the need to have available guidelines for the management of immunodeficiency in hematological patients; to perform a baseline immunological evaluation in patients with chronic lymphocytic leukemia (CLL), multiple myeloma (MM), lymphoma and hematopoietic stem cell transplantation (HSCT) recipients; and to quantify serum IgG, IgA and IgM levels when SID is suspected. More than 90% agreed on the need for active immunization against seasonal influenza and H1N1, pneumococcus and Haemophilus influenzae. There was a consensus on the monitoring of IgG levels every 3 months (83%) and the need to have available a clinical protocol for the use of IVIG in the management of SID (94%), to monitor trough IgG levels to determine the correct IVIG dose (86%) and to discontinue IVIG after the recovery of IgG levels after 12 months of follow-up (77%). The findings of the present survey may be useful recommendations for hematologists and immunologists to improve the management of SID in daily practice.
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Affiliation(s)
- Concepción Boqué
- Department of Hematology, Hospital Duran i Reynals, Institut Català d’Oncologia, 08908 Hospitalet de Llobregat, Barcelona, Spain
| | - Silvia Sánchez-Ramón
- Department of Clinical Immunology, Instituto de Medicina de Laboratorio, Hospital Clínico San Carlos, Universidad Complutense, 28040 Madrid, Spain;
| | - Raúl Córdoba
- Department of Hematology, Fundación Jimenez Diaz University Hospital, Health Research Institute-Fundación Jimenez Diaz, 28040 Madrid, Spain;
| | - Carol Moreno
- Department of Hematology, Hospital de la Santa Creu i Sant Pau, Josep Carreras Leukaemia Research Institute, Universitat Autónoma de Barcelona, 08025 Barcelona, Catalonia, Spain;
| | - Elena Cabezudo
- Service of Hematology, ICO-Hospital de Sant Joan Despí Moisès Broggi, 08970 Sant Joan Despí, Barcelona, Spain;
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Giralt S, Jolles S, Kerre T, Lazarus HM, Mustafa SS, Papanicolaou GA, Ria R, Vinh DC, Wingard JR. Recommendations for Management of Secondary Antibody Deficiency in Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:719-732. [PMID: 37353432 DOI: 10.1016/j.clml.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/05/2023] [Accepted: 05/18/2023] [Indexed: 06/25/2023]
Abstract
Secondary antibody deficiency (SAD) is a subtype of secondary immunodeficiency characterized by low serum antibody concentrations (hypogammaglobulinemia) or poor antibody function. SAD is common in patients with multiple myeloma (MM) due to underlying disease pathophysiology and treatment-related immune system effects. Patients with SAD are more susceptible to infections and infection-related morbidity and mortality. With therapeutic advancements improving MM disease control and survival, it is increasingly important to recognize and treat the often-overlooked concurrent immunodeficiency present in patients with MM. The aims of this review are to define SAD and its consequences in MM, increase SAD awareness, and provide recommendations for SAD management. Based on expert panel discussions at a standalone meeting and supportive literature, several recommendations were made. Firstly, all patients with MM should be suspected to have SAD regardless of serum antibody concentrations. Patients should be evaluated for immunodeficiency at MM diagnosis and stratified into management categories based on their individualized risk of SAD and infection. Infection-prevention strategy education, early infection reporting, and anti-infective prophylaxis are key. We recommend prophylactic antibiotics or immunoglobulin replacement therapy (IgRT) should be considered in patients with severe hypogammaglobulinemia associated with a recurrent or persistent infection. To ensure an individualized and efficient treatment approach is utilized, patient's immunoglobin G concentration and infection burden should be closely monitored throughout treatment. Patient choice regarding route and IgRT treatment is also key in reducing treatment burden. Together, these recommendations and proposed management algorithms can be used to aid physician decision-making to improve patient outcomes.
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Affiliation(s)
- Sergio Giralt
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
| | - Tessa Kerre
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - Hillard M Lazarus
- Department of Medicine, Division of Hematology and Oncology, Case Western Reserve University, Cleveland, OH, United States
| | - S Shahzad Mustafa
- Rochester Regional Health, Rochester, NY, United States; University of Rochester School of Medicine & Dentistry, Rochester, NY, United States
| | - Genovefa A Papanicolaou
- Department of Medicine, Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Roberto Ria
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Bari, Italy
| | - Donald C Vinh
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - John R Wingard
- Department of Medicine, Division of Hematology Oncology, University of Florida, Gainesville, FL, United States
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5
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Oster C, Stolte B, Asan L, Pul R, Klebe S, Köhrmann M, Breuckmann K, Rischpler C, Deuschl C, Dolff S, Kleinschnitz C, Hagenacker T. Brainstem Infarction in Immunodeficiency Identified as Adenosine Deaminase 2 Deficiency: Case Report. J Clin Immunol 2023; 43:1597-1602. [PMID: 37306896 PMCID: PMC10258773 DOI: 10.1007/s10875-023-01526-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/24/2023] [Indexed: 06/13/2023]
Abstract
PURPOSE We present the case of a 24-year-old male with CNS granulomatosis due to an immunodeficiency syndrome which was identified as deficiency of adenosine deaminase 2 (DADA2) as a cause of brainstem infarction. METHODS Case report and detailed description of the clinical course of diagnosis and treatment. CASE The patient's medical history consisted of an unknown immunodeficiency syndrome. Based on former findings, common variable immunodeficiency (CVID) was diagnosed. The patient suffered from three consecutive brainstem strokes of unknown etiology within 3 years. An MRI scan detected gadolinium-enhancing, granulomatous-suspect lesions in the interpeduncular cistern, temporal lobe, and tegmentum. Laboratory analysis was compatible with CVID, with leukopenia and immunoglobulin deficiency. Because granulomatous CNS inflammation was suspected, the patient received methylprednisolone immunosuppressive therapy, which led to partially regressive MRI lesions. However, in contrast to imaging, the patient showed a progressive cerebellar syndrome, indicating plasma exchange therapy and immunoglobulin treatment, which led to rapid symptom amelioration. After a relapse and a further stroke, expanded analysis confirmed DADA2 (and not CVID) as the inflammatory cause for recurrent stroke. After starting the therapy with immunoglobulins and adalimumab, no further strokes occurred. CONCLUSION We present the case of a young adult with diagnosis of DADA2 as a cause for recurrent strokes due to vasculitis. This stroke etiology is rare but should be considered as a cause of recurrent stroke of unknown origin in young patients to avoid a disabling disease course by disease-specific treatment options.
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Affiliation(s)
- Christoph Oster
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Benjamin Stolte
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Livia Asan
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Refik Pul
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Stephan Klebe
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Katharina Breuckmann
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christoph Rischpler
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
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Ar MC, El Fakih R, Gabbassova S, Alhuraiji A, Nasr F, Alsaeed A, Sayinalp N, Marashi M. Management of humoral secondary immunodeficiency in hematological malignancies and following hematopoietic stem cell transplantation: Regional perspectives. Leuk Res 2023; 133:107365. [PMID: 37643508 DOI: 10.1016/j.leukres.2023.107365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 07/17/2023] [Accepted: 07/25/2023] [Indexed: 08/31/2023]
Abstract
Secondary immunodeficiency (SID) can occur as a result of multiple factors, including hematological malignancies, hematopoietic stem cell transplantation (HSCT), immunosuppressive treatment, biologics, and anti-inflammatory drugs. SID includes disorders resulting from impairment of both cellular and humoral immunity. This review focuses on the current risk factors, implications, and challenges in managing SID patients with impaired humoral immunity, which includes quantitative (hypogammaglobulinemia) and/or functional antibody and B-cell deficiencies specifically related to hematological malignancies and post-HSCT. Increased physician awareness is needed surrounding the disease presentation and early risk factors, as SID may be caused by several etiologies. Careful clinical assessment is then required to optimize management, which encompasses close monitoring of clinical parameters, vaccination, antibiotic prophylaxis, and immunoglobulin replacement therapy (IGRT). Novel methods of IGRT administration are associated with enhanced pharmacokinetics, IgG trough level stability, no need for venous access, as well as fewer systemic adverse events and better administration flexibility compared with traditional methods. Published international guidelines supported by observations from clinical data are broadly followed; however, best practices within each country have nuances that underline the need to tailor treatment plans to the individual patient.
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Affiliation(s)
- Muhlis Cem Ar
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa School of Medicine, Istanbul University, Cerrahpaşa, Istanbul, Turkey
| | - Riad El Fakih
- Oncology Center, Section of Stem Cell Transplant and Cellular Therapy, King Faisal Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saule Gabbassova
- Center for Hematology and Bone Marrow Transplantation, Kazakh Scientific Research Institute of Oncology and Radiology, Almaty, Kazakhstan; Al-Farabi Kazakh National University, Almaty, Kazakhstan
| | - Ahmad Alhuraiji
- Department of Hematology, Kuwait Cancer Control Center, Kuwait City, Kuwait
| | - Fady Nasr
- Department of Hemato-Oncology, Hôtel-Dieu de France Hospital, Faculty of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Ahmad Alsaeed
- Princess Noorah Oncology Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Nilgun Sayinalp
- Department of Hematology, Hacettepe University Medical School, Ankara, Turkey
| | - Mahmoud Marashi
- Department of Hematology, Mediclinic City Hospital, Dubai, United Arab Emirates.
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7
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Poto R, Pecoraro A, Ferrara AL, Punziano A, Lagnese G, Messuri C, Loffredo S, Spadaro G, Varricchi G. Cytokine dysregulation despite immunoglobulin replacement therapy in common variable immunodeficiency (CVID). Front Immunol 2023; 14:1257398. [PMID: 37841257 PMCID: PMC10568625 DOI: 10.3389/fimmu.2023.1257398] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/07/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction Common variable immunodeficiency (CVID) is the most prevalent symptomatic primary immunodeficiency. CVID is a heterogeneous disorder with a presumed multifactorial etiology. Intravenous or subcutaneous immunoglobulin replacement therapy (IgRT) can prevent severe infections but not underlying immune dysregulation. Methods In this study, we evaluated the serum concentrations of proinflammatory (TNF-α, IL-1β, IL-6) and immunoregulatory cytokines (IL-10), as well as lipopolysaccharide (LPS) and soluble CD14 (sCD14) in CVID individuals with infectious only (INF-CVID), and those with additional systemic autoimmune and inflammatory disorders (NIC-CVID), and healthy donors (HD). Results Our results showed increased serum concentrations of TNF-α, IL-1β, IL-6, and IL-10 in both INF-CVID and NIC-CVID subjects compared to HD. However, elevations of TNF-α, IL-1β, IL-6, and IL-10 were significantly more marked in NIC-CVID than INF-CVID. Additionally, LPS concentrations were increased only in NIC-CVID but not in INF-CVID compared to HD. Circulating levels of sCD14 were significantly increased in NIC-CVID compared to both INF-CVID and HD. Discussion These findings indicate persistent cytokine dysregulation despite IgRT in individuals with CVID. Moreover, the circulating cytokine profile reveals the heterogeneity of immune dysregulation in different subgroups of CVID subjects.
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Affiliation(s)
- Remo Poto
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- World Allergy Organization (WAO), Center of Excellence (CoE), Naples, Italy
| | - Antonio Pecoraro
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- World Allergy Organization (WAO), Center of Excellence (CoE), Naples, Italy
- Unità Operativa (UO) Medicina Trasfusionale, Azienda Sanitaria Territoriale, Ascoli Piceno, Italy
| | - Anne Lise Ferrara
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- World Allergy Organization (WAO), Center of Excellence (CoE), Naples, Italy
| | - Alessandra Punziano
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- World Allergy Organization (WAO), Center of Excellence (CoE), Naples, Italy
| | - Gianluca Lagnese
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- World Allergy Organization (WAO), Center of Excellence (CoE), Naples, Italy
| | - Carla Messuri
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- World Allergy Organization (WAO), Center of Excellence (CoE), Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Stefania Loffredo
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- World Allergy Organization (WAO), Center of Excellence (CoE), Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- Institute of Experimental Endocrinology and Oncology, National Research Council (CNR), Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- World Allergy Organization (WAO), Center of Excellence (CoE), Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- World Allergy Organization (WAO), Center of Excellence (CoE), Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- Institute of Experimental Endocrinology and Oncology, National Research Council (CNR), Naples, Italy
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Dimou M, Speletas M, Milito C, Pyzik A, Huscher D, Kamieniak M, Pittrow D, Borte M. Insights into Facilitated Subcutaneous Immunoglobulin Use in Patients with Secondary Immunodeficiency Diseases: A FIGARO Subgroup Analysis. Cancers (Basel) 2023; 15:4524. [PMID: 37760493 PMCID: PMC10526788 DOI: 10.3390/cancers15184524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/22/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
The Facilitated Immunoglobulin Administration Registry And Outcomes (FIGARO) Study was a European, multicenter, prospective, observational study conducted across Europe designed to provide insights on the clinical use and tolerability of facilitated subcutaneous immunoglobulin (fSCIG). Data herein are reported for the cohort of patients with secondary immunodeficiency (SID), with a subgroup analysis by age. The SID cohort included 31 patients: 1 pediatric, 15 adult, and 15 older adult patients. Over the 36-month observation period, the median monthly dose of fSCIG (30 g) and median monthly infusion volume per patient (300 mL) remained constant in both adult-age cohorts. Serum trough levels tended to increase over time. Most patients required only one infusion site and could receive the full dose every 3-4 weeks. There was a trend toward self-administration at home. In the adult group, infusion site inflammation and headache were reported at the inclusion visit (n = 1 each), with no adverse drug reactions reported at any of the follow-up visits. No acute severe bacterial infections were reported during the study follow-up. These results demonstrate the feasibility and tolerability of fSCIG use in patients with SID and the flexibility of administration settings including self-administration at home in patients aged ≥65 years.
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Affiliation(s)
- Maria Dimou
- First Department of Propaedeutic Internal Medicine, National & Kapodistrian University of Athens Medical School, General Hospital “LAIKO”, 11527 Athens, Greece
| | - Matthaios Speletas
- School of Health Sciences, Department of Immunology and Histocompatibility, Faculty of Medicine, University of Thessaly, GR-41500 Larissa, Greece;
| | - Cinzia Milito
- Department of Molecular Medicine, Sapienza University of Rome, 00161 Rome, Italy;
| | - Aleksandra Pyzik
- Department of Clinical Immunology, Center of Oncology St. Jana, 20-090 Lublin, Poland;
| | - Dörte Huscher
- Institute of Biometry and Clinical Epidemiology, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Marta Kamieniak
- Takeda Development Center Americas, Inc., Cambridge, MA 02142, USA;
| | - David Pittrow
- Institute for Clinical Pharmacology, Medical Faculty, Technical University of Dresden, 01307 Dresden, Germany;
- Innovation Center Real World Evidence, GWT-TUD GmbH, 01067 Dresden, Germany
| | - Michael Borte
- Hospital for Children and Adolescents, St. Georg Hospital, Academic Teaching Hospital of the University of Leipzig, IDCL (ImmunoDeficiency Center Leipzig), 04129 Leipzig, Germany;
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Hlavackova E, Krenova Z, Kerekes A, Slanina P, Vlkova M. B cell subsets reconstitution and immunoglobulin levels in children and adolescents with B non-Hodgkin lymphoma after treatment with single anti CD20 agent dose included in chemotherapeutic protocols: single center experience and review of the literature. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023. [PMID: 37227099 DOI: 10.5507/bp.2023.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND RTX, an anti-CD20 monoclonal antibody, added to chemotherapy has proven to be effective in children and adolescents with high-grade, high-risk and matured non-Hodgkin lymphoma. RTX leads to prompt CD19+ B lymphocyte depletion. However, despite preserved immunoglobulin production by long-lived plasmablasts after treatment, patients remain at risk of prolonged hypogammaglobulinemia. Further, there are few general guidelines for immunology laboratories and clinical feature monitoring after B cell-targeted therapies. The aim of this paper is to describe B cell reconstitution and immunoglobulin levels after pediatric B-NHL protocols, that included a single RTX dose and to review the literature. METHODS A retrospective single-center study on the impact of a single RTX dose included in a chemotherapeutic pediatric B Non-Hodgkin Lymphoma (B-NHL) treatment protocols. Immunology laboratory and clinical features were evaluated over an eight hundred days follow-up (FU) period, after completing B-NHL treatment. RESULTS Nineteen patients (fifteen Burkitt lymphoma, three Diffuse large B cell lymphoma, and one Marginal zone B cell lymphoma) fulfilled the inclusion criteria. Initiation of B cell subset reconstitution occurred a median of three months after B-NHL treatment. Naïve and transitional B cells declined over the FU in contrast to the marginal zone and the switched memory B cell increase. The percentage of patients with IgG, IgA, and IgM hypogammaglobulinemia declined consistently over the FU. Prolonged IgG hypogammaglobulinemia was detectable in 9%, IgM in 13%, and IgA in 25%. All revaccinated patients responded to protein-based vaccines by specific IgG antibody production increase. Following antibiotic prophylaxes, none of the patients with hypogammaglobulinemia manifested with either a severe or opportunistic infection course. CONCLUSION The addition of a single RTX dose to the chemotherapeutic treatment protocols was not shown to increase the risk of developing secondary antibody deficiency in B-NHL pediatric patients. Observed prolonged hypogammaglobulinemia remained clinically silent. However interdisciplinary agreement on regular long-term immunology FU after anti-CD20 agent treatment is required.
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Affiliation(s)
- Eva Hlavackova
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University Brno, Czech Republic
| | - Zdenka Krenova
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University Brno, Czech Republic
| | - Arpad Kerekes
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University Brno, Czech Republic
| | - Peter Slanina
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marcela Vlkova
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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10
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Qian L, Lin X, Gao X, Khan RU, Liao JY, Du S, Ge J, Zeng S, Yao SQ. The Dawn of a New Era: Targeting the "Undruggables" with Antibody-Based Therapeutics. Chem Rev 2023. [PMID: 37186942 DOI: 10.1021/acs.chemrev.2c00915] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
The high selectivity and affinity of antibodies toward their antigens have made them a highly valuable tool in disease therapy, diagnosis, and basic research. A plethora of chemical and genetic approaches have been devised to make antibodies accessible to more "undruggable" targets and equipped with new functions of illustrating or regulating biological processes more precisely. In this Review, in addition to introducing how naked antibodies and various antibody conjugates (such as antibody-drug conjugates, antibody-oligonucleotide conjugates, antibody-enzyme conjugates, etc.) work in therapeutic applications, special attention has been paid to how chemistry tools have helped to optimize the therapeutic outcome (i.e., with enhanced efficacy and reduced side effects) or facilitate the multifunctionalization of antibodies, with a focus on emerging fields such as targeted protein degradation, real-time live-cell imaging, catalytic labeling or decaging with spatiotemporal control as well as the engagement of antibodies inside cells. With advances in modern chemistry and biotechnology, well-designed antibodies and their derivatives via size miniaturization or multifunctionalization together with efficient delivery systems have emerged, which have gradually improved our understanding of important biological processes and paved the way to pursue novel targets for potential treatments of various diseases.
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Affiliation(s)
- Linghui Qian
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Cancer Center, & Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, China
| | - Xuefen Lin
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Cancer Center, & Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, China
| | - Xue Gao
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Cancer Center, & Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, China
| | - Rizwan Ullah Khan
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Cancer Center, & Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, China
| | - Jia-Yu Liao
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Cancer Center, & Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, China
| | - Shubo Du
- School of Bioengineering, Dalian University of Technology, Dalian 116024, China
| | - Jingyan Ge
- Key Laboratory of Bioorganic Synthesis of Zhejiang Province, College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou 310014, China
| | - Su Zeng
- Institute of Drug Metabolism and Pharmaceutical Analysis, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Cancer Center, & Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, China
| | - Shao Q Yao
- Department of Chemistry, National University of Singapore, 4 Science Drive 2, Singapore, 117544
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11
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Shah N, Mustafa SS, Vinh DC. Management of secondary immunodeficiency in hematological malignancies in the era of modern oncology. Crit Rev Oncol Hematol 2023; 181:103896. [PMID: 36528276 DOI: 10.1016/j.critrevonc.2022.103896] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 11/29/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
Abstract
Secondary immunodeficiency (SID) in patients with B-cell hematological malignancies is a common condition that presents with recurrent infection. SID is due to both the inherent immune defects due to the malignancy, as well as secondary to cancer therapies, many of which have B-cell depleting properties. The early diagnosis of SID and the optimization of intervention strategies are key to delivering the most effective cancer treatments and reducing infection-related morbidity and mortality. This review discusses current practice, recommendations, and challenges for SID diagnosis, based on the evaluation of clinical history and laboratory assessments, and the effectiveness of specific vaccines and immunoglobulin replacement therapy in reducing the frequency and recurrence of infections in patients with SID, and the healthcare system-associated costs.
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Affiliation(s)
- Nina Shah
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States.
| | - S Shahzad Mustafa
- Rochester Regional Health, Rochester, NY, United States; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Donald C Vinh
- Department of Medicine, McGill University Health Centre, Montreal, Canada
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12
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Peterson LK. Application of vaccine response in the evaluation of patients with suspected B-cell immunodeficiency: Assessment of responses and challenges with interpretation. J Immunol Methods 2022; 510:113350. [PMID: 36067869 DOI: 10.1016/j.jim.2022.113350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/01/2022] [Accepted: 08/30/2022] [Indexed: 12/31/2022]
Abstract
Diagnostic vaccination is an integral component in the evaluation of patients suspected to have a B cell or humoral deficiency. Evaluation of antibody production in response to both protein- and polysaccharide-based vaccines aids in distinguishing between specific categories of humoral deficiency. Although assessment of pneumococcal polysaccharide responses is widely available and included in diagnostic guidelines, significant variability still exists in the measurement and interpretation of these responses. Interpretation can also be complicated by age, vaccination history and treatment with immunoglobulin replacement therapy. Despite the challenges and limitations of evaluating pneumococcal polysaccharide vaccine responses, it can provide valuable diagnostic and prognostic information to guide therapeutic intervention. Future efforts are needed to further standardize measurement and interpretation of pneumococcal antibody responses to vaccination and to identify and establish other methods and/or vaccines as alternatives to pneumococcal vaccination to address the challenges in certain patient populations.
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Affiliation(s)
- Lisa K Peterson
- Department of Pathology, University of Utah, 15 N Medical Dr. East Ste. 1100, Salt Lake City, UT 84112, USA; ARUP Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84108, USA.
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13
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Alonso-Larruga A, Barrios Y, Franco A, Suárez-Toste I, Rodríguez-Salazar MJ, Matheu V. Salmonella Typhi Vaccination Response as a Tool for the Stratification of Risk in Patients with Predominantly Antibody Deficiencies. Diagnostics (Basel) 2022; 12:diagnostics12102423. [PMID: 36292112 PMCID: PMC9600355 DOI: 10.3390/diagnostics12102423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/13/2022] [Accepted: 09/30/2022] [Indexed: 11/16/2022] Open
Abstract
Predominantly antibody deficiencies are the most frequent type of primary immunodeficiency (PID). Diagnosis requires evaluation of the immune function by distinguishing the presence or absence of a response against polysaccharide antigens. Salmonella enterica serovar Typhi-based vaccines have proved to be a suitable tool. We studied a group of patients with suspicion of primary immunodeficiency and classified them by final diagnosis. We analyzed the vaccination response to S. Typhi and other immune biomarkers and clinical data. The aim of this study was to classify patients regarding the intensity of their immune response measured as the difference between specific immunoglobulin G levels before and after vaccination and antibody levels in the post-vaccination sample in order to improve clinical decisions regarding follow up and treatment of immunodeficiency patients. We established four groups of response: Non responders (NR), Low responders (LR), Intermediate responders (IR), and High responders (HR), where we found differences in IgG, IgG1, IgG2, IgG4, IgA, IgA1, IgA2, and IgM, and where the finally achieved diagnosis was also different and corresponding to the level of vaccination response.
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Affiliation(s)
- Ana Alonso-Larruga
- Bioquímica Clínica, Laboratorio Central, Hospital Universitario de Canarias, Universidad de La Laguna, 38320 La Laguna, Spain
| | - Yvelise Barrios
- Inmunología, Laboratorio Central, Hospital Universitario de Canarias, Universidad de La Laguna, 38320 La Laguna, Spain
| | - Andrés Franco
- Inmunología, Laboratorio Central, Hospital Universitario de Canarias, Universidad de La Laguna, 38320 La Laguna, Spain
| | | | | | - Víctor Matheu
- Alergología, Hospital Universitario de Canarias, Universidad de La Laguna, 38320 La Laguna, Spain
- Correspondence:
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14
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Guptill JT, Sleasman JW, Steeland S, Sips M, Gelinas D, de Haard H, Azar A, Winthrop KL. Effect of FcRn antagonism on protective antibodies and to vaccines in IgG-mediated autoimmune diseases pemphigus and generalised myasthenia gravis. Autoimmunity 2022; 55:620-631. [PMID: 36036539 DOI: 10.1080/08916934.2022.2104261] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Antagonism of the neonatal Fc receptor (FcRn) by efgartigimod has been studied in several autoimmune diseases mediated by immunoglobulin G (IgG) as a therapeutic approach to remove pathogenic IgGs. Whereas reduction of pathogenic titres has demonstrated efficacy in multiple autoimmune diseases, reducing total IgG could potentially increase infection risk in patients receiving FcRn antagonists. The objective of this study was to analyse the effect of FcRn antagonism with efgartigimod on existing protective antibody titres and the ability to mount an immune response after vaccine challenge. Serum levels of total IgG and protective antibodies against tetanus toxoid (TT), varicella zoster virus (VZV), and pneumococcal capsular polysaccharide (PCP) were measured in all patients enrolled in an open-label trial of efgartigimod for the treatment of pemphigus. Vaccine specific-responses were assessed by measuring changes in IgG titres in patients with generalised myasthenia gravis (gMG) who were treated with efgartigimod and who received influenza, pneumococcal, or coronavirus disease 2019 (COVID-19) vaccines during participation in the double-blind trial ADAPT or open-label extension, ADAPT+ (n = 17). FcRn antagonism reduced levels of protective anti-TT, anti-VZV, and anti-PCP antibodies and total IgG to a similar extent; anti-TT and anti-VZV titres remained above minimally protective thresholds for the majority of patients, (10/12) 83% and (14/15) 93% respectively. Protective antibodies returned to baseline values upon treatment cessation. Antigen-specific IgG responses to influenza, pneumococcal, and COVID-19 immunisation were detected in patients with gMG who received these vaccines while undergoing therapy with efgartigimod. In conclusion, FcRn antagonism with efgartigimod did not hamper generation of IgG responses but did transiently reduce IgG titres of all specificities.
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Affiliation(s)
- Jeffrey T Guptill
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA.,argenx, Ghent, Belgium
| | - John W Sleasman
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | | | | | - Antoine Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kevin L Winthrop
- Division of Infectious Disease, Oregon Health and Science University, Portland, Oregon, USA
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15
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Ochoa-Grullón J, Guevara-Hoyer K, Pérez López C, Pérez de Diego R, Peña Cortijo A, Polo M, Mateo Morales M, Anguita Mandley E, Jiménez García C, Bolaños E, Íñigo B, Medina F, Rodríguez de la Peña A, Izquierdo Delgado C, de la Fuente Muñoz E, Mayol E, Fernández-Arquero M, González-Fernández A, Benavente Cuesta C, Sánchez-Ramón S. Combined Immune Defect in B-Cell Lymphoproliferative Disorders Is Associated with Severe Infection and Cancer Progression. Biomedicines 2022; 10:biomedicines10082020. [PMID: 36009567 PMCID: PMC9406016 DOI: 10.3390/biomedicines10082020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/12/2022] [Accepted: 08/13/2022] [Indexed: 11/16/2022] Open
Abstract
B cell chronic lymphoproliferative diseases (B-CLPD) are associated with secondary antibody deficiency and other innate and adaptive immune defects, whose impact on infectious risk has not been systematically addressed. We performed an immunological analysis of a cohort of 83 B-CLPD patients with recurrent and/or severe infections to ascertain the clinical relevance of the immune deficiency expression. B-cell defects were present in all patients. Patients with combined immune defect had a 3.69-fold higher risk for severe infection (p = 0.001) than those with predominantly antibody defect. Interestingly, by Kaplan–Meier analysis, combined immune defect showed an earlier progression of cancer with a hazard ratio of 3.21, than predominantly antibody defect (p = 0.005). When B-CLPD were classified in low-degree, high-degree, and plasma cell dyscrasias, risk of severe disease and cancer progression significantly diverged in combined immune defect, compared with predominantly antibody defect (p = 0.001). Remarkably, an underlying primary immunodeficiency (PID) was suspected in 12 patients (14%), due to prior history of infections, autoimmune and granulomatous conditions, atypical or variegated course and compatible biological data. This first proposed SID classification might have relevant clinical implications, in terms of predicting severe infections and cancer progression, and might be applied to different B-CLPD entities.
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Affiliation(s)
- Juliana Ochoa-Grullón
- Department of Clinical Immunology, Institute of Laboratory Medicine and IdISSC, Hospital Clínico San Carlos, Calle Profesor Martín Lagos SN, 28040 Madrid, Spain
| | - Kissy Guevara-Hoyer
- Department of Clinical Immunology, Institute of Laboratory Medicine and IdISSC, Hospital Clínico San Carlos, Calle Profesor Martín Lagos SN, 28040 Madrid, Spain
| | - Cristina Pérez López
- Department of Hematology, Institute of Laboratory Medicine, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Rebeca Pérez de Diego
- Laboratory of Immunogenetics of Human Diseases, IdiPAZ Institute for Health Research, 28046 Madrid, Spain
| | - Ascensión Peña Cortijo
- Department of Hematology, Institute of Laboratory Medicine, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Marta Polo
- Department of Hematology, Institute of Laboratory Medicine, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Marta Mateo Morales
- Department of Hematology, Institute of Laboratory Medicine, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Eduardo Anguita Mandley
- Department of Hematology, Institute of Laboratory Medicine, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Carlos Jiménez García
- Department of Clinical Immunology, Institute of Laboratory Medicine and IdISSC, Hospital Clínico San Carlos, Calle Profesor Martín Lagos SN, 28040 Madrid, Spain
| | - Estefanía Bolaños
- Department of Hematology, Institute of Laboratory Medicine, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Belén Íñigo
- Department of Hematology, Institute of Laboratory Medicine, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Fiorella Medina
- Department of Hematology, Institute of Laboratory Medicine, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Antonia Rodríguez de la Peña
- Department of Clinical Immunology, Institute of Laboratory Medicine and IdISSC, Hospital Clínico San Carlos, Calle Profesor Martín Lagos SN, 28040 Madrid, Spain
| | - Carmen Izquierdo Delgado
- Department of Clinical Immunology, Institute of Laboratory Medicine and IdISSC, Hospital Clínico San Carlos, Calle Profesor Martín Lagos SN, 28040 Madrid, Spain
| | - Eduardo de la Fuente Muñoz
- Department of Clinical Immunology, Institute of Laboratory Medicine and IdISSC, Hospital Clínico San Carlos, Calle Profesor Martín Lagos SN, 28040 Madrid, Spain
| | - Elsa Mayol
- Department of Clinical Immunology, Institute of Laboratory Medicine and IdISSC, Hospital Clínico San Carlos, Calle Profesor Martín Lagos SN, 28040 Madrid, Spain
| | - Miguel Fernández-Arquero
- Department of Clinical Immunology, Institute of Laboratory Medicine and IdISSC, Hospital Clínico San Carlos, Calle Profesor Martín Lagos SN, 28040 Madrid, Spain
| | - Ataúlfo González-Fernández
- Department of Hematology, Institute of Laboratory Medicine, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Celina Benavente Cuesta
- Department of Hematology, Institute of Laboratory Medicine, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Silvia Sánchez-Ramón
- Department of Clinical Immunology, Institute of Laboratory Medicine and IdISSC, Hospital Clínico San Carlos, Calle Profesor Martín Lagos SN, 28040 Madrid, Spain
- Correspondence: ; Tel.: +34-91-3303000 (ext. 3342); Fax: +34-91-3303879
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16
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Cauchi M, Willis M, Andrews A, Backx M, Brownlee W, Ford HL, Gran B, Jolles S, Price S, Rashid W, Schmierer K, Tallantyre EC. Multiple sclerosis and the risk of infection: Association of British Neurologists consensus guideline. Pract Neurol 2022; 22:practneurol-2022-003370. [PMID: 35863879 DOI: 10.1136/practneurol-2022-003370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/03/2022]
Abstract
Infection in people with multiple sclerosis (MS) is of major concern, particularly for those receiving disease-modifying therapies. This article explores the risk of infection in people with MS and provides guidance-developed by Delphi consensus by specialists involved in their management-on how to screen for, prevent and manage infection in this population.
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Affiliation(s)
- Marija Cauchi
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, University Hospital of Wales, Cardiff, UK
| | - Mark Willis
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, University Hospital of Wales, Cardiff, UK
| | - Angela Andrews
- Pharmacy Neurosciences Directorate, University Hospital of Wales, Cardiff, UK
| | - Matthijs Backx
- Infectious Diseases, University Hospital of Wales and Department of Microbiology, Public Health Wales, Cardiff, UK
| | - Wallace Brownlee
- Queen Square MS Centre, University College London Institute of Neurology, Queen Square Multiple Sclerosis Centre, London, UK
| | - Helen L Ford
- Centre for Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds, UK, Leeds, UK
| | - Bruno Gran
- Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Mental Health and Clinical Neuroscience Academic Unit, University of Nottingham School of Medicine, Nottingham, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Sian Price
- Department of Neuroscience, University of Sheffield, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Waqar Rashid
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Klaus Schmierer
- The Blizard Institute (Neuroscience, Surgery & Trauma), Queen Mary University of London Faculty of Medicine and Dentistry, London, UK
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Emma C Tallantyre
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, University Hospital of Wales, Cardiff, UK
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17
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Nguyen A, Martin-Silva N, de Boysson H, Deshayes S, Gac AC, Reboursière E, Damaj G, Aouba A. Low total gamma globulin level discovery at diffuse large B-cell lymphoma diagnosis predicts high risk of infection-related death: data from a monocentric retrospective study. Swiss Med Wkly 2022; 152:w30143. [PMID: 35704942 DOI: 10.4414/smw.2022.w30143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Diffuse large B-cell lymphoma can complicate the course of B-cell primary immunodeficiencies or induce lowering of total gamma globulin levels, whose clinical status as an effective secondary immunodeficiency remains unspecified. This study aimed to assess the frequency, and clinical and prognostic relevance of the low total gamma-globulin levels discovered at diagnosis of diffuse large B-cell lymphoma. RESULTS In a 2-year monocentric retrospective study, 96 patients diagnosed with diffuse large B-cell lymphoma who had a serum electrophoresis were included. Patients were divided into those with lower (L-TGL and higher (H-TGL) total gamma-globulin levels (total gamma-globulin levels ≤5.5 g/l and >5.5 g/l) and compared for outcomes, including fatal infectious events. Twelve (12.5%; 8 males; age median 68 years, range 55-82 years) exhibited L-TGL. There was no difference between the both groups regarding demographics, Ann Arbor lymphoma stage, inflammatory parameters or chemotherapy regimen. However, overall death rates (10/12, 83.3% versus 22/96, 26.2%; p = 0.03) and infection-related death rates (10/12, 83% versus 6/96, 6.2%; p <0.001) were significantly higher in the L-TGL group. CONCLUSION We demonstrate for the first time the strong negative impact of L-TGL on overall and infection-related mortality in diffuse large B-cell lymphoma. Prospective studies should distinguish immunodeficiencies secondary to the lymphoma from pre-existing humoral primary immunodeficiencies, using biomolecular testing and post-treatment total gamma-globulin level monitoring, to determine the best management strategy for infectious risk during diffuse large B-cell lymphoma treatment in the context of L-TGL.
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Affiliation(s)
- Alexandre Nguyen
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Nicolas Martin-Silva
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Hubert de Boysson
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Samuel Deshayes
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Anne-Claire Gac
- Department of Clinical Haematology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Emilie Reboursière
- Department of Clinical Haematology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Gandhi Damaj
- Department of Clinical Haematology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Achille Aouba
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
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18
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Lawrence MG, Borish L. Specific antibody deficiency: Pearls and pitfalls for diagnosis. Ann Allergy Asthma Immunol 2022; 129:572-578. [PMID: 35671934 DOI: 10.1016/j.anai.2022.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Specific antibody deficiency is an immune deficiency defined by the presence of normal quantitative levels of immunoglobulins but impaired antibody responses to polysaccharide antigens in patients presenting with frequent otosinopulmonary infections with pyogenic bacteria. This review summarizes the pitfalls associated with defining exactly what constitutes an "impaired" antibody response to polysaccharide antigens and the importance of documenting actual pyogenic infections before making a diagnosis of an immune deficiency. DATA SOURCES PubMed review using the following words: specific antibody deficiency, pneumococcal vaccination, salmonella vaccination, infectious sinusitis Study Selection: This review focused on key studies that have been utilized to define what constitutes a "normal" humoral immune response to pneumococcal and salmonella vaccination in healthy subjects as well as published papers defining current expert opinion. RESULTS Published studies demonstrate wide variability in response to pneumococcal vaccination in healthy individuals making it daunting to define what constitutes an abnormal response. These challenges are exacerbated by striking laboratory variability in reporting results. CONCLUSION Clinical evaluations in individuals with self-reported recurrent acute sinusitis or lower respiratory infections need to document an infectious etiology with pyogenic bacteria and must rule out an underlying primary airway inflammatory disorder before consideration is made regarding the presence of an immune deficiency. In addition, decision making regarding diagnosis and treatment of patients being evaluated for humoral immunodeficiency should not hinge solely on the strict application of defined cutoffs for "normal" response to a single polysaccharide vaccine, but rather a global assessment of humoral immune function in the context of the clinical presentation.
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Affiliation(s)
- Monica G Lawrence
- Department of Medicine - University of Virginia, Charlottesville, Virginia; Department of Pediatrics - University of Virginia, Charlottesville, Virginia.
| | - Larry Borish
- Department of Medicine - University of Virginia, Charlottesville, Virginia; Department of Microbiology - University of Virginia, Charlottesville, Virginia
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19
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Tallantyre EC. Long-term treatment with anti-CD20 monoclonal antibodies is untenable because of risk - No. Mult Scler 2022; 28:1175-1177. [PMID: 35485436 DOI: 10.1177/13524585221091404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Emma C Tallantyre
- Department of Neurology, University Hospital of Wales, Heath Park Way, Cardiff, UK/Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK Department of Neurology, University Hospital of Wales, Cardiff, UK
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20
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Pastorczak A, Attarbaschi A, Bomken S, Borkhardt A, van der Werff ten Bosch J, Elitzur S, Gennery AR, Hlavackova E, Kerekes A, Křenová Z, Mlynarski W, Szczepanski T, Wassenberg T, Loeffen J. Consensus Recommendations for the Clinical Management of Hematological Malignancies in Patients with DNA Double Stranded Break Disorders. Cancers (Basel) 2022; 14:2000. [PMID: 35454905 PMCID: PMC9029535 DOI: 10.3390/cancers14082000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 12/03/2022] Open
Abstract
Patients with double stranded DNA repair disorders (DNARDs) (Ataxia Telangiectasia (AT) and Nijmegen Breakage syndrome (NBS)) are at a very high risk for developing hematological malignancies in the first two decades of life. The most common neoplasms are T-cell lymphoblastic malignancies (T-cell ALL and T-cell LBL) and diffuse large B cell lymphoma (DLBCL). Treatment of these patients is challenging due to severe complications of the repair disorder itself (e.g., congenital defects, progressive movement disorders, immunological disturbances and progressive lung disease) and excessive toxicity resulting from chemotherapeutic treatment. Frequent complications during treatment for malignancies are deterioration of pre-existing lung disease, neurological complications, severe mucositis, life threating infections and feeding difficulties leading to significant malnutrition. These complications make modifications to commonly used treatment protocols necessary in almost all patients. Considering the rarity of DNARDs it is difficult for individual physicians to obtain sufficient experience in treating these vulnerable patients. Therefore, a team of experts assembled all available knowledge and translated this information into best available evidence-based treatment recommendations.
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Affiliation(s)
- Agata Pastorczak
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, 91-738 Lodz, Poland;
| | - Andishe Attarbaschi
- Department of Pediatrics, Pediatric Hematology and Oncology, St. Anna Children’s Hospital, Medical University of Vienna, 1090 Vienna, Austria;
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Simon Bomken
- Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK; (S.B.); (A.R.G.)
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Arndt Borkhardt
- Department of Pediatric Oncology, Hematology and Clinical Immunology, University Children’s Hospital, Medical Faculty, Heinrich Heine University, 40225 Düsseldorf, Germany;
| | - Jutte van der Werff ten Bosch
- Department of Pediatric Hematology, Oncology and Immunology, University Hospital Brussels, 1090 Jette Brussels, Belgium;
| | - Sarah Elitzur
- Pediatric Hematology-Oncology, Schneider Children’s Medical Center, Petach Tikvah 4920235, Israel;
| | - Andrew R. Gennery
- Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK; (S.B.); (A.R.G.)
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Eva Hlavackova
- Department of Pediatric Oncology, University Hospital and Faculty of Medicine, Masaryk University, 662 63 Brno, Czech Republic; (E.H.); (Z.K.)
- Department of Clinical Immunology and Allergology, St. Anne’s University Hospital in Brno, Faculty of Medicine, Masaryk University, 662 63 Brno, Czech Republic;
| | - Arpád Kerekes
- Department of Clinical Immunology and Allergology, St. Anne’s University Hospital in Brno, Faculty of Medicine, Masaryk University, 662 63 Brno, Czech Republic;
| | - Zdenka Křenová
- Department of Pediatric Oncology, University Hospital and Faculty of Medicine, Masaryk University, 662 63 Brno, Czech Republic; (E.H.); (Z.K.)
| | - Wojciech Mlynarski
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, 91-738 Lodz, Poland;
| | - Tomasz Szczepanski
- Department of Pediatric Hematology and Oncology, Medical University of Silesia (SUM), 41-800 Zabrze, Poland;
| | - Tessa Wassenberg
- Department of Neurology and Child Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Jan Loeffen
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands;
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21
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Scarpa R, Dell'Edera A, Felice C, Buso R, Muscianisi F, Finco Gambier R, Toffolo S, Grossi U, Giobbia M, Barberio G, Landini N, Facchini C, Agostini C, Rattazzi M, Cinetto F. Impact of Hypogammaglobulinemia on the Course of COVID-19 in a Non-Intensive Care Setting: A Single-Center Retrospective Cohort Study. Front Immunol 2022; 13:842643. [PMID: 35359947 PMCID: PMC8960988 DOI: 10.3389/fimmu.2022.842643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/01/2022] [Indexed: 12/11/2022] Open
Abstract
Background Severity and mortality of COVID-19 largely depends on the ability of the immune system to clear the virus. Among various comorbidities potentially impacting on this process, the weight and the consequences of an antibody deficiency have not yet been clarified. Methods We used serum protein electrophoresis to screen for hypogammaglobulinemia in a cohort of consecutive adult patients with COVID-19 pneumonia, hospitalized in non-intensive care setting between December 2020 and January 2021. The disease severity, measured by a validated score and by the need for semi intensive (sICU) or intensive care unit (ICU) admission, and the 30-day mortality was compared between patients presenting hypogammaglobulinemia (HYPO) and without hypogammaglobulinemia (no-HYPO). Demographics, comorbidities, COVID-19 specific treatment during the hospital stay, disease duration, complications and laboratory parameters were also evaluated in both groups. Results We enrolled 374 patients, of which 39 represented the HYPO cohort (10.4%). In 10/39 the condition was previously neglected, while in the other 29/39 hematologic malignancies were common (61.5%); 2/39 were on regular immunoglobulin replacement therapy (IgRT). Patients belonging to the HYPO group more frequently developed a severe COVID-19 and more often required sICU/ICU admission than no-HYPO patients. IgRT were administered in 8/39 during hospitalization; none of them died or needed sICU/ICU. Among HYPO cohort, we observed a significantly higher prevalence of neoplastic affections, of active oncologic treatment and bronchiectasis, together with higher prevalence of viral and bacterial superinfections, mechanical ventilation, convalescent plasma and SARS-CoV-2 monoclonal antibodies administration during hospital stay, and longer disease duration. Multivariate logistic regression analysis and Cox proportional hazard regression confirmed the impact of hypogammaglobulinemia on the COVID-19 severity and the probability of sICU/ICU admission. The analysis of the mortality rate in the whole cohort showed no significant difference between HYPO and no-HYPO. Conclusions Hypogammaglobulinemia, regardless of its cause, in COVID-19 patients hospitalized in a non-intensive care setting was associated to a more severe disease course and more frequent admission to s-ICU/ICU, particularly in absence of IgRT. Our findings emphasize the add-value of routine serum protein electrophoresis evaluation in patients admitted with COVID-19 to support clinicians in patient care and to consider IgRT initiation during hospitalization.
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Affiliation(s)
- Riccardo Scarpa
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Alessandro Dell'Edera
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Carla Felice
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Roberta Buso
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy
| | - Francesco Muscianisi
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Renato Finco Gambier
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Sara Toffolo
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Ugo Grossi
- Department of Surgery, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy
| | - Mario Giobbia
- Infectious Diseases Unit, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy
| | - Giuseppina Barberio
- Laboratory Medicine, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy
| | - Nicholas Landini
- Radiology Unit, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy
| | - Cesarina Facchini
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy
| | - Carlo Agostini
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Marcello Rattazzi
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
| | - Francesco Cinetto
- Internal Medicine I, Ca' Foncello Hospital, Azienda Unità Locale Socio Sanitaria n. 2 (AULSS2) Marca Trevigiana, Treviso, Italy.,Department of Medicine, University of Padova, Padua, Italy
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22
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Aliberti S, Amati F, Gramegna A, Vigone B, Oriano M, Sotgiu G, Mantero M, Simonetta E, Saderi L, Stainer A, Tammaro S, Marchisio P, Polverino E, Chalmers JD, Blasi F. Comparison of different sets of immunological tests to identify treatable immunodeficiencies in adult bronchiectasis patients. ERJ Open Res 2022; 8:00388-2021. [PMID: 35350277 PMCID: PMC8958217 DOI: 10.1183/23120541.00388-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/27/2021] [Indexed: 11/05/2022] Open
Abstract
Background The reported prevalence of immunodeficiencies in bronchiectasis patients is variable depending on the frequency and extent of immunological tests performed. European Respiratory Society guidelines recommend a minimum bundle of tests. Broadening the spectrum of immunological tests could increase the number of patients diagnosed with an immunodeficiency and those who could receive specific therapy. The primary objective of the present study was to assess the performance of different sets of immunological tests in diagnosing any, primary, secondary or treatable immunodeficiencies in adults with bronchiectasis. Methods An observational, cross-sectional study was conducted at the Bronchiectasis Program of the Policlinico University Hospital in Milan, Italy, from September 2016 to June 2019. Adult outpatients with a clinical and radiological diagnosis of bronchiectasis underwent the same immunological screening during the first visit when clinically stable consisting of: complete blood count; immunoglobulin (Ig) subclass tests for IgA, IgG, IgM and IgG; total IgE; lymphocyte subsets; and HIV antibodies. The primary endpoint was the prevalence of patients with any immunodeficiencies using five different sets of immunological tests. Results A total of 401 bronchiectasis patients underwent the immunological screening. A significantly different prevalence of bronchiectasis patients diagnosed with any, primary or secondary immunodeficiencies was found across different bundles. 44.6% of bronchiectasis patients had a diagnosis of immunodeficiency when IgG subclasses and lymphocyte subsets were added to the minimum bundle suggested by the guidelines. Conclusion A four-fold increase in the diagnosis of immunodeficiencies can be found in adults with bronchiectasis when IgG subclasses and lymphocyte subsets are added to the bundle of tests recommended by guidelines.
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Affiliation(s)
- Stefano Aliberti
- Dept of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Respiratory Unit, Rozzano, Italy.,These authors contributed equally
| | - Francesco Amati
- Dept of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Respiratory Unit, Rozzano, Italy.,These authors contributed equally
| | - Andrea Gramegna
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy.,Dept of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Barbara Vigone
- Scleroderma Unit, Referral Center for Systemic Autoimmune Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Martina Oriano
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy.,Dept of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Marco Mantero
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy.,Dept of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Edoardo Simonetta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy.,Dept of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Anna Stainer
- Dept of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Respiratory Unit, Rozzano, Italy
| | - Serena Tammaro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| | - Paola Marchisio
- Dept of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.,Pediatric Highly Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Eva Polverino
- Pneumology Dept, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Francesco Blasi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy.,Dept of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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23
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Lee EY, Betschel S, Grunebaum E. Monitoring patients with uncomplicated common variable immunodeficiency: a systematic review. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:21. [PMID: 35264237 PMCID: PMC8908590 DOI: 10.1186/s13223-022-00661-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 02/20/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Non-infectious complications have become a major cause of morbidity and mortality in patients with Common Variable Immunodeficiency (CVID). The monitoring of patients with CVID prior to the development of non-infectious complications is not well defined. OBJECTIVE Our objectives were to systematically review the current literature on the monitoring of CVID patients without non-infectious complications and to develop recommendations for such monitoring. METHODS MEDLINE and EMBASE were searched from January 1st, 2000 to March 25th, 2021. Studies on any aspects of CVID monitoring were included. Studies that included only children, on monitoring CVID patients with existing non-infectious complications, or in the format of case reports were excluded. RESULTS Nine studies on CVID monitoring, including 3 cohort studies, 3 experts' opinions, 2 consensus statements and a single guideline report were identified. These studies revealed that clinical assessment and bloodwork were preformed every 6 to 12 months in asymptomatic patients. Some centers performed computerized tomography scan of the chest every 2-5 years to identify chronic lung disease, although the majority did chest imaging in accordance with clinical indications. Pulmonary function tests were done annually at most centers. Most studies did not address the role of abdominal imaging to screen for liver diseases or endoscopy to screen for gastric cancer in asymptomatic patients with uncomplicated CVID. CONCLUSIONS There is paucity of evidence-based information to guide the routine monitoring of CVID patients without non-infectious complications. Prospective studies are needed to determine the best monitoring practices in this group of patients.
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Affiliation(s)
- Erika Yue Lee
- Division of Clinical Immunology and Allergy, Department of Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Stephen Betschel
- Division of Clinical Immunology and Allergy, Department of Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Eyal Grunebaum
- Division of Immunology and Allergy, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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24
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Abstract
Over the past 20 years, the rapid evolution in the diagnosis and treatment of primary immunodeficiencies (PI) and the recognition of immune dysregulation as a feature in some have prompted the use of "inborn errors of immunity" (IEI) as a more encompassing term used to describe these disorders [1, 2] . This article aims to review the future of therapy of PI/IEI (referred to IEI throughout this paper). Historically, immune deficiencies have been characterized as monogenic disorders resulting in immune deficiencies affecting T cells, B cells, combination of T and B cells, or innate immune disorders. More recently, immunologists are also recognizing a variety of phenotypes associated with one genotype or similar phenotypes across genotypes and a role for incomplete penetrance or variable expressivity of some genes causing inborn errors of immunity [3]. The IUIS classification of immune deficiencies (IEIs) has evolved over time to include 10 categories, with disorders of immune dysregulation accounting for a new subset, some treatable with small molecule inhibitors or biologics. [1] Until recently, management options were limited to prompt treatment of infections, gammaglobulin replacement, and possibly bone marrow transplant depending on the defect. Available therapies have expanded to include small molecule inhibitors, biologics, gene therapy, and the use of adoptive transfer of virus-specific T cells to fight viral infections in immunocompromised patients. Several significant contributions to the field of clinical immunology have fueled the rapid advancement of therapies over the past two decades. Among these are educational efforts to recruit young immunologists to the field resulting in the growth of a world-wide community of clinicians and investigators interested in rare diseases, efforts to increase awareness of IEI globally contributing to international collaborations, along with advancements in diagnostic genetic testing, newborn screening, molecular biology techniques, gene correction, use of immune modulators, and ex vivo expansion of engineered T cells for therapeutic use. The development and widespread use of newborn screening have helped to identify severe combined immune deficiency (SCID) earlier resulting in better outcomes [4]. Continual improvements and accessibility of genetic sequencing have helped to identify new IEI diseases at an accelerated pace [5]. Advances in gene therapy and bone marrow transplant have made treatments possible in otherwise fatal diseases. Furthermore, the increased awareness of IEI across the world has driven networks of immunologists working together to improve the diagnosis and treatment of these rare diseases. These improvements in the diagnosis and treatment of IEI noted over the past 20 years bring hope for a better future for the IEI community. This paper will review future directions in a few of the newer therapies emerging for IEI. For easy reference, most of the diseases discussed in this paper are briefly described in a summary table, in the order mentioned within the paper (Appendix).
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Affiliation(s)
- Elena Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, FL, USA.
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25
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Health-related quality of life in primary immunodeficiencies: Impact of delayed diagnosis and treatment burden. Clin Immunol 2022; 236:108931. [DOI: 10.1016/j.clim.2022.108931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/13/2022] [Indexed: 12/28/2022]
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26
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Mallick R, Divino V, Smith BD, Jolles S, DeKoven M, Vinh DC. Infections in secondary immunodeficiency patients treated with Privigen ® or Hizentra ®: a retrospective US administrative claims study in patients with hematological malignancies. Leuk Lymphoma 2021; 62:3463-3473. [PMID: 34569910 DOI: 10.1080/10428194.2021.1961233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
B cell-derived lymphoproliferative disorders are associated with secondary immunodeficiency (SID); some patients require immunoglobulin replacement therapy (IgRT) to mitigate infections. Using IQVIA's PharMetrics® Plus database, patients with SID who received IgPro10/IgPro20 in the 12 months post-diagnosis (IgRT users) were matched to patients with SID not receiving IgRT (non-IgRT users). The risk of severe infection was compared using within-patient change from baseline to follow-up as well as between cohorts. Overall, 277 IgRT users were matched to 1019 non-IgRT users. Before IgRT, more IgRT users experienced any bacterial infection (88.4% vs. 72.9%; p<.0001) or ≥1 severe bacterial infection (SBI) (42.2% vs. 31.8%; p=.0011) vs. non-IgRT users. During follow-up, risk of SBI among IgRT users (21.7%) reached parity with non-IgRT users (21.2%). IgRT was associated with a reduction in SBIs to levels comparable with the lower 'baseline infection risk' of non-IgRT users. These criteria help define SID patients who may benefit from IgRT.
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Affiliation(s)
| | | | - B Douglas Smith
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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27
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Šedivá A, Milota T, Litzman J, Quinti I, Meyts I, Burns S, Jolles S. Medical algorithm: Diagnosis and management of antibody immunodeficiencies. Allergy 2021; 76:3841-3844. [PMID: 34037990 DOI: 10.1111/all.14961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/21/2021] [Accepted: 05/12/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Anna Šedivá
- Department of Immunology 2nd Faculty of Medicine Motol University Hospital Charles University Prague Czech Republic
- EAACI Primary Immunodeficiency Working Group
| | - Tomáš Milota
- Department of Immunology 2nd Faculty of Medicine Motol University Hospital Charles University Prague Czech Republic
- EAACI Primary Immunodeficiency Working Group
| | - Jiří Litzman
- EAACI Primary Immunodeficiency Working Group
- Faculty of Medicine Masaryk University Brno Czech Republic
- Department of Clinical Immunology and Allergology St Anne´s University Hospital Brno Czech Republic
| | - Isabella Quinti
- EAACI Primary Immunodeficiency Working Group
- Department of Molecular Medicine Sapienza University of Rome Rome Italy
| | - Isabelle Meyts
- Department of Pediatrics Leuven University Hospitals Leuven Belgium
- ESID Clinical Working Party
| | - Siobhan Burns
- ESID Clinical Working Party
- Institute of Immunity and Transplantation University College London London UK
- Department of Immunology Royal Free London NHS Foundation Trust London UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales University Hospital of Wales Cardiff UK
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28
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Lewis BJ, Binnington B, Blacquiere M, Spirig R, Käsermann F, Branch DR. Mechanism of increased efficacy of recombinant Fc‐μTP‐L309C compared to IVIg to ameliorate mouse immune thrombocytopenia. EJHAEM 2021; 2:789-793. [PMID: 35845218 PMCID: PMC9175896 DOI: 10.1002/jha2.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/06/2021] [Accepted: 09/09/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Bonnie J.B. Lewis
- Donald R. Branch, BS, MT(ASCP)SBB, PhD Donald R. Branch, BS, MT(ASCP)SBB, PhD 30 Bond Street, Keenan Research Centre Toronto M5B 1W8 Canada
- Department of Laboratory Medicine and Pathobiology University of Toronto Toronto Canada
| | - Beth Binnington
- Donald R. Branch, BS, MT(ASCP)SBB, PhD Donald R. Branch, BS, MT(ASCP)SBB, PhD 30 Bond Street, Keenan Research Centre Toronto M5B 1W8 Canada
| | - Megan Blacquiere
- Donald R. Branch, BS, MT(ASCP)SBB, PhD Donald R. Branch, BS, MT(ASCP)SBB, PhD 30 Bond Street, Keenan Research Centre Toronto M5B 1W8 Canada
| | - Rolf Spirig
- Research, CSL Biologics Research Center CSL Behring AG Wankdorfstrasse 10 Bern 3010 Switzerland
| | - Fabian Käsermann
- Research, CSL Biologics Research Center CSL Behring AG Wankdorfstrasse 10 Bern 3010 Switzerland
| | - Donald R. Branch
- Donald R. Branch, BS, MT(ASCP)SBB, PhD Donald R. Branch, BS, MT(ASCP)SBB, PhD 30 Bond Street, Keenan Research Centre Toronto M5B 1W8 Canada
- Department of Medicine University of Toronto Toronto Canada
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29
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Wasserman RL. Immunoglobulin replacement for primary immunodeficiency: Indications for initiating and continuing treatment. Allergy Asthma Proc 2021; 42:489-494. [PMID: 34871156 DOI: 10.2500/aap.2021.42.210082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Immunoglobulin replacement therapy (IGRT) is the foundation of treatment for the majority of patients with primary immunodeficiency. Clinical history and laboratory evaluation define the patients for whom IGRT is necessary and appropriate. During the 70 years since the first patient was treated, new products have led to the development of several modes of administration that facilitate the individualization of treatment that enables the optimization of care. Objective: The objective was to explain the assessment of candidates for IGRT and approaches to reevaluating recipients of IGRT to decide on the need to continue treatment and to review the approaches to optimize IGRT. Methods: The relevant literature was reviewed in the context of the author's experience supervising > 20,000 IGRT treatments over a 40-year period. Results: Providing the most appropriate form of IGRT for individual patients ameliorates disease and lessens the burden of care for patients with primary immunodeficiency. Conclusion: IGRT is safe and effective when used to treat patients with primary immunodeficiency who meet established and appropriate clinical and laboratory criteria.
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30
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Jolles S, Smith BD, Vinh DC, Mallick R, Espinoza G, DeKoven M, Divino V. Risk factors for severe infections in secondary immunodeficiency: a retrospective US administrative claims study in patients with hematological malignancies. Leuk Lymphoma 2021; 63:64-73. [PMID: 34702119 DOI: 10.1080/10428194.2021.1992761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Real-world data are lacking to identify patients with secondary immunodeficiency (SID) who may benefit most from anti-infective interventions. This retrospective analysis used the IQVIA PharMetrics® Plus database to assess baseline characteristics associated with risk of severe infections post-SID diagnosis in patients with hematological malignancies. In 4066 patients included, the mean number of any and severe infections per patient in the one-year pre-SID diagnosis period was 9.5 and 0.7, respectively. Post-SID diagnosis, the mean annualized number of any and severe infections was 19.1 and 1.5, respectively. Receiver operating characteristic curve analysis identified a threshold (cutoff) of three bacterial infections at baseline as optimally predictive of severe infections post-SID diagnosis. Multivariate analysis indicated that hospitalizations, infections (≥3), or antibiotic use pre-SID diagnosis were predictive of severe infections post-SID diagnosis. Evaluation of these risk factors could inform clinical decisions regarding which patients may benefit from prophylactic anti-infective treatment, including immunoglobulin replacement if warranted.
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Affiliation(s)
| | - B Douglas Smith
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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31
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Karakulska-Prystupiuk E, Dwilewicz-Trojaczek J, Drozd-Sokołowska J, Kmin E, Chlebus M, Szczypińska K, Boguradzki P, Tomaszewska A, Mądry K, Biliński J, Basak GW, Jędrzejczak WW. Prevalence of hypogammaglobulinemia and its management with subcutaneous immunoglobulin supplementation in patients after allogeneic hematopoietic stem cell transplantation-a single-center analysis. Ann Hematol 2021; 100:3007-3016. [PMID: 34477951 PMCID: PMC8593025 DOI: 10.1007/s00277-021-04649-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/18/2021] [Indexed: 11/16/2022]
Abstract
Secondary immunodeficiencies are frequently observed after allo-HSCT. The efficacy of subcutaneous IgG preparations in this population is unknown. A retrospective single-institution study involved 126 adult patients transplanted in 2012–2019 for hematological malignancies. Patients were tested every 2–3 weeks for plasma IgG concentration during the 1st year after transplantation and supplemented with facilitated subcutaneous immunoglobulin when they either had IgG concentration < 500 mg/dl or between 500 and 700 mg/dl and recurrent infection. The IgG concentration < 500 mg/dL was diagnosed in 41 patients, while 500–700 mg/dL in 25 and altogether 53 patients received IgG supplementation. The median number of IgG administrations was 2. The median time to the first IgG administration after allo-HSCT was 4.1 months, while to the next administration (if more than one was required) 53 days (prophylactic group) and 32 days (group with infections). We did not observe any significant toxicity. Two situations were associated with increased probability of meeting criteria for IgG supplementation: diagnosis of either acute lymphoblastic leukemia (ALL) or chronic lymphocytic leukemia (CLL) (83.8% versus 39.3% for other diagnosis, p = 0.000) and the systemic use of corticosteroids (64.2% versus 31.5% for patients without systemic corticosteroids, p = 0.005). Over 40% of the adult recipients may require at least incidental immunoglobulin supplementation during the first year after allo-HSCT. Low IgG concentrations are associated with inferior outcomes. The subcutaneous route of IgG administration appeared to be safe and may allow for long persistence.
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Affiliation(s)
- Ewa Karakulska-Prystupiuk
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Banacha Str 1a, 02-097, Warsaw, Poland.
| | - Jadwiga Dwilewicz-Trojaczek
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Banacha Str 1a, 02-097, Warsaw, Poland
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Banacha Str 1a, 02-097, Warsaw, Poland
| | - Ewelina Kmin
- Central Laboratory of the Medical University of Warsaw, Warsaw, Poland
| | - Marcin Chlebus
- Division of Quantitative Finance, Faculty of Economic Sciences, University of Warsaw, Warsaw, Poland
| | - Karolina Szczypińska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Banacha Str 1a, 02-097, Warsaw, Poland
| | - Piotr Boguradzki
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Banacha Str 1a, 02-097, Warsaw, Poland
| | - Agnieszka Tomaszewska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Banacha Str 1a, 02-097, Warsaw, Poland
| | - Krzysztof Mądry
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Banacha Str 1a, 02-097, Warsaw, Poland
| | - Jarosław Biliński
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Banacha Str 1a, 02-097, Warsaw, Poland
| | - Grzegorz Władysław Basak
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Banacha Str 1a, 02-097, Warsaw, Poland
| | - Wiesław Wiktor Jędrzejczak
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Banacha Str 1a, 02-097, Warsaw, Poland
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Secondary Dysgammaglobulinemia in Children with Hematological Malignancies Treated with Targeted Therapies. Paediatr Drugs 2021; 23:445-455. [PMID: 34292515 DOI: 10.1007/s40272-021-00461-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
Targeted therapies have emerged as innovative treatments for patients whose disease does not respond to conventional chemotherapy, and their use has widely expanded in the field of pediatric hematologic malignancies in the last decade. While they carry the promise of improved disease control and survival and are currently investigated in first-line treatment protocols for patients with poor prognostic markers, they are associated with a considerable incidence of specific toxicities, including cytokine-release syndrome, neurotoxicity, hepatotoxicity, nephrotoxicity, cardiotoxicity, endocrine adverse events, and infectious complications. Iatrogenic or secondary dysgammaglobulinemia is a main consequence of targeted therapies using monoclonal antibodies and other antibody-derived treatments that target specific antigens on lymphoid cells (blinatumomab, inotuzumab ozogamicin, rituximab), chimeric antigen receptor T cells, tyrosine kinase inhibitors (imatinib, dasatinib, nilotinib) and, to a lesser extent, checkpoint inhibitors (pembrolizumab, nivolumab). This review discusses the diagnosis and incidence of secondary or iatrogenic dysgammaglobulinemia in children treated with targeted therapies for leukemias and lymphomas, and options for monitoring and treatment.
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Ochoa‐Grullón J, Peña Cortijo A, Guevara‐Hoyer K, Jiménez García C, de la Fuente E, de la Peña AR, Fernández‐Arquero M, González Fernández A, Sánchez‐Ramón S. B-cell haematological malignancies and SARS-CoV-2 infection: Could immunological interventions influence the outcome? EJHAEM 2021; 2:503-507. [PMID: 34518828 PMCID: PMC8426868 DOI: 10.1002/jha2.249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/26/2021] [Accepted: 06/01/2021] [Indexed: 01/08/2023]
Abstract
B cell haematological malignancies (HMs) have been described as the worst cancer type for concomitant COVID-19 in terms of mortality, with rates up to 65%. This risk factor for COVID-19 cannot only be explained by comorbidities and advanced age of patients, but aggravated by secondary immunodeficiency (SID). We aimed at evaluating the impact of COVID-19 on 86 HM patients with concomitant SID from a single centre. Only 14 HM patients of 86 (16.28%) patients suffered COVID-19, with mortality rate of 7%. When we considered patients according to B-cell defect only or multiple immune defect overlap (B-T-cell/NK cells/complement), patients with immune defect overlap presented 5.30-fold higher risk of COVID-19 than only B cell defect (95% CI, 1.67-17.0) (p = 0.004). Seven (50%) patients were on active IgRT; while five (36%) had received prior mucosal vaccines for respiratory infections. Our results show that modelling SID in HM may contribute to better prediction of infectious risk and to prompt more targeted and timely preventive therapies.
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Affiliation(s)
- Juliana Ochoa‐Grullón
- Department of Clinical Immunology and IdISSCHospital Clínico San CarlosMadridSpain
- Department of ImmunologyOphthalmology and Otorhinolaryngology (IOO)Complutense University School of MedicineMadridSpain
| | | | - Kissy Guevara‐Hoyer
- Department of Clinical Immunology and IdISSCHospital Clínico San CarlosMadridSpain
- Department of ImmunologyOphthalmology and Otorhinolaryngology (IOO)Complutense University School of MedicineMadridSpain
| | | | - Eduardo de la Fuente
- Department of Clinical Immunology and IdISSCHospital Clínico San CarlosMadridSpain
- Department of ImmunologyOphthalmology and Otorhinolaryngology (IOO)Complutense University School of MedicineMadridSpain
| | | | - Miguel Fernández‐Arquero
- Department of Clinical Immunology and IdISSCHospital Clínico San CarlosMadridSpain
- Department of ImmunologyOphthalmology and Otorhinolaryngology (IOO)Complutense University School of MedicineMadridSpain
| | | | - Silvia Sánchez‐Ramón
- Department of Clinical Immunology and IdISSCHospital Clínico San CarlosMadridSpain
- Department of ImmunologyOphthalmology and Otorhinolaryngology (IOO)Complutense University School of MedicineMadridSpain
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34
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Park MA, Jenkins SM, Smith CY, Pyle RC, Sacco KA, Ryu E, Hagan JB, Joshi AY, Snyder MR, Abraham RS. Pneumococcal serotype-specific cut-offs based on antibody responses to pneumococcal polysaccharide vaccination in healthy adults. Vaccine 2021; 39:2850-2856. [PMID: 33896666 DOI: 10.1016/j.vaccine.2021.04.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 02/08/2023]
Abstract
Antibody responses to pneumococcal polysaccharide vaccination are frequently used as a diagnostic tool for humoral immunodeficiencies, part of the larger collection of inborn errors of immunity. Currently, arbitrary criteria, such as a serotype specific titer of >/= 1.3 µg/mL is most often used as a cut-off for interpretation of pneumococcal antibody responses. The magnitude of the antibody response to each of the 23 serotypes in Pneumovax®, and serotype-specific cut-offs in healthy pneumococcal vaccine-naïve adults has not been previously characterized. IgG antibody concentrations were measured prospectively for 23 pneumococcal serotypes pre and 4-6 weeks post-Pneumovax® vaccination in 100 healthy adults, using a multiplex bead-based assay. Antibodies to 19 of 23 serotypes were informative for distinguishing subjects who responded to vaccination, and the serotype threshold was determined to be 9 of 19 serotypes, which characterized an antibody response to pneumococcal vaccination. While this study may facilitate classification of IgG serotype-specific antibody responses post-pneumococcal vaccination in adult patients undergoing diagnostic immunological evaluation for antibody immunodeficiencies or other relevant contexts, additional studies in healthy children and S. pneumoniae protein-conjugate-vaccinated healthy adults will need to be undertaken in the future.
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Affiliation(s)
- Miguel A Park
- Division of Allergic Diseases, Department of Medicine, USA; Mayo Clinic, Rochester, MN, USA
| | - Sarah M Jenkins
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, USA; Mayo Clinic, Rochester, MN, USA
| | - Carin Y Smith
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, USA; Mayo Clinic, Rochester, MN, USA
| | - Regan C Pyle
- Division of Allergic Diseases, Department of Medicine, USA; Allergy, Asthma & Immunology of the Rockies, PC., Glenwood Springs, CO, USA
| | - Keith A Sacco
- Allergy & Immunology Program, National Institutes of Health, USA
| | - Euijung Ryu
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, USA; Mayo Clinic, Rochester, MN, USA
| | - John B Hagan
- Division of Allergic Diseases, Department of Medicine, USA; Mayo Clinic, Rochester, MN, USA
| | - Avni Y Joshi
- Division of Allergic Diseases, Department of Medicine, USA; Mayo Clinic, Rochester, MN, USA
| | - Melissa R Snyder
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Roshini S Abraham
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
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Wallace LJ, Ware MS, Cunningham-Rundles C, Fuleihan RL, Maglione PJ. Clinical disparity of primary antibody deficiency patients at a safety net hospital. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2923-2925.e1. [PMID: 33766581 DOI: 10.1016/j.jaip.2021.03.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 03/05/2021] [Accepted: 03/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Luke J Wallace
- Pulmonary Center and Section of Pulmonary, Allergy, Sleep & Critical Care, Boston University School of Medicine and Boston Medical Center, Boston, Mass
| | - Matthew S Ware
- Pulmonary Center and Section of Pulmonary, Allergy, Sleep & Critical Care, Boston University School of Medicine and Boston Medical Center, Boston, Mass
| | | | - Ramsay L Fuleihan
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Paul J Maglione
- Pulmonary Center and Section of Pulmonary, Allergy, Sleep & Critical Care, Boston University School of Medicine and Boston Medical Center, Boston, Mass.
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Ochoa-Grullón J, Benavente Cuesta C, González Fernández A, Cordero Torres G, Pérez López C, Peña Cortijo A, Conejero Hall L, Mateo Morales M, Rodríguez de la Peña A, Díez-Rivero CM, Rodríguez de Frías E, Guevara-Hoyer K, Fernández-Arquero M, Sánchez-Ramón S. Trained Immunity-Based Vaccine in B Cell Hematological Malignancies With Recurrent Infections: A New Therapeutic Approach. Front Immunol 2021; 11:611566. [PMID: 33679698 PMCID: PMC7928395 DOI: 10.3389/fimmu.2020.611566] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022] Open
Abstract
Infectious complications are a major cause of morbidity and mortality in B-cell hematological malignancies (HM). Prophylaxis for recurrent infections in HM patients with antibody deficiency consists of first-line antibiotics and when unsuccessful, gammaglobulin replacement therapy (IgRT). Recent knowledge of trained immunity-based vaccines (TIbV), such as the sublingual polybacterial formulation MV130, has shown a promising strategy in the management of patients with recurrent infections. We sought to determine the clinical benefit of MV130 in a cohort of HM patients with recurrent respiratory tract infections (RRTIs) who underwent immunization with MV130 for 3 months. Clinical information included the frequency of infections, antibiotic use, number of visits to the GP and hospitalizations previous and after MV130 immunotherapy. Improvement on infection rate was classified as: clear (>60% reduction of infection), partial (26%-60%) and low (≤25%) improvement. Fifteen HM patients (aged 42 to 80 years; nine females) were included in the study. All patients reduced their infection rate. Analysis of paired data revealed that the median (range, min - max) of respiratory infectious rate significantly decreased from 4.0 (8.0-3.0) to 2.0 (4.0-0.0) (p<0.001) at 12 months of MV130. A clear clinical improvement was observed in 53% (n = 8) of patients, partial improvement in 40% (n = 6) and low improvement in 7% (n = 1). These data correlated with a decrease on antibiotic consumption from 3.0 (8.0-1.0) to 1.0 (2.0-0.0) (p = 0.002) during 12 months after initiation of treatment with MV130. The number of infectious-related GP or emergency room visits declined from 4.0 (8.0-2.0) to 2.0 (3.0-0.0) (p<0.001), in parallel with a reduction in hospital admissions due to infections (p = 0.032). Regarding safety, no adverse events were observed. On the other hand, immunological assessment of serum IgA and IgG levels demonstrated an increase in specific antibodies to MV130-contained bacteria following MV130 immunotherapy. In conclusion, MV130 may add clinical benefit reducing the rate of infections and enhancing humoral immune responses in these vulnerable patients.
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Affiliation(s)
- Juliana Ochoa-Grullón
- Department of Clinical Immunology, IML and IdISSC, Hospital Clínico San Carlos, Madrid, Spain
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
| | | | | | - Gustavo Cordero Torres
- Department of Clinical Immunology, IML and IdISSC, Hospital Clínico San Carlos, Madrid, Spain
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
| | | | | | | | | | | | | | - Edgard Rodríguez de Frías
- Department of Clinical Immunology, IML and IdISSC, Hospital Clínico San Carlos, Madrid, Spain
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
| | - Kissy Guevara-Hoyer
- Department of Clinical Immunology, IML and IdISSC, Hospital Clínico San Carlos, Madrid, Spain
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
| | - Miguel Fernández-Arquero
- Department of Clinical Immunology, IML and IdISSC, Hospital Clínico San Carlos, Madrid, Spain
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
| | - Silvia Sánchez-Ramón
- Department of Clinical Immunology, IML and IdISSC, Hospital Clínico San Carlos, Madrid, Spain
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
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Matson EM, Abyazi ML, Bell KA, Hayes KM, Maglione PJ. B Cell Dysregulation in Common Variable Immunodeficiency Interstitial Lung Disease. Front Immunol 2021; 11:622114. [PMID: 33613556 PMCID: PMC7892472 DOI: 10.3389/fimmu.2020.622114] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/23/2020] [Indexed: 12/16/2022] Open
Abstract
Common variable immunodeficiency (CVID) is the most frequently diagnosed primary antibody deficiency. About half of CVID patients develop chronic non-infectious complications thought to be due to intrinsic immune dysregulation, including autoimmunity, gastrointestinal disease, and interstitial lung disease (ILD). Multiple studies have found ILD to be a significant cause of morbidity and mortality in CVID. Yet, the precise mechanisms underlying this complication in CVID are poorly understood. CVID ILD is marked by profound pulmonary infiltration of both T and B cells as well as granulomatous inflammation in many cases. B cell depletive therapy, whether done as a monotherapy or in combination with another immunosuppressive agent, has become a standard of therapy for CVID ILD. However, CVID is a heterogeneous disorder, as is its lung pathology, and the precise patients that would benefit from B cell depletive therapy, when it should administered, and how long it should be repeated all remain gaps in our knowledge. Moreover, some have ILD recurrence after B cell depletive therapy and the relative importance of B cell biology remains incompletely defined. Developmental and functional abnormalities of B cell compartments observed in CVID ILD and related conditions suggest that imbalance of B cell signaling networks may promote lung disease. Included within these potential mechanisms of disease is B cell activating factor (BAFF), a cytokine that is upregulated by the interferon gamma (IFN-γ):STAT1 signaling axis to potently influence B cell activation and survival. B cell responses to BAFF are shaped by the divergent effects and expression patterns of its three receptors: BAFF receptor (BAFF-R), transmembrane activator and CAML interactor (TACI), and B cell maturation antigen (BCMA). Moreover, soluble forms of BAFF-R, TACI, and BCMA exist and may further influence the pathogenesis of ILD. Continued efforts to understand how dysregulated B cell biology promotes ILD development and progression will help close the gap in our understanding of how to best diagnose, define, and manage ILD in CVID.
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Affiliation(s)
- Erik M Matson
- Pulmonary Center, Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Miranda L Abyazi
- Pulmonary Center, Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Kayla A Bell
- Pulmonary Center, Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Kevin M Hayes
- Pulmonary Center, Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Paul J Maglione
- Pulmonary Center, Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
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38
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Jolles S, Michallet M, Agostini C, Albert MH, Edgar D, Ria R, Trentin L, Lévy V. Treating secondary antibody deficiency in patients with haematological malignancy: European expert consensus. Eur J Haematol 2021; 106:439-449. [PMID: 33453130 DOI: 10.1111/ejh.13580] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/12/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Secondary antibody deficiency (SAD), associated with severe, recurrent or persistent infections, is common in patients with haematological malignancies (HM), but unifying guidance on immunoglobulin replacement therapy (IgRT) in these patients is lacking. We aimed to develop consensus statements for the use of IgRT in patients with HM. METHODS A Delphi exercise was employed to test the level of agreement on statements developed by a Task Force based on available data and their clinical experience. In Round 1, an Expert Panel, comprising specialist EU physicians caring for patients with HM, helped to refine the statements. In Round 2, experts rated their agreement with the statements. In Round 3, experts who had scored their agreement as ≤4 were invited to review their agreement based on the overall feedback. RESULTS Three definitions and 20 statements were formulated and tested for consensus, covering measurement of IgG levels, initiation and discontinuation of IgRT, dosing, and the use of subcutaneous IgG. Consensus (agreement ≥70% on Likert-type scale) was reached for all three definitions and 18 statements. CONCLUSIONS Recommendations have been developed with the aim of providing guidance for the use of IgRT to prevent severe, recurrent or persistent infections in patients with HM and SAD.
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Affiliation(s)
- Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | | | - Carlo Agostini
- Ca' Foncello Internal Medicine 1st and Centre for Immunologic and Respiratory Rare Diseases, Padua University, Padua, Italy
| | - Michael H Albert
- Dr. von Hauner Children's Hospital, University Hospital, LMU, Munich, Germany
| | - David Edgar
- St James's Hospital & Trinity College Dublin, Dublin, Ireland
| | - Roberto Ria
- Department of Biomedical Science and Human Oncology, University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Livio Trentin
- Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Vincent Lévy
- Département de Recherche Clinique, Avicenne Hospital, Sorbonne Paris Nord University, Bobigny, France
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39
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Monleón Bonet C, Waser N, Cheng K, Tzivelekis S, Edgar JDM, Sánchez-Ramón S. A systematic literature review of the effects of immunoglobulin replacement therapy on the burden of secondary immunodeficiency diseases associated with hematological malignancies and stem cell transplants. Expert Rev Clin Immunol 2020; 16:911-921. [PMID: 32783541 DOI: 10.1080/1744666x.2020.1807328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Secondary immunodeficiency diseases (SID) caused by hematological malignancies (HMs), stem cell transplant (SCT), and associated therapies are mainly characterized by the presence of hypogammaglobulinemia or antibody production deficits. AREAS COVERED The authors summarized the scientific literature on disease burden of SIDs in patients who had HMs or SCT. Systematic searches were conducted to identify English-language articles from 1994-2020, reporting on clinical, humanistic, and economic burdens of SID due to HMs or SCT. Definitions of SID and serum immunoglobulin G thresholds varied across 24 eligible studies. In most (n = 16) studies, patients received immunoglobulin replacement therapy (IGRT). Several studies found IGRT was associated with significant reductions in rates of infection and antimicrobial use. However, 1 study found no statistically significant difference in antibiotic use with IGRT. Only 3 studies reported on quality of life, and no economic studies were identified. EXPERT OPINION Overall, the findings show several beneficial effects of IGRT on clinical outcomes and quality of life; however, disparate definitions, infrequent reporting of statistical significance, and scarcity of clinical trial data after the 1990s present areas for further investigation. This paucity indicates an unmet need of current evidence to assess the benefits of IGRT in SID.
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Affiliation(s)
- Clara Monleón Bonet
- Global Evidence and Outcomes, Immunology, Takeda Pharmaceuticals International AG , Zurich, Switzerland
| | - Nathalie Waser
- Real World Evidence Strategy and Analytics, ICON Plc , Vancouver, Canada
| | - Karen Cheng
- formerly in Global Medical Affairs, Rare Immunology, Takeda Pharmaceuticals International AG , Zurich, Switzerland
| | | | - J David M Edgar
- Department of Immunology, St James's Hospital and Trinity College Dublin , Dublin, Ireland
| | - Silvia Sánchez-Ramón
- Departmento de Inmunologia Clinica, Hospital Clinico San Carlos and Universidad Complutense of Madrid , Madrid, Spain
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40
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Smits BM, Kleine Budde I, de Vries E, Ten Berge IJM, Bredius RGM, van Deuren M, van Dissel JT, Ellerbroek PM, van der Flier M, van Hagen PM, Nieuwhof C, Rutgers B, Sanders LEAM, Simon A, Kuijpers TW, van Montfrans JM. Immunoglobulin Replacement Therapy Versus Antibiotic Prophylaxis as Treatment for Incomplete Primary Antibody Deficiency. J Clin Immunol 2020; 41:382-392. [PMID: 33206257 PMCID: PMC7858555 DOI: 10.1007/s10875-020-00841-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/01/2020] [Indexed: 11/18/2022]
Abstract
Background Patients with an IgG subclass deficiency (IgSD) ± specific polysaccharide antibody deficiency (SPAD) often present with recurrent infections. Previous retrospective studies have shown that prophylactic antibiotics (PA) and immunoglobulin replacement therapy (IRT) can both be effective in preventing these infections; however, this has not been confirmed in a prospective study. Objective To compare the efficacy of PA and IRT in a randomized crossover trial. Methods A total of 64 patients (55 adults and 9 children) were randomized (2:2) between two treatment arms. Treatment arm A began with 12 months of PA, and treatment arm B began with 12 months of IRT. After a 3-month bridging period with cotrimoxazole, the treatment was switched to 12 months of IRT and PA, respectively. The efficacy (measured by the incidence of infections) and proportion of related adverse events in the two arms were compared. Results The overall efficacy of the two regimens did not differ (p = 0.58, two-sided Wilcoxon signed-rank test). A smaller proportion of patients suffered a related adverse event while using PA (26.8% vs. 60.3%, p < 0.0003, chi-squared test). Patients with persistent infections while using PA suffered fewer infections per year after switching to IRT (2.63 vs. 0.64, p < 0.01). Conclusion We found comparable efficacy of IRT and PA in patients with IgSD ± SPAD. Patients with persistent infections during treatment with PA had less infections after switching to IRT. Clinical Implication Given the costs and associated side-effects of IRT, it should be reserved for patients with persistent infections despite treatment with PA. Electronic supplementary material The online version of this article (10.1007/s10875-020-00841-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bas M Smits
- Department of Pediatric Immunology and Infectious Diseases, UMC Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
| | - Ilona Kleine Budde
- Clinical Operations, Sanquin Plasma Products B.V, Amsterdam, The Netherlands
| | - Esther de Vries
- Department of Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands.,Department of Jeroen Bosch Academy Research, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Ineke J M Ten Berge
- Department of Internal Medicine, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - Robbert G M Bredius
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel van Deuren
- Department of Internal Medicine, Radboud UMC, Nijmegen, The Netherlands
| | - Jaap T van Dissel
- Department of Infectious Diseases, Leiden University Medical Centre, University of Leiden, Leiden, The Netherlands
| | - Pauline M Ellerbroek
- Division of Internal Medicine and Dermatology, Department of Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel van der Flier
- Department of Pediatric Immunology and Infectious Diseases, UMC Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands.,Pediatric Infectious Diseases and Immunology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - P Martin van Hagen
- Department of Internal Medicine/Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Chris Nieuwhof
- Department of Allergology and Clinical Immunology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Bram Rutgers
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lieke E A M Sanders
- Department of Pediatric Immunology and Infectious Diseases, UMC Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
| | - Anna Simon
- Department of Internal Medicine, Radboud UMC, Nijmegen, The Netherlands
| | - Taco W Kuijpers
- Department of Paediatric Immunology and Infectious Diseases, Emma Children's Hospital, AUMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris M van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, UMC Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands.
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41
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JAHNZ-RÓŻYK KARINA, WIĘSIK-SZEWCZYK EWA, ROLIŃSKI JACEK, SIEDLAR MACIEJ, JĘDRZEJCZAK WIESŁAW, SYDOR WOJCIECH, TOMASZEWSKA AGNIESZKA. Secondary immunodeficiencies with predominant antibody deficiency: multidisciplinary perspectives of Polish experts. Cent Eur J Immunol 2020; 45:334-341. [PMID: 33437186 PMCID: PMC7790006 DOI: 10.5114/ceji.2020.101265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 11/20/2019] [Indexed: 12/17/2022] Open
Abstract
At present, secondary immune deficiencies have become a clinical problem, recognized in different specialties. The aim of this paper was to increase awareness and support the need for screening at-risk populations. Secondary immune deficiencies result in variety of conditions, but not all of them require immunoglobulin replacement therapy, as specific antibody response might be preserved. Moreover, the management of secondary immune deficiencies vary between countries and different medical disciplines. This literature review presents the most common causes and clinical presentation of secondary immunodeficiencies with predominant impaired antibody production. We present diagnostic guidelines for patients at-risk, with an emphasis on the role of prophylactic vaccination as a treatment and diagnostic tool. This review considers the specificity and disparities of the Polish healthcare system and ultimately, suggests that management teams should include a clinical immunologist experienced in the treatment of humoral immunodeficiencies.
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Affiliation(s)
- KARINA JAHNZ-RÓŻYK
- Department of Internal Medicine, Pneumonology, Allergology and Clinical Immunology, Central Clinical Hospital of the Ministry of National Defense, Military Institute of Medicine, Warsaw, Poland
| | - EWA WIĘSIK-SZEWCZYK
- Department of Internal Medicine, Pneumonology, Allergology and Clinical Immunology, Central Clinical Hospital of the Ministry of National Defense, Military Institute of Medicine, Warsaw, Poland
| | - JACEK ROLIŃSKI
- Department of Clinical Immunology, Medical University of Lublin, Lublin, Poland
| | - MACIEJ SIEDLAR
- Department of Clinical Immunology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - WIESŁAW JĘDRZEJCZAK
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - WOJCIECH SYDOR
- Department of Rheumatology and Immunology, Jagiellonian University Medical College, Krakow, Poland
| | - AGNIESZKA TOMASZEWSKA
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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42
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Więsik-Szewczyk E, Jahnz-Różyk K. From infections to autoimmunity: Diagnostic challenges in common variable immunodeficiency. World J Clin Cases 2020; 8:3942-3955. [PMID: 33024751 PMCID: PMC7520788 DOI: 10.12998/wjcc.v8.i18.3942] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/29/2020] [Accepted: 08/26/2020] [Indexed: 02/05/2023] Open
Abstract
Common variable immunodeficiency (CVID) is the most common clinically significant primary antibody deficiency diagnosed in adults. The early symptoms are not specific. They include common infections, mainly of the respiratory tract, caused by typical microorganisms, so cases can be missed in primary care. In the majority of patients increased susceptibility to infections coexists with signs or symptoms of autoimmunity, inflammation or polyclonal lymphoproliferation, which can divert diagnosis from immune deficiency. The overall incidence of malignancy is increased in CVID and certain cancers are significantly more common. Lymphomas and gastric carcinoma are the most frequently reported malignancies in CVID, so a high index of suspicion is recommended. Diagnostic delay in CVID is seen worldwide. The main goal of this paper is to increase the awareness about CVID among health care professionals. We aim to present features which can be helpful in CVID diagnosis in order to shorten the “latency” of proper management of CVID patients. We review clinical symptoms, complications and laboratory abnormalities of CVID. Immunoglobulin replacement therapy is regarded as the cornerstone of pharmacological intervention. New modes of Ig application, mainly subcutaneously and via the hyaluronidase-facilitated subcutaneous route, help to adjust therapy to patients’ needs and preferences. Still there remain unmet needs. It remains to be seen whether CVID complications can be avoided by earlier diagnosis, treatment and thorough monitoring in the context of increased risk of malignancy. Development of patient tailored protocols depending on the clinical phenotype and risk factors might be more appropriate. The most important consideration is to diagnose suspected cases and stratify patients in a precise and timely way. Work is needed to define features predictive of unfavorable prognosis.
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Affiliation(s)
- Ewa Więsik-Szewczyk
- Department of Internal Medicine, Pulmonology, Allergy and Clinical Immunology, Central Clinical Hospital of the Ministry of National Defense, Military Institute of Medicine, Warsaw 04-141, Poland
| | - Karina Jahnz-Różyk
- Department of Internal Medicine, Pulmonology, Allergy and Clinical Immunology, Central Clinical Hospital of the Ministry of National Defense, Military Institute of Medicine, Warsaw 04-141, Poland
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43
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Ponsford MJ, Steven R, Bramhall K, Burgess M, Wijetilleka S, Carne E, McGuire F, Price CR, Moody M, Zouwail S, Tahir T, Farewell D, El-Shanawany T, Jolles SRA. Clinical and laboratory characteristics of clozapine-treated patients with schizophrenia referred to a national immunodeficiency clinic reveals a B-cell signature resembling common variable immunodeficiency (CVID). J Clin Pathol 2020; 73:587-592. [PMID: 32094276 PMCID: PMC7476264 DOI: 10.1136/jclinpath-2019-206235] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 01/05/2023]
Abstract
AIMS An association between antibody deficiency and clozapine use in individuals with schizophrenia has recently been reported. We hypothesised that if clozapine-associated hypogammaglobulinaemia was clinically relevant this would manifest in referral patterns. METHODS Retrospective case note review of patients referred and assessed by Immunology Centre for Wales (ICW) between January 2005 and July 2018 with extraction of clinical and immunological features for individuals with diagnosis of schizophrenia-like illness. RESULTS 1791 adult patients were assessed at ICW during this period; 23 patients had a psychiatric diagnosis of schizophrenia or schizoaffective disorder. Principal indications for referral were findings of low calculated globulin and immunoglobulins. Clozapine was the single most commonly prescribed antipsychotic (17/23), disproportionately increased relative to reported use in the general schizophrenia population (OR 6.48, 95% CI: 1.79 to 23.5). Clozapine therapy was noted in 6/7 (86%) of patients subsequently requiring immunoglobulin replacement therapy (IgRT). Marked reduction of class-switched memory B cells (CSMB) and plasmablasts were observed in clozapine-treated individuals relative to healthy age-matched controls. Clozapine duration is associated with CSMB decline. One patient discontinued clozapine, with gradual recovery of IgG levels without use of IgRT. CONCLUSIONS Our findings are consistent with enrichment of clozapine-treatment within schizophrenic individuals referred for ICW assessment over the last 13 years. These individuals displayed clinical patterns closely resembling the primary immunodeficiency common variable immunodeficiency, however appears reversible on drug cessation. This has diagnostic, monitoring and treatment implications for psychiatry and immunology teams and directs prospective studies to address causality and the wider implications for this patient group.
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Affiliation(s)
- Mark James Ponsford
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
- Tenovus Institute, Division of Infection & Immunity, Cardiff University, Cardiff, UK
| | - Rachael Steven
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Kathyrn Bramhall
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Mathew Burgess
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Sonali Wijetilleka
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Emily Carne
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Frances McGuire
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Colin R Price
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Mo Moody
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Soha Zouwail
- Department of Medical Biochemistry, University Hospital of Wales, Cardiff, UK
- Department of Medical Biochemistry, Medical School, Alexandria University, Alexandria, Egypt
| | - Tayyeb Tahir
- Liaison Psychiatry, University Hospital of Wales, Cardiff, UK
| | - Daniel Farewell
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Tariq El-Shanawany
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Stephen R A Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
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44
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Abstract
PURPOSE OF REVIEW Clozapine has recently been described as a novel cause of secondary antibody deficiency (SAD), associated with long-term therapy. Here we critically review the evidence linking clozapine use to an increased infection risk, describe immunological alterations, and discuss potential mechanisms. RECENT FINDINGS Individuals with schizophrenia are at two to five times more likely to develop pneumonia than the general population, in particular, when receiving clozapine. Delayed-onset distinguishes clozapine-associated hypogammaglobulinaemia from agranulocytosis or neutropenia that occur at lesser frequency. Biomarker searches in treatment-resistant schizophrenia highlight an immune signature associated with long-term clozapine use. This includes reduction in class-switched memory B cells, echoing common variable immunodeficiency. Recent identification of a role for dopamine in T follicular helper-B cell interactions may inform future clinical studies. SUMMARY The detrimental impact of the increased infection risk associated with clozapine necessitates a re-evaluation of the current monitoring strategies as well as further studies to better understand the underlying mechanisms of SAD in this setting. On the basis of available evidence, we suggest simple modifications to clozapine monitoring including integration of routine vaccination, smoking cessation, and assessment of humoral immunity. Further studies are required to understand the role of clozapine in neuroinflammation as well as other potentially autoantibody-mediated diseases.
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45
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Weide R, Schnell R, Schardt C, Koenigsmann M, Otremba B, Zahn MO, Wierecky J, Braun U, Hensel M, Klausmann M, Fleckenstein D, Ehscheidt P, Feiten S. Health status and infections in patients with symptomatic primary and secondary immunoglobulin G (IgG) deficiencies receiving intravenous IgG replacement. BMC Immunol 2020; 21:39. [PMID: 32600256 PMCID: PMC7325170 DOI: 10.1186/s12865-020-00368-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/17/2020] [Indexed: 11/16/2022] Open
Abstract
Background The effects of intravenous immunoglobulin G replacement on perceived health and infection susceptibility of patients suffering from immunoglobulin G (IgG) deficiencies should be evaluated in a prospective analysis. Methods Patients with symptomatic primary or secondary IgG deficiencies were interviewed prior to the first IgG infusion (t0) and over the course of their treatment (t1 - t6). The respondents rated their current health using a 100 point scale (EQ-5D-5L), ranging from 0 (‘worst imaginable health’) to 100 (‘best imaginable health’). The patients also provided information on the frequency of infections and of infections requiring antibiotics in the past 8 weeks. A healthy control group (CG) without oncologic diseases answered the questions once. Results One hundred six patients with a median age of 65 years (21–85 years) were investigated. The median serum IgG concentration changed from 500 mg/dl (t0) to 772 mg/dl (t6). The mean number of infections and of infections requiring antibiotics decreased during IgG replacement significantly. Current health according to EQ-5D-5L improved from 57 (t0) to 68 (t6), compared to 73 in the CG. Conclusion During the course of IgG replacement patients reported fewer and less severe infections. Their health assessment improved but still was inferior to the healthy CG.
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Affiliation(s)
- Rudolf Weide
- Praxis für Hämatologie und Onkologie Koblenz, Neversstr. 5, 56068, Koblenz, Germany.
| | - Roland Schnell
- pioh - Praxis Internistischer Onkologie und Hämatologie, Frechen, Germany
| | - Christof Schardt
- Onkologische Gemeinschaftspraxis und Tagesklinik, Gelsenkirchen, Germany
| | | | | | | | - Jan Wierecky
- Überörtliche Gemeinschaftspraxis, Dres. Verpoort, Wierecky & Brandl, Schwerpunkt Onkologie & Hämatologie, Hamburg, Germany
| | - Ute Braun
- Gemeinschaftspraxis für Hämatologie und Onkologie, Ludwigshafen, Germany
| | | | | | | | | | - Stefan Feiten
- Institut für Versorgungsforschung in der Onkologie, Koblenz, Germany
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46
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Pedini V, Verga JU, Terrenato I, Menghini D, Mezzanotte C, Danieli MG. Incidence of malignancy in patients with common variable immunodeficiency according to therapeutic delay: an Italian retrospective, monocentric cohort study. Allergy Asthma Clin Immunol 2020; 16:54. [PMID: 32944022 PMCID: PMC7491341 DOI: 10.1186/s13223-020-00451-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/15/2020] [Indexed: 11/12/2022] Open
Abstract
Background Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency and has a broad spectrum of clinical manifestations. Among non-infectious complications, an increased incidence of malignancies may have a special relevance for survival, but little is known about treatment efficacy on malignant complications. Methods This was a monocenter retrospective study on CVID patients, designed to provide preliminary data for the investigation of the possible link between therapeutic delay and tumor incidence. Results A total of 67 CVID subjects were included. The median diagnostic delay was 7.5 years (range: 0–63 years), and the median therapeutic delay was 8.5 years (range: 0–67 years). Malignancies were diagnosed in 18 (27%) patients. Eight out of 18 (44%) patients with a malignancy had lymphoma. Patients who developed a malignancy showed a longer therapeutic delay in comparison to patients with no malignancy, although no statistical significance was achieved (11 years vs 8 years, respectively, p = 0.424). We observed a lower frequency of malignancy in CVID patients with reduced therapeutic delay compared with patients with therapeutic delay ≥ 10 years. With a therapeutic delay of > 1 year, 74% had no tumor, and 25% had a tumor; with a therapeutic delay of > 10 years, 65% had no tumor and 35% had a malignancy. Among patients who had no malignancy, 64% had a therapeutic delay of < 10 years, and 36% had a therapeutic delay of ≥ 10 years. Among patients with malignancy, 47% of subjects had a therapeutic delay < 10 years, and 53% a therapeutic delay ≥ 10 years. Conclusions The observation of clinical characteristics of our patients with CVID may suggest that an early institution of IgG replacement therapy could be of benefit for the prevention of malignant complications. Name of the registry: Comitato Etico Regionale delle Marche. Trial registration number: 1505. Date of registration: 27/10/2016, Retrospectively registered URL of trial registry record: http://www.ospedaliriuniti.marche.it/portale/archivio13_cerm-ancona_0_446_1.html. The trial was not registered before the first participant was enrolled
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Affiliation(s)
- Veronica Pedini
- Medical Clinic, United Hospitals and DISCLIMO, Polytechnic University of Marche, Ancona, Italy.,Medicine Departement, Destra Secchia Hospital, Pieve di Coriano, ASST Mantova, Mantua, Italy
| | | | - Irene Terrenato
- Biostatistic and Bioinformatic Unit, Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Denise Menghini
- Medical Clinic, United Hospitals and DISCLIMO, Polytechnic University of Marche, Ancona, Italy
| | - Cristina Mezzanotte
- Medical Clinic, United Hospitals and DISCLIMO, Polytechnic University of Marche, Ancona, Italy
| | - Maria Giovanna Danieli
- Medical Clinic, United Hospitals and DISCLIMO, Polytechnic University of Marche, Ancona, Italy
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47
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Jablonka A, Etemadi H, Adriawan IR, Ernst D, Jacobs R, Buyny S, Witte T, Schmidt RE, Atschekzei F, Sogkas G. Peripheral Blood Lymphocyte Phenotype Differentiates Secondary Antibody Deficiency in Rheumatic Disease from Primary Antibody Deficiency. J Clin Med 2020; 9:jcm9041049. [PMID: 32272789 PMCID: PMC7230453 DOI: 10.3390/jcm9041049] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023] Open
Abstract
The phenotype of primary immunodeficiency disorders (PID), and especially common variable immunodeficiency (CVID), may be dominated by symptoms of autoimmune disorders. Furthermore, autoimmunity may be the first manifestation of PID, frequently preceding infections and the diagnosis of hypogammaglobulinemia, which occurs later on. In this case, distinguishing PID from hypogammaglobulinemia secondary to anti-inflammatory treatment of autoimmunity may become challenging. The aim of this study was to evaluate the diagnostic accuracy of peripheral blood lymphocyte phenotyping in resolving the diagnostic dilemma between primary and secondary hypogammaglobulinemia. Comparison of B and T cell subsets from patients with PID and patients with rheumatic disease, who developed hypogammaglobulinemia as a consequence of anti-inflammatory regimes, revealed significant differences in proportion of naïve B cells, class-switched memory B cells and CD21low B cells among B cells as well as in CD4+ memory T cells and CD4+ T follicular cells among CD4+ T cells. Identified differences in B cell and T cell subsets, and especially in the proportion of class-switched memory B cells and CD4+ T follicular cells, display a considerable diagnostic efficacy in distinguishing PID from secondary hypogammaglobulinemia due to anti-inflammatory regimens for rheumatic disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Faranaz Atschekzei
- Correspondence: (F.A.); (G.S.); Tel.: +49-(0)-511-532-3871 (F.A.); +49-(0)-511-532-3799 (G.S.)
| | - Georgios Sogkas
- Correspondence: (F.A.); (G.S.); Tel.: +49-(0)-511-532-3871 (F.A.); +49-(0)-511-532-3799 (G.S.)
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48
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Bansal RA, Tadros S, Bansal AS. The presence of overlapping quality of life symptoms in primary antibody deficiency (PAD) and chronic fatigue syndrome (CFS). Allergy Asthma Clin Immunol 2020; 16:21. [PMID: 32256619 PMCID: PMC7106611 DOI: 10.1186/s13223-020-0417-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 03/04/2020] [Indexed: 01/26/2023] Open
Abstract
Background Fatigue, sleep disturbance and altered mood are frequently reported in patients with primary antibody deficiency syndrome (PADS) on adequate immunoglobulin replacement therapy. This study aimed to determine the frequency of symptoms compatible with chronic fatigue syndrome (CFS) in patients with PADS. Methods The study involved the distribution of 682 self-completed postal questionnaires to ascertain the presence and frequency of symptoms compatible with CFS in patients with PADS. The reporting of symptoms for each patient were scored against the CFS diagnostic criteria used within our own South London Chronic Fatigue service. Results The frequency of symptoms compatible with CFS were evident in 26 of the 188 patients (16.25%) returning adequately completed questionnaires. We considered a bias in the return of questionnaires amongst PADS patients with fatigue to be likely. As such we estimated the minimum frequency of CFS in patients with PADS to be 4% based on the 682 PAD patients to whom the questionnaire was distributed. This was significantly higher than the 0.5% estimate of the prevalence of CFS in the community in western populations. While the presence of significant fatigue correlated with the presence of anxiety and depression, there was no association with self-reported lung damage. Sleep disturbance affected 60% of the PAD patients returning satisfactory questionnaires and as expected the CFS score was higher in those with greater physical limitation. Conclusions We conclude that patients with PADS have a high frequency of fatigue, low mood and anxiety. We suggest routine questioning for the symptoms of fatigue, disturbed sleep and altered mood in patients with PADS. The use of several treatment strategies in CFS may prove beneficial in improving the quality of life of patients with PAD.
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Affiliation(s)
- Rhea A Bansal
- Frimley Health NHS Trust, Portsmouth Road, Camberley, Surrey GU16 7UJ UK
| | - Susan Tadros
- 2The Royal Free Hospital, Pond Street, Hampstead, London, NW3 2QG UK
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49
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Tsai M, Wonnaparhown A, Garcia-Lloret MI, Butte MJ. Chronic Rhinosinusitis in Pediatric Immunodeficiency. CURRENT TREATMENT OPTIONS IN ALLERGY 2020. [DOI: 10.1007/s40521-019-00230-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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50
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Ponsford MJ, Steven R, Bramhall K, Burgess M, Wijetilleka S, Carne E, McGuire F, Price CR, Moody M, Zouwail S, Tahir T, Farewell D, El-Shanawany T, Jolles SRA. Clinical and laboratory characteristics of clozapine-treated patients with schizophrenia referred to a national immunodeficiency clinic reveals a B-cell signature resembling common variable immunodeficiency (CVID). J Clin Pathol 2020. [PMID: 32094276 DOI: 10.1136/jclinpath‐2019‐206235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS An association between antibody deficiency and clozapine use in individuals with schizophrenia has recently been reported. We hypothesised that if clozapine-associated hypogammaglobulinaemia was clinically relevant this would manifest in referral patterns. METHODS Retrospective case note review of patients referred and assessed by Immunology Centre for Wales (ICW) between January 2005 and July 2018 with extraction of clinical and immunological features for individuals with diagnosis of schizophrenia-like illness. RESULTS 1791 adult patients were assessed at ICW during this period; 23 patients had a psychiatric diagnosis of schizophrenia or schizoaffective disorder. Principal indications for referral were findings of low calculated globulin and immunoglobulins. Clozapine was the single most commonly prescribed antipsychotic (17/23), disproportionately increased relative to reported use in the general schizophrenia population (OR 6.48, 95% CI: 1.79 to 23.5). Clozapine therapy was noted in 6/7 (86%) of patients subsequently requiring immunoglobulin replacement therapy (IgRT). Marked reduction of class-switched memory B cells (CSMB) and plasmablasts were observed in clozapine-treated individuals relative to healthy age-matched controls. Clozapine duration is associated with CSMB decline. One patient discontinued clozapine, with gradual recovery of IgG levels without use of IgRT. CONCLUSIONS Our findings are consistent with enrichment of clozapine-treatment within schizophrenic individuals referred for ICW assessment over the last 13 years. These individuals displayed clinical patterns closely resembling the primary immunodeficiency common variable immunodeficiency, however appears reversible on drug cessation. This has diagnostic, monitoring and treatment implications for psychiatry and immunology teams and directs prospective studies to address causality and the wider implications for this patient group.
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Affiliation(s)
- Mark James Ponsford
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK .,Tenovus Institute, Division of Infection & Immunity, Cardiff University, Cardiff, UK
| | - Rachael Steven
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Kathyrn Bramhall
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Mathew Burgess
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Sonali Wijetilleka
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Emily Carne
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Frances McGuire
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Colin R Price
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Mo Moody
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Soha Zouwail
- Department of Medical Biochemistry, University Hospital of Wales, Cardiff, UK.,Department of Medical Biochemistry, Medical School, Alexandria University, Alexandria, Egypt
| | - Tayyeb Tahir
- Liaison Psychiatry, University Hospital of Wales, Cardiff, UK
| | - Daniel Farewell
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Tariq El-Shanawany
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Stephen R A Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
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