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Thomas SJ, Ouellette CP. Viral meningoencephalitis in pediatric solid organ or hematopoietic cell transplant recipients: a diagnostic and therapeutic approach. Front Pediatr 2024; 12:1259088. [PMID: 38410764 PMCID: PMC10895047 DOI: 10.3389/fped.2024.1259088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 01/26/2024] [Indexed: 02/28/2024] Open
Abstract
Neurologic complications, both infectious and non-infectious, are frequent among hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients. Up to 46% of HCT and 50% of SOT recipients experience a neurological complication, including cerebrovascular accidents, drug toxicities, as well as infections. Defects in innate, adaptive, and humoral immune function among transplant recipients predispose to opportunistic infections, including central nervous system (CNS) disease. CNS infections remain uncommon overall amongst HCT and SOT recipients, compromising approximately 1% of total cases among adult patients. Given the relatively lower number of pediatric transplant recipients, the incidence of CNS disease amongst in this population remains unknown. Although infections comprise a small percentage of the neurological complications that occur post-transplant, the associated morbidity and mortality in an immunosuppressed state makes it imperative to promptly evaluate and aggressively treat a pediatric transplant patient with suspicion for viral meningoencephalitis. This manuscript guides the reader through a broad infectious and non-infectious diagnostic differential in a transplant recipient presenting with altered mentation and fever and thereafter, elaborates on diagnostics and management of viral meningoencephalitis. Hypothetical SOT and HCT patient cases have also been constructed to illustrate the diagnostic and management process in select viral etiologies. Given the unique risk for various opportunistic viral infections resulting in CNS disease among transplant recipients, the manuscript will provide a contemporary review of the epidemiology, risk factors, diagnosis, and management of viral meningoencephalitis in these patients.
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Affiliation(s)
- Sanya J. Thomas
- Host Defense Program, Section of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH, United States
- Division of Infectious Diseases, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, United States
| | - Christopher P. Ouellette
- Host Defense Program, Section of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH, United States
- Division of Infectious Diseases, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, United States
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2
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Chu S, McCormick TS, Lazarus HM, Leal LO, Ghannoum MA. Invasive fungal disease and the immunocompromised host including allogeneic hematopoietic cell transplant recipients: Improved understanding and new strategic approach with sargramostim. Clin Immunol 2021; 228:108731. [PMID: 33892201 DOI: 10.1016/j.clim.2021.108731] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/12/2021] [Accepted: 04/17/2021] [Indexed: 12/17/2022]
Abstract
In hosts with damaged or impaired immune systems such as those undergoing hematopoietic cell transplant (HCT) or intensive chemotherapy, breakthrough fungal infections can be fatal. Risk factors for breakthrough infections include severe neutropenia, use of corticosteroids, extended use of broad-spectrum antibiotics, and intensive care unit admission. An individual's cumulative state of immunosuppression directly contributes to the likelihood of experiencing increased infection risk. Incidence of invasive fungal infection (IFI) after HCT may be up to 5-8%. Early intervention may improve IFI outcomes, although many infections are resistant to standard therapies (voriconazole, caspofungin, micafungin, amphotericin B, posaconazole or itraconazole, as single agents or in combination). We review herein several contributing factors that may contribute to the net state of immunosuppression in recipients of HCT. We also review a new approach for IFI utilizing adjunctive therapy with sargramostim, a yeast-derived recombinant human granulocyte-macrophage colony-stimulating factor (rhu GM-CSF).
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Affiliation(s)
- Sherman Chu
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA; College of Osteopathic Medicine of the Pacific, Northwest (COMP), Lebanon, OR, USA.
| | - Thomas S McCormick
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA.
| | - Hillard M Lazarus
- Department of Medicine, Division of Hematology and Oncology, Case Western Reserve University, Cleveland, OH, USA.
| | - Luis O Leal
- Partner Therapeutics, Inc., 19 Muzzey St, Lexington, MA, USA.
| | - Mahmoud A Ghannoum
- Department of Dermatology, Case Western Reserve University, Cleveland, OH, USA; Center for Medical Mycology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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3
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Diavati S, Asimakopoulos JV, Galopoulos D, Konstantinou I, Argyrakos T, Toulas P, Vassilakopoulos TP, Konstantopoulos K, Angelopoulou MK. Progressive Multifocal Leukoencephalopathy Following Treatment With Obinutuzumab in a Patient With Non-Hodgkin Follicular Lymphoma: A Case Report. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e601-e605. [PMID: 33814337 DOI: 10.1016/j.clml.2021.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 02/27/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Stavrianna Diavati
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John V Asimakopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Galopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Iliana Konstantinou
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Panagiotis Toulas
- Department of Radiology, Biiatrics Group Diagnostic Centers, Athens, Greece
| | - Theodoros P Vassilakopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Kostas Konstantopoulos
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria K Angelopoulou
- Department of Haematology and Bone Marrow Transplantation, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece.
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Keller MD, Bollard CM. Virus-specific T-cell therapies for patients with primary immune deficiency. Blood 2020; 135:620-628. [PMID: 31942610 PMCID: PMC7046606 DOI: 10.1182/blood.2019000924] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 09/23/2019] [Indexed: 02/07/2023] Open
Abstract
Viral infections are common and are potentially life-threatening in patients with moderate to severe primary immunodeficiency disorders. Because T-cell immunity contributes to the control of many viral pathogens, adoptive immunotherapy with virus-specific T cells (VSTs) has been a logical and effective way of combating severe viral disease in immunocompromised patients in multiple phase 1 and 2 clinical trials. Common viral targets include cytomegalovirus, Epstein-Barr virus, and adenovirus, though recent published studies have successfully targeted additional pathogens, including HHV6, BK virus, and JC virus. Though most studies have used VSTs derived from allogenic stem cell donors, the use of banked VSTs derived from partially HLA-matched donors has shown efficacy in multicenter settings. Hence, this approach could shorten the time for patients to receive VST therapy thus improving accessibility. In this review, we discuss the usage of VSTs for patients with primary immunodeficiency disorders in clinical trials, as well as future potential targets and methods to broaden the applicability of virus-directed T-cell immunotherapy for this vulnerable patient population.
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Affiliation(s)
- Michael D Keller
- Center for Cancer and Immunology Research and
- Division of Allergy and Immunology, Children's National Health System, Washington, DC
- GW Cancer Center, George Washington University, Washington, DC; and
| | - Catherine M Bollard
- Center for Cancer and Immunology Research and
- GW Cancer Center, George Washington University, Washington, DC; and
- Division of Blood and Marrow Transplantation, Children's National Health System, Washington, DC
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5
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de la Fuente MI, Alderuccio JP, Lossos IS. Central nervous system emergencies in haematological malignancies. Br J Haematol 2019; 189:1028-1037. [PMID: 31483060 DOI: 10.1111/bjh.16184] [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: 01/19/2023]
Abstract
Neurological emergencies are frequently catastrophic events in the course of haematological malignancies (HM) that, if not promptly recognized and treated, may lead to lethal outcomes or chronic sequelae. They may occur at any time during the disease course, but are more frequently observed following relapse. Practice guidelines are lacking in the management of most central nervous system (CNS) complications in HM. Herein we review the pathophysiology, presentation and treatment of elevated intracranial pressure, spinal cord compression, status epilepticus, neurovascular complications, CNS infection, leucostasis and hyperviscosity. Further, we discuss the expanding spectrum of neurological complications of old and novel treatments in HM.
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Affiliation(s)
- Macarena I de la Fuente
- Departments of Neurology and Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Juan Pablo Alderuccio
- Department of Medicine, Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Izidore S Lossos
- Department of Medicine, Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA.,Department of Molecular and Cellular Pharmacology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
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Lam W, Al-Shaibani Z, Kumar D, Viswabandya A, Thyagu S, Michelis FV, Kim DDH, Lipton JH, Messner HA, Deotare U. Progressive multifocal leukoencephalopathy due to John Cunningham (JC) virus following allogeneic haematopoietic cell transplantation. Antivir Ther 2019; 22:721-725. [PMID: 28362268 DOI: 10.3851/imp3162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2017] [Indexed: 10/19/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is an uncommon infectious complication post allogeneic stem cell transplant. We present a case report of a patient developing this complication with a review of the current literature. It also describes the first use of artesunate in a clinical case of PML with no beneficial effect.
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Affiliation(s)
- Wilson Lam
- Allogeneic Blood and Marrow Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Zeyad Al-Shaibani
- Allogeneic Blood and Marrow Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Deepali Kumar
- Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Auro Viswabandya
- Allogeneic Blood and Marrow Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Santhosh Thyagu
- Allogeneic Blood and Marrow Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Fotios V Michelis
- Allogeneic Blood and Marrow Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Dennis Dong-Hwan Kim
- Allogeneic Blood and Marrow Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jeffrey H Lipton
- Allogeneic Blood and Marrow Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Hans A Messner
- Allogeneic Blood and Marrow Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Uday Deotare
- Allogeneic Blood and Marrow Transplant Program, Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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7
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Obeid KM. Infections with DNA Viruses, Adenovirus, Polyomaviruses, and Parvovirus B19 in Hematopoietic Stem Cell Transplant Recipients and Patients with Hematologic Malignancies. Infect Dis Clin North Am 2019; 33:501-521. [PMID: 30940465 DOI: 10.1016/j.idc.2019.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Infections due to adenovirus, polyomaviruses (BK and JC viruses), and parvovirus B19 may not be as common as infections due to other DNA viruses, such as cytomegalovirus in patients with hematological malignancies and the recipients of hematopoietic stem cell transplantation. However, these infections may result in life-threatening diseases that significantly impact patients' recovery, morbidity, and mortality. Treating physicians should be aware of the diseases associated with these viruses, the patient populations at increased risk for complications due to these infections, and the available diagnostic and therapeutic approaches.
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Affiliation(s)
- Karam M Obeid
- Division of Infectious Diseases and International Medicine, University of Minnesota, 420 Delaware Street SE, MMC250, Minneapolis, MN 55455, USA.
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Yuan C, Deberardinis C, Patel R, Shroff SM, Messina SA, Goldstein S, Mori S. Progressive multifocal leukoencephalopathy after allogeneic stem cell transplantation: Case report and review of the literature. Transpl Infect Dis 2018. [PMID: 29512846 DOI: 10.1111/tid.12879] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare, yet typically fatal complication of allogeneic stem cell transplantation. It is caused by reactivation of the John Cunningham (JC) virus in an immunocompromised host. This report describes an unfortunate case of PML in a recipient of an allogeneic stem cell transplant for acute myelogenous leukemia. The JC virus was undetectable in the patient's cerebrospinal fluid by polymerase chain reaction (PCR); however, a positive diagnosis was made after a brain biopsy. This and other published cases demonstrate that recipients of allogeneic stem cells can develop PML. Moreover, early diagnosis of the disease is often difficult and, as demonstrated in this case, screening with PCR does not appear to have strong diagnostic significance. With no effective treatment presently available, restoration of immune function is the only intervention that can affect prognosis. Further prospective studies are needed to understand the pathophysiology and treatment of this disease.
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Affiliation(s)
- Cai Yuan
- Hematology and Oncology Fellowship, University of Florida, Gainesville, FL, USA
| | | | - Rushang Patel
- Blood & Marrow Transplant Center, Florida Hospital, Orlando, FL, USA
| | - Seema M Shroff
- Pathology Department, Florida Hospital, Orlando, FL, USA
| | | | - Steven Goldstein
- Blood & Marrow Transplant Center, Florida Hospital, Orlando, FL, USA
| | - Shahram Mori
- Blood & Marrow Transplant Center, Florida Hospital, Orlando, FL, USA
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9
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Ikegawa S, Fujii N, Tadokoro K, Sato K, Iwamoto M, Matsuda M, Inomata T, Sugiura H, Asano T, Yoshida S, Nishimori H, Matsuoka KI, Maeda Y. Progressive multifocal leukoencephalopathy after T-cell replete HLA-haploidentical transplantation with post-transplantation cyclophosphamide graft-versus-host disease prophylaxis. Transpl Infect Dis 2018; 20:e12850. [PMID: 29359846 DOI: 10.1111/tid.12850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 07/19/2017] [Accepted: 10/15/2017] [Indexed: 12/26/2022]
Abstract
A 52-year-old man suffered from progressive multifocal leukoencephalopathy (PML) after human leukocyte antigen (HLA)-haploidentical transplantation with post-transplantation cyclophosphamide (PTCY). Mirtazapine, mefloquine, and cytarabine failed to improve his symptoms, and he finally died 4.5 months after PML onset. This is the first case report of a patient with PML after HLA-haploidentical transplantation with PTCY. Although T-cell replete HLA-haploidentical transplantation with PTCY has enabled early immune reconstitution, PML should be considered if a patient's mental condition deteriorates.
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Affiliation(s)
- Shuntaro Ikegawa
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Nobuharu Fujii
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Koh Tadokoro
- Department of Neurology, Okayama University Hospital, Okayama, Japan
| | - Kota Sato
- Department of Neurology, Okayama University Hospital, Okayama, Japan
| | - Miki Iwamoto
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Masayuki Matsuda
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Tomoko Inomata
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Hiroyuki Sugiura
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Takeru Asano
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Shohei Yoshida
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Hisakazu Nishimori
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Ken-Ichi Matsuoka
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Yoshinobu Maeda
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
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10
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Neurologic complications after allogeneic hematopoietic stem cell transplantation: risk factors and impact. Bone Marrow Transplant 2017; 53:199-206. [PMID: 29131150 DOI: 10.1038/bmt.2017.239] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/08/2017] [Accepted: 09/12/2017] [Indexed: 01/16/2023]
Abstract
Neurologic complications (NCs) may be a significant source of morbidity and mortality after hematopoietic cell transplantation (HCT). We performed a retrospective study of 263 consecutive patients undergoing allogeneic HCT for hematological malignancies to determine the incidence, risk factors and clinical impact of NCs in the first 5 years after HCT. We determined the incidence of central nervous system (CNS) infection, intracranial hemorrhage, ischemic stroke, metabolic encephalopathy, posterior reversal encephalopathy syndrome, seizure and peripheral neuropathy. In all, 50 patients experienced 63 NCs-37 early (⩽day +100), 21 late (day +101 to 2 years) and 5 very late (2 to 5 years). The 1- and 5-year cumulative incidences of all NCs were 15.6% and 19.2%, respectively, and of CNS complication (CNSC; all of the above complications except peripheral neuropathy) were 12.2 and 14.5%. Risk factors for CNSC were age (hazard ratio (HR)=1.06 per year, P=0.0034), development of acute GvHD grade III-IV (HR=2.78, P=0.041), transfusion-dependent thrombocytopenia (HR=3.07, P=0.025) and delayed platelet engraftment (>90th centile; HR=2.77, P=0.043). CNSCs negatively impacted progression-free survival (HR=2.29, P=0.0001), overall survival (HR=2.63, P<0.0001) and non-relapse mortality (HR=8.51, P<0.0001). NCs after HCT are associated with poor outcomes, and usually occur early after HCT.
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Abstract
In patients with membranous nephropathy, alkylating agents (cyclophosphamide or chlorambucil) alone or in combination with steroids achieve remission of nephrotic syndrome more effectively than conservative treatment or steroids alone, but can cause myelotoxicity, infections, and cancer. Calcineurin inhibitors can improve proteinuria, but are nephrotoxic. Most patients relapse after treatment withdrawal and can become treatment dependent, which increases the risk of nephrotoxicity. The discovery of nephritogenic autoantibodies against podocyte M-type phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain- containing protein 7A (THSD7A) antigens provides a clear pathophysiological rationale for interventions that specifically target B-cell lineages to prevent antibody production and subepithelial deposition. The anti-CD20 monoclonal antibody rituximab is safe and achieves remission of proteinuria in approximately two-thirds of patients with membranous nephropathy. In those with PLA2R-related disease, remission can be predicted by anti-PLA2R antibody depletion and relapse by antibody re-emergence into the circulation. Thus, integrated evaluation of serology and proteinuria could guide identification of affected patients and treatment with individually tailored protocols. Nonspecific and toxic immunosuppressive regimens will fall out of use. B-cell modulation by rituximab and second-generation anti-CD20 antibodies (or plasma cell-targeted therapy in anti-CD20 resistant forms of disease) will lead to a novel therapeutic paradigm for patients with membranous nephropathy.
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Yamashita Y, Kusakabe S, Toda J, Ohshima K, Masaie H, Yagi T, Yoshida H, Ishikawa J. Sequential Onset of Varicella-Zoster Virus Encephalomeningitis and Progressive Multifocal Leukoencephalopathy in an Allogeneic Hematopoietic Stem Cell Transplant Recipient. EXP CLIN TRANSPLANT 2016; 16:628-630. [PMID: 27938314 DOI: 10.6002/ect.2016.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Here, we describe a case of sequential varicella-zoster virus encephalomeningitis and progressive multifocal leukoencephalopathy following an allogeneic hematopoietic stem cell transplant procedure. A 37-year-old male patient presented with fever, incomplete paralysis of bilateral legs, and bullous eruptions 8 months after allogeneic transplant. Polymerase chain reaction assays of cerebrospinal fluid samples for varicella-zoster virus were positive. Bullous eruptions and incomplete paralysis of bilateral legs improved after administration of acyclovir. However, higher brain dysfunction was present and getting worse. We detected no herpes simplex virus, varicella-zoster virus, Cytomegalovirus, human herpes virus 6, Epstein-Barr virus, or JC virus in cerebrospinal fluid samples with polymerase chain reaction assays. Pathologic findings and polymerase chain reaction assays with brain biopsy samples revealed that the patient had progressive multifocal leukoencephalopathy. This is the first report of a case showing dual central nervous system infections due to varicella-zoster virus and JC virus after allogeneic stem cell transplant.
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Affiliation(s)
- Yukiko Yamashita
- From the Department of Hematology and Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
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Drug-associated progressive multifocal leukoencephalopathy: a clinical, radiological, and cerebrospinal fluid analysis of 326 cases. J Neurol 2016; 263:2004-21. [PMID: 27401179 PMCID: PMC5037162 DOI: 10.1007/s00415-016-8217-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 02/07/2023]
Abstract
The implementation of a variety of immunosuppressive therapies has made drug-associated progressive multifocal leukoencephalopathy (PML) an increasingly prevalent clinical entity. The purpose of this study was to investigate its diagnostic characteristics and to determine whether differences herein exist between the multiple sclerosis (MS), neoplasm, post-transplantation, and autoimmune disease subgroups. Reports of possible, probable, and definite PML according to the current diagnostic criteria were obtained by a systematic search of PubMed and the Dutch pharmacovigilance database. Demographic, epidemiologic, clinical, radiological, cerebrospinal fluid (CSF), and histopathological features were extracted from each report and differences were compared between the disease categories. In the 326 identified reports, PML onset occurred on average 29.5 months after drug introduction, varying from 14.2 to 37.8 months in the neoplasm and MS subgroups, respectively. The most common overall symptoms were motor weakness (48.6 %), cognitive deficits (43.2 %), dysarthria (26.3 %), and ataxia (24.1 %). The former two also constituted the most prevalent manifestations in each subgroup. Lesions were more often localized supratentorially (87.7 %) than infratentorially (27.4 %), especially in the frontal (64.1 %) and parietal lobes (46.6 %), and revealed enhancement in 27.6 % of cases, particularly in the MS (42.9 %) subgroup. Positive JC virus results in the first CSF sample were obtained in 63.5 %, while conversion after one or more negative outcomes occurred in 13.7 % of cases. 52.2 % of patients died, ranging from 12.0 to 83.3 % in the MS and neoplasm subgroups, respectively. In conclusion, despite the heterogeneous nature of the underlying diseases, motor weakness and cognitive changes were the two most common manifestations of drug-associated PML in all subgroups. The frontal and parietal lobes invariably constituted the predilection sites of drug-related PML lesions.
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14
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Abstract
Neurologic complications of cancer are common and are frequently life-threatening events. Certain neurologic emergencies occur more frequently in the cancer population, specifically elevated intracranial pressure, epidural cord compression, status epilepticus, ischemic and hemorrhagic stroke, central nervous system infection, and treatment-associated neurologic dysfunction. These emergencies require early diagnosis and prompt treatment to ensure the best possible outcome and are best managed in the intensive care unit. This article reviews the presentation, pathophysiology, and management of the most common causes of acute neurologic decompensation in the patient with cancer.
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Affiliation(s)
- Andrew L Lin
- 1 Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edward K Avila
- 1 Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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15
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Cravedi P, Remuzzi G, Ruggenenti P. Rituximab in primary membranous nephropathy: first-line therapy, why not? Nephron Clin Pract 2014; 128:261-9. [PMID: 25427622 DOI: 10.1159/000368589] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The ideal treatment of patients with primary membranous nephropathy (MN) and persistent nephrotic syndrome (NS) is still a matter of debate. This is a major issue since these patients may progress to end-stage kidney disease (ESKD) in 5-10 years. Steroids, alkylating agents, and calcineurin inhibitors have been suggested to achieve NS remission and prevent ESKD in this population. Treatment benefits, however, are uncertain and are often offset by serious adverse events (SAEs). Evidence that B cells play a crucial role in the pathogenesis of the disease, both as precursors of autoantibody-producing cells and as antigen-presenting cells, provided the background for explorative studies testing the role of B cell-depletion therapy with the monoclonal antibody rituximab. This approach aimed at selectively inhibiting disease mechanisms without the devastating consequences of unspecific immunosuppression. Finding that rituximab safely ameliorated NS in 8 patients with primary MN fueled a series of observational studies that uniformly confirmed the safety/efficacy profile of rituximab in this context. Although head-to-head comparisons in randomized clinical trials are missing, comparative analyses between series of homogeneous patient cohorts clearly show at least similar efficacy of rituximab as compared to steroid plus alkylating agents. Moreover, data confirm the dramatically superior safety profile of rituximab that actually appears to be associated with a rate of SAEs even lower than that observed with conservative therapy. Rituximab is also effective in patients resistant to other treatments and its cost-effectiveness is further increased when treatment is titrated to circulating B cells. Recently identified pathogenic antibodies against the M type phospholipase A2 receptor will likely provide a novel tool to monitor disease activity and drive rituximab therapy, at least in a subset of patients. Newly developed anti-CD20 antibodies could represent a valuable option for those who fail rituximab therapy. Steroids, alkylating agents, and calcineurin inhibitors should likely be abandoned.
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Affiliation(s)
- Paolo Cravedi
- Icahn School of Medicine at Mount Sinai, New York, N.Y., USA
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16
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Gasnault J, de Goër de Herve MG, Michot JM, Hendel-Chavez H, Seta V, Mazet AA, Croughs T, Stankoff B, Bourhis JH, Lambotte O, Delfraissy JF, Taoufik Y. Efficacy of recombinant human interleukin 7 in a patient with severe lymphopenia-related progressive multifocal leukoencephalopathy. Open Forum Infect Dis 2014; 1:ofu074. [PMID: 25734144 PMCID: PMC4281783 DOI: 10.1093/ofid/ofu074] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 07/08/2014] [Indexed: 12/24/2022] Open
Abstract
In this study, we report the case of a patient with profound lymphopenia after allogenic bone marrow transplantation who developed severe progressive multifocal leukoencephalopathy. Single-agent recombinant human interleukin-7 therapy was associated with restoration of anti-John Cunningham polyomavirus (JCV) T-cell responses, JCV clearance from cerebrospinal fluid, and a dramatic clinical improvement.
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Affiliation(s)
- Jacques Gasnault
- Department of Internal Medicine , Assistance Publique-Hôpitaux de Paris (AP -HP), Hôpital Bicêtre , Le Kremlin-Bicêtre , France ; Institut National de la Santé et de la Recherche Médicale (INSERM) U1012, Faculté de Médecine , Université Paris Sud , Le Kremlin-Bicêtre , France
| | - Marie-Ghislaine de Goër de Herve
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1012, Faculté de Médecine , Université Paris Sud , Le Kremlin-Bicêtre , France
| | - Jean-Marie Michot
- Department of Internal Medicine , Assistance Publique-Hôpitaux de Paris (AP -HP), Hôpital Bicêtre , Le Kremlin-Bicêtre , France ; Department of Haematology , Institut Gustave Roussy , Villejuif , France
| | - Houria Hendel-Chavez
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1012, Faculté de Médecine , Université Paris Sud , Le Kremlin-Bicêtre , France
| | - Vannina Seta
- Department of Internal Medicine , Assistance Publique-Hôpitaux de Paris (AP -HP), Hôpital Bicêtre , Le Kremlin-Bicêtre , France
| | - Anne-Aurélie Mazet
- Department of Virology , AP-HP, Hôpital Paul Brousse , Villejuif , France
| | - Thérèse Croughs
- INSERM-Agence Nationale pour la Recherche sur le SIDA , Paris , France
| | - Bruno Stankoff
- Department of Neurology , AP-HP, Hôpital Tenon , Paris , France
| | - Jean-Henri Bourhis
- Department of Haematology , Institut Gustave Roussy , Villejuif , France
| | - Olivier Lambotte
- Department of Internal Medicine , Assistance Publique-Hôpitaux de Paris (AP -HP), Hôpital Bicêtre , Le Kremlin-Bicêtre , France ; Institut National de la Santé et de la Recherche Médicale (INSERM) U1012, Faculté de Médecine , Université Paris Sud , Le Kremlin-Bicêtre , France
| | - Jean-François Delfraissy
- Department of Internal Medicine , Assistance Publique-Hôpitaux de Paris (AP -HP), Hôpital Bicêtre , Le Kremlin-Bicêtre , France ; Institut National de la Santé et de la Recherche Médicale (INSERM) U1012, Faculté de Médecine , Université Paris Sud , Le Kremlin-Bicêtre , France ; INSERM-Agence Nationale pour la Recherche sur le SIDA , Paris , France
| | - Yassine Taoufik
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1012, Faculté de Médecine , Université Paris Sud , Le Kremlin-Bicêtre , France
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