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Conti F, Moratti M, Leonardi L, Catelli A, Bortolamedi E, Filice E, Fetta A, Fabi M, Facchini E, Cantarini ME, Miniaci A, Cordelli DM, Lanari M, Pession A, Zama D. Anti-Inflammatory and Immunomodulatory Effect of High-Dose Immunoglobulins in Children: From Approved Indications to Off-Label Use. Cells 2023; 12:2417. [PMID: 37830631 PMCID: PMC10572613 DOI: 10.3390/cells12192417] [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: 08/07/2023] [Revised: 09/23/2023] [Accepted: 10/05/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND The large-scale utilization of immunoglobulins in patients with inborn errors of immunity (IEIs) since 1952 prompted the discovery of their key role at high doses as immunomodulatory and anti-inflammatory therapy, in the treatment of IEI-related immune dysregulation disorders, according to labelled and off-label indications. Recent years have been dominated by a progressive imbalance between the gradual but constant increase in the use of immunoglobulins and their availability, exacerbated by the SARS-CoV-2 pandemic. OBJECTIVES To provide pragmatic indications for a need-based application of high-dose immunoglobulins in the pediatric context. SOURCES A literature search was performed using PubMed, from inception until 1st August 2023, including the following keywords: anti-inflammatory; children; high dose gammaglobulin; high dose immunoglobulin; immune dysregulation; immunomodulation; immunomodulatory; inflammation; intravenous gammaglobulin; intravenous immunoglobulin; off-label; pediatric; subcutaneous gammaglobulin; subcutaneous immunoglobulin. All article types were considered. IMPLICATIONS In the light of the current imbalance between gammaglobulins' demand and availability, this review advocates the urgency of a more conscious utilization of this medical product, giving indications about benefits, risks, cost-effectiveness, and administration routes of high-dose immunoglobulins in children with hematologic, neurologic, and inflammatory immune dysregulation disorders, prompting further research towards a responsible employment of gammaglobulins and improving the therapeutical decisional process.
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Affiliation(s)
- Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Mattia Moratti
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Lucia Leonardi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Arianna Catelli
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Elisa Bortolamedi
- Specialty School of Paediatrics, University of Bologna, 40138 Bologna, Italy; (A.C.); (E.B.)
| | - Emanuele Filice
- Department of Pediatrics, Maggiore Hospital, 40133 Bologna, Italy;
| | - Anna Fetta
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marianna Fabi
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Elena Facchini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Maria Elena Cantarini
- Pediatric Oncology and Hematology Unit “Lalla Seràgnoli”, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (E.F.); (M.E.C.)
| | - Angela Miniaci
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
| | - Duccio Maria Cordelli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell’Età Pediatrica, 40139 Bologna, Italy
| | - Marcello Lanari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.C.); (A.M.); (A.P.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
| | - Daniele Zama
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (A.F.); (D.M.C.); (M.L.); (D.Z.)
- Paediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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Zhang X, Che R, Xu H, Ding G, Zhao F, Huang S, Zhang A. Hemoperfusion and intravenous immunoglobulins for refractory gastrointestinal involvement in pediatric Henoch-Schönlein purpura: a single-center retrospective cohort study. BMC Pediatr 2022; 22:692. [PMID: 36460986 PMCID: PMC9716741 DOI: 10.1186/s12887-022-03709-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/25/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Henoch-Schönlein purpura (HSP) with refractory gastrointestinal (GI) symptoms is always difficult to handle because of its resistance to supportive therapies and glucocorticoid. This study aimed to evaluate the efficacy of hemoperfusion (HP) and intravenous immunoglobulins (IVIG) therapies in this population. METHODS Sixty-four HSP patients with refractory GI involvement (R-GI group) and 64 cases with mild GI symptoms (control group) were retrospectively analyzed in our center from March 2016 to October 2019. In R-GI group, 42 cases (subgroup A) were treated with IVIG and steroid, 13 cases (subgroup B) used HP and steroid, 9 cases (subgroup C) executed a combination of IVIG, HP and steroid. Demographic characteristics, clinical features, laboratory indexes and treatment outcomes were recorded. t-test, One-way ANOVA, Mann-Whitney U test, and multivariate logistic regression were used in comparing differences among subgroups and predicting independent risk factors. RESULTS Compared with the control group, R-GI cases experienced higher risk of renal involvement (P = 0.000), more steroid exposure (P = 0.000), six times expenses (P = 0.000) and 2.3 times length of hospitalization (P = 0.000). The independent risk factors of R-GI group were elevated neutrophils (OR 1.250 [95% CI 1.130-1.383]) and the percentage of B lymphocytes (OR 1.100 [95% CI 1.026-1.179]) as well as decreased IgG (OR 0.847 [95% CI 0.732-0.98]). In R-GI group, increased age (OR 1.039 [95% CI 1.016-1.062]) and IgM (OR 5.994 [95% CI 1.403-27.611]) were verified to be risk factors of HSP nephritis. All three subgroups could alleviate the symptoms effectively. Compared with those in subgroup A, patients in subgroup B were elder (P = 0.004), had less relapse (P = 0.002), steroid exposure (P = 0.033) and expenses (P = 0.031), more significant decrease of WBC (P = 0.026) after treatment. CONCLUSION The HSP with refractory GI involvement had much higher risk of medical burden and renal involvement. Both IVIG and HP therapies could ameliorate refractory GI symptoms efficiently. HP therapy tended to reduce the relapse, costs and steroid exposure in its audiences who were cooperated and with stable hemodynamics, while IVIG had better use in younger children.
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Affiliation(s)
- Xiaolu Zhang
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Ruochen Che
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Haisheng Xu
- grid.452511.6Department of Emergency Medicine, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Guixia Ding
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Fei Zhao
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Songming Huang
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China ,grid.452511.6Nanjing Key Laboratory of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Aihua Zhang
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China ,grid.452511.6Nanjing Key Laboratory of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
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Alonso de la Hoz J, Martínez Antequera CE, Fernández Manso B, Llorente Otones L, de Inocencio Arocena J. Hemorrhagic bullous IgA vasculitis (Schönlein-Henoch purpura), does it have a worse prognosis? REUMATOLOGIA CLINICA 2021; 17:549-551. [PMID: 34756318 DOI: 10.1016/j.reumae.2020.07.011] [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: 05/01/2020] [Accepted: 07/08/2020] [Indexed: 06/13/2023]
Abstract
Haemorrhagic bullous form of IgA vasculitis (IgAV), or Schönlein-Henoch purpura, is an unusual presentation of the disease in paediatric patients (<2%). Blistering eruptions can sometimes be very striking, leading to hospital admissions and administration of high-dose steroids and even immunosuppressants. Review of the literature, however, does not suggest that this clinical form carries a worse prognosis than the other forms of IgAV. In fact, the prognosis of the disease depends on the organic involvement. We present the case of a 5-year-old girl that is very representative. She developed palpable purpura and four days later the skin lesions evolved into blistering lesions. She did not receive any anti-inflammatory nor immunosuppressive treatment and the lesions spontaneously subsided within 14 days. She did not develop any extracutaneous nor systemic involvement.
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Affiliation(s)
- Julia Alonso de la Hoz
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain.
| | | | | | - Lucía Llorente Otones
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | - Jaime de Inocencio Arocena
- Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, Spain; Departamento de Salud Pública y Materno-Infantil, Universidad Complutense de Madrid, Madrid, Spain
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Morotti F, Bracciolini G, Caorsi R, Cattaneo L, Gattorno M, Ravelli A, Felici E. Intravenous immunoglobulin for corticosteroid-resistant intestinal Henoch-Schönlein purpura: worth a controlled trial against corticosteroids? Rheumatology (Oxford) 2021; 60:3868-3871. [PMID: 34340243 DOI: 10.1093/rheumatology/keaa743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/01/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Henoch-Schönlein purpura (HScP) may present in children with severe, occasionally refractory, gastrointestinal (GI) involvement. The use of corticosteroids (CSs) is commonplace in the management of the disease, but to date no standardized protocol is available and, although rare, resistance to CS therapy may be challenging to clinicians. IVIG has been proposed as an effective alternative to CSs, but to date no controlled trial has been conducted to ascertain their real efficacy. We share our personal experience of successful IVIG treatment in two cases of GI HScP, comparing it with similar experiences reported in literature. METHODS Retrospective clinical data collection, comparison with available literature. RESULTS We describe two children with severe HScP GI vasculitis refractory to high-dose intravenous CSs that responded rapidly to IVIG administration, with complete recovery within a few days. Patient characteristics and response to IVIG administration were comparable to those of other previously reported cases. CONCLUSION Our observation confirms that IVIG may be useful in the treatment of CS-resistant HScP-related GI vasculitis in children, and highlights the need for more structured research, including a randomized trial against CSs, in order to ascertain their real effectiveness.
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Affiliation(s)
- Francesco Morotti
- SCDU of Pediatrics, Department of Health Sciences, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Giulia Bracciolini
- Pediatrics and Pediatric Emergency Unit, The Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Roberta Caorsi
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Lorella Cattaneo
- Pediatrics and Pediatric Emergency Unit, The Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Marco Gattorno
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Angelo Ravelli
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Enrico Felici
- Pediatrics and Pediatric Emergency Unit, The Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy.,'Umberto Bosio' Centre for Digestive Diseases, The Children Hospital, Azienda Ospedaliera Nazionale SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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Intravenous γ Globulin for Intractable Abdominal Pain due to IgA Vasculitis. Case Rep Pediatr 2020; 2020:8867621. [PMID: 33123401 PMCID: PMC7586148 DOI: 10.1155/2020/8867621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/26/2020] [Accepted: 09/30/2020] [Indexed: 11/17/2022] Open
Abstract
IgA vasculitis (formerly known as Henoch–Schönlein purpura or anaphylactoid purpura) is a usually benign vasculitis that affects children of school age. The disease is characterized by the tetrad of palpable purpura, arthralgia/arthritis, abdominal pain, and hematuria. Treatment of IgA vasculitis is mainly supportive, with administration of simple analgesics. Corticosteroids have been shown to reduce and/or ameliorate the occurrence of abdominal pain which may be severe. We present two children with IgA vasculitis and severe abdominal pain despite corticosteroid administration, who responded promptly to intravenous γ globulin (IVIg) with complete resolution of their symptoms and review of the relevant medical literature. Given the toxicity and/or need for long-term administration of other second-line immunosuppressive therapies in corticosteroid-resistant IgA vasculitis, such as rituximab, cyclosporine, cyclophosphamide, azathioprine, or colchicine, we propose that IVIg may be a useful and safe treatment option, although randomized controlled clinical trials are needed in order to clarify its role in the treatment of abdominal pain in IgA vasculitis.
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Alonso de la Hoz J, Martínez Antequera CE, Fernández Manso B, Llorente Otones L, de Inocencio Arocena J. Hemorrhagic Bullous IgA Vasculitis (Schönlein-Henoch purpura), Does it Have a Worse Prognosis? REUMATOLOGIA CLINICA 2020; 17:S1699-258X(20)30195-9. [PMID: 32893147 DOI: 10.1016/j.reuma.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/17/2020] [Accepted: 07/08/2020] [Indexed: 06/11/2023]
Abstract
Haemorrhagic bullous form of IgA vasculitis (IgAV), or Schönlein-Henoch purpura, is an unusual presentation of the disease in paediatric patients (<2%). Blistering eruptions can sometimes be very striking, leading to hospital admissions and administration of high-dose steroids and even immunosuppressants. Review of the literature, however, does not suggest that this clinical form carries a worse prognosis than the other forms of IgAV. In fact, the prognosis of the disease depends on the organic involvement. We present the case of a 5-year-old girl that is very representative. She developed palpable purpura and four days later the skin lesions evolved into blistering lesions. She did not receive any anti-inflammatory nor immunosuppressive treatment and the lesions spontaneously subsided within 14 days. She did not develop any extracutaneous nor systemic involvement.
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Affiliation(s)
- Julia Alonso de la Hoz
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España.
| | | | | | - Lucía Llorente Otones
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - Jaime de Inocencio Arocena
- Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, España; Departamento de Salud Pública y Materno-Infantil, Universidad Complutense de Madrid, Madrid, España
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