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Wu L, Wang J, Song D, You Y, Wang Z. Haemophagocytic lymphohistiocytosis caused by GATA2 deficiency: a report on three patients. BMC Infect Dis 2024; 24:482. [PMID: 38730328 PMCID: PMC11088005 DOI: 10.1186/s12879-024-09356-3] [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: 07/05/2023] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Haemophagocytic lymphohistiocytosis (HLH) is a syndrome that occurs in patients with severe systemic hyperinflammation. GATA binding protein 2 (GATA2) is a transcription factor and key component in haematopoiesis and stem cell biology. CASE PRESENTATION Three patients with HLH, one with Mycobacterium avium infection, one with Epstein-Barr virus (EBV) infection, and one with Mycobacterium kansasii infection, were all subsequently found to have a defect in the GATA2 gene through genetic testing. CONCLUSIONS GATA2 deficiency syndrome should be considered in patients with myelodysplastic syndrome, nontuberculous mycobacterium infection and HLH. In addition, the GATA2 gene variant may be a genetic defect that could be the cause of the primary HLH. However, further studies are needed to confirm the role of GATA2 pathogenic variants in the pathogenesis of HLH.
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Affiliation(s)
- Lin Wu
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, No.95 Yongan Road Xicheng District, Beijing, China
| | - Jingshi Wang
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, No.95 Yongan Road Xicheng District, Beijing, China
| | - Deli Song
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, No.95 Yongan Road Xicheng District, Beijing, China
| | - Yahong You
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, No.95 Yongan Road Xicheng District, Beijing, China
| | - Zhao Wang
- Department of Haematology, Beijing Friendship Hospital, Capital Medical University, No.95 Yongan Road Xicheng District, Beijing, China.
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2
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Ricci S, Sarli WM, Lodi L, Canessa C, Lippi F, Dini D, Ferrari M, Pisano L, Sieni E, Indolfi G, Resti M, Azzari C. HLH as an additional warning sign of inborn errors of immunity beyond familial-HLH in children: a systematic review. Front Immunol 2024; 15:1282804. [PMID: 38415256 PMCID: PMC10896843 DOI: 10.3389/fimmu.2024.1282804] [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: 08/25/2023] [Accepted: 01/29/2024] [Indexed: 02/29/2024] Open
Abstract
Background Hemophagocytic Lymphohistiocytosis (HLH) is a rare and life-threatening condition characterized by a severe impairment of the immune homeostasis. While Familial-HLH (FHL) is a known cause, the involvement of other Inborn Errors of Immunity (IEI) in pediatric-HLH remains understudied. Objective This systematic review aimed to assess the clinical features, triggers, laboratory data, treatment, and outcomes of pediatric HLH patients with IEI other than FHL (IEInotFHL), emphasizing the importance of accurate identification and management. Methods A systematic search for studies meeting inclusion criteria was conducted in PubMed, EMBASE, MEDLINE, and Cochrane Central. Quality assessment was performed through JBI criteria. Results A comprehensive search yielded 108 records meeting inclusion criteria, involving 178 patients. We identified 46 different IEI according to IUIS 2022 Classification. Combined immunodeficiencies, immune dysregulation disorders, and phagocyte defects were the IEI most frequently associated with HLH. In 75% of cases, HLH preceded the IEI diagnosis, often with an unrecognized history of severe infections. Triggers reflected the specific infection susceptibilities within IEI groups. Liver and central nervous system involvement were less common than in FHL cases. Treatment approaches and outcomes varied, with limited long-term follow-up data, limiting the assessment of therapeutic efficacy across IEI groups. Conclusion A comprehensive evaluation encompassing immunological, infectious, and genetic aspects is essential in pediatric-HLH. Relying solely on FHL or EBV susceptibility disorders tests is insufficient, as diverse other IEI can contribute to HLH. Early recognition of HLH as a potential warning sign can guide timely diagnostic investigations and facilitate tailored therapeutic interventions for improved outcomes. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=371425, PROSPERO, CRD42022371425.
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Affiliation(s)
- Silvia Ricci
- Department of Health Sciences, University of Florence, Florence, Italy
- Immunology Division, Section of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Walter Maria Sarli
- Department of Health Sciences, University of Florence, Florence, Italy
- Immunology Division, Section of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Lorenzo Lodi
- Department of Health Sciences, University of Florence, Florence, Italy
- Immunology Division, Section of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Clementina Canessa
- Immunology Division, Section of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Francesca Lippi
- Immunology Division, Section of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Donata Dini
- Department of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Marta Ferrari
- Department of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Laura Pisano
- Department of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Elena Sieni
- Pediatric Hematology-Oncology Department, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Giuseppe Indolfi
- Department of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
- Department Neurofarba, University of Florence, Florence, Italy
| | - Massimo Resti
- Department of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Chiara Azzari
- Department of Health Sciences, University of Florence, Florence, Italy
- Immunology Division, Section of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
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3
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Thomsen MM, Skouboe MK, Møhlenberg M, Zhao J, de Keukeleere K, Heinz JL, Werner M, Hollensen AK, Lønskov J, Nielsen I, Carter-Timofte ME, Zhang B, Mikkelsen JG, Fisker N, Paludan SR, Assing K, Mogensen TH. Impaired STING Activation Due to a Variant in the E3 Ubiquitin Ligase AMFR in a Patient with Severe VZV Infection and Hemophagocytic Lymphohistiocytosis. J Clin Immunol 2024; 44:56. [PMID: 38277122 PMCID: PMC10817851 DOI: 10.1007/s10875-024-01653-5] [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: 05/12/2023] [Accepted: 01/06/2024] [Indexed: 01/27/2024]
Abstract
Varicella zoster virus (VZV) is a neurotropic alphaherpesvirus exclusively infecting humans, causing two distinct pathologies: varicella (chickenpox) upon primary infection and herpes zoster (shingles) following reactivation. In susceptible individuals, VZV can give rise to more severe clinical manifestations, including disseminated infection, pneumonitis, encephalitis, and vasculopathy with stroke. Here, we describe a 3-year-old boy in whom varicella followed a complicated course with thrombocytopenia, hemorrhagic and necrotic lesions, pneumonitis, and intermittent encephalopathy. Hemophagocytic lymphohistiocytosis (HLH) was strongly suspected and as the condition deteriorated, HLH therapy was initiated. Although the clinical condition improved, longstanding hemophagocytosis followed despite therapy. We found that the patient carries a rare monoallelic variant in autocrine motility factor receptor (AMFR), encoding a ubiquitin ligase involved in innate cytosolic DNA sensing and interferon (IFN) production through the cyclic GMP-AMP synthase-stimulator of IFN genes (cGAS-STING) pathway. Peripheral blood mononuclear cells (PBMCs) from the patient exhibited impaired signaling downstream of STING in response dsDNA and 2'3'-cGAMP, agonists of cGAS and STING, respectively, and fibroblasts from the patient showed impaired type I IFN responses and significantly increased VZV replication. Overexpression of the variant AMFR R594C resulted in decreased K27-linked STING ubiquitination compared to WT AMFR. Moreover, ImageStream technology revealed reduced STING trafficking from ER to Golgi in cells expressing the patient AMFR R594C variant. This was supported by a dose-dependent dominant negative effect of expression of the patient AMFR variant as measured by IFN-β reporter gene assay. Finally, lentiviral transduction with WT AMFR partially reconstituted 2'3'-cGAMP-induced STING-mediated signaling and ISG expression in patient PBMCs. This work links defective AMFR-STING signaling to severe VZV disease and hyperinflammation and suggests a direct role for cGAS-STING in the control of viral infections in humans. In conclusion, we describe a novel genetic etiology of severe VZV disease in childhood, also representing the first inborn error of immunity related to a defect in the cGAS-STING pathway.
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Affiliation(s)
- Michelle Mølgaard Thomsen
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Morten Kelder Skouboe
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Michelle Møhlenberg
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Jian Zhao
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Kerstin de Keukeleere
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Johanna Laura Heinz
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Marvin Werner
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Anne Kruse Hollensen
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Jonas Lønskov
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Ian Nielsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Baocun Zhang
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Niels Fisker
- Department of Pediatrics, Odense University Hospital, Odense, Denmark
| | - Søren R Paludan
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Kristian Assing
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Trine H Mogensen
- Department of Infectious Diseases, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark.
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.
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Huang X, Wu B, Wu D, Huang X, Shen M. Case Report: Missing zinc finger domains: hemophagocytic lymphohistiocytosis in a GATA2 deficiency patient triggered by non-tuberculous mycobacteriosis. Front Immunol 2023; 14:1191757. [PMID: 37680631 PMCID: PMC10482092 DOI: 10.3389/fimmu.2023.1191757] [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: 03/22/2023] [Accepted: 07/28/2023] [Indexed: 09/09/2023] Open
Abstract
Haploinsufficiency of GATA2, also known as GATA2 deficiency, leads to a wide spectrum of clinical manifestations. Here we described another 28-year-old man with a GATA2 variant who also suffered from hemophagocytic lymphohistiocytosis(HLH), who was finally diagnosed with HLH triggered by Mycobacterium avium bloodstream infection due to primary immunodeficiency. We reviewed GATA2 deficiency patients with HLH and found that GATA2 variants causing loss of zinc finger domains were associated with HLH, and erythema nodosa might be an accompanying symptom.
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Affiliation(s)
- Xin Huang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Bingxuan Wu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Di Wu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaoming Huang
- Department of General Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Min Shen
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Determinants of neurological syndromes caused by varicella zoster virus (VZV). J Neurovirol 2020; 26:482-495. [PMID: 32495195 PMCID: PMC7438298 DOI: 10.1007/s13365-020-00857-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/24/2020] [Accepted: 05/14/2020] [Indexed: 12/13/2022]
Abstract
Varicella zoster virus (VZV) is a pathogenic human herpes virus which causes varicella as a primary infection, following which it becomes latent in peripheral autonomic, sensory, and cranial nerve ganglionic neurons from where it may reactivate after decades to cause herpes zoster. VZV reactivation may also cause a wide spectrum of neurological syndromes, in particular, acute encephalitis and vasculopathy. While there is potentially a large number of coding viral mutations that might predispose certain individuals to VZV infections, in practice, a variety of host factors are the main determinants of VZV infection, both disseminated and specifically affecting the nervous system. Host factors include increasing age with diminished cell-mediated immunity to VZV, several primary immunodeficiency syndromes, secondary immunodeficiency syndromes, and drug-induced immunosuppression. In some cases, the molecular immunological basis underlying the increased risk of VZV infections has been defined, in particular, the role of POL III mutations, but in other cases, the mechanisms have yet to be determined. The role of immunization in immunosuppressed individuals as well as its possible efficacy in preventing both generalized and CNS-specific infections will require further investigation to clarify in such patients.
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6
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A Panoply of Rheumatological Manifestations in Patients with GATA2 Deficiency. Sci Rep 2020; 10:8305. [PMID: 32433473 PMCID: PMC7239896 DOI: 10.1038/s41598-020-64852-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/23/2020] [Indexed: 12/01/2022] Open
Abstract
Purpose: To characterize rheumatological manifestations of GATA2 deficiency. Methods: Single-center, retrospective review of 157 patients with GATA2 deficiency. Disease course, laboratory results, and imaging findings were extracted. In-person rheumatological assessments were performed on selected, available patients. A literature search of four databases was conducted to identify additional cases. Results: Rheumatological findings were identified in 28 patients, out of 157 cases reviewed (17.8%). Twenty-two of those patients (78.6%) reported symptom onset prior to or in conjunction with the molecular diagnosis of GATA2 deficiency. Notable rheumatological manifestations included: piezogenic pedal papules (PPP), joint hyperextensibility, early onset osteoarthritis, ankylosing spondylitis, and seronegative erosive rheumatoid arthritis. In peripheral blood of patients with rheumatological manifestations and GATA2 deficiency, CD4+ CD3+ helper T cells and naïve CD3+ CD4+ CD62L+ CD45RA+ helper T cell subpopulation fractions were significantly lower, while CD8+ cytotoxic T cell fractions were significantly higher, compared to those without rheumatological manifestations and with GATA2 deficiency. No changes in CD19, CD3, or NK populations were observed. Conclusion: GATA2 deficiency is associated with a broad spectrum of rheumatological disease manifestations. Low total helper T lymphocyte proportions and low naïve helper T cell proportions are associated with those most at risk of overt rheumatological manifestations. Further, PPP and joint hyperextensibility may explain some of the nonimmunologically-mediated joint problems encountered in patients with GATA2 deficiency. This catalogue suggests that rheumatological manifestations and immune dysregulation are relatively common in GATA2 deficiency.
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7
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The genetics of macrophage activation syndrome. Genes Immun 2020; 21:169-181. [PMID: 32291394 DOI: 10.1038/s41435-020-0098-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/13/2020] [Accepted: 03/27/2020] [Indexed: 12/12/2022]
Abstract
Macrophage activation syndrome (MAS), or secondary hemophagocytic lymphohistiocytosis (HLH), is a cytokine storm syndrome associated with multi-organ system dysfunction and high mortality rates. Laboratory and clinical features resemble primary HLH, which arises in infancy (1 in 50,000 live births) from homozygous mutations in various genes critical to the perforin-mediated cytolytic pathway employed by NK cells and cytotoxic CD8 T lymphocytes. MAS/secondary HLH is about ten times more common and typically presents beyond infancy extending into adulthood. The genetics of MAS are far less defined than for familial HLH. However, the distinction between familial HLH and MAS/secondary HLH is blurred by the finding of heterozygous perforin-pathway mutations in MAS patients, which may function as hypomorphic or partial dominant-negative alleles and contribute to disease pathogenesis. In addition, mutations in a variety of other pathogenic pathways have been noted in patients with MAS/secondary HLH. Many of these genetically disrupted pathways result in a similar cytokine storm syndrome, and can be broadly categorized as impaired viral control (e.g., SH2P1A), dysregulated inflammasome activity (e.g., NLRC4), other immune defects (e.g., IKBKG), and dysregulated metabolism (e.g., LIPA). Collectively these genetic lesions likely combine with states of chronic inflammation, as seen in various rheumatic diseases (e.g., still disease), with or without identified infections, to result in MAS pathology as explained by the threshold model of disease. This emerging paradigm may ultimately support genetic risk stratification for high-risk chronic and even acute inflammatory disorders. Moving forward, continued whole-exome and -genome sequencing will likely identify novel MAS gene associations, as well as noncoding mutations altering levels of gene expression.
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8
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Human inborn errors of immunity to herpes viruses. Curr Opin Immunol 2020; 62:106-122. [PMID: 32014647 DOI: 10.1016/j.coi.2020.01.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/16/2019] [Accepted: 01/07/2020] [Indexed: 12/16/2022]
Abstract
Infections with any of the nine human herpes viruses (HHV) can be asymptomatic or life-threatening. The study of patients with severe diseases caused by HHVs, in the absence of overt acquired immunodeficiency, has led to the discovery or diagnosis of various inborn errors of immunity. The related inborn errors of adaptive immunity disrupt α/β T-cell rather than B-cell immunity. Affected patients typically develop HHV infections in the context of other infectious diseases. However, this is not always the case, as illustrated by inborn errors of SAP-dependent T-cell immunity to EBV-infected B cells. The related inborn errors of innate immunity disrupt leukocytes other than T and B cells, non-hematopoietic cells, or both. Patients typically develop only a single type of infection due to HHV, although, again, this is not always the case, as illustrated by inborn errors of TLR3 immunity resulting in HSV1 encephalitis in some patients and influenza pneumonitis in others. Most severe HHV infections in otherwise healthy patients remains unexplained. The forward human genetic dissection of isolated and syndromic HHV-driven illnesses will establish the molecular and cellular basis of protective immunity to HHVs, paving the way for novel diagnosis and management strategies.
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Mangioni D, Grasselli G, Abbruzzese C, Muscatello A, Gori A, Bandera A. Adjuvant treatment of severe varicella pneumonia with intravenous varicella zoster virus-specific immunoglobulins. Int J Infect Dis 2019; 85:70-73. [PMID: 31132473 DOI: 10.1016/j.ijid.2019.05.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/13/2019] [Accepted: 05/20/2019] [Indexed: 12/11/2022] Open
Abstract
Varicella zoster virus (VZV) pneumonia is associated with significant mortality, especially in the immunocompromised host. VZV-specific immunoglobulins (VZIG) are currently used as post-exposure prophylaxis for at-risk patients, but not as adjunctive therapy. A novel case of VZV pneumonia in an immunocompromised patient, treated successfully with intravenous VZIG in combination with acyclovir, is reported here.
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Affiliation(s)
- Davide Mangioni
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, School of Medicine and Surgery, University of Milan, Milan, Italy.
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, School of Medicine and Surgery, University of Milan, Milan, Italy; Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Abbruzzese
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Muscatello
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, School of Medicine and Surgery, University of Milan, Milan, Italy
| | - Alessandra Bandera
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, School of Medicine and Surgery, University of Milan, Milan, Italy
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