1
|
Wijburg MT, Warnke C, McGuigan C, Koralnik IJ, Barkhof F, Killestein J, Wattjes MP. Pharmacovigilance during treatment of multiple sclerosis: early recognition of CNS complications. J Neurol Neurosurg Psychiatry 2021; 92:177-188. [PMID: 33229453 DOI: 10.1136/jnnp-2020-324534] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/27/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022]
Abstract
An increasing number of highly effective disease-modifying therapies for people with multiple sclerosis (MS) have recently gained marketing approval. While the beneficial effects of these drugs in terms of clinical and imaging outcome measures is welcomed, these therapeutics are associated with substance-specific or group-specific adverse events that include severe and fatal complications. These adverse events comprise both infectious and non-infectious complications that can occur within, or outside of the central nervous system (CNS). Awareness and risk assessment strategies thus require interdisciplinary management, and robust clinical and paraclinical surveillance strategies. In this review, we discuss the current role of MRI in safety monitoring during pharmacovigilance of patients treated with (selective) immune suppressive therapies for MS. MRI, particularly brain MRI, has a pivotal role in the early diagnosis of CNS complications that potentially are severely debilitating and may even be lethal. Early recognition of such CNS complications may improve functional outcome and survival, and thus knowledge on MRI features of treatment-associated complications is of paramount importance to MS clinicians, but also of relevance to general neurologists and radiologists.
Collapse
Affiliation(s)
- Martijn T Wijburg
- Department of Neurology, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands .,Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Clemens Warnke
- Department of Neurology, University Hospital Köln, University of Cologne, Köln, Germany.,Department of Neurology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Christopher McGuigan
- Department of Neurology, St Vincent's University Hospital & University College Dublin, Dublin, Ireland
| | - Igor J Koralnik
- Department of Neurological Sciences, Division of Neuroinfectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
| | - Frederik Barkhof
- Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Institutes of Neurology and Healthcare Engineering, UCL, London, UK
| | - Joep Killestein
- Department of Neurology, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mike P Wattjes
- Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| |
Collapse
|
2
|
Nematollahi S, Dioverti-Prono V. Cryptococcal infection in haematologic malignancies and haematopoietic stem cell transplantation. Mycoses 2020; 63:1033-1046. [PMID: 32740974 DOI: 10.1111/myc.13153] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 12/18/2022]
Abstract
This review summarises both the recent and relevant studies about cryptococcal infections in haematologic malignancies and haematopoietic stem cell transplantation. Although uncommon in this patient population, this infection carries a high mortality, especially if left untreated. Given the limited data, we draw some conclusions with respect to management from the solid organ transplantation and HIV-infected literature. Herein, we discuss cryptococcosis with a particular attention to its background, epidemiology, risk factors, clinical presentation, diagnosis, treatment and prevention in this group.
Collapse
Affiliation(s)
- Saman Nematollahi
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Veronica Dioverti-Prono
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
3
|
Mohamedy I, Forrest GN. Cryptococcal Immune Reconstitution Inflammatory Syndrome: a Paradoxical Response to a Complex Organism. Curr Treat Options Infect Dis 2020; 12:13-29. [DOI: 10.1007/s40506-020-00210-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
4
|
Temfack E, Boyer-Chammard T, Lawrence D, Delliere S, Loyse A, Lanternier F, Alanio A, Lortholary O. New Insights Into Cryptococcus Spp. Biology and Cryptococcal Meningitis. Curr Neurol Neurosci Rep 2019; 19:81. [PMID: 31673881 DOI: 10.1007/s11910-019-0993-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW Defective cell-mediated immunity is a major risk factor for cryptococcosis, a fatal disease if untreated. Cryptococcal meningitis (CM), the main presentation of disseminated disease, occurs through hematogenous spread to the brain from primary pulmonary foci, facilitated by yeast virulence factors. We revisit remarkable recent improvements in the prevention, diagnosis and management of CM. RECENT FINDINGS Cryptococcal antigen (CrAg), main capsular polysaccharide of Cryptococcus spp. is detectable in blood and cerebrospinal fluid of infected patients with point of care lateral flow assays. Recent World Health Organization guidelines recommend 7-day amphotericin B plus flucytosine, then 7-day high dose (1200 mg/day) fluconazole for induction treatment of HIV-associated CM. Management of raised intracranial pressure, a consequence of CM, should rely mainly on daily therapeutic lumbar punctures until normalisation. In HIV-associated CM, following introduction of antifungal therapy, (re)initiation of antiretroviral therapy should be delayed by 4-6 weeks to prevent immune reconstitution inflammatory syndrome, common in CM. CM is a fatal disease whose diagnosis has recently been simplified. Treatment should always include antifungal combination therapy and management of raised intracranial pressure. Screening for immune deficiency should be mandatory in all patients with cryptococcosis.
Collapse
|
5
|
Campagna A, Gianfelici V, Antolino G, Pelliccia S, Galassi G, Piedimonte M, Bianchi MP, Mirabilii S, Ricciardi MR, Tasca G, Iorio R, Conte E, Ferrari A, La Verde G, Tafuri A. Central nervous system immune reconstitution inflammatory syndrome after autologous stem cell transplantation. Bone Marrow Transplant 2019; 55:268-271. [PMID: 31068657 DOI: 10.1038/s41409-019-0532-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/08/2019] [Accepted: 02/20/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Alessia Campagna
- Hematology, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Valentina Gianfelici
- Laboratory of Cell Kinetics and Applied Proteomics, Faculty of Medicine and Psychology, Department of Clinic and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giusy Antolino
- Hematology, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Sabrina Pelliccia
- Hematology, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Giulia Galassi
- Hematology, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Monica Piedimonte
- Laboratory of Cell Kinetics and Applied Proteomics, Faculty of Medicine and Psychology, Department of Clinic and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Maria Paola Bianchi
- Laboratory of Cell Kinetics and Applied Proteomics, Faculty of Medicine and Psychology, Department of Clinic and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Simone Mirabilii
- Laboratory of Cell Kinetics and Applied Proteomics, Faculty of Medicine and Psychology, Department of Clinic and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Maria Rosaria Ricciardi
- Laboratory of Cell Kinetics and Applied Proteomics, Faculty of Medicine and Psychology, Department of Clinic and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giorgio Tasca
- Neurology, Department of Aging, Neurological and Head-Neck Sciences, A. Gemelli University Hospital, IRCCS, Rome, Italy
| | - Raffaele Iorio
- Neurology, Department of Aging, Neurological and Head-Neck Sciences, A. Gemelli University Hospital, IRCCS, Rome, Italy
| | - Esmeralda Conte
- Hematology, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Antonella Ferrari
- Hematology, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Giacinto La Verde
- Hematology, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Agostino Tafuri
- Hematology, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy. .,Laboratory of Cell Kinetics and Applied Proteomics, Faculty of Medicine and Psychology, Department of Clinic and Molecular Medicine, Sapienza University of Rome, Rome, Italy.
| |
Collapse
|
6
|
Baddley JW, Forrest GN. Cryptococcosis in solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13543. [PMID: 30900315 DOI: 10.1111/ctr.13543] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 02/15/2019] [Accepted: 03/15/2019] [Indexed: 02/06/2023]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of cryptococcosis in the pre- and post-transplant period. The current update now includes a discussion of cryptococcosis, which is the third most common invasive fungal infection in SOT recipients. Infection often occurs a year after transplantation; however, early infections occur and donor-derived infections have been described within 3 months after transplant. There are two main species that cause infection, Cryptococcus neoformans and C gattii. Clinical onset may be insidious, but headaches, fevers, and mental status changes should warrant diagnostic testing. The lateral flow cryptococcal antigen assay is now the preferred test from serum and cerebrospinal fluid due to its rapidity, accuracy, and cost. A lumbar puncture with measurement of opening pressure is recommended for patients with suspected or proven cryptococcosis. Lipid amphotericin B plus 5-flucytosine is used as initial treatment of meningitis, disseminated infection, and moderate-to-severe pulmonary infection, followed by fluconazole as consolidation therapy. Fluconazole is effective for mild-to-moderate pulmonary infection. Immunosuppression reduction as part of management may lead to immune reconstitution syndrome that may resemble active disease.
Collapse
Affiliation(s)
- John W Baddley
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | | | | |
Collapse
|
7
|
Dellière S, Guery R, Candon S, Rammaert B, Aguilar C, Lanternier F, Chatenoud L, Lortholary O. Understanding Pathogenesis and Care Challenges of Immune Reconstitution Inflammatory Syndrome in Fungal Infections. J Fungi (Basel) 2018; 4:E139. [PMID: 30562960 PMCID: PMC6308948 DOI: 10.3390/jof4040139] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/14/2018] [Accepted: 12/15/2018] [Indexed: 12/16/2022] Open
Abstract
Immune deficiency of diverse etiology, including human immunodeficiency virus (HIV), antineoplastic agents, immunosuppressive agents used in solid organ recipients, immunomodulatory therapy, and other biologics, all promote invasive fungal infections. Subsequent voluntary or unintended immune recovery may induce an exaggerated inflammatory response defining immune reconstitution inflammatory syndrome (IRIS), which causes significant mortality and morbidity. Fungal-associated IRIS raises several diagnostic and management issues. Mostly studied with Cryptococcus, it has also been described with other major fungi implicated in human invasive fungal infections, such as Pneumocystis, Aspergillus, Candida, and Histoplasma. Furthermore, the understanding of IRIS pathogenesis remains in its infancy. This review summarizes current knowledge regarding the clinical characteristics of IRIS depending on fungal species and existing strategies to predict, prevent, and treat IRIS in this patient population, and tries to propose a common immunological background to fungal IRIS.
Collapse
Affiliation(s)
- Sarah Dellière
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
| | - Romain Guery
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
| | - Sophie Candon
- Medical School, Paris-Descartes University, INSERM U1151-CNRS UMR 8253APHP, Necker-Enfants Malades Hospital, APHP, Clinical Immunology, 75015 Paris, France.
| | - Blandine Rammaert
- Medical School, Poitiers University, Poitiers, France; Poitiers University Hospital, Infectious Disease Unit, Poitiers, France; INSERM U1070, 86022 Poitiers, France.
| | - Claire Aguilar
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
| | - Fanny Lanternier
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
- Pasteur Institute, Molecular Mycology Unit, National Reference Center for Invasive Fungal Disease and Antifungals, CNRS UMR 2000, 75015 Paris, France.
| | - Lucienne Chatenoud
- Medical School, Paris-Descartes University, INSERM U1151-CNRS UMR 8253APHP, Necker-Enfants Malades Hospital, APHP, Clinical Immunology, 75015 Paris, France.
| | - Olivier Lortholary
- Medical School, Paris-Descartes University, APHP, Necker-Enfants Malades Hospital, Infectious Disease Center Necker-Pasteur, IHU Imagine, 75015 Paris, France.
- Pasteur Institute, Molecular Mycology Unit, National Reference Center for Invasive Fungal Disease and Antifungals, CNRS UMR 2000, 75015 Paris, France.
| |
Collapse
|
8
|
Abstract
Hematopoietic cell transplantation (HCT) is widely performed for neoplastic and non-neoplastic diseases. HCT involves intravenous infusion of hematopoietic progenitor cells from human leukocyte antigen (HLA)-matched donor (allogeneic) or from the patient (autologous). Before HCT, the patient is prepared with high dose chemotherapy and/or radiotherapy to destroy residual malignant cells and to reduce immunologic resistance. After HCT, chemotherapy is used to prevent graft rejection and graft versus host disease (GvHD). Neurological complications are related to the type of HCT, underlying disease, toxicity of the conditioning regimens, immunosuppression caused by conditioning regimens, vascular complications generated by thrombocytopenia and/or coagulopathy, GvHD and inappropriate immune response. In this review, neurological complications are presented according to time of onset after HCT: (1) early complications (in the first month) - related to harvesting of stem cells, during conditioning (drug toxicity, posterior reversible encephalopathy syndrome), related to pancytopenia, (2) intermediate phase complications (second to sixth month) - central nervous system infections caused by prolonged neutropenia and progressive multifocal leukoencephalopathy due to JC virus, (3) late phase complications (after sixth month) - neurological complications of GvHD, second neoplasms and relapses of the original disease.
Collapse
Affiliation(s)
- Adriana Octaviana Dulamea
- University of Medicine and Pharmacy Carol Davila; Department of Neurology, Fundeni Clinical Institute, Bucharest, Romania
| | - Ioana Gabriela Lupescu
- University of Medicine and Pharmacy Carol Davila; Radiology and Medical Imaging Department, Fundeni Clinical Institute, Bucharest, Romania
| |
Collapse
|
9
|
Kyriakidis I, Tragiannidis A, Zündorf I, Groll AH. Invasive fungal infections in paediatric patients treated with macromolecular immunomodulators other than tumour necrosis alpha inhibitors. Mycoses 2017; 60:493-507. [DOI: 10.1111/myc.12621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Ioannis Kyriakidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Infectious Disease Research Program; Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology; University Childrens Hospital; Muenster Germany
| |
Collapse
|
10
|
Abstract
INTRODUCTION Opportunistic mycoses remain a significant complication in organ recipients. Areas covered: This review is an evidence-based presentation of current state-of-knowledge and our perspective on recent developments in the field Expert commentary: Invasive fungal infections are associated with reduced allograft and patient survival, increase in healthcare resource utilization, and newly appreciated but largely unrecognized immunologic sequelae, such as immune reconstitution syndrome. Given adverse outcomes associated with established infections, prophylaxis is a widely used strategy for the prevention of these infections. Currently available biomarkers that detect circulating fungal cell wall constituents i.e., galactomannan and 1, 3-β-D-glucan have not proven to be beneficial as screening tools for employing targeted prophylaxis or as diagnostic assays in this patient population. However, subsets of patients at risk for opportunistic fungal infections can be identified based on clinically identifiable characteristics or events. Preventive strategies targeted towards these patients are a rational approach for optimizing outcomes.
Collapse
Affiliation(s)
- Palash Samanta
- a Division of Infectious Diseases , University of Pittsburgh , Pittsburgh , PA , USA
| | - Nina Singh
- b Division of Infectious Diseases , University of Pittsburgh and VA Pittsburgh Medical Center , Pittsburgh , PA , USA
| |
Collapse
|
11
|
Meya DB, Manabe YC, Boulware DR, Janoff EN. The immunopathogenesis of cryptococcal immune reconstitution inflammatory syndrome: understanding a conundrum. Curr Opin Infect Dis 2016; 29:10-22. [PMID: 26658650 DOI: 10.1097/QCO.0000000000000224] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Cryptococcal meningitis causes significant mortality among HIV-infected patients, despite antifungal therapy and use of antiretroviral therapy (ART). In patients with cryptococcal meningitis, ART is often complicated by immune reconstitution inflammatory syndrome (IRIS), manifesting as unmasking of previously unrecognized subclinical infection (unmasking CM-IRIS) or paradoxical worsening of symptoms in the central nervous system after prior improvement with antifungal therapy (paradoxical CM-IRIS). We review our current understanding of the pathogenesis of this phenomenon, focusing on unifying innate and adaptive immune mechanisms leading to the development of this often fatal syndrome. RECENT FINDINGS We propose that HIV-associated CD4 T-cell depletion, chemokine-driven trafficking of monocytes into cerebrospinal fluid in response to cryptococcal meningitis, and poor localized innate cytokine responses lead to inadequate cryptococcal killing and clearance of the fungus. Subsequent ART-associated recovery of T-cell signaling and restored cytokine responses, characterized by IFN-γ production, triggers an inflammatory response. The inflammatory response triggered by ART is dysregulated because of impaired homeostatic and regulatory mechanisms, culminating in the development of CM-IRIS. SUMMARY Despite our incomplete understanding of the immunopathogenesis of CM-IRIS, emerging data exploring innate and adaptive immune responses could be exploited to predict, prevent and manage CM-IRIS and associated morbid consequences.
Collapse
|
12
|
Chan KL, Lokan J, Tam CS, Lew TE, Prince HM. Central nervous system immune reconstitution inflammatory syndrome after ibrutinib therapy for Richter transformation. Leuk Lymphoma 2016; 58:207-210. [PMID: 27326828 DOI: 10.1080/10428194.2016.1179298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Kah-Lok Chan
- a Department of Haematology , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Julie Lokan
- b Department of Pathology , Austin Hospital , Melbourne , Australia
| | - Constantine S Tam
- a Department of Haematology , Peter MacCallum Cancer Centre , Melbourne , Australia.,c The University of Melbourne , Melbourne , Australia
| | | | - H Miles Prince
- a Department of Haematology , Peter MacCallum Cancer Centre , Melbourne , Australia.,c The University of Melbourne , Melbourne , Australia
| |
Collapse
|
13
|
Schmalzle SA, Buchwald UK, Gilliam BL, Riedel DJ. Cryptococcus neoformans infection in malignancy. Mycoses 2016; 59:542-52. [PMID: 26932366 DOI: 10.1111/myc.12496] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/10/2016] [Accepted: 02/04/2016] [Indexed: 12/25/2022]
Abstract
Cryptococcosis is an opportunistic invasive fungal infection that is well described and easily recognised when it occurs as meningitis in HIV-infected persons. Malignancy and its treatment may also confer a higher risk of infection with Cryptococcus neoformans, but this association has not been as well described. A case of cryptococcosis in a cancer patient is presented, and all cases of coincident C. neoformans infection and malignancy in adults published in the literature in English between 1970 and 2014 are reviewed. Data from these cases were aggregated in order to describe the demographics, type of malignancy, site of infection, clinical manifestations, treatment and outcomes of cryptococcosis in patients with cancer. Haematologic malignancies accounted for 82% of cases, with lymphomas over-represented compared to US population data (66% vs. 53% respectively). Cryptococcosis was reported rarely in patients with solid tumours. Haematologic malignancy patients were more likely to have central nervous system (P < 0.001) or disseminated disease (P < 0.001), receive Amphotericin B as part of initial therapy (P = 0.023), and had higher reported mortality rates than those with solid tumours (P = 0.222). Providers should have heightened awareness of the possibility of cryptococcosis in patients with haematologic malignancy presenting with infection.
Collapse
Affiliation(s)
- Sarah A Schmalzle
- University of Maryland School of Medicine Division of Infectious Diseases, Institute of Human Virology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
| | - Ulrike K Buchwald
- University of Maryland School of Medicine Division of Infectious Diseases, Institute of Human Virology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
| | - Bruce L Gilliam
- University of Maryland School of Medicine Division of Infectious Diseases, Institute of Human Virology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
| | - David J Riedel
- University of Maryland School of Medicine Division of Infectious Diseases, Institute of Human Virology, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
| |
Collapse
|
14
|
Gupta M, Jafri K, Sharim R, Silverman S, Sindher SB, Shahane A, Kwan M. Immune reconstitution inflammatory syndrome associated with biologic therapy. Curr Allergy Asthma Rep 2015; 15:499. [PMID: 25504263 DOI: 10.1007/s11882-014-0499-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The use of biologics in the treatment of autoimmune disease, cancer, and other immune conditions has revolutionized medical care in these areas. However, there are drawbacks to the use of these medications including increased susceptibility to opportunistic infections. One unforeseen risk once opportunistic infection has occurred with biologic use is the onset of immune reconstitution inflammatory syndrome (IRIS) upon drug withdrawal. Although originally described in human immunodeficiency virus (HIV) patients receiving highly active antiretroviral therapy, it has become clear that IRIS may occur when recovery of immune function follows opportunistic infection in the setting of previous immune compromise/suppression. In this review, we draw attention to this potential pitfall on the use of biologic drugs.
Collapse
Affiliation(s)
- Malika Gupta
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | | | | | | | | |
Collapse
|
15
|
Bahr NC, Wallace J, Frosch AEP, Boulware DR. Unmasking Cryptococcal Meningitis Immune Reconstitution Inflammatory Syndrome due to Granulocyte Colony-Stimulating Factor Use in a Patient with a Poorly Differentiated Germ Cell Neoplasm. Case Rep Oncol 2014; 7:1-5. [PMID: 24575007 PMCID: PMC3934776 DOI: 10.1159/000357666] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cryptococcal meningitis immune reconstitution inflammatory syndrome (IRIS) is frequently seen in patients with HIV and less frequently in patients on immune suppressive medications for other conditions. Here, we describe the first reported case of unmasking cryptococcal IRIS due to granulocyte colony-stimulating factor used in an HIV-negative patient with chemotherapy-induced neutropenia.
Collapse
Affiliation(s)
- Nathan C Bahr
- Department of MedicineCenter for Infectious Diseases and Microbiology Translational Research, Minn., USA ; Center for Infectious Diseases and Microbiology Translational Research, Minn., USA ; Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minn., USA
| | - James Wallace
- Department of MedicineCenter for Infectious Diseases and Microbiology Translational Research, Minn., USA
| | - Anne E P Frosch
- Department of MedicineCenter for Infectious Diseases and Microbiology Translational Research, Minn., USA ; Center for Infectious Diseases and Microbiology Translational Research, Minn., USA ; Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minn., USA
| | - David R Boulware
- Department of MedicineCenter for Infectious Diseases and Microbiology Translational Research, Minn., USA ; Center for Infectious Diseases and Microbiology Translational Research, Minn., USA ; Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minn., USA
| |
Collapse
|
16
|
Abstract
Hematopoietic cell transplantation (HCT) is the preferred treatment for an expanding range of neoplastic and nonmalignant conditions. Increasing numbers of solid organ transplantations (SOTs) add an additional population of immunosuppressed patients with multiple potential neurological problems. While the spectrum of neurological complications varies with conditioning procedure and hematopoietic cell or solid organ source, major neurological complications occur with all transplantation procedures. This 2 part review emphasizes a practical consultative approach to central and peripheral nervous system problems related to HCT or SOT with clinical and neuroimaging examples from the authors' institutional experience with the following conditions: the diversity of manifestations of common infections such as varicella zoster virus, Aspergillus, and progressive multifocal leukoencephalopathy (PML), drug therapy-related complications, stroke mechanisms, the spectrum of graft versus host disease (GVHD), and neurologically important syndromes of immune reconstitution inflammatory syndrome (IRIS), posterior reversible encephalopathy syndrome (PRES), and posttransplantation lymphoproliferative disorder (PTLD). These complications preferentially occur at specific intervals after HCT and SOT, and neurological consultants must recognize an extensive spectrum of syndromes in order to effect timely diagnosis and expedite appropriate treatment.
Collapse
Affiliation(s)
- Amy A Pruitt
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | | | | |
Collapse
|
17
|
Affiliation(s)
- J W Baddley
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | | |
Collapse
|
18
|
Abstract
Cryptococcal meningitis is a life-threatening opportunistic fungal infection in both HIV-infected and HIV-uninfected patients. According to the most recent taxonomy, the responsible fungus is classified into a complex that contains two species (Cryptococcus neoformans and C. gattii), with eight major molecular types. HIV infection is recognized worldwide as the main underlying disease responsible for the development of cryptococcal meningitis (accounting for 80-90% of cases). In several areas of sub-Saharan Africa with the highest HIV prevalence despite the recent expansion of antiretroviral (ARV) therapy programme, cryptococcal meningitis is the leading cause of community-acquired meningitis with a high mortality burden. Although cryptococcal meningitis should be considered a neglected disease, a large body of knowledge has been developed by several studies performed in recent years. This paper will focus especially on new clinical aspects such as immune reconstitution inflammatory syndrome, advances on management, and strategies for the prevention of clinical disease.
Collapse
|
19
|
Affiliation(s)
- Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia.
| | | |
Collapse
|
20
|
Masutani K, Shapiro R, Basu A, Tan H, Ninomiya T, Randhawa P. Putative episodes of T-cell-mediated rejection in patients with sustained BK viruria but no viremia. Transplantation. 2012;94:43-49. [PMID: 22691957 DOI: 10.1097/tp.0b013e318253e7a4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Polyomavirus BK (BKV) infection characterized by viruria alone is considered to be of little clinical significance, but this issue has not been systematically studied. METHODS We studied 230 patients with sustained viruria from whom multiple samples taken after a median of 877 days (range, 24-2739) showed no progression to viremia or nephropathy. Biopsies satisfying Banff thresholds for inflammation and tubulitis in the presence of viruria but negative for BKV stains were designated as putative T-cell-mediated acute rejection. RESULTS Compared with no viruria (n=515), sustained viruria was associated with more putative rejection episodes (0.62 vs. 0.33 per patient, P=0.006) and greater incidence of steroid resistance (36.2% vs. 19.6%, P=0.002). Most putative rejection episodes (52.1%) occurred concurrently with viruria, with a minority before (7.8%) or after (40.1%) BKV clearance. Steroid resistance was more frequent in putative rejection with concurrent viruria (48.6%), compared with rejection before (9.1%) or after (26.0%) viral clearance. These observations remained valid even on a separate analysis of patients with BKV load 1E+07 copies per mL or less. As assessed by the slope of reciprocal serum creatinine levels, accelerated deterioration of graft function resulted from rejection episodes occurring more than 2 years after transplantation. CONCLUSIONS These observations indicate that intrarenal viral replication in sustained viruria is frequently associated with putative acute rejection. The implications of this association on the development of immune tolerance deserve further investigation.
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW This article provides a practical clinical approach to potential CNS infections in patients with cancer, discusses problematic presentations of posterior reversible encephalopathy syndrome and immune reconstitution inflammatory syndrome, and includes specific testing and treatment recommendations for bacterial meningitis, invasive fungal infections, and opportunistic viral infections. RECENT FINDINGS The major deficits predisposing patients with cancer to CNS infection are neutropenia, barrier disruption, B-lymphocyte or immunoglobulin deficiency, and impaired T lymphocyte-mediated immunity. Evolving patterns of drug resistance and prophylactic antimicrobial regimens have altered the timing and range of organisms causing infections. Increasingly intensive immunosuppression has made new groups of patients vulnerable to infections such as progressive multifocal leukoencephalopathy. New MRI sequences offer the potential to diagnose such infections earlier, at a stage when they are more treatable. SUMMARY Despite improved prophylactic and therapeutic antibiotic regimens, CNS infections remain an important source of morbidity and mortality among several cancer patient groups, particularly those patients undergoing craniotomy and those with hematologic malignancies receiving either hematopoietic cell transplantation or other intensive chemotherapy regimens.
Collapse
Affiliation(s)
- Amy A Pruitt
- University of Pennsylvania, 3400 Spruce St, Department of Neurology, Philadelphia, PA 19104, USA.
| |
Collapse
|
22
|
Meyer-Olson D, Ernst D, Stoll M. [Immune reconstitution syndrome]. Z Rheumatol 2012; 71:187-98. [PMID: 22527213 DOI: 10.1007/s00393-011-0858-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) represents a heterogeneous group of conditions. Whilst they typically present in HIV-infected patients with advanced immunodeficiency, IRIS have also been described in HIV-negative patients with immune reconstitution due to other causes of immunosuppression. Frequently IRIS results from an immune response against underlying infection (pathogen-associated IRIS). However, IRIS might become evident during immune reconstitution without an underlying pathogen such as a sarcoid-like illness or an autoimmune thyropathy. Here we report on the epidemiology and risk factors of IRIS along with diagnosis and management of this clinically important inflammatory syndrome.
Collapse
|
23
|
Maziarz EK, Perfect JR. IRIS and Fungal Infections: What Have We Learned? Curr Fungal Infect Rep 2012. [DOI: 10.1007/s12281-011-0075-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
|
24
|
|
25
|
Affiliation(s)
- N Singh
- VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, PA, USA. nis5+@pitt.edu
| | | | | |
Collapse
|
26
|
Cadena J, Thompson GR, Ho TT, Medina E, Hughes DW, Patterson TF. Immune reconstitution inflammatory syndrome after cessation of the tumor necrosis factor α blocker adalimumab in cryptococcal pneumonia. Diagn Microbiol Infect Dis 2009; 64:327-30. [DOI: 10.1016/j.diagmicrobio.2009.03.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 03/16/2009] [Accepted: 03/17/2009] [Indexed: 12/31/2022]
|
27
|
Abstract
PURPOSE OF REVIEW Expanding access to antiretroviral treatment has dramatically improved the long-term prognosis of patients with HIV-associated cryptococcal disease who survive the acute infection. However, the incidence and acute mortality of HIV-associated cryptococcal meningitis remain high. In this context, this review summarizes urgently needed recent work aimed at improving the acute management of cryptococcal infection in immunocompromised hosts. RECENT FINDINGS Studies have started to optimize antifungal regimens and address the complications of raised cerebrospinal fluid pressure and cryptococcal immune reconstitution syndrome. Amphotericin B at 1 mg/kg per day has been shown to be more rapidly fungicidal than the standard dose of 0.7 mg/kg per day, and new data support the importance of combination therapy with flucytosine. Amphotericin B and fluconazole at 800 mg is an alternative combination that appears superior to amphotericin B alone. At a dosage of 400 mg per day, fluconazole alone is much less rapidly fungicidal than amphotericin B and is associated with the development of secondary resistance. SUMMARY Recent findings support the use of rapidly fungicidal initial antifungal therapy with amphotericin B-based combination treatment. Where amphotericin B treatment is not yet feasible, studies are needed to optimize oral regimens. Based on accumulating data on rate of clearance of infection, the most promising new regimens in terms of fungicidal activity and safety could be selected for clinical endpoint trials.
Collapse
|
28
|
Singh N, Dromer F, Perfect JR, Lortholary O. Cryptococcosis in solid organ transplant recipients: current state of the science. Clin Infect Dis 2008; 47:1321-7. [PMID: 18840080 DOI: 10.1086/592690] [Citation(s) in RCA: 152] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Cryptococcosis remains a significant opportunistic infection in solid organ transplant recipients. Disease presentation and outcomes may be affected by, among other factors, the use of calcineurin inhibitor immunosuppressive agents. It is being increasingly recognized that rapid reversal of immunosuppression in transplant recipients treated for cryptococcosis incurs the risk of immune reconstitution inflammatory syndrome, which resembles worsening disease or relapse. This review summarizes the current state of knowledge regarding cryptococcosis in transplant recipients and highlights areas where future investigations are needed to further optimize outcomes for these patients.
Collapse
Affiliation(s)
- Nina Singh
- University of Pittsburgh, Pennsylvania, USA.
| | | | | | | |
Collapse
|
29
|
Singh N. Novel immune regulatory pathways and their role in immune reconstitution syndrome in organ transplant recipients with invasive mycoses. Eur J Clin Microbiol Infect Dis 2008; 27:403-8. [PMID: 18214557 PMCID: PMC2702776 DOI: 10.1007/s10096-008-0461-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2007] [Accepted: 01/01/2008] [Indexed: 10/22/2022]
Abstract
Immune regulatory pathways involving the newly discovered T regulatory (Treg) and Th17 cells are amongst the principal targets of immunosuppressive agents employed in transplant recipients and key mediators of host inflammatory responses in fungal infections. These novel signaling pathways, in concert with or independent of Th1/Th2 responses, have potentially important implications for yielding valuable insights into the pathogenesis of immune reconstitution syndrome (IRS) in transplant recipients, for aiding the diagnosis of this entity, and for achieving a balance of immune responses that enhance host immunity while curbing unfettered inflammation in IRS.
Collapse
Affiliation(s)
- N Singh
- Infectious Diseases Section, VA Medical Center, University Drive C, Pittsburgh, PA 15240, USA.
| |
Collapse
|
30
|
Lanternier F, Chandesris MO, Poirée S, Bougnoux ME, Mechai F, Mamzer-Bruneel MF, Viard JP, Galmiche-Rolland L, Lecuit M, Lortholary O. Cellulitis revealing a cryptococcosis-related immune reconstitution inflammatory syndrome in a renal allograft recipient. Am J Transplant 2007; 7:2826-8. [PMID: 17927804 DOI: 10.1111/j.1600-6143.2007.01994.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) has rarely been described in the course of disseminated cryptococcosis in solid organ transplant recipients. We report here the case of a renal transplant recipient who developed severe cellulitis in the context of Cryptococcus neoformans-associated IRIS while undergoing reduction of his immunosuppressive therapy. IRIS appeared concomitantly with a dramatic increase of blood CD4+ T cells (94-460/mm(3)) and required the administration of a short-term steroid therapy to resolve.
Collapse
Affiliation(s)
- F Lanternier
- Service des Maladies Infectieuses et Tropicales Hôpital Necker-Enfants Malades, Université Paris V Centre d'Infectiologie Necker-Pasteur, Paris, Cedex 15, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|