Neuropathologic findings in a Guillain-Barré patient with strokes after IVIg therapy

Safety of Therapeutic Plasma Exchange for the Treatment of Guillain-Barré Syndrome in Polycythemia Vera

Polycythemia vera (PV) is a risk factor for systemic thromboses and ischemic stroke. This has been attributed to blood hyperviscosity, the result of increased blood cell production. Intravenous immunoglobulin, which is indicated for the treatment of numerous hematologic and neurological conditions also causes increased serum viscosity and has been associated with ischemic strokes in the setting of PV. Here we report a case of a 70-year-old man with prior stroke and PV who developed Guillain-Barré syndrome, an acute inflammatory demyelinating disorder of peripheral nerves causing ascending paresis, numbness, and paresthesia, who was treated safely with therapeutic plasma exchange. Plasma exchange may be preferable to administration of intravenous immunoglobulin for treatment of various medical conditions in patients with comorbid PV.

Posterior reversible encephalopathy syndrome and stroke after intravenous immunoglobulin treatment in Miller-Fisher syndrome/Bickerstaff brain stem encephalitis overlap syndrome

The association of a posterior reversible encephalopathy syndrome (PRES) without arterial hypertension with autoimmune-mediated inflammatory neuropathies such as Guillain-Barré syndrome (GBS) is a rare and poorly understood phenomenon. To date, PRES has been described as initial manifestation, coincidental finding, or adverse event subsequent to immunomodulatory treatment with intravenous immunoglobulin (IVIG) in cases of axonal and demyelinating GBS as well as in Miller-Fisher syndrome (MFS). We here report a case of MFS/Bickerstaff brain stem encephalitis (BBE)-overlap syndrome and nonhypertensive PRES that occurred in close temporal association with IVIG treatment and caused stroke. Immunoadsorption ameliorated the disease course. Our case supports the notion that in severe cases, immunoadsorption should be considered as first-line therapy instead of IVIG for rapid removal of IgG and thus to hasten recovery and improve functional outcome.

Cerebral infarction 3 weeks after intravenous immunoglobulin for Miller Fisher syndrome: a case report

Introduction

Intravenous immunoglobulin is considered generally safe and is used widely as proven, and sometimes empiric, treatment for an expanding list of autoimmune diseases. Thromboembolic complications following intravenous immunoglobulin therapy are rare and there have been only five previous reports of stroke occurring within 2 to 10 days of infusion. This is the first report of cerebral infarction occurring after a longer latency of 3 weeks following intravenous immunoglobulin therapy in a patient presenting with Miller Fisher syndrome.

Case presentation

A previously well, 44-year-old Sri Lankan man progressively developed ophthalmoplegia, facial paralysis, ataxia and areflexia with neurophysiological and cerebrospinal fluid evidence consistent with the Miller Fisher syndrome. He made an unremarkable recovery with intravenous immunoglobulin therapy (0.4g/kg/day for 5 days, total 180g), but developed a cerebral infarct with haemorrhagic transformation 25 days later. He was noted to have a low blood pressure. Extensive investigations ruled out vasculopathic, embolic, thrombophilic and inflammatory aetiologies. Circulating intravenous immunoglobulins combined with a low blood pressure was considered the most probable cause of his stroke.

Conclusions

Cerebral infarction following intravenous immunoglobulin is thought to be secondary to hyperviscosity, thromboemboli, vasculitis, or cerebral vasospasm and reported to occur after a short latency when the immunoglobulin load is highest. Even though the immunoglobulin load is halved by 3 weeks, our case suggests that that the predisposition to thromboembolism persists over a longer period and may result in vascular complications if synergised with other vascular risk factors. It is recommended that intravenous immunoglobulin be infused at a rate of not less than 8 hours per day and that factors predisposing to thromboembolism such as dehydration, immobilisation and low blood pressure be avoided for the duration of at least two half-lives of immunoglobulin (6 weeks).

In VitroCytotoxic Effects of Stabilizing Sugars within Human Intravenous Immunoglobulin Preparations against the Human Macrophage THP-1 Cell-line

Intravenous immunoglobulin (IVIg) is a safe and effective therapy for the treatment of primary and secondary humoral immune deficiencies and autoimmune disorders. Both minor and more serious side effects may occur following IVIg administration in approximately 1-15% of infusions and stabilizing sugars found in IVIg preparations may contribute some of these. In this report, we aimed to determine the cytotoxic effects of IVIg as compared with four stabilizing sugars (glucose, sucrose, maltose and D-sorbitol) found in IVIg preparations on human monocyte-macrophages. The human THP-1 macrophage cell-line was used as a model to determine the effects of stabilizing sugars and IVIg preparations on cell viability and growth. The sugars differentially affected the viability of THP-1 cells. In experiments using doses of the sugars commonly found in IVIg preparations, cell viability and proliferation was unaffected when compared with doses of IVIg typically administered to patients (5 mg/ml). However, in an LDH-release cell lysis assay that measures changes in cell permeability, glucose (50 mg/ml) induced significant release of LDH as compared with complete IVIg (5 mg/ml, p<0.0001). Intranucleosomal DNA fragmentation was not detected at therapeutically relevant doses of IVIg. This suggested that THP-1 cell death was not due to apoptosis. We conclude that osmotic stress mediated by the sugars at high doses promoted THP-1 cell death. We propose that IVIg per se is not cytotoxic to the autonomously growing human THP-1 cell-line but rather, the stabilizing sugars used in the preparations are the cytotoxic factors. This observation was evident when preparations of IVIg were used at high concentrations but not at levels one would associate with clinically relevant doses of IVIg.

Reversible posterior encephalopathy syndrome due to intravenous immunoglobulin in a child with Guillain-Barré syndrome

Reversible posterior leukoencephalopathy syndrome is characterized clinically by headache, abnormalities of mental status, and visual perception and seizures. We report a rare case of acute encephalopathy following intravenous immunoglobulin treatment for Guillain-Barré syndrome in whom posterior reversible encephalopathy syndrome developed without severe hypertension.

Posterior reversible encephalopathy syndrome associated with IVIG in a patient with Guillain-Barré syndrome

A 14-year-old girl with Guillain-Barré syndrome manifested headaches during the administration of intravenous immunoglobulin. Magnetic resonance imaging revealed posterior reversible encephalopathy syndrome. Several reports described posterior reversible encephalopathy syndrome associated with intravenous immunoglobulin, but only in adults. We suggest that this syndrome should be considered in children as a neurologic complication.

Intravenous immunoglobulins induce CD32-mediated platelet aggregation in vitro

BACKGROUND

Intravenous immunoglobulins (IVIg) and cytomegalovirus immunoglobulins (CMVIg) are currently finding increased acceptance in clinical states of high immune activity and in transplant recipients. A rare side-effect of their application is intravascular thrombosis, which is thought to be related to pre-existing hyperviscosity. In a previous study we have shown that rabbit antithymocyte globulin causes platelet aggregation in vitro via the Fc IgG receptor (CD32).

OBJECTIVES

To investigate if IVIg and CMVIg have the potential to cause CD32-dependent platelet aggregation.

METHODS

The influence of CMVIg or IVIg on platelets pre-incubated with or without monoclonal antibody AT10 was studied in an aggregometer. Expression of platelet surface activation marker CD62P was determined by fluorescence-activated cell sorting analysis and presence of soluble CD40L (sCD40L) was evaluated by enzyme-linked immunosorbent assay. All in vitro experiments were performed using platelet concentrates from the blood bank, at therapeutic concentrations of immunoglobulins. Results Incubation of platelets with CMVIg and IVIg markedly induced platelet aggregation, and increased expression of CD62P and secretion of sCD40L. The capacity of CMVIg and IVIg to induce platelet aggregation was completely abrogated by adding the blocking antibody AT10 directed against the low-affinity Fc IgG receptor (CD32).

CONCLUSIONS

Our results suggest that CMVIg and IVIg solutions with activating Fc domains are able to bind CD32 on platelets and cause platelet aggregation in vitro. These results indicate a mechanism by which in vivo intravascular thrombosis may be explained and suggest caution with concomitant use of packed platelets and IVIg in autoimmune diseases in the clinical setting.

The use of i.v. IG therapy in dermatology

The intravenous administration of exogenous pooled human immunoglobulin (i.v. IG) was originally licensed as antibody replacement therapy in patients with primary immunodeficiencies and there are currently six FDA-approved uses for this agent. Despite a current lack of FDA approval, off-label treatment of a multitude of dermatologic disorders with i.v. IG has shown exciting potential for this unique treatment modality. The diseases successfully treated with i.v. IG include autoimmune bullous diseases, connective tissue diseases, vasculitides, toxic epidermal necrolysis, and infectious disorders (such as streptococcal toxic shock syndrome). Currently the biggest drawback in the consideration of i.v. IG therapy in dermatologic disorders is the lack of randomized controlled trials. Nevertheless, there is a significant body of evidence demonstrating the efficacy of i.v. IG in patients with dermatologic disorders that are resistant to treatment with standard agents. In summary, i.v. IG constitutes a valuable and potentially life-saving agent in managing patients with a variety of dermatologic disorders under the appropriate circumstances.

An autopsy case of drug-induced diffuse cerebral axonopathic leukoencephalopathy: the pathogenesis in relation to reversible posterior leukoencephalopathy syndrome

An autopsy case of diffuse axonopathic leukoencephalopathy induced by drug treatment is reported. A 70-year-old woman with multiple myeloma developed encephalopathy several days after completing a course of intravenous human immunoglobulin (IVIg) and granulocyte-colony stimulating factor (G-CSF), and died within I month. T2-weighted MRI demonstrated multifocal high-signal areas in the bilateral cerebral white matter, especially in the right frontal lobe. Neuropathologically, multifocal hydropic axonal swelling with a poor glial reaction was recognized diffusely in the bilateral deep cerebral white matter, being especially marked in the frontal lobe. The cortex, subcortical U-fibers, corpus callosum, and anterior commissure were spared. The cerebellar white matter also showed similar changes, albeit less marked, but the brainstem was spared. Microscopically, the myeloma involvement of the CNS was limited to the dura, and the cerebral arteries showed slight atherosclerosis, but neither thrombi nor angitis. This case, although ultimately fatal, neurologically and neuroradiologically resembled reversible posterior leukoencephalopathy syndrome (RPLS) induced by IVIg and/or G-CSF, and the nature and selective distribution of the neuropathological changes suggested that the pathogenesis involved vasospasm of the bilateral internal carotid artery and the main trunks of the cerebral arteries, due to unknown cause, inducing ischemia in the deep white matter, which is supplied by long nutrient arteries.

Intravenous immunoglobulins contain naturally occurring antibodies that mimic antineutrophil cytoplasmic antibodies and activate neutrophils in a TNFα-dependent and Fc-receptor–independent way

Intravenous immunoglobulin (IVIg) preparations are increasingly used for therapy of several neuroimmunologic diseases. IVIg therapy is considered safe, although serious side effects like aseptic meningitis, cerebral vasospasm, or ischemic encephalopathy have been reported. These side effects are frequently associated with neutrophilic pleocytosis in the cerebrospinal fluid (CSF), suggesting a neutrophil-mediated mechanism. To elucidate the potential role of neutrophil activation, we analyzed IVIg preparations from 5 different commercial sources for the presence of antineutrophil cytoplasmic antibody (ANCA)–like immunoglobulins against ethanol-fixed peripheral-blood neutrophils, purified human antigens, and a panel of human and nonhuman tissues. All IVIg batches tested (n = 13) contained atypical ANCAs (IgG titer up to 1:2048, IgA up to 1:512). Moreover, all preparations were capable of inducing hydrogen peroxide production in TNFα-primed human neutrophils, with a significant correlation (P < .005) between atypical ANCA titers in IVIg preparations and neutrophil activation. Fc-mediated binding and activation was ruled out by the use of IVIg-F(ab′)2 fragments. Our findings strongly suggest that in vivo activation of TNFα-primed neutrophils by atypical ANCAs of IVIg may contribute to the side effects of IVIg therapy and for the first time demonstrate that the activation of neutrophil granulocytes by IVIg occurs in an Fc receptor (FcR)–independent, hence antigen-dependent, way.

Venous and arterial thrombosis following administration of intravenous immunoglobulins

Thrombotic events are an increasingly recognized complication of treatment with intravenous immunoglobulins (IVIg). We aimed to define clinical characteristics, risk factors and outcome for venous thrombosis as opposed to arterial thrombosis following administration of IVIg. Six patients with post-IVIg venous thrombosis were identified at our institution. In addition, a review of the literature revealed 65 reported cases. Arterial thrombosis (stroke and myocardial infarction) was four times more common than venous thrombosis (deep vein thrombosis and pulmonary embolism). The incidence rate was estimated at 0.15-1.2% per treatment course, but the large increase in reported cases in 2003 suggests that the true incidence may be significantly greater. The following differences were found between arterial and venous events: arterial thrombosis occurred early after IVIg administration (49% within 4 h, 77% within 24 h) and was associated with advanced age and atherosclerotic vascular disease; venous thrombosis occurred later (54% more than 24 h after IVIg administration) and was associated with factors contributing to venous stasis (obesity and immobility). Thirteen patients died (mortality 20%), 11 of whom had arterial thrombosis. In conclusion, IVIg-associated thrombosis is more common than previously recognized, and is associated with significant mortality. The different characteristics of arterial and venous events may reflect different pathophysiological mechanisms. A better understanding of these mechanisms should aid in defining a risk-benefit ratio for the individual patient.

Intravenous immunoglobulin-associated arterial and venous thrombosis; report of a series and review of the literature

BACKGROUND

To date, the prevalence of intravenous immunoglobulin (IvIg)-related thrombotic complications has not been evaluated in patients with autoimmune disorders followed up in Departments of Internal Medicine.

OBJECTIVES

To assess prevalence and characteristics of IvIg-related thrombotic complications in patients with autoimmune disorders receiving IvIg therapy; to evaluate the predictive factors for onset of IvIg-related thrombotic manifestation in patients, and to detect patients at risk for these types of complications.

PATIENTS AND METHODS

The medical records of 46 patients with autoimmune disorders who were given IvIg therapy at our Department of Internal Medicine between January 2002 and December 2004 were reviewed.

RESULTS

Among the 46 patients, nine exhibited IvIg-associated severe complications (19.6%). Six patients (13%) developed IvIg-related thrombotic complications. Thrombotic complications frequently occurred during IvIg infusion (50%), although they were also observed within 1-8 days following IvIg infusion in other patients. IvIg-related thrombotic complications consisted of: deep venous thrombosis or pulmonary embolism (n = 3), myocardial infarction (n = 2) and stroke (n = 1). The outcome of thrombotic complications was favourable in all patients, after appropriate therapy institution. Older age, history of associated arterial hypertension and hypercholesterolaemia were more common in the group of patients with IvIg-related thrombotic complications.

CONCLUSIONS

Our study demonstrates that IvIg-related thrombotic arterial/venous complications are not uncommon in patients with autoimmune disorders (13% of patients). Nevertheless, patients, who are followed up in Departments of Internal Medicine often have concomitant disorders placing them at increased risk to develop IvIg-related thrombotic complications; the latter may also explain the high rate of IvIg-related thrombosis in our cohort. Our series further indicates that patients should be monitored closely for these types of adverse events during the whole period of IvIg therapy, as thrombotic manifestations occurred in patients who had received multiple IvIg infusions without exhibiting complications. In addition, our results suggest that it is questionable to initiate IvIg therapy in patients presenting with predictive factors of thrombotic complications; in this subgroup of patients, IvIg should be prescribed cautiously, after re-weighing risk-benefit considerations.

Adverse events associated with intravenous immunoglobulin therapy

In addition to its U.S. Food and Drug Administration (FDA) approved conditions, immune globulin intravenous (IGIV) is now being used to treat a vast array of autoimmune disorders. Some of the reasons for this overall increase in the use of IGIV include its effectiveness and safety. Despite many years of safe use, side effects and adverse reactions still occur. Common and mild side effects associated with IGIV include: headache, malaise, nausea, low-grade fever, urticaria, arthralgias, and myalgia. These symptoms typically resolve within a few days after their onset. Although rare, the serious and potentially fatal side effects include: anaphylactic reactions, aseptic meningitis, acute renal failure, stroke, myocardial infarction, and other thrombotic complications. Many of these side effects have occurred in patients who have significant, underlying risk factors for the development of the event. Thus, it is vitally important that a thorough and comprehensive medical evaluation be performed on every patient who is being evaluated for potential IGIV therapy. This evaluation can, to some extent, significantly minimize the risk of these side effects. Careful, constant, and close monitoring by trained personnel during the infusion can also result in early detection of such events. Physicians should thoroughly discuss the risks and benefits of IGIV with patients who are being considered for this therapy.

Single high-dose intravenous immunoglobulin therapy for kawasaki disease increases plasma viscosity

BACKGROUND

Intravenous immunoglobulin therapy, widely used for various autoimmune and systemic inflammatory diseases including Kawasaki disease (KD), is occasionally associated with thromboembolic adverse effects caused by an abrupt increase in blood viscosity. Scarce information is available, however, regarding the effect of single high-dose immunoglobulin therapy for KD on blood viscosity.

METHODS AND RESULTS

Eleven boys and 5 girls (mean age: 2.1 years) with acute-phase KD underwent single high-dose immunoglobulin therapy. Plasma viscosity before the treatment was 1.18 centipoises (SD = 0.06), but it significantly rose to 1.34 centipoises (SD = 0.06) (p < 0.001). Multiple regression analysis revealed that, among various factors including hematocrit, plasma concentrations of total protein, immunoglobulin G (IgG), immunoglobulin A (IgA), and immunoglobulin M (IgM), only plasma IgG concentration was included in the model to explain plasma viscosity (R2 = 0.59, p < 0.001).

CONCLUSIONS

Single high-dose regimen for acute-phase KD increases blood viscosity and therefore might increase the risk of thromboembolism.

Strokes after intravenous gamma globulin: thrombotic phenomenon in patients with risk factors or just coincidence?

We report the case of an 82-year-old woman with a diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) for more than 10 years, who developed an ischemic stroke during infusion of immunoglobulin (IVIG). She had received IVIG intermittently for several years, and the previous 86 doses were well tolerated. Thromboembolism was suspected based on magnetic resonance angiogram and on further extension of the deficit after 4 days of evolution. Strokes were associated with the use of IVIG in different clinical circumstances. Pre-existing thrombogenic risk factors should be carefully considered for patients undergoing treatment with IVIG. Clinical evaluation, with attention to history, a focused vascular work-up, and looking for markers of dehydration, can identify the high-risk patient for whom a careful analysis of the risk/benefit ratio is warranted.

Thromboembolic events as an emerging adverse effect during high-dose intravenous immunoglobulin therapy in elderly patients: a case report and discussion of the relevant literature

A case of an 82-year-old man who suffered an acute ST-elevation myocardial infarction while receiving treatment with intravenous immunoglobulin (IVIg) for thrombocytopenia is discussed. A total of 29 other cases of thromboembolism related to IVIg therapy have been reported, and the incidence seems to be especially high in elderly patients with cerebrovascular risk factors and also in patients with paraproteinemias. Possible mechanisms to account for this complication may include some of the following: platelet activation, increased blood viscosity, contamination of IVIg with activated coagulation factors, induced arterial vasospasm, production of vasoconstrictive cytokines, and vasculitis. Ten patients out of the 29 reported patients died from this serious complication. In our patient, spontaneous reperfusion occurred without any treatment and he had an uneventful outcome.