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Cavassin FB, Magri MMC, Vidal JE, de Moraes Costa Carlesse FA, Falci DR, Baú-Carneiro JL, Breda GL, de Araújo Motta F, de Miranda Godoy CS, de Bastos Ascenço Soares R, De Oliveira CS, Mendes AVA, Morales HP, Montes PS, Taborda M, Rego CM, Félix MA, Katopodis PP, da Silva do Ó JR, Abrão MPL, Pereira TTT, Queiroz-Telles F. Effectiveness, Tolerability, and Safety of Different Amphotericin B Formulations in Invasive Fungal Infections: A Multicenter, Retrospective, Observational Study. Clin Ther 2024:S0149-2918(24)00019-5. [PMID: 38403508 DOI: 10.1016/j.clinthera.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 10/05/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 02/27/2024]
Abstract
PURPOSE Data on the real-life use of amphotericin B lipid complex (ABLC) compared with other available formulations are limited. This study aimed to evaluate the effectiveness, tolerability, and safety of different amphotericin B (AMB) intravenously administered in the context of hospital practice for the treatment of invasive fungal infections (IFI) and to provide new insights into the profile of ABLC. METHODS This is a multicenter, retrospective, observational study conducted at 10 tertiary Brazilian hospitals. Patients first exposed to any formulation of AMB for treating endemic and opportunistic IFI who had received at least 2 intravenous doses were screened. Retrospective data (from January 2014 to December 2019) were extracted from the patients' medical records. Clinical parameters were examined pre- and post-treatment to determine effectiveness; acute infusion-related side effects (IRSE) and drug interruption to determine tolerability; and adverse events, toxicity, and treatment interruption were stated to analyze safety. FINDINGS Overall, 1879 medical records of patients were identified. The median (interquartile rate) duration of treatment was 14 (7-21) days. The overall success rate (95% confidence interval [CI]) was 65% (95% CI 60-65). ABLC proved to be effective among AMB formulations with 59% (95% CI 55.6-62.5) within complete response. This was significantly higher in patients who received the drug for a longer period, ≥4 weeks compared to <1 week treatment (P < 0.001). IRSE was observed in 446 (23.7%) patients. Eight cases (1.4%) of severe IRSE in pediatrics and 14 (1.1%) in adults resulted in treatment discontinuation. Regarding safety, 637 (33.9%) patients presented some alteration in creatinine levels during AMB exposure, and 89 (4.74%) had to interrupt or discontinue the drug within the first 14 days of therapy because of renal dysfunction. Overall mortality was 34%. IMPLICATIONS ABLC is an effective formulation for the treatment of invasive fungal infections, with few adverse events leading to drug discontinuation or lethal outcomes. Furthermore, this real-life study confirmed the comparative safety of AMB lipid formulations versus AMB deoxycholate.
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Affiliation(s)
| | | | | | | | | | | | - Giovanni Luís Breda
- Hospital de Clínicas da Universidade Federal do Paraná (HC/UFPR), Curitiba, Brazil
| | | | | | | | | | | | | | - Patrícia Silva Montes
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FAMUSP), São Paulo, Brazil
| | - Mariane Taborda
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FAMUSP), São Paulo, Brazil
| | | | | | | | | | | | | | - Flávio Queiroz-Telles
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas da Universidade Federal do Paraná (HC/UFPR), Curitiba, Brazil
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2
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Santos ES, Lima ACM, Breda GL, Tomaz APDO, Nabhan SK, Funke VAM, Loth G, Nogueira KDS. Colonization by multidrug-resistant bacteria in hematological patients undergoing hematopoietic stem cell transplantation and clinical outcomes: A single-center retrospective cohort study. Transpl Infect Dis 2023; 25:e14119. [PMID: 37561358 DOI: 10.1111/tid.14119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 07/05/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Bloodstream infections are a leading cause of death in patients who undergo hematopoietic stem cell transplantation (HSCT) and are more severe when caused by multidrug-resistant (MDR) bacteria. This study proposed to investigate if colonization by MDR bacteria negatively affects the clinical outcomes in hematological patients after HSCT, as well as to evaluate possible risk factors for death due to bacteremia by the same colonizing agent. METHODS A single-center retrospective cohort study was conducted with 405 hematological patients submitted to a single HSCT procedure between 2015 and 2021. Patients were classified as colonized (n = 132) or noncolonized (n = 273) based on the surveillance cultures from D-30 to D+30 of transplantation, and their relevant clinical and laboratory data were collected until D+100. RESULTS Colonization by MDR bacteria increased blood culture positivity by all micro-organisms and also specifically by MDR bacteria, with a more pronounced effect when caused by carbapenemase-producing Klebsiella pneumoniae. Patients colonized with carbapenem-resistant K. pneumoniae had increased overall mortality (HR = 4.07, 95% CI 1.85-8.91, P = .0005) and had prolonged hospital length of stay in the context of autologous transplantation. Risk factors for death due to bacteremia by the same colonizing agent were neutropenia, colonization by carbapenem-resistant K. pneumoniae and use of high-dose total body irradiation in conditioning. CONCLUSION Hematological patients colonized by MDR bacteria presented a higher incidence of bloodstream infections, and colonization by carbapenemase-producing K. pneumoniae was associated with reduced overall survival.
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Affiliation(s)
- Eduardo Sbrana Santos
- Clinical Analysis and Pathological Anatomy Unit, Complexo do Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | - Alberto Cardoso Martins Lima
- Clinical Analysis and Pathological Anatomy Unit, Complexo do Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | - Giovanni Luís Breda
- Infectious Diseases Division, Complexo do Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | - Ana Paula de Oliveira Tomaz
- Clinical Analysis and Pathological Anatomy Unit, Complexo do Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | - Samir Kanaan Nabhan
- Bone Marrow Transplantation Unit, Complexo do Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | - Vaneuza Araújo Moreira Funke
- Bone Marrow Transplantation Unit, Complexo do Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | - Gisele Loth
- Bone Marrow Transplantation Unit, Complexo do Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | - Keite da Silva Nogueira
- Clinical Analysis and Pathological Anatomy Unit, Complexo do Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
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3
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Agnelli C, Guimarães T, Sukiennik T, Lima PRP, Salles MJ, Breda GL, Queiroz-Telles F, Chaves Magri MM, Mendes AV, Camargo LFA, Morales H, de Carvalho Hessel Dias VM, Rossi F, Colombo AL. Prognostic Trends and Current Challenges in Candidemia: A Comparative Analysis of Two Multicenter Cohorts within the Past Decade. J Fungi (Basel) 2023; 9:jof9040468. [PMID: 37108922 PMCID: PMC10144195 DOI: 10.3390/jof9040468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/29/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Candidemia remains a major public health challenge due to its high mortality rates, especially in developing countries. Monitoring epidemiological trends may provide insights for better clinical outcomes. This study aimed to describe trends in the epidemiology, therapeutic practices, and mortality in candidemia through a retrospective comparative analysis between two surveillance cohorts of all candidemic adults at eleven tertiary hospitals in Brazil, from 2010-2011 (Period I) versus 2017-2018 (Period II). A total of 616 cases were diagnosed, with 247 being from Period II. These patients were more likely to have three or more coexisting comorbidities [72 (29.1%) vs. 60 (16.3%), p < 0.001], had a prior history of in-hospital admissions more often [102 (40.3%) vs. 79 (21.4%), p = 0.001], and presented with candidemia earlier after admission, within 15 days (0-328) vs. 19 (0-188), p = 0.01. Echinocandins were more frequently prescribed [102 (41.3%) vs. 50 (13.6%), p = 0.001], but time to antifungal initiation [2 days (0-14) vs. 2 (0-13), p = 0.369] and CVC removal within 48 h [90/185 (48.6%) vs. 148/319 (46.4%), p = 0.644] remained unchanged. Additionally, many patients went untreated in both periods I and II [87 (23.6%) vs. 43 (17.4%), p = 0.07], respectively. Unfortunately, no improvements in mortality rates at 14 days [123 (33.6%) vs. 93 (37.7%), p = 0.343] or at 30 days [188 (51.4%) vs. 120 (48.6%), p = 0.511] were observed. In conclusion, mortality rates remain exceedingly high despite therapeutic advances, probably associated with an increase in patients' complexity and suboptimal therapeutic interventions. Management strategies should be tailored to suit epidemiological changes, expedite diagnosis to reduce the number of untreated eligible patients and guarantee early antifungal initiation and source control.
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Affiliation(s)
- Caroline Agnelli
- Division of Infectious Diseases, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo 04024-002, Brazil
| | - Thaís Guimarães
- Hospital do Servidor Público Estadual de São Paulo, São Paulo 04039-000, Brazil
| | - Teresa Sukiennik
- Santa Casa de Misericórdia de Porto Alegre, Rio Grande do Sul 90050-170, Brazil
| | - Paulo Roberto Passos Lima
- Division of Infectious Diseases, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo 04024-002, Brazil
| | - Mauro José Salles
- Santa Casa de Misericórdia de São Paulo, São Paulo 01221-010, Brazil
| | | | | | | | | | | | - Hugo Morales
- Hospital Erasto Gaertner, São Paulo 81520-060, Brazil
| | | | - Flávia Rossi
- Pathology Department, Laboratório de Microbiologia da Divisão de Laboratório Central, Hospital das Clínicas da Faculdade de Medicina USP (FMUSP), São Paulo 05403-010, Brazil
| | - Arnaldo Lopes Colombo
- Division of Infectious Diseases, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo 04024-002, Brazil
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4
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Bridi Cavassin F, Vidal JE, Baú-Carneiro JL, Silva de Miranda Godoy C, de Bastos Ascenço Soares R, Magri MMC, Falci DR, Sakuma De Oliveira C, Verena Almeida Mendes A, Breda GL, Rego CM, Araujo Félix M, Pacheco Katopodis P, da Silva do Ó JR, Pereira Lima Abrão M, Taborda M, Teles Teixeira Pereira T, Queiroz-Telles F. Characteristics, mortality, associated variables with death, and therapeutic response among HIV-positive, solid organ transplant (SOT), and non-HIV-positive/non-transplant (NHNT) patients with cryptococcosis: First multicenter cohort study in Brazil. Med Mycol 2023; 61:7008505. [PMID: 36708168 DOI: 10.1093/mmy/myad011] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 10/28/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 01/29/2023] Open
Abstract
Cryptococcosis is traditionally associated with immunocompromised patients but is increasingly being identified in those without the human immunodeficiency virus (HIV) or other immunocompetent individuals. We aim to describe the characteristics, mortality, and associated variables with death among hospitalized patients with cryptococcosis in Brazil. This is the first multicenter retrospective cohort study conducted in seven public tertiary Brazilian hospitals. A total of 384 patients were included; the median age was 39 years and 283 (73.7%) were men. In all, 304 HIV-positive were hosts (79.2%), 16 (4.2%) solid organ transplant (SOT), and 64 (16.7%) non-HIV-positive/non-transplant (NHNT). Central nervous system (CNS) cryptococcosis had a significantly higher number across disease categories, with 313 cases (81.5%). A total of 271 (70.6%) patients were discharged and 113 (29.4%) died during hospitalization. In-hospital mortality among HIV-positive, SOT, and NHNT was 30.3% (92/304), 12.5% (2/16), and 29.7% (19/64), respectively. Induction therapy with conventional amphotericin B (AMB) mainly in combination with fluconazole (234; 84.2%) was the most used. Only 80 (22.3%) patients received an AMB lipid formulation: liposomal (n = 35) and lipid complex (n = 45). Most patients who died belong to the CNS cryptococcosis category (83/113; 73.4%) when compared with the others (P = .017). Multivariate analysis showed that age and disseminated cryptococcosis had a higher risk of death (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.05; P = .008 and OR, 1.84; 95% CI, 1.01-3.53; P = .048, respectively). Understanding the epidemiology of cryptococcosis in our settings will help to recognize the burden and causes of mortality and identify strategies to improve this scenario.
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Affiliation(s)
- Francelise Bridi Cavassin
- Internal Medicine and Health Sciences Department, Universidade Federal do Paraná (UFPR), Curitiba, Brazil
| | - Jose Ernesto Vidal
- Infectious Diseases Department, Instituto de Infectologia Emílio Ribas (IIER), São Paulo, Brazil
| | | | | | | | - Marcello Mihailenko Chaves Magri
- Infectious Diseases Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FAMUSP), São Paulo, Brazil
| | - Diego Rodrigues Falci
- Infectious Diseases Department, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Carla Sakuma De Oliveira
- Infectious Diseases Department, Hospital Universitário do Oeste do Paraná (HUOP), Cascavel, Brazil
| | | | - Giovanni Luís Breda
- Infectious Diseases Department, Hospital de Clínicas da Universidade Federal do Paraná (HC/UFPR), Curitiba, Brazil
| | - Caroline Martins Rego
- Infectious Diseases Department, Instituto de Infectologia Emílio Ribas (IIER), São Paulo, Brazil
| | - Maíra Araujo Félix
- Infectious Diseases Department, Instituto de Infectologia Emílio Ribas (IIER), São Paulo, Brazil
| | - Paula Pacheco Katopodis
- Medical Education and Research Department, Pontifícia Universidade Católica de Goiás, Goiânia, Brazil
| | | | | | - Mariane Taborda
- Infectious Diseases Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FAMUSP), São Paulo, Brazil
| | | | - Flávio Queiroz-Telles
- Public Health Department, Universidade Federal do Paraná (UFPR), Hospital de Clínicas da Universidade Federal do Paraná (HC/UFPR), Curitiba, Brazil
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5
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Jardim TDAP, Jardim BA, Breda GL, Bonfim C, Raboni SM. Mortality among pediatric hematopoietic stem cell transplantation patients: Report from a single center in southern Brazil. Pediatr Transplant 2021; 25:e13944. [PMID: 33512786 DOI: 10.1111/petr.13944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/11/2020] [Revised: 11/06/2020] [Accepted: 11/23/2020] [Indexed: 01/20/2023]
Abstract
INTRODUCTION HSCT has grown in number in recent years. This treatment in children has its particularities and has been characterized in previous studies only on a limited basis. There are important causes of morbidity and mortality in this group of patients, including evolution of primary disease, graft failure, infectious diseases, and GVHD. The aim of this study was to report case series of TRM within 100 days after transplantation and associated factors. METHODS Retrospective cohort. All children transplanted between January 1, 2010 and December 31, 2017 were included and those who underwent the first HSCT in another center were excluded. RESULTS Data from 292 children were analyzed. TRM in 100 days was 5.8%, being significantly higher in patients with umbilical cord blood as the cell source. Infectious complications were frequent in this sample (bacterial infections in 27%, viral infections in 75.3%, and fungal infections in 12%) and both the presence of fungal disease and more than one infection during the follow-up (viral and bacterial, viral and fungal or bacterial and fungal) had statistically significant association with the outcome. CONCLUSIONS The prognosis in allogeneic HSCT is influenced by the origin of the stem cells, the presence of acute GVHD and the occurrence of infectious diseases. Studies that evaluate pediatric individuals undergoing HSCT and analyze their mortality profile, can improve the management of these patients, possibly leading to a reduction in TRM.
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Affiliation(s)
| | - Bruno Araújo Jardim
- Postgraduate Program in Internal Medicine and Health Science, Federal University of Paraná, Curitiba, Brazil
| | - Giovanni Luís Breda
- Infectious Diseases Division, Federal University of Paraná, Curitiba, Brazil
| | - Carmem Bonfim
- Bone Marrow Transplant Division, Federal University of Paraná, Curitiba, Brazil
| | - Sonia Mara Raboni
- Postgraduate Program in Internal Medicine and Health Science, Federal University of Paraná, Curitiba, Brazil.,Infectious Diseases Division, Federal University of Paraná, Curitiba, Brazil.,Laboratory of Virology, Federal University of Paraná, Curitiba, Brazil
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6
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Ferreira MG, Scavasine VC, Breda GL, Almeida BMMD, Zétola VDHF, Lange MC. Small vessel occlusion and syphilis in patients with first-ever ischemic stroke. Arq Neuropsiquiatr 2021; 79:103-106. [PMID: 33759975 DOI: 10.1590/0004-282x-anp-2020-0178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 07/07/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Syphilis is an endemic disease, particularly in low- and middle-income countries, with vascular involvement in large vessels (aortitis), but no clear relationship with stroke patients, except for those who presented with meningovascular neurosyphilis. OBJECTIVE To investigate the relationship between a positive history of syphilis determined by serological testing and ischemic stroke etiology, particularly small vessel disease (SVD). METHODS In total, 269 first-ever ischemic stroke patients admitted to the stroke unit were tested for syphilis. Patients with neurosyphilis were excluded. All patients were classified according to the ASCOD phenotyping as SVD - when SVD was the potential causal mechanism (S1) - or non-SVD - when SVD was uncertain (S2), unlike (S3), or not detected (S0). RESULTS Syphilis was positive in 32 (12%) patients. When comparing patients with positive and negative serology, the only significant difference was SVD as the causal mechanism (S1) in patients with positive results: 9 (28%) vs. 22 (9%), p<0.01. CONCLUSION The current study showed that the frequency of positive syphilis serological test was higher in patients with first-ever ischemic stroke and SVD as the potential causal mechanism. This finding could be related to the endothelial dysfunction occurring in syphilis.
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Affiliation(s)
- Matheus Gomes Ferreira
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Neurologia, Curitiba PR, Brazil
| | | | - Giovanni Luís Breda
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Doenças Infecciosas, Curitiba PR, Brazil
| | | | | | - Marcos Christiano Lange
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Neurologia, Curitiba PR, Brazil
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7
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Pinto TDA, Jardim BA, Breda GL, Morales HMP, Bonfim C, Raboni SM. Infectious complications in pediatric allogeneic hematopoietic stem cell transplantation recipients-A retrospective clinical and epidemiological cohort study. Transpl Infect Dis 2020; 22:e13369. [PMID: 32538520 DOI: 10.1111/tid.13369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/17/2019] [Revised: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) is an important therapeutic strategy for several hematologic diseases. In the absence of a matched related donor, allogeneic HSCT has been associated with increased risk of infectious complications. Here, we present the clinical and epidemiological characteristics of early infectious complications in children undergoing HSCT from Southern Brazil. METHODS This is a retrospective unicentric cohort study of infections in all children receiving their first HSCT during the period between 2010 and 2017. RESULTS Data from 292 patients were analyzed; bone marrow failures (52.7%) comprised most of the baseline diagnosis. Bone marrow (BM) was the stem cell source in 254 (87%), followed by cord blood (CB) in 34 (11.6%) children. The use of alternative donors (77.8%) and presence of acute graft-vs-host disease (GVHD) (23.6%) were associated with an increased risk of viral and fungal infection. Bacterial infection was observed in 79 patients (27%); 220 patients (75.3%) were diagnosed with viral infection, and 35 patients (12%) developed fungal infection. The presence of fungal disease together with the presence of multiple infections during follow-up was associated with an increased risk of death (P < .001). CONCLUSIONS The clinical profile of HSCT-related infections in this cohort suggests that prognosis in allogeneic HSCT is influenced by the source of stem cells (CB having worse prognosis), presence of acute GVHD and complications arising from fungal infections. The appropriate management of these factors has the potential to improve the overall prognosis rates in pediatric allogeneic HSCT recipients.
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Affiliation(s)
- Tyane de Almeida Pinto
- Postgraduate Program in Internal Medicine and Health Science, Federal University of Paraná, Curitiba, Brazil
| | - Bruno Araújo Jardim
- Postgraduate Program in Internal Medicine and Health Science, Federal University of Paraná, Curitiba, Brazil
| | - Giovanni Luís Breda
- Infectious Diseases Division, Federal University of Paraná, Curitiba, Brazil
| | | | - Carmem Bonfim
- Bone Marrow Transplant Division, Federal University of Paraná, Curitiba, Brazil
| | - Sonia Mara Raboni
- Postgraduate Program in Internal Medicine and Health Science, Federal University of Paraná, Curitiba, Brazil.,Infectious Diseases Division, Federal University of Paraná, Curitiba, Brazil.,Laboratory of Virology, Federal University of Paraná, Curitiba, Brazil
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8
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Queiroz-Telles F, Mercier T, Maertens J, Sola CBS, Bonfim C, Lortholary O, Constantino-Silva RMN, Schrijvers R, Hagen F, Meis JF, Herkert PF, Breda GL, França JB, Filho NAR, Lanternier F, Casanova JL, Puel A, Grumach AS. Successful Allogenic Stem Cell Transplantation in Patients with Inherited CARD9 Deficiency. J Clin Immunol 2019; 39:462-469. [PMID: 31222666 DOI: 10.1007/s10875-019-00662-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 06/03/2019] [Indexed: 10/26/2022]
Abstract
Autosomal recessive (AR) CARD9 (caspase recruitment domain-containing protein 9) deficiency underlies invasive infections by fungi of the ascomycete phylum in previously healthy individuals at almost any age. Although CARD9 is expressed mostly by myeloid cells, the cellular basis of fungal infections in patients with inherited CARD9 deficiency is unclear. Therapy for fungal infections is challenging, with at least 20% premature mortality. We report two unrelated patients from Brazil and Morocco with AR CARD9 deficiency, both successfully treated with hematopoietic stem cell transplantation (HSCT). From childhood onward, the patients had invasive dermatophytic disease, which persisted or recurred despite multiple courses of antifungal treatment. Sanger sequencing identified homozygous missense CARD9 variants at the same residue, c.302G>T (p.R101L) in the Brazilian patient and c.301C>T (p.R101C) in the Moroccan patient. At the ages of 25 and 44 years, respectively, they received a HSCT. The first patient received a HLA-matched HSCT from his CARD9-mutated heterozygous sister. There was 100% donor chimerism at D + 100. The other patient received a T cell-depleted haploidentical HSCT from his CARD9-mutated heterozygous brother. A second HSCT from the same donor was performed due to severe amegakaryocytic thrombocytopenia despite achieving full donor chimerism (100%). At last follow-up, more than 3 years after HSCT, both patients have achieved complete clinical remission and stopped antifungal therapy. HSCT might be a life-saving therapeutic option in patients with AR CARD9 deficiency. This observation strongly suggests that the pathogenesis of fungal infections in these patients is largely due to the disruption of leukocyte-mediated CARD9 immunity.
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Affiliation(s)
- F Queiroz-Telles
- Department of Public Health, Federal University of Parana, Curitiba, Brazil.,Infectious Diseases Unit, Hospital de Clinicas, Federal University of Parana, Curitiba, Brazil
| | - T Mercier
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - J Maertens
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - C B S Sola
- Bone Marrow Transplant Unit, Hospital de Clinicas, Federal University of Parana, Curitiba, Brazil
| | - C Bonfim
- Bone Marrow Transplant Unit, Hospital de Clinicas, Federal University of Parana, Curitiba, Brazil
| | - O Lortholary
- Imagine Institute, Paris Descartes University, 75015, Paris, France
| | - R M N Constantino-Silva
- Clinical Immunology, Faculdade de Medicina ABC, Av Lauro Gomes 2000, Santo Andre, Sao Paulo, 09060-870, Brazil
| | - R Schrijvers
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - F Hagen
- Department of Medical Mycology, Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands
| | - J F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands.,Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - P F Herkert
- Carlos Chagas Institute, Oswaldo Cruz Foundation(Fiocruz), Curitiba, Brazil.,National Institute of Science and Technology (INCT) of Inovation in Neglected Diseases, Curitiba, Brazil
| | - G L Breda
- Infectious Diseases Unit, Hospital de Clinicas, Federal University of Parana, Curitiba, Brazil
| | - J B França
- Infectious Diseases Unit, Hospital de Clinicas, Federal University of Parana, Curitiba, Brazil
| | - N A Rosario Filho
- Department of Pediatrics, Federal University of Parana, Curitiba, Brazil
| | - F Lanternier
- Unite de Mycologie Moleculaire, Institut Pasteur, CNRS URA3012, Paris, France.,Centre National de Référence Mycoses invasives et Antifongiques, Institut Pasteur, Paris, France.,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015, Paris, France
| | - J L Casanova
- Imagine Institute, Paris Descartes University, 75015, Paris, France.,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015, Paris, France.,Pediatric Hematology and Immunology Unit, Necker Hospital for Sick Children, AP-HP, Paris, France.,St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY, 10065, USA.,Howard Hughes Medical Institute, New York, NY, 10065, USA
| | - A Puel
- Imagine Institute, Paris Descartes University, 75015, Paris, France.,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015, Paris, France.,St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY, 10065, USA
| | - Anete S Grumach
- Clinical Immunology, Faculdade de Medicina ABC, Av Lauro Gomes 2000, Santo Andre, Sao Paulo, 09060-870, Brazil.
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