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Margarit-Soler A, Deyà-Martínez À, Canizales JT, Vlagea A, García-García A, Marsal J, Del Castillo MT, Planas S, Simó S, Esteve-Sole A, Grande MSL, Badell I, Tarrats MR, Fernández-Avilés F, Alsina L. Case report: Challenges in immune reconstitution following hematopoietic stem cell transplantation for CTLA-4 insufficiency-like primary immune regulatory disorders. Front Immunol 2022; 13:1070068. [PMID: 36636328 PMCID: PMC9831655 DOI: 10.3389/fimmu.2022.1070068] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/28/2022] [Indexed: 12/28/2022] Open
Abstract
Cytotoxic T-lymphocyte antigen-4 (CTLA-4) haploinsufficiency is a T-cell hyperactivation disorder that can manifest with both immunodeficiency and immune dysregulation. Approximately one-third of patients may present mild symptoms and remain stable under supportive care. The remaining patients may develop severe multiorgan autoimmunity requiring lifelong immunosuppressive treatment. Hematopoietic stem cell transplantation (HSCT) is potentially curable for patients with treatment-resistant immune dysregulation. Nevertheless, little experience is reported regarding the management of complications post-HSCT. We present case 1 (CTLA-4 haploinsufficiency) and case 2 (CTLA-4 insufficiency-like phenotype) manifesting with severe autoimmunity including cytopenia and involvement of the central nervous system (CNS), lung, and gut and variable impairment of humoral responses. Both patients underwent HSCT for which the main complications were persistent mixed chimerism, infections, and immune-mediated complications [graft-versus-host disease (GVHD) and nodular lung disease]. Detailed management and outcomes of therapeutic interventions post-HSCT are discussed. Concretely, post-HSCT abatacept and human leukocyte antigen (HLA)-matched sibling donor lymphocyte infusions may be used to increase T-cell donor chimerism with the aim of correcting the immune phenotype of CTLA-4 haploinsufficiency.
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Affiliation(s)
- Adriana Margarit-Soler
- Bone Marrow Transplant Unit, Oncology Service, Hospital Sant Joan de Déu, Barcelona, Spain,*Correspondence: Adriana Margarit-Soler, ; Laia Alsina,
| | - Àngela Deyà-Martínez
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain,Clinical Immunology Program Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
| | - Juan Torres Canizales
- Clinical Immunology Unit, Department of Immunology, Biomedical Diagnostic Center, Hospital Clínic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alexandru Vlagea
- Clinical Immunology Unit, Department of Immunology, Biomedical Diagnostic Center, Hospital Clínic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ana García-García
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain,Clinical Immunology Program Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
| | - Júlia Marsal
- Bone Marrow Transplant Unit, Oncology Service, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Sílvia Planas
- Department of Pathology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Sílvia Simó
- Infectious Diseases Unit, Department of Pediatrics, Hospital Sant Joan de Déu, Barcelona, Spain,Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Ana Esteve-Sole
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain,Clinical Immunology Program Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain
| | - María Suárez-Lledó Grande
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Spain,Department of Surgery and Surgical Specializations, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Isabel Badell
- Bone Marrow Transplant Unit, Oncology Service, Hospital Sant Joan de Déu, Barcelona, Spain,Pediatric Haematology and Stem Cell Transplantation Unit, Pediatric Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Montserrat Rovira Tarrats
- Bone Marrow Transplant Unit, Oncology Service, Hospital Sant Joan de Déu, Barcelona, Spain,Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Spain
| | - Francesc Fernández-Avilés
- Hematopoietic Transplantation Unit, Hematology Department, Clinical Institute of Hematology and Oncology (ICMHO), Hospital Clínic de Barcelona, Barcelona, Spain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Spain
| | - Laia Alsina
- Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain,Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Barcelona, Spain,Clinical Immunology Program Hospital Sant Joan de Déu-Hospital Clínic Barcelona, Barcelona, Spain,Department of Surgery and Surgical Specializations, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain,*Correspondence: Adriana Margarit-Soler, ; Laia Alsina,
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Barberán J, Mensa J, Llamas JCV, Ramos IJ, Ruiz JCG, Marín JRC, Tello PB, Massana MB, Vidal JB, Viñas JMC, Huelva FJC, Pons EC, Mediavilla JD, Morfa MLD, Barrigón FE, Avellán PF, López SG, García CG, Maraver DH, Guía ALDL, Jiménez JL, Chacón EM, Rubio MO, Oteyza JPD, Ramírez GR, Contreras RR, Barbero AR, Tarrats MR, Félix DR, Godoy PS, Salinas AS, Alonso MAS, Torroba JDLS, Ferreiras DV, López LV, García JMA, Perea JRA, Moreno RC, Cáncer RC, Abete JF, Rodríguez JG, Gómez JG, Pedrosa EGGDL, Baranda JMM, García FJP, Camps IR, Lleti MS, Cisneros JDLT. Recommendations for the treatment of invasive fungal infection caused by filamentous fungi in the hematological patient. Rev Esp Quimioter 2011; 24:263-270. [PMID: 22173196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Antifungal treatment in the hematological patient has reached a high complexity with the advent of new antifungals and diagnostic tests, which have resulted in different therapeutic strategies. The use of the most appropriate treatment in each case is essential in infections with such a high mortality. The availability of recommendations as those here reported based on the best evidence and developed by a large panel of 48 specialists aimed to answer when is indicated to treat and which agents should be used, considering different aspects of the patient (risk of fungal infection, clinical manifestations, galactomanann test, chest CT scan and previous prophylaxis) may help clinicians to improve the results.
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Affiliation(s)
- José Barberán
- Servicio de Enfermedades Infecciosas, Hospital Central de la Defensa Gómez Ulla, E-28047 Madrid, Spain.
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