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Garbarino MC, Manzano N, Messina O, Zylberman M. Rheumatological adverse events secondary to immune checkpoint inhibitors. Reumatología Clínica (English Edition) 2023; 19:215-222. [PMID: 37005129 DOI: 10.1016/j.reumae.2023.03.001] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/29/2022] [Indexed: 04/03/2023]
Abstract
The first experiences with a group of drugs called immune checkpoint inhibitors for the treatment of cancer were described in 2010. They are currently used in many tumours, with successful survival outcomes but a new profile of adverse events. This new spectrum of immune-mediated toxicities includes an exaggerated inflammatory response of T lymphocyte and the development of autoimmune diseases or similar pathologies. Of these, of particular note are the rheumatological toxicities. This review aims to alert internists and rheumatologists to their recognition and clinical management.
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Affiliation(s)
- María Cecilia Garbarino
- Departamento de Medicina Interna, Hospital General de Agudos «Dr. Cosme Argerich», Buenos Aires, Argentina; Sección Reumatología, Hospital General de Agudos «Dr. Cosme Argerich», Buenos Aires, Argentina.
| | - Natalia Manzano
- Departamento de Medicina Interna, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Osvaldo Messina
- Sección Reumatología, Hospital General de Agudos «Dr. Cosme Argerich», Buenos Aires, Argentina
| | - Marcelo Zylberman
- Departamento de Medicina Interna, Hospital General de Agudos «Dr. Cosme Argerich», Buenos Aires, Argentina; Departamento de Medicina Interna, Instituto Alexander Fleming, Buenos Aires, Argentina
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Nicolini C, Manzano N, Flagel S, Sánchez C, García X, Coliva G, Pombo T, Zylberman M. [Pembrolizumab-induced gastritis with PDL1 histological expression]. Medicina (B Aires) 2023; 83:994-997. [PMID: 38117721] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
Immune-mediated gastritis is a rare adverse effect in patients treated with immune checkpoint inhibitors. We present a patient with a diagnosis of cervical carcinoma under treatment with pembrolizumab who was admitted with nausea, vomiting and weight loss; an endoscopy revealed a ulcerated lesion covered by mucus in the antrum and gastric body. The biopsy revealed extensive denudation of the gastric mucosa with fibrin leukocyte reaction. Into the lamina propria, an increased lymphocytic and polymorphonuclear inflammatory infiltrate was observed. Immunohistochemistry confirmed positivity for PDL1 (clone SP2630) and combined positive score of 35%, with a relative contribution of epithelial cells of 25% and inflammatory cells of 10%. After three weeks with 30 mg meprednisone, a new endoscopy revealed a stomach with clear mucus content; fundus and body without lesions, and an antrum with congestive mucosa and multiple superficial ulcers covered by fibrin. Diagnostic and therapeutic aspects of immune-mediated gastritis are described.
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Affiliation(s)
| | | | | | | | - Ximena García
- Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Gisela Coliva
- Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Teresa Pombo
- Instituto Alexander Fleming, Buenos Aires, Argentina
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Díaz‐Couselo FA, Flagel S, Nicolini C, Halac S, Manzano N, Aguirre M, Rébora J, Valle S, Noro L, Mohindroo C, McAllister F, Zylberman M. Impact of high neutrophil-to-lymphocyte ratio on survival in hospitalized cancer patients with COVID-19. Cancer Med 2022; 12:7164-7169. [PMID: 36372937 PMCID: PMC9877941 DOI: 10.1002/cam4.5426] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/07/2022] [Accepted: 10/23/2022] [Indexed: 11/15/2022] Open
Abstract
Neutrophil-to-lymphocyte ratio (NLR) has been studied as a prognostic factor for mortality in COVID-19 patients. Our study aimed to evaluate the association between NLR at COVID-19 diagnosis and survival during the following 90 days in hospitalized patients with solid cancer. Between May 2020 and June 2021, 120 patients were included in a retrospective cohort study. Univariable analysis showed patients with an NLR > 8.3 were associated with an increased risk of death (HR: 4.34; 95% CI: 1.74-10.84) compared to patients with NLR < 3.82 and with NLR ≥3.82 and ≤8.30 (HR: 2.89; 95% CI: 1.32-6.36). Furthermore, on multivariable analysis, NLR > 8.30 independently correlated with increased mortality. In patients with solid malignancies with COVID-19, an NLR > 8.3 is associated with an increased risk of death.
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Affiliation(s)
| | - Santiago Flagel
- Department of Internal MedicineInstituto Alexander FlemingBuenos AiresArgentina
| | - Carla Nicolini
- Department of Internal MedicineInstituto Alexander FlemingBuenos AiresArgentina
| | - Sebastián Halac
- Department of Internal MedicineInstituto Alexander FlemingBuenos AiresArgentina
| | - Natalia Manzano
- Department of Internal MedicineInstituto Alexander FlemingBuenos AiresArgentina
| | - Marina Aguirre
- Department of Internal MedicineInstituto Alexander FlemingBuenos AiresArgentina
| | - Juan Rébora
- Department of Infectious DiseasesInstituto Alexander FlemingBuenos AiresArgentina
| | - Sandra Valle
- Microbiology LaboratoryInstituto Alexander FlemingBuenos AiresArgentina
| | - Laura Noro
- Clinical Analysis and Molecular Medicine LaboratoryInstituto Alexander FlemingBuenos AiresArgentina
| | - Chirayu Mohindroo
- Department of Clinical Cancer PreventionThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA,Department of Internal MedicineSinai Hospital of BaltimoreBaltimoreMarylandUSA
| | - Florencia McAllister
- Department of Clinical Cancer PreventionThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Marcelo Zylberman
- Department of Internal MedicineInstituto Alexander FlemingBuenos AiresArgentina
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Zylberman M, Aguirre M, Paganini L, Manzano N, de Abreu M, Flagel S. [Massive left ventricular calcification]. Medicina (B Aires) 2021; 81:484. [PMID: 34137717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023] Open
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Manzano N, Díaz Couselo FA, Zylberman M. [Adverse drug reactions associated with immune checkpoint inhibitors]. Medicina (B Aires) 2021; 81:208-213. [PMID: 33906139] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023] Open
Abstract
The management of patients with immune-related adverse events (irAEs) frequently demands a multidisciplinary approach. We reviewed the causes and clinical course of medical visits and admissions at the Instituto Alexander Fleming due to irAEs between September 2015 and July 2019. Demographic data, diagnosis, toxicity and its severity, requirement of admission, treatment, mortality, and evaluation of the re-administration of immunotherapy were collected. We found 124 irAEs in 89 patients. Sixty-eight of them received monotherapy (76.4%) and 21 (23.6%) combination of drugs. Cutaneous manifestations were the most frequent cause of irAEs, followed by general manifestations, endocrine dysfunctions (hypothyroidism the most frequent), colitis, pneumonitis, neurologic disorders, and hepatitis. In 26 adverse events (in 25 patients), severity grade was = 3. Fifteen were admitted and 6 required ICU admission. One patient died. Thirty-four received glucocorticoids, 12 of them by intravenous route. One patient received mycophenolate and one IVIG. In 20, the treatment was discontinued; 8 were re-exposed, with definitive discontinuation in one patient. In this case series we report our experience in the diagnosis and management of adverse reactions related to a family of drugs whose use has grown in recent years.
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Zylberman M, Díaz-Couselo FA, Irrazabal C, Flagel S, Custidiano R, Racciopi A, Nicolini C, Bachetti P, Rébora J, Manzano N, Tavella M, Valle S, Noro L, Halac S, Cassal E, Paganini L, Aguirre M, Dictar M. [Clinical outcomes in cancer patients hospitalized with COVID-19]. Medicina (B Aires) 2021; 81:695-702. [PMID: 34633941] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023] Open
Abstract
Cancer patients are exposed to more complications from COVID-19 than non-cancer patients. We report a cohort of 74 cancer patients (87.8% with solid neoplasia and 12.2% with hematological diseases) with COVID-19 infection admitted to a tertiary medical cancer center in Argentina. Pulmonary infiltrates were diagnosed at admission in 78.3% (N = 58) of the cases. COVID-19 infection was hospital-acquired in 20 (27.0%) patients. Thirty-nine patients (52.7%) received anticancer therapy within the 30 days prior to COVID-19 diagnosis; one was on radiation therapy. Twenty-four (32.4%) patients were admitted in the intensive care unit (ICU) and 18 (75.0%) required mechanical ventilation. All cause in-hospital mortality was 32.4% (N = 24) and ICU mortality was 62.5% (N = 15). Mortality under mechanical ventilation was 72.2% (N = 13). In the univariate analysis age, neutrophil count, neutrophil/lymphocyte index, D-dimer, ferritin, smoking, and nosocomial acquired infection were associated with in-hospital mortality. There were no statistically significant differences in mortality related to disease stage for solid tumors, neither cancer treatment within 30 days of COVID-19 diagnosis. Age and smoking were associated with mortality in the multivariate analysis. The adjusted odds ratios (95 CI) for age = 65 years and smoking were 8.87 (1.35-58.02) and 8.64 (1.32 - 56.64), respectively. Our experience can be useful for other institutions that assist cancer patients during the pandemic.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Juan Rébora
- Instituto Alexander Fleming, Buenos Aires, Argentina
| | | | | | - Sandra Valle
- Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Laura Noro
- Instituto Alexander Fleming, Buenos Aires, Argentina
| | | | - Eric Cassal
- Instituto Alexander Fleming, Buenos Aires, Argentina
| | | | | | - Miguel Dictar
- Instituto Alexander Fleming, Buenos Aires, Argentina
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Manzano N, Ocampo P, Nicolini C, Halac S, Aguirre M, Rivero S, Zylberman M. [Diabetes by immunotherapy]. Medicina (B Aires) 2018; 78:60. [PMID: 29360082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Affiliation(s)
| | - Paloma Ocampo
- Instituto Alexander Fleming, Buenos Aires, Argentina
| | | | | | | | - Sergio Rivero
- Instituto Alexander Fleming, Buenos Aires, Argentina
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Aguirre M, Manzano N, Salas Y, Angel M, Díaz-Couselo FA, Zylberman M. [Vitamin D deficiency]. Medicina (B Aires) 2015; 75:426-427. [PMID: 26707675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
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Tovar A, Manzano N, Torres N. [Metabolism of cholesterol and fatty acids in nephrotic syndrome and its regulation by sterol regulatory element binding proteins (SREBP's). Effect of soy protein consumption]. GAC MED MEX 2005; 141:407-15. [PMID: 16353886] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
Hyperlipidemia occurs during nephrotic syndrome (NS). It is known that cholesterol and fatty acid biosynthesis is controlled by the transcription factors sterol regulatory element binding proteins (SREBPs). Soy protein consumption reduces the concentration of these lipids, although its mechanism of action is not well known. The aim of the present study was to establish whether soy protein consumption reduces cholesterol and triglycerides levels by regulating of SREBPs. Male Wistar rats with experimental NS were studied for 64 days. The results showed that rats fed with soy protein had significantly lower plasma cholesterol and triglyceride concentrations as well as proteinuria than rats fed with casein diet. These decrements were associated with a decrease in the expression of SREBP-1 and fatty acid biosynthetic enzymes. In addition, Western blot analysis revealed that in nuclear extracts from hepatocytes of rats fed with soy protein, there was a lower concentration of SREBP-1 than in rats fed with casein. The results of this study indicate that consumption of a soy protein diet has beneficial effects on nephrotic syndrome.
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Affiliation(s)
- Armando Tovar
- Departamento de Fisíologia de la Nutrición, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México.
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