Predictive factors for dose reduction and discontinuation of nintedanib in fibrotic interstitial lung diseases: Real life data

Nintedanib, an intracellular inhibitor targeting multiple tyrosine kinases, has emerged as a standard treatment for various fibrotic lung diseases. Despite its efficacy, side effects such as nausea, diarrhea, and hepatotoxicity often lead to dose reduction or discontinuation. In this retrospective analysis at an university hospital's interstitial lung disease clinic, we aimed to identify baseline characteristics associated with dose adjustment or treatment discontinuation. Of the 58 patients included, 41.4% maintained the full nintedanib dose, while 31.0% required dosage reduction, and 27.6% discontinued treatment due to adverse events, predominantly gastrointestinal and hepatotoxic effects. Multivariate analysis revealed body surface area (BSA) as an independent and significant baseline risk factor (adjusted Odds Ratio [aOR] 0.22), suggesting a 78% decreased chance of requiring dose modification for every decimal point increase in BSA. A BSA cutoff of ≤1.73 m [2] exhibited a sensitivity of 73% and specificity of 91.7%, with significant impact on one-year survival under full-dose treatment (p < 0.001). Lower BSA was associated with early onset adverse effects, particularly gastrointestinal, supporting the need for regular clinical monitoring. The study emphasizes the importance of recognizing baseline factors to ensure the safety and tolerability of nintedanib, thereby preventing the progression of pulmonary fibrosis. These findings contribute to the evolving understanding of nintedanib management in fibrotic interstitial lung diseases, guiding clinicians in personalized treatment approaches.

Interstitial nephritis secondary to treatment with pembrolizumab, a rare complication in two patients with lung adenocarcinoma

Immune checkpoint inhibitors (ICPi) have become nowadays one of the most widely prescribed anticancer treatments. Pembrolizumab is a highly selective monoclonal immunoglobulin approved as a first-line monotherapy treatment in adult patients with untreated advanced non-small cell lung cancer (NSCLC) with programmed cell death 1 (PD-L1) expression greater than 50% and lack of mutations. ICPi can precipitate immune-related adverse events. Data on the incidence and characteristics of nephrotoxicity from ICPi are limited and caused largely from small case series and oncologic studies. Two patients with a diagnosis of pulmonary adenocarcinoma, undergoing treatment with pembrolizumab who manifested interstitial nephritis secondary to this treatment, are presented below. The growing use of immunotherapy in the treatment of cancer imposes the physician's attention to possible adverse effects.

Sarcoidosis-like reaction secondary to adalimumab treatment in a patient with axial spondyloarthritis

Anti-TNF agents, namely adalimumab, are safe drugs that represent an important arsenal in the treatment of immune-mediated inflammatory diseases. "Paradoxical effects" have been described with their use. A sarcoidosis "like" reaction induced by these agents is rare and is characterized by a systemic granulomatous reaction indistinguishable from sarcoidosis. We present a 55-year-old male patient, with axial spondyloarthritis, treated with with adalimumab. About 17 months under this therapy, he complained of dry cough and wheezing. Chest CT showed a peri-lymphatic and pericisural micronodular pattern and hilo-mediastinal lymph nodes, suggestive of sarcoidosis. Angiotensin converting enzyme was increased. Assuming the hypothesis of a sarcoidosis-like reaction secondary to adalimumab this therapy was discontinued with progressive improvement in the patient's complaints and in the radiological changes.

PTX3 Inhibits Complement-Driven Macrophage Activation to Restrain Granuloma Formation in Sarcoidosis

RATIONALE

Sarcoidosis is a multisystemic inflammatory disease characterized by the formation of granulomas in response to persistent stimuli. The long pentraxin PTX3 has emerged as a component of humoral innate immunity with essential functions in the resolution of inflammation, but its role during granuloma formation is unknown.

OBJECTIVES

To evaluate PTX3 as a modulator of pathogenic signals involved in granuloma formation and inflammation in sarcoidosis.

METHODS

Peripheral blood mononuclear cells obtained from sarcoidosis patients harboring loss-of-function genetic variants and gene-deleted mice were used to assess the role of PTX3 in experimental models of granuloma formation in vitro and in vivo. The identified mechanisms of granulomatous inflammation were further evaluated in tissue and bronchoalveolar lavage samples and correlated with the disease course.

MEASUREMENTS AND MAIN RESULTS

We have identified a molecular link between PTX3 deficiency and the pathogenic amplification of complement activation to promote granuloma formation. Mechanistically, PTX3 deficiency licensed the complement component C5a-mediated activation of the metabolic checkpoint kinase mammalian target of rapamycin complex 1 (mTORC1) and the reprogramming of macrophages toward increased glycolysis to foster their proliferation and aggregation. This process sustained the further recruitment of granuloma-promoting immune cells and the associated pro-inflammatory microenvironment, and influenced the clinical course of the disease.

CONCLUSIONS

Our results identify PTX3 as a pivotal molecule that regulates complement-mediated signaling cues in macrophages to restrain granulomatous inflammation and highlight the therapeutic potential of this signaling axis in targeting granuloma formation in sarcoidosis.

Late diagnosis of pulmonary agenesis

Pulmonary agenesis is defined as the complete absence of one or both lungs, including the bronchi, bronchioles, vasculature and lung parenchyma. Most of these malformations are detected in early childhood. A residual number remains asymptomatic and undiagnosed until adulthood. The clinical presentation is wide, ranging from asymptomatic to respiratory complaints like dyspnoea, respiratory distress and a history of recurrent lung infections. This case presents a 54-year-old woman with complaints of coughing, dyspnoea for medium exertion and wheezing for a couple of months. Based on the results of complementary diagnosis methods, right pulmonary agenesis was diagnosed without other malformations. Simultaneously, an asthma diagnosis was also performed. The treatment of pulmonary agenesis is symptomatic. Simultaneous cardiovascular malformations could require surgical interventions. This case demonstrates that pulmonary agenesis may remain undiagnosed, be identified incidentally, and have a good and long prognosis.

Pneumonia Organizativa Fibrinosa Aguda Induzida pelo Rituximab: Uma Entidade a (Re)conhecer

A pneumonia organizativa fibrinosa aguda é uma entidade histológica, incluída no grupo das doenças pulmonares intersticiais, com múltiplas etiologias, incluindo a toxicidade farmacológica.Os autores descrevem o caso de um homem de 73 anos, com diagnóstico de linfoma linfoplasmocítico, sob tratamento de manutenção com rituximab após quimioterapia. O doente desenvolveu um quadro clínico insidioso caracterizado por tosse não produtiva, dispneia e astenia. A integração dos aspetos imagiológicos e da histologia de biópsia pulmonar conduziram ao diagnóstico de pneumonia organizativa fibrinosa aguda. Após suspensão do fármaco e instituição de corticoterapia o doente apresentou evolução clínica e imagiológica favorável.Dada a utilização crescente de terapêuticas-alvo em oncologia, o presente caso pretende contribuir para o reconhecimento desta entidade como potencial evento adverso. Recebido: 07/06/2017 - Aceite: 30/08/2017

Chronic granulomatous disease associated with common variable immunodeficiency - 2 clinical cases

INTRODUCTION

Chronic granulomatous disease associated with common variable immunodeficiency (GD-CVID), although well documented, is rare. Granulomatous lesions can affect several organs and are histologically indistinguishable from sarcoidosis.

CLINICAL CASES

Case 1: A 39-year-old male patient with CVID, asymptomatic although with thrombocytopenia and mediastinal-hilar adenopathies. GD-CVID was diagnosed by bone marrow biopsy. Progressive clinical and radiological improvement was obtained with corticotherapy. Case 2: A 38-year-old male patient with CVID, suffered from asthenia, anorexia, myalgia, lower limbs edemas, and dry cough. He had mediastinal and bilateral hilar adenopathies within which biopsy revealed non-necrotizing granulomatous infiltrate. A spontaneous resolution was detected after 9 months of evolution.

CONCLUSION

GD-CVID is rare and can mimetize other pathologies, namely, sarcoidosis; it should therefore be publicized and discussed so that it becomes a general clinical knowledge.