Coordination régionale et suivi prospectif du traitement prophylactique et curatif de 301 patients traités par anticorps monoclonaux anti-SARS-CoV-2

Introduction

La pandémie a particulièrement mis en danger nos patients immunodéprimés et questionne notre place dans l’organisation de l’administration des anticorps monoclonaux à titre préventif et curatif. L’objectif de l’étude a été d’évaluer l’activité d’une cellule régionale mise en place pour évaluer l’indication, organiser le traitement prophylactique ou curatif par anticorps monoclonaux ou par antiviraux, quelle que soit la pathologie chronique des patients concernés.

Matériels et méthodes

La cellule « anticorps monoclonaux et traitements du COVID », composée d’un médecin coordonnateur, de médecins retraités, et d’une secrétaire médicale, a été mise en place début janvier 2022 grâce à un financement par l’ARS. Tous les médecins ont été informés par l’ARS et les URPS, des critères d’éligibilité aux anticorps monoclonaux et du rôle de la cellule dans l’évaluation de l’indication, l’aide apportée pour la demande d’accès précoce et la logistique (injections en hospitalisation de jour ou en hospitalisation à domicile (HAD)). Les structures d’HAD ont été spécifiquement formées aux formalités de prescription, à l’administration et au suivi de ces patients. Les patients ayant reçu un traitement prophylactique ont été recontactés par la cellule la semaine suivant l’injection, 3 mois et 6 mois suivant l’injection. Des questionnaires ont été adressés aux médecins généralistes pour évaluer leur perception concernant les anticorps monoclonaux et les antiviraux.

Résultats

Au total, 216 patients (dont 121 patients ayant des facteurs de risque cardiovasculaire) ont reçu un traitement prophylactique par anticorps monoclonaux (Evusheld), pour les indications suivantes : 110 patients transplantés d’organe, 95 patients traités par anti-CD20, 2 patients traités par chimiothérapie, 8 patients ayant d’autres facteurs d’immunodépression et 1 contre-indication au vaccin. Les sollicitations de la cellule dans cette indication émanaient quasi exclusivement de médecins spécialistes. Avec un suivi médian de 6 mois, aucun événement indésirable (EI) grave, y compris cardiovasculaire, n’est survenu. Des EI non graves ont été observés chez 50 patients (23 %). Trente patients (14 %) ont été infectés par le SARS-CoV-2, dont 2 ont été traités par anticorps monoclonaux à titre curatif et 2 par Paxlovid. Aucun patient n’a été hospitalisé pour COVID, aucun n’a développé de COVID sévère. Sur les 214 patients recontactés pour une ré-administration d’anticorps à visée prophylactique, 12 (5 %) l’ont refusée. Au total, 85 patients ont été traités par anticorps monoclonaux à visée curative dont 3 par Ronapreve, 68 par Xevudy, 14 par Evusheld, dont 53 (62,3 %) en HAD et 30 patients ont été traités par Paxlovid. Les sollicitations de la cellule dans cette indication émanaient le plus souvent de médecins généralistes. Aucun effet indésirable grave n’a été observé.

Conclusion

La coordination régionale pour l’aide au traitement par anticorps monoclonaux et antiviraux est utile pour faciliter la prescription de ces traitements. Le suivi prospectif confirme leur tolérance très satisfaisante. Cette coordination a également permis d’évaluer les difficultés rencontrées par les médecins généralistes, en partie liées au caractère innovant, aux difficultés logistiques ou aux contraintes administratives de ces traitements.

[French practical guidelines for the diagnosis and management of IPF - 2021 update, full version]

BACKGROUND

Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated.

METHODS

Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale.

RESULTS

After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis.

CONCLUSION

These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.

[French practical guidelines for the diagnosis and management of IPF - 2021 update, short version]

BACKGROUND

Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated.

METHODS

Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale.

RESULTS

After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis.

CONCLUSION

These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.

[Effect of surgery of pulmonary cysts related to immunoglobulin light chain deposits]

INTRODUCTION

Light chain deposition disease is a rare anatomo-clinical disorder, which rarely leads to cystic lung destruction.

CASE REPORT

We report the case of a 62years old female patient with a history of a monoclonal gammopathy of unknown significance who developed progressive dyspnea. Thoracic CT-scan demonstrated a diffuse pulmonary cystic disorder with predominance in the right lower lobe. Thoracoscopic surgical resection of that lobe led to a diagnosis of non-amyloid kappa light chain deposits. Surgery also resulted in a lung volume reduction effect with clinical and functional benefits related to improved ventilation of adjacent segments.

CONCLUSION

This report of pulmonary cystic disorder related to a light chain deposition disease highlights the potential clinical and functional benefits observed after lung volume reduction surgery.

Blood CD9+ B cell, a biomarker of bronchiolitis obliterans syndrome after lung transplantation

Bronchiolitis obliterans syndrome is the main limitation for long-term survival after lung transplantation. Some specific B cell populations are associated with long-term graft acceptance. We aimed to monitor the B cell profile during early development of bronchiolitis obliterans syndrome after lung transplantation. The B cell longitudinal profile was analyzed in peripheral blood mononuclear cells from patients with bronchiolitis obliterans syndrome and patients who remained stable over 3 years of follow-up. CD24^hi CD38^hi transitional B cells were increased in stable patients only, and reached a peak 24 months after transplantation, whereas they remained unchanged in patients who developed a bronchiolitis obliterans syndrome. These CD24^hi CD38^hi transitional B cells specifically secrete IL-10 and express CD9. Thus, patients with a total CD9⁺ B cell frequency below 6.6% displayed significantly higher incidence of bronchiolitis obliterans syndrome (AUC = 0.836, PPV = 0.75, NPV = 1). These data are the first to associate IL-10-secreting CD24^hi CD38^hi transitional B cells expressing CD9 with better allograft outcome in lung transplant recipients. CD9-expressing B cells appear as a contributor to a favorable environment essential for the maintenance of long-term stable graft function and as a new predictive biomarker of bronchiolitis obliterans syndrome-free survival.

Acute Cardiac Failure Due to Takotsubo Cardiomyopathy Secondary to a Phone Call for Lung Transplantation: A Case Report

Lung transplantation is a therapeutic option for certain end-stage lung diseases. The phone call for lung transplantation is a major event in the life of these patients; as a result, it can generate significant stress. We herein present the case of a 58-year-old female patient with end-stage chronic obstructive pulmonary disease (COPD) who, while on the lung transplantation waiting list, received such a call. Complete transplant work-up, including cardiac tests undertaken shortly before, had revealed no contraindication to lung transplantation. She was admitted with severe acute respiratory failure, and her extensive work-up was compatible with pulmonary edema due to takotsubo cardiomyopathy. The lung transplantation was thus cancelled, owing to the patient's health condition and the poor quality of the graft as well. The patient stayed in the intensive care unit for several days, requiring noninvasive ventilation. The left ventricular function recovered completely within 10 days postdiagnosis, and the patient was discharged 13 days after her admission. The patient was transplanted 1 month thereafter, without any particular problems; she is currently, 8 months post-transplantation, in good condition. In the given case, the call for lung transplantation could have generated emotional stress severe enough to lead to takotsubo cardiomyopathy.

Design and assembly of a chemically switchable and fluorescently traceable light-driven proton pump system for bionanotechnological applications

Energy-supplying modules are essential building blocks for the assembly of functional multicomponent nanoreactors in synthetic biology. Proteorhodopsin, a light-driven proton pump, is an ideal candidate to provide the required energy in form of an electrochemical proton gradient. Here we present an advanced proteoliposome system equipped with a chemically on-off switchable proteorhodopsin variant. The proton pump was engineered to optimize the specificity and efficiency of chemical deactivation and reactivation. To optically track and characterize the proteoliposome system using fluorescence microscopy and nanoparticle tracking analysis, fluorescenlty labelled lipids were implemented. Fluorescence is a highly valuable feature that enables detection and tracking of nanoreactors in complex media. Cryo-transmission electron microscopy, and correlative atomic force and confocal microscopy revealed that our procedure yields polylamellar proteoliposomes, which exhibit enhanced mechanical stability. The combination of these features makes the presented energizing system a promising foundation for the engineering of complex nanoreactors.

Clinical usefulness of oral immunoglobulins in lung transplant recipients with norovirus gastroenteritis: a case series

Viral gastroenteritis causing diarrhea is a common complication observed in lung transplant recipients. Differently from the mild and typically self-limited disease seen in immunocompetent subjects, immunocompromised patients frequently have a more severe course. Norovirus and rotavirus are among the leading causes of severe gastroenteritis in transplant recipients. Specific treatment is unavailable, although good supportive treatment can significantly reduce morbidity. Previous studies have suggested that oral immunoglobulins may be used for the treatment of acute viral gastroenteritis after solid-organ transplantation. Herein, we conducted a retrospective chart review of 12 lung transplant recipients with norovirus-induced gastroenteritis who were treated with oral immunoglobulins for 2 days. Eleven patients were successfully treated, whereas 1 subject was only mildly improved. Four patients had at least 1 recurrence. No significant adverse effects were observed. We conclude that oral immunoglobulins may be clinically useful for lung transplant recipients with norovirus-induced gastroenteritis.

[The Overlap Syndrome: association of COPD and Obstructive Sleep Apnoea]

Chronic obstructive pulmonary disease (COPD) and the obstructive sleep apnoea-hypopnoea syndrome (OSAHS) are both common diseases affecting respectively 10 and 5% of the adult population over 40 years of age. Their coexistence, which is denominated "Overlap Syndrome", can be expected to occur in about 0.5% of this population. Two recent epidemiologic studies have shown that the prevalence of OSAHS is not higher in COPD than in the general population, and that the coexistence of the two conditions is due to chance and not through a pathophysiological linkage. Patients with "overlap" have a higher risk of sleep-related O(2) desaturation than do patients with COPD alone and the same degree of bronchial obstruction. They have an increased risk of developing hypercapnic respiratory failure and pulmonary hypertension when compared with patients with OSAHS alone and with patients with "usual" COPD. In patients with overlap, hypoxaemia, hypercapnia, and pulmonary hypertension can be observed in the presence of mild to moderate bronchial obstruction, which is different from "usual" COPD. Treatment of the overlap syndrome consists of nasal continuous positive airway pressure or nocturnal non-invasive ventilation (NIV), with or without nocturnal O(2). Patients who are markedly hypoxaemic during the daytime (PaO(2)<55-60 mmHg) should be given conventional long-term O(2) therapy in addition to nocturnal ventilation.

Ulcère gastrique perforé révélé par un pneumothorax hypertensif

Fistulous communications between the abdomen and pleural space are rare. The Authors report a case of hydropneumothorax following transdiaphragmatic perforation of an anterior wall gastric ulcer.

Bilateral hemothorax revealing mediastinal parathyroid adenoma

We report the case of a 63-year-old woman admitted to hospital because of bilateral hemothorax associated with acute respiratory failure and laterotracheal neoformation. A right thoracoscopy biopsy revealed a paratracheal parathyroid adenoma which was responsible for bilateral hemothorax and primary hyperparathyroidism. A curative resection was successfully performed by cervicotomy.

[Pulmonary sarcoid-like granulomatosis associated with Hodgkin's disease and complicated by bleomycin-induced pulmonary nodules]

We report the case of a man in whom multiple lung macronodules developed after chemotherapy containing bleomycin for Hodgkin's disease, which was itself shortly preceded by a pulmonary sarcoid-like granulomatosis. Biopsy of the nodules showed fibrotic and granulomatous lesions. The etiological diagnosis is discussed.