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Rai MP, Lee EJ, Bussel JB. Maintenence rituximab following induction in autoimmune cytopenias. Br J Haematol 2023. [PMID: 37086173 DOI: 10.1111/bjh.18814] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 04/23/2023]
Abstract
About 50% of immune thrombocytopenia (ITP) patients respond to rituximab induction, but most relapse. The effectiveness of rituximab maintenance remains untested. This study included autoimmune cytopenia patients who had previously responded to rituximab induction but subsequently relapsed. After re-induction, patients received rituximab maintenance regimen consisting of a single 375 mg/m2 dose administered at 4 month intervals, with a maximum of 6 doses. Primary endpoints were duration of response and safety. Sixteen patients: ITP (9), autoimmune haemolytic anaemia (2), and Evans syndrome (5) received rituximab maintenance. 15/16 achieved complete response (CR); 8/15 CR + 1 partial reponse remain in remission. Median response: 43 months; estimated 5-year relapse-free >50%. Three developed hypogammaglobulinemia. Rituximab maintenance led to prolonged remissions in patients with autoimmune cytopenias who had previously responded to rituximab induction.
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Affiliation(s)
- Manoj P Rai
- Division of Hematology-Oncology, Oregon Health and Science University, Portland, Oregon, USA
- Divisions of Hematology/Oncology and Pediatric Hematology-Oncology, Weill Cornell Medical College, New York, New York, USA
| | - Eun-Ju Lee
- Divisions of Hematology/Oncology and Pediatric Hematology-Oncology, Weill Cornell Medical College, New York, New York, USA
| | - James B Bussel
- Divisions of Hematology/Oncology and Pediatric Hematology-Oncology, Weill Cornell Medical College, New York, New York, USA
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Miano M, Guardo D, Grossi A, Palmisani E, Fioredda F, Terranova P, Cappelli E, Lupia M, Traverso M, Dell'Orso G, Corsolini F, Beccaria A, Lanciotti M, Ceccherini I, Dufour C. Underlying Inborn Errors of Immunity in Patients With Evans Syndrome and Multilineage Cytopenias: A Single-Centre Analysis. Front Immunol 2022; 13:869033. [PMID: 35655776 PMCID: PMC9152001 DOI: 10.3389/fimmu.2022.869033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/07/2022] [Indexed: 02/05/2023] Open
Abstract
Background Evans syndrome (ES) is a rare disorder classically defined as the simultaneous or sequential presence of autoimmune haemolytic anaemia and immune thrombocytopenia, but it has also been described as the presence of at least two autoimmune cytopenias. Recent reports have shown that ES is often a manifestation of an underlying inborn error of immunity (IEI) that can benefit from specific treatments. Aims The aim of this study is to investigate the clinical and immunological characteristics and the underlying genetic background of a single-centre cohort of patients with ES. Methods Data were obtained from a retrospective chart review of patients with a diagnosis of ES followed in our centre. Genetic studies were performed with NGS analysis of 315 genes related to both haematological and immunological disorders, in particular IEI. Results Between 1985 and 2020, 40 patients (23 men, 17 women) with a median age at onset of 6 years (range 0-16) were studied. ES was concomitant and sequential in 18 (45%) and 22 (55%) patients, respectively. Nine of the 40 (8%) patients had a positive family history of autoimmunity. Other abnormal immunological features and signs of lymphoproliferation were present in 24/40 (60%) and 27/40 (67%) of cases, respectively. Seventeen out of 40 (42%) children fit the ALPS diagnostic criteria. The remaining 21 (42%) and 2 (5%) were classified as having an ALPS-like and an idiopathic disease, respectively. Eighteen patients (45%) were found to have an underlying genetic defect on genes FAS, CASP10, TNFSF13B, LRBA, CTLA4, STAT3, IKBGK, CARD11, ADA2, and LIG4. No significant differences were noted between patients with or without variant and between subjects with classical ES and the ones with other forms of multilineage cytopenias. Conclusions This study shows that nearly half of patients with ES have a genetic background being in most cases secondary to IEI, and therefore, a molecular evaluation should be offered to all patients.
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Affiliation(s)
- Maurizio Miano
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Daniela Guardo
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alice Grossi
- Unità Operativa Semplice DIpartimentale (UOSD) Genetics and Genomics of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Elena Palmisani
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Paola Terranova
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Enrico Cappelli
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Michela Lupia
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Monica Traverso
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | - Gianluca Dell'Orso
- Stem Cell Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Fabio Corsolini
- Laboratory of Molecular Genetics and Biobanks, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Beccaria
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Isabella Ceccherini
- Unità Operativa Semplice DIpartimentale (UOSD) Genetics and Genomics of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Carlo Dufour
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Garg M, Agarwal S, Altohami M. A single dose of eculizumab terminated life-threatening haemolysis in idiopathic IgM-mediated warm autoimmune haemolytic anaemia: A case report. Br J Haematol 2022; 197:e28-e31. [PMID: 34993954 DOI: 10.1111/bjh.18011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 12/07/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Mamta Garg
- Department of Haematology, University Hospitals of Leicester, Leicester, UK
| | - Siddharth Agarwal
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Mohammed Altohami
- Department of Haematology, University Hospitals of Leicester, Leicester, UK
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Stöver A, Haberl B, Helmreich C, Müller W, Musshoff F, Fels H, Graw M, Groth O. Fatal Immunohaemolysis after the Consumption of the Poison Pax Mushroom: A Focus on the Diagnosis of the Paxillus Syndrome with the Aid of Two Case Reports. Diagnostics (Basel) 2019; 9:E130. [PMID: 31561486 DOI: 10.3390/diagnostics9040130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 11/16/2022] Open
Abstract
This retrospective report focuses on the diagnosis of the Paxillus syndrome, based on two fatal cases of haemolysis following the consumption of Paxillus involutus. These mushrooms are still consumed regularly, despite earlier reports of life-threatening autoimmune haemolytic anaemia. Such cases are nevertheless rare, and thus far no toxin could be identified that causes this unusual form of mushroom poisoning. All these factors contribute to the difficulty in diagnosing the Paxillus syndrome. The following aspects support the diagnosis in the two cases presented here: Both patients consumed the mushroom oftentimes before, yet allegedly without ill effects. Symptoms occurred 2–3 h after the last consumption, exacerbating into circulatory collapse, multiorgan failure, and death. Disseminated intravascular coagulation was identified as cause of death by autopsy of patient 1. Patient 2 died of multiorgan failure, mainly hepatic. Our mycological analyses could identify the consumed mushroom in both cases as Paxillus involutus. Furthermore, we could exclude anticoagulants and several other drugs as trigger for the haemolysis by post-mortem toxicological analysis. However, findings in each of the two cases may have led to the haemolysis, independent of the consumption of Paxillus involutus. Patient 1 carried the anti-erythrocytic antibody, auto-anti-e. Patient 2 contracted chronic hepatitis C years prior to the current incident. Considering the rarity of the Paxillus syndrome, our findings suggest that these patients were particularly susceptible for haemolysis after consuming this mushroom over a prolonged period. Occurrence of the Paxillus syndrome may thus be restricted to regular consumers of Paxillus involutus mushrooms with an existing predisposition for haemolysis.
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Hampel PJ, Larson MC, Kabat B, Call TG, Ding W, Kenderian SS, Bowen D, Boysen J, Schwager SM, Leis JF, Chanan-Khan AA, Muchtar E, Hanson CA, Slager SL, Kay NE, Chaffee KG, Shanafelt TD, Parikh SA. Autoimmune cytopenias in patients with chronic lymphocytic leukaemia treated with ibrutinib in routine clinical practice at an academic medical centre. Br J Haematol 2018; 183:421-427. [PMID: 30117139 DOI: 10.1111/bjh.15545] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [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: 04/24/2018] [Accepted: 07/05/2018] [Indexed: 01/04/2023]
Abstract
The effects of ibrutinib on the natural history of autoimmune cytopenias (AIC) among chronic lymphocytic leukaemia (CLL) patients treated in routine clinical practice require further investigation. Using the Mayo Clinical CLL Database, 193 CLL patients treated with ibrutinib between November 2013 and January 2017 outside the context of a clinical trial were identified; complete review of their medical records was performed for details of past history of AIC and treatment-emergent AIC. We identified 29/193 (15%) patients with history of AIC prior to ibrutinib start. Of 12 patients requiring AIC therapy at ibrutinib start, 8 (67%) were able to discontinue or de-escalate AIC treatment, and no patient had worsening of their AIC after initiating ibrutinib. Eleven (6%) patients developed treatment-emergent AIC after a median of 59 (range, 6-319) days following the initiation of ibrutinib, 7 of whom (64%) were able to continue ibrutinib. Overall and event-free survival from time of ibrutinib start were not significantly different between patients with history of AIC and those with no history of AIC. Treatment-emergent AIC were seen exclusively in patients with unmutated IGHV and were associated with a shorter EFS. These results suggest a low rate of treatment-emergent AIC and improvement in patients with existing AIC.
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Affiliation(s)
- Paul J Hampel
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Melissa C Larson
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Brian Kabat
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Timothy G Call
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wei Ding
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Saad S Kenderian
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Deborah Bowen
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Justin Boysen
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Susan M Schwager
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jose F Leis
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Eli Muchtar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Curtis A Hanson
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Susan L Slager
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Neil E Kay
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kari G Chaffee
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Tait D Shanafelt
- Department of Hematology, Stanford University Medical Center, Stanford, CA, USA
| | - Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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