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Chastain DB, Spradlin M, Ahmad H, Henao-Martínez AF. Unintended Consequences: Risk of Opportunistic Infections Associated With Long-term Glucocorticoid Therapies in Adults. Clin Infect Dis 2024; 78:e37-e56. [PMID: 37669916 DOI: 10.1093/cid/ciad474] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Indexed: 09/07/2023] Open
Abstract
Glucocorticoids are widespread anti-inflammatory medications used in medical practice. The immunosuppressive effects of systemic glucocorticoids and increased susceptibility to infections are widely appreciated. However, the dose-dependent model frequently used may not accurately predict the risk of infection in all patients treated with long-term glucocorticoids. In this review, we examine the risks of opportunistic infections (OIs) in patients requiring glucocorticoid therapy by evaluating the influence of the glucocorticoid dose, duration, and potency, combined with biological and host clinical factors and concomitant immunosuppressive therapy. We propose strategies to prevent OIs, which involve screening, antimicrobial prophylaxis, and immunizations. While this review focuses on patients with autoimmune, inflammatory, or neoplastic diseases, the potential risks and preventative strategies are likely applicable to other populations. Clinicians should actively assess the benefit-harm ratios of systemic glucocorticoids and implement preventive efforts to decrease their associated infections complications.
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Affiliation(s)
- Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, Georgia, USA
| | - Megan Spradlin
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hiba Ahmad
- Division of Medical Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
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2
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Esnault V, Hoisnard L, Peiffer B, Fihman V, Fourati S, Angebault C, Champy C, Gallien S, Attias P, Morel A, Grimbert P, Melica G, Matignon M. Beyond the First Year: Epidemiology and Management of Late-Onset Opportunistic Infections After Kidney Transplantation. Transpl Int 2024; 37:12065. [PMID: 38468638 PMCID: PMC10926380 DOI: 10.3389/ti.2024.12065] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/13/2024] [Indexed: 03/13/2024]
Abstract
Late opportunistic infections (OI) occurring beyond the first year after kidney transplantation (KT) are poorly described and not targeted by prophylactic strategies. We performed a ten-year retrospective monocentric cohort study describing epidemiology, risk factors and impact of late OI occurring 1 year after KT. We included clinically symptomatic OI requiring treatment besides BK virus nephropathy. Control groups included early OI occurring in the first year after KT, and KT recipients without OI since KT and alive with a functional allograft at 1 year. Among 1066 KT recipients, 185 (19.4%) presented a first episode of OI 21.0 (8.0-45.0) months after KT: 120 late OI (64.9%) and 65 early OI (35.1%). Late OI were mainly viral (N = 83, 69.2%), mostly herpes zoster (HZ) (N = 36, 43.4%). Pneumocystis represented most late fungal infections (N = 12/25, 48%). Compared to early OI, we reported more pneumocystis (p = 0.002) and less invasive aspergillosis (p = 0.01) among late OI. Patients with late OI were significatively younger at KT (54.0 ± 13.3 vs. 60.2 ± 14.3 years, p = 0.05). Patient and allograft survival rates between late OI and control groups were similar. Only age was independently associated with mortality. While late OI were not associated with higher mortality or graft loss, implementing prophylactic strategies might prevent such infections.
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Affiliation(s)
- V. Esnault
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Maladies Infectieuses et d’Immunologie Clinique, Centre Hospitalo-Universitaire (CHU) Henri Mondor, Créteil, France
| | - L. Hoisnard
- Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, AP-HP, Henri Mondor Hospital, Créteil, France
- INSERM, Centre d’Investigation Clinique 1430, Créteil, France
- EpiDermE Epidemiology in Dermatology and Evaluation of Therapeutics, EA7379, Paris Est Créteil University UPEC, Créteil, France
| | - B. Peiffer
- AP-HP, Département Médico-Universitaire Médecine, CHU Henri Mondor, Créteil, France
| | - V. Fihman
- AP-HP, Service de Microbiologie, Département de Prévention, Diagnostic et Traitement des Infections, CHU Henri Mondor, Créteil, France
| | - S. Fourati
- AP-HP, Service de Microbiologie, Département de Prévention, Diagnostic et Traitement des Infections, CHU Henri Mondor, Créteil, France
| | - C. Angebault
- AP-HP, Service de Microbiologie, Département de Prévention, Diagnostic et Traitement des Infections, CHU Henri Mondor, Créteil, France
- EA DYNAMiC 7380, Faculté de Santé, University Paris-Est Créteil (UPEC), Ecole Nationale Vétérinaire d’Alfort (ENVA), USC Anses, Créteil, France
| | - C. Champy
- AP-HP, Service d’Urologie, CHU Henri Mondor, Créteil, France
| | - S. Gallien
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Maladies Infectieuses et d’Immunologie Clinique, Centre Hospitalo-Universitaire (CHU) Henri Mondor, Créteil, France
- EA DYNAMiC 7380, Faculté de Santé, University Paris-Est Créteil (UPEC), Ecole Nationale Vétérinaire d’Alfort (ENVA), USC Anses, Créteil, France
| | - P. Attias
- AP-HP, Service de Néphrologie et de Transplantation Rénale, Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », CHU Henri Mondor, Créteil, France
| | - A. Morel
- AP-HP, Service de Néphrologie et de Transplantation Rénale, Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », CHU Henri Mondor, Créteil, France
| | - P. Grimbert
- AP-HP, Service de Néphrologie et de Transplantation Rénale, Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », CHU Henri Mondor, Créteil, France
- University of Paris-Est-Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Team 21, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - G. Melica
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Maladies Infectieuses et d’Immunologie Clinique, Centre Hospitalo-Universitaire (CHU) Henri Mondor, Créteil, France
| | - M. Matignon
- AP-HP, Service de Néphrologie et de Transplantation Rénale, Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », CHU Henri Mondor, Créteil, France
- University of Paris-Est-Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Team 21, Institut Mondor de Recherche Biomédicale, Créteil, France
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Little JS, Duléry R, Shapiro RM, Aleissa MM, Prockop SE, Koreth J, Ritz J, Antin JH, Cutler C, Nikiforow S, Romee R, Issa NC, Ho VT, Baden LR, Soiffer RJ, Gooptu M. Opportunistic Infections in Patients Receiving Post-Transplantation Cyclophosphamide: Impact of Haploidentical versus Unrelated Donor Allograft. Transplant Cell Ther 2024; 30:233.e1-233.e14. [PMID: 37984797 DOI: 10.1016/j.jtct.2023.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
Post-transplantation cyclophosphamide (PTCy) is an effective strategy for graft-versus-host disease (GVHD) prophylaxis and is the standard of care for haploidentical hematopoietic cell transplantation (HCT). It is increasingly used for matched and mismatched unrelated donor (MUD/MMUD) HCT, but infections remain a concern. The objective of this study was to evaluate the characteristics and risk factors for infections in haploidentical and unrelated donor HCT recipients treated with PTCy-based GVHD prophylaxis. This single-center retrospective study examined 354 consecutive adults undergoing HCT with PTCy-based GVHD prophylaxis (161 MUD/MMUD; 193 haploidentical) between 2015 and 2022. Opportunistic infections (OIs), including cytomegalovirus (CMV), adenovirus (AdV), Epstein-Barr virus (EBV), and invasive fungal disease (IFD), were assessed from day 0 through day +365. The 1-year cumulative incidence functions of OIs and nonrelapse mortality (NRM) were calculated using dates of relapse and repeat HCT as competing risks. Secondary analysis evaluated risk factors for OIs and NRM using univariate and multivariable Cox regression models. Haploidentical HCT recipients had an increased risk of OIs compared to unrelated donor allograft recipients (39% for haploidentical versus 25% for MUD/MMUD; hazard ratio [HR], 1.70; 95% confidence interval [CI], 1.16 to 2.49; P = .006). On multivariable analysis, haploidentical donor (HR, 1.50; 95% CI, 1.01 to 2.23; P = .046), prior HCT (HR, 1.99; 95% CI, 1.29 to 3.09; P = .002), and diagnosis of aGVHD (HR, 1.47; 95% CI, 1.02 to 2.14; P = .041) were associated with increased risk of OIs. NRM within the first year was not significantly different between the 2 cohorts (HR, 1.11; 95% CI, .64 to 1.93; P = .70). Overall, haploidentical donor was a significant risk factor for OIs in patients receiving PTCy, although 1-year NRM was not different between haploidentical HCT and MUD/MMUD HCT recipients. CMV and AdV infections were significantly increased among haploidentical HCT recipients, whereas the incidences of EBV infection and IFD were similar in the 2 cohorts. Our findings may have implications for infection monitoring and prophylaxis in the setting of PTCy, particularly in haploidentical HCT recipients.
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Affiliation(s)
- Jessica S Little
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Rémy Duléry
- Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts; Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Inserm UMRs 938, Centre de recherche Saint-Antoine, Paris, France
| | - Roman M Shapiro
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Muneerah M Aleissa
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Susan E Prockop
- Harvard Medical School, Boston, Massachusetts; Hematopoietic Stem Cell Transplant Program, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - John Koreth
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jerome Ritz
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joseph H Antin
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Corey Cutler
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sarah Nikiforow
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Rizwan Romee
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nicolas C Issa
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Vincent T Ho
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lindsey R Baden
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert J Soiffer
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mahasweta Gooptu
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
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Agrawal D, Ravula PK, Verma G. An unusual opportunistic infection causing lower gastrointestinal tract bleeding in a patient with severe alcoholic hepatitis, post-liver transplantation. Transpl Infect Dis 2023; 25:e14062. [PMID: 37073834 DOI: 10.1111/tid.14062] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/20/2023]
Affiliation(s)
- Dhiraj Agrawal
- Department of Gastroenterology and Hepatology, PACE Hospitals, Hyderabad, Telangana, India
| | - Phani Krishna Ravula
- Department of Surgical Gastroenterology, PACE Hospitals, Hyderabad, Telangana, India
| | - Govind Verma
- Department of Gastroenterology and Hepatology, PACE Hospitals, Hyderabad, Telangana, India
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D'Haens G, Dubinsky M, Kobayashi T, Irving PM, Howaldt S, Pokrotnieks J, Krueger K, Laskowski J, Li X, Lissoos T, Milata J, Morris N, Arora V, Milch C, Sandborn W, Sands BE. Mirikizumab as Induction and Maintenance Therapy for Ulcerative Colitis. N Engl J Med 2023; 388:2444-2455. [PMID: 37379135 DOI: 10.1056/nejmoa2207940] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Mirikizumab, a p19-directed antibody against interleukin-23, showed efficacy in the treatment of ulcerative colitis in a phase 2 trial. METHODS We conducted two phase 3, randomized, double-blind, placebo-controlled trials of mirikizumab in adults with moderately to severely active ulcerative colitis. In the induction trial, patients were randomly assigned in a 3:1 ratio to receive mirikizumab (300 mg) or placebo, administered intravenously, every 4 weeks for 12 weeks. In the maintenance trial, patients with a response to mirikizumab induction therapy were randomly assigned in a 2:1 ratio to receive mirikizumab (200 mg) or placebo, administered subcutaneously, every 4 weeks for 40 weeks. The primary end points were clinical remission at week 12 in the induction trial and at week 40 (at 52 weeks overall) in the maintenance trial. Major secondary end points included clinical response, endoscopic remission, and improvement in bowel-movement urgency. Patients who did not have a response in the induction trial were allowed to receive open-label mirikizumab during the first 12 weeks of the maintenance trial as extended induction. Safety was also assessed. RESULTS A total of 1281 patients underwent randomization in the induction trial, and 544 patients with a response to mirikizumab underwent randomization again in the maintenance trial. Significantly higher percentages of patients in the mirikizumab group than in the placebo group had clinical remission at week 12 of the induction trial (24.2% vs. 13.3%, P<0.001) and at week 40 of the maintenance trial (49.9% vs. 25.1%, P<0.001). The criteria for all the major secondary end points were met in both trials. Adverse events of nasopharyngitis and arthralgia were reported more frequently with mirikizumab than with placebo. Among the 1217 patients treated with mirikizumab during the controlled and uncontrolled periods (including the open-label extension and maintenance periods) in the two trials, 15 had an opportunistic infection (including 6 with herpes zoster infection) and 8 had cancer (including 3 with colorectal cancer). Among the patients who received placebo in the induction trial, 1 had herpes zoster infection and none had cancer. CONCLUSIONS Mirikizumab was more effective than placebo in inducing and maintaining clinical remission in patients with moderately to severely active ulcerative colitis. Opportunistic infection or cancer occurred in a small number of patients treated with mirikizumab. (Funded by Eli Lilly; LUCENT-1 and LUCENT-2 ClinicalTrials.gov numbers, NCT03518086 and NCT03524092, respectively.).
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Affiliation(s)
- Geert D'Haens
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Marla Dubinsky
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Taku Kobayashi
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Peter M Irving
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Stefanie Howaldt
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Juris Pokrotnieks
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Kathryn Krueger
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Janelle Laskowski
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Xingyuan Li
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Trevor Lissoos
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Joe Milata
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Nathan Morris
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Vipin Arora
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Catherine Milch
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - William Sandborn
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
| | - Bruce E Sands
- From the Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam (G.D.); Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York (M.D., B.E.S.); the Center for Advanced IBD Research and Treatment, Kitasato University, Kitasato Institute Hospital, Tokyo (T.K.); Guy's Hospital, St. Thomas' Hospital, and the School of Immunology and Microbial Sciences, King's College London - all in London (P.M.I.); Research Institute for IBD-HaFCED, Hamburg, Germany (S.H.); Riga Stradins University, Riga, Latvia (J.P.); Eli Lilly, Indianapolis (K.K., J.L., X.L., T.L., J.M., N.M., V.A., C.M.); and the University of California San Diego, La Jolla (W.S.)
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Olivera PA, Lasa JS, Zubiaurre I, Jairath V, Abreu MT, Rubin DT, Reinisch W, Magro F, Rahier JF, Danese S, Rabaud C, Peyrin-Biroulet L. Opportunistic Infections in Patients with Inflammatory Bowel Disease Treated with Advanced Therapies: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Crohns Colitis 2023; 17:199-210. [PMID: 36087107 DOI: 10.1093/ecco-jcc/jjac133] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Advanced therapies for inflammatory bowel disease [IBD] could potentially lead to a state of immunosuppression with an increased risk of opportunistic infections [OIs]. We aimed to provide an update on the incidence of OIs among adult IBD patients in randomized controlled trials [RCTs] of approved biologics and small-molecule drugs [SMDs]. Also, we aimed to describe OI definitions utilized in RCTs, to ultimately propose a standardized definition. METHODS Electronic databases were searched from January 1, 1990, until April 16, 2022. Our primary outcome was incidence rate of overall OIs among IBD patients exposed and unexposed to biologics or SMDs. We also describe specific OIs reported in included trials, as well as definitions of OIs within studies when provided. RESULTS Ninety studies were included. The incidence rates of reported OIs were 0.42 and 0.21 per 100 person-years in patients exposed to advanced therapies and placebo, respectively. This was highest for anti-tumour necrosis factors [0.83 per 100 person-years] and Janus kinase inhibitors [0.55 per 100 person-years] and lowest for anti-integrins and ozanimod. On meta-analysis, no increased risk of OIs was observed. None of the studies provided a detailed definition of OIs, or a comprehensive list of infections considered as OIs. CONCLUSION Different mechanisms of action may have specific OI profiles. In the absence of a uniform definition of OIs, these estimates are less reliable. We propose a definition to be used in future studies to help provide standardized reporting. When using this definition, we saw significant differences in incidence rates of OIs across mechanisms of action.
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Affiliation(s)
- Pablo A Olivera
- IBD Unit, Gastroenterology Section, Department of Internal Medicine, Centro de Educación Médica e Investigación Clínica (CEMIC), Buenos Aires, Argentina
- Zane Cohen Centre for Digestive Diseases, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Juan S Lasa
- IBD Unit, Gastroenterology Section, Department of Internal Medicine, Centro de Educación Médica e Investigación Clínica (CEMIC), Buenos Aires, Argentina
- Gastroenterology Department, Hospital Británico de Buenos Aires, Argentina
| | - Ignacio Zubiaurre
- Gastroenterology Department, Hospital Británico de Buenos Aires, Argentina
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- Alimentiv Inc., London, ON, Canada
| | - Maria T Abreu
- Department of Medicine, Division of Gastroenterology, Crohn's and Colitis Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David T Rubin
- University of Chicago Medicine, Inflammatory Bowel Disease Center, Chicago, IL, USA
| | - Walter Reinisch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Fernando Magro
- Department of Pharmacology & Therapeutics; CINTESIS, Faculty of Medicine University of Porto, and Department of Gastroenterology, Hospital de São João, Porto, Portugal
| | - Jean-François Rahier
- Department of Gastroenterology and Hepatology, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milano, Italy
| | - Christian Rabaud
- Department of Infectious Disease, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Laurent Peyrin-Biroulet
- INSERM NGERE and Department of Hepatogastroenterology, Nancy University Hospital, Lorraine University, Vandoeuvre-lés-Nancy, France
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7
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Kim DJ, Jeong S, Kong SG, Lee S, Lim SN, Oh SY, Do YR, Lee WS, Lee MH, Bae SH, Kim SH, Kim MK, Lee HS. Incidence and risk factors of opportunistic infections after autologous stem cell transplantation: a nationwide, population-based cohort study in Korea. Sci Rep 2023; 13:2551. [PMID: 36781859 PMCID: PMC9925816 DOI: 10.1038/s41598-023-27465-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 01/02/2023] [Indexed: 02/15/2023] Open
Abstract
Several guidelines classify autologous stem cell transplantation (ASCT) as a low to intermediate risk group for infection. In a nationwide population-based study, using the Korean Health Insurance Review and Assessment Service database, patients with lymphoma and multiple myeloma (MM) who underwent ASCT from 2002 to 2016 were retrospectively analyzed. Cumulative incidence rates (CIRs) and risk factors of opportunistic infections were investigated. CIRs of fungal, Varicella zoster virus (VZV), cytomegalovirus (CMV), and Pneumocystis jirovecii infections in lymphoma were 7.9%, 16.0%, 7.4%, and 5.1%, respectively, and CIRs in MM were 6.3%, 19.1%, 4.2%, and 5.6%, respectively. Fungal infection was significantly higher in patients with previous infection (Hazard ratio (HR) 2.003, p = 0.005) in lymphoma. Incidence of CMV infection was significantly higher in patients with prior CMV infection: HR 4.920, p < 0.001 (lymphoma); HR 3.022, p = 0.030 (MM). VZV infection was significantly lower in patients receiving prophylaxis: HR 0.082, p < 0.001 (lymphoma); HR 0.096, p < 0.001 (MM). For P. jirovecii infection, busulfex and melphalan conditioning (HR 1.875, p = 0.032) and previous P. jirovecii infection (HR 4.810, p < 0.001) had a higher incidence in MM. Patients who underwent ASCT should receive VZV prophylaxis and prophylaxis for fungal and P. jirovecii may be considered in patients with previous same infection.
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Affiliation(s)
- Da Jung Kim
- Department of Internal Medicine, Kosin University College of Medicine, 34 Amnam-Dong, Seo-Gu, Busan, 49267, South Korea
| | - Seri Jeong
- Department of Laboratory Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, 07441, South Korea
| | - Seom Gim Kong
- Department of Pediatrics, Kosin University College of Medicine, Busan, 49267, Korea
| | - Sangjin Lee
- Graduate School, Department of Statistics, Pusan National University, Busan, 46241, Korea
| | - Sung-Nam Lim
- Department of Internal Medicine, Haeundae Paik Hospital, College of Medicine Inje University, Busan, 48108, Korea
| | - Sung Yong Oh
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, 49201, Korea
| | - Young Rok Do
- Division of Hematology-Oncology, Department of Medicine, Dongsan Medical Center, Keimyung University, Daegu, 41931, Korea
| | - Won Sik Lee
- Department of Internal Medicine, Busan Paik Hospital, College of Medicine Inje University, Busan, 47392, South Korea
| | - Mark Hong Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, 05030, South Korea
| | - Sung Hwa Bae
- Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, 42472, South Korea
| | - Se Hyung Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, 14584, South Korea
| | - Min Kyoung Kim
- Department of Hematology-Oncology, Yeungnam University Medical Center, Yeungnam University School of Medicine, Daegu, 42415, South Korea
| | - Ho Sup Lee
- Department of Internal Medicine, Kosin University College of Medicine, 34 Amnam-Dong, Seo-Gu, Busan, 49267, South Korea.
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Fragoulis GE, Dey M, Zhao S, Schoones J, Courvoisier D, Galloway J, Hyrich KL, Nikiphorou E. Systematic literature review informing the 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. RMD Open 2022; 8:rmdopen-2022-002726. [PMID: 36323488 PMCID: PMC9639159 DOI: 10.1136/rmdopen-2022-002726] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To conduct a systematic literature review (SLR) on the screening and prophylaxis of opportunistic and chronic infections in autoimmune inflammatory rheumatic diseases (AIIRD). METHODS SLR (inception-12/2021) based on the following search domains: (1) infectious agents, (2) AIIRD, (3) immunosuppressives/immunomodulators used in rheumatology, (4) screening terms and (5) prophylaxis terms. Articles were retrieved having the terms from (1) AND (2) AND (3) plus terms from (4) OR(5). Databases searched: PubMed, Embase and Cochrane Library. EXCLUSION CRITERIA studies on postoperative infections, paediatric AIIRD, COVID-19, vaccinations and non-Εnglish literature. Study quality was assessed with Newcastle-Ottawa scale for non-randomised controlled trials (RCTs), RoB-Cochrane for RCTs, AMSTAR2 for SLRs. RESULTS From 5641 studies were retrieved, 568 full-text articles were assessed for eligibility, with 194 articles finally included. For tuberculosis, tuberculin skin test (TST) is affected by treatment with glucocorticoids and conventional synthetic disease modifying anti-rheumatic drugs (DMARDs) and its performance is inferior to interferon gamma release assay (IGRA). Agreement between TST and IGRA is moderate to low. For hepatitis B virus (HBV): risk of reactivation is increased in patients positive for hepatitis B surface antigen. Anti-HBcore positive patients are at low risk for reactivation but should be monitored periodically with liver function tests and/or HBV-viral load. Risk for Hepatitis C reactivation is existing but low in patients treated with biological DMARDs. For Pneumocystis jirovecii, prophylaxis treatment should be considered in patients treated with prednisolone ≥15-30 mg/day for >2-4 weeks. CONCLUSIONS Different screening and prophylaxis approaches are described in the literature, partly determined by individual patient and disease characteristics.
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Affiliation(s)
- George E Fragoulis
- Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Rheumatology, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Sizheng Zhao
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Jan Schoones
- Directorate of Research Policy, Leiden University Medical Center, Leiden, The Netherlands
| | | | - James Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- National Institute of Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK
- Rheumatology Department, King's College London, London, UK
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Núñez I, Crabtree-Ramirez B, Shepherd BE, Sterling TR, Cahn P, Veloso VG, Cortes CP, Padgett D, Gotuzzo E, Sierra-Madero J, McGowan CC, Person AK, Caro-Vega Y. Late-onset opportunistic infections while receiving anti-retroviral therapy in Latin America: burden and risk factors. Int J Infect Dis 2022; 122:469-475. [PMID: 35768025 PMCID: PMC9851270 DOI: 10.1016/j.ijid.2022.06.041] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 04/28/2022] [Accepted: 06/23/2022] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES The aim of this study was to describe the incidence, clinical characteristics, and risk factors of late-onset opportunistic infections (LOI) in people who live with HIV (PWLHA) within the Caribbean, Central and South America network for HIV epidemiology. METHODS We performed a retrospective cohort study including treatment-naive PWLHA enrolled at seven sites (Argentina, Brazil, Chile, Peru, Mexico, and two sites in Honduras). Follow-up began at 6 months after treatment started. Outcomes were LOI, loss to follow-up, and death. We used a Cox proportional hazards model and a competing risks model to evaluate risk factors. RESULTS A total of 10,583 patients were included. Median follow up was at 5.4 years. LOI occurred in 895 (8.4%) patients. Median time to opportunistic infection was 2.1 years. The most common infections were tuberculosis (39%), esophageal candidiasis (10%), and Pneumocystis jirovecii (P. jirovecii) pneumonia (10%). Death occurred in 576 (5.4%) patients, and 3021 (28.5%) patients were lost to follow-up. A protease inhibitor-based regimen (hazard ratio 1.25), AIDS-defining events during the first 6 months of antiretroviral-treatment (hazard ratio 2.12), starting antiretroviral-treatment in earlier years (hazard ratio 1.52 for 2005 vs 2010), and treatment switch (hazard ratio 1.31) were associated with a higher risk of LOI. CONCLUSION LOI occurred in nearly one in 10 patients. People with risk factors could benefit from closer follow-up.
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Affiliation(s)
- Isaac Núñez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Infectología, Ciudad de México, México
| | - Brenda Crabtree-Ramirez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Infectología, Ciudad de México, México
| | | | | | - Pedro Cahn
- Fundación Huésped, Buenos Aires, Argentina
| | - Valdiléa G Veloso
- Instituto Nacional de Infectología Evandro Chagas, Rio de Janeiro, Brazil
| | | | - Denis Padgett
- Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Eduardo Gotuzzo
- Instituto de Medicina Tropical "Alexander von Humboldt," Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Juan Sierra-Madero
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Infectología, Ciudad de México, México
| | | | - Anna K Person
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yanink Caro-Vega
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Departamento de Infectología, Ciudad de México, México.
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10
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Mohtashami M, Li YR, Lee CR, Zúñiga-Pflücker JC. Thymus Reconstitution in Young and Aged Mice Is Facilitated by In Vitro-Generated Progenitor T Cells. Front Immunol 2022; 13:926773. [PMID: 35874726 PMCID: PMC9304753 DOI: 10.3389/fimmu.2022.926773] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
The prolonged lag in T cell recovery seen in older patients undergoing hematopoietic stem cell transplant (HSCT), after chemo-/radiotherapy, can lead to immune dysfunction. As a result, recovering patients may experience a relapse in malignancies and opportunistic infections, leading to high mortality rates. The delay in T cell recovery is partly due to thymic involution, a natural collapse in the size and function of the thymus, as individuals age, and partly due to the damage sustained by the thymic stromal cells through exposure to chemo-/radiotherapy. There is a clear need for new strategies to accelerate intrathymic T cell reconstitution when treating aged patients to counter the effects of involution and cancer therapy regimens. Adoptive transfer of human progenitor T (proT) cells has been shown to accelerate T cell regeneration in radiation-treated young mice and to restore thymic architecture in immunodeficient mice. Here, we demonstrate that the adoptive transfer of in vitro-generated proT cells in aged mice (18-24 months) accelerated thymic reconstitution after treatment with chemotherapy and gamma irradiation compared to HSCT alone. We noted that aged mice appeared to have a more limited expansion of CD4-CD8- thymocytes and slower temporal kinetics in the development of donor proT cells into mature T cells, when compared to younger mice, despite following the same chemo/radiation regimen. This suggests a greater resilience of the young thymus compared to the aged thymus. Nevertheless, newly generated T cells from proT cell engrafted aged and young mice were readily present in the periphery accelerating the reappearance of new naïve T cells. Accelerated T cell recovery was also observed in both aged and young mice receiving both proT cells and HSCT. The strategy of transferring proT cells can potentially be used as an effective cellular therapy in aged patients to improve immune recovery and reduce the risk of opportunistic infections post-HSCT.
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Affiliation(s)
| | - Yue Ru Li
- Department of Immunology, University of Toronto, Toronto, ON, Canada
| | - Christina R. Lee
- Biological Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Juan Carlos Zúñiga-Pflücker
- Biological Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Immunology, University of Toronto, Toronto, ON, Canada
- *Correspondence: Juan Carlos Zúñiga-Pflücker,
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Noreña I, Fernández-Ruiz M, Aguado JM. Is there a real risk of bacterial infection in patients receiving targeted and biological therapies? Enferm Infecc Microbiol Clin (Engl Ed) 2022; 40:266-272. [PMID: 35577446 DOI: 10.1016/j.eimce.2020.10.014] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/06/2020] [Indexed: 06/15/2023]
Abstract
Over the past decades, the advent of targeted and biological therapies has revolutionized the management of cancer and autoimmune, hematological and inflammatory conditions. Although a large amount of information is now available on the risk of opportunistic infections associated with some of these agents, the evidence regarding the susceptibility to bacterial infections is more limited. Biological agents have been shown to entail a variable risk of bacterial infections in pivotal randomized clinical trials and post-marketing studies. Recommendations on risk minimization strategies and therapeutic interventions are therefore scarce and often based on expert opinion, with only a few clear statements for some particular agents (i.e. meningococcal vaccination for patients receiving eculizumab). In the present review the available information regarding the incidence of and risk factors for bacterial infection associated with the use of different groups of biological agents is summarized according to their mechanisms of action, and recommendations based on this evidence are provided. Additional information coming from clinical research and real-world studies is required to address unmet questions in this emerging field.
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Affiliation(s)
- Ivan Noreña
- Teaching and Training Unit, Division of Infectious Diseases and Tropical Medicine, LMU University Hospital Munich, Munich, Germany.
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain; School of Medicine, Universidad Complutense. Madrid, Spain
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12
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COŞKUN AYŞENURSÜMER, DURMAZ ŞENAYÖZTÜRK. Fungal Infections in COVID-19 Intensive Care Patients. Pol J Microbiol 2021; 70:395-400. [PMID: 34584533 PMCID: PMC8459001 DOI: 10.33073/pjm-2021-039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/05/2021] [Accepted: 08/09/2021] [Indexed: 01/08/2023] Open
Abstract
Opportunistic fungal infections increase morbidity and mortality in COVID-19 patients monitored in intensive care units (ICU). As patients' hospitalization days in the ICU and intubation period increase, opportunistic infections also increase, which prolongs hospital stay days and elevates costs. The study aimed to describe the profile of fungal infections and identify the risk factors associated with mortality in COVID-19 intensive care patients. The records of 627 patients hospitalized in ICU with the diagnosis of COVID-19 were investigated from electronic health records and hospitalization files. The demographic characteristics (age, gender), the number of ICU hospitalization days and mortality rates, APACHE II scores, accompanying diseases, antibiotic-steroid treatments taken during hospitalization, and microbiological results (blood, urine, tracheal aspirate samples) of the patients were recorded. Opportunistic fungal infection was detected in 32 patients (5.10%) of 627 patients monitored in ICU with a COVID-19 diagnosis. The average APACHE II score of the patients was 28 ± 6. While 25 of the patients (78.12%) died, seven (21.87%) were discharged from the ICU. Candida parapsilosis (43.7%) was the opportunistic fungal agent isolated from most blood samples taken from COVID-19 positive patients. The mortality rate of COVID-19 positive patients with candidemia was 80%. While two out of the three patients (66.6%) for whom fungi were grown from their tracheal aspirate died, one patient (33.3%) was transferred to the ward. Opportunistic fungal infections increase the mortality rate of COVID-19-positive patients. In addition to the risk factors that we cannot change, invasive procedures should be avoided, constant blood sugar regulation should be applied, and unnecessary antibiotics use should be avoided.
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Menaldi SL, Dinakrisma AA, Thio HB, Rengganis I, Oktaria S. Unusual presentations of a severe type 2 leprosy reaction mimicking sepsis induced by helminth infection. PLoS Negl Trop Dis 2021; 15:e0009453. [PMID: 34314436 PMCID: PMC8315541 DOI: 10.1371/journal.pntd.0009453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We describe an unusual case of type 2 leprosy reaction (T2R) with septic shock–like features induced by helminth infection in a 31-year-old Moluccan male patient with a history of completed treatment of WHO multidrug therapy (MDT)–multibacillary (MB) regimen 2 years before admission. During the course of illness, the patient had numerous complications, including septic shock, anemia, and disseminated intravascular coagulation (DIC). Nevertheless, antibiotic therapies failed to give significant results, and the source of infection could not be identified. Helminth infection was subsequently revealed by endoscopic examination followed by parasitological culture. Resolution of symptoms and normal level of organ function–specific markers were resolved within 3 days following anthelmintic treatment. This report demonstrated the challenge in the diagnosis and treatment of severe T2R. Given that helminth infections may trigger severe T2R that mimics septic shock, health professionals need to be aware of this clinical presentation, especially in endemic regions of both diseases.
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Affiliation(s)
- Sri Linuwih Menaldi
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- * E-mail: (SLM); (IR)
| | | | - Hok Bing Thio
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Iris Rengganis
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- * E-mail: (SLM); (IR)
| | - Salma Oktaria
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, the Netherlands
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14
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Mauro C, de Jesus VHF, Barros M, Costa FP, Weschenfelder RF, D'Agustini N, Angel M, Luca R, Nuñez JE, O'Connor JM, Riechelmann RP. Opportunistic and Serious Infections in Patients with Neuroendocrine Tumors Treated with Everolimus: A Multicenter Study of Real-World Patients. Neuroendocrinology 2021; 111:631-638. [PMID: 32403102 DOI: 10.1159/000508632] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/13/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The incidence of infections is poorly studied in patients with neuroendocrine tumors (NET) treated with everolimus outside of clinical trials. We aimed to evaluate the frequency of and risk factors for opportunistic infections (Opl) or any serious infection in eligible patients. METHODS This was a retrospective multicenter study of a Latin American cohort of consecutive patients with advanced NET treated with everolimus. Duration of everolimus, comorbidities, Charlson comorbidity score, type of prior treatment, institution, and concurrent immunosuppressive conditions were tested for possible associations with serious (grade 3-5) infections in univariate and multivariable logistic regression models. RESULTS One hundred eleven patients from 5 centers were included. The median duration of everolimus was 8.9 months. After a median follow-up of 32.9 months, 34 patients (30.6%; 95% CI 22.2-40.1) experienced infections of any grade, with 24 (21.6%; 95% CI 14.8-30.4) having a serious infection and 7 (6.3%; 95% CI 2.6-12.6) having at least 1 OpI (Candida sp., Toxoplasma gondi, Pneumocystis sp., Herpes sp., and Cryptococcus sp.). Four patients (3.6%) died from infections, but only 2 deaths (1.8%) were deemed to be related to everolimus. The multivariable analysis identified everolimus duration (every 6-month increase; OR = 1.28; 95% CI 1.02-1.60; p = 0.03) as an independent risk factor for serious infection. CONCLUSION Infections are more frequent in NET patients using everolimus than previously reported in clinical trials. Patients on everolimus should be closely monitored for infections, especially those receiving it for several months.
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Affiliation(s)
- Carine Mauro
- Department of Clinical Oncology, AC Camargo Cancer Center, São Paulo, Brazil
| | | | - Milton Barros
- Department of Clinical Oncology, AC Camargo Cancer Center, São Paulo, Brazil
| | | | - Rui F Weschenfelder
- Department of Oncology, Hospital Moinhos de Vento, Rio Grande do Sul, Brazil
| | - Nathalia D'Agustini
- Department of Oncology, Hospital Moinhos de Vento, Rio Grande do Sul, Brazil
| | - Martin Angel
- Department of Oncology, Institute Alexander Fleming, Buenos Aires, Argentina
| | - Romina Luca
- Department of Oncology, Institute Alexander Fleming, Buenos Aires, Argentina
| | - Jose Eduardo Nuñez
- Department of Clinical Oncology, Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil
| | - Juan Manuel O'Connor
- Department of Clinical Oncology, Hospital de Gastroenterología Bonorino Udaondo, Buenos Aires, Argentina
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15
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Affiliation(s)
- Jordan D Anderson
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| | - Vincent T Ho
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| | - Kyle T Wright
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| | - Bruce D Levy
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
| | - Joseph Loscalzo
- From the Departments of Medicine (J.D.A., V.T.H., B.D.L., J.L.) and Pathology (K.T.W.), Brigham and Women's Hospital, Boston
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16
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Spencer MS, Cullom AC, Rhoads WJ, Pruden A, Edwards MA. Replicable simulation of distal hot water premise plumbing using convectively-mixed pipe reactors. PLoS One 2020; 15:e0238385. [PMID: 32936810 PMCID: PMC7494094 DOI: 10.1371/journal.pone.0238385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/14/2020] [Indexed: 11/18/2022] Open
Abstract
A lack of replicable test systems that realistically simulate hot water premise plumbing conditions at the laboratory-scale is an obstacle to identifying key factors that support growth of opportunistic pathogens (OPs) and opportunities to stem disease transmission. Here we developed the convectively-mixed pipe reactor (CMPR) as a simple reproducible system, consisting of off-the-shelf plumbing materials, that self-mixes through natural convective currents and enables testing of multiple, replicated, and realistic premise plumbing conditions in parallel. A 10-week validation study was conducted, comparing three pipe materials (PVC, PVC-copper, and PVC-iron; n = 18 each) to stagnant control pipes without convective mixing (n = 3 each). Replicate CMPRs were found to yield consistent water chemistry as a function of pipe material, with differences becoming less discernable by week 9. Temperature, an overarching factor known to control OP growth, was consistently maintained across all 54 CMPRs, with a coefficient of variation <2%. Dissolved oxygen (DO) remained lower in PVC-iron (1.96 ± 0.29 mg/L) than in PVC (5.71 ± 0.22 mg/L) or PVC-copper (5.90 ± 0.38 mg/L) CMPRs as expected due to corrosion. Further, DO in PVC-iron CMPRs was 33% of that observed in corresponding stagnant pipes (6.03 ± 0.33 mg/L), demonstrating the important role of internal convective mixing in stimulating corrosion and microbiological respiration. 16S rRNA gene amplicon sequencing indicated that both bulk water (Padonis = 0.001, R2 = 0.222, Pbetadis = 0.785) and biofilm (Padonis = 0.001, R2 = 0.119, Pbetadis = 0.827) microbial communities differed between CMPR versus stagnant pipes, consistent with creation of a distinct ecological niche. Overall, CMPRs can provide a more realistic simulation of certain aspects of premise plumbing than reactors commonly applied in prior research, at a fraction of the cost, space, and water demand of large pilot-scale rigs.
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Affiliation(s)
- M. Storme Spencer
- Department of Civil and Environmental Engineering, Virginia Tech, Blacksburg, VA, United States of America
| | - Abraham C. Cullom
- Department of Civil and Environmental Engineering, Virginia Tech, Blacksburg, VA, United States of America
| | - William J. Rhoads
- Department of Civil and Environmental Engineering, Virginia Tech, Blacksburg, VA, United States of America
| | - Amy Pruden
- Department of Civil and Environmental Engineering, Virginia Tech, Blacksburg, VA, United States of America
| | - Marc A. Edwards
- Department of Civil and Environmental Engineering, Virginia Tech, Blacksburg, VA, United States of America
- * E-mail:
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Lan SH, Lai CC, Huang HT, Chang SP, Lu LC, Hsueh PR. Tocilizumab for severe COVID-19: a systematic review and meta-analysis. Int J Antimicrob Agents 2020; 56:106103. [PMID: 32712333 PMCID: PMC7377685 DOI: 10.1016/j.ijantimicag.2020.106103] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/15/2020] [Accepted: 07/19/2020] [Indexed: 12/22/2022]
Abstract
This systemic review and meta-analysis aimed to assess the efficacy of tocilizumab for the treatment of severe coronavirus disease 2019 (COVID-19). Candidate studies up to 24 May 2020 were identified from PubMed, Cochrane Library, Embase, medRxiv and bioRxiv. Treatment outcomes included mortality, risk of intensive care unit (ICU) admission and the requirement for mechanical ventilation (MV). Seven retrospective studies involving 592 adult patients with severe COVID-19, including 240 in the tocilizumab group and 352 in the control group, were enrolled. All-cause mortality of severe COVID-19 patients among the tocilizumab group was 16.3% (39/240), which was lower than that in the control group (24.1%; 85/352). However, the difference did not reach statistical significance [risk ratio (RR) = 0.62, 95% confidence interval (CI) 0.31-1.22; I2 = 68%]. Additionally, risk of ICU admission was similar between the tocilizumab and control groups (35.1% vs. 15.8%; RR = 1.51, 95% CI 0.33-6.78; I2 = 86%). The requirement for MV was similar between the tocilizumab and control groups (32.4% vs. 28.6%; RR = 0.82, 95% CI 0.14-4.94; I2 = 91%). However, these non-significant differences between the tocilizumab and control groups may have been the result of baseline characteristics of the tocilizumab group, which were more severe than those of the control group. Based on low-quality evidence, there is no conclusive evidence that tocilizumab would provide any additional benefit to patients with severe COVID-19. Therefore, further recommendation of tocilizumab for COVID-19 cases should be halted until high-quality evidence from randomised controlled trials is available.
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Affiliation(s)
- Shao-Huan Lan
- School of Pharmaceutical Sciences and Medical Technology, Putian University, Putian 351100, China
| | - Chih-Cheng Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Tainan, Taiwan
| | - Hui-Ting Huang
- Department of Pharmacy, Chi Mei Medical Center, Liouying, Taiwan
| | | | - Li-Chin Lu
- School of Management, Putian University, Putian 351100, China
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
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18
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Giancane G, Swart JF, Castagnola E, Groll AH, Horneff G, Huppertz HI, Lovell DJ, Wolfs T, Herlin T, Dolezalova P, Sanner H, Susic G, Sztajnbok F, Maritsi D, Constantin T, Vargova V, Sawhney S, Rygg M, K Oliveira S, Cattalini M, Bovis F, Bagnasco F, Pistorio A, Martini A, Wulffraat N, Ruperto N. Opportunistic infections in immunosuppressed patients with juvenile idiopathic arthritis: analysis by the Pharmachild Safety Adjudication Committee. Arthritis Res Ther 2020; 22:71. [PMID: 32264969 PMCID: PMC7136994 DOI: 10.1186/s13075-020-02167-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/27/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To derive a list of opportunistic infections (OI) through the analysis of the juvenile idiopathic arthritis (JIA) patients in the Pharmachild registry by an independent Safety Adjudication Committee (SAC). METHODS The SAC (3 pediatric rheumatologists and 2 pediatric infectious disease specialists) elaborated and approved by consensus a provisional list of OI for use in JIA. Through a 5 step-procedure, all the severe and serious infections, classified as per MedDRA dictionary and retrieved in the Pharmachild registry, were evaluated by the SAC by answering six questions and adjudicated with the agreement of 3/5 specialists. A final evidence-based list of OI resulted by matching the adjudicated infections with the provisional list of OI. RESULTS A total of 772 infectious events in 572 eligible patients, of which 335 serious/severe/very severe non-OI and 437 OI (any intensity/severity), according to the provisional list, were retrieved. Six hundred eighty-two of 772 (88.3%) were adjudicated as infections, of them 603/682 (88.4%) as common and 119/682 (17.4%) as OI by the SAC. Matching these 119 opportunistic events with the provisional list, 106 were confirmed by the SAC as OI, and among them infections by herpes viruses were the most frequent (68%), followed by tuberculosis (27.4%). The remaining events were divided in the groups of non-OI and possible/patient and/or pathogen-related OI. CONCLUSIONS We found a significant number of OI in JIA patients on immunosuppressive therapy. The proposed list of OI, created by consensus and validated in the Pharmachild cohort, could facilitate comparison among future pharmacovigilance studies. TRIAL REGISTRATION Clinicaltrials.gov NCT01399281; ENCePP seal: awarded on 25 November 2011.
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Affiliation(s)
- Gabriella Giancane
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy
| | - Joost F Swart
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, University Utrecht, European Reference Network-RITA, Utrecht, The Netherlands
| | - Elio Castagnola
- Department of Infectious Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andreas H Groll
- Infectious Disease Research Program, Department of Pediatric Hematology and Oncology, University Children's Hospital, Münster, Germany
| | - Gerd Horneff
- Asklepios Clinic Sankt Augustin, Department of General Paediatrics, Sankt Augustin, Germany
- Medical Faculty, Department of Paediatric and Adolescents Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hans-Iko Huppertz
- Clinic Bremen-Mitte, Prof.-Hesse Children's Hospital and Pediatric Intensive Care Medicine, Bremen, Germany
| | - Daniel J Lovell
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tom Wolfs
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, University Utrecht, European Reference Network-RITA, Utrecht, The Netherlands
| | - Troels Herlin
- Pediatric Rheumatology Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Pavla Dolezalova
- 1st Faculty of Medicine, Department of Pediatrics and Adolescent Medicine, Charles University in Prague and General University Hospital, Praha, Czech Republic
| | - Helga Sanner
- Department of Rheumatology, Oslo University Hospital, Oslo, Norway
- Norwegian National Advisory Unit on Rheumatic Diseases in Children and Adolescents, Oslo, Norway
| | - Gordana Susic
- Institute of Rheumatology of Belgrade, Division of Pediatric Rheumatology, Belgrade, Serbia
| | - Flavio Sztajnbok
- Hospital Universitario Pedro Ernesto, Nucleo de Estudos da Saúde do Adolescente, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Despoina Maritsi
- 2nd Department of Pediatrics Athens Medical School, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Tamas Constantin
- Unit of Pediatric Rheumatology-Immunology, Second Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Veronika Vargova
- Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, Pavol Jozef Šafárik University in Košice, Kosice, Slovakia
| | - Sujata Sawhney
- Sir Ganga Ram Hospital Marg, Centre for Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Marite Rygg
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Pediatrics, St. Olavs University Hospital of Trondheim, Trondheim, Norway
| | - Sheila K Oliveira
- Instituto de Puericultura e Pediatria Martagao Gesteira (IPPMG), Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marco Cattalini
- Clinica Pediatrica dell'Università di Brescia, Spedali Civili, Unità di Immunologia e Reumatologia Pediatrica, Brescia, Italy
| | - Francesca Bovis
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy
| | - Francesca Bagnasco
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy
| | - Angela Pistorio
- IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy
| | - Alberto Martini
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Nico Wulffraat
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, University Utrecht, European Reference Network-RITA, Utrecht, The Netherlands
| | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica e Reumatologia, PRINTO, Genoa, Italy.
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Malpica L, van Duin D, Moll S. Preventing infectious complications when treating non-malignant immune-mediated hematologic disorders. Am J Hematol 2019; 94:1396-1412. [PMID: 31571266 DOI: 10.1002/ajh.25642] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 09/11/2019] [Accepted: 09/16/2019] [Indexed: 01/19/2023]
Abstract
Immunosuppressants, targeted antibody therapies, and surgical splenectomy are amongst the treatment choices for immune-mediated non-malignant hematologic disorders, with infection being the most common non-hematological adverse event from these therapies. Corticosteroids are associated with a length-of-treatment and dose-dependent risk for infection, including opportunistic infections. Screening and antimicrobial prophylaxis against tuberculosis, Strongyloides stercoralis, and Pneumocystis jirovecii pneumonia, are indicated in selected patients on steroids and with certain risk factors for infection. Rituximab is associated with hepatitis B virus reactivation. All patients planned to be started on rituximab should be screened for hepatitis B surface antigen and total core antibody, with antiviral prophylaxis given depending on test results. In eculizumab treated patients, immunization against meningococcal serogroups ACWY and B is recommended. In addition, some guidelines suggest antibiotic prophylaxis for the duration of eculizumab treatment. In splenectomized patients, counseling and immunization are cornerstones of infection prevention. Several federal and society guidelines about immunizations and prophylactic antimicrobial therapies for patients treated with various immunosuppressive agents exist and are summarized in this manuscript in a clinical-focused table. In addition, management suggestions are made where no formal guidelines exist.
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Affiliation(s)
- Luis Malpica
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David van Duin
- Department of Medicine, Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Stephan Moll
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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20
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Abstract
Renal transplant recipients are prone to opportunistic infections due to iatrogenic immunosuppression. Infectious esophagitis can present as an opportunistic infection in the post-transplant period. Common pathogens are candida, herpes simplex virus (HSV) and cytomegalovirus (CMV). Having a dual infection is uncommon and the diagnoses can be missed at initial presentation. Our patient, a 29-year-old African-American woman, status post deceased-donor-kidney transplant presented with difficulty and pain in swallowing with clinical features suggestive of candida esophagitis, confirmed by fungal culture. She did not get better with antifungal treatment. On further testing, the patient was found to have HSV-2 infection of the oesophagus as well. She received both fluconazole as well as acyclovir that lead to complete resolution of her symptoms. In the right clinical setting, esophagitis can be caused by more than one organism present at the same time and a high level of suspicion is warranted.
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Affiliation(s)
- Imran Gani
- Nephrology, Hypertension and Transplant Medicine, Augusta University Health, Augusta, Georgia, USA
| | - Vatsalya Kosuru
- Internal Medicine, Augusta University Health System, Augusta, Georgia, USA
| | - Muhammad Saleem
- Internal Medicine, Augusta University Health System, Augusta, Georgia, USA
| | - Rajan Kapoor
- Nephrology, Hypertension and Transplant Medicine, Augusta University Health, Augusta, Georgia, USA
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21
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Morishita M, Sada KE, Matsumoto Y, Hayashi K, Asano Y, Hiramatsu Asano S, Ohashi K, Miyawaki Y, Katsuyama E, Watanabe H, Kawabata T, Wada J. Risk factors for cytomegalovirus infection in patients with antineutrophil cytoplasmic antibody-associated vasculitis. PLoS One 2019; 14:e0218705. [PMID: 31291263 PMCID: PMC6619987 DOI: 10.1371/journal.pone.0218705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 06/07/2019] [Indexed: 11/30/2022] Open
Abstract
Aims Cytomegalovirus (CMV) infection under immunosuppression sometimes causes death. This study aimed to elucidate risk factors for CMV infection in patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV). Methods Patients with AAV who underwent remission induction treatment at Okayama University Hospital between 2006 and 2016 were retrospectively analyzed. The primary outcome was the development of CMV infection within 3 months. Results Of the 111 patients, 13 (11.7%) patients developed CMV infection. Patients with CMV infection were older (p = 0.030) and had a higher body mass index (p = 0.029) in comparison to those without CMV infection. A higher proportion had a severe form (p = 0.001) and granulomatosis with polyangiitis (GPA) (p = 0.001), as well as a higher Birmingham Vasculitis Activity Score (p = 0.018) and C-reactive protein (p = 0.018) levels at baseline. Using logistic regression analysis, severe form and GPA were independent risk factors (odds ratio [OR] = 9.68, 95% confidence interval [CI] = 1.92–60.23, and OR = 7.46, 95% CI = 1.46–47.60, respectively). In addition, patients with CMV infection were more likely than those without infection to be glucocorticoid-related diabetes mellitus (p = 0.025). Conclusion Our study highlights disease severity and subgroups of AAV as risk factors for CMV infection.
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Affiliation(s)
- Michiko Morishita
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- * E-mail:
| | - Yoshinori Matsumoto
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Keigo Hayashi
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yosuke Asano
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Sumie Hiramatsu Asano
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Keiji Ohashi
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshia Miyawaki
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Eri Katsuyama
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Haruki Watanabe
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tomoko Kawabata
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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22
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Schad CA, Haac BE, Cross RK, Syed A, Lonsako S, Bafford AC. Early Postoperative Anti-TNF Therapy Does Not Increase Complications Following Abdominal Surgery in Crohn's Disease. Dig Dis Sci 2019; 64:1959-1966. [PMID: 30684075 DOI: 10.1007/s10620-019-5476-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 01/17/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The impact of postoperative anti-TNF therapy on infectious complications following Crohn's disease surgery remains controversial. Use of anti-TNF therapy 2-4 weeks postoperatively appears safe, but safety of use within 2 weeks is unknown. AIMS We sought to evaluate the effect of anti-TNF therapy initiated within 2 weeks of abdominal surgery in patients with Crohn's disease. METHODS We conducted a retrospective review of adult Crohn's disease patients undergoing abdominal surgery between 2004 and 2011. Infectious and non-infectious complications were compared between patients exposed to anti-TNF therapy within 2 weeks or between 2 and 4 weeks postoperatively and to those without exposure using chi-squared and regression analysis. RESULTS Three hundred thirty-one abdominal surgeries were included; 241 were without anti-TNF exposure, 46 received postoperative anti-TNF within 2 weeks of surgery, and 44 received anti-TNF therapy 2-4 weeks after surgery. Patients who received anti-TNF therapy within 2 weeks of surgery, those initiated between 2 and 4 weeks of surgery, and those who did not receive anti-TNF therapy within 4 weeks of surgery had no significant difference in rates of infectious complications (22%, 32%, 33%, p = 0.332). Rates of non-infectious complications (4%, 9%, 14%, p = 0.143), mortality (0%, 0%, 3%, p = 0.105), hospital readmission (17%, 16%, 15%, p = 0.940), and reoperation (11%, 11%, 16%, p = 0.563) were also similar between groups. CONCLUSIONS Use of early anti-TNF therapy within 2 weeks or between 2 and 4 weeks following abdominal surgery did not increase risk of postoperative surgical infections in Crohn's patients.
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Affiliation(s)
- Christine A Schad
- Department of Surgery, University of Maryland School of Medicine, 29 South Greene Street, 6th Floor, Baltimore, MD, 21201, USA
| | - Bryce E Haac
- Department of Surgery, University of Maryland School of Medicine, 29 South Greene Street, 6th Floor, Baltimore, MD, 21201, USA
| | - Raymond K Cross
- Division of Gastroenterology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ali Syed
- Division of Gastroenterology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shumet Lonsako
- Division of Gastroenterology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrea C Bafford
- Department of Surgery, University of Maryland School of Medicine, 29 South Greene Street, 6th Floor, Baltimore, MD, 21201, USA.
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23
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Ferrer Bradley I, Maroto Arce N, Mora Escrig M, Hinojosa Del Val J. Pulmonary aspergillosis in a Crohn's disease patient receiving adalimumab and steroid therapy. Gastroenterol Hepatol 2019; 42:387-388. [PMID: 30042000 DOI: 10.1016/j.gastrohep.2018.05.028] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/09/2018] [Accepted: 05/15/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Isabel Ferrer Bradley
- Unidad de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Hospital de Manises, Manises, Valencia, España.
| | - Nuria Maroto Arce
- Unidad de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Hospital de Manises, Manises, Valencia, España
| | - María Mora Escrig
- Unidad de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Hospital de Manises, Manises, Valencia, España
| | - Joaquín Hinojosa Del Val
- Unidad de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Hospital de Manises, Manises, Valencia, España
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Affiliation(s)
- Nicholas Raffa
- Department of Medical Microbiology and Immunology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Nancy P. Keller
- Department of Medical Microbiology and Immunology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- Department of Bacteriology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- * E-mail:
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25
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Ballo O, Tarazzit I, Stratmann J, Reinheimer C, Hogardt M, Wichelhaus TA, Kempf V, Serve H, Finkelmeier F, Brandts C. Colonization with multidrug resistant organisms determines the clinical course of patients with acute myeloid leukemia undergoing intensive induction chemotherapy. PLoS One 2019; 14:e0210991. [PMID: 30673776 PMCID: PMC6343922 DOI: 10.1371/journal.pone.0210991] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/04/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction The global spread of multidrug-resistant organisms (MDRO) complicates treatment and isolation measures in hospitals and has shown to increase mortality. Patients with disease- or therapy-related immunodeficiency are especially at risk for fatal infections caused by MDRO. The impact of MDRO colonization on the clinical course of AML patients undergoing intensive induction chemotherapy—a potentially curative but highly toxic treatment option—has not been systematically studied. Materials & methods 312 AML patients undergoing intensive induction chemotherapy between 2007 and 2015 were examined for MDRO colonization. Patients with evidence for MDRO before or during the hospital stay of induction chemotherapy were defined as colonized, patients who never had a positive swab for MDRO were defined as noncolonized. Results Of 312 AML patients 90 were colonized and 130 were noncolonized. Colonized patients suffered from significantly more days with fever, spent more days on the intensive care unit and had a higher median C-reactive protein value during the hospital stay. These findings did not result in a prolonged length of hospital stay or an increased mortality rate for colonized patients. However, in a subgroup analysis, patients colonized with carbapenem-resistant enterobacteriaceae (CRE) had a significantly reduced 60- and 90-day, as well as 1- and 2-year survival rates when compared to noncolonized patients. Conclusion Our analysis highlights the importance of intensive MDRO screening especially in patients with febrile neutropenia since persisting fever can be a sign of MDRO-colonization. CRE-colonized patients require special surveillance, since they seem to be at risk for death.
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Affiliation(s)
- Olivier Ballo
- Department of Medicine, Hematology/Oncology, Goethe University Hospital, Frankfurt/Main, Germany
- University Cancer Center Frankfurt (UCT), Goethe University Hospital, Frankfurt/Main, Germany
- * E-mail: (OB); (CB)
| | - Ikram Tarazzit
- Department of Medicine, Hematology/Oncology, Goethe University Hospital, Frankfurt/Main, Germany
| | - Jan Stratmann
- Department of Medicine, Hematology/Oncology, Goethe University Hospital, Frankfurt/Main, Germany
| | - Claudia Reinheimer
- Institute of Medical Microbiology and Infection Control, Goethe University Hospital, Frankfurt/Main, Germany
- University Center for Infectious Diseases, Goethe University Hospital, Frankfurt/Main, Germany
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, Goethe University Hospital, Frankfurt/Main, Germany
- University Center for Infectious Diseases, Goethe University Hospital, Frankfurt/Main, Germany
| | - Thomas A. Wichelhaus
- Institute of Medical Microbiology and Infection Control, Goethe University Hospital, Frankfurt/Main, Germany
- University Center for Infectious Diseases, Goethe University Hospital, Frankfurt/Main, Germany
| | - Volkhard Kempf
- Institute of Medical Microbiology and Infection Control, Goethe University Hospital, Frankfurt/Main, Germany
- University Center for Infectious Diseases, Goethe University Hospital, Frankfurt/Main, Germany
| | - Hubert Serve
- Department of Medicine, Hematology/Oncology, Goethe University Hospital, Frankfurt/Main, Germany
- University Cancer Center Frankfurt (UCT), Goethe University Hospital, Frankfurt/Main, Germany
- University Center for Infectious Diseases, Goethe University Hospital, Frankfurt/Main, Germany
| | - Fabian Finkelmeier
- University Cancer Center Frankfurt (UCT), Goethe University Hospital, Frankfurt/Main, Germany
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Christian Brandts
- Department of Medicine, Hematology/Oncology, Goethe University Hospital, Frankfurt/Main, Germany
- University Cancer Center Frankfurt (UCT), Goethe University Hospital, Frankfurt/Main, Germany
- * E-mail: (OB); (CB)
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Affiliation(s)
- James E Mojica
- From the Departments of Medicine (J.E.M., C.J.R.), Radiology (J.S.H.), and Pathology (L.P.H.), Massachusetts General Hospital, and the Departments of Medicine (J.E.M., C.J.R.), Radiology (J.S.H.), and Pathology (L.P.H.), Harvard Medical School - both in Boston
| | - Christopher J Richards
- From the Departments of Medicine (J.E.M., C.J.R.), Radiology (J.S.H.), and Pathology (L.P.H.), Massachusetts General Hospital, and the Departments of Medicine (J.E.M., C.J.R.), Radiology (J.S.H.), and Pathology (L.P.H.), Harvard Medical School - both in Boston
| | - Jad S Husseini
- From the Departments of Medicine (J.E.M., C.J.R.), Radiology (J.S.H.), and Pathology (L.P.H.), Massachusetts General Hospital, and the Departments of Medicine (J.E.M., C.J.R.), Radiology (J.S.H.), and Pathology (L.P.H.), Harvard Medical School - both in Boston
| | - Lida P Hariri
- From the Departments of Medicine (J.E.M., C.J.R.), Radiology (J.S.H.), and Pathology (L.P.H.), Massachusetts General Hospital, and the Departments of Medicine (J.E.M., C.J.R.), Radiology (J.S.H.), and Pathology (L.P.H.), Harvard Medical School - both in Boston
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Mease P, Coates LC, Helliwell PS, Stanislavchuk M, Rychlewska-Hanczewska A, Dudek A, Abi-Saab W, Tasset C, Meuleners L, Harrison P, Besuyen R, Van der Aa A, Mozaffarian N, Greer JM, Kunder R, Van den Bosch F, Gladman DD. Efficacy and safety of filgotinib, a selective Janus kinase 1 inhibitor, in patients with active psoriatic arthritis (EQUATOR): results from a randomised, placebo-controlled, phase 2 trial. Lancet 2018; 392:2367-2377. [PMID: 30360969 DOI: 10.1016/s0140-6736(18)32483-8] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 09/24/2018] [Accepted: 09/28/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND The Janus kinase 1 (JAK1) pathway has been implicated in the pathogenesis of psoriatic arthritis. We aimed to investigate the efficacy and safety of filgotinib, a selective JAK1 inhibitor, for the treatment of psoriatic arthritis. METHODS The EQUATOR trial was a randomised, double-blind, placebo-controlled phase 2 trial that enrolled adults from 25 sites in seven countries (Belgium, Bulgaria, Czech Republic, Estonia, Poland, Spain, and Ukraine). Patients (aged ≥18 years) had active moderate-to-severe psoriatic arthritis (defined as at least five swollen joints and at least five tender joints) fulfilling Classification for psoriatic arthritis (CASPAR) criteria, active or a documented history of plaque psoriasis, and an insufficient response or intolerance to at least one conventional synthetic disease-modifying anti-rheumatic drug (csDMARD). Patients continued to take csDMARDs during the study if they had received this treatment for at least 12 weeks before screening and were on a stable dose for at least 4 weeks before baseline. Using an interactive web-based system, we randomly allocated patients (1:1) to filgotinib 200 mg or placebo orally once daily for 16 weeks (stratified by current use of csDMARDs and previous use of anti-tumour necrosis factor). Patients, study team, and sponsor were masked to treatment assignment. The primary endpoint was proportion of patients achieving 20% improvement in American College of Rheumatology response criteria (ACR20) at week 16 in the full analysis set (patients who received at least one dose of study drug), which was compared between groups with the Cochran-Mantel-Haenszel test and non-responder imputation method. This trial is registered with ClincalTrials.gov, number NCT03101670. FINDINGS Between March 9, and Sept 27, 2017, 191 patients were screened and 131 were randomly allocated to treatment (65 to filgotinib and 66 to placebo). 60 (92%) patients in the filgotinib group and 64 (97%) patients in the placebo group completed the study; five patients (8%) in the filgotinib group and two patients (3%) in the placebo group discontinued treatment. 52 (80%) of 65 patients in the filgotinib group and 22 (33%) of 66 in the placebo group achieved ACR20 at week 16 (treatment difference 47% [95% CI 30·2-59·6], p<0·0001). 37 (57%) patients who received filgotinib and 39 (59%) patients who received placebo had at least one treatment-emergent adverse event. Six participants had an event that was grade 3 or worse. The most common events were nasopharyngitis and headache, occurring at similar proportions in each group. One serious treatment-emergent adverse event was reported in each group (pneumonia and hip fracture after a fall), one of which (pneumonia) was fatal in the filgotinib group. INTERPRETATION Filgotinib is efficacious for the treatment of active psoriatic arthritis, and no new safety signals were identified. FUNDING Galapagos and Gilead Sciences.
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Affiliation(s)
- Philip Mease
- Swedish-Providence-St Joseph Health Systems, Seattle WA, USA; University of Washington, Seattle, WA, USA.
| | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Filip Van den Bosch
- Ghent University Hospital, Ghent, Belgium; VIB-UGent Center for Inflammation Research, Ghent University, Ghent, Belgium
| | - Dafna D Gladman
- University of Toronto and Krembil Research Institute, Toronto Western Hospital, Toronto, Canada
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van der Heijde D, Baraliakos X, Gensler LS, Maksymowych WP, Tseluyko V, Nadashkevich O, Abi-Saab W, Tasset C, Meuleners L, Besuyen R, Hendrikx T, Mozaffarian N, Liu K, Greer JM, Deodhar A, Landewé R. Efficacy and safety of filgotinib, a selective Janus kinase 1 inhibitor, in patients with active ankylosing spondylitis (TORTUGA): results from a randomised, placebo-controlled, phase 2 trial. Lancet 2018; 392:2378-2387. [PMID: 30360970 DOI: 10.1016/s0140-6736(18)32463-2] [Citation(s) in RCA: 171] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 09/24/2018] [Accepted: 09/28/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND At present, biological disease-modifying anti-rheumatic drugs (DMARDs) are the only treatment recommended for patients with ankylosing spondylitis who have not responded to first-line treatment with non-steroidal anti-inflammatory drugs (NSAIDs). The TORTUGA trial investigated the efficacy and safety of filgotinib, an oral selective Janus kinase 1 (JAK1) inhibitor, for the treatment of patients with active ankylosing spondylitis. METHODS In this completed, randomised, double-blind, placebo-controlled, phase 2 trial, we enrolled adult patients from 30 sites in seven countries (Belgium, Bulgaria, Czech Republic, Estonia, Poland, Spain, and Ukraine). Eligible patients had active ankylosing spondylitis and an inadequate response or intolerance to two or more NSAIDs. Patients were randomly assigned (1:1) with an interactive web-based response system to receive filgotinib 200 mg or placebo orally once daily for 12 weeks. Randomisation was stratified by current use of conventional synthetic DMARDs and previous receipt of anti-tumour necrosis factor therapy. The patients, study team, and study sponsor were masked to treatment assignment. The primary endpoint was the change from baseline in ankylosing spondylitis disease activity score (ASDAS) at week 12, which was assessed in the full analysis set (ie, all randomised patients who received at least one dose of study drug). Safety was assessed according to actual treatment received. This trial is registered with ClinicalTrials.gov, number NCT03117270. FINDINGS Between March 7, 2017, and July 2, 2018, 263 patients were screened and 116 randomly assigned to filgotinib (n=58) or placebo (n=58). 55 (95%) patients in the filgotinib group and 52 (90%) in the placebo group completed the study; three (5%) patients in the filgotinib group and six (10%) in the placebo group discontinued treatment. The mean ASDAS change from baseline to week 12 was -1·47 (SD 1·04) in the filgotinib group and -0·57 (0·82) in the placebo group, with a least squares mean difference between groups of -0·85 (95% CI -1·17 to -0·53; p<0·0001). Treatment-emergent adverse events were reported in 18 patients in each group, the most common being nasopharyngitis (in two patients in the filgotinib group and in four patients in the placebo group). Treatment-emergent adverse events led to permanent treatment discontinuation in two patients (a case of grade 3 pneumonia in the filgotinib group and of high creatine kinase in the placebo group). No deaths were reported during the study. INTERPRETATION Filgotinib is efficacious and safe for the treatment of patients with active ankylosing spondylitis who have not responded to first-line pharmacological therapy with NSAIDs. Further investigation of filgotinib for ankylosing spondylitis is warranted. FUNDING Galapagos and Gilead Sciences.
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Affiliation(s)
| | | | - Lianne S Gensler
- Division of Rheumatology, University of California, San Francisco, CA, USA
| | | | - Vira Tseluyko
- Department of Rheumatology, Kharkiv Medical Academy of Postgraduate Education, Kharkiv, Ukraine
| | | | | | | | | | | | | | | | - Ke Liu
- Gilead Sciences, Foster City, CA, USA
| | | | - Atul Deodhar
- Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University, Portland, OR, USA
| | - Robert Landewé
- Department of Rheumatology & Clinical Immunology, Amsterdam University Medical Center, Amsterdam, Netherlands; Department of Rheumatology, Zuyderland Hospital, Heerlen, Netherlands
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Balcan B, Ozcelik U, Ugurlu AO, Aydin M, Nalcaci S, Yarbug Karakayali F. Increased Mortality Among Renal Transplant Patients With Invasive Pulmonary Aspergillus Infection. Prog Transplant 2018; 28:349-353. [PMID: 30235978 DOI: 10.1177/1526924818800044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Renal transplantation is the most effective and preferred definite treatment option in patients with end-stage renal disease. Due to long-term immunesuppressive treatment, renal transplant recipients become vulnerable to opportunistic infections, especially to fungal infections. METHOD This was a single-center, retrospective observational study of 438 patients who underwent renal transplantation between 2010 and 2016. RESULTS Thirty-eight renal transplant recipients who had lower respiratory tract infection with median age of 41.5 years were evaluated for invasive pulmonary aspergillus (IPA). Of these, 52.6% were female and 84.2% had living donors. Eleven of 38 lower respiratory patients were found to have IPA infection, 5 with proven infection. Compared to patients who did not have fungal pulmonary infection, patients with invasive aspergillus were older and had high fever, galactomannan levels, and leukocyte counts. Mortality was also higher in those patients. Having fever at the baseline and IPA infection was significantly associated with mortality in univariate analysis and remained related in multivariate model after adjustment for age, gender, and fever. CONCLUSION Invasive pulmonary aspergillus infection is highly associated with increased mortality rates in renal transplant patients. Fungal pulmonary infections in immune-suppressed patients should be diagnosed and treated immediately in order to avoid the life-threatening complications and may greatly improve prognosis.
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Affiliation(s)
- Baran Balcan
- 1 Department of Pulmonary Medicine, Baskent University, Istanbul, Turkey
- 2 Department of Pulmonary Medicine, Marmara University, Istanbul, Turkey
| | - Umit Ozcelik
- 3 Department of General Surgery, Baskent University, Istanbul, Turkey
| | | | - Mehtap Aydin
- 4 Department of Infectious Diseases, Baskent University, Istanbul, Turkey
| | - Serdar Nalcaci
- 5 Department of Nephrology, Baskent University, Istanbul, Turkey
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Magi B, Migliorini L, Sansoni A, Cusi MG. Brevibacterium casei bacteraemia in a port-a-cath carrier patient: a case report. Infez Med 2018; 26:263-265. [PMID: 30246770] [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: 06/08/2023]
Abstract
Brevibacteria are part of the normal flora of the skin and adjacent structures, but have been increasingly encountered in humans as opportunistic pathogens and have been isolated from various clinical specimens, generally causing infections in immuno-compromised patients. We present a case of a port-a-cath-related bacteraemia caused by Brevibacterium casei in a woman with a prior history of bilateral breast cancer. The clinical outcome was favourable.
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Affiliation(s)
- Barbara Magi
- Microbiology and Virology Unit, Siena University Hospital, University of Siena, Italy
| | - Lucia Migliorini
- Infectious Diseases Unit, Siena University Hospital, Siena, Italy
| | - Anna Sansoni
- Infectious Diseases Unit, Siena University Hospital, Siena, Italy
| | - Maria Grazia Cusi
- Microbiology and Virology Unit, Siena University Hospital, University of Siena, Italy
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31
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Garrido-Jareño M, Frasquet-Artes J, Tasias-Pitarch M, López-Hontangas JL. First case of renal abscess by Parvimonas micra. Enferm Infecc Microbiol Clin 2018; 37:140-141. [PMID: 29631929 DOI: 10.1016/j.eimc.2018.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/02/2018] [Accepted: 03/06/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Marta Garrido-Jareño
- Servicio de Microbiología, Hospital Universitario y Politécnico la Fe, Valencia, España.
| | - Juan Frasquet-Artes
- Servicio de Microbiología, Hospital Universitario y Politécnico la Fe, Valencia, España
| | - María Tasias-Pitarch
- Unidad de Enfermedades Infecciosas, Hospital Universitario y Politécnico la Fe, Valencia, España
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Grateau A, Le Maréchal M, Labussière-Wallet H, Ducastelle-Leprêtre S, Nicolini FE, Thomas X, Morisset S, Michallet M, Ader F. Chronic disseminated candidiasis and acute leukemia: Impact on survival and hematopoietic stem cell transplantation agenda. Med Mal Infect 2018; 48:202-206. [PMID: 29307444 DOI: 10.1016/j.medmal.2017.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/09/2017] [Accepted: 12/12/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To study the management of chronic disseminated candidiasis (CDC) in patients presenting with acute leukemia. PATIENTS AND METHODS Single-center retrospective study of acute leukemia patients (2006-2015) to investigate three aspects of CDC: its impact on the time interval between diagnosis and hematopoietic stem cell transplantation, when required (non-parametric Wilcoxon-Mann-Whitney test); its impact on overall survival (Cox proportional hazard regression model); antifungal therapeutic strategies implemented. RESULTS A total of 639 patients presenting with acute leukemia were included; 144 were transplanted and 29 developed CDC. CDC did not significantly increase the time interval between diagnosis and transplantation, nor did it impact the overall survival of recipients. An improved overall survival was observed in non-transplanted acute leukemia patients presenting with CDC. CONCLUSION CDC should not postpone transplantation if antifungal treatment is optimized.
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Affiliation(s)
- A Grateau
- Département d'hématologie, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - M Le Maréchal
- Université de Lorraine, EA 4360 APEMAC, Nancy, France; Département de santé publique, CHU de Nice, Nice, France
| | - H Labussière-Wallet
- Département d'hématologie, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - S Ducastelle-Leprêtre
- Département d'hématologie, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - F-E Nicolini
- Département d'hématologie, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - X Thomas
- Département d'hématologie, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - S Morisset
- Département d'hématologie, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - M Michallet
- Département d'hématologie, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France; Département de maladies infectieuses et tropicales, hospices civils de Lyon, 69004 Lyon, France
| | - F Ader
- Département de maladies infectieuses et tropicales, hospices civils de Lyon, 69004 Lyon, France; Inserm U1111 CIRI, université Claude-Bernard-Lyon 1, Lyon, France.
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Dudreuilh C, Aguiar R, Ostermann M. Acute kidney injury in kidney transplant patients. Acute Med 2018; 17:31-35. [PMID: 29589603] [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: 06/08/2023]
Abstract
Managing kidney transplant patients in an acute medical unit can be challenging, as patients have a single functioning kidney, underlying chronic kidney disease, and are immunosuppressed. Transplant patients develop AKI for all usual reasons but the differential diagnosis is wider and includes specific problems, such as obstruction of a single functioning kidney, vascular thrombosis, rejection, drug toxicity and drug-induced thrombotic microangiopathy. Septic AKI is common but again, the differential diagnosis of sepsis is wider. Transplant patients are at higher risk of developing both community and opportunistic infections, especially in the first year after the transplant or after any increase in immunosuppressive medication. In addition, there is always a risk of rejection, especially in case of reduction of immunosuppressive medications. Therefore, any change in the immunosuppressive therapy should to be discussed with the transplant team to achieve an appropriate balance between avoiding rejection and preventing opportunistic infections.
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Affiliation(s)
- C Dudreuilh
- Senior Clinical Fellow in Transplantation and Renal Medicine Departments of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - R Aguiar
- Clinical Fellow in Transplantation and Renal Medicine Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - M Ostermann
- Consultant in Critical Care & Nephrology Guy's & St Thomas' Hospital London
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35
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Bebeshko VG, Bruslova KM, Pushkareva TI, Tsvietkova NM, Lyashenko LO, Sergeeva AS, Kuzmenko VF, Iatsemyrskiy SM, Samson YM, Boyarsky VG, Tryhlіb IV. Cortisol level as risk factor for malignant hematologic pathology in children exposed to ionizing radiation after Chornobyl accident. Probl Radiac Med Radiobiol 2017; 22:306-315. [PMID: 29286515] [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] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Determination of serum cortisol level in the initial period of acute leukemia in children, who exposed to ion izing radiation and other factors of Chornobyl accident, depending on their age and prognosis of disease. MATERIALS AND METHODS The study involved 283 children residents of Kyiv, Zhytomyr and Chernihiv regions. There were 90 acute leukemia patients(AL) (ALL - 56, AML - 34), and 193 people of comparison group with anemia, leukemoid reactions and lymphadenopathy. We analyzed the type of comorbid somatic pathology, diseases in the genealogy, hematological parameters, cortisol levels in blood serum and irradiation doses in all children. In patients with AL expected median survival was calculated. RESULTS In 28.9 % of AL children the initial cortisol content was below 200 nmol/l, in 7.8 % - higher than 500 nmol/l (in the comparison group 10.4 % and 17.1 % respectively). Among AL patients with cortisol levels below 200 nmol/l were significantly less amount of persons with chronic bacterial infections and persistent viral infections (CMV, EBV) and in the genealogy of these children allergic reactions, endocrine pathology diagnosed more often compared with patients, whose hormone levels was higher than 200 nmol/l (p < 0.05). Distribution of children from control group by gradations of cortisol, age groups, defined somatic pathology and diseases in genealogy had no difference. It is shown, that lower initial blood serum cortisol level in ALL children correlates to a greater probability of relapse (Rs = -0,67). In patients with AML a direct correlation between cortisol level and median survival was detected (Rs = 0,79). Children radiation doses were ranging from 0.08 mSv to 14.9 mSv, and there were slightly higher among residents of Zhytomyr region (8.4 ± 1.2 mSv) compared to other regions. However, these doses did not affect blood serum cortisol levels in children and the course of AL. CONCLUSIONS These data suggest the need for correction and individualization of corticosteroid doses for optimization of AL patients treatment. Children, who have lower than normative serum cortisol levels are at increased risk of hema tologic pathology and they need for hematologic monitoring.
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MESH Headings
- Adolescent
- Anemia/blood
- Anemia/pathology
- Bacterial Infections/blood
- Bacterial Infections/etiology
- Bacterial Infections/mortality
- Bacterial Infections/pathology
- Biomarkers/blood
- Chernobyl Nuclear Accident
- Child
- Child, Preschool
- Female
- Humans
- Hydrocortisone/blood
- Leukemia, Myeloid, Acute/blood
- Leukemia, Myeloid, Acute/etiology
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/pathology
- Life Expectancy
- Lymphadenopathy/blood
- Lymphadenopathy/pathology
- Male
- Opportunistic Infections/blood
- Opportunistic Infections/etiology
- Opportunistic Infections/mortality
- Opportunistic Infections/pathology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/blood
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/etiology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/mortality
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/pathology
- Radiation Dosage
- Radiation Exposure/adverse effects
- Radiation, Ionizing
- Risk Factors
- Survival Analysis
- Ukraine
- Virus Diseases/blood
- Virus Diseases/etiology
- Virus Diseases/mortality
- Virus Diseases/pathology
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Affiliation(s)
- V G Bebeshko
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», Melnykova str., 53, Kyiv, 04050, Ukraine
| | - K M Bruslova
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», Melnykova str., 53, Kyiv, 04050, Ukraine
| | - T I Pushkareva
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», Melnykova str., 53, Kyiv, 04050, Ukraine
| | - N M Tsvietkova
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», Melnykova str., 53, Kyiv, 04050, Ukraine
| | - L O Lyashenko
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», Melnykova str., 53, Kyiv, 04050, Ukraine
| | - A S Sergeeva
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», Melnykova str., 53, Kyiv, 04050, Ukraine
| | - V F Kuzmenko
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», Melnykova str., 53, Kyiv, 04050, Ukraine
| | - S M Iatsemyrskiy
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», Melnykova str., 53, Kyiv, 04050, Ukraine
| | - Yu M Samson
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», Melnykova str., 53, Kyiv, 04050, Ukraine
| | - V G Boyarsky
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», Melnykova str., 53, Kyiv, 04050, Ukraine
| | - I V Tryhlіb
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», Melnykova str., 53, Kyiv, 04050, Ukraine
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Affiliation(s)
- Benjamin D Smith
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT 06520, USA
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Mecoli CA, Saylor D, Gelber AC, Christopher-Stine L. Pneumocystis jiroveci pneumonia in rheumatic disease: a 20-year single-centre experience. Clin Exp Rheumatol 2017; 35:671-673. [PMID: 28134084] [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] [Received: 08/28/2016] [Accepted: 10/10/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Pneumocystis jiroveci pneumonia (PJP) is an opportunistic infection with high mortality among patients with underlying rheumatologic conditions. Given the paucity of prospective data to guide treatment, clinical guidelines to initiate PJP prophylaxis are based on expert opinion and identify patients on ≥20 mg daily prednisone for ≥4 weeks duration for treatment. Herein we describe the PJP experience in rheumatic disease over a 20-year period at a single academic medical centre to investigate this 20 mg threshold and risk associated with lymphocyte counts, co-existing lung disease and immunosuppressive medications. METHODS We conducted a retrospective review of all admitted patients who received a PJP or PCP ICD-9 code (136.3) from January 1996 through October 2015. RESULTS Twenty-one cases of confirmed PJP (by immunofluorescence or polymerase chain reaction) were reviewed, averaging to one case/year. The most common underlying rheumatologic conditions were inflammatory myopathy, lupus, and granulomatosis with polyangiitis. None of these 21 patients was receiving PJP prophylaxis upon admission. Eighteen (86%) were receiving ≥20 mg prednisone daily at the time of PJP diagnosis. Of the 3 treated with <20 mg prednisone, all received concomitant immunosuppressive medications, 2 with cyclophosphamide. Overall, there was a 43% (9/21) mortality rate. Immunosuppressant medication use, interstitial lung disease, or lymphocyte count did not impact mortality risk. CONCLUSIONS PJP portends high mortality yet is a largely preventable complication of rheumatic disease treatment. Consideration to initiate prophylaxis should be made for patients exceeding the daily 20 mg prednisone threshold, and those receiving cyclophosphamide.
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Affiliation(s)
- Christopher A Mecoli
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, USA.
| | - Deanna Saylor
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Allan C Gelber
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, USA
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Fonsah JY, Njamnshi AK, Kouanfack C, Qiu F, Njamnshi DM, Tagny CT, Nchindap E, Kenmogne L, Mbanya D, Heaton R, Kanmogne GD. Adherence to Antiretroviral Therapy (ART) in Yaoundé-Cameroon: Association with Opportunistic Infections, Depression, ART Regimen and Side Effects. PLoS One 2017; 12:e0170893. [PMID: 28141867 PMCID: PMC5283684 DOI: 10.1371/journal.pone.0170893] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 01/12/2017] [Indexed: 12/30/2022] Open
Abstract
Following global efforts to increase antiretroviral therapy (ART) access in Sub-Saharan Africa, ART coverage among HIV-infected Cameroonians increased from 0% in 2003 to 22% in 2014. However, the success of current HIV treatment programs depends not only on access to ART, but also on retention in care and good treatment adherence. This is necessary to achieve viral suppression, prevent virologic failure, and reduce viral transmission and HIV/AIDS-related deaths. Previous studies in Cameroon showed poor adherence, treatment interruption, and loss to follow-up among HIV+ subjects on ART, but the factors that influence ART adherence are not well known. In the current cross-sectional study, patient/self-reported questionnaires and pharmacy medication refill data were used to quantify ART adherence and determine the factors associated with increased risk of non-adherence among HIV-infected Cameroonians. We demonstrated that drug side-effects, low CD4 cell counts and higher viral loads are associated with increased risk of non-adherence, and compared to females, males were more likely to forego ART because of side effects (p<0.05). Univariate logistic regression analysis demonstrated that subjects with opportunistic infections (on antibiotics) had 2.42-times higher odds of having been non-adherent (p<0.001). Multivariable analysis controlling for ART regimen, age, gender, and education showed that subjects with opportunistic infections had 3.1-times higher odds of having been non-adherent (p<0.0003), with significantly longer periods of non-adherence, compared to subjects without opportunistic infections (p = 0.02). We further showed that compared to younger subjects (≤40 years), older subjects (>40 years) were less likely to be non-adherent (p<0.01) and had shorter non-adherent periods (p<0.0001). The presence of depression symptoms correlated with non-adherence to ART during antibiotic treatment (r = 0.53, p = 0.04), and was associated with lower CD4 cell counts (p = 0.04) and longer non-adherent periods (p = 0.04). Change in ART regimen was significantly associated with increased likelihood of non-adherence and increased duration of the non-adherence period. Addressing these underlying risk factors could improve ART adherence, retention in care and treatment outcomes for HIV/AIDS patients in Cameroon.
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Affiliation(s)
- Julius Y. Fonsah
- Department of Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Alfred K. Njamnshi
- Department of Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Charles Kouanfack
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- HIV-Day Care Service, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Fang Qiu
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, United States of America
| | - Dora M. Njamnshi
- HIV-Day Care Service, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Claude T. Tagny
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Yaoundé University Teaching Hospital, Yaoundé, Cameroon
| | | | | | - Dora Mbanya
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Yaoundé University Teaching Hospital, Yaoundé, Cameroon
| | - Robert Heaton
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, United States of America
| | - Georgette D. Kanmogne
- Department of Pharmacology and Experimental Neuroscience, College of Medicine, University of Nebraska Medical Center, Omaha, NE, United States of America
- * E-mail:
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Muñoz-Oca JE, Villarreal Morales ML, Nieves-Rodriguez A, Martínez-Bonilla L. Concomitant disseminated histoplasmosis and disseminated tuberculosis after tumor necrosis factor inhibitor treatment: a case report. BMC Infect Dis 2017; 17:70. [PMID: 28086756 PMCID: PMC5237312 DOI: 10.1186/s12879-016-2097-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 12/07/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Tumor necrosis factor antagonist inhibitors have transformed the approach to patients with severe autoimmune conditions, such as rheumatoid arthritis. Although the therapy can be highly effective, TNF-α inhibitors are associated with an increased risk of opportunistic infections. CASE PRESENTATION Here, we report a case of concomitant disseminated histoplasmosis and tuberculosis in a 65-year-old female with rheumatoid arthritis treated with TNF-α inhibitor. Both conditions can be found in disseminated form in immunosuppressed hosts, but co-infection is rare with only a few cases having been reported, to our knowledge, all in HIV patients. CONCLUSIONS This case posed a considerable challenge for diagnosis and treatment due to the unusual disseminated co-infection, the overlapping symptoms, and the interactions between medications.
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Affiliation(s)
- Juan E. Muñoz-Oca
- JEMO: Family Medicine Residency Program, Manatí Medical Center, P.O Box 1142, Manatí, PR 00674 USA
| | | | | | - Lemuel Martínez-Bonilla
- LMB: Department of Internal Medicine /Infectious diseases, Manatí Medical Center, P.O Box 1142, Manatí, PR 00674 USA
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Ozábalová E, Krejčí J, Hude P, Godava J, Honek T, Špinarová L, Pavlík P, Bedáňová H, Němec P. [Heart transplantation and infection]. Vnitr Lek 2017; 63:535-539. [PMID: 28933181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Heart transplantation (HTx) is a method of treatment for patients with end-stage heart failure with severe symptoms despite complex therapy. Post-transplant difficulties include acute rejection and infectious complications, which are the most common reason of morbidity and mortality in the first year after heart transplant. It requires the patient to remain on immunosuppressive medication to avoid the possibility of graft rejection. Therefore the range of infection is much larger. The diagnosis and treatment of viral, bacterial and fungal infections is often difficult.Key words: heart transplantation - immunosuppression - infection.
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Abstract
Major neurologic morbidity, such as seizures and encephalopathy, complicates 20-30% of organ and stem cell transplantation procedures. The majority of these disorders occur in the early posttransplant period, but recipients remain at risk for opportunistic infections and other nervous system disorders for many years. These long-term risks may be increasing as acute survival increases, and a greater number of "sicker" patients are exposed to long-term immunosuppression. Drug neurotoxicity accounts for a significant proportion of complications, with posterior reversible leukoencephalopathy syndrome, primarily associated with calcineurin inhibitors (i.e., cyclosporine and tacrolimus), being prominent as a cause of seizures and neurologic deficits. A thorough evaluation of any patient who develops neurologic symptoms after transplantation is mandatory, since reversible and treatable conditions could be found, and important prognostic information can be obtained.
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Affiliation(s)
- R Dhar
- Division of Neurocritical Care, Department of Neurology, Washington University, St. Louis, MO, USA.
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Affiliation(s)
- Tom Nieto
- Renal Services, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Nicholas Inston
- Renal Services, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Paul Cockwell
- Renal Services, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
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Abstract
Kidney transplantation represents a major medical victory in patients with whom dialysis and medical therapy have failed. To increase survival rates and optimize the use of limited organs, both patient care and immunosuppression therapy must be improved. Reduction in rejection episodes or severity of rejection may ultimately improve long-term allograft survival. Traditional engineered monoclonal antibodies have been associated with severe cytokine release reactions and an increased risk of opportunistic infections. Basiliximab and daclizumab are chimeric and humanized monoclonal antibodies that inhibit thymus-dependent lymphocyte proliferation. Interleukin 2 also affects the proliferation of natural killer cells, macrophages and monocytes, bursa-equivalent lymphocytes, epidermal dendritic cells, and lymphokine-activated killer cells. Interleukin-2 receptor antagonists have been shown to reduce the incidence of acute rejection without increasing the incidence of opportunistic infections or malignancy. Further studies are needed to evaluate the overall effect of these agents on long-term patient and allograft survival.
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Affiliation(s)
- A J Olyaei
- Oregon Health Sciences University, Portland, Ore., USA
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Abstract
Solid-organ transplantation is often the last alternative in many patients with end-stage organ disease. Although advances in immunosuppressive regimens, surgical techniques, organ preservation, and overall management of transplant recipients have improved graft and patient survival, infectious complications remain problematic. Bacterial, fungal, viral, and parasitic infections are implicated after transplantation depending on numerous factors, such as degree of immunosuppression, type of organ transplant, host factors, and period after transplantation. Proper prophylactic and treatment strategies are imperative in the face of chronic immunosuppression, nosocomial and community pathogens, emerging drug resistance, drug-drug interactions, and medication toxicities. This review summarizes the pathophysiology, incidence, prevention, and treatment strategies of common post-transplant infections.
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Affiliation(s)
- Loretta M Chiu
- University of Washington Medical Center, Seattle, Washington, USA
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Asher I, Mahlab-Guri K, Elbirt D, Ezalel-Rosenberg S, Sthoeger Z. Idiopathic CD4 Lymphopenia: Severe CD4 Lymphopenia in the Absence of Human Immunodeficiency Virus Infection. Isr Med Assoc J 2016; 18:627-629. [PMID: 28471626] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Ilan Asher
- Department of Internal Medicine B and Clinical Immunology, Allergy and Naveh-Or AIDS Center, Kaplan Medical Center, Rehovot, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Keren Mahlab-Guri
- Department of Internal Medicine B and Clinical Immunology, Allergy and Naveh-Or AIDS Center, Kaplan Medical Center, Rehovot, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Daniel Elbirt
- Department of Internal Medicine B and Clinical Immunology, Allergy and Naveh-Or AIDS Center, Kaplan Medical Center, Rehovot, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Shira Ezalel-Rosenberg
- Department of Internal Medicine B and Clinical Immunology, Allergy and Naveh-Or AIDS Center, Kaplan Medical Center, Rehovot, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Zev Sthoeger
- Department of Internal Medicine B and Clinical Immunology, Allergy and Naveh-Or AIDS Center, Kaplan Medical Center, Rehovot, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Jamilloux Y, Bernard C, Lortholary O, Kerever S, Lelièvre L, Gerfaud-Valentin M, Broussolle C, Valeyre D, Sève P. [Opportunistic infections and sarcoidosis]. Rev Med Interne 2016; 38:320-327. [PMID: 27639910 DOI: 10.1016/j.revmed.2016.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 06/14/2016] [Accepted: 08/09/2016] [Indexed: 11/17/2022]
Abstract
Opportunistic infections (OI) are uncommon in sarcoidosis (1 to 10%) and mostly occur in patients with previously diagnosed disease or can rarely be the presenting manifestation. The most common OIs are, in descending order: aspergillosis, cryptococcosis, and mycobacterial infections. Treatment with corticosteroids is the most frequent risk factor for OI occurrence during sarcoidosis but immunosuppressive drugs and therapy with anti-TNFα are also risk factors. Overall, clinical presentation, treatment, and outcome are identical to that occur in other conditions complicated with the occurrence of OIs. However, some atypical presentations of OIs can mimic sarcoidosis exacerbation and misdiagnosis may lead clinicians to increase immunosuppression, causing worsening of the OI. The meticulous collection of patient's history along with factors differentiating OI from sarcoidosis exacerbation is key factor to optimally manage these patients.
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Affiliation(s)
- Y Jamilloux
- Service de médecine interne, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard-Lyon 1, 69004 Lyon, France; International research center on infectiology (CIRI), Inserm U1111, 69007 Lyon, France.
| | - C Bernard
- Service de médecine interne, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard-Lyon 1, 69004 Lyon, France
| | - O Lortholary
- Necker Pasteur center for infectious diseases and tropical medicine, Necker enfants malades, IHU Imagine, AP-HP, 75743 Paris, France; Institut Pasteur, centre national de référence des mycoses invasives, des antifongiques, et de mycologie moléculaire, 75743 Paris, France; CNRS URA3012, 75743 Paris, France
| | - S Kerever
- ECSTRA, épidémiologie et biostatistiques, UMR 1153, Inserm, 75004 Paris, France
| | - L Lelièvre
- Service de médecine interne, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard-Lyon 1, 69004 Lyon, France
| | - M Gerfaud-Valentin
- Service de médecine interne, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard-Lyon 1, 69004 Lyon, France
| | - C Broussolle
- Service de médecine interne, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard-Lyon 1, 69004 Lyon, France
| | - D Valeyre
- COMUE Sorbonne Paris Cité, hôpital Avicenne et université Paris 13, Assistance publique-Hôpitaux de Paris, 93000 Bobigny, France
| | - P Sève
- Service de médecine interne, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69004 Lyon, France; Université Claude-Bernard-Lyon 1, 69004 Lyon, France
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Simões do Espírito Santo K, Teixeira VDPC, Costa HDO, Franco M. Renal Tuberculosis in Adult Polycystic Kidney Disease: Report of 2 Cases and Review of the Literature. Int J Surg Pathol 2016; 15:196-8. [PMID: 17478782 DOI: 10.1177/1066896906295956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Adult polycystic kidney disease (APKD) is a common and potentially fatal disease, leading to end-stage renal failure in 50% of cases. The disease is frequently complicated by arterial hypertension, bacterial pyelonephritis, and hematuria. The association between APKD and tuberculosis has rarely been reported and is related to a more unfavorable course since the infection becomes refractory to specific treatment. The authors report 2 cases of renal tuberculosis diagnosed in the native nephrectomy specimens of 2 patients with APKD after renal transplantation. Tuberculosis, although not common, must be recognized as a potential source of infection of native polycystic kidneys in immunocompromised transplant recipients.
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Abstract
Infections remain a major cause of mortality and morbidity after both kidney and liver transplantation, and internists increasingly play a major role in diagnosing and treating these infections. Because of immunosuppression, solid organ transplant recipients do not often demonstrate classic signs and symptoms of infection and have a broader variety of common and opportunistic infections, many of which are generally more difficult to diagnose and treat. Although these patients have many risk factors for infection, a major determinant is the time after transplant as it relates to levels of immunosuppression, healing, and hospital or environmental exposures.
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Affiliation(s)
- William G Greendyke
- Division of Infectious Diseases, Columbia University College of Physicians and Surgeons, 622 West 168th Street, Box 82, New York, NY 10032, USA
| | - Marcus R Pereira
- Division of Infectious Diseases, Columbia University College of Physicians and Surgeons, 622 West 168th Street, Box 82, New York, NY 10032, USA.
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Tutelyan AV, Pisarev VM, Minaeva NZ, Gaponov AM, Gracheva AN, Solopova GG. [Generation of Antibiotic Tolerant Bacterial Persisters in Immunocompromized Patients with Hematologic and Malignant Diseases: A New Problem of Health-Care Associated Infections]. Vestn Ross Akad Med Nauk 2016; 71:183-189. [PMID: 29297622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Antibiotic tolerance (AT) represents one of the causes of the phenomenon of antibiotic resistance that allows escape of non-replicating metabolically inert microorganisms (persisters) from any antibiotics attack because molecular targets of antibiotics are lacking thereby creating the potential for chronic infections. AIMS Determine the heterogeneity of the strains of opportunistic pathogens E. coli and P. aeruginosa isolates from children with hematologic malignancies containing bacterial persisters that cause the AT phenomenon. METHODS Children with hematological malignancies were divided into 2 groups according to the intensity of antibiotic treatment of infectious complications. Ciprofloxacin-induced persisters were quantitatively determined in the biological materials obtained from sick children. RESULTS Within the clinical isolates of E. coli and P. aeruginosa, about a third of the strains belong to high-persisting. The numbers of persistent forms of bacteria did not correlate with a minimal inhibitory concentration values ciprofloxacin (r=0.148, n=25, p>0.05). Interestingly, higher level of formation of persistent E. coli and P. aeruginosa, is associated with higher frequencies of infection attacks, massive antibiotic use and unfavorable course of the disease in children. CONCLUSIONS Therefore, detecting the persistent forms of bacterial pathogens including those associated with the health-care associated infection, specifically, in immunocompromised patients, should be included into the contemporary algorithms of microbiological observation and monitoring of patients and intrahospital environment.
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Kassar O, Charfi M, Trabelsi H, Hammami R, Elloumi M. Fusarium solani endocarditis in an acute leukemia patient. Med Mal Infect 2015; 46:57-9. [PMID: 26706407 DOI: 10.1016/j.medmal.2015.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 09/12/2015] [Accepted: 11/12/2015] [Indexed: 11/18/2022]
Affiliation(s)
- O Kassar
- Service d'hématologie, hôpital Hedi Chaker, université de Sfax, route Al Ain, 3029 Sfax, Tunisia.
| | - M Charfi
- Service d'hématologie, hôpital Hedi Chaker, université de Sfax, route Al Ain, 3029 Sfax, Tunisia
| | - H Trabelsi
- Laboratoire de parasitologie-mycologie, hôpital Habib Bourguiba, université de Sfax, Sfax, Tunisia
| | - R Hammami
- Service de cardiologie, hôpital Hedi Chaker, université de Sfax, Sfax, Tunisia
| | - M Elloumi
- Service d'hématologie, hôpital Hedi Chaker, université de Sfax, route Al Ain, 3029 Sfax, Tunisia
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