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Al-Yousuf H, O'Nions J, Wilson AJ, Gohil S, Manson JJ, Payne EM. Safety and efficacy of anakinra in hemophagocytic lymphohistiocytosis associated with acute leukemia. Haematologica 2024; 109:1947-1950. [PMID: 38299608 PMCID: PMC11141663 DOI: 10.3324/haematol.2023.283879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/22/2024] [Indexed: 02/02/2024] Open
Abstract
Not available.
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Affiliation(s)
- Hannah Al-Yousuf
- Department of Hematology, University College London Hospitals, London.
| | - Jenny O'Nions
- Department of Hematology, University College London Hospitals, London
| | - Andrew J Wilson
- Department of Hematology, University College London Hospitals, London
| | - Satyen Gohil
- Department of Hematology, University College London Hospitals, London
| | - Jessica J Manson
- Department of Hematology, University College London Hospitals, London
| | - Elspeth M Payne
- Department of Hematology, University College London Hospitals, London, United Kingdom; UCL Cancer Institute, London, United K ingdom.
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2
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Ruffer N, Kosch R, Weisel K, Kötter I, Krusche M. [Hemophagocytic lymphohistiocytosis and macrophage activation syndrome : A multidisciplinary challenge]. Z Rheumatol 2024; 83:376-386. [PMID: 38267764 DOI: 10.1007/s00393-023-01472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/26/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that is characterized by hyperferritinemia, cytopenia, disseminated intravascular coagulopathy and functional disorders of the liver and the central nervous system. The term macrophage activation syndrome is predominantly used for secondary HLH in the context of autoimmune diseases (e.g., systemic juvenile idiopathic arthritis). In addition, malignancies and genetic inborn errors of immunity can predispose to the development of HLH. Infections (e.g., Epstein-Barr virus) in turn represent possible triggers of an acute episode. Due to the unspecific manifestation of the disease, a systematic evaluation of the organ systems is recommended in the clinical and laboratory analytical clarification of hyperinflammatory syndromes. In general, the treatment should be carried out by a multidisciplinary team with expertise in rheumatology, hematological oncology, infectious diseases and intensive care medicine. The primary treatment of HLH usually consists of glucocorticoids and in cases of a rapid deterioration of the condition anakinra (interleukin 1 block) and intravenous immunoglobulins can be employed. Treatment of the underlying disease should be consequently carried out in parallel, together with antimicrobial treatment.
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Affiliation(s)
- Nikolas Ruffer
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Ricardo Kosch
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Katja Weisel
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Ina Kötter
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Martin Krusche
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Çakmak R, Yüce S, Ay M, Uyar MH, Kılıç Mİ, Bektaş M. Intravenous high-dose anakinra drops venous thrombosis and acute coronary syndrome in severe and critical COVID-19 patients: a propensity score matched study. Sci Rep 2024; 14:12369. [PMID: 38811592 PMCID: PMC11137068 DOI: 10.1038/s41598-024-62079-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/13/2024] [Indexed: 05/31/2024] Open
Abstract
In our study, we aimed to evaluate the effect of high-dose intravenous anakinra treatment on the development of thrombotic events in severe and critical COVID-19 patients. This retrospective observational study was conducted at a tertiary referral center in Aksaray, Turkey. The study population consisted of two groups as follows; the patients receiving high-dose intravenous anakinra (anakinra group) added to background therapy and the patients treated with standard of care (SoC) as a historical control group. Age, gender, mcHIS scores, and comorbidities such as diabetes mellitus, hypertension, and coronary heart disease of the patients were determined as the variables to be matched. We included 114 patients in SoC and 139 patients in the Anakinra group in the study. Development of any thromboembolic event (5% vs 12.3%, p = 0.038; OR 4.3) and PTE (2.9% vs 9.6%, p = 0.023; OR 5.1) were lower in the Anakinra group than SoC. No patient experienced cerebrovascular accident and/or clinically evident deep venous thrombosis both in two arms. After 1:1 PS matching, 88 patients in SoC and 88 patients in the Anakinra group were matched and included in the analysis. In survival analysis, the development of any thromboembolic event, pulmonary thromboembolism, and acute coronary syndrome (ACS) were higher in SoC compared to Anakinra. Survival rate was also lower in patients with SoC arm than Anakinra in patients who had any thromboembolic event as well as ACS. In our study, the development of thrombosis was associated with hyperinflammation in patients with severe and critical COVID-19. Intravenous high-dose anakinra treatment decreases both venous and arterial events in patients with severe and critical COVID-19.
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Affiliation(s)
- Ramazan Çakmak
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Istinye University, Istanbul, Turkey
| | - Servet Yüce
- Department of Public Health and Biostatistics, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Mustafa Ay
- Aksaray University, Aksaray Training and Research Hospital, Aksaray, Turkey
| | | | - Muhammed İkbal Kılıç
- Department of Internal Medicine, Aksaray Training and Research Hospital, Aksaray, Turkey
| | - Murat Bektaş
- Division of Rheumatology, Department of Internal Medicine, Aksaray Training and Research Hospital, Yeni Sanayi Street, Merkez, 68200, Aksaray, Turkey.
- Division of Rheumatology, Department of Internal Medicine, Istanbul Aydın University, Istanbul, Turkey.
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Katsin M, Shman T, Migas A, Lutskovich D, Serada Y, Khalankova Y, Kostina Y, Dubovik S. Case report: Rapid resolution of grade IV ICANS after first line intrathecal chemotherapy with methotrexate, cytarabine and dexamethasone. Front Immunol 2024; 15:1380451. [PMID: 38765003 PMCID: PMC11099209 DOI: 10.3389/fimmu.2024.1380451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024] Open
Abstract
Corticosteroid therapy is the mainstay of immune effector cell-associated neurotoxicity syndrome (ICANS) management, although its use has been associated with worse overall survival (OS) and progression-free survival (PFS) after chimeric antigen receptor T-cell (CAR-T cell) therapy. Many options are being investigated for prophylaxis and management. Accumulating evidence supports the use of intrathecal (IT) chemotherapy for the management of high-grade ICANS. Here, we describe a case of a patient with stage IV Primary mediastinal B-cell lymphoma (PMBCL) successfully treated with IT methotrexate, cytarabine, and dexamethasone as first-line therapy for CD19 CAR-T cell-associated grade IV ICANS. The stable and rapid resolution of ICANS to grade 0 allowed us to discontinue systemic corticosteroid use, avoiding CAR-T cells ablation and ensuring preservation of CAR-T cell function. The described patient achieved a complete radiologic and clinical response to CD19 CAR-T cell therapy and remains disease-free after 9 months. This case demonstrates a promising example of how IT chemotherapy could be used as first-line treatment for the management of high-grade ICANS.
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Affiliation(s)
- Mikalai Katsin
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Tatsiana Shman
- Laboratory of Genetic Biotechnologies, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Alexandr Migas
- Laboratory of Genetic Biotechnologies, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Dzmitry Lutskovich
- Laboratory of Genetic Biotechnologies, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Yuliya Serada
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Yauheniya Khalankova
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Yuliya Kostina
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Simon Dubovik
- Laboratory of Molecular Diagnostics and Biotechnology, Institute of Bioorganic Chemistry of the National Academy of Sciences of Belarus, Minsk, Belarus
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Dong Y, Wang T, Wu H. Heterogeneity of macrophage activation syndrome and treatment progression. Front Immunol 2024; 15:1389710. [PMID: 38736876 PMCID: PMC11082376 DOI: 10.3389/fimmu.2024.1389710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
Macrophage activation syndrome (MAS) is a rare complication of autoimmune inflammatory rheumatic diseases (AIIRD) characterized by a progressive and life-threatening condition with features including cytokine storm and hemophagocytosis. Predisposing factors are typically associated with microbial infections, genetic factors (distinct from typical genetically related hemophagocytic lymphohistiocytosis (HLH)), and inappropriate immune system overactivation. Clinical features include unremitting fever, generalized rash, hepatosplenomegaly, lymphadenopathy, anemia, worsening liver function, and neurological involvement. MAS can occur in various AIIRDs, including but not limited to systemic juvenile idiopathic arthritis (sJIA), adult-onset Still's disease (AOSD), systemic lupus erythematosus (SLE), Kawasaki disease (KD), juvenile dermatomyositis (JDM), rheumatoid arthritis (RA), and Sjögren's syndrome (SS), etc. Although progress has been made in understanding the pathogenesis and treatment of MAS, it is important to recognize the differences between different diseases and the various treatment options available. This article summarizes the cell types and cytokines involved in MAS-related diseases, the heterogeneity, and treatment options, while also comparing it to genetically related HLH.
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Affiliation(s)
- Yuanji Dong
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ting Wang
- Department of Respiratory Disease, Thoracic Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Huaxiang Wu
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Magnarelli A, Shalen J, Gutierrez MJ. Cytokine Storm Syndrome Responsive to IL-1 Inhibition in Trisomy 21. Case Rep Pediatr 2024; 2024:9946401. [PMID: 38577256 PMCID: PMC10994700 DOI: 10.1155/2024/9946401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 01/02/2024] [Accepted: 02/26/2024] [Indexed: 04/06/2024] Open
Abstract
Background Cytokine storm syndromes (CSS) are life-threatening systemic inflammatory disorders caused by immune system dysregulation. They can lead to organ failure and are triggered by various factors, including infections, malignancy, inborn errors of immunity, and autoimmune conditions. Trisomy 21 (TS21), also known as Down syndrome, is a genetic disorder associated with immune dysfunction, increased infection susceptibility, and inflammation. While TS21 has been linked to infectious-triggered hyperinflammation, its role as a primary cause of CSS has not been confirmed. Case Presentation. We present a case of a 16-year-old male with TS21 with fever, rash, joint pain, and abdominal symptoms. Extensive investigations ruled out infections, autoimmune conditions, malignancies, and inborn errors of immunity as triggers for a CSS. The patient's symptoms improved with treatment using IL-1 inhibition and corticosteroids. Conclusions This case reinforces that TS21 is an immune dysregulation disorder and highlights the importance of considering CSS in TS21 patients, even when triggers are unclear. The positive response to IL-1 inhibition in this patient suggests that dysregulation of the IL-1 superfamily and the NLRP3 inflammasome may contribute to CSS in TS21. This finding raises the possibility of using IL-1 inhibition as a treatment approach for CSS in TS21 patients.
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Affiliation(s)
- Aimee Magnarelli
- Division of Pediatric Allergy, Immunology and Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julia Shalen
- Division of Pediatric Allergy, Immunology and Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maria J. Gutierrez
- Division of Pediatric Allergy, Immunology and Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Brisca G, Bellini T, Pasquinucci M, Mariani M, Romanengo M, Buffoni I, Tortora D, Parodi A, Fueri E, Mesini A, Tibaldi J, Piccotti E, Ramenghi LA, Moscatelli A. Clinical course and peculiarities of Parechovirus and Enterovirus central nervous system infections in newborns: a single-center experience. Eur J Pediatr 2024:10.1007/s00431-024-05518-2. [PMID: 38492030 DOI: 10.1007/s00431-024-05518-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/04/2024] [Accepted: 03/09/2024] [Indexed: 03/18/2024]
Abstract
Parechovirus (HpEV) and Enterovirus (EV) infections in children mostly have a mild course but are particularly fearsome in newborns in whom they may cause aseptic meningitis, encephalitis, and myocarditis. Our study aimed to describe the clinical presentations and peculiarities of CNS infection by HpEV and EV in neonates. This is a single-center retrospective study at Istituto Gaslini, Genoa, Italy. Infants aged ≤ 30 days with a CSF RTq-PCR positive for EV or HpEV from January 1, 2022, to December 1, 2023, were enrolled. Each patient's record included demographic data, blood and CSF tests, brain MRI, therapies, length of stay, ICU admission, complications, and mortality. The two groups were compared to identify any differences and similarities. Twenty-five patients (15 EV and 10 HpEV) with a median age of 15 days were included. EV patients had a more frequent history of prematurity/neonatal respiratory distress syndrome (p = 0.021), more respiratory symptoms on admission (p = 0.012), and higher C-reactive protein (CRP) levels (p = 0.027), whereas ferritin values were significantly increased in HpEV patients (p = 0.001). Eight patients had a pathological brain MRI, equally distributed between the two groups. Three EV patients developed myocarditis and one HpEV necrotizing enterocolitis with HLH-like. No deaths occurred. Conclusion: EV and HpEV CNS infections are not easily distinguishable by clinical features. In both cases, brain MRI abnormalities are not uncommon, and a severe course of the disease is possible. Hyper-ferritinemia may represent an additional diagnostic clue for HpEV infection, and its monitoring is recommended to intercept HLH early and initiate immunomodulatory treatment. Larger studies are needed to confirm our findings. What is Known: • Parechovirus and Enteroviruses are the most common viral pathogens responsible for sepsis and meningoencephalitis in neonates and young infants. • The clinical course and distinguishing features of Parechovirus and Enterovirus central nervous system infections are not well described. What is New: • Severe disease course, brain MRI abnormalities, and complications are not uncommon in newborns with Parechovirus and Enteroviruses central nervous system infections. • Hyper-ferritinemia may represent an additional diagnostic clue for Parechovirus infection and its monitoring is recommended.
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Affiliation(s)
- Giacomo Brisca
- Neonatal and Pediatric Intensive Care Unit, and Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy.
| | - Tommaso Bellini
- Emergency Room and Pediatric Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Mattia Pasquinucci
- Department of Neurosciences, Genetics and Maternal and Child Health (DINOGMI), University of Genova, RehabilitationGenoa, Ophthalmology, Italy
| | - Marcello Mariani
- Pediatric Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marta Romanengo
- Neonatal and Pediatric Intensive Care Unit, and Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Isabella Buffoni
- Neonatal and Pediatric Intensive Care Unit, and Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alessandro Parodi
- Department Mother and Child, Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Elena Fueri
- Department of Neurosciences, Genetics and Maternal and Child Health (DINOGMI), University of Genova, RehabilitationGenoa, Ophthalmology, Italy
| | - Alessio Mesini
- Pediatric Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Jessica Tibaldi
- Emergency Room and Pediatric Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Emanuela Piccotti
- Emergency Room and Pediatric Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Luca Antonio Ramenghi
- Department of Neurosciences, Genetics and Maternal and Child Health (DINOGMI), University of Genova, RehabilitationGenoa, Ophthalmology, Italy
- Department Mother and Child, Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, and Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
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Guclu KG, Geyiktepe-Guclu C, Bayramlar OF, Tuncer G, Aydin M. Use of high-dose steroid therapy: addition of anakinra in the treatment of severe COVID-19. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e20230671. [PMID: 38511750 PMCID: PMC10941869 DOI: 10.1590/1806-9282.20230671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 09/28/2023] [Indexed: 03/22/2024]
Abstract
OBJECTIVE The aim of this study was to compare the clinical effects of the addition of anakinra to high-dose steroid therapy in COVID-19 patients with macrophage activation syndrome. METHODS This was a single-center retrospective study conducted in Ümraniye Training and Research Hospital between March 11, 2020, and April 28, 2021. Patients receiving only high-dose steroid or anakinra+steroid were enrolled. The first day of anakinra was considered as day 0. Laboratory values and oxygen requirements were followed up for 7 days. Patients were divided into two groups: 66 patients in the high-dose steroid group and 67 patients in the anakinra+steroid group. The primary outcome was 28-day mortality. RESULTS After treatment, a significant decrease in ferritin levels was detected only in the anakinra+steroid group (p=0.001). In both groups, there were significant changes in lymphocytes, C-reactive protein, lactate dehydrogenase, and fibrinogen levels during the 7-day follow-up. Changes in oxygen status according to the World Health Organization clinical scale on day 3 and day 7 between high-dose steroid and anakinra+steroid groups were similar (p=0.976). Complications were higher in the anakinra+steroid group than in the steroid group (26% vs. 12%, p=0.03). The rates of 28-day mortality were 57% in the anakinra+steroid group and 42% in the high-dose steroid group (p=0.48). In multivariate regression, anakinra did not affect 28-day mortality (p=0.67). CONCLUSION The addition of anakinra to steroid treatment resulted in a significant decrease in biochemical parameters. However, no significant difference was observed in the oxygen status between the groups. The addition of anakinra to steroid treatment did not decrease mortality. Clinicians should be aware of the complications of anti-inflammatory therapies.
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Affiliation(s)
- Kadir Gorkem Guclu
- Umraniye Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology – İstanbul, Turkey
| | - Ceyda Geyiktepe-Guclu
- Haseki Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology – İstanbul, Turkey
| | - Osman Faruk Bayramlar
- Turkish Ministry of Health - Istanbul Health Directorate, Bakırköy District Health Directorate – İstanbul, Turkey
| | - Gulsah Tuncer
- Bilecik Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology – Bilecik, Turkey
| | - Mehtap Aydin
- Umraniye Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology – İstanbul, Turkey
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Bektaş M, Ay M, Hamdi Uyar M, İkbal Kılıç M. Combination therapy of high-dose intravenous anakinra and baricitinib in patients with critical COVID-19: Promising results from retrospective observational study. Int Immunopharmacol 2024; 129:111586. [PMID: 38309091 DOI: 10.1016/j.intimp.2024.111586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION In this study, we aimed to evaluate the safety and efficacy of combination treatment of high-dose intravenous anakinra and baricitinib in patients with critically ill COVID-19. MATERIAL AND METHODS This retrospective observational study was conducted in a tertiary center with diagnosis of COVID-19 patients.Study population consisted of patients with positive polymerase chain reaction and computer tomography findings compatible with COVID-19 as well as critical illness. RESULTS Data of 15 patients in combination group and 43 patients in control group were evaluated and included into the study. Overall mortality was 46.7 % (n = 7) in combination arm and 69.8 % (n = 30) in control group although it was not statistically significant (p = 0.1). Similarly, need of intubation was also lower in combination arm (46.7 %) compared to control group (69.8 %), it was not significantly different (p = 0.1). ICU admission was significantly lower in combination (46.7 %, n = 7) arm than control group (76.7 %, n = 33) (p = 0.03, Odds ratio [OR]:4.7). Development of severe infection (20 %, n = 3 vs 25 %, n = 9/36), pulmonary embolism (6.7 %, n = 1 vs 0), myocardial infarction (6.7 %, n = 1 vs 2.6 %, n = 1/38) and pneumothorax (13.3 %, n = 2 vs 2.6 %, n = 1/38) were not different between two groups (p = 0.7, p = 0.3, p = 0.5 and p = 0.2). In multivariable analysis only cHIS score was associated with high mortality (p = 0.018, OR:2.8, [95 % confidence interval: 1.2-6.6]). In survival analysis, mortality rate was significantly lower in combination arm than control group (Log-Rank:p = 0.04). CONCLUSION Combination therapy of high-dose anakinra and baricitinib may be an adequate treatment option in patients with COVID-19 who had critical disease and has acceptable safety profile.
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Affiliation(s)
- Murat Bektaş
- Division of Rheumatology, Department of Internal Medicine, Istanbul Aydın University, Istanbul, Turkey; Division of Rheumatology, Department of Internal Medicine, Aksaray Training and Research Hospital, Aksaray, Turkey.
| | - Mustafa Ay
- Department of Emergency Medicine, Aksaray Training and Research Hospital, Aksaray, Turkey
| | - Muhammed Hamdi Uyar
- Department of Emergency Medicine, Aksaray Training and Research Hospital, Aksaray, Turkey
| | - Muhammed İkbal Kılıç
- Department of Internal Medicine, Aksaray Training and Research Hospital, Aksaray, Turkey
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Bellal M, Malherbe J, Damaj G, Du Cheyron D. Toxicities, intensive care management, and outcome of chimeric antigen receptor T cells in adults: an update. Crit Care 2024; 28:69. [PMID: 38444031 PMCID: PMC10916319 DOI: 10.1186/s13054-024-04851-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/27/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Chimeric antigen receptor T cells are a promising new immunotherapy for haematological malignancies. Six CAR-T cells products are currently available for adult patients with refractory or relapsed high-grade B cell malignancies, but they are associated with severe life-threatening toxicities and side effects that may require admission to ICU. OBJECTIVE The aim of this short pragmatic review is to synthesize for intensivists the knowledge on CAR-T cell therapy with emphasis on CAR-T cell-induced toxicities and ICU management of complications according to international recommendations, outcomes and future issues.
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Affiliation(s)
- Mathieu Bellal
- Department of Medical Intensive Care, Caen University Hospital, Avenue de la côte de nacre, 14000, Caen, France.
- UNICAEN, INSERM UMRS U1237 PhIND, Normandie Univ, 14000, Caen, France.
| | - Jolan Malherbe
- Department of Medical Intensive Care, Caen University Hospital, Avenue de la côte de nacre, 14000, Caen, France
| | - Gandhi Damaj
- Hematology Institute, Caen University Hospital, 14000, Caen, France
| | - Damien Du Cheyron
- Department of Medical Intensive Care, Caen University Hospital, Avenue de la côte de nacre, 14000, Caen, France
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Holloway A, Ahmed S, Manson JJ. Does your unwell patient have haemophagocytic lymphohistiocytosis? Br J Hosp Med (Lond) 2024; 85:1-12. [PMID: 38557089 DOI: 10.12968/hmed.2023.0394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Haemophagocytic lymphohistiocytosis is a severe systemic hyperinflammatory syndrome characterised by dysregulation of immune cells and excessive production of cytokines, also known as a cytokine storm. It has distinctive clinical features with fever, hyperferritinaemia and falling blood counts. In adults, this usually occurs secondary to an underlying driver or trigger including infection, malignancy or rheumatic diseases. Prompt treatment with immunomodulatory therapy, including corticosteroids and the recombinant IL-1 receptor antagonist anakinra, is recommended to switch off the cytokine storm. Etoposide-based regimens are sometimes needed, and newer therapies such as emapalumab and JAK inhibitors are increasingly being used. The incidence of haemophagocytic lymphohistiocytosis has increased significantly over the last 20 years which may partly reflect increased awareness of the condition. Although relatively rare, haemophagocytic lymphohistiocytosis can be encountered by a broad range of hospital physicians, so knowing how to diagnose and treat this condition is essential. This article reviews the pathogenesis, clinical features, causes, diagnosis and treatment of haemophagocytic lymphohistiocytosis to improve physician recognition and management of this condition to improve future patient outcomes.
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Affiliation(s)
- Amelia Holloway
- Department of Rheumatology, Kings College Hospital, London, UK
| | - Saad Ahmed
- Department of Rheumatology, Addenbrookes Hospital, Cambridge, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
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Gleeson TA, Kaiser C, Lawrence CB, Brough D, Allan SM, Green JP. The NLRP3 inflammasome is essential for IL-18 production in a murine model of macrophage activation syndrome. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.02.27.582284. [PMID: 38464243 PMCID: PMC10925192 DOI: 10.1101/2024.02.27.582284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Hyperinflammatory disease is associated with an aberrant immune response resulting in cytokine storm. One such instance of hyperinflammatory disease is known as macrophage activation syndrome (MAS). The pathology of MAS can be characterised by significantly elevated serum levels of interleukin (IL)-18 and interferon (IFN)-γ. Given the role for IL-18 in MAS, we sought to establish the role of inflammasomes in the disease process. Using a murine model of CpG-DNA induced MAS, we discovered that the expression of the NLRP3 inflammasome was increased and correlated with IL-18 production. Inhibition of the NLRP3 inflammasome, or downstream caspase-1, prevented MAS-mediated upregulation of plasma IL-18 but interestingly did not alleviate key features of hyperinflammatory disease including hyperferritinaemia and splenomegaly. Furthermore IL-1 receptor blockade with IL-1Ra did not prevent the development of CpG-induced MAS, despite being clinically effective in the treatment of MAS. These data demonstrate that in the development of MAS, the NLRP3 inflammasome was essential for the elevation in plasma IL-18, a key cytokine in clinical cases of MAS, but was not a driving factor in the pathogenesis of CpG-induced MAS.
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Affiliation(s)
- Tara A Gleeson
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | | | - Catherine B Lawrence
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - David Brough
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Stuart M Allan
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Jack P Green
- Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
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Sola D, Smirne C, Bruggi F, Bottino Sbaratta C, Tamen Njata AC, Valente G, Pavanelli MC, Vitetta R, Bellan M, De Paoli L, Pirisi M. Unveiling the Mystery of Adult-Onset Still's Disease: A Compelling Case Report. Life (Basel) 2024; 14:195. [PMID: 38398704 PMCID: PMC10890189 DOI: 10.3390/life14020195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder. Diagnosis can take a long time, especially in the presence of confounding factors, and it is, to some extent, a process of exclusion. AOSD has life-threating complications ranging from asymptomatic to severe, such as macrophage activation syndrome (MAS), which is also referred to as hemophagocytic lymphohistocytosis (HLH). This condition is correlated with cytokine storm production and monocyte/macrophage overactivation and typically occurs with rash, pyrexia, pancytopenia, hepatosplenomegaly and systemic involvement. Exitus occurs in approximately 10% of cases. For the treatment of MAS-HLH, the Histiocyte Society currently suggests high-dose corticosteroids, with the possible addition of cyclosporine A, anti-interleukin (IL)-1, or IL-6 biological drugs; the inclusion of etoposide is recommended for the most severe conditions. In all cases, a multidisciplinary collaboration involving the resources and expertise of several specialists (e.g., rheumatologist, infectiologist, critical care medicine specialist) is advised. Herein, we provide a detailed description of the clinical case of a previously healthy young woman in which MAS developed as a dramatic onset manifestation of AOSD and whose diagnosis posed a real clinical challenge; the condition was finally resolved by applying the HLH-94 protocol (i.e., etoposide in combination with dexamethasone).
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Affiliation(s)
- Daniele Sola
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
- CAAD (Center for Autoimmune and Allergic Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
- IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
| | - Carlo Smirne
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Francesco Bruggi
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Chiara Bottino Sbaratta
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Aubin Cardin Tamen Njata
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Guido Valente
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Pathology Unit, Sant'Andrea Hospital, 13100 Vercelli, Italy
| | | | - Rosetta Vitetta
- Rheumatology Unit, Sant'Andrea Hospital, 13100 Vercelli, Italy
| | - Mattia Bellan
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
- CAAD (Center for Autoimmune and Allergic Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
- IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
| | | | - Mario Pirisi
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
- Internal Medicine Unit, Maggiore della Carità Hospital, 28100 Novara, Italy
- CAAD (Center for Autoimmune and Allergic Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
- IRCAD (Interdisciplinary Research Center of Autoimmune Diseases), Università del Piemonte Orientale, 28100 Novara, Italy
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14
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Slaney ED, Modica R, Woolnough L, Kafisheh D, Bell-Brunson DH, Elder M. Case Report: Refractory macrophage activation syndrome requiring high-dose anakinra, emapalumab, and etoposide therapy in early-onset systemic juvenile idiopathic arthritis associated with adenoviremia. Front Pediatr 2024; 11:1336554. [PMID: 38322244 PMCID: PMC10845352 DOI: 10.3389/fped.2023.1336554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/21/2023] [Indexed: 02/08/2024] Open
Abstract
Macrophage activation syndrome (MAS) is a life-threatening condition characterized by the excessive stimulation of macrophages and T lymphocytes, provoked by infections, malignancy, and autoimmune or autoinflammatory conditions such as systemic juvenile idiopathic arthritis (sJIA). Clinical signs of sJIA may include high-spiking, quotidian fevers, lymphadenopathy, hepatosplenomegaly, and a salmon-colored migratory, evanescent rash. By contrast, MAS is characterized by unremitting fevers and diffuse, fixed, maculopapular rashes. In addition to hepatosplenomegaly and lymphadenopathy, patients with MAS may also have clinical signs of coagulopathy, as well as cardiac, lung, renal, and central nervous system dysfunction. The empiric treatment for MAS is initially high-dose IV corticosteroids, but usually requires addition of immunomodulators such as tacrolimus or a biologic such as Anakinra to control. The addition of immunotherapies for MAS has improved patient outcomes. We present a 2-year-old male patient with a history of early-onset sJIA, who presented with MAS refractory to corticosteroids and anakinra triggered by adenoviremia that required addition of emapalumab to control. We believe this is the first reported case of a combination of immunosuppressive therapy of emapalumab, etoposide, anakinra, tacrolimus, and corticosteroids used in the successful treatment of infection-induced MAS in early-onset sJIA. Given the lack of treatment guidelines and approved therapies for MAS, alternative strategies should be considered for patients with an intractable course.
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Affiliation(s)
| | - Renee Modica
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Leandra Woolnough
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Dina Kafisheh
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Denise Heather Bell-Brunson
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Melissa Elder
- College of Medicine, University of Florida, Gainesville, FL, United States
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida, Gainesville, FL, United States
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15
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Qidwai T. Cytokine storm in COVID-19 and malaria: Annals of pro-inflammatory cytokines. Cytokine 2024; 173:156420. [PMID: 37976701 DOI: 10.1016/j.cyto.2023.156420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023]
Abstract
Infectious diseases are affecting the people worldwide. Mostly, infectious agents activate excessive production of cytokines so called cytokine storm. Among the infectious diseases COVID-19 is one of the deadliest diseases affecting individuals all over the world, moreover, Plasmodium falciparum malaria and HIV are major killers. An excessive pro-inflammatory response is one of the major causes of pathological conditions in these diseases. It is important to investigate the pathophysiology in the infectious diseases such as COVID-19, malaria and HIV as there is no concrete therapy against them so far. Exploration of excessive pro-inflammation could be important for therapeutic intervention. In this article, an attempt has been made to analyze the pathological conditions arise due to excessive inflammatory response in COVID-19, malaria and other infectious diseases. Targeting excessive pro-inflammatory response/cytokine storm in infectious diseases could be a useful strategy.
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Affiliation(s)
- Tabish Qidwai
- Faculty of Biotechnology, Shri Ramswaroop Memorial University, Lucknow Deva Road, Uttar Pradesh 225003, India.
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16
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Vasco AE, Talano JA, Broglie L. Hemophagocytic Lymphohistiocytosis in Adolescents and Young Adults: Genetic Predisposition and Secondary Disease. Med Clin North Am 2024; 108:189-200. [PMID: 37951650 DOI: 10.1016/j.mcna.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a disorder of impaired immune regulation resulting in hyperinflammation that is ultimately fatal if not treated. HLH is categorized into familial disease, caused by genetic mutations affecting the function of cytotoxic T lymphocytes and natural killer cells, and secondary disease, triggered by infections, malignancies, rheumatologic disorders, or immune deficiency. Adolescent and young adults with HLH represent a unique population with specific diagnostic challenges. Here we review the diagnostic criteria, possible etiologies, pathophysiology, and management of HLH with focus on the adolescent population.
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Affiliation(s)
- Alejandra Escobar Vasco
- Medical College of Wisconsin, 8701 Watertown Plank Road, MFRC 3018, Milwaukee, WI 53226, USA; Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, MFRC 3018, Milwaukee, WI 53226, USA
| | - Julie-Ann Talano
- Medical College of Wisconsin, 8701 Watertown Plank Road, MFRC 3018, Milwaukee, WI 53226, USA; Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, MFRC 3018, Milwaukee, WI 53226, USA
| | - Larisa Broglie
- Medical College of Wisconsin, 8701 Watertown Plank Road, MFRC 3018, Milwaukee, WI 53226, USA; Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, MFRC 3018, Milwaukee, WI 53226, USA.
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17
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Dubinsky SDJ, Watt KM, Imburgia CE, Mcknite AM, Hunt JP, Rice C, Rower JE, Edginton AN. Anakinra Removal by Continuous Renal Replacement Therapy: An Ex Vivo Analysis. Crit Care Explor 2023; 5:e1010. [PMID: 38107537 PMCID: PMC10723863 DOI: 10.1097/cce.0000000000001010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES Patients with sepsis are at significant risk for multiple organ dysfunction, including the lungs and kidneys. To manage the morbidity associated with kidney impairment, continuous renal replacement therapy (CRRT) may be required. The extent of anakinra pharmacokinetics in CRRT remains unknown. The objectives of this study were to investigate the anakinra-circuit interaction and quantify the rate of removal from plasma. DESIGN The anakinra-circuit interaction was evaluated using a closed-loop ex vivo CRRT circuit. CRRT was performed in three phases based on the method of solute removal: 1) hemofiltration, 2) hemodialysis, and 3) hemodiafiltration. Standard control samples of anakinra were included to assess drug degradation. SETTING University research laboratory. PATIENTS None. INTERVENTIONS Anakinra was administered to the CRRT circuit and serial prefilter blood samples were collected along with time-matched control and hemofiltrate samples. Each circuit was run in triplicate to assess inter-run variability. Concentrations of anakinra in each reference fluid were measured by enzyme-linked immunosorbent assay. Transmembrane filter clearance was estimated by the product of the sieving coefficient/dialysate saturation constant and circuit flow rates. MEASUREMENTS AND MAIN RESULTS Removal of anakinra from plasma occurred within minutes for each CRRT modality. Average drug remaining (%) in plasma following anakinra administration was lowest with hemodiafiltration (34.9%). The average sieving coefficient was 0.34, 0.37, and 0.41 for hemodiafiltration, hemofiltration, and hemodialysis, respectively. Transmembrane clearance was fairly consistent across each modality with the highest during hemodialysis (5.53 mL/min), followed by hemodiafiltration (4.99 mL/min), and hemofiltration (3.94 mL/min). Percent drug remaining within the control samples (93.1%) remained consistent across each experiment, indicating negligible degradation within the blood. CONCLUSIONS The results of this analysis are the first to demonstrate that large molecule therapeutic proteins such as anakinra, are removed from plasma with modern CRRT technology. Current dosing recommendations for patients with severe renal impairment may result in subtherapeutic anakinra concentrations in those receiving CRRT.
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Affiliation(s)
- Samuel D J Dubinsky
- University of Waterloo, School of Pharmacy, Faculty of Science, Waterloo, ON, Canada
| | - Kevin M Watt
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT
| | - Carina E Imburgia
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT
| | - Autumn M Mcknite
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT
| | - J Porter Hunt
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT
| | - Cassandra Rice
- Department of Pharmacology and Toxicology, Center for Human Toxicology, University of Utah, Salt Lake City, UT
| | - Joseph E Rower
- Department of Pharmacology and Toxicology, Center for Human Toxicology, University of Utah, Salt Lake City, UT
| | - Andrea N Edginton
- University of Waterloo, School of Pharmacy, Faculty of Science, Waterloo, ON, Canada
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18
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Baba M, Fenech M, Saeed MU, McCormick A, Jawad M. A rare case of orbital inflammation complicated by hemophagocytic lymphohistiocytosis. Orbit 2023:1-4. [PMID: 37942808 DOI: 10.1080/01676830.2023.2274868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/18/2023] [Indexed: 11/10/2023]
Abstract
We report a rare case of orbital inflammation complicating hemophagocytic lymphohistiocytosis (HLH) patient. HLH is a rare, life-threatening disorder characterized by uncontrolled activation of cytotoxic T lymphocytes, natural killer cells, and macrophages. A 37-year-old man known to have HLH, presented with a left periorbital swelling that was unsuccessfully treated as an orbital cellulitis, with intravenous antibiotics. A computed tomography (CT) scan of the orbits revealed inflammatory changes with no orbital collection or paranasal sinus disease. An orbital biopsy demonstrated lymphoplasmacytic infiltrations admixed with histiocytes. The patient deteriorated and was admitted to the intensive care unit. Ensuing blood results supported a diagnosis of HLH, and the patient responded well to subsequent immunosuppression. This case report highlights the importance of re-considering the diagnosis of orbital cellulitis in treatment resistant cases, particularly in the absence of sinus disease. To our knowledge, this is the third case of orbital inflammation associated with HLH patients.
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Affiliation(s)
- Mohamad Baba
- Department of Ophthalmology, Aintree University Hospital NHS Foundation Trust, Aintree, UK
| | - Matthew Fenech
- Department of Ophthalmology, Aintree University Hospital NHS Foundation Trust, Aintree, UK
| | - Muhammad Usman Saeed
- Department of Ophthalmology, St Pauls Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Austin McCormick
- Department of Ophthalmology, Aintree University Hospital NHS Foundation Trust, Aintree, UK
| | - Muhammed Jawad
- Department of Ophthalmology, Aintree University Hospital NHS Foundation Trust, Aintree, UK
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19
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Mastrangelo A, Monardo R, Galli L, Tomelleri A, Tassan Din C, Canetti D, Messina E, Guffanti M, Danise A, Campochiaro C, Cavalli G, Monti G, Cinque P, Scarpellini P, Landoni G, Ciceri F, Dagna L, Castagna A, Ripa M. High-dose anakinra in addition to standard of care including corticosteroids in patients with severe COVID-19 treated with non-invasive ventilation. Eur J Clin Microbiol Infect Dis 2023; 42:1383-1387. [PMID: 37723323 DOI: 10.1007/s10096-023-04661-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023]
Abstract
Management of COVID-19 patients experiencing persisting respiratory failure despite corticosteroids remains challenging. Data on high-dose intravenous anakinra (HD-ANK) in this context are lacking. We aimed to investigate the impact of HD-ANK on mortality in COVID-19 patients progressing to non-invasive ventilation (NIV) while receiving corticosteroids. We retrospectively analyzed the impact of HD-ANK on 28-day mortality in individuals hospitalized with COVID-19 necessitating NIV after corticosteroid initiation. A total of 256 patients were identified: 146 received standard-of-care only (SOC), and 110 received HD-ANK+SOC. The groups were well-balanced at baseline. In-hospital mortality at 28 days did not differ between the two groups. HD-ANK is not beneficial in patients with severe COVID-19 deteriorating despite corticosteroids.
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Affiliation(s)
- Andrea Mastrangelo
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Roberta Monardo
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Laura Galli
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Alessandro Tomelleri
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Tassan Din
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Diana Canetti
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Emanuela Messina
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Monica Guffanti
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Anna Danise
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Corrado Campochiaro
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Cavalli
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Monti
- Vita-Salute San Raffaele University, Milan, Italy
- Anesthesia and Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola Cinque
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Paolo Scarpellini
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy
- Anesthesia and Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Hematology and Stem Cell Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Dagna
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonella Castagna
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Stamira d'Ancona 20, 20127, Milan, Italy
| | - Marco Ripa
- Vita-Salute San Raffaele University, Milan, Italy.
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Stamira d'Ancona 20, 20127, Milan, Italy.
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20
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Fugere T, Baltz A, Mukherjee A, Gaddam M, Varma A, Veeraputhiran M, Gentille Sanchez CG. Immune Effector Cell-Associated HLH-like Syndrome: A Review of the Literature of an Increasingly Recognized Entity. Cancers (Basel) 2023; 15:5149. [PMID: 37958323 PMCID: PMC10647774 DOI: 10.3390/cancers15215149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/21/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Since CAR-T cell therapy was initially approved in 2017, its use has become more prevalent and so have its side effects. CAR-T-related HLH, also named immune effector cell-associated HLH-like syndrome (IEC-HS), is a rare but fatal toxicity if not recognized promptly. We conducted a review of the literature in order to understand the prevalence of IEC-HS as well as clarify the evolution of the diagnostic criteria and treatment recommendations. IEC-HS occurrence varies between CAR-T cell products and the type of malignancy treated. Diagnosis can be challenging as there are no standardized diagnostic criteria, and its clinical features can overlap with cytokine release syndrome and active hematological disease. Suggested treatment strategies have been extrapolated from prior experience in HLH and include anakinra, corticosteroids and ruxolitinib. IEC-HS is a potentially fatal toxicity associated with CAR-T cell therapy. Early recognition with reliable diagnostic criteria and prompt implementation of treatment specific to IEC-HS is imperative for improving patient outcomes.
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Affiliation(s)
- Tyler Fugere
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (A.B.); (A.M.); (M.G.); (A.V.); (M.V.); (C.G.G.S.)
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21
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van Baalen A. Febrile infection-related epilepsy syndrome in childhood: A clinical review and practical approach. Seizure 2023; 111:215-222. [PMID: 37703593 DOI: 10.1016/j.seizure.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023] Open
Abstract
Febrile infection-related epilepsy syndrome (FIRES) of unknown aetiology is an extremely rare but severe epilepsy syndrome. It is characterized by a nonspecific febrile infection a few days before the onset of super-refractory status epilepticus, followed by refractory epilepsy and high morbidity in previously healthy children and young adults. To date, FIRES is incurable and irreversible. The clinical course may depend more on time than on therapy, while the outcome may depend more on the clinical spectrum than on therapy. Based on a literature search, retrospective data analysis, and personal observations, this review aimed to explore the clinical spectrum and therapeutic options for FIRES to improve outcomes by optimized and more standardized diagnosis and therapy, including adapted immunotherapy and a less aggressive approach to manage seizures, as seizure-freeness is difficult to achieve and, therefore, not the primary goal for cryptogenic FIRES.
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Affiliation(s)
- Andreas van Baalen
- Department of Neuropediatrics, University Medical Center Schleswig-Holstein, Kiel University (CAU), Arnold-Heller-Street 3, House C, Kiel 24105, Germany.
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22
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Mizuta M, Inoue N, Shimizu M, Sakumura N, Yokoyama T, Kuroda R, Ikawa Y, Sugimoto N, Harada K, Yachie A, Wada T. Distinct roles of IL-18 and IL-1β in murine model of macrophage activation syndrome. J Allergy Clin Immunol 2023; 152:940-948.e6. [PMID: 37352976 DOI: 10.1016/j.jaci.2023.05.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/25/2023] [Accepted: 05/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND IL-18 and IL-1β play a central role in the pathogenesis of systemic juvenile idiopathic arthritis and its life-threatening complication, macrophage activation syndrome (MAS). OBJECTIVES This study aimed to clarify the role of IL-18 and IL-1β in the pathogenesis of MAS. METHODS We developed a mouse model to evaluate the role of each cytokine with Toll-like receptor 9 stimulation after continuous infusion with IL-18, IL-1β, and a combination of both for 7 days. The symptoms and laboratory findings were compared among the IL-18, IL-1β, and combination (IL-18+IL-1β) groups. RESULTS Body weight was significantly decreased in the IL-1β and combination groups. Splenomegaly was observed in all groups, whereas hepatomegaly was noted in the IL-18 group only. Decreased T-cell numbers, anemia, and thrombocytopenia were observed in the combination group. IFN-γ, CXCL9, and IL-12A mRNA levels were upregulated and IL-10 mRNA levels in the spleen were downregulated in the IL-18 group. Hepatomegaly and splenomegaly in the IL-18 group were observed in a dose-dependent manner. TNF-α, CXCL9, and IL-12A mRNA levels were upregulated only in those mice with extremely elevated plasma IL-18 levels. CONCLUSION IL-18 and IL-1β have distinct roles in the pathogenesis of MAS. Dual blockade of IL-18 and IL-1β might be necessary to treat MAS.
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Affiliation(s)
- Mao Mizuta
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Natsumi Inoue
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Masaki Shimizu
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan; Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Naoto Sakumura
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Tadafumi Yokoyama
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Rie Kuroda
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Yasuhiro Ikawa
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Naotoshi Sugimoto
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan; Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kenichi Harada
- Department of Human Pathology, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Akihiro Yachie
- Division of Patient Safety, Kanazawa University Hospital, Kanazawa, Japan
| | - Taizo Wada
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
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23
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Zeng Z, Tu W, Ji B, Liu J, Huang K, Nie D, Yang L. IFN-α induced systemic lupus erythematosus complicated with hemophagocytic lymphohistiocytosis: a case report and literature review. Front Immunol 2023; 14:1223062. [PMID: 37600795 PMCID: PMC10436618 DOI: 10.3389/fimmu.2023.1223062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/21/2023] [Indexed: 08/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe and life-threatening hyperinflammatory condition characterized by excessive activation of macrophages and T cells and resulted in multi-organ dysfunction. HLH can be a primary disease or secondary to infections, malignancy, and some autoimmune diseases, including adult-onset Still's disease (AOSD) and systemic lupus erythematosus (SLE). However, it is rare for HLH to occur as a secondary condition to drug-induced lupus erythematosus (DILE). In this report, we present a case of HLH as an unusual complication during SLE treatment in a 31-year-old male patient. The patient initially suffered from active chronic hepatitis B (CHB) and was treated with pegylated INFα-2b (Peg-INFα-2b), tenofovir disoproxil and lamivudine. After 19 months, CHB obtained biochemical and virological response with HBsAg positive to HBsAb. The patient developed fever, headache, and cytopenia after Peg-INFα-2b treatment for 33 months, and laboratory studies revealed that ANA and anti dsDNA were positive. He displayed 5 features meeting the HLH-2004 criteria for diagnosis including fever, pancytopenia, hyperferritinemia, high levels of soluble CD25, and hemophagocytosis on bone marrow biopsy. The patient was initiated with a combination treatment of intravenous methylprednisolone pulse therapy, oral cyclosporine, and etoposide (VP-16), which was followed by a course of oral prednisolone, intravenous cyclophosphamide pulse therapy, and entecavir with complete response. To our knowledge, this is the first report of IFN-α induced SLE complicating with HLH. Physicians should consider the potential autoimmune side effects of IFN-α therapy and be alert to insidious HLH in patients diagnosed with SLE.
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Affiliation(s)
- Zhipeng Zeng
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Tu
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bai Ji
- Department of Internal Medicine, the People Hospital of Tongshan, Xianning, China
| | - Jie Liu
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kecheng Huang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Daan Nie
- Department of Cardiology, the Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Liu Yang
- Department of Reproductive Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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24
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Gullickson M, Nichols L, Scheibe M. A Novel Therapy for a Rare Condition: Continuous Anakinra Infusion for a Patient With Macrophage Activation Syndrome. Cureus 2023; 15:e42968. [PMID: 37667692 PMCID: PMC10475328 DOI: 10.7759/cureus.42968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 09/06/2023] Open
Abstract
Macrophage activation syndrome (MAS) is a type of hemophagocytic lymphohistiocytosis (HLH), which occurs due to excessive stimulation of the immune system. Common precipitants of MAS include disseminated infection or underlying rheumatologic disorders such as adult-onset Still's disease which is characterized as an inflammatory arthritis with daily fevers and a salmon-colored rash. We present a case of a patient with probable adult-onset Still's disease and subsequent disseminated cytomegalovirus (CMV) infection, who met the criteria for MAS based on the presence of a fever, cytopenia in multiple cell lines, elevated ferritin, presence of hemophagocytosis on bone marrow, low fibrinogen, and mild splenomegaly on physical exam. The patient responded to treatment with continuous anakinra infusion and ganciclovir for treatment of CMV. Though cytotoxic medications such as etoposide have traditionally been considered first-line treatment for HLH/MAS, interleukin-1 inhibitors such as anakinra are emerging as aless cytotoxic alternative.
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Affiliation(s)
| | - Laura Nichols
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Fargo, USA
- Internal Medicine, Sanford Health, Fargo, USA
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25
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Talasaz AH, Sculthorpe R, Pak M, Lipinski M, Roberts C, Markley R, Trankle CR, Canada JM, Wohlford GF, Golino M, Dixon D, Van Tassell BW, Abbate A. Comparison of Safety and Biological Efficacy of Anakinra (Kineret) Dispensed in Polycarbonate Plastic versus Borosilicate Glass Syringes: A Patient-Level Analysis of VCUART2 and VCUART3 Clinical Trials. J Pharmacol Exp Ther 2023; 386:138-142. [PMID: 36868827 PMCID: PMC10353132 DOI: 10.1124/jpet.122.001404] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 02/09/2023] [Accepted: 02/16/2023] [Indexed: 03/05/2023] Open
Abstract
Anakinra is a recombinant human interleukin-1 receptor antagonist approved for the treatment of inflammatory diseases. Kineret is available as a solution prepared in a borosilicate glass syringe. For implementing a placebo-controlled double-blind randomized clinical trial, anakinra is commonly transferred into plastic syringes. However, there is limited data on anakinra's stability in polycarbonate syringes. We described the results of our previous studies on the use of anakinra in glass (VCUART3) versus plastic syringes (VCUART2) compared with placebo. These studies were conducted in patients with ST-segment elevation myocardial infarction (STEMI), and we assessed the anti-inflammatory effects of anakinra versus placebo by comparing the area under the curve for high-sensitivity cardiac reactive protein (AUC-CRP) levels during the first 14 days of STEMI, its clinical effects on heart failure (HF) hospitalization, cardiovascular death, or new diagnosis of HF as well as adverse events profile between groups. The levels of AUC-CRP were 75 (50-255 mg·day/l) for anakinra in plastic syringes versus 255 (116-592 mg·day/l) in placebo and 60 (24-139 mg·day/l) and 86 (43-123 mg·day/l) for anakinra once and twice daily in glass syringes, respectively, compared with placebo 214 (131-394 mg·day/l). The rate of adverse events was also comparable between groups. There were no differences in the rate of HF hospitalization or cardiovascular death in patients who received anakinra in plastic or glass syringes. Fewer cases of new-onset heart failure occurred in patients receiving anakinra in plastic or glass syringes compared with placebo. Anakinra stored in plastic (polycarbonate) syringes provides comparable biologic and clinical effect to glass (borosilicate) syringes. SIGNIFICANCE STATEMENT: Anakinra (Kineret) 100 mg administered subcutaneously in patients with ST-segment elevation myocardial infarction (STEMI) for a duration of up to 14 days appears to have comparable safety and biological efficacy signals when delivered in prefilled glass or transferred into plastic polycarbonate syringes. This may have important implications for the feasibility of designing clinical trials in STEMI and other clinical conditions.
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Affiliation(s)
- Azita H Talasaz
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
| | - Robin Sculthorpe
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
| | - Mary Pak
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
| | - Michael Lipinski
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
| | - Charlotte Roberts
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
| | - Roshanak Markley
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
| | - Cory R Trankle
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
| | - Justin M Canada
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
| | - George F Wohlford
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
| | - Michele Golino
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
| | - Dave Dixon
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
| | - Antonio Abbate
- Department of Pharmacotherapy and Outcome Sciences, School of Pharmacy (A.H.T.), Investigation Drug Pharmacy Department (R.S., M.P., G.F.W., D.D., B.W.V.T.), and Pauley Heart Center (M.L., C.R., R.M., C.R.T., J.M.C., M.G., D.D., B.W.V.T., A.A.), Virginia Commonwealth University, Richmond, Virginia; and Berne Cardiovascular Research Center and Division of Cardiology, Heart and Vascular Center, University of Virginia, Charlottesville, Virginia (A.A.)
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26
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Zhang L, Jiang Y, He J, Chen J, Qi R, Yuan L, Shao T, Zhao H, Chen C, Chen Y, Wang X, Lei X, Gao Q, Zhuang C, Zhou M, Ma J, Liu W, Yang M, Fu R, Wu Y, Chen F, Xiong H, Nie M, Chen Y, Wu K, Fang M, Wang Y, Zheng Z, Huang S, Ge S, Cheng SC, Zhu H, Cheng T, Yuan Q, Wu T, Zhang J, Chen Y, Zhang T, Li C, Qi H, Guan Y, Xia N. Intranasal influenza-vectored COVID-19 vaccine restrains the SARS-CoV-2 inflammatory response in hamsters. Nat Commun 2023; 14:4117. [PMID: 37433761 DOI: 10.1038/s41467-023-39560-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 06/19/2023] [Indexed: 07/13/2023] Open
Abstract
The emergence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) variants and "anatomical escape" characteristics threaten the effectiveness of current coronavirus disease 2019 (COVID-19) vaccines. There is an urgent need to understand the immunological mechanism of broad-spectrum respiratory tract protection to guide broader vaccines development. Here we investigate immune responses induced by an NS1-deleted influenza virus vectored intranasal COVID-19 vaccine (dNS1-RBD) which provides broad-spectrum protection against SARS-CoV-2 variants in hamsters. Intranasal delivery of dNS1-RBD induces innate immunity, trained immunity and tissue-resident memory T cells covering the upper and lower respiratory tract. It restrains the inflammatory response by suppressing early phase viral load post SARS-CoV-2 challenge and attenuating pro-inflammatory cytokine (Il6, Il1b, and Ifng) levels, thereby reducing excess immune-induced tissue injury compared with the control group. By inducing local cellular immunity and trained immunity, intranasal delivery of NS1-deleted influenza virus vectored vaccine represents a broad-spectrum COVID-19 vaccine strategy to reduce disease burden.
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Affiliation(s)
- Liang Zhang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Yao Jiang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Jinhang He
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Junyu Chen
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Ruoyao Qi
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Lunzhi Yuan
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Tiange Shao
- Tsinghua-Peking Center for Life Sciences, Laboratory of Dynamic Immunobiology, School of Medicine, Tsinghua University, 100084, Beijing, China
| | - Hui Zhao
- National Institute for Food and Drug Control, 102629, Beijing, China
| | - Congjie Chen
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Yaode Chen
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Xijing Wang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Xing Lei
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Qingxiang Gao
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Chunlan Zhuang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Ming Zhou
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Jian Ma
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Wei Liu
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Man Yang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Rao Fu
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Yangtao Wu
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Feng Chen
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Hualong Xiong
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Meifeng Nie
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Yiyi Chen
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Kun Wu
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Mujin Fang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
- Xiang An Biomedicine Laboratory, 361102, Xiamen, Fujian, China
| | - Yingbin Wang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
- Xiang An Biomedicine Laboratory, 361102, Xiamen, Fujian, China
| | - Zizheng Zheng
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
- Xiang An Biomedicine Laboratory, 361102, Xiamen, Fujian, China
| | - Shoujie Huang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
- Xiang An Biomedicine Laboratory, 361102, Xiamen, Fujian, China
| | - Shengxiang Ge
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
- Xiang An Biomedicine Laboratory, 361102, Xiamen, Fujian, China
| | - Shih Chin Cheng
- State Key Laboratory of Cellular Stress Biology, School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
| | - Huachen Zhu
- State Key Laboratory of Emerging Infectious Diseases, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, 999077, China
- Guangdong-Hong Kong Joint Laboratory of Emerging Infectious Diseases/Joint Laboratory for International Collaboration in Virology and Emerging Infectious Diseases, Joint Institute of Virology (STU/HKU), Shantou University, 515063, Shantou, China
| | - Tong Cheng
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
- Xiang An Biomedicine Laboratory, 361102, Xiamen, Fujian, China
| | - Quan Yuan
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China
- Xiang An Biomedicine Laboratory, 361102, Xiamen, Fujian, China
| | - Ting Wu
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China.
- Xiang An Biomedicine Laboratory, 361102, Xiamen, Fujian, China.
| | - Jun Zhang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China.
- Xiang An Biomedicine Laboratory, 361102, Xiamen, Fujian, China.
| | - Yixin Chen
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China.
- Xiang An Biomedicine Laboratory, 361102, Xiamen, Fujian, China.
| | - Tianying Zhang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China.
- Xiang An Biomedicine Laboratory, 361102, Xiamen, Fujian, China.
| | - Changgui Li
- National Institute for Food and Drug Control, 102629, Beijing, China.
| | - Hai Qi
- Tsinghua-Peking Center for Life Sciences, Laboratory of Dynamic Immunobiology, School of Medicine, Tsinghua University, 100084, Beijing, China.
| | - Yi Guan
- State Key Laboratory of Emerging Infectious Diseases, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, 999077, China.
- Guangdong-Hong Kong Joint Laboratory of Emerging Infectious Diseases/Joint Laboratory for International Collaboration in Virology and Emerging Infectious Diseases, Joint Institute of Virology (STU/HKU), Shantou University, 515063, Shantou, China.
| | - Ningshao Xia
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics; National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health & School of Life Sciences, Xiamen University, 361102, Xiamen, Fujian, China.
- Xiang An Biomedicine Laboratory, 361102, Xiamen, Fujian, China.
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Phoophiboon V, Brown P, Burns KEA. Systemic lupus erythematosus associated with development of macrophage activation syndrome and disseminated aspergillosis. Can J Anaesth 2023; 70:1255-1260. [PMID: 37349668 DOI: 10.1007/s12630-023-02506-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 01/05/2023] [Accepted: 01/14/2023] [Indexed: 06/24/2023] Open
Abstract
PURPOSE Macrophage activation syndrome (MAS) is a rare illness, especially in critically ill adults. The diagnosis of MAS is challenging, requiring the expertise of multiple specialists, and treatments for MAS can be associated with catastrophic complications. CLINICAL FEATURES We describe the case of a 31-yr-old Vietnamese student who was diagnosed with cutaneous systemic lupus erythematosus (SLE) in November 2020 and was initiated on treatment with low-dose corticosteroids and hydroxychloroquine as an outpatient. Ten days later, she presented to hospital with decreased consciousness, fever, periorbital swelling, and hypotension necessitating intubation. Computed tomography angiography (CTA) and lumbar puncture did not show a stroke or central nervous system infection. Serology and clinical presentation were consistent with MAS. She was initially treated with 4.5 g pulse methylprednisolone and subsequently with the interleukin-1 receptor antagonist, anakinra, and maintenance corticosteroids because of persistently elevated inflammatory markers. Her intensive care unit stay was complicated by aspiration, airway obstruction due to fungal tracheobronchitis necessitating extracorporeal membrane oxygenation (ECMO), and ring-enhancing cerebral lesions, and, ultimately, massive hemoptysis resulting in death. CONCLUSIONS Four features of this case merit discussion, including the: 1) infrequent association of SLE with MAS; 2) short interval between SLE diagnosis and critical illness; 3) manifestation of fungal tracheobronchitis with airway obstruction; and 4) lack of response to antifungal treatment while receiving ECMO.
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Affiliation(s)
- Vorakamol Phoophiboon
- Interdepartmental Division of Critical Care Medicine, Temerty School of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Paula Brown
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
| | - Karen E A Burns
- Division of Critical Care Medicine, Unity Health Toronto - St. Michael's Hospital, Li Ka Shing Knowledge Institute, 30 Bond Street, Office 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
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Reiff DD, Cron RQ. Cytokine Storm Syndrome Triggered by Extracorporeal Membrane Oxygenation in Pediatric Patients. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1052. [PMID: 37371283 DOI: 10.3390/children10061052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
Cytokine storm syndrome (CSS) is a serious and potentially life-threatening condition caused by severe systemic inflammation, immune activation, and a positive feedback loop of cytokine release. Typically triggered by systemic infection, malignancy, monogenic or rheumatic disease, similar patterns of hyper-inflammation have been seen in patients undergoing cardiopulmonary bypass (CPB) and in patients treated with extracorporeal membrane oxygenation (ECMO). Typical treatments used for the prevention and treatment of CPB/ECMO-induced hyper-inflammation have not been shown to be substantially effective. Two patients suffering from ECMO-related CSS were identified by their severe hyper-inflammatory profile and life-threatening sequelae of vasodilatory shock and respiratory failure. Anakinra, an interleukin-1 receptor antagonist, was employed as specific cytokine-directed therapy for the treatment of CSS in these two patients to good effect, with significant improvement in hyper-inflammation and cardiorespiratory status. The use of cytokine-directed therapies in CPB/ECMO-related CSS has great potential to improve the treatment and outcomes of this serious condition.
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Affiliation(s)
- Daniel D Reiff
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Randy Q Cron
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
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29
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De Benedetti F, Grom AA, Brogan PA, Bracaglia C, Pardeo M, Marucci G, Eleftheriou D, Papadopoulou C, Schulert GS, Quartier P, Antón J, Laveille C, Frederiksen R, Asnaghi V, Ballabio M, Jacqmin P, de Min C. Efficacy and safety of emapalumab in macrophage activation syndrome. Ann Rheum Dis 2023; 82:857-865. [PMID: 37001971 PMCID: PMC10314091 DOI: 10.1136/ard-2022-223739] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/02/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVES Macrophage activation syndrome (MAS) is a severe, life-threatening complication of systemic juvenile idiopathic arthritis (sJIA) and adult-onset Still's disease (AOSD). The objective of this study was to confirm the adequacy of an emapalumab dosing regimen in relation to interferon-γ (IFNγ) activity by assessing efficacy and safety. The efficacy outcome was MAS remission by week 8, based on clinical and laboratory criteria. METHODS We studied emapalumab, a human anti-IFNγ antibody, administered with background glucocorticoids, in a prospective single-arm trial involving patients who had MAS secondary to sJIA or AOSD and had previously failed high-dose glucocorticoids, with or without anakinra and/or ciclosporin. The study foresaw 4-week treatment that could be shortened or prolonged based on investigator's assessment of response. Patients entered a long-term (12 months) follow-up study. RESULTS Fourteen patients received emapalumab. All patients completed the trial, entered the long-term follow-up and were alive at the end of follow-up. The investigated dosing regimen, based on an initial loading dose followed by maintenance doses, was appropriate, as shown by rapid neutralisation of IFNγ activity, demonstrated by a prompt decrease in serum C-X-C motif chemokine ligand 9 (CXCL9) levels. By week 8, MAS remission was achieved in 13 of the 14 patients at a median time of 25 days. Viral infections and positive viral tests were observed. CONCLUSIONS Neutralisation of IFNγ with emapalumab was efficacious in inducing remission of MAS secondary to sJIA or AOSD in patients who had failed high-dose glucocorticoids. Screening for viral infections should be performed, particularly for cytomegalovirus. TRIAL REGISTRATION NUMBER NCT02069899 and NCT03311854.
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Affiliation(s)
| | - Alexei A Grom
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Paul A Brogan
- University College London Great Ormond Street Institute of Child Health, London, UK
| | - Claudia Bracaglia
- Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Manuela Pardeo
- Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Giulia Marucci
- Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Despina Eleftheriou
- University College London Great Ormond Street Institute of Child Health, London, UK
| | | | - Grant S Schulert
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Pierre Quartier
- Pediatric Immuno-Hematology and Rheumatology Unit, RAISE Rare Disease Reference Centre, Hopital Universitaire Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris, Paris, France
- Université Paris-Cité, Paris, France
| | - Jordi Antón
- Pediatric Rheumatology, Hospital Sant Joan de Deu, Barcelona, Spain
- Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
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Saunders BN, Kuijpers MV, Sloan JJ, Gertner E. Continuous IV infusion of anakinra. Front Pharmacol 2023; 14:1162742. [PMID: 37229265 PMCID: PMC10203171 DOI: 10.3389/fphar.2023.1162742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/26/2023] [Indexed: 05/27/2023] Open
Abstract
Objective: A review of the use of continuous IV infusion of anakinra; a description of the protocol for continuous IV infusion of anakinra in the treatment of cytokine storm developed over the past 4 years at a tertiary level academic medical center in the United States. Methods: We reviewed published reports of continuous IV infusion of anakinra in cytokine storm and summarize this method of treatment in other diseases. As well, over the past 4 years, continuous IV infusions of anakinra were administered at our tertiary level academic medical center in the United States (Regions Hospital, St. Paul, Minnesota) for approximately 400 patient days of treatment primarily for the cytokine storm associated with macrophage activation syndrome (MAS) in adults. This updated protocol is presented. While this a single center protocol, it may serve as an initial guide for further refinement of protocols in MAS and other conditions. Conclusion:Continuous IV infusion of anakinra has advantages over subcutaneous infusions and may be important in controlling severe life-threatening cytokine storm as seen in macrophage activation syndrome. This has the potential to be an important therapy for other syndromes including Cytokine Release Syndrome related to CAR T-cell therapy. Close collaboration between Rheumatology, Pharmacy and Nursing allows this treatment to be delivered rapidly and efficiently.
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Lee PY, Cron RQ. The Multifaceted Immunology of Cytokine Storm Syndrome. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2023; 210:1015-1024. [PMID: 37011407 PMCID: PMC10071410 DOI: 10.4049/jimmunol.2200808] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/20/2022] [Indexed: 04/05/2023]
Abstract
Cytokine storm syndromes (CSSs) are potentially fatal hyperinflammatory states that share the underpinnings of persistent immune cell activation and uninhibited cytokine production. CSSs can be genetically determined by inborn errors of immunity (i.e., familial hemophagocytic lymphohistiocytosis) or develop as a complication of infections, chronic inflammatory diseases (e.g., Still disease), or malignancies (e.g., T cell lymphoma). Therapeutic interventions that activate the immune system such as chimeric Ag receptor T cell therapy and immune checkpoint inhibition can also trigger CSSs in the setting of cancer treatment. In this review, the biology of different types of CSSs is explored, and the current knowledge on the involvement of immune pathways and the contribution of host genetics is discussed. The use of animal models to study CSSs is reviewed, and their relevance for human diseases is discussed. Lastly, treatment approaches for CSSs are discussed with a focus on interventions that target immune cells and cytokines.
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Affiliation(s)
- Pui Y. Lee
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Randy Q. Cron
- Division of Pediatric Rheumatology, Children’s of Alabama, University of Alabama Heersink School of Medicine, Birmingham, AL
- Department of Pediatrics, University of Alabama Heersink School of Medicine, Birmingham, AL
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Lee JC, Logan AC. Diagnosis and Management of Adult Malignancy-Associated Hemophagocytic Lymphohistiocytosis. Cancers (Basel) 2023; 15:1839. [PMID: 36980725 PMCID: PMC10046521 DOI: 10.3390/cancers15061839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/08/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe, dysregulated inflammation driven by the inability of T cells to clear an antigenic target. When associated with malignancy (mHLH), the HLH syndrome is typically associated with extremely poor survival. Here, we review the diagnosis of secondary HLH (sHLH) syndromes in adults, with emphasis on the appropriate workup and treatment of mHLH. At present, the management of HLH in adults, including most forms of mHLH, is based on the use of corticosteroids and etoposide following the HLH-94 regimen. In some cases, this therapeutic approach may be cohesively incorporated into malignancy-directed therapy, while in other cases, the decision about whether to treat HLH prior to initiating other therapies may be more complicated. Recent studies exploring the efficacy of other agents in HLH, in particular ruxolitinib, offer hope for better outcomes in the management of mHLH. Considerations for the management of lymphoma-associated mHLH, as well as other forms of mHLH and immunotherapy treatment-related HLH, are discussed.
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Affiliation(s)
- Jerry C. Lee
- Hematology, Blood and Marrow Transplantation, and Cellular Therapy Program, Division of Hematology/Oncology, University of California, San Francisco, CA 94143, USA;
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sCD25 as an independent adverse prognostic factor in adult patients with HLH: results of a multicenter retrospective study. Blood Adv 2023; 7:832-844. [PMID: 35973195 PMCID: PMC9986715 DOI: 10.1182/bloodadvances.2022007953] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/11/2022] [Accepted: 08/02/2022] [Indexed: 11/20/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but often fatal hyperinflammatory syndrome caused by an inborn or acquired error of immunity. In adults, the underlying immunodeficiency generally arises alongside severe infections, malignancies, autoimmune diseases, and immunosuppressive treatment. To analyze risk factors and outcome in adults, we conducted a multicenter retrospective study. A total of 62 adult (age ≥18 years) patients met at least one of the following inclusion criteria: (1) ≥5 of 8 HLH-2004 criteria, (2) HScore ≥ 200 plus 4 HLH-2004 criteria, or (3) mutation compatible with an HLH diagnosis. Most patients (65%) were male, and the median age at diagnosis was 53.5 years (range, 19-81 years). All patients were assigned to 4 etiologic subgroups based on their most likely HLH trigger. The survival probability of the 4 etiologic subgroups differed significantly (P = .004, log-rank test), with patients with an underlying malignancy having the worst clinical outcome (1-year survival probability of 21%). The parameters older age, malignant trigger, elevated serum levels of aspartate transferase, creatinine, international normalized ratio, lactate dehydrogenase, sCD25, and a low albumin level and platelet count at treatment initiation were significantly (P < .1) associated with worse overall survival in the univariate Cox regression model. In multivariate analysis, sCD25 remained the only significant prognostic factor (P = .005). Our results suggest that sCD25 could be a useful marker for the prognosis of patients with HLH that might help to stratify therapeutic interventions.
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Bindoli S, Galozzi P, Doria A, Sfriso P. Intravenous anakinra to curb cytokine storm in adult-onset Still's disease and in macrophage activation syndrome: A case series. Joint Bone Spine 2023; 90:105524. [PMID: 36623798 DOI: 10.1016/j.jbspin.2023.105524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Adult-onset Still's disease (AOSD) is an auto-inflammatory polygenic disorder, for which the diagnosis is essentially clinical. The exclusion of mimickers [such as common bacterial and viral infections, hematologic malignancies, and, more recently, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] is necessary to confirm the diagnosis. Anti-interleukin (IL)-1 therapy is considered a treatment milestone for AOSD. Herein, we present a short series of newly-diagnosed AOSD or upcoming macrophage activation syndrome (MAS) cases who received intravenous (IV) anakinra, an IL-1 receptor blocker. METHODS Four patients with newly-diagnosed AOSD or upcoming MAS were treated with IV anakinra at the Rheumatology Unit of Padova University Hospital, Italy. We obtained informed consent from the patients for use of their cases and medical images for publication purposes. RESULTS All patients presented with AOSD or MAS during the COVID-19 pandemic, making diagnosis challenging due to similar immunological and clinical characteristics across both pathologies. All patients presented with hyperpyrexia and elevated inflammatory markers; two patients had a skin rash typically seen in AOSD. IV anakinra slowed down AOSD progression in all patients, prevented severe outcomes and mitigated the risk of multiorgan failure. All cases improved within 24hours of anakinra administration. CONCLUSION We found that administration of anakinra in patients with newly-diagnosed AOSD and/or upcoming MAS reduced hyperinflammation and prevented life-threatening complications. The IV route appears to be preferable in the hospital setting, where comorbidities such as coagulopathies and thrombocytopenia can complicate the use of other routes of administration.
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Affiliation(s)
- Sara Bindoli
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, via Giustiniani 2, 35128 Padova, Italy
| | - Paola Galozzi
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, via Giustiniani 2, 35128 Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, via Giustiniani 2, 35128 Padova, Italy
| | - Paolo Sfriso
- Rheumatology Unit, Department of Medicine (DIMED), University of Padova, via Giustiniani 2, 35128 Padova, Italy.
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Hughes SA, Lin M, Weir A, Huang B, Xiong L, Chua NK, Pang J, Santavanond JP, Tixeira R, Doerflinger M, Deng Y, Yu C, Silke N, Conos SA, Frank D, Simpson DS, Murphy JM, Lawlor KE, Pearson JS, Silke J, Pellegrini M, Herold MJ, Poon IKH, Masters SL, Li M, Tang Q, Zhang Y, Rashidi M, Geng L, Vince JE. Caspase-8-driven apoptotic and pyroptotic crosstalk causes cell death and IL-1β release in X-linked inhibitor of apoptosis (XIAP) deficiency. EMBO J 2023; 42:e110468. [PMID: 36647737 PMCID: PMC9975961 DOI: 10.15252/embj.2021110468] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 12/08/2022] [Accepted: 12/19/2022] [Indexed: 01/18/2023] Open
Abstract
Genetic lesions in X-linked inhibitor of apoptosis (XIAP) pre-dispose humans to cell death-associated inflammatory diseases, although the underlying mechanisms remain unclear. Here, we report that two patients with XIAP deficiency-associated inflammatory bowel disease display increased inflammatory IL-1β maturation as well as cell death-associated caspase-8 and Gasdermin D (GSDMD) processing in diseased tissue, which is reduced upon patient treatment. Loss of XIAP leads to caspase-8-driven cell death and bioactive IL-1β release that is only abrogated by combined deletion of the apoptotic and pyroptotic cell death machinery. Namely, extrinsic apoptotic caspase-8 promotes pyroptotic GSDMD processing that kills macrophages lacking both inflammasome and apoptosis signalling components (caspase-1, -3, -7, -11 and BID), while caspase-8 can still cause cell death in the absence of both GSDMD and GSDME when caspase-3 and caspase-7 are present. Neither caspase-3 and caspase-7-mediated activation of the pannexin-1 channel, or GSDMD loss, prevented NLRP3 inflammasome assembly and consequent caspase-1 and IL-1β maturation downstream of XIAP inhibition and caspase-8 activation, even though the pannexin-1 channel was required for NLRP3 triggering upon mitochondrial apoptosis. These findings uncouple the mechanisms of cell death and NLRP3 activation resulting from extrinsic and intrinsic apoptosis signalling, reveal how XIAP loss can co-opt dual cell death programs, and uncover strategies for targeting the cell death and inflammatory pathways that result from XIAP deficiency.
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Use of extracorporeal immunomodulation in a toddler with hemophagocytic lymphohistiocytosis and multisystem organ failure. Pediatr Nephrol 2023; 38:927-931. [PMID: 35869162 PMCID: PMC9307428 DOI: 10.1007/s00467-022-05692-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a dysregulated immune disorder in children, associated with Epstein-Barr virus (EBV) infection or malignancies. In severe forms, HLH presents with signs and symptoms of hyperinflammation that progress to life-threatening multiorgan failure. Intervention with an extracorporeal immunomodulatory treatment utilizing a selective cytopheretic device (SCD) could be beneficial. The SCD with regional citrate anticoagulation selectively binds the most highly activated circulating neutrophils and monocytes and deactivates them before release to the systemic circulation. Multiple clinical studies, including a multicenter study in children, demonstrate SCD therapy attenuates hyperinflammation, resolves ongoing tissue injury and allows progression to functional organ recovery. We report the first case of SCD therapy in a patient with HLH and multi-organ failure. CASE DIAGNOSIS/TREATMENT A previously healthy 22-month-old toddler presented with fever, abdominal distension, organomegaly, pancytopenia, and signs of hyperinflammation. EBV PCR returned at > 25 million copies. The clinical and laboratory pictures were consistent with systemic EBV-positive T-cell lymphoma with symptoms secondary to HLH. The patient met inclusion criteria for an ongoing study of integration of the SCD with a continuous kidney replacement therapy (CKRT) as part of standard of care. The patient received CKRT-SCD for 4 days with normalization of serum markers of sepsis and inflammation. The patient underwent hematopoietic stem cell transplantation 52 days after presentation and has engrafted with normal kidney function 8 months later. CONCLUSIONS SCD treatment resulted in improvement of poor tissue perfusion reflected by rapid decline in serum lactate levels, lessened systemic capillary leak with discontinuation of vasoactive agents, and repair and recovery of lung and kidney function with extubation and removal of hemodialysis support.
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Lee J, Pham B, Karanjawala ZE, Adesina O. Postpartum fevers, a rare presentation of secondary hemophagocytic lymphohistiocytosis. Clin Case Rep 2023; 11:e7070. [PMID: 36941837 PMCID: PMC10023518 DOI: 10.1002/ccr3.7070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 01/05/2023] [Accepted: 02/13/2023] [Indexed: 03/20/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare disease of excessive immune system activation. We report a case of HLH in a 20-year-old primigravid woman who presented with postpartum fevers. She was successfully treated with dexamethasone and anakinra, a deviation from the HLH-94 protocol, to preserve her ability to breastfeed.
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Affiliation(s)
- Jacqueline Lee
- Department of Internal Medicine University of California Davis School of Medicine Sacramento California USA
| | - Brian Pham
- Division of Hematology and Oncology University of California Davis School of Medicine Sacramento California USA
| | - Zarir E Karanjawala
- Division of Hematopathology University of California Davis School of Medicine Sacramento California USA
| | - Oyebimpe Adesina
- Division of Hematology and Oncology University of California Davis School of Medicine Sacramento California USA
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38
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Yang L, Lowry S, Heath T. Use of Intravenous Anakinra for Management of Pediatric Cytokine Storm Syndromes at an Academic Medical Center. Hosp Pharm 2023. [DOI: 10.1177/00185787221142470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Background: Off-label intravenous (IV) route of anakinra is increasingly recognized to enable higher and faster maximal plasma concentrations than subcutaneous route for treatment of cytokine storm syndromes. Objective: To describe off-label indications of IV anakinra, corresponding dosing and safety profiles, particularly during the coronavirus disease 19 (COVID-19) pandemic. Methods: A retrospective, single-cohort study was conducted at an academic medical center to evaluate use of IV anakinra in hospitalized pediatric patients (age ≤21 years). Institutional Review Board review was considered exempt. The primary endpoint was the primary indication(s) for IV anakinra. The key secondary endpoints were dosing of IV anakinra, previous immunomodulatory therapies, and adverse events. Results: Of 14 pediatric patients, 8 (57.1%) received IV anakinra for treatment of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19, whereas 3 and 2 were treated for hemophagocytic lymphohistiocytosis (HLH) and flares of systemic onset juvenile idiopathic arthritis (SoJIA), respectively. The initial dosing regimen of IV anakinra for MIS-C associated with COVID-19 was a median dose of 2.25 mg/kg/dose with a median dosing interval of 12 hours for a median initial treatment duration of 3.5 days. Eleven (78.6%) patients received previous immunomodulatory therapies (IV immune globulin [n = 10; 71.4%] and steroids [n = 9; 64.3%]). No adverse drug events were documented. Conclusion: IV anakinra was used off-label for treatment of MIS-C associated with COVID-19, HLH and SoJIA flares in critically ill patients with no adverse drug events documented. This study helped ascertain the off-label indications of IV anakinra and corresponding patient characteristics.
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Della Casa F, Petraroli A, Mormile I, Lagnese G, Di Salvatore A, Rossi FW, de Paulis A. Adult-onset macrophage activation syndrome treated by interleukin-1 inhibition. Rheumatol Adv Pract 2023; 7:rkad014. [PMID: 36789245 PMCID: PMC9912699 DOI: 10.1093/rap/rkad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 02/05/2023] Open
Affiliation(s)
- Francesca Della Casa
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Angelica Petraroli
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy,Center for Basic and Clinical Immunology Research, WAO Center of Excellence, University of Naples Federico II, Naples, Italy
| | - Ilaria Mormile
- Correspondence to: Ilaria Mormile, Department of Translational Medical Sciences, University of Naples Federico II, Via Sergio Pansini 5, 80131 Naples, Italy. E-mail:
| | - Gianluca Lagnese
- Post-Graduate Program in Clinical Immunology and Allergy, University of Naples Federico II, Naples, Italy
| | - Antonio Di Salvatore
- Post-Graduate Program in Clinical Immunology and Allergy, University of Naples Federico II, Naples, Italy
| | - Francesca Wanda Rossi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy,Center for Basic and Clinical Immunology Research, WAO Center of Excellence, University of Naples Federico II, Naples, Italy
| | - Amato de Paulis
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy,Center for Basic and Clinical Immunology Research, WAO Center of Excellence, University of Naples Federico II, Naples, Italy
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Bektaş M, Yüce S, Ay M, Uyar MH, Önder ME, Kılıç Mİ. High-dose intravenous anakinra treatment is safe and effective in severe and critical COVID-19 patients: a propensity score-matched study in a single center. Inflammopharmacology 2023; 31:787-797. [PMID: 36707494 PMCID: PMC9882740 DOI: 10.1007/s10787-023-01138-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/12/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND In COVID-19, severe disease course such as need of intensive care unit (ICU) as well as development of mortality is mainly due to cytokine storm. In this study, we aimed to evaluate the high-dose intravenous anakinra treatment response and outcome in patients with severe and critically ill COVID-19 compared to standard of care. METHODS This retrospective observational study was carried out at a tertiary referral center. The study population consisted of two groups as follows: the patients receiving high-dose intravenous anakinra (anakinra group) between 01.09.2021 and 01.02.2022 and the patients treated with standard of care (SoC, control group) as historical control group who were hospitalized between 01.07.2021 and 01.09.2021. RESULTS After the propensity score 1:1 matching, 79 patients in anakinra and 79 patients in SoC matched and were included into the analysis. Mean ± SD patient age was 67.4 ± 16.7 and 67.1 ± 16.3 years in anakinra and SoC groups, respectively (p = 0.9). Male gender was 38 (48.7%) in anakinra and 36 (46.2%) in SoC (p = 0.8). Overall, ICU admission was in 14.1% (n = 11) and 30.8% (n = 24) (p = 0.013; OR 6.2), intubation in 12.8% (n = 10) and 16.7% (n = 13) patients (p = 0.5), and 14.1% (n = 11) and 32.1% (n = 25) patients died in anakinra and control groups, respectively (p = 0.008; OR 7.1). CONCLUSION In our study, mortality was lower in patients receiving anakinra compared to SoC. Intravenous high-dose anakinra is safe and effective treatment in patients with severe and critical COVID-19.
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Affiliation(s)
- Murat Bektaş
- Division of Rheumatology, Department of Internal Medicine, Aksaray Training and Research Hospital, Yeni Sanayi Mahallesi, 68200 Merkez/Aksaray, Turkey
| | - Servet Yüce
- Department of Public Health and Biostatistics, Istanbul Faculty of Medicine, Çapa, Şehremini, Istanbul, Turkey
| | - Mustafa Ay
- Department of Emergency Medicine, Aksaray Training and Research Hospital, 68200 Merkez/Aksaray, Turkey
| | - Muhammed Hamdi Uyar
- Department of Emergency Medicine, Aksaray Training and Research Hospital, 68200 Merkez/Aksaray, Turkey
| | - Mustafa Erkut Önder
- Division of Rheumatology, Department of Physical Therapy and Rehabilitation, Aksaray Training and Research Hospital, Yeni Sanayi Mahallesi, 68200 Merkez/Aksaray, Turkey
| | - Muhammed İkbal Kılıç
- Department of Internal Medicine, Aksaray Training and Research Hospital, Yeni Sanayi Mahallesi, 68200 Merkez/Aksaray, Turkey
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Elmekaty EZI, Maklad A, Abouelhassan R, Munir W, Ibrahim MIM, Nair A, Alibrahim R, Iqbal F, Al Bishawi A, Abdelmajid A, Aboukamar M, Hadi HA, Khattab MA, Al Soub H, Al Maslamani M. Evaluation of anakinra in the management of patients with COVID-19 infection: A randomized clinical trial. Front Microbiol 2023; 14:1098703. [PMID: 36778864 PMCID: PMC9910697 DOI: 10.3389/fmicb.2023.1098703] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/06/2023] [Indexed: 01/27/2023] Open
Abstract
Background The global COVID-19 pandemic led to substantial clinical and economic outcomes with catastrophic consequences. While the majority of cases has mild to moderate disease, minority of patients progress into severe disease secondary to the stimulation of the immune response. The hyperinflammatory state contributes towards progression into multi-organ failure which necessitates suppressive therapy with variable outcomes. This study aims to explore the safety and efficacy of anakinra in COVID-19 patients with severe disease leading to cytokine release syndromes. Methods In this open-label, multi-center, randomized clinical trial, patients with confirmed COVID-19 infection with evidence of respiratory distress and signs of cytokine release syndrome were randomized in 1:1 ratio to receive either standard of care (SOC) or anakinra (100 mg subcutaneously every 12 h for 3 days then 100 mg subcutaneously once daily for 4 days) in addition to SOC. The primary outcome was treatment success at day 14 as defined by the WHO clinical progression score of ≤3. Primary analysis was based upon intention-to-treat population, with value of p of <0.05. Results Out 327 patients screened for eligibility, 80 patients were recruited for the study. The mean age was 49.9 years (SD = 11.7), with male predominance at 82.5% (n = 66). The primary outcome was not statistically different (87.5% (n = 35) in anakinra group vs. 92.5% (n = 37) in SOC group, p = 0.712; OR = 1.762 (95%CI: 0.39-7.93). The majority of reported adverse events were mild in severity and not related to the study treatment. Elevated aspartate aminotransferase was the only significant adverse event which was not associated with discontinuation of therapy. Conclusion In patients with severe COVID-19 infection, the addition of anakinra to SOC treatment was safe but was not associated with significant improvement according to the WHO clinical progression scale. Further studies are warranted to explore patients' subgroups characteristics that might benefit from administered therapy. Clinical Trial Registration Trial registration at ClinicalTrials.gov, identifier: NCT04643678.
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Affiliation(s)
- Eman Zeyad I. Elmekaty
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar,*Correspondence: Eman Zeyad I. Elmekaty,
| | - Aya Maklad
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | | | - Waqar Munir
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar
| | | | - Arun Nair
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar
| | - Rim Alibrahim
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar
| | - Fatima Iqbal
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar
| | - Ahmad Al Bishawi
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohamed Aboukamar
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar
| | - Hamad Abdel Hadi
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar
| | | | - Hussam Al Soub
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar
| | - Muna Al Maslamani
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar
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Mayne ES, George JA, Louw S. Assessing Biomarkers in Viral Infection. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1412:159-173. [PMID: 37378766 DOI: 10.1007/978-3-031-28012-2_8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Current biomarkers to assess the risk of complications of both acute and chronic viral infection are suboptimal. Prevalent viral infections like human immunodeficiency virus (HIV), hepatitis B and C virus, herpes viruses, and, more recently, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) may be associated with significant sequelae including the risk of cardiovascular disease, other end-organ diseases, and malignancies. This review considers some biomarkers which have been investigated in diagnosis and prognosis of key viral infections including inflammatory cytokines, markers of endothelial dysfunction and activation and coagulation, and the role that more conventional diagnostic markers, such as C-reactive protein and procalcitonin, can play in predicting these secondary complications, as markers of severity and to distinguish viral and bacterial infection. Although many of these are still only available in the research setting, these markers show promise for incorporation in diagnostic algorithms which may assist to predict adverse outcomes and to guide therapy.
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Affiliation(s)
- Elizabeth S Mayne
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town and National Health Laboratory Service, Cape Town, South Africa.
| | - Jaya A George
- National Health Laboratory Service and Wits Diagnostic Innovation Hub, University of Witwatersrand, Johannesburg, South Africa
| | - Susan Louw
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
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Amikishiyev S, Gunver MG, Bektas M, Aghamuradov S, Ince B, Koca N, Torun ES, Aliyeva N, Sari S, Cetin C, Yalcin-Dulundu BC, Deniz R, Kemik F, Agargun BF, Gulseren UA, Besisik B, Alkan O, Bagriacik C, Tor YB, Senkal N, Catma Y, Durak G, Mese S, Agacfidan A, Kose M, Erelel M, Cagatay AA, Simsek-Yavuz S, Kalayoglu-Besisik S, Esen F, Gül A. Criteria for Hyperinflammation Developing in COVID-19: Analysis of 2 Cohorts From Different Periods of the Pandemic. Arthritis Rheumatol 2022; 75:664-672. [PMID: 36508470 PMCID: PMC9878117 DOI: 10.1002/art.42417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 11/15/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Hyperinflammation (HI) that develops in week 2 of COVID-19 contributes to a worse outcome. Because week 2 laboratory findings can be relatively mild, the available criteria for classification of hemophagocytic lymphohistiocytosis or macrophage activation syndrome are not helpful. METHODS Our study included a discovery cohort of patients from Turkey with symptomatic COVID-19 who were followed up while hospitalized during the initial wave and a replication cohort of hospitalized patients from a later period, all of whom required oxygen support and received glucocorticoids. Diagnosis of HI was made by an expert panel; most patients with COVID-19-associated HI (HIC) received tocilizumab or anakinra. Clinical and laboratory data from start day of treatment with tocilizumab or anakinra in HIC patients were compared with the data from day 5-6 in patients without HIC. Values maximizing the sensitivity and specificity of each parameter were calculated to determine criteria items. RESULTS The discovery cohort included 685 patients, and the replication cohort included 156 patients, with 150 and 61 patients receiving treatment for HI, respectively. Mortality rate in HI patients in the discovery cohort (23.3%) was higher than the rate in patients without HI (3.7%) and the rate in patients in the overall replication cohort (10.3%). The 12-item criteria that we developed for HIC showed that a score of 35 provided 85.3% sensitivity and 81.7% specificity for identification of HIC. In the replication cohort, the same criteria resulted in 90.0% sensitivity for HIC; however, lower specificity values were observed because of the inclusion of milder cases of HIC responding only to glucocorticoids. CONCLUSION The use of the 12-item criteria for HIC can better define patients with HIC with reasonable sensitivity and specificity and enables an earlier treatment start.
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Affiliation(s)
- Shirkhan Amikishiyev
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - M Guven Gunver
- Department of Medical Statistics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Murat Bektas
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sarvan Aghamuradov
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Burak Ince
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nevzat Koca
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ege Sinan Torun
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Numune Aliyeva
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Selma Sari
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Cigdem Cetin
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Banu C Yalcin-Dulundu
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Rabia Deniz
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Fatih Kemik
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Besim Fazil Agargun
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ubeyde Ayse Gulseren
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Beliz Besisik
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Onur Alkan
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ceren Bagriacik
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yavuz B Tor
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Naci Senkal
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yunus Catma
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Gorkem Durak
- Department of Radiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sevim Mese
- Division of Virology and Fundamental Immunology, Department of Medical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ali Agacfidan
- Division of Virology and Fundamental Immunology, Department of Medical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Murat Kose
- Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mustafa Erelel
- Department of Chest Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - A Atahan Cagatay
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Serap Simsek-Yavuz
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sevgi Kalayoglu-Besisik
- Division of Hematology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Figen Esen
- Department of Anesthesiology and Reanimation, Intensive Care Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ahmet Gül
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Tang JP, Peters CW, Quiros C, Wang X, Klomhaus AM, Yamada RE, Timmerman JM, Moore TB, Nowicki TS. Hypophosphatemia Due to Increased Effector Cell Metabolic Activity Is Associated with Neurotoxicity Symptoms in CD19-Targeted CAR T-cell Therapy. Cancer Immunol Res 2022; 10:1433-1440. [PMID: 36259217 PMCID: PMC9722515 DOI: 10.1158/2326-6066.cir-22-0418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/27/2022] [Accepted: 09/15/2022] [Indexed: 01/10/2023]
Abstract
A major complication of chimeric antigen receptor (CAR) T-cell therapy is immune effector cell-associated neurotoxicity syndrome (ICANS), which presents as aphasia, confusion, weakness, somnolence, seizures, and coma. This is similar to the neurologic manifestations of hypophosphatemia, which can result from sudden increases in metabolic demand for phosphorylated intermediates (e.g., refeeding syndrome and sepsis). Given these similarities, we investigated whether CAR T-cell effector metabolic activity is associated with increased extracellular phosphate consumption and a possible association between hypophosphatemia and ICANS. In vitro 4-1BB and CD28 CD19-targeted CAR T-cell effector activity was found to be associated with increased consumption of media phosphorus, which was temporally associated with increased single-cell effector secretomic activity and increased phosphorus-dependent metabolic demand of the CAR T cells. A clinical cohort of 77 patients treated with CD19-targeted CAR T-cell therapy demonstrated a significant anticorrelation between serum phosphorus and ICANS incidence and severity, with earlier onset of hypophosphatemia after CAR T-cell infusion more likely to result in neurotoxicity. These results imply phosphorous level monitoring could alert to the development of ICANS in clinical scenarios. See related Spotlight by Tobin et al., p. 1422.
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Affiliation(s)
- Jack Pengfei Tang
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Cole W. Peters
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Crystal Quiros
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Xiaoyan Wang
- Department of General Internal Medicine and Health Services Research, University of California, Los Angeles, California
| | - Alexandra M. Klomhaus
- Department of General Internal Medicine and Health Services Research, University of California, Los Angeles, California
| | - Reiko E. Yamada
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles, California
| | - John M. Timmerman
- Division of Hematology-Oncology, Department of Medicine, University of California, Los Angeles, California
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California
| | - Theodore B. Moore
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Theodore S. Nowicki
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California
- Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, University of California, Los Angeles, California
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, California
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Summerlin J, Wells DA, Anderson MK, Halford Z. A Review of Current and Emerging Therapeutic Options for Hemophagocytic Lymphohistiocytosis. Ann Pharmacother 2022:10600280221134719. [DOI: 10.1177/10600280221134719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Objective: To provide an overview of clinical sequelae and emerging treatment options for hemophagocytic lymphohistiocytosis (HLH). Data Sources: A literature search was conducted using the search terms “hemophagocytic lymphohistiocytosis,” “hemophagocytic syndrome,” “macrophage activation syndrome,” and “treatment” on Ovid and PubMed from January 1, 2017, through September 28, 2022. Study Selection and Data Extraction: Relevant clinical trials, meta-analyses, case reports, review articles, package inserts, and guidelines to identify current and emerging therapeutic options for the management of HLH. Data Synthesis: Genetic disorders and secondary causes may trigger HLH in both children and adults. Notable improvements in the diagnosis of HLH were seen with implementation of the HLH-2004 standard diagnostic criteria; however, timely and accurate identification of HLH remain significant barriers to optimal management. Multiagent immunochemotherapy are the backbone of aggressive therapy for acutely ill patients with HLH. Relevance to Patient Care and Clinical Practice: The global coronavirus 2019 (COVID-19) pandemic and emerging immune effector cell therapies have served to highlight the concerns with immune dysregulation and subsequent HLH precipitation. Without prompt identification and treatment, HLH can be fatal. Historically, the clinician’s armamentarium for managing HLH was sparse, with etoposide-based protocols serving as the standard of care. Relapsed or refractory disease portends a poor prognosis and requires additional treatment options. Second- or subsequent-line options now include hematopoietic stem cell transplantation, emapalumab, alemtuzumab, anakinra, ruxolitinib, and tocilizumab. Conclusions: Improvements in diagnostic methods and novel immunosuppressive treatment strategies, including noncytotoxic immunochemotherapy, have transformed the therapeutic landscape. Unfortunately, many unanswered questions remain. Additional studies are required to optimize dosing, schedules, treatment sequences, and indications for novel treatment options.
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Affiliation(s)
- Jenna Summerlin
- Division of Pharmacy Practice, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Drew A. Wells
- Internal Medicine, Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA
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Nazerian Y, Ghasemi M, Yassaghi Y, Nazerian A, Mahmoud Hashemi S. Role of SARS-CoV-2-induced Cytokine Storm in Multi-Organ Failure: Molecular Pathways and Potential Therapeutic Options. Int Immunopharmacol 2022; 113:109428. [PMCID: PMC9637536 DOI: 10.1016/j.intimp.2022.109428] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/19/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022]
Abstract
Coronavirus disease 2019 (COVID-19) outbreak has become a global public health emergency and has led to devastating results. Mounting evidence proposes that the disease causes severe pulmonary involvement and influences different organs, leading to a critical situation named multi-organ failure. It is yet to be fully clarified how the disease becomes so deadly in some patients. However, it is proven that a condition called “cytokine storm” is involved in the deterioration of COVID-19. Although beneficial, sustained production of cytokines and overabundance of inflammatory mediators causing cytokine storm can lead to collateral vital organ damages. Furthermore, cytokine storm can cause post-COVID-19 syndrome (PCS), an important cause of morbidity after the acute phase of COVID-19. Herein, we aim to explain the possible pathophysiology mechanisms involved in COVID-19-related cytokine storm and its association with multi-organ failure and PCS. We also discuss the latest advances in finding the potential therapeutic targets to control cytokine storm wishing to answer unmet clinical demands for treatment of COVID-19.
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Affiliation(s)
- Yasaman Nazerian
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mobina Ghasemi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Younes Yassaghi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Seyed Mahmoud Hashemi
- Medical nanotechnology and Tissue Engineering Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Corresponding author at: Medical nanotechnology and Tissue Engineering Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran / Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Gál P, Brábek J, Holub M, Jakubek M, Šedo A, Lacina L, Strnadová K, Dubový P, Hornychová H, Ryška A, Smetana K. Autoimmunity, cancer and COVID-19 abnormally activate wound healing pathways: critical role of inflammation. Histochem Cell Biol 2022; 158:415-434. [PMID: 35867145 PMCID: PMC9305064 DOI: 10.1007/s00418-022-02140-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 11/30/2022]
Abstract
Recent evidence indicates that targeting IL-6 provides broad therapeutic approaches to several diseases. In patients with cancer, autoimmune diseases, severe respiratory infections [e.g. coronavirus disease 2019 (COVID-19)] and wound healing, IL-6 plays a critical role in modulating the systemic and local microenvironment. Elevated serum levels of IL-6 interfere with the systemic immune response and are associated with disease progression and prognosis. As already noted, monoclonal antibodies blocking either IL-6 or binding of IL-6 to receptors have been used/tested successfully in the treatment of rheumatoid arthritis, many cancer types, and COVID-19. Therefore, in the present review, we compare the impact of IL-6 and anti-IL-6 therapy to demonstrate common (pathological) features of the studied diseases such as formation of granulation tissue with the presence of myofibroblasts and deposition of new extracellular matrix. We also discuss abnormal activation of other wound-healing-related pathways that have been implicated in autoimmune disorders, cancer or COVID-19.
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Affiliation(s)
- Peter Gál
- Department of Pharmacology, Pavol Jozef Šafárik University, Košice, Slovak Republic
- Department of Biomedical Research, East-Slovak Institute of Cardiovascular Diseases, Košice, Slovak Republic
- Prague Burn Centre, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Jan Brábek
- Department of Cell Biology, Faculty of Science, Charles University, 120 00 Prague 2, Czech Republic
- BIOCEV, Faculty of Science, Charles University, 252 50 Vestec, Czech Republic
| | - Michal Holub
- Department of Infectious Diseases, First Faculty of Medicine, Military University Hospital Prague and Charles University, 160 00 Prague, Czech Republic
| | - Milan Jakubek
- Department of Paediatrics and Adolescent Medicine, First Faculty of Medicine, Charles University, 120 00 Prague 2, Czech Republic
- BIOCEV, First Faculty of Medicine, Charles University, 252 50 Vestec, Czech Republic
- Department of Analytical Chemistry, University of Chemistry and Technology Prague, 166 28 Prague 6, Czech Republic
| | - Aleksi Šedo
- Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, 120 00 Praha 2, Czech Republic
| | - Lukáš Lacina
- BIOCEV, First Faculty of Medicine, Charles University, 252 50 Vestec, Czech Republic
- Institute of Anatomy, First Faculty of Medicine, Charles University, 120 00 Prague 2, Czech Republic
- Department of Dermatovenereology, First Faculty of Medicine, Charles University, 120 00 Prague 2, Czech Republic
| | - Karolína Strnadová
- BIOCEV, First Faculty of Medicine, Charles University, 252 50 Vestec, Czech Republic
- Institute of Anatomy, First Faculty of Medicine, Charles University, 120 00 Prague 2, Czech Republic
| | - Petr Dubový
- Institute of Anatomy, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Helena Hornychová
- The Fingerland Department of Pathology, Faculty of Medicine Hradec Králové, Charles University, 500 05 Hradec Králové, Czech Republic
| | - Aleš Ryška
- The Fingerland Department of Pathology, Faculty of Medicine Hradec Králové, Charles University, 500 05 Hradec Králové, Czech Republic
| | - Karel Smetana
- BIOCEV, First Faculty of Medicine, Charles University, 252 50 Vestec, Czech Republic
- Institute of Anatomy, First Faculty of Medicine, Charles University, 120 00 Prague 2, Czech Republic
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Variation of Diagnostic Approaches and Treatment Practices for Hemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome Among Pediatric Subspecialists. J Pediatr 2022; 255:65-71.e6. [PMID: 36328191 DOI: 10.1016/j.jpeds.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess the diagnostic and treatment practices among a variety of subspecialists at pediatric institutions in the US. STUDY DESIGN Using a web-based survey, we assessed the consultation, diagnostic, and treatment preferences of providers from the different pediatric subspecialties who care for pediatric patients with hemophagocytic lymphohistiocytosis (HLH)/macrophage activating syndrome (MAS). Domains included demographics, provider training level and specialty, experience and comfort level with the diagnosis and treatment of HLH/MAS, and institutional approaches toward the diagnosis and management of HLH/MAS. Participants also were given 2 case scenarios: one describing Epstein-Barr virus-associated HLH and another describing an underlying rheumatologic condition with MAS. RESULTS Of 263 respondents, 23%, 29%, 39%, and 7% identified as hematology/oncology, rheumatology, general pediatrics/critical care/hospitalist, and allergy/immunology, respectively. For Epstein-Barr virus/HLH, hematology/oncology was the preferred first consultant by most respondents other than rheumatologists, of whom only 47% agreed. For MAS, 92% of respondents from all specialties favored a rheumatology consultation. Preferred diagnostic tests varied by subspecialty, with hematology/oncology more likely than rheumatology to order an infectious workup, natural killer cell function, soluble interleukin-2 receptor, bone marrow biopsy, and genetic testing. First-line therapy also varied, with hematology/oncology preferring dexamethasone and etoposide and rheumatology more often preferring methylprednisolone and anakinra. One-half of respondents were unaware of institutional algorithms for diagnosis and treatment of HLH/MAS. Most (85.6%) favored the development of treatment algorithms for HLH/MAS, and 90% supported a multidisciplinary approach. CONCLUSIONS Current consulting patterns, diagnostic workup, and treatment approaches of HLH/MAS vary by specialty, highlighting the need for standardized management algorithms and institutional multidisciplinary HLH/MAS teams.
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Green EA, Metz D, Galinsky R, Atkinson R, Skuza EM, Clark M, Gunn AJ, Kirkpatrick CM, Hunt RW, Berger PJ, Nold-Petry CA, Nold MF. Anakinra Pilot - a clinical trial to demonstrate safety, feasibility and pharmacokinetics of interleukin 1 receptor antagonist in preterm infants. Front Immunol 2022; 13:1022104. [PMID: 36389766 PMCID: PMC9647081 DOI: 10.3389/fimmu.2022.1022104] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/10/2022] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD), its complication pulmonary hypertension (BPD-PH) and preterm brain and gut injury lead to significant morbidity and mortality in infants born extremely prematurely. There is extensive evidence that the pro-inflammatory cytokine interleukin 1 (IL-1) plays a key role in the pathophysiology of these illnesses. Two decades of clinical use in paediatric and adult medicine have established an excellent safety and efficacy record for IL-1 blockade with IL-1 receptor antagonist (IL-1Ra, medication name anakinra). Building on robust pre-clinical evidence, the Anakinra Pilot trial aims to demonstrate safety and feasibility of administering anakinra to preterm infants, and to establish pharmacokinetics in this population. Its ultimate goal is to facilitate large studies that will test whether anakinra can ameliorate early-life inflammation, thus alleviating multiple complications of prematurity. METHODS AND ANALYSIS Anakinra Pilot is an investigator-initiated, single arm, safety and feasibility dose-escalation trial in extremely preterm infants born between 24 weeks 0 days (240) and 276 weeks of gestational age (GA). Enrolled infants will receive anakinra intravenously over the first 21 days after birth, starting in the first 24 h after birth. In the first phase, dosing is 1 mg/kg every 48 h, and dosage will increase to 1.5 mg/kg every 24 h in the second phase. Initial anakinra dosing was determined through population pharmacokinetic model simulations. During the study, there will be a interim analysis to confirm predictions before undertaking dose assessment. Anakinra therapy will be considered safe if the frequency of adverse outcomes/events does not exceed that expected in infants born at 240-276 weeks GA. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/, identifier NCT05280340.
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Affiliation(s)
- Elys A. Green
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia
| | - David Metz
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- Monash Children’s Hospital, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Rebecka Atkinson
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia
| | - Elizbeth M. Skuza
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Megan Clark
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia
- Faculty of Pharmacy and Pharmaceutical Science, Monash University, Melbourne, VIC, Australia
| | - Alistair J Gunn
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Carl M. Kirkpatrick
- Monash Institute for Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Rod W. Hunt
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia
| | - Philip J. Berger
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Claudia A. Nold-Petry
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Marcel F. Nold
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia
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Macovei LA, Burlui A, Bratoiu I, Rezus C, Cardoneanu A, Richter P, Szalontay A, Rezus E. Adult-Onset Still's Disease-A Complex Disease, a Challenging Treatment. Int J Mol Sci 2022; 23:12810. [PMID: 36361602 PMCID: PMC9655522 DOI: 10.3390/ijms232112810] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 12/02/2022] Open
Abstract
Adult-onset Still's disease (AOSD) is a systemic inflammatory disorder with an unknown cause characterized by high-spiking fever, lymphadenopathy, hepatosplenomegaly, hyperferritinemia, and leukocytosis. The clinical course can be divided into three significant patterns, each with a different prognosis: Self-limited or monophasic, intermittent or polycyclic systemic, and chronic articular. Two criteria sets have been validated. The Yamaguchi criteria are the most generally used, although the Fautrel criteria offer the benefit of adding ferritin and glycosylated ferritin values. AOSD's pathogenesis is not yet completely understood. Chemokines and pro-inflammatory cytokines, including interferon (IFN)-γ, tumor necrosis factor α (TNFα), interleukin (IL)-1, IL-6, IL-8, and IL-18, play a crucial role in the progression of illness, resulting in the development of innovative targeted therapeutics. There are no treatment guidelines for AOSD due to its rarity, absence of controlled research, and lack of a standard definition for remission and therapy objectives. Non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids (CS), and conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) are used in AOSD treatment. Biological therapy, including IL-1, IL-6, IL-18, and IL-17 inhibitors, as well as TNFα or Janus-kinases (JAKs) inhibitors, is administered to patients who do not react to CS and csDMARDs or achieve an inadequate response.
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Affiliation(s)
- Luana Andreea Macovei
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Alexandra Burlui
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ioana Bratoiu
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Anca Cardoneanu
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Patricia Richter
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Andreea Szalontay
- Department of Psychiatry, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Psychiatry “Socola”, 700282 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
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