51
|
Abstract
Ceftriaxone is a commonly used antibiotic in hospitals for the treatment of pneumonia, urinary tract infection, bacteremia, meningitis, skin, and soft tissue infection. It can be associated with common allergic reactions like skin rash, itching, and, rarely, angioedema. Ceftriaxone-induced immune hemolytic anemia (IHA) is a rare and potentially fatal complication if not identified and managed in time. We report a case of ceftriaxone-induced IHA in a young woman.
Collapse
Affiliation(s)
- Anil Singh
- Hospital Medicine, Geisinger Community Medical Center, Scranton, USA
| | | | - Amit Sharma
- Infectious Disease, Geisinger Community Medical Center, Scranton, USA
| | - Namita Sharma
- Hematology, Geisinger Community Medical Center, Scranton, USA
| | | |
Collapse
|
52
|
Quiroga D, Liebner DA, Philippon JS, Hoffman S, Tan Y, Chen JL, Lenobel S, Wakely PE, Pollock R, Tinoco G. Activity of PD1 inhibitor therapy in advanced sarcoma: a single-center retrospective analysis. BMC Cancer 2020; 20:527. [PMID: 32503455 PMCID: PMC7275332 DOI: 10.1186/s12885-020-07021-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/28/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Sarcomas constitute a heterogeneous group of tumors with different clinical behaviors and variable responses to systemic therapies. Recent immunotherapy studies with PD1 inhibitors (PD1i) show promising results with use in certain soft-tissue sarcomas; however, the clinical and molecular features that best predict response to PD1i remain unclear. METHODS Demographic, imaging, histologic, and genetic sequencing data was collected for sarcoma patients who received nivolumab or pembrolizumab (PD1i) treatment at our institution between January 1st 2015 and April 23rd 2018. The primary objective was to determine progression-free survival (PFS) in patients with advanced sarcomas receiving PD1i. Secondary objectives included determining overall survival (OS) and assessment of characteristics associated with response to PD1i. Fifty-six patients who were treated with PD1i therapy met inclusion criteria for this study. RESULTS Partial response towards PD1i treatment was seen in 3 in 26 evaluable patients, but no complete responses were observed (overall response rate 11.5%). Within this group of patients, the 90 day PFS was found to be 48.8%. In patients in whom PD1 expression was known, there was a statistically significant positive correlation between expression of PD1 and longer PFS and OS rates. Patients that were treated with more than four cycles of PD1i therapy were also more likely to have a greater OS. CONCLUSIONS This study suggests activity of PD1i in a pretreated cohort of advanced sarcoma patients, particularly for the subset of patients with PD1 positive tumors. Our results highlight the importance of further research to better target the optimal patient population and markers of response.
Collapse
Affiliation(s)
- Dionisia Quiroga
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 410 W 12th Avenue, Columbus, OH, 43210, USA
- Department of Internal Medicine, Division of Medical Oncology, The Ohio State University, Starling Loving Hall, 320 W 10th Ave, Columbus, OH, 43210, USA
| | - David A Liebner
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 410 W 12th Avenue, Columbus, OH, 43210, USA
- Department of Internal Medicine, Division of Medical Oncology, The Ohio State University, Starling Loving Hall, 320 W 10th Ave, Columbus, OH, 43210, USA
- Department of Biomedical Informatics, The Ohio State University, 250 Lincoln Tower, 1800 Cannon Dr, Columbus, OH, 43210, USA
| | - Jennifer S Philippon
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 410 W 12th Avenue, Columbus, OH, 43210, USA
| | - Sarah Hoffman
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 410 W 12th Avenue, Columbus, OH, 43210, USA
| | - Yubo Tan
- Center for Biostatistics, The Ohio State University, 2012 Kenny Rd, Columbus, OH, 43221, USA
| | - James L Chen
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 410 W 12th Avenue, Columbus, OH, 43210, USA
- Department of Internal Medicine, Division of Medical Oncology, The Ohio State University, Starling Loving Hall, 320 W 10th Ave, Columbus, OH, 43210, USA
- Center for Biostatistics, The Ohio State University, 2012 Kenny Rd, Columbus, OH, 43221, USA
| | - Scott Lenobel
- Department of Radiology, The Ohio State University, 410 W 12th Avenue, Columbus, OH, 43210, USA
| | - Paul E Wakely
- Department of Pathology, The Ohio State University, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Raphael Pollock
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 410 W 12th Avenue, Columbus, OH, 43210, USA
- Department of Surgery, The Ohio State University, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Gabriel Tinoco
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 410 W 12th Avenue, Columbus, OH, 43210, USA.
- Department of Internal Medicine, Division of Medical Oncology, The Ohio State University, Starling Loving Hall, 320 W 10th Ave, Columbus, OH, 43210, USA.
- The Ohio State University Comprehensive Cancer Center, 320 W 10th Ave, A444 Starling Loving Hall, Columbus, OH, 43210, USA.
| |
Collapse
|
53
|
Barcellini W, Fattizzo B. The Changing Landscape of Autoimmune Hemolytic Anemia. Front Immunol 2020; 11:946. [PMID: 32655543 PMCID: PMC7325906 DOI: 10.3389/fimmu.2020.00946] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/22/2020] [Indexed: 12/20/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a greatly heterogeneous disease due to autoantibodies directed against erythrocytes, with or without complement activation. The clinical picture ranges from mild/compensated to life-threatening anemia, depending on the antibody's thermal amplitude, isotype and ability to fix complement, as well as on bone marrow compensation. Since few years ago, steroids, immunesuppressants and splenectomy have been the mainstay of treatment. More recently, several target therapies are increasingly used in the clinical practice or are under development in clinical trials. This has led to the accumulation of refractory/relapsed cases that often represent a clinical challenge. Moreover, the availability of several drugs acting on the different pathophysiologic mechanisms of the disease pinpoints the need to harness therapy. In particular, it is advisable to define the best choice, sequence and/or combination of drugs during the different phases of the disease. In particular relapsed/refractory cases may resemble pre-myelodysplastic or bone marrow failure syndromes, suggesting a careful use of immunosuppressants, and vice versa advising bone marrow immunomodulating/stimulating agents. A peculiar setting is AIHA after autologous and allogeneic hematopoietic stem cell transplantation, which is increasingly reported. These cases are generally severe and refractory to standard therapy, and have high mortality. AIHAs may be primary/idiopathic or secondary to infections, autoimmune diseases, malignancies, particularly lymphoproliferative disorders, and drugs, further complicating their clinical picture and management. Regarding new drugs, the false positivity of the Coombs test (direct antiglobulin test, DAT) following daratumumab adds to the list of difficult diagnosis, together with the passenger lymphocyte syndrome after solid organ transplants. Diagnosis of DAT-negative AIHAs and evaluation of disease-related risk factors for relapse and mortality, notwithstanding improvement in diagnostic approach, are still an unmet need. Finally, AIHA is increasingly described following therapy of solid cancers with inhibitors of immune checkpoint molecules. On the whole, the double-edged sword of new pathogenetic insights and therapies has changed the landscape of AIHA, both providing enthusiastic knowledge and complicating the clinical management of this disease.
Collapse
Affiliation(s)
- Wilma Barcellini
- UO Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- UO Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
54
|
Barcellini W, Giannotta J, Fattizzo B. Autoimmune hemolytic anemia in adults: primary risk factors and diagnostic procedures. Expert Rev Hematol 2020; 13:585-597. [PMID: 32274943 DOI: 10.1080/17474086.2020.1754791] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Autoimmune hemolytic anemia (AIHA) is due to autoantibodies against erythrocytes that may arise either because of primary tolerance breakage or along with several associated conditions, including genetic predispositions, congenital syndromes, environmental triggers, autoimmune diseases, immunodeficiencies, and neoplasms. AREAS COVERED This review evaluated the risk of AIHA development in associated conditions and summarized disease-intrinsic risk factors for relapse and outcome. Diagnostic procedures were analyzed to properly identify primary and secondary forms. A Medline including clinical trials, meta-analyses, guidelines, consensus, and case reports, published in the last 30 years were performed. EXPERT OPINION The several associated conditions listed above constitute a risk for AIHA development and should be considered since disease course and therapy may be different. Particularly, AIHA developing after transplant or novel checkpoint inhibitors is an emerging complex entity whose proper therapy is still an unmet need. Concerning intrinsic risk factors, the severity of anemia at onset correlated with the recurrence of relapses, refractoriness, and fatal outcome. This finding reflects the presence of several mechanisms involved in AIHA, i.e. highly pathogenic antibodies, complement activation, and failure of marrow compensation. With the advent of novel target therapies (complement and various tyrosine kinase inhibitors), a risk-adapted therapy for AIHA is becoming fundamental.
Collapse
Affiliation(s)
- Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Juri Giannotta
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy.,Università degli Studi di Milano , Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy.,Università degli Studi di Milano , Milan, Italy
| |
Collapse
|
55
|
Kitao A, Kawamoto S, Kurata K, Hayakawa I, Yamasaki T, Matsuoka H, Sumi Y, Kakeji Y, Kamesaki T, Minami H. Band 3 ectopic expression in colorectal cancer induces an increase in erythrocyte membrane-bound IgG and may cause immune-related anemia. Int J Hematol 2020; 111:657-666. [PMID: 31997080 DOI: 10.1007/s12185-020-02831-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/20/2020] [Accepted: 01/20/2020] [Indexed: 12/20/2022]
Abstract
Autoimmune hemolytic anemia (AIHA) is a rare comorbidity in colorectal cancer (CRC) and has an unknown etiology. Previously, we described an AIHA case secondary to CRC with ectopic band 3 expression. Herein, we investigated ectopic band 3 expression and erythrocyte membrane-bound IgG in a CRC cohort. Between September 2016 and August 2018, 50 patients with CRC and 26 healthy controls were enrolled in the present study. The expression of band 3 and SLC4A1 mRNA was observed in 97% of CRC surgical specimens. Although clinical AIHA was not observed in any patient with CRC, a direct antiglobulin test was positive in 10 of the patients in the CRC group (p = 0.01). Flow cytometry revealed significantly increased erythrocyte membrane-bound IgG among patients with CRC compared to healthy controls (mean ± standard deviation; 38.8 ± 4.7 vs. 29.9 ± 15.6, p = 0.012). Normocytic anemia was observed, including in cases negative for fecal occult blood, suggesting a shortened erythrocyte life-span due to increased membrane-bound IgG. Immunoprecipitation revealed increased anti-band 3 autoantibodies in patients' sera. Mouse experiments recapitulated this phenomenon. We also confirmed that band 3 expression is controlled by 5'AMP-activated protein kinase under hypoxic conditions. These findings increase our understanding of the etiology of cancer-related anemia.
Collapse
Affiliation(s)
- Akihito Kitao
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Shinichiro Kawamoto
- Department of Transfusion Medicine and Cell Therapy, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Keiji Kurata
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Ikuyo Hayakawa
- Department of Transfusion Medicine and Cell Therapy, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Takashi Yamasaki
- Department of Diagnostic Pathology, Kohnan Hospital, Kobe, Hyogo, Japan
| | - Hiroshi Matsuoka
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Yasuo Sumi
- Department of Surgery, Asahikawa Medical University Hospital, Asahikawa, Hokkaido, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Toyomi Kamesaki
- Center for Community Medicine, Jichi Medical University Hospital, Shimotsuke, Tochigi, Japan
| | - Hironobu Minami
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Hospital, Kobe, Hyogo, Japan
- Department of Transfusion Medicine and Cell Therapy, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| |
Collapse
|
56
|
Williams H, Aitchison R. Pembrolizumab-induced autoimmune haemolytic anaemia and cholangitis. BMJ Case Rep 2019; 12:12/12/e232505. [PMID: 31811095 DOI: 10.1136/bcr-2019-232505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Increasing numbers of patients are now offered immunotherapy as part of their cancer treatment. These treatments, while often very effective, have a wide range of adverse effects that are distinct from those of traditional chemotherapy regimens. Thyroid disease, dermatological disease, colitis and pneumonitis are some of the most commonly reported immune side effects. We present a case of life-threatening de novo autoimmune haemolytic anaemia (AIHA) complicated by immune cholangitis induced by pembrolizumab. An 81-year-old woman with metastatic melanoma completed a two-year course of pembrolizumab in August 2018 and six weeks later presented to hospital with jaundice. Admission haemoglobin (Hb) was 91 g/L, rapidly decreasing to 31 g/L, at which point she required admission to the intensive care unit. AIHA is a rare but potentially life-threatening complication of checkpoint inhibitors and should be considered in patients presenting with anaemia during or after immunotherapy treatment.
Collapse
Affiliation(s)
- Harriet Williams
- Haematology Department, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - Robin Aitchison
- Haematology Department, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| |
Collapse
|
57
|
Ferner R, Aronson J. Susceptibility to adverse drug reactions. Br J Clin Pharmacol 2019; 85:2205-2212. [PMID: 31169324 PMCID: PMC6783620 DOI: 10.1111/bcp.14015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 12/19/2022] Open
Abstract
The pharmacological effects of a drug depend on its concentration at the site of action, and therefore on the concentration in blood and on the dose. The relationship between the concentration or dose and the corresponding effect can usually be represented mathematically as a rectangular hyperbola; when effect is plotted against log concentration or log dose, the curve is sigmoidal. Inevitably, the effect size and the doses causing benefit and harm will differ among individuals, since they are biological phenomena: some individuals are more likely than others to suffer harm at any given dose. Some harmful effects can occur at much lower doses than those used in therapeutics; that is, the log dose-response curve for harm lies far to the left of the log dose-response curve for benefit. Those who suffer such reactions are hypersusceptible. When the dose-response curves for harm and therapeutic effect are in the same range, dose cannot separate the harmful effects from the therapeutic effects, and adverse reactions are collateral. Toxic effects occur when harmful doses are above the doses needed for benefit. In this review we consider factors that influence a subject's susceptibility to adverse drug reactions. Determinants of susceptibility include Immunological, Genetic, demographic (Age and Sex), Physiological and Exogenous factors (drug-drug interactions, for example), and Diseases and disorders such as renal failure, giving the mnemonic I GASPED. Some susceptibility factors are discrete (for example, all-or-none) and some are continuous; susceptibility can therefore be discrete or continuous; and the factors can interact to determine a person's overall susceptibility to harm.
Collapse
Affiliation(s)
- Robin Ferner
- West Midlands Centre for Adverse Drug Reactions, City HospitalBirminghamUK
- Institute of Clinical SciencesUniversity of BirminghamUK
| | - Jeffrey Aronson
- West Midlands Centre for Adverse Drug Reactions, City HospitalBirminghamUK
- Nuffield Department of Primary Care Health SciencesCentre for Evidence Based MedicineOxfordUK
| |
Collapse
|
58
|
Affiliation(s)
- Robert A Brodsky
- From the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| |
Collapse
|
59
|
Abstract
This year again, several breaking news were published in our field of oncodermatology, especially in the domain of immunotherapy. Many works have reported results on predictive biomarker identification. Concerning melanoma treatment, we were disappointed by the negative results of the phase III trial evaluating the IDO1 inhibitor epacadostat + pembrolizumab versus pembrolizumab. However, many promising preliminary results involving the combinations of anti-PD1 and innate immunity activators have been published. We also have a new anti-BRAF + anti-MEK combination: encorafenib + binimetinib with a good benefit/risk ratio and a particularly favorable safety profile as compared with existing similar combinations. Major steps forward were obtained for locally advanced Merkel cell carcinoma and squamous cell carcinoma with anti-PDL-1 avelumab and anti-PD1 cemiplimab respectively.
Collapse
|
60
|
Karp Leaf R, Ferreri C, Rangachari D, Mier J, Witteles W, Ansstas G, Anagnostou T, Zubiri L, Piotrowska Z, Oo TH, Iberri D, Yarchoan M, Salama A, Johnson DB, Leavitt AD, Rahma O, Reynolds KL, Leaf DE. Clinical and laboratory features of autoimmune hemolytic anemia associated with immune checkpoint inhibitors. Am J Hematol 2019; 94:563-574. [PMID: 30790338 PMCID: PMC9552038 DOI: 10.1002/ajh.25448] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 12/20/2022]
Abstract
Immune checkpoint inhibitors (ICPis) are a novel class of immunotherapeutic agents that have revolutionized the treatment of cancer; however, these drugs can also cause a unique spectrum of autoimmune toxicity. Autoimmune hemolytic anemia (AIHA) is a rare, but often severe, complication of ICPis. We identified 14 patients from nine institutions across the United States who developed ICPi-AIHA. The median interval from ICPi initiation to development of AIHA was 55 days (interquartile range [IQR], 22-110 days). Results from the direct antiglobulin test (DAT) were available for 13 of 14 patients: 8 patients (62%) had a positive DAT and 5 (38%) had a negative DAT. The median pretreatment and nadir hemoglobin concentrations were 11.8 g/dL (IQR, 10.2-12.9 g/dL) and 6.3 g/dL (IQR, 6.1-8.0 g/dL), respectively. Four patients (29%) had a preexisting lymphoproliferative disorder, and two (14%) had a positive DAT prior to initiation of ICPi therapy. All patients were treated with glucocorticoids, with three requiring additional immunosuppressive therapy. Complete and partial recoveries of hemoglobin were achieved in 12 (86%) and 2 (14%) patients, respectively. Seven patients (50%) were rechallenged with ICPis, and one (14%) developed recurrent AIHA. Clinical and laboratory features of ICPi-AIHA were similar in DAT positive and negative patients. ICPi-AIHA shares many clinical features with primary AIHA; however, a unique aspect of ICPi-AIHA is a high incidence of DAT negativity. Glucocorticoids are an effective first-line treatment in the majority of patients with ICPi-AIHA, and most patients who are rechallenged with an ICPi do not appear to develop recurrence of AIHA.
Collapse
Affiliation(s)
- Rebecca Karp Leaf
- Department of Hematology and Oncology, Massachusetts General Hospital, Boston, MA
| | | | - Deepa Rangachari
- Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - James Mier
- Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Wesley Witteles
- Divison of Hematology and Oncology, VA Palo Alto Health Care System, Palo Alto, CA
| | - George Ansstas
- Division of Hematology and Oncology, Washington University St. Louis, St. Louis, MO
| | | | - Leyre Zubiri
- Department of Hematology and Oncology, Massachusetts General Hospital, Boston, MA
| | - Zofia Piotrowska
- Department of Hematology and Oncology, Massachusetts General Hospital, Boston, MA
| | - Thein H. Oo
- Section of Benign Hematology, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - David Iberri
- Division of Hematology, Stanford University Medical Center, Stanford, CA
| | - Mark Yarchoan
- Division of Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - April Salama
- Department of Internal Medicine, Duke University Hospital, Durham, NC
| | - Douglas B. Johnson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Andrew D. Leavitt
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, CA
| | - Osama Rahma
- Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, MA
| | - Kerry Lynn Reynolds
- Department of Hematology and Oncology, Massachusetts General Hospital, Boston, MA
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA
| |
Collapse
|