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Zarakas MA, Desai JV, Chamilos G, Lionakis MS. Fungal Infections with Ibrutinib and Other Small-Molecule Kinase Inhibitors. CURRENT FUNGAL INFECTION REPORTS 2019; 13:86-98. [PMID: 31555394 DOI: 10.1007/s12281-019-00343-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose of review Small molecule kinase inhibitors (SMKIs) have revolutionized the management of malignant and autoimmune disorders. Emerging clinical reports point toward an increased risk for invasive fungal infections (IFIs) in patients treated with certain SMKIs. In this mini-review, we highlight representative examples of SMKIs that have been associated with or are expected to give rise to IFIs. Recent findings The clinical use of the Bruton's tyrosine kinase inhibitor ibrutinib as well as other FDA-approved SMKIs has been associated with IFIs. The fungal infection susceptibility associated with the clinical use of certain SMKIs underscores their detrimental effects on innate and adaptive antifungal immune responses. Summary The unprecedented development and clinical use of SMKIs is expected to give rise to an expansion of iatrogenic immunosuppressive factors predisposing to IFIs (and other opportunistic infections). Beyond increased clinical surveillance, better understanding of the pathogenesis of SMKI-associated immune dysregulation should help devising improved risk stratification and prophylaxis strategies in vulnerable patients.
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Affiliation(s)
- Marissa A Zarakas
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jigar V Desai
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Georgios Chamilos
- Department of Clinical Microbiology and Microbial Pathogenesis, School of Medicine, University of Crete, Greece, and Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology, 71300, Heraklion, Crete, Greece
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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Klotz L, Havla J, Schwab N, Hohlfeld R, Barnett M, Reddel S, Wiendl H. Risks and risk management in modern multiple sclerosis immunotherapeutic treatment. Ther Adv Neurol Disord 2019; 12:1756286419836571. [PMID: 30967901 PMCID: PMC6444778 DOI: 10.1177/1756286419836571] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 02/14/2019] [Indexed: 12/13/2022] Open
Abstract
In recent years, there has been a paradigm shift in the treatment of multiple
sclerosis (MS) owing to the approval of a number of new drugs with very distinct
mechanisms of action. All approved disease-modifying drugs primarily work
directly on the immune system. However, the identification of an ‘optimal
choice’ for individual patients with regard to treatment efficacy, treatment
adherence and side-effect profile has become increasingly complex including
conceptual as well as practical considerations. Similarly, there are
peculiarities and specific requirements with regard to treatment monitoring,
especially in relation to immunosuppression, the development of secondary
immune-related complications, as well as the existence of drug-specific on- and
off-target effects. Both classical immunosuppression and selective immune
interventions generate a spectrum of potential therapy-related complications.
This article provides a comprehensive overview of available immunotherapeutics
for MS and their risks, detailing individual mechanisms of action and
side-effect profiles. Furthermore, practical recommendations for patients
treated with modern MS immunotherapeutics are provided.
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Affiliation(s)
- Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University of Münster, Building A1, Albert Schweitzer Campus 1, 48149 Münster, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, University Hospital; Data Integration for Future Medicine consortium (DIFUTURE), Ludwig-Maximilians University, Munich, Germany
| | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, University Hospital, Ludwig-Maximilians University, Munich, Germany Munich Cluster for Systems Neurology, Ludwig-Maximilians University, Munich, Germany
| | | | - Stephen Reddel
- Brain and Mind Centre, University of Sydney, NSW, Australia
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Building A1, Albert Schweitzer Campus 1, 48149 Münster, Germany
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Kulkarni, AP, Sengar, M, Chinnaswamy, G, Hegde, A, Rodrigues, C, Soman, R, Khilnani, GC, Ramasubban, S, Desai, M, Pandit, R, Khasne, R, Shetty, A, Gilada, T, Bhosale, S, Kothekar, A, Dixit, S, Zirpe, K, Mehta, Y, Pulinilkunnathil, JG, Bhagat, V, Khan, MS, Narkhede, AM, Baliga, N, Ammapalli, S, Bamne, S, Turkar, S, K, VB, Choudhary, J, Kumar, R, Divatia JV. Indian Antimicrobial Prescription Guidelines in Critically Ill Immunocompromised Patients. Indian J Crit Care Med 2019; 23:S64-S96. [PMID: 31516212 PMCID: PMC6734470 DOI: 10.5005/jp-journals-10071-23102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
How to cite this article: Kulkarni AP, Sengar M, Chinnaswamy G, Hegde A, Rodrigues C, Soman R, Khilnani GC, Ramasubban S, Desai M, Pandit R, Khasne R, Shetty A, Gilada T, Bhosale S, Kothekar A, Dixit S, Zirpe K, Mehta Y, Pulinilkunnathil JG, Bhagat V, Khan MS, Narkhede AM, Baliga N, Ammapalli S, Bamne S, Turkar S, Bhat KV, Choudhary J, Kumar R, Divatia JV. Indian Journal of Critical Care Medicine 2019;23(Suppl 1): S64-S96.
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Affiliation(s)
- Atul P Kulkarni,
- Division of Critical Care Medicine, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai, Maharashtra, India
| | - Manju Sengar,
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai, Maharashtra, India
| | - Girish Chinnaswamy,
- Department of Paediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai, Maharashtra, India
| | - Ashit Hegde,
- Consultant in Medicine and Critical Care, PD Hinduja National Hospital, Mahim, Mumbai, Maharashtra, India
| | - Camilla Rodrigues,
- Consultant Microbiologist and Chair Infection Control, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Rajeev Soman,
- Consultant ID Physician, Jupiter Hospital, Pune, DeenanathMangeshkar Hospital, Pune, BharatiVidyapeeth, Deemed University Hospital, Pune, Courtsey Visiting Consultant, Hinduja Hospital Mumbai, Maharashtra, India
| | - Gopi C Khilnani,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Suresh Ramasubban,
- Pulmomary and Critical Care Medicine, Apollo Gleneagles Hospital, 58, Canal Circular Road, Kolkata, West Bengal, India
| | - Mukesh Desai,
- Department of Immunology, Prof of Pediatric Hematology and Oncology, Bai Jerbaiwadia Hospital for Children, Consultant, Hematologist, Nanavati Superspeciality Hospital, Director of Pediatric Hematology, Surya Hospitals, Mumbai, Maharashtra, India
| | - Rahul Pandit,
- Intensive Care Unit, Fortis Hospital, Mulund Goregaon Link Road, Mulund (W), Mumbai, Maharashtra, India
| | - Ruchira Khasne,
- Critical Care Medicine, Ashoka - Medicover Hospital, Indira Nagar, Wadala Nashik, Maharashtra, India
| | - Anjali Shetty,
- Microbiology Section, 5th Floor, S1 Building, PD Hinduja Hospital, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
| | - Trupti Gilada,
- Consultant Physician in Infectious Disease, Unison Medicare and Research Centre and Prince Aly Khan Hospital, Maharukh Mansion, Alibhai Premji Marg, Grant Road, Mumbai, Maharashtra, India
| | - Shilpushp Bhosale,
- Intensive Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Amol Kothekar,
- Division of Critical Care Medicine, Departemnt of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Subhal Dixit,
- Consultant in Critical Care, Director, ICU Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Kapil Zirpe,
- Neuro-Trauma Unit, Grant Medical Foundation, Ruby Hall Clinic, Pune, Maharashtra, India
| | - Yatin Mehta,
- Institute of Critical Care and Anesthesiology, Medanta The Medicity, Gurgaon, Haryana, India
| | - Jacob George Pulinilkunnathil,
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr E Borges Road, Mumbai, Maharashtra, India
| | - Vikas Bhagat,
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, HomiBhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Mohammad Saif Khan,
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Amit M Narkhede,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Nishanth Baliga,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Srilekha Ammapalli,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Shrirang Bamne,
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
| | - Siddharth Turkar,
- Department of Medical Oncology, Tata Memorial Hospital, HomiBhabha National Institute, Mumbai, Maharashtra, India
| | - Vasudeva Bhat K,
- Department of Pediatric Oncology, Tata Memorial Hospital, HomiBhabha National Institute, Dr E. Borges Marg, Parel, Mumbai, Maharashtra, India
| | - Jitendra Choudhary,
- Critical Care, Fortis Hospital, 102, Nav Sai Shakti CHS, Near Bhoir Gymkhana, M Phule Road, Dombivali West Mumbai, Maharashtra, India
| | - Rishi Kumar,
- Critical Care Medicine, PD Hinduja National Hospital and MRC, Mumbai, Maharashtra, India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, India
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Rong HM, Li T, Zhang C, Wang D, Hu Y, Zhai K, Shi HZ, Tong ZH. IL-10-producing B cells regulate Th1/Th17-cell immune responses in Pneumocystis pneumonia. Am J Physiol Lung Cell Mol Physiol 2018; 316:L291-L301. [PMID: 30284926 DOI: 10.1152/ajplung.00210.2018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Pneumocystis pneumonia (PCP) is a common opportunistic infectious disease that is prevalent in immunosuppressed hosts. Accumulating evidence shows that B cells play an important role in infectious diseases. In the present study, the immune regulatory role of mature B cells in host defense to Pneumocystis was evaluated. Pneumocystis infection resulted in a decrease in B cells in patients and mice, and the Pneumocystis burden in B cell-deficient mice also progressively increased from weeks 1 to 7 after infection. The clearance of Pneumocystis was delayed in B cell-activating factor receptor (BAFF-R)-deficient mice (BAFF-R-/- mice), which had few B cells and Pneumocystis-specific IgG and IgM antibodies, compared with clearance in wild-type (WT) mice. There were fewer effector CD4+ T cells and higher percentages of T helper (Th)1/Th17 cells in BAFF-R-/- mice than in WT mice. Adoptive transfer of naive B cells, mRNA sequencing, and IL-1β neutralization experiments indicated that IL-1β is a likely determinant of the IL-10-producing B cell-mediated suppression of Th1/Th17-cell immune responses in BAFF-R-/- PCP mice. Our data indicated that B cells play a vital role in the regulation of Th cells in response to Pneumocystis infection.
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Affiliation(s)
- Heng-Mo Rong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University , Beijing , China
| | - Ting Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University , Beijing , China
| | - Chao Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University , Beijing , China
| | - Dong Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University , Beijing , China
| | - Yang Hu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University , Beijing , China
| | - Kan Zhai
- Department of Medical Research Center, Beijing Chao-Yang Hospital, Capital Medical University , Beijing , China
| | - Huan-Zhong Shi
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University , Beijing , China
| | - Zhao-Hui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University , Beijing , China
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55
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Limper AH. In Search of Clinical Factors that Predict Risk for Pneumocystis jirovecii Pneumonia in Patients without HIV/AIDS. Am J Respir Crit Care Med 2018; 198:1467-1468. [PMID: 30095970 DOI: 10.1164/rccm.201807-1358ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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56
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Rutherford AI, Patarata E, Subesinghe S, Hyrich KL, Galloway JB. Opportunistic infections in rheumatoid arthritis patients exposed to biologic therapy: results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis. Rheumatology (Oxford) 2018. [PMID: 29529307 DOI: 10.1093/rheumatology/key023] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objectives This analysis set out to estimate the risk of opportunistic infection (OI) among patients with RA by biologic class. Methods The British Society for Rheumatology Biologics Register for Rheumatoid Arthritis is a prospective observational cohort study established to evaluate safety of biologic therapies. The population included adults commencing biologic therapy for RA. The primary outcome was any serious OI excluding tuberculosis (TB). Event rates were compared across biologic classes using Cox proportional hazards with adjustment for potential confounders identified a priori. Analysis of the incidence of TB was performed separately. Results In total, 19 282 patients with 106 347 years of follow-up were studied; 142 non-TB OI were identified at a rate of 134 cases/100 000 patient years (pyrs). The overall incidence of OI was not significantly different between the different drug classes; however, the rate of Pneumocystis infection was significantly higher with rituximab than with anti-TNF therapy (adjusted hazard ratio = 3.2, 95% CI: 1.4, 7.5). The rate of TB fell dramatically over the study period (783 cases/100 000 pyrs in 2002 to 38 cases/100 000 pyrs in 2015). The incidence of TB was significantly lower among rituximab users than anti-TNF users, with 12 cases/100 000 pyrs compared with 65 cases/100 000 pyrs. Conclusions The overall rate of OI was not significantly different between drug classes; however, a subtle difference in the pattern of OI was seen between the cohorts. Patient factors such as age, gender and comorbidity were the most important predictors of OI.
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Affiliation(s)
- Andrew I Rutherford
- Academic Rheumatology Department, King's College London, London, UK.,Rheumatology Department, King's College Hospital NHS Foundation Trust, London, UK
| | - Eunice Patarata
- Rheumatology Department, King's College Hospital NHS Foundation Trust, London, UK.,Autoimmune Disease Unit, Hospital Curry Cabral, Centro Hospitalar Lisboa Central, Lisbon, Portugal, UK
| | | | - Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester University, Manchester, UK.,NIHR Manchester Musculoskeletal Biomedical Research Centre, Central Manchester Foundation Trust, Manchester, UK
| | - James B Galloway
- Academic Rheumatology Department, King's College London, London, UK.,Rheumatology Department, King's College Hospital NHS Foundation Trust, London, UK
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57
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Dumas G, Bigé N, Lemiale V, Azoulay E. Patients immunodéprimés, quel pathogène pour quel déficit immunitaire ? (en dehors de l’infection à VIH). MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le nombre de patients immunodéprimés ne cesse d’augmenter en raison de l’amélioration du pronostic global du cancer et de l’utilisation croissante d’immunosuppresseurs tant en transplantation qu’au cours des maladies auto-immunes. Les infections sévères restent la première cause d’admission en réanimation dans cette population et sont dominées par les atteintes respiratoires. On distingue les déficits primitifs, volontiers révélés dans l’enfance, des déficits secondaires (médicamenteux ou non), les plus fréquents. Dans tous les cas, les sujets sont exposés à des infections inhabituelles de par leur fréquence, leur type et leur sévérité. À côté des pyogènes habituels, les infections opportunistes et la réactivation d’infections latentes font toute la complexité de la démarche diagnostique. Celle-ci doit être rigoureuse, orientée par le type de déficit, les antécédents, les prophylaxies éventuelles et la présentation clinicoradiologique. Elle permettra seule de guider le traitement probabiliste et les examens étiologiques, l’absence de diagnostic étant associée à une mortalité élevée.
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58
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Limper AH. In Replay: Pneumocystis Pneumonia Following Rituximab. Chest 2018; 145:664. [PMID: 27845645 DOI: 10.1378/chest.13-2747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine., Rochester, MN.
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59
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Pneumocystis jirovecii pneumonia in HIV-uninfected, rituximab treated non-Hodgkin lymphoma patients. Sci Rep 2018; 8:8321. [PMID: 29844519 PMCID: PMC5974272 DOI: 10.1038/s41598-018-26743-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 05/16/2018] [Indexed: 01/03/2023] Open
Abstract
Rituximab is associated with a higher incidence of Pneumocystis jirovecii pneumonia infection. Pneumocystis prophylaxis is advised in many immunocompromised populations treated with rituximab. However, the beneficial effect of pneumocystis prophylaxis in HIV-uninfected, rituximab-treated non-Hodgkin lymphoma (NHL) patients has not been assessed. Thus, we conducted this retrospective study to explore pneumocystis infection in HIV-uninfected NHL patients who received at least three courses of chemotherapy without haematopoietic stem cell transplantation using the Taiwan National Health Insurance Research Database. Patients who had rituximab-based chemotherapy were included in the experimental (rituximab) group, while the rest of the patients who did not receive any rituximab-based chemotherapy throughout the study period formed the control group. The prevalence rate of pneumocystis infection in the rituximab group (N = 7,554) was significantly higher than that in the control group (N = 4,604) (2.95% vs. 1.32%). The onset of pneumocystis infection occurred between 6 and 16 weeks after chemotherapy. Patients who had pneumocystis prophylaxis, whether or not they had a pneumocystis infection later in their treatment course, had significantly better first-year survival rates (73% vs. 38%). Regular pneumocystis prophylaxis should be considered in this group of patients.
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60
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Graham KF, McEntegart A. Pneumocystis jiroveci pneumonia in a patient taking Benepali for rheumatoid arthritis. BMJ Case Rep 2018; 2018:bcr-2018-224764. [PMID: 29680792 PMCID: PMC5926557 DOI: 10.1136/bcr-2018-224764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2018] [Indexed: 01/07/2023] Open
Abstract
We present a case of a 57-year-old woman who contracted Pneumocystis jiroveci pneumonia while on Benepali, the biosimilar version of etanercept for rheumatoid arthritis. She had seropositive erosive disease. She was admitted to clinic with a 2-week history of dyspnoea, dry cough and fever. Her initial examination showed her to be hypoxic on air with saturations of 77% and left basal crackles. Her admission chest X-ray showed fine reticular shadowing, with an initial suspicion of pulmonary fibrosis. She was empirically treated for community-acquired pneumonia but continued to deteriorate with a worsening type 1 respiratory failure. She was intubated and ventilated on intensive care. The suspicion was raised of P. jiroveci pneumonia given her immunosuppression, hypoxic presentation and chest X-ray changes. This was confirmed on sputum PCR. She was treated with a 3-week course of steroids and co-trimoxazole. She was discharged home after a 2-week admission.
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MESH Headings
- Anti-Bacterial Agents/therapeutic use
- Arthritis, Rheumatoid/complications
- Arthritis, Rheumatoid/drug therapy
- Diagnosis, Differential
- Drug Combinations
- Etanercept/adverse effects
- Female
- Humans
- Immunosuppressive Agents/adverse effects
- Injections, Subcutaneous
- Intensive Care Units
- Methotrexate/adverse effects
- Middle Aged
- Pneumocystis carinii/isolation & purification
- Pneumonia, Pneumocystis/complications
- Pneumonia, Pneumocystis/diagnostic imaging
- Pneumonia, Pneumocystis/drug therapy
- Radiography, Thoracic/methods
- Respiration, Artificial/methods
- Respiratory Insufficiency/etiology
- Sputum/metabolism
- Steroids/administration & dosage
- Steroids/therapeutic use
- Tomography, X-Ray Computed/methods
- Treatment Outcome
- Trimethoprim, Sulfamethoxazole Drug Combination/administration & dosage
- Trimethoprim, Sulfamethoxazole Drug Combination/therapeutic use
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61
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Salzer HJF, Schäfer G, Hoenigl M, Günther G, Hoffmann C, Kalsdorf B, Alanio A, Lange C. Clinical, Diagnostic, and Treatment Disparities between HIV-Infected and Non-HIV-Infected Immunocompromised Patients with Pneumocystis jirovecii Pneumonia. Respiration 2018; 96:52-65. [PMID: 29635251 DOI: 10.1159/000487713] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/13/2018] [Indexed: 01/15/2023] Open
Abstract
The substantial decline in the Pneumocystis jirovecii pneumonia (PCP) incidence in HIV-infected patients after the introduction of antiretroviral therapy (ART) in resource-rich settings and the growing number of non-HIV-infected immunocompromised patients at risk leads to considerable epidemiologic changes with clinical, diagnostic, and treatment consequences for physicians. HIV-infected patients usually develop a subacute course of disease, while non-HIV-infected immunocompromised patients are characterized by a rapid disease progression with higher risk of respiratory failure and higher mortality. The main symptoms usually include exertional dyspnea, dry cough, and subfebrile temperature or fever. Lactate dehydrogenase may be elevated. Typical findings on computed tomography scans of the chest are bilateral ground-glass opacities with or without cystic lesions, which are usually associated with the presence of AIDS. Empiric treatment should be initiated as soon as PCP is suspected. Bronchoalveolar lavage has a higher diagnostic yield compared to induced sputum. Immunofluorescence is superior to conventional staining. A combination of different diagnostic tests such as microscopy, polymerase chain reaction, and (1,3)-β-D-glucan is recommended. Trimeth-oprim/sulfamethoxazole for 21 days is the treatment of choice in adults and children. Alternative treatment regimens include dapsone with trimethoprim, clindamycin with primaquine, atovaquone, or pentamidine. Patients with moderate to severe disease should receive adjunctive corticosteroids. In newly diagnosed HIV-infected patients with PCP, ART should be initiated as soon as possible. In non-HIV-infected immunocompromised patients, improvement of the immune status should be discussed (e.g., temporary reduction of immunosuppressive agents). PCP prophylaxis is effective and depends on the immune status of the patient and the underlying immunocompromising disease.
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Affiliation(s)
- Helmut J F Salzer
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,German Center for Infection Research, Clinical Tuberculosis Center, Borstel, Germany
| | - Guido Schäfer
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Section of Rheumatology, 3rd Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Hoenigl
- Division of Infectious Diseases, University of California at San Diego, San Diego, California, USA.,Section of Infectious Diseases and Tropical Medicine and Division of Pulmonology, Medical University of Graz, Graz, Austria
| | - Gunar Günther
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,Department of Internal Medicine, School of Medicine, University of Namibia, Windhoek, Namibia
| | - Christian Hoffmann
- Infektionsmedizinisches Centrum Hamburg (ICH) Study Center, Hamburg, Germany.,Department of Medicine II, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Barbara Kalsdorf
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,German Center for Infection Research, Clinical Tuberculosis Center, Borstel, Germany
| | - Alexandre Alanio
- Parasitology-Mycology Laboratory, Lariboisière Saint-Louis Fernand Widal Hospitals, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris-Diderot, Sorbonne Paris Cité University, Paris, France.,Institut Pasteur, Molecular Mycology Unit, CNRS CMR2000, Paris, France
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany.,German Center for Infection Research, Clinical Tuberculosis Center, Borstel, Germany.,International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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62
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Alexandre K, Ingen-Housz-Oro S, Versini M, Sailler L, Benhamou Y. Pneumocystis jirovecii pneumonia in patients treated with rituximab for systemic diseases: Report of 11 cases and review of the literature. Eur J Intern Med 2018; 50:e23-e24. [PMID: 29198498 DOI: 10.1016/j.ejim.2017.11.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 11/23/2017] [Accepted: 11/28/2017] [Indexed: 11/27/2022]
Affiliation(s)
- K Alexandre
- Department of Infectious Disease, Rouen University Hospital, Rouen F-76031, France.
| | | | - M Versini
- Department of Internal Medicine, Archet Hospital, Nice, France
| | - L Sailler
- Department of Internal Medicine, Purpan University Hospital, Toulouse, France
| | - Y Benhamou
- Department of Internal Medicine, Rouen University Hospital, Rouen F-76031, France; Inserm, U1096, Rouen, F-76000, France
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Dos Santos Ramos MA, Da Silva PB, Spósito L, De Toledo LG, Bonifácio BV, Rodero CF, Dos Santos KC, Chorilli M, Bauab TM. Nanotechnology-based drug delivery systems for control of microbial biofilms: a review. Int J Nanomedicine 2018; 13:1179-1213. [PMID: 29520143 PMCID: PMC5834171 DOI: 10.2147/ijn.s146195] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Since the dawn of civilization, it has been understood that pathogenic microorganisms cause infectious conditions in humans, which at times, may prove fatal. Among the different virulent properties of microorganisms is their ability to form biofilms, which has been directly related to the development of chronic infections with increased disease severity. A problem in the elimination of such complex structures (biofilms) is resistance to the drugs that are currently used in clinical practice, and therefore, it becomes imperative to search for new compounds that have anti-biofilm activity. In this context, nanotechnology provides secure platforms for targeted delivery of drugs to treat numerous microbial infections that are caused by biofilms. Among the many applications of such nanotechnology-based drug delivery systems is their ability to enhance the bioactive potential of therapeutic agents. The present study reports the use of important nanoparticles, such as liposomes, microemulsions, cyclodextrins, solid lipid nanoparticles, polymeric nanoparticles, and metallic nanoparticles, in controlling microbial biofilms by targeted drug delivery. Such utilization of these nanosystems has led to a better understanding of their applications and their role in combating biofilms.
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Affiliation(s)
- Matheus Aparecido Dos Santos Ramos
- São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, Department of Biological Sciences, Araraquara, SP, Brazil
| | - Patrícia Bento Da Silva
- São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, Department of Drugs and Medicines. Araraquara, SP, Brazil
| | - Larissa Spósito
- São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, Department of Biological Sciences, Araraquara, SP, Brazil
| | - Luciani Gaspar De Toledo
- São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, Department of Biological Sciences, Araraquara, SP, Brazil
| | - Bruna Vidal Bonifácio
- São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, Department of Biological Sciences, Araraquara, SP, Brazil
| | - Camila Fernanda Rodero
- São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, Department of Drugs and Medicines. Araraquara, SP, Brazil
| | - Karen Cristina Dos Santos
- São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, Department of Drugs and Medicines. Araraquara, SP, Brazil
| | - Marlus Chorilli
- São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, Department of Drugs and Medicines. Araraquara, SP, Brazil
| | - Taís Maria Bauab
- São Paulo State University (UNESP), School of Pharmaceutical Sciences, Campus Araraquara, Department of Biological Sciences, Araraquara, SP, Brazil
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64
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Park SY, Kim MY, Choi WJ, Yoon DH, Lee SO, Choi SH, Kim YS, Suh C, Woo JH, Kim SH. Pneumocystis pneumonia versus rituximab-induced interstitial lung disease in lymphoma patients receiving rituximab-containing chemotherapy. Med Mycol 2018; 55:349-357. [PMID: 28339533 DOI: 10.1093/mmy/myw095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/01/2016] [Indexed: 01/11/2023] Open
Abstract
It is difficult to differentiate Pneumocystis pneumonia (PCP) from rituximab-induced interstitial lung disease (RILD) in lymphoma patients with diffuse pulmonary infiltrates who are receiving rituximab-containing chemotherapy. Using a clinical scoring system, we aim to differentiate PCP from RILD who are receiving rituximab-containing chemotherapy. We reviewed the medical records of lymphoma patients who had received rituximab-containing chemotherapy between 2012 and 2015 in a tertiary hospital. Among 613 lymphoma patients receiving rituximab-containing chemotherapy, 97 (16%) had diffuse pulmonary infiltrates. Of these, 16 (16%) with an alternative diagnosis and 22 (23%) with an indeterminate diagnosis were excluded. Finally, 21 (22%) patients were classified as having PCP and the remaining 38 (39%) as having RILD. Fever, short duration of symptoms (≤5 days), systemic inflammatory response syndrome (SIRS), and severe extent of disease on CT scan (>75%) were more common in patients with PCP than in those with RILD. Clinical scores were determined using the following system: SIRS = score 1, symptom duration ≤5 days = score 1, extent of disease on CT >75% = score 4. A score of ≥2 differentiated PCP from RILD with 91% sensitivity (95% CI, 70-99) and 71% specificity (95% CI, 54-84). A clinical scoring system based on presence of SIRS, short duration of symptoms, and severe extent of disease on CT scan appears to be useful in differentiation of PCP from RILD.
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Affiliation(s)
- Se Yoon Park
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Mi Young Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Jin Choi
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Department of Radiology, Dong-A University Hospital, Busan, Korea
| | - Dok Hyun Yoon
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Cheolwon Suh
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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65
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Ghrenassia E, Mariotte E, Azoulay E. Rituximab-related Severe Toxicity. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [PMCID: PMC7176228 DOI: 10.1007/978-3-319-73670-9_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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66
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Lionakis MS, Levitz SM. Host Control of Fungal Infections: Lessons from Basic Studies and Human Cohorts. Annu Rev Immunol 2017; 36:157-191. [PMID: 29237128 DOI: 10.1146/annurev-immunol-042617-053318] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In the last few decades, the AIDS pandemic and the significant advances in the medical management of individuals with neoplastic and inflammatory conditions have resulted in a dramatic increase in the population of immunosuppressed patients with opportunistic, life-threatening fungal infections. The parallel development of clinically relevant mouse models of fungal disease and the discovery and characterization of several inborn errors of immune-related genes that underlie inherited human susceptibility to opportunistic mycoses have significantly expanded our understanding of the innate and adaptive immune mechanisms that protect against ubiquitous fungal exposures. This review synthesizes immunological knowledge derived from basic mouse studies and from human cohorts and provides an overview of mammalian antifungal host defenses that show promise for informing therapeutic and vaccination strategies for vulnerable patients.
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Affiliation(s)
- Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892;
| | - Stuart M Levitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01655;
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67
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Tudesq JJ, Cartron G, Rivière S, Morquin D, Iordache L, Mahr A, Pourcher V, Klouche K, Cerutti D, Le Quellec A, Guilpain P. Clinical and microbiological characteristics of the infections in patients treated with rituximab for autoimmune and/or malignant hematological disorders. Autoimmun Rev 2017; 17:115-124. [PMID: 29180125 DOI: 10.1016/j.autrev.2017.11.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Rituximab is commonly used for the treatment of hematological malignancies and autoimmune diseases. Despite a reputation for good tolerance, case-series and registries reported rituximab-related infections of variable severity including opportunistic infections. We aimed at describing the natural history of infectious events (IE) after treatment by rituximab providing clinical and microbiological features and outcome. PATIENTS AND METHODS We retrospectively analyzed the medical records of patients treated with rituximab in an internal medicine department of a tertiary hospital between 2007 and 2015, and identified all IE after this therapy. Events' severity was assessed using the Common Terminological Criteria of Adverse Events (version 4.3) definitions. RESULTS Among 101 patients treated with rituximab, we identified 228 IE in 74 (73.3%) of these patients (median follow-up 30.4months). Indication for rituximab was either autoimmune disease (AID) (52.5% of patients), or monoclonal hematological disease (MHD) (47.5%). Patients received an overall median number of 5 rituximab infusions [interquartile range: 4-8], representing a cumulative dose of 4340mg [2620-6160]. After last rituximab infusion, IE occurred after 3.1months [0.7-9.4]. Respectively, IE were severe in 28.1% of cases in patients treated for AID vs 58.0% in patients treated for MHD (p<0.001), due to opportunistic pathogens in 7.8% vs 11.0% (p=0.49) and fatal in 4.7% vs 13.0% (p=0.044). Factor associated with mortality were polymicrobial infection (p<0.001), monoclonal hematological disease (p=0.035), use of steroids over 10mg/d within the last two weeks (p=0.003), and rituximab cumulative dose (p<0.001). We identified a group of 10 patients (9.9%) showing life-threatening, polymicrobial, and opportunistic infections constituting a 'catastrophic infectious syndrome', which was lethal in 7 cases. CONCLUSION IE after treatment by rituximab can be extremely severe, especially in patients immunocompromised by several other drugs. Further studies should focus on the group with life-threatening polymicrobial infections.
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Affiliation(s)
- Jean-Jacques Tudesq
- Internal Medicine and Multi-organic Diseases Department, Local Referral Center for Rare Autoimmune Diseases, Montpellier University Hospital, Montpellier F-34000, France; Medical Intensive Care Unit, Montpellier University Hospital, Montpellier F-34000, France
| | - Guillaume Cartron
- Clinical Hematology Department, Montpellier University Hospital, Montpellier, F-34000, France; Centre National de Recherche Scientifique (CNRS), UMR 5235, Montpellier University, Montpellier F-34000, France
| | - Sophie Rivière
- Internal Medicine and Multi-organic Diseases Department, Local Referral Center for Rare Autoimmune Diseases, Montpellier University Hospital, Montpellier F-34000, France
| | - David Morquin
- Infectious Diseases Department, Montpellier University Hospital, Montpellier, F-34000, France
| | - Laura Iordache
- Internal Medicine Department, Saint-Louis University Hospital, AP-HP, Paris F-75010, France
| | - Alfred Mahr
- Internal Medicine Department, Saint-Louis University Hospital, AP-HP, Paris F-75010, France
| | - Valérie Pourcher
- Infectious Diseases Department, Pitié-Salpêtrière University Hospital, AP-HP, Paris F-75005, France
| | - Kada Klouche
- Medical Intensive Care Unit, Montpellier University Hospital, Montpellier F-34000, France
| | - Diane Cerutti
- Internal Medicine and Multi-organic Diseases Department, Local Referral Center for Rare Autoimmune Diseases, Montpellier University Hospital, Montpellier F-34000, France
| | - Alain Le Quellec
- Internal Medicine and Multi-organic Diseases Department, Local Referral Center for Rare Autoimmune Diseases, Montpellier University Hospital, Montpellier F-34000, France
| | - Philippe Guilpain
- Internal Medicine and Multi-organic Diseases Department, Local Referral Center for Rare Autoimmune Diseases, Montpellier University Hospital, Montpellier F-34000, France; Institut National de la Santé Et de la Rercherche Médicale (INSERM) U1183, Institute for Regenerative Medicine and Biotherapies (IRMB), Montpellier F-34000, France.
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68
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Hoving JC, Kolls JK. New advances in understanding the host immune response to Pneumocystis. Curr Opin Microbiol 2017; 40:65-71. [PMID: 29136537 DOI: 10.1016/j.mib.2017.10.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 10/22/2017] [Accepted: 10/24/2017] [Indexed: 12/16/2022]
Abstract
Pneumocystis jirovecii causes clinical pneumonia in immunocompromised hosts. Despite this, the inability to cultivate this organism in vitro has likely hindered the field in ascertaining the true impact of Pneumocystis in human infection. However the recent release of the genome as well as in advances in understanding host genetics, and other risk factors for infection and robust experimental models of disease have shed new light on the impact of this fungal pathogen as to better define populations at risk. This review will highlight these recent advances as well as highlight future needed areas of research.
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Affiliation(s)
- J Claire Hoving
- Institute of Infectious Disease and Molecular Medicine (IDM), Department of Pathology, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - Jay K Kolls
- Center for Translational Research in Infection and Inflammation, Tulane School of Medicine, New Orleans, USA.
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69
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Hellmich B. [Current guidelines on ANCA-associated vasculitides : Common features and differences]. Z Rheumatol 2017; 76:133-142. [PMID: 27848024 DOI: 10.1007/s00393-016-0223-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The results of a number of prospective randomized controlled clinical trials have led to changes in established strategies for the treatment of antineutrophil cytoplasmic antibody (ANCA) associated vasculitides (AAV) in recent years. Since 2014, a total of 4 scientific societies and study groups have systematically reviewed the new data and have formulated evidence-based recommendations for the management of AAV based on the analysis. These recommendations contain information on diagnosis, treatment (induction and maintenance), supportive care and monitoring of disease activity and resulting damage. This review compares the recently published recommendations of the German Society of Rheumatology (Deutschen Gesellschaft für Rheumatologie, DGRh), the European League Against Rheumatism (EULAR)/European Renal Association (ERA), the British Society of Rheumatology (BSR) and the Canadian Vasculitis Research Network (CanVasc). The comparative analysis reveals a high level of agreement on numerous topics but also shows some minor and even a few major differences in the respective recommended approach to diagnosis and treatment of AAV. Divergent recommendations predominantly exist in areas with little scientific evidence from clinical studies. Furthermore, some differences result from different interpretation of existing data or are influenced by characteristic features of the respective national healthcare system.
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Affiliation(s)
- B Hellmich
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Klinik Kirchheim, Akademisches Lehrkrankenhaus der Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland.
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70
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Pingili CS, Sivapalan V. PJP granuloma in an Immune competent host: Case report and literature review. IDCases 2017; 10:32-34. [PMID: 28856102 PMCID: PMC5565774 DOI: 10.1016/j.idcr.2017.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 06/15/2017] [Accepted: 06/26/2017] [Indexed: 11/25/2022] Open
Abstract
PJP (Pneumocystis jirovecii) is a fungal agent by taxonomy. Ones considered a protozoan, it is now recognized as fungi based on ribosomal RNA and other gene sequence homologies, the composition of their cell walls, and structure of key enzymes. This organism generally affects immunocompromised hosts with a CD4 count <200 or <15%.Review of literature does support a rare occurrence of PJP infections in immunocompetent hosts.PJP can occur at normal CD 4 levels.
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Affiliation(s)
- Chandra S Pingili
- Columbia University medical center, The Affiliation at Harlem hospital, New York, USA.,Lincoln medical & mental health center, New York, USA
| | - Vel Sivapalan
- Columbia University medical center, The Affiliation at Harlem hospital, New York, USA.,Lincoln medical & mental health center, New York, USA
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71
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Okada M, Watarai Y, Iwasaki K, Murotani K, Futamura K, Yamamoto T, Hiramitsu T, Tsujita M, Goto N, Narumi S, Takeda A, Morozumi K, Uchida K, Kobayashi T. Favorable results in ABO-incompatible renal transplantation without B cell-targeted therapy: Advantages and disadvantages of rituximab pretreatment. Clin Transplant 2017; 31. [PMID: 28792635 DOI: 10.1111/ctr.13071] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2017] [Indexed: 12/17/2022]
Abstract
The effectiveness of desensitization with rituximab in ABO-incompatible renal transplantation (ABO-I) has been widely reported. However, ABO-I outcomes are still worse than those of ABO-identical or ABO-compatible renal transplantation (ABO-Id/C). We retrospectively examined the outcomes in consecutive living donor ABO-Id/C (n = 412) and ABO-I (n = 205) cases to elucidate the causes of inferiority in ABO-I. ABO-I cases included recipients treated with rituximab (RIT, n = 131), splenectomy (SPX, n = 21), or neither because of low anti-A/B antibody titers (NoR/S, n = 53). Graft survival, infection, and de novo HLA antibody production were compared for ABO-I and ABO-Id/C, followed by stratification into RIT and NoR/S groups. Propensity score-based methods were employed to limit selection bias and potential confounders. Overall graft survival for ABO-I was significantly lower than that for ABO-Id/C (92.8% vs 97.2% after 5 years, P = .0037). Graft loss due to infection with ABO-I was significantly more frequent than that with ABO-Id/C, whereas acute antibody-mediated rejection (AMR) caused no graft failure in ABO-I recipients. Stratified analysis demonstrated significantly higher infection risk with RIT than with NoR/S. Safe reduction or avoidance of rituximab in desensitization protocols might contribute to further improvement of ABO-I outcome.
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Affiliation(s)
- Manabu Okada
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.,Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kenta Iwasaki
- Department of Kidney Disease and Transplant Immunology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kenta Murotani
- Division of Biostatistics, Clinical Research Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takayuki Yamamoto
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Makoto Tsujita
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Asami Takeda
- Department of Nephrology, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kunio Morozumi
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Japan
| | - Kazuharu Uchida
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan.,Department of Kidney Disease and Transplant Immunology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
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Takemoto S, Ebara M, Hasebe S, Yakushijin Y. A study on the colonization of Pneumocystis jirovecii among outpatients during cancer chemotherapy and among healthy smokers. J Infect Chemother 2017; 23:752-756. [PMID: 28843641 DOI: 10.1016/j.jiac.2017.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/15/2017] [Accepted: 07/07/2017] [Indexed: 10/19/2022]
Abstract
AIMS Pneumocystis Jirovecii (PJ) is regarded as an agent of fungal infection and in cases of pneumocystis pneumonia (PCP) in immune-compromised patients including cancer patients. It is not clear what kinds of cancer, treatments, and environment need prophylaxis for PCP. In this study, we have analyzed the detectability of PJ DNA from sputum, and discussed prophylaxis and risk factors regarding PCP. METHODS A total of forty-nine materials (twenty-four from outpatients during cancer chemotherapies and twenty-five from healthy control subjects) was collected. Their PJ DNAs were amplified using nested PCR with specific primers of the PJ gene (the mitochondrial small subunit rRNA gene). RESULTS PJ DNA was detectable in 46% of specimens (sputum) from cancer patients during chemotherapies, and incidences of not significantly different among types of cancer and chemotherapy regimens. Prophylactic use of Sulfamethoxazole/Trimetoprim (ST) reduced the detection of PJ DNA. Detection of PJ DNA is not high among healthy non-smokers (20%) and high among healthy smokers (47%). CONCLUSIONS Prophylactic use of ST may be necessary for cancer patients during chemotherapies. Also, smoking may be associated with PJ colonization in the airway and air vesicles, and may increase the mortality rate for PCP. All patients undergoing cancer chemotherapies should cease smoking.
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Affiliation(s)
| | | | - Shinji Hasebe
- Department of Clinical Oncology, Ehime University Graduate School of Medicine, Japan
| | - Yoshihiro Yakushijin
- Department of Clinical Oncology, Ehime University Graduate School of Medicine, Japan.
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73
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Khan BA, Khan S, White B, Eranki A. Severe pneumocystis jiroveci pneumonia in a patient on temozolomide therapy: A case report and review of literature. Respir Med Case Rep 2017; 22:179-182. [PMID: 28861334 PMCID: PMC5568882 DOI: 10.1016/j.rmcr.2017.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/31/2017] [Accepted: 08/11/2017] [Indexed: 11/17/2022] Open
Abstract
A 66 year old man was diagnosed with CNS diffuse large B-cell lymphoma, and underwent treatment with Temozolomide, Dexamethasone, Rituximab, and radiation therapy, and prolonged steroid taper with Dexamethasone. Approximately one month after this, he presented with severe acute hypoxemic respiratory failure, and was admitted to the Medical Intensive Care Unit. Imaging showed diffuse ground glass opacities. Patient underwent diagnostic bronchoalveolar lavage which was positive for Pneumocystis jiroveci. He did not respond well to appropriate therapy and was transitioned to comfort care per his family's wishes, and expired. Pneumocystis jiroveci should always be included in the differential diagnosis of pneumonia in patients treated with Temozolomide, especially when this agent is used in combination with long term, high dose corticosteroids and radiation therapy.
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Abstract
Vasculitides comprise several diseases affecting vessels of different sizes, mainly arteries, but also capillaries and veins. Antineutrophil cytoplasm antibody-associated vasculitides (AAVs) belong to the systemic necrotizing small-vessel vasculitis group that comprises granulomatosis with polyangiitis, microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis. Internists often see AAV patients, and although their outcomes are usually good, the disease can be responsible for morbidity and mortality. Herein, after reviewing the literature, we concentrate on selected aspects important for the internist, including classification, diagnostic dilemmas, treatment novelties, and follow-up.
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Affiliation(s)
- Benjamin Chaigne
- Department of Internal Medicine, Hôpital Cochin, APHP, Université Paris Descartes, 27, rue du faubourg Saint-Jacques, 75679, Paris Cedex 14, France
| | - Loïc Guillevin
- Department of Internal Medicine, Hôpital Cochin, APHP, Université Paris Descartes, 27, rue du faubourg Saint-Jacques, 75679, Paris Cedex 14, France.
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75
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Asai N, Motojima S, Ohkuni Y, Matsunuma R, Iwasaki T, Nakashima K, Sogawa K, Nakashita T, Kaneko N. Clinical Manifestations and Prognostic Factors of Pneumocystis jirovecii Pneumonia without HIV. Chemotherapy 2017; 62:343-349. [PMID: 28719897 DOI: 10.1159/000477332] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 05/05/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii pneumonia (PCP) can occur in HIV patients but also in those without HIV (non-HIV PCP) but with other causes of immunodeficiency including malignancy or rheumatic diseases. OBJECTIVE AND METHODS To evaluate the clinical presentation and prognostic factors of non-HIV PCP, we retrospectively reviewed all patients diagnosed as having PCP without HIV at Kameda Medical Center, Chiba, Japan, from January 2005 until June 2012. For the purpose of examining a prognostic factor for non-HIV PCP with 30-day mortality, we compared the characteristics of patients, clinical symptoms, radiological images, Eastern Cooperative Oncology Group performance status (PS), and the time from the onset of respiratory symptoms to the start of therapy, in both survival and fatality groups. RESULTS A total of 38 patients were eligible in this study. Twenty-five survived and 13 had died. The non-HIV PCP patients in the survivor group had a better PS and received anti-PCP therapy earlier than those in the nonsurvivor group. Rales upon auscultation and respiratory failure at initial visits were seen more frequently in the nonsurvivor group than in the survivor group. Lactate dehydrogenase and C-reactive protein values tended to be higher in the nonsurvivor group, but this was not statistically significant. Multivariate analyses using 5 variables showed that a poor PS of 2-4 was an independent risk factor for non-HIV PCP patients and resulted in death (odds ratio 15.24; 95% confidence interval 1.72-135.21). CONCLUSION We suggest that poor PS is an independent risk factor in non-HIV PCP, and a patient's PS and disease activity may correlate with outcome.
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Affiliation(s)
- Nobuhiro Asai
- Division of Respiratory Medicine and Allergology, Department of Internal Medicine, Aichi Medical University School of Medicine, Nagakute, Japan
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76
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Hu Y, Wang D, Zhai K, Tong Z. Transcriptomic Analysis Reveals Significant B Lymphocyte Suppression in Corticosteroid-Treated Hosts with Pneumocystis Pneumonia. Am J Respir Cell Mol Biol 2017; 56:322-331. [PMID: 27788015 DOI: 10.1165/rcmb.2015-0356oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Pneumocystis pneumonia (PCP) is an opportunistic, infectious disease that is prevalent in immunosuppressed hosts. Corticosteroid treatment is the most significant risk factor for patients with PCP who are human immunodeficiency virus negative, although little is known about how corticosteroids alter the host defense against Pneumocystis infection. In the present study, we used transcriptome analysis to examine the immune response in the lungs of corticosteroid-treated PCP mice. The results showed down-regulation in the genes related to both native immunity, such as antigen processing and presentation, inflammatory response, and phagocytosis, as well as B and T lymphocyte immunity. The repression of gene expression, corresponding to B cell immunity, including B cell signaling, homeostasis, and Ig production, was prominent. The finding was confirmed by quantitative PCR of mouse lungs and the peripheral blood of patients with PCP. Flow cytometry also revealed a significant depletion of B cells in corticosteroid-treated PCP mice. Our study has highlighted that corticosteroid treatment suppresses the B cell immunity in the PCP host, which is likely one of the main reasons that corticosteroid treatment may stimulate PCP development.
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Affiliation(s)
- Yang Hu
- 1 Department of Respiratory Medicine and Critical Care Medicine, and
| | - Dong Wang
- 1 Department of Respiratory Medicine and Critical Care Medicine, and
| | - Kan Zhai
- 2 Department of Medical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhaohui Tong
- 1 Department of Respiratory Medicine and Critical Care Medicine, and
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77
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Kyriakidis I, Tragiannidis A, Zündorf I, Groll AH. Invasive fungal infections in paediatric patients treated with macromolecular immunomodulators other than tumour necrosis alpha inhibitors. Mycoses 2017; 60:493-507. [DOI: 10.1111/myc.12621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Ioannis Kyriakidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Infectious Disease Research Program; Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology; University Childrens Hospital; Muenster Germany
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78
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Kronbichler A, Windpessl M, Pieringer H, Jayne DRW. Rituximab for immunologic renal disease: What the nephrologist needs to know. Autoimmun Rev 2017; 16:633-643. [PMID: 28414152 DOI: 10.1016/j.autrev.2017.04.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 12/12/2022]
Abstract
Rituximab (RTX), a chimeric, monoclonal anti-CD20 antibody, is increasingly used in immune-mediated renal diseases. While licensed in the induction treatment of ANCA-associated vasculitis, it represents one of the most commonly prescribed off-label drugs. Much of the information regarding its safety has been drawn from experience in hematology and rheumatology. Ample evidence illustrates the safety of RTX, however, rare but serious adverse events have emerged that include progressive multifocal leucoencephalopathy and hepatitis B reactivation. Moderate to severe hypogammaglobulinemia and late-onset neutropenia following RTX therapy confer an increased infectious risk and factors predicting these side effects (i.e. a genetic basis) need to be identified. Nephrologists initiating RTX need to bear in mind that long-term risks and optimal dosing for many renal indications remain unclear. Special considerations must be given when RTX is used in women of childbearing age. We summarize practical aspects concerning the use of RTX. This review will provide nephrologists with information to guide their use of RTX alerting them to safety risks and the need for patient counselling.
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Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria.
| | - Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Herwig Pieringer
- Academic Research Unit, 2nd Department of Medicine, Kepler University Hospital, Med Campus III, Linz, Austria; Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK; Department of Medicine, University of Cambridge, Cambridge, UK
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79
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Kapoor TM, Mahadeshwar P, Nguyen S, Li J, Kapoor S, Bathon J, Giles J, Askanase A. Low prevalence of Pneumocystis pneumonia in hospitalized patients with systemic lupus erythematosus: review of a clinical data warehouse. Lupus 2017; 26:1473-1482. [PMID: 28399687 DOI: 10.1177/0961203317703494] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective In the era of powerful immunosuppression, opportunistic infections are an increasing concern in systemic lupus erythematosus. One of the best-studied opportunistic infections is Pneumocystis pneumonia; however, the prevalence of Pneumocystis pneumonia in systemic lupus erythematosus is not clearly defined. This study evaluates the prevalence of Pneumocystis pneumonia in hospitalized systemic lupus erythematosus patients, with a focus on validating the Pneumocystis pneumonia and systemic lupus erythematosus diagnoses with clinical information. Methods This retrospective cohort study evaluates the prevalence of Pneumocystis pneumonia in all systemic lupus erythematosus patients treated at Columbia University Medical Center-New York Presbyterian Hospital between January 2000 and September 2014, using electronic medical record data. Patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and patients with renal transplants (including both early and late post-transplant patients) represented immunocompromised control groups. Patients with systemic lupus erythematosus, Pneumocystis pneumonia, HIV/AIDS, or renal transplant were identified using diagnostic codes from the International Classification of Diseases, Ninth Revision (ICD-9). Results Out of 2013 hospitalized systemic lupus erythematosus patients, nine had presumed Pneumocystis pneumonia, yielding a low prevalence of Pneumocystis pneumonia in systemic lupus erythematosus of 0.45%. Three of the nine Pneumocystis pneumonia cases were patients with concomitant systemic lupus erythematosus and HIV/AIDS. Only one of these nine cases was histologically confirmed as Pneumocystis pneumonia, in a patient with concomitant systemic lupus erythematosus and HIV/AIDS and a CD4 count of 13 cells/mm3. The prevalence of Pneumocystis pneumonia in renal transplant patients and HIV/AIDS patients was 0.61% and 5.98%, respectively. Conclusion Given the reported high rate of adverse effects to trimethoprim-sulfamethoxazole in systemic lupus erythematosus and the low prevalence of Pneumocystis pneumonia in hospitalized systemic lupus erythematosus patients, our data do not substantiate the need for Pneumocystis pneumonia prophylaxis in systemic lupus erythematosus patients, except in those with concurrent HIV/AIDS.
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Affiliation(s)
- T M Kapoor
- 1 Division of Rheumatology, Columbia University School of Physicians and Surgeons, USA
| | - P Mahadeshwar
- 1 Division of Rheumatology, Columbia University School of Physicians and Surgeons, USA
| | - S Nguyen
- 1 Division of Rheumatology, Columbia University School of Physicians and Surgeons, USA
| | - J Li
- 2 Department of Endocrine, Columbia University School of Physicians and Surgeons, USA
| | - S Kapoor
- 3 Department of Cardiology, Rutgers-New Jersey Medical School, USA
| | - J Bathon
- 1 Division of Rheumatology, Columbia University School of Physicians and Surgeons, USA
| | - J Giles
- 1 Division of Rheumatology, Columbia University School of Physicians and Surgeons, USA
| | - A Askanase
- 1 Division of Rheumatology, Columbia University School of Physicians and Surgeons, USA
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80
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Overcoming Hurdles to Development of a Vaccine against Pneumocystis jirovecii. Infect Immun 2017; 85:IAI.00035-17. [PMID: 28115507 DOI: 10.1128/iai.00035-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Development of Pneumocystis pneumonia (PCP) is a common problem among immunosuppressed individuals. There are windows of opportunity in which vaccination would be beneficial, but to date, no vaccines have made it to clinical trials. Significant hurdles to vaccine development include host range specificity, making it difficult to translate from animal models to humans. Discovery of cross-reactive epitopes is critical to moving vaccine candidates from preclinical animal studies to clinical trials.
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81
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Li R, Rezk A, Li H, Gommerman JL, Prat A, Bar-Or A. Antibody-Independent Function of Human B Cells Contributes to Antifungal T Cell Responses. THE JOURNAL OF IMMUNOLOGY 2017; 198:3245-3254. [PMID: 28275140 DOI: 10.4049/jimmunol.1601572] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 02/11/2017] [Indexed: 12/16/2022]
Abstract
Fungal infections (e.g., Candida albicans) can manifest as serious medical illnesses, especially in the elderly and immune-compromised hosts. T cells are important for Candida control. Whether and how B cells are involved in antifungal immunity has been less clear. Although patients with agammaglobulinemia exhibit normal antifungal immunity, increased fungal infections are reported following B cell-depleting therapy, together pointing to Ab-independent roles of B cells in controlling such infections. To test how human B cells may contribute to fungal-associated human T cell responses, we developed a novel Ag-specific human T cell/B cell in vitro coculture system and found that human B cells could induce C. albicans-associated, MHC class II-restricted responses of naive T cells. Activated B cells significantly enhanced C. albicans-mediated Th1 and Th17 T cell responses, which were both strongly induced by CD80/CD86 costimulation. IL-6+GM-CSF+ B cells were the major responding B cell subpopulation to C. albicans and provided efficient costimulatory signals to the T cells. In vivo B cell depletion in humans resulted in reduced C. albicans-associated T responses. Of note, the decreased Th17, but not Th1, responses could be reversed by soluble factors from B cells prior to depletion, in an IL-6-dependent manner. Taken together, our results implicate an Ab-independent cytokine-defined B cell role in human antifungal T cell responses. These findings may be particularly relevant given the prospects of chronic B cell depletion therapy use in lymphoma and autoimmune disease, as patients age and are exposed to serial combination therapies.
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Affiliation(s)
- Rui Li
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Ayman Rezk
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Hulun Li
- Department of Neurobiology, Harbin Medical University, Harbin, Heilongjiang 150086, China
| | - Jennifer L Gommerman
- Department of Immunology, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Alexandre Prat
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal-Hôpital Notre-Dame, Montreal, Quebec H2L 4M1, Canada; and
| | - Amit Bar-Or
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada; .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104.,Experimental Therapeutics Program, Montreal Neurological Institute, McGill University, Montreal, Quebec H3A 2B4, Canada
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82
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Messiaen PE, Cuyx S, Dejagere T, van der Hilst JC. The role of CD4 cell count as discriminatory measure to guide chemoprophylaxis against Pneumocystis jirovecii pneumonia in human immunodeficiency virus-negative immunocompromised patients: A systematic review. Transpl Infect Dis 2017; 19. [PMID: 28035717 DOI: 10.1111/tid.12651] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 09/11/2016] [Accepted: 09/17/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND In recent years, the incidence of Pneumocystis jirovecii pneumonia (PJP) has increased in immunocompromised patients without human immunodeficiency virus (HIV) infection. Chemoprophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) is highly effective in preventing PJP in both HIV-positive and -seronegative patients. In HIV-positive patients, the risk of PJP is strongly correlated with decreased CD4 cell count. The role of CD4 cell count in the pathogenesis of PJP in non-HIV immunocompromised patients is less well studied. For most immunosuppressive conditions, no clear guidelines indicate whether to start TMP-SMX. METHOD We conducted a systematic literature review with the aim to provide a comprehensive overview on the role of CD4 cell counts in managing the risk of PJP in HIV-seronegative patients. RESULTS Of the 63 individual studies retrieved, 14 studies report on CD4 cell counts in a variety of immunosuppressive conditions. CD4 cell count were <200/μL in 73.1% of the patients. CONCLUSION CD4 cell count <200/μL is a sensitive biomarker to identify non-HIV immunocompromised patients who are at risk for PJP. Measuring CD4 cell counts could help clinicians identify patients who may benefit from TMP-SMX prophylaxis.
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Affiliation(s)
- Peter E Messiaen
- Department of Infectious Diseases and Immunity, Jessa Hospital, Hasselt, Belgium.,Biomedical Research Institute BIOMED, Hasselt University, Hasselt, Belgium
| | - Senne Cuyx
- Department of Infectious Diseases and Immunity, Jessa Hospital, Hasselt, Belgium
| | - Tom Dejagere
- Department of Nephrology, Jessa Hospital, Hasselt, Belgium
| | - Jeroen C van der Hilst
- Department of Infectious Diseases and Immunity, Jessa Hospital, Hasselt, Belgium.,Biomedical Research Institute BIOMED, Hasselt University, Hasselt, Belgium
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83
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Chan TSY, Au-Yeung R, Chim CS, Wong SCY, Kwong YL. Disseminated fusarium infection after ibrutinib therapy in chronic lymphocytic leukaemia. Ann Hematol 2017; 96:871-872. [PMID: 28184982 DOI: 10.1007/s00277-017-2944-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 02/01/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas S Y Chan
- Department of Medicine, Queen Mary Hospital, Pokfulam Road, Hong Kong, China
| | - Rex Au-Yeung
- Department of Pathology, Queen Mary Hospital, Pokfulam Road, Hong Kong, China
| | - Chor-Sang Chim
- Department of Medicine, Queen Mary Hospital, Pokfulam Road, Hong Kong, China
| | - Sally C Y Wong
- Department of Microbiology, Queen Mary Hospital, Pokfulam Road, Hong Kong, China
| | - Yok-Lam Kwong
- Department of Medicine, Queen Mary Hospital, Pokfulam Road, Hong Kong, China.
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84
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Infections Associated with Immunobiologics. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00088-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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85
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Michel M, Terriou L, Roudot-Thoraval F, Hamidou M, Ebbo M, Le Guenno G, Galicier L, Audia S, Royer B, Morin AS, Marie Michot J, Jaccard A, Frenzel L, Khellaf M, Godeau B. A randomized and double-blind controlled trial evaluating the safety and efficacy of rituximab for warm auto-immune hemolytic anemia in adults (the RAIHA study). Am J Hematol 2017; 92:23-27. [PMID: 27696475 DOI: 10.1002/ajh.24570] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 09/29/2016] [Indexed: 12/27/2022]
Abstract
This Phase 3 multicentre randomized double-blind and placebo-controlled trial aimed to compare the efficacy and safety of rituximab (RTX) to placebo for treating newly diagnosed warm autoimmune hemolytic anemia (wAIHA) in adults receiving prednisone. Adults with a confirmed diagnosis of wAIHA who previously received corticosteroids for less than 6 weeks could be included. At inclusion, all patients received prednisone at a daily dose of 1 mg/kg for 2 weeks, and then tapered according to a pre-defined recommended reduction scheme. Besides prednisone, eligible patients received 2 infusions of RTX or placebo at a fixed dose of 1,000 mg 2-week apart. The primary endpoint was overall response rate (complete response [CR] + partial response [PR]) in an intent-to-treat (ITT) analysis at 1 year. A total of 32 patients (17 females [53%], mean age at inclusion 71 ± 16 years) were enrolled and randomized. In all, 27 patients were followed for at least 1 year and their data were evaluable for response. With an ITT analysis, the overall response rate at 1 year was 75% [95%CI: 47.6-92.7] with 11 CR and 1 PR with RTX versus 31% [11.0-58.7] (5 CR) with placebo (P = 0.032). At 2 years, 10/16 patients with RTX versus 3/16 with placebo still showed CR (P = 0.011). Overall, eight severe infections occurred during follow-up, six with placebo and two with RTX (P = 0.39). At 2 years, six patients with placebo had died, but none with RTX (P = 0.017). Compared to placebo, RTX combined with prednisone may be effective and safe for treating newly-diagnosed wAIHA in adults. Am. J. Hematol. 92:23-27, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Marc Michel
- Department of Internal Medicine; National Referral Center for Adult'Immune Cytopenias Henri Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Université Paris-Est Créteil; Créteil France
| | - Louis Terriou
- Department of Internal Medecine and Clinical Hematology; Claude-Huriez University Hospital, Université Lille Nord de France; Lille France
| | - Francoise Roudot-Thoraval
- Department of Public Health and Statistics; Henri Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Université Paris-Est Créteil; Créteil France
| | - Mohamed Hamidou
- Department of Internal Medicine; Hôtel Dieu University Hospital; Nantes France
| | - Mikael Ebbo
- Department of Internal Medicine; La Timone University Hospital; Marseille France
| | - Guillaume Le Guenno
- Department of Internal Medicine; D'Estaing University Hospital; Clermont Ferrand France
| | - Lionel Galicier
- Department of Clinical Immunology; Saint Louis University Hospital; Paris France
| | - Sylvain Audia
- Department of Internal Medicine and Clinical Immunology; Bocage Central University Hospital, CR INSERM 1098; Dijon France
| | - Bruno Royer
- Deparment of Hematology; University Hospital; Amiens France
| | - Anne-Sophie Morin
- Department of Internal Medicine; Jean Verdier University Hospital; Bondy France
| | - Jean Marie Michot
- Department of Internal Medicine and Clinical Immunology Assistance Publique-Hôpitaux de Paris; Bicêtre University Hospital, Université Paris Sud; Le Kremlin-Bicêtre France
| | - Arnaud Jaccard
- Department of Hematology; Dupuytren University Hospital; Limoges France
| | - Laurent Frenzel
- Department of Hematology; Necker University Hospital; Paris France
| | - Mehdi Khellaf
- Department of Internal Medicine; National Referral Center for Adult'Immune Cytopenias Henri Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Université Paris-Est Créteil; Créteil France
| | - Bertrand Godeau
- Department of Internal Medicine; National Referral Center for Adult'Immune Cytopenias Henri Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Université Paris-Est Créteil; Créteil France
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86
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Enoch DA, Yang H, Aliyu SH, Micallef C. The Changing Epidemiology of Invasive Fungal Infections. Methods Mol Biol 2017; 1508:17-65. [PMID: 27837497 DOI: 10.1007/978-1-4939-6515-1_2] [Citation(s) in RCA: 238] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Invasive fungal infections (IFI) are an emerging problem worldwide with invasive candidiasis and candidemia responsible for the majority of cases. This is predominantly driven by the widespread adoption of aggressive immunosuppressive therapy among certain patient populations (e.g., chemotherapy, transplants) and the increasing use of invasive devices such as central venous catheters (CVCs). The use of new immune modifying drugs has also opened up an entirely new spectrum of patients at risk of IFIs. While the epidemiology of candida infections has changed in the last decade, with a gradual shift from C. albicans to non-albicans candida (NAC) strains which may be less susceptible to azoles, these changes vary between hospitals and regions depending on the type of population risk factors and antifungal use. In certain parts of the world, the incidence of IFI is strongly linked to the prevalence of other disease conditions and the ecological niche for the organism; for instance cryptococcal and pneumocystis infections are particularly common in areas with a high prevalence of HIV disease. Poorly controlled diabetes is a major risk factor for invasive mould infections. Environmental factors and trauma also play a unique role in the epidemiology of mould infections, with well-described hospital outbreaks linked to the use of contaminated instruments and devices. Blastomycosis is associated with occupational exposure (e.g., forest rangers) and recreational activities (e.g., camping and fishing).The true burden of IFI is probably an underestimate because of the absence of reliable diagnostics and lack of universal application. For example, the sensitivity of most blood culture systems for detecting candida is typically 50 %. The advent of new technology including molecular techniques such as 18S ribosomal RNA PCR and genome sequencing is leading to an improved understanding of the epidemiology of the less common mould and dimorphic fungal infections. Molecular techniques are also providing a platform for improved diagnosis and management of IFI.Many factors affect mortality in IFI, not least the underlying medical condition, choice of therapy, and the ability to achieve early source control. For instance, mortality due to pneumocystis pneumonia in HIV-seronegative individuals is now higher than in seropositive patients. Of significant concern is the progressive increase in resistance to azoles and echinocandins among candida isolates, which appears to worsen the already significant mortality associated with invasive candidiasis. Mortality with mould infections approaches 50 % in most studies and varies depending on the site, underlying disease and the use of antifungal agents such as echinocandins and voriconazole. Nevertheless, mortality for most IFIs has generally fallen with advances in medical technology, improved care of CVCs, improved diagnostics, and more effective preemptive therapy and prophylaxis.
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Affiliation(s)
- David A Enoch
- National Infection Service, Public Health England, Cambridge Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Box 236, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QW, UK.
| | - Huina Yang
- National Infection Service, Public Health England, Cambridge Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Box 236, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QW, UK
| | - Sani H Aliyu
- National Infection Service, Public Health England, Cambridge Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Box 236, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QW, UK
| | - Christianne Micallef
- National Infection Service, Public Health England, Cambridge Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Box 236, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QW, UK
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Successful Treatment of Life-Threatening Interstitial Lung Disease Secondary to Antisynthetase Syndrome Using Rituximab: A Case Report and Review of the Literature. Am J Ther 2016; 23:e639-45. [PMID: 25830868 DOI: 10.1097/mjt.0000000000000245] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We are presenting a case of antisynthetase syndrome (ASS) that manifested with severe interstitial pneumonitis in the presence of anti-Jo-1 and Ro (SSA) antibodies. Our patient developed respiratory failure with high oxygen requirements despite treatment by high-dose steroids. The patient was then treated with rituximab. This treatment led to significant improvement in the patient condition, with resolution of the ground glass opacities on high-resolution computerized tomography and near normalization of pulmonary function tests. In this communication, we performed a literature review and summarized previous reports pertinent to using of rituximab to treat interstitial lung disease (ILD) secondary to ASS by searching the PubMed database from 1980 to 2014. We were able to find 14 reports that included total of 45 patients with ILD secondary to ASS. A significant improvement in ILD was reported in the majority of reported patients who received rituximab, while there was only 1 mortality-related to Pneumocystis jirovecii pneumonia. Rituximab treatment was tolerated well in the majority of cases. It is our conclusion that rituximab can be considered a therapeutic option in ILD secondary to ASS based on our experience with this case and the currently available evidence in the literature. Nevertheless, there is a need for additional controlled studies to assess the efficacy and safety of rituximab in ILD secondary to ASS compared with other immunosuppressive regimens.
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88
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Trivin C, Tran A, Moulin B, Choukroun G, Gatault P, Courivaud C, Augusto JF, Ficheux M, Vigneau C, Thervet E, Karras A. Infectious complications of a rituximab-based immunosuppressive regimen in patients with glomerular disease. Clin Kidney J 2016; 10:461-469. [PMID: 28852482 PMCID: PMC5570029 DOI: 10.1093/ckj/sfw101] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 08/24/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Recent years have seen increasing use of rituximab (RTX) for various types of primary and secondary glomerulopathies. However, there are no studies that specifically address the risk of infection related to this agent in patients with these conditions. METHODS We reviewed the outcomes of all patients who received RTX therapy for glomerular disease between June 2000 and October 2011 in eight French nephrology departments. Each case was analysed for survival, cause of death if a non-survivor and/or the presence of infectious complications, including severe or opportunistic infection occurring within the 12 months following RTX infusion. RESULTS Among 98 patients treated with RTX, 25 presented with at least one infection. We report an infection rate of 21.6 per 100 patient-years. Five patients died within 12 months following an RTX infusion, of whom four also presented with an infection. The median interval between the last RTX infusion and the first infectious episode was 2.1 months (interquartile range 0.5-5.1). Most infections were bacterial (79%) and pneumonia was the most frequent infection reported (27%). The presence of diabetes mellitus (P = 0.006), the cumulative RTX dose (P = 0.01) and the concomitant use of azathioprine (P = 0.03) were identified as independent risk factors. Renal failure was significantly associated with an increased infection risk by bivariate analysis (P = 0.03) and was almost significant by multivariate analysis (P = 0.05). Nephrotic syndrome did not further increase the risk of infection and/or death. CONCLUSION The risk of infection after RTX-based immunosuppression among patients with glomerulopathy must be considered and patients should receive close monitoring and appropriate infection prophylaxis, especially in those with diabetes and high-dose RTX regimens.
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Affiliation(s)
- Claire Trivin
- Department of Nephrology, Hopital Europeen Georges Pompidou, Paris, France
| | - Antoine Tran
- Pediatric Emergency, Hopitaux pediatrique CHU Nice Lenval, France
| | - Bruno Moulin
- Department of Nephrology, Hôpitaux Universitaires de Strasbourg, France
| | | | | | - Cécile Courivaud
- Nephrology, Dialysis and Renal Transplantation, CHU Saint Jacques, Besançon, France
| | - Jean-François Augusto
- Department of Nephrology-Dialysis-Transplantation, University Hospital of Angers, France.,University of Angers, INSERM, U892-CRCNA, France
| | | | - Cécile Vigneau
- Service de Néphrologie, CHU Rennes, France.,Université Rennes 1, CNRS UMR 6290 equipe Kyca, France
| | - Eric Thervet
- Department of Nephrology, Hopital Europeen Georges Pompidou, Paris, France
| | - Alexandre Karras
- Department of Nephrology, Hopital Europeen Georges Pompidou, Paris, France
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Barreto JN, Ice LL, Thompson CA, Tosh PK, Osmon DR, Dierkhising RA, Plevak MF, Limper AH. Low incidence of pneumocystis pneumonia utilizing PCR-based diagnosis in patients with B-cell lymphoma receiving rituximab-containing combination chemotherapy. Am J Hematol 2016; 91:1113-1117. [PMID: 27472910 DOI: 10.1002/ajh.24499] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/25/2016] [Accepted: 07/26/2016] [Indexed: 12/25/2022]
Abstract
Recent literature has demonstrated concern over the risk of Pneumocystis jirovecii pneumonia (PJP) when administering rituximab with combination chemotherapy such as in R-CHOP; however, the exact risk and potential need for prophylaxis is unknown. We sought to determine the incidence of PJP infection following R-CHOP administration in patients with B-cell lymphoma. Consecutive patients diagnosed with B-cell lymphoma receiving R-CHOP were evaluated from chemotherapy initiation until 180 days after the last administration. The primary outcome was cumulative incidence of PJP infection. Secondary endpoints included the association of rituximab, prednisone and subsequent chemotherapy with PJP infection risk. A total of 689 patients (53% male, median age 66 years) were included. Seventy-three percent of patients completed at least 6 cycles of R-CHOP treatment. Median rituximab and prednisone cumulative doses were 3950 mg and 5325 mg, respectively. Median daily prednisone dose through end of treatment was 45 mg (range 7.6 mg to 119 mg). The cumulative incidence of PJP was 1.51% (95% CI 0.57-2.43, at maximum follow-up of 330 days), below 3.5%, the conventional threshold for prophylaxis. Univariate analysis did not detect a statistically significant association between PJP and rituximab, steroids, or receipt of additional chemotherapy in this patient population. Our results demonstrate a low occurrence of Pneumocystis pneumonia during R-CHOP treatment of B-cell lymphoma and argue against universal anti-Pneumocystis prophylaxis in this setting. Further investigations should focus on targeted anti-Pneumocystis prophylaxis for patients presenting with high-risk baseline characteristics or when receiving rituximab-inclusive intensive combination chemotherapy regimens as treatment for other aggressive lymphoma subtypes. Am. J. Hematol. 91:1113-1117, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jason N. Barreto
- Department of Pharmacy Services; Mayo Clinic; Rochester Minnesota
| | - Lauren L. Ice
- Department of Pharmacy; Spectrum Health; Grand Rapids Michigan
| | - Carrie A. Thompson
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota
| | - Pritish K. Tosh
- Division of Infectious Diseases; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota
| | - Douglas R. Osmon
- Division of Infectious Diseases; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota
| | - Ross A. Dierkhising
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Rochester Minnesota
| | - Matthew F. Plevak
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Rochester Minnesota
| | - Andrew H. Limper
- Division of Pulmonary and Critical Care Medicine; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota
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90
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Intermittent Courses of Corticosteroids Also Present a Risk for Pneumocystis Pneumonia in Non-HIV Patients. Can Respir J 2016; 2016:2464791. [PMID: 27721666 PMCID: PMC5046011 DOI: 10.1155/2016/2464791] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 08/18/2016] [Indexed: 01/03/2023] Open
Abstract
Introduction. Pneumocystis pneumonia (PCP) is rising in the non-HIV population and associates with higher morbidity and mortality. The aggressive immunosuppressive regimens, as well as the lack of stablished guidelines for chemoprophylaxis, are likely contributors to this increased incidence. Herein, we have explored the underlying conditions, immunosuppressive therapies, and clinical outcomes of PCP in HIV-negative patients. Methods. Retrospective analysis of PCP in HIV-negative patients at Mayo Clinic from 2006–2010. The underlying condition, immunosuppressive therapies, coinfection, and clinical course were determined. PCP diagnosis required symptoms of pneumonia and identification of the organisms by visualization or by a real-time polymerase chain reaction. Results. A total of 128 cases of PCP were identified during the study period. Hematological malignancies were the predisposing condition for 50% of the patients. While 87% had received corticosteroids or other immunosuppressive therapies for >4 weeks prior to the diagnosis, only 7 were receiving PCP prophylaxis. Up to 43% of patients were not on daily steroids. Sixty-seven patients needed Intensive Care Unit (ICU) and 53 received mechanical ventilation. The mortality for those patients requiring ICU was 40%. Conclusions. PCP diagnosis in the HIV-negative population requires a high level of suspicion even if patients are not receiving daily corticosteroids. Mortality remains high despite adequate treatment.
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91
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Atypical Pneumocystis jirovecii pneumonia in previously untreated patients with CLL on single-agent ibrutinib. Blood 2016; 128:1940-1943. [PMID: 27503501 DOI: 10.1182/blood-2016-06-722991] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 07/29/2016] [Indexed: 12/18/2022] Open
Abstract
Ibrutinib is not known to confer risk for Pneumocystis jirovecii pneumonia (PCP). We observed 5 cases of PCP in 96 patients receiving single-agent ibrutinib, including 4 previously untreated. Clinical presentations included asymptomatic pulmonary infiltrates, chronic cough, and shortness of breath. The diagnosis was often delayed. Median time from starting ibrutinib to occurrence of PCP was 6 months (range, 2-24). The estimated incidence of PCP was 2.05 cases per 100 patient-years (95% confidence interval, 0.67-4.79). At the time of PCP, all patients had CD4 T-cell count >500/μL (median, 966/μL) and immunoglobulin G (IgG) >500 mg/dL (median, 727 mg/dL). All patients underwent bronchoalveolar lavage. P jirovecii was identified by polymerase chain reaction in all 5 cases; direct fluorescence antibody staining was positive in 1. All events were grade ≤2 and resolved with oral therapy. Secondary prophylaxis was not given to 3 patients; after 61 patient-months of follow up, no recurrence occurred. Lack of correlation with CD4 count and IgG level suggests that susceptibility to PCP may be linked to Bruton tyrosine kinase (BTK) inhibition. If confirmed, this association could result in significant changes in surveillance and/or prophylaxis, possibly extending to other BTK inhibitors. This trial was registered at www.clinicaltrials.gov as #NCT01500733 and #NCT02514083.
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92
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Abstract
Rituximab is a monoclonal antibody that depletes B cells from the circulation. It was originally used to treat lymphoma but is increasingly used for the treatment of autoimmune diseases. Rituximab was found to be effective in randomised controlled trials for rheumatoid arthritis, granulomatosis with polyangiitis and other antineutrophil cytoplasmic antibody-associated vasculitides. However, evidence of efficacy is very limited for many other autoimmune conditions. Before starting rituximab, it is important to check the patient's baseline immunoglobulins and immunisation status. Patients should also be screened for latent infections and other contraindications.
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93
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Davies HD. Infectious Complications With the Use of Biologic Response Modifiers in Infants and Children. Pediatrics 2016; 138:peds.2016-1209. [PMID: 27432853 DOI: 10.1542/peds.2016-1209] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Biologic response modifiers (BRMs) are substances that interact with and modify the host immune system. BRMs that dampen the immune system are used to treat conditions such as juvenile idiopathic arthritis, psoriatic arthritis, or inflammatory bowel disease and often in combination with other immunosuppressive agents, such as methotrexate and corticosteroids. Cytokines that are targeted include tumor necrosis factor α; interleukins (ILs) 6, 12, and 23; and the receptors for IL-1α (IL-1A) and IL-1β (IL-1B) as well as other molecules. Although the risk varies with the class of BRM, patients receiving immune-dampening BRMs generally are at increased risk of infection or reactivation with mycobacterial infections (Mycobacterium tuberculosis and nontuberculous mycobacteria), some viral (herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, hepatitis B) and fungal (histoplasmosis, coccidioidomycosis) infections, as well as other opportunistic infections. The use of BRMs warrants careful determination of infectious risk on the basis of history (including exposure, residence, and travel and immunization history) and selected baseline screening test results. Routine immunizations should be given at least 2 weeks (inactivated or subunit vaccines) or 4 weeks (live vaccines) before initiation of BRMs whenever feasible, and inactivated influenza vaccine should be given annually. Inactivated and subunit vaccines should be given when needed while taking BRMs, but live vaccines should be avoided unless under special circumstances in consultation with an infectious diseases specialist. If the patient develops a febrile or serious respiratory illness during BRM therapy, consideration should be given to stopping the BRM while actively searching for and treating possible infectious causes.
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94
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Pneumocystis Jirovecii Pneumonia in a Patient with Anti-N-Methyl-D-Aspartate Receptor Postherpetic Encephalitis. Pediatr Infect Dis J 2016; 35:816-7. [PMID: 27093160 DOI: 10.1097/inf.0000000000001165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Anti-N-methyl-D-aspartate receptor encephalitis is a neuroimmunologic disorder that has been increasingly diagnosed during the past 5 years. It provokes a predictable syndrome treated with several immunomodulatory agents, such as corticosteroids and/or biologics. We managed a child with this disease who developed Pneumocystis jirovecii pneumonia as a direct infectious complication of the use of rituximab.
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95
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Cordonnier C, Cesaro S, Maschmeyer G, Einsele H, Donnelly JP, Alanio A, Hauser PM, Lagrou K, Melchers WJG, Helweg-Larsen J, Matos O, Bretagne S, Maertens J. Pneumocystis jirovecii pneumonia: still a concern in patients with haematological malignancies and stem cell transplant recipients. J Antimicrob Chemother 2016; 71:2379-85. [DOI: 10.1093/jac/dkw155] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The risk of patients with ALL and recipients of an allogeneic HSCT developing Pneumocystis jirovecii pneumonia is sufficiently high to warrant guidelines for the laboratory diagnosis, prevention and treatment of the disease. In this issue, the European Conference on Infections in Leukemia (ECIL) presents its recommendations in three companion papers.
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Affiliation(s)
- Catherine Cordonnier
- Department of Haematology, Henri Mondor Teaching Hospital, Assistance Publique-hôpitaux de Paris, and Université Paris-Est-Créteil, Créteil, France
| | - Simone Cesaro
- Department of Haematology, Oncoematologia Pediatrica, Policlinico G. B. Rossi, Verona, Italy
| | - Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Ernst-von-Bergmann Klinikum, Potsdam, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, Julius Maximilians University, Würzburg, Germany
| | - J. Peter Donnelly
- Department of Haematology Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexandre Alanio
- Parasitology-Mycology Laboratory, Groupe Hospitalier Lariboisière Saint-Louis Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Diderot, Sorbonne Paris Cité, and Institut Pasteur, Unité de Mycologie Moléculaire, CNRS URA3012, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | - Philippe M. Hauser
- Institute of Microbiology, Lausanne University Hospital and University, Lausanne, Switzerland
| | - Katrien Lagrou
- Department of Microbiology and Immunology, KU Leuven – University of Leuven, Leuven, Belgium and National Reference Center for Mycosis, Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Willem J. G. Melchers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jannik Helweg-Larsen
- Department of Infectious Diseases, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
| | - Olga Matos
- Medical Parasitology Unit, Group of Opportunistic Protozoa/HIV and Other Protozoa, Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Stéphane Bretagne
- Parasitology-Mycology Laboratory, Groupe Hospitalier Lariboisière Saint-Louis Fernand Widal, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Diderot, Sorbonne Paris Cité, and Institut Pasteur, Unité de Mycologie Moléculaire, CNRS URA3012, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France
| | - Johan Maertens
- Department of Haematology, Acute Leukaemia and Stem Cell Transplantation Unit, University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium
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96
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Pneumocystose chez les patients immunodéprimés non infectés par le VIH. Rev Med Interne 2016; 37:327-36. [DOI: 10.1016/j.revmed.2015.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 10/02/2015] [Indexed: 12/15/2022]
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97
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Gonzalez Santiago TM, Wetter DA, Kalaaji AN, Limper AH, Lehman JS. Pneumocystis jiroveci pneumonia in patients treated with systemic immunosuppressive agents for dermatologic conditions: a systematic review with recommendations for prophylaxis. Int J Dermatol 2016; 55:823-30. [PMID: 27009930 DOI: 10.1111/ijd.13231] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 10/29/2015] [Accepted: 11/04/2015] [Indexed: 11/29/2022]
Abstract
Pneumocystis jiroveci pneumonia is an opportunistic infection associated with substantial rates of mortality in immunosuppressed patients. Prophylaxis recommendations are mostly targeted toward patients with non-dermatologic diagnoses. This study was conducted to determine when dermatology patients treated with immunosuppressive medications should be offered P. jiroveci pneumonia prophylaxis. We searched the literature from January 1, 1993, to December 31, 2013, using terms relating to P. jiroveci pneumonia and dermatologic diagnoses to analyze the clinical characteristics of previously affected patients. Guidelines for P. jiroveci pneumonia prophylaxis from other medical fields were also analyzed. Of 17 dermatology patients reported to have contracted P. jiroveci pneumonia, eight (47.1%) died of the pneumonia. Risk factors included lack of prophylaxis, systemic corticosteroid therapy, lymphopenia, hypoalbuminemia, low serum CD4 counts, comorbid pulmonary or renal disease, malignancy, and prior organ transplantation. The present conclusions are limited by heterogeneity among the selected studies and limitations in their identification and selection. However, P. jiroveci pneumonia in dermatology patients is associated with a high mortality rate. Based on our analysis, we propose that prophylaxis be considered in dermatology patients in whom treatment with systemic corticosteroids at doses exceeding 20 mg/day or treatment with corticosteroid-sparing immunosuppressive agents is anticipated for at least 4 weeks, and in patients with additional risk factors for P. jiroveci pneumonia.
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Affiliation(s)
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Amer N Kalaaji
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Lee J, Lee JG, Kim S, Song SH, Kim BS, Kim HO, Kim MS, Kim SI, Kim YS, Huh KH. The effect of rituximab dose on infectious complications in ABO-incompatible kidney transplantation. Nephrol Dial Transplant 2016; 31:1013-21. [DOI: 10.1093/ndt/gfw017] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 01/19/2016] [Indexed: 02/06/2023] Open
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99
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Joven MH, Anderson RJ. Pneumocystis jirovecii Pneumonia Associated with Systemic Glucocorticoids in the Treatment of Type 2 Amiodarone-Induced Thyrotoxicosis. AACE Clin Case Rep 2016. [DOI: 10.4158/ep15613.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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100
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Cost-effectiveness of Prophylaxis Against Pneumocystis jiroveci Pneumonia in Patients with Crohn's Disease. Dig Dis Sci 2015; 60:3743-55. [PMID: 26177704 DOI: 10.1007/s10620-015-3796-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 06/30/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Emerging evidence suggests that Pneumocystis jiroveci pneumonia is occurring more frequently in Crohn's disease patients on immunosuppressive medications, especially corticosteroids. Considering its excess mortality and the efficacy of chemoprophylaxis in reducing P. jiroveci pneumonia in acquired immunodeficiency syndrome, there is debate without consensus on the need for chemoprophylaxis in Crohn's disease patients on corticosteroids. AIMS We sought to address this debate using insights from simulation modeling. METHODS We used a Markov microsimulation model to simulate the natural history of Crohn's disease in 1 million virtual patients receiving appropriate care and who faced P. jiroveci pneumonia risks that varied with corticosteroid use. We examined several chemoprophylaxis strategies and compared their population-level economic and clinical impact using various indices including costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios. We also performed several nested probabilistic sensitivity analyses to estimate the health and economic impact of chemoprophylaxis in patients on triple immunosuppressive therapy. RESULTS At the current PJP incidence, no PJP chemoprophylaxis was the preferred strategy from a population perspective. Considered chemoprophylactic strategies led to higher average costs and fewer P. jiroveci pneumonia cases. However, they also led to lower average quality-adjusted life expectancy and were thus dominated. Nevertheless, these alternative strategies became preferred with progressively higher risks of P. jiroveci pneumonia. Our results also suggest that PJP chemoprophylaxis may be cost-effective in patients on triple immunosuppressive therapy. CONCLUSION Our findings support a case-by-case consideration of P. jiroveci pneumonia chemoprophylaxis in Crohn's disease patients receiving corticosteroids.
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