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Abstract
Advances in understanding the ways in which the immune system fails to control tumor growth or prevent autoimmunity have led to the development of powerful therapeutic strategies to treat these diseases. In contrast to conventional therapies that have a broadly suppressive effect, immunotherapies are more akin to targeted therapies because they are mechanistically driven and are typically developed with the goal of "drugging" a specific underlying pathway or phenotype. This means that their effects and toxicities are, at least in theory, more straightforward to anticipate. The development of functionalized antibodies, genetically engineered T cells, and immune checkpoint inhibitors continues to accelerate, illuminating new biology and bringing new treatment to patients. In the following sections, we provide an overview of immunotherapeutic concepts, highlight recent advances in the field of immunotherapies, and discuss controversies and future directions, particularly as these pertain to hematologic oncology or blood-related diseases. We conclude by illustrating how original research published in this journal fits into and contributes to the overall framework of advances in immunotherapy.
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202
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Wilson-Morkeh H, Frise C, Youngstein T. Haemophagocytic lymphohistiocytosis in pregnancy. Obstet Med 2021; 15:79-90. [DOI: 10.1177/1753495x211011913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 12/17/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis is a life-threatening systemic inflammatory syndrome defined by persistent fever, cytopenia and multi-organ dysfunction. Primary haemophagocytic lymphohistiocytosis classically presents in childhood as a result of genetically abnormal perforin or inflammasome function, leading to the aberrant release of pro-inflammatory cytokines causing a hyperinflammatory state. Secondary haemophagocytic lymphohistiocytosis is an acquired phenomenon occurring at any age as a result of immune dysregulation to a specific trigger such as infection, haematological malignancy or autoimmune disease. Secondary haemophagocytic lymphohistiocytosis occurring in the pregnant woman represents a diagnostic challenge and carries a significant mortality. This has led to its first inclusion in the fourth Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the United Kingdom annual maternal report in 2017. This article presents an overview of haemophagocytic lymphohistiocytosis, reviews the literature on haemophagocytic lymphohistiocytosis in pregnancy, suggests diagnostic pathways and explores the safety and efficacy of existing and potential treatment strategies for haemophagocytic lymphohistiocytosis occurring during pregnancy.
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Affiliation(s)
- Harold Wilson-Morkeh
- Department of Rheumatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Charlotte Frise
- Fetal-Maternal Medicine Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- De Swiet’s Obstetric Medicine Centre, Imperial College Healthcare NHS Trust, Queen Charlotte’s and Chelsea Hospital, London, UK
| | - Taryn Youngstein
- Department of Rheumatology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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203
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Hellman T, Uusalo P, Järvisalo MJ. Renal Replacement Techniques in Septic Shock. Int J Mol Sci 2021; 22:10238. [PMID: 34638575 PMCID: PMC8508758 DOI: 10.3390/ijms221910238] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022] Open
Abstract
Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to an infection; it carries a risk for mortality, considerably exceeding that of a mere infection. Sepsis is the leading cause for acute kidney injury (AKI) and the requirement for renal replacement therapy (RRT) in intensive care unit (ICU) patients. Almost every second critically ill patient with sepsis will develop AKI. In septic shock, the dysregulated host response to infectious pathogens leads to a cytokine storm with uncontrolled production and release of humoral proinflammatory mediators that evoke cellular toxicity and promote the development of organ dysfunction and increased mortality. In addition to treating AKI, RRT techniques can be employed for extracorporeal adsorption of inflammatory mediators using specifically developed adsorption membranes, hemoperfusion sorbent cartridges or columns; these techniques are intended to decrease the level and early deleterious effects of circulating proinflammatory cytokines and endotoxins during the first hours and days of septic shock treatment, in order to improve patient outcomes. Several methods and devices, such as high cut-off membranes, the Oxiris®-AN69 membrane, CytoSorb® and HA380 cytokine hemoadsorption, polymyxin B endotoxin adsorption, and plasmapheresis have been examined in small study series or are under evaluation as ways of improving patient outcomes in septic shock. However, to date, the data on actual outcome benefits have remained controversial, as discussed in this review.
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Affiliation(s)
- Tapio Hellman
- Kidney Center, Turku University Hospital and University of Turku, Building 4, AA7, Kiinanmyllynkatu 4-8, FIN-20521 Turku, Finland;
| | - Panu Uusalo
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Building 18, TG3B, Hämeentie 11, FIN-20521 Turku, Finland;
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Building 18, TG3B, Hämeentie 11, FIN-20521 Turku, Finland
| | - Mikko J. Järvisalo
- Kidney Center, Turku University Hospital and University of Turku, Building 4, AA7, Kiinanmyllynkatu 4-8, FIN-20521 Turku, Finland;
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Building 18, TG3B, Hämeentie 11, FIN-20521 Turku, Finland;
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Building 18, TG3B, Hämeentie 11, FIN-20521 Turku, Finland
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204
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Cleves D, Lotero V, Medina D, Perez PM, Patiño JA, Torres-Canchala L, Olaya M. Pediatric hemophagocytic lymphohistiocytosis: A rarely diagnosed entity in a developing country. BMC Pediatr 2021; 21:411. [PMID: 34537050 PMCID: PMC8449481 DOI: 10.1186/s12887-021-02879-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 09/06/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is an exaggerated inflammatory reaction secondary to a host's inadequate immune response causing a self-perpetuating loop of altered regulation. Signs and symptoms of HLH are compatible with other common diseases and are nonspecific. Underdiagnosis makes it difficult to estimate the real incidence of HLH, especially in developing countries. METHODS Retrospective, descriptive study of pediatric patients admitted to a high-complexity institution in Cali, Colombia between 2012 and 2019 with HLH diagnosis. Medical history review to complete an electronic database and a secondary, descriptive analysis was carried out. The study was approved by the Institutional Ethics Committee. RESULTS Twenty-one patients were included. 52.4 % of the population was male with a median age of 9.3 years [IQR (3.0-13.7 years)]. More than half of patients (66.6 %) had viral disease at diagnosis, the most frequent being Epstein-Barr Virus (EBV) (52.3 %) and dengue (14.3 %). Three patients had confirmed gene mutations (G6PC3, XIAP, and UNC13D). 95 % of the patients were treated with the HLH 2004 protocol, half of them received incomplete protocol with intravenous immunoglobulin (IVIG) and/or systemic steroids, while the other half received the complete protocol including etoposide and cyclosporine. More than three-fourths (76.2 %) required admission to an ICU with a median stay of 14 days [IQR (11-37 days)] and a median hospital stay of 30 days [IQR (18-93 days)]. 14.3 % (n = 3) of patients died. CONCLUSIONS HLH is a complex disease that requires multidisciplinary management with secondary HLH due to EBV infection being a common cause. There is increasing awareness of HLH diagnosis in developing countries such as Colombia which can offer earlier treatment options and better outcomes.
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Affiliation(s)
- Daniela Cleves
- Pediatrics Department, Fundación Valle de Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Viviana Lotero
- Pediatrics Department, Fundación Valle de Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Pediatric Hematooncology Service, Fundación Valle de Lili, Cali, Colombia
| | - Diego Medina
- Pediatrics Department, Fundación Valle de Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Primary Immunodeficiency (IDP) Group, Fundación Valle de Lili, Cali, Colombia
- Bone Marrow Trasplant Service, Fundación Valle de Lili, Cali, Colombia
| | - Paola M Perez
- Pediatrics Department, Fundación Valle de Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Primary Immunodeficiency (IDP) Group, Fundación Valle de Lili, Cali, Colombia
- Pediatric Infectious Diseases Service, Fundación Valle de Lili, Cali, Colombia
| | - Jaime A Patiño
- Pediatrics Department, Fundación Valle de Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Primary Immunodeficiency (IDP) Group, Fundación Valle de Lili, Cali, Colombia
- Pediatric Infectious Diseases Service, Fundación Valle de Lili, Cali, Colombia
| | | | - Manuela Olaya
- Pediatrics Department, Fundación Valle de Lili, Cali, Colombia.
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia.
- Primary Immunodeficiency (IDP) Group, Fundación Valle de Lili, Cali, Colombia.
- Pediatric Allergy-Immunology Service, Fundación Valle de Lili, Cali, Colombia.
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205
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Ku C, Chen I, Lai M. Infection-induced inflammation from specific inborn errors of immunity to COVID-19. FEBS J 2021; 288:5021-5041. [PMID: 33971084 PMCID: PMC8236961 DOI: 10.1111/febs.15961] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/10/2021] [Accepted: 05/07/2021] [Indexed: 01/07/2023]
Abstract
Inborn errors of immunity (IEIs) are a group of genetically defined disorders leading to defective immunity. Some IEIs have been linked to mutations of immune receptors or signaling molecules, resulting in defective signaling of respective cascades essential for combating specific pathogens. However, it remains incompletely understood why in selected IEIs, such as X-linked lymphoproliferative syndrome type 2 (XLP-2), hypo-immune response to specific pathogens results in persistent inflammation. Moreover, mechanisms underlying the generation of anticytokine autoantibodies are mostly unknown. Recently, IEIs have been associated with coronavirus disease 2019 (COVID-19), with a small proportion of patients that contract severe COVID-19 displaying loss-of-function mutations in genes associated with type I interferons (IFNs). Moreover, approximately 10% of patients with severe COVID-19 possess anti-type I IFN-neutralizing autoantibodies. Apart from IEIs that impair immune responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), SARS-CoV-2 encodes several proteins that suppress early type I IFN production. One primary consequence of the lack of type I IFNs during early SARS-CoV-2 infection is the increased inflammation associated with COVID-19. In XLP-2, resolution of inflammation rescued experimental subjects from infection-induced mortality. Recent studies also indicate that targeting inflammation could alleviate COVID-19. In this review, we discuss infection-induced inflammation in IEIs, using XLP-2 and COVID-19 as examples. We suggest that resolving inflammation may represent an effective therapeutic approach to these diseases.
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Affiliation(s)
- Cheng‐Lung Ku
- Laboratory of Human Immunology and Infectious DiseasesGraduate Institute of Clinical Medical SciencesChang Gung UniversityTaoyuanTaiwan,Department of NephrologyLinkou Chang Gung Memorial HospitalTaoyuanTaiwan
| | - I‐Ting Chen
- Institute of Molecular BiologyAcademia SinicaTaipeiTaiwan
| | - Ming‐Zong Lai
- Institute of Molecular BiologyAcademia SinicaTaipeiTaiwan
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206
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Verweyen EL, Schulert GS. Interfering with interferons: targeting the JAK-STAT pathway in complications of systemic juvenile idiopathic arthritis (SJIA). Rheumatology (Oxford) 2021; 61:926-935. [PMID: 34459891 PMCID: PMC9123899 DOI: 10.1093/rheumatology/keab673] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/27/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023] Open
Abstract
Systemic JIA (SJIA) is distinguished from other forms of JIA by the prevalence of the severe, life-threatening complications macrophage activation syndrome (SJIA-MAS) and lung disease (SJIA-LD). Alternative therapeutics are urgently needed, as disease pathogenesis diverges from what is observed in SJIA, and currently available biologics are insufficient. SJIA-MAS, defined by a cytokine storm and dysregulated proliferation of T-lymphocytes, and SJIA-LD which presents with lymphocytic interstitial inflammation and pulmonary alveolar proteinosis, are both thought to be driven by IFNs, in particular the type II IFN-γ. Involvement of IFNs and a possible crosstalk of type I IFNs with existing biologics indicate a distinct role for the JAK-STAT signalling pathway in the pathogenesis of SJIA-MAS and SJIA-LD. Here, we review this role of JAK-STATs and IFNs in SJIA complications and discuss how new insights of ongoing research are shaping future therapeutic advances in the form of JAK inhibitors and antibodies targeting IFNs.
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Affiliation(s)
- Emely L Verweyen
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center
| | - Grant S Schulert
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA,Correspondence to: Grant Schulert, Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH 45208, USA.
E-mail:
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207
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Bishton MJ, Stilwell P, Card TR, Lanyon P, Ban L, Elliss-Brookes L, Manson J, Nanduri V, Earp K, Flower L, Amarnani R, Rankin J, Sen ES, Tattersall RS, Crooks CJ, Aston J, Siskova V, West J, Bythell M. A validation study of the identification of haemophagocytic lymphohistiocytosis in England using population-based health data. Br J Haematol 2021; 194:1039-1044. [PMID: 34386978 DOI: 10.1111/bjh.17768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/28/2021] [Indexed: 11/29/2022]
Abstract
We assessed the validity of coded healthcare data to identify cases of haemophagocytic lymphohistiocytosis (HLH). Hospital Episode Statistics (HES) identified 127 cases within five hospital Trusts 2013-2018 using ICD-10 codes D76.1, D76.2 and D76.3. Hospital records were reviewed to validate diagnoses. Out of 74 patients, 73 were coded D76.1 or D76.2 (positive predictive value 89·0% [95% Confidence Interval {CI} 80·2-94·9%]) with confirmed/probable HLH. For cases considered not HLH, 44/53 were coded D76.3 (negative predictive value 97·8% [95% CI 88·2-99·9%]). D76.1 or D76.2 had 68% sensitivity in detecting HLH compared to an established active case-finding HLH register in Sheffield. Office for National Statistics (ONS) mortality data (2003-2018) identified 698 patients coded D76.1, D76.2 and D76.3 on death certificates. Five hundred and forty-one were coded D76.1 or D76.2 of whom 524 (96·9%) had HLH in the free-text cause of death. Of 157 coded D76.3, 66 (42·0%) had HLH in free text. D76.1 and D76.2 codes reliably identify HLH cases, and provide a lower bound on incidence. Non-concordance between D76.3 and HLH excludes D76.3 as an ascertainment source from HES. Our results suggest electronic healthcare data in England can enable population-wide registration and analysis of HLH for future research.
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Affiliation(s)
- Mark J Bishton
- Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | | | - Tim R Card
- Population and Lifespan Sciences, University of Nottingham, Nottingham, UK.,NIHR Biomedical Research Centre, Nottingham, UK
| | - Peter Lanyon
- Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Lu Ban
- Evidera by PPD, London, UK
| | | | | | | | - Kate Earp
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Judith Rankin
- Public Health England, London, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ethan S Sen
- Great North Children's Hospital, Newcastle upon Tyne, UK.,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | | | - Colin J Crooks
- Public Health England, London, UK.,NIHR Biomedical Research Centre, Nottingham, UK.,Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | | | | | - Joe West
- Public Health England, London, UK.,Population and Lifespan Sciences, University of Nottingham, Nottingham, UK.,NIHR Biomedical Research Centre, Nottingham, UK
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208
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Müskens KF, Lindemans CA, Belderbos ME. Hematopoietic Dysfunction during Graft-Versus-Host Disease: A Self-Destructive Process? Cells 2021; 10:cells10082051. [PMID: 34440819 PMCID: PMC8392486 DOI: 10.3390/cells10082051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022] Open
Abstract
Graft-versus-host disease (GvHD) is a major complication of allogeneic hematopoietic (stem) cell transplantation (HCT). Clinically, GvHD is associated with severe and long-lasting hematopoietic dysfunction, which may contribute to the high mortality of GvHD after HCT. During GvHD, excessive immune activation damages both hematopoietic stem and progenitor cells and their surrounding bone marrow niche, leading to a reduction in cell number and functionality of both compartments. Hematopoietic dysfunction can be further aggravated by the occurrence—and treatment—of HCT-associated complications. These include immune suppressive therapy, coinciding infections and their treatment, and changes in the microbiome. In this review, we provide a structured overview of GvHD-mediated hematopoietic dysfunction, including the targets in the bone marrow, the mechanisms of action and the effect of GvHD-related complications and their treatment. This information may aid in the identification of treatment options to improve hematopoietic function in patients, during and after GvHD.
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Affiliation(s)
- Konradin F. Müskens
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (K.F.M.); (C.A.L.)
| | - Caroline A. Lindemans
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (K.F.M.); (C.A.L.)
- Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3584 EA Utrecht, The Netherlands
| | - Mirjam E. Belderbos
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (K.F.M.); (C.A.L.)
- Correspondence:
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209
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Abstract
Influenza viruses are one of the leading causes of respiratory tract infections in humans and their newly emerging and re-emerging virus strains are responsible for seasonal epidemics and occasional pandemics, leading to a serious threat to global public health systems. The poor clinical outcome and pathogenesis during influenza virus infection in humans and animal models are often associated with elevated proinflammatory cytokines and chemokines production, which is also known as hypercytokinemia or "cytokine storm", that precedes acute respiratory distress syndrome (ARDS) and often leads to death. Although we still do not fully understand the complex nature of cytokine storms, the use of immunomodulatory drugs is a promising approach for treating hypercytokinemia induced by an acute viral infection, including highly pathogenic avian influenza virus infection and Coronavirus Disease 2019 (COVID-19). This review aims to discuss the immune responses and cytokine storm pathology induced by influenza virus infection and also summarize alternative experimental strategies for treating hypercytokinemia caused by influenza virus.
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Affiliation(s)
- Fanhua Wei
- Key Laboratory of Ministry of Education for Conservation and Utilization of Special Biological Resources in Western China, Ningxia University, Yinchuan, China.,College of Agriculture, Ningxia University, Yinchuan, China
| | - Chengjiang Gao
- Key Laboratory of Infection and Immunity of Shandong Province & Department of Immunology, School of Biomedical Sciences, Shandong University, Jinan, China
| | - Yujiong Wang
- Key Laboratory of Ministry of Education for Conservation and Utilization of Special Biological Resources in Western China, Ningxia University, Yinchuan, China.,College of Life Science, Ningxia University, Yinchuan, China
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210
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Bottari G, Murciano M, Merli P, Bracaglia C, Guzzo I, Stoppa F, Pardeo M, Nunziata J, Del Bufalo F, Genuini L, De Benedetti F, Locatelli F, Cecchetti C. Hemoperfusion with CytoSorb to Manage Multiorgan Dysfunction in the Spectrum of Hemophagocytic Lymphohistiocytosis Syndrome in Critically Ill Children. Blood Purif 2021; 51:417-424. [PMID: 34344006 DOI: 10.1159/000517471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/27/2021] [Indexed: 11/19/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by a state of hyperinflammation. Blood purification techniques can blunt the inflammatory process with a rapidly relevant nonselective effect on the cytokine storm, thus potentially translating into survival benefit for these patients. In this cohort, we evaluated the impact of hemoadsorption with CytoSorb combined with continuous kidney replacement therapy used as adjunctive therapy in 6 critically ill children with multiple organ dysfunction due to HLH. In our series, we found a reduction in inflammatory biomarkers in patients with HLH secondary to infection. Ferritin, one of the most important bedside biomarkers of HLH, showed a reduction in most of the treated patients. The same results were found measuring interleukin-6 and interleukin-10. The same patients showed hemodynamic stabilization measured by the Vasopressor-Inotropic-Score, and reduction in the organ disease score measured with the Pediatric Logistic Organ Dysfunction score. In our cohort, mortality was less than expected based on the Pediatric Index of Mortality 3 score at pediatric intensive care unit admission. Our study shows that hemoperfusion could be a valuable therapeutic option in HLH: stronger scientific evidence is needed to confirm our preliminary experience.
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Affiliation(s)
- Gabriella Bottari
- Division of Rheumatology, Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Manuel Murciano
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Merli
- Department of Pediatric Hematology and Oncology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Claudia Bracaglia
- Division of Rheumatology, Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Stoppa
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Manuela Pardeo
- Division of Rheumatology, Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Joseph Nunziata
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Del Bufalo
- Department of Pediatric Hematology and Oncology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Leonardo Genuini
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabrizio De Benedetti
- Division of Rheumatology, Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Corrado Cecchetti
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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211
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De Matteis A, Bracaglia C, Pires Marafon D, Piscitelli AL, Alessio M, Naddei R, Orlando F, Filocamo G, Minoia F, Ravelli A, Tibaldi J, Cimaz R, Marino A, Simonini G, Mastrolia MV, La Torre F, Tricarico I, Licciardi F, Montin D, Maggio MC, Alizzi C, Martini G, Civino A, Gallizzi R, Olivieri AN, Ardenti Morini F, Conti G, De Benedetti F, Pardeo M. CANAKINUMAB IN SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS: REAL-LIFE DATA FROM A RETROSPECTIVE ITALIAN COHORT. Rheumatology (Oxford) 2021; 61:1621-1629. [PMID: 34343275 DOI: 10.1093/rheumatology/keab619] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/16/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To evaluate in real-life the effectiveness and safety of canakinumab in Italian patients with systemic juvenile idiopathic arthritis (sJIA). METHODS A retrospective multicentre study of children with sJIA was performed. Clinical features, laboratory parameters and adverse events were collected at baseline, after 6 and 12 months from starting canakinumab. The effectiveness primary outcome was clinical inactive disease (CID) off glucocorticoids (GCs) treatment at 6 months. RESULTS A total of 80 children were analyzed from 15 Italian centers. Of the 12 patients who started canakinumab in CID while receiving anakinra, all maintained CID. Of the 68 with active disease at baseline, 57.4% achieved CID off GCs at 6 months and 63.8% at 12 months. In univariate analysis, the variables significantly related with non-response were number of active joints (NAJ) ≥5, history of macrophage activation syndrome (MAS) and disease duration. Multivariate analysis confirmed the association with non-response of NAJ ≥5 (OR 6.37 (95%CI 1.69-24.02), p= 0.006) and history of MAS (OR 3.53 (95%CI 1.06-11.70), p= 0.039). No serious adverse events were recorded in this series. There were two cases of MAS during canakinumab, leading to a rate of 2.9 episodes per 100 patient year. CONCLUSION We confirm, in real-life, the efficacy of canakinumab in sJIA in a multicentric cohort. History of MAS and higher NAJ were associated with lower probability of achieving clinical inactive disease.
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Affiliation(s)
- Arianna De Matteis
- Division of Rheumatology, ERN RITA Center, IRCCS Ospedale Pediatrico Bambino Gesù, Roma
| | - Claudia Bracaglia
- Division of Rheumatology, ERN RITA Center, IRCCS Ospedale Pediatrico Bambino Gesù, Roma
| | - Denise Pires Marafon
- Division of Rheumatology, ERN RITA Center, IRCCS Ospedale Pediatrico Bambino Gesù, Roma
| | - Anna Lucia Piscitelli
- Division of Rheumatology, ERN RITA Center, IRCCS Ospedale Pediatrico Bambino Gesù, Roma
| | - Maria Alessio
- Department of Translational Medical Sciences, Pediatrics Section, University of Naples Federico II
| | - Roberta Naddei
- Department of Translational Medical Sciences, Pediatrics Section, University of Naples Federico II
| | - Francesca Orlando
- Unit of Pediatrics 2, Santobono-Pausilipon Children's Hospital, Napoli
| | - Giovanni Filocamo
- Pediatric Rheumatology, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milano
| | - Francesca Minoia
- Pediatric Rheumatology, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milano
| | - Angelo Ravelli
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genova
| | - Jessica Tibaldi
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genova
| | | | | | - Gabriele Simonini
- Pediatric Rheumatology Unit, Meyer Children's University Hospital, Firenze
| | | | - Francesco La Torre
- Pediatric Rheumatology Center, Department of Pediatrics, Ospedale 'Giovanni XXIII', AOU Consorziale Policlinico, Bari
| | - Ilaria Tricarico
- Pediatric Rheumatology Center, Department of Pediatrics, Ospedale 'Giovanni XXIII', AOU Consorziale Policlinico, Bari
| | - Francesco Licciardi
- Department of Pediatrics and Infectious Diseases, School of Medicine, University of Turin, Regina Margherita Children's Hospital, Torino
| | - Davide Montin
- Department of Pediatrics and Infectious Diseases, School of Medicine, University of Turin, Regina Margherita Children's Hospital, Torino
| | | | - Clotilde Alizzi
- University Department Pro.Sa.M.I. 'G. D'Alessandro', University of Palermo, Palermo
| | - Giorgia Martini
- Department of Women's and Children's Health, University of Padua, Padova
| | - Adele Civino
- Department of Pediatrics, Division of Rheumatology and Immunology, Ospedale 'Vito Fazzi', Lecce
| | - Romina Gallizzi
- Unit of Pediatric Nephrology and Rheumatology, University of Messina, Messina
| | - Alma Nunzia Olivieri
- Department of General and Specialized Surgery for Women and Children, University 'Luigi Vanvitelli', Napoli
| | | | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit, AOU Policlinico 'G. Martino', Messina, Italy
| | - Fabrizio De Benedetti
- Division of Rheumatology, ERN RITA Center, IRCCS Ospedale Pediatrico Bambino Gesù, Roma
| | - Manuela Pardeo
- Division of Rheumatology, ERN RITA Center, IRCCS Ospedale Pediatrico Bambino Gesù, Roma
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Henderson LA. Deciphering the cytokine fingerprint of macrophage activation syndrome. THE LANCET. RHEUMATOLOGY 2021; 3:e535-e538. [PMID: 38287614 DOI: 10.1016/s2665-9913(21)00180-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/19/2021] [Indexed: 01/31/2024]
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213
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Singh JK, Terao MA, Sarangi S, Toth J, Toretsky JA. Afebrile S. aureus bacteremia in two patients with hemophagocytic lymphohistiocytosis receiving emapalumab/dexamethasone/etoposide. Pediatr Blood Cancer 2021; 68:e29001. [PMID: 33751768 DOI: 10.1002/pbc.29001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Jatinder K Singh
- Division of Pediatric Adolescent and Young Adult Hematology and Oncology, Department of Pediatrics, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Michael A Terao
- Division of Pediatric Adolescent and Young Adult Hematology and Oncology, Department of Pediatrics, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Susmita Sarangi
- Division of Pediatric Adolescent and Young Adult Hematology and Oncology, Department of Pediatrics, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Jennifer Toth
- Division of Pediatric Adolescent and Young Adult Hematology and Oncology, Department of Pediatrics, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Jeffrey A Toretsky
- Division of Pediatric Adolescent and Young Adult Hematology and Oncology, Department of Pediatrics, Medstar Georgetown University Hospital, Washington, District of Columbia, USA.,Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
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Abstract
Since SARS-CoV-2 first appeared in humans, the scientific community has tried to gather as much information as possible in order to find effective strategies for the containment and treatment this pandemic coronavirus. We reviewed the current published literature on SARS-CoV-2 with an emphasis on the distribution of SARS-CoV-2 in tissues and body fluids, as well as data on the expression of its input receptors on the cell surface. COVID-19 affects many organ systems in many ways. These varied manifestations are associated with viral tropism and immune responses of the infected person, but the exact mechanisms are not yet fully understood. We emphasize the broad organotropism of SARS-CoV-2, as many studies have identified viral components (RNA, proteins) in many organs, including immune cells, pharynx, trachea, lungs, blood, heart, blood vessels, intestines, brain, kidneys, and male reproductive organs. Viral components are present in various body fluids, such as mucus, saliva, urine, cerebrospinal fluid, semen and breast milk. The main SARS-CoV-2 receptor, ACE2, is expressed at different levels in many tissues throughout the human body, but its expression levels do not always correspond to the detection of SARS-CoV-2, indicating a complex interaction between the virus and humans. We also highlight the role of the renin-angiotensin aldosterone system and its inhibitors in the context of COVID-19. In addition, SARS-CoV-2 has various strategies that are widely used in various tissues to evade innate antiviral immunity. Targeting immune evasion mediators of the virus can block its replication in COVID-19 patients. Together, these data shed light on the current understanding of the pathogenesis of SARS-CoV-2 and lay the groundwork for better diagnosis and treatment of patients with COVID-19.
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215
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Xi Y, Bai Y. Diagnostic value of red blood cell distribution width, platelet distribution width, and red blood cell distribution width to platelet ratio in children with hemophagocytic lymphohistiocytosis. J Clin Lab Anal 2021; 35:e23909. [PMID: 34273201 PMCID: PMC8418495 DOI: 10.1002/jcla.23909] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/26/2021] [Accepted: 07/05/2021] [Indexed: 11/17/2022] Open
Abstract
Background To investigate whether red blood cell distribution width (RDW), platelet distribution width (PDW), and red blood cell distribution width to platelet ratio (RPR) can serve as biomarkers to distinguish hemophagocytic lymphohistiocytosis (HLH) from sepsis in children. Methods This is a retrospective study, involving 71 HLH patients, 105 sepsis patients, and 88 normal controls from January 2018 to December 2019. RDW, PDW, and RPR values were obtained from peripheral blood samples before standard treatment. The clinical differential diagnostic values of RDW, PDW, and RPR were analyzed by receiver operating characteristic (ROC) curve. In addition, peripheral blood samples after treatment from HLH patients were also collected for the same analyses. Results RDW, PDW, and RPR levels of the HLH patients were significantly higher than those of sepsis and normal controls (p < 0.001). In ROC curve analysis of the RDW, PDW, and RPR for diagnosis of HLH, the area under the curve (AUC) could reach to 0.7799 (95% CI = 0.7113–0.8486), 0.7835 (95% CI = 0.7093–0.8577), and 0.9268 (95% CI = 0.8886–0.9649), respectively. When using the criteria of RDW >13.75, PDW >13.30, and RPR >0.08, the sensitivity was 76.06%, 67.61%, and 84.51%, while the specificity was 68.57%, 85.71%, and 87.62%, respectively. After treatment of HLH patients, PDW and RPR were significantly reduced (p < 0.001). Conclusions This study shows that RDW, PDW, and RPR, which can be easily and cheaply detected, are novel indicators for differential diagnosis of HLH. PDW and RPR are useful indices for monitoring the effects of treatment on HLH.
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Affiliation(s)
- Ya Xi
- Department of Central Laboratory, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yongying Bai
- Department of Clinical Laboratory, Branch of National Clinical Research Center for Obstetrics and Gynecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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216
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JAK inhibition for murine HLH requires complete blockade of IFNg signaling and is limited by toxicity of JAK2 inhibition. Blood 2021; 138:1034-1039. [PMID: 34232994 DOI: 10.1182/blood.2020007930] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/28/2021] [Indexed: 11/20/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an inflammatory disorder in which numerous cytokines are elevated, though interferon gamma (IFN-g) is central to disease pathogenesis and a key therapeutic target. Experimental and early clinical reports have shown that ruxolitinib, a small molecule inhibitor of Janus kinases (JAKs) which are essential for cytokine signaling, may be therapeutic in HLH. In contrast, we found that intermittently administered ruxolitinib at various dose levels failed to prevent HLH development or treat established murine HLH. High doses of ruxolitinib blocked IFN-g signaling only transiently after administration, consistent with human pharmacokinetics, and only continuously administered drug could prevent HLH development or treat established HLH. Continuously administered ruxolitinib was therapeutic in only a narrow dose range and intermittently dosed ruxolitinib worsened survival and decreased bone marrow cellularity of animals concurrently treated with anti-IFN-g antibody, indicating a narrow therapeutic window and potential toxicity. As JAK2 is essential for hematopoietic cytokine signaling, we also tested a JAK1-selective inhibitor and observed therapeutic benefit without apparent toxicity, though it did not improve survival when combined with anti-IFN-g. We conclude that continuous blockade of IFN-g signaling is necessary for optimal control of HLH and that JAK2 inhibition may be toxic in this disorder.
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217
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The preparation of N-IgY targeting SARS-CoV-2 and its immunomodulation to IFN-γ production in vitro. Int Immunopharmacol 2021; 96:107797. [PMID: 34162159 PMCID: PMC8133490 DOI: 10.1016/j.intimp.2021.107797] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/14/2021] [Accepted: 05/15/2021] [Indexed: 02/07/2023]
Abstract
Specific antibodies against SARS-CoV-2 structural protein have a wide range of effects in the diagnose, prevention and treatment of the COVID-19 epidemic. Among them, egg yolk immunoglobulin Y (IgY), which has high safety, high yield, and without inducing antibody-dependent enhancement, is an important biological candidate. In this study, specific IgY against the conservative nucleocapsid protein (NP) of SARS-CoV-2 was obtained by immunizing hens. Through a series of optimized precipitation and ultrafiltration extraction schemes, its purity was increased to 98%. The hyperimmune IgY against NP (N-IgY) at a titer of 1:50,000 showed strong NP binding ability, which laid the foundation of N-IgY's application targeting NP. In an in vitro immunoregulatory study, N-IgY (1 mg/mL) modulated NP-induced immune response by alleviating type II interferon secretion stimulated by NP (20 μg/mL). In summary, N-IgY can be mass produced by achievable method, which endows it with potential value against the current COVID-19 pandemic.
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218
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Karki R, Kanneganti TD. The 'cytokine storm': molecular mechanisms and therapeutic prospects. Trends Immunol 2021; 42:681-705. [PMID: 34217595 DOI: 10.1016/j.it.2021.06.001] [Citation(s) in RCA: 158] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 12/15/2022]
Abstract
Cytokine storm syndrome (CSS) has generally been described as a collection of clinical manifestations resulting from an overactivated immune system. Cytokine storms (CSs) are associated with various pathologies, as observed in infectious diseases, certain acquired or inherited immunodeficiencies and autoinflammatory diseases, or following therapeutic interventions. Despite the role of CS in tissue damage and multiorgan failure, a systematic understanding of its underlying molecular mechanisms is lacking. Recent studies demonstrate a positive feedback loop between cytokine release and cell death pathways; certain cytokines, pathogen-associated molecular patterns (PAMPs), and damage-associated molecular patterns (DAMPs), can activate inflammatory cell death, leading to further cytokine secretion. Here, we discuss recent progress in innate immunity and inflammatory cell death, providing insights into the cellular and molecular mechanisms of CSs and therapeutics that might quell ensuing life-threatening effects.
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Affiliation(s)
- Rajendra Karki
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN, USA
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219
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Zhang Q, Wei A, Ma HH, Zhang L, Lian HY, Wang D, Zhao YZ, Cui L, Li WJ, Yang Y, Wang TY, Li ZG, Zhang R. A pilot study of ruxolitinib as a front-line therapy for 12 children with secondary hemophagocytic lymphohistiocytosis. Haematologica 2021; 106:1892-1901. [PMID: 32732367 PMCID: PMC8252948 DOI: 10.3324/haematol.2020.253781] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Indexed: 12/12/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an immune-regulatory disorder characterized by excessive production of inflammatory cytokines. The treatment recommendations of the HLH-1994 and HLH-2004 protocols have long been used in HLH therapy, but some patients still do not respond well to or have unacceptable side effects from conventional therapies. It is believed that cytokine-targeted strategies that directly target disease-driving pathways will be promising options for HLH. This prospective study aimed to investigate the efficacy and safety of ruxolitinib, a Janus kinase (JAK) 1/2 inhibitor, as a front-line therapy in children with secondary HLH. Twelve newly diagnosed patients without previous treatment were enrolled in this study with a median follow-up of 8.2 (7.1-12.0) months, including 8 cases of Epstein-Barr virus associated HLH (EBV-HLH), 2 cases of autoinflammatory disorder (AID)- associated HLH, and 2 cases of unknown etiology. Patients received oral ruxolitinib dosed on 2.5 mg, 5 mg or 10 mg twice daily depending on the body weight for 28 consecutive days. The overall response rate at the end of treatment (day 28) was 83.3% (10/12), with 66.7% (8/12) in complete response (CR), 8.3% (1/12) in partial response (PR), and 8.3% (1/12) in HLH improvement. Among the patients achieving CR, 87.5% (7/8) maintained CR condition for>6 months, and one patient with EBV-HLH relapsed following CR. For the EBV-HLH subgroup, all 8 patients responded to ruxolitinib, with a CR rate of 75% and a PR rate of 25%. Two patients with AID-associated HLH had quite different responses, with one showing reversal of the HLH abnormalities soon and the other showing no improvement, as did the two cases of unknown etiology. Patients who had no response or discontinued ruxolitinib all responded well to the subsequent HLH-1994 regimen. The expected 6-month event-free survival (EFS) rate was 58.3%±10.2%. No serious adverse effects were reported. Our study provides further support for the possibility of ruxolitinib targeted therapy for secondary HLH in children. This study was registered in the Chinese Clinical Trials Registry Platform (http://www.chictr.org.cn/) as ChiCTR2000029977.
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Affiliation(s)
- Qing Zhang
- Beijing Pediatric Research Institute and Children Hospital, Capital Medical Univ, Beijing, China
| | - Ang Wei
- Dept of Hematology Oncology, Beijing Children Hospital, Capital Medical University, Beijing, China
| | - Hong-Hao Ma
- Dept of Hematology Oncology, Beijing Children Hospital, Capital Medical University, Beijing, China
| | - Li Zhang
- Dept of Hematology Oncology, Beijing Children Hospital, Capital Medical University, Beijing, China
| | - Hong-Yun Lian
- Dept of Hematology Oncology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Dong Wang
- Dept of Hematology Oncology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yun-Ze Zhao
- Dept of Hematology Oncology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Lei Cui
- Beijing Pediatric Research Institute and Children Hospital, Capital Medical Univ, Beijing, China
| | - Wei-Jing Li
- Beijing Pediatric Research Institute and Children Hospital, Capital Medical Univ, Beijing, China
| | - Ying Yang
- Dept of Hematology Oncology, Beijing Children Hospital, Capital Medical University, Beijing, China
| | - Tian-You Wang
- Dept of Hematology Oncology, Beijing Children Hospital, Capital Medical University, Beijing, China
| | - Zhi-Gang Li
- Beijing Pediatric Research Institute and Children Hospital, Capital Medical Univ, Beijing, China
| | - Rui Zhang
- Dept of Hematology Oncology, Beijing Children Hospital, Capital Medical University, Beijing, China
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220
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Cure E, Kucuk A, Cure MC. Can emapalumab be life saving for refractory, recurrent, and progressive cytokine storm caused by COVID-19, which is resistant to anakinra, tocilizumab, and Janus kinase inhibitors. Indian J Pharmacol 2021. [PMID: 34169908 DOI: 10.4103/ijp.ijp_615_20.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Although many potent drugs have been used for cytokine storm, mortality is high for patients with coronavirus disease-2019 (COVID-19), which is followed up in the intensive care unit. Interferons (IFNs) are the major cytokines of the antiviral defense system released from many cell types. However, IFN-γ plays a key role in both primary and secondary cytokine storms. If the cytokine storm is not treated urgently, it will be fatal; therefore, it should be treated immediately. Anakinra, an interleukin-1 (IL-1) antagonist, tocilizumab, an IL-6 antagonist, and Janus kinase (JAK) inhibitors are successfully used in cytokine storm caused by COVID-19. However, sometimes, despite these treatments, the patient's clinical course does not improve. Emapalumab (Eb) is the human immunoglobulin G1 monoclonal antibody and is a potent and noncompetitive antagonist of IFN-γ. Eb can be life saving for cytokine storm caused by COVID-19, which is resistant to anakinra, tocilizumab, and JAK inhibitors.
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Affiliation(s)
- Erkan Cure
- Department of Internal Medicine, Ota and Jinemed Hospital, Istanbul, Turkey
| | - Adem Kucuk
- Department of Rheumatology, Meram Tip Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Medine Cumhur Cure
- Department of Biochemistry, Private Kucukcekmece Hospital, Istanbul, Turkey
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221
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El-Mallawany NK, Curry CV, Allen CE. Haemophagocytic lymphohistiocytosis and Epstein-Barr virus: a complex relationship with diverse origins, expression and outcomes. Br J Haematol 2021; 196:31-44. [PMID: 34169507 DOI: 10.1111/bjh.17638] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/17/2021] [Accepted: 05/20/2021] [Indexed: 12/22/2022]
Abstract
Epstein-Barr virus (EBV) is a ubiquitous herpesvirus with rare but severe potential for lymphoproliferative complications. EBV is associated with a variety of presentations of haemophagocytic lymphohistiocytosis (HLH). HLH is a life-threatening hyperinflammatory syndrome that can occur in patients with genetic defects associated with dysregulation of the immune response (familial HLH) or arise in patients with underlying infection or malignancy (non-familial or secondary HLH). EBV can both serve as the incidental trigger of familial HLH or as the driving factor in patients with selective inherited vulnerability (e.g. X-linked lymphoproliferative disease). Alternatively, acute infection can idiosyncratically cause non-neoplastic HLH in patients without inherited predisposition (i.e. secondary HLH), while EBV-associated T/natural killer (NK)-cell lymphoproliferative disorders and lymphomas can cause neoplasia-associated HLH. The present review will discern between EBV-associated familial and non-familial HLH and highlight diagnostic and therapeutic considerations. Non-familial EBV-associated HLH is a major diagnostic dilemma, as it represents a diverse spectrum of disease ranging from highly curable (non-neoplastic EBV-HLH) to indolent but incurable (chronic active EBV) to acutely fatal (systemic EBV-positive T-cell lymphoma of childhood). Increased clinical awareness and understanding of this rare and potentially devastating subset of EBV-related complications is desperately needed to improve survival for patients with neoplasia-associated HLH.
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Affiliation(s)
- Nader Kim El-Mallawany
- Department of Paediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Haematology Centres, Houston, TX, USA
| | - Choladda V Curry
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Hospital, Houston, TX, USA
| | - Carl E Allen
- Department of Paediatrics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Cancer and Haematology Centres, Houston, TX, USA
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Gera A, Misra A, Tiwari A, Singh A, Mehndiratta S. A hungry Histiocyte, altered immunity and myriad of problems: Diagnostic challenges for Pediatric HLH. Int J Lab Hematol 2021; 43:1443-1450. [PMID: 34118134 DOI: 10.1111/ijlh.13626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 05/04/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is an immune deregulation disorder with varied clinical presentation which clinically overlaps with widespread tropical infections. METHODS We conducted a retrospective chart review of children diagnosed with HLH at our center from February-2017 to October-2020. RESULTS Out of the nine diagnosed patients, genetic predisposition was present in three children; two had identified infectious triggers. The mean age of presentation was 30 months with male predominance. The most common clinical findings were fever, organomegaly, and pancytopenia. The median value of fibrinogen was-156 mg/dL, ferritin-12 957 ng/mL and for triglycerides-349 mg/dL, respectively. In children with identified genetic predisposition, serum ferritin levels were usually more than 10 000 ng/mL. The majority of our patients had evidence of hemophagocytosis on bone marrow examination. In our experience, although nonspecific, very high ferritin and serum triglycerides with low fibrinogen in a patient with bi-cytopenia, pancytopenia was the most suggestive evidence of HLH. Genetic evaluation in our series identified three children, one with primary HLH genetic mutation and two with underlying immune deficiency syndrome. The presence of HLH in the accelerated phase of Chediak-Higashi and AD Hyper IgE syndrome with HLH is extremely rare. Leishmaniasis (in nonendemic area) and Ebstein-Barr virus (EBV) was identified as an infectious trigger in two cases. Most of our cases received treatment as per HLH 2004 protocol. Three children died during the initial diagnosis and treatment. HLH with subcutaneous panniculitis-like T-cell lymphoma recovered well. CONCLUSION HLH remains a life-threatening disorder associated with a variety of underlying illnesses as highlighted by our case series.
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Affiliation(s)
- Akriti Gera
- Department of Pediatrics, VMMC and Safdarjung Hospital, New Delhi, India
| | - Aroonima Misra
- Indian Council of Medical Research, National Institute of Pathology, New Delhi, India
| | - Aditi Tiwari
- Department of Pediatrics, VMMC and Safdarjung Hospital, New Delhi, India
| | - Amitabh Singh
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, VMMC and Safdarjung Hospital, New Delhi, India
| | - Sumit Mehndiratta
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, VMMC and Safdarjung Hospital, New Delhi, India
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Inflammatory biomarkers in COVID-19-associated multisystem inflammatory syndrome in children, Kawasaki disease, and macrophage activation syndrome: a cohort study. LANCET RHEUMATOLOGY 2021; 3:e574-e584. [PMID: 34124694 PMCID: PMC8186852 DOI: 10.1016/s2665-9913(21)00139-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Multisystem inflammatory syndrome in children (MIS-C) is a potentially life-threatening hyperinflammatory syndrome that occurs after primary SARS-CoV-2 infection. The pathogenesis of MIS-C remains undefined, and whether specific inflammatory biomarker patterns can distinguish MIS-C from other hyperinflammatory syndromes, including Kawasaki disease and macrophage activation syndrome (MAS), is unknown. Therefore, we aimed to investigate whether inflammatory biomarkers could be used to distinguish between these conditions. Methods We studied a prospective cohort of patients with MIS-C and Kawasaki disease and an established cohort of patients with new-onset systemic juvenile idiopathic arthritis (JIA) and MAS associated with systemic JIA (JIA-MAS), diagnosed according to established guidelines. The study was done at Cincinnati Children's Hospital Medical Center (Cincinnati, OH, USA). Clinical and laboratory features as well as S100A8/A9, S100A12, interleukin (IL)-18, chemokine (C-X-C motif) ligand 9 (CXCL9), and IL-6 concentrations were assessed by ELISA and compared using parametric and non-parametric tests and receiver operating characteristic curve analysis. Findings Between April 30, 2019, and Dec 14, 2020, we enrolled 19 patients with MIS-C (median age 9·0 years [IQR 4·5–15·0]; eight [42%] girls and 11 [58%] boys) and nine patients with Kawasaki disease (median age 2·0 years [2·0–4·0]); seven [78%] girls and two [22%] boys). Patients with MIS-C and Kawasaki disease had similar S100 proteins and IL-18 concentrations but patients with MIS-C were distinguished by significantly higher median concentrations of the IFNγ-induced CXCL9 (1730 pg/mL [IQR 604–6300] vs 278 pg/mL [54–477]; p=0·038). Stratifying patients with MIS-C by CXCL9 concentrations (high vs low) revealed differential severity of clinical and laboratory presentation. Compared with patients with MIS-C and low CXCL9 concentrations, more patients with high CXCL9 concentrations had acute kidney injury (six [60%] of ten vs none [0%] of five), altered mental status (four [40%] of ten vs none [0%] of five), shock (nine [90%] of ten vs two [40%] of five), and myocardial dysfunction (five [50%] of ten vs one [20%] of five); these patients also had higher concentrations of systemic inflammatory markers and increased severity of cytopenia and coagulopathy. By contrast, patients with MIS-C and low CXCL9 concentrations resembled patients with Kawasaki disease, including the frequency of coronary involvement. Elevated concentrations of S100A8/A9, S100A12, and IL-18 were also useful in distinguishing systemic JIA from Kawasaki disease with high sensitivity and specificity. Interpretation Our findings show MIS-C is distinguishable from Kawasaki disease primarily by elevated CXCL9 concentrations. The stratification of patients with MIS-C by high or low CXCL9 concentrations provides support for MAS-like pathophysiology in patients with severe MIS-C, suggesting new approaches for diagnosis and management. Funding Cincinnati Children's Research Foundation, National Institute of Arthritis and Musculoskeletal and Skin Diseases/National Institutes of Health, the Deutsche Forschungsgemeinschaft, and The Jellin Family Foundation.
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Marois L, Touzot F, Haddad E, Fernandez I, Morin MP, De Bruycker JJ, Duval M, Cellot S, Teira P, Bittencourt H, Decaluwe H. Successful management of familial hemophagocytic lymphohistiocytosis by the JAK 1/2 inhibitor ruxolitinib. Pediatr Blood Cancer 2021; 68:e28954. [PMID: 33694335 DOI: 10.1002/pbc.28954] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/27/2022]
Affiliation(s)
- Louis Marois
- Immunology and Rheumatology Division, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Fabien Touzot
- Immunology and Rheumatology Division, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Elie Haddad
- Immunology and Rheumatology Division, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Isabel Fernandez
- Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montréal, Québec, Canada
| | - Marie-Paule Morin
- Immunology and Rheumatology Division, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Jean Jacques De Bruycker
- Immunology and Rheumatology Division, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Michel Duval
- Hematology-Oncology Division, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Sonia Cellot
- Hematology-Oncology Division, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Pierre Teira
- Hematology-Oncology Division, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Henrique Bittencourt
- Hematology-Oncology Division, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Hélène Decaluwe
- Immunology and Rheumatology Division, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
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Ombrello MJ, Schulert GS. COVID-19 and cytokine storm syndrome: are there lessons from macrophage activation syndrome? Transl Res 2021; 232:1-12. [PMID: 33684592 PMCID: PMC7934701 DOI: 10.1016/j.trsl.2021.03.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/01/2021] [Accepted: 03/01/2021] [Indexed: 12/14/2022]
Abstract
Although interest in "cytokine storms" has surged over the past decade, it was massively amplified in 2020 when it was suggested that a subset of patients with COVID-19 developed a form of cytokine storm. The concept of cytokine storm syndromes (CSS) encompasses diverse conditions or circumstances that coalesce around potentially lethal hyperinflammation with hemodynamic compromise and multiple organ dysfunction syndrome. Macrophage activation syndrome (MAS) is a prototypic form of CSS that develops in the context of rheumatic diseases, particularly systemic juvenile idiopathic arthritis. The treatment of MAS relies heavily upon corticosteroids and cytokine inhibitors, which have proven to be lifesaving therapies in MAS, as well as in other forms of CSS. Within months of the recognition of SARS-CoV2 as a human pathogen, descriptions of COVID-19 patients with hyperinflammation emerged. Physicians immediately grappled with identifying optimal therapeutic strategies for these patients, and despite clinical distinctions such as marked coagulopathy with endothelial injury associated with COVID-19, borrowed from the experiences with MAS and other CSS. Initial reports of patients treated with anti-cytokine agents in COVID-19 were promising, but recent large, better-controlled studies of these agents have had mixed results suggesting a more complex pathophysiology. Here, we discuss how the comparison of clinical features, immunologic parameters and therapeutic response data between MAS and hyperinflammation in COVID-19 can provide new insight into the pathophysiology of CSS.
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Affiliation(s)
- Michael J Ombrello
- Translational Genetics and Genomics Unit, Pediatric Translational Research Branch, Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland.
| | - Grant S Schulert
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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226
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Vagrecha A, Patel HB, Mamdouhi T, Acharya S, Appiah‐Kubi A, Aygun B, Vlachos A, Wolfe LC, Lipton JM, Cron RQ, Fein Levy C. Effect of COVID-19 on anakinra-induced remission in homozygous STX11 hemophagocytosis lymphohistiocytosis. Pediatr Blood Cancer 2021; 68:e28897. [PMID: 33442938 PMCID: PMC7995056 DOI: 10.1002/pbc.28897] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Anshul Vagrecha
- Department of PediatricsDivision of Hematology/Oncology and Cellular TherapyCohen Children's Medical CenterNew Hyde ParkNew York,Zucker School of Medicine at Hofstra/NorthwellHempsteadNew York
| | - Hiren B. Patel
- Department of PediatricsDivision of Hematology/Oncology and Cellular TherapyCohen Children's Medical CenterNew Hyde ParkNew York,Zucker School of Medicine at Hofstra/NorthwellHempsteadNew York
| | - Tania Mamdouhi
- Zucker School of Medicine at Hofstra/NorthwellHempsteadNew York
| | - Suchitra Acharya
- Department of PediatricsDivision of Hematology/Oncology and Cellular TherapyCohen Children's Medical CenterNew Hyde ParkNew York,Zucker School of Medicine at Hofstra/NorthwellHempsteadNew York
| | - Abena Appiah‐Kubi
- Department of PediatricsDivision of Hematology/Oncology and Cellular TherapyCohen Children's Medical CenterNew Hyde ParkNew York,Zucker School of Medicine at Hofstra/NorthwellHempsteadNew York
| | - Banu Aygun
- Department of PediatricsDivision of Hematology/Oncology and Cellular TherapyCohen Children's Medical CenterNew Hyde ParkNew York,Zucker School of Medicine at Hofstra/NorthwellHempsteadNew York
| | - Adrianna Vlachos
- Department of PediatricsDivision of Hematology/Oncology and Cellular TherapyCohen Children's Medical CenterNew Hyde ParkNew York,Zucker School of Medicine at Hofstra/NorthwellHempsteadNew York
| | - Lawrence C. Wolfe
- Department of PediatricsDivision of Hematology/Oncology and Cellular TherapyCohen Children's Medical CenterNew Hyde ParkNew York,Zucker School of Medicine at Hofstra/NorthwellHempsteadNew York
| | - Jeffrey M. Lipton
- Department of PediatricsDivision of Hematology/Oncology and Cellular TherapyCohen Children's Medical CenterNew Hyde ParkNew York,Zucker School of Medicine at Hofstra/NorthwellHempsteadNew York
| | - Randy Q. Cron
- Division of Pediatric RheumatologyChildren's of AlabamaUniversity of AlabamaBirminghamNew York
| | - Carolyn Fein Levy
- Department of PediatricsDivision of Hematology/Oncology and Cellular TherapyCohen Children's Medical CenterNew Hyde ParkNew York,Zucker School of Medicine at Hofstra/NorthwellHempsteadNew York
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227
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Cooper MA, Zimmerman O, Nataraj R, Wynn RF. Lifelong Immune Modulation Versus Hematopoietic Cell Therapy for Inborn Errors of Immunity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:628-639. [PMID: 33551038 DOI: 10.1016/j.jaip.2020.11.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023]
Abstract
Advances in diagnosis of inborn errors of immunity (IEI) and an understanding of the molecular and immunologic mechanisms of these disorders have led to both the development of new therapies and improved approaches to hematopoietic cell transplantation (HCT). For example, monoclonal antibodies (mAbs) and small molecules, such as Janus tyrosine kinase inhibitors, that can modulate immunologic pathways have been designed for or repurposed for management of IEI. A better understanding of molecular mechanisms of IEI has led to use of drugs typically considered "immunosuppressive" to modulate the immune response, such as mammalian target of rapamycin inhibitors in disorders of phosphoinositide 3-kinase gain of function. Since the first HCT in a patient with severe combined immunodeficiency (SCID) in 1968, transplantation strategies have improved, with more than 90% probability of survival after allogeneic HCT in SCID and hence HCT is now the therapeutic standard for SCID and many other IEI. When tailoring treatment for IEI, multiple disease-specific and individual factors should be considered. In diseases such as SCID or agammaglobulinemia, the choice between HCT or medical management is straightforward. However, in many IEI, the choice between the options is challenging. This review focuses on the factors that should be taken into account in the quest for the optimal treatment for patients with IEI.
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Affiliation(s)
- Megan A Cooper
- Department of Pediatrics, Division of Rheumatology/Immunology, Washington University in St Louis, St Louis, Mo.
| | - Ofer Zimmerman
- Department of Medicine, Division of Allergy/Immunology, Washington University in St Louis, St Louis, Mo
| | - Ramya Nataraj
- Department of Blood and Marrow Transplant, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Robert F Wynn
- Department of Blood and Marrow Transplant, Royal Manchester Children's Hospital, Manchester, United Kingdom.
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228
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Nouveau L, Buatois V, Cons L, Chatel L, Pontini G, Pleche N, Ferlin WG. Immunological analysis of the murine anti-CD3-induced cytokine release syndrome model and therapeutic efficacy of anti-cytokine antibodies. Eur J Immunol 2021; 51:2074-2085. [PMID: 33945643 PMCID: PMC8237068 DOI: 10.1002/eji.202149181] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/23/2021] [Accepted: 04/28/2021] [Indexed: 12/21/2022]
Abstract
The aberrant release of inflammatory mediators often referred to as a cytokine storm or cytokine release syndrome (CRS), is a common and sometimes fatal complication in acute infectious diseases including Ebola, dengue, COVID-19, and influenza. Fatal CRS occurrences have also plagued the development of highly promising cancer therapies based on T-cell engagers and chimeric antigen receptor (CAR) T cells. CRS is intimately linked with dysregulated and excessive cytokine release, including IFN-γ, TNF-α, IL 1, IL-6, and IL-10, resulting in a systemic inflammatory response leading to multiple organ failure. Here, we show that mice intravenously administered the agonistic hamster anti-mouse CD3ε monoclonal antibody 145-2C11 develop clinical and laboratory manifestations seen in patients afflicted with CRS, including body weight loss, hepatosplenomegaly, thrombocytopenia, increased vascular permeability, lung inflammation, and hypercytokinemia. Blood cytokine levels and gene expression analysis from lung, liver, and spleen demonstrated a hierarchy of inflammatory cytokine production and infiltrating immune cells with differentiating organ-dependent kinetics. IL-2, IFN-γ, TNF-α, and IL-6 up-regulation preceded clinical signs of CRS. The co-treatment of mice with a neutralizing anti-cytokine antibody cocktail transiently improved early clinical and laboratory features of CRS. We discuss the predictive use of this model in the context of new anti-cytokine strategies to treat human CRS.
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Affiliation(s)
- Lise Nouveau
- Light Chain Bioscience-Novimmune S.A., Geneva, Switzerland
| | | | - Laura Cons
- Light Chain Bioscience-Novimmune S.A., Geneva, Switzerland
| | | | | | - Nicolas Pleche
- Light Chain Bioscience-Novimmune S.A., Geneva, Switzerland
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229
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Abstract
Macrophage activation syndrome (MAS) is a severe, potentially life-threatening complication of systemic juvenile idiopathic arthritis (s-JIA). An immunological feature is the excessive activation and proliferation of T lymphocytes and macrophages. Massive hypercytokinemia is strongly associated with its pathogenesis, particularly the overproduction of interleukin (IL)-1, IL-6 and IL-18; interferon (IFN)-γ; and tumor necrosis factor (TNF)-α. Furthermore, heterozygous mutations in causative genes for primary hemophagocytic lymphohistiocytosis and in vivo exposure to highly elevated levels of IL-6 and IL-18 might induce natural killer cell dysfunction and decrease their numbers, respectively. A proper diagnosis is important to begin appropriate therapeutic interventions and change an unfavorable prognosis. The 2016 ACR/EULAR classification criteria for MAS have a high diagnostic performance; however, the diagnostic sensitivity for onset is relatively low. Therefore, careful monitoring of laboratory values during the course of MAS is necessary to diagnose it early in s-JIA. Further studies on the diagnosis and monitoring of disease activity using serum cytokine profile and a targeted cytokine strategy are required.
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Affiliation(s)
- Masaki Shimizu
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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230
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Yamada M, Sakamoto S, Sakamoto K, Uchida H, Shimizu S, Osumi T, Kato M, Shoji K, Arai K, Miyazaki O, Nakano N, Yoshioka T, Fukuda A, Kasahara M, Imadome KI. Fatal Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis with virus-infected T cells after pediatric multivisceral transplantation: A proof-of-concept case report. Pediatr Transplant 2021; 25:e13961. [PMID: 33368911 DOI: 10.1111/petr.13961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/28/2020] [Accepted: 12/07/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND EBV-associated HLH driven by EBV-infected CD8+ T cells is a rare complication after pediatric solid organ transplantation. The etiology and disease spectrum of post-transplant EBV-HLH are poorly understood, and making a precise diagnosis and providing optimal treatment remain a challenge. METHODS/CASE DESCRIPTION/RESULTS We report a 2-year-old multivisceral transplant recipient who developed fever and cytopenia with a persistent high EBV-load state. Repeated tissue examinations and CT scans could not identify a localized mass, which is the key to the diagnosis of PTLD as per the WHO classification. Hence, EBV-HLH was diagnosed by clinical manifestations as well as characterization of EBV-infected cells, pathological examination on cell block of pleural effusion and clonality analysis. This EBV-HLH did not respond to intensive chemotherapy, resulted in the recipient's death, acting similarly to hematological malignancy. CONCLUSIONS Characterization of EBV-infected cells in peripheral blood should be considered when persistent high EBV loads develop with symptoms consistent with PTLD, but no evidence of localized mass, and the tissue diagnosis is unavailable after pediatric solid organ transplantation.
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Affiliation(s)
- Masaki Yamada
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | | | | | | | | | - Tomoo Osumi
- Children's Cancer Center, NCCHD, Tokyo, Japan
| | | | - Kensuke Shoji
- Division of Infectious Diseases, NCCHD, Tokyo, Japan
| | | | | | | | | | | | | | - Ken-Ichi Imadome
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development (NCCHD), Tokyo, Japan
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231
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Iovino L, Thur LA, Gnjatic S, Chapuis A, Milano F, Hill JA. Shared inflammatory pathways and therapeutic strategies in COVID-19 and cancer immunotherapy. J Immunother Cancer 2021; 9:e002392. [PMID: 33986127 PMCID: PMC8126446 DOI: 10.1136/jitc-2021-002392] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 01/28/2023] Open
Abstract
COVID-19, the syndrome caused by the infection with SARS-CoV-2 coronavirus, is characterized, in its severe form, by interstitial diffuse pneumonitis and acute respiratory distress syndrome (ARDS). ARDS and systemic manifestations of COVID-19 are mainly due to an exaggerated immune response triggered by the viral infection. Cytokine release syndrome (CRS), an inflammatory syndrome characterized by elevated levels of circulating cytokines, and endothelial dysfunction are systemic manifestations of COVID-19. CRS is also an adverse event of immunotherapy (IMTX), the treatment of diseases using drugs, cells, and antibodies to stimulate or suppress the immune system. Graft-versus-host disease complications after an allogeneic stem cell transplant, toxicity after the infusion of chimeric antigen receptor-T cell therapy and monoclonal antibodies can all lead to CRS. It is hypothesized that anti-inflammatory drugs used for treatment of CRS in IMTX may be useful in reducing the mortality in COVID-19, whereas IMTX itself may help in ameliorating effects of SARS-CoV-2 infection. In this paper, we focused on the potential shared mechanisms and differences between COVID-19 and IMTX-related toxicities. We performed a systematic review of the clinical trials testing anti-inflammatory therapies and of the data published from prospective trials. Preliminary evidence suggests there might be a benefit in targeting the cytokines involved in the pathogenesis of COVID-19, especially by inhibiting the interleukin-6 pathway. Many other approaches based on novel drugs and cell therapies are currently under investigation and may lead to a reduction in hospitalization and mortality due to COVID-19.
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Affiliation(s)
- Lorenzo Iovino
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Laurel A Thur
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Sacha Gnjatic
- Medicine-Hematology/Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aude Chapuis
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Joshua A Hill
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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232
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Di Giorgio A, Bartolini E, Calvo PL, Cananzi M, Cirillo F, Della Corte C, Dionisi-Vici C, Indolfi G, Iorio R, Maggiore G, Mandato C, Nebbia G, Nicastro E, Pinon M, Ranucci G, Sciveres M, Vajro P, D'Antiga L. Diagnostic Approach to Acute Liver Failure in Children: A Position Paper by the SIGENP Liver Disease Working Group. Dig Liver Dis 2021; 53:545-557. [PMID: 33775575 DOI: 10.1016/j.dld.2021.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
Acute liver failure (ALF) is a clinical condition characterized by the abrupt onset of coagulopathy and biochemical evidence of hepatocellular injury, leading to rapid deterioration of liver cell function. In children, ALF has been characterized by raised transaminases, coagulopathy, and no known evidence of pre-existing chronic liver disease; unlike in adults, the presence of hepatic encephalopathy is not required to establish the diagnosis. Although rare, ALF has a high mortality rate without liver transplantation (LT). Etiology of ALF varies with age and geographical location, although it may remain indeterminate in a significant proportion of cases. However, identifying its etiology is crucial to undertake disease-specific management and evaluate indication to LT. In this position statement, the Liver Disease Working Group of the Italian Society of Gastroenterology, Hepatology and Nutrition (SIGENP) reviewed the most relevant studies on pediatric ALF to provide recommendations on etiology, clinical features and diagnostic work-up of neonates, infants and children presenting with ALF. Recommendations on medical management and transplant candidacy will be discussed in a following consensus conference.
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Affiliation(s)
- A Di Giorgio
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy.
| | - E Bartolini
- Department Neurofarba, University of Florence and Liver Unit, Meyer Children's University Hospital, Florence, Italy
| | - P L Calvo
- Paediatric Gastroenterology Unit, Regina Margherita Children's Hospital Azienda Ospedaliera-Universitaria Citta della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - M Cananzi
- Unit of Pediatric Gastroenterology and Hepatology, Dpt. of Women's and Children's Health, University Hospital of Padova, Italy
| | - F Cirillo
- Paediatric Department and Transplantation, Ismett, Palermo, Italy
| | - C Della Corte
- Paediatric Gastroenterology, Hepatology, Nutrition and Liver Transplantation, IRCCS Bambino Gesù Paediatric Hospital, Rome, Italy
| | - C Dionisi-Vici
- Division of Metabolic Diseases, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - G Indolfi
- Department Neurofarba, University of Florence and Liver Unit, Meyer Children's University Hospital, Florence, Italy
| | - R Iorio
- Paediatric Liver Unit, Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
| | - G Maggiore
- Paediatric Gastroenterology, Hepatology, Nutrition and Liver Transplantation, IRCCS Bambino Gesù Paediatric Hospital, Rome, Italy
| | - C Mandato
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - G Nebbia
- Pediatric Liver Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - E Nicastro
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy
| | - M Pinon
- Paediatric Gastroenterology Unit, Regina Margherita Children's Hospital Azienda Ospedaliera-Universitaria Citta della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - G Ranucci
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - M Sciveres
- Paediatric Department and Transplantation, Ismett, Palermo, Italy
| | - P Vajro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" Section of Pediatrics, University of Salerno, Baronissi (Salerno), Italy
| | - L D'Antiga
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy
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233
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Cure E, Kucuk A, Cure MC. Can emapalumab be life saving for refractory, recurrent, and progressive cytokine storm caused by COVID-19, which is resistant to anakinra, tocilizumab, and Janus kinase inhibitors. Indian J Pharmacol 2021; 53:226-228. [PMID: 34169908 PMCID: PMC8262416 DOI: 10.4103/ijp.ijp_615_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Although many potent drugs have been used for cytokine storm, mortality is high for patients with coronavirus disease-2019 (COVID-19), which is followed up in the intensive care unit. Interferons (IFNs) are the major cytokines of the antiviral defense system released from many cell types. However, IFN-γ plays a key role in both primary and secondary cytokine storms. If the cytokine storm is not treated urgently, it will be fatal; therefore, it should be treated immediately. Anakinra, an interleukin-1 (IL-1) antagonist, tocilizumab, an IL-6 antagonist, and Janus kinase (JAK) inhibitors are successfully used in cytokine storm caused by COVID-19. However, sometimes, despite these treatments, the patient's clinical course does not improve. Emapalumab (Eb) is the human immunoglobulin G1 monoclonal antibody and is a potent and noncompetitive antagonist of IFN-γ. Eb can be life saving for cytokine storm caused by COVID-19, which is resistant to anakinra, tocilizumab, and JAK inhibitors.
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Affiliation(s)
- Erkan Cure
- Department of Internal Medicine, Ota and Jinemed Hospital, Istanbul, Turkey
- Address for correspondence: Dr. Erkan Cure, Department of Internal Medicine, Ota and Jinemed Hospital, Muradiye Mahallesi Nuzhetiye Cad, Deryadil Sokagi No: 1, Istanbul 34357, Turkey. E-mail:
| | - Adem Kucuk
- Department of Rheumatology, Meram Tip Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Medine Cumhur Cure
- Department of Biochemistry, Private Kucukcekmece Hospital, Istanbul, Turkey
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234
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Chaturvedi V, Marsh RA, Zoref-Lorenz A, Owsley E, Chaturvedi V, Nguyen TC, Goldman JR, Henry MM, Greenberg JN, Ladisch S, Hermiston ML, Jeng M, Naqvi A, Allen CE, Wong HR, Jordan MB. T-cell activation profiles distinguish hemophagocytic lymphohistiocytosis and early sepsis. Blood 2021; 137:2337-2346. [PMID: 33512385 PMCID: PMC8085480 DOI: 10.1182/blood.2020009499] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/25/2020] [Indexed: 12/18/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a fatal disorder of immune hyperactivation that has been described as a cytokine storm. Sepsis due to known or suspected infection has also been viewed as a cytokine storm. Although clinical similarities between these syndromes suggest similar immunopathology and may create diagnostic uncertainty, distinguishing them is critical as treatments are widely divergent. We examined T-cell profiles from children with either HLH or sepsis and found that HLH is characterized by acute T-cell activation, in clear contrast to sepsis. Activated T cells in patients with HLH were characterized as CD38high/HLA-DR+ effector cells, with activation of CD8+ T cells being most pronounced. Activated T cells were type 1 polarized, proliferative, and displayed evidence of recent and persistent activation. Circulating activated T cells appeared to be broadly characteristic of HLH, as they were seen in children with and without genetic lesions or identifiable infections and resolved with conventional treatment of HLH. Furthermore, we observed even greater activation and type 1 polarization in tissue-infiltrating T cells, described here for the first time in a series of patients with HLH. Finally, we observed that a threshold of >7% CD38high/HLA-DR+ cells among CD8+ T cells had strong positive and negative predictive value for distinguishing HLH from early sepsis or healthy controls. We conclude that the cytokine storm of HLH is marked by distinctive T-cell activation whereas early sepsis is not, and that these 2 syndromes can be readily distinguished by T-cell phenotypes.
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Affiliation(s)
- Vandana Chaturvedi
- Division of Immunobiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Adi Zoref-Lorenz
- Division of Immunobiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Erika Owsley
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Vijaya Chaturvedi
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Trung C Nguyen
- Section of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Jordana R Goldman
- Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey VA Medical Center, Houston, TX
| | - Michael M Henry
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ
| | - Jay N Greenberg
- Division of Hematology, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Stephan Ladisch
- Division of Hematology, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Michelle L Hermiston
- Division of Hematology Oncology, Department of Pediatrics, UCSF School of Medicine, San Francisco, CA
| | - Michael Jeng
- Hematology and Oncology, Department of Pediatrics, Stanford Medical School, Stanford, CA
| | - Ahmed Naqvi
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Carl E Allen
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX; and
| | - Hector R Wong
- Division of Critical Care, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael B Jordan
- Division of Immunobiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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235
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Kessel C, Vollenberg R, Masjosthusmann K, Hinze C, Wittkowski H, Debaugnies F, Nagant C, Corazza F, Vély F, Kaplanski G, Girard-Guyonvarc'h C, Gabay C, Schmidt H, Foell D, Tepasse PR. Discrimination of COVID-19 From Inflammation-Induced Cytokine Storm Syndromes Using Disease-Related Blood Biomarkers. Arthritis Rheumatol 2021; 73:1791-1799. [PMID: 33880885 PMCID: PMC8251089 DOI: 10.1002/art.41763] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/06/2021] [Indexed: 12/26/2022]
Abstract
Objective Infection with the novel coronavirus SARS–CoV‐2 triggers severe illness with high mortality in a subgroup of patients. Such a critical course of COVID‐19 is thought to be associated with the development of cytokine storm, a condition seen in macrophage activation syndrome (MAS) and secondary hemophagocytic lymphohistiocytosis (HLH). However, specific data demonstrating a clear association of cytokine storm with severe COVID‐19 are still lacking. The aim of this study was to directly address whether immune activation in COVID‐19 does indeed mimic the conditions found in these classic cytokine storm syndromes. Methods Levels of 22 biomarkers were quantified in serum samples from patients with COVID‐19 (n = 30 patients, n = 83 longitudinal samples in total), patients with secondary HLH/MAS (n = 50), and healthy controls (n = 9). Measurements were performed using bead array assays and single‐marker enzyme‐linked immunosorbent assay. Serum biomarker levels were assessed for correlations with disease outcome. Results In patients with secondary HLH/MAS, we observed pronounced activation of the interleukin‐18 (IL‐18)–interferon‐γ axis, increased serum levels of IL‐1 receptor antagonist, intercellular adhesion molecule 1, and IL‐8, and strongly reduced levels of soluble Fas ligand in the course of SARS–CoV‐2 infection. These observations appeared to discriminate immune dysregulation in critical COVID‐19 from the well‐recognized characteristics of other cytokine storm syndromes. Conclusion Serum biomarker profiles clearly separate COVID‐19 from MAS or secondary HLH in terms of distinguishing the severe systemic hyperinflammation that occurs following SARS–CoV‐2 infection. These findings could be useful in determining the efficacy of drugs targeting key molecules and pathways specifically associated with systemic cytokine storm conditions in the treatment of COVID‐19.
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Affiliation(s)
- Christoph Kessel
- Department of Pediatric Rheumatology and Immunology, University Children's Hospital Muenster, Muenster, Germany
| | - Richard Vollenberg
- Department of Gastroenterology, Hepatology, Endocrinology and Clinical Infectiology, University Hospital Muenster, Muenster, Germany
| | - Katja Masjosthusmann
- Department of General Pediatrics, University Children's Hospital Muenster, Muenster, Germany
| | - Claas Hinze
- Department of Pediatric Rheumatology and Immunology, University Children's Hospital Muenster, Muenster, Germany
| | - Helmut Wittkowski
- Department of Pediatric Rheumatology and Immunology, University Children's Hospital Muenster, Muenster, Germany
| | - France Debaugnies
- Laboratory of Translational Research, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, Brussels, Belgium and Medical Biology Department, Laboratoire National de Santé, Dudelange, Luxembourg
| | - Carole Nagant
- Immunology Department, LHUB-ULB, Université Libre de Bruxelles, Brussels, Belgium
| | - Francis Corazza
- Laboratory of Translational Research, Centre Hospitalier Universitaire Brugmann and Immunology Department, LHUB-ULB, Université Libre de Bruxelles, Brussels, Belgium
| | - Frédéric Vély
- Aix Marseille Université, CNRS, INSERM, CIML and Assistance Publique des Hôpitaux de Marseille, Hôpital de la Timone, Immunology, Marseille Immunopole, Marseilles, France
| | - Gilles Kaplanski
- Assistance Publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire Conception, Service de Médecine Interne et Immunologie Clinique, Aix-Marseille Universitô and Center for Cardiovascular Research and Nutrition, Aix-Marseille Université, INSERM UMRS1263, Marseilles, France
| | - Charlotte Girard-Guyonvarc'h
- Division of Rheumatology, Department of Medicine, University Hospital of GenevaDepartment of Medicine, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
| | - Cem Gabay
- Division of Rheumatology, Department of Medicine, University Hospital of GenevaDepartment of Medicine, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
| | - Hartmut Schmidt
- Department of Gastroenterology, Hepatology, Endocrinology and Clinical Infectiology, University Hospital Muenster, Muenster, Germany
| | - Dirk Foell
- Department of Pediatric Rheumatology and Immunology, University Children's Hospital Muenster, Muenster, Germany
| | - Phil-Robin Tepasse
- Department of Gastroenterology, Hepatology, Endocrinology and Clinical Infectiology, University Hospital Muenster, Muenster, Germany
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Yildiz H, Bailly S, Van Den Neste E, Yombi JC. Clinical Management of Relapsed/Refractory Hemophagocytic Lymphohistiocytosis in Adult Patients: A Review of Current Strategies and Emerging Therapies. Ther Clin Risk Manag 2021; 17:293-304. [PMID: 33888986 PMCID: PMC8056168 DOI: 10.2147/tcrm.s195538] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/25/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction Haemophagocytic lymphohistiocytosis (HLH) is a severe disorder with high mortality. The aim of this review is to update clinical management of relapsed/refractory HLH in adults, with a focus on current and new therapies. Methods We searched relevant articles in Embase and PUBMED with the MESH term “hemophagocytic lymphohistiocytosis; refractory; relapsing; adult.” Results One hundred eight papers were found; of these, 22 were retained for this review. The treatment of HLH in adult is based on the HLH-94 regimen. The response rate is lower than in pediatric patients, and 20–30% are refractory to this therapy. DEP regimen and allogenic hematopoietic stem cell transplantation (HSCT) are associated with complete response and partial response in 27% and 49.2%, respectively. However, many patients fail to achieve a stable condition before HSCT, and mortality is higher in them. New drugs have been developed, such as emapalumab, ruxolitinib, and alemtuzumab, and they may be used as bridges to the curative HSCT. They are relatively well tolerated and have few or mild side effects. With these agents, the rate of partial response ranges from 14.2% to 100%, while the rate of complete response is highly variable according to study and medication used. The number of patients who achieved HSCT ranged from 44.8% to 77%, with a survival rate of 55.9% to 100%. However, the populations in these studies are mainly composed of mixed-age patients (pediatric and adult patients), and studies including only adult patients are scarce. Conclusion Relapsed or refractory HLH in adult patients is associated with poor outcome, and consolidation with HSCT may be required in some cases. Mortality related to HSCT is mainly due to active HLH disease before HSCT and post HSCT complications. New drugs, such as empalumab, ruxolitinib, and alemtuzumab are interesting since these agents may be used as bridges to HSCT with increases in the numbers of patients proceeding to HSCT and survival rate.
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Affiliation(s)
- Halil Yildiz
- Departement of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Sarah Bailly
- Departement of Hematology, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Eric Van Den Neste
- Departement of Hematology, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
| | - Jean Cyr Yombi
- Departement of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint Luc, Bruxelles, Belgique
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Murray GM, Sen ES, Ramanan AV. Advancing the treatment of juvenile idiopathic arthritis. THE LANCET. RHEUMATOLOGY 2021; 3:e294-e305. [PMID: 38279412 DOI: 10.1016/s2665-9913(20)30426-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/05/2020] [Accepted: 12/02/2020] [Indexed: 01/28/2024]
Abstract
Treatment for juvenile idiopathic arthritis has undergone substantial changes in recent decades. These changes are partly due to the availability of new treatments, mainly biological agents, as well as developments in treatment strategies, including a focus on concepts such as treat-to-target. In addition, the creation of large paediatric research networks has improved patient access to, and design of, clinical trials for rare paediatric diseases. Although these advances have resulted in improvements in care for most patients with juvenile idiopathic arthritis, certain subgroups of patients continue to have a poor prognosis. Further research aims to identify patients in these subgroups early, to personalise their care, improve functional outcomes, and minimise long-term damage and harm. Optimising the duration of therapy for those individuals who require systemic immunosuppression is also of importance. Incorporation of novel biomarkers in combination with validated clinical measures in an effort to predict outcomes and target therapy accordingly is an exciting development.
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Affiliation(s)
- Grainne M Murray
- Department of Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ethan S Sen
- Department of Paediatric Rheumatology, Great North Children's Hospital, Newcastle upon Tyne, UK; Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK; Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
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238
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Boonstra PS, Ahmed A, Merrill SA, Wilcox RA. Ruxolitinib in adult patients with secondary hemophagocytic lymphohistiocytosis. Am J Hematol 2021; 96:E103-E105. [PMID: 33428805 DOI: 10.1002/ajh.26091] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Philip S. Boonstra
- Department of Biostatistics and the Center for Cancer Biostatistics University of Michigan Ann Arbor Michigan
| | - Asra Ahmed
- Division of Hematology/Medical Oncology, Department of Internal Medicine University of Michigan Rogel Cancer Center Ann Arbor Michigan
| | - Samuel A. Merrill
- The Section of Hematology, Department of Medicine West Virginia University Morgantown West Virginia
| | - Ryan A. Wilcox
- Division of Hematology/Medical Oncology, Department of Internal Medicine University of Michigan Rogel Cancer Center Ann Arbor Michigan
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239
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Merli P, Quintarelli C, Strocchio L, Locatelli F. The role of interferon-gamma and its signaling pathway in pediatric hematological disorders. Pediatr Blood Cancer 2021; 68:e28900. [PMID: 33484058 DOI: 10.1002/pbc.28900] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 12/15/2022]
Abstract
Interferon-gamma (IFN-γ) plays a key role in the pathophysiology of hemophagocytic lymphohistiocytosis (HLH), and available evidence also points to a role in other conditions, including aplastic anemia (AA) and graft failure following allogeneic hematopoietic stem cell transplantation. Recently, the therapeutic potential of IFN-γ inhibition has been documented; emapalumab, an anti-IFN-γ monoclonal antibody, has been approved in the United States for treatment of primary HLH that is refractory, recurrent or progressive, or in patients with intolerance to conventional therapy. Moreover, ruxolitinib, an inhibitor of JAK/STAT intracellular signaling, is currently being investigated for treating HLH. In AA, IFN-γ inhibits hematopoiesis by disrupting the interaction between thrombopoietin and its receptor, c-MPL. Eltrombopag, a small-molecule agonist of c-MPL, acts at a different binding site to IFN-γ and is thus able to circumvent its inhibitory effects. Ongoing trials will elucidate the role of IFN-γ neutralization in secondary HLH and future studies could explore this strategy in controlling hyperinflammation due to CAR T cells.
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Affiliation(s)
- Pietro Merli
- Department of Pediatric Hematology and Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Concetta Quintarelli
- Department of Pediatric Hematology and Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.,Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Luisa Strocchio
- Department of Pediatric Hematology and Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, Cell and Gene Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.,Sapienza, University of Rome, Rome, Italy
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Zoref-Lorenz A, Jordan MB. Challenges in improving global outcomes for hemophagocytic lymphohistiocytosis. Pediatr Hematol Oncol 2021; 38:191-193. [PMID: 33843440 DOI: 10.1080/08880018.2021.1912228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Adi Zoref-Lorenz
- Hematology Institute, Meir Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Immunobiolgy, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Michael B Jordan
- Division of Immunobiolgy, Cincinnati Children's Medical Center, Cincinnati, OH, USA.,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Abstract
Macrophage activation syndrome is a severe yet under-recognized complication encountered in pediatric rheumatology. It manifests as secondary hemophagocytic lymphohistiocytosis leading to a hyper-inflammatory state resulting from an underlying cytokine storm. If unchecked, it may lead to multiorgan failure and mortality. Early diagnosis and timely initiation of specific therapy is pivotal for a successful outcome. This review outlines the key clinical and laboratory features and management of macrophage activation syndrome.
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Affiliation(s)
- Narendra Kumar Bagri
- Division of Pediatric Rheumatology, Department of Pediatrics, AIIMS, New Delhi; India. Correspondence to: Dr Narendra Kumar Bagri, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110 027, India.
| | - Latika Gupta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ethan S Sen
- Department of Pediatric Rheumatology, Great North Children's Hospital, and Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - A V Ramanan
- Department of Pediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust and Translational Health Sciences, University of Bristol, Bristol, UK
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Garonzi C, Chinello M, Cesaro S. Emapalumab for adult and pediatric patients with hemophagocytic lymphohistiocytosis. Expert Rev Clin Pharmacol 2021; 14:527-534. [PMID: 33686916 DOI: 10.1080/17512433.2021.1901576] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening hyperinflammatory syndrome. Standard treatment is based on immunosuppressive, cytotoxic drugs and hematopoietic stem cell transplantation (HSCT) in primary HLH. Interferon-gamma (IFN-γ) plays a key pathogenic role. Emapalumab, a monoclonal antibody directed against IFN-γ, is the first target therapy approved for primary HLH with refractory, recurrent or progressive disease or intolerance to conventional therapy. AREAS COVERED We reviewed the pharmacological characteristics, safety, efficacy and clinical uses of emapalumab. We summarized the results of current standard treatment based on chemo-immunosuppressive protocols and outlined the alternative options available. EXPERT OPINION Emapalumab is an effective treatment for HLH with a good safety profile. Its efficacy was demonstrated in a phase II/III study on primary HLH pediatric patients with refractory, relapsing HLH or intolerance to first-line treatment. The use of emapalumab allowed most patients to proceed to HSCT, with a high estimated probability of survival 12 months after transplantation. The outcomes in patients who underwent transplantation compare favorably with those reported previously with either myeloablative or reduced-intensity conditioning regimens. The potential role of emapalumab in the treatment of secondary HLH and as a prevention of graft failure after HSCT deserves to be further assessed.
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Affiliation(s)
- Chiara Garonzi
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Matteo Chinello
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
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Caforio M, Sorino C, Caruana I, Weber G, Camera A, Cifaldi L, De Angelis B, Del Bufalo F, Vitale A, Goffredo BM, De Vito R, Fruci D, Quintarelli C, Fanciulli M, Locatelli F, Folgiero V. GD2 redirected CAR T and activated NK-cell-mediated secretion of IFNγ overcomes MYCN-dependent IDO1 inhibition, contributing to neuroblastoma cell immune escape. J Immunother Cancer 2021; 9:jitc-2020-001502. [PMID: 33737337 PMCID: PMC7978286 DOI: 10.1136/jitc-2020-001502] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 12/31/2022] Open
Abstract
Immune escape mechanisms employed by neuroblastoma (NB) cells include secretion of immunosuppressive factors disrupting effective antitumor immunity. The use of cellular therapy to treat solid tumors needs to be implemented. Killing activity of anti-GD2 Chimeric Antigen Receptor (CAR) T or natural killer (NK) cells against target NB cells was assessed through coculture experiments and quantified by FACS analysis. ELISA assay was used to quantify interferon-γ (IFNγ) secreted by NK and CAR T cells. Real Time PCR and Western Blot were performed to analyze gene and protein levels modifications. Transcriptional study was performed by chromatin immunoprecipitation and luciferase reporter assays on experiments of mutagenesis on the promoter sequence. NB tissue sample were analyzed by IHC and Real Time PCR to perform correlation study. We demonstrate that Indoleamine-pyrrole 2,3-dioxygenase1 (IDO1), due to its ability to convert tryptophan into kynurenines, is involved in NB resistance to activity of immune cells. In NB, IDO1 is able to inhibit the anti-tumor effect displayed by of both anti-GD2 CAR (GD2.CAR) T-cell and NK cells, mainly by impairing their IFNγ production. Furthermore, inhibition of MYCN expression in NB results into accumulation of IDO1 and consequently of kynurenines, which negatively affect the immune surveillance. Inverse correlation between IDO1 and MYCN expression has been observed in a wide cohort of NB samples. This finding was supported by the identification of a transcriptional repressive role of MYCN on IDO1 promoter. The evidence of IDO1 involvement in NB immune escape and its ability to impair NK and GD2.CAR T-cell activity contribute to clarify one of the possible mechanisms responsible for the limited efficacy of these immunotherapeutic approaches. A combined therapy of NK or GD2.CAR T-cells with IDO1 inhibitors, a class of compounds already in phase I/II clinical studies, could represent a new and still unexplored strategy capable to improve long-term efficacy of these immunotherapeutic approaches.
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Affiliation(s)
- Matteo Caforio
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.,Departement of Biochemical Sciences "A Rossi Fanelli", Sapienza University of Rome, Rome, Italy
| | - Cristina Sorino
- SAFU Laboratory, Department of Research, Advanced Diagnostic, and Technological Innovation, Istituto Regina Elena Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy, Italy
| | - Ignazio Caruana
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Gerrit Weber
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Antonio Camera
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Loredana Cifaldi
- Academic Department of Pediatrics (DPUO), IRCCS Bambino Gesù Children's Hospistal, Rome, Italy.,Department of Clical Sciences and Translational Medicine, University of Tor Vergata, Rome, Italy
| | - Biagio De Angelis
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Francesca Del Bufalo
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessia Vitale
- Division of Metabolism and Research Unit of Metabolic Biochemistry, IRCCS Bambino gesù Children's Hospital, Rome, Italy
| | - Bianca Maria Goffredo
- Division of Metabolism and Research Unit of Metabolic Biochemistry, IRCCS Bambino gesù Children's Hospital, Rome, Italy
| | - Rita De Vito
- Department of Laboratories, Pathology Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Doriana Fruci
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Concetta Quintarelli
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.,Departyment of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Maurizio Fanciulli
- SAFU Laboratory, Department of Research, Advanced Diagnostic, and Technological Innovation, Istituto Regina Elena Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy, Italy
| | - Franco Locatelli
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.,Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Valentina Folgiero
- Department of Hematology/Oncology and Gene and Cell Therapy, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
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Pascarella A, Bracaglia C, Caiello I, Arduini A, Moneta GM, Rossi MN, Matteo V, Pardeo M, De Benedetti F, Prencipe G. Monocytes From Patients With Macrophage Activation Syndrome and Secondary Hemophagocytic Lymphohistiocytosis Are Hyperresponsive to Interferon Gamma. Front Immunol 2021; 12:663329. [PMID: 33815425 PMCID: PMC8010171 DOI: 10.3389/fimmu.2021.663329] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/01/2021] [Indexed: 12/28/2022] Open
Abstract
Objective To investigate the activation of the IFNγ signaling pathway in monocytes of patients with secondary hemophagocytic lymphohistiocytosis (sHLH)/macrophage activation syndrome (MAS) and to evaluate whether levels of phosphorylated STAT1 represent a biomarker for the identification of patients at early stages of the disease. Methods Fresh whole blood samples from pediatric patients with active sHLH/MAS, not receiving (n=10) and receiving glucocorticoids (n=14) at time of sampling, were prospectively collected. As disease control groups, patients with active systemic juvenile idiopathic arthritis (sJIA) without MAS, patients with sHLH/MAS in remission and patients with other rheumatic diseases were also sampled. Whole blood cells were left unstimulated or stimulated with increasing concentrations of IFNγ for 10 minutes and the intracellular Tyrosine (701)-phosphorylated STAT1 (pSTAT1) levels were evaluated in monocytes by flow cytometry. Results Monocytes from untreated sHLH/MAS patients showed significantly higher basal levels of pSTAT1 compared to those observed in monocytes from glucocorticoid-treated sHLH/MAS patients and from all the other disease controls. In addition, a significant increase in responsiveness to IFNγ, as assessed by increased levels of pSTAT1 following ex vivo stimulation, was observed in monocytes from untreated sHLH/MAS patients. pSTAT1 levels in monocytes distinguished patients with sHLH/MAS not treated with glucocorticoids from patients with active sJIA or with other rheumatic diseases [AUC, 0.93; 95% confidence interval 0.85-1.00, p<0.001]. Statistically significant correlations between IFNG mRNA levels in whole blood cells, circulating IFNγ levels and pSTAT1 levels in sHLH/MAS monocytes were found. Conclusion Our data demonstrating higher basal levels of pSTAT1 as well as a hyperreactivity to IFNγ stimulation in monocytes from patients with sHLH/MAS point to perturbations in the activation of downstream IFNγ signaling pathway as a contributor to the hyperinflammation occurring in these patients. Finally, the observation that glucocorticoids affect pSTAT1 levels in vivo, makes it difficult to consider the measurement of pSTAT1 levels as a biomarker to identify patients at early stages of sHLH/MAS in clinical practice.
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Affiliation(s)
- Antonia Pascarella
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Claudia Bracaglia
- Laboratory of Immuno-Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Ivan Caiello
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Alessia Arduini
- Laboratory of Immuno-Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Gian Marco Moneta
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | | | - Valentina Matteo
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Manuela Pardeo
- Laboratory of Immuno-Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Fabrizio De Benedetti
- Laboratory of Immuno-Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Giusi Prencipe
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
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245
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Possible roads to improve hemophagocytic lymphohistiocytosis outcome. Blood Adv 2021; 4:6127-6129. [PMID: 33351106 DOI: 10.1182/bloodadvances.2020003263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/05/2020] [Indexed: 11/20/2022] Open
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246
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de Miguel M, Umana P, Gomes de Morais AL, Moreno V, Calvo E. T-cell-engaging Therapy for Solid Tumors. Clin Cancer Res 2021; 27:1595-1603. [PMID: 33082210 DOI: 10.1158/1078-0432.ccr-20-2448] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/29/2020] [Accepted: 10/15/2020] [Indexed: 11/16/2022]
Abstract
T-cell engagers (TCE) are a rapidly evolving novel group of treatments that have in common the concurrent engagement of a T-cell surface molecule and a tumoral cell antigen. Bispecific antibodies and genetically engineered adoptive cell therapies, as chimeric antigen receptors or T-cell receptors, have similarities and differences among their mechanisms of action, toxicity profiles, and resistance pathways. Nevertheless, the success observed in the hematologic field has not been obtained with solid tumors yet, as they are biologically more complex and have few truly tumor-specific cell surface antigens that can be targeted with high avidity T cells. Different strategies are under study to improve their short-term perspective, such as new generations of more active TCEs, multi-target or combination of different treatments approaches, or to improve the manufacturing processes. A comprehensive review of TCEs as a grouped treatment class, their current status, and research directions in their application to solid tumors therapeutics are discussed here.
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Affiliation(s)
- Maria de Miguel
- START Madrid-HM Centro Integral Oncológico Clara Campal (CIOCC) Early Phase Program, HM Sanchinarro University Hospital, Madrid, Spain
| | - Pablo Umana
- Roche Innovation Center Zurich Schlieren, Zurich, Switzerland
| | - Ana Luiza Gomes de Morais
- START Madrid-HM Centro Integral Oncológico Clara Campal (CIOCC) Early Phase Program, HM Sanchinarro University Hospital, Madrid, Spain
| | - Victor Moreno
- START Madrid-Fundación Jiménez Díaz (FJD) Early Phase Program, Fundación Jiménez Díaz Hospital, Madrid, Spain
| | - Emiliano Calvo
- START Madrid-HM Centro Integral Oncológico Clara Campal (CIOCC) Early Phase Program, HM Sanchinarro University Hospital, Madrid, Spain.
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Ehl S, von Bahr Greenwood T, Bergsten E, Fischer A, Henter JI, Hines M, Lehmberg K, Janka G, Moshous D, Nichols KE. Is neutralization of IFN-γ sufficient to control inflammation in HLH? Pediatr Blood Cancer 2021; 68:e28886. [PMID: 33405364 DOI: 10.1002/pbc.28886] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Stephan Ehl
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Pediatrics, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tatiana von Bahr Greenwood
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.,Pediatric Oncology, Theme of Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabet Bergsten
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Alain Fischer
- Imagine Institute, Paris, France.,Paediatric Immunology, Haematology and Rheumatology Unit, Hôpital Necker-Enfants Malades, APHP, Paris, France.,Collège de France, Paris, France
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.,Pediatric Oncology, Theme of Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Melissa Hines
- Department of Pediatric Medicine, Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kai Lehmberg
- Department of Pediatric Hematology and Oncology, Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gritta Janka
- Clinic of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Despina Moshous
- Paediatric Immunology, Haematology and Rheumatology Unit, Hôpital Necker-Enfants Malades, APHP, Paris, France.,Genome Dynamics in the Immune System, Imagine Institute, Paris, France.,Paris-Descartes University, Sorbonne Paris Cité, Paris, France
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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McGonagle D, Ramanan AV, Bridgewood C. Immune cartography of macrophage activation syndrome in the COVID-19 era. Nat Rev Rheumatol 2021; 17:145-157. [PMID: 33547426 PMCID: PMC7863615 DOI: 10.1038/s41584-020-00571-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2020] [Indexed: 02/06/2023]
Abstract
A hyperinflammatory 'cytokine storm' state termed macrophage activation syndrome (MAS), culminating from a complex interplay of genetics, immunodeficiency, infectious triggers and dominant innate immune effector responses, can develop across disparate entities including systemic juvenile idiopathic arthritis (sJIA) and its counterpart adult-onset Still disease (AOSD), connective tissue diseases, sepsis, infection, cancers and cancer immunotherapy. Classifying MAS using the immunological disease continuum model, with strict boundaries that define the limits of innate and adaptive immunity, at one boundary is MAS with loss of immune function, as occurs in the 'perforinopathies' and some cases of sJIA-AOSD. Conversely, at the other boundary, immune hypersensitivity with gain of immune function in MHC class II-associated sJIA-AOSD and with chimeric antigen receptor (CAR) T cell therapy also triggers MAS. This provides a benchmark for evaluating severe inflammation in some patients with COVID-19 pneumonia, which cripples primary type I interferon immunity and usually culminates in a lung-centric 'second wave' cytokine-driven alveolitis with associated immunothrombosis; this phenomenon is generally distinct from MAS but can share features with the proposed 'loss of immune function' MAS variant. This loss and gain of function MAS model offers immune cartography for a novel mechanistic classification of MAS with therapeutic implications.
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Affiliation(s)
- Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
- National Institute for Health Research (NIHR), Leeds Biomedical Research Centre (BRC), Leeds Teaching Hospitals, Leeds, UK.
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Translational Health Sciences, University of Bristol, Bristol, UK
| | - Charlie Bridgewood
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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Hu Z, Dalal J. Challenges in HLH transplant: Tricks to prevent menace of mixed chimerism. Pediatr Blood Cancer 2021; 68:e28602. [PMID: 32893946 DOI: 10.1002/pbc.28602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/05/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Zhongbo Hu
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Jignesh Dalal
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
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Abstract
Primary immune regulatory disorders (PIRDs) are a group of diseases belonging to inborn errors of immunity. They usually exhibit lymphoproliferation, autoimmunities, and malignancies, with less susceptibility to recurrent infections. Unlike classical primary immune deficiencies, in autoimmune manifestations, such as cytopenias, enteropathy can be the first symptom of diseases, and they are typically resistant to treatment. Increasing awareness of PIRDs among specialists and a multidisciplinary team approach would provide early diagnosis and treatment that could prevent end-organ damage related to the diseases. In recent years, many PIRDs have been described, and understanding the immunological pathways linked to these disorders provides us an opportunity to use directed therapies for specific molecules, which usually offer better disease control than known classical immunosuppressants. In this review, in light of the most recent literature, we will discuss the common PIRDs and explain their clinical symptoms and recent treatment modalities.
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Affiliation(s)
- Burcu Kolukısa
- Marmara University Faculty of Medicine, Division of Pediatric Allergy and Immunology, İstanbul, Turkey,İstanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, İstanbul, Turkey,The Işıl Berat Barlan Center for Translational Medicine, İstanbul, Turkey
| | - Safa Barış
- Marmara University Faculty of Medicine, Division of Pediatric Allergy and Immunology, İstanbul, Turkey,İstanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, İstanbul, Turkey,The Işıl Berat Barlan Center for Translational Medicine, İstanbul, Turkey
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