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Ding J, Xu K, Niu Y, Qin Y, Shen H, Wang Y, Guo W, Liu X, Wang Z, Zhu AX. Plonmarlimab, a novel anti-GM-CSF blocking antibody, ameliorates disease progression in the pre-clinical model of macrophage activation syndrome. Immunology 2024. [PMID: 39095968 DOI: 10.1111/imm.13842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 07/13/2024] [Indexed: 08/04/2024] Open
Abstract
OBJECTIVES We aimed to characterize and investigate the safety and efficacy of Plonmarlimab, a novel anti-granulocyte-macrophage colony-stimulating factor (anti-GM-CSF) neutralizing antibody, on the treatment of macrophage activation syndrome (MAS), a life-threatening systemic inflammatory disease, in pre-clinical models. METHODS The binding affinity was evaluated using Biacore. The neutralizing activity was measured through the blockade of ligand-receptor interaction, inhibition of STAT5 phosphorylation and suppression of TF-1 cell proliferation. The efficacy of Plonmarlimab was evaluated in a humanized MAS model, which was established by engrafting human umbilical cord blood (UCB) cells into NOG-EXL mice. Additionally, the safety profile of Plonmarlimab was investigated in cynomolgus monkeys. RESULTS At the molecular level, Plonmarlimab showed sub-nanomolar binding affinity with human GM-CSF and effectively blocked the binding of GM-CSF to its receptor. At the cellular level, Plonmarlimab dose-dependently inhibited intracellular STAT5 phosphorylation and suppressed GM-CSF-induced TF-1 proliferation. In the UCB-engrafted NOG-EXL MAS mouse model, Plonmarlimab treatment significantly ameliorated disease progression, demonstrated by the improvements in body weight loss, anaemia and some histopathological features. Furthermore, Plonmarlimab was well tolerated up to 150 mg/kg weekly in monkeys with no reported adverse effects. CONCLUSIONS Plonmarlimab is a highly potent GM-CSF blocking antibody and has demonstrated promising efficacy in a pre-clinical MAS model with a favourable safety profile, supporting its clinical development.
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Affiliation(s)
- Jian Ding
- TJ Biopharma, Co., Ltd., Hangzhou, China
| | - Ke Xu
- TJ Biopharma, Co., Ltd., Hangzhou, China
| | | | - Yihui Qin
- TJ Biopharma, Co., Ltd., Hangzhou, China
| | - Hong Shen
- Zhejiang Institute for Food and Drug Control, Hangzhou, China
| | | | - Wenyu Guo
- TJ Biopharma, Co., Ltd., Hangzhou, China
| | - Xuejun Liu
- TJ Biopharma, Co., Ltd., Hangzhou, China
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Ishimura M, Eguchi K, Sonoda M, Tanaka T, Shiraishi A, Sakai Y, Yasumi T, Miyamoto T, Voskoboinik I, Hashimoto K, Matsumoto S, Ozono S, Moritake H, Takada H, Ohga S. Early hematopoietic cell transplantation for familial hemophagocytic lymphohistiocytosis in a regional treatment network in Japan. Int J Hematol 2024; 119:592-602. [PMID: 38507116 DOI: 10.1007/s12185-024-03721-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 01/11/2024] [Accepted: 01/23/2024] [Indexed: 03/22/2024]
Abstract
Familial hemophagocytic lymphohistiocytosis (FHLH) is a fatal hyperinflammation syndrome arising from the genetic defect of perforin-mediated cytolysis. Curative hematopoietic cell transplantation (HCT) is needed before development of central nervous system (CNS) disease. We studied treatment outcomes of 13 patients (FHLH2 n = 11, FHLH3 n = 2) consecutively diagnosed from 2011 to 2022 by flow cytometric screening for non-myeloablative HCT in a regional treatment network in Kyushu, Japan. One patient with a novel PRF1 variant escaped screening, but all patients with FHLH2 reached diagnosis and 8 of them received HCT until 3 and 9 months of age, respectively. The earliest HCT was conducted 65 days after birth. Three pretransplant deaths occurred in newborns with liver failure at diagnosis. Ten posttransplant patients have remained disease-free, 7 of whom had no neurological involvement. Time from first etoposide infusion to HCT was shorter in patients without CNS disease or bleeding than in patients with those factors (median [range] days: 62 [50-81] vs. 122 [89-209], p = 0.016). Six of 9 unrelated patients had a PRF1 c.1090_1091delCT variant. These results suggest that the critical times to start etoposide and HCT are within 3 months after birth and during etoposide control, respectively. Newborn screening may increase the percentage of disease-free survivors without complications.
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Affiliation(s)
- Masataka Ishimura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Katsuhide Eguchi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Motoshi Sonoda
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Tamami Tanaka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Akira Shiraishi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Takahiro Yasumi
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takayuki Miyamoto
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ilia Voskoboinik
- Cancer Immunology Program, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Kunio Hashimoto
- Department of Pediatrics, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Shirou Matsumoto
- Department of Pediatrics, Faculty of Life Science, Kumamoto University, Kumamoto, Japan
| | - Shuichi Ozono
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Hiroshi Moritake
- Division of Pediatrics, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Hidetoshi Takada
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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3
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Song Y, Zhou F, Du F, Wang Z, Bai L, Yao Y, Liu L, Ma X, Chen S, Wu D, He X. Combined emapalumab and ruxolitinib in patients with haemophagocytic Lymphohistiocytosis. Blood Cancer J 2024; 14:70. [PMID: 38658542 PMCID: PMC11043404 DOI: 10.1038/s41408-024-01056-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Affiliation(s)
- Yue Song
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, 215031, China
| | - Fei Zhou
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, 215031, China
| | - Feng Du
- Department of hematology, Soochow Hopes Hematonosis Hospital, Suzhou, 215128, Jiangsu, China
| | - Ziyan Wang
- Department of hematology, Soochow Hopes Hematonosis Hospital, Suzhou, 215128, Jiangsu, China
| | - Liyun Bai
- Department of hematology, Soochow Hopes Hematonosis Hospital, Suzhou, 215128, Jiangsu, China
| | - Yifang Yao
- Department of hematology, Soochow Hopes Hematonosis Hospital, Suzhou, 215128, Jiangsu, China
| | - Limin Liu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, 215031, China
| | - Xiao Ma
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, 215031, China
| | - Suning Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, 215031, China
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, 215031, China.
| | - Xuefeng He
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, 215031, China.
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Guo T, Liu Z, Chen Y, Cheng Y, He K, Lin X, Wang M, Sun Y. Hemophagocytic lymphohistiocytosis during treatment of intracranial multifocal germinoma: a case report and literature review. Front Oncol 2024; 14:1264926. [PMID: 38532931 PMCID: PMC10963405 DOI: 10.3389/fonc.2024.1264926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 02/19/2024] [Indexed: 03/28/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH), also known as hemophagocytic syndrome (HPS), is a benign histiocytosis with hyperreactive proliferation of the mononuclear phagocyte system caused by immune function abnormalities, which often occurs under the background of genetic mutations, inflammation, infection or tumors. Because the research on malignancy-associated HLH (M-HLH) is focused on hematological malignancies, reports on HLH secondary to solid tumors are rare. In this case, we report a 14-year-old girl who developed HLH during treatment for intracranial multifocal germinoma, and the disease was controlled after hormone combined with etoposide(VP-16) and other related treatments. To our knowledge, there have been no documented cases of HLH caused by intracranial multifocal germinoma.
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Affiliation(s)
- Ting Guo
- Department of Clinical Laboratory, Fengcheng Hospital of Fengxian District, Shanghai, China
| | - Zichun Liu
- Department of Clinical Laboratory, Fengcheng Hospital of Fengxian District, Shanghai, China
| | - Yixin Chen
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yangyang Cheng
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Kaitong He
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xin Lin
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Mingzhu Wang
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yihua Sun
- Department of Clinical Laboratory, Harbin Medical University Cancer Hospital, Harbin, China
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Landy E, Varghese J, Dang V, Szymczak-Workman A, Kane LP, Canna SW. Complementary HLH susceptibility factors converge on CD8 T-cell hyperactivation. Blood Adv 2023; 7:6949-6963. [PMID: 37738167 PMCID: PMC10690564 DOI: 10.1182/bloodadvances.2023010502] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/24/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening hyperinflammatory syndromes. Familial HLH is caused by genetic impairment of granule-mediated cytotoxicity (eg, perforin deficiency). MAS is linked to excess activity of the inflammasome-activated cytokine interleukin-18 (IL-18). Though individually tolerated, mice with dual susceptibility (Prf1⁻/⁻Il18tg; DS) succumb to spontaneous, lethal hyperinflammation. We hypothesized that understanding how these susceptibility factors synergize would uncover key pathomechanisms in the activation, function, and persistence of hyperactivated CD8 T cells. In IL-18 transgenic (Il18tg) mice, IL-18 effects on CD8 T cells drove MAS after a viral (lymphocytic choriomeningitis virus), but not innate (toll like receptor 9), trigger. In vitro, CD8 T cells also required T-cell receptor (TCR) stimulation to fully respond to IL-18. IL-18 induced but perforin deficiency impaired immunoregulatory restimulation-induced cell death (RICD). Paralleling hyperinflammation, DS mice displayed massive postthymic oligoclonal CD8 T-cell hyperactivation in their spleens, livers, and bone marrow as early as 3 weeks. These cells increased proliferation and interferon gamma production, which contrasted with increased expression of receptors and transcription factors associated with exhaustion. Broad-spectrum antibiotics and antiretrovirals failed to ameliorate the disease. Attempting to genetically "fix" TCR antigen-specificity instead demonstrated the persistence of spontaneous HLH and hyperactivation, chiefly on T cells that had evaded TCR fixation. Thus, drivers of HLH may preferentially act on CD8 T cells: IL-18 amplifies activation and demand for RICD, whereas perforin supplies critical immunoregulation. Together, these factors promote a terminal CD8 T-cell activation state, combining features of exhaustion and effector function. Therefore, susceptibility to hyperinflammation may converge on a unique, unrelenting, and antigen-dependent state of CD8 T-cell hyperactivation.
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Affiliation(s)
- Emily Landy
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA
- Graduate Program in Microbiology and Immunology, University of Pittsburgh, Pittsburgh, PA
| | - Jemy Varghese
- Rheumatology & Immune Dysregulation, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Vinh Dang
- Rheumatology & Immune Dysregulation, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Lawrence P. Kane
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA
| | - Scott W. Canna
- Rheumatology & Immune Dysregulation, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Dong Y, Gao R, He K, Zhong J, Dong L. The Role of the IL-33/ST2 Axis in CpG-Induced Macrophage Activation Syndrome. J Immunol Res 2023; 2023:2689360. [PMID: 37842289 PMCID: PMC10569892 DOI: 10.1155/2023/2689360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 03/26/2023] [Accepted: 09/07/2023] [Indexed: 10/17/2023] Open
Abstract
Background Macrophage activation syndrome (MAS) is a fatal inflammatory condition, which is often associated with the elevation of multiple proinflammatory cytokines and multiple organ dysfunction. Previous studies have shown that ST2 contributes to T cell overactivation and plays a detrimental role in mouse models of primary hemophagocytic lymphohistiocytosis. The purpose of this study was to investigate the role of the IL-33/ST2 axis in a mouse model of MAS induced by repeated injections of cytosine-phosphate-guanine (CpG). Methods Serum cytokines were determined using the cytometric bead array by flow cytometry. IL-33 and ST2 were detected by immunohistochemistry and real-time quantitative PCR in the liver and spleen of mice. CD3 and F4/80 in the liver were detected by immunohistochemistry. Inflammatory macrophages and effector memory T lymphocytes were detected by flow cytometry. Result The CpG-induced MAS model was successfully induced after repeated CpG injections, presenting with hypercytokinemia and hepatosplenomegaly. The numbers of IL-33 positive cells in the liver and spleen decreased significantly, while the expression of ST2 in the liver tended to increase in the mice with MAS. IL-33 and St2 knockout mice showed similar levels of hepatosplenomegaly, peripheral blood count, and cytokine storm when compared with wild-type (WT) mice after induction of MAS. There were also no significant differences in liver pathology (including inflammatory cell infiltration of CD3 and F4/80) and levels of splenic inflammatory macrophages and effector memory T cells between the WT and knockout mice. Conclusion These results suggested that IL-33 decreased in the liver and spleen tissues of MAS mice. Further results suggest that IL-33 and St2 knockout mice have no treatment potential in CpG-induced MAS. Thus, the IL-33/ST2 axis has little effect on the prognosis of CpG-induced MAS.
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Affiliation(s)
- Yuanji Dong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Rongfen Gao
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Kailin He
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jixin Zhong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Lingli Dong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Diamond T, Lau M, Morrissette J, Chu N, Behrens EM. CXCL9 inhibition does not ameliorate disease in murine models of both primary and secondary hemophagocytic lymphohistiocytosis. Sci Rep 2023; 13:12298. [PMID: 37516815 PMCID: PMC10387083 DOI: 10.1038/s41598-023-39601-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/27/2023] [Indexed: 07/31/2023] Open
Abstract
Hemophagocytic Lymphohistiocytosis (HLH) is a group of disorders culminating in systemic inflammation and multi-organ failure with high incidence of hepatic dysfunction. Overproduction of IFN-γ is the main immunopathological driver in this disorder. Monokine induced by IFN-γ (CXCL9) serves as a biomarker for disease activity and response to treatment in this disorder. However, very little is understood about the actual functional role of CXCL9 in pathogenesis in HLH. In the current study, we sought to determine the role of CXCL9 in pathogenesis in murine models of both Familial HLH (prf1-/-) and Toll Like Receptor (TLR) 9 repeated stimulation induced Macrophage Activation Syndrome (MAS), a form of secondary HLH. FHL and MAS were induced in both CXCL9 genetically deficient mice (cxcl9-/-) and controls as well as using AMG487, a pharmacological antagonist of the CXCL9 receptor, CXCR3. Results showed that CXCL9 genetic deficiency did not improve disease parameters or hepatitis in both models. Consistent with genetic ablation of CXCL9, inhibition of its receptor, CXCR3, by AMG487 did not show any significant effects in the FHL model. Taken together, inhibition of CXCL9-CXCR3 interaction does not ameliorate HLH physiology in general, or hepatitis as a classical target organ of disease.
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Affiliation(s)
- Tamir Diamond
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
| | - Michelle Lau
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeremy Morrissette
- Department of Immunology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Niansheng Chu
- Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward M Behrens
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Albeituni S, Oak N, Tillman HS, Stroh A, Keenan C, Bloom M, Nichols KE. Cellular and transcriptional impacts of Janus kinase and/or IFN-gamma inhibition in a mouse model of primary hemophagocytic lymphohistiocytosis. Front Immunol 2023; 14:1137037. [PMID: 37228616 PMCID: PMC10204641 DOI: 10.3389/fimmu.2023.1137037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/14/2023] [Indexed: 05/27/2023] Open
Abstract
Background Primary hemophagocytic lymphohistiocytosis (pHLH) is an inherited inflammatory syndrome driven by the exuberant activation of interferon-gamma (IFNg)-producing CD8 T cells. Towards this end, ruxolitinib treatment or IFNg neutralization (aIFNg) lessens immunopathology in a model of pHLH in which perforin-deficient mice (Prf1-/-) are infected with Lymphocytic Choriomeningitis virus (LCMV). However, neither agent completely eradicates inflammation. Two studies combining ruxolitinib with aIFNg report conflicting results with one demonstrating improvement and the other worsening of disease manifestations. As these studies used differing doses of drugs and varying LCMV strains, it remained unclear whether combination therapy is safe and effective. Methods We previously showed that a ruxolitinib dose of 90 mg/kg lessens inflammation in Prf1-/- mice infected with LCMV-Armstrong. To determine whether this dose controls inflammation induced by a different LCMV strain, we administered ruxolitinib at 90mg/kg to Prf1-/- mice infected with LCMV-WE. To elucidate the impacts of single agent versus combination therapy, Prf1-/- animals were infected with LCMV, treated or not with ruxolitinib, aIFNg or both agents, and analyzed for disease features and the transcriptional impacts of therapy within purified CD8 T cells. Results Ruxolitinib is well-tolerated and controls disease regardless of the viral strain used. aIFNg, administered alone or with ruxolitinib, is most effective at reversing anemia and reducing serum IFNg levels. In contrast, ruxolitinib appears better than aIFNg, and equally or more effective than combination therapy, at lessening immune cell expansion and cytokine production. Each treatment targets distinct gene expression pathways with aIFNg downregulating IFNg, IFNa, and IL-6-STAT3 pathways, and ruxolitinib downregulating IL-6-STAT3, glycolysis, and reactive oxygen species pathways. Unexpectedly, combination therapy is associated with upregulation of genes driving cell survival and proliferation. Conclusions Ruxolitinib is tolerated and curtails inflammation regardless of the inciting viral strain and whether it is given alone or in combination with aIFNg. When administered at the doses used in this study, the combination of ruxolitinb and aIFNg appears no better than treatment with either drug alone in lessening inflammation. Further studies are warranted to elucidate the optimal doses, schedules, and combinations of these agents for the treatment of patients with pHLH.
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Affiliation(s)
- Sabrin Albeituni
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Ninad Oak
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Heather S. Tillman
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Alexa Stroh
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Camille Keenan
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Mackenzie Bloom
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Kim E. Nichols
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
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Joly JA, Vallée A, Bourdin B, Bourbonnais S, Patey N, Gaboury L, Théorêt Y, Decaluwe H. Combined IFN-γ and JAK inhibition to treat hemophagocytic lymphohistiocytosis in mice. J Allergy Clin Immunol 2023; 151:247-259.e7. [PMID: 35973477 DOI: 10.1016/j.jaci.2022.07.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/26/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Familial hemophagocytic lymphohistiocytosis is a life-threatening hyperinflammatory disease caused by genetic defects in the granule-mediated cytotoxic pathway. Success of hematopoietic cell transplantation, the only cure, is correlated with the extent of disease control before transplantation. Unfortunately, disease refractoriness and toxicities to standard chemotherapy-based regimens are fatal in a fraction of patients. Novel targeted immunotherapies, such as IFN-γ blocking antibodies or ruxolitinib, a Janus kinase (JAK) 1/2 inhibitor, are promising but only partially effective at controlling disease. OBJECTIVE We asked whether combinations of cytokine-targeted therapies, using antibodies or JAK inhibitor, work synergistically to counteract HLH. METHODS Genetically predisposed mice were infected and treated with distinct combinations of immunotherapies. Disease outcome was monitored and compared to monotherapies. RESULTS We showed that inhibiting IL-6 or IL-18 signaling in combination with IFN-γ blockade or ruxolitinib did not increase disease control compared to anti-IFN-γ antibodies or ruxolitinib monotherapies. In contrast, clinically relevant doses of ruxolitinib combined with low doses of anti-IFN-γ blocking antibodies corrected cytopenias, prevented overt neutrophilia, limited cytokinemia, and resolved HLH immunopathology and symptomatology. CONCLUSIONS Our findings demonstrate that IFN-γ blockade and ruxolitinib act synergistically to suppress HLH progression. This supports the use of combined cytokine-targeted therapies as a bridge to hematopoietic cell transplantation in severe familial hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Josée-Anne Joly
- Cytokines and Adaptive Immunity Laboratory, Sainte-Justine University Hospital Research Center, Université de Montréal, Montréal, Québec, Canada
| | - Alexis Vallée
- Cytokines and Adaptive Immunity Laboratory, Sainte-Justine University Hospital Research Center, Université de Montréal, Montréal, Québec, Canada; Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montréal, Québec, Canada
| | - Benoîte Bourdin
- Cytokines and Adaptive Immunity Laboratory, Sainte-Justine University Hospital Research Center, Université de Montréal, Montréal, Québec, Canada
| | - Sara Bourbonnais
- Cytokines and Adaptive Immunity Laboratory, Sainte-Justine University Hospital Research Center, Université de Montréal, Montréal, Québec, Canada
| | - Natalie Patey
- Department of Pathology and Cellular Biology, Université de Montréal, Montréal, Québec, Canada
| | - Louis Gaboury
- Department of Pathology and Cellular Biology, Université de Montréal, Montréal, Québec, Canada; Histology and Molecular Pathology Research Unit, Institute for Research in Immunology and Cancer (IRIC), Université de Montréal, Montréal, Québec, Canada
| | - Yves Théorêt
- Department of Pharmacology and Physiology, Université de Montréal, Montréal, Québec, Canada
| | - Hélène Decaluwe
- Cytokines and Adaptive Immunity Laboratory, Sainte-Justine University Hospital Research Center, Université de Montréal, Montréal, Québec, Canada; Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montréal, Québec, Canada; Department of Pediatrics, Université de Montréal, Montréal, Québec, Canada.
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10
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Furci F, Murdaca G, Allegra A, Gammeri L, Senna G, Gangemi S. IL-33 and the Cytokine Storm in COVID-19: From a Potential Immunological Relationship towards Precision Medicine. Int J Mol Sci 2022; 23:ijms232314532. [PMID: 36498859 PMCID: PMC9740753 DOI: 10.3390/ijms232314532] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 11/23/2022] Open
Abstract
Coronavirus SARS-CoV-2 has represented, and still represents, a real challenge from a clinical, diagnostic and therapeutic point of view. During acute infection, the increased levels of pro-inflammatory cytokines, which are involved in the pathology of disease and the development of SARS-CoV-2-induced acute respiratory disease syndrome, the life-threatening form of this infection, are correlated with patient survival and disease severity. IL-33, a key cytokine involved in both innate and adaptive immune responses in mucosal organs, can increase airway inflammation, mucus secretion and Th2 cytokine synthesis in the lungs, following respiratory infections. Similar to cases of exposure to known respiratory virus infections, exposure to SARS-CoV-2 induces the expression of IL-33, correlating with T-cell activation and lung disease severity. In this work, we analyse current evidence regarding the immunological role of IL-33 in patients affected by COVID-19, to evaluate not only the clinical impact correlated to its production but also to identify possible future immunological therapies that can block the most expressed inflammatory molecules, preventing worsening of the disease and saving patient lives.
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Affiliation(s)
- Fabiana Furci
- Asthma Centre and Allergy Unit, University of Verona and Verona University Hospital, 37124 Verona, Italy
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, Policlinico G. Martino, University of Messina, 98100 Messina, Italy
| | - Giuseppe Murdaca
- Department of Internal Medicine, University of Genoa, 16126 Genoa, Italy
- Correspondence:
| | - Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98122 Messina, Italy
| | - Luca Gammeri
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, Policlinico G. Martino, University of Messina, 98100 Messina, Italy
| | - Gianenrico Senna
- Asthma Centre and Allergy Unit, University of Verona and Verona University Hospital, 37124 Verona, Italy
- Department of Medicine, University of Verona and Verona University Hospital, 37124 Verona, Italy
| | - Sebastiano Gangemi
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, Policlinico G. Martino, University of Messina, 98100 Messina, Italy
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11
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Kong Q, Wang J, Zhang Y, Hu J, Yu M, Wu L, Wang Z. Misdiagnosis of adult primary hemophagocytic lymphohistiocytosis as NK/T-cell lymphoma: A case report. EJHAEM 2022; 3:1367-1373. [PMID: 36467838 PMCID: PMC9713033 DOI: 10.1002/jha2.564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 06/17/2023]
Abstract
We reported a case of a 19-year-old male patient with central nervous system symptoms as the main clinical manifestations, and multiple intracranial and abdominal occupying lesions visualized by imaging examinations, who was initially misdiagnosed as NK/T-cell lymphoma but poorly responsive to the treatment. Finally, he was diagnosed as familial hemophagocytic lymphohistiocytosis type-2 by genome sequencing, perforin test and pedigree study. The patient survived well after allogeneic hematopoietic stem cell transplantation. Central nervous system symptoms could be the main clinical manifestations in patients with primary hemophagocytic lymphohistiocytosis , whose early-stage manifestations of blood system were usually atypical, easily leading to misdiagnosis. In clinical practice, primary hemophagocytic lymphohistiocytosis should be considered in patients with central nervous system symptoms and unknown causes. The combination of rapid immunological function test and genome sequencing contributes to the diagnosis of primary hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Qi Kong
- Department of HematologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Jingshi Wang
- Department of HematologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Yanlin Zhang
- Department of PathologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Junxia Hu
- Department of HematologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Mingzhu Yu
- Department of HematologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Lin Wu
- Department of HematologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Zhao Wang
- Department of HematologyBeijing Friendship HospitalCapital Medical UniversityBeijingChina
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12
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Excessive IL-10 and IL-18 Trigger HLH-Like Hyperinflammation and Enhanced Myelopoiesis. J Allergy Clin Immunol 2022; 150:1154-1167. [DOI: 10.1016/j.jaci.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/19/2022] [Accepted: 06/27/2022] [Indexed: 11/22/2022]
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13
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Diamond T, Burn TN, Nishiguchi MA, Minichino D, Chase J, Chu N, Kreiger PA, Behrens EM. Familial hemophagocytic lymphohistiocytosis hepatitis is mediated by IFN-γ in a predominantly hepatic-intrinsic manner. PLoS One 2022; 17:e0269553. [PMID: 35671274 PMCID: PMC9173616 DOI: 10.1371/journal.pone.0269553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/23/2022] [Indexed: 12/03/2022] Open
Abstract
Interferon gamma (IFN-γ) is the main cytokine driving organ dysfunction in Familial Hemophagocytic Lymphohistiocytosis (FHL). Blockade of IFN-γ pathway ameliorates FHL hepatitis, both in animal models and in humans with FHL. Hepatocytes are known to express IFN-γ receptor (IFN-γ-R). However, whether IFN-γ induced hepatitis in FHL is a lymphocyte or liver intrinsic response to the cytokine has yet to be elucidated. Using a IFNgR-/- bone marrow chimeric model, this study showed that non-hematopoietic IFN-γ response is critical for development of FHL hepatitis in LCMV-infected Prf1-/- mice. Lack of hepatic IFN-γ responsiveness results in reduced hepatitis as measured by hepatomegaly, alanine aminotransferase (ALT) levels and abrogated histologic endothelial inflammation. In addition, IFN-γ non-hematopoietic response was critical in activation of lymphocytes by soluble interleukin 2 receptor (sIL-2r) and recruitment of CD8+ effector T lymphocytes (CD8+ CD44hi CD62Llo) (Teff) and inflammatory monocytes. Lastly, non-hematopoietic IFN-γ response results in increased hepatic transcription of type 1 immune response and oxidative stress response pathways, while decreasing transcription of genes involved in extracellular matrix (ECM) production. In summary, these findings demonstrate that there is a hepatic transcriptional response to IFN-γ, likely critical in the pathogenesis of FHL hepatitis and hepatic specific responses could be a therapeutic target in this disorder.
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Affiliation(s)
- Tamir Diamond
- Division of Gastroenterology Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Thomas N. Burn
- Perlman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Mailyn A. Nishiguchi
- Perlman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Danielle Minichino
- Perlman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Julie Chase
- Division of Rheumatology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Niansheng Chu
- Division of Rheumatology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Portia A. Kreiger
- Department of Pathology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Edward M. Behrens
- Division of Rheumatology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
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14
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Lindahl H, Bryceson YT. Neuroinflammation Associated With Inborn Errors of Immunity. Front Immunol 2022; 12:827815. [PMID: 35126383 PMCID: PMC8807658 DOI: 10.3389/fimmu.2021.827815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 12/27/2021] [Indexed: 01/16/2023] Open
Abstract
The advent of high-throughput sequencing has facilitated genotype-phenotype correlations in congenital diseases. This has provided molecular diagnosis and benefited patient management but has also revealed substantial phenotypic heterogeneity. Although distinct neuroinflammatory diseases are scarce among the several thousands of established congenital diseases, elements of neuroinflammation are increasingly recognized in a substantial proportion of inborn errors of immunity, where it may even dominate the clinical picture at initial presentation. Although each disease entity is rare, they collectively can constitute a significant proportion of neuropediatric patients in tertiary care and may occasionally also explain adult neurology patients. We focus this review on the signs and symptoms of neuroinflammation that have been reported in association with established pathogenic variants in immune genes and suggest the following subdivision based on proposed underlying mechanisms: autoinflammatory disorders, tolerance defects, and immunodeficiency disorders. The large group of autoinflammatory disorders is further subdivided into IL-1β-mediated disorders, NF-κB dysregulation, type I interferonopathies, and hemophagocytic syndromes. We delineate emerging pathogenic themes underlying neuroinflammation in monogenic diseases and describe the breadth of the clinical spectrum to support decisions to screen for a genetic diagnosis and encourage further research on a neglected phenomenon.
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Affiliation(s)
- Hannes Lindahl
- Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
- Center for Molecular Medicine, Department of Clinical Neuroscience, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Yenan T. Bryceson
- Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
- Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
- Brogelmann Research Laboratory, Department of Clinical Sciences, University of Bergen, Bergen, Norway
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15
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Meeths M, Bryceson YT. Genetics and pathophysiology of haemophagocytic lymphohistiocytosis. Acta Paediatr 2021; 110:2903-2911. [PMID: 34192386 DOI: 10.1111/apa.16013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 12/11/2022]
Abstract
Haemophagocytic lymphohistiocytosis (HLH) represents a life-threatening hyperinflammatory syndrome. Familial studies have established autosomal and X-linked recessive causes of HLH, highlighting a pivotal role for lymphocyte cytotoxicity in the control of certain virus infections and immunoregulation. Recently, a more complex etiological framework has emerged, linking HLH predisposition to variants in genes required for metabolism or immunity to intracellular pathogens. We review genetic predisposition to HLH and discuss how molecular insights have provided fundamental knowledge of the immune system as well as detailed pathophysiological understanding of hyperinflammatory diseases, highlighting new treatment strategies.
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Affiliation(s)
- Marie Meeths
- Childhood Cancer Research Unit Department of Women’s and Children’s Health Karolinska Institutet Stockholm Sweden
- Theme of Children’s Health Karolinska University Hospital Stockholm Sweden
| | - Yenan T. Bryceson
- Centre for Hematology and Regenerative Medicine Department of Medicine Karolinska Institute Stockholm Sweden
- Division of Clinical Immunology and Transfusion Medicine Karolinska University Hospital Stockholm Sweden
- Broegelmann Research Laboratory Department of Clinical Sciences University of Bergen Bergen Norway
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16
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Targeting interferon-γ in hyperinflammation: opportunities and challenges. Nat Rev Rheumatol 2021; 17:678-691. [PMID: 34611329 DOI: 10.1038/s41584-021-00694-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 02/08/2023]
Abstract
Interferon-γ (IFNγ) is a pleiotropic cytokine with multiple effects on the inflammatory response and on innate and adaptive immunity. Overproduction of IFNγ underlies several, potentially fatal, hyperinflammatory or immune-mediated diseases. Several data from animal models and/or from translational research in patients point to a role of IFNγ in hyperinflammatory diseases, such as primary haemophagocytic lymphohistiocytosis, various forms of secondary haemophagocytic lymphohistiocytosis, including macrophage activation syndrome, and cytokine release syndrome, all of which are often managed by rheumatologists or in consultation with rheumatologists. Given the effects of IFNγ on B cells and T follicular helper cells, a role for IFNγ in systemic lupus erythematosus pathogenesis is emerging. To improve our understanding of the role of IFNγ in human disease, IFNγ-related biomarkers that are relevant for the management of hyperinflammatory diseases are progressively being identified and studied, especially because circulating levels of IFNγ do not always reflect its overproduction in tissue. These biomarkers include STAT1 (specifically the phosphorylated form), neopterin and the chemokine CXCL9. IFNγ-neutralizing agents have shown efficacy in the treatment of primary haemophagocytic lymphohistiocytosis in clinical trials and initial promising results have been obtained in various forms of secondary haemophagocytic lymphohistiocytosis, including macrophage activation syndrome. In clinical practice, there is a growing body of evidence supporting the usefulness of circulating CXCL9 levels as a biomarker reflecting IFNγ production.
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17
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Cleavage of DNA and RNA by PLD3 and PLD4 limits autoinflammatory triggering by multiple sensors. Nat Commun 2021; 12:5874. [PMID: 34620855 PMCID: PMC8497607 DOI: 10.1038/s41467-021-26150-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/15/2021] [Indexed: 11/26/2022] Open
Abstract
Phospholipase D3 (PLD3) and PLD4 polymorphisms have been associated with several important inflammatory diseases. Here, we show that PLD3 and PLD4 digest ssRNA in addition to ssDNA as reported previously. Moreover, Pld3−/−Pld4−/− mice accumulate small ssRNAs and develop spontaneous fatal hemophagocytic lymphohistiocytosis (HLH) characterized by inflammatory liver damage and overproduction of Interferon (IFN)-γ. Pathology is rescued in Unc93b13d/3dPld3−/−Pld4−/− mice, which lack all endosomal TLR signaling; genetic codeficiency or antibody blockade of TLR9 or TLR7 ameliorates disease less effectively, suggesting that both RNA and DNA sensing by TLRs contributes to inflammation. IFN-γ made a minor contribution to pathology. Elevated type I IFN and some other remaining perturbations in Unc93b13d/3dPld3−/−Pld4−/− mice requires STING (Tmem173). Our results show that PLD3 and PLD4 regulate both endosomal TLR and cytoplasmic/STING nucleic acid sensing pathways and have implications for the treatment of nucleic acid-driven inflammatory disease. Loss of function polymorphisms of phospholipase D3 and D4 are associated with inflammatory diseases and their function is unclear. Here the authors show that PLD3/4 function as RNAses and deletion of these proteins in mice leads to accumulation of ssRNA which exacerbates inflammation through TLR signalling.
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18
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Posas-Mendoza TF, McLeod C, Davis W, Zakem J, Quinet R. Etiologies and management of haemophagocytic lymphohistiocytosis: is it time for an updated protocol and targeted treatments? Rheumatology (Oxford) 2021; 60:2927-2933. [PMID: 33313881 DOI: 10.1093/rheumatology/keaa741] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/07/2020] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The objective of this study was to analyse the features, therapeutic approaches, and outcomes for adult patients with haemophagocytic lymphohistiocytosis (HLH) at a single centre. METHODS This study was a retrospective chart review of all patients >18 years of age diagnosed with HLH according to HLH-2004 or H-score criteria at Ochsner Medical Center-New Orleans between 2013 and 2019. RESULTS A total of 29 patients with HLH met inclusion criteria. A total of 7 patients had an underlying malignancy, 12 had an autoimmune disease, 2 were transplant patients, and 2 had a combination of malignancy, autoimmune disease, or immunodeficiency. A total of 6 patients developed HLH precipitated by infection alone. All 29 patients presented with fever. A total of 28 (97%) patients met H-score criteria, and only 20 (67%) met HLH-2004 criteria. Fifteen patients were treated with the HLH-2004 protocol. Of those treated with the HLH-2004 protocol, 73% (11/15) died, 8% (1/15) had recurrence of HLH, and 20% (3/15) had resolution of HLH. A total of 14 patients were treated with targeted therapy. Of those treated with targeted therapy, 93% (13/14) had resolution of HLH and 1 died. Targeted therapy included pulse steroids, tocilizumab, anakinra, IVIG, CSA, rituximab, and/or CYC in addition to antiviral or antibiotic therapy. CONCLUSION Our findings suggested that the rheumatologic patient population responded well to a targeted therapeutic approach and poorly to the HLH-2004 protocol. Whether the poor outcomes found with the use of the HLH-2004 protocol are secondary to the protocol itself or the aggressive nature of malignancy-associated HLH is unclear. Further studies are needed to develop tailored therapeutic regimens.
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Affiliation(s)
| | - Cara McLeod
- Department of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - William Davis
- Department of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA, USA.,The University of Queensland, Faculty of Medicine, Ochsner Clinical School, New Orleans, LA, USA
| | - Jerald Zakem
- Department of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA, USA.,The University of Queensland, Faculty of Medicine, Ochsner Clinical School, New Orleans, LA, USA
| | - Robert Quinet
- Department of Rheumatology, Ochsner Clinic Foundation, New Orleans, LA, USA.,The University of Queensland, Faculty of Medicine, Ochsner Clinical School, New Orleans, LA, USA
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19
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Li Z, Liu J, Man Y, Liu F, Gao L, Hu P, Zhao R, Wang Y, Yang T. Analysis of cytokine risk factors in the early death of patients with secondary phagocytic lymphocytic histiocytosis. Am J Transl Res 2021; 13:2388-2398. [PMID: 34017397 PMCID: PMC8129357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/25/2021] [Indexed: 06/12/2023]
Abstract
Secondary hemophagocytic lymphohistiocytosis (sHLH) is an excessive inflammatory response syndrome caused by immune abnormalities. Up to date, the risk factors for cytokines causing early death in sHLH patients have not been elucidated. Our study reviewed the cytokine expression levels in peripheral blood of 50 sHLH patients. Through Cox proportional hazard model analysis, we found that IL-17F ≥2.835 pg/mL (HR = 5.922, 95% CI = 1.793-19.558, P = 0.004) was an independent death risk factor in sHLH patients, and it was also 30 days (Cutoff-value = 2.890 pg/mL, HR = 16.568, 95% CI = 1.917-143.195, P = 0.011), 60 days (Cutoff-value = 2.890 pg/mL, HR = 7.559, 95% CI = 1.449-39.423, P = 0.016), 90 day death risk factor (Cutoff-value = 2.835 pg/mL, HR = 7.649, 95% CI = 1.965-29.778, P = 0.003); IL-10 ≥16.730 pg/mL (HR = 4.821, 95% CI = 1.151-20.116, P = 0.031) is not only a death risk factor within 90 days, but also within 10 days (Cutoff-value = 944.350 pg/mL, HR = 13.321, 95% CI = 1.123-158.03, P = 0.027); and IL-5 ≥2.495 pg/mL (HR = 15.687, 95% CI = 1.377-178.645, P = 0.04) was also a death risk factor within 10 days. Besides, IL-17F, IL-10, IL-5, and the previously reported common risk factors Age, platelets, activated partial thromboplastin time, triglyceride, and lactate dehydrogenase were analyzed together. It was found that the patient age ≥56 years-old is was an important risk factor for death within 30 days, IL-17 ≥2.89 pg/mL and IL-10 ≥16.73 pg/mL are important risk factors for patient death. In summary, our data indicate that age, IL-10 and IL-17F are important risk factors for early death in sHLH patients.
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Affiliation(s)
- Zengzheng Li
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
| | - Jianqiong Liu
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
| | - Yan Man
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
- Kunming University of Science and TechnologyKunming, China
| | - Fusheng Liu
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
- Kunming University of Science and TechnologyKunming, China
| | - Lili Gao
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
| | - Peng Hu
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
| | - Renbin Zhao
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
| | - Yajie Wang
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
- Kunming University of Science and TechnologyKunming, China
| | - Tonghua Yang
- Department of Hematology, The First People’s Hospital of Yunnan ProvinceKunming, China
- Yunnan Blood Disease Clinical Medical CenterKunming, China
- Yunnan Blood Disease HospitalKunming, China
- Kunming University of Science and TechnologyKunming, China
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20
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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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21
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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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22
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Interleukin-18 and cytotoxic impairment are independent and synergistic causes of murine virus-induced hyperinflammation. Blood 2021; 136:2162-2174. [PMID: 32589707 DOI: 10.1182/blood.2019003846] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 06/02/2020] [Indexed: 11/20/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening hyperinflammatory syndromes typically associated with underlying hematologic and rheumatic diseases, respectively. Familial HLH is associated with genetic cytotoxic impairment and thereby to excessive antigen presentation. Extreme elevation of serum interleukin-18 (IL-18) has been observed specifically in patients with MAS, making it a promising therapeutic target, but how IL-18 promotes hyperinflammation remains unknown. In an adjuvant-induced MAS model, excess IL-18 promoted immunopathology, whereas perforin deficiency had no effect. To determine the effects of excess IL-18 on virus-induced immunopathology, we infected Il18-transgenic (Il18tg) mice with lymphocytic choriomeningitis virus (LCMV; strain Armstrong). LCMV infection is self-limited in wild-type mice, but Prf1-/- mice develop prolonged viremia and fatal HLH. LCMV-infected Il18-transgenic (Il18tg) mice developed cachexia and hyperinflammation comparable to Prf1-/- mice, albeit with minimal mortality. Like Prf1-/- mice, immunopathology was largely rescued by CD8 depletion or interferon-γ (IFNg) blockade. Unlike Prf1-/- mice, they showed normal target cell killing and normal clearance of viral RNA and antigens. Rather than impairing cytotoxicity, excess IL-18 acted on T lymphocytes to amplify their inflammatory responses. Surprisingly, combined perforin deficiency and transgenic IL-18 production caused spontaneous hyperinflammation specifically characterized by CD8 T-cell expansion and improved by IFNg blockade. Even Il18tg;Prf1-haplosufficient mice demonstrated hyperinflammatory features. Thus, excess IL-18 promotes hyperinflammation via an autoinflammatory mechanism distinct from, and synergistic with, cytotoxic impairment. These data establish IL-18 as a potent, independent, and modifiable driver of life-threatening innate and adaptive hyperinflammation and support the rationale for an IL-18-driven subclass of hyperinflammation.
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23
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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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24
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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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25
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Keenan C, Nichols KE, Albeituni S. Use of the JAK Inhibitor Ruxolitinib in the Treatment of Hemophagocytic Lymphohistiocytosis. Front Immunol 2021; 12:614704. [PMID: 33664745 PMCID: PMC7923355 DOI: 10.3389/fimmu.2021.614704] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/22/2021] [Indexed: 12/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory syndrome driven by overactive T cells and macrophages that abundantly secrete numerous pro-inflammatory cytokines, including interferon (IFN)-gamma, interleukin (IL)-1-beta, IL-2, IL-6, IL-10, IL-18, and tumor necrosis factor (TNF). The release of these and other cytokines underlies many of the clinical and pathologic manifestations of HLH, which if left untreated, can lead to multi-organ failure and death. The advent of etoposide-based regimens, such as the Histiocyte Society HLH-94 and HLH-2004 protocols, has substantially decreased the mortality associated with HLH. Nevertheless, the 5-year survival remains low at ~60%. To improve upon these results, studies have focused on the use of novel cytokine-directed therapies to dampen inflammation in HLH. Among the agents being tested is ruxolitinib, a potent inhibitor of the Janus Kinase (JAK) and Signal Transducer and Activation of Transcription (STAT) pathway, which functions downstream of many HLH-associated cytokines. Here, we review the basic biology of HLH, including the role of cytokines in disease pathogenesis, and discuss the use of ruxolitinib in the treatment of HLH.
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Affiliation(s)
- Camille Keenan
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kim E Nichols
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Sabrin Albeituni
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
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26
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Tang S, Li S, Zheng S, Ding Y, Zhu D, Sun C, Hu Y, Qiao J, Fang H. Understanding of cytokines and targeted therapy in macrophage activation syndrome. Semin Arthritis Rheum 2020; 51:198-210. [PMID: 33385860 DOI: 10.1016/j.semarthrit.2020.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/01/2020] [Accepted: 12/21/2020] [Indexed: 12/29/2022]
Abstract
Macrophage activation syndrome (MAS) is a potentially life-threatening complication of systemic autoinflammatory/autoimmune diseases, generally systemic juvenile idiopathic arthritis and adult-onset Still's disease. It is characterized by an excessive proliferation of macrophages and T lymphocytes. Recent research revealed that cytokine storm with elevated pro-inflammatory cytokines, including IFN-γ, IL-18, and IL-6, may be central to the pathogenesis of MAS. Though the mainstream of MAS treatment remains corticosteroids and cyclosporine, targeted therapies with anti-cytokine biologics are reported to be promising for controlling systemic inflammation in MAS.
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Affiliation(s)
- Shunli Tang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sheng Li
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Siting Zheng
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuwei Ding
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dingxian Zhu
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chuanyin Sun
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yongxian Hu
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianjun Qiao
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Hong Fang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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27
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Zizzo G, Cohen PL. Imperfect storm: is interleukin-33 the Achilles heel of COVID-19? THE LANCET. RHEUMATOLOGY 2020; 2:e779-e790. [PMID: 33073244 PMCID: PMC7546716 DOI: 10.1016/s2665-9913(20)30340-4] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The unique cytokine signature of COVID-19 might provide clues to disease mechanisms and possible future therapies. Here, we propose a pathogenic model in which the alarmin cytokine, interleukin (IL)-33, is a key player in driving all stages of COVID-19 disease (ie, asymptomatic, mild-moderate, severe-critical, and chronic-fibrotic). In susceptible individuals, IL-33 release by damaged lower respiratory cells might induce dysregulated GATA-binding factor 3-expressing regulatory T cells, thereby breaking immune tolerance and eliciting severe acute respiratory syndrome coronavirus 2-induced autoinflammatory lung disease. Such disease might be initially sustained by IL-33-differentiated type-2 innate lymphoid cells and locally expanded γδ T cells. In severe COVID-19 cases, the IL-33-ST2 axis might act to expand the number of pathogenic granulocyte-macrophage colony-stimulating factor-expressing T cells, dampen antiviral interferon responses, elicit hyperinflammation, and favour thromboses. In patients who survive severe COVID-19, IL-33 might drive pulmonary fibrosis by inducing myofibroblasts and epithelial-mesenchymal transition. We discuss the therapeutic implications of these hypothetical pathways, including use of therapies that target IL-33 (eg, anti-ST2), T helper 17-like γδ T cells, immune cell homing, and cytokine balance.
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Affiliation(s)
- Gaetano Zizzo
- Temple Autoimmunity Center, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA
- Unit of Rheumatology, Department of Internal Medicine, ASST Ovest Milanese, Milan, Italy
| | - Philip L Cohen
- Temple Autoimmunity Center, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA
- Section of Rheumatology, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA
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28
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Kidder K, Bian Z, Shi L, Liu Y. Inflammation Unrestrained by SIRPα Induces Secondary Hemophagocytic Lymphohistiocytosis Independent of IFN-γ. THE JOURNAL OF IMMUNOLOGY 2020; 205:2821-2833. [PMID: 33028619 DOI: 10.4049/jimmunol.2000652] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/14/2020] [Indexed: 12/28/2022]
Abstract
A hallmark of secondary hemophagocytic lymphohistiocytosis (sHLH), a severe form of cytokine storm syndrome, is the emergence of overactivated macrophages that engulf healthy host blood cells (i.e., hemophagocytosis) and contribute to the dysregulated inflammation-driven pathology. In this study, we show that depleting SIRPα (SIRPα-/-) in mice during TLR9-driven inflammation exacerbates and accelerates the onset of fulminant sHLH, in which systemic hemophagocytosis, hypercytokinemia, consumptive cytopenias, hyperferritinemia, and other hemophagocytic lymphohistiocytosis hallmarks were apparent. In contrast, mice expressing SIRPα, including those deficient of the SIRPα ligand CD47 (CD47-/-), do not phenocopy SIRPα deficiency and fail to fully develop sHLH, albeit TLR9-inflamed wild-type and CD47-/- mice exhibited hemophagocytosis, anemia, and splenomegaly. Although IFN-γ is largely considered a driver of hemophagocytic lymphohistiocytosis pathology, IFN-γ neutralization did not preclude the precipitation of sHLH in TLR9-inflamed SIRPα-/- mice, whereas macrophage depletion attenuated sHLH in SIRPα-/- mice. Mechanistic studies confirmed that SIRPα not only restrains macrophages from acquiring a hemophagocytic phenotype but also tempers their proinflammatory cytokine and ferritin secretion by negatively regulating Erk1/2 and p38 activation downstream of TLR9 signaling. In addition to TLR9 agonists, TLR2, TLR3, or TLR4 agonists, as well as TNF-α, IL-6, or IL-17A, but not IFN-γ, similarly induced sHLH in SIRPα-/- mice but not SIRPα+ mice. Collectively, our study suggests that SIRPα plays a previously unappreciated role in sHLH/cytokine storm syndrome pathogenesis by preventing macrophages from becoming both hemophagocytic and hyperactivated under proinflammation.
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Affiliation(s)
- Koby Kidder
- Program of Immunology and Cellular Biology, Department of Biology, Georgia State University, Atlanta, GA 30302; and
| | - Zhen Bian
- Program of Immunology and Cellular Biology, Department of Biology, Georgia State University, Atlanta, GA 30302; and.,Center for Diagnostics and Therapeutics, Georgia State University, Atlanta, GA 30302
| | - Lei Shi
- Program of Immunology and Cellular Biology, Department of Biology, Georgia State University, Atlanta, GA 30302; and.,Center for Diagnostics and Therapeutics, Georgia State University, Atlanta, GA 30302
| | - Yuan Liu
- Program of Immunology and Cellular Biology, Department of Biology, Georgia State University, Atlanta, GA 30302; and .,Center for Diagnostics and Therapeutics, Georgia State University, Atlanta, GA 30302
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29
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Canna SW, Cron RQ. Highways to hell: Mechanism-based management of cytokine storm syndromes. J Allergy Clin Immunol 2020; 146:949-959. [PMID: 33007328 PMCID: PMC7522622 DOI: 10.1016/j.jaci.2020.09.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 12/12/2022]
Abstract
Since the first textbook devoted to cytokine storm syndromes (CSSs) was published in 2019, the world has changed dramatically and the term’s visibility has broadened. Herein, we define CSSs broadly to include life/organ-threatening systemic inflammation and immunopathology regardless of the context in which it occurs, recognizing that the indistinct borders of such a definition limit its utility. Nevertheless, we are focused on the pathomechanisms leading to CSSs, including impairment of granule-mediated cytotoxicity, specific viral infections, excess IL-18, and chimeric antigen receptor T-cell therapy. These mechanisms are often reflected in distinct clinical features, functional tests, and/or biomarker assessments. Moreover, these mechanisms often indicate specific, definitive treatments. This mechanism-focused organization is vital to both advancing the field and understanding the complexities in individual patients. However, increasing evidence suggests that these mechanisms interact and overlap. Likewise, the utility of a broad term such as “cytokine storm” is that it reflects a convergence on a systemic inflammatory phenotype that, regardless of cause or context, may be amenable to “inflammo-stabilization.” CSS research must improve our appreciation of its various mechanisms and their interactions and treatments, but it must also identify the signs and interventions that may broadly prevent CSS-induced immunopathology.
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Affiliation(s)
- Scott W Canna
- University of Pittsburgh/UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa.
| | - Randy Q Cron
- University of Alabama, Birmingham/Children's of Alabama, Birmingham, Ala
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30
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Mehta P, Porter JC, Manson JJ, Isaacs JD, Openshaw PJM, McInnes IB, Summers C, Chambers RC. Therapeutic blockade of granulocyte macrophage colony-stimulating factor in COVID-19-associated hyperinflammation: challenges and opportunities. THE LANCET. RESPIRATORY MEDICINE 2020; 8:822-830. [PMID: 32559419 PMCID: PMC7834476 DOI: 10.1016/s2213-2600(20)30267-8] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 01/19/2023]
Abstract
The COVID-19 pandemic is a global public health crisis, with considerable mortality and morbidity exerting pressure on health-care resources, including critical care. An excessive host inflammatory response in a subgroup of patients with severe COVID-19 might contribute to the development of acute respiratory distress syndrome (ARDS) and multiorgan failure. Timely therapeutic intervention with immunomodulation in patients with hyperinflammation could prevent disease progression to ARDS and obviate the need for invasive ventilation. Granulocyte macrophage colony-stimulating factor (GM-CSF) is an immunoregulatory cytokine with a pivotal role in initiation and perpetuation of inflammatory diseases. GM-CSF could link T-cell-driven acute pulmonary inflammation with an autocrine, self-amplifying cytokine loop leading to monocyte and macrophage activation. This axis has been targeted in cytokine storm syndromes and chronic inflammatory disorders. Here, we consider the scientific rationale for therapeutic targeting of GM-CSF in COVID-19-associated hyperinflammation. Since GM-CSF also has a key role in homoeostasis and host defence, we discuss potential risks associated with inhibition of GM-CSF in the context of viral infection and the challenges of doing clinical trials in this setting, highlighting in particular the need for a patient risk-stratification algorithm.
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Affiliation(s)
- Puja Mehta
- Centre for Inflammation and Tissue Repair, Division of Medicine, University College London, London, UK; Department of Rheumatology, University College London Hospital, London, UK
| | - Joanna C Porter
- Centre for Inflammation and Tissue Repair, Division of Medicine, University College London, London, UK
| | - Jessica J Manson
- Department of Rheumatology, University College London Hospital, London, UK
| | - John D Isaacs
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Peter J M Openshaw
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | | | - Rachel C Chambers
- Centre for Inflammation and Tissue Repair, Division of Medicine, University College London, London, UK.
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31
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Harel M, Girard-Guyonvarc'h C, Rodriguez E, Palmer G, Gabay C. Production of IL-18 Binding Protein by Radiosensitive and Radioresistant Cells in CpG-Induced Macrophage Activation Syndrome. THE JOURNAL OF IMMUNOLOGY 2020; 205:1167-1175. [PMID: 32651219 DOI: 10.4049/jimmunol.2000168] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/15/2020] [Indexed: 12/20/2022]
Abstract
IL-18 binding protein (IL-18BP) acts as a naturally occurring IL-18 decoy receptor. If the balance between IL-18 and IL-18BP is dysregulated, abnormal levels of free bioactive IL-18 are detected, such as in the sera of Il-18bp knockout (KO) mice with CpG-induced macrophage activation syndrome. To determine the cellular sources of Il-18bp in vivo, we selectively depleted Il-18bp expression in either radiosensitive or radioresistant cells using bone marrow transfer between wild-type (WT) and Il-18bp KO mice. Following repeated CpG injections, Il-18bp KO (donor)→ Il-18bp KO (recipient) chimeric mice exhibited more severe disease, with an enhanced Ifn-γ signature and circulating free Il-18 levels, in comparison with WT→WT chimeras. Interestingly, the phenotype of KO→WT and WT→KO mice did not differ from that of WT→WT mice. Consistent with this finding, serum Il-18bp levels were similar in these three groups of mice. The contribution of radioresistant and radiosensitive cells to Il-18bp production varied markedly according to the organ examined, with a major contribution of radiosensitive cells in the spleen as opposed to a major contribution of radioresistant cells in the lung. Finally, Ifn-γ blockade abrogated the CpG-induced but not the constitutive Il-18bp production. Our results demonstrate that circulating Il-18bp is induced in response to Ifn-γ during CpG-induced macrophage activation syndrome and is present at high levels in the circulation to prevent the deleterious systemic effects of Il-18.
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Affiliation(s)
- Mathilde Harel
- Department of Pathology and Immunology, School of Medicine, University of Geneva, CH-1211 Geneva 4, Switzerland; and.,Division of Rheumatology, Department of Medicine, University Hospitals, CH-1211 Geneva 14, Switzerland
| | | | - Emiliana Rodriguez
- Department of Pathology and Immunology, School of Medicine, University of Geneva, CH-1211 Geneva 4, Switzerland; and.,Division of Rheumatology, Department of Medicine, University Hospitals, CH-1211 Geneva 14, Switzerland
| | - Gaby Palmer
- Department of Pathology and Immunology, School of Medicine, University of Geneva, CH-1211 Geneva 4, Switzerland; and.,Division of Rheumatology, Department of Medicine, University Hospitals, CH-1211 Geneva 14, Switzerland
| | - Cem Gabay
- Department of Pathology and Immunology, School of Medicine, University of Geneva, CH-1211 Geneva 4, Switzerland; and .,Division of Rheumatology, Department of Medicine, University Hospitals, CH-1211 Geneva 14, Switzerland
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32
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Razaghian A, Parvaneh L, Delkhah M, Abbasi A, Sadeghirad P, Shahrooei M, Parvaneh N. Bacillus Calmette-Guérin (BCG)-associated hemophagocytic lymphohistiocytosis in the setting of IFN-γR1 deficiency: A diagnostic dilemma. EJHAEM 2020; 1:334-337. [PMID: 35847695 PMCID: PMC9175834 DOI: 10.1002/jha2.5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 11/07/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) disease is a severe immune dysregulation caused by mutations in genes required for lymphocyte cytotoxicity function. However, HLH-like syndrome may develop secondary to infections, malignancy, and autoimmunity. Primary immunodeficiencies (PIDs) could predispose to HLH syndrome after uncontrolled infections. Mendelian susceptibility to mycobacterial disease (MSMD) is a PID characterized by a predisposition to clinical disease caused by weakly virulent mycobacteria, such as bacillus Calmette-Guérin (BCG). Inborn errors of interferon-γ immunity caused by mutations in 16 genes, underly MSMD development. Here, we report a case of fatal interferon-γ receptor 1 deficiency with disseminated BCG infection, which was initially diagnosed with HLH disease. We also include a review of cases reported in the literature.
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Affiliation(s)
- Anahita Razaghian
- Department of PediatricsDivision of Allergy and Clinical ImmunologyTehran University of Medical SciencesTehranIran
| | - Leila Parvaneh
- Department of BiologyCentral Tehran BranchIslamic Azad UniversityTehranIran
| | - Mona Delkhah
- Flow Cytometry LaboratoryChildren's Medical CenterTehranIran
| | - Arash Abbasi
- Department of PediatricsTehran University of Medical SciencesTehranIran
| | - Parisa Sadeghirad
- Department of PediatricsDivision of Allergy and Clinical ImmunologyTehran University of Medical SciencesTehranIran
| | - Mohammad Shahrooei
- Department of Microbiology and ImmunologyLaboratory of Clinical Bacteriology and MycologyKU LeuvenLeuvenBelgium
| | - Nima Parvaneh
- Department of PediatricsDivision of Allergy and Clinical ImmunologyTehran University of Medical SciencesTehranIran
- Research Center for ImmunodeficienciesTehran University of Medical SciencesTehranIran
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33
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De Luca G, Cavalli G, Campochiaro C, Della-Torre E, Angelillo P, Tomelleri A, Boffini N, Tentori S, Mette F, Farina N, Rovere-Querini P, Ruggeri A, D'Aliberti T, Scarpellini P, Landoni G, De Cobelli F, Paolini JF, Zangrillo A, Tresoldi M, Trapnell BC, Ciceri F, Dagna L. GM-CSF blockade with mavrilimumab in severe COVID-19 pneumonia and systemic hyperinflammation: a single-centre, prospective cohort study. LANCET RHEUMATOLOGY 2020; 2:e465-e473. [PMID: 32835256 PMCID: PMC7430344 DOI: 10.1016/s2665-9913(20)30170-3] [Citation(s) in RCA: 149] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Mortality in patients with COVID-19 pneumonia and systemic hyperinflammation is high. We aimed to examine whether mavrilimumab, an anti-granulocyte–macrophage colony-stimulating factor receptor-α monoclonal antibody, added to standard management, improves clinical outcomes in patients with COVID-19 pneumonia and systemic hyperinflammation. Methods This single-centre prospective cohort study included patients aged 18 years or older who were admitted to San Raffaele Hospital (Milan, Italy) with severe COVID-19 pneumonia, hypoxia, and systemic hyperinflammation. Patients received a single intravenous dose (6 mg/kg) of mavrilimumab added to standard care given by the hospital at the time. The control group consisted of contemporaneous patients with similar baseline characteristics who received standard care at the same hospital. The main outcome was time to clinical improvement (defined as improvement of two or more points on the seven-point ordinal scale of clinical status). Other outcomes included proportion of patients achieving clinical improvement, survival, mechanical ventilation-free survival, and time to fever resolution. Adverse events were monitored daily. Findings Between March 17 and April 15, 2020, 13 non-mechanically ventilated patients (median age 57 years [IQR 52–58], 12 [92%] men) received mavrilimumab and 26 patients (median age 60 [IQR 53–67], 17 [65%] men) in the control group received standard care. During the 28-day follow-up, no patients in the mavrilimumab group died, and seven (27%) patients in the control group died (p=0·086). At day 28, all patients in the mavrilimumab group and 17 (65%) patients in the control group showed clinical improvement (p=0·030), with earlier improvement in the mavrilimumab than in the control group (mean time to improvement 8 days [IQR 5 to 11] vs 19 days [11 to >28], p=0·0001). By day 28, one (8%) patient in the mavrilimumab group progressed to mechanical ventilation compared with nine (35%) patients in the control group who progressed to mechanical ventilation or died (p=0·14). By day 14, fever resolved in ten (91%) of 11 febrile patients in the mavrilimumab group, compared with 11 (61%) of 18 febrile patients in the control group (p=0·18); fever resolution was faster in mavrilimumab recipients versus controls (median time to resolution 1 day [IQR 1 to 2] vs 7 days [3 to >14], p=0·0093). Mavrilimumab was well tolerated, with no infusion reactions. Three (12%) patients in the control group developed infectious complications. Interpretation Mavrilimumab treatment was associated with improved clinical outcomes compared with standard care in non-mechanically ventilated patients with severe COVID-19 pneumonia and systemic hyperinflammation. Treatment was well tolerated. Confirmation of efficacy requires controlled testing. Funding IRCCS San Raffaele Scientific Institute.
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Affiliation(s)
- Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Giulio Cavalli
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Piera Angelillo
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Nicola Boffini
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Tentori
- Internal Medicine and Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Mette
- Emergency Department, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Nicola Farina
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Patrizia Rovere-Querini
- Internal Medicine, Diabetes and Endocrinology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Annalisa Ruggeri
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Teresa D'Aliberti
- General Medicine and Advanced Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Scarpellini
- Department of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco De Cobelli
- Department of Radiology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | | | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Moreno Tresoldi
- General Medicine and Advanced Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Bruce C Trapnell
- Translational Pulmonary Science Center, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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